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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
11,801
| 157,489
|
46101+58879
|
Discharge summary
|
report+addendum
|
Admission Date: [**2197-11-2**] Discharge Date:
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
male with a history of coronary artery disease status post
catheterization in [**2182**] and repeat catheterization on
[**2197-10-31**]. At that time, he was stented in his proximal left
anterior descending and was discharged home later that night,
developed one episode of syncope and dizziness, and presented
to the Emergency Department with those complaints.
The patient had a routine stress echocardiogram done by his
primary care physician [**Last Name (NamePattern4) **] [**2197-10-12**], which demonstrated five
minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol which was stopped for fatigue and
shortness of breath without chest pain. He demonstrated 2 to
[**Street Address(2) 2051**] depressions in the inferolateral area, mild mitral
regurgitation and tricuspid regurgitation, trace aortic
insufficiency and posterior inferior as well as septal
ischemia.
The patient was referred for catheterization at [**Hospital6 11896**], which demonstrated two vessel disease, a
70% left anterior descending and a total right. The patient
was brought to [**Hospital1 69**] for
intervention on [**10-31**]. He was stented in his proximal left
anterior descending, and discharged home the next day, as he
was clinically stable.
His electrocardiogram prior to his intervention in [**Month (only) 547**]
demonstrated a normal sinus rhythm with occasional premature
ventricular contractions. Post-procedure on [**10-31**], the
patient demonstrated a right bundle branch block pattern with
Type I conduction delay. On the night of the 7th, the day
after the intervention, the patient developed one episode of
syncope and dizziness when trying to leave the bathroom. He
returned to bed and had no other episodes of syncope or
dizziness over the course of the evening.
The next day, the patient presented to the hospital on [**11-2**]
with complaints of dizziness, no shortness of breath, no
chest pain, and no other complaints. The patient's
electrocardiogram demonstrated complete heart block at that
time. His blood pressure was 98/64. His heart rate was 45,
wide complex rhythm, and the patient had an oxygen saturation
of 98% on 2 liters of oxygen at that time.
PHYSICAL EXAMINATION: Physical examination was significant
for jugular venous pressure of approximately 8 cm. He had
bibasilar rales and 2+ pulses throughout. The abdominal
examination was benign. His cardiac examination was regular
and bradycardic, with a normal S1 and S2.
LABORATORY DATA: CBC: White count 9.2, hemoglobin and
hematocrit 10.6/31.5, platelets 335. Chem 7:
138/4.5/104/25/34/1.4/116. Coags were normal.
Electrocardiogram demonstrated complete heart block on his
first electrocardiogram and his third electrocardiogram while
still in the Emergency Department demonstrated a 2:1 heart
block with a left bundle branch morphology. CK on admission
was 159, MB was 15, troponin was 15.
HOSPITAL COURSE: The patient was brought to the Coronary
Care Unit for continued monitoring for low blood pressure.
At that time, a temporary pacemaker wire was inserted in the
right groin without complication. The following day, the
patient went to catheterization to evaluate whether his left
anterior descending stent remained patent, and it did. No
other changes were noted on coronary angiography.
Later that day, the patient had a pacemaker placed, a
permanent one. The patient had a DDD-type pacemaker placed.
After the permanent pacemaker was placed, the patient
remained hemodynamically stable, with blood pressures in the
110s/60s and heart rates in the 90s and low 100s. However,
over the course of the next few days, the patient developed
increasing oxygen requirements with 5 liters oxygen nasal
cannula to maintain an oxygen saturation of greater than 95%.
The patient continued to feel fatigued and, on two different
episodes, experienced syncope when arising from a seated
position.
Due to the patient's increasing respiratory distress as well
as crackles in his lung fields halfway to three-quarters of
the way up his posterior lung fields, the patient was
aggressively diuresed with intravenous lasix as needed as
well as afterload-reducing agents started with Captopril 6.25
and titrated up to Captopril 25 three times a day. However,
after a three day course of diuretics and afterload
reduction, the patient continued to have unchanged
respiratory distress and, on chest x-ray, what appeared to be
pulmonary edema that was unresponsive to diuretic therapy as
well as afterload reduction. An echocardiogram was performed
to evaluate whether the patient had underlying diastolic
dysfunction that could be contributing to his pulmonary
edema. An echocardiogram was performed which demonstrated an
ejection fraction of greater than 60%, no systolic
dysfunction was noted, no left ventricular hypertrophy was
noted. The patient, however, was noted to have left
ventricular wall stiffness with decreased left ventricular
filling, which was consistent with diastolic dysfunction.
At that time, a beta blocker was started, Lopressor 12.5 mg
by mouth twice a day, and was titrated up to a dose of 75 mg
three times a day over the course of the next two to three
days to improve diastolic filling time by slowing the heart
rate, however, this treatment has not demonstrated
significant improvement in the patient's chest x-ray or
physical examination or his respiratory distress.
Because of his continued oxygen requirements as well as his
desaturation into the high 70s to low 80s with any exertion,
the patient was seen by Pulmonary for an evaluation as to the
etiology of his slowly progressive but new onset shortness of
breath and respiratory distress. A CT was taken on [**11-10**] to
further evaluation his pulmonary status.
DISCHARGE DIAGNOSIS:
1. Complete heart block
The patient's medications, as well as follow up and discharge
date will all be dictated by [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 916**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 2917**]
Dictated By:[**Last Name (NamePattern1) 98094**]
MEDQUIST36
D: [**2197-11-10**] 14:14
T: [**2197-11-11**] 00:27
JOB#: [**Job Number 98095**]
Name: [**Known lastname **] [**Known lastname **],[**Known firstname 126**] Unit No: [**Numeric Identifier 15650**]
Admission Date: [**2197-11-2**] Discharge Date: [**2197-12-14**]
Date of Birth: Sex: M
Service:
ADDENDUM:
This is an addendum to the Discharge Summary dated [**2197-11-13**]. This addendum covers the [**Hospital 1325**] hospital course
from [**2197-11-13**], until his death on [**2197-12-14**].
On [**2197-11-10**], the patient underwent a CT scan of his
chest for persistent hypoxia. The CT scan revealed ground
glass opacity pattern in the upper zones. The Pulmonary
Service was consulted. The patient underwent a VATS
procedure on [**2197-11-13**]. Biopsy showed usual
interstitial pneumonia, possibly associated with rheumatoid
arthritis. The VATS procedure was complicated by a
pneumothorax which resolved with a chest tube.
The patient also suffered persistent aspirations. A gastric
tube was placed by Interventional Radiology. The patient was
begun on therapy with Prednisone and Imuran for the usual
interstitial pneumonitis and underlying rheumatoid arthritis.
He was transferred from the Cardiac Care Unit to the Medical
Floor on [**2197-11-17**].
On [**11-20**], the patient had desaturations to the low
80's. He was intubated and transferred to the Medical
Intensive Care Unit for hypoxic respiratory failure. During
the [**Hospital 1325**] Medical Intensive Care Unit course, he remained
intubated despite maximal therapy with steroids and Imuran.
He was started on Bactrim for PCP [**Name Initial (PRE) 2515**]. He also
developed a white count and was put on broad-spectrum
antibiotics.
On [**11-28**], the patient was doing somewhat better with
his respiratory function. He was extubated with the plan
that should he fail extubation, he would be re-intubated and
a tracheostomy would be discussed with the family. The
patient did not tolerate extubation and was re-intubated on
[**11-28**]. Following reintubation, his respiratory status
decompensated and the patient required high levels of
pressure support in order to maintain adequate oxygenation.
Interventional Pulmonary was consulted at this time and felt
that a tracheostomy could not be performed while the patient
was on such high levels of pressure support.
Despite aggressive diuresis, paralysis, and treatment with
steroids and Imuran, the patient was not able to be weaned
off aggressive levels of ventilatory support. Multiple
discussions were held with the patient's family and although
the situation was clearly difficult for the medical staff and
the family, ultimately, it was decided that care should be
withdrawn and the patient expired of respiratory failure on
[**2197-12-14**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3662**]
Dictated By:[**Last Name (NamePattern1) 4499**]
MEDQUIST36
D: [**2198-4-19**] 12:23
T: [**2198-4-19**] 15:20
JOB#: [**Job Number **]
|
[
"790.7",
"714.0",
"426.0",
"428.0",
"427.1",
"515",
"721.8",
"507.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"37.22",
"33.28",
"96.04",
"96.72",
"37.72",
"88.56",
"37.83",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5924, 9427
|
3063, 5903
|
2359, 3044
|
102, 2336
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,656
| 123,944
|
42233
|
Discharge summary
|
report
|
Admission Date: [**2164-3-22**] Discharge Date: [**2164-3-25**]
Date of Birth: [**2135-1-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Drug overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 29 yo female college student with no PMH, who was
brought in by EMS for altered MS, agitation and tachycardia s/p
taking 20 50-mg tablets of benedryl. Pt states that she first
took two pills for insomina, but subsequent took another 18
pills. No other known ingestions. Last time seen normal by
roommates was at 3:30 PM.
On exam in the ED she appeared agitated, mumbling (but can
answer short questions like name), pupils 6-7mm with dry mucus
membranes.
In the [**Name (NI) **] pt was given IVF's, 2 mg of IV lorazepam, and 2 mg
of physostigmine over 5 minutes. A bedside U/S showed
significant urinary retention and a foley was placed.
Per boyfriend, pt has recently been increasingly depressed
Past Medical History:
none
Social History:
She is originally from [**Country 3992**] and came to the
US at age 8. Her permanent home is now in [**Hospital1 1559**],
[**State 350**], and she is currently a student at Mass College of
Pharmacy. She has no tobacco, occasional alcohol use, no drug
use. She is currently sexually active with one partner and they
use condoms with every sexual encounter.
Family History:
none
Physical Exam:
Physical Exam on admission:
General: Confused, picking at skin
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, 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: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally
Physical Exam on discharge:
Vitals: T 98.7, BP 106-119/54-68, HR 60-80s, RR 18, O2 97-99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL ~4mm
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Labs on admission:
[**2164-3-22**] 09:50PM BLOOD WBC-10.1 RBC-5.42* Hgb-15.2 Hct-42.8
MCV-79* MCH-28.0 MCHC-35.5* RDW-15.4 Plt Ct-356
[**2164-3-22**] 09:50PM BLOOD PT-11.4 PTT-30.8 INR(PT)-1.1
[**2164-3-22**] 09:50PM BLOOD Glucose-130* UreaN-12 Creat-0.9 Na-139
K-3.4 Cl-99 HCO3-19* AnGap-24*
[**2164-3-22**] 09:50PM BLOOD ALT-13 AST-19 AlkPhos-50 TotBili-0.6
[**2164-3-25**] 06:50AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.3
[**2164-3-22**] 09:46PM BLOOD Lactate-4.8*
[**2164-3-22**] 10:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2164-3-22**] 10:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2164-3-22**] 10:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2164-3-22**] 10:20PM URINE UCG-NEGATIVE
[**2164-3-22**] 10:20PM URINE Hours-RANDOM
Labs on discharge:
[**2164-3-25**] 06:50AM BLOOD WBC-7.8 RBC-4.43 Hgb-12.3 Hct-34.2*
MCV-77* MCH-27.8 MCHC-36.1* RDW-15.3 Plt Ct-249
[**2164-3-25**] 06:50AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-142
K-4.0 Cl-108 HCO3-26 AnGap-12
[**2164-3-25**] 06:50AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.3
[**3-22**] ECG:
Sinus tachycardia with prolonged Q-T interval for rate. Consider
metabolic or drug effect.
Brief Hospital Course:
Pt is a 29 yo female college student with no PMH who was brought
in by EMS for altered MS, agitation and tachycardia s/p taking
20 50-mg tablets of benedryl.
ACTIVE ISSUES BY PROBLEM:
# Anti-cholinergic overdose: Pt ingested benadryl at home and
presented with classic anti-cholinergic presentation of AMS,
urinary retention, dilated pupils and dry mucous membranes. Pt
responded well in terms of her mental status and tachycardia
after administration of physostigmine (HR dropped from 110's to
80's and she was able to give a full history). Pt has a
anion-gap acidosis that likely [**2-23**] lactic acidosis the setting
of dehydration that quickly resolved with 4 liters of NS. Her
QRS was monitored and remained below 100. She therefore did not
require any sodium bicarb boluses. She did not require any
benzodiazepimes for agitation, and her symptoms abated as the
benadryl washed out of her system.
# Intentional overdose: appeared to have intentionally overdosed
in the setting of of severe stress due to worries about academic
performance at pharmacy school. Seen by psychiatry and was
placed on a section 12 with a 1:1 sitter. They felt this was an
"impulsive overdose", and she expressed a desire to seek
treatment, not actively suicidal while inpatient. She was
discharged to the crisis unit at [**Hospital1 2177**] for further evaluation and
treatment.
# Pyuria: had positive UA without symptoms of dysuria, so she
was not treated with antibiotics.
TRANSITION OF CARE ISSUES:
- Depression: will need close follow up with her psychiatrist
and counselors
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 1313**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital 4189**] Health Center - [**Location (un) 86**]
Discharge Diagnosis:
Anticholinergic toxicity
Intentional overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname **],
You were admitted to the hospital after taking too many benadryl
pills. We gave you a medicine to reverse the effects of the
benadryl pills and watched your vital signs very carefully. Our
psychiatry team saw you while you were admitted and felt like it
would be a good idea for you to go to the crisis unit at [**Hospital1 2177**] for
closer monitoring before going home to your sisters.
It was a pleasure to take care of you at [**Hospital1 **]!
Followup Instructions:
Please follow up with your psychiatrist as recommended by the
doctors at the crisis unit.
Completed by:[**2164-3-26**]
|
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] |
icd9cm
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,872
| 116,584
|
13729
|
Discharge summary
|
report
|
Admission Date: [**2142-7-30**] Discharge Date: [**2142-9-4**]
Service: MED
Allergies:
Penicillins / Sulfa (Sulfonamides) / Aspirin / Heparin Agents
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Transfer from [**Hospital3 628**] for infectious disease and
neurosurgical evaluation of epidural abscess with MRSA
Major Surgical or Invasive Procedure:
Multiple VAC Dressing Changes in the Operating [**Apartment Address(1) 41332**]/204: "Incision and drainage of postoperative
wound which was treated elsewhere."
[**2142-8-16**]:"Incision and drainage of the
osteomyelitis, incision and drainage of the postoperative
wound, and exchange nailing using Synthes, subtrochanteric
nail."
[**2142-8-30**]: Closure of Wound with irrigation and drainage
History of Present Illness:
This is an 87 y.o. female s/p Right Hip ORIF in [**2142-2-4**]
who presented to [**Hospital3 628**] on [**2142-7-11**] after her daughter
tripped on her and she fell, sustaining a Left Hip Fracture.
She underwent a Left Hip ORIF on [**2142-7-13**]. (She was
anticoagulated with coumadin given a heparin allergy). Her
hospital course was complicated by a temp spike to 101 on [**7-14**]
with 2/4 bottles + for MRSA. (per her family she had been
febrile for several weeks prior). A TEE on [**7-17**] was (-) for SBE
and a PICC line was placed for 6 weeks of vancomycin.
Surveillance cx on [**7-18**] grew [**4-8**] MRSA and the PICC line was
d/c'd. On [**7-24**] surveillance cultures were (-) and another PICC
line was placed. On the same day the patient complained of back
pain and a CT T-L Spine demonstrated multiple compression
fractures and an MRI on [**7-27**] demonstrated L2-3 diskitis and a
small epidural abscess (w/o evidence of cord compression). She
was transferred to [**Hospital1 18**] on [**2142-7-30**] for neurosurgical and
infectious disease evaluation.
Past Medical History:
1) Hypertension
2) GERD
3) CVA [**2140**] (residual short-term memory loss and diminished
vision b/l)
4) Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-7**]
5) Hypothyroidism
6) Asthma
Social History:
No Tob/EtOH. Independent prior to 1st hip fracture. Close with
daughters [**Name (NI) **] (Healthcare proxy) and [**Name (NI) **].
Family History:
non-contributory
Physical Exam:
T:99.3, BP:140/70, HR:102, RR:22, O2:99% 2L
Gen: NAD. A/O x 3
HEENT: Small ulcer on hard palate. No LAD, supple neck
CV: II/VI SM at RUSB
Pulm: CTA B/L.
ABD: S/NT/ND
Ext:Swollen left LE with TTP. Trace PT.
Erythematous Papules in diaper area, under breasts, eythema at
Right PICC line site.
Neuro: CN II-XII GI. MAEW. Sensation GI
Pertinent Results:
WBC:12.3
Hct:31.5
Plt:636
Na:132
K:3.4
Cl:91
HCO3:31.6
BUN:9
Cr:0.7
Gluc:91
Ca:8.2
CXR: PICC line well positioned w/o CHF/infiltrates
MRI: L2-3 diskitis, possible small epidural abscess, no cord
compression
Brief Hospital Course:
The patient had a long and complicated hospital course as
follows by issue:
1) ID:(ID Service--[**Doctor First Name **] [**Doctor Last Name **]--following) (also see ortho
below)
She spiked a temp to 101 on [**7-14**] and blood cx drew [**2-7**] MRSA and
vancomycin was started.
[**7-16**] - repeat cx no growth
[**7-17**]- no growth, picc line placed. TTE negative
[**7-18**] spiked temp and cultures at that time grew [**4-8**] mrsa
[**7-19**] continued to be febrile -- picc line d/c'd (picc tip cx
grew staph coag negative NOT MRSA), gent added for synergy
(duration 4 days)
abdominal CT negative for abscess
[**7-20**] TEE negative for evidence of endocarditis
[**Date range (1) 9435**] surveillence cultures negative
[**7-22**] LOST IV ACCESS therefore no IV abx for 2 days
[**2058-7-22**] -- spiked temp, surviellence cx negative
[**7-25**] PICC placed, then cx from [**7-24**] [**1-7**] MRSA
[**7-26**] pt c/o back pain, plain films negative, rifampin added, ESR
66
[**7-27**] underwent MRI L2-L3 diskitis, small epidural abcess, no
cord compression
When initially evaluated by ID the following recommendations
were made:
-Dose of vanco (begun on [**7-14**]) was changed to [**Hospital1 **] with trough
checks q72 hours
-Rifampin (begun on [**7-28**]) was continued with LFT checks qweek.
[**8-1**] and [**8-5**]: left knee was tapped with no growth
[**8-3**]: Repeat MRI with L2-3 epidural abscess without cord
compression
[**2142-8-5**]: Vanco changed to q8 hours
[**2142-8-6**]: Ortho hardware removal with Deep tissue (from hip)
Culture + for Enterobacter resistant to all organisms save
meropenem, bactrim and cefepime. Given possibility of inducible
resistance,
Meropenem begun after desensitization in the MICU (given h/o
cefepime allergy)
[**2142-8-7**]: Spiked to 102.4 on [**8-14**]. CXR with ? LLL infiltrate
[**2142-8-16**]: Left hip hardware exchange performed with I+D.
[**2142-8-20**]: Given persistent low-grade fevers and +yeast in tissue
cx and urine, started Fluconazole on [**8-20**].
D/C Antibiotic Plan as follows:
-Vanco/Rifampin until [**2142-9-17**] for treatment of epidural abscess
and left hip, then po doxycycline 100 po BID indefinitely (given
sensitivity of MRSA and Enterobacter to doxycycline)
-Meropenem for enterobacter soft issue infectionuntil [**2142-9-27**]
-Fluconazole until [**2142-9-2**]
-LFTs, CBC and Chem-7 followed at rehab
-F/U with [**Doctor First Name **] [**Doctor Last Name 9404**] in [**Hospital **] clinic in [**10-8**]
2) EPIDURAL ABCESS
Dr [**Last Name (STitle) 1338**] (neurology) consulted. He advised medical
management, neurologically intact.
[**8-2**]: incontinence of stool, ? decreased rectal tone
therefore repeated MRI ---> stable epidural abcess, no cord
compression
3) ORTHO: Intertrochanteric fx of Left Hip s/p orif
ortho following (Dr. [**First Name (STitle) 1022**].
[**8-1**]: knee tap negative for septic joint
[**8-5**]: Ct guided aspiration of left hip -- cx ngtd
[**8-6**]: ortho took to or and removed hardware, took cx from hip
tissue and placed new hardware as joint unstable
++ Enterobacter
[**8-10**]: increased pain in left knee, lenis negative (except
could not visualize popliteal), ortho retapped knee, cx NTD.
[**8-12**] LENI (repeated given LLE edema) (-).
[**8-16**] to OR to replace hardware. Gross drainage of pus.
***POST-OP with SBP in 80s w/o tachycardia, bolused with
1L NS with normalization of pressure. O2 sat remained>92% on
RA.
Urine output was minimal but slowly picked up (to
~20-25cc/hour) with boluses and lasix (thought to be ATN)
>>to OR [**8-20**] for sterile VAC DSG change
>>to OR [**8-24**] for sterile VAC DSG Change
>>to OR [**8-27**] for sterile VAC DSG Change
>> Wound Closed with 2 JP drains placed on [**8-30**] with plans
for aggressive rehab with PWB on LLE.
>>JP drain #2 pulled after no output x 24 hours.
>>Per ortho recs, the remaining JP drain should be pulled
(one suture in place) after no output for 24 hours. Patient
will follow-up with Dr. [**First Name (STitle) 1022**] in 3 weeks.
4. HEPARIN ALLERGY
-consulted allergy --> NO HEPARIN PRODUCTS.
5. SVT/ A TACH -- occasional burst of SVT in 160s w/o sx,
evaluated by EP on [**8-4**] and recommended metoprolol. underwent
CTA (given not adequately anticoagulated -- use of coumadin and
possible surgery) but NEGATIVE for PE.
6. ATN (by muddy brown cast on [**8-8**]) and oliguria s/p surgeries
on [**8-6**] and [**8-16**] in the setting of transient hypotension.
-- at dischargee resolved with CrCL >80.
7. ?CAD
See SVT above.
