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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
18,442
| 181,492
|
47868
|
Discharge summary
|
report
|
Admission Date: [**2120-9-6**] Discharge Date: [**2120-9-10**]
Date of Birth: [**2051-10-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Elective cath for right femoral artery stenting
Major Surgical or Invasive Procedure:
femoral artery stenting
brachial artery embolectomy
History of Present Illness:
HPI: The pt. is a 68 year-old female with hypertension,
hyperlipidemia, peripheral vascular disease (s/p multiple
stenting procedures) who presented for elective left CFA
revascularization. The pt. underwent this procedure with a right
brachial artery approach from 10:30-12:30 today. She had
successful atherectomy of the left CFA, SFA, and PFA and
successful balloon angioplasty of the left CFA. Apparently, the
pt developed asystole for a brief period during the procedure,
requiring chest compressions and intravenous atropine with
successful resuscitation. The [**Name8 (MD) **] RN noticed on routine
post-procedure evaluation that she appeared to have lost her
right brachial pulse. The pt was taken emergently to ultrasound
where a large clot was discovered in the right brachial artery.
After return from this study, the [**Name8 (MD) **] RN noted that she acutely
developed "garbled speech" at some point around 4pm. [**Name6 (MD) **] the RN,
this was clearly a new finding from earlier in the afternoon,
even post-procedure. The medical house officer was called and
confirmed this finding. Was seen by stroke fellow at 4:05 pm. On
arrival, the pt offered no complaints. NIHSS examination was
immediately performed and the pt was taken for stat CT of the
head which was negative. Neuro thought her exam findings were
c/w transcortical sensory aphasia and a lesion in
temporoparietal junction in proximity to Wernicke's area in the
territory of the inferior division of the left MCA. Likely was
secondary to embolism but could have been d/t hypotension from
asystole. Pt was then taken back to cath lab but neuro thought
she may be able to receive TPA, so she was taken to MRI. At MRI
a left sided inferior anterior infarct was noted. TPA was not
done b/c pt had chest compressions and possible source for
bleed. She was taken to the cath lab for embolectomy with
successful revascularization of the right brachial artery. She
was transferred to CCU where she had an episode of bradycardia
to the 30s with high bps and began to dry heave. This resolved
with no intervention. The patient had a second identical
episode later during the night, but it again resolved with no
intervention. The next morning but the patient became
bradycardic to the 20s and had an episode of emesis but reverted
back to normal rate with no intervention.
Past Medical History:
-hypetension
-hyperlipidemia
-peripheral vascular disease, s/p multiple stenting procedures
-Cholestasis, s/p cholecystectomy [**2120-7-10**]
-History of lung CA status post lobectomy three years ago,
presumptive cure.
-Peripheral vascular disease with bilateral lower extremity
claudication with left lower extremity ischemia.
Social History:
She has been married for 50 years. She is a retired
receptionist.
Family History:
NC
Physical Exam:
General: Awake, alert, not answering questions appropriately,
not oriented to time or place
HEENT: no scleral icterus noted, MMM, EOMI, PERRL
Neck: supple, no JVD, bilateral carotid bruits appreciated
Pulmonary: Lungs few inspiratory wheezes bilaterally, no
crackles
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: right femoral sheath pulled, dressing intact, no
oozing, bruit noted
Right brachial cath entry site dressing intact, no oozing
Skin: ecchymosis noted on ant chest wall
Neurologic: Pt is not oriented to time or place, does not
appropriately answer questions
CN 2-12 intact, though pt has trouble following some commands
and unable to assess whether peripheral vision intact
Motor: Motor strength intact in bilateral lower and left upper
extremities, though did not move right upper extremity secondary
to embolectomy. Grip strength intact in right upper extremity.
Sensory: Unable to assess sensory function in pt, b/c she was
not responding appropriately
Downgoing babinski bilaterally
Pertinent Results:
[**2120-9-9**] 06:00AM BLOOD WBC-8.0 RBC-4.07* Hgb-11.7* Hct-33.3*
MCV-82 MCH-28.9 MCHC-35.2* RDW-14.8 Plt Ct-158
[**2120-9-6**] 09:32PM BLOOD WBC-8.9 RBC-3.34*# Hgb-9.5*# Hct-28.3*
MCV-85 MCH-28.6 MCHC-33.7 RDW-14.7 Plt Ct-188
[**2120-9-8**] 05:00AM BLOOD PT-12.5 PTT-41.5* INR(PT)-1.0
[**2120-9-6**] 09:32PM BLOOD PT-13.3 PTT-46.5* INR(PT)-1.2
[**2120-9-9**] 06:00AM BLOOD Glucose-127* UreaN-14 Creat-0.9 Na-138
K-3.9 Cl-107 HCO3-24 AnGap-11
[**2120-9-6**] 09:32PM BLOOD Glucose-187* UreaN-15 Creat-1.0 Na-136
K-3.9 Cl-106 HCO3-23 AnGap-11
[**2120-9-7**] 06:14AM BLOOD ALT-12 AST-16 LD(LDH)-200 CK(CPK)-57
AlkPhos-66 TotBili-0.4
[**2120-9-7**] 06:14AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2120-9-6**] 09:32PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2120-9-9**] 06:00AM BLOOD Calcium-9.4 Phos-2.0* Mg-2.1
[**2120-9-6**] 09:32PM BLOOD Calcium-8.2* Phos-5.6* Mg-1.7
.
Prior cath: [**7-14**]
FINAL DIAGNOSIS:
1. Moderate to severe distal abdominal aorta disease.
2. Moderate to severe right common iliac artery disease.
3. Severe left common iliac disease.
4. Successful distal aorta reconstruction.
.
cath [**9-6**]:
FINAL DIAGNOSIS:
1. Left lower extremity peripheral arterial disease.
2. Normal central blood pressure.
3. Successful atherectomy of the left CFA, SFA, and PFA.
4. Successful balloon angioplasty of the left CFA.
5. Transient, severe vagal episode treated with atropine.
6. A few chest compressions were performed during vagal episode.
7. Addendum--aphasia thought to represent TIA/CVA
post-procedure.
8. Addendum--right brachial thrombus requiring treatment
tonight.
.
[**2120-8-1**] the patient underwent abdominal aortic run offs. This
was notable for:
-distal abdominal aorta with diffuse disease up to 70%.
-RCIA with a 70% stenosis. The AT was occluded.
-LCIA subtotally occluded at its origin. The EIA had mild
diffuse
disease. The CFA had a calcified stenosis just at the
bifurcation
of the SFA and PFA. The AT and PT were totally occluded.
The patient underwent successful stenting of the distal aorta.
Post procedure had new bruit and noted to have AVF involving
left common femoral artery and vein.
.
MRI/MRA ([**2120-9-6**])
FINDINGS:
BRAIN MRI: The diffusion images demonstrate acute infarct in
the left frontal region in the anterior middle cerebral artery
territory. There is no mass effect or hydrocephalus seen.
IMPRESSION: Acute left frontal infarct.
MRA OF THE HEAD: The head MRA demonstrates no evidence of
vascular occlusion or high-grade stenosis in the arteries of
anterior and posterior circulation.
IMPRESSION: Slightly motion limited normal MRA of the head.
.
Brachial U/S ([**2120-9-9**]):
No evidence of thrombus
.
Carotid U/S ([**2120-9-9**]):
60% veterbal artery stenosis; <40% R carotid stenosis
Brief Hospital Course:
HPI: This is a 68 year-old female with hypertension,
hyperlipidemia, peripheral vascular disease (s/p stenting
procedure in [**7-14**]) who presented for elective left CFA
revascularization, now with left frontal stroke and s/p right
brachial artery thrombectomy.
.
A/P;
1)CVA: MRI shows acute infarct in the left frontal region in the
anterior middle cerebral artery territory. Neuro felt this was
likely secondary to emoblic stroke but other possibility
included watershed ischemia secondary to hypotension. During
cath for brachial artery embolectomy it was noted there was L
carotid ostial stenosis > 90% and in conjunction with
hypotensive episode yesterday may also explain the infarction.
Patient originally had trouble comprehending speech and
responded inappropriately to questions. Neuro status has
improved throughout the admission. Blood pressure was optimized
and carotid ultrasound was obtained.
.
2)Bradycardia: Pt has had several episodes of transient
bradycardia to 30s with dry heaving or emesis and reverted back
to NSR without intervention. EP consulted and fekt this was
vagal reaction in response to stents in distal aorta or
intervention in femoral artery.
.
3)s/p embolectomy: Had embolectomy for R brachial artery
thrombus that resulted in successful revascularization. Treated
with ASA and plavix. Post op brachial u/s showed no thrombus.
.
4)Suspected CAD: pt has severe PVD, htn, hyperlipidemia and
likely has CAD.
Contiued on ASA, plavix,statin.
.
Medications on Admission:
Atenolol 50mg daily every morning
Norvasc 10mg daily every morning
ASA 325mg daily
Plavix 75mg daily every morning
Lipitor 40mg every evening
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Outpatient Speech/Swallowing Therapy
6. Outpatient Occupational Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
L frontal stroke
R brachial embolism s/p embolectomy
R femoral stenosis
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed
Please do not drive for 2weeks
Please keep all you appointments
Please call your PCP/Return to the ER for:
1. shortness of breath
2. chest pain
3. cold/weak/tingling arms or legs
4. fever to 101
5. visual changes/HA/weakness/trouble with speech
6. fainting
7. other concerning symptoms
Call your physician or go to the emergency room with weakness,
dizziness, or other concerning symptoms.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] 1 week
Follow up with Dr. [**First Name (STitle) **] on [**9-24**] at 1:30pm.
Completed by:[**2120-9-30**]
|
[
"401.9",
"E878.8",
"V10.11",
"997.2",
"414.01",
"444.21",
"997.02",
"440.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
9305, 9311
|
7134, 8620
|
363, 416
|
9426, 9435
|
4366, 5253
|
9918, 10091
|
3239, 3243
|
8813, 9282
|
9332, 9405
|
8646, 8790
|
5496, 6750
|
9459, 9895
|
3258, 4347
|
276, 325
|
444, 2788
|
6768, 7111
|
2810, 3140
|
3156, 3223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,310
| 183,978
|
38912
|
Discharge summary
|
report
|
Admission Date: [**2181-3-15**] Discharge Date: [**2181-3-24**]
Date of Birth: [**2111-7-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Lisinopril / Nifedipine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SOB;angina
Major Surgical or Invasive Procedure:
[**2181-3-19**] CABG x1 (LIMA to LAD)/AVR ( [**Street Address(2) 6158**]. [**Male First Name (un) 923**] Epic porcine)
History of Present Illness:
69 yo female with worsening SOB and intermittent chest
discomfort for severla months. Cath showed 3VD and moderate AS
and pt transferred from OSH for surgery.
Past Medical History:
peripheral vascular disease, hypertension, diabetes mellitus,
dyslipidemia, Left carotid stenosis, LLE strep infection [**2175**]
s/p
IV abx tx
Social History:
Lives with: husband
Occupation: retired nurse
Tobacco: 30 pack years, quit ~15yrs. ago
ETOH: 2/year
Physical Exam:
Pulse: Resp: O2 sat:
B/P Right: Left:
Height: 5'4" Weight: 81.65
General:
Skin: Dry [x] intact []
HEENT: PERRLA [] EOMI [x] right pupil reactive, left eye
cataract
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x], obese, ventral hernia
Extremities: Warm-cool feet [x], well-perfused-no [] trace edema
b/l LEs, minimal varicosities, slow healing lesion right medial
ankle, onychomycotic toe nails, feet slightly mottled
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid: bruit vs. transmitted murmur bilaterally, +thrill right
carotid
Pertinent Results:
Conclusions
Pre-bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity size is normal. Overall
left ventricular systolic function is mildly depressed (LVEF= 45
%). Right ventricular chamber size is normal. with borderline
normal free wall function. There are complex (>4mm) atheroma in
the aortic arch. There are focal calcifications in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
severe mitral annular calcification. Mild to moderate ([**2-10**]+)
mitral regurgitation is seen. There is no pericardial effusion.
Post-bypass:
The patient is receiving 0.04 mcg/kg/min of epinephrine
post-CPB. There is an bioprosthetic valve well-seated in the
aortic position with good leaflet excursion. There is no
paravalvular or transvalvular regurgitation. The peak pressure
gradient is 7 mm Hg and the valve area is calculated to be 1.4
cm3. Biventricular systolic function is similar to pre-bypass
function. All other findings are consistent with pre-bypass
findings. The aorta is intact post-decannulation. All findings
communicated to the surgeon.
PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician.
[**Name Initial (NameIs) **] certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
Brief Hospital Course:
Transferred in from OSH on [**3-15**] and pre-op work-up completed.
Significant carotid disease noted and vascular surgery consulted
for clearance.Underwent surgery with Dr. [**Last Name (STitle) **] on [**3-19**].
Transferred to the CVICU in stable condition on epinephrine,
phenylephrine, insulin, and propofol drips. Extubated that
evening and transferred to the floor on POD #2 to begin
increasing her activity level. Transferred back to CVICU on POD
#2 for bradycardia. Transferred back to floor on POD #3. Gently
diuresed toward her preop weight. Chest tubes removed per
protocol. The patient developed post-op atrial fibrillation
which converted to sinus rhythm with increased beta blockade.
Pacing wires were discontinued. The patient was evaluated by
the vascular surgery team for her history of significant carotid
stenosis. She will follow up as an outpatient. She was
discharged in good condition to rehab on POD 5.
Medications on Admission:
lopressor 50'', metformin 1000'', glipizide 5'', diovan 160',
asa 325'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp.
9. Glucophage 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 20 units glargine in am, regular
insulin per sliding scale.
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
15. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
aortic stenosis s/p AVR/cabg x1
coronary artery disease
PVD
HTN
NIDDM
left carotid stenosis
LLE Strep infection [**2175**]
postop A Fib
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with encouragement, 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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] [**4-26**] @ 1:15 PM [**Telephone/Fax (1) 170**]
Vascular Surgery Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1241**]
Primary Care Dr.[**Last Name (STitle) 11791**] in [**2-10**] weeks
Cardiologist Dr. [**Last Name (STitle) 4922**] in [**2-10**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2181-3-24**]
|
[
"525.9",
"433.10",
"433.30",
"401.9",
"285.9",
"997.1",
"424.1",
"414.2",
"443.9",
"E878.2",
"250.00",
"414.01",
"521.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6013, 6060
|
3600, 4534
|
318, 440
|
6240, 6355
|
1762, 3577
|
6980, 7460
|
4656, 5990
|
6081, 6219
|
4560, 4633
|
6379, 6957
|
929, 1743
|
268, 280
|
468, 628
|
650, 796
|
812, 914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,101
| 179,384
|
45033
|
Discharge summary
|
report
|
Admission Date: [**2111-1-19**] Discharge Date: [**2111-1-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Right IJ catheter
History of Present Illness:
85 yr old male with hx of AAA s/p endovascular repair in [**11-29**]
presents from [**Hospital 100**] Rehab with increasing WBC count (to 25.2),
fever to 102 and bulging R groin with clear fluid seeping. Pt is
a poor historian [**2-26**] dementia but denied chest pain, sob, n/v/d.
Three hours after arrival in the [**Name (NI) **], pt noted to be more
lethargic with labored breathing and SBP had dropped from the
100s to the 80s/40s. Pt was intubated for airway protection and
started on a dopamine drip. BP improved to 120s/50s. He was sent
for head CT which showed a lacunar infarct. CT chest/abd
negative for abscess, UA positive for infection and pt was
admitted to the SICU.
.
In the SICU, pt was started on vanc/levo/flagyl. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim was
done and showed an inappropriate response (10.6 --> 19.0) so pt
received three days of stress dose steroids. Cardiology was
consulted given the hx of pericardial effusion on prior CT. An
echo showed that the pericardial effusion was stable in size
without evidence of tamponade. Pt was extubated on HD#3 as his
mental status improved and he has been maintaining his sats on
50% face mask. The dopamine was weaned off on HD#4 and BP has
been stable in the 120s/60s. ID was consulted on [**1-22**] given
that pt was growing MRSA in his urine. Speech and swallow was
consulted after pt was seen coughing after sips of water which
he failed so an NGT remains in place.
Past Medical History:
1. Parkinson's Disease
2. Hypertension
3. DM
4. h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Doctor Last Name **] tear
5. Scoliosis/Kyphosis
6. Stable pericardial effusion, last echo [**10-28**] at [**Location (un) **]
(followed by Kanam)
7. Secondary pulm HTN likely [**2-26**] OSA
8. h/o AAA s/p Aortic stent graft repair of abdominal aortic
aneurysm with a Zenith device in [**11-29**]
Social History:
Lives with wife prior to Rehab. Quit tobacco many years ago, but
smoked [**2-27**] cigarettes/day x 10 years. Veteran. Retired; used to
worked in advertising. No ETOH
Family History:
NC
Physical Exam:
Exam on transfer from SICU:
tmax/c 98.4, BP 126/56 (110-120/50-70), HR 69 (60-80), R 28, O2
99% on 50%FM; I/O 1.3/1.2 today, 2.4/2.1 yesterday (+9.8L po
Gen: NAD, AO x 3,
HEENT: MM dry, EOMI, no scleralm icterus
Neck: JVD to mid ear
CV: RRR, 2/6 systolic murmur heard best at LLSB
Chest: diffuse rhonchi, decreased breath sounds at left base
Abd: decreased bowel sounds, soft, nontender
Groin: 3cm erythematous swelling, nontender, draining serous
fluid
Ext: resting tremor in left arm, 2+ edema in right arm; [**2-27**]+
edema in lower ext to sacrum
Neuro: CN 2-12 intact, strength 4-/5 in upper and lower ext
though left weaker than the right; sensation intact
Pertinent Results:
Studies:
Abd CT [**1-19**]:
1. Interval development of simple-fluid containing collection
within the right inguinal region, and interval increase in size
of two left inguinal fluid collections. There is no evidence of
rim enhancement, surrounding inflammatory fat stranding, or
extravasation of contrast into these simple containing fluid
collections.
2. Stable appearance of aortic endovascular graft without
evidence of endoleak. Stable appearance of infrarenal abdominal
aortic aneurysm.
3. Moderate sized bilateral pleural effusions with bibasilar
collapse/consolidation.
.
Head CT [**1-19**]:
No intracranial hemorrhage or mass effect. Chronic microvascular
angiopathy. Left basal ganglia lacunar infarction.
.
Echo [**1-20**]:
- Overall left ventricular systolic function is normal
(LVEF>55%).
- Right ventricular systolic function appears depressed.
- Mild (1+) mitral regurgitation is seen.
- Moderate to severe [3+] tricuspid regurgitation is seen.
- There is moderate pulmonary artery systolic hypertension.
- Significant pulmonic regurgitation is seen.
- There is a moderate to large sized pericardial effusion. The
effusion appears circumferential. No right ventricular diastolic
collapse is seen. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
.
RUE LENI [**1-23**]:
No evidence of deep venous thrombosis in the imaged vessels
.
Micro:
Urine Cx [**1-19**]: MRSA, enterococcus
Urine Cx [**1-19**]: MRSA, enterococcus
Right Groin Swab: MRSA
Rectal Swab for VRE: positive
Blood cx: pending
Stool for c diff: negative
Brief Hospital Course:
85M with hx of Parkinson's disease, AAA s/p repair in [**11-29**]
admitted on [**1-19**] from [**Hospital 100**] Rehab with fever and leukocytosis
and subsequently became hypotensive and unresponsive in ED with
intubation for airway protection likely [**2-26**] MRSA UTI
.
1. Sepsis: In the SICU, patient was started on
vancomycin/levofloxacin/flagyl. A cortisol stimulation test was
done and showed an inappropriate response (10.6 --> 19.0) so
patient received three days of stress dose steroids. Urine grew
out MRSA and pt was continued on Vancomycin. ID was consulted
and recommended completing a 10-day course. The dopamine was
weaned off on HD#4 and BP remained stable in the 120s/60s.
.
2. Respiratory failure/Pneumonia: Patient was intubated in the
ED for labored breathing in the setting of sepsis. He was
extubated on HD#3 as his mental status improved and he has been
maintaining his sats on 50% face mask. Due to a persistent
elevated WBC and MRSA in urine, ID was consulted. A possible
pneumonia was seen on CXR, likely ventilator-associated so
patient was continued on Levofloxacin/Flagyl for 10 day course.
.
3. Leukocytosis: WBC trending down. Likely elevated in setting
of pneumonia and urinary tract infection and also high dose
steroids. C diff was negative
.
4. Acute on chronic Renal Failure: Baseline creatinine of
1.4-1.5 during last admission. Acute renal failure this
admission is likely secondary to acute tubular necrosis during
hypotension in ED. Creatinine trended down to baseline with
gentle hydration.
.
5. Volume overload: EF normal and with normal E/A ratio so no
clear evidence for heart failure. Patient is 9L over hospital
stay. Patient has been gently diurese after ICU stay and is
almost euvolemic on discharge.
.
5. AAA s/p repair: no evidence of infection of graft, vascular
was involved throughout hospital stay
.
6. Parkinsons: continue sinemet, mirapex
.
7. New lacunar infarct:Neurology consult was obtained while
patient was inpatient. It was probably due to small vessel
disease from long standing diabetes. It is not likely related to
his dysphagia. His swallowing problem was probably from
deconditioning and post intubation. His Parkinson disease was
also thought to be stable. Aspirin was started as stroke
prevention. Blood pressure should be controlled at around 130/80
8. HTN: continue Toprol
.
9. DM: Fingerstick well controlled on insulin sliding scale
.
10. Anemia: Baseline hct appears to be 30
.
11. FEN: On thickend nectar liquid and ground solid(aspirate on
thin liquid). Should have repeat speech and swallow in [**2-27**] weeks
to reasssess.
.
12. Prophylaxis: Sc heparin, PPI, bowel regimen
.
13. Access: right internal jugular, should pull this out after
finishing antibiotic. This should not be left longer than that
as it can act as a source of infection.
.
14. Code: full
Medications on Admission:
Meds at home:
* nebs prn
* Toprol XL 100mg qd
* Amiodarone 200mg qd
* Carbidopa/Levodopa 25/100mg tid
* Protonix
* Mirapex 0.5mg tid
* Senna
* Aranesp 25mcg q14 days
* Heparin SQ [**Hospital1 **]
* Lidoderm patch to left shoulder
* MVI
.
Meds on transfer from ICU:
1. Carbidopa-Levodopa (25-100) 1 TAB PO TID
2. Metronidazole 500 mg IV Q8H
3. Metoprolol 2.5 mg IV Q6H
4. Heparin 5000 UNIT SC TID
5. Mirapex *NF* 0.5 mg Oral TID
6. Insulin SC
7. Pantoprazole 40 mg IV Q24H
8. Levofloxacin 250 mg IV Q48H
9. Lorazepam 0.5-1 mg IV Q4H:PRN agitation
10. Vancomycin HCl 1000 mg IV Q48H
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
3. Pramipexole 0.25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed.
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days. Tablet(s)
12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous every eight (8) hours for 4
days.
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
MRSA urosepsis
urinary tract infection
lacunar infarct
Secondary:
Parkinson's disease
hypertension
diabetes
scoliosis
Discharge Condition:
stable
Discharge Instructions:
please return to the hospital or call your doctor if you have
chest pain, shortness of breath, increased sputum production,
abdominal pain, dizziness or if there are any concerns at all
Followup Instructions:
Please call [**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 3070**] to make an appointment
within 2 weeks of discharge
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 5088**]( your
neurologist) to make an appointment soon
Completed by:[**2111-1-29**]
|
[
"331.82",
"585.9",
"996.64",
"041.11",
"V09.0",
"423.8",
"250.00",
"434.91",
"518.81",
"599.0",
"276.2",
"403.91",
"584.5",
"486",
"285.9",
"995.92",
"276.50",
"294.10",
"998.13",
"276.6",
"737.30",
"530.81",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9424, 9497
|
4741, 7589
|
267, 286
|
9660, 9669
|
3133, 4718
|
9904, 10239
|
2430, 2434
|
8221, 9401
|
9518, 9639
|
7615, 8198
|
9693, 9881
|
2449, 3114
|
222, 229
|
314, 1789
|
1811, 2228
|
2244, 2414
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,182
| 123,399
|
42309
|
Discharge summary
|
report
|
Admission Date: [**2116-10-1**] Discharge Date: [**2116-11-24**]
Date of Birth: [**2047-9-10**] Sex: M
Service: SURGERY
Allergies:
XIBROM
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Acute hemorrhagic pancreatitis
Major Surgical or Invasive Procedure:
[**2116-10-2**]- Bedside exploratory laparotomy for abdominal
compartment syndrome
[**2116-10-21**]- Re-exploration with placement of [**Last Name (un) **]
gastrostomy and debridement of subcutaneous tissue, muscle,
and fascia in the suprapubic region; a negative pressure
dressing placed.
[**2116-11-17**] - Uncomplicated placement of a 16 French pigtail
catheter into the right complex air and fluid collection via a
right flank approach.
History of Present Illness:
The patient is a 69-year-old gentleman, primarily Arabic
speaking, who initially presented to St [**Hospital 80150**] Hospital on
[**2116-9-27**] with complaint of abdominal pain rated [**10-19**] in
intensity. Emergency department labs demonstrated a lipase of
6940 and hypokalemia, with ultrasound revealing
pericholecystic fluid and an edematous gallbladder wall with no
evidence of stones. CT of the abdomen and pelvis demonstrated
findings consistent with pancreatitis and peri-pancreatic
fluid/stranding which extended around the right kidney
posterolaterally, around the gallbladder laterally, and aroudn
the stomach anteriorly. No focal abscess was noted. An
electrocardiogram did not reveal any evidence of ischemia. The
patient was admitted to the MICU team during which time his
pancreatic enzymes trended down to a lipase of 243 and an
amylase of 680 and WBC of 9 by hosptial day 4 ([**2116-10-1**]). He
underwent a left thoracentesis on [**2116-9-30**] with removal of
250cc of serosanguinous fluid, however he continued to have
respiratory distress and was electivley intubated in the morning
on the following day ([**2116-10-1**]) due to concern for airway
protection. 20 minutes following intubation he coded with a
witnessed asystolic event requiring epinephrine and 1 amp of
bicarbonate (CPR x5 minutes and pressors x40 minutes). Hct had
dropped from 34 to 21 (the patient's admission Hct was 48).
Troponins were negative x1. His Cr had increased from 0.9 to
>2.5 with severe acidosis and HCO3 of 14 prior to the code. A
Shiley was placed in the right groin at that time and he was
given 3 units of blood and aggressively recuscitated with
crystalloid fluids. Transfer was arranged to [**Hospital1 18**] for further
management.
Past Medical History:
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease
2. Vitamin deficiency
3. Hypertension
4. B12 deficiency anemia
5. Gastritis
6. Benign prostatic hypertrophy
7. Hyperlipidemia
8. Calculus of the kidney
9. Macular degeneration of the retina
10. Cataracts, status post cataract removal with lens
prosthesis
Social History:
The patient lives with his wife. Denies tobacco and alcohol use
or other toxic habits
Family History:
No family history of pancreatitis or pancreatic malignancy
Physical Exam:
Admission Physical Exam:
Vital Signs: T 100.0 HR 117 BP 134/64 RR 17 Pox 97% vent CPAP
[**12-24**]
Blood pressure 130/61 to 164/77, heart rate 52 to
General: intubated, sedated
Head: Atraumatic, normocephalic.
Heart: S1, S2, tachy.
Lungs: Symmetric rise and fall of the chest. No accessory
muscle breathing. Decreased right side
Abdomen: distended, [**Doctor Last Name 352**] coloration right flank, unable to
assess
tenderness as pt sedated. BS hypoactive
Peripheral Vascular: No carotid bruits, no jugular venous
distension, bilateral radial pulses 2+, bilateral dorsalis pedis
pulses 1+
Discharge Physical Exam:
VS: 99.4, 110, 140/80, 16, 96%RA
GEN: Severely deconditioned, but NAD
CV: Sinus tachycardia, S1, S2
Lungs: Diminished breath sounds bilateraly
Abdomen: Abdomen distended. Midline incision with wet-to-dry
dressing covered by ABD pads. LUQ G-tube patent with dry drain
sponge. RLQ JP to dravity drainage into ostomy bag, ostomy
appliance intact. R flank with 16F drainage catheter, site with
dry dressing, suture intact.
GI: Condom catheter to Foley bag.
GU: Flexi-Seal rectal tube
Extr: LUE PICC, dressign c/d/i. Multipodus boots b/l.
Pertinent Results:
SELECTED MICRO:
[**10-2**] Blood cultures x 2 - Pseudomonas
[**10-3**] Sputnum - E.coli, MSSA
[**10-13**] CDiff toxin - negative
[**10-14**] CDiff toxin - negative
[**10-15**] CDiff toxin - negative
[**10-20**] BCx: GNR pansensitive
[**10-21**] HD line Cx: GNR
[**10-21**] OR: Pseudomonas, GNR #2, enterococcus
[**10-22**] BCx, R CVL: GPC clusters
[**10-28**] RP fluid: VRE, pseudomonas
[**2116-11-17**] Abscess: ESCHERICHIA COLI, ENTEROCOCCUS
[**2116-11-18**] PERITONEAL FLUID: PSEUDOMONAS AERUGINOSA
[**2116-11-18**] Urine - negative
[**2116-11-18**] Blood - negative
SELECTED IMAGING:
[**10-2**]: CT Torso: Bilateral pleural effusions. Diffuse infiltrates
of the aerated lungs, particularly in the right middle
lobe.Pancreatitis with extensive inflammation and abdominal free
fluid in the
mesentery, paracolic gutters, retroperitoneum, perisplenic and
perihepatic spaces. ileus. anasarca
[**10-2**] TTE: normal systolic and diastolic function
[**10-9**]: CT Head w/o contrast - 1. No acute intracranial findings.
Mild atrophy 2. Sinus opacification, including complete
opacification of the left mastoid air cells and partial
opacification of the right mastoid air cells.
[**10-10**] RUQ U/S: Sludge; no stones in GB. Not acute cholecystitis.
[**10-14**] CXR: no change, no acute process.
[**10-14**] ncCT C/A/P: worsening of pancreatic inflammation, new fluid
collection lesser sac. worsening of retroperitoneal free fluid.
RLL collapse, interval resolution of pleural effusions
[**10-14**] LENI: no DVT, bilaterally
[**10-15**] CXRport: s/p RIJ HDcath; no ptx, tip at cavoatrial jxn.
[**10-15**] CXR: Mild vascular congestion, no pneumothorax or
effusions, improvement of bibasilar opacities on left
[**10-17**] CXR: Improving aeration left lung base. New L basilar
opacity.
[**10-20**] CXR: L base opacity, most likely atelectasis, can't r/o
PNA\
[**10-24**] LENI: no DVT, bilaterally
[**10-25**] CT abd: numerous abdominal abscesses, air pockets in R
retroperitoneum
[**10-25**] CT chest: no evidence of PE, possible mucus plug in R lung
[**11-13**] CT abd/pelvis: interval increase in size of retroperitoneal
fluid collection
[**2116-11-18**] CXR: Low lung volumes, with bilateral pleural effusions
and atelectasis. No convincing evidence of pneumonia.
Brief Hospital Course:
Mr. [**Known lastname **] is a 69 year old male who was transferred to [**Hospital1 18**]
from [**Hospital2 **] [**Hospital3 6783**] Hospital with acute hemorrhagic pancreatitis
complicated by an episode of asystolic arrest, respiratory
failure, and acute renal failure. The patient was transferred to
the SICU overnight in an intubated and sedated state.
Neuro: Initially sedated on a propofol drip at time of transfer,
no neuro exam was possible after the OH arrest. Over the course
of the hospitalization sedation was continued when necessary for
intubation or operations; as much as possible sedation was held.
He underwent Head CT on [**10-9**] demonstrating no acute intracranial
process. Mental status gradually returned. Family remained at
bedside during the entire hospitalization and reported a gradual
return of personality and memory. At time of discharge he is
receiving intermittent IV dilaudid for pain, which is well
controlled. He is alert and oriented x3 and interacts
appropriately with family and staff.
Cardiovascular: Pt had intermittent pressor requirements during
the first part of his hospital stay, and again transiently after
his operative washout and abdominal closure. After weaning all
pressors, he remained persistently tachycardic. This was
initially not treated as it was felt it might be an indicator of
pain or fever. However as he became afebrile and mental status
improved he remained tachycardic. Metoprolol was started and
titrated up as blood pressure tolerated to maintain HR <100.
Pulm: Pt had been electively intubated prior to transfer to
[**Hospital1 18**]; at time of transfer he was maintained on the vent with
ARDS protocol. The vent was weaned as tolerating; initially CVVH
was used to assist in diuresis to improve respiratory status and
bronchoscopy successfully removed secretions from both lungs. He
was extubated on [**10-16**]. He was reintubated for abdominal washout
and closure in the operating room on [**10-21**]; he remained
intubated for a day post-operatively and then was successfully
extubated. He did well for several days, then became
increasingly tachypneic, with blood gasses demonstrating
respiratory acidosis. He was reintubated on [**10-27**] and
bronchoscopy cleared large mucus plugs from the right upper
lobe. A tracheostomy was considered, however after bronch he
improved. He was successfully extubated on [**11-1**] and remained
extubated for the rest of his hospital stay. At discharge he is
comfortable on room air with no oxygen requirements.
FEN/GI:
# Severe pancreatitis with abdominal compartment syndrome: Pt
was initially admitted to [**Hospital6 23316**] with lipase of
6940. At time of transfer, he had lactic acid of 3.8 and lipase
of 243 with CT scan demonstrating severe pancreatitis. On
admission physical exam, his abdomen was markedly distended and
tense. Over the next 24 hours he became progressively more
difficult to ventilate and hypotensive despite pressors. Bladder
pressures rose to 28 and a bedside laparotomy was performed,
evacuating app. 300cc intra-abdominal fluid. The abdomen was
left open at that point. A [**State 19827**] patch was placed on [**10-5**] and
gradually tightened over the next several days. On [**2116-10-21**] he
was taken to the operating room for washout and fascial closure;
the inferior portion was found to have necrotic fascia and
muscle and this was left open. A vac dressing was applied. This
was changed every three days. At the first dressing change, a JP
drain was manually inserted into the retroperitoneum to drain
the fluid collection seen on CT scan. This JP has put out
approximately 200-300cc dark, murky fluid since placement. On
[**11-11**], the vac dressing was removed; at discharge the wound is
maintained with [**Hospital1 **] wet-to-dry dressing changes and is healing
well. Due to concern over continued fevers and high output from
the JP, a repeat abdominal CT was obtained on [**11-13**] and showed
increase in size of the large right retroperitoneal abscess.
Interventional radiology placed a 16F pigtail catheter on
[**2116-11-17**]; this drain is to gravity and puts out dark, murky fluid
similar in appearance to the JP output. Both drains remain in
place at time of discharge.
# Nutrition: Pt has been maintained on tube feeds for the
majority of the hospital stay, initially via dobhoff. A g-tube
was placed intraoperatively on [**10-21**] which was then used for
continued feeding. Complicated by continued diarrhea requiring
flexiseal placement. Multiple c. diff assays were sent at
several points throughout the stay; they have all been negative.
Nutrition was consulted and followed along throughout the
course. He was started on pancreatic enzyme supplementation and
tincture of opium for the diarrhea. Tube feeds were eventually
cycled and changed to a high fiber formula. Diarrhea is not
entirely resolved at discharge, however it is improved. He is
also taking a regular diet by mouth; intake so far has been
minimal but with family encouragement he is able to take small
amounts. He is discharged on cycled tube feeds with the goal of
slowly transitioning back to a regular diet during his
rehabilitation process.
GU: He was in ARF at time of admission; an HD line had been
placed at [**Hospital3 75037**] in preparation for starting dialysis. Renal
consult service followed the pt throughout his hospital stay.
CVVH was initiated on HD2. He was initially ran positive as he
was requiring multiple fluid boluses to maintain BP. By HD 10,
he was clinically improving and CVVH was continued to take
volume off and assist with diuresis. He was at that point ~12L
positive for the hospital stay and fluid was removed until he
was net even. His urine output continued to improve along with
improvement in his serum BUN/Cr. At time of discharge he is
urinating without difficulty; he is receiving occasional doses
of Lasix for further diuresis based on clinical volume status
but overall maintaining his fluid balance without assistance.
ID: Initial blood cultures grew pseudomonas and the patient was
started on zosyn; however he became thrombocytopenic and so was
changed to nafcillin. He began having multiple loose bowel
movements and on [**10-13**] PO vancomycin and IV flagyl were
empirically started for treatment for c. diff. However multiple
c. diff studies were negative and these were taken off on [**10-15**].
He remained persistently febrile and infectious disease was
consulted for management of antibiotic regimen. The
retroperitoneal fluid from the JP drain grew VRE and he was
started on linezolid. The IR drain culture grew both
enterococcus and pan-sensitive e.coli; he is on cipro for the
e.coli. At time of discharge he has been afebrile >48 hours, and
he is on linezolid for VRE and cipro for e.coli. He should
complete a total of 14 additional days of both medications after
discharge.
Heme: He required multiple blood transfusions over the course of
his hospital stay for downtrending hematocrit; the last
transfusion was [**2116-11-16**] and he responded appropriately. Since
then he has been hemodynamically stable. Of note, at admission
he became thrombocytopenic. Heparin was help and HIT antibodies
were sent; heme/onc was consulted and zosyn was held as well.
HIT panel was negative, and heparin was restarted. Platelets
began to improve and remained stable for the rest of the
hospital stay. To address the downtrending hematocrit he was
also started on iron supplementation and B12 shots.
Prophylaxis: Pt was maintained on heparin except for a brief
period where it was held prior to HIT results. He also wore
lower extremity compression devices. Physical therapy and
occupational therapy worked with him throughout the hospital
stay to address the deconditioning that accompanied this very
prolonged hospital stay.
At time of discharge, Mr. [**Known lastname **] is in stable condition. His
pancreatitis has resolved and he is maintained on tube feeds
with supplementation of pancreatic enzymes. Respiratory failure
and renal failure have resolved. He is hemodynamically stable
and afebrile. His acute needs at time of discharge are for
extensive rehabilitation, including physical and occupational
therapy and nutrition. He is discharged to an acute care
facility for wound care, drain monitoring, physical/occupational
therapy, and nutritional optimization. He will follow up as
scheduled, in 2 week, with Dr. [**First Name (STitle) **].
Medications on Admission:
prilosec 20', timolol left eye', Vit D', cyanocobalamin
injection qmonth, FeSulfate 200', systane ophthalmic solution
bilat'''
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
2. ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for pain.
3. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID (3 times a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
5. Systane 0.4-0.3 % Drops Sig: One (1) Ophthalmic [**Hospital1 **] (2 times
a day).
6. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily): Left eye only.
8. Thera Tears 0.25 % Drops Sig: One (1) Ophthalmic QID (4
times a day).
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
10. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. opium tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q6H
(every 6 hours).
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
14. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks. Tablet(s)
15. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 weeks.
16. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
17. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
18. lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed for anxiety.
19. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection once a month.
20. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea: Stop if more distended,
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
1. Acute Pancreatitis
2. Abdominal compartment syndrome
3. Acute renal failure
4. Acute respiratory distress syndrome
5. Bacteremia
6. Anemia of chronic disease
7. Intraperitoneal fluid collections
8. Chronic diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with significant assistance ([**Doctor Last Name 2598**]
lift) to chair or wheelchair.
Discharge Instructions:
You have been treated at [**Hospital1 18**] for severe pancreatitis
complicated by multi-organ failure. Please continue to take the
medications listed in your discharge paperwork. Please follow up
with physical therapy and rehabilitation as directed by the
rehab facility. You have a follow-up appointment scheduled with
Dr. [**First Name (STitle) **].
Continue to take Creon and Tincture of Opium with meals;
increase your food intake slowly over the next few weeks. Once
you are able to tolerate a wider variety of foods you will be
able to decrease your tube feeds. This will be coordinated by
Dr. [**First Name (STitle) **] or your primary care provider.
Incision care will be provided by the rehab center. Specific
wound care instructions are included in your discharge
paperwork.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2116-12-9**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 2998**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Completed by:[**2116-11-24**]
|
[
"560.1",
"995.92",
"570",
"682.2",
"275.41",
"934.1",
"787.91",
"729.73",
"272.1",
"041.49",
"276.2",
"E912",
"287.5",
"038.8",
"785.52",
"511.9",
"V09.80",
"567.38",
"789.59",
"041.04",
"518.81",
"577.0",
"348.31",
"041.7",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"83.45",
"96.72",
"38.97",
"99.15",
"39.95",
"54.19",
"33.24",
"43.19",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17142, 17216
|
6533, 14981
|
298, 743
|
17478, 17478
|
4247, 6510
|
19183, 19545
|
2992, 3052
|
15158, 17119
|
17237, 17457
|
15007, 15135
|
17701, 19160
|
3092, 3667
|
228, 260
|
771, 2525
|
17493, 17677
|
2570, 2871
|
2887, 2976
|
3692, 4228
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,697
| 162,482
|
18323
|
Discharge summary
|
report
|
Admission Date: [**2128-4-13**] Discharge Date: [**2128-4-17**]
Date of Birth: [**2053-2-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic coronary artery disease.
Major Surgical or Invasive Procedure:
[**2128-4-13**] - Coronary artery bypass grafting to four vessels. (Left
internal mammary artery->left anterior descending artery,
Saphenous veiin graft(SVG)->Obtuse marginal artery,
SVG->Diagonal artery, SVG->Posterior left ventricular artery).
History of Present Illness:
Mr. [**Known lastname 12130**] is a 75-year-old male who had an inferior wall MI on
[**2128-1-19**]. Cardiac catheterization performed on
[**2128-1-20**] revealed severe
three-vessel disease along with left main 50% stenosis. His
right coronary artery was also 100% occluded and subsequently
stented with good result. He is currently asymptomatic, but due
to his severe coronary artery disease, he is referred to me for
a bypass surgery. In addition to his cardiac catheterization,
he had a cardiac echocardiogram on [**2127-2-18**], which
revealed an EF of 35-40%, mild left ventricular hypertrophy, no
aortic stenosis or insufficiency, trace mitral regurgitation, 1+
tricuspid regurgitation, trace pulmonic insufficiency, mild left
atrial enlargement, and mild dilatation of his ascending aorta
at 4.0 cm.
Past Medical History:
coronary artery disease, inferior wall myocardial infarction
with bare metal stent to his right coronar artery,
hypercholesterolemia, hypertension, prostate cancer, status post
seed implantation, benign prostatic hypertrophy, gout. He is
status post hernia repair and status post melanoma and basal
cell resection.
Social History:
His occupation, he is a retired police officer. His last dental
examination was approximately six months ago. He quit smoking
43 years ago and rarely drinks alcohol.
Family History:
His family history is negative.
Physical Exam:
On physical exam, his pulse is 68. Respirations are 14. Blood
pressure is 130/78. His height is 5'[**29**]" and he weighs 210
pounds. Generally, he appears to be a well-developed and well
nourished male, in no acute distress. His skin is warm, dry,
and intact. HEENT examination reveals extraocular movements are
intact. Pupils are equal, round, and reactive to light.
Normocephalic and atraumatic head. His neck is supple with full
range of motion without any jugular venous distention. His
lungs are clear to
auscultation bilaterally. Cardiac exam reveals a regular rate
and rhythm without any murmurs. Abdomen is soft, nontender, and
nondistended with positive bowel sounds with healed incision on
his right side. Extremities are warm and well perfused without
any edema. There are superficial varicosities. Neurologically,
he is grossly intact, alert and oriented x3.
Pertinent Results:
[**2128-4-13**] ECHO
PRE-BYPASS: The left atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. Overall left
ventricular systolic function is midly depressed(LVEF40 to 45%).
There is mild to moderate hypokinesis of the LV apex. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The left ventricular inflow pattern suggests
impaired relaxation. There is no pericardial effusion.
POST-BYPASS: The patient is in sinus rhythm and on an infusion
of phenylephrine. Mild improvement in the preivously hypokinetic
areas with LVEF of 45% to 50%. Right ventricular function is
preserved. The aorta is intact. Apical hypokinesis remains. PA
catheter is in good postion. The remainder of the examination is
unchanged.
[**2128-4-16**] 08:55AM BLOOD WBC-9.6 RBC-2.83* Hgb-8.7* Hct-25.3*
MCV-89 MCH-30.8 MCHC-34.5 RDW-14.7 Plt Ct-114*
[**2128-4-13**] 04:46PM BLOOD PT-15.5* PTT-36.0* INR(PT)-1.4*
[**2128-4-16**] 08:55AM BLOOD Glucose-138* UreaN-34* Creat-1.0 Na-133
K-4.2 Cl-100 HCO3-31 AnGap-6*
[**Known lastname **],[**Known firstname **] [**Medical Record Number 50493**] M 75 [**2053-2-13**]
Radiology Report CHEST (PA & LAT) Study Date of [**2128-4-16**] 5:58 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2128-4-16**] 5:58 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 50494**]
Reason: f/u atx, effusions
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
f/u atx, effusions
Final Report
TWO VIEW RADIOGRAPH
COMPARISON: [**2128-4-15**].
INDICATION: Status post coronary artery bypass surgery.
FINDINGS: Cardiac silhouette remains enlarged. Mediastinal
contours are
stable in the postoperative period. Left lower lobe atelectasis
and
small-to-moderate left pleural effusion are similar in
appearance, but right
retrocardiac opacity and small right pleural effusion have
nearly resolved.
Retrosternal gas in the lateral view is likely a normal
postoperative finding,
considering the recent sternotomy.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SAT [**2128-4-17**] 8:30 AM
Brief Hospital Course:
Mr. [**Known lastname 12130**] was admitted to the [**Hospital1 18**] on [**2128-4-13**] for surgical
management of his coronary artery disease. He was taken directly
to the operating room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. He later awoke neurologically intact and was
extubated. He was transfused 1 unit of packed red blood cells
for postoperative anemia. He remained on low dose phenylephrine
for hypotension but ultimately was weaned from this by
postoperative day two. He was then transferred to the step down
unit for further recovery. Mr. [**Known lastname 12130**] was gently diuresed
towards his preoperative weight. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. His epicardial pacing wires were discontinued on
postoperative day three and he was discharged to home in stable
condition on postoperative day four.
Medications on Admission:
ASA 325', Plavix 75', Lopressor 50", Zocor 40', Flomax 0.4'
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
CAD s/p CABG
Myocardial infraction
Hyperlipidemia
Hypertension
Prostate cancer
Benign prostate hypertrophy
Gout
PTCA/Stenting in past
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 8579**] in 2 weeks.
Please follow-up with Dr. [**Last Name (STitle) 8522**] in [**2-24**] weeks. [**Telephone/Fax (1) 8577**]
Please call all providers for appointments.
Completed by:[**2128-4-17**]
|
[
"274.9",
"V10.46",
"412",
"285.9",
"458.29",
"401.9",
"272.4",
"511.9",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
8012, 8070
|
5607, 6631
|
359, 607
|
8248, 8257
|
2947, 4655
|
9055, 9397
|
1991, 2025
|
6741, 7989
|
4695, 4725
|
8091, 8227
|
6657, 6718
|
8281, 9032
|
2040, 2928
|
282, 321
|
4757, 5584
|
635, 1449
|
1471, 1789
|
1805, 1975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,536
| 131,003
|
33377
|
Discharge summary
|
report
|
Admission Date: [**2101-4-3**] Discharge Date: [**2101-4-16**]
Date of Birth: [**2052-4-8**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
hyponatremia, n/v
Major Surgical or Invasive Procedure:
plasmaphoresis with hemodialysis
temporary HD/plasmapheresis catheter placement
History of Present Illness:
48 y/o F with h/o sjogrens, cryoglobulinemia, transferred from
[**Location (un) **] [**Location (un) **] with hyponatremia to 112. Felt poorly for
several weeks feeling weak, tired. Started vomiting (non-bloody,
non-bilious) on wednesday with decreased apetite, nausea. No
associated headache, abdominal pain, diarrhea, or fevers.
However, also did have a non-productive cough with episode of
bronchitis 5 weeks ago. She reports no similar prior episodes
like this. Of note ,symptoms worsened after starting a trial of
doxcycline on wednesday. She stopped after one day due to the
N/V. No associated rash.
She has a long history of sjogrens for which she has chronic dry
eyes and dry mouth. She also has a history of cryoglubinemia for
which she required cytoxan and plasmapheresis in [**2092**]. It was
diagnosed after her toe went numb. She denies N/V at that time
and reports no kidney involvement as far as she knows. And she
has had no further problems since then. She says she was told
her Na runs low, but she does not know her baseline levels. she
went to her PCP where she was found to have a Na of 117, so she
was sent to [**Hospital3 **]. There, her Na was 112, Cr 1.9,
bicarb 19, k 4.3. Rec'd 800cc NS and transferred to [**Hospital1 18**]. Of
note ,patient has never been here. Normally seen at [**Hospital **],
where her PCP [**Last Name (NamePattern4) **]. [**Name10 (NameIs) 3081**] she admits she has never need
hospital admission before. Even during her cytoxan treatments
for cryoglobulinemia it was all outpatient.
Of note, she reports being tested for hepb/c and was negative.
Denies HIV risk factors. no history of thyroid disease or
adrenal insufficiency that she knows of.
In ER here, na 113, bicarb 17, cr 1.8. Given 3L NS in ER.
Zofran 4mg IV. U/A with 21-50 RBC, large blood, 500 protein;
serum osm 252, urine osm 245, urine Na 10
Admit to medicine
ROS: on arrival pt denies abd pain, no current n/v, f/c. no
headache. +dry mouth, dry eyes. still feels mildly dehydrated,
but at her baseline. denies changes in her urine. + decrease in
apetite, fatigue over last several weeks. no rash, bruising,
bleeding. + numbness in her left pinky that was transient, now
gone. no cp, sob, lh, dizziness
Past Medical History:
sjogren's disease
h/o cryoglobulinemia
Social History:
denies tobacco, occ ETOH. no IVDU. denies HIV risk factors. no
tattoos. Works at a private high school. Irish descent, lives in
[**Location 246**] now.
Family History:
no fh of auto-immune disease. brother with gout
Physical Exam:
98.3, BP 134/70, HR 79, RR 16, 94% RA, 134 lb
gen- awake, alert, pleasant, NAD
heent- dry eyes, mouth. + swollen 2-3 cm, non-tender salivary
glands b/l at angle of jaw b/l.
neck- supple. no add'l swollen glands/lad
pulm- CTA b/l. no r/r/w
cv- RRR. no m/r/g
abd- soft, NT/ND, NABS, no bruits auscultated
ext- no rash, no edema, warm, 2+ pulses
neuro- alert and oriented x 3. CNII-XII intact. motor strength
full. normal sensation
skin- no hyperpigmentation, no jaundice
affect- normal
Pertinent Results:
admission labs:
-------------
[**2101-4-2**] 09:50PM WBC-6.6 RBC-3.12* HGB-9.8* HCT-25.8* MCV-83
MCH-31.4 MCHC-37.8* RDW-13.1
[**2101-4-2**] 09:50PM NEUTS-83.1* LYMPHS-9.1* MONOS-6.5 EOS-1.3
BASOS-0.1
[**2101-4-2**] 09:50PM PT-12.8 PTT-32.5 INR(PT)-1.1
[**2101-4-2**] 09:50PM OSMOLAL-252*
[**2101-4-2**] 09:50PM PHOSPHATE-4.9* MAGNESIUM-2.1
[**2101-4-2**] 09:50PM ALT(SGPT)-13 AST(SGOT)-19 ALK PHOS-59
AMYLASE-38 TOT BILI-0.7
[**2101-4-2**] 09:50PM GLUCOSE-86 UREA N-41* CREAT-1.8* SODIUM-113*
POTASSIUM-4.3 CHLORIDE-88* TOTAL CO2-17* ANION GAP-12
[**2101-4-3**] 12:30AM URINE RBC-21-50* WBC-[**2-23**] BACTERIA-FEW
YEAST-NONE EPI-1
[**2101-4-3**] 12:30AM URINE HYALINE-[**2-23**]*
[**2101-4-3**] 12:30AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2101-4-3**] 12:30AM URINE OSMOLAL-245
[**2101-4-3**] 12:30AM URINE HOURS-RANDOM SODIUM-10 POTASSIUM-39
CHLORIDE-11
Reports-
EKG- w/ NSR, normal axis, TWI V1. No acute ST changes
CXR: CHEST, PA AND LATERAL: The cardiac and mediastinal contours
are within normal limits. The lungs are clear. There are no
pleural effusions. Pulmonary vasculature is within normal
limits. There is slight widening of the AP diameter of the chest
which may indicate underlying obstructive lung disease.
IMPRESSION: No acute cardiopulmonary disease.
--------------
CT ABDOMEN W/O CONTRAST [**2101-4-14**] 9:18 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: eval for hematoma from prior renal biopsy
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with cryo, resolving ARF on plasmaphoresis
with worsening anemia.
REASON FOR THIS EXAMINATION:
eval for hematoma from prior renal biopsy
CONTRAINDICATIONS for IV CONTRAST: ARF;ARF
INDICATION: 49-year-old woman with acute renal failure on
plasmapheresis and worsening anemia. Please evaluate for
hematoma from prior renal biopsy.
TECHNIQUE: Axial MDCT images were obtained from lung bases to
pubic symphysis with no IV or oral contrast administration.
Sagittal and coronal reformatted images were then obtained.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized portion of
the lung bases demonstrate moderate bilateral pleural effusions.
Dependent atelectatic changes are also noted at both lung bases.
The visualized part of the heart and great vessels appear
normal. There are CT signs of anemia with relative increased
density of the septum compared to the intraventricular contents.
The liver, spleen, and the adrenal glands are normal. The
gallbladder demonstrates diffuse wall thickening. The kidneys
demonstrate normal appearance with no stone, mass, or
hydronephrosis. There is a 1.3 x 2.5 x 2.1 cm perinephric
hematoma around the left kidney. Small subcapsular hematoma is
also identified. The stomach, duodenum, loops of small bowel and
large bowel have normal appearance. No free or fluid is noted
within the abdomen.
CT OF THE PELVIS WITHOUT IV CONTRAST: The urinary bladder,
distal ureters, uterus and adnexa, and rectum and sigmoid colon
have normal appearance. Small amount of free fluid is noted
within the pelvis.
BONE WINDOWS: No concerning lytic or sclerotic lesion is
identified.
IMPRESSION:
1. Small perinephric hematoma measuring approximately 1.3 x 2.5
x 2.1 cm and tiny subcapsular hematoma. These are are not
uncommon after uncomplicated renal biopsy and do not explain the
patient's severe anemia.
2. Diffuse gallbladder wall thickening with no evidence of
cholecystitis.
3. Moderate bilateral pleural effusion and dependent atelectatic
changes at both lung bases.
4. Small amount of fluid is noted within the pelvis consistent
with ascites.
5. CT signs of anemia.
---------------
SPECIMEN SUBMITTED: Native renal biopsy.
Procedure date Tissue received Report Date Diagnosed
by
[**2101-4-4**] [**2101-4-4**] [**2101-4-12**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/mrr??????
DIAGNOSIS:
Renal biopsy, needle: Cryoglobulinemic nephropathy, see note.
Note:
Light Microscopy: The specimen consists of renal cortex,
containing approximately 27 glomeruli, of which 4 are globally
sclerotic. The remainder show varying degrees of endocapillary
proliferation and double contour formation accompanied by
numerous PAS positive "hyalin thrombi". No cellular crescents
are noted. CD68 highlights many macrophages in the glomeruli.
There is mild interstitial fibrosis and tubular atrophy. Mild
chronic inflammation accompanies the scarring. Intact
tubulointerstitium shows minimal inflammation.
Arteries show mild intimal fibroplasia.
Arterioles show mild mural thickening, with some hyaline change.
Occasional arterioles show "hyalin thrombi", some with an
associated inflammatory vasculitis.
Immunofluorescence: The specimen consists of renal cortex only,
containing approximately 8 glomeruli, of which 1 is globally
sclerotic. There is intraluminal "thrombus" and granular
peripheral capillary loop (and to a less extent mesangial)
staining for IgG (2+), IgA (1+), IgM (2+), C3 (3+), kappa (3+)
and lambda (1+). Vascular positivity is seen for IgM and fibrin,
but not IgG. C1q is negative.
Albumin is non-contributory.
Electron microscopy: Findings will be issued in an addendum.
Comment: The amount of "hyalin thrombi" present is striking.
Focal vasculitis is seen.
ELECTRON MICROSCOPY (C-4849):
Fine structural studies of three similar and representative
glomeruli reveal widespread foot process effacement. No
subepithelial deposits are noted. Endocapillary cellularity is
increased, and widespread mesangial interposition is noted.
Subendothelial/endocapillary/mesangial electron dense deposits
are easily identified, and most show cryoglobulin type
substructure. Only focal areas of subendothelial electron
lucency, in association with the cryoglobulin type deposits, are
seen. Many capillaries show prominent cryoglobulin "thrombi".
Rare fibrin tactoids are seen in association with the deposits.
No definite tubuloreticular structures are noted.
A vessel wall shows some granular deposition with a vague
substruture, as well as electron dense material suggestive of
hyalin.
These findings support the diagnosis of Cryoglobulinemic
nephropathy. The amount of deposition is striking.
Electron microscopy added by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/is??????
Date: [**2101-4-15**]
Clinical: Sjogren's syndrome. ARF; SCr=3.1. Positive
cryoglobulin and RF factor. Low C3 and C4. Hepatitis B and C
negative. [**Doctor First Name **] positive; dsDNA negative.
Gross:
Received are needle core(s) of light brown tissue. The
specimen is viewed in the dissecting microscope, identified as
renal by Dr. [**First Name4 (NamePattern1) 3535**] [**Last Name (NamePattern1) **], and divided into material for light
(formalin) and electron microscopy and immunofluorescence
studies.
PAS and [**Doctor Last Name **] stains were done to evaluate basement membranes -
Masson's trichrome stains were done to evaluate interstitial
fibrosis.
Brief Hospital Course:
The patient was transferred from [**Location (un) **] [**Location (un) 1459**] for critical
hyponatremia and acute renal failure. She was initially accepted
on the floor, and was then transferred to the MICU, where she
was started on hypertonic saline with slow correction of her
hyponatremia. Due to hyperkalemia, she was also started on
hemodialysis. She received a renal biopsy consistent with
cryoglobulinemia, and was started on plasmapheresis and high
dose steroids. She had a good response to therapy, limiting her
to only two runs of dialysis, and a short course of
plasmapheresis. She was subsequently maintained on prednisone
with resolution of her acute renal failure. After a discussion
between nephrology and the patient, she was started on rituximab
for her cryoglobulinemia rather than cyclophosphamide given her
prior treatment for her index presentation of cryoglobulinemia
several years ago and the risk of cumulative toxicity. She
received her first dose during this hospitalization, and is
scheduled for three additional doses over the next three weeks
as an outpatient. She was discharged with normal serum
creatinine, normal urine output, on prednisone, and appropriate
opportunistic infection prophylaxis.
Medications on Admission:
doxycycline- stopped
multivitamins
melatonin
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
Disp:*120 Troche(s)* Refills:*0*
2. Calcium Carbonate-Vitamin D2 500-200 mg-unit Tablet Sig: One
(1) Tablet PO twice a day: Take between meals.
Disp:*60 Tablet(s)* Refills:*0*
3. Pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday): Take while on
prednisone.
Disp:*12 Tablet(s)* Refills:*0*
5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*45 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Take while on
prednisone.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. Outpatient Lab Work
[**2101-4-19**] Draw CBC with differential, basic metabolic panel,
phosphorus, calcium. Please have results faxed to Dr. [**First Name (STitle) 4102**]
[**Name (STitle) 4090**] Office ([**Telephone/Fax (1) 817**], Fax ([**Telephone/Fax (1) 77460**].
Discharge Disposition:
Home
Discharge Diagnosis:
Cryoglobulinemia
Acute renal failure, resolved
Sjogren's disease
Anemia
Hyponatremia, resolved
Discharge Condition:
stable
Discharge Instructions:
You were admitted with cryoglobulinemia that resulted in kidney
damage. You will need careful follow up with nephrology upon
discharge (see below). Please call your PCP or return to the ER
if you develop any numbness, weakness, or coolness of your
extremities.
Followup Instructions:
You will receive a call from the nephrology fellow for a follow
up appointment.
Provider: [**Name Initial (NameIs) 455**] 4-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2101-4-21**] 10:00
Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2101-5-4**] 3:00
|
[
"276.7",
"584.9",
"583.9",
"276.1",
"710.2",
"285.9",
"273.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"55.23",
"38.95",
"99.71"
] |
icd9pcs
|
[
[
[]
]
] |
13139, 13145
|
10505, 11735
|
284, 366
|
13284, 13293
|
3437, 3437
|
13604, 13951
|
2868, 2917
|
11830, 13116
|
5003, 5087
|
13166, 13263
|
11761, 11807
|
13317, 13581
|
2932, 3418
|
227, 246
|
5116, 10482
|
394, 2621
|
3453, 4966
|
2643, 2683
|
2699, 2852
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,267
| 160,350
|
41862
|
Discharge summary
|
report
|
Admission Date: [**2172-12-18**] Discharge Date: [**2172-12-31**]
Date of Birth: [**2097-6-21**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
ruptured AAA
Major Surgical or Invasive Procedure:
[**2172-12-18**]: EVAR with SMA stenting, exploratory laparotomy
[**2172-12-19**]: Abdominal washout
[**2172-12-21**]: Exploratory laparotomy, cholecystectomy, G-J tube
placement
[**2172-12-25**]: Abdominal fascial closure
History of Present Illness:
The patient is a 75-year-old woman with no previously known
documentation of an abdominal aortic aneurysm, who was awoken
with abdominal pain and was later for found to be somnolent by
her spouse. She was brought to an outside hospital emergency
room where a noncontrast CT scan confirmed the diagnosis of a
large abdominal aortic aneurysm with suspicion of rupture. She
was transferred to
our facility with stable blood pressure, responsive but
somnolent. She underwent a contrast CT scan upon arrival here
which demonstrated a large infrarenal abdominal aortic aneurysm
with clear evidence of rupture. She therefore presents to the
operating room for endovascular repair of her aneurysm.
Past Medical History:
PMH: hypertension, hypercholesterolemia
PSH: per family no known abdominal operations
Social History:
lives with husband
Family History:
noncontributory
Physical Exam:
On initial evaluation:
SBP 117/60mmHg
Drowsy but responding to commands
Lungs: Clear bilateral
Heart: RRR
Abdomen: Pulsatile mass Soft
Pulses: No femoral pulse palpable on right; Weakly palpable on
Left; DP and PT not palpable
Pertinent Results:
[**2172-12-18**] 05:00PM BLOOD WBC-9.6 RBC-2.00* Hgb-6.0* Hct-19.1*
MCV-96 MCH-30.1 MCHC-31.4 RDW-14.1 Plt Ct-174
[**2172-12-19**] 06:23AM BLOOD WBC-3.1* RBC-3.46* Hgb-10.3* Hct-29.3*
MCV-85 MCH-29.9 MCHC-35.2* RDW-14.8 Plt Ct-69*
[**2172-12-21**] 01:35PM BLOOD WBC-6.6 RBC-3.10* Hgb-9.0* Hct-26.4*
MCV-85 MCH-29.1 MCHC-34.2 RDW-16.5* Plt Ct-90*#
[**2172-12-24**] 01:30PM BLOOD WBC-8.4 RBC-3.49* Hgb-10.3* Hct-30.6*
MCV-88 MCH-29.4 MCHC-33.6 RDW-17.8* Plt Ct-48*
[**2172-12-29**] 01:32AM BLOOD WBC-17.1* RBC-2.89* Hgb-8.7* Hct-25.9*
MCV-90 MCH-30.3 MCHC-33.7 RDW-17.5* Plt Ct-126*
[**2172-12-18**] 05:00PM BLOOD PT-13.8* PTT-31.6 INR(PT)-1.2*
[**2172-12-30**] 04:57AM BLOOD PT-16.1* PTT-24.6* INR(PT)-1.5*
[**2172-12-18**] 07:15PM BLOOD Glucose-295* UreaN-34* Creat-1.8* Na-149*
K-5.5* Cl-119* HCO3-9* AnGap-27*
[**2172-12-24**] 02:08AM BLOOD Glucose-94 UreaN-27* Creat-1.7* Na-138
K-4.7 Cl-100 HCO3-26 AnGap-17
[**2172-12-30**] 04:57AM BLOOD Glucose-96 UreaN-80* Creat-3.3*# Na-136
K-4.5 Cl-96 HCO3-20* AnGap-25*
[**2172-12-18**] 08:36PM BLOOD ALT-195* AST-194* CK(CPK)-150 AlkPhos-35
TotBili-0.3
[**2172-12-19**] 01:27PM BLOOD ALT-829* AST-1717* LD(LDH)-2601*
AlkPhos-32* Amylase-757* TotBili-0.9
[**2172-12-21**] 01:28AM BLOOD ALT-264* AST-1013* LD(LDH)-1874*
CK(CPK)-1803* AlkPhos-56 Amylase-313* TotBili-1.2
[**2172-12-30**] 04:57AM BLOOD ALT-15 AST-141* AlkPhos-108* Amylase-53
TotBili-20.3*
[**2172-12-29**] 01:32AM BLOOD ALT-11 AST-104* AlkPhos-66 Amylase-55
TotBili-16.9*
[**2172-12-19**] 10:14AM BLOOD Lipase-2139*
[**2172-12-19**] 01:27PM BLOOD Lipase-2630*
[**2172-12-21**] 01:28AM BLOOD Lipase-508*
[**2172-12-22**] 01:57AM BLOOD Lipase-74*
[**2172-12-25**] 01:53AM BLOOD Lipase-19
[**2172-12-30**] 04:57AM BLOOD Lipase-57
[**2172-12-18**] 08:36PM BLOOD CK-MB-8 cTropnT-0.06*
[**2172-12-19**] 03:26AM BLOOD CK-MB-46* MB Indx-5.1 cTropnT-0.23*
[**2172-12-19**] 10:14AM BLOOD CK-MB-42* MB Indx-3.8 cTropnT-0.30*
[**2172-12-22**] 02:23PM BLOOD cTropnT-2.37*
Imaging:
[**2172-12-29**] HIDA:
Minimal uptake within the liver consistent with cholestasis.
[**2172-12-27**] RUQ U/S:
IMPRESSION:
1. Heterogeneous left hepatic echotexture.
2. Patent hepatic arteries, portal veins, and hepatic veins.
However segmental and subsegmental arterial patency cannot be
established on current exam, particularly in the setting of
segmental left hepatic infarct on recent CT.
[**2172-12-27**] CT torso:
IMPRESSION:
1. Left lateral segment hepatic infarcts.
2. Multiple small splenic infarcts.
3. Suspected type 2 endoleak of abdominal aneurysm repair.
4. New large right pelvic hematoma extending to the groin.
5. Stable retroperitoneal hematoma.
6. There is no specific evidence of a bile leak.
[**2172-12-27**] Head CT:
IMPRESSION:
1. Multiple new areas of hypoattenuation within the right
occipital lobe and left cerebellum concerning for subacute
embolic infarcts.
2. Local mass effect though no evidence of subfalcine or
transtentorial
herniation.
3. No evidence of hemorrhage.
4. No evidence of abscess formation.
[**12-23**] ECHO:
IMPRESSION: EXTREMELY suboptimal image quality. Cannot exclude
focal wall motion abnormality. Overall left ventricular systolic
function is probably preserved. Right ventricular function
appears preserved. No obvious valvular pathology, but cannot be
entirely excluded on the basis of this study
[**12-18**] CT abd:
IMPRESSION:
Ruptured abdominal aortic aneurysm, as described above, with
hemorrhage seen predominantly in the retroperitoneum with some
extension into the peritoneal cavity extending down into the
pelvis. The left kidney appears displaced and hypoperfused.
Medialized calcification at the inferior portion of the aneurysm
with mural thrombus raises the question of prior chronic
dissection
Brief Hospital Course:
The patient was admitted to the vascular surgery service after
endovascular repair of her ruptured AAA.
Neuro: The patient was intubated and sedated throughout her
hospital course post-operatively. Neurological exams showed
motor deficits in bilateral lower extremities. Neurology was
consulted and prognosis for full neurological recovery was
deemed very limited. The expected neurological outcome is
paraplegia, severly impaired if not absent sensation below the
umbilicus (with some uncertainty regarding the extent of the
sensory level) and incontinence. Although imaging did not show
any spinal cord abnormalities, there was likely an ischemic
injury to the spinal cord causing this paraplegia. The present
cerebral lesions were expected to cause left hemianopia (unknown
extent) and potential left-sided ataxia (may resolve). There
was no indication of impairment of comprehension based on
CT-head and exam. Neurocognitive deficits were possible
(potential additional small lesions undetected on CT head) but
this could currently not be evaluated.
Cardiovascular: The patient was stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: Patient remained intubated for airway protection.
Gastrointestinal: The patient underwent decompressive laparotomy
for large retroperitoneal hematoma. There was no evidence of
ischemic bowel. On re-exploration, the gall bladder appeared
ischemic and was removed. The patient eventually tolerated
enteral tube feeds through a G-J tube.
Genitourinary: Post operatively, the patient was NPO with IVF.
She was aggressively fluid resuscitated. She became anuric due
to ischemic injury to bilateral kidneys during the AAA rupture
and repair, CVVH was initiated through temporary HD line.
ID: Patient was kept on brought spectrum antibiotics. She was
treated empirically for ventilator associated pneumonia on
vancomycin and cefepime. She was treated with metronidazole for
empiric enteric coverage. She received fluconazole for candidal
peritonitis.
Endocrine: Blood sugar levels were controlled by regular insulin
sliding scale.
Hematologic: She received heparin SC for DVT prophylaxis.
On [**2172-12-30**], due to the severity of medical and neurological
impairment, the family decided to change goals of care to CMO.
She was extubated and expired in the early morning on [**2172-12-31**].
Medications on Admission:
Metaprolol; Isosorbide; FeSo4; Diovan; Lasix; Simvastatin; ASA;
Nifedipine; Calcitriol
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Ruptured abdominal aortic aneurysm
Cholecystitis
Stroke
Paraplegia
Acute renal failure
Discharge Condition:
Expired.
Discharge Instructions:
She who has gone, so we but cherish her memory.
Followup Instructions:
None.
Completed by:[**2172-12-31**]
|
[
"112.89",
"585.9",
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"276.4",
"995.94",
"287.5",
"729.73",
"348.30",
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"567.89",
"336.1",
"568.81",
"276.0",
"785.59",
"434.11",
"344.1",
"289.59",
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"584.5",
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"441.3",
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"998.2",
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icd9cm
|
[
[
[]
]
] |
[
"51.22",
"39.50",
"39.31",
"39.90",
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"39.95",
"96.72",
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"96.6",
"00.45",
"99.15",
"54.25",
"46.39",
"39.71"
] |
icd9pcs
|
[
[
[]
]
] |
8029, 8038
|
5476, 7862
|
318, 543
|
8169, 8180
|
1707, 4418
|
8276, 8314
|
1428, 1445
|
8000, 8006
|
8059, 8148
|
7888, 7977
|
8204, 8253
|
1460, 1688
|
266, 280
|
571, 1266
|
4427, 5453
|
1288, 1376
|
1392, 1412
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,810
| 189,751
|
34290
|
Discharge summary
|
report
|
Admission Date: [**2100-9-18**] Discharge Date: [**2100-10-26**]
Date of Birth: [**2078-4-20**] Sex: M
Service: SURGERY
Allergies:
Piperacillin/Tazobactam/Dex-Is
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p High speed motor vehicle crash
Major Surgical or Invasive Procedure:
ICP bolt placement
Tracheosotmy and PEG placement
History of Present Illness:
22 yo male s/p high speed motor vehicle crash with likely
ejection from vehicle. It is unknown whether or not he was
wearing a seatbelt as he was found to be unconscious and outside
his vehicle at the scene. He was transported to [**Hospital1 18**] for
further management of his injuries.
Past Medical History:
None
Social History:
Patient lives with his family - parents, brother and twin
sisters. Family denies IVDU, occasional ETOH and marijuana use.
Family History:
Noncontributory
Physical Exam:
Upon admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**4-11**] and sluggish
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: unarousable
Orientation: not oriented
Language: intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
V, VII: Facial strength and sensation intact and symmetric.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength cannot be tested. Off sedation, he was
withdrawing all 4 extremities to noxious stimulation
no eye opening
positive gag, cough, and corneal reflexes
Toes downgoing bilaterally
Coordination: could not be tested
Pertinent Results:
Imaging:
[**9-18**] CT cspine: C5 spinous process fx
[**9-18**] CT head: Diffuse cerebral edema, no herniation, possible
SAH, no obvious facial fxs
[**9-18**] CT torso: RUL contusions no solid organ injury, no fxs
[**9-19**] CT head: Stable
[**9-19**] C-spine: C5 fx unchanged
[**9-19**] CXR: Right subclavian catheter, endotracheal tube and
Nasogastric tube in correct place. Increased opacification at
the right base, suggesting aspiration or pneumonia in the right
lower lobe.
[**9-20**] CXR: increase in bilateral lower lobe opacities, greater on
the left side due to atelectasis and/or aspiration
[**9-21**] CXR: Enlarging bilateral pleural effusions with associated
atelectasis.
[**9-22**] CXR: no change in the position of the ET tube, enteric
tube, or right subclavian central venous catheter. No
pneumothorax. Unchanged hazy basilar opacity that may represent
aspiration. Less atelectasis at lung bases.
[**9-22**] CXR: slight improvement in consolidations in right lower
lung. The left basal atelectasis has improved as well.
[**9-22**] EEG: No epileptiform activity
[**9-22**] CXR: R lower lung opacities, L atelectasis
[**9-23**] CT head: stable SAH and IVH, mild ventricular enlargement,
decreased R subgaleal hematoma
[**9-25**] CXR: Right pleural effusion. Increased retrocardiac density
(atelectasis versus pneumonia).
[**9-27**] CT head: stable edema, slightly smaller ventricles. stable
interventricular hemorrhage, subgaleal hematoma. further sinus
opacification.
[**9-28**] MRI brain/ c-spine - prevertebral/posterior soft tissue
swelling C4-C5, marrow edema at C5 lamina fx. Areas of signal
abnl of splenium, body of corpus callosum, pericallosal white
matter, right paramedian cerebellar vermis c/w diffuse axonal
injury. Symmetric signal abnl of cortical spinal tract
propagating towards the mid brain, c/w wallerian degeneration.
[**9-30**] CT head: decrease in cerebral swelling, otherwise unchanged
[**10-4**] CT chest/abd/pelvis: WET READ - NO SOURCE OF INFECTION IN
TORSO. NEARLY RESOLVED LUNG OPACITIES WITH SCATTERED
ATELECTASIS. FINE DETAIL OBSCURED BY BREATHING ARTIFACT AND
ARTIFACT FROM ARM POSITIONING.
[**10-4**] CT head : await final read, no interval changes
[**10-5**] MR [**Name13 (STitle) 430**]: No abscess is identified.
[**10-6**] CT Head w/ and w/o contrast: No areas of abnormal
enhancement, ? acute or chronic sinusitis, [**Doctor First Name **], No mass effect
or midline shift
[**10-7**] CXR: No change
[**10-8**] B upper Ext U/S: Occlusive thrombus in the superficial
branch of the right basilic vein. Remainder of the bilateral
upper extremity veins are patent.
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery was
immediately [**Month/Year (2) 4221**] given his injuries.
[**9-19**]: ICP monitor placed. Patient started on mannitol and Lasix
for elevated intracranial pressures.
[**9-21**]: On exam, decorticate posturing however localizes to pain.
23% Saline begun and mannitol discontinued to attempt to control
intracranial pressures.
[**9-22**]: EEG showed diffuse encephalopathy. Started on
vanc/cipro/zosyn for question aspiration pneumonia. Sputum
growing sparse gram negative rods.
[**9-23**]: In OR, prior to Trach/PEG ICP spiked to 50's, given
Pentothal and hypertonic saline which decreased ICP to 30's.
Procedure was not done and patient was returned to ICU where ICP
returned to teens. Repeat CT head improved.
[**9-24**]: ICP 6-12, no sodium needed, goal SBP<180
[**9-26**]: 1 episode of elevated ICP for 5 min of 36, which came down
by increasing propofol.
[**9-27**]: Repeat CT stable. Underwent tracheostomy and peg. Sputum
culture growing MSSA, sparse yeast, and pan-sensitive
klebsiella.
[**9-28**]: ICP bolt discontinued. MRI showed diffuse axonal injury.
[**9-29**]: Neurosurgery recommended LP, which family declined.
[**9-30**]: Family discussion with all teams where family was told of
poor prognosis. Repeat CT head showed improvement in ventricle
size. Decision by family to proceed with care.
[**10-1**]: Posturing on left side with minimal to no movement on
right side. No eye opening.
[**10-4**] CT head: No change. No evidence of increased mass effect.
Sinus aspirate showed staph aureus, gram positive rods, and
yeast. BAL showed 4+ PMNs and 3+ gram negative rods.
[**10-5**] MR [**Name13 (STitle) 430**]: No abscess is identified. Desaturation to 70's in
MRI, new vent need. CXR showed LLL collapse; underwent
bronchoscopy.
[**10-6**]: CT Head with and without contrast: No areas of abnormal
enhancement, ? acute or chronic sinusitis, [**Doctor First Name **], No mass effect
or midline shift.
[**10-7**]: sputum growing MRSA and rare yeast.
[**10-8**]: Bilateral upper extremity ultrasound showed occlusive
thrombus in the superficial branch of the right basilic vein.
Remainder of the bilateral upper extremity veins were patent.
Ciprofloxacin and vancomycin were stopped
[**10-11**]: Sinus aspirate and sputum grew sparse Staph; patient
started on Linezolid.
[**10-13**]: Negative c. Diff culture
[**10-19**]: A pressure ulcer was noted at insertion site of his PEG
tube. The wound ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and have made
recommendations for care (see Page 1 under wound care).
[**10-23**]: Linezolid discontinued.
[**10-25**]: Received word that he has been accepted by [**Hospital3 **]
which is the family's first choice of facilities.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Artificial Tear with Lanolin Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed) as needed for dry eyes.
3. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML's PO BID (2 times a
day) as needed for constipation.
4. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) ML's PO
Q6H (every 6 hours) as needed for fever.
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical twice
a day.
10. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p High speed motor vehicle crash
Diffuse axonal brain injury
C5 Spinous process fracture
MRSA Pneumonia
Discharge Condition:
Hemodynamically stable, tolerating tube feedings
Followup Instructions:
Follow up in [**Hospital 4695**] Clinic in 4 weeks, call [**Telephone/Fax (1) 1669**]
for an appointment.
Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery, call
[**Telephone/Fax (1) 6429**] for an appointment.
Completed by:[**2100-11-3**]
|
[
"E930.8",
"E816.0",
"805.05",
"851.86",
"482.41",
"348.5",
"276.1",
"693.0",
"453.8",
"518.5",
"707.05",
"348.1",
"263.9",
"692.6",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"01.10",
"31.1",
"33.24",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
8199, 8269
|
4390, 5857
|
327, 379
|
8419, 8470
|
1751, 1815
|
8493, 8757
|
882, 899
|
7209, 8176
|
8290, 8398
|
7180, 7186
|
914, 916
|
252, 288
|
407, 698
|
1206, 1732
|
5866, 7154
|
930, 1116
|
1131, 1190
|
720, 726
|
742, 866
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,842
| 170,616
|
30119
|
Discharge summary
|
report
|
Admission Date: [**2155-3-12**] Discharge Date: [**2155-3-17**]
Date of Birth: [**2100-5-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
transfer from OSH for hematemesis
Major Surgical or Invasive Procedure:
TIPS
History of Present Illness:
54 M HCV & EtOH Cirrhosis with known esophageal varices.
Transfer from [**Hospital6 3105**] for hematemasis. Woke up
~4:30 am with dizziness, then vomited approx "[**12-3**] coke can" of
bright red blood with clots. Otherwise no chest pain or dyspnea.
No hematochezia or melena. No subsequent episodes. Of note,
patient has had ~5 similar presentations within the past 2
months. Had outpatient EGD 2 weeks ago that showed large gastric
varices. Chronic lower abd pain x ~5 years.
.
Pt has known cirrhosis with apparent decompensation by gi
bleeding with known gastric and esophageal varices as well as
portal gastropathy, ascites and encephalopathy although history
is unclear. His meld is currently 15 and CPT is grade B. His
hepatitis has never been treated and this should be considered
as well as beginning evaluation for listing for transplantation
as he appears to be a good candidate.
.
Tips thurs was successful with gradient down from 12 to 3. Doing
well, needs cont supportive care and outpt follow up in
liver/transplant clinic.
Past Medical History:
Hepatitis C / EtOH Cirrhosis
- h/o bleeding esophageal varices
- throbocytopenia
h/o substance abuse
Diabetes Mellitus
Hypertension
Pancreatitis
h/o vertigo
Depression
Chronic back pain
h/o peptic ulcer
chronic gall bladder disease
Social History:
Lives at [**Location 71793**] House Nursing Home x 3 months. Previously
homeless. Previous alcoholic, sober since [**2154-7-2**]. History
of illicits many years ago, no injection drug use.
Family History:
non-contributory
Physical Exam:
Vitals - T 98.0, HR 79, BP 110/69, RR 18, O2 sat 100% RA
General - well-appearing, speaking full sentences, NAD
HEENT - sclera anicteric, PERRL, EOMI, OP clr, MMM, no LAD, no
JVD
CV - RRR, 2-3/6 syst mur @ apex
chest - CTAB
abdomen - soft, mild tenderness to deep palpation in lower
abdomen, NABS, no g/r
extremities - WWP, no edema
neuro - no asterixis, A&Ox3
Pertinent Results:
136 101 14
-------------< 101
3.9 28 0.9
ALT: 41 AP: 126 Tbili: 2.6 Alb: 2.7
AST: 78 LDH: Dbili: TProt:
[**Doctor First Name **]: 93 Lip: 43
4.3 > 11.6 < 89
33.4
N:64.7 L:23.9 M:5.3 E:4.7 Bas:1.5
Anisocy: 1+ Macrocy: 2+
[**2155-3-12**] @ 12:19 sinus brady @ 48, nl axis & intervals, no ST/T
changes; no prior for comparison
TIPS [**2155-3-13**]: Successful transjugular intrahepatic portosystemic
shunt placement with improvement of pressure gradients as
described above. TIPS shunt baseline ultrasound assessment is
recommended 7 days after this procedure or before patient
discharge.
ABD U/S [**2155-3-13**]: Cirrhotic liver, without lesion or biliary
ductal dilatation showing patency and normal direction of flow
and normal color waveform of the hepatic arterial branches,
hepatic veins, and the portal vein and its branches. The main
hepatic artery is not seen. There is moderate ascites.
Brief Hospital Course:
A/P: 54 M HCV & EtOH Cirrhosis with known esophageal and gastric
varices, transferred from OSH for hematemasis.
.
# HEMATEMSIS:
From alcoholic ESLD. Pt underwent a successful TIPS during this
hospital course. He remained hemodynamically stable and his hct
was stable after the procedure. His hct was 30 on admission and
trended down to 25, but was stable at 25 x 48 hours before
discharge. He did not have signs of bleeding and had no
episodes of hematemesis during this admission. He has normal
brown stools without blood. He was put on [**Hospital1 **] PPI. His liver
function was observed x 3 days after the procedure to make sure
the shunting of blood away from the liver will not compromise
liver function. His sythetic function is about the same as
admission: INR is 1.5 to 1.6. His LFTs are mildly elevated and
remained at similar levels at discharge. He will need follow up
with Dr. [**Last Name (STitle) 497**] at the Liver clinic on [**2155-3-28**]. At that time he
will also have an ultrasound to check for patency of the TIPS.
At discharge, he will need to take cipro x 7 days, first day
[**2155-3-15**].
.
# CIRRHOSIS: [**1-3**] EtOH and HCV. He has h/o encephalopathy and
ascites but currently no evidence of encephalopathy. Unclear
whether he has h/o SBP. Moderate ascites by ultrasound. He
needs to continue his lactulose and rifaximin on discharge.
Since he has TIPS and does not have a large amount of ascites,
his diuretics were stopped on this admission.
.
# HEPC: untreated. Meld 19.
.
# COAGULOPATHY: Likely [**1-3**] cirrhosis. He was given 3 days of
vitamin K.
.
# DIABETES: He does not take any diabetic medication as an
outpatient. He was covered here with a sliding scale, and he
will follow up with his PCP after discharge.
Medications on Admission:
Aldactone 50 qd
lasix 20 qd
MVI qd
lactulose 15cc qd
oxycodone [**4-10**] prn
valium 2 [**Hospital1 **] prn
protonix 40 qd
thiamine 100 qd
folate-b6-b12 qd
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
5. Phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care Agency
Discharge Diagnosis:
PRIMARY:
End stage liver disease
Bleeding varices
SECONDARY:
Hepatitis C
EtOH Cirrhosis
h/o substance abuse
Diabetes Mellitus
Hypertension
Pancreatitis
Vertigo
Depression
Chronic back pain
Peptic ulcer
Chronic gall bladder disease
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
Please take all medication as prescribed. Keep all appointments
listed below. If you have chest pain or shortness of breath,
seek medical attetion immediately. If you have bloody emesis,
go to the emergency room or call 911.
You will need to follow up with Dr. [**Last Name (STitle) 497**] on [**2155-3-28**]. At that
time, you will need an ultrasound of the liver to see if your
hepatic shunt is working properly. Dr.[**Name (NI) 948**] office will give
you a call.
In general, please call your doctor or go to the emergency
department if you have any medical questions or concerns.
Followup Instructions:
Please follow up with your primary care doctor in 1 week.
You will need to follow up with Dr. [**Last Name (STitle) 497**] on Friday [**2155-3-28**].
His office will give you a call to set up the appointment as
well as an ultrasound to look at your liver and shunt. Dr. [**Name (NI) 8390**] number is ([**Telephone/Fax (1) 1582**] if you need to reach him.
Completed by:[**2155-3-17**]
|
[
"578.0",
"456.20",
"789.5",
"070.70",
"287.5",
"280.0",
"286.9",
"572.8",
"303.93",
"250.00",
"572.3",
"571.2",
"456.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
5845, 5915
|
3228, 5000
|
315, 322
|
6191, 6226
|
2289, 3205
|
6866, 7256
|
1873, 1892
|
5206, 5822
|
5936, 6170
|
5026, 5183
|
6250, 6843
|
1907, 2270
|
242, 277
|
350, 1392
|
1414, 1650
|
1666, 1857
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,511
| 147,896
|
24537
|
Discharge summary
|
report
|
Admission Date: [**2136-3-29**] Discharge Date: [**2136-4-4**]
Date of Birth: [**2081-1-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted for ventral hernia repair and panniculectomy
Major Surgical or Invasive Procedure:
Status Post:
1. Incisional hernia repair.
2. Excision of scar.
3. Abdominal exploration.
4. Bilateral component separation for closure of ventral
hernia.
5. Panniculectomy.
History of Present Illness:
55-year-old male with a
history of having open bypass surgery in [**2133**]. He had a maximum
weight of 540 pounds. Currently, his weight is 410 pounds and
he
has a height of 6 feet 3. His current body mass index is 51.2
and he presents for combination procedure with you regarding a
hernia repair and abdominal wall closure with panniculectomy.
He
has also history of several suture sinuses that are seen in the
midline incision that is a vertical midline incision. He does
have a history of excoriation and open wounds that are seen in
the area.
Past Medical History:
PMH:
Hypertension
Hyperlipidemia
Atrial fibrillation, on coumadin
Obstructive Sleep Apnea (on CPAP of 10 with 2 liters of
oxygen)Lower extremity venous stasis with recurrent cellulitis
Osteoarthritis of back and lower extremity joints
Social History:
He is married living with his wife. [**Name (NI) **] has a business involved
in medical transportation. He is former Olympic-style wrestler
in the old Soviet [**Hospital1 1281**]. He was former one pack cigarettes daily
stopping in [**9-/2131**], no recreational drugs, occasional alcohol
on weekends.
Family History:
Family history is noted for father deceased age 68 of MI and
obesity and mother deceased age 72 from stroke. His son
underwent [**Name2 (NI) 33554**] gastric bypass for morbid obesity through
[**Hospital1 18**] Program in [**2132**].
Physical Exam:
Physical Examination: He is alert and oriented in no apparent
distress, fully ambulatory, fully conversant. He has a weight
of
410 pounds. He has a height of 6 feet 3. He has a current BMI
of 51.2. Physical examination of the abdomen reveals a slightly
widened midline vertical scar. His umbilicus is in place. He
does have several small areas of suture sinuses that are seen,
medial aspect of the superior portion of the incision as well as
inferior portion of the incision. When probed these wounds
appear not to extend to the abdominal fascia. He has pigmentary
changes of the lower portion of the pannus and he has a midline
hernia that is fully palpated ventrally. Neurologically,
cranial
nerves are intact to gross examination.
Pertinent Results:
[**2136-3-30**] 04:16AM BLOOD WBC-13.9*# RBC-5.07 Hgb-15.8 Hct-47.8
MCV-94 MCH-31.3 MCHC-33.1 RDW-14.2 Plt Ct-289
[**2136-3-31**] 01:10PM BLOOD WBC-13.2* RBC-3.62* Hgb-11.7* Hct-33.9*
MCV-94 MCH-32.4* MCHC-34.6 RDW-13.8 Plt Ct-227
[**2136-4-4**] 07:15AM BLOOD WBC-7.1 RBC-3.45* Hgb-10.9* Hct-31.6*
MCV-92 MCH-31.5 MCHC-34.3 RDW-15.1 Plt Ct-255
[**2136-3-30**] 04:16AM BLOOD Plt Ct-289
[**2136-4-2**] 07:55AM BLOOD PT-14.2* PTT-24.0 INR(PT)-1.2*
[**2136-4-4**] 07:15AM BLOOD PT-17.5* PTT-25.6 INR(PT)-1.6*
[**2136-3-30**] 04:16AM BLOOD Glucose-123* UreaN-29* Creat-1.9* Na-136
K-5.8* Cl-104 HCO3-21* AnGap-17
[**2136-4-4**] 07:15AM BLOOD Glucose-104 UreaN-17 Creat-1.1 Na-137
K-3.8 Cl-102 HCO3-29 AnGap-10
[**2136-3-30**] 04:16AM BLOOD Calcium-7.3* Phos-5.4*# Mg-1.7
[**2136-4-4**] 07:15AM BLOOD Calcium-7.9* Phos-3.1# Mg-1.9
[**2136-3-29**] 11:57AM BLOOD Glucose-93 Lactate-1.9 Na-138 K-4.8
Cl-99*
[**2136-3-29**] 05:42PM BLOOD Lactate-1.6 Na-133* K-5.2 Cl-101
[**2136-3-29**] 11:57AM BLOOD Hgb-16.2 calcHCT-49
[**2136-3-29**] 05:42PM BLOOD Hgb-17.1 calcHCT-51
Brief Hospital Course:
Patient admitted for ventral hernia repair and panniculectomy.
He tolerated the procedure very well without complications.
Postoperatively his labs were followed closely. His pain was
well controlled with pca and then transitioned to oral
narcotics.
He was discharged from the hospital with follow up with Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) **] and with his primary care to follow his
coumadin dosing.
Medications on Admission:
hydrochlorothiazide, Coumadin, atenolol,
lisinopril.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Warfarin 5 mg Tablet Sig: 7.5 mg PO Once Daily at 4 PM:
Please schedule an appointment with your docotor to have your
INR checked within 1 week.
Disp:*30 tablets* Refills:*0*
3. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 2 weeks: take while drains are in place.
Disp:*28 Capsule(s)* Refills:*0*
6. Colace 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a day:
take while using narcotics for pain control to help prevent
constipation.
Disp:*300 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Ventral Hernia
Discharge Condition:
hemodynamically stable, tolerating oral intake, ambulating in
[**Doctor Last Name **], pain controlled with oral regimen, voiding without issue,
tolerating a normal diet.
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**9-6**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
You should continue to wear your abdominal binder at all times
until follow up with Dr. [**First Name (STitle) **].
Followup Instructions:
Provider: [**Name10 (NameIs) 357**] see Dr. [**Last Name (STitle) **] in two weeks, call [**Telephone/Fax (1) 2723**]
to make an appointment.
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**]
Date/Time:[**2136-4-6**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2136-7-4**] 11:15
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2136-7-4**] 11:30
Please make an appointment to see your primary care provider
[**Name Initial (PRE) 176**] 1 week to have you INR checked and coumadin dosing
adjusted.
Completed by:[**2136-4-5**]
|
[
"278.01",
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"715.89",
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"560.1",
"401.9",
"427.31",
"V45.86",
"997.4",
"584.9",
"568.0",
"272.4",
"327.23",
"E878.8",
"459.81",
"V85.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.61",
"86.3",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
5145, 5203
|
3828, 4258
|
373, 552
|
5262, 5435
|
2743, 3805
|
7143, 7925
|
1728, 1963
|
4362, 5122
|
5224, 5241
|
4284, 4339
|
5459, 6657
|
1978, 1978
|
2001, 2724
|
272, 335
|
6669, 7120
|
580, 1134
|
1156, 1392
|
1408, 1712
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,801
| 101,382
|
7748
|
Discharge summary
|
report
|
Admission Date: [**2180-8-24**] Discharge Date: [**2180-8-29**]
Date of Birth: [**2112-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
PCI with 3 sequential stents widely patent, first two to LAD,
third to amend LMCA dissection, all with good angiographic
result.
History of Present Illness:
67 year old blind, deaf man with ESRD, htn, CAD s/p NSTEMI,
cardiomyopathy with EF 35%, initially admitted to [**Hospital3 **]
hospital with burning chest pain radiating to shoulders. Ruled
out for MI. Yesterday, patient returned to [**Location **] with burning chest
pain radiating to his shoulder. No EKG changes, but known LBBB.
Initial negative troponin negative, but afternoon trop elevated
to 0.97. Overnight episodes of CP responded to 2 SL NTG +/-
morphine. Continued to have episodes of CP responsive to NTG.
Patient was transferred directly to [**Hospital1 18**] cath lab on [**8-24**].
.
Coronary angiography on [**8-24**] revealed a right dominant system
with diffuse coronary artery disease. The LMCA was without
angiographically apparent stenosis. The LAD had 3 sequencial
stents that were widely patent. There was a 50% stenosis at the
D1 level proximal to the stents. There was diffuse disease
between the 2nd and 3rd stents with approximately 60% stenosis,
and there was a 90% focal lesion just distal to the 3rd stent
that was new since the prior catheterization in [**2180-4-28**]. The
D1 had 90% proximal disease that was not apparently changed
since prior. The LCX had a widely patent stent and no
significant disease. The RCA had chronic subtotal occlusion in
the mid-portion, with collaterals from the LAD distally. He had
a successful PCI of the distal LAD with a DES which was
post-dilated to 2.5mm. At this point the patient could not
tolerate further intervention due to marked agitation, so it was
elected not to intervene on the D1 lesion.
.
After this intervention the patient was transferred to [**Hospital Ward Name 121**] 3
and continued to have chest pain on the floor. He continued to
ask for nitroglycerin for chest pain overnight. EKGs were
consistently unchanged. The pain was not relieved with a GI
cocktail. Trop was 0.63, CK=53 on AM of [**8-25**] and previously was
trop=0.97 at OSH on [**8-24**]. Due to his continued symptoms, he was
taken to cath again on the afternoon of [**8-25**] after his regularly
scheduled HD session. The D1 lesion was successfully
angioplastied and a successful PCI of prox/mid LAD with DES was
performed, but the procedure was complicated by LMCA artery
dissection. On the last final angiography injection, the LMCA
was dissected, at which point the patient arrested. CPR was
immmediately initiated and atropine was given. The Prowater
wire was still in place in the LAD and a 3.5x28mm Xience DES was
able to be delivered to the LMCA/prox LAD. This stent was
post-dilated to 4.0 NC balloon with sealing of the dissection
and restoration of TIMI 3 flow into the LAD and LCx. The
patient left the lab intubated and on 5mcg/kg/min of dopamine to
maintain a SBP of 100-110mmHg. Reportedly, his home SBP runs in
the 90s-100s.
.
Upon transfer to the CCU the patient was sedated, intubated, and
on dopamine to maintain his pressures. He had a peripheral line
and femoral sheath for access. Initial blood gas was pH 7.53,
pCO2 36, pO2 237, HCO3 31, BaseXS 7.
Past Medical History:
As above, and:
1) Hypertension.
2) Speech and hearing deficit.
3) Peptic ulcer disease, dyspepsia
4) Gout
5) Osteoarthritis.
6) Chronic renal insufficiency, thought [**1-31**] nephrosclerosis
7) Retinitis pigmentosa
8) A fib on Amio
9) h/o NSTEMI
Social History:
He denies tobacco or alcohol use. He is currently unemployed on
disability and lives with girlfriend.
Family History:
Mother died of MI after age 80. Father died at 20's of an
unspecified brain "problem". Other family history is not known
by patient.
Physical Exam:
VS: T=99.7 BP=126/68 HR=103 RR=18 O2 sat=100% intubated
GENERAL: Caucasian male, sedated, intubated.
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: Supple with no JVD
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no crackles, wheezes, or rhonchi. Right chest wall
with temporary HD cath site clean, intact.
ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation.
No abdominial bruits. Has bowel sounds in all four quadrants.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No rashes
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Exam at discharge:
T 98.1 BP 104/61 HR 85 RR 20 99% RA
GENERAL: Caucasian male, sedated, intubated.
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: Supple with no JVD
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: rare rales left base, otherwise CTAB
ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation.
No abdominial bruits. Has bowel sounds in all four quadrants.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No rashes
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
CXR [**2180-8-26**]:
FINDINGS: In comparison with study of [**8-25**], the nasogastric tube
has been
pushed forward slightly so that the side hole appears to extend
beyond the
esophagogastric junction. Endotracheal tube has been removed.
Progressive
improvement in pulmonary vascular status.
.
TTE [**2180-8-26**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
No masses or thrombi are seen in the left ventricle. Overall
left ventricular systolic function is moderately depressed
(LVEF= 35 %) with global hypokinesis and akinesis of the
infero-lateral and apical segments. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. with mild
global free wall hypokinesis. The aortic root is moderately
dilated at the sinus level. The ascending aorta is moderately
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate ([**12-31**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. Coompared to the prior
study dated [**2180-5-26**], no major change.
.
Cardiac cath [**2180-8-25**]:
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PTCA of D1 branch.
3. Successful PCI of prox/mid LAD with DES.
4. LMCA dissection successfully treated with DES.
.
Cardiac cath [**2180-8-24**]:
COMMENTS:
1. Coronary angiography in this right dominant system revealed
diffuse
coronary artery disease. The LMCA was without angiographically
apparent
stenosis. The LAD had 3 sequencial stents that were widely
patent.
There was a 50% stenosis at the D1 level proximal to the stents.
There
was diffuse disease between the 2nd and 3rd stents with
approximately
60% stenosis, and there was a 90% focal lesion just distal to
the 3rd
stent that was new since the prior catheterization in [**2180-4-28**].
The D1
had 90% proximal disease that was not apparently changed since
prior.
The LCX had a widely patent stent and no significant disease.
The RCA
had chronic subtotal occlusion in the mid-portion, with
collaterals from
the LAD distally.
2. Resting hemodynamics demonstrated low to normal systemic
blood
pressures with SBP 101 mmHg and DBP 51 mmHg.
3. Successful PCI of the distal LAD with a 2.25x12mm Taxus DES,
post-dilated to 2.5mm.
4. Successful closure of the right femoral arteriotomy site with
a 8F
Angioseal device.
FINAL DIAGNOSIS:
1. Diffuse coronary artery disease with new distal LAD stenosis.
2. Successful PCI of the distal LAD with DES.
Labs at discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
7.8 3.45* 9.6* 30.6* 89 27.7 31.3 19.6* 171
Glucose UreaN Creat Na K Cl HCO3 AnGap
101 35* 6.1*# 143 4.0 99 32 16
Calcium Phos Mg
8.3* 3.7# 2.5
Brief Hospital Course:
67 y/o blind, deaf male w/ESRD, cardiomyopathy with EF 35%,
transferred to [**Hospital1 18**] with NSTEMI, s/p cath here on [**8-24**] with
stenting of distal LAD stenosis with continued chest pain, whose
repeat cath on [**2180-8-25**] was complicated by LMCA dissection.
.
# CORONARIES: Cath [**2180-8-24**]: LAD w/ 3 sequential stents widely
patient. 50% lesion at D1 proximal to stents. 60% diffuse
disease between 2nd and 3rd stents; 90% focal lesion just distal
to 3rd stent (new since [**5-6**]). D1 with prximal 90% disease
(unchanged). New stent placed over distal LAD lesion. Procedure
stopped prematurely secondary to agitation. Patient returned to
the floor and continued with chest pain. Went back to the cath
lab on [**2180-8-25**] where he received a DES to mid LAD. This second
cath was complicated by LAD dissection, the patient became
asystolic, coded for 20 minutes and received DES to LMCA. On
return to the CCU, patient did well. He was continued on his
aspirin, plavix, metoprolol, lipitor. Imdur was discontinued.
Lisinopril was started, and he was sent home on this regimen on
[**2180-8-29**]. He is to take aspirin and plavix for life given his
stent to the LMCA. He was discharged on [**2180-8-29**] in improved and
stable condition.
.
# PUMP: Has known cardiomyopathy with EF 35% on [**5-6**] Echo. No
overt clinical signs of heart failure at this time. No
peripheral edema, crackles, or JVD.
.
# RHYTHM: h/o paroxysmal atrial fibrillation, but was in NSR for
most of admission. Patient was continued on amiodarone, started
on metoprolol as bp could tolerate.
.
# Hypotension: initially on dopamine, but weaned off. Goal sbp
maintained near 90s-100s. Patient continued on metoprolol, and
eventually tolerated introduction of lisinopril, as indicated
post-myocardial infarction.
.
# Anemia: Hct dropped from 30.9 pre-procedure to 24.8
post-procedure. Hct on discharge was 30.6, at baseline.
.
# ESRD w/ HD on MWF: Underwent normal session of HD Friday
morning prior to cath. Patient continued on nephrocaps,
renagel. Patient will continue regular Monday, Wednesday,
Friday schedule for hemodialysis.
.
# Gout: allopurinol continued on discharge.
.
# Congenital deafness: Can read lips effectively at baseline.
Involved ASL interpreters as needed following extubation.
.
# Peptic ulcer disease, dyspepsia: continued on famotidine.
Pt remained a full code throughout hospitalization.
Medications on Admission:
Lopressor 100 PO BID
ASA 325 mg PO daily
Zocor 40 mg PO daily
Colace 100 mg PO daily
Esomeprazole 40 mg PO daily
Sevelamer 1600 mg PO with meals
MVI PO daily
Allopurinol 100 mg PO daily
Cholecalciferol 400 units PO daily
Amiodarone 200 mg PO daily
Isosorbide mononitrate 120 mg PO daily
Metoprolol tartrate 100 mg PO BID
Lorazepam 0.5 mg PO Q6 hrs PRN
Oxazepam 10 PO QHS PRN
Maalox 30 cc PO Q8 PRN
Morphine Sulfate 2 mg IV Q4 hrs PRN
Nitroglycerin 1 tab SL PRN
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
3. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
[**Month/Year (2) **]:*180 Tablet(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
[**Month/Year (2) **]:*90 Cap(s)* Refills:*2*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-31**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for angina:
take one tablet every 5 minuties for chest pain, if pain
continues after three doses, call your doctor.
[**Last Name (Titles) **]:*30 Tablet, Sublingual(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagosis:
NSTEMI, s/p stent x 2 to LAD, with subsequent LAD dissection,
s/p stent to LMCA with good angiographic result
Secondary Diagnoses: (prior to this hospitalization)
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Dilated Cardiomyopathy (EF 35%); NSTEMI
[**5-6**], LAD stent in [**2169**], cypher to OM3 with POBA to distal LCX
in [**5-3**]; unsuccessful PTCA of RCA chronic total occlusion [**5-6**];
Paroxysmal atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
ESRD w/ HD on MWF
Gout
Congenital deafness
Retinitis pigmentosa
Hypertension
Speech deficit
Peptic ulcer disease, dyspepsia
Gout
Osteoarthritis.
Discharge Condition:
stable and improved
Discharge Instructions:
You were admitted to the hospital for chest pain. After
initially being evaluated at [**Hospital3 417**] Hospital, you were
transferred to [**Hospital1 18**] for further care. Your chest pain was
coming from your heart, and you required 3 stent placements
during your hospital course. Your heart stopped for a short
period of time, and you were resuscitated. You needed
assistance breathing, and had a breathing tube for a short
period of time. After the heart procedure, you were cared for
in the ICU. You continued to improve, and had the breathing
tube removed. Other medications used to support your heart were
also no longer needed. You resumed your regularly scheduled
hemodialysis, which you tolerated well. You were discharged on
[**2180-8-29**] in good condition.
The following changes were made to your medications:
You will continue taking Aspirin 325 mg daily and Plavix 75 mg
daily for the rest of your life unless you are told to stop by
your Cardiologist
You have been started on lisinopril 2.5 mg daily for your heart
You will stop taking Imdur for your blood pressure.
Please see below for follow up appointments. You will need to
have repeat catheterizations in the next 12 months to ensure
that the stents are working well.
Please call your doctor or 911 if you develop chest
pain/pressure, shortness of breath, fevers/chills,
lightheadedness, or any other concerning medical symptoms.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] at
[**Telephone/Fax (1) 8725**]. They will contact you. Please discuss a repeat
cardiac catheterization with him during this visit.
.
Please follow up with your primary care doctor within one week
of discharge.
|
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icd9cm
|
[
[
[]
]
] |
[
"36.07",
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"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
13207, 13262
|
8478, 10899
|
326, 457
|
13956, 13978
|
5225, 6837
|
15444, 15772
|
3926, 4060
|
11410, 13184
|
13283, 13412
|
10925, 11387
|
8099, 8212
|
14002, 15421
|
4075, 4674
|
13434, 13518
|
13538, 13757
|
4689, 5206
|
276, 288
|
8231, 8455
|
485, 3519
|
13788, 13935
|
3541, 3790
|
3806, 3910
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,083
| 186,985
|
41219
|
Discharge summary
|
report
|
Admission Date: [**2182-2-18**] Discharge Date: [**2182-3-2**]
Date of Birth: [**2100-10-9**] Sex: F
Service: MEDICINE
Allergies:
Lipitor / Prozac / sertraline
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
leg weakness, back pain
Major Surgical or Invasive Procedure:
Thoracic laminectomies and fusion
History of Present Illness:
Ms. [**Known lastname 7168**] is an 81 year old woman with history of multiple
myeloma, chronic renal insufficiency, T10-T11 lesion with cord
compression, admitted from nursing home for elective surgery.
.
She was admitted to [**Hospital3 **] in [**2180**] for pneumonia. She then
developed significant back pain. X-rays and MRI revealed a
pathological fracture of her thoracic spine, given TLSO and
after serial MRIs showed worsening fracture.
.
Multiple Myeloma diagnosis was made in [**2178**], treated with
radiotherapy, but noted in the past month to have progressive
neurologic decline with lower extremity weakness and difficulty
with walking. MRI showed T10-T11 lesion with severe fracture and
anterior wedging with near collapse of T11, resulting in cord
compression. Patient did not tolerate TLSO brace well, and lower
extremity weakness progressed to significantly decreased
proximal muscle strength with some decreased distal strength as
well. Spinal cord edema was noted on repeat MRI, and patient was
started on dexamethasone. She was taken to the OR on [**2182-2-18**] for
laminectomy. Patient had wanted to wait until results of recent
bone marrow biopsy on [**2182-2-15**] to have surgery.
.
Patient was treated with Bactrim DS [**Hospital1 **] x5 days, starting on
[**2182-2-3**]. Urine culture showed E. Coli >100,000 which was
resistant to ampicillin/sulbactam, cefoxitin, ciprofloxacin,
levofloxacin; cultures were sensitive to bactrim, ceftazidime,
cefepime, gentamicin.
Past Medical History:
Past Medical History:
- Multiple myeloma diagnosed [**2178**], presenting with back pain,
treated with Thalidomide + Dexamethasone. Thalidomide was
stopped [**2182-2-19**].
Relevant labs:
-Serum protein electrophesis: Ig G ([**2181-12-25**]) 2150 H
-Free Kappa light chain: 123 ([**2181-7-25**]) --> 273.9([**2181-12-25**])
-Free Lambda light chain: 90.1 ([**2181-7-25**]) --> 129.1 ([**2181-12-25**])
- Chronic diastolic CHF, EF 50-55%
- DM-II on SQ insulin bolus-basal regimen
- Chronic kidney disease stage III to IV with baseline creatine
2.2 mg/dL in [**11/2181**]
- Parkinson's Disease
- GERD
- Anemia of chronic disease
- Chronic leg edema
.
Past Surgical History:
- Severe cord compression and myelopathy T10-T11 due to anterior
wedge compression fracture from multiple myeloma and
osteoarthritis
- Cholecystectomy
Social History:
never smoked
Family History:
nc
Physical Exam:
Discharge Exam:
Vitals: 97.1 107/44 (90-136/53-62) 71-81 18 96% RA FS: 96-99)
General: Alert, oriented and conversational.
HEENT: Sclera anicteric, moist mucous membranes
Neck: Large ecchymosis over R neck. Port-a-cath clean and dry on
R chest.
Lungs: Clear to auscultation, without wheezing or crackles.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Ext: Hands edematous and cool with + radial pulses. No LE edema,
feet warm.
Neuro: Able to wiggle toes (movement restricted by braces), full
sensation in legs. Full strength and ROM in upper extremities.
Back: Deferred this morning. Yesterday staples were clean and in
place. No erythematous, no drainage.
Pertinent Results:
ADMISSION LABS:
[**2182-2-18**] 04:19PM WBC-10.6 RBC-3.27* HGB-10.6* HCT-30.7* MCV-94
MCH-32.3* MCHC-34.4 RDW-15.7*
[**2182-2-18**] 04:19PM PLT COUNT-69*
[**2182-2-18**] 04:19PM PT-12.3 PTT-24.1 INR(PT)-1.0
[**2182-2-18**] 03:14PM GLUCOSE-90 UREA N-61* CREAT-1.3* SODIUM-135
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-35* ANION GAP-8
[**2182-2-18**] 03:14PM CALCIUM-7.8* PHOSPHATE-3.0 MAGNESIUM-1.6
[**2182-2-18**] 10:14AM TYPE-[**Last Name (un) **] PO2-36* PCO2-56* PH-7.43 TOTAL
CO2-38* BASE XS-10
DISCHARGE LABS:
[**2182-2-27**] 05:22AM BLOOD WBC-6.5 RBC-3.26* Hgb-10.1* Hct-29.5*
MCV-91 MCH-31.1 MCHC-34.4 RDW-17.2* Plt Ct-107*
[**2182-2-27**] 05:22AM BLOOD Plt Ct-107*
[**2182-2-27**] 05:22AM BLOOD PT-13.2 PTT-31.3 INR(PT)-1.1
[**2182-2-27**] 05:22AM BLOOD Glucose-73 UreaN-49* Creat-1.3* Na-136
K-4.2 Cl-102 HCO3-31 AnGap-7*
[**2182-2-27**] 05:22AM BLOOD Calcium-7.7* Phos-3.2 Mg-2.0
[**2182-2-27**] 05:22AM BLOOD Cortsol-15.0
MICROBIOLOGY:
[**2182-2-18**] 8:00 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2182-2-20**]**
URINE CULTURE (Final [**2182-2-20**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
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
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2182-2-23**] 6:05 pm URINE Source: Catheter.
**FINAL REPORT [**2182-2-25**]**
URINE CULTURE (Final [**2182-2-25**]): NO GROWTH.
Blood Cultures: Negative [**2-21**]. Pending [**2-23**].
[**2182-2-26**] 10:37 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Preliminary):
CAMPYLOBACTER CULTURE (Preliminary):
OVA + PARASITES (Preliminary):
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2182-2-27**]):
Reported to and read back by [**Location (un) **] [**Last Name (un) 89787**] [**2182-2-27**] @ 10:00
AM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
IMAGING:
MRI of thoracic spine [**2182-1-16**]:
Significant for T10 and T11 fractures with cord compression at
these levels and cord edema.
Lumbar Spine [**2182-2-19**]:
FINDINGS/IMPRESSION: Two [**Location (un) 931**] rods were placed, bilateral
pedicle screws are in the L1, T12, T10, T9 vertebral bodies.
There are laminal hooks in T8 level. Again note is made of a
marked compression deformity of T11 and compression fracture of
T10. Intervertebral disc space is obliterated. Posterior skin
staples are seen. There is a right internal jugular catheter and
a right-sided Port-A-Cath through the right internal jugular as
well. The location of tip of the catheter has not changed, and
compared to the most recent prior radiographs. Incidentally
noted are cholecystectomy clips.
CT Ab/Pelvix [**2-21**]:
IMPRESSION:
1. No evidence of retroperitoneal hemorrhage. Small amount of
free simple
fluid in the pelvis.
2. Left and right colonic diverticulosis without diverticulitis.
3. Extensive vascular calcifications.
4. Surgical absence of gallbladder.
5. No abnormal fluid collections,
intraperitoneal/retroperitoneal free air, or upper abdominal
ascites.
6. Post posterior spinal fusion with advanced degenerative
changes as above.
7. Fluid distended distal esophagus. [**Month (only) 116**] represent dysmotiliy,
reflux, or
mechanial process. Clinical correlation would be useful and
endoscopy can be performed if necessary.
CXR [**2-24**]: FRONTAL CHEST RADIOGRAPH: A right sided port and left
internal jugular
central venous line are in unchanged position without
pneumothorax. The
cardiomediastinal silhouette is stable. There is mild vascular
congestion and
a newly apparent right basilar opacity mildly obscuring the
right
hemidiaphragm. This could represent a combination of pleural
fluid and
atelectasis, although consolidation is not excluded. There is a
small left
effusion/atelectasis and linear atelectasis in the lingula.
NOTE:
CrossMatch information with irregular antibodies:
CLINICAL/LAB DATA: Ms. [**Known lastname 7168**] is a 81-year-old female with
worsening
thoracic spine fracture who is scheduled for laminectomies on
[**2182-2-18**].
A blood sample was sent for type and screen. Of note, she was
hospitalized in [**2180**] at [**Hospital6 1597**] where an anti-K
antibody was
identified.
Laboratory testing:
Patient ABO/Rh: Group O, Rh positive
Antibody screen: positive
Antibody identity: anti-Fya ([**Hospital1 18**]); anti-K previously
identified at [**Hospital1 **] but was not seen on most recent testing at [**Hospital1 18**].
Antigen phenotype: Fya-antigen negative, K-antigen negative
Transfusion history:
No previous transfusions at [**Hospital1 18**].
Last transfused in [**9-2**] at [**Hospital6 1597**].
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [**Known lastname 7168**] has a new
diagnosis of anti-Fya antibody and a history of anti-K antibody
at an
outside hospital. Fya-antigen is a member of the [**Doctor Last Name 5239**] blood
group
system and K-antigen is a member of the [**Doctor Last Name **] blood group system.
Both
anti-Fya and anti-K antibodies are clinically significant and
capable of
causing hemolytic transfusion reactions. The fact that the most
recent
antibody screen and panel did not detect the anti-K antibody
indicates
that the titer of the antibody has fallen below the threshold of
detection. Nevertheless, in the future, Ms. [**Known lastname 7168**] should
receive
Fya-antigen and K-antigen negative products for all red cell
transfusions. Approximately 31% of ABO compatible blood will be
Fya-antigen and K-antigen negative.
OVERALL PENDING INFORMATION: Stool cultures [**2-26**]. Blood cultures
[**2-23**]. Free Kappa/Lambda light chains
Brief Hospital Course:
Ms. [**Known lastname 7168**] is an 81 yo woman with PMH significant for multiple
myeloma who was admitted from her nursing home for an elective
laminectomy for cord compression.
SURGICAL COURSE:
Pt was admitted to the hospital electively and was brought to OR
where under general anesthesia she underwent posterior thoracic
laminectomy and fusion. While in pre-op, it was noted that
patient has multiple ulcers on body, two decubitis ulcers, L
elbow, and bilateral heels. It was documented in OR. OR course
was uncomplicated otherwise. Post operatively, patient was
hypotensive, she recieved 250 bolus of fluid and 1 unit of PRBCs
in the PACU for a hematocrit drop from 30-26. Her blood pressure
improved to the 90s and patient was stable on post op check.
Strength in B IP was [**12-29**], antigravity in B Q/H, AT, and [**Last Name (un) **].
She was transferred to the step down unit.
On [**2-20**] patient remained hypotensive in bed, despite holding
Lasix. Upon checking the HCT a five point drop was observed.
Patient was transfused with one unit of PRBCs. Patient was
transferred to the Medicine service for better medical
management. TLSO brace was at bedside and PT/OT ordered.
MICU COURSE:
In the MICU [**2-23**] she was volume rescuscitated with 6L isotonic
fluids after CVL was placed and MAP improved to >65 with minimal
time on norepi for BP support. Norepi weaned off within 6 hours
of starting. Patient was placed on vancomycin and cefepime given
clinical instability. Troponins initially trended up, likely [**12-26**]
demand, but MBs were flat. She was placed on stress dose
hydrocortisone which was subsequently tapered. Neurosurgery
continued to follow and planned to keep staples in for 2 weeks.
BPs remained stable, she had no further hypoglycemia, and MS
returned to baseline. [**2-25**] she continued to improve and was
transfered to the medical floor with MAP>65.
HOSPITAL FLOOR COURSE:
.
#Urosepsis: Patient was continued on Cefepime as treatment for
infection. Of note, her sepsis in the ICU was thought to be due
to a pan-sensitive Klebsiella UTI (see sensitivities in results
section.) We considered changing to PO Ciprofloxacin to cover
this UTI. However, there was a question of HCAP in the ICU as
well- with an opacity seen on CXR but no clinical symptoms.
Although the patient did not have a cough and was weaned off
oxygen on the floor, Cefepime was continued for possible HCAP as
well as UTI. Planned 2 week course of Cefepime. Of note, if she
clinically improves at rehab, could change to PO medication. Of
note, the patient has a port for IV antibiotic administration
and so no additional line will be required. It was confirmed
with neurosurgery that there was no need to be on antibiotics
from a post-surgical perspective.
.
Of note, she remained normotensive, alert and oriented on the
floor without fluid resuscitation.
.
# Possible adrenal insufficiency: The patient had been on
standing steroids for approximately one month prior to admission
for cord compression. These were initially tapered post surgery
but then she was given stress dose steroids in the ICU. She was
again tapered down after her ICU stay. An AM cortisol on [**2-27**] was
15 on dexamethasone was reassuring. Plan to discharge on
prednisone and taper completely off steroids. It was confirmed
with neurosurgery that she could completely stop steroids.
.
# Diabetes Mellitus: The patient was hypoglycemic prior to
transfer to MICU with FS in the 30s. She recovered and was
placed back on her home insulin regimen. However, on the floor
FS were 60s- 80s, in the context of poor PO intake, and so her
pm insulin glargine was reduced. She will be discharged on
reduced glargine with humalog sliding scale. This can be
increased as her PO intake increases in rehab.
.
# C.diff diarrhea: Patient developed C.diff positive diarrhea.
PO Flagyl was started on [**2182-2-27**], with plan to treat throughout
the duration of her antibiotic treatment and for a few days
afterwards, as long as symptoms persist. Stool studies are still
pending. x3 overnight as well as yesterday. C.diff and stool
studies sent.
.
# Multiple myeloma: Patient was on thalidomide and dexamethasone
prior to admission. During her stay, she developed worsening
anemia and thrombocytopenia, thought to be due to these
medications. Thrombocytopenia improved during his stay and
anemia was stable. AntiPF4 antibody negative. She was evaluated
by Hematology-Oncology, who did not want to treat further at
this time; she will followup with her outpatient hematologist.
Of note, free kappa and lambda light chain pending.
.
# Guiaic positive stools: The patient did have guiaic positive
stools during her stay. However, there was no evidence of acute
bleed but this should be followed up by her primary physician.
.
# S/P laminectomy and fusion of T10-11: Patient's back wound is
not completely approximated but appears stable. The patient
needs staples removed in 2 weeks and will have followup with
Neurosurgery in 6 weeks. Patient requires TSLO when HOB > 30
degrees of OOB. Wound care recommendations included in discharge
instructions for rehab center. Patient comfortable on pain
regimen of Oxycontin, Oxycodone and Gabapentin.
.
# Decubitus Wounds: The patient has skin wounds from her [**Hospital1 1501**]
stay. Wound care recommendations were included in discharge
instructions for rehab center.
.
# dCHF: EF 50-55% reported but there is no echo in our system.
The patient was discharged on her home lasix dose. Her Cr was
improved from baseline at discharge, but she does have upper and
lower extremity edema, likely from large volume fluid
resuscitation during her stay. She was successfully weaned off
oxygen.
.
# Chronic kidney disease: Stable. Stage III. Creatinine better
than baseline on discharge.
.
# Parkinsonism: Resting tremor. Patient continued on
Carbidopa-Levodopa .
.
#Communication: Patient and HCP [**Name (NI) **] [**Name (NI) **] [**Name (NI) 805**] [**Name (NI) **] [**Telephone/Fax (1) 89788**]
.
2nd MICU Course: Patient was transferred to ICU for hypotension
and altered mental status. Her BP did not improve despite
aggressive IVF resuscitation and her mental status also did not
improve. Family meeting was held given volume overload and
DNR/DNI status and need to escalate care to maintain adequate
MAPs, and family, incl [**Telephone/Fax (1) 802**] [**Name (NI) 382**] decided to focus on comfort.
Meds stopped except IV morphine prn and scopolamine patch.
Family at bedside. Patient expired at 3:50pm on [**2182-3-2**]. Autopsy
declined by family. Immed cause of death was hypotension, chief
cause was multiple myeloma, other causes were CHF and [**Last Name (un) **]. PCP's
office made aware of death along with neurosurgical service.
HCP grateful for care received.
Medications on Admission:
albuterol neb, asa 325(stopped [**2-13**]),colace, decadron 4q6,lantus
20u HS, SSI, ferrous sulfate, lasix 60 qd, neurontin 100 TID,
miralax, MVI, Vit B12, Vit B1, procrit, calcitonin, thalomid,
oxycodone, sinemet 25/100 TID, trazadone, vicodin, senokot,
dulcolax, MOM
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Thoracic fractures T10/11 with cord compression
Klebsiella [**Hospital **]
Hospital Acquired Pneumonia
C.diff diarrhea
Hypotension
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
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5,247
| 103,106
|
22295
|
Discharge summary
|
report
|
Admission Date: [**2155-3-1**] Discharge Date: [**2155-3-4**]
Date of Birth: [**2111-3-24**] Sex: M
Service: MEDICINE
Allergies:
Valium
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
This is a 43 yo M who presents with increased urinary frequency
x one week, found to have new onset [**Hospital 23051**] transferred to MICU for
management on HONC. He complained of urinary incontinence and
episodic R-sided weakness. He reports 3 falls at home in last
week. He woke up on the floor, not remembering how he got from
the bed to the floor.
.
In the ER he was given a regular insulin bolus of 4 units (0.05
u/kg of ideal weight) at 4 units insulin gtt (0.05u/kg/hr) at 1
a.m. At 4:30 am he received a 10 unit bolus with 6 units/hr
gtt. EKG showed worsening ST depressions in leads 2, 3, 4, and
v4-v6. He received 325 mg of ASA. Head CT and CXR were
negative. UA negative for infection and ketones. IVF were
given via 20g IV. The IV team was unable to obtain second IV.
He was given 1.5 grams of amoxicillin.
History of Present Illness:
This is a 43 yo M who presents with increased urinary frequency
x one week, found to have new onset [**Hospital 23051**] transferred to MICU for
management on HONC. He complained of urinary incontinence and
episodic R-sided weakness. He reports 3 falls at home in last
week. He woke up on the floor, not remembering how he got from
the bed to the floor.
.
In the ER he was given a regular insulin bolus of 4 units (0.05
u/kg of ideal weight) at 4 units insulin gtt (0.05u/kg/hr) at 1
a.m. At 4:30 am he received a 10 unit bolus with 6 units/hr
gtt. EKG showed worsening ST depressions in leads 2, 3, 4, and
v4-v6. He received 325 mg of ASA. Head CT and CXR were
negative. UA negative for infection and ketones. IVF were
given via 20g IV. The IV team was unable to obtain second IV.
He was given 1.5 grams of amoxicillin.
Past Medical History:
-Type A Aortic Dissection Repair (hemiarch and ascending aorta
repair, aortic valve repair) - [**1-/2152**]
-Strokes: several peri-procedural embolic strokes involving
bilateral hemispheres.
-chronic renal insufficiency (ARF due to ATN during admission
for aortic dissection in [**2151**] and required transient HD); cr
baseline 2.0-2.2
-bilateral peroneal neuropathies
-chronic low back pain
-peripheral neuropathy
-hypertension
-prurigo nodularis
-Hypercholesterolemia
-Asthma
-Sarcoid
-h/o ishemic hepatitis s/p celiac stent along with L CIA/EIA
stent
-h/o Klebsiella UTI
Social History:
lives with wife, no ETOH, no drugs, no tobacco
Family History:
Non-contributory.
Physical Exam:
Vitals: 99.6 89 125/70 21 94% RA
GEN: Morbidly obese male in NAD, breathing comfortably
HEENT: Sclera anicteric, OP clear with dry MM
Neck: thick, unable to assess JVP
CV: RRR, S1/S2 with mechanical click. no MRG
Resp: CTAB
Abd: Obese, soft, NT/ND, +BS
Ext: No peripheral edema
Skin: xerosis to LE
Neuro: PERRLA, EOMI intact, L Amblyopia (previously noted),
+Horizonal Nystagmus bilaterally, CN otherwise intact.
Decreased sensation to light touch on bilateral lower
extremities. 4+ strength og R LE, otherwise 5/5 strength
throughout.
Pertinent Results:
Head CT [**2-28**]: No evidence of acute intracranial pathology.
Please note that MRI with diffusion-weighted sequences is more
sensitive for detection of acute ischemia.
.
CXR [**3-1**]: No pneumonia or CHF. Improving right discoid
atelectasis.
.
EKG [**2-28**]: NSR @ 87, nl axis/intervals, STD in II, III, aVF,
V4-V6 (new since [**11-11**])
.
.
[**2155-2-28**] 09:50PM WBC-7.3 RBC-4.49* HGB-15.0 HCT-47.1 MCV-105*
MCH-33.4* MCHC-31.9 RDW-15.1
[**2155-2-28**] 09:50PM NEUTS-64.0 LYMPHS-30.4 MONOS-2.3 EOS-2.8
BASOS-0.6
[**2155-2-28**] 09:50PM PLT COUNT-192
.
[**2155-2-28**] 09:50PM CK-MB-3 cTropnT-0.02*
[**2155-2-28**] 09:50PM CK(CPK)-197*
[**2155-3-1**] 08:49AM CK-MB-3 cTropnT-0.03*
[**2155-3-1**] 10:12PM CK-MB-4 cTropnT-0.03*
[**2155-3-1**] 10:12PM CK(CPK)-194*
.
[**2155-2-28**] 09:50PM GLUCOSE-989* UREA N-45* CREAT-3.9*#
SODIUM-120* POTASSIUM-4.4 CHLORIDE-75* TOTAL CO2-30 ANION GAP-19
[**2155-3-1**] 08:49AM GLUCOSE-250* UREA N-42* CREAT-3.5* SODIUM-134
POTASSIUM-3.0* CHLORIDE-92* TOTAL CO2-26 ANION GAP-19
.
[**2155-2-28**] 10:53PM URINE RBC-0-2 WBC-[**4-9**] BACTERIA-RARE YEAST-RARE
EPI-[**7-15**]
[**2155-2-28**] 10:53PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-2-28**] 10:53PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
.
[**2155-3-1**] 02:25PM TYPE-ART PO2-82* PCO2-49* PH-7.40 TOTAL
CO2-31* BASE XS-3 INTUBATED-NOT INTUBA
[**2155-3-1**] 02:25PM LACTATE-1.8
[**2155-2-28**] 10:53 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2155-3-2**]**
URINE CULTURE (Final [**2155-3-2**]): NO GROWTH.
Brief Hospital Course:
A/P: 42 yoM with MMP, including morbid obesity, aortic
dissection s/p repair and complicated by h/o multiple embolic
strokes, CKD who presents with hyperglycemia now on insulin gtt.
.
1) Hyperglycemia: the patient was given IV insulin, aggressive
IVF and placed in the [**Hospital Unit Name 153**] for further care. A TLC was placed
given the patient's poor IV access. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was
obtained for titration of lantus and humalog. The patient's BG
trended down and he was transitioned to sc regimen without
difficulty. He was transferred to the floor with diabetic
teaching. He will follow up with [**Last Name (un) **] the day after discharge
for further care.
2) Altered Mental Status: combination of hyperglycemia and
uremia. head CT was unremarkable. This resolved with adequate
control of BG.
3) History of aortic dissection: No active issues.
- Continue lopressor
.
4) Status post CVA: No active issues.
- Continue ASA, lopressor, trileptal
.
5) Peripheral neuropathy: No active issues.
- Continue amitryptiline, vitamin B12
6) Hypertension: The patient's HCTZ was held during the
admission as he was admitted with severe volume depletion and
ARF that improved with IVF. The HCTZ will need to be restarted
by his PCP as an outpatient.
Medications on Admission:
albuterol IH prn wheezing
amitriptyline 50 mg QHS
androgel 1.25g transdermal QDay
aspirin 81 QD
calcitriol 0.25 mcg TIW
cyanocobalamin [**2147**] mcg QDay
gabapentin 600 mg TID
hydrochlorothiazide 25 mg QDay
Lopressor 200 mg [**Hospital1 **]
amlodipine 10 mg QDay
Trileptal 300 mg [**Hospital1 **]
Xalatan 1 drop OU daily
- amoxicillin 500 mg PO QDay x 3 days (for recent dental
procedure)
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Metoprolol Tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO three
times a week.
8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
10. Lantus 100 unit/mL Solution Sig: One (1) 40 Subcutaneous at
bedtime.
Disp:*1 bottle* Refills:*5*
11. Humalog 100 unit/mL Solution Sig: One (1) as directed by
sliding scale Subcutaneous four times a day.
Disp:*2 bottles* Refills:*5*
12. Syringe (Disposable) Syringe Sig: One (1) Miscellaneous
four times a day.
Disp:*1 box* Refills:*5*
13. Lancets,Ultra Thin Misc Sig: One (1) Miscellaneous four
times a day.
Disp:*1 box* Refills:*2*
14. Humalog sliding scale
Please see attached sliding scale for your Humalog dose. You
should check your blood sugar four times daily (prior to each
meal and once at bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Diabetes Type II, insulin dependent
hyperglycemia
HTN
dyslipidemia
asthma
ARF
Discharge Condition:
stable
Discharge Instructions:
You were admitted with hyperglycemia and diagnosed with diabetes
Type 2. You will need careful follow up in the future from both
your PCP and the [**Name9 (PRE) **] Clinic. Please call your PCP if you
develop increased urinary frequency, thirst, dizziness, or new
symptoms.
Followup Instructions:
[**Hospital **] Clinic [**Telephone/Fax (1) 2384**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] [**2155-3-5**] at
2:30 PM
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2155-3-7**] 9:45
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2155-4-1**]
1:45
Provider: [**Name8 (MD) 23218**],MD Phone:[**Telephone/Fax (1) 1091**]
Date/Time:[**2155-4-10**] 9:10
Your hydrochlorathiazide is currently on hold until your renal
function improves.
|
[
"584.9",
"250.22",
"272.0",
"135",
"585.9",
"356.9",
"276.51",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8165, 8220
|
4944, 5685
|
279, 1111
|
8342, 8351
|
3245, 4921
|
8675, 9339
|
2649, 2668
|
6701, 8142
|
8241, 8321
|
6287, 6678
|
8375, 8652
|
2683, 3226
|
226, 241
|
1139, 1971
|
5700, 6261
|
1993, 2569
|
2585, 2633
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,227
| 173,468
|
10979
|
Discharge summary
|
report
|
Admission Date: [**2161-3-5**] Discharge Date: [**2161-4-4**]
Date of Birth: [**2102-11-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
CC: worsening pleural effusion and SOB
Major Surgical or Invasive Procedure:
Paracentesis [**2161-3-6**]
Thoracentesis x 2
Pleurodesis
Pleural biopsy
Swan-Ganz catheter placement [**2161-3-25**]
History of Present Illness:
This is a 58 yo woman with a history of cirrhosis and portal HTN
likely [**1-22**] sarcoidosis who is s/p failed TIPS procedure on
[**2161-1-20**] due to clots in the intrahepatic and extrahepatic portal
vein with short segment portal vein occlusion and cavernous
transformation. Patient also has a history of esophageal
varices and variceal bleeds and is s/p band ligation therapy
most recently on [**2161-1-1**]. Patient was recently hospitalized at
[**Hospital1 18**] between [**2161-1-13**] and [**2161-2-6**] during which she was found to
have a polymycrobial right thigh abcess likely [**1-22**]
?endocarditis--patient had MSSA bacteremia, but had a negative
TTE (TEE contraindicated given patient's severe esophageal
varices). Patient is currently being treated with an [**7-30**] week
course of vancomycin and levofloxacin, and continued diuresis on
lasix and aldactone as an outpatient. She had a large volume
paracentesis on [**2161-2-25**] with removal of 4.5L, which reportedly
helped ameliorate her abdominal discomfort.
.
She then presented to OSH in [**State 1727**] experiencing 3 days of
worsening SOB/DOE and L sided chest pain. She rates the pain as
an [**7-30**] described as a "rubber band tightening up more and
more." Patient was r/o for MI and was found to have normal LV
function by Echo. She was found to have worsening pleural
effusion, and underwent a left thoracentesis on [**2161-3-4**] that
provided significant improval in her symptoms. Discussion
regarding possible chest tube placement with pleurodiesis was
initiated at the OSH, and deferred to our further management
here.
