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4,588
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43983
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Discharge summary
|
report
|
Admission Date: [**2116-7-22**] Discharge Date: [**2116-7-27**]
Date of Birth: [**2073-1-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 43 year old male with alpha-1 antitrypsin
deficiency and emphysema on 3 L home oxygen, diabetes mellitus,
osteoporosis, adrenal insufficiency, hypothyroidism, and HCV
infection who has required intubation several times in the past
for COPD exacerbation. He presented to the ED today with
several days of worsening SOB, particularly with exertion and an
increased oxygen requirement of 5 L from his usual baseline of 3
L. He reports coughing more often than usual, and his cough has
been more productive, with dark green sputum, which is not
typical for him. He has also felt increasingly fatigued over
the last several days. He has not noticed any fever or chills,
but has had some occasional diaphoresis. He is not aware of any
recent sick contact.
.
In the ED, initial vitals were T 98.8, BP 124/76, HR 138, RR 32,
SpO2 93% on 5L NC. He triggered on arrival to the ED for his
tachycardia and tachypnea. EKG showed sinus tachycardia at 125
bpm. CXR showed severe emphysema but no superimposed
infiltrate. Labs were notable for Na 112, glucose 556, WBC 12.2
with 75.4% neutrophils, lactate 1.6, and anion gap 6. UA showed
glucose 1000 and ketones 40. He was given Solumedrol,
Azithromycin, and nebulizer treatments for his apparent COPD
exacerbation. He was given Insulin 10 units IV with a decrease
to FBG 388. He also received normal saline 1 L bolus and an
additional 1L over several hours while in the ED, with
improvement of his tachycardia. He was admitted to the ICU for
management of his COPD exacerbation, hyperglycemia, and
hyponatremia. Prior to transfer, his VS were afebrile, HR 98,
BP 125/59, RR 20, and SpO2 94% on 5L.
.
On arrival to the ICU, he appeared chronically ill but was not
in acute distress. He felt that he was breathing more
comfortably, and was on 3L NC. He continued to have a
productive cough. His chronic pain was at baseline and improved
with his home pain medication regimen. He denied any other
specific complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, or recent weight loss. Denies
headache, confusion, rhinorrhea, or congestion. Denies chest
pain, chest pressure, or palpitations. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies new
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- Alpha-1 antitrypsin deficiency on [**First Name3 (LF) **] for 8 years
(followed by Dr [**Last Name (STitle) 6174**] at [**Hospital1 112**]); portocath for [**Hospital1 **]
infusions
- Type 1 diabetes
- COPD on home O2 (3L at rest, 4L with activity)
- Hep C (Dr [**Last Name (STitle) **] at [**Hospital1 112**]), A1A def, h/o ETOH (he reports
cirrhosis on liver bx in past at [**Hospital1 112**] although recent RUQ u/s
reports normal liver echotexture and spleen 12cm)
- Chronic back pain secondary to compression fractures
- Hypogonadism
- Osteoporosis
- Chronic methadone therapy for his chronic pain
- History of polysubstance abuse, currently not using any
illicits
- Anxiety/depression
- Distal fibula fracture
-adrenal insufficiency
Social History:
Currently on disability; formally employed as a furniture mover.
Admits to prior alcohol abuse and IVDU. Prior 25-pack-year
smoking history. Denies current use.
Family History:
Father died at 46 of throat/mouth cancer. Mother recently died;
he is unsure of cause.
Physical Exam:
Admission Physical Exam:
Vitals: T 96.7, BP 113/81, HR 104, RR 14, SpO2 93% on 3L NC
General: Alert, oriented, no acute distress
[**Hospital1 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: JVP not elevated, no LAD
Lungs: Poor air movement with wheezes throughout. No crackles.
CV: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs,
or gallops.
Abdomen: Bowel sounds present. Voluntary guarding. Diastasis
recti. Non-tender, non-distended.
GU: No foley
Ext: Warm, well perfused, 2+ pulses. No edema.
On day of discharge pt with stable physical exam.
VSS 94% on 3-4L NC
NAD a+ox3
Neck: no JVD
Lungs: Slight wheezes throughout with no rhonchi or crackles.
CV: rrr no m/r/g
abd: soft nt nd bs+
Ext: Warm, well perfused 2+ pulses
Pertinent Results:
[**2116-7-22**] 05:25PM BLOOD WBC-12.2*# RBC-5.13 Hgb-16.6 Hct-48.0
MCV-94 MCH-32.3* MCHC-34.5 RDW-14.2 Plt Ct-190
[**2116-7-22**] 05:25PM BLOOD Neuts-75.4* Lymphs-20.4 Monos-3.2 Eos-0.3
Baso-0.8
[**2116-7-22**] 05:25PM BLOOD Glucose-556* UreaN-26* Creat-1.1 Na-112*
K-4.3 Cl-82* HCO3-24 AnGap-10
[**2116-7-22**] 11:02PM BLOOD ALT-47* AST-35 LD(LDH)-196 AlkPhos-86
TotBili-0.6
[**2116-7-22**] 11:02PM BLOOD Albumin-3.9 Calcium-8.7 Phos-2.5* Mg-1.8
[**2116-7-22**] 11:02PM BLOOD TSH-4.2
[**2116-7-22**] 05:28PM BLOOD Lactate-1.6
[**2116-7-23**] CXR: IMPRESSION: There is no radiographic evidence of
any acute cardiopulmonary
findings.
EKG: sinus tachycardia
Brief Hospital Course:
The patient is a 43 year old male with A1A deficiency, emphysema
on 3 L home oxygen, diabetes mellitus, adrenal insufficiency,
chronic pain, osteoporosis, hypothyroidism, and HCV infection
who presented with a COPD exacerbation, hyperglycemia, and
hyponatremia.
.
# COPD Exacerbation/possible pna: His respiratory symptoms were
consistent with COPD exacerbation and acute bronchitis without
initial evidence of pneumonia on imaging or labs. He responded
well to initial treatment with nebulizers, steroids, and
azithromycin. In the ICU, he was kept on his home Advair, given
Albuterol and Ipratropium nebs. He was transitioned to
Prednisone 60 mg PO daily (increased from current home dose of
20 mg). His initial azithromycin was changed to Levofloxacin on
[**2116-7-24**] when sputum gram stain showed mixed flora, with
predominant GNRs which grew pseudomonas thought to be secondary
to colonization as he clinically did not have a pneumonia.
Patient was discharged with a prednisone taper and levaquin x 4
days complete on [**7-31**]. He will f/u with pulmonary at
[**Hospital1 756**]&women where he gets his chronic care.
.
# Hyperglycemia: Most likely secondary to underlying diabetes,
exacerbated by systemic stress of infection and treatment with
steroids. He presented with glucose>500 and was treated with
insulin in the ED. His glucose had decreased to 347 on arrival
to the ICU. Initial UA showed ketones but no anion gap. In the
ICU, he was transiently treated with an insulin drip, after
which his SSI and Lantus doses were adjusted, with the advice of
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult. He was discharged on lantus 12 qam, 20 qpm
and will f/u with the [**Last Name (un) **] center on [**8-4**].
# Hyponatremia: The patient was found to have Na 112 on
presentation to the ED, and received a total of 2 L normal
saline prior to reaching the ICU. Initial labs in the ICU
showed Na 132, which was confirmed on repeat. Given the rapid
rise in sodium over a short period of time, the level of 112 was
thought to be spurious. The patient had no mental status
changes. His sodium levels remained stable throughout the rest
of his ICU stay.
# Hypothyroidism: He was continued on his home Levothyroxine
150 mcg PO daily
.
# Chronic Pain: He has chronic pain from prior compression
fractures related to osteoporosis and is on a regimen of
Methadone, Oxycodone, and Gabapentin. He was continued on his
home pain regimen with holding parameters
# Adrenal insufficiency: The patient was continued on higher
dose prednisone.
#Depression: The patient was continued on his outpatient
regiment.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - [**1-5**] HFA(s)
inhaled every 4-6 hours as needed for shortness of breath or
wheezing
ALPHA-1 PROTEINASE INHIB.(HUM) [[**Name8 (MD) 94451**] NP] - 1,000 mg
Suspension for Reconstitution - once a week
ALPHA-1 PROTEINASE INHIB.(HUM) [[**Name8 (MD) 94451**]] - (Prescribed by Other
Provider) - 500 mg Suspension for Reconstitution - Suspension(s)
AMITRIPTYLINE - 50 mg Tablet - 1 (one) Tablet(s) by mouth HS
Call with any worsening of symptoms.
CICLOPIROX - 0.77 % Cream - Apply to affected areas of soles of
both feet twice a day as directed.
CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth twice a day
DESONIDE - 0.05 % Cream - AAA face twice a day use for up to 2
weeks; then as needed
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth weekly
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk with Device - 1 discus inhaled one in the morning and one
in the evening
GABAPENTIN - 600 mg Tablet - 1 (one) Tablet(s) by mouth three
times a day
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100 unit/mL Cartridge - 24 units every evening
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - Take according
to your sliding scale at home Four times a day
KETOCONAZOLE - 2 % Cream - AAA face twice daily
LEVOTHYROXINE [SYNTHROID] - 150 mcg Tablet - 1 Tablet(s) by
mouth each morning Take on an empty stomach before eating.
METHADONE - 10 mg Tablet - [**2-7**] Tablet(s) by mouth once a day FOR
PAIN Take 2 with meals and 4 in the evening prior to sleep.(10
per day)
MIRTAZAPINE - 30 mg Tablet - 2 Tablet(s) by mouth at bedtime
NYSTATIN - 100,000 unit/mL Suspension - 1 teaspoon(s) by mouth
three times a day as needed for [**Month/Day (3) 11395**] swish and swallow
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice a day
OXYCODONE - 15 mg Tablet - [**1-5**] Tablet(s) by mouth three times a
day, no more than 3 a day total
PRAVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
PREDNISONE - 10 mg Tablet - 1 to 2 Tablet(s) by mouth once a day
TESTOSTERONE ENANTHATE - 200 mg/mL Oil - 0.5 cc SC in lateral
buttock weekly WARM BOTTLE SLIGHTLY IN HAND RUB INJ. SITE 15
SECS.TO DISPERSE
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 puff inh once a day
ZOLEDRONIC ACID-MANNITOL&WATER [RECLAST] - (Prescribed by Other
Provider: [**Name Initial (NameIs) 94459**]) - 5 mg/100 mL Solution - [**Name Initial (NameIs) 94459**]
CALCIUM CARBONATE-VITAMIN D3 - 500 mg-125 unit Tablet - 1
Tablet(s) by mouth twice a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth once a day
MULTIVITAMIN - (OTC) - Dosage uncertain
NUT.TX.GLUC.INTOL,LAC-FREE,SOY [GLUCERNA] - Liquid - 1
bottle(s) by mouth 6 times a day (food supplement)
SENNOSIDES [SENNA] - 8.6 mg Tablet - 1 Tablet(s) by mouth twice
a day as needed for constipation
TERBINAFINE - 1 % Cream - twice a day to feet/toes
Discharge Medications:
1. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
3. desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] PRN () as
needed for acne.
4. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
8. methadone 10 mg Tablet Sig: Four (4) Tablet PO [**Hospital1 **] (once a
day (at bedtime)).
9. methadone 10 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
10. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day) as needed for pain.
11. mirtazapine 30 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. prednisone 20 mg Tablet Sig: Three (3) Tablet PO qday () for
1 days.
Disp:*3 Tablet(s)* Refills:*0*
14. prednisone 20 mg Tablet Sig: Two (2) Tablet PO qday () for 4
days.
Disp:*8 Tablet(s)* Refills:*0*
15. prednisone 20 mg Tablet Sig: One (1) Tablet PO qday () for 4
days.
Disp:*4 Tablet(s)* Refills:*0*
16. prednisone 10 mg Tablet Sig: One (1) Tablet PO qday () for
60 days.
Disp:*60 Tablet(s)* Refills:*0*
17. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
19. Lantus 100 unit/mL Solution Sig: One (1) 20 U Subcutaneous
at bedtime.
20. Humalog 100 unit/mL Solution Sig: One (1) Per sliding scale
Subcutaneous three times a day.
21. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
22. Lantus 100 unit/mL Solution Sig: One (1) 12 Units
Subcutaneous once a day.
Discharge Disposition:
Home With Service
Facility:
[**Doctor Last Name **] Nursing
Discharge Diagnosis:
COPD exacerbation
hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a COPD exacerbation and pnemonia. To
finish treatment for this disease, please:
1. Continue taking Prednisone taper as instructed.
2. Continue taking your antibiotic levaquin until you run out.
3. We changed your insulin dosing because of the increased blood
sugars. You are taking lantus twice daily 12U in the morning,
20 U at night
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2116-7-29**] 2:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1877**], MD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2116-8-4**] 3:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2116-8-17**] 12:20
|
[
"285.9",
"276.1",
"273.4",
"305.53",
"305.03",
"287.5",
"V13.51",
"733.00",
"311",
"070.54",
"V46.2",
"491.22",
"257.2",
"255.41",
"338.29",
"724.5",
"244.9",
"427.89",
"250.01",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13024, 13086
|
5252, 7902
|
323, 329
|
13161, 13161
|
4567, 5229
|
13694, 14167
|
3697, 3785
|
10910, 13001
|
13107, 13140
|
7928, 10887
|
13311, 13671
|
3825, 4548
|
2365, 2738
|
264, 285
|
357, 2346
|
13176, 13287
|
2760, 3502
|
3518, 3681
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,353
| 119,323
|
53573
|
Discharge summary
|
report
|
Admission Date: [**2187-2-12**] Discharge Date: [**2187-2-15**]
Date of Birth: [**2124-1-24**] Sex: M
Service: [**Last Name (un) **]
HISTORY: This was an unfortunate 63 year-old man who was
transferred to the [**Hospital3 **] Trauma Service from an outside
facility after suffering blunt trauma. His outside CT scan
had demonstrated a large subdural hematoma with associated
intracranial hemorrhage and partial herniation of the brain.
Upon arrival here, the patient was completely obtunded. He
had only minimal brain stem function. A repeat head CT
showed a massive subdural hemorrhage with frank herniation.
After discussion with the neurosurgery service and the
family, he was thought to be unsalvageable. He was made
comfort measures only and expired on the second hospital day.
DISCHARGE DIAGNOSIS: Massive intracranial hemorrhage with
death.
PATIENT CONDITION: Deceased.
DISPOSITION: Deceased.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern4) 17555**]
MEDQUIST36
D: [**2187-4-3**] 13:35:20
T: [**2187-4-4**] 09:03:12
Job#: [**Job Number 110095**]
|
[
"412",
"345.90",
"V45.82",
"305.00",
"276.2",
"852.20",
"E880.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
829, 1201
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,812
| 112,678
|
247
|
Discharge summary
|
report
|
Admission Date: [**2143-11-22**] Discharge Date: [**2143-11-25**]
Date of Birth: [**2075-10-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Reason for ICU admission: ROMI, coffee ground emesis
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
HPI:
68 y.o. man with HTN presented to PCP for routine visit on day
of admission, c/o 2 months of worsening DOE and chest pressure
with exertion. He reports having a stress test 1 year ago which
was stopped after 3 minutes for hypertension (SBP in the 230s).
He had no symptoms and no ST wave changes. In addition, he
complains of severe heartburn (different than his chest
pressure) intermittently every few days x 3 months, along with
violent coughing fits which cause him to vomit dark brown
liquid. He denies frank blood in his emesis. The heartburn is
worse at night with lying flat. He denies NSAID use, but does
admit to drinking at least [**2-9**] drinks of burbon daily.
.
He was referred to the ED for concern of ACS. In the ED, he was
afebrile, HR 70s, BP 116/73m RR 16, and 97% RA. Hct was 41. His
trop was negative but ECG showed TWI in V1-V3 which were new. He
was given ASA 325, Lopressor, and started on nitroglycerin and
heparin gtt. Became hypotensive with nitro to SBP 80s, BP
responded to 2L NS. He then started to vomit brown colored,
guiac positive emesis. The heparin and nitro drips were stopped.
He was given IV protonix and Reglan. He was admitted to MICU for
further monitoring/ROMI.
.
ROS: Denies fever, chills. No h/o blood clot or recent travel.
.
Past Medical History:
PMH:
HTN
ETOH abuse
h/o perianal abscess
CKD, baseline Cr 1.3-1.4
Glaucoma
.
Social History:
Social hx: Lives with his partner (male). Retired budjet analyst
for park service. Has history of alchoholism, quit for 20 yrs,
then starting drinking again when he retired, but much less.
Drinks 2-3 glasses burbon daily, more when with friends. Starts
drinking around 5pm. Former smoker, >50 pack years, quit 1.5
years ago. No illicits
.
Family History:
.
Family hx: Father died age 51 of melanoma, but had "silent MI"
in late 40s. Mother had MI in her 70s.
Physical Exam:
PE:
VS: T 97.8, BP 160/61, RR 16, HR 79, 96% 2L
Gen: shaky, no apparent distress
HEENT: eomi, moist mucous membranes
Neck: supple, no appreciable JVD
Lungs: CTA b/l
Heart: RRR nl S1S2, no M/R/G
Abd: +BS, soft, ND/NT
Ext: no edema, +PP b/l
Neuro: intention tremor. No asterixis. No pronator drift.
+dysmetria with FNF. Strength 5/5 b/l upper and lower. CN II-XII
intact
.
Pertinent Results:
ECG: NSR @ 81. TWI V1-V3, new since [**8-/2140**]
.
CXR [**2143-11-22**]:
AP upright chest radiograph is obtained. A small amount of left
basilar atelectasis is noted. There is no evidence of pneumonia,
CHF. There is no pneumothorax. Cardiomediastinal silhouette is
unremarkable. Mildly unfolded thoracic aorta noted. Visualized
osseous structures are intact.
IMPRESSION: No evidence of pneumonia or CHF
.
[**2143-11-22**].
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%) The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. Right
ventricular systolic function is normal. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic arch is mildly dilated. There are
focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate ([**1-8**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2142-12-6**], the findings are similar.
.
[**2143-11-25**]. EGD.
Severe esophagitis in the middle third of the esophagus and
lower third of the esophagus compatible with severe reflux
esophagitis (biopsy)
Erythema in the antrum compatible with gastritis (biopsy,
biopsy)
Erythema and congestion in the second part of the duodenum
compatible with duodenitis (biopsy)
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
In summary, Mr. [**Name14 (STitle) 2469**] is a 68 y.o. man with PMH significant
for HTN and alcohol abuse, admitted for DOE and chest pressure.
Patient was ruled out for MI, but developed coffee ground emesis
while on heparin drip. EGD showed severe esophagitis and
gastritis.
.
Upper GI bleed. Patient developed coffee-ground emesis in ED in
setting of chronic heartburn and alcohol abuse while on heparin
drip. EGD showed severe esophagitis and gastritis, likely due
to chronic alcohol use. Hct fell to 32 from 42 on admission,
but patient did not require transfusions. He was sent home on
PPI [**Hospital1 **]. Gastric biopsies for H. pylori were pending at time of
discharge.
.
Chest pressure/ SOB. Patient presented with CP and SOB on
exertion. He has no history of CAD. He had a stress test one
year ago which was terminated early due to hypertension.
Cardiac enzymes were negative. He was initally started on a
heparin drip in the ED due to concern for unstable angina, but
this was stopped when patient developed coffee ground emesis.
His antihypertensives were intially held, but resumed on
hospital day 2. A lipid panel was checked and his LDL was in
the 40s. He was advised to get outpatient stress test and PFTs.
Patient has a significant smoking history and CSR showed
hyperinflation, suggesting that his DOE may be pulmonary in
origin.
.
Alcohol abuse. Patient has history of alcoholism and quit
drinking for 20 years and now drinks daily. He denies history
of DTs or seizure. He was tremulous and required a CIWA scale.
He was given thiamine, folate, and multivitamin during his
hospitalization.
.
Transaminitis. Patient had mildly elevated LFTs that were
thought to be due to alcohol hepatitis. Hepatitis serologies
were sent, but were pending at time of discharge.
.
Contact: patient and his partner [**Name (NI) **] [**Name (NI) 2470**] [**Telephone/Fax (1) 2471**]
Medications on Admission:
Home Meds:
Toprol XL 25mg daily
Lisinopril 40mg daily
Amlodipine 10mg daily
Xalatan oph drops, 1 drop each eye QHS
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Upper GI bleed
GERD
.
Secondary diagnosis:
Hypertension
Alcohol abuse
Chronic kidney disease
Glaucoma
Discharge Condition:
good
Discharge Instructions:
You were admitted for chest pain. You were coughing up blood in
the emergency department, so you went to the intensive care unit
for monitoring. You had an endoscopy on [**11-25**] which showed
severe inflammation in the esophagus and stomach due to acid
reflux.
.
Please resume all medications as you were taking prior to
admission. In addition, please take pantoprazole twice daily
for acid reflux. You should avoid alcohol use and avoid using
over the counter anti-inflammatory medications like Aleive or
Advil.
.
You should follow up with Dr. [**Last Name (STitle) 2472**] in [**1-8**] weeks and schedule
pulmonary function tests and a stress test.
.
Please call your physician or come to the emergency department
for shortness of breath, chest pain, chest pressure, fevers,
chills, leg swelling, coughing up blood, blood in stool, or any
other concerning symptoms.
Followup Instructions:
Please schedule a follow up appointment with Dr. [**Last Name (STitle) 2472**] in [**1-8**]
weeks. You will likely need a stress test and pulmonary
function tests, but you should discuss this with your Dr.
[**Last Name (STitle) 2472**] first. Ph. [**Telephone/Fax (1) 133**]. The results of the gastric
biopsy were pending at the time of discharge, so Dr. [**Last Name (STitle) 2472**]
will check the results for you.
.
You will need a repeat endoscopy in [**6-14**] weeks. Please call
[**Telephone/Fax (1) 463**] to schedule it.
.
You will need a follow up appointment in [**Hospital **] clinic with Dr.
[**Last Name (STitle) 2473**] in 4 weeks. Please call [**Telephone/Fax (1) 463**] to schedule
appointment.
|
[
"V15.82",
"365.9",
"424.1",
"416.8",
"585.9",
"403.90",
"535.60",
"305.01",
"790.4",
"578.0",
"530.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
7041, 7047
|
4448, 6353
|
370, 381
|
7212, 7219
|
2679, 4425
|
8142, 8861
|
2166, 2272
|
6518, 7018
|
7068, 7068
|
6379, 6495
|
7243, 8119
|
2287, 2660
|
278, 332
|
409, 1689
|
7130, 7191
|
7087, 7109
|
1712, 1791
|
1808, 2149
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,354
| 144,776
|
53471+59530
|
Discharge summary
|
report+addendum
|
Admission Date: [**2171-7-24**] Discharge Date: [**2171-7-25**]
Date of Birth: [**2125-3-27**] Sex: F
Service: MEDICINE
Allergies:
Codeine / adhesive tape
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
SOB, increased work of breathing, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 60118**] is a 46yoF with a history of asthma (previously
intubated), HTN, HLD, and DM2 who was refferred to the ED by her
PCP for increased work of breathing, SOB, and cough similar to
her previous asthma exacerbations.
.
She was in her usual state of health until 5 days prior to
admission when she developed URI type symptoms including
coughing, nasal congestion, sore throat, malaise, and headache.
She then developed worsening shortness of breath requiring
around-the-clock albuterol inhalations through the present day.
Her PCP placed her on a course of azithromycin and had suspicion
for viral sinusitis. She had completed 4/5 days of azithromycin
without significant improvement of her respiratory function.
When symptoms persisted today, she again presented to the [**Location (un) 2274**]
acute care clinic, who promptly referred her to the ED for
increased WOB and tachypnea to the 30s.
.
In the ED, initial vs were: T99 P122 BP166/91 R 100%NRB. EKG
showed only sinus tachycardia. CXR was without acute
cardiopulmonary process. She was aggressively treated with nebs,
125mg IV solumedrol, heliox, and 500mg azithromcyin. BiPap was
attempted but poorly tolerated.
.
On arrival to the [**Hospital Unit Name 153**], her initial VS were T99.4 P130 BP157/72
100%RA. Her respiratory status had greatly improved. She was
speaking in full sentences, though coughing periodically. On
review of systems, she notes intermittent diarrhea since the
onset of her symptoms. She vomited once today without lingering
nausea. No chest pain or pressure, abdominal pain, constipation,
bloody stools, dysuria, hematuria, anxiety symptoms, myalgias or
arthralgias.
Past Medical History:
-DM2
-hypergriglyceridemia
-history heavy Etoh intake
-HTN
-iron deficiency anemia
-asthma
Social History:
Lives in [**Location 2251**] with son. [**Name (NI) 1403**] as security guard at [**Location (un) 2274**].
Denies h/o tobacco use. +Etoh about 2 drinks a week. reports
social use though heavy use in the past. Pt denies current heavy
use; has cut down considerable - no h/o DTs or seizures. Denies
h/o DUI. No drugs.
Family History:
+ for DM, thyroid disorder and asthma on mothers side
Physical Exam:
Admission Examination:
Vitals: T99.4 P130 BP157/72 100%RA
General: Alert, oriented, no acute distress, shallow breaths but
speaking in full sentences, coughing frequently. Generally
tremulous.
HEENT: Sclera anicteric, MMM, oropharynx clear. No cervical LAD.
Tenderness to palpation over the frontal and maxillary sinuses
bilaterally. Poor dentition.
Neck: supple, JVP not elevated, no LAD
Lungs: Shallow breathing, however generally quite clear to
auscultation bilaterally, no wheezes, rales, rhonchi
CV: tachycardic though regular with a systolic ejection murmur
heard best at lower left sternal border. Normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact bilaterally. Strength 5/5 throughout. No
sensory deficits. Tremulous.
Discharge Examination:
-breathing completely unlabored, speaking in full sentences
-pulmonary exam is clear
-tremulousness improved
-exam otherwise unchanged
Pertinent Results:
Admission Labs:
[**2171-7-24**] 11:38AM PO2-137* PCO2-38 PH-7.37 TOTAL CO2-23 BASE
XS--2 COMMENTS-GREEN TOP
[**2171-7-24**] 11:38AM LACTATE-4.2*
[**2171-7-24**] 11:30AM GLUCOSE-333* UREA N-5* CREAT-0.7 SODIUM-140
POTASSIUM-2.8* CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
[**2171-7-24**] 11:30AM estGFR-Using this
[**2171-7-24**] 11:30AM proBNP-39
[**2171-7-24**] 11:30AM CALCIUM-9.1 PHOSPHATE-2.6* MAGNESIUM-1.3*
[**2171-7-24**] 11:30AM WBC-5.8# RBC-3.91* HGB-10.0*# HCT-31.2*
MCV-80*# MCH-25.7*# MCHC-32.2# RDW-18.4*
[**2171-7-24**] 11:30AM NEUTS-67.8 LYMPHS-27.8 MONOS-1.5* EOS-2.3
BASOS-0.6
[**2171-7-24**] 11:30AM PLT COUNT-282
Discharge Labs:
EKG: sinus tachycardia
Imaging:
CXR [**2171-7-24**]: Lung volumes are diminished. There is mild
respiratory motion obscuring the hemidiaphragms at the lung
bases. The previously noted right perihilar consolidation has
resolved in the interval. No definite new consolidation is
evident. The mediastinum and cardiac silhouette are distorted by
low lung volumes and AP technique but are otherwise grossly
stable. No effusion or pneumothorax is noted. The osseous
structures are unremarkable.
IMPRESSION: Resolved right pneumonia. Low lung volumes with
limitations above. No gross consolidation.
Brief Hospital Course:
Ms. [**Known lastname 60118**] is a 46yo female asthmatic here with progressive
dyspnea concerning for an acute exacerbation of asthma triggered
by likely viral URI/sinusitis that improved with nebs,
antibiotics, and steroids.
ACTIVE PROBLEMS:
1. ACUTE ASTHMA EXACERBATION: Her increased chest tightness,
coughing, and shortness of breath are consistent with an acute
exacerbation of asthma, which was likely triggered by a viral
upper respiratory infections several days prior to admission.
Her blood gas showed adequate oxygenation and ventilation, and
her CXR lacked the typical hyper-expanded appearance of an
air-trapping acute asthmatic, which were both reassuring. There
was no evidence of pneumonia. She received 125mg IV
methylprednisolone, albuterol, azithromycin 500mg, heliox, and
oxygen in the ED. She was in minimal respiratory distress upon
arrival to the ICU from the emergency department and was
saturating 100% on room air with a clear pulmonary examination.
Because of her tremors and hypokalemia (see below) we held her
albuterol. We switched to PO prednisone 40mg the morning
following admission, which she should continue to complete a 5
day steroid course. She completed a five day azithromycin
course prior to discharge and required no further antibiosis due
to her clinical stability. Her outpatient regimen includes
advair and prn albuterol. She was told to get in touch with her
doctor when she gets a URI and feels tight to try a possible
steroid burst to avoid hospitalization.
2. TREMULOUSNESS/HYPERTENSION/TACHYCARDIA: She was tremulous
and tachycardic on arrival, which was likely due to
around-the-clock albuterol treatment over the past 5 days, with
a large amount of nebulized albuterol administered in the ED.
We held this drug with good effect, and instructed her to use it
only as needed as an outpatient.
3. HYPOKALEMIA: She presented with significant hypokalemia to
2.8 probably due to an intracellular shift from exogenous
beta-agonists and endogenous catecholamines from her respiratory
distress. Her K normalized with gentle repletion and albuterol
withdrawal
4. DIABETES MELLITUS TYPE 2: She had very poor glycemic control
due to her steroids and generally poor dietary choices in house.
She was covered with her home 20units lantus and a humalog
sliding scale. Metformin was restarted on discharge.
INACTIVE PROBLEMS
5. HYPERTENSION: Continued atenolol, lisinopril, and verapamil.
Atenolol may not be an optimal long-acting drug due to the
possibility of worsening bronchoconstriction.
6. ANXIETY: gave low-dose ativan prn
PENDING TESTS AT DISCHARGE: none
TRANSITIONAL CARE ISSUES:
- may benefit from diabetic teaching/nutrition
Medications on Admission:
1. verapamil 120 mg Tablet Sustained Release QHS
2. lisinopril 40 mg Tablet daily
3. atenolol 25 mg Tablet daily
4. ferrous sulfate 325 mg daily
5. fluticasone-salmeterol 100/50
6. albuterol MDI 1-2puff q4-6hr prn
7. metformin 1000mg [**Hospital1 **]
8. oxycodone/APAP 5mg q3hr prn pain
9. diazepam 5mg tabs, 1-3 tabs qhs prn insomnia/anxiety
Disp:*4 Tablet(s)* Refills:*0*
10. glargine insulin 20units qhs
Discharge Medications:
1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*1 cannister* Refills:*1*
2. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours.
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO q3hr as needed for pain.
10. diazepam 5 mg Tablet Sig: 1-3 Tablets PO at bedtime as
needed for insomnia.
11. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-3**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for congestion.
Disp:*1 bottle* Refills:*0*
12. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
13. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*1 bottle* Refills:*0*
14. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
15. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough.
Disp:*15 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Acute exacerbation of asthma
Secondary diagnoses: diabetes mellitus type 2, hypertension,
hyperlipidemia, iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 60118**],
You were admitted to [**Hospital1 18**] for an exacerbation of your asthma,
which was probably caused by a lingering viral upper respiratory
infection from earlier in the week. You were given oxygen,
nebulizer treatments, steroids, and antibiotics, and your
breathing improved considerably.
You were very shaky and had a very high heart rate while in the
ICU. These symptoms were probably caused by taking too much
albuterol. We stopped giving you this medication and you
started to feel better. Please only take this medicine every 6
hours at most at home, and only if you feel tight or short of
breath. When you get cold-like symptoms and feel tight, please
call your doctor because a short course of steroids may be able
to help avoid a hospitalization for asthma.
Your sugar was quite high in the hospital due to the steroids
used to control your lung inflammation. It is very important to
eat well and avoid sugary foods always, but particularly while
you are treated with steroids! Please check your blood glucose
several times per day. If they are consistently elevated above
300, please call your primary care provider.
The following changes were made to your medications:
1. START PREDNISONE 40mg daily for 3 additional days
2. STOP AZITHROMYCIN
3. START SALINE NASAL SPRAY 2-3 times a day to help with your
nasal congestion and sinusitis
4. START GUAIFENESIN (ROBITUSSEN) every 6 hours for cough as
needed
5. START IPRATROPIUM every 6 hours as needed for shortness of
breath.
6. START Tessalon perles up to three times a day as needed for
cough.
Please continue all other medications as previously prescribed.
It was a pleasure taking care of you, Ms. [**Known lastname 60118**]
Followup Instructions:
We have arranged the following appointments for you.
Name: [**Last Name (LF) 67691**],[**First Name3 (LF) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appointment: Thursday [**2171-8-1**] 11:20am
We are working on a follow up appointment in Pulmonary at
[**Location (un) 2274**]-[**Location (un) **] within 2 weeks. The office will contact you at home
with an appointment. If you have not heard within 2 business
days or have any questions please call [**Telephone/Fax (1) 2296**].
Name: [**Known lastname 11008**],[**Known firstname 153**] R Unit No: [**Numeric Identifier 18035**]
Admission Date: [**2171-7-24**] Discharge Date: [**2171-7-25**]
Date of Birth: [**2125-3-27**] Sex: F
Service: MEDICINE
Allergies:
Codeine / adhesive tape
Attending:[**First Name3 (LF) 5448**]
Addendum:
Shortly following Ms. [**Known lastname 18036**] departure from the hospital, the
medical team was contact[**Name (NI) **] regarding a positive blood culture
(1/4 bottles, anaerobic) taken on admission, which was growing
gram positive cocci in pairs and chains. The patient completed
Z-pack dosing of azithromycin during this admission but was
discharged off of antibiotics. Given concern for undertreated
infection contributing to her presentation, the patient was
contact[**Name (NI) **] at home and instructed to return to the [**Hospital1 8**] ED for
repeat cultures and treatment.
Chief Complaint:
Shortness of braeth
Major Surgical or Invasive Procedure:
none
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5451**] MD [**MD Number(2) 5452**]
Completed by:[**2171-7-27**]
|
[
"E945.7",
"790.6",
"493.22",
"250.00",
"300.00",
"280.9",
"079.99",
"401.9",
"473.9",
"E932.0",
"276.8",
"272.4",
"785.0",
"781.0",
"465.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13437, 13600
|
4956, 7553
|
13407, 13414
|
9876, 9876
|
3674, 3674
|
11788, 13331
|
2500, 2555
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8105, 9654
|
9704, 9704
|
7673, 8082
|
10027, 11765
|
4338, 4933
|
2570, 3655
|
9774, 9855
|
7567, 7573
|
13348, 13369
|
7599, 7647
|
359, 2036
|
3690, 4321
|
9723, 9753
|
9891, 10003
|
2058, 2151
|
2167, 2484
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,990
| 107,819
|
54376
|
Discharge summary
|
report
|
Admission Date: [**2133-8-4**] Discharge Date: [**2133-8-26**]
Date of Birth: [**2061-5-11**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents / Ativan
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Cecal colon cancer and infected abdominal wall mesh, EtOH
cirrhosis
Major Surgical or Invasive Procedure:
Exploratory laparotomy, right colectomy and excision of infected
mesh, repair ventral hernia [**2133-8-4**]
Past Medical History:
ETOH cirrhosis
grade 1 esoph varices
h/o encephalopathy
DM-2 diagnosed 20 years ago
grand mal seizures in the setting of hypoglycemia ([**2132-7-31**]).
pneumonia hospitalized [**2132-7-1**] with sepsis, admission also
complicated by UTI.
vocal cord polyps s/p surgery
cataracts surgery
hypertension
right foot drop following discectomy surgery [**44**] years ago
heparin-induced thrombocytopenia
Social History:
Patient lives with his wife in [**Name (NI) 2312**]. He is her
primary caretaker. Former [**Name2 (NI) **], retired 16 years ago when
he
sustained a back injury.
50 pk.yr tobacco use; 1ppd for 50 years from age 13 to 63.
Denies illicit drug use. h/o Alcohol abuse.
Family History:
diabetes
grandmother w/ h/o CVA
Physical Exam:
afebrile, vss
NAD
no flap/asterixis
not icteric
rrr
ctab
soft, nt, nd
warm
Pertinent Results:
[**2133-8-4**] 05:57PM BLOOD WBC-10.8 RBC-4.03* Hgb-12.3* Hct-35.4*
MCV-88 MCH-30.5 MCHC-34.8 RDW-14.7 Plt Ct-138*
[**2133-8-7**] 06:33AM BLOOD WBC-4.2 RBC-2.94* Hgb-9.0* Hct-25.8*
MCV-88 MCH-30.7 MCHC-35.0 RDW-15.2 Plt Ct-76*
[**2133-8-8**] 06:00AM BLOOD WBC-5.5 RBC-3.49* Hgb-10.8* Hct-30.0*
MCV-86 MCH-30.9 MCHC-35.9* RDW-14.7 Plt Ct-131*
[**2133-8-13**] 03:15AM BLOOD WBC-11.0 RBC-2.65* Hgb-8.5* Hct-23.6*
MCV-89 MCH-32.0 MCHC-36.0* RDW-17.6* Plt Ct-97*
[**2133-8-14**] 11:05AM BLOOD WBC-11.5* RBC-3.56* Hgb-10.8* Hct-31.0*
MCV-87 MCH-30.3 MCHC-34.7 RDW-17.6* Plt Ct-64*
[**2133-8-22**] 03:25AM BLOOD WBC-4.5 RBC-3.39* Hgb-10.5* Hct-31.8*
MCV-94 MCH-30.9 MCHC-32.9 RDW-17.7* Plt Ct-63*
[**2133-8-26**] 10:06AM BLOOD WBC-13.4* RBC-2.89* Hgb-9.2* Hct-28.4*
MCV-98 MCH-31.7 MCHC-32.4 RDW-18.8* Plt Ct-124*
[**2133-8-4**] 11:45AM BLOOD PT-14.3* PTT-26.5 INR(PT)-1.3
[**2133-8-6**] 04:51AM BLOOD PT-16.9* PTT-35.7* INR(PT)-1.9
[**2133-8-8**] 06:00AM BLOOD PT-14.8* PTT-31.2 INR(PT)-1.4
[**2133-8-12**] 06:53PM BLOOD PT-19.9* PTT-39.4* INR(PT)-2.6
[**2133-8-13**] 04:05PM BLOOD PT-17.6* PTT-45.3* INR(PT)-2.1
[**2133-8-15**] 04:00AM BLOOD PT-25.1* PTT-46.0* INR(PT)-4.2
[**2133-8-16**] 09:54AM BLOOD PT-18.3* PTT-42.4* INR(PT)-2.2
[**2133-8-24**] 03:41AM BLOOD PT-17.3* PTT-41.7* INR(PT)-2.0
[**2133-8-26**] 12:08PM BLOOD PT-20.2* PTT-50.6* INR(PT)-2.7
[**2133-8-11**] 06:40AM BLOOD Glucose-94 UreaN-31* Creat-3.6*# Na-133
K-4.0 Cl-96 HCO3-20* AnGap-21*
[**2133-8-12**] 06:53PM BLOOD Glucose-70 UreaN-48* Creat-5.5* Na-134
K-4.4 Cl-100 HCO3-14* AnGap-24*
[**2133-8-15**] 03:43PM BLOOD Glucose-160* UreaN-52* Creat-3.0* Na-140
K-3.7 Cl-103 HCO3-23 AnGap-18
[**2133-8-16**] 02:11PM BLOOD Glucose-118* UreaN-55* Creat-2.1* Na-144
K-3.9 Cl-110* HCO3-24 AnGap-14
[**2133-8-19**] 03:53AM BLOOD Glucose-101 UreaN-44* Creat-1.1 Na-141
K-3.7 Cl-113* HCO3-22 AnGap-10
[**2133-8-23**] 04:04AM BLOOD Glucose-124* UreaN-38* Creat-1.0 Na-128*
K-4.4 Cl-107 HCO3-15* AnGap-10
[**2133-8-25**] 05:45AM BLOOD Glucose-142* UreaN-58* Creat-1.3* Na-131*
K-5.4* Cl-105 HCO3-17* AnGap-14
[**2133-8-26**] 05:20AM BLOOD Glucose-203* UreaN-64* Creat-2.0* Na-128*
K-6.5* Cl-103 HCO3-9* AnGap-23*
[**2133-8-4**] 07:42PM BLOOD Ammonia-79*
[**2133-8-23**] 04:57PM BLOOD Ammonia-39
[**2133-8-25**] 04:43PM BLOOD Ammonia-94*
[**2133-8-26**] 04:50AM BLOOD Ammonia-161*
[**2133-8-23**] 04:23AM BLOOD Type-ART pO2-92 pCO2-34* pH-7.36
calHCO3-20* Base XS--5
[**2133-8-26**] 06:28AM BLOOD Type-ART pO2-124* pCO2-25* pH-7.13*
calHCO3-9* Base XS--19 Intubat-NOT INTUBA
[**2133-8-26**] 01:14PM BLOOD Type-ART pO2-142* pCO2-30* pH-7.13*
calHCO3-11* Base XS--18
[**2133-8-26**] 03:52PM BLOOD Type-ART pO2-81* pCO2-50* pH-7.06*
calHCO3-15* Base XS--16
Brief Hospital Course:
The pt tolerated the procedure well, please see the operative
note for details. The pt was extubated and transferred to the
floor in a stable condition. The pt's diet was advanced and his
immediate post op course was remarkable only for hypoglycemia.
[**Doctor First Name 8392**] was consulted. The pt developed nausea and vomiting on
POD 6 and his urine output began to decline. He was bolused
with IVF with some improvement. His abdomen was distended and a
therapeutic paracentiesis was performed. Fluid analysis was
consisted with SBP and ceftriaxone was started. A ct abdomen
was performed (see results below). His renal function
deteriorated and he developed acute renal failure. His hepatic
function also decompensated and his INR rose to > 2.5. He was
transferred to the ICU for further monitoring on [**2133-8-12**]. A
CVL/swan ganz catheter/NGT/Aline were placed. He became
hypotension despite fluid resusitation on POD 9 and neo ggt was
started. The pt was given FFP/vit k for his coagulopathy. He
became increasingly acidotic and was intubated for respiratory
distress. Broad spectrum antibiotics were started. The pt's
clinically condition slowly improved; his liver/renal function
and coagulopathy improved, his urine output increased, he was
weaned from the vent and off pressors. TPN was initiated and
continued throughout most of his hospital stay. He was
extubated without difficulty on POD15.
He passed a video swallow study and was started on PO's. He was
doing well and transferred to the floor in a stable condition on
POD22. On [**8-26**], the pt'd urine output began to decrease. IVF
boluses were given without response.
CT abd [**2133-8-13**]: Redemonstration of bowel wall thickening to the
segment of distal small bowel just proximal to the anastomosis.
Contrast study reveals lack of bowel wall enhancement, and lack
of enhancement to mesenteric vasculature draining this segment
of small bowel. The findings are thereby highly concerning for
bowel ischemia/New left lower lobe consolidation, likely
secondary to aspiration/Increase to intra-abdominal ascites and
mesenteric edema, mildly increased
Echocardiogram [**2133-8-13**]: EF 55%, 1+MR, mild pulm HTN
OR Pathology [**2133-8-4**]:
Adenocarcinoma, Low-grade (well or moderately differentiated)
Primary Tumor: pT3: Tumor invades through the muscularis
propria into the subserosa or the nonperitonealized pericolic or
perirectal soft tissues. No regional lymph node metastasis.
Proximal margin: Uninvolved by invasive carcinoma: Distance of
tumor from closest margin: 185 mm.
Distal margin: Uninvolved by invasive carcinoma: Distance of
tumor from closest margin: 40 mm.
Circumferential (radial) margin: Uninvolved by invasive
carcinoma: Distance of tumor from closest margin: 7 mm.
Medications on Admission:
[**Last Name (un) 1724**]: aldactone 50'', nadolol 20', prilosec 40', dilantin 400'
qMTh and 500' qSuTuWFSa, lactulose 30'''', insulin 70/30 38qam
and 18qpm, MVI, thiamine 100', folate 1', vit c 1000', Fe 650'.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
cecal adenocarcinoma
infected adominal wall mesh
ventral hernia
Exploratory laparotomy, right colectomy and excision of infected
mesh, repair ventral hernia [**2133-8-4**]
ESLD
ETOH cirrhosis
ARF requiring CVVH
respiratory failure requiring intubation
arrythmia-bradycardia/atrial fibrillation
severe acidosis
coagulopathy requiring blood products
death
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2133-9-14**]
|
[
"997.4",
"427.31",
"153.6",
"553.20",
"038.9",
"995.92",
"250.00",
"584.9",
"567.2",
"401.9",
"572.2",
"276.2",
"276.5",
"518.81",
"458.29",
"996.69",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"45.94",
"96.04",
"54.92",
"45.73",
"38.95",
"53.59",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
7141, 7150
|
4052, 6849
|
350, 460
|
7548, 7557
|
1322, 4029
|
7609, 7643
|
1179, 1212
|
7112, 7118
|
7171, 7527
|
6875, 7089
|
7581, 7586
|
1227, 1303
|
242, 312
|
482, 880
|
896, 1163
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,630
| 103,362
|
32825
|
Discharge summary
|
report
|
Admission Date: [**2154-10-30**] Discharge Date: [**2154-10-31**]
Date of Birth: [**2091-1-19**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Exercise intolerance
Major Surgical or Invasive Procedure:
Catheterization and stenting
History of Present Illness:
This is a 63 y.o. patient of Dr [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 7842**] and Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] with CAD s/p CABG x 3 [**11-6**] (LIMA-LAD, Lrad-OM1, and
sVG-PDA), HTN, Hypercholesterolemia, Gout, and a family history
of CAD (brother with MI and CABG in his 50's). He has done very
well since his surgery and a stress test in [**2153-4-4**] which
revealed mild anterolateral ischemia which did not impair his
LV.
He was asymptomatic at that time, continuing to be very active
running and swimming, and further work up was deferred.
He states that prior to CABG he did experience
with angina with reported chest discomfort with exertion. Since
his CABG, he has had rib cage tenderness and pain that occurs
with
any movement. When he palpates the area of tenderness it
resolves. He denies any true angina discomfort since his
surgery.
Two months ago the patient noted decreasing activity that his
times in running and swimming were increasing. He did not have
any difficulty breathing or special fatigue, but simply could
not keep up to his recent paces. The patient mentioned this to
his physician during his annual physical exam. He also recently
noted an increase in gastric reflux and burping,although he
denies any formal diagnosis of GERD. Because of his physician's
concern, he underwent a nuclear stress which revealed ST
depressions along with a drop in his blood pressure during
exercise. He did not experience any chest discomfort. He now
presents for cardiac catheterization.
.
Past Medical History:
Dyslipidemia, Hypertension
CABG: x3 [**11-6**] (LIMA-LAD, Lrad-OM1, and sVG-PDA)
CAD
HTN
Hyperlipidemia
Gout
Hemorrhoids
Abdominal aortic ulceration
Social History:
The patient lives with his wife in [**Name (NI) 932**], MA. He is a
professor [**First Name (Titles) **] [**Last Name (Titles) **] [**Location (un) 86**].
-Tobacco history: None
-ETOH: Prior history of heavy alcohol use , but sober more than
15 years
Family History:
Brother with MI and CABG in 50s.
Physical Exam:
Admission Exam
VS: BP 119/53 HR 54 100% sat on room air
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. CN III-XII grossly intact.
NECK: Supple, no JVD noted.
CARDIAC: RR, normal S1, S2. No murmurs, rubs, gallops
auscultated. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. No
accessory muscle use. CTA bilaterally; no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, bowel sounds positive
EXTREMITIES: No femoral bruit auscultated on right femoral cath
site. No hematoma felt.
PULSES: radial/pedal pulses 2+
Pertinent Results:
[**2154-10-30**] 03:47PM UREA N-12 CREAT-1.1 SODIUM-139 POTASSIUM-4.3
CHLORIDE-104 TOTAL CO2-30 ANION GAP-9
[**2154-10-30**] 03:47PM CK(CPK)-57
[**2154-10-30**] 03:47PM CK-MB-4
[**2154-10-30**] 03:47PM PLT COUNT-213
Cardiology Cath note pending
Brief Hospital Course:
This is a 63 y.o. M h/r CAD s/p CABG x 3 [**11-6**] (LIMA-LAD,
Lrad-OM1, and
sVG-PDA), HTN, Hypercholesterolemia, Gout, and a family history
of CAD (brother with MI and CABG in his 50's) who presents to
[**Hospital1 18**] with positive nuclear stress test and admitted for cardiac
cath. Pt noted 2 months of decreased activity tolerance and
underwent nuclear stress test which revealed ST depressions and
drop in BP during exersize.
.
# CORONARIES: Had cardiac cath procedure. The patient was
ballooned in circumflex, some dissection, unable to deliver
stents into distal OM1. Balloon/stented left main with 2.5 x 12
Endeavor (DES), small OM dissection, good flow. Patient received
integrillin for 18 hours.
He was then started on [**10-31**] with loading dose of 60 mg
Prasugrel, followed by a daily regimen of 10 mg for at least 30
days. Patient started on ASA once desensitized. Pt will follow
up with cardiology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to decide whether or not to
continue with Prasugrel or switch to plavix.
.
# Aspirin desensitization
Patient underwent aspirin desensitization protocol outlined by
Allergy. Patient received his daily dose of 325 mg ASA after the
end of the desensitization protocol (which also has a 325 mg
dose) and was asymptomatic of allergy before discharge.
Tryptase level sent, per Allergy recommendation, and will need
to be followed up outpatient.
.
# Hypertension
Continued atenolol from home medications.
.
# Hyperlipidemia
Continued Crestor therapy at home dose.
.
# Gout
Continued allopurinol therapy.
Medications on Admission:
ALLOPURINOL - (Prescribed by Other Provider) - 300 mg Tablet -
1
Tablet(s) by mouth DAILY (Daily)
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
CLOPIDOGREL - (Prescribed by Other Provider) - 75 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth at bedtime
Discharge Medications:
1. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
CAD s/p drug eluting stent in the left main artery
Aspirin Desensitization
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 after having an abnormal
stress test. A cardiac catheterization procedure was performed
and a stent was placed in a vessel of the heart to improve blood
flow. You tolerated the procedure well. You were desensitized of
your aspirin allergy and are now able to take aspirin every day.
Please make sure to take 325mg of aspirin every day. You will
also need to take Prasugrel 10mg every day to protect your heart
and to keep the stent open.
Please STOP your daily Plavix.
Please START: Prasugrel 10mg daily and START Aspiring 325mg
daily.
You will follow up with your cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Followup Instructions:
Please make sure to follow up with your cardiologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], within the next few days.
|
[
"401.9",
"V45.81",
"414.01",
"V17.3",
"V07.1",
"272.0",
"274.9",
"V14.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"99.20",
"00.45",
"00.40",
"00.66",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
6116, 6122
|
3335, 4921
|
291, 321
|
6241, 6241
|
3057, 3312
|
7102, 7256
|
2380, 2414
|
5369, 6093
|
6143, 6220
|
4947, 5346
|
6392, 7079
|
2429, 3038
|
231, 253
|
349, 1923
|
6256, 6368
|
1945, 2095
|
2111, 2364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,829
| 179,494
|
45785+45786
|
Discharge summary
|
report+report
|
Admission Date: [**2180-8-13**] Discharge Date: [**2180-8-17**]
Date of Birth: [**2116-10-28**] Sex: F
Service: NEUROSURGERY:
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
woman found asleep on the bathroom floor by her husband. She
has been sleepy for the last two weeks but able to perform
her activities of daily living. The husband states that the
patient has a questionable drinking history.
PAST MEDICAL HISTORY:
1. Breast cancer seven to eight years ago with lumpectomy
and recurrence.
2. Anxiety. Agoraphobia on Neurontin.
3. Basal cell carcinoma.
PHYSICAL EXAMINATION: Blood pressure is 115/70, heart rate
90, temperature 97.7, respiratory rate 14, oxygen saturation
100% in room air. In general, a sleepy woman in no acute
distress. Cranial nerves - the left pupil is 3.0 millimeter
and reactive, the right is 3.0 millimeter and reactive.
Variable reaction to the left pupil on prior examination.
Face symmetric. Hearing grossly intact. Extraocular
movements left to right intact. Question ability to
cooperate with moving up, not cooperative with mouth opening.
Motor - hyperreflexia in the upper extremities. Legs normal,
increased tone diffusely. Able to move all extremities to
commands. Sensory intact to noxious stimulation, not
cooperative with coordination. Mental status - sleepy,
arousible, unable to open eyes, able to follow one step
commands.
LABORATORY DATA: White count 9.0, hematocrit 39.7. A2H
level was 55. Sodium 142, potassium 5.2, chloride 102, CO2
25, blood urea nitrogen 19, creatinine 0.7, glucose 111.
Head CT shows left sided subdural hematoma with fresh blood
and chronic 2.0 centimeter midline shift.
Toxicology screen negative for benzodiazepines.
HOSPITAL COURSE: The patient went to the operating room on
[**2180-8-13**], and had a left frontotemporal craniotomy for
evacuation of acute subdural hematoma. Neurologically after
surgery, the patient was monitored in the Surgical Intensive
Care Unit. She was sleepy but arousible. The pupils were 3.0
down to 2.0 millimeter. She was moving all extremities.
Laboratories were stable.
The patient was transferred to the regular floor on [**2180-8-14**],
in stable condition. Her vital signs remained stable and she
was afebrile. She was awake, alert and oriented times three
with no drift. She does have bilateral upper extremity
tremors when testing for drift.
The patient was seen by physical therapy and occupational
therapy and found to be unsafe for discharge to home unless
the patient was going to have 24 hour supervision. That was
arranged and the patient was discharged to home with home
safety evaluation from home physical therapy.
MEDICATIONS ON DISCHARGE:
1. Dilantin 100 mg p.o. q8hours times one week total and
then discontinue.
2. Percocet one to two tablets p.o. q4hours p.r.n.
3. Neurontin 300 mg p.o. q.a.m. and 300 mg p.o. q.noon and
200 mg p.o. q.p.m.
4. Klonopin 1 mg p.o. t.i.d.
The patient will follow-up with Dr. [**First Name (STitle) **] in one month. The
patient will return to [**Hospital Ward Name 32936**] in ten days from the day of
surgery for staple removal. The patient was in stable
condition at the time of discharge.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2180-8-17**] 10:47
T: [**2180-8-21**] 18:50
JOB#: [**Job Number **]
Admission Date: [**2180-8-13**] Discharge Date: [**2180-8-19**]
Date of Birth: [**2116-10-28**] Sex: F
Service: NEUROSURG
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
woman who was found sleeping on the floor of her basement on
the morning of [**2180-8-13**]. She had been sleepy times two
weeks. Her husband stated that there was a questionable
drinking history.
PAST MEDICAL HISTORY:
1. Breast cancer seven to eight years ago, status post
lumpectomy.
2. Anxiety/agoraphobia, for which she is taking Neurontin.
3. Basal cell carcinoma.
ALLERGIES: The patient had no known drug allergies.
MEDICATIONS ON ADMISSION: Her medications included
Neurontin, Klonopin, Luvox and vitamins.
SOCIAL HISTORY: The patient's social history was positive
for alcohol. She had a husband and two daughters.
PHYSICAL EXAMINATION: The patient had a temperature of
97.7??????F, a heart rate of 90, a blood pressure of 115/70, a
respiratory rate of 14 and an oxygen saturation of 100% on
room air. In general, the patient was a sleepy woman in no
acute distress. On examination of cranial nerves II through
XII, the left pupil was 3 mm and reactive and the right pupil
was also 3 mm and reactive. The face was symmetric. Hearing
was grossly intact. The extraocular motions on the left and
right were intact. There was a questionable ability to
cooperate on upward eye movement. The patient was not
cooperative with mouth opening.
On motor examination, there was hyperreflexic upper
extremities bilaterally. The legs were normal. There was
increased tone diffusely. She was able to move all four
extremities on command. Sensory examination was intact to
noxious stimuli. The patient was not cooperative with
coordination. On mental status examination, the patient was
sleepy but arousable. She was unable to open eyes. She was
able to follow one step commands.
LABORATORY DATA: On admission, the patient had a white blood
cell count of 9000 with a hematocrit of 39.7. Alcohol level
was 55. Chem 7 revealed a sodium of 142, potassium of 5.2,
chloride of 102, bicarbonate of 25, BUN of 19, creatinine of
0.7 and glucose of 111.
RADIOLOGY DATA: A head CT scan showed left sided subdural
fresh and chronic blood with a 2 cm midline shift.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2180-8-13**] for a left frontal craniotomy with evacuation of
the acute subdural hematoma by Dr. [**Last Name (STitle) 1906**] Postoperatively, the
patient
was admitted to the neurological intensive care unit. She
did well and on postoperative day #1 had a repeat head CT
scan, which was normal. Her Foley catheter was discontinued,
as was her arterial line, on postoperative day #1. At that
time, the patient was transferred to the floor.
On postoperative day #2, the patient got out of bed with
physical therapy and did well. She continued to have some
gait and balance disability, so physical therapy was
continued.
On postoperative day #3, the patient was screened for
rehabilitation; however, her insurance would not pay for a
rehabilitation stay. Therefore, the patient was kept in the
hospital until the physical therapy service thought her to be
safe for home.
On [**2180-8-18**], the patient spiked a temperature to 101.5??????F.
Blood cultures and urine cultures were drawn. A chest x-ray
was obtained, as well as a CBC. The blood cultures and urine
cultures were still pending at discharge but were, so far,
negative. The urinalysis was negative. The chest x-ray
looked clear.
On [**2180-8-19**], with no possible source found for her fever,
the patient was sent for a lower extremity ultrasound to rule
out deep vein thrombosis. On [**2180-8-19**], the patient received
the lower extremity ultrasound and no clot was found.
DISPOSITION: The patient was discharged to home on [**2180-8-19**]
and was told to follow up on [**2180-8-23**] for staple removal on
the floor. She is to follow up with Dr. [**First Name (STitle) **] in one month's
time.
DISCHARGE MEDICATIONS: The patient was discharged on her
incoming medications as well as Dilantin 100 mg p.o. t.i.d.
DISCHARGE DIAGNOSES:
Subdural hematoma, status post evacuation.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2180-8-19**] 19:36
T: [**2180-8-19**] 20:35
JOB#: [**Job Number 97546**]
|
[
"V10.3",
"E888",
"V15.3",
"852.21",
"300.00",
"300.22",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
7655, 7978
|
7539, 7634
|
2721, 3631
|
4145, 4212
|
5788, 7515
|
4346, 5770
|
3660, 3888
|
3910, 4118
|
4229, 4323
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,216
| 142,528
|
22060
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 57703**]
Admission Date: [**2135-8-30**]
Discharge Date: [**2135-9-8**]
Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 84-year-old white male was
admitted to [**Hospital3 **] with acute shortness of breath
and pulmonary edema on [**2135-8-28**]. He was intubated on
admission secondary to hypoxia and was extubated on [**8-29**]. His troponin was mildly elevated at 1.25, and he had
normal creatine kinase enzymes. He was transferred to [**Hospital1 1444**] for cardiac catheterization.
PAST MEDICAL HISTORY: Significant for a history of prostate
cancer 15 years ago, status post radical prostatectomy,
history of bronchitis one and a half weeks prior to admission
which was treated with Zithromax, history of colon cancer 17
years prior to admission which was treated with a colon
resection, history of skin cancer, and a history of
neuropathy in his lower legs and feet.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 81mg p.o. q.d., iron 325
mg p.o. q.d., and multivitamin one tablet p.o. q.d., stool
softener as needed.
SOCIAL HISTORY: He lives alone. His wife died six months
ago. He quit smoking 30 years ago - he had a 50-pack-year
history. He drinks one glass of wine per day.
FAMILY HISTORY: Significant for coronary artery disease.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION ON ADMISSION: He is an elderly white
male in no apparent distress. Vital signs were stable. He
was afebrile. Head, eyes, ears, nose, and throat examination
revealed normocephalic and atraumatic. The extraocular
movements were intact. The oropharynx was benign. The neck
was supple. Full range of motion. No lymphadenopathy or
thyromegaly. He had bilateral radiating murmurs to the
carotids. Carotids were 2 plus and equal bilaterally and
without bruits. The lungs were clear to auscultation and
percussion. Cardiovascular examination revealed a regular
rate and rhythm. Normal first heart sounds and second heart
sounds with a 3/6 systolic ejection murmur. The abdomen was
soft and nontender with positive bowel sounds. No masses or
hepatosplenomegaly. The extremities were without clubbing,
cyanosis, or edema. Pulses were 1 plus and equal bilaterally
throughout with the exception of the radial pulses which were
2 plus and equal bilaterally. Neurologic examination was
nonfocal.
SUMMARY OF HOSPITAL COURSE: He underwent cardiac
catheterization on admission which revealed a severe aortic
stenosis with an aortic valve area of 0.7 cm2, and moderate
mitral regurgitation, a 60 percent ostial left main coronary
artery stenosis. The LAD had mild luminal irregularities.
The left circumflex had mild diffuse disease. The right
coronary artery had a 15 percent ostial stenosis. His
ejection fraction was 25 percent.
Dr. [**Last Name (STitle) **] was consulted, and the patient also had a carotid
Duplex studies which showed no significant stenosis
bilaterally. He had a dental consultation who cleared him
for surgery.
On [**9-1**], the patient underwent an AVR with a 23-mm
pericardial tissue valve and a coronary artery bypass
grafting times one with a saphenous vein graft to the LAD.
The patient was transferred to the Cardiac Surgery Recovery
Unit on Levophed, epinephrine, milrinone, amiodarone, and
propofol. He was extubated. Shortly after extubation, he
was in respiratory distress, and stridor, and tachypnea and
was emergently re-intubated.
On postoperative day one, he remained on amiodarone and
milrinone. He was then extubated again over a bronchoscope
on postoperative day one and did well. He remained on
milrinone and Neo-Synephrine on postoperative day two. He
had his chest tubes discontinued on postoperative day two.
He remains on milrinone with a slow wean, and he had atrial
fibrillation. On postoperative day three, he was started on
captopril to wean off the milrinone. He also received some
beta blocker and became bradycardic, and this was
discontinued as well. On postoperative day five, he was
transferred to the floor in stable condition. He continued
to progress.
DISCHARGE DISPOSITION: On postoperative day seven, he was
discharged to rehabilitation in stable condition.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. b.i.d. (for seven days).
2. Colace 100 mg p.o. b.i.d.
3. Potassium 20 mEq p.o. b.i.d. (for seven days).
4. Aspirin 325 mg p.o. q.d.
5. Tylenol as needed.
6. Percocet one to two tablets by mouth q.4-6h. as needed.
7. Captopril 25 mg p.o. t.i.d.
LABORATORY DATA ON DISCHARGE: White blood cell count was
10,200; his hematocrit was 40.8; and his platelets were
281,000. Sodium was 137, potassium was 4, chloride was 103,
bicarbonate was 24, blood urea nitrogen was 20, creatinine
was 0.8, and blood glucose was 88.
DISCHARGE DIAGNOSES:
1. Aortic stenosis.
2. Coronary artery disease.
DISCHARGE FOLLOWUP: He will be followed by Dr. [**Last Name (STitle) 57704**] in one
to two weeks and by Dr. [**Last Name (STitle) **] in four weeks.
[**Name6 (MD) **] [**Name8 (MD) 1911**], [**MD Number(1) 10456**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2135-9-8**] 11:40:31
T: [**2135-9-8**] 12:07:32
Job#: [**Job Number 57705**]
|
[
"411.1",
"458.29",
"V17.3",
"398.91",
"414.01",
"466.0",
"V15.82",
"518.5",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"35.21",
"96.04",
"88.56",
"37.23",
"39.61",
"36.11",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4138, 4224
|
1290, 1332
|
4808, 4858
|
4250, 4533
|
994, 1107
|
2414, 4114
|
4548, 4787
|
1352, 1384
|
4879, 5252
|
157, 534
|
1399, 2385
|
557, 967
|
1124, 1273
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,090
| 124,977
|
11644
|
Discharge summary
|
report
|
Admission Date: [**2145-3-2**] Discharge Date: [**2145-3-6**]
Date of Birth: [**2072-4-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Carotid stenosis
Major Surgical or Invasive Procedure:
R CEA [**2145-3-2**]
Past Medical History:
PMH: orthostatic hypotension p CVA, GERD, CRI, laryngeal CA (s/p
surgery and [**Month/Day/Year 16859**]), PTSD, ex-smoker
PSH: laryngectomy '[**31**], trach for tracheal stenosis, L CEA of
external '[**39**] (L internal occluded), GT, TURP
Pertinent Results:
[**2145-3-2**] 12:30PM GLUCOSE-210* UREA N-17 CREAT-1.0
POTASSIUM-3.6
[**2145-3-2**] 12:30PM HCT-27.5*
[**2145-3-2**] 12:30PM PT-15.3* INR(PT)-1.4*
Brief Hospital Course:
Patient was admitted for R CEA. He underwent surgery without
intraoperative complications. Post-operative, his course was
complicated by a labile blood pressure with SBP's as high as 220
despite, nitro, lopressor, and hydralazine. He was transferred
to the SICU for a higher level of care until his blood pressure
could be stabilized. On POD 3 his blood pressure stabilized on
his home doses of anti-hypertensives and he was transferred back
to [**Hospital Ward Name 121**] 11. On route to [**Hospital Ward Name 121**] 11, his G-tube came out. It was
replaced with a new tube and the position was confirmed with a
gastrograffin KUB. The patient was discharged on POD 4 doing
well, tolerating a regular diet, with a stable BP, and no new
neurological deficits.
Medications on Admission:
ambien 10hs, coumadin 5', flomax 0.8', klonopin 0.5", florinef
0.2', percocet, zantac 300', vicodin, zoloft 200', dipyridamole
75"
Discharge Medications:
1. Dipyridamole 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. Fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
GERD
CRI
laryngeal CA s/p laryngectomy and [**Name (NI) 16859**]
PTSD
trachostomy
L external carotid endarterectomy
TURP
G tube
R CEA [**2145-3-2**]
Discharge Condition:
Good
Discharge Instructions:
You may shower. Pat incision dry immediately afterward.
Allow tapes on incision to fall off. You may remove them [**3-11**] if still in place.
You may not drive until after you've seen Dr. [**Last Name (STitle) 1391**] in
follow-up.
Call your Primary Care Provider and make an appointment this
week to assess your blood pressure.
Followup Instructions:
On [**Last Name (LF) 766**], [**3-8**], please call [**Telephone/Fax (1) 1393**] to make an
appointment to see Dr. [**Last Name (STitle) 1391**]
|
[
"V44.0",
"585.9",
"433.10",
"V10.21",
"403.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
2640, 2646
|
813, 1581
|
329, 352
|
2839, 2846
|
635, 790
|
3226, 3374
|
1762, 2617
|
2667, 2818
|
1607, 1739
|
2870, 3203
|
273, 291
|
374, 616
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,866
| 161,145
|
31897
|
Discharge summary
|
report
|
Admission Date: [**2124-9-5**] Discharge Date: [**2124-9-18**]
Date of Birth: [**2058-2-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath (Transferred: Mitral valve rupture)
Major Surgical or Invasive Procedure:
[**2124-9-8**] Mitral Valve Replacement (27mm St. [**Male First Name (un) 923**] Mechanical
Valve)
[**2124-9-7**] Cardiac Cath
History of Present Illness:
This is a 66 year old woman with known CAD, s/p inferior wall MI
with bare metal stent to LCx on [**2124-8-4**], CHF with EF 40%. Since
that time she had been admitted several times with dyspnea. She
had been admitted on [**9-1**] to [**Hospital3 6592**] with increasing SOB,
getting extremely dyspneic with exertion. She was subsequently
transferred to [**Hospital 74789**] Hospital on [**2124-9-2**] for further
management. There she was diuresed and ruled out for MI by
enzymes. She had been on heparin until this AM. As she was
persistently dyspneic, a TEE was performed on [**2124-9-5**] which
reportedly revealed severe mitral regurgitation with a ruptured
posterior chord; LVEF was calculated 40%. Patient at that time
was advised that they need valve surgery. Patient's family then
requesting that the patient be transferred to [**Hospital1 18**] for further
management under Dr.[**Name (NI) 5452**] care.
Past Medical History:
Congestive Heart Failure, Coronary Artery Disease s/p MI and
stents to LCX [**8-4**], Carotid Stenosis, Hypertension,
Hypercholesterolemia, s/p Hysterectomy
Social History:
Extensive smoking history (1 pk a day for over 30 years)
Family History:
Non-contributory
Physical Exam:
Vital Signs: T 98.1; P 80; BP 115/85; O2 95% on 3 liters.
Gen: WD obese Caucasian woman. NAD. speaks in full sentences,
pleasant and cooperative
Mouth: MMM
Neck: JVD to 7 cm, no HJR
Chest: Decreased breath sounds bilaterally
Cor: 3/6 systolic murmur, harsh and blowing and best heard at
the apex.
Abd: Obese NT
Ext: No edema, DP pulses nl
GU: Yellow urine in foley.
Pertinent Results:
CNIS [**9-9**]: 1. 80-99% right ICA stenosis. 2. No significant left
ICA stenosis (graded as less than 40%). 3. Incomplete left-sided
subclavian. Cardiac Cath [**9-7**]: 1. Selective coronary
angiography of this left dominant system demonstrated no
angiographically apparent flow limiting epicardial coronary
artery disease. The LMCA had seperate ostia for LAD and LCX. The
LAD had mild narrowing at its ostium and 50% ostial stenosis in
the diagonal branch. The LCX was a dominant vessel with 40%
stenosis proximal to the prior stent which was widel patent. The
RCA was known to be a non-dominant vessel and was not engaged.
2. Resting hemodynamics were performed. The right sided filling
pressures were mildly elevated (mean RA pressures were 8mmHg and
RVEDP wa 11mmHg). The pulmonary artery pressures were elevated
measuring 66/20mmHg. The left sided filling pressures were
significant elevated (mean PCW pressure was 29mmHg and LVEDP was
29mmHg). The systemic arterial pressures were within normal
range measuring 120/71mmgHg. There was no signficant gradient
across the aortic valve upon pull back from the left ventricle
to the ascending aorta. The cardiac index was depressed
measuring 1.58 l/min/m2. 3. Contrast ventriculography revealed a
depressed LVEF of 40% with infero posterior hypokinesis. There
was severe (4+) mitral regurgitation.
Echo [**9-8**]: PRE-BYPASS: 1. The left atrium is markedly dilated.
No atrial septal defect is seen by 2D or color Doppler. 2. The
left ventricular cavity is severely dilated. There is moderate
to severe regional left ventricular systolic dysfunction with
thinning of the inferior wall. The inferior, infero septal and
infero lateral walls are severely hypokinetic in the mid and
basal segments. Overall left ventricular systolic function is
moderately depressed (LVEF= 30-35 %). 3. Right ventricular
chamber size is normal. There is moderate global right
ventricular free wall hypokinesis. 4. There are complex (>4mm)
atheroma in the aortic arch. A hypoechoic lesion is noted in the
anterior wall of the aortic arch possibly representing an
ulceration. There are complex (>4mm) atheroma in the descending
thoracic aorta. 5. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. 6. The mitral valve leaflets are mildly
thickened. An eccentric, posterior directed jet of MR is
seen.The mitral regurgitation vena contracta is >=0.7cm. Severe
(4+) mitral regurgitation is seen. 7. There is no pericardial
effusion. POST-BYPASS: For the post-bypass study, the patient
was receiving vasoactive infusions including milrinbone,
epinephrine and phenylephrine. Pt is being AV paced. 1. A
well-seated bileaflet valve is seen in the mitral position with
normal leaflet motion and gradients (mean gradient = 2 mmHg).
Trivial (normal for prosthesis) mitral regurgitation is seen. 2.
Biventricular systolic function is unchanged. 3. TR is unchanged
4. Aortic contours are intact post decannulation 5. Other
findings are unchanged
CXR [**9-14**]: Two views of the chest obtained and compared to
previous studies. When compared with the previous films, the
pulmonary artery line has been removed. The artificial valve in
place. The lungs are clear with the exception of bilateral
pleural effusions. There also is a dense convexity along the
left lateral chest, which could be partially artifact, but could
also represent some loculated fluid, this should be carefully
followed.
CXR [**9-18**]: Resolution of left pleural effusion. Improved right
pleural effusion.
[**2124-9-5**] 08:58PM BLOOD WBC-13.4* RBC-3.72* Hgb-10.5* Hct-32.3*
MCV-87 MCH-28.3 MCHC-32.7 RDW-17.3* Plt Ct-292
[**2124-9-8**] 04:38PM BLOOD WBC-21.4* RBC-3.20*# Hgb-9.3*# Hct-27.9*#
MCV-87 MCH-29.1 MCHC-33.4 RDW-16.4* Plt Ct-182
[**2124-9-18**] 07:30AM BLOOD WBC-12.2* RBC-3.96* Hgb-12.1 Hct-35.2*
MCV-89 MCH-30.4 MCHC-34.3 RDW-17.0* Plt Ct-387
[**2124-9-5**] 08:58PM BLOOD PT-12.8 PTT-24.5 INR(PT)-1.1
[**2124-9-8**] 04:38PM BLOOD PT-16.9* PTT-54.6* INR(PT)-1.6*
[**2124-9-18**] 07:30AM BLOOD PT-29.2* INR(PT)-3.1*
[**2124-9-5**] 08:58PM BLOOD Glucose-129* UreaN-26* Creat-0.9 Na-136
K-3.8 Cl-97 HCO3-26 AnGap-17
[**2124-9-12**] 02:54AM BLOOD Glucose-89 UreaN-17 Creat-0.6 Na-128*
K-4.2 Cl-94* HCO3-26 AnGap-12
[**2124-9-18**] 07:30AM BLOOD Glucose-121* UreaN-25* Creat-0.8 Na-133
K-3.2* Cl-81* HCO3-41* AnGap-14
Brief Hospital Course:
Ms. [**Known lastname **] is a 66 year old woman with coronary artery
disease s/p inferior wall MI with PCI to L Circumflex [**8-4**] at an
outside hospital. She had persistent dyspnea after her
catheterization and by [**9-2**] was found to have systolic CHF with
dyskinetic posterior wall and, on [**9-4**], was found by
transesophageal echocardiogram to have severe mitral
regurgitation secondary to posterior leaflet rupture. The
CHF/mitral regurgitation are likely sequelae of her MI. She has
inferior Q waves unfortunately. She was transferred for
management of her mitral valve regurgitation. On transfer, the
pt was hemodynamically stable but with somewhat tenuous with her
breathing status with continued dyspnea; saturating normally on
3 L oxygen with no accessory muscle use. CT surgery was
consulted on arrival. Aggressive diuresis was continued with
Lasix and metoprolol was used for heart rate and blood pressure
control. A cardiac catheterization was performed which showed
unchanged hemodynamics, but the patient was dyspneic with
orthopnea and increased oxygen requirement immediately following
cath, and was transferred to the CCU. There she was found to
have a VRE UTI and was started on linezolid pending her MVR.
Following aggressive medical management and ID consults she was
brought to the operating room where she underwent a mitral valve
replacement. Please see operative report for surgical details.
Following surgery she was transferred to the CVIICU for invasive
monitoring in stable condition. Within 24 hours she was weaned
from sedation and awoke neurologically intact. She required
milrinone for several days post-op. Chest tubes were removed on
post-op day two and epicardial pacing wires on post-op day
three. Beta blockers and diuretics were started and she was
gently diuresed towards her pre-op weight. Coumadin was started
with Heparin used as a bridge until patient became therapeutic.
On post-op day four she was transferred to the SDU for further
management. Over remainder of hospital course she awaited her
INR to increase and required aggressive diuresis. She worked
with physical therapy for strength and mobility. She did have
decrease in pulse oximetry (more during PT) which required
multiple inhalers and supplemental oxygen for several days. Her
status improved and on post-op day ten her INR was within
therapeutic range and she was discharged home with VNA services.
Dr. [**Last Name (STitle) **] will follow her INR and adjust Coumadin accordingly.
Medications on Admission:
1) Coreg 3.125 daily
2) Bumex IV 2 mg AM, 1 mg PM
3) Aspirin 81 daily
4) Plavix 75 mg daily
5) KCL 10 mcg daily
6) Protonix 40 mg PO daily
7) Colace 100 daily
8) Senna 2 tablets qHS
Allergies: Levaquin ( GI disturbance); ACE
inhibitors--angioedema
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
goal INR 3-3.5 doses: please take 5mg [**9-19**] and have blood
drawn [**9-20**] for further dosing by Dr [**Last Name (STitle) **].
Disp:*100 Tablet(s)* Refills:*0*
8. Warfarin 2 mg Tablet Sig: goal INR 3-3.5 Tablets PO once a
day.
Disp:*100 Tablet(s)* Refills:*0*
9. Coumadin
please take 5mg [**9-19**] and have blood drawn [**9-20**] for further
dosing by Dr [**Last Name (STitle) **]
You have been given 5mg and 2mg tablets
10. Outpatient [**Name (NI) **] Work
PT/INR mon/wed/fri
Results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 7960**]
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): until you see Dr [**Last Name (STitle) **] [**9-27**].
Disp:*16 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours):
while on lasix.
Disp:*128 Capsule, Sustained Release(s)* Refills:*0*
15. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation every six (6) hours.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] VNA
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Replacement
Congestive Heart Failure (systolic)
Urinary Tract Infection
Acute Renal Failure
PMH: Coronary Artery Disease s/p MI and stents to LCX [**8-4**],
Carotid Stenosis, Hypertension, Hypercholesterolemia, s/p
Hysterectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Blood draws for coumadin dosing mon-wed-fri with results to Dr
[**Last Name (STitle) **] office # [**Telephone/Fax (1) 7960**] goal INR 3-3.5 for mechanical mitral
valve
Followup Instructions:
PCP that Dr. [**Last Name (STitle) **] has referred you to (Dr. [**Last Name (STitle) **]) in [**11-30**] weeks
Dr. [**Last Name (STitle) **] on [**9-27**] at 12:15PM. [**Telephone/Fax (1) 7960**]
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Wound check appointment [**Hospital Ward Name **] 2 - please schedule with RN
[**Telephone/Fax (1) 3633**]
Completed by:[**2124-9-19**]
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
[]
]
] |
11498, 11557
|
6499, 9007
|
336, 464
|
11866, 11872
|
2099, 6476
|
12553, 12956
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|
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9033, 9282
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11896, 12530
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1710, 2080
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241, 298
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492, 1407
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1429, 1587
|
1603, 1661
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,948
| 169,928
|
15433
|
Discharge summary
|
report
|
Admission Date: [**2123-11-19**] Discharge Date: [**2123-11-23**]
Date of Birth: [**2089-2-18**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
acute renal insufficiency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
34M with chronic systolic CHF with EF 20%, hypothyroidism,
DM-II, CVA, SDH, and 12 previous admissions over the past year
to [**Hospital1 **] as well as admissions to [**Hospital1 2025**] presents with headache and
dizzniess. Patient was discharged [**2123-11-8**]. He states that after
this, he began having daily headaches, 2-3x/day, [**2124-5-1**] in
severity, in different locations, pressure-like. H/a is not
worse upon waking, no photo/phonia-phobia, no visual sx, no neck
stiffness. Patient also c/o dizziness/lightheadedness, worse
with standing or walking. He usually stops to rest and symptoms
improve.
.
Patient also describes feeling "heavy all over." However he
denies any visible increase in swelling. He sleeps on [**11-27**]
pillows at baseline and has orthopnea on lying flat, denies PND.
He has a longstanding cough, productive of white-green sputum.
Had small amount of blood-tinged sputum today.
He has been trying to comply with low salt diet, but does add a
small amount of salt to food. He denies decreased PO intake, but
he has been "dry" and thirsty. He has been compliant with his
medications. He has taken a few extra doses of torsemide, about
1 extra per week.
Pt has chest pain at baseline, last episode was 4 days PTA, a/w
palpitations. Also c/o SOB worse than baseline.
.
In the ED, initial vs were T 97.1 P 73 BP 94/53 R 16 O2 sat 100%
on RA. His admission INR was 4.4, so he was sent to head CT
given his HA and supratherapeutic INR. The scan was negative for
bleed. His CXR was at baseline as was his BNP. His creatinine
was elevated to 5.6 from a baseline of 2.5. His SBP dropped to
82/40 and he was bolused 500mL NS and his blood pressure
improved to 100/37. He was admitted to the MICU for management
of acute on chronic renal insufficiency and hypotension. His
hypotension was asymptomatic and consistent with his known
systolic CHF with EF of 20%. He was monitored in the MICU
overnight then transfered to cards floor.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies cough, wheezing.
Denies chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, or changes in bowel habits.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies skin changes.
Past Medical History:
-Diabetes type 2
-Dyslipidemia
-Hypertension
-Dilated Cardiomyopathy, TTE [**8-2**]: EF 20%, Dry weight 200lbs
-Ventricular Tachycardia, first noted in [**9-27**], s/p syncope from
NSVT in [**9-1**] despite amiodarone put for prophylaxis (EF 25%),
[**Date Range 3941**] in place ([**Company 1543**] EnTrust DR [**Last Name (STitle) 3941**])
-Atrial Fibrillation
-CVA (L PCA, thought to be cardioembolic)
-Hyperthyroidism, secondary to amiodarone (d/c'd [**3-1**]), s/p
prednisone and methimazole-->hypothyroidism
-SDH s/p fall [**12-28**] syncope in [**9-1**] (Coumadin held [**Date range (1) 9358**])
-Anemia
-Osteoporosis
-s/p R knee surgery
-Seizure disorder thought multifacotria (after fall, hematoma,
stoke)
-Varicose veins
-Left medial malleolus ulcer
-Gout
-Admission to [**Hospital1 2025**] from [**Date range (1) 44779**] for CHF exacerbation
Social History:
- 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 but was only employed one day per week and the
restaurant closed. Wife works at [**Company 2486**] and this is the
only income source for the family. Pt is primary child
caretaker.
- Tobacco: denies
- Alcohol: infrequent
- Illicits: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father with
"[**Last Name **] problem" at age 52; mother with "[**Last Name **] problem" at age
25, also with a thyroid condition.
Physical Exam:
T 97.5 HR 83 BP 103/55 (78-103/40-66) RR 23 02sat 97/RA
urine output 60-160cc/hr ([**Location 44781**] [**Location **]840)
GEN: NAD, pleasant, conversant in broken English
HEENT: MMM, no OP lesions, JVP at base of earlobe, no LAD
CV: irregular, NL S1S2, no MRG, S3
PULM: CTAB no wheezes or rhonchi
ABD: BS+, soft, mildly distended, non-tender, collaterals
visable on the abdominal wall, no angiomata, palpable
hepatomegaly 3cm below the costal margin, no splenomegaly, no
rebound/guarding. Shifting dullness to percussion 2-3 cm.
LIMBS: trace pedal edema bilat.
SKIN: Chronic skin changes of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**] consistent
with venous stasis
NEURO: deferred
Pertinent Results:
Admission Labs:
8.2>9.8/31.4<150
(remained stable during admission, platelets mild decrease to
114)
N69.9, L16.9, M8.7, E4, B0.4
PT 41.5, PTT 43.4, INR 4.4
(INR 2.3 at discharge)
134/4.6/97/21/84/5.6<86
(Cr decreased to 1.9 at discharge, bicarb to 27)
Ca 9.4, Phos 6.9, Mg 3.1
(9.0 3.0 2.6 at discharge)
ALT 19, AST 31, LD 294, CK 79, AlkPhos 147, TB 2.4
(stable during admission, LDH down to 270, AlkPhos 128, TB 2.0
at discharge)
Trop .04
BNP 3478
TIBC 501, ferritin 52, TRF 385
TSH 3.0
T4 8.3
UA X2 with 3-5 RBC, tr-25 protein, neg eos
Urine culture [**11-20**] negative
Blood cultures 12/25 NGTD but pending at discharge
CT Head ([**2123-11-19**]) -
1. No acute intracranial process.
2. Unchanged foci of right frontal and left occiptal
encephalomalacia in
comparison to [**2123-8-4**].
Renal U/S ([**2123-11-20**])-
1. No hydronephrosis or other renal pathologies to explain new
onset acute
renal failure.
2. Left renal interpolar cortical thinning with an echogenic
focus likely
corresponds to exophytic cyst noted on multiple prior CTs,
unchanged.
CXR:
FINDINGS: Single lead left-sided pacer/AICD device is stable
with single lead extending to the expected position of the right
ventricle. Marked
cardiomegaly is again seen without significant change from the
prior study.
No overt pulmonary edema or pleural effusion is seen. No focal
consolidation is seen. Subtle evidence of old right-sided rib
fractures are again noted. Mild degenerative changes of the
spine are again seen.
IMPRESSION: Marked cardiomegaly, without significant interval
change. No
focal consolidation or pulmonary edema.
EKG at admission:
Baseline artifact precludes definite assessment. Probable atrial
fibrillation with a moderate ventricular response. Very low
voltage diffusely. Right axis deviation. Q waves in leads I and
aVL with very slow R wave progression may be due to underlying
anterolateral myocardial infarction. The findings could also be
due to non-ischemic cardiomyopathy, severe chronic obstructive
pulmonary disease, etc. Non-specific ST-T wave change with QTc
interval prolongation. Compared to the previous tracing of
[**2123-10-15**] no diagnostic change. Clinical correlation is
suggested.
ECG [**11-20**]
Atrial fibrillation with a moderate ventricular response.
Compared to the
previous tracing of [**2123-11-19**] multiple abnormalities and
differential diagnosis are as previously given. Clinical
correlation is suggested.
Brief Hospital Course:
34M with a history of dilated CM [**12-28**] Chagas with EF 22%, AF, DM2
presents with headache, dizziness and acute on chronic renal
insufficiency.
# Acute on chronic renal insufficiency: Pt with a baseline Cr of
2.5, was 5.6 on presentation. Volume status was difficult to
assess. On one hand, weight was 20 lbs elevated above his
optimal dry weight and 10 lbs elevated since [**11-16**], he had
elevated JVP and S3 at admission. CXR and BNP were at baseline.
However, patient had been feeling dry, thirsty and describes
symptoms of orthostasis. FeUREA was c/w pre-renal etiology.
Also, his creatinine improved upon holding his diuretics.
Renal U/S neg for obstruction. UA and urine sediment
unremarkable. CR continued to improve to baseline. During his
admission, patient was followed by renal and his diuretics were
held until his creatinine was 1.9 on [**11-23**]. His Toresmide was
only started at 1/2 dose at discharge. Patient was discharged on
a decreased dose of Allopurinol due to his renal failure,
however, this should be increased back to his normal dose if his
renal function remains stable as an outpatient.
# Chronic systolic CHF: [**12-28**] Chagas. EF 20% s/p [**Month/Day (2) 3941**]. Has been
compliant with medications and diet. Pt interested in
transplant, however per Dr. [**First Name (STitle) 437**] is not a candidate. Does not
need asa as anticoagulated on coumadin. We held his Metoprolol
at first given his low BP, and it was restarted at home dose of
200mg TID prior to discharge due to increased HRs on night of
[**11-22**] to the 140s. His rate was controlled in the 90s at
discharge. Low dose digoxin should be started as an outpatient.
He was restarted on [**11-27**] dose of Torsemide and full dose of
Spironolactone at discharge.
# Supretherapeutic INR: Likely in the setting of acute renal
insufficiency. Patient's coumadin was held and restarted on
[**11-22**] once his INR was 3.0.
# Hypothyroidism: TSH and fT4 wnl. Continued Levothyroxine
Sodium 75 mcg PO DAILY
# Anemia: Likely combination of chronic renal insufficiency and
iron deficiency given low MCV and high RDW. Continued Ferrous
Sulfate 325 mg PO DAILY. Patient may need to be restarted on
vitamin C 500mg PO daily with iron to increase bioavailability.
# GERD: Pt with history of symptomatic GERD. Continued home
omeprazole 40mg PO BID
# History of seizures s/p SAH and CVA. Continued home Keppra
250mg PO TID
# leg lesions: patient was noted to have chronic mottling of his
b/l lower extremities with one particular concerning scab on his
left lower leg. This should be followed as an outpatient and
biopsied if necessary.
# Code: Full
Medications on Admission:
- Warfarin 5 mg PO DAILY
- Torsemide 80 mg PO DAILY
- Ferrous Sulfate 325 mg PO DAILY
- Levoxyl 75 mcg PO DAILY
- Allopurinol 100 mg PO DAILY
- Spironolactone 25 mg PO DAILY
- Omeprazole 40 mg PO BID
- Levetiracetam 250 mg PO TID
- Metoprolol Tartrate 200 mg PO TID
- Colchicine 0.6 mg PO every other day
- Multivitamins PO DAILY
- Calcium 600 + D(3) PO DAILY
- Lisinopril 2.5 mg PO DAILY
- Sucralfate 1 g PO QID
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: continue to follow with your coumadin clinic and take a dose
as prescribed.
Disp:*30 Tablet(s)* Refills:*1*
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*1*
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*1*
6. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*15 Tablet(s)* Refills:*1*
11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
12. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*1*
13. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
14. Outpatient [**Month/Year (2) **] Work
INR check weekly starting [**11-25**].
15. Metoprolol Tartrate 100 mg Tablet Sig: Two (2) Tablet PO
three times a day.
Disp:*180 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-acute on chronic renal failure
Secondary:
-chronic systolic heart failure
-supratherapeutic INR
Discharge Condition:
stable, ambulating and oriented with creatine improved at 1.9.
Discharge Instructions:
You were admitted to the hospital because of headaches. Your
headache might be because you are dehydrated. While you were
here we found that you were in renal failure. This was probably
because your torsemide and spironolactone had been increased for
3 days. Your renal function and creatinine improved and your
creatinine was 1.9 on the day of discharge. You had a renal
ultrasound which was normal. You had a catscan of your head
which was normal. We also found that your INR was elevated,
suggesting that your coumadin level was too high. You were also
seen by the kidney doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **] were here.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
While you were here some of your medications were changed.
Your Toresmide dose is now 40mg daily.
Your coumadin was restarted and is now 5mg daily but you should
continue to follow-up with your coumadin clinic.
Please continue to take all other medications as prescribed by
your doctors.
Followup Instructions:
You should follow-up with your [**Hospital 197**] clinic this week on
[**11-25**]. A prescription is included.
Provider: [**First Name8 (NamePattern2) 21015**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2123-12-1**]
2:35
Provider: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2123-12-1**] 4:00
Provider: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2123-12-1**] 4:00
|
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"584.9",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12199, 12205
|
7376, 10041
|
299, 306
|
12358, 12423
|
4907, 4907
|
13498, 14067
|
3916, 4162
|
10504, 12176
|
12227, 12337
|
10067, 10481
|
12447, 13475
|
4177, 4888
|
2314, 2611
|
234, 261
|
334, 2295
|
4923, 7353
|
2633, 3487
|
3503, 3900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,998
| 159,591
|
2830
|
Discharge summary
|
report
|
Admission Date: [**2144-10-18**] Discharge Date: [**2144-11-2**]
Date of Birth: [**2093-9-6**] Sex: M
Service: MEDICINE
Allergies:
Augmentin / Tetracycline / Adhesive Tape Wp / Latex / Iodine /
Demerol
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Mechanical Ventillation and Extubation
Central line placement and removal
History of Present Illness:
51 y/o M with hx of DM, asthma, depression and CKD who presents
today with respiratory distress. Starting three days prior to
admission, he was noting a very dry cough and having some
shortness of breath. Was nauseated but no vomiting. Also have
some mild diarrhea. He was having increasing wheezing and using
his albuterol inhaler at home. Also noted fevers, chillls and
sweats and had a fever up to 104 at home. He was trying to keep
himself out of the hospital to make it a doctors [**Name5 (PTitle) 648**] on
the day after admission. Some of his family also had
respiratory symptoms.
He has had asthma exaccerbations before, but has never needed to
be intubated. He recently has a hernia repair.
In the ED, his initial vitals were 100.4, 90s on RA; RR 50, 98%
NRB. He was treated with levofloxacin and cipro. He was given
continuous nebs and IV steroids for asthma exaccerbation. He
was transferred to the ICU on a face mask.
On arrival, he is feeling slightly better than when he first
presented. He cannot speak in full sentences and is using his
accessory muscle to breath. He is tachypneic and uncomfortable
and visibly diaphoretic drenching his gown. He complains of RUQ
pain that started with these current respiratory symptoms. His
hernia repair was on his L side. He denies chest pain,
dizziness, nausea, dysuria.
Past Medical History:
1. Depression
2. Non-Hodkins Lymphoma (angioimmunoblastic -> Rx w/ steroids
and fludarabine x 8 cycles; in remission)
3. Asthma (PF ~ 550)
4. Chronic renal insufficiency (baseline ~ 1.4)
5. EtOH abuse
6. Tobacco abuse
7. Osteoarthritis
8. COPD
9. Elective Hernia Repair
Social History:
Married with 2 sons. Currently on disability. Previous 60pk/yr
smoker and EtOH abuser but since quit. Previously worked in
laundry servies at a hotel.
Family History:
Sister w/ diabetes and suicide. Mother w/ MI, DM, and cirrhosis.
Physical Exam:
Exam on Admission to MICU:
General Appearance: Well nourished, Overweight / Obese, Anxious,
Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Paradoxical), (Breath Sounds:
Crackles : , Wheezes : , Rhonchorous: )
Abdominal: Soft, Bowel sounds present.
Exam on Transfer to the Medicine Floor:
VITALS: T: 98.4, BP 102/85, HR 67, RR 18, 97% on 2L. FSBG 120.
Weight 86.7kg
GENERAL: Pleasant, well appearing, in NAD, hands with mild
tremor
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. [**1-23**] deltoid, 4-/5 triceps, [**2-23**] biceps,
4+/5 wrist extensors. [**1-23**] IP, 4+/5 Hamstring and Quardriceps,
[**3-24**] DF, PF and TE. 2+ reflexes, equal BL. Couldn't assess
coordination because patient does not have the strength to move
fingers between nose and examiner's finger, and does not have
the strength to do heel-to-shin. Moderate hand tremor. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS:
[**2144-10-18**] 06:25PM WBC-5.8 RBC-5.27 HGB-14.5 HCT-42.8 MCV-81*
MCH-27.5 MCHC-33.9 RDW-15.3
[**2144-10-18**] 06:25PM NEUTS-84.7* LYMPHS-12.9* MONOS-1.5* EOS-0.3
BASOS-0.7
[**2144-10-18**] 06:25PM PT-14.7* PTT-34.5 INR(PT)-1.3*
[**2144-10-18**] 06:25PM ALT(SGPT)-48* AST(SGOT)-134* ALK PHOS-64 TOT
BILI-0.3
[**2144-10-18**] 06:25PM LIPASE-152*
[**2144-10-18**] 06:25PM GLUCOSE-150* UREA N-36* CREAT-2.7*
SODIUM-128* POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-20* ANION
GAP-18
[**2144-10-18**] 06:44PM LACTATE-1.6 K+-3.5
DISCHARGE LABS:
WBC 5.4 HCT 35.3 PLATELET 253
PT 14.4 PTT 32.7 INR 1.2
Creatinine 1.1
ALT 88 AST 27 LDH 212 CK 166 AP 59 Tbili 0.5
MICRO:
Influenza A/B DFA ([**2144-10-18**]): POSITIVE FOR INFLUENZA A VIRAL
ANTIGEN.
.
Bronchial washings ([**2144-10-23**]): KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
Sputum culture ([**2144-10-25**] and [**2144-10-26**]): KLEBSIELLA PNEUMONIAE.
Sensitivies as above.
.
Blood culture ([**2144-10-18**]): Neg
Blood culture ([**10-26**], [**10-28**]): NGTD
.
Urine culture ([**10-19**], [**10-24**], [**10-26**]): Neg
Urine culture ([**2144-10-31**]): Neg
.
C. Diff ([**2144-10-23**]): Neg
.
STUDIES:
RUQ US ([**2144-10-18**]):
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. Cholelithiasis with no sign of cholecystitis.
3. Persistent right hydronephrosis.
CXR ([**2144-10-18**]):
Chronic blunting of the right costophrenic angle presumably due
to scarring and/or chronic effusion. No acute pulmonary process.
CXR ([**2144-10-21**]): The patient remains intubated. A right internal
central jugular venous catheter terminates at the cavoatrial
junction. A nasogastric tube again courses towards the stomach,
although its distal course is not well characterized.
The cardiac and mediastinal contours are unchanged. The lung
volumes are slightly increased, but in spite of increased lung
volumes, left perihilar and lower lobe opacities seem somewhat
more prominent, suggestive of worsening atelectasis or
pneumonia. Much or all of the left lower lobe is probably
involved. The presence of a coexisting right perihilar opacity
may be due to co-existing pulmonary vascular congestion.
CXR ([**2144-10-26**]): 1. Interval increase of left upper lobe opacity
2. Interval improvement of the left lower lobe opacity
3. Stable mild pulmonary edema.
CXR ([**2144-10-28**]): As compared to the previous examination, the
monitoring and support devices are unchanged. The pre-existing
predominantly left parenchymal opacities have clearly decreased
in extent. The size of the cardiac silhouette is unchanged. No
newly appeared focal parenchymal opacities suggesting pneumonia.
CXR ([**2144-10-29**]): As compared to the previous radiograph, the
endotracheal tube and the nasogastric tube has been removed. The
right-sided central venous access line is unchanged. Slight
increase in extent of a pre-existing right basal and
retrocardiac opacity. No other parenchymal opacities. Unchanged
size of the cardiac silhouette.
TTE ([**2144-10-20**]): The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. No mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Indeterminate pulmonary artery systolic pressures.
Compared with the report of the prior study (images unavailable
for review) of [**2132-6-3**], left ventricular hypertrophy is now
identified.
Brief Hospital Course:
51 y/o M with hx of asthma, CKD, DM, who presented with
respiratory distress.
# ACUTE RESPIRATORY DISTRESS SYNDROME: On arrival to MICU, he
appeared to be in respiratory distress, as he was his accessory
muscle to breath, was tachypneic and uncomfortable and visibly
diaphoretic drenching his gown. He was intubated shortly after
MICU admission. The patient was found to be H1N1 positive and
also developed a severe asthma exacerbation. His chest x-ray was
initially normal, but developed bilateral pulmonary infiltrates
during his ICU admission. He was treated with high-dose
osaltamavir for 10 days, continuous albuterol nebs, and
solumedrol followed by steroid taper. He was initially very
hard to ventilate and had difficulty with sedation and was tried
on versed, fentanyl, propofol, and dilaudid. Fentanyl was
stopped for concern of frozen chest and propofol was limited by
elevated triglycerides. He was paralysed on [**10-20**] and a CVL was
placed. He was maintained on intermittant paralytics until
[**10-24**]. He was extubated on [**10-28**]. His CVL was removed the same
day. On the day of discharge, patient was off oxygen, satting
well on room air.
# VENTILATOR-ASSOCIATED PNEUMONIA: On [**10-26**], he spiked fever to
101.2 and was started on cefepime/vanc. He developed
erythematous rash on face after cefepime and during vancomycin
infusion. Antibiotic was changed to meropenem on [**10-27**]. Sputum
grew out klebsiella pneumoniae. He was treated with meropenem
for 8 days ([**10-26**] to [**11-2**]). On the day of discharge on [**11-2**],
patient was afebrile, satting well on room air. His lung exam
was clear to auscultation bilaterally.
# ACUTE ON CHRONIC RENAL FAILURE: Patient was admitted with
acute on chronic renal failure, with FeNa 0.47. His sodium was
initially 128, which improved with hydration. After aggressive
rehydration his creatinine improved. Following the peak of his
ARDS, he was diuresed with Lasix 20 mg [**Hospital1 **] until euvolemic. He
did not require lasix after transfer to the floor. Cr on
discharge was 1.1. RUQ US showed persistent right
hydronephrosis, which could be related to his chronic renal
insufficiency. He should have continued outpatient followup on
this right hydronephrosis.
# RIGHT UPPER QUADRANT PAIN: He had RUQ pain on admission, and
an ultrasound showed echogenic liver consistent with fatty
infiltration, but other forms of liver disease and more advanced
liver disease including significant hepatic fibrosis/cirrhosis
cannot be excluded on this study. He had elevated LFTs as well,
which were stable during this hospital stay. This was possibly
related to influenza. He should have follow up to confirm
resolution of these abnormalities.
# DIABETES: At home his blood sugars were well controlled on
glyburide. However, in the MICU, his blood sugars were poorly
controlled on high-dose steroids. He required an insulin drip
on [**10-23**]. Following cessation of IV steroids, he was weaned back
to an insulin sliding scale. His glucose was well-controlled
after he was transferred to medicine floor. He was discharged
home on glyburide.
# HYPERTENSION: Patient was normotensive on admission, but
became hypertensive while not tolerating vent and as home BP
meds were held. Around the time of extubation, he required a
labetalol drip for sytolics in the 200s. He was well controlled
on his home regimen prior to discharge.
# STEROID-ASSOCIATED MYOPATHY: Patient developed marked muscle
weakness in MICU in the setting of paralytics and high dose
steroids. His CK peaked at 6958 on [**10-19**], which trended down
steadily as the dose of steroid was tapered down. On the day of
discharge, his CK was within normal range, and he had regained
most of his strength. He was evaluated by physical therapy and
was cleared for discharge home with home PT. Patient finished
his steroid taper on the last day of this hospital stay.
# DEPRESSION: Outpatient amitriptyline and sertraline were
continued.
# PROPHYLAXIS: SQ hep, ompeprazole, bowel reg PRN
# FEN: regular diet per S&S.
# ACCESS: PIVs
# COMMUNICATION: with patient, daughter [**Name (NI) **] HCP [**Telephone/Fax (1) 13807**]
# CODE: full, confirmed
Medications on Admission:
Albuterol MDI
Amitriptyline 50 qHS
Zyrtec 10 mg daily
Diltiazem 180 mg ER daily
Advair 500-50mcg 1 puff [**Hospital1 **]
Glyburide 1.25 mg daily
Lisinopril 30 mg daily
Lorazepam 0.5 mg daily
Omeprazole 20 mg daily
Sertraline 200 mg daily
Zafirlukast [Accolate] 20 mg daily
ASA 81 mg daily
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Diltiazem HCl 180 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation once a day as needed for shortness of
breath or wheezing.
8. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
Discharge Disposition:
Home With Service
Facility:
Nightingale Nursing
Discharge Diagnosis:
Primary diagnoses:
H1N1 pneumonia
ventilator-associated bacterial pneumonia
Secondary diagnoses:
Type II diabetes
COPD
Asthma
Hypertension
GERD
Depression
Discharge Condition:
Stable, afebrile, satting well on room air, regaining strength,
ambulating well with assistance
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname 1538**].
You were admitted to [**Hospital1 69**]
because of respiratory distress. You were found to have H1N1
flu virus, and you had to be intubated in the intensive care
unit. You were also found to have bacterial pneumonia, for
which you were treated with antibiotics. You were extubated on
[**2144-10-28**], and since then you have been recovering
rapidly. On discharge, you did not require oxygen, and your
lung exam sounds clear.
You developed significant weakness while you were in the
intensive care unit because of the medications you received.
You have been working with physical therapy daily, and are
regaining your strength nicely. The physical therapist cleared
you to go home with visiting nurse service.
You were found to have slightly elevated liver function test
enzymes during this hospital stay. Please follow up with your
primary care doctor on this. Ultrasound of the abdomen also
showed that your right kidney has some distention from urine
(called "hydronephrosis"), please follow up with your primary
care doctor on this as well.
Please note that your medications have not been changed. You
have finished the antibiotic course.
Please follow up with your primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]
below.
Followup Instructions:
We have made an [**Last Name (Titles) 648**] for you to see your primary care
doctor, Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] on Monday, [**2144-11-16**] at
10:00am. Please call [**Telephone/Fax (1) 250**] if you have any questions.
|
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icd9cm
|
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,515
| 177,425
|
48303+59074
|
Discharge summary
|
report+addendum
|
Admission Date: [**2157-4-26**] Discharge Date: [**2157-5-12**]
Date of Birth: [**2110-9-29**] Sex: F
Service: GENERAL SURGERY BLUE TEAM
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
African-American woman that presented on [**4-26**] to the
Emergency Department complaining of abdominal pain, vomiting
and chills. She was recently discharged home with VNA
services after she underwent a left below the knee popliteal
bypass reverse saphenous vein graft on [**2157-4-18**] by Dr.
[**Last Name (STitle) 1391**]. It was described as an uneventful procedure which
she tolerated well. She was transferred postoperatively to
the VICU which was monitored over the next couple of days.
She was then restarted on her immunosuppressant agents which
she takes for past cadaveric renal transplant. Through that
time, she required transfusion as her hematocrit was dropping
with no clear evidence of a bleeding source. On
postoperative day 3 after this operation, she did need to be
taken back to the Operating Room for reexploration in the
Operating Room. A pulsatile arterial bleeder that appeared
to be a branch of the common femoral artery was found and was
oversewn with Prolene suture. The patient then continued to
improve and she was discharged to home on postoperative day
7. At the time of her discharge, she was afebrile and did
not have any abdominal pain. However, the next morning at
around 1 a.m., the patient then developed acute onset of
sharp abdominal pain that localized in the periumbilical
region with no radiation. She then went to the Emergency
Department for further evaluation.
PAST MEDICAL HISTORY:
1. Systemic lupus erythematosus
2. Dilated cardiomyopathy
3. Mitral regurgitation
4. Aortic insufficiency
5. End stage renal disease status post cadaveric renal
transplant in [**2151**]
6. Hypothyroidism
7. Peripheral vascular disease
8. Osteoarthritis
9. Distant history of bipolar disease
PAST SURGICAL HISTORY: (As previously mentioned)
1. Left femoral BK [**Doctor Last Name **] on [**4-18**]
2. Multiple AV fistula placements
3. Right femoral [**Doctor Last Name **] in the past
MEDICATIONS:
1. Calcitriol
2. Colace
3. CellCept [**Pager number **] [**Hospital1 **]
4. Cyclosporin 50 [**Hospital1 **]
5. Zantac
6. Roxicet
7. Methadone in the past
8. Diltiazem 240 mg po q day
9. Lopressor 25 mg po bid
10. Prednisone 10 mg po q day
ALLERGIES: THE PATIENT HAS AN ALLEGED ALLERGY TO HEPARIN
WHICH IS ACTUALLY JUST BLEEDING SECONDARY TO HEPARIN AND
ERYTHROMYCIN CAUSES NAUSEA.
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Her temperature is 98.2??????. She is in obvious
discomfort. She is tachycardic to 104. Blood pressure is
105/58.
ABDOMEN: Distended, firm. There is decreased bowel sounds,
positive rebound, positive shake tenderness.
IMAGING: CT scan showed a large 8 x 7 cm intraabdominal
abscess with free air, thus the patient immediately went to
the Operating Room for an ischemic colon. The patient
underwent a total abdominal colectomy with end ileostomy.
Dr. [**Last Name (STitle) **], the surgeon of record, Dr. [**First Name (STitle) 2819**] and Dr. [**Last Name (STitle) **]
are the first and second assistants. The findings included
an ischemic perforated transverse colon.
HOSPITAL COURSE: The patient required an extended Intensive
Care Unit stay in which she was sustained on a respirator.
She also suffered a small myocardial infarction
postoperatively and cardiology was thus involved in her care.
She was extubated on [**4-28**] and seemed to be doing well
at this time. She was, of course, npo up to this time and
her prednisone 10 mg q day and cyclosporin 50 mg [**Hospital1 **] were
restarted on [**4-29**]. She was also started on sips at
this time.
Throughout her stay in the Intensive Care Unit, one of the
major issues was constant spiking of fevers. The source was
initially unclear, although her left thigh incision appeared
to be erythematous. Two small areas were opened up and the
patient was sent to ultrasound for drainage of fluid
collection around the staple line. This fluid grew out
Methicillin resistant Staphylococcus aureus, thus the patient
was started on vancomycin. The patient continued to spike
fevers despite being put on vancomycin and she was
re-cultured in several areas. On [**5-5**], her
[**Location (un) 1661**]-[**Location (un) 1662**] culture that was collected grew out Pseudomonas
aeruginosa and infectious disease was consulted. In addition
to being on vancomycin, she was started on imipenem,
aztreonam and fluconazole. The aztreonam and imipenem is for
double coverage of Pseudomonas and the fluconazole is empiric
therapy. Renal continued to follow the patient's cyclosporin
levels and was happy with the trough levels which were in the
150 range. The patient was placed on TPN for additional
nutrition support.
NOTE: This is the end of the first dictation. An addendum
will follow.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 4039**]
MEDQUIST36
D: [**2157-5-12**] 09:24
T: [**2157-5-12**] 09:32
JOB#: [**Job Number 1738**]
Name: [**Known lastname 16378**], [**Known firstname **] W Unit No: [**Numeric Identifier 16379**]
Admission Date: [**2157-4-26**] Discharge Date: [**2157-5-12**]
Date of Birth: [**2110-9-29**] Sex: F
Service: GENERAL [**Doctor First Name **]
AGE: 46.
ADDENDUM: The patient had an echocardiogram status post
having a small myocardial infarction in the perioperative
period. Echocardiogram showed no change from previous
echocardiograms. The patient was transferred to the floor on
[**5-5**]. She continued to have fevers despite being on
Vancomycin, Imipenem, Aztreonam, and Fluconazole. She also
had 120 cc of emesis on [**5-7**]. Thus, on the morning of
the 21st, the patient had a temperature maximum of 102.8. On
that day, we decided to get a CT scan to image the patient's
abdomen to rule out the possibility of an abscess. The
patient adamantly refused the study. It was explained to the
patient that she may have an abscess. The surgery team
talked to her for at least an hour after the infectious
disease team. Neither team could convince her to go through
with the CT scan. We thus continued to follow the patient
and she defervesced over the next few days. She started to
have more p.o. intake and ostomy was putting out a good
amount of fluid and gas. The patient was doing much better.
The TPN was discontinued on the 23rd, as she was taking a
much better p.o. intake. She is to be discharged to [**Hospital3 7766**] on the 25th.
DISCHARGE MEDICATIONS:
1. Prednisone 10 mg p.o.q.d.
2. Cephalosporin 50 mg p.o.q.12h.
3. Diltiazem extended release 120 mg p.o.q.d. NOTE: This
is a change from her preoperative Diltiazem of 240 p.o.q.d.,.
but the Renal attending has recommended that she stay now at
120 mg p.o.q.d.
4. Vancomycin one gram IV q.24h. until [**5-28**]. Peak and
trough should be checked on the 27th at rehabilitation and
should be called to the Infectious Disease Clinic.
5. Lovenox 30 mg subcutaneously q.12h.
6. Acyclovir 400 mg p.o.q.12h.
7. Imipenem 500 mg IV q.6h. to be discontinued at midnight
on [**5-19**].
8. Aztreonam [**2155**] mg IV q.8h. to be discontinued at midnight
on [**5-19**].
9. Fluconazole 400 mg p.o.q.24h. to be discontinued at
midnight on [**5-19**].
10. Protonix 40 mg p.o.q.24h.
11. Lopressor 25 mg p.o.b.i.d.
12. Percocet.
FOLLOW-UP CARE: The patient is to followup with Dr. [**Last Name (STitle) **]
when she leaves rehabilitation. The patient is to followup
with Dr. [**Last Name (STitle) **] of the Vascular Surgery Department in 10 to
14 days. The patient is to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of
Nephrology in two weeks. Cephalosporin level should be
checked at rehabilitation every Monday and be faxed or called
over to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient should followup with
the Infectious Disease Clinic in approximately two weeks.
The patient's Vancomycin peak and trough done on the 27th,
should be called into the Infectious Disease Clinic for
possible change. Phone #: [**Telephone/Fax (1) 496**].
DIET: The patient is discharged on a regular diet.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Status post subtotal colectomy with end
ileostomy for ischemic/perforated colon.
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**], M.D. [**MD Number(1) 3596**]
Dictated By:[**Last Name (STitle) 16380**]
MEDQUIST36
D: [**2157-5-12**] 10:00
T: [**2157-5-12**] 10:06
JOB#: [**Job Number 16381**]
|
[
"682.6",
"568.0",
"998.59",
"710.0",
"038.9",
"410.91",
"569.83",
"V42.0",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.21",
"54.59",
"96.71",
"83.95",
"45.79",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8486, 8845
|
6759, 8430
|
3298, 6736
|
1982, 2572
|
2587, 3280
|
187, 1636
|
1658, 1959
|
8455, 8464
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,560
| 183,573
|
44742
|
Discharge summary
|
report
|
Admission Date: [**2180-4-27**] Discharge Date: [**2180-5-8**]
Date of Birth: [**2104-3-26**] Sex: F
Service: CARDIOTHOR
CHIEF COMPLAINT: Chest pain.
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname **] is a 76-year-old
female with a history of hypertension, diabetes mellitus,
hypercholesterolemia, and a past myocardial infarction. Over
the last several years, she has had stable class I to II
angina followed by Dr. [**Last Name (STitle) 95717**] in the clinic. The patient, the
day prior to admission, was in her usual state of health
until she developed an increase in the severity and frequency
of her chest pain. She described it as an intermittent low
sternal chest pressure radiating around her left breast. It
was associated with shortness of breath, nausea, diaphoresis.
She took three sublingual nitroglycerin without any relief
and then called 911. She was transferred to the [**Hospital6 23267**]. She was ruled out for myocardial
infarction by enzymes at the outside hospital. On the day of
admission she had recurrent radiating low sternal chest
pressure without any associated symptoms, which was relieved
with one sublingual nitroglycerin. She is now being
transferred to [**Hospital1 69**] for
further evaluation and workup by the cardiac medicine team.
PAST CARDIAC HISTORY: PTCA of the left circumflex. LAD in
[**2171**]. PTCA stenting of the mid RCA in [**2174-5-18**].
Echocardiogram done in [**5-/2178**] demonstrated mild left atrial
enlargement, inferior and posterior hypokinesis, no aortic
insufficiency, moderate MR
[**Last Name (Titles) **] 45 percent. She has had a past Holter monitor report from
[**2176**], which was unremarkable.
PAST MEDICAL HISTORY: History was significant for MI in
[**2174**], history of atrial fibrillation, bronchitis, spinal
stenosis, and diverticulitis. She also has a history of
hypertension, diabetes mellitus, and hypercholesterolemia.
PAST SURGICAL HISTORY: History is significant for status
post mid RCA stent in [**2174**], status post left circumflex, LAD,
PTCA in [**2171**], status post spinal surgery.
MEDICATIONS ON ADMISSION:
1. Amiodarone 200 mg p.o.q.d.
2. ASA 81 mg p.o.q.d.
3. Celebrex 200 mg p.o.q.d.
4. Detrol 1 mg p.o.b.i.d.
5. Lasix 80 mg p.o.q.d.
6. Glyburide 5 mg p.o.b.i.d.
7. Imdur 60 mg p.o.q.d.
8. Prinivil 40 mg p.o.q.d.
9. Glucophage 500 mg p.o.b.i.d.
10. Toprol XL 100 mg p.o.q.d.
11. Trazodone 50 mg p.o.q.h.s.
12. Lipitor 40 mg p.o.q.d.
13. Questran 1 packet p.o.b.i.d.
14. Procardia XL 90 mg p.o.q.d.
15. Zantac 300 mg p.o.q.h.s.
16. Vancenase MDI q.d.
ALLERGIES: The patient is allergic to MOTRIN, VICODIN, AND
ULTRAM.
SOCIAL HISTORY: The patient lives with her middle-aged son,
who is paraplegic times 50 years. She also lives with
grandchildren, who are 20 and 24 years old. The patient
denied any alcohol, tobacco use. She uses a cane to
ambulate.
PHYSICAL EXAMINATION: The patient is an overweight, elderly
female in no acute distress. Heart rate: 74, blood pressure
112/62, oxygen saturation 100% on two liter nasal cannula,
fingerstick 134. NECK: No bruits. LUNGS: Lungs were clear
to auscultation bilaterally. HEART: Regular rate and rhythm
with no murmurs, rubs, or gallops. ABDOMEN: Obese, soft,
nontender, positive bowel sounds. She has palpable distal
pulses. She has one plus bipedal edema. Skin has pallor.
GENERAL: The patient is alert and oriented times three.
LABORATORY DATA: Laboratory data on admission revealed the
following: White count 9.9, hematocrit 38.1, platelet count
213,000, sodium 139, potassium 3.4, chloride 104, bicarbonate
26, BUN 27, creatinine 1.3, glucose 154, INR of 1.0.
Chest x-ray showed no evidence of pneumothorax, infiltrate,
or cardiopulmonary process.
EKG: Normal sinus rhythm with normal access. No evidence of
acute ischemia.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Medical Service. She underwent cardiac catheterization on
hospital day #1. This was significant for stenosis of the
RCA of 50%, stenosis of the left main of 50%, stenosis of LAD
70%, stenosis of the diagonal 1 of 50%, left circumflex 70%,
OM1 50%, OM2 50%. She also underwent echocardiography, which
showed ejection fraction of 50% with a 1% mitral
regurgitation, otherwise, normal.
The patient was evaluated by the cardiothoracic surgery team,
Dr. [**Last Name (STitle) 1537**]. On hospital day #5, she started on Ciprofloxacin
for UTI. She remained afebrile. White count remained
stable.
On hospital day #6, the patient was taken to the operating
room by the Cardiothoracic Surgery Team and underwent
coronary artery bypass graft times three. The grafts were
LIMA to LAD, SVG to OM1, SVG to OM2. She tolerated this
procedure well. She was transferred to the Cardiothoracic
Unit in stable condition on propofol and Neodrip.
Postoperatively, the patient remained hemodynamically stable.
She was weaned off all drips. She was extubated without
incident. Chest tube output remained appropriate. Chest
tubes were discontinued on postoperative day #1. She was
transferred to the floor. On the floor, the patient remained
hemodynamically stable and afebrile. On the night of
postoperative day #1, the patient became severely agitated
and confused. She self removed her IV and Foley catheter.
She required physical restraint in order to maintain the
patient's safety and staff safety. Oxygen saturation was in
the low 90's and arterial blood gas was 7.42, 105, 28, during
this episode. Blood culture and urine cultures were sent,
which were both negative. The patient's fingerstick was 114
at the time. The Department of Psychiatry was called to
evaluate the patient and determine that the patient most
likely had postoperative delirium. The patient was
transferred back to the Intensive Care Unit for close
monitoring.
On postoperative day #, agitation was controlled with p.r.n.
Haldol. All narcotics and benzodiazepines were held. Oxygen
saturations remained in the 90s on nasal cannula and face
mask. She remained hemodynamically stable. The mental
status began to clear over the next several days and Haldol
was slowly weaned off. During this time, she also went into
rapid atrial fibrillation. This was controlled by increasing
the Amiodarone that she was already on and Diltiazem drip.
She was converting spontaneously into sinus rhythm on several
occasions. On postoperative day #5, she was found to be in
normal sinus rhythm. The diltiazem drip was stopped.
Lopressor was continued and the amiodarone was continued at
400 mg p.o.q.d. During this time, the blood pressure
remained stable in the 100 teens to 120s. During this time
the mental status continued to clear. She has required no
Haldol for agitation. She was transferred to the floor in
stable condition, where she has continued to improve. She is
tolerating a cardiac diet. She has been working with the
Department of Physical Therapy and she is currently at a
class II to III activity. Hematocrits remained stable at 26.
BUN and creatinine have remained stable at 21 and 1.2. Wires
were discontinued on postoperative day #7 without incident.
The patient was started on anticoagulation for intermittent
conversion to atrial fibrillation and normal sinus rhythm.
The INR was 1.6 with a goal of 2 to 2.5.
The patient's saturation remained in the high 90s, although
she has continued to require nasal cannula up to six liters
to maintain her oxygen saturation. On ambulating, the oxygen
saturations will go down to the low 90s. She has been doing
deep breathing incentive spirometry. She has been restarted
on her Vancenase MDI q.d.
The patient is stable and now ready for discharge to
rehabilitation, where she will undergo further physical
therapy, and pulmonary toilet.
The patient's wound has remained clean and dry. There was a
dehiscence in the mid portion of the wound approximately
1.5 cm in length. The wound has remained clean, dry, and
intact and it has been undergoing dressing changes with
Betadine swabbing b.i.d. This will be allowed to granulate
through secondary tension. She has also been started on IV
Kefzol, which will be continued for a total of ten days and
switched to PO Keflex until the wound has healed.
FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 1537**] in
four weeks. The patient will followup with Dr. [**Last Name (STitle) **],
primary care physician, [**Name10 (NameIs) **] two weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times three.
2. Diabetes mellitus.
3. Hypertension.
4. Atrial fibrillation, how anticoagulated and on
amiodarone.
5. Postoperative delirium.
6. Sternal wound dehiscence.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o.b.i.d.
2. Lasix 40 mg p.o.b.i.d.
3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o.b.i.d.
4. Colace 100 mg p.o.b.i.d.
5. Zantac 150 mg p.o.q.d.
6. Cardizem CD 240 mg p.o.q.d.
7. Amiodarone 400 mg p.o.q.d.
8. Glyburide 2.5 mg p.o.b.i.d.
9. Glucophage 500 mg p.o.b.i.d.
10. Kefzol 1 gram IV q.8h. stop [**2180-5-15**], then start Keflex
100 mg p.o.q.i.d.
11. Tylenol 650 mg p.o.q.4h.p.r.n.
12. Dulcolax 10 mg pr, p.r.n.
13. Haldol 1 mg to 2 mg IV p.o.q.4h.p.r.n. for agitation.
14. Insulin sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **].
15. Coumadin 5 mg p.o.q.d. dose per medical doctor.
16. Plavix 75 mg p.o.q.d.
17. Lipitor 40 mg p.o.q.d.
18. Vancenase MDI two puffs q.d.
19. Detrol 1 mg p.o.b.i.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP CARE: The patient is to followup with Dr. [**Last Name (STitle) 1537**] in
four weeks. The patient is to followup with Dr. [**Last Name (STitle) **] in
two weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2180-5-9**] 11:12
T: [**2180-5-9**] 11:18
JOB#: [**Job Number **]
|
[
"411.1",
"401.9",
"427.31",
"599.0",
"414.01",
"272.0",
"250.00",
"998.3",
"293.9"
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.15",
"36.12",
"39.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8497, 8745
|
8771, 9565
|
2146, 2672
|
3873, 8476
|
1969, 2120
|
2932, 3855
|
160, 1708
|
1731, 1945
|
2689, 2909
|
9590, 10050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,682
| 110,966
|
31000
|
Discharge summary
|
report
|
Admission Date: [**2146-6-8**] Discharge Date: [**2146-6-17**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
c diff colitis, s/p fall, dysarthria
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
[**Age over 90 **] yo m s/p fall 2 weeks ago. Patient was admitted to [**Hospital1 **]
with PNA (briefly in ICU) then discharged to rehab 6 days ago
where he was doing well until fall (?slipped on diarrhea)
yesterday. Per family now noticed slurred speech and vague motor
difficulties.
.
Of note, pt was diagnosed with C diff at rehab today started
Flagyl.
.
On ROS patient reports new onset of hand tremor bilaterally. Has
h/o gait disturbance [**3-11**] peripheral neuropathy at baseline.
Reportedly head CT at [**Hospital3 **] 2 wks ago was "normal"
.
In ED, repeat head ct showed no bleed but incidental mass likely
meningioma. Neurosurg saw patient in ED and suggested MRI to
evaluate further.
Past Medical History:
Idiopathic peripheral neuropathy (per family),
HTN,
Petite mal sz 8yrs and 2.5yrs ago on phenobarb
s/p hernia repair
PNA at [**Hospital3 **] 2 weeks ago
Social History:
nonsmoker, ex-etoh drinker (non x 2yrs). lived with
wife at home before last admitting to [**Hospital3 **] hosp.
Family History:
noncontributory.
Physical Exam:
Tmax 101 Tc 99.2 115/57 89 18 98 on 2L
Gen: WD/WN, comfortable, NAD
HEENT: Pupils: PERRLA, EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm no edema
Neuro: Oriented to person, place, and date.
Language: no speech abnormalities noted, easily understandable,
with good comprehension and repetition.
Neuro: nl strength b/l, intentional tremor, mild dysmetria on
finger to nose bilaterally. CN2-12 intact.
Pertinent Results:
.
IMAGING:
CT HEAD W/O CONTRAST [**2146-6-8**] 5:12 PM
1. No acute intracranial pathology including no intracranial
hemorrhage.
2. Well-defined relatively hyperdense extra-axial mass seen
within the frontal interhemispheric fissure measuring up to 18
mm in greatest dimension. The appearance of this mass is most
consistent with a meningioma. MRI is recommended for further
evaluation.
3. White matter changes consistent with small vessel
disease and multiple old lacunar infarcts.
.
ECG Study Date of [**2146-6-8**] 2:41:08 PM
Probable multifocal atrial tachycardia
Consider left ventricular hypertrophy
Modest nonspecific ST-T wave changes
No previous tracing available for comparison
.
MR HEAD W & W/O CONTRAST [**2146-6-9**] 1:21 AM
Probable meningioma along the anterior falx.
There is a second small meningioma in the left posterior fossa
abutting the
sigmoid sinus.
Small vessel ischemic sequela. No acute infarction.
.
ECG Study Date of [**2146-6-9**] 8:26:22 AM
[**Month (only) 116**] be sinus tachycardia but consider also atrial tachycardia
Borderline left axis deviation - is nonspecific
Modest nonspecific ST-T wave changes
Since previous tracing of the same date, ventricular response
more regular
.
[**6-11**] renal us:
IMPRESSION: No evidence of hydronephrosis. Mild scarring of the
kidneys bilaterally, otherwise normal-appearing parenchyma
.
[**6-13**] abd film:
IMPRESSION: Unremarkable bowel gas pattern. No evidence of
ileus.
.
ct abd [**6-14**]:
IMPRESSION:
1. No bowel obstruction.
2. No fluid collections or abscesses. A small amount of free
fluid is seen in the abdomen and pelvis.
3. Thickened loops of bowel as described above consistent with
the given history of colitis. Progression of wall thickening of
bowel loops is seen to involve the distal ileum as well.
4. Anasarca.
5. Bilateral pleural effusions and atelectasis as described
above.