EF by ECHO on [**7-8**] was 75%.
8. Anticoag: Given heparin allergy, she was placed on coumadin
with INR goal of 1.5-2.0.
9. Code Status/Goals of Care: Discussed with daughter [**Name (NI) **] (HCP)
on [**8-13**]. [**Telephone/Fax (1) 41333**]. Changed to DNR/DNI status on [**8-19**]. She
would, however, want pressors and all other aggressive measures
short of defibrillation and intubation. She provided us with
the health care proxy form indicating that her daughter [**Name (NI) **] will
make all decisions for her should she not be able to make
decisions for herself. She values her function and would want
all measures that would allow a reasonable chance of retaining
her physical and mental function. She found comfort in prayer.
Medications on Admission:
(Medications on transfer from [**Location (un) 620**] to [**Hospital1 18**])
Vanco 1.5 qd, Rifampin 300 [**Hospital1 **], Lumigan eye gtts, advair,
lexapro, protonix, norvasc 2.5, fosamax qweek, coumadin 3,
tylenol, oxycodone [**5-14**] prn
Discharge Medications:
1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
twice a day: START on [**2142-9-17**].
2. Outpatient Lab Work
LFTs, CBC, Chem-7 qweek
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic qd ().
7. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 2 weeks: LAST DOSE ON [**2142-9-17**]
Please follow LFTs qweek.
8. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QWED
(every Wednesday).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
15. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO
QD (once a day).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
17. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days: LAST DOSE on [**2142-9-2**].
20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
21. Multivitamin Capsule Sig: One (1) Cap PO QD (once a
day).
22. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
23. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day).
24. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
25. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
26. Warfarin Sodium 2 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime): Titrate to INR 1.5-2.0 for DVT Prophylaxis given
heparin allergy.
27. Morphine Sulfate 1-3 mg IV Q4H:PRN
hold for sedation, or RR <12
28. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous
three times a day for 2 weeks: Last dose on [**2142-9-17**].
29. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous once a day for 2 weeks: LAST DOSE ON [**2142-9-17**]
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Congestive Heart Failure
Right Hip Fracture s/p ORIF
Left Hip Fracture s/p ORIF and hardware exchanges
Hypertension
Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
Please notify your [**Location (un) 2449**] or doctors of chest [**Name5 (PTitle) **], shortness of
breath, palpitations, swelling, weakness, numbness, fevers,
chills, dysuria, constipation, diarrhea, rashes or any other
symptoms of concern. You will take meropenem until [**2142-9-17**] and
then begin taking doxycycline. Please follow-up (see below)
with Dr. [**First Name (STitle) **] [**Name (STitle) 9404**].
Notify your doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] of weight gain (>3 pounds). Limit
fluid intake to less than 1.5 L per day and salt intake to less
than 2g/day.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2142-10-8**] 11:30
Please call [**First Name8 (NamePattern2) **] [**Name8 (MD) 1022**], MD (orthopedics) to be seen in 2 weeks
Phone: [**Telephone/Fax (1) 5499**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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icd9cm
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2,398
| 138,345
|
13599+13600
|
Discharge summary
|
report+report
|
Admission Date: [**2189-4-1**] Discharge Date: [**2189-4-3**]
Date of Birth: [**2131-8-12**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 10840**] is a 57 year old
gentleman with a past medical history of Parkinson's Disease,
depression, anxiety, seizure disorder, coronary artery
disease status post inferior myocardial infarction, who was
found to be confused and walking in the streets disoriented
on the evening of the 14th. EMS was called and he was
brought to [**Hospital1 69**] where he had
an altered mental status. In the Emergency Department, he
was found to have an [**Hospital1 **] CK to 5,000, negative MB
fraction of less than 1% with a positive [**Hospital1 **] up to 20.
He had no EKG changes, however, he did have evidence of an
inferior myocardial infarction with Qs in the inferior leads
with a tall R wave in V2 consistent with a posterior
involvement.
The patient also had a bedside echocardiogram in the
Emergency Department which showed an ejection fraction of
approximately 30% with left ventricular dilation and global
left ventricular dysfunction, one plus aortic regurgitation,
three plus mitral regurgitation. The patient was found to
have a white count [**Hospital1 **] to 17.4, being afebrile and an
anion gap was 17 with ketones in his urine. He had a
negative head CT scan. He had an lumbar puncture with 560
red blood cells in tube four, 470 in tube one, one white
blood cell, protein 49, glucose 70, no PMNs, no organisms on
Gram stain.
The patient initially received a dose of Ceftriaxone,
Acyclovir and Vancomycin. The patient had a follow-up MRI /
MRA with no abnormalities.
The Cardiology Team was consulted and did not feel that the
patient was having an acute event that required cardiac
catheterization at the time of admission, and that the
patient's neurological mental status was more important as an
acute issue. They recommended medical management.
The patient was started on aspirin, beta blocker, ACE
inhibitor and a statin. Neurosurgery was consulted regarding
the red blood cells in the lumbar puncture tube. They
recommended an MRI which showed no acute bleed or acute
parenchymal process.
Over the patient's Emergency Department course, the patient's
mental status improved. He was alert and oriented times
three. He did not recall the events of the day of admission.
He said he has been under a lot of stress with his car being
stolen last week. He also reported running out of his
medicines and not taking them.
He reports having dreams that are like seizure-like events in
the evening. He does not recall when his last seizure was
except for this "seizure events".
PAST MEDICAL HISTORY:
1. History of seizure disorder.
2. Parkinson's Disease.
3. Coronary artery disease.
4. Depression.
5. Anxiety / post-traumatic stress disorder.
ALLERGIES: No known drug allergies.
MEDICATIONS AS AN OUTPATIENT:
1. Lamictal 150 twice a day.
2. Venlafaxine.
3. Klonopin 1 twice a day.
4. Lorazepam 1 q. h.s.
5. Sinemet 25/100 three times a day.
6. Sinemet CR 50/200, one tablet four times a day.
7. Mirapex one three times a day.
8. He had a history of taking Metoprolol 25 twice a day,
although according to his primary care physician who was
consulted, she said that he was noncompliant.
SOCIAL HISTORY: The patient lives alone. He had been a
mail carrier until a car accident. He was in a motorcycle
accident in [**2187-6-20**]. Since then, he has been on
disability. Parkinson's for six years. Care in the VA
system with Dr. [**Last Name (STitle) 41058**] at the [**Hospital1 1559**] VA as the patient's
primary care physician.
PHYSICAL EXAMINATION: On presentation, temperature 98.0 F.;
pulse 96; blood pressure 133/60; respiratory rate 20;
saturation of 100% on room air. He was alert and oriented
times three, disheveled. Pupils are equal, round, and
reactive to light and accommodation. Extraocular muscles are
intact. Anicteric sclerae. No lymphadenopathy, no jugular
venous distention. No bruit. Clear to auscultation
bilaterally. He has no wheezes, rales or rhonchi. Heart is
S1, S2, regular rate and rhythm, no murmurs, rubs or gallops.
Abdomen was nontender, nondistended, soft, with active bowel
sounds. He had no cyanosis, clubbing or edema. Cranial
nerves II through XII were intact. He had a pill rolling
tremor at baseline with increased cogwheel rigidity.
LABORATORY DATA: On admission, white blood cell count was
17.4, and this was decreased to 12 on the day of discharge.
Hematocrit was 39 at admission; 31.7 on the day of discharge.
Platelets were 259 at date of admission and 208 on the date
of discharge
Sodium 137, potassium 4.6, chloride 101, bicarbonate 19 with
a gap of 17. BUN 36, creatinine 1.0. These were all
admission labs on the day of discharge.
The patient's creatinine was down to 0.8, BUN down to 18,
anion gap was down to 7. When the patient presented, he had
ketones in his urine. His toxicology screen was negative for
alcohol and all other substances.
His glucose was within normal limits. His calcium was 8.8,
magnesium 2.0, phosphorus 3.1, lactate was 1.0.
When he presented, CK 5,712; on the day of discharge, this
was down to 1900. On admission his MB index was less than
1.0, his [**Hospital1 **] was 20 at admission. His MB index is 0.5
on the date of discharge, and his [**Hospital1 **] was 6 on the date
of discharge.
Albumin 3.7, total cholesterol 201, triglycerides 48, HDL 45,
LDL 146, B12 331, folate 5.5, TSH 1.8. The patient's
Lamictal level is pending.
The patient's EKG shows sinus tachycardia on admission, left
axis deviation, left ventricular hypertrophy as per AVL
greater than 11 millimeters. He has Q waves in the inferior
leads and a tall R in V2 consistent with an old inferior
posterior myocardial infarction.
HOSPITAL COURSE BY PROBLEM:
1. This is a 57 year old male who presents with delta MS
[**First Name (Titles) **] [**Last Name (Titles) **], [**Last Name (Titles) **] CKs with flat MB index. For
delta MS [**First Name (Titles) **] [**Last Name (Titles) 41059**] includes post-ictal state status
post seizure. The patient mentions having events at night
that were consistent with seizures but he was not sure if
they were dreams or he was dreaming about having seizures, or
actually having seizures. Delirium secondary to alcohol
withdrawal, but his tox screen was negative, although the
ketones in his urine and the anion gap were within normal
limits, glucose is suggestive of alcoholic ketosis; possible
encephalitis but the patient's lumbar puncture and MRI/MRA
were not consistent with this; secondary to psychiatric
manifestations of his neurological disorder. The patient
carries a diagnosis of Parkinson's and possibly could have
[**Last Name (un) 309**] body involvement. Neurology was consulted and was
following the patient.
An EEG was ordered but the patient refused to participate in
the EEG as it would involve the removal of his hairpiece.
The patient was continued on his Lamictal 150 twice a day on
his Sinemet 25/100 three times a day, Sinemet CR 50/200 four
times a day, Mirapex one three times a day. He was also
continued on his venlafaxine and received ativan as well
p.r.n. for agitation.
Psychiatric saw the patient and generally thought his picture
was one of resolving delirium. His mental status has
gradually improved during his course, although he does have
episodes of confabulation, flat affect and poor insight into
his overall medical condition. The patient has threatened to
leave against medical advice multiple times during the
hospitalization.
Psychiatric has seen him and felt that he is unable at
different times to have insight and weigh the pros and
consequences of his leaving the hospital against medical
advice at the current time.
2. [**Last Name (un) **] [**Last Name (un) **]: Due to the high [**Last Name (un) **] at 20, the
patient denies any chest pain and no EKG changes. The
patient either had a silent non-ST elevation myocardial
infarction or demand ischemia possibly secondary to
arrhythmia that may have lead to the patient being down. The
[**Last Name (un) **] CKs are consistent with rhabdomyolysis not secondary
to a large ST elevation myocardial infarction as the MB index
was negative. The patient was placed on beta blocker, 37.5
three times a day, aspirin 81 q. day; ACE inhibitor 12.5
three times a day of Captopril and 10 q. day of Lipitor.
The patient had an echocardiogram repeated at the bedside.
Ejection fraction was less or equal to 25%. Right atrium
mildly dilated and left atrium mildly dilated. Left
ventricular cavity mildly dilated. Severe global left
ventricular hypertrophy, overall systolic left function
severely depressed. Right ventricular chamber size is
normal. Right ventricular systolic function appears
depressed. The aortic root is normal in diameter. Four plus
mitral regurgitation, trivial tricuspid regurgitation, and
trace aortic regurgitation.
3. ANION GAP ACIDOSIS: Secondary to ketones, alcohol,
starvation. The patient's anion gap resolved after
hydration.
4. LEUKOCYTOSIS: The patient was afebrile with no evidence
of fever. On his hospital stay, blood cultures, urine
cultures, sputum cultures were negative. Chest x-ray showed
no evidence of congestive heart failure or pneumonia. White
count decreased to 12 and no evidence of infection.
5. NUTRITION: The patient received intravenous fluids
secondary to rhabdomyolysis and his anion gap. As both of
these resolved, the fluids were discontinued. The patient
was taking p.o. with a cardiac heart healthy diet and low
sodium.
6. PROPHYLAXIS: The patient was initially on Pneumoboots
and subcutaneous heparin and then was ambulating and
requiring these discontinued. Taking p.o. and not requiring
any gastrointestinal prophylaxis.
He is full code.
DISCHARGE DIAGNOSES:
1. Change in mental status, delirium.
2. Myocardial infarction.
3. Coronary artery disease.
4. Hyperlipidemia.
5. Hypertension.
6. Parkinson's.
7. Seizure disorder.
8. Post-traumatic stress disorder.
9. Anxiety.
DISCHARGE MEDICATIONS:
1. Cardiolevodopa CR 50/200, one tablet p.o. four times a
day.
2. Lipitor 10 mg p.o. q. day.
3. Captopril 12.5 mg p.o. three times a day.
4. Lorazepam 1 mg p.o. three times a day.
5. Metoprolol 37.5 mg p.o. three times a day.
6. Aspirin 81 mg p.o. q. day.
7. Lamotrigine 150 mg p.o. twice a day.
8. Mirapex 1 mg p.o. three times a day.
9. Venlafaxine 450 mg p.o. three times a day.
10. Cardiolevodopa 25/100, one tablet p.o. three times a day.
11. Folic acid 1 mg intravenously q. day.
12. Thiamine 100 mg intravenously q. day.
13. Acetaminophen 325 to 650 mg p.o. q. four to six hours
p.r.n.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 7853**] C. 12-869
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2189-4-3**] 14:33
T: [**2189-4-3**] 18:38
JOB#: [**Job Number 41060**]
Admission Date: [**2189-4-1**] Discharge Date: [**2189-4-15**]
Date of Birth: [**2131-8-12**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 57-year-old male with
a history of seizure disorder and coronary artery disease,
who was brought into the [**Hospital1 69**]
Emergency Room on [**2189-4-1**] secondary to confusion.
Patient was reportedly found on the street in a confused and
disoriented state by emergency medical technicians and
subsequently brought to [**Hospital1 69**]
for further evaluation and management. In the Emergency
Department, the patient was noted to be disoriented and
confused with a CPK of 5712 and a [**Hospital1 **] of 20.
Patient's electrocardiogram demonstrated sinus tachycardia at
112, inferior lead Q waves, and mild ST depression in lead
V5. In addition, the patient was noted to have an [**Hospital1 **]
white blood cell count of 17.4, but was noted to be afebrile
and hemodynamically stable. The patient continued to have
waxing and [**Doctor Last Name 688**] mental status in the Emergency Department,
after which point he received head CT scan which was negative
and a lumbar puncture which demonstrated 560 red blood cells
and 1 white blood cell. Due to the patient's [**Doctor Last Name **] CK and
[**Doctor Last Name **], Cardiology consult was obtained in the Emergency
Department.
A bedside echocardiogram was performed, which demonstrated
hypokinesis with an ejection fraction of approximately 30%
and 2+ mitral regurgitation. Initial Cardiology
recommendations advised conservative management with a beta
blocker, but no Heparinization given the patient's lumbar
puncture results.
While in the Emergency Department, the patient's mental
status was noted to improve gradually. Although the patient
reported having no memory of the days events, he did report
being under a fair amount of increased stress over the past
several days secondary to his car being stolen and him
running out of his standard home medications. The patient
was subsequently admitted to the Medical Intensive Care Unit
team for further evaluation and management.
PAST MEDICAL HISTORY:
1. Seizure disorder.
2. Parkinson's.
3. Coronary artery disease.
4. Depression.
5. Anxiety.
HOME MEDICATIONS:
1. Carbidopa/levodopa.
2. Effexor.
3. ............
4. Klonopin.
5. Metoprolol.
6. Diclofenac.
7. Lamictal.
8. Lorazepam.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives alone. Works as a postal worker.
Reports a remote history of alcohol abuse, but states the
last drink was in [**2170**]. Denies any other history of drug
abuse.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit team under the direction of Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] on [**2189-4-2**]. Given the patient's
presenting symptoms and his lumbar puncture results, a
neurosurgical consult was obtained and the patient was
referred for head MRI/MRA which subsequently demonstrated no
gross structural abnormalities and no evidence of infarction
or intracranial enhancement.
Over the course of the hospital day #1, the patient's mental
status was noted to improve tremendously, and the patient was
noted to be fully oriented to person, place, and time. The
patient subsequently stated that he would like to be
discharged immediately; however, following discussions with
case management and primary team, the patient was convinced
to remain in-house for the duration of his medical workup.
Given the patient's negative head scan and markedly improved
mental status with little intervention, the leading diagnosis
for his acute mental status change was believed to be a
postictal state. The patient was subsequently restarted on
his outpatient seizure and Parkinson's medications to good
effect. In addition, a Psychiatry consultation was obtained
who deemed the patient mentally competent, but described him
as exhibiting impaired judgement from his recently altered
mental status. The patient was subsequently advised to
remain on an one-to-one sitter for risk of elopement, and
Ativan standing dosage was recommended given the potential
for the patient to go into benzodiazepine withdrawal.
The patient continued to progress well clinically through
hospital day #2, at which point he was cleared for transfer
to the regular medical floor, and was admitted to the [**Hospital **]
Medical Service. While on the floor, the patient
demonstrated several episodes of acute shortness of breath
and tachypnea subsequently ascribed to transient panic
attacks that the patient stated were consistent with his
normal baseline.
On [**2189-4-3**], the patient underwent a repeat
echocardiogram, which demonstrated severe global left
ventricular hypokinesis with an estimated ejection fraction
of 25% and 4% mitral regurgitation. The patient subsequently
recommended for a cardiac catheterization, which he underwent
on [**2189-4-6**], which subsequently demonstrated three vessel
coronary artery disease with 70% proximal irregular stenosis
of the left anterior descending artery, total occlusion of
the circumflex, and total occlusion of the proximal right
coronary artery. In addition, the patient's cardiac
catheterization demonstrated moderate right ventricular
diastolic dysfunction, severe left ventricular diastolic
dysfunction, moderate primary pulmonary hypertension, and a
depressed cardiac index of 1.8.
Given these findings, a Cardiac Surgery consultation was
obtained. Following a discussion of the relative risks and
benefits of surgical intervention, the patient subsequently
consented to undergo a coronary artery bypass graft and
mitral valve repair to take place on [**2189-4-8**]. On [**2189-4-8**], the patient therefore underwent a coronary artery
bypass graft using anastomosis from the LIMA to the LAD, and
a mitral annuloplasty using a 28 mm [**Doctor Last Name 405**] ring. In
addition, an intra-aortic balloon pump was inserted via the
patient's right femoral artery. The patient tolerated the
procedure well with a bypass time of 122 minutes and a
cross-clamp time of 79 minutes.
Patient's pericardium was left open; lines placed included an
arterial line, Swan-Ganz catheter, CVP catheter, and IAVP;
both ventricular and atrial wires were placed; mediastinal
and right and left pleural tubes were placed
intraoperatively. The patient was subsequently transferred
to the CSRU, intubated, further evaluation and management.
On transfer, the patient's mean arterial pressure was 80, his
CVP was 19, his ......... was 15 and his [**Doctor First Name 1052**] was 25. The
patient was A-V paced at a rate of 100 beats per minute.
Drips on transfer included milrinone, epi, and propofol.
In the CSRU, the patient's IAVP remained in place through
postoperative day #2, at which point it was removed without
complication. The patient demonstrated a gradual respiratory
wean, and was finally successfully extubated on postoperative
day #3 without complication. Patient was subsequently
advanced to regular oral intake, which he tolerated well
through the duration of his stay.
On postoperative day #4, the patient's PA catheter, pacer
wires, and chest tube were removed without complication, and
on postoperative day #5, the patient was cleared for transfer
to the floor. The patient was subsequently admitted to the
Cardiothoracic Service in the direction of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**].
On the floor, the patient progressed well clinically through
the time of his discharge. Physical Therapy consultation was
obtained, and the patient was cleared for discharge to home
following resolution of his acute medical issues. The
patient demonstrated several additional episodes of anxiety
attacks through the course of his time on the regular patient
floor, all of which responded well to Ativan administration.
Patient's Foley catheter was subsequently removed without
complication. He was noted to ............... productive of
urine for the duration of his stay.
On postoperative day #6, a routine chest radiograph
demonstrated evidence of a left basilar infiltrate versus
atelectasis; the patient was subsequently begun on
levofloxacin for a 10 day course to be completed as an
outpatient.
On postoperative day #8, [**2189-4-15**], the patient was
cleared by Physical Therapy, full independent ambulation.
Although Physical Therapy stated that patient would be likely
benefit from short rehab stay, the patient clearly stated his
preference to return home. Patient was subsequently cleared
for discharge to home with home VNA services and home
Physical Therapy on postoperative day #7, [**2189-4-15**].
CONDITION ON DISCHARGE: Patient is to be discharged to home
with services.
DISCHARGE STATUS: Stable.
DISCHARGE MEDICATIONS:
1. Percocet 1-2 tablets po q4-6h prn.
2. Colace 100 mg po bid.
3. Lamotrigine 115 mg po bid.
4. Lopressor 25 mg po bid.
5. Carbidopa/levodopa 25/100 one tablet po tid.
6. Clonidine 0.1 mg po tid.
7. Captopril 6.25 mg po tid.
8. Potassium chloride 20 mEq po bid x10 days.
9. Levofloxacin 500 mg po q day x7 days.
10. Lasix 20 mg po bid x10 days.
11. Venlafaxine 150 mg po q day.
12. Pramipexole dihydrochloride 1 mg tablet po tid.
13. Lorazepam 0.5 mg po q4-6h prn.
DISCHARGE INSTRUCTIONS: Patient is to maintain his incisions
clean and dry at all times. The patient may shower, but
should pat dry incisions afterwards; no bathing or swimming
until further notice. The patient has been advised to limit
his physical activity, no heavy exertion. The patient has
been advised to observe a cardiac diet. No driving while
taking prescription pain medications. The patient is to
receive home VNA services for regular wound checks, and home
physical therapy for strength and endurance training. The
patient is to followup with the provider of his choice at his
local [**Hospital **] Hospital within 1-2 weeks following discharge.