Past Medical History:
1) Hepatic sarcoid (dx [**2134**]) -> cirrhosis s/p liver biopsy X 3;
significant portal hypertension with massive splenomegaly and
esophageal varices
2) Sarcoidosis - pulm involvement, s/p mediastinsocopy and
biopsy
[**2124**]
3) Esophageal varices s/p bleeds in [**3-25**] and another one in
[**11-24**] in spite of band ligation therapy (most recent [**2161-1-1**])
4) ? Endocarditis ([**Date range (1) 35604**])
5) Thigh abscesses (?rel to septic emboli, [**Date range (1) 35604**])
6) Hypersplenism - splen 19 cm -> thrombocytopenia
7) History of dysphagia
8) GERD
9) Hypertension
10) OSA
11) Bipolar disorder, type II
12) Spastic bladder with incontinence
13) Constipation
Social History:
Denies smoking, EtOH, and illicits. Married with 2 adult
daughters. Retired from her position as a surgical residency
administrator 2 years ago.
Family History:
Denies h/o CVA, heart attack. Mother lung cancer (smoker).
Physical Exam:
Physical Exam on Admission [**2161-3-6**]
Vitals: T 98.9 (max 99.5) BP 108/58 HR 94 (max 107) RR 18
O2sat 98% on 3L (90% on RA earlier in the AM)
General: ill-appearing woman in NAD who is lying in bed
comfortably--she is not using accessory mm of breathing, but
becomes SOB after talking for extended periods of time
HEENT: PERRL; slight scleral icterus; OP clear of erythema,
lesions, or exudates, but notable for poor dentition and white
film lining the tongue
Neck: no TMG or LAD
Chest: notable for decreased breath sounds in the entire L lung
field and decreased breath sounds starting half way down on the
R side with bronchial breath sounds in the upper field
Cardiac: tachycardic; normal S1 and S2 with a II/VI systolic
murmur heard best in the LUSB with no radiation to the carotids;
no JVD
Abdomen: soft, non-tended, non-distended but full at the
flanks; she has dullness to percussion laterally and has
shifting dullness to percussion; she denies any rebound
tenderness and has no other peritoneal signs; hepatomegaly,
splenomegaly, and any other masses not appreciated; active BSX4
Extremites: 1+ pitting edema at the ankles b/l; distal pulses
2+; r thigh notable for a 3 inch well-healed scar with no signs
of infection, including erythema, warmth, or tenderness
Neuro: A&OX3; no asterixis; good affect; pleasant and
appropriately interactive
Pertinent Results:
CBC
[**2161-3-6**] 02:24AM BLOOD WBC-5.7 RBC-2.78* Hgb-9.8* Hct-28.3*
MCV-102*# MCH-35.1* MCHC-34.5 RDW-17.3* Plt Ct-103*
[**2161-3-7**] 06:12AM BLOOD WBC-4.7 RBC-2.80* Hgb-9.7* Hct-28.6*
MCV-102* MCH-34.5* MCHC-33.8 RDW-17.2* Plt Ct-125*
[**2161-3-7**] 06:12AM BLOOD Neuts-76.0* Lymphs-15.5* Monos-7.1
Eos-1.2 Baso-0.1
[**2161-3-8**] 05:45AM BLOOD WBC-5.9 RBC-2.87* Hgb-9.9* Hct-29.1*
MCV-101* MCH-34.4* MCHC-33.9 RDW-17.1* Plt Ct-146*
[**2161-3-9**] 06:10AM BLOOD WBC-4.1 RBC-2.65* Hgb-9.1* Hct-27.0*
MCV-102* MCH-34.1* MCHC-33.5 RDW-16.8* Plt Ct-123*
[**2161-3-10**] 05:56AM BLOOD WBC-8.8# RBC-3.04* Hgb-10.5* Hct-31.2*
MCV-103* MCH-34.4* MCHC-33.6 RDW-16.5* Plt Ct-178
[**2161-3-11**] 04:29AM BLOOD WBC-5.2 RBC-2.57* Hgb-8.9* Hct-26.3*
MCV-102* MCH-34.5* MCHC-33.7 RDW-16.4* Plt Ct-109*
[**2161-3-12**] 05:14AM BLOOD WBC-5.4 RBC-2.54* Hgb-8.7* Hct-26.2*
MCV-103* MCH-34.4* MCHC-33.4 RDW-16.4* Plt Ct-111*
[**2161-3-13**] 05:51AM BLOOD WBC-4.0 RBC-2.47* Hgb-8.2* Hct-25.6*
MCV-103* MCH-33.3* MCHC-32.2 RDW-16.5* Plt Ct-102*
[**2161-3-6**] 02:24AM BLOOD PT-15.6* PTT-30.9 INR(PT)-1.4*
[**2161-3-13**] 05:51AM BLOOD PT-14.7* PTT-34.0 INR(PT)-1.3*
.
Chemistry
[**2161-3-6**] 02:24AM BLOOD Glucose-111* UreaN-21* Creat-1.0 Na-129*
K-3.6 Cl-95* HCO3-29 AnGap-9
[**2161-3-9**] 06:10AM BLOOD Glucose-102 UreaN-20 Creat-1.1 Na-131*
K-3.6 Cl-94* HCO3-28 AnGap-13
[**2161-3-13**] 05:51AM BLOOD Glucose-109* UreaN-17 Creat-1.0 Na-132*
K-3.8 Cl-97 HCO3-27 AnGap-12
[**2161-3-6**] 02:24AM BLOOD ALT-16 AST-43* AlkPhos-213* TotBili-3.3*
[**2161-3-7**] 06:12AM BLOOD ALT-16 AST-46* LD(LDH)-163 AlkPhos-227*
TotBili-2.7*
[**2161-3-8**] 05:45AM BLOOD ALT-18 AST-46* AlkPhos-244* TotBili-2.6*
[**2161-3-9**] 06:10AM BLOOD ALT-16 AST-39 AlkPhos-208* TotBili-3.0*
[**2161-3-10**] 05:56AM BLOOD ALT-15 AST-42* LD(LDH)-163 AlkPhos-204*
TotBili-2.7*
[**2161-3-11**] 04:29AM BLOOD ALT-14 AST-42* AlkPhos-204* TotBili-2.6*
[**2161-3-12**] 05:14AM BLOOD ALT-14 AST-42* AlkPhos-203* TotBili-2.4*
[**2161-3-13**] 05:51AM BLOOD ALT-14 AST-42* LD(LDH)-150 AlkPhos-204*
TotBili-2.2*
[**2161-3-6**] 06:23AM BLOOD Albumin-2.7* Calcium-8.9 Phos-2.0* Mg-1.8
[**2161-3-7**] 06:12AM BLOOD Albumin-2.6* Calcium-8.9 Phos-2.3* Mg-2.0
[**2161-3-10**] 05:56AM BLOOD TotProt-6.3* Albumin-3.2* Globuln-3.1
Calcium-8.5 Phos-1.7* Mg-1.7
[**2161-3-13**] 05:51AM BLOOD TotProt-5.9* Albumin-2.7* Globuln-3.2
Calcium-9.4 Phos-2.0* Mg-1.8
.
Vancomycin Level
[**2161-3-10**] 10:00PM BLOOD Vanco-22.6*
.
Cardiac Enzymes Negative X 3
[**2161-3-6**] 06:23AM BLOOD CK-MB-NotDone
[**2161-3-6**] 01:41PM BLOOD CK-MB-NotDone
[**2161-3-6**] 09:02PM BLOOD CK-MB-NotDone cTropnT-0.01
.
STUDIES:
Abdominal US [**3-6**] COMPARISONS: MR [**First Name (Titles) 767**] [**2161-1-31**].
FINDINGS: There are no stones within the gallbladder. There is
no intra- or extra-hepatic biliary ductal dilatation. A large
amount of ascites is again noted. The liver is quite
heterogeneous and irregular, consistent with cirrhosis.
On duplex Doppler examination, again noted is occlusive
thrombosis of the main portal vein. No portal venous flow is
detectable in the main portal vein or regions which would
correspond to its major tributaries. However, the main, right,
and left hepatic arteries are patent. The right, middle, and
left hepatic veins are also patent with appropriate directional
flow.
IMPRESSION:
1. Large amount of ascites.
2. Cirrhosis.
3. Patency of the main hepatic artery and the major hepatic
veins.
4. Occlusive thrombosis of the main portal vein, as noted
previously.
.
CXR [**3-6**] Comparison is made to [**2161-2-3**].
AP UPRIGHT RADIOGRAPH OF THE CHEST: The heart size, mediastinal
and hilar contours are within normal limits and unchanged.
Left-sided PICC line appears to be in unchanged position with
the tip in the lower SVC. There has been interval development of
retrocardiac consolidations with air bronchograms and
obscuration of the left hemidiaphragm. In addition, there is
increase in the bilateral pleural effusions, predominantly on
the left. These findings are consistent with interval
development of a left lower lobe pneumonia. There are stable
mild fibrotic lung changes.
IMPRESSION: New left lower lobe pneumonia. Increased bilateral
pleural effusions.
.
EKG [**3-6**] Sinus rhythm. Minimal ST segment elevation in the
lateral and anterolateral leads with minimal ST segment
depression in the anterior leads consistent with possible
ischemia or infarction. Compared to the previous tracing these
changes are more apparent
.
Chest CT [**3-8**]
1. No evidence of pulmonary.
2. Moderate to severe layering bilateral pleural effusions with
associated compressive atelectasis and patchy bilateral ground
glass opacity suggestive of fluid overload.
.
CXR [**3-8**] CHEST: PA and lateral views are compared to previous
examination of [**2161-3-6**]. Again seen left lower lobe
parenchymal opacity with bilateral pleural effusions greater on
the left. There is diffuse increased interstitial marking,
suggesting chronic interstitial lung disease. There is no
evidence of pulmonary edema.
IMPRESSION: Left lower lobe pneumonia vs atelectsis without
significant change since the previous examination of [**2161-3-6**]. Moderate left and small right pleural effusions.
.
EKG [**3-8**] Sinus tachycardia
Poor R wave progression - ? lead placement Nonspecific ST
segment elevation in leads l, aVL, V5-V6 with ST segment
depression in leads V1-V2 - clinical correlation is suggested
Since previous tracing, sinus tachycardia present
.
CXR [**3-9**] INDICATION: Left-sided thoracentesis, now with
worsening shortness of breath and chest pain, evaluate for
pneumothorax. Comparison is made with radiograph obtained
earlier on [**2161-3-9**]. The cardiac silhouette is unchanged
and unremarkable. Small bilateral pleural effusions are again
noted. No pneumothorax is noted. Lung volumes are low
bilaterally with bibasilar atelectasis. Chest wall is
unremarkable.
IMPRESSION:
1. No pneumothorax.
2. Persistent small bilateral effusions with bibasilar
atelectasis.
.
CXR [**3-9**] COMPARISON: [**2161-3-8**] at 09:03.
FINDINGS: The radiograph is not significantly different from
yesterday. Again seen is a left lower lobe opacity. In addition,
bilateral pleural effusions are present, left greater than the
right, and that do not appear significantly different from
yesterday.
IMPRESSION:
1. No significant change in bilateral pleural effusions, left
greater than right.
2. Left lower lobe opacity that is unchanged from yesterday.
.
EKG [**3-9**] Sinus tachycardia. Delayed precordial R wave
progression as recorded on tracing of [**2161-3-8**]. Technically
limited study. There is continued ST segment elevation in leads
I and aVL and V5-V6 consistent with lateral ischemic process.
Rule out myocardial infarction. Followup and clinical
correlation are suggested.
.
Esophagus, biopsy [**3-10**]: Tiny strips of squamous epithelium with
acute inflammation and fungi consistent with [**Female First Name (un) **].
.
CXR [**3-11**] COMPARISON: [**2161-3-9**]. FINDINGS: There is a
moderate/large left-sided effusion markedly increased compared
to the prior examination. Given the history hemothorax cannot be
excluded. The right lung is clear. The osseous structures are
unremarkable. IMPRESSION: Increased moderate/large left-sided
effusion. Please note that a hemothorax cannot be excluded.
Short-term follow-up is recommended.
.
Ankle Plain Film Right ankle: Three views, shows mild soft
tissue swelling about the ankle. There may be small joint
effusion posteriorly, however, the lateral view of the ankle is
obtained in plantar-flexed position. A posterior calcaneal spur
is seen. There is no bone destruction or erosion. The joint
space and articular cortices are preserved.
.
LE US [**3-11**] TECHNIQUE: Limited extremity ultrasound of the right
ankle.
FINDINGS: These views show subcutaneous edema but no evidence of
a well-defined fluid collection. To assess for symmetry, a few
images of the left ankle in a similar location were taken along
the medial ankle, and show symmetry of the subcutaneous edema.
IMPRESSION: Subcutaneous edema, without evidence of a
well-defined fluid collection.
.
Thigh MRI [**3-11**] TECHNIQUE: T1, inversion recovery and pre- and
post-gadolinium T1 fat sat sequences were performed in multiple
planes.
COMPARISON: Thigh MRI dated [**2161-1-16**].
FINDINGS: The multiple fluid collections within the soft tissues
of the right thigh are no longer identified. There is persistent
edema within the subcutaneous tissues of both thighs, right side
greater than left. This subcutaneous edema has not significantly
changed from prior exam.
No new fluid collections are identified. There are no hip
effusions. Bone marrow signal is normal. Post-gadolinium imaging
demonstrates no abnormal enhancement.
IMPRESSION: Interval resolution of the multiple fluid
collections within the right thigh. Persistent subcutaneous
edema
.
MRI [**3-12**] TECHNIQUE: Multiplanar T1- and T2-weighted images were
obtained including axial in- and out-of-phase, axial and coronal
HASTE, 2D time-of-flight and 3D VIBE pre-, during, and
post-gadolinium enhancement with subtractions in each phase.
3D reconstructions were made in a separate workstation.
FINDINGS: Bilateral pleural effusions, right greater than left,
unchanged from the prior study. There is a small pericardial
effusion with possible pericardial enhancement post-gadolinium
administration. The significance of this finding is unknown and
linical correlation is recommended.
The liver is atrophic with a background of innumerable nodules
surrounded by extensive fibrosis. There is no biliary duct
dilatation. There are no focal arterial enhancing lesions. The
spleen shows heterogeneous enhancement likely related to portal
hypertension. There is a tiny 7-mm cystic lesion projecting
anteriorly through the main pancreatic duct in the body of the
pancreas, unchanged from prior studies back to [**2158**]. Otherwise
the pancreas is unremarkable. The adrenal glands, left kidney,
and gallbladder are unremarkable. The right kidney is atrophic,
unchanged from prior studies.
The proximal main portal vein and the right portal veins are
attenuated but patent. There is a very thin vessel within the
left lobe that may represent a recanalized left portal vein,
however, we cannot see connection with the main portal vein.
The superior mesenteric is attenuated but patent. The splenic
vein is widely patent. There are extensive varices within the
abdomen as well as esophageal varices. There is a large amount
of ascites throughout the abdomen.
3D reconstructions were helpful in the delineation of anatomy
and pathology.
IMPRESSION:
Cirrhotic liver consistent with patient's history sarcoidosis.
No suspicious hepatic lesions
Attenuated patent main and right portal veins. There is a very
thin vessel within the left lobe that may represent a
recanalized left portal vein, however, we cannot see connection
with the main portal vein.
Attenuated but patent SMV. The splenic vein is widely patent.
Bilateral pleural effusions, ascites, and splenomegaly,
unchanged from prior studies.
Chronically atrophic right kidney and small cystic lesion in the
body of the pancreas, unchanged from prior study.
Small pericardial effusion with pericardial enhancement
post-gadolinium administration. Correlate clinically and if
indicated with echocardiogram.
.
CXR [**3-13**] COMPARISON: Chest x-rays [**3-9**] and [**2161-3-11**].
FINDINGS: Since the previous exam, there has been slight
decrease in size of the moderate left pleural effusion. Small
right pleural effusion persists. Left lower lobe
consolidation/collapse is again noted with air bronchograms. The
right lung appears predominantly clear. There is no
pneumothorax. The heart size appears unchanged although slightly
difficult to assess given the left pleural effusion.
IMPRESSION: Decrease in size of still moderate left pleural
effusion. No change in size of small right pleural effusion.
.
ECHO [**3-13**]
Conclusions:
1. The left ventricular cavity size is normal. Regional left
ventricular wall
motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%).
2. There is a small to moderate sized pericardial effusion with
thick
fibrin/thrombus deposits on the surface of the heart. There are
no
echocardiographic signs of tamponade.
3. Compared with the findings of the prior study of [**2161-1-23**], the
size of the
pericardial effusion has increased.
Echo: [**3-24**]:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%).
There is a small to moderate sized pericardial effusion. There
is sustained
right atrial collapse, consistent with low filling pressures or
early
tamponade.
Compared with the prior study (images reviewed) of [**2161-3-13**],
the effusion
appears similar. Right atrial collapse was also present
previously
Echo: [**3-25**]
Left ventricular systolic function is hyperdynamic (EF>75%).
There is a small
to moderate sized pericardial effusion. There is sustained right
atrial
collapse, consistent with low filling pressures or early
tamponade (however
views are technically suboptimal).
Echo: [**2161-3-30**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right
ventricular chamber size and free wall motion are normal. The
mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated
pulmonary artery systolic pressure is normal. There are no
echocardiographic
signs of tamponade. No right atrial diastolic collapse is seen.
No right
ventricular diastolic collapse is seen. There is borderline
accentuated
respiratory variation in mitral/tricuspid valve inflows (approx
20% variation
which is not diagnostic).
Compared with the prior study (images reviewed) of [**2161-3-25**], the
effusion
appears smaller. RA diastolic collapse is no longer seen.
IMPRESSION: Small pericardial effusion without tamponade.
Pleural Biopsy:
Pleural biopsies:
a. Pleural tissue with fibrinous exudate, and granulation
tissue.
b. No granulomas seen.
c. No malignancy identified.
Pleural Fluid Cytology and Flow Cytometry
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR, FMC-7,
and CD antigens 3, 4, 5, 8, 10, 19, 20, 23, and 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
Cell marker analysis demonstrates a reduction in the percentage
of B cells.
T cells express mature lineage antigens and have a
helper-cytotoxic ratio of 0.5.
INTERPRETATION
Non-specific T-cell dominant reactive lymphoid profile; no
phenotypic evidence of lymphoma in specimen. Correlation with
clinical findings and morphology is recommended. Flow cytometry
immunophenotyping may not detect all lymphoma as due to
topography, sampling or artifacts of sample preparation.
Lower Extremity Non-Invasive Studies: No DVT identified
Cardiac MRI: read pending upon discharge from [**Hospital1 18**]
Abdominal Ultrasound:
FINDINGS: There is a 1.1 cm stone in the nondistended
gallbladder. The liver is nodular and heterogeneous in
echotexture and significantly decreased in size consistent with
the patient's known cirrhosis. The hepatic artery, hepatic vein,
and portal vein are patent with appropriate direction of flow.
The common duct is not dilated. A 1.5 cm periportal lymph node
is identified. The pancreas is unremarkable. Note is made of
tortuous collateral vessels in the epigastric region. The spleen
is markedly enlarged measuring 19 cm. There are bilateral
pleural effusions. A moderate amount of ascites is identified. A
spot was marked in the left flank for paracentesis.
IMPRESSION:
1. Spot marked in left flank for bedside paracentesis.
2. Cirrhotic liver and marked splenomegaly.
3. Cholelithiasis without evidence of cholecystitis.
4. Bilateral pleural effusions.
Brief Hospital Course:
This is a 58 yo woman with cirrhosis [**1-22**] to sarcoidosis
complicated by esophageal varices and a failed TIPS procedure
attempted in in [**12-26**] who presents from an OSH for evaluation of
worsening pleural effusions (s/p L thoracentesis on [**3-4**] at
OSH).
.
* Pleural Effusion (presented w/ CP, tachycardia, &
SOB)--likely hepatic hydrothorax [**1-22**] to cirrhosis and ascites
(requires therapeutic paracentesis every week). Ddx also
includes hypoalbuminemia (albumin 2.7 on [**3-6**]) vs. pulmonary
complication of sarcoidosis vs. possible infectious process (WBC
not elevated, afebrile) vs. malignancy (no recent Hx of weight
loss) vs. recent onset diastolic dysfunction [**1-22**] sarcoidosis
(new Echo results pending) vs. heart failure [**1-22**] pericardial
effusion (seen on MRI, slight PR depressions on EKG). No h/o
heart failure (most recent echo in [**1-26**] shows normal LV
function), cardiac enzymes negative X 3, Pt is s/p Right-sided
thoracentesis on [**3-9**] in which 1.5 L of fluid was taken off--she
was repleted with 12 g of albumin following her procedure.
Follow-up CXR showed no significant change in bilateral pleural
effusions and no pneumothorax. Pleural specimen results were
consistent with an exudative process--LDH effusion/LDH serum is
157/163 which is significantly > 0.6 (Light's Criteria).
However, has been on long-term chronic diuretic therapy which
increases the concentration of LDH in peritoneum. However, the
serum-albumin gradient is > 1.2 meeting criteria for a
transudative process. Pulmonary was consulted regarding her
recurrent pleural effusions--they opine that effusions are
likely transudative [**1-22**] to asctes, but would like to r/o
malignancy and diastolic heart dysfunction. Pleuredesis may not
be effective in this patient due to the frequent recurrence of
effusion. Patient eventually underwent pleurodesis+pleural bx
which has stopped the fluid from re-accumulating. Pleural
biopsy showed inflammation, but no granulomas, no malignancy was
identified. Pleural effusions were shown to be stable by
multiple xrays. Patient does retain some degree of dyspnea most
likely due to atelectasis and deconditioning.
.
Pericardial effusion: Earlier in the week, Mrs. [**Known lastname 496**] was
noted so be a bit more hypotensive and a bit more short of
breath. An Echocardiogram revealed a small to moderate sized
pericardial effusion with right atrial collapse during diastole.
This could have been low intravascular volume or early
tamponade. Pulsus paradoxus ranged from [**4-1**] over a few days.
On [**3-26**], bc seemed even more dyspneic and despite the lower
concern for tamponade, it was felt important to accurately make
the diagnosis so she was brought to the CCU for Right heart
catheterization. RHC showed low filling pressures (PCWP 11, CVP
7, PAP 22/5). After fluid resusitation (albumin and rbcs
given), pressures were better (PCWP 16, CVP 13, PAP 32/20).
Systolic pressures remained in 80s. This was NOT felt to be
tamponade physiology. The effusion has not enlarged based on
multiple echos. A cardiac MRI was performed and the read was
pending on the time of discharge. ? cardiac sarcoid, causing
pericardial effusion.
.
* Cirrhosis/Ascites--[**1-22**] sarcoid liver disease--patient has
persistently elevated Tbili & AlkPhos and slightly elevated AST.
Thrombocytopenia and hypoalbuminemia indicate synthetic
dysfunction. Initially, abdominal U/S shows a large amount of
ascites--the ascites chemistries are notable for only 5% PMNs
arguing against a bacterial infection. The SAAG is calculated
to be 1.6, confirming portal hypertension related ascites.
Abdominal/Pelvic MRI showed attenuated patent main and right
portal veins, a very thin vessel within the left lobe that may
represent a recanalized left portal vein, (however, connection
with the main portal vein is not appreciated), an attenuated but
patent SMV, and a widely patent splenic vein. Patient has grade
II varices, s/p 1 banding, was due for the second banding, not
performed during this admission due to complicated medical
situation. The patient will follow up this issue after
discharge.
.
* h/o bacteremia (Blood Cx Staph Aureus Coag + on
[**2160-12-2**])/thigh abcesses (wound cx positive for Strep Milleri on
[**2160-12-19**]) [**1-22**] ?endocarditis
--Vancomycin was D/C on [**3-13**] as MRI showed interval resolution
of the multiple fluid collections within the right thigh as
compared to imaging done on [**2161-1-16**].
.
So, in summary:
58 yo woman with hepatic sarcoid. Diagnosed with pulmonary
sarcoid in [**2151**], stopped chronic Prednisone for pulmonary
sarcoid in [**2155**] as per the pulmonary clinc. Had esophageal
variceal bleed in [**3-25**] requiring banding. Subsequent banding
sessions not successful at eradicating esophageal varices.
Developed presumed endocarditis and R thigh abscess (cx grew out
Strep milleri, TTE negative for vegetations) in [**11-24**]. Has been
on chronic iv Vancomycin and Levofloxacin since [**11-24**] and is
closely followed by ID. Admitted to [**Hospital1 18**] on [**2161-1-13**] to [**2161-2-6**]
for elective TIPS placement due to esophageal varices. This was
attempted but not successful due to distal main PV clot and
clotted intrahepatic portal veins. She became hypotensive
peri-TIPS procedure, requiring stay in ICU. During admission,
had pretransplant evaluation, and right thigh abscess was
reassessed, right thigh MRI showed decreased size of abscess,
with no fluid collection that was amenable to drainage by
radiology. ID recommends long-term Vanc and Levo, and plans to
do repeat MRIs periodically. Negative P-MIBI. As for
pretransplant status, still willing to consider for liver
transplant, despite PV clots, because SMV was patent on
abdominal MRI. Presented to Hospital in [**State 1727**] on [**2161-3-3**] with 1
day chest pain and shortness of breath. Found to have bilateral
pleural effusions, which were tapped. Transferred to [**Hospital1 18**] for
further eval. During long [**2161-1-13**] to [**2161-2-6**] hospital course,
would typically get progressively short of breath as abdominal
ascites reaccumulated, and generally needed a large volume
paracentesis about once a week, when more than 3 L was removed,
became hypotensive despite pre procedure Albumin, requiring
short ICU stays. Last LVP at [**Hospital1 18**] was 4.5 L and tolerated OK.
Shortness of breath was different from when ascites
reaccumulated, chest pain is new, does not feel like her usual
GERD pain. Large volume paracentesis. Recurrent exudative
pleural effusions, also small-mod pericardial effusion, ?hepatic
hydrothorax vs. other process. Got pleuroscopy with pleural bx
and pleurodesis [**2161-3-20**]. Repeat MRI of thigh showed resolution
of thigh abscess and now off abx. Repeat MRI abd shows patent
SMV.
[**Date range (1) 35607**]
Pleural biopsy w/o granulomas. Has had low BP, hyponatremia.
Holding off on diuretics due to dehydration. Bursts of atrial
tachycardia and increased pulsus. ECHO with mod pericardial
effusion. Started on Nadolol. Trnasferred to CCU for Swan to
check pressure and R/O tamponade. PA diastolic pressures low
suggesting underfilling. Replenished with improvement in PAD.
Not a candidate for drainage since effusion is stable on
repeated echo, ?cardiac sarcoid. Pulmonary does not feel this is
pulm/cardiac sarcoid, rather there may be another reason for
serositis. No steroids for now. Called out to floor. Stable from
hepatology standpoint, ascites small, no peripheral edema,
continuing to hold diuretics. Had slight drop in blood pressure,
Nadolol held, afebrile.
Still dyspneic, hypoxic, CXR showed persistent pleural effusion.
No further W/U needed, but need aggressive pulm toilet and
rehab.
Card: fluid restriction
Pulm: W/U for other serositis
[**3-30**] ECHO: small pericardial effusion
[**3-30**] US: mod ascites
[**3-31**] card MRI: pending
Plan:
Patient will follow up with Dr. [**Last Name (STitle) **] to discuss further
options about liver transplantation, esophageal banding and sbp
prophylaxis, since last abdominal ultrasound showed
re-accumulating ascites.
Medications on Admission:
Medications on Transfer
1. Vancomycin 750 mg Q 24H for right thigh abscess which needs
to be continued for 8-10 weeks (started at end of [**December 2160**])
2. Lasix 20mg IV qd
3. Ditropan 10mg qd
4. Levofloxacin 250mg qd
5. Lamictal 25mg qd (pt states she take 50mg qd at home)
6. Protonix 40mg qd
7. Prozac 20mg qd
8. Ursodiol 300mg [**Hospital1 **]
9. Lactulose tid
10. nystatin swish and swallow
11. albuterol inhaler
.
Additional Home Medications per Patient:
Aldactone 50 mg tid (not given at OSH)
Sucralfate 1 g [**Hospital1 **] - not given at OSH
Nadolol 20mg qd - d/c'ed [**1-22**] hypotension
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
L pleural effusion
Sarcoidosis-related liver cirrhosis
Pericardial effusion
Esophageal candidiasis
Polyserositis
Ascites
Paroxysmal Atrial Tachycardida
Hypotension
Discharge Condition:
stable, afebrile, ambulating with assistance
Discharge Instructions:
-please take your medications as directed
-please follow up all outpatient appointments
-please call your [**Hospital6 3390**] or go to the ER should you experience more
shortness of breath, abdominal pain, fevers, chills, nausea,
vomiting, diarrhea.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2161-4-15**] 1:00
.
Dr. [**Last Name (STitle) **] (cardiology): appointment to be arranged. Please
call ([**Telephone/Fax (1) 5862**] to arrange an appointment.
.
please call your [**Telephone/Fax (1) 3390**] to make an appontment after discharge from
extended care facility.
Completed by:[**2161-4-7**]
|
[
"518.82",
"284.8",
"289.4",
"456.21",
"276.1",
"423.2",
"273.8",
"286.7",
"135",
"571.5",
"427.1",
"570",
"458.9",
"511.8",
"572.3",
"327.23",
"420.0",
"112.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"89.64",
"99.04",
"45.16",
"34.92",
"54.91",
"34.24",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
29190, 29263
|
20384, 28533
|
310, 429
|
29471, 29518
|
4416, 20361
|
29818, 30253
|
2958, 3018
|
29284, 29450
|
28559, 29167
|
29542, 29795
|
3033, 4397
|
231, 272
|
457, 2075
|
2097, 2778
|
2794, 2942
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,093
| 147,521
|
4454
|
Discharge summary
|
report
|
Admission Date: [**2185-3-31**] Discharge Date: [**2185-4-8**]
Date of Birth: [**2128-2-17**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Prednisone
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
dizziness and lethargy
Major Surgical or Invasive Procedure:
[**2185-4-6**]: Right frontal craniotomy for tumor resection
History of Present Illness:
57F who reports dizziness and lethargy for the last 3 weeks. She
reports feeling confused and having headaches. Her husband
reports that last weekend she collapsed from dizziness but the
details are unknown. She was seen by her PCP and he was
concerned that she suffered a seizure and did a head CT. She
denies any other symptoms
Past Medical History:
Hypertension
[**10/2184**] benign cyst removal (small portion of small and large
intestine removed)
Social History:
Married, lives with husband. [**Name (NI) **] two adult children in their
30's. Works as a sale coordinator. + Tobacco - 1 ppd, denies
ETOH
Family History:
Positive for father with heart attack at 55. He was a heavy
smoker. Mother died of liver problem at 42 and two older
brothers with hypertension.
Physical Exam:
O: T: 98.6 BP: 127/82 HR: 90 R 16 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Slight difficulty with commands.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: R pupil 3-2mm, L pupil 2-1mm. Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact with left
[**Last Name (un) **]-labial flattening.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-23**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Handedness: Right
PHYSICAL EXAM UPON DISCHARGE:
O: AVSS
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: R pupil 3-2mm, L pupil 2-1mm. Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact with left
[**Last Name (un) **]-labial flattening.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-23**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: Normal on finger-nose-finger
Handedness: Right
Incision: Clean/Dry/Intact with sutures in place, no erythema,
drainage, fluctuance
Pertinent Results:
[**3-31**] MRI BRAIN- IMPRESSION:
1. Multiple enhancing lesions in bilateral frontal and temporal
lobes and left cerebellar hemisphere with surrounding vasogenic
edema causing mass effect and leftward shift by 1.2 cm. The
findings are concerning for brain metastases; less likely
lymphoma, infectious or inflammatory process. Rec. NS/ oncology
consult and further workup.
Findings were discussed by Dr. [**First Name (STitle) 13414**] [**Name (STitle) 13415**] with Dr.
[**Last Name (STitle) **] on [**2185-3-31**] at 3:30 p.m. at the time of scanning.
It was decided to send the patient to the ER for urgent
management. Findings were later discussed by Dr. [**First Name (STitle) 13414**] [**Name (STitle) 13415**]
with the ER attending, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10751**] over the phone at
5:45 p.m.
2. Incidental small 3.3x2.9 millimeter aneurysm at the right
middle cerebral artery division- needs further assessment with
MRA and INR consult.
[**4-1**] CT TORSO:
IMPRESSION:
1. Multiple pulmonary nodules. The largest of these are seen in
the left
upper lobe (3:28) , has sattelite nodules and may represent the
primary
lesion. There are multiple smaller nodules seen throughout the
lungs. There is extensive hilar and mediastinal lymphadenopathy
with central necrosis seen of the lymph nodes. In the right
setting, the findings could also be infectious in origin (ex
TB).
2. There is left axillary lymphadenopathy with a 1.7 cm in
diameter lymph
node with central necrosis, which is amenable to CT or
ultrasound-guided
biopsy.
3. There is 8-mm left breast nodule seen in image 3:25.
4. There are multiple intermediate to solid density nodules seen
within the thyroid lobes bilaterally.
5. There is a right adrenal mass measuring, likely benign.
[**2185-4-5**]:
MRI BRAIN
FINDINGS: Multiple brain enhancing brain lesions are identified
with the largest at the right frontal lobe at the convexity with
surrounding edema and in mass effect on the adjacent lateral
ventricle. Several other lesions are seen including lesions in
the posterior fossa and the right temporal and left posterior
temporal lobes. There is no hydrocephalus.
IMPRESSION: MRI performed for surgical planning with markers
again
demonstrates multiple brain lesions seen on the previous MRI
[**2185-3-31**].
4/.17.12 CT BRAIN
FINDINGS: The patient is status post right frontal craniotomy
with expected subcutaneous gas and post-procedural
pneumocephalus as well as a trace amount of subarachnoid blood
in the resection bed. The sulci of the right frontal lobe are
effaced into a lesser extent the anterior [**Doctor Last Name 534**] of the right
lateral ventricle there is 8 mm of right to left shift of
normally midline structures (2A:13). There continues to be
vasogenic edema of the right frontal lobe in the resection bed.
There is no ntraventricular hemorrhage and the basal cisterns
are patent. The visualized paranasal sinuses and mastoid air
cells are clear.
IMPRESSION: Status post right frontal craniotomy with expected
post-procedural subcutaneous gas, pneumocephalus, extra-axial
blood products, and edema.
[**2185-4-6**] MRI BRAIN:
IMPRESSION: Postoperative changes after resection of right
frontal lobe
lesions. Minimal residual enhancement at the posterior margin of
the right
frontal lobe lesion is seen, best visualized on series 14, image
20. Minimal marginal restricted diffusion appears to be
secondary to surgery. Other enhancing brain lesions in the
temporal lobes and cerebellum are again identified, unchanged.
Brief Hospital Course:
Ms. [**Known lastname 19103**] was admitted to the neurosurgical service for further
work up of her brain lesions. A CT Torso was requested which
revealed multiple pulmonary lesions and adrenal lesions.
Neuro and Radiation oncology were consulted for assistance with
plan of care. It was recommended that she undergo surgical
intervention on [**4-1**] but she wanted to wait at that time. She
was started on decadron and keppra.
She was weaned off steroids due to anxiety, ativan was given as
needed. She had a rahc and was started on benadryl and sarna.
She was seen by socail work for coping on [**4-3**]. She had some
left sided weaknedd and was taken to the OR on [**4-5**] for a right
craniotomy for mass resection on [**4-5**]. She was taken to the SICU
post-operatively and had a MRI on POD1. She was neurlogically
stable and was taken to the floor. She was stable on the floor,
alert and oriented, neurologically intact, worked with PT on
[**4-7**] and was ambulating independently without difficulty. She
was discharged home in stable condition on [**4-8**] with plans for
follow up in the brain tumor clinic.
Medications on Admission:
Losartan 50mg Daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain/ fever.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Right frontal brain mass
Discharge Condition:
Discharge Condition: Stable
Clear and coherent
Alert and interactive
Ambulatory - Independent
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to the office in [**6-28**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain with / without contrast.
The appointments below were in our system / they are listed here
to serve as a reminder for you
Provider: [**Name10 (NameIs) 9977**] IN [**Location (un) 2788**] Phone:[**Telephone/Fax (1) 19104**]
Date/Time:[**2185-7-14**] 8:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 19104**] Date/Time:[**2185-7-14**] 9:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 19105**] Date/Time:[**2185-4-13**] 3:00
Completed by:[**2185-4-21**]
|
[
"E932.0",
"300.00",
"198.3",
"E947.9",
"162.8",
"255.9",
"401.9",
"611.9",
"785.6",
"348.5",
"780.39",
"305.1",
"693.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
9068, 9143
|
7047, 8167
|
343, 405
|
9232, 9307
|
3468, 7024
|
10992, 12066
|
1062, 1211
|
8238, 9045
|
9164, 9190
|
8193, 8215
|
9331, 10969
|
1226, 1351
|
281, 305
|
2352, 2429
|
433, 764
|
2681, 3449
|
2444, 2665
|
786, 888
|
904, 1046
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,666
| 119,064
|
427
|
Discharge summary
|
report
|
Admission Date: [**2159-5-26**] Discharge Date: [**2159-6-12**]
Date of Birth: [**2099-4-13**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Opioid Analgesics / Levaquin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Intubation/Extubation
RIJ central line, now removed
Lumbar puncture
History of Present Illness:
60 y.o. M with hx of ESRD s/p cadaveric renal tx in [**2155**], on
immunosuppressants, Hep C, HTN, [**Year (4 digits) 2320**], PVD presents from home
with fever to 105.8. Patient says he was in his usual state of
health as recently as Weds, when he saw his cardiologist in
preparation for hernia repair surgery early next week. Some of
his usual medications including his prophylactic bactrim were
held and he stayed home from work trying to avoid sick contacts
pre-operatively. On Thursday afternoon he started to feel some
malaise and his temperature started to rise. He took some
tylenol and his fever appeared initially to abate, but returned
[**Year (4 digits) 2974**] with nausea and vomiting, constant shivering, shoulder
aches, headaches, and three episodes of loose stools. Denies
any urinary symptoms (no changes in color, consistency, dysuria,
frequency, urgency), abd pain, neck stiffness, cough or cold
symptoms. No sick contacts. [**Name (NI) **] recent travel. He was last
admitted to [**Hospital1 18**] from [**4-23**] to [**5-2**] for new diagnosis of atrial
flutter, acute on chronic renal failure and HAP.
.
In the ED, patient had labs which showed and elevated white
count with a 10% bandemia. He had a CXR which was negative for
any acute process. A R IJ line was placed and he was started on
Vancomycin and Gentamycin for presumptive endocarditis. UA,
urine culture, and blood cultures were sent. No recent invasive
dental work. No recent IVDU.
Past Medical History:
Congestive heart failure with EF 65% on [**2158-6-13**]
Type 2 diabetes with triopathy, controlled.
Hypertension.
Hypercholesterolemia.
History of seizure disorder.
History of hepatitis C - no therapy - [**11-22**] bx -Minimal portal
and lobular mononuclear cell inflammation, consistent with
involvement by chronic viral hepatitis C ( Grade 1 activity).
End-stage renal disease, status post cadaveric renal
transplant, creatinine 1.5 in [**2159-4-17**]
Peripheral [**Year (4 digits) 1106**] disease.
Post-Op AFIB s/p DCCV in [**2-22**]
Rt rectus femoris intramuscular hematoma - [**2-22**] (INR 4.2)
? enlarged LN in his neck s/p bx - 2-3 years ago, pt reports nl
EBV IgG positive in [**2154**]/CMV IgG positive
hep B core ab + transplant: on lamivudine
.
PAST SURGICAL HISTORY:
1. Right AK [**Doctor Last Name **]-PT with nonreversed saphenous vein on [**2154-5-15**]
by Dr. [**Last Name (STitle) **].
2. Left AV fistula.
3. Cadaver renal transplant in [**2155-2-16**]. Induction with
Thymoglobulin and Tacrolimus
4. Cholecystectomy.
5. Parathyroidectomy in [**8-19**] by Dr. [**Last Name (STitle) **] - path c/w
hypercellular parathyroid
6. Status post second toe amputation in [**12-19**].
7. Right first toe amputation.
8. Aortic Valve Replacement [**2157-12-15**] - Well seated aortic
bioprosthesis with high-normal gradient and trace aortic
regurgitation ([**2158-6-13**]).
Social History:
Lives with wife who is PT and 21 y.o. son.
[**Name (NI) **] tobacco, ETOH once monthly; distant h/o IVDA (>40yrs ago) per
record.
Family History:
Two Brothers: 74yo with bladder cancer in remission, 68yo with
kidney failure, [**Name (NI) 2320**], and polymyalgia rheumatica.
Mother: Died of [**Name (NI) 2481**] disease at age 82, hx of [**Name (NI) 2320**]
Father: Died of an MI at 54, hx of [**Name (NI) 2320**] and leukemia at 18
months.
Physical Exam:
VS: T: 101.3 P: 92 BP: 132/48 RR: 33 O2 sat: 100% on
GEN: NAD
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM, neck supple
CV: RRR, [**3-22**] sys murmur loudest at apex, with rdaiation to L
carotid
PULM: CTAB to anterior exam
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL, multiple toes amputated
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated.
PSYCH: appropriate affect
Pertinent Results:
CXR: Limited study, no evidence of PNA
.
ECHO ([**2159-4-30**]):
The left atrium is markedly dilated. The right atrium is
moderately dilated. The interatrial septum is aneurysmal. The
estimated right atrial pressure is 10-15mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall is hypertrophied.
The right ventricular cavity is mildly dilated with normal free
wall contractility. A bioprosthetic aortic valve prosthesis is
present. The prosthetic aortic valve leaflets appear normal The
transaortic gradient is higher than expected for this type of
prosthesis. A paravalvular aortic valve leak is present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2158-6-16**], the
aortic prosthesis gradient is significantly elevated. Preserved
systolic function with elevated filling pressures is similar.
.
CT Torso: [**5-29**]: IMPRESSION:
1. Decreased volume of air within the collecting system of the
transplant kidney. There is no significant perinephric stranding
about the transplant or about the transplant ureter. This
suggests possibility that this air may have been related to
Foley catheter insertion.
2. New ascites is seen within the peritoneal cavity which
extends into the patient's left inguinal hernia.
3. Increasing bilateral airspace opacities with infectious
etiologies as a differential consideration. Recommend clinical
correlation.
.
[**5-31**]: LENI:
IMPRESSION: No DVT in both lower extremities.
.
[**6-3**]: CXR: IMPRESSION: AP chest compared to [**6-1**] and 17:
Mild pulmonary edema, seen best in perihilar left lung has
worsened slightly since [**6-2**], accompanied by persistent
increase in caliber of mediastinal veins. Right lung base is
elevated, and atelectasis may explain consolidation in the right
lower lung, but I am more concerned this is pneumonia. Mild
cardiomegaly stable. Anatomic detail in the upper lungs is
obscured by radiographic technique. No pneumothorax is present.
Pleural effusion if any is minimal, on the right. Moderate
cardiomegaly unchanged. Right jugular line ends in the SVC.
.
[**2159-6-5**]: NC Head CT: IMPRESSION:
1. No evidence of acute intracranial hemorrhage or large
[**Month/Day/Year 1106**] territory infarction; if suspicion for infarct is
present, MRI would be recommended for more sensitive evaluation.
2. Air-fluid levels in paranasal sinuses and mastoid air cells
may relate in part to recent intubation and recently removed NG
tube.
.
[**2159-6-5**]: RU Noninvasive: IMPRESSION: There is no evidence of
deep venous thrombosis in the right upper extremity. Right
cephalic vein was not visualized in the present exam.
.
[**2159-6-6**]: MR [**Name13 (STitle) 2853**]: FINDINGS: There is diffuse low signal
visualized in the vertebral bodies which could be due to marrow
hyperplasia or infiltration and clinical correlation
recommended. There is no evidence of ligamentous disruption seen
on limited evaluation on the sagittal inversion recovery images.
From C2-3 to C4-5 no significant disc bulge, herniation, spinal
stenosis or foraminal narrowing seen.
At C5-6 there is posterior ridging and bulging with mild spinal
stenosis and minimal extrinsic indentation on the spinal cord.
Mild bilateral foraminal narrowing seen.
At C6-7 there is mild disc bulging and left-sided foraminal
narrowing seen.
At C7-T1 and T1-2 no significant abnormalities are noted. The
paraspinal soft tissues are unremarkable. The previously noted
[**Name13 (STitle) 1106**] abnormality on the MRA of [**2154-7-3**] is not apparent on
the current study on axial images. The spinal cord shows normal
intrinsic signal.
IMPRESSION: Limited study with motion on the sagittal images.
Mild spinal stenosis at C5-6 with minimal extrinsic indentation
on the spinal cord. No evidence of increased signal within the
spinal cord. Other changes as described above.
.
[**2159-6-6**]: MR [**Name13 (STitle) 430**]: IMPRESSION:
1. No evidence of acute infarct.
2. Chronic left frontal cortical and subcortical infarcts.
3. Low signal in the visualized bone marrow could be due to
marrow hyperplasia or infiltration. Clinical correlation
recommended.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation. No evidence of [**Name13 (STitle) 1106**]
occlusion or stenosis is seen.
IMPRESSION: Normal MRA of the head.
Brief Hospital Course:
A/P: 60M PMH ESRD s/p cadaveric renal transplant in [**2155**] on
immunosuppressants, HBV/HCV, HTN, DM2 presented from home with
fever to 105.8, malaise, with nonspecific GI symptoms but no
other localizing signs or symptoms.
.
# Hypoxic respiratory failure: Due to pneumonia versus
infiltrates from sepsis with component of fluid overload which
improved after diuresis. Improved. Now extubated and doing well
on room air. He was maintained on antibiotics as discussed
below for and has completed his course.
.
# Fever: The patient was followed by the infectious disease
teamand had an extensive infectious workup for possible source
of his fever. I the end no definitive source was found. It was
believed to be most likely pneumonia. Urinalysis was positive
but urine culture negative; CSF suggested possible Aseptic
meningitis; Rapid respiratory viral screen was negative; C.
difficile was negative x3; TTE was negative for vegetation to
suggest endocarditis; bronchoalveolar lavage was negative; LFTs
were normal. He became hemodynamically unstable [**5-27**] requiring
aggressive volume resuscitation and pressors which were
discontinued on [**5-30**]. He was covered broadly with vancomycin,
zosyn and flagyl, which were discontinued on [**6-5**]. Infectious
Disease followed throughout his stay and also raised the
possibility of Addisonian crisis as an etiology of these
recurrent culture-negative septic episodes for which endocrine
follow up would be indicated. he was given a course of stress
dose steroids during his acute hypotension.
.
# Right sided Weakness: The patient was initially diffusely
weak, then localized on the right side, more upper than lower
extremity, with intact sensation. Swallowing, which was also
initially weak, began to improve and the patient passed his
swallow exam. Noncontrast head CT scan was negative, MRI
c-spine and head were negative for acute abnormalities as well.
Weakness is possibly due to deconditioning thorughout prolonged
hospitalization and ICU stay. He was seen by physical therapy,
who recommended rehab stay for conditioning.
.
#Penile lesions: Pressure ulcers formed while in the ICU, both a
large frank ulcerated area on the glans penis (multiple smaller
ulcerated areas on the foreskin) for which he was seen by
urology, who recommended treatment with bacitracin with
improvement, and a sacral decubitus ulcer for which we have
tried turning patient and keeping him out of bed as much as
possible, as well as general wound care.
.
# Hypotension: Most likely this was secondary to septic shock,
also possibly relative adrenal insufficiency given chronic
prednisone use. He was given Cortisol empiric high-dose steroids
[**5-29**] and discontinued [**5-31**], without recurrence of hypotension.
He required pressors for a short period in the ICU. Blood
pressure has been stable on the floor. At the time of discharge
we are continuing to hold his home Avapro, but this may be
restarted by his PCP as needed.
.
# Acute on chronic kidney failure: Baseline creatinine 1.5 per
recent records but has had intermittent acute on chronic
disease, thought due to prograf toxicity. Peak creatinine was
5.6, which trended downwards and hit baseline of 1.5 on [**6-6**].
ARF was thought to be secondary to ATN vs prerenal azotemia from
septic shock with poor perfusion. He was anuric, then
subsequently began to autodiurese. At the time of discharge his
renal function is normal and we have restarted lasix at 1/4 of
his home dose (prior home dose 80mg po qday). This may require
uptitration as an outpatient as needed.
.
# acute on chronic systolic CHF: The patient was admitted with a
history of diastolic CHF and an EF of 65%. He was on lasix at
home. During his admission he was noted to have an EF of 40% on
echocardiogram with global hypokinesis in the setting of his
SIRS. At the time of his discharge we have restarted lasix, but
at only 20mg qday (less than his prior dose). This may need to
be uptitrated in the future, but he is currently euvolemic on
this dose. We anticipate that his EF may recover as the patient
recovers overall and repeat echo may be considered in the
future.
# Rash: A maculopapular rash appeared on the patient's feet
[**Date range (1) 3643**]. Only new medications at that time were lasix IV and
chlorthiazide so these were discontinued (lasix PO is a home
medication). The rash then resolved over the next three days. It
was believed to be a drug rash, albeit an unusual location.
.
# Diarrhea: the patient's diarrhea on this admission was ruled
out for c diff x 3. It began to abate after cessation of
antibiotics and was felt to be antibiotic associated diarrhea.
.
# Anemia/thrombocytopenia: Likely bone marrow suppression in the
setting of sepsis versus side effect of CellCept. Once coumadin
was restarted, the patient's stool became guaiac positive and
required 2 units total of pRBC's (given on different days) to
maintain Hct > 21. His hematocrit was subsequently stable and he
has no sign of active bleeding. He was Hit Ab negative.
Thrombocytopenia was stable.
.
# DM2: Blood sugars were initially poorly controlled in the
setting of sepsis and suspected PNA. He improved on an insulin
gtt was then resumed on his home lantus and an insulin sliding
scale with good control. The patient began to have FS in hte
60s-70s and stated that although he is prescribed 40 units
lantus qam and qpm, he often takes only 20. We decreased his
dose to lantus 20units qam and 20 qpm. FS should be followed
with likely uptitrating of his lantus dose at rehab as needed.
.
# Atrial flutter: The patient remained rate controlled. Coumadin
was held on admission due to supratherapeutic INR. He was given
vitamin K. Coumadin was restarted on callout to the floor from
the ICU, however his INR was elevated after 5mg dosing. His
coumadin is now being held for drifting down of INR and should
be restarted at 1mg po qday once his INR is <2.5. His goal INR
is [**2-18**] and this should be checked in three days and eevery three
days until stable.
.
# HTN: Initially, anti-hypertensives were held given septic
shock. Once hemodynamically stable, his metoprolol was restarted
at half of his home dose, with plan to titrate up as tolerated.
Diovan was held in the setting of renal failure nad should be
restarted as needed as an outpatient by his PCP.
.
# Hepatitis C: No active issues.
.
# Hepatitis B: Core Ab + in transplanted kidney. Continued
lamivudine, which was initially dosed for renal failure and now
with improved creatinine is at regular dose.
.
# Hyperlipidemia: No active issues. Continued simvastatin. At
the time of discharge we are holding his niacin, but this may be
restarted by his PCP after discharge as needed.
.
#ACCESS: Right IJ was placed on [**5-26**] and pulled on the day of
discharge, the patient has a Left AV fistula.
.
#CODE: full
Medications on Admission:
ASA 81 mg
Avapro
Bactrim
Mycophenolate Mofetil 500 mg Tablet One (1) Tablet PO BID
Warfarin 1 mg Tablet Sig: Tablet PO as directed
Amiodarone 200 mg Tablet 1 PO twice a day.
Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QAM
Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Fosamax
Lasix 80 in AM, 40 in PM
Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous twice a day.
Insulin Lispro 100 unit/mL Solution Sig: 0-50 units
Subcutaneous four times a day: Per your sliding scale.
Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Metoprolol Tartrate 100 mg Tablet 1 Tablet PO BID
Niacin
Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY
Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Prograf
Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Viagra
Warfarin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
8. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous twice a day: note prior home dose was 40 twice per
day, so may need uptitration in rehab.
9. Insulin Lispro 100 unit/mL Cartridge Sig: per sliding scale
units Subcutaneous four times a day.
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
13. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical TID (3 times a day).
16. Outpatient Lab Work
pls check INR monday [**6-12**] and every 2-3 days thereafter; pls
restart coumadin 1mg when INR<2.5. goal INR [**2-18**]
17. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day.
18. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL
Injection once a week.
19. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
# High grade fever to 105.8 on presentation, SIRS
- ?infection with subsequent stress repsonse and adrenal
insufficiency
# Congestive heart failure, previous EF 65%, in setting of SIRS
was 40%, and likely will recover
# Penile traumatic ulcers and paraphimosis
# Acute on chronic kidney failure, baseline creatinine 1.5 per
- Peak creatinine 5.6, trended downwards and hit baseline of 1.5
on [**6-6**].
# Anemia/thrombocytopenia
- bone marrow suppression in the setting of sepsis versus side
effect of CellCept.
# Weakness
- head CT and MRI with chronic changes and neuro c/s stated
unmasking old stroke in setting of acute illness.
# Coagulopathy with INR elevated on presentation (likely from
liver dysfn)
.
Secondary diagnosis:
# Type 2 diabetes with triopathy, controlled.
# Hypertension.
# Hypercholesterolemia.
# History of seizure disorder.
# History of hepatitis C - no therapy - [**11-22**] bx -Minimal portal
and lobular mononuclear cell inflammation, consistent with
involvement by chronic viral hepatitis C ( Grade 1 activity).
# Hepatitis B: Core Ab + in transplanted kidney
# End-stage renal disease, status post cadaveric renal
transplant, creatinine 1.5 in [**2159-4-17**]
# Peripheral [**Year (4 digits) 1106**] disease.
# Post-Op AFIB s/p DCCV in [**2-22**]
# Rt rectus femoris intramuscular hematoma - [**2-22**] (INR 4.2)
# ? enlarged LN in his neck s/p bx - 2-3 years ago, pt reports
nl EBV IgG positive in [**2154**]/CMV IgG positive
# hep B core ab + transplant: on lamivudine
# Right AK [**Doctor Last Name **]-PT with nonreversed saphenous vein on [**2154-5-15**]
by Dr. [**Last Name (STitle) **].
# Left AV fistula.
# Cadaver renal transplant in [**2155-2-16**]. Induction with
Thymoglobulin and Tacrolimus
# Cholecystectomy.
# Parathyroidectomy in [**8-19**] by Dr. [**Last Name (STitle) **] - path c/w
hypercellular parathyroid
# Status post second toe amputation in [**12-19**].
# Right first toe amputation.
# Aortic Valve Replacement [**2157-12-15**] - Well seated aortic
bioprosthesis with high-normal gradient and trace aortic
regurgitation ([**2158-6-13**]).
Discharge Condition:
Stable
Discharge Instructions:
You were admitted and treated for a severe fever and severe
inflammatory response syndrome and shock. The cause of this is
unknown although may have been related to an infection with
subsequent stress response.
.
If you develop fever greater than 101F chest pain, shortness of
breath, severe dizziness, or if you at any time become concerned
about your health please contact Dr. [**Last Name (STitle) **], [**Hospital1 18**] at [**Telephone/Fax (1) **]
or present to the nearest ED.
.
Please take your medications as prescribed. We are holding the
following medications on your previous medication list, please
resume as indicated or instructed by MD:
- Viagra
- Warfarin
- Avapro
- Niacin
Please maintain a low sodium diet (<2grams), weight yourself
.
Please go to your scheduled appointments listed below:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2159-6-19**] 10:10
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2159-6-19**] 10:10
Completed by:[**2159-6-12**]
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70,002
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42718+58550
|
Discharge summary
|
report+addendum
|
Admission Date: [**2171-4-28**] Discharge Date: [**2171-5-4**]
Date of Birth: [**2112-8-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 8049**] is a 58 y/o female with a history of COPD on home
oxygen (3L), atrial fibrillation. morbid obesity, DM2 who was
sent in from her nursing home due to altered mental status. She
was first noted to be altered yesterday when her family visited
her at her nursing home. She was asking for help but was able to
follow commands and was appropriate. Later on in the night she
became progressively more confused and required [**Last Name (un) 10737**] restrained.
The morning of admission, she was noted to be incoherent and
making inappropriate comments. During her confusion she was
awake and at times redirectable. She was recenlty started on
Nefazodone on [**2171-4-23**] by psychiatry.
Of note she was recently admitted for septic shock (2/17-2/29),
with presumed abdominal source (recto-cutaneous fistula). She
was initially started on zosyn, changed to unasyn, which she is
due to receive until [**2171-5-14**]. Pt refused surgical intervention
due to extremely high operative risk given weight and
co-morbidities.
In the ED, initial VS were: 98.0 88 132/53 16 93%. She had an
abdominal CT which showed a soft tissue tract extending from the
rectum to the skin surface through the ischiorectal fat and
gluteal subcutaneous fat with increased superficial subcutaneous
air without evidence for drainable collection. She also had a
head CT which showed no acute intracranial process. Chest X-ray
showed a confluent opacity at the left base, increased vascular
congestion c/w mild pulm edema and a streaky opacity in lingula
which may represent volume loss vs consolidation. She received
1L of NS and a dose of Vancmycin and Zosyn. U/A ahowed >182 WBC
and >182 RBC's and no EPI's.
On arrival to the MICU, she was noted to be awake, alert and
oriented to hospital and year but was not oriented to situation.
She stated that she was not doing well but could not identify
why she was not feeling well. She noted on ROS that she did not
some buring around her urinary tract but had a foley in place.
Past Medical History:
-h/o L AKA [**3-21**] to DVT/gangrene when she was 18 on OCPs
-COPD on home oxygen 3L
-h/o large left breast hematoma, not on AC [**3-21**] to that (refused)
-AF
-depression, h/o hospitalization
-obesity
-DM-2
-hypothryroidism
-chronic LBP
Social History:
Patient has history of smoking but quit 4 months ago. Denies
ETOH, other drug use. Pt lives alone with aid who comes help her
get around and basic needs. one son in another state. Pt has
history of left leg above the knee amputation at age 18 after
having blood clots while on OCPs.
Family History:
noncontributory
Physical Exam:
Physical Exam on admission:
Vitals: T: 98.4 BP: 119/75 P: 83 R: 18 O2: 94% 4L
General: Alert and oriented to place and year but not situation
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Difficult to appreciate due to body habitus however
appeared to be clear to auscultation bilaterally, no wheezes,
rales, ronchi
Abdomen: obese abdomen, soft, nontender, nondistended, no
rebound or guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
Labs on admission:
[**2171-4-28**] 02:00PM BLOOD WBC-8.3 RBC-3.35* Hgb-10.6* Hct-32.7*
MCV-98 MCH-31.5 MCHC-32.2 RDW-18.6* Plt Ct-292#
[**2171-4-28**] 02:00PM BLOOD Neuts-69 Bands-0 Lymphs-23 Monos-5 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-2*
[**2171-4-28**] 02:00PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL
[**2171-4-28**] 02:00PM BLOOD PT-10.9 PTT-27.5 INR(PT)-1.0
[**2171-4-28**] 02:00PM BLOOD Glucose-158* UreaN-21* Creat-1.1 Na-143
K-4.1 Cl-99 HCO3-34* AnGap-14
[**2171-4-29**] 05:49AM BLOOD Glucose-89 UreaN-18 Creat-0.9 Na-145
K-3.8 Cl-102 HCO3-36* AnGap-11
[**2171-4-28**] 02:00PM BLOOD ALT-11 AST-14 AlkPhos-140* TotBili-0.2
[**2171-4-28**] 02:00PM BLOOD Lipase-12
[**2171-4-28**] 02:00PM BLOOD cTropnT-<0.01
[**2171-4-29**] 05:49AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.3
[**2171-4-28**] 02:00PM BLOOD Albumin-2.7*
[**2171-4-29**] 05:49AM BLOOD Digoxin-2.0
[**2171-4-28**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2171-4-29**] 12:25AM BLOOD Type-ART Temp-36.7 O2 Flow-4 pO2-110*
pCO2-58* pH-7.42 calTCO2-39* Base XS-11 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2171-4-28**] 02:08PM BLOOD Lactate-2.2*
[**2171-4-29**] 12:25AM BLOOD Lactate-1.2
[**2171-4-28**] 02:00PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.025
[**2171-4-28**] 02:00PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-LG
[**2171-4-28**] 02:00PM URINE RBC->182* WBC->182* Bacteri-MOD
Yeast-MANY Epi-0
[**2171-4-28**] 02:00PM URINE CastHy-45*
[**2171-4-28**] 02:00PM URINE WBC Clm-MANY Mucous-MOD
Microbiology:
[**2171-5-1**]: C. diff postitive
BCx [**4-30**], [**5-1**] pnd
.
[**2171-4-28**] 2:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2171-4-30**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 4174**] ON [**2171-4-30**] AT
0155.
GRAM POSITIVE COCCI IN CLUSTERS.
[**2171-4-28**] 2:00 pm URINE
**FINAL REPORT [**2171-4-29**]**
URINE CULTURE (Final [**2171-4-29**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
Imaging:
CT Abdomen/Pelvis [**2171-4-28**]:
1. Probable colocutaneous fistula between the sigmoid colon the
the gluteal cleft with an interposed 4-cm fluid collection. This
finding was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by Dr. [**Last Name (STitle) 7867**] by
phone at 8:09 p.m. on [**2171-4-28**].
2. Large area of left anterior body wall subcutaneous edema.
Clinical
correlation is recommended. This finding was discussed with Dr.
[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] by Dr. [**Last Name (STitle) 7867**] by phone at 8:09 p.m. on [**2171-4-28**].
3. Interval resolution of pubic symphseal air with persistent
irregularity of the cortical margins of the pubic symphysis.
This finding was discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in person by
Dr. [**Last Name (STitle) 7867**] at 6:09 p.m. on [**2171-4-28**].
4. Healing left rib fractures. This finding was discussed with
Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in person by Dr. [**Last Name (STitle) 7867**] at 6:09 p.m. on [**2171-4-28**].
5. Low position of Foley catheter, which may be due to pelvic
floor
dysfunction but is difficult to determine on this study.
Clinical correlation is recommended. This finding was discussed
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by Dr. [**Last Name (STitle) 7867**] by phone at 9:30 p.m. on
[**2171-4-28**].
CT Head [**2171-4-28**]:
No acute intracranial process
CXR [**4-28**]:
1. Highly limited exam by body habitus and underpenetration.
2. Severe cardiomegaly. No definite pulmonary pathology
TTE [**2171-4-29**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Diastolic function could not be assessed.
The right ventricular cavity is moderately dilated with
depressed free wall contractility. There is abnormal septal
motion/position. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal regional and global left ventricular function. Moderately
dilated and hypokinetic right ventricle. Mild pulmonary artery
systolic hypertension.
CT Chest [**2171-4-30**]:
1. No pneumonia evident. Lingular atelectasis identified
concordant with
prior radiographic report.
2. Moderate-to-severe centrilobular emphysematous changes.
3. Hepatic steatosis with focal fat deposition in the left
hepatic lobe.
Multiple healing left rib fractures identified.
Brief Hospital Course:
58yoF with COPD on home oxygen (3L), atrial fibrillation, DM2,
hypothryoidism, dCHF, s/p L AKA who was admitted to the MICU on
[**4-28**] after being sent in from her nursing home due to altered
mental status.
.
# Altered Mental Status/Toxic-Metabolic Encephalopathy: Patient
with waxing and [**Doctor Last Name 688**] mental status, likely [**3-21**] multiple
infectious etiologies including ?UTI vs ?PNA vs colocutaneous
fistula with CT showing fluid collection concerning for abscess.
ID followed, on Vanc/Zosyn. UA positive, culture growing only
yeast. BCx negative to date other than 1 bottle with coag
negative staph. CXR showed concern for pneumonia but CT chest
showed no evidence of PNA. Most likely source UTI. Surgery
signed off for fluid collection noted on CT scan given pt
refused surgery: recommended colonoscopy, tumor markers. Mental
status improved on Vanc/Zosyn. In noting blood culture positive
for coag-negative Staph (noting that the positive C. diff
occurred after resolution of mental status changes), the patient
was switched to Vancomycin and Unasyn, with plans to have 7 days
of Vancomycin, last dose 3/17, and continued course of Unasyn
until [**5-14**] as per prior ID recommendations on her previous
admission. She will have ID follow up as an outpatient.
TSH wnl, less likely medication effect [**3-21**] recently started
Nefazodone by psychiatry for depression. This was held since
admission, but will be restarted given infectious etiologies are
more likely to be the source and patient reporting severe
depression with lack of hope. Digoxin dose was borderline high,
also decreased for potential mental status changes, and then
later discontinued for bradycardia and asymptomatic but multiple
pauses seen on telemetry. Other potentially altering
medications are chronic, including oxycontin, oxycodone and
lamotrigine, and were therefore continued as they were not
likely to be contributing to the altered mental status.
# C. Difficilie Colitis: After the resolution of mental status
changes, the patient was found to have significantly increased
stool output, and C. diff test returned positive. She was
started on PO Vancomycin for (+) C. diff, with the last dose to
end 1 week after the discontinuation of antibiotics. Last dose
of PO vancomycin will be [**2171-5-21**].
.
# Colocutaneous Fistula: As described during her recent
admission the fistula is of unclear etiology. Crohn's disease
and malignancy are possibilities but patient refused colonoscopy
and surgical intervention. GI not consulted as patient refused
colonoscopy, but recommended MRE, but patient too large to fit
into MR machine. She was planned for a 6-week course of Unasyn
(last day [**2171-5-14**]). Surgery signed off, GI not consulted given
no diagnostic options other than MRE and not likely therpeutic
options. She was continued on Vanc/Zosyn as above and then
transitioned to Vanc/Unasyn. Vancomycin last dose will be [**5-4**]
and Unasyn last dose will be [**5-14**]. ID was following in-house,
and will follow up with the patient as an outpatient, either at
the rehab facility or as per the already scheduled appointment.
There is thoughts of discussing possible IR guided drainage of
the fluid collection around the fistula as an outpatient.
.
# Atrial Fibrillation: Patient has a history of afib with RVR
which required a dilt drip during her last admission. Currently
she is rate controlled on her current regimen. Occasional
pauses on telemetry but brief and asymptomatic. Digoxin dose
decreased as described above for mental status changes and
borderline high level of 2.0 on initial presentation. The dose
was decreased to 0.125 mg daily and then was subsequently
discontinued for bradycardia and frequent pauses. Continued
home aspirin 325mg and decreased Metoprolol and Diltiazem doses
for bradycardia and pauses, in the setting of adequate blood
pressure control.
.
# Hypothyroidism: Continued home Levothyroxine. TSH was wnl.
.
# COPD: On home oxygen 3-4L, PO2's in the 90's. She was
continued on duo-nebs.
.
# Type 2 Diabetes mellitus: Patient is insulin dependent and
has had some recent changes during her stay at [**Hospital3 105**].
Her Glargine was decreased to 10U qAM, and this was continued
in-house with good glucose control. She was covered with SSI.
.
# Depression: She has a history of depression with a suicide
attempt at an early age. She endorsed suicidal ideations
in-house and psychiatry was called. It was determined that the
patient reports suicidal ideations when she feels overwhelmed,
and this is a coping mechanism and a call for attention.
Psychiatry felt this was not true, acute suicidal ideation and
confirmed her outpatient medications, which were different than
those initially written for in the ICU. Her Nefazodone dose was
originally ordered in-house as 250 mg qhs, but is actually 200
mg tid as an outpatient, confirmed with her outpatient
psychiatrist. Per psych consult, her Nefazodone can be
uptitrated every 3-4 days back to home dose of 200 mg tid given
her severe depression. Her home Gabapentin 600 mg, Lamotrigine
400 mg, and Ritalin 30 mg qAM, 20 mg qPM were continued
in-house. Of note, the Lamotrigine was originally ordered as
200 mg daily, but this was increased to the correct home dose
prior to discharge.
.
.
#CODE STATUS: Full (confirmed per MICU)
#CONTACT: son [**Name (NI) **], [**Telephone/Fax (1) 92324**]
Transitional Issues:
- Check TSH on [**5-7**]
- Check electrolytes on [**5-7**]
- Check LFT's on [**5-7**] and [**5-12**]
- Outpatient follow up to determine if the patient is amenable
to IR drainage of the fluid collection around the
enterocutaneous fistula as an outpatient
- Digoxin was discontinued and Metoprolol and Diltiazem were
decreased. Will need to follow up heart rate and blood pressure
- Nefazodone is at a LOWER DOSE than previously; please INCREASE
this dose to 200 mg THREE TIMES DAILY on [**5-8**], to the previous
outpatient dose as per the patient's outpatient psychiatrist
- f/u Hct: this was 30 on last check
- Imaging revealed hepatic steatosis. Would recommend
surveillance imaging and LFT checks.
- Imaging revealed lung emphysema
- Echocardiogram was notable for mild symmetric LVH, and
moderately dilated and hypokinetic RV
Antibiotic Courses:
- Vancomycin oral was STARTED, to be continued until [**5-21**]
- Vancomycin IV was STARTED, to be continued until [**5-4**]
- Unasyn IV to be continued until [**5-14**]
Laboratory:
****Please check liver function tests (LFT's) on [**5-7**] and on
[**5-12**], and then once every month thereafter.
****Please check electrolytes on [**5-7**]
Medications on Admission:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8 ().
2. heparin (porcine) 5,000 unit/mL Solution Sig: 7500 (7500)
units Injection TID (3 times a day): can hold for ambulating.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily): hold for SBP< 95;
HR<60.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation: hold for loose stools.
7. oxycodone 10 mg Tablet Extended Release 12 hr Sig: Three (3)
Tablet Extended Release 12 hr PO Q8H (every 8 hours): hold for
sedation or RR<12.
8. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ritalin 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash/itchiness.
11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: hold for sedation or RR<12.
12. Ondansetron 4 mg IV Q8H:PRN nausea
13. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation: hold for loose stools.
17. lamotrigine 100 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
18. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. levothyroxine 300 mcg Tablet Sig: One (1) Tablet PO qAM.
20. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO qAM.
21. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for sob/wheeze.
22. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob/wheeze.
23. nystatin 100,000 unit/mL Suspension Sig: [**Numeric Identifier 78144**] ([**Numeric Identifier 78144**])
unit PO Q8H (every 8 hours).
24. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for SBP<95; HR<60.
25. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for anxiety.
26. insulin glargine 100 unit/mL Solution Sig: Fifty Five (55)
unit Subcutaneous qAM.
27. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
28. ampicillin-sulbactam 3 gram Recon Soln Sig: 3g Recon Solns
Injection Q6H (every 6 hours): last day [**2171-5-14**] unless otherwise
directed at [**Hospital **] clinic follow up.
29. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous qACHS: per sliding scale.
30. Nefazodone 250mg qhs
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every [**7-26**]
hours.
4. nefazodone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please increase to 200 mg tid on [**5-8**]. Check LFT's
weekly.
5. Ampicillin-Sulbactam 3 g IV Q6H
switched [**5-1**], until [**5-14**]
6. Vancomycin 750 mg IV Q 12H Start: [**2159**]
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. 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.
9. vancomycin 125 mg Capsule Sig: One [**Age over 90 **]y Five (125)
mg PO Q6H (every 6 hours) for 18 days: Until [**5-21**].
10. methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO QPM
(once a day (in the evening)): 20 mg qPM.
11. methylphenidate 10 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)): 30 mg qAM.
12. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day): Hold while diarrhea and increased fistula
output (while on C. diff treatment).
14. OxyContin 30 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every eight (8) hours: Hold for
sedation.
15. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for Rash.
17. oxycodone 5 mg Capsule Sig: [**2-18**] Capsules PO every four (4)
hours as needed for pain.
18. Ondansetron 4 mg IV Q8H:PRN Nausea
19. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
20. gabapentin 300 mg Capsule Sig: [**2-18**] Capsules PO HS (at
bedtime).
21. lamotrigine 200 mg Tablet Sig: Two (2) Tablet PO twice a
day.
22. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
23. levothyroxine 175 mcg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
24. 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.
25. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/Wheezing.
26. nystatin 100,000 unit/mL Suspension Sig: 500,000 units PO
every eight (8) hours.
27. alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed for agitation, anxiety.
28. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous qAM.
29. Humalog 100 unit/mL Solution Sig: as per sliding scale
Subcutaneous qachs: as per sliding scale.
30. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
31. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary Diagnosis:
- Urinary tract infection
- Enterocutaneous fistula
- Clostridium Difficile infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital for mental status changes and
delirium. You were found to have a urinary tract infection, and
continued fluid around your enterocutaneous fistula. You were
started on an additional antibiotic for the infection with
improvement of your symptoms. You were also found to have a
stool infection called C. difficile infection, and you were
started on an additional antibiotic to treat this infection.
Your mental status was at baseline on discharge.
The following changes were made to your home medications:
- Digoxin was STOPPED
- Insulin was DECREASED
- Metoprolol was DECREASED
- Diltiazem was DECREASED
- Nafazodone is at a LOWER DOSE than previously; please INCREASE
this dose to 200 mg THREE TIMES DAILY on [**5-8**], which was your
previous outpatient dose
- Levothyroxine was INCREASED
- Vancomycin oral was STARTED, to be continued until [**5-21**]
- Vancomycin IV was STARTED, to be continued until [**5-4**]
Please continue the Unasyn IV until [**5-14**]
Followup Instructions:
Please have the infectious disease specialist follow up with you
at your rehab facility if possible. If this is not possible,
please follow up as below:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2171-5-24**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14518**]
Admission Date: [**2171-4-28**] Discharge Date: [**2171-5-4**]
Date of Birth: [**2112-8-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 14519**]
Addendum:
Patient instructions state that Levothyroxine dose was
increased, but this was deleted on the discharge paperwork as
she was maintained on the same home dose of Levothyroxine (350
mcg daily)
The patient was also not discharged on heparin flush, as her
PICC line is not heparin dependent. This was changed in her
discharge paperwork.
These two changes could not be documented in the discharge
summary, as it had already been finalized.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] - [**Location (un) 95**] - [**Location (un) 4534**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14520**] MD [**MD Number(2) 14521**]
Completed by:[**2171-5-4**]
|
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[
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,700
| 170,053
|
46334
|
Discharge summary
|
report
|
Admission Date: [**2158-6-11**] Discharge Date: [**2158-6-14**]
Date of Birth: [**2094-2-6**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: A 64 year old female with
Parkinson's, status post CVA and COPD, who was recently admitted
to [**Hospital 87525**] Hospital for unresponsiveness and hypotension.
During that admission her blood cultures were positive for
Klebsiella and Proteus. She was found to have thickening of the
colon, splenic flexure and colonoscopy showed colitis. She was
presumed to have ischemic bowel as the cause of sepsis. The
patient does report a history of bloody diarrhea for about a week
and the stool has been negative for C. diff. During that
hospital course she required pressors including Dopamine and Neo-
Synephrine and was initially treated with Imipenem, Vancomycin
which was then switched to p.o. Levofloxacin and Flagyl. Her
course was also complicated by new onset atrial fibrillation
which spontaneously converted. She was discharged on [**6-9**] on a
full liquid diet to the nursing home from which she came.
At the nursing home she developed sudden onset of shortness of
breath and desatted to the 70's. The patient stated that the
episode was acute and no preceded by fevers, coughing or chest
pain. She was treated with morphine, Lasix and nitrates without
any change in the symptoms. She was transferred back to
[**Hospital 87525**] Hospital where she was intubated. At the time of
admission she was noted to have mottled and bruised left upper
extremity. She underwent left upper extremity doppler which was
negative though by the time study was performed her arm has
turned pink and warm again. She was extubated one day after
admission and did relatively well. A CT at that time showed no
pulmonary embolus. She was transferred to our facility at the
request of the family.
Currently the patient denies any chest pain, shortness of breath,
abdominal pain, nausea or vomiting. She does have some mild
headache as well as continuing diarrhea.
PAST MEDICAL HISTORY: 1. Parkinson's. 2. Status post CVA
with residual right-sided weakness. 3. COPD. 4. Anxiety.
5. Depression. 6. History of aspiration pneumonia. 7.
Borderline diabetes mellitus in the past. 8. Hypertension.
MEDICATIONS: Levofloxacin 500 p.o. q.d., Flagyl 500 p.o. q8,
magnesium oxide 400 p.o. q.d., potassium chloride 40 mEq p.o.
q.d., Megace 800 mg p.o. q.d., Effexor 37.5 p.o. b.i.d.,
Sinemet 25-100 two tabs t.i.d.
ALLERGIES: Penicillin, codeine, Dilantin, Demerol and sulfa.
SOCIAL HISTORY: The patient is a resident of Life Cove Center,
has 8 children, daughter [**Name (NI) 1356**] is a health care proxy. The
patient is unable to ambulate secondary to Parkinson's, stroke,
uses a wheelchair. She is a prior smoker about 30 pack years.
PHYSICAL EXAMINATION: Temperature 98.3, pulse 100, blood
pressure 125/70, respiratory rate 22, satting 90% on room
air, 95 on 2 liters. In general, alert female, alert and
oriented. HEENT: Oropharynx is clear, moist mucous
membranes. Neck: Supple, no lymphadenopathy, no JVD. Lungs:
Fair air movement with no crackles or wheezes.
Cardiovascular: S1, S2, II/VI soft crescendo decrescendo
murmur in the right upper sternal border, no gallops, no rub.
Abdomen: Soft, nontender, nondistended, there is no liver
edge, no peritoneal signs. Stool is brown, guaiac positive.
Extremities show no edema and poor distal pulses.
Neurological exam is mild left eyelid droop, bilateral
contractures in the upper extremities. Strength in the lower
extremities appears [**4-1**] but per daughter apparently unchanged
from past.
LABORATORY DATA: On admission included white count of 17.2,
hematocrit 33, platelets 308. INR 3.8. Unremarkable Chem-7.
HOSPITAL COURSE: 1. Respiratory failure. The patient did
relatively well from respiratory standpoint here. She was mostly
comfortable, breathing on room air and only occasionally
requiring oxygen at night. On admission it was somewhat unclear
what caused the initial insult. The 2 possibilities include
mucous plugging and aspiration. To further elucidate the
possibility of aspiration a consultation with Speech and Swallow
was obtained and after a video swallow study the feelings of the
speech and swallow team was that the patient is not at a
particularly high risk for aspiration. In this context,
therefore, it is most likely that he had a mucus plug which had
led to transient lung collapse necessitating intubation.
To prevent further mucus plugging the patient was started on
chest physical therapy and will need chest PT while at the
nursing home to prevent further mucus plugging. She had no
wheezing at any point on exam. The patient was continued on her
outpatient dose inhalers for her chronic COPD.
2. Ischemic colitis. The patient was continued on p.o.
evofloxacin and Flagyl which she will require until [**6-18**]. She
continued to have occasional diarrhea during the stay but no
other complaints. She was able to take relatively good p.o. with
no significant problems and no abdominal pain.
3. Parkinson's. Stable from Parkinson's standpoint, continued on
Sinemet and Baclofen.
4. Hypertension. Tenormin was held on admission but restarted
during transfer to regular Floor; blood pressure in good control.
DISCHARGE CONDITION: Stable and same as prior to admission.
Discharged to [**Hospital **] nursing home.
DISCHARGE DIAGNOSES: 1. Respiratory failure requiring
intubation. 2. Mucus plugging. 3. Ischemic colitis. 4.
Parkinson's. 5. Hypertension.
DISCHARGE MEDICATIONS: Levofloxacin 500 mg p.o. q.d. to be
continued until [**6-18**], Flagyl 500 mg p.o. t.i.d. to be
continued until [**6-18**], Xanax 0.5 mg p.o. t.i.d., Baclofen 500
mg p.o. q.i.d., Effexor 37.5 p.o. b.i.d., Sinemet 25-100 two
tabs p.o. t.i.d., Atenolol 25 p.o. q.d., Albuterol inhalers,
Atrovent inhalers.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 5094**]
MEDQUIST36
D: [**2158-6-14**] 08:26
T: [**2158-6-14**] 08:50
JOB#: [**Job Number 98502**]
|
[
"438.89",
"038.40",
"933.1",
"285.9",
"401.9",
"557.9",
"332.0",
"496",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5319, 5403
|
5425, 5548
|
5572, 6107
|
3772, 5297
|
2833, 3754
|
168, 2031
|
2054, 2543
|
2560, 2810
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,390
| 189,206
|
23312
|
Discharge summary
|
report
|
Admission Date: [**2149-4-16**] Discharge Date: [**2149-4-24**]
Date of Birth: [**2076-7-5**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamides) / Acetaminophen / Percocet
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
left groin drainage
Major Surgical or Invasive Procedure:
IR guided left groin fluid collection for diagnostic purposes
History of Present Illness:
Ms. [**Known lastname 59838**] is a 72 year old female who presented to the ED on
[**2149-4-16**] with a 2week history of left groin erythema,
tenderness and drainage at her nursing home of residence; an
abscess was identified and aspirated at an outside hospital and
she was subsequently put on keflex however she continued to
drain from the left groin. Given her PSH of aortobifemoral
graft ([**11/2147**]) Ms. [**Known lastname 59838**] was admitted for concern of an
infected graft.
Past Medical History:
PMH:
CAD s/p NSTEMI in [**12/2147**] with BMS in LAD, a-fib, HTN,
hypercholesterolemia, COPD, h/o PNA and UTIs, PVD,
hydrocephalus,
h/o GI bleed, anemia, ventral hernia, anxiety
PSH:
VP shunt, aortobifemoral graft, right AKA, IVC filter,
resection of PSA of left limb of aortobifemoral graft with
Dacron
reconstruction ([**11/2147**])
Social History:
Lives at [**Hospital 756**] [**Hospital 731**] nursing home. Former heavy smoker. No
ETOH.
Family History:
Non-contributory
Physical Exam:
On admission:
PE: 96.9, 98, 121/55, 18, 98% on 2L
Gen: no distress, A&Ox3
HEENT: PERLA, EOMI, anicteric, mucus membranes dry
Neck: supple
Chest: irregular rhythm, lungs clear
Abd: soft, nontender, nondistended, reducible ventral incisional
hernia
Pertinent Results:
[**2149-4-16**] 09:40PM BLOOD WBC-12.2* RBC-4.57# Hgb-10.9*# Hct-34.9*#
MCV-76* MCH-23.8*# MCHC-31.2 RDW-18.2* Plt Ct-347
[**2149-4-18**] 05:21AM BLOOD WBC-9.2 RBC-3.54* Hgb-8.7* Hct-26.9*
MCV-76* MCH-24.6* MCHC-32.4 RDW-18.2* Plt Ct-228
[**2149-4-21**] 06:02AM BLOOD WBC-13.2* RBC-4.93 Hgb-12.8 Hct-40.1
MCV-82 MCH-26.0* MCHC-32.0 RDW-18.2* Plt Ct-278
Brief Hospital Course:
The patient was admitted on the [**2149-4-16**] for a left groin
infection and concern for a graft infection. A CTA demonstrated
fluid surrounding the right graft and multi-loculated fluid
collections within the psoas muscle. No evidence of a
pseudoaneurysm was seen. She was started on empiric broad
spectrum antibiotics. Given Ms. [**Known lastname 59838**] overall health and
her history of heart disease it was felt that she wouldn't be a
surgical candidate for a graft removal. ID was consulted to
advise for empiric antibiotic treatment while cultures were
pending. Aspiration of deep abscess material was obtained via
an IR procedure but cultures were negative. Superficial wound
swab cultures eventually demonstrated different strains of
coag. neg. Staph. While in hospital she continued to be afebrile
and stable. She was put on an oral regimen of doxycycline.
Uro:
Her CTA on her admission day revealed an incidental finding of
bilateral hydronephrosis. Following urology consult, a Foley
catheter was placed, IV fluid hydration initiated and creatinine
closely monitored; creatinine remained stable over the course of
her hospital stay and she didn't exhibit any flank or abdominal
pain. The patient is instructed to carefully monitor herself for
any new onset of belly or flank pain, that my warrant the
placement of a Nephrostomy in the presence of her graft
infection.
Neuro:
The patient exhibited signs of altered mental status, raising
concern that abscess fluid collections might cause obstruction
of her VP shunt. Neurosurgical carefully reviewed her scan and
it was felt that her VP shunt is not affected retroperitoneal
fluid collection .
Heart:
On [**4-17**], the patient experienced a brief episode of sinus
bradycardia with a heart rate of 24 bpm. She was subsequently
transferred to the ICU for close monitoring. Cardiology was
consulted. Based on their recommendation, we temporary
discontinued all AV node blocking agents. Repeat cardiac
enzymes turned out to be negative. The patients heart rate
returned subsequently to normal and she was transferred to the
floor where she remained stable.
Metoprolol was restarted on the [**2149-4-23**] which was well
tolerated by the patient.
The rest of Ms. [**Known lastname 59869**] hospital course was unremarkable and
she is being discharged to her extended care facility on
[**2149-4-24**] in stable condition. She will continue on e lifelong
course of antibiotics. ( currently on doxycycline 100 mg po
BID)
Medications on Admission:
Pletal 100mg [**Hospital1 **]
Advair 250/50 [**Hospital1 **]
Coreg 6.25mg [**Hospital1 **]
Mag oxide 400mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Lasix 40mg daily
Neurontin 100mg daily
KCl 20meq daily
Spiriva daily
Aspirin 81mg daily
Cardizem 120mg daily
Coumadin 5mg daily
Wellbutrin 100mg [**Hospital1 **]
Remeron 15mg daily
Discharge Medications:
1. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO bid ().
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for to peri area, labial folds.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO every twelve (12) hours.
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: follow INR, goal INR 2.0-3.0. Please contact PCP.
14. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
twice a day.
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]
Discharge Diagnosis:
-left groin infection with underlying vascular graft infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive alternating with
lethargic episodes
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
ACTIVITIES:
- [**Month (only) 116**] shower pat dry your incision, no tub baths
- Resume activities as tolerated, slowly increase activiy as
tolerated
DIET:
- Diet as tolerated eat a well balanced meal
- 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. Also
call if you experience any new onset of abdominal pain and/or
flank pain
MEDICATIONS:
- Continue all medications as instructed
Followup Instructions:
FU APPOINTMENT:
- Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone:
[**Telephone/Fax (1) 1393**]
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2149-5-14**] 10:50
Provider: [**Name10 (NameIs) 1423**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2149-6-27**] 11:00
Completed by:[**2149-4-24**]
|
[
"V45.2",
"272.0",
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"996.62",
"427.31",
"585.4",
"427.89",
"591",
"414.01",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.01"
] |
icd9pcs
|
[
[
[]
]
] |
6363, 6465
|
2088, 4583
|
341, 405
|
6572, 6572
|
1711, 2065
|
7413, 7840
|
1410, 1428
|
4972, 6340
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6486, 6551
|
4609, 4949
|
6783, 7390
|
1443, 1443
|
281, 303
|
433, 923
|
1457, 1692
|
6587, 6759
|
945, 1283
|
1299, 1394
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,632
| 139,914
|
50257
|
Discharge summary
|
report
|
Admission Date: [**2185-7-12**] Discharge Date: [**2185-7-17**]
Date of Birth: [**2117-6-19**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Shellfish Derived
Attending:[**Last Name (un) 11974**]
Chief Complaint:
bradycardia and hypotension following PVI
Major Surgical or Invasive Procedure:
Pulmonary vein isolation (PVI)
Atrial fibrillation ablation
Direct current cardioversion (DCV)
[**Hospital1 **]-ventricular pacemaker placement
History of Present Illness:
Ms. [**Known lastname 104800**] is a 68yoF with a h/o myxomatous mitral valve s/p
core valve in [**2179**] c/b postoperative paroxysmal atrial
fibrillation. She was managed on amiodarone until [**2184-8-27**].
At that time event monitoring demonstrated accelerated
junctional rhythm with APBs and atrial couplets, and amiodarone
was discontinued. She was then asymptomatic until [**2185-2-25**]
when she began to experience episodes of palpitations. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor revealed frequent
APBs and VPBs, short runs of atrial tachycardia and bigeminy.
She was started on propafenone and metoprolol, but subsequently
reverted to afib. She underwent successful DCCV on [**2185-6-3**], but
on [**2185-6-6**] she presented to OSH ED for palpitations and was
found to again be in atrial fibrillation on [**2185-6-6**]. She was
again cardioverted and her Propafenone was increased to 225mg
TID. Stress echo was done on [**2185-6-15**] which was notable for a
junctional rhythm that occurred during peak exercise. Echo
imaging was negative for ischemia and showed preserved EF. She
was admitted today for elective PVI.
.
Post ablation pt underwent DCV with 200 joules. She cardioverted
to sinus rhythm but was bradycardic with HR 30s and hypotensive
(SBP 80s). Temp wire inserted and pacer set at 90, and she was
started on dopamine gtt. She was transferred to the CCU for
further management. On arrival, vitals were T 96.6, HR 81, BP
110/48. She was still intubated on arrival but quickly extubated
and then breathing comfortably with O2 sats 100% on 2L NC. She
noted mild chest discomfort, but denied palpitations, SOB.
Past Medical History:
MR/MVP s/p minimally invasive mitral valve repair (38 mm
Annuloplasty band) on [**2180-7-5**]
Paroxysmal Atrial fibrillation - post MVR
Atrial tachycardia and frequent PVCs
HTN
Hyperlipidemia
GERD
Diverticulosis
Osteopenia
Schatzki's ring
h/o Hearing loss - conductive loss, has a hearing aid
s/p L ear surgery
s/p trigger finger release R hand
Social History:
Married and lives in [**Location 745**] with husband. Retired. [**Name2 (NI) 4084**] smoked.
Occas EtOH, none recently.
Family History:
Father died age [**Age over 90 **]
Brother with connective tissue disease and 2 valve replacements
AVR/Asc aorta. Numerous family members with cholecystectomies.
Physical Exam:
Admission physical exam:
GENERAL: NAD. Drowsy, but oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK: Supple, no JVD.
CARDIAC: RR, normal S1, S2. II/VI holosystolic murmur at LLSB.
No S3 or S4.
LUNGS: Decreased air movement bilat. No accessory muscle use.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. L femoral temp wire in
place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge physical exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK: Supple, no JVD.
CARDIAC: RR, normal S1, S2. II/VI holosystolic murmur at LLSB.
No S3 or S4.
LUNGS: No accessory muscle use. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Palpable superficial cord on right arm.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission labs:
WBC 4.7 Hgb 11.9 Hct 34.2 Plts 252
INR 3.0
Pertinent studies:
Renal ultrasound ([**2185-7-13**]): 1. Polypoid urothelial lesion seen
within the lumen of the urinary bladder suggestive of a
urothelial tumor vs. intraluminal clot. A cystoscopy is
recommended. Note is made that the bladder is moderately
distended despite a Foley catheter in place.
2. Normal appearance of the kidneys.
Discharge labs:
PT-27.8* INR(PT)-2.7*
WBC-3.7* RBC-3.06* Hgb-9.2* Hct-26.6* MCV-87 MCH-30.0 MCHC-34.5
RDW-13.6 Plt Ct-192
Brief Hospital Course:
68yoF with h/o paroxysmal atrial fibrillation after percutaneous
MVR in [**2179**] now s/p PVI today c/b sinus bradycardia with HR to
20s-30s.
# Sinus bradycardia/tachycardia: S/p PVI, successfully
cardioverted to sinus rhythm but bradycardic to 20s-30s.
Initially with temporary atrial pacing and dopamine drip.
However, in AM on HD1, patient reverted back into atrial
tachycardia to 150s. Patient was given 5mg IV metoprolol and
loaded with digoxin with no effect. She was cardioverted but
returned to tachycardic rhythm within an hour. She was started
on an esmolol drip with rate control to the 100s. On HD2,
patient had a dual chamber pacer palced in the right atria and
ventricle. They were unable to place a lead in the LV, however,
the device may be upgraded at a later date. Rate was controlled
at 80 following the procedure. She was loaded with amiodarone
for rhythm control. Metoprolol was held initially as pressures
were low but was started on HD4 at home dose. Heart rate and
blood pressure remained stable after this, and she was
transferred to the floors where she remained hemodynamically
stable. She was discharged on amiodorone taper and metoprolol.
# Hypotension: Patient required a dopamine drip to maintain
blood pressures following initial procedure. After pacemaker
was placed, dopamine drip was held, but patient's pressures
continued to be low. This resolved with placement of permanent
pacemaker and blood pressure remained stable after she was
transitioned to the floors, tolerating the addition of
metoprolol and her home valsartan.
# Hematuria: The patient was noted to have gross hematuria in
the setting of foly placement with an elevated INR. Urine
studies showed 182 RBCs and 182 white cells. The patient
underwent a renal US which showed polypoid mass in the bladder
concerning for a mass but which could also present a blood clot.
Urology was contact[**Name (NI) **] and recommended outpatient f/u with
repeat U/A in 6 months and possible cystoscopy.
# HLD: Continued home gemfibrozil.
# GERD: Continued home pantoprazole.
# Transitional issues:
- f/u with urology for bladder mass
Medications on Admission:
BETAMETHASONE DIPROPIONATE -0.05 % Ointment -
EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL
ESTRADIOL [ESTRING] - 2 mg Ring - per vagina q 3 months
GEMFIBROZIL - 600 mg Tablet - 1 Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Extended Release 24 hr - 1.5 Tablet(s) by mouth daily
increased from 12.5 when she went into afib
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth once a day
PROPAFENONE - 225 mg Tablet - 1 Tablet(s) by mouth three times a
day
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 Tablet(s) by mouth daily
WARFARIN [COUMADIN] - 2 mg Tablet - 1- 3 Tablet(s) by mouth at
bedtime. As directed by anticoag to maintain inr
ASPIRIN [ENTERIC COATED ASPIRIN] - (OTC) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
BIOTIN - (Prescribed by Other Provider) - Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Capsule - 1
Capsule(s) by mouth once a day
DOCUSATE CALCIUM
Discharge Medications:
1. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. docusate calcium 240 mg Capsule Sig: One (1) Capsule PO prn
(as needed) as needed for constipation.
7. amiodarone 200 mg Tablet Sig: as directed Tablet PO as
directed: Take 2 pills 3 times/day for one week ([**Date range (1) 95898**]),
then take 2 pills 1 time/day until you are seen in cardiology
clinic with Dr. [**Last Name (STitle) **].
Disp:*100 Tablet(s)* Refills:*0*
8. biotin Oral
9. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
10. betamethasone dipropionate 0.05 % Cream Topical
11. EpiPen Intramuscular
12. Estring 2 mg Ring Sig: One (1) per vagina Vaginal q3 months.
13. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
Disp:*5 Tablet(s)* Refills:*0*
14. cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 3 days: Stop after taking your doses on [**7-17**].
Disp:*2 Capsule(s)* Refills:*0*
15. Outpatient Lab Work
INR check [**2185-7-19**] At [**Hospital Ward Name 23**] Center [**Hospital 197**] Clinic
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Atrial fibrillation
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 104800**],
As you know, you were admitted to [**Hospital3 **] for surgical
ablation of your atrial fibrillation and cardioversion (shock)
of your heart into normal rhythm. After the procedure, your
heart rate and blood pressure became very low, requiring you to
be treated in the ICU. Your heart rate then became rapid again,
so you had a pacemaker placed. Your heart rate and blood
pressure have now improved.
While you were in the ICU, you had blood in your urine, and
ultrasound imaging showed a mass in your bladder. This was most
likely a blood clot from trauma caused by your urinary catheter.
However, we would like you to follow up with a urologist in [**3-2**]
weeks for a cystoscopy (bladder study using a tiny camera
inserted into the urethra) and full exam to be sure that it is
not a tumor.
We made the following changes to your medications:
1.) ADDED Amiodarone 400mg three times/day for one week
([**Date range (1) 95898**]), then 400mg once daily until you are seen in
cardiology clinic (Dr. [**Last Name (STitle) **]
2.) DECREASED Valsartan to 80mg daily
3.) ADDED Cephalexin 250 mg three times/day for 3 days
(start=[**7-15**], last day=[**7-17**])
4.) STOPPED Propafenone
5.) PLEASE CHECK YOUR INR AT [**Hospital **] CLINIC ON TUESDAY [**7-19**].
Please START 2.5mg coumadin on [**7-17**] and again on [**7-18**] and have
INR checked on [**7-19**].
Please attend the following doctor's appointments listed below
to follow up on the conditions for which you were hospitalized.
It was a pleasure taking care of you!
Followup Instructions:
Please continue to go to the [**Hospital Ward Name 23**] Center [**Hospital 197**] Clinic as
directed. Make sure to go on Tuesday [**7-19**] to have your INR
checked.
Already scheduled appointments:
Department: CARDIAC SERVICES
When: FRIDAY [**2185-7-22**] at 11:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2185-7-27**] at 10:50 AM
With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
***We are working on a follow up appointment in Cardiology with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] within 1 month. 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) 62**].
Department: SURGICAL SPECIALTIES (Urology)
When: TUESDAY [**2185-8-2**] at 8:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
|
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"451.82",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"37.83",
"37.26",
"99.62",
"89.45",
"37.34",
"37.72",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
9374, 9380
|
4652, 6728
|
329, 475
|
9475, 9475
|
4102, 4102
|
11216, 13093
|
2702, 2865
|
7825, 9351
|
9401, 9401
|
6814, 7802
|
9626, 10482
|
4522, 4629
|
2905, 3507
|
10511, 11193
|
248, 291
|
503, 2181
|
4118, 4506
|
9420, 9454
|
9490, 9602
|
6751, 6788
|
2203, 2549
|
2565, 2686
|
3532, 4083
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,722
| 161,571
|
13731
|
Discharge summary
|
report
|
Admission Date: [**2104-2-25**] Discharge Date: [**2104-3-1**]
Date of Birth: [**2029-4-6**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
male with a history of hypertension, diabetes, and a long
history of cigarette smoking; who was in his usual state of
health until he developed some unstable angina. The patient
was transferred from an outside hospital for cardiac
catheterization at our facility.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Benign prostatic hypertrophy.
4. Peripheral neuropathy.
5. Osteoarthritis.
6. Lyme disease.
7. Asbestosis.
8. Colonic polyps.
PAST SURGICAL HISTORY: No previous past surgical history.
ALLERGIES: He has no known drug allergies.
HOSPITAL COURSE: This 74-year-old man, who was transferred
to our facility, underwent cardiac catheterization.
Catheterization revealed an 80% stenosis of the proximal left
anterior descending artery, and an 80% stenosis of the obtuse
marginal, with a normal left ventricular ejection fraction.
Based on these findings, Cardiothoracic Surgery was consulted
and the patient was deemed appropriate for a coronary artery
bypass graft. So, on [**2104-2-26**], the patient was taken
to the operating room where he underwent a coronary artery
bypass graft. His grafts were left internal mammary artery
to the second diagonal and saphenous vein graft to obtuse
marginal. The patient tolerated the procedure well, and
there were no complications.
Postoperatively, he was transferred to the Cardiothoracic
Surgery Recovery Unit where he was maintained briefly on
pressors. The patient woke up extubated and was weaned off
of his pressor support.
On postoperative day two, he was transferred out of the
Intensive Care Unit to the floor, where his chest tubes and
Foley catheter were removed, and his pacing wires were
removed. His diet was advanced. He worked with Physical
Therapy, and he was deemed to be a candidate for
rehabilitation and was to be discharged there on
postoperative day four.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: To rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Lipitor 10 mg p.o. q.h.s.
2. Glucophage 500 mg p.o. b.i.d.
3. Acetylsalicylic acid 325 mg p.o. q.d.
4. Metoprolol 25 mg p.o. b.i.d.
5. Lasix 20 mg p.o. b.i.d. (for seven days).
6. Potassium chloride 20 mEq p.o. b.i.d. (for seven days).
7. Colace 100 mg p.o. b.i.d.
8. Zantac 150 mg p.o. b.i.d.
DISCHARGE FOLLOWUP: The patient was to follow up with his
primary care doctor, Dr. [**Last Name (STitle) 23651**], in two to four weeks and
with Dr. [**Last Name (STitle) 70**] in Cardiothoracic Surgery in two to four
weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2104-3-1**] 11:40
T: [**2104-3-1**] 10:43
JOB#: [**Job Number 35887**]
|
[
"250.00",
"715.90",
"414.01",
"410.71",
"443.9",
"305.1",
"501",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.11",
"36.15",
"39.61",
"88.53",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
2198, 2504
|
792, 2082
|
692, 773
|
2097, 2172
|
2526, 3035
|
182, 477
|
499, 667
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,237
| 119,222
|
35121
|
Discharge summary
|
report
|
Admission Date: [**2151-1-17**] Discharge Date: [**2151-1-21**]
Date of Birth: [**2109-5-30**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Codeine / Reglan / Ketorolac / Oxycodone /
Hydromorphone Hcl / Peanut
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Requiring insulin gtt
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 41 year old female with asthma (poorly
controlled, recently started Xolair), DM2, HTN, vertigo,
depression, CVA [**2142**] with residual L hemiplegia who was admitted
[**1-17**] with chest pain and SOB, worsening peak flows (150 from
300) felt to be [**12-29**] to asthma exacerbation. In the ED she was
tachycardic but 02 sats 99% on 2L, wheezing on exam. She
received 125 IV solumedrol as well as nebs. She did not receive
insulin for breakfast or lunch while in the ED, her serum
glucose at 7am was 92.
.
On arrival to the medicine floor, BG >500 at 16:30. Got 26U of
regular insulin (patient reported she was on 26 units of insulin
with [**Last Name (LF) 16429**], [**First Name3 (LF) **] she received regular insulin at this dose.
However, it was later realized that she is on concentrated
insulin --U-500 Insulin--so she was effectively underdosed.
Rechecked at 17:10 BG 466 and 473 at 18:40. Repeated lytes (as
below) and there was no gap. IVF were started and and [**Last Name (un) **] C/S
obtained. Administered additional 30U of humalog at 20:30. BG
460 at 21:00. BG 466 at 22:30. [**Last Name (un) **] C/S recommending MICU
transfer for insulin gtt.
.
On arrival to the ICU, the patient reports her breathing is bad
but has been improved with nebs, her FSG is >500.
.
ROS: + as per HPI. Additionally, notes fatigue, dizziness, sinus
pain, N/V, constipation and urinary retention x2d.
.
Denies: F/C/night sweats, HA, productive cough, palpitations,
abd pain, dysuria, myalgias, arthralgias
Past Medical History:
-Asthma diagnosed in childhood with multiple hopitalizations
each year requiring two previous intubations
-DM2 with known neuropathy followed by [**Doctor First Name 4375**] [**Doctor Last Name 3617**] at [**Last Name (un) **].
Per pt, she has required MICU admission for hyperglycemia in
setting of steroids.
-GERD s/p Nissen fundoplication
-HLD
-morbid obesity
-depression
-HTN
-s/p CVA [**2142**] with residual L hemiplegia
-spinal stenosis
-hx of Ganglion cystectomy
-vertigo
Social History:
Married and originally from [**Location (un) 9012**], GA. She is currently going
to
school for teaching and is active in her church. She has been on
disability since [**2133**]. 2 pack year smoking hx. Denies ETOH,
illicits.
Family History:
Per pt, (+) FHx of "blood clots." Maternal grandmother and
father with history of CAD. Father also
had asthma. Maternal grandmother had diabetes and also maternal
aunts and sister. Mother with h/o low BP and DVT. Maternal aunt
with same "mitral" problem.
Physical Exam:
VS: HR:114 BP: 118/53 92% on RA
GENERAL -
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP without
erythema or exudate
NECK - supple, trachea midline, no JVD, no thyromegaly, no LAD
LUNGS - Audible breathing with prolonged expiratory phase. R
lung with expiratory wheezes and in all fields. Unable to assess
L lung because pt will not sit forward and will only turn onto L
side. HEART - RRR, normal S1 and S2, no m/r/g. CP with radiation
reproducible with palpation.
ABDOMEN - Obese abd. normal BS, S/NT/NT, no rebound or guarding,
no organomegaly.
EXTREMITIES - MAE. WWP. PTs and radials 2+ b/l. No c/c/e.
SKIN - no rashes or lesions
NEURO - alert, oriented x3, attentive. Difficult to assess
strengnth as clear give way weakness on R side and lack of
effort on L. Sensation grossly intact throughout.
Pertinent Results:
CXR [**1-17**]: IMPRESSION: Low lung volumes with mild bibasilar
atelectasis. No focal consolidation seen.
.
Hgb A1C [**2150-10-27**] 9.4 --> currently 7.4
.
Trop-T: <0.01
.
Chem 10
137 101 14 92 AGap=15
4.3 25 0.9
.
CBC
8.2 > 10.4 < 538
33.2
N:59.3 L:30.6 M:6.4 E:3.3 Bas:0.4
.
[**Name (NI) 2591**]
PT: 10.6 PTT: 25.0 INR: 0.9
.
DDimer 577
Brief Hospital Course:
Ms. [**Known lastname **] is a 41 year old female with asthma, DM2, HTN,
vertigo, depression, CVA, admitted for shortness of breath and
chest pain [**12-29**] asthma exacerbation who developed hyperglycemia
in the setting of missing her insulin while in the ED, receiving
steroids and her insulin underdosed on the floor, transferred to
the MICU for insulin gtt.
# Hyperglycemia: Likely secondary to steroids and
missed/underdosing of insulin upon admission. Of note, patient's
unmanaged OSA was felt likely a contributor to her insulin
resistance (hyperadrenergic from episodic apnea). Patient did
not have a gap throughout this and her electrolytes were
regularly checked. Patient was initially on an insulin gtt with
close monitoring also by [**Last Name (un) **]. Patient was initially NPO in
the ICU on maintainance fluids (normal saline) with plan to
either resume diet when blood sugars <250 or transition to
D51/2. Given the possibility of confusing U:500 with U:100 on
the floor, patient's insulin doses were converted to U:100. Plan
was for patient to be given lantus 180 units and the insulin gtt
stopped four hours later with initiation of a tight sliding
scale. Patient's blood sugars remained persistently high,
however, so her insulin gtt was continued, [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs, at
high doses (60-70 units per hour). There was concern on the
second day in the MICU that patient's brother was bringing her
fast foods inconsistent with the hospital diabetic diet,
resulting in volatile blood sugars up to 450+. Ultimately,
patient was transferred to the floor on NPH 180 in the morning
and 20 units before bed and tight humalog sliding scale. [**Last Name (un) **]
continued to folllow patient closely on the floor. She was
discharged home after completion of pulse-dose steroids on her
home insulin regimen.
# Shortness of Breath/COPD exacerbation: Likely multifactorial,
consistent with previous asthma exacerbations (wheezing,
decreased peak flow, improvement with nebs and steroids) and
patient with notable restrictive component to her SBO due to
obesity and deconditioning. [**Month (only) 116**] also have evolving pulm htn
from OSA and not wearing bipap at home. No signs of PNA (CXR
unchanged, no cough, fever, white count). CHF unlikely (NL echo
[**2149**], no edema or JVD, no CXR evidence). PE remained a
possibility given her tachycardia (although baseline HR90-100s
per OMR), immobilization and recent initiation of Xolair. D
dimer checked and was 557, which is similar or less than three
prior hospitalizations in the past 15 months with similar
presentations. Each time, D-Dimer obtained, D-Dimer was mildly
positive, and pt was ruled out for PE by negative V/Q scan,
treated for Asthma exacerbation and improved. Given this hx, PE
was felt unlikely and VQ scan was not pursued. Patient was
continued on Prednisone 60mg daily for presumed asthma
exacerbation, albuterol/ipratropium nebulizers, home
anti-leukotriene and Advair. Patient was continued on her home
CPAP which she is not compliant with at home but was compliant
with in-house. Patient also received one dose Magnesium for
management of her asthma as she remained persistently wheezy
until day of transfer out of MICU. Given the extreme elevations
in her blood sugar and the fact that patient's symptoms had
completely resolved by the time of transfer to the floor, a
5-day pulse dose course of steroids at 60 mg daily was felt
preferable to taper. The patient was kept in-house until
completion of the pulse course, and then discharged home on her
usual insulin regimen.
# Chest Pain: Reproducible with palpation so felt likely
MSK/non-cardiac chest pain. Unlikely ACS as no EKG changes, CE
negative x 2. GI related pain also possible, but unlikely reflux
given pt on Omeprazole and Ranitidine at home. Cardiac enzymes
negative X2 for myocardial ischemic/infarction. Patient's chest
pain was managed with Morphine initially and did not require
further pain medications for chest pain. Upon transfer to floor,
did request narcotic analgesia for chronic back pain. Patient
was continued on home Omeprazole and Ranitidine with good
effect. Of note, in discussions with her primary care provider,
[**Name10 (NameIs) **] was not prescibed narcotics prior upon discharge given
on-going issues regarding this matter.
# Vulvovaginal itch: Likely yeast infection in setting of
significantly elevated blood sugars. Patient was given a dose of
Diflucan and started on Miconazole cream without significant
relief of her symptoms. She received second dose of Diflucan
prior to transfer to floor.
# Psychiatric: Patient became agitated overnight on Day 3 in the
MICU, refusing subcutaneous heparin, becoming combative and
threw a pitcher of water. Patient then proceeded to remove
telemetry and other lines to leave AMA. Code Purple was called
and House Staff in conjunction with Security were able to
persuade patient to stay. She received a dose of Valium and pain
medications; she slept through the night. Patient has a history
of combative agitation towards staff in the past and has been
seen by psychiatry in-house. Social Work consult was ordered in
MICU and patient will likely benefit from Psychiatric follow-up.
#Tachycardia: Likely [**12-29**] anxiety, pain and inhalers. Less likely
PE. Noted to be tachy to 100-110 range at clinic visits in OMR.
# Hypertension: Patient normotensive on arrival to the ICU and
was continued on her home lisinopril.
#Peripheral Neuropathy: Continued on home gabapentin,
amitriptyline, lidocaine patch
#Spinal Stenosis: Seen as outpatient by pain clinic with recent
steroid injection in Januuary.
#HLD: Continued home simvastatin
#Depression: Continued on Doxepin and social work was consulted
for patient coping with asthma/blood sugars
#Vertigo: Continued on home Diazepam PRN (did not require)
#GERD: Continued on ranitidine and omeprazole
#Urinary Rentention: Patient reported urinary retention in the
ED so a Foley was placed. Unclear if a bladder scan was
initially done. Urinalysis was negative. Foley was discontinued
upon discharge to floor.
#OSA: Patient reports having CPAP at home though not usually
wearing it and had refused it on the floor prior to transfer to
MICU. She was amenable to CPAP and demonstrated good compliance
while in the ICU.
# Fxnal Status: Patient is wheelchair bound with limited
mobility at baseline. Physical therapy worked with patient while
she was in-house
#. Communication - Brother [**Name (NI) 3403**] [**Name (NI) **] [**Telephone/Fax (1) 80191**].
#. Code - Full code
Medications on Admission:
ALBUTEROL SULFATE - Q4H PRN SOB
ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg - 2 puffs(s) inhaled q
4-6h PRN chest tightness/SOB
AMITRIPTYLINE - 75 mg QHS
AMMONIUM LACTATE - 12 % Cream - apply to feet twice a day
DOXEPIN - 10-30 mg PO QHS
EPINEPHRINE [EPIPEN] 1:1,000 Injector IM PRN anaphylaxis
ETODOLAC - 300 mg PO BID
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg [**Hospital1 **]
HYDROCORTISONE - 1 % Lotion - apply to affected area daily PRN
IPRATROPIUM BROMIDE - 0.02% Solution - 1 U INH [**Hospital1 **]:PRN as needed
for SOB
KETOCONAZOLE - 2 % Shampoo - apply to scalp and wash 1 time
weekly
LIDOCAINE - 5 % adhesive patch daily
LISINOPRIL - 10 mg daily
METFORMIN - 1000mg [**Hospital1 **]
OMALIZUMAB [XOLAIR] - 300 mg SC q 2 weeks
OMEPRAZOLE - 20 mg [**Hospital1 **]
POTASSIUM CHLORIDE [K-DUR] - 20 mEq PO BID
PREGABALIN [LYRICA] - 150 mg, 1 tablet QAM, 2 tablets QPM
RANITIDINE HCL - 300 mg QHS
SIMVASTATIN - 20 mg daily
UREA - 40 % Cream - Apply to soles of feet [**Hospital1 **]
ZAFIRLUKAST [ACCOLATE] - 20 mg [**Hospital1 **]
Morphine 5mg Q6H PRN pain
Valium 5mg [**Hospital1 **] vertigo
ASPIRIN - 325 mg daily
CALCIUM CARBONATE - 600 mg [**Hospital1 **]
CHOLECALCIFEROL (VITAMIN D3) - 1000U daily
INSULIN REGULAR HUMAN [d-500] - 20 units Q meal
MULTIVITAMIN
Xolair as follows: 375mg every 2 weeks
.
ALLERGIES:
Iodine- Unknown/SOB
Codeine- Hives
Reglan- tongue swelling
Ketorolac- Rash
Oxycodone- Rash/wheezing
IV Hydromorphone- Hives
Peanut- Hives
.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation every four (4)
hours as needed for shortness of breath or wheezing.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
3. Amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
4. Ammonium Lactate 12 % Cream Sig: As directed Topical twice a
day: Apply to feet.
5. Doxepin 10 mg Capsule Sig: [**11-29**] Capsules PO HS (at bedtime).
6. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Intramuscular
As directed as needed for Allergic reaction.
7. Etodolac 300 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
twice a day as needed for shortness of breath or wheezing.
10. Hydrocortisone 1 % Lotion Sig: As directed Topical once a
day: Apply to affected area as needed.
11. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a week:
Apply to scalp and wash.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off - apply to back .
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. Xolair 150 mg Recon Soln Sig: Two (2) Subcutaneous Every 2
weeks.
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
17. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO twice a day.
18. Pregabalin 150 mg Capsule Sig: As directed Capsule PO twice
a day: 1 tablet in the morning, 2 tablets at night.
19. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
20. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
21. Urea 40 % Cream Sig: As directed Topical twice a day: Apply
to soles of feet [**Hospital1 **].
22. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO twice a day.
23. Valium 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for vertigo.
24. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
25. Calcium Carbonate 600 mg (1.5 gram) Tablet, Chewable Sig:
One (1) Tablet, Chewable PO twice a day.
26. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
27. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
28. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig:
Twenty (20) units Injection three times a day: With [**Hospital1 16429**]. Draw
back to 20 mark on 30-syringe.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
PRIMARY:
- Asthma exacerbation
- Uncontrolled type II diabetes mellitus
SECONDARY:
- Morbid obesity
- GERD
- Depression
- Hypertension
- Vertigo
- s/p CVA with residual left hemiparesis, wheelchair-bound
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to [**Hospital1 69**] with a
complaint of shortness of breath and wheezing. You were started
on high-dose prednisone to treat an asthma exacerbation. You
were transferred to the intensive care unit for better control
of your blood sugar and you were evaluated by the [**Last Name (un) **]
diabetes consult team. Your breathing improved and your steroids
were stopped after a 5-day pulse dose.
We have made no changes to your medication regimen. When you
return home, please take your first dose of U-500 insulin prior
to dinner as you would according to your usual sliding scale.
Please follow up as recommended below. You may also wish to
contact your pulmonologist to discuss this admission.
Followup Instructions:
1. Primary care - Post discharge clinic (Dr. [**Last Name (STitle) **]
[**Hospital3 **]
Phone: [**Telephone/Fax (1) 250**]
Date/time: Monday, [**2151-1-25**]:30 AM
2. [**Last Name (un) **] diabetes center - Dr. [**Last Name (STitle) 3617**]
[**Telephone/Fax (1) 27738**]
- Please call to schedule a follow-up appointment for 2 weeks
following discharge.
Other follow up:
Provider: [**Name Initial (NameIs) 6436**] ([**Month (only) **]) [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2151-1-22**] 3:00
Provider: [**Name10 (NameIs) **] NURSE Phone:[**Telephone/Fax (1) 9316**] Date/Time:[**2151-1-27**]
8:15
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2151-1-27**] 9:40
Completed by:[**2151-1-23**]
|
[
"V46.3",
"493.22",
"401.9",
"V45.89",
"786.59",
"327.23",
"250.02",
"438.20",
"278.01",
"112.1",
"356.9",
"307.9",
"311",
"272.4",
"788.20",
"724.00",
"780.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
15031, 15092
|
4178, 10770
|
362, 368
|
15341, 15341
|
3797, 4155
|
16252, 16614
|
2693, 2951
|
12293, 15008
|
15113, 15320
|
10796, 12270
|
15514, 16229
|
2966, 3778
|
16626, 17098
|
301, 324
|
396, 1931
|
15356, 15490
|
1953, 2434
|
2450, 2677
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,826
| 101,492
|
893
|
Discharge summary
|
report
|
Admission Date: [**2174-6-8**] Discharge Date: [**2174-6-11**]
Service: [**Location (un) **] General Medicine Firm
HISTORY OF PRESENT ILLNESS: 85-year-old woman with history
of metastatic pancreatic biliary cancer who presents from
home with 3-4 days of malaise with weakness. Her last bowel
movement was three days prior to admission. She has
decreased urine output the prior two days, no chest pain
although she does have some shortness of breath and abdominal
pain over the past few days. She feels weak and has diffuse
aches and pains. She has a history of GI bleed in the
setting of anticoagulation for pulmonary embolism. In
[**2174-2-18**] she underwent embolization of a duodenal artery
by interventional radiology at that time. She has a large
pancreatic mass requiring gastrojejunostomy done by Dr.
[**Last Name (STitle) **] because of stricture/obstruction. She has not
noticed any melena or bright red blood per rectum. In the
Emergency Room she was with blood pressure 80/60, hematocrit
12.5, received one liter of normal saline, one unit of packed
red blood cells. EGD showed bleeding of a pancreatic mass in
the stomach. Patient and family wanted to proceed with IR
intervention.
PAST MEDICAL HISTORY: Metastatic pancreatic cancer, biliary
cancer with mets to the liver diagnosed in [**2-19**] during GJ
tube placement with liver biopsy. Pulmonary embolism status
post IVC filter placement in [**2173-12-18**]. GI bleed in the
setting of anticoagulation for pulmonary embolism.
Hypertension. Diabetes mellitus type 2, coronary artery
disease status post MI, status post cholecystectomy, chronic
obstructive pulmonary disease.
ALLERGIES: No known drug allergies.
MEDICATIONS: Calcium carbonate 1 gm tid, Captopril 150 mg po
tid, Reglan 10 mg po tid, Metoprolol 50 mg po bid, Zantac 150
mg po bid, Ativan .25 mg po q 8 hours prn, Darvocet two
tablets po prn, OxyContin 20 mg po bid prn, Ambien 5 mg po q
h.s. prn, Glucotrol 5 mg po bid.
SOCIAL HISTORY: No tobacco or alcohol use, she immigrated 9
years ago.
FAMILY HISTORY: Father had esophageal cancer, mother had a
stroke, brother has lung cancer.
PHYSICAL EXAMINATION: On admission is notable for
temperature 97.7, pulse 79, blood pressure 94/63,
respirations 15. 100% sat on room air. In general, alert
and oriented times three, no acute distress, Russian
speaking. HEENT: Pupils are equal, round, and reactive to
light, extraocular movements intact, oropharynx clear, right
IJ line in place, no lymphadenopathy. Heart tachycardic, no
murmurs, rubs or gallops. Chest is clear to auscultation
bilaterally, no wheezes or rales. Abdomen soft, nontender,
active bowel sounds, positive ascites. Extremities, no
edema, dorsalis pedis pulses +2 bilaterally. Neuro, cranial
nerves II through XII intact.
LABORATORY DATA: White blood count 13.2, hematocrit 12.5,
platelet count 219,000, INR 1.3, BUN 56, creatinine 1.0.
LFTs within normal limits. CK and troponin within normal
limits. Albumin 2.9. EKG was normal sinus rhythm at 86 with
normal axis, normal intervals, a Q in lead 3 which is old
with flipped T in 1 and 2 and 3 which is new.
HOSPITAL COURSE: The patient was admitted and taken to the
Intensive Care Unit. For left GI bleed she received multiple
units of packed red blood cells and then a stable hematocrit
after transfusions in the mid 30's. EGD was done which
showed a bleeding pancreatic mass and therefore patient went
to angiography, had embolization of her gastroduodenal branch
with good results. She has been hemodynamically stable since
the procedure and was called out of the Intensive Care Unit
on [**2174-6-9**]. The procedure was complicated with right groin
hematoma which has since improved. A radiation oncology
consult was obtained to evaluate for palliative radiation to
the site of her mass. They felt it would not be of benefit.
After discussion with the family and with the patient, we
decided on no further treatment at this time for the
malignancy but to try to optimize her status by transferring
her to [**Hospital **] [**Hospital **] Rehab. Her PO intake has been
gradually increased with the normal 50 cc IV fluids. Also of
note, her CKs were normal and her blood pressure was
initially low and then as it increased the Metoprolol and
then the Captopril were able to be added back on. She had
occasional runs of supraventricular tachycardia which all
stopped spontaneously. Her hematocrit after 6 units of
packed red blood cells is in the mid 30's.
DISCHARGE MEDICATIONS: Calcium carbonate one po tid,
Captopril 25 mg po tid, Metoprolol 50 mg po bid, Reglan 10 mg
po tid, Protonix 40 mg po bid, Ativan .25 mg po q 8 hours
prn, Darvocet two tabs prn, OxyContin 20 mg po bid prn,
Ambien 5 mg po q h.s. prn, Glucotrol 5 mg po bid, Colace 100
mg po bid. Diet is cardiac and diabetic. She will have
physical therapy at [**Hospital1 **].
FINAL DIAGNOSIS:
1. Metastatic pancreatic cancer/biliary cancer.
2. Pulmonary embolism.
3. Upper GI bleed, now status post embolization.
Patient is stable for transfer. Upon transfer her oncologist
will have further discussions with the family about code
status and possible hospice placement.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2174-6-10**] 16:15
T: [**2174-6-10**] 17:54
JOB#: [**Job Number 6070**]
|
[
"285.1",
"560.1",
"197.7",
"412",
"998.12",
"250.00",
"578.9",
"157.8",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.44",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
2073, 2150
|
4538, 4901
|
3170, 4514
|
4918, 5431
|
2173, 3152
|
156, 1219
|
1242, 1983
|
2000, 2056
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,180
| 178,470
|
37516
|
Discharge summary
|
report
|
Admission Date: [**2173-3-18**] Discharge Date: [**2173-3-23**]
Date of Birth: [**2108-5-14**] Sex: F
Service: MEDICINE
Allergies:
Banana / Melon Flavor / Avocado / IV constrast / Lorazepam
Attending:[**First Name3 (LF) 11839**]
Chief Complaint:
Fever and right flank pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 yo F with cervical cancer diagnosed 2 months ago, ongoing
radiation (last [**2173-3-18**]), and chemo (last [**2173-3-16**]). Today she was
seen by the Heme/ onc RN service for a lab draw. She complained
the the onset of right flank pain (at the site of her
nephrostomy tube) which awoke her from sleep Wednesday am. She
has had ongoing output from bilateral nephrostomy drains, which
is occasionally bloody. Prior to leaving she had a T of 99.
After arriving home she developed a fever to 102 at 7pm
associated with rigors. She was instructed to go to the
emergency apartment. She also has had alternating diarrhea and
constipation (most recently diarrhea). No bloody BM. No severe
nausea. No cough or SOB. No CP. Poor PO intake x 2 days.
In the ED, VS 98.7 100 133/50 20 100%. Got 2L fluid for BP 90s
to 110s, HR 80s to 90s. Given Potassium Chloride 20 mEq PO and
40 IV,Acetaminophen 500mg Tablet,CefePIME 1 g, mag 2 gm, calcium
gluconate 1gm. She was writtin for vancomycin but it was not
recieved. Blood and UCx were obtained. CXR nml
Patient was admitted to the [**Hospital Unit Name 153**] for hypotension. She was
maintained on vanco/cefepime and her urine culture from left
nephrostomy grew enterococcus and e.coli. She also has GNRs in
one set of blood cultures from [**3-19**]. Repeat blood cx are NGTD.
Currently, she is feeling much better. She denies any fevers or
chills. She denies any flank pain. She denies any other
symptoms at this time.
Review of Systems:
(+) Per HPI. + 20 lb wt loss.
(-) Review of Systems: HEENT: No headache, sinus tenderness,
rhinorrhea or congestion. CV: No chest pain or tightness,
palpitations. PULM: No cough, shortness of breath, or wheezing.
GI: No vomiting, or abdominal pain. No recent change in bowel
habits, no hematochezia or melena. GUI: No dysuria or change in
bladder habits. MSK: No arthritis, arthralgias, or myalgias.
DERM: No rashes or skin breakdown. NEURO: No numbness/tingling
in extremities. PSYCH: No feelings of depression or anxiety. All
other review of systems negative.
Past Medical History:
Past Oncologic History:
# Stage [**Doctor First Name **] squamous cell cervical carcinoma:
- developed vaginal bleeding around [**Holiday 1451**] [**2172**]. Recurred
approximately 1-2 weeks later in early [**2173-1-13**].
- Pap smear showed showed high-grade squamous intraepithelial
lesion.
- continued to experience vaginal bleeding, and also developed
suprapubic abdominal pain, urinary frequency/urgency, and 5-10lb
weight loss.
- presented to [**Hospital1 18**] ED [**2173-2-9**] after noting gross hematuria. A
pelvic ultrasound on the day of admission showed a bladder
hematoma with no clear visualization of the uterus or ovaries.
Abd/pelvic CT the same day showed mild right hydronephrosis and
hydroureter with clotted blood in the bladder.
- was admitted to the Urology service and on [**2173-2-10**] had an
MR
urogram which showed a 5.7 x 3.6 x 1.9 cm cervical mass with
bilateral parametrial involvement, mild hydrometria, invasion
into the posterior bladder wall over 3.5 cm and right
hydronephrosis. A small amount of free fluid was seen in the
pelvis. There was also a 1.6-cm gallbladder wall nodule.
- Dr. [**Last Name (STitle) **] performed a cystoscopy [**2173-2-10**] which showed the
cervical mass to be invading the trigone and posterior wall with
a large amount of old clot and oozing. The ureteral orifices
were involved. He fulgurated the area of the involved bladder
and obtained biopsies of the trigone mass.
- Pathology from this biopsy returned positive for invasive
squamous cell carcinoma consistent with a cervical origin
involving the muscularis propria and the lamina propria without
involvement of the bladder mucosa, with lymphovascular invasion.
- Examination under anesthesia performed by Dr. [**Last Name (STitle) 5797**]
[**2173-2-11**] showed a necrotic cervical mass which obliterated the
vaginal fornices and infiltrated the anterior upper half of the
vagina, with left parametrial involvement to the sidewall and
medial right parametrial involvement. Proctoscopy showed no
rectal involvement. Biopsies of the cervix again showed squamous
cell carcinoma with vascular invasion. She was discharged from
the hospital on [**2173-2-13**].
- Ms. [**Known lastname 5936**] had a PET-CT scan on [**2173-2-16**] that showed
FDG-avidity in the region of the known cervical mass, with
irregularity of the posterior urinary bladder and extension
of FDG-avidity through the uterine myometrium to the fundus. No
distant metastases were seen, and therefore staging is
consistent
with T4, FIGO stage [**Doctor First Name 690**] disease.
- She was seen by Dr. [**Last Name (STitle) **] of Radiation Oncology on [**2173-2-16**]
and
started radiation therapy on [**2173-2-19**] for planned 37 sessions
- saw Dr. [**Last Name (STitle) 4149**] in Oncology on [**2173-2-22**], planning to start
radiosensitizing weekly cisplatin on [**2173-2-25**]
- admitted [**2-25**] to [**3-4**] with ARF relieved with BL nephectomy
tubes and developed LGIB [**3-17**] tumor invading into bowel
- started cisplatin weekly [**2173-3-4**], last dose [**2173-3-16**]
.
OTHER MEDICAL HISTORY:
# Status post resection of a benign pituitary adenoma at age 21
at [**Hospital1 2025**] with resultant hypopituitarism; she was previously
followed at [**Hospital1 2025**], last saw Endocrinology at [**Hospital1 **]-[**Location (un) **] in [**Month (only) 547**]
[**2172**].
# Osteoporosis
# Multiple food allergies
# Gynecologic History: Menarche, age 14; menopause, age 22. The
patient used hormone replacement therapy from age 22 to her 50s.
G2P2, with deliveries at ages 18 and 20.
Social History:
She grew up in the West End of [**Location (un) 86**]. She lives in [**Location 4628**], MA
with her husband [**Name (NI) **]. They have two daughters. [**Name (NI) **] [**Name2 (NI) 1685**]
daughter lives in [**Name (NI) 3844**]. She describes their family as
supportive, close-knit. She has a sister in [**Name (NI) 4565**] who will
be flying here to be with pt. She was employed very briefly in
[**Location (un) 6692**] airport. Her husband is a supervisor of construction for
Massport. The patient smoked approximately one-third to [**2-14**]
pack per day for 33 years, recently quitting. She had one
alcoholic
beverage daily until her illness.
Family History:
[**Name (NI) 1094**] brother died of leukemia at age 64 in [**2164**]. Pt was a match,
donated peripheral blood stem cells. Both parents had heart
disease.
Physical Exam:
VS: 96.8 115/59 64 14 100%RA
I/O: 3075/3950
GEN: awake, alert. AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RR, 1/6 SEM at RUSB. R chest por in place
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Flank: bilateral nephrostomy tubes present. no CVA tenderness.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS).
gait WNL.
Pertinent Results:
Labs on admission:
[**2173-3-18**] 04:40PM BLOOD WBC-10.1 RBC-2.81* Hgb-8.9* Hct-25.2*
MCV-90 MCH-31.7 MCHC-35.3* RDW-13.7 Plt Ct-118*
[**2173-3-18**] 04:40PM BLOOD Neuts-95* Bands-0 Lymphs-2* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-3-18**] 10:42PM BLOOD PT-15.2* PTT-26.2 INR(PT)-1.3*
[**2173-3-18**] 02:30PM BLOOD UreaN-19 Creat-1.2* Na-128* K-3.0* Cl-91*
HCO3-26 AnGap-14
[**2173-3-18**] 10:42PM BLOOD ALT-20 AST-19 AlkPhos-80 TotBili-0.5
[**2173-3-18**] 10:42PM BLOOD Calcium-7.1* Phos-1.8* Mg-1.1*
[**2173-3-18**] 10:46PM BLOOD Lactate-1.2
Pertinent lab trends
Creatinine
[**2173-3-18**] 02:30PM Creat-1.2*
[**2173-3-19**] 01:50PM Creat-0.9
[**2173-3-20**] 02:39PM Creat-0.8
Sodium
[**2173-3-18**] 02:30PM Na-128*
[**2173-3-19**] 04:36AM Na-136
[**2173-3-20**] 05:07AM Na-133
[**2173-3-20**] 02:39PM Na-134
Hct, Plt
[**2173-3-18**] 04:40PM Hct-25.2* Plt Ct-118*
[**2173-3-19**] 04:36AM Hct-22.5* Plt Ct-84*
[**2173-3-20**] 05:07AM Hct-22.4* Plt Ct-81*
[**2173-3-20**] 02:39PM Hct-23.9*
MICRO:
Blood culture - GNRs
Urine culture - ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
IMAGING:
CXR:
FINDINGS: There is no pneumonia. There is no pleural effusion or
pneumothorax. Hilar, mediastinal, and cardiac silhouette are
within normal
limits. There is a Port-A-Catheter with tip projecting at the
upper right
atrium. There are bilateral nephrostomy tubes.
Renal U/S:
IMPRESSION:
1. Moderate fullness of the right collecting system with
nephrostomy tubes
visualized within the midline renal pelvis. No evidence of
adjacent abscess cavity or focal infection on this ultrasound
examination.
2. Normal appearance of the left kidney, nephrostomy tube not
visualized.
Brief Hospital Course:
64-year-old woman with recently diagnosed stage [**Doctor First Name **] cervical
cancer, currently on chemo / radiation, presents with fever and
right flank pain.
# E.coli and Enterococcus UTI with GNR bacteremia: In the
setting of chemo and radiation, the fever was felt to represent
infection. Patient was symptomatic with right CVA tenderness and
U/A from the right nephrostomy tube was suggestive of a UTI with
positive nitrites. Renal U/S showed some right collecting
system fullness, but was otherwise unremarkable. Urine cultures
grew both E. coli and enterococcus and blood cultures also grew
out e/coli bacteremia, . Her WBCs trended down and she did not
spike any fevers or have any more rigors during her ICU
admission. She was covered broadly with cefepime and vanco.
Both e.coli and enetrecoccus were pan-sensitive and antibiotic
switched to ciporflox and amoxicillin per sensitivities.Pt to
compete a two course at home. Surveillance blood cultures were
all negative.
# Mild hypotension and hypopituitarism: Pt's systolic blood
pressure dropped to 90's and responded to IVF in the [**Hospital Unit Name 153**]. She
was continued on prednisone and thryoid replacement therapy. In
setting of stress and fever, it was felt that she was relatively
[**Name2 (NI) 84258**] and was given stress dose prednisone at 20mg daily.
Prednisone was tapered down as blood pressure remained stable
and afebrile.On discharge patinet bck to 5 mg po daily of
prednisone.
# Electrolyte abnormalities with high urine output: Given her
poor PO intake and continued high urine output, she was given
IVF boluses for hypovolemia and hyponatremia. She was also
hypokalemic,hypo-phosphotemic an dhypomagnesemia. All likely due
to the cisplatin she received. Lytes were monitored closely and
repleted as needed. Pt d/c with oral replation and close f/u of
labs as an outpt.
# Thrombocytopenia: New onset thrombocytopenia/ Likely due to
the infection in addition te recent chemotherapy. Pt had no
evidence of bleed and plts remained in the range of 70-80's.
They will need to be monitored as an outpatient as well.
# Anemia: Likely due to recent bleeding from tumor ans well as
anemia of inflammation. Pt did receive 2 units of PRBCS with
appropriate response.
# Cervical ca: Pt continued radiation treatment while on the
floor. She will contniue radiation adn f/u with her primary
oncologist as well.a
#Pain: Pt with lower abdominal/pelvic pain due to her cervical
cancer. Pain was not well ocntrolled oxycontin 10 mg and
recently decreased to 20 mg [**Hospital1 **] , which pt reported made her
toosleepy throughtout te day. Regimen changed to 10 mg in the
morning and afternoon and 20 mg at night. Pt tolerated this
regimen well with good pain control.