Brief Hospital Course:
Mr. [**Known lastname 20400**] was a [**Age over 90 **] year old male with htn, seizure d/o, who
presented with speech difficulty/new bilateral hand tremors and
C. diff colitis. In brief, he had a MICU stay for hematemesis
and ARF with rising WBC. He abdomen continued to be distended
and he continued to have copious diarrhea. It was determined
that his C.diff infection was so severe he would require
colectomy but his family did not want to put the patient through
surgery. After much discussion with the MICU attending Dr.
[**Last Name (STitle) **], the family decided to make the patient DNR/DNI and keep
only minimal support with antibiotics. Upon transfer to the
floor, the family, including his son the HCP, the patient's wife
and daughter in law, decided to pursue comfort measures only
around 10pm. The antibiotics and IVF were discontinued. The
patient was maintained on morphine for pain control. He expired
around 1AM.
.
His hospital course is described below by problem list.
.
# C diff:
Found positive at OSH, likely secondary to recent antibiotics
used for treating pneumonia. WBC count began to rise day after
admission, with low grade fevers, and increase abdominal
distension. Pt had a CT abd scan which showed thickened loops of
bowel consistent with the given history of colitis. Vancomycin
PO was added to flagyl as pt was not clinically improving after
couple of days on flagyl alone. Pt had decrease PO intake and
was encouraged to drink more fluids and was aggressively
hydrated. He was transferred to the ICU for hematemesis and ARF
and in the unit his white count continued to rise and he
continued to have signs of colitis. He was treated with flagyl,
PO/PR vancomycin, cholestyramine and zosyn. His studies lacked
signs of ileus, though he was noted to have distention and
trouble with tube feeds so he was kept NPO and followed by GI.
He had daily KUB to monitor for toxic megacolon.
.
# Hematemesis: New onset coffee-ground emesis with likely
aspiration of contents. NGT placed and suctioned ~1L dark brown
material. Pt hemodynamically stable, Hct 42. Transferred to ICU
for monitoring. He had his hematocrit checked frequently, was
given IVF and remained stable and never required blood products.
GI followed the patient and an endoscopy was not done. He
remained NPO for aspiration risks.
.
# Aspiration pneumonia: New LL lobe infiltrate with likley
aspiration noted. Already on broad coverage with zosyn, but
concern that patient may be becoming septic with hypothermia and
increased wbc count, given this the patient was kept on zosyn
and vancomycin was added. He was kept NPO as well.
.
# Dysarthria:
Unclear duration of speech difficulty per history. Possibly due
to underlying delirium secondary to new Cdiff infection.
Unlikely to be TIA or stroke given negative head imaging post
fall and no other focal neurological deficits, absence of signs
concerning neighboring brainstem dysfunction. Extra-axial mass
not in location to be contributing to speech difficulty as not
in Broca's area and no evidence of mass effect on brain
parenchyma region involved in facial, tongue motor function.
Cannot exclude toxic-metabolic etiologies given underlying
infection and renal failure.
.
# Intention tremor:
Also of unknown duration. Not on medications that would cause
tremors. No electrolye abnormalities. Calcium low but within
normal when corrected for albumin. He has family hx of essential
tremors and is currently on beta blocker for heart disease.
Thyroid panel was normal.
.
# Intracranial mass:
Found incidentally on head imaging upon admission. Most likely
meningioma based on CT and MRI. Neurosurgery eval pt on
admission and no intervention was recommended, with suggested
followup in 3 month with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] and a repeat MRI
head at that time.
.
# HTN: The patient was normotensive, though in the ICU his
beta-blocker was held given his hematemesis.
.
# Seizure d/o:
Does not seem to be cause of fall as it appears to be mechanical
with lack of post-ictal state and no loss of consciousness.
Continued on phenobarb and gapabentin, without epileptic
activity during hospital course. Prior to transfer out of the
ICU his gabapentin was held given his renal failure.
.
# ARF:
Baseline Cr 1.2 and increased to 1.8 on day 2 of hospital
course. Most likely in the setting of infection and diarrhea. UA
negative for UTI. He was aggressively hydrated, but given his
diarrhea, his renal failure continued to worsen. The family did
not want dialysis, so hydration was continued and nephrotoxins
were held.
Medications on Admission:
Toprol xl 50mg qd
Milk of Mag
Neurontin
Tylenol
Prilosec,
Phenobarbitol
Triamterene/HCTZ 50/25 qd
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Clostridium difficile colitis
Meningioma
Acute renal failure
Intention tremor
Seizure disorder
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2146-6-28**]
|
[
"557.0",
"293.0",
"780.39",
"486",
"356.9",
"008.45",
"507.0",
"584.5",
"333.1",
"578.0",
"276.2",
"784.5",
"401.9",
"225.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
8487, 8502
|
3713, 8309
|
250, 258
|
8641, 8650
|
1813, 3690
|
8703, 8738
|
1310, 1328
|
8458, 8464
|
8523, 8620
|
8335, 8435
|
8674, 8680
|
1343, 1794
|
174, 212
|
286, 986
|
1008, 1163
|
1179, 1294
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,053
| 130,857
|
53189
|
Discharge summary
|
report
|
Admission Date: [**2112-5-10**] Discharge Date: 04/04/2091
Date of Birth: [**2056-4-16**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: Shortness of breath, hemoptysis.
HISTORY OF PRESENT ILLNESS: This is a 56 year old male with
a history of severe chronic obstructive pulmonary disease
(pulmonary function tests [**8-/2107**]: FEV1 1.04/FVC 2.11/RV
3.98), on home oxygen, status post recent admission
([**2112-4-20**], to [**2112-4-26**]), for hypercarbic respiratory failure
requiring mechanical ventilation for 36 hours, treated for
bilateral pneumonia with Levaquin and started on slow
Prednisone taper over one month, who presents today with two
to three days of increased dyspnea, intermittent pleuritic
chest pain lasting seconds to minutes, and epigastric pain.
Per primary care physician, [**Name10 (NameIs) **] patient has also continued to
smoke outside with oxygen off at times, although the patient
currently denies. He reports chills over the past two days,
no fever. Cough mostly nonproductive and not worse compared
to baseline. Also reports three to four episodes of dime to
quarter size hemoptysis over the past one to two days, which
is new. He denies a history of tuberculosis. He denies calf
pain. He denies lower extremity edema. Perhaps slight
increase in orthopnea. No paroxysmal nocturnal dyspnea.
REVIEW OF SYSTEMS: Chest pain is not associated with any
other symptoms such as nausea or vomiting or abdominal pain.
No radiation, and no diaphoresis. Not associated with
exertion. Abdominal pain appears to be for the most part
confined to the right upper quadrant epigastric region. No
melena or bright red blood per rectum. No change in color of
stools.
PAST MEDICAL HISTORY:
1. Severe chronic obstructive pulmonary disease; home oxygen
two liters nasal cannula, status post Endotracheal tube
for hypercarbic respiratory failure in [**4-14**], continuing
tobacco use.
2. Obesity.
3. Type II diabetes mellitus, diet controlled.
4. Diverticulosis.
5. Low back pain (C6-C7 disc herniation).
MEDICATIONS ON ADMISSION:
1. Enteric Coated Aspirin 325 milligrams p.o. q.d.
2. Atrovent MDI two to three puffs q.i.d.
3. Prilosec 20 milligrams p.o. q.d.
4. Beconase MDI four puffs b.i.d.
5. Norvasc 7.5 milligrams q.d.
6. Prednisone taper currently at 30 milligrams q.d.
7. Saline nasal spray.
8. Tylenol 650 milligrams q4hours p.r.n.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married and lives with his
wife and two children. The patient has a 160 pack year
smoking history starting at the age of 14. He has a history
of heavy alcohol use including drinking up to five beers a
day.
FAMILY HISTORY: The patient has a daughter with fibrosis.
PHYSICAL EXAMINATION: Vital signs reveal temperature 96.8,
pulse 104, blood pressure 118/60, respiratory rate 24, 66% on
two liters, 85% on two liters postnebulizer treatment. In
general, obese middle age male sitting in a chair in moderate
respiratory distress with pursed lips. Head, eyes, ears,
nose and throat - Anicteric. Extraocular movements are
intact. Moist mucous membranes. The neck is supple with
full range of motion. No jugular venous distention
appreciated. Cardiovascular tachycardia, regular, normal S1
and S2. No murmurs, rubs or gallops appreciated. Lungs -
Expiratory wheezes, increased E:I ratio. Bilateral midlung
crackles. Abdomen is obese, normoactive bowel sounds, soft,
nondistended, nontender. Extremities 1+ edema bilaterally to
the knees.
LABORATORY DATA: 9:00 a.m., white blood cell count 7.7,
hematocrit 52.9 (baseline 40 to 55 over the last five years),
MCV 95, RDW 12.7, platelets 108,000 (baseline 130,000 to
140,000 in 07/00), 83 segs, 8 bands, 6 lymphocytes, 2
monocytes. At 9:00 a.m., sodium 132, potassium greater than
10.0 and hemolyzed, repeat 4.7, chloride 93, bicarbonate 24
(baseline 30), blood urea nitrogen 16, creatinine 0.6,
glucose 416. At 5:00 p.m., sodium 137, potassium 4.0,
chloride 92, bicarbonate 32, blood urea nitrogen 19,
creatinine 0.8, glucose 426, ALT 16, AST 89, alkaline
phosphatase 93, total bilirubin 0.9, amylase 3, calcium 8.7,
phosphorus 4.4, magnesium 2.2. CK #1 146 with MB 2.0, CK #2
15, CK #3 10, troponin less than 0.3. Arterial blood gases
reveal 1:15 p.m. 7.37/64/29/38.
Chest x-ray reveal bilateral mid and lower lung patchy
opacities, bilateral pleural effusions, slightly large
cardiac silhouette, slight upper zone redistribution,
flattening of diaphragms consistent with chronic obstructive
pulmonary disease.
Electrocardiogram sinus tachycardia, borderline right axis
deviation, repolarization abnormalities in the anterior leads
V1 through V3, no ischemic changes.
ASSESSMENT AND PLAN:
1. Pulmonary - The patient was admitted for chronic
obstructive pulmonary disease exacerbation in the setting of
possible aspiration pneumonia. The patient was initially
admitted to the floor but after pulmonary consultation, the
patient was transferred for observation to the MICU for
aggressive nebulizer treatment and possible noninvasive
ventilation. The patient's hypoxia was thought to be most
likely due to severe chronic obstructive pulmonary disease
and pneumonia.
The patient was initially treated with nebulizers q2hours and
q1hour p.r.n., supplemental oxygen to maintain oxygen
saturation of 87 to 90%, Solu-Medrol 40 milligrams
intravenously q.i.d. The patient was also started on
Levaquin and Clindamycin for empiric coverage of aspiration
pneumonia. The patient stabilized and did well with this
treatment.
In the MICU, the patient did not require intubation or BIPAP.
Multiple arterial blood gases were sent with increased but
stable pCO2. The patient was transferred to the floor on
[**2112-5-12**], requiring nebulizer treatment q4hours. The patient
was able to be changed to Atrovent, Albuterol, Flovent and
Serevent inhalers with nebulizer treatments q4hours p.r.n.
The patient was also switched from intravenous Solu-Medrol to
a Prednisone taper beginning at 60 milligrams.
Levaquin and Clindamycin were continued to complete a
fourteen day course. On the day before discharge, the patient
was saturating 82 to 92% on two liters nasal cannula. The
patient continued to have baseline dyspnea and cough. The
patient agreed to smoking cessation and was willing to go to
inpatient pulmonary rehabilitation for further observation of
his status.
The patient did not report further hemoptysis after
admission. Initial hemoptysis was likely secondary to
bronchitis. As the patient has a negative chest CT for
masses one year ago, repeat chest CT was not performed during
this admission. The patient likely will need pulmonary
function testing and chest physical therapy as outpatient.
2. Infectious disease - The patient was started on Levaquin
and Clindamycin for presumed aspiration pneumonia. The
patient remained afebrile and had decreased white blood count
during admission.
3. Cardiovascular - The patient ruled out for myocardial
infarction with CPK times three, negative troponin, no
ischemic electrocardiographic changes. The patient does have
risk factors for coronary artery disease including tobacco
and diabetes mellitus and may need outpatient exercise stress
test.
4. Endocrine - The patient has a history of type II diabetes
mellitus, diet controlled. The [**Hospital 228**] hospital course was
complicated by hyperglycemia on steroids. The patient was
placed on a NPH regimen of 20 units q.a.m. and 12 units
q.p.m.. with sliding scale regular insulin.
5. Hematology - The patient developed thrombocytopenia
(platelets 92,000) on subcutaneous Heparin. Heparin was
discontinued and replaced with Venodyne boots. Heparin
antibody, however, was negative. Platelets on discharge were
193,000.
6. FEN - The patient was maintained on cardiac, [**Doctor First Name **] diet.
7. Prophylaxis - Prilosec. Physical therapy was consulted
and the patient was able to ambulate 150 feet on two liters
of oxygen without assistance. Saturation was 85% on oxygen
after ambulation.
8. Full code.
9. Disposition - The patient will need pulmonary
rehabilitation, ideally inpatient.
DISCHARGE DIAGNOSES:
1. Severe chronic obstructive pulmonary disease.
2. Aspiration pneumonia.
3. Type II diabetes mellitus exacerbated by steroids.
DISCHARGE MEDICATIONS:
1. Atrovent inhaler two puffs q.i.d.
2. Albuterol inhaler four puffs q.i.d. p.r.n.
3. Serevent inhaler two puffs b.i.d.
4. Flovent inhaler four puffs b.i.d.
5. Albuterol/Atrovent nebulizer q4hours p.r.n.
6. Prednisone taper (currently at 50 milligrams p.o. q.d.).
7. Levaquin 500 milligrams p.o. q.d. for a fourteen day
course (the patient started [**2112-5-10**]).
8. Clindamycin 300 milligrams p.o. q.i.d. for a fourteen day
course.
9. Enteric Coated Aspirin 325 milligrams p.o. q.d.
10. Prilosec 20 milligrams p.o. q.d.
11. Norvasc 5 milligrams p.o. q.d.
12. NPH 20 units subcutaneous q.a.m. and 12 units
subcutaneous q.p.m.
13. TUMS 500 milligrams p.o. t.i.d.
14. Regular insulin sliding scale.
[**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 95609**]
Dictated By:[**Last Name (NamePattern1) 19145**]
MEDQUIST36
D: [**2112-5-16**] 18:16
T: [**2112-5-16**] 19:58
JOB#: [**Job Number **]
|
[
"724.2",
"428.0",
"786.3",
"287.4",
"507.0",
"305.1",
"491.21",
"250.02",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2709, 2752
|
8194, 8326
|
8349, 9345
|
2094, 2451
|
2775, 8173
|
1373, 1716
|
153, 187
|
216, 1353
|
1738, 2068
|
2468, 2692
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,089
| 183,040
|
38601
|
Discharge summary
|
report
|
Admission Date: [**2130-12-11**] Discharge Date: [**2130-12-17**]
Date of Birth: [**2061-2-11**] Sex: F
Service: NEUROLOGY
Allergies:
Phenobarbital
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 69 yo RHW with HTN, hypercholesterolemia and hx
of L pontine hemorrhage in [**2126**] with residual right
sided-weakness rendering her [**Year (4 digits) **] dependent who was in her
usual state of health when she suddenly appeared weaker with
slurring of speech plus R facial droop around 3 in the
afternoon. This information is corroborated per son over the
phone and the medical records. Patient initially taken to
[**Hospital 8641**]
Hospital where she was hypertensive to 166/86 and she was
witnessed to have generalized seizure possibly several times.
She was given Ativan 2mg IV x1 and loaded with fosphenytoin 1g.
Head CT revealed L BG hemorrhage (2.6 x 1cm per report) hence
patient transferred here for further care. Per report,
patient's
BP decreased to 110's without anti-hypertensive.
ROS negative for falls, fever/chills, cough, N/V/D or sick
contact per family. She did not complain of HA even today
around
the onset of symptoms.
While in the ED, patient is lethargic and not following any
commands hence right after the quick, emergent neuro evaluation,
patient was intubated per [**Hospital1 **] ED staff. Patient was sneezing
intermittently and stirring to noxious stim but was not
following
any commands. She did not have any seizure like activity.
Past Medical History:
1. hx of L pontine hemorrhage in [**2126**]
2. HTN
3. Hypercholesterolemia
4. Peripheral neuropathy
5. Anxiety
Social History:
Lives at home with husband and son. [**Name (NI) 4886**]-dependent at
baseline, no tobacco and occasional EtOH. No HCP but next of
[**Doctor First Name **]
would be husband, [**Name (NI) **] [**Name (NI) 85805**], [**Telephone/Fax (1) 85806**] and presumed full
code.
Family History:
n/c
Physical Exam:
Exam: except for vitals - examination prior to intubation but
after Ativan.
T BP 157/70 HR 71 RR 16 O2Sat 100% CMV
Gen: Lying in bed - sneezing frequently.
HEENT: Slight abrasion over tip of the tongue
CV: RRR, no murmurs/gallops/rubs
Lung: Clear anteriorly
Abd: +BS, soft, nontender
Ext: No edema
Neurologic examination:
Mental status: Lethargic and does not follow any commands. No
spontaneous opening of eyes but some spontaneous motor
movements.
Does stir/flutter eyes with loud verbal stimuli or sternal rub.
Occasional sneezing.
Cranial Nerves:
R pupil larger than L but both reactive. (4mm and 3mm
respectively). No blinking to visual threat bilaterally but
+Doll's eyes. Face appears symmetric.
Motor:
Slightly higher tone on R compared to L - moving L side more
than
R. Initially was not moving RUE even to noxious stim but later
found to have spontaneous movement of R arm anti-gravity.
Sensation: Intact to noxious stim.
Reflexes:
+2 for R side and 2s for L. No clonus bilaterally. Toes
upgoing
bilaterally.
Pertinent Results:
[**2130-12-11**] 06:50PM BLOOD WBC-10.4 RBC-4.03* Hgb-12.5 Hct-37.5
MCV-93 MCH-31.0 MCHC-33.3 RDW-12.4 Plt Ct-214
[**2130-12-15**] 05:20AM BLOOD WBC-6.4 RBC-3.64* Hgb-11.1* Hct-33.2*
MCV-91 MCH-30.5 MCHC-33.5 RDW-12.1 Plt Ct-171
[**2130-12-11**] 06:50PM BLOOD Neuts-85.1* Lymphs-10.7* Monos-3.5
Eos-0.3 Baso-0.4
[**2130-12-11**] 06:50PM BLOOD PT-12.1 PTT-24.1 INR(PT)-1.0
[**2130-12-11**] 06:50PM BLOOD Plt Ct-214
[**2130-12-15**] 05:20AM BLOOD Glucose-105* UreaN-6 Creat-0.5 Na-142
K-3.2* Cl-108 HCO3-25 AnGap-12
[**2130-12-11**] 06:50PM BLOOD CK(CPK)-392*
[**2130-12-11**] 06:50PM BLOOD cTropnT-<0.01
[**2130-12-11**] 06:50PM BLOOD Albumin-4.2 Calcium-8.9 Phos-3.5 Mg-2.1
[**2130-12-12**] 02:53AM BLOOD %HbA1c-5.7
[**2130-12-12**] 02:53AM BLOOD Triglyc-64 HDL-58 CHOL/HD-2.5 LDLcalc-72
[**2130-12-11**] 06:50PM BLOOD Phenyto-14.7
[**2130-12-11**] 06:50PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2130-12-11**] 06:50PM URINE RBC-[**1-19**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
CT head [**2130-12-11**]
FINDINGS: Left basal ganglia hemorrhage in the left lentiform
nucleus
measures 3.0 x 1.1 cm, with a rim of surrounding edema. Given
location,
findings are most likely due to hypertensive hemorrhage,
although underlying
lesion can not be entirely excluded. Clinical correlation
advised. There is
mild mass effect on the frontal [**Doctor Last Name 534**] of the left lateral
ventricle, and 2-mm
rightward shift of midline structures. There is no
intraventricular
hemorrhage, and no hydrocephalus. [**Doctor Last Name **]-white matter
differentiation appears
preserved, although examination is somewhat limited by motion.
There is increased soft tissue density within the posterior
nasopharynx. The
visualized paranasal sinuses and mastoid air cells are clear.
There are no
concerning osseous lesions. The orbits are symmetric.
IMPRESSION: Acute intraparenchymal hemorrhage in the left
lentiform nucleus,
as above, with mild mass effect on the left fronal [**Doctor Last Name 534**]. 2mm
rightward shift
of midline structures.
CT head [**2130-12-12**]
IMPRESSION: Stable left basal ganglionic hemorrhage with
vasogenic edema, and
minimal mass effect. No new hemorrhage.
CXR [**2130-12-11**]
IMPRESSION: ETT 5 cm above the carina. No acute cardiopulmonary
abnormality.
Brief Hospital Course:
Ms. [**Known lastname 85805**] is a 69yo RHW with hx of HTN, hypercholesterolemia
and L pontine hemorrhage in [**2126**] with residual R sided weakness
who is [**Year (4 digits) **]-dependent who developed slurred speech with
worsened R sided weakness without any associated trauma.
Initial evaluation at OSH revealed L BG hemorrhage and patient
was witnessed to have generalized seizure possibly multiple
times and was loaded with fosphenytoin prior to transfer. Her
hemorrhage was presumed to be hypertensive in etiology and she
was intubated and admitted to the neuro ICU.
.
Neurology; Follow-up CT head revealed stable BG hemorrhage. She
was initially continued on dilantin, however this was changed to
keppra and she is currently on 1000 mg [**Hospital1 **]. She has had no
further seizure activity. Her systolic blood pressure was
maintained below 160 and HOB > 30 degrees. She was transferred
out of the ICU on [**12-13**] to the neurology floor.
.
Respiratory; The patient was extubated on [**12-12**].
.
CV; The patient was continued on her beta blocker, ace inhibitor
and statin, and BPs were well controlled.
.
Medications on Admission:
1. Metoprolol 12.5mg [**Hospital1 **]
2. Vitamin D
3. Pravastatin 20mg daily
4. Enalapril 20mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day) as needed for hold if BP < 100 or HR < 55.
2. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) as needed for hold if SBP < 100.
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH
Discharge Diagnosis:
Left basal ganglia hemorrhage, likely secondary to hypertension
Discharge Condition:
A&Ox3, mildly inattentive. Hypophonic. R facial droop. R
drift. Mild R hemiparesis but moves all extremities
antigravity.
Discharge Instructions:
You were admitted with right-sided weakness and a seizure and
found to have a hemorrhage in your brain. You were started on
an anti-seizure medication (keppra).
Followup Instructions:
Please call Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] (neurology) to schedule an
appointment in [**4-24**] weeks. His office can be reached at ([**Telephone/Fax (1) 19129**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"784.51",
"401.9",
"518.81",
"780.39",
"728.87",
"272.0",
"438.89",
"356.9",
"300.00",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7238, 7345
|
5504, 6633
|
298, 305
|
7453, 7581
|
3138, 5481
|
7791, 8102
|
2064, 2069
|
6785, 7215
|
7366, 7432
|
6659, 6762
|
7605, 7768
|
2084, 2385
|
238, 260
|
333, 1625
|
2640, 3119
|
2424, 2624
|
2409, 2409
|
1647, 1760
|
1776, 2048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,741
| 124,998
|
1944
|
Discharge summary
|
report
|
Admission Date: [**2172-3-29**] Discharge Date: [**2172-4-4**]
Date of Birth: [**2090-10-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Cold and painful LLE
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Thrombectomy of femoral artery.
2. Fasciotomy of the posterior compartment deep and
superficial.
3. Second order catheterization, introduction of catheter
into the femoral artery and unilateral angiogram.
4. Left SFA to posterior tibial bypass graft using
nonreversed saphenous vein angioscopy, vein inspection
and valve lysis.
History of Present Illness:
81yo M with idiopathic pulmonary fibrosis, chronic renal
insufficiency, and h/o aorto-biiliac graft for aneurysmal
disease [**2158**] who was in USGH until ~5d ago when noticed
intermittent cramping pain of the posterior L calf. These
episodes lasted only several minutes, were self-relieved, and
not associated with activity. Then last night at 10pm he
describes the pain as now
being unrelenting, and stronger in nature. He tried an NSAID
and topical cream without relief, prompting presentation to the
[**Hospital1 18**] ED this morning.
ROS: denies rest pain or pain upon ambulation of either leg.
denies fever or chills. uses home O2 only at night, otherwise
fairly active. no CP or SOB. no history of cardiac
dysrhythmias. no abd pain, nausea, emesis, diarrhea, or
constipation.
Past Medical History:
[**Last Name (un) 1724**]: diltiazem 240', lasix 20qod, flonase nasal ', robitussin
with codeine, prilosec prn
Social History:
n/c
Family History:
n/c
Physical Exam:
PE: 96.5, 87, 209/114, 17, 98 on RA
A&Ox3, NAD. conversant.
neck supple, trachea midline, no carotid bruits
CTAB
RRR, no murmur
soft, NT, ND. well-healed midline scar without hernia. no
masses.
groins soft and flat without lesions
ext: L leg warm, motor [**5-3**] and sensation diminished but present.
no lesions, calf soft, nontender.
RLE WWP without C/C/E.
Pulses: Fem [**Doctor Last Name **] DP PT
Rt 2+ 3+ 2+ 2+
Lt 2+ x 2+
Pertinent Results:
[**2172-4-2**] 06:45AM BLOOD WBC-8.8 RBC-2.98* Hgb-9.2* Hct-26.6*
MCV-89 MCH-30.8 MCHC-34.6 RDW-14.0
[**2172-3-29**] 04:39PM BLOOD CK(CPK)-464*
BLOOD CK(CPK)-3585* [**2172-4-2**] 06:45AM
BLOOD CK(CPK)-2509*
MRSA SCREEN (Final [**2172-4-1**]): No MRSA isolated.
Vein Mapping: The right greater saphenous vein is patent from
the ankle to the saphenofemoral junction. The diameters from
ankle to knee range from 1.4 to 2.0 mm. From the knee to the
groin the diameters range from 2.0 to 2.9 mm.
[**2172-4-3**] CTA: Patent aorto-[**Hospital1 **]-iliac graft. Stable aneurysms of
both internal iliac arteries. Stable dilatation of both external
iliac arteries. Patent L SFA/ PT graft. 3- vessel run-off on the
left. On the right side, the contrast column opacifies only
until the level of parcially thrombosed popliteal aneurysm, even
on the delayed phase.
[**3-31**]/ Ct ches:Bilateral internal iliac artery aneurysms as above.
Interstitial lung disease with basilar predominance has
slightly
progressed since [**2164-2-18**].
Brief Hospital Course:
Pt admitted [**3-29**] with cold left foot.
IV heparin strted immediatly. PTT followed. Adjusted for goal of
60-80.
Pt hydrated prior to angio with bicarb. PO Mucomyst given.
PROCEDURE:
1. Thrombectomy of femoral artery.
2. Fasciotomy of the posterior compartment deep and
superficial.
3. Second order catheterization, introduction of catheter
into the femoral artery and unilateral angiogram.
4. Left SFA to posterior tibial bypass graft using
nonreversed saphenous vein angioscopy, vein inspection
and valve lysis.
He tolerated the procedure well with complications. Sent to the
CVICU in stable condition.
POD # 1: Remained bedrest, adat, hliv, home meds started.
Creatinine followed, Serial CPK followed 484 initiallly, high
3585, down trend to 2509
POD # 2: Transfered to the VICU, started on BPG pathway, serial
CK's, hydrated for increase in creatine, Foley remained.
POD # 3: Foley removed. PT consult obtained. Creatinine peaked
at 2.3, on DC is 2.1.
POD # 4: Made floor status, urinating well, ambulation improved,
Pt [**Last Name (un) 10737**] mapped just in case needs anothe BPG.
POD # 5: Pt recieved mucomyst and bicarb for CTA (results
pending) -looking at RLE for future BPG. Could not tolerate dye
load from angio.
POD # 6: Pt stable for DC. Follow creatinine at rehab,
ambulating well.
POD # 7: Pt discharged to home with apropriate follow up.
Medications on Admission:
[**Last Name (un) 1724**]: diltiazem 240', lasix 20qod, flonase nasal ', robitussin
with codeine, prilosec prn
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
11. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Thrombosed superficial femoral artery/popliteal aneurysm.
ARF on CRF secondary to contrast induced nephropathy
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-3**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2172-4-14**] 10:15
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2172-6-1**] 1:30
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2172-8-17**]
10:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2172-8-17**] 10:15
Please follow up with your PCP for appropriate follow up
regarding new medications, and cardiovascular risk reduction.
Completed by:[**2172-4-4**]
|
[
"716.96",
"515",
"E947.8",
"442.3",
"585.9",
"403.90",
"444.22",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.08",
"88.48",
"39.29",
"83.14"
] |
icd9pcs
|
[
[
[]
]
] |
6071, 6167
|
3237, 4629
|
336, 696
|
6322, 6331
|
2176, 3214
|
9175, 9896
|
1690, 1695
|
4790, 6048
|
6188, 6301
|
4655, 4767
|
6355, 8742
|
8768, 9152
|
1710, 2157
|
275, 298
|
724, 1518
|
1540, 1653
|
1669, 1674
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,027
| 181,593
|
1298
|
Discharge summary
|
report
|
Admission Date: [**2116-5-28**] Discharge Date: [**2116-5-30**]
Date of Birth: [**2035-12-31**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 yo female with PMHx of CAD, HTN, TIAs, hyperparathyroidism
on Unasyn at [**Hospital 100**] rehab for acute cholecystitis (no surgery,
cooling down w/ abx), presents with lethary. Patient denies
chest pain or abdominal pain. Patient is able to answer
questions but slow response.
.
In the ED patient was found to be thrombocytopenic and have
elevated WBC, she was also found to be hypercalcemic and was
given IVF. She underwent CTA to rule out PE as patient reporting
some dyspnea and was found to have PE in the R pulmonary artery
and left upper lobe branch. Patient was given vanc/levo/flagyl
for cholecystitis as felt unasyn could be contributing to
thrombocytopenia. She was seen by surgery in the ED who
recommended previous plan to hold off on any type of surgery
until patient more stable.
Past Medical History:
1. CAD, NSTEMI '[**10**], treated with PCI and stent of LCx. Most
recent echo [**4-25**] shows LVEF 65% to 70%
2. HTN
3. Type 2 diabetes
4. ?TIA many years ago - from record, but pt does not recall
5. DVT in '[**11**] (LLE) and again in '[**15**] (LUE - no line; thought to
be [**2-21**] anatomical variant, but did not r/o hypercoagulable
state), now on warfarin
6. Obesity
7. Lower Back Pain
8. Hyperparathyroidism
9. s/p TAH
10. h/o arthritis
11. CKD with Cr 1.0-1.2
12. Lipoma (abdomen)
13. s/p appy
14. Acute Cholecystitis (being treated with Unasyn)
15. H/O hip fracture
16. gall bladder mass
.
Social History:
From [**Hospital 100**] Rehab facility, she is a retired epidemiologist. Pt
moved to US in [**2102**].
Tob: none currently, remote 20 pk yr hx.
EtOH: no history of alcohol abuse.
Family History:
Father w/ HTN
No history of clots in the family.
Physical Exam:
Upon arrival to MICU:
T 97.8 HR 96 BP 126/104 RR 24 O2Sat 100% on NRB
Gen: NAD
Heent: [**Last Name (un) **], EOMI, sclera anicteric, OP clear
Lungs: CTA b/l
Cardiac: Irregularly Irregular, no murmurs
Abdomen: obese soft, NT +BS
Ext: no edema
Neuro: Awake and alert
Pertinent Results:
[**2116-5-28**] 01:15PM WBC-18.0* RBC-3.63* HGB-10.6* HCT-30.4*
MCV-84 MCH-29.3 MCHC-35.0 RDW-17.7*
[**2116-5-28**] 01:15PM PLT SMR-VERY LOW PLT COUNT-58*# LPLT-1+
[**2116-5-28**] 01:15PM NEUTS-86* BANDS-1 LYMPHS-4* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-2* MYELOS-0 NUC RBCS-1*
[**2116-5-28**] 01:15PM GLUCOSE-257* UREA N-46* CREAT-1.2* SODIUM-137
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2116-5-28**] 01:15PM ALT(SGPT)-8 AST(SGOT)-23 LD(LDH)-673*
CK(CPK)-59 ALK PHOS-480* AMYLASE-80 TOT BILI-1.9*
[**2116-5-28**] 01:15PM LIPASE-134*
[**2116-5-28**] 01:15PM ALBUMIN-3.2* CALCIUM-13.2* PHOSPHATE-2.7
MAGNESIUM-1.7
[**2116-5-28**] 01:15PM PT-32.4* PTT-35.5* INR(PT)-3.5*
Micro:
Imaging:
[**2116-5-28**] - lower ext ultrasound - 1. Intraluminal thrombus
extending from the left common femoral vein to the popliteal
vein, nonocclusive.
2. Intraluminal thrombus extending from the right superficial
vein distally and possibly to the popliteal vein, also
nonocclusive.
[**2116-5-28**] - CTA chest -
1. Bilateral pulmonary emboli, greatest within the distal right
main pulmonary artery extending into the right upper and right
lower lobes. Small pulmonary embolus within the arteries to the
left upper lobe. Ground-glass opacity and small right pleural
effusion distal to the major portion of pulmonary embolism could
reflect small pulmonary infarction.
2. Prominent, ectatic thoracic aorta.
3. Small intra-aortic thrombus, unchanged by imaging compared to
a CT from [**2116-5-14**].
[**2116-5-29**] - U/S liver - Persistent areas of thickening within the
gallbladder wall, and soft tissue within the lumen, with an
enlarged periportal lymph node. These findings are concerning
for gallbladder carcinoma.
Brief Hospital Course:
80 y/o female with recent diagnosis of acute cholecystitis who
present from [**Hospital **] rehab with dyspnea found to have PE on CTA
and thrombocytopenia.
.
1. PE/DVT and thrombocytopenia: The patient presented with
multiple thrombi in lungs and legs. She was found to have HIT
type 1 which was thought to be the main driver of the clotting.
Complicating her treatment was her simultaneous DIC which was
felt to be driven by her likely (although never biopsy proven)
locally advanced gallbladder cancer. The patient was treated
with empiric antibiotics directed at acute cholecystitis but
further imaging was not consistent with active infection or
gallbladder inflammation. The patient was felt to have both DIC
and HIT as she had a significantly positive PF4 antibody and
evidence of hemolysis and a consumptive coagulopathy. In
discussions with the patient's family, given that the underlying
DIC cause (i.e. gallbladder cancer) was not treatable and
therapies for the HIT driven thromboembolic disease would put
her at significant risk for bleeding, comfort was made the prime
goal of care. Over the course of the next day, her consumptive
coagulopathy progressed with resulting oliguria and depressed
mental status. The patient's condition continued to deteriorate
and she expired in the early morning of [**2116-5-30**]. The family
(son and daughter-in-law) was [**Date Range 653**]. The family declined
autopsy.
.
2. Hypercalcemia - Patient with elevated calcium, appears to
have elevated CA at baseline. Most likely secondary to
hyperparathyroidism as this has been noted in OMR worsened by
the thiazide diuretic.
.
3. Diabetes - BS elevated, will cover patient with RISS
.
4. CAD - Patient with history of fixed defect on stress-MIBI.
- Will hold ASA given thrombocytopenia
- Continue BBlocker and statin once po
.
5. PPx - supratheraputic INR, tylenol, bowel regimin
.
FEN - NPO
.
Code - DNI/DNR, later changed to CMO following extensive
discussions with her next of [**Doctor First Name **] [**Doctor First Name 1975**] [**Known lastname 8024**] and his
wife.
.
Dispo: expired
Medications on Admission:
Docusate Sodium 100 mg PO BID
Compazine
Senna 8.6 mg Tablet PO BID
Acetaminophen 325 mg 1-2 Tablets PO Q4-6H prn
Metoprolol Tartrate 25 mg PO TID
Nifedipine 10 mg PO Q8H
Simvastatin 20 mg PO DAILY
Ondansetron 4 mg IV Q8H:PRN
HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3-4H:PRN
Triamterene-Hydrochlorothiazide 37.5-25 mg Capsule Sig: 1-1.5
Caps PO DAILY
Ampicillin-Sulbactam 1-0.5 g q8 until [**2116-6-3**]
Coumadin 1mg qhs
Rosiglitazone 1 mg PO DAILY
Metformin 500mg daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
pulmonary embolism
disseminated intravascular coagulation
heparin induced thrombocytopenia type 1
gall bladder cancer
Secondary:
coronary artery disease
hypertension
Type 2 diabetes mellitus
Deep venous thrombosis
Obesity
Primary Hyperparathyroidism
osteoarthritis
Chronic kidney disease
hip fracture treated with nail placement.
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"427.31",
"585.9",
"288.60",
"V45.82",
"415.19",
"275.42",
"403.90",
"588.81",
"286.6",
"285.9",
"414.01",
"575.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6717, 6726
|
4070, 6169
|
285, 291
|
7110, 7119
|
2313, 4047
|
7170, 7175
|
1961, 2012
|
6688, 6694
|
6747, 7089
|
6195, 6665
|
7143, 7147
|
2027, 2294
|
237, 247
|
320, 1121
|
1144, 1748
|
1764, 1945
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,411
| 173,718
|
1156
|
Discharge summary
|
report
|
Admission Date: [**2183-3-12**] Discharge Date: [**2183-3-21**]
Date of Birth: [**2141-5-14**] Sex: F
Service:
CHIEF COMPLAINT: Mrs. [**Known lastname 5655**] is a 41-year-old woman with a
history of systemic lupus erythematosus, hypertension and
BOOP, who came to the Emergency Department on [**2183-3-12**]
for cough of two weeks duration and subsequently went into
hypoxic respiratory arrest, was intubated, and transferred to
the Medical Intensive Care Unit.
HISTORY OF PRESENT ILLNESS: Over the two weeks prior to
admission, Mrs. [**Known lastname 5655**] complained of increasing shortness of
breath with a cough productive of yellow sputum, flecked with
blood. She denied any chills, fever, chest pain or headache.
Shortly before admission, she was unable to walk more than
eight feet without having to rest and catch her breath. She
decided to come to the Emergency Department when she was
unable to walk up a flight of stairs without extreme
shortness of breath.
While at the Emergency Department, Mrs. [**Known lastname 5655**] got up to go
to the bathroom, and on her return to her stretcher
experienced a hypertensive crisis with systolic blood
pressure in the 190s and a heart rate greater than 140. She
became tachypneic, short of breath, confused and pulse
oximetry could not be obtained. She continued to be very
short of breath on 100% nonrebreather. She was intubated for
presumed respiratory failure and transported to the Medical
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Systemic lupus erythematosus, diagnosed in [**2173**] with
AWA/ds-DNA/anti-[**Doctor Last Name **] positivity.
2. Lupus nephritis - membranoproliferative
glomerulonephritis.
3. Hemolytic anemia.
4. Thrombocytopenia.
5. Lupus cerebritis.
6. Lupus peritonitis, [**2179-1-6**].
7. Pleuritis.
8. Arthritis.
9. Raynaud's syndrome.
10. BOOP in [**2179-9-6**].
11. Hypertension.
12. Salmonella bacteremia in [**2182-7-6**].
13. TTP - HUS.
14. Membranous glomerulonephritis with a necrotizing
component and focal crescent formations, mixed Type III/V
lupus erythematosus.
SOCIAL HISTORY: Patient lives in [**Location 669**] with her brother.
She works part time as a tax accountant. She has a negative
tobacco history. She stopped drinking alcohol in [**2170**]. She
denies any other drug use. She is not currently sexually
active.
FAMILY HISTORY: The patient's mother died of lupus at the
age of 47. She does not know her father well and is unable
to report on his health history. She has seven brothers and
sisters. Two of her brothers have alcoholism. One sister
has insulin dependent diabetes mellitus. There is no
significant family history of cancer, asthma or heart
disease.
ALLERGIES: Haldol - acute dystonic reaction. Sulfa - hives
and shortness of breath. Biaxin.
MEDICATIONS ON ARRIVAL AT THE EMERGENCY DEPARTMENT:
Lopressor 50 mg b.i.d., Zestril 5 mg q.d., prednisone 5 mg
q.d., aspirin 81 mg q.d., Lipitor 20 mg q.d., Prilosec 20 mg
q.d., Nephrocaps.
REVIEW OF SYSTEMS: Chronic constipation, treated with
Colace. Joint pain significantly worse in winter time with
Raynaud's. No history of chest pain or palpitations.
PHYSICAL EXAM ON ADMISSION TO THE MEDICAL INTENSIVE CARE
UNIT: General: intubated, sedated, middle-aged woman.
Vital signs: Blood pressure 140/90. Heart rate 130.
Temperature 99.1. Head, eyes, ears, nose and throat: pupils
equal, round and reactive to light. Sclerae are anicteric.
Neck, supple, no LAD. Chest: bilateral breath sounds
anteriorly. No wheezing. Coarse bilateral breath sounds
throughout. Inspiratory crackles. Cardiovascular:
tachycardic rhythm, no murmurs. Abdomen: soft, nontender,
nondistended, normal active bowel sounds. Light brown guaiac
negative stool. Extremities: warm without edema. Neuro:
Babinski downgoing bilaterally. Sedated. Symmetric
reflexes.
LABORATORIES VALUES ON ADMISSION: White blood cell count
2.6, differential 57 neutrophils, 2 basophils, 25
lymphocytes, 9 macrophages. Hematocrit 28.2, platelets
142,000. MCV 82. Sodium 138, potassium 3.7, chloride 98,
bicarbonate 28, BUN 27, creatinine 7.1, glucose 82.
Urinalysis: small amount of blood. Greater than 300 protein.
2 red blood cells, 1 white blood cell, 20 epithelial cells.
Electrocardiogram, sinus tachycardia. Rate 110, normal axis.
TWI, V4 through V6, lead I.
HOSPITAL COURSE: While in the Emergency Department, Mrs.
[**Known lastname 5655**] received nitroglycerin paste, Lasix 80 mg intravenous,
500 mg levofloxacin, heparin per protocol, Versed 1-2 mg per
hour via IV drip. After intubation in the Emergency
Department, Mrs. [**Known lastname 5655**] received a bedside echocardiogram
which showed severe left ventricular systolic functional
depression and a small loculated pericardial effusion. Right
ventricular diastolic collapse was present consistent with
impaired filling and tamponade. A chest x-ray at the time
showed congestive heart failure with pulmonary edema,
although pneumonia could not be excluded. An
electrocardiogram revealed T wave inversions laterally. Mrs.
[**Known lastname 5655**] then underwent CT angiography for pulmonary embolus
which was negative; however, the CT showed fluid overload
with left and right pleural effusions and pulmonary edema.
After intubation and in the Medical Intensive Care Unit, Mrs.
[**Known lastname 5655**] was initially placed on SIMV plus PFs, but was not
well sedated and had rapid respiration rate. An arterial
blood gas at the time post intubation was 7.18/55/76. The
patient was switched to ACV/500/14/FIO2 100% with PEEP of
7.5. Arterial blood gases then was 7.24/56/57.
Initial differential diagnosis at the time of admission to
the Medical Intensive Care Unit was infectious community-
acquired pneumonia versus lupus pneumonitis versus flash
pulmonary edema or congestive heart failure. During her stay
in the Medical Intensive Care Unit, Mrs. [**Known lastname 5655**] showed rapid
improvement. On [**3-12**], she was started on Solu-Medrol
intravenous 80 mg q. 8 hours, Lasix 40 mg q.d. and
levofloxacin 500 mg q.d. By [**3-14**], Solu-Medrol had been
changed to 60 mg intravenous q. 8 hours. By [**3-15**], to 40
mg intravenous q. 8 hours. She continued with Lasix at 40 mg
q.d. and levofloxacin at 500 mg q.d.
Mrs. [**Known lastname 5655**] was extubated on [**3-14**] with adequate 02
saturation. By [**3-15**], a chest x-ray showed significant
interval improvement of pulmonary edema with an accompanying
decrease in the size of her pleural effusions. Mrs. [**Known lastname 5655**]
was then discharged to the Medicine [**Hospital1 **] on [**3-15**].
PHYSICAL EXAMINATION ON ADMISSION TO THE MEDICINE FLOOR:
Vital signs, temperature 98.6. Heart rate 105 with a maximum
of 117. Blood pressure 142/98 with a maximum systolic blood
pressure of 162 and a minimum of 109 in a 24-hour period.
Respiratory rate 18 to 20 breaths per minute. 02 saturation
99-100% on two liters 02. General: middle-aged African
American woman sitting quietly in bed, applying makeup and
talking on the phone while eating. Head, eyes, ears, nose
and throat: oropharynx pink, no injection. Cervical range
of motion limited by IJ line, right neck. No sinus
tenderness. No auricular, submandibular, cervical or
clavicular LAD. Pulmonary: rales at the right base and 1/3
up from the base on the left. No dullness on percussion. No
accessory muscle use. No wheezes. Cardiovascular: regular
rate and rhythm. S1, S2 auscultated. No murmurs, rubs or
gallops. Pulses 2+ at carotids and femorals. Palpable
pulses at radials and bilateral dorsalis pedis pulses. No
jugular venous distention. No carotid or abdominal aortic
bruits. Abdomen: soft, no organomegaly, no masses palpated.
Right upper quadrant tenderness at palpation with positive
[**Doctor Last Name 515**] sign, positive bowel sounds. Extremities: cool,
dry without edema. Dermatology: no visible petechia or other
lesions. Lymph: palpable 1 cm x 1 cm lymph node in right
axilla. No LAD in left axilla. No inguinal LAD. Neuro:
cranial nerves II through XII are grossly intact. Pupils
equal, round and reactive to light. Strength: 4+/5 in upper
extremities and lower extremities bilaterally. Reflexes:
[**1-9**] in triceps bilaterally, [**2-9**] in biceps and brachioradialis
bilaterally. [**2-9**] in quadriceps bilaterally, 0/4 in ankle
jerks. Downgoing toes Babinski. Sensation: sensation to
light touch intact in upper and lower extremities.
Cerebellar signs: finger-to-nose and finger tapping within
normal limits.
MEDICATIONS ON ADMISSION TO MEDICINE FLOOR: Nephrocaps 1 tab
po q.d., levofloxacin 250 mg po q.o.d., enteric-coated
aspirin 325 mg po q.d., Lopressor 50 mg po b.i.d., Nifedipine
20 mg po t.i.d., Zantac 150 mg po q.d., Solu-Medrol 40 mg
intravenous t.i.d., captopril 7.5 mg po b.i.d., Tylenol 650
mg po q. 4-6 hours prn pain, Tums 2 tabs po q.a.c.
LABORATORY VALUES ON ADMISSION TO THE MEDICINE FLOOR: White
blood cell count 13.7, hematocrit 32, platelets 168,000. MCV
81. RDW 19.0. Sodium 139, potassium 5.2, chloride 99,
bicarbonate 20, BUN 60, creatinine 7.1, glucose 125, calcium
8.4, magnesium 2.4, phosphorus 6.0.
Cardiac enzymes were cycled through to rule out myocardial
infarction. Troponin values went from 4.5 on [**3-12**] to 1.1
on [**3-13**] to 0.8 on [**3-14**]. CK-MB values went from 8 on
[**3-13**] to 9 on [**3-14**] to 4 on [**3-15**].
REVIEW BY SYSTEM:
1. Pulmonary. Mrs. [**Known lastname 5655**] had a series of chest x-rays
during her hospitalization. Chest x-ray on [**3-14**] stated
that there was significant interval improvement of the
pulmonary edema over previous x-ray the week before. There
was also interval decrease in the size of pleural effusions.
Overall impression was that there had been interval
improvement of pulmonary edema and pleural effusion. Chest
x-ray from [**3-15**] stated that there were newly developed
bilateral pleural effusions blunting both costophrenic
angles. There was also upper zone redistribution suggesting
mild congestive heart failure. The heart size was prominent
for the portable examination taken. There was no
pneumothorax. During her time in the hospital, Mrs. [**Known lastname 5655**]
had a cough productive of yellow sputum, sometimes tinged
with blood, that had resolved by discharge to first clear
sputum and then no productive cough and no cough at all by
[**3-21**]. She denied any shortness of breath at rest or
exertion at discharge.
2. Cardiovascular. Echocardiography was performed on [**2183-3-14**]. Overall conclusions were that the left ventricle
was mildly hypertrophic with sparing of the septum. The
overall left ventricular systolic function was severely
depressed. Right ventricular function was good. The aortic
leaflets were mildly thickened. The mitral leaflets were
mildly thickened. There was a small circumferential
pericardial effusion. The pericardium may have been
thickened. Compared with a prior study of [**2183-3-12**], the
effusion was somewhat smaller, especially anteriorly and
right ventricular collapse was less pronounced. Ejection
fraction was estimated to be between 20-25%.
Cardiac catheterization was performed on [**3-18**]. Internal
comments were: 1. Coronary angiography of this right
dominant system revealed normal coronary arteries. The LM as
normal. The left anterior descending and its D1 and D2
branches were all normal. The left circumflex artery and its
OM1 and OM2 branches were all normal. The right coronary
artery and its AM, R-PDA, R-PL branches were all normal. 2.
Hemodynamic measurement revealed mildly elevated PAP
(32/19/24 mmHg), highly elevated central aortic pressure
(170/98/125 mmHg), and highly elevated left ventricular
end-diastolic pressure (27 mmHg). No transaortic gradient
was seen. 3. Left ventriculography revealed global
hypokinesis and an estimated ejection fraction of 22%.
Mitral regurgitation was at least 2+. The final diagnosis
was: 1. Coronary arteries are normal. 2. Moderate mitral
regurgitation. 3. Severe systolic ventricular dysfunction.
Blood pressure. Blood pressure was difficult to control
during Mrs. [**Known lastname 5655**] stay in the hospital. Her systolic blood
pressure was persistently greater than 150. It was
particularly well-controlled during the catheterization
productive. During nitroglycerin drip the systolic blood
pressure was in the 120s, but noted to be in the 160s to 170s
with discontinuation of the drip.
As a consequence of the catheterization procedure, Mrs.
[**Known lastname 5655**] developed a hematoma at her right groin. Her
hematocrit dropped from 25-22 within 24 hours following the
procedure while serial hematocrits were taken every 2 hours.
Her hematocrit stabilized at 22. An ultrasound of the right
groin at the time showed the common femoral artery. There
was no evidence of pseudoaneurysm or AV fistula. There was
no hematoma over the puncture site.
3. Infectious Disease. Blood cultures taken at the time of
admission were eventually negative. Urine cultures also
taken showed no growth. A sputum culture showed [**10-30**] PMNs
with more than 10 epithelial cells. There were gram positive
cocci in pairs and clusters. There was sparse growth of
oropharyngeal flora. Legionella urinary antigen was also
negative. Levofloxacin was discontinued before discharge.
4. Renal. During her stay in Medical Intensive Care Unit
and during her stay on the Medicine floor, Mrs. [**Known lastname 5655**]
underwent dialysis numerous times. During dialysis she
consistently received several units of packed red blood cells
as well as Epogen.
5. Heme. As mentioned above, Mrs. [**Known lastname 5655**] received numerous
units of packed red blood cells during her hospitalization,
as well as Epogen. Iron studies provided the following
values: FE: 49 within normal limits. TIBC: 211/ TRF: 162.
Haptoglobin: 179. LD: 252. Reticulocyte count on [**3-20**]:
5.2. Her hematocrit on admission was 28.2. Her hematocrit
on discharge was 32.
CONDITION ON DISCHARGE: Stable.
DIAGNOSES ON DISCHARGE:
1. Systemic lupus erythematosus.
2. Lupus nephritis/membranoproliferative glomerulonephritis
with a necrotizing component and focal crescent
formations.
3. Hypertension.
4. Congestive heart failure.
DISPOSITION: The patient was discharged to home. She was
instructed to follow-up with her primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within one week; as well as to make an appointment
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient refused to allow the House
Officer to schedule those appointments and said that she
would schedule them herself.
[**First Name11 (Name Pattern1) 971**] [**Last Name (NamePattern4) 7425**], M.D. [**MD Number(1) 7426**]
Dictated By:[**Last Name (NamePattern1) 7427**]
MEDQUIST36
D: [**2183-4-2**] 22:26
T: [**2183-4-3**] 09:17
JOB#: [**Job Number 7428**]
|
[
"323.8",
"518.81",
"710.0",
"287.3",
"404.93",
"486",
"516.8",
"582.81",
"459.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"39.95",
"96.71",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
2394, 3021
|
4397, 14110
|
14168, 15126
|
3041, 3910
|
145, 481
|
510, 1496
|
3925, 4379
|
1518, 2111
|
2128, 2377
|
14135, 14154
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,685
| 155,798
|
41615+58461+58462
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2188-8-30**] Discharge Date: [**2188-9-15**]
Date of Birth: [**2117-9-8**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
abdominal pain and no ostomy output
Major Surgical or Invasive Procedure:
[**2188-9-3**]
1. Exploratory laparoscopy.
2. Removal of infected mesh.
3. Repair of paracolostomy hernia.
4. Reversal of Hartmann's with low colorectal anastomosis.
5. Secondary abdominal closure.
[**2188-9-11**]
Right midline placement
History of Present Illness:
70 yr old female admit from OSH with high grade SBO with chronic
parastomal hernia. She was admitted with abdominal pain and no
ostomy output. Upon arrival to [**Hospital1 18**] she was stable, she stated
that her abdominal pain started 3 days prior to her presentation
at the OSH. She c/o nausea, emesis but she denied f/c/SOB/CP/
bright red blood stool from ostomy or any urinary symptoms.
However she acknowledged a decrease in her ostomy output over
the
last 3 days. patient reports previous episodes of SBO and has
been treated conservatively at [**Hospital1 2025**].
During our interview She had about 30 cc of watery brown stool
from her stoma which was last change the day prior.
Past Medical History:
PMH: DM2, Afib on Coumadin, PM placement, CHF, Hx DVT/PE s/p IVC
filter, hx CVA (disconjugate gaze), HTN, Hyperlipidemia, COPD on
home O2 at night, morbid obesity, Hiatal hernia, Hx SBO (managed
conservatively at [**Hospital1 2025**] [**2185**]), Hypothyroidism, Known incidental
adrenal tumor, Pituitary tumor (managed via observation only),
Hx
leukemia, Hx Diverticulitis, Osteoporosis, Cerebral aneurysms, L
ankle fx ([**2186**])
PSH: Hartmann's procedure (?[**2170**]), open CCY (date unknown), IVC
filter placement (date unknown), Pacemaker placement ([**12-11**]),
Ventral hernia repair w mesh ([**Hospital1 2025**]-[**8-11**])
Social History:
lives alone, daughter provides assistance w [**Name (NI) 4461**], mobile w
walker, Tobacco: 50+ pack year hx (quit [**2178**]), EtOH: Denies
Family History:
non contributory
Physical Exam:
Temp 98 HR 105 BP 112/70 RR 20 O2 sat 99% 2L
Gen: Obese woman who looked older then stated age, A&O x3,
speaking in full sentence and non-toxic appearing
HEENT: NCAT, EOMI, PERRL, Oropharynx: dry, No LNA no
thyromegally
CV: RRR no mr/g
Lungs; CTAB with diminished BS throughout, most likely secondary
to body habitus vs effort
Abd: Obese soft, ND, with a stoma Located in LLQ it's slightly
below skin level, unable to view os,large parastomal hernia.
small area of denuded tissue along stomal edge at 3 and 9
o'clock.Fistula at midline draining small amount of creamy green
drainage
Pertinent Results:
[**2188-8-30**] 09:43PM WBC-4.9 RBC-4.47 HGB-13.7 HCT-39.9 MCV-89
MCH-30.6 MCHC-34.2 RDW-13.9
[**2188-8-30**] 09:43PM NEUTS-65.2 BANDS-0 LYMPHS-22.4 MONOS-11.2*
EOS-0.5 BASOS-0.7
[**2188-8-30**] 09:43PM PT-27.2* PTT-24.9 INR(PT)-2.6*
[**2188-8-30**] 09:43PM PLT SMR-NORMAL PLT COUNT-245
[**2188-8-30**] 09:43PM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2188-8-30**] 09:43PM ALT(SGPT)-56* AST(SGOT)-56* ALK PHOS-71 TOT
BILI-0.9
[**2188-8-30**] 09:43PM GLUCOSE-135* UREA N-30* CREAT-1.1 SODIUM-134
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-26 ANION GAP-15
[**2188-8-30**] 9:42 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2188-9-1**]**
MRSA SCREEN (Final [**2188-9-1**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2188-9-3**] 4:00 pm SWAB ABDOMINAL WALL ABSCESS.
**FINAL REPORT [**2188-9-7**]**
GRAM STAIN (Final [**2188-9-3**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2188-9-6**]):
STAPH AUREUS COAG +. RARE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2188-9-7**]): NO ANAEROBES ISOLATED.
[**2188-9-1**] Gastrograffin enema
1. Small colonic diverticulum.
2. Filling defect within the pouch likely retained material.
Correlation
with physical exam is recommended.
3. No evidence of leak or fistula within the pouch or the colon.
4. No evidence of obstruction or parastomal hernia.
[**2188-9-3**] Cardiac echo :
The left atrium is markedly dilated. The left atrium is
elongated. Moderate to severe spontaneous echo contrast is seen
in the body of the left atrium. The right atrium is moderately
dilated. A mass/thrombus associated with a catheter/pacing wire
is seen in the right atrium. A patent foramen ovale is present.
A left-to-right shunt across the interatrial septum is seen at
rest. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular free wall
thickness is normal. The right ventricular cavity is mildly
dilated with borderline normal free wall function. 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. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
[**2188-9-10**] CT Abd/pelvis :
1. 4.1 cm fluid collection adjacent to the anastomosis. This
does have an
enhancing rim and may represent an abscess.
2. Large fluid collection in the anterior abdominal wall
immediately
underneath the surgical staples, this contains a large amount of
air, but has no enhancing rim, and thus is more consistent with
a seroma; however,
infection cannot be excluded.
3. Partial small-bowel obstruction, with contrast reaching the
ascending
colon.
4. Bilateral pleural effusions, moderate on the left and small
on the right with adjacent atelectasis of the lower lobes.
5. Right renal artery stenosis with atrophic right kidney.
[**2188-9-12**] Duplex scan right upper extremity :
Extensive deep vein thrombosis seen within the right brachial,
axillary, and subclavian veins.
Brief Hospital Course:
Ms. [**Known lastname **] was evaluated by the Acute Care team in the Emergency
Room and scans were reviewed She had a high grade SBO and
incarcerated parastomal hernia, and most likely infected mesh.
She was admitted to the SICU due to her multiple comorbidiities.
She was NPO with a nasogastric tube in place for decompression
and she was hydrated with IV fluids. Her nasogastric tube
continued to drain large amounts of feculent smelling drainage
and surgery was recommended once her INR decreased.
On [**2188-9-3**] she was taken to the Operating Room and underwent an
exploratory laparotomy, removal of infected mesh, hernia repair
and Hartmann's reversal. She had some hemodynamic instability
on induction then required pressors intermittently. Following
return to the SICU her pressors were gradually weaned off and
that was possible after her atrial fibrillation rate was
controlled. She was extubated on [**2188-9-4**] and underwent vigorous
pulmonary toilet including nebulizers and chest PT and remained
free of any pulmonary complications post op. Her anticoagulation
was started on post op day 2 with a goal PTT of 50-60 then as
she became further out from surgery she was titrated to 60-80
range.
As she continued to improve she was transferred out to the
Surgical floor on [**2188-9-6**]. Her bowel function slowly returned and
at that point her nasogastric tube was removed and a liquid diet
was started. She was slowly advanced to a regular diabetic diet
and tolerated it well. Her abdominal wounds were healing well.
Her WBC was followed closely post op and although she was
afebrile and without pain her WBC gradually rose to 16K by post
op day 6. At that point she had a CT scan of the abdomen which
showed a large fluid collection adjacent to the anastomosis.
The radiologists evaluated the scan and felt that overlying
bowel made it impossible to percutaneously drain the fluid. She
was started on Cipro and Flagyl and her WBC began to trend down.
She remains afebrile and her WBC today is 8K. She is tolerating
her diet without pain and she will complete her antibiotics on
[**2188-9-23**].
On [**2188-9-12**] a PICC line was attempted as she had poor access and
her right IJ CVL was 9 days old. Her right arm was edematous
compared to her left and a duplex scan was done which noted DVT
up to the subclavian vein. Her anticoagulation continued,
including heparin and Coumadin and her CVL was removed.
Currently she is off heparin and her INR is 3.7 today. Her
Coumadin will be held tonight and can be redosed tomorrow
pending her INR to keep her in the 2-3 range.
The Physical Therapy service worked with her during her stay and
recommended a short term rehab to help increase her mobility and
improve her endurance. After a prolonged hospital stay she was
transferred to rehab on [**2188-9-15**].
Medications on Admission:
Coumadin 2 MTuWFSa, 4 ThSu, Coreg ER 80', Cardizem CD 100',
HCTZ 25', Lisinopril 5', Lipitor 40', Spiriva 1cap QD, Advair
discus 250/50 1puff'', Prilosec 20', Fosamax Qweek, Tums 750
QAC,
Synthroid 125', Metformin 500', MVI, Vit D 400'
Discharge Medications:
1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Hold for SBP < 100, HR < 60.
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP < 100.
13. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours): thru [**2188-9-23**].
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): thru [**2188-9-23**].
16. insulin regular human 100 unit/mL Solution Sig: 2-10 units
Injection four times a day as needed for per sliding scale.
17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: dose
daily to maintain INR [**2-7**];
No Coumadin [**9-15**] as INR 3.7.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 4693**]
Discharge Diagnosis:
1. Incarcerated obstructed parastomal hernia.
2. Small bowel obstruction.
3. Fistula to ventral mesh.
4. Stenosis of prior colostomy
5. DVT right brachial, axillary and subclavian veins
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*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 [**5-13**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed at rehab.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a folow up
appointment in [**2-7**] weeks.
Completed by:[**2188-9-15**] Name: [**Known lastname **],[**Known firstname 14294**] Unit No: [**Numeric Identifier 14295**]
Admission Date: [**2188-8-30**] Discharge Date: [**2188-9-15**]
Date of Birth: [**2117-9-8**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9036**]
Addendum:
Dr. [**Last Name (STitle) **] would like to see Ms. [**Known lastname **] in the clinic in 2 weeks
for removal of retention sutures/staples.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) **]
[**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**]
Completed by:[**2188-9-15**] Name: [**Known lastname **],[**Known firstname 14294**] Unit No: [**Numeric Identifier 14295**]
Admission Date: [**2188-8-30**] Discharge Date: [**2188-9-15**]
Date of Birth: [**2117-9-8**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9036**]
Addendum:
Please note that Ms. [**Known lastname 14296**] fluid collection was most likely a
small intra abdominal abscess.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) **]
[**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**]
Completed by:[**2188-9-30**]
|
[
"567.22",
"V15.82",
"244.9",
"272.4",
"V10.60",
"401.9",
"E849.0",
"V46.2",
"V12.51",
"998.59",
"E878.1",
"428.0",
"V58.61",
"496",
"285.9",
"453.82",
"V45.01",
"996.69",
"458.29",
"998.6",
"996.74",
"560.89",
"569.69",
"E879.8",
"427.31",
"E849.7",
"E878.8",
"250.00",
"568.0",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.79",
"54.59",
"46.42",
"46.52",
"38.97",
"54.63"
] |
icd9pcs
|
[
[
[]
]
] |
15167, 15399
|
6873, 9719
|
338, 579
|
11913, 11913
|
2776, 6850
|
13742, 14397
|
2133, 2151
|
10006, 11585
|
11704, 11892
|
9745, 9983
|
12096, 13365
|
13381, 13719
|
2166, 2757
|
263, 300
|
607, 1299
|
11928, 12072
|
1321, 1958
|
1974, 2117
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,922
| 168,886
|
7637
|
Discharge summary
|
report
|
Admission Date: [**2130-7-6**] Discharge Date: [**2130-7-30**]
Service: VASCULAR SURGERY
The patient expired on [**2130-7-30**].
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 27830**] is an unfortunate 84
year old female with a history diabetes mellitus,
polycythemia [**Doctor First Name **], prior transient ischemic attacks,
bilateral carotid artery stenosis measured at 40 and 60% by
ultrasound and carotid Duplex studies; history of
hypertension, history of deep venous thrombosis, recurrent
pulmonary embolism, and renal insufficiency, who was admitted
to the Vascular Service after complaining of a several months
history, approximately four to five months, of claudication
and rest pain. She had a right foot toe ulceration. She was
noted to have Doppler-able dorsalis pedis and posterior
tibial on the right lower extremity. She had a right femoral
angiogram which showed an occluded SFA and occluded dorsalis
pedis. Given this finding, the patient was admitted and
optimized for surgery.
HOSPITAL COURSE: Ultimately, after being evaluated by
Cardiology and being cleared and being followed by the
Diabetes Service of [**Last Name (un) **], the patient did go to the
Operating Room by [**2130-7-13**], where she underwent a right
common femoral artery to above the knee popliteal graft using
PTFE and composite to the AT with non-reversed saphenous vein
graft done with angioscopy and valve lysis. The patient had
a 200 cc blood loss. There were no complications. She got
transfused a unit of packed cells interoperatively and
received 3500 cc of Crystalloid, and underwent ............
and ................ with a PTFE, composite graft. She left
the Operating Room in stable condition.
Over the next several days, the patient had complications of
postoperative renal failure and mental status changes. Renal
consultation was obtained. Their impression was she had a
cardiac event complicated with low cardiac output versus
sepsis as the likely potentiator of this persistent oliguria
and renal failure. The patient was accordingly supported in
the VICU as well as the SICU intermittently as she did go
between both of these care units.
By [**7-24**], which would be postoperative day number 11 from
her operation, the renal attending that was consulting on the
case, Dr. [**First Name (STitle) 1313**], felt that the patient was probably
pre-renal secondary to worsening cor pulmonale, and
recommended to attempt to diurese the patient. Her albumin
at this time was 2.5.
Dr. [**First Name (STitle) 1313**] did suggest to check troponin I for a question of
a cardiac event, as covered in the perioperative period to
precipitate this, to check for a fractional excretion of urea
to see if this was consistent with a prerenal state, continue
the diuretics, maintain blood pressure greater than 120 for
renal perfusion, and to start optimizing her nutrition. A
Neurology consultation was obtained at this time also for her
altered mental status. At that time, Neurology's impression
was that this was just an 84 year old woman with a prior
polycythemia [**Doctor First Name **], prior transient ischemic attacks,
hypertension, and diabetes mellitus, who was noted to have
difficulty speaking after right femoral to AT bypass graft
using composite PTFV and non-reversed saphenous vein.
Her neurologic examination was significant for inattention
and somewhat lethargic, which might reflex a metabolic
encephalopathy. Their recommendations were to check a head
CT scan to evaluate a large stroke or bleed. Also, to check
an MRI and diffusion wave images in an MRA. Would defer if
her staples are an issue. Consider to stop her
subcutaneously heparin since her INR was therapeutic.
Recheck urinalysis since the leukocyte esterase was also
positive and to continue support as needed.
By postoperative day number 12, she continued on diuresis.
Neurologically, a head CT scan was achieved that showed no
evidence of large intracranial bleed. Cardiac-wise she had
good ejection fraction. The rest of her electrolytes were
stable. GI: She was tolerating tube feeds to goal.
Infectious Disease: She had an increasing white count. She
was being diuresed with Lasix and Zaroxolyn. Dr. [**First Name (STitle) 1313**] was
continued for her low urine output management.
Again the mental status changes were persistent. There was
some question of a new cerebrovascular accident event despite
some negative imaging. She was noted to have an orbital
bruit which was questionable of siphon stenosis. A PA
catheter was thereafter changed to a CVL.
A consultation with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2148**], was obtained for
assistance in her mental status issue. He was really unable
to shed much new light. Ultimately over the next several
days, the patient's clinical status deteriorated. Neurology
consult stated that an EEG that was obtained during her
work-up was a flat line result from [**2130-7-26**]. They wanted
to repeat the EEG to rule out any artifacts or rule out
seizure for any reason to explain her persistent
encephalopathy.
Overnight from [**7-27**] to [**7-28**], she developed some facial
twitching. This responded to an Ativan dose times one and
then being stopped as well as repleting electrolytes as
needed. Continued on LR at 15 hour tube feeds at goal,
Unasyn and Vancomycin, and ceftriaxone, and a bowel regimen
with medications.
After an extensive discussion was carried out with the
family, the family wished to make the patient comfort
measures only, and on [**2130-7-28**], this was done.
On [**2130-7-30**], the patient went into respiratory and cardiac
arrest. Her pupils were noted to be fixed and dilated.
Bilateral carotid pulses were absent. Thereafter she was
pronounced dead at 12:03 hours.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2130-10-30**] 15:50
T: [**2130-10-30**] 16:11
JOB#: [**Job Number 7206**]
|
[
"707.0",
"413.9",
"707.15",
"250.60",
"440.23",
"584.5",
"238.4",
"511.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"34.04",
"88.48",
"39.57",
"96.04",
"99.15",
"38.93",
"39.29",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
1040, 6095
|
171, 1022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,798
| 160,505
|
46979
|
Discharge summary
|
report
|
Admission Date: [**2172-8-5**] Discharge Date: [**2172-8-24**]
Service: MEDICINE
Allergies:
Thiazides
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
unresponsiveness, GI bleed
Major Surgical or Invasive Procedure:
intubation, femoral venous line, PICC line, aline
History of Present Illness:
88 y/o F with PMHx of CAD, DM, Atrial Fib, Alzheimers, CVA in
[**5-12**] on coumadin who was found unresponsive and bradycardic at
[**Hospital1 **] this morning. She received atropine and had an LMA
placed by EMS, BP 80/40 while en route to [**Hospital 8**] hospital. At
[**Hospital1 8**], she was found to have blood around her mouth, BRBPR,
hct of 27, creatinine 3.2 & INR of 10.5. Dopamine was started
and she received 2 units of FFP. She underwent proper ETT
intubation and initial ABG 7.3/38/200/19 before family requested
transfer to [**Hospital1 18**] ED.
.
In the ED, initial vs were: T 93 P 65 BP 122/72 R 14 O2 sat
100%. Vent AC Fi02 100% Vt 400, Peep 5, RR 16. Pt has a left
femoral line placed and had left EJ and PICC line in place from
[**Hospital1 **]. Pt received another 2units of FFP at [**Hospital1 **] and repeat hct
was 20. She received Vanc/levo/flagyl for possible aspiration
and dopamine was weaned prior to transfer.
.
Pt was intubated and sedated on arrival to ICU. After she was
settled, sBPs dropped from 87 to 70s, pt was given 2L NS IVF and
started on Dopamine.
.
Review of systems: unable to obtain
Past Medical History:
Ischemic/embolic left hemispheric CVA in [**5-12**]
Atrial fibrillation, diagnosed [**5-12**] on Coumadin
Dysphagia, S/P PEG [**2172-5-19**]
Gastritis
Sinus bradycardia
Type 2 DM, diet-controlled
Benign Hypertension
CAD native Vessle
CKD Stage IV b/l Cr ~2.0
Alzheimer dementia with vascular components, baseline A&O x3, in
History of reactive RPR with a titer 1:4 & reactive treponemal
antibody test, treated with 3 IM injections of penicillin
Gout
Chronic venous stasis
Alcohol abuse
Anemia
Cataract surgery
Urinary tract infections (most recent [**5-12**])
Recent admission to [**Hospital1 8**] for Aspiration PNA
Social History:
She previously lived alone, with her daughter living upstairs.
At [**Hospital 100**] rehab since [**2172-5-23**] follwing her stroke. She is
retired from nutritional services at [**Hospital1 18**]. She denies cigarette
use, has a history of alcohol abuse. No history of illicit drug
use.
Family History:
Her two daughters report that there is no family
history of stroke, but prior discharge summary notes that her
son
had a stroke at 53 years old. Her children have hypertension
Physical Exam:
Vitals: T: 93 BP: 87/53 (repeat sbp 70s) P: 61 R: 30 O2: 100%
General: sedated, minimal response to sternal rub
HEENT: blood in mouth, ETT and OG in place
Lungs: Audible airway secretions, moving air well bilaterally,
no w/r
CV: RRR, difficult to appreciate any murmur over resp sounds
Abdomen: mildly distended, decreased bowel sounds
Ext: warm (bairhugger), diffuse pitting edema tracks to thighs
Derm: multiple skin tears
Pertinent Results:
on admission:
[**2172-8-5**] 05:20AM BLOOD WBC-10.9# RBC-2.94* Hgb-8.1* Hct-26.8*
MCV-91 MCH-27.6 MCHC-30.3*# RDW-16.6* Plt Ct-214
[**2172-8-5**] 05:20AM BLOOD Neuts-91.6* Lymphs-4.8* Monos-3.2 Eos-0.3
Baso-0.1
[**2172-8-5**] 05:20AM BLOOD PT-48.7* PTT-41.4* INR(PT)-5.3*
[**2172-8-9**] 05:00AM BLOOD Fibrino-439*
[**2172-8-5**] 05:20AM BLOOD Glucose-104 UreaN-123* Creat-2.8*# Na-138
K-3.8 Cl-106 HCO3-18* AnGap-18
[**2172-8-5**] 05:20AM BLOOD ALT-36 AST-36 CK(CPK)-93 AlkPhos-95
TotBili-0.3
[**2172-8-5**] 05:20AM BLOOD Lipase-186*
[**2172-8-8**] 05:52AM BLOOD CK-MB-5
[**2172-8-5**] 08:45AM BLOOD Albumin-2.6*
[**2172-8-5**] 03:30PM BLOOD Calcium-8.0* Phos-3.6 Mg-2.0
cardiac enzymes:
[**2172-8-5**] 05:20AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2172-8-6**] 06:01AM BLOOD CK-MB-14* MB Indx-8.7* cTropnT-0.38*
[**2172-8-6**] 03:10PM BLOOD CK-MB-15* MB Indx-9.1* cTropnT-0.39*
[**2172-8-7**] 03:07AM BLOOD CK-MB-12* MB Indx-11.7* cTropnT-0.38*
cxr: Bilateral pleural effusions, increased on the right, with
adjacent
atelectasis. Underlying consolidation is not excluded.
OG tube tip below the expected location of the diaphragm,
however the side
port maybe in the distal esophagus.
Endotracheal tube in appropriate position.
Mild CHF.
TTE: The left atrium is mildly dilated. The right atrium is
moderately dilated. The right atrial pressure is indeterminate.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with mild basal inferior and inferoseptum
hypokinesis. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is moderately
dilated with focal basal free wall hypokinesis. 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.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Severe [4+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
The pulmonic valve leaflets are thickened. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is a
trivial/physiologic pericardial effusion
The study and the report were reviewed by the staff radiologist.
CT ABD/PELVIS: Large bilateral pleural effusions with bilateral
lower lobe compressive
atelectasis. No consolidation or pneumothorax.
Diffuse intra-abdominal free fluid. No bowel dilatation,
pneumatosis, or
intra-abdominal free air to suggest bowel ischemia.
Diffuse aortic valvular, mitral annulus, and coronary artery
calcification
with moderate cardiomegaly and probable mild pulmonary arterial
hypertension.
Pleural calcification and thickening suggests prior asbestos
exposure.
Thoracolumbar degenerative changes with facet joint disease in
the lower
lumbar and lumbosacral spine, benign right iliac bone island,
and healed left inferior pubic ramus fracture of unknown
chronicity.
Satisfactory position of left femoral venous line, endotracheal
tube, urinary catheter, and gastrostomy tube.
EGD: Esophagitis
Blood in the esophagus
Abnormal mucosa in the stomach
PEG tube site without any evidence of bleeding. Old blood clot
washed away with saline.
No evidence of active bleeding.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
88 y/o F with PMHx of CAD, DM, Atrial Fib, Alzheimers, CVA in
[**5-12**] on coumadin who was found unresponsive and bradycardic, INR
of 10 and active upper/lower GI bleeds who was transferred from
[**Hospital 8**] hospital intubated and on pressors, EGD showed reflux
esophagitis also [**Last Name (un) **] and NSTEMI. Pt was found esophagitis on EGD
and this was felt to be the etiology of her GIB. Her INR was
reversed and pt was transfused appropriately and pt started on
IV PPI. Pt did not have further bleeding with her INR <2. She
was also found to have NSTEMI c peak troponin of 0.39 which was
managed conservatively. Pt was admitted in respiratory failure,
and found to have a MRSA pneumonia (treated c 2week course of
vancomycin), felt to possibly be [**1-6**] aspiration while down (in
this frequently hospitalized and nursing home pt), further pt
had been resuscitated aggresively and was found to be volume
overloaded on exam. Pt was also found to be in oliguric [**Last Name (un) **].
Pt's blood pressure was managed c pressors and gentle fluid
boluses, however, her kidneys did not recover. Renal was
consulted and pt started on HD as it was felt that patient might
be able to be extubated if some volume could be removed. Pt was
started on hemodialysis and was able to be extubated. Throughout
this time pt had experienced occasional atrial fibrillation with
rapid ventricular response which was treated with metoprolol IV
as pt had NSTEMI on admission and it was felt that heart rates
>120s might induce further demand ischemia. On [**2172-8-24**], while on
hemodialysis session #4 (approx 1 hr into HD) pt became
bradycardic and a code was called. ACLS protocol was initiated,
however, pt did not survive.
Medications on Admission:
Warfarin unclear dose
Aspirin 81mg daily
Lipitor 40mg daily
Questran 1 packet tid
Prevacid 20mg daily
Metoprolol 25mg TID
Sodium Bicarb [**Hospital1 **]
Theravite daily
Tylenol prn
Benadryl prn
Discharge Medications:
Discharge Disposition:
Expired
Discharge Diagnosis:
Discharge Condition:
Discharge Instructions:
Followup Instructions:
Completed by:[**2172-8-25**]
|
[
"518.0",
"707.22",
"V13.02",
"584.5",
"511.9",
"707.03",
"562.10",
"038.9",
"V12.54",
"707.05",
"331.0",
"274.9",
"294.10",
"403.10",
"785.52",
"250.00",
"507.0",
"459.81",
"455.0",
"V12.04",
"530.10",
"054.9",
"276.2",
"410.71",
"427.31",
"585.4",
"285.1",
"518.81",
"276.0",
"578.1",
"414.01",
"V44.1",
"276.6",
"530.11",
"V58.61",
"707.09",
"995.92",
"482.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.02",
"38.91",
"33.23",
"45.13",
"38.95",
"39.95",
"96.6",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8602, 8611
|
6609, 8333
|
243, 294
|
8657, 8657
|
3056, 3056
|
8709, 8737
|
2419, 2596
|
8579, 8579
|
8634, 8634
|
8359, 8554
|
8683, 8683
|
2611, 3037
|
1435, 1454
|
3745, 6586
|
177, 205
|
322, 1416
|
3070, 3728
|
1476, 2096
|
2112, 2403
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,866
| 194,431
|
38522+38523
|
Discharge summary
|
report+report
|
Admission Date: [**2150-3-27**] Discharge Date: [**2150-4-3**]
Date of Birth: [**2078-1-7**] Sex: M
Service: PSYCHIATRY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2116**]
Chief Complaint:
depression, seeking ECT
Major Surgical or Invasive Procedure:
ECT [**4-1**] and [**4-3**]
History of Present Illness:
72 yo M with multiple medical problems, including transitional
cell carcinoma of left kidney, COPD, HTN and HLD, and reported
treatment resistant depression and SI involving cutting his
throat with a knife. He states that he thinks about killing
himself constantly, but has never followed through on his
thoughts. He often sharpens the knife in preparation to cut his
throat, and has even put the knife to his throat, but has never
cut himself, in part because he is afraid he won't succeed and
will end up disabled. He states he has felt depressed for his
whole life and cannot say whether he is more depressed today
than
he was a week, a month ago or a year ago. The best he has felt
over past 10 years was one night several years ago when he used
his CPAP, but it is too uncomfortable so he doesn't use it any
more.
Past Medical History:
Urologist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 85694**]
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 85695**]
HCP [**Name (NI) 56581**] [**Name (NI) 5700**]
COPD, on 2.5L home 02
OSA
HTN
HLD
Transitional cell carcinoma, dx [**2-28**]
Peripheral neuropathy
Arthritis, cervical spine
Gastro esophageal reflux
Gait imbalance
Constipation
Benign prostatic hypertrophy
Vitamin d deficiency
Chronic neck and back pain
Anemia
Social History:
Patient currently lives alone in [**Location 1268**]. He has a friend
who visits him frequently. Patient also has VNA who visits him
weekly. Worked as an electrician for many years but was unable
to work consistently [**12-23**] alcoholism. He is estranged from his
daughter and twin sons.
Family History:
brother with EtOH
Physical Exam:
T 99.2 P 107 BP 171/92 R 90% 3L
Awake, diaphoretic, mild visible distress
Tachycardic, no m/r/g
Wheezes throughout bilateral lung fields
Abd obese with mild midepigastric tenderness, no rebound, +BS
MSE:
Appearance: diaphoretic, mildly distressed
Mood: "it could be a lot better--i'm trying to breathe"
Affect: anxious
Behavior: calm, cooperative, good eye contact. Very weak
physically.
Speech: fluent, normal rate/volume/tone
TF: linear
TC: denies SI/HI/AH/VH
I/J: fair/fair
Pertinent Results:
[**2150-3-27**] 12:30PM GLUCOSE-110* UREA N-12 CREAT-1.0 SODIUM-143
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-33* ANION GAP-13
[**2150-3-27**] 12:30PM estGFR-Using this
[**2150-3-27**] 12:30PM ALT(SGPT)-19 AST(SGOT)-20 ALK PHOS-77 TOT
BILI-0.3
[**2150-3-27**] 12:30PM ALBUMIN-4.2 CALCIUM-9.4 PHOSPHATE-2.8
MAGNESIUM-2.3
[**2150-3-27**] 12:30PM VIT B12-320 FOLATE-9.6
[**2150-3-27**] 12:30PM TSH-2.1
[**2150-3-27**] 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-3-27**] 12:30PM WBC-10.2 RBC-4.92 HGB-14.3 HCT-42.5 MCV-86
MCH-29.0 MCHC-33.6 RDW-13.8
[**2150-3-27**] 12:30PM NEUTS-73.8* LYMPHS-19.7 MONOS-4.2 EOS-1.2
BASOS-1.1
[**2150-3-27**] 12:30PM PLT COUNT-297
Brief Hospital Course:
1. Depression. Patient was evaluated for ECT on admission and
began treatments on [**4-1**]. He received a total of 2 treatments
with plans for additional treatments next week. Prozac and
abilify were continued. At time of d/c he reports that he feels
better from a psychiatric standpoint and that he thinks the ECT
has been helpful. He currently denies suicidal ideation and
depressed mood, and he feels that he would be safe (from a
mental health standpoint) outside of the psychiatric unit.
2. Shortness of breath/epigastric pain
On the evening after Mr. [**Known lastname 39940**] second ECT treatment, he began
to complain of mild midepigastric pain. Physical exam at the
time showed no abdominal tenderness, and he took his usual
regimen of oxycodone; over the next 2 hours his pain worsened,
and he began to describe his breathing as "labored." O2 sats,
which usually run close to 95%, then dropped to 88-90%, and he
became incontinent of urine x1 [**12-23**] total body weakness and not
reaching the bathroom. At this point medicine consult was
called, who recommended r/o MI workup on the medicine floor.
Initial EKG showed no change from [**3-30**]. ASA 325 and nitro were
given x1.
3. COPD
Oxygen continued at 3L (unable to give 2.5 on [**Hospital1 **] 4) along with
home medications to target sat 94%. No complications prior to
difficult breathing that prompted medicine transfer.
Medications on Admission:
Lisinopril 5mg PO qday
Diltiazem 360mg PO qday
Terazosin 5mg PO qday
Simvastatin 10mg PO qday
ASA 81mg PO qday
Prilosec 20mg PO qday
Albuterol 2puffs qid PRN SOB
Spiriva
Advair 250-50 one puff [**Hospital1 **]
Flonase 50mcg 2puffs qday
Prozac 80mg qday
Abilify 5mg PO qdaily
Neurontin 200mg PO qhs
Colace 100mg PO qdaily
Ambien 10mg PO qhs
Oxycodone 5-10 mg PO q4-6hrs PRN pain
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Albuterol Sulfate Inhalation
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
10. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
11. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
12. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
13. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze/SOB.
17. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
18. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Axis I: MDD
Axis II: deferred
Axis III: COPD, OSA, transitional cell cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent although weak.
Discharge Instructions:
Transfer to medicine service for further evaluation
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2133**], MD Phone:[**Telephone/Fax (1) 2134**]
Date/Time:[**2150-4-6**] 12:00
Admission Date: [**2150-4-3**] Discharge Date: [**2150-4-21**]
Date of Birth: [**2078-1-7**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
PICC placement
skin biopsy
History of Present Illness:
72 year-old male with pmh of COPD on home oxygen, OSA, htn,
recent dx of transitional cell carcinoma of his left kidney, and
depression who was admitted on [**3-27**] under section 12 status for
suicidal ideation. He has undergone 2 ECT treatments since
admission with improvement in his symptoms. He is no longer
currently suicidal.
.
Today after his ECT treatment he developed abdominal pain across
the front of his abdomen, nonradiating, which was [**2149-12-24**] and
felt like pressure. No N/V, no diarrhea. No fevers or chills. He
has also noticed increased dyspnea since the ECT treatment. He
has DOE at baseline, however usually is not dyspneic at rest. He
has also dropped his sats from the mid 90's to the low 90's on 3
L NC. Admits to associated nonradiating substernal chest
pressure. Also had an epsidoe of incontinence today. He states
he's had incontinece before when he can't make it to the
bathroom in time.
.
He was evaluated on [**Hospital1 **] 4 and was continuing to complain of
chest pressure. An EKG was unchaged from his admission EKG
except that he was slightly tachycardic. He was given ASA 325 mg
po once and 1 SL nitro with improvement in his chest pressure.
Labs were drawn, a CXR was preformed, and he was transferred to
medicine on [**Wardname 836**].
.
On [**Wardname 836**] he was found to have a temperature of 102. His WBC came
back at 20 and his CXR showed a bilateral Lt> Rt lower lobe PNA.
He continues to feel poorly and feels dyspneic. He denies
current chest pressure.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- COPD, on 2.5L home 02, PFTs [**2140**] with FEV1/FVC 69%, no
significant response to bronchodilators
- OSA, has not tolerated CPAP in past secondary to discomfort
- HTN
- AAA, 4 cm descending aorto on [**2146**] CT
- HLD
- Transitional cell carcinoma of left kidney, dx [**2-28**]
- Peripheral neuropathy thought secondary to alcoholism
- Arthritis, cervical spine
- Gastro esophageal reflux
- Gait imbalance
- Constipation
- Benign prostatic hypertrophy
- Vitamin d deficiency
- Chronic neck and back pain, [**2141**] L-spine MRI with degerative
disease, L3/L4 disc herniation with involvement of spinal
nerves, mild to moderate neural foraminal narrowing multilevel,
mild central canal stenosis L3/L4 and L4/L5
- Mandibular osteomyelitis in past
- Anemia
Social History:
HCP [**Name (NI) 56581**] [**Name (NI) 5700**]. He worked as an electrician until
retirement 12 years ago. H/o alcoholism, last drank 15 years
ago. Denies h/o DTs and seizures. Has been through detox
multiple times. smokes 1ppd for 60 years, has smoked as much as
[**1-22**] ppd.
Family History:
alcoholism in brother. depression in mother.
Physical Exam:
Vitals: T: 102.7 BP 200/110 P 144 Sat 91% on 3L RR 24
General: Elderly male lying in bed, ill-appearing and sweaty.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Increased RR rate, crackles present bilaterally at the
bases. Gets noticeably dyspneic with any movement.
CV: Tachycardic and regular. No MRG.
Abdomen: +BS, soft NTND
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert, confused. Knows he's in a hospital, but can't tell
me the year.
Pertinent Results:
Admission labs:
[**2150-4-3**] 10:12PM BLOOD WBC-20.1*# RBC-4.74 Hgb-13.5* Hct-41.2
MCV-87 MCH-28.4 MCHC-32.7 RDW-14.0 Plt Ct-339
[**2150-4-3**] 10:12PM BLOOD Neuts-86.1* Lymphs-8.6* Monos-3.9 Eos-1.0
Baso-0.4
[**2150-4-5**] 08:49PM BLOOD PT-13.5* PTT-25.3 INR(PT)-1.2*
[**2150-4-3**] 10:12PM BLOOD Glucose-119* UreaN-16 Creat-1.1 Na-138
K-4.4 Cl-98 HCO3-27 AnGap-17
[**2150-4-3**] 10:12PM BLOOD ALT-24 AST-40 CK(CPK)-606* AlkPhos-91
TotBili-0.5
[**2150-4-4**] 08:15AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0
[**2150-4-5**] 08:49PM BLOOD calTIBC-276 Ferritn-129 TRF-212
[**2150-4-6**] 10:56AM BLOOD %HbA1c-6.3* eAG-134*
[**2150-4-5**] 08:49PM BLOOD TSH-2.1
.
Discharge labs:
[**2150-4-21**] 07:15AM BLOOD WBC-10.0 RBC-3.88* Hgb-10.7* Hct-33.9*
MCV-87 MCH-27.6 MCHC-31.6 RDW-15.1 Plt Ct-510*
[**2150-4-21**] 07:15AM BLOOD Neuts-75.0* Lymphs-17.7* Monos-4.4
Eos-2.3 Baso-0.5
[**2150-4-16**] 07:10AM BLOOD PT-12.6 PTT-24.9 INR(PT)-1.1
[**2150-4-21**] 07:15AM BLOOD Glucose-89 UreaN-6 Creat-1.1 Na-141 K-4.5
Cl-103 HCO3-29 AnGap-14
[**2150-4-21**] 07:15AM BLOOD ALT-33 AST-14 LD(LDH)-182 AlkPhos-58
TotBili-0.4
[**2150-4-21**] 07:15AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.3
.
Cardiac enzymes:
[**2150-4-6**] 04:32AM BLOOD CK(CPK)-211 CK-MB-3 cTropnT-<0.01
[**2150-4-5**] 08:49PM BLOOD CK(CPK)-294 CK-MB-3 cTropnT-<0.01
proBNP-[**2066**]*
[**2150-4-5**] 07:25AM BLOOD CK(CPK)-255 CK-MB-2 cTropnT-0.01
proBNP-1018*
[**2150-4-4**] 05:33PM BLOOD CK(CPK)-413* CK-MB-4 cTropnT-<0.01
[**2150-4-4**] 08:15AM BLOOD CK(CPK)-426* CK-MB-4 cTropnT-0.02*
[**2150-4-3**] 10:12PM BLOOD CK(CPK)-606* CK-MB-5 cTropnT-<0.01
.
Urinalysis:
[**2150-4-3**] 09:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2150-4-3**] 09:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
Microbiology:
[**2150-4-3**] 11:15 pm BLOOD CULTURE
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET
ONLY.
Aerobic Bottle Gram Stain: GRAM POSITIVE COCCI IN PAIRS AND
CLUSTERS.
.
[**2150-4-5**] 11:16 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2150-4-5**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2150-4-8**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH.
YEAST. SPARSE GROWTH.
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**2150-4-6**] 2:15 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2150-4-6**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE: Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
STAPH AUREUS COAG +. RARE GROWTH.
LEGIONELLA CULTURE: NO LEGIONELLA ISOLATED.
FUNGAL CULTURE: YEAST. OF TWO COLONIAL MORPHOLOGIES.
.
[**2150-4-13**] 2:51 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Venipuncture.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
-Urine legionella antigen [**2150-4-4**]: negative
-C. diff toxin: negative x 5
-Blood cultures [**2150-4-4**], [**2150-4-5**], [**2150-4-6**], [**2150-4-11**], [**2150-4-12**]: no
growth
-Urine cultures [**2150-4-3**], [**2150-4-5**], [**2150-4-11**], [**2150-4-13**]: no growth
[**2150-4-13**] 09:25AM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-negative
[**2150-4-13**] 09:25AM BLOOD B-GLUCAN-negative
.
Imaging:
.
CXR (portable AP) [**2150-4-3**]: Increased vague densities at the
bases, which could be atelectasis or pneumonia. Study degraded
by subtle patient motion.
.
CXR (PA and lateral) [**2150-4-4**]: On the current study there is
evidence of a patchy density at the left lower lobe posteriorly,
consistent with pneumonia in the appropriate clinical setting.
There is also some obscuration of the right heart border and
increased density overlying the cardiac silhouette in the
lateral view consistent with right middle lobe consolidation
again likely pneumonia in the appropriate clinical setting.
Upper lungs remain clear. There are no features of CHF and the
heart size is normal.
IMPRESSION: Bilateral pneumonias as described above.
.
Echocardiogram (TTE) [**2150-4-6**]: The left atrium is normal in size.
No left atrial mass/thrombus seen (best excluded by
transesophageal echocardiography). The estimated right atrial
pressure is 10-20mmHg. 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 are mildly thickened (?#). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Mild pulmonary
artery systolic hypertension.
.
Bilateral lower extremity venous ultrasound [**2150-4-6**]: There is
normal compressibility, augmentation and spontaneous phasic flow
with no evidence of intraluminal filling defect. There is an
anechoic structure in the left popliteal fossa measuring 1.7 x
1.2 x 1.2 cm, most consistent with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4675**] cyst.
IMPRESSION: No evidence of DVT. Left [**Hospital Ward Name 4675**] cyst.
.
Abdomen (supine and erect) [**2150-4-12**]: Nonspecific bowel gas
pattern. Unclear etiology of the gas-filled loops of bowel in
the upper abdomen. This will be better assessed with CT if
clinically indicated.
.
CT head w/o contrast [**2150-4-12**]:
1. No acute intracranial process. If there is clinical concern
for subtle metastasis, or acute ischemia, MRI is more sensitive,
if not contraindicated.
2. Markedly prominent ventricles and sulci, stable, representing
global atrophy.
3. Stable chronic small vessel ischemic changes.
4. Left maxillary mucosal thickening on limited views of the
paranasal sinuses.
.
CT abdomen/pelvis [**2150-4-12**]:
1. No evidence of distention of colon.
2. Prominent loops od jejunum, could be due to enteritis of
infectiuos, ischemic, or inflammatory etiology. Short term KUB
to follow- if clinical concern.
3. Mass at the lower pole of the left renal pelvis.
4. Questionable lytic lesion in the right femoral neck,
incompletely characterized. Further evaluation with a dedicated
radiograph is recommended.
.
CT right lower extremity [**2150-4-13**]:
1. No femoral osseous lesion detected. In particular no lesion
is identified in the right femoral neck. The lucency quesitoned
in this area on the [**2150-4-12**] abdominal CT likely represents
partial imaging of a prominent area of more diffuse osteopenia
([**Hospital1 **] triangle), but is not thought to represent a focal lytic
lesion.
2. Incompletely imaged left intrarenal soft tissue mass with
delayed clearance of contrast from an inferior left renal calix,
concerning for a transitional cell carcinoma, similar in
appearance to the study performed on [**2150-4-12**].
3. Descending colon and sigmoid colon diverticulosis.
4. Scrotal skin thickening and trace subcutaneous fat stranding
in the proximal left thigh, nonspecific in appearance. This
could represent edema or inflammatory changes. However, no
associated subcutaneous emphysema to indicate a necrotizing
infection is identified.
.
Scrotal ultrasound [**2150-4-14**]:
1. No intratesticular mass.
2. No signs of Fournier's gangrene or epididymitis.
3. Small bilateral hydrocele.
4. Small indeterminate nodule adjacent to the left epididymis
may represent a granuloma, but cannot be further characterized
by ultrasound.
.
Femur (AP and lateral) [**2150-4-14**]: This exam is WNL with no bone
destruction, fracture, or other osseous abnormality. No overt
abnormality in the partially visualized hip and knee and no knee
effusion.
.
CXR (portable AP) [**2150-4-21**]: Interval placement of a PICC line is
seen with right arm entry and tip in the expected location of
the superior vena cava. There is left basilar opacity most
compatible with atelectasis given the linear appearance. There
is lucent appearance of the upper lungs suggestive of underlying
emphysema. Cardiomediastinal silhouette is stable. There is no
pneumothorax. Bones appear intact. Adequate position of right
arm PICC line with tip in the expected location of the SVC.
.
Bone scan [**2150-4-21**] (wet read): negative
.
Pathology:
.
Skin biopsy right thigh [**2150-4-13**]: Marked superficial dermal edema
and perivascular and interstitial mixed cell infiltrate with
lymphocytes, neutrophils, and rare eosinophils.
.
Note: The marked dermal edema is suggestive of erysipelas. The
number of neutrophils is less than usually observed, however,
inflammation may be decreased in resolving lesions of
erysipelas. The decreased inflammation may, in part, be due to
partial treatment from prior antibiotics. The histologic
differential diagnosis includes a bullous hypersensitivity
reaction including a drug eruption. PAS and gram stains are
negative for fungi and bacteria respectively.
Clinical-pathologic correlation is recommended.
Brief Hospital Course:
72 year-old male COPD on home oxygen, OSA, HTN, recent diagnosis
of transitional cell carcinoma of his left kidney, and
depression admitted initially to psychiatry for suicidal
ideation s/p 2 ECT treatments with pneumonia. He was
transferred [**2150-4-5**] to the MICU for bibasilar pneumonia and back
to the floor [**2150-4-7**]. He was readmitted to the MICU on [**2150-4-12**]
for somnolence and increased oxygen requirement.
.
# Health-care associated pneumonia: On [**2150-4-3**], the patient
developed fever to 102 and tachycardia to 140s. He treated for
health-care associated pneumonia with vancomycin, cefepime, and
ciprofloxacin, later changed to vancomycin, Zosyn with
improvement in his respiratory status. Sputum grew
methicillin-sensitive staph aureus.
.
# COPD: The patient's shortness of breath was thought to be
multifactorial, related not only to pneumonia but also to COPD
and acute on chronic diastolic heart failure. He was treated
with methylprednisolone, followed by prednisone taper. The
prednisone taper was completed prior to discharge. The patient
was discharged on albuterol and Spiriva.
.
# Acute on chronic diastolic congestive heart failure: The
patient's shortness of breath was thought to be multifactorial,
related not only to pneumonia but also to COPD and acute on
chronic diastolic heart failure. BNP was [**2066**]. The patient was
diuresed with IV Lasix, putting out as much as 6 liters of urine
to a single dose of Lasix 20 mg IV. An echocardiogram was
performed and showed mild symmetric left ventricular hypertrophy
with normal cavity size and global systolic function (LVEF>55%).
The patient was euvolemic at the time of discharge.
.
# Paroxysmal atrial fibrillation: The patient had two episodes
of paroxysmal atrial fibrillation. The first episode occurred in
the intensive care unit in the setting of pneumonia and
responded to IV diltiazem. The second occurred on the medical
floor in the setting of profuse diarrhea and dehydration and
responded to IV fluids alone. With CHADS-2 score of 1 (HTN),
patient was started on full dose ASA for anticoagulation. TSH
was normal and ECHO showed normal global systolic function
(LVEF>55%). MI was ruled out with serial cardiac enzymes.
.
# Benign prostatic hypertrophy: Continued terazosin. The
patient's Foley catheter was removed on the day of discharge,
and the patient voided a small amount of urine. He was bladder
scanned for 350 cc prior to discharge and refused a Foley
[**Last Name (un) **]. He should have a voiding trial on arrival to [**Hospital 100**]
Rehab and consideration should be given to Foley placement if he
is retaining urine.
.
# Diarrhea: The patient developed profuse diarrhea while on the
medical floor. C. diff was negative x 5. His diarrhea was
presumed to be due to antibiotics. He was treated with Immodium.
The patient's fluid status will need to be monitored closely at
rehab due to ongoing.
.
# Erysipelas: On the medical floor, the patient developed a
worsening groin rash that was initially thought to be fungal but
worsened on Nystatin. Dermatology was consulted and thought the
rash to be likely cellulitis/erysiphelis. Skin biopsy was
consistent with this. The patient was initially treated with IV
fluconazole and nafcillin, subsequently narrowed to just
nafcillin. CT and ultrasound were done to rule out Fournier's
gangrene. The patient's rash was improving and sutures were
removed prior to disharge.
# Drug rash: Patient developed a maculopapular rash during his
ICU stay. Dermatology thought likely drug reaction secondary to
Zosyn that he had received a week prior. The rash improved
despite ongoing treatment with nafcillin. The patient was
monitored for signs of DRESS syndrome. He should have CBC with
diff and LFTs checked weekly while on nafcillin.
.
# Question of lytic lesion in right femur: A possible lytic bone
lesion was noted in the patient's right femoral neck during
abdomen/pelvis CT. This finding was not confirmed by plain films
or by CT of the patient's right lower extremity. After
discussion with radiology, the decision was made to proceed with
bone scan given the patient's known transitional cell carcinoma
and the high-risk location of the lesion. The preliminary read
of this scan was negative, but the final read will need to be
followed after discharge.
.
# Depression: The patient was initially admitted to the
psychiatry service for depression under section 12. During his
psychiatric admission, the patient received two
electroconvulsive therapy treatments, which were complicated by
aspiration and pneumonia. In the ICU and on the medical floor,
the patient was followed by the psychiatry consult service. He
continued his regimen of Aripiprazole 5 mg PO HS, Fluoxetine 80
mg PO DAILY. At rehab, the patient will need ongoing psychiatric
care. The psychiatry service should be consulted on admission to
rehab. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] recommended consulting Dr.
[**Last Name (STitle) **] at [**Hospital 100**] Rehab.
.
# Transitional cell carcinoma: The patient was recently
diagnosed with transitional cell carcinoma. He has urology
follow-up for this on Per patient, he will be undergoing
nephrectomy after depression treatment.
.
# Hypertension: Increased lisinopril to 10 mg daily and
decreased diltiazem extended-release to 240 mg daily.
.
# Hyperlipidemia: Continued Simvastatin 10 mg PO DAILY
.
# Chronic neck and back pain: Stopped gabapentin and oxycontin.
Discharged patient on only oxycodone 5 mg Q6H PRN pain.
.
# GERD: Continued Omeprazole 20 mg PO DAILY
.
# Obstructive sleep apnea: Continued Autoset CPAP at night.
.
# Tobacco abuse: Initially treated with nicotine patch and gum
but discontinued this prior to discharge.
.
# Communication: Healthcare proxy is [**Name (NI) 20695**] [**Name (NI) 5700**]
[**0-0-**].
Medications on Admission:
Current Inpatient Mediations:
Aripiprazole 5 mg PO/NG HS
Nicotine Patch 14 mg TD DAILY
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze/SOB
OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain
Multivitamins 1 TAB PO/NG DAILY
Oxycodone SR (OxyconTIN) 30 mg PO Q12H
Gabapentin 200 mg PO/NG HS
Diltiazem Extended-Release 360 mg PO DAILY
Fluoxetine 80 mg PO/NG DAILY
Fluticasone Propionate NASAL 2 SPRY NU DAILY
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Tiotropium Bromide 1 CAP IH DAILY
Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB/Wheeze
Omeprazole 20 mg PO DAILY
Aspirin 81 mg PO/NG DAILY
Simvastatin 10 mg PO/NG DAILY
Terazosin 5 mg PO HS
Lisinopril 5 mg PO/NG DAILY
Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO Q4H:PRN
Milk of Magnesia 30 ml PO Q8H:PRN constipation
Acetaminophen 650 mg PO Q4H:PRN
Nicotine Polacrilex 1 STCK PO Q2H:PRN cravings
.
Medications:
Lisinopril 5mg PO qday
Diltiazem 360mg PO qday
Terazosin 5mg PO qday
Simvastatin 10mg PO qday
ASA 81mg PO qday
Prilosec 20mg PO qday
Albuterol 2puffs qid PRN SOB
Spiriva
Advair 250-50 one puff [**Hospital1 **]
Flonase 50mcg 2puffs qday
Prozac 80mg qday
Abilify 5mg PO qdaily
Neurontin 200mg PO qhs
Colace 100mg PO qdaily
Ambien 10mg PO qhs
Oxycodone 5-10 mg PO q4-6hrs PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
depression
aspiration pneumonia
COPD
erisipelas
paroxysmal atrial fibrillation
.
Secondary:
hypertension
transitional cell carcinoma
obstructive sleep apnea
GERD
benign prostatic hypertrophy
tobacco use
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 came to the hospital with depression. You were transferred
to the intensive care unit due to shortness of breath. Your
found to have pneumonia and an exacerbation of your COPD. You
were treated with antibiotics for pneumonia and with steroids
for COPD. With this treated, your breathing improved.
Subsequently, you developed a groin rash, diarrhea, confusion,
and an increased oxygen requirement, requiring transfer back to
the intensive care unit. Your antibiotics were changed. As your
condition improved, so you were transferred back to the medical
floor. Just prior to discharge, you were given a special type of
IV called a PICC that will allow you to receive antibiotics at
rehab.
.
In addition to the groin rash, you developed a second, more
generalized rash, which was thought to be due to an antibiotic
called Zosyn (pipercillin/tazobactam). You are currently on a
related antibiotic called nafcillin, which you are tolerating
well. However, you should avoid Zosyn and related antibiotics in
the future.
.
You had two episodes of an abnormal heart rhythm called atrial
fibrillation. Due to this, your aspirin dose was increased to
325 mg daily.
.
You developed severe diarrhea. You were treated with a
medication called loperamide, with improvement in you diarrhea.
.
You will need further psychiatric treatment after your medical
condition improves. The psychiatrist at [**Hospital 100**] Rehab should be
consulted and will arrange for appropriate follow-up, which may
include transfer back to the psychiatry service at [**Hospital1 18**].
.
You Foley catheter was removed on the day of discharge. You had
a bladder scan which showed that there was still 350 mL of urine
in your bladder. You will need to have a voiding trial as soon
as you arrive at [**Hospital 100**] Rehab and may need a Foley catheter
placed if you are found to be retaining urine.
.
There have been some changes to your medications:
START nafcillin for skin rash until [**2150-5-4**]
START loperamide for diarrhea
START multivitamin
INCREASE aspirin to 325 mg daily due to atrial fibrillation
INCREASE lisinopril to 10 mg daily
DECREASE diltiazem to 240 mg daily
STOP Neurontin (gabapentin)
STOP Colace (docusate) due to diarrhea
STOP Ambien
DECREASE oxycodone to 5 mg every 6 hours as needed for pain
STOP oxycontin
CONTINUE nystatin for thrush for another 5 day
.
Follow up as indicated below.
Followup Instructions:
For your transitional cell carcinoma, please follow-up with your
urologist, Dr. [**First Name (STitle) **], at [**Hospital6 **] on [**2150-5-5**] at 2:30
p.m. Address is at [**Location (un) 25716**] on the [**Location (un) **]. Phone
#[**Telephone/Fax (1) 85694**].
.
As above, patient may need transfer for inpatient psychiatric
treatment after medically cleared. Per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Hospital1 18**]), will need to be evaluated by psychiatrist (Dr. [**Last Name (STitle) **]
at rehab.
|
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66,386
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42338
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Discharge summary
|
report
|
Admission Date: [**2199-11-3**] Discharge Date: [**2199-11-11**]
Date of Birth: [**2139-6-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
1. Urgent coronary artery bypass graft x4; left internal
mammary artery to left anterior descending artery and
saphenous vein grafts to ramus, obtuse marginal and
posterior descending arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
60 yo male with PMHX significant for
HTN, dyslipidemia, and obesity who admitted to OSH with several
minutes of substernal chest pain which began with exertion and
radiated to the left arm which began on [**10-31**]. He was in his
usual state of health when he was carrying a 5 pound box and
developed exertional chest pain, which lasted 1 hour. He had a
similar episode previously when climbing stairs in the past. He
presented to his PCP at Greater [**Name9 (PRE) 487**] Family Health Center
and
referred to the ED. Initial troponin 0.35->0.47->0.52 with no
EKG changes in ED. He was cath'd [**11-1**] with found to have left
main disease. He was Plavix loaded at the time of the
catherization. He was transferred to [**Hospital1 18**] for CABG evaluation.
Past Medical History:
Coronary Artery Disease, s/p CABG x 4
PMH:
Obesity, HTN, dyslipidemia, ashma,
hemmorrhoids, asbestos exposure
Past Surgical History:s/p surgery for prostate cancer, s/p
urethrostomy for bladder neck contracture, s/p tonsillectomy
Social History:
Contact:[**Name (NI) 91716**] Phone #(H) [**Telephone/Fax (1) 91717**]
(C) [**Telephone/Fax (1) 91718**]
Amalfis (Daughter) Cell [**Telephone/Fax (1) 91719**]
Occupation: Retired from work in demolition and asbestos
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:none
ETOH: < 1 drink/week [x] [**3-18**] drinks/week [] >8 drinks/week []
Illicit drug use- none
Family History:
Premature coronary artery disease
Physical Exam:
Pulse:75 Resp:18 O2 sat:98% RA
B/P Right: 137/86 Left:
Height: 5'7" Weight: 192#
General: AAO x 3 in NAD
Skin: Dry [x] intact [x] Well healed pelvic midline incision
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema None
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Pertinent Results:
TEE [**2199-11-5**]
Conclusions
PRE-CPB: 1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No thrombus is seen in the left atrial
appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
LVEF=60%.
4. The right ventricular free wall thickness is normal. The
right ventricular cavity is mildly dilated with normal free wall
contractility.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened . There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
7. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is mild MAC.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine briefly. No infusion
meds. Preserved biventricular systolic function post cpb. MR [**First Name (Titles) **] [**Last Name (Titles) **]I remain trace. Aortic contour is normal post decannulation
[**2199-11-11**] 05:50AM BLOOD WBC-9.0 RBC-4.35* Hgb-10.6* Hct-31.4*
MCV-72* MCH-24.5* MCHC-33.9 RDW-17.7* Plt Ct-417
[**2199-11-10**] 02:50PM BLOOD Hct-28.7*
[**2199-11-9**] 06:55AM BLOOD WBC-10.8 RBC-3.74*# Hgb-8.8*# Hct-27.3*
MCV-73*# MCH-23.4* MCHC-32.2 RDW-16.7* Plt Ct-293
[**2199-11-11**] 05:50AM BLOOD UreaN-15 Creat-0.9 Na-134 K-4.9 Cl-97
[**2199-11-9**] 06:55AM BLOOD Glucose-99 UreaN-17 Creat-0.9 Na-140
K-4.9 Cl-101 HCO3-31 AnGap-13
[**2199-11-11**] 05:50AM BLOOD Mg-2.4
[**2199-11-9**] 06:55AM BLOOD Mg-2.5
Brief Hospital Course:
The patient was brought to the Operating Room on [**2199-11-5**] where
the patient underwent Coronary Artery Bypass x 4 with Dr.
[**First Name (STitle) **]. Please see operative note for further details. Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. On [**2199-11-8**] HCT was 20% he transfused with 2
units of red cells to a HCT of 27%. The patient was evaluated
by the physical therapy service for assistance with strength and
mobility. He did develop ecchymosis of the left thigh. Dark
blood mixed with clot was expressed from the JP exit site of the
right leg. There was no erythema of the wound and hematocrit
continued to rise. The patient is advised to keep the left leg
and thigh wrapped for 3 days. By the time of discharge on POD 6
the patient was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. The patient was
discharged home in good condition with appropriate follow up
instructions. He will have Free Care medications. He will not
have VNA services.
Medications on Admission:
Enalapril 40 mg daily, HTCZ 25 daily,
Lopressor 50 daily, Nasonex, Colace, Albuterol 2 puffs, Zocor 40
daily, Naproxen 500 mg PRN, Cetirizine 10 mg daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
7. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG x 4
PMH:
Obesity, HTN, dyslipidemia, ashma,
hemmorrhoids, asbestos exposure
Past Surgical History:s/p surgery for prostate cancer, s/p
urethrostomy for bladder neck contracture, s/p tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace to 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]: [**2199-11-19**]
10:00
[**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2199-12-9**] 1:15 in the [**Hospital Unit Name **] [**Last Name (NamePattern1) **]
[**Hospital Unit Name **]
Cardiology: Dr. [**Last Name (STitle) 91720**] office will call you with appt.
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J [**Telephone/Fax (1) 63099**] in [**5-14**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2199-11-11**]
|
[
"782.3",
"305.1",
"V10.46",
"493.90",
"401.9",
"V15.84",
"782.7",
"272.4",
"V85.30",
"V17.3",
"413.9",
"414.01",
"780.62",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7248, 7267
|
4704, 6265
|
321, 582
|
7541, 7716
|
2813, 4681
|
8504, 9480
|
2097, 2132
|
6470, 7225
|
7288, 7398
|
6291, 6447
|
7740, 8481
|
7420, 7520
|
2147, 2794
|
271, 283
|
610, 1375
|
1397, 1507
|
1645, 2081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,787
| 106,780
|
2560
|
Discharge summary
|
report
|
Admission Date: [**2129-6-8**] Discharge Date: [**2129-6-11**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Meropenem / Penicillins / Carbapenem
Attending:[**Doctor First Name 3290**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
85M hypotensive to SBP 60s prior to HD today. Did not get
[**Doctor First Name 2286**]. Overall tells me that he was feeling well, had
breakfast this morning. Specifically he denied any fevers,
chills, nausea, vomiting ,diarrhea (had a normal BM this
morning). He is using a wheelchair at baseline and has been
using it today to get around his apartment without any
difficulty. He has not noticed any rashes. Of note, he had
fractured his left foot recently, but this has healing. He still
wears a brace when trying to walk with a walker.
ED Course:
- Initial Vitals: 97.4 78 80/46 20 98% 4L Nasal Cannula
- EKG: afib @ 67, LAD, QRS 114, TWI III, TW flattening v2-5
- WBC up from b/l
- 70s/30s, improved with bolus ~ 800 cc total
[x] bld cx
[x] CXR - low lung volumes, streaky basilar opacities, more in
left retrocardiac region, likely atelectasis, pleural
effusion/PNA not excluded
[x] UA --> doesn't make urine
[x] abx for ? PNA on CXR --> written for levo, vanc
.
On arrival to the MICU, patient told me that he was feeling much
better. His BP was 113/71, HR 68.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- ESRD on HD (MWF)
- CAD s/p MI
- Afib, not anticoagulated
- CVAs x2, residual R sided weakness, from 12 [**Doctor First Name 1686**] then 5 [**Doctor First Name 1686**] ago
- Hx of GI Bleed
- Nephrolithiasis
- OSA, not using CPAP
- Iron Deficiency Anemia
- Depression
- Hx of C.diff
- Restrictive Ventalatory Pulmonary Defect
- Pelvic and wrist fractures [**1-29**]
- Recurrent UTIs, including VRE and klebsiella
- Multiple episodes of line related bacteremia:
- MRSA in [**2125-9-6**] treated for 6 weeks of vanc given possible
clot in fistula. Line removed. TTE negative for vegetation. TEE
not performed.
- ESBL E.coli bacteremia in [**2125-9-26**] thought to be line related.
- ESBL E.coli bacteremia in [**2125-11-26**]. Thought to be line
related. s/p total 4-week course of meropenem/ertapenem.
([**Date range (1) 12915**]) for likely endovascular infection in setting of R
IJ clot.
- ESBL E.coli x 2 types, E. faecium [**Name (NI) 12916**] unclear source despite
extensive work-up ([**2126-6-27**]). s/p 4 weeks of Vancomycin and
Meropenem.
- ESBL E. coli and E. faecium [**Month/Day/Year 12916**] ([**2126-7-28**]) thought to be line
related s/p 2 weeks Vancomycin/Meropenem.
- Pansusceptible Klebsiella pneumoniae [**Month/Day/Year 12916**] thought [**1-20**] 7mm CBD
stone. s/p ERCP and stenting. Due for repeat ERCP
Social History:
Lives with wife [**Name (NI) **], wife of 62 [**Name2 (NI) 1686**]; she is his primary
caregiver. [**Name (NI) **] is wheelchair bound but has a nurse to help with
showering, daughter lives downstairs
-h/o smoking [**12-20**] PPD for 50 years, quit 20 years ago, occasional
beer, no drugs.
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, neck collar 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, no CVA
tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, CN II-XII w/out decrement, PERRL, [**2-21**] RLE strength,
[**3-24**] RUE strength
Pertinent Results:
ADMISSION LABS
[**2129-6-8**] 01:05PM BLOOD WBC-9.5# RBC-3.61* Hgb-11.6* Hct-35.0*
MCV-97 MCH-32.1* MCHC-33.2 RDW-15.3 Plt Ct-137*
[**2129-6-8**] 01:05PM BLOOD Neuts-73.5* Lymphs-20.4 Monos-4.2 Eos-1.6
Baso-0.3
[**2129-6-8**] 01:05PM BLOOD PT-11.4 PTT-48.2* INR(PT)-1.1
[**2129-6-8**] 01:05PM BLOOD Glucose-97 UreaN-61* Creat-6.7*# Na-137
K-4.8 Cl-98 HCO3-22 AnGap-22*
[**2129-6-8**] 01:05PM BLOOD ALT-13 AST-15 AlkPhos-133* TotBili-0.2
[**2129-6-8**] 02:12PM BLOOD Lactate-1.7
[**2129-6-8**] 02:19PM BLOOD Lactate-0.9
.
[**2129-6-8**] CXR Portable AP
IMPRESSION: Low lung volumes with patchy basilar opacities,
greater on the left than right, probably attributable to
atelectasis, but not entirely specific.
If pulmonary symptoms are present or other concern for
pneumonia, than when clinically appropriate, short-term followup
chest radiographs, preferably with standard PA and lateral
technique if possible, could be considered
[**2129-6-11**] CXR PA and lateral
PENDING
Brief Hospital Course:
85 M w/ hx of ESRD on HD, CAD, afib, CVA w/ residual R sided
weakness who presented from [**Month/Day/Year 2286**] with hypotension.
#Hypotension: The patient was initially hypotensive in the ED
however BP normalized with one liter of IVF. BP normal upon
presentation to ICU (last admission BP normalized to approx
100-110 systolic). Hypotension was felt to most likely be
secondary to hypovolemia as the patient had no clear e/o
infection (WBC normal, no fevers). He was continued on
vancomycin and levofloxacin initially. The patients blood
pressure remained stable and he remained afebrile and was
transferred to the general medical service. Thereafter, BP were
normal with the exception of one event during hemodialysis; this
episode of hypotension was attributed to not taking midodrine
prior to hemodialysis as the patient normally does. The patient
declined further labs and ECHO and requested discharge to home.
As the patient remained afebrile and hemodynamically stable, the
antibiotics were discontinued and the patient was discharged
home.
STABLE ISSUES
#ESRD on HD: Patient is dialyzed on a MWF schedule. He had
missed [**Month/Day/Year 2286**] on the day of admission. As above blood pressure
stabilized and he was dialyzed on HD 1 and 3. He was also
continued on his home phosphate binder.
#Hx of CAD: no e/o active ischemia. No EKG changes. A cardiac
evaluation for heart failure was attempted; troponin 0.05 but
the patient declined further cardiac biomarkers and ECHO.
Patient was continued on his home statin and ASA.
# Atrial Fibrillation- Patient has a known hx of a fib in the
past. He is not currently anti-coagulated due to frequent falls.
His was intermittently in atrial fib throughout this admission.
However HR remained stable in the 80s-90s.
#Pulm Htn: noted TTE from [**2128-1-20**]. Has OSA but is not currently
on CPAP. No e/o heart failure on exam.
Medications on Admission:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for SOB.
4. midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous HD
protocol for 2 weeks.
Disp:*6 * Refills:*0*
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Gabapentin 300 mg PO HS
3. Ipratropium Bromide MDI 1 PUFF IH QID shortness of breath
4. Midodrine 5 mg PO BID
Please give dose before HD session.
5. Omeprazole 20 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Acetaminophen 650 mg PO Q 8H
9. Ascorbic Acid 1000 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Cyanocobalamin 100 mcg PO DAILY
12. Calcium Acetate 1334 mg PO TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 12731**],
You were admitted to [**Hospital1 18**] for evaluation of low blood pressure
during hemodialysis. It is unclear what caused these low blood
pressures. We do not think you have an infection, and we could
not complete our tests of your heart function. We recommended
further tests, but you elected to defer these studies. Please
continue to take your medications as you had been taking them.
It was a pleasure taking care of you and we wish you a speedy
recovery!
Followup Instructions:
Please call your PCP on [**Name9 (PRE) 766**] to move up your appointment with
Dr. [**Last Name (STitle) **] to an earlier date.
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: TUESDAY [**2129-7-12**] at 1:30 PM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2129-6-13**]
|
[
"427.31",
"412",
"458.9",
"416.8",
"585.6",
"438.89",
"280.9",
"780.79",
"414.01",
"V45.11",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8776, 8782
|
5219, 7115
|
308, 322
|
8838, 8838
|
4216, 5196
|
9518, 10033
|
3568, 3585
|
8309, 8753
|
8803, 8817
|
7141, 8286
|
8989, 9495
|
3600, 4197
|
1441, 1889
|
257, 270
|
350, 1422
|
8853, 8965
|
1911, 3243
|
3259, 3552
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,217
| 170,747
|
36771
|
Discharge summary
|
report
|
Admission Date: [**2193-10-14**] Discharge Date: [**2193-10-19**]
Date of Birth: [**2128-10-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2193-10-15**] left heart catheterization, placement of intra aorrtic
balloon
[**2193-10-15**] 1. Emergency coronary artery bypass graft x3 -- left
internal mammary artery to left anterior descending
artery and saphenous vein graft to obtuse marginal and
posterior descending arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
This 64 year old white male presented elsewhere with 3-4 weeks
of progressive angina.He initially presented to [**Hospital1 **]-[**Location (un) 620**] where
he had a normal EKG but troponins were 0.04/0.113. He recieved
325mg ASA.
Heparin was begun and he was transferred here. Catheterization
was done to demonstrate 95% proximal left main disease with
thrombus. An intra aortic balloon was placed and surgical
consultation was obtained.
Past Medical History:
Dyslipidemia
Hypertension
s/p Right femoral endarterectomy and vein patch angioplasty with
profundaplasty and right common femoral to above-knee popliteal
artery.
Social History:
Worked as an offset printing specialist at TPI, Married, lives
with wife independent in ADLS/IADLS
-Tobacco history: 40 pack year smoking history, quit 2 yrs ago
-ETOH: 3-4 beers daily
-Illicit drugs: None
Family History:
Mother died of MI at age of 82, Father died of colon cancer at
an advanced age. No other family history of MI or HLD, or HTN.
Physical Exam:
VS: T=97.1...BP=141/81...HR=55...RR=18...O2 sat=97% on RA
GENERAL: well developed man 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 at mid-neck at 90 degrees
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 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+
Pertinent Results:
Intra-op TEE [**2193-10-15**]
Conclusions
PRE-BYPASS:
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. There is an intra-aortic balloon pump in place
with the tip 5 cm distal to the takeoff of the right sublclavian
artery. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. There is no aortic valve stenosis.
Trace aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2193-10-15**]
at 1:00 PM.
POST-BYPASS:
The patient is on no inotropic infusions. Biventricular function
is unchanged. Mitral regurgitation is unchanged. The aorta is
intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2193-10-15**] 15:57
[**2193-10-19**] 06:50AM BLOOD WBC-11.5* RBC-3.46* Hgb-11.0* Hct-33.0*
MCV-95 MCH-31.9 MCHC-33.5 RDW-12.5 Plt Ct-209#
[**2193-10-19**] 06:50AM BLOOD UreaN-14 Creat-0.8 Na-137 K-3.8 Cl-103
Brief Hospital Course:
Mr [**Known lastname 5395**] is a 65 year old man with several weeks of exertional
angina that worsened on the day of admission, it was at this
time that he presented to the emergency room in [**Location (un) 620**]. He was
transferred to [**Hospital1 18**] for cardiac catheterization and found to
have 95% thrombus of the left main coronary artery. An intra
aortic balloon pump was placed, cardiac surgery was consulted
and he was taken emergently to the Operating Room where
revascularization was undertaken. Please see the operative note
for details, in summary he had: Emergency coronary artery bypass
graft times three with left internal mammary artery to left
anterior descending artery and saphenous vein graft to obtuse
marginal and posterior descending arteries. Endoscopic
harvesting of the long saphenous vein. His bypass time was 71
minutes and cross clamp time 61 minutes. He weaned from bypass
in stable condition on Neosynephrine and Propofol with the IABP.
He awoke, weaned from the ventilator and was extubated. The
IABP was removed with out incident. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility.
By the time of discharge on post-operative day four the patient
was ambulating freely, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged in
good condition with appropriate follow up instructions.
Medications on Admission:
CONFIRMED WITH PHARMACY
Lisinopril 40mg daily
Metoprolol tartrate 25mg daily
amlodipine 10mg daily
Pravastatin 80mg daily
ASA 81mg
Discharge Medications:
1. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*2*
2. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 10 days.
Disp:*10 Tablet Extended Release(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. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
left main coronary artery disease
crescendo angina
hypertension.
hyperlipidemia
s/p emergent coronary artery bypass
s/p right femoral endarterecmy,vein patch
angioplasty/profundaplasty,right femoral to popliteal graft
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema *****
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) Date/Time:[**2193-11-18**] 1:30
Cardiologist/PCP:[**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**11-6**] at 2:00pm
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2193-10-19**]
|
[
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"410.71",
"414.01"
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icd9cm
|
[
[
[]
]
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[
"37.22",
"37.61",
"36.12",
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|
[
[
[]
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6914, 6973
|
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1352, 1560
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,736
| 184,633
|
41933
|
Discharge summary
|
report
|
Admission Date: [**2132-1-11**] Discharge Date: [**2132-1-22**]
Date of Birth: [**2068-5-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2132-1-11**]: Aortic valve replacement with a size 25-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue valve.
History of Present Illness:
63 M with no significant past medical history who is being
transferred from [**Hospital1 **] for severe AS with heart failure.
Patient initially presented to BIDN with worsening shortness of
breath. He first noticed increasing weakness about six weeks ago
and then over the last two weeks, he also reports worsening
shortness of breath. Previously had very good exercise
tolerance, but over the last two weeks has been getting dyspneic
with walking. Also reports having a new 2 pillow orthopnea that
developed over the last two weeks, as well as
intermittent PND. The patient also reports having new LE edema
that for the last few weeks has been getting worse.
Prior to this, the patient has been very active; he was a
marathon runner, was working out up to four hours/day as
recently as six months ago. He reports having intermittent night
sweats over the last few weeks - occasional night cough; only
occasionally productive of whitish sputum. Denies any bloody
sputum. Denies any recent fevers. Reports decreased appetite
for the last six weeks, with 5-6 pound weight loss over last two
weeks. The patient also reports increased urinary frequency
(but reports that this has been a long standing issue since he
was in his teens), hesitancy; denies any blood in urine. He also
reports having lower back pain that started about 5-6 weeks ago.