Patient is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] four weeks
following discharge; the patient is to call to schedule his
appointment.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2189-4-16**] 01:20
T: [**2189-4-16**] 05:46
JOB#: [**Job Number 41061**]
|
[
"410.41",
"276.5",
"428.30",
"293.0",
"416.0",
"424.0",
"780.39",
"414.01",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71",
"39.61",
"88.56",
"37.23",
"37.64",
"96.04",
"36.15",
"37.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
9899, 10121
|
19795, 20261
|
13608, 19667
|
20286, 21395
|
13243, 13403
|
3684, 5838
|
5866, 9878
|
11149, 13110
|
13132, 13225
|
13420, 13590
|
19692, 19772
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,982
| 159,716
|
25920
|
Discharge summary
|
report
|
Admission Date: [**2156-7-28**] Discharge Date: [**2156-8-12**]
Date of Birth: [**2087-3-18**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Pulmonary artery catherization
PICC line placement
History of Present Illness:
This is a 69-year-old gentleman with a history of endstage
cardiomyopathy (NYHA class 4, on home O2) and severe CHF with an
EF of 15% as well as severe MR. [**Name13 (STitle) **] was admitted to OSH
yesterday in failure yesterday morning. He called the heart
failure clinic here on [**2156-7-27**] with reports of weakness,
shortness of breath with minimal exertion. At that time he was
continued on Lasix 60mg in am and 40mg was added in early
afternoon; the CHF APRN ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) broached the subject of
hospice with the patient's wife. [**Name (NI) **] was seen by his local PCP
recently and CXR showed mild CHF. He apparently has been
coughing much more at night and needing to sleep in a recliner
over the past couple of nights. He had his lasix increased by
40 mg in the early afternoon but it apparently did not help as
he presented to the ED today this am and was given IV lasix 20
mg with approximately 600 ml of urine output. He is currently
breathing easier with O2 sats of 98%. Transferred to the [**Hospital1 **].
.
Upon admission patient states that he has had worsening
orthopnea x 1 week since being discharged from [**Hospital **] Rehab.
Initially 1 week ago when he arrived home he was able to lie
almost flat (1 pillow orthopnea) and not use his home O2. The
next day he required 2L O2 his baseline O2 requirement. The
following day he required his hospital bed @ 60 degrees.
.
He denies PND. No pedal edema currently, none usually. 10 pound
weight loss over past 1 month, 3 pound over past 1 week. + cough
which is non productive, no fevers. No sick contacts.
.
This morning, patient states that he felt chills/sweats
overnight. He has a productive cough and slept @ 60 degree
angle O/N.
Past Medical History:
CAD, s/p CABG x 4 in [**7-/2148**]
Ischemic cardiomyopathy s/p ICD, NYHA class 4, on home O2
Atrial fibrillation with a h/o of being treated with dofetelide
and coumadin x 1 month only
HIT with + Ab screen, treated w/ argatroban in past
Depression / memory loss
Hyperlipidemia
Mitral regurgitation
GIB from gastric ulcer in [**3-/2154**]
H/o AVMs s/p injection in [**2152**] and [**2153**]
Rheumatoid arthritis
H/o sacral ulcer-healed
S/p right 5th toe amputation
S/p right 4th toe ulcer
S/p inguinal hernia repair
Relative adrenal insufficiency
Thrombocytopenia thought to be autoimmune, s/p bone marrow bx
H/o C-diff
Anemia
Chronic renal insufficiency
Allergies: Heparin agents (HIT) and Latex
Social History:
Retired orthopedic surgeon, lives at home with wife, quit
smoking 50 years ago, social drinker, no other drug use.
Family History:
Sister with DM, mother died of liver cancer, father has CAD.
Physical Exam:
VS - T 98.9, BP 116/63, P 70, R 20, 99% on 2L
Gen: NAD, AOX3
HEENT: JVP 14 without kussmauls. No LAD, supple
CARD: RRR, no m/r/g
PULM: Bibasilar rales, [**1-29**] way up on R, slight dullness at R
base, and rales just at L base
ABD: Soft, NT, ND, no masses or organomegaly, BS+
EXT: no edema, cyanosis, clubbing
Pertinent Results:
OSH [**2156-7-28**]
WBC 5.2, HCT 36.6, PLT 173
INR 1.1, PTT 28
Na 134, K 4.9, Cl 97, Co2 29, BUN 60, Cr 1.7, Glucose 94
LFTs normal
CK 22, Tn I 0.02, BNP 958
UA negative
[**2156-7-29**] 07:20AM BLOOD WBC-5.4 RBC-4.29* Hgb-11.3* Hct-35.1*
MCV-82 MCH-26.3* MCHC-32.1 RDW-14.2 Plt Ct-177
[**2156-7-29**] 07:20AM BLOOD PT-15.4* PTT-34.2 INR(PT)-1.4*
[**2156-7-29**] 02:20AM BLOOD Glucose-134* UreaN-54* Creat-1.6* Na-134
K-4.9 Cl-100 HCO3-27 AnGap-12
[**2156-7-29**] 02:20AM BLOOD Mg-2.2
[**2156-8-5**] 05:11AM BLOOD ALT-144* AST-128* AlkPhos-70 TotBili-0.4
[**2156-7-29**] 07:20AM BLOOD CK(CPK)-17*
[**2156-7-29**] 07:20AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2156-7-29**] 06:52PM BLOOD CK-MB-2 cTropnT-0.02*
[**2156-7-31**] 03:49AM BLOOD CK(CPK)-13*
[**2156-7-31**] 03:49AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2156-7-31**] 12:08PM BLOOD CK(CPK)-13*
[**2156-7-31**] 12:08PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2156-8-3**] 05:32AM BLOOD CK(CPK)-18*
[**2156-8-3**] 05:32AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2156-7-29**] 06:52PM BLOOD Cortsol-10.4
[**2156-7-29**] 07:49PM BLOOD Cortsol-20.8*
[**2156-7-29**] 09:21PM BLOOD Cortsol-31.8*
[**2156-7-30**] 08:20AM BLOOD Cortsol-17.1
[**2156-8-5**] 05:11AM BLOOD ALT-144* AST-128* AlkPhos-70 TotBili-0.4
[**2156-8-5**] 05:11AM BLOOD TSH-3.5
[**2156-8-3**] 01:02AM BLOOD Lactate-2.2*
[**2156-8-3**] 06:26AM BLOOD Lactate-1.4
[**2156-8-5**] 09:22PM BLOOD Hgb-10.0* calcHCT-30 O2 Sat-66
[**2156-8-5**] 11:51PM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-64
[**2156-8-11**] 07:55AM BLOOD WBC-6.7 RBC-3.65* Hgb-9.3* Hct-29.6*
MCV-81* MCH-25.6* MCHC-31.6 RDW-16.6* Plt Ct-127*
[**2156-8-12**] 04:26AM BLOOD Glucose-102 UreaN-54* Creat-1.5* Na-132*
K-4.2 Cl-97 HCO3-29 AnGap-10
[**2156-8-12**] 04:26AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.3
CXR [**2156-7-29**]:
The patient is after median sternotomy with unchanged appearance
of multiple broken sternal wires. The left-sided pacemaker
defibrillator leads terminate in right ventricle and right
atrium. The cardiomegaly is severe and unchanged. Mediastinal
contours are stable. There are bibasilar areas of opacity
consistent with retrocardiac atelectasis accompanied by
bilateral pleural effusion partially involving the fissure.
There is no current evidence of failure, and there are also no
discrete consolidations worrisome for pneumonia. Overall, there
is increase in the degree of retrocardiac atelectasis in both
lung bases and slight increase in the pleural effusion compared
to the prior study from [**2156-7-3**]. There is no pneumothorax.
CHEST CT [**2156-8-3**]:
1. Mild hydrostatic edema, bilateral effusions and adjacent
atelectasis. This limits evaluation for interstitial disease. A
repeat limited prone high resolution chest CT is recommended
upon radiographic resolution of the patient's pleural effusions.
2. Broken sternal wires and mild sternal dehiscence.
3. Small bilateral pleural effusions.
4. Sub 5-mm pulmonary nodules. [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] criteria, if there
are no
significant risk factors no further evaluation is necessary.
EKG [**2156-7-29**]:
Sinus rhythm. Prolonged P-R interval. Left axis deviation.
Inferior myocardial infarction, age undetermined. Right
bundle-branch block. QR complexes signify probable anterior wall
myocardial infarction. Premature ventricular complexes. Compared
to the previous tracing no diagnostic change.
EKG [**2156-7-31**]:
Probable atrial flutter with 2:1 A-V conduction and marked
increase in rate as compared with prior tracing of [**2156-7-29**]. Right
bundle-branch block configuration with wider QRS complexes.
Followup and clinical correlation are suggested.
TTE [**2156-8-6**]:
The left atrium is markedly dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is severely dilated.
Overall left ventricular systolic function is severely depressed
(LVEF = 20%) secondary to akinesis of the septum and anterior
free wall, with extensive apical akinesis; the basal half of the
posterior (inferolateral) and lateral walls contract best.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP > 18mmHg). There is no ventricular septal
defect. Right ventricular chamber size is normal. with depressed
free wall contractility. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. There is moderate thickening of the
mitral valve chordae. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. Severe
[4+] tricuspid regurgitation is seen. The main pulmonary artery
is dilated. The branch pulmonary arteries are dilated. There is
no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2156-6-8**], the left ventricle is slightly less dilated; the
ejection fraction may be somewhat increased secondary to
augmentation of contractile function of the basal posterior and
lateral walls.
PICC W/O PORT [**2156-8-6**]:
Uncomplicated ultrasound and fluoroscopically guided [**Last Name (un) **]
catherter placement via the right cephalic venous approach, with
the tip
positioned in the SVC. The line is ready to use.
Brief Hospital Course:
A/P: 69 y/o M with severe cardiomyopathy, EF of < 20% who was
admitted with CHF exacerbation. He was transfered on [**7-31**] to the
CCU when he developed VT in the setting of a fever, converting
back to sinus rhythm after amiodarone load. Pt transferred back
to CCU for acute respiratory distress [**2-28**] acute pulmonary edema
in the setting of increased BP, now resolved. At discharge,
clinically improved on milrinone drip.
Pump:
Pt has ischemic cardiomyopathy with severely depressed EF of
15-20% and Class IV CHF symptoms on home O2. He was admitted for
a CHF exacerbation and diuresing on lasix gtt. On [**7-31**], SBPs
dropped in setting of slow VT but stabilized once patient
converted back in sinus rhythm on amiodarone. His course was
complicated by a few episodes of acute pulmonary edema in
setting of increased SBP, likely due to catecholamine surge with
acute worsening of MR. Pt subsequently received lasix prn for
diuresis with well-controlled SBPs and improvement in cough/CSB
on NTG gtt (subsequently discontinued), increased carvedilol,
and low dose ACE I. On [**8-5**], pt had a R heart cath which showed
a cardiac index of 1.8 that improved to 2.6 and a mixed venous
oxygen sat that improved from 41 to 64% after initiation of
milrinone. A single-lumen PICC was placed for home milrinone
infusion, which was titrated up to 0.5 mcg/kg/min to allow for
further increase in his dose of carvedilol to 25 mg [**Hospital1 **] and and
captopril to 6.25 mg tid while maintaining SBPs in the goal
range of 80s-90s. Appropriate fluid status was maintained with
Lasix 20 mg po daily, and patient was able to respirate
comfortably on room air at discharge. His weight at discharge
was 79.3 kg.
Rhythm:
Pt has a history of severe ischemic cardiomyopathy and atrial
fibrillation treated with dofetilide. On [**7-31**], in the setting of
febrile illness, patient developed slow VT (not picked up by
ICD) and became hypotensive, although he continued to mentate
properly. He was loaded with amiodarone and fluid resuscitated
with normal saline, developed faster VT in the 140s, and then
converted back to NSR. He was transferred to the CCU, where he
was started on an amiodarone drip; dofetilide was discontinued.
It is likely that the pt's ischemic scar as the substrate for
ectopy & VT from multiple origins in the setting of an acute
catechol surge secondary to fever. K and Mg were repleted
agressively to suppress dysrrhythmias, and pt remained generally
stable in NSR on amiodarone with occasional short runs of NSVT.
Pt was not started on his trial of milrinone until the
amiodarone was properly loaded in order to prevent development
of intractable vfib. On discharge, pt was stable with no
significant rhythm abnormalities on amiodarone 400 mg daily and
a milrinone drip of 0.5 mcg/kg/min. The patient should have his
TFTs, LFTs, and PFTs followed on amiodarone.
CAD:
Pt has known coronary disease and is s/p CABG in [**2148**]. An old
ischemic scar likely acted as the substrate for his VT in the
setting of a catechol surge. There was no evidence of acute
ischemia as all cardiac markers were wnl and patient without CP.
SOB resolved once fluid status stabilized. Pt was continued on
aspirin, beta blocker, and ACE inhibitor; statin was
discontinued per Dr. [**First Name (STitle) 437**].
Acute on Chronic Renal Insufficiency:
Pt had a baseline Creatinine of 1.4 to 1.6 in [**7-4**]. During his
CCU coures, his creatinine peaked at 2.2, likely secondary to
lack of forward flow with his CHF. As his fluid status
normalized, his ARF resolved. On discharge, his creatinine was
back to its baseline at 1.5.
R/o Infection:
Pt was febrile to 102 with elevated WBC at 11.6, productive
cough and coarse BS R>L on transfer to CCU on [**7-31**]. Pt was
started empirically on vancomycin and Zosyn for possible
infection. Antibiotics were subsequently discontinued after he
defervesced the following day and remained afebrile for the
remainder of his hospital course with a normal WBC. A CXR on
[**8-1**] showed no signs of PNA, and blood and urine cultures were
negative. Pt was on contact precautions for his h/o C. diff
infection, but C. diff toxin assay during this admission was
negative.
Cortisol Insufficiency:
Patient has a h/o RA and was treated with prednisone until [**Month (only) 547**]
[**2156**], when it was discontinued due to the possibility of
exacerbating CHF. Per Dr. [**Name (NI) **], pt had decompensated since his
prednisone was discontinued. During his admission, pt had a
cortisol stim test that showed appropriate response per
endocrine.
Rheumatoid Arthritis:
Patient was started on prednisone 5mg po daily for RA control.
Anemia:
Pt was treated with oral ferrous sulfate for anemia.
Phlebitis:
Pt developed phlebetic area on his left forearm secondary to
infiltrated peripheral IV used for amiodarone infusion. There
was no sign of infection, and the area was resolving with hot
compresses to area.
Medications on Admission:
Lipitor 80 mg 1 tab daily
Captopril 25 mg 1 tab tid
Carvedilol 12.5 mg 1.5 tabs [**Hospital1 **]
Continuous Oxygen
Tikosyn 125 mg 3 caps [**Hospital1 **]
Escitalopram 10 mg daily
Lasix 40 mg 2 tabs in am 1 in pm
Protonix 40 mg 1 tab daily
Spironolactone 25 mg 1 tab daily
ASA 81 mg 1 tab daily
Ferrous Sulfate 325mg 1 tab daily
MVI 1 tab daily
Niacin 500 mg 1 tab daily
Discharge Medications:
1. PICC Line
PICC line care per protocol
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
9. Milrinone 1 mg/mL Solution Sig: infusion 0.5 mcg/kg/min
Intravenous continuously.
Disp:*qs infusion bags* Refills:*3*
10. Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection twice
a day as needed.
Disp:*100 syringes* Refills:*2*
11. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] Ctr VNA
Discharge Diagnosis:
Primary:
Acute on chronic systolic congestive heart failure
Ventricular Tachycardia
Acute on chronic kidney disease
Secondary:
Rheumatoid arthritis
Hyperlipidemia
Atrial fibrillation
Discharge Condition:
Stable. Average SBP 80-95. Weight on discharge 79.3kg
Discharge Instructions:
You were evaluated and treated for worsening congestive heart
failure. During the hospital stay you developed a ventricular
arrhythmia that was treated with amiodarone. You have been
started on a milrinone infusion to improve your heart function.
There was no sign of active infection found during the hospital
course.
Please take your medications as prescribed.
New Medications include:
- Amiodarone
- Milrinone
- Ferrous sulfate
Dose changes include:
- Captopril 6.25mg three times daily (take as tolerated)
- Carvedilol 25mg twice daily
Discontinued medications include:
- Tikosyn
- Atorvastatin
Please take all medications as prescribed.
If you develop any new or concerning symptoms such as chest
pain, ICD discharges, worsening shortness of breath, trouble
with the PICC line, or fevers; please seek immediate medical
attention.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Followup Instructions:
Please make follow-up apppointments with the following
physicians:
Primary Care physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 64452**] [**Name (STitle) 64450**] ([**Telephone/Fax (1) 64451**])
General Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 64453**] ([**Telephone/Fax (1) 64454**])
You have appointments scheduled for the following Cardiology
Clinics:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**2156-8-19**] at 11:20 ([**Telephone/Fax (1) 62**])
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP [**2156-8-17**] at 1:30 ([**Telephone/Fax (1) 3512**])
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] MD on [**2156-9-6**] at 2:30pm ([**Telephone/Fax (1) 3512**])
|
[
"272.0",
"584.9",
"E879.8",
"428.0",
"428.23",
"714.0",
"403.90",
"V45.02",
"585.9",
"999.2",
"451.82",
"V45.81",
"427.1",
"427.31",
"426.11",
"396.3",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
15372, 15427
|
8841, 13815
|
303, 356
|
15655, 15711
|
3436, 8818
|
16700, 17497
|
3024, 3087
|
14235, 15349
|
15448, 15634
|
13841, 14212
|
15735, 16677
|
3102, 3417
|
244, 265
|
384, 2154
|
2176, 2875
|
2891, 3008
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,683
| 178,738
|
36643
|
Discharge summary
|
report
|
Admission Date: [**2164-7-16**] Discharge Date: [**2164-7-24**]
Date of Birth: [**2089-2-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion, chest pain
Major Surgical or Invasive Procedure:
[**2164-7-19**] - Coronary artery bypass grafting to four vessels.(Left
internal mammary->Left anterior descending artery, Left lesser
saphenous vein->Diagonal artery, Left Radial artery->Obtuse
marginal artery, Right internal mammary->Distal right coronary
artery)
[**2164-7-16**] - Cardiac Catheterization
History of Present Illness:
75 yo F with history of MI [**74**] years ago with exertional angina-
chest pressure, dypnea, weakness, and dizziness. Pt had an
abnormal stress test and was referred for cardiac
catheterization to further evaluate. Now asked to evaluate for
surgical revascularization.
Past Medical History:
Hypothyroidism
Osteoporosis
Hypertension
MI in her early 50s, treated medically
Arthritis
Gall stones
Depression
?TIA- facial numbness 6 yrs ago
Social History:
Occupation: Retired
Last Dental Exam: 3 weeks ago, needs 2 fillings
Lives with: alone
Race:Caucasian
Tobacco:denies
ETOH:denies
Family History:
Family History: (parents/children/siblings CAD < 55 y/o):denies
Physical Exam:
Pulse:65 Resp: 16 O2 sat: 98%RA
B/P Right:162/79 Left: 161/82
Height: 5'2" Weight:128 lbs
General:Alert & oriented
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] No Murmur or gallops.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
s/p
vein stripping
Neuro: Grossly intact
Pulses:
Femoral Right:+2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:+2 Left:+2
Pos. Allens test on left wrist.
Carotid Bruit Right:None Left: None
Pertinent Results:
[**2164-7-16**] Cardiac Catheterization:
1. Coronary angiography in this right dominant system
demonstrated three
vessel disease. The LMCA had no angiographically apparent
disease but
tapered distally. The LAD had 90% proximal and mid stenoses. The
LCx had
a long proximal stenosis up to 90%. The RCA had a proximal 90%
stenosis
and a long 70% mid stenosis.
2. Limited resting hemodynamics revealed SBP of 134 mmHg and a
DBP of 64
mmHg.
[**2164-7-18**] Vein Mapping
Surgically absent greater saphenous veins. Patent left lesser
saphenous vein with small diameters.
[**2164-7-18**] Arterial Duplex Ultrasound
Patent radial arteries bilaterally with normal flow and
diameters
as noted above.
[**2164-7-17**] Carotid Duplex Ultrasound
Right ICA stenosis less than 40%.
Left ICA stenosis less than 40%.
[**2164-7-19**] ECHO
PRE BYPASS The left atrium is elongated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity is unusually small. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. 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 being A paced. There is normal
biventricular systolic function. Valvular function is unchanged.
The thoracic aorta appears intact.
[**2164-7-24**] 04:50AM BLOOD WBC-9.6 RBC-3.93* Hgb-12.4 Hct-34.9*
MCV-89 MCH-31.6 MCHC-35.6* RDW-13.9 Plt Ct-203#
[**2164-7-16**] 11:20AM BLOOD WBC-5.1 RBC-3.73* Hgb-11.3* Hct-33.5*
MCV-90 MCH-30.3 MCHC-33.8 RDW-13.1 Plt Ct-206
[**2164-7-19**] 01:56PM BLOOD PT-17.2* PTT-60.4* INR(PT)-1.5*
[**2164-7-16**] 11:20AM BLOOD PT-13.0 PTT-28.5 INR(PT)-1.1
[**2164-7-24**] 04:50AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-136
K-4.3 Cl-99 HCO3-26 AnGap-15
[**2164-7-16**] 11:20AM BLOOD Glucose-172* UreaN-19 Creat-0.7 Na-139
K-3.6 Cl-107 HCO3-25 AnGap-11
[**2164-7-19**] 10:10PM BLOOD ALT-27 AST-62* AlkPhos-32* Amylase-17
TotBili-1.5
Brief Hospital Course:
Ms. [**Known lastname 82908**] was admitted to the [**Hospital1 18**] on [**2164-7-16**] for a cardiac
catheterization. This revealed severe three vessel disease.