# FEN: regular diet;
# PPx: heparin sc
colace/senna/miralax
# Full code
# Dispo: Pt d/c home with VNA services.
Medications on Admission:
levothyroxine 125mcg daily
lidocain-prilociaine crm for accessing port
nystatin [**Numeric Identifier 4856**] u/ml 5ml QID
zyprexa 2.5 to 5mg q6h
zofran 8mg PO q8h prn
oxycontin 10mg q12h prn
polyethylene glycol 1 packet daily prn
prednisone 5mg PO daily
compazine 10mg PO q6h prn
acetaminophen 325mg [**2-14**] Tab q6h prn
colace 1 cap [**Hospital1 **]
Senna 1 cap [**Hospital1 **] prn
CURRENT MEDICATIONS:
1. Neutra-Phos 2 PKT PO/NG ONCE
2. Olanzapine 2.5 mg PO BID:PRN aggitation
3. Acetaminophen 650 mg PO/NG Q6H:PRN fever
4. Ondansetron 8 mg IV Q8H:PRN nausea
5. CefePIME 1 g IV Q12H day 1 = [**3-19**]
6. OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain
7. Docusate Sodium 100 mg PO BID
8. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
9. Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation
10. Heparin 5000 UNIT SC TID
11. PredniSONE 20 mg PO/NG DAILY
12. Levothyroxine Sodium 125 mcg PO/NG DAILY
13. Prochlorperazine 10 mg IV Q6H:PRN nausea
14. Lidocaine-Prilocaine 1 Appl TP ASDIR
15. Senna 2 TAB PO/NG [**Hospital1 **]
16. Vancomycin 1000 mg IV Q 12H
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
4. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): do not take together with calcium.
5. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for aggitation.
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical ASDIR (AS DIRECTED): for port access.
8. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO DAILY (Daily).
10. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO BID (2 times a day): in the
morning and afternoon.
11. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO HS (at bedtime).
12. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 11 days.
Disp:*66 Tablet(s)* Refills:*0*
13. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours) for 6 days.
Disp:*36 Capsule(s)* Refills:*0*
14. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO BID
(2 times a day) for 5 days.
15. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
Disp:*30 Tablet(s)* Refills:*0*
17. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
18. Phospha 250 Neutral 250 mg Tablet Sig: One (1) Tablet PO
once a day for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
19. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**2-14**] Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Urinary tract infection
Gram negative ( e.coli) bacteremia
hypomagnesemia
hypokalemia
hypophosphotemia
anemia
thrombocytopenia
pan-hypopituitarism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Known lastname 5936**] you were admitted for a urinary tract infection and a
bacteria in your blood.You presented with low blood pressure and
therefore admitted to the intensive care unit. Blood pressure
improved with IV hydration and increase in your prednisone dose
as well as IV antibiotics. After final results of the blood and
urine cultures and antibiotic sensitivities your antibiotics
were switched to oral antibiotics which you will need to
continue at home. You did receive 2 units of red blood cells and
electrolyte repletion.You will need to have close follow up and
blood work to assure that you do not get dehydrated and you may
need additional electrolyte supplementation.You also developed
diarrhea prior to discharge which is likely due to the
antibiotics. A stool was sent for culture and at the time of
discharge this result is pending.
Change in medications:
1. Ciprofloxacin 750 mg po bid x 11 days.
2. Amoxicillin 500 mg TID x 6 days
3. Oxycontin 10 mg in the morning and afternoon and 20 mg at
night.
4. Magnesium oxide daily
5. Potassium chloride 20 [**Female First Name (un) **] daily.
6. Neutraphos 1 packet twice a day.
Followup Instructions:
1.F/U tomorrow for CBC and chem 10 and possible need for IV
fluids and electrolytes.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2173-3-24**] at 9:00 AM
With: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
2.Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2173-3-25**] at 10:00 AM
With: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
3.Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2173-3-29**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
4. Continue radiation treatment as scheduled.
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
]
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15390, 15448
|
9352, 12224
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347, 353
|
15639, 15639
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,076
| 101,787
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5292
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Discharge summary
|
report
|
Admission Date: [**2182-5-20**] Discharge Date: [**2182-5-30**]
Date of Birth: [**2119-6-30**] Sex: M
Service: MEDICINE
Allergies:
Lasix / Betalactams / Haldol / Ceftriaxone
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Tachypnea, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 yo Russian-speaking man w/anoxic brain injury and with hx of
DMI, s/p cadaveric kidney transplant([**2175**]), h/o CVA and chronic
aspiration (multiple admissions for aspiration PNA - last [**3-19**]),
CABG in [**2170**], widespread tracheomalacia with trach stent, and
recent admission to the ICU from [**Date range (2) 21579**] for PNA, stent
removal and tracheostomy. He was treated for aspiration PNA
with Vanc, Levo, Flagyl and then switched to Cefepime and
Azithro to complete a 10 day course. He was also given Cipro x
7 days for a UTI. He was discharged with a dobhoff feeding tube
and on tube feeds. He was found today at rehab to be hypoxic to
the mid-80s. Suction was attempted but did not show improvement
and he was sent to [**Hospital1 18**] ED.
.
In the ED, initial vs were: T100.4 HR102 BP163/93 RR24 O2sat96.
Patient was given Vanc, Cefepime, Azithro and Solumedrol 125mg
IV x 1. He was given Kayexalate PR for potassium of 5.7 and
aspirin for troponin of 0.62. He was seen by IP due to possible
air leak as he was pulling tidal volumes of 200. The plan was
to replace his trach once in the ICU.
.
On the floor, he appears comfortable, unable to answer
questions, not following commands.
Past Medical History:
- Cadaveric renal transplant in [**2175**]
- CVA-residual right hemiparesis
- DM Type I
- HTN
- Hx non-QMI and Vfib arrest [**2169**] with anoxic brain injury
- CAD/CABG [**2170**]
- Swallow study-showed silent aspiration
- hx of aspiration pneumonia
- tracheomalacia after long intubation requiring trach stent and
button complicated by site cellulitis and granulation tissue
requiring cryoptherapy.
Social History:
Lives with wife. Former endocrinologist in [**Country 532**]. Has homemaker
who comes in 5 times a week. Has 3 daughters who visit him.
Family History:
No history of lung disease
Physical Exam:
General: Awake, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Course breath sounds bilaterally, left sided rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley with brown sediment
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
TRANSTHORACIC ECHO:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate regional left ventricular systolic
dysfunction with inferior/inferolateral akinesis/hypokinesis and
apical septal akinesis/dyskinesis. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2181-11-16**],
left ventricular sysotlic function is now more significantly
impaired. Focal apical septal hypokinesis was present
previously. Inferolateral /inferior akinesis is new (there may
have mild inferior hypokinesis previously).
.
.
CXR:
BEDSIDE FRONTAL RADIOGRAPH OF THE CHEST: Bilateral airspace
opacities which are more confluent in the left lung, worrisome
for pneumonia. Distended azygous contour, could represent volume
overload with part of the RUL opacity representing early edema.
There is no pleural effusion or pneumothorax. Heart size is
normal. Median sternotomy wire and mediastinal clips from prior
CABG are present. Tracheostomy tube is in standard location with
the tip terminating 3 cm above the carina.
.
IMPRESSION: Multifocal pneumonia with mild volume overload.
.
.
[**2182-5-20**] 05:35AM BLOOD cTropnT-0.62*
[**2182-5-20**] 02:40PM BLOOD CK-MB-23* MB Indx-6.7* cTropnT-1.47*
proBNP-[**Numeric Identifier 21580**]*
[**2182-5-20**] 11:01PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-1.70*
[**2182-5-21**] 04:36AM BLOOD CK-MB-12* MB Indx-4.7 cTropnT-1.79*
[**2182-5-21**] 01:59PM BLOOD CK-MB-7 cTropnT-1.36*
[**2182-5-20**] 05:35AM BLOOD Glucose-415* UreaN-65* Creat-2.4* Na-146*
K-5.7* Cl-106 HCO3-21* AnGap-25*
[**2182-5-20**] 02:40PM BLOOD Glucose-405* UreaN-75* Creat-2.7* Na-146*
K-4.9 Cl-111* HCO3-23 AnGap-17
[**2182-5-20**] 11:01PM BLOOD Glucose-170* UreaN-68* Creat-2.4* Na-149*
K-4.9 Cl-115* HCO3-23 AnGap-16
[**2182-5-21**] 04:36AM BLOOD Glucose-66* UreaN-67* Creat-2.2* Na-151*
K-4.7 Cl-117* HCO3-23 AnGap-16
[**2182-5-24**] 05:38AM BLOOD Glucose-98 UreaN-36* Creat-1.1 Na-144
K-3.8 Cl-107 HCO3-31 AnGap-10
[**2182-5-20**] 02:40PM BLOOD CK(CPK)-345*
[**2182-5-20**] 11:01PM BLOOD CK(CPK)-277
[**2182-5-21**] 04:36AM BLOOD CK(CPK)-254
[**2182-5-23**] 05:27AM BLOOD CK(CPK)-70
[**2182-5-20**] 05:35AM BLOOD tacroFK-14.6
[**2182-5-21**] 04:36AM BLOOD tacroFK-5.4
[**2182-5-23**] 05:27AM BLOOD tacroFK-7.2
[**2182-5-24**] 05:38AM BLOOD tacroFK-4.9*
[**2182-5-30**] 06:09AM BLOOD WBC-4.5 RBC-3.87* Hgb-9.9* Hct-30.9*
MCV-80* MCH-25.7* MCHC-32.2 RDW-17.2* Plt Ct-249
[**2182-5-30**] 06:09AM BLOOD Glucose-290* UreaN-30* Creat-1.1 Na-145
K-4.7 Cl-108 HCO3-30 AnGap-12
[**2182-5-27**] 07:38PM BLOOD ALT-23 AST-19 LD(LDH)-231 CK(CPK)-33*
AlkPhos-58 TotBili-0.4
[**2182-5-28**] 05:50AM BLOOD CK-MB-NotDone cTropnT-1.05*
[**2182-5-25**] 08:45AM BLOOD CK-MB-NotDone cTropnT-1.81*
[**2182-5-23**] 05:27AM BLOOD CK-MB-NotDone cTropnT-1.58*
[**2182-5-22**] 04:03AM BLOOD CK-MB-5 cTropnT-1.35*
[**2182-5-21**] 01:59PM BLOOD CK-MB-7 cTropnT-1.36*
[**2182-5-21**] 04:36AM BLOOD CK-MB-12* MB Indx-4.7 cTropnT-1.79*
[**2182-5-20**] 02:40PM BLOOD CK-MB-23* MB Indx-6.7* cTropnT-1.47*
proBNP-[**Numeric Identifier 21580**]*
[**2182-5-20**] 05:35AM BLOOD cTropnT-0.62*
[**2182-5-30**] 06:09AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9
[**2182-5-23**] 05:27AM BLOOD Triglyc-114 HDL-55 CHOL/HD-2.8 LDLcalc-76
[**2182-5-28**] 02:36PM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]-1.015
[**2182-5-28**] 02:36PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose->1000 Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-TR
[**2182-5-28**] 02:36PM URINE RBC->50 WBC-[**4-12**] Bacteri-FEW Yeast-FEW
Epi-0-2
MICRO:
[**2182-5-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2182-5-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2182-5-28**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2182-5-22**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-5-22**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2182-5-20**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2182-5-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST} INPATIENT
[**2182-5-20**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2182-5-20**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
EMERGENCY [**Hospital1 **]
[**2182-5-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL EMERGENCY [**Hospital1 **]
[**2182-5-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2182-5-27**]
FINDINGS: Despite repeated image acquisition, the study is
limited by patient motion. Hyperdensity projecting over the left
inferolateral frontal lobe (3:20) is likely a bone-related
artifact in the setting of motion. Otherwise, there is no
evidence of acute intracranial hemorrhage, mass effect, edema or
major vascular territorial infarct. The prominent ventricles and
sulci are unchanged in size or configuration. There is no shift
of normally midline structures. Moderate periventricular and
subcortical white matter hypodensities are compatible with known
chronic microvascular ischemic disease. Lacunar infarcts in the
basal ganglia are unchanged.
There is persistent moderate opacification of the left sphenoid
sinus.
IMPRESSION:
1. No evidence of an acute intracranial process on
motion-limited evaluation.
2. Moderate chronic microvascular ischemic disease with numerous
lacunar
infarcts.
3. Unchanged moderate opacification of the left sphenoid sinus
without
evidence of acute sinusitis.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2182-5-28**]
FINDINGS: In comparison with the study of [**5-24**], there has been
placement of a right PICC line that extends to the lower portion
of the SVC. There is increased aeration at the left base with
minimal residual atelectasis.
Nasogastric tube has been removed. Tracheostomy tube remains in
place.
Brief Hospital Course:
62 year old man with history of multiple strokes, type one
diabetes, and recurrent aspiration PNA s/p tracheostomy who
presents after witnessed aspiration event with hypoxia, diabetic
ketoacidosis, and NSTEMI.
.
#. Hypoxia: This was most likely due to an acute aspiration
event given his history and witnessed aspiration. He was
initially covered with broad spectrum antibiotics although
culture grew out sparse commensals and imaging was thought to be
more consistent with atelectasis and volume overload than
pneumonia so antibiotics were stopped after two days. He was
given bumex boluses to maintain fluid balance a negative fluid
balance until this volume overload resolved. His hypoxia
resolved after this.
.
#. NSTEMI: Patient with EKG changes, elevated cardiac biomarkers
with troponinT peaking at 1.8, and transthoracic echo with new
wall motion abnormalities. He was started on aspirin 325mg daily
and high dose statin initially. A heparin drip was continued for
48 hours. He was started on low dose beta blocker and
subsequently on clopidogrel. The cardiology service was
consulted and after discussion with the family the plan was for
in-patient cardiac catheterization. He was transfered to the
cardiology service for this. After discussion with the patient's
wife it was decided not to pursue cardiac catheterization due to
the patient being 5 days post medically treated NSTEMI and the
complications that could arise with this procedure. [**Hospital 21581**]
medical management was pursued.
.
#. CHF: Patient was found to be volume overloaded on admission.
This was thought to be the cause of his initial hypoxia and was
probably caused by his NSTEMI given the new wall motion
abnormalities and depressed EF of 35-40% (previously 55%) on
TTE. He was treated with bumex boluses and his volume overload
resolved. After resolution of the acute episode he remained
euvolemic and did not need further duiresis.
.
# Diabetic Ketoacidosis: In the emergency department, he had
hyperglycemia, an anion gap in the twenties, and ketones in the
urine on admission. The precipitant was thought to be cadiac
ischemia. Patient treated with insulin gtt with closure of
anion gap and return to normoglycemia. [**Last Name (un) **] was consulted
regarding glargine and insulin sliding scale dosing. He had
several episoded of hypoglycemia on his home dose of glargine
that were atributed to poor PO intake. Glargine was subsequently
decreased to 10 units at bedtime and his ISS was changed to
humalog and adjusted for meals. He then had episodes of
hyperglycemia and his HSS was adjusted further.
.
# Positive blood culture: He had one out of 2 sets of blood
cultures growing coag negative staph on [**5-20**] (with subsequent
negative blood cultures) and another [**2-9**] sets positive for coag
negative staph from [**5-29**] that came back after he was discharged.
This information was reported verbally to his nurse and by fax
to [**Hospital **] Hospital [**Hospital1 8**] where he is currently.
.
#. Acute renal failure: He was found to have an elevated
creatinine of 2.2, up from his baseline of 1.1-1.3. This was
thought to be pre-renal azotemia in the setting of dehydration
with osmotic diuresis due to DKA and poor forward flow due to
his NSTEMI and acute CHF exacerbation. His renal function
returned to baseline with gentle IVF initially and then with
diuresis. His medications were renally dosed and nephrotoxic
medications (enalpril) were held. The renal transplant team was
consulted given his history of cadevaric renal transplant in
[**2175**]. Once his renal function returned to his baseline enlapril
was re-started without complications.
.
#. Altered mental status: Patient was found to have acute mental
status change after he was transfered to the cardiology service
from the ICU. This was thought to be due delirium as the patient
was waxing and [**Doctor Last Name 688**] between agitation and somnolence. A CT
head was done to evaluate for an intracranial process causing
his AMS but this was negative. Infectious work up was also
negative. After reviewing patient's record it had been mentioned
in past discharge summaries that the patient had similar
episodes after long hospitalizations. He was treated with low
dose zyprexa prn which he received few doses of. His MS [**First Name (Titles) 21299**] [**Last Name (Titles) 21582**]r and he was back to his baseline on the day of
discharge.
.
#. Immunosuppression: s/p cadaveric renal transplant [**2175**]. His
tacrolimus level was monitored closely in the setting of acute
renal failure. He was continued on his home dosage for a goal of
[**4-13**]. The renal transplant service was consulted. He was
continued on cellcept and prednisone. He was continued on
bactrim.
.
#. Recurrent UTI: He recently completed a course of cipro for a
UTI. Urine culture grew out E.coli that was pan-resistant except
to nitrofurantoin (contraindicated in renal insufficiency)
ceftriaxone, ceftaz (allergy) and cefepime. He completed a 7
day course of cefepime.
Medications on Admission:
Medications from prior d/c summary:
1. Mycophenolate Mofetil 500mg PO BID
2. Pravastatin 20 mg Tablet PO qday
3. Fluvoxamine 100mg PO BID
4. Aspirin 81 mg Tablet qday
5. Docusate Sodium suspension 100mg PO BID
6. Senna 8.6 mg Tablet 1 tab [**Hospital1 **] PRN constipation
7. Prednisone 4mg PO qday
8. Sulfamethoxazole-Trimethoprim 800-160 mg qMWF
9. Metoprolol Tartrate 25 mg Tablet PO TID
10. Albuterol Sulfate neb q2H PRN wheezing
11. Insulin Glargine 100 unit/mL Solution 25 unit SC qHS
12. Bisacodyl 5 mg tab PO qday PRN constipation
13. Docusate Sodium 100 mg Capsule PO BID
14. Enalapril Maleate 20 mg Tablet PO qday
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, PO qday
16. Ipratropium Bromide 0.02 % Solution inhalation q6H
17. Tacrolimus 3mg PO qPM, 4mg PO qAM
19. Polyethylene Glycol 3350 17 gram/dose Powder PO qday PRN
constipation
20. Quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS
21. Morphine 2-4 mg Intravenous Q6H PRN as needed for pain.
23. Lorazepam 0.5-2 mg Injection Q4H (every 4 hours) PRN
agitation.
24. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: Last dose [**2182-5-20**].
.
Discharge Medications:
1. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
[**Month/Day/Year **]: 2.5 ML PO BID (2 times a day).
2. Pravastatin 80 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
3. Fluvoxamine 50 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times
a day).
4. Aspirin 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: Ten (10) ML PO BID (2
times a day) as needed for constipation.
6. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Prednisone 1 mg Tablet [**Month/Day/Year **]: Four (4) Tablet PO DAILY (Daily).
8. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [**Month/Day/Year **]: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
9. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID
(3 times a day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) neb Inhalation Q2H (every 2 hours) as
needed for wheezing.
11. Bisacodyl 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day as
needed for constipation.
12. Enalapril Maleate 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY
(Daily).
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
15. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO QPM (once
a day (in the evening)).
16. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: Four (4) Capsule PO QAM (once a
day (in the morning)).
17. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
19. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Ten (10) units
Subcutaneous at bedtime.
20. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: One (1) units
Subcutaneous four times a day: per sliding scale.
21. Polyethylene Glycol 3350 17 gram Powder in Packet [**Last Name (STitle) **]: One
(1) packet PO once a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital-[**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
Secondary Diagnosis:
Cadaveric renal transplant in [**2175**]
- CVA-residual right hemiparesis
- Hx NSTEMI and Vfib arrest [**2169**] with anoxic brain injury
- Swallow study-showed silent aspiration
- hx of aspiration pneumonia
- tracheomalacia after long intubation requiring trach stent and
button complicated by site cellulitis and granulation tissue
requiring cryoptherapy.
- recurrent aspiration PNA s/p tracheal stent removal and
tracheostomy
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 were admitted to the [**Hospital1 18**] because you were breathing fast
and you oxygen was low. You were initially admitted to the
intensive care unit were they treated you for pneumonia. Upon
further testing you were found to have had a small heart attack.
We treated you with the appropriate medications for this. Your
heart attack caused acute systolic heart failure that we treated
with diuretics. This resolved with treatment and your heart
funtion remained stable. We spoke with your family about doing a
cardiac catheterization but this was not pursued as you had
already been treated medically. You also had a UTI and were
treated with antibiotics. You were found to be agitated and
disoriented at times but this improved. The diabetes doctors saw [**Name5 (PTitle) 17773**] and made changes to your insulin treatment. You should
follow the new sliding scale that was provided.
Medication Changes:
INCREASE: Pravastatin to 80 mg daily
INCREASE: Aspririn to 325 mg daily
START: Clopidogrel 75 mg daily
Followup Instructions:
Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2182-6-20**] 9:00
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2182-6-20**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2182-6-20**]
10:00
[**2182-6-21**] 02:20p [**Doctor Last Name **]-CC7 [**Hospital6 29**], [**Location (un) **]
CC7 CARDIOLOGY (SB)
|
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[
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[
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icd9pcs
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[
[
[]
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17573, 17642
|
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|
323, 330
|
18164, 18164
|
2708, 8956
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2173, 2202
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18342, 19233
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358, 1578
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17711, 18143
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17682, 17690
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|
1600, 2003
|
2019, 2157
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,140
| 167,442
|
16464
|
Discharge summary
|
report
|
Admission Date: [**2157-8-29**] Discharge Date: [**2157-9-2**]
Date of Birth: [**2101-9-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
s/p fall, fluid retention
Major Surgical or Invasive Procedure:
Paracentesis x 2
History of Present Illness:
55 y.o. male with h/o cirrhosis [**3-12**] HCV and EtOH currently
listed for [**Month/Day (2) **] transfered from [**Hospital3 **] Hospital s/p fall
after concern on imaging for splenic laceration. Pt. suffered a
mechanical fall on [**8-28**] while walking up his back concrete step.
States he lost his balance due to 'lower extremity swelling',
tipped over and fell, hitting his face and right flank. There
were no presyncopal symptoms and no LOC. He subsequently
developed abdominal pain. At OSH, CT scan showed ascites and a
small area at the superior portion of the spleen suspicious for
a small laceration. Since he was on the liver [**Month/Year (2) **] list at
[**Hospital1 18**], he was transferred here for further management and
admitted to the SICU where a repeat CT scan showed no laceration
and instead suggested perfusion defects. Patient remained
hemodynamically stable and was then called out to the liver
[**Hospital1 **] floor for further management.
Past Medical History:
- Cirrhosis, s/p TIPS placement [**8-15**]
- HepC, dx [**2129**]: Nonresponder to interferon and ribavirin after
six months of therapy in [**2149**]. From [**Month (only) 116**] to [**2151-12-10**], the
patient was treated with pegylated interferon and ribavirin for
a period of six months. For unclear reasons, this treatment was
discontinued. The patient was subsequently enrolled in the
colchicine arm of the COPILOT trial in the past. [**10-15**] viral load
is 441,000 IU/mL.
- Chronic Renal Insufficiency (baseline Cr 1.1-1.7 over last
year)
- Depression.
- Osteoarthritis
- Hip osteopenia
- Right knee surgery
- Bilateral hip repair
- s/p Umbilical hernia repair
.
Social History:
Lives on [**Hospital3 **] in a garage apartment which he rents from a
family with whom he has a good relationship. Also has
supportive ex-wife and daughter. [**Name (NI) **] works in a recording studio
and plays the guitar in a band. He has a history of alcohol
abuse (last drink [**2136-10-9**], drank heavily for 12 years). Also
h/o IV drug use many years ago. Pt smoked occasionally for 30
years, quit a year ago. Denies any recent ETOH ingestion.
Family History:
non-contributory
Physical Exam:
T 99.1 HR 96 BP 124/81 RR 23 SaO2 95% RA
General: Thin male, weathered appearance, NAD, lying flat,
breathing comfortably on RA
HEENT: PERRL, EOMi, scleral icterus, abrasions scattered on face
Neck: supple, trachea midline
Cardiac: RRR, s1s2 normal, 2/6 sem at LSB, no r/g
Pulmonary: CTAB anterior
Abdomen: +BS, soft, nontender, distended but not tense,
+dullness, periumbilical hernia, well-healed scars
Extremities: warm, 3+ bilateral pitting LE edema, mild erythema
right foot but nontender to palpation
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities, follows commands
Pertinent Results:
Admission Labs:
WBC-9.5# Hgb-9.5* Hct-27.8* MCV-112* MCH-38.2* Plt Ct-84*
PT-20.2* PTT-35.8* INR(PT)-1.9*
Glucose-107* UreaN-22* Creat-1.1 Na-137 K-4.3 Cl-100 HCO3-33*
ALT-38 AST-57* AlkPhos-121* TotBili-6.1*
Albumin-2.5* Calcium-9.6 Phos-2.2*# Mg-2.0
.
Discharge Labs:
WBC-14.2 (N - 86.3, bands - 0, lymphs - 7.9, M - 4.4, E - 1.2,
Bas - 0.3) * Hgb-9.5* Hct-27.0* MCV-113* MCH-39.9* Plt Ct-104*
PT-20.9* PTT-39.7* INR(PT)-2.0*
Glucose-103 UreaN-10 Creat-0.7 Na-134 K-3.5 Cl-95* HCO3-34*
ALT-31 AST-48* AlkPhos-140* TotBili-4.5*
Albumin-2.2* Calcium-8.2* Phos-2.2* Mg-1.8
.
.
Studies:
CT Pelvis ([**8-29**]):
1. Multiple perfusion defects in the spleen without evidence of
splenic
laceration. Findings discussed with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 5700**] in the
evening of
the study.
2. Cirrhotic liver with large-volume ascites. Prior TIPS
procedure, the
shunt is patent.
3. Multiple compression fractures in the thoracic spine of
indeterminate age,
but new from [**2154-6-9**], suggest correlation with clinical
symptoms.
4. Distended gall bladder without CT evidence for stones or
inflammation.
Brief Hospital Course:
55 y.o. male with a history of cirrhosis [**3-12**] HCV and EtOH listed
for [**Month/Day (2) **] who presents s/p fall and was transferred to
[**Hospital1 18**] where he receives his hepatology care, for evaluation of
possible splenic laceration. The following issues were
investigated during this hospitalization:
.
# Fall: Felt to be a mechanical fall as patient was later
evaluated by PT and noted to have a very unsteady gait. Initial
concern was for splenic laceration, but repeat CT showed
perfusion defects, rather than laceration. Both splenic vessels
were patent. Patient was thus transferred from the SICU to the
liver-kidney [**Hospital1 **] service for further management with
stable Hct and hemodynamic stability.
.
# Cirrhosis: S/P TIPS with continued ascites, though TIPS was
found to be patent. Patient underwent two paracenteses for
relief with approximately 2 liters being removed and no evidence
of SBP. Upon discharge, abdomen was soft and comfortable and
patient was maintained on diuretics.
.
# Leukocytosis: Patient was noted to have a leukocytosis to 14
on the day of discharge. Differential did not reveal a bandemia.
Patient additionally did not have any localizing symptoms or
fevers. Paracentesis performed on the day of discharge was
negative for SBP. This information was communicated to the
facility that the patient was discharged to and any positive
cultures will be faxed over.
.
# Chronic renal failure: Previously and likely in the setting of
acute illness. Creatinine was within normal limits with adequate
urinary output during hospitalization.
.
# Depression: Patient was maintained on outpatient Fluoxetine
and Mirtazapine.
Medications on Admission:
Fluoxetine 20mg daily
Lasix 40mg daily
Vicodin TID prn (currently tapering with PCP)
Lactulose 30ml TID
Mirtazipine 45mg daily
Spironolactone 50mg daily
Ursodiol 300mg [**Hospital1 **]
MVI
Vitamin D
Ca2+
Vitmain E
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
Eagle [**Hospital **] Rehabilitation Center - [**Location 23723**]
Discharge Diagnosis:
Primary
Mechanical Fall
Cirrhosis w/ ascites
.
Secondary
- Chronic Renal Insufficiency (baseline Cr 1.1-1.7 over last
year)
- Depression
- Osteoarthritis
- Hip osteopenia
- Right knee surgery
- Bilateral hip repair
- S/p umbilical hernia repair
- Bilateral inguinal hernia repair
Discharge Condition:
Stable
Discharge Instructions:
You were seen and evaluated after suffering a fall at home.
There was an initial concern for damage to your spleen as a
result of this fall, but repeat imaging of your belly showed
that in fact, your spleen was normal. Since then, you were
managed for your cirrhosis and two attempts were made to remove
fluid from your belly, which was moderately successful,
resulting in approximately 2 liters removal. You are now being
discharged to a rehabilitation facility for further care and
strengthening.
Take all of your medications as directed.
Keep all of your follow-up appointments.
Call your doctor or go to the ER for any of the following:
worsened abdominal distention or ascites, fevers/chills,
confusion, chest pain, shortness of breath,
nausea/vomiting/diarrhea or if you suffer a fall again.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-9-7**] 10:20
|
[
"V15.88",
"715.90",
"303.90",
"V15.82",
"585.9",
"070.70",
"789.59",
"784.0",
"305.93",
"733.90",
"311",
"789.00",
"571.2",
"571.5",
"781.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6993, 7086
|
4342, 6008
|
339, 357
|
7410, 7419
|
3195, 3195
|
8268, 8396
|
2537, 2555
|
6273, 6970
|
7107, 7389
|
6034, 6250
|
7443, 8245
|
3466, 4319
|
2570, 3176
|
274, 301
|
385, 1356
|
3211, 3449
|
1378, 2051
|
2067, 2521
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,762
| 162,199
|
32845
|
Discharge summary
|
report
|
Admission Date: [**2196-11-6**] Discharge Date: [**2196-11-18**]
Date of Birth: [**2154-6-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
alcohol withdrawal
Major Surgical or Invasive Procedure:
Right ankle ORIF.
History of Present Illness:
42 year old man with history of alcohol abuse, who was admitted
status post fall and ankle fracture. He underwent ORIF of right
ankle [**11-7**] and was transferred to floor without complication
that day. The following afternoon he was found to be hypoxic to
80's with witnessed vomiting/seizure activity. Code blue called
and ativan was given, oxygen saturations recovered. Patient was
transferred to trauma SICU service. Had to be managed in PACU
because of bed availabilty. Since then, requiring 20mg IV
ativan/12 hours and very agitated. He did appear to be off
benzodiazepines for several hours and, at the end of this
period, he escalated--requiring multiple people to restrain him.
Per previous history, he claimed only to be consuming 4 drinks a
day.
Past Medical History:
Alcohol abuse
Born premature; reports he had a feeding tube as a baby
PCP: [**Name Initial (NameIs) **]
All: NKDA
Social History:
Per chart 4 drinks a day. No known smoking history or drug
abuse.
Family History:
Not available
Physical Exam:
VS: Temp: BP: 133/79 HR: 112 RR: 16 O2sat 100 on room air
Gen: Somnolent but arousable, mildly agitated. Follows commands,
largely non verbal
Eyes: Sclerae injected, pupils reactive
Mouth: MM dry
Neck: Obese
Chest: CTA b/l with good air movement throughout
Cor: Tachycardic, regular, S1 and S2 wnl, no m/r/g
Abd: Obese, non-distended, +b/s, soft, nt, no masses or
hepatosplenomegaly
Ext: No edema, warm, good pulses
Neuro: Somnolent
Pertinent Results:
[**2196-11-6**] 09:58PM BLOOD WBC-6.7 RBC-4.01* Hgb-14.1 Hct-41.5
MCV-103* MCH-35.1* MCHC-33.9 RDW-13.1 Plt Ct-24*
[**2196-11-12**] 06:45AM BLOOD WBC-7.0 RBC-2.68* Hgb-9.3* Hct-27.5*
MCV-103* MCH-34.8* MCHC-33.9 RDW-13.2 Plt Ct-124*
[**2196-11-6**] 09:58PM BLOOD PT-14.0* PTT-30.0 INR(PT)-1.2*
[**2196-11-6**] 09:58PM BLOOD Glucose-133* UreaN-6 Creat-0.8 Na-139
K-3.4 Cl-97 HCO3-26 AnGap-19
[**2196-11-12**] 06:45AM BLOOD Glucose-117* UreaN-10 Creat-0.6 Na-137
K-3.3 Cl-104 HCO3-26 AnGap-10
[**2196-11-10**] 04:18AM BLOOD ALT-35 AST-178* LD(LDH)-379* AlkPhos-83
Amylase-55 TotBili-2.6*
[**2196-11-10**] 06:00PM BLOOD ALT-41* AST-245* LD(LDH)-473* AlkPhos-91
Amylase-75 TotBili-2.9*
[**2196-11-11**] 10:01AM BLOOD ALT-45* AST-260* AlkPhos-91 TotBili-2.9*
[**2196-11-12**] 06:45AM BLOOD ALT-43* AST-187* LD(LDH)-308* AlkPhos-101
TotBili-2.0*
[**2196-11-10**] 04:18AM BLOOD Lipase-146*
[**2196-11-10**] 06:00PM BLOOD Lipase-190*
[**2196-11-7**] 09:04PM BLOOD Calcium-8.5 Phos-1.1* Mg-1.5*
[**2196-11-12**] 06:45AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.0 Mg-2.0
[**2196-11-6**] 09:58PM BLOOD ASA-NEG Ethanol-428* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-11-7**] 08:25PM BLOOD Type-ART pO2-294* pCO2-50* pH-7.28*
calTCO2-24 Base XS--3
[**2196-11-8**] 12:11PM BLOOD Type-ART pO2-74* pCO2-40 pH-7.48*
calTCO2-31* Base XS-5
[**2196-11-6**] 09:55PM BLOOD Lactate-4.1*
[**2196-11-8**] 06:42AM BLOOD Lactate-1.4 K-3.8
EKG [**11-6**]:
Sinus rhythm. Borderline left axis deviation. Possible left
anterior
fascicular block.
Imaging:
R Knee and Ankle films [**11-6**]:
Oblique right distal fibular fracture and transverse right
medial
malleolar fracture with disruption of the ankle mortise.
CT Head without contrast [**11-7**]:
1. No hemorrhage or mass effect.
2. Prominent ventricles and cerebral sulci, likely related to
parenchymal volume loss; NPH is another possibility given the
greater dilation of the ventricles.
CXR [**11-7**]:
Aside from a mild atelectasis in the right lower lung accounting
for elevation of the lung base, the lungs are clear on the
frontal view. On the lateral view detail is obscured by motion,
probably respiratory. There is no pleural effusion. Heart is
mildly enlarged but there is no vascular congestion in the lungs
or in the mediastinum compared to mediastinal venous engorgement
that was present two hours earlier. The lateral view suggests
substantial compression of at least one lower thoracic vertebral
body with kyphosis. Clinical correlation advised.
ORIF fluoro images [**11-7**]:
Six fluoroscopic images from the operating room shows placement
of a lateral fibular fracture plate and interfragmentary screw
and two lag screws through the right medial malleolus. The
fracture lines are faintly visualized. There is good anatomic
alignment. There are no signs for hardware related
complications. Please refer to the operative note for additional
details.
CXR [**11-10**]:
No relevant interval changes. No pneumonia.
ON DISCHARGE
[**2196-11-17**] 09:10AM BLOOD WBC-10.0 RBC-3.35* Hgb-11.5* Hct-34.0*
MCV-102* MCH-34.5* MCHC-34.0 RDW-13.5 Plt Ct-400
[**2196-11-14**] 09:40AM BLOOD PT-14.2* PTT-29.8 INR(PT)-1.2*
[**2196-11-17**] 09:10AM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-135
K-3.5 Cl-98 HCO3-29 AnGap-12
[**2196-11-12**] 06:45AM BLOOD ALT-43* AST-187* LD(LDH)-308* AlkPhos-101
TotBili-2.0*
[**2196-11-12**] 06:45AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.0 Mg-2.0
Brief Hospital Course:
42yo gentleman with h/o alcohol abuse admitted with R ankle
fracture s/p ORIF who developed alcohol withdrawal seizures and
DTs during admission.
1) Alcohol withdrawal with Delerium Tremens and Alcohol
Withdrawal Seizures
Patient had witnessed alcohol withdrawal seizures during his
hospitalization. He became hypoxic and improved with ativan, at
which point he was transferred to the MICU. His vital signs
were labile and he was treated for delirium tremens with valium
IV. He was eventually transferred to the floor when he no
longer needed IV benzodiazepines for withdrawal. Clonidine
patch was given as well as IV fluids with thiamine, folate, and
multivitamin. The clonidine patch was discontinued, and the
patient was started on oral thiamin, folate and multivitamin.
Social work followed the patient to assist with resources for
quitting his addiction.
.
2) Open Right ankle fracture
ORIF was performed by orthopedics [**2196-11-7**]. His pain was
well-controlled and he was given lovenox for DVT prophylaxis.
He is touchdown weight bearing in his right lower extremity, and
the patient was followed by physical therapy. He was given a
prescription for outpatient physical therapy and provided with
orthopedics follow-up. After discharge he lost his prescription
for lovenox, which is documented in a separate note.
.
3) Thrombocytopenia:
Platelets were 24 on admission, and increased on their own
during his stay. His platelets were most likely low secondary
to his alcohol abuse. Orthopedics felt that it was safe to
continue lovenox despite his thrombocytopenia. At discharge his
platelets were 400.
.
4) Benign Hypertension:
It was unclear whether the patient has HTN or if his blood
pressure was elevated in the setting of withdrawal. He was
treated with metoprolol [**Hospital1 **] to control his BP. His blood
pressure remained controlled on metoprolol and he was felt to
have essential hypertension. On discharge, maintained on
metoprolol [**Hospital1 **] with good control of his blood pressure.
.
5) Anemia of chronic disease:
Patient had a stable, macrocytic anemia. This is likely due to
the patient's alcohol abuse. Folate and B12 were within normal
limits.
.
6) Hyperglycemia:
Patient had some transient hyperglycemia while in the MICU. He
was treated with a sliding scale of insulin. His sugars
normalized on their own during his hospital course.
.
7) Disposition: home with family, wheelchair provided by PT,
home PT, orthopedics follow-up, social work provided help in
arranging medication assistance.
Medications on Admission:
None.
Discharge Medications:
1. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 14 days: until follow up with orthopedics.
Disp:*56 Capsule(s)* Refills:*0*
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 5 doses.
Disp:*5 syringe* Refills:*0*
8. Outpatient Physical Therapy
Please evaluate patient for outpatient physical therapy after
ORIF for right ankle fracture [**11-7**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Right ankle fracture status post repair
2. Alcohol withdrawal
3. Hypertension
4. Wound infection
.
Secondary:
Alcohol abuse
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were admitted with a right ankle fracture. This was
repaired by orthopedics. You should take antibiotics as below
for potential wound infection until follow up with orthopedics.
You should take aspirin 325 mg daily for one month to prevent a
blood clot including lovenox injections for the next 4 days from
discharge. You should follow-up with Dr. [**Last Name (STitle) **] in 10 days
from discharge as below.
.
Please change the dressing on your ankle once a day. Remove the
gauze, cleanse the area with normal saline, apply triple
antibiotic cream and re-wrap with dry gauze.
.
You were provided with a prescription for outpatient physical
therapy. Please call ([**Telephone/Fax (1) 30541**] to set up an appointment.
You may only touch your foot to the floor, you may not put any
weight on your right ankle.
.
During admission you had alcohol withdrawal and needed admission
to the intensive care unit. You should continue a multivitamin,
thiamine, and folate for alcohol abuse. You should abstain from
alcohol in the future.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, worsening ankle pain, or any
other concerning symptoms.
.
Please take your medications as below.
- You should take lovenox 30 mg twice daily for five doses to
prevent blood clots.
- You should take aspirin 325 mg daily for two weeks after
lovenox is complete to prevent blood clots.
- You should take keflex for 2 weeks to treat a wound infection
(or until follow up with orthopedics).
- You were started on a multivitamin, thiamine, and folate for
alcohol abuse. These can be purchased at your local pharmacy
- You were started on metoprolol for high blood pressure.
.
Please keep your follow-up appointments as below.
Followup Instructions:
Follow-up with orthopedics:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2196-11-29**] 9:00
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2196-11-29**] 9:20
|
[
"790.29",
"518.5",
"291.81",
"287.4",
"737.10",
"E888.8",
"401.1",
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"780.39",
"E849.9",
"303.90",
"824.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"79.36",
"99.60",
"79.66"
] |
icd9pcs
|
[
[
[]
]
] |
8862, 8868
|
5309, 7850
|
335, 355
|
9048, 9080
|
1868, 5286
|
10884, 11200
|
1385, 1400
|
7906, 8839
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8889, 9027
|
7876, 7883
|
9104, 10861
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1415, 1849
|
277, 297
|
383, 1144
|
1166, 1286
|
1302, 1369
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,943
| 116,206
|
28360
|
Discharge summary
|
report
|
Admission Date: [**2146-4-10**] Discharge Date: [**2146-4-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 68839**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Right great toe amputation
History of Present Illness:
This is a [**Age over 90 **] year old male with MDS, CAD, CHF, and CKD as well
as multiple recent admissions for bacteremia secondary to a
gangrenous toe who presented yesterday with fever and
hypotension. The patient reports "a couple" of days of feeling
generally unwell with malaise and a fever. He is not able to
endorse any localizing symptoms like cough, chest pain,
dysuria/hematuria, or abdominal discomfort. He also endosres
some loose stools over the past few days but no [**Age over 90 **] diarrhea.
No other abdominal symptoms and he denies abdominal pain,
nausea, or vomiting. He was sent to the ED after his daughter
noted him rigoring at rehab and demanded he be sent to the
hospital.
In the ED, initial vs were: T 99.1 P 120 BP 132/80 R 26 O2 sat
99% on NRB but temperature then spiked to 104.2 rectally. As
the patient has had multiple admissions for bacteremia related
to his toe gangrene vascular and podiatry were consulted
regarding management. The patient was given levofloxacin,
acetaminophen, vancomycin, and ceftriaxone in the ED. He became
hypotensive (SBP's in the 90's) and thus received 2L of NS
without much effect before before being started on
norepinephrine and sent to the ICU.
Overnight the patient was weaned off norepinephrine. He also
defervesced and has been afebrile today. He received one unit
Plt and one unit pRBC's as was worse than baseline. ID
consulted and are recommending daptomycin (patient was on course
as an outpatient) and pipercillin-tazobactam as well as
discontinuing PICC and scan to r/o abscess. Plan was for
podiatry to amputate toe in AM but patient's daughter and HCP
requested vascular to perform this operation so timing is
currently unclear. [**Name2 (NI) **] report blood cultures from [**Hospital 100**] Rehab
are growing gram positive cultures in pairs and clusters as well
as gram negative rods. Currently, he reports feeling fatigued
but denies specific complaints.
Past Medical History:
-Stage 3 Chronic Kidney Disease with baseline Cr of 2
-Coronary Artery Disease (PTCA in [**2123**] w/o stents)
-Sick sinus syndrome --> s/p pacemaker [**2118**], [**2128**], [**2139**]; no
history of pacemaker infections
-Transient Ischemic Attack in [**2135**]
-Myelodysplastic syndrome with anemia, thrombocytopenia and
leukopenia
-Pseudogout
-Benign prostatic hypertrophy
-Cryptogenic cirrhosis and ? of hepatitis B (chronic bilateral
upper extremity edema)
-Polymyalgia rheumatica on chronic prednisone (5mg >1 yr)
-GI bleed:Gastric varices; GAVE
-Hiatal hernia
-Enterococcal endocarditis [**2140**]
-Group G Strep bacteremia, [**1-/2144**] (tx 6 weeks with
amp/sublactam)
-Group G Strep bacteremia + R hallux cellulitis, [**10/2144**] (tx 4
weeks with Ceftriaxone)
-MRSA septicemia without endocarditis, [**2-/2146**] (original tx plan
4 weeks of vancomycin through [**4-8**])
-MRSA, VRE, multiple strains of Streptococcus bacteremia, [**3-/2146**]
(tx daptomycin x 6 weeks to end [**5-6**])
Social History:
He lives at [**Hospital 100**] Rehab and has been there for the past month
but was living with his daughter prior to that. He was a smoker
at one point but has not smoked since [**2088**]. He is a retired
foreign service officer with previous postings in [**Location (un) **], [**Country 3992**],
and most recently northern [**Country 2559**]. He was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 68836**] Scholar.
Family History:
Father, mother, brother all died of "heart disease"
Physical Exam:
Vitals: T: 97.3 BP: 122/38 P: 105 R: 21 O2: 99% on 2L NC
General: Alert, oriented, no acute distress, speaks very slowly
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles at the right base posteriorly, no wheezes or
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses. Forearms with chronic skin
changes bilaterally, purple color. Lower legs bilaterally with
shiny skin, no hair. Right great toe swollen with darker color
and open wound at over the first MTP joint.
Pertinent Results:
LABORATORY RESULTS
====================
On Presentation:
WBC-5.8# RBC-3.02* Hgb-8.8* Hct-26.9* MCV-89 RDW-16.1* Plt
Ct-44*
----Neuts-90.2* Lymphs-7.9* Monos-1.7* Eos-0.2 Baso-0
PT-16.1* PTT-30.9 INR(PT)-1.4*
Glucose-187* UreaN-32* Creat-1.9* Na-131* K-4.0 Cl-96 HCO3-25
AnGap-14
ALT-28 AST-54* CK(CPK)-32* AlkPhos-236* TotBili-1.1
Lactate-2.6*
MICROBIOLOGY
=============
[**2146-4-10**] Blood Cultures: 2/2 Bottles with
Staph Aureus
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>4 R
GENTAMICIN------------ 2 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>8 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2146-4-12**]: Bone tissue and swab from amputation with Staph Aureus
Pathology from Amputation:
DIAGNOSIS:
1. Bone, right first toe, excision (A):
A. Bone with changes consistent with acute and chronic
osteomyelitis with osteonecrosis.
B. Dense fibroconnective tissue with chronic inflammation.
2. Toe, right first, amputation (B):
A. Skin with ulceration and necrosis, present at resection
margin.
B. Bone with marrow fibrosis compatible with chronic
osteomyelitis
OTHER RESULTS
==============
Chest Radiograph [**2146-4-10**]:
IMPRESSION: No acute pulmonary process.
EKG [**2146-4-10**]:
Sinus tachycardia. Right bundle-branch block. Possible anterior
wall
myocardial infarction of indeterminate age. Compared to the
previous tracing of [**2146-3-8**] heart rate is significantly
increased.
CT Abdomen and Pelvis [**2146-4-11**]:
IMPRESSION: No CT evidence to explain recurrent bacteremia.
Transthoracic Echocardiogam [**2146-4-13**]:
IMPRESSION:Prior (stable) antero-apical myocardial infarction
with mild to moderately depressed LVEF. No valvular vegetations
seen.
Right Upper Extremity Ultrasound [**2146-4-13**]:
IMPRESSION: No right upper extremity DVT.
Brief Hospital Course:
This is a [**Age over 90 **] year old male with a history of multiple
bacteremias due to gangrene of the right great toe (initially
precipitated by anatomical abnormality), myelodysplastic
syndrome, coronary artery disease, and chronic kidney disease
presenting from rehab with fever and hypotension and found to be
bacteremic again.
1) Bacteremia/Sepsis: Patient was clearly septic at presentation
with hypotension requiring norepinehprine on the night of
admission and positive blood cultures for MRSA. On presentation
to the ICU the patient received his daptomycin as well as a dose
of pipercillin-tazobactam for broad coverage. Outside hospital
blood cultures revealed MRSA, pan-sensitive klebsiella, and two
kinds of streptococcus. After spending one night in the ICU the
patient defervesced and was able to be quickly weaned off
norepinephrine. He was transferred to the floor on his second
hospital day and remained hemodynamically stable and afebrile.
The most likely etiology of his recurrent bacteremia was
considered to be his right great toe, which was status post
multiple debridements, so this was amputated on [**2146-4-12**]. In
order to rule out other sources of infection the patient had a
CT abdomen and pelvis on recommendation on the infectious
disease consult team, which showed no clear etiology of
bacteremia though this was a suboptimal study due to the lack of
IV contrast. Given bacteremia with a PICC line in place the
patient's PICC was discontinued on the recommendation of the ID
consult service. Surveillance cultures were persistently
negative except for one set on [**2146-4-13**], which showed S. aureus
raising concern for a persistent source of infection. Given the
patient has a pacemaker in place and had MRSA bacteremia there
was concern for seeding, therefore TEE was considered necessary.
TEE did not show evidence of vegetations, but showed fibrous
changes along the leads of Mr [**Known lastname 68840**] pacemaker. Despite being
on Daptomycin for MRSA and Ceftriaxone for Klebsiella, the pt
continued to have positive blood cultures following amputation
of the toe and TEE. The infectious disease service recommended
removal of the pacemaker, but after discussion with Mr [**Known lastname 3012**] and
his health care proxies (daughter [**Name (NI) 1022**] [**Last Name (NamePattern1) **] and her husband [**Name (NI) **]
[**Name (NI) **]), it was clear that the pt did not desire this aggressive
approach to the treatment of his bacteremia. Mr [**Known lastname 3012**] accepted
the fact that without pacemaker extraction his life expectancy
would likely be limited to weeks (according to the ID service)
and the decision was made for the pt to go home with hospice, on
antibiotics for comfort. The pt was discharged on vancomycin 1g
daily and rifampin on the recommendation of the ID service.
.
# Great toe gangrene: The patient has had chronic infection of
his right great toe and he and his daughter had previously been
unwilling to go through with amputation. After he became
bacteremic once again, however, they agreed to amputation. This
was performed by the vascular surgery service on [**2146-4-13**] without
incident. Pathology on bone specimens revealed changes
consistent with chronic osteomyelitis.
.
# Myelodysplastic syndrome / thrombocytopenia: Patient has
history of transfusion dependent thrombocytopenia and chronic
anemia. He was transfused in the hospital to maintaine Hct >25
and Plt >50 (prior to surgery) and Hct >25 thereafter.
.
# CKD: The patient has CKD with a baseline Cr of 1.7-1.9. This
improved throughout his hospitalization and was simply followed.
.
# CAD/CHF: Patient has a historical diagnosis of chronic
systolic CHF with EF of approximately 40%. He appeared
euvolemic during this hospitalization. Initially, his home
furosemid dosing was held but then was restarted with stable
blood pressures. Despite a history of CAD the patient is not on
aspirin, statin, or beta blocker.
.
# Delerium: The patient was initially with waxing and [**Doctor Last Name 688**]
mental status presumed to be multifactorial and due to his
infection and perhaps an element of ICU delirium. This improved
with transfer to floor and resolution of hypotension as well as
treatment of infection. The patient would continue to have
short periods of confusion even on the floor but these were
always brief, worse at night, and more consistent with
sundowning, which was not considered concerning given the
patient's advanced age. He always responded well to
reorientation.
.
# Depression: The patient's mirtazapine was initially held given
hypotension but then was restarted with good effect.
.
# BPH: The patient initially had a foley catheter in place and
tamsulosin was held given his hypotension. He was restarted on
tamsulosin after 24 hours of normal blood pressures and his
foley was discontinued without incident. Prostate exam was
performed as part of an infectious work up and revealed no
tenderness and UA's were persistently benign. The pt was
discharged with a condom catheter for urinary incontinence.
.
# Polymyalgia rheumatica: The patient has chronically (>1yr)
been on prednisone for PMR. He received stress dose IV
hydrocortisone on presentation but was transitioned back to his
baseline prednisone dose on the day after his surgery.
.
# Code status: Following the patient's decision not to remove
the pacemaker, the pt elected to be DNR DNI. The pt was
discharged to his home, with [**Hospital 3005**] Hospice.
Medications on Admission:
1. Omeprazole 20 [**Hospital1 **]
2. Prednisone 5 mg DAILY
3. Pyridoxine 50 mg DAILY
4. Tamsulosin 0.4 mg PO HS
5. Albuterol Sulfate 1 NEB TID
6. Cyanocobalamin 500 mcg DAILY
7. Ferrous Sulfate 325 mg (65 mg Iron) DAILY
8. Fluticasone 50 mcg/Actuation [**Hospital1 37062**], 2 sprays DAILY
9. Folic Acid 1 mg PO DAILY
10. Lidocaine 5 %(700 mg/patch) 1 DAILY
11. Senna 8.6 mg Tabs, 2 Tabs PO BID
12. Docusate Sodium 100 PO BID
13. Furosemide 40 mg PO DAILY
14. Remeron 15 mg PO DAILY
15. Daptomycin 400 mg IV Q48H for 5 weeks: end date [**2146-5-6**].
16. Regular ISS
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation three times a day as
needed.
Disp:*qs qs* Refills:*0*
5. Cyanocobalamin 100 mcg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*80 Tablet(s)* Refills:*2*
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
13. Fluticasone 50 mcg/Actuation [**Month/Day/Year 37062**], Suspension Sig: Two (2)
Nasal once a day.
Disp:*qs qs* Refills:*2*
14. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
g Intravenous Q 24H (Every 24 Hours).
Disp:*30 g* Refills:*2*
16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
17. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical once a day.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
19. 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*
20. Roxanol Concentrate 20 mg/mL Solution Sig: 0.5-1 ml PO q1h
as needed for pain.
Disp:*120 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Season's Hospice
Discharge Diagnosis:
Primary Diagnosis:
-Methicillin Resistant Staphylococcus Aureus Bacteremia
-Osteomyelitis of the right great toe
Secondary Diagnoses:
Myelodysplastic syndrome
Chronic systolic heart failure
Chronic Kidney Disease
Discharge Condition:
Pt breathing comfortably on room air.
Discharge Instructions:
Mr. [**Known lastname 3012**]: You were admitted because you had a bloodstream
infection. We think the source of this infection was your
infected toe. We treated you with antibiotics and you had an
amputation to remove the source of the infection. It was then
evident that you had not cleared the infection as your blood
continued to grow the bacteria, and this was thought to be due
to your pacemaker wires. You opted to not have aggressive
treatment and leave your pacemaker in place. You decided to
continue to take antibiotics, knowing that your life expectancy
on an antibiotic regimen may be short.
.
During this admission your home medications were continued. You
were started on two IV antibiotics that you will continue to
take at home. The medications that were STARTED are: Vancomycin
and Rifampin.
.
If you develop chest pain, shortness of breath, dizzyness,
bleeding or any other concerning symptom, please return call
your primary care doctor.
Followup Instructions:
Vascular surgery follow up: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD
Phone:[**Telephone/Fax (1) 1237**]
.
Dermatology follow up: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D.
Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2146-4-19**] 10:45
.
Gerontology follow up: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 13171**], MD
Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2146-5-11**] 11:30
.
Infectious disease follow up: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2146-5-13**] 10:00
|
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72,517
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41176
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Discharge summary
|
report
|
Admission Date: [**2164-7-9**] Discharge Date: [**2164-7-22**]
Date of Birth: [**2109-3-13**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Ulcerative Colitis
Major Surgical or Invasive Procedure:
total abdominal colectomy and end ileostomy
History of Present Illness:
Mr. [**Known lastname 44880**] is a 55M with a h/o ulcerative colitis previously
treated with Asacol, Remicade and prednisone who presented for a
scheduled total abdominal colectomy with end ileostomy for
refractory ulcerative colitis. He was first diagnosed with UC in
[**2159**] and a few months later had a microperforation and abscess
formation, for which he had his sigmoid colon removed with a
temporary ileostomy, which was reversed 3-4 months later. He
was recently seen in surgical consultation in [**Month (only) 958**] for weight
loss for past few months (40 lbs over past year), as well as
perianal leakage and difficult to control gas passage concerning
for a fistula. MR enterography showed a stricture in the hepatic
flexure as well as some inflammation in the perirectal/perianal
area. So, he presented for a scheduled total abdominal colectomy
and end ileostomy.
During the procedure today, received epidural anesthesia at T7-8
with Dilaudid running at 8cc/hr. In the OR, he had a 500cc
blood loss, and received 3units RBCs for a total of 914cc, then
LR 2L and had an intraoperative UOP 1.2L.
Past Medical History:
- Type II Diabetes
- Distal pancreatectomy at the age of 3 after injury from a car
accident
- Incision and drainage of a left groin abscess
- Resection of part of his colon (perhaps sigmoid) for
perforation with a temporary ileostomy which was reversed 3-4
months later ([**2159**])
Social History:
He is married and has two adopted children. He does not drink
or smoke. He works as a engineering operations manager.
Family History:
Notable for lung cancer in his father (he was a smoker) and
breast cancer in his mother. Negative for any colon or GI
cancers or IBD.
Physical Exam:
Vitals: T:97.6 BP:111/76 P:92 RR:18 SpO2:96%(RA)
General: NAD
Lungs: Clear to auscultation bilaterally from anterior, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: S, NT/ND, incisions c/d/i, ostomy productive
Perineum: Some hematoma, incision clean, some old blood exuding,
no active bleeding.
Pertinent Results:
[**2164-7-10**] 02:54AM BLOOD WBC-19.6* RBC-4.21* Hgb-10.7* Hct-31.7*
MCV-75*# MCH-25.4*# MCHC-33.7# RDW-19.9* Plt Ct-278#
[**2164-7-9**] 06:59PM BLOOD Hct-31.3*
[**2164-7-10**] 02:54AM BLOOD Glucose-119* UreaN-20 Creat-0.9 Na-136
K-3.7 Cl-103 HCO3-23 AnGap-14
[**2164-7-9**] 06:59PM BLOOD Glucose-347* UreaN-18 Creat-0.8 Na-132*
K-4.1 Cl-98 HCO3-24 AnGap-14
[**2164-7-10**] 02:54AM BLOOD Calcium-7.0* Phos-3.4 Mg-1.8
[**2164-7-9**] 06:59PM BLOOD Calcium-7.7* Phos-4.8* Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 44880**] is a 55 y/o M w/h/o Ulcerative colitis who was
admitted to the Colorectal Surgery service at [**Hospital1 18**] after an
open proctocolectomy with end-ileostomy on [**2164-7-9**], please see
the operative note for more detail. Postoperatively he was
transfered to the ICU for hyperglycemia and was started on an
insulin drip. This was stopped and he was transitioned to NPH
on POD1 and he was transferred to the floor. On POD2 he was
noted to have sanguenous drainage from his JP site and he
recieved 2 units of PRBCs. This resolved and his JP was removed
on POD4. He was slowly advanced to a regular diet and he was
tolearting this well at discharge. His post-operative course
was complicated by chest pain and shortness of breath on POD 5;
a CTA performed showed bilateral subsegmental PEs for which he
was started on a heparin gtt. On POD8 he was started on
lovenox. Later that day he noted significant bleeding from his
perineal wound. This resolved with pressure and he was
transitioned back to heparin gtt with a lower PTT goal. He had
an IVC filter placed on POD10 by vascular surgery, please see
their operative note for more detail. On POD11/1 he had another
episode of bleeding from his perineal wound so his
anticoagulation was stopped. His post operative course was
further complicated by urinary retention. His foley was
replaced on POD7 and he will go home with a leg bag with follow
up with urology. He was noted to have a UTI on POD11/1, he was
started on Cipro, which he will continue a 3 day course of at
home. On the day of discharge he was ambulating well and
tolerating a regular diet, he was stable for discharge to home
with VNA for wound and ostomy care, and close follow up with the
ostomy nurses, urology, and Dr. [**Last Name (STitle) 1120**].
Medications on Admission:
Glyburide 5mg [**Hospital1 **]
Prednisone 40mg daily
Mesalamine 800mg [**Hospital1 **]
Remicaide - last infusion ...
Lidocaine-Hydrocortisone 1%/3% cream
Discharge Medications:
1. glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 7 days: Please do not drink alcohol or
drive a car while taking this medication.
Disp:*40 Tablet(s)* Refills:*0*
4. prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day:
Taper: 15mg on [**7-23**]; 10mg [**Date range (1) 89693**]; 5mg [**Date range (1) 89694**].
Disp:*20 Tablet(s)* Refills:*1*
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 7 days: do not drink alcohol while taking
tylenol, do not take more than 4000mg of tylenol daily. .
Tablet(s)
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Please monitor blood pressure.
Disp:*30 Tablet(s)* Refills:*0*
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
9. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: Twenty Five (25) Units Subcutaneous qAM.
Disp:*1 month's supply* Refills:*0*
10. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Twenty (20) Units Subcutaneous qPM.
Disp:*1 month's supply* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Medically refractory ulcerative colitis.
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 an Open Proctocolectomy
for surgical management of your ulcerative colitis. You have
recovered from this procedure well and you are now ready to
return home. You have tolerated a regular diet, are passing gas
and your pain is controlled with pain medications by mouth. You
may return home to finish your recovery.
Please monitor your bowel function closely. If you have any of
the following symptoms please call the office for advice or go
to the emergency room if severe: increasing abdominal
distension, increasing abdominal pain, nausea, vomiting,
inability to tolerate food or liquids, prolonged loose stool, or
constipation.
You have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. You must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
you find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if you notice
your ileostomy output increasing, take in more electrolyte drink
such as gatoraide. Please monitor yourself for signs and
symptoms of dehydration including: dizziness (especially upon
standing), weakness, dry mouth, headache, or fatigue. If you
notice these symptoms please call the office or return to the
emergency room for evaluation if these symptoms are severe. You
may eat a regular diet with your new ileostomy. However it is a
good idea to avoid spicy foods.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery, You
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until you are comfortable caring
for it on your own. Please continue to record your input and
output on the ileostomy flowsheet provided to you by the nursing
staff.
You have a long vertical incision on your abdomen that is closed
with steri-strips. This incision can be left open to air or
covered with a dry sterile gauze dressing. The strips will stay
in place until your first post-operative visit at which time
they can be removed in the clinic, most likely by the office
nurse. Please monitor the incision for signs and symptoms of
infection including: increasing redness at the incision, opening
of the incision, increased pain at the incision line, draining
of white/green/yellow/foul smelling drainage, or if you develop
a fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
The peri-anal wound is oozing a small amount of old blood and
clots, which will likely continue for some time. You may shower
with this wound open, pat dry afterwards. Monitor the area for
signs and symptoms of infection: white/green/yellow/foul
smelling drainage, increased redness, increased pain, or if you
develop a fever. Please apply clean dry sterile gauze dressing
to underwear. Please call the office if the wound has increased
drainage when you return home. Inspect the wound daily (the
visiting nurse will help with this). Try to avoid sitting or
lying on the wound if possible. Please apply air cushion to
seat.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
exercise ith Dr. [**Last Name (STitle) 1120**].
Unfortunately, you developed a blood clot in your lungs, this is
called a pulmonary embolism. This was most likely caused by a
combination of inflamation and immobility after surgery. An IVC
filter was placed to prevent further clots from travelling to
your lungs. You were briefly on anticoagulant medication, but
this was stopped after the IVC filter was placed.
You were also unable to void after removal of your foley
catheter. You will need to be discharged home with the foley and
a shorter leg bag. Please monitor the foley catheter closely.
There should always be a small amount of urine in the bag, if
you develop lower abdominal pain and urine is not in the bag the
catheter may be blocked and you should call the office right
away for instruction. You developed a urinary tract infection
as well, and were started on antibiotics. Take these as
directed until the pills are all gone.
Voiding trial with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT
Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2164-7-26**] 2:30.
You will be prescribed a small amount of the pain medication
dilaudid for pain. Please take this medication exactly as
prescribed. You may take Tylenol as recommended for pain. Please
do not take more than 4000mg of Tylenol daily. Do not drink
alcohol while taking narcotic pain medication or Tylenol. Please
do not drive a car while taking narcotic pain medication.
You are taking a new medication for your blood pressure. Please
continue to take this as ordered. Please have the visiting nurse
monitor your blood pressure.
Please make an appointment with your PCP to go over your new
medications and your hospitalization.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please make an appointment with the wound/ostomy nurses for 7
days after your discharge, call [**Telephone/Fax (1) 3541**] to make this
appointment.
Please call the Colorectal Surgery office at [**Telephone/Fax (1) 160**] to
make an appointment with Dr. [**Last Name (STitle) 1120**] for your first post-operative
visit.
Please make an appointment with your PCP to discuss your
diabetes, anticoagulation, and blood pressure.
Voiding trial with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP:
Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2164-7-26**] 2:30
Completed by:[**2164-7-22**]
|
[
"568.0",
"415.11",
"788.20",
"E878.3",
"V45.3",
"998.11",
"787.60",
"556.6",
"599.0",
"453.41",
"566",
"783.21",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.77",
"54.59",
"03.90",
"45.82",
"38.7",
"48.69",
"46.23"
] |
icd9pcs
|
[
[
[]
]
] |
6550, 6599
|
3000, 4817
|
321, 367
|
6684, 6684
|
2499, 2977
|
13192, 13854
|
1971, 2108
|
5022, 6527
|
6620, 6663
|
4843, 4999
|
6835, 13169
|
2123, 2480
|
263, 283
|
395, 1509
|
6699, 6811
|
1531, 1816
|
1832, 1954
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,787
| 118,558
|
30697
|
Discharge summary
|
report
|
Admission Date: [**2154-7-30**] Discharge Date: [**2154-8-21**]
Date of Birth: [**2113-8-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Direct admit for work up of abnormal CXR and positive sputum AFB
Major Surgical or Invasive Procedure:
Bronchoscopy [**7-31**]
VATS [**8-2**]
History of Present Illness:
40 year old immigrant from rural [**Country 11150**] with 10-15 years of
symptoms including slowly progressive wasting, with a 30 lb
weight loss, cough productive of white sputum. Latter symptoms
have acutely worsened over the last 2-3 months, now with
additional 10lb weight loss, DOE, and hypoxemia with O2
saturations down to 91-93% on room air. She has had an abnormal
chest CT, elevated B-glucan, and three negative AFB smears. One
of her cultures on [**2154-5-27**] showed [**12-18**] tubes positive for fast
growing AFB, with [**Doctor First Name **] and MTB probes negative. ROS is negative
for chest pain, night sweats, hemoptysis, nausea, vomiting,
diarrhea, fevers, or dyspnea at rest. The patient moved to the
US last year from northern [**Country 11150**] in Punjab. She has had no
known exposures to TB, and does not note contact with any
symptomatic people.
Past Medical History:
None
s/p BCG vaccination as a child
Social History:
Emmigrated to the US from rural northern [**Country **], in punjab
province to join her husband last year, who has been here for 10
years. Non-smoker, non-drinker. No contact with farm animals,
no pets.
Family History:
No family history of TB or any other pulmonary diseases.
Physical Exam:
VITALS: 98 122/88 104 24 96%RA
.
PHYSICAL EXAM:
GEN: Cachectic female in NAD. Non-english speaking. Husband is
at the bedside.
HEENT: NC/AT. PERRLA, EOMI, no scleral icterus or injection.
Oropharynx is without lesions, and is pink and moist. Shotty
anterior cervical LAD, nontender and mobile.
CARDIAC: Regular rhythm, normal rate, no murmurs, rubs or
gallops. No JVD. 2+ radial, DP, and PT pulses.
RESPIRATORY: Bilateral, diffuse inspiratory and expiratory
wheezing. No splinting. Uses accessory muscles to breathe.
Audible breath sounds without stethoscope.
ABDOMEN: NABS, nontender to palpation. No masses. Liver tip
palpated 2cm below costal margin. No splenomegaly. No CVA
tenderness.
EXTREMITIES: No calf edema or tenderness. No clubbing or
cyanosis.
Pertinent Results:
LABS/STUDIES:
Ace level: 43
Schistoma IgG: <1.00
Strongyloides Antibody, IgG: <1.00
B-Glucan: 137
Blood cultures [**2154-7-16**]: negative for AFB and fungus
Sputum cultures [**2154-5-27**]: [**12-18**] positive for rapid growing AFB,
negative AFB smear
Suptum cultures [**2154-5-20**] and [**2154-5-6**]: negative for AFB on
smear and culture
*
Chest CT non-contrast [**2154-7-17**]:
IMPRESSION:
1. Chronic interstitial fibrotic changes predominantly
affecting upper lung with subsequent upper lobe volume loss
highly suspicious for chronic sarcoid especially given the
patient gender and age. The differential diagnosis might
include chronic hypersensitivity pneumonitis.
2. The centrilobular nodules and endobronchial secretions most
likely represent superimposed infection. In the presence of the
provided clinical history, the infection is most likely indolent
bringing [**Doctor First Name **] a very high in differential diagnosis. The right
lower lobe endobronchial inspissation might represent allergic
bronchopulmonary aspergillosis, although is less likely.
3. No particular radiological signs favor reactivation of TB,
although given the multiple centrilobular nodules and upper lobe
predominance, bronchogenic spread of microbacterium tuberculosis
cannot be excluded.
*
Bronchoalveolar Lavage:
GRAM STAIN 1+ POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS
SEEN.
RESPIRATORY CULTURE 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL
FLORA.
Immunoflourescent test for Pneumocystis jirovecii: NEGATIVE
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON CONCENTRATED
SMEAR.
ACID FAST CULTURE (Pending)
VIRAL CULTURE (Preliminary): No Virus isolated so far.
*
Bronchial washings:
NEGATIVE FOR MALIGNANT CELLS. Postive Pulmonary macrophages,
lymphocytes and neutrophils.
CHEST (PA & LAT) [**2154-8-21**] 8:21 AM
[**Hospital 93**] MEDICAL CONDITION:
41 year old woman with chronic lung disease s/p VATS- s/p
pleurodesis
REASON FOR THIS EXAMINATION:
interval change after Pneumostat placement. please do early am
INDICATION: Followup evaluation after pneumostat placement,
history of chronic lung disease with recent VATS and
pleurodesis.
COMPARISON: [**8-19**] and 4, [**2153**].
PA AND LATERAL VIEWS OF THE CHEST: There has been a small
interval improvement in the right hydropneumothorax. The
underlying interstitial lung disease is unchanged. The heart and
mediastinum are unchanged. The right chest tube is in unchanged
position terminating in the right apex.
IMPRESSION: Mild interval improvement in right
hydropneumothorax.
Brief Hospital Course:
40F indian immigrant admitted for work up of abnormal chest CT,
with background [**9-30**] year history of chronic wasting and cough.
Labs at outpatient [**Hospital **] clinic were inconsistent with MTB, as
three sputum cultures were negative, however, one of the three
AFB cultures showed [**12-18**] samples with rapid-growing AFB, so the
patient was placed in a negative pressure room on admission with
respiratory precautions until her broncho-alveolar lavage
specimen was confirmed AFB negative.
*
Pulmonary and Infectious disease consults were obtained to
ensure a tissue diagnosis could be made as the work-up on
admission was equivocal. A bronchoscopy with BAL and bronchial
washings was performed on [**7-31**]. The patient did not tolerate
the procedure well, experiencing bronchospasms, thus only a
lavage could be obtained. The lavage was AFB negative on smear,
and the patient was taken off of respiratory precautions. The
lavage also revealed eosinophilia. The decision was made with
consultation from the primary team, infectious diseases and
pulmonology to proceed with VATS to ensure a tissue diagnosis
before starting the patient on steroids, as there was still a
possibility of an infectious etiology. Thoracic surgery was
consulted on [**8-1**], and the patient underwent a VATS procedure on
[**8-2**].
Operative course was uneventful. Post op course was complicated
by over sedation from basal PCA requiring observation in the
ICU. Once stabilized, pt returned to the floor. Her chest tube
was initially to sxn with minimal drainage. On POD# 3 chest
tube was removed and it resulted in a moderate PTX. Serial CXR's
revealed stable but persistant PTX. A dart was placed with
minimal improvement on sxn. A water seal trial resulted in a
large PTX w/ increased pleural pain and tacycardia. Pleural dart
was placed back to sxn with minimal improved physiology.
Subsequently, a right apical chest tube was inserted and placed
to sxn. Serial attempts to decrease the amount of sxn resulted
in a large PTX. The best lung re-expansion occurred at -40cm
sxn. She was maintained on -40cm sxn and rec'd doxycycline
pleuradesis x 4. After successful doxy pleuradesis the suction
was gradually decreased over a period of days from -40, -20, -10
then placed to water seal w/ stable CXR. On the day prior to
discharge ([**2154-8-20**]) a pneumostat was placed w/ stable cxr and the
pt was d/c'd to home 24 hrs after w/ pneumostat in place. The
VNA was following for ongoing pneumostat care.
She was intermittantly tacycardic 130-150's in a reg rhythm. She
was started on po lopressor and her dose was titrated to 25 mg
po bid. At the time of d/c her HR was in the mid 80's and her
lopressor dose was cut [**12-18**]. The lopressor will continue to be
weaned at her follow up visits with Dr. [**Last Name (STitle) **].
During her hospital course she was followed closely by
pulmonology for esosinophlic PNA. She was placed on 40mg po
prednisone daily. After the first failed doxycylcine attempt,
pulmonary was consulted to decrease steroid dose as that was
thought to be preventing the inflammatory response to tthe doxy.
Her steroids were temporarily decreased to 5mg and a steroid MDI
was added. She will remain on 5mg prednisone until the chest
tube is d/c'd in approx 2 weeks from discharge.
During her hospital course her WBC peaked in the mid 20's and
despite being afeb she was started on emperic zosyn which was
d/c'd on the day on dischange after a 5 day course. All culture
data was neg.
Medications on Admission:
None
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 mdi* Refills:*2*
7. 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*
8. Metoprolol Tartrate 25 mg Tablet Sig: [**12-18**] Tablet PO BID (2
times a day): DR. [**Last Name (STitle) **] will atper this medicine.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
eosinophilic PNA
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if experience:
-Fever >101.0, chills
-Increased shortness of breath, cough
-Chest pain
Chest tube site: daily dressing change.
empty and record pneumostat drainage daily- bring this to your
follow up appointment.
The visiting nurse will check for air leak daily.
If the sutures on the chest tube break, tape the tube securely
and call the office [**Telephone/Fax (1) 170**] immediately.
You may sponge bathe but no showering while the chest tube is
in.
Followup Instructions:
You have follow up appointments with Dr. [**Last Name (STitle) **] on [**2154-8-29**]
at 11:30am, and [**2154-9-5**] at 10:30am on the [**Hospital Ward Name **] in the
[**Hospital Ward Name 23**] clinical center [**Location (un) **]. plesae arrive 45 minutes
prior to these appointments and report to the [**Location (un) **]
radiology for a Chest XRAY.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2154-9-9**] 1:10
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2154-9-9**] 1:30
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 2515**] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2154-9-30**] at 3pm
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1723**] Date/Time:[**2154-8-26**]
10:45
Provider: [**Name10 (NameIs) **] SKIN TESTS Date/Time:[**2154-8-26**] 9:15
Completed by:[**2154-8-21**]
|
[
"519.11",
"518.81",
"997.3",
"515",
"512.1",
"785.0",
"518.3",
"799.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"32.29",
"34.92",
"33.24",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
9702, 9760
|
5113, 8631
|
385, 425
|
9821, 9828
|
2503, 4014
|
10393, 11427
|
1629, 1688
|
8686, 9679
|
4405, 4475
|
9781, 9800
|
8657, 8663
|
9852, 10370
|
1762, 2484
|
4044, 4368
|
281, 347
|
4504, 5090
|
453, 1332
|
1354, 1391
|
1407, 1613
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,308
| 105,985
|
18888
|
Discharge summary
|
report
|
Admission Date: [**2123-3-15**] Discharge Date: [**2123-4-8**]
Date of Birth: [**2068-9-7**] Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Small bowel obstruction.
Major Surgical or Invasive Procedure:
Partial vertebrectomy of L3 and L4.
2. Fusion L3-L5.
3. Anterior interbody spacers x2.
4. Autograft, allograft and bone morphogenic protein.
1. Reopening of recent laparotomy wound and exploratory
laparotomy.
2. Small-bowel resection with primary anastomosis.
3. Closure of ventral abdominal wall hernia defect with Vicryl
mesh .
Past Medical History:
s/p lumbar laminectomy 18 years ago.
right rotator cuff tear and tendinosis.
bilateral R> L CTS.
Social History:
schooled to 11th grade. was a gas station manager but has been
on disability due to LBP. lives in the basement of his step-
parents' house. smoked 3 ppd tobacco x 30 years but recently
quit 98 days ago, denies EtOH use, no illicits or IVDA
Family History:
His mother died of CAD and stroke at 76.
Physical Exam:
NAD
RRR
CTA
incision clean dry intact
Pertinent Results:
[**2123-3-15**] 08:01PM HCT-35.3*
[**2123-3-15**] 06:45PM TYPE-[**Last Name (un) **] RATES-/12 TIDAL VOL-700 PO2-69*
PCO2-40 PH-7.27* TOTAL CO2-19* BASE XS--7 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2123-3-15**] 06:45PM GLUCOSE-179* LACTATE-1.8 NA+-139 K+-4.5
CL--108
[**2123-3-15**] 06:45PM HGB-12.6* calcHCT-38
[**2123-3-15**] 06:45PM freeCa-1.23
Brief Hospital Course:
54-year-old gentleman was initially on the orthopedic service
for the last few days
recovering from a spinal fusion operation performed by
Dr.[**Last Name (STitle) 363**]. This required an anterior abdominal approach through
a lower midline incision in this extremely portly gentleman. He
is now in postoperative day 3 and has evidence of bowel
obstruction clinically. A CT scan confirmed this and on this
scan, there was a clear-cut transition point in the middle of
this lower abdominal incision with what looks to be a piece of
bowel extruding out to the skin level. There was dilated
proximal bowel with decompressed distal bowel. The patient
refused an NG tube on multiple occasions proir to OR. Patient
was brought to the OR [**2123-3-20**] for small bowel obstruction and
fascial dehiscence. The patient tolerated the procedure well,
but remained intubated and was transferred to the PACU in
guarded condition. He was transferred to ICU after it ws access
that he aspirated during induction and developed ARDS & ARF.
Patient had an extensive ICU course that included management of
ARDs and ATN. Patient was transfered to the floor POD 21/16
instable condition. He receieved a bedside and video swallow
study that deemed him capable of having a regular ground solids
and thin liquids. On POD 25/20 patient was cleared for discharge
for furhter rehabilatation at a extended care facility.
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**Year (4 digits) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Year (4 digits) **]: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
3. Chlorhexidine Gluconate 0.12 % Mouthwash [**Year (4 digits) **]: One (1) ML
Mucous membrane QID (4 times a day) as needed.
4. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Year (4 digits) **]: One (1)
Appl Ophthalmic PRN (as needed) as needed for dry eyes .
5. Bisacodyl 10 mg Suppository [**Year (4 digits) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection TID (3 times a day).
7. Acetaminophen 325 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
8. Metoprolol Tartrate 25 mg Tablet [**Year (4 digits) **]: 1.5 Tablets PO TID (3
times a day).
9. Ferrous Sulfate 300 mg/5 mL Liquid [**Year (4 digits) **]: One (1) PO DAILY
(Daily).
10. Haloperidol 2 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
11. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Year (4 digits) **]: One (1)
Subcutaneous sliding scale.
12. Methadone 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO TID (3 times a
day).
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
15. Epoetin Alfa 3,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
16. Fentanyl 25 mcg/hr Patch 72HR [**Last Name (STitle) **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Lumbar spondylosis, disk degeneration and kyphosis of the lumbar
spine,Small bowel obstruction, Fascial dehiscence.
Discharge Condition:
stable
Discharge Instructions:
Resume your regular medications. Take all new medications as
directed. Do not drive while taking narcotics.
You may shower. Allow water to run over the wound, and do not
scrub. Pat the wound dry. Do not take a bath or swim until
after follow-up appointment. No heavy lifting (> 10 lbs) for 6
weeks.
Please call your doctor or return to the ER if you experience:
-Fever (> 101.4)
-Inability to eat/drink or persistant vomiting
-Increased pain
-Redness or discharge from your wound
-Other symptoms concerning to you
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] call to scheduele
appointment.
Please followup with Dr. [**Last Name (STitle) 363**] call to schedule an appointment.
Completed by:[**2123-4-8**]
|
[
"998.59",
"293.0",
"707.05",
"584.5",
"737.30",
"682.2",
"401.9",
"721.3",
"280.9",
"518.5",
"305.1",
"738.4",
"997.4",
"038.9",
"998.32",
"722.52",
"507.0",
"552.21",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"99.04",
"81.62",
"33.24",
"38.95",
"39.95",
"99.15",
"84.52",
"96.6",
"45.62",
"81.06",
"53.61",
"03.90",
"45.91",
"96.72",
"99.00",
"81.08"
] |
icd9pcs
|
[
[
[]
]
] |
4825, 4898
|
1516, 2911
|
291, 624
|
5058, 5067
|
1134, 1493
|
5636, 5837
|
1019, 1061
|
2934, 4802
|
4919, 5037
|
5091, 5613
|
1076, 1115
|
225, 251
|
646, 745
|
761, 1003
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,435
| 184,207
|
29713
|
Discharge summary
|
report
|
Admission Date: [**2145-12-3**] Discharge Date: [**2145-12-9**]
Date of Birth: [**2077-10-17**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Zometa / Keflex / Tetracycline / erythromycin /
Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
ventricular tachycardia, ICD generator change
Major Surgical or Invasive Procedure:
ICD generator change
History of Present Illness:
The patient is a 68 y/o F with PMHx significant for NIICMP
(EF5-10%) s/p AICD/BiV pacer, PAF s/p ablation, who presented to
OSH on [**2145-12-2**] with worsening DOE, cough, runny nose, diarrhea,
fatigue. BNP was noted to be elevated at 1000, and there was
some concern for dietary indiscretion during a recent trip.
Symptoms were initially attributed to CHF exacerbation, and she
was treated with lasix. Given leukocytosis, there was also
concern for underlying respiratory infection, for which she was
started on doxycycline.
.
However, on the day after admission, the patient had a syncopal
event while in the bathroom, hitting her head on the door.
During this event, telemetry recorded VT/?torsades and she
received a shock from her AICD. She endorseded lightheadedness
prior to the event, denies any chest pain, palpitations, or
shortness of breath. Given that she was scheduled to have and
AICD generator change at [**Hospital1 18**] in the next few weeks, her
cardiologist was contact[**Name (NI) **] and recommended transfer to [**Hospital1 18**].
ICD was interrogated at OSH and reported to episodes of
device-classified VT (vs. Afib with RVR).
.
Of note, imaging performed after the patient's head strike was
significant for anterior C4 fracture of unclear chronicity.
Telephone neurosurgery consult was placed at OSH, and it was
recommended that patient be placed in a neck collar. Patient
also experienced a significant head laceration, which was
sutured prior to transfer. VS at the time of transfer were HR
80s - 100s with SBP 100s - 110s. She has been experiencing
significant nausea and diarrhea; her doxycycline has been
stopped out of concern that it could be contributing to her GI
symptoms.
.
On arrival to the CCU, the patient's VS were . She denies any
shortness of breath or chest pain. She reports pain in the area
where she struck her forehead. She denies any other complaints.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: AICD and BiV pacer
3. OTHER PAST MEDICAL HISTORY:
- nonischemic idiopathic cardiomyopathy, EF 5-15%, s/p AICD and
biventricular pacer
- paroxysmal atrial fibrillation status post ablation
- severe asthma
- old compression fractures of T8 and T10
- venous stasis disease
- anxiety
- depression
- restless legs syndrome
- recent septic bursitis of right knee
Social History:
Used to work as a jeweler. Lives with son.
- Tobacco history: Remote, 1 ppw, quit 42 years ago.
- ETOH: approx. 1-2 drinks 4 times a week
- Illicit drugs: None
Family History:
Father had "heart problems" and died at 69. Brother had some
form of arrhythmia. No other cardiac history.
Physical Exam:
PHYSICAL EXAMINATION (on admission):
VS: T=96.4 BP=105/62 HR=94 RR=20 O2 sat=95%2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Cervical collar in place. NCAT. Sclera anicteric. PERRL,
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. Abrasions and sutured laceration on right forehead.
NECK: Unable to asses JVP 2/2 cervical collar.
CARDIAC: Irregular rhythm, 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. Some bibasilar crackles
anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+
Left: DP 2+.
.
ON DISCHARGE:
Unchanged except of note: cervical collar no longer in place.
Pertinent Results:
[**2145-12-3**] 11:51PM BLOOD WBC-11.8* RBC-4.64 Hgb-15.1 Hct-43.4
MCV-93 MCH-32.6* MCHC-34.9 RDW-14.2 Plt Ct-180
.
[**2145-12-3**] 11:51PM BLOOD PT-26.7* PTT-37.6* INR(PT)-2.6*
.
[**2145-12-4**] 10:00AM BLOOD Glucose-198* UreaN-21* Creat-1.2* Na-135
K-4.6 Cl-96 HCO3-30 AnGap-14
.
[**2145-12-4**] 10:00AM BLOOD Albumin-3.6 Calcium-8.4 Phos-2.7 Mg-2.1
.
[**2145-12-4**] 10:00AM BLOOD ALT-36 AST-51* AlkPhos-89 TotBili-1.8*
.
OSH CXR - Cardiomegaly with pulmonary vascular congestion (per
d/c summary)
.
OSH Cervical Xray - Limited exam, not visualizing C7. Moderate
degenerative change. No fracture seen.
.
OSH CT Head and C-Spine - No acute intracranial finding. Right
forehead soft tissue swelling. Bilateral maxillary sinusitis.
Fracture line through the anterior osteophyte of the inferior
endplate of the C4, age-indeterminate. No visible associated
soft tissue swelling. No prior study available for correlation.
Cervical spondylosis.
.
[**2145-12-4**] CXR - Left dual-lead pacemaker has its leads terminating
over the expected location of the right atrium and right
ventricle respectively. An external pacing wire also is
unchanged. Heart remains enlarged. There is worsening
indistinctness of the perihilar and pulmonary vasculature which
is suggestive of moderate pulmonary edema. No evidence of
pleural effusions.
DISCHARGE LABS
[**2145-12-8**] 06:55AM BLOOD WBC-10.9 RBC-4.18* Hgb-13.2 Hct-39.3
MCV-94 MCH-31.5 MCHC-33.5 RDW-14.1 Plt Ct-205
[**2145-12-8**] 06:55AM BLOOD Plt Ct-205
[**2145-12-8**] 06:55AM BLOOD PT-15.1* PTT-33.4 INR(PT)-1.4*
[**2145-12-8**] 06:55AM BLOOD Glucose-122* UreaN-23* Creat-1.2* Na-137
K-4.3 Cl-99 HCO3-29 AnGap-13
[**2145-12-5**] 07:57AM BLOOD ALT-31 AST-39 TotBili-1.4
[**2145-12-8**] 06:55AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9
Brief Hospital Course:
68F with with a PMH significant for non-ischemic and ischemic
cardiomyopathy (LVEF 5-10%) s/p AICD and biventricular pacer,
paroxysmal atrial fibrillation s/p ablation, admitted to an
outside hospital with worsening dyspnea on exertion, cough,
rhinorrhea, diarrhea and fatigue who was initially treated for a
CHF exacerbation but through her hospital course she developed
ventricular tachycardia and Torsades de Pointes with firing of
her ICD and a shock successfully delivered with maintenance of
her circulation; thus, she was transferred to [**Hospital1 18**] for further
monitoring and AICD generator change.
.
# VENTRICULAR TACHYCARDIA / TORSADES DE POINTES - The event on
telemetry strip from her outside hospital appears to be
polymorphic ventricular tachycadia with a Torsades de Pointes
morphology. There was no clear inciting event noted. The patient
is not on any new QT-prolonging medications (although Sertraline
and Zofran have been known to prolong the QT), and only new
medication was Doxycycline. She had no significant electrolyte
abnormalities noted (K was 3.5 the morning of admission to the
outside hospital and her magnesium was reassuring). The most
likely etiology at this point seems to be patient's underlying
ischemic cardiomyopathy and prior scarring. Her electrolytes
were optimized with a magnesium of greater than 2.0 and
potassium greater than 4.0 to 4.5. We consulted the
Electrophysiology team and planned for ICD generator change
early in the week. She was maintained on telemtry and had serial
EKG monitoring.
.
# CORONARIES - The patient had no documented history of coronary
disease in our records; or cardiac catheterizations. On
admission, she denied any chest pain and her EKG was without
ischemic changes.
.
# DYSPNEA ON EXERTION - The patient has a known history of
non-ischemic and ischemic cardiomyopathy with an LVEF of [**5-11**]%.
On presentation to the outside hospital, she was noted to have
worsening dyspnea on exertion, an elevated BNP, and fluid
overload on CXR. She was treated with IV Lasix. On admission to
the CCU, her exam still was notable for bibasilar crackles, a
CXR showing mild fluid overload. Of note, the patient also has
history of asthma and was recently on a steroid taper; however,
her exam did not reveal any wheezing or evidence of asthma
exacerbation. While she was started on Vancomycin and Cefepime
empirically at the outside hospital, there did not appear to be
any evidence of infection (afbrile and she was without
leukocytosis). We continued her home dosing of Lasix 80 mg PO
twice daily. She had no indication for steroids. She was also
maintained on her home Advair medication. We did not feel she
warranted antibiotic treatment.
.
# NAUSEA & DIARRHEA - An infectious process vs. medication
effect from her Doxycycline is the most likely etiology. If
infectious, a viral process seems more likely than bacterial. A
C.diff was negative at the outside hospital; while her other
stool cultures were pending. She was given IV anti-emetics and
her loose stools and nausea steadily improved. She did not
warrant antibiotic therapy.
.
# C-SPINE FRACTURE ON C-SPINE IMAGING - The patient presented
with a syncope episode
that resulted in a presumed head injury and CT head with C-spine
imaging showed evidence of a C4-fracture of unknown chronicity.
The neurosurgery team and Neurology service were consulted at
the outside hospital, at which time a [**Location (un) 2848**]-J hard collar was
recommended and she was transferred with that in place. On exam
in the CCU at [**Hospital1 18**], she had no evidence of neurologic
compromise. Ortho-Spine was consulted here and they reviewed the
outside hospital imaging in our PACS system, noting that a
likely osteophyte was probable and that the fracture was
chronic. They recommended a soft collar while active for
3-months for comfort only.
.
# PAROXYSMAL ATRIAL FIBRILLATION - History of paroxysmal atrial
fibrillation with rate control with beta-blocker; we maintained
her on Metoprolol and monitored her via telemtry with
electrolyte optimization.
.
# RESTLESS LEG SYNDROME - We continued Ropinirole at her home
dosing.
.
# DEPRESSION/ANXIETY - We continued Zoloft at her home dosing.
.
# CHRONIC BACK PAIN - We continued Oxycodone 2.5 mg by mouth in
the evenings as needed, which was her home dosing.
# CODE STATUS: full confirmed
# COMMUNICATION: Patient, [**Telephone/Fax (1) 71174**]
# PENDING STUDIES: OSH culture data
# ISSUES TO ADDRESS AT FOLLOW UP:
- VNA for INR checks, weights, electrolytes, dressing changes
- magnesium oxide daily use
- Bactrim x1 week from day of discharge
Medications on Admission:
HOME MEDICATIONS:
- advair 500/50 1 puff [**Hospital1 **]
- ferrous sulfate
- mvi
- vitamin d 1000 units
- tums 3 times per day
- lasix 80 mg PO BID
- aspirin 81 mg daily
- zoloft 100 mg daily
- magnesium oxide 400 mg daily
- aldactone 25 mg [**Hospital1 **]
- diovan 40 mg daily
- claritin 10 mg daily
- protonix 40 mg daily
- digoxin 0.125 mcg daily
- singulair 10 mg at night
- requip 0.25 mg at night
- trazodone 50 mg - [**1-3**] tablet [**Hospital1 **] as needed for anxiety, 1
tablet at bedtime as needed for insomnia
- metoprolol succinate 12.5 mg at night
- warfarin at night
- oxycodone 2.5 - 5 mg as needed for pain
- gabapentin 300 mg up to 3 a day at night
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
5. calcium carbonate Oral
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
14. trazodone 50 mg Tablet Sig: 0.25 Tablet PO BID (2 times a
day) as needed for anxiety: OR take one tablet at bedtime for
insomnia.
15. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO HS (at bedtime).
16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at
bedtime)) as needed for pain: Do not drive or drink alcohol
while you are on this medication.
17. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM: Please discuss dosing with your PCP.
18. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
19. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
20. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for pain: USE UP TO THREE TIMES A DAY.
21. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
primary diagnosis: non-ischemic and ischemic cardiomyopathy,
atrial fibrillation, cervical compression fracture, depression,
anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 71175**],
You were transferred to [**Hospital1 18**] because your heart went into an
abnormal rhythm at an outside hospital and you required a
generator change in your ICD at [**Hospital1 **]. [**First Name (Titles) **] [**Last Name (Titles) 8783**]t change of your ICD generator without issue.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please note the following changes to your medications:
- START Clindamycin for one week after your day of discharge
- DISCUSS with your PCP whether you should continue to take
magnesium daily
- CONTINUE the remainder of your medications as directed by your
physicians.
Please be sure to follow up with your physicians.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Address: 131 ORNAC , STE#800 JCB BLDG, [**Location (un) **],[**Numeric Identifier 15215**]
Phone: [**Telephone/Fax (1) 71176**]
*It is recommended that you see your PCP within one week.
Someone from Dr. [**Last Name (STitle) 71177**] office will call you to schedule an
appointment.
You should follow up at the device clinic regarding your ICD as
well.
Name: [**Last Name (LF) **], [**First Name3 (LF) **]
Department: CARDIOLOGY/CONORD
Location: 131 ORNAC, [**Apartment Address(1) 71178**]
Phone: [**Telephone/Fax (1) 71179**]
When: THURSDAY [**2146-1-20**] at 4:00 PM
Name: [**Last Name (LF) **], [**First Name3 (LF) **] and [**First Name8 (NamePattern2) 16901**] [**Last Name (NamePattern1) **] NP
Department: CARDIOLOGY/CONORD
Location: 131 ORNAC, [**Apartment Address(1) 71178**]
Phone: [**Telephone/Fax (1) 71179**]
When: Thursday [**12-16**] at 3:00pm
|
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28,790
| 122,369
|
33086
|
Discharge summary
|
report
|
Admission Date: [**2156-1-6**] Discharge Date: [**2156-1-11**]
Date of Birth: [**2084-8-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
thoracic aortic penetrating
Major Surgical or Invasive Procedure:
Repair of descending thoracic aortic penetrating ulcer with a
[**Doctor Last Name 4726**] TAG endograft, reference number [**Serial Number 65878**], lot number [**Serial Number 76913**]
History of Present Illness:
This is a woman who presented with anemia and CT scan showing
left chest full of blood and a bedside MR [**First Name (Titles) **] [**Last Name (Titles) **] indicative of
ulceration of the aorta with intramural hematoma just past the
subclavian takeoff. The patient was
transferred here and CT was repeated without an interval change
in the left chest hematoma or the appearance of the aorta. She
is taken emergently for stent graft repair.
Past Medical History:
PMH: PUD,Asthma, Hypothyroid, migranes
PSH: Hyst, Bilat Knee [**Doctor First Name **], Hernia repair, Back surgery(tumor)
Social History:
neg alcohol
neg tobacco
Family History:
n/c
Physical Exam:
a/o
cta
rrr
benign
distal pulses palp
CT site - serous sang drainage
Pertinent Results:
[**2156-1-10**] 07:00AM BLOOD
WBC-11.0 RBC-3.46* Hgb-10.9* Hct-31.7* MCV-92 MCH-31.4 MCHC-34.3
RDW-13.6 Plt Ct-225
[**2156-1-8**] 02:06AM BLOOD
PT-12.2 PTT-24.5 INR(PT)-1.0
[**2156-1-10**] 07:00AM BLOOD
Glucose-101 UreaN-15 Creat-0.6 Na-140 K-3.9 Cl-100 HCO3-31
AnGap-13
[**2156-1-7**] 02:56AM BLOOD
ALT-13 AST-16 LD(LDH)-155 AlkPhos-73 Amylase-33 TotBili-0.4
[**2156-1-9**] 04:22AM BLOOD Mg-2.0
[**2156-1-6**] 05:15AM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.048*
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
URINE Hours-RANDOM
URINE bnzodzp-NEG barbitr-POS opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
[**2156-1-10**] 9:39 AM
CHEST (PA & LAT)
The cardiomediastinal contour is stable with no change in
appearance of the endo-aortic graft. The left retrocardiac
atelectasis is unchanged. Small amount of subcutaneous air in
the right chest wall is stable. There is no change in small
right pleural effusion. There is no pneumothorax. There is no
evidence of failure
[**2156-1-9**] 11:04 AM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: Since the examination
of [**2156-1-6**], there has been placement of an endovascular
aortic stent graft with its proximal end at the level of the
distal aspect of the left subclavian artery, terminating in the
distal descending aorta. There is no evidence of contrast
extravasation beyond the margins of the graft. The mediastinal
hematoma has decreased slightly in size since [**1-6**]. The
left-sided hemothorax has been largely evacuated, and a
left-sided chest tube is in place entering via a left
intercostal approach, tracking in the major fissure and
terminating adjacent to the mediastinum. A small right-sided
hydropneumothorax with apical/anterior and posteromedial
component is present. A right-sided pleural effusion and
adjacent compressive atelectasis have decreased. The heart and
pericardium, and central airways appear unremarkable.
CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: The
aorta is normal in caliber and contour with mural calcification
consistent with atheromatous disease. The branch vessels,
including the celiac, superior mesenteric, renal, and inferior
mesenteric arteries, are patent. Note is made of an accessory
renal artery on the right. There is an accessory left hepatic
artery arising from the left gastric artery.
Two hypodense lesions in the liver (segment IVB, 3:109 and
segment I,
3:97) are unchanged and likely represent cysts. Contrast in the
gallbladder is consistent with vicarious excretion. In the
pancreatic head, a 7-mm oval hyperenhancing nodule appears
unchanged from the contrast-enhanced examination performed at
the outside hospital on [**1-6**]. The spleen and splenule,
right adrenal gland, appear unremarkable. Multiple parapelvic
cysts are present on the left. A 3.5 x 6.5 cm fat and soft
tissue density lesion which is continuous with the medial limb
of the left adrenal gland, is consistent with a myelolipoma. A
second smaller fat density lesion in the upper portion of the
left adrenal gland (3:87), is consistent with a smaller adrenal
myelolipoma. The large and small bowel loops are normal in
caliber. There is diverticulosis of the sigmoid colon with
contrast retained in multiple diverticulae.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder, distal
ureters, prostate and seminal vesicles, rectum appear
unremarkable. There is sigmoid colonic diverticulosis without
evidence of inflammatory change. There are no pathologically
enlarged pelvic or inguinal lymph nodes. Bilateral
fat-containing inguinal hernias are present.
BONE WINDOWS: No lesions worrisome for osseous metastatic
disease are identified. There is subcutaneous emphysema within
the tissues of the left chest wall near the site of insertion of
the chest tube.
IMPRESSION:
1. Status post placement of descending aortic endovascular stent
graft without evidence of leak.
2. Left-sided hydropneumothorax with marked decrease in
hemothorax since [**1-6**], and with interval placement of a
chest tube.
3. Decreased simple right pleural effusion and atelectasis.
4. 7 mm enhancing nodule in the pancreatic head most likely
represents a hyperenhancing pancreatic mass such as a
neuroendocrine tumor.
5. Two fat and soft tissue density containing left adrenal
lesions consistent with myelolipoma.
6. Unchanged hypodense hepatic lesions consistent with cysts.
Brief Hospital Course:
This is a woman who presented with anemia and CT scan showing
left chest full of blood and a bedside MR [**First Name (Titles) **] [**Last Name (Titles) **] indicative of
ulceration of the aorta with intramural
hematoma just past the subclavian takeoff. The patient was
transferred here and CT was repeated without an interval change
in the left chest hematoma or the appearance of the aorta. She
is taken emergently for stent graft repair.
Pt did recieve transfusion x 3 / HCT stable
CT placed - left chest hematoma
Pt tolerated the procedure well. No complications. She was
transfered to the CVICU in stable condition. Weaned from
pressure suppore / Extubated.
She [**Last Name (un) 19692**] then transfered to the Fllor in stable condition.
Pt worked with patient
CTA performe post - placement of descending aortic endovascular
stent graft without evidence of leak.
CT DC'd
CXR showed - post removal of a right central line, a left chest
drainage tube with no pneumothorax. Small post-operative
pneumomediastinum seen along the left heart border. Prominent
aorta; ascending aorta and arch secondary to previous surgery
with graft placement.
Slight increase in the left pleural effusion.
Medications on Admission:
[**Last Name (un) 1724**]: Premarin 0.3', Advair 50/100", Zantac 150', Fiorocet-prn,
Levothyroxine 137'
Discharge Medications:
1. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
6. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO prn.
8. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*3*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home Health of [**Location (un) 5028**]
Discharge Diagnosis:
Penetrating ulcer on mid arch w/intramural hematoma
Asthma
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-4**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-7**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
See Dr. [**Last Name (STitle) 914**] in 3 months with a CT angio of the torso with
MMS reconstruction.
Call Dr [**Last Name (STitle) 468**] and schedule an appointment. This should be done
in one week. Phone: [**Telephone/Fax (1) 2835**].
Completed by:[**2156-1-11**]
|
[
"493.90",
"441.01",
"997.4",
"E878.8",
"244.9",
"560.1",
"511.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.42",
"39.73"
] |
icd9pcs
|
[
[
[]
]
] |
8149, 8219
|
5837, 7037
|
347, 535
|
8322, 8329
|
1318, 5814
|
10934, 11205
|
1209, 1214
|
7191, 8126
|
8240, 8301
|
7063, 7168
|
8353, 10354
|
10380, 10911
|
1229, 1299
|
280, 309
|
563, 1006
|
1028, 1152
|
1168, 1193
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,453
| 157,477
|
11481
|
Discharge summary
|
report
|
Admission Date: [**2138-9-12**] Discharge Date: [**2138-9-20**]
Date of Birth: [**2080-7-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
[**2138-9-15**] CABG x 3 (LIMA to LAD, left radial to RAMUS, SVG to
PDA)
History of Present Illness:
58 yo male with acute MI in [**3-8**]. Experienced heartburn/weakness
and diaphoresis in [**8-8**] elevations. Received IV NTG,
aggrastat, plavix, heparin and IABP inserted. Ultimately sent
home on coumadin for poor LV function. Readmitted [**9-12**] for IV
heparin bridge off coumadin.
Past Medical History:
- COPD (on no inhalers)
- HTN
- dyslipidemia
- CAD s/p LAD DES in [**2132**] for NSTEMI and midLAD and RPDA BMS in
[**3-/2138**] for STEMI.
- PVD s/p L fem-[**Doctor Last Name **] bypass [**2131**], R fem-[**Doctor Last Name **] bypass [**2132**]
- COPD
- HTN
- GERD
- Chronic systolic dysfunction
Social History:
Social history is significant for prior tobacco use, h/o 40 pk
year history, quit in [**2132**]. Pt drinks 2 beers per day and denies
h/o withdrawal sxs. He smokes marijuana daily.
There is no family history of premature coronary artery disease
or sudden death. Mother had a MI at age 78.
Family History:
NC
Physical Exam:
Admission
VS 98.6 HR 80 101/70 RR 18 96% RA sat
Wt 75.6 kg Ht 70"
Neuro non focal
Pulm CTAB
CV RRR no m/r/g
Abdm + BS, soft, NT
Discharge:
Pertinent Results:
[**2138-9-12**] 05:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2138-9-12**] 01:25PM GLUCOSE-94 UREA N-6 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-27 ANION GAP-10
[**2138-9-12**] 01:25PM ALT(SGPT)-22 AST(SGOT)-19 LD(LDH)-142 ALK
PHOS-71 TOT BILI-0.3
[**2138-9-12**] 01:25PM WBC-10.7 RBC-2.89* HGB-8.3* HCT-26.5* MCV-92
MCH-28.8 MCHC-31.3 RDW-17.0*
[**2138-9-12**] 01:25PM PLT COUNT-571*
[**2138-9-12**] 01:25PM PT-15.0* PTT-31.8 INR(PT)-1.3*
[**2138-9-17**] 05:45AM BLOOD WBC-16.3* RBC-2.76* Hgb-8.0* Hct-24.6*
MCV-89 MCH-29.1 MCHC-32.6 RDW-16.6* Plt Ct-363
[**2138-9-18**] 05:45AM BLOOD PT-15.0* INR(PT)-1.3*
[**2138-9-17**] 05:45AM BLOOD Plt Ct-363
[**2138-9-17**] 05:45AM BLOOD Glucose-115* UreaN-11 Creat-0.8 Na-134
K-4.4 Cl-101 HCO3-27 AnGap-10
Conclusions
PRE CPB The left atrium is markedly dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. The left ventricular cavity is moderately
dilated. There is moderate regional left ventricular systolic
dysfunction with apical, distal anterior, distal septal, distal
anterolateral, and distal anteroseptal akinesis. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
very mild anterior leaflet prolapse which combined with some
posterior leaflet retraction results in at least moderate mitral
regurgitation. The mitral regurgitation may actually be slightly
worse as it is an eccentic and posteriorly directed jet. There
is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
POST CPB The patient is receiving epinephrine by infusion. Right
ventricular systolic function is normal. The left ventricle
displays the same regional wall motion abnormalities noted in
the pre bypass study. The mitral regurgitation appears to be
slightly worse - now likely moderate to severe. The thoracic
aorta appears intact. 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) **] [**2138-9-15**] 13:41
[**Known lastname 36642**],[**Known firstname 1955**] H [**Medical Record Number 36643**] M 58 [**2080-7-27**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2138-9-17**] 9:31
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2138-9-17**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 36644**]
Reason: ? ptx after CT removal
Provisional Findings Impression: DLnc WED [**2138-9-17**] 11:25 AM
Stable appearance of post-operative chest. Removal of tubes and
lines as
described. No increase in left pneumothorax after
discontinuation of left
chest tube.
Final Report
REASON FOR EXAMINATION: Followup of a patient after removal of
the chest
tube.
Portable AP chest radiograph was compared to the prior study
obtained on
[**2138-9-15**].
The patient was extubated in the meantime interval and the
Swan-Ganz catheter was removed. The left chest tube as well as
two mediastinal drains have been also removed in the interim.
The cardiomediastinal contour is stable including
post-sternotomy wires and surgical clips projecting over the mid
sternum. There is no appreciable pneumothorax. There is no
increase in pleural effusion. There is no failure. No change in
the appearance of the right upper lobe bulla is demonstrated.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: WED [**2138-9-17**] 3:53 PM
Brief Hospital Course:
Admitted [**9-12**] for IV heparin bridge while off coumadin pre-op.
PAT completed over the weekend and underwent surgery with Dr.
[**Last Name (STitle) **] on [**9-15**] at which time he had CABGx3 with LIMA-LAD,
SVG-PDA, Lft Rad Artery-Ramus.Please see OR report for details.
He tolerated the operation well and was transferred to the CVICU
in stable condition. He did well in the immediate post-op period
and extubated later that afternoon.
He remained hemodynamically stable and on POD1 was transferred
to the step down floor for continued care and recovery. Once on
the floor, he was transfused, his activity level was advanced,
his medications were titrated and on POD6 he was discharged home
with visiting nurses.
Medications on Admission:
folic acid 1 mg daily
thiamine 100 mg daily
colace 100 mg [**Hospital1 **]
ferrous sulfate 325 mg daily
omeprazole 20 mg daily
amlodipine 2.5 mg daily
toprol XL 150 mg daily
ECASA 325 mg daily
crestor 40 mg daily
IV heparin drip
plavix 75 mg daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day:
20mg [**Hospital1 **] x7 days then 20 mg Qd x10 days.
Disp:*24 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours):
20 mEq [**Hospital1 **] x7 days the 20 mEqs x10 days.
Disp:*24 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] x 5 days then 400 mg QD x 7 days then 200mg
qd.
Disp:*60 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO Q12H (every 12
hours).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA and hospice
Discharge Diagnosis:
CAD s/p cabg x3(LIMA to LAD, left radial to RAMUS, SVG to
PDA)prior stenting
MI
COPD
HTN
GERD
elev. lipids
PVD s/p right and left fem-[**Doctor Last Name **] bypass grafting
chronic systolic HF
Discharge Condition:
good
Discharge Instructions:
Daily weight, [**Name8 (MD) 138**] MD if weight > 3 lbs.
2 gm sodium diet
keep wound clean and dry, ok to shower daily and pat incisions
dry
no lotions, creams or powders on any incision
call for fever greater than 100.5, redness, or drainage from
wounds
no driving for 6 wks AND off all narcotics
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) 36645**] in [**1-1**] weeks
Dr. [**Last Name (STitle) **] in [**2-2**] weeks
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2138-9-20**]
|
[
"414.01",
"496",
"V58.61",
"304.31",
"428.22",
"V58.83",
"530.81",
"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.16",
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"39.61"
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icd9pcs
|
[
[
[]
]
] |
8579, 8637
|
5732, 6454
|
328, 404
|
8876, 8883
|
1556, 5709
|
9276, 9520
|
1367, 1371
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8658, 8855
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6480, 6730
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8907, 9253
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1386, 1537
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282, 290
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432, 720
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742, 1044
|
1060, 1351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,903
| 179,497
|
45026
|
Discharge summary
|
report
|
Admission Date: [**2197-9-27**] Discharge Date: [**2197-9-30**]
Date of Birth: [**2152-5-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
45 y/o man with alleged hx of seizure disorder and polysubstance
abuse presents after being found unresponsive by family. Per
report from EMS, his family heard a thump and found him on the
floor laying still without tonic/clonic movements, no tongue
biting or bowel/bladder incontinence and had a bruise on his
head. They called EMS immediately who boarded and collared the
patient, reported a normal glucose and ECG showing normal sinus
rhythm, and gave narcan without improvement in mental status.
Upon arrival to the ED, he was unresponsive with a GCS of 8. He
had small movements of his upper extremities, but no movement of
his lower extremities and he did not withdraw to pain. Pupils
were 4mm and not reactive in the bright trauma room. He had
significant respiratory secretions with normal oxygen
saturations and was soon after intubated for airway protection.
.
Induction for intubation included 100mg lidocaine, 20mg
etomodate, 120mg succinylcholine. 7.0 ET tube was placed
without immediate complication and he was sedated with propofol.
CT head and C-spine were completed which did not show acute
intracranial hemorrhage or fracture respectively. Utox showed +
benzos, and serum tox, including ethanol, was negative. ECG
showed narrow complex normal sinus rhythm. He was given
maintenance fluids @75cc/hr.
Past Medical History:
Past psychiatric history:
- multiple dual diagnosis hospitalizations, including several at
[**Hospital1 18**] in late 90's. Pt is vague about when most recent hosp was.
- several suicide attempts, including Tegretol OD in [**2178**] and
cutting wrists in [**2171**]
- current psychiatrist is Dr. [**First Name (STitle) **] at [**Hospital1 1680**] JP
- denies h/o violence
Past Medical History:
- Scrotum and testicle injury in [**2171**], s/p orchiectomy and
multiple subsequent surgeries, which resulted in chronic pain.
Social History:
Substance use history:
- Xanax from illicit sources.
- EtOH: long h/o abuse/dependence since late teens
- Marijuana: h/o chronic use, which pt says he has "cut down
on," most recent use "a few days ago"
- Cocaine: past abuse, none in several years
- Opiates: pt denies but OMR indicates misuse of prescription
opiates for pain in past
- Denies h/o IVDU
Family History:
Father- recovering alcoholic
Physical Exam:
ADMISSION EXAM
Vitals: T:94.4 BP: 91/61 P: 70 R: 20 O2: 99% on vent
General: intubated, sedated
HEENT: Sclera anicteric, PERRL 3->2cm, ETT in place. Small
edematous area on top of calveria, skin intact, no bony step
offs or depression, no racoon eyes or otorrhea or rhinorrhea,
facial bones intact.
Neck: supple, JVP not elevated. No pain to palpation of cspine.
CV: Distant quiet heart heart sounds, regular rate and rhythm,
normal S1 + S2, no apparent murmurs, rubs or gallops but exam is
limited
Lungs: Clear to auscultation bilaterally, mechanical breath
sounds no wheezes, rales, ronchi
Abdomen: soft, cannot assess tenderness, non-distended, active
bowel sounds, no organomegaly, midline surgical scar. Pelvic
girdle intact, no flexion.
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: PERRL, normal tone in upper and lower extremities, does
not withdraw to pain, no reflex or babinksi response
D/C EXAM
VSS. AAOx3. Conversant, attention intact to months backward. No
nystagmus
Pertinent Results:
[**2197-9-27**] ADMISSION LABS
WBC-9.3 RBC-4.67 Hgb-14.9 Hct-42.8 MCV-92 MCH-31.9 MCHC-34.8
RDW-13.4 Plt Ct-244 [Neuts-77.6* Lymphs-17.7* Monos-3.4 Eos-1.0
Baso-0.4]
PT-12.6 PTT-22.2 INR(PT)-1.1
Glucose-97 UreaN-19 Creat-0.9 Na-142 K-4.4 Cl-111* HCO3-23
AnGap-12
ALT-21 AST-20 LD(LDH)-148 CK(CPK)-146 AlkPhos-80 TotBili-0.1
cTropnT-<0.01 x3
Calcium-8.4 Phos-3.3 Mg-2.1
TSH-0.47
BLOOD GAS: Type-ART Rates-/16 Tidal V-600 PEEP-5 FiO2-4.5
pO2-137* pCO2-55* pH-7.31* calTCO2-29 Base XS-0 -ASSIST/CON
Intubat-INTUBATED
BLOOD GAS: Type-ART pO2-178* pCO2-40 pH-7.42 calTCO2-27 Base
XS-1 Intubat-INTUBATED
URINE
Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
UreaN-872 Na-118 K-GREATER TH Cl-167
Osmolal-814
bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG
mthdone-NEG
D/C LABS
WBC-7.7 RBC-3.96* Hgb-13.0* Hct-36.2* MCV-91 MCH-32.9*
MCHC-36.0* RDW-13.1 Plt Ct-172
Glucose-92 UreaN-15 Creat-0.8 Na-139 K-3.9 Cl-107 HCO3-28
AnGap-8
Calcium-8.8 Phos-2.4* Mg-2.2 Iron-84
calTIBC-230* VitB12-648 Folate-13.0 Ferritn-87 TRF-177*
[**2197-9-27**] URINE URINE CULTURE-FINAL INPATIENT
[**2197-9-27**] BLOOD CULTURE NGSF
[**2197-9-27**] BLOOD CULTURE NGSF
[**2197-9-27**] BLOOD CULTURE NGSF
[**2197-9-27**] MRSA SCREEN MRSA SCREEN-FINAL
EEG [**9-27**]
This telemetry captured no pushbutton activations. The record
showed primarily medication effect in the first couple of hours,
progressing to a more normal waking record, without areas of
focal slowing. At no point in the record were there any clearly
epileptiform discharges or electrographic seizures.
CT HEAD [**9-27**]
1. No acute intracranial process.
2. Paranasal sinus acute-on-chronic inflammatory disease;
correlate clinically.
CT C-SPINE [**9-27**]
1. No acute fracture or malalignment.
2. Paraseptal emphysema.
CXR [**9-27**]
The patient is situated on a trauma board, limiting assessment
for fine detail. Within that limitation, the endotracheal tube
tip sits 6 cm above the carina. The endogastric tube coils
within a prominent gas-distended stomach. A right IJ central
venous catheter tip sits in the mid-to-lower SVC. The heart size
is at the upper limits of normal. The mediastinal contours are
not widened. The mediastinal contours are not widened. The lung
volumes are low with minimal left basal atelectasis. There is no
pulmonary edema. There is no large pleural effusion or
pneumothorax.
Brief Hospital Course:
Mr. [**Known lastname **] is a 46 yo M with hx of suicide attempts who
presented to [**Hospital1 18**] on [**2197-9-27**] with likely overdose of his home
oxcarbazepine and alprazolam after argument with his father. His
respiratory and mental status were stabilized in the ICU.
# Aprazolam/oxcarbazepine overdose
The initial etiology of the altered mental status was unclear.
The pt was intubated immeditately for airway protection. CT of
his head and C-spine had no acute pathology. The toxicolgy
serum screen was remarkable for no ethanol, and no other
intoxicants. The urine toxicology screen was positive for
benzodiazepines only. The pt had no initial reponse to narcan
by the paramedics, and had a normal blood glucose level in the
ER. His ECG was not suggestive of an acute cardiac or
toxidromic process, but was notable for Q-waves in inferior
leads. The pt was reported to have a seizure disorder, but had
no focal neurological findings or tonic-clonic movements or
abnormal eye gaze. The pt had no signs trauma anywhere on
physical exam. The pt remained unconcious initially while in
the ICU, but then in the AM became arousable to vocal and
painful stimuli. He had good respiratory function as assesed by
the ventilator, was on minimal ventilator support, and he had a
cough reflex, and had minimal secretions. The pt was extubated
without incident and maintained good oxygenation. A bedside
video EEG was initiated. The pt eventually became more alert
and oriented throughout the day. As the pt became more awake,
we were able to talk to him more, and he admited to taking his
Xanax and Trileptal in excess, reportedly 10mg yesterday. The
pt did well in the ICU and was transferred to the floor where he
was stable and his xanax was reinitated per psychiatry recs. He
was discharged with plan to f/u with [**Hospital1 **] Counseling and his
PCP. [**Name10 (NameIs) **] father will be in charge of administering his [**Name10 (NameIs) 96263**] and
helping him taper his dose downward from 10mg/day.
# Alcohol/benzodiazepine withdrawal
The pt had no signs of withdrawl initially, but he was started
on a CIWA and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] score at the time of admission. Later in
the evening the pt became increasingly agitated, requiring
several dose of lorazepam. Once in the late evening he became
acutely agitated and was threatening nurses. A Code Purple was
called and the pt was sedated with haldol and ativan. He
received 30mg of valium during the following day and his [**Last Name (NamePattern4) **]
was restarted.
#Seizure disorder
Reportedly longstanding. Pt had a bedside EEG here but removed
all of his EEG leads, after a few hours, and the study was
discontinued. The pt was then comfortable throughout the night
without any further incident. The pt was monitored more while
here, and had no further complaints. There was no evidence of
seizure during the hospitalization and his home seizure
medications were continued.
# Substance dependence
Longterm use of alcohol, with recent relapse, and alprazolam.
Would like to try home taper of this meds with his father giving
him appropriate amount. Ammenable to inpt stay if this is not
succesful.
# Anemia
HCT at admission was 43, fell to 36. Baseline 39-40. Normocytic.
Etiology of this unclear as there is no apparent source of
bleeding, T bili is normal- no suggestion of hemolysis. Possible
that one of the meds causes marrow supression. Iron studies
non-specific. Normal folate/b12. The inpatient team defers to
outpt work-up if indicated.
TRANSITIONAL ISSUES
-Patient to start outpt taper of alprazolam, with medication
beign administered by his father.
-Pt will make appointment with [**Hospital1 1680**] Counseling services.
Medications on Admission:
1. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. alprazolam 1 mg Tablet Sig: Two (2) Tablet PO Q6H PRN as
needed for anxiety.
3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Discharge Medications:
1. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. alprazolam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety: Do not exceed 9 mg per day. To be
tapered further by patient.
3. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H:PRN as
needed for pain: Not to exceed [**2186**] mg/day.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H:PRN as needed
for pain.
7. diazepam 10 mg Tablet Sig: One (1) Tablet PO three times a
day for 2 days: Take for a maximum of two days until you are
able to refill your [**Year (4 digits) **] prescription.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure to take care of you during your stay at [**Hospital1 18**].
You were admitted here because you were unresponsive after
taking too much of your Trileptal and [**Hospital1 96263**] at home. Your family
called EMS and you were brought to the hospital. You were
intubated and placed on a ventilator to breath for you. As you
recovered from the overdose, the breathing tube was removed and
you were able to breathe on your own. You became agitated after
experiecing withdrawal from alcohol and Xanax. You were treated
with Valium for this and your Xanax was restarted. The
Psychiatry team was consulted and they helped you to create a
plan for reducing your use of Xanax. Your father will administer
you [**Name (NI) 96263**] while you slowly taper down from 10mg daily. At
discharge, he will give you 9mg each day. You should make a
follow-up appointment with [**Hospital1 **] Counselling; they can help you
continue to taper this medication. You were observed for
additional signs of alcohol or benzodiazepine withdrawal until
[**2197-9-30**] and were stable for discharge to home.
Your medications have been changed as follows:
1. STOP taking alprazolam 10mg daily as needed for anxiety
2. START taking alprazolam 9mg daily as needed for anxiety
3. As you do not have alprazolam at home, take valium 10mg three
times a day as needed until you are able to refill your
prescription from your primary care doctor.
Your other medications were not changed.
Please remember to call [**Hospital1 **] Counseling at the numbers below to
start outpatient counselling.
Followup Instructions:
Please call [**Hospital1 **] Counseling to set up an appointment as soon as
possible.
[**Hospital1 **] Counseling
[**Location (un) 538**]
[**Apartment Address(1) 96264**], [**Location (un) 86**], [**Numeric Identifier 7023**]
[**Telephone/Fax (1) 88923**]
We have made a follow-up appointment with your primary care
doctor:
Thursday [**2197-10-5**]
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital6 **]
Address: [**Apartment Address(1) 25834**], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 19752**]
You may call his office on Monday to request prescription
refills.
Completed by:[**2197-10-2**]
|
[
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"966.3",
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"780.09",
"303.90",
"969.4",
"292.0",
"291.81",
"285.9",
"345.90",
"E950.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11342, 11348
|
6253, 10023
|
325, 350
|
11401, 11401
|
3760, 6230
|
13186, 13846
|
2643, 2673
|
10551, 11319
|
11369, 11380
|
10049, 10528
|
11552, 13163
|
2688, 3741
|
264, 287
|
378, 1709
|
11416, 11528
|
2126, 2255
|
2271, 2627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,730
| 103,365
|
21012+21013
|
Discharge summary
|
report+report
|
Admission Date: [**2166-6-11**] Discharge Date: [**2166-6-14**]
Date of Birth: [**2089-8-17**] Sex: F
Service: MED
CHIEF COMPLAINT: Short of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
Portugese speaking only female treated at [**Hospital6 36598**] with a history of prolonged intubation after sepsis
in [**11/2165**] status post multiple failed extubations,
complicated by laryngeal edema status post tracheostomy
discontinued two months ago. She reports two to three months
of shortness of breath on home O2, two liters nasal cannula.
On [**6-9**], she was acutely short of breath, gasping for air
and admitted to [**Hospital3 **] on [**6-9**]. She had a cough
productive for white sputum; no fevers or hemoptysis.
White blood cell count of 19.6 and no bands. She was
recently started on steroids on [**6-5**]. She was noted to have
inspiratory and expiratory stridor, hypercapnia on admission.
Temperature of 98.5 F.; pulse 101, respiratory rate 20, blood
pressure 118/70; O2 saturation 99 percent on 3.5 liters nasal
cannula and chest x-ray with mild congestive heart failure.
Neck film with normal epiglottis. EKG atrial fibrillation
with right ventricular strain patterns. [**Hospital3 **] course
with ABG at 07:06, 135, 98, 95 percent on 100 percent non
rebreather, placed on BiPAP at 10:04. ABG improved. Since
then, she has been transferred to [**Hospital1 190**] for a repeat bronchoscopy, CT scan of the
neck, possible repeat tracheostomy.
Here she had a bronchoscopy and was found to actually have
tracheal stenosis and since then has had a tracheal stent
placed by Interventional Pulmonary and has done well since.
She is now transferred back to the Medicine floor and now
being transferred back to [**Hospital6 14576**] for further
care.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease.
Diastolic dysfunction.
Multiple admissions for congestive heart failure.
Atrial fibrillation.
Diabetes mellitus.
Hyperlipidemia.
Osteoarthritis of the left knee.
History of pneumonia.
Hemicolectomy for benign mass.
History of laryngeal edema per extubation for bronchoscopies
in the past.
History of granulating wound infection in abdominal wall.
History of a left buttocks decubitus ulcer.
Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy, cholecystectomy, hemorrhoidectomy.
ALLERGIES: Penicillin.
SOCIAL HISTORY: No tobacco or ethanol. She lives in [**Location (un) 38520**], [**Location (un) 3844**]. Home one week prior to admission. At
baseline, she walks with a walker.
HOSPITAL COURSE: CENTRAL AIRWAY OBSTRUCTION: Since she has
been here, she had bronchoscopy and was found to have
tracheal stenosis which was stented without any
complications. The patient tolerated it well. Also, the
patient had a history of hypercapneic respiratory failure /
chronic obstructive pulmonary disease and is a known CO2
retainer from past admissions. Currently she is well
compensated on six liters and was weaned off of her O2.
Given that she is a chronic retainer her best O2 saturation
was to keep between 90 and 93 percent or the low 90s. She was
doing well and she has actually done well and was weaned off
the oxygen and is now having saturation in the low 90s on
room air. Also, her steroid was weaned down per Pulmonary
Team each day by about 25 percent. Further taper at the
discretion of the outside hospital. Continue with Albuterol,
ipratropium; discontinued theophylline given in narrow
therapeutic window. Her hypoxia has actually resolved since.
Given the history of atrial fibrillation, she was restarted
back on her Coumadin with the goal of 2.0 to 2.5 INR to be
adjusted at the outside hospital.
Congestive heart failure: Asymptomatic currently. Obtain
echocardiogram at the outside hospital.
Uncontrolled SVT, coronary artery disease: To continue
Lopressor, Imdur; no aspirin at the time.
Diabetes mellitus: Regular insulin sliding scale and
actually restarted back on her Metformin and her other
diabetic medications; see Page one.
Infectious Disease: Was discontinued off of Levofloxacin.
Psychiatric: Continued on Zoloft, BuSpar and Ativan.
Kept on diabetic diet, NPO. Vitals were stable.
CONDITION ON DISCHARGE: She is discharged to the outside
hospital in stable condition.
DISCHARGE INSTRUCTIONS:
1. Per Interventional Pulmonary, to continue guiafenesin 1200
twice a day.
2. Final recommendation to followup also anemia with outside
hospital for an anemia workup.
FINAL DIAGNOSIS: Tracheal stenosis status post bronchoscopy
and stent placement.
Chronic obstructive pulmonary disease.
Congestive heart failure with known diastolic dysfunction.
Diabetes mellitus.
Hyperlipidemia.
Eventual wound healing left buttocks decubitus ulcer, see
page one for further details.
DISCHARGE MEDICATIONS:
1. Warfarin 6 mg p.o. q day; INR between 2.0 and 2.5 goal.
2. Albuterol.
3. Ipratropium.
4. Sertraline.
5. Isosorbide 30 q day.
6. Metoprolol 25 twice a day.
7. Pantoprazole 40 q day.
8. Docusate 100 twice a day.
9. Magnesium hydroxide p.r.n.
10. Buspirone 10 mg p.o. twice a day.
11. Acetaminophen p.r.n.
12. Furosemide 40 mg p.o. twice a day.
13. Metformin 500 mg p.o. three times a day.
14. Replignoride 2 mg, one tablet p.o. twice a day with
meals only.
15. Insulin sliding scale to continue.
16. Dexamethasone now at 3 mg intravenously q. 12; taper
at the discretion of the outside hospital team.
17. Guaifenesin 1200 mg tablet q 12 hours per
Interventional Pulmonary.
The patient has a central line which is going to stay in
place and removed at the discretion of the outside hospital.
FOLLOW UP: Interventional Pulmonary will call the patient
for further followup. Also other followup with primary care
physician in [**Name Initial (PRE) **] week or two once discharged from the outside
hospital.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 2019**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2166-6-14**] 16:18:48
T: [**2166-6-14**] 18:25:30
Job#: [**Job Number 55832**]
Admission Date: [**2166-6-11**] Discharge Date: [**2166-6-14**]
Date of Birth: [**2089-8-17**] Sex: F
Service: MED
ADDENDUM TO PREVIOUS DISCHARGE SUMMARY: Patient was seen by
attending and discharged back to the old hospital.
DISCHARGE INSTRUCTIONS: As noted on . The change was
transfer to the old hospital.
FINAL DIAGNOSES: Tracheal stenosis, status post bronch and
stent placement.
Chronic obstructive pulmonary disease.
Congestive heart failure.
Known diastolic dysfunction.
Diabetes.
Hyperlipidemia.
Ventral wound healing.
Left buttock decubitus ulcer.
RECOMMENDATIONS FOR FOLLOWUP: Has an appointment to be seen
in [**Hospital 197**] Clinic on Monday, after followup appointment to
see primary care. Or if not going to [**Hospital 197**] Clinic, needs
to actually have INR levels checked since now back on
Coumadin, to keep a therapeutic INR of 2 - 3. The patient
was transferred back to old hospital.
DISCHARGE MEDICATIONS ON TRANSFER BACK: Warfarin 6 mg p.o.
q.day
Albuterol/ipratropium/sertraline p.o. q.day
Isosorbide mononitrate 30 mg p.o. q.day.
Metoprolol 25 mg tablet p.o. b.i.d.
Pantoprazole 40 mg q.day.
Docusate 100 mg p.o. b.i.d.
Magnesium hydroxide q.6 hours as needed for constipation.
Risperidone 10 mg p.o. b.i.d.
Acetaminophen p.r.n.
Furosemide 40 mg p.o. b.i.d.
Metformin 500 mg p.o. t.i.d.
Repaglinide 2 mg tablets p.o. b.i.d. with meals
Insulin, sliding scale, to continue per physician's
discretion.
Dexamethasone I.V. q.12 hours, currently at 3 mg, per
pulmonary being weaned down at 25 percent taper at discretion
of outside hospital.
Guaifenesin was added, 1200 mg b.i.d.
For anemia, attending recommended outpatient followup or
followup at the outside hospital.
Followup as discussed above. IP will contact patient for
followup later on.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 20070**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2166-6-14**] 15:16:33
T: [**2166-6-14**] 17:21:32
Job#: [**Job Number 55833**]
|
[
"427.0",
"428.0",
"428.30",
"519.1",
"496",
"427.31",
"250.00",
"707.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.99",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
4863, 5706
|
2612, 4243
|
4549, 4840
|
6420, 6481
|
6499, 8196
|
5718, 6395
|
154, 172
|
201, 1808
|
1831, 2412
|
2429, 2594
|
4268, 4332
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,446
| 163,911
|
52251+59412
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-11-10**] Discharge Date: [**2111-11-14**]
Service: CORONARY
HISTORY OF THE PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is an
88-year-old female with a history of inferior myocardial
infarction several years ago and a non-Q-wave myocardial
infarction in [**Month (only) **] of this year with a maximum troponin
of 22.4. She was scheduled for an elective cardiac
catheterization on [**2111-11-25**], but presented to the
emergency room on [**2111-11-10**] with the chief
complaint of chest heaviness. The chest pain occurred at
rest and it was rated at a 6 out of 10 in severity. The
patient had noted onset of the pain at 10 p.m. the night
prior to admission. There was no associated nausea,
vomiting, diaphoresis, palpitations, or shortness of breath.
On the morning of admission, the patient told her visiting
nurse about her chest pain, which inhibited her ability to
sleep all night and the EMS was called. She received
sublingual nitroglycerine, which reduced the severity of her
pain to 2 out of 10. In the emergency room the EKG showed
T-wave inversion in the lateral distribution, which were
unchanged from prior EKG. Initial CK was 27. Troponin was
less than 0.3. She had persistent chest pain despite one
inch Nitropaste, aspirin, Morphine, Maalox, and Lopressor.
She was sent to the cardiac catheterization laboratory.
Catheterization revealed 100% occlusion of the right coronary
artery, diffuse disease of the left main, 80% lesion of the
proximal LAD, diffuse disease of the S1, 80% mid LAD
stenosis, 80% stenosis of diagonal 1, normal distal LAD,
normal diagonal 2, diffuse disease of the proximal and the
distal left circumflex, 80% stenosis of the obtuse marginal 1
and normal appearing obtuse marginal 2. The lesion at OM1
was successfully stented. However, she continued to have
similar chest discomfort with no difference in quality after
stenting. Therefore, an intraaortic balloon pump was placed
for symptomatic control. She also was started on ReoPro
drip, Heparin drip, nitroglycerin drip, and Plavix. She was
admitted to the Coronary Intensive Care Unit for further
management.
PAST MEDICAL HISTORY:
1. Coronary artery disease. Stress test in [**2110-9-14**],
resulted in anginal symptoms with ischemic EKG changes. The
sestamibi image showed a reversible perfusion defect in
inferior distribution. Status post myocardial infarction in
[**2111-8-15**]. Echocardiogram in [**2111-9-14**] showed
posterior and apical hypokinesis/akinesis. Ejection fraction
40 to 45%. There is 2+ mitral regurgitation and trace aortic
insufficiency.
2. Paroxysmal atrial fibrillation.
3. Hypertension.
4. Hypercompression.
5. Macular degenerative and she is legally blind.
6. History of rheumatoid arthritis.
7. Anxiety.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o.q.d.
2. Zocor 10 mg p.o.q.d.
3. Fosamax 10 mg p.o.q.d.
3. Senna 1 tablet p.o.q.h.s.
4. Lopressor 37 mg p.o.t.i.d.
5. Remeron 7.5 mg p.o.q.h.s.
6. Atacand 4 mg p.o.q.d.
7. Protonix 40 mg p.o.q.d.
8. Calcium 500 mg p.o.t.i.d.
9. Multivitamin, one tablet p.o.q.d.
ALLERGIES: There was no known drug allergies.
SOCIAL HISTORY: The patient has no alcohol, no tobacco use
in the last four years.
FAMILY HISTORY: Both parents had coronary artery disease in
their 70s. The patient's son had two myocardial infarctions
in his 40s.
PHYSICAL EXAMINATION: Examination revealed the following on
admission: VITAL SIGNS: Afebrile, blood pressure 115/62,
heart rate 65. She was breathing at 16 with an oxygen
saturation of 97% on two liters by nasal cannula. GENERAL:
The patient was lying flat in bed in no acute distress. She
was complaining of 4 out of 10 midepigastric discomfort.
HEENT: Normocephalic, atraumatic. Extraocular muscles are
intact. Pupils surgical, minimally reactive, sclerae
anicteric. CHEST: Chest was clear to auscultation
bilaterally. CARDIAC: Normal S1 and S2, regular rate and
rhythm, no S3, no S4. There is a 2 out of 6 holosystolic
apical murmur. ABDOMEN: Soft, nontender, nondistended,
positive bowel sounds. EXTREMITIES: Right groin site
dressing soaked with blood, secondary to bleeding from suture
sites, but no actual bleeding from the insertion site of the
intraaortic balloon pump. There were palpable pulses
bilaterally in the lower and upper extremities. There is
evidence of good perfusion.