Of note, CT from OSH showed that the patient had a chest
infiltrate, as well as concern for malignant lesions in bones.
Patient was also found to have multiple bony lesions and a high
PSA thought to be widely metastatic prostate cancer however this
is not yet confirmed with tissue and oncology feels that he
still
would have a three year prognosis regardless. CT also showed
enlarged heart, ECHO showed EF 20-25%, with severe left
ventricular systolic dysfunction, mild AR, severe aortic
stenosis. Cardiac surgery was consulted for AVR.
Past Medical History:
Prostate CA
Social History:
- Tobacco history: The patient denies any cigarette use in the
past.
- ETOH: 3-4 beers daily, four days/week for last 30 years
- Illicit drugs: denies
The patient lives with his mother who is a 85 y/o.
He used to work as a physical education teacher. Now
intermittently works as a painter.
Family History:
Brother diagnosed with [**Name (NI) 4278**] lymphoma at 51 y/o, sister with
acromegaly, father with stroke at 87 y/o.
Denies any history of early MI or cardiovascular disease.
Physical Exam:
Pulse:100 Resp:18 O2 sat:98/RA
B/P Right:91/65 Left:95/66
Height:5'9" Weight:80kgs
General: awake alert oriented, with some temporal area wasting
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur [[**3-18**]] systolic ejection with radiation to
the R carotid area
Abdomen: Soft [x] non-distended [x] non-tender [x]
+ bowel sounds
Extremities: Warm [x], well-perfused [x] + Edema LE's
Varicosities: None
Neuro: Grossly intact []
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit Right: soft Left: no
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Findings
LEFT ATRIUM: Moderate LA enlargement. Elongated LA. Moderate to
severe spontaneous echo contrast in the body of the LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Severely depressed LVEF.
RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV
free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal descending aorta diameter. Focal calcifications
in descending aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: No pericardial effusion.
Conclusions
Pre Bypass The left atrium is moderately dilated. The left
atrium is elongated. Moderate to severe spontaneous echo
contrast is seen in the body of the left atrium. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= [**6-19**] %). LVEF improves with institution of 0.04mcg/kg/min
epinepherine to 15%. The right ventricular cavity is moderately
dilated with severe global free wall hypokinesis, which improved
to moderate free wall hypokineisis on epinepherine. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
Post Bypass: Patient is on epinephreine 0.08 mcg/kg/min,
Norepinepherine, 0.08 mcg/kg/min, vasopression 3.6 units/hr. LV
function improved on ionotropes to 25%. RV function mildly
hypokinetic. There is a tissue prosthesis (#25 magna per
surgeons) in the aortic position with no perivalvular leaks.
Peak graident 12 mm Hg, Mean 6 mm Hg. Aortic contours intact.
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2132-1-13**]
11:06 AM
Final Report:
1. Interval extubation and removal of the nasogastric tube.
Interval removal of several of the mediastinal drains. Bibasilar
chest tubes and right internal jugular Swan-Ganz catheter with
its tip in the pulmonary outflow tract are stable.
2. Status post median sternotomy with stable postoperative
cardiac and
mediastinal contours. There continues to be patchy bibasilar
airspace
opacities likely reflecting moderate pulmonary edema, which is
essentially
unchanged, although a diffuse pneumonia cannot be excluded. No
pneumothorax is seen. Relative density of the ribs raises
concern for sclerotic metastases, for which clinical correlation
is advised. No pneumothorax or pleural effusions.
[**2132-1-19**] 06:45AM BLOOD WBC-8.5 RBC-4.44* Hgb-12.5* Hct-39.0*
MCV-88 MCH-28.3 MCHC-32.2 RDW-19.0* Plt Ct-224
[**2132-1-18**] 06:22AM BLOOD WBC-7.7 RBC-4.14* Hgb-11.7* Hct-36.4*
MCV-88 MCH-28.2 MCHC-32.0 RDW-19.3* Plt Ct-182
[**2132-1-19**] 06:45AM BLOOD Glucose-92 UreaN-20 Creat-0.7 Na-136
K-3.7 Cl-98 HCO3-28 AnGap-14
[**2132-1-18**] 06:22AM BLOOD Glucose-81 UreaN-21* Creat-0.7 Na-136
K-4.6 Cl-101 HCO3-25 AnGap-15
[**2132-1-17**] 06:15AM BLOOD Na-135 K-4.5 Cl-98
Brief Hospital Course:
Mr [**Known lastname **] was a direct admission to the operating room where he
had an aortic valve replacement by Dr [**Last Name (STitle) 7772**] on [**1-11**].
Please see operative report for further details, in summary he
had: an aortic valve replacement with a size 25-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue valve, bypass time was 102
minutes with a crossclamp of 76 minutes. He tolerated the
operation however had low ejection fraction/ he was transferred
to the cardiac surgery ICU on multiple pressors and inotropes.
He remained hemodynamically stable in the early post-op course,
because of his poor cardiac performance he was kept sedated
through the first post operative night. On POD1 his sedation was
lightened, he awoke neurologically intact, his ventilator was
weaned he was extubated. Additionally his pressors were weaned
to off and his inotropes were weaned as tolerated. He was
started on diuretics and by POD2 his inotropes were off
completely, and he was transferred to the cardiac stepdown floor
for continued recovery. He was also noted to have a brief
episode of atrial fibrillation which was treated with beta
blockers and Amiodarone, after which he converted to sinus
rhythm. Right chest tube was removed [**1-17**] and CXR showed small
anterior PTX. Left chest tube was pulled on [**1-20**] and CXR showed
persistent right small anterior PTX and reaccumulating right
effusion. He was found to have an unstageable coccyx decub and
was seen by the wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 7219**] were made (
see wound care note for deatils). Once on the floor the nursing
and physical therapy staff worked to optimize activity and
improve endurance. The remainder of his hospital course was
uneventful. On POD#10 he was evaluated by the heart failure team
and his regimen was changed- torsemide was changed to lasix and
aldactone, amiodarone was decreased to 100mg and ASA was
increased to 325mg. Lisinopril was not strated due to
hypotension. On POD#11 he was ready for discharge home with
family support. due to lack of insurance coverage, he was not
sent home with VNA services. He is to follow up in wound clinic
in 1 week and with Dr [**Last Name (STitle) 7772**] in 1 month.
Medications on Admission:
Home-None
Transfer-Lasix, Vitamin B12, Trazodone, Percocet,
Azythromycin/Ceftriaxone
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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
3. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
Disp:*60 Tablet Extended Release(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. 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*
10. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
s/p 25mm Magna tissue AVR [**2132-1-11**]
PMH:
Prostate CA
coccyx decub unstageable
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: 3+ edema bilat lower extrem
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
wound care to coccyx
cleanse skin on coccyx and pat dry
apply thin layer of critic aid to rash around wound and wound
Cover with slighlty moistened Aquacel AG sheet and cover with
dry gauze and ABD pad.
Put on your thight high [**Male First Name (un) **] stockings every day before you get
out of bed and take them off at night when you go to bed.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr [**Last Name (STitle) 7772**] [**2-19**] at 1:00pm. [**Telephone/Fax (1) 170**]
[**Hospital **] Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] [**1-24**] at 11:00am
[**Hospital **] Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2132-1-23**] 2:40
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 250**] in [**5-15**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Other [**Hospital1 18**] Appts:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2132-2-12**]
10:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2132-1-22**]
|
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"995.94",
"428.0"
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icd9cm
|
[
[
[]
]
] |
[
"34.04",
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icd9pcs
|
[
[
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329, 461
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,316
| 163,658
|
19517
|
Discharge summary
|
report
|
Admission Date: [**2153-7-18**] Discharge Date: [**2153-9-24**]
Date of Birth: [**2103-7-8**] Sex: M
Service: SURGERY
Allergies:
Demerol
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Hyponatremia
Major Surgical or Invasive Procedure:
Paracentesis
Dobhoff placement
PICC placement
History of Present Illness:
HPI: 50 y/o M w/ HCC +HCV cirrhosis s/p OLT [**5-/2148**], w/ recurrent
HCV infection and cirrhosis decompensated w/ ascites and PSE,
listed for 2nd transplant, who presents from home for evaluation
of hyponatremia. Per patient (who is a questionable historian),
he saw his hepatologist, Dr. [**Last Name (STitle) 497**] in clinic today and had
routine labs drawn. Dr. [**Last Name (STitle) 497**] called him at home and asked him
to present to the hospital as he was found to be hyponatremic.
.
Pt says that he has generally been feeling weak over the past
three months (since he was last hospitalized.) He reports taking
all medications as directed. He may have increased sodium intake
recently at a family party as he reports cheese and crackers
while at the beach over the weekend. He reports having
intermittent, diffuse abdominal pain since his lymph node
resection/ ex-lap/ appendectomy which was complicated by wound
infection. This is relieved by the oxycodone he is taking at
home. He also reports one episode of non-bloody emesis this
morning. Denies current nausea, sick contacts, recent illness.
.
ROS:
+ As per HPI, +weight loss, +weakness, +abdominal pain,
+diarrhea (on lactulose)
- No fevers, chills. No headache, visual changes, seizures. No
sinus tenderness, no sore throat. No chest pain, shortness of
breath, palpitations, orthopnea, cough, increased sputum
production. He denies hematemesis, melena, hematochezia, but he
does have hemorrhoids. He denies dysuria, hematuria, urinary
frequency. He denies muscle and joint pain.
Past Medical History:
1. Cirrhosis (Hep C/ETOH) s/p liver transplant [**5-/2148**]
2. Hepatoma s/p ablation
3. Esophageal varices
4. S/p femur/tibia/fib fx
5. H/o polysubstance abuse
Social History:
Currently unemployed. Lives with his girlfriend. H/o alcohol
use, in remission for 5 years. Used to smoke tobacco, 1 ppd x22
yrs. H/o cocaine, heroine, amphetamine abuse, none since [**2138**].
Family History:
Mother died of MI at 65 yo
Physical Exam:
ON ADMISSION:
VS: 97.4, 102, 112/77, 18, 100% on RA
GEN: pt comfortable, conversant, in no acute distress
HEENT: sclera non-icteric, moist mucus membranes, no LAD, no
increased JVP
CV: RRR, S1, S2, no murmurs/rubs/gallops
LUNGS: CTA b/l, no wheezes/rales/rhonchi
ABD: +BS, soft, distended, abdomen dullness to percussion,
abdominal wall edema, large healing ex-lap wound, pink, clean,
with granulation tissue; slightly TTP diffusely, no rebound or
guarding
EXT: 1+ LE edema, no clubbing, no cyanosis,
NEURO: A&Ox3, no asterixis
.
ON DISCHARGE:
Deceased
Pertinent Results:
ADMISSION LABS:
[**2153-7-18**] 09:20AM BLOOD WBC-8.9 RBC-3.33* Hgb-10.5* Hct-32.1*
MCV-97 MCH-31.4 MCHC-32.5 RDW-15.3 Plt Ct-273
[**2153-7-18**] 09:20AM BLOOD PT-14.5* INR(PT)-1.3*
[**2153-7-18**] 09:20AM BLOOD UreaN-20 Creat-1.3* Na-122* K-4.8 Cl-93*
HCO3-22
[**2153-7-18**] 09:20AM BLOOD ALT-24 AST-52* AlkPhos-625* TotBili-0.6
[**2153-7-18**] 09:20AM BLOOD Albumin-1.9* Calcium-7.6* Phos-3.7 Mg-1.8
.
PERTINENT LABS:
[**2153-7-19**] 08:55AM BLOOD Fibrino-252#
[**2153-8-2**] 05:40AM BLOOD Cortsol-11.5
[**2153-8-7**] 06:13AM BLOOD RheuFac-<3
[**2153-8-7**] 06:13AM BLOOD C3-32* C4-12
[**2153-8-8**] 07:00AM BLOOD calTIBC-25* Ferritn-614* TRF-19*
[**2153-8-9**] 02:13PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2153-8-24**] 08:00AM BLOOD calTIBC-90* VitB12-663 Folate-16.1
Ferritn-901* TRF-69*
[**2153-9-2**] 05:54AM BLOOD TSH-2.9
.
MICRO:
Stool Cx ([**2153-9-7**]): no C. diff
Peritoneal fluid Cx ([**2153-9-6**]: no growth
Urine Cx ([**2153-9-5**]): no growth
.
IMAGING:
Abdominal XR ([**2153-9-4**]): Nasogastric tube with tip in the
proximal duodenum (first or second portion). Nonspecific bowel
gas pattern without concern for ileus or obstruction. Probable
ascites.
.
Portable CXR ([**2153-9-3**]): 1) New large left pleural effusion and
left basilar opacity, could reflect infection with parapneumonic
effusion and/or compressive atelectasis. 2) Probable small right
pleural effusion and right basilar consolidation. 3) Mild volume
overload.
[**9-11**] CT TORSO: 1. Worsening adenopathy throughout the abdomen,
most heavily concentrated in the periaortic region. There are
also enlarged lymph nodes in the paratracheal, pericardial, and
epicardial regions. This diffuse lymphadenopathy has increased
since the comparison CT from [**2153-2-5**], and is concerning
for progression of the known lymphomatous process. Occlusion of
the IVC between the confluence of the iliac veins and the left
renal vein, likely secondary to extrinsic compression by the
periaortic collection of enlarged lymph nodes. Bilateral pleural
effusions, greater on the left, with complete collapse of the
left lower lobe and partial collapse of the right lower lobe.
Diffuse thickening of the ascending colon suspicious for
involvement by the lymphomatous process.
[**9-11**] CT Head: No evidence of bleeding infarct, mass or mass
effect.
[**9-18**] TTE: The left ventricle is not well seen. 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 mitral valve
leaflets are grossly structurally normal. Aortic valve was not
well seen. Valvular regurgitation was not adequately assessed.
The pulmonary artery systolic pressure could not be determined.
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
50 yo man with HCV and EtOH cirrhosis s/p OLT ([**2148**]), c/b
ascites who presented with worsening hyponatremia. Brief
hospital course by problem:
.
# Hyponatremia: Pt was admitted with asymptomatic hyponatremia
to 122 found on routine labs. As per his urine studies, this was
likely secondary to his cirrhosis-related intravascular volume
depletion. He was initiated on a trial of Tolvaptan 15mg, which
was discontinued due to a rise in his creatinine. The pt is
currently being fluid restricted to 1500ml water/day.
.
# Renal Failure: Admission creatinine was 1.3, however creat
began to rise while on tolvaptan and later while being fluid
restricted. Urine studies were suggestive of a prerenal
etiology, likely secondary to hepatorenal syndrome. The pt was
started on midodrine and octreotide, with daily albumin.
Tacrolimus was discontinued due to its potential nephrotoxic
effects. Urine output gradually decreased and the pt became less
alert, likely due to uremia, therefore HD was initiated on [**8-7**].
After 2 weeks of dialysis, the pt was also listed for kidney
transplant in addition to liver transplant.
.
# HCV/ETOH Cirrhosis S/P OLT: Tacrolimus was discontinued due to
its potential nephrotoxicity, however cellcept was continued,
along with bactrim prophylaxis, lactulose, and rifaximin. The pt
is currently listed for both liver and kidney transplant.
.
# Pneumonia: The pt's WBC increased on [**9-3**] and a CXR was
suggestive of pneumonia. Vancomycin and cefepime was started for
HAP.
.
# Abdominal pain: Pt has has intermittent abdominal pain
throughout this admission. Several KUBs have shown a dilated
transverse colon but no mechanical obstruction. Abdominal pain
is likely secondary to gas as well as ascites. The pain has been
moderately controlled with simethicone, occasional paracentesis,
and HD.
.
# Tachycardia: The patient has a chronic sinus tachycardia. EKG
is w/o evidence of right heart strain to suggest PE. It is felt
to be due to fluid shifts in the setting of frequent HD and
[**Doctor First Name 4397**].
.
# Anemia: Throughout the hospital stay, the patient's HCT was
variable, dropping and rising from day to day. On several
occasions, the patient underwent severe or sustained drops,
necessitating pRBC transfusions. During these instances, there
was no clear source of acute bleed (no melena, hematochezia,
blood paracenteses). More likely, there was a chronic component
complicated by large fluid shifts related to his liver and
kidney failures. Transfusions were complicated by the patient's
fluid overload, necessitating them to be given with lasix or
during HD.
.
# Nausea: Pt has had chronic nausea, likely multifactorial:
hyponatremia, medications, uremia, ascites, and infection (an
EGD revealed candidal esophagitis) as potential causes. The
patient's candidal esophagitis was treated with fluconazole. He
received multiple paracenteses to relieve his severe recurrent
ascites. Uremia is being treated with HD as described above. The
nausea is now moderately controlled with zofran and compazine,
and the pt is tolerating tube feeds.
.
# Nutrition: Secondary to the patient's nausea, he had very poor
PO intake. A dobhoff was placed and he began to receive tube
feeds, however, as his nausea progressed, he could no longer
tolerate tube feeds, and was started on TPN. He has since been
switched back to tube feeds but continues to have very poor PO
intake.
.
# Depression: Venlafaxine was initially held due to it's
possible contribution to [**Last Name (un) **]. However, since starting HD the
venlafaxine has been restarted.
.
# Code Status: Full code on admission, made CMO on [**2153-9-24**]
On the morning of [**9-10**], the patient was seen by transplant
surgery at hemodialysis. The patient was minimally responsive
and was barely awake. Over the past week, he has worsening
mental status changes, has been consistently tachycardic and was
hypotensive during HD. HD was stopped due to the hypotension.
Mr. [**Known lastname **] was tranferred to the SICU and the transplant
surgery service for further hemodynamic montitoring for possible
sepsis, where he was maintained eventually on triple pressors
and then made CMO once it was determined that further escalation
of care would be outside of his wishes. His ICU course will be
discussed with regards to organ systems.
Neuro: On admission to the SICU, the patient was obtunded. He is
on lactulose and rifaximin. He received fent prn once intubated.
Once the patient was made CMO he was given a morphine gtt for
comfort.
Cardio: The patient was admitted to the SICU tachycardic. The
patient was started on Neo-synephrine for hypotension. He ruled
out MI and TTE showed collapsing IVC. The patient was then
started on vasopressin. The patient received PRBCs and albumin
for hemodynamic support. The patient became progressively
tachycardic. He responded to low dose lopressor, but had
increased wheezing. ECHO on [**9-18**] showed EF>55% and only small
pericardial effusion. The patient remained on constant
Vasopressin neosynephrine and levophed until he was made CMO at
which time the pressors were withdrawn.
Pulm: CXR on [**9-3**] was consistent with a large left pleural
effusion. On [**9-11**], the patient was intubated. The patient
remained stable on PS 5/5 ventilation. His left pleural effusion
was tapped for 1.5L. The patient was extubated on [**9-13**]. On [**9-15**],
the patient had increased wheezing after receiving lopressor for
tachycardia. On the morning of [**9-16**], the patient was reintubated.
The patient had another thoracentesis in which 2.5 L were
removed. He remained intubated with a PS of 5 and PEEP of 8. On
[**9-18**], the patient was bronched, which showed no evidence of
obstruction or thick secretions. Due to risk of infection, it
was decided to not place a pigtail drain in the left pleural
cavity.
GI/FEN: The patient has a Dobhoff tube. TF were held on SICU
admission. The patient had a paracentesis on [**9-10**] in which 2L
fluid was removed. Liver ultrasound showed no abnormalities. CT
TORSO on [**9-11**] was consistent with worsening adenopathy
throughout the abdomen, most heavily concentrated in the
periaortic region, which is concerning for PTLD. On [**9-12**], TF were
started. TF were advanced to goal. Speech and swallow was
consulted and they recommended thin liquids and soft solids. On
[**9-15**], the patient had some blood-tinged BM; TF were held. 2hrs
after holding TF, the patient vomitted with question of
aspiration. The patient was restarted on TF intermittently, and
stopped intermittently due to inceased residuals.
GU: The patient has hepatorenal syndrome and is listed for a
combined liver/kidney transplant. He has chronic hyponatremia.
On [**9-12**], CVVHD was started. The patient initially tolerated
being run negative on CVVHD. However, he became more
tachycardic, which improved with running the CVVHD positive.
The patient continued to not tolerate running the CVVHD
negative, even with the increase in pressor requirement.
Heme: The patient has stable anemia. The patient received
3uPRBCs on [**9-11**] for decreased hematocrit.
Endo: The patient had stable BS and was covered with a RISS.
Cortisol stimulation showed no adrenal insuffiency.
Infectious disease: The patient has blood cultures on SICU
admission. He was on vanc and cefepime. Antibioitics were
broadened to Linezolid, Meropenem, and Micafungin. The patient
remained on CellCept. Possible causes of sepsis include SBP,
PNA, or line infection. The patient had a peritoneal tap, which
had 300 WBCs and a negative culture, thus ruling out SBP. His
PICC was removed, and a LIJ was placed. Culture for the PICC was
negative. Thoracentesis fluid was also cultured, with negative
results. On [**9-19**], CellCept was discontinued. Blood, urine,
pleural fluid, and abdominal fluid cultures remained negative.
Medications on Admission:
1. Vitamin D2 50,000u qweekly
2. Lactulose 30ml PO BID
3. Reglan 0.5mg PO QIDACHS
4. Cellcept 500mg daily
5. Omeprazole 40mg daily
6. Zofran 4mg q8h PRN nausea
7. oxycodone 5mg 1-2 tabs PO q6h
8. Rifaximin 550mg [**Hospital1 **]
9. Bactrim 1 tab daily
10. Tacrolimus 0.5mg daily
11. venlafaxine 37.5mg daily
Discharge Medications:
N/A
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
- Hyponatremia
- Hepatorenal syndrome
- Hospital acquired pneumonia
- Enchephalopathy
- Sinus tachycardia
- Anemia
- Depression
Secondary Diagnosis:
- S/p liver transplant with recurrent hepatitis C cirrhosis
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/a
|
[
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"276.2",
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"275.3",
"571.5",
"572.3",
"486",
"112.84",
"451.82",
"311",
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"427.89",
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"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"00.14",
"54.91",
"38.95",
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"96.71",
"45.13",
"33.24",
"99.15",
"39.95",
"38.91",
"96.72",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14082, 14140
|
5822, 5943
|
279, 326
|
14412, 14422
|
2931, 2931
|
14474, 14480
|
2315, 2343
|
14054, 14059
|
14161, 14161
|
13722, 14031
|
14446, 14451
|
2358, 2358
|
2902, 2912
|
227, 241
|
5971, 13696
|
354, 1903
|
5214, 5799
|
14329, 14391
|
2947, 3336
|
14180, 14308
|
2372, 2888
|
3352, 5205
|
1925, 2087
|
2103, 2299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,592
| 188,658
|
31815+57766
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-8-18**] Discharge Date: [**2137-8-29**]
Date of Birth: [**2064-12-27**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
# SDH/SAH [**1-4**] fall
# Facial fractures [**1-4**] fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72M h/o HTN, Alzheimer??????s dementia, admitted initially by trauma
surgery to SICU s/p fall down stairs onto concrete with LOC and
witnessed seizure-like episode. Pt sustained multiple facial
fractures, small R front SAH, and significant epistaxis.
.
ED:
# VS: T unmeasured, BP 140/80, HR 102, RR 24, SaO2 96/RA
# Intervention: Intubated given epistaxis
# Notable studies
--CT head: R frontal subdural, subarachnoid hemorrhage. R
temporal subarachnoid hemorrhage. B inferior temporal lobe
hemorrhagic contusions. No midline shift.
--CT cervical spine: No fracture.
# Transferred to Trauma SICU
# Consults
--Plastics: No intervention recommended
--Neurosurgery: No acute issues
.
After initial admission, pt had increased delirium requiring 1:1
sitter. Pt also developed hypernatremia, and was transferred to
medicine for management of hypernatremia and delirium.
Past Medical History:
# HTN
# Hyperlipidemia
# Alzheimer's dementia
# Prostate CA
# B glaucoma
# B cataracts
# Chronic back pain
# GERD
Social History:
# Personal: Lives with wife in son's home
# Professional: Retired school custodian
# Tobacco: Never
# Alcohol: Never
# Recreational drugs: Never
Family History:
Pt was adopted and does not know his biological FH.
Physical Exam:
VS: Tm 99.8, Tc 99.8, BP 147/98 (124-147/72-98), HR 97-101, RR
16-18, SaO2 94/RA - 98/RA, FS 133
I 340 PO + 1200 IVF / O 1900
.
Gen: NAD, sleeping
HEENT: B raccoon ecchymosis under eyes
CV: RRR, S1S2, no m/r/g appreciated
Chest: CTAB although pt difficult to position.
Abd: Soft, NTND, mildly tympanic, hypoactive BS
Ext: Moving all extremities spontaneously, no c/c/e noted at
BLE.
Pertinent Results:
Notable admission labs:
.
[**2137-8-18**] 12:40AM WBC-11.0 RBC-4.85 HGB-15.9 HCT-42.4 MCV-88
MCH-32.7* MCHC-37.4* RDW-13.3
[**2137-8-18**] 12:40AM UREA N-30* CREAT-1.1
[**2137-8-18**] 12:53AM GLUCOSE-148* LACTATE-2.4* NA+-139 K+-3.3*
CL--97* TCO2-26
[**2137-8-18**] 12:13PM PHENYTOIN-8.3*
[**2137-8-18**] 12:13PM CK-MB-10 MB INDX-0.9 cTropnT-<0.01
[**2137-8-29**] 08:55AM BLOOD WBC-10.7 RBC-3.46* Hgb-11.5* Hct-32.6*
MCV-94 MCH-33.3* MCHC-35.4* RDW-14.5 Plt Ct-181
[**2137-8-29**] 08:55AM BLOOD Glucose-117* UreaN-15 Creat-0.7 Na-144
K-3.7 Cl-109* HCO3-24 AnGap-15
[**2137-8-28**] 02:41AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.1
.
Notable studies:
.
# CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2137-8-18**] 2:14 PM
IMPRESSION: Multiple fractures as described above involving both
orbits, the right temporal bone, and the sphenoid bone with
several fracture clefts extending intracranially as described
above.
.
# CT HEAD W/O CONTRAST [**2137-8-18**] 2:14 PM
IMPRESSION: Since approximately 13 hours prior, there is
increase in extent of subarachnoid hemorrhages. Newly visible
are hemorrhagic contusions of the inferior temporal lobes
bilaterally. There is new intraventricular blood within the
lateral and fourth ventricles. No significant change in the
subdural hematomas over the right frontal and temporal lobes as
well as layering along the tentorium.
[**2137-8-28**] CXR FINDINGS: Recently described left retrocardiac
opacity has slightly improved and may be due to an area of
resolving aspiration. Lateral chest radiograph is technically
nondiagnostic due to low lung volumes and respiratory motion.
Allowing for this limitation, lungs are otherwise grossly clear
and there are no pleural effusions.
IMPRESSION: Improving left retrocardiac opacity, likely due to
resolving area of aspiration or atelectasis.
[**2137-8-28**] Head CT FINDINGS: Since the prior study, there has been
evolution of both the right frontal epidural hemorrhage, which
is less evident than on the prior study, adjacent to the
nondisplaced right frontal and temporal bone fracture. There has
also been evolution of the bilateral extensive subarachnoid
blood, which is not now as evident as it was on the prior study.
No new hemorrhage is identified. The ventricular size in the
temporal horns of the lateral ventricle, the frontal horns, as
well as the third ventricle appears slightly larger than on the
prior study, for example, the third ventricular diameter
previously measured 6 mm and now measures 8 mm, and at roughly
the same level, the diameter of the frontal [**Doctor Last Name 534**] of the left
lateral ventricle measures 10 mm where before it measured 8 mm.
There is no change in the size of the fourth ventricle. A small
subdural hemorrhage tracking along the anterior convexity on the
left is likely, and also appears to have evolved since the prior
study.
Hypodensity of the left temporal lobe is seen, consistent with
contusion. Small hypodensities of the left basal ganglia region
and the periventricular white matter are noted, which likely
represent microangiopathic changes.
Fractures across the lateral orbital walls bilaterally also
appears stable. Air-fluid levels are noted within the sphenoid
air cells with a fracture through the sphenoid bone again noted
as well. Please refer to the CT of the sinus study done on
[**8-18**] for full details regarding multiple fractures.
IMPRESSION:
1. Evolution of the previously demonstrated subarachnoid, right
epidural, probable left subdural blood. No new hemorrhage.
2. Apparent mild increase in the size of the lateral ventricles
as well as the third ventricle. Continued attention in followup
is recommended to exclude developing hydrocephalus
Brief Hospital Course:
72M h/o HTN, Alzheimer's dementia, admitted to [**Hospital1 18**] after
falling and sustaining R frontal and temporal SAH and SDH,
bilateral infratemporal contusions, and extensive facial
fractures which did not require intervention. Pt's admission
complicated by hyperactive delirium.
.
# Delirium: Pt's hyperactive delirium likely multifactorial,
with contributing factors including pain, hospitalization,
SAH/SDH, intracranial contusions, and Foley catheter. The
patient was initially treated with Haldol and required a 1:1
sitter for several evenings. His Haldol was eventually
discontinued and replaced with quetiepine, which the patient has
tolerated well. In addition, he has not required a 1:1 sitter
in two days. His mental status still fluctuates, being most
alert during the day and most somnolent/confused in the evening
and early morning.
.
# Sleep/wake cycle: Patient's trazodone dose was decreased from
100mg QHS to 50-100mg QHS, for fear that the increased dose
could be exacerbating delirium.
.
# Pain control: patient has been receiving acetomenophen 1000mg
PR TID for pain control. This was switched to Acetomenophen
650mg PO q6h with 650mg PR PRN in the event that the patient
could not tolerate PO intake.
.
# Bowel regimen: Patient was placed on an aggressive bowel
regimen to minimize factors which could exacerbate delirium.
Senna 2tab PO HS, lactulose 30 ml PO TID, bisacodyl 10 mg PO/PR
daily, and docusate 200 mg PO BID, all titrated to 1BM daily.
.
# Witnessed seizure: Pt's family reported that pt seized around
his fall, and this may have contributed to his fall, although pt
had not been previously diagnosed with seizures. Pt was started
on phenytoin 100 mg PO TID as inpatient ppx against seizures,
given his subdural and subarachnoid hemmorrhages. Per
neurosurgery reccommendations, the patient's phenytoin was
switched to Keppra. He was begun on 500mg PO BID for two days,
and continued on 1000mg PO BID for two days, and then 1500mg PO
BID continuous. He has received two days of 500mg. He will
begin keppra 1000mg PO BID starting [**8-30**].
.
# Hypernatremia: Patient developed hypernatremia secondary to
dehydration. The hypernatremia resolved with fluid
resuscitation.
.
# Alzheimer's dementia: Pt continued on home regimen of Exelon
*NF* 6 mg PO BID.
.
# Hyperglycemia, impaired glucose tolerance: Pt's fasting blood
glucose had been high during this admission, ranging between
130-190, and pt was therefore covered with humalog insulin
sliding scale. The patient should be evaluated by his PCP for
further management of impaired glucose tolerance.
.
# Urinary retention: Pt had been having difficulty voiding
during this admission, and therefore was started on terasozin 3
mg QHS. The subsequently developed hypotension and so his
terazosin was discontinued. He will be discharged with a foley
in place. This foley should be replaced with a foley catheter
with leg bag attachment upon arrival to his extended care
facility. He has a follow-up urology appointment scheduled.
.
# Prostate CA: Pt continued on home regimen of megestrol 20 mg
PO BID.
.
# B glaucoma: Pt administered timolol 0.5% 1 drop OU [**Hospital1 **].
Patient should schedule an ophthalmology appointment in [**1-5**]
weeks.
.
# HTN: patient's dose of quinapril was decreased to 5mg PO QD.
.
# Hyperlipidemia: Pt continued on Tricor 145 mg PO daily and
simvastatin 80mg PO daily.
.
Medications on Admission:
# Rivastigmine 6mg [**Hospital1 **]
# HCTZ 25mg daily
# Furosemide 40mg PO BID
# Simvastatin 80mg daily
# Fenofibrate 145mg PO daily
# Megestrol 20mg [**Hospital1 **]
# Pantoprazole 40mg PO daily
# MVI
# Vitamin B + C
# Trazodone 100mg QHS
Discharge Medications:
1. Megestrol 40 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
5. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
6. Rivastigmine 3 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
10. Quinapril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
13. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal q6h:prn as needed for if cannot tolerate PO.
14. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 2 days.
15. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 days.
16. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): to start [**9-1**] and continue, after patient has
received two days of leviracetam 1000mg [**Hospital1 **] for two days.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
18. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Olanzapine 2.5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day) as needed.
20. Insulin Lispro 100 unit/mL Solution Sig: Two (2) units
Subcutaneous ASDIR (AS DIRECTED).
21. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO tid: prn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Fall
Facial fractures
Subdural hematoma
subarachnoid hemmorrhage
Alzhemier's dementia
Delirium
Discharge Condition:
good
97.0 99.1 118/73 98 17 95%RA
Discharge Instructions:
You were admitted to the hospital after falling and sustaining
multiple facial fractures, along with subdural and subarachnoid
bleeding.
Please return to the hospital if you experience chest pain,
shortness of breath, nausea, headache, or light headedness.
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 43880**] and ask how best to
manage your increased blood sugar levels.
Your extended are facility should replace your current foley
catheter with a catheter with a leg attachment. You are
scheduled to see a urologist, Dr. [**Last Name (STitle) 770**] on [**2137-9-5**]
Followup Instructions:
Please follow-up with patient's ophthalmologist in two weeks.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 43880**] [**Telephone/Fax (1) 27929**] [**2137-9-5**] at 2:00pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2137-9-5**] 3:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2137-10-2**] 8:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2137-10-2**] 9:30
Name: [**Known lastname 6016**],[**Known firstname **] J, Unit No: [**Numeric Identifier 12302**]
Admission Date: [**2137-8-18**] Discharge Date: [**2137-8-29**]
Date of Birth: [**2064-12-27**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 12303**]
Addendum:
Signout was given to Dr. [**Last Name (STitle) 12304**]. Pager # [**Telephone/Fax (1) 12305**]
Right upper extremity ultrasound was cancelled due to low
clinical suspicion of upper extremity thrombus.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) 437**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 12306**] MD [**MD Number(2) 12307**]
Completed by:[**2137-8-29**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
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] |
icd9pcs
|
[
[
[]
]
] |
13381, 13605
|
5764, 9171
|
328, 335
|
11542, 11580
|
2021, 2029
|
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|
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|
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1618, 2002
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230, 290
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363, 740
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750, 1235
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2045, 5741
|
1257, 1372
|
1388, 1534
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,667
| 140,578
|
29247
|
Discharge summary
|
report
|
Admission Date: [**2124-2-9**] Discharge Date: [**2124-2-15**]
Date of Birth: [**2057-2-10**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Prozac / Clozaril / Chlorpromazine
Attending:[**First Name3 (LF) 1631**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. [**Known lastname 23705**] is a 66yo female with PMH significant for COPD, HTN,
and schizophrenia. She is being transferred from [**Hospital1 **] 4 to
the MICU for increasing respiratory distress. The patient was
initially admitted to the psych service on [**1-6**] for disorganized
behavior but was transferred to the medicine service twice since
her initial admisssion for acute COPD exacerbations on [**1-22**] and
[**2-7**]. She completed a 6 day course of Levofloxacin and is
currently completing a steroid taper; her last day is tommorow.
She was discharged to the psych service on [**2-8**].
.
The patient was noted to have difficulty breathing overnight.
She was found to be tachypneic this morning with RR~40's. She
required 8L via face mask. ABG at the time was 7.41/48/85/31.
The patient received 3 nebulizer treatments. She was then
transferred to the MICU for closer monitoring. On transfer to
the MICU she received Lasix 40mg IV x1.
.
MICU course: Received albuterol and atrovent nebs with good
improvement in symptoms and oxygen. Currently satting 92% on RA.
Transferred to medical floor for further management prior to
transfer back to [**Hospital1 **] 4.
Past Medical History:
COPD on 4L NC home O2 as needed
HTN
Schizophrenia
Dementia
Arthritis
Social History:
Ms. [**Known lastname 23705**] is single and lives in [**Hospital1 **] community housing for
the elderly. She has a very heavy smoking history, but currently
smokes approximately [**1-7**] cigarettes per day. She does her own
ADLs, walks, and bicycles independently.
Family History:
Mental illness in mother and stepfather (does not know
biological father).
Physical Exam:
vitals T 96.9 BP 122/57 AR 94 RR 31 O2 sat 96% on 2L VM
Gen: Patient does not appear acutely ill, + auditory wheezes
HEENT: MMM
Heart: RRR, no m,r,g
Lungs: CTAB, poor air movement posteriorly,
Abdomen: soft, mildly distended, tenderness in RLQ
Extremities: No LE edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
[**2124-2-8**] 06:50AM BLOOD WBC-12.2* RBC-3.31* Hgb-10.0* Hct-30.8*
MCV-93 MCH-30.2 MCHC-32.5 RDW-14.8 Plt Ct-397
[**2124-2-9**] 12:43PM BLOOD WBC-10.6 RBC-3.67* Hgb-11.2* Hct-34.1*
MCV-93 MCH-30.6 MCHC-32.9 RDW-14.9 Plt Ct-378
[**2124-2-10**] 02:38AM BLOOD WBC-9.8 RBC-3.75* Hgb-11.2* Hct-34.8*
MCV-93 MCH-29.9 MCHC-32.1 RDW-14.9 Plt Ct-446*
[**2124-2-8**] 06:50AM BLOOD Ret Aut-3.2
[**2124-2-8**] 06:50AM BLOOD Glucose-104 UreaN-26* Creat-0.9 Na-140
K-3.7 Cl-100 HCO3-30 AnGap-14
[**2124-2-9**] 12:43PM BLOOD Glucose-112* UreaN-26* Creat-1.1 Na-131*
K-7.3* Cl-99 HCO3-20* AnGap-19
[**2124-2-10**] 02:38AM BLOOD Glucose-215* UreaN-27* Creat-1.0 Na-132*
K-4.4 Cl-93* HCO3-27 AnGap-16
[**2124-2-8**] 06:50AM BLOOD calTIBC-434 Ferritn-20 TRF-334
[**2124-2-9**] 11:29AM BLOOD Type-ART Temp-36.4 Rates-/52 Tidal V-500
pO2-85 pCO2-48* pH-7.41 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2124-2-9**] 11:29AM BLOOD K-4.7
.
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with COPD exacerbation. Currently tachypnic
and mildly hypoxic.
REASON FOR THIS EXAMINATION:
? COPD exacerbation vs. another acute process
INDICATION: 66-year-old woman with COPD exacerbation. Currently,
tachypneic and mildly hypoxic. Evaluate for acute process.
COMPARISON: [**2124-2-7**].
SINGLE VIEW, CHEST: There has been interval improvement in
parenchymal aeration. There may be a small left pleural
effusion, unchanged. There is evidence of bilateral pleural
thickening. Hilar contour, cardiomediastinal contour, pulmonary
vasculature appear within normal limits. Unchanged subtle right
lower lobe atelectasis. Cardiac silhouette is upper limit of
normal, unchanged.
IMPRESSION: Interval improvement in bilateral parenchymal
aeration. No other acute cardiopulmonary abnormalities.
Brief Hospital Course:
Ms. [**Known lastname 23705**] is a 66yo female with PMH as listed above who presents
with increasing respiratory distress.
.
# Respiratory distress/Hypoxia: Patient presented with
increasing respiratory distress and oxygen requirement. Upon
transfer to the MICU her O2 requirement rapidly decreased
although she remained extremely wheezy on exam. No mental status
changes. No report of fevers, chills, chest pain, or LE edema.
Clinically, most consistent with COPD exacerbation. Infection
is unlikely given lack of white count, fevers, productive cough,
and CXR without infiltrate. CHF exacerbation is unlikely given
EF>60% on most recent [**Known lastname **]. Given her immobility and concern for
PE, LE dopplers were performed which were negative. Patient was
started back on prednisone 60mg. Had recently completed rapid
taper of steroids after prior COPD exacerbation. Concern that
steroids were potentially exacerbating her psychosis. However,
given her current exacerbation, using longer taper this time.
She was continued on albuterol and atrovent nebulizer
treatments with transition to home regimen including advair,
tiotropium and albuterol inhalers prior to discharge.
.
# COPD: Patient presented with symptoms suggestive of a COPD
exacerbation. She has been transferred to the medical service
several times over the past few weeks for closer management. She
has required antibiotics and nearly completed a 3 day prednisone
taper prior to her exacerbation. Patient is home oxygen
dependent using 4L NC at baseline. Per old [**Known lastname **] notes, appears
baseline sats on RA are 88-92%. Prednisone and nebulizers as
above with transition to home regimen prior to discharge.
.
# Abdominal pain: Unclear etiology. Patient states she has had
this for many years. Also difficult to illicit true exam due to
patient's psychiatric status. LFTs on [**1-26**] wnl. CXR suggested
stool impaction. Bowel regimen was increased and patient was
having regular bowel movements prior to discharge.
.
# Hypertension: Patient is on beta-blocker and thiazide as
outpatient. Concerned over beta blockade in the setting of
severe COPD. Her beta blocker was held and initially she was
continued on her thiazide with good control. However, she
subsequently developed hyponatremia and her thiazide was stopped
as well. Should the need arise, would add low dose Norvasc for
blood pressure control if she is hypertensive off her home
medications.
.
# Hyponatremia: Appears patient has had this in the past. [**Month (only) 116**]
have been component of hypovolemia secondary to low PO and
thiazide diuretic, combined with component of adrenal
insufficiency in the settting of rapid steroid taper. Also
SIADH in the setting of severe pulmonary disease. Patient was
placed on a fluid restriction of 1.5L daily. Thiazide diuretic
was discontinued. Sodium returned to baseline prior to
discharge.
.
# Schizophrenia: Patient was transferred from psych unit on [**Hospital1 **]
4. She is on an extensive medication regimen. She is section 12.
She was continued on her outpatient regimen with several
changes as listed and was pleasant and redirectable during
admission.
.
# Leukocytosis: Developed after prednisone initiated. No
evidence of UTI or other infectious process. Likely secondary to
steroids. Should continue to monitor.
Medications on Admission:
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB/wheezing
Tolterodine 1 mg PO BID
Albuterol [**1-5**] PUFF IH Q4H:PRN SOB/wheezing
Clonazepam 0.5 mg PO QAM
Clonazepam 1mg PO QHS
Clonazepam 1 mg PO DAILY
Risperidone 3mg PO HS
Risperidone 2mg PO QAM
Vitamin D 800 UNIT PO DAILY
Calcium Carbonate 1250mg PO BID
Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **]
Donepezil 5mg PO HS
Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
Nicotine Patch 14 mg TD DAILY
Olanzapine 30mg PO HS
Loxapine Succinate 5mg PO QHS
Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Tiotropium Bromide 1 CAP IH DAILY
Pantoprazole 40mg PO Q24H
Multivitamins 1 CAP PO DAILY
Benztropine Mesylate 1mg PO QHS
Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO Q4H:PRN
Milk of Magnesia 30 ml PO Q8H:PRN
Acetaminophen 650 mg PO Q4H:PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Risperidone 2 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Loxapine Succinate 5 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Olanzapine 5 mg Tablet Sig: Six (6) Tablet PO HS (at
bedtime).
10. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
12. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
14. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety/agitation.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
21. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
22. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-5**]
Drops Ophthalmic PRN (as needed).
23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
24. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO AT 2 () as
needed.
25. Prednisone 5 mg Tablet Sig: As directed below Tablet PO once
a day for 8 days: Starting on [**2-15**]: Take 4 tablets daily x 3
days;
Starting on [**2-18**]: Take 2 tablets daily x 2 days;
Starting on [**2-20**]: Take 1 tablet daily for two days, then stop.
26. Tolterodine 1 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
27. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
28. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q4H (every 4 hours) as needed.
29. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
30. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
31. Loxapine Succinate 5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily) as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8221**] - [**Location (un) 583**]
Discharge Diagnosis:
COPD exacerbation
.
Secondary diagnoses:
Schizophrenia
Cognitive changes [**2-5**] dementia
COPD
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a COPD exacerbation. It is very important
that you take all your medications as prescribed. You should
take your prednisone as directed which will be slowly tapered
off.
In addition, we have stopped your blood pressure medications.
You Atenolol was discontinued because this type of medication
can complicate severe COPD. In addition, your other blood
pressure medicine, triamterene-hydrochlorothiazide may have been
making your sodium low. If you need a different blood pressure
medication, Norvasc might be a good medication for your doctor
to consider for you.
If you develop any new shortness of breath, chest pain, or other
concerning symptom, please seek immediate medical care.
Followup Instructions:
Please follow up with your primary care physician within two
weeks of discharge. You can call [**Telephone/Fax (1) 719**] to arrange this
appointment with Dr. [**First Name (STitle) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1636**]
|
[
"564.00",
"276.1",
"401.9",
"491.21",
"305.1",
"V58.65",
"733.00",
"V46.2",
"295.62",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11296, 11369
|
4123, 7459
|
323, 330
|
11510, 11519
|
2338, 3255
|
12278, 12590
|
1928, 2004
|
8315, 11273
|
3292, 3374
|
11390, 11410
|
7485, 8292
|
11543, 12255
|
2019, 2319
|
11431, 11489
|
264, 285
|
3403, 4100
|
358, 1535
|
1557, 1627
|
1643, 1912
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,228
| 108,310
|
40279
|
Discharge summary
|
report
|
Admission Date: [**2103-11-3**] Discharge Date: [**2103-11-30**]
Date of Birth: [**2040-6-6**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
EVD placement [**2103-11-3**]
Trach placement
PEG placement
History of Present Illness:
This is a 63 year old gentleman with history of testicular
cancer and resection who was found unconsious at home on his
toilet at approximately 1000. The patient was found by his wife
who last saw him at 0630am. The patient reportedly has been
experiencing syncopal events daily but has not sought medical
treatment. The patient was brought to [**Hospital 47255**]
intubated and was given fentanyl 100 mcq, succinycholine 150 mg,
and etomidate 10 mg for intubation at approximately 1020 am. A
Head Ct at [**Hospital **] revealed an extensive acute
intercranial hemorhage within the suprasellar cistern and within
the ventricles most prominently the left lateral ventricle is
expanded. The patient was transferred here for further care.
The
patient is not accompanied by family at the time of this exam.
Past Medical History:
testicular cancer with resection-unknown date
Social History:
married. Wife not present at the time of this exam.
Family History:
NC
Physical Exam:
O: BP: 191/71 HR: 91 R:20 O2Sats:50% FIO2 500x20
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:2.5 NR EOMs:unable to test
Neck: not tested
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated GCS: 3T
Orientation: Not oriented
Recall/Language: unable to test
Cranial Nerves:
I: Not tested
II: Pupils 2.5 mm NR mm bilaterally. Visual fields- non able to
test
III, IV, VI: Extraocular movements unable to test
V, VII: Facial strength/sensation unable to test
VIII: Hearing-unable to test
IX, X: Palatal elevation-unable to test
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius-unable to test
XII: Tongue-unable to test
Motor: No movement in upper extremities to pain. Posturing in
lower extremities to pain
Sensation:unable to test
Babinski's: Toes mute
Coordination: unable to test
Upon Discharge:
Awake, Alert, EO spont. PERRL. Mouthing words. No RUE mvmt. BLE
withdrawl, LUE spont and purposeful.
Pertinent Results:
CTA HEAD [**2103-11-3**]:
1. Basal ganglia hemorrhage extending to the ventricles with
ventriculomegaly. The ventricular size appears to have slightly
increased
since the previous CT examination from outside hospital.
2. CT angiography demonstrates no evidence of aneurysm,
stenosis, or
occlusion or abnormal vascular structures but tortuous
intracranial arteries
are seen.
3. New intubation with blood products in the left sphenoid sinus
and
nasopharynx as well as retained secretions.
CT HEAD W/O CONTRAST [**2103-11-4**]:
Stable appearance of left basal ganglonic parenchymal
hemorrhage,
intraventricular hemorrhage, and scattered foci of subarachnoid
hemorrhage. Status post right transfrontal ventriculostomy
catheter placement, with decompression of the right and minimal
change of the left lateral ventricle.
MRI BRAIN W/WO CONTRAST [**2103-11-7**]:
Intraventricular hemorrhage, status post EVD placement with
interval
improvement in hydrocephalus. No abnormal enhancement. No
abnormally
enhancing mass, or acute territorial infarct is seen. As this
study was not done as an MRA, evaluation for aneurysm is
limited. The patient's recent CTA examination is a better
evaluation for this. Scattered foci of diffusion restriction
described above, most consistent with subacute shower of emboli.
CT HEAD W/O CONTRAST [**2103-11-8**]:
Redemonstration of intracranial hemorrhage predominantly
intraventricular,
although also seen in the left at the caudate as well as
subarachnoid
locations. The overall volume of blood is decreased from the CT
done on
[**2103-11-4**] and when accounting for differences in
technique appears
minimally changed from the MR done on [**2103-11-7**]. The
size of left
temporal [**Doctor Last Name 534**] has also decreased.
CT HEAD W/O CONTRAST [**2103-11-10**]:
Overall slight decrease in size of the temporal horns with
unchanged blood products seen on the previous CT of [**2103-11-8**].
No significant new abnormalities.
CT HEAD W/O CONTRAST [**2103-11-11**]:
Interval evolution of previously seen hemorrhage, without
dramatic regression or progression since yesterday's study. No
evidence of
new hemorrhage.
CT Head [**2103-11-21**]:
Marked interval resorption of intraventricular and left caudate
hemorrhage
since the most recent study.
CT Head [**2103-11-22**]:
IMPRESSION:
Stable layering of intraventricular hemorrhage and left caudate
hemorrhage
with stable mass effect on the left basal ganglia. Stable mild
rightward
shift of midline structures. No new hemorrhage.
Stable prominence of the third ventricle.
Small amount of air within the right temporal [**Doctor Last Name 534**].
LABS:
[**2103-11-29**] 06:11AM BLOOD WBC-9.3 RBC-3.01* Hgb-9.0* Hct-26.6*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.9 Plt Ct-218
[**2103-11-30**] 04:13AM BLOOD WBC-10.0 RBC-2.84* Hgb-8.6* Hct-25.0*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.1 Plt Ct-238
[**2103-11-29**] 06:11AM BLOOD PT-17.8* PTT-59.9* INR(PT)-1.6*
[**2103-11-29**] 06:11AM BLOOD Plt Ct-218
[**2103-11-29**] 02:39PM BLOOD PTT-57.1*
[**2103-11-29**] 10:02PM BLOOD PTT-73.9*
[**2103-11-30**] 04:13AM BLOOD PT-19.0* PTT-60.9* INR(PT)-1.7*
[**2103-11-30**] 04:13AM BLOOD Plt Ct-238
[**2103-11-30**] 09:55AM BLOOD PTT-67.3*
[**2103-11-29**] 06:11AM BLOOD Glucose-120* UreaN-31* Creat-0.5 Na-145
K-3.5 Cl-110* HCO3-28 AnGap-11
[**2103-11-30**] 04:13AM BLOOD Glucose-118* UreaN-30* Creat-0.6 Na-145
K-4.1 Cl-110* HCO3-29 AnGap-10
[**2103-11-29**] 06:11AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.0
[**2103-11-30**] 04:13AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0
Brief Hospital Course:
63 y/o M with significant past medical history presents after
being found unresponsive on the toilet by wife. Unknown how long
patient was down and he was transferred to [**Hospital3 15402**] ED where
head CT showed ICH. He intubated was transferred to [**Hospital1 18**] for
further neurosurgical workup. Once at [**Hospital1 **], he was sedated on
propofol, exam poor. Pupils were 2.5 and non reactive, + cough,
+gag, +corneals, but no movement of extremities to noxious
stimuli. Repeat head CT revealed a basal ganglia hemorrhage with
IVH extension into the L lateral, 3rd, and 4th ventricle. He was
also noted to be hypertensive with a SBP of 220 when off
sedation. His exam off sedation was poor revealing nonreactive
pupils and extensor posturing in BLE. Patient was placed back on
propofol and nicardipine drip started to reduce SBP. An EVD was
placed at bedside with opening pressure of 15. The drain was
leveled to 15cm H2O and ICP was stable at 8. TPA was also
administered Q8H. On [**11-4**], patient was spiking temperature to
101.6, he was pancultured and CXR revealed pneumonia. He was
started on triple antibiotics for treatment.
On [**11-5**] he continued to receive tpa and exam was noted to be
improving, he was intermittently following commands on the left.
Neurology was consulted and recommended a MRI to rule out
underlying lesion. An MRI was performed on [**2103-11-7**] showing
intraventricular hemorrhage, status post EVD placement with
interval
improvement in hydrocephalus. There was no abnormally enhancing
mass, or acute territorial infarct is seen. On [**11-6**] a family
meeting was held and it was noted the patient would likely
prefer independent care post-hospitalization, but further
discussion of the plan of care was deferred to later. There was
significant serosanguinous oozing from the EVD site on [**11-6**]. On
[**11-7**] the patient underwent bronchoscopy for hemoptysis which
was unrevealing. On [**11-8**] he had recurrent temperature spikes
and the patient was cultured, including a CSP specimen which
demonstrated no growth. The patient underwent percutaneous
tracheostomy placement on [**11-9**]. tPA through the EVD had been
initiated a few days prior given poor drainage and concern for
clotting, but this was discontinued on [**11-9**]. A clamp trial was
performed on [**11-10**], but increasing ICP was noted and the the EVD
drain was re-opened to 15 cmH20. On [**11-11**] his EVD had improved
drainage, his ICPs remained in the 7-10 range and a re-attempt
at clamp trial was performed at 15:30 the afternoon of [**11-12**]
which also proved unsuccessful. The patient had also been
experiencing hypernatremia a few days prior to [**11-12**], which
resolved with free water flushed through his Dobhoff tube along
with 0.45% normal saline infusions.
On [**2104-11-14**] the patient was placed on continuious EEG which
showed diffuse encephalopathy. The patient's exam remained poor,
he would have some spontaneous movement on his left side but he
would not follow commands, his eye opening was mininmal.
Multiple meetings were had with the family in regards to goals
of care. Initially the family considered making the patient CMO.
However, his exam started to improve and he started mouthing
words. He received a trach on [**11-19**]. He was given a third
clamping trial on [**11-20**] which went well and again on [**11-22**] a
clamping trial proved that his ICPs were stable. Thus, on [**11-22**]
the EVD was removed and a post-removal head CT revealed a stable
exam without hydrocephalus or significant change in shift. His
neurologic status remained stable.
On [**11-24**] keppra was discontinued. Patient has been having
periods of apnea, difficult to wean to trach mask. He continues
to require CPAP intermittently given respiratory muscle atrophy
and central apneic episodes. He remained tachypneic during the
day on [**11-26**] and a DVT was found on extremity ultrasound. The
patient began heparinization treatment for his DVT. Otherwise
his neurologic exam remained unchanged.
On [**11-27**] he was transitioned to trach mask and remained stable
for 24 hrs and was transferred to the Step Down Unit on [**11-28**]. On
[**11-30**] patient did not meet Step Down Unit criteria and became
floor status. On [**11-30**] he was offered a bed at an extended care
facility and was discharged.
Medications on Admission:
None
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. acetaminophen 650 mg/20.3 mL Suspension Sig: One (1) PO Q6H
(every 6 hours) as needed for pain/fever.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for const.
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. warfarin 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1
doses.
8. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): PTT
40-60, INR 2-2.5.
9. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic Q3H (every 3 hours).
10. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
12. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Basal Ganglia hemorrhage with IVH extension
DVT
VAP
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2103-11-30**]
|
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32,453
| 105,863
|
32317
|
Discharge summary
|
report
|
Admission Date: [**2131-7-24**] Discharge Date: [**2131-7-27**]
Date of Birth: [**2089-3-19**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Ciprofloxacin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
abdominal pain, coffee ground emesis
Major Surgical or Invasive Procedure:
Esophagogastroduodonoscopy ([**First Name3 (LF) **])
History of Present Illness:
42 year old man with a history of alcohol dependence, alcoholic
cirrhosis with grade II varices s/p banding, and chronic
pancreatitis, presenting with one day of coffee-ground emesis
and abdominal pain. Mr. [**Known lastname 53917**] was recently admitted to [**Hospital1 18**]
from [**2131-7-15**] to [**2131-7-21**] for coffee ground emesis and abdominal
pain following an episode of heavy drinking, which was thought
to be due to esophagitis/gastritis in the setting of vomiting
from an exacerbation of chronic pancreatitis. Upon discharge
from [**Hospital1 18**], he drank 1.5 pints of vodka and a few beers 1 day
prior to admission and 1 pint of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] on the day of
admission.
.
In the late morning on the day of admission, Mr. [**Known lastname 53917**] began
to feel sharp, epigastric/right upper adbominal pain that was
[**6-29**] in severity and radiated to the back. Associated with the
pain was nausea, which resulted in 3 episodes of emesis. The
first episode was yellow in color, but the last vomitis had a
coffee ground appearance. He presented to the ED at [**Hospital1 18**] due
to this emesis.
.
His current abdominal pain is more severe than his baseline [**2-27**]
epigastric pain associated with his chronic pancreatitis and was
similar past episodes of acute on chronic pancreatitis. In the
past, his similar pain has been improved by sitting still and
Dilaudid, and his nausea has subsided with Zofran. He last ate a
large breakfast at 10 AM the day of admission. He denies recent
the consumption of fatty or spicy foods or coffee.
.
Last fever was [**2131-7-20**] in the hospital. He reports several weeks
of intermittent night sweats. He has mild, intermittent chronic
right knee pain. He has mild pain in the nasal passageway from
an NG tube from his recent hospitalization. He has experience
recent episodes of loose stool without hematochezia, melena, or
bright red blood. He denies the use of aspirin or Tylenol.
.
In ED, he continued to experience abdominal pain and nausea. He
received Protonix 80 mg IV, IVF, Zofram4 mg , Dilaudid 3mg IV,
and Ciprofloxacin 400mg IV, and octreotide bolus + drip. He was
seen by GI, and a NG lavage revealed brown coffee grounds that
cleared after 500 mL. He was guaiac negative. Vitals afebrile HR
68 BP 133/71 RR 18 O2sat 93% RA.
.
Past Medical History:
-Alcoholic cirrhosis with [**Month/Day/Year **] on [**6-28**] with Grade II varices.
-Variceal bleeds, 6 episodes from [**2128**] to [**11-27**] s/p multiple
bandings. Bleed in [**11-27**] was grade II on [**Date Range **], s/p banding.
-Chronic pleural effisions
-Chronic pancreatitis
-Alcohol dependence: heavy drinking started at age 30-35. Has
been to detox and dual diagnosis clinics in the past. Has had
periods of sobriety. H/o delirium with past withdrawal; no h/o
seizures.
-Bipolar disorder and anxiety disorder NOS, well controlled on
citalopram, quetiapine, and ativan. Has psychiatrist in the
community.
-S/p cholecystectomy on [**5-29**]
-S/p right ACL replacement and meniscectomy in [**2126**]
Social History:
Currently homeless. Divorced. Has daughter in [**Name (NI) 614**] and
son in [**Name (NI) 3320**]. 12 year history of drinking 1-1.75 liters of
vodka daily. Denies tobacco or other illicits.
Family History:
History of alcoholism. Paternal grandfather died of prostate
cancer. Maternal grandmother died of MI; no other family h/o
CVD. Father alive, with h/o kidney cancer. Mother and children
healthy.
Physical Exam:
General: comfortable, NAD.
HEENT: No scleral icterus, MMM, oropharynx clear.
Lungs: CTA bilaterally with no w/r/r.
CV: RRR with no m/r/g.
Abdomen: Soft, non-distended. No mottling of skin. +BS in all 4
quadrants. Warm to touch. Diffusely positive to light palpation
and percussion but increased tenderness in epigastric and right
upper quadrants. No guarding or rigidity. Scar located in right
upper quadrant from prior cholecystectomy. No caput medusa. No
angiomas.
Ext: Warm, well perfused, 2+ DP and PT pulses, no clubbing,
cyanosis or edema. No asterixis.
Neuro: A+O to person, place, time.
Pertinent Results:
[**2131-7-27**] 05:50AM BLOOD WBC-2.5* RBC-4.25* Hgb-10.6* Hct-33.8*
MCV-80* MCH-25.0* MCHC-31.4 RDW-14.9 Plt Ct-126*
[**2131-7-26**] 03:45PM BLOOD Hct-33.6*
[**2131-7-26**] 06:25AM BLOOD WBC-1.7* RBC-4.08* Hgb-10.8* Hct-32.3*
MCV-79* MCH-26.6* MCHC-33.6 RDW-14.9 Plt Ct-111*
[**2131-7-26**] 12:05AM BLOOD Hct-32.4*
[**2131-7-25**] 12:43PM BLOOD Hct-30.7*
[**2131-7-25**] 07:57AM BLOOD Hct-31.0*
[**2131-7-25**] 04:30AM BLOOD WBC-2.0* RBC-3.82* Hgb-10.1* Hct-29.9*
MCV-78* MCH-26.5* MCHC-33.9 RDW-15.8* Plt Ct-105*
[**2131-7-25**] 12:29AM BLOOD Hct-31.1*
[**2131-7-24**] 08:20PM BLOOD Hct-30.8*
[**2131-7-24**] 01:15PM BLOOD WBC-2.9* RBC-4.34* Hgb-11.7* Hct-33.5*
MCV-77* MCH-27.0 MCHC-35.0 RDW-15.8* Plt Ct-113*
[**2131-7-27**] 05:50AM BLOOD Glucose-117* UreaN-3* Creat-0.8 Na-142
K-3.6 Cl-104 HCO3-28 AnGap-14
[**2131-7-24**] 01:15PM BLOOD Glucose-117* UreaN-9 Creat-0.8 Na-142
K-3.5 Cl-105 HCO3-22 AnGap-19
[**2131-7-27**] 05:50AM BLOOD ALT-18 AST-31 Amylase-8
[**2131-7-24**] 01:15PM BLOOD ALT-25 AST-49* LD(LDH)-170 AlkPhos-255*
TotBili-0.8
[**2131-7-27**] 05:50AM BLOOD Lipase-8
[**2131-7-24**] 01:15PM BLOOD Lipase-12
[**2131-7-27**] 05:50AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
[**2131-7-25**] 04:30AM BLOOD Albumin-3.8 Calcium-8.3* Phos-3.7 Mg-1.7
Iron-30*
[**2131-7-25**] 04:30AM BLOOD calTIBC-334 VitB12-501 Folate-GREATER TH
Ferritn-23* TRF-257
[**2131-7-24**] 01:15PM BLOOD ASA-NEG Ethanol-154* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2131-7-24**]: [**Month/Day/Year **]: stage 1 varices, portal hypertensive gastropathy,
and 2cm non-bleeding nodule consistent with pancreatic rest
.
[**2131-7-25**]: EKG: Sinus rhythm. Mildly prolonged Q-T interval.
Non-specific inferior and anteroseptal T wave changes. Compared
to the previous tracing of [**2131-7-18**] the heart rate is slower. QT
interval prolonged. QTc: 466
.
[**2131-7-26**]: Sinus rhythm. Non-specific anterolateral ST-T wave
changes. Compared to the previous tracing of [**2131-7-26**] the Q-T
interval is not as long on the current tracing. QTc: 410.
Brief Hospital Course:
Assessment/Plan: This is a 42 yo [**Male First Name (un) 4746**] with extensive alcohol
abuse, alcoholic cirrhosis with grade I varices s/p banding, and
chronic alcoholic pancreatitis, MICU transfer, admitted for
coffee-ground emesis following and acute drinking binge.
.
# Upper GI bleed: Due to findings of bright red blood via
nasogastric lavage, patient was admitted directly to the MICU.
Patient's vital signs and Hct were stable. Liver service was
consulted, and pt underwent endoscopy, which showed stage 1-2
varices, portal hypertensive gastropathy, and 2 cm non-bleeding
nodule consistent with pancreatic rest grade. There was no
active bleeding visualized. Esophagitis was noted. Pt was
continued with protonix. Cipro was started for SBP prophylaxis,
then held for hx or prolonged QTc. As patient's symptoms
improved, he was restarted on a regular diet, and was considered
stable for call out to the floor.
.
Upon reaching the floor, vital signs and hematocrits were
measured often and remained steady. An active type and screen
was maintained. Patient was continued with [**Hospital1 **] PPi and
sucralfate. Given lack of variceal bleeding found on [**Hospital1 **],
ciprofloxacin and octreotide were no longer warranted. Patient
did not experience any further episodes of vomiting, nausea, or
melena. Upon discharge, patient was started on nadolol to
decrease portal hypertension and reduce the risk of future
episodes of variceal bleeding. Given lack of ascites, patient
was not initiated on spironolactone.
.
Patient has extensive past medical history of alcoholic
cirrhosis complicated by history of numerous episodes of UGI
bleeding and grade II varices that were banded in the past. The
lack in finding an active source of bleeding via [**Hospital1 **] makes it
difficult to cite a clear source, but bleeding etiology may have
been multifactorial. It was thought by GI that the most likley
cause of bleeding was from esophagitis secondary to alcohol
consumption and vomiting. Patient was discharged on nadolol for
reduction in portal hypertension and reduction in the risk of
variceal bleeding. Patient will follow up with Dr. [**Name (NI) **]
in 2 weeks for follow up.
.
# Alcohol dependence. Given extensive alcohol abuse, recent
binge, and history of prior withdrawal episodes (no prior
seizures), patient was at risk for alcohol withdrawal during
this admission. Upon reaching the MICU, pt was started
initially on CIWA scale but later discontinued. It was believed
by the MICU team that pt was unlikely to develop significant
withdrawal as he was abstinent from alcohol from [**Date range (1) 61239**]/09
during his prior admission. However, patient reported binging
upon returning home and appeared anxious, jittery, and
tachycardic upon reaching the floor. He was restarted on
diazepam 10mg PO q3h:PRN for CIWA > 10 and agitation. Patient's
sympathetic symptoms improved. Patient was continued on
outpatient regimen of folate, thiamine, and MVI. Addictions
social work saw the patient and provided counselling regarding
cessation. Patient also spoke with social work and agreed to
follow up with alcoholics anonymous.
.
#Abdominal pain and nausea: Patient has chronic [**2-27**] baseline
pain secondary to chronic pancreatitis that was exacerbated with
alcoholic binge prior to admission. Lack of fever,
leukocytosis, and abdominal distension was less worrisome for
spontaneous bacterial peritonitis. LFTs and lipase were within
normal limits. Patient was initially placed NPO, with diet
advanced and tolerated well. Patient was given PO dilaudid with
an attempt to wean doses throughout her admission. Zofran was
given for nausea. PPi and sucralfate were continued as above.
Patient was discharged with 20 pills (4 day supply) of 5mg
oxycodone PO q6-8 hours and told to follow up with his scheduled
appointment with his primary care physician [**Name Initial (PRE) 176**] 4 days of
discharge. Patient will follow up with Dr. [**Name (NI) **] in 2
weeks for follow up.
.
# Alcoholic cirrhosis: Complicated by coagulopathy, varices,
and gastric changes on [**Name (NI) **] consistent with portal hypertension
gastropathy. LFT, [**Name (NI) **], and CBC abnormalities were at baseline
during this admission. No indication of hepatic encephalopathy
was observed. Lactulose was given and no signs of
encephalopathy were present.
.
# leukopenia, anemia, thrombocytopenia: Lab disruptions were
most likely secondary to bone suppression secondary to alcoholic
suppression of bone marrow. Stable during this admission.
Liver disease also likely contributing. Patient given ferrous
sulfate upon discharge to help with anemia secondary to
bleeding.
.
# Coagulopathy. Believed to be secondary to liver cirrhosis,
but may also be due to poor absorption due to poor nutritional
status. Patient reported complying with vitamin K supplements.
Recently received vitamin K injection x 1 during hospitalization
at [**Hospital1 18**] in prior week.
.
#Bipolar disorder and anxiety disorder NOS: Conditions were
well controlled on outpatient regimen of citalopram, quetiapine,
ativan, and trazadone.
Medications on Admission:
Medications on admission:
-Ciprofloxacin 500 mt PO daily for 7 days until [**2131-7-27**] was
being given for SBP ppx
-Oxycodone 5 mg PO Q6-8H PRN pain. Takes ~10 mg Q4H but does not
frequently run out of medication.
-Citalopram 40 mg PO daily
-Quetiapine 400 mg SR once daily
-Trazadone 100 mg PO QHS PRN insomnia
-Amylase-lipase-protease 20,000-4,500-25,000 unit capsule, one
capsule three times daily with meals.
-Folic acid 1 mg PO daily
-Thiamine 100 mg PO daily
-Multivitamin once daily
-Pantoprazole 40 mg PO Q12H
-Propanolol 10 mg PO BID hold for pulse <60
-Sucralfate 1 gram PO QID
-Ativan 0.5 mg, [**12-22**] rablets PO Q8H PRN anxiety
-Lactulose 10 gram/15mL, 30 mL PO TID PRN constipation.
.
Medications on transfer:
citalopram 40 mg po daily
folic acid 1 mg IV q24h
dilaudid 2 mg po q4h:prn pain
lactulose 30 ml PO TID titrate to BM, hold after BM
lorazepam 0.5-1 mg PO q8h:prn anxiety, hold for sedation (CIWA
scale d/c'ed in AM of [**7-25**])
MVI
zofran 8 mg IV q8h: prn nausea
quietiapine XR 400 mg PO daily
sucralfate 1 gm PO qid
thiamine 100 mg IV daily, for 5 days
trazodone 100 mg PO HS: prn insomnia
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
2. Quetiapine 200 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lactulose 10 gram Packet Sig: One (1) PO three times a day
as needed for constipation.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO three times a day: Take with meals.
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for anxiety.
12. Nadolol 20 mg Tablet Sig: [**12-22**] Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- upper gastrointestinal bleed
- alcohol dependence
- alcoholic cirrhosis
- chronic pancreatitis
.
Secondary:
- stage I esophageal varices
- portal hypertensive gastropathy
- 2cm non-bleeding nodule/pancreatic rest
- bipolar disorder
Discharge Condition:
Afebrile, vital signs stable. Nausea and vomiting have
resolved. No melena. Abdominal pain significantly improved.
Discharge Instructions:
You were admitted for coffee ground vomitting and abdominal
pain. You spent 2 days in the intensive care unit due to your
upper gastrointestinal bleeding. You underwent a scoping
procedure and were found to have no active bleeds. It is
believed that your bleeding was from irritation of your
esophagus. You were also treated for alcohol withdrawal. Upon
going home, please do not consume any alcohol.
.
We have added the following NEW medications:
1) nadolol 10mg PO daily
2) Ferrous sulfate 325mg twice a day
.
Please take all other medication as previously directed.
We have made the following CHANGES to your medications:
-stopped the cipro
-stopped the propranolol
.
Should you develop worsening abdominal pain, fever, chills,
lightheadedness, bloody vomiting, please contact your primary
care physician or visit the emergency room.
Followup Instructions:
Please follow up with your previously scheduled appointment with
your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75523**]. She will
also be availble any Tuesday of the month for walk-in
appointments.
Date: [**2131-8-21**] at 9:30AM
Phone: [**Telephone/Fax (1) 5135**]
.
Please follow up with a hepatologist, Dr. [**Name (NI) **]:
[**2131-8-6**] at 8:30 AM. Phone Number: Phone: [**Telephone/Fax (1) 2422**]
.
Please attend the alcoholic anonymous meetings, as directed by
paperwork given to you by social work.
|
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46,257
| 123,393
|
46943
|
Discharge summary
|
report
|
Admission Date: [**2193-11-24**] Discharge Date: [**2193-12-1**]
Date of Birth: [**2134-1-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Meningitis
Major Surgical or Invasive Procedure:
Intubation.
History of Present Illness:
Patient is a 59 yo male with hx of TIIDM, HTN, hyperlipidemia
and recurrent ear infections who presented to an OSH with
altered mental status shortly after beginning azithromycin for
an ear infection. He was in his usual state of health until
Friday (2 days prior to admission) when he developed the acute
onset of right ear pain. He called his PCP who was unavailable
having some drainage from right ear throughout the next day. One
day prior to admission he developed acute mental status changes
and fevers. In the ED, vitals T: 104.3 HR: 130 RR: 20 BP 118/67
O2: 96% FS: 231. He was given ativan, tylenol, folate, thiamine,
magnesium. He had a head CT showing possible mastoiditis. He
underwent LP with the following CSF results: opening pressure
23, purulent appearance, protein 749 RBC 4000 tube 1 WBC 15,875
in tube 4. Gram positive cocci seen on GS. Occasional
intracellular organisms seen. At OSH recieved IV vanc,
rocephin, and decadron for presumed bacterial meningitis and was
transferred to the [**Hospital1 **].
Past Medical History:
Diabetes
HTN
Gout
Nephrolithiasis
Hyperlipidemia
CKD
Social History:
Quit tobacco x >10 years, prior 1.5 ppd x 25 years
Drinks occasionally on the weekends
Family History:
Uncle with renal failure
Physical Exam:
Upon transfer to the floor:
Vitals: T: 97.6 BP: 150/80 HR: 75 RR: 26 O2 Sat: 97% RA FS: 237
Gen: Cooperative, A&O x3. NAD. Non-toxic.
HEENT: PERRLA, EOMI, fields intact. R ear with crusted blood in
external canal. TM opaque, whitish-yellow in appearance. L ear
with clear TM. Oropharynx benign.
Cardiac: RRR, no MRG.
Pulm: LCTAB.
Abd: NT/ND. No organomegaly, +BS.
Extremities: 2+ pulses throughout.
Neuro: A&Ox3
MS: Patient has difficulty recalling recent and distant events
in his life, and frequently makes statements about his history
that his family states are inaccurate. He also describes seeing
"bubbles" or "jellyfish" coming out of the air vent in his room
during the interview.
CN: Hearing is decreased, CN otherwise grossly intact.
Motor grossly intact.
DTRs: 2+ in upper extremities. 3+ in patella bilaterally. No
anlke jerk elicited. No clonus.
Coordination: Tremor noted in both hands. Dysmetria seen
bilaterally on figer to nose testing.
Pertinent Results:
[**2193-11-24**] 12:48PM TYPE-ART RATES-18/ TIDAL VOL-550 PEEP-5
O2-100 PO2-399* PCO2-39 PH-7.25* TOTAL CO2-18* BASE XS--9
AADO2-290 REQ O2-54 -ASSIST/CON INTUBATED-INTUBATED
[**2193-11-24**] 12:13PM LACTATE-3.0*
[**2193-11-24**] 11:50AM GLUCOSE-270* UREA N-32* CREAT-1.7* SODIUM-140
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-15* ANION GAP-23*
[**2193-11-24**] 11:50AM WBC-17.4* RBC-4.79 HGB-14.2 HCT-42.2 MCV-88
MCH-29.6 MCHC-33.6 RDW-14.8
[**2193-11-24**] 11:50AM NEUTS-83* BANDS-1 LYMPHS-10* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1*
[**2193-11-24**] 11:50AM BLOOD PT-14.5* PTT-26.4 INR(PT)-1.3*
[**2193-11-24**] 11:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2193-11-24**] 11:50AM BLOOD Plt Smr-LOW Plt Ct-145*
[**2193-11-25**] 12:27AM BLOOD Lactate-2.0
[**2193-11-30**] 09:11AM BLOOD ALT-43* AST-27 LD(LDH)-172 AlkPhos-50
TotBili-0.4
[**2193-11-29**] 06:50AM BLOOD ESR-42*
[**2193-12-1**] 08:41AM BLOOD Glucose-236* UreaN-43* Creat-1.6* Na-139
K-5.2* Cl-109* HCO3-19* AnGap-16
[**2193-12-1**] 01:00PM BLOOD WBC-11.1* RBC-4.74 Hgb-13.5* Hct-41.3
MCV-87 MCH-28.4 MCHC-32.6 RDW-14.5 Plt Ct-214
[**2193-12-1**] 01:00PM BLOOD Plt Ct-214
.
OSH CT: prelim: opacification of the right mastoid air cells.
Fluid in right external auditory canal. Findings c/w
otomastoiditis.
.
CTU at OSH: Normal Kidneys. No stones noted, limited study given
lack of IV contrast.
.
CT head [**2193-11-24**]: slight asymmertry of occipital bones (may be
congenital), No hydro, hemorrhage, mass or ischemia noted. .
.
MRI Brain [**2193-11-29**]:
1. Signal abnormalities along the sulci on FLAIR and diffusion
images are
findings secondary to patient's known meningitis with likely
purulent material
within the sulci. No hydrocephalus seen.
2. Bilateral soft tissue changes in the mastoid air cells, right
greater than
left side. No definite evidence of osteomyelitis is seen within
the adjacent
bony structures or evidence of epidural abscess identified
adjacent to the
right tegmen tympani. No evidence of focal cerebritis seen in
the right
temporal lobe.
Brief Hospital Course:
#Meningitis: He was initially started on ceftriaxone, bactrim,
vancomycin and dexamethasone at the OSH. CSF and blood cultures
from the OSH grew strep pneumo, and at the [**Hospital1 **] bactrim was
discontinued and he was continued on ceftriaxone and vancomycin.
He completed a four day course of dexamethasone and his
vancomycin was subsequently stopped when culture sensitivities
showed ceftriaxone-sensitive s. pneumo. His mental status was
altered upon transfer to the floor, and he was very irritable
and uncooperative with care. He was given haldol several times
for agitation. He also endorsed visual hallucinations for the
first several days that he was on the floor. These symptoms were
most likely due to the combination of meningitis and systemic
steroids, and his mental status had improved back to his
baseline at the time of discharge. He will continue his
Ceftriaxone via PICC at home for a total course of 14 days
(start date of [**11-25**]). CBC with diff, BUN, Cr,
AST, ALT, Alk phos, Tbili should be done next week for
comparison with values drawn this week to monitor ceftriaxone.
.
#Respiratory Failure:
Following arrival at the [**Hospital1 **], he was intubated due to prolonged
tachypnea on [**11-24**] and remained intubated until the evening of
[**11-25**]. In the MICU, he was given norepinephrine on [**11-25**] for SBP
in 70s but did not need any further pressors. He was transferred
to the floor on [**11-27**].
.
#Otitis media/mastoiditis: Patient reports frequent ear
infections, and on exam his TM was erythematous and bulging.
His CT findings were consistent with R otitis media and
mastoiditis. He was seen by ENT and underwent bedside
myringotomy on [**11-25**] with copious purulent drainage sent for
culture which showed polymicrobial flora. He was started on
ciprofloxacin and dexamethasone ear drops. He will begin taking
levofloxacin after his course of ceftriaxone ends and continue
taking it for a total course of 14 days to finish treatment for
mastoiditis. He will follow up with ENT in one week.
.
# Anemia: His crit initially dropped from 42 to 31.6 during his
time in the MICU. The most likely etiology for his anemia is
dilutional. Upon discharge from the MICU, he was several liters
positive as compared to admission. By the time of his discharge
his hematocrit had risen to 41.3.
.
# Renal Failure: His creatinine during this admission was stable
and close to his baseline Cr of 1.7. Should investigate
beginning an ACE inhibitor in outpatient f/u for
nephroprotective effect.
.
#Diabetes: His diabetes is poorly controlled at home and his
sugars were chronically elevated during this admission. [**Last Name (un) **]
followed him during his admission here. He was taking glyburide
at home, and this was changed to glipizide due to his poor renal
function. [**Last Name (un) **] also recommended that his Lantus dose be
increased multiple times over his visit due to poor control. He
will follow up with [**Last Name (un) **] the day after discharge to review his
diabetes management plan and learn to do self injections.
.
#HTN: He was not given any antihypertensives until the last two
days of his admission due to either hypotension or bradycardia.
His HCTZ was discontinued due to his poor renal function. He was
continued on his home dose of atenolol.
.
#Hyperlipidemia: He was continued on his home dose of
pravastatin.
.
#Hyperkalemia: He was intermittently mildly hyperkalemic
throughout his admission to the floor, likely due to
dehydration. When PO water intake was encouraged, the
hyperkalemia would resolve.
.
Medications on Admission:
Atenolol 100mg daily
Colchicine 0.6mg [**Hospital1 **]
Glyburide 10mg [**Hospital1 **]
Losartan-HCTZ 100mg-25mg
Pravastatin 80mg daily
ASA 81mg daily
Januvia 100mg daily
Discharge Medications:
1. Ciprofloxacin 0.3 % Drops Sig: Five (5) Drop Ophthalmic DAILY
(Daily) for 5 days: right ear.
Disp:*1 dropper* Refills:*0*
2. Dexamethasone 0.1 % Drops, Suspension Sig: Five (5) Drop
Ophthalmic DAILY (Daily) for 5 days: right ear.
Disp:*1 dropper* Refills:*0*
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): morning and afternoon.
Disp:*60 Capsule(s)* Refills:*0*
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
5. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-28**] Sprays Nasal
TID (3 times a day) as needed for dry nares.
10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary: Bacterial meningitis
Secondary: Diabetes mellitus type 2, otitis media, anemia, renal
failure
Discharge Condition:
Good. Alert and oriented, gait normal, neuro exam nonfocal.
Vitals in the normal range.
Discharge Instructions:
You were kept in the hospital after developing a infection
around your brain due to an inner ear infection. You were
intubated in the ICU for several days then you were transferred
to the general floor where we continued to give you antibiotics
and began treatment for diabetes.
You medications have changed in the following ways:
ceftriaxone 2g IV twice daily for __ days
glipizide 5 mg po daily
lantus 18U injected subcutaneously every night- [**Last Name (un) **] will give
you a prescription for this and for a glucometer with testing
strips when you follow up with them on Monday.
Please keep all of your outpatient appointments.
Go to the ER or seek medical advice if you develop:
-chest pain or shortness of breath
-increased confusion
-headache
-changes in your vision
-visual or auditory hallucinations
-fever or chills
-any other new or concerning symptom.
You were kept in the hospital after developing a infection
around your brain due to an inner ear infection. You were
intubated in the ICU for several days then you were transferred
to the general floor where we continued to give you antibiotics
and began treatment for diabetes.
You medications have changed in the following ways:
START ceftriaxone 2g IV twice daily until [**2193-12-7**]
START glipizide 10 mg po daily
START lantus 18U injected subcutaneously every night- [**Last Name (un) **]
will give you a prescription for this and for a glucometer with
testing strips when you follow up with them on Monday.
START gabapentin 100 mg at morning and lunch then 300 mg at
bedtime. Please follow up with your primary doctor in regards
to the gabapentin.
STOP your HYZAAR 100-25mg pills for blood pressure
Please keep all of your outpatient appointments.
Go to the ER or seek medical advice if you develop:
-chest pain or shortness of breath
-increased confusion
-headache
-changes in your vision
-visual or auditory hallucinations
-fever or chills
-any other new or concerning symptom.
Followup Instructions:
Please follow up with [**Hospital **] clinic as scheduled on Monday=
[**2193-12-2**] at 3:30 pm with [**First Name5 (NamePattern1) 16883**] [**Last Name (NamePattern1) **]. You have a second
appointment scheduled on [**2193-12-9**] at 3 pm with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11679**].
Also, please call your primary doctor, Dr. [**First Name (STitle) **], at [**Telephone/Fax (1) 6163**],
for a follow up appointment in the next 1-2 weeks for a checkup.
Please follow up with ENT in one week to assess how your ear
infection is resolving. Contact Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 6213**]
to set up an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2193-12-4**]
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icd9cm
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9808, 9899
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233, 245
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,229
| 130,589
|
27716
|
Discharge summary
|
report
|
Admission Date: [**2165-5-13**] Discharge Date: [**2165-5-30**]
Date of Birth: [**2105-8-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Trazodone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of breath, transfer from 12 [**Hospital Ward Name 1827**]
Major Surgical or Invasive Procedure:
Endotracheal intubation
Arterial line placement
History of Present Illness:
Ms. [**Known lastname **] is a 59 year-old female with newly diagnosed
metastatic malignancy, who presents from the out-patient
gynecology unit with complaints of progressive shortness of
breath.
She was recently evaluated as an out-patient for complaints of
weakness, abdominal pain and shortness of breath. At that time,
an abdominal U/S was obtained, which revealed an enlarged uterus
with an echogenic mass. Further work-up included an abdominal
MRI remarkable for an enlarged uterus, thickened endometrial
stripe, and a vaginal mass. A CXR was also obtained, concerning
for metastatic disease, and a CT chest subsequently confirmed
pulmonary metastases, without PE. An MRI brain was negative. She
was seen by an oncologist at [**Hospital3 **], and seen today on the
day of admission in the [**Hospital 6669**] [**Hospital **] clinic for a biopsy of
the vaginal mass, which was performed.
She reports a 2-week history of progressive shortness of breath,
with progressive limitation in exercise tolerance. She endorses
a cough, largely non-productive, and tightening "like a band"
around her chest, without definite pleuritic chest pain. She
reports no PND, no orthopnea, no lower extremity edema. She
denies fever or chills. Recent HIV test negative. No sick
contacts at home. While in the [**Hospital **] clinic, her saturation was
noted to be 86% on RA, and she was referred to L&D triage on the
[**Hospital Ward Name 516**]. From there, she was admitted to 12 [**Hospital Ward Name 1827**], where
concern was raised over her breathing status, and she was
transferred to the ICU for close monitoring. Saturation 90-95%
on 6L NC at the time of transfer.
She endorses a 40-lbs weight loss in the past 8 months. No night
sweats. No fever as noted above. No history of abnormal PAP,
last in 09/[**2163**]. Normal mammograms, last in [**2162**]. No
colonoscopy.
Past Medical History:
1. Metastatic malignancy as above
2. Fibromyalgia
Social History:
She lives at home with her husband. They have no children. She
is a lifelong non-smoker.
Family History:
Sister with uterine cancer at age 53, other sister with breast
cancer at age 50, mother with breast cancer at age 74. She has a
brother who is healthy. No testing for BRCA done.
Physical Exam:
Physical examination on admission
VITALS: T 99.4 HR104 BP125/71 RR32 O2sat: 92%RA on 6L NC
GEN: Tachypneic, able to speak with full sentences, short of
breath with minimal exertion.
HEENT: Anicteric. Thrush in oropharynx.
NECK: JVP not elevated.
RESP: Bilateral inspiratory crackles, no wheezing, no bronchial
breathing.
CVS: Tachycardic, normal S1, S2. No S3, S4. No murmur
appreciated.
GI: Obese abdomen, soft, non-tender.
EXT: Without edema.
Pertinent Results:
Relevant laboratory data:
From [**Hospital3 **]: CEA normal 1.3, Ca125 elevated at 52.5, HIV
negative, RPR negative.
On day of admission:
CBC:
[**2165-5-13**] 01:18PM WBC-27.0* RBC-5.20 HGB-14.3 HCT-43.1 MCV-83
MCH-27.5 MCHC-33.1 RDW-15.4 PLT COUNT-294
NEUTS-88.9* LYMPHS-6.5* MONOS-3.5 EOS-0.9 BASOS-0.2
Coagulation:
[**2165-5-13**] 01:18PM PT-13.5* PTT-28.4 INR(PT)-1.2*
Chemistry:
[**2165-5-13**] 01:18PM GLUCOSE-136* UREA N-26* CREAT-0.7 SODIUM-133
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-20* ANION GAP-20
ALT(SGPT)-22 AST(SGOT)-39 LD(LDH)-579* ALK PHOS-237* AMYLASE-17
TOT BILI-0.5 LIPASE-16 ALBUMIN-3.3* CALCIUM-12.0* PHOSPHATE-2.0*
MAGNESIUM-2.9* URIC ACID-6.9*
CA125-149*
RELEVANT IMAGING DATA:
[**2165-5-2**] PELVIC U/S: The uterus measures 11.6 x 9.2 x 11.1 cm
and is
heterogeneous in echotexture and contains a 9.2 x 5.4 x 6.7 cm
echogenic mass anteriorly.
[**2165-5-6**] CXR: Multiple nodular opacities in both lungs,
concerning
for metastatic disease.
[**2165-5-7**] MRI BRAIN with gad:1. Nonspecific white matter changes.
2. Several small foci of increased T2 signal in the cerebellum
most,
consistent with chronic ischemic injury.
[**2165-5-7**] MRI PELVIS: The uterus is enlarged measuring 10.9 x 9.7
x 10.0 cm. Endometrial stripe markedly thickened measuring
approximately
5 cm. Several large uterine fibroids. Large T2 hypointense T1
isointense enhancing myometrial fibroid in the right aspect of
the uterine fundus, 5.0 x 5.3 cm in diameter. Second large
anterior fundal fibroid measuring 5.0 x 5.7 cm which has mass
effect on the endometrial stripe, slightly hyperintense the T2
sequence and enhances following administration of contrast.
Smaller usual myometrial fibroids are seen elsewhere. Evidence
of a mass in the posterior superior vaginal wall. Marked
thickening of the posterior wall of the vagina with a focal mass
superiorly and posteriorly that measures 2.5 by 1.4 cm. This
projects slightly posteriorly and deforms the right ventral
aspect of the rectum. Note is made of a prominent left iliac
chain lymph node which measures approximate 8 mm in short axis
dimension.
[**2165-5-9**] CT CHEST/[**Last Name (un) **] with contrast: 1. Innumerable pulmonary
metastases. 2. Enlarged uterus with soft tissue in the
endometrial canal which appears confluent with a fundal fibroid.
Differential diagnostic considerations include endometrial
carcinoma invading a fibroid or a leiomyosarcoma invading
endometrial canal. Both endometrial carcinoma and
leiomyosarcomas of the uterus had been described to demonstrate
vaginal metastases.
[**2165-5-13**] CT CHEST/[**Last Name (un) **] WITH CONTRAST: 1. No evidence of
pulmonary embolism. 2. Innumerable noncalcified nodules, and
masses within the lungs concerning for metastatic disease. 3.
Right hilar lymphadenopathy. 4. Enlarged uterine mass, as per
patient history.
[**2165-5-27**] CT CHEST: 1. Slight regression in overall tumor burden
with decrease in the size of most of the pulmonary nodules by
10-20%. The increased lung volumes are due to ventilation. 2.
Slightly enlarged mediastinal lymph nodes. 3. New bibasilar
atelectasis and pleural effusion.
Pathology [**2165-5-13**] Vaginal biopsy: Poorly differentiated
carcinoma, favor squamous cell carcinoma, involving lamina
propria of squamous mucosa. No definitive in situ component or
lymphovascular invasion is seen.
Brief Hospital Course:
59 year-old woman with newly diagnosed metastatic malignancy
with innumerable pulmonary metastases and progressive
respiratory decline. Her [**Hospital Unit Name 153**] course will be briefly reviewed by
problems.
1) Pulmonary: As noted above, her initial CT chest was
remarkable for innumerable pulmonary metastases, without PE
(although a subsegmental PE could not be excluded). Given her
respiratory compromise and hypoxemia, she was admitted to the
ICU on the day of presentation. Empiric Levofloxacin and Flagyl
were initiated to cover for a possible pneumonia or
post-obstructive process, even though no definite airway
compression or obstruction was seen on imaging. The pathology
from her vaginal biopsy eventually returned as poorly
differentiated squamous cell carcinoma, and per
Hematology/Oncology, systemic chemotherapy was initiated with
Carboplatin and Taxol (day 1 on [**2165-5-14**]). Following
chemotherapy, her respiratory status continued to decline, and
she was intubated electively. She required continued mechanical
ventilation, without clinical signs of improvement.
2) Metastatic malignancy: As noted above, pathology from her
vaginal biopsy eventually returned as poorly differentiated
carcinoma, most likely squamous. Hematology/Oncology was
consulted, and systemic chemotherapy was initiated with
Carboplatin and Taxol (day 1 on [**2165-5-14**]). Following initiation
of chemotherapy, she developed febrile neutropenia, and
antibiotic coverage was broadened appropriately with Aztreonam
and Vancomycin in addition to Levofloxacin and Flagyl.
Caspofungin was subsequently added given persistent fevers
without a clear source. Cultures all returned negative. She was
given a granulocyte colony stimulating factor to help count
recovery. A repeat CT chest on [**2165-5-30**] showed some radiographic
improvement in tumor burden, albeit with limited meaningful
clinical improvement.
The patient's husband and sister were kept abreast of her
clinical status throughout her hospital stay. She was made DNR,
but kept intubated to allow for a potential response to systemic
chemotherapy. Unfortunately, given minimal radiographic response
to chemotherapy, lack of clinical improvement, continued
requirement for mechanical ventilation with obvious discomfort
with any attempt to wean, and grim prognosis, support was
withdrawn at the family's request, and a focus on comfort
measures was instituted on [**5-30**]. She expired on [**5-30**].
Medications on Admission:
Celebrex 200 mg PO QD
Prozac 20 mg PO QD
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic poorly differentiated carcinoma, likely squamous cell
carcinoma
Hypoxemic respiratory failure secondary to pulmonary metastases
Febrile neutropenia
Hypercalcemia
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2165-7-2**]
|
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icd9cm
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[
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9139, 9148
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62,698
| 125,132
|
36916
|
Discharge summary
|
report
|
Admission Date: [**2123-8-18**] Discharge Date: [**2123-8-20**]
Date of Birth: [**2076-11-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Upper GI bleed s/p duodenal polypectomy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 y/o F with PMhx of MUTYH associated polyposis who underwent
duodenal polypectomy on [**8-17**] and returned home that evening. She
noticed some black stools but was feeling otherwise at baseline.
In the evening, she noticed some mild nausea which progressed to
emesis of BRB. This was followed by episodes of BRB per rectum,
lightheadedness, diaphoresis and chills. She was in the bathroom
with her husband when she had a witnessed syncopal episode
without any head trauma. She was taken to [**Hospital3 **], admitted to the ICU with a hct of 28.6 and SBPs in 100s.
She received a total of 2 units prbcs, IVF and was started on a
PPI and octreotide gtt. She underwent a EGD which revealed
active bleeding, this was treated with local epinephrine prior
to transfer to [**Hospital1 18**].
.
Pt had a transient episode of sbp in the 80s during transfer
which responded to a 250cc bolus of IVF. She remained
asymptomatic and on arrival to the ICU, she was denying
lightheadedness, nausea, palpitations, chest pain, shortness of
breath, weakness or abdominal pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
Appendectomy
MUTYH associated polyposis (followed with yearly colonoscopy and
now regular EGDs)
Social History:
She works as a nurse at an IVF center and lives at home with
four children and her husband. She denies smoking and drink [**1-29**]
alcohol beverages per day. Denies any history of withdrawal.
Family History:
+ FAP syndrome
Physical Exam:
Vitals: T: 97.9 BP: 121/66 P: 73 R: 12 O2: 94%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g
Abdomen: soft, NT/ND, NABS, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Rectal: guaic + melanotic stool
Pertinent Results:
[**2123-8-18**] 09:49PM GLUCOSE-117* UREA N-6 CREAT-0.6 SODIUM-141
POTASSIUM-3.6 CHLORIDE-113* TOTAL CO2-25 ANION GAP-7*
[**2123-8-18**] 09:49PM estGFR-Using this
[**2123-8-18**] 09:49PM ALT(SGPT)-8 AST(SGOT)-10 ALK PHOS-33* TOT
BILI-0.7
[**2123-8-18**] 09:49PM WBC-8.0 RBC-2.96* HGB-9.1* HCT-27.2* MCV-92
MCH-30.8 MCHC-33.6 RDW-13.7
[**2123-8-18**] 09:49PM NEUTS-67.4 LYMPHS-26.0 MONOS-5.5 EOS-1.1
BASOS-0.1
[**2123-8-18**] 09:49PM PLT COUNT-205
[**2123-8-18**] 09:49PM PT-11.9 PTT-22.2 INR(PT)-1.0
[**2123-8-20**] 04:33AM BLOOD WBC-5.6 RBC-2.75* Hgb-8.7* Hct-25.3*
MCV-92 MCH-31.5 MCHC-34.2 RDW-13.1 Plt Ct-198
Brief Hospital Course:
46 y/o F with PMhx of MAP who presents with upper GI bleed s/p
duodenal polypectomy on [**8-17**].
# Upper GI Bleed: When Mrs. [**Known lastname 2520**] arrived to the [**Hospital Unit Name 153**] all vital
signs were stable. She was s/p EGD with local epi injections and
2u prbcs as well as IVF at an OSH. Initially there was a very
minor amount of melena in the [**Hospital Unit Name 153**] which subsequently resolved
and there were no repeat episodes of melena, emesis, or BRBPR.
Her Hcts were stable in the range of 25-27. No further
transfusions were necessary. The octreodide drip was continued
over night and stopped the next morning. IV PPI was given [**Hospital1 **]
and switched to PO on discharge. Her diet was advanced and on
[**8-20**] she was tolerating a full diet. GI did not feel that repeat
EGD was necessary at this time and will repeat it in 2 months as
an outpatient.
.
# MAP: Pt with known polyposis syndrome with risk for malignant
transformation. Up until this year she has undergone yearly
colonoscopies that result in removal of several polyps each
time. [**2123-6-28**] was her first EGD which revealed the duodenal
polyp that was removed just prior to admission. She will follow
up regularly with GI (Dr. [**Last Name (STitle) **] for colonoscopies/EGDs.
Medications on Admission:
None
Discharge Medications:
Pantoprazole 40mg PO daily
Ferrous Sulfate 325 mg PO daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Upper gastrointestinal bleed
Secondary: MAP
Discharge Condition:
Afebrile, stable vital signs, tolerating normal diet, ambulatory
Discharge Instructions:
You were admitted because of bleeding from your gastroinestinal
tract. You were treated with some fluids, lansoprazole IV, and
octreotide IV.
At home, your medicines will be changed and you can take:
1. Ferrous sulfate 325mg by mouth once/day
2. Pantoprazole 40mg by mouth once/day
Please take all medicines as prescribed. Please follow-up with
all appointments. Please do not hesitate to return to the
hospital for any concerning symptoms such as bleeding,
lightheadedness, fainting, or anything else concerning.
Followup Instructions:
Follow-up with your gastroenterologist, Dr. [**Last Name (STitle) **], for repeat
EGD and colonoscopy as he recommends.
|
[
"E878.8",
"211.2",
"285.1",
"998.11",
"211.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.30"
] |
icd9pcs
|
[
[
[]
]
] |
4602, 4608
|
3177, 4464
|
356, 363
|
4705, 4772
|
2525, 3154
|
5335, 5458
|
2030, 2046
|
4519, 4579
|
4629, 4684
|
4490, 4496
|
4796, 5312
|
2061, 2506
|
1475, 1684
|
277, 318
|
391, 1456
|
1706, 1804
|
1820, 2014
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,128
| 180,170
|
16583+56783
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-9-8**] Discharge Date: [**2177-9-13**]
Date of Birth: [**2121-2-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex / Ketamine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
Sacral wound debridement
History of Present Illness:
56M with history of CML, ESRD T/TH/S s/p recently diverting
colostomy several days ago at [**Hospital 1263**] hospital for attempt to
heal large stage IV sacral decub, presenting from rehab ([**Hospital1 **] at [**Doctor Last Name 1263**]) with concern for aspiration pneumonia
in setting of increased cough. He was in usually state of
illness today when he developed a severe cough productive of
small amount of whitish phlegm. He had a severe cough and
respiratory was called to do suction but before they suctioned
him he coughed up something and his symptoms resolved. He was
then suctioned by respiratory and per report was better
afterward. CXR was done at the rehab facillity and showed ? PNA
so he was transferred to [**Hospital1 18**]. CXR here showed possible RLL
infiltrate he was admitted to MICU for level of complexity. U/A
positive. He denied any complaints other than thirst and said
that his cough had resolved since earlier in the day.
.
Surgery was consulted for decubitus ulcer and recent ostomy and
said to make pt. NPO for OR debridement of sacral wound.
.
In the ED, initial vs were: 98.1 96 104/41 20 100% on 5L.
Patient was given
Today 18:14 MetRONIDAZOLE (FLagyl) 500mg Premix Bag 1
Today 18:44 Vancomycin 1g Frozen Bag 1
Levofloxacin
.
On the floor, The patient was comfortable and not sure why he
was in the hospital.
Past Medical History:
CAD
CML with BCR-ABL followed by Dr. [**Last Name (STitle) **] initially received
leukophoresis and hydrea then gleevac which was stopped on
[**2177-6-19**] given nl WBC count and anemia/thrombocytopenia.
Osteomyelitis of right foot treated with dapto/cfp until [**2177-7-8**]
when course was supposed to finish
HTN
diastolic HF
Chronic Foley for BPH with recurrent UTI
ESRD on HD (T/T/S)
MS [**First Name (Titles) **] [**Last Name (Titles) 3781**] interactive but unable to follow commands
NGT but able to swallow pureed foods (no pills)
CAD s/p MI with stent in [**2161**]
Atrial fibrillation on Coumadin
Diabetes Type 2 on Insulin
Hypertension
Hyperlipidemia
CML (new diagnosis)
Peripheral [**Year (4 digits) 1106**] disease s/p R SFA stent angioplasty and L
SFA stent placement
Lower extremity cellulitis with surgical debridement/VAC
intradural tumor compressing spinal cord at C1/C2 and s/p
anterior cervical decompression at C5/6 fusion ([**8-29**]) and
extradural tumor removal of C1 intradural tumor (meningioma)
([**8-30**])
Gastroporesis
Neuropathy
Congenital Pulmonic Stenosis s/p surgery at 2 and 9years old
Chronic indwelling foley.
Depression diagnosed at [**Hospital3 **], refused SSRIs
Social History:
The patient is married and has two adult sons who do not live at
home. He lives in [**Hospital1 1474**], MA. His wife works 60 hours a week,
and he is left at home for most of the day. He has been bedbound
for several years. A visiting nurse can only come once a week to
change the dressings on his lower extremity ulcers. His sons
struggle with alcoholism and heroin abuse. His younger son has
recently threatened suicide and homicide (against the patient's
wife), a source of much stress at home. He used to work as a
"bouncer" and in construction, and enjoyed riding his
motorcycle. The patient says he tries to keep a positive
attitude about his condition. He says he feels depressed, but
says he is not interested in therapy or medication for
depression. He has not seen his primary care physician [**Last Name (NamePattern4) **] 2
years because he will only travel in an ambulance but his PCP's
office is in touch with the patient and wife weekly.
-[**Name2 (NI) **] has a 2 pack per year smoking history for "several years"
-He drinks alcohol occasionally, and has never had a problem
with alcoholism
-He denies recreational or IV drug use
Family History:
No history of renal failure or disease. Mother with ? [**Name2 (NI) **]
dyscrasia
Heart disease in unspecificed family members.
Physical Exam:
General: Alert, disoriented, ([**Month (only) 321**], hospital) unable to [**First Name8 (NamePattern2) **]
[**Doctor Last Name 1841**] or DOW in reverse.
Neuro: CN II-XII intact, able to move upper extremities
bilaterally but weak w/ marked wasting of arm/hand musculature
bilaterally.
HEENT: Sclera anicteric, MMM, oropharynx clear, dry skin on
scalp and face, with multiple areas of excoriation.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, III/VI holosystolic murmur best
heard over mitral and aortic areas, non-radiating.
Abdomen: soft, slightly tender diffusely, anarsarcic, bowel
sounds present, no rebound tenderness or guarding, obese, liquid
stool in colostomy, no erythema around wounds from recent
surgery.
Back: Large, black necrotic ulcer on sacrum, spreading upwards
to L3-5.
GU: foley in place with muddy urine output.
Ext: anasarca, necrotic wounds on LLE, feet cool w/ slow cap
refill.
.
Pertinent Results:
ADMISSION LABS:
[**2177-9-8**] 06:00PM URINE RBC-0-2 WBC->50 BACTERIA-MOD YEAST-FEW
EPI-0-2
[**2177-9-8**] 06:00PM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2177-9-8**] 06:00PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025
[**2177-9-8**] 06:00PM PT-15.1* PTT-32.3 INR(PT)-1.3*
[**2177-9-8**] 06:00PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
SPHEROCYT-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL
[**2177-9-8**] 06:00PM NEUTS-74* BANDS-9* LYMPHS-1* MONOS-6 EOS-3
BASOS-1 ATYPS-0 METAS-4* MYELOS-2*
[**2177-9-8**] 06:00PM WBC-41.8* RBC-3.80* HGB-11.0* HCT-34.1*
MCV-90 MCH-28.9 MCHC-32.2 RDW-18.6*
[**2177-9-8**] 06:00PM CALCIUM-8.8 PHOSPHATE-4.1 MAGNESIUM-1.8
[**2177-9-8**] 06:00PM estGFR-Using this
[**2177-9-8**] 06:00PM GLUCOSE-105* UREA N-21* CREAT-2.7*
SODIUM-132* POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-28 ANION GAP-13
[**2177-9-8**] 06:09PM LACTATE-1.2
OTHER PERTINENT LABS:
[**2177-9-10**] 03:46AM [**Month/Day/Year 3143**] ESR-12
[**2177-9-9**] 03:02PM [**Month/Day/Year 3143**] CRP-40.7*
[**2177-9-11**] 12:25PM [**Month/Day/Year 3143**] Tobra-1.6*
URINE:
[**2177-9-8**] 06:00PM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.025
[**2177-9-8**] 06:00PM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-NEG pH-6.5 Leuks-MOD
[**2177-9-8**] 06:00PM URINE RBC-0-2 WBC->50 Bacteri-MOD Yeast-FEW
Epi-0-2
MICRO:
[**2177-9-10**] [**Year (4 digits) 3143**] CULTURE Routine-PENDING
[**2177-9-9**] WOUND SWAB GRAM STAIN-NEGATIVE; WOUND
CULTURE-NEGATIVE; ANAEROBIC CULTURE-NEGATIVE
[**2177-9-8**] [**Year (4 digits) 3143**] CULTURE Routine-PRELIMINARY {ANAEROBIC GRAM
NEGATIVE ROD(S)}; Anaerobic Bottle Gram Stain-NEGATIVE
[**2177-9-8**] URINE CULTURE-FINAL {YEAST}
[**2177-9-8**] [**Year (4 digits) 3143**] CULTURE Routine-PRELIMINARY {STAPHYLOCOCCUS,
COAGULASE NEGATIVE, ANAEROBIC GRAM NEGATIVE ROD(S)}; Anaerobic
Bottle Gram Stain-NEGATIVE
STUDIES:
[**9-8**] CXR: Findings compatible with congestive heart failure,
right pleural effusion. Limited study.
[**9-9**] Wound tissue path: pending
[**9-9**] XR L foot: There is generalized demineralization with more
prominent focal subchondral bone loss in the region of the fifth
MP and talonavicular joints. No discrete fracture or focal bone
destruction although assessment limited by lack of localizing
history. Generalized soft tissue swelling particularly along the
dorsum of the foot. No discrete soft tissue ulceration.
Appearances are little changed from similar exam [**2177-7-9**].
[**9-12**] CXR: In comparison with the study of [**9-11**], the patient
has taken a
somewhat better inspiration. Continued enlargement of the
cardiac silhouette. Respiratory motion somewhat obscures details
of the pulmonary vessels, but there probably is some continued
elevation of pulmonary venous pressure. Retrocardiac
opacification persists, consistent with atelectasis and probable
pleural effusions.
[**9-12**] PICC PLACEMENT CXR:
1. PICC line in right atrium; instructions to withdraw the
catheter by 2 cm. (done by IV team shortly afterward)
2. Unchanged pulmonary congestion.
DISCHARGE LABS:
[**9-13**] CBC: WBC 27 Hgb 10.2 HCT 31.5 Plt 243
[**9-13**] CHEM: Na 130 K 4.9 Cl 94 HCO3 23 BUN 23 Cr 1.8 Glc 115
[**9-13**] Ca 8.3 Mg 1.7 Ph 4.0
Brief Hospital Course:
Mr. [**Known lastname 47031**] is a 56 yo M w/ multiple comorbid conditions, who
presented with cough. s/p sacral decub debridement. Found to
have GNR bacteremia.
#Goals of care: Pt has a poor prognosis. A family meeting was
held at 3 pm on [**9-9**] and a decision was made for no escalation
of care. Antibiotics and hemodialysis are to be continued.
However, the patient does not want to be intubated or
resuscitated, no pressors, no central or arterial lines.
#GNR Bacteremia: The patient was found to have [**Month/Year (2) **] cultures
positive for GNR in 2 bottles. He was seen by Infectious
Disease, and his antibiotic regimen was changed to Tobramycin
100mg IV qHD, Metronidazole 500mg IV TID, and Tigecycline 50mg
IV q12h.
[ ] Tobramycin trough 1hour prior to HD
#Sacral Decubitus: The patient had his sacral decubitis debrided
by surgery. He is on Abx as outlined above. He was also seen by
the wound nurse. [**First Name (Titles) **] [**Last Name (Titles) 39640**] for wound care are:
pressure ulcer care per guidelines
turn and reposition q 2 hours and prn
waffle boots( off load heels )
Cleanse sacral pressure ulcer with 1/4 strength Dakins solution
then rinse with saline ( discontinue after 4 days )
apply santyl to necrotic tissue in wound bed- rub in
antifungal cream to periwound tissue
pack wound with kerlix- barely moist.
cover with dry gauze then softsorb dressing
secure with medipore H soft cloth tape
change daily
If odor persists after 4 days, consider imaging - pt may require
further surgical debridement as this is quicker method of
debridement vs enzymes( santyl)
For left heel and ankle ulcers:
adaptic to heel and dry gauze/abd pads to ankle to protect from
potential trauma
wrap with kerlix
change daily
#Hypoxia/cough: Pt was admitted from rehab out of concern for
aspiration. The patient was not febrile and it was felt that
likelihood for PNA was low, so the patient was not treated for a
PNA.
#AMS: Has been waxing and [**Doctor Last Name 688**] for a long time now, possibly
worse now [**12-31**] infection and chronic illness. We minimized his
opiates.
#ESRD: Pt was continued on hemodialysis TuThSa. Last dialyzed on
the day of discharge ([**2177-9-13**]). Of note, the patient has low
[**Month/Day/Year **] pressures at baseline (SBP 90s-low 100s). His [**Month/Day/Year **]
pressure tends to decrease during sessions, but this should not
limit his ability to be dialyzed as he has been short of breath
secondary to pulmonary edema. Please continue to remove adequate
amounts of fluid during hemodialysis (~2L). As above, he does
not want to be started on pressors in the event of hypotension.
Continued Nephrocaps.
#CML: Pt was recently diagnosed with CML in [**2177-4-29**]. Given
his poor prognosis, we have discontinued his Gleevec. Continue
Allopurinol.
#Chronic Pain: Pt was started on Methadone 7.5mg PO TID with
Dilaudid for breakthrough pain. He was also continued on
Methocarbamol and Gabapentin.
#A. Fib: Continued Metoprolol for rate control. Coumadin was
discontinued on prior admission due to poor overall prognosis.
#Diabetes: Insulin sliding scale.
#SOB: Pt with an episode of shortness of breath during
admission, likely [**12-31**] to pulmonary edema. Improved after
dialysis.
#ACCESS: PICC line was placed Friday [**2177-9-12**]. Initial report
from the radiologist instructed that the line be pulled back
2cm. This was done in the afternoon by the IV team. Repeat CXR
with PICC in appropriate location.
Medications on Admission:
Per recent D/C summary
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID PRN as needed
for Constipation.
3. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: One (1)
Subcutaneous ASDIR (AS DIRECTED): Follow Insulin Sliding Scale
regimen.
4. Gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO Q24H (every
24 hours).
5. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID
(3 times a day).
6. Lactulose 10 gram/15 mL Syrup [**Month/Day/Year **]: Thirty (30) ML PO TID PRN
as needed for constipation.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Imatinib 400 mg Tablet [**Last Name (STitle) **]: [**11-30**] Tablet PO DAILY (Daily):
Patient receives Gleevac in specially formulated liquid form.
200mg daily, several hours before bed.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) Inhalation q 6hr PRN as needed for
wheezing .
11. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash .
12. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. Hydromorphone 4 mg Tablet [**Hospital1 **]: 1-1.5 Tablets PO q 2hr PRN as
needed for pain: 4-6mg PO every 2 hrs for pain.
14. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day).
15. Lidocaine HCl 2 % Solution [**Hospital1 **]: One (1) ML Mucous membrane
TID PRN as needed for throat pain.
16. Meropenem 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 5 weeks: Start
date=[**2177-7-8**] for total 6 week course. On HD days, please give
dose AFTER HD.
17. Daptomycin 600 mg IV Q48H
On HD days, please give dose after dialysis, thanks
18. HYDROmorphone (Dilaudid) 0.75 mg IV ONCE MR1 pain Duration:
1 Doses
Discharge Medications:
1. Outpatient Lab Work
Tobramycin trough 1 hour prior to HD.
2. Tigecycline 50 mg IV Q12H Start: In am
Start 12 hours post first dose.
3. heparin (porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: 5000 (5000)
units Injection TID (3 times a day).
4. insulin lispro 100 unit/mL Solution [**Year (4 digits) **]: as directed units
Subcutaneous every six (6) hours: 101-150: 2 units
151-200: 4 units
201-250: 6 units
251-300: 8 units
301-350: 10 units
351-400: 12 units.
5. glucagon (human recombinant) 1 mg Recon Soln [**Year (4 digits) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. methadone 5 mg Tablet [**Year (4 digits) **]: 1.5 Tablets PO TID (3 times a
day).
8. methocarbamol 500 mg Tablet [**Year (4 digits) **]: 1.5 Tablets PO TID (3 times
a day).
9. metoprolol tartrate 25 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO TID
(3 times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. gabapentin 300 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO DAILY
(Daily).
12. allopurinol 100 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
13. B complex-vitamin C-folic acid 1 mg Capsule [**Year (4 digits) **]: One (1) Cap
PO DAILY (Daily).
14. docusate sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID
(2 times a day).
15. senna 8.6 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
16. lactulose 10 gram/15 mL Syrup [**Year (4 digits) **]: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Year (4 digits) **]: One (1) neb Inhalation every four (4) hours as
needed for SOB.
18. terbinafine 1 % Cream [**Year (4 digits) **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
19. tobramycin sulfate 60 mg/6 mL Solution [**Hospital1 **]: One Hundred
(100) mg Intravenous qHD: please draw trough 1 hour prior to HD,
and adjust dose prn.
20. [**Doctor Last Name **] I.V. 500 mg/100 mL Piggyback [**Doctor Last Name **]: Five Hundred (500)
mg Intravenous three times a day.
21. HYDROmorphone (Dilaudid) 0.5 mg IV Q2H:PRN pain
Hold for SBP < 90
22. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**]
Discharge Diagnosis:
Primary Diagnosis:
Bacteremia
Decubitus ulcer
Pulmonary edema
Secondary Diagnosis:
End stage renal disease
CML
Chronic pain
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 47031**],
You were admitted because you had a cough. While you were
admitted, we consulted the surgeons who debrided your wound. We
have started you on antibiotics for a bacterial [**Known lastname **] infection.
While in the hospital you also were treated with dialysis for
your renal failure.
Several changes were made to your medications. Please use the
attached list.
It was a pleasure meeting you and taking part in your care.
Followup Instructions:
Please follow up with infectious disease:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD
Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2177-9-25**] 11:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Name: [**Known lastname 8695**],[**Known firstname **] Y. Unit No: [**Numeric Identifier 8696**]
Admission Date: [**2177-9-8**] Discharge Date: [**2177-9-13**]
Date of Birth: [**2121-2-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex / Ketamine
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
#. Chemical pneumonia: The patient had a chemical pneumonia
secondary to aspiration.
#. Bacteremia: The patient was found to have gram negative
bacteremia. The likely source was his large sacral decubitus
ulcer and osteomyelitis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1699**] Hospital Transitional Care Unit - [**Location (un) 1777**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2177-10-28**]
|
[
"585.6",
"403.91",
"V45.82",
"600.01",
"790.7",
"E879.6",
"311",
"428.0",
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"788.20",
"996.64",
"599.0",
"730.17",
"414.01",
"V44.0",
"272.4",
"V44.3",
"285.21",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"86.22",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
18875, 19152
|
8731, 12214
|
304, 331
|
17294, 17294
|
5281, 5281
|
17915, 18852
|
4119, 4248
|
14497, 16980
|
17128, 17128
|
12240, 14474
|
17429, 17892
|
8559, 8708
|
4263, 5262
|
259, 266
|
359, 1707
|
17212, 17273
|
5297, 6309
|
17147, 17191
|
6331, 8543
|
17309, 17405
|
1729, 2934
|
2950, 4103
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,340
| 190,099
|
24357
|
Discharge summary
|
report
|
Admission Date: [**2140-10-4**] Discharge Date: [**2140-10-10**]
Date of Birth: [**2089-12-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (un) 11220**]
Chief Complaint:
Tremor
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50M with a history of depression, anxiety, EtOH abuse with PMHx
non-functional adrenal adenoma who presented to the ED ON [**10-4**]
c/o diaphoresis, tremulousness, and nausea since [**32**]:00 that
morning. Per the patient's report, he feels this is EtOH
withdrawal, with last drink at 8pm [**10-3**]. He states that he
usually has these symptoms due to his history of TBI, but also
when he tries to cut back on his drinking. Ordinarily they
resolve after he takes ativan or valium. He says today his
tremors are worse and that they did not resolve when he tried to
take some po ativan and valium. He endorses some chills and
nausea as well. Drinks [**2-1**] to 1 pint a day normally.
In the ED, initial vs were T 98.1 HR 122 BP 151/99 RR 16 SpO2
99%RA. Received lorazepam 2mg IV x1, folic acid 1mg po x1,
thiamine 100mg po x1, diazepam 5mg po x1, magnesium sulfate 2gm
IV x1. Unclear if patient recieved NS in the ED, nothing in [**Month (only) 16**].
On the floor initial VS Tc 97.9 HR 87 BP 132/94 RR 20 SpO2
98%RA. He reported continued tremulousness and nausea. Denied
headache, focal weakness, fevers or chills. States that he has
been having difficulty with ambulation for some weeks now,
although denies any falls with head-strike. Endorses some visual
hallucinations, but denies auditory hallucinations, ELOC, SI/HI.
His tremors were thought to be somewhat inconsistent with
alcohol withdrawal as it was only seen on intention. He was
started on CIWA scale with Diazepam 5-10mg q2hr PRN CIWA>8 but
was not [**Doctor Last Name **] over [**4-3**] when tremor was discluded from score.
TSH was checked for concern for hyperthyroidism and was normal
at 2.4.
Sodium had initially been elevated at 147 on admission, thought
to be hypovolemia and he was treated with fluids, now improved
to wnl.
He was seen by neurology who recommended outpatient follow up
for workup of what is most likely an essential tremor
complicated by his alcohol withdrawal once his acute illness has
resolved.
This morning, he was found to be tachycardic to the 140s and
diaphoretic. He insisted upon leaving and began to walk off the
floor; code purple was called and pt received IV benzo. After
d/w SW and family members, agreed to stay.
On arrival to the MICU, patient's VS.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies
constipation, abdominal pain, diarrhea, dark or bloody stools.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Past Medical History:
Hepatitis C sp biopsy, Etoh abuse, history of TBI [**2132-7-31**],
right brachial plexus injury, non-functional adrenal adenoma,
leg surgery,
/08 - There is an irregular tremor of both his upper
extremities present throughout the exam even when he is holding
the arm still but it is not a classic rest tremor. It seems to
vary in intensity and frequency and it went away with
distracting. It is present more in the right upper extremity
than the left.
Not noted on visit [**10-9**].
Social History:
States he drinks approximately [**2-1**] - 1 pint of alcohol daily.
Endorses 30 pack year history of smoking
Family History:
Denies any family history of neurologic disorders in his family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS Tc 99.7 HR 83 BP 144/99 RR 24 SpO2 100%RA
GEN Alert, oriented, no acute distress, extremely tremulous with
voice tremor noted
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, rhonchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g. Even abdominal
muscles are tremulous throughout examination
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, Motor strength 5/5 throughout upper and
lower extremities bilaterally. Sensation grossly intact. FTN is
accurate but with a significant amount of tremor. Gait deferred.
SKIN no ulcers or rashes
Pertinent Results:
Labs on Admission
[**2140-10-4**] 08:05PM GLUCOSE-214* UREA N-5* CREAT-0.6 SODIUM-142
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
[**2140-10-4**] 08:05PM CALCIUM-8.0* PHOSPHATE-2.0* MAGNESIUM-1.6
[**2140-10-4**] 02:56PM URINE HOURS-RANDOM
[**2140-10-4**] 02:56PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2140-10-4**] 02:10PM LACTATE-1.4
[**2140-10-4**] 01:50PM URINE HOURS-RANDOM
[**2140-10-4**] 01:50PM URINE GR HOLD-HOLD
[**2140-10-4**] 01:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2140-10-4**] 01:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2140-10-4**] 01:50PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2140-10-4**] 01:50PM URINE MUCOUS-MOD
[**2140-10-4**] 12:17PM LACTATE-4.0*
[**2140-10-4**] 12:10PM GLUCOSE-130* UREA N-6 CREAT-0.8 SODIUM-149*
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-22*
[**2140-10-4**] 12:10PM estGFR-Using this
[**2140-10-4**] 12:10PM CALCIUM-10.0 PHOSPHATE-3.3 MAGNESIUM-1.1*
[**2140-10-4**] 12:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-10-4**] 12:10PM WBC-6.8 RBC-4.17* HGB-14.3 HCT-41.2 MCV-99*
MCH-34.2* MCHC-34.6 RDW-12.8
[**2140-10-4**] 12:10PM NEUTS-79.2* LYMPHS-15.6* MONOS-3.7 EOS-0.8
BASOS-0.8
[**2140-10-4**] 12:10PM PLT COUNT-143*
Brief Hospital Course:
Mr. [**Known lastname 61689**] is a 51 year old gentleman with a history of TBI in
[**2132**] secondary to blunt head trauma, hepatitis C and alcohol
abuse admitted with alcohol withdrawl and tremors.
.
EtOH withdrawal
- he was given thiamine, folate and MVI, maintained on a CIWA
score with diazepam scheduled for elevated CIWA scores
- multiple Code Purples were called as he tried to leave
- the patient required ICU level care for alcohol withdrawl
- he required restraints and psychiatry was consulted
- they felt he likely had acute benzodiazepine intoxication, so
valium was held in favor of PRN haldol
- ultimately he came off CIWA and required no more haloperidol
- of note he had transaminase elevation to the 100s-200s, with
normal alk phos and bilirubin, this was suggestive of
hepatocellular injury, chronic Hep C vs. mild EtOH hepatitis
.
Persistent tremor
- essential tremor with possible anxiety component
- Neurology recommended starting propranolol, which was well
tolerated and quite efficacious by the time of discharge
- he was directed to follow-up with his PCP (and Neurology if
needed) about this
.
Inactive issues
- Hx of TBI [**2132-7-31**] -- f/u as outpt
- Depression -- continued home citalopram
- Chronic Hepatitis C -- to be followed up as outpatient
Day of discharge
Interval hx: No events overnight. The patient felt well, was
ambulating better now that his tremor was controlled. No
lightheadedness or dizziness. He wanted to go home. We
discussed his medications and follow-up plan. He understood.
Exam: VSS, afebrile
Gen: middle aged AAM lying in bed, alert, cooperative, very mild
tremor (much improved)
HEENT: MMM, no oral lesions, PERRL, anicteric
Chest: equal chest rise, CTAB posteriorly
Heart: RRR, no obv m/r/g
Abd: soft, NTND
GU: no CVAT
Extr: WWP, no edema
Skin: no rashes
Neuro: tremor much improved, otherwise neurological exam normal
(CN intact, strength 5/5 bilat, sensation to light touch intact,
gait, reflexes and cerebellar testing deferred)
Psych: normal affect
Lines/tubes: PIV
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Citalopram 20 mg PO DAILY
2. Lorazepam 1 mg PO HS
3. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Propranolol 40 mg PO BID
Hold for SBP <100 or HR <60 and notify MD.
RX *propranolol 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Lorazepam 1 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawl
Essential tremor
Depression
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with alcohol withdrawl and a tremor. You were
treated for both of these, and required a short stay in the
intensive care unit for the withdrawl. Ultimately, you
improved, and you were discharged to follow-up with your primary
care doctor [**First Name (Titles) **] [**Last Name (Titles) **] as an outpatient. As we discussed,
you should never drink alcohol ever again.
Followup Instructions:
Primary Care, with Dr. [**Hospital1 30727**] at [**Hospital1 **]. You indicated
that you can be seen this Friday, the 14th, and I strongly
recommend this. You and your doctor can decide if you need to
see a Neurologist.
If you would like to see a Neurologist, Dr. [**First Name4 (NamePattern1) 53239**] [**Last Name (NamePattern1) **] at
[**Hospital1 18**] (who saw you in the hospital) would be happy to follow
you. You can schedule an appointment with her by calling [**Telephone/Fax (1) 61690**].
Psychiatry, with Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) 4135**] at [**Hospital1 **]. You indicated
you would reschedule a follow-up appointment with her, and
preferred that we not do this. I encourage you to be seen
within the next week.
Social work -- you indicated the Neurology Management Center
would arrange a social worker for you. Our Social Worker spoke
with you about this.
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2140-10-25**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: TUESDAY [**2141-2-7**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
Completed by:[**2140-10-10**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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5905, 7946
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280, 286
|
8663, 8663
|
4464, 5882
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|
3677, 3744
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|
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|
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|
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|
3784, 4445
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2593, 3005
|
234, 242
|
314, 2574
|
8678, 8789
|
3049, 3535
|
3551, 3661
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,404
| 122,896
|
47619
|
Discharge summary
|
report
|
Admission Date: [**2162-4-1**] Discharge Date: [**2162-4-9**]
Date of Birth: [**2103-7-7**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This 58-year-old female, status
post MI on [**2162-1-31**], presented to [**Hospital3 417**] Hospital
with cramping of the left chest and was referred to [**Hospital1 18**] for
cardiac catheterization. She underwent cardiac
catheterization on [**1-/2087**] which revealed severe three-vessel
disease. A stent of the PDA was unsuccessful and led to a
dissection. It was angioplastied with a 20% residual
stenosis. She is a Jehovah's Witness and is chronically
anemic, so she went home on iron to increase her hematocrit.
She now has a hematocrit of 39.5, and is admitted for
elective CABG.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus.
2. Hyperlipidemia.
3. Coronary artery disease.
4. Anemia of chronic disease.
5. Osteomyelitis, right shoulder, which was positive for
MRSA.