Given the severity of her disease, the cardiac surgical service
was consulted for surgical management. She was worked-up in the
usual preoperative manner including a carotid duplex ultrasound
which showed a less then 40% bilateral internal carotid artery
stenosis. As she had past vein stripping, a venous ultrasound
and arterial duplex ultrasound were obtained. These revealed a
patent but very small lesser saphenous vein and patent left
radial artery. Ciprofloxacin was started for treatment of a
urinary tract infection. Plavix was allowed to wash out. On
[**2164-7-19**], Ms. [**Known lastname 82908**] was taken to the operating room where she
underwent coronary artery bypass grafting to four vessels. Cross
Clamp time= 84minutes. Cardiopulmonary Bypass time= 129
minutes.Please see Dr[**Doctor Last Name 14333**] operative note for further
details. She tolerated the procedure well and was transferred in
critical but stable condition to the CVICU. A very mild rash
was noted which was thought to be related o the vancomycin.
Within 24 hours, Ms. [**Known lastname 82908**] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. All lines and drains were discontinued in a timely
fashion. Beta-blocker, statin and aspirin initiated. On
postoperative day one, she was transferred to the step down unit
for further recovery. She was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility. She
developed some confusion overnight which was treated with
Haldol. The confusion resolved by the next morning. She
continued to progress and Dr.[**Last Name (STitle) **] cleared her for
discharge on POD#5. All follow up appointments were advised.
Medications on Admission:
Actonel 35mg once weekly on Saturday
Flonase nasal spray once in the am
Temazepam 30mg daily at hs
Unithroid 75mcg daily
Atenolol 50mg daily
Tramadol 50mg four times daily PRN for arthritis pain
Aspirin 325mg daily
Plavix 75mg daily
Isosorbide MN 30mg daily
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. Isosorbide Mononitrate 20 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily) for 3 months.
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
11. Metoprolol Tartrate 37.5 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
12. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
***Please do not dispense Metoprolol/Isosorbide Mononitrate /and
Lasix at the same time->may cause hypotension if taken at the
same time
Discharge Disposition:
Home With Service
Facility:
n/a
Discharge Diagnosis:
CAD s/p CABGx4
Hyperlipidemia
Hypertension
MI in early 50's
Arthritis
Gallstones
Depression
Osteoporosis
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact your [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] for all wound issues.
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) You may wash incision and pat dry. No lotions, creams or
powders to incision until after 6 weeks. No swimming or bathing
for 6 weeks.
5) No driving for 1 month.
6) No lifting more then 10 pounds for 10 weeks from date of
surgery.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-1**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 3321**] in [**1-31**] weeks.
Please call all providers for appointments.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2164-7-24**]
|
[
"733.00",
"412",
"693.0",
"599.0",
"413.9",
"V12.54",
"401.9",
"293.9",
"E930.8",
"244.9",
"311",
"574.20",
"414.01",
"716.90",
"724.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"36.11",
"36.19",
"99.04",
"39.61",
"39.64",
"88.56",
"37.22",
"36.16"
] |
icd9pcs
|
[
[
[]
]
] |
8344, 8378
|
4842, 6765
|
352, 662
|
8527, 8536
|
2108, 4819
|
9120, 9530
|
1312, 1361
|
7074, 8321
|
8399, 8506
|
6791, 7051
|
8560, 9097
|
1376, 2089
|
281, 314
|
690, 963
|
985, 1132
|
1148, 1280
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,707
| 127,356
|
5340+5341
|
Discharge summary
|
report+report
|
Admission Date: [**2152-6-19**] Discharge Date: [**2152-6-22**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Sulfonamides / Gadolinium-Containing
Agents / Demerol / Morphine
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Respiratory Distress and Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, this is a 50 year old female with mast cell
degranulation syndrome who presented last PM with a recurrent
episode of respiratory distress, chest pain and abd pain
consistent with her syndrome, who has required 3 doses of 0.3mg
epinephrine SQ since admission and is being transferred to the
ICU for closer monitoring. In the ED she was given epi IM,
methylprednisolone 125mg x 1, pepcid, benadryl 50 x2, dilaudid 2
x3, atarax 25, zofran 4 and ativan. Tonight at 5pm, the pt was
found to be c/o SOB with labored breathing but able to speak,
received albuterol neb without improvement. VS 136/77, HR 99,
Sat 97% on RA. She was given IV benadryl, 0.3mg SQ epi with
improvement, transferred to the ICU for further monitoring.
Past Medical History:
- Mast cell activation syndrome: Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **]
who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by
Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice.
- Depression/anxiety/bipolar d/o, hx of SI
- MI in [**2147**] after receiving cardiac arrest dose epi instead of
anaphylactic dose epi
- HTN
- Erosive osteoarthritis
- GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
- Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
laryngoscopy
- Anemia, iron studies c/w AOCD
- Hemorrhoids
- pt reports EGD demonstrated vegetable bezoar (?[**12-6**]).
- Status post hysterectomy and oophorectomy
- h/o MRSA infection (porthacath associated)
- portacath placed [**3-7**] - d/c'd [**2-4**] MRSA infection
- portacath placed [**2151-6-9**]
Social History:
Pt is divorced. Lives alone. She works as an ER tech in
[**Hospital3 **]. No tobacco or EtOH or illicit drugs. Son is
HCP [**Telephone/Fax (1) 21738**]
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
Vitals: T 97.6, BP 124/64, HR 81, RR 26, Sat 97% on NRB, FS 145
(on admit to ICU)
Gen: middle-aged woman, slightly cushingoid in appearance,
awake, alert, no distress resp or otherwise
HEENT: NCAT, EOMI, no rash
Neck: supple, no tenting, no accessory muscle use
CV: RRR, [**2-8**] holosyst murmur at apex without rads, no rub, no
gallop
Pulm: shallow breaths, no rales, no wheeze on inspiration after
cough
Abd: + soft, mildly tender in the epigastric area, no r/g
Ext: no edema, no rashes, skin warm and perfused well
Pertinent Results:
[**2152-6-18**] 09:40PM BLOOD cTropnT-<0.01
[**2152-6-19**] 09:38PM BLOOD CK-MB-3 cTropnT-<0.01
[**2152-6-20**] 05:29AM BLOOD CK-MB-3 cTropnT-<0.01
[**2152-6-18**] 09:40PM BLOOD CK(CPK)-67
[**2152-6-19**] 02:20PM BLOOD ALT-22 AST-12 LD(LDH)-266* AlkPhos-69
TotBili-0.2
[**2152-6-19**] 09:38PM BLOOD CK(CPK)-30
[**2152-6-20**] 05:29AM BLOOD CK(CPK)-22*
[**2152-6-18**] 09:40PM BLOOD Neuts-68.0 Lymphs-25.0 Monos-6.0 Eos-1.0
Baso-0.1
[**2152-6-19**] 02:20PM BLOOD Neuts-92.4* Lymphs-3.4* Monos-3.8 Eos-0.1
Baso-0.3
[**2152-6-18**] 09:40PM BLOOD WBC-7.6# RBC-3.75* Hgb-10.6* Hct-31.3*
MCV-84 MCH-28.4 MCHC-33.9 RDW-14.6 Plt Ct-274
[**2152-6-22**] 05:03AM BLOOD WBC-5.3 RBC-3.41* Hgb-9.7* Hct-28.9*
MCV-85 MCH-28.3 MCHC-33.4 RDW-14.2 Plt Ct-229
.
PORTABLE AP CHEST RADIOGRAPH: The lungs are clear. The heart,
mediastinum, hila, and pulmonary vascularity are within normal
limits. A right chest wall Port-A-Cath is seen with tip
terminating in the distal SVC. No pneumothorax is identified.
Brief Hospital Course:
Mast Cell Degranulation Syndrome: initially admitted to the
floor but subsequently trasnferred to ICU after requiring
additional doses of SQ Epi. Started on Hydrocort taper in ICU.
She did not required additional epi while in the ICU. CP likely
related to flare. Ruled out for MI. ECG unchanged. She was
continued on regimen of gastrocrom (cromolyn), ranitidine,
atarax, benadryl, Fexofenadine. Will complete taper of
prednisone as an outpatient.
.
# HTN: Continued diltiazem.
.
# Depression/anxiety/bipolar: continued outpt cymbalta and
adderall.
.
# osteoarthritis: cont plaquenil
Medications on Admission:
diltiazem CD 180mg qday
atarax 25 QID
Vivelle dot 0.05 twice per week
ranitidine 300mg daily
cymbalta 60mg qday
plaquenil 200 [**Hospital1 **]
adderal XR 25
fexofenadine 180 [**Hospital1 **]
ambien 10 prn
zofran 8 prn
dilaudid 2 prn
percocet prn
fiorcet prn
epi pen prn
Discharge Medications:
1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24
hr Sig: One (1) Capsule, Sust. Release 24 hr PO daily ().
5. Cromolyn 100 mg/5 mL Solution Sig: Three Hundred (300) ml PO
QID (4 times a day).
6. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
11. Prednisone 10 mg Tablet Sig: Taper PO once a day: 40 mg x 4
days
30 mg x 3 days
20 mg x 3 days
10 mg x 3days.
Disp:*34 Tablet(s)* Refills:*0*
12. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Masth Cell Degranulation Syndrome Exascerbation
Secondary Diagnoses
- GERD
- Depression/anxiety/bipolar d/o, has attempted suicide in the
past
- MI in [**2147**] after receiving cardiac arrest dose epi instead of
anaphylactic dose epi
- HTN
- erosive osteoarthritis
- Anemia, iron studies c/w AOCD
- Status post hysterectomy and oophorectomy
Discharge Condition:
stable
Discharge Instructions:
Please contact your primary care physician or Dr. [**Last Name (STitle) 79**] you
develop any chest pain, nausea, vomiting, shortness of [**Last Name (STitle) 1440**],
wheezing, or any other serious complaint.
Followup Instructions:
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2152-10-19**] 1:00
Admission Date: [**2152-6-26**] Discharge Date: [**2152-6-29**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Sulfonamides / Gadolinium-Containing
Agents / Demerol / Morphine / Haldol
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 60yo woman with frequent hospitalizations (last
four days ago) for flares of mast cell degranulation syndrome.
She notes that since her d/c 4 ago she has had progressive
abdominal, backand chest pain which are consistent with her
usual flares. She initially had SOB nad felt her tongue was
swollen and itchy but these have both resolved since arrival
here. She felt dizzy at home, but denies neck or arm pain,
lightheadedness or dizziness. She does report diarrhea and N/V
at home so that she could not hold down POs and came to the ER
today for this reason. Notably she was on a prednisone taper
from her last admission but did not yet step down from 40 to
30mg.
.
In the [**Hospital1 18**] ER, CXR was negative, she was initially tachycardic
to 120s and RR 30s, sats were in high 90s with no stridor. No
tongue swelling was seen on exam. After her initial treatment
with epinephrine 0.3 x 3, methylprednisolone, benadryl 75,
zofran, dilaudid a total of 6mg and nonrebreather mask (her
usual protocol), she noted improvement with tachycardiand
tachypnea resolved. she was satting well on RA and was admitted
for pain control and inability to tolerate POs.
Past Medical History:
- Mast cell activation syndrome: Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **]
who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by
Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice.
- Depression/anxiety/bipolar d/o, hx of SI
- MI in [**2147**] after receiving cardiac arrest dose epi instead of
anaphylactic dose epi
- HTN
- Erosive osteoarthritis
- GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
- Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
laryngoscopy
- Anemia, iron studies c/w AOCD
- Hemorrhoids
- pt reports EGD demonstrated vegetable bezoar (?[**12-6**]).
- Status post hysterectomy and oophorectomy
- h/o MRSA infection (porthacath associated)
- portacath placed [**3-7**] - d/c'd [**2-4**] MRSA infection
- portacath placed [**2151-6-9**]
Social History:
Pt is divorced. Lives alone. She works as an ER tech in
[**Hospital3 **]. No tobacco or EtOH or illicit drugs. Son is
HCP [**Telephone/Fax (1) 21738**]
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
T: 98.6 BP: 166/84 P: 89 RR:18 O2 sats: 99% RA
Gen: pt cries out in pain periodically, holding abd in pain,
speaking full sentences
HEENT: pupils small but reactive, NCAT, MM dry
Neck: supple, no LAd
CV: RRR, nl S1S2, no R/G/M
Resp: speaks in full sentences, no stridor, CTAB with poor
cooperation
Abd: soft, nondistended, NABS, no HSM, tender to palpation
diffusely (moreso with manual palpation than with deep
compression with stethoscope)
Ext: nl tone and bulk, moves all 4, DP 2+ bilaterally
Neuro: grossly nl
Pertinent Results:
[**2152-6-26**] 09:50PM GLUCOSE-107* UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17
[**2152-6-26**] 09:50PM estGFR-Using this
[**2152-6-26**] 09:50PM WBC-9.6# RBC-4.14* HGB-11.5* HCT-34.1* MCV-83
MCH-27.9 MCHC-33.8 RDW-14.8
[**2152-6-26**] 09:50PM NEUTS-75.8* LYMPHS-19.4 MONOS-4.6 EOS-0.1
BASOS-0.2
Brief Hospital Course:
60 yo woman with h/o mast cell degranulation syndrome presented
with abdominal pain, back pain, CP, sob and subjective tongue
swelling found to be c/w usual flares of MCDS.
1. Mast Cell Degranulation Syndrome: In ER was given usual
protocol with some relief: benadryl IV, dilaudid IV,
methylprednisolone, epinephrine x 3, zofran and a non-rebreather
mask. On the floors, pt was started on her usual regimen of
gastrocrom (cromolyn), ranitidine, atarax, benadryl, and
fexofenadine. Also given dilaudid, zofran, and ativan for
nausea per protocol. Throughout admission, pt had 4 episodes of
CP and SOB that improved with a combination of reassurance,
benadryl, epinephrine, and/or dilaudid. Pt was also continued
on predinsone 40. These epsiodes were thought to be related to
anxiety and flare of mast cell degranulation. Pt also had 1
episode of subjective tongue swelling and pruritus ([**6-27**]) that
also resolved with benadryl. At discharge pt was tolerating PO
diet. Allergy (Dr. [**Last Name (STitle) **] was consulted to evaluate the role of
other pharmacologic therapies. Pt was discharged with doxepin
25 qhs and singulair 10 qhs as recommended by Dr. [**Last Name (STitle) **]. Pt
will be followed by Dr. [**Last Name (STitle) **] (see below for details of
appointment). It was also felt that pt would benefit from being
evaluated for OSA as she endorsed sxs of daytime fatigue and
dyspnea during sleep. Pt was also seen by speech therapy to
further evaluate her paradoxical vocal cord dysfunction as it
was felt that dyspnea secondary to paradoxical vocal function
may contribute further to her anxiety. Outpatient speech
therapy training in diaphragmatic breathing techniques was
recommended.
2. HTN: Diltiazem was continued. BP fluctuations throughout
admission was thought to be secondary to pain and anxiety.
3. Depression/anxiety/bipolar/ADHD: Cymbalta and adderall were
continued.
4. Osteoarthritis: plaquenil was continued.
- Pt is to schedule appointment with rheumatology for
progressively worsening arthritis
Medications on Admission:
diltiazem CD 180mg qday
atarax 25 QID
Vivelle dot 0.05 twice per week
ranitidine 300mg daily
cymbalta 60mg qday
plaquenil 200 [**Hospital1 **]
adderal XR 25
fexofenadine 180 [**Hospital1 **]
prednisone 40
ambien 10 prn
zofran 8 prn
dilaudid 2 prn
percocet prn
fiorcet prn
epi pen prn
Discharge Medications:
1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24
hr Sig: One (1) Capsule, Sust. Release 24 hr PO daily ().
6. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q8H (every 8 hours) as needed for pain.
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses.
9. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Doxepin 25 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*0*
11. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
12. 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*
13. Prednisone 20 mg Tablet Sig: 10-40 Tablets PO DAILY (Daily):
As directed.
Discharge Disposition:
Home
Discharge Diagnosis:
Mast Cell Degranulation Syndrome Flare
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a flare of mast cell degranulation
syndrome. You should resume your previous medication regimen.
In addition, the following medications should be added to your
medication regimen:
Singulair 10 mg by mouth at bedtime
Doxepin 25 mg by mouth at bedtime
You should also taper your prednisone as instructed at the time
of your last discharge ([**2152-6-22**]):
Prednisone 30 mg x 3 days
Prednisone 20 mg x 3 days
Prednisone 10 mg x 3 days.
If you experience any of the symptoms below you should contact
your PCP or return to the [**Name (NI) **]:
Throat/tongue swelling, change in the severity of your chest
pain, difficulty breathing, or any other serious concerns.
Followup Instructions:
1) You should follow with your PCP [**Name Initial (PRE) 176**] 1 week.
2) You should also follow with Dr. [**Last Name (STitle) **] on [**7-20**] at 9:15 am
on the [**Location (un) 436**] of [**Hospital Ward Name 23**] Center.
3) You should also schedule an appointment with rheumatology at
([**Telephone/Fax (1) 1668**] for your arthritis.
4) You should also schedule an appointment with ENT at
([**Telephone/Fax (1) 21740**] for further evaluation of your vocal cord
dysfunction.
5) A speech therapist will contact you with an appointment.
Completed by:[**2152-7-9**]
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25,256
| 153,803
|
12436
|
Discharge summary
|
report
|
Admission Date: [**2162-4-17**] Discharge Date: [**2162-5-19**]
Date of Birth: [**2123-3-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypoxia, fever, respiratory distress.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 39-year-old gentleman with NHL s/p alloSCT [**2155**] and
DLI [**2156**], in remission but with chronic GVHD including
bronchiolitis obliterans and severe restrictive lung disease
being admitted from [**Hospital1 **] with hypoxia to 82%, increased
yellow-white secretions, and respirtory distress. Prior to this
he had been doing quite well - gained weight, weaned to trach
collar for longest 6 hours, with relatively acute decompensation
this morning. He denies dysuria, diarrhea, abdominal pain,
nausea or other symptoms. Tmax at rehab was [**Age over 90 **]F. He received
Meropenem 500mg and brought to [**Hospital1 18**] ED.
Of note, he was recently discharged on [**3-16**] after 2 month
hospital stay complicated by repeated respiratory failure
ultimately requiring trach ([**3-8**]) and VAP. He was readmitted to
[**Hospital Unit Name 153**] for fever on [**3-22**], for which he was treated for Klebsiella
pneumonia and bacteremia. Patient presented with fevers,
increased pulmonary secretions and increased ventilator
requirements. His blood cultures and sputum cultures were
positive for Klebsiella. He was initially treated with
Vancomycin/Meropenem/Bactrim, but this was later tailored to
Meropenem and Tobramycin for ESBL Klebs double coverage. He was
later transitioned to ceftriaxone monotherapy when further lab
investigation confirmed sensitivity. He was discharged on a 21
course to end on [**4-12**]. He was readmitted and discharged on
[**4-6**] for clogged NG tube and new Dobhoff placed.
.
Upon arrival to the ED, his vitals were temp 100.4 139 118/96
20 100% on FiO2 50%. He was given 3L of IVFs and his HR came
down to 100. Given Tylenol and Vancomycin, afebrile on time of
transfer to ICU.
.
Upon arrival to the [**Hospital Unit Name 153**], he is feeling significantly better,
denies respiratory distress or any other symptoms.
Past Medical History:
- [**4-/2154**] p/w fevers, night sweats, and weight loss in the
setting of a left inguinal lymph node.
- CT scan: 15x14x10cm mass in the LUQ.
- Bx grade II/III follicular lymphoma.
- Treated with six cycles of CHOP/Rituxan with good response,
but showed evidence for relapse in [**12/2154**] and was treated with
MINE chemotherapy for two cycles.
- [**3-/2155**]: Underwent stem cell mobilization with Cytoxan followed
by autologous stem cell transplant in
- [**7-/2155**]: Noted for disease recurrence. He was initially treated
with a course of Rituxan without response followed by Zevalin
with
- [**3-/2156**]: Noted progression of his disease. He was treated with
one cycle of [**Hospital1 **] followed by one cycle of ESHAP.
- [**2156-7-29**]: Nonmyeloablative allogeneic stem cell transplant
with a [**5-30**] HLA-matched unrelated donor with Campath conditioning
- Six-month follow-up CT noted for disease progression.
- [**1-/2157**]: Received donor lymphocyte infusion in , complicated by
acute liver/GI GVHD grade IV, for which [**Known firstname **] required a
prolonged hospitalization in the summer of [**2156**].
- Multiple GI bleeds requiring ICU admissions and multiple
transfusions and embolization of his bleeding.
- Noted to have CNS lesions felt consistent with PTLD and this
was treated with a course of Rituxan. No evidence for recurrence
of the PTLD.
- Acute liver GVHD, on CellCept, prednisone, and photophoresis.
- [**2157-12-28**] Photophoresis was d/c'd due to episodes of
bacteremia and eventual removal of his apheresis catheter.
- [**2158-6-13**] restarted photopheresis on a weekly basis on , but
then discontinued this again on [**2158-9-7**] as this was felt not
to be making any impact on his liver function tests.
- undergone phlebotomy due to iron overload with corresponding
drop in his ferritin. He has continued with transient rises in
his transaminases and bilirubin and has remained on varying
doses of CellCept and prednisone which has been slowly tapered
over the time.
- [**2160-1-10**] CellCept discontinued.
- [**2159-1-19**] admission due to increasing right hip pain. MRI
revealed edema and infiltrating process in the psoas muscle
bilaterally. After extensive workup, this was felt related to an
infection and required several admissions with completion of
antibiotics in 03/[**2158**].
- [**7-/2160**]: Last scans showed no evidence for lymphom and he has
remained in remission.
- [**2160-10-20**]: URI and treatment with course of Levaquin.
- [**2160-11-13**] completed a 4 week course of Rituxan to treat his
GVHD.
-In [**5-/2161**], noted to have tiny echogenic nodule on abdominal
[**Year (4 digits) 950**]. MRI of the liver also showed this nodule but was not
as concerning on review and he is due to have a repeat MRI
imaging in early [**Month (only) **].