LABORATORY DATA: Laboratory studies revealed the following:
White blood cells 8.4, hematocrit 35.9, platelet count
236,000, MCV 85, differential 73% neutrophils, 20%
lymphocytes, PTT 24.1, INR 1.0. Chem 7 revealed the sodium
of 140, potassium 3.9, chloride 102, bicarbonate 29, BUN 16,
creatinine 0.7, glucose 120, CK 23, troponin less than 0.3,
calcium 10.3, magnesium 1.7, phosphate 3.5. ABGs revealed
the pH of 7.41, pCO2 of 43, pO2 81. Chest x-ray revealed no
CHF or infiltrate. The EKG upon arrival at 6:45 a.m. on
[**2111-11-10**] showed normal sinus rhythm at a rate of 60, normal
intervals, leftward axis, Q wave in leads 3, AVF, and a small
Q wave in lead 2. There is 1-mm ST elevation in lead V3, T-
wave inversion in leads V4 to V6. Post catheterization EKG
showed normal sinus rhythm at a rate of 60 with T wave
inversions in leads 2, 3, AVF, V2 through V5, Q waves in
leads 2 and 3 were no longer present. There was .5-mm ST
elevation in lead V3.
IMPRESSION: This is an 88-year-old woman with history of
asymptomatic inferior myocardial infarction and a non-Q-wave
myocardial infarction in [**2111-8-15**] as well as
documented left ventricular systolic dysfunction, who
presents with chest tightness at rest, beginning the night
prior to admission and lasting through the night. The EKG
was unchanged from previous.
Given the patient's persistent pain she was brought to the
Cardiac Catheterization Laboratory and underwent stent to
OM1. She had mild pain after the procedure, so an
intraaortic balloon pump was placed. She was admitted to the
Coronary Intensive Care Unit.
HOSPITAL COURSE: (by system)
#1. CARDIOVASCULAR:
A. Coronary artery disease. The patient ruled out for
myocardial infarction by enzymes and the EKG was without
change. Chest pain resolved shortly after her arrival in the
Coronary Intensive Care Unit. It was felt that her chest
pain was atypical and most likely not of cardiac origin. The
nitroglycerin drip was weaned with no return of her symptoms.
We continued the aspirin, beta blocker and Ace inhibitor.
She was started on Plavix in the Cardiac Catheterization
Laboratory and this was continued. The day after admission
the intraaortic balloon pump was discontinued as it did not
appear to be providing significant hemodynamic or symptomatic
benefit.
B. Ventricular function. Filling pressures were measured at
right heart catheterization. Right atrial pressure was 3.
Right ventricular pressure was 26/6. Pulmonary artery
pressure was 24/13 with a mean of 17 and the mean wedge was
8. The aortic pressure was 155/77 with a MAP of 108.
Cardiac output was 3.8. Index was 2.6, as measured by the
Fick Method. As indicated above, the intraaortic balloon
pump did not appear to be providing hemodynamic benefit as
shown by the pressure tracings. Therefore, it was felt that
this intervention could be safely discontinued after
twenty-four hours.
C. Rate and rhythm. There were no acute issues. Telemetry
was with normal sinus rhythm and there were no alarms.
#2. HEMATOLOGY: The patient had continued bleeding from the
sutures where her groin catheter was inserted. She received
one unit of blood for hematocrit of 26 and the
post-transfusion hematocrit was 30. After the balloon pump
had been discontinued, Heparin was stopped. ReaPro was
stopped at 11 p.m. the evening of her cardiac
catheterization. After the removal of the intraaortic
balloon pump there was good hemostasis at the groin. No
further transfusions were necessary.
#3. PULMONARY: The patient's post balloon pump placement
x-ray showed evidence of partial right upper lobe collapse.
Room air saturation was 97%. We provided incentive
spirometry and chest physical therapy for lung re-expansion.
#4. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient had a
cardiac diet and electrolytes were replaced as needed.
#5. PYSCHIATRY: The patient is on Remeron and per her
family's report, she is much brighter since she began this
medication.
The patient had one episode of disorientation and confusion
on the night of [**2111-11-11**]. She was easily redirected and
well oriented the next morning. It was felt that the patient
had an episode of "sundowning."
#6. PROPHYLAXIS: Heparin prophylaxis was provided while the
patient was not ambulating and Protonix was continued.
CODE STATUS: The patient has previously expressed her wishes
to be DNR/DNI. However, this was revisited and the patient
stated that she was willing to have life support if necessary
on a temporary basis. Therefore, her code status was changed
to full code.
Disposition and medication information will be provided in
the discharge addendum.
DIAGNOSES:
1. Atypical chest pain.
2. Rule out myocardial infarction.
3. Cardiac catheterization with stent to the OM1 with
diffuse three-vessel disease.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2111-11-12**] 10:31
T: [**2111-11-12**] 10:28
JOB#: [**Job Number **]
Name: [**Known lastname **], [**Known firstname 634**] Unit No: [**Numeric Identifier 17661**]
Admission Date: [**2111-11-10**] Discharge Date: [**2111-11-13**]
Date of Birth: [**2023-11-14**] Sex: F
Service: Medicine
HOSPITAL COURSE: Mrs. [**Known lastname 3693**] had an unremarkable course
after her stent placement. On [**2111-11-12**], it was
noted that the patient had symptoms of frequency and urgency
on urination. A urinalysis was sent which revealed multiple
white blood cells and red blood cells on high powered field
with multiple bacteria. The patient was started on oral
ciprofloxacin 500 mg twice a day and Pyridium 200 mg three
times a day for three days. She showed marked improvement
overnight.
DISPOSITION: The patient was accepted at [**Hospital 17662**]
Rehabilitation and was discharge to rehabilitation on
[**2111-11-13**].
DISCHARGE MEDICATIONS:
Protonix 40 mg p.o.q.d.
Enteric coated aspirin 325 mg p.o.q.d.
Colace 100 mg p.o.b.i.d.
Senna one p.o.q.h.s.
Milk of Magnesia 30 cc p.o.q.6h.p.r.n.
Remeron 7.5 mg p.o.q.h.s.
Tylenol 650 mg p.o.q.4-6h.p.r.n.
Tums 500 mg p.o.t.i.d.
Plavix 75 mg p.o.q.d. times 28 days.
Zocor 10 mg p.o.q.d.
Atacand 4 mg p.o.q.d.
Fosamax 10 mg p.o.q.d., give with eight ounces of water.
Multivitamins one p.o.q.d.
Ciprofloxacin 500 mg p.o.b.i.d. times three days.
Pyridium 200 mg p.o.t.i.d. times three days.
Lopressor 37.5 mg p.o.t.i.d.
[**Name6 (MD) **] [**Last Name (NamePattern4) 8732**], M.D. [**MD Number(1) 8733**]
Dictated By:[**Name8 (MD) 6624**]
MEDQUIST36
D: [**2111-11-13**] 14:17
T: [**2111-11-19**] 09:35
JOB#: [**Job Number **]
|
[
"414.01",
"512.8",
"410.72",
"998.11",
"599.0",
"786.59",
"272.0",
"401.9",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"88.56",
"37.23",
"37.61",
"36.06",
"37.64",
"99.20"
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icd9pcs
|
[
[
[]
]
] |
3280, 3398
|
10412, 11174
|
2837, 3178
|
9770, 10389
|
3421, 6011
|
2195, 2811
|
3195, 3263
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,215
| 192,478
|
38783
|
Discharge summary
|
report
|
Admission Date: [**2176-3-8**] Discharge Date: [**2176-3-14**]
Date of Birth: [**2091-10-20**] Sex: M
Service: NEUROLOGY
Allergies:
Lamisil
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Left sided weakness/ICH
Major Surgical or Invasive Procedure:
NG Tube placement and removal
History of Present Illness:
84 yo man with PMH of HTN, DM, macular degeneration and gout and
CAD (s/p 3 MIs and 3 stents) p/w AMS.
The family did not know about the events. He apparently pressed
the life button and was taken to NorthEast ([**Hospital1 **]) Hosp at
9:48 am with: "LEFT?? sided weakness and garbled speech per
report. RIGHT facial droop. 144/ 63. FSG 255. NOt following
commands. Sleepy bur responding to verbal commands. Yawning".
EKG with ventricular pacing. CT CNS w/o contrast showed per
report a 5 cm IPH temporal bleed on the LEFTwith vasogenic
edema. Received PHT 1 g iv. Transferred to [**Hospital1 18**]. COags: normal.
Chem: Na 131, glucose 169, creat 1.3, BUN 37. BNP 1824. Cxr:
normal with PPM.
Past Medical History:
CAD s/p MI (hx of inferior MI and apical akinesis) and CABG
s/p 3 stents around 1 year ago. He was on plavix and
ASA (the later stopped 1 week ago).
Pacemaker (unknown reason)
CHF (? last EF of 25%)
Major depressive d/o
Syncope
Esophageal stricture
Social History:
No toxic habits. IADLs.
Family History:
Not obtained
Physical Exam:
ED EXAMINATION
Temp 98.5F, BP 140/99, MAP 109, 65 bpm (paced), SO2 100% in RA
with 16 RR. NO Abnormal respiratory pattern. Not on ventilator
GSC: 9
Gen: Lying in bed, unresponsive.
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, nontender, non-distended. No masses or megalies.
Percussion within normal limits. +BS.
Ext: no edema, no DVT data. Pulses ++ and symmetric.
Neurologic examination:
No meningismus. No photophobia.
MS:
Drowsy. Responsive to sternal rub. Not to verbal command.
CN: Brain stem reflexes : preserved Corneals + bl. Pupils
anisocoric: 2 to 1.5 LEFT (surgical) and 3 to 2 on the RIGHT.
Looks when stimulated to RIGTH and LEFT. No EOM paresis. No gaze
deviation. No bobbing or Robbing. No nystagmus.
Gag +.
Motor:
He does withdraw to pain with all limbs symmetrically.
Tone: DTR: 3+ throughout. Patellas: postsurgical. Toes:
amputated
on the RIGHT foot. Cavus deformity in LEFT foot with toes
upgping
at rest
ATTENDING EXAM IN ICU
VS: BP 145/52 P 65 R 15 O2 97%
Neuro exam: drowsy, follows commands to squeeze with the left
hand, does not open eyes to verbal or noxious, moans but does
not
say any words
CN: does not blink to threat or track (legally blind, but has
some sight at baseline), perrla, right lower facial droop
Motor: flaccid right arm, decreased tone of the right leg, 0/5
strength of the right arm, right leg [**1-16**]
normal tone of the left arm and leg, left arm is [**4-15**], and left
leg is [**2-16**].
Sensory: right arm has extensor posturing to noxious, right leg
withdraws to noxious, left arm and leg withdraw to noxious.
Reflexes: 2+ biceps, 1+ knees bilaterally
right foot amputation at mid foot, left toe is mute
Coord: unable to assess
Pertinent Results:
[**2176-3-8**] 01:15PM WBC-7.0 RBC-2.90* HGB-8.6* HCT-27.1* MCV-94
MCH-29.6 MCHC-31.7 RDW-14.3
[**2176-3-8**] 01:15PM NEUTS-87.9* LYMPHS-7.5* MONOS-3.0 EOS-1.4
BASOS-0.2
[**2176-3-8**] 01:15PM CALCIUM-9.6 PHOSPHATE-4.3 MAGNESIUM-2.1
[**2176-3-8**] 05:46PM GLUCOSE-133* UREA N-39* CREAT-1.3*
SODIUM-131* POTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-25 ANION GAP-13
[**2176-3-8**] 01:15PM cTropnT-0.02*
[**2176-3-9**] 03:50AM BLOOD CK-MB-4 cTropnT-0.05*
[**2176-3-12**] 05:05AM BLOOD CK-MB-4 cTropnT-0.05*
[**2176-3-10**] 10:34AM BLOOD %HbA1c-7.0* eAG-154*
[**2176-3-11**] 06:00AM BLOOD Triglyc-66 HDL-71 CHOL/HD-1.7 LDLcalc-34
Time Taken Not Noted Log-In Date/Time: [**2176-3-8**] 5:47 pm
MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2176-3-11**]**
MRSA SCREEN (Final [**2176-3-11**]): No MRSA isolated.
CT HEAD W/O CONTRAST Study Date of [**2176-3-9**] 11:35 AM
IMPRESSION:
1. Essentially unchanged size of the large left temporal
intraparenchymal
hemorrhage.
2. Interval mild increase of peri-hemorrhagic edema, with
increase of the
effacement of the left lateral ventricle. A new 2-mm rightward
shift of
midline structures.
3. No new hemorrhage or developing hydrocephalus.
Final Attending Comment:
The wedge shaped configuration of the hypodensity in the left
parietal lobe suggests that this represents hemorrhagic
transformation of an infarct.
CHEST (PORTABLE AP) Study Date of [**2176-3-12**] 3:31 PM
FINDINGS: In comparison with study of [**3-10**], the Dobbhoff tube
and pacemaker device remains in place. Moderate enlargement of
the cardiac silhouette is again seen without evidence of
vascular congestion. No evidence of acute focal pneumonia.
Brief Hospital Course:
Mr. [**Known lastname 85751**] is an 84 yo man with a history of hypertension,
Diabetes, and CAD who presented with altered mental status and
hemorrhage on outside CT scan.
NEURO/Ischemic Stroke:
The patient was initially treated with dilantin for seizure
prophylaxis. While his CT scan was notable for a large left
sided parenchymal hemorrhage, repeat CT scans revealed this to
be an infarction of the left MCA with subsequent hemorrhagic
conversion. Dilantin was discontinued. The patinet was
restarted started on plavix given his cardiac stents and for
continued stroke prevention. Although his stroke was likely a
thrombolic event, no additional anticoagulation was considered
in light of his hemorrhage.
The patient's mental status improved significantly. He was
initially fluently aphasic with relatively [**Name2 (NI) 86107**]
speech but retained comprehension. He has right sided weakness
which vastly improved. Of note, the patient was legally blind at
baseline and did not blink to threat on exam. While his speech
output has improved significantly, he continues to have a
prominant fluent aphasia with dysarthria (also possibly related
to his edentulous state). He was cleared by speech and swallow
for a diet of nectar thickened fluids and pureed solids. He
should continue to undergo speech and physical therapy. He is
enrolled in a dysphagia study at [**Hospital1 18**] under the direction of
[**First Name8 (NamePattern2) 2530**] [**Doctor Last Name **]. He is scheduled for follow up in the neurology
clinic in [**Month (only) 547**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
CADIOVASCUALR/Hypertension/Hyperlipidemia:
The patient's antihypertensive regimen was initially held in the
setting is his stroke. He was initially agressively hydrated
and in the setting of his diminished EF, he did require
subsequent diuresis with good results. His home antihypertensive
regimen was reinstituted over the course of his hospitalization
with the exception of his Nifedipine as the patient could not
take continuous release pills (all medications were to be
crushable). He was started, instead, on diltiazem at 30mg TID
and this can be uptitrated as needed for blood pressure control.
Alternatively, the patient may resume Nifedipine 60mg daily
once he is able to take whole pills.
The patient's lipid panel was within goal range and no changes
where made.
The patient was monitored on telemetry and no events were seen.
There was a noted increase in troponin without EKG changes and
relatively flat CK. This was felt to be related to
subendocardial ischemia and renal failure. No interventions
where made.
ENDOCRINE/Diabetes:
The patient's A1C was 7.0. During this hospitalization, he was
treated with sliding scale insulin and routinely required
upwards of 10units of insulin daily. Standing insulin was not
started in the setting of his transition from tube feeds to oral
diet but oral hypoglycemic agents should be considered.
PULM/Tachypnea:
The patient was noted to be tachypneic with rales. Chest x-ray
was without evidence of infection or effusion, no frank CHF. It
was felt his tachypnea was related to volume overload and he was
diureased with good effect.
RENAL/Chronic renal failure:
The patient has a history of renal insufficency with a baseline
creatinine of 1.3. There was acute elevation to 1.5 in the
setting of diuresis but this improved to his baseline prior to
discharge.
CODE STATUS: DNI. NOT DNR.
Medications on Admission:
Plavix 75 mg daily
lisinopril 20mg
Zocor 40mg
Metoprolol 12.5mg [**Hospital1 **]
Allopurinol 100mg
Lasix 20mg daily
Iron 325mg [**Hospital1 **]
vitamin D 400U
MVI
Protonix 40mg
Nifedipine 60mg daily
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clopidogrel 75 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. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a
day.
9. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.
10. Multivitamin Oral
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Left MCA infarct with hemorrhagic conversion
Hypertension
Diabetes, type II
Chronic Renal Insufficiency
Hyperlipidemia
Blindness
Discharge Condition:
The patinet was hemodynamically stable. Neuro exam was notable
for blindness (no blink to threat), fluent aphasia with frequent
neologisms and impaired but some retained comprehension, slight
right facial droop but good strength in extremities (exam
limited by ability to follow commands).
Discharge Instructions:
You were admitted for evaluation of altered mental status. You
were found to have a stroke affecting the left side of your
brain and this stroke had bled.
You are being discharged to a rehabilitation facility for
further treatment.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD
Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2176-5-1**] 2:00
Completed by:[**2176-3-14**]
|
[
"272.4",
"V49.73",
"784.3",
"412",
"274.9",
"585.9",
"434.01",
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"348.5",
"784.51",
"276.6",
"342.00",
"V45.81",
"276.0",
"369.4",
"593.9",
"403.90",
"428.0",
"V45.82",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9516, 9559
|
5003, 8494
|
301, 332
|
9732, 10025
|
3297, 4980
|
10307, 10520
|
1387, 1401
|
8743, 9493
|
9580, 9711
|
8520, 8720
|
10049, 10284
|
1416, 1949
|
238, 263
|
360, 1057
|
1973, 3278
|
1079, 1330
|
1346, 1371
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,801
| 195,220
|
46239
|
Discharge summary
|
report
|
Admission Date: [**2102-3-31**] Discharge Date: [**2102-4-5**]
Date of Birth: [**2036-7-29**] Sex: F
Service: FENARD INTENSIVE CARE UNIT
HISTORY OF PRESENT ILLNESS: A 65-year-old female recently
admitted to [**Hospital1 69**] on
[**2-28**] for workup of hemoptysis which revealed
metastatic cancer likely ovarian to lung, who is returning
status post asystolic arrest. The patient eventually did
well status post VATS pleurodesis and was discharged to
rehabilitation on [**3-28**].
She was reportedly doing well until rehabilitation until the
am of admission when she had a witnessed aspiration event and
then was subsequently asystolic, hypotensive, cyanotic.
Patient was intubated and given atropine and Epinephrine with
CPR, and sent to [**Location (un) **]Hospital. She was noticed at
the [**Location (un) **]to have no pupillary reflexes,
vestibulo-ocular reflexes or spontaneous respirations at the
time. Estimated down time was approximately 5-10 minutes.
PAST MEDICAL HISTORY:
1. Ovarian cancer.
2. Bipolar disease.
3. Diverticular disease.
4. Recent admission for liver hematoma.
5. Hyponatremia.
6. Pneumonia.
7. Right sided hydropneumothorax.
8. Staph bacteremia as in previous discharge summary.
ALLERGIES: Prolixin, Stelazine, Flonase, Ativan, Dimetapp,
Trilafon, lithium, aspirin, Persantine, Relafen, ranitidine,
Prilosec, Procardia, strawberries, Sudafed, tofu, and all
eyedrops.
MEDICATIONS ON TRANSFER:
1. Tylenol.
2. Miconazole.
3. Risperdal.
4. Loxapine.
5. Flagyl.
6. Colace.
7. Senna.
8. Dulcolax.
PHYSICAL EXAMINATION ON ADMISSION: The patient was
intubated, unresponsive. Blood pressure was 112/86, pulse
was 85, sinus rhythm, 99% on the ventilator. Pupils were 2
mm, minimally reactive. There is no dolls eyes. No
corneals. There is some spontaneous pupillary oscillation.
Decerebrate posturing was elicited to painful stimuli, no
deep tendon reflexes.
HOSPITAL COURSE: Patient remained afebrile and
hemodynamically stable on the ventilator. Was eventually
able to be changed over from AC to pressure support and noted
to take good tidal volumes with pressure support of [**5-15**].
Bronchoscopy was done to rule out a foreign body which was
negative. Her Clostridium difficile toxin came back negative
and Flagyl was discontinued.
Neurology consultation was obtained for continued myoclonus
and for evidence of hippus. Broncoscopy was done to rule out
foreign body. Myoclonus was treated with benzodiazepines and
she was given a Dilantin load.
MRI was obtained which was negative for mass and showed
possible enhancement of the caudae nuclei on preliminary read
thought consistent with anoxic encephalopathy.
Her myoclonic jerking subsided and stabilized. It was
initially thought secondary to propofol. Propofol was weaned
and discontinued. After discussion with the daughter, there
was some evidence of a gag and evidence of spontaneous
respirations and she was extubated.
On the following [**Last Name (LF) 766**], [**First Name3 (LF) **] electroencephalogram was obtained
which did show some seizure activity. Per Neurology, this
was actually a sign of poor prognosis, but after further
discussion with the daughter, we elected to treat with the
Dilantin load and see if there is any improvement in
response.
The next day an electroencephalogram still showed some
seizure activity after Dilantin load, but at this point given
no significant response of the patient to any stimuli, no
signs of any neurologic recovery, it was elected to make her
comfort measures only, and she expired the next day with her
daughter at the bedside.
DISCHARGE DIAGNOSES:
1. Asystolic arrest secondary to aspiration.
2. Asystolic encephalopathy.
3. Metastatic ovarian cancer.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Name8 (MD) 13286**]
MEDQUIST36
D: [**2102-4-26**] 17:38
T: [**2102-4-27**] 09:21
JOB#: [**Job Number 98304**]
|
[
"276.2",
"933.1",
"197.0",
"427.5",
"008.45",
"780.39",
"348.3",
"295.70",
"183.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"96.04",
"96.71",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
3647, 3969
|
1946, 3626
|
183, 986
|
1599, 1928
|
1455, 1584
|
1008, 1430
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,359
| 144,898
|
47069
|
Discharge summary
|
report
|
Admission Date: [**2123-9-28**] Discharge Date: [**2123-10-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
I&D of rectal abscess
History of Present Illness:
86 y.o. DM, HTN, HLD, BPH, who was in his usual state of health
until 4-5 months prior to admission when the patient noted that
he began having more difficulty having bowel movements. He This
persisted and he became increasingly constipated. He stated
that he had not had a bowel movement for 1 and a half weeks
until the day prior to admission, when he had diarrheal like
movement [**12-22**] suppository use. He said that he has not had any
abdominal pain, no nausea or vomiting, or sense of bloating. he
said he woke up on the day of admission feeling "chipper". His
wife reports that he had been confused the few days prior to
admission and that he had a low grade temperature at home during
this period. She called EMS and was brought to the ED.
.
Of note the patient had a 13 pound weight loss over the
preceding 4 months. He had been trying to lose weight for 1
year to no effect, but then suddenly started losing weight. He
also had cystoscopy 2 weeks prior for BPH symptoms and was
started on flomax. He also states that he has not been taking
his diabetes medications. He denies decreased appetite,
dysphagia, odynophagia, recent illness, fevers, URI symtpoms,
SOB, cough, chest pain, abd pain, fatigue, weakness.
.
On presentation to ED, VS: T 101, BP 118/73, HR 104, 100% on 2L.
On exam pt was A&Ox1 and tachycardic. FS 253. While he was in
ED spiked temp 105 rectally. Pt received Tylenol 650mg PR. His
pressures subsquently dropped to systolics in the 80's. He
received 2L NS, but BP dropped as low as 77/48, HR 90. A right
subclavian CVL was palced and levophed was started. His
mentation improved w/ IVFs. He was also given vanc, flagyl and
zosyn. Pt mental status responded to fluids and was A&Ox3. His
blood pressures normalized on pressors and at the time of
transfer VS were BP 131/64, HR 86, RR 18, 100% 2L NC, T 98.8.
Past Medical History:
1. Type 2 Diabetes c/b neuropathy and retinopathy
2. Hypertension
3. Hyperlipidemia
4. BPH
5. Anemia
6. S/P bilateral cataract surgery
7. Glaucoma
8. Chronic Kidney Disease
9. Rectal Polyp excised in [**2108**] - hyperplastic polyp
Social History:
Social History: lives with wife of 62 years. Retired, but used
to own his own plastics company.
- Tobacco: 25 pack year history, quit over 50 years ago
- Alcohol: glass of scotch a night
- Illicits: none
Family History:
Did not assess
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pale conjuctiva
Neck: supple, JVP elevated 5cm, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**12-26**] soft systolic
murmur heard best at the left lower sternal border
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema 0
On discharge [**2123-10-5**]
+ drained perirectal abscess with wick in place
Neuro: AO x 3, but occasionally inattentive with some
impairment in short term memory.
Pertinent Results:
Imaging:
ECHO [**2123-9-29**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Physiologic mitral
regurgitation is seen (within normal limits). There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mildly thickened aortic valve leaflets with trace
aortic regurgitation. Mild pulmonary artery systolic
hypertension. Dilated ascending aorta. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function. Increased PCWP.
[**2123-9-28**]:
CT CHEST/ABD/PELVIS
1. Suggestion of a posterior anorectal lesion, possibly a
submucosal mass or intramural abscess, with large amount of gas
and fecal loading throughout the colon upstream to this lesion.
Recommend clinical correlation with direct visualization.
2. Normal appendix.
3. Cholelithiasis without evidence of cholecystitis.
4. Incompletely characterized hypodensity within segment VI of
the liver,
possibly a cyst. Consider ultrasound for further evaluation.
[**2123-9-28**]
CXR:
PORTABLE AP UPRIGHT VIEW OF THE CHEST: Cardiac silhouette is top
normal in
size. The aorta is mildly unfolded with vascular calcifications
demonstrated at the aortic knob. Pulmonary vascularity is not
engorged. The hilar contours are unremarkable. Except for
minimal atelectasis at the left lung base, the lungs are clear
without focal consolidation. No pleural effusion or large
pneumothorax is demonstrated. No acute osseous findings are
seen. There is mild gaseous distention of colonic loops of
bowel in the upper abdomen.
IMPRESSION: Minimal left basilar atelectasis. No acute
cardiopulmonary
abnormality. Mild gaseous distention of the colonic loops of
bowel in the
upper abdomen.
Fluid culture (abscess)
FLUID CULTURE (Final [**2123-10-5**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
DR. [**First Name (STitle) **] #[**Numeric Identifier 16672**] REQUESTED SENSITIVITIES ON GRAM
NEGATIVE RODS
[**2123-10-2**].
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
__________________________________________________
KLEBSIELLA PNEUMONIAE
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 4 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Blood culture:
[**2123-9-28**] 6:10 pm BLOOD CULTURE SETS #2.
**FINAL REPORT [**2123-10-2**]**
Blood Culture, Routine (Final [**2123-10-2**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP.
CLINDAMYCIN MIC <= 0.12 MCG/ML.
Sensitivity testing performed by Sensititre.
VANCOMYCIN Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| STREPTOCOCCUS ANGINOSUS
(MILLERI) GROU
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PENICILLIN G---------- 0.12 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1.0 S
Brief Hospital Course:
Assessment and Plan: 86 y.o. DM, HTN, HLD, BPH who presented to
the ED with AMS and fevers diagnosed with sepsis and perirectal
abscess.
.
# Sepsis/peri-rectal abscess: His BP stabilized on pressors and
AMS responded to 3L of NS. His U/A and CXR were negative for
any signs of infection so a CT abdomen/pelvis was done to look
for other sources of infection. A peri-rectal hypodense region
was seen that was concerning for mass or abscess. Pt has had
recent change in bowel habits over the past 4-5 months with no
associated pain. He has also had recent weight loss, although
seemingly intentional. On day 1 of admission with positivve
blood cultures and rising white count, it seemmed more likely
that the hypodense region was an abscess. Surgery re-evaluated
the area and brought the patient to the OR for drainage.
Abscess drained about 40cc of foul smelling fluid. A drain was
placed, but it repeatedly fell out so surgery paccked the wound.
Fluid culture from the abscess showed that the polymicrobial,
but klebsiella and E coli were identified. Blood cultures grew
out klebsiella and alpha hemolytic strep. ID saw the patient,
and advised treatment with two weeks of zosyn, from [**Date range (1) 99797**],
with f/u with ID on [**10-12**] to reassess drained abscess site.
On day of discharge, site of drained abscess appeared clean with
mild serous drainage, not purulent. [**Last Name (un) **] inserted.
# Delirium: Patient with mild delirium through much of the
hospital stay. Per family, occasionally impulsive, and he
demonstrated some deficits in short and long term memory. THe
delirium was felt to be from infection and prolonged hospital
stay. It improved over the course of his stay, and he was aox3
on the day of discharge.
# Hyperlipidemia: Cont statin
# BPH: Patient with long standing difficulty in voiding, and
has had recent urological evaluation done by Dr [**Last Name (STitle) **], [**Hospital1 18**]
urology. He had urinary retention while in the hospital despite
continuation of flomax. He had a foley inserted, but he failed
TWO voiding trials. Would reattempt next voiding trial on
[**2124-10-6**]. If he fails voiding trial, please reinsert foley
catheter, and move up his existing appointment with Dr [**Last Name (STitle) **]. He
was continued on the tamsulosin which was started a couple of
weeks prior to this admission.
# Hypertension: Initially bp meds held when he was septic. His
home blood pressure medicines include lisinopril 30 mg and hctz
25 mg daily. He has been on lisinopril 10 mg a day, and hctz
should be restarted. Please uptitrate lisinopril to 30 mg if
his blood pressure tolerates it. He has stage I CKD with some
mild proteinuria, thus necessitating use of ACE-I.
# Diabetes Mellitus: Patient takes levemir at home, but was put
on lantus in the hospital. Please resume home dose of levemir
at rehab.
# Somnolence: Patient took at nap on [**10-5**] afternoon, and was
very difficult to arouse from the nap. He had a full battery of
blood tests and vitals were normal at that time. He awoke about
1/2 hour later, completely oriented and with a normal neurologic
exam. Per the family, he is typically not so difficult to
arouse. We advised him to avoid napping during the day and to
sleep at night so as to maintain a normal sleep/wake cycle.
Medications on Admission:
HYDROCHLOROTHIAZIDE - 25 mg Tablet 1 tab daily
INSULIN DETEMIR [LEVEMIR] 100 unit/mL Solution - 12 u qh
LISINOPRIL - 30 mg Tablet 1 tab PO BID
METFORMIN - 1,000 mg Tablet 1 tab PO BID
SIMVASTATIN - 20 mg Tab Daily
SITAGLIPTIN [JANUVIA] - 100 mg 1 tab Daily
TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Sust. Release 24 hr Daily
TIMOLOL - Dosage uncertain
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 g Intravenous Q8H (every 8 hours): Continue until he is
evalutated by ID at [**Hospital1 18**] next week. .
6. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. insulin detemir 100 unit/mL Solution Sig: 12 units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 55**]
Discharge Diagnosis:
1. Peri-rectal Abscess
2. Sepsis
3. Urinary retention
4. Diabetes Mellitus
5. Hypertension
6. MIld delirium
Discharge Condition:
AO x 3, mildly delirious, but improving. Decreased safety
awareness when participating with PT.
Discharge Instructions:
1. Please continue zosyn until patient is seen at [**Hospital 18**] [**Hospital **]
clinic on [**10-12**].
THe infectious disease doctors [**Name5 (PTitle) **] determine if antibiotic
duration needs to be extended beyond that date.
2. Please place wick at site of drained abscess daily.
3. Please check cbc/chem7 on [**10-11**] and fax them to the [**Hospital 18**]
[**Hospital 4898**] clinic (outpatient antibiotic therapy clinic - infectious
disease) at [**Telephone/Fax (1) 1419**]
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2123-10-12**] at 3:10 PM [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES- UROLOGY
When: MONDAY [**2123-12-13**] at 9:45 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC--NEPHROLOGY
When: MONDAY [**2124-2-28**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"276.1",
"V45.61",
"362.01",
"600.01",
"038.49",
"995.91",
"250.62",
"455.3",
"566",
"365.9",
"560.1",
"250.52",
"348.30",
"276.2",
"780.09",
"403.90",
"357.2",
"038.0",
"272.4",
"285.9",
"585.1",
"V45.89",
"041.4",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.81",
"38.91",
"38.93",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12790, 12856
|
8275, 11609
|
285, 308
|
13013, 13111
|
3453, 8252
|
13647, 14564
|
2700, 2716
|
12013, 12767
|
12877, 12992
|
11635, 11990
|
13135, 13624
|
2731, 3434
|
224, 247
|
336, 2198
|
2220, 2462
|
2494, 2684
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,254
| 129,946
|
37395
|
Discharge summary
|
report
|
Admission Date: [**2169-1-10**] Discharge Date: [**2169-1-13**]
Date of Birth: [**2095-8-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Codeine / Prednisone / Lipitor / Vytorin
/ Tricor
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
LAD Perforation
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
73 yr old male w/ COPD, HTN, Hypercholesterolemia, h/o silent [**Hospital **]
transferred from [**Hospital1 **] after LAD perforation. The patient
had one month of intermittent left sided chest pain, right arm
pain and SOB. He underwent a persantine thallium stress test
that was abnormal showing large anteroseptal, apical, and
inferoseptal, inferoapical and anteroapical partially reversible
defects (EF 45%). He was scheduled for outpatient cath at
[**Hospital1 **] on [**1-11**] (Wednesday), but presented Monday ([**1-9**]) with
chest pain to the [**Hospital1 **] ED. He did not have any acute ECG
changes and CE were negative x1. The patient underwent cath
today that showed 100% occulsion of the LAD. He received 325mg
ASA, 600mg plavix in the cath lab. A stent was deployed and
resulted in perforation of the mid LAD. The stent balloon was
inflated in LAD and was transferred for coated stent placment.
The bivalirudin was turned off after his perforation. He
remained hemodynamically stable with BP 160/70, sinus 70s, sat
92-96% 2L NC.
.
On arrive here to the cath lab the balloon was deflated. There
was severe dissection of mid LAD after the first diag and just
proximal to mid LAD stent with reduced flow in the mid LAD stent
and a possible dissection distal to the stent edge with a
significant step down from the LAD stent into the LAD with
reduced outflow. There was no evidence of continued
perforation. During the case the LAD stent thrombosed, but chest
pain improved. The distal LAD filled with collaterals. There
was also a small pericardial effusion seen and ECHO was
performed that did not show RV collapse. A pericardiocentesis
was attempted, but no fluid was able to be drained. The LAD
remained completely occluded and it was decided to manage him
medical overnight.
.
On arrive the patient had complaints of sharp pain across his
chest that was not similar to his anginal pain. He rated the
pain [**2169-3-15**]. He otherwise had no other complaints.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Social History:
Retired, lives with his wife. Worked in construction
-Tobacco history: quit 30 yrs ago, [**2-12**] ppd x20yrs
-ETOH: occasional
-Illicit drugs: denied
Family History:
Mother with MI at 86
Physical Exam:
T 35.4 ??????C (95.8 ??????F)
HR: 75 (67 - 75) bpm
BP: 144/79(105) {122/67(88) - 144/79(105)} mmHg
RR: 19 (14 - 19) insp/min
SpO2: 95% 4L NC
Heart rhythm: SR (Sinus Rhythm)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with flat JVP
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. CTA anteriorly, no
crackles, wheezes or rhonchi.
ABDOMEN: dressing of ther epigastric region, 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 doppler PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2169-1-10**]
WBC-11.8* RBC-4.75 Hgb-14.0 Hct-41.2 Plt Ct-180
Neuts-86.8* Lymphs-7.5* Monos-3.9 Eos-1.4 Baso-0.5
PT-14.6* PTT-29.2 INR(PT)-1.3*
Glucose-119* UreaN-12 Creat-0.9 Na-141 K-4.7 Cl-108 HCO3-22
AnGap-16
ALT-20 AST-32 LD(LDH)-215 CK(CPK)-229* AlkPhos-81 Amylase-57
TotBili-0.5
[**2169-1-10**] 09:14PM CK-MB-17* MB Indx-7.4* cTropnT-0.36*
[**2169-1-11**] 04:15AM CK-MB-25* MB Indx-8.6* cTropnT-1.21*
[**2169-1-11**] 11:55AM CK-MB-18* MB Indx-7.2*
[**2169-1-13**]
WBC-7.3 RBC-4.25* Hgb-12.6* Hct-36.7* Plt Ct-161
Glucose-96 UreaN-19 Creat-0.9 Na-143 K-3.8 Cl-107 HCO3-26
AnGap-14
ECG:
sinus rhythm at 75. normal axis. PR prolongated (234). 1mm ST
elevations in V2-V4. T wave inversions V1-V4.
ECHO [**1-10**]:
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade but views are limited and
technically suboptimal. Right ventricular systolic function
appears globally preserved. Left ventricular systolic function
appears impaired but is not fully visualized.
ECHO [**1-11**]: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with mid to distal septal
hypokinesis/akinesis, mid to distal anterior hypokinesis and
apical akinesis. Overall left ventricular systolic function is
mildly depressed (LVEF= 45 %). Right ventricular chamber size is
normal with overall preserved free wall motion (cannot exclude
apical free wall hypokinesis). The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). The left ventricular inflow pattern suggests
impaired relaxation. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
.
labs at discharge:
[**2169-1-13**] 06:30AM BLOOD WBC-7.3 RBC-4.25* Hgb-12.6* Hct-36.7*
MCV-86 MCH-29.7 MCHC-34.4 RDW-13.9 Plt Ct-161
[**2169-1-13**] 06:30AM BLOOD Glucose-96 UreaN-19 Creat-0.9 Na-143
K-3.8 Cl-107 HCO3-26 AnGap-14
Brief Hospital Course:
73 yr old male w/ COPD, HTN, Hypercholesterolemia, h/o silent [**Hospital **]
transferred from [**Hospital1 **] after LAD perforation found to have
dissection of the mid LAD, thrombosis of his stent and small
pericardial effusion.
.
# NSTEMI/LAD perforation/dissection/ pericardial effusion: Pt
with 100% occlusion of his LAD. Attempted intervention was
complicated by mid LAD dissection at OSH. Upon transfer for
covered stent placement he subsequently thrombosed his stent. No
further attempts at PCI were made given the perforation. Given
that pt noted that his CP is not similar to his angina, and more
consistent with pericardial irritation. Small effusion was
noted on ECHO w/o tamponade. Pericardiocentesis was attempted,
but no fluid was removed. Pt was hemodynamically stable and CP.
Repeat ECHO was performed the following day with no worsening of
his pericardial effusion. Cardiac enzymes were trended, with
peak CK 292 and CKMB of 25, felt to be a mild NSTEMI. He was
monitored further with no change in his status and discharged
home. Given the thrombosis of his LAD did not appear to be new,
with sufficient collateral development, supported by low cardiac
enzymes, no further acute intervention seemed appropriate. CABG
was considered due to the pericardial effusion, but as the
effusion was stable, it was not pursued.
Statin was increased to Crestor 40mg. ACEI, and ASA were held
initially given concern for possible effusion/tamponade. Pt was
not on a beta blocker on admission because of his poorly
controlled COPD, this was also not started at discharge for the
same reason. Telemetry was unremarkable.
# COPD: Pt breathing comfortably. Reports home O2 use only at
night. He was maintained on his home medications and nebulizers
and was able to ambulate comfortably without oxygen.
# Atrial fibrillation/Atrial Flutter: Noted in CCU about 24
hours after LAD thrombosis. Pt was asymptomatic and rate
controlled with diltiazem. He spontaneously converted to NSR
within 24 hours and did not reoccur. Pt was not discharged home
on Diltiazem. Aspirin was increased to 325 mg.
Medications on Admission:
Spiriva 18mcg one daily
Clonazapam 1mg hs
Lisinopril 5mg daily
Theophylline 200mg ER one tab [**Hospital1 **]
Nexium 40mg daily
Crestor 10mg daily
percocet prn
Combivent nebs q 4 hours during day
Symbicort 4.5 mg 2 puffs in am.
Performist inhaler 160/4.5 neb at hs
Aspirin 81 mg daily
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) puff Inhalation once a day.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as
needed for shortness of breath.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Theophylline 200 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Perforomist 20 mcg/2 mL Solution for Nebulization Sig: One
(1) vial Inhalation at bedtime.
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total of 3 doses: Call 911 if you
still have chest pain after 3 doses of nitroglycerin. .
Disp:*25 tabllets* Refills:*2*
12. Outpatient Lab Work
Please check Chem 7 on Monday [**1-16**] and call results to Dr.
[**Last Name (STitle) 1295**] at [**Telephone/Fax (1) 6256**]
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Hypertension
Chronic obstructive Pulmonary Disease
Coronary Artery Disease
Atrial Fibrillation
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had a cardiac catheterization at [**Hospital6 **]
and a stent placed that perforated the left anterior artery. You
were transferred here and we were not able to open the artery.
You are getting blood flow through smaller collateral arteries
and have been stable. You also had some atrial
fibrillation/atrial flutter which is an irregular heart rhythm.
This is now gone but may come back in the future.
.
Medication changes:
1. Stop taking Advil, take Tylenol instead.
2. Increase your aspirin to 325 mg
3. Increase your Crestor to 40 mg daily
4. Take nitroglycerin for chest pain
Followup Instructions:
Cardiology:
[**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 1295**], MD Phone: [**Telephone/Fax (1) 6256**] Please keep your appt on
[**2169-1-19**].
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] N Phone: [**Telephone/Fax (1) 8036**] Date/time: Please keep any
previously scheduled appts.
Completed by:[**2169-1-13**]
|
[
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"998.2",
"272.0",
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"414.01",
"401.9",
"998.12",
"420.90",
"E879.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
10241, 10247
|
6324, 8430
|
349, 375
|
10425, 10425
|
4149, 6070
|
11179, 11532
|
3074, 3096
|
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|
10268, 10404
|
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|
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3111, 4130
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|
294, 311
|
6089, 6301
|
403, 2888
|
10439, 10546
|
2905, 3057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,098
| 147,256
|
52949
|
Discharge summary
|
report
|
Admission Date: [**2141-3-3**] Discharge Date: [**2141-3-19**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
transferred from Medicine [**Hospital1 **] to the MICU w/ hypercarbic
respiratory failure
Major Surgical or Invasive Procedure:
EGD
Intubation for resp failure
History of Present Illness:
82-year-old man from [**Country 4812**] w/ asthma, HTN, CRI was
transferred from OSH 2 days ago w/ PNA and acute renal failure.
He initially presented to his PCP [**Last Name (NamePattern4) **] [**3-3**] w/ 2 days of fever,
productive cough, and increasing dyspnea w/ wheezing. His PCP
referred him to the [**Location (un) 620**] ED at that time. At [**Location (un) 620**], he was
afebrile w/ Tm 98.8 and O2 sat 96% RA. CXR demonstrated R hilar
consolidation, prompting treatment w/ levaquin, prednisone 60mg,
and albuterol/atrovent. He was then transferred to the [**Hospital1 18**]
for ongoing eval of acute renal failure.
.
At the [**Hospital1 18**], dx of PNA was confirmed w/ CXR w/ elevated WBC and
10% bandemia. Baseline ABG was 7.4/27/102/17. He was treated
w/ levaquin, and workup of his renal failure was begun w/ UA,
urine sediment exam, etc. This AM, he was found to be agitated
on rounds, refusing to take medications and disoriented per his
family. This prompted ABG, which was 7.07/63/63. MICU team was
called for eval. The pt was intubated for resp support and
treated w/ lasix 20mg IV. He is now transferred to the MICU for
ongoing care.
Past Medical History:
PAST MEDICAL HISTORY:
1. Asthma: FEV1 1.27L, seen in pulm clinic in past ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
2. Hypertension
3. Chronic renal insufficiency: baseline creat 2-2.5
4. h/o MRSA bacteremia & septic cavernous sinus thrombosis:
[**2136**], s/p 8 wk vanco
9. h/o giardia [**2136**]
10. h/o GIB: lower bleed [**1-19**] colonic diverticulosis per c-scope
[**2137-3-18**]
11. colonic adenoma, status post right colectomy in [**2130**]
12. CVA: [**2128-9-17**] with residual left lower extremity
weakness
13. Bilat carotid artery stenosis: 60-69% on right and 40-59% on
left
Social History:
lives w/ his wife and other family members. Originally from
[**Country 4812**], now lives in US for > 25 years. Never smoked. No
alcohol, IVDU, cocaine use.
Physical Exam:
VS: Tm 98.0, HR 86, BP 152/66, RR 22, O2 sat 98% on vent
Gen: elderly man lying flat in bed w/ ETT in place, sedated,
responsive to sternal rub w/ grimace and reaching
HEENT: PERRL, OP clear w/ MMM, no JVD
CV: reg s1/s2, no s3/s4/m/r
Lungs: scattered exp wheezes throughout, no crackles anteriorly
Abd: obese, +BS, soft, NT, ND
Extrem: warm, 1+ DP pulses, no edema
Pertinent Results:
MICRO:
======
SPUTUM x2 ([**2141-3-4**]): >25 PMNs and >10 epithelial cells/100X
field. Gram stain indicates extensive contamination with upper
respiratory secretions. Bacterial culture results are invalid
.
UA ([**2141-3-4**]): 3+ protein, large bld, no dysmorphic RBC
.
BCX ([**2141-3-5**]): pending
.
Radiology:
=========
CXR ([**2141-3-5**]): increased R hilar consolidation, no pulm edema
.
Renal U/S ([**2141-3-7**]):
.
FINDINGS: The right kidney measures 8.6 cm. The left kidney
measures 8.8 cm. Multiple 1-cm cysts present in the right
kidney, and one 1.5-cm cyst is present within the left kidney.
.
IMPRESSION: No evidence for hydronephrosis.
.
Chest CT [**2141-3-7**]:
.
Multifocal pulmonary consolidation--in the apex of right upper
lobe, anterior segment of the left upper lobe, right middle lobe
extending to the hilus, apicoposterior segment of the left upper
lobe, and right lower lobe--has rapidly progressed since [**3-3**] and 19
.
1) Multifocal pneumonia continues to worsen. No airway
obstruction except for bronchomalacia, involving at least the
bronchus intermedius. Full assessment would require expiratory
imaging without positive pressure ventilation.
.
2) Likely anemia.
.
Labs:
====
[**2141-3-5**] WBC-21.6 Hgb-10.6* Hct-33.1* Plt Ct-315
[**2141-3-5**] Neuts-79.4* Bands-0 Lymphs-15.7* Monos-4.2 Eos-0.1
Baso-0.5
[**2141-3-5**] PT-15.0* PTT-33.1 INR(PT)-1.3
[**2141-3-5**] Glucose-190* UreaN-61* Creat-4.7* Na-135 K-4.5 Cl-101
HCO3-14*
.
Cardiac Enzymes:
===============
[**2141-3-5**] 08:00AM BLOOD CK(CPK)-386
[**2141-3-3**] 09:41PM BLOOD CK-MB-9 cTropnT-0.03
[**2141-3-4**] 10:20AM BLOOD CK-MB-12* MB Indx-3.7 cTropnT-0.07
[**2141-3-4**] 09:46PM BLOOD Lactate-2.4
[**2141-3-5**] 08:36AM BLOOD Lactate-5.2
[**2141-3-5**] 05:51PM BLOOD Lactate-1.2
[**2141-3-6**] 02:22AM BLOOD Lactate-1.4
.
Urinalysis:
==========
[**2141-3-4**] URINE Blood-LGE Nitrite-NEG Protein-500 Glucose-TR
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-115*
WBC-0 Bacteri-NONE Yeast-NONE Epi-0
.
[**2141-3-4**] Urine Blood-LG Nitrite-NEG Protein-100 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-21-50*
WBC-0-2 Bacteri-FEW
.
[**2141-3-5**] URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-75*
WBC-2
.
[**2141-3-6**] URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG. [**2-19**]
Granular casts
.
[**2141-3-3**] Iron Studies: calTIBC-244* VitB12-504 Folate-14.4
Ferritn-210 TRF-188, Iron 10
.
[**2141-3-3**] TotProt-7.3 Calcium-8.0* Phos-2.3*# Mg-1.4* Iron-10*
.
[**2141-3-5**] [**Doctor First Name **]-NEGATIVE
[**2141-3-3**] PEP-NO SPECIFI
[**2141-3-7**] ANCA-PND
[**2141-3-5**] GM1 TRIAD ANTIBODIES-PND
Brief Hospital Course:
82-yo-man w/ asthma, HTN, CRI, glucose intolerance, transferred
to [**Hospital1 18**] on [**3-3**] w/ RML PNA and acute renal failure. He was
transferred to MICU for mgmt of respiratory failure on [**2141-3-6**].
His pulmonary status was optimized on ventilatory support and he
was successfully extubated on [**3-10**].
.
1. Respiratory failure: He was emergently intubated for
hypercarbic resp failure, most likely from respiratory muscle
fatigue secondary to compensation for metabolic acidosis in the
setting of acute renal failure and sepsis. He was found to have
a MRSA pneumonia and was treated with a course of vancomycin. He
was also empirically treated for CAP with levofloxacin. He was
extubated on [**2141-3-10**] and transferred to the
.
2. PNA/sepsis: Initially had elevated WBC w/ bandemia on
admission, resp distress, and evolving R hilar consolidation on
CXR despite levaquin treatment. This raised concern for PNA
that was resistant to levaquin therapy. Therefore started on
broad abx with Vanco/Zosyn/Levo. In addition, elevated lactate
was concerning for hyoperfusion in the setting of sepsis,
although this may be confounded by acidosis in the setting of
renal failure. Improved respiratory status on antibiotics, with
improved productive secretions. Blood cultures remained sterile
and sputum cultures were unrevealing. Legionella antigen
negative. Given continued improvement, zosyn was discontinued on
[**3-7**]. Follow-up chest CT demonstrated no obstructive lesion-
non-obstructive mass vs infiltrate. He completed 14 day course
of vanco/levo. F/U CT scan will need to be done as outpatient to
evaluate resolution of opacity.
.
3. Asthma: Felt to contribute to respiratory distress, and
exacerbated by PNA.
Treated with solumedrol initially and weaned successfully to
prednisone taper. B-blocker discontinued given exacerbation of
his reactive airway disease. He remained respiratory stable with
standing albuterol and atrovent inhalers
.
4. Acute on Chronic Renal Failure: Prior renal U/S on [**1-23**]
showed small kidneys with cystic disease consistent with chronic
renal failure. Recent baseline creat has been high 2s; creat 3.9
at [**Location (un) 620**] ED and 3.7 here on admission. BUN also higher than
baseline, but maintained good urine output throughout. Prerenal
state felt unlikely with FeNA 3%. +Blood on UA at [**Location (un) 620**] but no
flank pain to suggest stone. Had large blood and 3+ protein by
dipstick. No dysmorphic RBC/casts seen on microscopy so less
likely glomerulonephritis, but could be FSBS. Spot urine
protein/Cr shows sig proteinuria 4.5. Likely FSGS [**1-19**] HTN. Renal
consulted and felt CKD [**1-19**] hypertensive nephropathy with acute
exacerbation. Urine eos negative. ASO titers negative. Anti-GBM,
[**Doctor First Name **], ANCA , SPEP/UPEP negative suggesting against alternative
etiology. Per renal, no need for biopsy at this time. His
creatinine was 3.2 at time of discharge.
.
5. HTN: controlled with norvasc, tamsulosin and metoprolol as
outpt.
- held metoprolol with exacerbation of asthma but tolerated
later in hospital course. We continued isordil. We started
clonidine and hydralazine.
.
6. Anemia: baseline HCT 38-42, now 30 on this admit w/ guaiac
positive stool. Iron studies c/w iron deficiency. He had an
EGD that showed gastritis. He will need outpatient colonoscopy.
We treated his iron deficient anemia with iron 325 mg PO TID
.
7. NSTEMI: CK-MB peak at 22. Likely some demand ischemia from
tachycardia and infection. ECHO w/o wall motion abnormality.
.
8. Diarrhea: Felt to be cdiff. Treated with flagyl x10 day
course for empiric coverage.
Medications on Admission:
atenolol 25 daily
lipitor 5 daily
norvasc 10 daily
Flovent 33 mcg 2 puff [**Hospital1 **]
flonase 2 sprays daily
serevent 1 puff [**Hospital1 **]
albut MDI prn
Flomax 1 tab daily
protonix 40 daily
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
1 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Lipitor 10 mg Tablet Sig: 0.5 Tablet PO once a day.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Please give only if patient has not had a bowel
movement in 24 hours.
Disp:*qs ML(s)* Refills:*2*
11. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
12. Prednisone 10 mg Tablet Sig: 1-3 Tablets PO once a day:
Please take 3 pills per day (all at once) until [**2141-3-21**], then 2
pills per day until [**2141-3-24**], then one pill per day until [**2141-3-29**].
Disp:*20 Tablet(s)* Refills:*0*
13. Inhalers
continue albuterol, serevent, flovent as you were taking at home
14. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal once a week: Place new patch every Saturday.
Disp:*4 patches* Refills:*0*
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Gastritis
Asthma
MRSA pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr.[**Name (NI) 5049**] office within the next few days. He
will let you know whether you need to come in to the office to
see him or a nurse and will also let you know if you need to
have your blood checked. He will discuss whether you need
continued injections for the blood.
Followup Instructions:
Call [**Hospital **] clinic at [**Telephone/Fax (1) 543**] for follow up
You need to follow up with [**Hospital 2793**] clinic for your kidney disease,
call ([**Telephone/Fax (1) 773**] for an appointment within 1 month. They will
set up the Epo injections
You should follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks.
You need to have a colonoscopy and repeat endoscopy within 1
months with GI. They will contact you, but here is the number in
case [**Telephone/Fax (1) 109148**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
|
[
"493.92",
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"V09.0",
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"584.9",
"599.7",
"038.9",
"276.2",
"703.8",
"428.0",
"414.8",
"280.9",
"535.50",
"287.5",
"280.0",
"110.1",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.72",
"38.91",
"86.27",
"38.93",
"96.04",
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
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11424, 11482
|
5536, 9177
|
310, 344
|
11558, 11567
|
2761, 4229
|
11908, 12477
|
9424, 11401
|
11503, 11537
|
9203, 9401
|
11591, 11885
|
2372, 2742
|
4246, 5513
|
181, 272
|
372, 1541
|
1585, 2180
|
2196, 2357
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,932
| 134,552
|
38930
|
Discharge summary
|
report
|
Admission Date: [**2151-4-1**] Discharge Date: [**2151-4-5**]
Date of Birth: [**2080-6-26**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Ace Inhibitors
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
70 yo gentleman with CAD and PVD, s/p recent angioplasty sent
from [**Hospital 582**] [**Hospital 620**] Rehab, presumably for hypoxia and
hypertension. Upon presentation, he was confused and unable to
answer further questions, but denied any dyspnea, chest pain,
nausea, vomiting.
In the [**Name (NI) 620**] [**Name (NI) **], pt started on Nitro gtt for
hypertension/edema, given ASA, Lasix 80 and transferred to
[**Hospital1 18**]. In the [**Hospital1 18**] ED, vital signs were initially: 60 130/70 24
90. Pt continued on nitro gtt, given CTX & levoflox.
REVIEW OF SYSTEMS:
Endorsed Cough, lightheadedness, regular diet
No fevers, chills, weight loss, diaphoresis, headache, visual
changes, sore throat, chest pain, shortness of breath, nausea,
vomiting, abdominal pain, constipation, diarrhea, melena, easy
bruising, dysuria, skin changes, pruritis.
Past Medical History:
Dementia
CAD s/p CABG [**2150-10-12**], BMS Left circumflex [**1-6**]
PVD s/p CEA x4; s/p common femoral endarterectomy with patch
angioplasty, left iliac stent and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] embolectomy of the
left iliac artery @ [**Location (un) 620**]
ESRD with Renal stenosis: [**Location (un) **] Dialysis, Dr. [**Last Name (STitle) **] T/Th/S
Hypertension
Depression
GERD
Hyperlipidemia
Hypothyroidism
COPD
Social History:
He smoked 40+ pack years and quit in [**2140**]. He drinks occasional
alcohol. He is married with 4 children. He is a retired computer
repair person.
Family History:
FAMILY HISTORY: Notable for history of coronary artery disease.
Physical Exam:
Admission exam:
VS: 57 157/55 14 93% NRB
GEN: Somnolent, arousable but confused.
SKIN: No rashes or skin changes noted
HEENT: JVP difficult to appreciate, No LAD, bilateral carotid
bruits
CHEST: Crackles bilaterally, R>L. L tunnelled HD line in place
CARDIAC: S1 & S2 regular with a systolic murmur
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES: no peripheral edema, warm without cyanosis, 1+ DP
NEUROLOGIC: Arousable, not oriented to time or event. CN II-XII
grossly intact.
At time of discharge, the patient was alert and oriented to
person, place, and time.
Pertinent Results:
[**2151-4-4**] 06:55AM BLOOD WBC-6.8 RBC-3.86* Hgb-11.0* Hct-36.1*
MCV-94 MCH-28.4 MCHC-30.4* RDW-18.1* Plt Ct-327
[**2151-4-3**] 08:05AM BLOOD WBC-7.0 RBC-3.35* Hgb-10.1* Hct-32.2*
MCV-96 MCH-30.2 MCHC-31.5 RDW-18.6* Plt Ct-372
[**2151-4-2**] 05:23AM BLOOD WBC-6.8 RBC-3.44* Hgb-10.1* Hct-32.2*
MCV-94 MCH-29.5 MCHC-31.4 RDW-18.5* Plt Ct-303
[**2151-4-2**] 03:59AM BLOOD WBC-7.4 RBC-3.1* Hgb-8.8* Hct-31.0*
MCV-94.6 MCH-28.2 MCHC-30.0* RDW-18.6* Plt Ct-320
[**2151-4-1**] 04:01AM BLOOD WBC-12.7* RBC-3.05* Hgb-9.1* Hct-29.1*
MCV-96 MCH-29.9 MCHC-31.3 RDW-18.8* Plt Ct-336
[**2151-4-1**] 04:01AM BLOOD Neuts-89.3* Lymphs-6.7* Monos-3.2 Eos-0.5
Baso-0.3
[**2151-4-4**] 06:55AM BLOOD Plt Ct-327
[**2151-4-3**] 08:05AM BLOOD Plt Ct-372
[**2151-4-4**] 06:55AM BLOOD Glucose-85 UreaN-31* Creat-4.7*# Na-138
K-4.9 Cl-91* HCO3-34* AnGap-18
[**2151-4-3**] 07:40AM BLOOD Glucose-121* UreaN-54* Creat-6.6*# Na-138
K-4.2 Cl-91* HCO3-30 AnGap-21*
[**2151-4-2**] 05:23AM BLOOD Glucose-78 UreaN-27* Creat-4.2*# Na-139
K-3.8 Cl-93* HCO3-34* AnGap-16
[**2151-4-1**] 04:01AM BLOOD Glucose-102* UreaN-36* Creat-5.9* Na-137
K-5.1 Cl-93* HCO3-31 AnGap-18
[**2151-4-4**] 12:35PM BLOOD CK(CPK)-18*
[**2151-4-1**] 05:55PM BLOOD CK(CPK)-25*
[**2151-4-1**] 12:27PM BLOOD CK(CPK)-26*
[**2151-4-1**] 04:01AM BLOOD CK(CPK)-27*
[**2151-4-4**] 12:35PM BLOOD Lipase-88*
[**2151-4-4**] 12:35PM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2151-4-1**] 05:55PM BLOOD CK-MB-NotDone cTropnT-0.39*
[**2151-4-1**] 12:27PM BLOOD CK-MB-NotDone cTropnT-0.38*
[**2151-4-1**] 04:01AM BLOOD cTropnT-0.34*
[**2151-4-1**] 04:01AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 86374**]*
[**2151-4-4**] 12:35PM BLOOD UricAcd-4.6 Cholest-PND
[**2151-4-4**] 06:55AM BLOOD Calcium-10.1 Phos-4.4# Mg-1.9
[**2151-4-3**] 07:40AM BLOOD Calcium-10.1 Phos-6.2*# Mg-2.3
[**2151-4-2**] 05:23AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.2
[**2151-4-4**] 12:35PM BLOOD Triglyc-PND HDL-PND
[**2151-4-4**] 12:35PM BLOOD TSH-PND
[**2151-4-1**] 09:10AM BLOOD Type-ART pO2-51* pCO2-42 pH-7.50*
calTCO2-34* Base XS-7
[**2151-4-1**] 09:10AM BLOOD Lactate-0.9
[**2151-4-1**] 04:41AM BLOOD Lactate-1.0
MICROBIOLOGY:
[**2151-4-1**] 4:11 am BLOOD CULTURE VENIPUNCTURE 1ST SET.
Blood Culture, Routine (Pending):
[**2151-4-1**] 4:40 am BLOOD CULTURE VENIPUNTURE 2ND SEET.
Blood Culture, Routine (Pending):
[**2151-4-1**] 9:42 am MRSA SCREEN Source: Nasal swab. **FINAL
[**2151-4-3**]** MRSA SCREEN (Final [**2151-4-3**]): No MRSA isolated.
[**2151-4-4**] 12:35 pm BLOOD CULTURE Blood Culture, Routine
(Pending):
STUDIES:
ECG [**2151-4-1**] 3:54:48 AM Sinus rhythm with prolonged QTc
interval and prominent U waves. Low QRS voltage in the limb
leads. Consider electrolyte abnormality versus drug effect. No
previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 132 100 474/474 37 6 23
TTE [**2151-4-1**]: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basal to mid inferior
hypokinesia. There is no ventricular septal defect. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
ECG [**2151-4-1**] 3:23:02 PM Sinus bradycardia. Left axis deviation.
Non-specific intraventricular conduction delay. Marked
repolarization abnormalities with prominent U waves. Consider
electrolyte abnormality or drug effect. Compared to the previous
tracing of [**2151-4-1**] multiple abnormalities as noted persist
without major change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 134 100 512/505 21 6 10
ECG [**2151-4-1**] 7:01:52 PM Sinus bradycardia. Compared to the
previous tracing there is no diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
54 160 98 496/485 23 7 13
CXR PA/LAT [**2151-4-1**]: IMPRESSION: PA and lateral chest reviewed in
the absence of prior chest radiographs: Patient has had median
sternotomy and coronary bypass grafting. Heart is not enlarged.
Mild interstitial abnormality could be edema or chronic
interstitial lung disease. Normal cardiomediastinal silhouette.
Small bilateral pleural effusions. Left lower lobe is largely
collapsed. No pneumothorax. A dual-channel left supraclavicular
central venous catheters end in the low SVC and upper right
atrium respectively. No pneumothorax.
Brief Hospital Course:
70 yo M w ESRD on HD who presented from rehab with hypertension
and hypoxia consistent with a decompensated diastolic CHF and
PNA improved back to baseline.
#. Hypoxia: Patient has baseline history COPD, unclear baseline
sats. His CXR was c/w hypervolemia with possibly underlying
PNA. Labs were notable for a leukocytosis and increased BNP. He
was treated for HCAP with a course of Vanc/CTX/Levo and HD was
done with UF for fluid removal with improvement in sats and
decreased oxygen requirement to 3L. Over the course of his
hospitalization, the patient's symptoms improved significantly
to the point of saturating >95% on room air on discharge.
#. Hypertensive Urgency: The patient has a history of
significant hypertension. He was on a nitro gtt on admission.
This was quickly weaned, with SBP 140s but then rising. Home
doses of Clonidine, Amlodipine, Diovan, Labetolol were started
sequentially. All BP meds were maintained at their previous
doses aside from clonidine which was increased to 0.2mg [**Hospital1 **].
#. ESRD: He underwent HD. PhosLo & renagel were continued.
Renagel dose was increased as per the renal consultant team.
Also per the renal team, the patient should be given all his BP
meds except labetalol on days he is going to receive HD.
#. CAD: Significant coronary history with recent CABG & stent,
now with elevated troponin without chest pain or CK elevation
likely [**3-2**] renal failure and demand. Enzymes were trended and
CK remained flat. EKG was repeated and was unchanged. Statin
was continued.
#. PVD: Significant PVD. ASA was continued. The patient was on
a 2 week course of vancomycin prior to his hospitalization for
angioplasty related issues. This was continued in house and he
should receive one final dose with HD on the day after discharge
as arranged by the [**Hospital1 18**] renal fellow.
#. Mild, normocytic anemia. Stable without symptoms or signs of
bleeding. Likely related to renal disease.
#. Depression: Celexa was continued.
#. Dementia: Toward the end of his hospital course, the patient
was at baseline mental status per conversations with his wife
and nursing home.
#. Hypothyroidism: Levothyroxine was continued.
#. GERD: PPI was switched from [**Hospital1 **] to daily.
Medications on Admission:
Cozaar 50mg PO BID
Labetalol 400mg PO BID
Amlodipine 10mg PO daily
Clonidine 0.1mg PO BID
Pravastatin 40mg PO daily
Aspirin 81mg PO daily
Nitropaste PRN
Levothyroxine 100 mcg PO Daily
Acetaminophen 325 mg PO Q4 PRN
Citalopram 40mg PO daily
Trazodone 25mg PO QHS
Renagel strength unknown
Phoslo 667mg PO TIDAC
Sorbitol 15mL Daily
Folic Acid 1mg PO daily
Protonix 40mg PO BID
Bisacodyl 10mg PR Daily: PRN
Senna 2 tabs PO BID
Colace 100mg PO BID
Vanc 1g IV QHD [**3-24**] x2 weeks s/p Angioplasty
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for toe pain for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, headache.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for Constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
12. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three
times a day.
Disp:*180 Tablet(s)* Refills:*2*
13. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
14. Cozaar 50 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
17. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day.
19. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
20. Sorbitol 70 % Solution Sig: Fifteen (15) ml Miscellaneous
once a day.
21. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
22. Vancomycin 1,000 mg Recon Soln Sig: as directed Intravenous
HD for 1 doses: Please provide patient with 1 final dose of
vancomycin with his next HD session with dose as directed by the
[**Hospital1 18**] renal fellow. .
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Decompensated diastolic congestive heart failure
pneumonia
Secondary:
coronary artery disease
end stage renal disease
peripheral arterial disease
chronic obstructive pulmonary disease
Discharge Condition:
Alert and oriented x 3, ambulatory, stable vital signs.
Discharge Instructions:
You were admitted to the hospital with low blood oxygenation
(hypoxia) and high blood pressure (hypertensive urgency).
Laboratory studies were sent, an ultrasound study of your heart
(echocardiogram) was performed, and chest x-rays were taken, and
you were diagnosed with likely decompensated congestive heart
failure related to your end stage renal disease, as well as
possible infection of your lungs (pneumonia). You were treated
with hemodialysis and antibiotics, and your breathing improved
to near 100% on room air.
You also have coronary artery disease, end stage renal disease
on hemodialysis and peripheral arterial disease, all of which
were managed to good effect while you were in the hospital.
The following changes were made to your medications:
1. Please increase clonidine from 0.1mg twice daily to 0.2mg
twice daily.
2. Please increase sevelamer/renagel as directed.
3. You will be given one final dose of vancomycin at your next
dialysis session.
4. You have been getting oxycodone for toe pain. We are giving
you a small script for your home use as needed but you should
discuss further pain medication needs with you previously
prescribing doctor.
Followup Instructions:
Please follow up with your primary care doctor within 1 week.
|
[
"V45.81",
"428.33",
"311",
"403.91",
"496",
"428.0",
"V45.82",
"440.20",
"585.6",
"486",
"285.9",
"440.1",
"530.81",
"272.4",
"294.8",
"244.9",
"440.4",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12158, 12235
|
7332, 9584
|
307, 321
|
12464, 12522
|
2561, 4772
|
13741, 13806
|
1877, 1927
|
10128, 12135
|
12256, 12443
|
9610, 10105
|
12546, 13718
|
1942, 2542
|
4909, 7309
|
928, 1206
|
248, 269
|
349, 909
|
1228, 1678
|
1694, 1845
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,902
| 173,194
|
16991
|
Discharge summary
|
report
|
Admission Date: [**2193-12-17**] Discharge Date: [**2194-1-6**]
Date of Birth: [**2115-3-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2193-12-21**] - Coronary artery bypass grafting to four vessels (Left
internal mammary->Left anterior descending artery, Saphenous
vein graft(SVG)->Diagonal artery, SVG->Obtuse marginal artery,
SVG->Posterior left ventricular artery).
History of Present Illness:
78 year old gentleman with extensive past medical history who
developed recent epigastric discomfort after consuming a large
meal. A nuclear stres test on [**2193-11-27**] revealed evidence of
ischemia. He underwent a cardiac catheterization [**2193-12-16**] which
revealed severe left main and three vessel disease and was thus
transferred to the [**Hospital1 18**] for surgical management.
Past Medical History:
Bilat claudication
Inferior myocardial infarction in [**2174**] complicated by
ventricular fibrillation arrest, anoxic encephalopathy resulting
in residual short-term memory loss and minor speech
impediment, and unsteady gait.
Cath [**5-11**] - 20% LM stenosis, 30% intermedius, 90% stenosis in
retroflexed Lcx s/p 2.5 x 9 S660 stent, 100% occlusion of the
right coronary artery with 3-4+ collaterals in the left
circumflex and left anterior descending
hypercholesterolemia
diet controlled DM
prostate CA treated seven years ago.
Social History:
SH: He smoked 10-15 years for a pack a day and quit 25 years
ago. No alcohol history. He lives with his wife. [**Name (NI) **] has two
grown children. He is an electronic engineer, retired 11 years
ago.
Family History:
FH: His father had a myocardial infarction in his 30s.
Physical Exam:
Admission
VS 67 113/46 68" 59KG
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign, poor dentition
NECK: Supple, no JVD, FROM.
LUNGS: CTA bilaterally.
HEART: RRR, No M/R/G
ABD: Soft, ND/NT/NABS
EXT:warm, well perfused, no bruits, small varicosities, no
peripheral edema. Right radial AV fistula
NEURO: No focal deficits.
Discharge
VS T 98.2 HR 78SR BP 116/47 RR 14 O2sat 98%
Gen NAD
Neuro A&Ox3, no focal deficits
CV RRR, no M/R/G. Sternum stable, incision C/D/I
Pulm Rhonchourous throughout/crackles @ bases Bilat
Abdm soft, NT/+BS. PEG site CDI
Ext warm, no edema, doppler pulses
Pertinent Results:
[**2193-12-17**] 05:10PM PT-15.6* PTT-28.5 INR(PT)-1.4*
[**2193-12-17**] 05:10PM WBC-10.9 RBC-3.73*# HGB-12.7*# HCT-37.8*#
MCV-101* MCH-34.1* MCHC-33.7 RDW-15.6*
[**2193-12-17**] 05:10PM ALT(SGPT)-11 AST(SGOT)-23 LD(LDH)-197 ALK
PHOS-138* AMYLASE-241* TOT BILI-0.3
[**2193-12-17**] 05:10PM GLUCOSE-83 UREA N-31* CREAT-4.9*# SODIUM-139
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-32 ANION GAP-14
[**2194-1-6**] 02:35AM BLOOD WBC-14.2* RBC-2.77* Hgb-9.3* Hct-27.8*
MCV-100* MCH-33.4* MCHC-33.3 RDW-16.9* Plt Ct-275
[**2194-1-6**] 02:35AM BLOOD Plt Ct-275
[**2194-1-4**] 02:02AM BLOOD PT-13.5* PTT-33.7 INR(PT)-1.2*
[**2194-1-6**] 02:35AM BLOOD Glucose-124* UreaN-26* Creat-3.4*# Na-136
K-3.4 Cl-94* HCO3-34* AnGap-11
[**2193-12-21**] ECHO
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.
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets are moderately thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. Mild to moderate ([**1-9**]+) aortic regurgitation is
seen.
The mitral valve leaflets are moderately thickened. Mild to
moderate ([**1-9**]+) mitral regurgitation is seen. There is no
pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results on Mr. [**Known lastname 47790**]
at 4:30pm.
POST-BYPASS:
Normal RV systolic function.
Overall LVEF 45%.
Thoracic aortic contour is intact.
Mild hypokinesis of apical anterior and anteroseptal wall
persist.
Thoracic aortic contour is intact.
Mild to moderate AI and MR.
[**2193-12-18**] Carotid Ultrasound
Bilateral ICA 1-39% stenosis with mild/moderate plaque. Right
vertebral artery occlusion. Normal left vertebral ___.
[**2193-12-19**] CT Scan
1. Cholelithiasis without cholecystitis and a distended
gallbladder.
2. No pancreatitis or pancreatic masses.
3. Extensive coronary artery disease and atherosclerosis of the
abdominal
aorta and abdominal vasculature.
4. Multiple bilateral renal hypodensities, likely cysts but too
small to
characterize.
5. Compression deformity of the L2 vertebral body, age
indeterminate, but
likely chronic.
[**2193-12-18**] Venous study
No available lesser saphenous vein. Small RGSV and LGSV below
the knee.
Brief Hospital Course:
Mr. [**Known lastname 47790**] was admitted to the [**Hospital1 18**] on [**2193-12-17**] for further
management of his coronary artery disease. He was worked-up in
the usual preoperative manner iin cluding a carotid duplex
ultrasound which showed a bilateral internal carotid artery
1-39% stenosis with mild/moderate plaque, a right vertebral
artery occlusion and a normal left vertebral artery. Vein
mapping was performed which showed small bilateral greater
saphenous veins and no lesser saphenous veins. Plavix was
allowed to clear from his system. The renal service was
consulted for assitance with his hemodialysis and he continued
on his schedule. On [**2193-12-21**], Mr. [**Known lastname 47790**] was noted to have a
slight troponin rise and nitroglycerin as well as heperain were
started. As he did have some chest pain with slight ST
elevations, it was decided to take him urgently to the operating
room for revascularization where he underwent coronary artery
bypass grafting to four vessels. Please see operative note for
details. Postoperatively he was taklen to the intensive care
unit for monitoring. Within 24 hours, he awoke neurologically
intact and was extubated. He underwent hemodialysis. The
electrophysiology service interrogated his ICD. On postoperative
day three, Mr. [**Known lastname 47790**] was transferred to the step down unit for
further recovery. He was noted to have difficulty swallowing and
was assessed by speechand swallow, who recommended that he
receive nutrition via feeding tube. He progressed slowly with
physical therapy. On POD6 he was noted to have a rising white
blood cell count and his CXR showed right lower lobe infiltrate,
which was felt to be aspiration PNA. He was started on antibx
and transferred back to the ICU for pulmonary toilet. General
surgewry was consulted and on POD 11 a PEG feeding tube was
placed. He continued to make slow progress and on POD15/5 he was
transferred to rehabilitation at [**Hospital3 **] in
[**Location (un) 1294**]
Medications on Admission:
Lasix 40, Flomax 0.4, Zoloft 100, Renagel 800(3), Nephrocaps,
Hydrocodone 7.5/750 prn, Plavix 75-last dose 12/9, nebulizers
prn, Omeprazole 20, Metoprolol 25 Q AM/50 Q PM, lopid 600(2),
Crestor 20,
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Location (un) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid [**Location (un) **]: One (1) PO BID (2
times a day).
3. Gemfibrozil 600 mg Tablet [**Location (un) **]: One (1) Tablet PO BID (2 times
a day).
4. Sevelamer HCl 800 mg Tablet [**Location (un) **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Clopidogrel 75 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY
(Daily).
6. Sertraline 50 mg Tablet [**Location (un) **]: Two (2) Tablet PO DAILY (Daily).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Location (un) **]: One (1) Cap
PO DAILY (Daily).
8. Rosuvastatin 20 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet [**Location (un) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Location (un) **]: One (1) neb Inhalation Q6H (every 6 hours).
11. Ipratropium Bromide 0.02 % Solution [**Location (un) **]: One (1) neb
Inhalation Q6H (every 6 hours).
12. Fluticasone 110 mcg/Actuation Aerosol [**Location (un) **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: Five (5)
ML PO Q4H (every 4 hours) as needed.
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
16. Prednisone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
17. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
18. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
19. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in
Packet [**Telephone/Fax (3) **]: One (1) Powder in Packet PO TID (3 times a day) for
2 days.
20. Atenolol 25 mg Tablet [**Telephone/Fax (3) **]: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
CAD s/p CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PLV)[**12-19**]
PMH:VF arrest [**2191**]
ESRD on HD
Hyperlipidemia
Pulmonary fibrosis
GERD
PVD
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. Shower and wash incision. Gently pat the wound dry.
Please shower daily. No bathing or swimming for 1 month. Use
sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] @ [**Hospital3 1280**] in 3-4weeks. (Pt
to call [**Telephone/Fax (1) 20259**] for appt)
Please follow-up with Dr. [**First Name (STitle) 1075**] in 2 weeks.
Please follow-up with Dr. [**First Name (STitle) **] in [**2-10**] weeks. [**Telephone/Fax (1) 5835**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2194-1-6**]
|
[
"250.00",
"414.01",
"276.1",
"440.21",
"997.39",
"403.91",
"585.6",
"263.9",
"515",
"272.0",
"507.0",
"784.5",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.95",
"39.61",
"96.6",
"43.11",
"38.93",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9455, 9529
|
5023, 7029
|
331, 571
|
9712, 9721
|
2517, 5000
|
10490, 10923
|
1786, 1842
|
7277, 9432
|
9550, 9691
|
7055, 7254
|
9745, 10467
|
1857, 2498
|
281, 293
|
599, 992
|
1014, 1545
|
1561, 1770
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,835
| 154,348
|
31075
|
Discharge summary
|
report
|
Admission Date: [**2192-7-20**] Discharge Date: [**2192-7-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fever and chills
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and attempted bile duct stent placement
- stent did not stay in place, however.
History of Present Illness:
[**Age over 90 **]M h/o HTN, CRF, CVA, Afib, tx from [**Hospital **] hosp with cbd
stone. Presented with urinary frequency, shaking chills from
[**Last Name (un) **] house 2 nights ago with shakes, urinary urgency. Seen
by PCP with negative [**Name Initial (PRE) **]/A. Then brought to [**Hospital **] hospital,
where urine noted to have small bilirubin in U/A with elevated
serum bilirubin. U/S with CBD stone at OSh, though no report
avialable. Given Levofloxacin and transferred for ERCP.
No abd pain. No n/v/d. Denies any current fever/chills
Past Medical History:
HTN
CRF (baseline unknown)
CHF
Afib
Anemia
glaucoma
CVA
hyperlipidemia
Social History:
Lives in [**Hospital1 **]
Family History:
NC
Physical Exam:
T 98.5, BP 120/84, HR 96, R 19, 96% RA
Gen: chronically ill appearing, in bed, few spontaneous
movements, arouses easily to voice with appropriate verbal
responses. NAD
HEENT: alopecia, MMM, anicteric, OP clear
Neck: cervical wasting, JVP flat
CV: RRR, no MRG
PULM: crackles at left base
Abd: softly distended, BS+, NT
Extrem: no CCE, 2+ DP, PT pulses,
Pertinent Results:
[**2192-7-19**] 11:00PM GLUCOSE-142* UREA N-49* CREAT-2.4* SODIUM-143
POTASSIUM-4.8 CHLORIDE-108 TOTAL CO2-23 ANION GAP-17
.
[**2192-7-19**] 11:00PM WBC-5.9 RBC-3.21* HGB-11.0* HCT-31.7* MCV-99*
MCH-34.3* MCHC-34.8 RDW-17.4*
[**2192-7-19**] 11:00PM NEUTS-77.5* LYMPHS-16.5* MONOS-4.9 EOS-0.9
BASOS-0.1
[**2192-7-19**] 11:00PM PLT COUNT-150
.
[**2192-7-19**] 11:19PM freeCa-1.13
OSH:
Total protein: 4.8
Albumin 0.2
Ca:9.1
bili total:3.6
bili direct 3.2
RUQ U/S:
Sludge filled gallbladder. No common bile duct stones
identified. Moderately dilated common hepatic duct measuring
approximately 14 mm, with common bile duct measuring
approximately 11 mm distally within the pancreatic head.
EKG: irregular, IVCD, Afib
Brief Hospital Course:
[**Age over 90 **]M p/w chills and common hepatic and biliary ductal dilation in
absence of overt stones.
ERCP completed:
Date: Friday, [**2192-7-20**] Endoscopist(s): [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **],
MD
[**First Name8 (NamePattern2) **] [**Last Name (Titles) 39870**], MD
Patient: [**Known firstname 122**] [**Last Name (NamePattern1) 73379**]
Ref.Phys.: [**Name6 (MD) 73380**] [**Name8 (MD) 21386**], M.D.
Assisting Nurse(s)/
[**First Name4 (NamePattern1) 7279**] [**Last Name (NamePattern1) **], RN
Birth Date: [**2097-12-9**] ([**Age over 90 **] years) Instrument: TJF-160Vf
[**Numeric Identifier 73381**] Indications: [**Age over 90 **] year old male with RUQ pain, elevated
LFTs and fever. CBD 14 mm by imaging.
A level 4 consult was performed
Medications: Midazolam 4.5mg iv
Fentanyl 150 micrograms
Phenergan 3.125 mg iv
Glucagon 1.4 mg
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
conscious sedation. The patient was placed in the prone position
and an endoscope was introduced through the mouth and advanced
under direct visualization until the second part of the duodenum
was reached. Careful visualization was performed. The procedure
was not difficult. The quality of the preparation was good. The
patient tolerated the procedure well. There were no
complications.
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was performed
with a sphincterotome using a free-hand technique.
Biliary Tree: Cholangiogram showed dilated CBD to 1.5 cm
with an impacted stone at the ampulla.
Procedures: 1. A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Bleeding was encountered during sphincterotomy.
2. CBD stones and sludge were extracted successfully using a 12
mm balloon.
4. A 5 cm by 10 Fr double pig tail biliary stent was placed
successfully to prevent occlusion due to clots.
5. An epinephrine injection was applied for hemostasis
successfully at the apex of the sphincterotomy.
Impression: 1. Normal major papilla
2. Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique
3. Cholangiogram showed dialated CBD to 1.5 cm.
4. A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire. Bleeding was
encountered during sphincterotomy.
5. CBD stones and sludge were extracted successfully using a 12
mm balloon.
6. A 5 cm by 10 Fr double pig tail biliary stent was placed
successfully to prevent occlusion due to clots.
7. An epinephrine injection was applied for hemostasis
successfully at the apex of the sphincterotomy.
Recommendations: 1. Return to medical service of Dr [**Last Name (STitle) 73380**]
[**Name (STitle) 21386**]
2. NPO tonight, clears in AM [**2192-7-21**] if stable
3. Advance diet on [**2192-7-21**] if tolerating clears and stable
4. IV fluids and analgesia as needed
5. Follow up with referring physician
6. ERCP in one month to remove the stent.
Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **] and
the GI fellow.
Repeated for bleeding
Date: Saturday, [**2192-7-21**] Endoscopist(s): [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73382**], MD
[**First Name8 (NamePattern2) **] [**Last Name (Titles) 39870**], MD
Patient: [**Known firstname 122**] [**Last Name (NamePattern1) 73379**]
Ref.Phys.: [**Name6 (MD) 73380**] [**Name8 (MD) 21386**], M.D.; [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Birth Date: [**2097-12-9**] ([**Age over 90 **] years) Instrument: TJF-160Vf
GIF 2T100 2-channel
[**Numeric Identifier 73381**] Indications: [**Age over 90 **] year old male SP ERCP and
sphincterotomy with subsequesnt bleeding. The initial bleeding
was controlled with 1:10,000 epi injection at the apex of the
sphincterotomy after double pigtail stent placement. Now with
recurrent bleeding.
Medications: Midazolam 5mg iv
Fentanyl 125 micrograms
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was placed in the prone
position and an endoscope was introduced through the mouth and
advanced under direct visualization until the second part of the
duodenum was reached. Careful visualization was performed. The
procedure was not difficult. The quality of the preparation was
good. The patient tolerated the procedure well. There were no
complications.
Findings: Esophagus: Limited exam of the esophagus was normal
Other Fresh blood and blood clots were seen in the lumen of the
stomach.
Other Blood clots were seen in the second portion of duodenum.
The double pig-tail stent was seen in the lumen of the second
portion of duodenum
Major Papilla: The double pig-tail stent was seen in the
duodenum. There was active bleeding form the apex of the
sphincterotomy.
Procedures: An epinephrine injection was applied for hemostasis
successfully at the Apex of the sphincterotomy.
Impression: Blood clots were seen in the second portion of
duodenum. The double pig-tail stent was seen in the lumen of the
second portion of duodenum
Fresh blood and blood clots were seen in the lumen of the
stomach.
The double pig-tail stent was seen in the duodenum. There was
active bleeding form the apex of the sphincterotomy.
The active bleeding site at the apex was injected with 5 cc
1:10,000 epinephrine. Hemostasis secured.
Otherwise normal ercp to second part of the duodenum
Recommendations: 1. Monitor in MICU
2. Keep NPO
3. Correct INR with FFP and vitamin K as needed
4. Blood transfusion
5. IV PPI [**Hospital1 **]
6. Cotinue antibiotics
7. Monitor H/H, LFTs and INR
Subsequent to this was moved to floor, continued treatment with
zosyn, then transitioned to cipro and flagyl po day prior to
d/c. Taking reg. diet.
#CRF: Cr. near baseline throughout stay; slightly elevated on
discharge, but likely not clinically significant, as change was
from 3.0 to 3.4 (small relative change); - pt. is making urine
(greater than 40 cc per hour on discharge) and appears
clinically euvolemic. Given this, however, the recommendation
was made on the Page 1 d/c instructions to the rehab hospital
that daily cr. should be monitored as well as digoxin level.
#Afib/pacer - EP consulted, and atrial lead appears to be
undersensing. Given this, pacer was mode-switched from DDD to
VVI. Recommended continued monitoring for return to sinus
activity in atrium, if so, could consider mode switch back to
DDD and/or atrial lead revision in the future.
Should hold warfarin until [**7-27**] for anticoagulation for afib
given bleeding above.
#Code:DNR/DNI
Medications on Admission:
Am:
colchicine qod
isosorbide 20mg tid
Diltizaem 60mg qid
lasix 40mg [**Hospital1 **]
K supplement
MVI
Ca
allopurinol 100mg
prilosec 40mg
neuronitin 100mg [**Hospital1 **]
proscar 5mg
digoxin 0.125mg
iron
coumadin
lipitor 20mg
terazosin 10mg qhs
ambiend [**1-19**] tablet qhs
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO NOON (At
Noon).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO NOON (At
Noon).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
13. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
17. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 5 days.
20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Last day of antibiotics is [**7-30**].
Do not restart warfarin until [**7-27**] given that a sphincterotomy
was done during ERCP, and this was complicated by bleeding.
Followup Instructions:
With your primary doctor after you leave the rehab hospital.
With EP doctors as needed/next available.
|
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"285.21",
"574.41",
"428.0",
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"427.31",
"272.4",
"E878.8",
"576.1",
"V58.61",
"998.11",
"276.52",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"51.64",
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
11373, 11453
|
2261, 9388
|
279, 386
|
11511, 11520
|
1510, 2238
|
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|
1117, 1121
|
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|
11474, 11490
|
9414, 9691
|
11544, 11749
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1136, 1491
|
223, 241
|
414, 964
|
986, 1058
|
1074, 1101
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,954
| 122,074
|
4718
|
Discharge summary
|
report
|
Admission Date: [**2128-9-17**] Discharge Date: [**2128-9-23**]
Date of Birth: [**2058-7-6**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70 y/o F s/p total abdominal colectomy [**3-6**] c. diff toxic
megacolon [**9-8**] presents with abdominal pain. Right flank pain
for 4 days, noted dark urine, dysuria, difficulty initiating
urination. She initially had pain at the site of her previous
ostomy, but it then radiated to her right flank. She describes
the pain as similar to her previous episode of pyelonephritis.
She also felt tired and occasionally dizzy. Denied fever,
chills, diarrhea, vomiting.
In the ED, initial vital BP was 69/34, HR 75, T 97.4, RR 18, 98%
on RA. She had blood and urine cultures received levofloxacin
and flagy and 6L NS and BP remained at 79/41, she was then
started on a levophed gtt. She remained afebrile, had good urine
output and her CVP was up to 15-16. When she got to the ICU her
pressure was 112/60. She was mentating well, oriented x3,
denied chest pain, dizziness. She continued to complain of RUQ/R
flank pain but denied nausea/vomiting. She was weaned from
levophed and given 500ml NS bolus and maintained SBP >110.
ROS: The patient denies any fevers, chills, weight change,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity oedema,
cough, lightheadedness, gait unsteadiness, focal weakness,
vision changes, headache, rash or skin changes.
.
Past Medical History:
#. Hypertension
#. Hypercholesterolemia
#. Glucose Intolerance (last A1c 5.7, [**2128-7-27**]; was ranging ~
6.0)
#. h/o Nephrolithiasis (20 y ago during pregnancy)
#. h/o Pyelonephritis
#. Osteopenia
#. Severe osteoarthritic changes, bilat hips, L>R, to have left
THR in Fall of [**2128**]
#. Chronic LBP, DJD lower lumbar spine, s/p SI steroid injection
([**2126-9-17**]), MRI lumbar spine neg for compression ([**2126-10-13**])
#. h/o C. difficile toxic megacolon, necessitating total
abdominal colectomy ([**12-9**]), s/p ileostomy takedown with
ileorectal anastamosis ([**7-10**])
#. h/o Partial small bowel obstruction ([**Doctor Last Name 2819**] [**Hospital1 18**], [**7-10**] and
[**10-10**])
#. Ventral hernia
#. GERD/hiatal hernia, s/p lap nissen fundoplication
#. Gastritis
#. Stable pulmonary nodules (6mm, 3mm, bilateral, likely
granulomas)
#. Tobacco: 20 PYHx, quit 15 yrs PTA
.
PSHx:
#. s/p Ileostomy takedown with ileorectal anastamosis ([**2127-7-11**])
#. s/p Exploratory laparotomy, splenic flexure take-down, total
abdominal colectomy, Rectal Hartmann's formation with end
ileostomy, feeding gastrojejunostomy, and [**Doctor Last Name 406**] drain placement
([**12-9**])
#. s/p Laparoscopic repair hiatal hernia, Nissen
fundoplication ([**2120-7-9**])
#. s/p Cervical spine decompression
#. s/p appendectomy
Social History:
Married, lives with husband in [**Name (NI) 10059**]. Has 4 grown children (3
daughters/1 son). One daughter is a cardiac nurse. 1 PPD smoker
x 20 years, quit 15 years ago. [**4-6**] glasses wine per week.
Denies IVDU.
Family History:
Sister died at 55 of MI.
Brother with heart problems.
Physical Exam:
VS: T:99 HR:110 BP:124/69 O2: 96% on 2L
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Multiple scars noted. Soft, tender to palpation R upper and
lower quadrants, marked R. CVA tenderness guarding, no rebound.
BS+. No hernia palpated.
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
Labs on admit:
[**2128-9-17**] 11:20AM WBC-13.4* RBC-3.42* HGB-10.9* HCT-32.2*
MCV-94 MCH-31.8 MCHC-33.8 RDW-13.3
[**2128-9-17**] 11:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-40.8*
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2128-9-17**] 11:20AM CALCIUM-8.9 PHOSPHATE-4.0 MAGNESIUM-1.8
[**2128-9-17**] 11:20AM ALT(SGPT)-62* AST(SGOT)-42* ALK PHOS-206*
AMYLASE-30 TOT BILI-1.2
[**2128-9-17**] 11:20AM GLUCOSE-121* UREA N-38* CREAT-2.8*
SODIUM-127* POTASSIUM-4.4 CHLORIDE-89* TOTAL CO2-21* ANION
GAP-21*
[**2128-9-17**] 11:22AM LACTATE-1.8
<br>
CT Abdomen: No acute pathology. Small bilateral pleural
effusions. Minimal possible left hepatic biliary dilation (eval
limited due to lack of IV contrast). Perisplenic varices of
unknown etiology.
<br>
CXR: Evidence of mild volume overload (taken after volume
resuscitation)
<br>
RUQ US ([**9-20**]):
FINDINGS: The liver is homogeneous in echotexture without
evidence of focal lesion. The gallbladder is mildly distended
likely related to fasting stage. There is no gallstone or
gallbladder wall edema. No intra- or extra- hepatic biliary
ductal dilatation is seen. The common duct measures 4 mm. The
son[**Name (NI) 493**] [**Name (NI) **] sign is not present; however, it is difficult
to assess since the patient received pain control medication.
Small amount of perihepatic fluid. The main portal vein is
patent with antegrade flow.
IMPRESSION: No evidence of acute cholecystitis.
Brief Hospital Course:
70 y/o F s/p total abdominal colectomy [**3-6**] c. diff toxic
megacolon [**9-8**] presents with abdominal pain [**2128-9-17**] with
urosepsis presentation.
<br>
# Sepsis - Patient met severe sepsis criteria with
hypotension(initially requiring levophed as pt initially
admitted to ICU), acute renal failure and possible shock liver
initially. Source appeared to be urosepsis [**3-6**] pyelonephritis
given 4 day history of dysuria, tea colored urine, evolving
right flank pain and positive UA. However imaging unrevealing
for radiological evidence of pyelo - given extreme presentation
plan is to treat for pyelonephritis for 14days with
levofloxacin, blood cx were negative throughout - noted
non-pseudmonas organism growing out - sensitive to quinolones.
Of note, Vanc/Levo/Flagy were initially chosen in ICU, changed
to Vanc/Cipro/Flagyl to cover for urinary (including
enterococcus) pathogens. And later given her possible GI and
UTI sources, single [**Doctor Last Name 360**] of Zosyn was used. Once on floor, abx
was changed to po levofloxacin. Pt had good initial responce,
however with low-grade temps (even with IV zosyn (100/99.8), ab
w/u as below for possible another occult source (neg). L SC
subsequently d/ced on [**2128-9-21**] - temps improved following, cath
tip showed no sig growth and [**9-21**] blood cx also without growth
at time of d/c (pt was monitored [**9-22**] to assure no gram + infx).
Pt again afebrile, without leukocytosis at time of d/c, stable
- plan for to continue and complete 14day treatment for
complicated UTI/pyelonephritis.
<br>
#Abdominal Pain - resolved at time of d/c but given R sided ab
sx - initial concern for choledocolithiasis along with
complicating infectious process. It was possible that she had a
concominant biliary tract disease given RUQ pain, possible
hepatobiliary dilatation on CT A/P initially. However, she
denied nausea, vomiting. RUQ pain could be [**3-6**] kidney
inflammation. Surgery consulted in ED and followed patient
initially, no interventions indicated. Pt then with RUQ US for
further biliary evaluation [**9-20**] - results above (neg study). Pt
sx subsequently resolved at time. LFT's trended down with
sepsis resolution as above
<br>
#Acute Renal Failure- Creatinine 2.8 on admission, down to 0.7
at time of d/c. Etiology [**3-6**] to sepsis/hypotension - at
baseline with stable lytes at time of d/c.
<br>
#Anemia-- HCT down to 28 from baseline of 30-35, at 30.4 at time
of d/c. Fe Studies more consistant with anemia of chronic dz -
(done in-house). Stable at time of d/c.
<br>
#Hyponatremia-- Hypovolemic hyponatremia. Patient reports trying
to drink more to compensate for her low urine output this week,
so this is likely [**3-6**] increased free water intake but overall
lack of po intake on top of fever and then sepsis. She does not
take diuretics at home, so this is an unlikely cause. Responded
well to NS IVF hydration - at 138 at time of d/c.
<br>
#Resolved unstable angina - pt with epigastric vs USA sx on
[**2128-9-21**] - EKG showed possible TW changes in V3-V4 - pt monitored
on tele with 3 sets CE with pt's risk factors - no further
events and all CE were negative.
<br>
#Depression--
-continued amitryptaline
<br>
#Insomnia--
-continued home temazepam
<br>
#Hyperlipidemia - continued home statin.
<br>
#HTN, benign - initially ace-i held, but once sepsis resolved,
BP increased -restarted home dose of ace-i and pt BP remained
controlled.
<br>
# FEN: Tolerating PO well
.
# Access: left subclavian placed in ED
.
# PPx: heparin subQ, pantoprazole, RISS, bowel regimen
.
# Code: full (confirmed with patient)
Medications on Admission:
Alprazolam 0.25 mg Tablet TID prn
Amitriptyline 25 mg Tablet po qhs
Enalapril Maleate 20mg daily
Simvastatin 20 mg daily
Temazepam 15 mg po qhs
Bisacodyl 10mg daily prn
Vicodin 5-500 mg Tablet PO q 6hr prn
.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
9. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Sepsis/Urinary Tract Infection/Pyelonephritis
Secondary:
Acute Renal Failure
Hypertension
Hyperlipidemia
Anemia of chronic disease
non-cardiac angina
Discharge Condition:
good
Discharge Instructions:
You were admitted sepsis secondary to a severe urinary tract
infection with likely pyelonephritis based your on your
symptoms. Continue the antibiotic as prescribed, if your
symptoms return and get worse (ab pain, problems with urination
or with new severe diarrhea along with fevers and chills) - call
your PCP [**Name Initial (PRE) **]/or return to emergency center.
Follow-up with your PCP as below (appt made), your PCP will be
able to re-assess you and decide the best course for your
planned left hip surgery at that time.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD Phone:[**Telephone/Fax (1) 142**]
Date/Time:[**2128-10-5**] 4:00
Provider: [**Name10 (NameIs) **] RM 7 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2128-10-8**]
9:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-1-28**] 3:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2128-9-23**]
|
[
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"V43.64",
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"535.50",
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"995.92",
"276.2",
"570",
"311",
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"715.35",
"401.9",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10349, 10355
|
5557, 9195
|
283, 289
|
10569, 10576
|
4096, 5534
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|
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|
3320, 4077
|
229, 245
|
317, 1638
|
10395, 10548
|
1660, 2994
|
3010, 3234
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,231
| 157,486
|
42526
|
Discharge summary
|
report
|
Admission Date: [**2161-9-23**] Discharge Date: [**2161-9-30**]
Date of Birth: [**2095-7-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 87305**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 YM with Hx CAD s/p stents, emphysema, HTN and hyperlipidemia,
stage 4 squamous cell lung ca with bone and adrenal mets
presenting to the emergency room with dyspnea and hypoxia. In
last 24 hours patient has had acute worsening of his shortness
of breath associated with some nonspecific chest pain on the
right side. Denies any significant cough. No fevers or chills.
Denies any abdominal pain, nausea, vomiting or diarrhea.
In the ED, initial VS were: HR 138, RR 28, 80% on RA. Temp: 99.5
??????F BP: 149/73. Came up to 91% on 3L NC, eventually transitioned
to NRB. CXR in ED revealed pneumonia on the right. He received 1
dose of zosyn and 1 dose of Levofloxacin in the ER, in addition
to at total of 1L NS IVF.
On arrival to the MICU, patient's VS. 98.1 112 129/61 19 96% on
50% Venti Mask
Review of systems:
(+) Per HPI, in addition to reported hematuria
(-) 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:
CAD s/p stents x3, 11 yrs ago per pt
HTN
AAA, no surgery
polyp
diverticulitis
GERD
Hyperlipidemia
Metastatic NSCLC Squamouse cell diagnosed [**2161-2-27**]
PSH: s/p appy
Onc Hx: 65 yrs. man with heavy smoking history, CAD s/p stents,
HTN and hyperlipidemia presented with cough with blood tinged
sputum, leukocytosis and weight loss at the beginning of [**Month (only) **]
[**2161**]. CXR on [**2161-1-23**] showed RLL infiltrates and he was treated
with Levaquin for pneumonia. He also developed right flank pain,
aggravated by cough. CT c/a/p on [**2160-2-14**] at [**Location (un) 2274**] showed a 3.5 cm
right infrahilar abnormal soft tissue density appearing necrotic
and with central cavity which extends along the pleural surface
medially into the right middle lobe. CT also showed a 4.9cm
enlarged left adrenal gland compatible with metastatic lesion,
possibly necrotic given its low density. Infiltration of the
surrounding fat and small nodules suggest metastatic spread from
the adrenal gland. He presented to [**Hospital1 92021**] hospital for pain
control over the weekend. His pain increased to [**10-21**] on [**2-16**] and
he was admitted to [**Hospital1 18**] for pain control and to expedite the
work up. CTA and CT a/p at [**Hospital1 18**] did not show PE but emphysema.
CT also showed a cavitating pulmonary mass adjacent to the
pericardium within the right medial lower lobe; Mediastinal and
bihilar lymphadenopathy; an enlarged left adrenal gland. MRI
brain did not show brain lesions. PET CT demonstrated FDG-avid
lesions in the right lung, bilateral mediastinal LN's, left
adrenal, right 11th rib and T-spine (T8, T11), all c/w with a
primary lung cancer with metastatic disease. Patient underwent 3
attempted diagnostic procedures, with the the first 2 procedures
being non-diagnostic. He underwent a EUS by the Advanced
Endoscopy/ERCP service with EUS-biopsy of the left adrenal mass
and subcarinal LN on [**2-18**], with samples returning non-diagnostic.
He then underwent a bronchoscopy with EBUS with biopsy of 3
mediastinal LN's, with all 3 samples being non-diagnostic. Of
note, during this procedure, he had an episode of SVT and brief
hypotension requiring IV pressor therapy. This all resolved
spontaneously post-procedure. Thoracic Surgery was consulted to
evaluate for possible VATS or mediastinoscopy, however, Thoracic
Surgery recommended to continue with less invasive measures
first, and recommended a CT-guided biopsy of the left adrenal
mass. He underwent CT-guided biopsy on [**2-27**] and tolerated the
procedure well. The path shows squamous cell carcinoma,
consistent with lung primary. Pt was noted to have an O2
requirement. He has CTA that is negative for PE and was kept on
DVT prophylaxis. He does have long smoking history and imaging
suggests a component of COPD, but he had no active wheeze. No
clear infiltrate on chest x-ray other than right-sided lung
mass. Felt to be likely due to a combination of his right lung
mass and also splinting from his metastatic bone pain that
prevents him from taking deep breaths. He remained on a stable
O2 requirement (2.5L).
He was initially discharged, but then readmitted to [**Hospital1 18**] on
[**3-5**] with dehydration and right chest/flank pain. He has a
metastatic lesion at T10, and pain was felt to be radicular. CTA
in ED showed no pulmonary embolus. He received radiation, 800
cGy in 1 fraction, to T8-T10 and adjacent right sided ribs, on
[**2161-3-6**]. He received chemotherapy with carboplatin, AUC 5, on
[**3-7**], (day 1) and gemcitabine, 1000 mg/m2, day 1 and d8, ([**3-14**]),
without difficulty. He received consultation from Dr [**Last Name (STitle) **],
Palliative Care. At the end he was quite comfortable on fentanyl
patch 75 mcg/hr, dilaudid 4 mg q 4h PRN breakthrough pain, and
provigil. Metoprolol was started after an episode of AF with
rapid ventricular response. He subsequently converted to sinus
rhythm. He was discharged in stable condition to [**Hospital1 **] in [**Location 1268**] on [**3-15**]. Admitted from [**8-3**] - [**8-7**] for
bilateral hip pain.
TREATMENT HISTORY:
[**2161-3-7**] Cycle 1 d1 [**Doctor Last Name **]+gemzar
[**2161-3-14**] Cycle 1 d8 gemzar
[**2161-4-6**] cycle 2 d1 [**Doctor Last Name **] + gemzar -- 20% dose reduction due to
neutropenia, thrombocytopenia and tolerance.
[**2161-4-6**] Zometa
[**2161-4-13**] cycle 2 d8 gemzar - 20% dose reduction
[**2161-4-28**] cycle 3 d1 [**Doctor Last Name **] + gemzar -- 20% dose reduction
[**2161-5-4**] cycle 3 d8 gemzar - 20% dose reduction
[**2161-5-4**] Zometa
[**2161-5-18**] cycle 4 d1 [**Doctor Last Name **] + gemzar -- 20% dose reduction
[**2161-5-25**] cycle 4 d8 gemzar - 20% dose reduction
[**2161-6-9**] cycle 5 d1 [**Doctor Last Name **] + gemzar -- 20% dose reduction, zometa
[**2161-6-15**] cycle 5 d8 gemzar - 20% dose reduction
[**2161-6-29**] cycle 6 d1 [**Doctor Last Name **] + gemzar--20% dose reduction
[**2161-7-6**] cycle 6 d8 gemzar - 20% dose reduction
[**2161-7-20**] cycle 1 maintenance Taxotere 20% dose reduction
[**2161-7-20**] Zometa
[**2161-8-10**] cycle 2 maintenance Taxotere full dose
Social History:
Former smoker; [**2-13**] ppd x 40y, 6 beer/day x "many years"-denies
ever having withdrawal, no drugs. Campus police at [**University/College 92022**]. also works with the T.
married, 2 sons and 1 daughter,
Family History:
father had rheumatoid arthritis
Physical Exam:
Admission:
Vitals: 98.1 112 129/61 19 96% on 50% Venti Mask
General: Somnolent, oriented to self, place, but cannot name
month and answers trail off/falls asleep in the middle of
answering questions
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, reg rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diminished breath sounds on right with crackles halfway
up right lung field
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Oriented to self and place but not time, gait deferred.
Exam prior to Discharge:
Vitals: 98.5, 156/84, 104-114, 16, 93% RA, 91-92% ambulating
General: NAD, AxOx3
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diminished breath sounds on right lower lung area, CTAB
elsewhere
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all 4 extremities.
Pertinent Results:
Admission:
[**2161-9-23**] 06:10PM BLOOD WBC-17.5*# RBC-4.07*# Hgb-12.9*#
Hct-39.9*# MCV-98 MCH-31.7 MCHC-32.3 RDW-18.5* Plt Ct-268
[**2161-9-23**] 06:10PM BLOOD Neuts-84.9* Lymphs-11.4* Monos-3.1
Eos-0.4 Baso-0.2
[**2161-9-23**] 06:10PM BLOOD PT-10.8 PTT-35.7 INR(PT)-1.0
[**2161-9-23**] 06:10PM BLOOD Glucose-93 UreaN-18 Creat-1.2 Na-142
K-4.0 Cl-106 HCO3-25 AnGap-15
[**2161-9-23**] 10:53PM BLOOD Type-ART pO2-75* pCO2-46* pH-7.35
calTCO2-26 Base XS-0
[**2161-9-23**] 06:16PM BLOOD Lactate-1.6
Imaging:
[**9-23**] CXR:
IMPRESSION: Right upper lobe pneumonia with equivocal
involvement of lower
Preliminary Reportand middle lobes with small accompanying
parapneumonic effusion.
CT CHEST W/O CONTRAST [**2161-9-24**]:
1. Right lung pneumonia, most severe in the lower lobe, with
small bilateral
pleural effusions, right greater than left. Continued followup
with
radiographs is recommended to assess for resolution. If there
is no
resolution, CTPA should be obtained for evaluation of the
pulmonary arteries.
2. Right paramediastinal mass is similar in size to [**9-16**], [**2161**].
Mediastinal lymphadenopathy is stable. Evaluation of this
region is limited
without IV contrast and, unless contraindicated, future exams
should be
obtained with contrast. Left adrenal gland nodule and right
eleventh rib
sclerotic lesion, similar in size to prior, were characterized
on PET-CT as
metastases.
3. Small pericardial effusion, minimally enlarged since [**7-26**], [**2161**],
without evidence of tamponade.
4. Severe diffuse centrilobular emphysema.
CXR [**2161-9-23**]:
IMPRESSION: Right upper lobe pneumonia with equivocal
involvement of lower
and middle lobes with small accompanying parapneumonic effusion.
Brief Hospital Course:
Brief Course:
66 YM with Hx CAD s/p stents, emphysema, HTN and hyperlipidemia,
stage 4 squamous cell lung cancer with bone and adrenal mets
presented to the emergency room with dyspnea and hypoxia and
found to have right-sided pneumonia.
Active Issues:
#Pneumonia: Need to cover healthcare associated PNA as patient
had hospitalization one month ago and immunosuppression from
chronic prednisone and dexamethasone use. Given that pt was
hypoxix in ED with O2 sats in 80s, pt was initially admitted to
MICU. He was put on a nonrebreather for O2 supplementation,
started on Vancomycin, levofloxacin, cefepime for healthcare
associated PNA. Pt stabilized on 3L NC in MICU over one day and
was later transferred to floor. Pt was gradually weaned off
oxygen as his condition improved with IV antibiotics.
#AMS: Most likely to be secondary to toxic metabolic
encephalopathy in setting of infection. However, in the setting
of his metastatic cancer, mets to the brain were also possible.
He did have a negative MRI of the head in late [**Month (only) 205**]. Mental
status improved with tx of PNA therefore reimagin of his head
was not done.
#Tachycardia: Suspected due to infection and resolved with IV
fluids. However it was noted to be in low 100s prior to
discharge.
#NSCLC: Stage 4 with mets to adrenal and bone. Completed 6
cycles of [**Doctor Last Name **]+gemzar. S/p 2 cycles of Taxotere maintenance
treatment, last on [**8-10**], was held in house given that he
developed fatigue and dehydration after chemo. Last MRI L spine
showed possibility of leptomeningeal disease. Recent PET from
[**9-16**] shows progression of disease.
#?Adrenal Insufficiency: Unclear why pt was on dexamethasone,
possibly has h/o AI given mets to adrenals but unclear. Pt's
dexamethasone was continued Atrius attending suggested a slow
taper with stopping it after [**2161-10-3**].
#CAD: There were no clear ST changes on EKG. Troponin not
elevated and chest pain seemed most likely pleuritic. Continued
ASA and statin. With reported h/o MI, unclear why patient is not
on beta blocker, need to clarify with PCP.
#H/o Atrial fibrillation: Currently NSR. Continue digoxin.
Unclear when this was diagnosed and whether discussion of
anticoagulation has been addressed; will discuss with PCP.
#Anemia: Normocytic, chronic, likely related to his
chemotherapy. Counts are up from his previous values closer to
chemo which were [**8-22**] when Hct was in low 30s.
TRANSITIONAL ISSUES:
======================
- pt to complete course of antibiotics at home with VNA support
through port
- With reported h/o MI, unclear why patient is not on beta
blocker
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Lorazepam 0.5 mg PO HS:PRN insomnia
2. Mirtazapine 30 mg PO HS
3. Guaifenesin [**5-21**] mL PO Q4H:PRN cough
4. Dexamethasone 2 mg PO DAILY
5. magnesium chloride *NF* 71.5 mg Oral 2 tabs three times a day
6. HYDROmorphone (Dilaudid) 4-8 mg PO Q3H:PRN pain
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Allopurinol 100 mg PO DAILY
9. Dronabinol 2.5 mg PO TID
10. Senna 1 TAB PO BID:PRN constipation
11. Prochlorperazine 10 mg PO Q6H:PRN nausea/ vomting
12. Tamsulosin 0.4 mg PO HS
13. Digoxin 0.125 mg PO DAILY
14. Thiamine 100 mg PO DAILY
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Omeprazole 20 mg PO DAILY
17. Atorvastatin 80 mg PO DAILY
18. Nitroglycerin SL 0.4 mg SL PRN chest pain
19. Morphine SR (MS Contin) 60 mg PO Q12H
20. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral three times a day
21. FoLIC Acid 400 mg PO DAILY
22. Tricor *NF* (fenofibrate nanocrystallized) 145 mg Oral daily
23. Sulfameth/Trimethoprim DS 1 TAB PO MWF
24. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO MWF
2. Tamsulosin 0.4 mg PO HS
3. Thiamine 100 mg PO DAILY
4. Senna 1 TAB PO BID:PRN constipation
5. Omeprazole 20 mg PO DAILY
6. Morphine SR (MS Contin) 60 mg PO Q12H
hold for sedation, RR<12
7. Mirtazapine 30 mg PO HS
8. HYDROmorphone (Dilaudid) 4-8 mg PO Q3H:PRN pain
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Digoxin 0.125 mg PO DAILY
11. Dexamethasone 2 mg PO EVERY OTHER DAY Duration: 7 Days
12. Atorvastatin 80 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Allopurinol 100 mg PO DAILY
15. CefePIME 2 g IV Q12H
Day 1= [**2161-9-23**]
RX *cefepime 2 gram infusion 2 gm every 12 hours Disp #*7 Bag
Refills:*0
16. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
17. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
18. Levofloxacin 750 mg PO DAILY
D1 = [**9-23**], last day [**10-2**]
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
19. Vancomycin 1000 mg IV Q 12H
Day 1=[**2161-9-23**]
RX *vancomycin 1 gram 1 gram every 12 hours Disp #*7 Bag
Refills:*0
20. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral three times a day
21. Dronabinol 2.5 mg PO TID
22. FoLIC Acid 400 mg PO DAILY
23. Guaifenesin [**5-21**] mL PO Q4H:PRN cough
24. magnesium chloride *NF* 71.5 mg Oral 2 tabs three times a
day
25. Nitroglycerin SL 0.4 mg SL PRN chest pain
26. Ondansetron 8 mg PO Q8H:PRN nausea
27. Prochlorperazine 10 mg PO Q6H:PRN nausea/ vomting
28. Tricor *NF* (fenofibrate nanocrystallized) 145 mg ORAL DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 4916**] Infusion
Discharge Diagnosis:
Primary: Healthcare Associated Pneumonia, stage IV squamous cell
lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing. You
were found to have pneumonia. You were treated with intravenous
antibiotics. Your breathing improved and you no longer required
oxygen at the time of discharge. You will need to continue on
antibiotics until [**2161-10-2**].
Followup Instructions:
Please keep the following appointments:
NAME: [**Name6 (MD) **] [**Name8 (MD) **], MD
SPECIALTY: Hematology/Oncology
WHEN: Monday [**2161-10-5**] at 1:30pm
LOCATION:[**Hospital1 **]
ADDRESS: [**Location (un) 4363**] [**Location (un) 86**] [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 92023**]
Name: [**Doctor First Name **] Z.[**Name8 (MD) **], MD
Specialty: Primary Care
When: Friday [**2161-10-9**] at 1:40pm
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 90060**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,953
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29510
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Discharge summary
|
report
|
Admission Date: [**2136-9-19**] Discharge Date: [**2136-10-26**]
Date of Birth: [**2065-9-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Altered mental status and desaturations
Major Surgical or Invasive Procedure:
Tunnelled line change
Intubation, tracheostomy
History of Present Illness:
70F with ESRD on hemodialysis (MWF) at [**Doctor First Name **]-[**Doctor Last Name 9449**] Dialysis
Center who was at HD on day of admission when they noticed
difficulty with flow through her HD catheter. After receiving
tPA through her HD catheter she began to develop fevers to 103.5
and rigors. Blood cultures were drawn at HD; she was given 1g
Vanco, 650mg Tylenol, and 80mg IV Gentamicin and sent to the
[**Hospital1 18**] ED. Had 1 week of nonproductive cough, without any other
localizing infectious sx's. No odynophagia, N/V/diarrhea,
dysuria, sinus tenderness, rhinorrhea. No CP, abd pain, SOB,
dyspnea, PND, orthopnea, LE edema. In the ED, her VS were
102.2, 161/66, 100, 97%RA. She had blood cx's drawn peripherally
and was admitted to medicine for further w/u.
On the floor, 2/2 blood cultures grew out pan-sensitive
Enterobacter on [**9-19**]. Her HD line was d/c'ed on [**9-20**], and the
tip grew Enterobacter and pan-sensitive Serratia. She was
initially placed on vancomycin on [**9-19**], and received one dose
each of Levofloxacin 250mg IV and aztreonam 500mg IV qday when
blood cultures grew GNR. Once growth was speciated on [**9-21**],
vanc/aztreonam stopped, and Ciprofloxacin 400mg IV qday was
started. She received 7 days of PO/IV Cipro, and subsequent BCx
on [**9-21**] and [**9-27**] were negative. Her course was complicated by
positive HIT (platelets 86 at admission from baseline 189 [**6-28**]),
and had been on intermittent argatroban under the supervision of
hematology. Argatroban was held from [**9-23**] to [**9-26**] due to guaiac
positive brown stool mild hemoptysis, then restarted on [**9-26**]. A
serotonin release assay is pending. A head CT was done on [**9-24**]
for occipital HA, and was negative for bleed. On [**9-26**], a new
tunneled RIJ HD catheter was placed. She also started
experiencing increasing leukocytosis with worsening right knee
pain, abdominal pain, and throat pain. A KUB demonstrated no
free air, and a tap of the right knee by rheumatology was most
c/w OA (normal wbc count when adjusted for rbc, no crystals).
Ms. [**Known lastname 46452**] also began experiencing worsening delerium and
agitation. Out of concern by ID for Cipro-induced delerium, her
antibiotics were changed to gentamicin on [**9-28**]. Reglan was also
d/c'ed as possible contributing factor to delerium.
On the evening of [**9-28**], Ms. [**Known lastname 46452**] received a total of 7mg IV
Haldol for agitation. On the morning of [**9-29**], she was noted to
have increasing periods of witnessed apnea and desaturations to
mid-80s. Her sats climbed after reawakening, and responded to 2L
O2 NC. She also c/o R shoulder pain and could not move her
shoulder more than 30 degrees. Rheumatology recommended U/S of
the shoulder to assess for effusion, due to concern of septic
joint, though thought hematogenous seeding of the joint was
unlikely since all recent BCx have been negative. Due to
increasing delerium and nursing needs and episodes of apnea and
desaturations, she was transferred to the [**Hospital Unit Name 153**] for observation.
In the [**Hospital Unit Name 153**], the patient was initially intubated for apnea and
respiratory distress. She was diagnosed with Ecoli pneumonia and
continued to have increasing thick tan secretions. Ceftriaxone
was d/ced on [**10-13**] and changed to Meropenem/Vanco Day 1 [**10-13**] due
to increasing secretions and fever spike to 102 on [**10-13**].
She was briefly extubated on [**2136-10-6**], but had to be reintubated
after 30 min because of stridor and respiratory distress. She
was found to have increased soft tissue vs upper airway edema,
CT neck showed soft tissue completely surrounding the ETT in the
upper airway. She is scheduled for trach on [**10-15**].
She was diagnosed with SVC syndrome, via CT venogram which
showed SVC clot and RIJ clot, and is s/p SVC stent placement
with improvement of upper extremity edema. Etiology of SVC
syndrome is unknown. Since patient is thought to be false
positive for HIT and does not have a true heparin allergy, she
is maintained on heparin gtt for SVC syndrome.
Hypercoagulability workup was planned as an outpatient.
Her mental status was last at baseline (walking, talking,
communicating clearly, socializing with family, very mild
dementia) three weeks ago and before initial intubation and [**Hospital Unit Name 153**]
transfer, per daughters and son in law. CT head showed no
cerebral edema as repercussion of SVC syndrome, and no stroke,
but showed a lateral ventricle lesion of unclear significance.
Her blood pressure was very labile, ranging from SBP 70-200,
becoming hypertensive when sedation is low and hypotensive with
increased sedation, especially with propofol which was no longer
used. Zyprexa appeared to work well for agitation.
Past Medical History:
1. Arthritis
2. Diabetes Mellitus, type 2 for 8-10 years
3. End-stage renal disease, on hemodialysis for 1 year. Dialysis
m,w,f in [**Location (un) **]
4. Left knee surgery three to four months ago for what sounds
like septic joint. Surgery was at [**Hospital6 **].
5. Hypertension.
6. Depression
7. H/O "arthritis" 30 years ago now resolved
8. sleep apnea previously but not currently treated with C-PAP
Social History:
The patient is from [**Male First Name (un) 1056**] originally and is Spanish
speaking. She currently is living with her daughter. She is
divorced and has five children. She is a lifetime nonsmoker. She
denies any alcohol or drug use.
Family History:
Several family members (siblings) have diabetes. Her father had
an MI at the age of 75. Grandfather had throat cancer.
Physical Exam:
T: 97.4F BP: 168/70, HR 84, RR: 17 SaO2 99% RA
Gen: Agitated Hispanic female, c/o being hot, and crying out to
remove hand restraints.
HEENT: PERRL, EOMI, OP clear with no lesions
Neck: Supple, no LAD
Chest: R HD line in place with mild oozing, no surrounding
erythema. Lungs CTA anteriorly, no w/r/r
CV: RRR, nl S1 and S2, no m/r/g
Abd: soft, NT/ND, +BS, no HSM appreciated
Extr: R knee slightly warm, non-erythematous, mild swelling, no
pain on passive or active movement as well as could be assessed
with MS changes. R shoulder with pain on passive movement,
guarding.
Neuro: A&Ox1, agitated. Unable to cooperate with full neuro
exam. Moving all extremities well, strength appears grossly
intact. No facial droop, follows across midline.
Pertinent Results:
Head CT [**9-19**]: No acute intracranial hemorrhage. Chronic small
vessel ischemia. Possible empty sella, correlate clinically.
CXR [**9-19**]:Overall unchanged appearance of the chest with faint
interstitial opacities in the lower lobes, which can be due to
atelectasis, however, mild edema cannot be totally excluded.
Slightly bent appearance of the distal catheter, which can be
positional, please check the patency of the line.
[**9-29**] portable CXR: Vascular catheter remains in standard
position. Cardiac and mediastinal contours are stable in
appearance. No focal areas of consolidation are identified, but
standard PA and lateral views of the chest would be more
sensitive and may be helpful for more complete evaluation given
clinical suspicion for infection.
[**9-28**] Knee film: End-stage osteoarthritic changes involving
predominantly the medial compartment. No acute bony injury.
[**9-27**] KUB: No evidence of obstruction.
[**9-25**] TTE: The left atrium is elongated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF 60-70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened, with focal
thickening of the right cusp. An aortic valve vegetation/mass
cannot be excluded. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. A mass or
vegetation on the mitral valve cannot be excluded. Trivial
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The left ventricular inflow pattern suggests
impaired relaxation. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
[**9-24**] Head CT: No acute intracranial hemorrhage. Persistent
fluid density within the sella turcica, unchanged compared to
[**2136-9-19**]. This most likely represent empmty sella.
[**2136-9-29**]: R. Shoulder Ultrasound: A 2.5 cm hypoechoic fluid
collection anterior to the glenohumeral joint, may represent a
bursal fluid collection. Lower echogenicity argues against
purulent nature of the fluid.
[**2136-9-30**]: CT abdomen and Pelvis
1. Geographic hyperdense focus within segment V of the liver,
new compared to [**2136-2-14**], could reflect underlying occlusion of
the superior vena cava.
2. Unchanged appearance of right adrenal myelolipoma and
hypoattenuating lesions within the kidneys, most likely
representing cysts.
3. Mild, dependent bibasilar atelectasis.
4. Prominent bilateral ovaries for a post-menopausal female. A
pelvic ultrasound is recommended as clinically indicated.
[**2136-10-2**]: Echocardiogram: No valvular vegetations identified.
Focally thickened mitral and aortic valves with trivial
regurgitation. Dynamic interatrial septum with stretched patent
foramen ovale. Complex non-mobile atheroma in the aortic arch.
Simple atheroma in descending aorta.
[**2136-10-8**]: CT Chest
1. Extensive venous thrombosis of head and neck drainage, with
occlusion of SVC, right brachiocephalic, bilateral subclavian
and probably right axillary veins, due at least in part to
indwelling large bore central venous catheter.
2. Severe laryngeal edema.
3. Bilateral axillary and subcarinal lymphadenopathy.
4. Interval resolution of hepatic parenchymal enhancement
abnormality.
5. Marked coronary atherosclerosis. Probable calcific aortic
stenosis.
6. Right adrenal myelolipoma.
[**2136-10-10**]: CT head
Apparent tiny area of hyperdensity adjacent to the posterior
portion of the left lateral ventricle which may represent an
area of abnormal enhancement. This could be further evaluated
with an MRI of the head if clinically indicated. No evidence of
cerebral edema or hemorrhage.
[**2136-10-12**] CT head and neck
1. No acute intracranial pathology is identified, including no
intracranial hemorrhage.
CT neck:
1. Epiglottis is enlarged and the piriform sinuses are
obliterated. The prominent soft tissue of the oropharynx and
nasopharynx completely surrounds the nasogastric tube and
endotracheal tube. These finding might be all secondary to
intubation.
2. Unchanged appearance of complete thrombosis of right internal
jugular vein, which extends to the skull base.
3. 9-mm round soft tissue of the right parotid gland might
represent a node or less likely pleomorphic adenoma. Clinical
correlation is recommended.
4. Hyperdense material are noted within the sphenoid sinuses,
which are most likely related to inspissated secretion or fungal
colonization.
[**2136-10-17**] CXR - The ET tube was removed with an interim insertion
of tracheostomy. The tracheostomy tip is about 5 cm above the
carina. There is no change in the appearance of the double-lumen
right central venous catheter with its tip terminating at the
cavoatrial junction. The SVC stent is again noted in unchanged
position. The cardiomediastinal silhouette is stable. The lung
volumes are low with no evidence of pulmonary edema. Left small
area of atelectasis is unchanged.
[**2136-10-21**] CXR - There is a moderate-sized right pneumothorax.
There are two central venous catheters from the right side.
There is a tracheostomy. There has been interval development of
extensive subcutaneous gas along the neck and left axilla and
mediastinum. The cardiac silhouette is within normal limits.
There are developing areas of consolidation within the left
suprahilar region and the right mid lung zone. No overt
pulmonary edema is seen.
Brief Hospital Course:
The patient is a 70 y F with ESRD on hemodialysis (MWF) who
developed fevers to 103 and rigors.
Bacteremia: The patient presented on [**2136-9-19**] with fevers to 103
and rigors. Blood cultures drawn in the ER grew pansensitive
enterobacter. Her hemodialysis catheter was removed and tip
culture grew enterobacter and serratia. The patient initially
received gentamicin at her hemodialysis center. On arrival here
she was started on ciprofloxacin. Her HD line was replaced on
[**2136-9-26**]. On [**2136-9-28**] the patient was noted to have increasing
agitation and delerium and the ciprofloxacin was switched back
to gentamicin. A transesophageal echocardiogram was performed
and showed no evidence of endocarditis. Eventually, ceftriaxone
was d/ced on [**10-13**] and changed to [**Last Name (un) 2830**]/vanc [**10-13**] for a fever
spike to 102 and increasing secretions. She was completed a 7
day course of meropenom for E.coli bacteremia on [**2136-10-19**] and
finished a course of vancomycin for bacteremia on [**2136-10-19**]/
Pneumonia: On [**10-1**] the patient was found to have e. coli in her
sputum with associated increased sputum production. The e coli
was sensitive to ceftriaxone and gentamicin and she was started
on ceftrixane with plans to complete a two week course. On [**10-13**]
the patient spiked a temperature to 102 degrees and her
antibiotic coverage was broadened to meropenem and vancomycin.
She completed a 10 day course of meropenom on [**2136-10-20**].
Fevers: The patient spiked fevers approximately 36-48h after
completing her antibiotic courses described above. The patient
had some increased secretions without a clear infiltrate on CXR.
Out of concern for either a pulmonary or indwelling line
infection. The patient was re-started on vanco and [**Last Name (un) 2830**] on
[**2136-10-24**]. Her blood cultures were without growth and she
remained afebrile for >24 hours prior to discharge. The patient
should complete a 14 day course (day 1: [**2136-10-24**]) of vancomycin,
meropenem, renally dosed.
Respiratory Failure: The patient was transferred to the MICU on
[**2136-9-29**] after she was noted to have witnessed apneic episodes on
the floor with associated desaturations to the 80s. The
etiology of these episodes was unclear but thought to be
secondary to sedating medications in the setting of known
obstructive sleep apnea. On [**2136-9-30**] the patient was noted to be
apneic in the setting of bradycardia to the 40s, desaturations
to the 80s with agonal breathing and was subsequently intubated.
Of note the intubation was quite difficult. At that time she
had no evidence of respiratory infection or congestion but on
[**10-1**] she was found to have increased sputum production and
evidence of e. coli pneumonia for which she was started on
ceftriaxone. She was extubated on [**10-5**] for a brief period but
required reintubation after she developed stridor and
desaturations thought to be secondary to increased soft tissue
in the upper airways as opposed to laryngeal swelling. Of note
the patient was also found to have SVC syndrome with associated
upper extremity swelling which was felt to be contributing to
her increased neck size and associated respiratory failure. She
was transferred to the MICU west for tracheostomy on [**2136-10-14**]
with thoracic surgery. She did well with the tracheostomy and
was doing well on trach collar and was fitted with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 64943**] [**Last Name (un) **]
valve on [**2136-10-18**]. On the evening of 9/92/07, the patient was
being turned and her trach dislodged. She was bagged by
respiratory and intubated from above. Thoracics was called and
were able to replace her trach that morning. Unfortuantly, she
was then found to have a small pneumothorax on the right. The
patient's pneumothoraces were thought secondary to subcutaneous
emphysema occurring at the time of trach dislodgement. The
pneumothoraces were seen to resolve on CXR. The patient was
successfully weaned to a trach collar at 10L/m, FiO2 35%. She
has a small positional air leak around the trach which was
discussed with thoracic surgery who felt that no further
intervention is indicated.
SVC syndrome: The patient was noted during her MICU stay to
have increased upper extremity swelling greater than lower
extremity swelling. She underwent CT venogram which demonstrated
extensive venous thrombosis of head and neck drainage, with
occlusion of SVC, right brachiocephalic, bilateral subclavian
and probably right axillary veins, due at least in part to
indwelling large bore central venous catheter. She also was
noted to have severe laryngeal edema likely contributing to her
respiratory failure. CT of the neck demonstrated thrombosis of
the right internal jugular vein. She was placed on a heparin
drip for anticoagulation. She underwent CT of the brain which
demonstrated no edema or mass effect. She underwent mechanical
evacuation of the clot by IR on [**2136-10-18**]. She was then
transitioned from heparin to coumadin.
Delirium: The patient began to develop worsening delerium and
agitation on [**2136-9-28**]. Initially this was felt to be secondary to
worsening infection or medication effects. All potential
offending medications were discontinued and blood and urine
cultures were obtained which were negative. She received haldol
and benzodiazepines for her severe agitation with resulting
apneic episodes. Multiple head CTs were negative for acute
intracranial process. At the time of her acute decompensation
the patient was complaining of shoulder and knee pain.
Rheumatology was consulted who performed an arhtrocentesis of
her knee which was negative for infection. An ultrasound of her
shoulder was performed which was not consistent with acute
infection. Her agitation persisted throughout her MICU course.
With limiting sedating medications, the patient mental status
improved and she appeared to respond to questions appropriately
and to follow commands in the days prior to discharge.
HIT Antibody Positive: On admission the patient was found to be
HIT antibody positive and was placed on an argatroban drip. She
later was found to have a negative serotonin release assay and
heparin products were reinitiated without complication.
Fluctuating Blood Pressures: Throughout this admission the
patient has been noted to have very labile blood pressures which
are very sensitive to propofol and fentanyl. Blood pressure
ranging from the 70s to 240s systolic. When the patient was
adequately sedated she would be hypotensive and as soon as her
sedation was lifted she would become agitated and hypertensive.
Given the patient's fluctuating blood pressures her
antihypertensive medications were limited. Her blood pressure
was extremely sensitive to sedative medications.
Junctional Rhythm: Patient was noted to have evidence of a
junctional rhythm which was associated with midazolam use.
Midazolam was thus avoided as much as possible.
ESRD: On admission she was thought to have evidence of a line
infection and her HD catheter was removed and replaced on [**9-26**].
The patient was followed by the dialysis team throughout her
MICU course. Given that she was receiving tube feeds her
sevelamer was discontinued and switched to calcium acetate for
phosphorus binding. She was continued on eopgen at dialysis.
The use of epogen in this patient with SVC syndrome and the
possibility of increased risk of clot formation were discussed.
Given that she is anticoagulated with severe anemia in end-stage
renal she was continued on epogen, though this issue may need to
be re-addressed in the future. She received hemodialysis per the
dialysis team.
Type II Diabetes: The patient was maintained on an insulin
sliding scale as an inpatient.
Medications on Admission:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
3. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Enterobacter line infection
E. Coli pneumonia
SVC syndrome
Labile blood pressure
Delirium
ESRD on HD
Anemia
DM
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a line infection and had a long
hospitalization with numerous complications. You will continue
to receive care at a rehab facility.
.
Take all medications as prescribed.
.
Attend all follow-up appointments.
.
Call your doctor or return to the hospital for worsening
shortness of breath or falling oxygen saturation, persistent
fevers, new upper or lower extremity swelling or any other
concerning symptoms.
Followup Instructions:
You must have your INR checked every other day and obtain dosage
recommendations on your coumadin from a physician for [**Name Initial (PRE) **] goal INR
of [**2-25**].
.
Primary care: Dr. [**Name (STitle) 70804**] Tuesday [**2137-1-1**]
2:30PM.
.
Hematology: You will be contact[**Name (NI) **] with an appointment time. If
you do not hear from the hematology department in the next 1
week, please call ([**Telephone/Fax (1) **]) to schedule an appointment.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2137-2-5**]
1:00
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27,166
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33664
|
Discharge summary
|
report
|
Admission Date: [**2195-2-14**] Discharge Date: [**2195-3-9**]
Date of Birth: [**2153-2-18**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Betadine
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Liver failure
Major Surgical or Invasive Procedure:
Patient was intubated on [**2195-2-21**] for hypoxia and bronchoscopy
demonstrated thick blood clot in lower left lobe, with evidence
of post-obstructive pneumonia past the blood clot.
History of Present Illness:
Ms. [**Known lastname **] is a 41yo female with PMH significant for hepatitis C
and ETOH abuse who is being transferred from [**Hospital 1474**] Hospital
for fulminant hepatic failure. Per patient, she presented to the
OSH with N/V and epigastric pain. She describes a burning pain
in her chest. She feels like she needs to burp but is unable to.
She denies any hematemesis or hemoptysis. She also admits to
significant tylenol use over the past 7 days to help relieve her
pain. She thinks that she was taking approximately 20 tablets
per day. Per boyfriend, she was taking 1000mg every 2 hours for
7 days. She denies a suicide attempt. She denies any fevers,
chills, jaundice, abdominal distention, poor urine output, LE
edema, or any other concerning symptoms. She does admit to poor
PO intake. Her last alcoholic beverage was on [**Hospital 766**]. She drank
approximately [**12-31**] gallon of hard liqour. No recent drug use. She
noticed that her eyes were yellow today and also felt slightly
confused.
.
Initial vitals at OSH were T 95 BP 138/78 AR 105 RR 20 O2 sat
99% RA. Preliminary labwork revealed fulminant hepatic failure,
renal insufficiency, and lactic acidosis. She received a total
of 4L NS. She was then loaded with Mucomyst 11,120mg IV over 60
minutes and then given 4100 over 4 hours.