6. History of chronic pancreatitis.
7. History of urinary tract infection
8. Status post left fem-PT bypass graft in [**11-5**].
9. Chronic renal insufficiency with a baseline creatinine of
1.3.
10.Dyspnea on exertion.
11.Peripheral vascular disease.
12.Neuropathy.
13.Status post cholecystectomy.
14.Hypertension.
15.DVT.
16.Hypothyroidism, status post partial thyroidectomy in [**2142**].
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg po qd.
2. Levoxyl 75 mcg po qd.
3. Calcium carbonate 500 mg po qid.
4. Protonix 40 mg po qd.
5. Colace 100 mg po tid.
6. Reglan 10 mg po tid.
7. Clotrimazole 1% topically.
8. Lasix 40 mg po qd.
9. Lisinopril 5 mg po qd.
10.Lipitor 40 mg [**Hospital1 **].
11.Imdur 60 mg po qd.
12.Ferrous gluconate 300 mg po tid.
13.Lopressor 100 mg po bid.
14.Lantus 60 U q hs.
15.Humalog sliding scale.
16.Home O2 occasionally.
ALLERGIES:
1. Morphine.
2. Percocet.
3. Darvocet.
SOCIAL HISTORY: She is divorced. Lives with her sister.
She does not smoke cigarettes and does not drink alcohol.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAM: She is a well-developed, well-nourished
female in no apparent distress.
VITAL SIGNS: Stable. Afebrile.
HEENT: Normocephalic, atraumatic. Extraocular movements
intact. Oropharynx benign.
NECK: Supple. Full range of motion. No lymphadenopathy or
thyromegaly. Carotids 2+ and equal bilaterally without
bruits.
LUNGS: Clear to auscultation and percussion.
CARDIOVASCULAR: Regular rate and rhythm. Normal S1, S2. No
rubs, murmurs or gallops.
ABDOMEN: Obese, soft, nontender with no masses or
hepatosplenomegaly.
EXTREMITIES: Well-healed surgical scars and a palpable graft
pulse.
NEURO: Nonfocal.
ECHO: Revealed that she had mild LVH and her EF was slightly
decreased with 1+ MR, 1+ TR, and mild pulmonary hypertension.
CARDIAC CATH: Revealed a 50% mid RCA lesion, occluded RPDA
lesion, 30% left main coronary artery lesion, 90% LAD lesion,
70% left circumflex, and 100% OM1.
HOSPITAL COURSE: She was admitted, and on [**4-1**] she
underwent a CABG x 4 with LIMA to the diag, saphenous vein
graft to LAD, right PL and PDA. Crossclamp time was 66
minutes. Total bypass time 84 minutes. She was transferred
to the CSRU in stable condition on dobutamine, Nitro, insulin
and propofol. She was extubated on her postop night. She
did have some EKG changes postop and was kept on Nitro and
dobutamine overnight. Her chest tubes were DC'd on postop
day #1.
[**Last Name (un) **] was consulted, and they followed her glucoses. She
was weaned off the Nitro on postop day #1. On postop day #2,
she was still on dobutamine which was slowly weaned off. She
was also started on captopril. On postop day #4, she was
transferred to the floor in stable condition. She continued
to progress, but was very slow with ambulation. She had her
epicardial pacing wires DC'd, and she was discharged to rehab
on postop day #8 in stable condition.
LABS ON DISCHARGE: White count 10,700, hematocrit 34.7,
platelet count 195, sodium 135, potassium 4.5, chloride 97,
CO2 28, BUN 30, creatinine 1.2, blood sugar 75.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg po bid.
2. Colace 100 mg po bid.
3. Ecotrin 325 mg po qd.
4. Protonix 40 mg po qd.
5. Levoxyl 75 mcg po qd.
6. Lipitor 40 mg po qd.
7. Colace 100 mg po qid.
8. Reglan 10 mg po tid.
9. Clotrimazole cream topically.
10.Captopril 25 mg po tid.
11.Dilaudid 2 mg q 4-6 h prn.
12.Lasix 40 mg po qd.
13.Potassium 20 mEq po qd.
14.Glargine 35 U subcu q hs.
15.Humalog sliding scale.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Insulin dependent diabetes.
3. Hyperlipidemia.
4. Anemia.
5. Chronic pancreatitis.
6. Hypertension.
7. Hypothyroidism.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2162-4-9**] 10:50
T: [**2162-4-9**] 10:53
JOB#: [**Job Number 100615**]
|
[
"411.1",
"401.9",
"443.9",
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"244.0",
"593.9",
"285.29",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4498, 4928
|
4082, 4477
|
1395, 1878
|
2951, 3893
|
2042, 2933
|
2015, 2026
|
3913, 4059
|
181, 775
|
797, 1369
|
1895, 1995
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,675
| 188,944
|
55035
|
Discharge summary
|
report
|
Admission Date: [**2132-5-22**] Discharge Date: [**2132-6-5**]
Date of Birth: [**2072-2-19**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Left Craniotomy for tumor
History of Present Illness:
60yo woman with no significant PMH found by her son at home [**5-22**]
to be very confused. She then had a tonic clonic seizure that he
witnessed. She was brought to an OSH where she was witnessed to
seize again. While obtaining a CT she began to vomit so she was
intubated. CT revealed a left parietal lesion.
She was transferred to [**Hospital1 18**] and was given Keppra and 10mg
decadron then neurology and neurosurgery consultations were
requested.
Past Medical History:
Obesity, Hyperlipidemia, Diabetes, Hypertension, depression and
anxiety, thyroid biopsy
Social History:
per son, no tobacco/drugs. occasional etoh. independent in ADL's
Family History:
non-contributory
Physical Exam:
O: BP: 158/91 HR: 82 R 18 O2Sats 100%
Gen: intubated and sedated (propofol and versed held for exam).
Neuro:
Mental status: EO to voice
Pupils: PERRL 3mm, tracks examiner
Motor: following commands x4 extremities, antigravity x4
Reflexes: R Br Pa Ac
Right 1+ 1+ 1+ 1+
Left 1+ 1+ 1+ 1+
Toes upgoing bilaterally
PHYSICAL EXAM UPON DISCHARGE:
VS: 98.2, 62, 138/83, 15, 96% on trach mask
HEENT: trach in place, no exudate or erythema noted on
examination of tympanic membranes bilaterally
CV: RRR
PULM: mildly rhonchorous breath sounds throughout.
ABD: soft, NT, ND
EXT: no edema
NEURO EXAM:
MS - AAOx3 (whispering over the trach)
CN - PERRL 3->2, EOMI, tongue midline, face symmetrical, facial
sensation intact
MOTOR - [**5-17**] throughout
SENSATION - intact to light touch throughout
Pertinent Results:
[**5-22**] CXR: IMPRESSION:
1. Endotracheal tube in standard position. Nasogastric tube
courses below
the diaphragm, with the tip not visualized, off the inferior
borders of the film.
2. Low lung volumes with probable mild pulmonary vascular
congestion and
bibasilar atelectasis.
[**5-22**] MRI BRAIN: IMPRESSION: Homogeneously enhancing extra-axial
lesion along the left parietal convexity with mild mass effect
on the left parietal lobe associated with perilesional edema.
This likely represents a meningioma.
[**5-23**] CXR The patient is intubated with the ET tube and NG tube
in appropriate position. Heart size and mediastinum are
unchanged in appearance. Interval resolution of pulmonary edema
has been demonstrated with overall clear lungs currently seen
with no definitive evidence of masses or consolidations.
[**5-23**] CTA head:
1. CT shows a partially calcified mass in the left
parietooccipital region consistent with a meningioma.
2. CT angiography demonstrates increased vascularity in the
region, but exact origin of this vascular structure is difficult
to ascertain given the limited ability of the CTA, but there
appears to be some meningeal supply from the superficial aspect
of the mass. The parietooccipital branch of the left middle
cerebral/posterior cerebral artery is seen draped over the mass.
[**5-25**] CXR preop: The cardiomediastinal contours are within normal
limits. Lungs and pleural surfaces are clear, and no acute
skeletal abnormalities are detected.
[**5-25**] MRI brain Wand: Unchanged enhancing extra-axial mass lesion
along the left parietal region, with mild mass effect on the
left parietal lobe and
associated with perilesional edema.
[**5-26**] CT head: Expected post-surgical changes with a small amount
of hemorrhage and pneumocephalus in the region of previously
visualized left occipital mass. Previously visualized calcified
occipital masse is no longer seen
MR HEAD W & W/O CONTRAST Study Date of [**2132-5-27**] 3:21 PM
IMPRESSION:
1. Post-surgical changes status post resection of left parietal
extra-axial mass, likely representing meningioma. No evidence
of residual enhancement to suggest residual tumor.
2. There is an area of slow diffusion anterior to the resection
cavity,
likely representing an area of ischemia or related to surgical
procedure.
CXR [**2132-6-2**]: IMPRESSION: Status post endotracheal tube removal
and tracheostomy tube placement. No acute cardiopulmonary
process.
CXR [**2132-6-3**]: FINDINGS: Tracheostomy tube in standard position.
An orogastric tube ends into the stomach. Both lungs are clear.
No opacities of concern. Mildly enlarged heart size is stable,
mediastinal and hilar contours are unremarkable. There is no
pleural effusion or pneumothorax.
Brief Hospital Course:
Ms. [**Known lastname 112347**] was admitted to the Neurosurgery service, to the
ICU. She was continued on Keppra for seizure phophylaxis and
steroids for cerebral edema. She underwent MRI imaging which
revealed a left parietal lesion, likely meningioma. She was
extubated and her neurological exam was nonfocal and so she was
transferred to the step down unit.
After discussion with the patient and family the decision was
made for surgical resection of the lesion. On [**5-26**] she
underwent a left parietal craniotomy for excision of mass. She
was a difficult intubation and thus remained intubated
postoperatively. She was placed on dexamethasone 4Q6 for the
mass but also for airway edema. Postoperative head CT showed
post operative changes, but was stable. On [**5-27**], patient
remained intubated and on decadron. She was a&ox2 and full
strength on exam. MRI of the head was performed to evaluate for
residual tumor. On [**5-28**] she was unable to be extubated due to a
lack of cuff leak. She was evalauted by ENT who scoped her at
the bedside and she was noted to still have edema. Eventually
ENT recommended that she remain intubated until Monday. She
remained stable on [**5-29**] and [**5-30**] while on the ventilator. She
continued to have airway issues and a tracheostomy was
recommended. The ACS team was consulted and they agreed to
proceed with tracheostomy on [**6-2**]. The patient had a
tracheostomy placed and continued to be on the ventilator and
was weaned as tolerated. The patient was neurologically intact.
The incision was clean dry and intact. She remained
neurologically intact but continued to need some ventilator
support until [**6-4**], when she was taken off the vent. She
remained in the ICU until [**6-5**] when she was able to be sent to a
vented rehab (in case she needed to be placed back on the vent).
Medications on Admission:
zoloft, zocor, klonopin, metformin, ativan, abilify, glypizide
Discharge Medications:
1. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aripiprazole 1 mg/mL Solution Sig: Two (2) PO DAILY (Daily).
4. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, T>38.5.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. hydrochlorothiazide 12.5 mg Capsule Sig: Four (4) Capsule PO
DAILY (Daily).
8. olmesartan 20 mg Tablet Sig: One (1) Tablet PO qday ().
9. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal Q12H (every 12 hours) as needed for rhinitis.
10. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
11. levetiracetam 100 mg/mL Solution Sig: 1,000 mg PO BID (2
times a day).
12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day.
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
16. insulin regular human 100 unit/mL Solution Sig: per sliding
scale units Injection QAHS.
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for continuing Medical Care
Discharge Diagnosis:
Left parietal mass
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:
General Instructions/Information
?????? Have a friend/family member, doctor or nurse 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 have dissolvable sutures so you may wash your hair
and get your incision wet day 3 after surgery. You may shower
before this time using a shower cap to cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna 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), so you
will not require blood work monitoring.
?????? While you are 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 once you are able to have your tracheostomy removed.
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.
We made the following changes to your medications:
1) We STARTED you on TYLENOL 650mg every 6 hours as needed for
pain or fever.
2) We STARTED you on SENNA 8.6mg once a day to help prevent
constipation.
3) We STARTED you on BISACODYL 10mg once a day as needed for
constipation.
4) We STARTED you on HYDROCHLOROTHIAZIDE 50mg once a day.
5) We STARTED you on FLUTICASONE 1 spray every 12 hours as
needed.
6) We STARTTED you on DOCUSATE 100mg twice a day.
7) We STARTED you on KEPPRA 1,000mg twice a day.
8) We STARTED you on ALBUTEROL 6 puffs inhaled every 6 hours as
needed for SOB/wheeze.
9) We STARTED you on DEXAMETHASONE 2mg once a day. At your
Brain [**Hospital 341**] Clinic follow-up they will determine if you should
stop taking this.
10) We STARTED you on FAMOTIDINE 20mg twice a day.
11) We STARTED you on SUBCUTANEOUS HEPARIN 5,000 units three
times a day while you are in rehab.
12) We STARTED you on an INSULIN SLIDING SCALE while you are in
rehab.
13) We STOPPED your CLONAZEPAM.
14) We STOPPED your METFORMIN as you are now on an insulin
sliding scale.
15) We STOPPED your ATIVAN.
16) We STOPPED your GLIPIZIDE as you are now on an insulin
sliding scale.
17) We STARTED you on OXYCODONE 5mg every 6 hours as needed for
pain. Do not drive, operate heavy machinery, drink alcohol or
take other sedating medications with this until you know how it
effects you.
Followup Instructions:
Follow-Up Appointment Instructions
** No wound check needed as patient was seen in the hospital 9
days s/p meningioma resection.
Department: RADIOLOGY
When: MONDAY [**2132-6-23**] at 8:35 AM
With: RADIOLOGY MRI [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY (BRAIN [**Hospital **] CLINIC)
When: MONDAY [**2132-6-23**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"780.39",
"225.2",
"V85.41",
"250.00",
"401.9",
"272.4",
"V58.67",
"599.0",
"278.00",
"300.00",
"348.5",
"311",
"V46.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"01.51",
"02.12",
"31.1",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8182, 8261
|
4689, 6544
|
315, 343
|
8324, 8324
|
1903, 3605
|
11818, 12572
|
1038, 1056
|
6658, 8159
|
8282, 8303
|
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|
8500, 10442
|
1071, 1188
|
10471, 11795
|
268, 277
|
1438, 1884
|
371, 827
|
3614, 4666
|
8339, 8476
|
849, 939
|
955, 1022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,831
| 135,880
|
9975
|
Discharge summary
|
report
|
Admission Date: [**2113-5-3**] Discharge Date: [**2113-5-6**]
Service: TRA
HISTORY OF PRESENT ILLNESS: The patient is an 83-year old
female status post fall out of bed. The patient presented to
the Emergency Room, in which a head computer tomography
revealed a small left frontal subarachnoid hemorrhage.
Neurosurgery was consulted; however, the patient was also
noted to have a right cortical evulsion fracture of the
dorsal triquetrum. Therefore, a Trauma consultation was
obtained. The patient was admitted to the Trauma Intensive
Care Unit in stable condition.
PAST MEDICAL HISTORY: Hypertension.
Hyperlipidemia.
Dementia.
Hypothyroidism.
Depression.
Osteoporosis.
PAST SURGICAL HISTORY: Open reduction internal fixation of
the right hip in [**2106**].
Status post appendectomy (date unknown).
MEDICATIONS ON ADMISSION:
1. Aricept 10 once per day.
2. Cardizem 240 once per day.
3. Detrol 4 once per day.
4. Synthroid 0.5 once per day.
5. Zoloft 50 once per day.
6. Zyprexa 5 once per day.
7. Evista 60 once per day (please note that the correct
spelling of this medication not know).
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98.7,
her pulse was 60, her blood pressure was 171/65, her
respiratory rate was 16, and her pulse oximetry was 94
percent on room air and 98 percent on 2 liters. Alert and
following commands. The extraocular movements were intact.
Cervical collar in place. Clear to auscultation bilaterally.
A regular rate and rhythm. The abdomen was soft, nontender,
and nondistended. On extremity examination, difficulty
lifting the left leg due to pain. The pelvis and hips were
stable. Right hand with third finger swollen and tenderness
throughout, and an ulcer at the snuff box. The skin was warm
and dry. Neurologically, cranial nerves II through XII were
grossly intact. Strength was [**3-29**] bilaterally in the upper
and lower extremities. Sensation was intact.
LABORATORY FINDINGS: White blood cell count was 11.4, her
hematocrit was 37.6, and her platelets were 232. Chemistry-7
was within normal limits.
RADIOLOGY-IMAGING: A head computed tomography as above.
Right wrist as above.
A chest x-ray was within normal limits.
Pelvis and left tibia no fractures.
A computer tomography of the spine showed degenerative
disease, but no acute fracture.
A computer tomography of the face revealed no fractures.
A plain film of the right knee revealed no fractures.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Trauma Intensive Care Unit in stable condition for q.1h.
neurologic checks. A repeat computer tomography the next day
showed the subarachnoid hemorrhage to be stable. A
Plastics/Hand consultation was obtained for her hand
fracture. The patient's right hand was placed in a volar
splint. Otherwise, the patient had a largely unremarkable
hospital course. The patient was transferred to the floor
without event.
DISCHARGE DISPOSITION: The patient was discharged to
rehabilitation on hospital day four in stable condition.
CONDITION ON DISCHARGE: Stable - to rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Aricept 10 once per day.
2. Cardizem 240 once per day.
3. Detrol 4 once per day.
4. Synthroid 0.5 once per day.
5. Zoloft 50 once per day.
6. Zyprexa 5 once per day.
7. Evista 60 once per day.
8. Pepcid 20 mg by mouth twice per day.
9. Percent one to two tablets q.4-6h. as needed (for pain).
10. Colace 100 mg twice per day.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern1) 27758**]
MEDQUIST36
D: [**2113-5-5**] 07:54:57
T: [**2113-5-5**] 09:07:16
Job#: [**Job Number 33382**]
|
[
"852.00",
"814.03",
"244.9",
"733.00",
"E884.4",
"294.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2953, 3041
|
3121, 3727
|
851, 2452
|
717, 825
|
2481, 2929
|
116, 582
|
605, 693
|
3066, 3095
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,134
| 124,953
|
580
|
Discharge summary
|
report
|
Admission Date: [**2173-8-14**] Discharge Date: [**2173-8-26**]
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
AMS, shortness of breath
Major Surgical or Invasive Procedure:
PICC line
History of Present Illness:
88yo F PMhx CHF, HTN presenting w AMS in the setting of a fall.
1d prior to presentation, patient was getting out of bathtub
when she slipped; this was an observed fall by the patient's
VNA; no head strike, no LOC. Patient reports she initially felt
fine, and refused to go to the ED at that time. On day of
admisison, family reported that patient sounded confused over
the phone, acting "sleepy". Patient denied fevers, chills,
nausea/vomitting, cough, motor/sensory deficits; reported pain
over her L ribs from her fall. Patient's family brought her to
the ED for further evaluation.
.
On presentation to the ED, initial vital signs were 99.4 60
117/45 20 92%. Exam was remarkable for hematoma over L rib,
atraumatic head, mild abdominal tenderness; labs were
significant or WBC 5.9, Hct 34.7, platelets 122, ALT 44, AST 80,
BNP 3244, Cr 1.9, UA wnl, trop .03; CXR unremarkable, RUQ u/s
unremarkable, CT unremarkable; while in the ED patient spiked
fever to 101.3. Blood cx were sent and patient was given
vancomycin/zosyn and was admitted to medicine for further
management. At time of transfer, vital signs were 98.9 61 142/63
20 100%3L.
.
On arrival to the floor vital signs were 99.9 160/75 59 18
93%2L. On further questioning patient reported increased SOB and
constipation; denied headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, nausea, vomiting,
diarrhea, , BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. CAD - 3 Vessel, medically managed
2. Severe aortic stenosis. [**Location (un) 109**] of 0.8-1.0 cm2, AV gradient of
60-33 mmHg per recent echocardiogram performed in 03/[**2172**]. AVR
was considered but the pt refused surgery, and preferred to
continue on medical therapy.
3. paroxysmal atrial fibrillation, s/p pacemaker placement in
[**2158**] for tachy-brady syndrome, followed by generator change in
[**2169**]. Amiodarone was re-initiated in [**2171-7-10**] d/t increased
frequency of AF.
4. HTN
5. diastolic CHF
6. Hypothyroidism
7. Chronic lung nodules
Social History:
Patient lives alone in [**Location (un) 583**], with daughter [**Name (NI) **] (health care
proxy)
living nearby. Patient has help for cleaning and bathing,
does some cooking, daughter does shopping. Walks with walker.
Weekly VNA services. No h/o tobacco, ETOH.
Family History:
mult family members w +CAD
Physical Exam:
ADMISSION EXAM:
VS: 99.9 160/75 59 18 93%2L
GENERAL: NAD, comfortable
HEENT: NC/AT, PERRL, EOMI, MMM, OP clear
NECK: Supple, 6cm JVD, no LAD.
HEART: RRR, no MRG
LUNGS: Inspiratory crackles bilaterally, decreased breathsounds
at R base
ABDOMEN: Soft/NT/ND, suprapubic fullness, no rebound/guarding
EXTREMITIES: WWP, trace edema to ankle, 2+ DP/PT/radial pulses
NEURO: AOx3, CNs II-XII grossly intact, muscle strength 5/5 x4
extremities, gait not observed
.
DISCHARGE EXAM:
Tm 99.6 Tc 99.5 131/41 59 20 95% 2L
General: Alert, no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral scattered crackles, worse at bases
CV: RRR, 3/6 systolic murmur radiates to carotids
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining transparent urine
Ext: warm, well perfused, 2+ pulses, no edema. L foot/ankle
swollen with slight erythema, tender to touch over toes
Pertinent Results:
Admission labs:
[**2173-8-14**] 03:18PM BLOOD WBC-5.9 RBC-4.03* Hgb-12.2 Hct-34.7*
MCV-86# MCH-30.3 MCHC-35.2* RDW-14.2 Plt Ct-122*
[**2173-8-14**] 03:18PM BLOOD Neuts-48* Bands-0 Lymphs-43* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-8-14**] 03:18PM BLOOD PT-13.8* PTT-23.5 INR(PT)-1.2*
[**2173-8-14**] 03:18PM BLOOD Glucose-104* UreaN-39* Creat-1.9* Na-140
K-5.1 Cl-102 HCO3-24 AnGap-19
[**2173-8-14**] 03:18PM BLOOD ALT-44* AST-80* AlkPhos-75 TotBili-0.6
[**2173-8-14**] 03:18PM BLOOD proBNP-3244*
[**2173-8-14**] 03:18PM BLOOD cTropnT-0.03*
[**2173-8-14**] 03:18PM BLOOD Albumin-3.9 Calcium-8.5 Phos-4.7* Mg-2.5
[**2173-8-14**] 03:26PM BLOOD Lactate-1.8
.
DISCHARGE LABS:
[**2173-8-25**] 05:47AM BLOOD WBC-6.5 RBC-3.48* Hgb-10.7* Hct-30.6*
MCV-88 MCH-30.6 MCHC-34.9 RDW-14.2 Plt Ct-264
[**2173-8-25**] 05:47AM BLOOD Glucose-94 UreaN-23* Creat-1.1 Na-141
K-3.6 Cl-105 HCO3-28 AnGap-12
[**2173-8-25**] 05:47AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.1
.
IMAGING:
CXR [**2173-8-14**]
1. Blunting of bilateral costophrenic angles; while could relate
to overlying soft tissue, but trace pleural effusions or pleural
thickening not excluded.
2. Possible minimal interstitial pulmonary edema.
.
Echo [**2173-8-17**]
The left atrium is dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to
moderate ([**1-10**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.
Compared with the prior study (images reviewed) of [**2172-3-9**], the
severity of aortic stenosis is similar.
.
BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND ([**8-19**]): [**Doctor Last Name **]-scale
and Doppler son[**Name (NI) 1417**] of the bilateral common femoral,
superficial femoral, and popliteal veins were obtained.
Evaluation of the calf veins was limited due to patient body
habitus. However, there is normal flow, compressibility, and
augmentation of the above examined veins.
IMPRESSION: No DVT.
.
CHEST CT ([**8-19**]):FINDINGS:
The airways are patent to the segmental level. Mediastinal
lymphadenopathy is longstanding measuring up to 30 x 12 mm in
the right upper posterior
paratracheal station, 11 mm right lower paratracheal station, 12
mm in the AP window. There is mild cardiomegaly. There is severe
calcification of the aortic valve and mitral annulus. There are
also severe/dense atherosclerotic calcifications in all coronary
arteries. Pacemaker leads are in standard position. There is no
pericardial effusion. The aorta is normal in caliber with
moderate calcifications in the ascending aorta and aortic arch.
There are small bilateral nonhemorrhagic pleural effusions.
Multifocal areas of lung consolidation in the upper lobes, left
greater than right, lingula, are most likely infectious in
etiology with a component of pulmonary edema given the fact that
there is mild interlobular septal thickening and ground-glass
opacities in the upper lobes bilaterally. In the lower lobes
bilaterally bibasilar consolidations are associated with loss of
volume in the left lower lobe and small bilateral nonhemorrhagic
pleural effusions.
A calcified small lung nodule in the right lobe, which is
stable.
Other previously described lung nodules are obscured by lung
opacities.
This examination is not tailored for subdiaphragmatic
evaluation. A
subcentimeter hypodense lesion in the right lobe of the liver
(2:45) is
unchanged, too small to be characterized. There is a small
hiatal hernia.
There are no bone findings of malignancy. There is a vertebral
hemangioma in L1.
IMPRESSION:
Multifocal pneumonia, small bilateral pleural effusion. There is
also a
minimal component of interstitial edema.
Brief Hospital Course:
88yo F PMHx CHF, HTN presented initially with pneumonia, s/p
fall with fevers to 103 and worsening pulmonary edema, required
ICU admission for BiPap. Fared well with broad spectrum
antibiotics and diuresis.
.
ACTIVE ISSUES:
.
Pneumonia: Pt was initially started on ceftriaxone and
doxycycline for presumed treatment for CAP given that patient is
on amiodarone and concern for prolonged QT. She was stable on
the floor until hospital day 2, when she developed acute
shortness of breath, tachypnea, and increase in O2 requirement
from 96% on 3L -> 90% on 3L. She received Lasix IV, nitropaste,
and was placed on facemask with no improvement in her
oxygenation. She was transferred to the MICU for initiation of
BiPap. In the ICU, her antibiotic coverage was broadened to
vancomycin, ceftriaxone, and doxycycline. Because she continued
to spike fevers, she was switched to vancomycin, Zosyn and
Cipro. CT chest was done given hx of lung nodules and showed
multifocal pneumonia, small bilateral pleural effusion and a
minimal component of interstitial edema. She has remained
afebrile since starting on vanc/zosyn/cipro and will be
discharged to rehab to complete a 14 day course, last day [**9-2**].
.
# Acute on chronic diastolic heart failure: Pt has known history
of severe diastolic heart failure with critical AS. She was
being managed with Lasix 40mg IV BID while in the hospital,
however on hospital day 2 pt developed increasing oxygen
requirement, and became tachypneic, likely due to flash
pulmonary edema. She was treated with IV Lasix, nitropaste and
morphine, however her O2 sats remained in mid 80s so she was
transferred to the MICU for BiPap. During her MICU stay, she
had a few episodes of hypotension which responded to small fluid
boluses (500cc). Echo was repeated, and aortic stenosis was
similar. On hospital day 4, she developed another episode of
hypoxia, this time with good response to IV Lasix. She was
resumed on her home dose of torsemide 40mg PO BID, with Lasix
PRN. BP remained stable and she was able to tolerate diuresis.
Her oxygen saturation remained stable at mid 90s on 2L. She did
have LENIs done to rule out PE as possible source of acute
hypoxia, but these were negative for DVT. Her oxygen saturation
and fluid status was complicated during this stay with
superimposed pulmonary edema upon her pneumonia in the setting
of critical AS.
.
# Gout: Pt developed acute gouty attack during hospitalization,
like secondary to diuresis she had been receiving. She was
started on low dose colchicine 0.6 daily, given concern for her
renal insufficiency, increasing to 0.6 [**Hospital1 **] as her renal function
improved. This was dosed with Zofran as necessary for nausea.
Her uric acid level was 6.4. We started a low dose prednisone
burst that we recommended to the rehab hospital.
.
# Acute on chronic Renal Failure: Pt presented with Cr 1.9 which
decreased to 1.1 over course of hospitalization. Her
antibiotics were renally dosed and adjusted for rapid changing
creatinine.
.
# Constipation: On Colace and senna at home, though has not been
taking recently. We suspect that this may be contributing to her
nausea. She was managed on polyethylene glycol, Colace and
senna.
.
CHRONIC ISSUES:
.
# Afib: Pt has long history of afib with pacer in place. We
continued her home medications of amiodarone and aspirin.
.
# CAD: Pt was continued on home regimen of simvastatin and
aspirin. Her carvedilol has been held because blood pressure is
under good control.
.
# HTN: Her Diovan and carvedilol has been held for low blood
pressure.
.
# Hypothyroidism: continued on home levothyroxine
.
TRANSITIONAL ISSUES:
#Code status: DNR, but OK to intubate per discussion with pt and
her daughter. Pt would like to defer all medical decisions to
her daughter, [**Name (NI) **], who is her HCP.
.
#Pt will need to complete 14 day course of antibiotics, last
dose to be given [**9-2**]
.
# Hospital course was prolonged by patient and family refusal to
have PICC placement. It appears that her daughter, who is the
health care proxy, has a more limited understanding of English
than initially thought. It is recommended that all future
conversations regarding health care be had with an interpreter.
.
# We have held her carvedilol and Diovan as her blood pressure
has been well controlled here without either. She may require
re-initiation of these medications as an outpatient.
Medications on Admission:
ASA 81mg daily
Amiodarone 200mg daily
carvedilol 12.5mg [**Hospital1 **]
simva 20mg daily
diovan 80mg daily
meclizine 12.5mg [**Hospital1 **]
levothyroxine 50mcg daily
colace [**Hospital1 **]
senna [**Hospital1 **]
torsemide 40mg [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
5. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours): last dose 8/25.
6. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 g
Intravenous Q6H (every 6 hours): Last dose 8/25.
7. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg
Intravenous Q 24H (Every 24 Hours): last dose 8/25.
8. torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. CONSIDER THESE MEDICATIONS
1. Metolazone 2.5 mg for weight gain (2lbs) or SOB
2. Predinsone 20-40mg for gout (5 day burst)
13. Outpatient Lab Work
Consider checking BMP to assess renal function on torsdemide
every 2-3 days. (Baseline 1.1-1.4)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
pneumonia
pulmonary edema
Secondary:
Gout
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 4602**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because you were having
trouble [**Hospital1 4605**]. You were found to have a pneumonia that we
are treating with IV antibiotics. You went to the ICU for a few
days because you had too much fluid on your lungs. We gave you
medicine to help you get rid of the extra fluid. The diuresis
caused a painful left leg gout flare that we treated with
colchicine and one dose of prednisone. We place an IV line
called a PICC line to give you antibiotics until [**9-2**].
The following changes were made to your medications:
1. Please take vancomycin 1500 mg IV every 48 hours until [**9-2**]
2. Please take Piperacillin-Tazobactam 2.25 g IV every 6 hours
until [**9-2**]
3. Please take Ciprofloxacin 750 mg by mouth once a day
4. Please take colchicine 0.6mg by mouth daily until foot pain
resolves
5. please stop taking meclizine
6. Please stop taking carvedilol and diovan. You may discuss
restarting this with your PCP.
7. Please take metolazone 2.5mg by mouth as necessary for weight
gain (2lbs) or shortness of breath.
8. Consider a 5 day burst of prednisone (20 or 40 mg) for your
gout
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day, or 5 pounds in 3 days.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2173-9-24**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2173-8-26**]
|
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"414.01",
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"403.90",
"428.33",
"244.9",
"V15.88",
"428.0",
"486",
"424.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13866, 13956
|
7940, 8149
|
249, 261
|
14052, 14052
|
3671, 3671
|
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|
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|
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|
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|
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|
14067, 14211
|
11182, 11578
|
1763, 2329
|
2345, 2609
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,688
| 132,950
|
15454+15455+56650+56651+56659
|
Discharge summary
|
report+report+addendum+addendum+addendum
|
Admission Date: [**2173-8-12**] Discharge Date: [**2173-8-23**]
Date of Birth: [**2115-2-13**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
male with a history of coronary artery disease status post
multiple myocardial infarctions and a ventricular
fibrillation arrest in [**2172-9-1**], who presented as a
transfer from an outside hospital for evaluation for cardiac
catheterization and/or ICD placement following a ventricular
fibrillation arrest.
The patient initially presented to the outside hospital
complaining of two weeks of shortness of breath, wheezing,
dyspnea on exertion, chest pain and lower extremity edema.
On [**2173-7-31**], the patient was admitted to [**Hospital 1562**]
Hospital after worsening chest pain times one hour. On
admission the patient's troponin was 0.26, and on hospital
day #1, his blood pressure dropped, and suffered a
ventricular fibrillation arrest requiring a code that lasted
greater than one hour.
The patient was intubated and started on Amiodarone and
required Levophed and epinephrine drips. His Intensive Care
Unit course was complicated by ATN with a peak creatinine of
5.8 requiring dialysis with questionable rhabdomyolysis and
CKs reaching 14,000, fever, C-diff colitis, and worsening
sacral decubitus ulcers.
The patient's mental status improved. The patient was
uneventfully extubated four days prior to transfer. The
patient was then transferred to [**Hospital6 2018**] for cardiac catheterization and possible AICD
placement.
PAST MEDICAL HISTORY: 1. Coronary artery disease status post
myocardial infarction in [**2160**], [**2167**], [**2168**], and [**2171**], with
catheterization in [**2172-9-1**] showing an ejection fraction
of 40%, with inferior-posterior basal hypokinesis. It showed
a left main with 20% stenosis, proximal left anterior
descending with 60% stenosis, proximal circumflex with 80%
stenosis, midcircumflex with 30%, OM2 100%, OM3 100%, status
post stent to the proximal circumflex through a radial artery
approach. 2. History of ventricular fibrillation arrest,
now times two, status post pacemaker placement. 3.
Insulin-dependent diabetes mellitus type 2. 4.
Gastroesophageal reflux disease. 5. Obstructive sleep
apnea, unable to tolerate CPAP. 6. Hypercholesterolemia.
7. Morbid obesity.
ALLERGIES: CEPHALOSPORINS CAUSING ANAPHYLAXIS.
FAMILY HISTORY: Father died of myocardial infarction.
SOCIAL HISTORY: He lives with his daughter, age 30. [**Name2 (NI) **] has
a 60 pack-year tobacco history; he quit in [**2160**]. He used to
work in the trucking industry.
MEDICATIONS ON TRANSFER: Lipitor 80 a day, KCl 40 a day,
Coreg 3.125 twice a day, NPH 4 U a.m., 5 U p.m., regular 5 U
a.m., 5 U p.m., regular Insulin sliding scale,
................. 250 q.i.d., Aldactone 25 once a day, Lasix
80 a day, Lisinopril 5 a day, Flagyl 500 IV q.6, Pepcid 20 IV
q.day, Amiodarone 400 b.i.d., Heparin subcue, Plavix 75 once
a day, Aspirin 160 once a day, Nitropaste q.6 hours.
LABORATORY DATA: From the outside hospital white count was
25.8, hematocrit 31, platelet count 341; BUN 18, creatinine
1.3, glucose 119, calcium 7.9.
Electrocardiogram normal sinus rhythm. On [**7-22**], after
the arrest, with PR prolongation, T-wave inversions in II,
III and AVF, Q in I and AVL, Qs in V2-V6.
On [**7-31**], electrocardiogram showed intermittently paced
atrial beats per minute.
PHYSICAL EXAMINATION: Vital signs: Temperature 99??????, blood
pressure 90/47, pulse 73, respirations 20, oxygen saturation
97% on 4 L, fingerstick 150. General: Obese male, lying
upright 45?????? in bed, uncomfortable. He stated he had pain
from his sacrum. HEENT: Extraocular movements intact.
Jugular venous distention could not be assessed secondary to
obesity. There were no bruits. Right IJ was nontender.
Heart: Very distant heart sounds. There were no murmurs,
rubs, or gallops. Could not heart S1 or S2. Lungs:
Diffusely decreased breath sounds throughout. There was some
rhonchi anteriorly with inspiration. There were no crackles.
Suboptimal exam. Abdomen: Morbidly obese. Soft and
nontender. Positive bowel sounds. Extremities: There was
[**1-4**]+ pitting edema, 1+ dorsalis pedis bilaterally. There was
skin blanching 1 mm maculars ................ on abdomen that
were nontender.
HOSPITAL COURSE: 1. Cardiovascular: A. Ischemia: With a
positive troponin upon admission to the outside hospital and
the history of his prior ventricular fibrillation arrest
occurring in the setting of ischemia, it was felt that the
patient's most recent ventricular fibrillation arrest was
again secondary to ischemia.
The plan was for cardiac catheterization once his other acute
issues including C-diff colitis and recent acute renal
failure were adequately resolved. The patient was continued
on his Aspirin, Plavix, and Lipitor. Low blood pressure
limited the use of beta-blockers or ACE inhibitors early in
the patient's course.
On approximately hospital day #8, the patient underwent
cardiac catheterization. This revealed three blockages in
the patient's left anterior descending of 90%, proximal, mid
and distal. All three underwent stenting. The patient's
hemodynamic numbers showed a wedge of 26, pulmonary vascular
resistance of 76, SVR 800, cardiac output of 6.3, cardiac
index of 2.4. The patient tolerated the procedure well.
Postcatheterization the patient was with improvement in
feelings of lethargy and improvement in his blood pressure,
allowing the addition of Captopril, as well as Lopressor and
eventual titration of the doses.
B. Pump: Due to the patient's obesity, exam was extremely
limited on assessing the patient's fluid status; however, the
patient had a 4 L oxygen requirement and was severely
orthopneic with 2-3+ pitting edema. The patient was diuresed
aggressively. Initially hypotension limited the use of
diuretics; therefore, low-dose Dopamine was started. The
patient's blood pressure responded well, and so Lasix was
added.
The patient then diuresed well on Dopamine. The patient was
negative [**2-2**] Lungs. After hospital day #5, Dopamine was
discontinued, and the patient maintained a good blood
pressure in the low 100s systolic. There was a decrease in
his orthopnea, as well as improvement in his oxygen
saturations with a reduced oxygen requirement.
Echocardiogram was obtained which was very limited secondary
to the patient's body habitus. This showed an estimated
ejection fraction of 35-40% with hypokinesis of the inferior
wall.
Postcardiac catheterization the patient was aggressively
diuresed for another two days secondary to the high wedge, as
well as the fluid given for the catheterization. Again the
patient was negative another 4 L with further improvement in
oxygen saturations, eventually with an oxygen saturation of
94% on room air.
As mentioned, beta-blocker was titrated up, eventually
changing to Toprol XL, as well as the ACE inhibitor dose
increased as tolerated. The patient then underwent a nuclear
study RVG for a better estimation of his ejection fraction.
Echocardiogram was not a good study. The RVG showed an
excellent ejection fraction of 59% with normal wall motion
and normal cavity sizes. The patient was felt to be
compensated from a congestive heart failure standpoint, and
Lasix was changed to a p.o. dose.
C. Rhythm: The patient was transferred initially for the
question of ICD placement; however, it was felt that his
ventricular fibrillation arrest occurred in the setting of
ischemia. Therefore after revascularization following his
catheterization, it was felt that there was not an indication
for ICD placement, unless the patient had a low ejection
fraction. Therefore, the RVG was done to get an accurate
estimation, and when the ejection fraction came back at 59%
with normal wall motion, the decision was made to forego on
the ICD placement.
Throughout the hospital stay, the patient was continued on
Amiodarone 400 mg b.i.d. with no further episodes of
ventricular arrhythmias. The patient did undergo some
additional tests, including a signal-average
electrocardiogram which was recorded as positive, as well as
a T-wave .................. test which was recorded as
nondiagnostic.
At the time of discharge, it was felt that the ventricular
fibrillation arrests were in the setting of acute ischemia,
and with a normal ejection fraction, no ICD was warranted.
2. C-diff colitis: The patient was positive for C-diff with
a white count in the 30s at the outside hospital. He was
transferred here on Vancomycin and Flagyl IV. This regimen
was changed to Flagyl 500 t.i.d. p.o. The patient was
treated for a 10-day course with improvement in his diarrhea
and decrease in his white count to normal.
3. Other infectious disease issues: The patient had an
increase in his white count back up to 16. There was no
clear etiology. The patient did have a right IJ that had
been placed on [**8-11**] at the outside hospital. This
was the only access the patient had. A peripheral line could
not be obtained. There was no erythema or tenderness around
the line. The patient did not appear septic. Blood cultures
were drawn off the line and showed no growth.
A urine culture did come back positive for fungal. The
patient had a Foley placed secondary to obstructive uropathy.
At the time of this dictation, the patient's Foley was going
to be removed, and a repeat urinalysis would be sent.
The patient also had a sacral decubitus ulcers which was
thought to possibly contribute to his white count. Please
see section on this issue.
4. Summary of hospital course: At the time of this
dictation, there was no clear etiology for the increased
white count, and this is to be followed as an outpatient or
at rehabilitation.
5. Sacral decubitus ulcers: The patient was with two large
necrotic-looking decubitus ulcers. Plastic Surgery was
consulted. They described the ulcers as being on the
buttocks. The left side was a 10 x 15 cm lesion, dark green
brown, no sensation to light touch. The border was raw and
slightly darker red and 2 cm wide.
On the right, there was a smaller lesion of similar nature,
about 6 x 3 cm. Plastic Surgery felt that these appeared to
be dry eschar, probably second degree ulcers and recommended
that there was no need for debridement. They felt that the
ulcers were likely to heal with conservative care.
Later in the patient's course, when his white count
increased, Plastic Surgery was reconsulted, and they again
felt that the decubitus ulcers were not responsible for the
increased white count and did not necessitate debridement.
6. Obstructive sleep apnea: The patient is set for OSA with
................. obesity. The patient was encouraged to try
CPAP at night. Both ventricular fibrillation arrests
occurred at night which was thought possibly secondary to
hypoxia initiating the ischemia; however, the patient could
not tolerate a CPAP secondary to claustrophobia.
A Pulmonary consult was considered; however, the patient
vastly improved after diuresis with improvement in his
orthopnea with no further events.
7. Diabetes: The patient's blood sugars were not
controlled. The patient's NPH was titrated upward, and upon
this dictation, sugars were improved.
8. Deconditioning: Physical Therapy evaluated the patient
and felt that he necessitated a rehabilitation stay.
The remainder of the [**Hospital 228**] hospital course, as well as
the discharge diagnosis, discharge medications, and discharge
instructions will be dictated in an addendum to this
dictation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2173-8-23**] 18:30
T: [**2173-8-23**] 20:25
JOB#: [**Job Number 44842**]
[**Numeric Identifier 44843**]
Admission Date: [**2173-9-23**] Discharge Date: [**2173-10-9**]
Date of Birth: [**2115-2-13**] Sex: M
Service:
ADDENDUM: The following addendum covers the patient's
hospitalization from [**2173-10-4**] to [**2173-10-9**].
The initial portion of the [**Hospital 228**] hospital course was
previously dictated. Please see that other dictation for
details concerning the patient's hospitalization up through
[**2173-10-4**].
HOSPITAL COURSE: 1.) Infectious disease: The patient
completed a two week course of Meropenem. He continued to
have an elevated white count although the differential
continued to show persistent eosinophilia. It was believed
that this eosinophilia was most likely due to his Meropenem
allergy. According to allergy and dermatology, it is
possible to have a delayed allergic reaction to medications
including antibiotics. The patient showed no evidence of
infection. The patient remained afebrile and hemodynamically
stable.
2.) Renal. The patient was continued on hemodialysis
throughout the remainder of the hospitalization. Prior to
discharge, his right sided Quinton catheter was changed by
transplant surgery service to a tunnel catheter. Immediately
following the placement of the tunnel catheter, it was noted
that the arterial line had poor flow. The ports had to be
reversed so the line could be used for hemodialysis. The
renal service noted that it is possible to have poor flow due
to swelling postoperatively. They felt that the patient could
be discharged and continued on hemodialysis as an outpatient.
The renal consult service will be contacting the nephrologist
at the rehabilitation facility the patient is being
discharged to.
3.) Cardiovascular: The patient remained hemodynamically
stable throughout the remainder of the hospitalization.
Prior to discharge, the patient was started on very low dose
Carvedilol 3.125 mg p.o. twice a day which he tolerated well.
There was an attempt to start the patient on Captopril but
the patient was unable to tolerate this due to low blood
pressure.
CONDITION ON DISCHARGE: Hemodynamically stable although bed
bound. The patient is on hemodialysis due to acute renal
failure. He is trached with a trach mask and FI02 of 40%.
He has a large sacral decubitus ulcer which appears to be
healing.
DISCHARGE STATUS: The patient is discharged to acute
rehabilitation.
DISCHARGE DIAGNOSES:
Coronary artery disease.
Coronary stent thrombosis.
Flash pulmonary edema.
Congestive heart failure.
Systolic dysfunction/ischemic cardiomyopathy.
Diabetes mellitus, type II, now insulin dependent.
Gastroesophageal reflux disease.
Obstructive sleep apnea.
Hypercholesterolemia.
Morbid obesity.
Clostridium difficile colitis.
Sacral decubitus ulcer.
Acute tubular necrosis.
Acute renal failure, requiring hemodialysis.
Anxiety.
Anemia.
Tracheostomy.
Septic shock with hypotension due to Pseudomonas, VRE and
Citrobacter.
VRE bacteremia.
Pseudomonas infection of the bladder.
Pseudomonas bacteremia.
Pseudomonas tracheitis.
Citrobacter bacteremia.
Urticaria from an allergic reaction Zosyn.
Ventricular fibrillation arrest.
Pseudomonas ventilatory assisted pneumonia.
Meropenem desensitization.
Zosyn desensitization.
DISCHARGE MEDICATIONS:
Plavix 150 mg p.o. q. day.
Amiodarone 200 mg p.o. twice a day.
Atorvastatin 80 mg p.o. q. day.
Collagenase 250 units per gram ointment, apply topically to
decubitus ulcer q. day.
Fluticasone 110 mcg four puffs inhaled twice a day.
Albuterol Ipratropium 103/18 mcg one to two puffs inhaled q.
six hours.
Aspirin 325 mg p.o. q. day.
Zinc sulfate 220 mg p.o. q. day.
Vitamin C 500 mg p.o. twice a day.
Papain urea ointment, apply topically prn to pressure sore as
needed.
Surchilene 100 mg p.o. q. day.
Miconazole powder twice a day.
Camphor menthol lotion apply topically twice a day prn.
Acetaminophen with codeine 120/12 mg per 5 ml; 12.5 to 25 ml
p.o. q. six hours prn.
Effexophenadine 60 mg p.o. twice a day.
Mineral oil/Hydrophil Petrolat ointment apply topically three
times a day prn to the skin.
Calcium carbonate 1000 mg p.o. three times a day with meals.
Metoclopramide 5 mg p.o. four times a day as needed.
Famotidine 20 mg p.o. twice a day.
Heparin flush to line.
Renagel 800 mg p.o. three times a day.
Regular insulin sliding scale.
Carvedilol 3.125 mg p.o. twice a day.
Fentanyl 100 to 200 mcg intravenous prn pain for changing of
the sacral decubitus dressing.
FOLLOW-UP PLANS: The patient should follow-up with his
primary care physician in one to two weeks following
discharge from rehabilitation. The patient's primary care
physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44844**] [**Name (STitle) 4922**]. The patient is asked to
follow-up with cardiology when he is discharged from
rehabilitation. The patient will be scheduled for outpatient
hemodialysis at acute rehabilitation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 4993**]
MEDQUIST36
D: [**2173-11-8**] 02:58
T: [**2173-11-8**] 16:38
JOB#: [**Job Number 44845**]
Name: [**Known lastname **], [**Known firstname 7090**] L Unit No: [**Numeric Identifier 8226**]
Admission Date: [**2173-8-12**] Discharge Date: [**2173-9-7**]
Date of Birth: [**2115-2-13**] Sex: M
Service: Medical
This is an addendum that will detail patient's CCU course.
Patient was admitted to the CCU on [**2173-8-26**] and discharged
from CCU on [**2173-9-7**].
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
diabetes, morbid obesity, CAD status post multiple MIs, and a
history of V-fib arrest in [**9-2**]. He presented to an outside
hospital on [**2173-7-31**] with two weeks of shortness of breath,
lower extremity edema, and one day of substernal chest pain.
He ruled in for a non-ST-elevation myocardial infarction with
troponin of 0.26.
On day one, he had a V-fib arrest/hypotension. He was
intubated, shocked, and started on amiodarone drip, Levophed
drip, and Epinephrine drip. His course was then complicated
by ATN/rhabdo/C. diff colitis. He was extubated, and then
transferred to [**Hospital1 536**] after
recovery on the [**9-11**] for cardiac catheterization
and evaluation for ICD placement. The Clostridium difficile
colitis and renal failure improved, and the patient went for
cardiac catheterization on the 17th. He had three stents to
the left anterior descending artery placed.
Patient was diuresed postcatheterization with good effect.
Postcatheterization, an EP evaluation was done for ICD.
Decision was made not to place ICD as the V-fib arrest was
thought to be likely secondary to ischemia. He was continued
on p.o. amiodarone and without further V-fib, VT. The
patient was planned for discharge on the [**9-25**].
At 4 a.m., the patient noted an acute onset of shortness of
breath and [**3-11**] dull chest pain. The chest pain and
shortness of breath persisted all morning on the day of
admission to CCU. He was seen by M.D. at 9 a.m. given
nitroglycerin x2 as well as p.o. Lasix. This decreased the
chest pain. Chest x-ray showed diffuse CHF. An ABG showed
7.89, 84, 67 on 10 liters. He was started on a nitroglycerin
drip and got IV Lasix. The patient did not tolerate BiPAP.
Patient was admitted for elective intubation to the CCU, and
then was to go to catheterization laboratory to rule out a
LAD stent occlusion.
PHYSICAL EXAMINATION: Patient was afebrile. Heart rate in
the 80s. Blood pressure 180/80, which decreased to 100/60,
respiratory rate in the 30s, that went down to 14
postintubation. Sating 80% on room air, 100% on
nonrebreather, and then intubated. In general, he is an
obese male, intubated, and sedated. HEENT: Pupils are
equal, round, and reactive to light. ETT in right nares.
Oropharynx clear. Neck full, jugular venous pressure not
visualized. Chest: Bibasilar rales, and scattered wheezes.
Abdomen: Bowel sounds positive, soft, and nontender. Skin:
Positive decubitus ulcers, not visualized. Extremities:
Trace pedal edema. Neurologic sedated.
LABORATORIES: Significant for a white count of 16.0,
hematocrit of 28.4, platelets of 524. Patient's creatinine
is 1.1. CK was 71. Troponin of 0.37 up from 0.35.
Chest x-ray demonstrated mild CHF with bibasilar effusions.
EKG showed paced rhythm in the 60s, no ST elevations or T
wave changes.
HOSPITAL COURSE:
1. Cardiovascular: Patient underwent catheterization
following transfer to the MICU, which demonstrated thrombolic
occlusion within the distal left anterior descending artery
stent which was treated with angioplasty. The previous left
anterior descending artery stent was also upsized. Final
angiography revealed no residual stenosis. There still was
severe disease in the distal left anterior descending artery,
but no dissection.
Patient was continued on high dosed Lovenox for
anticoagulation following stent and also put on a statin,
Plavix, ASA, as well as a beta blocker. Lovenox was
monitored and the level was maintained therapeutically.
During his course in the MICU, however, the beta blocker was
later D/C'd when the patient became hypotensive and septic.
Patient required dopamine earlier on in his course during the
MICU for low blood pressures. This was weaned on the [**9-4**] with good results. Patient was diuresed gently
because he was thought to be in fluid overload during his
time in the CCU.
As far as his rhythm, the patient maintained V paced without
AICD. He was not a candidate for AICD during the course of
the MICU. He remained on amiodarone during his course in the
CCU.
As far as his valves, there was a question of endocarditis.
This will be discussed further in the ID section of this
summary.
2. Pulmonary: Patient was intubated on transfer to the CCU
for respiratory failure. He was extubated on the [**9-1**] and initially transitioned with BiPAP. He tolerated
this well. He also continued on nebulizers for COPD.
Patient spiked a temperature and became septic on [**2173-8-29**].
Cultures have been drawn during these fever spikes and grew
MRSA in aerobic bottles x2. Patient had been treated
previously with levofloxacin for questionable aspiration
pneumonia as well as Flagyl for questionable anaerobes and
aspiration. The patient received Tobramycin on [**8-29**] for
continued antibiotics.
Since [**8-28**], the patient has been on Vancomycin. ID was
concerned for infective endocarditis on this patient as well
as question of MRSA infection on the wire in his pacer. They
recommend continue to treat with Vancomycin and following his
levels concerning his renal failure which began at the
outside hospital. They also recommended having rifampin and
gentamicin, and to follow cultures. They also D/C'd
levofloxacin and Flagyl. Patient also continued to receive
tobramycin as well as Vancomycin, but was never started on
rifampin. He was continued on levofloxacin and Flagyl for
aspiration pneumonia.
Patient also developed Clostridium difficile, and was treated
with p.o. Vancomycin after the Clostridium difficile
resistant to Flagyl. Patient also was treated for [**Female First Name (un) 1441**] in
his urine during his course in the MICU. He received full
course of Fluconazole.
Patient also had decubitus ulcers which were followed
intermittently by Plastics. Were not considered to be a
primary source of fever. The patient received a total of 10
day course of levofloxacin for questioned aspiration
pneumonia. He is continuing to receive Vancomycin, and will
require a six week course total on discharge from the
hospital. He got a two week course. Patient also received a
total course of Diflucan.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4474**], M.D. [**MD Number(1) 4475**]
Dictated By:[**Last Name (NamePattern1) 1527**]
MEDQUIST36
D: [**2173-9-20**] 09:44
T: [**2173-9-20**] 09:45
JOB#: [**Job Number 8227**]
Name: [**Known lastname **], [**Known firstname 7090**] L Unit No: [**Numeric Identifier 8226**]
Admission Date: [**2173-8-12**] Discharge Date:
[**2173-9-20**]
Date of Birth: [**2115-2-13**] Sex: M
Service: [**Hospital Unit Name 319**]
ADDENDUM:
INFECTIOUS DISEASE: When transferred from the CCU to the
[**Hospital Unit Name 319**] Service, the patient's white count was down to 16.7. He
was still receiving vancomycin, levo, fluconazole, and
Flagyl.
RENAL: The patient had developed acute renal failure at the
outside hospital which was thought to be ATN. He was
followed by the Renal Team during his course in the CCU. On
[**2173-9-2**], his creatinine was noted to increase and Renal was
consulted. This was thought to be secondary to ATN in the
setting of sepsis and hypotension. The patient was also
treated for funguria and pyuria with fluconazole as it was
difficult to examine sediment. The patient's creatinine
remained at approximately 1.6 and 1.7 during his CCU course.
On transfer out of the MICU, his creatinine was approximately
1.8.
HEME: The patient had a chronic anemia secondary to illness
as well as renal failure and required a transfusion. The
patient was also started on Epogen.
DIABETES: The patient continued on sliding scale insulin
while in the unit and on transfer was attempted to transfer
to NPH insulin. On transfer to the [**Hospital Unit Name 319**] Service, the patient
still had multiple issues including infection requiring six
to eight weeks of IV vanco, cardiac issues, status post V fib
arrest, as well as CHF, as well as renal issues of ATN.
The rest of the course in the [**Hospital Unit Name 319**] Service has been dictated
by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 212**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4474**], M.D. [**MD Number(1) 4475**]
Dictated By:[**Last Name (NamePattern1) 1527**]
MEDQUIST36
D: [**2173-9-20**] 10:00
T: [**2173-9-20**] 10:06
JOB#: [**Job Number 8228**]
Name: [**Known lastname **], [**Known firstname 7090**] L Unit No: [**Numeric Identifier 8226**]
Admission Date: [**2173-8-12**] Discharge Date: [**2173-9-18**]
Date of Birth: [**2115-2-13**] Sex: M
Service: [**Hospital Unit Name 319**]
This addendum is from [**2173-9-7**] to [**2173-9-18**].
HOSPITAL COURSE: This is a summary of the [**Hospital 1325**] hospital
course after being transferred from the Cardiac Care Unit and
transferred to the [**Hospital Unit Name 319**] Service.
1. Cardiovascular: The patient continued on aspirin, Plavix
and Amiodarone. He was continually paced throughout his
hospital course and had no significant events on telemetry.
The patient had some low blood pressures with systolic blood
pressures in the 90s so his previous blood pressure
medications as well as his diuretics were held. An attempt
was made at the end of his hospitalization to re-add some
cardiac protective medications. A repeat TTE revealed an
ejection fraction of 30 to 35%. Otherwise the patient's
cardiovascular status remained stable throughout this portion
of his hospitalization.
2. Renal: The patient was transferred on high dose
diuretics from the Cardiac Care Unit. He had been heavily
diuresed, because of elevating filling pressures as well as a
history of pulmonary edema. The patient slowly developed
increasing BUN and creatinine, which worsened up until a peak
creatinine of 3.7. The Renal Service was involved in his
care. All diuretics were held in light of the patient's
acute renal failure thought to be due to ATN, because of
numerous renal insults. His diuretics and blood pressure
medications were held in an attempt to increase renal
perfusion and his ace inhibitor was held as well. The
patient's BUN and creatinine slowly began to fall and it was
thought that his ATN was likely resolving.
3. Infectious disease: The patient was transferred on
intravenous Vancomycin, because of positive coagulase
positive and negative staph aurous grew in the blood thought
to be endocarditis of his pacer wire. Blood cultures were
repeated. The patient had no positive blood cultures of
staph, however, had one day of positive blood cultures with
enterococcus thought to be a contaminate and/or transient
bacteremia. Infectious disease was heavily involved with his
care. The patient had a PICC line and continued on his
intravenous Vancomycin to finish a six week course.
Vancomycin levels were obtained, which showed
supratherapeutic levels in light of his acute renal failure.
A standing dose of Vancomycin was discontinued and daily
levels were checked and dosed by level. The patient finished
a fourteen day course of Fluconazole, because of positive
fungal cultures on the IJ tip. The patient was noted to have
diarrhea and has a history of C-diff and was transferred on
Flagyl for suspected C-diff, although cultures had been
negative. It was thought that the patient may have resistant
C-diff and he was switched to po Vancomycin and was finishing
a ten day course. Discussion was held with the medical team
as well as with the CCU team about the vegetation noted on
the patient's prior transesophageal echocardiogram. It could
not be determined whether vegetation seen was on the pacer
wire or the Swan-Ganz catheter. A TTE was repeated, but the
pacer wire was not adequately visualized. It was decided
that the patient would complete his six week course of
Vancomycin. It was discussed as to whether the patient
should receive a repeat transesophageal echocardiogram,
however, because of his obesity and oxygen requirement it was
thought to be technically difficult and risky and a
transesophageal echocardiogram was not repeated, because of
this. Initially the patient had elevated white count and had
CT of the abdomen done to look for an abscess or other source
of infection to explain his increasing white count. CT of
the abdomen was negative. The patient remained afebrile and
his white count slowly decreased.
4. Hematology: The patient had some low hematocrits at 29,
but had no active source of bleeding and was guaiac negative.
He received 1 unit of packed red blood cells to keep his
hematocrit above 30 in light of his coronary artery disease
with an appropriate bump. Epogen was added as well in light
of patient's decreasing hematocrit and acute renal failure.
5. Pulmonary: The patient continued on O2 via face mask as
well as nebulizer treatments and CPAP. The patient had
stable O2 sats in O2 requirements throughout his hospital
course with improved shortness of breath.
6. Sacral ulcer: The patient had continued wound care and
dressing changes.
7. Diabetes mellitus: The patient continued with fixed
insulin regimen as well as insulin sliding scale.
8. Prophylaxis: The patient continued on proton pump
inhibitor and subcutaneous heparin 5000 units q 8.
9. Disposition: Case management was involved and a bed was
found for the patient at [**Hospital3 **]. At [**Hospital3 **]
the patient would have an air mattress, which could support
him and help prevent bed ulcers. The patient also received
physical therapy and skilled nursing.
An addendum to this discharge summary will follow. It will
include the patient's discharge status and discharge
medications as well as follow up plans.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-703
Dictated By:[**Last Name (NamePattern1) 8247**]
MEDQUIST36
D: [**2173-9-19**] 09:14
T: [**2173-9-20**] 06:57
JOB#: [**Job Number 8248**]
|
[
"410.81",
"584.5",
"038.19",
"707.0",
"427.41",
"507.0",
"996.61",
"038.0",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"99.20",
"88.56",
"88.72",
"96.72",
"37.23",
"37.22",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
2405, 2444
|
14321, 15138
|
15161, 16336
|
26347, 31550
|
9652, 12359
|
19375, 20321
|
16354, 17435
|
17464, 19352
|
2645, 3425
|
1562, 2388
|
2461, 2619
|
14008, 14300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,887
| 162,750
|
52682
|
Discharge summary
|
report
|
Admission Date: [**2159-12-22**] Discharge Date: [**2159-12-24**]
Date of Birth: [**2113-5-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
VF arrest
Reason for MICU transfer: therapeutic hypothermia
Major Surgical or Invasive Procedure:
intubation
arterial line
central venous line
History of Present Illness:
46 y/o male w/ PHMx HCV, opioid/benzo abuse who was found down
at home earlier today. He was recently hospitalized from
[**Date range (1) 108693**] for hypercarbic respiratory failure felt secondary to a
multifocal pneumonia with septic shock. He completed a course
of vanco/zosyn/levo while in house - problems also consisted of
shock liver and [**Last Name (un) **], both of which were improving on discharge.
A note from his PCP was listed in OMR on [**12-21**] that states he was
complaining of unrelenting headache and posterior neck and
upper back pain - there is a mention of chronic headache that
was used for drug seeking behavior and the PCP did not provide
opioid therapy. It is unclear who found him or how long he was
down but he was intubated by EMS immediately on arrival. There
was suspicion for a heroin overdose with aspiration as food was
found in the orophraynx - narcan was administered without
result. While EMS was on the scene, he went into VF arrest and
was pulseless for 30 minutes prior to ROSC. He underwent CPR
and received 1 shock with return of pulse in the ED. .
.
In the ED, initial VS were:
Chest xray showed right middle/lower lobe infiltrate c/w
atelectasis or aspiration. CT head showed possible signs of
cerebral edema. Given the VF, he was given a procainamide bolus
followed by gtt. Cardiology was consulted who felt this was
likely not from ischemic cardiac disease and cath would not be
helpful at this time. A femoral triple lumen catheter was
placed. Post-arrest team consulted and patient started on
therapeutic hypothermia protocol with Arctic Sun - sedated with
fent/midaz and paralyzed with cisatracurium. He was on max dose
levophed and phenylephrine in the ED, but these were able to be
weaned prior to transfer. Labs notable for WBC 32.6 (band 1,
N78), plt 654, Cr 4.1, bicarb 17, K 6.4 (hemolyzed specimen).
ABG showed profound respiratory and gap and nongap metabolic
acidosis to 6.85/102/230/20. Vitals prior to transfer: hr 119
bp 169/92 14 ON VENT 100% AC 22/5 TV 500 FiO2 99%
.
On arrival to the MICU, he is intubated and sedated with arctic
cooling apparatus in place.
.
Review of systems:
Unable to be obtained [**12-27**] intubation and sedation
Past Medical History:
-HCV
-Opiod and benzodiazepine abuse
-RLL PNA tx'd with levofloxacin in [**Month (only) **] and [**2159-10-25**]
-HTN
-Severe depression
-Tobacco use
-addiction
-allergic rhinitis
-anxiety
-erectile dysfunction
-headache
-rosacea
Appendectomy
Deviated Septum repair
Left shoulder [**Doctor Last Name **], debridement of biceps tendon tear, open
Biceps tenodesis [**2159-7-13**]
Social History:
(Per OMR):
-lives with and takes care of his mother, who has [**Name (NI) 2481**]
dementia in [**Location (un) **]. Used to work as an electrician, but has
been unemployed for several years with the exception of one
month recently.
-tobacco: several packs daily for decades
-alcohol: none
-drugs: opiates and benzo abuse, heroine use in the past
Family History:
(per OMR):
mother with dementia
father - died from lung cancer
sister - colon cancer
Physical Exam:
ADMISSION EXAM
hr 119 bp 169/92 14 ON VENT 100% AC 22/5 TV 500 FiO2 99%
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
not overbreathing ventilator
no vestibulo-ocular reflex
pupils 2mm, minimally reactive
no cough/gag reflex
Pertinent Results:
ADMISSION LABS
[**2159-12-22**] 02:00AM BLOOD WBC-32.6* RBC-3.47* Hgb-10.7* Hct-33.5*
MCV-97 MCH-30.9 MCHC-32.0 RDW-14.3 Plt Ct-654*
[**2159-12-22**] 02:00AM BLOOD Neuts-78* Bands-1 Lymphs-14* Monos-5
Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2159-12-22**] 06:06AM BLOOD PT-12.8* PTT-38.6* INR(PT)-1.2*
[**2159-12-22**] 02:00AM BLOOD Glucose-236* UreaN-45* Creat-4.1* Na-142
K-6.4* Cl-103 HCO3-17* AnGap-28*
[**2159-12-22**] 06:06AM BLOOD ALT-87* AST-179* CK(CPK)-100 AlkPhos-85
TotBili-0.2
[**2159-12-22**] 06:06AM BLOOD Calcium-7.7* Phos-7.7* Mg-2.0
[**2159-12-22**] 02:00AM BLOOD cTropnT-0.10*
[**2159-12-22**] 06:06AM BLOOD CK-MB-6 cTropnT-0.40*
CT HEAD [**12-22**]
1. No evidence of hemorrhage, large vessel infarction, or shift
of the
normally midline structures.
2. The sulci do not appear prominent for a patient this age.
While this may be a normal finding in a relatively young patient
without atrophy, the patient's clinical history elevates
suspicion for cerebral edema. As a result, continued followup is
recommended.
CXR [**12-22**]
Evaluation is limited due to overlying trauma backboard.
Endotracheal tube is high, the tip is 7.1 cm above the carina.
An enteric
tube is visualized traversing through the stomach with tip out
of the field of view. There is prominence of the pulmonary
vasculature consistent with increased central venous pressure.
Additionally, there is a focal opacity overlying the right
middle and lower lobes suggestive of atelectasis, possibly due
to aspiration.
[**12-22**], [**12-23**], [**12-24**] EEG - pending at the time of discharge
Brief Hospital Course:
Mr. [**Known lastname 15427**] is a 46y/o gentleman with HCV, opioid/benzo abuse,
recent admission for multifocal PNA c/b hypercarbic resp failure
with septic shock who was found down for an unclear amount of
time, had Vfib arrest and was intubated & initiated on
therapeutic hyperthermia for neuroprotection. The etiology of
his Vfib arrest was unclear; MI was unlikely. Drug overdose
possible.
His course was marked by profound mixed acidosis, kidney injury,
leukocytosis on broad-spectrum antibiotics. After he was
rewarmed and his sedation was weaned off, his exam revealed loss
of many brainstem reflexes. EEG suggested sequelae of anoxic
brain injury. Family meeting was held, and the decision was
made to withdraw care. He expired on [**2159-12-24**].
Medications on Admission:
Medications on transfer:
Tylenol 650 PRN
Atenolol 25mg QD
Albuterol nebs
Diltiazem Gtt currently at 15mg /hr
Famotidine 20mg QD
Glucagone per protocol
Heparin SC
Insulin Sliding scale
Atrovent nebs
MOM
Metoprolol 5 MG IV prn
Oxycodone 2.5 mg PRN pain
Odensetron 4mg PRN
Vitmain K 10mg QD for 2 days. Day 1 [**12-19**]
Senna
Simvastatin 20mg QD
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
|
[
"070.70",
"305.40",
"276.2",
"305.50",
"584.9",
"401.9",
"311",
"507.0",
"348.1",
"305.1",
"427.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"99.60",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7159, 7168
|
5957, 6724
|
366, 412
|
7227, 7244
|
4354, 5934
|
7308, 7326
|
3444, 3531
|
7119, 7136
|
7189, 7206
|
6750, 6750
|
7268, 7285
|
3546, 4335
|
2603, 2662
|
266, 328
|
440, 2584
|
6775, 7096
|
2684, 3064
|
3080, 3428
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,118
| 102,445
|
37287
|
Discharge summary
|
report
|
Admission Date: [**2110-11-17**] Discharge Date: [**2110-11-24**]
Date of Birth: [**2062-3-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 1406**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 with left
internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the right coronary
artery, obtuse marginal artery, and diagonal artery.
History of Present Illness:
48 year old male with 2-3 week history of exertional chest
pressure, now increasing in frequency - underwent ETT which he
had chest pain and ST depressions. Underwent cardiac
catheterization at NEBH which revealed coronary
artery disease and is being transferred in for surgical
evaluation.
Past Medical History:
Hypertension
Diabetes mellitus
GERD
Asthma
Social History:
Lives with: spouse
Occupation: owns janitorial company
Tobacco: 3 pack year history quit 15 years ago
ETOH: denies
Family History:
Father CABG at age 62
Physical Exam:
Pulse: 80 Resp: 20 O2 sat: 100% 2 l nc
B/P Right: 130/80 Left: 129/79
Height: 5'9" Weight: 203pouunds stated
General: No acute distress
Skin: Dry [x] [**Known firstname 5235**] [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no lymphadenopathy
Chest: Lungs clear bilaterally [x] anterior
Heart: RRR [x] Irregular [] Murmur no
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly [**Known firstname 5235**]
Pulses:
Femoral Right: femoral sheath Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2110-11-24**] 06:50AM BLOOD WBC-10.2 RBC-3.13* Hgb-9.4* Hct-27.5*
MCV-88 MCH-29.9 MCHC-34.0 RDW-13.2 Plt Ct-287#
[**2110-11-23**] 05:00AM BLOOD WBC-9.2 RBC-2.70* Hgb-8.4* Hct-23.9*
MCV-89 MCH-31.1 MCHC-35.1* RDW-13.1 Plt Ct-175
[**2110-11-23**] 05:00AM BLOOD Glucose-126* UreaN-20 Creat-0.9 Na-137
K-3.8 Cl-102 HCO3-26 AnGap-13
[**2110-11-24**] 06:50AM BLOOD K-4.4
[**2110-11-24**] 06:50AM BLOOD Mg-2.2
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic [**Year/Month/Day 5236**] are
normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
Preserved biventricular systolic fxn.
No AI, no MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**].
Brief Hospital Course:
Transferred in from outside hospital after cardiac
catheterization on nitroglycerin drip and femoral sheath to
intensive care unit. He underwent preoperative workup and was
transferred to the floor on hospital day two on heparin, sheath
removed, for completion of preoperative workup.
The patient was brought to the operating room on [**2110-11-19**] where he
underwent CABGx4 with Dr. [**Last Name (STitle) **]. Please see op report for
details. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for invasive monitoring. The patient does have a
history of diabetes and blood glucose was difficult to manage
following surgery. [**Last Name (un) **] was consulted, and we appreciate
their recommendations. Blood glucose came under good control,
and he was transferred to the telemetry floor. Beta blockade
and diuresis were initiated. Chest tubes and pacing wires were
discontinued without complication. PT worked with the patient
on strength and mobility. By POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. He was found suitable for discharge to home with
VNA at this time. He will be on insulin at home and he did
undergo insulin teaching prior to discharge.
Medications on Admission:
Metformin 1000 mg daily stopped [**11-13**]
Aspirin 81 mg daily
Effient 10 mg daily
Coreg ER 10 mg daily
Lipitor 20 mg daily
Prilosec 40 mg [**Hospital1 **] stopped [**11-13**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO Q12H (every 12 hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO twice
a day.
Disp:*120 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 40 units in am.
Disp:*qs * Refills:*2*
11. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous with
meals: see sliding scale instructions.
Disp:*qs * Refills:*2*
12. Insulin Needles (Disposable) Needle Sig: One (1)
Miscellaneous four times a day.
Disp:*qs * Refills:*2*
13. Insulin Syringes (Disposable) 1 mL Syringe Sig: One (1)
Miscellaneous four times a day.
Disp:*qs * Refills:*2*
14. DME
glucometer
15. DME
lancets for glucometer
disp: qs 1 month
16. DME
glucose test strips
disp: qs 1 month
Discharge Disposition:
Home With Service
Facility:
vna care of [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Angina
Diabetes Mellitus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr [**Last Name (STitle) **] in [**11-15**] weeks
Cardiologist Dr [**Last Name (STitle) 7389**] in [**11-15**] weeks
[**Last Name (un) **] Diabetes Center ([**Telephone/Fax (1) 4847**] in 1 week
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2110-11-24**]
|
[
"285.9",
"401.9",
"780.62",
"530.81",
"414.01",
"414.2",
"250.92",
"411.1",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6255, 6318
|
3056, 4358
|
333, 551
|
6420, 6516
|
1930, 3033
|
7057, 7526
|
1088, 1112
|
4586, 6232
|
6339, 6399
|
4384, 4563
|
6540, 7034
|
1127, 1911
|
283, 295
|
579, 872
|
894, 939
|
955, 1072
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,923
| 113,044
|
24700
|
Discharge summary
|
report
|
Admission Date: [**2193-3-22**] Discharge Date: [**2193-3-28**]
Date of Birth: [**2143-6-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
hypotension post-dialysis and abnormal CT scan
Major Surgical or Invasive Procedure:
aortic root pseudoaneurysm endostenting/ placement of ECMO
[**2193-3-27**]
History of Present Illness:
49 yo male with prior hospitalization for endocarditis from
[**2192-9-6**] to [**2193-2-7**]. He underwent multiple aortic repairs, AVR,
sternal debridement and flap closure, cholecystectomy, G-J tube
placement, HD cath placement, and tracheostomy. After a
prolonged ICU course, he became stable hemodynamically and was
transferred to a rehab bed at [**Hospital1 336**]. At rehab on [**3-21**] , he became
hypotensive to the 70's systolic after hemodialysis, and did not
recover quickly. He had an urgent CT scan to evaluate his chest
in the ED, and this revealed a large right PA pseudoaneurysm.
Turned down for surgery at [**Hospital1 336**], and transferred back here for
evaluation by Dr. [**Last Name (STitle) 1290**].
Past Medical History:
endocarditis
AVR/ multiple aortic replacements and repairs
renal failure
respiratory failure/tracheostomy
asthma
spontaneous PTX
coccyx ulcer
( see DC summary dated [**1-13**] for full details)
Social History:
lives with wife and 2 sons
has spent past 2 months in rehab unit
no alcohol or tobacco use
Family History:
mother with CVA
father with cardiomyopathy due to lymphoma
Physical Exam:
sedated, but awakens, nods head to questions, moves extrems
weakly
few coarse rhonchi bilat.
RRR
well-healed sternal chest wound, HD cath in place
flat, soft abd; + BS with G-J tube in place
extrems warm; increasing edema in right arm
SBP 70's to 80's
RA sats on 50% are 97%
Pertinent Results:
[**2193-3-28**] 04:44PM BLOOD WBC-9.2 RBC-3.30* Hgb-9.9* Hct-28.7*
MCV-87 MCH-29.9 MCHC-34.4 RDW-18.6* Plt Ct-76*
[**2193-3-22**] 11:25AM BLOOD WBC-18.8*# RBC-2.99* Hgb-8.4* Hct-28.7*
MCV-96 MCH-28.2 MCHC-29.3* RDW-23.7* Plt Ct-220
[**2193-3-28**] 04:44PM BLOOD Plt Smr-VERY LOW Plt Ct-76*
[**2193-3-22**] 11:25AM BLOOD PT-16.8* PTT-63.3* INR(PT)-1.5*
[**2193-3-28**] 04:44PM BLOOD Creat-2.9* Cl-108 HCO3-13*
[**2193-3-28**] 03:48AM BLOOD Glucose-88 UreaN-63* Creat-3.0* Na-152*
K-4.2 Cl-103 HCO3-22 AnGap-31*
[**2193-3-22**] 11:25AM BLOOD Glucose-103 UreaN-44* Creat-2.7* Na-141
K-4.3 Cl-98 HCO3-25 AnGap-22*
[**2193-3-28**] 04:44PM BLOOD ALT-860* AST-2261* LD(LDH)-2483*
AlkPhos-168* Amylase-369* TotBili-4.1*
[**2193-3-22**] 11:25AM BLOOD ALT-20 AST-25 LD(LDH)-342* AlkPhos-240*
Amylase-35 TotBili-1.1
[**2193-3-28**] 04:44PM BLOOD Lipase-718*
[**2193-3-28**] 04:44PM BLOOD Mg-2.7*
[**2193-3-22**] 11:25AM BLOOD Albumin-4.2 Calcium-9.3 Phos-5.9*# Mg-2.2
[**2193-3-28**] 07:11PM BLOOD Type-ART pO2-425* pCO2-30* pH-7.26*
calHCO3-14* Base XS--12
[**2193-3-28**] 07:11PM BLOOD Lactate-16.3* K-4.3
Brief Hospital Course:
Admitted [**3-22**] and underwent MRI of chest which confirmed
pseudoaneurysm of aortic root. Followed by the renal and
transplant teams for his renal failure and ? of abdominal
hypoperfusion and ? of abdominal distention. ID also consulted
once again on Mr. [**Known lastname **], who had prior fungemia/[**Female First Name (un) **]/MSSA and
who was well-known to all of these services. Pressor support was
instituted for hypotension and quadruple abx therapy continued.
Cardiac cath was repeated on [**3-26**] with confirmation of anatomy.
Lactate started to rise and there was concern for abdominal
catastrophe and hypoperfusion to the gut. Dr. [**First Name (STitle) **] from the
transplant surgery team consulted with cardiac surgery again
given his grave prognosis and increasing acidosis.
On [**3-27**], he returned to the OR for endostent placement to help
plug the aortic root pseudoaneurysm and ECMO
placement/institution with Drs. [**Last Name (STitle) 914**] and [**Name5 (PTitle) 1290**]. He
remained critically ill and the family was informed.He developed
ST elevations likely due to the endostent's proximity to the
left main coronary artery. Plans were made to wean the ECMO
support, and cardiac tamponade developed due to leakage of the
psuedoaneurysm. He continued to rapidly decline and the family
made him DNR after discussions with Dr. [**Last Name (STitle) 1290**].
The patient became hypotensive in the evening with bradycardia.
This was followed by asystole. He was pronounced expired at 7:45
PM on [**2193-3-28**] by Dr. [**Last Name (STitle) 2637**]. Dr. [**Last Name (STitle) 1290**] and the family
were notified.
Medications on Admission:
tobramycin
caspo
cefepime
vancomycin
synthroid
phoslo
Discharge Disposition:
Expired
Discharge Diagnosis:
endocarditis
pseudoaneurysm of aortic root
s/p endovascular stent placement in aortic root
s/p ECMO
Discharge Condition:
expired
Completed by:[**2193-5-21**]
|
[
"038.9",
"427.1",
"V44.0",
"996.61",
"444.0",
"427.5",
"585.6",
"996.1",
"707.03",
"441.01",
"420.90",
"427.31",
"995.92",
"785.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.44",
"34.04",
"99.62",
"39.61",
"96.72",
"88.53",
"00.17",
"39.58",
"39.65",
"37.22",
"88.42",
"96.6",
"39.73",
"39.95",
"88.55",
"88.43"
] |
icd9pcs
|
[
[
[]
]
] |
4783, 4792
|
3032, 4679
|
369, 445
|
4935, 4973
|
1911, 3009
|
1539, 1599
|
4813, 4914
|
4705, 4760
|
1615, 1892
|
282, 330
|
473, 1198
|
1220, 1415
|
1431, 1523
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,657
| 139,682
|
29899
|
Discharge summary
|
report
|
Admission Date: [**2133-1-14**] Discharge Date: [**2133-1-23**]
Date of Birth: [**2060-3-3**] Sex: F
Service: NEUROLOGY
Allergies:
Morphine
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
change in mental status x several days
Major Surgical or Invasive Procedure:
Stereotactic brain biopsy of left frontopariental mass
History of Present Illness:
72 yo woman with history of cervical cancer s/p resection,
radiation,
complications from radiation [**2130**] and resulting R nephrectomy,
cystectomy and ileostomy, chronic renal insufficiency, anemia,
recurrent UTIs with MRSA, who presents as transfer from [**Known firstname **]
Hospital with brain mass,
discovered after 2nd presentation for change in mental status.
Per notes from [**Known firstname **] Hospital, she had been admitted there
from [**Hospital3 4634**] with altered mental status and had
apparently said "I haven't felt like myself" - no further
details are provided about mental status, but it appears that
urinalysis was positive, and she was discharged the following
day on Levaquin. (Incidentally, Urine culture shows Pseudomonas
resistant to Levaquin.) She returned home and
was sent back to [**Known firstname **] emergency room with continued altered
mental
status. Head CT was performed, and showed large L
fronto-parietal brain mass with shift of midline structures.
She was transferred to [**Hospital1 18**] ER. Her son, [**Name (NI) 401**], is her health
care proxy, per paperwork.
.
She denies all other neurologic problems, including weakness,
numbness, confusion, dysarthria, dysphagia, diplopia or visual
problems, headache or any pain anywhere.
Past Medical History:
* Cervical cancer s/p TAH-BSO with radiation, complicated by
radiation
* proctitis and R kidney failure [**2130**], s/p L ureteral stent and
cystectomy/R nephrectomy, ileal conduit, ileostomy
* Chronic renal insufficiency
* Renal Tubular Acidosis
* Recurrent UTIs (with MRSA)
* GERD
* Anemia (chronic of unknown etiology)
* Osteoporosis
* History of deep venous thrombosis (on coumadin)
Social History:
Ms. [**Known lastname 71459**] is a widow and lives in [**Hospital3 4634**]. Her son,
[**Name (NI) 401**], is her health care proxy.
Family History:
Unknown
Physical Exam:
General: Lying in bed in no acte distress
HEENT: neck supple
CV: Regular, rate, rhythm
Pulm: Clear to ascultation bilaterally
Abd: Soft, non-tender, non-distended
Ext: No edema
.
NEURO
* Mental Status: Awake and alert, responsive to voice from
either side of
space. Follows simple commands. Oriented to person, place (when
given multiple choice) but not the year or month.
Perseverateswhen asked to recite days of week forwards, then is
able to do so, but not backwards. Unable to count 20->1
backwards as well. Requires prompting to cooperate. No apraxia
or signs of neglect. Speech is fluent with intact naming to
high/low frequency items, no errors. Repetition intact.
.
* Cranial Nerves: Visual fields full to confrontation. R pupil
surgical, L reacts to light
3->2. Extraocular movements intact with no nystagmus. Face with
R nasolabial fold. Tongue midline and palate rises
symmetrically. No dysarthria.
.
* Motor: R pronator drift. No asterixis. Inconsistent
cooperation with power testing. Holds all limbs antigravity but
right side seems weaker.
.
* Sensory: Intact to light touch, pinprick. Unable to assess
joint position sense due to inattention. Vibration reduced at
toes, ankles bilaterally.
.
* Coordination: Finger-to-nose intact
.
* Gait: deferred
Pertinent Results:
[**2133-1-16**] 12:50PM BLOOD WBC-11.8*# RBC-3.03* Hgb-9.6* Hct-28.8*
MCV-95 MCH-31.8 MCHC-33.5 RDW-15.7* Plt Ct-255#
[**2133-1-15**] 03:13AM BLOOD Albumin-2.9* Calcium-7.9* Phos-4.6*
Mg-1.7
[**2133-1-14**] 07:50PM URINE RBC-21-50* WBC-[**6-7**]* Bacteri-FEW
Yeast-NONE Epi-0-2
Brief Hospital Course:
Ms. [**Known lastname 71459**] was admitted to the neurology intensive care unit
and started on Decadron 4mg q6hr to reduce vasoigenic edema
surrounding the left front-parietal mass. Zosyn was started for
positive urinalysis for urinary tract infection; it should
continue for a 10 day course until after [**1-24**].
Brain biopsy was preliminarily positive for glioblastoma. She
will follow with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] of neuro-oncology for treatment
determination.
Her mental status improved after initiation of steroids. She
returned to her baseline, with only mild anomia and right-sided
hemiparesis on exam. She is not demented at baseline and her
change in behavior on admission was instead related to her tumor
and possible seizures. She should continue on keppra 1000/1000
for seizure prophylaxis.
The patient's son is involved in her care. He will discuss with
Dr. [**Last Name (STitle) 724**] what treatment she will undertake (likely cyberknife).
She should be intermittently monitored for UTI, with urine
culture, as she is colonized with pseudomonas.
Medications on Admission:
Coumadin 1mg daily
fosamax 70 qwk
levaquin 500 daily
oscal 1000
remeron 50mg qhs
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
2. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: sliding
scale Subcutaneous four times a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: hold for diarrhea.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 1 days: discontinue
after [**1-24**] dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
change in mental status secondary to glioblastoma
Brain tumor (final pathology pending)
Discharge Condition:
patient is at her neurological baseline.
Improved
Discharge Instructions:
Please continue to take all medications as prescribed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2133-2-2**]
11:30
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
Completed by:[**2133-1-23**]
|
[
"733.00",
"585.9",
"244.9",
"200.01",
"V10.41",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.13"
] |
icd9pcs
|
[
[
[]
]
] |
6156, 6235
|
3863, 4981
|
308, 364
|
6367, 6419
|
3561, 3840
|
6521, 6897
|
2252, 2261
|
5113, 6133
|
6256, 6346
|
5007, 5090
|
6443, 6498
|
2276, 2463
|
230, 270
|
392, 1676
|
2968, 3542
|
2478, 2952
|
1698, 2086
|
2102, 2236
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,745
| 139,372
|
5895
|
Discharge summary
|
report
|
Admission Date: [**2148-8-22**] Discharge Date: [**2148-8-27**]
Date of Birth: [**2117-1-19**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22608**]
Chief Complaint:
elective induction of labor for pubic symphysis separation
Major Surgical or Invasive Procedure:
c/section
xlap for bleeding s/p 4 units of PRBC
History of Present Illness:
31YO gravida 2 para 0-0-1-0 presenting for induction of labor
secondary to h/o pubic symphysis separation and decreased fetal
movement. + occasional contractions, no loss of fluid, no
vaginal bleeding, + active fetal movements
Estimated date of delivery: [**2148-9-3**]
Prenatal care:
labs: O+/Ab-, RPRNR, rubella immune, HBsAg neg, group B strep
neg
screening: 1st trimester screen wnl
monitoring: last ultrasound [**2148-8-21**], biophysical profile [**9-11**],
amniotic fluid index 17.7, vertex, posterior placenta
estimated fetal weight 7#9oz (US [**2148-8-15**])
issues: pubic symphysis separation @ 35wks gestational age
Past Medical History:
asthma-uses albuterol 1x/month
h/o back cyst removal
h/o therapeutic abortion s/p dilation and curettage
h/o genital herpes on acyclovir ppx prior to delivery
Social History:
Married, works in advertising, no tobacco, etoh (during
pregnancy), or illicit drug use.
Family History:
noncontributory
Physical Exam:
98.1 83 20 117/64
NAD, A&O x3
RRR
CTAB
soft, NT, gravid, estimated fetal weight 8# by [**Last Name (un) 23291**], vertex
ext 1+ pitting edema, NT
sterile vaginal exam: [**4-/2121**]/-2
fetal heart tracing: 140s, reactive, no decelerations
Pertinent Results:
CT PELVIS and ABDOMEN W/O CONTRAST [**2148-8-23**]:
1. Large amount of intra-abdominal and pelvic hemorrhage. A site
of active extravasation cannot be identified without IV
contrast.
2. Foci of air surrounding the thecal sac likely secondary to
epidural catheter placement. Clinically correlate.
3. Small bilateral pleural effusions.
.
[**2148-8-22**] 08:01AM BLOOD WBC-13.5* RBC-4.14* Hgb-13.2 Hct-38.2
MCV-92 MCH-31.8 MCHC-34.4 RDW-13.7 Plt Ct-239
[**2148-8-23**] 07:19AM BLOOD WBC-18.5* RBC-2.97*# Hgb-9.9*# Hct-28.0*#
MCV-94 MCH-33.2* MCHC-35.3* RDW-13.9 Plt Ct-253
[**2148-8-23**] 09:24AM BLOOD WBC-17.3* RBC-2.27* Hgb-7.4*# Hct-20.9*#
MCV-92 MCH-32.4* MCHC-35.1* RDW-14.3 Plt Ct-230
[**2148-8-23**] 09:00PM BLOOD WBC-15.4* RBC-3.31*# Hgb-10.5*#
Hct-29.4*# MCV-89 MCH-31.7 MCHC-35.6* RDW-15.2 Plt Ct-159
[**2148-8-24**] 07:30AM BLOOD WBC-14.5* RBC-2.99* Hgb-9.5* Hct-26.7*
MCV-89 MCH-31.8 MCHC-35.7* RDW-14.8 Plt Ct-143*
[**2148-8-24**] 10:38AM BLOOD Hct-28.5*
[**2148-8-25**] 09:00AM BLOOD WBC-12.8* RBC-2.87* Hgb-9.1* Hct-25.7*
MCV-90 MCH-31.8 MCHC-35.6* RDW-14.7 Plt Ct-164
.
[**2148-8-23**] 07:19AM BLOOD PT-11.9 PTT-25.5 INR(PT)-1.0
[**2148-8-23**] 12:52PM BLOOD PT-12.1 PTT-26.2 INR(PT)-1.0
[**2148-8-23**] 09:00PM BLOOD PT-11.4 PTT-23.9 INR(PT)-1.0
[**2148-8-24**] 07:30AM BLOOD PT-10.9 INR(PT)-0.9
.
[**2148-8-23**] 07:19AM BLOOD Fibrino-439*
[**2148-8-23**] 12:52PM BLOOD Fibrino-310
[**2148-8-23**] 09:00PM BLOOD Fibrino-417*
[**2148-8-24**] 07:30AM BLOOD Fibrino-585*#
.
[**2148-8-23**] 09:00PM BLOOD Glucose-91 UreaN-12 Creat-0.7 Na-138
K-4.2 Cl-107 HCO3-23 AnGap-12
[**2148-8-23**] 09:00PM BLOOD Calcium-7.9* Phos-4.0 Mg-1.5*
[**2148-8-24**] 07:30AM BLOOD Glucose-82 UreaN-11 Creat-0.7 Na-135
K-4.1 Cl-102 HCO3-25 AnGap-12
[**2148-8-24**] 07:30AM BLOOD Calcium-7.7* Phos-4.0 Mg-1.5*
[**2148-8-25**] 09:00AM BLOOD Glucose-112* UreaN-9 Creat-0.7 Na-137
K-3.5 Cl-103 HCO3-25 AnGap-13
[**2148-8-25**] 09:00AM BLOOD Albumin-2.2* Calcium-7.4* Phos-4.3 Mg-2.1
.
[**2148-8-23**] 11:27AM BLOOD Type-ART pO2-168* pCO2-38 pH-7.36
calTCO2-22 Base XS--3
Brief Hospital Course:
Pt. was admitted to labor and delivery and proceeded with an
induction of labor with pitocin. She progressed to full
dilation, however, she pushed for approximately 2 1/2 hours with
no descent below the +2 station and therefore it was recommended
to the patient that she undergo primary cesarean delivery and
the patient and her husband agreed. On [**2148-8-23**] @ 0423, she
delivered via primary lower transverse cesarean section a baby
girl, 3805gm, [**Name2 (NI) 23292**] 9 and 9. She was started on gentamicin and
clindamycin for intrapartum fever. Immediately postpartum, her
course was complicated by low BP and tachycardia. Bedside U/S
showed free fluid in the peritoneal cavity and subsequent CT
scan showed large amount of intra-abdominal and pelvic
hemorrhage. She was taken to the OR emergently for exploratory
laparotomy, where 2500cc of clot was evacuated from the abdomen.
There was no obvious foci of bleeding. She received 4 units of
PRBC intraoperatively. Please see operative note for complete
details. She was transfered from the OR to the [**Hospital Unit Name 153**] for
observation. She recovered well and was called out of the ICU on
POD#1. Antibiotics were discontinued on POD#3. She was
eventually discharged on POD#4 with adequate pain control,
afebrile, ambulating, tolerating regular food, and without any
symtoms of hypovolemia or hemorrhage.
Medications on Admission:
Prenatal vitamins
Tylenol #3 for h/o pubic symphysis
Discharge Medications:
1. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Breast Pump Device Sig: One (1) Miscellaneous as needed.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p c/section, s/p xlap for bleeding at incision
Discharge Condition:
good
Discharge Instructions:
see discharge instructions
Followup Instructions:
6 weeks with Dr. [**Last Name (STitle) **]
|
[
"E935.8",
"674.32",
"655.71",
"665.61",
"656.61",
"560.1",
"V27.0",
"659.21",
"648.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"74.1",
"75.99",
"73.09",
"73.4",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5612, 5618
|
3787, 5161
|
388, 438
|
5711, 5718
|
1703, 3764
|
5793, 5839
|
1401, 1418
|
5264, 5589
|
5639, 5690
|
5187, 5241
|
5742, 5770
|
1433, 1684
|
290, 350
|
466, 1096
|
1118, 1279
|
1295, 1385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,264
| 104,901
|
44597
|
Discharge summary
|
report
|
Admission Date: [**2129-2-11**] Discharge Date: [**2129-2-14**]
Date of Birth: [**2086-5-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
42 y/o male with HIV, Hep C, cardiomyopathy, hypertension,
polysubstance abuse including cocaine in addition to membranous
GN now ESRD on HD presenting with acute SOB, epigastric pain,
respiratory distress. The patient is a heavy smoker and per
verbal report from mother, patient and girlfriend broke up more
recently, and consumption of cocaine may have surrounded this
event.
.
In the ED, he triggered on arrival for sat of 84% on RA. He
usually is not hypoxic. On exam he was hypertensive and
clinically had fluid overload. CXR demonstrated diffuse
pulmonary infiltrates consistent with volume overload. Started
on nitro drip and BIPAP in addition to 2.5mg IV enaparil.
.
An EKG in sinus tachycardia with depressions V4-V6 slightly
worse than his baseline. His overall status improved with BiPAP
-> agitation decreased, although still confused mildly. Trop
and BNP sent. Dilaudid, Ativan, refused straight cath, on
nitro
drip with improved BP from 200/110 to 186/110.
.
WBC 24k, no report of fevers but covered with levo/vanco/flagyl.
On transfer BP 186/104 97.7 96 RR high 20's 90% on NRB.
.
Past Medical History:
1. HIV - He was diagnosed with HIV in [**2112**]. Risk factors
included unprotected heterosexual sex as well as intravenous
drug use. His nadir CD4 count is 91 and he has no known
opportunistic infections. Last viral load undetectable, CD4 556
([**10-31**]).
2. Hepatitis C. Genotype 1B. Viral load 187,000 in [**12-28**].
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%.
5. Chronic renal insufficiency - MPGN by biopsy in [**2123**] and
hypertensive nephrosclerosis
5. GERD.
6. Hypertension.
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction [**2126-7-23**].
8. Polysubstance abuse, including cocaine and alcohol.
9. Anemia, hematocrit 20-24.
10. Hypertriglyceridemia - TG 282 in [**3-/2126**]
11. Right hydrocele.
12. A subacute infarct in the right caudate head seen on MRI in
[**1-29**]
13. Influenza B, [**2126-2-22**].
14. Erectile dysfunction.
15. Depression
16. Inguinal hernia repair in [**2123**].
17. Left ankle ORIF in [**2122**].
18. Appendectomy in [**2101**].
Social History:
History of incarceration for 4 yrs. Is self-employed, unmarried.
He
has three children. Denies alcohol. Reports marijuana use daily,
denies tobacco or cocaine.
Family History:
Mother and father have hypertension; has 3 bros, 3 sis: all
healthy, none with HTN. There is also a family history of type 2
diabetes mellitus. No family history of sudden death and
premature atherosclerotic cardiovascular disease.
Physical Exam:
On admission:
97.9, 88-105, 137/90 (137-197/90-114), 97% 3L NC
GEN: Sleeping initially, no acute distress. Mild diaphoresis.
HEENT: MMM
Heart: S1+, S2+, RRR
Lungs: CTA b/l
Ab: scar from appendectomy, soft, non-distended, minimal
abdominal tenderness in the epigastric region. No rebound or
gaurding.
Ex: No edema. Fistula site on left without skin breakdown or
erythema or warmth.
Skin: No rashes, mild diaphoresis.
.
On Discharge:
Physical exam:
Tm/c: 98.6/96.7, BP 106/74 (82-106/55-74), HR: 76 (60-76), RR:
16, O2 97%
GEN: Awake in bed, no acute distress.
HEENT: MMM, no LAD, neck supple
Heart: S1+, S2+, RRR, harsh murmur in right upper sternal
border,
Lungs: CTA b/l
Ab: scar from appendectomy, soft, non-distended, minimal
abdominal tenderness in the epigastric region. No rebound or
gaurding.
Ex: No edema. Fistula site on left without skin breakdown or
erythema or warmth. +thrill over fistula site
Skin: No rashes, mild diaphoresis, multiple tattoos, one on left
chest and left hand homemade, while right shoulder seems
professional, multiple scars on right chest from HD lines.
Pertinent Results:
CBC:
[**2129-2-11**] 08:20PM BLOOD WBC-24.6*# RBC-3.83* Hgb-12.9* Hct-38.1*
MCV-99* MCH-33.6* MCHC-33.8 RDW-14.0 Plt Ct-301
[**2129-2-12**] 03:00AM BLOOD WBC-31.2* RBC-3.38* Hgb-11.4* Hct-32.7*
MCV-97 MCH-33.6* MCHC-34.7 RDW-14.1 Plt Ct-271
[**2129-2-14**] 06:30AM BLOOD WBC-12.9* RBC-3.56* Hgb-11.9* Hct-35.4*
MCV-99* MCH-33.4* MCHC-33.6 RDW-13.8 Plt Ct-258
.
Diff:
[**2129-2-11**] 08:20PM BLOOD Neuts-95.1* Lymphs-2.5* Monos-2.1 Eos-0.2
Baso-0.1
[**2129-2-13**] 06:25AM BLOOD Neuts-87.5* Lymphs-6.7* Monos-4.6 Eos-0.6
Baso-0.7
.
Coags:
[**2129-2-11**] 08:20PM BLOOD PT-14.8* PTT-29.5 INR(PT)-1.3*
[**2129-2-13**] 06:25AM BLOOD PT-19.6* PTT-33.3 INR(PT)-1.8*
[**2129-2-14**] 09:55AM BLOOD PT-18.5* PTT-32.5 INR(PT)-1.7*
.
BMP:
[**2129-2-11**] 08:20PM BLOOD Glucose-153* UreaN-40* Creat-4.1* Na-143
K-4.3 Cl-99 HCO3-28 AnGap-20
[**2129-2-13**] 06:25AM BLOOD Glucose-104* UreaN-46* Creat-4.8* Na-139
K-4.8 Cl-93* HCO3-30 AnGap-21*
[**2129-2-14**] 06:30AM BLOOD Glucose-97 UreaN-79* Creat-7.4*# Na-137
K-4.4 Cl-92* HCO3-26 AnGap-23*
.
LFT:
[**2129-2-11**] 08:20PM BLOOD ALT-19 AST-29 LD(LDH)-236 AlkPhos-183*
TotBili-0.5
[**2129-2-14**] 06:30AM BLOOD ALT-24 AST-25 LD(LDH)-149 CK(CPK)-23*
AlkPhos-137* TotBili-0.6
.
Cardiac Enzymes:
[**2129-2-11**] 08:20PM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier 95484**]*
[**2129-2-12**] 03:00AM BLOOD cTropnT-0.03*
[**2129-2-13**] 06:25AM BLOOD CK-MB-2 cTropnT-0.07*
[**2129-2-14**] 06:30AM BLOOD CK-MB-1 cTropnT-0.18*
.
Mineral:
[**2129-2-11**] 08:20PM BLOOD Albumin-4.4 Calcium-10.2 Phos-4.6*#
Mg-2.2
[**2129-2-14**] 06:30AM BLOOD Albumin-3.9 Calcium-9.3 Phos-5.8* Mg-2.5
[**2129-2-11**] 08:26PM BLOOD Glucose-155* Lactate-2.7* K-4.5
[**2129-2-13**] 07:27AM BLOOD Lactate-2.5*
##########################################################
[**2129-2-11**] CXR
FINDINGS: There is diffuse interstitial and alveolar opacity
throughout both lungs, favoring the lung bases. Slightly more
confluent opacity is noted at the medial right lung. The
mediastinum is unremarkable. The cardiac silhouette has actually
decreased significantly in size from the prior exam suggesting a
resolved pericardial effusion. There are bilateral pleural
effusions, left slightly greater than right. No pneumothorax is
seen. The osseous structures are unremarkable.
IMPRESSION: Overall, the radiographic features favor diffuse
interstitial and alveolar edema. The opacity at the medial right
lung base may indicate
confluent edema or possibly underlying concurrent infection or
significant
aspiration. Correlate clinically. Repeat radiography after
appropriate
diuresis is recommended to assess for underlying infection.
.
[**2129-2-12**] CXR
FINDINGS: As compared to the previous radiograph from [**3-14**], the signs of bilateral diffuse pulmonary edema
have completely resolved. No remnant focal parenchymal
opacities. Borderline size of the cardiac silhouette. No pleural
effusions. No pneumothorax.
.
[**2129-2-14**] ECHO
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild global left ventricular hypokinesis (LVEF =
quantitative 44%). Systolic function of apical segments is
relatively preserved. The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
.
IMPRESSION: Symmetric left ventricular hypertrophy with mild
global hypokinesis c/w diffuse process (toxin, metabolic, etc.).
Dilated ascending aorta.
.
Compared with the prior study (images reviewed) of [**2128-11-18**],
global left ventricular systolic function is slightly less
vigorous.
Brief Hospital Course:
42 y/o male with MMP, ESRD on dialysis presents with
hypertensive emergency and shortness of breath in the setting of
likely cocaine use.
.
#) Hypertensive emergency: The patient's baseline hypertension
is very difficult to control--per our records he is on
isosorbide, hydralazine, carvedilol, and clonidine at baseline.
On his first night in the MICU, his blood pressure decrased
approximately 20% on nitro drip and enalapril IV; diastolic
stable at 100. Potential for concurrent cocaine use makes
treatment additionally challenging. Beta blockers were avoided
given cocaine use. Pt started on amlodipine 10mg daily, as well
as valsartan 160mg daily x 1. He received dialysis on the
morning after admission. After dialysis his hypertension
resolved. There was some concern that his hypertensive episode
was related to cocaine use (though pt adamently denied). He has
had previous admissions for similar symptoms and each time he
has tested positive for cocaine. He refused tox screen at this
time. He is more aware of this now as he knows it may interfere
with his transplant prospects. The patient stabilized and he
was transferred to the floor for further management. His BP
meds were continued and this was no longer an active issue. In
fact, his blood pressure was borderline low on less medications
than he reportedly takes at home raising the question of
noncompliance as an outpatient.
.
#) Inferior lead ST depressions: Likely demand ischemia, but
given initially flat troponins there was unclear [**Name2 (NI) 68402**].
The patient was asymptomatic. He received an ECHO, which was
unrevealing and had no wall motion abnormalities. There was
evidence of known non-ischemic cardiomyopathy. Repeat EKG had
persistent depressions and unclear as to the underlying cause,
but ECHO was negative. He was continued on aspirin 81 daily,
beta blocker and nitrate and will follow up with his PCP.
.
#) Leukocytosis: likely stress response in context of pulmonary
edema/hypertension. No clear evidence of infection. Pt was
empirically started on vanc/zosyn that was later removed and his
white count trended down without Abx. He remained afebrile and
no further workup was done.
.
Abd Pain: pt having persistent chronic abdominal pain. There
was initial concern that this pain, was different and new, but
after speaking with the patient, he said it was the same pain
and did not want further imaging since all CT scanning has come
back negative. He is scheduled for repair of his ventral hernia
in [**Month (only) 956**] and believes that this is the source of the pain.
He said if this surgery does not resolve his pain he will seek
medical help for further evaluation.
.
#) HIV: HAART regimen restarted on the morning after admission.
This was not an active issue during this hospitalization.
.
#) Substance abuse: Unclear if patient is on methadone
currently, and if so for pain or for chronic abuse. Attmepted
to clarify dose while in the MICU, but unable to reach his
methadone clinic. Started on reported home dose of 40mg daily,
pending verification. I was able to reach the patient's
methadone clinic while he was on the floor, but he was being
discharged that day and so the paperwork that needed to get
faxed over to verify his dose was never sent. If he returns, he
will need his dose verified. He goes to the community clinic in
[**Location (un) **] MA for his methadone.
.
#)GERD: Ranitidine. This was not an active issue during his
hospital stay.
Medications on Admission:
Abacavir 300 x 2
Carvediolol 50mg [**Hospital1 **]
Clonidine 0.4 TID
Sustiva 600 daily
Hydral 50 Q8
Isosorbide 30 daily
Lamivudine 2.5 after HD
Methadone 50mg daily
Ranitidine 150 [**Hospital1 **]
Terazosin 3mg QHS
Discharge Medications:
1. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. lamivudine 10 mg/mL Solution Sig: 2.5 PO three times/week
after HD ().
6. methadone 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. docusate sodium 100 mg Capsule Sig: [**1-23**] Capsules PO twice a
day.
11. [**Doctor First Name **]-Vite 0.8 mg Tablet Sig: One (1) Tablet PO once a day.
12. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
13. hydralazine 50 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypertensive Emergency
.
Secondary Diagnosis:
1. HIV - He was diagnosed with HIV in [**2112**]. Risk factors
included unprotected heterosexual sex as well as intravenous
drug use. His nadir CD4 count is 91 and he has no known
opportunistic infections. Last viral load undetectable, CD4 556
([**10-31**]).
2. Hepatitis C. Genotype 1B. Viral load 187,000 in [**12-28**].
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%.
5. Chronic renal insufficiency - MPGN by biopsy in [**2123**] and
hypertensive nephrosclerosis
5. GERD.
6. Hypertension.
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction [**2126-7-23**].
8. Polysubstance abuse, including cocaine and alcohol.
9. Anemia, hematocrit 20-24.
10. Hypertriglyceridemia - TG 282 in [**3-/2126**]
11. Right hydrocele.
12. A subacute infarct in the right caudate head seen on MRI in
[**1-29**]
13. Influenza B, [**2126-2-22**].
14. Erectile dysfunction.
15. Depression
16. Inguinal hernia repair in [**2123**].
17. Left ankle ORIF in [**2122**].
18. Appendectomy in [**2101**].
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were
intially admitted to the hospital for extremely elevated blood
pressure and difficulty breathing. You were admitted to the
intensive care unit and you receive emergency hemodialysis to
have the fluid removed from your body. After that, your
breathing greatly improved and you were ready to be transferred
to the general medicine floor. There were some concerning lab
values that were likely all secondary to the stress your body
went through during the elevated blood pressure and fluid
overload. You also had some abdominal pain, but this pain was
the same as chronic pain you have had in the past. We wanted to
do a further work up of this pain and do some abdominal
immaging, but you denied this as you have said this was done
multiple times in the past and always negative. You said you
have a hernia that is being repaired in [**Month (only) 956**]. You will be
discharged from the hospital with close follow up with your PCP.
.
please take all your medications as prescribed.
Followup Instructions:
Department: PAT-PREADMISSION TESTING
When: FRIDAY [**2129-2-18**] at 11:00 AM
With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2129-2-25**] at 11:40 AM
With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2129-3-4**] at 11:10 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15398**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: FRIDAY [**2129-3-4**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,736
| 161,398
|
35604
|
Discharge summary
|
report
|
Admission Date: [**2119-3-12**] Discharge Date: [**2119-3-25**]
Date of Birth: [**2060-3-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 58F w/ HTN, diveritculosis who was transferred
from [**Hospital3 10310**] after presenting with abdominal pain. She
had diffuse, sharp abdominal pain yesterday and this morning was
able to eat breakfast but afterwards had severe abdomianl pain
associated with nausea and vomiting. She did not have
hematemsis, diarrhea, fevers. She presented to [**Hospital3 10310**]
ED where her lipase level was 1365 and she was admitted for
pancreatitis. CT abdomen/pelvis showed severe pancreatic
inflammation as well as probable cholelithiasis. She was kept
NPO and given IVF and Dilaudid for pain. The most likely
etiology of pancreatitis was thought to be gallstones. She was
transferred to [**Hospital1 18**] for ERCP.
On arrival, she was not in distress but reported some abdominal
"soreness". She has not had lightheadedness, fevers, chills,
change in urination or bowel habits. She has difficulty taking
deep breaths due to the abdominal pain.
ROS:
-Constitutional: [x]WNL []Weight loss []Fatigue/Malaise []Fever
[]Chills/Rigors []Nightsweats []Anorexia
-Eyes: [x]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: []WNL [x]Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: [x]WNL []Chest pain []Palpitations []LE edema
[]Orthopnea/PND []DOE
-Respiratory: [x]WNL []SOB []Pleuritic pain []Hemoptysis []Cough
-Gastrointestinal: []WNL [x]Nausea [x]Vomiting [x]Abdominal pain
[]Abdominal Swelling []Diarrhea []Constipation []Hematemesis
[]Hematochezia []Melena
-Heme/Lymph: [x]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: [x]WNL []Incontinence/Retention []Dysuria []Hematuria
[]Discharge []Menorrhagia
-Skin: [x]WNL []Rash []Pruritus
-Endocrine: [x]WNL []Change in skin/hair []Loss of energy
[]Heat/Cold intolerance
-Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain
-Neurological: []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache
-Psychiatric: [x]WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [x] WNL []Seasonal Allergies
Past Medical History:
HTN
diverticulosis
internal hemorrhoids
s/p appendetomy
Social History:
She lives alone and has no children. Does not smoke. She drinks
one or two glasses of wine at night. She works as an accountant.
She is fully independent in her ADLs.
Family History:
Mother died at age 43 from brain tumor; Father left the family
was she was very young and so she does not know his medical
history.
Physical Exam:
Physical Exam:
Appearance: NAD
Vitals: T: 98.8 BP: 99/67 HR: 89 RR: 18 O2: 93% 2 liters O2
Eyes: EOMI, PERRL, conjunctiva clear, noninjected, anicteric, no
exudate
ENT: Dry MM
Neck: No JVD, no LAD, no thyromegaly, no carotid bruits
Cardiovascular: RRR, nl S1/S2, no m/r/g
Respiratory: CTA bilaterally, decreased air movement from
splinting due to abdominal pain, comfortable, no wheezing, no
ronchi, no rales
Gastrointestinal: Soft, diffusely tender, mildly distended, no
hepatosplenomegaly, normal bowel sounds
Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint
swelling, no edema in the bilateral extremities
Neurological: Alert and oriented x3, fluent speech, no pronator
drift, no asterixis, sensation WNL, CNII-XII intact, strength
[**5-9**] bilaterally in upper and lower extremities, FTN intact
Integument: warm, no rash, no ulcer
Psychiatric: appropriate, pleasant
Pertinent Results:
OSH labs:
Chem 7: 140/4.2/97/26/21/1/209
Calcium 8.7
AST/LT: 312/334
AP: 138
[**Doctor First Name **]/Lip 1759/1365
CBC: 12/15/43/345
CT abd/pelvis with contrast from OSH [**3-12**]:
CT findings are consistent with acute pancreatitis with
peripancreatic inflammation and fluid. No phlegmon or abscess
formation at this time. Cholelithiasis.
Brief Hospital Course:
The patient was admitted to the ICU from an OSH with acute
pancreatitis and cholelithiasis. She was NPO, on IV fluids and
given IV Dilaudid and antiemetics for symptom management. She
was continued on IV Levaquin and Flagyl.
[**3-13**]: The patient underwent EUS which was unable to visualize the
common bile duct, she subsequently underwent ERCP with failure
to cannulate the common bile duct due to duodenal edema. The
pancreatic duct did not show any obstruction. A surgical consult
was called and the patient was trans ferred to the surgical ICU
and the surgical service for further management. A foley
catherer was placed, arterial blood gases showed hypoxia and
hypercarbia, her chest Xray was showed small bilateral pleural
effusions without any pneumonia. She did not require intubation,
and her fluid status and vital signs were closely monitored.
[**3-14**]: The patients respiratory status improved with resolving
hypoxia, she continued to be aggressively resuscitated and her
pain controlled.
[**3-15**]: She was transferred to the inpatient floor on [**Wardname 7911**], a
PICC line was placed in interventional radiology and she was
started on TPN. She remained hemodynamically stable.
[**3-16**]: The patient was continued on TPN. A repeated CXR showed
persistent small bilateral effusions, an MRCP revealed findings
compatible with acute edematous pancreatitis and cholithiasis
with normal appearance of the common bile duct without evidence
of choledocholithiasis.
[**3-17**]: Continued abdominal discomfort treated with IV morphine
with good effect. Hypernatremia treated with free water, TPN
adjustment with improvement. Continues NPO, receiving IV fluids
and TPN. Elevated BP treated with increased dose Lopressor and
diuresis.
[**3-18**]: Remained hemodynamically stable; no events.
[**3-19**]: Remained hemodynamically stable; no events.
[**3-20**]: Tmax 101.7 PO; cultures sent. Clinically improving.
Continues on TPN. Receiving free water for hypernatremia. Diet
advanced to sips.
[**3-21**]: TPN continued, improving. Diet advanced to clears
[**3-22**]: Diet advanced to full liquids.
[**3-23**]: Underwent ERCP showing edematous and congested major
papilla, normal pancreatic duct, normal CBD.
[**3-24**]: repeat CT shows increased edema but otherwise unchanged,
advanced to regular diet
[**3-25**]: ready for discharge home
Medications on Admission:
Medications at home:
Atenolol 50mg qd
HCTZ 12.5mg qd
Medications on transfer:
Atenolol 50mg qd
Levaquin 500mg IV
Flagyl 500mg q8h IV
Dilaudid 1-2mg IV q4h prn
Zofran 4mg IV q6h prn
Ambien 5mg po qhs
Discharge Medications:
1. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
2. 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*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
QAM.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
1. Acute pancreatitis
2. Cholelithiasis
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid 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.
Followup Instructions:
Please call ([**Telephone/Fax (1) 81028**] to schedule follow-up with Dr. [**Last Name (STitle) **]
(PCP) in 2 weeks.
Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment
with Dr. [**First Name (STitle) **] (Surgery) in [**2-7**] weeks.
|
[
"275.41",
"511.9",
"584.9",
"799.02",
"455.0",
"562.10",
"276.0",
"574.20",
"401.9",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"51.10",
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7207, 7226
|
4163, 6531
|
329, 336
|
7310, 7317
|
3797, 4140
|
8425, 8691
|
2742, 2875
|
6782, 7184
|
7247, 7289
|
6557, 6557
|
7341, 8402
|
6578, 6611
|
2905, 3778
|
275, 291
|
364, 2463
|
6636, 6759
|
2485, 2542
|
2558, 2726
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,917
| 179,390
|
8200
|
Discharge summary
|
report
|
Admission Date: [**2107-3-7**] Discharge Date: [**2107-3-22**]
Date of Birth: [**2047-5-25**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**Known lastname 668**]
Chief Complaint:
esrd
Major Surgical or Invasive Procedure:
living non-related renal transplant [**2107-3-8**]
History of Present Illness:
59 y.o. female with ESRD who dialysis M-W-F using Left arm loop
graft presents for LURT. She is on coumadin which she stopped on
[**3-5**]. Last dialyzed today to her dry weight of 124 kg.
Past Medical History:
ESRD (diabetic nephropathy) on HD for the last 9 months
DM2 x 30yrs with subsequent nephropathy, retinopathy, neuropathy
HTN
CAD s/p 3v CABG in [**10/2103**]
Hyperlipidemia
PVD with several toe amputations; s/p bilateral leg
revascularization in [**2098**]
Remote hx of skin cancers on back and face
Social History:
Smokes 1 ppd x 30 yrs, denies heavy EtOH, denies drugs incl
IVDU. On disability
Family History:
Father died of bulbar palsy, mother died of MI.
Physical Exam:
99 90 127/63 24 95% wt 124kg
NAD, lying in bed
oral mucosa pink/moist, dentition okay, no pharyngeal reness or
exudate
lungs CTA, bilaterally
Cards-+femoral pulses
Card-RRR, no m/r/g noted. 2+ pedal and radial pulses
abd-soft, non-tender, obese. +BS
ext-1+ LE edema bilaterally. +bruit/thrill in Left arm AVG loop
skin-warm&dry
Pertinent Results:
[**2107-3-7**] 03:20PM PT-18.1* PTT-30.9 INR(PT)-1.7*
[**2107-3-7**] 03:20PM PLT COUNT-217
[**2107-3-7**] 03:20PM WBC-6.0 RBC-4.03* HGB-13.0 HCT-39.4 MCV-98
MCH-32.4* MCHC-33.1 RDW-15.7*
[**2107-3-7**] 03:20PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-2.4*#
MAGNESIUM-1.5*
[**2107-3-7**] 03:20PM ALT(SGPT)-16 AST(SGOT)-17
[**2107-3-7**] 03:20PM estGFR-Using this
[**2107-3-7**] 03:20PM UREA N-19 CREAT-3.1* SODIUM-141 POTASSIUM-3.8
CHLORIDE-96 TOTAL CO2-35* ANION GAP-14
[**2107-3-7**] 09:15PM PTT-45.0*
Brief Hospital Course:
She was admitted the night prior for IV heparin given h/o of
CABG/leg bypass for which she was on coumadin. She was also
dialyzed the day of admission. Heparin was stopped preop. She
underwent living unrelated renal transplant on [**2107-3-8**] by Dr.
[**Known lastname **] [**Last Name (NamePattern1) **]. Intraop after arterial anastomosis, "The kidney
filled up with blood but remained somewhat dusky and
bluish-appearing." IV fluid bolus was given to improve BP and
Neo-Synephrine was given, but this didnot make any substantial
improvement. TheBookwalter retractors were adjusted and "this
appeared to take some compression off the right-sided iliac
artery and dramatically improved flow to the kidney which then
pinked-up immediately." Cardiac, she was transferred to the ICU
post-op because she was having hypotension in the recovery room
which she was started on levophed. She was then weaned off of
levophed by the AM of POD 1 and did not require pressors for the
rest of her hospitalization. On POD 3 she was started on
lopressor low dose due to her cardiac history and she was
re-started on her aspirin. Renally she had low urine output and
early impaired graft function. On POD 4 she had a renal
ultrasound that showed loss of diastolic flow consistent with
ATN. On POD 8 she had a kidney biopsy done. The pathology was
not finalized at time of discharge.
GI: She tolerated a regular diet but by POD 7 she still had not
had a bowel movement and she even started to have some bilious
emesis. She was started on an aggressive bowel regimen with
gastrograffin enemas, and go-lytley. She finally had several
bowel movements on POD 12 when she was given lactulose. When
she was straining her bowels she had some leakage of blood from
her wound. At CT scan was done revealing a fluid collection in
the left flank inseparable from the small bowel. Subcutaneous
hematoma anteriorly in the pelvis with intact underneath fascia.
There was no bowel obstruction.
She was discharged home in stable condition with persistent
difficulty moving her bowels. Vital signs were stable.
Creatinine had decreased to 4.5. Urine output for 24 hours was
400cc.
Medications on Admission:
coumadin 5 QD: Last dose 3/31, Lyrica 75', Phos-Lo 667 2 tabs q
meals, Lisinopril 40', Effexor XR 150', Renal Cap', Protonix
40', Toprol 50', Lipitor 20', Ambien 10'hs, Aspirin 81', colace
100', Insulin N 4units breakfast/dinner, Novolog SS
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on pain medication. stop if diarrhea.
Disp:*60 Capsule(s)* Refills:*2*
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QOD ().
6. 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*
7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 * Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day:
Take in AM.
Disp:*30 Tablet(s)* Refills:*0*
14. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. Tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO twice a day.
16. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day: Take at lunchtime.
Disp:*2 bottles* Refills:*2*
17. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale Subcutaneous four times a day: Please follow Printed
sliding scale.
Disp:*2 bottles* Refills:*2*
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
esrd
delayed graft function
depression
Discharge Condition:
good
Discharge Instructions:
Please call transplant office if fevers, chills, nausea,
vomiting, inability to take medications, incision
red/bleeding/draining, decreased urine ouptut, shortness of
breath or increased edema
Labs every Monday and Thursday for cbc, chem 7, calcium,
phosphorus, ast, t.bili, albumin, urinalysis, and trough prograf
level. fax to [**Telephone/Fax (1) 697**]
No driving while taking pain medications. [**Month (only) 116**] shower, pat
incision dry.
No heavy lifting (nothing >10lbs.)
Measure and record JP drain output. Bring record to clinic with
you
Followup Instructions:
[**Name6 (MD) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2107-3-24**] 10:40
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2107-3-28**] 1:00
Provider: [**Known lastname **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2107-4-4**] 2:00
Completed by:[**2107-3-22**]
|
[
"403.91",
"250.02",
"585.6",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"38.93",
"55.23",
"00.92"
] |
icd9pcs
|
[
[
[]
]
] |
6437, 6496
|
1933, 4093
|
272, 324
|
6579, 6586
|
1397, 1910
|
7185, 7614
|
980, 1029
|
4385, 6414
|
6517, 6558
|
4119, 4362
|
6610, 7162
|
1044, 1378
|
228, 234
|
352, 542
|
564, 865
|
881, 964
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
495
| 186,199
|
7204+7292
|
Discharge summary
|
report+report
|
Admission Date: [**2183-5-13**] Discharge Date: [**2183-5-17**]
Date of Birth: [**2106-9-23**] Sex: M
Service: [**Hospital Unit Name 196**]
This is a partial discharge summary to [**2183-5-18**].
HISTORY OF PRESENT ILLNESS: A 76-year-old male with a
history of MI with systolic dysfunction, EF less than 20%,
hyperlipidemia, AFib, and chronic renal insufficiency, who is
seen in Advanced Heart Failure Clinic and sent to [**Hospital1 18**] for
nesiritide tailored therapy. Patient had gone to [**State 108**] for the
winter in decompensated heart failure with recurrent atrial
fibrillation. Despite promising to seek medical care, he had not
sought cardiology followup in [**State 108**], while decompensating
further. Patient went up 30 pounds in weight in [**State 108**].
Creatinine was found to be worsening. Patient walks 10 yards and
is short of breath.
Patient was on admission not on an aspirin or beta-blocker.
Complains of moderate-to-low sodium diet.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS:
1. Amiodarone 200 mg q.d.
2. Folic acid 1 mg q.d.
3. Atorvastatin 10 mg q.d.
4. Coumadin.
5. Furosemide 80 mg q.d.
6. Lisinopril 5 mg q.d.
7. Started nesiritide
PAST MEDICAL HISTORY:
1. CHF: Systolic EF of less than 20%.
2. Coronary artery disease status post MI in [**2176**].
3. AFib status post on Coumadin.
4. Chronic renal insufficiency.
5. Hypothyroid.
SOCIAL HISTORY: Patient dates the owner of [**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) **] in
[**Location 1268**]. History of smoking. No alcohol use recently.
PHYSICAL EXAM: Temperature 96.3, blood pressure 90/62, heart
rate 76, respiratory rate 18, and 95% on room air. Weight
70.6 kg. Lungs with decreased breath sounds at the right
base half the way up the left base, but not as pronounced,
diffuse crackles. Irregularly, irregular S1, S2 normal, no
murmur. Abdomen: Markedly distended and firm, nontender,
positive bowel sounds, positive fluid wave. No lower
extremity edema. Mild non-pitting edema on the left, mild
non-pitting edema on the right. 2+ pulses bilaterally.
LABORATORIES: Creatinine found to be 3.6 on admission,
hematocrit 33.4. LFTs unremarkable. TSH greater than 100.
Chest x-ray showed heart failure.
HOSPITAL COURSE:
1. CHF: The patient was markedly decompensated and up
approximately 30 pounds. Patient was on Natrecor 0.15, Lasix
drip of 7, and dopamine of 3 mcg to maintain pressure and
kidney perfusion. Patient had a PICC line placed for these
medications. Patient was still having difficulty diuresing
and his weight was still around 70 kg at this time.
2. Anemia: The patient's hematocrit had been stable at
approximately around 33.
3. Ascites: Plans were to do a paracentesis. The Coumadin
was discontinued and the INR allowed to drift down. This
was going slowly so vitamin K 5 mg subq was given.
4. Coronary artery disease: We continued his aspirin,
atorvastatin. The beta-blocker and ACE inhibitor were not
started because he was in such decompensated heart failure
and was so hypotensive.
5. Hyperlipidemia: We increased his Lipitor to 80 mg q.d.
6. Hypothyroid: TSH was greater than 100 most likely from
amiodarone toxicity. We restarted the patient on low-dose
levothyroxine at 25 mcg so that as not to cause any ischemia
to the patient.
7. Atrial fibrillation: We discontinued the amiodarone
because of thyroid dysfunction, the patient not staying in
sinus rhythm. We discontinued the Coumadin because of the
hopes of paracentesis next week. Spoke with the attending
and there was no reason to place the patient on Heparin for
anticoagulation.
8. Chronic renal insufficiency: Baseline creatinine 1.2-1.7
has been slowly decreasing from 3.6-3.0. It has not gone
back towards baseline.
9. Full code: I spoke with the patient and his girlfriend,
who wishes to be his healthcare proxy. They wish all
measures to be performed.
10. Diet: He was on a 2-gram sodium diet and restricted to 1
liter of fluid per day. Electrolytes were repleted as
needed.
The rest of this discharge summary will be dictated at the
time of discharge.
DR [**First Name4 (NamePattern1) 2064**] [**Last Name (NamePattern1) 26704**] 12.ABZ
Dictated By:[**Name8 (MD) 26705**]
MEDQUIST36
D: [**2183-5-18**] 11:49
T: [**2183-5-20**] 05:32
JOB#: [**Job Number 26706**]
Admission Date: [**2183-5-13**] Discharge Date: [**2183-5-22**]
Date of Birth: [**2106-9-23**] Sex: M
Service: CCU
Note, this dictation covers the [**Hospital 228**] hospital course
from [**2183-5-17**] to [**2183-5-22**].