-- GI varices and attempts at banding have been unsuccessful due
to difficulty with passing the necessary instruments. He has
been on a low dose beta blocker as well as simvastatin, which
was started on [**2161-7-7**] to help with medical management of his
varices.
-On [**2161-8-3**], worsening cough and was noted to have a small
new pneumothorax in the left apical area. This has essentially
resolved over time
- Issues with weight loss (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]);
multiple tests done with no etiology found; question
malabsorption related to GVHD
- Has on and off respiratory infections and has been treated
with antibiotics with possible pneumonia. Question underlying
exacerbations of pulmonary GVHD in setting of his URIs.
- Currently receives IVIG every month.
.
Other Past Medical History:
1. Non-Hodgkin's lymphoma s/p allo SCT
2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed,
chronic transaminitis, portal HTN with esophageal varices (not
able to band)
3. History of intracranial lesions felt consistent with PTLD.
4. Extensinve chronic GVHD of lung, liver, skin, mucous
membranes.
5. Grade II esophageal varices, intollerant to beta blockade.
6. HSV in nasal washing [**11/2159**](completed course of Valtrex)
7. Hypothyroidism
8. hx of Psoas muscle infection
Social History:
No smoking, alcohol abuse, or other drug use. Born in [**Country **]
and moved to the U.S. for college ([**Hospital1 **]). Married in
[**2160-8-25**] and lives in [**Location **]. By report, wife is
pregnant. Stays at home and writes (currently writing a book on
being diagnosed with cancer at young age).
Family History:
Without history of lymphoma or other cancers in the family
No FHx of DM or HTN
Mother: Alive, Thyroid disease
Father: CAD with ecent cardiac cath with angioplasty of 2
vessels, asthma
2 older brothers: alive and well.
Physical Exam:
98 105 104/63 24 100% on RA
Gen: Cachectic male (appears less so since last admission),
+Trach present, + NGT small caliber
HEENT: sclera anicteric
CV: Tachycardic, no m/r/g
Pulm: coarse breath sounds bilaterally, no wheezes, crackles
Abd: soft, NT, ND, bowel sounds present
Ext: no peripheral edema
Pertinent Results:
[**2162-4-17**] 11:10AM BLOOD WBC-21.7*# RBC-3.08* Hgb-9.2* Hct-28.1*
MCV-91 MCH-29.9 MCHC-32.7 RDW-17.3* Plt Ct-347
[**2162-4-17**] 11:10AM BLOOD Neuts-83* Bands-8* Lymphs-4* Monos-4
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2162-4-17**] 11:10AM BLOOD Glucose-156* UreaN-11 Creat-0.3* Na-135
K-4.1 Cl-96 HCO3-31 AnGap-12
[**2162-4-17**] 11:20AM BLOOD Glucose-148* Lactate-2.1* K-4.1
CXR: Persistent left lung base infectious consolidation;
possible
involvement of right medial lung base and right costophrenic
angle.
RUQ: 1. Normal flow and waveforms within the hepatic
vasculature. Normal
appearance to the hepatic parenchyma. 2. Gallbladder wall
thickening similar to prior examination without gallbladder
distention. 3. A small amount of intra-abdominal ascites and
small pleural effusion.
LUE US [**5-5**]: Soft tissue edema, without discrete fluid
collection underlying prior left basilic vein PICC insertion
site. Left basilic vein patent.
________________________________________________________
[**2162-4-19**] 4:14 pm SPUTUM Source: Endotracheal.
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
[**2162-4-24**]. COLISTIN <=2 (MCG/ML) Sensitive.
________________________________________________________
[**2162-4-23**] 8:44 pm SPUTUM Source: Endotracheal.
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
________________________________________________________
[**2162-4-24**] 12:02 pm SPUTUM Source: Endotracheal.
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
________________________________________________________
[**2162-4-27**] 6:17 pm SPUTUM Source: Endotracheal.
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
________________________________________________________
[**2162-5-3**] 3:51 pm SPUTUM Source: Endotracheal.
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 16 S 8 S
CEFEPIME-------------- 8 S 8 S
CEFTAZIDIME----------- 8 S 8 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM------------- 1 S 0.5 S
PIPERACILLIN/TAZO----- =>128 R =>128 R
TOBRAMYCIN------------ =>16 R =>16 R
LUE US [**2162-5-15**]: Findings compatible with thrombosis of one of
the left brachial veins, new since [**2162-4-27**]. This does not
extend into the axillary or subclavian vein.
Brief Hospital Course:
Mr. [**Known lastname 38598**] is a 39-year-old gentleman with chronic repiratory
failure, vent dependent, secondary to GVHD-associated
bronchiolitis obliterans who was admitted for ventilator
associated pneumonia with sputum cultures growing multiple
strains of multi-drug resistant pseudomonas.
# PSEUDOMONAS PNA: Mr. [**Known lastname 38598**] has had numerous strains of high
resistant pseudomonas, and had been on tobramycin prophylaxis
prior to admission. He was initially started on meropenem and
as sensitivites changed, antibiotics were switched to
ceftazidime, amikacin and eventually colistin. Vanco IV and
flagyl were added as well, as Mr. [**Known lastname 38651**] white count seemed to
go down on these medications. A CT chest on [**4-27**] showed
increased bilateral pleural effusions without evidence of
empyema. Sputum cultures continued to show multi-drug resistent
pseudomonas. On the recommendation of the infectious disease
consulting team, he was started on both inhaled and intravenous
colistin in addition to amikacin. Patient should remain on
inhaled colistin, intravenous colistin, and amikacin through
[**5-26**]. After that, he should continue on inhaled colistin
three times a week until directed otherwise by the infectious
disease doctors. Vancomycin and flagyl were discontinued prior
to discharge. We also encourage aggressive chest physical
therapy and frequent suctioning to help with secretions.
FEVER/LEUKOCYTOSIS: Likely due to recurrent pneumonias
(multiple sputum samples positive for pseudomonas aeruginosa)
though other sources were ruled out. Patient's left PICC line
was pulled on [**4-30**]; he was started on IV vancomycin for empiric
gram positive coverage and this was continued despite a negative
catheter tip culture. Moreover, patient was treated with flagyl
despite multiple negative stool samples for clostridium
difficile. Multiple urine and blood cultures were negative.
There was also concern for infection at the site of previous
PICC line in LUE however, [**Month/Day (4) 950**] was negative for fluid
collection or other signs of infection. Finally, it was thought
that fevers/white count may be the results of underlying GVHD,
and prednisone was increased from 15mg to 40mg; however, as
fevers resolved and white count remained stable, prednisone was
decreased to baseline of 15mg QD. Ms. [**Known lastname 38598**] was put on the
colistin and amikacin above at the advice of the ID team. His
fevers stopped and his white count remained stable on these
medications. The vancomycin and the flagyl were discontinued as
per ID and heme/onc recommendations. Mr. [**Known lastname 38598**] will have close
follow-up with ID.
ACUTE ON CHRONIC RESPIRATORY FAILURE: Although Mr. [**Known lastname 38598**] was
initially stable on pressure support, he became tachypnic after
multiple episodes of mucous plugging and was switched to assist
control. Mr. [**Known lastname 38598**] remained intermittently on AC and PS. He
was allowed to dictate his own ventilator settings. Upon
discharge, Mr. [**Known lastname 38598**] was doing well on pressure support; he was
encouraged to remain on PS during the day and AC at night. He
was aggressively suctioned and given mucomyst and
bronchodilators.
HISTORY OF NHL STATUS-POST ALLO [**Known lastname 3242**] COMPLICATED BY GVHD: Most
recent PET scan with no evidence of recurrent disease. GVHD is
underlying cause for patient??????s liver dysfunction and
bronchiolitis obliterans. His prednisone was increased on [**5-5**]
and subsequently tapered back to his prior dosage of 15mg QD. He
was continued on mycophenolate, bactrim, acyclovir, and
voriconazole. He was continued on his monthly IVIG and received
a dose on [**4-18**] and on [**5-13**]. He was followed by the
hematology-oncology consult service throughout his entire
hospital stay. Mr. [**Known lastname 38598**] will have close follow-up with the
heme/onc service.
ELEVATED LFTS: This is secondary to his GVHD. LFTS remained at
baseline throughout hospital course. He also had a RUQ
[**Known lastname 950**] that was unchanged from prior.
LEFT UPPER EXTREMITY DVT: Mr. [**Known lastname 38598**] was found to have a clot in
one of his left brachial veins. Systemic anticoagulation was
not initiated in context of history of GI bleeding (we DID NOT
give Lovenox, Coumadin, or IV heparin). Heparin subcu
(prophylaxis) was increased from 2500 to 5000 units subcu TID.
Resolution of DVT should be evaluated as an outpatient.
FEEDING TUBE: In the past, issue of a PEG or G-tube was
discussed with GI. It appears as though patient's anatomy was
never amenable to PICC; he is now being fed through Doboff tube.
This should be discussed further as an outpatient.
ELEVATED CREATININE: Creatinine rose from 0.2 to 0.4 after
patient was started on nephrotoxic drugs including colistin and
amikacin. Creatinine remained stable at 0.4 for over 1 week.
Patient's creatinine should be followed closely while at rehab,
and outside providers contact[**Name (NI) **] if it begins to rise further.
Medications on Admission:
1. Acyclovir 400 mg IV Q12H
2. Ascorbic Acid 500 mg/5 mL PO DAILY
3. Ergocalciferol (Vitamin D2) 50,000 unit PO 1X/WEEK
4. Therapeutic Multivitamin PO DAILY
5. Prednisone 20 mg Tablet PO DAILY
6. Simvastatin 20 mg Tablet PO HS
7. Zinc Sulfate 220 mg Capsule PO DAILY
8. Albuterol Sulfate 90 mcg 1-2 Puffs Q4H PRN SOB, wheeze.
9. Bisacodyl 5 mg Tablet Two PO DAILY (Daily) PRN constipation.
10. Ipratropium Bromide 17 mcg Inhaler 2 Puff Q4H PRN SOB,
wheeze.
11. Senna 8.6 mg Tablet PO BID PRN constipation.
12. Sodium Chloride 0.65 % Aerosol [**12-26**] Sprays QID PRN dry nares.
13. Trazodone 50 mg Tablet .[**4-24**] Tablet PO HS PRN insomnia.
14. Voriconazole 200 mg IV Q12H
15. Acetaminophen 500 mg Tablet PO Q6H PRN fever.
16. Docusate Sodium 50 mg/5 mL Liquid PO BID
17. Lansoprazole 30 mg Tablet,Rapid Dissolve PO DAILY
18. Dextromethorphan-Guaifenesin 10-100 mg/5 mL PO Q6H PRN
cough.
20. Simethicone 80 mg One (1) Tablet PO BID (2 times a day).
21. Sulfamethoxazole-Trimethoprim 800-160 mg one Tablet PO
QMOWEFR
22. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid One PO DAILY
23. Levothyroxine 125 mcg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
24. Ondansetron 8 mg IV Q8H:PRN nausea
26. 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.
27. Mycophenolate Mofetil 200 mg/mL 250 mg PO twice a day.
28. Fluticasone 50 mcg/Actuation Spray 1 spray Nasal once a day.
Discharge Medications:
1. Morphine Sulfate 1-2 mg IV Q2H:PRN pain
hold for sedation, premedicate before suctioning
2. Ascorbic Acid 500 mg/5 mL Syrup [**Month/Day (3) **]: One (1) PO DAILY
(Daily).
3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Month/Day (3) **]: One (1)
Capsule PO 1X/WEEK (SA).
4. Zinc Sulfate 220 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO DAILY
(Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (3) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Senna 8.6 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Sodium Chloride 0.65 % Aerosol, Spray [**Month/Day (3) **]: [**12-26**] Sprays Nasal
TID (3 times a day) as needed for nasal dryness.
8. Acetaminophen 650 mg/20.3 mL Solution [**Month/Day (2) **]: One (1) PO Q6H
(every 6 hours) as needed for pain, fever.
9. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: Ten
(10) ML PO Q6H (every 6 hours) as needed for cough.
12. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for indigestion.
13. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One (1)
PO DAILY (Daily).
14. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
15. Fluticasone 50 mcg/Actuation Spray, Suspension [**Last Name (STitle) **]: One (1)
Spray Nasal DAILY (Daily).
16. Ondansetron 8 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
17. Levothyroxine 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO 6
DAYS/WEEK ().
18. Acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: One (1) ML
Miscellaneous Q2H (every 2 hours) as needed for thin out
secretions.
19. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
Six (6) Puff Inhalation Q2H (every 2 hours) as needed for
shortness of breath or wheezing.
20. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
[**Last Name (STitle) **]: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
21. Colistimethate Sodium 150 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon
Soln Injection [**Hospital1 **] (2 times a day): Give via nebulizer twice a
day through [**2162-5-26**]. Then give 3 times a week thereafter.
22. Prednisone 5 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO DAILY
(Daily).
23. Trazodone 50 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
24. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
Injection TID (3 times a day).
25. 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.
26. Mycophenolate Mofetil HCl 500 mg Recon Soln [**Month/Day/Year **]: One (1)
Recon Soln Intravenous [**Hospital1 **] (2 times a day).
27. Acyclovir Sodium 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
28. Colistimethate Sodium 150 mg Recon Soln [**Hospital1 **]: One (1) Recon
Soln Injection Q12H (every 12 hours): Please give through
[**2162-5-26**].
29. Voriconazole 200 mg Solution [**Month/Day/Year **]: One (1) Solution
Intravenous Q12H (every 12 hours).
30. Lorazepam 2 mg/mL Syringe [**Month/Day/Year **]: One (1) Injection Q4H (every
4 hours) as needed for anxiety.
31. Amikacin 250 mg/mL Solution [**Month/Day/Year **]: One (1) Injection Q24H
(every 24 hours): Please give through [**2162-5-26**].
32. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
--Pseudomonas aeruginosa pneumonia
--Graft-versus-Host Disease affecting liver and lungs
--Non-Hodgkin's Lymphoma s/p allo transplant
--Ventilator dependent
--LUE DVT
Discharge Condition:
Vented (alternately on assist control and pressure support),
alert and oriented to person, place, time, and event, nutrition
via dobhoff tube
Discharge Instructions:
Dear Mr. [**Known lastname 38598**],
It was a pleasure taking care of you on this admission. You
came to the hospital because of low oxygen saturations and
increased secretions. You were found to have a pneumonia caused
by an organism called pseudomonas aeuruginosa. Unfortunately,
the strain of organisms that we found in your lungs is resistant
to multiple antibiotics. As such, it was necessary to treat you
with many drugs that you will need to take intravenously and via
inhalation.
We also found a clot in your left arm, likely the result of a
PICC line that had been placed there. We increased your heparin
to 5000 units every day, which should provide better protection
against developing these clots again.
Please see below for a list of your new medications.
Please keep all of your follow-up appointments. Please take all
of your medications as prescribed.
Return to the hospital if you develop increased shortness of
breath or trouble breathing, fevers, rising white count, pain
with urination, nausea, vomiting, diarrhea, confusion, abdominal
pain, palpitations, or any other concerning signs or symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2162-5-25**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2162-5-25**] 2:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2162-5-25**] 1:00
|
[
"785.0",
"E879.8",
"453.81",
"572.3",
"516.8",
"997.31",
"996.74",
"202.80",
"E849.8",
"519.19",
"V44.0",
"799.02",
"996.85",
"518.84",
"456.21",
"041.7",
"E878.0",
"244.9",
"E849.7",
"279.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
21648, 21691
|
10941, 16025
|
353, 360
|
21901, 22044
|
7338, 10918
|
23222, 23701
|
6780, 6999
|
17571, 21625
|
21712, 21880
|
16051, 17548
|
22068, 23199
|
7014, 7319
|
276, 315
|
388, 2257
|
5950, 6438
|
6454, 6764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,837
| 134,680
|
53393
|
Discharge summary
|
report
|
Admission Date: [**2113-11-21**] Discharge Date: [**2113-11-27**]
Date of Birth: [**2059-12-21**] 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:
[**2113-11-22**] Coronary Artery Bypass Graft x 4 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
diagonal, Saphenous vein graft to obtuse marginal 1 to obtuse
marginal 2)
[**2113-11-21**] Cardiac Catheterization
History of Present Illness:
53 year old male without significant [**Hospital **] transferred from
[**Hospital6 27369**] with sudden onset chest pain this morning
while sitting in his car. Pain was not accompanied by SOB or
diaphoresis. Pt did report some numbness traveling down his L
arm. Pt reports similar symptoms 2 weeks ago which didn't prompt
medical attention. At OSH CK 177, trop 0.25, was treated with
ASA/ PLavix/ Heparin/ Morphine- diagnosed as NSTEMI and
transferred to [**Hospital1 **] for cardiac catheterization.
Past Medical History:
Arthritis
s/p left knee arthroscopy
s/p cataract surgery
s/p hernia repair
s/p palate surgery x 2
Social History:
Race:Caucasian
Last Dental Exam:unknown
Lives with: at home, with son
Occupation: machinist
Tobacco: current, 1 ppd /15years
ETOH: 1 per week
Family History:
Father's side w/CAD- not premature
Physical Exam:
VS: T: 98.1 HR: 80-100 SR BP: 100/60 Sats: 92% RA Wt: 80.3
General: 53 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR normal S1, S2 no murmur/gallop or rub
Resp: decreased breaths bilateral otherwise clear
GI: benign
Extr: warm no edema
Incision: sternal and LLE clean dry no hematoma
Neuro: non-focal
Pertinent Results:
[**2113-11-21**] WBC-8.0 RBC-4.10* Hgb-13.0* Hct-37.9* Plt Ct-186
[**2113-11-21**] PT-14.2* PTT-98.9* INR(PT)-1.2*
[**2113-11-21**] Glucose-103 UreaN-8 Creat-0.8 Na-137 K-3.6 Cl-103
HCO3-25 AnGap-13
[**2113-11-21**] CK-MB-94* MB Indx-13.7* cTropnT-0.37*
[**2113-11-22**] cTropnT-0.65*
[**2113-11-22**] CK-MB-128* MB Indx-11.4* cTropnT-0.98*
[**2113-11-21**] Albumin-3.7
[**2113-11-21**] %HbA1c-6.1*
[**2113-11-22**] Triglyc-139 HDL-47 CHOL/HD-3.9 LDLcalc-109
[**2113-11-22**] Echo: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed (LVEF= 50 %) with
inferior/inferolateral hypokinesis/akinesis and probable apical
septal hypokinesis. Left ventricular systolic function may be
more depressed than suggested by the current LVEF in the setting
of IABP support. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
.
[**2113-11-21**] Cath: 1. Selective coronary angiography of this right
dominant system revealed left main plus two vessel obstructive
coronary artery disease. The LMCA had a 70% stenosis distally.
The LAD was diffusely diseased, with a 80% proximal stenosis.
The LCX had a 90% proximal stenosis, and had and occluded OM2.
The RCA had mild disease, with a 50% stenosis in the PL. 2. A 9
Fr 30 CC intraaortic balloon pump was inserted due to ongoing
chest pain.
.
[**2113-11-25**] CXR: As compared to the previous radiograph, the size of
the cardiac silhouette is unchanged. Also unchanged is the
extent of the bilateral pleural effusions. There is no evidence
of newly appeared focal parenchymal opacities suggesting
pneumonia. Unchanged retrocardiac atelectasis.
.
[**2113-11-27**] WBC-7.7 RBC-2.94* Hgb-9.4* Hct-27.4* Plt Ct-208#
[**2113-11-27**] Glucose-97 UreaN-14 Creat-1.0 Na-137 K-4.4 Cl-102
HCO3-26
[**2113-11-25**] WBC-7.7 RBC-2.92* Hgb-9.2* Hct-26.6* Plt Ct-111*#
[**2113-11-25**] Glucose-153* UreaN-11 Creat-0.9 Na-137 K-3.7 Cl-101
HCO3-29
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 20741**] was transferred to [**Hospital1 18**]
with a NSTEMI and underwent a cardiac cath on [**2113-11-21**]. Cath
showed two vessel coronary artery disease(see result section for
additional detail), a IABP was placed and he was referred for
surgical revascularization. He underwent usual pre-operative
work-up and on [**11-22**] he was taken to the operating room where he
underwent an urgent coronary artery bypass graft x 4. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours, he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one IABP was
weaned and removed without complication. On post-op day two
chest tubes were removed and he was transferred to the telemetry
floor for further care. He was started on beta-blockers with
good rate control. Beta blockade was advanced as tolerated and
he remained in a normal sinus rhythm. On post-op day three
epicardial pacing wires were removed without incident. He was
gently diuresed. His pain was well controlled with PO pain
medications. His renal function remained within normal range
with good urine output. Over several days medial therapy was
optimized, he continued to make clinical improvements and was
eventually cleared for discharge to home on POD5.
Medications on Admission:
None
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 6-8 hours as needed for pain.
Disp:*50 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:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x [**Street Address(2) **] Elevation Myocardial Infarction
Slightly Elevated Hemoglobin A1c
Arthritis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact you [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues.
2) Report any fever of greater then 100.5
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) Please shower daily. Wash wound with soap and water. No
lotions, creams or pwoders to incision until it has healed.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month from date of surgery.