Past Medical History:
1)Hepatitis C: Diagnosed in [**2171**], has not received any treatment
2)Mitral valve prolapse
Social History:
Patient lives with boyfriend and 18yo son. Unemployed. Alcohol
use since the age of 20. Consumes approximately [**12-31**] to 1 gallon
of hard liquor. Smokes 1ppd. Occasional drug use. Per boyfriend,
smoked cocaine several weeks ago. No IVDA.
Family History:
Mother and sister with hepatitis C.
Physical Exam:
Physical Exam:
vitals T 97.9 BP 138/88 HR 96 RR 12 O2 sat 100% on 4L
i/o 1.8 in/ 785cc out
Gen: Patient awake and alert, appears flushed
HEENT: MMM, +scleral icterus, yellow face
Heart: distant hrt sounds, tachycardia, no m,r,g
Lungs: CTAB, rhonchi throughout
Abdomen: soft, tenderness to palpation in RUQ, negative [**Doctor Last Name 515**]
sign, tenderness to palpation in epigastrum
Extremities: No LE edema, 2+ DP/PT pulses bilaterally
Neuro: No asterixis
Pertinent Results:
LFTS
[**2195-2-14**] 01:20AM BLOOD ALT-1427* AST-7002* LD(LDH)-4595*
AlkPhos-122* Amylase-58 TotBili-5.7*
[**2195-2-14**] 05:48AM BLOOD ALT-1318* AST-6454* LD(LDH)-3970*
AlkPhos-127* TotBili-5.9*
[**2195-2-14**] 05:40PM BLOOD ALT-1076* AST-4926* LD(LDH)-2079*
AlkPhos-132* TotBili-7.3*
[**2195-2-15**] 04:54AM BLOOD ALT-868* AST-3418* LD(LDH)-893*
AlkPhos-134* TotBili-7.8*
[**2195-2-17**] 03:35AM BLOOD ALT-387* AST-716* AlkPhos-160*
TotBili-12.9*
[**2195-2-18**] 04:51AM BLOOD ALT-270* AST-288* LD(LDH)-354*
AlkPhos-160* TotBili-14.2*
[**2195-2-19**] 04:17AM BLOOD ALT-190* AST-196* LD(LDH)-344*
AlkPhos-166* TotBili-14.4*
[**2195-2-20**] 04:22AM BLOOD ALT-148* AST-158* LD(LDH)-341*
AlkPhos-168* TotBili-14.7*
[**2195-2-23**] 05:19AM BLOOD ALT-74* AST-177* LD(LDH)-338*
AlkPhos-146* TotBili-12.8*
[**2195-2-28**] 05:55AM BLOOD ALT-48* AST-115* LD(LDH)-259*
AlkPhos-141* TotBili-9.4*
[**2195-3-3**] 06:55AM BLOOD ALT-39 AST-84* LD(LDH)-227 AlkPhos-173*
Amylase-30 TotBili-6.0*
[**2195-3-7**] 05:13AM BLOOD ALT-39 AST-85* LD(LDH)-209 AlkPhos-167*
TotBili-5.4*
[**2195-3-9**] 06:00AM BLOOD ALT-34 AST-62* LD(LDH)-194 AlkPhos-149*
TotBili-4.9*
COAGS
*
[**2195-2-14**] 01:20AM BLOOD PT-37.7* PTT-52.7* INR(PT)-4.1*
[**2195-2-14**] 01:20AM BLOOD Plt Ct-188
[**2195-2-14**] 05:48AM BLOOD PT-35.3* PTT-50.7* INR(PT)-3.7*
[**2195-2-14**] 05:48AM BLOOD Plt Ct-191
[**2195-2-14**] 05:40PM BLOOD PT-28.6* PTT-50.2* INR(PT)-2.9*
[**2195-2-16**] 03:55AM BLOOD PT-22.3* PTT-63.6* INR(PT)-2.1*
[**2195-2-26**] 05:25AM BLOOD PT-14.7* PTT-33.0 INR(PT)-1.3*
[**2195-3-9**] 06:00AM BLOOD PT-15.2* PTT-35.5* INR(PT)-1.3*
[**2195-2-14**] 01:42AM BLOOD AFP-5.4
[**2195-2-14**] 01:42AM BLOOD HBsAg-NEGATIVE IgM HBc-NEGATIVE IgM
HAV-NEGATIVE
[**2195-3-4**] 07:00AM BLOOD T3-73* Free T4-1.2
[**2195-3-3**] 06:55AM BLOOD TSH-11*
[**2195-2-14**] 01:20AM BLOOD Ammonia-175*
[**2195-3-3**] 06:55AM BLOOD Ammonia-53*
[**2195-2-27**] 06:20AM BLOOD VitB12-1549* Folate-18.1
CHEM 7
*
[**2195-2-14**] 01:20AM BLOOD Glucose-137* UreaN-21* Creat-1.5* Na-133
K-4.5 Cl-93* HCO3-25 AnGap-20
[**2195-3-9**] 06:00AM BLOOD Glucose-112* UreaN-3* Creat-0.9 Na-134
K-3.5 Cl-104 HCO3-24 AnGap-10
CBC
*
[**2195-2-14**] 01:20AM BLOOD WBC-8.0 RBC-3.16* Hgb-12.4 Hct-33.8*
MCV-107* MCH-39.4* MCHC-36.7* RDW-13.0 Plt Ct-188
[**2195-3-9**] 06:00AM BLOOD WBC-8.6 RBC-2.24* Hgb-8.4* Hct-26.2*
MCV-117* MCH-37.7* MCHC-32.2 RDW-13.9 Plt Ct-261
CT HEAD [**2-17**]
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or acute territorial infarction. The ventricular system
appears within normal limits. The sulci are slightly prominent
for the patient's age. Soft tissues and bone structures appear
unremarkable. The paranasal sinuses demonstrate bilateral
ethmoidal mucosal thickening. The visualized aspect of the
maxillary sinuses also demonstrates mucosal thickening. Fluid
level is identified in the sphenoidal sinus. The mastoid air
cells demonstrate normal aeration.
.
IMPRESSION: There is no evidence of hemorrhage, edema, or acute
territorial infarction.
.
Mild prominence of the sulci for the patient's age. Bilateral
ethmoidal mucosal thickening, there is also mucosal thickening
in the visualized aspect of the maxillary sinuses and the
sphenoidal sinus.
TTE [**2-17**]
The left atrium is normal in size. 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
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 pericardial effusion.
[**2195-2-19**] Abdominal US
FINDINGS: The liver is heterogeneous and predominantly
echogenic. There is a 2.1 x 1.6 x 2.1 cm well-circumscribed more
echogenic lesion in the left hepatic lobe, without internal
flow, compatible with a hemangioma. There is no intrahepatic
biliary ductal dilatation. The common duct measures 3.3 mm. The
spleen is not enlarged at 11.8 cm. The main portal vein is
patent, with hepatopetal flow.
.
The gallbladder demonstrates moderate wall thickening and
pericholecystic fluid. However, it is not distended and contains
no stones. There is no upper abdominal ascites. The distal
abdominal aorta is obscured. The remainder demonstrates a normal
caliber. The pancreas appears grossly unremarkable. Both kidneys
demonstrated normal echogenicity, without hydronephrosis or
calculi. The right kidney measures 14.3 cm and the left kidney
measures 12.9 cm.
.
IMPRESSION:
1. Gallbladder wall thickening and pericholecystic fluid is
believed to be related to liver disease rather than acute
cholecystitis, given the absence of gallbladder distention.
2. Echogenic liver, compatible with fatty infiltration.
Additional and more severe forms of liver disease including
fibrosis cannot be excluded.
3. Hepatic hemangioma in the left lobe.
CTA CHEST [**2-22**]
CT CHEST WITH CONTRAST: There is partial collapse of the left
lower lobe and superimposed patchy consolidations that do not
enhance as well, suspicious for superimposed pneumonia. There is
a small left pleural effusion. There is very mild atelectasis at
the right base with a very small pleural effusion. The airways
are otherwise clear, though limited by respiratory motion.
.
The patient is intubated with the endotracheal tube
approximately 3.5 cm above the carina. NG tube is located in the
stomach. The pulmonary arteries opacify without filling defects.
.
The heart and other great vessels of the mediastinum are
unremarkable. There are multiple prominent but
non-pathologically enlarged mediastinal and left hilar lymph
nodes, likely reactive. No pathologic axillary adenopathy is
present.
.
The visualized portions of the liver demonstrate diffuse fatty
infiltration of the liver. No suspicious lesions are identified
in the bones but note is made of multiple healed left posterior
rib fractures.
.
IMPRESSION:
1. Partial left lower lobe collapse with superimposed pneumonia.
2. No evidence for pulmonary embolism.
3. Fatty liver.
[**2195-2-27**]
CT CHEST w/o constrast
CT OF THE CHEST WITHOUT IV CONTRAST: There are several mildly
prominent paratracheal lymph nodes, which are unchanged. All
measure less than 10 mm in shortest axis dimension. A discretely
identifiable left hilar lymph node of 5 mm in width (2:28) is
also unchanged. Bilateral hilar lymph nodes visualized on the
recent CT are difficult to distinctly identify without
intravenous contrast, but the right hilar contour appears
similar.
.
There has been progressive atelectasis of the left lower lobe,
which is now fully collapsed with near occlusion of the distal
left lower lobe bronchus. A small left-sided pleural effusion is
somewhat larger than before, and a tiny right-sided pleural
effusion with minimal associated atelectasis has also increased
somewhat.
.
There are several new poorly defined nodules in the right upper
lobe (3:22, 30, 31, and 34) and an apical nodule has grown.
.
The patient has been extubated. A nasogastric tube enters the
stomach. Otherwise, limited views of the upper abdomen are
unremarkable.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
.
IMPRESSION:
1. New ill-defined nodules in the right upper lobe, suggestive
of invasive fungal infection, as suspected clinically.
2. Progressive atelectasis of the left lower lobe, now fully
collapsed.
3. Larger, but small pleural effusions, with new trace ascites.
[**2195-3-8**] CT CHEST w/o contrast
CT CHEST WITHOUT CONTRAST: There are several prominent
mediastinal and hilar lymph nodes that do not meet CT size
criteria for enlargement. Heart size is normal.
.
Partial collapse of the left lower lobe is improved since
[**2195-2-27**]. Bilateral simple layering pleural effusions, left
greater than right, have slightly increased in size since
[**2195-2-27**]. Several nodules in the right upper lobe have decreased
in size since [**2195-2-27**] (4:111,155). Patchy opacity in the right
lower lobe may represent atelectasis or infiltrate, and if
infiltrative, represents incresed infectuous burden in the right
lower lobe.
.
Bone windows demonstrate no suspicious lytic or blastic lesions.
.
Although this exam was not optimized for subdiaphrahmatic
diagnosis, the imaged abdominal organs are unremarkable
.
IMPRESSION:
1. Ill-defined nodules in the right upper lobe are moderately
decreased in size since [**2195-2-27**] although right lower lobe has
patchy opacities that may represent atelectasis or infiltrate
are more prominent since that time.
2. Partial atelectasis of the left lower lobe has improved since
[**2195-2-27**].
3. Small bilateral pleural effusions, slightly larger than on
[**2195-2-27**]
[**2195-3-7**]
MRI ABD w/ and w/o contrast
FINDINGS: Bilateral pleural effusions and lower lobe atelectasis
are noted and better evaluated on the recent chest CT of [**3-8**], [**2194**] and [**2195-2-27**]. There is mild loss of signal
intensity on out-of-phase images in comparison with in-phase
images throughout the liver consistent with fatty infiltration.
Heterogeneous enhancement throughout the hepatic parenchyma
suggests the possibility of underlying cirrhosis although the
hepatic contour is not nodular. In segment III (100:80; 4:27), a
1.9 X 1.8 cm nodule is seen which corresponds with the echogenic
focus on ultrasound of [**2195-2-19**]. The lesion is mildly
hyperintense to hepatic parenchyma on T2-weighted images and
contains a linear band of precontrast T1 hyperintensity
centrally. There is minimal enhancement on post-gadolinium
images and no evidence of peripheral rim enhancement. No other
focal hepatic lesions are identified. The portal vein is patent,
and there is no biliary ductal dilation. The gallbladder is
nondistended with mural edema. There is splenomegaly (14 cm).
Mildly enlarged periportal lymph nodes are present up to 8 mm in
diameter. The pancreas, adrenal glands and kidneys appear
unremarkable. There is no ascites.
Image marrow signal appears within normal limits.
Multiplanar reformations provided multiple perspectives for the
dynamic series with kinetic information.
IMPRESSION:
1. A 1.8 cm nodule in segment III of the liver, corresponding to
the echogenic focus seen on ultrasound, has indeterminate
features. Infectious etiology is considered, and given hepatic
risk factors hepatocellular carcinoma with atypical appearance
cannot be excluded. Atypical or thrombosed hemangioma is
possible, but continued surveillance in short-term (three
months) with MRI is recommended.
2. Fatty infiltration of the liver and features consistent with
cirrhosis. Mild splenomegaly.
3. Gallbladder edema consistent with underlying liver disease.
Brief Hospital Course:
Ms. [**Known lastname **] is a 41 year old F who was transferred to [**Hospital 18**]
hospital MICU from an OSH for unintentional tylenol overdose 1gm
q 2 hours x 7day, w/ liter of vodka a day for greater than a
month, noted to have developed fulminant hepatic failure.
Patients hepatic failure was complicated by hypoxic respiratory
failure requiring intubation. Patient was treated empirically
for a hospital aquired pneumonia. She underwent bronchoscopy and
was found to have a large aspergillus bronchus cast. She was
treated with caspofungin for likely invasive fungal disease. She
was then transitioned to PO voriconazoles as an outpatient.
Patient was noted to have a persistently collapsed left lower
lobe of her lung. Despite this her respiratory status continued
to improve during hospital stay until she was successfully
weaned off of supplemental oxygen. Patient was encephalopathic
during most of her hospital stay, but cleared mentally by
discharge. Pt was also noted to have VRE in her urine, but this
was thought to be an asymptomatic colonization. Patients hepatic
function continued to improve during her hospital course. She
was also noted to have hepatitis C. Of note a 1.9 x1.8cm mass
was found in patients liver on ultrasound. This was confirmed on
MRI. The mass was felt to be either a hemangioma or an atypical
hepatocellular carcinoma. Follow up was recommended. During stay
patient was also treated for a gluteal skin
infection/cellulitis. The issues of substance abuse were
addressed with the patient. Patient was recommended to a
substance abuse program by social work. Pt was willing to
participate in AA, but felt that she did not need an inpatient
substance abuse program. She was told that she could absolutely
not have another drink of alcohol and that she should avoid the
use of tylenol in the future.
.
# Hepatic failure: Patient presented to OSH with markedly
elevated LFTs, elevated INR consistent with fulminant liver
failure. A CT abd/pelvis did not reveal cirrhosis but did
reveal a mass in her liver, as she did have a history of
hepatitis C and significant ETOH abuse. This was a likely
subacute event of liver failure as patient was on tylenol over
the past 1-2 weeks superimposed on underlying liver disease.
Her tylenol level was initially 21. She was loaded with
N-acetylcysteine at OSH for presumed Tylenol intoxication so
toxicology and liver were both involved. She was maintained on
N-acetylcysteine infusion until her coagulation normalized. Her
coagulation factors and LFTs were monitered daily and trended
down towards normal. She had an ultrasound which demonstrated a
likely hemangioma in the liver and alpha feto-protein was low.
Serologies were also checked demonstrating that patient had
Hepatitis C with no evidence of other hepititidies and HIV was
negative. Blood cultures on [**2195-2-22**] were negative for growth.
.
# Mental status changes: Patient had difficulty with mental
status during hospital course. Initially felt to be due to
hepatic encephalopathy from liver failure above, as ammonia
level was elevated, as well as from alcohol withdrawl as patient
noted to have DTs. She was treated with lactulose and rifaximin
for hepatic encephalopathy, and with IV valium for treatment of
alcohol withdrawl. It was felt as though the valium she
received for her alcohol withdrawl was slow to clear given her
liver failure, so her mental status was monitered closely.
Lactulose and rifaximin continued and titrated to stool output.
She improved to baseline at discharge. Patient was discharged on
lactulose.
.
# Respiratory failure: Patient intubated on [**2195-2-21**] for hypoxia
initially of unknown etiology. She underwent bronchoscopy on
day of intubation that demonstrated thick blood clot in LLL,
with evidence of post-obstructive pneumonia past the blood clot.
She underwent CTA which was negative for PE, but again showed
evidence of post-obstructive pneumonia. BAL washings during
bronchoscopy were sent for culture and for cytology. Cultures
were negative, cytology was negative for malignant cells,
predominantly blood with a few bronchial cells and macrophages.
Vanc/Zosyn were discontinued on [**2195-2-24**]. She was successfully
extubated on [**2-24**]. Chest CT on [**2195-2-27**] showed new nodules in
the right upper lobe suggestive of invasive fungal infection.
CT also showed fully collapsed atelectasis of the left lower
lobe. Prior blood clot found on bronchoscopy was found to be
mixed clot and aspergillus. Patient was begun on IV caspofungin
as fungal disease was felt to be invasive (however this was
debated). Patient had a second bronchoscopy in order to try to
reopen collapsed left lower lobe of lung. LLL remained collapse
on imaging. Pt was transitioned to oral voriconazole at
discharge for a 21 day course. She was scheduled for weekly
LFTs. patient is due for repeat CT in 8 weeks. Repeat
bronchoscopy, pulm and ID follow up as is indicated in discharge
planning below.
.
# Liver mass: Patient was noted to have a mass in liver on CT
scan at OSH. Concerned about an underlying malignancy given
history of underlying liver disease. AFP checked and was normal
at 5.4. RUQ U/S demonstrated likely hemangioma. MRI suggested
cirrhosis, and noted a 1.9 X 1.8 cm nodule. The interpretation
of the MRI was that the nodule could be of infectious etiology,
an atypical hepatocellular carcinoma or a thrombosed hemangioma.
Radiology recommended repeat MRI in 3 months. This was indicated
to patient.
.
# Acute renal failure: Patient presented with Cr~1.8 to OSH.
Improved to 1.5 on admission. This ARF resolved during hospital
course with IVF hydration. Then on [**2-23**] patient developed an
elevation in Cr again to 1.8. This was in the setting of
receiving large dye load for a CT scan. Felt that patient had
developed a contrast nephropathy. Cr was 0.9 at d/c.
.
# Anion gap acidosis: Patient presents with mildly elevated
anion gap~15 in the setting of renal failure and high lactate.
Elevated lactate may be secondary to underlying liver disease
(decreasing metabolism of lactate) which is improving in the
setting of hydration. Acidosis and elevated lactate resolved
after initial IVF hydration.
.
# Epigastric pain: Patient presented to OSH with burning
epigastric pain. History suggests underlying gastritis vs. PUD.
She was maintained on protonix 40mg IV daily, with plans to
re-address upon clearance of above issues. C.diff toxin on
[**2195-2-27**] and [**2195-2-28**] were negative, stool cultures on [**2195-2-26**]
was negative for Salmonella, Campylobacter, and Enteric gram
negatives. All blood cultures were negative.
.
# Substance abuse: She has a history of significant alcohol
abuse. She also smokes and has a history of drug use. Initial
tox screen was unremarkable. She was treated for alcohol
withdrawl as above. Also given her high risk behavior,
hepatitis serologies and HIV were sent, which returned positive
for known Hep C only. Social work saw her upon resolution of
mental status issues and recommended her for rehab. She refused
rehab and was willing to attend AA as an outpatient. Patient was
discharged on thiamine and folic acid.
.
#Smoking Cessation was encouraged. Pt was discharged w/ nicotine
patch.
.
#VRE colonized urine: Urine culture on [**2-22**] had VRE, changed
foley on floor. Repeat UA, on [**1-/2116**] was negative. VRE precautions
while inpatient.
.
# Hospital Acquired PNA: Patient received 7 days of Abx
cipro/vanc.
.
# Buttock Cellulitis: Treated w/ a 7 day course Vanc/cipro.
#Hypernatremia: treated with IV fluid boluses
.
#FEN: Patient received TF while her mental status was altered.
She had transient hypernatremia which was treated with free
water boluses. She was eventually transitioned back to a low
sodium diet.
.
# Follow up as described in discharge worksheet.
Medications on Admission:
Medications on transfer:
Mucomyst
Protonix
Zofran
Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day:
Blood pressure control.
Disp:*60 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
twice a day.
Disp:*1 1* Refills:*2*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Voriconazole 50 mg Tablet Sig: Six (6) Tablet PO Q12H (every
12 hours) for 21 days: 300mg twice a day.
Disp:*360 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Liver function panel, electrolyte panel, please fax results to
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] from ID [**Telephone/Fax (1) 432**]
11. CT Scan
CT scan of the chest for [**2195-3-24**]. No contrast.
12. CT scan
CT chest w/o contrast. [**2195-5-20**]
13. MRI/MRA liver
MRI/MRA of liver on [**5-21**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Fulminant hepatic failure
2. Mental status changes
Secondary
3. Aspergillus pneumonia
3. Respiratory failure
4. Liver mass
5. Acute renal failure
6. Anion gap acidosis
7. Epigastric pain
8. Substance abuse
9. Leukocytosis
10. Hypernatremia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
because of fulminant hepatic failure due to unintentional
tylenol overdose 1gm q 2 hours x 7day, w/ liter of vodka a day
resulting in fulminant hepatic failure. This was complicated by
respiratory failure that required intubation, but you were
extubated, with continued hepatic encephalopathy, colonized
Vancomycin resistent E.Coli in your urine, and a bronchoscopy
and removal of a fungus ball.
.
You were found to have an fungal pneumonia. For this fungal
pneumonia you need to complete 3 more weeks of antifungal
therapy. We want you to have a repeat chest CT done on [**3-18**].
This can be done at the [**Hospital Ward Name **] of [**Hospital1 18**].
.
You will then need a repeat CT again 8 weeks from now and a
repeat bronchoscopy to make sure that you have cleared the
fungal pneumonia.
.
You will take voriconazole 300mg twice a day for 21 days. Please
get your liver funtion checked on [**2195-3-14**].
.
During your hospital stay you were also treated for a bacterial
pneumonia and a cellulitis.
.
We also found you to have a mass in your liver. You had an MRI
during your hospital stay, but it is unclear if this mass is a
tumor or just a vessel. As a result we want you to get a repeat
MRI of your liver in 3 months.
.
If you experience worsening jaundice, nausea, vomiting,
dizziness/lightheadedness, loss of consciousness, abdominal
pain, fever greater than 101.5 degrees F, or any other symptoms
that concern you, please go to the nearest Emergency Room or
call your primary care physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in [**Hospital **] clinic. You have an
appointment scheduled with him for [**2195-3-27**] at 930am in
the basement of the [**Hospital Unit Name **], [**Street Address(2) **].
.
Please have your liver function tests faxed to Dr. [**First Name (STitle) 1075**] at
[**Telephone/Fax (1) 432**].
.
Please follow up with Dr. [**Last Name (STitle) **] from the department of
Interventional Pulmonary medicine. You will need to call
[**Telephone/Fax (1) 3020**] to schedule a follow up appointment.
.
Please call [**Telephone/Fax (1) 3020**] to get a follow-up bronchoscopy during
this period of time.
.
Please follow up with your new primary care physician at [**Hospital1 18**],
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**4-1**] at 3pm on the [**Location (un) **] of the
[**Hospital Ward Name 23**] building [**Hospital1 18**] [**Hospital Ward Name 516**]. If you have to call to
change this visit call [**Telephone/Fax (1) 250**].
.
Please follow up with Dr.[**Last Name (STitle) **] [**Name (STitle) 766**], [**5-4**], at 930pm,
in [**Doctor First Name **] the [**Location (un) **]. Please call [**Telephone/Fax (1) 2422**] if
you must change this appointment.
|
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"33.24",
"96.56",
"96.6",
"33.22",
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] |
icd9pcs
|
[
[
[]
]
] |
22999, 23005
|
13599, 21446
|
291, 478
|
23300, 23310
|
2743, 13576
|
24941, 26229
|
2209, 2247
|
21547, 22976
|
23026, 23279
|
21472, 21472
|
23334, 24918
|
2277, 2724
|
238, 253
|
506, 1813
|
21497, 21524
|
1835, 1932
|
1948, 2193
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,288
| 115,816
|
25688
|
Discharge summary
|
report
|
Admission Date: [**2170-6-28**] Discharge Date: [**2170-7-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
transfer from [**Hospital3 26615**] Hospital w/ GIBleed
Major Surgical or Invasive Procedure:
CABG [**2161**]
cholecystectomy
appendectomy
Total abdominal hysterectomy
History of Present Illness:
Pt is an 85 yo lady w/ recent admit for NSTEMI, CHF ?EF, LE
cellulitis, Afib on coumadin, severe AS, who presents from [**Hospital 39437**] ICU w/ LGIB. She initially presented from a subacute
facility on [**2170-6-24**] with "mahogany stools" x 1 day. She had a
hct checked which was 29.9 from 34.2 on [**6-21**]. She was supposed
to have outpatient c scope/sigmoidoscopy, but then started
passing bright red clots and was admitted to the ICU. VS noted
to be BP 116/60, P 60's, sat 98%.
.
She was evaluated with a colonoscopy that showed blood
throughout the colon but "darker" on the right side. Small
polyps noted, but not removed. A larger 1.5 cm polyp noted at 40
cm in sigmoid that was bleeding from its base. This was not
removed [**2-7**] coagulopathy (INR 2.3), but endoloop placed at the
base and three hemoclips placed w/ good hemostasis. Non bleeding
hemorrhoids also noted. Since the procedure, patient has been
"oozing" blood and has required 2 units per day, totalling 7?
units since her admission, 3 units of FFP. She had a pan
positive bleeding scan throughout colon (see report below). She
remained hemodynamically stable throughout her admission and was
transferred here for further evaluation and treatment. Aspirin,
plavix, and coumadin were held. Vitamin K given as well.
Patient has been monitored in the MICU. She received blood
transfusions as well as FFP to reverse her coagulopathy ;
aspirin, plavix and coumadin were all held. She was evaluated by
GI and underwent a colonoscopy whihc demonstrated an AVM as the
cause of bleeding. The bleeding site was cauterized. She was
also found to have diverticulosis of the sigmoid colon that was
non-bleeding. Her hematocrit remained stable. MICU course was
complicated by episodes of desaturation whihc seemed to resolve
spontaneously and were thought to be secondary to mucus plugs.
Past Medical History:
CAD w/ recent NSTEMI [**6-10**]
CHF w/ ?EF- no data sent
AS with area 0.86 cm2 per OSH record
CABG [**2161**]
Afib
chronic voice hoarseness-- known benign polyps
osteoporosis
chronic LE edema
PVD w/ non healing ulcers w/ recent tx for cellulitis
cholecystectomy
appendectomy
TAH
Social History:
quit tobacco 25 yrs ago- 10 pack year history; no etoh; lives
alone; DNR/DNI per records.
Family History:
father died of colon ca, age 70; CAD and HTN
Physical Exam:
T Afebrile
BP 138/42
HR 69
RR 31
sat 97% Humidified air
Gen: comfortable, thin, elderly lady, NAD
HEENT: MM dry, nasal cannula in place, hoarse/quiet voice
Neck: supple, JVP to ear?
Lung: bibasilar crackles, decreased breath sounds b/l with poor
inspiratory and expiratory effort.
CV: [**Year (4 digits) 64063**] [**Last Name (LF) 64063**], [**First Name3 (LF) **], harsh [**3-11**] crescendo/decrescendo sysolic
murmur w/ no rads to carotids or axilla. Poor peripheral pulses
(Upper and lower exremities).
Abd: soft, NT, normal bowel sounds, ND, no hsm
Ext: thin, dry skin, no edema, ecchymoses over LUE near IV site
Neuro: alert, conversant, appropriate, alert and oriented x 1
(self). Follows all commands. cranial nerves intact.
Pertinent Results:
[**2170-6-28**] 10:18PM HCT-32.2*
[**2170-6-28**] 05:43PM GLUCOSE-76 UREA N-27* CREAT-0.8 SODIUM-148*
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-44* ANION GAP-10
[**2170-6-28**] 05:43PM ALT(SGPT)-14 AST(SGOT)-31 LD(LDH)-197
CK(CPK)-69 ALK PHOS-65 TOT BILI-1.8*
[**2170-6-28**] 05:43PM CK-MB-NotDone cTropnT-0.07*
[**2170-6-28**] 05:43PM CALCIUM-9.2 PHOSPHATE-3.3 MAGNESIUM-1.4*
[**2170-6-28**] 05:43PM WBC-8.5 RBC-4.12* HGB-11.7* HCT-34.1* MCV-83
MCH-28.4 MCHC-34.3 RDW-17.9*
[**2170-6-28**] 05:43PM NEUTS-82.9* LYMPHS-10.8* MONOS-4.3 EOS-1.4
BASOS-0.5
[**2170-6-28**] 05:43PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MICROCYT-1+
[**2170-6-28**] 05:43PM PLT COUNT-86*
[**2170-6-28**] 05:43PM PT-12.8 PTT-26.8 INR(PT)-1.1
Brief Hospital Course:
85F with history of NSTEMI, CHF, LE cellulitis, Afib on
coumadin, severe AS, who presented from [**Hospital3 26615**] ICU w/ LGIB.
.
1. GI bleed: Evidence of bleeding on colonoscopy with bleeding
polyp in the colon s/p endoloop placed at the base and three
hemoclips placed w/ good hemostasis but that continue to bleed.
Pt was seen by GI because she continued to have blood loss per
rectum. Given patient's recent MI there was concern for ischemia
if bleeding recurred. Pt was typed and crossed in the event of a
recurrent bleed.
.
2. Aortic stenosis: fluid balance was carefully regulated given
pt' pre load dependent status. Of note, Aortic Valve 0.8 cm;
gradient unknown.
.
3. CAD: Aspirin/plavix were held as was atenolol (pt
bradycardiac). Had recent NSTEMI ([**6-10**]) and CABG [**2161**]. EKG on
[**2170-7-4**] showed previous atrial fibrillation with PVCs, left axis
deviation, IV conduction defect and lateral ST-T changes likely
due to myocardial ischemia. The pt also continued to have a
persistent Trop leak that had been noted at the outside
(referring) hospital. During her admission, the pt did not
complain of any chest pain.
.
4. AF: given pt's GI bleed and relative bradycardia, coumadin
and beta-blocker were held, respectively.
.
5. CHF: EF unknown. We did decide to repeat echo if pt went into
respiratory distress. We managed the pt's pleural effusions
with Lasix prn and gave her prbc's to prevent further cardiac
strain.
.
6. GI: was on flagyl 250 po tid at the OSH for presumed C.Diff.
She had no wbc elevation. We planned on sending stool cultures
in the event of future diarrhea suggestive of C. difficile. Pt
had a few episodes of LGIB and on colonoscopy was found to have
an AVM in transverse colon that was cauterized.
7. code: After discussion with the family it was decidde that
the patient's code status would be DNR/DNI and CMO.
** The patient expired on [**2170-7-4**] due to progressive respiratory
distress likely due to mucus plugging. She had a progressive
decline in mental status and was eventually at a risk for
aspirating. AFter extensive discussion with the family it was
decided that the staff would provide comfort only measures.
Medications on Admission:
MEDS ON transfer:
Protonix 40 mg IV qd
lasix 20 mg po bid (+lasix IV prn (in between prbc's)
atenolol 12.5 mg qd
ntg patch 0.1 on am, off pm
asa 325 mg on hold
plavix on hold
digoxin 0.125 mg qd
zoloft 50 mg qd
coumadin on hold
flagyl 250 po tid
KCl 10 meq qd
vitamin K 10 mg PO and 10 mg sc x 1
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
1. AVM
2. CAD w/ recent NSTEMI [**6-10**]
3. CHF
4. Aortic Stenosis
5. Afib
6. Chronic voice hoarseness-- known benign polyps
7. Osteoporosis
8. Chronic Lower Extremity edema
9. Peripheral Vascular Disease
Discharge Condition:
Patient expired [**2170-7-4**].
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
Completed by:[**2170-9-17**]
|
[
"518.81",
"285.1",
"478.32",
"511.9",
"V58.61",
"428.0",
"783.21",
"410.72",
"427.31",
"V45.81",
"569.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6845, 6854
|
4275, 6459
|
317, 393
|
7103, 7136
|
3520, 4252
|
7199, 7244
|
2703, 2749
|
6806, 6822
|
6875, 7082
|
6485, 6485
|
7160, 7176
|
2764, 3501
|
222, 279
|
421, 2277
|
2299, 2580
|
2596, 2687
|
6503, 6783
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,553
| 126,138
|
9146
|
Discharge summary
|
report
|
Admission Date: [**2122-10-31**] Discharge Date: [**2122-12-10**]
Date of Birth: [**2076-12-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Change in mental status, epistaxis and falls
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central line placement
Paracentesis
Continuous [**Last Name (un) **]-venous hemodialysis
History of Present Illness:
45 year-old male with EtOH/Hep C cirrhosis, portal hypertension,
hepatic encephalopathy admitted to [**Hospital1 2177**] [**2122-10-26**] with mental
status changes and epistaxis. Patient noted to have increased
falls, hallucinations and confusion at home prior to admission
as well as some diarrhea and hematuria preceeding his admission.
On admission he was lethargic and icteric, with BP 122/80, HR
59, satting 100%RA, oriented x 2. He had a paracentesis which
ruled out SBP. Over the next several days, his INR continued to
climb (from 2.7 on admission to 4.0 on transfer). His
creatinine also climbed (up to 5.5 on transfer from 0.8 @
baseline) with decreased urine output. He received IVF and
bicarbonate as well as albumin without improvement. He was
noted to have R hydronephrosis, however his ARF was attributed
to hepatorenal syndrome and not to obstructive hydronephrosis.
He was also noted to have waxing and [**Doctor Last Name 688**] mental status that
was attributed to hepatic encephalopathy. On [**2122-10-29**] he
received 2 U PRBC's for hct 19, but his hct has largely been
stable ~ mid 20's.
The day prior to transfer to [**Hospital1 18**], pt was transferred to the
[**Hospital1 2177**] ICU for decreased mental status. At that time he was noted
to have asterixis and increased lethargy. He had had no melena
or hematemesis over the course of his hospitalization. His
vitals today prior to transfer were T 99.8 106/64 65 96%RA. He
had been hemodynamically stable througout his hospitalization.
His I/O over the time in the ICU was 600cc in/500cc out (all
urine).
Currently, patient is unable to answer questions regarding his
condition. Patient was transferred initially to the floor but
represented to the MICU with persistent and heavy penile
bleeding after possible traumatic insertion of a foley catheter.
Past Medical History:
Cirrhosis, EtOH/Hep C
Hepatic encephalopathy
Nonbleeding grade II esophageal varices
Depression s/p suicide attempt w/ drug overdose [**7-/2118**]
Hemorrhoids
Ascites
Portal hypertensive gastritis
Social History:
MR. [**Known lastname 31498**] is separated from his common law wife with whom he
has 6 children, works for [**Location (un) 86**] housing authority; prior to
admission was living w/ his mother. [**Name (NI) **] chart no EtOH x 6
months.
Family History:
Maternal great aunt w/ [**Name2 (NI) 2320**], no other FHx of ca or CAD.
Physical Exam:
PE: 98.8 135/97 61 95%RA
Gen: AA young M lying in bed in NAD having blood drawn by RN
HEENT: PERRLA, sclerae icteric, dried, crusted blood around
nares;
Heart: RRR, S1, S2, no m/r/g
Lungs: occ bibasilar crackles, no wheezing
Abd: distended, + fluid wave, no masses palpable
Ext: 1+ pitting edema b/l LE
Neuro: does not follow commands, does not answer questions,
obtunded, lethargic;
Pertinent Results:
Labs @ [**Hospital1 2177**] [**2122-10-31**]: hct 24.1 creat 5.5 BUN 67 wt 78.2kg
[**Hospital1 2177**] [**2122-10-26**]: diagnostic peritoneal tap clear fluid wbc 51 RBC
2375 alb <1.0 tot prot <2.0 (serum alb 2.2); cytology - no tumor
cells, few mesothelial cells; micro - NGTD x 2 days;
Admission creat 3.9 BUN 43 INR 2.8; T.bili 11.1 ALT 75 AST 143
alk phos 93, NH3 159; Serum tox negative;
[**9-19**] creat 0.8
[**2122-10-29**] @ [**Hospital1 2177**] hep C Ab +;
Radiology:
[**Hospital1 2177**] renal U/S new c/w [**2122-9-25**] small R hydro, no stones; L kidney
no stones or hydro; bladder not visualized [**2-16**] ascites.
Brief Hospital Course:
On admission, the patient's mental status change was felt
secondary to hepatic encephalopathy. Possible etiologies
included SBP, ARF, non-ascitic infection, epistaxis and
increased NH3 load from blood. Ascites evaluation was initially
negative for infection. CT head was within normal limits. His
renal failure was felt secondary to hepatorenal syndrome +/- ATN
secondary to intravascular volume depletion/prerenal failure
which was addressed.
The patient was evaluated by the transplant service early in his
hospital course, and initially considered a candidate for
liver/kidney transplant. Over the course of his hospitalisation,
he developed worsening renal failure requiring institution of
dialysis and CVVHD. His liver function also progressively
deteriorated, with evidence of worsening coagulopathy and
decreased hepatic reserve and synthetic function. His course was
further complicated by MSSA bacteremia/MRSA in sputum treated
with broad-spectrum antibiotics, respiratory failure requiring
intubation, then spontaneous bacterial peritonitis requiring
continued antibiotherapy. His hepatic function further
deteriorated with evidence of worsening coagulopathy and
hypoglycemia requiring continuous glucose infusion. On [**12-8**],
Mr. [**Known lastname 31498**] developed melena. An EGD revealed non-bleeding
esophageal varices and no ulcers, but evidence of oozing from
the gastric mucosa. He was medically managed and required
continued aggressive transfusional support for his anemia,
thrombocytopenia and coagulopathy. He also had recurrent
hypotensive episodes.
Given the above events and ominous prognostic signs, a consensus
recommendation, involving the hepatology service, transplant
surgery service and primary team, was made to withdraw the
patient from the transplant list on [**12-9**]. A family meeting was
held on [**12-10**] to review the hospital events and most recent
recommendation. The patient's ominous prognosis was also
reviewed. The decision was made by the family to withdraw care
and comforts measures were instituted. Mr. [**Known lastname 31498**] was
extubated. He expired on [**12-10**] at 20:58.
Medications on Admission:
Meds on transfer:
Zoloft 150mg po qd
Lactulose 20cc po qid
Protonix 40mg po qd
Anusol 25mg po qhs
Nadolol 40mg po qd
Midodrine 7.5mg po tid
Octreotide 100mg sc po tid
As outpt but held inpt: Llasix 40mg po qd, spironolactone 300mg
po qd
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver cirrhosis
Respiratory failure
Spontaneous bacterial peritonitis
Upper gastrointestinal bleed
Renal failure
Hepatic encephalopathy
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
Completed by:[**2122-12-11**]
|
[
"518.82",
"571.2",
"482.41",
"070.44",
"584.5",
"607.82",
"V09.0",
"428.0",
"572.3",
"572.4",
"585",
"567.2",
"599.0",
"286.7",
"038.11",
"995.92",
"285.1",
"401.9",
"535.01",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"96.72",
"33.24",
"45.13",
"39.95",
"54.91",
"96.6",
"38.95",
"96.04",
"38.93",
"99.07",
"99.04",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
6467, 6476
|
4000, 6140
|
362, 476
|
6656, 6673
|
3340, 3977
|
6737, 6784
|
2845, 2920
|
6427, 6444
|
6497, 6635
|
6166, 6166
|
6697, 6714
|
2935, 3321
|
278, 324
|
504, 2351
|
2373, 2572
|
2588, 2829
|
6184, 6404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,977
| 175,159
|
29893
|
Discharge summary
|
report
|
Admission Date: [**2188-1-10**] Discharge Date: [**2188-1-17**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x3 (Left internal mammary artery ->
Left anterior descending, saphenous vein graft -> obtuse
marginal, Saphenous vein graft -> right coronary artery), Atrial
Septal defect closure [**2188-1-11**]
History of Present Illness:
83 year old female with exertional chest pain for the last two
years. The chest pain has been progressively increasing and is
now limiting normal physical activities and referred for further
work up
Past Medical History:
Coronary Artery Disease
Atrial Septal defect
Elevated cholesterol
GERD
Arthritis
Anemia
Anxiety
Appendectomy
Tonsillectomy
varicose vein ligation
Social History:
Lives with spouse
Retired, worked for MDC
Tobacco 4 pack year history - quit 35 years ago
ETOH 3 drinks per week
Family History:
Father deceased at 54 from MI
brother deceased in 50's from MI
Physical Exam:
Admission
Vitals HR 77 RR 18 B/P 151/72, wt 57.2kg
General no acute distress
Skin unremarkable
HEENT unremarkable
Chest CTA bilaterally anteriorly
Heart RRR
Abdomen Soft NT, ND, +BS
Ext: warm well perfused no edema
Varicosities: bilat lower ext
Neuro: grossly intact
Pertinent Results:
[**2188-1-17**] 07:10AM BLOOD WBC-6.8 RBC-3.21* Hgb-10.0* Hct-28.6*
MCV-89 MCH-31.1 MCHC-35.0 RDW-15.7* Plt Ct-328#
[**2188-1-17**] 07:10AM BLOOD Plt Ct-328#
[**2188-1-13**] 03:30AM BLOOD PT-12.8 PTT-30.3 INR(PT)-1.1
[**2188-1-14**] 06:50AM BLOOD Glucose-108* UreaN-13 Creat-0.6 Na-136
K-4.2 Cl-101 HCO3-28 AnGap-11
[**2188-1-16**] 06:10AM BLOOD UreaN-16 Creat-0.6 K-3.6
Brief Hospital Course:
Admitted for cardiac catherization which revealed coronary
artery disease and was referred to cardiac surgery for
evaluation. She underwent preoperative workup and was
transferred to the operating [****] for coronary artery
bypass graft and atrial septal defect closure, please see
operative report for for further details. She was then
transferred to the cardiac surgery recovery unit for hemodynamic
monitoring on vasopressor and propofol. She did well and in the
first 24 hours was weaned from sedation, awoke neurologically
intact, and was extubated with out incidence. She was weaned
from pressors and started on betablockers and diuresis. She was
ready for transfer to the floor on POD 2. Continued to
improving, diuresis was increased, and she continued to increase
her physical activity. She was ready for discharge to home on
[**1-17**].
Medications on Admission:
Imdur 60mg daily
Atenolol 25mg daily
[**Doctor First Name **] 18mg daily
Protonix 40 mg daily
Iron 65 mg daily
MVI
ASA 325mg daily
Nitroquick prn
Vitamin C 500mg 2 tabs daily
Tylenol 500mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*120 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks: 40mg [**Hospital1 **] x2 wk then 40mg QD x1 wks.
Disp:*35 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
3 weeks: 20mEq [**Hospital1 **] x2wk then 20 mEq QD x1 wks.
Disp:*84 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Atrial Septal defect s/p closure
PMH:
Elevated cholesterol
GERD
Arthritis
Anemia
Anxiety
Appendectomy
Tonsillectomy
varicose vein ligation
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
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) 44890**] in 1 week ([**Telephone/Fax (1) 68961**]) please call for appointment
Dr [**Last Name (STitle) **] in [**1-26**] week - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2188-1-17**]
|
[
"458.29",
"414.01",
"E849.5",
"429.71",
"E878.2",
"998.2",
"285.9",
"530.81",
"E870.0",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.49",
"36.12",
"37.22",
"39.61",
"99.04",
"36.15",
"35.71",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
4399, 4457
|
1812, 2666
|
279, 506
|
4673, 4680
|
1417, 1789
|
5146, 5569
|
1051, 1115
|
2912, 4376
|
4478, 4652
|
2692, 2889
|
4704, 5123
|
1130, 1398
|
229, 241
|
534, 735
|
757, 904
|
920, 1035
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,666
| 167,424
|
30508
|
Discharge summary
|
report
|
Admission Date: [**2105-1-19**] Discharge Date: [**2105-1-28**]
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Cardizem
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
increased SOB
Major Surgical or Invasive Procedure:
[**1-21**] AVR (pericardial)
History of Present Illness:
85 yo F with history of AS no with increasing SOB x 1 week.
Admitted to HFH on [**1-14**] and was diuresed and transfused. Of note
she also had quaiac positive stool and a negative EGD (no
colonsoscopy secondary to AS). She underwent cardiac cath there
and was transferred here for AVR/CABG.
Past Medical History:
CHF
HTN
AS
hypercholesterolemia
anemia
s/p IHR
s/p partial hysterectomy
s/p cataract surgery
Social History:
lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] complex
retired
Family History:
nC
Physical Exam:
Admission:
HR 58 RR 18 BP 107/38 96% on RA
NAD
Skin nickel sized red lesion mid sternal area
Lungs CTAB
RRR 4/6 SEM radiating to carotids
Abdomen benign
Pertinent Results:
[**2105-1-27**] 07:00AM BLOOD WBC-9.1 RBC-3.30* Hgb-10.1* Hct-30.2*
MCV-91 MCH-30.6 MCHC-33.6 RDW-15.3 Plt Ct-197#
[**2105-1-28**] 07:00AM BLOOD PT-21.6* INR(PT)-2.1*
[**2105-1-27**] 07:00AM BLOOD PT-20.7* PTT-37.6* INR(PT)-2.0*
[**2105-1-24**] 06:12AM BLOOD PT-13.1 PTT-30.2 INR(PT)-1.1
[**2105-1-28**] 07:00AM BLOOD Creat-1.0 K-5.0
[**2105-1-27**] 04:15PM BLOOD K-4.8
[**2105-1-27**] 07:00AM BLOOD Glucose-78 UreaN-25* Creat-1.1 Na-132*
K-5.3* Cl-99 HCO3-26 AnGap-12
Carotid u/s:
There is 40-59% stenosis within bilateral internal carotid
arteries.
Echo [**1-20**]:
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular
systolic dysfunction with focal mid to distal inferior and
inferoseptal
hypokinesis. The remaining walls contract normally. Right
ventricular chamber
size and free wall motion are normal. The aortic arch is mildly
dilated. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic
valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is
seen. The
mitral valve leaflets are moderately thickened. There is no
mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
moderate
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is
seen. The end-diastolic pulmonic regurgitation velocity is
increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial
effusion.
IMPRESSION: Severe aortic stenosis. Mild aortic regurgitation.
Moderate mitral
regurgitation without mitral valve prolapse. Moderate pulmonary
hypertension.
Mild symmetric left ventricular hypertrophy with mild regional
left
ventricular dysfunction consistent with coronary artery disease.
Brief Hospital Course:
She was transferred from the OSH on [**1-20**]. She underwent
preoperative work up including carotid u/s and echo.
She was taken to the operating room on [**1-21**] where she underwent
an AVR with a 21mm [**Doctor Last Name **] pericardial valve. She was
transferred to the SICU in critical but stable condition on
neosynephrine. She awoke and was extubated later that same day.
ON POD #2 she developed atrial fibrillation for which she was
put on amiodarone gtt and remained on neo. SHe converted to
sinus rhythm and was trasnferred to the floor on POD #3. She
continued to have episodes of atrial fibrillation and was
therefore started on heparin and coumadin. She had some
difficulty urinating after her foley was removed, her foley was
reinserted and a urinalysis was positive. She was started on
macrodantin. She was seen by physical therapy and was ready for
discharge to rehab on POD # 7.
Medications on Admission:
lopressor 50 [**Hospital1 **]
nitrostat PRN
zocor
lasix 40 IV BID
asa
procardia
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
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.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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).
Tablet, Delayed Release (E.C.)(s)
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: Then take a total of 400mg daily (two pills)
for 7 days, then 200mg daily (one pill) continuously .
Disp:*40 Tablet(s)* Refills:*0*
8. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO QID (4 times a day) as needed for UTI for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
titrate coumadin daily to reach an INR goal of [**1-9**].3.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**]
Discharge Diagnosis:
AS
HTN
lipids
anemia
s/p IHR
s/p partial hysterectomy
s/p cataract surgery
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting or driving until follow up with surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 72458**] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 4783**] 2 weeks
Completed by:[**2105-1-28**]
|
[
"424.1",
"272.0",
"428.0",
"401.9",
"997.1",
"599.0",
"E878.1",
"285.9",
"427.31",
"416.8",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5099, 5151
|
2859, 3756
|
259, 290
|
5270, 5278
|
1048, 2836
|
855, 859
|
3886, 5076
|
5172, 5249
|
3782, 3863
|
5302, 5541
|
5592, 5748
|
874, 1029
|
206, 221
|
318, 611
|
633, 727
|
743, 839
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,839
| 168,517
|
48342
|
Discharge summary
|
report
|
Admission Date: [**2102-9-3**] Discharge Date: [**2102-9-7**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This is an 80 year old white
male with a history of multiple medical problems including
recent prostatectomy, who presents with fever, mental status
changes and urinary tract infection. The patient was in his
usual state of health until [**2102-7-9**], when he underwent an
uncomplicated prostatectomy. He remained at [**Hospital1 **] for
rehabilitation until approximately one week ago. Several days
ago, he had an appointment with Dr. [**Last Name (STitle) 261**], his urologist,
for Foley removal and a couple days after the Foley removal,
he began to experience confusion according to his wife. The
patient went to the Emergency Department and was diagnosed
with urinary tract infection on [**2102-9-2**], and given
Ciprofloxacin. The patient began antibiotic course but began
to get worse with decreasing p.o. intake and worsening mental
status. The patient returns today on [**2102-9-4**], with
worsening somnolence and diaphoresis, suprapubic pain, poor
p.o. intake and temperature of 102.5. In the Emergency
Department, the patient received two grams of Ceftriaxone
intravenously, Flagyl, 2.5 liters of normal saline and a
Nitroglycerin for an episode of chest pain which resulted in
a temporary drop in systolic blood pressure to 88.
PHYSICAL EXAMINATION: Vital signs revealed a temperature
maximum of 102.5 to 99.0, blood pressure 141/64, heart rate
85, oxygen saturation 99% on two liters. The patient in
general was diaphoretic in no apparent distress. Head, eyes,
ears, nose and throat - The pupils are equal, round, and
reactive to light and accommodation with mildly dry mucous
membranes. His neck was supple with no jugular venous
distention. Cardiovascular examination was regular rate and
rhythm, with a II/VI systolic murmur at the left upper
sternal border. Chest was positive for expiratory wheeze
diffusely. His abdomen was soft, nontender, nondistended
with positive bowel sounds, mildly obese, with some
suprapubic tenderness. Extremities showed trace lower
extremity edema and 2+ distal pulses. Neurologic examination
was arousible, was unable to speak or follow commands. He can
move all four extremities.
PAST MEDICAL HISTORY:
1. In [**2101-9-8**], the patient had a pericardial window for
a history secondary to endocarditis versus bacteremia.
2. Colon cancer status post resection.
3. Benign prostatic hypertrophy.
4. Transitional cell bladder cancer diagnosed in [**2101**],
status post VCG and Interferon washing and an open suprapubic
prostatectomy done on [**2102-8-1**].
5. Atrial fibrillation, status post ablation with
ventricular pacing.
6. Hypertension.
7. Hypercholesterolemia.
8. Coronary artery disease, status post myocardial
infarction approximately twenty-five years ago.
9. Positive PPD in the past, status post one year INH
therapy.
10. Alzheimer's versus vascular dementia.
11. Depression.
12. Hypothyroidism.
13. Prior transient ischemic attacks.
14. Renal cell cancer approximately thirty years ago, status
post resection in [**2070**].
ALLERGIES: Amoxicillin, Ampicillin produce hives. Diltiazem
drowsiness. Bactrim hives. Lasix urinary hesitancy.
MEDICATIONS ON ADMISSION:
1. Aricept 10 mg q.h.s.
2. Bumex 2 mg p.o. once daily.
3. Celexa 20 mg once daily.
4. Coreg 25 mg twice a day.
5. Coumadin 10 mg q.h.s.
6. Lipitor 20 mg once daily.
7. K-Dur 20 meq once daily.
8. Multivitamin once daily.
9. Prevacid 30 mg once daily.
10. Quinine 260 q.h.s...
11. Synthroid 0.075 once daily.
12. Trazodone q.h.s.
13. Atrovent.
14. Maxair.
15. Combivent.
16. Nitroglycerin.
17. Colace 100 mg twice a day.
SOCIAL HISTORY: The patient is a retired dentist.
Concentration camp survivor. Tobacco 100 pack year history.
No alcohol abuse or use.
LABORATORY DATA: On admission, white blood cell count 13.1,
hematocrit 32.7, platelet count 235,000. Sodium 137,
potassium 4.2, chloride 101, bicarbonate 26, blood urea
nitrogen 27, creatinine 1.5 with a baseline of 1.2. Glucose
was 113. INR 1.7, partial thromboplastin time 28.0.
Urinalysis with a specific gravity of 1.011, large blood, no
nitrites, trace protein, negative glucose, ketone and
bilirubin, pH 5.0, moderate leukocyte esterase, [**7-18**] red
blood cells, 21-50 white blood cells, few bacteria, no yeast,
0-2 epithelial cells. Lactate was 1.4. Neutrophils 90,
lymphocytes 5, monocytes 4, eosinophils 1, differential for
the white blood cell count.
Abdominal CT on [**2102-9-4**], showed no abscess.
Electrocardiogram was paced at 79 beats per minute, no
obvious change from prior electrocardiogram.
Urine culture from [**2102-9-2**], was negative. On [**2102-9-3**],
urine culture was pending. Blood cultures were pending from
[**2102-9-3**], as well.
HOSPITAL COURSE: The patient was sent from the Emergency
Department to the Medical Intensive Care Unit for observation
given mental status changes and urinary tract infection,
possible sepsis picture.
1. Urosepsis - The patient with increased white blood cell
count, left shift and positive urinalysis without evidence of
hypotension currently. The patient was started on
intravenous Ciprofloxacin as the patient showed some response
by urinalysis since Emergency Department visit on [**2102-9-2**].
The patient was fluid resuscitated with normal saline.
Cultures were followed and turned out to be negative
throughout the admission. Bumex and Coreg were held
initially given the patient's tenuous blood pressure and
fluid status. The patient was changed to p.o. Ciprofloxacin
on day three of admission as began to become more alert and
oriented. The patient had occasional fever spikes,
temperature maximum of 101.3, during hospital stay but was 48
hours afebrile prior to discharge. The patient was sent home
on p.o. Ciprofloxacin to finish a fourteen day course for
complicated urinary tract infection given recent
instrumentation.
2. Change in mental status most likely secondary to toxic
metabolic event given likely urinary tract infection. It may
also have been related to dehydration. Sedation was held
during hospitalization and the patient was rehydrated. The
patient's mental status improved after 24 hours in the
Intensive Care Unit and he became awake, alert and oriented
times three with meaningful interactions. CT of head and
lumbar puncture were not performed given the patient's
response to antibiotics and intravenous fluids.
3. Atrial fibrillation - The patient is status post ablation
and ventricular pacer. His Coumadin dose was continued and
his INR level was closely monitored while on antibiotics.
His INR on discharge was 2.0 which was within range for his
goal.
4. Hypothyroidism - The patient was continued on his
outpatient Synthroid.
5. Prophylaxis - The patient was continued on his outpatient
Prevacid and given Heparin subcutaneously and started on a
bowel regimen while in hospital of Colace and Senna.
6. Fluids, electrolytes and nutrition - The patient was
restarted on a p.o. diet once his mental status improved and
his input and output were approximately equal upon discharge.
7. Code Status - Code status was discussed with the patient
and wife and the patient agreed that he was full code despite
prior reports. Primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], met with
the patient and will have further discussion concerning code
status as an outpatient.
8. Cardiovascular - The patient had an echocardiogram done
on [**2102-9-6**], which showed an ejection fraction of 20%, global
hypokinesis of the left ventricle, 1 to 2+ mitral
regurgitation and right ventricular hypokinesis. This showed
some worsening left ventricular function since prior study
done in [**2102-4-8**]. The patient denied any chest pain
throughout hospitalization.
9. Right pleural effusion - The patient had decreased breath
sounds at the right base throughout admission with pleural
effusion seen on chest x-ray and CT of the abdomen. The
pleural effusion did not change throughout admission and the
patient denied any shortness of breath throughout admission.
A thoracentesis was deferred given the patient being
asymptomatic and afebrile 48 hours prior to discharge.
10. Right popliteal pain - The patient had a history of leg
cramps for which he takes Quinine at night. A lower
extremity ultrasound with Doppler was done on [**2102-9-6**], which
showed no signs of deep vein thrombosis. The patient was on
Heparin subcutaneously and Coumadin throughout
hospitalization.
DISPOSITION: The patient was evaluated by physical therapy
and occupational therapy concerning home functioning level.
The patient was deemed to be safe to return home with family
and was thought to require home physical therapy to increased
mobility and endurance. Methicillin resistant Staphylococcus
aureus screens were done while the patient was in the
Intensive Care Unit which were both positive for Methicillin
resistant Staphylococcus aureus. Nasal and rectal swabs were
done which were both positive on [**2102-9-6**].
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient was discharged home with
physical therapy services.
DISCHARGE DIAGNOSES:
1. Urinary tract infection.
2. Mental status changes.
3. Atrial fibrillation.
4. Hypothyroidism.
5. Right pleural effusion.
6. Congestive heart failure.
7. Bladder cancer.
8. Benign prostatic hypertrophy.
9. Coronary artery disease.
10. Depression.
11. Hypertension.
12. Dementia.
MEDICATIONS ON DISCHARGE:
1. Donepezil 10 mg q.h.s.
2. Celexa 20 mg once daily.
3. Coumadin 10 mg p.o. q.h.s.
4. Atorvastatin 20 mg p.o. once daily.
5. Multivitamin one p.o. once daily.
6. Lansoprazole 30 mg p.o. once daily.
7. Levothyroxine 75 mcg p.o. once daily.
8. Quinine 260 mg p.o. q.h.s.
9. Bumex 2 mg p.o. once daily.
10. Ciprofloxacin 500 mg p.o. q12hours times eight days.
11. Carvedilol 25 mg p.o. twice a day.
FOLLOW-UP PLANS: The patient is to follow-up with Dr.
[**Last Name (STitle) **] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week. The patient was given
the telephone number and told to have his INR checked at this
appointment. The patient was also to follow-up with Dr.
[**Last Name (STitle) **] on [**2102-9-20**], at 2:15 p.m. at the [**Hospital Ward Name 23**] Cardiac
Center.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 101828**]
MEDQUIST36
D: [**2102-9-28**] 14:58
T: [**2102-9-30**] 19:25
JOB#: [**Job Number 101829**]
|
[
"511.9",
"041.11",
"780.09",
"780.57",
"599.0",
"401.9",
"V09.0",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9250, 9541
|
9567, 9974
|
3271, 3701
|
4837, 9113
|
1388, 2264
|
9992, 10639
|
115, 1365
|
2286, 3245
|
3718, 4819
|
9138, 9229
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,406
| 128,270
|
45997
|
Discharge summary
|
report
|
Admission Date: [**2119-2-8**] Discharge Date: [**2119-2-10**]
Date of Birth: [**2050-9-10**] Sex: F
Service: MEDICINE
Allergies:
Chlorpromazine / Seroquel / Tape [**12-19**]"X10YD / ibuprofen /
trazodone
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
dizziness, malaise
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: [**2119-2-9**]
ADMIT TIME: 0315
.
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] [**Telephone/Fax (1) 608**], fax [**Telephone/Fax (1) 4647**]
.
68 YO F with smoldering multiple myeloma, GERD, bipolar disorder
and recent urosling for stress urinary incontinence who is sent
to the ED from ECF with hypotension to systolic in the 60s.
.
Patient reports one day of malaise and lightheadedness. She
also endorses mild nausea and difficulty urinating with
hesitancy. Poor po intake. No fevers, cp, sob, diarrhea or
abdominal pain. Patient found to have a sbp in the 60s at ECF.
In the ED her systolic was in the 80s. Patient's mentation was
at baseline and she was never tachycardic.
.
Of note, patient is 4 weeks post-op from an I-STOP suburethral
sling procedure plus cystoscopy with placement of a suprapubic
catheter which has since been removed. Procedure done on
[**2119-1-9**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18522**] without any complications. Patient
discharged on [**2119-1-12**] on macrobid 100mg daily x 14 days.
Suprapubic catheter removed on [**2119-1-17**]. She was restarted on
macrobid on [**2119-1-22**] at ECF x 7 days for unclear reasons.
.
ED: 97.8 68 81/65 16 94%RA; + UA, lactate 1.6, hct 33.5 and
Cr 1.4. CXR negative for infiltrate. Bedside FAST negative, no
obvious pericardial effusion. Patient bolused 2L of IVF with
improvement of bp to 128/70. Also given vancomycin and
pip/tazo. Initially booked to ICU however given rapid turn
around of bp felt to be stable for floor. EKG: 65 NSR, no
ischemic changes
.
ROS as per HPI, 10 pt ROS otherwise negative
Past Medical History:
PAST MEDICAL HISTORY:
1. Multiple myeloma
2. Anxiety/Depression
3. hypthyroidism
4. Insomnia
5. Asthma/Bronchitis
6. GERD
7. Hypercholesterolemia
8. Constipation
9. Memory deficits
10. Chronic lower back pain
11. Stage III CKD
PAST SURGICAL HISTORY
1. Laminectomy (L4-L5)
2. Appendectomy
3. Left knee
PAST OB HISTORY
nulligravid
PAST GYN HISTORY
She denies having Chlamydia, Gonorrhea, Syphilis, Genital
Herpes,
Trichomonas, Human Papilloma Virus (HPV) or HIV
She denies having an abnormal Pap test
She denies having an abnormal Mammogram
She has been Postmenopausal since age 55
She denies using hormone therapy or vaginal estrogen cream.
She denies post-menopausal bleeding.
Social History:
Lives at [**Location (un) **] Nursing Home. Not currently working, has
MSW. No tobacco, etoh or illicits.
Family History:
Father passed away from tongue cancer. Mother passed away from
"enlarged heart".
Physical Exam:
97 128/66 64 18 95%RA
Appearance: aaox3, nad
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, nt, nd, +bs, no rebound/guarding, no ecchymoses
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
GU: external genitalia wnl, no erythema or discharge, + foley in
place
Pertinent Results:
[**2119-2-8**] 09:19PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.004
[**2119-2-8**] 09:19PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2119-2-8**] 09:19PM URINE RBC-5* WBC->182* Bacteri-NONE Yeast-NONE
Epi-4
.
[**2119-2-8**] URINE URINE CULTURE-FINAL EMERGENCY
[**Hospital1 **]-mixed flora
[**2119-2-8**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2119-2-8**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
.
[**2-8**] EKG
Sinus rhythm. Non-specific inferior ST-T wave change and slowing
of the rate as compared to the previous tracing of [**2118-12-28**].
Otherwise, no diagnostic interim change.
.
[**2-7**] CXR:
IMPRESSION: No signs of pneumonia
[**2119-2-10**] 06:25AM BLOOD WBC-5.3 RBC-3.52* Hgb-10.6* Hct-31.8*
MCV-90 MCH-30.2 MCHC-33.4 RDW-14.3 Plt Ct-211
[**2119-2-9**] 01:38PM BLOOD Hct-31.5*
[**2119-2-9**] 05:40AM BLOOD WBC-6.2 RBC-3.40* Hgb-10.1* Hct-31.1*
MCV-92 MCH-29.6 MCHC-32.3 RDW-14.3 Plt Ct-192
[**2119-2-8**] 08:11PM BLOOD WBC-8.5 RBC-3.61* Hgb-10.9* Hct-33.5*
MCV-93 MCH-30.3 MCHC-32.6 RDW-14.2 Plt Ct-221
[**2119-2-8**] 08:11PM BLOOD Neuts-74.9* Lymphs-18.5 Monos-3.1 Eos-2.8
Baso-0.6
[**2119-2-8**] 08:11PM BLOOD PT-12.1 PTT-32.6 INR(PT)-1.1
[**2119-2-10**] 06:25AM BLOOD Glucose-85 UreaN-15 Creat-1.1 Na-144
K-4.5 Cl-110* HCO3-27 AnGap-12
[**2119-2-9**] 05:40AM BLOOD Glucose-110* UreaN-14 Creat-1.2* Na-144
K-4.4 Cl-112* HCO3-27 AnGap-9
[**2119-2-8**] 08:11PM BLOOD Glucose-103* UreaN-14 Creat-1.4* Na-139
K-4.4 Cl-103 HCO3-26 AnGap-14
[**2119-2-8**] 08:11PM BLOOD ALT-19 AST-26 AlkPhos-104 TotBili-0.3
[**2119-2-8**] 08:11PM BLOOD Lipase-37
[**2119-2-10**] 06:25AM BLOOD Calcium-10.4* Phos-2.9 Mg-1.5*
[**2119-2-9**] 05:40AM BLOOD Calcium-9.7 Phos-2.8 Mg-1.6
[**2119-2-8**] 08:11PM BLOOD Albumin-3.8
[**2119-2-8**] 08:16PM BLOOD Lactate-1.6
Brief Hospital Course:
Assessment/Plan:
Pt is a 68 y.o female with h.o MM, anxiety/depression,
hypothyroidism, asthma, GERD, LBP, CKD who was transferred from
[**Hospital1 1501**] with hypotension.
.
#hypotension-likely related to hypovolemia. No fever or
leukocytosis, but infection such as UTI is a possibility. CXR
negative for PNA, no GI symptoms. Other possibilities considered
included acute blood loss, but HCT appeared similiar to prior,
was stable, and there were no current signs of active bleeding.
Also considered cardiac causes, but EKG unchanged from prior and
did not have any cardiac symptoms. Pt felt clinically well
during admission and there were no further episodes of
hypotension. Pt's oxybutynin was held during admission. Case
discussed with gyn as pt has recently underwent a urogyn
procedure. It was not thought that this procedure ~1month ago
was related to current presentation and HCT was stable, not
suggestive of bleeding. BCX were NGTD. UCX grew contaminated,
but pt did have symptoms of urinary hesitancy prior to admission
and clinically improved with antibiotic therapy and IV fluids.
Considered need for TSH and/or [**Last Name (un) 104**] stim but hypotension was not
present during admission.
.
#urinary tract infection/recent urogynecology
procedure-complicated-pt with urinary hesitancy, but no dysuria.
UCX contaminated. Pt was given IV ceftriaxone empirically while
awaiting culture. This was changed to PO cipro. Pt should
complete a 10 day total course of therapy. 7 more days after
discharge.
-Pt has f/u already scheduled with her urogyn for continued
post-op monitoring. See below.
.
#Bipolar disorder-continued venlafaxine, gabapentin, clozapime,
clonazepam
.
#CKD-stage III, baseline 1.2-1.4, presented at 1.4. Improved to
1.1 on day of discharge. Monitor Cr levels upon discharge.
.
#smoldering multiple myeloma-followed by Dr. [**Last Name (STitle) 410**], stable.
Possibly the cause of chronic LBP, hypercalcemia and anemia. Pt
has an appointment scheduled for follow up with Dr. [**Last Name (STitle) 410**] after
discharge for continued care
.
#lower back pain-pt states chronic and has had for some time.
Denies any associated neurologic symptoms. Reports that she does
not usually take any thing for pain. Could be due to MM vs. DJD.
No fever, leukocytosis or acuity to suggest infection. Pt was
given tylenol and tramadol prn (home regimen). She was offered a
lidocaine patch as well.
.
#hypercalcemia-likely a result of Multiple myeloma. Outpt follow
scheduled. Pt should have monitoring of her calcium levels upon
discharge.
.
#hypothyroidism-continued levothyroxine
.
#GERD-continued PPI, H2 blocker
.
#HLD-continued pravastatin
.
#COPD-continued inhalers
.
#anemia-normocytic-likely [**1-19**] CKD. Currently at baseline but
will trend and monitor. No current signs of active bleeding. Can
consider further outpt work up prn. Has hematology appointment
scheduled. Can consider colonoscopy prn.
.
FEN: cardiac diet
.
DVT PPx: hep SC TID
.
CODE: FULL
.
.
Medications on Admission:
Per [**Location (un) 45045**] Records:
Albuterol neb [**Hospital1 **] prn
Combivent inh prn
Miralax 17gm daily
Nitrofurantoin 100mg daily x 7 days - d/c'ed [**2119-1-20**], restarted
[**2119-1-22**] x 7 days
Enablesc 15mg daily - d/c'ed [**2119-1-21**]
Melatonin 1mg po qhs prn insomnia
Oxybutynin 5mg qhs
Clozapine 125mg qhs
Lunesta 2mg qhs
Ranitidine 150mg qhs
Venlafaxine 225mg daily
Vit b12 1000mcg daily
Omeprazole 20mg daily
Folic acid 1mg daily
Synthroid 50mcg daily
MVI
Cortizone to rash daily
Tramadol 50mg tid
Colace 100mg daily
Advair 500/50 [**Hospital1 **]
Acidophilus 1 tab tid
Gabapentin 600mg qhs
Klonopin 1mg qhs
Pravastatin 20mg qhs
Senna qhs
Discharge Medications:
1. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation twice a day as needed for
shortness of breath or wheezing.
3. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**12-19**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
5. oxybutynin chloride 5 mg Tablet Extended Rel 24 hr Sig: One
(1) Tablet Extended Rel 24 hr PO at bedtime.
6. clozapine 150 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO HS (at bedtime).
7. Lunesta 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. venlafaxine 225 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
10. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
16. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Acidophilus Capsule Sig: One (1) Capsule PO once a day.
18. gabapentin 600 mg Tablet Sig: One (1) Tablet PO at bedtime.
19. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
20. pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
21. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
hypotension
urinary tract infection
lower back pain
hypercalcemia
.
Chronic
CKD
COPD
hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for evaluation of low blood pressure that was
found at your nursing facility. You work up was unrevealing
including chest xray, blood cultures, EKG. You low blood
pressure may have been due to dehydration and a urinary tract
infection. For this, you were given IV fluids with good effect
and started on antibiotic therapy for a possible urinary tract
infection. Your symptoms improved.
.
Medication changes:
1.start cipro 500mg twice a day for 7 more days
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Department: URO/GYNECOLOGY CC8 (SB)
When: TUESDAY [**2119-2-21**] at 9:45 AM
With: [**Name6 (MD) **] [**Name6 (MD) **], MD [**Telephone/Fax (1) 2797**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2119-3-2**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"300.00",
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"458.9",
"493.90",
"285.21",
"272.4",
"244.9",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11206, 11221
|
5568, 8562
|
352, 358
|
11365, 11365
|
3642, 5545
|
12141, 12762
|
2969, 3052
|
9274, 11183
|
11242, 11344
|
8588, 9251
|
11548, 11954
|
3067, 3623
|
11974, 12118
|
294, 314
|
386, 2092
|
11380, 11524
|
2138, 2828
|
2844, 2953
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,002
| 153,172
|
10600
|
Discharge summary
|
report
|
Admission Date: [**2174-9-26**] Discharge Date: [**2174-9-29**]
Date of Birth: [**2104-10-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Pulmonary edema
Major Surgical or Invasive Procedure:
intubated
colonoscopy - outpatient -> prompting admission
History of Present Illness:
69 y/o male with PMHx significant for CHF, DM type II, AAA s/p
repair and stent with known endoleak, OSA, tachy/brady syndreome
s/p pacemaker who underwent a colonoscopy and EGD as an
outpatient and became hypertensive and went into respiratory
failure. The paitent received Fent, versed and phenergan and
tolerated the colonoscopy well. However, during the EGD he was
noted to have BP's in 180-190 and was agitated and pulling at
EGD tube. When camaera removed pt sat up on edge of bed,
diaphoretic, tachypneic and stated "I am not going to make it."
VS at this time noted to be HR 80-90, BP 230/130 (unclear if
accurate read due to location of BP cuff) and O2sat 70%. Pt
placed on NRB and code blue called.
During code pt found to be in resp distress with RR 30 and O2sat
80% on NRB. Pt received Lasix 80mg IV for presumed flash pulm
edema given hx of recent admission ([**2174-9-20**]) for CHF
exacerbation, Nitro gtt for BP control and was intubated for
ventilation. ABG on NRB 7.07/95/61. Pt transfered to [**Hospital Unit Name 153**] after
intbation and found to be hypotensive transiently. Nitro stopped
and all BP meds held. Received nebs and resp status improved.
CXR revealed pulm edema.
Past Medical History:
PMHx/PSurgHx:
--a fib w/ tachy-brady syndrome s/p pacemaker placement on
[**2174-2-1**] by Dr. [**Last Name (STitle) 284**] @ [**Hospital1 18**]
--AAA s/p endovascular repair by Dr. [**Last Name (STitle) 1111**] [**2-10**] with known
endoleak per records.
--Type II diabetes, insulin-dependent
--Bilateral LE fx s/p fixation 20 yrs ago
--Morbid obesity
--Sleep apnea
--HTN
--diabetic retinopathy
--CHF most likely diastolic as has preserved EF 55%
--Pulmonary artery hypertension
--Hyperlipidemia
--Chronic venous stasis
--Prior syncope
--Arthritis
-- Cardiac Cath [**4-12**] [**2-9**] to abnormal stress which showed no
significanty blockage. One vessel coronary artery disease.
Normal LV systolic function. Mild LV diastolic dysfunction.
No significant subclavian stenosis on the right or left.
Angioseal of right femoral artery.
- Restrictive pattern on PFT's [**3-12**]
Social History:
Social Hx: lives w/ wife, no tobacco for 25 yrs, social EtOH,
former heavy drinker, retired realtor/salesman
Family History:
non-contributory
Physical Exam:
T: 96.5 BP84/40 P 80 RR 20 O2sat 93% intubated.
Gen: Morbidly obese male intubated with minimal sedation. Able
to
communicate and answer questions appropriately.
Heent: PERRL, sclera anicteric, MM dry.
Neck: could not appreciate JVD given large neck
Lungs: Decreased BS at bases with rales [**1-10**] way up. Occ wheeze
after intubation.
Cardiac: RRR no murmurs.
Abd: Obese, soft, NT, +BS
Ext: Hyperpigmented LE b/l; 3+ pitting edema up to shins b/l. L
toe with panniculitis and toe nail removed.
Neuro: Intbated and lightly sedated. Able to answer all
questions.
Pertinent Results:
[**2174-9-26**] 09:32PM TYPE-ART TEMP-36.8 RATES-20/ TIDAL VOL-600
PEEP-10 O2-50 PO2-83* PCO2-41 PH-7.39 TOTAL CO2-26 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED
[**2174-9-26**] 07:03PM TYPE-ART TEMP-36.9 PEEP-10 O2-100 PO2-281*
PCO2-44 PH-7.35 TOTAL CO2-25 BASE XS--1 AADO2-408 REQ O2-69
INTUBATED-INTUBATED
[**2174-9-26**] 04:49PM GLUCOSE-225* UREA N-16 CREAT-1.4* SODIUM-143
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
[**2174-9-26**] 04:49PM CK-MB-3 cTropnT-<0.01
[**2174-9-26**] 04:49PM CK(CPK)-36*
[**2174-9-26**] 04:49PM CALCIUM-8.5 PHOSPHATE-6.3*# MAGNESIUM-1.9
[**2174-9-26**] 04:49PM WBC-12.4*# RBC-4.21* HGB-10.3* HCT-34.4*
MCV-82 MCH-24.5* MCHC-30.0* RDW-17.5*
[**2174-9-26**] 04:49PM NEUTS-79.9* LYMPHS-13.5* MONOS-3.5 EOS-1.8
BASOS-1.3
[**2174-9-26**] 04:49PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2174-9-26**] 04:49PM PLT COUNT-337
[**2174-9-26**] 04:49PM PT-13.4* PTT-30.4 INR(PT)-1.2
[**2174-9-26**] 03:59PM TYPE-ART PO2-61* PCO2-95* PH-7.07* TOTAL
CO2-29 BASE XS--5
.
CXR: Pulm edema.
ECG: V paced, no ST changes.
.
CBCs:
[**2174-9-27**] 03:23AM BLOOD WBC-13.2* RBC-3.59* Hgb-9.0* Hct-28.0*
MCV-78* MCH-25.0* MCHC-32.1 RDW-18.1* Plt Ct-209
[**2174-9-27**] 04:38PM BLOOD WBC-7.5 RBC-3.60* Hgb-9.0* Hct-28.2*
MCV-78* MCH-25.1* MCHC-32.1 RDW-17.9* Plt Ct-190
[**2174-9-28**] 07:00AM BLOOD WBC-7.1 RBC-3.95* Hgb-9.7* Hct-30.9*
MCV-78* MCH-24.5* MCHC-31.3 RDW-17.6* Plt Ct-209
[**2174-9-29**] 07:00AM BLOOD WBC-5.7 RBC-3.63* Hgb-9.0* Hct-28.5*
MCV-79* MCH-24.7* MCHC-31.5 RDW-17.4* Plt Ct-196
.
Coags:
[**2174-9-27**] 03:23AM BLOOD PT-13.9* PTT-30.6 INR(PT)-1.3
[**2174-9-28**] 07:00AM BLOOD PT-13.4* PTT-32.7 INR(PT)-1.2
[**2174-9-29**] 07:00AM BLOOD PT-12.6 PTT-30.0 INR(PT)-1.1
.
Retic count:
[**2174-9-28**] 07:00AM BLOOD Ret Man-2.0*
.
Electrolytes:
[**2174-9-27**] 03:23AM BLOOD Glucose-143* UreaN-21* Creat-1.7* Na-143
K-3.7 Cl-108 HCO3-23 AnGap-16
[**2174-9-27**] 04:38PM BLOOD Glucose-186* UreaN-23* Creat-1.9* Na-140
K-3.3 Cl-105 HCO3-25 AnGap-13
[**2174-9-28**] 07:00AM BLOOD Glucose-147* UreaN-23* Creat-1.5* Na-142
K-3.6 Cl-105 HCO3-27 AnGap-14
[**2174-9-29**] 07:00AM BLOOD Glucose-162* UreaN-23* Creat-1.2 Na-144
K-3.8 Cl-106 HCO3-28 AnGap-14
[**2174-9-27**] 03:23AM BLOOD Calcium-8.7 Phos-6.0* Mg-1.8
[**2174-9-27**] 04:38PM BLOOD Calcium-8.6 Phos-3.7# Mg-1.8
[**2174-9-28**] 07:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
[**2174-9-29**] 07:00AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9
.
Enzymes:
[**2174-9-26**] 04:49PM BLOOD CK(CPK)-36*
[**2174-9-27**] 12:21AM BLOOD CK(CPK)-26*
[**2174-9-27**] 10:53AM BLOOD CK(CPK)-32*
[**2174-9-28**] 07:00AM BLOOD LD(LDH)-190 TotBili-0.4
[**2174-9-26**] 04:49PM BLOOD CK-MB-3 cTropnT-<0.01
[**2174-9-27**] 12:21AM BLOOD CK-MB-2
[**2174-9-27**] 10:53AM BLOOD CK-MB-2
[**2174-9-28**] 07:00AM BLOOD cTropnT-0.02*
.
[**2174-9-28**] 07:00AM BLOOD Hapto-257*
.
ABGs:
[**2174-9-26**] 03:59PM BLOOD Type-ART pO2-61* pCO2-95* pH-7.07*
calHCO3-29 Base XS--5
[**2174-9-26**] 07:03PM BLOOD Type-ART Temp-36.9 PEEP-10 FiO2-100
pO2-281* pCO2-44 pH-7.35 calHCO3-25 Base XS--1 AADO2-408 REQ
O2-69 Intubat-INTUBATED
[**2174-9-26**] 09:32PM BLOOD Type-ART Temp-36.8 Rates-20/ Tidal V-600
PEEP-10 FiO2-50 pO2-83* pCO2-41 pH-7.39 calHCO3-26 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2174-9-27**] 06:29AM BLOOD Type-ART Temp-36.9 Rates-/22 PEEP-0
FiO2-40 pO2-67* pCO2-43 pH-7.37 calHCO3-26 Base XS-0
Intubat-INTUBATED
[**2174-9-27**] 11:19AM BLOOD Type-ART Temp-37.0 Rates-18/ FiO2-100
pO2-118* pCO2-41 pH-7.40 calHCO3-26 Base XS-0 AADO2-572 REQ
O2-92 Intubat-NOT INTUBA Comment-FACE TENT
Brief Hospital Course:
69 y.o male with extensive PMH, presents with resp failure after
HTN episode during procedure.
.
## Resp failure - Felt to be secondary to flash pulm edema
likely secondary to hypertensive event during procedure. In
addition, pts wife is not sure pt took his lasix in am prior to
procedure. Patient received IV lasix and his symptoms
improved. Pt had transient hypotension after intubation possible
secondary to combination of sedation and PEEP with decrease in
preload. However, sepsis vs cardiogenic shock consideredbut BP
improved with no intervention.
- Patient was diuresed with lasix; initially problem[**Name (NI) 115**] because
patient was on PEEP.As patient was weaned off PEEP, diuresis
improved. Patient was weaned off his O2 requirement on days on
floor and was off O2 on day of discharge. He was discharged with
lasix 40mg PO daily.
Patient was also scheduled for PFTs as an outpatient.
.
## Cardiac - Pt has an extensive cardiac hx. Also with hx of AAA
repair with reported leak. Pt could have flashed from MI. Was
experiencing nausea prior to event which could have represented
an inferior MI. ECG difficult to interpret due to V pacing, but
no changes comapred to prior. Enzymes were negative (note: all 3
troponins were not done; however, the 2 that were were below
<0.01 and 0.02.
- Pt was on coumadin as outpt for afib which was held for
procedure. Restart if stable and no furhter procedures planned.
- Cont asa, BB when BP stable, statin.
.
## Anemia - Patient has a low Hct at baseline (around 33) and
has had a AAA repair with known endoleak. He was
hemodynamically stable throughout his last admission and was
transfused 1 unit PRBC for slowly decreasing hct with nadir of
25.7. Iron studies were consistent with iron deficiency anemia
and he was started on ferrous sulfate. CT scan of
abdomen/pelvis was obtained to assess for interval change of the
AAA repair site and endo leak, which showed no significant
change. Pt was having colonoscopy to asses for source of bleed.
HCT stable during hospital course.
.
## DMII - Metformin was held as patient's Cr was greater than
1.5. Cover with sliding scale while NPO and restarted on NPH 40
in am after extubated and eating.
.
## HTN - Pt on Amiodarone, Lopressor, and Lasix as an
outpatient. His lisinopril was held on last admission due to
BUN/Cr elevation over his baseline. BP was stabilized while
patient was on the floor and his outpt BP meds were restarted.
.
## CRI - Patient with baseline Cre 1.1-1.2; Increased after
diuresis but may improved with improved forward flow. Cr were
1.7 and 1.9 on HOD#2 and HOD#3, but decreased back to 1.2 on
discharge.
.
## Sleep apnea - Patient was on CPAP for sleeping.
.
## ID: placed on cefpodoxime (originally on ceftriaxone) because
of pulmonary infiltrates.
.
## PPx - Heparin SC
.
## FEN - Npo overnight with possibility of extubation in am.
Diabetic, low sodium, heart healthy, fluid restrict 1500cc once
taking PO. Replete lytes to maintain K>4 and Mg>2.
.
Medications on Admission:
NPH 40 qam
Amiodarone 100 QD
Atorvistatin 10
ASA
Lasix 40mg QD
Ferrous sulfate
Lopressor 50mg PO BID
Colace
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Capsule(s)* Refills:*0*
8. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure
Diabetes mellitus type II
Abdominal aortic aneurysm s/p repair with endoleak
iron deficiency anemia
afib with tachy brady syndrome s/p pacemaker
Discharge Condition:
stable
Discharge Instructions:
Please come to the ED if you have sob or chest pain. Please
weigh yourself everyday and call Dr. [**Last Name (STitle) 5263**] if you gain >2lbs.
Followup Instructions:
f/u with Dr. [**Last Name (STitle) 5263**] on monday morning, call for the exact time.
[**Last Name (LF) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 250**]
.
You are scheduled for repeat PFT's as listed below
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
.
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2174-10-3**]
3:50
.
Provider: [**Name10 (NameIs) 1571**] EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2174-10-3**] 4:10
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] & DR. [**First Name (STitle) **] Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2174-10-3**] 4:10
Completed by:[**2174-10-9**]
|
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"780.57",
"416.8",
"280.9",
"362.01",
"681.10",
"486",
"278.01",
"518.81",
"562.10",
"V45.01",
"250.50",
"402.91",
"478.29",
"428.31",
"211.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"45.42",
"96.04",
"93.90",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10916, 10922
|
6940, 9930
|
332, 391
|
11136, 11145
|
3277, 6917
|
11340, 12089
|
2660, 2678
|
10088, 10893
|
10943, 11115
|
9956, 10065
|
11169, 11317
|
2693, 3258
|
277, 294
|
419, 1619
|
1641, 2517
|
2533, 2644
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,132
| 121,845
|
7761
|
Discharge summary
|
report
|
Admission Date: [**2142-4-11**] Discharge Date: [**2142-4-15**]
Date of Birth: [**2084-1-17**] Sex: F
Service: SURGERY
Allergies:
Taxol / Taxotere
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Nausea, vomiting, constipation
Major Surgical or Invasive Procedure:
-Ultrasound-guided therapeutic paracentesis [**2142-4-12**]
-Exploratory laparotomy with loop ileostomy [**2142-4-14**]
-Bronchoscopy [**2142-4-14**]
History of Present Illness:
Ms. [**Known lastname 28138**] is a 65F with a PMH s/f stage 4 ovarian cancer s/p
taxol and carboplatinum, and most recently enrolled in the
volociximab trial (c1w7 on [**4-5**]). Over the past few weeks, she
had been experiencing increasing symptoms of nausea, vomiting,
constipation, and ascities- requiring therapeutic paracentesis.
Her most recent ultrasound-guided paracentesis on [**4-9**] noted
colonic distention. A CT torso showed colonic distention to the
sigmoid colon with collapse, suspicious for obstruction due to
possible drop metastasis. In addition to this, there was
interval enlargement of pulmonary nodules and development of a
left sided pleural effusion. Given these findings, she was
taken off the volicixumab trial by her oncologist. She presents
today with increasing abdominal distension, mild nausea, and
mild discomfort. She has not vomited, and her last bowel
movement was today.
.
In the ED a KUB was performed which showed no free air, but
multiple distended loops of small bowel with air fluid levels.
General surgery was consulted and felt thiw was likely an ileus.
An NGT was attempted but not tolerated. Her exam was
consistent with distention, tympany, and tenderness to palpation
without peritoneal signs. VSS, labs wnl, lactate 1.1
Past Medical History:
1. Stage IV Ovarian cancer
-Diagnosed [**5-/2141**] when she presented with a malignant pleural
effusion
-Initiated on Taxol and carboplatinum, which she did not
tolerate despite taxol desensitization. She subsequently
developed neuropathy and visual loss
-Started the volociximab clinical trial after progression of
disease, receiving c1w7 on [**4-5**]
-Taken off of the volociximab trial on [**4-9**] secondary to disease
progression, documented interval increase in lung nodules and
possible drop metastasis.
2. Myotonic dystrophy
3. Hyperlipidemia
4. GERD
Social History:
Lives alone. Quit smoking 10 years ago. No ETOH or drug use.
Family History:
Mother living with HTN, Muscular dystrophy, h/o MI. Father
living with no serious medical problems. Family history of
hypercholesterolemia. Brother wit DM. No cancers in the family.
Physical Exam:
T:97.3 HR:100 BP:156/86 RR:20 O2:100% RA
.
PHYSICAL EXAM
GENERAL: Pleasant, nauseated caucasian female
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. Dry, tacky mucous membranes. OP
clear. Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVD flat.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Distended and shifted to the left. hypoactive bowel
sounds. Soft and non tender to palpation, no peritoneal signs.
Diffusely tympanitic to percussion.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses. Port site c/d/i
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-17**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2142-4-11**] 10:30AM PLT COUNT-367
[**2142-4-11**] 10:30AM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
FRAGMENT-OCCASIONAL
[**2142-4-11**] 10:30AM NEUTS-83.2* BANDS-0 LYMPHS-11.8* MONOS-4.3
EOS-0.6 BASOS-0.1
[**2142-4-11**] 10:30AM WBC-7.5 RBC-3.72* HGB-11.8* HCT-35.5* MCV-95
MCH-31.8 MCHC-33.4 RDW-13.5
[**2142-4-11**] 10:30AM CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-2.0
[**2142-4-11**] 10:30AM GLUCOSE-117* UREA N-10 CREAT-0.5 SODIUM-140
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
.
CT chest/abdomen/pelvis [**4-9**]:
Interval progression of parenchymal lung nodules, with interval
development of left-sided pleural effusion and probable
worsening of large bowel distention. Findings in the sigmoid
region are worrisome for drop metastasis to the sigmoid colon.
A degree of bowel obstruction at the level of the sigmoid colon
is not excluded
.
KUB [**4-11**]:
There is no free air. There are multiple loops of dilated small
bowel measuring up to 3.5 cm. This is new from recent CT. There
are air-fluid levels within the small bowel. The visualized
lungs and adjacent bones are normal. Early high grade or partial
small bowel obstruction cannot be ruled out, ileus is also in
the differential.
.
Ultrasound-guided therapeutic paracentesis [**2142-4-12**]: Limited
abdominal ultrasound demonstrated an apparently small amount of
ascites throughout the abdomen. Using direct ultrasound guidance
a 5 French [**Last Name (un) 11097**] catheter was inserted into the peritoneal cavity
with approximately 1.3 liters of a clear yellow liquid aspirate.
There were no complications immediately post-procedure.
IMPRESSION: Successful ultrasound-guided therapeutic
paracentesis with removal of 1.3 liters of clear yellow ascites.
.
CHEST (PORTABLE AP) [**2142-4-15**] FINDINGS: The ET tube, right IJ
line, and left subclavian line are unchanged. The NG tube is
slightly high with the proximal port at the GE junction and the
tip in the stomach. There are bilateral patchy alveolar
infiltrates left greater than right and a moderate right
effusion.
Brief Hospital Course:
ONCOLOGY SERVICE COURSE:
Ms. [**Known lastname 28138**] is a 58F with a PMH of stage IV ovarian cancer s/p
carboplatin and taxol, and most recently taken off of the
volociximab trial secondary to progression of disease. She is
presenting with nausea, vomiting and constipation.
.
#. Nausea, vomiting, and constipation: Based on CT scan and KUB
findings, this is likely a partial small bowel obstruction vs.
an ileus from likely drop metastasis from her ovarian cancer.
-Bowel rest, NPO, D5NS, and advance diet as tolerated
-Anti-emetics with compazine and lorazepam
-Aggressive bowel regimen with colace, senna, bisacodyl, and
lactulose
-NGT decompression prn
-Therapeutic paracentesis prn
-Repeat CT and general surgery consultation if she acutely
worsens
.
#. Pleural effusion: New right sided pleural effusion, not large
and likely malignant.
-Monitor clinically and with CXR's
-Therapeutic thoracentesis if it gets larger
.
#. Ovarian cancer: Now with progression of disease on
volociximab trial, documented on CT torso.
-Will discuss options with primary oncologist
.
#. GERD
-continue home regimen of omeprazole
.
#. Hyperlipidemia
-continue home regimen of lovastatin
.
FEN:
-NPO with IVF, advance diet as tolerated
-replete lytes prn
.
PPX:
-Pain management with tylenol and home oxycodone prn
-Heparin SC
-home omeprazole
.
.
.
SURGICAL SERVICE COURSE:
The surgical service was consulted on [**2142-4-11**] for patients
progressive abdominal distension and apparent obstruction at the
sigmoid colon likely from cancer metastasis. The patient
requested decompression and resection of the tumor burden. She
was pre-op'd and taken to the OR on [**2142-4-14**] for an exploratory
laparotomy and loop ileostomy (please refer to operative note
for details). The patient tolerated the procedure and was
extubated post-operatively. However, she had an episode of
acute desaturation with somnolence and she was reintubated by
anesthesia. She became progressively difficult to ventilate.
Given the acute nature of her hypoxemia, PE was considered a
possible etiology and a heparin drip was started. Aspiration
was also suspected and a bronchoscopy was performed that showed
a moderate amount of brown fluid in the upper airway (trachea,
mainstem bronchi). A CXR was obtained, which demonstrated:
increased haziness overlying the right lower lung likely
representing effusion layering posteriorly, with opacity in the
retrocardiac region consistent with volume loss/atelectasis.
She was eventually transferred to the SICU where ventilatory
status was difficult to stablize. She had elevated PIPs and
required high PEEP (max of 22) on PCV. An esophageal balloon
was placed to monitor transthoracic pressures. She required
multiple vasopressors, initially levophed and neosynephrine,
which were transitioned to vasopressin and levophed given she
was febrile and exhibiting signs of sepsis/ARDS. Her antibiotic
regimen included vancomycin, zosyn and flagyl. Cultures were
pending at the time of this report. She was fluid resuscitated
and this culminated in approximately 5 liters of crystalloid and
3 doses of colloid given in the SICU and over 3 liters of
cystalloid in the PACU. Her lactate progressively increased to
a max of 5.9 and she became persistently neutropenic.
Her family, namely her brother & health care proxy, [**Name (NI) **] was
notified of her grave condition by Dr. [**First Name (STitle) 2819**], the oncology and
SICU staff. Her brother decided to make her DNR without any
escalation of care. Shortly after he arrived from [**State 531**]
State on [**2142-4-15**], he decided, after discussions with the family,
to make the patient comfort measures only. She expired shortly
thereafter. An autopsy was declined.
Medications on Admission:
Lorazepam 0.5-1.0 mg q4-6 hours for nausea or insomnia
Lovastatin 10mg qhs
Oxycodone 5mg q4h prn pain
Colace 200mg daily
Omeprazole 20mg daily
Senna
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
|
[
"197.5",
"197.8",
"288.09",
"998.2",
"568.0",
"789.51",
"530.81",
"197.2",
"359.21",
"197.4",
"197.6",
"518.5",
"197.7",
"272.4",
"183.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"46.01",
"54.59",
"54.91",
"33.22",
"46.73"
] |
icd9pcs
|
[
[
[]
]
] |
9735, 9744
|
5783, 9535
|
307, 458
|
9795, 9804
|
3642, 5760
|
2449, 2633
|
9765, 9774
|
9561, 9712
|
9828, 9838
|
2648, 3623
|
237, 269
|
486, 1768
|
1790, 2353
|
2369, 2433
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,651
| 153,297
|
46065
|
Discharge summary
|
report
|
Admission Date: [**2137-4-9**] Discharge Date: [**2137-4-17**]
Date of Birth: [**2055-7-24**] Sex: M
Service: MEDICINE
Allergies:
Protamine
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
NSTEMI; transfer for cardiac catheterization
Major Surgical or Invasive Procedure:
Cardiac catheterization x2 with placement of drug eluting stents
History of Present Illness:
81 yo M with h/o CAD (s/p PCI in [**2129**], CABG in [**2118**], on home O2
3-5L, who is being transfered from NWH to [**Hospital1 **] for cardiac
catheterization. The patient initially presented on [**2137-4-4**] to
NWH after a fall, when his wife's caretaker found him in the
bathroom confused. When EMS arrived the pt had an O2 sat of 82%
on RA. The patient was started on empiric heparin gtt for PE v
ACS. He was admitted to the ICU for requirement for NRB and trop
of 8. The pt was managed in the ICU for presumed PE, and started
on coumadin as well as heparin gtt. On [**2137-4-9**] the patient had a
PE CT that did not show e/o PE. The pt's troponin peaked at 22,
with MBs of 26. ECG showed Mobitz I AV block and 0.5-1mm ST
depressions in V2-V5. Echo showed an EF of 45% and after
conferring with the pt's cardiologist the pt was trasferred for
cardiac catheterization.
Past Medical History:
- Dyslipidemia
- Hypertension
- CAD s/p CABG x4 [**2118**] ([**Hospital1 2025**]), s/p PCI [**2130-7-7**] in which his
saphenous vein graft was stented x4 with overlapping TAXUS
stents
- H/o paroxysmal AFib
- NSCLC diagnosed in [**2125**], s/p resection and XRT; recurrence in
[**2135**], s/p 13 cycles of carboplatin/Alimta recently changed to
Navelbine d/t new diagnosis of liver mets in [**3-/2137**]
- COPD on 3-5L home O2
- OSA on CPAP
- AAA (4cm)
- GERD
- Barretts esophagus
Social History:
Lives with wife who has dementia. Used to work in the grocery
store business.
-Tobacco history: Denies current use. Former 1-2ppd.
-ETOH: None
-Illicit drugs: None
Family History:
No family history of early MI; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: T97 BP 136/87 HR 85 RR 22 O2 sat= 98 on 5L
GENERAL: WDWN 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 of 10-12cm.
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. Bilateral crackles, no
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+
DISCHARGE EXAM:
VS: Tmax = Tc 98.4 BP 90/45 (90-111/45-74) HR 86 (56-90) RR 18
O2 sat 96% CPAP (93-100% on 3L-6L)
I/O: 0/500 cc over 8H; 1510/1225 over 24H
GENERAL: WDWN 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, no JVD
CARDIAC: RR, normal S1, S2. No m/r/g.
LUNGS: Resp unlabored, no accessory muscle use. Bilateral
crackles, at bases, no wheezes. Right upper lobe
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace pedal edema. Right groin site ecchymoses
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2137-4-10**] 12:03AM BLOOD WBC-5.2 RBC-2.95*# Hgb-10.0* Hct-29.9*
MCV-101*# MCH-34.1*# MCHC-33.7 RDW-20.7* Plt Ct-133*
[**2137-4-10**] 12:03AM BLOOD PT-22.9* PTT-35.5* INR(PT)-2.2*
[**2137-4-10**] 12:03AM BLOOD Glucose-89 UreaN-20 Creat-1.2 Na-142
K-4.6 Cl-108 HCO3-29 AnGap-10
[**2137-4-10**] 12:03AM BLOOD ALT-253* AST-76* AlkPhos-143* TotBili-0.3
[**2137-4-10**] 12:03AM BLOOD Calcium-8.4 Phos-3.9# Mg-1.3*
.
PERTINENT LABS:
[**2137-4-12**] 12:42AM BLOOD CK-MB-17* MB Indx-15.2*
[**2137-4-12**] 07:15AM BLOOD CK-MB-41* MB Indx-14.6* cTropnT-0.98*
[**2137-4-12**] 04:30PM BLOOD CK-MB-34* MB Indx-12.5* cTropnT-1.19*
[**2137-4-12**] 10:45PM BLOOD CK-MB-25* MB Indx-10.8* cTropnT-1.12*
[**2137-4-12**] 12:42AM BLOOD CK(CPK)-112
[**2137-4-12**] 07:15AM BLOOD CK(CPK)-281
[**2137-4-12**] 04:30PM BLOOD CK(CPK)-272
[**2137-4-12**] 10:45PM BLOOD CK(CPK)-232
[**2137-4-11**] 02:54AM BLOOD Iron-44 TIBC-235* Ferritin-2120*
VitB12-861 Folate >20
[**2137-4-11**] 02:54AM BLOOD Chol 144 Triglyc-111 HDL-72 LDLcalc-50
.
DISCHARGE LABS:
[**2137-4-17**] 11:30AM BLOOD WBC-6.4 RBC-2.74* Hgb-9.2* Hct-28.6*
MCV-104* MCH-33.5* MCHC-32.1 RDW-19.5* Plt Ct-224
[**2137-4-17**] 05:37AM BLOOD PT-12.6 PTT-81.0* INR(PT)-1.1
[**2137-4-17**] 01:15PM BLOOD Glucose-147* UreaN-27* Creat-1.8* Na-142
K-5.0 Cl-106 HCO3-29 AnGap-12
[**2137-4-17**] 05:37AM BLOOD CK(CPK)-192
[**2137-4-17**] 05:37AM BLOOD CK-MB-22* MB Indx-11.5*
[**2137-4-17**] 01:15PM BLOOD Calcium-8.2* Phos-3.7 Mg-2.1
[**2137-4-11**] 02:54AM BLOOD calTIBC-235* VitB12-861 Folate-GREATER TH
Ferritn-2120* TRF-181*
[**2137-4-11**] 02:54AM BLOOD Triglyc-111 HDL-72 CHOL/HD-2.0 LDLcalc-50
[**2137-4-15**] 05:37AM BLOOD Osmolal-300
[**2137-4-12**] 07:15AM BLOOD Cortsol-15.7
ECG [**2137-4-11**]:
Sinus rhythm. P-R interval prolongation and type I second degree
A-V block is most likely. However, there is considerable
artifact making interpretation difficult. Somewhat early R wave
progression. ST-T wave abnormalities. Since the previous tracing
of [**2130-7-8**] the second degree A-V block is new. Ventricular
premature beats are now not seen. Atrial premature beats are
also probably not seen. Clinical correlation is suggested.
TTE [**2137-4-12**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with inferior and infero-lateral akiensis.
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. RV with borderline normal free wall
function. The aortic valve leaflets (3) are mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
PROCEDURES:
[**2137-4-11**] CARDIAC CATH:
1. Severe native 3-vessel CAD, with old occlusion of the LAD,
RCA, and OM1 proximally, and new 95% proximal and 70% mid
stenoses of the LCX.
2. Patent LIMA-LAD
3. Patent SVG-OM1, but with proximal filling defect suggestive
of a thrombus.
4. Patent SVG-AM-RCA, but with severe diffuse atherosclerosis
(cannot rule out in-stent restenosis) with possible thrombus
present.
5. Successful [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5303**] of the entire SVG-AM-RCA.
[**2137-4-16**] CARDIAC CATH: (preliminary report)
Assessment
1. Successful [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5303**] of the proximal and mid LCX
2. Stenting of a focal thrombus in the proximal portion of the
SVG-OM1.
3. Angioseal closure of the left femoral arteriotomy site
Brief Hospital Course:
81M with CAD (s/p PCI in [**2129**], CABG in [**2118**]), HTN, HLD,
metastatic lung CA, and COPD (on home O2), with NSTEMI s/p cath
found to have significant CAD.
.
# NSTEMI: Pt was transferred from OSH with NSTEMI and EKG
revealing new Mobitz type 1 AV block. He was continued on
medical management with aspirin, plavix, statin, and was started
on a heparin gtt. He underwent cardiac cath on [**2137-4-11**] which
revealed severe 3-vessel native coronary artery disease with
several graft stenoses. He had four DES placed in the SVG-RCA.
The procedure was complicated by a right groin hematoma and
brief hypotension to systolic 70s that was felt to be a
vasovagal response during closure of sheath. He was kept on a
heparin gtt until a repeat cardiac cath on [**2137-4-16**] during which
he received 4 additional stents, one stent was placed in the
SVG-OM1 and three stents in the LCx. He initially was not
started on a beta blocker due to his AV block. During
hospitalization, he did receive one dose of metoprolol 12.5mg
but this was discontinued on discharge. His AV block was
assumed to be due to ischemia from his NSTEMI but pt should
follow-up with his cardiologist regarding Holter monitor testing
for further evaluation of nodal disease. His lisinopril was
held given his hypotension and worsening renal function.
.
# SYSTOLIC CHF: ECHO with mild to moderate regional left
ventricular systolic dysfunction with inferior and
infero-lateral akiensis. LVEF 40%. He was diuresed periodically
with IV lasix and discharged home on half dose of his home lasix
due to worsening renal function. Lisinopril was held due to low
BPs (90s to 110s systolic) and worsening renal function.
.
# AFIB: It was clarified with the patient's PCP that he has a
history of AFib only in the setting of previous
hospitalizations. He was not previously anticoagulated for afib.
He had been started on coumadin at OSH due to concern for PE
but this had been discontinued when CTA ruled out PE. He was
not discharged on any anticoagulation.
.
# HYPOTENSION: The patient was briefly hypotensive (systolic
70s) following the first cardiac catheterization, felt likely to
be a vasovagal response. His BP was subsequently in the 100s,
which is his baseline per the patient. BP remained stable in 90s
to 110s during hospital admission. Tamsulosin and home lasix
were briefly held and restarted by discharge as BPs remained
stable.
.
# DYSLIPIDEMIA: Chol 144, TG 111, HDL 72, LDL 50. LDL is at goal
(<70). Continued atorvastatin 20mg daily.
.
# COPD: Pt was on 3-5L home O2; oxygen saturation remained
within goal on oxygen. He was continued on home albuterol,
advair, ipratropium.
.
# LUNG CANCER: Pt with history of lung cancer with known mets to
liver. Patient currently undergoing chemotherapy. His primary
oncologist was contact[**Name (NI) **] regarding pt's admission and agreed to
hold chemotherapy until follow-up with oncologist.
.
# TRANSAMINITIS: LFTs were elevated at 253/76 on admission and
downtrended to 96/51. Transaminitis may be due to known liver
metastases or medications or shock liver. He should discuss
with his oncologist/PCP if he should remain on fluconazole on
discharge.
.
# [**Last Name (un) **]: Cr had peaked at outside hospital at 2.4. Upon admission
to [**Hospital1 18**], Cr was 1.2 on admission. Cr again rose, peaking at
2.0, during this admission, likely due to contrast dye load for
cardiac cath and diuresis. He was given gentle IV fluids and Cr
was stable at 1.8 by time of discharge. His lasix dose was
reduced to half of his home dose and lisinopril was held.
.
# ANEMIA: HCT was stable in the high 20s-low 30s; macrocytic.
Iron was borderline low, TIBC low, and ferritin high, indicating
anemia of chronic inflammation. B12 and folate were wnl.
.
# GERD/BARRETT's: Currently asymptomatic. He was on pantoprazole
during hospital admission and discharged back on home nexium.
.
# Confusion: Per nursing, pt was mildly confused at night. His
home ambien was discontinued. He was A & O x 3 by time of
discharge.
Medications on Admission:
1. Plavix 75mg daily
2. Aspirin 81mg daily
3. Lasix 40mg daily
4. Atorvastatin 20mg daily
5. Nexium 40mg daily
6. Advair 250/50, 1 inh [**Hospital1 **]
7. Albuterol inh QID
8. Ipratropium inh TID
9. Finasteride 5mg daily
10. Tamsulosin 0.4mg daily
11. Enablex (Darifenacin) 7.5mg po daily
12. Levothyroxine 175mcg daily
13. Neurontin 100mg TID
14. (Boniva) ibandronate 150 monthly
15. Multivitamin 1 tablet daily
16. Selenium 200mcg daily
17. Folic acid 1mg [**Hospital1 **]
18. Iron controlled release 160mg daily
19. Vitamin B complex 1 tab daily
20. Vitamin B6 100mg daily
21. Vitamin C 500mg daily
22. Calcium carbonate 600mg [**Hospital1 **] + Vitamin D 1500mg [**Hospital1 **]
23. Vitamin D3 400units daily
24. Bacitracin ophth ointment 0.5 inches OS [**Hospital1 **]
25. Tobramycin 0.3% ophth solution OU TID
26. Compazine 10mg q8h prn
27. Zofran 8mg q8h prn
28. Dexamethasone 4mg [**Hospital1 **] the day before, of, and after chemo
29. Zolpidem 5mg QHS
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation QID (4 times a day).
7. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
8. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Enablex 7.5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO twice a day.
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
14. ibandronate 150 mg Tablet Sig: One (1) Tablet PO once a
month.
15. multivitamin Tablet Sig: One (1) Tablet PO once a day.
16. selenium 200 mcg Tablet Sig: One (1) Tablet PO once a day.
17. iron 160 mg (50 mg Iron) Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
18. Vitamin B Complex Capsule Sig: One (1) Capsule PO once a
day.
19. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO once a day.
20. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
21. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
22. bacitracin 500 unit/g Ointment Ophthalmic
23. tobramycin sulfate 0.3 % Drops Sig: One (1) drop Ophthalmic
three times a day.
24. oxygen
Oxygen via nasal cannula 3-5L
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 38296**],
You were transferred to [**Hospital1 18**] for a cardiac catheterization
because you were found to have a heart attack at an outside
hospital. You had 2 separate catheterizations and had several
stents placed in your coronary arteries. It is very important
that you continue to take the aspirin and plavix daily unless
instructed otherwise by your cardiologist. Your cardiologist
may want to pursue a test called a Holter monitor to observe
your heart rhythm as outpatient.
.
During your hospitalization, your kidney function test was
elevated. This was likely due to the contrast load that you
received for your two cardiac catheterizations. You will need
close follow-up with your primary care doctor to monitor your
kidney function. In the meantime, your lasix was reduced to
half your regular dose as lasix can also affect your kidneys.
.
We made the following changes to your medications:
-INCREASED aspirin from 81mg to 325mg daily
-DECREASED furosemide (lasix) from 40mg to 20mg daily
-STOP ambien at night because this medication can make you
confused
-Please discuss with your primary care doctor whether you should
remain on Enablex and Neurontin
-Please discuss with your primary care doctor about when to
restart your lisinopril. This medication was held because of
your low blood pressures and because of your worsening kidney
function
-Please talk to your cardiologist about the initiation of a beta
blocker
-Please speak with your oncologist about whether you should
remain on fluconazole as your liver enzyme tests were elevated
Followup Instructions:
The following appointments have been scheduled for you:
PCP [**Name Initial (PRE) **]: [**Last Name (LF) 766**], [**4-22**] at 9am
With:[**Doctor Last Name **] [**Name Initial (MD) **] [**Name8 (MD) **],MD
Address: [**State **], STUITE 245,
[**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 98031**]
Hematology/Oncology Appointment: Thursday, [**4-25**] at 1:15pm
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18365**],MD
Location: [**Hospital **] CANCER CENTER
Address: [**2137**], [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 83767**]
Cardiology Appointment: Tuesday, [**5-21**] at 2pm
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 98032**], MD
Location: HEART CENTER OF [**Hospital1 **]
Address: [**Location (un) **],2ND FL, [**Location (un) **],[**Numeric Identifier 7398**]
Phone: [**Telephone/Fax (1) 6256**]
Completed by:[**2137-4-17**]
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icd9cm
|
[
[
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[
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14529, 14588
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314, 380
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1988, 2048
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4173, 4755
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,038
| 133,242
|
43850
|
Discharge summary
|
report
|
Admission Date: [**2103-12-23**] Discharge Date: [**2104-1-1**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Abdominal pain, confusion
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
86 M with CABG, CHF EF 25% with BiV ICD/pacer, AFIB,
diet-controlled DM, R ear melanoma, here with confusion,
abdominal pain, diarrhea, cough for several hours. His son [**Name (NI) **]
noticed that his father sounded confused and disoriented on the
phone today, and he had been normal in mental status earlier
today and yesterday. He entered his father's house and his
father was looking up at the ceiling and his speech was making
no sense, so his son called an ambulance to take him to the
hospital. Abdominal pain was described as moderate, sharp and
dull, and in lower quadrants. Diarrhea characteristics/color
could not be described, but was little in volume and rare
frequency. Cough was productive with sputum of unknown color.
.
He has had no fever, no chills, no CP, no SOB, no headache, no
dizziness, no leg swelling. He has no sick contacts, no recent
travel, and is compliant with all medications and
salt-restricted diet. He is on home O2 2L nc, but has never been
diagnosed with a lung disease per patient. He used to smoke
cigars for 5 years, but quit decades ago, and he never smoked
cigarettes in his life.
.
In the ED, he had a fever to 104, WBC 17.6 with 0 bands, lactate
2.3, ABG 7.48/31/89. RIJ central line was placed, received 4L NS
with 1L out, received levo/flagyl. CXR showed RLL opacity, UA
was positive. CT head was negative, CT abd was negative for
acute process or bleed.
Past Medical History:
1) CAD s/p CABG in [**2089**]
2) CHF with last [**Year (4 digits) **] in [**11-29**] showed EF<20%
3) h/o Afib, now with AICD/pacer
4) BPH
5) Diet controlled DM
6) GIB without clear etiology and resulting anemia
7) Hypothyroidism
8) R ear melanoma, surgically removed
Social History:
Used to deliver milk for job. Lives by himself but son is in
same house, widower, retired. Denies tobacco past or present,
previous moderate EtOH use, no IVDU.
Family History:
Father>>Tb
Physical Exam:
VS: T 97.9 99/47 / 82 / 20 / 100% shovel mask
GEN: A&Ox3, speaks clearly, pleasant
HEENT: JVD difficult to assess for RIJ line, mild LAD, OP clear,
dry mm
LUNGS: Rales in L base, rales and cardiac wheezing in R base,
both [**11-28**] way up
HEART: RRR, 3/6 SEM radiating up, S3
ABD: Moderately distended, firm, ND throughout
EXTR: L inguinal hernia easily reduced, soft, no erythema or
edema. No c/c/edema, 2+ DP bilaterally.
NEURO: [**3-29**] motor throughout
Pertinent Results:
.
Radiology
[**12-24**] CXR: Mild pulmonary vascular cephalization consistent with
slightly worsened fluid overload as compared to yesterday.
Otherwise grossly unchanged appearance.
.
[**12-24**] CT Abd w/o contrast: No evidence of colitis or
diverticulitis (noncontrast). Bilateral dependent atelectasis
and additional possible infectious consolidation at the right
lung base. Gallbladder sludge without evidence of cholecystitis.
Multiple hypoattenuating lesions in both kidneys, incompletely
assessed on this noncontrast study. Additional US could be
performed on a nonemergent basis. High atherosclerotic burden of
abdominal aorta and major tributaries.
.
[**12-22**] Head CT: No evidence of acute intracranial hemorrhage.
Extensive periventricular and deep white matter hypodensities
consistent
with chronic small vessel infarcts.
.
[**12-22**] CXR: Perihilar fullness and perivascular haze with
increased opacity in the right lower lung zone. Findings are
consistent with failure with possible focal consolidative
process in the right lower lung.
.
[**12-22**] [**Month/Year (2) **]: EF 30% LA mod dilated, RA markedly dilated, no ASD by
doppler. Mod symm LVH, mod global LV hypoK. No mass or thrombi,
no VSD. RV dilated w/ depressed systolic fx, mod dilated asc
aorta, no AV vegetations. Minimal AS, trace AR. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
AP supine and erect views of the abdomen show no distention of
bowel in the imaged areas. The lower pelvis is excluded from the
examination. There is heavy atherosclerotic calcification
extending from the iliacs into the pelvic arteries. Larger
calcific ring shadows in the left upper abdominal quadrant could
be a combination of colonic diverticula with residual barium or
smaller arterial aneurysms and calcified left renal mass as
evaluated on recent abdomen CT, [**2103-12-23**].
[**2104-1-1**] 05:00AM BLOOD WBC-6.3 RBC-3.27* Hgb-9.2* Hct-28.2*
MCV-86 MCH-28.2 MCHC-32.8 RDW-17.8* Plt Ct-251
[**2103-12-22**] 07:40PM BLOOD WBC-17.6*# RBC-4.11* Hgb-12.0* Hct-34.6*
MCV-84 MCH-29.1 MCHC-34.6 RDW-17.9* Plt Ct-195
[**2103-12-24**] 04:23AM BLOOD Neuts-87.7* Lymphs-7.2* Monos-4.9 Eos-0.1
Baso-0.1
[**2103-12-22**] 07:40PM BLOOD Neuts-93.0* Bands-0 Lymphs-3.5* Monos-3.2
Eos-0.1 Baso-0.2
[**2104-1-1**] 05:00AM BLOOD PT-27.5* INR(PT)-2.8*
[**2103-12-22**] 07:40PM BLOOD PT-22.5* PTT-38.3* INR(PT)-2.2*
[**2103-12-23**] 04:38PM BLOOD Fibrino-304 D-Dimer-744*
[**2103-12-23**] 04:38PM BLOOD FDP-0-10
[**2104-1-1**] 05:00AM BLOOD Glucose-87 UreaN-20 Creat-0.9 Na-135
K-4.0 Cl-102 HCO3-25 AnGap-12
[**2103-12-22**] 07:40PM BLOOD Glucose-182* UreaN-35* Creat-1.6* Na-135
K-4.2 Cl-99 HCO3-24 AnGap-16
[**2103-12-30**] 05:25AM BLOOD ALT-17 AST-14 AlkPhos-54 TotBili-1.0
[**2103-12-23**] 04:56AM BLOOD ALT-30 AST-38 LD(LDH)-211 AlkPhos-58
TotBili-1.0
[**2103-12-24**] 04:23AM BLOOD CK(CPK)-838*
[**2103-12-23**] 08:51AM BLOOD CK(CPK)-286*
[**2103-12-30**] 05:25AM BLOOD Lipase-20
[**2103-12-27**] 05:40PM BLOOD CK-MB-3 cTropnT-0.04*
[**2103-12-24**] 04:23AM BLOOD CK-MB-5 cTropnT-0.04*
[**2103-12-23**] 08:51AM BLOOD CK-MB-6 cTropnT-0.04*
[**2103-12-31**] 04:21AM BLOOD Mg-2.2
[**2103-12-30**] 05:25AM BLOOD Albumin-3.2* Calcium-7.9* Mg-2.1
[**2103-12-30**] 01:34AM BLOOD Albumin-3.6 Calcium-8.4 Mg-2.1
[**2103-12-27**] 04:17AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.2 Iron-41*
[**2103-12-23**] 04:56AM BLOOD Albumin-3.6 Calcium-7.6* Phos-4.1 Mg-2.1
[**2103-12-27**] 04:17AM BLOOD calTIBC-300 VitB12-214* Folate-GREATER TH
Ferritn-150 TRF-231
[**2103-12-29**] 06:33AM BLOOD TSH-1.9
[**2103-12-29**] 06:33AM BLOOD TSH-1.9
[**2103-12-23**] 06:11AM BLOOD Cortsol-45.0*
[**2103-12-23**] 04:56AM BLOOD Cortsol-25.9*
[**2103-12-28**] 06:45AM BLOOD Vanco-12.6
[**2103-12-29**] 06:33AM BLOOD Digoxin-0.3*
[**2103-12-22**] 08:00PM BLOOD Type-ART pO2-89 pCO2-31* pH-7.48*
calTCO2-24 Base XS-0
[**2103-12-23**] 11:34AM BLOOD Lactate-1.2
[**2103-12-22**] 07:56PM BLOOD Lactate-2.3*
[**2103-12-23**] 01:15PM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.025
[**2103-12-23**] 01:15PM URINE Blood-LGE Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2103-12-23**] 01:15PM URINE RBC-374* WBC->1000* Bacteri-OCC
Yeast-NONE Epi-0
[**2103-12-22**] 07:40PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2103-12-22**] 07:40PM URINE Blood-SM Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
[**2103-12-22**] 07:40PM URINE RBC-0-2 WBC-21-50* Bacteri-FEW Yeast-NONE
Epi-0-2
[**2103-12-30**] 12:00PM URINE Hours-RANDOM UreaN-862 Creat-123 Na-12
Date 6 Specimen Tests Ordered By
All [**2103-12-22**] [**2103-12-23**] [**2103-12-25**] [**2103-12-29**] [**2103-12-30**]
[**2103-12-31**] All BLOOD CULTURE CATHETER TIP-IV STOOL URINE All
EMERGENCY [**Hospital1 **] INPATIENT
[**2103-12-31**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2103-12-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2103-12-29**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2103-12-25**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2103-12-25**] URINE URINE CULTURE-FINAL INPATIENT
[**2103-12-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2103-12-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2103-12-25**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2103-12-23**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2103-12-23**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2103-12-23**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA,
2ND ISOLATE} INPATIENT
[**2103-12-22**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}
EMERGENCY [**Hospital1 **]
[**2103-12-22**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG
+}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +} EMERGENCY [**Hospital1 **]
Brief Hospital Course:
86 M with 86 M with CABG, CHF EF 25% with AICD/dual chamber
pacer, AFIB, diet-controlled DM, R ear melanoma, here with UTI,
RLL pna, diarrhea, severe sepsis.
.
# Sepsis: Urine was grossly purulent following foley placement
on admission. In review of previous culture data, he has a
history of quinolone resistant proteus and pseudomonas in past
urine cultures. He was started on meropenem and vancomycin on
admission. 2/2 blood cultures from [**12-22**] grew out coagulase
positive staph. aureus. Urine culture grew pseudomonas which
had intermediate resistance to meropenem --> he was subsequently
switched to cefepime for his UTI. Levophed was required to
maintain MAPs of >65, discontinued on [**12-21**]. Source of MRSA
unclear. [**Name2 (NI) **] was negative for masses or vegetations, but in
setting of thickened aortic valve, will need TEE to rule out
endocarditis. Patient also has a pacemaker in place which could
also be a source of bacteremia. Pacer site is not red or
fluctuant. ID followed him in hospital. They did not think the
pacer needed to be removed at this time since the repeat
cultures were negative. He will be followed by ID in clinic - Dr
[**Last Name (STitle) 9404**](instructions below). Weekly CBC, LFT, BUN, creat,
vancomycin trough levels should be faxed toDr [**Doctor Last Name 9404**] as below.
Vancomycin should be continued for atleast 4 weeks and maybe
more at the discretion of Dr [**Last Name (STitle) 9404**]. Cefepime should be
continued for 6 more days. ID did not think pt needed a TEE.
.
# Hypoxemic respiratory insufficiency:
Unknown intrinsic lung disease, but PFTs [**5-30**] show restrictive
and diffusion defect consistent with interstitial process. Was
on Amiodarone, and no signs of pulmonary toxicity on high res CT
chest in [**11-29**], but difficult to read HRCT in setting of active
CHF exacerbation. HRCT shows ground glass opacity, septal
thickening, bilateral pleural effusions. Smoked cigars for 5
yrs, has never smoked cigarettes in his life. Usually on home O2
2L nc at baseline. Is ambulatory and active normally. There is
evidence of CHF on chest imaging and, thus, this may have played
role in original increased O2 requirement from baseline. He
will need pulm outpatient followup for PFTs with DLCO when
euvolemic.
.
# CHF with EF 25%:
Had BiV ICD/pacer interrogated on [**2103-12-13**] in device clinic
showing good function. Used to be on Amiodarone for significant
ventricular arrhythmia and then for AFIB. Per PCP< this was
stopped over a year ago. Had 6 beat VT spontaneously aborted.
Followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] as an outpatient. He was
admitted on metoprolol and moexipril which were both held for
hypotension. as BP stabilised, metoprolol, moexepril and lasix
and digoxin were restarted.
.
# Urinary retention: [**Last Name (un) **] from a large prostae. He failed void
trials twice. The second time PVR was 1500ml. Foley was placed
and is on flomax and terazosin. GU follow up should be arranged
in [**11-27**] weeks.
# Diarrhea - 3 days prior to discharge, the patient developed
profuse diarrhea. Likely antibiotic associated. Flagyl was
started and diarrea slowed down. C diff was negative x3. should
have follow up of lytes if diarrhea continues.
# Acute renal failure: Baseline creatinine 0.9-1.1. Admission
creatinine was 1.6 which improved with fluids, pressor support,
and treatment of his infection/sepsis.
# anemia - lower B12 levels for which oral B12 was started. PCP
follow up.
.
# Atrial fibrillation: INR was 2.3 on admission. His coumadin
was continued on his home dose of 5mg qhs.
.
# DM2: Diet controlled. He was placed on HISS and did require
coverage (BS 140s-180s).
.
# Hypothyroidism: He was continued on levothyroxine.
Medications on Admission:
Medications obtained from last discharge summary from 5/[**2102**].
Son will bring current list of medications.
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Terazosin HCl 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime): please hold for SBP<100.
12. Moexipril HCl 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please hold for SBP<110.
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): please hold for SBP<100 or HR<55.
14. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Amiodarone HCl 200 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Cefepime 1 g Recon Soln Sig: One (1) g Intravenous once a day
for 6 days.
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
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 in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 4 weeks.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
Disp:*0 Tablet(s)* Refills:*0*
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
16. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-27**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed.
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
21. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Sepsis due to pseudomonal UTI, MRSA septicemia
Congestive heart failure, systolic
acute renal failure, resolved
Diarrhea - likely antibiotic associated
Urinary retention
Anemia, low B12 levels
Secondary:
h/o atrial fibrillation
Restrictive lung disease
home oxygen user
Hypothyroidism
Kidney lesions on CT (seen since CT [**2101**])
Discharge Condition:
Stable
Discharge Instructions:
1) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.2L
2) Please follow-up as indicated below
3) Please come to the emergency room or see your PCP if you
develop chest pain, worsening shortness of breath, persistent
diarrhea, abdominal pain, fevers, chills, or other symptoms that
concern you.
4. You have a few more days of cefepime. Vancomycin will haave
to be completed for atleast 4 weeks. Thereafter, as per the
discretion of ID physician.
5. weekly blood tests will have to sent to Dr [**Last Name (STitle) 9404**] as below.
6) INR should be closely monitored while on flagyl and may cause
elevated levels.
Followup Instructions:
1) Infectious disease
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-1-22**]
11:30
2) Primary Care: Follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 608**]) within
1-2 weeks following discharge
3) Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/CUT. ONC. DERM
Date/Time:[**2104-1-9**] 10:45
4) Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 19848**] CUTANEOUS ONCOLOGY
Date/Time:[**2104-1-9**] 11:00
5) weekly CBC, differential, LFT, BUN/Creat, vancomycin trough
levels should be drawn and results faxed to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at
[**Telephone/Fax (1) 1419**]
|
[
"995.92",
"V45.81",
"600.01",
"428.0",
"486",
"427.31",
"038.11",
"788.20",
"425.4",
"250.00",
"401.9",
"428.23",
"397.0",
"599.0",
"584.9",
"V10.82",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16088, 16161
|
8869, 12650
|
241, 263
|
16548, 16557
|
2691, 3363
|
17290, 18096
|
2180, 2192
|
14161, 16065
|
16182, 16527
|
12676, 14138
|
16581, 17267
|
2207, 2672
|
176, 203
|
291, 1695
|
3372, 8846
|
1717, 1986
|
2002, 2164
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,257
| 163,899
|
37261
|
Discharge summary
|
report
|
Admission Date: [**2182-5-1**] Discharge Date: [**2182-5-10**]
Date of Birth: [**2128-10-30**] Sex: F
Service: MEDICINE
Allergies:
Vicodin / Risperidone
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
Abdominal pain, fever
Major Surgical or Invasive Procedure:
Central line placement
Endotracheal intubation
History of Present Illness:
53 year old female with pancreatitis diagnosed [**2182-4-16**],
schizoaffective disorder, morbid obesity. On arrival the
patient is intubated and sedated, history is largely per medical
records. The patient presented on [**2182-5-1**] with worsening
abdominal pain, nausea, vomiting and diarrhea. She initially
presented to [**Hospital6 204**] where she was febrile to
101 degrees. She received 1 mg IV dilaudid, levofloxacin 750 mg
IV, flagyl 500 mg IV and zofran 4 mg IV. CT of the abdomen
showed necrotizing pancreatitis with possible pseudocyst. She
was transferred to this hospital for further management.
She was transfered to [**Hospital1 18**] and found to have diffuse abdominal
pain with rebound tenderness. She received 2mg IV dilaudid and
then desated to low 80s on RA and 93% on 15L. She also
complained of CP without EKG changes. Pt was accessed to be a
difficult airway and was intubated while awake with fiberoptics.
CT abdomen was re-read as necrotizing pancreatitis with
pseudocyst. Surgery was consulted but declined surgical
intervention and suggested holding antibiotics. The patient had
a clear CXR but got dexamethasone and combivent for possible
COPD exacerbation. She received 1 gm vancomycin for a RLE
cellulitis. She also received zofran, fentanyl, versed and
tylenol.
On arrival to the MICU the patient is intubated but arrousable.
Able to nod head. Grimaces to abdominal palpation. All other
review of systems negative in detail.
Past Medical History:
Schizoaffective disease
? previous pancreatitis
Spastic colon
Multiple Sclerosis
Allergic Rhinitis
Obstructive sleep apena
Asthma
Hematuria
Transverse myelitis
Obesity
Hypertension
Venous insufficiency
Diabetes Mellitus
Chronic pain
Chronic constipation
Ovarian cyst
s/p cholecystectomy [**2163**]
Knee surgery x2 [**2169**], [**2170**].
Associative disorder.
h/o overdose tylenol, singular.
Social History:
Lives alone, no tobacco and alcohol use.
Family History:
Mother with hypertension and asthma.
Physical Exam:
General: intubated and sedation. morbid obesity
HEENT: Sclera anicteric, MMM, OG, ET tube
Neck: supple, JVP not appreciated given body habitus, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, diffusely grimacing with palpation, greatest
Lside / epigastric, non-distended, bowel sounds absent, no
organomegaly
GU: foleywith cloudy urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema RLE 8 x 13 cm area of erythema /warmth
Pertinent Results:
Hematology:
[**2182-5-1**] 08:20PM BLOOD WBC-16.9*# RBC-4.28 Hgb-11.8* Hct-36.3
MCV-85 MCH-27.5 MCHC-32.5 RDW-15.3 Plt Ct-178
[**2182-5-7**] 05:40AM BLOOD WBC-10.9 RBC-3.46* Hgb-9.6* Hct-30.3*
MCV-88 MCH-27.9 MCHC-31.8 RDW-14.3 Plt Ct-195
[**2182-5-1**] 08:20PM BLOOD Neuts-88.2* Lymphs-6.8* Monos-4.7 Eos-0.3
Baso-0.1
[**2182-5-1**] 08:20PM BLOOD PT-14.8* PTT-24.0 INR(PT)-1.3*
[**2182-5-7**] 05:40AM BLOOD Plt Ct-195
Chemistries:
[**2182-5-2**] 05:30AM BLOOD Fibrino-687*
[**2182-5-1**] 08:20PM BLOOD Glucose-150* UreaN-6 Creat-0.7 Na-139
K-4.3 Cl-105 HCO3-26 AnGap-12
[**2182-5-7**] 05:40AM BLOOD Glucose-154* UreaN-6 Creat-1.0 Na-145
K-3.7 Cl-107 HCO3-34* AnGap-8
[**2182-5-5**] 04:00AM BLOOD ALT-24 AST-29 LD(LDH)-201 AlkPhos-128*
TotBili-0.3
[**2182-5-1**] 08:20PM BLOOD ALT-36 AST-45* CK(CPK)-619* AlkPhos-116*
TotBili-0.5
[**2182-5-5**] 04:00AM BLOOD ALT-24 AST-29 LD(LDH)-201 AlkPhos-128*
TotBili-0.3
[**2182-5-1**] 08:20PM BLOOD Lipase-31
[**2182-5-3**] 04:23AM BLOOD Lipase-19
[**2182-5-1**] 08:20PM BLOOD Albumin-2.9* Calcium-8.0* Phos-2.9 Mg-1.6
[**2182-5-7**] 05:40AM BLOOD Calcium-7.7* Phos-4.3 Mg-1.9
[**2182-5-2**] 04:15AM BLOOD Triglyc-51 HDL-38 CHOL/HD-1.8 LDLcalc-19
[**2182-5-2**] 04:15AM BLOOD Hapto-389*
[**2182-5-3**] 04:23AM BLOOD Vanco-20.4*
[**2182-5-2**] 11:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2182-5-1**] 08:30PM BLOOD Lactate-1.0 K-4.2
[**2182-5-2**] 11:49PM BLOOD Lactate-0.7
Cardiac Enzymes:
[**2182-5-1**] 08:20PM BLOOD cTropnT-<0.01
[**2182-5-2**] 04:15AM BLOOD CK-MB-6 cTropnT-<0.01
[**2182-5-2**] 11:25AM BLOOD CK-MB-5 cTropnT-<0.01
Blood Gas:
[**2182-5-2**] 03:57AM BLOOD Type-ART Temp-37.4 Rates-15/4 Tidal V-480
PEEP-10 FiO2-50 pO2-145* pCO2-64* pH-7.23* calTCO2-28 Base XS--2
-ASSIST/CON Intubat-INTUBATED
[**2182-5-5**] 04:23PM BLOOD Type-CENTRAL VE Temp-36.8 Rates-/14 Tidal
V-400 PEEP-5 FiO2-40 pO2-41* pCO2-56* pH-7.32* calTCO2-30 Base
XS-0 Intubat-INTUBATED Vent-SPONTANEOU Comment-PRESS SUPP
Urine Studies:
[**2182-5-1**] 09:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.035
[**2182-5-1**] 09:40PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2182-5-1**] 09:40PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2182-5-2**] 03:40AM URINE Mucous-RARE
[**2182-5-2**] 11:31AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Microbiology:
Blood cultures x 2 [**2182-5-1**] no growth to date
Urine culture [**2182-5-2**] no growth
Imaging:
[**5-1**] CT chest/abdomen:
1. Necrotizing pancreatitis with 6.3 x 7.4 cm area of loculated
fluid adjacent to the pancreas. While this may represent
inflammatory changes from severe pancreatitis or
developingpseudocyst, infectious process/developing abscess can
not be excluded.
2. Diminutive splenic vein.
3. Splenomegaly.
[**5-1**] CXR: IMPRESSION: Limited study due to low lung volumes and
patient rotation to the right. Superior mediastinum remains
prominent. Endotracheal tube in appropriate position.
Brief Hospital Course:
This is a 53 year old female with morbid obesity presenting with
necrotizing pancreatitis and respiratory failure.
Necrotizing pancreatitis: Unclear etiology. She has had a
cholecystectomy and does not consume etoh. Lipids normal.
Lipase was already low by the time of arrival here. CT with
necrotizing pancreatitis and a fluid collection. Her WBC's came
down and she has not had fever so concern for secondary
infection was low. Her exam was reassuring as her abdomen is
soft, but with some tenderness. She continues to have some
residual pain so an N-J tube was placed to start jejunal tube
feedings. She will be discharged with a plan to remain NPO and
on only tube feeds until pain free, then diet should be slowly
advanced. Would be conservative with diet advancement as her
diet was advanced fairly quickly during her prior admission and
her conditioned worsened. Would consider having GI and nutrition
follow at LTAC. As she has no clear etiology of this episode,
she has f/u with a pancreatitis specialist in 4 weeks here at
[**Hospital1 18**]. When it is time to advanced her diet she passed s/s eval
with no restrictions. A picc was placed to facilitate IV meds
and lab draws(she has very difficult peripheral access).
Respiratory Failure:With diuresis the patient was weaned an
extubated. At the time of discharge we suspect that she is
euvolemic to slightly volume up, although difficult to assess by
exam. Would monitor i/o closely and given lasix 40 IV prn to
keep even.
OSA:Patient has OSA but refused CPAP.