HOSPITAL COURSE: The patient as noted in the previous
discharge summary developed worsening renal insufficiency and
worsening liver insufficiency. He was transferred to the
Coronary Care Unit for inotropic therapy and CVVHD. He was
started on multiple pressor agents. In the morning of [**2183-5-22**]
the patient underwent a cardiac arrest and was noted to have
pulseless electrical activity. An attempt at resuscitation
was made, however, it was unsuccessful and the patient was
pronounced dead at 9:35 a.m.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Name8 (MD) 8288**]
MEDQUIST36
D: [**2183-5-22**] 01:48
T: [**2183-5-23**] 07:20
JOB#: [**Job Number 26952**]
|
[
"428.20",
"286.9",
"584.5",
"428.0",
"285.9",
"244.9",
"572.8",
"427.31",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04",
"38.91",
"38.93",
"89.64",
"96.04",
"38.95",
"00.13",
"54.91",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
4650, 5410
|
1609, 2272
|
1045, 1207
|
243, 1024
|
1229, 1407
|
1424, 1593
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,108
| 111,990
|
4287
|
Discharge summary
|
report
|
Admission Date: [**2127-7-1**] Discharge Date: [**2127-7-9**]
Date of Birth: [**2070-8-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tape / Percocet / Zyvox
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Trachaelbronchialmalcia
Major Surgical or Invasive Procedure:
[**2127-7-2**]: Right thoracotomy and tracheoplasty with mesh, right
mainstem bronchus/bronchus intermedius bronchoplasty with mesh,
left mainstem bronchus bronchoplasty with mesh, and flexible
bronchoscopy with aspiration.
[**2127-7-1**]: Dynamic flexible bronchoscopy.
History of Present Illness:
Mr. [**Known lastname **] is a 56-year-old gentleman with a history of COPD who
was found to have severe tracheobronchomalacia. He [**Known lastname 1834**] a
placement of a tracheobronchial silicone Y stent on [**2127-5-20**].
Following this his dyspnea on exertion markedly improved.
Unfortunately, he did suffer a stent-related infection and this
needed to be removed. We spoke at length at the utility of
moving on to a surgical correction of his malacia with posterior
splinting with Marlex mesh. We talked about the risks of this
procedure including injury to the recurrent laryngeal nerve,
tracheal injury, esophageal injury, vessel,
heart, or diaphragmatic injury. We talked about the risks of
pneumonia or other infection as a result of this, as well as the
possibility of postoperative pain from the thoracotomy. We also
talked about the possibility that the cervical
trachea may develop or may present with symptomatic malacia
which would not be corrected by this intrathoracic procedure.
Finally, we discussed the possibility of improvement of the
malacia without betterment of his symptoms despite the stent
trial findings, if his underlying lung disease were to take
precedence. Mr. [**Known lastname **] and his partner had a chance to ask all
pertinent questions following this discussion and they wished to
proceed.
Past Medical History:
# HTN
# tracheobronchomalacia (90-95% collapse of mid-distal trachea,
b/l mainstem bronchi collapse 95%) s/p Y stent placement
- COPD x 4 yrs, RAD x 15 yrs (trigger floor wax)
- recent esophageal candidiasis while on steroids [**3-7**]
- GERD w/ laryngitis
- thalassemia minor
- hypogonadism
- osteopenia
- L arm neuropathy
anxiety
- infrarenal AAA 3.2cm, stable CT [**5-6**]
- hx cdiff (clinical dx, flagyl x 7 days)
# Sleep apnea
# GERD with laryngitis s/p Bravo procedure ([**2127-3-26**].
[**Doctor First Name 18348**], [**Location (un) 9095**] CT), and Nissen fundoplication [**2125**]
# Thalassemia minor
# Hypogonadism with decreased testosterone, reliance on patch
# hx HSV/shingles tx valacyclovir
# Osteopenia
# L arm neuropathy
# h/o MRSA
# Anxiety
# s/p tracheostomy (closed [**4-2**])
# s/p uvulopalatoplasty, rhinoplasty, adenoidectomy,
septoplasty, tonsillectomy
# s/p B knee surgery
# s/p B saphenous vein stripping
# s/p pilonidal cyst excision
Social History:
# Professional: RN at [**Hospital1 1012**]-affiliated VA
# Tobacco: Smoked from age 16 - mid 40s, maximum 2 ppd
Family History:
Noncontributory
Physical Exam:
VS: Temp 98.9, HR 104, BP 122/60, RR 18, 90% on RA
General: 56 year-old male no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopathy
Card: RRR
Resp; scattered crackles throughout R>L
GI: benign
Extr: warm no edema
Incision: Right thoracotomy site clean, dry, intact
Neuro: non-focal
Pertinent Results:
[**2127-7-6**] WBC-4.5 RBC-4.81 Hgb-9.7* Hct-31.2* Plt Ct-209
[**2127-7-1**] WBC-5.5 RBC-6.43* Hgb-12.3* Hct-42.4 Plt Ct-219
[**2127-7-6**] Glucose-92 UreaN-10 Creat-0.9 Na-144 K-3.9 Cl-106
HCO3-31
[**2127-7-1**] Glucose-115* UreaN-14 Creat-1.3* Na-144 K-4.3 Cl-105
HCO3-29
CHEST (PA & LAT) [**2127-7-6**]
The heart size is normal. Mediastinal position, contour and
width are unremarkable. The appearance of the lungs is stable
including right mid lung scarring, left lower lobe linear
opacities consistent with atelectasis and there is no change in
small amount of right pleural effusion and right pleural
thickening. There is a small amount of right subcutaneous
emphysema.
The known severe emphysema is unchanged.
SPECIMEN SUBMITTED: LEVEL 7 LYMPH NODES.
Procedure date Tissue received Report Date Diagnosed
by
[**2127-7-2**] [**2127-7-2**] [**2127-7-7**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mb????????????
Lymph node, level 7:
One unremarkable lymph node, no malignancy identified.
Pathology Report Tissue: SKIN BX (PENIS)...1 JAR. Study Date of
[**2127-7-7**]
Report not finalized at time of discharge
Brief Hospital Course:
56M former smoker with TBM and COPD who presented to [**Hospital1 18**] on
[**2127-7-1**] s/p Y-stent removal for follow-up bronchoscopy and
Tracheoplasty. On [**2127-7-2**] Mr.[**Known lastname **] [**Last Name (Titles) 1834**] Right thoracotomy
and tracheoplasty with mesh. He tolerated the procedure well and
a right chest tube was left in place. Pt was extubated
transferred to the surgical ICU from the operating room.
Post-operative pain was controlled with an epidural catheter as
well as a PCA (split bupivacaine/Dilaudid) managed by the acute
pain service. Pt received scheduled nebulizer treatments. On
POD#2 PCA and epidural were increased, and clonidine was started
for improved pain control. The patients blood pressure was low
via arterial line with systolic pressures in the 70's and 80's.
The pts urine output was also decreased during this time for
which he was bolused with crystalloid and transfused with
Hespan. Diltiazem was held and narcotics were reduced with good
effect of SBP in the 120's and return of appropriate urine
output by the morning of POD#3. On POD#3 the chest tube was
removed and the patient was transferred from the ICU to the
surgical floor. Pt continued to improve with scheduled
nebulizer treatments, and was ambulating and tolerating a
regular diet. O2 was weaned as tolerated but still required to
maintain saturations >90%. Pts home medications were restarted
including his home dose of diltiazem which he tolerated well. On
POD#5 dermatology was consulted for a lesion on the patients
penis which was not improving with antifungal cream. A biopsy of
the lesion was taken by dermatology, of which the pathology was
pending at the time of discharge. On POD#6 pt was weaned off of
oxygen and maintained saturations above 90% with ambulation. Pt
was discharged home on POD#7 off of supplemental oxygen,
tolerating a regular diet, and ambulating without assistance.
Medications on Admission:
Duloxetine 40mg daily, fluticasone-Salmeterol 500-50 mcg/disk
[**Hospital1 **], montelukast 10mg daily, clonazepam 0.5mg [**Hospital1 **], gabapentin
100mg tid, pantoprazole 40mg daily, guaifenesin 1200mg [**Hospital1 **],
albuterol sulfate 2.5mg/3ml q4hprn, acetylcysteine 20% tid,
ipratropium bromide 0.02% q4h, MVI, testim 1% TP daily, cymalta
40mg daily,
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
5. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day).
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*1*
8. Hydromorphone 4 mg Tablet Sig: 1 or 1 [**1-29**] Tablet PO Q3H
(every 3 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation Q4H (every 4 hours).
12. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q4H (every 4 hours).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
15. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO daily ().
16. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
18. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day).
Disp:*120 Troche(s)* Refills:*1*
19. Testim 50 mg/5 gram (1 %) Gel Sig: One (1) Transdermal
daily ().
20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*300 ML(s)* Refills:*1*
21. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
VNA Services, INC
Discharge Diagnosis:
TBM, COPD, RAD x 15 yrs, GERD w/ laryngitis, thalassemia minor,
hypogonadism, osteopenia, L arm neuropathy, MRSA, anxiety,
infrarenal AAA 3.2cm stable CT [**5-6**], OSA
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, or cough
-Difficulty swallowing, nausea, vomiting
-Incision develops drainage or increased redness
You may shower: No tub bathing or swimming for 6 weeks
No driving while taking narcotics: Take stool softners with
narcotics.
wear your oxygen 2 liters continuously
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on [**2127-7-22**] 10:00am in the chest
disease center [**Hospital Ward Name **] building [**Hospital1 **] one. Please arrive 45
minutes prior to you appointment and report to the [**Location (un) 470**]
radiology for a chest XRAY.
|
[
"530.81",
"607.2",
"780.57",
"733.90",
"401.9",
"441.4",
"257.2",
"519.19",
"496",
"282.49",
"354.9",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"64.11",
"33.24",
"31.79",
"33.48"
] |
icd9pcs
|
[
[
[]
]
] |
9016, 9064
|
4632, 6542
|
312, 585
|
9276, 9283
|
3458, 4609
|
9730, 10011
|
3081, 3098
|
6951, 8993
|
9085, 9255
|
6568, 6928
|
9307, 9707
|
3113, 3439
|
249, 274
|
613, 1948
|
1970, 2935
|
2951, 3065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,379
| 104,931
|
26641
|
Discharge summary
|
report
|
Admission Date: [**2127-1-13**] Discharge Date: [**2127-1-25**]
Date of Birth: [**2083-8-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
hypothermia, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: This is a 41 homeless man with no known medical history
who was found down in the park today. The patient had been in
the park drinking Listerine with a friend. When the patient was
found by EMS he had a temp of 74. They were unable to obtain a
blood pressure or a pulse.
.
On arrival to [**Hospital1 18**] his temp was 74.6, BP 57/49, R16. Upon
arrival the patient was able to open his eyes, but he was not
responsive. Given his clinical picture, he was intubated. The
patient received a bear hugger. He was resuscitated with warm
fluids. Head CT was obtained and showed a comminuted nasal bone
fracture. No acute hemorrhage. CTA was negative for a PE. EKG
showed NSR at 55, no ST elevations or depressions
Past Medical History:
MHX: unknown
Physical Exam:
PE: T97.2 HR100 BP 104/56 AC O2sat 99%
GEN: thin, poorly groomed Caucasian male who is intubated and
sedated
HEENT: poorly dental hygeine, dried dirt in nares
HEART: nl rate, S1S2, no gmr
LUNGS: CTA-anteriorly
ABD: benign
EXT: cool, +DP bilaterally
Neuro: unable to assess
Pertinent Results:
[**2127-1-13**] 02:50PM PLT SMR-VERY LOW PLT COUNT-79*
[**2127-1-13**] 02:50PM WBC-11.1* RBC-4.79 HGB-17.0 HCT-47.9 MCV-100*
MCH-35.4* MCHC-35.4* RDW-14.1
[**2127-1-13**] 02:50PM ASA-NEG ETHANOL-261* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-1-13**] 02:50PM AMYLASE-132*
[**2127-1-13**] 02:50PM GLUCOSE-23* UREA N-20 CREAT-0.8 SODIUM-145
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-13* ANION GAP-34*
[**2127-1-13**] 03:10PM CK-MB-36* MB INDX-1.2 cTropnT-0.01
[**2127-1-13**] 03:10PM CK(CPK)-2987*
[**2127-1-13**] 06:35PM WBC-4.5# RBC-3.35*# HGB-11.9*# HCT-34.4*#
MCV-103* MCH-35.4* MCHC-34.5 RDW-13.3
[**2127-1-13**] 06:35PM OSMOLAL-345*
[**2127-1-13**] 06:35PM ALBUMIN-2.7* CALCIUM-6.2* PHOSPHATE-3.8
MAGNESIUM-1.7
[**2127-1-13**] 06:35PM GLUCOSE-95 UREA N-17 CREAT-0.5 SODIUM-146*
POTASSIUM-3.2* CHLORIDE-115* TOTAL CO2-11* ANION GAP-23*
[**2127-1-25**] 07:02AM BLOOD WBC-5.0 RBC-3.26* Hgb-11.4* Hct-31.7*
MCV-97 MCH-34.9* MCHC-35.9* RDW-13.5 Plt Ct-187
[**2127-1-25**] 07:02AM BLOOD Glucose-138* UreaN-12 Creat-0.8 Na-140
K-4.0 Cl-105 HCO3-22 AnGap-17
[**2127-1-22**] 04:35AM BLOOD ALT-40 AST-31 AlkPhos-70 TotBili-0.5
.
CT spine:
1. Comminuted nasal bone fractures.
2. Severe mucosal thickening in the ethmoid sinuses and nasal
cavity.
3. No evidence of acute intracranial hemorrhage.
.
CXR: 24 year-old male with hypothermia, intubation. A single
portable view of the chest reveals slight rotation to the right.
No evidence of a pneumothorax. An endotracheal tube is in
satisfactory position. The lungs are well inflated. The ribcage
is intact with no evidence of a fracture. A nasogastric tube tip
lies in the stomach.
.
EKG: Baseline artifact. Sinus bradycardia. Modest non-specific
intraventricular conduction delay. Prominent"J" point in leads
V4-V6 - possible [**Doctor Last Name **] wave. Findings suggest hypothermia.
Clinical correlation is suggested. No previous tracing available
for comparison.
.
CTA:
1. No evidence of pulmonary embolism.
2. Moderate-to-large bilateral pleural effusions with associated
atelectasis.
3. Airspace opacity and infiltrate noted in the lungs, most
predominantly in the left lower lobe. Diffuse patchy nodular
opacities also seen scattered throughout the upper and right
middle lobes. Nodular findings could represent infection versus
metastasis, and followup imaging following treatment is
recommended to document resolution.
.
ECHO: The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
systolic anterior motion of the mitral valve leaflets. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Brief Hospital Course:
43 year old white male with hypothermia and unknown source of
fevers.
1. Pulmonary - Patient was initally intubated for airway
production but rapidly extubated after improvement of
hemodynamics, metabolic acidosis, and mental status. Upon
extubation, patient had a nonproductive cough and fevers
concerning for PNA. Although he had a clear CXR, given LOC and
possible aspiration event, he was started on Unasyn. His fever
and cough persisted with a continued O2 requirement despite
antibiotics. Antibiotics were thus changed to Zosyn. The
patient was started on vancomycin for persistent fevers and
tachypnea. He received nebulizer treatments and chest PT given
possible underlying obstructive lung disease. Seven days prior
to discharge, patient was changed to oral cefpdoxime (with plan
to end course on [**1-27**]); patient's respiratory status was at
baseline, on room air, satting well with ambulation. No evidence
of hospital acquired organisms.
.
2. Hypothermia - Unclear etiology of hypothermia, although
likely secondary to exposure in setting of LOC vs early SIRS.
Patient was warmed with bear hugger and warmed IV fluids.
Workup for hypothyroidism was negative. At the time of
transfer, the patient had been warmed to normal body
temperature.
.
3. Cardiovascular - Patient was admitted with hypothermia, low
WBC, and hypotension concerning for sepsis. Resuscitated with
large volumes of IV fluids to which his blood pressure
responded. He remained bradycardic throughout his time in the
ED however maintained a normal blood pressure after fluid
resuscitation without further intervention. Patient had two,
asymptomatic episodes of bradycardia while on the floor. His
heart rate was maintained between 60-70s prior to discharge.
.
4. Neuro/Psyche - Patient had altered mental status on
admission, likely secondary to hypothermia, hypoglycemia, or
intoxication. At the time of transfer, his mental status
improved and he was alert and oriented to person, place, and
time. He remained oriented to time and place throughout his
stay. Psychiatry was consulted to address a possible underlying
depression, for which remeron treatment was initiated. He was
ruled out for a dual diagnosis and not deemed appropriate for an
inpatient hospitalization.
- Alcoholism: Patient received thiamine iv x3 days, folate, and
an MVI. He was treated for withdrawal with lorazepam by CIWA
scale and was seen by the addiction nurse.
- Extremity tingling - was initiated on neurontin 200 qhs two
days prior to discharge. Patient should follow up with his PCP
regarding possible EtOH induced neuropathy.
.
5. Rhabdomyolysis: Patient was admitted with elevated CK likely
secondary to prolonged LOC. He was treated with aggressive
fluid hydration to prevent renal failure. Serial CKs
demonstrated a steadily decreasing CK. Creatinine was 0.5 at the
time of transfer. Renal function remained stable throughout
stay.
.
6. Pancreatitis: Admitted with elevated pancreatic enzymes,
likely secondary to EtOH. His enzymes trended down throughout
his admission. He was asymptomatic through the admission and
tolerated a PO diet at the time of transfer.
- hepatitis serologies were checked, which showed prior exposure
to hepatitis B.
.
7. Left hand swelling: Likely [**1-24**] trauma. He was followed
clinically without any evidence of compartment syndrome or clot.
Edema had resolved at time of transfer.
.
8. Heme:
- Thrombocytopenia: Unknown etiology/baseline. HIT negative.
Question secondary to alcoholism/hypersplenism. [**Month (only) 116**] be secondary
to marrow suppression in setting of acute illness. HIV was
negative
- Anemia: Normocytic, although MCV 96. Unknown
etiology/baseline. Likely marrow suppression in setting of
alcoholism. [**Month (only) 116**] be secondary to marrow suppression in setting of
acute illness. HIV was also on differential but was negative.
.
9. Comminuted nasal fracture: The patient was seen by plastic
surgery, who believed the fracture to be chronic. No further
management was deemed necessary.
Medications on Admission:
unknown
Discharge Medications:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 doses: To complete course on [**2127-1-27**].
Disp:*14 Tablet(s)* Refills:*0*
2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypothermia
Pneumonia
Lung nodules
.
Secondary:
Elevated liver function tests
Alcholism
Anemia
Thrombocytopenia
Comminuted nasal fracture
Pancreatitis
Rhabdomyolosis
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were admitted for hypothermia (low body temperature) and
decreased ability to breath. You subsequently acquired fevers,
with no obvious source found, but you clinically improved.
Your breathing also improved a few days after admission.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, abdominal pain, nausea,
diarrhea, or any other concernging symptoms.
.
Please take your medications as prescribed.
.
Please see Dr.[**Name (NI) 5118**], your physician, [**Name10 (NameIs) **] receive your
medical care.
Followup Instructions:
1. Dr.[**Doctor Last Name 5118**] - he will set this appt up for you or you
should go to his clinic within 2 weeks to set it up. He visited
you here in the hospital and knows of your discharge from here.
.
Patient needs a follow-up CT scan to assess lung nodules. CT
scan showed airspace opacity and infiltrate noted in the lungs,
most predominantly in the left lower lobe. Diffuse patchy
nodular opacities also seen scattered throughout the upper and
right middle lobes. Nodular findings could represent infection
versus metastasis, and followup imaging following treatment is
recommended to document resolution.
.
Patient was evaluated by psychiatry while an inpatient. It was
recommended that Mr. [**Known lastname 38758**] follow-up with a psychiatrist as an
outpatient.
.
Patient will need a colonoscopy for routine screening (with
anemia signs by laboratories).
|
[
"287.5",
"995.91",
"571.1",
"E901.1",
"518.89",
"V60.0",
"276.2",
"802.0",
"507.0",
"991.6",
"E849.5",
"303.01",
"038.9",
"976.6",
"518.0",
"577.1",
"E928.8",
"790.92",
"291.81",
"428.0",
"518.81",
"E858.7",
"728.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"99.15",
"96.04",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
9042, 9048
|
4525, 8569
|
350, 356
|
9267, 9299
|
1454, 4502
|
9903, 10780
|
8627, 9019
|
9069, 9246
|
8595, 8604
|
9323, 9880
|
1160, 1435
|
276, 312
|
384, 1109
|
1131, 1145
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,476
| 132,468
|
36480
|
Discharge summary
|
report
|
Admission Date: [**2121-4-17**] Discharge Date: [**2121-5-4**]
Date of Birth: [**2052-9-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
OSH transfer for TIPS eval
Major Surgical or Invasive Procedure:
TIPS
Multiple Paracentesis
Colonoscopy
EGD
History of Present Illness:
This is a 68 yo F with h/o newly diagnosed cirrhosis likely
secondary to alcohol who is being transferred from [**Hospital1 3325**] for evaluation of TIPS placement in the setting of
massive ascites refractory to medical therapy. She was initially
admitted on [**4-9**] complaining of significant abdominal
distention, LE edema, and some SOB that had developed over a
period of many months without prior evaluation. She had 3
paracenteses performed during OSH course with 6L being removed
on each, peritoneal fluid studies negative for SBP X 3. Pt was
initiated on lasix 40 mg daily and spirinolactone 100 mg [**Hospital1 **]
without any improvement in abdominal girth. During
hospitalization, pt had negative hep A,B,C serologies and
negative [**Doctor First Name **], anti-mitochondrial, and anti-smooth muscle
antibodies. Hospital course also complicated by rising white
count up to 17.3 without a clear source that was treated
intially with CTX and then transitioned over to Zosyn. Also had
1 episode of coffee ground emesis upon admission, Hct reportedly
stable, NGL results unknown, put on protonix gtt X 24 hrs, EGD
deferred as no further hematemesis. Given refractory ascites,
she was transferred to [**Hospital1 18**] for further care. Of note, though
not reported the patient has a pleural effusion and arrived on
3L 02 via NC (and has history of COPD).
.
On arrival to [**Hospital Ward Name 121**] 10, the patient reports that all day today
she has had bright red blood per rectum. She has cough which is
chronic and she notes she has had some blood in her sputum over
the past few days. She denies dizziness, chest pain and reports
her baseline shortness of breath. She denies history of GI
bleeding. She reports her abdomen feels full and is tender when
she lays on her side. Per the patient her last drink was in the
fall, though records indicate she was drinking up until her
admission to [**Hospital1 46**]. She also reports a 40 pack year history of
smoking.
Past Medical History:
Likely EtOH cirrhosis
COPD
Alcohol Abuse
Tobacco Abuse
Hypertension? (the patient reports she was on atenolol prior to
admission)
Social History:
EtOH -per patient 15 years ETOH. Currently smoking [**12-20**] PPD but
formerly smoked 1 pack for 40 years. She has 2 children. Retired
administrative assitant.
Family History:
no liver disease.
Physical Exam:
PE: T: 97.8 BP: 100/57 HR: 67 RR: 20 O2 sat: 95% on RA
Wt: 150lbs by bed scale (appears to be much less)
Gen - Thin female, looks older than stated age.
HEENT - PERRL, scleral non-icteric
CV - RRR, soft distolic murmur
Lungs - CTAB, telangiectasias across chest, left subclavian line
without erythema
Abd - capu medusae, distended, firm, non-tender to palpation.
Rectal: Mod. amount of Bright red blood pooled under patient,
rectal exam with bright red blood in rectal vault. Good rectal
tone. No hemmorrhoids.
Ext - 2+ edema to thighs
Neuro - Alert, orientedx3. Poor historian, particularly with
time and sequence. No asterixis.
.
Pertinent Results:
[**2121-4-17**] 08:12PM BLOOD WBC-14.9* RBC-3.80* Hgb-12.6 Hct-37.8
MCV-100* MCH-33.0* MCHC-33.2 RDW-15.3 Plt Ct-189
[**2121-4-19**] 06:17AM BLOOD WBC-12.0* RBC-3.34* Hgb-11.2* Hct-33.7*
MCV-101* MCH-33.6* MCHC-33.3 RDW-15.7* Plt Ct-162
[**2121-4-21**] 04:50AM BLOOD WBC-11.8* RBC-2.91* Hgb-9.8* Hct-29.3*
MCV-101* MCH-33.9* MCHC-33.6 RDW-16.3* Plt Ct-117*
[**2121-4-22**] 04:56AM BLOOD WBC-23.6*# RBC-3.08* Hgb-10.4* Hct-29.7*
MCV-97 MCH-33.6* MCHC-34.8 RDW-17.0* Plt Ct-118*
[**2121-4-22**] 04:56AM BLOOD Neuts-88.3* Lymphs-4.2* Monos-6.5 Eos-0.6
Baso-0.4
[**2121-4-17**] 08:12PM BLOOD Neuts-80* Bands-0 Lymphs-11* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2121-4-17**] 08:12PM BLOOD PT-17.0* PTT-34.3 INR(PT)-1.5*
[**2121-4-22**] 04:56AM BLOOD PT-19.9* PTT-42.9* INR(PT)-1.9*
[**2121-4-17**] 08:12PM BLOOD Glucose-92 UreaN-30* Creat-1.2* Na-140
K-4.1 Cl-105 HCO3-25 AnGap-14
[**2121-4-19**] 06:17AM BLOOD Glucose-64* UreaN-37* Creat-1.4* Na-144
K-3.8 Cl-106 HCO3-23 AnGap-19
[**2121-4-21**] 04:50AM BLOOD Glucose-142* UreaN-47* Creat-1.4* Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
[**2121-4-22**] 04:56AM BLOOD Glucose-127* UreaN-47* Creat-1.3* Na-144
K-3.8 Cl-110* HCO3-21* AnGap-17
[**2121-4-22**] 04:56AM BLOOD ALT-8 AST-22 AlkPhos-48 TotBili-1.8*
[**2121-4-20**] 06:48AM BLOOD ALT-7 AST-25 AlkPhos-74 TotBili-1.1
[**2121-4-19**] 06:17AM BLOOD ALT-8 AST-18 AlkPhos-58 TotBili-1.1
[**2121-4-18**] 05:55AM BLOOD ALT-11 AST-22 LD(LDH)-197 AlkPhos-68
TotBili-1.1
[**2121-4-17**] 08:12PM BLOOD ALT-9 AST-23 AlkPhos-74 TotBili-1.2
[**2121-4-17**] 08:12PM BLOOD Albumin-2.8* Calcium-9.5 Phos-2.9 Mg-2.1
[**2121-4-18**] 05:55AM BLOOD TotProt-5.0* Albumin-2.6* Globuln-2.4
Calcium-8.9 Phos-3.1 Mg-2.1
[**2121-4-22**] 04:56AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.3
Brief Hospital Course:
A/P: 68 yo F with h/o EtOH cirrhosis, COPD and HTN transferred
from OSH for further management of massive ascites and possible
TIPS placement, also with BRBPR.
.
#) EtOH cirrhosis - Patient has never been followed by a liver
doctor. Though a poor historian, ascites appeared to have
developed over the last 9 months. ETOH most likely as viral,
autoimmune causes have been ruled out at OSH. Liver ultraound
showed patent vessels. Liver synthetic function mildly abnormal
at admission. Patient had 18L of ascites removed at OSH and
quickly reaccumulated. We did 2 more paracentesis on [**4-18**] and
[**4-22**] and removed 7.2L and 4L respectively (followed by albumin).
We did not start diuretics given patient's GI bleeding. Patient
was evaluated for TIPS by liver team and it was felt she would
likely benefit symptomatically from TIPS so this was preformed
[**2121-5-2**]. Patient not encephalopathic on exam while here and has
no history of encephalopathy.
.
#) GI/Vaginal Bleeding: Patient with moderate amount of maroon
blood on rectal exam and guaiac positive stool. She also
appeared to have some vaginal bleeing. Vaginal ultrasound was
done and showed a normal endometrium. Flex sig was planned for
the morning of [**4-22**] but the patient had decompensated the night
before and so this was cancelled. Per report, the patient had 1
episode of coffee ground emesis at the OSH but was not scoped
(HCT on transfer 36). She was placed on a PPI IV BID and the
following morning she had an EGD that showed esophagitis and 4
cords of grade 1 varices. The patient did well until the
evening of [**4-21**] the patient had coffee ground emesis, about 100
ccs. She was given one unit of blood and her HCT stayed the
same. The following morning the patient had more episodes of
coffee ground emesis and tube feeds were stopped and dobhoff put
on suction. She initially had 1L of cofee ground fluid removed,
then the fluid turned into maroon color. Repeat HCT was 26
(3pts down from previous). Patient ordered for 2 more units of
blood, had 2 large bore IVs placed and she was transferred to
the MICU. In the MICU she did not receive any more blood, had
no more emesis and her HCT remained stable so decision was made
not to do an EGD. PAtient was transferred back to the floor the
next morning and her HCT remained stable, she had no more
emesis.
.
#) Anasarca: [**1-20**] both cirrhosis and malnutrition (in the setting
of poor po and etoh use): Post-pyloric dobhoff placed and
patient started on tube feeds and diet supplemented with ensure.
.
#) Leukocytosis: Elevated WBC count at OSH concerning for
infection, but patient afebrile and no evidence of infection on
any fluid culture from the OSH though patient on Zosyn. Zosyn
was d/c'd and the patient did well for 5 days with WBC count
trending down. However, her WBC count acutely jumped from 11 to
22 (at the time she started bleeding). She was empirically
covered with Vanco, flagyl and Ceftriaxone. Dx paracentesis was
done and showed no evidence of infection. The following morning
after control of her bleeding, her WBC count was down to 12 and
Vanco and flagyl were d/c'd. She was continued on Cipro for SBP
prophylaxis given her upper GI bleed. The dose of PPX CIpro was
500 daily becuase she is on continuous tube feeds.
.
#) h/o hypertension: Patient not hypertensive here. Atenolol
held.
.
#)Hypoxia: Patient desat on the night she started bleeding to
88% on RA. DDX included aspiration, PE, and decreased lung
volumes from increased ascites and atelectasis. CXR not
consistent with pneumonia or aspiration. Patient given 2 doses
of mucomyst for concern of getting CTA, but when patient lies on
her side she can come off 02 so increased ascites is most likely
underlying cause. She improved markedly with therapeutic
paracentesis and remained stable on room air.
.
#) Acute Renal Failure: Patient's baseline creatinine at OSH is
0.8 and on arrival here she was 1.4. She was volume
resisciatated but this did not cause decrease in creatinine.
She was started on midodrine, octreotide, IV albumin for
hepatorenal syndrome and her creatinine trended down to
baseline.
Medications on Admission:
MEDICATIONS ON TRANSFER:
Lasix 40 mg qam
Spironolactone 100 mg [**Hospital1 **]
Protonix 40 mg IV bid
Zosyn 3.375 g IV q6h
Xopenex neb tid
Percocet prn
Morphine 2-4 mg q3h prn
Reglan 10 mg q6h prn
Calcium carbonate prn
Ambien 5 mg qhs prn
.
MEDICATIONS AT HOME:
? atenolol, unknown dose daily
Aspirin 81 mg (patient taking every other day)
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob/ wheezing.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for sob/wheezing.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
10. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
11. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Alcoholic Cirrhosis
Portal Hypertensive Gastropathy
Diverticulosis
Discharge Condition:
vital signs stable, ambulating with assistance
Discharge Instructions:
You were admitted because of liver failure and fluid build up in
your liver. You also had bleeding from your GI tract that
required endoscopies. You had a short stay in the ICU but
stabilized quickly. You had multiple taps and fluid removal
from your belly. You had a procedure called a TIPS to reduce the
pressure in your belly and prevent the fluid from
reaccumulating. We started the workup for a liver transplant.
.
To complete the workup for your liver transplant you will need
Pulmonary Function Tests, Mammogram, Pap smear, U/s of your
liver (in 1 week), and to abstain from alcohol.
.
Please have an ultrasound of your belly on Friday [**2121-5-9**]. You
will need to call radiology ([**Telephone/Fax (1) 6713**] to schedule an
appointment.
.
Please follow up with the Liver clinic in two weeks. Call to
schedule an appointment.
.
Please take all your medications as prescribed.
.
If you develop any chest pain, shortness of breath, cough,
fever/chills, abdominal pain, confusing, nausea, vomiting, or
diarrhea please tell the doctors and rehab [**Name5 (PTitle) **] go to your local
emergency room.
Followup Instructions:
To complete the workup for your liver transplant you will need
Pulmonary Function Tests, Mammogram, Pap smear, U/s of your
liver (in 1 week), and to abstain from alcohol.
.
Please have an ultrasound of your belly on Friday [**2121-5-9**]. You
will need to call radiology to schedule an appointment.
.
Please follow up with the Liver clinic in on Friday [**2121-5-9**]
also. Call ([**Telephone/Fax (1) 16670**] to schedule this appointment.
Completed by:[**2121-5-5**]
|
[
"496",
"584.9",
"511.9",
"261",
"623.8",
"456.1",
"569.3",
"303.91",
"276.51",
"571.2",
"562.10",
"305.1",
"455.3",
"578.0",
"789.59",
"537.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"99.04",
"38.93",
"54.91",
"88.51",
"45.25",
"39.1",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10893, 10965
|
5211, 9366
|
342, 387
|
11085, 11134
|
3429, 5188
|
12295, 12766
|
2742, 2761
|
9757, 10870
|
10986, 11064
|
9392, 9392
|
11158, 12272
|
9654, 9734
|
2776, 3410
|
276, 304
|
415, 2393
|
9417, 9633
|
2415, 2547
|
2564, 2726
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,255
| 118,138
|
41483
|
Discharge summary
|
report
|
Admission Date: [**2163-1-24**] Discharge Date: [**2163-2-15**]
Date of Birth: [**2122-7-31**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
IVH
Major Surgical or Invasive Procedure:
EVD
PEG
Trach
History of Present Illness:
PER OMR:
40 yo M with no known past medical history transferred from
OSH with IVH.
Per his parents, he had difficulty getting up this AM and seemed
sleepy and was slumped over. He had a severe frontal headache
and went to his PCP and was found to be hypertensive (210/112
per
father) and went to Good Samaratin [**Name (NI) **]. There his BP was
204/134.
CT head revealed blood throughout the left lateral ventricle as
well as 3rd and 4th ventricle with mild ventricular enlargement.
He was intubated, received labetalol, hydralazine, phenytoin,
nicardipine, and labetalol and transferred here for further
care.
Past Medical History:
none
Social History:
-lives with parents, works as an accountant. No tobacco, etoh,
or drug hx per parents.
Family History:
-no history of aneurysms. Grandfather with stroke in his 60s.
Physical Exam:
General: No acute distress
HEENT: Conjuctival hemorrhage.
Pulmonary: rhonchi b/l
CV: RRR no murmur appreciated
Abd: Soft + bowel sounds
Ext: No edema
Neurologic: Alert, on Trach/Vent.
Able to follow simple appendicular and midline commands. PERRL.
EOMI. Face symmetric to smile. Tongue midline. Sensation intact
to light touch in all four extremities. reflexes are brisk
throughout Right greater then left with upgoing right toe.
Clonus B/L at the ankles (4 beats) Was observed with PT and was
able to stand unsuported and able to take small shuffling steps
with support from a wheelchair. On strength testing he was [**3-1**]
b/l at the delts. [**3-31**] at the biceps b/l . 5-/5 at the triceps
b/l. 5-/5 Right Finger flexors. IP [**3-1**] at left IP and 5-/5 right
IP. 4+/5 b/l at the TA.
Pertinent Results:
[**2163-1-27**] Sputum
SERRATIA MARCESCENS
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM-------------<=0.25 S
OXACILLIN------------- 0.5 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
[**2163-2-8**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL Negative
[**2163-2-6**] CATHETER TIP-IV WOUND CULTURE-FINAL
Negative
[**2163-2-6**] URINE Legionella Urinary Antigen -FINAL
Negative
[**2163-2-5**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL Negative
[**2163-2-3**] BLOOD CULTURE Blood Culture, Routine-FINAL
Negative
[**2163-1-29**] URINE URINE CULTURE-FINAL Negative
[**2163-1-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
Negative
RESPIRATORY CULTURE (Final [**2163-2-1**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
SERRATIA MARCESCENS. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
317-1889N
ON [**2163-1-27**].
STAPH AUREUS COAG +. ~4000/ML.
SENSITIVITIES PERFORMED ON CULTURE # 317-3757N [**2163-1-29**].
GRAM NEGATIVE ROD #2. ~1000/ML.
[**2163-2-13**] : CXR One portable view. Comparison with the previous
study done [**2163-2-12**].
Extensive bilateral patchy pulmonary opacities persist.
Mediastinal
structures are unchanged. A tracheostomy tube and left
subclavian catheter
remain in place. There is no significant interval change.
CT chest/Abd/ Pelvis [**2163-2-11**]
IMPRESSION:
1. lnterval improvement in extensive bilateral pulmonary
consolidation and
ground-glass opacities, which may represent multifocal infection
or diffuse
lung injury. No pleural or pericardial effusions.
2. No adrenal tumors or abdominal pathology identified to
explain the
patient's hypertension.
3. Two liver lesions, not completely characterized on this
single-phase
study, almost certainly represent hemangiomas. An additional
ill-defined
non-mass like hypodense area in segment IV is not well
characterized in this
single phase imaging. If LFT's are abnormal this could be
further investigated
urgently. If not this can be further evaluated in a non-urgent
basis. While
MRI would be the test of choice, the patient would be unlikely
to have a good
quality study at this time.
4. Small left renal infarct or scar
[**2163-2-5**] CT head
IMPRESSION:
1. Interval decrease of intraventricular and subarachnoid
hemorrhage.
2. No evidence of hydrocephalus, unchanged ventricular size
compared to [**2-4**], [**2162**].
[**2163-1-25**] cerebral angio
IMPRESSION:
1. Mr. [**Known firstname **] [**Known lastname **] underwent diagnostic cerebral angiogram which
did not
demonstrate intracranial arterial or venous abnormality to
explain the
intraventricular hemorrhage.
2. On delayed cerebral venous phase imaging, the left transverse
sinus does not demonstrate good contrast opacification. The left
sigmoid sinus is demonstrated draining to the left jugular vein.
On correlation with the MRI of the brain obtained same day at
2:47 a.m., this lack of filling of the left transverse sinus is
consistent with a congenitally hypoplastic sinus vs chronic
occlusion.
[**2163-1-24**] CTA head/neck
IMPRESSION:
Extensive intraventricular hemorrhage and dilated third and
lateral
ventricles. Fenestration at the anterior communicating artery.
No evidence of intracranial aneurysm.
[**2163-1-27**] Right UE Doppler
Deep vein thrombosis seen in one of the right brachial veins and
occlusive thrombus is also seen in the right basilic vein
Brief Hospital Course:
Pt [**Name (NI) **] Was admitted as an OSH transfer after being found to have
an extensive interventricular hemorrhage. He was intubated and
had an emergent EVD placed by neurosurgery. He was noted to be
very hypertensive on admission and throughout his stay here
requiring four antihypertensive agents for control.
He has serial CT heads and a cerebral Angio which failed to
demonstrate an etiology in terms of underlying structural
abnormalities.
In terms of his neurologic status he had interventricular tPA
placed x 3 days with resolution of blood products. He tolerated
clamping of the EVD x24 hours and the drain was removed. Over
his course here he went from a comatose state to being able to
communicate using non verbal cues. He followed simple commands
without problems. On strength testing he is weak throughout in
upper and lower extremities in flexor and extensor muscle groups
that relates to critical illness weakness. He was also noted to
have more weakness on the right side compared to his left side
with brisker reflexes on the right that probably relates to his
IVH starting off from the left lateral ventricle with some
encephalomalacia noted around the motor fibers around this area
(left).
With regards to his pulmonary issues he did develop ARDS with
some clinical improvement over the course of 15 days as his
ventilator settings have been slowly weaned down. He was started
on broad spectrum antibiotics and it was recommended that he
finish off a course of ciprofloxacin and cephalexin for a total
of 3 weeks.
Below is the antibiotic course:
Cefepime [**Date range (1) 29682**]
Cefazolin 2gIVQ8 3/9-3-14
Vancomycin [**Date range (1) 59479**]
To end [**2163-3-1**].
Ciprofloxacin start [**1-30**]-
Cephalexin 500 Q12hrs [**2-7**]-
Fever was noted throughout his stay. Dooplers of the exremities
was completed and was significant for RUE DVT. See report. His
fever was multifactorial. ARDS, DVT, Central origin.
With regards to his blood pressure. He was placed on 4
antihypertensive agents but this has been changed daily as his
blood pressure has been under better control. [**2163-2-14**] we have
taken him off the clonidine today and have increased his
lisinopril to 20mg daily. His medications should be titrated to
SBP 95-160 goal. Because he had high blood pressure a screening
test for pheochromocytoma was initiated but an endocrine consult
stated that the tests are not interpretable during this acute
phase and recommended they get tested once he is no longer
infected, stable, and off a beta blocker. A CT of the chest
abdomen and pelvis was completed and failed to show a
pheochromocytoma. He will need follow up with the
endocrinologist for this.
With regards to his renal function he had ARF that was
secondary to Ibuprofen use and this was discontinued. His renal
function normalized, but there was slight increase in his BUN/Cr
which is likely prerenal as he was diuresed by the ICU team. he
may need some fluid repletion.
He had a PEG and trach placed. He tolerated the PEG and tube
feeds he developed diarrhea but failed to show infection in his
stool.
He needs continued care regarding his pulmonary issues. he is
recovering from a neurologic prospective and will need endocrine
follow up.
Teams:
Infectious Disease
Endocrinology
Neurology
Neurosurgery
ICU
Things to follow up:
ARDS
Work up for pheocromocytoma
Completions of antibiotics
Physcial therapy
Medications on Admission:
none
Discharge Medications:
1. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Acetaminophen Extra Strength 500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for pain/fever.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
8. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 13 days.
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 13 days.
11. codeine sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for cough.
12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) Inhalation [**Hospital1 **] (2 times a day) as needed for cough.
14. lidocaine HCl 10 mg/mL (1 %) Solution Sig: One (1) ML
Injection Q4H (every 4 hours) as needed for cough.
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
17. HydrALAzine 10 mg IV Q6H:PRN HTN
For SBP>140
18. lisinopril 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Interventricular hemorrhage
Hypertension
Being worked up for a pheochromocytoma
Discharge Condition:
Fair
Discharge Instructions:
You were admitted as a transfer for a large bleed in your brain.
The reason for your bleed is believed to be from your high blood
pressure. You had a drain temporarily placed in your brain to
relieve the pressure. This was taken out. You developed a
serious lung infection and you required a tracheostomy and PEG
tube. Your lungs and neurologic status improved. You were
discharged to a long term health care facility for further care.
Please call the numbers below to make an appointment.
Followup Instructions:
Please call ([**Telephone/Fax (1) 7394**] to make a follow up appointment with
DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the Neurology Stroke department to be seen in
[**5-4**] weeks.
Please call ([**Telephone/Fax (1) 9072**] to make a follow up appointment with
DR [**Last Name (STitle) 6092**], Mala of endocrinology. Please call in 1 month.
Completed by:[**2163-2-15**]
|
[
"V49.87",
"041.11",
"041.85",
"225.0",
"331.4",
"584.9",
"359.81",
"997.31",
"430",
"401.9",
"372.72",
"431",
"518.81",
"047.9",
"348.5",
"348.39",
"787.91",
"453.81",
"E935.6",
"322.9",
"453.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"38.91",
"31.1",
"43.11",
"96.6",
"38.93",
"88.41",
"99.10",
"02.39",
"33.24",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
11367, 11410
|
6061, 9402
|
286, 301
|
11533, 11539
|
1988, 6038
|
12077, 12486
|
1097, 1162
|
9547, 11344
|
11431, 11512
|
9518, 9524
|
11563, 12054
|
1177, 1969
|
9413, 9492
|
242, 248
|
329, 947
|
969, 975
|
991, 1081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,824
| 184,335
|
3985
|
Discharge summary
|
report
|
Admission Date: [**2163-10-10**] Discharge Date: [**2163-10-16**]
Date of Birth: [**2100-9-11**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
male with a history of coronary artery disease since [**2155**].
He has had a series of positive stress tests. The cardiac
catheterization performed in [**2159-6-4**] then showed a totally
occluded right coronary artery with a left ventricular
ejection fraction of 70%. The patient was continued to be
managed medically and was followed with annual stress
echocardiograms. For the past few years, the patient reports
that he has had exertional chest pain and shortness of breath
with activity such as pushing the lawn mower or walking one
block down the street. He also reported occasional episodes
of dizziness. He denied any symptoms at rest. His most
recent stress echocardiogram showed mild ST changes, chest
pain and inferior/posterior wall motion abnormalities. He
was consequently referred for another cardiac catheterization
for a further evaluation. The patient also denies any
symptoms of claudication, orthopnea, edema, or paroxysmal
nocturnal dyspnea. Cardiac catheterization performed on
[**2163-10-10**] revealed right coronary artery and left main
coronary artery disease in addition to mild diastolic left
ventricular dysfunction. Calculated ejection fraction was
62%.
PAST MEDICAL HISTORY: 1. Coronary artery disease; 2.
Hypertension; 3. Hyperlipidemia; 4. History of shingles two
months ago.
PAST SURGICAL HISTORY: Anal fissurectomy.
ALLERGIES: Possible allergy to contrast dye.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o. q. day;
Atenolol 100 mg p.o. q. day; Diltiazem 240 mg p.o. q. day;
Isordil 60 mg p.o. q. day; Lipitor 80 mg p.o. q. day; Mavik 1
mg p.o. q. day; Folic acid 1 mg p.o. q. day.
LABORATORY DATA: Laboratory studies on admission revealed
hematocrit of 40.2, white blood cell count 6.3, platelets
213, urine analysis negative. Glucose 134, BUN 15,
creatinine 0.7, sodium 137, potassium 4.2. ALT 40, AST 28,
alkaline phosphatase 109, amylase 41.
HOSPITAL COURSE: Given the results of the cardiac
catheterization the patient was admitted to the Cardiac
Surgery Service for a coronary artery bypass graft. On
[**2163-10-11**], the patient underwent coronary artery bypass
grafting times five with a left internal mammary to the left
anterior descending coronary artery; radial artery to the
distal right coronary artery; reverse saphenous vein graft
from the aorta to the left anterior descending diagonal
coronary artery and reversed saphenous vein graft from the
aorta in sequence from the first obtuse marginal coronary
artery and sequence to the second obtuse marginal coronary
artery. The patient tolerated the procedure well. There
were no complications. Please see the full operative report
for details. After the procedure the patient was transferred
to the Intensive Care Unit in satisfactory condition. The
patient was extubated on the same day in the evening. He
remained in stable condition. He continued to make good
urine. A good left radial and ulnar flow was confirmed by
pulse oximetry waveform. On postoperative day #2, his
hematocrit was 29.7. He was continued to be weaned off of
supplemental oxygen. On postoperative day #2 the patient got
out of bed to chair. Lopressor was started. On
postoperative day #2 he was noted to have heartrate in the
120s to 130s range. The rhythm was irregular. The patient
was treated with intravenous Lopressor. Physical therapy was
consulted who was following the patient throughout his
hospitalization. On postoperative day #2 the patient was
transferred to the regular floor in stable condition. On
postoperative day #3 the patient was noted to have runs of
irregular rhythm. Electrophysiology Service was consulted.
It was thought that the patient was having frequent
intermittent postoperative atrial tachycardia. His Beta
blocker was increased accordingly to control his heartrate.
The following night the patient had another run of irregular
rate which again was thought to be atrial tachycardia. There
were no sustained arrhythmias noted. The patient remained in
sinus rhythm without any arrhythmias throughout the last 36
hours of his hospitalization. His basic wires were removed.
The patient was ambulating and was cleared by physical
therapy. The patient was discharged to home on postoperative
day #5 in stable condition.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass graft times five
2. Hypertension
3. Hypercholesterolemia
PHYSICAL EXAMINATION: Alert and oriented times three. Head,
eyes, ears, nose and throat examination was within normal
limits. Chest examination, incision clean, dry and intact.
Chest was stable. Abdomen soft, nontender, nondistended.
Cardiac, regular rate and rhythm, no murmurs. Extremities,
donor lower extremity incision clean, dry and intact. No
evidence of edema. Right arm, donor site clean, dry and
intact.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with his surgeon, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in approximately six weeks.
2. The patient is to call the Holter laboratory at [**Hospital6 1760**] next week to schedule an
appointment for a monitor pickup.
3. The patient is to follow up with Dr. [**Last Name (STitle) 17642**] in
approximately two to three weeks with a result of Holter
monitoring.
4. The patient is to follow up with Dr. [**Last Name (STitle) **], his primary
care physician, [**Name10 (NameIs) **] approximately one to two weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 100 mg t.i.d.
2. Imdur 60 mg p.o. q. day times one month
3. Aspirin enteric coated, 325 mg p.o. q. day
4. Percocet one to two tablets p.o. q. 4-6 hours prn pain
5. Lipitor 80 mg p.o. q. day
6. Mavik 1 mg p.o. q. day
7. Iron 325 mg p.o. q. day
8. Folic acid 1 mg p.o. q. day
9. Lasix 20 mg p.o. b.i.d. times seven days
10. Potassium chloride 20 mEq p.o. b.i.d. times seven days
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2163-10-16**] 15:16
T: [**2163-10-16**] 15:51
JOB#: [**Job Number 17643**]
|
[
"997.1",
"272.0",
"414.01",
"411.1",
"401.9",
"553.3",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.53",
"36.15",
"36.14",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
5729, 6435
|
4559, 4682
|
1652, 2114
|
2132, 4481
|
5128, 5706
|
1558, 1625
|
4705, 5104
|
179, 1404
|
1427, 1534
|
4506, 4538
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,612
| 156,161
|
14559
|
Discharge summary
|
report
|
Admission Date: [**2156-3-12**] Discharge Date: [**2156-3-27**]
Date of Birth: [**2081-10-8**] Sex: F
Service:
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old
female, transferred from an outside hospital, with a history
of abdominal pain, status post aorta celiac SMA bypass for
mesenteric ischemia in [**2154-7-8**]. Status post right
axillobifemoral in [**2155-7-8**] by Dr. [**Last Name (STitle) **]. The
patient complained at the outside hospital of six weeks of
post prandial abdominal pain and upper gastrointestinal
bleeding. The patient did receive 10 units of packed red
blood cells at the outside hospital. The patient was
subsequently discharged from the outside hospital but
continued with the lower abdominal pain. The patient was then
referred to [**Hospital1 69**] for further
evaluation.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Aortic insufficiency.
3. Hypertension.
4. Coronary artery disease.
5. Status post myocardial infarction.
6. Status post left carotid stenosis.
7. Chronic obstructive pulmonary disease.
8. History of fecal impaction.
9. History of upper gastrointestinal bleeds.
10. Status post axillo-bifemoral in [**7-10**].
11. Status post aorta celiac SMA bypass graft, [**7-9**].
MEDICATIONS:
1. Dilaudid PCA.
2. Protonix 40 mg p.o. q. day.
3. Compazine 5 mg intramuscular q. six hours prn.
4. Senokot.
5. Lopressor 50 mg p.o. twice a day.
6. Nitropaste one inch q. six hours prn for a blood pressure
greater than 140.
7. Folate 1 mg p.o. q. day.
ALLERGIES: Penicillin and Erythromycin.
PHYSICAL EXAMINATION: 97.9; 180/80; 80; 20 and 94% on room
air. No acute distress. Regular rate and rhythm. Clear to
auscultation. Abdomen: Soft, positive bowel sounds.
Negative peritoneal signs. No inguinal hernias. Initial
pulses: Carotid bruits bilaterally; radials +2; femorals
Dopplerable; dorsalis pedis Dopplerable on the right;
posterior tibial Dopplerable bilaterally.
HOSPITAL COURSE: The patient was admitted to the hospital
with question of mesenteric ischemia and was followed by the
vascular service. The patient had an uneventful course.
Gastrointestinal was consulted for an evaluation and
recommended a GoLYTELY prep and a colonoscopy. During that
time, a duplex of the axillo-bifemoral showed a patent
axillary conduit to the femoral outlet. It did show an
occluded left femoral crossover. The patient was initially
continued n.p.o. and had TPN for nutrition.
General surgery was consulted for an evaluation for a feeding
tube. It was decided that the patient, when ready, could
receive a gastric tube placement via general surgery and/or
IR. The patient was transitioned from TPN to N-J tube
feedings without complications. Prior to the colonoscopy, the
patient went into flash pulmonary edema and required
Intensive Care Unit monitoring. During that time, a central
line, A line and an endotracheal tube was placed. Cardiology
was consulted and initially thought that the patient's flash
pulmonary edema was secondary to cardiac diastolic
hypertension. The patient's course in the Intensive Care Unit
was initially uneventful. On the [**7-27**], the patient
became hypotensive with a metabolic acidosis. The acidosis
worsened and the patient became hyperdynamic. Aggressive
volume resuscitation was initiated. At that time, it was
thought that the patient's axillo-bifemoral may have clotted
off. During that time, it was also thought that the
patient's SMA may also have clotted off. Aggressive
resuscitation was continued. The patient's acidosis did not
improve and her lactate continued to rise. It was decided
that the patient would have an angiogram done through
interventional radiology to evaluate the SMA. Prior to the
angiogram, the patient suffered a cardiac arrest. ACLS was
initiated. CPR, epinephrine, calcium, magnesium, Lidocaine
and cardioversion were attempted to revive the patient.
These attempts were unsuccessfully and the patient expired at
6:25 p.m. Dr. [**Last Name (STitle) **] and the family were notified.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2156-5-3**] 06:49
T: [**2156-5-3**] 18:51
JOB#: [**Job Number 42961**]
|
[
"428.0",
"496",
"518.82",
"428.31",
"453.8",
"427.5",
"996.74",
"557.1",
"402.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.60",
"99.15",
"45.16",
"88.47",
"96.04",
"38.93",
"88.42",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2029, 4385
|
1646, 2011
|
149, 166
|
195, 872
|
894, 1623
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,896
| 185,934
|
27365
|
Discharge summary
|
report
|
Admission Date: [**2169-4-5**] Discharge Date: [**2169-4-18**]
Date of Birth: [**2095-8-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
constipation, dizziness, nausea, weakness
Major Surgical or Invasive Procedure:
repair right common femoral pseudoaneurysm [**2169-4-9**]
cabg x5 [**2169-4-11**] (LIMA to LAD, SVG to PDA, SVG to
Diag2,sequentially to OM1, sequentially to OM3
exploratory laparoscopy/open cholecystectomy [**2169-4-13**]
bedside abd. washout and segmental colectomy [**2169-4-14**]
completion right colectomy/ileostomy [**2169-4-16**]
History of Present Illness:
73 yo female presented to OSH on [**3-31**] with c/o nausea, weakness,
constipation and dizziness. Also found to be anemic with Hct
27.6. Work-up revealed NSTEMI with troponin 11.7. Cath on [**4-4**]
showed three vessel CAD.Prior echo [**5-15**] showed EF 60-65% and
[**12-12**]+ MR. [**First Name (Titles) **] [**Last Name (Titles) 37566**] did not suggest GI source for anemia. Also
treated for a UTI at OSH. Developed CHF and transferred to [**Hospital1 18**]
for further management.
Past Medical History:
HTN
NSTEMI
anemia
elev. lipids
GERD
duodenal ulcer/gastritis
MI [**2148**]
chronic constipation
no prior surgeries
Social History:
no ETOH or tobacco
lives alone
Family History:
father and sister died of MI in their 50's
Physical Exam:
frail, cachectic appearing elderly woman in NAD
39.9 kg 96% 2L NC 111/63 HR 73 RR 20
non-icteric sclera
no JVD
bilat. carotid bruits
lungs CTAB
RRR 3/6 systolic murmur
soft, NT, ND, no organomegaly or masses
extrems without edema or varicosities
2+ bil radials/2+ right femoral trace left femoral
1+ right DP/PT, non-palpable left DP/PT
Pertinent Results:
[**2169-4-6**] 07:51AM BLOOD WBC-10.6 RBC-4.79 Hgb-14.1 Hct-41.7
MCV-87 MCH-29.4 MCHC-33.8 RDW-13.8 Plt Ct-356
[**2169-4-18**] 12:29AM BLOOD WBC-30.6* RBC-3.74* Hgb-10.9* Hct-32.6*
MCV-87 MCH-29.3 MCHC-33.5 RDW-17.6* Plt Ct-86*
[**2169-4-18**] 12:29AM BLOOD PT-35.9* PTT-94.1* INR(PT)-3.9*
[**2169-4-18**] 12:29AM BLOOD Plt Ct-86*
[**2169-4-6**] 07:51AM BLOOD PT-14.3* PTT-150* INR(PT)-1.3*
[**2169-4-18**] 12:29AM BLOOD Glucose-190* UreaN-39* Creat-2.0* Na-131*
K-5.1 Cl-92* HCO3-17* AnGap-27*
[**2169-4-6**] 07:51AM BLOOD Glucose-105 UreaN-23* Creat-1.5* Na-137
K-4.3 Cl-105 HCO3-20* AnGap-16
[**2169-4-17**] 02:37AM BLOOD ALT-568* AST-384* LD(LDH)-514*
AlkPhos-110 Amylase-17 TotBili-17.0*
[**2169-4-6**] 07:51AM BLOOD ALT-95* AST-75* LD(LDH)-253* AlkPhos-104
TotBili-0.5
[**2169-4-17**] 02:37AM BLOOD Lipase-11
[**2169-4-18**] 12:29AM BLOOD Calcium-7.8* Phos-4.1 Mg-2.1
[**2169-4-6**] 07:51AM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
[**2169-4-16**] 09:17PM BLOOD TSH-0.43
[**2169-4-17**] 09:56AM BLOOD Cortsol-37.6
Cardiology Report ECHO Study Date of [**2169-4-11**]
PATIENT/TEST INFORMATION:
Indication: cabg
Status: Inpatient
Date/Time: [**2169-4-11**] at 10:02
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW595-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.9 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Valve Level: 1.9 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.5 cm (nl <= 2.5 cm)
Aortic Valve - Peak Gradient: 18 mm Hg
Aortic Valve - LVOT Diam: 1.5 cm
Aortic Valve - Valve Area: *0.8 cm2 (nl >= 3.0 cm2)
Mitral Valve - MVA (P [**12-12**] T): 3.1 cm2
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thicknesses and cavity size.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Simple atheroma in aortic
root. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderate AS. Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was under
general anesthesia throughout the procedure.
Conclusions:
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage.
Left ventricular wall thicknesses and cavity size are normal.
Right
ventricular chamber size and free wall motion are normal. There
are simple
atheroma in the aortic root. There are simple atheroma in the
ascending aorta.
There are simple atheroma in the descending thoracic aorta.
There are three
aortic valve leaflets. There is moderate aortic valve stenosis,
with a
gradient of 18 mmHg. Area 0.8 by planimetry, 0.7 by continuity.
Discussed with
surgeons. . Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. There is no
pericardial effusion.
Epi-aortic scan showed isolated atheroma in ascending aorta and
helped in
deciding location of aortic cannula and cross-clamp.
Post- CPB: Preserved biventricular systolic function. 1+ MR,
trace AI. Aorta
intact. Other parameters as pre-bypass.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2169-4-11**] 12:29.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 67044**])
Cardiology Report ECHO Study Date of [**2169-4-11**]
PATIENT/TEST INFORMATION:
Indication: cabg
Status: Inpatient
Date/Time: [**2169-4-11**] at 10:02
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW595-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.9 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Valve Level: 1.9 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.5 cm (nl <= 2.5 cm)
Aortic Valve - Peak Gradient: 18 mm Hg
Aortic Valve - LVOT Diam: 1.5 cm
Aortic Valve - Valve Area: *0.8 cm2 (nl >= 3.0 cm2)
Mitral Valve - MVA (P [**12-12**] T): 3.1 cm2
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thicknesses and cavity size.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Simple atheroma in aortic
root. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderate AS. Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was under
general anesthesia throughout the procedure.
Conclusions:
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage.
Left ventricular wall thicknesses and cavity size are normal.
Right
ventricular chamber size and free wall motion are normal. There
are simple
atheroma in the aortic root. There are simple atheroma in the
ascending aorta.
There are simple atheroma in the descending thoracic aorta.
There are three
aortic valve leaflets. There is moderate aortic valve stenosis,
with a
gradient of 18 mmHg. Area 0.8 by planimetry, 0.7 by continuity.
Discussed with
surgeons. . Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. There is no
pericardial effusion.
Epi-aortic scan showed isolated atheroma in ascending aorta and
helped in
deciding location of aortic cannula and cross-clamp.
Post- CPB: Preserved biventricular systolic function. 1+ MR,
trace AI. Aorta
intact. Other parameters as pre-bypass.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2169-4-11**] 12:29.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 67044**])
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2169-4-12**] 8:51 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: r/o ischemic bowel
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with abd pain RLQ s/p Cardiac cath/R groin,
and flu, w/ Elevated WBC count, and HCT drop
REASON FOR THIS EXAMINATION:
r/o ischemic bowel
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 73-year-old woman with abdominal pain, right lower
quadrant, status post cardiac catheterization and elevated
lactate and white blood cell count. Please evaluate for ischemic
bowel.
COMPARISON: [**2169-4-9**].
TECHNIQUE: Contrast-enhanced axial CT imaging of the abdomen and
pelvis was compared to [**2169-4-9**].
CT ABDOMEN WITH CONTRAST: There are new moderate sized bilateral
pleural effusions with bilateral atelectasis that is moderate in
severity. Patient is status post recent CABG with chest tubes in
the mediastinum. The liver enhances homogeneously. There is a
small amount of ascites. The density of the gallbladder is
increased suggesting sludge. There is minimal pericholecystic
fluid. The common bile duct is not clearly seen but does not
appear dilated. The pancreas, spleen, kidneys, stomach, are
unchanged from [**2169-4-9**]. The small bowel loops are normal
caliber. Examination of the small bowel wall is somewhat limited
secondary to artifact from previous contrast in the colon, but
there is no evidence for pneumatosis or small bowel wall
thickening. There is no portal venous air. A large heterogeneous
retroperitoneal structure representing a hematoma is unchanged
in size from [**2169-4-9**].
CT PELVIS WITH CONTRAST: There is a new ascites in the pelvis.
There is evidence for anasarca throughout the soft tissues.
Evaluation of the large bowel wall is somewhat limited due to
artifact from retained contrast. The bowel is caliber is normal.
Evaluation for pneumatosis and bowel wall thickening is limited.
The distal ureters and bladder are normal. A Foley is present in
the bladder. Air is present throughout the medial and anterior
compartment of the thigh. This is likely secondary to a graft
harvest, but clinical correlation at this site is recommended.
Subcutaneous edema is present in both extremities (right greater
than left).
BONE WINDOWS: The osseous structures are unchanged except for
new sternotomy wires.
IMPRESSION:
1. Moderate bilateral pleural effusions and moderate atelectasis
that is new.
2. New ascites and anasarca.
3. Gallbladder sludge.
4. Evaluation of the bowel wall is limited secondary to contrast
artifact, but there is no portal venous air or obvious bowel
wall thickening to indicate ischemia.
5. Stable right retroperitoneal hematoma.
6. Right thigh gas that is likely secondary to graft harvest,
but clinical correlation recommended.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: [**Doctor First Name **] [**2169-4-13**] 9:44 AM
Brief Hospital Course:
Admitted [**4-5**] and heparin started. Tamiflu continued for URI/?
flu. Cipro continued for UTI. Carotid US showed bilat. ICA <
40% stenoses.Chest CT done [**4-8**] showed an atrophic kidney and
coronary and aortic calcifications.Had nausea and vomiting on
[**4-9**] and vascular consult done to r/o retroperitoneal bleed due
to prior cath. Hct decreased from 38 to 22 and she c/o
abd/back/unilateral LE pain. Pt. also became hypotensive with
SBP in 80's during vasc. exam. Transferred to CSRU for further
management. CT scan showed retroperitoneal bleed. Emergent right
femoral arterial repair done [**4-9**] by Dr. [**Last Name (STitle) **]. Extubated the
following morning. Underwent cabg x5 with Dr. [**Last Name (STitle) 914**] on [**4-11**].
Transferred to the CSRU in stable condition on titrated
phenylephrine and propofol drips. Became hypotensive later that
day and epinephrine and levophed drips started.Milrinone and
insulin drips also started. Acidosis progressively worsened and
distending abdomen with RUQ tenderness prompted an evaluation by
general surgery on [**4-12**]. LFTs also continued to rise.CT scan and
RUQ ultrasound done showing gall bladder edema and sludge,
ascites, and no obvious portal venous air or bowel ischemia.
Dr. [**First Name (STitle) **] elected to take the pt. to the OR for exploratory
laparoscopy to definitively rule out ischemia and a diagnosis of
gangrenous cholecystitis was made. Converted to open
cholecystectomy with significant bleeding due to hepatic
congestion and coagulopathy.Abdomen tense with decreasing urine
output and increasing ventilatory requirements noted the
following morning.She developed atrial flutter/fib and was seen
by the EP service.Abdomen opened at the bedside for
decompression and washout on [**4-13**].She developed right hand and L
leg ischemia on [**4-14**] while on continuing pressor support, and
vasc. surgery re-consulted. On [**4-14**] exploratory lap done by gen.
surgery and partial colectomy done for ischemia. She developed
ATN and thrombocytopenia. Renal and hematology consults done
with diagnosis of DIC and liver failure. IV Amiodarone started
for recurrent arrhythmias per EP. She remained critically ill on
significant pressor support.
Epinephrine drip restarted [**4-16**] for additional support and CVVH
started. Pt. returned to OR for completion right colectomy and
ileostomy on [**4-16**]. She had a brief period of asystole in surgery.
Prognosis grim with multi-system organ failure. She required
increasing pressors and lactic acid rose to 19 on [**4-18**]. She went
into PEA and pacer unable to capture. No resuscitation
performed. Expired at approx. 5:55 AM and pronounced by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Medications on Admission:
protonix 40 mg daily
labetalol 100 ng [**Hospital1 **]
ASA 325 mg daily
lisinopril 20 mg daily
simvastatin 80 mg daily
isosorbide mononitrate 30 mg daily
tamiflu 75 mg [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
CAD s/p CABG x5
NSTEMI
CHF
bowel ischemia s/p colectomy/ileostomy/cholecystectomy
multi-system organ failure
retroperitoneal bleed
DIC
HTN
GERD
gastritis/duodenal ulcer
anemia
elev. lipids
prior MI [**2148**]
Discharge Condition:
expired
Completed by:[**2170-7-18**]
|
[
"518.5",
"557.0",
"414.01",
"997.4",
"997.1",
"286.6",
"584.5",
"276.52",
"285.9",
"427.31",
"410.71",
"442.3",
"575.0",
"427.5",
"570",
"997.2",
"998.0",
"998.11",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"39.31",
"36.15",
"38.93",
"54.25",
"54.12",
"39.61",
"51.22",
"36.14",
"45.73",
"47.19",
"99.04",
"99.07",
"45.79",
"96.72",
"46.20",
"39.95",
"99.05",
"88.72",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
16286, 16295
|
13294, 16051
|
361, 717
|
16548, 16586
|
1864, 2939
|
1436, 1480
|
10345, 10452
|
16316, 16527
|
16077, 16263
|
6586, 10054
|
1495, 1845
|
280, 323
|
10481, 13271
|
745, 1233
|
10089, 10308
|
1255, 1372
|
1388, 1420
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,399
| 175,418
|
47793
|
Discharge summary
|
report
|
Admission Date: [**2138-9-10**] Discharge Date: [**2138-9-25**]
Service: C-MED
HISTORY OF PRESENT ILLNESS: Dr. [**Known lastname **] is a [**Age over 90 **]-year-old
gentleman with a history of coronary artery disease, aortic
insufficiency, atrial fibrillation, asthma, and chronic renal
insufficiency, who was transferred to [**Hospital1 190**] from [**Hospital3 **] following an
episode of respiratory distress.
Four days prior to admission the patient had fallen at home
and was taken to [**Hospital1 **] where hip films
indicated no fracture. He was discharged to [**Hospital3 1761**] short-term unit where he received Tylenol
No. 3 as well as Ambien. On the morning of admission, the
patient became confused, anxious, and dyspneic with a
respiratory rate in the 40s, and oxygen saturation dropping
to 70% on 2 liters; this improved to 95% on a 40% face mask.
The patient was also noted to have recently developed zoster
in the right fifth cranial nerve, ophthalmic division
distribution.
The patient was taken to the Emergency Department at [**Hospital1 **], again, on [**9-10**], which is the date of
admission, where his vital signs were stable; however, his
mental status was still altered. Electrocardiogram indicated
atrial flutter at a rate of 110. He was given Lopressor,
nitroglycerin paste, Levaquin, Lasix, acyclovir, and
Captopril in the Emergency Department with better rate
control. The patient also had lower extremity noninvasive
Doppler studies which were negative. According to the
patient's son, the patient has been agitated and not himself
since admission to the [**Hospital3 **] four days prior
to admission. The patient also has baseline changes of
[**Last Name (un) 6055**]-[**Doctor Last Name **] respiration; however, his baseline mental
status is extremely lucid per the patient's family.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post non-Q-wave
myocardial infarction in [**2116**]; catheterization in [**2124**] with
percutaneous transluminal coronary angioplasty of the left
anterior descending artery; catheterization in [**2130**] with left
main stenting, and multiple cardiac catheterizations in [**2131**]
including a left anterior descending rotablation and stent.
2. Asthma/chronic obstructive pulmonary disease with
restrictive pulmonary function tests and on home oxygen.
3. Pericarditis in [**2135**].
4. Chronic renal insufficiency with a baseline creatinine
of 1.8.
5. Congestive heart failure, 35% ejection fraction.
6. Atrial fibrillation, chronic.
7. Aortic insufficiency.
8. Temporal arteritis.
9. Ascending aortic dilatation, 6.2 cm in [**2133**].
10. Zoster, first noted on [**2138-9-2**], started Valtrex
on [**2138-9-4**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Acyclovir 600 mg p.o. five times
per day times five days, Coumadin 3 mg p.o. q.h.s.,
Lopressor 12.5 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d.,
folate 1 mg p.o. q.d., aspirin 325 mg p.o. q.d.,
Isordil 30 mg p.o. t.i.d., captopril 25 mg p.o. t.i.d.,
co-enzyme Q 100 mg p.o. q.d., vitamin E 400 mg p.o. q.d.,
vitamin C 500 mg p.o. q.d., Tylenol No. 3 p.r.n.,
vitamin B6 100 mg p.o. q.d., vitamin B12 1000 mg p.o. q.d.,
Ambien p.r.n., Milk of Magnesia p.r.n.
SOCIAL HISTORY: The patient is a retired ophthalmologist
from [**State 350**] Eye & Ear Infirmary. He denies smoking or
alcohol use.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: The patient was a
somnolent and arousable elderly gentleman, slightly agitated,
in no acute distress. He was afebrile with a heart rate
of 72, respiratory rate of 24, blood pressure of 170/58,
oxygen saturation 95% on 2.5 liters. HEENT examination
indicated zoster in a cranial nerve V division 1 distribution
on the right. The pupils were equal, round, and reactive to
light. Extraocular muscles were intact. The oral mucosa was
dry. The patient had a right subconjunctival hemorrhage.
The neck was supple with no jugular venous distention. The
chest indicated reduced breath sounds at the bases. No
wheezes, rhonchi or rales. Cardiovascular examination
indicated a regular rhythm, normal S1 and S2. A [**1-4**]
decrescendo diastolic murmur at the right upper sternal
border and a soft systolic murmur at the apex. The abdomen
was soft, with mild diffuse tenderness, without guarding or
rebound. It was not distended. There were normal abdominal
bowel sounds, and no hepatosplenomegaly. The extremity
examination indicated peripheral pulses that were 2+. No
clubbing, cyanosis or edema. On neurologic examination, the
patient was somnolent but arousable, oriented to person,
month, and year only. He had a positive oculocephalic gag
and corneal reflexes, was moving all four extremities.
Reflexes were 1+ and symmetric. Toes were upgoing
bilaterally.
LABORATORY VALUES ON PRESENTATION: Initial laboratory
studies indicated a creatine kinase of 90, MB negative,
troponin of 0.3. Chem-7 with sodium of 140, potassium 5.3,
chloride 110, bicarbonate 28, BUN 72, creatinine 2.1, glucose
of 131. White blood cell count 10.8, hematocrit 36.5,
platelets 175. PT 23.4, PTT 34.8, INR of 3.6. An initial
arterial blood gas indicated a pH of 7.35, PCO2 of 52, and
PO2 of 77.
RADIOLOGY/IMAGING: Chest x-ray indicated stable mediastinal
widening and aortic root dilatation with a tracheal shift to
the right which was old. There were small bilateral pleural
effusions that were unchanged.
Lower extremity noninvasive Doppler studies were negative as
was a urinalysis.
Electrocardiogram #1 indicated atrial flutter at a rate
of 111 with 2:1 conduction, left axis deviation, left
ventricular hypertrophy, Q waves in leads III and aVF, ST
depressions in V4 through V6, and a T wave inversion in I and
aVL.
Electrocardiogram #2 indicated a rate of 72, continued atrial
flutter with persistent electrocardiogram changes.
HOSPITAL COURSE BY SYSTEM: The patient was admitted to the
C-MED Service for rule out of myocardial infarction as well
as for management of altered mental status.
1. CARDIOVASCULAR: The patient was ruled out for myocardial
infarction. He remained in atrial flutter with heparin for
anticoagulation. He was occasionally tachycardic to the low
100s which was treated successfully times two with
intravenous Lopressor.
An echocardiogram indicated mild left ventricular
hypertrophy, moderately decreased left ventricular function,
2+ aortic regurgitation, and 1+ mitral regurgitation, 4+
tricuspid regurgitation, as well as severe cor pulmonale and
severe pulmonary hypertension.
The patient's rate remained stable in the 70s to 80s, in
atrial flutter throughout the remainder of his hospital stay
until the last few hours prior to the patient's expiration.
2. INFECTIOUS DISEASE: An Infectious Disease consultation
was obtained on the first day of hospitalization. Per
Infectious Disease recommendations, the patient had a lumbar
puncture which indicated 45 white blood cells in tube #1, 28
white blood cells in tube #4, and elevated protein at 67,
normal opening pressure, and normal glucose. A VVV PCR from
the patient's cerebrospinal fluid was sent for analysis and
was still pending at the time of the patient's demise;
however, ultimately, the VVV PCR was read as negative.
The patient was started on intravenous acyclovir and
maintained on this throughout his hospital course. An MRI of
the head indicated moderate atrophy, small vessel disease.
No evidence of meningoencephalitis. No hematoma or mass
effect.
3. PULMONARY: The patient continued to exhibit
[**Last Name (un) 6055**]-[**Doctor Last Name **] respiration throughout his hospital course.
Serial blood gases indicated PCO2 in the 70s to 80s; however,
this did not always correlate with the patient's mental
status. Two times over the course of the hospitalization,
the patient was sent to the Medical Intensive Care Unit in
order to receive BiPAP treatment overnight. Each time the
patient was returned to the floor with some improvement in
mental status as well as in PCO2; however, again, the patient
would revert to a waxing and [**Doctor Last Name 688**] mental status with
elevated PCO2. He was also given a course of intravenous
steroids which was later tapered to p.o. steroids, as well as
tried on an aminophyllin drip; however, neither seemed to
effect the patient's pulmonary status. The patient was also
started on levofloxacin and Flagyl to treat possible
aspiration pneumonia; although, a sputum culture ended up
being negative, and the Infectious Disease consultation did
not think the patient had a pneumonia, and these antibiotics
were subsequently discontinued.
4. OPHTHALMOLOGY: The patient was seen by the Ophthalmology
consultation service and was determined not to have zoster
ophthalmicus. Ophthalmology continued to follow him during
his hospital course. He was also started on prophylactic
antibiotic eyedrops.
5. NEUROLOGY: The patient had a head CT on the date of
admission which was negative for mass lesion or bleed.
Neurologically was consulted secondary to the patient's
waxing and [**Doctor Last Name 688**] mental status. A metabolic workup was
initiated which was negative with the exception of an
elevated PCO2, which again did not seem to correlate with the
patient's mental status. Initially, it was thought that the
patient's altered mental status might be secondary to Tylenol
No. 3 and Ambien which he had received at [**Hospital3 1761**]; however, during his course at [**Hospital1 **] the patient received no benzodiazepines or other
sedating medication, and his mental status continued to wax
and wane.
6. DISPOSITION: On hospital day 16, following extended
discussions with the patient's family and his attending
Dr. [**Known lastname **], it was determined that given the patient's likely
poor outcome he should be do not intubate as well as do not
resuscitate.
On hospital day 16, the patient was noted to develop
hypotension with a systolic blood pressure in the 60s as well
as bradycardia. He was continued on nasal CPAP; however, two
hours prior to the initial finding of hypotension and
bradycardia, the patient expired at 1 o'clock in the morning
of [**2138-9-25**]. The patient's family was contact[**Name (NI) **] and
came into the hospital. They declined a postmortem
examination.
DISCHARGE DIAGNOSES:
1. Zoster.
2. Viral encephalitis.
3. Restrictive lung disease.
4. Coronary artery disease.
5. Renal insufficiency.
6. Congestive heart failure.
7. Atrial fibrillation/flutter.
8. Aortic dilatation.
CONDITION AT DISCHARGE: Expired.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2138-10-1**] 00:17
T: [**2138-10-2**] 07:46
JOB#: [**Job Number 100909**]
(cclist)
|
[
"507.0",
"707.0",
"593.9",
"053.0",
"790.92",
"518.84",
"786.04",
"428.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"03.31",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
3406, 3464
|
10374, 10591
|
2797, 3253
|
5941, 10353
|
10606, 10887
|
118, 1841
|
3479, 5913
|
1864, 2770
|
3270, 3389
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,915
| 106,104
|
21708
|
Discharge summary
|
report
|
Admission Date: [**2134-11-11**] Discharge Date: [**2134-11-13**]
Date of Birth: [**2089-1-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
transferred from OSH for hypoxic respiratory failure
Major Surgical or Invasive Procedure:
bronchoscopy;
pulmonary stent adjustment
History of Present Illness:
45yo man with h/o pulmonary polychondritis, s/p L and R main
bronchial stent placement for tracheobrochomalacia on [**11-8**], who
was transferred from an OSH intubated for respiratory support
after presenting with shortness of breath. The pt's symptoms of
PC started in [**12-2**] with dry hacking cough, were misdiagnosed
until the Fall of [**2132**] when he saw Dr. [**Last Name (STitle) 57069**] at [**Hospital1 1774**]. There
he underwent a nondiagnostic bronchial biopsy that failed to
include cartilage in the sample. In [**2-3**], the pt went to see
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 2025**], where review of a prior CT scan revealed
tracheal thickening and narrowing of the mainstem bronchi, R>L.
The pt then went to the [**Hospital3 14659**] to see Dr. [**Last Name (STitle) 57070**] in [**3-4**],
where a biopsy confirmed his diagnosis of PC. He was started on
Prednisone 60mg PO qd, Chlorambucil 2mg qd, Bactrim, and
referred to [**Hospital1 18**] for further management. The pt had rib
fractures from coughing at some point, and was also started on
Forteo for osteoporosis from the steroids. Chlorambucil was
eventually discontinued secondary to elevated LFTs.
The patient underwent fiberoptic bronch on [**10-14**], which showed
40% anterior movement of the posterior tracheal wall during
exhalation, as well as almost complete obstruction of the left
and right main bronchi during exhalation. This indicated severe
brochomalacia. The patient then underwent rigid bronch with
stent placements on [**11-8**], where a 10x40 left main stent and a
10x27 right main stent were placed without complication.
The patient was fine until the DOA when he developed SOB
suddenly at 3am while sleeping. He went to the nearest ER,
where he was found to have an O2 sat 80%, SBP in 90s, HR 170s
with unclear rhythm. He was intubated, placed on SIMV at 750 x
10 with 50% FiO2, 5 PEEP. He received adenosine for his
apparent SVT which broke the rhythm, also 40mg IV lasix with
1500cc urine output, then was transferred to [**Hospital1 18**].
Past Medical History:
pulmonary polychondritis
osteoporosis from chronic steroids
multiple rib fractures from osteoporosis and cough
s/p tonsilectomy
s/p adenoidectomy
R auricular deformity
Social History:
married with two children
disabled [**6-4**] from postal service
tob: smoked cigarettes x 1 year, quit 3y ago
etoh: none since [**2120**], no significant use
drugs: none
Family History:
F - cirrhosis, CVA
M - pancreatic CA
Sis - lymphoma
A - breast CA
Physical Exam:
Vitals: T 98.3 HR 102 BP 108/57 RR 14 O2 sat 99%
on AC mode with TV600 RR14 5 PEEP, 50%FiO2
Gen: NAD, intubated middle-aged man, NGT in place
Skin: wnl
HEENT: PERRL, anicteric sclerae
CV: rrr, nl s1s2, no mgr
Lungs: rhonchorous breath sounds b/l, no wheezing or rales
Abd: soft, nt/nd, +bs
Ext: warm, well-perfused b/l
Neuro: unresponsive, sedated
Pertinent Results:
Labs:
[**2134-11-11**] 01:57PM BLOOD WBC-4.9 RBC-3.79* Hgb-11.8* Hct-34.6*
MCV-91 MCH-31.1 MCHC-34.1 RDW-11.8 Plt Ct-376
[**2134-11-13**] 06:54AM BLOOD WBC-10.8 RBC-3.59* Hgb-11.1* Hct-32.5*
MCV-90 MCH-30.9 MCHC-34.1 RDW-12.2 Plt Ct-341
[**2134-11-13**] 06:54AM BLOOD PT-13.1 PTT-23.7 INR(PT)-1.1
[**2134-11-11**] 01:57PM BLOOD Glucose-157* UreaN-11 Creat-0.6 Na-140
K-5.4* Cl-99 HCO3-32* AnGap-14
[**2134-11-13**] 06:54AM BLOOD Glucose-94 UreaN-15 Creat-0.6 Na-141
K-3.8 Cl-101 HCO3-31* AnGap-13
[**2134-11-11**] 01:57PM BLOOD Albumin-3.7 Calcium-9.5 Phos-4.4 Mg-1.9
[**2134-11-11**] 01:50PM BLOOD Type-ART pO2-90 pCO2-59* pH-7.36
calHCO3-35* Base XS-5 Intubat-INTUBATED
[**2134-11-11**] 06:26PM BLOOD Type-ART Rates-14/ Tidal V-650 FiO2-50
pO2-79* pCO2-48* pH-7.47* calHCO3-36* Base XS-9 -ASSIST/CON
Intubat-INTUBATED
[**2134-11-11**] 01:50PM BLOOD Lactate-2.5*
[**2134-11-11**] 01:50PM BLOOD freeCa-1.26
[**2134-11-11**] 06:55PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.034
[**2134-11-11**] 06:55PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2134-11-11**] 06:55PM URINE RBC-[**6-10**]* WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-0
[**2134-11-11**] 06:55PM URINE AmorphX-MANY
[**2134-11-12**] 03:20AM URINE Hours-RANDOM Creat-150 Na-88
[**2134-11-12**] 03:20AM URINE Osmolal-655
Micro:
[**2134-11-12**] BRONCHIAL WASHINGS
GRAM STAIN (Final [**2134-11-12**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2134-11-14**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
[**2134-11-11**] URINE no growth
Rads:
[**2134-11-13**] Radiology CHEST
The patient has been extubated. Some atelectasis is present at
the left base but no other infiltrates are seen. Cardiac size is
not enlarged. There is no evidence of failure. The right
costophrenic angle is sharp
[**2134-11-11**] Radiology CHEST (PORTABLE AP)
There are no prior studies available for comparison at this
time. There is an ET tube with tip 4 cm above the carina.
Patient reportedly has stents in the main stem bronchi, by
history, however these are difficult to visualize
radiographically. The main stem bronchi appear narrowed, also
seen on prior CT. There is linear and patchy density at the left
base, likely reflecting atelactasis. There are no definite
pleural effusions and there is no CHF. There is an NG tube with
tip below the diaphragm
Brief Hospital Course:
After arriving at [**Hospital1 18**], the patient underwent a flexible
bronchoscopy to examine his airways and stent placements. The
bronch revealed that his right bronchus stent migrated up to his
trachea, such that it was obstructing his left bronchus stent.
The patient was maintained on respiratory support, sedated and
prepared for relocation of his stent. The stent was removed
without incident, he was started on Mucinex and given an
acapella valve, to follow up as an outpatient with the Pulmonary
Service.
Medications on Admission:
MVI
Lidocaine patches to ribs
Bactrim
Prednisone
Oxycodone
Tussinex
Lexapro
Forteo
Discharge Medications:
1. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Resume forteo
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
6. Mucinex DM 30-600 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO twice a day.
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
7. acapella valve
please use as directed by respiratory therapy to loosen
secretions.
8. Tussinex
please continue home use as directed.
9. Oxycodone HCl 40 mg Tablet Sustained Release 12HR Sig: Two
(2) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
10. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q2H (every
2 hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Relapsing Polychondritis, s/p [**Hospital1 **]-bronchial stent placement with
stent migration no s/p stent removal
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as directed. Contact Dr.
[**Name (NI) **] on Monday to arrange follow up appointment for
bronchial stents.
Followup Instructions:
Call Dr. [**Name (NI) **] to arrange follow up appointment on
Monday.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2134-11-29**] 12:00
|
[
"V58.65",
"733.99",
"934.0",
"518.82",
"996.59",
"733.00",
"519.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"98.15",
"33.24",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7528, 7534
|
5956, 6472
|
369, 411
|
7693, 7701
|
3395, 5933
|
7884, 8153
|
2929, 2996
|
6606, 7505
|
7555, 7672
|
6498, 6583
|
7725, 7861
|
3011, 3376
|
277, 331
|
439, 2535
|
2557, 2726
|
2742, 2913
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,511
| 165,998
|
25901
|
Discharge summary
|
report
|
Admission Date: [**2164-9-5**] Discharge Date: [**2164-9-14**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p fall on coumadin
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 85 yo male with complex PMH significant for
cerebrovascular accident x 2 on home coumadin who presents to
[**Hospital1 18**] s/p mechanical fall from standind. He was working in his
front yard when he tripped over a garden hose and fell to the
pavement, striking his abdomen, right hand and his head. No loss
of consciousness. Denies antecedent chest
pain/dyspnea/lightheadedness, but noted increased SOB after
fall. He was brought by EMS to [**Hospital6 5016**] where he was
hemodynamically stable with GCS of 15 and complaining of mild L
abdominal pain. A limited trauma workup was notable for CT scans
demonstrating R orbital floor fracture, maxillary sinus
opacification, free fluid collection around spleen. The patient
was given Vitamin K and transferred to [**Hospital1 18**] via [**Location (un) **].
Past Medical History:
Colon Cancer s/p resection x 2
CVAx2
hypothyroidism
s/p appendectomy
Inguinal hernia repair
Ventral hernia repair
Idiopathic Thrombocytopenic Purpura
Social History:
15+ pack year tobacco, quit 50 years ago
Heavy EtOH, abstinent x 2 years
No IVDU
Former Dye factory worker
Retired
Lives in [**Location 7661**] with wife and daughter
Family History:
Noncontributory
Physical Exam:
74 120/80 16 100% 2LNC
NAD, A+Ox3
Ecchymoses over R orbit, EOMI, PERRL
RRR
CTA B, trachea midline
Abdomen Soft, mildly distended, ,mildly tender
Reducible incisional hernia, Bilaterally reducible inguinal
hernias
Extremities WWP no edema
Sensation x 4, MAE x 4 spontaneously
R wrist in splint, NV intact
Pertinent Results:
[**2164-9-5**] 03:15PM FIBRINOGE-310
[**2164-9-5**] 03:15PM PT-22.4* PTT-27.8 INR(PT)-3.3
[**2164-9-5**] 03:15PM PLT SMR-VERY LOW PLT COUNT-59* LPLT-3+
[**2164-9-5**] 03:15PM WBC-11.3* RBC-2.72* HGB-7.7* HCT-23.0* MCV-85
MCH-28.4 MCHC-33.5 RDW-14.2
[**2164-9-5**] 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-9-5**] 03:15PM AMYLASE-75
[**2164-9-5**] 03:15PM UREA N-50* CREAT-2.9*
[**2164-9-5**] 03:23PM GLUCOSE-193* LACTATE-2.9* NA+-142 K+-5.1
CL--115* TCO2-20*
[**2164-9-5**] 03:23PM GLUCOSE-193* LACTATE-2.9* NA+-142 K+-5.1
CL--115* TCO2-20*
[**2164-9-5**] 03:43PM URINE RBC-[**12-30**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0
[**2164-9-5**] 03:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2164-9-5**] 03:43PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2164-9-5**] 03:43PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2164-9-5**] 03:43PM URINE GR HOLD-HOLD
[**2164-9-5**] 03:43PM URINE HOURS-RANDOM
[**2164-9-5**] 03:43PM URINE HOURS-RANDOM
[**2164-9-5**] 06:28PM PLT COUNT-77*
[**2164-9-5**] 06:28PM HCT-18.8*
[**2164-9-5**] 08:59PM PT-16.1* PTT-20.5* INR(PT)-1.7
XR RIGHT WRIST- Comminuted fracture distal radius with probable
intra-articular extension.
CT HEAD - negative at outside hospital
CT FACIAL - Right inferior orbital wall blow-out fracture with
herniation of fat into the maxillary sinus . No evidence of
herniation of the inferior rectus muscle. Nondisplaced fracture
of the lateral wall of the right maxillary sinus. Probable small
right lamina papyrecea fracture also.
CT CSPINE - Degenerative change within the cervical spine. No
evidence of fracture or malalignment.
CT ABD/PELVIS -Heterogeneously attenuating collection, which
extends from surrounding the spleen in the left upper quadrant
through the mid abdomen and down into the left inguinal canal
consistent with a large intra-abdominal hematoma. No other
significant abnormality identified. An underlying mass cannot be
excluded and a followup study is recommended to assess for
resolution.
[**2164-9-5**] 08:59PM CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-1.8
[**2164-9-5**] 08:59PM CK-MB-3 cTropnT-0.04*
[**2164-9-5**] 08:59PM CK(CPK)-105
Brief Hospital Course:
Patient was admitted to the trauma ICU for further monitoring of
his hematocrit, which trended downward over the inital days of
his stay. His hematocrit stabilized with transfusion of several
units of pRBC over the course of several days. On HD#5 he was
transferred to the floor with stable hematocrits.
On HD#5, the patient was noted to be in atrial fibrillation,
which was rate controlled. Previously in his hospital stay, he
had been in regular sinus rhythm. The patient, his family, and
his primary care doctor [**First Name (Titles) **] [**Name (NI) 653**], and none corroborated a
history of Afib, so it was presumed to be of new onset.
Cardiology was consulted, and reccomended rate control with
lopressor, which was performed. Anticoagulation, although
indicated for this diagnosis, was held due to the patient's
splenic laceration. The patient will follow the question of
whether to be on coumadin with his primary care provider as an
outpatient. Coumadin was held, and he was not discharged on
coumadin.
The patient also experienced a slight bump in his BUN and Cr on
HD#7, which appeared to be prerenal in origin. The patient has
only one kidney, and has a baseline chronic renal failure
(Cr~3.0), and this increased acutely to 3.5. The patient was
volume rescusitated and his renal function was improving. On
discharge, he was almost back to his intake creatinine.
Orthopedics was consulted regarding the R wrist fracture, and
after evaluation, declined urgent/emergent operative repair.
Place patient in wrist splint and reccomended outpatient follow
up once medical condition was stabilized.
Plastic surgery was consulted regarding the facial bone
fractures, and advised delayed operative management until the
patient became symptomatic, or elective repair as outpatient.
The ophthomology service also saw the patient and, as he was
aymptomatic from his orbital floor fractures, reccomended that
the patient follow up in Eye Clinic in 2 weeks for repeat eye
exam.
Medications on Admission:
Coumadin
Levoxyl
Calcitriol
Folate
Terazosin
Prednisone
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
5. 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*
6. 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*
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
1. splenic laceration
2. COmminuted radial head fracture (right)
3. Right inferior orbital wall blow-out fracture
4. Left maxillary sinus fracture
5. New onset Atrial fibrillation
6. Acute on chronic renal failure (resolving)
7. Idiopathic Thrombpocytopenic purpura
8. Hypothyroidism
Discharge Condition:
Stable.
Discharge Instructions:
It is very important that you continue to maintain as much
liquid intake as you can, especially with drinks which are not
plain water. This will help to protect your kidney.
You must speak with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**]
your coumadin medication. It was stopped because of the bleeding
you had in your abdomen.
Take care not to cause any further trauma to your left side for
at least 6 months, because you are at an elevated risk of having
your spleen bleed again over this time.
Call or come back to the emergency department if you have any of
the following: fevers, chills, mental status changes, chest
pain, increasing shortness of breath, abdominal pain,
lightheadedness or any other symptom which
Followup Instructions:
1. Follow up with Trauma clinic in 2 weeks. Call 1-[**Telephone/Fax (1) 2359**]
for appointment.
2. Follow up with Dr. [**Last Name (STitle) **] (orthopedics) for wrist fractures in 1
week. Call ([**Telephone/Fax (1) 8746**] for an appointment.
3. Follow up with plastic surgery clinic in 2 weeks regarding
your facial bone fractures. Call ([**Telephone/Fax (1) 23144**] for an
appointment.
4. Follow up with your primary care provider regarding your
[**Name9 (PRE) 64409**] atrial fibrillation and anticoagulation in 1 week.
Call his office for an appointment.
5. Follow up with [**Hospital **] clinic in 1 week. Call ([**Telephone/Fax (1) 7572**] for an appointment.
|
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"V10.05",
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icd9cm
|
[
[
[]
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[
"99.05",
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icd9pcs
|
[
[
[]
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7281, 7328
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4230, 6213
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281, 288
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7656, 7665
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1875, 4207
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316, 1140
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,178
| 145,273
|
5450
|
Discharge summary
|
report
|
Admission Date: [**2112-12-29**] Discharge Date: [**2113-1-5**]
Date of Birth: [**2052-9-3**] Sex: M
Service: MEDICINE
Allergies:
Plavix / Roxicet
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
OSH transfer for possible cath
Major Surgical or Invasive Procedure:
Left heart catheterization with selective coronary angiography.
Ablation.
History of Present Illness:
60M with CAD s/p Omnilink bare metal stent to mid-RCA [**2-6**], EF
32%. Presented this afternoon to [**Hospital6 19155**] after
two episodes CP overnight (3:30am, 5am). Took 1 SL NTG for each
with resolution of his symptoms, and went to the ER. In the ER,
VSS: T 98.0F, BP 125/85 HR 77, RR 20, SaO2 97% RA. He was given
lopressor 2.5mg IV. Initial OSH labs were significant for CK
312(4), trop 0.01. Hct 52.4, plt 319, INR 1.3 (on coumadin), K
3.9, gluc 106. Transferred to [**Hospital1 18**] by Dr. [**Last Name (STitle) **] for
possible cardiac catheterization.
.
On arrival to [**Hospital1 18**], he stated that he has not had additional
episodes of chest pain since this am. He usually has episodes
about every 2 weeks but the episodes have been more frequent
over the past week and has had three other episodes this past
week. His chest pain awoke him from sleep at 3:30 and then 5:00
this am and he described the pain as radiating across his chest.
He also had "the sweats" at the time and felt dizzy. Each
episode lasted 10 minutes and was relieved by NTG.
.
Note: Approx. 1 hour after arriving to the floor, he began to
flip in and out of VT. His blood pressure was stable throughout
the episode and he appeared to flip out with valsalva but
immediately went back in. The episodes lasted 30 seconds to 1
mins. Amio bolus and drip was started and the runs of VT stopped
but he continued to have ectopy. He was asymptomatic throughout,
although scared.
.
ROS: No PND, +/- orthopnea (doesn't like to sleep flat) but
hasn't increased the number of pillows. No f/c/n/v. No abd
pain/const/diarrhea. No dysuria. No cold sx.
Past Medical History:
CAD: s/p MI
CHF: EF 32% on [**2-6**] cath
AF s/p CV [**6-8**]. [**12-20**] INR 1.9, coumadin switched to 4mg MWF, 5mg
other nights.
Hypertension
Hyperlipidemia
OSA (he denies, no snoring)
BPH s/p prostate resection
h/o LE superficial thrombophlebitis
.
PSurgH:
Prostate resection
Double Hernia repair
Social History:
Currently smokes 2.5 ppd X 24 yrs. Denies EtOH or illicit drug
use. Lives with wife and brother-in-law. Now retired but last
worked at the [**Holiday **] Tree Shop. Lives a sedentary lifestyle.
Family History:
Father died of cirrhosis [**1-6**] EtOH. Mom an [**Name2 (NI) 22078**] who had
CHF. Brother died of a brain aneurysm.
Physical Exam:
Vitals: T: 95.5 P: 74 BP: 97/56 R: 15 SaO2: 97% on 3L
General: Dishevelled; obese. Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, very poor dentition
Neck: supple, no JVD appreciated, no carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: irreg irreg, nl. S1S2, no M/R/G noted
Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: bilat LE edema 1+ to mid shins, 2+ radial and DP
pulses bilaterally. PT pulses non-palpable
Lymphatics: No cervical, supraclavicular lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-strength 5/5 in upper and lower extremities bilaterally
Pertinent Results:
[**2112-12-29**] EKG: Atrial fibrillation. Left anterior fascicular
block. Poor R wave progression could be due to left anterior
fascicular block but also consider old anterior wall myocardial
infarction. T wave inversions in leads V4-V6 suggest myocardial
ischemia.
.
[**2112-12-30**] CATH: COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
patent LMCA, minimal disease in the LAD and LCX vessels and
widely
patent RCA stent with 30% lesion distal to the stent.
2. Left ventriculography showed a moderatedly depressed ejection
fraction of 37% with global hypokinesis.
3. Limited hemodynamic assessment showed normal systemic aortic
pressure
and LVEDP.
.
[**2112-12-31**] TTE: IMPRESSION: Regional left ventricular systolic
dysfunction with EF 30-35% and moderate to severe regional left
ventricular systolic dysfunction with septal, anterior, and
inferior hypokinesis. Moderate symmetric LVH with mildly dilated
LV cavity. Elevated LV filling pressure. Mild mitral
regurgitation.
.
[**2113-1-2**] TEE:
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. LV systolic function appears depressed. Regional left
ventricular dysfunction is present with basal-to-mid inferior
hypokinesis. There are simple atheroma in the aortic arch and
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: No left atrial or left atrial appendage thrombus.
Mild mitral
regurgitation.
Compared with the report of the prior TEE study (images
reviewed) of [**2111-6-10**], trace aortic regurgitation is now seen.
.
[**2113-1-2**] CXR:
An endotracheal tube is positioned 5 cm above the carina. There
is a new dense air space consolidation involving the left lower
lung zone. Fullness in bilateral hila is concerning for
underlying adenopathy. The right lung is clear. The
surrounding soft tissues are unchanged.
IMPRESSION:
1. Endotracheal tube in good position at the thoracic inlet.
2. New left lower lung dense airspace consolidation, concerning
for
pneumonia. Follow-up status post treatment to exclude an
underlying mass
lesion.
.
[**2113-1-2**] CXR:
Since [**1-2**], trachea has been extubated. Lung volumes are
normal. Lungs are now clear. Previous opacification in the
left upper lobe is due to atelectasis. Mild cardiomegaly is
longstanding, probably unchanged since [**2110-11-5**]. No
pleural effusion.
.
Labs:
[**2112-12-29**] 09:32PM BLOOD WBC-10.1 RBC-5.28 Hgb-16.3 Hct-47.7
MCV-91 MCH-30.8 MCHC-34.1 RDW-13.2 Plt Ct-300
[**2113-1-5**] 08:00AM BLOOD WBC-9.8 RBC-4.54* Hgb-14.5 Hct-41.5
MCV-91 MCH-31.9 MCHC-34.9 RDW-13.2 Plt Ct-244
[**2112-12-29**] 09:32PM BLOOD PT-14.7* PTT-25.5 INR(PT)-1.3*
[**2113-1-5**] 08:00AM BLOOD PT-14.5* PTT-86.5* INR(PT)-1.3*
[**2112-12-29**] 09:32PM BLOOD Glucose-136* UreaN-14 Creat-1.0 Na-139
K-3.9 Cl-106 HCO3-22 AnGap-15
[**2113-1-5**] 08:00AM BLOOD Glucose-142* UreaN-11 Creat-1.0 Na-139
K-3.9 Cl-104 HCO3-26 AnGap-13
[**2113-1-5**] 08:00AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.2
.
Cardiac enzymes:
[**2112-12-29**] 09:32PM BLOOD CK(CPK)-233*
[**2112-12-30**] 01:48AM BLOOD CK(CPK)-187*
[**2112-12-31**] 01:45AM BLOOD CK(CPK)-154
[**2112-12-31**] 05:44AM BLOOD CK(CPK)-139
[**2112-12-29**] 09:32PM BLOOD CK-MB-4 cTropnT-<0.01
[**2112-12-30**] 01:48AM BLOOD CK-MB-4 cTropnT-<0.01
[**2112-12-31**] 01:45AM BLOOD CK-MB-3
[**2112-12-31**] 05:44AM BLOOD CK-MB-3
Brief Hospital Course:
Mr. [**Known lastname 22079**] is a 60 year old male with a history of CAD,
ischemic cardiomyopathy (EF 37% 07/05), HTN, afib who presented
with chest pain concerning for unstable angina. While being
admitted to the floor, he had several episodes of asymptomatic
sustained ventricular tachycardia and was transferred to CCU
care.
.
#) Cardiac:
RHYTHM:
a) Sustained asymptomatic VT: Monomorphic VT with an uncertain
etiology but ddx included significant structural heart disease
(eg, coronary heart disease with prior myocardial infarction,
dilated cardiomyopathy, or hypertrophic cardiomyopathy). Patient
describes several episodes of CP with dizziness leading up to
hospitalization, and of note, his lisinopril was recently
discontinued secondary to dizziness and what was thought to be
hypotension. Concern that this could have been episodes of
arrythmias as well.
.
Most likely the etiology is from ischemic scar with ectopic
foci. He was initially loaded with amiodarone which broke the
rhythm and then maintained on a lidocaine drip (shorter
half-life to allow for EP studies). He was taken to the cath
lab and found to have mild CAD with a patent stent. He was next
scheduled for an EP study and possible ablation of ectopic foci.
During lidocaine wean the patient continued to have self
limited episodes of asymptomatic VT. During the EP study, VT of
two morphologies were triggered, originating in the left
coronary cusp and right mid-septum. There was successful
ablation of the VT originating in the left coronary cusp. There
was no inducible VT at the termination of the procedure. The
patient was administered amiodarone. During the procedure, the
patient needed to be intubated due to agitation/thrashing. He
was extubated in the morning after the procedure without
complication.
.
b) afib: He was on Coumadin as outpatient for afib although he
was subtherapeutic on admission. He was maintained on a heparin
gtt to allow for procedures while in house. Before his EP
study, a TTE was preformed and was negative for a clot. He was
on diltiazem at home for rate control. This was held in house
given his low blood pressures (80-120 systolic) and controlled
rates in the 70's (was continued on metoprolol).
.
ISCHEMIA: known CAD from cath in [**2110**] with bare metal stent to
RCA. He was originally referred for catheterization and on
[**2112-12-30**] his cath showed LAD min dz, LCx min dz, RCA widely
patent, 30% lesion distal to stent. He was continued on
aspirin, metoprolol and a statin.
.
PUMP: LVEF now 37% with regional hypokinesis based on TTE. He
was euvolemic during admission. He was continued on his
metoprolol. He was not restarted on his ACEI (lisinopril) as it
was recently held secondary to his lightheadedness which was
attributed to hypotension (but may have been arrhythmia
associated). Can consider reinstating ACEI if SBP can tolerate.
.
#) Prophylaxis: PPI, heparin gtt, bowel regimen
.
#) smoking cessation: nicotine patch and counseling done
.
#) FEN: heart healthy diet; low sodium. replete electrolytes prn
.
#) Access: PIVs
.
#) Code Status: Full
Medications on Admission:
All: Roxicet? rash (patient unsure, states his allergy is to
plavix- stopped ~1week after starting [**1-6**] rash on arms, itchy,
no edema)
.
Meds:
Aspirin 325 mg PO qD
Plavix 75 mg PO qD (denies taking and says he has an allergy
which causes a skin rash)
Diltiazem 120 mg PO qD
Coumadin 4 mg MWF, 5mg all other nights.
Toprol XL 25 mg PO qD
Crestor 10 mg PO qD
Mucinex
Note: Lisinopril recently d/c'ed [**1-6**] low BP. Gemfibrozil d/c'ed
[**1-6**] CK increase and good lipids. Crestor dose cut to 10mg PO qD
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-6**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*QS * Refills:*0*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
INR check. Also check Chem 10, LFTs, TSH, PFTs
Please foward results to PCP [**Name9 (PRE) **],[**First Name8 (NamePattern2) 1141**] [**Last Name (NamePattern1) 2671**]
[**Telephone/Fax (1) 4775**]. PLease also forward results to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], ([**Telephone/Fax (1) 22080**]
7. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: one and a
half Tablet Sustained Release 24HR PO once a day.
Disp:*45 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
Continue to have your INR level checked.
Disp:*90 Tablet(s)* Refills:*2*
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia.
.
Coronary artery disease, atrial fibrilation, hypertension,
hyperlipidemia, benign prostatic hypertrophy.
Discharge Condition:
Good, ambulatory, respiratory status stable
Discharge Instructions:
Please take all medications as prescribed. Please stop taking
diltiazem. Your toprol XL dose has been increased to 150mg by
mouth once daily. You will also be taking a new medication
called amiodarone. Take 400mg by mouth TWICE daily FOR ONE
WEEK, then take amiodarone 200mg by mouth ONCE DAILY.
.
Please keep all follow-up appointments. Please notify your
primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3306**], ([**Telephone/Fax (1) 22081**], or return to the Emergency room if you have chest
pain, shortness of breath, nausea, vomitting, palpitations,
light headedness, fainting, or any other symptoms that concern
you.
.
Continue to eat a low sodium low fat diet. Continue to refrain
from smoking.
.
Please follow the instructions given to you about your "[**Doctor Last Name **] of
hearts" heart monitor.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3306**] on [**1-12**], [**2112**] at 10:30 am. Please call ([**Telephone/Fax (1) 3346**] if questions
regarding this appointment. It is very important to have your
labs tested at this visit especially your INR for the coumadin
dose.
.
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2113-1-17**]
at 1:40pm. Please call ([**Telephone/Fax (1) 22080**] if questions regarding
this appointment.
.
Please continue to have your INR (coumadin) level checked
regularly. You should go to [**Hospital3 **] (where you usually
have your INR checked) in the next 1-3 days. Phone [**Telephone/Fax (1) 22082**]
|
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icd9cm
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icd9pcs
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3388, 3452
|
2061, 2364
|
2380, 2575
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,180
| 156,018
|
31385
|
Discharge summary
|
report
|
Admission Date: [**2171-7-18**] Discharge Date: [**2171-8-16**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Ms. [**Known lastname 9063**] is an 84F with a suspicious RUL nodule who presented
to [**Hospital1 18**] for further evaluation and treatment.
Major Surgical or Invasive Procedure:
1. Flexible bronchoscopy and right thoracoscopy
2. Right thoracotomy and right upper lobectomy, mediastinal
lymph node dissection
3. Serial bronchoscopies for pulmonary toilet
4. Picc line placement
Flexible bronchoscopy and right thoracoscopy, right thoracotomy
and right upper lobectomy, mediastinal lymph node dissection
serial bronchoscopies for pulmonary toilet
Picc line placement
History of Present Illness:
Ms. [**Known lastname 9063**] is an 84F with a suspicious dominant right upper lobe
mass, which is just over 3cm. Her mediastinal staging is
negative. The smaller smooth bordered nodules in the left lower
lobe were indeterminate, but bear further watching on followup
CT scanning. Her pulmonary function test today does show some
degree of impairment of her lung function consistent with her
emphysema. Her DLCO is most concerning with only 43% of
predicted value. She appears to have some likelihood of
respiratory failure or worsening oxygen requirement following
this operation. Dr. [**Last Name (STitle) **] discussed this at length with
Ms. [**Known lastname 9063**] and her family and they agree to proceed with the
operation.
Past Medical History:
1. s/p diagnostic bronch and med ([**7-10**])
2. COPD
3. Hypothyroidism
4. GERD
5. s/p hip replacements '[**34**], '[**35**], '[**54**], '[**55**]
6. s/p CCY
7. throat cancer s/p local radiation '[**61**]
Social History:
A 35-pack-year ex-smoker, discontinued in [**2154**]. Retired nanny
and homemaker. She lives with her husband. Denies alcohol use
or exposure history.
Family History:
Mother had a brain tumor. Her father had heart failure. She
has a sister with ovarian cancer, and she has three healthy
children.
Physical Exam:
PHYSICAL EXAMINATION: ON ADMISSION [**2171-7-18**]
VITAL SIGNS: Temperature 96.9, pulse 79, blood pressure 137/69,
respiratory rate 18, oxygen saturation 95% on room air.
GENERAL: Well-nourished, well-developed elderly woman in no
apparent distress.
NECK: The neck incision is clean, dry, and intact and healing
well without fluctuance, purulence, or erythema.
LUNGS: Distant breath sounds with some coarse left lower lung
field and right upper lung field rales.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nontender, and nondistended.
PHYSICAL EXAMINATION: ON DISCHARGE [**2171-8-16**]
Gen: no acute distress
CV: RRR, no murmurs
Pulm: distant coars breath sounds in the R lung fields, clear
breath sounds in the L lung fields
Abd: soft, nontender, nondistended
Pertinent Results:
PICC XRAY [**2171-8-14**]
Uncomplicated ultrasound of fluoroscopically-guided single lumen
PICC line placement via the right brachial venous approach.
Final internal length is 34 cm, with the tip positioned in the
SVC. The line is ready to use.
CXR
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman s/p RUL lobectomy, now s/p bronchoscopy and
PEG, repeat bronchoscopy for right lung collapse done.
REASON FOR THIS EXAMINATION:
Evaluate interval change
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Followup right lung collapse, s/p right upper
lobectomy.
Comparison is made with multiple prior studies including most
recent one performed a day before at 1540 hours.
There is complete white-out of the right hemithorax consistent
with total collapse of the remaining right lung. Patient has
known loculated right pleural effusion. There has been interval
increase in shifting of the cardiomediastinum towards the right
side, otherwise no changes in interstitial opacities in the left
lung due to pulmonary edema.
PATHOLOGY
1. Lung right upper lobe, wedge resection (A-F):
Squamous cell carcinoma, poorly differentiated, see synoptic
report.
2. L10 (G-H):
Lymph node(s) with non-necrotizing granulomas; no malignancy
identified.
3. L12 (I):
One lymph node with non-necrotizing granulomas; no malignancy
identified.
4. L11 (J):
Lymph node(s); no malignancy identified.
5. Right upper lobe (K-Q):
No malignancy identified.
Specimen Type: Lobectomy.
Laterality: Right.
Tumor Site: Upper lobe.
Tumor Size
Greatest dimension: 2.5 cm.
MICROSCOPIC
Histologic Type: Squamous cell carcinoma.
Histologic Grade: G3: Poorly differentiated.
EXTENT OF INVASION
Primary Tumor: pT1: Tumor 3 cm or less in greatest dimension,
surrounded by lung or visceral pleura, without bronchoscopic
evidence of invasion more proximal than the lobar bronchus (ie,
not in the main bronchus).
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Margins uninvolved by invasive carcinoma.
Venous invasion (V): Absent.
Comments: Lymph node with non-necrotizing granulomas. Special
stains will be issued in an addendum.
ADDENDUM:
Stains for fungi and acid fast bacilli are negative with
satisfactory controls.
Brief Hospital Course:
Pt was admitted and taken to the OR on [**2171-7-19**] for Flexible
bronchoscopy and right thoracoscopy, right thoracotomy, right
upper lobectomy, and mediastinal lymph node dissection
complicated by an avulsion injury to the posterior recurrent
branch of the pulmonary artery which was repaired. Post
operatively, pt was admitted to the SICU for hemodynamic
monitoring which stabilized quickly.
The pt's initial post operative course was complicated by
ongoing respiratory compromise requiring re-intubation x2, BIPAP
support and pulmonary tiolet via almost daily bronchoscopies for
pulmonary tiolet. She had several mucus plugs that were removed
by bronchoscopy, and her BAL grew out pseudomonas; ID was
consulted and continued to follow the pt thru-out her hospital
course. Presently she is on vancomycin and meropenem (started
[**8-11**] x 7days).
She had intermittant confusion and occasionally refused
interventions. She was seen by psychiatry and her family and
health care proxy (daughter [**Name2 (NI) **]) were responsible for
treatment decisions when pt was unable.
An open J-tube was placed [**8-9**] for feeding after pt failed
bedside and video swallow. Since this surgery, pt has had a
complete white out of her right lung which has required daily
bronchoscopies and aggressive pulmonary toilet with little to no
improvement on CXR. Her oxygen sats are currently 95% on 4
liters. Pt has refused intubation and requested to be made DNI.
Her family was in agreement with her decision.
On [**2171-8-15**] she received a R US-guided chest tap by
interventional pulmonology which yielded no fluid. Her and her
family are in agreement to discharge her to a rehabilitation
facility. She is currently tolerating tube feeds via her
J-tube.
Medications on Admission:
1. Zantac 300mg
2. Synthroid 25mcg
3. Spiriva 18mg
4. Dorzolamide (L eye [**Hospital1 **])
Discharge Medications:
1. Dorzolamide 2 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: [**11-27**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Ibuprofen 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8
hours) as needed: elixir via j-tube.
6. Acetaminophen 650 mg Suppository [**Hospital1 **]: [**11-27**] Suppositorys Rectal
Q6H (every 6 hours) as needed.
7. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
8. Levothyroxine 25 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily): via j-tube.
9. Potassium Iodide 1 g/mL Solution [**Month/Day (2) **]: 0.4 ML PO QID (4 times
a day).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): via j-tube.
11. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Last Name (STitle) **]: One (1) gm
Intravenous Q 24H (Every 24 Hours) for 7 days: Started [**8-11**].
12. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Year (2) **]: 4-8 mg
Injection Q8H (every 8 hours) as needed for nausea.
13. Paroxetine HCl 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily): via j-tube.
14. Aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily):
via j-tube.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Year (2) **]: One (1)
Inhalation Q2H (every 2 hours) as needed.
17. Acetylcysteine 10 % (100 mg/mL) Solution [**Month/Year (2) **]: One (1) ML
Miscellaneous every 4-6 hours as needed: mix w/ albuterol.
18. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO BID (2
times a day): via j-tube.
19. Tobramycin 300 mg/5 mL Solution for Nebulization [**Month/Year (2) **]: Three
Hundred (300) mg Inhalation [**Hospital1 **] (2 times a day).
20. Meropenem 500 mg Recon Soln [**Hospital1 **]: Five Hundred (500) mg
Intravenous Q8H (every 8 hours) for 7 days: Started [**8-11**].
21. Hydromorphone 2 mg/mL Syringe [**Month/Year (2) **]: .25 Injection Q4H (every
4 hours) as needed for pain.
22. picc line
picc line flush per protocol
23. regular insulin
regular insulin per sliding scale finger stick every 6 hours
while on tube feed
24. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Right upper lobe lesion s/p RUL lobectomy
2. COPD
3. Hypothyroidism
4. GERD
5. Glaucoma left eye
6. Throat cancer s/p local radiation treatment [**2161**]
7. status post hip replacement
8. status post cholecystectomy
9. Ventilator associated pneumonia
Discharge Condition:
Deconditioned and requires pulmonary rehab
Discharge Instructions:
Strict NPO: Aspiration precautions
Conintinue aggressive Pulmonary toileting
Tube feeding and tube site care
Flush feeding tube with 50cc water q8hrs
Continue antibiotics until [**8-18**]
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**12-29**] weeks. Call his office at
([**Telephone/Fax (1) 1504**] to schedule your appointment.
|
[
"162.3",
"458.29",
"512.1",
"998.2",
"482.1",
"496",
"934.8",
"V15.82",
"365.9",
"999.9",
"244.9",
"998.11",
"V43.64",
"V15.3",
"V10.21",
"787.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"96.56",
"34.91",
"43.11",
"99.04",
"38.93",
"33.22",
"40.3",
"96.6",
"39.31",
"34.21",
"32.4"
] |
icd9pcs
|
[
[
[]
]
] |
10024, 10096
|
5237, 6990
|
411, 801
|
10395, 10440
|
2924, 3174
|
10677, 10827
|
1984, 2117
|
7131, 10001
|
3211, 3328
|
10117, 10374
|
7016, 7108
|
10464, 10654
|
2132, 2132
|
2700, 2905
|
229, 373
|
3357, 5214
|
829, 1569
|
1591, 1797
|
1813, 1968
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,615
| 172,441
|
54691
|
Discharge summary
|
report
|
Admission Date: [**2152-8-23**] Discharge Date: [**2152-8-30**]
Date of Birth: [**2087-3-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Multivessel coronary artery disease.
Major Surgical or Invasive Procedure:
[**2152-8-23**] Coronary artery bypass grafting x3, left internal
mammary artery to left anterior descending artery, bypass
from the ascending aorta to the obtuse marginal branch of the
circumflex artery using reverse autologous saphenous vein
graft, bypass from the ascending aorta to the posterior
lateral branch of the right coronary artery using reverse
autologous saphenous vein graft.
History of Present Illness:
Mr. [**Known lastname 10919**] is a 65 M with h/o HTN, Hyperlipidemia, and smoking
history hre with
recent cardiac cath showing significant 3 vessel disease.
Patient's only symptoms thus far have been DOE over the past few
years and claudication symptoms in his thighs and calves. He is
scheduled to undergo a left TKR in [**2152-10-7**], had a positive
cardiac stress test, and underwent a cardiac cath today. We
have been consulted for possible surgical evaluation.
Past Medical History:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Sleep Apnea(was on C-PAP-pt has not used for 10 yrs)
Emphysema
Osteoarthritis
PSH:
Tonsillectomy
Left rotator cuff repair six years ago
Two lumbar spinal surgeries 10-12 years ago
Bilateral knee surgeries x3(each)
CCY
Social History:
Race: Caucasian
Lives with: Patient lives with his wife and has four adult
children
Contact: [**Name (NI) **] [**Name (NI) 10919**] (wife) cell# [**Telephone/Fax (1) 111838**]
Occupation: unemployed
Cigarettes: Smoked no [] yes [] last cigarette _____ Hx:
Other Tobacco use: 10 cigars/day X 20 years
ETOH: < 1 drink/week [x] [**3-14**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
Non-contributory
Physical Exam:
Pulse: 56 Resp: 18 O2 sat: 95%
B/P Right: 131/88 Left:
Height: Weight:
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema [] _____
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: P Left: P
DP Right: P Left:P
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: P Left: P
Carotid Bruit None heard
Pertinent Results:
[**2152-8-23**] Intra-op TEE:
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Dr.[**First Name (STitle) **] was notified in person of the results before surgical
incision.
Post_Bypass:
Preserved biventricular systolic function.
LVEF 55%.
Intact thoracic aorta.
No new valvular findings.
.
[**2152-8-29**] 05:20AM BLOOD WBC-10.8 RBC-4.41* Hgb-13.5* Hct-38.5*
MCV-87 MCH-30.6 MCHC-35.1* RDW-14.4 Plt Ct-263
[**2152-8-30**] 08:40AM BLOOD PT-24.9* INR(PT)-2.4*
[**2152-8-29**] 09:00AM BLOOD PT-23.9* INR(PT)-2.3*
[**2152-8-28**] 05:45AM BLOOD PT-17.3* INR(PT)-1.6*
[**2152-8-27**] 07:34AM BLOOD PT-20.3* INR(PT)-1.9*
[**2152-8-29**] 05:20AM BLOOD Glucose-134* UreaN-23* Creat-1.0 Na-140
K-3.6 Cl-102 HCO3-28 AnGap-14
[**2152-8-29**] 05:20AM BLOOD Mg-2.1
[**8-28**] PA& LAT
PA AND LATERAL CHEST X-RAY
FINDINGS:
There is stable bilateral small pleural effusion, more prominent
on the left
side. There is no pneumothorax. Mild cardiac enlargement is
stable. There
is no pulmonary edema.
CONCLUSION:
There is no significant change since the previous exam.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] SOM [**Doctor First Name **] LE
Brief Hospital Course:
The patient was brought to the Operating Room on [**2152-8-23**] where
the patient underwent CABG x 3 with Dr. [**First Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. Plavix was
started for poor targets. AFib developed and amiodarone was
initiated and anticoaulation started. He transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. Sternal drainage
developed which prolonged his post-op course. He was started on
vanco, his sternal culture was negative, he remained afebrile
and WBC stable. The drainage subsided and was minimal at the
time of discharge. He was transitioned to PO Keflex for one
week. Coumadin was started for AFib and plavix was dc'd. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD#7 the patient was ambulating freely, the wound was
healing with minimal drainage and pain was controlled with oral
analgesics. The patient was discharged in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Atenolol 25 mg PO DAILY
2. ergocalciferol (vitamin D2) *NF* 50,000 unit Oral QFRi
3. Ibuprofen 800 mg PO Q8H:PRN pain
4. Lisinopril 10 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Aspirin EC 162 mg PO DAILY
7. Vitamin D [**2140**] UNIT PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO BID
RX *lisinopril 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
2. Acetaminophen 650 mg PO Q4H:PRN pain
3. Docusate Sodium 100 mg PO BID
4. Furosemide 40 mg PO DAILY Duration: 4 Days
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
5. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *Dilaudid 2 mg 1 tablet(s) by mouth every six (6) hours PRN
Disp #*40 Tablet Refills:*0
6. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *Lopressor 50 mg 1.5 (One and a half) tablet(s) by mouth
twice a day Disp #*90 Tablet Refills:*2
7. Potassium Chloride 40 mEq PO DAILY Duration: 4 Days
start [**2152-8-29**]
Hold for K+ > 4.5
RX *Klor-Con 20 mEq 40 Meq by mouth once a day Disp #*8 Tablet
Refills:*0
8. ergocalciferol (vitamin D2) *NF* 50,000 unit Oral QFRi
9. Simvastatin 10 mg PO DAILY
increase back to 20mg daily once amiodarone dc'd
RX *simvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
10. Amiodarone 400 mg PO BID
take 400mg [**Hospital1 **] x 1 week then decrease to 400mg daily x 1 week
then 200mg daily until seen by cardiologist
RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*1
11. Ranitidine 150 mg PO DAILY
12. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
friday
13. Warfarin MD to order daily dose PO DAILY16
14. Cephalexin 500 mg PO Q6H Duration: 1 Weeks
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Sleep Apnea(was on C-PAP-pt has not used for 10 yrs)
Emphysema
Osteoarthritis
PSH:
Tonsillectomy
Left rotator cuff repair six years ago
Two lumbar spinal surgeries 10-12 years ago
Bilateral knee surgeries x3(each)
CCY
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming, and look at your incisions
NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Name (NI) **] [**Telephone/Fax (1) 170**] [**2152-9-26**] at 2:15p in the
[**Hospital **] Medical Building [**Last Name (NamePattern1) **] [**Apartment Address(1) **] A
Wound care appointment [**Telephone/Fax (1) 170**] [**2152-9-7**] 10:00 in the [**Hospital **]
Medical Building [**Last Name (NamePattern1) **] [**Apartment Address(1) **] A
Cardiologist Dr. [**Last Name (STitle) 1911**] [**2152-9-6**] at 4:40p
Please call to schedule the following appointment with:
Primary Care Dr. [**Last Name (STitle) 17029**] [**Telephone/Fax (1) 17030**] in [**5-11**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Daily PT/INR, INR goal 2.5
Coumadin to be managed by Dr. [**Last Name (STitle) 17029**] #[**Telephone/Fax (1) 17030**]
Next INR draw [**8-31**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2152-8-30**]
|
[
"427.31",
"998.89",
"V45.89",
"414.01",
"327.23",
"272.4",
"492.8",
"V15.82",
"E878.2",
"997.1",
"V85.31",
"715.90",
"278.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
8043, 8092
|
4554, 6057
|
347, 740
|
8407, 8575
|
2622, 4531
|
9349, 10414
|
1956, 1974
|
6457, 8020
|
8113, 8386
|
6083, 6434
|
8599, 9326
|
1989, 2603
|
270, 309
|
768, 1239
|
1261, 1533
|
1549, 1940
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,012
| 126,266
|
5463
|
Discharge summary
|
report
|
Admission Date: [**2135-7-3**] Discharge Date: [**2135-7-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6578**]
Chief Complaint:
fever, lethargy, new onset rapid afib/aflutter
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]yoF NH resident with h/o CHF (EF 35%), s/p CVA (L
hemiparesis), HTN, PVD, recent SBE (staph hominis), dementia
presents from [**Hospital1 5595**] today with increasing lethargy, decreased
responsiveness, fever 100.6 and new onset rapid Afib/flutter. Pt
was given digoxin 0.5mg for loading dose, started on D51/2NS. Pt
also noted to have FSBG in 800s with no prior hx of diabetes.
Sent in to [**Hospital1 18**] for further mngmt. In [**Name (NI) **], pt noted to have temp
101.8, Na 156, glucose 734, Cr 1.5, lactate of 6.3, WBC 20.1 (L
shift), UA with signs of UTI. Given ceftaz x1 in ED, started on
insulin gtt and given 1L NS with 40meq KCl. Head CT and CXR neg.
Sent to [**Hospital Unit Name 153**] for further care. Goals d/w family and on-call
geriatrics fellow. No invasive procedures, DNR/DNI.
In the [**Name (NI) 153**] pt was on insulin gtt for >24h (stopped [**7-4**] around
10am). Changed to SSI, with which she has had occasional
hypoglycemic episodes. Transitioning now to oral hypoglycemics
with SSI coverage. Hypernatremia was corrected with appropriate
hydration. Electrolytes monitored and repleted. Sodium on [**7-5**]
afternoon 143, so D5W stopped and now just on PO fluids. Afib
has been treated with digoxin and metoprolol. No
anticoagulation so far given uncertain fall risk. Likely UTI
being treated with ceftriaxone (7 day course) and also on vanco
for possibility of SBE. Pt now back to her presumed baseline in
terms of mental status.