7) Please call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) 109826**] in 4 weeks
Dr. [**Last Name (STitle) 11493**] in [**2-21**] weeks
Dr. [**Last Name (STitle) 14016**] in [**1-20**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2113-11-27**]
|
[
"E878.2",
"410.71",
"272.4",
"287.4",
"285.9",
"414.01",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.52",
"36.13",
"36.15",
"88.55",
"37.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6071, 6090
|
4157, 5562
|
334, 584
|
6293, 6299
|
1845, 4134
|
6938, 7218
|
1410, 1446
|
5617, 6048
|
6111, 6272
|
5588, 5594
|
6323, 6915
|
1461, 1826
|
284, 296
|
612, 1114
|
1136, 1235
|
1251, 1394
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,143
| 120,660
|
54268
|
Discharge summary
|
report
|
Admission Date: [**2182-1-1**] Discharge Date: [**2182-1-15**]
Date of Birth: [**2101-4-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
mostly asymptomatic with slight decrease in lower extremity
weakness
Major Surgical or Invasive Procedure:
cabg x3/AVR/repl. asc.and hemiarch aorta [**2182-1-1**]
(LIMA to LAD, SVG to DIAG, SVG to RAMUS, 25 mm CE pericardial
valve, 28 mm Gelweave graft)
History of Present Illness:
80 yo male with history of SVT and positive family history who
moticed increasing weakness of his left leg (polio). Had
dobutamine stresst echo done which showed septal and apical
hypokinesis. Cath revealed LAD 90%, DIAG 90%, RAMUS 90%, RCA
10-20%, PDA 60-70%, EF 62%. Referred for surgical intervention.
Past Medical History:
polio ( LLE weakness and prior muscle transplant)
SVT
elev. chol.
hernia repair
tonsillectomy
Social History:
retired
denies ETOH
several cigars per day for 5 years ( stopped almost 60 years
ago)
no recr. drugs
Family History:
brother with CABG at 62
Physical Exam:
Preop
HR 100 RR 12 right 150/72 left 148/76 5'9" 140 #
NC/AT, PERRL, OP benign
no JVD or adenopathy, supple , full ROM
CTAB
RRR no m/r/g
soft, NT, ND, + BS
warm, well-perfused, no edema, bilat. atrophied LE
superficial varicosities at left ankle
MAE, alert and oriented x 3, uses cane and wears brace on RLE to
prevent hyperextension of right knee, weakness LLE > RLE
2+ bil. fems/radials
1+ bil. DP/PTs
no carotid bruits appreciated
Discharge
HR 97SR BP 100/62 RR 18 O2Sat 94%RA
Gen NAD
Neuro A&Ox3, MAE-nonfocal
Pulm CTA
Cor RRR, S1-S2. Sternum stable, incision CDI w/steri's
Abdm soft/NT/ND/NABS
Ext warm-well perfused. Lft svg site eccymotic
Pertinent Results:
[**2182-1-7**] 05:50AM BLOOD WBC-10.9 RBC-4.55* Hgb-14.2 Hct-42.0
MCV-92 MCH-31.2 MCHC-33.8 RDW-14.3 Plt Ct-96*
[**2182-1-9**] 05:40AM BLOOD Hct-37.4*
[**2182-1-8**] 05:55AM BLOOD Plt Ct-106*
[**2182-1-9**] 05:40AM BLOOD PT-13.0 PTT-26.9 INR(PT)-1.1
[**2182-1-9**] 05:40AM BLOOD Glucose-164* UreaN-23* Creat-0.7 Na-141
K-3.9 Cl-106 HCO3-24 AnGap-15
[**2182-1-7**] 05:50AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.5
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 3310**], [**Known firstname 7178**] [**Hospital1 18**] [**Numeric Identifier 111186**]
(Complete) Done [**2182-1-1**] at 2:23:27 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2101-4-9**]
Age (years): 80 M Hgt (in):
BP (mm Hg): 101/55 Wgt (lb): 140
HR (bpm): 57 BSA (m2):
Indication: Coronary artery disease. Aortic valve disease.
ICD-9 Codes: 440.0, 441.2, 424.1
Test Information
Date/Time: [**2182-1-1**] at 14:23 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2006AW-:1 Machine: aw02
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: *5.1 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aortic Valve - Valve Area: *2.4 cm2 >= 3.0 cm2
Aortic Valve - Pressure Half Time: 468 ms
Tricuspid Valve - Peak TS Velocity: 2.0 m/sec
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Low normal LVEF.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic root diameter. Markedly dilated ascending
aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
Moderate to severe (3+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was under
general anesthesia throughout the procedure.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre - Bypass
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%).
3. Right ventricular systolic function is normal.
4. The ascending aorta is markedly dilated There are simple
atheroma in the descending thoracic aorta.
5. The aortic valve leaflets are moderately thickened. Moderate
to severe (3+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
Post - Bypass
1. The prosthetic valve is seated well in the aortic position.
There are no perivalvular leaks. There is no aortic stenosis.
2. There is no dissection in the descending aorta.
3. The LV function is well preserved.
4. The mitral regurgitation is mild.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician
FINAL REPORT
INDICATION: Assess Dobbhoff position.
COMPARISON: CXR [**2182-1-6**].
FINDINGS: Upright radiograph of the chest. The patient is status
post CABG
and multiple surgical clips and median sternotomy wires are
unchanged. A
Dobbhoff tube is again identified and unchanged in position with
its tip
curved within the fundus of the stomach and possibly pointing
towards the GE
junction. Left lower lobe atelectasis and left-sided pleural
effusion is
unchanged. Some increased caliber of the upper lobe pulmonary
vessels are
noted, most prominent on the left. Right lung is clear. No
pneumothorax.
IMPRESSION:
1. Unchanged position of Dobbhoff tube with tip curved within
the fundus and OBJECT: CORONARY ARTERY DISEASE. ? STROKE.
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
RADIOLOGY Final Report
MR HEAD W/O CONTRAST [**2182-1-10**] 8:53 PM
MR HEAD W/O CONTRAST; MRA NECK W/O CONTRAST
Reason: r/o CVA
[**Hospital 93**] MEDICAL CONDITION:
80 year old man s/pCABG, asc arch, AVR
REASON FOR THIS EXAMINATION:
r/o CVA
INDICATION: 80-year-old status post CABG, aortic valve repair,
presenting with dysphasia.
COMPARISON: Not available. Note made of CT head [**2182-1-5**].
TECHNIQUE: Multiplanar T1 and T2 images were obtained, as well
as FLAIR and diffusion-weighted imaging.
FINDINGS: There are several foci in the left posterior temporal
lobe, demonstrating increased FLAIR and T2 signal, as well as
restricted diffusion, suggestive of subacute infarction. There
are no foci of hemorrhage. Some of the foci demonstrate
increased anisotropy, consistent with acute infarction. The
anatomical distribution is indicative of embolic etiology.
There is no intracranial mass, hydrocephalus, or shift of normal
midline structures. The surrounding osseous and soft tissue
structures are unremarkable.
MRA CAROTID & VERTEBRAL ARTERIES TECHNIQUE: 2 and 3 dimensional
time of flight imaging with multiplanar reconstructions.
FINDINGS: No areas of hemodynamically significant stenosis or
ulceration is seen in the carotid or vertebral arteries.
IMPRESSION: 1) Several foci of acute and subacute infarction in
the left posterior temporal lobe, anatomic distribution
indicative of embolic etiology.
Normal MRI of the carotid and vertebral arteries.
Please note that MRI of Circle of [**Location (un) 431**] was not performed due
to patient's intolerance of the rest of the exam.
FINDINGS:
BACKGROUND: Was often very disorganized but reached an 8.5-9 Hz
alpha
frequency posteriorly in wakefulness.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient progressed from wakefulness to early sleep
with no
additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Largely normal EEG in the waking and sleeping
states. The
background was disorganized but reached normal frequencies.
There were
no areas of focal slowing to correlate with any suspected stroke
(but
some strokes, especially small ones, do not affect the EEG
substantially). There were no epileptiform features.
likely pointing towards the GE junction.
2. Stable left basilar atelectasis and left-sided pleural
effusion. Interval
increase in caliber of upper lobe vasculature noted most
prominently on the
left.
CAROTID SERIES COMPLETE [**2182-1-9**] 3:12 PM
CAROTID SERIES COMPLETE
Reason: S/P CABG, ? CVA
[**Hospital 93**] MEDICAL CONDITION:
80 year old man s/p CABG
REASON FOR THIS EXAMINATION:
?CVA
CAROTID SERIES COMPLETE.
REASON: _____ stroke.
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Minimal plaque is identified.
On the right, peak systolic velocities are 82, 82, 93 in the
ICA, CCA, and ECA respectively. This is consistent with less
than 40% stenosis.
On the left, peak systolic velocities are 73, 82, 76 in the ICA,
CCA, and ECA respectively. This is consistent with less than 40%
stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.
?????? [**2178**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted [**2182-1-1**] and underwent surgery same day. Please see OR
report for details, in summary the pt had AVR(#25CE
pericardial)Asc Ao Replacement(#28
Gelweave)CABGx3(LIMA-LAD,SVG-Diag,SVG-Ramus). Transferred to the
CSRU in stable condition on epinephrine, neosynephrine, and
propofol drips. Extubated the morning of POD #1. He developed
Afib tx w/Amiodarone-Lopressor and Warfarin. Had difficulty
swallowing po meds and swallowing eval. obtained. Changed to
tube feeds via Dobhoff while being monitored,Repeat video
swallow revealed continued aspiration and ultimately PEG was
placed on [**1-11**]. Transferred to the floor on POD #4. Pt had an
episode of aphasia-unresposiveness that completely resolved w/in
1 hour. Pt was seeen by neurology and had MRI/EEG/and carotid
US, see reports for details.
Over the next week the patients diet was afvanced, his activity
level was increased with help from PT and he was gradually
anticoagulated following PEG placement.
On POD 14/4 it was decided that the patient was ready for
transfer to rehabilitation at [**Hospital3 **].
Medications on Admission:
verapamil SR 120 mg alternating with 180 mg every other day
niaspan 500 mg daily
zetia 10 mg daily
ASA 325 mg daily
MVI daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital3 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 150 mg/15 mL Liquid [**Hospital3 **]: One Hundred (100) mg
PO BID (2 times a day).
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital3 **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Hospital3 **]: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
5. Warfarin: as directed Tablet PO DAILY (Daily): target INR
2.0. Pt to receive 3mg today([**1-15**])
6. Ciprofloxacin 500 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
7. Amiodarone 200 mg Tablet [**Month/Day (1) **]: Two (2) Tablet PO three times a
day: 400mg TID thru [**1-19**] then
400mg [**Hospital1 **] x1wk then 400mg QD x1wk then 200mg QD.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
CAD / AI/ asc. aortic aneurysm
SVT
elev. chol.
polio (LLE weakness) with muscle transplant surgery
Discharge Condition:
stable
Discharge Instructions:
no lifting greater than 10 pounds for 10 weeks
may shower over incisions and pat dry
no lotions, creams or powders on any incision
no driving for one month
call for fever greater than 100, redness or drainage
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 7389**] in [**2-12**] weeks
follow up with Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
follow up in [**Hospital 4038**] clinic in 4 weeks call [**Telephone/Fax (1) **] for
appointment
Completed by:[**2182-1-15**]
|
[
"424.1",
"787.2",
"451.82",
"599.0",
"999.2",
"414.01",
"458.29",
"441.2",
"272.0",
"780.39",
"138",
"401.9",
"728.87",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"99.04",
"88.72",
"36.15",
"43.11",
"39.61",
"35.21",
"96.6",
"99.05",
"99.06",
"38.45",
"99.07",
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] |
icd9pcs
|
[
[
[]
]
] |
12495, 12560
|
10108, 11187
|
388, 538
|
12703, 12712
|
1846, 4818
|
12969, 13254
|
1123, 1148
|
11363, 12472
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9417, 9442
|
12581, 12682
|
11213, 11340
|
12736, 12946
|
4862, 6918
|
1163, 1827
|
280, 350
|
9471, 10085
|
566, 872
|
894, 989
|
1005, 1107
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,064
| 111,752
|
51619
|
Discharge summary
|
report
|
Admission Date: [**2133-4-28**] Discharge Date: [**2133-5-7**]
Date of Birth: [**2051-10-23**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
confusion, fall
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
81 year old man with CAD s/p CABG, AF s/p pacemaker, CVA,
dementia presented to the Emergency Department from nursing home
with 1 day of increasing confusion and a fall. Per daughter
patient had fallen in bathroom. Found wearing only a towel--had
apparently been using toilet; further details unknown. Pt had
been off home medications Initial evaluation was unremarkable
with normal vital signs; laboratories only notable for mild
leucocytosis. Anticipated that he would be returned to the
nursing home.
Soon thereafter, the patient was found to be unresponsive and
cyanotic. Code called. Pt initially in PEA and then in VF
arrest. Shocked once and given one round of epinephrine and of
atropine. Pt intubated. BP and P reportedly returned. Shortly
thereafer the patient went again into VF arrest. Shocked once
and received one round of epinephrine and atropine. Pulse and
pressure returned. Central line (R IJ) placed. Cooling protocol
initiated. Pt did not require pressors.
VBG on vent 7.32/46/83/25, lactate 2.3. Chest X-ray
unremarkable. CTA without evidence of PE or dissection. Bedside
echo performed by cardiology fellow revealed akinesis of
anterior wall.
Past Medical History:
- ECHO [**2131**]: EF 55-60%, abnormal septal motion, mild enlargement
of atria bilaterally, moderate TR and MR. LV wall thickness
normal. LV slightly dialated. No other focal wall motion
abnormalities.
- cath [**2126**]: 80% lesion OM, 85% LAD mid, large intermedius with
80% proximal, 90% proximal LCx, dominant RCA with 50% ostial and
proximal.
- CABG (LIMA to LAD, SVG to D1, SVG to ramus), post operative
course c/b thyroid storm and bilateral pleural effusions.
Reportedly taken for CABG after new "block" noted on EKG. Pt
without chest pain
- Dementia, on aricept
- Atrial fibrillation s/p pacemaker placement in [**2123**], then in
[**2129**], [**Company 1543**]
- Status post L carotid endarectomy for severe stenosis;
however, no history of CVA per daughters.
- amio-induced thyroiditis
- afib s/p cardioversion [**2126**]
- rapid ventricular rhythms
- hx of PEG tube
- left foot drop
- perineal nerve damage [**2126**]
- mild hypercholesterolemia
- exercise mibi [**2126**] - moderate ischemia in LCx or RCA. EF was
50% then
- 50+ year smoking history
- hemorrhagic effusion
- sick sinus requiring DDD pacing in [**2123**]
Social History:
Recently moved by daughters from [**Name (NI) 108**] to Social history is
significant for tobacco use for several years. There is, per
daughter, a history of alcohol abuse--less use in recent year.
His health care proxy is his daughter [**Name (NI) **] [**Name (NI) 28221**].
Family History:
Family history is non-contributory
Physical Exam:
Admission:
VS: T 92.3 ( cooling protocol), BP 113/72 on 0.48 levophed , HR
70-80 , RR 14, O2 100% on
Ventilator settings: AC TV 500 RR 16 FiO2 100 PEEP 5
Gen: Intubated, sedated, paralyzed
HEENT: NCAT. Sclera anicteric. Pupils pinpoint reactive.
Mouth: Dry oral mucosa, poor dentition.
Neck: Supple with JVP of 10 cm on L. R IJ in place, L
endarectomy scar
CV: Irregularly irregular. Heart sounds somewhat distant. Could
not appreciate murmur.
Chest: Decreased breath sounds. No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Rectal: Tone absent, guaiac negative.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Radial 1+; Femoral 2+ without bruit; DP dopplerable
(monophasic)
Left: Radial thready; Femoral 2+ without bruit; DP dopplerable
Pertinent Results:
CT C-SPINE W/O CONTRAST [**2133-4-28**] 9:00 AM
FINDINGS: The alignment is normal. There is no evidence of
fracture. There is cerumen in both external auditory canals,
suggest clinical correlation for hemotympanum. The vertebral
body heights are preserved. There is ossification of the
posterior longitudinal ligament. There are subchondral cysts and
osteophytes throughout the cervical spine both anteriorly and
posteriorly. There is some foramenal narrowing due to
uncovertebral and facet joint hypertrophy at C2-3 (right >
left), C3-4 (left > right), C4-5 (left > right) and bilaterally
at C5-6. There are dystrophic changes anterior to the spinous
processes, causing very mild canal stenosis at C4-C5. There is
no prevertebral soft tissue swelling. There are blebs at the
left lung apex and paraseptal emphysema.
IMPRESSION: No fracture. Multilevel degenerative change as
detailed above. Blebs at the left lung apex.
.
CT HEAD W/O CONTRAST [**2133-4-28**] 8:49 AM
FINDINGS: There is no evidence of intracranial hemorrhage, mass
effect or edema. There is marked cerebral atrophy. There is
thickened mucosa in bilateral maxillary sinuses. There is small
vessel ischemic disease. There is no evidence of fracture.
IMPRESSION: No acute intracranial hemorrhage.
.
CT Head w/ Contrast [**2133-5-5**]
FINDINGS: There is no evidence of intracranial hemorrhage,
hydrocephalus, shift of normally midline structures, edema, or
large vascular territory infarction. Prominence of the sulci and
ventricles is again noted, consistent with age-related
involutional changes. Regions of periventricular white matter
hypoattenuation are consistent with small vessel ischemic
disease. Hypodensity in the right basal ganglia is consistent
with old lacunar infarct. Calcifications are again noted in the
cavernous carotid arteries. No fractures are seen. Mild mucosal
thickening is again noted in bilateral maxillary sinuses.
IMPRESSION: No evidence of acute intracranial process. Mild
bilateral maxillary sinus mucosal thickening again noted.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2133-4-28**] 3:34 PM
CT OF THE CHEST WITH IV CONTRAST: An endotracheal tube is noted.
The heart is enlarged. Coronary artery calcifications are seen.
The pulmonary artery is normal in size without filling defects
to suggest pulmonary embolism. The ascending aorta demonstrates
calcifications within the wall without evidence of dissection.
There is a left apical paraseptal bullae. Bilateral dependent
atelectasis is identified. There are small pleural effusions,
left greater than right. There is no pneumothorax or
consolidation. There is no mediastinal, hilar, or axillary
lymphadenopathy.
This study is not designed for evaluation of the abdomen,
however, the visualized portions of the upper abdomen are
unremarkable. The patient is status post CABG.
No suspicious lytic or sclerotic lesions are identified.
Extensive degenerative changes of the spine are identified.
IMPRESSION: No evidence of pulmonary embolism or thoracic aortic
dissection.
.
Echo:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. There is
severe global left ventricular hypokinesis (LVEF = <20 %) with
contraction best at the base of the heart. No LV apical thrombus
is seen. The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe left ventricular
systolic dysfunction with contraction best at the base of the
heart (?stress-induced cardiomyopathy vs. large LAD territory
infarct). Mild right ventricular dilation with mild global
hypokinesis. Moderate to severe mitral regurgitation.
.
Cardiac Cath:
COMMENTS:
1. Coronary angiography in this right-dominant system revealed:
--the LMCA had an 80% ostial stenosis.
--the LAD had a 50% mid-vessel stenosis. D1 was occluded and
filled via
SVG graft.
--the LCx had a 70% proximal lesion, and a subtotally occluded
high OM1
which fills via SVG with no significant disease.
--the RCA had <50% proximal disease.
2. Arterial conduit angiography revealed the LIMA-LAD graft to
be
atretic. The SVG-Diag-OM1 Y-graft was normal.
3. Limited resting hemodynamics revealed normal systemic
arterial
systolic pressures, with SBP 108 mmHg.
4. Successful ptca and stenting of the ostial Left main
coronary artery
with a 4.0x15mm vision stent which was postdilated to 4.5mm.
Final
angiography revealed 0% residual stenosis, no angiographically
apparent
dissection and timi 3 flow. The patient left the lab in
unchanged
condition and pain free.
FINAL DIAGNOSIS:
1. Native three-vessel coronary artery disease including
significant
left main disease.
2. Patent SVG-Diag-OM1 Y-graft
3. Atretic LIMA-LAD
4. Successful bare metal stenting of the left main coronary
artery.
.
EEG [**5-5**]
IMPRESSION: This is an abnormal portable EEG due to the low
voltage,
disorganized, and slowed background which was interrupted by
bursts of
generalized mixed frequency slowing. This constellation of
findings is
consistent with a mild encephalopathy suggesting dysfunction of
bilateral subcortical or deep midline structures. Medications,
metabolic disturbances, infection, and anoxia are among the
common
causes of encephalopathy. There were no areas of prominent focal
slowing although encephalopathic patterns can sometimes obscure
focal
findings. There were no epileptiform features. The superimposed
beta
frequency rhythm likely reflects concomitant medication effects
from
benzodiazepine or barbiturate administration. No electrographic
seizure
activity was noted.
.
CXR [**5-6**]:
FINDINGS: In the interim, there is increase in the size of the
heart, which is mild-to-moderate. Lesser pulmonary edema in both
lungs is noted. Right upper lobe opacity likely aspiration has
not changed. In the lung bases, there are bilateral
small-to-moderate pleural effusions with adjacent bibasilar
atelectasis. A feeding tube distal tip is out of view on this
image. No change in the lead position of the left-sided
pacemaker.
IMPRESSION:
1. Persistent right upper lobe opacity likely aspiration.
2. Lesser pulmonary edema bilaterally.
3. Persistent small bilateral pleural effusion and atelectasis.
4. Worsening cardiomegaly.
.
ABG
[**2133-5-6**] 09:10AM ART 7.34/ 54 / 176
[**2133-5-6**] 05:12AM ART 7.31/ 59 / 242
Brief Hospital Course:
81 year old gentleman admitted to CCU status post VF arrest, on
a ventilator, completed cooling protocol, continuing with
hemodynamic instability.
.
#) Hypotension: Patient was intubated, and on cooling protocol
at presentation. he was on levophed and maintained blood
pressures 80-85/40's. Given recent echo findings of LVEF being
only 20%, it was thought that the patient may have been in
cardiogenic shock. He was therefore started on dobutamine.
However, he had no pulmonary edema, which is inconsitent with
cardiac shock. He also had a large fluid requirement, receiving
over 11 liters of fluid over the first two days. Given his
tenuous hemodynamic status, a PA catheter was placed on [**4-30**]. He
was found to have a wedge of 20 and CI 3.6 and so was deemed to
not be in cardiogenic shock. His dobutamine was weaned off, and
his blood pressures were maintained with further IVF. As the
patient's cultures were negative, no fever and no leukocytosis,
it was not thought that he was in septic shock. As his blood
pressures remained stable, he was switched to maintenace fluids
and required no futher fluid resuscitation.