Pain/anxiety: Can be given morphine IV or po.
RLE cellulitis: Resolved. Completed course of Cephalexin.
Anemia: Hematocrit stable. Likely from critical illness.
Hypertension: Blood pressures stable. continued to hold home
enalapril
Schizoaffective disease: The patient is well compensated. In
discussion with psychiatry it is unclear if she actually carries
the diagnosis of schizoaffective d/o. No hallucinations or
delusions noted.
Hypothyroidism: Continued home levothyroxine
Type II Diabetes: Regular insulin sliding scale q6 was done with
TF. Januvia was stopped out of concern for medication induced
pancreatitis.
Asthma: albuterol prn
Access:PICC, confirmed in upper SVC
Medications on Admission:
Albuterol
Advair 500/50 mcg 1 puff [**Hospital1 **]
Levothyroxine 100mg PO daily
Enalapril 5mg PO daily
Pravastatin 10 PO daily
Janumet 50/500 PO bid switched to actos/metformin 15/500mg [**Hospital1 **]
after pancreatitis flair.
Lasix 80 mg daily
Gabapentin 100mg PO TID
Singulair 10mg PO daily
Zyprexa 5mg PO daily
Klonopin 0.5mg PO TID prn
Nexium 40mg Daily
Ceftin 500mg PO BID through [**4-27**].
Augmentin 875/125 PO BID starting [**4-30**]
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: 5000 (5000)
Units Injection TID (3 times a day): until patient ambulatory.
2. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization [**Month/Year (2) **]:
One (1) neb Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
3. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: One (1)
standard sliding scale Injection every six (6) hours.
4. Quetiapine 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
5. Quetiapine 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily)
as needed for agitation/anxiety.
6. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Morphine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Morphine 100 mg/4 mL Solution [**Hospital1 **]: 1-4 mg Intravenous every
six (6) hours as needed for pain.
12. Advair Diskus 500-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1)
puff Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] HealthCare Center at [**Location (un) 4047**]
Discharge Diagnosis:
Primary Diagnosis: 577.0 PANCREATITIS, ACUTE
Secondary Diagnosis: 518.81 RESPIRATORY FAILURE, ACUTE
Secondary Diagnosis: 327.23 APNEA, OBSTRUCTIVE SLEEP
Secondary Diagnosis: 682.6 CELLULITIS, LEG
Secondary Diagnosis: 278.01 OBESITY, MORBID
Secondary Diagnosis: 250.82 DIABETES TYPE II, UNCONTROLLED W/
COMPLICATIONS
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:
Patient being transferred to a facility
Followup Instructions:
She should have follow up arranged with her primary care
phsyician at the time of discharge from LTAC.
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2182-6-5**] at 12:45 PM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"295.72",
"285.9",
"250.02",
"401.1",
"278.01",
"682.6",
"577.0",
"518.81",
"493.90",
"276.2",
"340",
"327.23",
"244.9",
"276.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"96.72",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10256, 10347
|
6069, 8286
|
304, 352
|
10707, 10707
|
2986, 4441
|
10947, 11419
|
2343, 2381
|
8783, 10233
|
10368, 10368
|
8312, 8760
|
10883, 10924
|
2396, 2967
|
4458, 6046
|
243, 266
|
380, 1853
|
10629, 10686
|
10387, 10413
|
10722, 10859
|
1875, 2269
|
2285, 2327
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,812
| 143,323
|
34380+57919
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-9-19**] Discharge Date: [**2149-9-23**]
Date of Birth: [**2120-5-20**] Sex: F
Service: MEDICINE
Allergies:
Lamictal / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
Mechanical Ventilation
History of Present Illness:
29 yo female with polysubstance ingestion in setting of a fight
with her mother. [**Name (NI) **] report, the pt had ingested a siginficant
amount of EtOH earlier on the day PTA, before she experienced a
conflict at home. In this setting, she locked herself in a
bathroom and apparently consumed an unknown quantity (question
one week pill case?) of Remeron, Ambien and Klonopin, which the
pt is apparently taking as prescription meds at home. At the
time of admission, a urine tox screen was also positive for
amphetamines.
At the time of admission to the ED, initial vitals were 98.6,
106, 26, 165/109, 100% NRB. The pt was reported to be agitated
and have snoring respirations. She was given two trial doses of
naloxone with minimal response. As she remained unable to
cooperate with additional testing, she was intubated and
sedated. A head CT was obtained which was preliminarily
negative.
ROS: unable to obtain at time of admission
Past Medical History:
Depression
ADHD
Frequent UTIs
Urinary Retention
Social History:
Reportedly no smoking, prior significant EtOH or drugs.
Family History:
Not-Relevant
Physical Exam:
In ED:
Vitals 98.6, 106, 26, 165/109, 100% NRB
Gen: Intubated, sedated adult female.
HEENT: 3mm pupils, ERRLA. MMM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD.
Chest: Mechanical breath sounds throughout.
Cor: Normal S1, S2. RRR. No murmurs appreciated.
Abdomen: Soft, non-tender and non-distended. +BS, no HSM.
Extremity: Warm, without edema. 2+ DP pulses bilat.
Neuro: Sedated but moving all extremities. Upgoing toes.
Reflexes intact throughout.
Pertinent Results:
Admission Labs:
[**2149-9-19**] 02:00AM PLT COUNT-406
[**2149-9-19**] 02:00AM WBC-5.3 RBC-4.57 HGB-13.7 HCT-39.8 MCV-87
MCH-29.9 MCHC-34.3 RDW-14.0
[**2149-9-19**] 02:00AM ASA-NEG ETHANOL-300* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2149-9-19**] 02:00AM AMYLASE-54
[**2149-9-19**] 02:00AM UREA N-6 CREAT-0.8
[**2149-9-19**] 02:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2149-9-19**] 02:05AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2149-9-19**] 02:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
[**2149-9-19**] 02:13AM HGB-14.8 calcHCT-44
[**2149-9-19**] 02:13AM GLUCOSE-92 LACTATE-2.3* NA+-150* K+-4.0
CL--108 TCO2-20*
[**2149-9-19**] 12:27PM PLT COUNT-357
[**2149-9-19**] 12:27PM WBC-9.0# RBC-3.82* HGB-11.4* HCT-33.3* MCV-87
MCH-29.9 MCHC-34.3 RDW-14.3
[**2149-9-19**] 12:27PM GLUCOSE-100 UREA N-3* CREAT-0.7 SODIUM-143
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-27 ANION GAP-12
[**2149-9-19**] 12:57PM O2 SAT-99
[**2149-9-19**] 12:57PM LACTATE-1.5 TCO2-25
[**2149-9-19**] 01:01PM GLUCOSE-101 UREA N-3* CREAT-0.8 SODIUM-144
POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-26 ANION GAP-14
.
Pertinent Labs:
[**2149-9-22**] 06:05AM BLOOD WBC-6.5 RBC-4.04* Hgb-12.0 Hct-35.5*
MCV-88 MCH-29.8 MCHC-33.8 RDW-13.3 Plt Ct-299
[**2149-9-22**] 06:05AM BLOOD Glucose-92 UreaN-7 Creat-0.5 Na-140 K-3.9
Cl-105 HCO3-26 AnGap-13
[**2149-9-19**] 02:00AM BLOOD Amylase-54
[**2149-9-19**] 12:57PM BLOOD Lactate-1.5 calHCO3-25
,
Non-Contast Head CT ([**2149-9-19**])
No priors are available. There is no evidence of intracranial
hemorrhage,
mass effect, shift of midline structures, hydrocephalus, or
acute major
vascular territorial infarction. Degree of frontal atrophy
bilaterally is
slightly more prominent than expected for age. Small
fat-containing lesion is
noted just anterior to the pons within the region of the
suprasellar cistern
likely of no clinical significance. [**Doctor Last Name **]-white matter
differentiation is well
preserved. The globes are intact and soft tissues are normal.
Mastoid air
cells and paranasal sinuses are normal. Aerosolized secretions
are noted
within the oro- and nasopharynx likely secondary to the
patient's intubated
status.
IMPRESSION:
No acute intracranial pathology.
.
CXR: ([**2149-9-19**])
No acute cardiopulmonary process. Endotracheal tube
approximately from the
carina would benefit from mild advancement.
.
Brief Hospital Course:
29 yo female without known significant PMH admitted with
polysubstance ingestion.
.
# Polysubstance Ingestion/Suicide Attempt: The patient was taken
to the MICU and was briefly intubated for airway protection.
Upon transfer to the floor the patient was recovering well from
over-sedation. She was AOx3, mildly drousy, and her mood was
stable and conversation appropriate. She was watched overnight
on the floor without complication and evaluated by psychiatry
the following morning that stated the patient was deemed section
12 and deemed unable to leave AMA. She was kept on a 1:1 sitter.
She will be transferred to [**Hospital1 **] 4 for inpatient
psychiatric rehabilitiation.
.
# Urinary Issues. These are followed by the patients PCP. [**Name10 (NameIs) **]
patient requested both macrobid and tamsulosin in the MICU and
these were administered. During her hospitalization she was
continued on both Tamulosin and Macrobid
Medications on Admission:
-Tamsulosin
-Nitrofurantoin
-Ambien 10mg po Qhs
-Amphetamine salts 20mg tab
-Remeron 45mg po QHS
-Prilosec
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis
- Drug Overdose
Discharge Condition:
Good. Patient mentating well, with stable mood, and at her
physical and mental baseline.
Discharge Instructions:
You were admitted to the hospital following an ingestion of
pills while at home. You were intubted in the ICU for airway
protection and monitored closely. You were subsequently
extubated an brought to a medicine floor for observation. You
were seen by our psychiatrists and they are recommending
inpatient psychiatric evaluation.
.
Please continue to take all your medications as prescribed
Followup Instructions:
Our psychiatrists will set this up for you.
Name: [**Known lastname 9949**],[**Known firstname 12726**] Unit No: [**Numeric Identifier 12727**]
Admission Date: [**2149-9-19**] Discharge Date: [**2149-9-23**]
Date of Birth: [**2120-5-20**] Sex: F
Service: MEDICINE
Allergies:
Lamictal / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1408**]
Addendum:
Please note she had a left foot plain film to evaluate pain
after a fall (prior to admission). She has a known 5th
metatarsal fracture, sustained about one month prior to
presentation, with planned follow up with her orthopedic surgeon
on [**2149-10-2**].
Discharge Disposition:
Extended Care
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1410**] MD [**MD Number(2) 1411**]
Completed by:[**2149-9-25**]
|
[
"E950.9",
"980.0",
"309.81",
"969.0",
"969.4",
"305.02",
"967.8",
"E950.2",
"300.4",
"E950.3",
"314.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7267, 7439
|
4516, 5445
|
300, 325
|
6039, 6130
|
1978, 1978
|
6569, 7244
|
1455, 1469
|
5602, 5923
|
5982, 6018
|
5471, 5579
|
6154, 6546
|
1484, 1959
|
252, 262
|
353, 1293
|
1994, 3238
|
3254, 4493
|
1315, 1364
|
1380, 1439
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,109
| 197,349
|
45019
|
Discharge summary
|
report
|
Admission Date: [**2134-2-4**] Discharge Date: [**2134-2-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Rectal Bleeding
Major Surgical or Invasive Procedure:
Flex sig with electrocautery and epinephrine injection
History of Present Illness:
Patient is a [**Age over 90 **] yo male with h/o prostate CA, COPD,
afib/aflutter and SSS, with recent sigmoidscopy on [**2134-1-22**], where
localized whitish sclerotic mucosa in perianal, internal area
(possibly ulcerated near nodule) were noted in the anus. Cold
forceps biopsies were performed for histology. A single 10mm
polyp was found in the appears to be part of an internal
hemorrhoid but has different mucosal appearance. Patient reports
that after dinner today he defecated and had [**1-22**] quarts of
BRBPR. Patient had no CP, SOB, + lower quadrant abd pain times
months that is stable. Patient reports no nausea or vomiting, no
recent fevers, NSAID use or sick contacts. [**Name (NI) **] then brought
to ED by son, and there contiued to have BRBPR. Initial HCT 39.3
at 8:30PM and then dropped to 29 at 1AM. Patient remaied
hemodynamically stable with SBP 140-150 and HR in 60s. Patient
given 4 U FFP and 10mg VIt K SQ. NG lavage negative. EKG with no
acute ischemic changes. Plans made for CT of abd and admission
to MICU for colonoscopy and possible bleeding scan.
Past Medical History:
1. prostate ca s/p XRT [**2119**]
2. bladder ca, Papillary urothelial carcinoma, high grade (dx in
[**2133-3-20**]), nonmetastatic (recent negative cystoscopy [**8-24**])
3. lumbar fracture -- followed closely in pain clinic w/
multiple steroid injections, on chronic opioid therapy
4. COPD (PFTs [**3-24**]: FVC 59% predicted, FEV1 58% predicted and
FEV1/FVC 98% predicted)
5. PUD with GIB in [**2120**]
6. atrial fibrillation and ?sick sinus syndrome
7. hx of rheumatic fever
8. hx of CVA
9. s/p appendectomy
10. s/p lap chole in [**2122**]
11. chronic LE edema- recently saw Dr.[**Last Name (STitle) **] for evaluation
12. tachy-brady sundrome
13. afib-aflutter on coumadin
Social History:
denies alcohol use since [**2127**] (used to drink vermouth); 75 pack
year smoking history (smoked 2-3 packs per day), quit in [**2127**];
lives in [**Location 12651**] [**Last Name (NamePattern1) **] House- has 24 hr caretaker who is with
him tonight. FULL CODE- discussed with patient on admission;
born and raised in [**Hospital3 4414**]
Family History:
NC
Physical Exam:
PE: 95.9 137/61 65 12 100% 3L
GEN:NAD, A and O times 3
HEENT:NCAT< EOMI, OP clear, dry MM, no JVD
CV: RRR, no M, distant HS
PULM:mod air movement, crackles at bases
ABD:+BS, soft, mild distension in lower quadrants bilat, no
rebound, no gaurding. no testicular pain with elevation of
ttestis.
EXT:no c/c- + pedal edema
NEURO:CN II-XII intact, strength 5/5, MAEW
Pertinent Results:
[**2134-2-4**] 08:23PM HGB-12.8* calcHCT-38
[**2134-2-4**] 08:24PM PT-28.0* PTT-35.5* INR(PT)-2.9*
[**2134-2-4**] 08:24PM CK-MB-4 cTropnT-<0.01
[**2134-2-4**] 08:24PM LIPASE-35
[**2134-2-4**] 10:26PM HGB-11.0* calcHCT-33
CXR:
Chronic consolidation and atelectasis in the right middle lobe
have improved. Upper lungs clear. No pleural effusion or
evidence of central adenopathy. Heart size normal.
Abd CT:
1. Active contrast extravasation in the inferior rectum. Given
the location, hemorrhoidal bleeding is the most likely cause.
Alternatively, this could represent bleeding from a rectal
artery.
2. Stable small bilateral pulmonary nodules.
3. Multiple bilateral renal cysts.
4. L5 wedge compression deformity.
Flex Sig: Bleeding site was identified approximately 3 cm from
ano-rectal junction. There was a possible Dieulafoy's lesion
that was actively bleeding. The overlying clot was removed.
Blood in the rectum, sigmoid colon and descending colon
Bleeding possibly secondary to Dieulafoy's lesion. Hemostasis
was successful.
Brief Hospital Course:
Mr. [**Known lastname **] is a [**Age over 90 **] yo Man with PMH sig for afib on coumadin
COPD, hx of CVA and PUD who presented to the ED with BRBPR, was
transferred to the MICU and seen by GI s/p Flex sig with
bleeding ulcer which was electrocauterized and s/p epinephrine
injection. His bleeding resolved, and his Hct stablized. He was
able to tolerate PO and had no further BRBPR, melena or
abdominal pain at discharge. His Coumadin was not restarted. It
was left to his PCP to reevaluate risk and benefits of coumadin
vs bleed. His lowest Hct was 21 for which he received 2 units of
PRBCs. He was discharged on hospital day number 4 with Hct of 31
and asymtomatic with ambulation. He was continued on all outpt
meds, cautioned about NSAID use and no Coumadin.
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: [**12-21**] Tablet PO TID (3
times a day).
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours.
Disp:*1 inhaler* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-21**] Inhalation every
4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
5. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Lower Gastrointestinal Bleed from Rectal Ulcer
Atrial Fibrillation
COPD
Discharge Condition:
Stable to be discharged to home with home physical therapy.
Discharge Instructions:
Please continue all medications as prescribed.
Your coumadin should be held for [**10-2**] more days. Please do not
restart your aspirin until you follow up with your primary care
physician.
If you have fevers, chills, sweats, chest pain, shortness of
breath, nausea, vomiting, diarrhea, blood in your stool or black
stool, please come back to the emergency department or call Dr. [**Name (NI) 96241**] office.
Followup Instructions:
1. Please call Dr.[**Name (NI) 14154**] office at [**Telephone/Fax (1) 904**] to schedule a
follow up appointment in 1 week. Unfortunately we were unable to
make an appointment due to the President's Day Holiday.
--You should have your hematocrit checked at this appointment.
--You should also discuss restarting your coumadin at this
appointment.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2134-3-22**] 11:30
3. Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2134-3-22**] 11:10
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2134-2-14**]
|
[
"427.31",
"585.9",
"496",
"V10.51",
"V10.46",
"569.86",
"V58.61",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5455, 5513
|
3996, 4763
|
275, 331
|
5629, 5691
|
2921, 3973
|
6152, 6905
|
2519, 2523
|
4786, 5432
|
5534, 5608
|
5715, 6129
|
2538, 2902
|
220, 237
|
359, 1441
|
1463, 2143
|
2159, 2503
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,172
| 103,195
|
2505
|
Discharge summary
|
report
|
Admission Date: [**2186-5-4**] Discharge Date: [**2186-5-10**]
Date of Birth: [**2120-4-21**] Sex: F
Service:
ADMITTING DIAGNOSIS: Diabetic ketoacidosis.
HISTORY OF PRESENT ILLNESS: This is a 66 year old female
with a history of Stage 2 breast cancer, hypertension,
hypercholesterolemia where family found her on the day of
admission unresponsive. Per the Triage, she did not complain
of any chest pain, shortness of breath, fever or chills. Per
family a few days ago, she was feeling weak, slurred speech
but had not been eating. She was back to herself the day
before admission until, on the day of admission, she had
mental status changes per her grandson upon arrival to the
Emergency Department. Denies any nausea or vomiting. In the
Emergency Room, she had abdominal pain, cool extremities,
hypotensive in the 70s over 30s systolic and diastolic,
started on Levophed but weaned after intravenous fluid
hydration which improved her blood pressure. She was
intubated for a questionable concern of tiring with arterial
blood gas of 7.09, 18, and 400 O2. Post intubation, she was
transferred to the Medical Intensive Care Unit for further
treatment.
PAST MEDICAL HISTORY:
1. Stage 2 breast cancer, invasive, ductal cell, diagnosed
in [**2183**], status post Radiation therapy and chemotherapy.
2. Hypertension.
3. Hypercholesterolemia.
4. Spinal stenosis.
5. Myoclonus in bilateral lower extremities.
6. History of B12 deficiency.
HOME MEDICATIONS:
1. Aspirin.
2. Lipitor.
3. Klonopin.
4. Ibuprofen.
5. Lisinopril.
6. Os-Cal.
7. Triamterene.
8. Vitamin B12.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No history of diabetes mellitus or other
history in siblings or other family members.
SOCIAL HISTORY: No tobacco, no ethanol. Lives alone.
Independent of all activities of daily living. Daughter
calls and visits frequently every day.
PHYSICAL EXAMINATION: On admission in the Emergency Room,
vital signs were temperature 96.4 F.; blood pressure 74/37;
pulse 110; respiratory rate 18; saturation of 85% on room air
and then afterwards was intubated on AC-500, 14, FIO2 of 80%,
tidal volume 700 to 800. On examination, generally was
intubated and sedated. Skin dry. HEENT: Pupils equally
round and reactive to light and accommodation. No
lymphadenopathy. Mucous membranes were moist.
Cardiovascular with tachycardia with a regular rhythm; no
murmurs, rubs or gallops. Pulmonary clear to auscultation
bilaterally. Abdomen with decreased bowel sounds but
present. Positive tenderness per Emergency Room diffusely.
Positive guaiac. No masses appreciated. Extremities with no
cyanosis, clubbing or edema. Fingers and toes were cool with
decreased capillary refill greater than two seconds.
Neurologic is sedated with occasional myoclonic jerking.
LABORATORY: On admission, white blood cell count 16.2,
hematocrit 31.4, platelets 241, MCV 90. Sodium 138,
potassium not logged; chloride 85, bicarbonate 7, BUN of 113
and creatinine of 8.3. Glucose of 1034.
Chest x-ray showed no failure; line in place. D-Dimers were
27 and 53, fibrinogen 604. CEA 13.
Urinalysis showed many bacteria with 6 to 10 epithelials,
large blood, moderate leukocyte esterase, negative nitrites,
250 glucose, 15 ketones, 11 to 20 red blood cells, greater
than 50 white blood cells.
HOSPITAL COURSE: The patient is a 66 year old female with a
history of Stage 2 invasive ductal cancer who now presents
with new onset diabetes mellitus and in diabetic ketoacidosis
with questionable urosepsis, admitted to Medical Intensive
Care Unit.
Per Medical Intensive Care Unit summary, the patient was
intubated after course as dictated. Had done well; was
extubated. Her diabetic ketoacidosis was treated with
insulin drip and intravenous fluids aggressively and the gap
was closed two days prior to transfer to the floor.
The patient extubated the day prior to transfer to the [**Hospital1 139**]
Medicine Floor and did well. Hypotension resolved with
intravenous fluid boluses. She was also ruled out for
myocardial infarction. She was transferred then to [**Hospital1 139**]
Medicine and extubated on the day prior to the transfer to
the Medicine Floor, doing well, and weaned off of her O2
nasal cannula, at which point on the day prior to discharge
the patient was educated about diabetic medication through [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consultation recommendations. Also, multiple
educational summaries were given by the nursing staff and
physicians of how to use insulin at home and how to check
blood glucose levels. The family was involved.
The patient was able to self administer insulin and will have
education by [**Hospital **] Clinic later on this afternoon on
discharge date. She is to follow-up with [**Hospital **] Clinic and
also with Dr. [**Last Name (STitle) 4844**] with whom she has an appointment in two
weeks.
Otherwise the patient is discharged in good condition.
Pulmonary status was all recovered and no other issues.
For her urinary tract infection she was to complete a 14 day
course. She has remained afebrile since transfer back to the
floor. She is continuing eight more days of Levaquin q. day.
She is to follow-up again with Dr. [**Last Name (STitle) 4844**].
DISPOSITION: The patient was discharged to home with
[**Hospital6 407**] services.
DISCHARGE INSTRUCTIONS:
1. She was told to seek medical attention as soon as
possible if symptoms return or new symptoms arise.
2. She has appointment with [**Last Name (un) **] Diabetes Center today at
02:00 o'clock and get educated on what to further follow-up
with [**Hospital **] Clinic.
3. Also appointment with Dr.[**Name (NI) 4864**] office, with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8271**], on [**2186-5-24**], at 03:00 p.m.
4. Other recommended follow-ups as noted.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Diabetes mellitus.
3. Urinary tract infection.
There were no major surgical or invasive procedures except
intubated in the unit.
CONDITION AT DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Ipratropium p.r.n.
2. Levofloxacin 500 mg p.o. q. day.
3. Aspirin 325 mg p.o. q. day.
4. Protonix 40 mg p.o. q. day.
5. Insulin 70/30, 18 units q. a.m. and 70/30, 10 units q.
p.m.
The patient and family are aware of diagnosis, treatment and
frequency as indicated and managed by primary care physician.
Diet: Diabetic, low carbohydrate, low cholesterol diet.
Arranging home health services with Physical Therapy and
[**Hospital6 407**] to teach medications and
administration and checking blood glucose at home. Home
Health Service, again, as discussed above, Physical Therapy
with weight bearing, activity as tolerated with caution.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6307**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2186-5-10**] 14:25
T: [**2186-5-11**] 18:38
JOB#: [**Job Number 12819**]
|
[
"518.81",
"599.0",
"577.0",
"276.3",
"584.9",
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"333.2"
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"96.71",
"99.07",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1659, 1746
|
5901, 6074
|
6120, 6997
|
3354, 5374
|
5398, 5880
|
1485, 1642
|
1921, 3336
|
6090, 6097
|
201, 1179
|
148, 172
|
1201, 1467
|
1763, 1898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,185
| 199,576
|
18901
|
Discharge summary
|
report
|
Admission Date: [**2159-11-20**] Discharge Date: [**2159-12-3**]
Date of Birth: [**2081-5-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 78-year-old white male has
a history of insulin dependent diabetes, hypertension,
hypercholesterolemia, and hypothyroidism. He is status post
CABG x4 on [**2159-10-17**], and was recently readmitted to [**Hospital1 1444**] with bilateral pleural
effusions and a pericardial effusion seen on echocardiogram
at [**Hospital3 7571**]Hospital. After placement of a left chest
tube, 1800 cc drained with position changes, and the patient
improved and was eventually transferred back to the rehab
facility on [**2159-11-14**].
On [**2159-11-18**], the patient was transferred from rehab to
[**Hospital3 7571**]Hospital with CHF and anasarca. He was
diuresed with Lasix and transfused 2 units of blood for a low
hematocrit. An echocardiogram showed a good EF and bilateral
pleural effusions. He underwent an ultrasound guided
thoracentesis, which drained 200 cc on the left side. A
followup chest x-ray revealed no improvement and the patient
began having sinus tachycardia and AFib in the rate of 120s.
He reportedly remained hemodynamically stable with a systolic
blood pressure of 120s to 140s. He had postoperative atrial
fibrillation which was treated with amiodarone and Coumadin,
and at the time of his last discharge on [**2159-11-14**], he had
been in normal sinus rhythm for approximately two weeks and
was discharged off amiodarone and Coumadin. Now he was
treated with 0.5 of digoxin IV and 0.125 the day of
admission, and he was on Lopressor 12.5 b.i.d. and a
diltiazem drip at 5 mg an hour. He was transferred to [**Hospital1 1444**] for further management.
PAST MEDICAL HISTORY:
1. History of hypertension.
2. History of CAD: Status post CABG x4 on [**2159-10-17**].
3. History of hypercholesterolemia.
4. History of hypothyroidism.
5. History of insulin dependent diabetes.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] is retired. He
quit smoking 30 years ago. Drinks alcohol occasionally.
ALLERGIES: He has no known allergies.
MEDICATIONS ON ADMISSION:
1. Levoxyl 0.75 mg p.o. q.h.s.
2. Protonix 40 mg p.o. q.a.m.
3. Niferex 150 mg p.o. b.i.d.
4. Insulin NPH 15 units q.a.m., 15 units q.p.m.
5. Aspirin 81 mg p.o. q.d.
6. Captopril 6.25 mg p.o. q.d.
7. Combivent two puffs b.i.d.
8. Humalog sliding scale.
9. Lovenox 40 mg subQ q.d.
10. Levaquin 500 mg IV q.d.
11. Rocephin 2 grams IV q.d.
12. Digoxin 0.125 mg p.o. q.d.
13. Lopressor 12.5 mg p.o. b.i.d.
14. Cardizem drip at 5 mg/hour.
REVIEW OF SYSTEMS: Review of systems was significant for
shortness of [**Name (NI) 1440**] and intermittent heartburn.
PHYSICAL EXAMINATION: On physical exam, he is a thin,
elderly white male in no apparent distress. Vital signs:
Heart rate is 123 in AFib, blood pressure 138/70,
respirations 30, and O2 saturation 93% on 2.5 liters nasal
cannula. HEENT examination is normocephalic, atraumatic.
Extraocular movements are intact. Oropharynx is benign.
Neck is supple, full range of motion, no lymphadenopathy or
thyromegaly. Carotids are 2+ and equal bilaterally
throughout. Lungs are clear to auscultation and percussion.
Cardiovascular examination: Irregular rate and rhythm,
normal S1, S2 with no murmurs, rubs, or gallops. Abdomen was
soft and nontender with positive bowel sounds. No masses or
hepatosplenomegaly. Extremities had 1+ pitting edema on the
bilateral upper extremities and the bilateral lower
extremities. Neurologic examination was nonfocal. Pulses
were 2+ and equal bilaterally in the radial arteries and
Doppler pulses on the dorsalis pedis.
His chest x-ray revealed increased vascular markings and a
small left effusion.
He was admitted to the CSRU in AFib and was started on
amiodarone drip and given Lopressor. He was diuresed with
Lasix. He was also started on a Heparin drip. He remained
in AFib until hospital day #2. He converted to sinus rhythm.
He is extubated and revealed bilateral pleural effusions and
on postoperative day three, the patient was transferred to
the floor in stable condition. He was slowly improving, but
continued to have pleural effusions and required O2. His
blood sugars also were elevated and his insulin required
adjustments.
Dr. [**Last Name (STitle) 952**] was consulted and felt that he needed a VATS
procedure, and on [**11-24**], the patient underwent a left VATS
with pleurodesis and pleural biopsy, and the insertion of a
right chest tube with pleural biopsy and pleurodesis by Dr.
[**Last Name (STitle) 954**]. The patient tolerated the procedure well. Was
transferred back to the floor and restarted on Heparin. He
continued to have a stable postoperative course, and the
chest tubes were left in for seven days to make sure the
pleurodesis succeeded.
He improved with his ambulation and remained in sinus rhythm.
Also his left pleural fluid revealed methicillin-sensitive
coag-negative Staph and he will need to be continued on
levofloxacin for two weeks, and on postoperative day #7, his
chest tubes were D/C'd. On postoperative day nine, he was
discharged to rehab in stable condition.
LABORATORIES ON ADMISSION: Hematocrit 31.8, white count
10,900, platelets 604,000. Sodium 133, potassium 4.8,
chloride 100, CO2 26, BUN 31, creatinine 1.0, blood sugar
181, INR 2.4.
DISCHARGE MEDICATIONS:
1. Ecotrin 81 mg p.o. q.d.
2. Lopressor 75 mg p.o. b.i.d.
3. Captopril 12.5 mg p.o. t.i.d.
4. Levoxyl 75 mcg p.o. q.d.
5. Lipitor 40 mg p.o. q.d.
6. Protonix 40 mg p.o. q.d.
7. Amiodarone 400 mg p.o. q.d. x2 days, then decrease to 200
mg p.o. q.d.
8. Multivitamin one p.o. q.d.
9. Levaquin 500 mg p.o. q.d. for 12 days.
10. Coumadin 1 mg p.o. tonight and titrate for an INR of
[**3-18**].5.
11. NPH insulin 15 units subQ b.i.d. and regular
insulin-sliding scale.
FOLLOW-UP INSTRUCTIONS: He will be followed by Dr.
[**Last Name (STitle) 27542**] in [**2-15**] weeks. Dr. [**Last Name (STitle) 11493**] in [**3-19**] weeks and Dr. [**Last Name (STitle) 1537**]
in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3116**]
MEDQUIST36
D: [**2159-12-3**] 10:34
T: [**2159-12-3**] 10:42
JOB#: [**Job Number 51704**]
|
[
"272.0",
"250.00",
"997.3",
"427.31",
"401.9",
"997.1",
"414.01",
"244.9",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"34.92",
"34.24",
"34.21",
"04.81"
] |
icd9pcs
|
[
[
[]
]
] |
5386, 5850
|
2160, 2595
|
2739, 5191
|
2615, 2716
|
161, 1741
|
5206, 5363
|
5875, 6345
|
1763, 1961
|
1978, 2134
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,275
| 108,084
|
40620
|
Discharge summary
|
report
|
Admission Date: [**2129-7-20**] Discharge Date: [**2129-8-3**]
Date of Birth: [**2052-11-25**] Sex: F
Service: MEDICINE
Allergies:
Hydralazine / Heparin,Porcine
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
GI bleed
Respiratory distress
Major Surgical or Invasive Procedure:
Ultrafiltration
Hemodialysis
History of Present Illness:
(History obtained from son and OSH record)
76 yo F with history of CKD recently started on hemodialysis (2
cycles as of [**7-20**]), h/o CVA x2, h/o RCC s/p nephrectomy, and
recent known [**Hospital **] transferred from the OSH to the ICU for planned
GI work-up; however, was in respiratory distress requiring
intubation in the [**Hospital1 **] ED.
.
Per the son, she has been having increased lethargy, decreased
energy, as well as LE swelling. Patient reported having had at
least 1 week of melena and 1 day of hematemesis on [**2129-7-15**].
This led to her admission to [**Hospital **] Hospital on [**2129-7-15**].
At the OSH ED, she was noteded to have BRBPR and initial Hct of
25.3 from 30.5 on [**7-12**] and 34.4 on [**6-7**]. Per OSH record, her NG
lavage in the ED was negative. Her hemodynamics remained
stable. Subsequently, she was on Protonix gtt and IV hydration
with GI consult. Her plavix was held. She apparently underwent
an endoscopy by DR. [**Last Name (STitle) 30885**], which showed a bleeding friable
large pyloric channel stalk polyp 4-5 cm as well as gastric
mucosal friability. Per discharge summary, patient vomited
blood on [**7-19**] and received DDAVP. During her time in the OSH,
she was initiated on hemodialysis per her nephrologist's
recommendations. Per the son, patient was supposed to be
transferred over on [**7-19**] but did not get here until [**7-20**].
.
Per the son, she had a colonoscopy that was not remarkable,
except for polyps, last year.
.
Patient received a cycle of dialysis today before transfer.
.
Per ED report, patient became hypoxic en route to the 70s to
endoscopy, so was rerouted to the ED. At triage, HR 69, BP
167/66, RR 25, O2Sat 85% on BiPAP. There was concern of
pneumonia vs. fluid overload. She was placed on BiPAP then was
intubated for hypoxic respiratory distress on fentanyl and
propofol. Apparently, OG tube lavage did not show blood. Per
ED report, patient had a living will from [**2117**] with DNR/DNI, but
this was discussed with patient prior to intubation, and she
agreed to it. She was given protonix 80 mg IV 1x, vancomycin,
levofloxacin, and zosyn. Nephrology and GI were made aware of
her. Bedside echocardiogram showed small pericardial effusion
with left sided pleural effusion. Upon transfer, HR 58, BP
142/58, RR 16, O2Sat 100% on FiO2 80%, TV 400, RR set 18, and
PEEP of 10 with fentanyl and propofol for sedation.
.
In the [**Hospital Unit Name 153**], she was quickly extubated without complication on
[**7-21**] after HD ultrafiltration. She has been on 2L NC since. Echo
showed EF 50% with apical hypokinesis attributed NSTEMI during
this admission although trop elevations are only modest
considering renal function and CK/MB not elevated. EKG notable
for non-specific t-wave changes. She is on plavix as an outpt
for hx of CVA, but this has been held in setting of GIB.
.
In terms of her GI bleed, she was found to have a large polyp
leading to obstruction of pylorus. She was transfused [**2129-7-23**] 1
unit of pRBCs. Patient also noted to have bleeding [**Doctor First Name **]-[**Doctor Last Name **]
tear on EGD on Monday [**2129-7-25**], after which she had 20 cc
hematemesis but has had none since and has been hemodynamically
stable the entire hospitalization throughout [**Hospital Unit Name 153**] stay. She has
been on [**Hospital1 **] IV PPI, transitioned to PO PPI today and tolerating
po intake. Her last transfusion was today [**7-27**] with HD, at which
time she got 1 unit PRBC. She has received total 2 units (one
today, one on [**7-23**]).
.
Her course was also complicated by MSSA bacteremia and a
hematoma next to her AV fistula. Blood cultures drawn on
admission to [**Hospital1 18**] grew MSSA, one out of four bottles. She is on
cefazolin with Hemodialysis (2/2/3 g after HD on M/W/F, today
day 7 of 14 - last day [**8-3**]). Initial concern for infected
fistula given mild tenderness but ultrasound ok and vascular
felt it was very unlikely (no graft). Subsequent cultures x 6
days no growth to date.
.
She also had thrombocytopenia and Plt 142 on presentation, that
decreased to nadir of 69. Patient has not been on heparin at
[**Hospital1 18**], but unclear if received at OSH or with hemodialysis. PF4
neg. Plts since rose to 110.
In terms of ESRD, patient received HD session prior to transfer
to the floor.
Vitals in [**Hospital Unit Name 153**] prior to transfer to floor were as follows: T
98.7, BP 128/64, P 70, RR 14, O2sat 99% 2L. Pt arrived at the
floor with no complaint of pain.
Past Medical History:
(per [**Hospital **] Hospital record)
- Upper GIB from bleeding large pyloric channel stalk polyp with
diffuse gastric friability
- Lower GIB
- history of CVAs x2, was on plavix (until OSH admission.
Initially on ASA-> Plavix. Did not tolerate Aggrenox per OSH
record)
- CKD stage 4, on dialysis (2 cycles as of [**7-20**])
- h/o renal cell cancer s/p nephrectomy
- HTN
- HLD
- Anemia of chronic disease
Social History:
- lived at home with son
- has 3 grown children: son [**Name (NI) **], daughter [**Name (NI) **] and another
daughter
- no tobacco or alcohol use per son
- has been physically inactive for at least 1 year
- stays at home most of the time, but has a good friend that she
talks to twice a day
Family History:
- father deceased at 66 with MI
- mother deceased at 91 to colon cancer
- 1 sister is in good health
Physical Exam:
On admission:
Vitals: T:97.1 BP:109/67 P:77 R:17 O2: 97%, CMV Vt450, PEEP 10,
RR set at 18
General: intubated
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
Lungs: bronchial breath sounds, clear to auscultation, no w/c/r
appreciated
CV: RRR, normal S1 and S2, soft [**2-10**] holosystolic and diastolic
murmur, no rub or gallops
Abd: soft, NT, ND, BS present, no guarding, no organomegaly, +
old scar
GU: Foley draining clear urine
Ext: Cool extremities, 1+ edema to the thighs, 2+ DP and radial
pulses bilaterally, no clubbing or cyanosis.
On discharge:
Vitals: T:98.9 BP:164/70 P:72 R:20 95% on 2L O2
General: Pleasant, older woman in NAD. Friendly, cooperative.
AAOx3
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
Lungs: breaths slightly shallow but unlabored, good air
movement, no use of supplementary muscles, clear to auscultation
bilaterally, no w/c/r appreciated
CV: RRR, normal S1 and S2, no murmur, rub, or gallops
Abd: soft, NT, ND, BS present, no guarding, no organomegaly, +
old scar
Ext: Warm extremities, minimal edema to the thighs, 2+ DP and
radial pulses bilaterally, no clubbing or cyanosis.
Pertinent Results:
1. Labs on admission:
[**2129-7-20**] 01:55PM BLOOD WBC-10.9 RBC-4.35 Hgb-13.3 Hct-38.9
MCV-89 MCH-30.5 MCHC-34.1 RDW-17.2* Plt Ct-138*
[**2129-7-20**] 01:55PM BLOOD Neuts-83.4* Lymphs-10.0* Monos-4.7
Eos-1.1 Baso-0.8
[**2129-7-20**] 01:55PM BLOOD PT-11.7 PTT-21.7* INR(PT)-1.0
[**2129-7-20**] 01:55PM BLOOD Glucose-54* UreaN-27* Creat-2.8* Na-144
K-4.1 Cl-106 HCO3-26 AnGap-16
[**2129-7-20**] 01:55PM BLOOD ALT-23 AST-35 LD(LDH)-291* CK(CPK)-141
AlkPhos-86 TotBili-0.6
[**2129-7-20**] 01:55PM BLOOD CK-MB-10 MB Indx-7.1* proBNP-[**Numeric Identifier 88886**]*
[**2129-7-20**] 01:55PM BLOOD cTropnT-0.20*
[**2129-7-20**] 09:22PM BLOOD CK-MB-11* MB Indx-8.3* cTropnT-0.28*
[**2129-7-21**] 05:44AM BLOOD CK-MB-9 cTropnT-0.22*
[**2129-7-20**] 09:22PM BLOOD Calcium-7.2* Phos-3.7 Mg-1.8
[**2129-7-21**] 05:44AM BLOOD Triglyc-150*
[**2129-7-21**] 05:44AM BLOOD TSH-51*
.
2. Labs on discharge:
Test Name Value Reference Range Units
[**2129-8-3**] 07:30
COMPLETE BLOOD COUNT
White Blood Cells 7.6 4.0 - 11.0 K/uL
Red Blood Cells 3.26* 4.2 - 5.4 m/uL
Hemoglobin 10.0* 12.0 - 16.0 g/dL
Hematocrit 29.6* 36 - 48 %
MCV 91 82 - 98 fL
MCH 30.5 27 - 32 pg
MCHC 33.6 31 - 35 %
RDW 15.9* 10.5 - 15.5 %
Platelet Count [**Telephone/Fax (3) 88887**] K/uL
[**2129-8-3**] 07:30
RENAL & GLUCOSE
Glucose 138* 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
Urea Nitrogen 44* 6 - 20 mg/dL
Creatinine 3.8* 0.4 - 1.1 mg/dL
Sodium 138 133 - 145 mEq/L
Potassium 3.4 3.3 - 5.1 mEq/L
Chloride 101 96 - 108 mEq/L
Bicarbonate 26 22 - 32 mEq/L
Anion Gap 14 8 - 20 mEq/L
Calcium, Total 7.9* 8.4 - 10.3 mg/dL
Phosphate 2.5* 2.7 - 4.5 mg/dL
Magnesium 2.3 1.6 - 2.6 mg/dL
.
3. Imaging/diagnostics:
- CXR ([**2129-7-20**]):
1. Enlarged cardiac silhouette, may be due to pericardial
effusion and/or
cardiomyopathy, not optimally evaluated due to the bibasilar
opacities.
2. Bilateral mid-to-lower lung opacities likely represent
layering bilateral pleural effusions with overlying atelectasis,
underlying consolidation cannot be excluded.
.
- CXR ([**2129-7-22**]):
.
- Echocardiogram ([**2129-7-21**]):
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with distal
septal/anterior/apical hypokinesis. The remaining segments
contract normally (LVEF = 50%). No masses or thrombi are seen in
the left ventricle. The right ventricular cavity is mildly
dilated with focal hypokinesis of the apical free wall. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Moderate aortic regurgitation. Mild mitral
regurgitation. Small circumferential pericardial effusion
without signs of tamponade. Bilateral pleural effusions with
atelectatic lung.
.
- Upper extremity ultrasound ([**2129-7-22**]):
Extensive soft tissue edema, without focal fluid collection.
These findings could reflect cellulitis. Clinical correlation is
advised.
.
- CXR ([**2129-7-25**]):
In comparison with the study of [**7-24**], there is no evidence of
pneumomediastinum or pneumothorax. Bibasilar opacification is
consistent with pleural effusions, compressive atelectasis, and
increased pulmonary venous pressure or pulmonary edema. Some of
the diffuse opacification could represent aspiration.
.
- EGD ([**2129-7-25**]):
A 4cm pedunculated gastric polyp was found at the pylorus,
prolapsing into duodenum. The tip of the polyp was erythematous
and ulcerated. An endoloop was placed at the base of the polyp
and the polyp was pulled into the stomach for better
visualization.
A single-piece polypectomy was then performed using a hot snare
in the gastric polyp. The polyp was completely removed. There
was no evidence of bleeding from the polypectomy site.
Two additional smalll polyps (<1cm) were found in the stomach
body.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear was seen at the GE junction, continuing
into the cardia. There was no evidence of bleeding initially,
however at the end of the procedure, there was a moderate amount
of fresh blood seen arising from the GE junction. The area was
flushed with water vigorously, and the bleeding appeared to stop
spontaneously.
Otherwise normal EGD to 3rd portion of duodenum.
Brief Hospital Course:
76 yo F with CKD on HD, h/o CVA, h/o RCC s/p nephroctomy
presents after recently initiating hemodialysis with GI bleed
transferred to [**Hospital Unit Name 153**] for hypoxic respiratory failure requiring
intubation, found to have troponin leak, also found to have
profound hypothyroidism and ?MSSA bacteremia.
# Hypoxic respiratory failure.
CXR on admission to [**Hospital1 18**] most consistent with fluid overload,
potentially from flash pulmonary edema in the setting of demand
ischemia. Echocardiogram showed pericardial effusion without
tamponade. Ultrafiltration and hemodialysis performed with
marked improvement in respiratory status. Patient successfully
extubated without complication. She continued to have large
pleural effusions and oxygen requirement of 3L NC on the floor.
Ultrafiltration was limited by blood pressures; because pt's
blood pressures could not tolerate pulling off significant
volume, she will require rehabilitation stay for period of time
until enough fluid is removed to decrease oxygen requirement
back to baseline. Pt does not require oxygen at home.
# ?NSTEMI vs Demand Ischemia
Cardiac enzymes elevated with troponin 0.22 on admission and
downtrended slowly, likely secondary to demand ischemia in
setting of GI bleed. She may have otherwise had an NSTEMI prior
to presentation. Echocardiogram showed mild regional left
ventricular systolic dysfunction with distal
septal/anterior/apical hypokinesis. EKG was noted for anterior
Qs in V1 V2 and TWI in V1-V4. Patient was asymptomatic. Patient
was not given ASA or heparin in setting of her GIB. Beta
blocker (metoprolol) and captopril were started. She continued
on home rosuvastatin. Aspirin 81mg and Plavix 75mg were held
temporarily due to the risk of reemergent GI bleed. Per GI
recommendations, the patient was started on Aspirin 81mg daily
[**7-29**], while hematocrit continued to be stable, and she was
transitioned from Aspirin 81mg to Plavix 75mg on [**8-2**]. She was
also transitioned from captopril as an inpatient to lisinopril
as an outpatient as its long half-life allows for once-daily
dosing.
# GI bleed.
Patient was transfered to [**Hospital1 18**] from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in setting of
GI bleed with known gastric polyp. Gastric polyp and pyloric
channel polyp biopsied at OSH, with pathology result showing
tublar adenoma. Patient was hemodynamically stable throughout
without bleeding. Maintained on IV pantoprazole 40 mg [**Hospital1 **].
Required 1 unit of pRBC transfusion for Hct drop of ~ [**10-15**]
points over the course of [**2-6**] days but no obvious melena or
BRBPR. GI was consulted and performed EGD with removal of
polyp. Patient also noted to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear at the GE
junction which was bleeding when endoscope was removed. Patient
had one episode of hematemesis after EGD but stayed
hemodynamically stable. Tranfused a total of 2 units pRBC during
dialysis. Plavix 75mg was restarted in [**8-2**] for stroke risk.
# MSSA Bacteremia/hypotension:
[**2-8**] Blood cultures on presentation to [**Hospital1 18**] grew Methicillin
Sensitive Staph Aureus. Patient was recently initiated on
hemodialysis through left arm fistula, although transplant
surgery does not believe the site to be infected. U/S of the
extremity showed edema but no abscess. Echocardiogram showed AR
and MR, but there is no history of echocardiogram at PCP's
office for comparison. No blood culture was done in the OSH.
She was initially started on vancomycin for presumed MRSA, which
then transitioned to cefazolin for MSSA and ease of dosing with
dialysis. ID was consulted and recommended 2-week course.
Cefazolin was dosed at dialysis as follows: 2g IV Mondays after
HD, 2g IV Wednesdays after HD, 3g IV on Fridays after HD. The
course was completed with the last dose of cefazolin was given
[**2129-8-3**].
# Hypothyroidism
Patient was found to have TSH>50, for which she was started on
levothyroxine 50mcg daily. TFTs should be rechecked in 5 weeks
as an outpatient.
# Thrombocytopenia.
She was noted to have an acute drop of platelets by half in the
MICU since her admission to the hospital. Patient did not
receive heparin products while in this hospital given her GIB.
Per nephrology, heparin was not being used with her
ultrafiltration. It is unclear if she got heparin at the OSH.
Medications such as vancomycin and PPI could also potentially
cause thrombocytopenia, and patient is now on Cefazolin. PPI
was continued in setting of her GI bleed. Anti-PF4 antibody was
negative and platelet counts improved spontaneously.
# Chronic/End-stage renal failure on Hemodialysis.
Patient was recently started on dialysis (2 session) by the time
of her transfer to the ICU. Outpatient nephrologist reported
recent [**Doctor First Name **]/ANCA nephropathy from ?hydralazine. Baseline
creatinine 8.5. Renal team was consulted and started
hemodialysis Monday/Wednesday/Friday. Epo was held off given
the history of renal cell carcinoma. PPD was placed and read as
negative, and patient was set up for outpatient hemodialysis on
M/W/F schedule in [**Hospital1 **]. She does have a left arm hematoma
near the site of her AV fistula which has been stable and does
not disrupt use of the fistula for hemodialysis.
# H/o CVA.
Continued on Rosuvastatin Calcium 40 mg po daily and held off on
plavix in the setting of the GI bleed. Plavix was restarted on
[**8-2**].
# HTN.
As her clinical pictures, her SBP also improved, requiring
reinitiation of the beta blocker. She was started on metoprolol
as well as captopril, and will switch from captopril to
lisinopril at discharge.
# CODE STATUS:
# Health Care Proxy = son [**Name (NI) **] [**Name (NI) 54371**] [**Telephone/Fax (1) 88888**]
Transition of Care Issues:
[ ] Discuss epo with outpatient nephrologist
[ ] Need TSH/T3/free T4 checked in 5 weeks
[ ] Taper PPI after 8 weeks at 40mg [**Hospital1 **]
[ ] Repeat EGD in 3 months to confirm adequate removal of polyp
[ ] Pathology report from gastric polyp
Medications on Admission:
Upon transfer from [**Hospital **] Hospital:
- labetolol 100 mg po BID
- Crestor 40 mg daily
- Vitamin B12 1000 mcg po daily
- Renvela 800 mg with meals TID
- Sodium bicarb 648 mg po TID
- Prilosec 20 mg po BID
- nephrocaps 1 cap daily
- Tylenol 650 mg q6h prn
- Ambien 5 mg po qHS prn
- Zofran 4 mg IV q6h prn
.
Home medications (per OSH record)
- labetolol 200 mg [**Hospital1 **]
- Crestor 40 mg daily
- Plavix 75 mg daily
- Calcitriol 0.25 mcg daily
- B12 1000 mcg daily
Discharge Medications:
1. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every 4-6 hours as needed
for SOB.
8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Outpatient Lab Work
Please check CBC, Chem-10 daily while on hemodialysis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary Diagnoses:
End Stage Renal Disease on Hemodialysis
Demand Ischemia
Upper Gastrointestinal Bleed secondary to gastric polyp
Pleural Effusions
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 54371**],
You were admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital to start
hemodialysis, but there you started bleeding from your gastric
polyp, so they transfered you to the [**Hospital1 18**]. Here, you were
having significant difficulty breathing in the Emergency [**Hospital1 **],
so you were intubated and placed on a ventilator machine for one
day in the medical intensive care unit. With another round of
hemodialysis, they were able to take off enough fluid to make
your breathing better, so the tube could be removed without any
difficulties.
You also had an endoscopy in the intensive care unit during
which we removed a large bleeding polyp in your stomach. You
were also found to have a tear in your esophageal mucosa, called
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear, which could have also caused some of the
bleeding. You were given two units of blood transfusion.
Your blood counts have been stable.
Dear Ms. [**Known lastname 54371**],
You were admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital to start
hemodialysis, but there you started bleeding from your gastric
polyp, so they transfered you to the [**Hospital1 18**]. Here, you were
having significant difficulty breathing in the Emergency [**Hospital1 **],
so you were intubated and placed on a ventilator machine for one
day in the medical intensive care unit. With another round of
hemodialysis, they were able to take off enough fluid to make
your breathing better, so the tube could be removed without any
difficulties.
In evaluation of your gastrointestinal bleed an endoscopy was
performed in the intensive care unit during which we removed a
large bleeding polyp in your stomach. You were also found to
have a tear in your esophageal mucosa, called [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]
tear, which could have also caused some of the bleeding. You
were transfused two units of blood after which your blood counts
have been stable.
There is some question of whether or not you had a small heart
attack before you came into our hospital. You should have your
primary care doctor set you up with a cardiologist after you go
home.
The following changes have been made to your medications:
1. please stop your labetalol
2. please stop your calcitriol
3. please start protonix (pantoprazole) 40 mg every 12 hours
4. please start metoprolol tartrate 37.5mg every 12 hours
*** please hold metoprolol on mornings before dialysis ***
5. please start lisinopril 10 mg once daily
6. please start levothyroxine 50 micrograms daily (please take
this medication on an empty stomach an hour prior to taking your
other medications)
.
Again it was a pleasure taking care of you. Please contact with
questions or concerns.
Followup Instructions:
Please be sure to keep all of your followup appointments.
You will be discharged to Rehab, but after you return home,
please set up an appointment with your primary care physician,
[**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as soon as possible.
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 13553**]
Please also have your primary care physician set you up with a
cardiologist after you are discharged.
Please also be sure to follow up with AV Care for your fistula.
You may have an area of narrowing with part of your fistula, so
you will need a study called a fistulagram to further evaluate
whether or not you will need a procedure to fix it.
Please follow up with AV care within the next month:
([**Telephone/Fax (1) 87407**]
FMC - [**Location (un) 1121**] Dialysis Center
[**Street Address(2) 88889**]
[**Hospital1 **] [**Numeric Identifier 26668**]
Phone: [**Telephone/Fax (1) 30127**]
Nephrologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Outpt hd schedule will be every Mon, Wed & Fri at 5:00pm
Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2129-9-8**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2129-8-6**]
|
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"428.31",
"790.7",
"428.0",
"V12.54",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.71",
"43.41"
] |
icd9pcs
|
[
[
[]
]
] |
19245, 19381
|
11636, 17749
|
319, 349
|
19576, 19576
|
6920, 6928
|
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|
4929, 5336
|
5352, 5645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
38
| 185,910
|
24769
|
Discharge summary
|
report
|
Admission Date: [**2166-8-10**] Discharge Date: [**2166-9-4**]
Date of Birth: [**2090-8-31**] Sex: M
Service: UROLOGY
Allergies:
Inderal / Bactrim / Codeine / Penicillins
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
epididymitis
Major Surgical or Invasive Procedure:
incision and drainage of Fournier's gangrene
History of Present Illness:
The patient is a 75 year old male who was transferred from an
outside hospital because of a suspected myocardial infarction on
[**2166-8-10**] and possible need for cardiac catheterization. He was
admitted to the cardiology service initially. His symproms
actually began six days prior to admission with flu-like
symptoms. Then five days prior to admission, the patient began
complaining of a painful lump in his left testicle. His
symptoms gradually worsened, with increasing pain, erythema, and
edema of his left testicle. In addition, he complained of
difficulty urinating for two days prior to admission. He was
admitted to an outside hospital four days prior to admission
here, at which time a Foley catheter was placed and he was
started on IV Levofloxacin and Clindamycin (which was switched
to Levofloxacin and Vancomycin the following day) for
epididymitis diagnosed by ultrasound. The ultrasound also
showed questionable air in the scrotum. The patient was seen by
a urologist, Dr. [**First Name (STitle) **], as well as an infectious disease
specialist. He denied any trauma to his scrotum. He has no
significant urologic history. His prostate examination revealed
a 20 to 25 gram nonfluctuent prostate. He is not diabetic and
he is not immunocompromised. He reported that his pain has been
improving on the antibiotics. However, on the night prior to
admission he developed acute pulmonary edema, shortness of
breath, hypotension and EKG changes suggestive of myocardial
infarction (ST elevation in leads V1-[**Street Address(2) 23394**] depression in
V5-6). His peak troponin was 0.96. Neo-synepherine was started
upon admission because of hypotension, which was presumed to be
secondary to sepsis. Significant cardiac history includes a
CABG in [**2141**], hypertension, aortic stenosis, mitral
regurgitation, high cholesterol, and congestive heart failure
(EF of 40%). Upon re-evaluation at this hospital, his EKG
changes were thought to be secondary to demand ischemia, rather
than a myocardial infarction. In addition, the patient was
noted to be in acute renal failure, with a createnine of 1.8 on
admission, likely due to prerenal causes. Blood and urine
cultures from the outside hospital were all negative.
Past Medical History:
As above. Left femoral to popliteal bypass graft
Social History:
none significant
Family History:
none
Physical Exam:
General: no apparent distress
HEENT: pupils equal, round and reactive to light, extraoccular
muscles in tact
Neck: supple
Lungs: bibasilar crackles
Heart: irregularly irregular, 2/6 systolic ejection murmur
diffusely
Gastrointestinal: soft, nontender, nondistended, bowel sounds
positive
Genitourinary: enlarged (grapefruit sized) and edematous
scrotum, can not palpate testicles due to edema, bilateral
testicular tenderness (left greater than right), scrotal
erythema extending faintly up the groin creases, penile edema,
Foley in place with dark yellow urine
Extremities: full range of motion and 5/5 strength in all four
extremities
Neurologic: alert and oriented X 3, cranial nerves [**1-11**] intact
Pertinent Results:
[**2166-8-10**] 01:17AM BLOOD WBC-18.2* RBC-3.82* Hgb-12.5* Hct-36.0*
MCV-94 MCH-32.6* MCHC-34.6 RDW-14.0 Plt Ct-76*
[**2166-8-11**] 03:48AM BLOOD WBC-14.0* RBC-4.01* Hgb-12.5* Hct-38.4*
MCV-96 MCH-31.2 MCHC-32.6 RDW-14.6 Plt Ct-112*
[**2166-8-11**] 08:02AM BLOOD WBC-14.0* RBC-3.32* Hgb-10.5* Hct-32.3*
MCV-97 MCH-31.6 MCHC-32.5 RDW-14.6 Plt Ct-99*
[**2166-8-11**] 01:20PM BLOOD WBC-13.9* RBC-3.20* Hgb-10.3* Hct-30.2*
MCV-95 MCH-32.3* MCHC-34.2 RDW-14.6 Plt Ct-99*
[**2166-8-12**] 02:24AM BLOOD WBC-10.5 RBC-3.35* Hgb-10.7* Hct-31.9*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.8 Plt Ct-121*
[**2166-8-12**] 12:30PM BLOOD Hct-28.5*
[**2166-8-13**] 01:53AM BLOOD WBC-9.3 RBC-2.91* Hgb-9.5* Hct-27.2*
MCV-94 MCH-32.7* MCHC-35.0 RDW-14.7 Plt Ct-99*
[**2166-8-14**] 02:30AM BLOOD WBC-8.8 RBC-2.90* Hgb-9.2* Hct-26.8*
MCV-92 MCH-31.6 MCHC-34.3 RDW-14.6 Plt Ct-88*
[**2166-8-14**] 01:29PM BLOOD Hct-26.1* Plt Ct-73*
[**2166-8-14**] 11:43PM BLOOD Hct-28.8*
[**2166-8-15**] 03:20AM BLOOD WBC-7.3 RBC-3.15* Hgb-9.9* Hct-29.1*
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.5 Plt Ct-53*
[**2166-8-15**] 02:32PM BLOOD WBC-8.8 RBC-3.07* Hgb-9.6* Hct-28.6*
MCV-93 MCH-31.4 MCHC-33.7 RDW-14.7 Plt Ct-58*
[**2166-8-16**] 02:39AM BLOOD WBC-7.7 RBC-2.81* Hgb-9.0* Hct-25.9*
MCV-92 MCH-31.9 MCHC-34.5 RDW-14.6 Plt Ct-58*
[**2166-8-16**] 02:15PM BLOOD WBC-12.1*# RBC-3.18* Hgb-10.1* Hct-29.1*
MCV-92 MCH-31.8 MCHC-34.6 RDW-14.5 Plt Ct-63*
[**2166-8-17**] 02:38AM BLOOD WBC-7.6 RBC-3.16* Hgb-10.0* Hct-29.5*
MCV-93 MCH-31.6 MCHC-33.9 RDW-14.6 Plt Ct-67*
[**2166-8-18**] 03:46AM BLOOD WBC-7.4 RBC-3.22* Hgb-10.1* Hct-30.0*
MCV-93 MCH-31.3 MCHC-33.6 RDW-14.7 Plt Ct-85*
[**2166-8-18**] 01:15PM BLOOD Hct-25.7*
[**2166-8-18**] 03:58PM BLOOD Hct-28.6*
[**2166-8-19**] 02:34AM BLOOD WBC-8.4 RBC-3.20* Hgb-10.0* Hct-30.9*
MCV-96 MCH-31.2 MCHC-32.4 RDW-14.5 Plt Ct-119*
[**2166-8-20**] 02:03AM BLOOD WBC-5.6 RBC-3.00* Hgb-9.4* Hct-28.4*
MCV-95 MCH-31.3 MCHC-33.1 RDW-14.5 Plt Ct-177
[**2166-8-21**] 02:37AM BLOOD WBC-5.3 RBC-2.98* Hgb-9.3* Hct-28.2*
MCV-95 MCH-31.3 MCHC-33.1 RDW-14.7 Plt Ct-183
[**2166-8-22**] 02:14AM BLOOD WBC-5.2 RBC-3.20* Hgb-10.0* Hct-30.2*
MCV-94 MCH-31.1 MCHC-33.0 RDW-15.5 Plt Ct-199
[**2166-8-10**] 01:17AM BLOOD PT-14.4* PTT-28.2 INR(PT)-1.4
[**2166-8-10**] 01:17AM BLOOD Plt Smr-VERY LOW Plt Ct-76* LPlt-2+
[**2166-8-10**] 05:13PM BLOOD PT-15.6* PTT-50.6* INR(PT)-1.7
[**2166-8-11**] 02:30AM BLOOD PTT-53.2*
[**2166-8-11**] 03:48AM BLOOD Plt Ct-112* LPlt-2+
[**2166-8-11**] 08:02AM BLOOD PT-15.3* PTT-33.1 INR(PT)-1.6
[**2166-8-11**] 08:02AM BLOOD Plt Ct-99* LPlt-1+
[**2166-8-11**] 01:20PM BLOOD PT-14.8* PTT-32.0 INR(PT)-1.5
[**2166-8-19**] 02:34AM BLOOD Plt Ct-119* LPlt-1+
[**2166-8-21**] 02:37AM BLOOD Plt Ct-183
[**2166-8-22**] 02:14AM BLOOD Plt Smr-NORMAL Plt Ct-199 LPlt-1+
[**2166-8-10**] 01:17AM BLOOD Glucose-94 UreaN-42* Creat-1.8* Na-140
K-4.4 Cl-106 HCO3-21* AnGap-17
[**2166-8-10**] 05:13PM BLOOD Glucose-137* UreaN-55* Creat-2.6* Na-139
K-4.2 Cl-107 HCO3-20* AnGap-16
[**2166-8-11**] 08:02AM BLOOD Glucose-114* UreaN-52* Creat-2.0* Na-139
K-3.9 Cl-111* HCO3-19* AnGap-13
[**2166-8-11**] 01:20PM BLOOD Glucose-156* UreaN-49* Creat-1.9* Na-138
K-4.2 Cl-110* HCO3-22 AnGap-10
[**2166-8-12**] 02:24AM BLOOD Glucose-92 UreaN-42* Creat-1.7* Na-138
K-4.8 Cl-110* HCO3-20* AnGap-13
[**2166-8-12**] 12:30PM BLOOD Glucose-84 UreaN-35* Creat-1.5* Na-141
K-4.2 Cl-112* HCO3-22 AnGap-11
[**2166-8-16**] 02:39AM BLOOD Glucose-118* UreaN-17 Creat-1.0 Na-139
K-4.1 Cl-106 HCO3-29 AnGap-8
[**2166-8-16**] 02:15PM BLOOD Glucose-115* UreaN-19 Creat-1.0 Na-137
K-3.7 Cl-102 HCO3-29 AnGap-10
[**2166-8-17**] 02:38AM BLOOD Glucose-111* UreaN-21* Creat-1.0 Na-137
K-4.2 Cl-103 HCO3-30 AnGap-8
[**2166-8-17**] 10:16AM BLOOD Glucose-113* UreaN-22* Creat-1.0 Na-138
K-4.1 Cl-104 HCO3-28 AnGap-10
[**2166-8-18**] 03:58PM BLOOD K-4.4
[**2166-8-20**] 02:03AM BLOOD Glucose-116* UreaN-21* Creat-1.0 Na-138
K-3.8 Cl-110* HCO3-23 AnGap-9
[**2166-8-22**] 02:14AM BLOOD Glucose-126* UreaN-25* Creat-0.9 Na-140
K-4.2 Cl-112* HCO3-23 AnGap-9
[**2166-8-10**] 01:17AM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2166-8-13**] 01:53AM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2166-8-10**] 01:17AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.0 Mg-1.7
UricAcd-6.4
[**2166-8-12**] 02:24AM BLOOD Albumin-2.2* Calcium-8.4 Phos-3.6 Mg-2.3
UricAcd-5.9
[**2166-8-22**] 02:14AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.8
[**2166-8-11**] 01:01AM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-43 pH-7.32*
calHCO3-23 Base XS--3
[**2166-8-11**] 01:36PM BLOOD Type-ART pO2-169* pCO2-48* pH-7.29*
calHCO3-24 Base XS--3
[**2166-8-15**] 03:38AM BLOOD Type-ART pO2-129* pCO2-43 pH-7.42
calHCO3-29 Base XS-3
[**2166-8-17**] 02:52AM BLOOD Type-ART Temp-37.8 Rates-/24 PEEP-5
FiO2-40 pO2-137* pCO2-46* pH-7.46* calHCO3-34* Base XS-8
Intubat-INTUBATED
[**2166-8-19**] 08:19PM BLOOD Type-ART pO2-114* pCO2-40 pH-7.43
calHCO3-27 Base XS-2
[**2166-8-21**] 04:14PM BLOOD Type-ART pO2-126* pCO2-32* pH-7.47*
calHCO3-24 Base XS-1
[**2166-8-22**] 05:30PM BLOOD Type-ART Temp-36.9 Rates-10/ Tidal V-900
PEEP-5 FiO2-40 pO2-130* pCO2-35 pH-7.48* calHCO3-27 Base XS-3
Intubat-INTUBATED
Brief Hospital Course:
The patient was admitted to the cardiology service at [**Hospital1 18**] on
[**2166-8-10**] for presumed myocardial infarction on electrocardiogram,
which was later attributed to demand ischemia due to sepsis. He
was initially started on neo-synephrine for hypotension. He was
continued on Vancomycin and Levofloxacin for his epididymitis.
The urology team saw and evaluated the patient as a consult
service under Dr. [**Last Name (STitle) 4229**]. Our suspicion of Fournier's gangrene
at that time was very low, considering his lack of risk factors
and lack of significant groin erythema, however a CT scan of his
abdomen and pelvis was ordered to rule out Fournier's. That CT
scan confirmed the diagnosis of Fournier's gangrene on the
morning of hospital day two (tracking of air around his left
hemi scrotum tracking up the left spermatic cord. At that time,
the patient was emergently rushed to the operating room for
emergent surgical debridement by Dr. [**Last Name (STitle) 4229**] and Dr. [**First Name (STitle) **], chief
urology resident. During the operation, the patient had the
majority of his left scrotum and all of his left testicle
removed. He was then admitted to the trauma intensive care
unit. He was sedated on Propofol with Fentanyl for pain. He
was started on a Levophed drip to maintain blood pressure. A
central venous line was placed, as well as a Swann Ganz
catheter. An oro-gastric tube was placed and put to gravity.
His Foley was continued from the operating room. Dressing
changes to his scrotum were scheduled for three times per day.
On postoperative day two, his maximum temperature was 101.0.
His Levophed drip was weaned to a low level. Tube feeds were
started through his NG tube. On postoperative day three, the
plastic surgery service began their evaluation of the patient
for future closure of his wound. His propofol was discontinued.
His Levophed was discontinued. He vomited twice and his tube
feeds were held for high residuals. He recieved one unit of red
blood cells for a hematocrit under 30, and his hematocrit
responded well. His acute renal appeared to have resolved, as
his createnine dropped down to 1.0. On postoperative day four,
his ventillator was weaned to pressure support, however he had
some apneic spells. A HIT panel was negative and his
subcutaneous heparin was restarted. He had some bedside
debridement by the urology team and his wound looked like it was
healing well. He was transfused with another unit of red blood
cells. The patient was noted to be roughly twenty liters
positive and diuresis with a Lasix drip was started as
tolerated. On postoperative day seven, the patient required
some propofol for sedation due to endotracheal tube and
oro-gastric tube irritation. A sputum culture came back
positive for MRSA sensative to Vancomycin. His wound cultures
were positive for mixed flora including Bacteroides, Provatella,
and coagulase negative Staphylococcus. A wound VAC was placed
by urology. On postoperative day eight, a post-pyloric feeding
tube was placed by interventional radiology because the patient
was not tolerating tube feeds via the oro-gastric tube. On
postoperative day nine, Dr. [**Last Name (STitle) 4229**] agreed to allow placement of a
tracheostomy tube and a PEG tube at a later date. The patient
had been unable to tolerate a ventillator wean up to this point,
most likely due to his fluid overload and his cardiac history.
Tube feeds were running at agoal of 90ml/ hour. On
postoperative day ten, his Flagyl and Levofloxacin were
discontinued. He was transfused one unit of blood for a
hematocrit less than thirty. On postoperative day twelve, he
recieved another unit of red blood cells.
On POD 14, a #8 percutaneous trach was placed at the bedside. A
perc PEG was placed uner direct visualization, but the tube was
pulled through the abdominal wall. The patient was subsequently
taken to the OR for an open gastrostomy tube which was placed
without further complication. Vancomycin was stopped on [**8-25**]
after a complete 14-day course. On [**2166-8-27**], the wound was
closed primarily at the bedside by the plastic surgery service.
TF were restarted on [**2166-8-27**] and advanced as tolerated. A PICC
line was also placed on [**2166-8-27**]. Propofol was d/c'd on [**2166-8-28**].
ON [**2166-8-28**], the patient spiked a temp to 102. Cultures were
drawn and the A-line tip sent for culture as well. [**2166-8-29**] tube
feeds were held for high residuals, an ileus was found on
imaginig. PT evaluation occured on [**2166-8-29**]. Trach mask trials
were started on [**2166-8-28**] and the vent weaned as tolerated, with
the patient still requring vent assistance most of the day.
Vancomycin was restarted on [**2166-8-30**] for MRSA sputum; it will be
continued for 7 days; the JP drain was removed on this day as
well. TF were restarted on [**2166-9-1**] and brought to goal over the
next day. The patient is now tolerating TF at goal with bowel
movements.
On [**2166-9-3**], the patient was tolerating TF at goal, having bowel
movements, tolerating trach mask trials daily, was working with
PT, had good pain control with roxicet elixer, was alert and
requring no sedation. He was subsequently transfered to rehab
for physical therapy and vent weaning.
Medications on Admission:
lipitor 20', atenolol 25', ASA 81', zestril 5', protonix 40'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed.
11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
15. Morphine Sulfate 1-2 mg IV Q3-4H:PRN
prn breakthrough pain
16. Metoclopramide 10 mg IV Q6H
17. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
18. Vancomycin HCl 1000 mg IV Q 12H
19. 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.
20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
22. Midazolam HCl 0.5-1 mg IV Q4H:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Fournier's gangrene
Discharge Condition:
stable
Discharge Instructions:
Tube feeds: promote with fiber @ 90cc/hr
[**Name8 (MD) **] MD for:
* fever
* inability to tolerate TF
* erythema/increased discharge from wound
* uncontrolled pain
Followup Instructions:
Abdominal staples to be removed on [**2166-9-8**]
Scrotal sutures to be removed 3 weeks after closure on [**2166-8-27**]
Vancomycin to be d/c'd [**2166-9-5**]
|
[
"427.31",
"584.9",
"997.4",
"414.00",
"608.83",
"E870.8",
"995.92",
"038.9",
"428.0",
"998.2",
"608.4",
"560.1",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.19",
"96.6",
"96.72",
"61.3",
"62.3",
"38.93",
"31.1",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
15899, 15978
|
8613, 13927
|
313, 359
|
16041, 16049
|
3506, 8590
|
16262, 16427
|
2759, 2765
|
14038, 15876
|
15999, 16020
|
13953, 14015
|
16073, 16239
|
2780, 3487
|
261, 275
|
387, 2636
|
2658, 2709
|
2725, 2743
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,520
| 145,163
|
21492
|
Discharge summary
|
report
|
Admission Date: [**2200-10-9**] Discharge Date: [**2200-10-12**]
Date of Birth: [**2151-11-3**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
Colonoscopy with interventions (epinephrine and
electrocauterization).
History of Present Illness:
48 yo F s/p R sided polyp removal [**9-29**] at [**Hospital 46**] Hosp p/w acute
onset of lower GI bleeding with clots today. States strained to
have BM today and has been constipated recently, had normal BM
at 3P today. Ate apple. At 5:30P was supermarket shopping when
noted crampiness/ gurgling in abdomen -> large amount rectal
bleeding, ~300 cc. While driving home, noted oozing of blood
through rectum, so stopped at store and asked them to call
ambulance, who brought her to [**Hospital 1562**] Hosp.
At [**Hospital1 1562**] ED, VSS (130-140/70s, P90s-100, O2 99%). Had 2
further smaller volume (~100cc) episodes BRBPR. At 7:50P, 10min
after 3rd episode of GIB, had transient BP decr to 104/68, P 97.
[**Name8 (MD) **] RN notes, put out 650 cc blood, 400 cc urine. Was treated
with total of protonix 80 mg iv, 2L of NS, and sent here for
colonoscopy. She is Jahovah's Witness and refuses all blood
products.
ROS + constipation recently, crampy gurgling in abdomen today
Denies recent f/c, abd pain, CP, SOB, LH/ dizziness, weakness.
She has never had GIB previously.
Past Medical History:
1. H/o colonoscopy for screening 4 yr ago, normal per pt
Colonoscopy [**9-29**] showing +~6mm R sided (ascending) [**Month/Year (2) 499**] polyp
2. s/p rsxn
3. S/p BSO [**1-13**] R ovarian tumor, benign, cystic
4. S/p TAH [**1-13**] uterine fibroids
5. S/p appy
6. ?depression/anxiety
Social History:
Lives with husband of 32 [**Name2 (NI) 1686**] in MA, has 2 grown sons (age 28,
30) who live nearby. No past/present tob. + EtOH 3 drinks of
wine/week. No drugs. Is Jehovah's Witness- refuses primary blood
products (rbc, plts, plasma)
Family History:
Father w/ [**Name2 (NI) 499**] ca at age 69, now A+W. Mother w/ HTN, allergies,
no h/o ca. Sons healthy.
Physical Exam:
T 97.3, 98-103, 97-107/52-78, 18, 98% RA
Gen: Pleasant F appearing younger than stated age, NAD on bedpan
HEENT: PERRLA, EOMI, anicteric, pale conjunctiva, mmm, clear OP
Neck: Supple, no JVD
CV: RRR, nl S1, S2, no m/r/g
Pulm: CTA bilat
Abd: +bs, soft NT/ND
Rectal: grossly + blood on skin/glove, no apparent hemorrhoids/
fissures/ lesions, nl rectal tone, no masses on internal rectal
palpation
Extr: No c/c/e, wwp, 2+ DP/PT pulses
Neuro: Fully conversant, AAO x 3, moving all extremities
equally, gait not assessed
Pertinent Results:
[**2200-10-9**] 11:04PM WBC-8.3 RBC-3.22* HGB-9.9* HCT-28.8* MCV-89
MCH-30.8 MCHC-34.4 RDW-12.7
[**2200-10-9**] 11:04PM PLT COUNT-174
[**2200-10-9**] 11:04PM PT-13.3 PTT-29.5 INR(PT)-1.1
[**2200-10-9**] 11:04PM WBC-8.3 RBC-3.22* HGB-9.9* HCT-28.8* MCV-89
MCH-30.8 MCHC-34.4 RDW-12.7
[**2200-10-9**] 11:04PM CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-1.6
[**2200-10-9**] 11:04PM GLUCOSE-120* UREA N-14 CREAT-0.6 SODIUM-140
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-26 ANION GAP-10
[**2200-10-12**] 06:06AM BLOOD WBC-3.9* RBC-2.63* Hgb-7.9* Hct-24.1*
MCV-92 MCH-30.1 MCHC-32.9 RDW-12.6 Plt Ct-162
[**2200-10-12**] 06:06AM BLOOD Plt Ct-162
[**2200-10-12**] 06:06AM BLOOD Glucose-84 UreaN-7 Creat-0.6 Na-142 K-3.6
Cl-109* HCO3-30* AnGap-7*
[**2200-10-12**] 06:06AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.9
.
.
EKG from OSH at 7P: ST at 103, nl axis, nl int, no ST or T wave
changes suggestive of ischemia
.
.
[**2200-10-10**] CXR: "UPRIGHT AP PORTABLE CHEST X-RAY: The right
costophrenic sulcus is excluded from this film. The nasogastric
tube is in satisfactory position with the tip in the distal
stomach. Heart size is normal, and the mediastinal and hilar
contours are unremarkable. The pulmonary vascularity is normal,
and the lungs are clear. There are no pleural effusions although
the right costophrenic sulcus is not visualized. No pneumothorax
is seen. The surrounding osseous structures and soft tissues are
unremarkable. Mild gaseous distention of the stomach is
observed.
IMPRESSION: Satisfactory position of nasogastric tube. "
.
.
[**2200-10-10**] Colonoscopy:
"a few diverticula with small openings were seen in the sigmoid
[**Month/Day/Year 499**]. 7mm ulcer with adherent clot was seen in the proxmial
ascending [**Month/Day/Year 499**]. The clot was washed off revealing a visible
vessel. No active bleeding was noted. 7cc of epinephrine
1/[**Numeric Identifier 961**] was injected with successful hemostasis. BICAP
electrocautery was applied for hemostasis successfully. Old
blood was seen throughout the entire [**Numeric Identifier 499**]. Clear bilious vluid
was seen coming from the ileocecal valve."
Brief Hospital Course:
A/P: 48 yo F with a recent history of colonic polyp removal now
presents with hematochezia. Pt is s/p colonoscopy with
epinephrine injection and electrocauterization.
.
1. LGIB: Pt was on the verge of hemodynamic instability on
arrival to the [**Hospital Unit Name 153**], with a 9 point decrease in Hct from the
OSH, as well as continuous rectal bleeding. The patient
received IVF boluses, however no PRBC were given to respect the
patient's religious beliefs (the patient is a Jehovah's
witness). The patient received an urgent colonoscopy by GI the
night of admission and was found to have an ulcerating lesion in
the R [**Hospital Unit Name 499**] at the old polypectomy site (reports from [**Hospital1 **] obtained). The site was injected with epinephrine and
cauterized electrically. No other suspicious sites for bleed
was found, however small TICs were visible in several locations.
The patient has since remained without another episode of GI
bleed. Pt tolerated PO intake of soft diet without abdominal
pain, nauseas, vomiting. Pt also reported a BM that was
greenish-brown in color without BRBPR, red streaks or melana.
Pt also was able to ambulate the hallways without any distress
or discomfort. During the entire hospital stay the patient had
two large bore peripheral IVs, was monitored on telemetry for
signs of hemodynamic compromise and was given IV PPI. The hct
was monitored for several days with some variability. At
discharge, the hct was 22.2. However since there were no
further episodes of bleeding and the patient remained adamant in
her refusal of PRBC transfusions, the patient was monitored for
clinical signs of anemia and having found none, was discharged
with close follow up. At time of discharge, the patient was
hemodynamically stable.
.
2. H/o BSO: Due to the patient's history of BSO, we continued
hormone patch.
.
3. Depression/anxiety: The patient's zoloft was held while an in
patient due to the inability to take PO. It will be re-started
once the patient begins taking PO.
.
4. FEN: The patient was originally made NPO prior to the
colonoscopy. An NG tube was placed and lavage returned no blood
or coffee grounds. The NG tube was removed after the urgent
colonoscopy (see above), however the patient was maintained NPO
for 24 hours. The patient was then started slowly on to clears
which she tolerated well. The patient was advanced to full diet
and discharged without complications.
.
5. Proph: The patient was placed on PPI and pneumoboots for
prophylaxis. The PPI was eventually discontinued when the
patient was found to have a lower GI bleed and not an upper GI
bleed. The patient was not placed on heparin sub Q TID for
obvious bleeding risks in this women with a GI bleed.
.
6. Lines: peripheral 18g iv x 2
.
7. Comm: [**Name (NI) 4906**] [**Name (NI) **] and son [**Name (NI) **]
.
8. Code: Full. Husband is HCP.
.
Medications on Admission:
Estrogen patch
Zoloft 50 mg daily
Vitamin C/E daily
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Clonazepam 0.5 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed for anxiety.
5. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
6. Ondansetron 4 mg IV Q6H:PRN
7. Fe-Tabs 325 (65) mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Lower GI bleed from previous polypectomy site
Discharge Condition:
Good.
Discharge Instructions:
Please take all of your medication.
Please follow up with all of your doctors.
You may notice some light bleeding from your rectum, especially
with some bowel movements. If you notice any significant
bleeding, or stool that is jet black in color with a
particularly foul odor, please call your PCP or your GI doctor,
or come to the ED.
Followup Instructions:
Primary Care: Please follow up with your PCP within two weeks of
discharge.
Gastroenterology: Please follow up with your GI doctor as
needed.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2200-10-12**]
|
[
"V16.0",
"300.4",
"276.8",
"V07.4",
"285.1",
"998.11",
"V12.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
8508, 8514
|
4897, 7785
|
331, 403
|
8612, 8619
|
2747, 4874
|
9005, 9316
|
2090, 2196
|
7887, 8485
|
8535, 8591
|
7811, 7864
|
8643, 8982
|
2211, 2728
|
279, 293
|
431, 1508
|
1530, 1822
|
1838, 2074
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,835
| 192,493
|
27319
|
Discharge summary
|
report
|
Admission Date: [**2182-6-9**] Discharge Date: [**2182-6-24**]
Date of Birth: [**2107-6-30**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Subdural Hematoma s/p fall
Major Surgical or Invasive Procedure:
Right sided frontal parietal temporal craniotomy
for decompression, evacuation of hematoma and duraplasty.
History of Present Illness:
The patient is a 74 year-old female who was transferred to the
[**Hospital1 69**] Emergency room from an
outside hospital. By
report, she had fallen this morning. She had been well after her
fall and rather delayed interval was found unresponsive. She
was brought to an outside hospital. A CAT scan was performed,
revealing a large acute subdural hematoma with midline shift.
The patient was transferred from the outside hospital to the
[**Hospital1 18**]. Upon arrival, the patient was in stable clinical
condition with a GSC of 3, secondary to medications. The patient
was rescanned while we set up and she was emergently taken to
the operating room for decompression.
Past Medical History:
PMH: HTN, DM2;
PSH: s/p VP shunt @ [**Hospital1 112**] '[**78**] for NPH;
Social History:
Has 7 children
Family History:
Unknown
Physical Exam:
/E: patient intubated, sedated; received curarizing [**Doctor Last Name 360**] at
time of intubation;
VS:
Non responsive to voice or pain; does not open eyes; withdraws
to
pain -> GCS 6;
Pupils: isocore, 2.5mm, symetric, minimally reactive;
No gag or cough rx observed;
No reaction to pain in UE;
Withdraw vs triple flexion in LE, L>R;
DTRs: bic, quad 2 bilat;
Babinsky up bilat;
Pertinent Results:
[**Known lastname **],[**Known firstname **]: Laboratory Detail - CCC Record #[**Numeric Identifier 66972**]
COMPLETE BLOOD COUNT (BLOOD)
DATE WBC
4.0-11.0
K/uL RBC
4.2-5.4
m/uL Hgb
12.0-16.0
g/dL Hct
36-48
% MCV
82-98
fL MCH
27-32
pg MCHC
31-35
% RDW
10.5-15.5
%
[**2182-6-22**] 3:09A 10.4 3.08* 9.8* 28.9* 94 31.8 33.9 14.7
[**2182-6-21**] 3:38A 12.4* 3.02* 9.5* 28.3* 94 31.6 33.8 14.4
[**2182-6-20**] 3:28A 14.5* 2.99* 9.5* 27.8* 93 31.7 34.2 14.1
[**2182-6-19**] 3:22A 18.6* 2.92* 9.2* 27.3* 94 31.6 33.8 14.1
[**2182-6-18**] 2:37A 19.1* 2.96* 9.6* 27.6* 93 32.4* 34.7 14.0
[**2182-6-17**] 3:39A 19.4* 3.25* 10.2* 29.7* 91 31.4 34.4 14.4
[**2182-6-16**] 3:01A 15.7* 3.44*# 10.8*# 31.5* 92 31.[**Known lastname **],[**Known firstname **]:
Laboratory
Brief Hospital Course:
Ms [**Known lastname 7111**] was brought to the OR on [**6-9**] and undewent a right
frontal parietal craniectomy for decompression of a subdural
hematoma. Post operatively for the first 3 days she would
follow commands on right side, post op CT showed good evacuation
on blood products the first two post operative days there was
interval increase in subdural fluids but remained stable after
post operative day two. Ms [**Known lastname 7111**] began having fevers on [**6-10**]
and was found to have a pneumonia and started on Levaquin. She
was started on an insulin drip for persistant high blood sugars.
Her mental status declined slowly on [**6-13**] and [**6-14**] where she was
no longer following commands an MRI showed:
A small high signal focus on diffusion imaging within the right
medial posterior frontal lobe corresponds to an area of high
signal on T2 and FLAIR imaging, sequela of subacute infarction.
Smaller high signal focus within the left anterior corpus
callosum represents another area of subacute infarction. These
all correspond to hypodensities identified on CT. The small
hyperdense focus on T2 imaging within the right cerebellum also
represents a small infarction, though is not identified on
diffusion imaging secondary to artifact. A few very small
diffusion signal hyperintense foci are locted in the right
insula cortex and the subinsular white matter. The age of these
likely infarctions is uncertain.
A neurology consult was obtained to work up source of infarcts a
MRA failed to show vertebral dissection, carotid stenosis was
40% bilaterally and echo was negative for embolic source.
An MRI of her neck showed no ligamentous injury and her collar
was cleared post flexion extension films.
Her exam on [**6-20**] opened her eyes towards examiner and localized
in RUE extremity. Her pneumonia appeared to be improving, an
EEG showed IMPRESSION: Abnormal EEG due to the slow and
disorganized background and bursts of generalized slowing as
well as focal delta slowing in the right fronto-temporal region.
The last two abnormalities signify a widespread encephalopathy
affecting both cortical and subcortical
structures. Medications and many other causes are possible. The
right
fronto-temporal slowing indicates an area of subcortical
dysfunction on
the right side. This could be structural although that cannot be
determined by the recording. There were no clear epileptiform
features.
On [**2182-6-21**] an extensive meeting was held with the family who
wished to extubated the patient as soon as possibly safe and not
to reintubate if needed she was already made DNR earlier in her
hospital stay. A repeat head CT showed relatively stable with
chronic right subdural and bilateral hygromas. On [**6-22**] a
meeting was held with Dr [**Last Name (STitle) **] and social work family was
determined to extubate to honor the patients wishes based on
living will. The patient was extubated and started on a
morphine drip.
She passed away with her daughter [**Name (NI) **] [**Name (NI) 3748**] by her side at
0230 [**2182-6-24**].
Medications on Admission:
metformin, ambien, prevacid, nexium, zelnorm, ibuprofen,
vitron
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2182-6-24**]
|
[
"997.3",
"401.9",
"276.3",
"348.31",
"285.8",
"E885.9",
"852.05",
"486",
"331.3",
"V66.7",
"250.00",
"276.0",
"V45.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"02.12",
"38.93",
"38.91",
"96.6",
"96.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5738, 5747
|
2505, 5594
|
345, 454
|
5809, 5819
|
1727, 2482
|
5872, 5908
|
1302, 1311
|
5709, 5715
|
5768, 5788
|
5620, 5686
|
5843, 5849
|
1326, 1708
|
279, 307
|
482, 1156
|
1178, 1254
|
1270, 1286
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,705
| 189,453
|
54618
|
Discharge summary
|
report
|
Admission Date: [**2158-4-6**] Discharge Date: [**2158-4-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Hemodialysis
Placement of temporary coronary sinus pacing wire
Placement of permanent pacemaker
Central venous intrajugular line
Femoral venous line for dialysis
Femoral venous sheath for pacing wire placement
History of Present Illness:
Mrs. [**Known lastname **] is an 84 year old female with history of CLL, HTN,
lymphedema of LE, atrial fibrillation, and HCV, who is sent in
by her PCP for symptomatic bradycardia and creatinine elevation.
The patient says that she first noted fatigue and weakness on
[**4-2**], in addition to increase in her baseline shortness of
breath. She denied chest pain. At that time she spoke with Dr.
[**Last Name (STitle) **], her PCP, [**Name10 (NameIs) 1023**] scheduled her for an echocardiogram.
She says that on the day prior to admission, while walking with
a home physical therapist, she felt extremely weak and her pulse
was found to be 40, with a BP of 85/40, per report from the
patient. She came in for her scheduled echo on the day of
admission and again felt lightheaded. Her pulse was noted to be
as low as the 30s at times, and she was sent to the ED.
The patient denies recent medication changes, and says that her
weight has been stable.
Additionally, the patient says that she has recently been
treated for a UTI with bactrim. She first noted difficulty
urinating about 2 months prior to admission, at which time she
had urgency, but decreased urine output. She was found to have
a UTI and treated with Bacrim, however symptoms recurred
recently and she was treated with a second course of abx which
she just finished on the day prior to admission. She denies any
increase in thirst, but she continues to have decreased urine
output. Denies fevers/chills, changes in urinary color,
dysuria.
In the ED her HR ranged in the 30s to 50s, with sbp 80-100. She
was afebrile, with O2 sat 100% on RA. She recieved one dose of
ASA 325 mg, and a 500 CC bolus of NS, with 50 cc urine output.
Past Medical History:
1) Chronic lymphocytic leukemia
2) Hypertension
3) Paroxysmal atrial fibrillation, on amiodarone since [**2153**].
Gets palpiations with atrial fibrillation though not
consistently. Had a holter in [**2155**] that did not demonstrate
atrial fibrillation.
4) Hepatitis C
5) Irritable bowel syndrome
6) Anxiety
7) Status post cholecystectomy
8) Status post hysterectomy
Social History:
Patient lives in senior apartment in [**Location (un) 583**] with her husband.
She denies any smoking history of alcohol use.
Family History:
No family history of CAD.
Physical Exam:
VS: 94.8, 89/27, 35, 14, 100% on RA
Gen: Overweight russian speaking female, lying flat in bed,
appearing comfortable and non-tachypneic.
HEENT: Moist MM.
Neck: JVP difficult to evaluate secondary to obesity.
Cor: RR, bradycardic, distant heart sounds.
Lungs: Rales at bases b/l.
Abd: NABS, soft, NT/ND, non-palpable liver/spleen.
Extr: Massive pitting edema b/l with hyperpigmentation, skin
fissuring and thickening.
Pertinent Results:
[**2158-4-6**] WBC-9.9 Hct-37.7 MCV-93 MCH-29.8 MCHC-32.2 RDW-15.6*
Plt Ct-123*
[**2158-4-7**] WBC-6.2 Hct-30.2* MCV-95 MCH-30.8 MCHC-32.6 RDW-15.6*
Plt Ct-96*
[**2158-4-9**] WBC-13.0* Hct-28.1* MCV-90 MCH-29.7 MCHC-32.9 RDW-15.6*
Plt Ct-89*
[**2158-4-10**] WBC-11.7* Hct-31.3* MCV-90 MCH-29.2 MCHC-32.5 RDW-16.0*
Plt Ct-89*
[**2158-4-14**] WBC-10.1 Hct-31.8* MCV-90 MCH-29.4 MCHC-32.8 RDW-15.3
Plt Ct-95*
[**2158-4-6**] Neuts-50 Bands-3 Lymphs-34 Monos-9 Eos-4 Baso-0 Atyps-0
Metas-0 Myelos-0
[**2158-4-14**] Neuts-37.8* Bands-0 Lymphs-54.0* Monos-4.4 Eos-3.4
Baso-0.4 Atyps-0 Metas-0 Myelos-0
[**2158-4-7**] PT-12.4 PTT-29.9 INR(PT)-1.0
[**2158-4-14**] PT-12.3 PTT-32.8 INR(PT)-1.0
[**2158-4-6**] Glucose-119* UreaN-69* Creat-3.3*# Na-140 K-5.5*
Cl-110* HCO3-18*
[**2158-4-14**] Glucose-95 UreaN-29* Creat-1.4* Na-146* K-3.5 Cl-105
HCO3-35*
[**2158-4-8**] UreaN-68* Creat-3.8* K-5.5*
[**2158-4-6**] ALT-90* AST-67* LD(LDH)-265* CK(CPK)-31 AlkPhos-96
TotBili-0.2
[**2158-4-9**] ALT-80* AST-61* LD(LDH)-280* AlkPhos-68 TotBili-0.6
[**2158-4-7**] proBNP-3049*
[**2158-4-13**] Albumin-2.8* Calcium-8.4 Phos-2.9 Mg-2.1 Iron-31
[**2158-4-13**] calTIBC-276 VitB12-639 Folate-6.2 Ferritn-251* TRF-212
[**2158-4-6**] Albumin-3.9 Calcium-9.2 Phos-4.5 Mg-2.4
[**2158-4-14**] Calcium-8.6 Phos-3.0 Mg-1.8
[**2158-4-8**] TSH-0.81
[**2158-4-11**] PTH-58
[**2158-4-6**] 06:35PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.018
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-MOD Urobiln-1 pH-5.0 Leuks-NEG RBC-205* WBC-6*
Bacteri-NONE Yeast-NONE Epi-<1 CastHy-8*
[**2158-4-9**] 11:15AM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.010
Blood-LGE Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG
Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG RBC-66* WBC-0
Bacteri-NONE Yeast-NONE Epi-<1
[**2158-4-6**] 6:35 pm URINE Site: CATHETER
**FINAL REPORT [**2158-4-7**]**
URINE CULTURE (Final [**2158-4-7**]): NO GROWTH.
[**2158-4-9**] 8:56 am BLOOD CULTURE Site: A LINE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2158-4-9**] 11:15 am URINE Site: CATHETER
**FINAL REPORT [**2158-4-10**]**
URINE CULTURE (Final [**2158-4-10**]): NO GROWTH.
Echo [**2158-4-6**]: Conclusions:
1. The left atrium is mildly dilated. The left atrium is
elongated. The right atrium is moderately dilated.
2. 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%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-4**]+)
mitral regurgitation is seen.
5. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension.
6. There is no pericardial effusion.
CXR [**4-6**]: IMPRESSION: No acute cardiopulmonary process. A
follow-up PA and lateral set of radiographs might be helpful if
there is continuing clinical concern for pneumonia.
EKG [**4-6**]: Sinus bradycardia with top normal P-R interval of 200
milliseconds. Non-specific QRS interval widening. Left axis
deviation. Possible left anterior fascicular block. Anteroseptal
myocardial infarction. Compared to the previous tracing of
[**2156-11-11**] cardiac rhythm is now sinus mechanism. Multiple other
abnormalities as previously noted persist without major change.
Renal US [**4-7**]: RENAL ULTRASOUND: The right kidney measures 9.7
cm. The left kidney measures 9.7 cm. There is no evidence of
stones, masses, or hydronephrosis. There is a Foley catheter
within the urinary bladder. The ureters are not dilated.
IMPRESSION: Normal renal ultrasound.
EKG [**4-7**]: Sinus bradycardia. Compared to the previous tracing no
major change.
CXR [**4-9**]: Temporary transvenous femoral pacemaker terminates in
the region of the tricuspid valve. Left basilar subsegmental
atelectasis versus early infiltrate. CHF.
CXR [**4-10**]: IMPRESSION: Satisfactorily placed cardiac pacemaker.
R Hip x-ray [**4-12**]: IMPRESSION: No evidence of right hip
fracture.
EKG [**4-12**]: Atrial paced rhythm. Intraventricular conduction
delay - probable atypical left bundle branch block. Consider
prior anteroseptal myocardial infarction. Clinical correlation
is suggested. Since previous tracing of [**2158-4-11**], atrial pacing
seen.
CXR [**4-13**]: IMPRESSION: Small bilateral pleural effusions with
associated compressive atelectasis. No CHF or pneumonia.
Brief Hospital Course:
84 year old female with history of CLL, HTN, lymphedema of LE,
atrial fibrillation, and HCV, who was sent in by her PCP for
symptomatic bradycardia and creatinine elevation. In brief, she
had an AV pacer placed in house, with normalization of her blood
pressure and renal function subsequently. She was started on
epogen for her anemia, attributed to her chronic renal
insufficiency, however she may not need this in the future.
1) Bradycardia: The patient had a history of PAF, and presented
with symptomatic bradycardia, taken together likely representing
sick sinus syndrome. However, the patient was on amiodarone and
a beta blocker, and given her renal failure on admission, she
may have had impaired clearance of her BB, further contributing
to her bradycardia. She was hypotensive to systolic of 80s on
admission, however asymptomatic, and was therefore kept on the
floors overnight with an attempt at bringing up her blood
pressure with IVF, and awaiting clearance of the beta blocker.
Unfortunately the following morning she was becoming hypoxic
from fluid overload, and her heart rate had not improved. The
patient was therefore transferred to the CCU, where she was
started on a dopamine drip with little resultant increase in
blood pressure or heart rate. This refractoriness did not
respond over several days, making beta blocker toxicity less
likely as an etiology and indicating a likely underlying sinus
node/conduction dysfunction. A temporary pacemaker was placed,
followed by a permanent pacemaker (DDI at 75 bpm).
Post-procedure she had an episode of afib, which was also
complicated by a pacemaker sensing error and wide complex
tachycardia from pacing. Given her PAF, she was restarted on
coumadin for anticoagulation, which she should continue for the
time being. If she is found to be in sinus rhythm and stays
that way for a prolonged period of time, her PCP and Dr.
[**Last Name (STitle) **] can considering stopping the coumadin, as the patient
is reluctant to be on it again. She was restarted on her
amiodarone, as well as the atenolol, both at her outpatient
doses. She remained atrial paced during the admission, however
her pacer does not guarantee that she will not go into
paroxysmal A-fib.
2) Pump: Her echo on admission showed normal EF, however it may
actually be lower given her MR. She had massive LE edema, with
chronic changes, however this did improve significantly during
the hospitalization, implying that she was volume overloaded on
admission. The patient was hypotensive even on the dopamine
(although this was likely [**1-4**] inability to increase the heart
rate), and was given large amounts of fluids to maintain her BP
while in the CCU. Post-PPM placement, she was felt to be fluid
overloaded with sat's decreasing occasionally into the low 90s,
and was given multiple doses of 40-80 mg IV lasix. Shortly
after pacer placement she began auto-diuresing (polyuric phase
ATN--see below) and became quite negative (4.6L Urine output on
[**4-10**]). However, on transfer to [**Hospital Unit Name 196**] she remained fluid
overloaded by exam and CXR and therefore received 1 more dose of
IV lasix prior to being switched over to her usual daily dose of
40 mg PO BID, which she will be discharged on. She had an
oxygen saturation of 98% on RA on the day of discharge, and did
not desaturate with ambulation.
3) Ischemia: Not an active issue during this hospitalization.
She had no enzyme elevation, no chest pain, echo without
evidence of ischemic changes. She was continued on ASA 81 mg
daily.
4) Acute renal failure: Her creatinine had increased from 1.8
in [**11-5**] to 3.3 on admission, most likely in the setting of
decreased renal perfusion from hypotensive bradycardia. On
transfer to the CCU, she was in frank oliguric ATN and over the
next couple of days required hemodialysis once due to concerns
of increasing acidosis and hypervolemia. Upon pacemaker
placement, her urine output improved and her creatinine decrease
back to around her baseline of 1.6 - 1.8. She continued to have
satisfactory urine output on the floors, with creatinine
decreasing to 1.4 on the day of discharge. Given that her
kidney has just recovered, she was sent home on half of her
usual dose of lisinopril (20 mg daily) - additionally, her blood
pressure was well controlled on the lower dose.
5) Thrombocytopenia: Stably low platelets in the setting of CLL.
HIT ab was sent, which was negative.
6) Anemia: The patient was anemic throughout the
hospitalization, with hct ranging around 30. This was felt
secondary to her chronic renal insufficiency, and she was
therefore started on epogen by the renal team. Given that her
renal function has improved markedly since her pacer placement,
to 1.4 which is better than it has been in over a year, she may
not continue to require epogen. She will have her hematocrit
checked by Dr. [**Last Name (STitle) **] when he sees her in clinic, and monthly
thereafter while she remains on the epogen.
7) R Hip Pain: The patient complained of R hip pain with weight
bearing, however there was no tenderness on palpation of the
region, and a hip x-ray was negative for fracture. It is
unclear what is causing this hip pain, however she was able to
ambulate with physical therapy. She is encouraged to take advil
sparingly for this pain, as needed.
Medications on Admission:
ACETAMINOPHEN 500MG--2 capsules four times a day as needed
AMIODARONE HCL 200MG--3 tabs every day x 14 days then one tablet
every day
AMLODIPINE BESYLATE 10MG--One tablet every day
ASPIRIN 81MG--One tablet every day
ATENOLOL 25 MG--One tablet in morning, [**12-4**] tablet in evening
CELEBREX 200MG--One by mouth q day
CELEXA 40MG--One tablet every morning
CLONAZEPAM 2MG--One tablet at bedtime
FLUOCINONIDE 0.05%--Apply 1-2 times daily to legs
FUROSEMIDE 40MG--One tablet twice a day
HYOSCYAMINE SULFATE 0.125MG--One tablet as needed
ISOSORBIDE MONONITRATE 60 mg--1 tablet(s) by mouth every morning
Incontinence Liner --use as directed for incontinence
LISINOPRIL 40 MG--One tablet every day
PRILOSEC 20 MG--One daily [**Name6 (MD) **] outside md
PROTONIX 40MG--One a day
SERAX 10MG--One daily as needed for nerves
SPIRONOLACTONE 25MG--One tablet every day
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Hyoscyamine Sulfate 0.125 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day) as needed for bladder spasm.
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Amlodipine Besylate 10 mg Tablet Sig: One (1) Tablet PO once
a day.
11. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
The coumadin clinic will change your dose according to your
blood tests.
Disp:*60 Tablet(s)* Refills:*2*
12. Atenolol 25 mg Tablet Sig: One (1) Tablet PO See below: Take
one tablet in the morning, [**12-4**] tablet in the evening.
Disp:*45 Tablet(s)* Refills:*2*
13. Epogen 3,000 unit/mL Solution Sig: One (1) mL Injection once
a week.
Disp:*8 syringes filled* Refills:*2*
14. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Sick Sinus Syndrome
Acute on Chronic renal failure requiring dialysis
Hypotension secondary to bradycardia
Urinary tract infection
Anemia secondary to chronic renal failure
Discharge Condition:
Good
Discharge Instructions:
You have the appointments below, with Dr. [**Last Name (STitle) **] (Nephrology),
Dr. [**Last Name (STitle) 2357**] for your heart, and Dr. [**Last Name (STitle) **].
We have started two new medications. One is called coumadin,
which you have been on in the past. You will need to follow up
in coumadin clinic to have your blood drawn every few days in
the beginning, and then less frequently once you are on a stable
dose of coumadin.
The other new medication is called epogen, which is a
subcutaneous injection once a week. The home health aid will
help you with this, and Dr. [**Last Name (STitle) **], the kidney doctor, will check
your blood when he sees you at the appointment listed below.
This medication will help to keep your blood level up.
We have also decreased your lisinopril dose to 20 mg daily (you
were on 40).
Otherwise, resume all of your previous medications, including
lasix 40 mg twice a day, and amiodarone 200 mg once a day.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2158-4-20**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9091**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2158-5-5**] 9:40
A.M.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2158-5-23**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2158-8-1**] 1:45
Provider: [**First Name11 (Name Pattern1) 1955**] [**Last Name (NamePattern4) 1956**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2158-8-4**] 2:00
|
[
"719.45",
"599.0",
"403.91",
"458.8",
"427.31",
"284.8",
"285.21",
"204.10",
"584.5",
"070.70",
"427.81",
"428.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"37.78",
"00.17",
"37.83",
"39.95",
"37.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15717, 15792
|
7904, 13261
|
269, 480
|
16009, 16015
|
3252, 5292
|
17019, 17982
|
2768, 2795
|
14172, 15694
|
15813, 15988
|
13287, 14149
|
16039, 16996
|
2810, 3233
|
222, 231
|
5322, 5322
|
5351, 7881
|
508, 2217
|
2239, 2609
|
2625, 2752
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,407
| 199,019
|
19385
|
Discharge summary
|
report
|
Admission Date: [**2159-11-21**] Discharge Date: [**2159-12-6**]
Date of Birth: [**2073-7-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Critical Aortic Stenosis, evaluate for AVR
Major Surgical or Invasive Procedure:
[**2159-11-22**]
left and right heart catheterization
[**2159-11-28**]
1. Aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna Ease
aortic valve bioprosthesis (model number 3300TFX, serial
number [**Serial Number 52716**]).
2. Aortic patch closure with bovine pericardium.
Pericardium data -- reference number [**Serial Number 52717**], lot
number [**Telephone/Fax (5) 52718**]).
History of Present Illness:
Ms. [**Known lastname 52719**] is an 86-year-old female with a history of critical
aortic stenosis, systolic congestive heart failure, and
deconditioning due to arthritis, who presented to [**Hospital1 **] on
[**2159-11-17**] with shortness of breath and dyspnea on exertion. At
the time of presentation she was unable to walk more than 10
feet without dyspnea. These symptoms were suspected to be due a
CHF exacerbation from her critical AS. This was her second CHF
exacerbation with the first being in [**9-/2159**] when she was first
diagnosed with AS. She has never had angina or syncope however
she has had lower energy level for at least a year that she was
not able to explain. At the OSH she was diuresed with IV Lasix.
She was transferred to [**Hospital1 18**] for cath and further evaluation of
her severe AF. Of note, she was also complaining of URI symptoms
which resolved during that admission, except for persistent
cough. She did not have any fevers or chills. Cardiac surgery
was consulted for evaluation of operative candidacy for aortic
valve replacement.
Past Medical History:
Critical aortic stenosis- Aortic Valve Replacement
PMH:
Moderate to severe osteoarthritis
Likely ischemic cardiomyopathy, EF of 40-45%
Moderate aortic regurgitation and mild MR
Moderate pulmonary artery hypertension
Hypertension
Hyperlipidemia
Scarlet fever at the age of 6
Chronic left leg edema for several years, after 3 attacks of
cellulitis 8 years apart
Anxiety disorder
Chronic kidney disease stage III, baseline creatinine 1.2
Neuropathy in bilateral hands s/p [**2159**]0-12 years ago
Chronic urinary urgency
Past Surgical History:
Bilateral total knee replacement.
Left shoulder replacement.
Surgery for cervical spondylosis.
Bilateral Carpal tunnel surgery
Right cataract surgery
Appendectomy
Social History:
- She lives at home with her husband in the house that they've
owned since [**2118**]. She has difficulty going up stairs to their
bedroom therefore she now has a bed on the [**Location (un) 448**]. She uses
walker at baseline.
- She has been retired for many years but she was previously an
ICU nurse.
- Tobacco: none. When she was in her 20's she smoked but "never
inhaled"
- EtOH: rare
- Illicits: none
Family History:
Father died of MI at 74
Mother died of ADPKD at age 37
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
VS: 99.4 106/72 79 22 97% on 2L
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, [**3-11**] crescendo/decrescendo systolic murmur that
radiates to carotids. No heave. No S4.
LUNGS: Diffuse expiratory wheeze
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema in LLE, 1+ pitting edema in RLE
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS
==============
[**2159-11-22**] 09:25AM BLOOD WBC-6.2 RBC-3.88* Hgb-11.7* Hct-34.8*
MCV-90 MCH-30.1 MCHC-33.6 RDW-12.4 Plt Ct-278
[**2159-11-22**] 03:24AM BLOOD Glucose-128* UreaN-27* Creat-1.1 Na-135
K-4.1 Cl-97 HCO3-32 AnGap-10
[**2159-11-22**] 09:25AM BLOOD ALT-24 AST-16 AlkPhos-76 TotBili-0.4
[**2159-11-23**] 06:05AM BLOOD proBNP-[**Numeric Identifier 52720**]*
[**2159-11-22**] 03:24AM BLOOD Mg-1.4*
[**2159-11-22**] 09:25AM BLOOD %HbA1c-6.4* eAG-137*
DISCHARGE LABS
==============
IMAGING
==============
Prelim Cath Report [**2159-11-22**]:
1) Selective coronary angiography of this right-dominant system
demonstrated insignificant coronary artery disease. The LMCA
was free
of flow-limiting stenoses. The LAD had a 50% mid-to-distal
stenosis;
there was also a 50% stenosis at the origin of the diagonal
branch. The
LCx was free of flow-limiting stenoses. The large dominant RCA
had a
30-40% stenosis in the proximal portion of the vessel.
2) Supravalvular aortography demonstrated 1+ aortic
regurgitation. The
sinus of Valsalva width was 25-27mm in diameter.
3) Distal abdominal aortography demonstrated patency of the left
iliac
artery (diameter >7mm) and an accordion effect of the right
iliac
artery, due to vessel tortuosity.
4) Limited resting hemodynamics revealed markedly elevated
left-sided
filling pressures, with a mean wedge pressure of 35 mmHg, and
marked
pulmonary arterial hypertension, with a PA systolic pressure of
75 mmHg
and a mean PA pressure of 49 mmHg. These findings are
consistent with
aortic stenosis. There was also marked systemic arterial
hypertension,
with a central aortic pressure of 188/80 mmHg.
5) Estimated cardiac index by Fick principle was normal at
2.4-2.6
l/min/m2.
FINAL DIAGNOSIS:
1. Critical aortic stenosis with markedly-elevated wedge
pressure.
2. Insignificant coronary artery disease.
3. Evaluate for aortic valve replacement surgery. In the
meantime,
would recommend diuresis and volume status optimization.
.
CT chest w/o contrast [**2159-11-23**]:
1. Bilateral pleural effusions, moderate. Left lower lobe
consolidation that potentially may represent atelectasis,
although infectious process cannot be entirely excluded.
Neoplasm is substantially less likely, but follow-up in 8 weeks
or comparison with prior studies is recommended.
2. Retrosternal component of large thyroid goiter, approximately
7 cm below the thoracic inlet.
3. Extensive coronary calcifications and aortic valve
calcifications.
4. Compression fracture of lower thoracic vertebral body, most
likely T11.
.
Carotid Doppler [**2159-11-23**]:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
.
Panorex [**2159-11-23**]:
Technically limited film. Questionable slight resorption of bone
surrounding the radix of [**1-10**]. No other evidence of periradicular
granulomas
.
[**2159-11-28**] Intra-op TEE
Conclusions
There is moderate symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right ventricular chamber size is normal with mild
global free wall hypokinesis. There are simple atheroma in the
ascending aorta and complex (mobile) atheroma in the descending
aorta. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. Trace
paravalvular leak is seen. There is trace aortic regurgitation.
There is echodense material around the aortic bioprosthesis
however without blood flow into the echodense space consistent
with normal postoperative changes. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen. There
is a very small pericardial effusion with no signs of tamponade.
IMPRESSION: Normal bioprosthetic valve function. Moderate
symmetric left ventricular hypertrophy with borderline left
ventricular hypokinesis. Basal to mid septal hypokinesis. Mild
global right ventricular hypokinesis.
In comparison to the post-AVR intra-operative TEE from earlier
today, the findings are similar.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2159-11-29**] 12:07
Brief Hospital Course:
MEDICINE COURSE:
86-year-old female who has critical aortic stenosis who
presented to OSH with CHF exacerbation and was transferred to
[**Hospital1 18**] for management of her AS
.
ACTIVE ISSUES:
==============
# Acute on Chronic Heart Failure due to Critical Aortic
Stenosis:
- Will undergo AVR on [**2159-11-28**]
- Patient improving with diuresis down to 89.4kg (197 lbs) from
213lbs on presentation to OSH. Transitioned to PO lasix 40mg
daily
- continued home dose of metoprolol
.
# Cough/Wheeze: PFTs consistent with obstructive pattern.
Possibly related to CHF (cardiac asthma). Patient has no history
of asthma or COPD and only minimal smoking history. ABG on room
air showed metabolic alkalosis (likely contraction alkalosis
from diuresis). No evidence of chronic C02 retention.
- Treatment of CHF as above.
.
CHRONIC ISSUES:
===============
# CKD: Creatinine at baseline (1.1-1.3 per report)
.
TRANSITIONAL ISSUES
===================
- Patient will need 8 week chest xray to evaluate left lower
lobe consolidation seen on CT chest [**2159-11-23**]
- Patient should follow-up with endodontist after discharge from
rehab to evaluate 4th tooth.
- EMERGENCY CONTACT: [**Name (NI) 4906**] [**Name (NI) **] (HCP) [**Telephone/Fax (1) 52721**]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 52722**] (daughter) [**Telephone/Fax (1) 52723**].
- For cough. PCP should consider further workup including
possibly repeat PFTs if patient with persistent cough after
improvement in cardiac function.
SURGICAL COURSE:
The patient was brought to the Operating Room on [**2159-11-28**] where
the patient underwent Aortic Valve Replacement (# 21-mm [**Doctor Last Name **]
Magna Ease aortic valve bioprosthesis (model number 3300TFX,
serial number [**Serial Number 52716**]). Aortic Endarterectomy Aortic patch
closure with bovine pericardium.(Pericardium data -- reference
number [**Serial Number 52717**], lot number [**Telephone/Fax (5) 52718**]with Dr. [**Last Name (STitle) 914**].
Please refer to operative report for further surgical details.
She left the Operating Room on titrated Levophed and Propofol
drips. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. She underwent
bronchoscopy for Right Upper Lobe collapse, mucous plug was
removed and lobe re-expanded. She was transfused two units of
blood for a hematocrit of 28%. The patient was extubated on POD
1. She was alert and slightly confused. Hemodynamics
stabilized and she was weaned from vasopressor support. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. All lines and drains were discontinued
per protocol. She remained in the CVICU for close monitoring of
her renal function. Her Creatnine peaked at 2.4 was trending
back down by POD# 5 when she was transferred to the telemetry
floor for further recovery. 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 [**Hospital **]
Rehabilitation in [**Location (un) 1110**] in good condition with appropriate
follow up instructions.
Medications on Admission:
Toprol XL 25 mg p.o. daily.
Lasix 20 mg p.o. daily.
K-Lor 20 mEq p.o. daily.
Motrin 800 mg p.o. daily.
Aspirin 81 mg p.o. daily.
Lipitor 20 mg p.o. daily.
Librium 10 mg p.o. daily.
Peri-Colace 1 tablet p.o. daily.
Detrol LA 4 mg p.o. daily.
Multivitamin 1 tablet p.o. daily.
Vicodin 1 tablet q.4 hours p.r.n.
Extra strength Tylenol as needed.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for temperature >38.0.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itchy skin.
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. chlordiazepoxide HCl 5 mg Capsule Sig: Two (2) Capsule PO
QHS (once a day (at bedtime)).
11. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. potassium chloride 20 mEq Packet Sig: One (1) Packet PO
DAILY (Daily).
15. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
16. furosemide 10 mg/mL Solution Sig: Four (4) Injection DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Critical aortic stenosis- Aortic Valve Replacement
PMH:
Moderate to severe osteoarthritis
Likely ischemic cardiomyopathy, EF of 40-45%
Moderate aortic regurgitation and mild MR
Moderate pulmonary artery hypertension
Hypertension
Hyperlipidemia
Scarlet fever at the age of 6
Chronic left leg edema for several years, after 3 attacks of
cellulitis 8 years apart
Anxiety disorder
Chronic kidney disease stage III, baseline creatinine 1.2
Neuropathy in bilateral hands s/p [**2159**]0-12 years ago
Chronic urinary urgency
Past Surgical History:
Bilateral total knee replacement.
Left shoulder replacement.
Surgery for cervical spondylosis.
Bilateral Carpal tunnel surgery
Right cataract surgery
Appendectomy
Discharge Condition:
Alert and oriented x 3
Deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Date/Time:[**2160-1-14**] 1:30
Cardiologist Dr [**Last Name (STitle) **] on [**12-26**] at 11:15am in [**Location (un) 620**] office
Please call to schedule the following:
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22882**] in [**4-10**] 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**
Completed by:[**2159-12-6**]
|
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icd9cm
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,054
| 169,276
|
686
|
Discharge summary
|
report
|
Admission Date: [**2128-3-14**] Discharge Date: [**2128-3-23**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
large intraparenchymal bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a [**Age over 90 **] yo woman with PMH of dementia, obesity, OA, DM2,
HTN, cataracts, falls, CRF, Anemia, DNR/DNI and active UTI who
suffered a fall at [**Hospital 100**] Rehab today. She is primarily Russian
speaking, but also speaks some English. She was heard to fall
in the bathroom at 0800. Patient denied LOC and was without any
apparent injury. She was put back in bed. some time
thereafter she was noted to have dysarhtira, left facial droop
and flaccid left hemiparesis in the left arm. She was
transfered to [**Hospital1 18**] for presumed CVA.
She reports to me that she fell and endorses pain in her head
and her lower back. She endorses that she fell around the time
of the pain, but she cannot communicate the exact sequence of
events.
At baseline she is demented but very active, walking with walker
and conversant. She has recently been getting treatment for UTI
with Levaquin. Her proxy [**Name (NI) 3535**] reports that her family noticed
some mild speech impairments last week, but no focal weakness.
This however was around the time of the positive UA and may have
been related to infection.
ROS: she is unable to offer full ROS. She is known to have
acitve UTI and she does endorse headache and LBP.
Past Medical History:
dementia, obesity, OA, DM2, HTN, cataracts, falls, CRF, Anemia
Social History:
She lives at [**Hospital 100**] Rehab. Her proxy is relative [**Name (NI) 3535**]
[**Name (NI) 5148**] who can be reached at [**Telephone/Fax (1) 5149**]. Cell:
[**Telephone/Fax (1) 5150**].
Family History:
N/c
Physical Exam:
T- 98 BP- 142-173/53-80 HR- 72 RR- 14 O2Sat 100 2l
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: Cervical collar in place
Back: No skin changes. No point tenderness entire spine and
pelvis.
CV: RRR, Nl S1 and S2, moderate soft ejection murmur.
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema. NO hips tenderness.
Neurologic examination:
Mental status: On arrival was reportedly only responsive to
heavy sternal rub. She is now awake, speaking a few words
coherently, but mostly incoherent. She is following many
commands. She regards the right side of the room better than
the left, but does regard her left arm. She is oriented to self
and says [**Hospital1 **]. She cannot name the day,date or year. She does
not sound dysarthric but mumbles. It is difficult as she has a
hard collar on, and speaks Russian as her primary language.
Difficult to assess attention, but seems to be mildly
inattentive at least. Cannot name watch. Repeats. Confuses
right with left but does not neglect left arm.
Cranial Nerves:
Pupils equally round and trace reactive to light,3 mm
bilaterally and surgical. Blinks to threat right, but not left.
Does not track. Appears to have right gaze preference. Crosses
past midline to left only slightly. Face symmetric at rest,
does not smile though. Hearing intact grossly. Does not
cooperate with testing tongut, SCM, Palate, Trap.
Motor:
Normal bulk bilaterally. Tone normal right but flaccid left arm.
No observed myoclonus or tremor She cannot cooperate with formal
strength testing, but is
definitely full strength in the right tricep and finger flexors.
Her left arm is briefly anti-gravity and withdraws weakly to
pain, and appears significantly weaker than the right. She has
very brief antigravity strength of the IPs bilaterally and
appears to withdraw relatively equally in the lower extremities.
Sensation: Grimaces x 4, but less so in LUE. Withdraws x 4.
Reflexes:
+2 and symmetric throughout. Crossed adductors.
Toes down right and up left.
Coordination: could not assess.
Gait: could not assess.
Pertinent Results:
[**2128-3-14**] 01:10PM BLOOD WBC-8.1 RBC-3.77* Hgb-11.7* Hct-34.1*
MCV-91 MCH-31.0 MCHC-34.2 RDW-12.7 Plt Ct-234
[**2128-3-16**] 12:42AM BLOOD WBC-11.3* RBC-3.30* Hgb-10.2* Hct-29.6*
MCV-90 MCH-30.8 MCHC-34.3 RDW-12.8 Plt Ct-253
[**2128-3-14**] 01:10PM BLOOD Plt Ct-234
[**2128-3-14**] 01:10PM BLOOD PT-11.9 PTT-24.4 INR(PT)-1.0
[**2128-3-14**] 01:10PM BLOOD Glucose-121* UreaN-23* Creat-1.3* Na-140
K-4.9 Cl-105 HCO3-28 AnGap-12
[**2128-3-16**] 12:42AM BLOOD Glucose-154* UreaN-25* Creat-1.2* Na-139
K-4.5 Cl-108 HCO3-23 AnGap-13
[**2128-3-14**] 01:10PM BLOOD Calcium-9.2 Phos-3.8 Mg-2.3
[**2128-3-15**] 05:08PM BLOOD %HbA1c-6.3*
[**2128-3-15**] 05:08PM BLOOD Triglyc-73 HDL-34 CHOL/HD-3.3 LDLcalc-63
[**2128-3-14**] 01:10PM BLOOD TSH-1.2
HCT:
Large intraparenchymal hemorrhage centered within the right
parietal lobe with small amount of blood in the subjacent
subdural and subarachnoid space. Differential include amyloid
angiopathy, underlying neoplasm and less likely vascular
malformation.
Brief Hospital Course:
Ms. [**Known lastname 5151**] was admitted to the ICU for closer monitoring. Her
hospital course by problem is as follows:
1) ICH: felt to be likely secondary to head trauma after her
fall. She was maintained with a SBP goal 130-170 and MAP < 130.
She was treated with lopressor 25 PO BID with holding
parameters. Dilantin was initially given and then held to avoid
confusion regarding her sedation. An EEG was ordered which
showed generalized slowing without epileptiform discharges. Her
secondary stroke risk factors where checked and were as follows:
HbA1c: 6.3, HDL: 34, LDL: 63. Over the course of her first
night, she became increasingly sedated and vomited. A stat head
CT was done which was unchanged but she was started on mannitol
to reduce intracerebral edema. Her OSM and Na where monitored.
She was also maintained normothermic and normoglycemic.
2) Goal's of Care-
The patient's neurologic exam did not improve despite the above
measures. She remained minimally responsive and unable to follow
commands. Extensive discussion with health care proxy and family
around benefits of placing a feeding tube ensued. The family
decided to not place a feeding tube and make the patient for
comfort measures only in hospice level care. The family would
like to provide an additional 2-3 days of IV fluid support in
hopes that the patient will survive another 10 days. The
palliative care service and [**Hospital1 18**] was consulted to aide in the
family's decision making. Recommend morphine oral concentrate
for comfort. Hyocyamine 0.125-0.25mg SL q4h PRN for excess
secretions. Haldol 0.5-1mg DL q4h PRN agitation. Ativan
0.5mg-1mg q4h PRN anxiety.
3) FEN/GI: She failed a swallow evaluation and would require a
PEG for nutrition. Extensive discussion with family determined
patient would be made for comfort measures only. She may take PO
as she is able.
Medications on Admission:
Levaquin 250 daily
Ativan 0.5 [**Hospital1 **]
Ativan 0.5 Q6 prn
Olanzapine 5mg daily
Tylenol
Lopressor 25 [**Hospital1 **]
Alphagan 0.2% drops both eyes, 1 drop [**Hospital1 **]
Preparation H
Trazadone 25 QHS
Asprin 81mg daily
Ca Carobnoate 650 [**Hospital1 **]
Vit D 1000 u daily
Colace 250 daily
Senna 2 tab HS
Discharge Medications:
1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
7. Morphine Concentrate 20 mg/mL Solution Sig: 5-15 mg PO q2hrs
as needed for pain, dyspnea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Right Intrparenchymal Hemorrhage
Dementia, likely Alzheimer type
Discharge Condition:
Hospice Care.
Discharge Instructions:
You were admitted for a large intracranial hemorrhage.
Followup Instructions:
Hospice Care for comfort
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
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|
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293, 299
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4040, 5039
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|
224, 255
|
327, 1575
|
2982, 4021
|
2313, 2966
|
2298, 2298
|
1597, 1662
|
1678, 1872
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,617
| 123,518
|
28343
|
Discharge summary
|
report
|
Admission Date: [**2195-10-31**] [**Month/Day/Year **] Date: [**2195-11-3**]
Date of Birth: [**2116-1-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Cough and fever.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo M DNR/DNI in hospice with end-stage CHF and cardiac
ascites admitted with pneumonia. The patient was in his usual
state of health until 24 hours prior to admission when he
developed fevers to 103, cough and shaking chills. The patient
requested that he be taken to the hospital for care. In the ED,
T 101.4 103 74/48 18 95% RA. The patient had a CXR revealing a
likely right middle lobe pneumonia. He received 1gm ceftriaxone
and was admitted to the floor. On presentation to the [**Last Name (un) 5355**], the
patient was found to be hypotensive to 50-60 systolic with poor
mental status. The patient received a total of 500cc NS prior to
transfer to the ICU.
Past Medical History:
1. Congestive heart failure, LVEF equals 20% to 25% ([**Month (only) 1096**]
[**2194**]).
2. Severe tricuspid regurgitation.
3. Moderate to severe mitral regurgitation.
4. Status post mechanical aortic valve replacement done in [**2182**]
in [**Hospital1 46**].
5. Chronic atrial fibrillation on Coumadin.
6. Chronic renal insufficiency (baseline creatinine 2.2-2.6)
7. Cirrhosis (right heart failure).
8. Ascites.
9. GI bleed (small bowel AVM)
10. MRSA bacteremia with neg endocarditis w/u
11. s/p Right hip fracture, ORIF [**2195-7-30**]
Social History:
Patient is Jordanian. Arabic speaking. Former farmer. Quit
smoking 30 years ago (1ppd x 24 years). [**Month/Day/Year 4273**] any alcohol or
other drug use history. Large extended family that is actively
involved in patient's care.
Family History:
Mother with history of stomach cancer. Father died of unknown
causes. No family history of liver disease
Physical Exam:
96.0 78 82/38 18 100% 2L NC
Gen: NAD. A&Ox3 though waxing and [**Doctor Last Name 688**] alertness.
HEENT: PERRL.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Rhoncorous sounds bilaterally.
Abd: Soft, mildly distended.
Ext: 2+ edema in the bilateral lower extremities.
Neuro: A&Ox3 with waxing and [**Doctor Last Name 688**] alertness.
Pertinent Results:
[**2195-10-31**] 12:40AM AMMONIA-45
[**2195-10-31**] 12:45AM PT-16.9* PTT-31.6 INR(PT)-1.6*
[**2195-10-31**] 12:45AM PLT SMR-NORMAL PLT COUNT-229
[**2195-10-31**] 12:45AM NEUTS-87.9* BANDS-0 LYMPHS-5.2* MONOS-6.6
EOS-0.2 BASOS-0.1
[**2195-10-31**] 12:45AM WBC-8.3 RBC-2.83* HGB-7.9* HCT-24.4* MCV-86
MCH-27.9 MCHC-32.5 RDW-16.3*
[**2195-10-31**] 12:45AM ALBUMIN-2.6*
[**2195-10-31**] 12:45AM LIPASE-60
[**2195-10-31**] 12:45AM ALT(SGPT)-9 AST(SGOT)-28 ALK PHOS-269*
AMYLASE-65 TOT BILI-0.7
[**2195-10-31**] 12:45AM GLUCOSE-123* UREA N-57* CREAT-2.2*
SODIUM-131* POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-22 ANION GAP-12
[**2195-10-31**] 12:53AM LACTATE-0.9
Brief Hospital Course:
A/P: 79 yo M DNR/DNI in hospice with end-stage CHF and cardiac
ascites admitted with pneumonia, transferred to the MICU for
hypotension and then to the floor after hypotension improved.
.
#Pneumonia-He was admitted with fever and cough and was found to
have a right lower lobe pneumonia. He was satting well, and
started on ceftriaxone and vancomycin as he is chronically
hospitalized. His cough improved throughout his
hospitalization. His blood cultures, urine cultures and sputum
cultures had no growth. A urine legionella angtigen was
negative. After several days on ceftriaxone and vancomycin his
antibiotic treatment was changed to levofloxacin. On the
medical floor he was satting in the high nineties on room air
and reported that his cough had improved significantly.
.
# Hypotension-He has baseline low bp secondary to severely
impaired cardiac function. BP appeared below baseline in the
MICU possibly secondary to sepsis physiology (with some signs of
underperfusion including waxing and [**Doctor Last Name 688**] mental status).
Source of infection pulmonary, though SBP could not be excluded.
After 24 hours of antibiotics his mental status improved as did
his hypotension. He also received IVF prn. Once transferred
to the floor he was not hypotensive below his baseline (systolic
in the 70's). His mental status was stably alert and oriented
times three.
.
# Hyponatremia-He is hyponatremic at baseline, likely secondary
to liver disease from heart failure. His hyponatremia was
stable and was not treated with fluids management as he is fluid
overloaded but hypotensive and was not symptomatic.
.
# End-stage CHF complicated by cardiac [**Hospital 68806**] hospital day 3
he became uncomfortable with the amount of fluid in his abdomen.
His abdominal port was accessed and 6 liters were removed. His
abdomen was less tense and his breathing improved afterwards.
His poor prognosis was discussed further with son and reason for
hospice. A conversation occurred with his son, himself, his
wife about his code status and they wished to have his code
status changed from DNR/DNI to full code.
.
# Renal insufficiency. His creatinine was at baseline and
stable. Medications were renally dosed.
.
# Anemia. His anemia was at baseline and stable
.
# FEN: full diet.
.
# Prophylaxis: Hep subq, PPI.
.
# Access: Peripheral IV.
.
# Comm. Health care proxy is son [**Name (NI) **] [**Telephone/Fax (1) 68807**] or
[**Telephone/Fax (1) 68808**]
.
# Code: full code (spoke with son [**2195-11-1**]), also spoke with Mr.
[**Known lastname 68791**] himself and he expressed that he is interested in pursuing
medical treatments that his medical team would feel would be
helpful. He stated that he has discussed this multiple times
with his family and they know what he would like.
.
Please note that his change in code status back to full code
appears to have been influenced by his acute presentation,
though he did not require pressors or any intubation this
admission. On further conversation with the pt after he was
clinically improved, he stated that "I've had many discussions
with my doctors about this in the past; I want to receive
treatments that the doctors think [**Name5 (PTitle) **] help me but do not want
the ones that would not benefit me." He did seem to understand
that intubation and resuscitation with his underlying conditions
likely would not result in improved quality of life and
successful recovery to his prior status; i.e. he likely would
not recover and leave the ICU setting.
Nonetheless, his code status remains full at this time and we
have communicated with his hospice nurse (who knows him well)
that this should continue to be addressed with the patient and
family.
Medications on Admission:
Warfarin 3 mg PO at bedtime
Furosemide 40 mg daily
Prilosec 40mg daily
Flutic-Salmeterol 100-50 mcg/Dose Disk Inhalation 2 times a day
Pantoprazole 40 mg daily
Tramadol 50 mg at bedtime
[**Name5 (PTitle) **] Medications:
1. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO QHS (once a day
(at bedtime)).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO ONCE (Once) for 1
doses.
7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
8. Lasix 40mg once a day
[**Name5 (PTitle) **] Disposition:
Extended Care
Facility:
[**Street Address(1) 19427**] Nursing & Rehab Center - [**Location (un) 3307**]
[**Location (un) **] Diagnosis:
pneumonia
cardiac ascites
CHF, LVEF equals 20% to 25% ([**2194-12-26**]).
Severe tricuspid regurgitation.
Moderate to severe mitral regurgitation.
S/P mechanical AVR done in [**2182**] in [**Hospital1 46**].
Chronic atrial fibrillation on Coumadin.
Chronic renal insufficiency (baseline creatinine 2.2-2.6)
Cirrhosis (right heart failure).
Ascites.
GI bleed (small bowel AVM)
MRSA bacteremia with neg endocarditis w/u
S/p Right hip fracture, ORIF [**2195-7-30**]
[**Month/Day/Year **] Condition:
stable, afebrile, satting well on room air, good po intake
[**Month/Day/Year **] Instructions:
You were admitted with a pneumonia, you also had very low blood
pressure. You were treated in the MICU with antibiotics. Your
pneumonia and low blood pressure improved and you were
transferred to the medical floor. You continued to improve.
You had a paracentesis through your abdominal port.
Please continue to take your medications as prescribed. You
will have to continue taking your antibiotics for the next 10
days.
Please follow up as directed below:
Call your doctor for any shortness of breath, increased
coughing, chest pain, abdominal pain, or any other concerning
symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:one liter
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] [**2199-11-24**]:00am
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2195-11-3**]
|
[
"785.51",
"285.9",
"V58.61",
"V43.3",
"397.0",
"276.1",
"482.9",
"789.59",
"424.0",
"573.0",
"427.31",
"428.23",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
3048, 6773
|
345, 351
|
2352, 3025
|
9172, 9392
|
1876, 1982
|
6799, 7803
|
1997, 2333
|
7835, 9149
|
289, 307
|
380, 1048
|
1070, 1612
|
1628, 1860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,099
| 161,395
|
25230
|
Discharge summary
|
report
|
Admission Date: [**2112-10-2**] Discharge Date: [**2112-10-29**]
Date of Birth: [**2056-5-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
hemorrhagic infarct
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 year old man with history of [**7-/2112**] stroke causing left
sided weakness who presents with hemorrhagic conversion of old
infarct. He was brought to [**Hospital3 3583**] for diaphoresis,
sob,
and flank pain. At OSH, pt noted to have left leg shaking and
left eye deviation. This activity stopped with 2 mg ativan and
patient was loaded with dilantin. He was sent for CT head after
which showed hemorrhage into an old right mca infarction. His
INR was 4.1 so he was given ffp and vitamin K. Given recent
history of UTI and Tm 100.4, he was given levofloxacin.
ROS: +abdominal pain
Past Medical History:
-[**7-/2112**] stroke with left sided weakness
-depression
Social History:
-he came from nursing home.
-his habits are unknown
Family History:
unknown
Physical Exam:
afebrile 90/50 HR 50 100% RA RR 22
cachectic man lying in bed, eyes closed
neck supple, no bruits. RRR, no murmurs
CTAB, abd soft, ext: no edema
Neuro: opens eyes to sternal rub, answers yes to name but
misses
that fact that this is a hospital. [**Doctor Last Name **]-decrease fluency saying
[**1-31**] words. intact repetition and comprhension. left sided
neglect.