Past Medical History:
PMHx (per NH records):
-- CHF (EF 35%, inf WMA)
-- c.diff
-- CVA with L hemiparesis
-- HTN
-- PVD
-- dementia
-- h/o SBE (staph hominis finished 6wks Vanco end of [**2135-5-25**])
Social History:
[**Hospital1 5595**] resident, son involved in care
Family History:
NC
Physical Exam:
Tmax 98.4 Tc 97.5 HR 80 (70-120) BP 100/46 (95-150/50s) RR 16
O2sat 97% RA
Gen: NAD, follows some commands, oriented x 1 (does not know
date or where she is)
HEENT: PERRL, arcus senilus b/l, moist MM
Neck: unable to assess [**Name (NI) 22116**] (pt not cooperative with exam)
CV: irreg, irreg; no m/r/g
Chest: CTA B/L but uncooperative (poor effort)
Abd: soft, NT/ND, + BS
Extr: no edema in LEs, L UE contractures
Neuro: follows some commands, can move RUE not LUE,
Pertinent Results:
[**7-3**]: Head CT: IMPRESSION: No intracranial hemorrhage or mass
effect identified.
[**7-3**] CXR: IMPRESSION: No evidence of acute cardiopulmonary
disease.
On admission WBC 24.6 -- came down to 11.9
Hct around 25.8.
Iron studies calTIBC-321 VitB12-1148* Folate-GREATER TH
Hapto-167 Ferritn-25 TRF-247 (c/w iron deficiency).
Glucose 734 -- came down to normal range (134)
AG was normal
Cardiac enzymes negative
ABG:
[**2135-7-3**] 06:50PM BLOOD pO2-82* pCO2-37 pH-7.46* calHCO3-27 Base
XS-2
[**2135-7-3**] 06:50PM URINE RBC-0 WBC->50 Bacteri-FEW Yeast-MANY
Epi-[**2-26**]
[**2135-7-6**] 09:44AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
[**2135-7-6**] 09:44AM URINE RBC-0 WBC-57* Bacteri-MANY Yeast-MOD
Epi-4
Brief Hospital Course:
Assessment: [**Age over 90 **]yoF with CHF, recent SBE, CVA, p/w new onset AFib,
hypernatremia, hyperglycemia and MS changes.
.
1. MS changes: On admission pt was very confused/delirious.
Improved since admission, still possibly with some element of
delerium, oriented to person only. With baseline dementia. Alert
and interactive. Had head CT without acute abnl and no focal
neuro findings aside from old CVA. Hypernatremia was corrected
with fluids (see below) and neuro exam was monitored,
unremarkable.
.
2. Hyperglycemia: no previously documented h/o diabetes, though
had routine chem7 with glucose >200 while at [**Hospital 100**] rehab.
Insulin gtt in ICU was stopped within 24h, then started on SSI,
but with occasional hypoglycemic episodes. Electrolytes were
aggressively repleted. On [**7-5**] transitioned to oral
hypoglycemic [**Doctor Last Name 360**] and covered with SSI. BG well-controlled.
Prior to discharge avandia was d/c'd. Covered with SSI in-house.
Once discharged FS will be monitored and covered w/SSI. Oral
[**Doctor Last Name 360**] can be restarted if needed. Hgb A1c 8.7
.
3. HyperNatremia: Admission Na of 161 (170s when corrected for
hyperglycemia), trended down with appropriate hydration. Pt
first received NS for volume repleteion. Then switched to 1/2NS
and then to D5W. IVF was stopped with Na143 on [**7-5**], restarted
on [**7-6**] with Na 148. Na normalized prior to discharge after D5W
administration
.
4. A-fib: Pt was reportedly in sinus rhythm normally at rehab.
Has had episodes of afib in the past per records. Dig loaded
[**7-4**] and also started on metoprolol for tachycardia. Digoxin
0.0625mg daily. Metoprolol 12.5 [**Hospital1 **]. HR well-controlled with
these medications. TSH was normal. Pt was on telemetry in the
ICU, off on the floor. Anticoagulation can be considered as
part of the long-term plan, but was not started on this
admission because of uncertain fall risk.
.
5. UTI - UA with >50 WBC, few bacteria, many yeast, [**2-26**] epith.,
urine cx with yeast. Was febrile with leukocytosis (max 24.6) on
admission. WBC has decreased and pt defervesced on abx
(ceftriaxone started [**7-4**], changed to PO cefpodoxime for total 7
day course). Foley was removed. Repeat UA: mod leuk, 57 WBC,
many bacteria, mod yeast, 4 epi (after 3 days abx).
Repeat Urine Cx was pending at time of discharge. Pt will
complete 7 day abx course after discharge.
.
6. Hx of SBE: Given fever and leukocytosis on admission,
vancomycin was started on admission because of past history of
SBE. UA indicates urine most likely source, pt treated with
ceftriaxone for UTI. Blood Cx NGTD after 3 days. Not finalized
yet, but vanco discontinued.
.
6. Anemia: Iron studies (Iron 17, ferritin 25, TIBC 321) c/w
iron deficiency anemia.
Started iron. B12/folate levels normal. Given hx of CAD and
current Hct 28.5, transfused 1U PRBCs to correct anemia.
.
7. CAD / CHF: EF reported as 35% with some inf WMA; pedal edema
on exam Treatment with Dig and metoprolol for A-fib as above.
Added ACE-I for afterload reduction. Given SBP in low 100s,
started at 5mg QD. BP remained 100s/60s so did not increase
dose.
.
Medications on Admission:
Asa 81, captopril 12.5 TID, diltiazem 60 qid, lasix 40/60,
paxil, senna
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day).
Disp:*300 mL* Refills:*2*
4. Multivitamins Tablet, Chewable Sig: One (1) tablet PO
DAILY (Daily).
Disp:*30 tablet* Refills:*2*
5. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Senna 8.6 mg Capsule Sig: [**12-26**] Capsules PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) 1
Subcutaneous ASDIR (AS DIRECTED).
Disp:*1 1* Refills:*2*
10. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary Dx:
hyperosmolar nonketotic syndrome hyperglycemia
atrial fibrillation/aflutter
hypernatremia
UTI
Secondary Dx:
CHF (EF 35%)
dementia
HTN
Discharge Condition:
stable
Discharge Instructions:
If you have fever, chills, shortness of breath, chest pain,
nausea/vomiting, abdominal pain, decreased urine output, or
dysuria please call your physician or return to the emergency
department immediately.
We have held your lasix while you were in the hospital. Please
evaluate fluid status and restart as indicated.
We have started 3 new medications for your heart: digoxin,
metoprolol, and lisinopril. Please take these medications as
instructed. Please stop taking captopril and diltiazem. These
new medications replace those old ones.
Your blood glucose should be checked before meals and at
bedtime, and you will receive sliding scale insulin based on the
glucose level.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **]. He will see you at [**Hospital 100**] Rehab
|
[
"294.8",
"428.0",
"443.9",
"414.01",
"593.9",
"599.0",
"790.6",
"276.0",
"427.31",
"780.99",
"280.9",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7822, 7887
|
3430, 6595
|
308, 314
|
8078, 8086
|
2629, 2640
|
8817, 8912
|
2123, 2127
|
6717, 7799
|
7908, 8057
|
6621, 6694
|
8110, 8794
|
2142, 2610
|
221, 270
|
342, 1832
|
2649, 3407
|
1854, 2037
|
2053, 2107
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,662
| 112,904
|
19685
|
Discharge summary
|
report
|
Admission Date: [**2171-1-17**] Discharge Date: [**2171-1-29**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
s/p exploratory laparotomy and right colectomy
History of Present Illness:
Patient is an 85 year old female who presented to the emergency
department with recurrent rectal bleeding. The patient has a
history of hypertension, high cholesterol, and stroke. The
patient was recently discharged after an admission for lower GI
bleeding ([**1-5**]) which required transfusion of 6 units of packed
RBC's. She has had two admissions prior to this for the same
complaint. During her most recent admission she had a tagged
red blood cell scan which showed bleeding at the hepatic
flexure, but subsequent angiograms were negative. A colonoscopy
revealed diverticulosis but no active bleeding. The nursing
home where the patient resides reported that the patient had
240cc of hematochezie with a negative lavage. The patient
reported some crampy abdominal pain prior to the onset of the
bleeding.
Past Medical History:
1. H/O GI bleeds in [**2168**] and as above
2. HTN
3. Hypercholesterolemia
4. S/P MCA CVA on [**2171-1-28**]- Since this time, pt has suffered
from residual aphasia and left hemiparesis.
5. Depression
6. S/P cholecystectomy
7. H/O nocturia
8. Recurrent UTIs
Social History:
Pt lives in the [**Hospital3 9475**] Home in [**Location (un) 3146**]. She is able
to bathe and dress herself. She ambulates using a walker. Pt
does receive assistance with eating. Her daughter lives in the
area and is involved. No tobacco, ETOH, or drugs.
Family History:
No family history of CAD, CVA, or bleeding disorders.
Physical Exam:
Vitals pulse 88, bp 149/47, respiratory rate 16, 100% O2 sats on
room air
General: awake, alert, n acute distress, pale
Pulm: clear to auscultation bilaterally
CV: regular rate/rhythm
Abd: slightly distended, soft, mild diffuse tenderness
Rectal: normal tone, no masses, positive hematochezia
Ext: warm, well-perfused
Pertinent Results:
[**2171-1-17**] 03:46PM BLOOD Hgb-12.2 calcHCT-37
[**2171-1-17**] 06:07PM BLOOD Hgb-12.7 calcHCT-38
[**2171-1-18**] 09:57PM BLOOD Hgb-10.5* calcHCT-32
[**2171-1-18**] 11:23PM BLOOD Hgb-11.2* calcHCT-34
[**2171-1-18**] 09:57PM BLOOD Glucose-135* Lactate-0.9 Na-141 K-3.6
Cl-111
[**2171-1-18**] 11:23PM BLOOD Glucose-145* Lactate-1.2 Na-140 K-3.7
Cl-110 calHCO3-27
[**2171-1-17**] 03:46PM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
[**2171-1-18**] 09:57PM BLOOD Type-[**Last Name (un) **] pO2-50* pCO2-44 pH-7.37
calHCO3-26 Base XS-0
[**2171-1-18**] 11:23PM BLOOD Type-[**Last Name (un) **] pH-7.37
[**2171-1-17**] 02:54AM BLOOD Albumin-3.3* Calcium-9.2 Phos-3.3 Mg-1.8
[**2171-1-18**] 04:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.6
[**2171-1-19**] 04:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-3.4*
[**2171-1-20**] 05:50AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.2
[**2171-1-22**] 05:07AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.1
[**2171-1-23**] 05:32AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.9
[**2171-1-24**] 06:19AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.7
[**2171-1-25**] 05:40AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.5*
[**2171-1-29**] 05:20AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.9
[**2171-1-17**] 02:54AM BLOOD CK-MB-2 cTropnT-<0.01
[**2171-1-20**] 05:50AM BLOOD CK-MB-4 cTropnT-<0.01
[**2171-1-17**] 02:54AM BLOOD ALT-11 AST-23 LD(LDH)-315* CK(CPK)-37
AlkPhos-53 Amylase-60 TotBili-0.3
[**2171-1-20**] 05:50AM BLOOD CK(CPK)-910*
[**2171-1-17**] 02:54AM BLOOD Glucose-131* UreaN-21* Creat-0.7 Na-139
K-4.9 Cl-108 HCO3-24 AnGap-12
[**2171-1-18**] 04:00AM BLOOD Glucose-149* UreaN-13 Creat-0.6 Na-143
K-4.1 Cl-112* HCO3-22 AnGap-13
[**2171-1-18**] 12:35PM BLOOD Glucose-138* UreaN-14 Creat-0.6 Na-143
K-3.6 Cl-112* HCO3-25 AnGap-10
[**2171-1-19**] 12:01AM BLOOD Glucose-147* UreaN-11 Creat-0.5 Na-143
K-3.4 Cl-111* HCO3-27 AnGap-8
[**2171-1-19**] 04:00AM BLOOD Glucose-102 UreaN-11 Creat-0.5 Na-143
K-3.6 Cl-111* HCO3-28 AnGap-8
[**2171-1-20**] 05:50AM BLOOD Glucose-101 UreaN-10 Creat-0.5 Na-142
K-4.1 Cl-108 HCO3-26 AnGap-12
[**2171-1-21**] 05:30PM BLOOD Glucose-113* UreaN-7 Creat-0.4 Na-142
K-3.9 Cl-106 HCO3-30* AnGap-10
[**2171-1-22**] 05:07AM BLOOD Glucose-111* UreaN-6 Creat-0.4 Na-139
K-3.7 Cl-104 HCO3-30* AnGap-9
[**2171-1-23**] 05:32AM BLOOD Glucose-124* UreaN-8 Creat-0.4 Na-140
K-4.3 Cl-104 HCO3-31* AnGap-9
[**2171-1-24**] 06:19AM BLOOD Glucose-119* UreaN-8 Creat-0.4 Na-139
K-3.8 Cl-106 HCO3-29 AnGap-8
[**2171-1-25**] 05:40AM BLOOD Glucose-102 UreaN-7 Creat-0.4 Na-138
K-3.6 Cl-102 HCO3-28 AnGap-12
[**2171-1-28**] 02:00PM BLOOD Glucose-96 UreaN-5* Creat-0.5 Na-139
K-3.4 Cl-106 HCO3-29 AnGap-7*
[**2171-1-17**] 02:54AM BLOOD PT-12.9 PTT-22.9 INR(PT)-1.0
[**2171-1-17**] 02:54AM BLOOD Plt Ct-369#
[**2171-1-18**] 04:00AM BLOOD Plt Ct-219
[**2171-1-18**] 12:35PM BLOOD PT-13.7* PTT-23.6 INR(PT)-1.2
[**2171-1-18**] 12:35PM BLOOD Plt Smr-NORMAL Plt Ct-226
[**2171-1-18**] 09:47PM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.2
[**2171-1-19**] 04:00AM BLOOD Plt Ct-188
[**2171-1-20**] 05:50AM BLOOD Plt Ct-208
[**2171-1-21**] 05:30PM BLOOD Plt Ct-248
[**2171-1-17**] 02:54AM BLOOD Neuts-65.1 Lymphs-27.0 Monos-4.3 Eos-3.4
Baso-0.2
[**2171-1-18**] 12:35PM BLOOD Neuts-91.5* Bands-0 Lymphs-4.8* Monos-3.6
Eos-0 Baso-0
[**2171-1-17**] 02:54AM BLOOD WBC-6.6 RBC-2.83* Hgb-9.0* Hct-26.4*#
MCV-93 MCH-31.7 MCHC-33.9 RDW-15.0 Plt Ct-369#
[**2171-1-17**] 11:00PM BLOOD Hct-32.2*
[**2171-1-18**] 04:00AM BLOOD WBC-18.4*# RBC-3.52* Hgb-10.7* Hct-31.4*
MCV-89 MCH-30.5 MCHC-34.3 RDW-16.6* Plt Ct-219
[**2171-1-18**] 06:40PM BLOOD Hct-26.3*
[**2171-1-19**] 12:01AM BLOOD Hct-33.6*#
[**2171-1-20**] 05:50AM BLOOD WBC-15.2* Hct-32.1* Plt Ct-208
[**2171-1-21**] 05:30PM BLOOD WBC-11.3* RBC-3.41* Hgb-10.2* Hct-31.1*
MCV-91 MCH-30.0 MCHC-32.9 RDW-15.2 Plt Ct-248
[**2171-1-24**] 01:30PM BLOOD Hct-31.0*
[**2171-1-25**] 05:40AM BLOOD WBC-8.5 RBC-3.22* Hgb-9.4* Hct-29.3*
MCV-91 MCH-29.2 MCHC-32.1 RDW-14.8 Plt Ct-345
Brief Hospital Course:
The patient was originally admitted to the medicine service at
[**Hospital1 18**]. Blood was transfused to a goal hematocrit of 30. SMA
embolization was performed on HD 2. Neurology was consulted due
to the patient's history of stroke and mental status changes on
admission. It was thought that these changes were most likely
related to sedative drugs and a urinary tract infection. The
infection was treated appropriately with antibiotics, and the
use of narcotic medications was minimized. The patient
subsequently developed ischemic bowel with peritoneal signs and
an elevated WBC thought to be a complication from the
embolization procedure. On HD 2 the patient underwent an
exploratory laparotomy and right colectomy for ischemic colitis.
She tolerated the procedure well with slow return of bowel
function. Physical therapy worked with her, and it was planned
that she would be discharged to rehab when clinically ready.
She demonstrated some irregularity in cardiac rhythm on post-op
day 2, and was monitored by telemetry to follow this rhythm.
She was placed on flagyl for a two-week course due to the
development of some diarrhea. Her foley was discontinued on
post-op day 10, and although the patient successfully voided,
she subsequently put out little output. It was decided that if
she had not voided again by the time of discharge that she would
be discharged with a foley in place.
The patient has a history of stroke and was placed on aspiration
precautions. She was not to have any thin liquids - all liquids
were thickened. She required encouragement in taking po's, and
her rehab facility was informed of this. In addition, her rehab
facility was advised to check her electrolytes several times per
week due to the need for repletion in the hospital.
Medications on Admission:
celexa 20 qd
vicodin 1 tab [**Hospital1 **]
xanax 0.25 [**Hospital1 **]
doxepin 10 qd
ferrous sulfate 325 [**Hospital1 **]
folic adic 1 qd
vitamin B12 1000mcg qd
lipitor 10 qd
colace 100 [**Hospital1 **]
senna 1 tab [**Hospital1 **]
lisinopril 20 qd
protonix 40 qd
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 more days (end on [**2171-2-8**]) days.
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
8. Senokot 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
12. FerrouSul 325 (65) mg Tablet Sig: One (1) Tablet PO once a
day.
13. Doxepin HCl 10 mg Capsule Sig: One (1) Capsule PO at
bedtime.
14. Lopressor 50 mg Tablet Sig: half tablet Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
1. s/p SMA embolectomy
2. s/p exploratory laparotomy and right colectomy
3. recurrent lower GI bleeds
4. hypertension
5. stroke with residual left hemiparesis
6. depression
6. recurrent UTIs
7. reflux
Discharge Condition:
stable; tolerating regular diet; out of bed daily
Discharge Instructions:
Please call ER or surgery clinic if you observe increased pain,
swelling, bleeding, drainage, temperature > 101.5, or other
symptoms which are concerning to you
Avoid directly soaking wound. [**Month (only) 116**] shower, but cover with
dressing at these times
Followup Instructions:
1. Follow-up with Dr. [**Last Name (STitle) **] in 1 week for wound evaluation
2. Follow-up with your primary care provider as needed for
medication management
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
|
[
"E937.9",
"438.20",
"998.12",
"996.62",
"599.0",
"530.81",
"530.3",
"438.11",
"557.0",
"272.0",
"008.45",
"569.0",
"E879.8",
"562.12",
"567.2",
"401.9",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"96.07",
"45.73",
"99.04",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
9314, 9400
|
6055, 7839
|
278, 327
|
9653, 9704
|
2159, 6032
|
10015, 10277
|
1744, 1799
|
8154, 9291
|
9421, 9632
|
7865, 8131
|
9728, 9992
|
1814, 2140
|
223, 240
|
355, 1173
|
1195, 1454
|
1470, 1728
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,494
| 113,824
|
3089
|
Discharge summary
|
report
|
Admission Date: [**2200-6-14**] Discharge Date: [**2200-7-16**]
Date of Birth: [**2125-1-23**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
fatigue, elevated WBC
Major Surgical or Invasive Procedure:
Central line for Plasmapheresis
Skin biopsy
History of Present Illness:
75-year-old woman with no significant medical problems presented
to her PCP complaining of "not feeling well". Patient reports
that on [**6-2**] she saw her dentist because she had been feeling
well for a few weeks. She basically states she was fatigued. Her
son who accompanies her surgeries sleeping a lot during the day.
She was found to have 3 abscessed teeth which were removed on
[**6-5**]. She was begun on clindamycin 300 mg QID on [**6-2**] she took
until [**6-12**]. For the last 3 nights she has had a fever with max
temperature of 100.8. She denies cough, shortness of breath,
abdominal pain, dysuria, frequency, stiff neck, headache. She
has noted that her stools are a little bit looser, but has not
had profuse diarrhea. She denies shaking chills, night sweats.
.
In the ED, initial vital signs were 98.3 88 130/69 16 100%.
White blood cell count was 257K with 98% other forms, hematocrit
29, platelets 58K. Her LDH was 472. Creatinine was 0.8. BMT
was consulted in the ED and recommended smear review and bone
marrow biopsy, further recommendations pending. Patient was
given allopurinol 300 mg PO x 1. She was planned [**Hospital Unit Name 153**] admit for
pheresis. Vitals upon transfer were pulse 84, RR 18, BP 140/84,
O2Sat 96% RA.
.
On arrival to the MICU, patient reports no problems. There is
no dyspnea, headache or confusion.
Past Medical History:
Osteopenia
Elevated blood pressure
Social History:
She is widowed and remarried. Her two sons are doing well
(daughter-in-law [**Name (NI) 553**] [**Name (NI) **]). Has 4 granddaughters. Does not
work. She lives in [**Location 14663**] for the summer. She does not use
tobacco, EtOH, drugs. Walks 20 min every morning, and a few
times a week walks in the evenings as well.
Family History:
Mother had pancreatic cancer. Father had a myocardial
infarction at age 82 and diabetes. Son w/ [**Name2 (NI) **] [**Location (un) **]
syndrome.
Sister with severe itching for 1 year, unexplained despite
extensive testing
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.4 BP 154/89 HR 90 R 19 Sat 93%RA
General: Alert, orientedx3, no acute distress
HEENT: Pupils equal round and reactive, extraocular movements
intact, oropharynx clear w/o lesions or petechiae, good
dentition, mild gingival hyperplasia
NECK: JVP flat
CV: nl s1s2, regular rate and rhythm, no murmur/rubs/gallops
PULM: clear to auscultation bilaterally w/good air movement, no
crackles/wheezes
ABD: soft, non-tender, non-distended, +Bowel sounds, no
hepatosplenomgaly
LYMPH: no cervical LAD
EXT: warm, well perfused, no cyanosis/clubbing/edema, no open
lesions
SKIN: no rashes
NEURO: AOx3, 5/5 strength in all extremities,
DISCHARGE PHYSICAL EXAM:
T98.7, BP 140/84, HR 103, RR 18, 98%RA
General: Alert, orientedx3, no acute distress
HEENT: Pupils equal round and reactive, extraocular movements
intact, oropharynx clear w/o lesions or petechiae, good
dentition, mild gingival hyperplasia
NECK: JVP flat
CV: nl s1s2, regular rate and rhythm, no murmur/rubs/gallops
PULM: clear to auscultation bilaterally w/good air movement, no
crackles/wheezes
ABD: soft, non-tender, non-distended, +Bowel sounds, no
hepatosplenomgaly
LYMPH: no cervical LAD
EXT: warm, well perfused, no cyanosis/clubbing/edema, no open
lesions
SKIN: no rashes
NEURO: AOx3, 5/5 strength in all extremities,
Pertinent Results:
ADMISSION LABS:
[**2200-6-14**] 02:30AM BLOOD WBC-249.5* RBC-2.94* Hgb-8.6* Hct-25.5*
MCV-87 MCH-29.2 MCHC-33.6 RDW-17.0* Plt Ct-52*
[**2200-6-13**] 04:20PM BLOOD Neuts-1* Bands-0 Lymphs-1* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-98* NRBC-2* Other-0
[**2200-6-14**] 02:30AM BLOOD PT-14.3* PTT-27.4 INR(PT)-1.3*
[**2200-6-13**] 04:20PM BLOOD UreaN-14 Creat-0.8 Na-138 K-3.4 Cl-98
HCO3-27 AnGap-16
[**2200-6-13**] 04:20PM BLOOD ALT-31 AST-28 LD(LDH)-472* AlkPhos-103
TotBili-0.5
[**2200-6-13**] 04:20PM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0 UricAcd-4.6
Blood smear [**6-13**]:
Numerous large monomorphic cells with very high N:C ratio,
minimal cytoplasm, multiple nucleoli, rare granules and no clear
auer rods. Rare platelets, normal appearing RBC with occasional
nucleated RBC.
FLOW CYTOMETRY IMMUNOPHENOTYPING [**2200-6-14**]
INTERPRETATION
Acute Myelogeneous Leukemia. Peripheral blood morphological
review shows high white counts, blasts with high N:C ratio,
irregular nuclear contours, very sparse granules. No Auer rods
seen. Given the absence of HLA-DR [**Last Name (STitle) **] CD34, while the morphology
does not support it, the flow profile does not rule out acute
promyelocytic leukemia. Correlation with cytogenetics and FISH
is recommended.
Cytogenetics Report [**2200-6-15**]
Culture of this specimen yielded no metaphase cells;
therefore, chromosome analysis could not be performed
FISH analysis with probes to the PML and RARA loci was
interpreted as NORMAL.
Imaging
Echo (pre-chemo) [**2200-6-15**]:
IMPRESSION: Normal left ventricular cavity size and
global/regional systolic function.
MR HEAD W/O CONTRAST [**2200-6-19**]
IMPRESSION:
Evidence of ischemia in the right centrum semiovale following
the distribution
of the superior division of the sylvian MCA.
BILAT LOWER EXT VEINS [**2200-6-19**]
IMPRESSION: No deep venous thrombosis in the right or left
lower extremity
TTE (Congenital, focused views) [**2200-6-20**]
This focused study demonstrates a patent foramen ovale with
small amount of right-to-left interatrial flow at rest.
CT CHEST W/CONTRAST CT ABD & PELVIS WITH CONTRAST [**2200-6-24**]
IMPRESSION:
1. Findings most consistent with typhlitis/neutropenic colitis,
given
patient's history.
2. 7 x 12 mm left lower lobe pulmonary nodule; given
substantial size,
follow-up CT is recommended within three months to show
resolution. A small
nearby nodule can also be reassessed at that time. Infectious
etiologies
could be considered or the nodule may incidental, though
substantial in size;
it would be an unlikely presentation of leukemia. Right middle
lobe
tree-in-[**Male First Name (un) 239**] process may represent early infection/inflammation.
3. Small hypodensities bilateral renal cortices, too small to
characterize
fully.
CT CHEST W/CONTRAST CT ABD & PELVIS WITH CONTRAST [**2200-7-1**]
IMPRESSION:
1. Persistent cecitis and ascending colitis with persistent and
perhaps
slightly increased wall thickening and also greater inflammatory
fat
stranding. The appearance suggests neutropenic colitis given
the patient's
history.
2. Left lower lobe pulmonary nodule, increased in the short
one-week interval since the prior study, worrisome for an
ongoing infectious etiology.
DISCHARGE LABS:
[**2200-7-16**] 12:00AM BLOOD WBC-30.4* RBC-2.84* Hgb-8.6* Hct-25.6*
MCV-90 MCH-30.3 MCHC-33.5 RDW-16.0* Plt Ct-782*
[**2200-7-16**] 12:00AM BLOOD Neuts-33* Bands-2 Lymphs-12* Monos-44*
Eos-0 Baso-0 Atyps-4* Metas-4* Myelos-1*
[**2200-7-16**] 12:00AM BLOOD PT-16.7* PTT-32.6 INR(PT)-1.6*
[**2200-7-16**] 12:00AM BLOOD Glucose-159* UreaN-17 Creat-0.4 Na-136
K-4.5 Cl-105 HCO3-23 AnGap-13
[**2200-7-16**] 12:00AM BLOOD ALT-11 AST-14 LD(LDH)-239 AlkPhos-154*
TotBili-0.2
[**2200-7-16**] 12:00AM BLOOD Albumin-2.6* Calcium-7.7* Phos-3.2 Mg-1.9
Brief Hospital Course:
75 yo F presenting with 2 weeks of increasing fatigue, mild
dyspnea, and recent low grade fever and dental abscess. Given
lab findings, with elevated WBC count to 257K with 98% blasts,
found to have likely acute myelomonocytic leukemia, course of
7+3 chemotherapy complicated by stroke, typhlitis, neutropenic
fever, and likely fungal lung infection.
# Acute leukemia: Healthy 75F with 2-3 weeks of fatigue and
recent possible dental abscess s/p extraction [**6-5**] who presented
with elevated WBC >200K and anemia/thrombocytopenia discovered
at her PCP [**Name Initial (PRE) **] [**6-13**]. She was admitted to the ICU for emergent
pheresis. In the [**Last Name (LF) 153**], [**First Name3 (LF) **] IJ central line catheter was placed
for pheresis given her WBC of 257 and risk for leukostasis.
After pheresis, her WBC count dropped to 127. She was also
started on hydroxyurea, allopurinol, and emperic cefepime for
chemo. After some discussions with the family she agreed to
chemotherapy and was transfered to BMT service for further
management. She underwent 7+3 cytarabine & idarubicin, course
was complicated by ischemic CVA on [**6-18**] found to have PFO & no
obvious source of thrombus, neutropenic colitis ([**2198-6-23**]),
likely fungal lung infection and neutropenic fever as discussed
below. After coming out of her nadir, patient had leukocytosis
to 20-30k, peripheral smear and flow showed mature monocytes,
possibly consistent with myelodysplasia or robust recovery, less
likely recurrence of leukemia or infection. Bone marrow biopsy
was not done for evidence of remission as patient does not wish
to have further chemotherapy, regardless of potential result.
-Patient will continue to follow with Dr. [**Last Name (STitle) 410**] in clinic
#Sepsis/Febrile neutropenia: Pt had low grade fevers on [**6-30**],
and fever to 101.7 @430 [**7-1**], afebrile at the time of transfer
[**7-2**]. Pt on broad spectrum abx coverage with [**Last Name (un) 2830**]/vanco. CT
chest/abd found new nodule in LLL that was increasing in size
suggesting infectious process. Sinus CT found possible
involvement of the right maxillary sinus. ENT was consulted and
swab culture of the sinus was unrevealing. Before being
transferred to the ICU for the second time during this
admission, she also developed hypotension with SBP in 80s after
receving ambisome. She responded to fluid boluses and did not
require pressor support. At time, the hypotension was consider
to be mult-factorial including side-effect of ambisome as well
as underlying infection. Cultures were negative. Pt was
continued on broad spectrum abx coverage. A CT chest/abd ([**7-1**])
found enlarging nodule in LLL, and sinus CT found possible
involvement of the right maxillary sinus with oral-antral
fistula. ID consult also followed patient during this admission.
- Per oral maxillofacial surgery there is no evidence of a
current dental abcess or dental infection
- All antibiotics except voriconazole were stopped and patient
was stable for two days prior to discharge.
# Syncope: Syncopal episode [**2200-6-23**] likely secondary to
vasovagal or orthostatic hypotension.Pt had difficult ambulating
and required more assistance than normal. Now ambulating better
since starting PT.
-PT and OT therapy to continue since pt is still functioning
below baseline. Pt will continue to benefit from acute PT.
# Ischemic CVA - pt w/ new isolated L-sided mouth droop since
[**6-18**], neurology was consulted, MRI showed subtle area of ischemia
in centrum stemi ovale, extending into right insula (vascular
territory of R MCA), echo w/ bubble showed PFO, doppler of
bilateral LEs negative.
-Blood pressure control
-ASA 162mg daily started prior to discharge
#Rash: Patient had new erythematous non-pruritic maculopapular,
blanching rash on the back from the nape of neck to the T8-T9
dermatome. Concern was for leukemia cutis or fungal or drug
rash. Dermatology was consulted and believed the rash was
dependent erythema with early miliaria from recent fevers,
biopsy showed likely drug hypersensitivity reaction. Rash
resolved with removal of meropenem from regimen.
# Typhlitis/Neutropenic colitis: Pt found to have significant
bowel wall thickening and edema from cecum to hepatic flexture
consistent with typhlitis/ neutropenic colitis on [**2200-6-24**]. Pt
did not have abdominal pain but has reported some loose stools.
Broad spectrum coverage with aztreonam and flagyl until [**2200-7-14**],
was stable of antibiotic until discharge, ID followed. C. diff
was negative.
# Pulmonary nodule: [**Month (only) 116**] represent infection vs inflammation.
- Pt on aztrenonam, flagyl, vanco, ambisome
- concern since nodule size has increased in size over 1 week
period
- pt will need follow up CT in 3 months to f/u on nodule
- pt will follow in outpatient [**Hospital **] clinic, to determine length of
voriconazole treatment
Transitional Issues:
- pt will need follow up CT in 3 months to f/u on nodule
- goals of care: patient does not want more chemotherapy if she
has a recurrence
Medications on Admission:
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (OTC) -
COD LIVER OIL - (OTC) - Dosage uncertain
MULTIVITAMIN - (OTC) - by mouth once a day
Discharge Medications:
1. Voriconazole 200 mg PO Q12H
RX *voriconazole 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*2
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Aspirin 162 mg PO DAILY
4. calcium carbonate-vitamin D3 *NF* 1 tablet Oral Daily
5. cod liver oil *NF* 1 tablet Oral Daily
6. Multivitamins 1 TAB PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*2
8. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight hours Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
Allcare VNA of greater [**Location (un) **]
Discharge Diagnosis:
AML
Neutropenic Colitis
Right MCA Stroke
Drug Rash
Febrile Neutropenia
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 14664**],
It was a pleasure caring for you during your recent
hospitalization at [**Hospital1 18**]. You came to the hospital because you
were tired, not feeling well and you were found to have a high
white blood cell count by your primary care physician. [**Name10 (NameIs) **] were
found to have acute myelogenous leukemia so you underwent
induction chemotherapy with (7+3) [**Doctor First Name **] + cytarabine. You
tolerated the chemotherapy well and your blood counts dropped as
expected. You also experienced a stroke which resulted in a
left facial droop and left arm weakness. A work-up for the
cause of the stroke revealed that you have a patent foramen
ovale, which is a hole between two [**Doctor Last Name 1754**] of your heart. In
addition you also developed neutropenic colitis which means that
the wall of your large intestines was inflammed which is a
complication of receiving chemotherpy. We put you on
appropriate antibiotics to prevent an infection, rested your
bowels, and provide you nutrition via an IV line. In addition
you also developed a rash which was a side effect of the
antibioitics you were taking. Your nutritional status improved
as did the infection in your bowels by the time you were
discharged.
The following changes were made to your medications:
START voriconazole for your fungal infection
START acyclovir to prevent viral infections
START two baby aspirin a day for your stroke
START metoprolol for your high blood pressure
Please keep your appointments as scheduled below.
Followup Instructions:
Please follow up with the following appointments which have been
scheduled for you:
Department: HEMATOLOGY/BMT
When: TUESDAY [**2200-7-22**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2200-7-22**] at 3:00 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN [**Telephone/Fax (1) 14665**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BMT CHAIRS & ROOMS
When: TUESDAY [**2200-7-22**] at 3:00 PM
Department: INFECTIOUS DISEASE
When: FRIDAY [**2200-8-1**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2200-7-18**]
|
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"285.9",
"693.0",
"276.1",
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icd9cm
|
[
[
[]
]
] |
[
"38.97",
"99.15",
"38.93",
"99.25",
"99.71",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
13434, 13508
|
7573, 12477
|
326, 372
|
13623, 13623
|
3750, 3750
|
15381, 16561
|
2179, 2404
|
12835, 13411
|
13529, 13602
|
12663, 12812
|
13806, 15358
|
7009, 7550
|
2444, 3079
|
12498, 12637
|
265, 288
|
400, 1763
|
3766, 6992
|
13638, 13782
|
1785, 1822
|
1838, 2163
|
3104, 3731
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,750
| 195,223
|
18086
|
Discharge summary
|
report
|
Admission Date: [**2102-12-12**] Discharge Date: [**2102-12-13**]
Date of Birth: [**2059-10-4**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: Briefly, the patient is a 43-
year-old male, previously diagnosed with metastatic renal
cell cancer, status post nephrectomy of his right kidney with
recent clinical course significant for T7 spinal cord
compression and large right loculated pleural effusion with
pigtail catheter drainage who presented from rehab with
shortness of breath, lethargy, pleuritic chest pain, and
decrease in hematocrit requiring transfusion. Prior to
transfer, the patient was noted to have systolic blood
pressure of approximately 100, to be tachycardiac to 110, and
to have continued dyspnea with desaturations to 80 percent on
nasal cannula oxygen.
PAST MEDICAL HISTORY: Metastatic renal cell cancer with
metastases to right pleura and spinal cord, status post right
nephrectomy in [**9-19**].
Hypertension.
Hyperlipidemia.
ALLERGIES: No known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Labetalol.
2. Colace.
3. Senna.
4. EPO.
5. Dilaudid.
6. Decadron.
7. Prevacid.
8. OxyContin.
9. Dulcolax.
10. Lactulose.
11. Home oxygen.
PHYSICAL EXAMINATION: Temperature 98.8 degrees, heart rate
117, blood pressure 134/53, respiratory rate 20, and
saturating 98 percent on nasal cannula oxygen. In general,
ill-appearing, diaphoretic, and dyspneic male. HEENT:
Extraocular movements intact. Neck: No jugular venous
distention. Lungs: Decreased breath sounds at the right
base with dullness to percussion. Cardiovascular:
Tachycardiac without a murmur. Abdomen: Obese, soft, and
nontender with normoactive bowel sounds. Extremities: No
edema. Neurologic: Alert, conversant, nonfocal.
DIAGNOSTIC STUDIES: CBC, white count 4.5, hematocrit 25, and
platelets of 85. Differential, 67 percent polymorphonuclear
leukocytes and 21 percent bands. Chemistry significant for
phosphorus 5.0 and no anion gap. Coags within normal limits.
Cardiac enzymes negative. LFTs significant for isolated
alkaline phosphatase elevation of 168.
Chest x-ray, re-accumulation of previously seen right-sided
pleural effusion with a density at the right lung base
representing pneumonia. CT of the chest, loculated pleural
fluid collections on the right with air-fluid levels
consistent with empyemas. Multiple pulmonary and liver
metastases with lesions eroding into the left fifth and sixth
proximal ribs. No evidence of pulmonary embolism. Arterial
blood gas on 100 percent nonrebreather mask, 7.2/84/66/34/2.
Lactate 1.3.
HOSPITAL COURSE: The patient was initially taken to
Radiology for a CAT scan of the chest to rule out pulmonary
embolus, at which time the patient became increasingly
lethargic with a decrease in respiratory rate and was
intubated for respiratory failure. For his respiratory
failure, the patient was initially covered with vancomycin,
levofloxacin, and clindamycin for a presumed
pneumonia/empyema. While at CT scan, the patient became
increasingly dyspneic, the patient was then admitted to the
Medical Intensive Care Unit and his hypotension was managed
with aggressive fluid resuscitation.
Additionally, the patient was given stress-dose steroids
given his chronic steroid dependency, and he was transfused
two units of packed red blood cells given his new-onset
anemia. Upon admission to the Medical Intensive Care Unit,
the Oncology Consultation Service was asked to evaluate the
patient to assist in the management. [**Hospital **] medical
resuscitation was continued until a discussion with the
family including the [**Hospital 228**] healthcare proxy revealed
wishes upon their part to provide comfort measures only to
the patient. On hospital day two, the patient was made CMO
and the cross covering medical intern was asked to evaluate
the patient as he had become apneic and unresponsive. Time
of death documented at 04:25 p.m. on [**2102-12-13**]. Family was
notified and refused autopsy.
CONDITION ON DISCHARGE: Deceased.
DISCHARGE DIAGNOSES: Renal cell carcinoma, metastatic.
Pneumonia.
Empyema.
Respiratory failure.
Septic shock.
Inflammatory response syndrome.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 48404**]
Dictated By:[**Doctor Last Name 21141**]
MEDQUIST36
D: [**2103-6-20**] 13:44:53
T: [**2103-6-20**] 15:15:28
Job#: [**Job Number 50053**]
|
[
"198.5",
"197.7",
"401.9",
"560.1",
"V10.52",
"510.9",
"785.52",
"518.81",
"197.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4061, 4436
|
2609, 4003
|
1052, 1205
|
1228, 2591
|
168, 803
|
826, 1020
|
4028, 4039
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,004
| 145,818
|
44965
|
Discharge summary
|
report
|
Admission Date: [**2140-2-25**] Discharge Date: [**2140-3-1**]
Date of Birth: [**2086-8-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Aspirin / Metoprolol Tartrate
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Cervical Stenosis
Major Surgical or Invasive Procedure:
[**2140-2-26**]: ACDF C4-5, C7-T1
History of Present Illness:
Patient is a 53M who presented for elective admission for
hypertensive managment and cervical fusion and decompression
Past Medical History:
s/p cervical fusion C4-5, C7-T1('[**23**]), s/p knee and ankle
surgery, s/p removal of finger cysts, HTN
Social History:
Non-contributory
Family History:
Non-contributory
Physical Exam:
Awake alert oriented with full motor exam except left tricep
[**5-9**]. Sensation intact. Incision intact. Tolerating po intake /
voiding freely / + BM. he is ambulatory without assistance.
Pertinent Results:
Labs on Admission:
[**2140-2-26**] 04:37AM BLOOD WBC-6.5 RBC-4.67 Hgb-13.7* Hct-40.6
MCV-87# MCH-29.4 MCHC-33.8 RDW-13.7 Plt Ct-291
[**2140-2-26**] 04:37AM BLOOD PT-12.1 PTT-32.8 INR(PT)-1.0
[**2140-2-26**] 04:37AM BLOOD Glucose-105* UreaN-14 Creat-1.0 Na-141
K-3.2* Cl-103 HCO3-32 AnGap-9
[**2140-2-26**] 04:37AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1
Labs on Discharge:
[**2140-2-29**] 04:40AM BLOOD WBC-11.3* RBC-4.08* Hgb-11.8* Hct-36.8*
MCV-90 MCH-28.9 MCHC-32.1 RDW-13.9 Plt Ct-291
[**2140-2-29**] 04:40AM BLOOD Glucose-101* UreaN-13 Creat-0.9 Na-142
K-3.5 Cl-104 HCO3-29 AnGap-13
[**2140-2-29**] 04:40AM BLOOD Calcium-8.7 Phos-2.4* Mg-2.1
Imaging:
CT C-Spine [**2-28**]:
IMPRESSION: Postoperative changes following C4-5 and C7-T1
fusion, with
grossly unchanged alignment and canal stenosis spanning the
C5-T1 region.
LUE ultrasound:
IMPRESSION: No left upper extremity DVT. Internal jugular veins
not
evaluated due to the presence of neck dressing.
Brief Hospital Course:
Patient was electively admitted on [**2140-2-25**] to the medical ICU
for systolic blood pressure management prior to elective
surgical decompression and fusion of the cervical spine. He went
to the OR [**2-26**] and returned to the ICU post-operatively for
continued management. Renal service was consulted on admission
to assist with hypertensive managment. He was started on
clonodine and ACE was increased under their managment. On [**2-28**],
his IV in the LUE infiltrated, and the arm appeared erythematous
and swollen. A UE ultrasound was performed to rule out
alternate cause of swelling; and interpreted to be negative for
DVT. He was seen and evaluated by PT/OT, who determined patient
is safe for discharge home. He was discharged on [**2140-3-1**] with
instructions to wear his cervical collar at all times and to
follow up with Dr. [**First Name (STitle) **] in approximately 6 weeks with
non-contrast CT C-spine. he was also instructed to follow up
with Dr. [**First Name (STitle) 10083**] at [**Last Name (un) **] for continued BP management.
Medications on Admission:
Minoxidil 10mg, Accupril 40m, Adalat SR 90mg, Lasix
Discharge Medications:
1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Minoxidil 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Quinapril 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily)
as needed for HTN.
Disp:*120 Tablet(s)* Refills:*0*
6. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical Stenosis
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? No pulling up, lifting more than 10 lbs
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? You are required to wear your cervical collar at all times.
?????? You may shower briefly without the collar; unless you have
been instructed otherwise.
?????? You will not be able to drive while the neck collar is on or
you are taking narcotics.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
Please return to the office for a wound check on [**3-7**] at 11 am
at [**Hospital Ward Name **] 3B the neurosurgical office [**Telephone/Fax (1) 4296**]
You will need to follow-up with Dr. [**First Name (STitle) **] in 6 weeks with
radiologic studies.
Please follow up with Dr. [**First Name (STitle) 10083**] at [**Last Name (un) **] for your blood
pressure control [**Telephone/Fax (1) 2378**] / you should see him within [**3-9**]
weeks of discharge.
Completed by:[**2140-3-1**]
|
[
"403.90",
"999.9",
"722.71",
"272.4",
"278.01",
"564.00",
"E879.8",
"585.3",
"250.40",
"E870.0",
"349.31",
"588.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.02",
"84.51",
"77.79",
"80.51",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
3908, 3914
|
1908, 2970
|
323, 359
|
3976, 4000
|
929, 934
|
5204, 5691
|
685, 703
|
3072, 3885
|
3935, 3955
|
2996, 3049
|
4024, 5181
|
718, 910
|
266, 285
|
1297, 1885
|
387, 507
|
948, 1278
|
529, 635
|
651, 669
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,274
| 193,779
|
44276+58698
|
Discharge summary
|
report+addendum
|
Admission Date: [**2179-12-31**] Discharge Date: [**2180-1-5**]
Date of Birth: [**2124-11-17**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Left sided weakness, blurry vision, facial droop
Major Surgical or Invasive Procedure:
IV t-PA
angiography by interventional neurosurgery
CT angio and multiple NCHCTs
History of Present Illness:
** History obtained from chart, co-residents, patient and
patient's wife **
Patient is a 55 year old right handed male with past medical
history of alcohol abuse, PTSD, anxiety, ADHD who presented to
the [**Hospital1 18**] ED on [**2179-12-31**] for acute stroke. History supplemented
by info from girlfriend.
Patient reports that he fell backwards and hit his head on ice
while shoveling snow in the afternoon of new years eve. He then
was watching TV just before 20:00 when he had acute onset of
blurred vision after coughing. Called his girlfriend. She
returned home between 20:00 and 20:15. His wife and her friend
are both nurses; they report that up to 20:20 pm, patient was
complaining of blurred vision, but was able to hold both arms
above head, walk, plantar flex. EMS called. By time EMS arrived
around 20:30, he was noted to have right gaze preference, dense
left hemiplegia and left neglect. BP 188/104 L, 150/80 right.
Transported to [**Hospital1 18**] ED where Code Stroke Called. ED notified at
20:40. Patient arrived at [**Hospital1 18**] at 20:55. Stroke Team called at
20:56; neurology on site by 21:00. CT ordered at 20:55, done and
interpreted by 21:20. CTA performed as well. Bolus dose tpa
started at 21:30.
Initial NIHSS 19. FSBG 111. Systolic blood pressures in 160s.
Patient with right gaze preference, left visual neglect, left
UMN facial palsy, left hemiplegia with no withdrawal to noxious
stimuli, mild dysarthria and left neglect.
Patient improved somewhat after tPA bolus with ability to hold
left upper extremity against gravity briefly, hold left lower
extremity and provide some resistance, decreased left neglect,
ability to gaze toward left, improved speech. However, as of
22:15, symptoms worsened with decreased movement of left side to
point of hemiplegia and more pronounced neglect. Final
interpretation of CTA suggestive of right ICA occlusion.
Patient was admitted to the Neuro ICU with post-tPA protocol
orders and placed on neosynephrine to keep SBP 160-170 range x
36 hrs. He underwent angiography by Dr. [**Last Name (STitle) 1132**] on [**2180-1-1**] which
showed a right ICA dissection and pseudoaneurysm. Repeat head
CT's after t-PA showed no evidence of bleeding, thus he was
placed on a full aspirin. Then, on [**2179-1-2**], head CT showed a
stroke on the right, less than one-half of the hemisphere, thus
it was decided to start him on low dose heparin gtt and coumadin
with a goal PTT 40-50.
Prior to angiograph, TTE was done and showed no PFO and no
shunt.
He passed a swallow study in the ICU and thus may eat solid
foods.
Past Medical History:
1. Anxiety
2. PTSD
3. ADHD
4. Depression
5. Alcohol abuse
6. Migraine
7. Status post C5-C6 laminectomy and fusion several years ago by
[**Doctor Last Name 1327**]
8. Diverticulitis, now status post partial colectomy
9. Asplenia secondary to trauma incurred during Vietman
10. Multiple sharpnel injuries while in Vietmam, [**2142**] - NO MRI!!
Social History:
Divorced. Lives with female partner for past 15 years. 2
biologic and 1 adopted child. Works as a real estate broker.
Smokes 1ppd for many years. History of alcohol abuse but no EtOH
for 6 weeks. No drug use.
Family History:
adopted
Physical Exam:
Exam upon transfer to floor:
Tc 97.8 Tm 100.1 BP 155/128 HR 85 NSR RR 17 O2 sat 96% RA I/O:
2743/3750, LOS +550cc
Gen: NAD, pleasant, conversant
Chest: CTA bilat
CV: RRR without mur
Extrem: no edema
MS: awake, alert, fluent, repeats, prosody normal, orients well
to the left (improved, no neglecct), no apraxia (brushes teeth)
CN: no field cut, pupils 4->2mm bilat, EOMI, left face droop,
midline tongue
MOTOR:
- left arm: 0/5 throughout, hypotonic
- left leg: externally rotated, some adduction but otherwise no
movement
- right side: full strength
[**Last Name (un) **]: + extinction to DSS on left, very little sensation to LT
on left arm, withdrawl to pain left leg. Right side normal.
DTRs:
[**Name2 (NI) **] BR Tri Pat Ach
Right 2 2 2 2 1
Left 2 2 2 2 1
toe left upgoing, toe right downgoing.
Gait: not tested
Pertinent Results:
As of [**2180-1-3**]
CBC: 10/44/301 diff 57/25/11
Chem: 140/4.2/108/27/8/0.8/119
Cal 8.6, phos 2.5, mag 1.9
PTT: 68 (on heparin), INR 1.1
ESR: 5
[**Doctor First Name **]: pending
Chol 151, LDL 97, HDL 47, TG 63
Tox: acetaminophen 8.6
Ruled OUT for MI
Blood Cx [**2180-1-1**] pending
TTE: The left atrium is normal in size. The right atrium is
dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal
(LVEF 60-70%). The right ventricular cavity is dilated. Right
ventricular
systolic function is normal. The aortic valve is not well seen.
The mitral valve leaflets are structurally normal. There is no
pericardial effusion. Air bubble contrast imaging did not
demonstrate the presence of right-to-left shunt across the
interatrial septum, but the study is technically suboptimal.
The presence of right heart chamber enlargement raises the
suspicion of the presence of an atrial septal defrect with
left-to-right shunt, but this abnormality was not demonstrated
on limited color-flow imaging.
NCHCT:
[**2180-1-2**]: 1. Continued evoluation of a known right MCA territory
infarct.
2. No intracranial hemorrhage.
[**2180-1-1**]: 1. Acute right middle cerebral artery territory
infarct.
2. No intracranial hemorrhage identified.
3. Stable ventricle size.
[**2179-12-31**]: No definite intracranial hemorrhage is seen on this
study performed 90 minutes after a contrast-enhanced study.
Contrast enhancement limits evaluation for subtle intra or
extra-axial hemorrhage.
CT angio head [**2179-12-31**]:
1. Occlusion of the right internal carotid artery distal to the
bifurcation of the common carotid artery within the neck. There
is, however, reconstitution of flow within the intracranial
right internal carotid artery and middle cerebral artery
branches, possibly from collateral flow through the anterior
communicating artery.
2. [**Doctor Last Name **]/white matter distinction is preserved.
Brief Hospital Course:
55 yo man with right ICA dissection and occlusion, s/p t-PA on
[**2179-12-31**]. Transfer to the floor. Exam: left hemiparesis
(plegia in the arm, but paresis in the leg with some adduction),
improved left visual neglect and left sided sensation.
This patient was given t-PA without complication on [**2179-12-31**].
His blood pressure was maintained with neosynephrine while in
the ICU. CT angio revealed right ICA occlusion. (Patient
cannot have MRI 2o2 srapnel). Angiography on [**2180-1-1**] showed
right ICA dissection with pseudoaneurysm. He was given asprin,
then transitioned to IV heparin drip and coumadin on [**2179-1-2**]
after repeated NCHCTs showed no hemorrhage and < [**1-2**] of right
hemisphere involved in the stroke. Once coumadin is theraputic
(INR 2-2.5), then heparin can be discontinued. The dissection
was likely caused by his fall onto the ice while shoveling,
however ESR and [**Doctor First Name **] were sent as part of the work up. ESR 5,
[**Doctor First Name **] pending.
Upon transfer to the floor, florinef was started to keep SBP >
120. This should be continued for another week (d/c on
[**2180-1-11**]).
He complained of a headache, occipital, radiating to the front
of the head, reproducible with pressure applied to greater
occipital nerve. Most likely etiology is occipital neuralgia
s/p fall on ice. Given percocet for the pain and compazine (to
prevent emesis as could worsen dissection). Neurontin should
help pain as well.
Cholesterol panel: 157, tg 63, hdl 47, ldl 97. Glucose was
tightly controlled.
TTE showed no PFO, no veggitations or clot.
He passed a bedside swallow eval and was placed on a heart
healthy diet. He was evaluated by PT/OT. To be discharged to
rehab.
Re: Psych meds, neurontin was restarted and antabuse was
continued. Ritalin was held.
Prophylaxis - Pneumoboots, PPI, RISS, on heparin drip
FULL CODE
Medications on Admission:
Medications prior to admission:
Wellbutrin 400
Ritalin 20
Antabuse
Thiamine 1
Neurontin prn insomnia, up to 1000 mg
Discharge Medications:
1. Prochlorperazine 10 mg Tablet Sig: 1-2 Tablets PO Q6H (every
6 hours) as needed for nausea: Take prophylactically with
percocet for nausea.
[**Date Range **]:*30 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
[**Date Range **]:*30 Tablet(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
[**Date Range **]:*60 Tablet(s)* Refills:*0*
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Date Range **]:*60 Capsule(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Date Range **]:*60 Capsule(s)* Refills:*2*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
[**Date Range **]:*30 Cap(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
9. Disulfiram 250 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Date Range **]:*15 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
[**Date Range **]:*30 Tablet(s)* Refills:*0*
11. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
[**Date Range **]:*120 Tablet Sustained Release(s)* Refills:*2*
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
[**Date Range **]:*250 ML(s)* Refills:*0*
13. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
[**Date Range **]:*60 Capsule(s)* Refills:*2*
14. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
15. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): discontinue on [**2179-1-10**].
[**Date Range **]:*30 Tablet(s)* Refills:*2*
16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
[**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
17. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Units, regular insulin Injection QACHS: Sliding scale:
BG 151-200: 2 units
BG 201-250: 4 units
BG 251-300: 6 units
BG 301-350: 8 units
BG 351-400: 10 units
BG >= 401: 12 units and call physician.
[**Name Initial (NameIs) **]:*QS Units, regular insulin* Refills:*2*
18. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Nine Hundred (900) Units per hour Intravenous Continuous
infusion: Check PTT Q 6 hours after starting or adjusting
Heparin and QD thereafter; adjust dose for target PTT of 45-55.
[**Name Initial (NameIs) **]:*QS Units per hour* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Rt sided MCA Stroke as complication of Rt. ICA dissection with
peudoaneurysm.
Discharge Condition:
Stable - left hemiplegia of face arm and leg (mild adduction of
left leg is present). Left neglect improved. Passed swallow
evaluation.
Discharge Instructions:
- discontinue florinef in one week on [**1-11**]
- check INR frequently, goal 2-2.5
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2180-4-12**] 11:30
Provider: [**Name10 (NameIs) **] SCAN Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2180-4-12**] 11:45
NOTE - do not eat any food or drink for three hours before the
above radiology appointments.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2180-4-12**] 1:00
Name: [**Known lastname 15024**],[**Known firstname **] G Unit No: [**Numeric Identifier 15025**]
Admission Date: [**2179-12-31**] Discharge Date: [**2180-1-5**]
Date of Birth: [**2124-11-17**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 15026**]
Addendum:
Patient will need a hypercoagulable workup as an outpatient
either by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or Dr. [**Last Name (STitle) 1801**], given h/o prior DVT as
well as clot formed on dissected artery. In Neurological
follow-up, after repeat CTA and lab work-up, determine whether
dissection has healed and whether hypercoagulable state is
absent. If healed, discontinue Coumadin and start antiplatelet
for stroke prophylaxis.
Also, patient should discontinue florinef on [**2180-1-11**].
Chief Complaint:
see d/c summ
Major Surgical or Invasive Procedure:
administration of t-PA
Angiogram by Dr. [**Last Name (STitle) 365**]
CT angio
History of Present Illness:
see d/c summ
Past Medical History:
1. Anxiety
2. PTSD
3. ADHD
4. Depression
5. Alcohol abuse
6. Migraine
7. Status post C5-C6 laminectomy and fusion several years ago by
[**Doctor Last Name **]
8. Diverticulitis, now status post partial colectomy
9. Asplenia secondary to trauma incurred during Vietman
10. Multiple sharpnel injuries while in Vietmam, [**2142**] - NO MRI!!
Social History:
see d/c summ
Family History:
see d/c summ
Physical Exam:
see d/c summ
Pertinent Results:
[**Doctor First Name **] negative
see d/c summ
Brief Hospital Course:
see d/c sum
Medications on Admission:
see d/c summ
Discharge Medications:
1. Prochlorperazine 10 mg Tablet Sig: 1-2 Tablets PO Q6H (every
6 hours) as needed for nausea: Take prophylactically with
percocet for nausea.
[**Doctor First Name 215**]:*30 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain: Please take
compazine with each dose to prevent emesis.
[**Doctor First Name 215**]:*30 Tablet(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): hold for loose stools.
[**Doctor First Name 215**]:*60 Tablet(s)* Refills:*0*
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Doctor First Name 215**]:*60 Capsule(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Doctor First Name 215**]:*60 Capsule(s)* Refills:*2*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
[**Doctor First Name 215**]:*30 Cap(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Doctor First Name 215**]:*30 Tablet(s)* Refills:*2*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Doctor First Name 215**]:*30 Tablet(s)* Refills:*2*
9. Disulfiram 250 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Doctor First Name 215**]:*15 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
[**Doctor First Name 215**]:*30 Tablet(s)* Refills:*0*
11. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
[**Doctor First Name 215**]:*120 Tablet Sustained Release(s)* Refills:*2*
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
[**Doctor First Name 215**]:*250 ML(s)* Refills:*0*
13. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
[**Doctor First Name 215**]:*60 Capsule(s)* Refills:*2*
14. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): goal INR 2-2.5, to be followed by Dr. [**Last Name (STitle) 1801**] as an
outpatient.
[**Last Name (STitle) 215**]:*30 Tablet(s)* Refills:*2*
15. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): discontinue on [**2179-1-10**].
[**Date Range 215**]:*30 Tablet(s)* Refills:*2*
16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
[**Date Range 215**]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
17. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Units, regular insulin Injection QACHS: Sliding scale:
BG 151-200: 2 units
BG 201-250: 4 units
BG 251-300: 6 units
BG 301-350: 8 units
BG 351-400: 10 units
BG >= 401: 12 units and call physician.
[**Name Initial (NameIs) 215**]:*QS Units, regular insulin* Refills:*2*
18. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1200 (1200) Units per hour Intravenous Continuous
infusion: Check PTT Q 6 hours after starting or adjusting
Heparin and QD thereafter; adjust dose for target PTT of 45-55.
[**Name Initial (NameIs) 215**]:*QS Units per hour* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
Rt sided MCA Stroke as complication of Rt. ICA dissection with
peudoaneurysm.
Discharge Condition:
Stable - left face and arm > leg hemiparesis (left leg can
mildly adduct). Fluent. Passed swallow study.
Discharge Instructions:
Please take all medications. Please continue florinef x one
more week (to be discontinued on [**2180-1-11**]). If you feel like
coughing or vomiting, ask for preventative medicine. Return to
the ED or call your doctor if you experience bleeding, worsening
or new weakness, or other concerning symtpoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) RADIOLOGY Phone:[**Telephone/Fax (1) 491**] Date/Time:[**2180-4-12**] 11:30
Provider: [**Name10 (NameIs) **] SCAN Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) RADIOLOGY Phone:[**Telephone/Fax (1) 491**] Date/Time:[**2180-4-12**] 11:45
NOTE - do not eat any food or drink for three hours before the
above radiology appointments.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 189**] NEUROLOGY
Phone:[**Telephone/Fax (1) 190**] Date/Time:[**2180-4-12**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] MD [**MD Number(1) 9973**]
Completed by:[**2180-1-5**]
|
[
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"443.21",
"V45.79",
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"314.01",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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] |
17506, 17587
|
14276, 14289
|
13611, 13691
|
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|
14204, 14253
|
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14170, 14185
|
8491, 8577
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13559, 13573
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13719, 13733
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14111, 14125
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,000
| 180,274
|
32354
|
Discharge summary
|
report
|
Admission Date: [**2199-12-18**] Discharge Date: [**2200-5-5**]
Date of Birth: [**2199-12-18**] Sex: F
Service: Neonatology
HISTORY: This patient's post discharge name is [**Name (NI) 16284**] [**Name (NI) **].
Baby girl [**Known lastname 16284**] [**Known lastname **] delivered at 26 and 0/7 weeks gestation
was admitted to the newborn intensive care unit for
management of extreme prematurity and respiratory distress.
Admission weight 723 gm in 10-25th percentile, length 32 cm
in 10-25th percentile, head circumference 22 cm in 10th
percentile.
Mother is a 29-year-old gravida 2, para 0 now 1 mother with
estimated date of delivery [**2200-3-26**]. Prenatal
screens included blood type O+, antibody negative, hepatitis
B surface antigen negative, RPR nonreactive, group B Strep
unknown, rubella unknown. There was no significant maternal
or family history. Pregnancy initially went well until she
presented to [**Hospital1 69**] on [**2199-12-15**] with spotting, preterm contractions and concerns for
abruption. Mother was treated with magnesium sulfate,
betamethasone, and erythromycin. She became betamethasone
complete on [**2199-12-17**]. On [**2199-12-17**] the
mother was transferred from the antepartum floor to labor and
delivery due to preterm premature rupture of membranes,
preterm labor that was unstoppable. There was no maternal
fever during labor and delivery, however, post delivery the
mother's T-max was 101.2.
The infant delivered by vaginal delivery. She emerged with
poor color, reduced activity, but with spontaneous cry and
respiratory effort. She was dried, stimulated, bulb suctioned
and given positive pressure ventilation via neo puff. The
infant responded well with improvement of heart rate, color
and activity. However, due to reduced overall aeration and
retractions she was intubated in the delivery room. Her Apgar
scores were 6 at one minute, 7 at five minutes.
PHYSICAL EXAM AT DISCHARGE: In general: A well-appearing,
alert infant. Head: Anterior fontanelle flat, soft, sutures
approximated. Eyes clear. Nasal stuffiness but without discharge.
Palate intact.
Chest: Breath sounds bilaterally equal, clear with mild subcostal
retracting. Heart: Normal S1, S2, no murmur. Normal pulses
and perfusion. Abdomen soft, nondistended, active bowel
sounds. No hepatosplenomegaly, no masses. Spine intact, no
dimples. Hips stable without clicks or clunks. No rashes.
Genitalia normal female external genitalia. Neurologic: Tone
appropriate for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory. [**Known lastname 16284**]
received 3 doses of surfactant for respiratory distress
syndrome. Her initial support on conventional ventilation was
pressures of 23/5, rate of 25. She had a brief trial of CPAP
on day of life 6, but require intubation for apnea. She was
extubated again on day of life 38 to CPAP and reintubated
again on day of life 39 for increased work of breathing and
carbon dioxide retention. She was extubated again
successfully on day of life 56 to CPAP requiring 25%-40%
oxygen. She transitioned to nasal cannula oxygen on day of
life 68. She remains on nasal cannula oxygen at discharge. At
home she will be on 125 cc flow.
[**Known lastname 16284**] received vitamin A 5000 units IM 3 times a week
following birth for a total of 12 doses.
[**Known lastname 16284**] received a trial of diuretic therapy with Diuril on
day of life 34 without any significant clinical difference so
the Diuril was discontinued on day of life 72.
[**Known lastname 16284**] received caffeine citrate for apnea prematurity from
day of life 1 to day of life 76. She has had no recent apnea
bradycardia associated with sleep. Her last bradycardia
associated with sleep was on [**2200-4-29**].
[**Known lastname 16284**] has chronic nasal congestion secondary to
nasopharyngeal reflux when she eats.
There was a pulmonary consult with Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] from
[**Hospital3 1810**] on [**2200-4-9**]. He will follow [**Known lastname 16284**]
as an outpatient.
Cardiovascular. [**Known lastname 16284**] received one 3-dose course of
Indomethacin for a patent ductus arteriosus with closure
documented with echocardiogram. She received a normal saline
bolus twice following birth for hypotension, but did not
require any pressor support. She has been hemodynamically
stable since, a recent blood pressure 94/47 with a mean of
62. The most recent echocardiogram was done on [**2200-4-8**]
which showed a patent foramen ovale and no pulmonary
hypertension.
Fluids, electrolytes and nutrition. She initially was
maintained on total parenteral nutrition. She started enteral
feeds on day of life 6 and advanced to full volume feeds
without problems. [**Name (NI) **] calories were increased gradually to a
maximum of 30 calories per ounce plus additional Beneprotein.
She has grown very well. At discharge she is breast feeding
or bottle feeding with breast milk that is supplemented with
Enfamil powder to equal 26 calories per ounce plus Thick-It 1
tablespoon per 2 ounces to help her with her feeding. She
also is using a Dr. [**Last Name (STitle) 174**] nipple stage 3. Her discharge
weight 3830gm, length 50cm and head circumference 37cm.
GI. Her bilirubin peaked on day of life 4 at a total of 3.8.
She received photo therapy for several days, the problem is
resolved.
[**Known lastname 16284**] had a trial of Zantac on day of life 113 for clinical
evidence of gastroesophageal reflux. She was evaluated by the
feeding team with a video fluoroscopic swallow study that was
done at [**Hospital3 1810**]. This showed discoordinated suck
swallow breathing pattern and in the initial phase of the
swallow she was characterized by severe nasopharyngeal reflux
likely due to the overall discoordination of swallowing and
respiration. They offered her nectar-thick liquids via the
Dr. [**Last Name (STitle) 174**] level 3 nipple which helped decrease the amount of
nasopharyngeal reflux. There was no aspiration, she was noted
to adequately protect her airway, so they felt that it was
safe for her to feed with thickened liquids.
Hematology. [**Known lastname 37871**] blood type is A+, direct Coombs is
negative. She received a total of 5 packed red blood cell
transfusions during her hospital stay with the last one on
[**2200-2-3**]. A recent hematocrit on [**2200-5-2**] was
34.5% with a reticulocyte count of 1.1%. She is receiving
supplemental iron around 4 mg per kg per day.
Infectious disease. She received 7 days of ampicillin and
gentamicin following birth for a suspected infection, the
blood culture was negative, the lumbar puncture was negative.
She received 7 days of vancomycin and gentamicin on day of
life [**10-13**] for suspected sepsis, the blood culture was
negative and LP was not performed. [**Known lastname 16284**] was clinically ill
around [**2200-4-8**] which appeared to be viral-like
illness; all the viral cultures were negative. She did
receive 48 hours of vancomycin and gentamicin with bacterial
infection ruled out.
Neurology. [**Known lastname 16284**] has had multiple ultrasound, one on day of
life 2, 7, 14 and 29 that showed no intraventricular
hemorrhage, some asymmetry of the ventricles that was within
normal limits. An ultrasound prior to discharge is pending.
Sensory:
Audiology: A hearing screening was performed with
automated auditory brainstem response, she passed both ears.
Ophthalmology. [**Known lastname 16284**] never had retinopathy of prematurity.
Her eyes were examined most recently on [**2200-4-22**] and
revealed mature retinal vessels. A follow-up exam was
recommended at 9 months of age.
Psychosocial. The parents have visited daily, are very
involved with [**Known lastname 37871**] care and are happy to be taking her
home finally.
CONDITION AT DISCHARGE: [**Known lastname 16284**] is now a 138-day-old, now 45
and 5/7 weeks post menstrual age infant with chronic lung
disease on oxygen, she is stable.
DISCHARGE DISPOSITION: Discharged home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47894**],
telephone number [**Telephone/Fax (1) 37887**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge. Breast feeding supplementing with
bottle feeds at 26 calorie per ounce with Enfamil powder
plus Thick-It 1 tablespoon per 2 ounces.
2. Medications. Multivitamin 1 mL daily, ferrous sulfate
0.8 mL daily.
3. Iron and vitamin D supplementation.
Iron supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age.
All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units (may be
provided as a multivitamin preparation) daily until 12 months
corrected age.
1. Car seat position screening test was done and she
passed.
2. State newborn screens, multiple have been sent, all have
been within normal limits.
3. Immunizations received: Received 1st hepatitis B
immunization on [**2200-1-17**], received 2-month
immunizations on [**2200-2-18**] which consisted of
Pediarix, HIB and pneumococcal 7-valent conjugate
vaccine. She received Synagis on [**2200-4-30**].
4. Immunizations recommended.
Synagis RSV prophylaxis should be considered from [**Month (only) **]-
[**Month (only) 958**] for infants who meet any of the following 4 criteria:
A. Born less than 32 weeks.
B. Born between 32-35 and 0/7 weeks with 2 of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school age
siblings.
C. Chronic lung disease.
D. Hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of a child's life
immunization against influenza is recommended for household
contacts and out of home caregivers.
This infant has not received Rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable and at least 6 weeks, but fewer
than 12 weeks of age.
FOLLOWUP APPOINTMENTS: Followup appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 47894**] for [**2200-5-6**] at 12 noon.
Early intervention referral to Criterion [**Location (un) 1468**], [**Telephone/Fax (1) 72773**]. A
VNA visit from Care Group VNA, telephone number [**Telephone/Fax (1) 14297**].
InfantFollowup Program referral made, telephone number [**Telephone/Fax (1) 75585**].
Will need followup ophthalmology appointment at 9
months of age, she can call Dr.[**Name (NI) **] [**Name (STitle) 56687**] to make this
appointment, telephone number [**Telephone/Fax (1) 54018**]
Pulmonary followup with Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 37305**], her appointment on
[**2200-5-23**] at 10:45 a.m.
DISCHARGE DIAGNOSES:
1. Extreme prematurity.
2. Appropriate for gestational age.
3. Respiratory distress syndrome, resolved.
4. Patent ductus arteriosus, resolved.
5. Hypotension, resolved.
6. Suspected sepsis, resolved.
7. Viral illness, resolved.
8. Chronic lung disease.
9. Apnea and bradycardia of prematurity, resolved.
10.Anemia.
11.Indirect hyperbilirubinemia, resolved.
12.Discoordinated feeding - much improved with thickening of
feedings.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2200-5-4**] 19:12:31
T: [**2200-5-4**] 20:48:04
Job#: [**Job Number 75586**]
|
[
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"276.1",
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
]
] |
8041, 8215
|
11041, 11732
|
8241, 11020
|
2561, 7853
|
7868, 8017
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,608
| 101,659
|
41163
|
Discharge summary
|
report
|
Admission Date: [**2137-2-27**] Discharge Date: [**2137-3-19**]
Date of Birth: [**2058-10-27**] Sex: M
Service: MEDICINE
Allergies:
Hydromorphone / Morphine / Amoxicillin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
HD catheter placement
History of Present Illness:
Patient is a 78 year old male with past medical history of CAD
NSTEMI, s/p CABG (LIMA to the LAD, SVG to OM1 and OM2) and St.
[**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] ([**12-12**]) with course complivated by wound dehisence,
chronic systolic dysfunction EF 30%, ESRD on HD, afib on
coumadin, stroke, chronic anemia, recent lower GI bleed with
bleeding rectal ulcers and CMV colitis, and chronic left-sided
pleural effusion transferred from [**Hospital 100**] Rehab for increasing
SOB and lethargy after receiving 1 unit PRBCs earlier today for
Hct 21; he recieved HD yesterday. HD was stopped prematurely
yesterday due to hypotension to 60/40. His discharge weight on
[**2-15**] was 60 kg; he was 73 kg pre-dialysis on [**2-21**]. Of note,
patient was discharged on [**2-15**] from the [**Hospital1 **] service after a
similar presentation, with status improving after emergent
dialysis removing 10 liters and thoracentesis. Course
complicated during this admission by presumed c. diff colitis
due to profuse diarrhea, treated with 14 days flagyl.
.
On arrival to the ED, initial vitals were T 97.2 HR 120 (afib)
BP 123/110 RR 20 100% 4L NC in acute respiratory distress. Labs
significant for H/H 7.1 AND 21.0, BNP [**Numeric Identifier 89668**] INR 2.3. He was
placed on BiPAP with resolution of respiratory distress. Prior
to transfer, patient was started on levophed for SBPs in 80s.
.
On review of systems, he has a history of stroke, PE, bleeding
with surgery, deep venous thrombosis. He denies myalgias, joint
pains, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. He denies exertional buttock or
calf pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for chest pain, severe SOB,
DOE, ankle edema, PND, Orthopnea, absence of chest pain,
palpitations.
.
In the ED initial VS were noted to be T97.2, HR 120, BP 123/110,
RR 20, Sat 100% on 4L.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
In [**2135-9-3**], per the patient's wife report, the patient
had a stent placed to the LAD and two other vessels and did well
on plavix, aspirin and coreg with an EF of 45%. On [**2136-12-7**]
after episode of CP, the patient was admitted to OSH with non- Q
wave MI and underwent cardiac catheterization which revealed 70%
LAD instent stenosis, 70-80% instent stenosis at the RCA and the
LCx had 90% stenosis and an
aortic valve area of 0.9cm. He underwent a CABG LIMA to LAD
saphenous graft sequential to an OM1 and OM2 and [**Hospital3 **] [**Hospital3 1291**].
Post -operatively course complicated by severe hyptnesion
requiring high dose pressor support with vasopressin,
epinephrine and levophed. A balloon pump was placed for several
days. He required multiple blood products. His post-op EF was
noted to be 30% per [**Hospital 100**] Rehab records. he was transferred to
[**Hospital 100**] rehab from OSH for an NSTEMI, [**Hospital 1291**] and CABG complicated by
multiple issues described below.
-CABG: LIMA to LAD saphenous graft sequential to an OM1 and OM2
and [**Hospital3 **] [**Hospital3 1291**] [**12-12**]
-PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD in [**2136**], prior
stent to RCA and LAD
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Chronic systolic dysfunction (EF 30%)
ESRD on HD
Chronic left-sided pleural effusion
Prior GI bleed - ?rectal ulcer
Hyperlipidemia
IDDM
chronic atrial fibrillation on coumadin
Stoke with no residual neurologic deficits
Hypothyroid
AS s/p [**Year (4 digits) 1291**] [**Hospital3 **]
Hyperparathyroidism
Right AV fistula
Rectal Ulcers: CMV positive
Blood cultures during his prior hospitalization grew gram
negative rods speciated to Aeromonas hydrophilia for which he
was treated with
6 weeks of ciprofloxacin last day of therapy [**2137-2-5**]. During
this time he developed lower GI bleed, colonscopy revealed
rectal uclers which were cauterizated and biospy was CMV
positive. Patient s/p 2 wks IV ganciclovir. Coumadin for afib
held and was restarted the nigth prior to admission to [**Hospital1 18**].
More recently on [**2-5**] at [**Hospital 100**] Rehab, due to persistent
diarrhea, the patient was empirically started on Flagyl for
cdiff colitis
Social History:
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Married, former salesman, several children. His wife and
children are very involved in his care.
Family History:
non contributatory
Physical Exam:
VS: BP= 69/37 HR=120s-130s RR= 24 O2 sat= 99% BiPAP 10/5 40%
FiO2
GENERAL: Mild respiratory distress.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at mandible.
CARDIAC: Irreg irreg nl S1 mechanical S2 .
LUNGS: CTAB, diffuse crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm wel perfused
Pertinent Results:
ADMISSION LABS:
[**2137-2-27**] 07:45PM BLOOD WBC-15.9* RBC-2.35*# Hgb-7.1*# Hct-21.0*#
MCV-90 MCH-30.7 MCHC-34.3 RDW-16.9* Plt Ct-297
[**2137-2-27**] 07:45PM BLOOD PT-23.7* PTT-30.8 INR(PT)-2.3*
[**2137-2-27**] 07:45PM BLOOD Glucose-139* UreaN-33* Creat-2.0*# Na-138
K-3.8 Cl-96 HCO3-34* AnGap-12
[**2137-2-27**] 07:45PM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 89668**]*
[**2137-2-28**] 05:10AM BLOOD Calcium-10.3 Phos-4.7* Mg-2.1
[**2137-2-27**] 10:26PM BLOOD Type-ART pO2-330* pCO2-51* pH-7.45
calTCO2-37* Base XS-10 Intubat-NOT INTUBA
.
CHEST XRAY [**2137-2-28**] IMPRESSION: Findings compatible with
pulmonary edema.
.
.
TTE [**2137-2-28**]
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is severely depressed (LVEF= 25 %)
with regional variation (lateral wall relatively preserved). The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with depressed free wall
contractility. There are focal calcifications in the aortic
arch. A bileaflet aortic valve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of 10 Janaury [**2137**], the tricuspid regurgitation appears reduced,
but the technically suboptimal nature of both studies precludes
definitive comparison.
.
CARDIAC CATHETERIZATION [**2137-2-28**]
1. Resting hemodynamics revealed elevated left-sided filling
pressure
with a mean PCWP of 20 mmHg. There was moderate pulmonary
hypertension
with a PA pressure of 60/28 mmHg. Cardiac output was mildly
depressed
at 4.76 L/min with an index of 2.61 L/min/m2.
2. The RVH sheath was coverted to a CVVH catheter following
right heart
cathterization.
.
FINAL DIAGNOSIS:
1. Elevated left sided filling pressure
2. Moderate-severe pulmonary hypertension.
3. CVVH catheter placed.
.
.
CT ABD/PELVIS: [**2137-3-2**]
1. No CT evidence of colitis.
2. Stable appearance of bilateral pleural effusions and
compressive
atelectasis.
3. Stable small pericardial effusion.
.
.
TTE [**2137-3-4**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is moderate global left
ventricular hypokinesis (LVEF = 30 %). Right ventricular chamber
size and free wall motion are normal. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. There is no pericardial
effusion.
.
Compared with the prior study (images reviewed) of [**2137-2-28**],
the findings are similar (estimated PASP may be slightly lower).
.
CHEST XRAY
IMPRESSION: AP chest compared to [**2-27**] through 30:
.
Progressive consolidation at the left lung base is most likely
atelectasis, worsened since [**3-3**], but pneumonia,
particularly due to aspiration could have the same appearance.
Previous pulmonary vascular congestion continues to improve.
Moderate cardiomegaly is longstanding. Small left pleural
effusion is stable. Stomach is distended with air and fluid,
gastrostomy tube in place. No pneumothorax
.
MICRO DATA
.
[**2137-2-28**] 12:27 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2137-3-2**]**
FECAL CULTURE (Final [**2137-3-2**]):
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final [**2137-3-2**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-2-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2137-2-28**] 2:52 pm Immunology (CMV) Source: Line-A Line.
**FINAL REPORT [**2137-3-5**]**
CMV Viral Load (Final [**2137-3-5**]):
CMV DNA not detected.
.
[**2137-3-4**] 7:36 am BLOOD CULTURE
Source: Line-femoral dialysis line.
**FINAL REPORT [**2137-3-7**]**
Blood Culture, Routine (Final [**2137-3-7**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
SENSITIVITIES PERFORMED ON REQUEST..
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final [**2137-3-5**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 89669**] #[**Numeric Identifier 25630**] [**2137-3-5**] 1350.
Anaerobic Bottle Gram Stain (Final [**2137-3-5**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
**FINAL REPORT [**2137-3-12**]**
Blood Culture, Routine (Final [**2137-3-12**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
[**Year/Month/Day **]------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final [**2137-3-7**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 25629**] ON [**2137-3-7**] AT 0030.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
.
Labs at discharge [**3-18**]:
HGB:9.3*
HCT:28.7*
PTT: 97
INR 1.4
WBC: 10.3
PLT: 246
Na: 123
K: 4.1
CL: 94
BUN: 20
Creat: 3.3
Gluc: 123
CA:10.3
Phos: 5.6*
Mag: 2.2
.
Brief Hospital Course:
HOSPITAL COURSE
78 year old male with past medical history of CAD, NSTEMI, s/p
CABG (LIMA to the LAD, SVG to OM1 and OM2) and St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**]
([**12-12**]) with course complivated by wound dehisence, chronic
systolic dysfunction EF 30%, ESRD on HD, afib on coumadin,
anemia, recent lower GI bleed with bleeding rectal ulcers and
CMV colitis with worsening SOB, acute decompensated heart
failure.
.
# GOALS OF CARE: Goals of care continuously discussed with
family members and the [**Name (NI) 89670**] consult team who had care for
the patient through two hospitalizations. After significant
discussion regarding sepsis, failure of dialysis without pressor
support, multiple wound infections and multiple co-morbities,
the patients was made comfort measures only on HD 9. Heparin gtt
was continued to prevent stroke per families wishes and dopamin
was slowly weaned off. CVVH, antibiotic therapy and all other
medications and lab draws were discontinued. On HD 13, the
patient was noted to be more alert with improved quality of
life. Goals of care was readdressed with the family and
hemodialysis was re-initiated. Antibiotic therapy ([**Name (NI) **])
was restarted to cover staph and enterococcus (VRE) positive
blood cultures. As Mr. [**Known lastname 89671**] [**Last Name (Titles) **] picture continued to
stabilize and he tolerated HD, there needs to be continuing
discussions regarding quality of life and goals of treatment.
Still holding all cardiac meds to allow BP for HD.
....
# CHF: Patient initially floridly volume overloaded in acute
decompensated heart failure. Patient 13 kg over discharge
weight several days prior to admission at dialysis, likely 15-20
Liters overloaded. Hyponatremia and extremely high BNP also
consistent with florid hypervolemia. Patient did not get full
HD session prior to admission due to hypotension. Acute
decompensation also likely triggered by unit of blood given
earlier today at rehab facility. Swan could not be floated but
had RHC during HD cath placement which showed wedge of 20. CKMB
stabilized at 6. Echo on [**2-28**] showed mild symmetric left
ventricular hypertrophy. The left ventricular cavity size was
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 25 %) with regional variation (lateral wall
relatively preserved). CVVH initiated for volume management and
NC for respiratory support. Dopamine gtt required to maintain
diuresis with CVVH. Ultimately, unable to wean dopamine gtt with
CVVH. Goals of care were discussed as above. Pt's fluid status
now being managed through HD and ACEi, Beta blocker being held
to allow for blood presure room during HD.
.
#. ESRD: Status post HD catheter placement on [**2-28**] after large
graft hematoma. CVVH via right groin line. Right upper arm
fistula repaired and now working normally. Tolerating HD
treatments as above and plan Mon/Wed/Fri schedule. Dr. [**Name (NI) 118**],
pt's nephrologist who has followed pt very closely here, will
continue to consult for HD issues after transfer.
.
#. ANEMIA: Patient with Hct 21 on admission, has a history of
transfusion-dependent anemia with GI sources, including rectal
ulcers. Transfused 3 units of PRBCs during admission. Initially
concerning for CMV colitis versus rectal ulcers. C diff sent
off as patient was being treated at rehab facility with PO vanco
and flagyl. Flexiseal placed. CMV VL negative and cdiff PCR
negative. Hct now 28. Has rec'd 2U PRBC during last HD
treatments and continued epogen injections during HD.
.
# GPC BACTEREMIA: GPC??????s in pairs & clusters grew from blood cx
from femoral line and art line on HD 6 which ultimately
speciated to staph aureus. Likely responsible for his
leukocytosis and worsening [**Name (NI) **] picture. He was continued
on Vancomycin. HD line was not removed, but changed over wire HD
7 after extensive discussion with Renal consult and family
regarding access. Dopamine was continued. After patient was
made CMO, vancomycin resistent enterococcus was positive in a
second set of blood cultures from HD 8. At this time the patient
was CMO and off antibiotic therapy. On HD 13, [**Name (NI) **] PO was
started to treat staph aureas and VRE after rediscussion of
goals of care. His last day will be [**2137-3-20**].
.
# HYPERCALCEMIA: Unclear etiology. Developed in the setting of
discontinuation of CVVH (in absence of citrate). Hypercalcemia
also possibly secondary to ischemia, in setting of hypotension
and elevated lactate. Lastly, patient likely has underlying
tertiary hyperparathyroidism from ESRD, known to have chronic
hypercalcemia in prior records. Likely acute on chronic
physiology. Ca has been stable at 10.
.
#. HYPOTENSION: Likely secondary decompensated heart failure,
septic physiology, and overdiuresis at times w/ CVVH. He was
continued on continuous dopamine for pressor support until goals
of care were discussed and dopamine was discontinued. Now BP is
rising off of cardiac meds.
.
#. GRAFT HEMATOMA: Large hematoma of RUE near graft site. Tender
to touch with small area of induration. Transplant surgery had
no plans to evacuate hematoma or fix graft while patient
unstable and bacteremic. Heparin gtt was continued for
anticoagulation. Now fixed and functioning well.
.
#. DIARRHEA: Flexiseal placed at rehab facility. Prior history
of CMV colitis. Per [**Hospital 100**] Rehab med list, was on PO Vanco. He
was started on oral vancomycin, metronidazole and gancyclovir. C
diff negative toxin two times, and PCR negative. No evidence of
colitis on CT scan. CMV VL negative. Gangcyclovir discontinued
on HD 6. Oral vancomycin and IV metronidazole were discontinued
on HD 7 after culture date negative. Has resolved but perineal
area still red and inflamed.
.
#. ANTICOAGULATION: Despite persistent anemia and GIB risk with
rectal ulcers, he was continued on heparin gtt given multiple
indications, including atrial fibrillation, mechanical valve and
presumed clot burden noted on previous hospitalizations.
Coumadin was restarted on [**3-18**] at 2mg daily and INR should be
checked on [**3-20**].
.
# AF: Patient presented in AFib with RVR. Has history of
chronic AFib, rate controlled with carvedilol, anticoagulated on
coumadin. He was started on amiodarone 400mg three times daily
but this medicine was held when pt made comfort care. Pt
currently in AF wtih rates 70's-80's. Coumadin restarted on [**3-18**]
at 2mg daily and currently on heparin drip as a bridge. Needs
INR on [**2137-3-20**] with goal 2.0-3.0.
.
#. CAD: Status post CABG [**12-12**]. Holding aspirin due to GIB. No
evidence of acute MI on ECG. Lateral ST changes on admission
likely secondary to demand ischemia from tachycardia. Enzymes
elevated likely due to renal failure.
.
# IDDM: Humalog SS, fingersticks QID. Will need to restart
lantus when tube feedings are started. Holding Lantus now in
setting of poor PO's.
.
#. Hypothyroid: On levothyroxine 75 mcg.
.
#. Depression: Zoloft should be restarted after [**Year (2 digits) **] is
finished on [**3-20**]. Pt is alert, talkative, aware of his situation
but wants to continue aggressive care for his family. He
currently has minimal SOB that is managed well with low dose
Morphine IV and no further CP. His goals of care may change if
his SOB and chest pain return and cannot be managed.
Medications on Admission:
Acetaminophen 650 mg QID PRN pain
ASA 81 mg daily
Ergocalciferol (vitamin D2) 50,000 unit qWednesday
Lantus 17units qPM
Lactobacillus acidoph-pectin
Levothyroxine 75 mcg daily
Metronidazole 500 mg TID (completed [**2-26**])
Omeprazole 40 mg daily
Sertraline 50 mg daily
Warfarin 1 mg daily
Carvedilol 3.125 mg [**Hospital1 **]
B complex-vitamin C-folic acid 1 mg daily
Cinacalcet 30 mg daily
PO Vanco
Megestrol
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) ml PO
Q6H (every 6 hours) as needed for fever, pain.
2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
3. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Mid-line, non-heparin dependent: Flush with 10 mL Normal
Saline daily and PRN per lumen.
4. zinc oxide-cod liver oil 40 % Ointment Sig: One (1)
application Topical [**Hospital1 **] (2 times a day) as needed for bottom
irritation.
5. [**Hospital1 11958**] 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): Last dose after dialysis on [**2137-3-20**].
6. morphine 2 mg/mL Syringe Sig: 0.5-1 ml Injection five times a
day as needed for pain or shortness of breath.
7. lorazepam 2 mg/mL Syringe Sig: 0.5-1 ml Injection Q4H (every
4 hours) as needed for anxiety.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for confusion or
agitation.
9. insulin lispro 100 unit/mL Solution Sig: 0-14 units
Subcutaneous four times a day: before meals and qhs.
10. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please start on [**2137-3-21**] when [**Date Range **] is finished.
12. heparin (porcine)-0.45% NaCl 25,000 unit/250 mL Parenteral
Solution Sig: as per weight based heparin protocol units
Intravenous continuous: D/C when INR > 2.0.
13. warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day:
Check INR on Thursday [**2137-3-21**] and adjust dose accordingly.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute on Chronic Systolic Congestive Heart Failure
Sepsis
End Stage Renal disease
Atrial Fibrillation
Anemia
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:
You had trouble breathing and was found to be in an acute
exacerbation of your congestive heart failure. It was difficult
to do dialysis because your blood pressure was very low and you
needed medicines to help keep your blood pressure up. At one
point, you and your family decided that you wanted to be made
comfortable. After we stopped all of your medicines, you
improved and was not short of breath or having chest pain. We
have resumed dialysis and restarted some of your medicines.
.
We made the following changes to your medicines:
1. Stop taking Omeprazole, Megatrol, vancomycin, carvedilol,
lactobacillus, aspirin, ergocalciferol, and nephrocaps.
2. Start taking Tylenol as needed for pain and fever
3. Start Heparin drip to prevent blood clots. We have started
coumadin pills to replace the heparin when the coumadin level is
therapeutic
4. Start Zinc ointment to use on your perineal area
5. Start [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic to treat the bacteria in your
blood. Your last day is [**3-20**].
6. Start Morphine as needed for pain
7. Start Lorazepam as needed for anxiety
8. Start olanzipine as needed to agitation
9. Use Humalog as per sliding scale to treat your high blood
sugars.
10. You will need to restart lantus if tube feedings are
started.
.
Daily weights. Call provider if weight goes up more than 3 lbs
in 1 day.
Followup Instructions:
Dr. [**Last Name (STitle) 118**] from Nephrology will follow patient in the MACU in a
consultative fashion.
.
Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 62**] on [**Hospital Ward Name 23**] 7 at [**Hospital1 18**].
He will be available to see patient on an emergent basis but
does not feel that routine f/u is needed at this time.
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"88.56",
"37.21",
"38.95"
] |
icd9pcs
|
[
[
[]
]
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21067, 21133
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11568, 18939
|
304, 327
|
21286, 21286
|
5375, 5375
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22852, 23247
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4848, 4868
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19400, 21044
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21154, 21265
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18965, 19377
|
7589, 11545
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21464, 22829
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4883, 5356
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2431, 3671
|
261, 266
|
355, 2327
|
5392, 7572
|
21301, 21440
|
3702, 4658
|
2349, 2411
|
4674, 4832
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,654
| 176,082
|
38247
|
Discharge summary
|
report
|
Admission Date: [**2174-8-15**] Discharge Date: [**2174-8-23**]
Date of Birth: [**2101-6-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Crestor / Lipitor
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2174-8-15**] - Redo sternotomy, Replacement of Aortic Valve (21mm
[**Doctor Last Name **] Pericardial Valve)/Replacement of Ascending Aorta
.
[**2174-8-15**]
Mediastinal exploration for bleeding, status post
aortic valve replacement and ascending aortic replacement
earlier in the day.
History of Present Illness:
73 year old female who now has recurrent exertional throat
tightness and headache. She was scheduled for her routine office
visit and reported her symptoms. This prompted a repeat exercise
thallium. This demonstrated some anteroseptal and apical
ischemia which was essentially unchanged from prior stress in
[**2173**]. However she developed exercise induced hypotension and did
report lightheadedness and throat tightness. Her [**Location (un) 109**] is now
0.6cm2 and peak gradient now at 121 mmHg and a mean of 76 mmHg.
She was referred for aright and left heart catheterization. Upon
cardiac catheterization she was found to have severe aortic
stenosis. She is now being referred to cardiac surgery for
redo-sternotomy and aortic valve replacment.
Past Medical History:
Coronary artery disease
GERD
Hyperlipidemia
Aortic stenosis
Obesity
Cataracts
s/p CABG x 2 at [**Hospital3 2358**] (LIMA to LAD and SVG to PDA)[**2160**]
s/p mid RCA PTCA [**2148**]
s/p Cypher stent to distal portion of SVG to PDA ([**Hospital1 112**]) [**4-12**]
s/p 3 Taxus stents in a nearly occluded native RCA at [**Hospital1 112**] [**2-12**]
Social History:
Lives with:Husband
Contact:[**Name (NI) **] (husband) Phone #[**0-0-**]
Occupation:retired teacher
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**3-15**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
maternal uncles with MI x 2 in his 40's and her sister had PCI
at age 65.
Her son had multiple stents placed in his early 40s.
Physical Exam:
Pulse:56 Resp:18 O2 sat:99/RA
B/P Right:103/63 Left:91/67
Height:5'6" Weight:220 lbs
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade __5/6 SEM loudest
at right upper sternal border____
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] obese, well healed RUQ incision, no hernias/masses
Extremities: Warm [x], well-perfused [x] Edema [x] __1+___ R
groin dsg c/d/i
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit Right: NO Left: NO
Pertinent Results:
[**2174-8-15**] ECHO
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). There
is no ventricular septal defect. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. Trivial mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION PREBYPASS: Critical aortic stenosis with mild aortic
regurgitaion and mildly dilated ascending aorta. Trivial MR [**First Name (Titles) **] [**Last Name (Titles) 85249**]d LV function.
POSTBYPASS:
1. Preserverd [**Hospital1 **]-ventricular systolci function.
2. Trace MRT and TR
3. Bioprosthetic valve in aortic position. Well seated with good
leaflet excursion. Trace AI and minimal gradiet acrooss the
valve.
4. A peri-aortic hemotoma is visualized around the sino-tubular
junction
5. No other change
.
[**2174-8-23**] 10:30AM BLOOD WBC-10.3 RBC-3.18* Hgb-9.7* Hct-29.7*
MCV-94 MCH-30.7 MCHC-32.8 RDW-14.6 Plt Ct-260
[**2174-8-21**] 06:30AM BLOOD WBC-7.8 RBC-3.04* Hgb-9.5* Hct-28.0*
MCV-92 MCH-31.0 MCHC-33.8 RDW-14.8 Plt Ct-187
[**2174-8-23**] 10:30AM BLOOD UreaN-26* Creat-1.4* Na-138 K-3.9 Cl-97
[**2174-8-21**] 06:30AM BLOOD Glucose-109* UreaN-24* Creat-1.3* Na-139
K-3.9 Cl-100 HCO3-29 AnGap-14
Brief Hospital Course:
Mrs. [**Known lastname 85250**] was admitted to the [**Hospital1 18**] on [**2174-8-15**] for surgical
management of her aortic valve disease. She was taken to the
operating room where she underwent replacement of her aortic
valve using a 21mm [**Doctor Last Name **] pericardial valve and replacement of
her ascending aorta. Please see operative note for details.
Postoperatively she was transferred to the intensive care unit
for monitoring. Immediately post-operatively, significant
sanginous output was noted in her chest tubes. The patient
became more hypotensive with increasing inotropic pressor
requirements. CXR showed a slightly more widened mediastinum
versus normal post-operative changes. Multiple products were
administered (PRBCs, Plts, FFP, Cryo, Protamine). She was taken
to the OR again for washout and hemostasis (please see operative
note) 4-5 hours after her initial operation.
After washout and chest reclosure, she was taken back to the
CVICU intubated. Over the next several hours, she was transfused
and her inotopic pressor requirements decreased. She was
ultimately weaned off of pressors and extubated. After
extubation, she was found to have mental status changes with
facial twitching. Neurology was consulted for a possible
post-operative CVA vs. seizure. CT of the head was negative and
EEG was inconclusive. Other labs were normal.
Over the next few days, the patient's mental status recovered.
She was A+OX3 and moving all extremities. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 8 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Rehab in [**Location (un) **] in good condition with
appropriate follow up instructions.
Medications on Admission:
ATENOLOL 25 mg Daily
NEXIUM 40 mg every other day
ZETIA 10 mg daily
TRICOR 145 mg Daily
FUROSEMIDE 80 mg Daily
NITROGLYCERIN 0.4 mg PRN
CRESTOR 10 mg daily
ASPIRIN 325 mg Daily
GLUCOSAMINE &CHONDROIT-MV-MIN3 1 tablet daily
ALEVE 220 mg Daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. Rosuvastatin Calcium 10 mg PO DAILY
4. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN mouth pain
5. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
6. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL QOD
7. Tricor *NF* (fenofibrate nanocrystallized) 145 mg ORAL DAILY
8. Glucosamine *NF* (glucosamine sulfate) 0 mg ORAL DAILY
9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
10. Acetaminophen 650 mg PO Q4H:PRN pain, fever
11. Furosemide 80 mg PO DAILY
12. Naproxen 220 mg PO DAILY
13. Ibuprofen 600 mg PO Q8H:PRN head ache
Discharge Disposition:
Extended Care
Facility:
tbd
Discharge Diagnosis:
Coronary artery disease
s/p CABGx2
GERD
Hyperlipidemia
Aortic stenosis
Obesity
Cataracts
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ lower extremity edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
The Cardiac Surgery Office will call you with the following
appointments:
Surgeon: Dr. [**Telephone/Fax (1) 85251**] in the [**Hospital **] Medical
office building, [**Doctor First Name **], suite2A
Cardiologist/PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8506**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2174-8-23**]
|
[
"348.30",
"285.1",
"530.81",
"V45.81",
"272.4",
"E878.1",
"441.2",
"424.1",
"E849.7",
"287.5",
"V45.82",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.45",
"34.03",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7733, 7763
|
4566, 6705
|
294, 585
|
7896, 8081
|
2966, 4543
|
9055, 9653
|
2030, 2159
|
6998, 7710
|
7784, 7875
|
6731, 6975
|
8105, 9032
|
2174, 2947
|
244, 256
|
613, 1367
|
1389, 1740
|
1756, 2014
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,553
| 169,690
|
12178
|
Discharge summary
|
report
|
Admission Date: [**2193-1-31**] Discharge Date: [**2193-2-12**]
Date of Birth: [**2145-6-8**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 4162**]
Chief Complaint:
cc:[**CC Contact Info 38119**]
Major Surgical or Invasive Procedure:
Intubation
Arterial line placement
History of Present Illness:
47 year old male with HTN, DM, ESRD on PD presenting with acute
onset myalgias, fevers/chills, cough since Tuesday, [**1-29**]. He
arrived around 9 am with temp 100.0, HR 96, BP 180s, O2 96% RA.
He was treated with several antiemetics without resolution of
nausea. Initial CXR in the ED was without infiltrate. H
received 1 liter normal saline and Influenza dfa ordered. ECG
showed peaked T V2-V4, K 5.3, Kayexelate ordered. Patient
unable to tolerate any po, therefore, bed request placed 11:30
am.
He was noted to be spitting up coffee-ground in clear fluid,
complaining of nausea, but not able to vomit. Vitals at that
time; HR 120s, SBP 160, Temp 101.6. Rectal exam was significant
for strongly guaiac positive green stool. T/S, rpt HCT sent, IVF
increased, IV PPI started and GI contact[**Name (NI) **]. GI fellow
recommended serial HCT, IV PPI, NPO and re-eval in AM, no need
for urgent endoscopy with gastritis vs. [**Doctor First Name 329**] [**Doctor Last Name **] as the
leading possibilities. Further history from patient indicates
vomiting X 10-14 times in last 24-36 hours--clear with small
specks of blood most recently. He was spitting up clear fluid
heavy with dark specks/coffee grounds. After the influenza came
back positive, Tamiflu was ordered at 75 mg/day given renal
insufficiency. O2 sat checked and found to be 85% on RA, 94% on
3L. Pt put on monitor, tachycardic to 120s-130s, SBP 160-180.
PCP notified of change. The patient was then found to be
satting in the mid 80s on 3L, with no change on increase to 5L.
His O2 sat remained 97-90 on NRB and was febrile and
hypertensive to 204/100, cxr showed new infiltrate. He was
intubated for hypoxic respiratory failure, post itubation X ray
showed worsening bilateraly infiltrates. Patient given 1 gram
vancomycin with plan to follow levels, 1 gram ceftriaxone and
500 mg Azithromycin--ID contact[**Name (NI) **] for abx choice--chosen because
influenza usually complicated by staph or strep.The renal team
was contact[**Name (NI) **] re: peritoneal dialysis. CTA considered, but given
clear alternate explanation, ongoing evidence of GIB and ESRD/PD
requirement, not performed. OGT placed, pt given tylenol, the
kayexelate (ordered earlier), and tamiflu. [**Name (NI) 38120**], pt
remained hypertensive, given several propofol doses then 100 mcg
of fentanyl with improvement to SBP 110s. HR remained 110s,
fluid running at 250 cc/hr. Had received 3 liters total prior to
transfer to MICU.
Past Medical History:
DM Type I x 30 years
HTN
S/p L vitrectomy and R vitrectomy (diabetic loss of vision)
ESRD on PD (recent baseline 6)
Gallstones
s/p arthroscopic knee surgery
Diveriticulosis
Social History:
medical assistant at [**Last Name (un) **], lives with partner who is HIV+,
tobacco (1 pack per week), social EtOH, no IVDU
Family History:
His mother has diabetes, as does maternal aunt and uncle. There
is also history of gastric cancer in his father's side
Physical Exam:
VS 102.4, HR 105, BP 130/70, 100%, RR 19
AC FiO2 100%, TV 546, RR 19, PEEP 10
GEN: intubated male, lying in bed
HEENT: PERRL, ET tube with pink secretions
CHEST: CTAB, some scattered crackles/rhonchi
CV: RRR, S1, S2 nl, no m/r/g
ABD: NABS, soft, non-tender, non-distended. No organomegaly
appreciated. PD cath site C/D/I on left mid-abdomen. No TTP
around cath site; no erythema, no swelling.
EXT: no c/c/e
NEURO: sedated, no spontaneous movements
Pertinent Results:
[**2193-1-31**] 09:50AM BLOOD WBC-9.7 RBC-3.79* Hgb-10.9* Hct-31.3*
MCV-83 MCH-28.6 MCHC-34.6 RDW-14.5 Plt Ct-235
[**2193-1-31**] 09:50AM BLOOD Neuts-86.2* Bands-0 Lymphs-9.2* Monos-4.2
Eos-0.2 Baso-0.1
[**2193-1-31**] 09:50AM BLOOD Plt Smr-NORMAL Plt Ct-235
[**2193-1-31**] 11:30PM BLOOD PT-15.3* PTT-31.6 INR(PT)-1.3*
[**2193-2-2**] 03:47AM BLOOD WBC-12.3* Lymph-11* Abs [**Last Name (un) **]-1353 CD3%-85
Abs CD3-1152 CD4%-43 Abs CD4-576 CD8%-44 Abs CD8-591 CD4/CD8-1.0
[**2193-1-31**] 09:50AM BLOOD Glucose-164* UreaN-41* Creat-12.5*#
Na-138 K-5.3* Cl-97 HCO3-29 AnGap-17
[**2193-1-31**] 09:50AM BLOOD ALT-21 AST-15 AlkPhos-61 TotBili-0.4
[**2193-1-31**] 09:50AM BLOOD Lipase-16
[**2193-1-31**] 11:30PM BLOOD Calcium-7.6* Phos-6.9* Mg-1.6
[**2193-2-3**] 04:09AM BLOOD HIV Ab-NEGATIVE
[**2193-2-4**] 08:10AM BLOOD Vanco-25.4*
[**2193-2-1**] 12:54AM BLOOD Type-ART Temp-38.3 Rates-[**12-8**] Tidal
V-550 PEEP-10 FiO2-100 pO2-180* pCO2-40 pH-7.38 calTCO2-25 Base
XS-0 AADO2-508 REQ O2-84 -ASSIST/CON Intubat-INTUBATED
[**2193-2-10**] 06:32AM BLOOD WBC-19.6* RBC-3.13* Hgb-8.9* Hct-26.9*
MCV-86 MCH-28.5 MCHC-33.2 RDW-14.3 Plt Ct-465*
[**2193-2-10**] 06:32AM BLOOD Neuts-83.0* Lymphs-11.0* Monos-3.5
Eos-2.2 Baso-0.2
[**2193-2-2**] 03:47AM BLOOD WBC-12.3* Lymph-11* Abs [**Last Name (un) **]-1353 CD3%-85
Abs CD3-1152 CD4%-43 Abs CD4-576 CD8%-44 Abs CD8-591 CD4/CD8-1.0
[**2193-2-10**] 06:32AM BLOOD Glucose-142* UreaN-42* Creat-10.0* Na-133
K-3.6 Cl-91* HCO3-26 AnGap-20
[**2193-2-10**] 06:32AM BLOOD Calcium-8.7 Phos-5.4* Mg-2.0
[**2193-2-3**] 04:09AM BLOOD HIV Ab-NEGATIVE
[**2193-2-7**] 06:25PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2193-2-7**] 06:25PM URINE RBC-[**2-20**]* WBC-[**11-7**]* Bacteri-MANY
Yeast-NONE Epi-0-2
[**2193-2-1**] 12:55AM URINE Blood-SM Nitrite-NEG Protein-500
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2193-2-1**] 12:55AM URINE RBC-[**5-28**]* WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
.
Studies:
CHEST (PORTABLE AP) [**2193-1-31**] 7:49 PM
The ET tube tip is 5.6 cm above the carina. The NG tube tip
passes the diaphragm with the side hole in the proximal stomach
with the tip most likely in the mid distal stomach. A rapid
development of bibasal opacities can be consistent with rapidly
progressing pulmonary edema, or rapidly developing pulmonary
infection which should be considered in giving the clinical
information and normal cardiomediastinal silhouette. No
appreciable pleural effusion is demonstrated. There is no
pneumothorax. The upper lungs are clear.
.
CHEST (PA & LAT) [**2193-1-31**] 10:54 AM
CHEST, PA AND LATERAL: The cardiac and mediastinal contours are
within normal limits. The lungs are clear. There are no pleural
effusions. The pulmonary vasculature is within normal limits.
Mild degenerative changes are seen within the thoracic spine.
IMPRESSION: No radiographic evidence of pneumonia.
.
Bronchial lavage [**2-7**]:
ATYPICAL.
Atypical epithelial cells in a background of abundant
macrophages, lymphocytes and neutrophils. (See note.)
Note: Few large crowded groups of epithelial cells with enlarged
nuclei and prominent nucleoli are seen. In this patient's
clinical setting , a reactive process is favored; however,
clinical correlation is required.
.
CHEST PORT. LINE PLACEMENT [**2193-2-6**] 2:53 PM
AP UPRIGHT CHEST: A new right PICC is seen with its tip
terminating just below the cavoatrial junction.
Cardiomediastinal silhouette is stable. There is slight interval
improvement in bibasilar patchy opacities, right greater than
left. No sizable pleural effusion is seen. There is no
pneumothorax. Visualized osseous structures stable.
IMPRESSION: Right PICC terminating just below the cavoatrial
junction. Interval improvement of bibasilar parenchymal
consolidation reflecting improving aspiration or pneumonia.
Brief Hospital Course:
A&P:
47 year old man with ESRD [**1-19**] DM I, HTN presents with myalgias,
shortness of breath and cough and was found to have infulenza B.
.
#Respiratory Failure-Pt presented with shortness of breath,
tested positive for influenza B, he had an increasing O2
requirement and rapidly progressing infiltrate on CXR, MRSA in
sputum. Extubated [**2-2**]. HIV antibody negative during this
admission. He was given 7 days of tamiflu. He was started on a
14 day course (day 1 [**1-31**], day 14 [**2-13**]) of vancomycin for MRSA
pneumonia, which was dosed by level. He oxygen requirement and
symptoms continued to improve on the floor after discharge from
the MICU. By discharge, he finished 2 weeks of vancomycin,
required no supplemental oxygen and reported no dyspnea.
.
#. Leukocytosis: plateauing around 20. patient remained
afebrile. Mild loose stools, cdiff negative x 5, x 2 after
latest leukocytosis. U/A had WBCs and leukocyte esterase; urine
culture negative. He was treated for three days with cipro then
sent home with 4 more days of ciprofloxacin after a second
urinalysis revealed persistent pyuria, though without any
urinary symptom. Abdominal exam is benign (no pain, no
tenderness); dialysate gs negative, culture negative.
.
#GI bleed/ anemia-There was report of coffee ground emesis in
the ED and guaiac positive stool. His Hct has been stable as
have been his hemodynamics. GI was consulted but did not think
EGD was indicated (had one in [**5-25**]) because diagnosis
(gastritis vs. [**Doctor First Name **]-[**Doctor Last Name **] tear vs. ulcer) would not change
treatment (PPI). Recent colonoscopy ([**5-25**]) showed diverticuli,
internal hemorrhoids, hypoplastic polyps. Recent colonoscopy and
EGD showed diverticuli and internal hemorrhoids as well as
hyperplastic polyps. GI states likely [**Doctor First Name 329**] [**Doctor Last Name **] tear. He
was given epoetin.
.
#ESRD-secondary to DMI and HTN, has been on PD for the past few
months, recent baseline Hct appears to be approximately 6.
creatinine is elevated @11, has been stable this admission.
Renal was consulted and he was given PD in the hospital. He had
mupirocin cream for his PD site, which he used chronically.
.
#DM type I-on humalog and lantus as [**First Name8 (NamePattern2) **] [**Last Name (un) **]. [**Last Name (un) **] was
consulted and his regimen was titrated accordingly.
.
#HTN-poorly controlled at home, non-adherence has been noted
several times, home regimen consists of enalapril 10mg q daily,
metoprolol 50mg [**Hospital1 **] and norvasc 10mg q daily. He remained
hypertensive after extubation. His regimen was titrated to
metoprolol 100 mg TID, hydralazine 50 mg PO q6H, furosemide 80
mg PO qAM, amlodipine 10 mg PO daily, enalapril 30 mg PO daily
with good control. By discharge, his metoprolol was adjusted
down to 100 mg [**Hospital1 **], and hydralazine was discontinued.
.
#Code-full
.
#Contact-[**Name (NI) **] [**Telephone/Fax (1) 38121**]-partner
.
Medications on Admission:
COLACE 100 mg--1 capsule(s) by mouth twice a day as needed for
constipation
ENALAPRIL MALEATE 10 mg--1 tablet(s) by mouth once a day
FUROSEMIDE 40 mg--1 tablet(s) by mouth twice a day
HUMALOG 100 U/ML--Ssi - [**First Name8 (NamePattern2) **] [**Last Name (un) 387**]
LANTUS 100 unit/mL--use as [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] qday
METOPROLOL TARTRATE 50 mg--1 tablet(s) by mouth twice a day
NORVASC 10 mg--1 tablet(s) by mouth once a day
calcitriol 0.25 mcg QD
phoslo 667 3 tabs with each meals
renagel 1 tab qd
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Enalapril Maleate 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 bottle* Refills:*2*
6. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Disp:*1 month supply* Refills:*2*
7. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
Disp:*1 month supply* Refills:*2*
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
11. PhosLo 667 mg Capsule Sig: Three (3) Capsule PO with each
meal.
12. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO
twice a day.
Disp:*120 Tablet(s)* Refills:*2*
14. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) unit
Injection QMOWEFR (Monday -Wednesday-Friday).
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Influenza
MRSA pneumonia
urinary tract infection
Secondary diagnoses:
type 2 diabetes mellitus
hypertension
end-stage renal disease
diverticulosis
Discharge Condition:
Stable for discharge home
Discharge Instructions:
You were admitted to the [**Hospital1 18**] ICU on [**2193-1-31**] with influenza
(the Flu), complicated by a MRSA (methicillin-resistant Staph
aureus) pneumonia. You received Tamiflu for the flu and
intravenous vancomycin for your MRSA pneumonia. Your peritoneal
dialysis was continued with alternating 1.5% and 2.5% dialysate
fluid as per the kidney doctors [**Name5 (PTitle) 7219**].
.
Please continue your medications as instructed below. Please
note that there have been changes to your home meds. Please take
ciprofloxacin for 4 days for urinary tract infection.
.
If you develop fevers, productive cough, abdominal pain,
diarrhea, or any other concerning symptoms, please call Dr. [**Last Name (STitle) **]
or go to the nearest Emergency Room.
Followup Instructions:
Please go to the following scheduled appointment:
* Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2193-2-18**] 11:10
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5,547
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20509
|
Discharge summary
|
report
|
Admission Date: [**2129-8-9**] Discharge Date: [**2129-8-15**]
Date of Birth: [**2084-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Referred from PCP with abnormal labs and high blood glucose
(700s). Routine testing after starting new antiviral regimen.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
45 year-old man with HIV (diagnosed [**2127**]), commencing HAART two
and a half weeks ago (Epzicom, Norvir, Rayataz) in the face of a
declining CD4 t-cell count, was found to have hyperglycemia of
759 mmol on PCP [**Name9 (PRE) 702**] two days ago. This was his first
antiretroviral regimen. PCP called early Tuesday and told him to
come to the hospital immediately.
.
In the ED, Mr. [**Known lastname 3903**] had elevated glucose and anion GAP.
Iinitial vitals were 98.1 113 133/90 18 99. His blood sugar was
719, Cr 1.4, anion gap 18, lactate 2.2. He appeared comfortable.
He was treated with 4 liters of NS and started on an insulin gtt
at 5 U/hr with no bolus. Prior to transfer, VS 106 112/87 24 and
99/RA, and FS remains critically high. Gap closed on insulin and
was given fluid in the ED. T-wave inversions were noted, but
cardiac enzymes were negative. Hypertriglyceridemia was noted.
No evidence of pancreatitis.
.
NPH started in the ICU today today, with some BS in 300s, upon
which NPH was increased. The [**Hospital **] Clinic team was consulted
for new onset DM, and suggested that it may not be related to
his newly started HIV medications. Nonetheless, HIVs meds were
held while in ICU.
.
Review of systems:
(+) Per HPI; He gained [**5-29**] lbs in the past few months.
(-) Denied blurry vision and copious urinatioins. denies recent
fever, infections, colds, flu. Denies fever, chills, night
sweats. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. Denied arthralgias or myalgias. Patient said
that he felt in his usual state of health at the time of
admission.
Past Medical History:
PMHx:
1. HIV ([**2127-7-22**] CD4 357 Viral load 9583) no history of
opportunistic infections, not on HAART
2. Right Sciatica with resultant LBP
3. Herpes zoster in [**6-26**] with residual scarring and post
herpetic neuralgia
4. Depression and anxiety, with hx SI/suicide attempts via
Prozac and seroquel overdose, recent hospitalization for SI
[**2127-9-6**]
5. Hx syncopal episodes in [**7-25**] and [**8-26**] with negative work up
including negative pMIBI
6. Question of alcohol abuse
7. Question Asperger's syndrome
8. Hypertension
9. Hx physical and sexual abuse as a child
10. PTSD
11. Fatty liver diagnosed by CT in [**7-25**]
12. Chronic mild thrombocytopenia
Social History:
Pt quit smoking about 3 months ago. He has not relapsed. Drinks
occasionally, last drink about a month ago. No IVDU. Pt has an
extensive history of sexual and physical abuse by his step
father from age [**9-4**]. He has been hospitalized twice for
injuries related to physical abuse. He also reports of domestic
abuse by his past partner. Mr. [**Known lastname 3903**] has been homeless off
and on for a number of years. He presently lives by himself in
the [**Location (un) 4398**] and engages in volunteer work with [**Location (un) 86**] Living
Center and another community organization.
Family History:
Family history of HTN and DM in his mother and DM in his
grandmother. Did not know of any history of autoimmune disease
or SLE. No known history of MI, stroke, heart disease or cancer.
Physical Exam:
Vitals: T:98.1 BP:111/86 P:80 R:26 O2: 100%/RA gluc:165 mmol/l
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, slightly dry mm, tongue appears rough
with blue marking (says had tablet in mouth to dissovle).
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, seems slightly distended, bowel sounds present,
non-tender, no rebound tenderness or guarding, no organomegaly,
no fluid thrill or shifting dullness.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: PEARL, EOM full with broken pursuits movements,
trigeminal sensation intact to light touch, facial movements
full, palatal elevation symmetric, spinal accessory full
strength. Strength was full for should abduction, biceps,
triceps, finger extension, hip flexion, dorsiflexion of the foot
and toe extension, bilaterally. Tone was normal. Areflexic
throughout (deep tendon). Dysmetria on finger pointing and
clumsy heel on knee to foot. No pronator drift. No asterixis.
Sensation to light touch was symmetrical and judged to be normal
on the limbs.
Pertinent Results:
[**2129-8-8**] 11:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE->1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2129-8-8**] 11:56AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2129-8-8**] 11:56AM WBC-8.0 LYMPH-22 ABS LYMPH-1760 CD3-72 ABS
CD3-1273 CD4-20 ABS CD4-347* CD8-50 ABS CD8-887* CD4/CD8-0.4*
[**2129-8-8**] 11:56AM PLT COUNT-144* LPLT-1+
[**2129-8-8**] 11:56AM NEUTS-73.5* LYMPHS-21.5 MONOS-4.0 EOS-0.4
BASOS-0.6
[**2129-8-8**] 11:56AM WBC-8.0# RBC-4.72 HGB-15.9 HCT-45.6 MCV-97#
MCH-33.7* MCHC-34.9 RDW-15.2
[**2129-8-8**] 11:56AM PSA-0.6
[**2129-8-8**] 11:56AM TSH-0.41
[**2129-8-8**] 11:56AM TRIGLYCER-3492* HDL CHOL-33 CHOL/HDL-15.3
LDL([**Last Name (un) **])-LESS THAN
[**2129-8-8**] 11:56AM TOT PROT-8.7* ALBUMIN-4.7 CALCIUM-9.9
CHOLEST-506*
[**2129-8-8**] 11:56AM ALT(SGPT)-33 AST(SGOT)-28 ALK PHOS-123* TOT
BILI-3.0*
[**2129-8-8**] 11:56AM UREA N-21* CREAT-1.3* SODIUM-128*
POTASSIUM-3.5 CHLORIDE-90* TOTAL CO2-19* ANION GAP-23*
[**2129-8-8**] 11:56AM GLUCOSE-769*
[**2129-8-9**] 08:35AM PLT COUNT-181
[**2129-8-9**] 08:35AM NEUTS-65.2 LYMPHS-30.8 MONOS-3.0 EOS-0.2
BASOS-0.7
[**2129-8-9**] 08:35AM WBC-7.0 RBC-4.67 HGB-15.6 HCT-42.4 MCV-91
MCH-33.3* MCHC-36.7* RDW-14.7
[**2129-8-9**] 08:35AM LIPASE-24
[**2129-8-9**] 08:35AM AMYLASE-36
[**2129-8-9**] 08:35AM estGFR-Using this
[**2129-8-9**] 08:35AM GLUCOSE-719* UREA N-24* CREAT-1.4*
SODIUM-132* POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-21* ANION
GAP-22*
[**2129-8-9**] 08:41AM GLUCOSE-GREATER TH LACTATE-2.2*
[**2129-8-9**] 09:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2129-8-9**] 09:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2129-8-9**] 09:00AM URINE OSMOLAL-576
[**2129-8-9**] 09:00AM URINE HOURS-RANDOM
[**2129-8-9**] 12:30PM ACETONE-SMALL
[**2129-8-9**] 12:30PM CALCIUM-9.4 PHOSPHATE-2.4* MAGNESIUM-2.3
[**2129-8-9**] 12:30PM CK-MB-2 cTropnT-<0.01
[**2129-8-9**] 12:30PM CK(CPK)-224* DIR BILI-0.5*
[**2129-8-9**] 12:30PM GLUCOSE-459* UREA N-21* CREAT-1.1 SODIUM-137
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-18* ANION GAP-19
[**2129-8-9**] 03:09PM CALCIUM-9.6 PHOSPHATE-2.0* MAGNESIUM-2.1
[**2129-8-9**] 03:09PM GLUCOSE-274* UREA N-19 CREAT-1.0 SODIUM-138
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16
[**2129-8-9**] 03:18PM PLT COUNT-171
[**2129-8-9**] 03:18PM PT-13.0 PTT-22.4 INR(PT)-1.1
[**2129-8-9**] 03:18PM WBC-8.7 RBC-4.33* HGB-14.6 HCT-38.7* MCV-89
MCH-33.6* MCHC-37.6* RDW-14.9
[**2129-8-9**] 03:35PM LACTATE-1.8
[**2129-8-9**] 03:35PM TYPE-[**Last Name (un) **] PH-7.36
[**2129-8-9**] 03:54PM %HbA1c-9.3*
[**2129-8-9**] 09:28PM GLUCOSE-126* UREA N-18 CREAT-0.8 SODIUM-137
POTASSIUM-3.3 CHLORIDE-110* TOTAL CO2-15* ANION GAP-15
.
CXR [**2129-8-9**]: No evidence of pneumonia as source of diabetic
ketoacidosis.
.
ISLET CELL ANTIBODY
Test Result Reference
Range/Units
ISLET CELL ANTIBODY SCREEN NEGATIVE NEGATIVE
THIS TEST WAS DEVELOPED AND ITS PERFORMANCE CHARACTERISTICS
HAVE BEEN DETERMINED BY [**Company **] [**Doctor Last Name **] INSTITUTE,
[**Location (un) **] CAPISTRANO. IT HAS NOT BEEN CLEARED OR APPROVED BY
THE U.S. FOOD AND DRUG ADMINISTRATION. THE FDA HAS
DETERMINED THAT SUCH CLEARANCE OR APPROVAL IS NOT NECESSARY.
PERFORMANCE CHARACTERISTICS REFER TO THE ANALYTICAL
PERFORMANCE OF THE TEST.
Test Result Reference
Range/Units
ISLET CELL ANTIBODY TITER SEE BELOW LESS THAN 1.25
JDF UNITS
TNP-SCREENING TEST NEGATIVE. TITER NOT PERFORMED.
NOTE: END POINT TITERS ARE COMPARED TO A SINGLE
INTERNATIONAL REFERENCE STANDARD AND VALUES ARE REPORTED IN
JDF (JUVENILE DIABETES FOUNDATION) UNITS.
THIS TEST WAS DEVELOPED AND ITS PERFORMANCE CHARACTERISTICS
HAVE BEEN DETERMINED BY [**Company **] [**Doctor Last Name **] INSTITUTE,
[**Location (un) **] CAPISTRANO. IT HAS NOT BEEN CLEARED OR APPROVED BY
THE U.S. FOOD AND DRUG ADMINISTRATION. THE FDA HAS
DETERMINED THAT SUCH CLEARANCE OR APPROVAL IS NOT NECESSARY.
PERFORMANCE CHARACTERISTICS REFER TO THE ANALYTICAL
PERFORMANCE OF THE TEST.
TEST PERFORMED AT:
[**Company **] [**Doctor Last Name **] INSTITUTE
[**Location (un) 54879**] CAPISTRANO, [**Numeric Identifier **]
.
.
[**2129-8-12**] 07:05AM
GLUTAMIC ACID DECARBOXYLASE
Test Result Reference
Range/Units
GAD-65 ANTIBODY <1.0 <=1.0 U/ML
SPECIMEN MODERATELY LIPEMIC
TEST PERFORMED AT:
[**Company **] [**Doctor Last Name **] INSTITUTE
[**Numeric Identifier 14272**] P.0. BOX [**Numeric Identifier 19430**]
CHANTILLY, [**Numeric Identifier 19431**]
[**2129-8-9**] 03:54PM BLOOD GLUTAMIC ACID DECARBOXYLASE-Test
Brief Hospital Course:
45 yo male, HIV +, changed HAART regimen in late [**Month (only) **], then
presented to PCPs office two-and-a-half weeks later. Glucose of
759 was found with presumed new onset diabetes.
.
# Diabetic ketoacidosis
Arrived in ICU after starting insulin drip in ED and after
receiving 4L NS. In the ICU his serum blood glucose was 459
with an anion gap of 19. He continued on insulin drip and NS
IVF until serum BG <250, when IVF was switched to D5 1/2NS +
40mEq/L K+. Treated with insulin and fluids with repletion of
potassium as necessary. This corrected quickly in the ICU.
Initially unclear if this was medication related vs. new onset
diabetes and if it was new onset type I or type II. Patient has
a family history but is somewhat late in onset. His HAART
(Norvir, Rayataz/Epzicom) was initially held in case this may
have been contributing. Antipsychitocs are also hyperglycemic
agents and may have contributed. Psychotropic medications were
not held. Insulin requirements continued and diabetes was
diagnosed.
.
# Diabetes
Antibodies for type I were negative. Given A1c of 9.7 %, a
family history and medications that may have contributed, we
thought that this was likely type II. Treatment with
subcutaneous insulin was started and titrated while he was an
inpatient. [**Last Name (un) **] followed the patient while in the hospital
and he had immediate follow-up with them and education both
while in the hospital and immediately after discharge. His
manual dexterity was not quite good enough for injection needles
- he was prescribed injecting pens.
.
# HIV
Per pharmacy, Norvir can cause hyperglycemia, Rayataz/Epzicom
can cause lactic acidosis. These drugs were initially held.
HAART, using different agents with knowledge of susceptibilities
of his viral stain, were restarted by Dr. [**Last Name (STitle) **] while he was in
the hospital. He was closely monitored for hyperglycemia.
Valacyclovir, Ritonavir, Atazanavir and Emtricitabine-Tenofovir
are his new regimen.
.
# EKG changes
Were initially noted in the ICU, with new TWI in anterior leads.
No symptoms. Cardiac enzymes x 2 sets negative, 14 hours
apart.
.
# Hypertriglyceridemia
Nomal pancreatic enzymes. [**Month (only) 116**] be secondary to hyperglycemia.
Was persistently elevated so fibrates were started.
.
# Hypertension
HCTZ was initially held because of potential contribution to
hyperglycemia. His blood pressure stayed well-controlled during
the admission. HCTZ was restarted prior to discharge.