.
#) VF arrest. Patient was immediately placed on cooling
protocol. He had positive cardiac enzymes, and so was there
thought to have suffered an ischemic event. Given his new wall
motion abnormalities, with anterior and apical hypokinesis, he
was begun on IV heparin to prevent LV thrombus formation.
Heparin was subsequently discontinued when he had persistent
bloody secretions. He underwent cardiac catheterization on
[**2133-5-1**] with stenting of the left main.
.
#) CAD/Ischemia: Pt s/p CABG 9yrs ago. Presented with elevated
cardiac biomarkers. he was continued on IV heparin, aspirin, and
a statin. He underwent cardiac catheterization on [**2133-5-1**] with
stenting of the left main. He was started on Plavix and required
a dobhoff NG tube for Plavix administration due to aspiration
concerns. Heparin was subsequently discontinued when he had
persistent bloody secretions. Metoprolol was added once he was
found not be be in cardiogenic shock and as his blood pressure
stabilized.
.
#)Mental Status: The patient's mental status was carefully
monitored after extubation. He had persistant depressed mental
status w/o any purposeful movements. Three days after
extubation, he briefly appeared to be clearing, possibly saying
a few unitelligable words. However, his mental status then
declined - he was responsive only to pain, w/o purposeful
movements but with brainstem reflexes. A repeat head CT showed
no acute pathology. An EEG was performed showing encephalopathy.
.
#)Pneumonia: On [**5-4**], a new RUL infiltrate was noted on CXR. He
was started on Vanc and Zosyn for Aspiration vs ventilator
acquired PNA. Follow up CXR showed evolution of the PNA. The
patient then developed a fever and leukocytosis with left shift.
He was maintained on Vanc and Zosyn until the family determined
that he should be [**Month/Year (2) 3225**].
.
# Respiratory failure: On [**4-30**], the patient was noted to be
doing well with ventilator weaning, tolerating pressure support
with RISBI 99. Sedation was weaned, and the patient was
sucessfully extubated. Initially the patient was ventilating
well but requiring high flow O2 on shovel mask. He continued to
require O2, frequent suctioning for copious secretions and was
persistantly tachypnic. On [**5-6**], his respiratory status
worsened; he appeared to be tiring, taking shorter, shallower
breaths. An ABG revealed respiratory acidosis with acute CO2
retention. The family was contact[**Name (NI) **]. Based on a conversation
with the [**Hospital 228**] health care proxy, the patient was made [**Name (NI) 3225**].
He was started on a morphine drip to decrease dyspnea, and all
other medications were stopped.
.
#) S/p fall. Head CT unremarkable. C-spine without fracture,
cleared in ED.
.
#) Code status: On arrival, the patient had been rescusitated.
The family subsequently decided that he should be DNR/DNI. As
his condition worsened, he family further decided to proceed
with comfort measures only. The patient died on [**2133-5-7**].
Medications on Admission:
Risperdal .5mg PO qHS
Depakote 250mg PO daily
Digitek .125mg Po Daily
Folic Acid 1mg PO daily
Prilosec 20mg Po daily
Metoprolol 25mg PO twice daily
simvastatin 40mg PO qhs
thiamine 100mg Po daily
aricept 10mg qHS
Celexa 10 mg daily
Tylenol 325mg PO three times daily
.
ALLERGIES: Amiodarone
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
PEA arrest.
Ventricular Fibrillation
Myocardial Infarction
Discharge Condition:
expired
Discharge Instructions:
You were admitted to the hospital after being found in
Ventricular Fibrillation and cardiac arrest. You were
resuscitated.
.
Please continue to take your medications as prescribed.
.
Please call your doctor or return to the hospital if you
experience chest pain, or shortness of breath.
Followup Instructions:
N/A
|
[
"424.0",
"427.5",
"518.81",
"428.0",
"794.02",
"V45.01",
"438.9",
"V45.81",
"414.01",
"427.41",
"428.20",
"272.0",
"486",
"410.71",
"294.8",
"348.30",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"37.22",
"36.06",
"96.04",
"89.14",
"96.72",
"99.62",
"00.45",
"99.20",
"00.40",
"88.56",
"00.66",
"88.57"
] |
icd9pcs
|
[
[
[]
]
] |
15197, 15206
|
10698, 12827
|
286, 312
|
15318, 15328
|
3893, 8912
|
15664, 15671
|
2974, 3010
|
15169, 15174
|
15227, 15297
|
14854, 15146
|
8929, 10675
|
15352, 15641
|
3025, 3874
|
231, 248
|
340, 1507
|
12842, 14828
|
1529, 2665
|
2681, 2958
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,086
| 150,031
|
19627
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 53187**]
Admission Date: [**2198-1-19**]
Discharge Date: [**2198-1-23**]
Date of Birth:
Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: Of note, the presentation of
this patient is written in a very detailed admission note
already posted to the CCC computer record. Please see that
admission note for full details.
In summary, the patient is a 50-year-old male with
interstitial lung disease secondary to a toxic reaction of
interferon treatment given to him for hepatitis in [**2191**] and
[**2192**]. He had a progressively worsening decline of
respiratory status which became acute approximately 2 months
prior to admission in [**11-2**]. On [**2198-1-19**], he presented to
the emergency room in acute respiratory distress and with
significant hypoxia. He was managed overnight in the
emergency department with nebulizers, high-dose steroids,
antibiotics including PCP coverage and was taken on the
following day to the OR, by CT Surgery, for open-lung biopsy
to take samples of the right lower lobe and right middle
lobe. The plan was to evaluate these samples from the
pathology and microbiology view point to determine the exact
nature of the patient's disease and prognosis.
Patient was transferred to the MICU status post the procedure
with a right chest tube in place, and he was intubated.
While in the MICU, the patient was never able to be
adequately weaned off the ventilator due to the severity of
his baseline lung disease. This was an anticipated risk when
the patient underwent the initial procedure. He also had
episodes of hypotension. His hypotension was treated with
Neo-Synephrine drips.
During this time, the patient's family was extremely anxious
as expected as well as very uncomfortable with the fact that
the patient remained intubated as they were in complete
agreement that this was contrary to his wishes. Multiple
family meetings were held with the patient's family which
included his wife, daughter, and son and it was agreed to
wait until the formal pathology results of the lung tissue
were available prior to making a decision. The formal
pathology results of the tissue were reviewed and results
were discussed again at family meetings. It was noted that
the patient had an extremely dismal prognosis. Even if he
was able to wean off the ventilator following this procedure,
it was felt that his life expectancy would be very poor.
Given the fact of his dismal outcome as well as the current
difficulty weaning the patient off the ventilator and the
patient's previous wishes to never be intubated per family,
it was decided to offer supportive and comfort care only.
The patient was extubated and expired shortly thereafter.
Social support was offered by the entire MICU team including
nursing staff and a social worker to the family who was
present at the time and funeral arrangements were made
between the morgue and the hospital staff.
DR.[**Last Name (STitle) 53188**],[**First Name3 (LF) **] 11-933
Dictated By:[**Last Name (NamePattern1) 41037**]
MEDQUIST36
D: [**2198-5-3**] 15:30:01
T: [**2198-5-4**] 12:27:39
Job#: [**Job Number 53189**]
|
[
"518.81",
"E933.1",
"496",
"571.5",
"070.51",
"714.0",
"799.0",
"515",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"34.21",
"96.04",
"96.71",
"33.28",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
174, 3172
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,349
| 155,780
|
35398+57996
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-4-25**] Discharge Date: [**2120-5-15**]
Date of Birth: [**2054-8-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Zosyn / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Complex subglottic tracheal stenosis with shortness of breath.
Major Surgical or Invasive Procedure:
[**2120-4-26**] Tracheal resection and reconstruction with infra-hyoid
release.
[**2120-5-6**]: 1. Rigid bronchoscopy using the Dumon green
tracheoscope.
Flexible bronchoscopy. Endotracheal tube removal.
[**2120-5-6**]: Percutaneous endoscopic gastrostomy tube placement.
[**2120-5-14**]: Flexible bronchoscopy
History of Present Illness:
Ms. [**Known lastname 24630**] is a 65-year-old woman with a stenosis of the upper
airway following a tracheostomy tube after prolonged intubation
for sepsis. She
had been treated with dilation and stenting. She now presents
for definitive resection. On preoperative bronchoscopy there was
stenosis from the level of the first ring stretching
approximately 2 cm inferiorly and encompassing the level of the
stoma. In addition, there was severe malacia at that location
and also malacia further down in the airway.
Past Medical History:
Trachael stenosis hospitalized [**7-4**] prolongued vent had trach
placed removed [**12-4**]
atrial fibrillation on warfarin
?OSA on CPAP no formal sleep study
ESRD on HD MWF has tunneled cath
multinodular goiter s/p biopsy
Morbid obesity
HTN
C difficile colitis
cellulitis with "fat necrosis" requiring skin grafting, c/b
sepsis
peripheral neuropathy ?GBS following birth of 2nd child
left leg weakness
tracheomalatia
Chronic leg ulcers
Recurrent UTI
urinary stress incontinence
iron deficiency anemia
nephrolithiasis
Social History:
The patient was living at home until hospitalized Spring [**2118**],
at which point she was staying in pulmonary rehab r/t dialysis
scheduling and rules regarding her trach. She denies smoking,
ETOH. Married to dermatologist. Daughter [**Name (NI) 1439**] highly involved
with mothers care.
Family History:
noncontributory
Physical Exam:
VS: T 98.4, HR 79, BP 96/64, RR 18, O2 sats 96% RA
Physical Exam:
Gen: pleasant in NAD, voice hoarse
Neck: insision with stable erythema and swelling to the left of
the incision.
Lungs: rhonchi on expiration. Clear RUL
CV: irreg rate and rhythm, S1, S2, no MRG or JVD
Abd: soft, NT, ND [**Name (NI) 282**] intact.
Ext: warm, trace BLE edema. Stage III Coccyx wound.
Pertinent Results:
Cultures:
[**2120-5-3**] mini BAL proteus
[**2120-5-2**] Sputum cx PROTEUS MIRABILIS pansensitive
[**2120-5-1**] Blood cx negative
[**2120-4-26**]: [**2120-4-29**]; [**2120-5-6**] MRSA screen Negative x 3
Chest X-Ray:
[**2120-5-12**] Only a single frontal view was obtained. Right and left
central venous catheters are identified and not substantially
changed in appearance. There is no evidence of progressive
accumulation of fluid or new parenchymal consolidation. Heart
size is at the upper limits of normal.
Line Placement:
[**2120-5-9**] 1. Uncomplicated PICC line exchange on the right;
double-lumen PICC measuring 50 cm with its tip in the lower SVC;
line is ready to use.
2. Left internal jugular tunneled hemodialysis catheter
exchange,
uncomplicated; tip-to-cuff length is 23 cm; the tip is in the
right atrium, and the line is ready for use.
3. Venogram demonstrating mild narrowing at the left
brachiocephalic vein and SVC junction; this likely reflects
patient's chronic indwelling catheter; if future vascular access
is needed, an interventional procedure is recommended.
[**2120-5-15**] 04:50AM BLOOD WBC-10.7 RBC-3.13* Hgb-8.9* Hct-29.7*
MCV-95 MCH-28.5 MCHC-30.1* RDW-18.3* Plt Ct-395
[**2120-5-14**] 05:30AM BLOOD WBC-12.9* RBC-3.13* Hgb-9.3* Hct-29.6*
MCV-95 MCH-29.7 MCHC-31.3 RDW-18.4* Plt Ct-323
[**2120-5-12**] 05:19AM BLOOD WBC-14.5* RBC-3.15* Hgb-9.0* Hct-30.4*
MCV-97 MCH-28.6 MCHC-29.6* RDW-17.5* Plt Ct-421
[**2120-5-15**] 06:00AM BLOOD PT-18.3* PTT-62.6* INR(PT)-1.7*
[**2120-5-15**] 04:50AM BLOOD Glucose-90 UreaN-39* Creat-6.6* Na-135
K-5.0 Cl-96 HCO3-24 AnGap-20
[**2120-5-15**] 04:50AM BLOOD Calcium-10.7* Phos-2.6* Mg-2.1
[**2120-5-10**] 11:12AM BLOOD calTIBC-182* Ferritn-1621* TRF-140*
[**2120-5-10**] 11:12AM BLOOD Triglyc-133 HDL-58 CHOL/HD-3.7
LDLcalc-128
[**2120-5-15**] 09:10AM BLOOD PTH-120*
[**2120-5-13**] 07:30AM BLOOD Vanco-28.4*
[**2120-5-7**] 04:18PM BLOOD Type-ART pO2-118* pCO2-42 pH-7.44
calTCO2-29 Base XS-4
Brief Hospital Course:
The patient was admitted to the Thoracic Surgery Service, under
Dr. [**Last Name (STitle) **] on [**2120-4-25**], for planned [**2120-4-26**] tracheal
resection and reconstruction for her complex subglottic tracheal
stenosis. She was admitted a day early preoperative preparation.
The patient underwent tracheal resection and reconstruction with
infra-hyoid release; please refer to the Operative Note for
details. The patient was transferred to the ICU, where the
patient was kept intubated for 10 days to allow her anastomosis
to heal, along with proper neck positioning and chin-chest
sutures. She received supportive ICU cares. She eventually
transferred to the floor on [**2120-5-10**] where she maintained stable
airway.
Neuro: The patient remained intubated and sedated on until
[**2120-5-6**], at which time she was extubated in the operating room
after her anastomosis was evaluated and appeared intact via
rigid bronchoscopy. She received prn fentanyl with good effect
and adequate pain control.
CV: The patient remained in her baseline atrial fibrillation
with rate control in the 70's, on QID diltiazem. This was held
periodically for low BP mostly after HD. She required diltiazem
drip for a couple days for rate control. On [**2120-5-7**] she was
converted to her PO dose with good rate control. Her
anticoagulation was held the week prior to her surgery and
resumed [**2120-5-9**], with heparin bridge. Listed are the coumadin
and INR trends:
[**2120-5-8**] INR 1.0 heparin drip started
[**2120-5-9**] INR 1.3 coumadin 2.5mg, heparin drip
[**2120-5-10**] INR 1.2 coumadin 2.5mg, heparin drip
[**2120-5-11**] INR 1.3 coumadin 2.5mg, heparin drip
[**2120-5-12**] INR 1.2 coumadin 5mg, heparin drip
[**2120-5-13**] INR 1.4 coumadin 3mg, heparin drip
[**2120-5-14**] INR 1.5 couamdin 5mg, heparin drip
[**2120-5-15**] INR 1.7- pt should get 5mg tonight, with no heparin
bridge.
Close INR followup needed until INR's stable around [**1-31**] for
atrial fibrillation.
Pulmonary: The patient was extubated in the OR on [**2120-5-6**]. She
was watched closely over the next 24 hours with guarded
pulmonary status, requiring CPAP, trialed heliox, and q 6 hour
Atrovent and close nursing care. Vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization. The
patient had bronchoscopy on [**2120-5-14**] which revealed intact
anastamosis
GI: Given concerns over postoperative ability to [**Last Name (LF) **], [**First Name3 (LF) 282**]
tube was placed in the OR by Dr. [**Last Name (STitle) **] at the time of her
extubation on [**2120-5-6**]. Proton Pump Inhibitor was continued.
Nutrition: Consult recommended Nutren 2.0 3/4 strength with Bene
protein Goal Rate: 40 mL/hr. The patient tolerated such. She
initially had problems with constipation. KUB on [**2120-5-13**] ruled
out ileus.
Speech & [**Month/Day/Year **] were consulted for a Video-[**Month/Day/Year **] for absent
laryngeal elevation [**1-30**] hyoid release which was done [**2120-5-13**]
which showed slight aspiration with thin liquids and laryngeal
penetration with nectar. They recommend continuation of tube
feeds as primary source of nutrition and nectar thick liquid
with moist puree. They also recommend swallowing therapy upon
return to rehab and repeat instrumental evaluation prior to
upgrading diet.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. She had a lung
infiltrate and to prevent further complications she had
bronchoscopy [**2120-5-3**], at which time she was started on vanco and
meropenum emperically. BAL was sent and her culture grew PROTEUS
MIRABILIS which was pan sensitive. She was switiched to
cefepime and ciprofloxacin, and vancomycin (for neck incision)
until [**2120-5-15**].
Endocrine: The patient's blood sugar was monitored throughout
her stay; they were self maintained in low 100's, without need
for insulin.
Hematology: Heparin to Coumadin bridge was started [**2120-5-10**] for
her atrial fibrillation. Her INR on discharge was 1.7. See above
trends for further anticipated dosing.
Renal: HD was continued throughout her hospital course. Last HD
[**2120-5-15**].
No Foley placed. Straight cath yields 15-20 cc of urine,
straight cath qweek, bladder scan 2x/weekly. Phosphorus was
watched closely and Nephrology recommended renagel 800mg po TID
with meals and uptitrate as needed.
Wound: She was followed by the Wound Care Nurse throughout her
hospital course. Coccyx pressure ulcer: Stage III, approx. 5.5
x 1.5 cm with sloughing yellow tissue 90% yellow with red
granular buds. Wound care RN recommends covering this area with
Mepilex Sacral Foam Border dressing, and changing every 3 days
or prn.
Extending from her anus to the left gluteal there is an intact
purple discoloration approx 0.3 x 5.5 cm. Extending from the
anus to the right gluteal there intact hyperpigmented tissue
approx. 0.3 x 9.5 cm. These sites have no edema, induration, or
fluctuance associated with the impairment. Apply Critic Aid
Clear Moisture Barrier Ointment daily. (see detail
recommendations)
Line Placement:
[**2120-5-9**] 1. Uncomplicated PICC line exchange on the right;
double-lumen PICC measuring 50 cm with its tip in the lower SVC;
line is ready to use.
2. Left internal jugular tunneled hemodialysis catheter
exchange,
uncomplicated; tip-to-cuff length is 23 cm; the tip is in the
right atrium, and the line is ready for use.
3. Venogram demonstrating mild narrowing at the left
brachiocephalic vein and SVC junction; this likely reflects
patient's chronic indwelling catheter; if future vascular access
is needed, an interventional procedure is recommended.
Disposition: Dr. [**Last Name (STitle) **] deemed the patient safe for
transfer to rehab today.
Medications on Admission:
-Coumadin 2.5mg (Held)
- Diltiazem 90 mg PO/NG QID
- Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
- Acetylcysteine 20% 1-10 mL NEB Q8H:PRN
- Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
- Senna 1 TAB PO/NG [**Hospital1 **]:PRN
- Docusate 100 mg [**Hospital1 **]
- Aranesp 100 mcg/0.5 ml Sln. 90 mcg Every tuesday
- Omeprazole 20mg
- Renagel 1600mg with each snack
- Renagel 2400mg TId with meals
- Renal caps 1 every day
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ml PO BID (2
times a day): hold for loose stools.
3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
4. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed for fungus.
5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Diltiazem HCl 90 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
need adjusting. Once stable discuss longer acting doseage with
PCP.
8. Acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Twenty (20) ml PO
Q6H (every 6 hours) as needed for pain / fever.
9. Lorazepam 0.25 mg IV Q6H:PRN anxiety
10. Renagel 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a
day: with meals. follow phosphate closely and uptitrate as
needed.
11. Aranesp (Polysorbate) 100 mcg/0.5 mL Syringe [**Last Name (STitle) **]: Ninety
(90) mcg Injection once a week: on Tuesdays.
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
13. Coumadin 2.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO at bedtime: MD to
order daily dose based on INR. Monitor frequently until stable
INR [**1-31**]. Should receive 5mg dose on night of [**2120-5-15**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
-Complex subglottic stenosis with history of tracheostomy s/p
[**2120-4-26**] Tracheal resection and reconstruction with hyoid
release.
-Stage III coccyx pressure ulcer.
-atrial fibrillation on warfarin
-?OSA on CPAP no formal sleep study
-ESRD on HD MWF has tunneled cath
-multinodular goiter s/p biopsy
-Morbid obesity
-HTN
-hx of C difficile colitis
-cellulitis with "fat necrosis" requiring skin grafting, c/b
sepsis
-peripheral neuropathy ?GBS following birth of 2nd child
left leg weakness
-tracheomalatia
-Chronic leg ulcers
-Recurrent UTI
-urinary stress incontinence
-iron deficiency anemia
-nephrolithiasis
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:
-Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2348**] if you have fevers greater
than 101.5, chills, rigors, cough, shortness of breath, or
difficulties with airway or managing secretions.
-Call your cardiologist if fast irregular heartbeat accompanied
with dizziness.
-Monitor neck incision and calls if this becomes red, purulent,
or drains.
-Followup with your cardiologist regarding coumadin dosing to
keep INR around 2.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] one week after you
leave rehab. You will need a bronchoscopy with this visit. Call
[**Telephone/Fax (1) 2348**] to schedule appointments and bronchscopy. You will
need to be NPO after midnight prior to your bronchoscopy.
Completed by:[**2120-5-15**] Name: [**Known lastname 12948**],[**Known firstname 2243**] A Unit No: [**Numeric Identifier 12949**]
Admission Date: [**2120-4-25**] Discharge Date: [**2120-5-15**]
Date of Birth: [**2054-8-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Zosyn / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 3454**]
Addendum:
It is noted that immediately postop, there was strict
instruction to the ICU nurses not to move the patient as her
airway was very guarded given the complex nature of her
operation, and fear that any move might disrupt the anastomosis
causing potentially life threatening injury. Once out of the
immediate post operative period we allowed ICU nurses to turn
the patient. An air mattress was also placed for protection.