Pupil 2 to 1 mm bilaterally. does not moves eyes past midline to
left. blink to threat on right only. left facial droop. tongue
midline.
Motor/sensory: increased tone left>right. does not move left
side but right arm is [**4-2**] and left leg [**3-5**]. localizes stimuli
in
four extremities
Coord/Gait: unable to test
Reflexes: brisk with left>right, toes downgoing bilaterally
Pertinent Results:
[**2112-10-2**] 06:30PM WBC-10.9 RBC-3.31* HGB-9.9* HCT-29.6* MCV-89
MCH-30.0 MCHC-33.6 RDW-12.9
[**2112-10-2**] 06:30PM PLT COUNT-418
[**2112-10-2**] 05:15AM PT-18.5* PTT-32.9 INR(PT)-2.3
[**2112-10-2**] 05:15AM PHENYTOIN-20.7*
[**2112-10-2**] 05:15AM CK-MB-5 cTropnT-0.03*
[**2112-10-2**] 05:15AM GLUCOSE-108* UREA N-10 CREAT-0.7 SODIUM-135
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15
[**2112-10-2**] 05:15AM ALT(SGPT)-28 AST(SGOT)-27 CK(CPK)-293* ALK
PHOS-79 AMYLASE-57 TOT BILI-0.3
[**2112-10-2**] 05:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
.
Head CT at admission:
There is a large chronic infarction in the right middle cerebral
artery territory distribution. There are acute blood products in
the anterior portion of this infarction, mostly in the frontal
lobe. There is minimal associated mass effect. There is no CT
evidence of an acute major territorial infarction. The
ventricles are normal in size. The visualized osseous structures
appear unremarkable. There is mild mucosal thickening in the
maxillary sinuses bilaterally.
IMPRESSION: Acute hemorrhage within a chronic infarction in the
right middle cerebral artery distribution.
.
RUQ US:
The gallbladder is dilated, however, contains no stones. There
is no evidence of gallbladder wall edema. The gallbladder wall
is normal measuring 2 mm. The common bile duct measures 3 mm
proximally and 5 mm distally, which is normal. No filling
defects or stones are identified within the bile duct. The
visualized liver does not demonstrate evidence of biliary ductal
dilatation. There is a small amount of intra-abdominal ascites
identified and a right pleural effusion is noted.
.
CT abdomen/pelvis:
1. Distended gallbladder with small amount of pericholecystic
fluid. However, there is intraperitoneal free fluid. A right
upper quadrant ultrasound could be perform to further evaluate
this finding.
2. Small amount of intra-abdominal and intrapelvic free fluid.
3. Small bilateral pleural effusions with minimal bibasilar
subsegmental atelectasis.
4. Small region of non-specific hypoperfusion in the upper pole
of the right kidney. Clinical correlation is recommended as
infection is not excluded. Second focus of cortical thinning
suggestive of prior infection or infarction.
.
EEG:
.
Repeat CT head:
.
KUB:
Brief Hospital Course:
56 year old man with recent right mca infarction ([**8-2**]) who
presented with sob and flank pain. At that point, L-leg shaking
and gaze deviation was noted: new hemorrhagic conversion of old
R-MCA stroke.
.
1. Hemorrhagic conversion of MCA stroke
He was found to have hemorrhagic conversion of his recent MCA
territory
stroke. In addition, he underwent an LP, which demonstrated
(traumatic: prot 452, glc 90, wbc 4 rbc 667 (tube 4), [**Numeric Identifier 63193**] tube
1; prot likely secondary to traumatic tap). An EEG demonstrated
theta and delta slow waves in R hemisphere with sharp features,
consistent with seizure activity. He was started on Dilantin for
seizures,
then subsequently changed to depakote with monitoring
demonstrating therapeutic
levels. He had no further seizure activity. He will be
discharged to rehab, and
will need furhter physical/occupational/speech therapy.
.
2. Hypoxic respiratory failure
Initially intubated for respiratory distress and hypoxia,
treated with levo/flagyl
for suspected aspiration pneumonia. In MICU, he was later
trached and had a PEG tube. Sputum cultures grew out MRSA, and
he was started on a 10 day course of
Vancomycin by PICC line. Another contribution was his CHF with
EF of 30%. His volume status was closely monitored, and he was
started on lasix 40mg po daily.
Before discharge, he was weaned off of the ventilator and doing
well on
a trach collar with Passy-Muir valve for speaking. He will need
continued
frequent suctioning (q1hr), as well as meticulous trach and
respiratory care.
.
3. Atrial fibrillation
Issues with atrial fibrillation with RVR during his hospital
course.
This was managed with Amiodarone (200mg po daily at time of
discharge), and
metoprolol 25mg TID.
.
4. Anemia
Consistent with anemia of chronic inflammation; stable with no
transfusion
requirement.
.
5. FEN
Enteral feeding by PEG tube. Will continue tube feeds.
No issues with high residual volumes.
Medications on Admission:
-coumadin
-bowel regimen
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-31**]
Puffs Inhalation Q4H (every 4 hours) as needed.
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-31**]
Drops Ophthalmic PRN (as needed).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
units Injection ASDIR (AS DIRECTED).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
10. Bacitracin-Polymyxin B unit/g Ointment Sig: One (1)
Ophthalmic Q6H (every 6 hours).
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4-6H (every 4 to 6 hours) as needed.
13. Captopril 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
17. Valproate Sodium 250 mg/5 mL Syrup Sig: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day) as needed for thru dobhoff.
18. Valproate Sodium 250 mg/5 mL Syrup Sig: 1000 (1000) mg PO
QHS (once a day (at bedtime)).
19. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
20. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation.
21. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] [**Hospital **] [**Hospital **]
Discharge Diagnosis:
1. Hypoxic respiratory failure
2. Congestive heart failure
3. MRSA tracheobronchitis/pneumonia
4. seizure disorder
5. anemia of chronic inflammation
6. h/o CVA, hemorrhagic conversion of previous CVA
7. agitation/delirium, resolving
Discharge Condition:
fair
Discharge Instructions:
1. Continue course of vancomycin to complete a 10 day course
2. Needs trach care and frequent (q1hour) suctioning for
respiratory
secretions.
3. Standing lasix 40mg po qD started while in house; need to
assess daily weights, volume status, ins/outs regularly
4. Needs line care/flushes for PICC line
5. Standing haldol, seroquel plus prn haldol for agitation
6. Need to monitor depakote levels, with therapeutic range
50-100
Followup Instructions:
1. Needs [**Hospital 4820**] rehabilitation, frequent/aggressive
respiratory/trach care, and follow up with his PCP
.
1. Continue course of vancomycin to complete a 10 day course
2. Needs trach care and frequent (q1hour) suctioning for
respiratory
secretions.
3. Standing lasix 40mg po qD started while in house; need to
assess daily weights, volume status, ins/outs regularly
4. Needs line care/flushes for PICC line
5. Standing haldol, seroquel plus prn haldol for agitation
6. Need to monitor depakote levels, with therapeutic range
50-100
7. He needs to f/u with Ophthamology for corneal ulcers in
2weeks
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
|
[
"682.3",
"427.31",
"425.4",
"428.0",
"438.11",
"V09.0",
"372.75",
"038.11",
"599.0",
"372.00",
"482.41",
"427.1",
"518.81",
"293.0",
"995.92",
"780.39",
"431",
"401.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"03.31",
"31.1",
"99.07",
"96.04",
"43.11",
"38.91",
"33.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8332, 8407
|
4316, 6270
|
337, 343
|
8684, 8691
|
1932, 4275
|
9164, 9892
|
1134, 1144
|
6346, 8309
|
8428, 8663
|
6296, 6323
|
8715, 9141
|
1159, 1913
|
277, 299
|
371, 965
|
4284, 4293
|
987, 1048
|
1064, 1118
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,742
| 151,052
|
28546
|
Discharge summary
|
report
|
Admission Date: [**2110-9-8**] Discharge Date: [**2110-10-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Right renal artey embolization [**2110-9-9**]
Thoracentesis [**2110-9-15**]
Arterial line placement
History of Present Illness:
This is an 84 yo male with DM, CRI, dementia, CVA, seizure
disorder, and recent MVA who was originally transferred from an
OSH for a right perinephric hematoma which he suffered from a
twisting motion while getting out of bed. He was originally
admitted to trauma surgery where he had an embolization of one
of the branches of the right renal artery done by IR. His
hematocrit remained stable.
.
His course was complicated by a worsening pleural effusion
thought to be [**2-6**] lymphatic tracking originating from the
perinephric space. A therapeutic tap of 1500mL of
serosanguinous fluid was done because he desaturated to 89% on
RA. Other complications include elevated troponins to 0.22 with
normal CK and CKMB, and new TWI in V1-V3. No report of chest
pain.
.
Then he was admitted to the MICU for mental status change. He
remained hemodynamically stable and is now transferred to the
regular floors for further management.
Past Medical History:
1) Diabetes type 2
2) HTN
3) CRI (baseline 2.4),
4) CHF
5) CVA
6) Seizure disorder on Keppra,
7) Emphysema
.
PSH:
L THA
Pacer
CCY
Appy
T+A
Social History:
Lives with wife, had apparently been doing all ADL's with good
independence before admission. No alcohol use since [**2106**] stroke,
only drank socially before then. No tobacco or illicit drug use.
Used to work as chemist.
Family History:
[**Name (NI) 2280**], mother with PMR, cousin with epilepsy
Physical Exam:
T 97.8 ax P 73 BP 161/67 RR 22 O2 100 on 2L NC
Gen: Elderly Caucasian gentleman in NAD, drowsy at times
Eyes: Sclerae anicteric
Neck: Supple, no LND
Mouth: MMM no lesions
Chest: Scattered rhonchi in all fields, decreased air movement
at bases.
Heart: RR distant S1S2
Abd: Flat NT, ND, nl bowel sounds.
Ext: No edema
Neurol: AOx2, not cooperative with neuro exam. Toes mute.
Pertinent Results:
[**9-17**] Head CT: No evidence of acute intracranial hemorrhage.
Large area of encephalomalacia in the region of the right
posterior cerebral artery territory, secondary to an old
infarct. No CT evidence to suggest acute major vascular
territorial infarction, though if clinical suspicion is high for
this entity, MRI would be more a superior diagostic imaging
study. Other findings, as noted above.
.
[**9-18**] CXR: Persistent severe pulmonary edema with pleural
effusions.
.
[**9-19**] CXR: Diffuse mild hydrostatic edema. Linear right
infrahilar opacity is likely anterior segment right upper lobe
atelectasis. Continued surveillance recommended. Stable right
pleural effusion. Left lower lobe collapse also evident.
.
[**9-19**] ECHO: The left atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF>55%). Regional left ventricular
wall motion is normal. Right ventricular chamber size and free
wall motion are normal. The right ventricular free wall is
hypertrophied. The aortic valve leaflets (3) are mildly
thickened. There is mild aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
.
[**9-23**] EEG: Abnormal EEG due to a diffusely slowed record with two
distinct patterns of slowing seen suggesting a moderate to
moderately
severe diffuse encephalopathy. No discharging features were
seen.
.
[**9-23**] CXR: Moderate bilateral pleural effusions, left lower lobe
atelectasis, and moderate pulmonary edema have all worsened
since [**9-20**]. Cardiac silhouette has enlarged in the
interim, but not appreciably. No pneumothorax. Transvenous right
atrial and right ventricular pacer leads unchanged in their
respective positions. No pneumothorax. Findings were discussed
with Dr. [**Last Name (STitle) **] by telephone at the time of dictation.
.
[**9-27**] CT chest: 1. Large bilateral pleural effusions and
compressive atelectasis of the majority of the lower lobes of
both lungs. Underlying infectious process within the atelectatic
lung cannot be entirely excluded. Pleural effusions are not
significantly changed in degree from [**2110-9-1**].
2. Subcapsular hemorrhage of the right kidney undergoing
expected evolution but not changed insize from [**9-8**].
Embolization coils are noted near the renal hilum. If the
patient is hypertensive, this may represent a Page kidney.
3. Left upper pole renal cyst with amorphous, but [**Known lastname **]
calcifications, not entirely simple in appearance. Further
evaluation with ultrasound (patient has a pacemeaker) is
recommended as this lesion was not entirely imaged on this
study.
4. Coronary artery calcifications and calcifications of the
aorta.
[**2110-9-8**] 06:00AM PT-20.4* PTT-150* INR(PT)-2.0*
[**2110-9-8**] 06:00AM PLT SMR-NORMAL PLT COUNT-203
[**2110-9-8**] 06:00AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL SCHISTOCY-1+
BURR-1+ ELLIPTOCY-1+
[**2110-9-8**] 06:00AM NEUTS-93.4* BANDS-0 LYMPHS-3.8* MONOS-2.6
EOS-0.1 BASOS-0
[**2110-9-8**] 06:00AM WBC-9.0 RBC-3.51* HGB-9.8* HCT-29.2* MCV-83
MCH-27.8 MCHC-33.5 RDW-18.1*
[**2110-9-8**] 06:00AM GLUCOSE-220* UREA N-30* CREAT-2.3* SODIUM-139
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-21* ANION GAP-14
[**2110-9-8**] 06:22AM HGB-10.6* calcHCT-32
[**2110-9-8**] 06:45AM URINE AMORPH-MANY
[**2110-9-8**] 06:45AM URINE GRANULAR-[**3-9**]*
[**2110-9-8**] 06:45AM URINE RBC->50 WBC-0-2 BACTERIA-MANY YEAST-NONE
EPI-[**3-9**]
[**2110-9-8**] 06:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2110-9-8**] 06:45AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
[**2110-9-8**] 08:05AM PT-18.1* PTT-34.8 INR(PT)-1.7*
[**2110-9-8**] 08:38AM LACTATE-2.2*
[**2110-9-8**] 08:38AM TYPE-ART PO2-110* PCO2-39 PH-7.34* TOTAL
CO2-22 BASE XS--4
[**2110-9-8**] 10:32AM FIBRINOGE-417*
[**2110-9-8**] 10:32AM PT-15.1* PTT-30.7 INR(PT)-1.4*
[**2110-9-8**] 10:32AM PLT COUNT-184
[**2110-9-8**] 10:32AM WBC-10.8 RBC-3.22* HGB-9.2* HCT-26.7* MCV-83
MCH-28.7 MCHC-34.7 RDW-17.6*
[**2110-9-8**] 10:32AM CALCIUM-7.7* PHOSPHATE-4.7* MAGNESIUM-2.2
[**2110-9-8**] 10:32AM GLUCOSE-211* UREA N-33* CREAT-2.4*
SODIUM-146* POTASSIUM-4.3 CHLORIDE-113* TOTAL CO2-21* ANION
GAP-16
[**2110-9-8**] 10:40AM freeCa-0.96*
[**2110-9-8**] 10:40AM LACTATE-2.2*
[**2110-9-8**] 10:40AM TYPE-ART PO2-94 PCO2-30* PH-7.40 TOTAL
CO2-19* BASE XS--4
[**2110-9-8**] 12:49PM O2 SAT-44
[**2110-9-8**] 12:49PM TYPE-[**Last Name (un) **] PO2-23* PCO2-39 PH-7.34* TOTAL
CO2-22 BASE XS--5
[**2110-9-8**] 02:30PM GLUCOSE-163* LACTATE-3.8*
[**2110-9-8**] 02:30PM TYPE-ART PO2-77* PCO2-30* PH-7.40 TOTAL
CO2-19* BASE XS--4
[**2110-9-8**] 03:09PM PT-13.7* PTT-28.1 INR(PT)-1.2*
[**2110-9-8**] 03:09PM PLT COUNT-256
[**2110-9-8**] 03:09PM HCT-24.3*
[**2110-9-8**] 06:15PM PT-13.7* PTT-27.6 INR(PT)-1.2*
[**2110-9-8**] 06:15PM HCT-30.1*
[**2110-9-8**] 06:15PM MAGNESIUM-2.0
[**2110-9-8**] 06:15PM POTASSIUM-4.4
[**2110-9-8**] 06:31PM O2 SAT-93
[**2110-9-8**] 06:31PM LACTATE-3.9*
[**2110-9-8**] 06:31PM TYPE-ART PO2-73* PCO2-33* PH-7.40 TOTAL
CO2-21 BASE XS--2
[**2110-9-8**] 07:02PM FIBRINOGE-287
[**2110-9-8**] 07:02PM PT-21.7* PTT-106.7* INR(PT)-2.1*
[**2110-9-8**] 07:39PM O2 SAT-79
[**2110-9-8**] 07:39PM TYPE-[**Last Name (un) **]
[**2110-9-8**] 08:23PM PT-13.8* PTT-27.8 INR(PT)-1.2*
[**2110-9-8**] 10:25PM HCT-28.6*
Brief Hospital Course:
84 yo male with DM, CRI, dementia, prior strokes and seizure
disorder admitted for perinephric hematoma s/p embolization now
admitted to the medical floors with mental status changes.
.
# MENTAL STATUS CHANGE - Patient's mental status improved
signficantly after transfer to the floor. The cause for his
mental status changes was thought most likely secondary to ICU
delerium and medication. However, it was also thought that
there could have been an effect of his high keppra dose and
anticholinergic drugs. There was no identifiable infection on
blood cultures, CXRs, or urinalysis. His EEG did not show any
seizures. An LP was not performed as clinical suspicion was
low. His Keppra was decreased to an appropriate renal dose and
all of his medications with anticholinergic side effects were
stopped. His Zoloft was held. He was initially given Haldol at
night to control his evening agitation but it was later weaned
off. He was not requiring a 1:1 sitter at the time of discharge
and was believed to be back close to his baseline level of
dementia.
.
# PLEURAL EFFUSION - His first thoracentesis removed 1.5 L but
the pleural fluid removed was not sent for diagnostic testing.
He had reaccumulation of bilateral pleural effusions during the
course of his admission. The differential for the effusion was
CHF versus malignancy but it seemed less likely to be CHF given
normal systolic function seen on ECHO [**9-19**]. His pleural
effusion was tapped again on [**2110-10-1**] for diagnostic purposes and
fluid was sent for analysis. Fluid analysis was suggestive of
transudate with LDH ratio of 0.3, total protein ratio of 0.3,
fluid LDH of 185. Fluid also had 72,000 RBCs and 4 mesothelial
cells. There was concern for a malignant pleural effusion,
possibly secondary to a mesothelioma not visualized on chest CT
due to the large pleural effusions. At the time of discharge,
the denied shortness of breath, had no other evidence on exam to
suggest CHF besides pleural effusions, and had good O2
saturations on minimal O2 requirements. Fluid cytology was
pending at the time of discharge and patient's PCP was notified
to follow up the results.
.
# BACTEREMIA - He had a coagulase neg staph grow out of 1 of 4
culture bottles on [**2110-9-17**] that was believed to be most likely a
contaminant. All subsequent cultures were negative and he
remained afebrile without leukocytosis throughout admission.
.
# PERINEPHRIC HEMATOMA - He had embolization of one of the
branches of his right renal artery by Interventional Radiology.
He was hemodynamically stable with a stable hematocrit
throughout his admission post-procedure. His anticoagulation
with warfarin was held. It was not restarted on discharge and he
will follow up with his PCP to discuss when to restart.
.
# hypertension- patient was hypertensive to the 190s on the
floor on beta blocker and long acting nitrate. Given his renal
insufficiency and likelihood of requiring large doses of ACE
inhibitor to obtain appropriate blood pressure control, he was
started on po hydralazine with excellent improvement in
pressures. He was discharged on metoprolol, Imdur, and
hydralazine. However, given QID dosing, patient may benefit
from switch to calcium channel blocker as an outpatient.
.
# CVA - he was on warfarin and aspirin prior to his perinephric
hematoma for stroke. Given his risk of falls and hematoma, only
his aspirin was continued and his warfarin was held.
.
# BPH - He was continued on his finesteride and flomax.
.
# ELEVATED TROPONIN - His troponin peaked at 0.22 with no
elevations in CK or CK/MB, and he had no chest pain. He had EKG
changes that were initially concerning for STEMI. However,
cardiology reviewed the EKGs and did not feel that the EKG
changes were consistent with acute coronary syndrome. The
troponin elevation was most likely given his known chronic renal
insufficiency. His CAD was treated conservatively with medical
management including asa, metoprolol and isosorbide.
.
# DM - His oral hypoglycemics were held during admission and he
was managed with an insulin sliding scale. His BGs remained
well controlled throughout admission. He was not restarted on
his glipizide given his renal failure but was started on low
dose avandia at the time of discharge.
.
# SEIZURE D/O - His keppra was decreased to 250 mg daily for
appropriate renal dosing. He had no episodes of seizure
activity. His EEG did not show any evidence of seizure activity.
.
# CRI - His renal function remained stable at his baseline of
2.1 to 2.3.
.
# SPEECH AND SWALLOW - He was evaluated by speech and swallow.
His PO meds needed to be crushed in puree. Liquid forms were
requried if medications were not crushable. He was put on
aspiration precautions, and all his meals needed to be
supervised.
.
# COMMUNICATION:
- Davidene [**Known lastname 4460**] [**Telephone/Fax (1) 69145**] (HCP)
- Daughter [**First Name8 (NamePattern2) 5627**] [**Name (NI) 8651**] [**Telephone/Fax (3) 69146**]
.
# CODE:
- DNR/DNI, discussed with wife who is health care proxy
Medications on Admission:
Metoprolol 50 [**Hospital1 **]
Coumadin 3 QHS
Proscar 5 daily
Zoloft 25 daily
Keppra 500 daily
Glucotrol 2.5 daily
ASA 81 daily
Flomax 0.4 daily
Albuterol prn
Prilosec 20 daily
Flourinef 0.1 daily
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for SOB.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
3. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
11. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed) as needed for Cough.
12. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mg PO BID (2 times a day).
13. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
16. Dextromethorphan Poly Complex 30 mg/5 mL Suspension, Sust.
Release 12HR Sig: Ten (10) ML PO BID (2 times a day).
17. Avandia 2 mg Tablet Sig: One (1) Tablet PO twice a day.
18. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
20. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary:
1. Right Perinephric/Paranephric Hemorrhage
2. Bilateral Pleural Effusions
3. delerium
.
Secondary:
1. DM2
2. hypertension
3. chronic renal failure
4. congestive heart failure
5. Seizure disorder
6. Emphysema
Discharge Condition:
hemodynamically stable, afebrile
Discharge Instructions:
Please take all medication as prescribed. Please note that your
Zoloft has been stopped. Your metoprolol has been increased.
You have also been started on isosorbide dinitrate, hydralazine,
and atorvastatin.
.
You have not been restarted on your coumadin. Please discuss
with your PCP about restarting this medication. You should also
discuss with him the labs results from your last thoracentesis
while in the hospital.
.
Please follow up with your Primary Care Doctor and Trauma
surgery as below.
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, fever, chills, or
any other concerns.
Followup Instructions:
Please follow up with your primary care physician in the next
1-2 weeks. Dr.[**Name (NI) 48786**] office will call your wife with your
scheduled follow up appointment.
Please follow up in Trauma Clinic on [**2110-10-14**] at 11:30 am.
Phone: [**Telephone/Fax (1) 6429**]
|
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71,211
| 109,263
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13652
|
Discharge summary
|
report
|
Admission Date: [**2153-5-3**] Discharge Date: [**2153-5-12**]
Date of Birth: [**2116-6-9**] Sex: F
Service: SURGERY
Allergies:
Erythromycin / Latex / Bactrim / Penicillins / Adhesive Bandage
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
sigmoidoscopy [**2153-5-10**]
History of Present Illness:
36f s/p pancreas transplant [**2-13**] notes 3 weeks of loose,
watery stools, food and medication intolerance, and, more
recently, BRBPR. She presented today to Dr[**Name (NI) 8584**] clinic, at
which time she was noted to be pale, hypotensive to the 80's,
tachycardic, and feeling very week. She was directly sent to
the
ER for further evaluation. Here she notes no abdominal pain,
recent melena, no further continued vomiting, no fevers, chills
or other constitutional symptoms. She appears with substantial
pallor, poor skin turgor, dry eyes and mucous membranes, and
states that she feels exhausted. Additionally, she is
neutropenic, acidotic with a HCO3 of 9, and anemic -- these
laboratory values are all substantial deviations from her prior
baseline. Also, her blood sugars have been noted by the patient
as being in the 170s, fasting, but she is found to have a
quick-fingerstick of 142 and a chemistry-glucose of 157.
Past Medical History:
DM1, hyperlipidemia, exploratory laparotomy for
endometriosis, C-section, left frozen shoulder s/p multiple
surgeries, and migraines.
Social History:
Denies ETOH, smoking, recreational drugs. Currently on
disability [**1-23**] her left shoulder pain.
Family History:
Significant for diabetes. Father had melanoma.
Physical Exam:
Physical exam on discharge:
AF, VSS
General: NAD, alert and oriented x 3
CV: RRR, no m/g/r
Pulm: CTAB, no rales/rhonchi/wheezes
Abd: soft, non-distended, mild tenderness to palpation in RLQ.
Well-healed vertical midline incision.
Ext: wwp, no edema
Pertinent Results:
Admission labs:
[**2153-5-3**] 11:25AM BLOOD WBC-0.6*# RBC-4.25 Hgb-12.3 Hct-36.8
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.6 Plt Ct-358
[**2153-5-3**] 01:10PM BLOOD Neuts-91* Bands-1 Lymphs-4* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2153-5-3**] 01:10PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL
[**2153-5-3**] 11:25AM BLOOD Plt Ct-358
[**2153-5-3**] 01:10PM BLOOD PT-14.0* PTT-29.4 INR(PT)-1.2*
[**2153-5-3**] 01:10PM BLOOD Plt Smr-NORMAL Plt Ct-277
[**2153-5-3**] 11:25AM BLOOD UreaN-87* Creat-5.7*# Na-131* K-4.1 Cl-98
HCO3-14* AnGap-23*
[**2153-5-3**] 11:25AM BLOOD Glucose-190*
[**2153-5-3**] 11:25AM BLOOD ALT-12 AST-24 Amylase-123* TotBili-0.3
[**2153-5-3**] 11:25AM BLOOD Lipase-62*
[**2153-5-3**] 11:25AM BLOOD Albumin-4.6 Calcium-9.8 Phos-7.0*#
[**2153-5-3**] 11:25AM BLOOD %HbA1c-4.8 eAG-91
[**2153-5-3**] 11:25AM BLOOD tacroFK-GREATER TH
[**2153-5-3**] 04:55PM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-32* pH-7.24*
calTCO2-14* Base XS--12 Comment-GREEN TOP
[**2153-5-3**] 01:17PM BLOOD Lactate-1.3 K-3.7
[**2153-5-3**] 01:17PM BLOOD Hgb-10.8* calcHCT-32
Discharge labs:
[**2153-5-11**] 06:10AM BLOOD WBC-4.6 RBC-3.32* Hgb-9.5* Hct-28.0*
MCV-84 MCH-28.5 MCHC-33.8 RDW-15.8* Plt Ct-168
[**2153-5-11**] 06:10AM BLOOD Plt Ct-168
[**2153-5-11**] 06:10AM BLOOD Glucose-103* UreaN-2* Creat-0.8 Na-140
K-4.5 Cl-114* HCO3-23 AnGap-8
[**2153-5-11**] 06:10AM BLOOD Amylase-55
[**2153-5-11**] 06:10AM BLOOD Lipase-14
[**2153-5-11**] 06:10AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.5*
[**2153-5-11**] 06:10AM BLOOD tacroFK-8.7
Micro:
[**2153-5-3**]:
BLOOD/FUNGAL CULTURE (Final [**2153-5-7**]):
DUE TO OVERGROWTH OF BACTERIA,.
UNABLE TO CONTINUE MONITORING FOR FUNGUS.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
ISOLATED FROM ONE SET ONLY.
BLOOD/AFB CULTURE (Final [**2153-5-6**]):
DUE TO OVERGROWTH OF BACTERIA,.
UNABLE TO CONTINUE MONITORING FOR AFB.
Myco-F Bottle Gram Stain (Final [**2153-5-5**]):
GRAM POSITIVE ROD(S) CONSISTENT WITH CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 9604**] [**Last Name (NamePattern1) 41183**] AT 2103 ON [**2153-5-5**].
[**2153-5-3**] 5:30 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2153-5-5**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2153-5-10**] 11:47 am
BIOPSY Site: COLON
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Virus isolated so far.
Fecal culture negative x 2, ova and parasites negative x 3.
Blood cultures negative x 2, urine culture negative x 1.
All other cultures negative or pending. Please refer to the
online medical record for details.
Brief Hospital Course:
36 y/o female aditted through the ED with loose stools and most
recently BRBPR. She was admitted directly from the ED to the
SICU.
A CT was obtained but without contrast there was no large fluid
collection or hematoma visualized. The assessment of the
pancreatic transplant is limited; however, there are no gross
fluid collections or inflammatory changes present.
Also seen is abdominal rectus diastasis with paraumbilical
hernia containing a single loop of herniated bowel, with no
evidence of bowel obstruction.
She received large volume resuscitation, and 2 units of RBC's on
[**5-3**] for hct 21% and then 2 units RBCs on [**5-4**] for 26%.
Following these transfusions her hematocrit remained stable and
the rectal bleeding had ceased.
On [**5-4**] a tagged Red cell scan was performed, and this did not
show evidence of active bleeding.
Blood cultures collected on admission and then during the
hospitalization were all negative.
CMV viral load and CMV antibody are both negative.
Stool culture, O&P and C diff x 3 were collected and were all
negative.
The patient continued to have multiple loose stools.
She was consulted to the GI service who performed a colonoscopy.
The results were: Normal mucosa in the colon and terminal ileum
with cold forceps biopsies taken wich were not finalized at
discharge. She also had Grade 3 internal hemorrhoids
Otherwise normal colonoscopy to terminal ileum.
She was started on immodium which helped decrease number of
stools.
Immunosuppression was changed during this hopsitalization. She
was discontinued off Cellcept, and after a few days of
monotherapy on Prograf, she was started on imuran, for which she
received a script for home.
She was taken off valcyte after it was determined her CMV status
was negative, and she is out approximately 3 months from
transplant.
ID consult had been obtained early in hospital course. They
followed with antibiotic recommendations, and suggestions
regarding neutropenia. She was initially covered with Levaquin,
Vanco and Flagyl, this was eventually trimmed to Flagyl only and
then no antibiotics for home were recommended.
She was also profoundly neutropenic, and part of adjusting
medications was goal of increasing WBCs as well as 7 days of
Filgrastim. WBC nadir was 0.2.
Upon discharge her stools had been mnimized, immunosuppression
was adjusted and she was tolerating diet.
She has also been followed by social work who will also be
following her as an outpatient due to concerns that she needs
encouragement to call earlier when not feeling well.
Medications on Admission:
FAMOTIDINE - 20 mg Tablet - 1 Tablet(s) by mouth twice a day
FEXOFENADINE [[**Doctor First Name **]] - (Prescribed by Other Provider) - 180
mg
Tablet - 1 Tablet(s) by mouth once a day
METOCLOPRAMIDE [REGLAN] - (Prescribed by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth three times a day
MYCOPHENOLATE MOFETIL - 500 mg Tablet - 1 Tablet(s) by mouth
four
times a day
PENTAMIDINE [NEBUPENT] - 300 mg Recon Soln - 300 mg ih monthly
dilute in 6 ml of sterile water
SODIUM POLYSTYRENE SULFONATE - Powder - Take 15 gms as
directed
prn for high k dispense 464 gms
TACROLIMUS - (Dose adjustment - no new Rx) - 1 mg Capsule - 3
Capsule(s) by mouth twice a day take up to 4 capsules [**Hospital1 **]
TACROLIMUS - (Dose adjustment - no new Rx) - 0.5 mg Capsule - 1
Capsule(s) by mouth twice a day
VALGANCICLOVIR [VALCYTE] - 450 mg Tablet - 2 Tablet(s) by mouth
once a day
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO three times
a day.
4. Pentamidine 300 mg Recon Soln Sig: One (1) inhalation
Inhalation once a month.
5. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO every twelve
(12) hours: Please have your tacrolimus levels drawn weekly and
follow up for dose changes.
6. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Myfortic Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Dehydration
Diarrhea
fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please have your tacrolimus levels drawn weekly and follow up
for dosage changes.
Please call the Transplant office [**Telephone/Fax (1) 41184**] if you
experience any of the warning signs listed below:
*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 except for cellcept
and valcyte. Also, please take any new medications as
prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink enough fluid to keep your urine pale yellow
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 673**] [**2153-5-18**]
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2153-6-8**] 9:50
Completed by:[**2153-5-14**]
|
[
"276.2",
"V42.83",
"250.01",
"285.9",
"272.4",
"276.51",
"584.9",
"578.9",
"288.00",
"538",
"455.0",
"553.1",
"E933.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
8806, 8812
|
4754, 7299
|
327, 359
|
8883, 8883
|
1950, 1950
|
10238, 10524
|
1616, 1666
|
8224, 8783
|
8833, 8862
|
7325, 8201
|
9034, 10215
|
3115, 4731
|
1681, 1681
|
1709, 1931
|
281, 289
|
387, 1323
|
1966, 3099
|
8898, 9010
|
1345, 1481
|
1497, 1600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,645
| 145,931
|
38718
|
Discharge summary
|
report
|
Admission Date: [**2105-11-19**] Discharge Date: [**2105-11-25**]
Date of Birth: [**2076-2-7**] Sex: F
Service: MEDICINE
Allergies:
Phenothiazines / Depakote / Thorazine
Attending:[**First Name3 (LF) 9965**]
Chief Complaint:
1. Verapamil overdose
2. Suicidal ideation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 10162**] is a 29 year old female with an extensive history of
psych admissions for overdoses and other suicidal attempts who
presents now with a verapamil overdose. She presented to the ED
1.5 hrs after taking 10 tablets of 180mg sustained release
verapamil as well as zofran 4mg to prevent nausea. In the past,
she has reported that she hurts herself in order to get "an
adrenaline rush" which she can't get any other way. She denies
suicidal attempt now btu reports indifference to death as a
result of her ingestion.
.
In the ED, initial VS were: 100 115 132/78 16 96% on RA. She
refused to take charcol due to nausea and vomiting but remained
hemodynamically stable. Toxicology team saw the patient and
made their recommendations (see plan below).
.
On arrival to the MICU, she was resting comfortably. She
reports that she did not want to kill herself, just that she
feels better when she "self-hurts" because it lets her "mind
rest". She got the verapamil from an ED in [**Hospital3 **] and
reports that she would have taken more pills if they had
prescribed more to her. She continues to refusing taking the PO
charcol because it tastes disgusting and she does not have any
of the symptoms that she had last time she overdosed.
.
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:
Morbid Obesity
OSA
GERD
Fibromyalgia
Hyperlipidemia
Gastroparesis
PAST PSYCHIATRIC HISTORY: (Per OMR, reviewed with and additions
per patient)
-Diagnoses:
* Borderline Personality Disorder
* Major depressive disorder
* Eating DO NOS (restricting, laxative use, binging/purging)
-Hospitalizations: Many. Most recently:
* [**Hospital3 **] [**Date range (1) 24294**]/11 due to SI with plan to jump
into
traffic
* [**Hospital1 18**] [**2105-8-8**] - [**2105-8-10**] following overdose on Verapamil 3600
mg requiring ICU admission but not intubation
* [**Hospital 882**] Hospital approximately [**2105-7-29**] - [**2105-8-1**]
* [**Hospital1 18**] [**2105-7-9**] - [**2105-7-27**] - ECT considered during this
hospitalization but pt ran out of ECT suite before she could
receive her first treatment, and outpatient team decided to hold
off on ECT
* [**Hospital1 18**] [**2105-6-17**] - [**2105-6-26**]
* [**Hospital1 18**] [**3-/2105**]
* [**Last Name (un) 3671**] [**1-/2105**]
* NWH [**1-/2105**]
* [**Hospital1 18**] [**12/2104**]
-SA/SIB: Numerous suicide attempts in the past including 8 by
means of overdose and one by means hanging; most recent attempt
was on [**2105-8-2**] (Verapamil overdose on 3600 mg requiring ICU
admission but not intubation). Previous to this, most recent
attempt was in [**2104-4-12**] when she overdosed on verapamil which
required an ICU admission; has had a suicide attempt by means of
acetaminophen which required ICU admission. Longstanding history
of SIB by means of cutting. Last cutting was in [**2105-7-13**].
Cutting began at age 13-14; self-injurious behaviors escalated
to
current state around age 26, patient unable to identify triggers
for this.
-Medications: Recently, restarted on Effexor. Prior to this
outpatient treaters had been withholding antidepressants due to
concern for bipolar diathesis. Many prior medication trials.
-Outpatient Program: DBT Program at Mass Mental
-Treaters:
* Previous therapist at DBT partial: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
* Psychiatry Resident and current therapist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 86018**]
(changes Q3 months)
* Psychiatry Attending: Dr. [**Last Name (STitle) **]
Social History:
Originally from [**Location (un) **]. Middle of three children. Parents
divorced when patient was 15 years old, though patient was
placed
in [**Doctor Last Name **] care at the age of 13 for both abuse and neglect.
Graduated from HS, looks forward to attending college in the
future as she wants to be a nurse. Moved to [**Location (un) 86**] about a year
ago. Patient is currently living in the DBT house in [**Location (un) **]
and attending the DBT partial at Mass Mental. Unemployed and
currently on SSDI. Previously worked at CVS for 1.5 years.
Family History:
mother - borderline personality disorder per patient
both parents - substance abuse problems
maternal aunt - completed suicide by means of heroin and
benzodiazepine overdose
Physical Exam:
Vitals: T: afebrile, BP 149/78, P113, R12, O2 99% RA
General: Alert, oriented obese female in 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. Extensive scarring from prior cutting on bilateral arms
Neuro: deferred
.
Discharge Vitals:
VS: 126/76 87 28 98%RA
GA: Obese female, sitting up in bed in NAD
HEENT: PERRLA. MMM. no lymphadenopathy. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT ND, +BS. no organomegaly.
Extremities: Multiple healed horizontal cut marks on the back of
both UE
Skin: warm and dry
Neuro/Psych: Awake and alert. Moving all extremeties.
Pertinent Results:
[**2105-11-20**] 05:15AM BLOOD WBC-8.7 RBC-4.75 Hgb-11.4* Hct-34.9*
MCV-74* MCH-24.0* MCHC-32.7 RDW-16.4* Plt Ct-291
[**2105-11-19**] 10:15PM BLOOD WBC-8.4 RBC-5.01 Hgb-12.1 Hct-36.9
MCV-74* MCH-24.2* MCHC-32.8 RDW-16.2* Plt Ct-303
[**2105-11-19**] 10:15PM BLOOD Neuts-73.8* Lymphs-22.8 Monos-2.9 Eos-0.4
Baso-0.2
[**2105-11-20**] 05:15AM BLOOD Plt Ct-291
[**2105-11-20**] 05:15AM BLOOD PT-11.3 PTT-33.6 INR(PT)-1.0
[**2105-11-19**] 10:15PM BLOOD Plt Ct-303
[**2105-11-20**] 05:15AM BLOOD Glucose-121* UreaN-12 Creat-0.6 Na-141
K-4.0 Cl-105 HCO3-23 AnGap-17
[**2105-11-19**] 10:15PM BLOOD Glucose-133* UreaN-15 Creat-0.7 Na-141
K-4.8 Cl-104 HCO3-25 AnGap-17
[**2105-11-20**] 05:15AM BLOOD ALT-17 AST-22 LD(LDH)-174 AlkPhos-70
TotBili-0.3
[**2105-11-20**] 05:15AM BLOOD Calcium-9.5 Phos-4.5 Mg-1.7
[**2105-11-19**] 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
29 year old female with an extensive history of suicide attempts
including prior OD on verapamil requiring ICU admission who
presents with verapamil overdose.
.
# Verapamil overdose: Total 1800 mg taken on day of admission.
Toxicology was consulted and we followed their recommendations.
Ingestion was intentional and she admitted to trying to hurt,
but not kill, herself. She has history of multiple past
self-harm gestures and was generally indifferent to thought of
her death in discussion with the patient. Serum chemistries and
tox screen were negative for co-ingestions. She refused to
ingest charcoal, but was kept NPO for the first 6 hours. Her
FSBS was monitored q15min for the first hour, q30min for hours
[**1-16**] and hourly until 6 hours. No abnormalities were noted. She
was also monitored on telemetry during this time course with
nothing abnormal noted. She was transferred to the floor and
continued to remain stable. FSG were stopped being monitored
and she was taken off tele. She was stable throughout the
course of her day.
.
# Borderline personality disorder: She has very close follow-up
with outpatient psych and is well known to our psych team. She
seems to be refractory to treatment and therapy. Also, from
prior notes and the frequency of presentation to the healthcare
system she appears to be seeking secondary gain/attention for
her peri-suicidal gestures. We held haldol, velafaxine and
benzodiazepines due to increased risk of arrhtyhmias. She will
be held section 12 pending inpatient placement.
.
She was formally evaluated by psychiatry in the ICU who felt
that she was not safe to return home, and she was placed on a
section 12. She will remain in the hospital pending bed search
and placement. She was followed by Psych while on the general
medicine service. She tried to leave AMA on a few occasions and
was seen by psychiatry and continued to be section 12. A
meeting was planned for [**2105-11-26**] to discuss disposition, but she
was given a bed at the crisis stabilization unit on [**2105-11-25**] and
so was discharged there.
.
#. OSA:
- Continue home CPAP. Patient brought her own mask. Setting
15/10
.
#. Back pain and fibromyalgia: Well controlled on home opiate
regimen.
.
# Gastroparesis/GERD: Restarted reglan, zofran, simethicone, and
omeprazole in the ICU. To continue on floor.
.
#. LE edema - Patient c/o LE edema. Had normal echo in [**8-/2105**]
but could not eval for pulm HTN. Most likely has some elevated
pulm artery pressure leading to right sided fluid back-up.
Medications on Admission:
1. lamotrigine 200 mg QAM
2. venlafaxine 37.5 mg QAM
3. haloperidol 1 mg TID
4. trazodone 100 mg HS
5. clonazepam 2 mg QHS
6. lorazepam 1 mg Q4H prn anxiety
7. hydroxyzine HCl 25 mg DAILY prn anxiety
8. omeprazole 40 mg daily
9. pregabalin 150 mg [**Hospital1 **]
10. oxycodone 10 mg Q12H
11. metoclopramide 10 mg [**Hospital1 **]
12. ondansetron 4 mg Q8H prn nausea
13. acetaminophen 1000 mg Q6H prn pain
14. ibuprofen 600 mg Q8H prn pain
15. simethicone 120 mg QID
Discharge Medications:
1. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO QAM.
2. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO QAM.
3. trazodone 100 mg Tablet Sig: One (1) Tablet PO QHS.
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety.
5. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO once a
day as needed for anxiety.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. pregabalin 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
8. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
9. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
10. simethicone 125 mg Tablet Sig: One (1) Tablet PO four times
a day.
11. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
12. haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
14. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for Pain.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Verapamil overdose
2. Suicidal ideation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 10162**],
We appreciated the opportunity to particpate in your care at
[**Hospital1 18**]. You were admitted for an ingestion of verapamil and
suicidal ideation. We monitored you in the ICU for signs of
verapamil toxicity which you did not develop. We also had you
meet with our psychiatry team for evaluation. At this time we
are discharging you back to DBT house where you receive your
care. You should continue treatment there and be sure to follow
up with your outpatient psychiatrist.
***Call your primary care physician or return to the ED
immediately if you experience:
- rapid heartbeat
- trouble breathing
- loss of consciousness
- dizziness or light-headedness
- fever, chills, nausea, vomiting
- slurred speech or confusion
- recurrent thoughts of hurting or killing yourself, or hurting
or killing others
- any other concerns
Followup Instructions:
You should continue to followup with your outpatient
psychiatrist. Please call to make an appointment within the next
several days.
You should also call your primary care physician to schedule
followup within the next several days.
Completed by:[**2105-11-26**]
|
[
"307.50",
"972.4",
"296.20",
"327.23",
"782.3",
"729.1",
"536.3",
"278.01",
"301.83",
"963.0",
"E950.4",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11459, 11474
|
7107, 9645
|
342, 349
|
11561, 11561
|
6187, 7084
|
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|
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11495, 11540
|
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5174, 6168
|
1665, 2113
|
260, 304
|
377, 1646
|
11576, 11688
|
2135, 4397
|
4413, 4967
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,496
| 144,243
|
31123+57733
|
Discharge summary
|
report+addendum
|
Admission Date: [**2165-8-2**] Discharge Date: [**2165-8-4**]
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
unresponsive and hypotensive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] year old man with CVA, R hemiparesis, COPD, PVD, was found
unresponsive at nursing home. Vitals were: 99.2, 96. 94/60, 20,
82% on 2LNC. There was a concern for aspiration; unclear
details as to why. He had a CXR that was reportedly
unremarkable. He was then transferred to [**Hospital1 18**].
.
In the ED, his initial vitals were: 98.3, 100, 53/37, 99%. He
remained minimally responsive; reportedly not withdrawing to
pain. His BP ranged from 50-70/30-40. There are also
anterolateral ST depressions on EKG. His daughter [**Name (NI) 4051**] was
contact[**Name (NI) **] and it was decided that he will be DNR/DNI. He will
not go on pressors. The daughter still wanted BIPAP, fluids and
antibiotics and she is on a bus to [**Location (un) 86**]. The patient is then
tranferred to the MICU for further care. Once the patient's
family arrived at the bedside, the family (daughter) made the
decision to remove BIPAP and all other therapies and the patient
was made CMO.
Past Medical History:
# CVA with right hemiparesis
# PVD
# COPD
# BPH
# Dysphagia
Social History:
NC
Family History:
NC
Physical Exam:
VITALS: 65/43, 94, 100% on BIPAP FiO2 100%, [**10-4**].
GEN: Barely opens eyes to voice; withdraws to pain, does not
engage
HEENT: BIPAP mask
NECK: obese
CV: RRR, no m/g/r
PULM: Diffuse rhonchi with scatterred wheezes, no rales
ABD: Soft, NT, ND, +BS
EXT: no c/e/c
Pertinent Results:
[**2165-8-2**] 05:45PM GLUCOSE-273* UREA N-51* CREAT-2.3*
SODIUM-154* POTASSIUM-4.8 CHLORIDE-120* TOTAL CO2-14* ANION
GAP-25*
[**2165-8-2**] 05:45PM estGFR-Using this
[**2165-8-2**] 05:45PM WBC-22.4* RBC-3.10* HGB-9.4* HCT-28.4* MCV-92
MCH-30.4 MCHC-33.2 RDW-14.4
[**2165-8-2**] 05:45PM NEUTS-84.7* LYMPHS-12.4* MONOS-2.6 EOS-0.1
BASOS-0.3
[**2165-8-2**] 05:45PM PLT COUNT-401
[**2165-8-2**] 05:45PM PT-16.2* PTT-26.8 INR(PT)-1.5*
Brief Hospital Course:
[**Age over 90 **] year old man with COPD and CVA with R hemiparesis found
unresponsive and hypotensive at nursing home; tranferred to
[**Hospital1 18**], here persistently hypotensive with minimal engagement.
Unclear cause for his decompesnation. Possibilities include
infection (PNA, bactermia, sepsis, MI, or stroke.) He is
currently on BIPAP for hypoxemia.
.
The ED had a discussion with the patient's daughter. [**Name (NI) **] is
DNR/DNI and no pressors should be used. She wants to keep him
comfortable but she also would like to see him before he passes.
She does not want any more tests. I confirmed this status on
the phone with her. The plan is to keep the patient comfortable
with morphine drip, titrate prn for comfort. BIPAP was continued
until the family was at the bedside. The family arrived on the
morning of [**2165-8-3**] and the patient was made CMO in discussion
with the family. The patient expired on the morning of [**2165-8-4**].
Medications on Admission:
(from ER notes, no list from rehab):
# Asa
# Plavix
# Prilosec
# Zoloft
# Verapermil
# Terazosin
# MOM
# Azithromycin
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Name: [**Known lastname **],[**Known firstname 1127**] Unit No: [**Numeric Identifier 12199**]
Admission Date: [**2165-8-2**] Discharge Date: [**2165-8-4**]
Date of Birth: [**2070-6-28**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 10841**]
Addendum:
Discharge DIagnosis: Hypotension
Discharge Disposition:
Expired
[**Name6 (MD) **] [**Last Name (NamePattern4) 9776**] MD [**MD Number(2) 10844**]
Completed by:[**2165-8-21**]
|
[
"600.00",
"443.9",
"438.20",
"799.02",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3923, 4072
|
2194, 3160
|
269, 275
|
3421, 3430
|
1727, 2171
|
3486, 3866
|
1422, 1426
|
3329, 3338
|
3887, 3900
|
3186, 3306
|
3454, 3463
|
1441, 1708
|
200, 231
|
303, 1302
|
1324, 1386
|
1402, 1406
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,187
| 167,725
|
40259
|
Discharge summary
|
report
|
Admission Date: [**2184-3-15**] Discharge Date: [**2184-3-27**]
Date of Birth: [**2149-11-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Worsening fatigue
Major Surgical or Invasive Procedure:
[**2184-3-15**] Aortic Valve Replacement(23mm St. [**Male First Name (un) 923**] mechanical) and
Mitral Valve Replacment(27mm St. [**Male First Name (un) 923**] mechanical).
History of Present Illness:
This is a 34 year old male with rheumatic heart disease. Serial
echocardiograms have shown progressive aortic and mitral valve
disease. He complains of fatigue and dry cough. He denies chest
pain or edema. After extensive preoperative evaluation, he was
admitted for cardiac surgical intervention.
Past Medical History:
Rheumatic Heart Disease
Severe Aortic Insufficiency/Moderate Aortic Stenosis
Moderate mitral regurgitation with modetate mitral stenosis
Hypertension
Hyperlipidemia
s/p Left foot surgery
Social History:
Race: Brazilian (Portuguese is primary language- but understands
some English)
Last Dental Exam: [**2182-12-13**]
Lives with: wife and young children
Occupation: lays tile
Tobacco: denies
ETOH: denies
Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse: 77 Resp: 16
BP Right: 138/60
Height: 72 inches Weight: 92 kg
General: No acute distress, well developed, well nourished
Skin: Warm[x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 systolic and diastolic
murmurs, +thrill
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: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: + rad murmur Left: + rad murmur
radiation of cardiac murmur
Pertinent Results:
04/05/11WBC-12.5* RBC-3.32* Hgb-9.3* Hct-27.4* Plt Ct-162
[**2184-3-17**] WBC-16.4* RBC-3.64* Hgb-10.3* Hct-29.8* Plt Ct-169
[**2184-3-18**] WBC-17.9*
[**2184-3-16**] PT-14.7* PTT-25.7 INR(PT)-1.3*
[**2184-3-17**] PT-18.0* INR(PT)-1.6*
[**2184-3-18**] PT-32.5* INR(PT)-3.2*
[**2184-3-16**] Glucose-109* UreaN-16 Creat-1.0 Na-136 K-4.1 Cl-104
HCO3-26
[**2184-3-17**] Glucose-118* UreaN-23* Creat-1.1 Na-130* K-4.9 Cl-97
HCO3-29
[**2184-3-17**] 04:50AM BLOOD Mg-1.7
Intra-op TEE [**2184-3-19**]
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild global left ventricular hypokinesis (LVEF = 40%) with
visually-significant intraventricular dyssynchrony. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. A bileaflet aortic valve prosthesis is present.
Trace aortic regurgitation is seen. [Due to acoustic shadowing,
the severity of aortic regurgitation may be significantly
UNDERestimated.] A bileaflet mitral valve prosthesis is present.
The mitral prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. Trivial mitral
regurgitation is seen. The degree of mitral regurgitation seen
is normal for this prosthesis. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: No significant pericardial effusion.
Normally-functioning mechanical aortic and mitral prostheses.
Mild global biventricular systolic dysfunction with evidence of
hemodynamic RV/LV interdependence. Moderate to severe tricuspid
regurgitation. At least moderate pulmonary hypertension.
[**2184-3-24**] 09:19AM BLOOD WBC-13.6* RBC-3.41* Hgb-9.8* Hct-29.5*
MCV-87 MCH-28.7 MCHC-33.2 RDW-19.4* Plt Ct-359
[**2184-3-24**] 09:19AM BLOOD PT-25.1* INR(PT)-2.4*
[**2184-3-24**] 09:19AM BLOOD Glucose-133* UreaN-23* Creat-1.2 Na-134
K-4.5 Cl-98 HCO3-28 AnGap-13
Brief Hospital Course:
On [**2184-3-15**] Mr. [**Known lastname 19688**] was taken to the operating room and
underwent Aortic valve replacement with a 23-mm St. [**Hospital 923**] Medical
mechanical valve and mitral valve replacement with a 27-mm St.
[**Hospital 923**] Medical mechanical valve with Dr. [**Last Name (STitle) **]. For surgical
details, please see operative note. Following surgery, he was
brought to the CVICU in stable condition. He initially required
fresh frozen plasma for increased chest tube output. Amiodarone
was started for episodes of rapid atrial fibrillation. He
otherwise maintained stable hemodynamics and chest tube output
improved over the next day. Within 24 hours of surgery, he awoke
neurologically intact and was extubated without incident. CVICU
course was otherwise uneventful and he was transferred to the
Step down unit on postoperative day one. Warfarin was started
and dosed for a goal INR between 3.0 - 3.5. Amiodarone was
titrated accordingly. INR became supra-therapeutic, peaking at
8.7. Fresh Frozen Plasma was administered, coumadin held, and
INR allowed to trend down. Postoperatively he had brief
episodes of transient atrial fibrillation treated with
beta-blocker. It should also be noted that Mr.[**Known lastname 19688**] had a
leukocytosis, WBC peaked to 17.9. He remained afebrile and
cultures remained negative. By discharge, his white count was
trending down to normal.The remainder of his hospital course was
essentially uneventful. Prior to discharge, arrangements were
made with [**Hospital 88272**] [**Hospital 197**] clinic, Dr.[**Last Name (STitle) 4610**] to manage his
Warfarin as an outpatient. POD#12 he was discharged to home. All
follow up appointments were advised. Target INR 3.0-3.5 for
mechanical valves.
***********Mr. [**Known lastname 19688**] was given a set of scripts for 4 days of
medications until he can fill his meds at the free care pharmacy
on tuesday. ***********
Medications on Admission:
-Lasix 20mg daily
-Protonix 40mg daily
-Lisinopril 5mg daily
-Toprol 25mg daily
-Amoxicillin SBE prophylaxis
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
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:*1*
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*4 Tablet(s)* Refills:*0*
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*4 Tablet(s)* Refills:*0*
6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*8 Tablet(s)* Refills:*0*
7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*12 Tablet(s)* Refills:*0*
8. warfarin 2.5 mg Tablet Sig: as directed for bilat mech valves
Tablet PO once a day: Take as directed based on INR
INR goal 3.0-3.5 for mechcanial AVR/MVR.
Disp:*8 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
Check INR daily (check first INR [**2184-3-28**] and dose coumadin per
[**Hospital1 **] coumadin clinic.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*4 Tablet(s)* Refills:*0*
******Needs free care meds so, given 2 sets of scripts one set
for 4 days and one set for 30 days********
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Rheumatic Heart Disease, s/p AVR, MVR(mechanical valve)
postop A Fib
Aortic Valve Insufficiency/Stenosis
Mitral Valve Insufficiency/Stenosis
Hypertension
Dyslipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema -none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] at [**Hospital1 **] Heart Center #[**Telephone/Fax (2) 6256**]
PCP/Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] [**Telephone/Fax (1) 42422**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechanical AVR/MVR
Goal INR 3.0 to 3.5
First draw [**2184-3-28**] and call results to Dr.[**Name (NI) 5572**] office
[**Telephone/Fax (1) 170**] on [**3-28**] for coumadin dosing then call to:
Results to [**Hospital **] [**Hospital **] clinic [**Telephone/Fax (1) 6256**], Dr.
[**Last Name (STitle) 4610**] to follow
Completed by:[**2184-3-27**]
|
[
"427.31",
"288.60",
"416.8",
"401.9",
"396.8",
"427.1",
"397.0",
"285.9",
"997.1",
"E878.1",
"511.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"35.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7695, 7754
|
4153, 6088
|
328, 504
|
7965, 8142
|
2117, 4130
|
8982, 9811
|
1278, 1320
|
6248, 7672
|
7775, 7944
|
6114, 6225
|
8166, 8959
|
1335, 2098
|
271, 290
|
532, 832
|
854, 1043
|
1059, 1262
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,246
| 197,870
|
53294
|
Discharge summary
|
report
|
Admission Date: [**2104-3-1**] Discharge Date: [**2104-3-6**]
Date of Birth: [**2032-11-26**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Buspar / Clonazepam
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Diarrhea and mental status change
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71F s/p [**2104-2-18**] colostomy take down and parastomal hernia
repair by Dr. [**Last Name (STitle) 1120**]. She returns to ED from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with
diarrhea 6 times / day and worsening mental status. Imaging
there revealed dilated loops c/w ileus. White count was 16.8.
She may have had a fever. They were treating the diarrhea with
immodium to no avail. She is c-diff negative x 2. C/o some abd
pain
Past Medical History:
PMH: Lumbar Spinal Stenosis, L sided Sciatica, Lumbar facet
arthritis, s/p bilateral L4-5 and L5-S1 facet blocks, HTN, OA,
diet controlled DM, OSA on BiPAP, ^lipids, GERD, Osteoporosis,
Obesity, Narrow angle glaucoma, Allergic rhinitis, Fibroid
uterus
PSH: Hartmann's takedown ([**2104-2-18**]), sigmoid colectomy,
[**Doctor Last Name 3379**] procedure, end colostomy for perforated sigmoid
diverticulitis [**4-27**], appy, tonsillectomy
Social History:
Former smoker, rare alcohol use, no drugs
Family History:
COPD, CHF, DM
Physical Exam:
PE: 100, 110 to 90 with 1L, 125/53, 18 100RA
A&Ox2, NAD
RRR
CTAB
Abd soft, distended, midline scar c/d/i, ostomy site skin
loosely
closed, minimally ttp
Ext warm, 1+ edema
Pertinent Results:
[**2104-3-1**] 03:25PM BLOOD WBC-14.4* RBC-3.92* Hgb-10.6* Hct-34.0*
MCV-87 MCH-27.0 MCHC-31.1 RDW-12.8 Plt Ct-687*#
[**2104-3-1**] 08:50PM BLOOD WBC-12.2* RBC-3.04* Hgb-8.5* Hct-27.3*
MCV-90 MCH-27.9 MCHC-31.1 RDW-13.2 Plt Ct-596*
[**2104-3-2**] 01:00AM BLOOD WBC-11.3* RBC-3.74* Hgb-10.7*# Hct-34.7*#
MCV-93 MCH-28.6 MCHC-30.8* RDW-13.0 Plt Ct-630*
[**2104-3-2**] 07:29AM BLOOD WBC-11.3* RBC-3.08* Hgb-8.8* Hct-28.4*
MCV-92 MCH-28.6 MCHC-31.0 RDW-13.1 Plt Ct-639*
[**2104-3-3**] 06:20AM BLOOD WBC-10.7 RBC-3.31* Hgb-9.4* Hct-30.3*
MCV-92 MCH-28.4 MCHC-30.9* RDW-12.9 Plt Ct-717*
[**2104-3-4**] 07:00AM BLOOD WBC-11.3* RBC-3.01* Hgb-8.6* Hct-27.2*
MCV-91 MCH-28.6 MCHC-31.6 RDW-12.8 Plt Ct-649*
[**2104-3-1**] 03:41PM BLOOD Lactate-1.5
[**2104-3-2**] 08:52AM BLOOD Lactate-0.9
Brief Hospital Course:
Patient was admitted to the surgical service and initially put
in the intensive care unit secondary to her low blood pressures.
Her pressures improved overnight with IVF resuscitation, she
did not require any pressors. She was transferred to the floor
in the morning. She was kept NPO and treated with IV
levofloxacin and flagyl. Her abdominal pain and diarrhea
improved, she did not have any nausea or vomiting. She was
given occasional narcotics for back pain. She was bolused
overnight on [**3-4**] for low UOP and had a repeat CT scan in the
morning, which showed improved small bowel wall thickening. She
was started on clears which she tolerated well, and advanced to
a regular diet. She was discharged back to rehab tolerating a
regular diet and having bowel function with a 10 day course of
antibiotics (levofloxacin and flagyl).
CT A/P ([**2104-3-1**])
1. Abnormal wall thickening and hyperemia of a proximal small
bowel loop
within the left mid abdomen, with adjacent trace free fluid.
Findings are
concerning for an enteritis that is ischemic, infectious, or
inflammatory.
The patient was also noted to be hypotensive in the Emergency
Department, and
findings may reflect sequela of hypoperfusion. There is
lateralization of
this loop of bowel relative to the colon, which may reflect
expected
post-surgical distortion of the anatomy following take down of
the colostomy.
However, an internal hernia may have a similar appearance.
2. Mild dilation of small bowel loops diffusely, without a
discrete
transition point identified to confirm small-bowel obstruction;
findings may
reflect an ileus.
3. Small foci of extraluminal air seen within the pelvis
anteriorly, atypical
given the time course of surgery. Clinical correlation
suggested.
4. New T12 compression fracture.
5. Fibroid uterus.
CT A/P ([**2104-3-4**])
1. No evidence of abscess. Mesenteric stranding and increased
fluid, likely
post-surgical, but attention on followup is recommended.
2. Diverticulosis, without evidence of acute inflammation.
3. Focus of gas in the bladder, likely due to Foley placement.
Clinical
correlation is suggested.
4. Mild small bowel dilatation, without evidence of obstruction.
Medications on Admission:
1. Diovan 320 mg Tablet Sig: One (1) Tablet PO once a day.
2. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
3. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for back pain.
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Diltiazem HCl 180 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
6. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO three times
a day.
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO four times
a day.
8. Ranitidine HCl 300 mg Tablet Sig: 1-2 Tablets PO once a day.
Discharge Medications:
1. Diovan 320 mg Tablet Sig: One (1) Tablet PO once a day.
2. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
3. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for back pain.
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Diltiazem HCl 180 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
6. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO three times
a day.
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO four times
a day.
8. Ranitidine HCl 300 mg Tablet Sig: 1-2 Tablets PO once a day.
9. bipap auto
Settings 16/12 with heated humidification. Patient's current
machine is broken beyond repair, needs new one.
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Dehydration
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
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.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1120**] as previously planned.
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2104-3-21**] 12:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2104-4-14**] 2:40
Completed by:[**2104-3-6**]
|
[
"250.00",
"733.00",
"038.9",
"530.81",
"278.00",
"721.3",
"558.9",
"401.9",
"327.23",
"995.92",
"560.1",
"293.0",
"276.52",
"785.52",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6310, 6383
|
2395, 4588
|
326, 333
|
6439, 6439
|
1592, 2372
|
7306, 7720
|
1369, 1384
|
5280, 6287
|
6404, 6418
|
4614, 5257
|
6587, 7283
|
1399, 1573
|
253, 288
|
361, 831
|
6454, 6563
|
853, 1293
|
1309, 1353
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,111
| 104,809
|
35005
|
Discharge summary
|
report
|
Admission Date: [**2175-12-11**] Discharge Date: [**2175-12-23**]
Date of Birth: [**2092-8-31**] Sex: F
Service: MEDICINE
Allergies:
Atorvastatin / Celebrex
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 83-year-old woman with chronic diastolic CHF
(LVH, EF 75%), chronic atrial fibrillation on anticoagulation,
severe pulmonary hypertension, diabetes, hypertension,
dyslipidemia, and metastatic thyroid cancer undergoing
cyberknife therapy, who presents to the ED today with complaints
of 20-pound weight gain over the last two weeks and increasing
shortness of breath, dyspnea on exertion, orthopnea, and PND.
She denies any palpitations, presyncope, or syncope. She was
evaluated by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2175-11-6**], at which
point her digoxin was stopped due to her normal EF and her
Lopressor was changed to Toprol XL and the dose was doubled. She
subsequently has been undergoing CyberKnife therapy for her
metastatic thyroid cancer, completing treatment [**4-16**] today. She
complained of progressive symptoms and was referred in to the ED
for further evaluation.
.
In the ED: VS - HR 130s, BP 80/54, Weight 148lbs (up from
124lbs). Her baseline SBPs are known to be in the 100s. ECG
showed AFib w/ RVR. CXR showed no significant effusion,
pneumothorax, or focal consolidation. She had a shock ultrasound
that was negative and was started on Neosynephrine for her
hypotension. She received Ceftriaxone as empiric coverage given
concern for sepsis contributing to her hypotension and possible
underlying pneumonia. She was seen by the CCU team in the ED and
started on an Esmolol drip and IV Digoxin. Esmolol and
Neosynephrine were titrated up and she received 1 more dose of
IV Digoxin. She was also hypoxic, with room air ABG 7.35/51/61.
She did not tolerate BiPAP so she was transitioned to NRB. She
is being admitted to the CCU for further care.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
PAST CARDIAC HISTORY:
1. Chronic Diastolic Heart Failure: EF 75%
2. Atrial Fibrillation on Coumadin
3. Severe pulmonary hypertension
.
OTHER PAST MEDICAL HISTORY:
4. Type 2 DM: complicated by diabetic retinopathy and peripheral
neuropathy
5. Hyperlipidemia
6. Chronic Lymphedema with multiple lower extremity ulcers
7. Goiter: prior Radioiodine therapy, followed Dr. [**Last Name (STitle) 80040**]
8. GERD
9. Crohn's Disease
10. Cholelithiasis - seen on U/S in past, no previous sx.
11. Achalasia
12. Sleep Apnea: h/o abnormal overnight pulse oximetry, but
large thryoid goiter obstructs depending upon patient position
.
PAST SURGICAL HISTORY:
1. TAH-BSO
2. Tonsillectomy
3. Cataract surgery
Social History:
Widowed. Lives in [**Location 3915**], MA in an apartment by herself. Her
son, [**Name (NI) **] leaves nearby, as do multiple grandchildren. Remote
smoking history, occasional alcohol consumption, no illicit
drugs.
Family History:
Father with coronary artery disease,
Two children and five grandchildren alive and healthy
Daughter with hyperthyroidism
Physical Exam:
VS: afeb, BP= 90s/40s, HR= 110s-130s, RR= 14-18, O2 sat= 96-99%
NRB
GENERAL: WD/WN elderly woman in moderate respiratory distress.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink,
no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with significant JVD to just below the angle of the
jaw. Large firm multinodular mass in the thyroid area. Carotid
upstrokes normal in volume and contour, without bruits. Trachea
is midline but not highly mobile. Tachycardia sensitive to
Carotid Sinus Massage.
CARDIAC: PMI located in 5th intercostal space, anterior axillary
line. Irregularly irregular. Normal S1, widely split S2 w/
prominent P2, no S3 or S4. +[**2-16**] HSM at apex.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
tachypneic but unlabored, mild accessory muscle use. +Crackles
and decreased breath sounds at the bases bilaterally. No rhonchi
or wheezes.
ABDOMEN: +BS, soft/NT/ND. Mildly obese. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: WWP, 2+ pedal edema bilaterally, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] in
compressive wrappings.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: Awake, A&Ox3, mood and affect appropriate. Fluently
conversant w/ no focal neurologic abnormalities.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+ Radial 2+
Left: Carotid 2+ DP 2+ PT 2+ Radial 2+
Pertinent Results:
ADMISSION LABS:
[**2175-12-11**] 11:30AM WBC-4.6 RBC-4.15* HGB-10.5* HCT-33.0* MCV-79*
MCH-25.3*# MCHC-31.8 RDW-17.5*
[**2175-12-11**] 11:30AM GLUCOSE-82 UREA N-72* CREAT-1.4* SODIUM-139
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
[**2175-12-11**] 11:45AM PT-26.2* PTT-32.8 INR(PT)-2.6*
.
Cardiac enzymes:
[**2175-12-11**] 11:45AM CK(CPK)-62
[**2175-12-11**] 11:45AM cTropnT-<0.01
[**2175-12-11**] 08:00PM cTropnT-<0.01
[**2175-12-11**] 08:00PM CK(CPK)-49
.
Thyroid labs:
[**2175-12-11**] 08:00PM T4-9.2 FREE T4-1.7
[**2175-12-11**] 08:00PM TSH-0.067*
.
.
Labs on Transfer:
[**2175-12-21**] 05:31AM BLOOD PT-55.3* PTT-37.2* INR(PT)-6.5*
[**2175-12-21**] 05:31AM BLOOD Glucose-177* UreaN-86* Creat-1.5* Na-143
K-4.4 Cl-95* HCO3-38* AnGap-14
.
.
CARDIOLOGY:
.
EKG [**2175-12-11**]
Atrial fibrillation with rapid ventricular response. Right axis
deviation.
Low limb lead QRS voltage. RSR' pattern in lead VI. Persistent
prominent
S waves in the left precordial leads. Modest right precordial
lead T wave
changes. Findings are consistent with right ventricular
hypertrophy/right
ventricular overload. Clinical correlation is suggested. No
previous tracing
available for comparison.
.
TTE [**2175-12-12**]
IMPRESSION: Markedly dilated right ventricle with moderate
global hypokinesis and relative sparing of the basal right
ventricular segments. Preserved left ventricular regional and
global systolic function. Severe diastolic dysfunction. Moderate
to severe pulmonary hypertension. Mild aortic and moderate
mitral regurgitation.
.
.
RADIOLOGY:
CXR ([**2175-12-12**]):
FINDINGS: Large right thyroid masses again appreciated with
calcification and leftward deviation of the trachea. Numerous
rounded masses within the chest bilaterally are again depicted
consistent with known metastatic disease. No significant
effusion or pneumothorax is detected. Double density with regard
to the cardiac shadow is consistent with a large hiatal hernia.
No focal consolidation to suggest pneumonia is detected.
.
CTA Chest ([**2175-12-13**]):
IMPRESSION:
1. No pulmonary embolism. Large pulmonary artery measuring 3.4
cm, greater
than the aorta. The heart is enlarged with large atria
bilaterally, right
ventricle greater than the left, although this has not changed
in appearance since [**8-14**]. Septal thickening consistent with fluid overload.
3. Large pleural effusions, right greater than left, much worse
than in
[**Month (only) **]. Significant right and left lower lobe atelectasis.
4. Numerous metastatic pulmonary nodules as before.
5. Hiatal hernia.
.
CT Chest ([**12-21**]): pending
Brief Hospital Course:
ASSESSMENT AND PLAN: 83-yo woman w/ chronic dCHF (LVH, EF 75%),
chronic A-fib on anticoagulation, severe pulm HTN, DM, HTN, HL,
and metastatic thyroid Ca s/p CyberKnife therapy, p/w 20-pound
weight gain x2 weeks and progressively worsening SOB and DOE,
found to be in A-fib w/ RVR in the ED, hypotensive, and hypoxic,
admitted to the CCU, improved w diuresis and transferred
temporarily to regular floor. Readmitted to CCU for hypercarbic
respiratory failure improved on BiPaP. Diltiazem had been used
for rate control - beta blockers were discontinued given concern
for ?contribution to respiratory decompensation on the floor.
She was empirically started on vancomycin and zosyn for possible
HAP on [**12-20**]. She was transfered to the MICU at the request of
the patient's family.
.
# Hypercarbic/hypoxemic respiratory failure: Multiple potential
etiologies, in part secondary to her hypervolemia as well as
known pulmonary hypertension, cardiogenic pulmonary edema.
Pulmonary consult was following the patient, then the patient
was transfered to the MICU. Considered tapping pleural
effusions, but determined to be technically difficult as the
patient had elevated INR. The patient was aggressively diuresed
with lasix drip. The patient was continued on BiPAP and was
able to be weaned to NC only. Neurology was consulted,
paradoxical breathing could be result of myopathy. However, the
patient decided after much discussion that she desired to have
comfort measures only. The patient was made comfortable,
underwent respiratory arrest and cardiac arrest in minutes
following.
.
#. PUMP: Pt w/ known chronic dCHF (LVH and EF 75%), p/w acute
exacerbation in the setting of afib with RVR. She was
overloaded on exam and was responsive to a lasix drip with
improvement in volume status. TTE showed EF 70-75%, markedly
dilated RV w/ moderate global HK, preserved LV regional and
global systolic function, severe diastolic dysfunction, moderate
to severe pulmonary hypertenion. Given hypotension and mild
acute renal failure, lasix drip was continued with 1-1.5 L net
diuresis daily. Spironolactone was also continued at home dose.
With improvement in her volume status, she was transferred to
the regular floor, however, readmitted to CCU for
hypercarbic/hypoxemic respiratory failure. Pt i/o slightly net
negative, but unable to adequately diurese secondary to
hypotension. Nonetheless, the patient appears volume
overloaded, restarted on lasix gtt yesterday. Continued lasix
gtt, then switched to bolus lasix.
.
# RHYTHM: Pt was noted to have chronic atrial fibrillation, no
previous attempts at cardioversion. She was in a-Fib w/ RVR on
presentation to ED, w/ hypotension as below, in setting of
worsening symptoms since stopping Digoxin and uptitrating Toprol
XL. Low TSH also suggested a contribution of thyrotoxicity
secondary to CyberKnife therapy for thyroid cancer. She was
started on Esmolol gtt which was titrated to max in ED. Also
given IV Digoxin 250mg x 2 in ED. Upon arrival to CCU,
Diltiazem bolus + gtt were started with good effect, and esmolol
was titrated off. No more digoxin was given. Rate was
subsequently well controlled on PO and diltiazem, which were
increased for goal HR <80. Coumadin was continued but INR
became supratherapeutic. Now s/p diltiazem and esmolol drips on
PO diltiazem and metoprolol with HR 90-100. Low TSH suggests
probable contribution from thyrotoxicity likely from CyberKnife
therapy to thyroid cancer. Due to supratherapeutic INR,
coumadin was d/c'd.
.
# CORONARIES: No known CAD, but w/ many risk factors.
.
# HYPOTENSION: Pt w/ SBP 80s-90s in ED in the setting of RVR,
and neosynephrine was started for BP support while on
rate-controlling agents. She continued to mentate well even
though hypotensive. She was briefly febrile, but no infection
was identified and sepsis was considered unlikely. Random
cortisol was high, ruling out adrenal insufficiency as a cause.
Hypotension was attributed to poor forward flow from acute on
chronic diastolic CHF and A-Fib/RVR. Blood pressure improved
with rate control and diuresis. Now low normal BP with
fluctuating mentation. Low UOP on lasix drip, ultrafiltration
was considered.
.
# ACUTE RENAL FAILURE: Likely [**1-15**] poor forward flow from
A-Fib/RVR. Will likely improve with HR control and diuresis.
Urine lytes c/w prerenal physiology. Renal following.
.
# DIABETES: On oral meds at home for glycemic control. ISS while
inpatient.
.
# CROHN'S DISEASE: continued home Pentasa, PPI.
.
# SUPRATHERAPEUTIC INR: Pt on coumadin for a-fib, but INR now >
6, unclear etiology.
.
# ETHICS: Pt was DNR/DNI, but family says pt confused. Patient
says "I want to die" but son wants full code. Had family meeting
with PCP and endocrinology. Ethics following. She has a
tortuous trachea - ENT has eval'd think intubation would not be
problem[**Name (NI) 115**]. Family meetings- pt to remain full code for now and
aggrees to trial intubation if needed. Pt eventually CMO.
Medications on Admission:
- Lasix 60mg PO daily
- Glyburide 2.5mg PO daily
- Lisinopril 2.5mg PO daily
- Lorazepam 0.5mg PO daily
- Pentasa 1000mg PO BID
- Toprol XL 200mg PO daily
- Omeprazole 40mg PO daily
- Spironolactone 25mg PO daily
- Warfarin 5mg PO daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2175-12-26**]
|
[
"362.01",
"416.8",
"530.81",
"427.31",
"530.0",
"414.01",
"241.0",
"518.81",
"V58.61",
"555.9",
"519.19",
"250.50",
"272.4",
"193",
"428.33",
"357.2",
"486",
"584.9",
"707.03",
"E934.2",
"327.23",
"250.60",
"707.22",
"790.92",
"428.0",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12915, 12924
|
7596, 12594
|
313, 319
|
12975, 12984
|
4963, 4963
|
13040, 13215
|
3399, 3521
|
12882, 12892
|
12945, 12954
|
12620, 12859
|
13008, 13017
|
3102, 3151
|
3536, 4944
|
5285, 7573
|
254, 275
|
347, 2435
|
4979, 5268
|
2620, 3079
|
3167, 3383
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,125
| 104,374
|
4502
|
Discharge summary
|
report
|
Admission Date: [**2103-7-11**] Discharge Date: [**2103-7-16**]
Service: ACOVE Medicine Service
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
woman with severe chronic obstructive pulmonary disease (with
an FEV1 of 0.62) who presented on the day of admission with
increased shortness of breath and lethargy times one day.
The patient has had multiple chronic obstructive pulmonary
disease exacerbations in the past. In the Emergency
Department, the patient's initial arterial blood gas was pH
of 7.21, PCO2 of 113, and PO2 was 76. She was given
Solu-Medrol and started on [**Hospital1 **]-level positive airway pressure
and was sent the [**Hospital Ward Name 332**] Intensive Care Unit. [**Hospital1 **]-level
positive airway pressure was not successful. She was changed
to nasal cannula with only 2 liters of oxygen producing an
oxygen saturation of 92%. She had no fevers or chills on
history, and no focus of infection was found on examination
other than thrush, for which she was given a dose of
fluconazole.
The patient was continued on Solu-Medrol in house. It was
converted to prednisone upon transfer from the [**Hospital Ward Name 332**]
Intensive Care Unit to the floor on [**7-14**]. She was started
on levofloxacin and continued on nebulizers and puffers. She
was clinically much improved when she was called to the
floor.
The patient also has a history of syndrome of inappropriate
secretion of antidiuretic hormone with her sodium during this
admission dropping from 137 to 132. She had been receiving
gentle intravenous fluids but was changed to a fluid
restriction. She also has a history of hypertension and
started having right shoulder pain on [**7-13**] at 11 a.m.
An electrocardiogram revealed V1 through V2 ST elevations;
consistent with otherwise old changes. Cardiac enzymes were
positive for a troponin leak to 3.2. She had no chest pain
currently at the time of transfer to the floor.
PAST MEDICAL HISTORY:
1. Severe chronic obstructive pulmonary disease.
2. Syndrome of inappropriate secretion of antidiuretic
hormone.
3. Seizures.
4. Dementia.
5. Hypertension.
6. Colon cancer; status post resection.
7. Osteoarthritis.
8. Iron deficiency anemia.
SOCIAL HISTORY: She lives at home with four children. A
20-pack-year tobacco history, second-hand [**Month (only) **] from her
children.
MEDICATIONS ON ADMISSION: Salmeterol, Combivent, aspirin,
calcium carbonate, multivitamin, Colace, vitamin D, and salt
tablets, Fosamax, and Detrol.
ALLERGIES: DOXYCYCLINE.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on transfer to the floor revealed vital signs were stable.
She was afebrile. Saturating 90% to 97% on 1 liter nasal
cannula. In general, in no apparent distress. Head, eyes,
ears, nose, and throat examination revealed extraocular
movements were intact. Pupils were equal, round, and
reactive to light and accommodation. The mucous membranes
were moist. The oropharynx was clear. The neck was supple.
No jugular venous distention, bruits, or lymphadenopathy.
Chest examination revealed decreased breath sounds.
Increased expiratory phase. Positive coarse breath sounds.
No crackles. Cardiovascular examination revealed a regular
rate and rhythm. Normal first heart sounds and second heart
sounds. No murmurs, rubs, or gallops. The abdomen revealed
positive bowel sounds. Soft, nontender, and nondistended.
Extremity examination revealed no clubbing, cyanosis, or
edema. Neurologically, alert and oriented to person and
place but not to date.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratory data revealed white blood cell count was 11,
hematocrit was 35.7, and platelets were 314. Glucose was 98,
sodium was 132, potassium was 4.5, chloride was 91,
bicarbonate was 37, blood urea nitrogen was 9, and creatinine
was 0.4. Magnesium was 2.2.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXACERBATION AND
TRACHEOBRONCHITIS: The patient was continued on a prednisone
taper, her nebulizers, and puffers. She was continued on
antibiotics for a total of five days.
2. QUESTION OF CORONARY ARTERY DISEASE: The patient did
have a positive troponin while in house. She was not started
on a beta blocker given her severe chronic obstructive
pulmonary disease. She was continued on aspirin.
Because of her debilitated state and severe chronic
obstructive pulmonary disease, she would not be a candidate
for any cardiac intervention, so the plan was made to
medically manage her to the best possibility.
3. SYNDROME OF INAPPROPRIATE SECRETION OF ANTIDIURETIC
HORMONE: The patient's sodium was followed while in house.
Fluid restrictions were maintained. Her sodium improved
while in house and was normal at the time of discharge.
4. DEMENTIA: Her dementia remained at baseline throughout
her hospital stay.
5. HYPERTENSION: The patient's hypertension was stable,
and she did not require any medications at the time of this
hospitalization.
6. ANEMIA: The patient's hematocrit levels were followed,
and they remained stable.
7. THRUSH: The patient was continued on clotrimazole
troches for her thrush.
8. PROPHYLAXIS: The patient received prophylaxis with
subcutaneous heparin for deep venous thrombosis, with
famotidine for gastrointestinal prophylaxis, and with calcium
and vitamin D for steroid-induced osteoporosis prophylaxis.
9. CODE STATUS: The patient's code status was to remain at
full status. After discussion with the family, this was
confirmed.
10. FLUIDS/ELECTROLYTES/NUTRITION: The patient was fluid
restricted. She tolerated a regular diet. Her electrolytes
were repleted.
DISCHARGE DISPOSITION: Given the patient's baseline clinical
condition, the decision was made to discharge the patient to
home.
DISCHARGE STATUS: Discharge status was to home with
services.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease
exacerbation/tracheobronchitis.
2. Coronary artery disease.
3. Mild dementia.
4. Urinary hesitancy.
5. Syndrome of inappropriate secretion of antidiuretic
hormone.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg by mouth once per day.
2. Calcium carbonate 500 mg by mouth twice per day.
3. Multivitamin one tablet by mouth every day.
4. Docusate 100 mg by mouth twice per day.
5. Detrol 1 mg by mouth every day.
6. Vitamin D 400 International Units by mouth every day.
7. Flovent 110-mcg inhaler 3 puffs inhaled twice per day
8. Albuterol as needed.
9. Albuterol nebulizers as needed.
10. Ipratropium nebulizers as needed.
11. Levofloxacin 250 mg by mouth q.24h. (times two more
days).
12. Salmeterol 2 puffs inhaled twice per day.
13. Sodium chloride 1-g tablets one tablet by mouth once per
day.
14. Prednisone taper 40 mg by mouth once per day times two
days; then 30 mg by mouth once per day times three days; then
20 mg by mouth once per day times three days; then 10 mg by
mouth once per day times three days; and then 5 mg by mouth
once per day.
15. Nystatin oral solution 5 mL by mouth four times per day
as needed (for thrush).
16. Home oxygen to keep oxygen saturations at 92% to 94%.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with her primary care
physician in less than one week.
2. The patient was to continue a 2-g sodium diet with fluid
restriction of 1500 mL.
3. [**Hospital6 407**] was requested for symptom
management and compliance with medications, diet, and fluid
restriction.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 910**]
Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36
D: [**2103-9-6**] 16:51
T: [**2103-9-15**] 04:31
JOB#: [**Job Number 19229**]
|
[
"112.0",
"294.8",
"253.6",
"410.71",
"280.9",
"715.90",
"518.84",
"491.21",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5713, 5883
|
5904, 6115
|
6142, 7167
|
2391, 3877
|
7200, 7741
|
3912, 5689
|
135, 1951
|
1973, 2224
|
2241, 2364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,096
| 174,784
|
33901
|
Discharge summary
|
report
|
Admission Date: [**2123-6-23**] Discharge Date: [**2123-6-25**]
Date of Birth: [**2070-10-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Transfer from OSH after being found unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 78337**] is a 52M with a PMH s/f OSA, HTN, and dyslipidemia
who was transferred to the [**Hospital Unit Name 153**] from an OSH on [**2123-6-23**] for
management of a PEA arrest. History is taken from the patients
family, as the patient is unconscious. The patient was found
sleeping in his home after heavy alcohol and drug use by his
family members. When his breathing seemed to stop, EMS was
called, and on arrival was found to be asystolic. He was
intubated in the field, and received CPR, epinephrine, and
atropine. Upon arrival to the OSH he regained a pulse after 20
minutes of CPR, with a HR of 20 BPM. He was started on
dopamine. Initial labs were notable for an alcohol level of
300; a salicylate level of 4.1; and a urine tox positive for
marijuana and opiates. A neurology consult was called, and
found the patient to have absent brainstem reflexes, consistent
with anoxic brain injury. CT scan of the head confrimed a
diffuse loss of [**Doctor Last Name 352**]-white differentiation.
Past Medical History:
HTN
Hyperlipidemia
Gout
OSA
Anxiety
Asthma
Seasonal allergies
Social History:
Notable for ETOH and marijuana abuse. No tobacco use.
Family History:
NC
Pertinent Results:
CT head:
Markedly abnormal head CT, with diffuse cerebral edema and basal
ganglial hypodensity concerning for global ischemia. There is
also suggestion of possible downward tonsillar herniation. MRI
would be helpful for further evaluation. This was discussed with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24692**] immediately following completion of the
study. Marked paranasal sinus oapciifcation
.
[**2123-6-23**] 10:32PM PT-14.1* PTT-27.4 INR(PT)-1.2*
[**2123-6-23**] 10:32PM PLT COUNT-218
[**2123-6-23**] 10:32PM NEUTS-86.2* LYMPHS-7.6* MONOS-6.0 EOS-0.1
BASOS-0.1
[**2123-6-23**] 10:32PM WBC-22.1* RBC-5.05 HGB-14.9 HCT-44.6 MCV-88
MCH-29.4 MCHC-33.3 RDW-13.8
[**2123-6-23**] 10:32PM OSMOLAL-305
[**2123-6-23**] 10:32PM ALBUMIN-3.8 CALCIUM-7.3* PHOSPHATE-3.7
MAGNESIUM-1.5*
[**2123-6-23**] 10:32PM ALT(SGPT)-346* AST(SGOT)-394* ALK PHOS-105
TOT BILI-0.3
[**2123-6-23**] 10:32PM estGFR-Using this
[**2123-6-23**] 10:32PM GLUCOSE-151* UREA N-35* CREAT-3.6* SODIUM-143
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-18* ANION GAP-18
[**2123-6-23**] 11:07PM LACTATE-1.7
[**2123-6-23**] 11:07PM TYPE-ART TEMP-37.8 RATES-25/32 TIDAL VOL-500
PEEP-5 O2-60 PO2-285* PCO2-39 PH-7.31* TOTAL CO2-21 BASE XS--6
-ASSIST/CON INTUBATED-INTUBATED
Brief Hospital Course:
Upon arrival to the [**Hospital Unit Name 153**] the patient was found to be
unresponsive. A neurology consult was called, and the patient
was found to have absent brain stem reflexes including cold
calorics, doll's eye, corneals, gag, and cough. He had fixed
dilated pupils, areflexia, and was unresponsive to noxious
stimuli. A head CT was consistent with anoxic brain injury with
impending tonsillar herniation. The patient was initially
managed with HOB elevation and mannitol, however given his grim
prognosis, and lack of response to treatment at 48hrs, the
family decided to withdrawl care.
Medications on Admission:
-Temazepam
-Advil
-Zyrtec
-Lorazepam
-Colchicine
-Nadolol
-Protonix
-Nifedipine
-Simvastatin
-HCTZ
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
[
"305.00",
"327.23",
"305.20",
"584.9",
"348.5",
"518.81",
"401.9",
"348.39",
"272.0",
"348.1",
"272.4",
"305.50",
"780.01",
"572.8",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3717, 3726
|
2924, 3527
|
364, 370
|
3785, 3802
|
1625, 1625
|
3866, 3884
|
1602, 1606
|
3677, 3694
|
3747, 3764
|
3553, 3654
|
3826, 3843
|
276, 326
|
398, 1428
|
1634, 2901
|
1450, 1514
|
1530, 1586
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,117
| 118,144
|
49818
|
Discharge summary
|
report
|
Admission Date: [**2148-6-1**] Discharge Date: [**2148-6-17**]
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman
with history of myelodysplastic syndrome and recent pneumonia
who completed a course of levofloxacin and who complained of
greenish watery diarrhea times one week and crampy diffuse
abdominal pain. She was admitted on [**2148-4-15**] with
shortness of breath and cough and also noted chills and low
grade temperature in the Emergency Room. Her saturations
dropped to 90% on room air. She was treated for pneumonia
with symptomatic improvement. On the day after admission,
her hematocrit dropped from 20 to 7 to 20 and she was
transfused two units of packed red blood cells. She had
guaiac negative stool. Hemolysis laboratories were negative.
She was sent to the [**Hospital3 2558**] for [**Hospital 3058**]
rehabilitation on [**5-18**]. She reports that after one week at
the [**Hospital3 2558**] she began having loose foul smelling
stools as frequently as seven times in an hour. This did not
resolve with Imodium per the OMR notes and she was sent to
the [**Hospital6 256**] Emergency
Department. She denied fever, chills and vomiting. She has
been taking po. Denies chest pain or shortness of breath.
She was weak and fatigued. Her abdominal pain was diffuse
but worse on the left side and not always relieved by bowel
movements. She had 15 bowel movement on the day of
admission.
PAST MEDICAL HISTORY:
1. Myelodysplastic syndrome.
2. Hypertension.
3. Gout.
4. Asthma.
5. Gastroesophageal reflux disease.
6. History of atypical chest pain.
7. Fibroadenomas of the left breast.
8. Hypothyroidism.
9. Incontinence.
10. Status post total knee replacement.
ALLERGIES: NSAIDs and aspirin.
MEDICATIONS: Levaquin, Protonix, Lisinopril, albuterol,
Tylenol, Serevent, Epogen, hydrochlorothiazide, allopurinol
and diltiazem.
PHYSICAL EXAM ON ADMISSION: Temperature 99.6. Pulse 72.
Blood pressure 130/50. Respirations 18, 02 saturation 98% on
room air. Head, eyes, ears, nose and throat: Pupils equal,
round and reactive to light. Extraocular movements intact.
Appears older than her stated age. Heart: Regular rate and
rhythm, 3/6 systolic murmur throughout. Abdomen is diffusely
tender to deep palpation with guarding, question rebound.
Per Emergency Department, stool guaiac negative. Green and
yellow and copious. Bruises throughout her extremities, 2+
pitting edema in the lower extremities. Alert and oriented
times three, moves all four extremities.
LABORATORIES ON ADMISSION: Notable for white blood cell
count of 9.4, hematocrit of 25.1 and platelets of 60,000.
Her BUN was 48, creatinine 2.0 and bicarbonate was 17. LFTs
were normal. Lactate was 3.6.
HOSPITAL COURSE: She was admitted on [**6-1**] with acidosis,
elevated lactate and gram negative stool and started on
levofloxacin and Flagyl for infectious versus ischemic
colitis. Abdominal CT revealed trace ascites and pan
colitis. C. difficile toxins were negative. She received
intravenous fluid and packed red blood cells and PICC line
was placed on [**6-5**]. Over [**6-5**] to [**6-6**], her urine
output dropped and her blood pressure dropped to 100/60.
Levofloxacin was started for positive urinalysis, but blood
pressure did not respond to boluses or normal saline.
Therefore, she was transferred to the Medical Intensive Care
Unit where she was switched to intravenous Flagyl and po
vancomycin for better C. difficile coverage, as well as
intravenous vancomycin because of Methicillin resistant
Staphylococcus aureus from her PICC line. She developed
extremity erythema believed to be secondary to trauma.
Levophed was started because of low blood pressures. Trial
steroids were discontinued because they did not appear to be
helping. Repeat abdominal CT showed resolving colitis. She
was made "Do Not Resuscitate, Do Not Intubate" on [**2148-6-10**] and Levophed was weaned off. Head CT was negative on
[**6-11**] because of mental status and echocardiogram revealed
no vegetations. She was then transferred to the floor on
[**2148-6-13**] in stable condition and on the floor, her mental
status improved over the next few days. When she was
transferred to the floor, she was not talkative and appeared
very agitated, whereas, on the floor, she became alert and
oriented times three and was not in any acute distress. Her
nasogastric tube was repositioned and she was able to tube
feeds which she tolerated well and TPN was discontinued.
Plans were made for transfer to rehabilitation and Physical
Therapy and Case Management were consulted. She continued
her course of vancomycin, Flagyl and levofloxacin and on [**2148-6-17**], she had increased secretions, which improved after
respiratory suction. There was no evidence of green dye from
the tube feeds in the suction secretions. Her 02 saturations
remained stable and she had not complained of chest pain or
discomfort. The plan was made for a swallowing study to
evaluate for the patient to advanced to po tube feeds and
discontinue the nasogastric tube. Chest x-ray revealed
bilateral pleural effusions and bilateral lower lobe
opacities. The right pleural effusion appeared possibly
larger than the previous one, however, the chest x-ray was PA
and lateral versus portables on prior films. At 5 p.m., the
nurse went into the room and checked on the patient and she
was conversant and had had recent stable vital signs at 4
p.m. with a systolic blood pressure in the 130s. She had no
complaints at that time, but after a few minutes became
unresponsive. Her oxygen saturation was in the 70s at this
point and the house officer was called. When he arrived, she
was unresponsive and had agonal breathing at 5:10 p.m. He
was able to palpate a pulse in her carotid arteries only.
She had breath sounds in both lungs fields, but they were
diminished. Her pupils were fixed and dilated at this point
and she quickly lost her pulse. The oxygen saturation meter
was not [**Location (un) 1131**] properly and an arterial blood gas attempt
was unsuccessful. Code was not called because the patient
had been "Do Not Resuscitate, "Do Not Intubate." She
appeared comfortable and was pronounced dead at 5:20 p.m.
without breath sounds, heart sounds, pulse, with fixed and
dilated pupils. The attending, Dr. [**Last Name (STitle) **], and the son were
called and the son and family members came in to view the
body.
DISCHARGE DIAGNOSIS: Probable etiologies for this acute
event in unclear, however, because of the quick change in
mental status to unresponsiveness and the manner of the
breathing, a central nervous system bleed is in the
differential diagnoses with her history of thrombocytopenia
with platelet count around 20,000. Other possibilities
include pulmonary embolism, myocardial infarction or massive
aspiration, however, there was no evidence of increased
secretions when suctioning was performed. We are encouraging
the family to consider an autopsy at this time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21189**], M.D. [**MD Number(1) 41641**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2148-6-20**] 16:13
T: [**2148-6-20**] 16:13
JOB#: [**Job Number **]
|
[
"038.11",
"557.9",
"287.3",
"276.5",
"584.9",
"785.59",
"599.0",
"238.7",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"89.61",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6492, 7304
|
2786, 6470
|
139, 1468
|
2588, 2768
|
1490, 1930
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,962
| 172,953
|
33405+57900
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-7-4**] Discharge Date: [**2185-7-16**]
Date of Birth: [**2109-2-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12077**]
Chief Complaint:
Spine surgery for low back pain
Major Surgical or Invasive Procedure:
anterior fusion L3-S1 on [**7-4**]
posterior fusion L3-S1 on [**7-8**]
History of Present Illness:
76 yo male with a h/o hypertension and degenerative lumbar spine
disease s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 77517**] L3-S1 for spinal stenosis; anterior approach
was performed by Dr. [**Last Name (STitle) 1391**] (vascular) due to prior abdominal
surgery. Post-operative course has been complicated by
hypotension requiring neosynephrine. Post-operative I/O's 4.8
liters in (blood + IVF), 1.3 liters out (800 cc UOP, EBL 500
cc). He received cefazolin in OR. Medical consult was initially
called for persistent hypotension, new O2 requirement, with
irregular heart rate. Pre-op BP 140/60, HR 52 in PACU.
.
In the SICU, the patient's HR was controlled with lopressor and
he returned to the OR on [**2185-7-8**] for the second part of his
procedure. On [**2185-7-12**], he had another episode of rapid afib to
the 150's, with desats to the 80's which improved on a NRB to
100%. He was given 5mg lopressor IV x 1 with good response. We
are reconsulted by ortho spine to assist in management of the
patient's afib.
.
Currently, the patient is newly febrile to 101.9, BP 140's
systolic, HR after lopressor is 103. He was transiently
disoriented but later his mental status improved. He denies
shortness of breath, chest pain, abdominal pain or diarrhea.
Past Medical History:
Hypertension
Gout
Lumbar spondylosis and disk degeneration
Social History:
He lives with his wife at home and is able to perform all
activities of daily living. Does not smoke or drink alcohol.
Family History:
Non-contributory
Physical Exam:
Discharge Exam:
S: BP 140/90, HR 70-80s, T 98.9, SpO2 96% RA
Gen: elderly [**Male First Name (un) 4746**], comfortable
HEENT: EOMI, PERRL, sclerae anicteric, MM dry
Neck: no JVD
CV: irregularly irregular
Abdomen: soft mildly ttp, no rebound or guarding
Extrem: no clubbing, cyanosis, edema; no calf tenderness or
cords; 2+ radial and DP pulses; moving lower extremities
Skin: NAD
Neuro: nonfocal, oriented x3
Pertinent Results:
[**2185-7-15**] 06:00AM BLOOD WBC-7.7 RBC-3.20* Hgb-9.6* Hct-28.7*
MCV-90 MCH-29.9 MCHC-33.4 RDW-14.1 Plt Ct-488*
[**2185-7-13**] 06:15AM BLOOD WBC-15.2* RBC-3.13* Hgb-9.4* Hct-28.7*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.2 Plt Ct-374
[**2185-7-4**] 03:34PM BLOOD WBC-15.0* RBC-3.56* Hgb-11.3* Hct-33.8*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.7 Plt Ct-321
[**2185-7-13**] 06:15AM BLOOD Neuts-86.2* Lymphs-10.3* Monos-3.0
Eos-0.5 Baso-0.1
[**2185-7-9**] 02:53AM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1
[**2185-7-15**] 06:00AM BLOOD Glucose-84 UreaN-9 Creat-0.8 Na-137 K-3.5
Cl-106 HCO3-21* AnGap-14
[**2185-7-4**] 09:19PM BLOOD ALT-19 AST-29 LD(LDH)-196 CK(CPK)-73
AlkPhos-87 Amylase-68 TotBili-1.3
[**2185-7-12**] 09:45AM BLOOD CK-MB-2 cTropnT-<0.01
[**2185-7-5**] 12:56PM BLOOD CK-MB-3 cTropnT-0.02*
[**2185-7-4**] 09:19PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2185-7-15**] 06:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.0
.
CTA CHEST [**2185-7-12**]
1. No evidence for pulmonary embolism.
2. Small bibasilar pleural effusion (slightly increased) and
adjacent
atelectasis.
3. Left hilar lymphadenopathy unchanged since previous study, a
3 months
follow-up chest CT is recommended to ensure stability of this
finding.
.
LE USG on [**2185-7-10**]
No DVT in both legs
.
Xray Abdomen [**2185-7-10**]
Non-obstructive bowel gas pattern.
.
L-spine AP/LAT 7/4/008
INDICATION: Status post fixation.
FINDINGS: Newly performed fixation, screws are in place from
lumbar body 2 to sacral 1. Regular position of the screws, no
screw displacement. No change in alignment.
.
ECHO [**2185-7-5**]
The left atrium is normal in size. The left ventricular cavity
size is normal. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The ascending aorta is moderately dilated. The
aortic valve leaflets are mildly thickened. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
Tissue Vertebral Body [**2185-6-24**]
I. Bone, L5 vertebral body, biopsy (A):
a. Fragments of dense connective tissue (ligament) with
fibrosis and numerous peripheral nerve fibers in association
with remodelled lamellar bone, suggestive of prior injury.
b. Bone marrow with trilineage hematopoiesis.
c. No malignancy or acute osteomyelitis identified.
II. Intervertebral disc (B):
Degenerating fibrocartilage and scant lamellar bone.
.
Brief Hospital Course:
Patient was admitted for scheduled surgery to treat his low back
pain. On [**7-4**] he underwent a partial vertebrectomy of L3, L4 and
L5, and fusion L3-S1 for lumbar spondylosis and disk
degeneration. His post-op course was complicated by hypotension
(SBP down to 70s), increased oxygen requirement and fever. He
was transferred to SICU, where he was found to be in atrial
fibrillation with RVR. He returned to the OR on [**7-8**] for
posterior revision and hardware placement. On [**7-12**] he was
transferred to the medicine service and then discharged to rehab
on [**2185-7-18**].
.
# Spine surgery: He needs to follow up with Dr. [**Last Name (STitle) 363**] in 10
days. Also should discuss with him if he can be on coumadin for
his Afib given his recent back surgery.
.
# Atrial fibrillation with RVR: he went from paroxysmal AFib to
Aflutter to sinus rhythm. He was discharged on Toprol XL with
sinus rhythm in 70-80s. He was kept on ASA and not started on
Coumadin for AFib given his recent spine surgery. He was
agreeable to coumadin and his PCP was aware that this needs to
be started once cleared by his spine surgeon.
.
# UTI and Respiratory distress: Patient became febrile in the
postop period with O2 requirement of 96%/6L. LENI's did not show
DVT and CTA was negative for any pulm embolus. He was kept on
broad spectrum abx for 2 days after which he became afebrile and
his O2 requirement improved. He was eventually found to have
pansensitive Pseudomonas and was started on 14 day course of
Ciprofloxacin (Vanc/Zosyn was d/c'ed).
.
# Delirium: he had some deliriume in the SICU which improved
during the hospitalization. It was thought to be due to his
fevers and hypoxia.
.
# f/u for hilar LAD: His CTA Chest showed enlarged mediastinal
and hilar lymph nodes remain unchanged in size (the largest one
measuring 12.1 mm at left hilar region). Recommend 3 month f/u
CTA Chest.
.
# Prophylaxis: he was started on prophylactic dose of Lovenox;
holding Coumadin due to recent spine surgery (can discuss with
Dr. [**Last Name (STitle) 363**] and his PCP).
Medications on Admission:
Lisinopril 20 mg [**Hospital1 **]
Amlodipine 5 mg daily
Gemfibrozil 600 mg [**Hospital1 **]
Metoprolol 25 mg [**Hospital1 **]
Allopurinol 300 mg daily
Ranitidine 300 mg qHS
ASA
Fishoil
Cranberry pills
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
syringe Injection ASDIR (AS DIRECTED).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day as needed.
16. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 2 weeks: Complete 14 day course with last
dose on [**2185-7-28**].
17. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
18. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
19. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
Clipper Home
Discharge Diagnosis:
Lumbar spondylosis
Post-op blood loss anemia
Post-op hypotension
Atrial fibrillation
Urinary Tract infection
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Do not smoke. Do not lifting anything greater than a gallon of
milk.
.
Please continue to take your Lovenox. We did not start you on
Coumadin for your irregular heart rate because of your back
surgery. You will eventually have to be on Coumadin after your
have been cleared by your Spine surgeon.
.
Please take the antibiotic Ciprofloxacin for your urinary tract
infection. Last dose is on [**2185-7-28**].
.
Please report to your doctors if [**Name5 (PTitle) **] have any shortness of
breath, chest pain, burning urination or any other concerns.
Followup Instructions:
Please follow up in the Spine Clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**].
Please call [**Telephone/Fax (1) 3573**] to schedule an appointment in 10 days.
.
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33344**], in the next few
weeks. Please call to make an appointment with him.
.
CT from [**2185-7-12**]: Left hilar lymphadenopathy unchanged since
previous study, a 3 months follow-up chest CT is recommended to
ensure stability of this finding.
Completed by:[**2185-7-16**] Name: [**Known lastname 12683**],[**Known firstname **] Unit No: [**Numeric Identifier 12684**]
Admission Date: [**2185-7-4**] Discharge Date: [**2185-7-16**]
Date of Birth: [**2109-2-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12685**]
Addendum:
He also had abdominal distension (tympanic, likely from postop
ileus). He started having bowel movements few days before
discharge.
.
He also had [**1-5**]+ lower extremity edema and penile edema. This
had been stable postop. He also got IV fluids for decreased
urine output. This improved his urine output but worsened his
edema. We did not give him any diuretics as he was urinating
well. Diuretics may be started as needed on outpatient basis.
Discharge Disposition:
Extended Care
Facility:
Clipper Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 12686**] MD [**MD Number(2) 12687**]
Completed by:[**2185-7-16**]
|
[
"041.7",
"E878.8",
"401.9",
"995.91",
"721.3",
"599.0",
"560.1",
"V43.64",
"274.9",
"285.1",
"722.52",
"997.5",
"998.59",
"293.0",
"593.9",
"038.43",
"518.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"84.52",
"81.62",
"81.06",
"81.63",
"81.08",
"38.93",
"80.99"
] |
icd9pcs
|
[
[
[]
]
] |
11531, 11711
|
4994, 7064
|
346, 419
|
9302, 9309
|
2422, 4971
|
10111, 11508
|
1959, 1977
|
7316, 9087
|
9170, 9281
|
7090, 7293
|
9333, 10088
|
1992, 1992
|
2008, 2403
|
275, 308
|
447, 1723
|
1745, 1806
|
1822, 1943
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,371
| 136,362
|
31639
|
Discharge summary
|
report
|
Admission Date: [**2146-10-17**] Discharge Date: [**2146-11-1**]
Date of Birth: [**2097-11-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right sided pain, increased cough
Major Surgical or Invasive Procedure:
Bronchoscopy, right thoracoscopy, drainage of right empyema,
partial decortication [**2146-10-18**]
History of Present Illness:
Ms. [**Known lastname **] is a 48 year-old female who was discharged on [**2146-10-15**]
s/p right lower lobectomy for atypical carcinoid tumor (T3N2) on
[**2146-10-10**]. She now presents with severe right sided chest pain
and increased shortness of breath. The chest CT showed a
loculated effusion with right middle lobe opacity. Her white
count was elevated with a shift to the left. She is being
admitted for an emypema with a plan to drain and culture fluid.
Past Medical History:
Hepatitis C s/p interferon and ribavarin therapy
Hypercholesterolemia
Appendectomy
Uterine Suspension
Social History:
Single with 2 adult children. Works as a mental health worker.
Tobacco: quit 25 years ago.
ETOH: denies
Family History:
Significant for sister with thyroid cancer.
Physical Exam:
General: 48 year-old female well-nourished in no apparent
distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, trachea midline, no lymphadenopathy
Resp: breath sounds diminished with rhonchus on right, clear on
left
Card; normal S1,S2, regular, rate & rhythm, no murmur/gallop or
rub
GI; obese, bowel sounds positive, abdomen soft
non-tender/non-distended
Extr; warm no edema
Incision: clean, dry, intact
Neuro: non-focal
Pertinent Results:
Labs on Admission:
[**2146-10-17**]: WBC-26.1*# RBC-4.25 HGB-13.0 HCT-36.8 PLTS: 243
[**2146-10-17**]: GLUCOSE-140* UREA N-12 CREAT-0.8 SODIUM-133
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-26
[**2146-10-17**] 04:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2146-10-17**] PLEURAL TOT PROT-3.5 GLUCOSE-0 LD(LDH)-2112
[**2146-10-17**] PLEURAL PH-6.78
Cultures:
[**2146-10-17**] URINE CULTURE (Final [**2146-10-19**]): KLEBSIELLA PNEUMONIAE.
[**2146-10-17**] 5:00 pm BRONCHIAL BRUSH - PROTECTED BRONCHIAL
LAVAGE-RML/BRONCHIAL PROTECTED BRUSH/RML. GRAM STAIN (Final
[**2146-10-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**2146-10-17**] 5:00 pm PLEURAL FLUID
GRAM STAIN (Final [**2146-10-17**]):
REPORTED BY PHONE TO [**Doctor First Name 275**] [**Doctor Last Name **] @ 1115PM ON [**2146-10-17**].
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN
PAIRS.
FLUID CULTURE (Final [**2146-10-20**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
_________________________________________________________
STAPH AUREUS COAG +
|
CIPROFLOXACIN--------- <=0.5 S
ERYTHROMYCIN---------- 1 I
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2146-10-21**]): NO ANAEROBES ISOLATED.
[**2146-10-18**] 5:10 pm TISSUE RIGHT PLEURAL TISSUE.
GRAM STAIN (Final [**2146-10-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
TISSUE (Final [**2146-10-21**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2146-10-22**]): NO ANAEROBES ISOLATED.
ACID FAST CULTURE (Pending):
ACID FAST SMEAR (Final [**2146-10-19**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2146-10-19**]):
NO FUNGAL ELEMENTS SEEN.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
X-Rays:
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2146-10-17**] 2:50 AM
IMPRESSION:
1. No central or segmental pulmonary emboli.
2. Moderate right-sided pleural effusion, and fluid in the right
lateral chest wall. Extensive subcutaneous emphysema in the
right chest wall.
3. Right middle lobe bronchial distortion, likely post-surgical,
causing right middle lobe atelectasis.
[**2146-10-20**]: PICC Placement: IMPRESSION: Uncomplicated ultrasound
and fluoroscopically guided 5-French double-lumen PICC line
placement via the left brachial venous approach. Final internal
length is 47.5 cm, with the tip positioned in SVC. The line is
ready to use.
CT CHEST W/CONTRAST [**2146-10-29**] 11:43 AM
IMPRESSION:
1. Right-sided pigtail catheter seen within the pleural space
anteriorly. There has been marked decrease in size of the
previously seen loculated right pleural collection with a small
amount of persistent pleural fluid and gas noted.
2. Decrease in size of left pleural effusion. 5-mm nodular
density at the left base likely represents atelectasis, although
attention to this area on followup studies is recommended.
3. Otherwise, no significant change from prior study with
multiple paraesophageal and mediastinal lymph nodes again seen.
CHEST (PA & LAT) [**2146-10-30**] 1:40 PM
No obvious pneumothorax. Loculated effusion on the right side.
The pigtail catheter on the right side appears to have been
removed.
Brief Hospital Course:
Ms [**Known lastname **] is a 48 year-old female readmitted on [**2146-10-17**] with a
loculated effusion and right middle lobe opacity and an elevated
white count. She was seen by interventional pulmonary for a
thoracentesis sent for culture and cytology which grew staph
aureus sensitive to nafcillin. She was seen by the pain service
who recommended PCA Dilaudid and Toradol. On hospital day #2 she
was taken to the operating room on [**2146-10-18**] and underwent
successful right thoracoscopy, drainage of right empyema, with
partial decortication. She transferred to the intensive care
unit intubed, 2 chest-tubes, a foley and IV Dilaudid for pain.
On postoperative day #1 she was extubed and her white count
trended downward from 26 to 12.4. On postoperative day #2 she
had a double lumen PICC line placed in the left brachial vein.
She was transferred to the floor in stable condition. On
postoperative day #3 she was seen by Infectious Disease who
recommended 4 weeks of nafcillin for MSSA. She was followed by
serial chest x-rays that remained stable. The foley was removed
and she voided without difficulty. Physical therapy was
consulted to assist with ambulation. She was converted to PO
pain medication with good pain control. A chest CT without
contrast was done on postoperative day #4. The posterior
chest-tube ([**2143-10-26**])was removed. The basal chest-tube was
converted to a empyema tube. A CT scan on [**10-25**] revealed anterior
right pleural loculation. The patient was sent to Interventional
Radiology for placement of pigtail and TPA was instilled into
the pigtail and empyema tube for 3 consecutive days with a good
response. On [**2146-10-29**] the pigtail and empyema tube were removed.
A follow-up chest x-ray revealed no pneumothorax. A follow-up
chest CT on [**2146-10-29**] showed marked decrease in the size of the
previously seen loculated right pleural collection with a small
amount of persistent pleural fluid and gas noted. She continued
to make steady progress and was discharged to home on
postoperative day #9. She will follow-up with Dr. [**Last Name (STitle) **] as an
outpatient.
Medications on Admission:
Lopressor 12.5 mg [**Hospital1 **]
Clonazepam 0.5 mg qhs
Oxybutynin 10 mg [**Hospital1 **]
Docusate 100 mg [**Hospital1 **]
Ibuprofen 600 mg q8h prn
Darvocet prn
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*0 Tablet(s)* Refills:*0*
2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*0 Tablet(s)* Refills:*0*
3. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) as needed for anxiety.
Disp:*0 Tablet(s)* Refills:*0*
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
Disp:*0 * Refills:*0*
6. Nafcillin 2 gm IV Q6H
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home care Services
Discharge Diagnosis:
Empyema drainage, right, partial decortication [**2146-10-18**]
Right lower lobe lung mas s/p resection [**2146-10-10**]
Hep C s/p interferon/Ribavirin treatment [**2140**]
Hyperlipidemia
Pneumonia [**2142**]
Appendectomy
Uterine Suspension
Discharge Condition:
Stable, good pain control, tolerating diet
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision: purulent discharge, increased redness
Chest-tube site: cover with a clean bandaid
No swimming or bathing for 6 weeks
Complete antibiotic course: through [**2146-11-18**]
PICC line double lumen: Left brachial, 47.5 cm tip positioned in
SVC.
Labs: Weekly CBC, BUN & Cre while on nafcillin: Fax results to
[**Telephone/Fax (1) 1419**] Dr. [**Last Name (STitle) **].
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**11-2**] at
9:30am at [**Hospital 2577**] Medical Building [**Last Name (NamePattern1) **] [**Location (un) **].
Report to the [**Location (un) 470**] [**Hospital Ward Name 517**] Clinical Center Radiology
Department for a Chest x-ray 45 minutes before your appointment.
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 457**]. Infectious Disease on
[**11-14**] at 10:00am at the [**Hospital 2577**] Medical Building
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 185**] [**Telephone/Fax (1) 21566**]
Completed by:[**2146-11-1**]
|
[
"786.3",
"272.4",
"041.3",
"196.9",
"V09.0",
"599.0",
"041.11",
"278.00",
"510.9",
"V15.82",
"511.9",
"070.70",
"162.5",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
8747, 8817
|
5446, 7586
|
311, 413
|
9102, 9147
|
1691, 1696
|
9750, 10409
|
1175, 1220
|
7798, 8724
|
8838, 9081
|
7612, 7775
|
9171, 9727
|
1235, 1672
|
3807, 5423
|
3673, 3774
|
238, 273
|
441, 911
|
1710, 3640
|
933, 1036
|
1052, 1159
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,898
| 126,963
|
40394
|
Discharge summary
|
report
|
Admission Date: [**2144-6-1**] Discharge Date: [**2144-6-5**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2144-6-1**]
Endograft exclusion of ruptured thoracoabdominal aneurysm with a
[**Doctor Last Name 4726**] 40 x 20-mm and 40 x 15-mm stentgraft.
History of Present Illness:
87F w/ no significant PMH that she knows
of, presented to [**Hospital 48951**]Hospital for acute onset of CP
w/ associated nausea and "shakiness." The chest pain woke her
from sleep. She denied any back pain or radiation of pain
elsewhere. Nothing improved nor made the pain worse. She
denied
SOB/Vomit/changes in bowel/bladder function. At [**Location (un) **], CT
was
performed that demonstrated possible thoracic aortic ruptured
aneurysm vs dissection. She was started on esmolol drip and was
transferred to [**Hospital1 18**] for further eval/management.
Past Medical History:
denies
Social History:
denies tobacco, etoh, drugs
Retired dressmaker, lives in [**Location 8957**] w/daughter
Family History:
n/a
Physical Exam:
Expired
Pertinent Results:
[**2144-6-5**] 10:30AM BLOOD
WBC-10.0 RBC-2.47* Hgb-8.1* Hct-22.7* MCV-92 MCH-33.0*
MCHC-35.8* RDW-14.2 Plt Ct-45*#
[**2144-6-5**] 10:30AM BLOOD
PT-18.1* PTT-76.2* INR(PT)-1.6*
[**2144-6-5**] 03:53AM BLOOD
Glucose-255* UreaN-16 Creat-0.7 Na-134 K-4.1 Cl-101 HCO3-23
AnGap-14
[**2144-6-5**] 03:53AM BLOOD
ALT-22 AST-29 LD(LDH)-213 AlkPhos-50 Amylase-86 TotBili-0.9
[**2144-6-4**] 07:45PM BLOOD
Calcium-8.2* Phos-1.6* Mg-2.0
[**2144-6-1**] 12:20PM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]->1.050*
URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-3* WBC-3 Bacteri-NONE Yeast-NONE Epi-0
URINE CULTURE (Final [**2144-6-4**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Pt was transfered to [**Hospital1 18**] on [**6-1**] with contained rupture of
thoracoabdominal aortic aneurysm. She was asymptomatic, and
hemodynamically stable on esmolol gtt. She was evaluated by Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 914**] in the ED and taken emergently to the
operating room where she underwent:
1. Ultrasound-guided puncture bilateral common femoral
arteries.
2. Bilateral catheter placement in thoracic aorta.
3. Thoracic aortogram.
4. Endograft exclusion of ruptured thoracoabdominal
aneurysm with a [**Doctor Last Name 4726**] 40 x 20-mm and 40 x 15-mm stent
graft.
5. Perclose closure of bilateral common femoral
arteriotomies.
She tolerated the procedure well and was taken to the PACU for
recovery. She remained hemodynamically stable with a lumbar
drain in place. From the PACU went to SCIVU, resusitated. Lumbar
drained removed
Transfered to the VICU in stable condition. While in the VICU
became hypoxic. Code called. Pt nonresponsiveness and
cardiopulmonary collapse requiring intubation and transfer to
ICU. Once stabilized patient was taken emergently for CTA
chest demonstrating large mediastinal hematoma causing
compression of LA and pulm veins, pulmonary arteries, the
trachea and airways, and the left brachiocephalic vein. No
active extravasation was seen.
Thoracic surgery consulted for VATS evacuation of hematoma.
Patient taken to OR and underwent VATS to drain right chest and
mediastinum. Patient continued to
require blood products and increasing inotropic support. Left
chest tube placed which also drained blood. Emergency angiogram
by Vascular Surgery did not show site of bleeding. Patient was
not responsive to volume resuscitation and inotropic support.
Open thoracotomy was not performed. She died on the OR table.
Declared at 1149 am.
Medications on Admission:
none
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Contained rupture of thoracoabdominal aortic aneurysm.
UTI
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2144-6-5**]
|
[
"041.4",
"518.0",
"441.1",
"459.2",
"599.0",
"998.11",
"511.89",
"401.9",
"997.1",
"519.19",
"785.51",
"447.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.73",
"96.04",
"34.06",
"88.42",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
4368, 4377
|
2439, 4281
|
259, 407
|
4488, 4497
|
1201, 2416
|
4553, 4590
|
1153, 1158
|
4336, 4345
|
4398, 4467
|
4307, 4313
|
4521, 4530
|
1173, 1182
|
209, 221
|
435, 1002
|
1024, 1032
|
1048, 1137
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,634
| 113,050
|
4047
|
Discharge summary
|
report
|
Admission Date: [**2158-1-2**] Discharge Date: [**2158-1-13**]
Date of Birth: [**2106-7-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Adhesive
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
pericardiocentisis
[**2158-1-6**]
Pericardial window for a large pericardial
effusion
History of Present Illness:
Ms [**Known lastname **] is a 51 year old female s/p AVR/MVR mechanical valve
replacements on [**2157-12-12**] with recent hospitalization for LOC
work-up presenting from clinic for management of new pericardial
effusion.
.
Patient recently hospitalized from [**12-22**] -[**12-26**] after unwitnessed
episode of loss of consciousness. Head CT negative. Seen by
neurology. Questionable if symptoms consistent with seizure
however started on Keppra and discharged back to rehab. Patient
also treated with 3day course of ceftriaxone for UTI.
.
Day prior to planned cardiology appt reports localized right
sided pleuritic chest pain as well as dyspnea on exertion.
Regarding chest pain lasts minutes, no appreciable trigger,
relieved with tylenol. Denies associated n/v, diaphoresis.
Denies any syncopal of pre-syncopal episode. At cardiology
clinic today found to be in atrial fibrillation; repeat
post-surgical echo demonstrated mod-large pericardial effusion
without signs of tamponade physiology. Transfer to cardiology
for potentional pericardiocentesis and cardioversion.
.
On arrival to the floor, patient without complaint.
.
On review of systems, patient with prior history of stroke,
reports pleuritic chest pain, occassional dizziness without
syncope.
Denies history of TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She denies
recent fevers, chills or rigors. She denies exertional buttock
or calf pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
Past Medical History:
Primary
Pericardial Effusion
Atrial Fibrillation
.
Secondary:
Seizure Disorder
Rheumatic Heart Disease, Paroxysmal atrial
fibrillation, Mitral and Aortic Stenosis, Anemia, s/p right
hemisphere stroke in [**2157-2-4**]: Her left side is still a little
weak.
Broken ankle
Past Surgical History
Mechanical AVR and mechanical MVR [**2157-12-12**]
Social History:
Divorced, 2 sons. Currently lives with one son; has two sons;
Previously employed as a seamstress, cleaning woman
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; Mother with diabetes. Father with possible
CVA.
Physical Exam:
VS: 97.3 120/80 86 18 100%RA
GENERAL: Well appearing female, NAD, speaking in full sentences
without problem, comfortable
[**Name (NI) 4459**]: Bilateral peri-orbital ecchymosis; laceration over right
eye with sutures in place, right conjunctival hemorrhage,
PERRLA, EOMI, OP clear withou exudates, lessions
NECK: Supple, JVD to level of mandible at 45degrees, no cervical
or supraclavicular LAD
CARDIAC: irreg, irreg with ii/VI systolic murmur and closing
click, no audible rub, no peripheral edema, JVD to level of
mandible
CHEST: Healed mildline sternotomy scar, no tenderness
LUNGS: 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.
PULSES: 2+ peripheral pulses
NEURO: II-XII intact, sensation intact, Strength 5/5 throughout
with exception of LUE [**3-7**] (c/w baseline
Pertinent Results:
CXR:
Compared to [**2157-12-24**], the large heart size is again noted which
is likely
unchanged considering differences in technique. It is uncertain
how much of this is from cardiomegaly or pericardial effusion.
The pulmonary vasculature is slightly plethoric, as before,
likely reflecting pulmonary vascular congestion. There appears
to be minimal atelectasis at the left lung base, otherwise,
lungs are clear. Sternal wires with valve replacements are again
noted.
.
TTE [**1-4**]
Focused views: Left ventricular wall thicknesses and cavity size
are normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. A
bileaflet aortic valve prosthesis is present. A bileaflet mitral
valve prosthesis is present. The tricuspid valve leaflets are
mildly thickened. There is a large circumferential pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2157-1-2**],
the circumferential pericardial effusion is similar in size
.
TTE [**1-2**]
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. A
mechanical aortic valve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal disc motion and
transvalvular gradients. Trace aortic regurgitation is seen.
[The amount of regurgitation present is normal for this
prosthetic aortic valve.] A bileaflet mitral valve prosthesis is
present. The mitral prosthesis appears well seated, with normal
disc motion and transvalvular gradients. No mitral regurgitation
is seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is a
moderate sized pericardial effusion measuring 1.8cm inferior to
the left ventricle, 2.5cm laterally, 0.6cm around the apex, and
<0.5cm anterior to the right ventricle. There are no
echocardiographic signs of tamponade.
IMPRESSION: Moderate pericardial effusion with suggestion of
loculation. No echocardiographic signs of tamponade. Well
seated, normal functioning aortic and mitral valve mechanical
prostheses. Low normal left ventricular systolic function
[**2158-1-13**] 04:30AM BLOOD WBC-8.8 RBC-3.51* Hgb-9.9* Hct-29.1*
MCV-83 MCH-28.1 MCHC-33.9 RDW-14.9 Plt Ct-262
[**2158-1-12**] 04:30AM BLOOD WBC-8.7 RBC-3.36* Hgb-9.4* Hct-27.9*
MCV-83 MCH-27.9 MCHC-33.5 RDW-14.3 Plt Ct-211
[**2158-1-13**] 04:30AM BLOOD PT-35.2* PTT-86.0* INR(PT)-3.6*
[**2158-1-12**] 04:30AM BLOOD PT-23.8* PTT-74.7* INR(PT)-2.3*
[**2158-1-11**] 04:25AM BLOOD PT-20.4* PTT-101.3* INR(PT)-1.9*
[**2158-1-10**] 12:00AM BLOOD PT-20.0* PTT-68.0* INR(PT)-1.8*
[**2158-1-9**] 06:40AM BLOOD PT-18.6* PTT-31.3 INR(PT)-1.7*
[**2158-1-8**] 04:25AM BLOOD PT-19.6* PTT-36.6* INR(PT)-1.8*
[**2158-1-7**] 02:05AM BLOOD PT-17.2* PTT-26.5 INR(PT)-1.5*
[**2158-1-6**] 08:15PM BLOOD PT-18.9* PTT-28.9 INR(PT)-1.7*
[**2158-1-12**] Echo:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). A mechanical
aortic valve prosthesis is present. A mechanical mitral valve
prosthesis is present. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: Low-normal global left ventricular systolic
function. Trivial pericardial effusion without echocardiographic
evidence of tamponade. Left pleural effusion.
Compared with the report of the prior study (images reviewed) of
[**2158-1-9**], the current study contains very limited views.
Although previously reported as a very small pericardial
effusion, on further review of the prior images the size appears
consistent with the trivial pericardial effusion noted today.
The left pleural effusion persists.
Brief Hospital Course:
Ms [**Known lastname **] is a 51 year old female s/p AVR/MVR mechanical valve
replacements on [**2157-12-12**] who presented with pleuritic pain and
pericardial effusion now s/p pericardiocentisis on .
.
# Percardial Effusion. Etiology likely post-cardiac surgery on
[**12-13**] with likely hemorrhagic in setting of supratherapeutic
INR. Patient was without any preceding fevers, URI symptoms
making infectious etiology less likely. WBC wnl, afebrile in
house. Biomarkers negative x2. No significant metabolic
derangements evident on labs. TSH wnl, rheumatod factor and [**Doctor First Name **]
negative. Patient remained hemodynamically stable. Monitored on
telemetry. Pulsus monitored [**Hospital1 **], thought hard to interpret in
setting of atrial fibrillation. [**1-2**] TTE with moderate
pericardial effusion with suggestion of loculation with no
echocardiographic signs of tamponade. Due to size of effusion
decision made to proceed with pericardiocentisis. INR was
allowed to trend down in preparation for pericardiocentesis.
The effusion was monitored on echo. The effusion increased
considerably and the patient was referred for pericardial window
with cardiac surgery.
.
# RHYTHM: Atrial Fibrillation. Patient with history of
paroxysmal atrial fibrillation on coumadin. CHADS3. Patient was
monitored on telemetry. Beta-blocker continued with rates well
controlled. Regarding anticoagulation, INR supratherapeutic on
admission, coumadin held and coags trended. On [**1-4**] INR 3.0 and
due to history of CVA decision made to initiate heparin
infusion. Rhythm monitor post-pericardiocentisis. possible
cardioversion s/p pericardiocentisis
.
# Chest pain. Described as pleuritic and nature and associated
with SOB. Patient without hypoxia, further INR supratherapeutic
on admission making pulmonary embolism unlikely. Though EKG
without signs of pericarditis likely effusion causing some
degree of pericardial irritation resulting in pain. Biomarkers
cycled and negative x2; EKG without signs of ischemia. CXR
without acute process. Patient with intermittent complaints of
pain in house - controlled with tylenol.
# Seizure Disorder. Patient admitted [**Date range (1) 17831**] after an episode
of LOC which was deemed secondary to seizure. Patient continued
on Keppra. No seizure inactivity while hospitalized.
.
# Dsyuria. Patient recently treated with 3 day course of
ceftriaxone for UTI.
Repeat UA/Ucx
.
# s/p CVA [**2-9**] with residual left upper extremity weakness. Per
patient at baseline
Neuro exam monitored. At time of discharge function at baseline
.
# Hypertension. Normotensive throughout hospitalization. Control
metoprolol and lisinopril.
.
# Depression. Continue Zoloft
.
Cardiac Surgery Course:
The patient was brought emergently to the operating room on
[**2158-1-6**] with Dr. [**First Name (STitle) **]. Pericardial window was performed.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for observation and recovery. 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 tube was
discontinued without complication. Initial CXR following
removal of drain revealed a widened mediastinum. In the setting
of hypotension and tachycardia, echo was performed which
revealed a small inferolateral effusion, with nothing anterior.
The patient remained hemodynamically stable. Heparin drip was
started as a bridge to coumadin. Heparin was discontinued when
INR became therapeutic. 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 with assistance, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged to
Bear [**Doctor Last Name **] Nursing and Rehab in good condition with appropriate
follow up instructions.
Medications on Admission:
1. levetiracetam 500 mg [**Doctor Last Name 8426**] Sig: One (1) [**Doctor Last Name 8426**] PO BID (2
times a day): plan to increase to 750 mg [**Hospital1 **] in 2 weeks.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
4. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. bisacodyl 5 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: Two (2)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. acetaminophen 325 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/headache.
8. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: [**12-4**] PO Q8H
(every 8 hours) as needed for itching.
9. metoprolol tartrate 50 mg [**Month/Day (2) 8426**] Sig: 1.5 Tablets PO TID (3
times a day).
10. warfarin 1 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO DAILY (Daily):
goal INR 3-3.5 for mechanical Aortic and Mitral valves.
11. lisinopril 5mg QD
12. Vitamin D-3 400u
13. Zoloft 50mg tab QD
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO DAILY
(Daily).
3. aspirin 81 mg [**Month/Day (2) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Month/Day (2) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg [**Month/Day (2) 8426**] Sig: Two (2) [**Month/Day (2) 8426**] PO Q4H (every
4 hours) as needed for pain, fever.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. sertraline 50 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO DAILY (Daily).
8. levetiracetam 500 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO BID (2
times a day).
9. lisinopril 5 mg [**Month/Day (2) 8426**] Sig: 0.5 [**Month/Day (2) 8426**] PO DAILY (Daily).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
11. metoprolol tartrate 50 mg [**Month/Day (2) 8426**] Sig: Two (2) [**Month/Day (2) 8426**] PO TID
(3 times a day).
12. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H
(every 6 hours) as needed for itching .
13. warfarin 1 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO DAILY (Daily):
MD to dose daily for goal INR 2.5-3.5, dx: mechanical aortic and
mitral valves. [**Month/Day (2) 8426**](s)
14. Outpatient Lab Work
DAILY INR until stable, then M, W, F for
goal 2.5-3.5
dx: mechanical aortic and mitral valves
Discharge Disposition:
Extended Care
Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**]
Discharge Diagnosis:
Primary
Pericardial Effusion
Atrial Fibrillation
.
Secondary:
Seizure Disorder
Rheumatic Heart Disease, Paroxysmal atrial
fibrillation, Mitral and Aortic Stenosis, Anemia, s/p right
hemisphere stroke in [**2157-2-4**]: Her left side is still a little
weak.
Broken ankle
Past Surgical History
Mechanical AVR and mechanical MVR [**2157-12-12**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
No edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 170**] [**2-6**] at 1:15pm
Cardiologist Dr. [**First Name (STitle) 437**] [**Telephone/Fax (1) 62**] [**2-13**] at 3:30pm
Neurologist: [**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2158-4-11**] 1:00
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) 17832**] [**Name (STitle) 16365**] in [**3-7**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for Mech AVR/MVR
Goal INR 2.5-3.5
First draw day after discharge [**2158-1-14**], then daily until stable,
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by MD
*
Please arrange for INR/coumadin follow-up on discharge from
rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2158-1-13**]
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10,487
| 109,385
|
14080
|
Discharge summary
|
report
|
Admission Date: [**2139-9-29**] Discharge Date: [**2139-10-10**]
Date of Birth: [**2069-5-26**] Sex: F
Service: MEDICINE
Allergies:
Rofecoxib / Percocet / Albuterol / Shellfish
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
# Bilateral lower extremity edema
Major Surgical or Invasive Procedure:
# Tunneled dialysis catheter
History of Present Illness:
70F h/o CRI (Cr 1.7-2.3), uterine cancer s/p XRT c/b proctitis,
s/p diverting colostomy c/b GIB, PCM, CAD s/p CABG/PCI,
hypersensitivity pneumonitis [**2-6**] possible psittacosis, admitted
for increased bilateral lower extremity edema.
Pt had been previously admitted 1 month ago for afib management
and was started on quinidine as renal function did not allow for
initiation of dofetilide. Outpatient furosemide 120mg TID had
been stopped during that admission, then restarted at 120mg
daily. Weight increased from 219 to 236 pounds, with worsening
leg swelling and dyspnea on exertion. Outpatient labs revelead
worsened renal function, with last Cr=3.3 four days prior to
this admission.
.
On ROS, pt denied any interval chest pain, although did
experience palpitations with chronic afib, and denied any
infectious symptomatology.
Past Medical History:
Uterine cancer- s/p XRT '[**34**]
Radiation proctitis s/p diverting colostomy [**2-9**]
GIB [**2-6**] hematochezia from radiation proctitis
Hyperlipidemia
HTN
DM type 2
CAD s/p CABG '[**35**], multiple cardiac catheterizations with PCIs
Sternal MRSA infection s/p debridement x 3
GERD
s/p appy/ccy
CHF with EF>55%
Atrial fibriilation
s/p pacemaker
CRI baseline creatinine 2.0
Social History:
Lives with daughter and son in law, widowed several years ago,
denies T/A/D.