.
# Mental status
Riperidal, citalopram and seroquel were continued as per his
home regimen throughout his admission. He was interactive,
alert, oriented, pleasant and cooperative throughout the
admission.
Medications on Admission:
DOCUSATE SODIUM 100 MG CAPS 1 cap po TID [**2129-8-8**]
FLUCONAZOLE 100 MG TABS 1 tab by mouth daily x 10 days for oral
candidiasis [**2129-8-8**]
EPZICOM 600-300 MG TABS 1 tab po every day [**2129-7-7**]
NORVIR SOFT GELATIN 100 MG CAPS 1 cap po every day [**2129-7-7**]
REYATAZ 300 MG CAPS 1 cap po every day [**2129-7-7**]
LOMOTIL TABS 1 tab po q 4-6 hrs prn [**2129-6-16**]
RISPERDAL 1 MG TABS 1 tabs p.o. qhs [**2129-5-26**]
TRAZODONE HCL 100 MG TAB 3 tabs po qhs [**2129-5-26**]
CLONIDINE HCL 0.2 MG TABS 1 tab po tid [**2129-5-26**]
VITAMIN C 500 MG TAB 1 tab po daily [**2129-5-26**]
BETA CAROTENE CAPS 1 cap po daily [**2129-5-26**]
FISH OIL 1000 MG CAPS 1 cap po daily [**2129-5-26**]
HYDROCHLOROTHIAZIDE TABS 50 MG 1 tab po daily [**2129-4-14**]
FIORICET TABS [**Medical Record Number 54880**] MG 1 tab po q 4-6 hours prn [**2128-9-29**]
CITALOPRAM HYDROBROMIDE 40 MG TABS 1.5 tabs po daily [**2128-7-20**]
SEROQUEL 200 MG TABS 1 tab po qhs [**2128-7-20**]
CYCLOBENZAPRINE HCL 10 MG TABS 1 tab po bid prn [**2127-12-31**]
IBUPROFEN 800 MG TAB 1 tab po tid prn with food [**2127-11-25**]
VALTREX 500 MG TABS 1 tab po bid [**2127-7-22**]
FLONASE 50 MCG/ACT SUSPN 2 sprays each nostril daily [**2126-2-28**]
Discharge Medications:
1. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
3. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
5. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
8. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
11. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Fenofibrate Micronized 200 mg Capsule Sig: One (1) Capsule
PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
13. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO TID
(3 times a day).
14. Insulin Admin Supplies Insulin Pen Sig: One (1) units
Subcutaneous twice a day: Please supply 75/25 humalog pen. Give
45 units with breakfat and 45 units with dinner.
Disp:*10 pens* Refills:*2*
15. Diabetic supplies
Test stips for glucometer. Please dispense 120 stips at one
time. Allow three refills.
16. diabetes supplies
Lancets for testing blood sugar. Please dispense approximately
120 at one time. Please refill three times.
17. Insulin Pen Needle 29 x [**1-21**] Needle Sig: One (1) needle
Miscellaneous twice a day: use with 75/25 disposable insulin
pen.
Disp:*60 needles* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Ketacidosis
Secondary to newly diagnosed uncontrolled diabetes
Hypertriglyceridemia
Secondary diagnosis:
HIV (managed during the stay with reinitiation of HAART)
Discharge Condition:
Mr. [**Known lastname 3903**] is in good condition on leaving the hospital. He
is taking a full diet and able to engage in activities of daily
living. He is stable from a medical point of view.
Discharge Instructions:
You were admitted to the hospital with high blood glucose. This
required one day of stay in the medical intensive care unit,
after which you were under the care of the medicine service. We
gave insulin and lots of fluid resuscitation. In addition, we
started medicine to manage your very high triglycerides, which
can also be a consequence of high blood glucose. We are still
waiting for the results of laboratory tests that will help
determine the cause of your diabetes, but feel that the
medications that you were taking may have contributed. These
medicines were adjusted, some changed, and then restarted while
you were here, and we monitored the effect that these
medications had on your blood glucose and triglycerides.
Your medications have changed. Please take the medications that
we have prescribed as detailed below. You are on new HIV
medications, and an insulin pen, also medication for your
cholesterol.
Please check your blood sugar before breakfast, lunch, dinner,
and at bedtime. Record these numbers and bring to your
appointments.
Please attend your follow-up appointments, the first of which is
this afternoon. They will be able to follow your blood sugar
and triglycerides, and see how you are going on your other
medications.
If you develop blurry vision, sweats, fever, nausea, vomiting,
diarrhea, abdominal pain, urinate large volumes, or develop any
other bothersome or worrying symtpom, please return to the
hospital.
Followup Instructions:
Appointment number 1:
[**Hospital **] Clinic for diabetes education.
Today (Monday the [**2129-8-15**]) at 3 p.m.
Appointment number 2:
Your primary care physician
[**Last Name (NamePattern4) **]: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine
Date and time: Monday [**2129-8-22**] at 11:30
Location: [**Hospital6 **] Center [**Location (un) **].,
[**Location (un) 86**], MA
Phone number: ([**Telephone/Fax (1) 5938**]
Appointment number 3:
[**Last Name (un) **] Diabetes [**Name8 (MD) **]
MD: Dr. [**First Name (STitle) 8473**] [**Name (STitle) **]
Specialty: Endocrinology
Date and time: Wednesday [**2129-8-17**] at 1 PM
Location: [**Last Name (un) **] Diabetes Center [**Last Name (un) 3911**] [**Location (un) 86**], MA
Phone number: ([**Telephone/Fax (1) 17484**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
[
"309.81",
"783.40",
"300.4",
"571.8",
"338.29",
"249.11",
"305.00",
"272.1",
"724.3",
"401.9",
"287.5",
"042",
"053.19",
"276.8",
"E931.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15547, 15605
|
9836, 12543
|
436, 444
|
15831, 16028
|
4993, 9813
|
17530, 18449
|
3576, 3763
|
13808, 15524
|
15626, 15626
|
12569, 13785
|
16052, 17507
|
3778, 4974
|
1697, 2259
|
275, 398
|
472, 1678
|
15751, 15810
|
15645, 15730
|
2281, 2952
|
2968, 3560
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,142
| 113,199
|
1930
|
Discharge summary
|
report
|
Admission Date: [**2174-5-7**] Discharge Date: [**2174-5-11**]
Date of Birth: [**2121-5-9**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2174-5-7**] Thoracentesis
History of Present Illness:
53 yo female who six weeks ago was a pedestrian struck by a
truck on the
left side resulting in multiple fractures including clavicle and
13 ribs. She was left with a pleural effusion on the left which
was documented during an emergency room visit on [**4-25**] at [**Hospital1 **]. She has been using an incentive spirometer at
home reportedly faithfully. Over the past 2-3 days she has
noticed dramatically increased orthopnea such that she is now
sleeping sitting up but no
significant increase in dyspnea on exertion, fever, sputum
production.
Physical exam:
Looks relatively
Past Medical History:
Osteopenia
OCD
Anxiety
Social History:
Married
Works as a social worker
Family History:
Non contributory
Pertinent Results:
Upon admission:
[**2174-5-7**] 11:49PM GLUCOSE-166* UREA N-10 CREAT-0.6 SODIUM-135
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
[**2174-5-7**] 11:49PM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2174-5-7**] 11:49PM WBC-13.2*# RBC-3.64* HGB-10.2* HCT-31.1*
MCV-85 MCH-28.1 MCHC-32.9 RDW-13.8
[**2174-5-7**] 11:49PM PLT SMR-HIGH PLT COUNT-536*
[**2174-5-7**] 11:49PM PT-14.2* PTT-33.5 INR(PT)-1.2*
CHEST (PORTABLE AP) [**2174-5-7**] 8:57 PM
IMPRESSION: AP chest compared to [**5-7**], 6:57 p.m.:
There has been no increase in left pleural effusion but
consolidation in the left mid and lower lung has increased
substantially, an unusual pattern for first reexpansion
pulmonary edema suggesting instead pulmonary hemorrhage. There
is no pneumothorax. Right lung is clear and heart size is
normal. Minimally displaced fracture of the left seventh rib is
unchanged and may be a second fracture, of the left tenth rib
laterally, chronicity indeterminate.
Cytology Report PLEURAL FLUID Procedure Date of [**2174-5-7**]
REPORT APPROVED DATE: [**2174-5-10**]
SPECIMEN RECEIVED: [**2174-5-9**] [**-7/1936**] PLEURAL FLUID
SPECIMEN DESCRIPTION: Received 5ml bloody fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: Undiagnosed effusion.
PREVIOUS BIOPSIES:
[**2173-11-19**] [**-6/4622**] THIN LAYER PREP PAP SMEAR WITH IMAGING
[**2172-8-18**] [**-5/3366**] THIN LAYER PREP PAP SMEAR WITH IMAGING
[**2171-3-28**] 05-[**Numeric Identifier 10694**] THIN LAYER PREP PAP SMEAR
[**2162-11-26**] 96-[**Numeric Identifier 10695**] PAP
95-[**Numeric Identifier 10696**] PAP
DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS.
CHEST (PA & LAT) [**2174-5-10**] 10:36 AM
IMPRESSION: PA and lateral chest compared to [**2174-5-9**]:
Previously severe left lung consolidation has improved. A
smaller volume of consolidation remains in the right apex and
perihilar right mid lung. Small bilateral pleural effusions are
probably unchanged over the past several days. Heart size is
normal. There is no pneumothorax.
Brief Hospital Course:
She was admitted to the Trauma Service. She underwent chest xray
which revealed no increase in left pleural effusion but
consolidation in the left mid and lower lung which had increased
substantially since last chest radiograph in early [**Month (only) 116**] but no
pneumothorax. She was transferred to the ICU where she was
monitored closely; she was placed on supplemental oxygen. Serial
chest xrays were followed. Interventional Pulmonology was
consulted for Thoracentesis; 2.5 liters was drained from the
left chest. A bronchoscopy was done 2 days later which revealed
patent airways with minimal to no secretions. She was started on
Levaquin for presumed pneumonia.
She is being discharged to home with skilled nursing from
visiting nurses. She will follow up in Surgery clinic in 1 week;
an xray will be [**Month (only) 1988**] prior to this appointment.
Medications on Admission:
MS Contin 30bid, Klonopin 0.25"', Prozac 60'
Discharge Medications:
1. Morphine 15 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO every twelve (12) hours.
Disp:*120 Tablet Sustained Release(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
4. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical every twenty-four(24)
hours: Apply to affected area.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VISITING NURSE AND COMMUNITY HEALTH
Discharge Diagnosis:
Left pleural effusion
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills,
headache, dizziness, chest pain, shortness of breath, nausea,
vomiting, diarrhea and/or any other symptoms that are concerning
to you.
Continue with the antibiotics for another 10 days.
You may resume your usual home medications as prescribed.
Followup Instructions:
Follow up next week with Dr. [**Last Name (STitle) **] in Surgery Clinic, call
[**Telephone/Fax (1) 6429**] for an appointment. You will need to have an xray
prior to this appointment.
You also have an appointment with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2174-6-16**] 8:30 you will need to have
an xray prior to this appointment on Date/Time:[**2174-6-16**] 8:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2174-5-11**]
|
[
"300.00",
"511.9",
"733.90",
"300.3",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
4988, 5054
|
3172, 4036
|
320, 350
|
5129, 5135
|
1111, 1113
|
5493, 6114
|
1074, 1092
|
4132, 4965
|
5075, 5108
|
4062, 4109
|
5159, 5470
|
944, 962
|
273, 282
|
378, 929
|
1128, 3149
|
984, 1008
|
1024, 1058
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,954
| 188,143
|
24396+57397
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-4-6**] Discharge Date: [**2195-4-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
L Hip pain
Major Surgical or Invasive Procedure:
Open reduction internal fixation with intramedullary Gamma nail
of L hip.
History of Present Illness:
The patient is an 85 year-old male w/ PMH significant for COPD,
AAA s/p endovascular repair and dementia, who presented with a
right hip fracture after experiencing an unwitnessed fall at
[**Hospital 100**] Rehab this morning. The patient reports that he was
trying to get back into bed after being in a chair for a while.
He remembers walking to the bed and then waking up on the floor.
He denies feeling weak or dizzy and denies palpitations,
urinary/fecal incontinence. He does not remember tripping on
anything. He was found by a NH assistant, When he awoke he had
some hip pain, but otherwise he felt fine.
ROS
On review of systems, the pt. denied recent fever or chills. No
night sweats or recent weight loss or gain. Denied headache,
sinus tenderness, rhinorrhea or congestion. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria.
Past Medical History:
- COPD
- AAA, s/p endovascular repair [**5-26**] (4.6cm [**2191**] --> 6.3cm [**5-26**]
--> 6.5cm, followed by Dr. [**Last Name (STitle) 61768**] [**Telephone/Fax (1) 61769**])
- DM, diet-controlled, last HgA1c 6.9 in [**5-27**]
- CKD, baseline Cr 1.7 - 1.9
- Prostate ca, tx'd w/ Lupron + flomax, lupron stopped [**9-26**],
developed hematuria in [**10-27**], lupron restarted
- Anemia, on aranesp, goal Hgb/Hct > 11/33 and < 13/36-37
- hyperlipidemia
- hypocalcemia
- hearing impaired
- depression
- DJD, lower back pain, L hip
- gait d/o
- s/p cataract surgery L eye
- Pneumococal vaccine in [**4-25**]
Social History:
Remote smoking history, 1 pack per day, but reports quitting 40
years ago. No current alcohol use. Has one son who lives in the
area. Widowed. Lives at [**Hospital 100**] Rehab, usually gets around with a
walker, participates in some activities.
Family History:
Noncontributory
Physical Exam:
VS T 97.2, P 75, BP 102/65, RR 20, O2Sat 97% RA
GENERAL: pleasant, overweight, elderly male in NAD
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MM dry, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA anteriorly, mild rales appreciated on
lateral basilar aspects
Cardiac: RRR, II/VI crescendo SEM in RUSB obscures S1, nl S2, no
R/G noted
Abdomen: soft, NT, obese, normoactive bowel sounds, no pulsatile
mass appreciated
Extremities: RLE externally rotated and shortened compared to
LLE, 2+ L DP, 1+ R DP, no C/C/E bilaterally,
Skin: no rashes or lesions noted, mild discoloration of dorsum
of feet b/l, paucity of hair noted on legs
Neurologic:
-mental status: Alert, oriented to person, thought he was at
home - [**Hospital 100**] Rehab, not oriented to year, but knew that it was
"Marathon Monday"
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. strength exam
deferred in RLE
-sensory: No deficits to light touch throughout
Pertinent Results:
[**2195-4-6**] 06:30AM PT-11.8 PTT-23.6 INR(PT)-1.0
[**2195-4-6**] 06:30AM PLT COUNT-188
[**2195-4-6**] 06:30AM NEUTS-69.0 LYMPHS-24.2 MONOS-4.3 EOS-2.3
BASOS-0.2
[**2195-4-6**] 06:30AM WBC-8.1 RBC-3.32* HGB-10.5* HCT-30.1* MCV-91
MCH-31.7 MCHC-34.9 RDW-14.1
[**2195-4-6**] 06:30AM CK-MB-2 cTropnT-0.02*
[**2195-4-6**] 06:30AM CK(CPK)-44
[**2195-4-6**] 06:30AM estGFR-Using this
[**2195-4-6**] 06:30AM GLUCOSE-127* UREA N-39* CREAT-2.2* SODIUM-140
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2195-4-6**] 10:05PM CK-MB-NotDone cTropnT-0.02*
[**2195-4-6**] 10:05PM CK(CPK)-45
[**2195-4-6**] 10:05PM UREA N-47* CREAT-2.8*
[**2195-4-6**] 10:31PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2195-4-6**] 10:31PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2195-4-6**] 10:31PM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
.
[**4-6**] AP VIEW OF THE PELVIS AND FOUR VIEWS OF THE RIGHT FEMUR:
There is a comminuted intratrochanteric fracture of the right
femur with a separate lesser trochanteric fragment which is
roughly 1.1 cm medially displaced vis-?-vis the remainder of the
bone. The right femoral head articulates normally with the
acetabulum. No other fractures are identified. Extensive
vascular calcifications are noted, and there is a stent in the
distal aorta extending into the common iliac arteries. There is
a nonspecific nonobstructive bowel gas pattern.
IMPRESSION: Comminuted intratrochanteric fracture of the right
femur.
.
[**4-6**] CXR: 1. Right hilar asymmetry which is not completely
evaluated on this film. Comparison with old radiographs would be
useful. Alternatively, this can be evaluated with CT chest with
IV contrast.
2. Asbestos related pleural disease.
.
[**4-6**] Head CT
No acute intracranial hemorrhage or fracture. Sinusitis.
.
[**4-6**] ABD/PELVIS CT
IMPRESSION: Mild decrease in size in the infrarenal abdominal
aortic sac aneurysm.
Cystic mass in the pancreatic [**Last Name (LF) **], [**First Name3 (LF) **] represent a cystadenoma
or cystadenocarcinoma. Further evaluation could be performed by
MRCP.
Diverticulosis.
Hiatal hernia.
Soft tissue mass within the bladder.
Findings were discussed with the staff member caring of the
patient.
Right femoral fracture.
.
BLADDER US
FINDINGS: Bladder is moderately distended, with a 4.7 x 2.9 x
2.1 cm heterogeneously hypoechoic lesion, arising from the lower
trigone of the bladder. That does not demonstrate vascular flow
on the color Doppler images. Patient is unable to void at the
time of the scan.
IMPRESSION: Possible 4.7 cm lesion arising from lower trigone of
the urinary bladder; does not demonstrate vascular flow on the
color Doppler images, differential diagnosis includes solid mass
versus hematoma. Kidney and bladder MR is recommended for
further evaluation.
.
URINE CYTOLOGY: ATYPICAL. Atypical urothelial cells present
singly and in clusters. Histiocytes, numerous neutrophils,
lymphocytes, crystals and red blood cells.
.
Brief Hospital Course:
Briefly, this is a 85 M with COPD, AAA s/p endovascular repair,
initially admitted s/p unwitnessed fall at [**Hospital 100**] Rehab with a R
hip fracture. The following issues were addressed during his
hospitalization.
# Hip Fracture: He was found to have a right intertrochanteric
with lesser trochanter fracture and was taken to the operating
room for repair on [**2195-4-9**]. PT was consulted. He was started
on Calcium and Vitamin D.
.
# Hematuria: The patient developed gross hematuria from a
bladder mass (clot vs soft tissue mass seen on CT and US;
Cytology consistent with atypical urothelial cells)
necessitating transfusion of 3U pRBCs and continuous bladder
irrigation. [**Year (4 digits) 159**] was consulted. He was discharged on CBI
and will follow up with [**Year (4 digits) **] as an outpatient for cystoscopy.
His SC Heparin was held (DVT prophylaxis) given ongoing
hematuria. Lupron will be continued.
.
# UTI: The patient was treated for a UTI with a 7 day course of
ciprofloxacin.
.
# Hemetemesis/Hypotension: The patient developed abdominal pain
and worsening abdominal distention on [**4-14**]; he then had an
episode of coffee ground emesis for which a nasogastric tube was
placed. He was noted to be hypotensive with BP 70s/P.
Transferred to MICU for further management. 2 units of PRBC's
were transfused. NG tube was placed and he was started on [**Hospital1 **]
PPI IV. GI was consulted and an EGD was performed, which showed
severe esophagitis with friability and bleeding in the lower
third of the esophagus as well as a few erosions c/w NG tube
trauma in the stomach body. Vascular surgery was also consulted
given concern for AAA leak; a CT scan showed no evidence of
leak. His hypotension responded to IVF bolus and was thought to
be due to hypovolemia. His Hct fell from 30.7-> 25.8 in 30
hours. He had no further episodes of hemetemesis and his presure
remained stable; he was called out to the floor on [**2195-4-15**]. On
the floor he received further PRBC transfusion to a goal Hgb of
9.
.
# Renal insufficiency: At baseline of 1.7-1.9 Avoid
nephrotoxins, renally dose meds.
.
# S/p unwitnessed fall: Likely mechanical, as workup was
remarkable only for aortic stenosis, though likely not severe
enough to cause syncope. Remainder of workup, including ECG and
ROMI, were negative.
.
# COPD: Currently stable w/o evidence of exacerbation. Patient
was continued on nebs with a goal O2 sat of 90-95%.
.
# Prostate CA: no evidence of recurrence. PSA normal. Continue
Lupron and Flomax.
.
# Diabetes: last HgA1c = 6.9%. Diet-controlled. [**Doctor First Name **] diet.
.
# Depression: Continue Celexa.
.
Code Status: DNR/DNI, confirmed.
Medications on Admission:
1. Acetaminophen 325-650 mg PO Q4-6H:PRN
2. Albuterol 0.083% Neb Soln 1 NEB IH [**Hospital1 **]
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, SOB
4. Aranesp *NF* 40 mcg/mL Injection q 14 days
5. Atorvastatin 40 mg PO DAILY
6. Budesonide (Nasal) *NF* 0.5 mg NU [**Hospital1 **]
7. Citalopram Hydrobromide 20 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, SOB
10. Oscal
11. Senna 1 TAB PO BID:PRN
12. Sorbitol 30 mL SC/PO DAILY
13. Tamsulosin HCl 0.8 mg PO HS
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sorbitol 70 % Solution Sig: One (1) ML Miscellaneous DAILY
(Daily).
6. Talc Powder Sig: One (1) Appl Topical QHS (once a day (at
bedtime)).
7. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing, SOB.
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed for SOB.
10. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) syringe
Injection QMOWEFR (Monday -Wednesday-Friday).
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Hip Fracture.
Esophagitis
Hematuria
Discharge Condition:
Hemodynamically stable, appropriate follow up arranged.
Discharge Instructions:
During this admission you were treated for a hip fracture, an
upper GI bleed secondary to esophagitis (inflammation of the
esophagus which lead to vomiting blood), and hematuria.
.
Please continue to take all medications as prescribed.
Please seek immediate medical care if you develop black or
bloody stools, vomiting blood, increasing abdominal pain,
increasing hip pain, worsening blood in your urine, or any other
concerning symptoms.
Followup Instructions:
1. Follow up with Orthopaedics in 2 weeks for staple removal and
post-op check. Call [**Telephone/Fax (1) **] for an appointment.
.
2. Follow up with [**Telephone/Fax (1) 159**] as listed below:
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2195-5-6**]
8:00
3. Please follow up with your vascular surgeon Dr. [**Last Name (STitle) 61768**] in 2
weeks.
[**Telephone/Fax (1) 61769**]
Name: [**Known lastname **],[**Known firstname 4076**] Unit No: [**Numeric Identifier 11154**]
Admission Date: [**2195-4-6**] Discharge Date: [**2195-4-19**]
Date of Birth: [**2109-10-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4541**]
Addendum:
The patient was prepared for discharge on [**4-18**], however, [**Name8 (MD) **] RN's
was splashed in the eyes with his urine (bloody) while emptying
his foley. The patient was kept overnight as it took some time
to obtain consent from his family for HIV testing given employee
exposure to his bodily fluids.
He was discharged the following day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) 2868**] [**Last Name (NamePattern4) 2869**] MD [**MD Number(1) 2870**]
Completed by:[**2195-4-19**]
|
[
"458.9",
"584.9",
"715.90",
"578.0",
"599.0",
"799.02",
"280.0",
"585.9",
"272.4",
"293.0",
"530.19",
"V10.46",
"596.8",
"250.00",
"E888.9",
"599.7",
"294.8",
"311",
"820.21",
"496",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"99.04",
"45.13",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
12916, 13143
|
6456, 9138
|
271, 347
|
11186, 11244
|
3363, 6433
|
11733, 12893
|
2277, 2294
|
9709, 11017
|
11127, 11165
|
9164, 9686
|
11268, 11708
|
3199, 3344
|
2310, 3028
|
221, 233
|
375, 1368
|
3043, 3182
|
1390, 1998
|
2014, 2261
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,164
| 118,421
|
23180
|
Discharge summary
|
report
|
Admission Date: [**2185-12-1**] Discharge Date: [**2186-1-10**]
Date of Birth: [**2121-3-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percodan
Attending:[**First Name3 (LF) 4272**]
Chief Complaint:
Right bronchopleural fistula, s/p right lower lobectomy
Major Surgical or Invasive Procedure:
[**12-5**] debridement of bronchopleural fistula
History of Present Illness:
Mrs. [**Known lastname 59614**] is a pleasant 64-year-old woman who underwent a right
lower lobectomy at an outside hospital in [**2185-7-21**]. She has had
a complicated hospital stay including the development of a
bronchopleural fistula and attempts to control this twice with
omental flaps. The fistula persists and she has been
transferred to the [**Hospital1 69**] for our
assistance in her care. She was admitted on [**2185-12-1**].
Past Medical History:
RLL NSCLC T2N0M0
[**8-9**] RLL lobectomy plus LN dissection
[**9-13**] readmission for hydropneumothorax
[**9-19**] R chest exploration, debridement, closure of bronchus
[**10-19**] Eloesser procedure, omental graft and bronchal closure
[**11-17**] tracheostomy, thoracotomy, redo omental flap
COPD
h/o candica sepsis
h/o MRSA tracheobronchitis
c-section x3
Social History:
100PY h/o smoking
Family History:
N/c
Physical Exam:
VS 52kg 98.3 (99.1) 102/58 73 20 97%TM 97-99% 2LNC
NAD, A&Ox3
trach size 6 fenestrated, capped
RRR, B CTA
R chest deep curving granulating cleen cavity, open bronchus
exposed in depth
Abd soft, NT/ND, BS +
B LE WWP, no edema
Pertinent Results:
[**2186-1-2**] 09:35AM BLOOD WBC-10.1 RBC-3.64* Hgb-11.8* Hct-35.6*
MCV-98 MCH-32.5* MCHC-33.3 RDW-18.5* Plt Ct-419
[**2186-1-2**] 09:35AM BLOOD Plt Ct-419
[**2186-1-5**] 10:00AM BLOOD Glucose-155* UreaN-10 Na-137 K-4.2 Cl-92*
HCO3-34* AnGap-15
[**2186-1-2**] 09:35AM BLOOD Lipase-33
[**2186-1-6**] 05:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2186-1-5**] 10:00AM BLOOD Calcium-9.1 Phos-5.4*
CXR [**2186-1-6**]
IMPRESSION
1. Progression of mild congestive heart failure.
2. Unchanged appearance of the chest, with a persistent small
air collection communicating with the posterior chest wall on
the right with small bilateral pleural effusions with possible
loculation on the right.
Brief Hospital Course:
Pt was admitted on date of surgery for repair of bronchopleural
fistula that developed after lobe resection in [**Month (only) 205**] of 04. She
tolerated the procedure well and was transferred to the Surgical
Intensive Care Unit for recovery. She was maintained on
levofloxacin, metronidazole, and fluconazole for coverage of
fistula. AGgressive wound packing was maintained along with
mechanical ventilation. Based on culture data, the fluconazole
was discontinued on [**12-12**]. Pt was tried on Passy-Muir valve on
the 22nd, but was noted to have only weak voice with the valve.
Remaining antibiotics were discontinued on [**12-13**]. Pt began trach
mask trials on [**12-14**], with some success. Open wound debridements
began on [**12-21**], with resection of a small amount of necrotic
tissue, and visualization of the fistula. Per Infectious disease
service pt was started on vanco based on culture data from
wound. AS of [**12-28**], pt continued to have occasional runs of afib,
and her metoprolol was increased in response to this. Began
re-entering cholecystostomy output into J-tube to prevent excess
loss of bile acids. Pt gradually recovered ability to take food
by mouth, and began requiring less tube feed support. By [**1-7**]
pt was doing well, with well-healing wound, and deemed a
suitable candidate for a rehabilitation facility to optimize her
functional status. She has excellent rehabilitation potential
for speech, ambulation, and eventual closure of her
bronchopleural fistula.
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: [**1-21**] Inhalation Q6H
(every 6 hours) as needed.
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-21**]
Puffs Inhalation Q6H (every 6 hours) as needed.
3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
4. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
9. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed.
12. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
13. Vancomycin HCl 1000 mg IV Q24H
14. Lorazepam 0.5 mg IV Q12H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right broncho-pleural fistula.
Discharge Condition:
Good.
Discharge Instructions:
Dressing change [**Hospital1 **].
Physical therapy to evaluate and treat.
Followup Instructions:
F/u with Dr. [**Last Name (STitle) 175**] in his clinic on [**2186-1-19**]
|
[
"V55.0",
"423.9",
"V44.4",
"401.9",
"510.0",
"162.9",
"V44.8",
"998.83",
"458.29",
"276.6",
"427.31",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"99.04",
"34.51",
"33.21",
"86.28",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
5047, 5117
|
2264, 3769
|
331, 381
|
5192, 5199
|
1555, 2241
|
5321, 5399
|
1283, 1288
|
3792, 5024
|
5138, 5171
|
5223, 5298
|
1303, 1536
|
236, 293
|
409, 851
|
873, 1232
|
1248, 1267
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,775
| 184,463
|
3825
|
Discharge summary
|
report
|
Admission Date: [**2126-6-26**] Discharge Date: [**2126-7-30**]
Date of Birth: [**2067-2-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin / Aloe [**Doctor First Name **] / vancomycin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Right Foot Gangrene
Major Surgical or Invasive Procedure:
[**2126-7-2**] Right Below the Knee Amputation
[**2126-7-12**]
1. Coronary artery bypass grafting x1 with saphenous vein
graft to obtuse marginal artery.
2. Aortic valve replacement with a [**Street Address(2) 17167**]. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**]
tissue valve, serial number [**Serial Number 17168**], reference number
[**Serial Number 17169**].
3. Tricuspid valve repair with [**Company 1543**] Contour 3D
annuloplasty ring size 28 mm, serial number [**Serial Number 17170**],
model number is 690R.
History of Present Illness:
59F with multiple medical problems including ESRD s/p failed
renal transplant on PD currently, severe AS/moderate MS, GI
sarcoma s/p surgery/radiotherapy in [**2111**], HTN, and CAD s/p
NSTEMI. Who was admitted from the vascular clinic with a new
open area on her right foot noted to be draining "dark fluid"
with increased confusion since [**2126-6-22**]. She was a patient at the
[**Hospital 5503**] Rehab Hospital. Patient had been complaining of
right foot/right great toe pain since [**2125-5-25**] and was
previously seen by vascular surgery in [**2126-3-26**] with decreased
pulses on the right foot. At that time arterial duplex noted
patent bilateral femoropopliteal vessels, SFA stenosis on the
left, greater than 50%, poor visualization of the tibial
arteries bilaterally and likely bilateral iliac disease. Her
vessels were noted to be heavily calcified bilaterally. She was
recommended to undergo CTA at that time but refused. Since that
time she has had continued pain in her right foot, with severe
pain even at rest, but does not know if she has ever had
claudication or prior
ulcers. She reported that she has seen another vascular surgeon
at [**University/College **] this month but he stated that her vessels were "too
calcified to do anything." She denied any fever or chills but
had some nausea and had one episode
of emesis today.
Past Medical History:
- Membranous glomeruloneprhitis, s/p cadaveric renal transplant
in [**2118**] with recurrent GN- rejection
- ESRD on peritoneal dialysis 2x daily and overnight (since
[**8-3**])
- EPO-dependent anemia
- Congestive heart failure
- GI sarcoma (rectal) with surgery and postop radiotherapy in
[**2111**]
- Histiocytosis X with thymectomy
- Multinodular Goiter
- Hypertension
- Asthma
- CAD s/p NSTEMI
- SEVERE Aortic Stenosis ([**Location (un) 109**] 0.52cm2, pk/mn 106/66)
- CHF- dCHF - EF 60% Dilated LA, Mild to moderate mitral
stenosis, mild to moderate TR, Mild to moderate PR, severe MAC
(pk/mn 18/10), Moderate mitral regurgitation
- R Renal mass (malignancy suspected, 3.1 x 2.6 x 2.8 cm on
[**1-/2126**] US)
Past Surgical History:
- s/p Ventral hernia repair with Omni mesh [**2125-6-6**]
- s/p Kidney transplant in [**2118-12-27**] and graft rejection to
ESRD requiring renal replacement therapy
- s/p Removal of GI rectal sarcoma
- s/p Thymectomy
Social History:
Used to live alone, now at [**Hospital 5503**] Rehab.
Has one adult son [**Name (NI) **] who lives nearby.
Retired housing manager. She denies any smoking, alcohol, or
drug use.
Family History:
Aunt and cousin who had breast cancer, father had prostate
cancer.
Lupus nepritis in sister. Otherwise no ESRD.
Both parents deceased.
Physical Exam:
Admission exam:
Pulse: 83 Resp: 18 O2 sat: 99%
B/P 84/58
General: Very Frail appearing cachetic female
Skin: Very Dry [X] intact []Other [x- unstageable coccyx decub
covered with DuoDerm].
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [x] Full ROM [x]
Chest: Poor inspiratory effort with diminished breath sounds
throughout. Healed MSI and other scars from thymectomy
Heart: RRR [X] Irregular [] Murmur [X] grade [**1-29**] radiated to
carotids bilaterally.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X] with peritoneal dialysis line.
Extremities: Bilaterally Cool lower extremities. R foot with
black, dry gangrene. Area demarcated from dorsal surface from
ankle to toes
Varicosities: None [X]
Neuro: poor historian with unclear comprehension of current
situation.
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: absent Left:dopperable
PT [**Name (NI) 167**]: absent Left:dopperable
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: Trans murmur
Discharge Exam:
VS: 99.5 75SR 93/59 18 96%-RA
Gen: NAD-withdrawn
Neuro: Alert-oriented x3/lethargic
CV:reg-sternum stable/ incision-clean dry
Pulm: diminished bases bilat
Abdm: soft, NT/ND/+BS, PD cath site-CDI
Ext: R BKA stump site dusky w/staples
Pertinent Results:
[**2126-7-12**] Intra-op TEE
Conclusions
Prebypass:
The left atrium is normal in size. No mass/thrombus is seen in
the left atrium or left atrial appendage. Trabeculations noted
in Left atrial appendage. A small, likely insignificant, patent
foramen ovale is present. There is mild global left ventricular
hypokinesis (LVEF = 40-45 %). Right ventricular chamber size and
free wall motion are normal. There are simple atheroma in the
ascending aorta. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Severe (4+) aortic regurgitation is
seen. The mitral valve leaflets are severely thickened/deformed,
anterior leaflet is heavily calcified and restricted, the
posterior leaflet has partial flail. There is severe mitral
annular calcification. Moderate (2+) mitral regurgitation is
seen with diastolic mitral regurgitation from aortic
regurgitation. Severe [4+] tricuspid regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**2126-7-12**] at 1000am.
Postbypass:
There is a well seated prosthetic valve in the aortic position.
No perivalvular leak is detected. A ring is visualized in the
tricuspid position with a decreased degree of tricuspid
regurgitation. No evidence of aortic dissection. Left
ventricular function is preserved from prebypass levels.
PCXR [**7-29**]:
Comparison is made with prior study, [**7-26**].
Moderate right pleural effusion with air-fluid level suggests
the presence of hydropneumothorax though the pleural line of the
pneumothorax is not as
conspicuous as before. Large left pleural effusion with
adjacent atelectasis is unchanged. Pulmonary edema has
improved, now mild. Enlargement of the cardiac silhouette and
widened mediastinum are stable. Sternal wires are aligned.
Feeding tube tip is out of view below the diaphragm.
Admission Labs:
[**2126-6-26**] 05:15PM PT-19.9* PTT-31.9 INR(PT)-1.9*
[**2126-6-26**] 05:15PM PLT COUNT-291
[**2126-6-26**] 05:15PM NEUTS-80.5* LYMPHS-11.2* MONOS-4.4 EOS-3.3
BASOS-0.6
[**2126-6-26**] 05:15PM WBC-13.1* RBC-4.24 HGB-11.8*# HCT-37.6 MCV-89
MCH-27.9 MCHC-31.4 RDW-17.6*
[**2126-6-26**] 05:15PM %HbA1c-5.5 eAG-111
[**2126-6-26**] 05:15PM CALCIUM-10.4* PHOSPHATE-2.9 MAGNESIUM-1.8
[**2126-6-26**] 05:15PM GLUCOSE-92 UREA N-30* CREAT-8.1* SODIUM-139
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-32 ANION GAP-13
Discharge Labs:
[**2126-7-30**] 02:47AM BLOOD WBC-13.3* RBC-3.00* Hgb-8.9* Hct-28.1*
MCV-94 MCH-29.7 MCHC-31.7 RDW-15.4 Plt Ct-552*
[**2126-7-28**] 04:27AM BLOOD Neuts-85.0* Lymphs-7.5* Monos-4.9 Eos-2.1
Baso-0.5
[**2126-7-30**] 02:47AM BLOOD Plt Ct-552*
[**2126-7-30**] 02:47AM BLOOD PT-17.9* INR(PT)-1.7*
[**2126-7-30**] 02:47AM BLOOD Glucose-98 UreaN-32* Creat-5.2* Na-136
K-3.7 Cl-93* HCO3-27 AnGap-20
[**2126-7-29**] 03:52AM BLOOD Glucose-105* UreaN-34* Creat-5.1* Na-136
K-3.8 Cl-94* HCO3-27 AnGap-19
[**2126-7-26**] 04:54AM BLOOD ALT-6 AST-18 AlkPhos-130* Amylase-100
TotBili-0.2
Brief Hospital Course:
MEDICINE COURSE:
Ms [**Known lastname **] is a 59 year old female with ESRD on PD,
moderate-to-severe AS and PVD now s/p right BKA who is being
transferred to the MICU for persistent hypotension.
.
# Hypotension: SBPs in 60s-70s in a woman with a history of
hypertension which was previously difficult to control.
According to the vascular surgery H/P admission blood pressure
was 80/38. Mixed venous O2 sat was 41 arguing against
distributive shock. Patient had leukocytosis to >20 and
underwent an infectious workup which was unrevealing. AM
cortisol was normal. She underwent ECHO cardiogram which showed
aortic stenosis and aortic regurgitation. Shock was attributed
to a cardiac cause, after discussion with cardiology it was
determined that ECHO severely underestimated aortic
regurgitation which appears to be wide open with essentially
laminar flow across the valve. She was changed from
phenylephrine to norepinephrine with moderate improvment in
pressures though SBP remained 80-90's. TTE showed severe AS with
severe aortic regurgitation. Cardiology was consulted and felt
that her hypotension was secondary to cardiogenic shock from
wide open MR. Cardiac cath revealed a cardiac index of .58, 80%
circ lesion. Cardiac surgery was consulted who recommended
emergent AVR/TV repair/Coronary artery bypass x1.
#. Leukocytosis: Patient admitted with leukocytosis to 13 which
trended up to 20. She was afebrile without clear sign of
infeciton. Perioneal dialysate fluid showed 42 PMN (below
cuttoff of 100) and was culture negative. Stool negative for
c.diff. CXR was clear, RUQ u/s was negative for acalculous
cholecystitis.
#. Calcific aortic stenosis: Patient with a history of severe
aortic stenosis. She was unable to compensate for the
combination of aortic stenosis and worsening aortic
regurgitation.
#. Right lower extremity Dry Gangene: She was initially admitted
to vascular surgery for angioplasty. Attempt at right tibial
artery angioplasty [**6-27**] was unsuccessful. Consideration for AVR
to improve hemodynamics was given but she was not a surgical
candidate at that time according to CT surgery. She underwent
right BKA on [**7-2**]. Following surgery, she as hypotensive and
treated with crystaloid and given 2 units PRBC. She was
ultimately transferred to the MICU for persistent hypotension.
She will need follow up with vascular surgery.
.
#. Hyponatremia: Hypervolemic hyponatremia. Sodium was in the
low 130's, likely related to receiving nutrition through tube
feeds. Adrenal insufficiency was ruled out.
.
#. Ansiocoria: History of right eye blindness in setting of
right retinal artery occlusion however no documented history of
ansiocoria. Head CT did not show any acute intracranial process.
#. Anemia: HCT ~25-28 since surgery vs baseline 30-34. Rec'd 1
unit pRBCs on [**7-6**]. Baseline anemia [**12-27**] CKD.
- daily HCTs
- transfuse to 25 given CAD
.
#. CAD: h/o NSTEMI. EKG without e/o current ischemia. Troponins
elevated in setting of CKD.
- continue aspirin 325mg
- continue statin
- repeat EKG
.
#. Renal Mass: History of mass in renal kidney which is
concerning for malignancy. In discussion with her nephrologist
this has not been fully evaluated yet given competing
priorities. The mass is highly concerning for RCC, she should
follow up with urology
.
#. Decubitus Ulcer: Patient with large decubitus ulcer related
to inactivity. She was treated with daily local wound care and
frequent repositioning.
.
# FEN: No IVF, replete electrolytes, tube feeds
# Prophylaxis: SQH
# Access: peripherals, right PICC
# Communication: patient
- Sister [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 17171**])
- Son [**Name (NI) **] ([**Telephone/Fax (1) 17172**])
.
# Family Meeting: tentatively [**Telephone/Fax (1) 1988**] for Thursday early
afternoon (he will be here at 1pm)
.
# Code: FULL CODE (confirmed)
# Disposition: ICU pending clinical improvement
VASCULAR SURGERY COURSE:
Ms. [**Known lastname **] was admitted to the vascular surgery B team where
she was admitted for right foot gangrene. Cardiac surgery was
consulted regarding her asymtomatic AS but it was decided that
her symptoms were note severe enouugh and she was too high risk
for open heart surgery. She was therefore pre-opped and
consented for her vascular sugery and on [**2126-6-27**] was taken for an
abdominal aortogram, a lower extrem angio and an angioplasty of
both the right anterior and posterior tibial arteries. After her
angio she continued to have poor blood flow to her Right lower
extremity. It was determined at this point that she still
required a BKA. She was taken to the OR on [**2126-7-2**] for a BKA.
The procedure went forward with no complications. During
awakening preceding extubation she did not return to baseline
mental functioning and only intermittently responded to
commands. She failed extubation, and was reintubated. Because of
her poor baseline pulmonary and cardiac function she got an echo
of her heart which revealed her baseline cardiac function. There
was no interval change in her CXR either. An EKG showed no
change. She was admitted to the CVICU where she eventually began
responding to commands. She was kept intubated because of her
poor respiratory drive.
On [**7-3**] [**2125**] she was extubated successfully, was responsive and
was started on IV bactrim for her gangrene. Overnight between
[**7-3**] to [**7-4**] she became hypotensive into the 70s and 80s, failed
to respond to fluid boluses times 3, and finally responded to a
bolus of albumin. Unfortunately she developed a decline in her
respiratory status, and her hypotension returned, at this point
she was transferred to the CVICU again for persistent
hypotension. She was started on levophed and then transitioned
to neo. She was transfused a single unit of PRBC for hypotension
and anemia. She was weaned off the neo on [**7-4**] [**2125**] though she
continued to have low BPs. Overnight between [**7-4**] and [**7-5**] she
was restarted on neo which was weaned by the morning. She became
hypotensive without any endorgan symptoms. Her neo was weaned
throughout the day. She continued to alternate between
requiring pressors and weaning them, until she was started on
midodrine on [**2126-7-7**]. Her blood pressure did not respond to the
midodrine and she was transferred to the MICU service for
further managment. During her time on the MICU servic she had a
repeat ECHO which revealed worening AS and was referred to
cardiac surgery for AVR.
CARDIAC SURGERY COURSE:
The patient was brought to the Operating Room on [**2126-7-12**] where
the patient underwent AVR, TV repair, CABG x 1 with Dr. [**Last Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. She left the OR
requiring multiple pressors.
Peritoneal Dialysis was resumed on POD 1. Rhythm vascillated
between junctional and rapid afib. She was treated with
amiodarone. She would eventually convert to Sinus Rhythm. INR
became supra-therapeutic and she received Vitamin K. INR would
trend down appropriately. Vasopressor/inotropic support would
be weaned by POD 3. She was extubated on POD 3. Chest tubes were
discontinued without complication. DobHoff was placed for tube
feeds. ID continued to follow the patient. She had persistent
fevers and remained pressor dependent. Cultures were sent and a
course of antibiotics tailored for a pseudomonas pneumonia.
Beta-blocker was not initiated due to persistent hypotension.
Midodrine was initiated and titrated up. SBP at the time of
discharge 110-116/70's. Intermittent colloid administered for
intravascular contraction. PD resumed daily. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD **** the
sternal wound was healing and pain was controlled with oral
analgesics. The wound care team had been actively following the
sacral decub with recommended treatments performed daily. The
decub extended to include her labia. Surgery was consulted to
evaluate the decubitus for possible diverting colostomy versus
debridement. It was debrided on [**7-23**] and per their
reccommendation, no diverting colostomy was performed. Wound
care was continued with xeroform with an ABD was applied PRN.
GI was consulted for a dropping Hematocrit and melana. The
recommended that she should have a endoscopic evaluation given
the drop in Hct and report of melena, but it did not need to be
done urgently. Hematocrit was stable at the time of discharge
with no further melana. Her white blood cell count had
increased to 22 and she was started on Bactrim and Flagyl. C
diff was negative x 2 and Flagyl was stopped. She was afebrile
at the time of discharge and WBC was decreasing on Bactim. The
vascular surgery team had evaluated her right BKA and did not
believe it to be the source of the elevated WBC. It was ischemic
with dry gangrene and will need AKA at a future date. The
patient was discharged on POD 17(AVR) to [**Hospital 5503**]
[**Hospital **] Hospital in good condition with appropriate
follow up instructions.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Aranesp (polysorbate) *NF* (darbepoetin alfa in polysorbat)
60 mcg/mL Injection every wednesday
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
hold for loose stools
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
5. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4hrs
while awake
6. Lanthanum 1000 mg PO TID W/MEALS
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Metoprolol Tartrate 12.5 mg PO DAILY
hold for sbp<100, hr<55
9. Omeprazole 20 mg PO DAILY
10. PredniSONE 7.5 mg PO EVERY OTHER DAY
11. Ranitidine 150 mg PO BID
12. sevelamer CARBONATE 1600 mg PO TID W/MEALS
13. Nephrocaps 1 CAP PO DAILY
14. Xenaderm *NF* (trypsin-balsam-castor oil) 90-87-788
unit-mg-mg/gram Topical [**Hospital1 **]
apply to buttocks [**Hospital1 **]
15. Bisacodyl 10 mg PO DAILY:PRN constipation
16. Acetaminophen 650 mg PO Q4H:PRN pain
17. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of
breath/wheezing
18. Lorazepam 0.25 mg PO Q8H:PRN anxiety
hold for sedation, rr<10
19. Ondansetron 4 mg PO Q8H:PRN nausea
20. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN severe pain
hold for sedation, RR<10
21. Senna 1 TAB PO BID:PRN constipation
22. Zinc Sulfate 220 mg PO DAILY Duration: 8 Days
23. Nitroglycerin SL 0.4 mg SL PRN chest pain
please go to ED or call your doctor if you have chest pain that
requires you to take this medication.
24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Aspirin 81 mg PO DAILY
if intubated. DC when NGT removed.
3. Amiodarone 400 mg PO DAILY
for one week then decrease to 200mg daily until seen by
cardiology
4. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eye
5. Cinacalcet 30 mg PO DAILY
6. Gabapentin 300 mg PO Q48H
7. Heparin Dwell (1000 Units/mL) 1250 UNIT DWELL WITH EACH
DIALYSIS DWELL
Please add 500 units of heparin to each peritoneal dialysis
dwell (each dwell is 1.8L so she will get 900 units with each
dwell)
8. MethylPHENIDATE (Ritalin) 5 mg PO BID
9. Metoclopramide 5 mg PO TID
10. Midodrine 15 mg PO TID
11. Pantoprazole 40 mg IV Q12H
12. Sertraline 50 mg PO DAILY
13. TraMADOL (Ultram) 50 mg PO BID:PRN pain
14. Warfarin MD to order daily dose PO DAILY16
goal INR 2.0
15. Warfarin 1 mg PO ONCE Duration: 1 [**Hospital1 **]
[**2126-7-30**] only
16. Levothyroxine Sodium 25 mcg PO DAILY
17. Nephrocaps 1 CAP PO DAILY
18. PredniSONE 7.5 mg PO EVERY OTHER DAY
19. Aranesp (polysorbate) *NF* (darbepoetin alfa in polysorbat)
60 mcg/mL Injection every wednesday
20. Bisacodyl 10 mg PO DAILY:PRN constipation
21. Docusate Sodium 100 mg PO BID
hold for loose stools
22. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4hrs
while awake
23. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
24. Lanthanum 1000 mg PO TID W/MEALS
25. Xenaderm *NF* (trypsin-balsam-castor oil) 90-87-788
unit-mg-mg/gram Topical [**Hospital1 **]
apply to buttocks [**Hospital1 **]
26. Senna 1 TAB PO BID:PRN constipation
27. Ondansetron 4 mg PO Q8H:PRN nausea
28. Nitroglycerin SL 0.4 mg SL PRN chest pain
please go to ED or call your doctor if you have chest pain that
requires you to take this medication.
29. Metoprolol Tartrate 12.5 mg PO DAILY
hold for sbp<100, hr<55
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
AS, TR, CAD, s/p AVR, TVr, CABG x 1
PMH:
- Membranous glomerulonephritis, s/p cadaveric renal transplant
in [**2118**] with recurrent GN
- ESRD on peritoneal dialysis daily (since [**8-3**])
- Myocardial infarction in [**12-6**] of this year with preserved EF
- Congestive heart failure
- GI sarcoma (rectal) with surgery and postop radiotherapy in
[**2111**]
- Histiocytosis X with thymectomy
- Multinodular Goiter
- Hypertension
- Asthma
- Anemia secondary to chronic kidney disease
- Left shoulder injury
Past Surgical History:
- s/p Ventral hernia repair with Omni mesh [**2125-6-6**]
- s/p Kidney transplant in [**2118-12-27**] and has since
progressed
to ESRD requiring renal replacement therapy
- s/p Removal of GI rectal sarcoma
- s/p Sternotomy for Thymectomy
Discharge Condition:
Alert, oriented x3, lethargic at times, very deconditioned
OOB to chair with [**Doctor Last Name 2598**] life
Sternal pain managed with Ultram
Sternal Incision - healing well, no erythema or drainage
Left BKA site dusky with staples in place
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of incision
Followup Instructions:
You are [**Telephone/Fax (1) 1988**] for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2126-8-15**] at 1:45pm
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5293**] on [**2126-8-16**] @ 11:20 AM
Vascular Surgeon: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] on [**8-7**] @9:30AM [**Hospital **]
Medical Office Building [**Hospital Unit Name 17173**]
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 17174**], SSAMA WAGIH [**Telephone/Fax (1) 17150**] in [**2-28**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2126-7-30**]
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8,695
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21565
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Discharge summary
|
report
|
Admission Date: [**2179-10-24**] Discharge Date: [**2179-10-30**]
Date of Birth: [**2105-3-12**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Sepsis, Endocarditis, Pneumonia, Breast Mass
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 y/o F w/ PMH: CAD, CHF, COPD, PNA, presented to OSH on [**10-23**]
w/ fevers, chills, dysuria, flank back pain x 3 days. Diagnosed
with pyelonephritis, received ampicillin/gentimicin +
ciprofloxacin + rocephin. Blood Cx were positive for GPC (later
identified as MRSA), Pt was switched to vacomycin + gentamicin.
Fever went to 105.3, Pt became hypotensive 80/20, had ST
elevations on ECG. INR was 3.8, Pt received 5 mg vitamin K.
Sent to [**Hospital1 18**] for further management.
Past Medical History:
CAD (anterior-inferior defects noted on previous stress tests),
s/p STEMI on [**2179-10-24**]. Plans for cardiac intervention during
recent hospitalization were deferred due to sepsis, hypotension,
and the discovery of high grade MRSA bacteremia. ECHO disclosed
EF 40-45%, and possible RV free wall depression. Peak CK=580,
Trop 1.55. Patient is followed by Dr. [**Last Name (STitle) 11493**].
Staph aureus bacteremia, [**10-18**], complicated by mitral valve
endocarditis. Patient started on Vancomycin [**2179-10-26**]. Source
of MRSA bacteremia not identified, although may have been
secondary to MRSA pneumonia (see below).
RUL multifocal pneumonia, associated with parapneumonic right
pleural effusion, noted on CT chest on [**2179-10-27**]. Attempts to
sample this fluid collection were unsuccessful due to its
relatively small size.
Right hilar lymphadenopathy (2.3 x 2.3 cm right hilar lymph
node) noted on [**10-27**] CT chest.
1.6 cm left breast mass
Left upper lip basal cell carcinoma
CHF (EF=40-45%, 1+ MR [**First Name (Titles) **] [**Last Name (Titles) **] [**2179-10-28**]),
COPD
Venous thromboembolism- PE. Patient takes Coumadin daily.
Hyperthyroidism
Hyperlipidemia
Obesity
Diverticulosis (noted on CT abdomen in [**10-18**])
Social History:
The patient lives alone, but was discharged from [**Hospital1 18**] on [**10-30**]
to [**Location (un) **] House rehabilatation facility. The patient has two
children. The patient has a 20 pack year history of tobacco
use. She has a history of occasional ETOH use. No history of
illicit drugs.
Family History:
Non-contributory
Physical Exam:
At admission:
T=102.7, BP=112/39, P=117, RR=35, O2sat=97% 2L?
GEN: obese female in NAD, AxOx3
HEENT: MMdry, EOMI, PERRL, JVP~6, crusty scaly plaque above
left lip (1cm diameter)
CV: regular tachycardic, 2/6 SEM @ sternal border
non-radiating, no rubs, gallops
PULMO: diminished breath sounds b/l @bases, fine anterior
wheezes
ABD: slightly distended, soft, NT, BS+, no rebound, no guarding
EXT: venous stasis, warm, DP bilaterally
NEURO: AxOx3
On the Floor:
T=101-101.3, BP=117-130/48-51, HR=110-111, RR=20, O2sat=97%
2L
GEN: lying in bed in NAD
CV: regular tachycardic, 2/6 SEM throughout pericardium,
non-radiating, no rubs/gallops, no elevated JVP, no JVD
PULMO: crackles at bases b/l, no wheezes/ronchi
ABD: obese, soft, NT, ND, BS+, no rebound, no guarding
EXT: warm, 2+ radial/PT/DP, no C/C, trace edema
Pertinent Results:
[**2179-10-24**] 10:57PM D-DIMER-3161*
[**2179-10-24**] 10:57PM PT-24.4* PTT-43.2* INR(PT)-3.7
[**2179-10-24**] 10:57PM WBC-9.1 RBC-4.43 HGB-12.5 HCT-36.6 MCV-83
RDW-13.9 PLT COUNT-125*
[**2179-10-24**] 10:57PM CALCIUM-8.7 PHOSPHATE-2.5* MAGNESIUM-1.8
[**2179-10-24**] 10:57PM CK-MB-29* MB INDX-5.0 cTropnT-1.55*
[**2179-10-24**] 10:57PM CK(CPK)-580*
[**2179-10-24**] 10:57PM GLUC-118* BUN-27* Cr-1.0 Na-137 K-3.8 Cl-101
CO2-24 A-GAP-16
[**2179-10-24**] 10:59PM URINE RBC-66* WBC-11* BACTERIA-FEW YEAST-MANY
EPI-0
[**2179-10-24**] 10:59PM URINE BLOOD-LG NIT-NEG PROT-30 GLUC-NEG KET-50
BILI-NEG UROBIL-NEG PH-5.0 LEUK-TR
[**2179-10-24**] 10:59PM URINE COLOR-Amber APPEAR-SlCldy SP [**Last Name (un) 155**]-1.025
[**2179-10-24**] 10:59PM URINE HYALINE-2*
[**2179-10-24**] 10:59PM URINE AMORPH-RARE
[**2179-10-25**] TTE: The left atrium is moderately dilated. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. LV
systolic function appears depressed with distal septal, distal
anterior and
apical hypokinesis but views are technically suboptimal
(estimated ejection
fraction ?45%). Right ventricular free wall motion appears
depressed (but the
free wall was not fully visualized). There is a moderate resting
left
ventricular outflow tract obstruction without significant change
with Valsalva
maneuver. The aortic valve leaflets are moderately thickened.
There is mild
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-15**]+)
mitral
regurgitation is seen (may be underestimated due to acoustic
shadowing). The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
[**2179-10-24**] 10:57 pm BLOOD FUNGAL CULTURE (Pending), BLOOD/AFB
CULTURE (Pending)
[**2179-10-24**] 10:57 pm BLOOD AEROBIC CULTURE (Pending), ANAEROBIC
BOTTLE (Pending)
[**2179-10-24**] 10:59 pm URINE CATHETER CULTURE (Pending)
[**2179-10-24**] 11:11 pm BLOOD AEROBIC CULTURE (Pending), ANAEROBIC
BOTTLE (Pending)
[**2179-10-26**] CLOSTRIDIUM DIFFICILE TOXIN ASSAY, FECES NEGATIVE FOR
C. DIFFICILE TOXIN BY EIA. Reference Range: Negative.
[**2179-10-27**] CT CHEST: 1. Multifocal air space consolidation within
the right upper lobe likely represents multifocal pneumonia.
Lymphadenopathy seen within the chest is
likely reactive to this, with note made of a 2.3 cm right hilar
node. 2. Right-sided parapneumonic pleural effusion. 3. 1.6 cm
left breast mass. This is concerning for breast cancer. Further
evaluation with mammography and ultrasound is recommended 4.
Cholelithiasis without cholecystitis. 5. Diverticulosis without
diverticulitis
[**2179-10-28**] TTE: The left atrium is dilated. No thrombus/mass is
seen in the body of the left atrium. The right atrium is
dilated. Overall left ventricular systolic
function is mildly depressed (LVEF 40-45%) with septal
hypokinesis. Right
ventricular systolic function appears mildly depressed. There
are complex
(>4mm, non-mobile) atheroma in the aortic arch and the
descending thoracic
aorta. The aortic valve leaflets are moderately thickened but
mobile. No
masses or vegetations are seen on the aortic valve. Mild (1+)
aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened.
There is moderate to severe, focal mitral annular calcification
of the
posterior leaflet.There is no mitral valve prolapse. There is a
small,
slightly mobile mass (0.3mm x 0.5mm)) attached to the posterior
MAC consistent
with a vegetation. There is no obvious paravalvular abcess
cavity. Mild (1+)
mitral regurgitation is seen (mitral regurgitaion may be
underestimated due to
acoustic shadowing). No vegetation/mass is seen on the tricupsid
or pulmonic
valve. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Small mitral valve vegetation c/w endocarditis.
Moderate to severe focal mitral annular calcification. Mild
mitral regurgitation. No paravalvular abcess seen. Mildly
depressed LVEF with regional hypokinesis c/w CAD.
[**2179-10-29**] ECG: Normal sinus rhythm. Left atrial abnormality. Q
waves in leads V1-V4 consistent with prior anterior myocardial
infarction. Non-specific ST-T wave abnormalities. Compared to
the previous tracing of [**2179-10-26**] no diagnostic interval change
Brief Hospital Course:
SEPSIS/ENDOCARDITIS/PNA: Post antibiotic blood (bacterial and
fungal) + urine cultures were all no growth to date at the time
of discharge. TTE demonstrated small mitral valve vegetation
c/w endocarditis. Moderate to severe focal mitral annular
calcification. Mild mitral regurgitation. No paravalvular abcess
seen. Mildly depressed LVEF with regional hypokinesis c/w CAD.
CT of the chest showed 1. Multifocal air space consolidation
within the right upper lobe likely represents multifocal
pneumonia. Lymphadenopathy of a 2.3 cm right hilar node. 2.
Right-sided parapneumonic pleural effusion. 3. 1.6 cm left
breast mass concerning for breast cancer. After identification
of the organism as MRSA (2 days), the gentamicin was
discontinued and vancomycin was maintained. The effusion was
deemed to small to do a thoracentesis.
STEMI: elvated C-MB and Trop-T, ST elevations in V2-V4.
maintained on metoprolol, atorvastatin, aspirin, clopidogrel,
nitro prn. no catheterization, as septic.
HYPERTHYROIDISM: controlled on methimazole 10 mg QD
ARF: Cr=1.6 on arrival to [**Hospital1 18**], reduced to 1.0 by first day of
hospitalization and remained at 0.7 throughout.
COPD: continued ipratropium neb q6h with 2 puffs q4-6h prn
PE: Pt w/ hx of PE maintained on coumadin which was held due to
pending cath, however, given sepsis and relative cardiac
stability cath postponed. coumadin will be reinitiated one day
after discharge.
BASAL CELL CARCINOMA: dermatology was consulted and a biopsy
was performed. Pt to follow-up as outpt.
YEAST INFECTION (groin): powder antifungal cream applied
HYPERLIPIDEMIA: continued on atorvastatin
Medications on Admission:
###########HOME MEDS:
toprol
coumadin
tapazole
lasix
lipitor
asa
###########OSH TRANSFER MEDS:
vancomycin 1 gm IV
gentamicin 60 mg IV
lopressor 1.5 mg q1h prn
lopressor 12.5 mg q6h
anzimet 12.5 mg IV prn
tylenol prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once 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. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours.
9. Methimazole 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
12. Promethazine HCl 25 mg/mL Solution Sig: One (1) Injection
Q6H (every 6 hours) as needed for nausea.
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO qam.
15. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous
every twelve (12) hours for 4 weeks.
16. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. ST Elevation Myocardial Infarction.
2. Staph Aureus Bactermia.
3. Mitral Valve Endocarditis.
4. Septicemia.
5. RUL Mutlifocal Pneumonia.
6. Parapneumonic Right Pleural Effusion.
7. Right Hilar Lymphadenopathy (2.3 x 2.3 cm right hilar lymph
node)
8. 1.6 cm Left Breast Mass.
9. Left Upper Lip Basal Cell Carcinoma.
Secondary:
1. Hyperthyroidism.
2. Venous Thromboembolism - PE.
3. COPD.
4. Hypertension.
5. CAD native vessel.
6. Obesity.
Discharge Condition:
O2satting in 90s on RA. SBPs in 120-130s. no fever, chest pain
Discharge Instructions:
1) Seek immediate medical attention if experiencing worsening
fever, cough, chest pain, palpitations, nausea, decreased urine
output.
2) Take all medications as prescribed.
3) Go to all follow-up appointments
Followup Instructions:
Dr. [**Last Name (STitle) 32905**] (Pulmonologist) saw patient while in hospital and
recommended that she receive a follow-up CT scan of her chest to
follow the 2.3 x 2.3 cm lymph node seen in hospital CT.
[**Last Name (LF) 11493**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6105**], MD [**Hospital1 69**]
Division of Interventional Cardiology-Cath lab [**Street Address(2) 8667**],
[**Location (un) **] 4 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 4022**] Please make an
appointment after being discharged from rehabilitation. Pt needs
further cardiac management status post STEMI and endocarditis.
She was also noted to have a breast mass on CT that needs
follow-up mammography. Please page Dr. [**Last Name (STitle) **] ([**Numeric Identifier 56814**]) for
results of blood cultures at time of discharge or any other
issues.
Provider: [**First Name4 (NamePattern1) 8694**] [**Last Name (NamePattern1) 8695**], MD (Dermatology) Where: [**Hospital 273**] Date/Time:[**2179-12-3**] 9:00 for basal cell carcinoma above
left lip, biopsy taken while in hospital.
1. Will need Bun/Creatinine/Electrolytes on Monday the 18th and
Thursday the 21st, as recent initiation of ACE-I.\
2. Vancomycin for 4 more weeks and then Infectious Disease
Evaluation - Please follow troughs and interval SMA-7's.
3. Outpatient Dental Evaluation for evaluation of occult source
of bactermia.
4. INR should be followed with goal of [**2-15**].25
|
[
"496",
"V12.51",
"242.90",
"140.0",
"038.11",
"995.92",
"428.0",
"V58.61",
"410.71",
"611.72",
"486",
"V09.0",
"421.0",
"785.6",
"511.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.73",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11131, 11202
|
7800, 9450
|
355, 362
|
11696, 11763
|
3379, 7777
|
12023, 13521
|
2495, 2513
|
9716, 11108
|
11223, 11675
|
9476, 9693
|
11787, 12000
|
2528, 3360
|
271, 317
|
390, 879
|
901, 2166
|
2182, 2479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
384
| 130,196
|
13318
|
Discharge summary
|
report
|
Admission Date: [**2161-4-7**] Discharge Date: [**2161-6-6**]
Date of Birth: [**2093-1-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 826**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 year old female with PMH ESRD on HD, bipolar disorder was
admitted to the hospital on Section 12 for HD, since she missed
2 weeks of dialysis, likely due to underlying psych issues.
Concern for paranoia and inability to care for herself at home.
On admission, BP was in 230s. On arrival to [**Name (NI) **], pt was confused
and unable to provide good history. During dialysis, BP acutely
fell to 100s systolic. After dialysis, pt was noted to be
unresponsive. Head CT showed new hypodense lesion in right
midbrain c/w infarction or edema. BP returned to 170-220s
systolic after HD.
.
Pt was evaluated by neurology/stroke team who noted neuro
abnormalities as follows. "Patient groans to noxious stimuli and
flexes left arm. Vertical skew of eyes at rest with right eye
depressed. There is impaired adduction of both eyes on doll's
eye manuever. Pt was withdrawing left side to pain but right
side was hypotonic, with depressed reflexes and flexion response
only to noxious." Initial thinking was acute cerebral infarct
vs. ischemia secondary to low flow state in setting of acute BP
drop.
CTA showed no evidence of thrombus in the vertebrobasilar
system. MRI showed diffuse subacute infarct of the brainstem.
.
ROS: Per nightfloat admission note from [**2161-4-6**]. No F/C/N/V. No
H/A. No visual changes. No abdominal pain/dysuria. No diarrhea
or change in bowel habits. No AH/VH. No racing thoughts. Could
not quantify how much she was sleeping. No feelings of
depression/guilt/ or feeling blue. No SI/HI.
Past Medical History:
1. ? bipolar disorder (Psych history is unclear)
2. Diabetes insipitus ([**3-5**] lithium use)
3. ESRD on HD - secondary to Lithium
4. HTN
Social History:
Pt is a homemaker. She used to work at [**Location (un) 40552**] as a
technician. No history of smoking or EtOH. No drugs. Graduated
college. She is widowed and has two children.
Family History:
No psychiatric disorders in the family.
Physical Exam:
VS: t98.4, p95, 170/87, rr10, 100% 2L
Gen: somnolent, somewhat arousable to sternal rub
HEENT: PERRL (3mm)
CVS: RRR, nl s1 s2, [**3-9**] holosystolic murmur @ apex
Lungs: poor inspiratory effor, grossly CTAB
Abd: soft, ND, decr BS
Ext: no edema
Neuro: Able to say full name. squeezes bilateral hands. unable
to wiggle hands or feet. upgoing toes bilaterally. 3+ knee and
ankle reflexes, hypertonia of lower extremities (L>R)
Pertinent Results:
UA: mod leuk, sm blood, neg nitrite, [**7-11**] wbc, mod bacteria
.
Urine and serum tox negative
.
EKG: Sinus at 100. LAD. Normal intervals. No ST changes.
.
Radiology:
CXR:Mild cardiomegaly but no CHF.
.
Head CT:
Hypodense appearance of the mid brain and brain stem concerning
for infarction or possibly edema. MRI with diffusion-weighted
images is recommended for further evaluation
.
CTA head/neck: no evidence of thrombus in the vertebrobasilar
system
.
MRI brain:
Diffuse involvement of the brainstem by T2 hyperintensity and
relatively abnormal diffusion. There is involvement of the
middle cerebellar peduncles, the thalami, left greater than
right and left internal capsule, all of which are consistent
with extensive subacute infarction with edema and expansion of
the brainstem itself. The presence of an underlying neoplastic
process would be less likely given the acute nature of the
events. Followup MRI with diffusion images, and correlation with
MRA of the posterior circulation would be helpful. The findings
could be related to an acute hypoxic event, which could have
happened during dialysis. Followup imaging of the brain would be
recommended as clinically indicated.
[**2161-4-6**] 08:35PM WBC-8.1 RBC-3.79* HGB-11.6* HCT-35.4* MCV-93
MCH-30.5 MCHC-32.6 RDW-17.6*
[**2161-4-6**] 08:35PM NEUTS-79.8* LYMPHS-14.5* MONOS-2.2 EOS-2.6
BASOS-0.8
[**2161-4-6**] 08:35PM PLT COUNT-284#
[**2161-4-6**] 08:35PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2161-4-6**] 08:35PM URINE RBC-0-2 WBC-[**7-11**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2161-4-6**] 08:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2161-4-6**] 08:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-4-6**] 08:35PM GLUCOSE-107* UREA N-117* CREAT-10.9*#
SODIUM-140 POTASSIUM-5.7* CHLORIDE-106 TOTAL CO2-10* ANION
GAP-30*
[**2161-4-6**] 08:35PM CALCIUM-8.7 PHOSPHATE-6.8* MAGNESIUM-3.1*
Cholesterol, Total 200* mg/dL
Triglycerides 117 mg/dL 0 - 149
Cholesterol, HDL 76 mg/dL
Cholesterol Ratio (Total/HDL) 2.6 Ratio
Cholesterol, LDL, Calculated 101 mg/dL
ECHO: 1. No atrial septal defect is seen by 2D or color Doppler.
2. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). 3. The aortic valve leaflets
are severely thickened/deformed. 4. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
Brief Hospital Course:
Hospital course, discussed by problem:
.
1) ESRD on HD: Patient was admitted to the nephrology service
and received hemodialysis three times weekly. Her initial two
hemodialysis sessions were complicated by acute hypotension and
unresponsiveness, as described below. Thereafter, she was
dialyzed with less aggressive ultrafiltration, which she
tolerated. However, she also began to cut dialysis sessions
short and occasionally even refuse dialysis altogether. Her
electrolytes were monitored closely. She had a persistently
elevated anion gap. She had one episode of hyperkalemia to 6.7.
EKG showed slightly peaked T waves. As she had only a HD
catheter for access and refused PIV placement, IV calcium, as
well as insulin and D50 could not be given (she refused these
things as well). She did take kayexelate, and she was taken for
an extra HD session that day. Potassium level remained stable
thereafter. She maintained on Nephrocaps daily, phosphate
binders, and eventually bicitra as well.
.
2) Altered mental status: Patient was admitted on a section 12
for having missed HD x 2 weeks. At her initial hemodialysis
session on HD #2, her SBP acutely dropped from 230s to 100s, and
she became unresponsive. A CTA of the head and neck was without
evidence of thrombus in the vertebrobasilar system. A subsequent
MRI was consistent with extensive infarction of the brainstem
and right midbrain. She was therefore thought to have a poor
prognosis and low likelihood of regaining normal consciousness.
However, within a few hours, the patient regained consciousness,
with intact cranial nerves, moving all 4 extremities and
interacting appropriately. The neurology stroke service was
consulted. A repeat MRI with contrast demonstrated persistent
lesions, which were thought to represent changes secondary to
electrolyte disturbances and hypotension induced by dialysis.
During her second dialysis session, she again became hypotensive
and became unresponsive. As described above, it was decided to
dialyze her more cautiously to avoid precipitating hypotension.
In addition, her blood pressure was allowed to autoregulate with
goal 170s-200s. The remainder of her hospital course was without
further episodes of altered mental status.
.
3) Hypertension: On admission, she was hypertensive to 230.
Despite having fluid removed at dialysis, her blood pressure
would continually increase to 200 systolic. She was started on
amlodipine followed by lisinopril with some effect. Her blood
pressure trended down as she tolerated longer dialysis sessions
with ultrafiltration. BP was well controlled at the time of
discharge.
.
4) Anemia: Patient was noted to be anemic, with a Hct ~30,
presumed secondary to ESRD. She was noted to also have
hematochezia during hospitalization. However, it was small
volume blood coating stools, and thought unlikely to fully
explain her anemia. She had previously insisted on Colace warmed
in hot water and multiple fleets enemas. It was thought that the
small amount of blood was secondary to a superficial abrasion
secondary to excessive use of these agents. Iron studies in
[**2160-10-2**], and repeat studies during this hospitalization
demonstrated normal serum iron levels. It was noted that she had
never had a colonoscopy, and was therefore discharged with
instructions to follow up with a gastroenterologist for an
outpatient colonoscopy.
.
5) Bipolar disorder: Pt carries a diagnosis of bipolar disorder
under the care of a psychiatrist. She was followed by the
psychiatry consultation service during hospitalization who was
in contact with her outpatient psychiatrist (Dr. [**First Name (STitle) **] [**Name (STitle) 40553**]) and
was started on Zyprexa, which she would take intermittently.
She also underwent extensive neuropsychiatric testing that
demonstrated a executive impairment consistent with a frontal
temporal dementia. She was started on Aricept. A team meeting
with her inpatient medical team, psychiatry consultation
service, and outpatient dialysis social worker revealed a
pattern of repeated noncompliance with dialysis despite
involvement by multiple social services. It was therefore
decided to pursue guardianship.
.
6) Leukocytosis: Patient was noted to have a leukocytosis with
WBC in the 20s, though likely to represent a stress reaction.
She was without localizing signs and symptoms of infection and
an infectious workup was entirely negative. She did received a
brief empiric course of levofloxacin for a presumed UTI. The
leukocytosis subsequently resolved.
.
7) Coagulopathy: Patient was noted to have a transient
coagulopathy of unclear etiology. This resolved without
intervention, and patient remained without evidence of bleeding
diathesis.
.
8) Code Status: FULL CODE. Per patient's caretaker, the
patient has a living will but we were unable to obtain a copy.
.
Medications on Admission:
Sennakot
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 caps* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
6. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
10. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
11. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
cqregroup
Discharge Diagnosis:
1. Bipolar disorder
2. Diabetes insipitus ([**3-5**] lithium use)
3. ESRD on HD - secondary to Lithium (immature R AVF and R
subclavian HD catheter placed [**2160-7-2**])
4. HTN
Discharge Condition:
good
Discharge Instructions:
If you experience fever, chills, chest pain, shortness of
breath, or any other new or concerning symptoms, please call
your doctor or return to the emergency room for evaluation.
.
Please continue taking all medications as prescribed.
.
Please make all of your dialysis appointments.
Followup Instructions:
On Monday, please return to [**Hospital1 18**], [**Hospital Ward Name 121**] 7 for your dialysis
appointment. You will commence outpatient dialysis in [**Location (un) **]
on Wednesday, [**2161-6-10**].
You should make an appointment for a colonoscopy as an
outpatient, since you have never had one.
You should also call [**Telephone/Fax (1) 250**] to make an [**Company 191**] appt.
Completed by:[**2161-6-11**]
|
[
"403.91",
"599.0",
"V62.5",
"V15.81",
"E939.8",
"585.6",
"286.9",
"588.89",
"294.8",
"458.21",
"588.1",
"296.80",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11513, 11553
|
5351, 6362
|
281, 287
|
11775, 11782
|
2702, 2907
|
12114, 12532
|
2201, 2242
|
10257, 11490
|
11574, 11754
|
10223, 10234
|
11806, 12091
|
2257, 2683
|
229, 243
|
315, 1827
|
2916, 5328
|
6377, 10197
|
1849, 1989
|
2005, 2185
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,118
| 164,298
|
50148+59227
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-4-25**] Discharge Date: [**2182-5-11**]
Date of Birth: [**2131-8-8**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Penicillins / Protamine / Quinidine Sulfate
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGC, intubation and mechanical ventilation, L SC central line
placed, L PICC placed: Removed on [**2182-5-11**]
History of Present Illness:
For full history and physical please see admission note on
[**2182-4-25**] by Dr. [**Last Name (STitle) 4460**]. Briefly, Ms. [**Known lastname 104673**] is a 50yo woman with
h/o AFib on coumadin, CHB s/p PM, MVR with prosthetic valvewho
presented on [**4-25**] with 4d of melena, feeling lightheaded and
weak. She was found to be anemic in the ER with Hct 10.8, SBP
60s, tachycardia 130s. Her INR was >88 at that time. She was
also noted to have ARF and hyperkalemia with peaked T waves on
EKG. She received 5L NS, 2u PRBC, calcium/D50/insulin in the ER.
She was admitted to the MICU, where she received a total of 7
additional units and 4 more units FFP. Her INR was reversed with
FFP and vitamin K and coumadin was held. Given her prosthetic
valve, heparin drip was started when her INR fell below 2.5. EGD
on [**4-27**] showed gastritis, ulcers in the cardia and the body of
the stomach but no active bleeding. Findings were thought to be
most likely cause of GI bleed. The patient was started on PPI IV
BID. Her Hct has been stable for the last 3d.
.
Of note, the patient also reported being scratched by a stray
cat 2-3 weeks ago. She has had B wrist swelling since then.
Blood cultures while in the unit revealed pasturella, for which
patient has been treated with ctx. B arm XR shows no sign of
osteomyelitis, although CRP and ESR were elevated. Due to mental
status changes with pt being confused her CTX was increased to
meningitis doses empirically, as LP could not be performed given
her high INR, which cannot be normalized [**2-14**] mechanical valve.
.
The patient was incidentally found to have an elevated
amylase/lipase and was kept NPO as well as hydrated. Abd U/s
revealed mod GB sludge, no stones, mild wall edema,
calcifications in the liver and patent vasculature. [**Doctor First Name **]/lipase
have continually trended down.
.
Creatinine was found to respond to fluid challenge on the day of
admission. Potassium responded well to treatment and urine
output on the day of admission.
.
On the day after admission [**4-26**] the patient was intubated for
tachypnea and hypoxia. CXR did not clearly show pna. L SC line
was placed sterilely. She was started on CTX/azithromycin/flagyl
at that time to cover for possible community acquired or
aspiration pna. Flagyl was later d/ced. She was extubated [**4-28**].
Azithromycin was d/ced once pasteurella cultures returned 2d ago
.
ROS: could not be performed at present given pt's lethargy.
Past Medical History:
- Complete heart block s/p PM
- Atrial fibrillation
--- anticoagulated and rate controlled
- Lower extremity edema
- Rheumatic heart disease with mitral valve disease s/p MVR
x3(porcine valve, prosthetic valve, Bjork-Shiley valve).
?tricuspid annuloplasty ring?
- GIB [**2170**]
Social History:
no tobacco x years, used to smoke for 30 yrs. h/o cocaine/MJ
use, last about 7 yrs ago.
Family History:
noncontributory
Physical Exam:
VS 99.8, 100/60, 81, 98% RA, 22
Gen: lethargic, answers questions appropriately, unable to fully
converse/cooperate with exam
HEENT: anisocoria R pupil 3mm, L 2mm, reactive to light, OP not
injected, MM dry, thrush over tongue
Neck: no JVD noted
Cor: s1s2, irreg irreg, III/VI systolic murmur, artificial valve
click
Pulm: CTAB except L base one wheeze/crackle at base
Abd: soft NT ND +BS, no HSM
Ext: no c/c/e LE, B hands edematous, erythematous over all
fingers, NT, full ROM
Neuro: confused, lethargic, unable to cooperate with neuro exam,
generalized weakness, BUE 2/5 strength
Pertinent Results:
bartonella panel pending
.
blood cxs [**4-25**] [**2-14**] pasteurella, 4/14 [**2-16**] pasteurella
STUDIES:
[**4-26**] CXR: no definite evidence of pna, L pleural clacification
possibly c/w asbestos exposure, small effusions
.
[**4-26**] RUQ US: GB sludge, mild wall edema, R hepatic calcified
density, pancreas normal
.
[**4-26**] echo: EF nl, physiologic MR, 3+ TR, mod systolic PA HTN
.
CT head: no hemorrhage, abcess or mass
.
CT chest/abd/pelvis: 1. Extensive coronary artery
calcifications.
2. Small right pleural effusion with atelectasis at the lung
bases and subcentimeter bibasilar calcified granulomas. 3.
Heterogeneous perfusion of the liver of unclear etiology. The
hepatic arteries and portal veins appear widely patent. This
pattern of perfusion may be seen in liver disorders such as
hepatitis. Please correlate clinically. 4. Feature-less fluid
filled distal colon. This finding is nonspecific although it
may be seen in infectious colitis (C. Difficile). 5.Diffuse
abdominal and pelvic ascites. 6. Generalized anasarca. 7. No
evidence of intra-abdominal or pelvic abscess.
.
B wrist/arm XR: Soft tissue swelling diffusely about both right
and left hands/wrist. Differential diagnosis includes edema or
cellulitis - - clinical correlation required. No bony changes
to confirm the presence of osteomyelitis. Diffuse osteopenia
noted
Brief Hospital Course:
50 yo woman with h/o MVR, afib, recent cat scratch presented
with 4d melena on coumadin for MVP and Afib, required brief
intubation, now s/p extubation doing well from respiratory
standpoint. Now transferred to floor from MICU with Pasturella
bacteremia in setting of prosthetic valve.
.
#. Pasturella bacteremia: day 5 CTX, day 2 of increased
meningitis dose.
- pt was unable to tolerate [**Month/Year (2) **] to rule out endocarditis
- azithro stopped yesterday per ID recs after 5d of treatment.
- increased CTX dose to cover meningitis as of [**4-29**] given pt
with mental status changes and INR elevation making LP risky
(cannot reverse anticoagulation given artificial valve)
- attempted [**Date Range **] today to rule out endocarditis, but pt could not
tolerate
- will give tetanus vaccine as pt last remembers having it in
[**2172**] after cut with metal.
.
#. Lip lesion: Per note, Tzank smear sent today by ICU team to
rule out HSV, although not logged. Will touch base with team in
AM to see whether sent. If not, consider sending.
.
#. supratherapeutic INR: unclear cause for supratherapeutic INR
on admission. No dose changes recently. Pt now in her goal
range with heparin IV. Were holding coumadin given possible
instrumentation, however at this point failed [**Last Name (LF) **], [**First Name3 (LF) **] not LP,
restart coumadin tonight at 5mg. Continue heparin IV drip as
bridge.
.
#. hyperemia/edema in B hands: per ID recs, this is concerning
as necrotizing fasciitis can occur with pasturella. ESR 100/CRP
116 but B arm XR no sign of osteomyelitis.
- will consider plastics consult to follow exam.
- will d/w ID re whether pt should have bone scan of B wrists -
this may not be helpful if pt has overlying cellulitis rather
than simply soft tissue swelling
.
#. UGIB: Hct has been stable. no active bleeding seen on EGD.
Likely gastric ulcers were etiology of anemia. Goal Hct >30.
.
# pancreatitis: amylase/lipase trending down. continue to
monitor and hydrate as needed. unclear cause of pancreatitis.
.
#. afib: continue rate control with metoprolol and disopyramide.
Restart coumadin as above. Heparin drip. h/o dig toxicity with
dig level 0.8.
.
#. thrombocytopenia: Pt has had steady decrease in plastelet
count since admission. HIT antibody negative. [**Month (only) 116**] be related to
PPI, however we cannot d/c this as pt is taking this for her
GIB/ulcer. Continue to monitor and transfuse platelets for
active bleeding or plts <20.
.
#. thrush: given pt's aspiration risk will continue clotrimazole
troches as cannot tolerate swish and swallow.
.
#. Access: L SC line placed [**4-26**], L AC PIV
.
#. FEN: per swallow eval soft solids and thin liquids but NO
STRAWS. Pt to take supervised meals, aspiration precautions. No
talking while eating/drinking and sitting fully upright.
Nutrition consult re pt's low albumin and cachectic appearance.
Replete lytes prn. continue thiamine, folate, MVI.
.
.
cardiology follow up - paravalvular leak needs to be followed on
[**Month/Year (2) **].
Medications on Admission:
aldactone 50 po qd
lasix 80mg po qd
digoxin .0625mg qmon/fri, 0.125mg qwed
KCl 10meq qd
norpace 100mg CR po bid
atenolol 100mg po qd
coumadin 2mg qmon/fri, 3mg other days
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): please take this new dose of coumadin, 3mg, at bedtime
and have your blood checked at your usual clinic twice per week.
Disp:*90 Tablet(s)* Refills:*4*
2. Disopyramide 100 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days: please take for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
Please check blood work every week starting on Monday [**5-13**]
for: CBC, ESR, CRP, Creatinine, ALT/AST/Alk phos/Tbili
Fax result to [**Hospital 18**] [**Hospital **] clinic [**Telephone/Fax (1) 1419**]
Please check blood work TWICE per week starting on Monday [**5-13**] for: INR
8. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
primary:
pasteurella bacteremia
gastric erosions
upper GI bleed
.
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as directed.
MEDICATION CHANGES:
1. LEVOFLOXACIN: please take this antibiotic every day for 7
days (last pill [**2182-5-17**]). Warning this will interact with
coumadin so be sure to have your INR checked twice per week
starting on Monday [**5-13**].
2. STOP taking digoxin.
3. COUMADIN: please take 3mg every night. Have your blood drawn
twice per week stating on Monday [**2182-5-13**] to have this dose
adjusted as needed.
4. STOP taking your potassium pill.
5. STOP your atenolol and instead take METOPROLOL 2 pills three
times per day for heart rate control. You may be able to switch
back to atenolol in the future when you follow up with your
primary doctor or Dr. [**Last Name (STitle) 1016**].
.
**Please be sure to have your blood drawn at your usual clinic
for your INR check TWICE per week so that your dose can be
readjusted. This is especially important while taking
levofloxacin, which interacts with coumadin.
.
**Please be sure to have your blood drawn ONCE per week at our
usual lab and have results faxed to our [**Hospital **] clinic at
[**Telephone/Fax (1) 1419**]. This is to monitor your infection and your kidney
and liver function.
.
**Please call our radiology department at [**Telephone/Fax (1) 327**] to
schedule a CT scan of your right arm and left shoulder about one
week before your infectious disease appointment. (Appt is [**5-30**],
so aim for about [**5-23**].)
.
Please go to your follow up appointments with infectious disease
on [**5-30**] and with Dr. [**Last Name (STitle) 1016**] on [**7-18**]. Please also be sure
to call the gastroenterology clinic (phone # below) to schedule
for a repeat endoscopy in 6 weeks, and call your primary doctor
for a follow up appointment in the next 1-2 weeks.
.
If you have bloody stool, black tarry stool, lightheadedness,
increased arm swelling, fever, chills or other concerning
symptoms please call your primary doctor or come to the
emergency room.
Followup Instructions:
1. Infectious Disease Clinic: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2182-5-30**] 9:30
2. Cardiology: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D.
Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2182-7-18**] 9:00
3. please call the gastroenterology clinic for a repeat
endoscopy to evaluate how your stomach ulcers are healing. You
should have this procedure done in [**6-20**] weeks.
4. Please call your primary doctor for a follow up appointment
in the next 1-2 weeks.
Name: [**Known lastname 16986**],[**Known firstname 13025**] Unit No: [**Numeric Identifier 16987**]
Admission Date: [**2182-4-25**] Discharge Date: [**2182-5-11**]
Date of Birth: [**2131-8-8**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Penicillins / Protamine / Quinidine Sulfate
Attending:[**First Name3 (LF) 161**]
Addendum:
***PLEASE NOTE, DUE TO A COMPUTING ERROR, THIS DISCHARGE SUMMARY
WAS FILED PRIOR TO ITS COMPLETION. PLEASE REFER TO THIS ADDENDUM
FOR A MORE ACCURATE HOSPITAL COURSE AND FOR THE REMAINDER OF THE
STUDIES PERFORMED DURING THIS HOSPITALIZATION.**
Pertinent Results:
B. HENSELAE IGG TITER >=1:1024 A <1:64 TITER
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16988**] IGG TITER >=1:1024 A <1:64 TITER
B. HENSELAE IGM TITER TNP-SCREENING TEST <1:16 TITER
NEGATIVE.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16988**] IGM TITER SEE BELOW <1:16 TITER
endoscopy: Ulcer in the cardia; Erosion in the stomach body;
Erythema and congestion in the stomach body and antrum
compatible with gastritis; There was no blood or active bleeding
noted. There was no blood to second portion of duodenum; There
were no esophagitis or varices; Otherwise normal EGD to second
part of the duodenum.
CT left shoulder: Limited examination due to lack of IV
contrast. Moderate joint effusion in the left shoulder and
lymph nodes, as described above. If peripheral IV axis is
obtained, the patient can receive repeat examination as
clinically indicated.
RUE U/S: Focused grayscale and color ultrasound of the right
antecubital
fossa was performed. Within the antecubital fossa is a long
hypoechoic,
poorly defined that is difficult to measure but likely measures
7 cm in
length, and 2.5-1.7 cm in transverse diameter. The echogenicity
suggests a large necrotic lymph node. . This collection appears
to be distinct from the joint capsule.
CT RUE: 7.4 x 2.3 x 2.2 cm multilobulated peripherally enhancing
mass in
the antecubital fossa, most consistent with necrotic lymph nodes
given
patient's history of cat scratch disease. Although this
peripherally enhancing mass is likely extracapsular in location,
given the lack of posterior fat-pad displacement, an ultrasound
examination is recommended to better exclude an infectious
arthropathy.
TEE: 1. The left atrium is dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. The atrial septum appears thickened with
echodense material consistent with a patch. No atrial septal
defect is seen by 2D or color Doppler.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%).
3.The aortic valve leaflets (3) are mildly thickened. No masses
or vegetations
are seen on the aortic valve. No aortic regurgitation is seen.
4. A single tilting disk mitral valve prosthesis is present. The
gradients are higher than expected for this type of prosthesis.
A posteriorly directed moderate-to-severe eccentric
paravalvular mitral prosthesis leak is present. No mass or
vegetation is seen on the mitral valve. No mitral valve abscess
is seen.
5. A tricuspid valve annuloplasty ring is present.
6.There is no pericardial effusion.
Lshoulder XR: There is no evidence of fracture or dislocation.
No evidence of osteomyelitis is identified. The small effusion
cannot be evaluated by the plain radiograph.
Bone scan: No focal abnormal tracer activity in the hands and
upper extremities to suggest the presence of osteomyelitis.
Nonspecific increased tracer activity in multiple joints of both
upper extremities is suggestive of degenerative change.
Brief Hospital Course:
Ms. [**Known lastname **] is a 50 yo woman with history of mitral valve
repair (x3) on coumadin, tricuspid valave annuloplasty ring,
atrial fibrillation, and recent cat scratch who presented with 4
days of melena and a hematocrit of 10.8, as well as INR of >88.
GI bleed: In the ER the patient received FFP x 2 as well as
PRBCs x 2. She was initially admitted to the ICU, where she was
given vitamin K, FFP, and 7 units of PRBCs in total. Her INR
was reversed with vitamin K, and her hematocrit remained stable.
She had one day of low O2 saturations (high 80s) and required
brief intubation, during which time she had an endoscopy, which
found gastritis, an ulcer in the cardia, and an erosion in the
stomach body, neither of which were actively bleeding and both
of which were felt to be likely causes of her GI bleed and
anemia. Her hematocrit stabilized and she continued to pass
guaiac positive, although not melanotic, stool. On her last two
days of hospitalization she passed guaiac negative stool. The
patient was instructed to follow up with our GI department for a
repeat endoscopy as an outpatient in [**6-20**] weeks. Colonoscopy was
not performed as an inpatient but this could be considered for
more complete outpatient work up.
Supratherapeutic INR: The patient arrived with a very elevated
INR of >88 (the limit of our laboratory). She denied taking
poor POs and denied low vitamin K diet. She last had her INR
checked 2months ago by her PCP and states that this has never
happened to her before. She was seen by our pharmacist while in
house for a very extensive discussion of her coumadin use, other
medication use, and diet, which were unrevealing with respect to
her sudden INR elevation. The patient's coumadin was initially
held, she was given FFP as above, and after reversal of her INR
with vitamin K, she was restarted on coumadin after her INR fell
below 2.5. She was given heparin IV to bridge her when she fell
below 2.5 given her high risk of thrombus to her mechanical
valve. Before discharge the patient was on coumadin 3mg po qhs
and remained stable at INR of about 2.7 for several days. She
was dishcarged on this dose and instructed to have her INR
checked 2d after discharge (on Monday) and twice per week
subsequently.
Pasteurella bacteremia: The patient suffered cat scratches
approximately 7-10 days prior to admission. She received a
tetanus vaccine as an inpatient. She was found to grow [**4-16**]
blood cultures bottles of pasteurella and was treated with
ceftriaxone. She was followed extensively by hte infectious
disease team while in-house. As the patient also appeared to
have mental status changes in the MICU, she was started on
meningitis doses. We did not perform LP, as the patient has a
mechanical valve and we could not let her INR drop low enough
for this to be safe, and instead treated her empirically, after
being transferred from the ICU to the floor, the patient's
mental status returned to baseline. It is believed unlikely
that she had pasteurella meningitis at this time. TTE and TEE
were performed and no vegetation was visualized, however a
paravalvular leak was noted around her mechanical mitral valve.
She was also noted to have persistent edema in her bilateral
arms/wrists/hands. Plain films, CT scan, and bone scan were all
negative for osteomyelitis. Upper extremity ultrasounds showed
no DVT, but did show some left antecubital necrotic lymph nodes.
She worked with physical therapy to mobilize her arms and the
edema appeared to respond somewhat to this. The patient also
had persistent pain in her left shoulder with markedly reduced
range of motion. CT of her left shoulder showed no sign of
osteomyelitis or effusion. Given hte absence of meningitis
(presumed), endocarditis, and osteomyolitis, the patient was
switched to PO levofloxacin on the last day of hospitalization,
to finish a total of three weeks of treatment, which is
scheduled to end on [**2182-5-17**].
On the day prior to discharge the patinet's bartonella
results came back positive IgG but negative IgM. It is unclear
how these should be interpreted, as with the patient's extensive
cat ownership she may have been infected with bartonella in the
past, versus a concurrent infection with the pasteurella 10 days
prior to admission so we may have missed the IgM peak. Repeat
bartonella studies were sent prior to discharge and will be
followed up by infectious disease.
The patient will be followed by Dr. [**Last Name (STitle) 16989**] in infectious
disease clinic and already has an appointment scheduled for
[**2182-5-30**]. She will have an outpatient CT of her R shoulder and L
arm one week prior to this appointment. She will have labwork
drawn weekly and faxed to the [**Hospital **] clinic after discharge as well.
Atrial fibrillation: The patient has a history of afib, and
remained in afib throughout her stay. As an outpatient she was
rate controlled on digoxin, norpace, and atenolol. Her digoxin
was discontinued during this admission, as it is a relatively
poor rate-controlling [**Doctor Last Name 932**], and she was maintained on norpace
and beta blocker as tolerated by her blood pressure. She is on
coumadin, as stated above, for anticoagulation and stroke risk
reduction. She has an appointment to follow up with her usual
cardiologist at his next available appointment in [**Month (only) 1176**].
Hyperemia of hands: The patients hands remained erythematous adn
in some places pale throughout her stay. Although she has no
stated history of Raynaud's disease, and denied exacerbation in
the cold, the patient stated that her hands did not appear
abnormal to her and they "look purple all winter and red all
summer." She likely has Raynaud's disease. This should be
followed up as an outpatient by her PCP.
Mechanical mitral valve: As stated above the patient is
anticoagulated on coumadin with goal 2.5-3.5 for her valve. A
TEE performed during her hospitalization showed paravalvular
leak. Per cardiology recommendations here, this should be
followed up by the patient's outpatient cardiologist and she
will likely require another TEE in the near future to monitor
progression. She has a follow up appointment with her usual
cardiologist (who the patient believed was no longer practicing,
so I do not know when she was last seen there) in his next
available slot in [**Month (only) 1176**].
Access: During her stay the patient had a L subclavian central
catheter and a L antecubital PICC. Both of these were removed
prior to discharge from the hospitalization without event.
General: It remains unclear to us whether Ms. [**Known lastname **] has an
underlying diagnosis of liver disease or some other systemic
illness. She comes in on chronic diuretic therapy for lower
extremity edema, yet does not have heart failure by echo. When
her diuretics were held during this hospitalization she indeed
did develop pitting edema bilaterally. Spot urine had an
elevated protein/Cr ratio, however 24 hour urine collection
showed protein in the normal range. She is at baseline somewhat
ill-appearing and also presented with a very low albumin. She
did eat well after recuperating somewhat during her stay here.
This issue is better served by the patient's PCP, [**Name10 (NameIs) **] it appears
to be chronic in nature, and remains to be followed up as an
outpatient.
The patient was discharged to home with follow up appointments
scheduled for her cardiologist and our infectious disease
clinic, as stated above. She was instructed to call her PCP for
[**Name Initial (PRE) **] follow up appointment in the next 1-2 weeks and to call our
gastroenterology department for a follow up endoscopy in the
next 6-8 weeks. She was also instructed ot have her bloodwork
drawn for INR check two days after d/c and twice per week after
that, and faxed to her usual PCP, [**Name10 (NameIs) **] well as to have labwork
faxed to our infectious disease clinic once per week.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**]
Completed by:[**2182-5-22**]
|
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,006
| 189,081
|
4629
|
Discharge summary
|
report
|
Admission Date: [**2159-4-30**] Discharge Date: [**2159-5-28**]
Date of Birth: [**2085-8-27**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 15519**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
picc line placement
thoracentesis
chest tube placement
History of Present Illness:
73year old man with history of right non-small cell lung ca s/p
pneumonetctomy, COPD, hypertension, sick sinus syndrome s/p
[**First Name3 (LF) 4448**] and ICD placement, BPH, and depression presenting with
shortness of breath. The patient had been admitted [**2159-3-27**]
with dyspnea. Extensive work up at that time included cardiac
catheterization which showed total occlusion of RCA, although no
intervention was done. At that time, it was felt his symptoms
were multifactorial with contributions from his COPD and left
sided pleural effusion. He underwent thoracentesis on [**2159-4-25**];
1300cc bloody fluid was drained. Cytology was negative,
however, given patient's history, it was still presumed to be
malignant. Pt subsequently discharged to home.
.
He presented to the ED [**2159-4-30**] with dyspnea and hypoxia,
initially on a 100% non-rebreather, with oxygen saturation in
the 60%'s. He was subsequently intubated and started on empiric
antibiotics for a suspected pneumonia. He also became
hypotensive after receiving sedation for intubation and was
transiently on pressor support.
.
He was admitted to teh MICU. He remained intubated with
difficulty to wean from ventilator. This was again thought to
be multifactorial, secondary to multifocal pneumonia, persistent
pleural effusion, COPD and poor pulmonary reserve s/p lobectomy.
.
He was treated with a 7 day course of meropenem ([**Date range (1) 19644**]) for a
multifocal pneumonia. He underwent repeat thoracentesis to r/o
empyema/help improve respiratory status, which revealed a
chylous effusion thought to be due to disruption of thoracic
duct during his lobectomy in [**2158-9-27**]. A chest tube was
placed with persistent output. On [**2159-5-8**], chest tube was
changed from suction to wet seal. The patient was started on
TPN which theoretically will decrease chylothorax. He was
continued on inhalers for treatment of his COPD.
.
The chylous effusion was followed by the pulmonary team, who
recommended the patient be kept NPO and be treated with 2weeks
of TPN. Repeat CT showed persistant output. As a result,
thoracic surgery was consulted and performed a mechanical
pleurodesis. In the SICU, the patient developed a respiratory
acidosis and was intubated and extubated on [**2159-5-22**].
.
SICU course was also notable for complicated left subclavian
central venous access attempt with cannulation of the subclavian
artery resulting in signficant bleeding and requiring vascular
consultation. Follow-up ultrasound did not show
aneurysm/fistula formation.
.
On admission the patient was also noted to have a left scapular
wound infection, persistent since his lobectomy in [**Month (only) **],
[**2158**]. He was seen by plastic surgery, who recommended treatment
with oxacillin which was discontinued. There were no plans for
further surgery by the plastics team. He continued to have
wound care addressed by the wound care service.
Past Medical History:
1. Non-small cell lung ca s/p XRT/chemo in [**Country 532**] and right
pneumonectomy [**9-/2158**]; c/b chronic left-sided effusion
2. sick sinus syndrome s/p [**Year (4 digits) 4448**]/ICD placement
3. COPD/bronchiectasis
4. s/p partial colectomy in [**2126**]
5. h/o (+)PPD in [**2146**], not treated
6. Hypertension
7. Benign prostatic hypertrophy
8. Depression
9. Left femoral A-V fistula [**2159-4-25**]
Social History:
Former TOB (~20 pack-yr hx), quit 25 yrs ago. Lives with wife.
Denies EtOH use. [**Name (NI) 1094**] son & daughter involved in his care
Family History:
Denies history of MI
no family h/o lung ca
Physical Exam:
Tc=98.9 P=75 BP=128/47 RR+25 99% on 3 liters I/O 731/420 (am)
2700/2200
Gen - NAD, AOX3, Russian-speaking male
Heart - RRR
Lungs - Decreased breath sounds on left with chest tube in
place, wound dressing over right scapula
Abdomen - Soft, NT, ND + BS
Ext - +2 nonpitting pedal edema bilaterally with bilateral SCD
Pertinent Results:
[**2159-4-30**] 11:43PM CK(CPK)-65
[**2159-4-30**] 05:56PM UREA N-17 CREAT-0.9 POTASSIUM-4.3
[**2159-4-30**] 04:20PM PLEURAL TOT PROT-3.1 GLUCOSE-128 LD(LDH)-138
TRIGLYCER-281
[**2159-4-30**] 04:20PM PLEURAL WBC-600* RBC-[**Numeric Identifier 19645**]* POLYS-7*
LYMPHS-76* MONOS-14* EOS-1* MESOTHELI-2*
[**2159-4-30**] 02:51PM ALBUMIN-2.5*
[**2159-4-30**] 02:36PM CORTISOL-14.9
[**2159-4-30**] 12:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-4-30**] 12:24PM CK-MB-NotDone cTropnT-0.02*
[**2159-4-30**] 12:24PM WBC-10.5 RBC-3.65* HGB-8.4* HCT-28.6* MCV-78*
MCH-22.9* MCHC-29.3* RDW-18.0*
[**2159-4-30**] 12:24PM NEUTS-94.3* BANDS-0 LYMPHS-3.1* MONOS-2.1
EOS-0.3 BASOS-0.2
[**2159-4-30**] 12:24PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL
STIPPLED-OCCASIONAL ELLIPTOCY-1+
[**2159-4-30**] 10:45AM WBC-15.2* RBC-3.72* HGB-8.5* HCT-29.5*
MCV-79* MCH-23.0* MCHC-28.9* RDW-18.0*
[**2159-4-30**] 08:35AM PT-12.8 PTT-23.0 INR(PT)-1.0
[**2159-4-30**] 08:35AM PLT COUNT-364#
[**2159-4-30**] 08:35AM CK-MB-NotDone
[**2159-4-30**] 08:35AM cTropnT-0.03*
[**2159-4-30**] 08:35AM CK(CPK)-37*
[**2159-4-30**] 08:58AM LACTATE-1.3
[**2159-4-30**] 08:58AM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2159-4-30**] 10:05AM LACTATE-1.3
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2159-5-8**] 5:58 PM
CHEST (PORTABLE AP)
Reason: eval for re-accumulating / expanding effusion s/p chest
tube
[**Hospital 93**] MEDICAL CONDITION:
73 year old man s/p right pneumonectomy w/ left pleural effusion
admitted with acute SOB now intubated and s/p an NGT placement.
REASON FOR THIS EXAMINATION:
eval for re-accumulating / expanding effusion s/p chest tube to
water seal. Please take CXR at 6pm (i.e. 6 hours s/p to water
seal, thank you).
INDICATION: 73-year-old man with history of right pneumonectomy.
Now with acute shortness of breath.
COMPARISON: [**2159-5-3**].
SINGLE UPRIGHT PORTABLE AP VIEW OF THE CHEST: The patient is
status post right pneumonectomy, with associated thoracic wall
changes and shift of midline structures to the right.
Additionally, there is fullness of the perihilar vasculature,
with left lower lobe atelectasis. A left-sided [**Year (4 digits) 4448**], median
sternotomy wires, and wires in the mid-right chest are
unchanged.
IMPRESSION: Mild cardiac failure.
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2159-4-30**] 10:42 AM
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: eval for pe
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
73M s/p R pneumectomy, with resp distress, intubated
REASON FOR THIS EXAMINATION:
eval for pe
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 73-year-old man status post right pneumonectomy with
respiratory distress. Evaluate for PE.
COMPARISON: [**2159-4-26**].
TECHNIQUE: Multidetector axial images of the chest were obtained
with IV contrast. 100 cc Optiray. Coronal and sagittal
reformatted images were obtained.
CT CHEST WITHOUT AND WITH IV CONTRAST: The patient is status
post right pneumonectomy. The main and left pulmonary arteries
are patent without evidence of filling defects to suggest a
pulmonary embolism. There has been interval increase in the
left-sided pleural effusion. There has also been development of
a left lower lobe consolidation with air bronchograms. There are
additional patchy ground-glass opacities in the left upper lobe.
The heart, pericardium, and great vessels are stable in
appearance. The right hemithorax is stable in appearance. Again,
noted are enlarged right paratracheal nodes. Visualized portions
of the upper abdomen are stable in appearance.
BONE WINDOWS: There are no suspicious lytic or sclerotic
lesions. Again, noted are significant deformities of the right
ribs.
Again, noted are the ETT and dual-lead [**Year (4 digits) 4448**].
IMPRESSION:
1) No PE.
2) Left lower lobe consolidation and patchy left upper lobe
opacities which are worrisome for pneumonia.
3) Interval increase in moderate-sized left pleural effusion.
CATH ([**2159-4-24**]) - Clean LCX, LMCA, LAD. RCA TO with L->R
collaterals. Unable to intervene on the RCA. No significant
shunt.
.
ECHO ([**2159-3-19**]) - EF 60%. L->R shunt at rest across the
intra-atrial septum. 1+MR, 1+TR. Moderate pulm artery systolic
HTN.
.
CHEST CT ([**2159-4-30**]) - No PE. LLL consolidation and LUL patchy
opacity. Interval increase in moderate left pleural effusion.
CHEST (PORTABLE AP) [**2159-5-23**] 5:39 AM
FINDINGS: AP single view of the chest obtained with patient in
semi-upright position is analyzed in direct comparison with the
next previous similar study obtained on [**5-22**], (15 hours
interval). The left sided chest tubes remain in unchanged
position and there is no evidence of pneumothorax. No new
parenchymal infiltrates are present. S/P right sided
pneumonectomy and left sided permanent pacer with dual electrode
system unchanged. NG tube reaches far below diaphragm as before.
IMPRESSION: No significant interval change.
Brief Hospital Course:
The patient is a 73 year old male with a history of NSCLC s/p
right pneumonectomy, chemo/XRT and COPD, presenting with
dyspnea, transferred from thoracic surgical service after
VATS/mechanical pleurodesis for chylous pleural effusion. For
details of hospitalization until transfer, please see history of
present illness section. During his hospitalization, the
following problems were addressed:
# PNA: The patient was diagnosed with a pneumonia in the MICU
and treated with a seven day course of meropenem. On transfer
to the floor, he was afebrile with no leukocytosis. In MICU, he
was thought to have multifocal pna based on imaging although
sputum culture was negative.
# Chylous pleural effusion: The patient presented with
significant right pleural effusion. Thoracentesis demonstrated
a chylous effusion. Interventional pulmonology was consulted
and stated that the effusion was likely from injury to the
thoracic duct during his previous surgery. They placed a chest
tube and recommended TPN with octretide to help decrease
tryglyceride intake and chylous output. a PICC line was placed
in the left upper extremity on [**2159-5-16**], and TPN was begun on
[**2159-5-17**]. The plan was for pleurodesis when drainage was <100 to
<125 cc/ day. However, as mentioned, the CT continued to put out
a significant amount of fluid and as a result, the patient was
transferred to the thoracics service where he underwent a VATS
and talc pleurodesis on [**2159-5-18**]. He was briefly intubated in
SICU for respiratory acidosis and was extubated on [**2159-5-22**]. The
chest tube was pulled [**2159-5-23**] with post xray showing possible
small apical left pneumothorax. Subsequent CXR showed
resolution. Thoracic surgery signed off prior to discharge and
recommended continued dry dressings to the chest tube site. He
will continue on TPN, PO intake no more than 200cc/day,
otherwise NPo, with continued octreotide for another week.
# COPD: He was continued on atrovent and albuterol inharlers per
his outpatient regimen. He has poor pulmonary reserve given his
pneumonectomy.
# CHF: The patient has an EF 60%, but likely has a component of
diastolic dysfunction. He was diuresed to euvolemia after
receiving fluids in the MICU and ED for resuscitation. Given
his elevated bicarb, he was started on diomax in addition to the
lasix. Once patient was euvelomic, diuretics were discontinued.
# HTN: The patient's ACE and Bblocker were discontinued in the
SICU as he was hypotensive. He continued to be normotensive off
medication. These may be restarted once stable.
# CAD: Patient has a history of CAD, no active issues during
this hospitalization. He was continued on aspirin.
Beta-blocker and ACE inhibitor held due to blood pressure. Once
stabilized, he will likely be restarted on these medicaitons and
statin.
# Back wound from previous pneumenctomy: The wound was growing
MSSA and patient was started in oxacillin (started on [**2159-5-5**]).
Duration of treatment was determined by wound response, and we
monitored LFTs q 3-4 days while on oxacillin. Oxacillin was
discontinued [**2159-5-14**]. The plastics stated that low likelihood
that the patient would be taken to the OR for further
debridement and signed off. Wound care service was consulted
and made recommendations. For details of wound care recc's,
please see page 1 summary.
# Right upper extremity DVT: Given the the patient's tenuous
status and history of coffee-ground emesis, and low risk of PE
and stroke with upper extremity clot no anticoagulation was
initiated.
# Anemia: Anemia was originally thought to be due to chronic
disease, but when transferred to the floor, patient had stool
that was guiac positive. He will be referred to GI for
colonoscopy and further work-up once his acute pulmonary issues
resolve. His hematocrit was monitored daily and remained
stable.
# foot drop: patient has a left-sided foot drop, thought to be
due nerve injury. He will continue with physical therapy at
[**Hospital3 **] for further care.
# FEN: the patient was discharged to rehab on TPN. This should
be continued for another week. After that, can be slowly
advanced. he should continue on a low triglyceride diet. A
video swallow study is being done to evaluate for aspiration
risk.
# Dispo: the patient was discharged to [**Hospital3 **]. His
son [**Telephone/Fax (1) 19643**] [**Doctor Last Name **] was the primary contact. [**Name (NI) **] is a full
code. He will follow-up with Dr. [**First Name (STitle) **], his PCP for further
care.
Medications on Admission:
Meds (on admission):
1. Lasix 80 mg po daily
2. ASA 325 daily
3. Atenolol 25 mg po daily
4. Protonix
5. colace
6. combivent
7. advair
.
Meds (on transfer from MICU):
1. tylenol 325-650 mg PO q4-6hr prn
2. Albuterol 2 puff IH q4h
3. ECASA 325 mg po qd
4. Bisacodyl 10 mg PO/PR daily:prn
5. Captopril 12.5 mg po tid
6. citalopram 10 mg PO qd
7. colace 100 mg po bid
8. heparin 5000 units SC TID
9. ipratropium 2 puff IH q4h
10. lansoprazole 30 mg po qd
11. metoclopramide 10 mg IV q6h prn nausea
12. metoprolol 25 mg po tid
13. morphine 2-4 mg IV q6h: prn
14. oxacillin 2g IV q6h
15. zolpidem 5 mg po qhs: prn
.
Meds on transfer from SICU:
Insulin SC (per Insulin Flowsheet)
Hydromorphone 1 mg SC Q6H:PRN pain
Octreotide Acetate 100 mcg SC TID Start: start with next dose
Sucralfate 1 gm PO QID
Ipratropium Bromide Neb 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Citalopram Hydrobromide 10 mg PO DAILY
Metoclopramide 10 mg IV Q6H:PRN nausea
Aspirin EC 325 mg PO DAILY
Ipratropium Bromide MDI 2 PUFF IH Q4H
Albuterol 2 PUFF IH Q4H
Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
Disp:*1 inh* Refills:*2*
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
Disp:*1 inh* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: Five (5)
thousand units Injection Q8H (every 8 hours): for DVT
prophylaxis.
7. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
8. Metoclopramide 10 mg IV Q6H:PRN nausea
9. Octreotide Acetate 0.1 mg/mL Solution Sig: One (1) hundred
micrograms Injection TID (3 times a day).
10. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO
DAILY (Daily).
11. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): units per sliding scale:
200-250 2units
251-300 4units
301-350 6units.
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Chylous pleural effusion (likely from thoracic duct injury)
Secondary:
Non-small cell lung ca
COPD
Sick sinus syndrome
Hypertension
benign prostatic hypertrophy
s/p partial colectomy
Depression
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or come to ED if you develop chest pain,
shortness of breath, nausea/vomiting, or fevers >101.3
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2159-6-19**] 10:20
Provider: [**Name10 (NameIs) **] CALL Where: NONE CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-5-17**] 9:15
Provider: [**Name10 (NameIs) **] CALL Where: NONE CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-6-21**] 9:15
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-7-26**] 11:00
|
[
"998.59",
"453.8",
"457.8",
"496",
"V45.01",
"V45.02",
"280.0",
"458.29",
"V10.11",
"428.0",
"511.8",
"414.01",
"401.9",
"518.81",
"486",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.71",
"38.93",
"99.15",
"34.04",
"99.29",
"96.6",
"96.04",
"99.04",
"34.21",
"34.6"
] |
icd9pcs
|
[
[
[]
]
] |
16578, 16648
|
9469, 14019
|
294, 350
|
16896, 16904
|
4330, 5872
|
17072, 17708
|
3932, 3977
|
15185, 16555
|
6979, 7032
|
16669, 16875
|
14045, 15162
|
16928, 17049
|
3992, 4311
|
235, 256
|
7061, 9446
|
378, 3324
|
3346, 3761
|
3777, 3916
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,501
| 119,347
|
7842+55877
|
Discharge summary
|
report+addendum
|
Admission Date: [**2165-10-20**] Discharge Date: [**2165-10-22**]
Date of Birth: [**2095-10-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Fall and unresponsiveness
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
69M with h/o HTN, CAD s/p CABG, AVR with mechanical St. [**Male First Name (un) 923**] s/p
strep endocarditis on coumadin, DM, PVD s/p osteo and amputation
of digits of R foot, who had mechanical fall at home and found
to be comatose.
.
Per family, he was in USOH when had mechanical fall at 7:45am on
way to get newspaper. Was able to walk and speak clearly after
the fall with no noted weakness. However, did appear dizzy,
pale, and diaphoretic. FSG was 186. Wife left for coffee,
returned at 9:30am and husband was sleeping and mumbling. At
10-11am, patient completely unresponsive with vomitus. 911 was
called.
.
On arrival to ED, he was intubated for airway protection. On ER
resident exam, he had anisocoria, with the left 4mm and the
right
3mm both reactive. Neurosurgery was [**Name (NI) 653**], and he was taken
to head CT. INR was 4.9. 160/73, 66, afebrile, RR 20. Pt was
evaluated nu Neurosurgery and no intervention was indicated,
poor prognosis conveyed to family. Pt received IV 10mg vitamin
K.
Past Medical History:
HTN
PVD
CAD s/p CABG
AVR (mechanical [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]) s/p Strep endocarditis
Diabetes, controlled with oral medication
MRSA Osteomyelitis of right foot [**3-7**]
Carotid stenosis
Hyperlipidemia
Social History:
Prior to this incident, patient lived independently, gets help
with bills. No tob/etoh.
Family History:
Noncontributory
Physical Exam:
VS - Temp 95.9F, BP188/80 , HR74 , R20 , 100% on CMV/TV 600/16.
PEEP 5, FiO2 100
Gen: Intubated, c-collar in place. Unresponsive to nailbed
pressure on upper extremities, but withdrawal to nailbed
pressure on lower extremities.
HEENT: pupil on left 5mm (unresponsive, fixed, dilated). On
right, 2mm, fixed unresponsive. no scleral icterus noted, MMM,
no lesions noted in oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l, s/p removal of right toes.
Neuro: L pupil fixed and dilated. R pupil fixed and not
reactive. Corneal reflex present. 0/0 reflexes. flexion in legs
to noxious stimuli.
Pertinent Results:
INR 4.9
Hct 42.1
.
Head CT: Initial read appears to show L thalamic bleed that
extended down into the 4th ventricle and upward to the 3rd and
both lateral
ventricles, likely hypertensive in origin
.
CT C-spine: initial read showing no acute fracture or
dislocation
Brief Hospital Course:
69M with h/o HTN, CAD s/p CABG, AVR with mechanical St. [**Male First Name (un) 923**] s/p
strep endocarditis on coumadin, DM, PVD s/p osteo and amputation
of digits of R foot, who had mechanical fall at home presented
comatose and found to have large hypertensive thalamic
hemorrhage.
.
Intracranial thalamic bleed: Likely secondary to HTN (77% of
thalamic hemorrhages are [**3-2**] HTN) and also in context of
supratherapeutic INR. Given current neurologic status, age,
volume and location of bleed, there is poor prognosis for any
meaningful neurologic recovery. Presentation with coma and
stupor are also found in studies to give the poorest chance of
survival. Patient has expressed the wish to be DNR/DNI in past.
Family gathered at patient's bedside to discuss goals of care. A
family meeting was held and the decision was made to respect the
patient's preferences and make him CMO. A priest came to bedside
and the patient was extubated. He was maintained on morphine
drip for comfort. The patient expired on [**2165-10-22**] at
2:20 PM with wife and daughter present.
Medications on Admission:
Glyburide 1.25
Zoloft 25
Atenolol 25
Folate
Flomax 0.4mg daily
Lipitor 40
Lisinopril 20
Coumadin 5
MVI
ASA 81
Aricept 5
Colace 100
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Intracranial hemorrhage
2. Fall
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Name: [**Known lastname 4926**],[**Known firstname **] Unit No: [**Numeric Identifier 4927**]
Admission Date: [**2165-10-20**] Discharge Date: [**2165-10-22**]
Date of Birth: [**2095-10-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4928**]
Addendum:
The head CT scan demonstrated moderate hydrocephalus, likely
related to the interventricular hemorrhage; however, given the
overall poor prognosis and the decision to make the patient CMO,
no specific intervention was performed regarding this finding.
Discharge Disposition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4929**] MD [**MD Number(2) 4930**]
Completed by:[**2165-11-22**]
|
[
"250.00",
"V58.61",
"V15.88",
"V49.71",
"780.01",
"331.4",
"401.9",
"431",
"V43.3",
"414.00",
"433.10",
"272.4",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4966, 5133
|
2883, 3962
|
344, 356
|
4230, 4239
|
2594, 2613
|
4291, 4943
|
1783, 1800
|
4173, 4209
|
3988, 4120
|
4263, 4268
|
1815, 2575
|
279, 306
|
384, 1396
|
2622, 2860
|
1418, 1662
|
1678, 1767
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,383
| 104,797
|
30447
|
Discharge summary
|
report
|
Admission Date: [**2145-3-19**] Discharge Date: [**2145-4-14**]
Date of Birth: [**2074-2-15**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Percocet
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
ICU treatment
History of Present Illness:
Briefly, this is a 71 yo Spanish-speaking male with a
complicated PMH significant for CAD s/p CABG in [**2140**], ischemic
cardiomyopathy (EF 17%) cath in [**1-/2145**] without intervention
(results of cath currently unknown), but with resultant diffuse
atheroembolic disease leading to renal failure, transaminitis,
pancreatitis, and skin phenomena. He required HD during that
hospital stay, but then became bacteremic with a form of
streptococcus, requiring pulling of the tunneled HD line and
treatment with ceftriaxone. He also had multiple bouts of
tachycardia (not otherwise specified) during that
hospitalization, requiring a brief stay in the CCU. He was
discharged from [**Hospital1 2177**] on [**2145-3-16**] after his month-long
hospitalization and went to [**Hospital3 537**] for rehab. At [**Hospital **], he was apparently doing well until the night of
presentation when he developed the acute onset of SOB. [**Name6 (MD) **] his
RN's report, he developed SOB with O2 sats in the 80s on 2L
nasal cannula, which is much lower than what he usually is. It
was unknown whether or not he was tachycardic at the time. He
was also reportedly diaphoretic, but denied any chest pain or
pressure. The [**Hospital1 1501**] reports that at baseline, he has a waxing and
[**Doctor Last Name 688**] mental status, but has not had any difficulties with SOB
or CP since his discharge. They have been giving him his IV
lasix regularly and he has been making good urine output. They
did not have a foley catheter in place at [**Hospital3 537**] and was
voiding on his own without difficulty. He does not walk, stays
in bed most of the day, but is able to get up to a chair. He was
taken by ambulance from [**Hospital3 537**] to our ED.
.
In the ED, he was felt to be fluid overloaded. However he had a
WBC of 13.4 with a left shift and a lactate of 3.4, raising
concern for infection/sepsis. His lasix was held and he was
given vancomycin and levofloxacin, as well as ASA 325mg. CTA was
not performed given his renal failure. His CXR was consistent
with CHF, however, and given his multiple cardiac issues, he
was admitted to [**Hospital Ward Name 121**] 6 for further management.
.
On arrival to the floor, he reported feeling improved. He mainly
complained of pain all over his body. He felt that his breathing
was back to baseline. He denied any associated chest discomfort.
He was interviewed with his sister at his bedside, and she felt
his MS was at his baseline.
.
This AM, he developed an SVT, likely an AVNRT, at a rate of 120.
He felt SOB and had chest tightness, along with "all over" body
pain. He was given 5mg IV lopressor w/o any improvement in HR.
He was given O2 and felt relief in terms of his dyspnea. He
refused breakfast but was given his PO medications. He then
began to dry heave and throw up his pills. An interpreter was
called to try to further identify his complaints. He denied any
recent fevers or chills, cough, cold symptoms, chest pain or
pressure, or SOB. He can't remember the events of yesterday and
complains only of fatigue, total body aches, nausea, and
constipation. He feels that his breathing is improved currently
but is frustrated at his lengthy medical illness and is
concerned that no one is helping and that he is going to die. He
denies any drug allergies (though is listed as being allergic to
percocet and lisinopril). He states that he previously was
functional and independent, before everything happened in
[**Month (only) 404**] after his cath. He fears he will never return to his
baseline level of functioning.
Past Medical History:
- CAD s/p CABG x3 ([**2-5**])
- Ischemic Cardiomyopathy (EF 17% 2/06)
- s/p AVR ([**2-5**]) with # 19 [**Last Name (un) 3843**]-[**Doctor Last Name **] (porcine) valve,
on ASA for anticoagulation
- hypercholesterolemia
- s/p L CEA
- Cervical stenosis
- GERD
Social History:
Most recently, has been living at [**Hospital3 537**] since his
prolonged hospitalization in [**1-10**]. Has son who is in boot camp,
sister who is involved and niece who works at [**Hospital1 **]. Used
to work as a carpenter, but has been retired for last several
years. Originally from [**Male First Name (un) 1056**]. Before [**1-10**], lived in an
apartment in [**Location (un) 2312**] by himself.
Family History:
NC
Physical Exam:
VS: Temp 96.1, BP 117/61, HR 82, RR 24, O2 sat 97% on RA
Generally the patient is ill appearing, spanish speaking only,
interviewed with sister present. The patient was oriented to
person, place and time. The patient's mood and affect were not
inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 11 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs had crackles a third of the
way up bilaterally.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There was a III/VI SEM at LUSB.
.
The abdominal aorta was not enlarged by palpation. There was
diffuse tenderness without guarding or rebound. The extremities
had 3+ edema bilaterally in the legs. There were purpuric
lesions in the extremities consistent with atheroembolic emboli.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
LABS on admission:
WBC-13.4* Hct-30.6* MCV-87 Plt Ct-219
Neuts-86.5* Lymphs-10.7* Monos-2.4 Eos-0.2 Baso-0.1
PT-17.6* PTT-30.5 INR(PT)-1.6*
Glucose-116* UreaN-69* Creat-2.7* Na-132* K-4.0 Cl-92* HCO3-26
AnGap-18
ALT-32 AST-58* LDH-586* AlkPhos-131* Amylase-110* TotBili-3.0*
Lipase-142*
Lactate-3.4*
.
Cardiac enzymes:
[**2145-3-18**] 10:30PM CPK-40 CK-MB-NotDone cTropnT-0.45* proBNP- >
than assay
[**2145-3-19**] 05:50AM CPK-39 CK-MB-5 cTropnT-0.46*
.
LABS on discharge:
.
MICRO:
.
IMAGING:
Brief Hospital Course:
71yo M with hx of multiple medical problems including CAD, CABG,
ischemic cardiomyopathy, atheroembolic disease, and renal
failure, presents with acute onset of dyspnea.
Unfortunately the patient's condition did not improve even with
aggressive ICU measures. He developed multisystem organ failure.
After [**Last Name (un) 72377**] with the sister and explaining in lenght the
infaust prognosis, the HCP decided to pursue comfort measures
only. The patient was seen by the priest. [**Name (NI) **] expired on [**2145-4-14**]
at 18:15. The family requested an autopsy. The attending, Dr. [**Last Name (STitle) **]
[**Last Name (STitle) **] notified.
Medications on Admission:
Pantoprazole 40mg daily
Metoprolol 12.5mg [**Hospital1 **]
Atorvastatin 10mg daily
Losartan 25mg daily
Lasix 80mg IV bid
Ceftriaxone 1 gram daily IV
MVI
Oxycodone 5mg q4hrs prn pain
Fentanyl 25mcg IV q2hrs prn pain
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
.
Discharge Instructions:
.
Completed by:[**2145-4-15**]
|
[
"576.1",
"414.00",
"790.6",
"272.0",
"530.81",
"444.89",
"V43.3",
"574.90",
"414.8",
"584.9",
"995.91",
"285.1",
"576.2",
"530.7",
"576.8",
"789.00",
"038.9",
"428.0",
"V45.81",
"585.9",
"518.81",
"287.5",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"38.93",
"45.13",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
7357, 7366
|
6441, 7091
|
286, 301
|
7417, 7420
|
5923, 5928
|
4612, 4616
|
7387, 7396
|
7117, 7334
|
7444, 7476
|
4631, 5904
|
6242, 6377
|
243, 248
|
6396, 6418
|
329, 3894
|
5942, 6225
|
3916, 4176
|
4192, 4596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,841
| 120,630
|
30116
|
Discharge summary
|
report
|
Admission Date: [**2126-6-25**] Discharge Date: [**2126-6-29**]
Date of Birth: [**2050-6-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Lipitor
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
s/p sternotomy [**2126-6-25**]
History of Present Illness:
76 yo female with known aortic stenosis followed by serial
echos, more severe at last echo. Cath showed severe AS, and 40%
RCA. Echo also showed mild MR and mild AI. CXR also showed a 5cm
descending thoracic aneurysm. Referred to Dr. [**Last Name (STitle) 1290**] for
surgery.