Family History:
Father passed away in 50's from CAD. Siblings with early CAD
Physical Exam:
VS: Temp 98.6, BP 160/D, HR 66, RR 18, O2 sat 99% on 2.5L NC
Gen: pleasant, elderly female in NAD, speaks in full sentences
HEENT: anicteric, obese face [**2-6**] prednisone per pt
Neck: thick supple, JVP 10cm, but difficult to visualize well
Resp: CTA b/l, no wheezes, no appreciable crackles, but
difficult [**2-6**] habitus
CV: irreg, no m/r/g. s/p sternotomy and no sternum
Abd: stoma in place, old scars, non tender, no hsm
Extr: 3+ edema b/l halfway up to knees, tr pulses
Pertinent Results:
Labs:
[**2139-9-30**] 12:00AM GLUCOSE-168* UREA N-92* CREAT-2.8*#
SODIUM-139 POTASSIUM-3.6 CHLORIDE-93* TOTAL CO2-36* ANION GAP-14
[**2139-9-30**] 12:00AM ALT(SGPT)-29 AST(SGOT)-16 ALK PHOS-53 TOT
BILI-0.4
[**2139-9-30**] 12:00AM proBNP-4556*
[**2139-9-30**] 12:00AM ALBUMIN-3.3* CALCIUM-9.2 PHOSPHATE-3.9
MAGNESIUM-2.4
[**2139-9-30**] 12:00AM TSH-1.3
[**2139-9-30**] 12:00AM WBC-7.0 RBC-3.42* HGB-11.0* HCT-32.5* MCV-95
MCH-32.2* MCHC-34.0 RDW-15.7*
[**2139-9-30**] 12:00AM NEUTS-85.6* LYMPHS-8.4* MONOS-5.0 EOS-0.8
BASOS-0.2
[**2139-9-30**] 12:00AM PLT COUNT-190
[**2139-9-30**] 12:00AM PT-11.4 PTT-20.0* INR(PT)-1.0
[**2139-10-9**] 04:01AM BLOOD WBC-15.6*# RBC-3.21* Hgb-10.4* Hct-31.0*
MCV-97 MCH-32.5* MCHC-33.6 RDW-16.2* Plt Ct-205
[**2139-10-8**] 02:46PM BLOOD PT-10.5 INR(PT)-0.9
[**2139-10-9**] 04:01AM BLOOD Glucose-165* UreaN-95* Creat-3.5* Na-137
K-5.3* Cl-94* HCO3-33* AnGap-15
[**2139-10-9**] 04:01AM BLOOD CK(CPK)-99
[**2139-10-8**] 09:08PM BLOOD CK(CPK)-87
[**2139-10-8**] 02:06PM BLOOD CK(CPK)-86
[**2139-10-8**] 10:31AM BLOOD CK(CPK)-61
[**2139-10-9**] 04:01AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2139-10-8**] 09:08PM BLOOD CK-MB-NotDone cTropnT-0.09* proBNP-8381*
[**2139-10-8**] 02:06PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2139-10-8**] 10:31AM BLOOD CK-MB-2 cTropnT-0.06*
[**2139-10-9**] 04:01AM BLOOD Calcium-8.9 Phos-5.5* Mg-2.0
[**2139-10-8**] 09:08PM BLOOD calTIBC-333 Ferritn-224* TRF-256
[**2139-10-9**] 01:19PM BLOOD PTH-260*
[**2139-10-8**] 03:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2139-10-9**] 02:36AM BLOOD Digoxin-2.1*
[**2139-10-8**] 03:00PM BLOOD HCV Ab-NEGATIVE
[**2139-10-8**] 07:16PM BLOOD Type-ART Temp-35.4 Rates-/22 FiO2-50
pO2-92 pCO2-52* pH-7.40 calTCO2-33* Base XS-5 Intubat-NOT INTUBA
Comment-VENTIMASK
[**2139-10-8**] 03:29PM BLOOD Type-[**Last Name (un) **] Temp-35.8 Rates-/25 pO2-40*
pCO2-83* pH-7.28* calTCO2-41* Base XS-8 Intubat-NOT INTUBA
Vent-SPONTANEOU
.
Micro:
URINE CULTURE (Final [**2139-10-1**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
AEROBIC BOTTLE (Final [**2139-10-14**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2139-10-14**]): NO GROWTH.
.
[**2139-10-8**] 10:09 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2139-10-12**]**
GRAM STAIN (Final [**2139-10-9**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2139-10-12**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
.
Imaging:
.
CHEST (PA & LAT) [**2139-9-30**] 10:18 AM
IMPRESSION:
1) Stable, moderate pulmonary edema.
2) Stable cardiomegaly.
.
ECHO [**9-30**]:
Suboptimal image quality. The left atrium is mildly dilated. 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 size is normal. There is
distal septal and apical akinesis suggested. The inferior wall
is not well seen. Overall left ventricular systolic function is
probably preserved (LVEF 50%). There is no ventricular septal
defect. Right ventricular chamber size is normal. Right
ventricular systolic function is borderline normal. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. An eccentric, posteriorly
directed jet of mild to moderate ([**1-6**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
If clinically indicated, a repeat study with contrast (Definity)
may aid in regional LV systolic function determination.
.
UNILAT LOWER EXT VEINS LEFT [**2139-10-6**] 9:01 AM
IMPRESSION:
1. No deep venous thrombosis in left common femoral, superficial
femoral, or popliteal veins.
2. 3.4-cm septated fluid collection corresponding to the
palpable abnormality in the left lateral ankle, a finding that
is of uncertain significance but could represent hematoma,
synovial cyst or infectious collection, among other entities.
.
CHEST (PA & LAT) [**2139-10-7**] 11:52 PM
IMPRESSION: PA and lateral chest compared to [**9-30**]
through earlier in the day:
Pulmonary and mediastinal vascular congestion have worsened
today consistent with cardiac decompensation though moderate
cardiomegaly is unchanged and there is no pulmonary edema or
pleural effusion. There are no focal abnormalities in the lungs
to suggest pneumonia. Transvenous right atrial and right
ventricular pacer leads in standard placements.
.
CHEST (PA & LAT) [**2139-10-7**] 1:52 PM
FINDINGS: In comparison with the study of [**9-30**], there is little
change. Again there is some enlargement of the cardiac
silhouette with fullness of the pulmonary vessels and a
dual-lead pacemaker device in place. No evidence of acute
pneumonia.
.
CT CHEST W/O CONTRAST [**2139-10-8**] 8:21 PM
IMPRESSION:
1. Left upper lobe and lingular pneumonia. Multiple small
peribronchial nodules likely from chronic small airways disease.
Follow up imaging after treatment is recommended to document
resolution and follow up nodules.
2. Evaluation for pulmonary embolism is not possible on this
noncontrast study, and if clincally indicated, VQ scan would be
helpful for further evaluation. Discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**2139-10-8**].
3. Asbestos related pleural disease.
4. Multinodular thyroid with calcifications. Clinical
correlation with labs and ultrasound recommended.
.
CHEST (PORTABLE AP) [**2139-10-8**] 11:00 AM
Portable AP chest radiograph was reviewed. The patient head
overlie the lung apices, thus evaluation of pneumothorax cannot
be obtained precisely, although no evidence of large
pneumothorax is present. The PermCath catheter can be visualized
up to cavoatrial junction. The cardiac size is mildly enlarged
but unchanged compared to [**2139-10-7**]. Two pacemaker leads
terminate in right atrium and right ventricle. Repeated
radiograph with improved technique is highly recommended.
Brief Hospital Course:
70F h/o DM2, atrial fibrillation, CAD s/p CABG, CHF (EF 45-50%),
and CRI with volume overload. Her diuretic regimen was titrated
while on the floor with good response initially, but she
continued to have worsening renal failure. Renal was consulted
and after several days of trying to diurese, she was taken to
get a tunneled catheter placed. In the PACU, she was unable to
lie down flat because of respiratory discomfort. She was
therefore consented to suspend her DNI status for intubation to
place the tunneled catheter. She was extubated with difficulty
after the procedure and suffered desaturations and delirium.
Her oxygen saturation recovered, but she was transferred to the
MICU given her tenuous respiratory status. She was given HD in
the MICU as is her course on the general medicine floor.
.
# Possible acute diastolic CHF exacerbation - cardiac vs renal
in etiology. Most likely the volume overload initially related
to the decreased dose of her diuretics. Concerning increase in
Cr reported from outside labs, pt continues to make good urine
according to patient, obstruction seems unlikely. Her diuretic
regimen was titrated and while her Cr worsened. HD was
considered the eventual endpoint of her disease. She suffered
worsening pulmonary edema in the days before the tunneled
catheter was placed and she was nearing HD.
.
# Respiratory distress: Patient experienced acute respiratory
decompensation in the PACU, and was noted to vomit while supine.
During that time, patient was also noted to be hypertensive
with EKG changes suspicious for ischemia, giving rise to the
suspicion that patient possibly experienced acute diastolic
failure leading to pulmonary edema. Because of the acuity of
patient's respiratory compromise, PE was also suspected. CTA
was considered but given patient's renal function, this was
deferred. Subsequent bilateral LENIs were negative, and CT w/o
contrast demonstrated extensive LUL and LLL infiltrate.
Follow-up sputum Gram stain demonstrated Gram-positive rods and
cocci, as well as Gram-negative rods. Acute desaturation was
therefore considered likely triggered by mucus plugging [**2-6**]
hospital-acquired PNA (although pt was chronically on prednisone
25mg daily [**2-6**] presumed psittacosis without Bactrim ppx, her
desaturation was considered unlikely related to PCP). Patient
therefore received extensive chest PT and BiPAP with good
effect, and started vancomycin/cefepime/ciprofloxacin. Because
little fluid was removed via HD ultrafiltration, chronic
diastolic dysfunction was considered to be a less likely
contributor. Because of pt's vomiting, pt was also noted to be
at risk for possible aspiration pneumonitis or PNA.
.
# Acute-on-chronic renal failure: As above for the floor. In
the MICU, patient underwent hemodialysis with removal of
approximately 500 cc. Further ultrafiltration was unable to be
performed given low blood pressures. Upon transfer to the
floor, pt's furosemide was continued given difficulty in
managing outpatient fluid status.
.
# Acute mental status change: Patient was noted to have acute
mental status change upon transfer post-op to the MICU. This
was felt likely [**2-6**] multifactorial contributions from
anesthesia, acute hypoxia and hypercarbia, and infection.
Patient required soft two-point restraints overnight during her
first night in the MICU, but returned to near baseline
subsequently.
.
# CAD s/p CABG: Patient was initially continued on her home
regimen of aspirin, metoprolol, and simvastatin, with no ACE
inhibitors in the setting of her renal dysfunction. During
patient's acute desaturation in the PACU post op, EKGs were
concerning for possible ischemic change given patient's
background of coronary artery disease. Cardiac enzymes were
cycled and were negative, and repeat EKGs showed no significant
change. Cardiology was consulted but had low suspicion that
patient had experienced an acute ischemic event.
.
# Atrial fibrillation: Patient was not anti-coagulated given her
history of hematuria, and was continued on metoprolol and
quinidine for rate control.
.
# DM2: Patient was continued on her home regimen of insulin NPH
[**Hospital1 **] with sliding scale. Her insulin regimen was titrated for
blood sugar control, though her glycemic control proved
difficult.
.
# LLE lesion: Ms. [**Known lastname **] was found to have a painful,
erythematous, floculent nodule on the lateral aspect of her LLE.
An ultrasound showed a fluid collection, but aspiration of the
lesion was unsuccessful. She remained afebrile throughout the
course of this lesion, which lasted roughly a week. The lesion
was stable through that week after its initial presentation.
.
# GERD: Patient was continued on her home regimen of omeprazole.
.
# Hypertension: Patient was continued on her home regimen of
metoprolol.
.
# Hyperlipidemia: Patient was continued on her home regimen of
simvastatin.
.
# Back pain: Patient was continued on home regimen of Vicodin
PRN.
.
Upon transfer from the MICU back to the floor, the patient was
initially respiratorily stable. She was later found in her room
in respiratory arrest followed by ventricular fibrillation.
Given her DNR/DNI status, no efforts were made to resuscitate
her.
Medications on Admission:
Furosemide 120mg daily (from 120mg TID prior to last
hospitalization)
Spironolactone 25mg daily
Metoprolol 100mg TID
[**Known lastname **] 325mg daily
Simvastatin 20mg daily
Prednisone 25mg daily
Omeprazole 20mg daily
Insulin (NPH 40 [**Hospital1 **]), Humalog sliding scale
Iron
Caltrate
Vicodin PRN
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
ventricular fibrillation from respiratory failure
.
Secondary:
Uterine cancer- s/p XRT '[**34**]
Radiation proctitis s/p diverting colostomy [**2-9**]
GIB [**2-6**] hematochezia from radiation proctitis
Hyperlipidemia
HTN
DM type 2
CAD s/p CABG '[**35**], multiple cardiac catheterizations with PCIs
Sternal MRSA infection s/p debridement x 3
GERD
s/p appy/ccy
CHF with EF>55%
Atrial fibriilation
s/p pacemaker
CRI baseline creatinine 2.0
Discharge Condition:
Deceased
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
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icd9cm
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] |
[
"39.95",
"38.95",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
14674, 14683
|
9081, 14323
|
340, 370
|
15174, 15314
|
2323, 9058
|
1746, 1808
|
14704, 15153
|
14349, 14651
|
1823, 2304
|
267, 302
|
398, 1236
|
1258, 1635
|
1651, 1730
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,103
| 184,630
|
53238
|
Discharge summary
|
report
|
Admission Date: [**2185-5-3**] Discharge Date: [**2185-5-19**]
Date of Birth: [**2146-9-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
1) unsuccessful pericardiocentesis
2) successful anterior pericardectomy and drainage of
pericardial effusion
History of Present Illness:
Pt is a 38 year-old female with a history of SLE,
anticardiolipin antibodies, multiple DVTs, including while on
therapeutic coumadin dosing, who now presents with 3-4 days of
constant pleuritic chest pain. The patient reports that the pain
is central in the chest, mid-sternum, and radiates through the
chest to the back. The pain does not radiate to the arm or to
the neck. There has been no associated diaphoresis, nausea,
vomiting, or shortness of breath, although the patient does note
that breathing is uncomfortable due to the pleuritic nature of
her pain. She reports that the pain is worsened by lying down,
and gets better when she sits up. The patient reports that she
has been compliant with all her medications. She denies any
antecedent illnesses, cough, sputum production, or URI symptoms.
She states that she has had pleuritis in the past, caused by her
SLE, but does not recall if this current pain is similar.
.
In the ED, the patient was found to be febrile to 101.1. She
denies dysuria or urinary frequency. She denies abdominal pain,
no nausea or vomiting. Basic labs obtained in the emergency room
revealed a markedly supratherapeutic INR at 10.9. She states
that she has not deviated recently from her usual warfarin
dosing regimen.
Past Medical History:
- LLE DVT [**2184-11-23**], on coumadin with goal INR 2.5-3.5, resolved
by [**12-3**] LENI
- Hypercoagulable state, anticardiolipin Ab+
- Right Orbital Cellulitis
- Possible optic neuritis
- Hypertension
- SLE, diagnosed in [**2171**] when she presented with large pleural
effusion
- Lupus nephritis, membranous GN grade V on biopsy [**8-/2175**]
- dry eyes c/w sicca
- parotiditis
- EMG-documented [**4-/2175**] Lt. polyradiculopathy in L1-5 myotomes;
etiology unclear as on MRI she only had mild central discs at
L2/3 and L4/5
- Low back pain
- Asthma with h/o intubation
- Migraines
Social History:
The patient has eight pack year smoking history now smokes 10
cigarettes per day down from 1.5 pk per day, rarely drinks
alcohol, used to smoke marijuana but does not use intravenous
drugs. The patient is on disability and does not work
Family History:
Significant for diabetes mellitus in her brother and mother, CAD
and stroke in her brother 37 and father at 70, [**Name2 (NI) 499**] cancer in
her grandmother. [**Name (NI) **] h/o clots.
Physical Exam:
VS: 101.1 | 110 | 140/56 | 18 | 100% 2L
.
GEN: Pleasant obese female, appears uncomfortable breathing
HEENT: OP clear, MMM. Anicteric. Pink conjunctivae.
COR: tachy, regular. Normal S1S2. No murmur, no rub appreciated.
CHEST: CTA B, no rub, rales, rhonchi appreciated
ABD: soft, obese. NT, ND. NABS. No masses appreciable.
EXT: No edema, extremities appear symmetric. No palpable cords.
Warm, well perfused.
NEURO: AA&Ox3. CN II-XII intact. MAEx4 with full strength. Pt
not ambulated [**12-30**] chest discomfort.
Pertinent Results:
[**2185-5-3**] 09:40PM CK(CPK)-38
[**2185-5-3**] 09:40PM CK-MB-NotDone cTropnT-<0.01
[**2185-5-3**] 06:00PM URINE HOURS-RANDOM
[**2185-5-3**] 06:00PM URINE HOURS-RANDOM
[**2185-5-3**] 06:00PM URINE GR HOLD-HOLD
[**2185-5-3**] 06:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2185-5-3**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2185-5-3**] 06:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2185-5-3**] 06:00PM URINE RBC-[**5-7**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2185-5-3**] 03:36PM GLUCOSE-82 LACTATE-0.6 K+-4.0
[**2185-5-3**] 03:30PM GLUCOSE-84 UREA N-15 CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-13
[**2185-5-3**] 03:30PM WBC-7.9# RBC-3.56* HGB-8.8* HCT-27.2* MCV-76*
MCH-24.6* MCHC-32.3 RDW-14.8
[**2185-5-3**] 03:30PM NEUTS-73.9* LYMPHS-22.2 MONOS-2.6 EOS-0.9
BASOS-0.4
[**2185-5-3**] 03:30PM HYPOCHROM-1+ MICROCYT-2+
[**2185-5-3**] 03:30PM PLT COUNT-582*
[**2185-5-3**] 03:30PM PT-82.4* PTT-61.3* INR(PT)-10.9*
[**2185-5-3**] 03:30PM D-DIMER-1185*
.
Echo: The left atrium is mildly dilated. No atrial septal defect
is seen by 2D or color Doppler. The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
The aortic arch is mildly dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. There is no aortic valve stenosis. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
Renal u/s:
1. No evidence of hydronephrosis or renal vein thrombosis.
2. Normal ultrasonographic appearance of the kidneys.
[**2185-5-11**] Chest CTA: Study is limited by patient's body habitus
and breathing artifact. New large pericardial effusion,
measuring greater than 3 cm is identified. There appears to be
slight indentation on the ventricles and atrium. There is no
evidence of aortic dissection. No central pulmonary embolism is
seen. No focal consolidations or pleural effusions are seen.
Linear opacities consistent with atelectasis are seen at the
lung bases. The previously described hilar lymphadenopathy and
pulmonary nodules are not well appreciated on today's study,
possibly secondary to breathing motion artifact. Limited views
of the upper abdomen are unremarkable.
BONE WINDOWS: No suspicious lytic or blastic lesions are
identified.
Multiplanar reformatted images confirm the axial findings.
IMPRESSION:
1. Large new pericardial effusion.
2. No evidence of aortic dissection or central pulmonary
embolism.
Findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] immediately
following completion of study with recommendation for
echocardiogram.
[**5-12**] Transthoracic echocardiogram:
PERICARDIUM: Large pericardial effusion. Effusion
circumferential. No
significant respiratory variation in mitral/tricuspid valve
flows. Brief RA diastolic collapse. RV diastolic collapse, c/w
impaired fillling/tamponade physiology.
Conclusions:
There is a large pericardial effusion. The effusion appears
circumferential.
There is brief right atrial diastolic collapse. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
IMPRESSION: TAMPONADE
[**2185-5-13**]: CXR: Large post-operative cardiomediastinal silhouette
stable. No pneumothorax. Small left pleural effusion, probably
unchanged. Residual left perihilar consolidation probably
atelectasis, improved. Right lung grossly clear. No
pneumothorax.
[**2185-5-16**] Echocardiogram: There is mild symmetric left ventricular
hypertrophy. The left ventricular
cavity is mildly dilated. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is mildly dilated. Right ventricular
systolic function appears depressed. There is abnormal septal
motion/position. The aortic root is mildly dilated. The mitral
valve leaflets are mildly thickened. There is borderline
pulmonary artery systolic hypertension. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
[**2185-5-19**] WBC 12.3 HCT 32.4 PLT 587
Creatinine 1.1
Brief Hospital Course:
38 year-old woman with history of SLE, anticardiolipin antibody,
multiple DVTs, frequent chest pain who presents to the ED with
chest pain x3 days and fever, likely pleuritis/pericarditis from
SLE flare. Course complicated by developmen t of pericardial
effusion with tamponade s/p emergent pericardectomy.
.
#. Chest pain/SLE/pericardial effusion s/p pericardectomy: This
was felt likely to be the result of a serositis-type picture, in
this case likely pericarditis. To rule-out pulmonary embolism a
CTA of the chest was performed with no evidence of PE, although
the exam was limited by body habitus. The had been treated with
NSAID early in stay, but with worsening Creatinine this
medication was discontinued. Hemolysis labs were checked and
were found to be negative. The patient's anemia on presentation
was attributed to anemia of chronic disease due to the patient's
iron panel. Because of the chest pain, a TTE was checked to
evaluate for pericardial effusion. This test revealed no
pericardial effusion, slight pulmonary hypertension, and a
mildly dilated left ventricle.
.
On [**5-11**] the patient noted sudden onset severe chest pain with
radiation to the back. As this raised concern for aortic
dissection an emergent CTA was performed. No dissection was
noted; however, a very large pericardial effusion was
discovered. The patient did have distended neck veins and
distant heart sounds but did not have hypotension. She had a
pulsus paradoxus greater the 20 mm Hg. Echo confirmed presence
of 3 cm circumferential pericardial effusion and revealed
tamponade physiology. Given the very large pericardial
effusion, the patient was taken urgently to the cardiac cath
laboratory for pericardiocentesis. This procedure could not,
however, be done safely because of the patient's large body
habitus. She was then immediately taken to the operating room
for open drainage.
In the operating room, the patient underwent anterior
pericardectomy with drainage of 700 cc of sanguinous fluid.
Three drains were placed. The patient was then transferred to
the CSRU and subsequently to the CCU. The following morning,
the drains were noted to have less than 40 cc output and were
therefore pulled. The patient remained hemodynamically stable
postoperatively but did require two blood transfusions. She
also received vitamin K therapy for persistently elevated INR.
The patient had no sign of recurrent pericarditis/pericardial
effusion while she was in the MICU. Per rheumatology, her
steroid doses were increased and she was continued on a taper
for the rest of her hospitalization receiving 30 mg on her last
hospital day with plans to taper to 15 mg daily. A repeat
echocardiogram was performed on [**5-16**] which revealed overall left
ventricular systolic
function is normal (LVEF>55%),right ventricular cavity is mildly
dilated and right ventricular systolic function appears
depressed as well as a small pericardial effusion, but no
echocardiographic signs of tamponade. She remained chest pain
free with a pulsus of about 8. Her incision was healing well and
she was compliant with sternotomy precautions. She was
discharged with 2 week f/u with [**Hospital Ward Name 121**] 2 nurses and 4 week f/u
with Cardiac surgery. She will have VNA to check her incision.
#. Fever: This occurred early in the hospitalization. The
patient has had recent presentations with a similar cluster of
symptoms, and no infectious cause was identified in those cases.
UA was checked and found to be negative. The aforementioned CT
of the chest revealed no infiltrate. No evidence of cellulitis.
Blood and urine cultures were sent, and were negative at the
time of discharge. At the time of discharge, the fever was
attributed to the overall inflammatory state. She was afebrile
for several days at discharge.
.
#. Coagulopathy: Pt has confirmed anticardiolipin antibody, and
has had confirmed DVTs while on Coumadin. AT III activity
recently checked and found to be normal. INR markedly supra
therapeutic on admission (goal 2.5-3.5). PTT elevated on
admission as well, likely [**12-30**] lupus anticoagulant effect.
Coumadin was held throughout the hospitalization due to the
elevated INR. A hematology consult was obtained and felt that
Lovenox would be a better choice for anticoagulation. She was
started on Lovenox 80 mg Q12H per their recommenedation. She
tolerated this well and will follow up in hematology clinic
.
#. Lupus Nephritis: Pt carries diagnosis of lupus nephritis,
membranous GN type V. Baseline Cr around 1.0-1.2. Initially
elevated after contrast and NSAIDs, received IVF during her
stay, with improvement back to 1.1. The short elevation in Cr
was deemed [**12-30**] mild contrast nephropathy with contribution of
NSAID effect. The renal consult team was involved in the care
of this patient. A biopsy was entertained, but due to the
patient's body habitus and coagulopathy, this evaluation was
deferred. Sediment was examined multiple times, and the
decision was made to NOT start empiric Cytoxan therapy during
this admission. Both a Rheumatology and Renal consult were
obtained, and after much discussion she was started on CellCept
[**Pager number **] mg Po BID. She tolerated this well. Her creatinine was 1.1
at discharge and she will follow up with Rheumatology and Renal
as an outpatient.
# Skin Lesions: The patient noted some nodular lesions on her
extremities during this hospitalization. These were initially
attributed to possible phlebitis, but rheumatology consultation
raised the question of possible sarcoidosis as she does have
some hilar adenopathy. The lesions remained stable and she was
scheduled for a dermatology and rheumatology follow up for
further evaluation.
# Hypertension: Patient was on Lisinopril 40 mg Po QD, Procardia
and Atenolol on admission. Her medications were held in the
setting of tamponade as there was fear of hypotension, although
she did not develop hypotension at any point. Her BP was closely
monitored and she was initially titrated on captopril and
eventually transitioned to Lisinopril 10 mg PO QD with SBPs
120s-130s. She will follow up with her new PCP as an outpatient
for any further titrating of her medications.
# Code: Full
Medications on Admission:
ALBUTEROL 17 GM 2puffs QID PRN
AMITRIPTYLINE HCL 25MG PO QHS
ATENOLOL 100 mg PO QD
BECLOMETHASONE (ORAL) 2puffs [**Hospital1 **]
COUMADIN 10MG PO QD
FERROUS GLUCONATE 325 mg PO QD
NORFLEX 100MG PO QD
PERCOCET 5-325 mg 1 tab PO QD PRN
PROCARDIA XL 90MG PO QD
PROTONIX 40MG PO QD
ZESTRIL 40MG PO QD
ZOMIG 2.5MG PRN migraine
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 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).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs inhaler* Refills:*2*
7. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Sumatriptan Succinate 25 mg Tablet Sig: One (1) Tablet PO
tidp ().
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Prednisone 5 mg Tablet Sig: Per taper Tablet PO once a day:
Please take 4 tablets once daily for 2 days ([**Date range (1) 43607**])
Then take 3 tablets daily thereafter.
Disp:*98 Tablet(s)* Refills:*2*
11. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous every twelve (12) hours.
Disp:*60 syringes* Refills:*2*
12. Mycophenolate Mofetil 500 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) 86**] VNA
Discharge Diagnosis:
Primary
1. Pericardial effusion with tamponade
2. Lupus nephritis
3. Anticardiolipin antibody syndrome
4. Asthma
Secondary
1. Hypertension
2. Low back pain
Discharge Condition:
Stable, tolerating adequate PO and ambulating without
assistance, pulsus 8, SBP 120s-130s, afebrile.
Discharge Instructions:
If you experience worsening chest pain, shortness of breath,
fevers, chills, nausea, vomiting, or any other concerning
symptoms, please contact your physician or return to the
emergency room.
.
The following changes have been made to your medications:
1. You are no longer taking coumadin, atenolol, or procardia
2. Your lisinopril dose has been decreased to 10 mg once daily
3. You are now taking cellcept [**Pager number **] mg twice daily for your lupus
4. You are now taking prednisone 20 mg once daily for the next 2
days ([**Date range (1) 43607**]) and then 15 mg daily thereafter.
You should not drive for the next 4 weeks. You should follow all
of the post-surgery recommendations in the pamphlet provided for
you and reviewed with physical therapy.
Please keep all of your follow up appointments as listed below.
Followup Instructions:
You hvae the following follow up appointments:
You have an [**Date range (1) 648**] with your new Primary care doctor, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11679**] [**Telephone/Fax (1) 250**] on [**7-6**] at 1:30 PM.
You have a follow up [**Month (only) 648**] with your nephrologist, Dr.
[**Last Name (STitle) 13525**], at ([**Telephone/Fax (1) 773**] on [**6-15**] at 2:00 pm.
.
You have the following Rheumatology follow up [**Month (only) 648**]:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2185-6-9**] 2:00
.
You have a nurse [**First Name (Titles) 3525**] [**Last Name (Titles) 648**]: Provider: [**Name10 (NameIs) **] FERN,
RNC Date/Time:[**2185-6-14**] 10:20
.
[**Last Name (NamePattern4) **]e a follow up [**Last Name (NamePattern4) 648**] with Dr. [**Last Name (Prefixes) **]
[**Telephone/Fax (1) 170**] on [**2185-6-9**] at 1:00 pm. His office is located at [**Doctor First Name **]. Please call the above number for directions.
.
You have a follow up [**Doctor First Name 648**] in the [**Hospital **] clinic
([**Hospital Ward Name 23**] 9) on [**2185-6-17**] at 11:30 AM. Please call ([**Telephone/Fax (1) 74300**]
if you have any questions or need directions.
.
You have the following Dermatology [**Telephone/Fax (1) 648**]:Provider:
[**Name10 (NameIs) **],[**Name11 (NameIs) 8754**] DERMATOLOGY GEN-[**Doctor First Name 8754**] (NHB) Date/Time:[**2185-5-27**] 3:00.
Please call [**Telephone/Fax (1) 1971**] for directions or questions.
.
You should also schedule the following:
[**Hospital Ward Name 121**] 2 Nurses for wound check 2 weeks post op. Your nurse will
discuss scheduling this with you at discharge.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"795.79",
"V12.51",
"584.9",
"709.9",
"285.29",
"493.90",
"401.9",
"582.81",
"780.6",
"423.2",
"710.0",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.21",
"99.07",
"37.31",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15869, 15926
|
7823, 14056
|
282, 393
|
16126, 16229
|
3301, 7800
|
17102, 17125
|
2559, 2750
|
14429, 15846
|
15947, 16105
|
14082, 14406
|
16253, 17079
|
2765, 3282
|
232, 244
|
17150, 18951
|
421, 1678
|
1700, 2288
|
2304, 2543
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,324
| 149,906
|
8362
|
Discharge summary
|
report
|
Admission Date: [**2102-1-16**] Discharge Date: [**2102-1-28**]
Date of Birth: [**2041-2-21**] Sex: F
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: 60-year-old female with a
history of insulin dependent diabetes mellitus now with end
stage renal disease on peritoneal dialysis for five years.
The patient presents in normal state of health for a
cadaveric renal transplant. The patient denies nausea,
vomiting, chest pain, shortness of breath, fevers, chills.
PAST MEDICAL HISTORY: Insulin dependent diabetes mellitus.
Peritoneal dialysis. End stage renal disease. Hypertension.
Glaucoma.
PAST SURGICAL HISTORY: Tenckhoff catheter placement five
years ago, cesarean section times three, umbilical hernia
repair.
SOCIAL HISTORY: No alcohol, no cigarettes.
MEDICATIONS: Cardizem 300 mg q day, Lipitor 10 mg q day,
Zestril 20 mg q day, Insulin 42 units NPH q a.m., Lasix 40 mg
po qid, TUMS 2 tabs tid, RenaGel 800 mg [**Hospital1 **], Cosopt eyedrops,
Xalatan eyedrops, Zantac, Nephrocaps one tab po q day.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was brought to the operating
room on [**1-16**] for cadaveric renal transplant. The patient
received intraoperative doses of thymoglobulin, Solu-Medrol,
Kefzol. Ischemic time during the surgery was 19 hours.
Intraoperatively the kidney was initially pink, then
developed areas of blue. Biopsies were negative for
rejection in the intraoperative period. It was determined
that the flow to the kidneys was dependent upon blood
pressure intraoperatively. Post-operatively the patient was
transferred to the surgical Intensive Care Unit on a
Dobutamine drip. There she was rapidly extubated. A Heparin
drip was also started at 400 units per hour. Postoperative
day #1 the patient was started on CellCept and Reglan. She
was receiving 1 cc per cc fluid replacement. Postoperative
day #2 a renal ultrasound was obtained which showed good flow
to both kidneys. Ganciclovir was started for CMV positive
status. On postoperative day #3 Bactrim was started as was
Aspirin and Heparin drip was discontinued. Postoperative day
#4 an MRA of her kidneys were obtained. The MRA revealed no
anastomotic stricture with the renal anastomosis. Also a
good flow was noted to the kidneys. Creatinine on
postoperative day #4 was 6.9. By postoperative day #5 the
patient's urine output began to significantly improve. Her
po intake was good. She was dialyzed using peritoneal
dialysis one time on postoperative day #5 as well. The
patient was on the floor by postoperative day #3. On
postoperative day #6 the patient's JP output was noted to be
approximately 300 cc per day. A creatinine was sent on the
JP fluid which revealed it to be consistent with a
lymphocele. JP creatinine value was 6. Prograf was started
on [**1-23**]. Up to this point the patient was receiving ?????? doses
of thymoglobulin. Rapamune was also started on this day.
The creatinine began to decrease. On [**1-24**] the creatinine was
4.8. Prograf levels were increased to 4 mg [**Hospital1 **] based upon a
low Prograf level. The patient became to experience
persistent nausea and emesis. A KUB was obtained which
revealed no signs of destruction. It appeared that the
patient was experiencing this emesis in relation to taking
her medications. Various anti-emetics were used to insure
the patient received her medications. Creatinine on [**1-26**] was
3.5. An EGD was obtained by the gastrointestinal service on
[**1-27**]. This showed esophagitis of the lower third of the
esophagus and pyloric spasms. The patient was started on
Protonix 40 mg [**Hospital1 **], as well as continuing with the Reglan.
Also patient was put Erythromycin 250 mg tid.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Prograf 4 mg [**Hospital1 **], Rapamune 5 mg q d,
Prednisone 20 mg q d, Ganciclovir 500 mg [**Hospital1 **], Insulin NPH 42
units subcu q a.m., Xalatan eyedrops, Cosopt eyedrops,
Dulcolax 10 mg pr q h.s. prn, Bactrim single strength one
tablet po q day, Erythromycin 250 mg po tid, Colace 100 mg
[**Hospital1 **], Protonix 40 mg [**Hospital1 **], Aspirin 325 mg q d, Reglan 10 mg
qid, Cardizem 300 mg q d.
DISCHARGE STATUS: Rehabilitation facility. The patient has
extensive follow-up set up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].
She also has multiple blood draws set up at appropriate
intervals.
DISCHARGE DIAGNOSIS:
1. Status post cadaveric renal transplant.
2. IDDM.
3. Hypertension.
4. Glaucoma.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2102-1-27**] 15:33
T: [**2102-1-27**] 15:12
JOB#: [**Job Number 29574**]
|
[
"250.41",
"530.11",
"250.51",
"585",
"583.81",
"401.9",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98",
"55.69",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
3813, 4446
|
4467, 4815
|
1104, 3755
|
651, 752
|
180, 494
|
517, 627
|
769, 1086
|
3780, 3789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,470
| 151,299
|
34634+57934
|
Discharge summary
|
report+addendum
|
Admission Date: [**2103-6-18**] Discharge Date: [**2103-7-2**]
Date of Birth: [**2022-11-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Elective intubation for ERCP
3 failed extubation attempts followed by re-intubation
Open trachesotomy placement
History of Present Illness:
80 y/o F with a history of COPD on home oxygen, lung cancer,
hypertension, diabetes, morbid obesity who presented today for
ERCP for RUQ abdominal pain. She was electively intubated given
her history of severe COPD. Post ERCP she was extubated and was
on her way to the recovery room when she became tachypneic and
oxygen saturation dropped into 80s, she also was having a good
amount of pink frothy sputum, of note she only received 800cc of
fluid during the ERCP.
An ECG was obtained which was initially concerning for ischemic
changes. A CXR showed left pleural effusion and cardiomegaly.
She was re-intubated given her oxygen saturations, no blood gas
was drawn prior to re-intubation. She was given ASA, furosemide
and labs were sent including cardiac enzymes. Of note she was
placed on propofol and her BP was in the 90s. An arterial line
was also placed.
Past Medical History:
Severe COPD on home oxygen
Lung cancer
Diabetes
Hypertension
Osteoarthritis
Morbid obesity
Social History:
[**Name (NI) 79450**] unclear how extensive, rare ETOH
Physical Exam:
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of *** cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
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:
[**2103-6-18**] 10:15AM WBC-9.8 RBC-3.90* HGB-12.3 HCT-35.2* MCV-90
MCH-31.6 MCHC-35.0 RDW-13.6
[**2103-6-18**] 10:15AM PLT COUNT-254
[**2103-6-18**] 10:15AM PT-12.9 INR(PT)-1.1
[**2103-6-18**] 10:15AM ALT(SGPT)-17 AST(SGOT)-45* ALK PHOS-57 TOT
BILI-0.4 DIR BILI-0.0 INDIR BIL-0.4
[**2103-6-18**] 10:15AM LIPASE-45
[**2103-6-18**] 03:03PM GLUCOSE-225* UREA N-24* CREAT-1.3* SODIUM-143
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-26 ANION GAP-15
[**2103-6-18**] 03:03PM CK(CPK)-78
[**2103-6-18**] 03:03PM CK-MB-5 cTropnT-0.16*
[**2103-6-18**] 03:03PM CALCIUM-8.5 MAGNESIUM-2.0
.
[**2103-6-18**] 03:03PM BLOOD CK-MB-5 cTropnT-0.16*
[**2103-6-18**] 11:18PM BLOOD CK-MB-15* MB Indx-4.9 cTropnT-0.81*
[**2103-6-19**] 05:33AM BLOOD CK-MB-16* MB Indx-2.8 cTropnT-0.58*
[**2103-6-19**] 12:29PM BLOOD CK-MB-17* MB Indx-1.8 cTropnT-0.58*
[**2103-6-19**] 07:21PM BLOOD CK-MB-16* MB Indx-2.2 cTropnT-0.71*
[**2103-6-20**] 04:30AM BLOOD CK-MB-15* MB Indx-1.9 cTropnT-0.50*
[**2103-6-20**] 12:45PM BLOOD CK-MB-13* cTropnT-0.34*
[**2103-6-21**] 02:23AM BLOOD CK-MB-8 cTropnT-0.27*
[**2103-6-28**] 04:58AM BLOOD CK-MB-3 cTropnT-0.03*
.
TTE [**2103-6-20**]: The left atrium and right atrium are normal in
cavity size. 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. The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild symmetric left ventricular
hypertrophy with preserved global biventricular systolic
function. Minimal aortic valve stenosis. Mild mitral
regurgitation.
.
C. Cath [**2103-6-21**]: FINAL DIAGNOSIS:
1. Coronary arteries are angiographically normal.
2. Biventricular diastolic dysfunction.
3. Moderate pulmonary arterial hypertension.
.
CXR [**2103-6-30**]: IMPRESSION: Persistent CHF. Unchanged left lower
lung opacity and left-sided pleural effusion.
.
ERCP [**2103-6-18**]: Impression: Partial pancreatogram revealed normal
pancreatic duct. Moderate biliary dilation compatible with
benign papillary stenosis.
Sludge in the CBD. Successful biliary sphincterotomy. Successful
sludge extraction using a 15mm balloon.
Brief Hospital Course:
Patient is a 80 year old female with severe COPD, diabetes,
lung cancer, morbid obesity, who presents to ICU s/p ERCP in
setting of hypoxia and reintubation
.
#. Respiratory Failure: the patient initially was distressed
upon extubation after her ECRP complicated by hypertension. She
was reintubated and sent to the [**Hospital Unit Name 153**]. She was able to be weaned
rather rapidly, and she did well on an SBT for over 1 hour prior
to being extubated for the second time. Within 1.5 hours of this
however, she developed extreme respiratory distress with
hypertension requiring re-intubation. At this time, the
physiology was felt to be that the patient was volume overloaded
and carried an amount of diastolic dysfunction, such that when
she was extubated, she had an increased venous return with loss
of peep that she was unable to handle well, resulting in sudden
pulmonary edema. The respiratory distress, in turn, resulted in
marked hypertension, refractory to nitro gtt, which only
worsened her pulmonary edema. The plan at this point was to
leave the patient intubated until we had effectively diuresed
her in order to maximize her chance for successful
re-extubation. She was placed on a lasix gtt and was diuresed
about 10L. She was weaned again to 0/0, which she breathed
successfully on for about 1 hour. She had a cuff leak prior to
extubation, and we were able to verify with the patient herself
that if she were unsuccessfully extubated that she would want
reintubation and ?trach. Upon extubation for the 3rd time, she
initially did well, but within 15 minutes developed stridor. She
was given epi nebs, decadron 6mg IVx1 and heliox, but the
respiratory distress worsened, and once again, the patient had a
marked elevation in blood pressures refractory to nitro gtt. She
did not seem to have any pulmonary edema. Upon reintubation by
anesthesia, there was significant laryngeal edema. She once
again did well, weaning rapidly, and underwent open tracheostomy
on [**2103-6-27**]. Upon discharge to pulmonary rehab, she was able to
wear her passy muir valve for several hours a day and to take
soft solids by mouth.
.
# Acute on Chronic Diastolic Heart Failure: the patient required
massive diuresis on a lasix gtt to optimize her volume status
and continues to still be volume overloaded on exam. She will
require careful attention to her volume status upon transfer to
pulmonary rehab. She was reinitiated on her outpatient does of
lasix, 40mg [**Hospital1 **], prior to discharge.
.
# NSTEMI: the patient, upon her second extubation and subsequent
respiratory failure, developed a LBBB on ekg, and elevated
cardiac enzymes. She was initiated on a heparin gtt, plavix,
high dose statin and aspirin. Beta blockade was also initiated.
Cardiology was consulted who felt that the patient likely had
rate and pressure related demand changes on the ekg, which was
also consistent with the LBBB resolution upon blood pressure and
heart rate control. Nonetheless, she was taken to cath to rule
out significant CAD, as the [**Hospital Unit Name 153**] team was especially concerned
with LAD disease which would be responsible for this rate
related LBBB. She was not found to have any proximal CAD on cath
on [**2103-6-21**]. Her heparin and plavix were then stopped. We have
continued beta blockade as tolerated by her blood pressure.
.
# s/p ERCP: the patient's initial complaints were of vague
epigrastric pain. The ERCP did not show any stones, rather,
moderate biliary dilation compatible with benign papillary
stenosis and sludge in the CBD. She underwent successful biliary
sphincterotomy. She has not had any further complaints of
epigastric pain since the procedure.
.
#. COPD: Patient on 3L home O2, verified by her outpatient
pulmonologist. He noted that she had moderate obstructive
disease. We continued nebulizer treatments while in house.
.
# Leukocytosis: patient grew MRSA from her sputum on two
different samples, with a right lower lobe infiltrate on CXR,
not felt to be VAP as they were isolated shortly after her
initial intubation. She was treated with 7 days of vancomycin.
.
#. Diabetes
- maintained on SSI
.
#. Lung cancer
- s/p LLL resection, did not receive any chemo or XRT, this was
done in [**Hospital3 **]
.
#. FEN- she is tolerating soft PO's while passy muir valve is in
place.
.
#. Access: PIVx2
.
#. PPx: SQ heparin, H2 blocker, elevate HOB, pulmonary toilet
.
The patient is full code.
Medications on Admission:
Lipitor 10mg daily
Citalopram 20mg daily
Advair
Lasix 40mg PO BID
Neurontin 300mg PO QID
Prevacid 30mg daily
Metformin 500mg daily
KCl
Ropinrole 1mg QID
Tiotropium inhaled once daily
Tolterodine 4mg daily
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day) as needed.
13. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q 8H (Every 8 Hours).
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1. Respiratory Failure x 3
2. S/p Tracheostomy
3. Acute Diastolic Congestive Heart Failure
4. Laryngeal Edema
5. Non ST elevation MI
6. COPD
.
Secondary:
1. Diabetes Mellitus
2. Hypertension
3. Lung ca s/p LUL lobectomy
Discharge Condition:
Stable on trach mask, tolerating passy muir valve, soft solids
Discharge Instructions:
Patient was admitted to the Intensive Care Unit initially for
failure to successfully extubate after elective intubation for
ERCP. She was attempted to be extubated 2 more times, but
failed, firstly from acute diastolic heart failure, and second
from laryngeal edema. She underwent open tracheostomy
subsequently, and has been stabilized on passy muir on trach
mask.
.
She will require pulmonary rehabilitation for trach wean, as
well as continued attention to rate control with beta blockade,
and volume status with lasix titration.
Followup Instructions:
Please make follow up appointments both with your outpatient
cardiologist and with your outpatient pulmonologist within 2
weeks of discharge.
Name: [**Known lastname 12770**],[**Known firstname 1116**] Unit No: [**Numeric Identifier 12771**]
Admission Date: [**2103-6-18**] Discharge Date: [**2103-7-2**]
Date of Birth: [**2022-11-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2097**]
Addendum:
Please continue to monitor for signs of infection, WBC was 18
upon discharge to rehab on [**7-2**]. It is believed that this is most
likely leukocytosis secondary to steroids given for laryngeal
edema.
Additionally, patient has been unable to receive her doses of
metoprolol, albeit small, due to borderline HR and blood
pressures. Would continue to try and administer this medication,
but use holding parameters (do not give for HR<60 or SBP<90).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] TCU - [**Location (un) 50**]
[**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**] MD [**MD Number(1) 2099**]
Completed by:[**2103-7-2**]
|
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icd9cm
|
[
[
[]
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[
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"31.1",
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"37.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13179, 13412
|
5128, 9564
|
292, 405
|
11565, 11630
|
2323, 4568
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|
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|
11313, 11544
|
9590, 9797
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4585, 5105
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11654, 12189
|
1500, 2304
|
233, 254
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433, 1298
|
1320, 1413
|
1429, 1485
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
149
| 154,869
|
49630
|
Discharge summary
|
report
|
Admission Date: [**2135-2-18**] Discharge Date: [**2135-2-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
fatigue, dyspnea on exertion
Major Surgical or Invasive Procedure:
cardiac catheterization with stent placed at left anterior
descending artery
History of Present Illness:
[**Age over 90 **] yo woman with htn brought to ED from her [**Hospital3 **]
facility after c/o several weeks of doe after walking across the
room, fatigue. History is difficult to obtain from pt secondary
to dementia, most history is provided by nephew. [**Name (NI) **] chest
pain, dizziness, paraesthesias.
Past Medical History:
dementia
kyphosis
hypertension
Social History:
lives in [**Hospital3 **] facility
no tobacco
Physical Exam:
T 98.0 HR 80s BP 110/80 RR 14 94% RA
no acute distress, obese, oriented to person only
no JVD
cardiac exam RRR nl s1s2 no mrg
soft b/l basilar rales
abdomen soft no nd nabs
extremities with trace edema
Pertinent Results:
ECHO:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.3 cm
Left Ventricle - Fractional Shortening: *0.27 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 35% (nl >=55%)
Aorta - Valve Level: 2.9 cm (nl <= 3.6 cm)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 183 msec
TR Gradient (+ RA = PASP): *45 to 50 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderately
depressed LVEF. No LV mass/thrombus.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Moderate (2+) MR.
TRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA
systolic
hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Overall left ventricular systolic
function is
moderately depressed. Anterior, distal septal, apical, distal
lateral, and
distal infeior akinesis is present.
3. The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation
is seen.
4. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
5. Moderate to severe [3+] tricuspid regurgitation is seen.
6. There is moderate pulmonary artery systolic htn.
.
.
CARDIAC CATHETERIZATION
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through a 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 6 French right [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French XBLAD 3.5 and a 6 French JR4 catheter, with manual
contrast
injections.
Visualization of the left coronary artery was repeated after the
i.c.
administration of 50 mcg of nitroglycerine.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.62 m2
HEMOGLOBIN: 10.7 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 25/26/24
RIGHT VENTRICLE {s/ed} 55/25
PULMONARY ARTERY {s/d/m} 55/30/41
PULMONARY WEDGE {a/v/m} 32/33/31
AORTA {s/d/m} 131/68/94
**CARDIAC OUTPUT
HEART RATE {beats/min} 70
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 81
CARD. OP/IND FICK {l/mn/m2} 2.5/1.5
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 2240
PULMONARY VASC. RESISTANCE 320
**% SATURATION DATA (NL)
SVC LOW 42
PA MAIN 43
AO 99
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 100
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 DISCRETE 70
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
**PTCA RESULTS
LAD
**BASELINE
STENOSIS PRE-PTCA 100
**TECHNIQUE
PTCA SEQUENCE 1
GUIDING CATH XBLAD 3.
GUIDEWIRES CHOICE P
INITIAL BALLOON (mm) 2.5 X 15
FINAL BALLOON (mm) 2.5 X 24
# INFLATIONS 8
MAX PRESSURE (PSI) 270
**RESULT
STENOSIS POST-PTCA 0
SUCCESS? (Y/N) Y
PTCA COMMENTS:
We elected to treat the totally occluded proximal LAD with
PTCA/Stenting using heparin and integrilin prophylactically. A
Choice
PTXS wire crossed into the LAD with significant difficulty (a
Wizdom SS
wire and several PT [**Name (NI) 9165**] Intermediate wires would not cross).
A 2.5
x 15 mm Voyager was used to predilate in five inflations at 8-9
atm. An
export catheter would not cross beyond the proximal LAD, but
suctioning
of this area resulted in minor improvement in flow. A 2.5 x 24
mm Taxus
DES was deployed proximally and into the mid-LAD at 12 atm, and
another
2.5 x 24 mm Taxus DES was deployed in overlapping fashion more
distally
at 12 atm. The second SDS was used to post-dilate the overlap
area at
18 atm. There was significant spasm and no-reflow in the
[**Last Name (LF) 12425**], [**First Name3 (LF) **]
intracoronary nitroglycerin and nitroprusside were adminstered
through
the guide, and more intracoronary nitroprusside was administered
through
the lumen of a 2.0 x 30 mm Maverick positioned just distal to
the second
stent.
Final angiography demonstrated no dissection, no residual
stenosis
within the stented segments with loss of a major diagonal branch
(closed
at the start of the case), and TIMI-3 flow into a diffusely
diseased
distal LAD.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 38 minutes.
Arterial time = 1 hour 34 minutes.
Fluoro time = 43.1 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 175
ml, Indications - Hemodynamic
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 1000 units IV
Other medication:
Fentanyl 12.5 mcg IV
Furosemide 80 mg IV
Integrilin 10 cc IV bolus
Integrilin 4.5 cc/hr
Nitroprusside 550 mcg IC
Plavix 300 mg PO
Cardiac Cath Supplies Used:
.014 CORDIS, WIZDOM SS 300
.014 [**Name (NI) **], PT [**Name (NI) **], 300CM
.014 [**Name (NI) **], PT [**Name (NI) **], 300CM
2.5 GUIDANT, VOYAGER 15
2.0 [**Company **], MAVERICK, 30
6F CORDIS, XBLAD 3.5
2.5 [**Company **], TAXUS EXPRESS 2 OTW, 24
2.5 [**Company **], TAXUS EXPRESS 2 OTW, 24
3F [**Company **], EXPORT ASPIRATION CATHETER
COMMENTS:
1. Selective coronary angiography demonstrated a right dominant
system
with two [**Company 12425**] CAD. The left main had mild disease. The LAD
had a 70%
lesion at it's origin and a 100% proximal occlusion. The left
circumlfex artery had a 70% lesion in the OM1 branch. The RCA
had mild
disease.
2. Resting hemodynamics demonstrated markedly elevated right and
left
sided filling pressures with a mean RA pressure of 24 mm Hg and
mean
PCWP of 31 mm Hg. Moderate pulmonary hypertension was present.
The
cardiac index was markedly reduced, based on an assumed oxygen
consumption index. Central aortic pressure was normal.
3. Left ventriculography was not performed.
4. Successful PCI of the LAD with two overlapping Taxus DES (2.5
x 24 mm
and 2.5 x 24 mm).
FINAL DIAGNOSIS:
1. Two [**Company 12425**] coronary artery disease.
2. Markedly reduced cardiac index with elevated left and right
sided
filling pressures but normal central aortic pressure.
3. Acute anterior STEMI treated with primary PCI.
.
.
[**2135-2-18**] 10:36PM CK(CPK)-606*
[**2135-2-18**] 10:36PM CK-MB-58* MB INDX-9.6*
Brief Hospital Course:
The patient is a [**Age over 90 **] year old woman with hypertension,
hyperlipidemia, and no known CAD. She presented to the
emergency
department with dyspnea. ECG demonstrated anterior STEMI.
After a
discussion with the patient's nephew, the patient was brought to
the
catheterization laboratory where she was found to have occlusion
of the LAD with 80% stenosis at OM1. She had a cypher stent
placed to the LAD. She was found to have a low cardiac index
with low mvo2 during catheterization. She was diuresed 1 liter
over the course of her hospitalization which she tolerated well,
and resulted in marked improvement in her oxygenation.
Hospitalization was complicated by increased bleeding at access
site after catheterization, for which hemostasis was eventually
obtained but integrellin was discontinued early. Her hematocrit
remained stable. As post MI echo showed akinesis, pt was
started on coumadin for a 6 month course after determining she
was not a fall risk with physical therapy and with her PCP. [**Name10 (NameIs) **]
was also found to have a UTI for which she was treated with
Levaquin.
Medications on Admission:
zyprexa, lipitor
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Sertraline HCl 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Atorvastatin Calcium 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
acute myocardial infarction
dementia
hypertension
Discharge Condition:
stable
Discharge Instructions:
Return to the emergency department if you develop chest pain,
shortness of breath, or dizziness.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 103787**] partner will see you while you are at [**Hospital 100**]
Rehab. Dr. [**Last Name (STitle) 6680**] will see you once you are back at [**Location (un) **].
.
You will follow up with a Cardiology appointment at [**Hospital1 **] out patient clinic with Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2135-3-21**] 11:00
.
***** TO FOLLOW UP:
1) Patient started on lasix 40mg qd, as well as potassium.
Please monitor Cr levels and potassium levels. At time of
discharge, Cr is 1.5.
2) Patient recently started on coumadin 5mg qd. At time of
discharge, INR is 1.4 (after 2 doses of coumadin). She is being
discharged on 3mg dose qd.
Import Follow-up Instructions
Follow-up Instructions:
Completed by:[**2135-2-25**]
|
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icd9cm
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[
[
[]
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[
"36.07",
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"88.53",
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"99.20",
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icd9pcs
|
[
[
[]
]
] |
10711, 10784
|
8910, 10023
|
292, 371
|
10878, 10886
|
1067, 6735
|
11031, 11592
|
10090, 10688
|
10805, 10857
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10049, 10067
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8569, 8887
|
10910, 11008
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845, 1048
|
11604, 11926
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6754, 8552
|
224, 254
|
399, 713
|
11953, 11981
|
735, 767
|
783, 830
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,331
| 110,704
|
11675
|
Discharge summary
|
report
|
Admission Date: [**2152-12-7**] Discharge Date: [**2152-12-13**]
Service: ACOVE/MED
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 36976**] is an 88-year-old
resident of [**Hospital **] Rehabilitation Center for Aged with a
past medical history of dementia, bipolar disorder,
Parkinson's, urinary and fecal incontinence, who presents
from the Medical Intensive Care Unit with hypernatremia.
The patient was in her usual state of health until three days
prior to arrival, when she was noted to be febrile and lethargic.
Urine
culture was sent and she was started on levofloxacin 250 mg by
mouth
once daily. The next day, the patient was alert but with
intermittent fevers. One day prior to arrival, laboratories
glucose of 645, and a creatinine of 1.7. The patient also
had tachycardia, tachypnea, and an oxygen saturation of 91 to
92% on room air. She was transferred to [**Hospital1 36977**] for evaluation.
In the Emergency Department, the patient was given
intravenous fluids, normal saline, changed to half-normal
saline, and started on an insulin drip. Ceftriaxone was given,
and
the patient had a corrected sodium at this time of 179, with a
free water deficit calculated at 8 liters. The source
of the increased white count was unclear, with urine,
pancreas,and decubiti possible sources. The patient
continued on ceftriaxone, was made NPO, and was
transferred to the floor from the Medical Intensive Care Unit
after 24 hours.
At presentation on the floor, the patient had a sodium of 162,
platelets decreased to 61. Chest x-ray was consistent with
pneumonia. The patient had no complaints, but was aphasic,
answers
questions with shaking of head.
PAST MEDICAL HISTORY:
1. Bipolar disorder
2. Parkinson's disease
3. Dementia
4. Gastroesophageal reflux disease
5. Status post right hip open reduction and internal
fixation
6. Urinary/fecal incontinence
7. Bilateral cataract surgery
MEDICATIONS ON ADMISSION: Aspirin 81 mg by mouth once
daily, multivitamin one tablet by mouth once daily, Axid 150
mg by mouth once daily, calcium carbonate 650 mg by mouth
twice a day, Sorbitol 5 ml by mouth once daily, Sinemet
25/100 two tablets three times a day one hour before meals,
Tylenol 650 mg by mouth every four hours as needed,
Guaifenesin syrup 15 ml every four hours as needed for cough.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Resident of [**Hospital1 5595**]. Patient is a widow, has
two daughters, emigrated from [**Name (NI) 36978**] in [**2071**].
PHYSICAL EXAMINATION: On presentation to the floor,
temperature 98.3, blood pressure 132/60, pulse 90,
respiratory rate 22, pulse oxygenation 90% on 3 liters,
finger stick oxygen saturation 66. Head, eyes, ears, nose
and throat anicteric, clear. Regular rate and rhythm, S1,
S2, II/VI systolic murmur at left upper sternal border.
Pulmonary showed crackles of the right lung three-quarters of
the way up. The left lung was clear. The abdomen was soft,
nontender, nondistended, positive bowel sounds. Extremities:
Trace edema bilaterally. Neurological: Patient responds to
questions with head shakes. Normal affect.
LABORATORY DATA: On presentation to the floor, sodium 162,
potassium 4.1, chloride 132, CO2 22, BUN 37, creatinine 1.1,
glucose 289. On [**12-8**], white count 18.3, hematocrit 37.0,
platelets 61, MCV 85. INR 1.4, PT 14.3, PTT 3.09. On [**12-7**],
ALT 42, AST 37, alkaline phosphatase 84, amylase 255, total
bilirubin 0.5, lipase 450. CKs showed progression from 90 to
101 to 164 to 175. Troponin went from 1.7 to 0.9 at the
third troponin check. On [**12-7**], serum osmolality of 420. On
[**12-7**], urine sodium 16, potassium 67, chloride 20. On [**12-8**],
urine culture showed less than 10,000 organisms. On [**12-7**],
urinalysis yellow, clear, specific gravity of 1.025, large
blood, negative nitrates, 100 protein, 500 glucose, trace
ketones, [**12-5**] red blood cells, [**6-25**] white blood cells,
moderate bacteria, [**12-5**] epithelial cells. On [**12-8**], chest
x-ray left hilar opacity, acute aspiration pneumonia vs.
pneumonia, no congestive heart failure, central line intact.
HOSPITAL COURSE: This is an 88-year-old resident of [**Hospital1 5595**]
with a past medical history of bipolar disorder, Parkinson's,
dementia, gastroesophageal reflux disease, status post right
hip open reduction and internal fixation, urinary and fecal
incontinence, who presents with hypernatremia, pneumonia,
decreased platelets, troponin elevation, and laboratories
consistent with pancreatitis.
1. Hypernatremia: The etiology was thought to be
secondary to hyperglycemia combined with decreased thirst related
to dementia. Patient's calculated free water
deficit when originally on the floor of 4 liters. The
patient did appear mildly dry. The patient's fluids were
managed carefully, and the patient was slowly brought down to
a normal sodium of 141. The patient did not correct faster
than 0.5 mEq/hour while on the floor. The patient's mental
status improved with rehydration and correction of
hypernatremia, so that the patient would verbalize three or
four words at the time of discharge.
2. Infectious Disease: Patient with unclear source to
elevated white count. Throughout her hospital stay, the
patient's white count declined to a normal level and, on
[**12-12**], the patient's white count was 9.6. The patient's
urine cultures did not grow anything. The patient's chest
x-ray, which was originally consistent with possible
pneumonia, cleared the next day on subsequent chest x-ray.
This was thought to possibly represent aspiration
pneumonitis. The patient was continued on ceftriaxone for
six days, then switched to oral levofloxacin to finish a 14
day course for a probable pneumonia.
3. Hematology: The patient's platelets declined while an
inpatient. The patient had a nadir of platelets at 38.
Subcutaneous heparin was stopped. DIC panel was checked.
Fibrinogen was normal, however, D-Dimers and FDP were both
consistent with DIC. The patient's coags continued to
correct. On [**12-11**], the patient's INR was 1.1 with a PT of
12.7 and PTT of 26.6. It was thought that her
thrombocytopenia was secondary to DIC. The patient's
platelets increased and, on [**12-11**], they were 57 and on [**12-12**]
they were 68. The patient's platelets should be monitored as an
outpatient.
4. Gastrointestinal: Patient with laboratories consistent
with pancreatitis. The patient did have mild tenderness in
the epigastrium to deep palpation. This pain appeared to
resolve over the next several days. Triglycerides were
checked and came back at 216 and were not thought to be the
cause of her pancreatitis. The patient did not have an
obstructive picture. The patient's amylase and lipase
declined and, at the time of discharge, lipase was mildly
elevated and amylase normal for two days.
5. Endocrinology: Patient admitted with extremely high
blood sugar. The patient had a hemoglobin A1c sent, which
came back high at 10.8. The patient was covered with sliding
scale while an inpatient, however, the patient was nothing by
mouth throughout much of her hospital stay. There was
thought given to starting an oral hyperglycemic medication.
This was deferred to the outpatient setting, where her sugars
will be monitored.
6. Fluids, electrolytes and nutrition: The patient was
started on an oral diet on [**12-12**] after pancreatitis had
resolved. The patient tolerated thick liquids. The patient
was discharged with the plan to increase oral intake as an
outpatient.
7. Pulmonary: Patient with oxygen requirement on admission.
The patient continued to have oxygen requirement throughout
her hospital stay of 3 liters. It was unclear what the cause
of the hypoxemia and hypoxia was. Patient with question
pneumonia per chest x-ray. Patient was seen by Physical
Therapy, who performed vigorous chest physical therapy on the
patient. This seemed to clear a lot of yellowish secretions.
These did not show any PMNs, and Gram stain was not positive
for bacteria. There was a possible diagnosis of ongoing
aspiration. The patient's head of bed was kept up at 30 to
45 degrees throughout her hospital stay.
DISCHARGE CONDITION: Fair
DISCHARGE PLACE: The patient was discharged to [**Hospital **]
Rehabilitation Center for Aged.
CODE STATUS: The patient is Do Not Resuscitate/Do Not
Intubate.
DISCHARGE MEDICATIONS: As per admission medications, plus
sliding scale of regular insulin and levofloxacin 500 mg by
mouth once daily for eight days.
DISCHARGE DIAGNOSIS:
1. Type 2 diabetes
2. Hypernatremia
3. Pancreatitis
4. Mild DIC
5. Possible pneumonia
FOLLOW UP:
1. The patient needs checking of her blood sugars with
recent diagnosis of Type 2 diabetes. She may need to start
on an oral hyperglycemia medication.
2. The patient will need continued assessment of fluid
status to prevent future hypernatremia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 16137**] 12-154
Dictated By:[**Last Name (NamePattern1) 1324**]
MEDQUIST36
D: [**2152-12-12**] 23:41
T: [**2152-12-13**] 00:00
JOB#: [**Job Number 36979**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
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icd9pcs
|
[
[
[]
]
] |
8235, 8405
|
8430, 8559
|
8580, 8672
|
1952, 2369
|
4168, 8213
|
8683, 9175
|
2538, 4149
|
125, 1682
|
1704, 1924
|
2387, 2514
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,896
| 198,260
|
33338
|
Discharge summary
|
report
|
Admission Date: [**2180-7-28**] Discharge Date: [**2180-8-1**]
Date of Birth: [**2108-9-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
PCI with stenting
History of Present Illness:
71 yo male with PMHx significant for known CAD s/p DES to
mid-LAD in [**2177**] presented to ED this morning with chest pain
that awoke him in the middle of the night. He said the pain
began suddenly and was excruciating. It radiated to both
shoulders and felt "as if someone were pulling my heart both
ways." It was associated with shortness of breath, diaphoresis,
but no nausea. His wife gave him two aspirin and a sublingual
nitroglycerin pill, but he experienced no relief. He decided to
present to the ED of an OSH. An EKG showed a new RBBB and
troponin of 0.05. He was given ASA and heparin and transferred
to [**Hospital1 18**] for urgent catheterization.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough. 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 and dyspnea
on exertion. He denies paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CAD - s/p stent
2. Hyperlipidemia
3. Back injury s/p surgery - uses walker, has problems with L
leg giving out on him at unpredictable times
Social History:
Pt is married and lives alone with his wife, they both use
walkers but are able to live independently. He has been smoking
since [**85**] y/o. No etoh or drug use.
Family History:
No history of CAD, MI, CVA or sudden death. Father with DM.
Physical Exam:
VS: T=97 BP=149/71 HR=64 RR=16 O2 sat=100% on 2LNC
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate. Pt supine for exam (s/p cath)
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm. No carotid bruits
CARDIAC: PMI located in 5th intercostal space, left of the
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. Site of cath has
dressing that is c/d/i. No active bleeding.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Hair
thinning and waxiness of the BLE, suggestive of changes
associated with arterial insufficiency.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP doppler PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP doppler PT 1+
Pertinent Results:
[**2180-7-28**] 07:20AM BLOOD WBC-9.4 RBC-4.87 Hgb-13.7* Hct-42.0
MCV-86 MCH-28.1 MCHC-32.6 RDW-13.7 Plt Ct-261
[**2180-7-28**] 07:20AM BLOOD Glucose-116* UreaN-18 Creat-0.9 Na-141
K-3.7 Cl-103 HCO3-24 AnGap-18
[**2180-7-28**] 07:20AM BLOOD cTropnT-0.08*
[**2180-7-28**] 07:20AM BLOOD Calcium-9.1 Phos-2.2*# Mg-1.9
CATH:
1. Selective coronray angiography in this right dominant system
revealed
single vessel disease. The LMCA had minimal disease. The LAD
was
occluded in the stent with slight TIMI 2 flow; 70% stenosis at
proximal
stent and subtotal occlusion in the mid stent. The LCx was
without
angiographically significant stenosis. The RCA was without
angiographically significant stenosis.
2. Limited resting hemodynamics revealed elevated central aortic
systemic pressures 154/71 with a mean of 99 mmHg.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderately elevated systemic hypertension.
Brief Hospital Course:
Mr. [**Known lastname **] is a 71M w hx of CAD s/p DES to mid-LAD in [**2177**]
who presented to ED with STEMI, found to have an in-stent
thrombosis in cath lab, was re-stented, transferred from
cardiology floor to CCU for large volume dark stool.
.
Coronary artery disease: The patient was brought to the cath lab
immediately upon transfer to [**Hospital1 18**]. Initial catheterization
revealed the LAD was occluded in the stent with slight TIMI 2
flow; 70% stenosis at proximal stent and subtotal occlusion in
the mid stent. PCI was performed with removal of the thrombosis
and deployment of two drug-eluting stents (of different
formulation than his previous stent). Upon transfer to the CCU
(after large GI bleed), he experienced similar chest pain to
presentation that progressed to [**8-27**]. ECG showed ST elevations
in V3 and V4 which were new compared to his post PCI ECG. He
was given IV morphine, was started on a nitroglycerin drip, and
was taken back to the cath lab out of concern for repeat
in-stent thrombosis. This second catheterization showed clean
coronaries, after which time his chest pain subsided, the nitro
drip was stopped, and he was continued on aspirin and plavix.
He remained in the CCU for monitoring and the next day was
transferred to the floor. An echocardiogram was completed which
showed mild symmetric left ventricular hypertrophy with mild
regional left ventricular systolic dysfunction and preserved
global function LVEF >55%. During his first night back on the
floor ([**2180-7-31**]), he had an episode of severe chest pain
associated with diaphoresis, new ST depressions on ECG and
hypertension and tachycardia. This was most likely due to post
PCI coronary vasospasm. He was given sublingual nitroglycerin
with relief. He reported feeling very anxious at the time.
Repeat ECG in the AM showed resolution of ST depressions, he was
given lorazepam once for anxiety, and he was restarted on his
home imdur. He remained chest pain free and was discharged on
[**2180-8-1**].
.
GI bleed: The patient had a large dark maroon bowel movement
after receiving eptifibatide, most likely from a lower GI source
such as diverticulosis. His Hct dropped from 42 to 29 and
received 3u of pRBCs with Hct stable 35-37. Heparin was given
just prior to his second catheterization, however once in-stent
thrombosis was ruled out, all heparin was stopped. Our
gastroenterology team saw the patient and because he did not
have any repeat bloody bowel movements, no NG lavage was
completed and he should have an elective EGD/colonoscopy to help
identify his bleeding source upon outpatient follow up. He was
discharged on ranitidine for PUD prophylaxis.
.
Hypertension: Blood pressures stable in the 130s systolic on
arrival to the CCU.
BP meds were initially held in the setting of his GI bleed,
however he was restarted on metoprolol 25mg [**Hospital1 **] once his HCT was
stabilized. Upon discharge, he was transitioned to toprol 50mg
daily, started on lisinopril 2.5mg daily and his HCTZ and
diltiazem were held.
.
Chronic Back Pain: No current complaints of back or leg pain.
Gabapentin 300 mg daily was continued.
.
The patient was seen by physical therapy who cleared him for
independent ambulation and he was sent home with VNA services.
.
The patient was full code for this admission.
Medications on Admission:
Diltiazem 120 mg daily
gabapentin 300 mg qhs
HCTZ 25 mg daily
isosorbide mononitrate 60 mg daily
simvastatin 40 mg daily
ASA 81 mg daily
Plavix 75 mg daily
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Imdur 60 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual asdir: Take 1 tab sublingually as needed for chest
pain. Can repeat after 5 minutes for total of 3 tabs. If chest
pain continues, call your doctor and go to the emergency
department to seek immediate care.
Disp:*25 tabs* Refills:*2*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: do not stop taking
daily for at least one year.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day:
do not stop taking daily for at least one year.
Disp:*30 Tablet(s)* Refills:*11*
8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Principal Diagnoses:
1. STEMI secondary to instent restenosis and thrombosis of the
LAD with placement of two drug eluting stents.
Secondary Diagnoses:
1. Hypertension
2. Chronic low back pain
3. Left main bronchus AVM
4. Endobronchial benign-appearing polyp (notbleeding)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 69**] after
you experienced chest pain. As you recall, you went to the
emergency department for your chest pain, where initial blood
work and an EKG suggested a myocardial infarction, sometimes
called a heart attack. This required you to be transferred to
[**Hospital3 **] for a cardiac catheterization.
At [**Hospital3 **], the cardiac catheterization showed a blockage in
one of the coronary arteries (the arteries in your heart). This
blockage occurred in the same location where a stent was placed
two years ago (also at [**Hospital3 **]). The blockage was removed,
and two stents were used to open this area.
Following your procedure, you were brought to the hospital floor
for monitoring. You had a very large bloody bowel movement while
on very strong blood thinners for your heart attack; this was
very concerning to us, so we transferred you to the Cardiac
Critical Care Unit to be monitored very closely and transfused
you with 3 units of blood. Around that time you had also
developed severe chest pain, so we took you back to the
Catheterization Lab where we found that the arteries in your
heart were clear of blockages.
You continued to do well and were determined to be stable for
discharge. You did not have another bloody bowel movement, but
per the gastroenterology team who saw you in the hospital, you
should schedule and outpatient endoscopy and colonoscopy to
evaluate your gastrointestinal bleed. Please see below for your
follow up clinic visit with your gastroenterologist.
We made the following changes to your medications.
-Stop Hydrochlorothiazide and Diltiazem
-Start Lisinopril 2.5 mg daily to lower your blood pressure.
- Stat Toprol XL to lower your heart rate and help your heart
recover from the heart attack.
-Increase aspirin to 325mg daily
-Start ranitidine 150mg twice daily to help prevent a repeat
bowel bleed
-Take nitroglycerin 0.4mg 1 tab as needed for chest pain. Can
repeat for total of 3 tabs (waiting 5 minutes in between tabs).
If chest pain continues, please call your doctor and go to the
emergency room to seek immediate care.
- Increase simvastatin to 80 mg daily
You must take Plavix and a aspirin for at least one year in
order to prevent narrowing in the arteries where the stent was
placed. Taking plavix will help lower your risk of having
another heart attack.
Please follow up with your new cardiologist Dr. [**Last Name (STitle) **] per
below. You may need to have some or all of your blood pressure
medications restarted in the future.
It was a pleasure taking care of you. We wish you a speedy
recovery.
Followup Instructions:
Primary Care:
Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 17753**]
Thursday, [**2180-8-10**] at 10:15am
[**State **]
Please schedule a followup appointment with your
Gastroenterologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Location (un) 620**]. Phone:
([**Telephone/Fax (1) 77392**]
We have otherwise set up a followup appointment for you with one
of the gastroenterologists you had seen here-- you may cancel
this appointment once you have set one up with Dr. [**Last Name (STitle) **] in
[**Location (un) 620**]:
Gastroenterology:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 10314**]
Date/Time: [**2180-8-22**] at 01:00p
[**Hospital1 **], [**Hospital Ward Name 516**]
[**Location (un) **]
[**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
GI [**Hospital 14974**] CLINIC
Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 4105**] Date/
Time: [**First Name9 (NamePattern2) **] [**8-8**] at 2:00pm at [**Hospital1 **]
Completed by:[**2180-8-2**]
|
[
"562.12",
"E878.1",
"729.5",
"426.4",
"410.11",
"V45.82",
"414.01",
"724.5",
"996.72",
"E934.8",
"272.4",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"99.20",
"37.22",
"00.46",
"00.40",
"00.66",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8821, 8870
|
4031, 7363
|
325, 345
|
9187, 9187
|
3086, 3904
|
12009, 13160
|
1897, 1959
|
7569, 8798
|
8891, 9022
|
7389, 7546
|
3921, 4008
|
9338, 11986
|
1974, 3067
|
9043, 9166
|
275, 287
|
375, 1531
|
9202, 9314
|
1553, 1699
|
1715, 1881
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,308
| 136,508
|
33866
|
Discharge summary
|
report
|
Admission Date: [**2196-7-19**] Discharge Date: [**2196-7-26**]
Date of Birth: [**2151-12-9**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Left Arm tingling
Major Surgical or Invasive Procedure:
[**7-20**]: Left craniotomy for mass resection
History of Present Illness:
44M with h/o of Stage III melanoma followed by neuro oncology.
Per pt he has been experiancing tingling in his R arm for 2
weeks and felt that it was a side affect of his interferon which
he has been on for 36 weeks. On [**7-19**], while he was at work
was noted to have spasm and uncontrollable contraction of RUE
and unable to operate heavy machinery.
Past Medical History:
Stage III melanoma [**May 2195**]
Social History:
Married, resides at home with wife; works full time with heavy
machinery
Family History:
Non-contributory
Physical Exam:
On Admission:
T:97.4 BP:141/91 HR:76 RR 16 O2Sats 97
Gen: WD/WN, comfortable, NAD.
HEENT:atraumatic Pupils:PERRL EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-7**] throughout however exam notable
for 5- grip LUE. No pronator drift
Sensation: Tingling on lateral aspect of RUE from just below the
deltoid to finger tips.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
On Discharge:
Alert, oriented to person, place, date(with some prompting). LUE
with full strength. RUE with 4+/5 weakness in tricep and grip,
5- bicep/delt. LE are full strength. Right pronator drift.
PERRL. Sensation intact.
Pertinent Results:
Labs On Admission:
[**2196-7-19**] 11:32AM BLOOD WBC-4.0 RBC-4.10* Hgb-12.9* Hct-35.1*
MCV-86 MCH-31.6 MCHC-36.9* RDW-13.4 Plt Ct-236
[**2196-7-19**] 11:32AM BLOOD Neuts-78.7* Lymphs-11.9* Monos-8.3
Eos-0.7 Baso-0.3
[**2196-7-19**] 11:32AM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1
[**2196-7-19**] 11:32AM BLOOD Glucose-125* UreaN-13 Creat-0.8 Na-139
K-3.9 Cl-104 HCO3-25 AnGap-14
[**2196-7-20**] 05:15AM BLOOD Calcium-9.8 Phos-2.8 Mg-2.1
Labs on Discharge:
[**2196-7-25**] 05:20AM BLOOD WBC-13.7* RBC-4.19* Hgb-13.1* Hct-35.8*
MCV-85 MCH-31.1 MCHC-36.5* RDW-13.4 Plt Ct-267
[**2196-7-25**] 05:20AM BLOOD PT-12.5 PTT-27.8 INR(PT)-1.1
[**2196-7-25**] 05:20AM BLOOD Glucose-81 UreaN-14 Creat-0.6 Na-133
K-4.4 Cl-101 HCO3-22 AnGap-14
[**2196-7-23**] 07:00AM BLOOD ALT-19 AST-9 AlkPhos-46 Amylase-122*
TotBili-0.6 DirBili-0.1 IndBili-0.5
[**2196-7-24**] 07:00AM BLOOD Amylase-98
[**2196-7-25**] 05:20AM BLOOD Amylase-99
[**2196-7-21**] 09:25PM BLOOD Lipase-470*
[**2196-7-23**] 07:00AM BLOOD Lipase-109*
[**2196-7-24**] 07:00AM BLOOD Lipase-105*
[**2196-7-25**] 05:20AM BLOOD Lipase-120*
[**2196-7-25**] 05:20AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.4
[**2196-7-23**] 07:00AM BLOOD Triglyc-130
-------------------
IMAGING:
CT Head [**7-19**]:
INDINGS: There is no evidence of acute hemorrhage or major
vascular
territorial infarction. There are two hyperdense masses in the
left cerebral hemisphere. The first is a 2.7 x 2.8 cm mass in
the elft frontal lobe, with surrounding hypodensity consistent
with edema. The second mass in the left parietal
corticomedullary junction measures 1 x 1 cm with a small amount
of surrounding edema and mass effect on the left occipital [**Doctor Last Name 534**].
The remainder of the ventricles and sulci are normal in size and
appearance. The visualized paranasal sinuses and mastoid air
cells are well aerated. No osseous abnormality is identified.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Left frontal and left parietal mass lesions most concerning
for
metastatic disease. MRI Head without and with IV contrast
ecommended for
further evaluation.
CT Head [**7-20**](Post-op):
FINDINGS: The patient is post-resection of a larger left frontal
mass, with trace hemorrhage in the surgical bed. There is a
moderate amount of
pneumocephalus, mainly in the anterior cranial fossa. The left
parietal 1-cm hyperdense metastasis with small amount of edema
is unchanged. There is no shift of normally midline structures
or hydrocephalus. Bone windows demonstrate evidence of left
parietal craniotomy. The paranasal sinuses remain clear, with
the exception of opacification of a few right mastoid air cells
and a retention cyst in the left maxillary sinus.
IMPRESSION:
1. Status post resection of the left frontal mass with trace
hemorrhagic
products in the surgical bed.
2. Moderate amount of pneumocephalus, predominantly in the
anterior cranial fossa, recommend short-term followup, to
exclude progression of
pneumocephalus.
3. No increase in edema and mass effect associated with
remaining left
parietal metastasis.
MRI Head [**7-21**](Post-op);
MRI BRAIN WITH CONTRAST
There is a large amount of pneumocephalus. Within the surgical
resection
cavity in the left parietal lobe, there are increased blood
products which
demonstrate T1-hyperintensity and were also seen on the most
recent head CT. No definite residual foci of enhancement are
noted post- gadolinium, but somewhat more prominent appearance
to the blood products is noted on the post-gadolinium MP-RAGE
sequences. The degree of edema surrounding the resected tumor
appears slightly improved from the preoperative examination. The
smaller lesion noted within the posterior left parietal lobe
with hemorrhagic component is unchanged and measures
approximately 13 x 14 mm, currently. A suspicious more punctate
focus within the right frontal lobe is less conspicuous on
today's exam (series 10, image 18). There is expected new
diffuse pachymeningeal enhancement, after surgery.
No new lesion isidentified. The remaining brain parenchyma is
unchanged in
appearance with no region of acute infarction.
IMPRESSION:
1. Status post resection of dominant hemorrhagic left parietal
metastatic
lesion. No definite foci suspicious for residual tumor are
identified,
though evaluation of the superior and posterior aspect of the
resection
cavity, is somewhat limited by the blood products at this site.
Attention
should be paid to this region on subsequent studies, as these
resorb.
2. Unchanged appearance to previously-described two other
presumed metastatic foci, the larger one, also within the left
parietal lobe displays unchanged hemorrhagic component/melanin
and internal enhancement.
RUQ US [**7-22**]:
FINDINGS: The liver is normal in appearance. There is no
intrahepatic
biliary ductal dilatation. The proximal common duct is minimally
dilated,
measuring 7 mm. There is normal Doppler flow within the main
portal vein. The gallbladder is normal, with no cholelithiasis
seen. There is limited
evaluation of the pancreas.
IMPRESSION: Normal gallbladder, with no cholelithiasis as
questioned.
Brief Hospital Course:
44M w/PMH for Stg III melanoma admitted to neurosurgery on [**7-19**]
for complaint of right arm tingling. Head CT done and showed two
intracranial masses. He was started on antiseizure prophylaxsis
and steroid therapy.
Given the size of the left frontal lesion, he taken to the OR on
[**7-20**] for resection of the lesion. Frozen pathology analysis
revealed findings consistent with metastatic melanoma.
Post-operatively, he was observed in the ICU for 24 hours and
[**Hospital 78264**] transferred to the floor. Post-op MRI revealed gross total
resection of the left frontal lesion.
On POD2, he complained of mild abdominal pain. Labs were
sent(including liver and pancreatic enzymes) and revealed a mild
pancreatitis with [**Doctor First Name **]/Lip in 400s. GI service was consulted who
recommended NPO with IVF. RUQ ultrasound was done, and was
negative for obstructive source. The symptoms resolved
subsequently with [**Doctor First Name 674**]/LIP trending toward normal. By [**7-25**], he
was tolerating full PO intake.
The patient's post-operative examination was notable for
decreased spatial sensation of his RUE. This improved
gradually. He was discharged on [**7-26**] to a rehabilitation
facility per PT/OT recommendation.
Medications on Admission:
Alleve as needed
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: Caution not to exceed
more than 4gm APAP in 24h.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left Frontal Mass
Left Parietal Mass
Pancreatitis
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-12**] days (from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2196-8-22**]
1:00 with Dr. [**Last Name (STitle) 724**]. The Brain [**Hospital 341**] Clinic is located on the
[**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will need an MRI of the brain prior to you appointment with
Dr. [**Last Name (STitle) 724**]; This will occur on. [**2196-8-22**] @10:35am. Please call
[**Telephone/Fax (1) 327**] if you require directions.
*You will also need to follow with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1729**](oncology)
in the [**Hospital 29684**] clinic in approximatley 2 weeks. Please call
([**Telephone/Fax (1) 16668**] to make your appointment and obtain directions to
their office.
You also need to schedule and appointment to be seen by Dr.
[**Last Name (STitle) 26672**](your PCP)to have follow up for your pancreatitis. You
will also be required to have a MRCP prior to this appointment.
Please schedule this when you call for your appointment ([**Telephone/Fax (1) 78265**]
Completed by:[**2196-7-26**]
|
[
"V10.82",
"780.39",
"198.3",
"348.5",
"577.0",
"348.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
9716, 9813
|
7573, 8820
|
337, 386
|
9907, 9931
|
2455, 2460
|
11819, 13438
|
934, 952
|
8887, 9693
|
9834, 9886
|
8846, 8864
|
9955, 11796
|
967, 967
|
2223, 2436
|
280, 299
|
2907, 7550
|
414, 770
|
1421, 2209
|
2474, 2888
|
1184, 1405
|
792, 828
|
844, 918
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,821
| 121,693
|
54443
|
Discharge summary
|
report
|
Admission Date: [**2131-1-12**] Discharge Date: [**2131-1-17**]
Date of Birth: [**2055-11-19**] Sex: M
Service: Cardiothoracic Surgery
Please note that this history is compiled from various
consults through the chart including Anesthesia consult as
there is no history or physical exam in this patient's chart
at this time.
HISTORY OF PRESENT ILLNESS: This 75-year-old gentleman had
known cardiomyopathy and severe mitral regurgitation. Past
medical history also includes chronic atrial fibrillation on
Coumadin therapy. Prior cardiac catheterization showed 4+
mitral regurgitation.
ADDITIONAL MEDICAL HISTORY:
1. Atrial fibrillation.
2. Mitral regurgitation.
3. Chronic renal insufficiency.
4. Hyperlipidemia.
5. Gout.
6. Status post bilateral knee replacements.
Cardiac catheterization prior to surgery showed some
diastolic dysfunction and no angiographic evidence of
significant coronary artery disease. The LVEDP was 20 with a
mean pulmonary capillary wedge pressure of 27. No gradient
was present across the aortic valve.
Echocardiography performed in [**2130-11-8**] showed a
dilated left atrium, dilated right atrium, ejection fraction
of greater than 55% with trace AI and 3+ MR.
EKG preoperatively showed atrial fibrillation with
inferolateral nonspecific ST-T wave changes.
Preoperatively, the patient did have some mild pulmonary
edema and some cardiomegaly. The patient had been diuresed
by the medical doctor caring for the patient prior to
surgery.
Preoperative laboratory work showed a hematocrit of 39.6, PT
13.9, PTT of 26.5, INR of 1.3. Sodium 134, K 3.8, chloride
96, bicarb 27, BUN 36, creatinine 1.4 with a blood sugar of
93, calcium 9.6, magnesium 1.8.
ALLERGIES: Patient had no known drug allergies.
MEDICATIONS: Listed as follows with no doses known at this
time:
1. Lipitor.
2. Tylenol.
3. Robitussin.
4. Latanoprost.
5. Dorzolamide.
6. Coumadin.
7. Fluticasone.
8. Aspirin.
9. Atrovent.
10. Dulcolax.
11. Lopressor.
12. Atropine.
13. Lisinopril.
14. Ambien.
15. Lasix.
PHYSICAL EXAMINATION: Preoperatively on exam by Anesthesia,
the heart was regular rate and rhythm with a positive murmur
and lungs were clear bilaterally. The abdominal exam was
benign.
The patient had opted for a mitral mechanical valve and on
the day of admission, [**2131-1-12**], the patient underwent
mitral valve replacement with a [**Street Address(2) 7163**]. [**Male First Name (un) 923**] mechanical
valve. Left atrial appendage was also stapled. Operation
was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
On postoperative day one, the patient had been extubated
overnight. Was on amiodarone drip at 0.5, dobutamine at 2.0,
insulin at 3.0, and Neo-Synephrine had been weaned off
overnight. Patient had a first degree A-V block. Was
saturating 95% on 4 liters nasal cannula with a blood
pressure of 97/60, heart rate of 95. Lungs had coarse breath
sounds bilaterally. The heart appeared to be in sinus rhythm
with the A-V block. Sternal incision was clean, dry, and
intact. The abdominal exam was benign. Extremities were
warm and well perfused. Patient remained on a dobutamine
drip at that time for output of 3.41 and an index of 1.69
with plans to monitor patient's index to see if dobutamine
can be weaned. Patient also continued on Vancomycin.
Patient had arrived from the OR on Neo-Synephrine drip as
well as amiodarone and dobutamine drips, and was A-V paced at
the time.
On postoperative day two, patient remained in the CSRU, was
alert and oriented. Heart was regular rate and rhythm.
Lungs were clear bilaterally. Incision was benign as well as
the rest of the exam. Chest tubes were pulled. Out index
was 2.38. Patient only remained on oral amiodarone in
addition to the aspirin. Dobutamine had been weaned off.
Swan was pulled, and patient started on Lasix diuresis with
plans to start 2 mg of Coumadin in the evening pending the
patient's morning coags.
Patient was seen by Physical Therapy, and patient was
transferred out to [**Hospital Ward Name 121**] 2 on postoperative day two later in
the day. Patient was dosed with Coumadin to start
anticoagulation again for his atrial fibrillation and his
mechanical mitral valve. Patient was also seen by case
management.
On postoperative day three, patient remained in AFib with
stable vital signs satting 96% on 2 liters. Lungs were clear
bilaterally. Wound was clean, dry, and intact. Chest tubes
were pulled as well as a Foley and pacing wires. Followup
chest x-ray was ordered for noted air leak around the chest
tube to rule out pneumothorax. Patient continued to
ambulate, and was encouraged to be out of bed and use the
incentive spirometer. White count dropped from 30 to 18.1
with a hematocrit of 27.1, platelet count of 146,000. Sodium
137, K 4.7, chloride 105, bicarb 26, BUN 25, creatinine 1.3,
and a blood sugar of 114.
Patient was alert and oriented, and was ambulating in the
[**Doctor Last Name **] on level 3 on postoperative day two. Patient was rate
controlled in atrial fibrillation. Patient dipped once to a
bradycardia in the 50s, but appeared to be tolerating that
well. At one point in the afternoon on [**1-15**], the
patient's bradycardia dropped to 37. The team was called.
Patient rapidly rose back up into the 50s and 60s without any
other episodes of the severe bradycardia. The patient was
dosed with 5 mg that evening, and continued to be in atrial
fibrillation.
On postoperative day four, the amiodarone was discontinued.
Patient continued on Heparin anticoagulation as the INR was
slowly rising. On the 9th, postoperative day four, PT was
13.6 with an INR of 1.2. The white blood count dropped to
11.0. Hematocrit remained stable at 26.4 and a creatinine of
1.2. Chest x-ray the day prior showed left atelectasis and a
small amount of mediastinal air. It was noted that the
patient did have a variable ventricular response to the
atrial fibrillation mostly with a heart rate in the 60s and
occasional block down to the high 40s. Patient remained
hemodynamically stable, and was awaiting anticoagulation with
a goal INR of 3.0-3.5 for the mitral mechanical valve.
The patient did have significant pitting edema in the lower
extremities, and Lasix was increased. Patient did the stairs
on postoperative day four also and was slightly unsteady, but
appeared to be doing well, and making good progress and
ambulation.
On the morning of the 10th, the INR rose to 2.0, and seemed
to be rising appropriately. The patient was sent home with
instructions to continue this 5 mg dose of Coumadin pending
blood work and a phone call from the patient's physician to
dose the Coumadin again since the patient already done the
level 5 and was hemodynamically stable with controlled rate
of the atrial fibrillation, which was baseline.
It was determined by Dr. [**Last Name (STitle) **] that the patient could go
home, and the patient was discharged on [**1-17**] to go
home with services from the VNA of Greater [**Hospital1 3597**].
DISCHARGE INSTRUCTIONS: Patient should have his blood drawn
the following day and have the results forward to Dr.[**Name (NI) 111438**] office, patient's primary care physician for daily
dosing of the Coumadin and instructed to followup also with
Dr. [**Last Name (STitle) **] in the office at one week, and to followup with
Dr. [**Last Name (STitle) 120**], his cardiologist on [**1-30**]. Patient was
also instructed to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], his
Cardiothoracic surgeon in one month in the office for his
postoperative visit.
DISCHARGE DIAGNOSES:
1. Status post mitral valve replacement with [**Street Address(2) 7163**]. [**Male First Name (un) 923**]
mechanical mitral valve.
2. Atrial fibrillation.
3. Cardiomyopathy.
4. Congestive heart failure.
5. Gout.
6. Hyperlipidemia.
7. Chronic renal insufficiency.
8. Hypokalemia.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 mg p.o. 1-2 tablets p.o. prn q.4h. for
pain.
2. Colace 100 mg p.o. b.i.d.
3. Aspirin 81 mg p.o. q.d.
4. Lasix 40 mg p.o. b.i.d.
5. Potassium chloride 40 mEq p.o. q.d. while the patient
remained on Lasix.
6. Levofloxacin 500 mg p.o. q.d. x4 days.
7. Coumadin 5 mg tablet one dose for the evening of
discharge, [**1-17**] with instructions to have the INR
level followed the following morning by Dr.[**Name (NI) 111439**] office.
8. Albuterol/ipratropium 103-18 mcg aerosol 1-2 puffs
inhalation q.4h.
The patient was instructed that the VNA service would draw
his blood the following day and twice weekly by the VNA.
Also to check potassium level this Friday to assure normal
electrolyte balances with the results to be forwarded to Dr.[**Name (NI) 111438**] office. Again, the patient was discharged to home
on [**2131-1-17**].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2131-2-27**] 11:15
T: [**2131-2-28**] 08:22
JOB#: [**Job Number 111440**]
|
[
"424.0",
"276.8",
"V58.61",
"428.0",
"274.9",
"425.1",
"593.9",
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icd9cm
|
[
[
[]
]
] |
[
"35.24",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7660, 7940
|
7963, 9087
|
7071, 7639
|
2055, 7046
|
371, 2032
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,106
| 118,314
|
34064
|
Discharge summary
|
report
|
Admission Date: [**2182-4-24**] Discharge Date: [**2182-5-9**]
Date of Birth: [**2162-1-23**] Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
s/p Multiple gunshot wounds
Major Surgical or Invasive Procedure:
[**2182-4-24**] Exploratory laparotomy; repair of colonic injury X2; IVC
filter placement
[**2182-5-3**] PICC line placement
History of Present Illness:
20 yo male s/p multiple gun shot wounds to his torso resulting
in injuries to his lumbar spine, liver, spleen and kidney. He
was transported to [**Hospital1 18**] for further care.
Past Medical History:
Asthma
Previous gunshot wound assault x2
Social History:
Lives with his parents
Family History:
Noncontributory
Physical Exam:
Upon admission:
BP 110/80 HR 76 RR 16
Awake
HEENT: EOMI
Chest: CTA bilat
Cor: RRR
Abd: firm; diffusely tender; wound left flank ~ 1 CM
Rectum: decreased tone
Sensory: absent sensation from thighs down
Pertinent Results:
Upon admission:
[**2182-4-24**] 09:52PM GLUCOSE-133* POTASSIUM-3.9
[**2182-4-24**] 09:52PM HCT-38.4*
[**2182-4-24**] 06:54PM HGB-11.7* calcHCT-35 O2 SAT-99
[**2182-4-24**] 05:15PM AMYLASE-88
[**2182-4-24**] 05:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2182-4-24**] 05:15PM WBC-11.1* RBC-4.37* HGB-14.8 HCT-42.5 MCV-97
MCH-33.8* MCHC-34.8 RDW-12.1
[**2182-4-24**] 05:15PM PLT COUNT-269
[**2182-4-24**] 05:15PM PT-12.7 PTT-21.3* INR(PT)-1.1
[**2182-4-24**] 05:15PM FIBRINOGE-230
CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: spinal/vascular injury?
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
20 year old man s/p GSW to left lower flank, no exit wound, cant
feel or move below knees bilaterally - vital signs stable, gcs
15
REASON FOR THIS EXAMINATION:
spinal/vascular injury?
CONTRAINDICATIONS for IV CONTRAST: None.
CT TORSO PERFORMED ON [**2182-4-24**].
IMPRESSION:
Gunshot wound to the abdomen with injuries to the descending
colon, bilateral psoas muscles, spinal cord (L3-4 level)
inferior pole of the right kidney, and segment VI of the liver.
Active extravasation of urine is noted on delayed imaging,
though no evidence of active bleeding. Bullet is noted lodged in
the liver in segment VI.
MR L SPINE W/O CONTRAST [**2182-4-25**] 1:14 AM
IMPRESSION: Status post abdominal and lumbar gunshot injuries as
described above. There is evidence of heterogeneous signal
intensity in the filum terminale at the level of L3/L4 likely
consistent with subarachnoid hemorrhage and multiple bone
fragments within the spinal canal. There is no evidence of
epidural hematoma or significant narrowing of the spinal canal.
At L2/L3, there is evidence of right paraspinal gunshot injury
involving the right psoas muscle with extension at the level of
the corresponding right neural foramen with possible lesion
along the nerve root and the dorsal root ganglion at L2 nerve
root, please correlate clinically. Similar findings are observed
at L3 on the left side. Free fluid is observed in the abdominal
cavity as described in the prior CT of the abdomen.
CT ABDOMEN W/CONTRAST [**2182-4-28**] 9:55 AM
IMPRESSION:
1. Multiple dilated loops of jejunum with air fluid levels and
wall thickening, ileal decompression. Findigs are c/w SBO.
2. Liver and right renal lacerations stable, no hematoma no
assocted adjacent fluid.
3. Tiny amount of fluid seen within the left paracolic gutter
and right perirenal space.
4. Foci of free air within the abdomen and pelvis likely due to
recent surgery.
Brief Hospital Course:
He was admitted to the Trauma Service and taken directly to the
operating room for
exploratory laparotomy, primary repair of left colon colotomy
x2, exploration of retroperitoneum, right and left and
evaluation of hepatic through-and-through gunshot wound with
drainage. There were no intraoperative complications.
Postoperatively he was taken to the Trauma ICU where he remained
sedated and intubated. On [**2182-4-25**] he was taken back to the
operating room for placement of an inferior vena cava filter.
He was eventually weaned and extubated and was later transferred
to the regular nursing unit. He developed an ileus; an NG tube
was placed, his output was high initially. The NG tube remained
in place for several days. A PICC line was placed in preparation
for possible TPN. A CT of the abdomen was performed to rule out
intra-abdominal fluid collection; none was identified. Bowel
function did eventually return and the NG tube was removed. His
diet was advanced slowly and he is currently tolerating a
regular diet. The PICC line was removed.
Orthopedic Spine surgery was consulted for his spine injury;
this was non operative.
He was evaluated by Physical therapy and was strongly
recommended for [**Hospital **] rehab post acute hospitalization. He has
slowly begun to have intermittent sensation in both lower
extremities.
Psychiatry was also consulted because patient began to have
nightmares of the events surrounding the trauma. It was
recommended to try Clonidine 0.1 mg qhs to treat the nightmares
and insomnia and to titrate up as needed. Because at the time he
was NPO he was started on Clonidine 0.1 mg patch. His overall
mood and mental status have improved significantly; he is more
engaging and participatory with his care; he even appears to be
more optimistic regarding the progress that he has made so far.
There have been no behavioral problems.
Social work has also been following closely with patient and his
family for emotional support. The Center for Violence Prevention
& Recovery were also consulted; providing information on
victim's compensation and counseling post hospitalization.
He does continue to have pain control issues; initially he was
on PCA and was later changed to oral Dilaudid with IV for
breakthrough pain. The Dilaudid was later changed to Oxycodone
prn. His current regimen appears to be more effective.
He developed a UTI and was treated with Cipro course. He does
have an indwelling Foley catheter and this was changed.
He continues to work with PT & OT and had made some progress; he
will clearly benefit from a [**Hospital **] rehab post acute hospital stay.
Medications on Admission:
None
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Neb Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
3. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed for throat
irritation.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
EVERY OTHER DAY (Every Other Day) as needed for constipation.
5. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
Twenty (20) MG Intravenous Q12H (every 12 hours).
6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
7. 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.
8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
9. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for spasm.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
12. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML
PO Q6H (every 6 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Gunshot wound to abdomen
Segment VI liver injury
Inferior pole right kidney injury
Descending colon injury
L2/L3 paraspinal injury - L4 paraplegia
Urinary tract infection
Discharge Condition:
Good
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1007**], Spine Surgery in [**2-12**] weeks, call
[**Telephone/Fax (1) 3736**] for an appointment.
Follow up with Dr. [**Last Name (STitle) **], Surgery in 2 weeks, call
[**Telephone/Fax (1) 2359**] for an appointment.
You also have an appointment with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2182-6-25**] 2:00
Completed by:[**2182-5-14**]
|
[
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icd9cm
|
[
[
[]
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] |
[
"38.93",
"46.75",
"38.7"
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icd9pcs
|
[
[
[]
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7679, 7749
|
3614, 6246
|
293, 420
|
7968, 7975
|
1006, 1008
|
7998, 8475
|
751, 768
|
6301, 7656
|
1693, 1824
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7770, 7947
|
6272, 6278
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783, 785
|
226, 255
|
1853, 3591
|
448, 630
|
1022, 1656
|
652, 695
|
711, 735
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,705
| 152,648
|
800
|
Discharge summary
|
report
|
Admission Date: [**2149-1-24**] Discharge Date: [**2149-2-4**]
Date of Birth: [**2087-11-13**] Sex: M
Service: Med
CHIEF COMPLAINT: Gastric varices.
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
male with past medical history of chronic hepatitis B
complicated by cirrhosis, portal hypertension, gastric
varices, and hepatic encephalopathy (failed interferon and
lamivudine therapy in the past and now on Hepsera for
hepatitis B), initially transferred from [**Hospital3 417**]
Hospital on [**2149-1-24**] in preparation for TIPS procedure. The
patient was admitted to [**Hospital3 417**] Hospital with 1-week
history of right-sided abdominal pain, episode of large
bloody emesis with clots and positive melena. EGD on
[**2149-1-13**] at the outside hospital revealed large gastric
varices with dark blood in the stomach and duodenum, but no
active bleeding. On [**2149-1-22**], the patient became obtunded
and was given octreotide drip and lactulose for hepatic
encephalopathy. Surgery was consulted who recommended TIPS.
The patient was then transferred to [**Hospital1 18**] MICU and was
somnolent on arrival. EGD performed on [**2149-1-25**], showed no
esophageal varices, 2 erosions in the antrum with clean
bases, no recent bleed, appearance consistent with portal
gastropathy; large mass of gastric varices in the
fundus/cardia. NG lavage on [**2149-1-24**] yielded blood-tinged
sputum, but hematocrit was unchanged at 29, hemodynamically
stable. TIPS procedure was deferred until Dr. [**Last Name (STitle) **]
returned from vacation on [**2149-1-30**] or until rebleeding
occurs. Currently, the patient is without complaints. He is
feeling well with no shortness of breath, no nausea or
vomiting, no abdominal pain, no fevers or chills, no
confusion, no bright red blood per rectum. He is tolerating
clear diet. Since the TIPS procedure was not performed, the
patient is now transferred to the medicine floor for further
management.
PAST MEDICAL HISTORY: Chronic hepatitis B complicated by
cirrhosis with known portal hypertension, gastric varices,
failed interferon therapy in the past. Treated with Hepsera
and lamivudine in the past. Question a mass lesion in the
liver.
Hypothyroidism.
Duodenal ulcer.
Sigmoid resection for diverticulitis.
Ventral hernia repair.
MEDICATIONS: Prior to admission:
1. Tylenol p.r.n.
2. Phenergan 25 mg p.r.n.
3. Nadolol 80 mg by p.o. q.d.
4. Haldol 5 mg p.r.n.
5. Octreotide 50 mcg per hour.
6. Lansoprazole 30 mg p.o. q.d.
7. Synthroid 150 mcg p.o. q.d.
8. Hepsera 10 mg q.d.
9. Aldactone 100 mg p.o. b.i.d.
Medications on transfer to the floor:
1. Ambien 5 mg p.o. q.h.s.
2. Lactulose 30 cc q.4 hours p.r.n., titrate to 4 bowel
movements per day.
3. Cipro 250 mg p.o. b.i.d.
4. Adefovir dipivoxil 10 mg p.o. q.d.
5. Protonix 40 mg IV b.i.d.
6. Aldactone 100 mg p.o. b.i.d.
7. Nadolol 80 mg p.o. q.d.
8. Albuterol nebulizers q.6 hours p.r.n.
9. Octreotide drip 50 mcg per hour IV drip.
ALLERGIES: PENICILLIN.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Denies tobacco or alcohol use. Mother is
his health care proxy, number is [**Telephone/Fax (1) 5702**], lives in a
single family home with a male roommate.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.3
degrees, blood pressure 103/45, pulse 66-70, respirations 11-
13, saturating 92-94 percent on room air. GENERAL: The
patient was alert and oriented x3, sitting comfortably,
pleasant, in no apparent distress. HEENT: Pupils were
equal, round, and reactive to light, extraocular movements
intact. Sclera anicteric. Oropharynx clear with moist
mucous membranes. NECK: Supple and nontender. No
lymphadenopathy. No JVD. PULMONARY: Clear to auscultation
bilaterally. No wheezes. CARDIOVASCULAR: Regular rate and
rhythm with no murmurs, rubs or gallops. ABDOMEN: Soft,
nontender, nondistended with normoactive bowel sounds. No
shifting dullness, could not appreciate hepatomegaly
secondary to the patient's position. EXTREMITIES: Trace
edema bilateral lower extremities. Plus 2 DP pulses present
bilaterally. SKIN: No spider angiomatas. No palmar
erythema. No jaundice. NEUROLOGICAL: No asterixis. No
focal deficits.
LABORATORY DATA ON ADMISSION: White blood cell count 3.4,
hematocrit 29.2, which is down from 36.7, and MCV 98, RDW
19.5, platelets 61, INR 1.6. Chem-7 was unremarkable.
Potassium was 4.2, creatinine was 0.6. ALT 34, AST 49,
alkaline phosphatase 79, total bilirubin 2.9, which is down
from 3.2; AST was 7.5 on [**12-31**]. Last HPV viral load was
78,600,000, which is increased from [**10-15**] for 178,000.
RADIOGRAPHIC STUDIES: EKG on [**2149-1-24**] was sinus rhythm at
75, normal axis and intervals, borderline long QT, no Q-waves
or ST changes. Abdominal CT on [**2148-12-31**] showed 3 x 8 x 3.7
cm low attenuation lesion in the liver consistent with RF
ablation near simple hepatic cyst. Liver ultrasound: Study
limited, simple cyst, and positive hypoechoic area consistent
with area ablated by RF. No intra or extrahepatic bile duct
dilatation. No ascites. Patency of hepatic and portal veins
cannot be assessed.
ASSESSMENT: This is a 61-year-old male with past medical
history of chronic hepatitis B complicated by cirrhosis,
portal gastropathy, transferred from outside hospital with
history of GI bleed and evidence of gastric varices here with
EGD, now awaiting possible TIPS procedure.
HOSPITAL COURSE: GI bleed/gastric varices: The patient was
initially admitted to [**Hospital1 18**] with a history of gastric varices
and bleeding and was awaiting a TIPS procedure. However,
given the risk, the patient had chosen to defer the TIPS
procedure until he could further discuss the procedure with
Dr. [**Last Name (STitle) **] when he returns from vacation on [**2149-1-30**]. The
patient also decided that he would have that procedure if he
had an episode of rebleeding. He was thus transferred to the
floor for monitoring until Dr. [**Last Name (STitle) **] could return from
vacation and then a decision would be made regarding TIPS
procedure. His hematocrits were followed b.i.d. and they
were stable. The patient was at high risk for bleeding given
his severe gastropathy and portal hypertension, known varices
and a recent bleed. The patient was maintained on IV
Protonix and IV octreotide initially on transfer to the
medicine floor, and his hematocrit and platelet count were
monitored closely. His hematocrit remained stable in the 28-
30 range as well as his platelet count. On [**2149-1-28**], the
patient's IV octreotide was discontinued since he had already
completed a 5-day course, and the patient continued to have a
stable hematocrit with no evidence of acute bleeding and
remained hemodynamically stable. However, on [**2149-1-29**] in the
morning, the patient had an episode of frank melena, moderate
to large amount. He was without complaints with no dizziness
or lightheadedness, and was sitting comfortably, and was
hemodynamically stable with his blood pressure in the 110
range and his pulse 62. NG lavage was then performed with
300 cc of normal saline, which did not reveal any bright red
blood, but did show clots and appearance of blood tinged
saline that was not clearing. The patient's hematocrit that
morning dropped from 28.5 to 26.7, and his INR was 1.8. The
patient was evaluated immediately by the GI service, who had
been following the patient during his entire hospital course.
The patient's octreotide was restarted with a 100 mcg bolus
and then a constant infusion. He was transfused 2 units of
packed red blood cells and was transferred to the MICU for
urgent TIPS procedure. The ciprofloxacin was also restarted
for SBP prophylaxis, and the patient was kept on n.p.o.
Overnight on [**2149-1-29**], a TIPS procedure was performed, but
was unsuccessful, and the patient had a repeat TIPS procedure
performed on [**2149-1-30**] morning. His hematocrit remained
stable in the MICU in the 29-30 range, and he remained on the
octreotide drip as well as Protonix. The patient then
underwent a successful TIPS procedure on [**2149-1-30**], although
was a technically complicated procedure. Although, the TIPS
was ultimately successful with good flow and positive
successful occlusion of both gastric shunts, one splenorenal
shunt and with minimal residual flow in the second
splenorenal shunt. The procedure appear to be very
technically difficult as evidenced by the operative note on
[**2149-1-30**]. The procedure required several cc of alcohol
injection into the varices, several placements of
embolization coils and stents as well as 350 cc of contrast.
Liver ultrasound showed low slow flow in the diminutive
portal [**Last Name (LF) 5703**], [**First Name3 (LF) **] to wall flow in the TIPS, and appropriate
reversal of the right and left portal veins. Since the
patient had remained hemodynamically stable in the MICU and
his hematocrit remained stable, he was transferred from the
MICU to the floor again for further monitoring. The patient
continued to have melena, although this was about two to
three episodes of melena per day and was thought to be likely
from old blood prior to the procedure and postprocedure. The
patient remained hemodynamically stable and his hematocrit
remained stable at 27-30. The liver team was aware of his
melena and felt that this was appropriate post procedure.
The patient received another unit of packed red blood cells
during his hospital course. The patient was continued on IV
octreotide, which was discontinued on [**2149-2-3**] after a total
of 5-day course. His hematocrit was monitored b.i.d. and
remained stable on the 27-30 range. The patient continued to
have black stools over the last several days of his hospital
course, but not as large as previously noted and no bright
red blood streaks. The liver team was aware, and the liver
attending suggested that the patient would most likely have
small amounts of melena from old blood prior to the procedure
and post procedure, and this melena could persist for as long
as 1 week after the procedure. The patient showed no
evidence of hemolysis post TIPS, with improved total
bilirubin and baseline INR at 1.8 and stable hematocrit. He
tolerated. He was switched to a low-sodium diet and
tolerated this well, and showed no further episodes of
increased melena now that he was off the octreotide. The
patient continued to have an elevated INR, but was not
responsive to repeated attempts with vitamin K. Ultimately,
after consultation with the liver service, interventional
radiology, and the primary medicine team, it was decided that
the patient was stable for discharge on [**2149-2-4**], and would
have a follow-up appointment with Dr. [**Last Name (STitle) **] and ultrasound
with Doppler in approximately 10 days after discharge as well
as hematocrit check later on in the week.
Cirrhosis/portal hypertension: The patient had a history of
hepatitis B cirrhosis with failed therapies of interferon and
lamivudine in the past and was started recently on adefovir.
He was continued on a adefovir throughout his hospital
course. The patient previously was on outpatient Aldactone,
but since he had no ascites and no evidence of fluid
overload, this medication was deferred into the outpatient
setting and this can be restarted as an outpatient when the
patient's acute issues resolve. The patient remained alert
and oriented during his entire hospital course. His
lactulose was restarted to prevent hepatic encephalopathy.
The patient was continued on Cipro for SBP prophylaxis, and
his liver function tests remained stable.
Coagulopathy: The patient had an elevated PT and INR thought
secondary to hepatic failure, but remained stable in the 1.7
to 1.9 range. The patient did not respond to large doses of
vitamin K subcutaneus and p.o.
Cough: The patient had a persistent cough throughout his
hospital course, which on discharge improved. He had
repeated chest x-rays, which were clear and showed no signs
of infiltrate. He had no symptoms of sinus tenderness or
rhinorrhea to suggest a sinusitis, a clear lung exam, and so
an infectious process did not seem likely, and it was thought
that the patient's cough was most likely secondary to a mild
viral pharyngitis. He was continued on Cepacol lozenges and
Robitussin p.r.n. for cough.
Hypothyroidism: The patient's TSH was within normal limits
and he was continued on his Levoxyl.
Cardiovascular: The patient had no cardiac issues and was
stable throughout his hospital course. He had a normal 2D
echo performed with normal systolic function.
Mental status: The patient remained alert and oriented, and
his lactulose was restarted prior to discharge to prevent
hepatic encephalopathy.
Right eye abrasion: After the TIPS procedure, the patient
had some mild erythema and bruising under his right eye. The
patient was continued on Lacri-Lube cream, and this right eye
swelling and abrasion resolved prior to discharge.
Access: The patient had a right IJ line placed in the MICU,
which remained in place until prior to his discharge when it
was pulled.
Code: The patient was initially DNR/DNI when he was admitted
to [**Hospital1 18**], but after his encephalopathy cleared and after
discussion with his mother, his health care proxy, his code
status was changed to full code, and it was felt that he was
quite lucid, alert, and oriented to make this decision. As
mentioned, the [**Hospital 228**] health care proxy is his mother.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Gastrointestinal variceal bleed.
Hepatitis B cirrhosis.
Portal hypertension.
Hypothyroidism.
DISCHARGE MEDICATIONS:
1. White petroleum mineral oil one application topical b.i.d.
as needed for feet dryness.
2. Adefovir dipivoxil 10 mg p.o. q.d.
3. Nadolol 80 mg p.o. q.d.
4. Levothyroxine 150 mcg p.o. q.d.
5. Ciprofloxacin 250 mg p.o. b.i.d. x 1 more day to complete
SBP prophylaxis treatment.
6. Lactulose 30 cc p.o. t.i.d.
7. Protonix 40 mg p.o. b.i.d.
8. Iron 325 mg by p.o. q.d.
FOLLOW-UP PLAN: The patient was told to resume his previous
medications and to continue his Protonix 40 mg p.o. b.i.d,
ciprofloxacin for 1 more day, and nadolol once daily. He was
also told to continue his lactulose 30 cc t.i.d. to prevent
hepatic encephalopathy.
The patient will return to the Liver Center on Friday after
discharge or will go to his outpatient lab for his CBC with
differential to follow-up on his hematocrit and was given a
prescription to do this.
The patient is to have a follow-up appointment with Dr.
[**Last Name (STitle) **] on [**2149-2-20**] at 11 a.m. and will also have an
ultrasound on the same day at 9:30 a.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Name8 (MD) 5706**]
MEDQUIST36
D: [**2149-5-19**] 19:07:07
T: [**2149-5-20**] 15:10:08
Job#: [**Job Number 5707**]
|
[
"244.9",
"456.8",
"572.2",
"572.3",
"578.1",
"285.9",
"070.20",
"571.5",
"286.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04",
"96.34",
"45.13",
"99.05",
"99.07",
"88.64",
"99.29",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
3030, 3048
|
13574, 13668
|
13691, 14970
|
5447, 12628
|
3246, 4231
|
154, 172
|
201, 1988
|
4246, 5429
|
12644, 13552
|
2011, 3013
|
3065, 3223
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,534
| 190,772
|
42065
|
Discharge summary
|
report
|
Admission Date: [**2105-11-2**] Discharge Date: [**2105-11-5**]
Date of Birth: [**2050-10-24**] Sex: F
Service: NEUROLOGY
Allergies:
Meperidine / Codeine / doxycycline / Amoxicillin / Clavulanic
Acid
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
R sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 2031**] is a 55-year-old right-handed woman presenting with
Right hemiplegia, aphasia on a background of numerous medical
problems, including prior left MCA stroke, left carotid
endarterectomy, dyslipidemia, hypertension, aortic and
peripheral
atherosclerosis, spondylosis.
She was in her usual state of health this morning, when her
grandson went to school at around 8 AM. He returned home at 3 PM
and neighbour visited - no answer and unable to get into the
house. [**Hospital1 392**] FD broke into home. Patient on floor, leaning to
left, unable to speak and with right-sided weakness. 911 was
called and she was then taken to [**Hospital3 **]. There, CT head
showed a dense left MCA and hypodense tissue in the basal
ganglia. Despite a possible long latency form onset, it was
thought that transfer to [**Hospital1 18**] may allow intervention if a
penumbra was present. Thus, she was transferred for perfusion
imaging and possible intervention.
Review of systems was negative except as above.
Past Medical History:
Past Medical History:
- Anal cancer, constipation, prior proctitis
- Lichen sclerosis
- Peripheral vascular disease
- Squamous cell cancer
- History of substance abuse - not specified
- Aortic atherosclerosis
- Tobacco use
- Urinary tract infection, prior
- Abdominal pain
- Constipation
- Goiter
- Pulmonary nodule
- Diagnosis of renal insufficiency, recent creatinine 0.7
however
- Prior anemia
- Squamous skin cancer
- Low back pain, lumbosacral and possible cervical spondylosis
- Hypertension
- Hyperlipidemia
- Son reports prior 'TIA's'
PMHx obtained from patient's son and [**Name (NI) 2287**] records
Social History:
Smoking: Yes, smokes 1.5-2 ppd.
Alcohol: Occasional - in past.
Drugs: Unknown.
Living Situation: Independent, lives with grandson.
Functional Baseline: Independent.
Family History:
Son doesn't know if his MGM had stroke. Son not sure of vascular
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals: 98.5, 136/81, 79, 19, 97% RA
GEN: middle aged woman lying in bed in mils distress trying to
reposition herself
HEENT: large surgical scar on L neck
PULM: CTA-B anteriorly
CV: RRR
ABD: soft, NT, ND
EXT: no peripheral edema
.
NEURO EXAM:
MS - follows short commands, difficulty producing speech, but
can answer yes, no and sure appropriately, but is unable to
name, read, may have some issues with comprehension, makes many
paraphasic errors
CN - R facial droop, EOMI, PERRL
MOTOR - plegus in RUE and RLE, with external rotation on RLE,
mild triple flexion in RLE to painful stim
REFLEXES - R biceps and R patella hyperreflexic, otherwise 2 and
symetrical throughout
SENSORY - intact to painful stimuli bilat
COORDINATION/GAIT - deferred
Pertinent Results:
ADMISSION LABS:
[**2105-11-2**] 05:15PM BLOOD WBC-9.1 RBC-4.37 Hgb-14.6 Hct-42.7 MCV-98
MCH-33.4* MCHC-34.1 RDW-12.8 Plt Ct-167
[**2105-11-2**] 05:15PM BLOOD Neuts-87.0* Lymphs-8.0* Monos-4.2 Eos-0.6
Baso-0.2
[**2105-11-2**] 06:10PM BLOOD PT-11.8 PTT-24.1 INR(PT)-1.0
[**2105-11-2**] 06:10PM BLOOD Glucose-106* UreaN-6 Creat-0.7 Na-139
K-3.9 Cl-104 HCO3-23 AnGap-16
[**2105-11-2**] 06:10PM BLOOD ALT-12 AST-15 LD(LDH)-213 CK(CPK)-97
AlkPhos-109* TotBili-0.2
[**2105-11-2**] 06:10PM BLOOD CK-MB-4 cTropnT-<0.01
[**2105-11-2**] 06:10PM BLOOD Albumin-4.2 Calcium-9.0 Phos-2.7 Mg-1.7
Cholest-300*
[**2105-11-2**] 06:10PM BLOOD Triglyc-129 HDL-48 CHOL/HD-6.3
LDLcalc-226*
[**2105-11-2**] 06:10PM BLOOD TSH-0.47
[**2105-11-2**] 05:26PM BLOOD Glucose-110* Na-141 K-4.9 Cl-107
calHCO3-21
IMAGING:
CT/CTA/CTP: IMPRESSION:
1. Noncontrast CT demonstrates cytotoxic edema in the left basal
ganglia. CT perfusion indicates acute infarction in the left
basal ganglia and frontal lobe, with ischemic penumbra in the
left temporal lobe.
2. Complete occlusion of the cervical and intracranial left
internal carotid artery, and of the M1 and M2 segments of the
left middle cerebral artery. There is reconstitution of flow in
the distal branches of the middle cerebral artery.
3. Exophytic left frontal scalp skin lesion. Please correlate
with physical exam.
CT HEAD REPEAT: IMPRESSION: Slight interval evolution of
hypodensity in left MCA distribution consistent with infarction.
No midline shift or hemorrhagic transformation.
Transthoracic echo:
No PFO, ASD, or cardiac source of embolism seen. Mild symmetric
left ventricular hypertrophy with normal global and regional
biventricular systolic function.
Brief Hospital Course:
Mrs. [**Known lastname 2031**] is a 55-year-old right-handed woman, presenting with
right hemiplegia and aphasia on a background of numerous medical
problems, including prior left MCA stroke, left carotid
endarterectomy, dyslipidemia, hypertension, aortic and
peripheral atherosclerosis and spondylosis. Laboratory studies
and imaging, taken together with the above findings suggest
either embolic or in situ thombosis of the left carotid with
propagation to the left MCA. There was infarcted tissue that
matched the exam.
.
# Neurologic: patient was initially admitted to the ICU for
better control of blood pressure. She was started on a PR full
dose aspirin. She remained stable and her repeat head CT the
next day showed no hemorrhagic transformation so she was
transferred to the SDU. Her neurologic exam remained stable. She
appears to have a global aphasia but with some preserved
comprehension. She was able to follow some simple commands,
midline more than appendicular, but was unable to name or
repeat. She was able to sing happy birthday with some dysarthria
but was able to produce mostly correct words. Her right arm and
leg remained hemiplegic.
She initially failed her bedside swallow eval and was maintained
NPO with meds crushed in puree with maintenance IVF. She passed
repeat eval on [**11-5**] and was advanced to a pureed diet with
nectar thick liquids.
We decided to keep her on aspirin, we may reconsider further
antiplatlet or anticoagulants in the future. Echo was normal.
# Psychiatric: her home dose trazodone and quetiapine were
restarted on [**11-5**] after she passed her swallow eval.
# Cardiovascular: we held patient's metoprolol initially to
allow for BP autoregulation but restarted this at her home dose
upon discharge.
# Code Status: DNR/DNI
TRANSITIONAL CARE ISSUES:
Ms. [**Known lastname 2031**] will need intensive PT/OT and speech therapy in order
to improve her level of functioning.
Medications on Admission:
- Trazodone 100-200 mg QHS
- Quetiapine 600 mg QHS
- Carisprodol 350 mg TID:PRN pain
- B12 1000 mcg QD
- Topical betamethasone
- Lidocaine 5 % topical
- Plavix 75 mg QD
- Lisinopril 40 mg QD
- HCTZ 12.5 mg QD
- Triamcinolone injection
- Famciclovir 125 mg QD
- Atorvastatin 80 mg QD
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. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain / temp.
5. trazodone 100 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for fungal rash.
7. quetiapine 300 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
once a day.
11. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
13. famciclovir 125 mg Tablet Sig: One (1) Tablet PO once a day.
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left MCA stroke
Complete left carotid occlusion
Discharge Condition:
Mental Status: Awake and alert, +global aphasia with some
preserved comprehension, follows some simple commands
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 2031**],
You were admitted to [**Hospital1 69**] on
[**2105-11-2**] with difficulty speaking and right sided weakness. You
were found to have a stroke on the left side of your brain. Your
stroke is likely related to blockage of your left carotid
artery. An echocardiogram showed no source of embolus. You will
need rehab and speech therapy in order to regain your prior
level of functioning.
We made the following changes to your medications:
We kept you on a full dose aspirin.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
The following appointment has been made for you in our stroke
clinic:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2105-12-22**] 1:30
You should also follow up with your primary care doctor within
1-2 weeks.
|
[
"305.1",
"342.01",
"443.9",
"564.00",
"721.3",
"401.9",
"V12.54",
"440.0",
"793.11",
"240.9",
"433.11",
"784.3",
"V49.86",
"721.0",
"V10.06",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8337, 8434
|
4860, 6647
|
354, 360
|
8526, 8526
|
3142, 3142
|
9499, 9803
|
2246, 2322
|
7129, 8314
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8455, 8505
|
6821, 7106
|
8779, 9221
|
2377, 3123
|
9250, 9476
|
298, 316
|
6673, 6795
|
388, 1414
|
3159, 4837
|
8541, 8755
|
1458, 2047
|
2063, 2230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,928
| 175,817
|
5361
|
Discharge summary
|
report
|
Admission Date: [**2176-12-9**] Discharge Date: [**2176-12-26**]
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: This 78-year-old concentration
camp survivor with a history of known arrhythmias, status
post cardioversion, presented with a one week history of
increasing dyspnea. He had some left-sided chest pain and
some pain behind jaw and ear which went away. He had some
coughing and production of yellow sputum which was treated
with a Z-Pak. He was also febrile and had decreased
appetite. He stated that he had increased DOE and occasional
PND, occasional orthopnea and sleeping on two pillows. His
cough had resolved already by the time he was seen by the
medicine service and admitted on the 28.
PAST MEDICAL HISTORY: 1) History of DVT, 2) Chronic renal
insufficiency, 3) Pronestyl-induced SLE, 4) Chronic leg
edema, 5) History of atrial fibrillation, status post
cardioversion, 6) Status post cholecystectomy, 7) Status post
nephrectomy secondary to renal cell cancer in [**2162**].
MEDS ON ADMISSION: Quinidine 325 tid, Pepcid 20 mg qd,
Zestril 30 mg qd, lasix 20 mg qod as needed, Norvasc 5 mg qd,
coumadin 3 mg qd, and alprazolam 0.25 mg [**Hospital1 **].
ALLERGIES: He had no known drug allergies.
He was seen by the medicine service. EKG showed an old left
bundle branch block with first degree AV block and left axis
deviation. His chest x-ray showed tiny calcified granulomas
at the left apices and new bilateral pleural effusions with a
question of early right upper lobe pneumonia. Blood cultures
were pending.
LABS ON ADMISSION: Sodium 137, K 4.0, chloride 101, CO2 24,
BUN 35, creatinine 1.8, blood sugar 118. White count 11.4,
hematocrit 35.4, platelet count 178,000. PT, PTT and INR
were pending at that time.
HOSPITAL COURSE: He was referred in from [**Hospital3 2358**], and
the patient was referred to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for his new congestive
heart failure with effusions. This was most likely due to a
recent MI. Lasix diuresis was begun. His baseline
creatinine was approximately 1.6 which was monitored. He was
seen by ID. PPD was placed to evaluate for TB exposure, and
rule out any active infection. He continued to have all
these systems worked on to improve his medical picture.
He was seen by Dr. [**First Name8 (NamePattern2) 3228**] [**Last Name (NamePattern1) **] of cardiology. He did have
crackles halfway up bilaterally. His enzymes showed non-ST
elevation myocardial infarction with some ischemia. He
continued on aspirin. Heparin was held, as his INR was
supertherapeutic. At admission it was 5.2 which went down to
4.3. His beta blocker was held while he was in failure, and
the plan was that he would have a cardiac cath as soon as his
INR dropped below 1.8. His hematocrit was at 35.6, and he
received some gentle rehydration precath. He received IV
lasix for diuresis and continued on his ACE inhibitor and
remained on telemetry. His creatinine was at 1.7.
He was seen by the heart failure nurse practitioner to
discuss his congestive heart failure and some planning for
home diet. He was seen by case management. He was also seen
by Dr. [**Last Name (STitle) **] of cardiology and EPS service for some
nonsustained VT in the setting of his MI, with
recommendations to try beta blocker, or decrease his Norvasc
if possible. A discussion was had about mapping him, but it
was determined that he should have a cardiac catheterization
as soon as possible as first line evaluation, as his INR
continued to drop.
He was also seen by the GI service, and Dr. [**Last Name (STitle) 1940**] who was
his former primary care physician. [**Name10 (NameIs) **] continued with his
lasix diaphoresis, as he was prepared for cardiac
catheterization. He had a hematology consult for his
longstanding, increased PTT. He had no further NSVT. On the
3, his INR dropped to 1.7. Hematology recommended checking
additional factors including lupus anticoagulant, and noted
also that his quinidine could produce lupus-like symptoms.
He was seen by the EP service on the 4, Dr. [**Last Name (STitle) **]. They
studied him and saw dual AV node physiology with some
short-lived episodes of SVT that were slow. Please refer to
their note, and they recommended getting his diagnostic
cardiac cath done, and then having his ICD after his cardiac
surgery and work-up. They also recommended continuing him on
beta blocker and ACE inhibitor.
Hem/Onc saw him again now that he had been off his coumadin
for seven days, but his INR remained resistant and elevated
at 1.8. They thought that this was possibly due to his
antibiotic which was causing a decreased Vitamin K producing
bacteria. Antibiotic were already stopped, and they
determined there was no need for Vitamin K. They were still
awaiting results of his factor panels and his lupus
anticoagulant.
He was seen by the nursing case manager. He had a cardiac
cath done on the 5, and it was recommended intra-aortic
balloon pump be placed and the patient transferred to the CCU
prior to his operation. He was seen by cardiac surgery
resident on the 5, who noted his history. His cardiac cath
showed a left main stenosis and LAD irregularity, some trace
MR, global hypokinesis, a nondominant right. Please refer to
the cardiac catheterization report.
His labs preoperatively were sodium 142, K 4.2, chloride 104,
CO2 26, BUN 37, creatinine 1.5, white count 7.0, hematocrit
34.2, blood sugar 108, platelet count 248,000, PT 16.3, PTT
56.9, INR 1.8 with positive lupus anticoagulant. Blood gases
7.43/39/72/27/1. His chest x-ray showed some mild pulmonary
edema from the 28. The plan was CABG.
HOSPITAL COURSE: The patient had his balloon placed and was
transferred to the Coronary Care Unit. The patient was seen
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], with plans for more Vitamin K today
and FFP, if needed in the OR, for his INR, and plans to
operate on him on the following day after he got his balloon.
He was followed by hematology. The patient was also seen by
Dr. [**Last Name (STitle) 21815**] from cardiothoracic surgery, the Chief
Resident, and on the 7 he underwent coronary artery bypass
grafting x 3 with a LIMA to the LAD, and a vein sequentially
from OM to his left PDA. He was transferred to
Cardiothoracic ICU on a Nitroglycerin drip at 2.0 and an epi
drip at 0.025 in stable condition.
On postoperative day #1, he had a T-max of 100.2, blood
pressure 114/58, satting 97% at 3 liters nasal cannula, as he
had been extubated overnight. His balloon pump remained at
1:1. White count 11.9, hematocrit 32.6, platelet count
100,000. Sodium 141, K 4.7, chloride 105, CO2 23, BUN 41,
creatinine 2.1, with a blood sugar of 125. He was awake and
alert. His heart was regular in rate and rhythm. He had an
index of 2.5 with the balloon in and a mixed venous of 68.
His lungs were clear bilaterally. His wounds were clean, dry
and intact. He had no extremity edema. He was on a dopamine
drip at 2.0 overnight, and this was weaned again in the
morning. He remained with his Swan and his A-line. He had
no bleeding complications postop, and hematology signed-off.
On postoperative day #2, his balloon came out. He continued
on his perioperative vancomycin. His creatinine dropped to
1.8 with a K of 4.6. His hematocrit remained stable at 28.
He was on a Nitro drip at 0.75. The lungs had decreased
breath sounds at the bases. He continued on aspirin and the
Nitroglycerin weaned. He was seen by physical therapy for
evaluation.
On postoperative day #3, he was started on the amiodarone
drip at 1.0 for new atrial fibrillation in the 70s, with a
blood pressure of 127/62. His creatinine remained stable at
1.8 with a white count of 9.4. His lungs were clear
bilaterally, but had decreased breath sounds at the bases.
He was switched to oral pain med. He was restarted on his
coumadin. He had a good urine output.
On postop day #4, he remained in atrial fibrillation. He was
on a heparin drip at 600, coumadin dosing at 3, with a PT of
14.2, INR of 1.3, and a PTT of 52.4. His creatinine rose
slightly to 1.9. He had a normal rate, but remained in
atrial fibrillation. His wounds were clean, dry and intact.
His lungs were clear bilaterally. He remained on heparin
while his INR became therapeutic. He was started on a PO
diet and had good urine output and was transferred to the
floor. He was seen by the venous access nurse who noted that
he did not have good peripheral access. He was seen by case
management and had a Cordis placed. His pacing wires were
discontinued. His line was changed over a wire to allow him
to continue to have central access. He remained on heparin
with the INR climbing slightly now to 1.5 with a goal of
[**3-16**].5 for his atrial fibrillation. He received chest PT. He
remained on an amiodarone drip, as well as his coumadin.
He continued to work with physical therapy. He was seen by
the EP Fellow who recommended an ICD which could be done in
three to four weeks as an outpatient, and be followed by Dr.
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Of note, his AST rose
to 95, with an ALT of 57, and a total bili of 1.6. They
recommended holding his amiodarone until his LFTs were
repeated. His amiodarone was held pending his LFTs. He
remained in atrial fibrillation. He continued on his
coumadin with the goal of [**3-17**]. He continued his ACE
inhibitors. Amiodarone was held. Plans were made for
follow-up with Dr. [**Last Name (STitle) **], and to have his ICD placement done
in the Cath Lab on Wednesday, [**1-22**], and EP signed-off
until that time.
On postoperative day #6, he had no complaints. He had a
T-max of 99.0, continued with his regular rate, remained off
amiodarone, still in atrial fibrillation, continuing his
coumadin, waiting to get therapeutic. He was a little
unsteady on his feet. This was discussed with case
management and physical therapy. He continued his
anticoagulation pending his therapeutic INR. He was screened
by clinical nutrition, and on the 14, his INR hit 2.0 with a
PT of 17.5. He was out of bed to chair. He was increasing
his work with physical therapy. Incisions were clean, dry
and intact. The sternum was stable. He remained in atrial
fibrillation. He was discharged to rehab with the [**Hospital3 1761**] on the following medications:
DISCHARGE MEDICATIONS: Coumadin daily dosing with the last
dose of 3 mg the night prior, to be followed for a goal INR
of 2.0-2.5; captopril 6.25 mg po tid; ranitidine 150 mg po
bid; lasix 20 mg po bid; KCL 20 mEq po bid; metoprolol 12.5
mg po bid; percocet 5, 1-2 tabs po prn q 4-6 h; colace 100 mg
po bid; Milk of Magnesia 30 ml prn; Xanax 0.25 mg po bid.
They recommended his PT and INR be checked daily for three
days in a row and then qod. Follow-up with physical therapy.
DISCHARGE DIAGNOSES: 1) Status post coronary artery bypass
grafting x 3 with intra-aortic balloon pump. 2) Atrial
fibrillation. 3) Chronic renal insufficiency. 4) History of
deep venous thrombosis. 5) Pronestyl induced systemic lupus
erythematosus. 6) Chronic leg edema. 7) Status post
cholecystectomy. 8) Status post nephrectomy. 9) Abnormal
electrophysiology study with automatic implantable
cardioverter-defibrillator placement planned for [**1-22**].
The patient had been given instructions for follow-up with
electrophysiology and Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], his cardiologist, as
well as discharge instructions to follow-up with Dr.
[**Last Name (STitle) 70**] in the office in approximately four to six weeks.
The patient was discharged to rehab on [**2176-12-26**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2177-3-24**] 10:40
T: [**2177-3-24**] 09:44
JOB#: [**Job Number **]
|
[
"593.9",
"414.01",
"424.1",
"428.21",
"427.1",
"710.0",
"410.71",
"427.31",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.61",
"88.42",
"39.61",
"37.23",
"88.53",
"36.12",
"36.15",
"89.68",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
11012, 12116
|
10533, 10990
|
5707, 10509
|
131, 729
|
1584, 1771
|
752, 1024
|
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