Past Medical History:
HTn
elev. chol.
AS
MV prolapse
[**Last Name (STitle) 2182**]
? lupus
obesity
[**Last Name (STitle) **]
macular degeneration
obstructive sleep apnea -BiPAP
cataracts s/p bil. removal
prior left TKR
Social History:
60 pack/yr history, quit 9 years ago
no ETOH
widowed, lives alone
Family History:
father expired MI at 48
Physical Exam:
63" 230 #
HR 76 RR 18 155/62
elderly, NAD
RLE with slight swelling and erythema
HEENT unremarkable
neck with full ROM with transmitted murmur
CTAB
RRR 3/6 SEM
soft, NT, ND, + BS , obese
warm, well-perfused, 1+ BLE edema
bil. superficial varicosities
neuro grossly intact
bil. 1+ fem/DP/PTs
bil. 2+ radials
Pertinent Results:
[**2126-6-28**] 06:30AM BLOOD WBC-9.2 RBC-3.33* Hgb-9.6* Hct-28.4*
MCV-85 MCH-28.8 MCHC-33.8 RDW-15.3 Plt Ct-128*
[**2126-6-28**] 06:30AM BLOOD Plt Ct-128*
[**2126-6-27**] 01:56AM BLOOD PT-14.2* PTT-27.6 INR(PT)-1.3*
[**2126-6-26**] 03:11AM BLOOD Fibrino-283
[**2126-6-28**] 06:30AM BLOOD Glucose-125* UreaN-19 Creat-0.9 Na-135
K-3.7 Cl-99 HCO3-30 AnGap-10
[**2126-6-28**] 06:30AM BLOOD Mg-2.2
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2126-6-27**] 8:19 AM
CHEST (PORTABLE AP)
Reason: s/p ct d/c
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman s/p sternotomy
REASON FOR THIS EXAMINATION:
s/p ct d/c
CHEST SINGLE AP FILM:
HISTORY: Sternotomy and AVR.
Status post median sternotomy. A Cordis catheter is present in
the right brachiocephalic vein. No pneumothorax. No change in
heart size or prominent thoracic aorta since prior film of [**6-25**], [**2126**]. Linear atelectasis is present at the left lung base.
There has been partial resolution of the atelectasis in the left
lower lobe since prior film and left hemidiaphragm is now
partially visualized. There has also been resolution of the
previously noted linear atelectasis in the right lateral zone.
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: [**Doctor First Name **] [**2126-6-27**] 10:51 AM
Cardiology Report ECHO Study Date of [**2126-6-25**]
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for CABG, AVR, MVR
Status: Inpatient
Date/Time: [**2126-6-25**] at 16:23
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW04-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.6 cm (nl <= 5.0 cm)
Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%)
Left Ventricle - Peak Resting LVOT gradient: 2 mm Hg (nl <= 10
mm Hg)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.6 cm (nl <= 3.4 cm)
Aorta - Arch: 3.0 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: *5.2 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: *2.9 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 61 mm Hg
Aortic Valve - Mean Gradient: 45 mm Hg
Aortic Valve - Valve Area: *0.9 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum.
No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic
function.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the
aortic arch. Markedly dilated descending aorta Complex (>4mm)
atheroma in the
descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Moderate-severe AS (area 0.8-1.0cm2). Mild to
moderate ([**2-5**]+)
AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
mitral annular
calcification. No MS. Moderate to severe (3+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
Conclusions:
PRE-BYPASS: The left atrium is moderately dilated. No atrial
septal defect is
seen by 2D or color Doppler. Right ventricular chamber size and
free wall
motion are normal. There appears to be extensive calcification
of the
ascending aorta. There are complex (>4mm) atheroma in the aortic
arch. The
descending thoracic aorta is markedly dilated. There are complex
(>4mm)
atheroma in the descending thoracic aorta. There are three
aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild
to moderate
([**2-5**]+) aortic regurgitation is seen. The mitral valve leaflets
are moderately
thickened. Moderate to severe (3+) mitral regurgitation is seen.
Vena
contracta is 5-6 mm. There is blunting or reversal of pulmonary
venous s wave
flow pattern. The mitral annulus averages 2.9 cm in diameter.
There is
bileaflet restriction of the mitral valve with central mitral
regurgitation.
There is a trivial/physiologic pericardial effusion. All
findings discussed
with surgeons at the time of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2126-6-25**] 18:50.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 71789**])
Brief Hospital Course:
Admitted [**6-25**] and was taken to the OR with Dr. [**Last Name (STitle) 1290**].
Intra-op echo also revealed moderate to severe MR, worsened from
TTE 5 weeks ago. In addition, after sternotomy was done, it was
noted that the ascending aorta was heavily calcified into the
aortic arch. Given that the nature of the operation had changed
to the need for AVR/MVR, and replacement of aortic arch with
circulatory arrest, the family was consulted by telephone from
the OR. Per Dr. [**Last Name (STitle) 1290**] , the risks had dramatically
increased. The family elected to abandon the operation, wake the
pt., and allow her to participate in the discussion and
reevaluate her decision if necessary. She was extubated the next
morning. CT scanning with MMS reconstruction done for further
evaluation of her aorta. Transferred to the floor on POD #2.
Cleared for discharge to rehab on POD #4. Pt. is to follow up
with Dr. [**Last Name (STitle) 1290**] in the office next Thursday.
Medications on Admission:
ASA 81 mg daily
lasix 40 mg daily
lopressor 50 mg [**Hospital1 **]
minipress 5 mg TID
norvasc 2.5 mg daily
levoxyl 150 mg daily
advair 250/50 [**Hospital1 **]
KCl 20 mg daily
quinine SO4 324 mg daily
motrin 800 mg TID prn
prednisone and zithromax ( completed [**5-20**])
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
HTN
AS
MR
[**First Name (Titles) 2182**]
[**Last Name (Titles) **]
descending thoracic aortic aneurysm
obesity
obstructive sleep apnea with BiPAP
? lupus
Discharge Condition:
good
Discharge Instructions:
shower daily
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
call for fever greater than 100.5, redness or drainage
no driving for one month
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (Prefixes) **] on Thursday, [**7-4**]. Please call
([**Telephone/Fax (1) 11763**] for appt.
Completed by:[**2126-6-29**]
|
[
"997.5",
"V15.82",
"788.5",
"V45.61",
"997.3",
"327.23",
"786.06",
"496",
"278.01",
"V43.65",
"440.0",
"362.50",
"518.0",
"441.7",
"285.9",
"V64.1",
"272.0",
"244.9",
"398.91",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"88.72",
"38.91",
"77.31",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
8231, 8333
|
6932, 7910
|
315, 347
|
8531, 8538
|
1343, 1850
|
973, 998
|
1887, 1920
|
8354, 8510
|
7936, 8208
|
8562, 8733
|
8784, 8930
|
2742, 6833
|
1013, 1324
|
272, 277
|
1949, 2716
|
375, 653
|
6868, 6909
|
675, 874
|
890, 957
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,936
| 174,504
|
10964
|
Discharge summary
|
report
|
Admission Date: [**2140-4-30**] Discharge Date: [**2140-5-8**]
Date of Birth: [**2062-9-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Norvasc / Zestril / Coumadin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
unstable angina/ ACS
Major Surgical or Invasive Procedure:
[**2140-5-2**]
1. Redo sternotomy.
2. Coronary artery bypass grafting x3, with reversed
saphenous vein graft to the obtuse marginal artery and
reversed saphenous Y-graft to the left anterior
descending artery and diagonal artery.
History of Present Illness:
77 yo Male with known coronary artery disease s/p CABG x3 '[**31**],
hypertension, dyslipidemia, chronic AFib (not on Warfarin 2' hx
retroperitoneal bleed while on Coumadin '[**36**]), CRI, who underwent
repeat cath 2' unstable angina, STEMI.
EMTs in the field performed ECG=ST elevations in V1-V3 with TWI
V1-V4. NTG sl given x3 with resolution of CP/ST elevations. He
was admitted to MWMC with Acute Coronary Syndrome, positive
Troponins, and under went an urgent cath which revealed
significant multivessel coronary disease and restenosis of
bypass
grafts. He was placed on Heparin drip, pain free,
hemodynamically
stable and transferrd th [**Hospital1 18**] for csurg evaluation of
redo-sternotomy/CABG. Denies current CP,dyspnea, nausea or
diaphoresis.
Past Medical History:
per HPI,CAD s/p CABG x3'[**31**], Chronic AFib-
No Coumadin 2' retroperitoneal bleed '[**36**], HTN, dyslipidemia,
hiatal hernia-nonobstructive Schatzki ring, CRI baseline 1.68,
GERD
Social History:
Lives with:wife
Occupation:retired engineer
Tobacco:quit smoking 52 years ago
ETOH:denies
Family History:
non-contributory
Physical Exam:
Pulse: 50 Resp: 18 O2 sat: 96% nc @ 2LPM
B/P Right:111/62 Left:
Height: 5'7" Weight:95 KG
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
(L)LE varicosity -(R)LE SVG 2 segments taken for bypass '[**31**] None
[]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit -none Right: 2+ Left:2+
Pertinent Results:
Conclusions
PRE-CPB: Redo CABG
1. The left atrium is markedly dilated. The left atrium is
elongated. Mild spontaneous echo contrast is seen in the body of
the left atrium. No mass/thrombus is seen in the left atrium or
left atrial appendage. Mild spontaneous echo contrast is present
in the left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No thrombus is seen in the left
atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild global left
ventricular hypokinesis (LVEF = 40 %). There is severe anterior
hypokinesis.
4. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
6. Mild to moderate ([**1-9**]+) mitral regurgitation is seen. There
is a very small pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results.
POST-CPB: On infusion of epinephrine, phenylephrine. V-pacing.
Preserved left ventricular systolic function on inotropic
support. LVEF = 55%, with improved anterior hypokinesis and MR
is now 1 +. RV systolic function is now moderately depressed. TR
is mild. Aortic contour is normal post decannulation. There is a
moderate left pleural effusion.
[**2140-5-7**] 08:17AM BLOOD WBC-10.9 RBC-3.40* Hgb-10.3* Hct-30.7*
MCV-90 MCH-30.3 MCHC-33.5 RDW-16.2* Plt Ct-142*#
[**2140-5-6**] 01:30AM BLOOD WBC-12.9* RBC-3.33* Hgb-10.1* Hct-30.0*
MCV-90 MCH-30.3 MCHC-33.6 RDW-15.6* Plt Ct-94*
[**2140-5-8**] 06:20AM BLOOD Glucose-96 UreaN-49* Creat-1.8* Na-137
K-4.0 Cl-94* HCO3-35* AnGap-12
[**2140-5-7**] 08:17AM BLOOD Glucose-122* UreaN-43* Creat-1.7* Na-137
K-3.6 Cl-92* HCO3-34* AnGap-15
[**2140-5-6**] 01:30AM BLOOD Glucose-102* UreaN-38* Creat-1.7* Na-140
K-3.8 Cl-95* HCO3-34* AnGap-15
Brief Hospital Course:
Transferred in from [**Hospital1 **] on [**4-30**] for pre-op workup. He was
continued on heparin drip until surgery. Underwent an urgent
redo CABG with Dr. [**Last Name (STitle) **] on [**5-2**] with a reverse saphenous vein
graft to the diagonal, Y graft to the left anterior descending
and reverse saphenous vein graft to the obtuse marginal. See
operative note for full details. He was transferred to the CVICU
in stable condition on titrated epinephrine and phenylephrine
and vasopressin drips. Milrinone was added postoperatively
secondary to a low cardiac index. A left chest tube was placed
postoperatively for a left hydropneumothorax. He was extubated
on the morning of POD #2. Vasoactive medications and inotropes
were weaned. He was kept in the intensive care unit for
pulmonary toilet issues. He was transferred to the floor on post
operative day 4 in stable condition. Chest tubes and pacing
wires were removed per cardiac surgery protocol. He was working
with physical therapy to increase strength and endurance. He
was not started on Coumadin for chronic atrial fibrillation due
to a history of retroperitoneal bleed. He had a preoperative
right groin hematoma which was stable with a stable hematocrit
at the time of discharge. Chest xrays showed a moderate right
pneumothorax, which was stable at the time of discharge with the
patient oxygenating at 100% on room air and asymptomatic. On
post operative day 6 he was ambulating in the halls with
assistance, tolerating a full oral diet and his incisions were
healing well. It was felt that he was safe for discharge home
with visiting nurse services at this time. He was instructed to
follow up with his PCP [**Last Name (NamePattern4) **] 1 week for chest x-ray to evaluate the
right pneumothorax. He was instructed to go to the emergency
room with any increase in shortness of breath or pain.
Medications on Admission:
Zocor 20(1),Toprol XL 100(1),Diovan 320(1),
Calcium 500(1), Allopurinol 300(1), Indapamide 2.591), Vit C
400(1), Glucosamine, ASA 81(1) M-W-F, Nexium 20(1)
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:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
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:*0*
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Combivent 18-103 mcg/Actuation Aerosol Sig: [**1-9**] Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 * Refills:*0*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24)
hours for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease, s/p coronary artery bypass
s/p CABG x3'[**31**],
Chronic AFib-No Coumadin 2' retroperitoneal bleed '[**36**], HTN,
dyslipidemia,
hiatal hernia-nonobstructive Schatzki ring, CRI baseline 1.68,
GERD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - no drainage or erythema, sternum stable
Leg Right-healing well, no erythema or drainage. Large area of
ecchymosis at medial thigh, soft, nontender, not warm
Edema 1+ bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] at MWMC(for Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 6256**] in [**2-10**]
weeks
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) 412**] A. [**Telephone/Fax (1) 20221**] in 1 weeks -
needs CXR at follow up to evaluate right pneumothorax
Cardiologist Dr. [**Last Name (STitle) 32255**] in 4 weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2140-5-8**]
|
[
"276.2",
"511.89",
"414.2",
"427.31",
"750.3",
"403.90",
"272.4",
"E879.0",
"553.3",
"E878.2",
"530.81",
"414.02",
"585.9",
"410.91",
"998.12",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"34.04",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
8146, 8205
|
4603, 6475
|
315, 559
|
8472, 8786
|
2407, 4580
|
9488, 10027
|
1679, 1697
|
6682, 8123
|
8226, 8451
|
6501, 6659
|
8810, 9465
|
1712, 2388
|
255, 277
|
587, 1348
|
1370, 1555
|
1571, 1663
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,906
| 136,499
|
5780
|
Discharge summary
|
report
|
Admission Date: [**2126-1-2**] Discharge Date: [**2126-1-7**]
Date of Birth: [**2064-6-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Ativan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 2 (Left internal mammary artery
-> left anterior descending, saphenous vein graft -> Diagonal),
Aortic Valve replacement ( 21mm pericardial [**Doctor Last Name **] valve),
Mitral Valve repair (28mm [**Doctor Last Name **] annuloplasty ring) [**2126-1-2**]
Bronchoscopy [**2126-1-2**]
History of Present Illness:
61 yo male presented to OSH with angina and ruled in for IMI.
Transferred to [**Hospital1 18**] for cardiac cath which revealed 3VD. IABP
was placed at that time. He was also diagnosed with a small
right pontine CVA (likely embolic per neuro)at that time. He
made a reasonable recovery and was discharged home with plans
for CABG/valve surgery in the near future with Dr. [**Last Name (STitle) **].
Past Medical History:
1. CAD s/p MI in [**2098**], MIs in [**2109**] with poba to LAD, and [**2116**]
with BMS to LCX.
2. CHF EF 35%
# previous h/o intermittent RBBB on ECG
3. perforated ulcer s/p gastrectomy for life-threatening bleed
in [**2104**], no recurrent bleeding
4. iron def anemia
5. seizures, last seizure in [**2078**] and he has been off dilantin
since
6. [**Year (4 digits) 22982**]
7. pontine CVA
Social History:
Married, has two biological children and three step children. He
works as an Accountant, smokes 1.5 ppd, occasional alcohol, no
drug use.
Family History:
M: died of MI at 84. F: lived until age [**Age over 90 **]
Physical Exam:
6' 137#
HR 84 RR 20 right 120/64 left 118/60
NAD
Skin/HEENT unremarkable
neck supple with full ROM and no carotid bruits
CTAB
RRR no murmur
soft, NT, ND, +BS
warm, well-perfused, no edema or varicosities
neuro grossly intact
2+ bil. fem/radials
1+ bil. DP/PTs
Pertinent Results:
[**2126-1-7**] 07:15AM BLOOD WBC-9.5 RBC-4.10* Hgb-11.0* Hct-33.0*
MCV-81* MCH-26.9* MCHC-33.4 RDW-18.4* Plt Ct-124*
[**2126-1-7**] 07:15AM BLOOD Plt Ct-124*
[**2126-1-6**] 05:30AM BLOOD Glucose-97 UreaN-17 Creat-0.7 Na-138
K-3.8 Cl-100 HCO3-30 AnGap-12
[**2126-1-4**] 06:26PM BLOOD ALT-17 AST-37 LD(LDH)-359* AlkPhos-69
Amylase-40 TotBili-1.0
[**2126-1-4**] 06:26PM BLOOD Lipase-20
[**2126-1-5**] 02:32AM BLOOD Phos-2.5* Mg-1.8
[**2126-1-1**] 11:45AM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE
[**2126-1-4**] 06:26PM BLOOD Ammonia-22
[**2126-1-4**] 06:26PM BLOOD TSH-2.8
Cardiology Report ECHO Study Date of [**2126-1-2**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Coronary artery disease.
Hypertension. Mitral valve disease. Myocardial infarction.
Status: Inpatient
Date/Time: [**2126-1-2**] at 11:13
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.3 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 0.7 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: *1.7 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *7.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.8 cm
Left Ventricle - Fractional Shortening: 0.39 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 25% to 30% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Valve Area: *2.4 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
Considering known global hypokinesis and history of two abn
valves, has
decided to proceed with intraoperative TEE in the setting of
prior partial
gastrectomy. Pt denies hx of dysphagia or any difficulties with
food getting
stuck. Risks/benefits discussed with patient. TEE passed
smoothly and without
any resistance met. Minimal manipulation of transgastric views.
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus
in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Severe
global LV hypokinesis. Severely depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Moderate global
RV free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Severe
(4+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient received antibiotic prophylaxis. The
TEE probe was
passed with assistance from the anesthesioology staff using a
laryngoscope.
The patient was under general anesthesia throughout the
procedure.
Conclusions:
Prebypass: The left atrium is moderately dilated. No spontaneous
echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is
severely dilated. There is severe global left ventricular
hypokinesis. Overall
left ventricular systolic function is severely depressed. Right
ventricular
chamber size and free wall motion are normal. There is moderate
global right
ventricular free wall hypokinesis. There are simple atheroma in
the descending
thoracic aorta. There are complex (>4mm) atheroma in the
descending thoracic
aorta. The aortic valve leaflets are mildly thickened. Severe
(4+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened.
Moderate (2+) mitral regurgitation is seen. There is no
pericardial effusion.
Post bypass: Annuloplasty ring in the mitral position well
seated and
mechanically stable. Good leaflet excusion with no regurgitaiton
and
insignificant gradient across the mitral valve. There is not
evidence of
dynamic LVOT obstruction. Slightly improved LV systolic function
(with
epinephrine ionotropic support.) Preserved RV systolic function.
Bioprosthesis seen in the aortic position, well seated and
mechanically
stable. Good leaflet excursion with no regurgitation. Gradient
not obtained
postbypass due to avoidance of transgastric maniupulation due to
hx of
gastrectomy.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2126-1-4**] 11:02.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 22983**])
Brief Hospital Course:
Admitted [**1-2**] and underwent AVR/ MV repair/cabg x2 with Dr.
[**Last Name (STitle) **]. Transferred to the CSRU in stable condition on
epinephrine, phenylephrine, and propofol drips. Bloody
secretions necessitated bronchoscopy which was done that
evening. Mucous plug removed during bronch. Extubated on POD #1
and chest tubes removed on POD #2. Transferred to the floor on
POD #3 to begin increasing his activity level. Keflex /warm
packs started for phlebitis in right arm. Neuro eval done to
follow his prior CVA. Beta blockade and diuresis titrated. Afib
treated and converted to SR with amiodarone. Cleared for
discharge to home with services on POD #5. Pt. to make all
follow-up appts. as per discharge instructions.
Medications on Admission:
ASA 325 mg daily
lipitor 20 mg daily
protonix 40 mg daily
cyanocobalamin 500 mg [**Hospital1 **]
plavix 75 mg daily
amoxicillin prn dental procedures
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. 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*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. 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*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg twice a day until [**2126-1-12**] then
decrease to 400mg daily for 7 days and then decrease to 200mg
daily .
Disp:*56 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks: continue until follow up appt with cardiologist .
Disp:*30 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day: take with lasix and
discontinue with lasix.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD/MR/AI
s/p cabg x2/AVR/ MV repair
pontine CVA [**10-31**]
MI [**2109**] with PTCA to LAD
MI with CX stent [**2116**]
MI [**10-31**]
CHF
[**First Name9 (NamePattern2) 22982**]
[**Doctor Last Name **] deficiency anemia
seizures- remote [**2078**]'s
AFIB
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Warm packs to right arm for comfort
Please call with any questions or concerns
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**Last Name (STitle) 22980**] in 1 week ([**Telephone/Fax (1) 22984**]) please call for appointment
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in [**12-29**] weeks ([**Telephone/Fax (1) 6256**]) please call for
appointment
Wound check appointment at [**Hospital1 **] heart center call for appt
[**Telephone/Fax (1) 6256**]
[**Hospital 4038**] Clinic [**Hospital1 18**] [**Telephone/Fax (1) 1694**] Please call for an appointment
Completed by:[**2126-1-8**]
|
[
"349.82",
"933.1",
"305.1",
"398.91",
"412",
"414.01",
"V45.82",
"396.3",
"280.9",
"999.2",
"427.31",
"451.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"89.60",
"39.61",
"99.07",
"36.15",
"98.15",
"35.33",
"99.04",
"35.21",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
10062, 10111
|
7431, 8159
|
299, 616
|
10409, 10416
|
1991, 2616
|
10918, 11511
|
1631, 1691
|
8359, 10039
|
10132, 10388
|
8185, 8336
|
10440, 10895
|
2642, 7338
|
1706, 1972
|
249, 261
|
644, 1044
|
7373, 7408
|
1066, 1458
|
1475, 1615
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,798
| 128,776
|
3280
|
Discharge summary
|
report
|
Admission Date: [**2101-12-20**] Discharge Date: [**2101-12-26**]
Date of Birth: [**2030-10-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Lumbar puncture [**2100-12-21**]
History of Present Illness:
Pt is a 71 yo F w/ h/o seizures who was recently admitted to the
neuro service with herpes encephalitis who presents with fevers
and hypotension. She had completed the course of acyclovir on
[**12-12**] and was currently at [**Hospital 15303**] Rehab after recent [**Hospital1 18**]
stay. New "baseline" per daughters included repeating herself,
decreased short-term memory, restlessness, and agitation
sometimes at night (ie, pulling tubes). Yesterday, she fell and
hit her head while trying to climb out of bed, she was cleared
by doctor at facility but no head scan done. She then developed
fever to 104, vomiting, headache this evening and had
"seizure-like" activity witnessed by nurse at rehab. Otherwise
at this time patient unable to give any history.
.
In the ED, the patient received Vanco 1g, Decadron 10mg, CTx 2g,
Acyclovir 700mg, flagyl 500 mg. Her pressure had dropped to
80/36, still with high O2 requirement. Labs rechecked and
Hemoglobin down to 7.8 from 9.1, though lactate slightly lower.
Had brief episode of aflutter. Sepsis protocol initiated;
levophed started to increase sbp to goal 90s.
Past Medical History:
-recent herpes simplex type 1 encephalitis- treated w/
acyclovir- PCR from [**12-8**] negative
-seizure disorder since [**91**]; had 3 GTC seizures; also partial
complex seizures: would stare, not respond and make circling
movement with her R-arm for example on the table in front of her
(per family); followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 15304**] problems, followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) **]/p knee fracture
Social History:
Denies tobacco, ETOH, illicit drug use. Married, 4 healthy
daughters
Family History:
N/C
Physical Exam:
T 97.7 BP 101/45 HR 77 RR 22 O2sats 100% NRB
SvO2 92 CVP 10
Gen: Lethergic, responds to noxious stimuli
HEENT: PERRL, anicteric, dry mm
Neck: No JVD
Lungs: Tubular breath sounds in RUL, + exp wheezes
Heart: RRR no m/r/g
Abd: Soft, NT, ND + BS
Ext: no edema, no cyanosis
Neuro: Letheragic, responds to noxious stimuli, moving all 4
extremities
.
Pertinent Results:
CXR [**12-20**]
1. Satisfactory left subclavian line placement.
2. Right upper lobe pneumonia.
3. Interval development of volume overload/CHF.
.
ECG- Sinus tachy, 100, normal axis, normal intervals,
non-specific ST changes in V5-V6
.
CT head- [**12-20**]
1. No acute intracranial hemorrhage or fracture.
2. Stable areas of edema in the right temporal and frontal
lobes, unchanged from study of four days prior.
.
Hip/knee X-ray [**12-20**]
No definite evidence for acute traumatic injury to the right hip
or right knee.
.
CXR [**12-23**]
1. Improving pulmonary edema.
2. Worsening bibasilar opacities, likely due to a combination of
atelectasis and effusion.
3. Improving right upper lobe opacity, which may be due to
asymmetric edema or improving pneumonia.
.
[**2101-12-19**] 11:54PM BLOOD WBC-15.4*# RBC-2.77* Hgb-9.1* Hct-25.1*
MCV-91 MCH-32.9* MCHC-36.3* RDW-17.9* Plt Ct-249
[**2101-12-22**] 04:45AM BLOOD WBC-9.6 RBC-2.72* Hgb-9.0* Hct-25.8*
MCV-95 MCH-33.0* MCHC-34.9 RDW-18.9* Plt Ct-252
[**2101-12-26**] 05:06AM BLOOD WBC-5.1 RBC-4.10*# Hgb-13.6# Hct-38.8#
MCV-95 MCH-33.2* MCHC-35.0 RDW-19.1* Plt Ct-178
[**2101-12-20**] 05:00AM BLOOD Neuts-84* Bands-7* Lymphs-5* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2101-12-19**] 11:54PM BLOOD PT-14.2* PTT-29.8 INR(PT)-1.4
[**2101-12-20**] 05:00AM BLOOD PT-14.4* PTT-32.3 INR(PT)-1.4
[**2101-12-19**] 11:54PM BLOOD Glucose-139* UreaN-9 Creat-0.6 Na-136
K-3.4 Cl-100 HCO3-24 AnGap-15
[**2101-12-26**] 05:06AM BLOOD Glucose-78 UreaN-7 Creat-0.4 Na-136 K-4.1
Cl-100 HCO3-26 AnGap-14
[**2101-12-19**] 11:54PM BLOOD ALT-19 AST-17 CK(CPK)-71 AlkPhos-82
Amylase-23 TotBili-0.6
[**2101-12-20**] 05:00AM BLOOD LD(LDH)-211
[**2101-12-19**] 11:54PM BLOOD Lipase-13
[**2101-12-19**] 11:54PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2101-12-19**] 11:54PM BLOOD Albumin-3.3* Calcium-7.7* Phos-2.7
Mg-1.2*
[**2101-12-26**] 05:06AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.5*
[**2101-12-19**] 11:54PM BLOOD Cortsol-28.8*
[**2101-12-20**] 09:40AM BLOOD Cortsol-32.7*
[**2101-12-19**] 11:54PM BLOOD CRP-239.0*
[**2101-12-19**] 11:54PM BLOOD Phenoba-21.9 Phenyto-18.8
[**2101-12-24**] 06:27AM BLOOD Phenyto-10.4 Phenyfr-PND
[**2101-12-19**] 11:59PM BLOOD Lactate-1.9
[**2101-12-20**] 05:22AM BLOOD Lactate-1.7
[**2101-12-20**] 01:42AM BLOOD Hgb-7.8* calcHCT-23 O2 Sat-95
[**2101-12-20**] 05:22AM BLOOD freeCa-1.04*
.
[**2101-12-19**] 11:30 pm BLOOD CULTURE
**FINAL REPORT [**2101-12-26**]**
AEROBIC BOTTLE (Final [**2101-12-26**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2101-12-26**]): NO GROWTH.
.
[**2101-12-19**] 11:15 pm URINE
**FINAL REPORT [**2101-12-21**]**
URINE CULTURE (Final [**2101-12-21**]):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). >100,000
ORGANISMS/ML..
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
.
[**2101-12-21**] 2:03 pm CSF;SPINAL FLUID Source: LP.
**FINAL REPORT [**2101-12-24**]**
GRAM STAIN (Final [**2101-12-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2101-12-24**]): NO GROWTH.
Brief Hospital Course:
A/P 71 yo F w/ h/o seizure, recent herpes encephalitis p/w
fevers and ?seizure like activity prior to presentation to the
ED.
.
# [**Name (NI) 15305**] Pt with several possible sources for sepsis given + UA
and likely PNA on CXR and recent herpes encephalitis. Initially
febrile, with hypotension requiring pressors. Lactate normal
although most likely cause of hypotension thought to be
pneumonia. She was started on sepsis protocol in the ED, with
Goal CVP>8, Goal MAP>60, Goal SvO2>70. On day of admission her
hct was 23 and she was given 1 unit prbc. [**Last Name (un) **] stim was done
which showed good response. She was started on vancomycin and
zosyn. Acyclovir was also started given recent hsv encephalitis
admission. She was also started on Insulin gtt for goal glucose
80-120. She improved during her admission requiring less O2 per
day and with good blood pressure. Levophed was weaned off, she
remained afebrile in the ICU after the initial temperature of
104. Antibiotics were changed to levo/flagyl to treat her RUL
pneumonia after the blood cx were negative; her CXR on [**12-23**]
showed resolving infection although her atelectasis/effusion did
not improve. She will finish 7 more days of levo/flagyl and
taper quickly off the dexamethasone in the week after discharge.
Acyclovir was discontinued after her CSF PCR was negative. She
is hemodynamically stable, afebrile w/ normal WBC and appears
well.
.
# Mental status changes - [**Month (only) 116**] be secondary to sepsis vs
recurrent herpes encephalitis vs post ictal from seizures vs
stroke. Pt also had fall at rehab in the day prior to admission
and then developed HA and vomiting, which was also concerning
for possible SDH. CT scan showed no ICH. LP was done which had
wbc count; however it was mainly lymphocytic. HSV PCR was
ordered, and she was empirically treated w/ acyclovir until the
results came back negative. She was continued on decadron per
neuro recs who followed pt during her stay in the icu. Her
mental status returned to baseline with resolving infection and
hemodynamic stability.
.
# Seizure disorder- On regimen of phenobarbital and phenytoin as
outpatient. Phenytoin level at 24 based on albumin of 3.3 on
admission. Decreased phenytoin to 100mg tid and levels within
therapeutic range prior to discharge. She did not have any
episodes of seizure like activity during her admission.
.
# Knee pain - pt complained of knee pain 1 day after admission,
plain films of hip and knee were done which showed no acute
fracture. Pain likely secondary to her fall prior to
admisssion, tylenol prn with good affect.
.
# Agitation - per family pt has had a new baseline after the hsv
encephalitis where she was more agitated. She required zyprexa
prn at nights; however per neurorecs, ativan should be used
instead of zyprexa for agitation as zyprexa can lower seizure
threshhold. She has not needed any ativan in the last several
days.
.
# Rhythm - Pt had brief episode of Aflutter on admission; no
events since on tele. No further work-up recommended.
# FEN- PO diet, replete lytes prn.
# PPX- Heparin SC, PPI, tylenol prn
# Code- DNR/DNI
# Communication: Daughter: [**First Name8 (NamePattern2) **] [**Known lastname 5850**], [**Telephone/Fax (1) 15306**];
[**Telephone/Fax (1) 15307**].
# Dispo: to rehab facility
Medications on Admission:
Paroxetine HCl 10 mg qday, Acetaminophen prn, Senna [**Hospital1 **],
Phenobarbital 45mg tid, Phenytoin 100mg [**Hospital1 **], colace [**Hospital1 **], RISS,
Heparin SC tid, Phenytoin 175mg qpm, Pantoprazole 40 mg qday,
Decadron 8 mg q6hrs, started on Augment [**12-19**] for possible UTI
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO BID (2 times a day).
9. Insulin Regular Human 100 unit/mL Solution Sig: see insulin
sliding scale Injection ASDIR (AS DIRECTED).
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO Q8H (every 8 hours).
11. Phenobarbital 15 mg Tablet Sig: Three (3) Tablet PO Q8H
(every 8 hours).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days. Tablet(s)
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Two (2)
mg Injection Q8H (every 8 hours) for 2 days.
17. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Two (2)
mg Injection every twelve (12) hours for 2 days: please give
after completing 2 days of dexamethasone 2mg IV Q8.
18. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: One (1)
mg Injection every twelve (12) hours for 2 days: Give after
completing 2mg q12 dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
hypotension and fever consistent w/ sepsis
urinary tract infection
RUL pneumonia
.
Secondary:
?herpes encephalitis
seizure disorder
anemia of chronic disease
knee pain s/p fall
Discharge Condition:
good
Discharge Instructions:
Please return for further care if you have fever, chills,
confusion, chest pain, shortness of breath, dizziness, seizure
or any other symptom that is concerning to you.
.
Please take all your medications as directed.
.
You should keep the appointments scheduled for you - the details
are listed below.
Followup Instructions:
Provider: [**Name10 (NameIs) 42**] [**Name11 (NameIs) 43**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2102-1-25**] 4:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2102-4-19**] 10:30
Completed by:[**2101-12-26**]
|
[
"272.0",
"780.39",
"285.29",
"599.0",
"995.91",
"486",
"038.9",
"054.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11299, 11371
|
5746, 9081
|
324, 358
|
11601, 11608
|
2477, 5723
|
11958, 12240
|
2092, 2097
|
9421, 11276
|
11392, 11580
|
9107, 9398
|
11632, 11935
|
2112, 2458
|
278, 286
|
386, 1508
|
1530, 1990
|
2006, 2076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,481
| 163,533
|
20296+20297
|
Discharge summary
|
report+report
|
Admission Date: [**2139-12-17**] Discharge Date: [**2139-12-27**]
Date of Birth: Sex:
Service:
MAIN PROCEDURE:
Coronary artery bypass graft times three for a diagnosis of
unstable angina, coronary artery disease, hypertension,
increased cholesterol and noninsulin dependent diabetes
mellitus.
HISTORY OF PRESENT ILLNESS: This is a 61 year old male who
presents to the [**Hospital1 69**]
Emergency Room on [**2139-12-17**] with shortness of breath and
sternal non radiating chest pressure of sudden onset in
nature while asleep. He took sublingual nitroglycerin with
no change in his chest pain. He presented to the Emergency
Room.
PHYSICAL EXAMINATION: Physical examination was significant
for a pulse of 80; blood pressure of 180/110; respirations of
28 and a pulse oximetry of 94% on two liters oxygen.
Physical examination upon admission was significant for being
alert and oriented times three. He was cool, pale and
diaphoretic. He had no jugular venous distention. He had
rales bilaterally on the lower lung bases with expiratory
wheezes. His abdomen was soft and nontender and
nondistended. He had no extremity edema. He was given
aspirin and then intravenous was started. He was given
nitroglycerin without relief. A nebulizer was administered.
He was also given Lasix 40 mg.
Upon arrival to [**Hospital1 69**], he was
taken to the cardiac catheterization laboratory at which time
a cardiac catheterization was initiated. The catheterization
revealed a left anterior descending that was 70% occluded and
a left circumflex which was 100% occluded and a right
circumflex which was 80% proximally occluded and 90% occluded
in the midway through. His troponin was 10.3. In summary,
his presentation was that of an acute posterolateral
myocardial infarction and heart failure. In the
catheterization laboratory, a stenting of the left circumflex
was placed with Hepikote stent with good angiographic result.
He remained with two vessel disease. It should be noted that
his home medications were Lipitor 10 mg q. day, Atenolol 50
mg q. day, Diltiazem XR 240 mg q. day, Glucotrol XR 10 mg q.
day, Hydrochlorothiazide, Moexipril 25/15 q. day, Nitropaste
.4 mg p.o. q. day. After his catheterization, he was started
on aspirin, Plavix, 2B, 3A, receptor antagonist and a beta
blocker. He was also started on statin. He was diuresed of
approximately one liter. The cardiac surgical service was
contact[**Name (NI) **]. It should also be noted on his catheterization
laboratory results that he had one and a half mm ST
depressions in leads 1 through V3 and small Q waves in V2, 3
and AVF. It was also significant for left ventricular
hypertrophy. His pulmonary artery pressure at the time was
35/20 with an index of 2 and pulmonary capillary wedge of
approximately 15. An echocardiogram was not done at that
time.
Subsequently, the patient was admitted to the floor where he
did well. He was seen by the cardiac service and evaluated
for an elective coronary artery bypass graft. On [**2139-12-21**], he
was taken to the operating room by Dr. [**Last Name (STitle) 1537**] for a coronary
artery bypass graft times three; left internal mammary artery
to the left anterior descending; saphenous vein graft to the
posterior descending artery and saphenous vein graft to the
diagonal, for diagnosis of coronary artery disease, unstable
angina, hypertension, hypercholesterolemia, noninsulin
dependent diabetes mellitus. The procedure went well and his
cross clamp time was 66 minutes and cardiopulmonary bypass
time was 80 minutes. On transfer to the CSRU, his mean
arterial pressure was 97. He was A-paced on Propofol of 15
and insulin drip of 2. He was extubated on postoperative day
number one and was on nitroglycerin drip at .5 at that time.
He had an uneventful postoperative course. His Captopril
dose was increased to 50 three times a day and his oral
intake was encouraged. His Foley was discontinued. He was
evaluated by the physical therapist and was thought to be
progressing appropriately but still had impaired tolerances.
However, he did continue to do well and, on postoperative day
number three, his Captopril was increased again to 100 three
times a day and his Lopressor was increased to 70 mg twice a
day. He had adequate urine output.
On the evening of [**2139-12-24**], he did complain of some chest
pain. He was pale, weak and slightly diaphoretic.
Electrocardiogram and chest x-ray were completed. An echo at
the bedside was also done. He was given sublingual
nitroglycerin with minimal effect. At this time, he was
ruled out for a myocardial infarction. His dose of Plavix
was increased to 150 mg q. day.
He was taken back to the catheterization laboratory on
[**2139-12-25**] and underwent coronary angiography. But after
angio-thrombectomy of the occluded left circumflex stent and
heparin coated stenting of the obtuse marginal distal to the
previous stent and angio-seal thermal closure. The findings
at that time were of a left anterior descending with 80% mid
stenosis with competitive filling of the distal vessels from
the left internal mammary artery. Left circumflex artery had
proximal total occlusion at the proximal edge of the stent.
Right right coronary artery had severe diffuse disease but a
distal vessel filling the patent saphenous vein graft and the
saphenous vein graft to right coronary artery posterolateral
was normal and saphenous vein graft to the diagonal was also
normal. With his stent being reopened, he was brought back
to the floor where he had no more chest pain. His
nitroglycerin drip was weaned off and his blood pressure
control was maximized. He did receive a transfusion on
[**2139-12-25**] as well to also maximize his hemodynamic status.
He remained stable and was discharged on [**2139-12-27**] with
recommendations to follow-up with Dr. [**Last Name (STitle) **], his
cardiologist, in one week and with Dr. [**Last Name (STitle) 1537**], the cardiac
surgeon, in one month.
DISCHARGE DIAGNOSES:
Coronary artery disease.
Unstable angina.
Hypertension.
Hypercholesterolemia.
Noninsulin dependent diabetes mellitus.
Status post tonsillectomy and adrenalectomy many years ago.
Hypovolemia requiring transfusion.
DISCHARGE MEDICATIONS:
Colace 100 mg p.o. twice a day.
Aspirin 320 mg enteric coated p.o. q. day.
Percocet 5/325 one to two tablets p.o. every four to six
hours prn for pain.
Glipizide 10 mg p.o. q. day.
Captopril 100 mg p.o. three times a day.
Lasix 20 mg p.o. twice a day times two weeks.
Lopressor 75 mg p.o. twice a day.
Plavix 150 mg p.o. q. day.
Norvasc 10 mg p.o. q. day.
Potassium chloride 20 mg p.o. twice a day times two weeks.
Levofloxacin 500 mg p.o. q. 24 hours times six days.
DISCHARGE CONDITION: Good.
The patient was discharged to home.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**First Name3 (LF) 54482**]
MEDQUIST36
D: [**2139-12-31**] 03:41
T: [**2139-12-31**] 17:53
JOB#: [**Job Number 54483**]
Admission Date: [**2139-12-17**] Discharge Date: [**2139-12-27**]
Date of Birth: [**2078-9-21**] Sex: M
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old man
with type 2 diabetes, hypertension, hyperlipidemia who
presents to an outside hospital with complaints of chest pain
and shortness of breath. He has had intermittent chest pain
for one week accompanied with acute worsening dyspnea this
morning. In the Emergency Department he was hypertensive,
hypoxemic and with an examination consistent with congestive
heart failure. He had an increased amount of chest pain and
was transferred to the [**Hospital1 69**].
An electrocardiogram at the [**Hospital1 188**] revealed ST depressions in V1 to V3. No ST elevations
and he was taken to the catheterization laboratory, which
revealed a left circumflex artery occlusion, which was
stented open fluoroscopically. In addition, the
catheterization revealed three vessel disease with 90% mid
vessel occlusions, stenosis of the left anterior descending
artery, 70% stenosis of the diagonal branches the left
anterior descending coronary artery and 80 to 90% stenoses of
the right coronary artery.
CURRENT MEDICATIONS:
1. Lipitor.
2. Atenolol.
3. Nitropaste.
At the outside hospital he received intravenous heparin,
Bumex, magnesium, nitroglycerin drip.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: Because of his three vessel disease the
patient was evaluated for a coronary artery bypass graft and
underwent a preoperative evaluation for a coronary artery
bypass graft over the next few days. He had an
echocardiogram that showed a 45 to 50% ejection fraction with
no significant valvular anomalies. Carotid ultrasound
revealed a left stenosis less then 40% and minimal disease on
the right side. After these tests were performed and he was
consented for the procedure he was brought to the Operating
Room on [**2139-12-21**] where he underwent a coronary artery bypass
graft times there. The left internal mammary coronary artery
was anastomosed to the left anterior descending coronary
artery and saphenous vein grafts were connected, the
ascending aorta to the posterior descending artery and the
diagonal branch. He was on cardiopulmonary bypass for 80
minutes and the aorta was cross clamped for 66 minutes. He
was transferred to the Cardiac Intensive Care Unit on
Propofol and insulin drips and later that evening he was
actually extubated without complications. On postoperative
day one the patient was doing very well and was transferred
to the floor. On postoperative day two his Foley, pacer
wires and chest tubes were discontinued. The rest of his
stay revolved around physical therapy and hypertensive
management, which was eventually controlled with increasing
levels of Captopril and Metoprolol.
On postoperative day three, however, the patient began to
complain of increasing chest pain. An electrocardiogram was
performed, which showed inferior and lateral ST elevations.
The patient underwent an echocardiogram, which showed a 40%
ejection fraction, which was decreased from the preop value
and the patient was brought to the catheterization laboratory
emergently that evening. The angiography performed in the
catheterization laboratory showed patent surgical grafts,
however, the left circumflex artery was occluded proximal to
the previously placed stent. This occlusion was opened and a
stent was put in place. He was transferred back to the floor
on a nitroglycerin intravenous drip and did well following
this procedure. On postoperative day four the nitroglycerin
drip was discontinued and the patient was transfused for a
low hematocrit. The patient was restarted on his physical
therapy other medications. The patient was discharged on
postoperative day six [**2139-12-27**].
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Unstable angina.
3. Hypercholesterolemia.
4. Hypertension.
5. Noninsulin dependent diabetes mellitus.
6. Two coronary angiographies and left circumflex artery
stenting and he underwent a coronary artery bypass graft
procedure.
FOLLOW UP: Follow up with Dr. [**Last Name (STitle) 1537**] in one month and Dr.
[**Last Name (STitle) **] his primary care physician in one week.
DISCHARGE MEDICATIONS:
1. Colace 100 mg b.i.d.
2. Aspirin 325 mg q.d.
3. Percocet prn pain.
4. Glipizide 10 mg q.d.
5. Captopril 100 mg po t.i.d.
6. Levofloxacin 500 mg po q.d. times six days.
7. Lasix 20 mg b.i.d.
8. Lopressor 75 mg b.i.d.
9. Plavix 150 mg po q.d.
10. Norvasc 10 mg po q.d.
11. K-Ciel 20 mg po b.i.d.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2139-12-30**] 04:52
T: [**2140-1-4**] 06:42
JOB#: [**Job Number 54484**]
|
[
"E878.1",
"410.71",
"E849.7",
"996.72",
"401.9",
"428.0",
"250.00",
"414.01",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"36.15",
"37.23",
"36.12",
"99.20",
"88.56",
"39.61",
"37.22",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
6764, 7228
|
10971, 11236
|
11408, 11716
|
8527, 10950
|
11248, 11385
|
689, 6015
|
7246, 7259
|
8331, 8509
|
7288, 8310
|
11741, 12034
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,220
| 195,345
|
9307
|
Discharge summary
|
report
|
Admission Date: [**2139-1-13**] Discharge Date: [**2139-1-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Hypoxemia and S/P fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 yo M with h/o dementia, Parkinson's, CAD, CHF (EF 30%)
presents following a fall w/ 3 days of worsening shortness of
breath since his discharge from [**Hospital1 18**] on [**2139-1-9**]. He was
admitted at that time s/p probable mechanical fall and hypoxia.
He again presents following multiple falls since last discharge.
He denies lightheadedness/dizziness, chest pain prior to the
falls and says that his walker slipped ahead of him. He does,
however, note some confusion following the fall. He does not
recall head trauma.
.
Also of note, his daughter reports that around the time of these
episodes he had significant sweats and chills. Since his
discharge, he has continued to be short of breath, even
[**Last Name (un) 6055**]-[**Doctor Last Name **] breathing according to his son-in-law (a
nephrologist).
.
In the ED, BNP was found to be [**Numeric Identifier 31854**], but CXR did not reveal
gross volume overload. Cardiac enzymes showed elevated troponin
(but this is at his baseline given his acute on chronic renal
failure) and CKs were flat. His initial vitals revealed T 98.0
HR 120 BP 88/40 and RR in the 20s with O2 sats of 88% on RA.
Given his elevated lactate and recent h/o sweats and rigors, he
received vancomycin and zosyn for broad coverage although there
currently is no clear source of infection.
Past Medical History:
1. CAD, h/o prior MIs with cath in [**2111**]
2. [**Last Name (un) 309**]-body dementia
3. Parkinson's
4. s/p ICD for history syncope
4. mild BPH
5. neurogenic bladder
7. h/o embolic CVA - on chronic coumadin
8. Moderate MR/TR
9. Compensated CHF, EF 30% in [**2136**]
10. ?aspiration
11. CRI, baseline Cr 1.4-1.5
12. Anemia (BL 34-36)
13. Recurrent falls
14. HTN
15. Atrial fibrillation
16. Hyperlipidemia
Social History:
Lives at home with his wife. Uses a walker occasionally. Former
smoker, quit 20 years ago. No EtOH or illicits.
Family History:
Father with MI, unknown age.
Physical Exam:
T 96.6 ax HR 112 V paced BP 123/88 RR 18 O2 sat 96% NRB
Gen: Alert and oriented to person, place, and time as [**Month (only) 404**],
[**2138**], not to day.
HEENT: PERRL
Neck: No JVD appreciated. Supple.
CV: Tachycardic, V-paced, no mrg
Resp: [**Month (only) **]. BS left lung base, no wheezes/rales/rhonchi
Abd: +BS, soft, NT, ND
Ext: 1+ edema b/l, midfoot to toes b/l cool, b/l fingers cool,
cyanotic
Neuro: + pill rolling tremor right hand > left, right foot with
tremor. Strength 5/5 b/l upper extremities.
Pertinent Results:
[**2139-1-13**] 08:26PM BLOOD Type-ART Temp-36.7 pO2-52* pCO2-25*
pH-7.39 calTCO2-16* Base XS--7 Intubat-NOT INTUBA
[**2139-1-13**] 08:05PM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 31854**]*
[**2139-1-13**] 08:05PM BLOOD cTropnT-0.13*
[**2139-1-13**] 08:05PM BLOOD Lipase-33
[**2139-1-13**] 08:05PM BLOOD ALT-57* AST-53* CK(CPK)-125 AlkPhos-126*
Amylase-88 TotBili-1.3
[**2139-1-13**] 08:05PM BLOOD Glucose-130* UreaN-37* Creat-1.9* Na-138
K-5.4* Cl-103 HCO3-17* AnGap-23*
[**2139-1-18**] 06:35AM BLOOD Glucose-83 UreaN-23* Creat-1.3* Na-140
K-3.8 Cl-105 HCO3-26 AnGap-13
[**2139-1-13**] 08:05PM BLOOD PT-16.1* PTT-30.9 INR(PT)-1.5*
[**2139-1-13**] 08:05PM BLOOD WBC-8.6# RBC-4.19* Hgb-13.8* Hct-41.8
MCV-100* MCH-33.0* MCHC-33.0 RDW-14.8 Plt Ct-134*
[**2139-1-18**] 06:35AM BLOOD WBC-4.8 RBC-3.55* Hgb-11.7* Hct-33.8*
MCV-95 MCH-32.8* MCHC-34.4 RDW-14.9 Plt Ct-116*
.
CHEST, AP: There is a dual lead pacemaker device in a similar
position. The heart is enlarged. The mediastinal and hilar
contours are unremarkable. There are no effusions. There is a
mildly displaced left lateral eighth rib fracture with air in
the adjacent subcutaneous tissues. In the absence of penetrating
trauma, this could possibly represent a small pneumothorax.
There is no evidence of pneumonia.
.
IMPRESSION: Left-sided rib fracture with question of small
pneumothorax
.
The left atrium is elongated. A left-to-right shunt across the
interatrial septum is seen at rest c/w a small secundum atrial
septal defect. The estimated right atrial pressure is 16-20
mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is moderate to severe regional left ventricular
systolic dysfunction with akinesis/thinning of the inferior and
inferolateral walls. The remaining segments are hypokinetic. No
masses or thrombi are seen in the left ventricle. The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be
determined. There is no pericardial effusion.
.
Compared with the report of the prior study (images unavailable
for review) of [**2137-10-2**], the right ventricular cavity now
appears dilated with free wall hypokinesis. The severity of
mitral regurgitation is now incresaed. Overall left ventricular
systolic function may be more depressed.
.
V/Q:
IMPRESSION:
1. Low likelihood ratio for recent pulmonary embolism. 2.
Evidence of
activity in the arterial system as demonstrated by increased
activity in the brain and kidneys consistent with a right to
left shunt.
.
CXR [**1-16**]:
Moderate-to-severe cardiomegaly is chronic. Lungs are fully
expanded and clear. There is no pleural effusion or
pneumothorax. Left subclavian transvenous right atrial pacer and
right ventricular pacer defibrillator leads are in standard
placements, unchanged.
Brief Hospital Course:
# Hypoxemia: On admission, CXR did not reveal pulmonary edema
nor infiltrate to suggest CHF, despite elevated BNP, or
pneumonia as contributors to his hypoxemia. Heparin gtt was
started in the ED given concern for PE. He had, however, been
subtherapeutic for only approx. 3 days once his coumadin (for a.
fib) had been recently been stopped [**1-30**] to his fall risk.
However, TTE on [**2139-1-14**] revealed worsening RV function and L-->R
shunt via ASD. Because of the worsening right heart function, a
V/Q scan was pursued given persistent concern for PE (renal
failure prevented CTPA). V/Q scan performed [**1-15**] showed low
probability of PE so heparin gtt was d/c'd. Additionally, V/Q
scan revealed e/o R-->L shunt, thus suggesting shunt as likely
cause of his transient, posititionally related hypoxemia. O2
saturations have otherwise been normal on room air. Left sided
pneumothorax from left 8th rib fracture was evaluated by
thoracics in the ED and remained stable on follow up imaging.
Repair of ASD discussed with family, declined.
.
# Pneumothorax: [**1-30**] to left 8th rib fracture. Evaluated by
thoracics in the ED who did not feel that intervention would
benefit him at this point and recommended serial CXRs. X-rays
have remained stable.
.
# CHF: [**2139-1-14**] EF was found to be depressed slightly to 25%
compared to EF 30% on echo [**10-2**]. He was found to have worsened
RV function on this echo, but as above, V/Q scan showed low
probability for PE. Clinically and on CXR he did not appear to
be fluid overloaded and his lasix was held in the setting of
elevated creatinine from baseline and presumed prerenal picture
in the setting of persistent diuresis with lasix in setting of
poor PO just prior to admission.
.
# CAD: Elevated troponin on admission, but this is within his
BL range in the setting of his acute on chronic renal failure.
EKG did not reveal e/o acute ischemic changes and CKs were flat.
He was continued on beta blocker and statin. ASA had recently
been held PTA [**1-30**] to his mulitiple falls. Coumadin held
(discussed with family) because of fall risk.
.
# Acute on chronic renal failure: Baseline creatinine appears
1.4-1.5; admission creatinine was 1.9. As above, hct appeared
hemoconcentrated. Despite elevated BNP, his pulm exam did not
reveal significant crackles and he did not appear grossly
overloaded. Rather, in the setting of poor PO x several days
and continuation of his standing lasix dose, he appeared
prerenal and intravascularly dry. Creatinine improved to his BL
(1.4). Lasix was added back at 10 mg qd.
.
# S/P fall: By history, sounds to be mechanical as patient
reports walker sliding out from in front of him. Echo and V/Q
raised the possiblity that he may be getting transiently
hypoxemic while ambulating if R-->L shunt occurs and this may be
contributing to his falls or causing the confusion at the time
of the fall.
.
#Tachy-brady: s/p pacemaker. Given change in code status (see
below), EP was consulted and turned off ICD portion.
.
# Hyperlipidemia: He was continued on a statin.
.
# Parkinson's: He was continued on his home doses of sinemet.
.
# [**Last Name (un) 309**] body dementia: Continued on aricept.
.
# HTN: Had been largely normotensive in the ICU. Transitioned
back to Atenolol
.
# Code: DNR/DNI after code status w/ family. EP to turn off ICD
while maintaining pacer.
.
The patient was doing well on the floor with no change in
clinical status. However, on the evening of [**1-18**], pt expired.
He had awoken in the middle of night and walked to the bathroom
using his walker; his LPN was at his bedside and helped him.
About 30-60 seconds after sitting on the toilet, pt fell
forward, unconscious. His aide caught him and laid him on the
floor. He was found to be pulsesless and not breathing. On the
monitor, he was still found to have a paced rhythm but again, no
pulse was palpated. He could not be aroused and given his
DNR/DNI status, nothing was done to resuscitate him. He was
pronounced dead and his family was notified along with his PCP's
office.
Medications on Admission:
1. Donepezil 5 mg PO HS
2. Carbidopa-Levodopa 50-200 mg PO DAILY
3. Carbidopa-Levodopa 25-100 mg Tablet PO TID
4. Quetiapine 25 mg Tablet PO QHS
5. Nitroglycerin 0.2 mg/hr Patch 24HR (1) Patch Q24H
6. Furosemide 20 mg PO DAILY
7. Simvastatin 10 mg Tablet PO DAILY
8. Metoprolol Tartrate 25 mg Tablet PO DAILY
9. Aspirin 81 mg Tablet PO DAILY
10. Proscar 5mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
|
[
"332.0",
"424.0",
"397.0",
"860.0",
"E888.9",
"427.31",
"V53.32",
"585.9",
"403.90",
"584.9",
"294.10",
"807.01",
"428.0",
"799.02",
"331.82",
"429.71"
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10457, 10466
|
5925, 10013
|
285, 291
|
10519, 10530
|
2806, 5902
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10583, 10591
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2226, 2256
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10428, 10434
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10487, 10498
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10039, 10405
|
10554, 10560
|
2271, 2787
|
223, 247
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319, 1651
|
1673, 2081
|
2097, 2210
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,396
| 168,082
|
25111
|
Discharge summary
|
report
|
Admission Date: [**2161-11-7**] Discharge Date: [**2161-11-25**]
Date of Birth: [**2100-9-2**] Sex: F
Service: MEDICINE
Allergies:
Lidocaine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
X-fer from [**Hospital 1474**] Hospital- COPD with RML PNA and RUL mass.
Major Surgical or Invasive Procedure:
CT guided lung biopsy
History of Present Illness:
HPI Summary: 61 YO female with Hx of COPD- bullous predominantly
in RUL that is transferred for a pulmonary second opinion and
RML pneumonia.
.
In [**2100**], pt developed a respiratory infection which was
Tx with PO Antibiotic with mild resolution. However, she
developed a reoccurence of a RML infiltrated. The Pt was
admitted to the hospital for IV Antibiotics- Ceftriaxone and
Gatifloxacin. The patient was discharged and was placed on
Augmentin. She improved clinically and radiographically. The
patient went on vacation in [**Month (only) 216**] and was doing well.
.
End of [**Name (NI) 216**], pt was fatigued and had a CBC which showed WBC of
50K. The pt was referred to [**Hospital3 328**] and a Bone Marrow Bx
showed a reactive process and not consistent with an acute
leukemia. The patient underwent a torso CT which showed
increased size of pneumonitis in RML eventhough symptomatically
was not worse. The pt was admitted to [**Hospital 1474**] Hospital in
middle [**Month (only) 462**]. After 3 days, the pt had an acute exacerbation
and had to be intubated and was extubated after 2 days in the
ICU. Pt was Tx with Zosyn and gatifloxacin since that time at a
rehab center at the hospital. Sputum at OSH showed yeast forms,
upper respiratory flora and a one sputum showed aspergillous.
.
CT scan after being Tx with Zosyn and gatifloxacin showed some
improvement in the RML, but also had continued sever bullous
emphysematous changes with chronic infiltrate with stable
lymphadenopathy and now a patchy left lower lobe infiltrate with
stable lymphadenopathy and a patchy left lower lobe infiltrate.
In the bulla there appears to be an area suggesting a possible
mass in one of her cavities which certainly could signify
possibility of a mycetoma, aspergilloma, or neoptlams. Sputum
cytologies and bronchosopies x2 at OSH have been negative.
Note: Mycetoma- is a chronic, specific, granulomatous,
progressive inflammatory disease; it usually involves the
subcutaneous tissue after a traumatic inoculation of the
causative organism. Mycetoma may be caused by true fungi or by
higher bacteria and hence it is usually classified into
eumycetoma and actinomycetoma respectively (1). Tumefaction and
formation of sinus tracts characterize mycetoma. The sinuses
usually discharge purulent and seropurulent exudate containing
grains. It may spread to involve the skin and the deep
structures resulting in destruction, deformity and loss of
function, very occasionally it could be fatal.
.
Currently, the patient states she is resting comfortably. + mild
dyspnea.
Denies F/C, N/V, cough, sinus discharge, CP, SOB, abdominal
pain, and urinary symptoms
Past Medical History:
PMH: RML PNA
COPD- with bullous lung disease
History of O2 dependence
?diverticulosis
DM
Social History:
Social History: lives alone in [**Location (un) **]. 3 healthy children.
Distant Hx of smoking 1 pack per year but quit 7 years ago. no
EtOH.
Physical Exam:
Physical Exam: 98.1 146/80 104 22 97%2l
cachecticm ill appearing female, very articulate, AAOx3,
speaking rapidly
MMM, OP-clear, No JVD, EOMI, PERRL
Neck FROM, No LAD
decreased BS in RUL, otherwise coarse BS but no wheezes or
crackles.
RR without m, carotids- no bruits.
soft, NT/ND +BS
no c/c/e, warm, DP2+-B
Pertinent Results:
[**2161-11-9**] 05:25AM BLOOD WBC-13.7* RBC-3.15* Hgb-9.3* Hct-28.4*
MCV-90 MCH-29.3 MCHC-32.6 RDW-15.4 Plt Ct-470*
[**2161-11-8**] 05:35AM BLOOD WBC-11.4* RBC-3.02* Hgb-8.9* Hct-27.8*
MCV-92 MCH-29.6 MCHC-32.2 RDW-15.7* Plt Ct-432
[**2161-11-9**] 05:25AM BLOOD Plt Ct-470*
[**2161-11-8**] 05:35AM BLOOD PT-13.0 PTT-34.4 INR(PT)-1.1
[**2161-11-8**] 05:35AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-140 K-4.0
Cl-99 HCO3-31 AnGap-14
Brief Hospital Course:
A/P: 61 YO female with COPD and bullous changes x-ferred to
[**Hospital1 18**] for further evaluation of her persistent RML
pneumonia/pneumonitis and RUL mass.
.
Patient was transferred to [**Hospital1 18**] for further evaluation of the
RUL mass by interventional pulmonology. CT scans were repeated
at [**Hospital1 18**] to better characterize the lesions (see results). IP
saw the patient; they biopsied and obtained tissue on [**11-12**],
results showed aspergillus. She was started on Voriconazole.
The patient was oberved off antibiotics for several days (as
felt to be fungal, not bacterial pathogen), whereupon she began
spike high fevers and her WBC count slowly trended upward.
Vanco and ceftaz were started for presumed bacterial
superinfection, then broadened further to include meropenem. C.
diff was diagnosed, and flagyl was started. Eventually, she had
to be intubated due to respiratory failure. In the MICU, she
became septic. Despite very aggressive antimicrobial and
pulmonary treatments, her conditioned worsened. After multiple
family meetings discussing the very poor prognosis, the decision
was made to prioritize comfort in her care. She passed away on
[**2161-11-25**].
Medications on Admission:
Meds on X-fer: Zosyn 4.5 Q6H
Albuterol
Gatifloxacin
Singulair 10 QD
Xanax 0.25 TID PRN anxiety
tiotropium bromide 18 mcg QD
Prednisone 10 AD
Advair 500/50 [**Hospital1 **]
Insulin SS
folic acid
MVI
Discharge Medications:
N/A
Discharge Disposition:
Home
Discharge Diagnosis:
Death
Discharge Condition:
Dead
|
[
"995.92",
"300.00",
"117.3",
"280.9",
"518.81",
"250.00",
"008.45",
"784.0",
"492.0",
"484.6",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.26",
"99.04",
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5609, 5615
|
4125, 5332
|
343, 367
|
5664, 5671
|
3673, 4102
|
5581, 5586
|
5636, 5643
|
5358, 5558
|
3357, 3654
|
231, 305
|
395, 3054
|
3077, 3168
|
3200, 3327
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,990
| 115,527
|
8521
|
Discharge summary
|
report
|
Admission Date: [**2128-7-5**] Discharge Date: [**2128-7-9**]
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**Doctor First Name 1402**]
Chief Complaint:
expressive aphasia and right sided weakness
Major Surgical or Invasive Procedure:
Implantation of Carotid Arterial Stent
Thrombin injection of right femoral pseudoaneursym
History of Present Illness:
88-yo-woman w/ CAD (S/P 3 vessle CABG [**41**] years ago) and left ICA
stenosis is now transferred to the CCU for post-procedure
monitoring after left ICA stenting. She was initially admitted
to the Neurology service on [**7-5**] after awaking from a nap w/ new
expressive aphasia and right sided weakness. She emphasizes that
she could not move her right arm, couldn't get up and was unable
to call her husband for help. He eventually found her and by
that time her arm weakness had subjectively improved but she was
still unable to speak. Urgent CTA of the head showed no
intracranial hemorrhage and possible hyperdense left MCA sign at
an outside hospital. She was treated conservatively w/ ASA and
heparin gtt given left ICA stenosis. Cardiac ischemica was ruled
out w/ serial biomarkers. By the morning after admission, her
symptoms had resolved entirely. She was ultimately diagnosed w/
TIA in the setting of significant left ICA stenosis.
.
[**2128-7-7**] she was treated w/ left ICA stent, with no complications.
She is now transferred to the CCU service for post-procedure
monitoring. She reports that her voice is almost back to normal
and that she has some residual right arm pain that she
attributes to the pressure cuff. Otherwise she is feeling much
better.
.
ROS: Incontinence of urine is not new, but more pronounced since
episode on [**2128-7-5**]. Vomited x1 on [**2128-7-6**] - no blood. Patient
denies any fever, chills, nausea, headache, dysphagia, numbness,
tingling, dizziness, visual changes, chest pain, shortness of
breath, diplopia, hearing changes, hematochezia, melena, and
hematuria.
Past Medical History:
- CAD s/p CABG: known LBBB
- left ICA stenosis(60-70% in [**7-/2127**])
- HTN
- hyperlipidemia
- hypothyroidism
- macular degeneration
- OA
- Osteoporosis
- Anxiety
Social History:
significant for the absence of tobacco use.
There is history of moderate alcohol abuse. She is married and
lives in a retirement community; takes care of her husband with
dementia.
Family History:
Family history: Father had MI, HF, mother with HF, brother with
HF
Physical Exam:
VS: T:97.0 BP:144/50 on 0.39mcg/kg/min neosynephrine gtt HR:74
RR:16 O2:98% on 2L.
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Jaw notable for prior osteonecrosis of the jaw - patient
attributes to fosamax.
Neck: Supple with JVP of 5 cm.
CV: PMI located in 5th intercostal space, midclavicular line. RR
2/6 systolic murmur at apex to axilla. No thrills, lifts. No S3
or S4.
Chest: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Examined anteriorly as sheath had recently been pulled.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation.
Ext: No c/c/e. Patient has a femoral bruit on the right and not
on the left.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro:
MENTAL STATUS: WNL, alert, oriented x 3. Aware of [**Last Name (un) 29999**].
Thinks [**Doctor First Name **] or Romney may become president.
CRANIAL NERVES: II-XII intact.
MOTOR SYSTEM: 5/5 strength in upper and lower extremities
bilaterally.
REFLEXES: 1+ in the patella and ankles bilaterally
SENSORY SYSTEM: intact to LT in the lower extremities
bilaterally.
COORDINATION: FNF intact bilaterally.
GAIT: Not tested.
.
Pulses:
Right: Carotid deferred Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid deferred Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
EKG demonstrated sinus brady at 59 bpm; LBBB; no ischemic
changes; no change from prior dated [**2127-8-20**].
.
Admission labs:
CK: 47
MB: Notdone
Trop-T: 0.02 - 0.01 - 0.01
12.1
10.1 >----< 309
35.3
PT: 12.3 PTT: 27.6 INR: 1.1
.
Hct: 35 - 30 - 26 (multiple times at 26)
Admission Lytes: Gluc-88 UreaN-28* Creat-1.0 Na-138 K-4.6
Cl-109* HCO3-21*
[**2128-7-6**] 04:20AM BLOOD %HbA1c-5.8
[**2128-7-6**] 04:20AM BLOOD Triglyc-72 HDL-49 CHOL/HD-2.7 LDLcalc-69
[**2128-7-6**] 04:20AM BLOOD TSH-2.3
.
[**7-5**] CT A Head:
ROUTINE CTA OF THE HEAD AND NECK WITH CONTRAST USING STANDARD
DEPARTMENTAL PROTOCOL.
There is a large calcified plaque at the origin of the right
internal carotid artery and carotid bulb causing approximately
60% stenosis. A similar circumferential calcified plaque is seen
at the origin of the left internal carotid artery and carotid
bulb causing approximately 63% diameter stenosis. Bilateral
external carotid artery stenosis is also seen.
There is a calcific plaque at the origin of the left vertebral
artery, which is not hemodynamically significant.
Intracranially, there is mild irregularity of the basilar
artery, without hemodynamically significant stenosis. There is
bilateral cavernous carotid calcification. No significant
stenosis is seen. There is a 3-mm aneurysm in the right
supraclinoid ICA, pointing posteriorly. This appears to be
separate from the posterior communicating artery.
IMPRESSION:
Bilateral ICA stenosis at the origin ranging from 60% to 65%
Small right supraclinoid ICA aneurysm pointing posteriorly,
which appears to be separate from the posterior communicating
artery origin.
.
[**7-6**] MRI head: Multiple bilateral deep cerebral and
periventricular white matter chronic small vessel ischemic
changes, with small punctate areas displaying restricted
diffusion, likely representing subacute multiple vascular
territorial infarcts. Please note no corresponding ADC map was
obtained due to the scanner employed, and which would have
helped to confirm the age of the latter infarcts.
.
[**7-6**] ECHO: No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**7-8**] femoral u/s: 3 cm pseudoaneurysm in right inguinal region
at site of prior vascular intervention. No evidence of AV
fistula formation. Thrombin successfully injected.
.
[**7-9**] u/s: complete thrombosis of pseudoaneurysm. normal arterial
and venous flow.
Brief Hospital Course:
Pt is a 88 year old female with remote hx of CABG and carotid
artery stenosis who presents with right sided weakness and
expressive aphasia. Hospital course by problem:
.
#)Neurologic: Imaging as above. She has bilateral ICA stenosis
but given her symptoms consistent with left sided cerebral
hypoperfusion, she was treated with stent placement to the left
ICA. She tolerated this well and had resolution of her neuro
sx. Imaging as above. The stent was placed on [**2128-7-7**]. We
treated with ASA, plavix, and zocor. She will need plavix for
at least 1 year. Followup ultrasound in one month and f/u with
Dr. [**Last Name (STitle) 911**] thereafter. We maintained her SBP>120 with pressors
temporarily in the CCU. Neuro exam was monitored closely by CCU
and neuro teams.
.
#)Femoral pseudoaneurysm: she had a pseudoaneursym as a
complication of the stent placement. It was detected promptly
and ultrasound showed aneurysm as above. She underwent thrombin
injection which was shown to be successful in followup
ultrasound. She required one unit transfusion given rapid hct
drop (nadir 25). It stabilized at 26 prior to discharge. She
ambulated to bedside commode with assist and was without
presyncopal sx.
.
#) Anemia - normocytic anemia with normal RDW. HCT was 35 on
admission. 31 on transfer to the CCU. Dropped as above.
received one unit with stabilization. Iron studies did not
suggest iron deficieny anemia. She did have an OB positive
stool but it was brown and not consistent with melena. This was
not thought to be her primary source of the hct drop. If she
has melena or her hct drops in followup, this must be considered
and she would benefit from an outpatient GI workup. In the
meantime, her asa and plavix were continued given her recent
stent placement.
.
#)Cards: substantial CAD history - S/P CABG [**41**] years ago.
-Rhythm: tele
-Ischemia: Ruled out for MI with three serial enzymes. Continued
ASA, plavix.
-Pump - TTE with EF 70%, mild MR, mild symmetric LVH
.
#) Endo:
-Synthroid 100 daily
.
#)OA: longstanding. required tylenol #3 for pain control. We
did not treat with nsaids.
.
#)Osteonecrosis of the jaw.
-on Doxycycline 100 [**Hospital1 **] for the last month after having
osteonecrosis of the Jaw from fosamax. continued
-There was no sign of infection on exam.
.
#)Communication - health care proxy is [**Name (NI) **] [**Known lastname 12303**]
Relationship: son
Phone number: [**Telephone/Fax (1) 30000**]
-PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]
.
#)Code: Full for now.
Medications on Admission:
aspirin 325
metoprolol 25 [**Hospital1 **]
Zocor 80 daily
Lasix 40 every other day
Altace 2.5 daily
Synthroid 100 daily
loratadine 10 daily
pepcid 20 daily
oxazepam 10 q6h prn
Pcuvite 1 daily
Doxycycline 100 [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
4. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Oxazepam 10 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO every other day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary:
-Symptomatic Carotid Stenosis now s/p stent placement
-femoral artery pseudoaneurysm s/p thrombin injection
-anemia likely secondary to mild blood loss at groin site, IVF;
controlled
-CAD
-HTN
-hyperlipidemia
Secondary
-hypothyroidism
-macular degeneratoin
-OA
-osteoporosis
-anxiety
Discharge Condition:
well
Discharge Instructions:
You came in with difficulty speaking and right sided weakness.
We placed a stent in your left carotid artery. You tolerated
this well. You had a pseudoaneurysm of your right femoral
artery and were treated with a thrombin injection.
.
We added plavix and simvastatin to your regimen. It is very
important for you to take all of your medications.
.
Please attend all follow up appointments. If you develop
dizziness, trouble with your vision, difficulty speaking: please
contact your health care providers or return to the ED.
.
Please followup with your PCP. [**Name10 (NameIs) **] may benefit from an
outpatient GI workup given your anemia.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:
[**2128-8-17**] 4pm
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2128-10-11**] 1:20
.
Please go to [**Hospital1 18**] [**Location (un) 620**] for a followup ultrasound of your
left carotid on [**8-6**] at 1pm. [**Telephone/Fax (1) 30001**].. Fax#
[**Telephone/Fax (1) 30002**].
.
Please contact your PCP for [**Name Initial (PRE) **] followup appointment within the
next month. You may benefit from an outpatient GI workup.
|
[
"244.9",
"733.00",
"E879.8",
"433.30",
"303.91",
"433.10",
"997.2",
"300.00",
"526.4",
"414.01",
"442.3",
"285.9",
"437.3",
"E849.7",
"788.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"00.40",
"00.45",
"00.61",
"99.10",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
10804, 10851
|
7221, 7363
|
282, 374
|
11188, 11195
|
3995, 4108
|
11889, 12552
|
2438, 2491
|
10066, 10781
|
10872, 11167
|
9816, 10043
|
11219, 11866
|
2506, 3427
|
199, 244
|
7391, 9790
|
402, 2018
|
3585, 3976
|
4124, 7198
|
3442, 3569
|
2040, 2207
|
2223, 2406
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,370
| 189,060
|
10491
|
Discharge summary
|
report
|
Admission Date: [**2147-10-3**] Discharge Date: [**2147-10-4**]
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
CC: dyspnea, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The pt is a 85 F with h/o CAD s/p MI w/ stent [**2142**], COPD on
home O2, HTN, sz d/o p/w dyspnea, chest pain for several months.
Pt presently residing at [**Hospital 100**] Rehab for the past 1 month "to
help with my back pain." She has had dyspnea for an
unquantifiable number of months. She experiences SOB when
walking from bed to bathroom which she had been able to do
before that. SOB never occurs at rest. +PND, +orthopnea, her
"hospital bed" is propped up at night. Pt has also had several
months of chest pain, she describes as "heartburn," occasionally
associated with eating, radiating to back. Episodes last a few
minutes. Can occur at rest or with exertion. Pt unable to say if
the SOB and CP are linked. Present pain different from her past
MI pain but she is unable to explain how. She denies any
HPs/LH/falls. She denies any abd pain/n/v/d. She denies any
dysuria/hematuria.
.
In the ED T 104, HR 87, BP 127/70, rr 14, sat 100% 3L. CXR
demonstrated retrocardiac opacity, U/A nitrite pos/large blood,
21-50 wbcs, many bacteria. EKG with nsr at 87 bpm RBBB, LAD, no
ST-T changes. Labs significantfor Tpn 0.15, CK-MB neg, BNP
[**Numeric Identifier 34614**]. Given vanc, zosyn, [**Last Name (LF) 1378**], [**First Name3 (LF) **] 325 mg, lasix 40 mg IV,
morphine 4 mg, GI cocktail. Had episode of BP 89/60, given 1
liter NS bolus. O/w was hemodynamically stable.
Past Medical History:
PMH:
CAD, MI [**2-/2142**] s/p stent
HTN
COPD, on home o2 2LNC
seizure disorder
longstanding peripheral neuropathy
hypothyroidism
spinal stenosis
bilateral TKR
s/p recent fall at home with bilateral ankle fractures
.
Social History:
SH: lives at [**Hospital 100**] Rehab, > 60 pk year hx tob, denies
illicits/etoh
Family History:
FH: non-contributory
Physical Exam:
Temp 97.4
BP 107/36
Pulse 60
Resp 16
O2 sat 00 3.5 L NC
Gen - Alert, no acute distress, OX3
HEENT - anicteric, mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - crackles left base
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, non-focal
Skin - No rash
.
Pertinent Results:
[**2147-10-3**] 05:30PM GLUCOSE-87 UREA N-27* CREAT-0.8 SODIUM-139
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-30 ANION GAP-12
[**2147-10-3**] 05:30PM TOT PROT-5.2* ALBUMIN-2.6* GLOBULIN-2.6
CALCIUM-7.8* PHOSPHATE-2.8 MAGNESIUM-1.7 IRON-13*
[**2147-10-3**] 05:30PM CK-MB-NotDone cTropnT-0.16*
[**2147-10-3**] 05:30PM calTIBC-212* FOLATE-9.9 FERRITIN-132 TRF-163*
[**2147-10-3**] 05:30PM WBC-7.0 RBC-3.09* HGB-9.9* HCT-29.6* MCV-96
MCH-32.2* MCHC-33.6 RDW-13.8
[**2147-10-3**] 05:30PM PT-13.5* PTT-34.8 INR(PT)-1.2*
[**2147-10-3**] 05:32AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2147-10-3**] 05:32AM URINE RBC-21* WBC-93* BACTERIA-FEW YEAST-NONE
EPI-1
[**2147-10-3**] 05:32AM URINE WBCCLUMP-FEW MUCOUS-RARE
[**2147-10-2**] 11:44PM LACTATE-1.5
[**2147-10-2**] 11:00PM URINE HOURS-RANDOM
[**2147-10-2**] 11:00PM URINE HOURS-RANDOM
[**2147-10-2**] 11:00PM URINE UHOLD-HOLD
[**2147-10-2**] 11:00PM URINE GR HOLD-HOLD
[**2147-10-2**] 11:00PM URINE BLOOD-LG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2147-10-2**] 11:00PM URINE RBC-[**12-4**]* WBC-21-50* BACTERIA-MANY
YEAST-OCC EPI-[**3-19**]
[**2147-10-2**] 11:00PM URINE AMORPH-OCC
[**2147-10-2**] 10:00PM CK(CPK)-36
[**2147-10-2**] 10:00PM calTIBC-234* VIT B12-1630* FOLATE-10.8
FERRITIN-124 TRF-180*
[**2147-10-2**] 10:00PM NEUTS-83.1* LYMPHS-10.1* MONOS-5.7 EOS-0.9
BASOS-0.2
[**2147-10-2**] 10:00PM PLT COUNT-132*
Brief Hospital Course:
Impression: The pt is a 85 F with h/o CAD s/p MI w/ stent [**2142**],
COPD on home O2, HTN, sz d/o p/w dyspnea, chest pain for several
months.
.
Chest pain/Dyspnea: On admission the differential diagnosis
included stable angina vs. NSTEMI vs. CHF vs. pulmonary embolism
vs. pneumonia vs. GI pain. The patient had elevated troponins on
cycling, 0.16 and 0.19, though negative CK-MBs no dynamic EKG
changes. Also, the patient's symptoms have not been evolving
over several months. CXR on admission demonstrated a possible
left retrocardiac opacity. Initially the pt was started on
broad-spectrum antibiotics, including vancomycin, zosyn, and
levofloxacin, for possible nosocomial pneumonia. CTA
demonstrated no pulmonary embolus. The CT did demonstrate small
bilateral effusions and small bilateral lower lobe opacities,
atelectasis vs. effusion. Given the CT findings, the patient's
treatment for possible pneumonia was discontinued, though
[**Year (4 digits) 1378**] was continued for UTI, as described below. A TTE was
performed which demonstrated an LVEF of 45-50%, mild regional
left ventricular systolic dysfunction, moderate mitral
regurgitation, similar to prior studies.
.
Given the the patient's work-up, her dyspnea/chest pain is most
likely associated with failure or CHF. Her elevated troponin
levels could be representative of either process. She was
continued on aspirin throughout her admission. She was started
on a low-dose statin. A beta-blocker was not started on
admission given borderline pressures. She was started on a
low-dose metoprolol on hospital day #2. At the time of discharge
she was asymptomatic. Given her heart failure, she should be
started on a ACE-I as an out-patient if her pressures tolerate
it.
.
UTI: The patient had a urinalysis suggestive of UTI as described
in the HPI. At the time of discharge her urine cultures were
negative. She is to be discharged on [**Year (4 digits) 1378**] to complete a
ten-day course.
.
COPD: She was continued on nebulizers as needed.
.
hypothyroidism: She was continued on her home synthroid
throughout the admission.
.
FEN: She was placed on a regular heart healthy diet throughout
the admission. She had no evidence of aspiration.
.
ppx: Heparin held given her allergy. She was placed on
pneumoboots. No need for a ppi given she was on a po diet.
.
Code status: DNR/DNI
.
Communication: With the patient's son/hcp [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 34615**].
Medications on Admission:
Meds:
[**Telephone/Fax (1) **]
fosamax
senna
lidocaine
remeron
colace
florinef
[**Telephone/Fax (1) **]
vitamin D/calcium
.
All: heparin
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary:
coronary artery disease
congestive heart failure
urinary tract infection
Secondary:
COPD
hypothyroidism
Discharge Condition:
Stable. The patient is asymptomatic.
Discharge Instructions:
Please continue your medications as prescribed.
.
Please follow-up with your appointments as below.
.
Please contact your doctor or go to the emergency room if you
experience:
--worsened chest pain or shortness of breath
--pain on urination
--blood in the urine
--abdominal pain
--any symptom that concerns you
Followup Instructions:
The patient should continue to be followed closely by her
physicians at [**Hospital3 **]. She should follow-up with
her primary care [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**] in one week. His phone
number is [**Telephone/Fax (1) 25798**].
|
[
"428.0",
"414.01",
"412",
"780.39",
"244.9",
"401.9",
"599.0",
"V45.82",
"356.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6670, 6735
|
4027, 6482
|
246, 252
|
6893, 6932
|
2494, 4004
|
7291, 7595
|
2018, 2041
|
6756, 6872
|
6508, 6647
|
6956, 7268
|
2056, 2475
|
182, 208
|
280, 1663
|
1685, 1903
|
1919, 2002
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,053
| 162,348
|
5020
|
Discharge summary
|
report
|
Admission Date: [**2161-5-16**] Discharge Date: [**2161-5-21**]
Date of Birth: [**2096-2-18**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
male with a past medical history of CAD, NQWMI, status post
two vessel CABG plus AVR ([**2148**]) and DC cardioversion,
[**2161-5-14**], who presented to the ER with a two-day history of
dyspnea and PND. The patient has a history of atrial
fibrillation and underwent DC cardioversion on [**2161-5-14**]. The
patient was hypotensive following the cardioversion and
required per report up to 7 liters of saline, accompanied by
a weight change of approximately 9 pounds (from 186 pounds to
195 pounds). The patient states that he was feeling well
prior to the DC cardioversion and that subsequently had
dyspnea on exertion as well as shortness of breath at rest.
The patient stated that he had approximately 3-4 episodes of
PND over the 2 nights prior to admission. He also had 1
brief episode of substernal chest pain that lasted 2-3
minutes the day prior to admission at 2:00 p.m. that began
when he went from a sitting to a standing position and
resolved spontaneously.
He describes the chest discomfort as central, substernal,
sharp, non-radiating, non-pleuritic and this is not
associated with diaphoresis, palpitations, nausea or
vomiting. He does deny lower extremity edema and denies
having any significant history of angina since his CABG in
[**2148**]. On further review of systems, the patient admits to
having upper respiratory tract infection symptoms over the
past 3-4 days including cough productive of clear white
sputum. There were no fever, chills, diarrhea, headache,
rash or arthralgia. The patient, of note, has a significant
EtOH history and drinks up to 8 beers per day. His last
drink was at 6:00 p.m. on the day prior to admission.
In the emergency department the patient received 40 mg of
Lasix, supplemental oxygen, 325 mg of aspirin and was started
on nitroglycerin drip. His ECG showed sinus bradycardia with
PR prolongation, as well as left ventricular hypertrophy and
atrioventricular conduction delay and diffused ST and T-wave
changes, (there was no significant change in comparison with
the prior ECG of [**2161-5-14**]). The patient's chest film was
consistent with mild CHF. An echocardiogram revealed mild
symmetric LVH with an EF of 50 to 55 percent and mechanical
aortic valve prosthesis with 1 plus AR and 1 plus MR.
PAST MEDICAL HISTORY: Status post coronary artery bypass
graft in [**2148**] at the [**Location (un) 511**] [**Hospital **] Hospital. He had
an SVG to the LAD and SVG to the OM. This procedure was done
in complement to an aortic valve replacement. Per report,
the patient received a St. [**Male First Name (un) 1525**] number 23 mechanical valve
for treatment of the aortic value stenosis. Per report, the
patient had non-Q wave MI in [**2143**].
Paroxysmal atrial fibrillation, status post DC cardioversion
on [**2161-5-14**] as well as on [**2161-2-26**].
Right parietal CVA in [**1-20**] with no residual symptoms.
Hyperlipidemia.
Diabetes mellitus, insulin dependent type 2 diabetic with
retinopathy. He is followed by the [**Hospital **] Clinic. The
patient reports that he checks sugars 6-7 times per day and
gives himself Regular though no longer, I think, insulin. He
had an A1c at 8.3 on most recent check.
Status post herniorrhaphy
Meckel diverticulum.
GERD.
Significant ethanol use.
No history of DTs or seizures.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 25 mg (increased from 12.5 mg).
2. Atenolol 25 mg q.a.m.
3. Lisinopril 20 mg q.a.m.
4. Coumadin 5 mg every Tuesday, Thursday, Saturday; 6 mg
every Sunday, Monday, Wednesday, Friday.
5. Lipitor 80 mg q.d.
6. Aspirin 81 mg q.d.
7. Zantac 150 mg p.r.n.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) **] is a former smoker with an approximate 20-pack year
history. The patient quit several years ago. He also drinks
up to 8-9 beers per day though he states that he has cut down
to 2 beers per day. Denies any illicit drug use. The
patient is a gambler and former boxer. He won a lottery
several years ago.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Temperature is 97.5
degrees, heart rate is 50, blood pressure initially 171/71
and decreased to 129/69 with nitroglycerin, respiratory rate
16, oxygen saturation 95 percent on room air. The patient is
found sitting in bed awake in no acute distress. HEENT:
NC/AT. Sclerae are anicteric. Pupils are equally round and
reactive to light. Extraocular muscles are intact. Mucous
membranes are moist. Oropharynx is clear. Neck is supple,
there are no bruits. JVD is 10-11 cm at 45 degrees. 2 plus
pulses bilaterally. Heart: Regular rate. No bradycardiac
rhythm with a 1/6 systolic ejection murmur at the right upper
sternal border. The patient has bilateral diminished breath
sounds at the bases, as well as bilateral rales at the bases
bilaterally. There are no wheezes. Abdomen is obese and
soft, nontender, nondistended. Normoactive bowel sounds.
Liver is palpable. The liver is approximately 10 cm to 11 cm
at the mid clavicular line. Rectal examination reveals
guaiac-negative brown stool. Extremities are warm and dry,
there is trace pitting edema at the ankles bilaterally.
Neurological Examination: The patient is awake, alert and
oriented x3. Speech is normal. Cranial nerves II to XII are
intact. Strength 5 plus in the upper and lower extremities.
Normal cerebellar examination.
LABORATORY DATA ON ADMISSION: White count is 12.3,
hematocrit is 42, platelets are 291. Sodium 136, potassium
3.8, chloride 92, bicarbonate 28. BUN 18 creatinine 1.2,
glucose 210. TSH 3.1, troponin T 0.19 with a CK of 295 and
MB of 6. UA is nitrite negative. ECG shows sinus
bradycardia, 45 beats per minute, normal axis. PR interval
of 272 milliseconds, [**Street Address(2) 4793**] elevations in V1 and V2, Q-wave
inversions in V3, aVF, and V6. Chest film demonstrates mild
CHF.
HOSPITAL COURSE: CAD. Serial cardiac enzymes were obtained
given the patient's history of chest pressure prior to
admission. The patient's initial Troponin T was 0.19 and
increased subsequently to 0.21. However, his CK was 295 and
subsequently decreased to 188. His CK-MB was initially 6,
decreased to 4. As the patient is status post recent
cardioversion and also has mild CRI, I felt that his troponin
elevation may well be due to both renal insufficiency as well
as recent cardioversion. The patient underwent exercise
tolerance test in which he carried out a modified [**Last Name (un) 20758**]
treadmill test with a 70 percent target heart rate achieved
(heart rate reached at 109 with a blood pressure of 180/110).
There were no anginal symptoms or EKG changes with the
baseline abnormalities at maximum workload. Nuclear imaging
revealed a mild reversible defect of the inferior wall.
Resting perfusion images did show resolution of this defect.
Ejection fraction was approximately 50 percent. There was
lack of septal translation consistent with his prior CABG.
The patient was restarted on atenolol though at a lower dose
of 12.5 mg q.d. He was maintained on atorvastatin 80 mg q.d.
as well as on the aspirin. His lisinopril dose was increased
to 40 mg q.d.
Atrioventricular conduction delay. The patient was noted to
have an elevated QT and QTc. His magnesium and potassium
were repleted aggressively. His QTc on the day of discharge
was 409 with a QT of 520. His hydrochlorothiazide was
switched to Aldactazide. He will take one-half tab q.d. for
a total of 12.5 mg of hydrochlorothiazide and 12.5 mg of
Aldactone. He will also begin taking magnesium oxide 400 mg
q.d. supplementation. The patient was asked and recommended
on several occasions to undergo Holter monitoring subsequent
to discharge. However, the patient states that he is not
willing to have a Holter monitor over the next several weeks
and will consider undergoing Holter monitoring at his next
visit with his cardiologist.
CHF. As mentioned in the HPI, the patient received
significant fluid resuscitation following his recent
cardioversion. The patient was aggressively diuresed back to
his baseline weight. The patient reported resolution of his
symptoms of shortness of breath, PND and dyspnea on exertion.
The patient's weight remained stable for several days prior
to discharge.
Atrial fibrillation. The patient remained in sinus rhythm
during the hospitalization. His is monitored on telemetry,
and he is noted to stay in sinus rhythm. He was maintained
on anticoagulation with Coumadin both for his atrial
fibrillation and for his mechanical aortic valve with target
INR of 2.5 to 3.5. The patient was begun on disopyramide, on
the day prior to discharge, he was loaded with 300 mg and EKG
on the day of discharge did not reveal any significant change
in QTc interval. The patient did not appear to have any
adverse reactions to disopyramide and did have any urinary
retention. The patient was explained at length in detail
every possible side effect of the disopyramide including
urinary retention and will contact his physician if he
experiences any of the side effects.
Bradycardia. The patient was noted to be bradycardiac on
admission and on several occasions throughout his admission.
He improved off atenolol and his atenolol was restarted at
the lower dose of 12.5 mg q.d. which he will continue taking
after this hospitalization.
Diabetes mellitus. The patient was maintained on a sliding
scale of Regular Insulin similar to his [**Last Name (un) **] dosing. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consult was obtained. The patient was intermittently
maintained on NPH insulin as well though he prefers to only
take Regular Insulin and on several occasions refused with
NPH dosing. The patient was noted to have labile blood
sugars over this hospitalization though did not allow changes
in general from his [**Last Name (un) **] sliding scale.
Ethanol abuse. The patient was placed on a CIWA scale given
a significant drinking history. However, his CIWAs remained
zero and required no Ativan.
Elevated LFTs. The patient was noted to have significantly
elevated liver tests on admission. His ALT was 217, his AST
was 192, alkaline phosphatase was 156 and his bilirubin total
was noted to be 0.8. Subsequent LFTs revealed improvement in
these values. LFTs diminished to 73 with an AST of 28 and
alkaline phosphatase of 112. It is likely that these
abnormalities were related to his alcohol intake (though the
ALT greater than AST is somewhat atypical). It is
recommended that the patient have followup LFTs on an
outpatient basis. The patient is discharged in stable
condition.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass graft.
Aortic stenosis status post mechanical aortic valve
replacement.
Diabetes mellitus
Paroxysmal atrial fibrillation status post cardioversion.
Congestive heart failure.
Hyperlipidemia.
Atrioventricular conduction delay.
The patient will follow up with Dr. [**First Name (STitle) **] A. F. [**Doctor Last Name 73**] on
[**2161-6-15**] at 11:30 a.m. He will also follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], in two weeks
if discharged and will also be the followed by the [**Hospital 197**]
Clinic.
MEDICATIONS ON DISCHARGE:
1. Ranitidine 150 mg b.i.d.
2. Lisinopril 40 q.d.
3. Atenolol 12.5 q.d.
4. Disopyramide 150 mg p.o. b.i.d.
5. Aldactazide 12.5/12.5 mg q.d.
6. Magnesium oxide 400 q.d.
7. Aspirin 81 q.d.
8. Humulin Insulin as directed per his [**Last Name (un) **] sliding scale.
9. Lipitor 80 mg q.d.
10.
Coumadin 5 mg Tuesday, Thursday, Saturday; 6 mg on the other
days.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Name8 (MD) **], [**MD Number(1) 20759**]
Dictated By:[**Last Name (NamePattern1) 8188**]
MEDQUIST36
D: [**2161-5-21**] 16:06:49
T: [**2161-5-23**] 03:44:04
Job#: [**Job Number 11233**]
|
[
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"414.00",
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icd9cm
|
[
[
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,009
| 117,245
|
7057
|
Discharge summary
|
report
|
Admission Date: [**2198-1-9**] Discharge Date: [**2198-1-18**]
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
known aortic stenosis with worsening left sided chest pain,
fatigue and DOE
Major Surgical or Invasive Procedure:
s/p AVR(23mm CE pericardial) and MV repair [**1-9**]
History of Present Illness:
Mrs. [**Known lastname 1001**] is an 83 yo with known severe aortic stenosis and a
few month h/o worsening DOE, fatigue and left sided chest pain.
Cardiac catheterization showed [**Location (un) 109**] 0.5cm2, moderate MR and no
coronary artery disease. She was refered to Dr. [**Last Name (STitle) **] for
operative management
Past Medical History:
pernicious anemia
OA
GERD
hiatal hernia
s/p L lobectomy
s/p cholecystectomy
s/p L leg vein stripping
Pertinent Results:
[**2198-1-17**] 06:40AM BLOOD Hct-33.7*
[**2198-1-16**] 07:10AM BLOOD WBC-6.6 RBC-3.51* Hgb-11.0* Hct-31.9*
MCV-91 MCH-31.4 MCHC-34.5 RDW-13.1 Plt Ct-169
[**2198-1-16**] 07:10AM BLOOD Plt Ct-169
[**2198-1-17**] 06:40AM BLOOD Glucose-101 UreaN-24* Creat-1.0 Na-139
K-4.6 Cl-101 HCO3-30* AnGap-13
Brief Hospital Course:
Mrs [**Known lastname 1001**] was admitted to [**Hospital1 18**] on [**1-9**] and taken to the
operating room with Dr.[**Last Name (STitle) **] for an AVR/MV repair. She
tolerated the procedure well and was transferred to the ICU in
stable condition. She was weaned and extubated without
difficulty. Postoperatively she had a good cardiac output, but
had persistent hypotension for which she required neo
synephrine. During this time she also had some sinus/junctional
bradycardia and required atrial pacing. The neo synephrine was
weaned to off by POD#6 and her sinus rhythm had returned. She
was transferred from the ICU to the floor, was started on
Lopressor without difficulty, and her epicardial pacing wired
were removed without incident. She was started on Lasix for
diuresis and responded appropriately, although she was very
fluid overloaded. It was determined by physical therapy that
she would benefit from a stay at short term rehab, and on POD#8
she was cleared for discharge to rehab.
Medications on Admission:
atenolol 50mg daily
omeprazole 20mg daily
HCTZ 12.5mg daily
FeSO4 325mg daily
lipitor 10mg daily
B12 injections monthly
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) 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. Ferrous Sulfate 325 (65) 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) **] at [**Location (un) 701**]
Discharge Diagnosis:
aortic stenosis
s/p AVR
pernicious anemia
osteoarthritis
GERD
s/p L lobectomy
s/p cholecysetectomy
s/p L leg vein stripping
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incision with mild soap and
water
do not swim or take a bath for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 10 pounds for 1 month
do not drive for 1 month
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**11-19**] weeks
follow up with Dr. [**Last Name (STitle) 7047**] in [**11-19**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**1-19**] weeks
Completed by:[**2198-1-18**]
|
[
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"281.0",
"441.2",
"396.2",
"401.9",
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icd9cm
|
[
[
[]
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[
"35.21",
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icd9pcs
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185, 262
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383, 713
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735, 838
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,658
| 196,036
|
27456
|
Discharge summary
|
report
|
Admission Date: [**2111-5-24**] Discharge Date: [**2111-6-2**]
Date of Birth: [**2053-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Bronchoscopy
PICC line placement
History of Present Illness:
Mr. [**Known lastname 67176**] is a 57-year-old man with h/o ILD, recent
admission for alveolar hemorrhage, also h/o afib, CAD, DM2, HTN
who was transferred from [**Location (un) 3844**] for hypoxia. He presented
to OSH with hypoxia, was intubated.
.
Mr. [**Known lastname 67176**] was admitted from [**2111-4-12**] to [**2111-5-1**] for dyspnea
and hypoxia. He was intubated for hypoxia, requiring high level
of sedation and APRV mode. Bronch revealed alveolar hemorrhage,
deemed to be due to pulmonary vasculitis. There was no evidence
of infection. He was treated with cyclophosphamide and steroids,
discharged with a PO prednisone taper. Prior to discharge, the
patient was requiring 50% venti mask to maintain O2 Sat ~94%,
with a respiratory rate in the mid 20s. He would desaturate with
exertion to the low 80s, with respiratory rate increasing to
~35. Because of the alveolar hemorrhage, his warfarin, for his
a-fib, was discontinued. He was discharged to [**Hospital1 **]. After a
few weeks in rehab, he was discharged home on constant 4-6 L NC.
.
At home for the past 1.5 weeks, the patient had experienced
worsening dyspnea, requiring 8-10 L of NC. He has also had
productive coughs with intermittent coin-sized globs of blood
for the past few days. Temperature maxed at 99-100F. He
presented to Lakes [**Hospital 12018**] Hospital in [**Location (un) 11252**], NH. T 36C, BP
142/66, HR 100, RR 26, O2 sat 77-84% on NC. WBC 6.1, Hct 30,
plts 221, INR 2.9, Cr 0.7. Her ABG, unclear if before or after
intubation, was 7.48/29/90/21. ECG was unchanged from prior. Was
intubated and transferred to [**Hospital1 18**].
On arrival to the MICU, patient was intubated.
Past Medical History:
- CAD s/p BMS to LAD in [**2101**], subsequent caths without
significant obstructive disease
- ILD (early IPF vs. NSIP)
- Afib s/p ablation/PVI x 2, first [**10/2110**] and second [**2111-4-7**].
Previously dofetilide (not tolerated due to side effects);
currently on sotalol.
- Mild pulmonary hypertension (PAP 38/19 seen on past RHC; no PA
HTN on CPET [**3-/2110**])
- Obesity
- OSH note of "PFO with shunting"
- Sleep apnea (intolerant of CPAP)
- Type II DM
- NAFLD
- Dyslipidemia
- HTN
- Bilateral torn rotator cuffs
- BPH
- GERD c/b Barrett's esophagus
- Anxiety
- severe spinal stenosis
- s/p CCY
- s/p multiple back surgeries (for disc herniation)
- s/p hernia repair
Social History:
Social history is significant for the absence of current tobacco
use. 50 pk year history of smoking. Prior h/o ETOH abuse - 7
years ago cut down significantly now occasional ETOH use. Last
drink was 2 weeks ago. Married w/ 2 children, on disability due
to back problems. Ambulates with crutches at baseline
Family History:
Father w/ MI in 50s or 60s, had a CABG. Mother: Type [**Name (NI) **] Diabetes
and hypertension.
Physical Exam:
General: elderly obese man, intubated
HEENT: Sclera anicteric, ET in place
Neck: supple, JVP not assessible due to body habitus
Lungs: Coarse breath sounds bilaterally, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-distended, rare bowel sounds, no
organomegaly
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2111-5-24**] 08:41PM TYPE-ART TEMP-36.1 RATES-14/0 TIDAL VOL-500
PEEP-5 O2-100 PO2-97 PCO2-40 PH-7.39 TOTAL CO2-25 BASE XS-0
AADO2-579 REQ O2-95 -ASSIST/CON INTUBATED-INTUBATED
[**2111-5-24**] 08:41PM LACTATE-1.1
[**2111-5-24**] 08:41PM O2 SAT-96
[**2111-5-24**] 08:15PM GLUCOSE-131* UREA N-10 CREAT-0.6 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
[**2111-5-24**] 08:15PM estGFR-Using this
[**2111-5-24**] 08:15PM ALT(SGPT)-51* AST(SGOT)-57* LD(LDH)-779*
CK(CPK)-32* ALK PHOS-80 TOT BILI-1.8*
[**2111-5-24**] 08:15PM CK-MB-NotDone cTropnT-<0.01
[**2111-5-24**] 08:15PM CALCIUM-8.2* PHOSPHATE-4.7* MAGNESIUM-1.3*
[**2111-5-24**] 08:15PM WBC-6.0# RBC-2.87* HGB-9.5* HCT-28.0* MCV-98
MCH-33.0* MCHC-33.8 RDW-18.9*
[**2111-5-24**] 08:15PM NEUTS-88.9* LYMPHS-5.8* MONOS-3.5 EOS-1.6
BASOS-0.4
[**2111-5-24**] 08:15PM PLT COUNT-224
[**2111-5-24**] 08:15PM PT-35.4* PTT-33.6 INR(PT)-3.8*
[**5-25**]: Chest CT
1. Continued progression of widespread ground-glass opacities in
addition to areas of subpleural interstitial chronic changes.
Ground-glass opacities are still relatively sparing the left
upper lobe, but to a lesser degree than on the prior study with
new involvement of priorly relatively normal regions. The
differential diagnosis still includes acute exacerbation of
chronic interstitial lung disease, DIP, AIP, or hemorrhage.
Infectious or drug related toxicity are very unlikely.
2. Signs of anemia.
3. New small bilateral pleural effusions, mostly on the right.
EKG [**5-24**]:
Sinus rhythm. Modest non-specific ST-T wave changes. Since the
previous
tracing of [**2111-4-23**] sinus tachycardia rate is slower.
Brief Hospital Course:
#. Respiratory failure: H/o ILD followed by Dr. [**Last Name (STitle) **].
Admitted with hypoxia requiring intubation. Pt started
empirically on vanco and ceftazidime, also high-dose solumedrol
with PCP [**Name Initial (PRE) 1102**]. CT chest with increased ground glass
opacity but no gross infiltrate. Bronched on [**5-26**] with Hct from
BAL <2 not c/w DAH on this admission. Pt successfully extubated
on [**2111-5-31**] to nasal cannula. Abx discontinued [**6-1**] given negative
bacterial cultures. Pt remained afebrile and hemodynamically
stable without leukocytosis. Plan to continue solumedrol 100mg
IV qday on discharge with plan to transition to prednisone 60mg
daily on [**2111-6-4**] with weekly taper to 40mg, then 20mg, then home
15mg; remaining on PCP [**Name Initial (PRE) 1102**]. Of note, micro data pending
on discharge: Respiratory cultures (prelim: moderate yeast and
rare GNR, galactomannan, and beta glucan.
#. Afib: Warfarin stopped given hemoptysis. Sotolol held
initially given recent hypotensive episodes but restarted prior
to discharge with stable BPs. Pt remained in sinus rhythm during
hospital course. Would advise against starting all
anticoagulants including aspirin and heparin given hemoptysis.
#. HTN: Sotalol initially held but restarted prior to discharge.
Captopril added for BP control; can titrate and transition to
lisinopril as needed.
#. DM2: Controlled on NPH 4 units [**Hospital1 **] with insulin sliding
scale; will likely need adjustment in setting of steroid taper.
#. Thrush: Developed in the hospital and started on nystatin on
[**2111-6-1**].
#. Constipation: Had gas pains. Started on simethecone and
aggressive BM regimen.
#. Restless Leg syndrome: Ropinerole QHS PRN with good effect.
#. Code: FULL
#. Communication: [**Name (NI) 67177**] son [**Name (NI) **] [**Telephone/Fax (1) 67178**] (c) [**Telephone/Fax (1) 67179**]
(h); co-HCP wife [**Name (NI) 5464**] [**Telephone/Fax (1) 67180**] (c); son [**Name (NI) 67181**]
[**Telephone/Fax (1) 67182**] (c)
Medications on Admission:
- atorvastatin 80 mg qday
- calcium carbonate 1000 mg qday
- cholecalciferol 800 units qday
- colchicine 0.6 mg qday
- cyanocobalamin 1000 mcg qday
- cyclophosphamide 100 mg qday
- heparin sc
- metformin 1000 mg qam / 500 mg qpm
- MVI
- omeprazole 20 mg [**Hospital1 **]
- paroxetine 50 mg qday
- prednisone 15 mg qday
- propoxyphene-acetaminophen prn
- ropinirole 0.25 mg qhs
- sotalol 160 mg [**Hospital1 **]
- tamsulosin 0.4 mg qday
- trazodone 25 mg qhs
- TMP-SMX 160-800 mg 3x/week
- warfarin 7.5 mg or 10 mg qday (son not sure)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Interstitial lung disease
Diffuse alveolar hemorrhage
Atrial fibrillation
Discharge Condition:
Fair, hemodynamically stable, satting well on 4LNC
Discharge Instructions:
You came to the hospital for shortness of breath and low oxygen.
You required intubation and had a brochoscopy that showed some
bleeding in your lungs, but the bleeding stopped and you were
extubated. You will need to follow-up with your pulmonary
doctor, Dr. [**Last Name (STitle) 67183**].
.
Medication changes:
Coumadin stopped given cough productive of blood
Captopril started for blood pressure control
Insulin NPH added with insulin Humalog sliding scale for glucose
control
Bowel meds and simethicone as needed for constipation and gas
pains
Please seek immediate medical attention if you develop chest
pain, shortness of breath, dizziness, bleeding, inability to
tolerate food/liquids, inability to pass stool/gas, or any other
concerning symptoms.
Followup Instructions:
Please call your PCP, [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 67184**], for an
appointment in 2 weeks.
.
Please call, ([**Telephone/Fax (1) 513**] for an appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 67185**] in [**1-2**] weeks.
|
[
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"515",
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"278.00",
"250.00",
"511.9",
"427.31",
"414.01",
"112.0",
"401.9",
"786.3",
"327.23",
"518.81",
"V58.67",
"V58.61",
"333.94",
"600.00",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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"96.72"
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icd9pcs
|
[
[
[]
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] |
7932, 8011
|
5326, 6152
|
330, 364
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8138, 8190
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3631, 5303
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8998, 9297
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3106, 3204
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8032, 8117
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7374, 7909
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8214, 8510
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3219, 3612
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6166, 7348
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8530, 8975
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283, 292
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392, 2065
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2087, 2764
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2780, 3090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,224
| 151,990
|
38854
|
Discharge summary
|
report
|
Admission Date: [**2102-5-1**] Discharge Date: [**2102-5-16**]
Date of Birth: [**2032-4-23**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
enlarging abdominal aortic aneurysm and right common iliac
artery aneurysm
Major Surgical or Invasive Procedure:
Open aortic and right iliac artery aneurysm repair with Dacron
16 x 8 bifurcated graft
History of Present Illness:
Ms. [**Known lastname **] is a 70-year-old woman who has an enlarging abdominal
aortic aneurysm and a right common iliac artery aneurysm.
Given that the aneurysm is in
the juxtarenal position, she was admitted for an elective open
aneurysm repair.
Past Medical History:
1. PVD
2. HTN
3. Diastolic heart failure
4. Dyslipidemia
5. Hypothyroidism
6. Emphysema - unclear if requires home O2
7. GERD
8. hx of renal artery stent placement
Social History:
Reports to drink 3 beers nightly and reports smoking hx.
Family History:
non-contributory
Physical Exam:
On discharge:
Vital Signs: T: 98.8 HR: 87 BP: 128/88 RR: 21 SO2: 97%/RA
General: No acute distress
Neuro: Awake, alert and oriented to person and date, cooperative
with exam,
Neck: No bruits over carotids, no JVD appreciated
Lungs: Clear to auscultation bilaterally, symmetric expansion.
Cardiac: Normal S1/S2, regular rate and rhythm, no murmurs, rubs
or gallops.
Abd: Soft, nontender, nondistended; midline scar well healed
Extremities: warm, good capillary refill plapable DP and PT, no
edema,
Pertinent Results:
[**2102-5-1**] 02:21PM BLOOD WBC-16.3*# RBC-3.55* Hgb-11.3* Hct-33.2*
MCV-94 MCH-31.7 MCHC-33.9 RDW-14.5 Plt Ct-189
[**2102-5-3**] 11:18AM BLOOD WBC-18.6* RBC-3.41* Hgb-10.8* Hct-31.4*
MCV-92 MCH-31.8 MCHC-34.5 RDW-15.6* Plt Ct-114*
[**2102-5-4**] 03:40AM BLOOD WBC-24.7* RBC-3.51* Hgb-11.2* Hct-32.6*
MCV-93 MCH-31.9 MCHC-34.3 RDW-15.5 Plt Ct-120*
[**2102-5-8**] 02:24AM BLOOD WBC-9.8 RBC-3.49* Hgb-10.7* Hct-32.4*
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.4 Plt Ct-154
[**2102-5-10**] 06:40AM BLOOD WBC-9.6 RBC-3.93* Hgb-11.7* Hct-35.9*
MCV-91 MCH-29.7 MCHC-32.5 RDW-14.3 Plt Ct-250
[**2102-5-14**] 05:18AM BLOOD WBC-17.0* RBC-4.08* Hgb-12.7 Hct-38.1
MCV-93 MCH-31.1 MCHC-33.3 RDW-15.6* Plt Ct-291
[**2102-5-15**] 02:47AM BLOOD WBC-14.1* RBC-3.88* Hgb-12.1 Hct-36.0
MCV-93 MCH-31.2 MCHC-33.6 RDW-15.4 Plt Ct-274
[**2102-5-1**] 02:21PM BLOOD PT-14.3* PTT-31.1 INR(PT)-1.2*
[**2102-5-2**] 02:28AM BLOOD PT-12.9 PTT-33.5 INR(PT)-1.1
[**2102-5-4**] 03:40AM BLOOD PT-14.3* PTT-29.9 INR(PT)-1.2*
[**2102-5-10**] 06:40AM BLOOD PT-15.3* PTT-27.1 INR(PT)-1.3*
[**2102-5-15**] 02:47AM BLOOD Plt Ct-274
[**2102-5-1**] 02:21PM BLOOD Glucose-161* UreaN-9 Creat-1.0 Na-135
K-3.9 Cl-110* HCO3-19* AnGap-10
[**2102-5-4**] 03:40AM BLOOD Glucose-150* UreaN-10 Creat-1.2* Na-135
K-3.8 Cl-99 HCO3-26 AnGap-14
[**2102-5-4**] 09:20AM BLOOD Glucose-158* UreaN-10 Creat-1.2* Na-138
K-2.9* Cl-102 HCO3-28 AnGap-11
[**2102-5-14**] 05:18AM BLOOD Glucose-214* UreaN-23* Creat-0.9 Na-140
K-3.7 Cl-109* HCO3-19* AnGap-16
[**2102-5-15**] 02:47AM BLOOD Glucose-213* UreaN-23* Creat-0.9 Na-137
K-3.5 Cl-108 HCO3-21* AnGap-12
[**2102-5-2**] 08:19PM BLOOD CK-MB-9 cTropnT-<0.01
[**2102-5-3**] 01:08PM BLOOD proBNP-1578*
[**2102-5-3**] 04:06PM BLOOD CK-MB-10 MB Indx-2.0 cTropnT-<0.01
[**2102-5-4**] 12:16AM BLOOD CK-MB-45* MB Indx-2.2 cTropnT-0.15*
[**2102-5-4**] 08:44AM BLOOD CK-MB-29* MB Indx-2.1 cTropnT-0.30*
[**2102-5-4**] 03:52PM BLOOD CK-MB-23* MB Indx-2.1 cTropnT-0.26*
[**2102-5-5**] 01:28AM BLOOD CK-MB-16* MB Indx-2.2 cTropnT-0.22*
[**2102-5-14**] 05:18AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9
[**2102-5-15**] 02:47AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.8
Brief Hospital Course:
The patient was admitted to the vascular service on [**2102-5-1**] for
an elective repair of an abdominal aortic aneurysm and right
common iliac artery aneurysm.
She underwent surgery on the same day, tolerated the procedure
well. She was extubated in the operating room and transferred to
the PACU in stable condition and later to the floor (VICU)
where she remained stable.
On post-operative day 3 she suffered an acute episode of
hypoxemia on the floor. She was subsequently transferred to the
ICU where she was intubated. Her cardiac enzymes were trending
up and she was also found to be in flash pulmonary edema. An
echocardiogram revealed moderate regional left ventricular
systolic dysfunction with anterior, septal and apical akinesis.
A Swan-Ganz catheter was placed for hemodynamic monitoring and
she remained intubated for 4 more days. Besides myocardial
infarction, there was also concern for a new onset of seizure
activity which was thought to be related either to
detoxification from alcohol withdrawal or a head bleed. A
non-contrast head CT was negative for a bleed. An EEG didn't
confirm any further seizure activity within the following days.
Over the next days she improved from a cardiovascular standpoint
and was weaned to extubate on post-operative day 7. After
extubation she was quite confused with visual hallucinations, no
further seizure activity was observed. Psychiatry has been
consulted and it was felt that her delirium is likely quite
multifactorial which might require a slow recovery. Her former
dose of Paxil and Imipramine have been discontinued according to
Psych recs and she was put on standing Haldol.
Ms. [**Known lastname **] failed two swallow evaluations and was subsequently
put on total parenteral nutrition. We started her on oral feeds
on [**2102-5-15**] after she passed a repeat swallow evaluation. Over
the last days she continued to increase her oral intake, which
she tollerated well. Her TPN was stopped on the [**2102-5-16**].
While in hospital Ms. [**Known lastname **] has been working with physical
therapy. She is being discharged to rehab on [**2102-5-16**]. According
to cardiology recommendations she will continue on beta blocker,
aspirin 325, lisinopril and a high dose statin and will follow
up in 6 weeks. According to Psych recommendations she will
continue short term on Haldol.
Medications on Admission:
Alprazolam, Atenolol, Paxil, Lisinopril, Levoxyl, Plavix,
Simvastatin
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-31**]
Puffs Inhalation Q6H (every 6 hours).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as
needed for wheezing.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): pat needs to stay on Keppra for 6 months.
9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): please taper haldol dose over next days as tollerated.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
1. Abdominal aortic aneurysm and right common iliac artery
aneurysm
2. Delirium
3. Myocardial infarction
4. popostoperative anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
ACTIVITIES:
- [**Month (only) 116**] shower pat dry your incision, no tub baths
- No driving till seen in FU by Dr. [**Last Name (STitle) 1391**]
- No heavy lifting for 4-6 weeks
- Resume activities as tolerated, slowly increase activiy as
tolerated
- Expect your activity level to return to normal slowly
- Ambulate as tolerated
DIET:
- Diet as tolerated eat a well balanced meal
- Your appetite will take time to normalize
- Prevent constipation by drinking adequate fluid and eat foods
[**Doctor First Name **] in fiber, take stool softener while on pain medications
WOUND:
- Keep wound dry and clean, call if noted to have redness,
draining, or swelling, or if temp is greater than 101.5
- Your staples will be removed on your FU with Dr. [**Last Name (STitle) 1391**]
MEDICATIONS:
- Continue all medications as instructed
Followup Instructions:
FU APPOINTMENT:
- A follow up appointment has been scheduled for you at Dr.
[**Last Name (STitle) 11918**] office in [**Location (un) 5028**] on [**2102-5-26**] at 12:10pm. Phone:
[**Telephone/Fax (1) 1393**]
- Follow up with Cardiology in 6 weeks. Call ([**Telephone/Fax (1) 2037**] to
schedule an appointment
Completed by:[**2102-5-16**]
|
[
"492.8",
"303.90",
"293.9",
"442.2",
"291.0",
"428.0",
"530.81",
"441.4",
"244.9",
"272.4",
"410.71",
"428.33",
"285.9",
"403.90",
"997.1",
"780.39",
"585.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.46",
"03.90",
"96.6",
"38.44",
"96.72",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
7203, 7246
|
3685, 6044
|
342, 431
|
7421, 7421
|
1542, 3662
|
8461, 8803
|
987, 1005
|
6165, 7180
|
7267, 7400
|
6070, 6142
|
7606, 8438
|
1020, 1020
|
1034, 1523
|
227, 304
|
459, 710
|
7436, 7582
|
732, 897
|
913, 971
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,912
| 103,856
|
47295
|
Discharge summary
|
report
|
Admission Date: [**2112-3-14**] Discharge Date: [**2112-3-31**]
Date of Birth: [**2057-8-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
lightheadedness, chest discomfort
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting (CABGx3)[**3-16**]
History of Present Illness:
54 yoM w/ a h/o CAD s/p stent->LAD in [**2102**], htn, hyperlipidemia,
and strong family history of CAD who p/w 48 hours of
lightheadedness and chest discomfort. Given these symptoms, his
wife brought him to [**Name (NI) 2079**] [**Name (NI) **]. At [**Name (NI) 2079**], ECG showed TW
inversions in ant leads and bradycardia in the 40s. Cardiac
enzyme were elevated w/ trop 0.29, CK 725, MB 71. Transfer was
arranged to [**Hospital1 18**] for potential cath.
Past Medical History:
Dyslipidemia, Hypertension, Percutaneous coronary intervention,
in [**2102**] w/ stent to LAD at [**Hospital6 **].
Social History:
Denies any tobacco, EtOH or illicit drug use. Works as a nurse
for an insurance company for the last year.
Family History:
His father and brother both died of MIs at age 48.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 97.3, BP 100/57, HR 60, RR 25, O2 95% on 2LNC
Gen: middle aged male in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. no pallor or cyanosis of
the oral mucosa.
Neck: Supple no JVd
CV: RR, normal S1, S2. No S4, no S3.
Chest:CTA
Abd: +BS, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without
bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Discharge
VST 99 HR 84 BP 124/70 RR 20 02sat 94%RA
Gen NAD
Neuro A&Ox3, nonfocal exam
CV RRR no M/R/G
Pulm CTA-bilat
Abdm soft, NT/+BS
Ext warm palpable pulses. Trace edema-bilat
Pertinent Results:
ADMISSION LABS:
[**2112-3-14**] 08:35PM BLOOD WBC-10.2 RBC-4.44* Hgb-14.6 Hct-41.5
MCV-93 MCH-32.8* MCHC-35.1* RDW-13.0 Plt Ct-227
[**2112-3-14**] 08:35PM BLOOD Neuts-76.2* Lymphs-17.1* Monos-5.6
Eos-0.7 Baso-0.4
[**2112-3-14**] 08:35PM BLOOD PT-14.3* PTT-137.7* INR(PT)-1.2*
[**2112-3-14**] 08:35PM BLOOD Plt Ct-227
[**2112-3-14**] 08:35PM BLOOD Glucose-109* UreaN-15 Creat-1.0 Na-143
K-5.0 Cl-110* HCO3-22 AnGap-16
[**2112-3-14**] 08:35PM BLOOD CK(CPK)-1145*
[**2112-3-14**] 08:35PM BLOOD CK-MB-147* MB Indx-12.8*
[**2112-3-14**] 08:35PM BLOOD cTropnT-0.84*
[**2112-3-15**] 03:54AM BLOOD Calcium-7.2* Phos-3.9 Mg-1.7 Cholest-92
[**2112-3-15**] 03:54AM BLOOD Triglyc-48 HDL-31 CHOL/HD-3.0 LDLcalc-51
[**2112-3-15**] 09:35AM BLOOD Type-ART pO2-80* pCO2-30* pH-7.46*
calTCO2-22 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
CXR: No acute cardiopulmonary process
[**2112-3-15**] TTE:
The left ventricular cavity is mildly dilated. LV systolic
function appears depressed with inferior, inferolateral and
apical hypokinesis/?akinesis (however views suboptimal;
estimated ejection fraction ?35-40). Right ventricular chamber
size is normal. with normal free wall contractility. The aortic
valve leaflets are mildly thickened. The aortic valve is not
well seen. There is no aortic valve stenosis. No aortic
regurgitation is seen. No mitral regurgitation is seen. There is
no pericardial effusion.
[**2112-3-15**] Cardiac Catheterization:
1. Coronary angiography of this right dominant system revealed
3 vessel
coronary artery disease. The LMCA had a 60% distal ulcerated
lesion.
The LAD had a widely patent previously placed stent. The origin
of the
LCx had an 80% stenosis. The proximal RCA was 90% stenosed,
with a 100%
distal RCA occlusion and left to right collaterals.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures, with RVEDP and LVEDP of 20 and 27 mm Hg,
respectively. Mean
PCWP was elevated at 19 mm Hg. Systemic arterial pressures were
low
with aortic systolic pressure of 92 mm Hg and mean arterial
pressure of
64 mm Hg. Cardiac index was 3.07 l/min/m2.
3. Left ventriculography revealed no mitral regurgitation and a
large
area of anteroapical and inferoapical dyskinesis. Estimated
left ventricular ejection fraction was 35%.
4. 40 cc IABP was placed in the setting of extensive myocardial
infarction, hypotension, and impending CABG.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2112-3-27**] 1:30 PM
CHEST (PORTABLE AP)
Reason: ?pneumonia
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with altered mental status, wbc 14.4 (?
infiltrate)
REASON FOR THIS EXAMINATION:
?pneumonia
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Elevated white blood count and altered mental
status.
Comparison is made with prior study [**2112-3-22**].
Mild cardiomegaly is accentuated by low lung volumes, unchanged
from prior study. The patient has been extubated. There is no
pneumothorax. The right lung is clear. There is a small left
pleural effusion. Ill-defined opacity in the left base is
persistent, could be atelectasis or pneumonia. Patient is post
median sternotomy and CABG.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
MC [**Last Name (LF) **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 100119**]
(Complete) Done [**2112-3-16**] at 12:08:58 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2057-8-27**]
Age (years): 54 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG with IABP
ICD-9 Codes: 410.92, 440.0, 424.0, 424.2
Test Information
Date/Time: [**2112-3-16**] at 12:08 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2008AW4-: Machine: B-[**Numeric Identifier **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - LVOT diam: 2.4 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. All four pulmonary veins identified and
enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV cavity size. Mild-moderate
regional LV systolic dysfunction. Moderately depressed LVEF.
RIGHT VENTRICLE: Focal apical hypokinesis of RV free wall.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Simple
atheroma in aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. The patient appears to be in sinus rhythm. Results were
Conclusions
PRE CPB No spontaneous echo contrast or thrombus is seen in the
body of the left atrium/left atrial appendage or the body of the
right atrium/right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with apical severe hypokinesis/akinesis. No
apical thrombus is seen. Overall left ventricular systolic
function is mildly to moderately depressed (LVEF= 40 %). The
right ventricle displays normal mid and basal function with mild
to moderate focal hypokinesis of the apical free wall. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion. An intra-aortic balloon pump is seen in
the descending aorta with its tip 2 cm below the distal aortic
arch.
POST-CPB The focal wall abnormalities noted in the pre-bypass
study are unchanged. The mitral regurgitation may be slightly
improved. No other significant changes.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2112-3-16**] 15:29
[**2112-3-29**] 06:30AM BLOOD WBC-14.8* RBC-3.45* Hgb-10.5* Hct-30.3*
MCV-88 MCH-30.4 MCHC-34.6 RDW-14.4 Plt Ct-846*
[**2112-3-29**] 06:30AM BLOOD Plt Ct-846*
[**2112-3-27**] 03:10AM BLOOD PT-15.8* PTT-22.9 INR(PT)-1.4*
[**2112-3-29**] 06:30AM BLOOD Glucose-102 UreaN-22* Creat-0.8 Na-137
K-4.0 Cl-103 HCO3-22 AnGap-16
Brief Hospital Course:
Admitted as transfer from [**Hospital6 33**] with acute MI on
[**3-14**]. Brought to cath lab on [**3-15**] found to have left main and
2VD/EF 35%. Intra Aortic Ballon Pump placed at that time. CT
surgery consulted and patient brought to operating room on [**3-16**]
for coronary artery bypass grafts. Patient tolerated the surgery
well and [**Hospital 19692**] transferred to the cardiac surgery ICU in stable
condition. He remained intubated and hemodynamically stable on
the day of surgery. On POD1 the IABP was weaned and removed,
after which his sedation was stopped. An attempt to wean from
ventilator was unsuccessful. On POD2 he was again weaned and
extubated however required reintubation because of agitation.
Neurology and psychiatry were consulted. The patient had ahead
CT that was negative as well as an MRI and Lumbar puncture that
were also negative. Over the next several days his neuro status
cleared and he was successfully extubated. He did remain
delerious for several additional days but was ultimately
transferred to the stepdown floor on POD 12. The patient also
experienced a Gout flare during this time, rheumatology was
consulted and he was started on Colchicine and Indocin. Over the
next several days he continued to make slow progress in his ADL
and ambulation and on POD 15 it was decided he was stable and
ready for discharge to [**Hospital 38**] Rehab. He will followup with Dr
[**Last Name (STitle) **] in 4 weeks
Medications on Admission:
atenolol 50 mg daily
lisinopril 20 mg daily
lipitor 10 mg daily
aspirin 325 mg daily
niacin 500 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed.
10. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
s/p CABGx3(LIMA-LAD, SVG-OM, SVG-RCA)[**3-16**]. Post-op delerium
PMH: CAD s/p MI-stent LAD w/IABP, HTN, ^chol, Piloneal cyst
removal,Tonsillectomy
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
wound check in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Dr [**First Name (STitle) 5936**] in [**4-12**] weeks
Completed by:[**2112-3-31**]
|
[
"414.01",
"272.0",
"401.9",
"274.0",
"458.29",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93",
"88.56",
"36.15",
"88.53",
"39.61",
"37.61",
"37.23",
"36.12",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12752, 12849
|
9966, 11416
|
356, 408
|
13041, 13050
|
1965, 1965
|
13251, 13399
|
1180, 1232
|
11572, 12729
|
4523, 4591
|
12870, 13020
|
11442, 11549
|
13074, 13228
|
1247, 1257
|
1279, 1946
|
282, 318
|
4620, 9943
|
436, 901
|
1981, 4486
|
923, 1039
|
1055, 1164
|
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