Unfortunately due to immobility and multiple comorbilities the
patient suffered from coccyx pressure ulcer which was addressed
with our wound care experts.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2653**] [**Hospital **] Hospital - [**Location (un) 2653**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 3455**] MD [**MD Number(2) 3456**]
Completed by:[**2120-5-15**]
|
[
"585.6",
"285.21",
"V58.61",
"707.23",
"327.23",
"241.1",
"707.03",
"355.8",
"041.6",
"403.91",
"997.31",
"278.01",
"519.02",
"519.19",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.5",
"38.93",
"96.72",
"38.95",
"88.67",
"33.21",
"38.91",
"96.04",
"96.6",
"77.89",
"31.79",
"43.11",
"97.39",
"33.22",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15197, 15434
|
4513, 10334
|
382, 695
|
13230, 13230
|
2523, 4490
|
13873, 15174
|
2105, 2122
|
10805, 12448
|
12590, 13209
|
10360, 10780
|
13406, 13850
|
2203, 2504
|
280, 344
|
723, 1238
|
13245, 13382
|
1260, 1781
|
1797, 2089
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,919
| 161,529
|
47195
|
Discharge summary
|
report
|
Admission Date: [**2185-5-1**] Discharge Date: [**2185-5-11**]
Date of Birth: [**2145-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5368**]
Chief Complaint:
Dyspnea, tachypnea, somnolence
Major Surgical or Invasive Procedure:
Left PICC placement
History of Present Illness:
Pt is a 39 y/o male with a PMH significant for DM2, Prader
Willi, CRI who presented to the ED w/ subjective SOB, tachypnea,
and somnolence.
Pt dicharged from [**Hospital1 18**] 1 month PTA after extended treatment for
R leg cellulitis. Shortly after arrival at [**Hospital1 **], maintained
on Vanc / Zosyn and developed C.diff colitis (toxin positive
[**2185-4-17**]), treated with 7d of Flagyl.
On day of admit, found to desaturate to 85% at [**Hospital1 **] and
become tachypneic. The patient became less responsive and was
sent to [**Hospital1 18**] for further evaluation.
In ER, Tm=104, hypotensive although this corrected with fluids.
He was given nebs, solumedrol, levaquin, and flagyl. His CBC
demonstrated a left shift and his CXR was concerning for a LUL
PNA. At his OSH, he had not had any cough or any fever.
In the [**Hospital Unit Name 153**] the pt was treated for Cdiff colitis with PO Flagyl,
with plan to continue for 3 week course. OSH PICC line (placed
[**2185-3-23**]) was removed due to MSSA bacteremia, new PICC placed
[**2185-5-4**].
Past Medical History:
Morbid obesity
Mental retardation thought secondary to possible Prader-Willi
Insulin dependent diabetes mellitus
Renal insufficiency
Obstructive sleep apnea requiring CPAP
Social History:
Patient lived in group home, came from rehab this time. Patient
denies any smoking, ethanol or drug use. Intermittently
sexually active with a female partner.
Family History:
Positive family history for diabetes.
Physical Exam:
PE: Tm 104 rectal; 100.2 ax; 115/51; 80; 97% on CPAP (18cm)
Gen: morbidly obese AAM lying flat in no distress
HEENT: mmm
CV: distant heart sounds; rrr
Lungs: cta anteriorly
Abd: obese; + BS
Ext: massive LE edema with venous stasis changes and scaling
over R shin
Neuro: slow speech; answers simple questions; follows commands;
non focal exam
Pertinent Results:
[**2185-5-1**] 10:00PM BLOOD WBC-7.9 RBC-4.37*# Hgb-10.4*# Hct-36.3*#
MCV-83 MCH-23.9* MCHC-28.7* RDW-20.9* Plt Ct-177
[**2185-5-2**] 06:03AM BLOOD WBC-9.0 RBC-4.04* Hgb-9.8* Hct-34.3*
MCV-85 MCH-24.4* MCHC-28.6* RDW-21.5* Plt Ct-174
[**2185-5-10**] 05:28AM BLOOD WBC-10.5 RBC-4.07* Hgb-9.6* Hct-33.9*
MCV-83 MCH-23.5* MCHC-28.2* RDW-21.0* Plt Ct-232
[**2185-5-1**] 10:00PM BLOOD Neuts-37* Bands-38* Lymphs-11* Monos-6
Eos-4 Baso-0 Atyps-1* Metas-1* Myelos-2* NRBC-2*
[**2185-5-2**] 06:03AM BLOOD Neuts-53 Bands-38* Lymphs-4* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-2*
[**2185-5-2**] 06:03AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-OCCASIONAL Polychr-1+ Ovalocy-OCCASIONAL
Stipple-1+ Tear Dr[**Last Name (STitle) 833**]
[**2185-5-1**] 10:00PM BLOOD PT-16.0* PTT-28.0 INR(PT)-1.5*
[**2185-5-1**] 10:00PM BLOOD Plt Ct-177
[**2185-5-10**] 05:28AM BLOOD Plt Ct-232
[**2185-5-1**] 10:00PM BLOOD Glucose-148* UreaN-66* Creat-1.8* Na-145
K-5.6* Cl-109* HCO3-29 AnGap-13
[**2185-5-10**] 05:28AM BLOOD Glucose-165* UreaN-53* Creat-1.1 Na-145
K-4.8 Cl-112* HCO3-30 AnGap-8
[**2185-5-1**] 10:00PM BLOOD Calcium-8.3* Phos-3.4 Mg-1.5*
[**2185-5-10**] 05:28AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.6
[**2185-5-3**] 06:55PM BLOOD Vanco-24.0*
[**2185-5-5**] 04:05AM BLOOD Vanco-28.4*
[**2185-5-6**] 08:18AM BLOOD Vanco-32.0
[**2185-5-7**] 06:55AM BLOOD Vanco-25.8*
[**2185-5-9**] 04:35AM BLOOD Vanco-18.1*
[**2185-5-2**] 09:53AM BLOOD Type-MIX Temp-36.7 pO2-29* pCO2-65*
pH-7.23* calHCO3-29 Base XS--2 Intubat-NOT INTUBA
[**2185-5-2**] 09:49AM BLOOD Lactate-1.4
[**2185-5-2**] 09:49AM BLOOD freeCa-1.16
=================
STUDIES:
CXR [**2185-5-1**]
IMPRESSION: Interval worsening of bilateral airspace opacities
as described. Pneumonia is not excluded.
.
ABDOMEN X-RAY [**2185-5-2**]
FINDINGS: Two portable abdominal radiographs were obtained.
These radiographs are extremely limited due to poor penetration
and are thus nondiagnostic. Repeat radiographic examination is
suggested.
.
CXR [**2185-5-2**]
IMPRESSION:
1. Resolution of left upper lobe opacity.
2. Bilateral perihilar haziness suggestive of perihilar edema
likely due to fluid overload
.
ECHO [**2185-5-3**]
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF 60%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
is abnormal septal motion/position. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. No masses or vegetations are seen on
the aortic valve. The mitral valve appears structurally normal
with trivial mitral regurgitation. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
There is mild pulmonary artery systolic hypertension. No
vegetation/mass is seen on the pulmonic valve.
CHEST PORT. LINE PLACEMENT [**2185-5-4**]
IMPRESSION: Suboptimal assessment. Doubt overt CHF or pneumonia
RIGHT PICC LINE PLACEMENT [**2185-5-4**]
IMPRESSION: Successful placement of a 55 cm 5- French double-
lumen PICC via the right brachial vein with tip in the superior
vena cava. A total of approximately 51 cm of the PICC is within
the patient. The PICC can be used immediately.
ULTRASOUND RIGHT LOWER EXTREMITY [**2185-5-5**]
IMPRESSION: Limited exam but no evidence for DVT.
Brief Hospital Course:
The pt is a 39 yo male with Prader Willi, diabetes, and CRI, who
recently developed C. diff after antibiotic treatment for
cellulitis. The patient presented with hypoxia which resolved,
but was noted to have possible radiographic findings significant
for pneumonia.
Mr. [**Known lastname 34682**] was also noted to have MRSA bacteremia and was
treated with Vancomycin. L PICC was likely source of MRSA
bacteremia, and PNA may be due to different organism.
ID service recommended 2 week course of Vancomycin. Once his
treatment is completed, he should have surveillance cultures to
verify resolution of bacteremia. The pt was also empirically
treated with oral Flagyl for the C.diff colitis, however 3 sets
of stool were negative for C. difficile toxin. Two sets of pt's
blood cultures showed MRSA and the rest of the cultures were
pending at the time of discharge and will need to be followed by
the pt's primary care physician.
ID: The pt was noted to have interval worsening of bilateral
airspace opacities which could have represented an underlying
pneumonia (however he did not have an elevated white cell
count). He was also noted to have MRSA bacteremia, with his left
side PICC as likely source. The left sided PICC was removed and
a new right sided PICC was placed. The pt was treated with
Vancomycin (to complete a total 14 day course on [**2185-5-16**]) for
the MRSA bacteremia (trough goal 15-20, current adjusted dose is
1 gram q48h). Once treatment with Vancomycin is completed, the
pt will need to have surveillance cultures to ensure clearance
of bacteremia.
The pt was also noted to have diarrhea in the setting of
antibiotic use. The pt had 3 stool samples sent that were
negative for C. difficile toxin. The pt's diarrhea gradually
resolved. Rectal tube fell out on the day prior to discharge,
but the pt remained continent.
Respiratory:
The pt was noted to have an interval worsening of airspaces
which could have represented an underlying pneumonia. The pt
remained afebrile on the floor and his white count was not
elevated. The pt was maintained on CPAP (18 cm QHS) at night for
his obstructive sleep apnea.
FEN:
Diarrhea resolved with treatment during the hospitalization.
His electrolytes were repleted.
Renal:
Patient has chronic renal insufficiency (baseline creatinine
1.3-1.5) and he was noted to have a creatinine of 1.8 on
admission. After hydration, Cr=1.1 at discharge.
Anemia:
The pt has a history of anemia of chronic disease, likely
secondary to chronic renal disease. The pt was continued on
Erythropoietin and iron.
Diabetes Mellitus:
The pt was noted to have elevated blood glucose level (in 200
range) for which his standing morning 70/30 dose of insulin was
increased. It is likely that the pt will need uptitration of his
insulin if the blood glucose levels continue to remain elevated.
Hypothyroidism:
The pt was maintained on his outpatient Thyroxine dose.
Prophylaxis:
The pt was maintained on subcutaneous Heparin and pantoprazole
for prophylaxis.
After 10 days, patient feeling well and with no changing medical
issues. The patient was very particular in choosing the
specific rehabilitation institution for discharge, noting that
he has had numerous negative experiences with various rehab
sites in the past. The patient was accepted to [**Hospital 92018**], and was pleased to be transferred there on [**2185-5-11**].
Maintained full code throughout hospital stay.
Medications on Admission:
Meds (on admit:)
1. Aspirin 81 mg qd
2. Levothyroxine 75 mcg qd
3. Hydrochlorothiazide 25 mg qd
4. Ferrous Sulfate 325 mg qd
5. Epoetin [**Numeric Identifier 890**] tiw
6. Tamsulosin 0.4 mg hs
7. Calcium Acetate 2668 mg tid
8. Insulin 70/30; 40u qam, 15u qpm
9. Morphine 15 mg prn
Allergies: NKDA
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin- as directed per attached sliding scale Sig: see
instructions as directed: Please referto fixed insulin dose
and insulin sliding scale. .
11. 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.
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours) for 7 days: last day to
complete 14 day course : [**2185-5-16**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Pneumonia
.
Secondary:
Prader Willi Syndrome
Morbid Obesity
DM II
CRI w/ baseline creatinine 1.8-2
OSA on home CPAP
Mental retardation
Discharge Condition:
Stable
Discharge Instructions:
Please report to the nearest emergency department if you have
fever, chills, nausea, vomiting, diarrhea or increasing pain in
your right leg.
.
There has been a change in your medications.
.
You have been scheduled for some follow-up appointments.
Followup Instructions:
*** THE REHAB WILL NEED TO ARRANGE FOR PATIENT TO BE TRANSPORTED
TO HIS APPOINTMENTS IN A BLS AMBULANCE *****
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2185-5-16**] 2:40
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2185-6-7**] 4:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8386**], M.D. Date/Time:[**2185-7-5**] 4:30
|
[
"790.7",
"707.02",
"319",
"V09.0",
"486",
"780.57",
"285.21",
"707.04",
"759.81",
"585.9",
"250.00",
"707.03",
"996.62",
"008.45",
"041.11",
"V58.67",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10981, 11052
|
5881, 9315
|
346, 368
|
11240, 11249
|
2264, 5858
|
11546, 12108
|
1848, 1887
|
9664, 10958
|
11073, 11219
|
9341, 9641
|
11273, 11523
|
1902, 2245
|
276, 308
|
396, 1458
|
1480, 1653
|
1669, 1832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,056
| 103,359
|
43543
|
Discharge summary
|
report
|
Admission Date: [**2146-6-27**] Discharge Date: [**2146-7-7**]
Date of Birth: [**2097-5-28**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old
gentleman who presented to an outside hospital with stiff
neck and severe headache. He states that the headache
started about 6 pm on the day of admission, treated with
ibuprofen without relief, and a few hours later stated the
stiff neck came on suddenly like gang busters. He went to
[**Hospital6 2561**] where a CT showed a posterior
communicating artery aneurysm rupture, and the patient was
transferred to [**Hospital6 256**] for
further management.
MEDICATIONS ON ADMISSION: Lipitor 10 mg qd.
PAST MEDICAL HISTORY: Hypercholesterolemia.
ALLERGIES: No known allergies.
PHYSICAL EXAM: He was afebrile, BP 149/89, heart rate 97,
SATs 96 percent on room air.
HEENT: Pupils were equal, round and reactive to light. EOMS
were full.
NECK: Supple. No masses. He had a stiff neck. His
strength was [**6-8**] in all muscle groups. His sensation was
intact to light touch throughout. He had no drift. His fine
finger movements were intact.
STUDIES: He had a CTA which was inconclusive, unable to
localize the bleed.
HOSPITAL COURSE: Therefore, the patient was admitted to the
ICU and underwent an arteriogram on [**2146-6-27**] which showed
no evidence of intracranial aneurysm. He was transferred to
the regular floor on [**2146-6-29**]. He had a couple of episodes
of sinus tachycardia which resolved spontaneously. His vital
signs remained stable. His neurologic exam remained intact,
awake, alert, oriented x 3. Following commands x 4. Speech
was fluent with no weakness and still complains of stiff neck
and actually leg pain.
He did have Dopplers done on [**2146-7-5**] which were negative
for DVT. He had a repeat angiogram on [**2146-7-2**] which,
again, showed no evidence of aneurysm, but a small amount of
vasospasm. The patient was monitored for signs and symptoms
of vasospasm of which he developed none, and he was
discontinued of his IV fluid, remained neurologically intact,
and was discharged to home on [**2146-7-7**] in stable condition,
with follow-up with Dr. [**Last Name (STitle) 1132**] in 2 weeks.
MEDICATIONS AT TIME OF DISCHARGE:
1. Nimodipine 60 mg po q 4 h prn.
2. Hydromorphone 2-6 mg po q 4 h prn.
3. Colace 100 mg po bid.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2146-7-7**] 10:47:57
T: [**2146-7-7**] 11:20:22
Job#: [**Job Number 93681**]
|
[
"435.8",
"427.89",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
678, 697
|
1244, 2377
|
792, 1226
|
164, 651
|
720, 776
|
2402, 2662
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,457
| 120,648
|
51426
|
Discharge summary
|
report
|
Admission Date: [**2129-4-6**] Discharge Date: [**2129-4-8**]
Date of Birth: [**2062-6-28**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Compazine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
aspirin desensitization
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
65 y/o woman with hx CAD, DM, HTN, CVA [**11-29**] presented to [**Hospital1 18**]
with CP and dyspnea, had EKG which showed STD V4 through V6 with
trop peak 0.17. There had been some concern for PE and she got
CTA, developed contrast induced nephropathy with Cr peaking at
2.2. A plan was made for cardiac cath but was deferred [**2-22**] acute
renal failure, and because she had been off aspirin (previously
desensitized) and she was sent to rehab for continued medical
management and optimization.
Prior to her previous desensitization she would get
hives,chills, rigors on exposure to ASA
.
On discharge from rehab her Cr was 1.88
On arrival to the floor she was chest pain free and
hemodynamically stable. An EKG was unchanged from prior.
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.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
CAD h/o cath at [**Hospital3 2005**] [**11/2128**], showed diffuse LAD and
LCx disease, RCA not imaged, not intervened upon, managed
medically.
CVA L hemiparesis
DM
CRI with microalbuminuria
Hyperlipidemia
HTN
Asthma
Morbid obesity - she says she was evaluated for OSA at [**Hospital1 **]
and was told she didn't have OSA
Social History:
Was in [**Hospital3 **] until 3 weeks prior rehab from her
stroke, now ambulates with walker and has VNA helping her with
her meds when at home. Since end of [**Month (only) 956**] she has been at
[**Hospital **] rehab following her NSTEMI. No history of smoking, no
EtoH, no ilicit drug use.
Family History:
mother had DM. no known CAD.
Physical Exam:
VS: T= 97 BP= 165/64 HR= 59 RR= 18 O2 sat=99%
GENERAL: Oriented x3., PERRLA, CNII-XII intact, [**4-25**] muscle
strengt h BL extremity, [**5-25**] on right
NECK: supple, full neck veins.
CARDIAC: distant heart sounds [**2-22**] body habitus
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2 + pitting edema to below the knee bilaterally
PULSES:
radial pulses strong
no femoral bruits
DP/PT dopplerable
cornified feet bilaterally
Pertinent Results:
[**2129-4-6**] 11:24PM URINE HOURS-RANDOM UREA N-414 CREAT-76
SODIUM-80
[**2129-4-6**] 11:24PM URINE HOURS-RANDOM UREA N-414 CREAT-76
SODIUM-80
[**2129-4-6**] 11:24PM URINE OSMOLAL-394
[**2129-4-6**] 08:57PM GLUCOSE-87 UREA N-35* CREAT-1.9* SODIUM-137
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-30 ANION GAP-13
[**2129-4-6**] 08:57PM estGFR-Using this
[**2129-4-6**] 08:57PM CALCIUM-9.7 PHOSPHATE-4.2 MAGNESIUM-2.0
[**2129-4-6**] 08:57PM WBC-6.8 RBC-3.20* HGB-9.3* HCT-29.0* MCV-91
MCH-29.2 MCHC-32.2 RDW-14.2
[**2129-4-6**] 08:57PM NEUTS-67.5 LYMPHS-22.0 MONOS-3.6 EOS-6.7*
BASOS-0.2
[**2129-4-6**] 08:57PM PLT COUNT-180
[**2129-4-6**] 08:57PM PT-12.5 PTT-27.4 INR(PT)-1.1
.
[**2129-4-7**]
Cardiac catheterization
1. Coronary angiography in this co-dominant system demonstrated
two
vessel CAD. The LMCA was very short with mild disease. The LAD
had an
ostial 80% stenosis with a 70% stenosis in the mid vessel. The
LCx had
an ostial 70% stenosis with a 60% stenosis after OM1 before the
L-PDA.
OM2 had a 70% stenosis. The RCA was small and co-dominant with
diffuse
irregularities.
2. Limited resting hemodynamics revealed moderate systemic
arterial
systolic hypertension with an SBP 141 mmHg.
3. There was no pressure gradient between the left ventricle and
ascending aorta to suggest aortic stenosis.
FINAL DIAGNOSIS:
1. Two vessel CAD.
2. Moderate systemic hypertension.
Brief Hospital Course:
65 y/o woman with hx CAD, DM, HTN, CVA [**11-29**] s/p NSTEMI in
[**Month (only) 956**] presenting for ASA desensitization prior to cath. Cath
was also deferred due to contrast induced /hypertensive
nephropathy.
.
# CORONARIES: CAD with cath [**11/2128**] showing diffuse LAD and Lcx
disease with cath deferred for NSTEMI in [**Month (only) **] secondary to renal
failure/asa allergy. She had previously undergone aspirin
desensitization but had at some point stopped taking aspirin
consistently. She underwent aspirin desensitization without
adverse event. On arrival from rehab the patients creatine was
still elevated at 1.9. She received prehydration and mucomyst
with her Cr 1.7 on the morning prior to her catheterization.Her
cardiac catheterization showed stable 2 vessel disease which was
not amenable to intervention. Cardiothoracic surgery consulted
on the patient and are considering coronary artery bypass
however she has multiple comorbidities and medical problems
which need to be optimized before she can undergo this surgery.
She will go to rehab for medical management. Her cardiac medical
management was continued with a high dose statin, labetolol,
plavix. Lisinopril continued to be held in the setting of her
renal failure but renal function should be assessed by her PCP
and lisinopril resumed when appropriate. The patient must
continue to take aspirin on a daily basis as missing doses for
greater than 48 hours will require repeat admission to the ICU
for desensitization. She will follow up with cardiothoracic
surgery in [**Month (only) 547**].
.
Renal Failure: Acute on chronic Renal Failure. The patient's
creatinine had been 1.1 in early [**Month (only) 956**]. She was hospitalized
after presenting with chest pain and shortness of breath, had a
CTA with dye load given to rule out for PE and subsequently
developed contrast induced nephropathy. She had also been in
hypertensive emergency that admission, which was thought to have
also contributed to her acute on chronic renal failure. On this
admission she had a Cr 1.9 and FENA 1.5 on admission. She
received prehydration and mucomyst before and after her cardiac
catheterization, with Cr 1.8 on discharge. Tight blood pressure
control was maintained during her admission and her lisinopril
continued to be held given its nephrotoxic potential. Her PCP
will continue to monitor her renal function as an outpatient,
and can decide when to resume her lisinopril.
.
# PUMP:Echo in [**3-2**] showed diastolic CHF, EF 55%.LVH pulmonary
HTN. Some volume overload with pitting edema however giving
gentle hydration in liue of cath for renoprotection. She was
able to tolerate this volume without any difficulty.
Her home lasix was held on discharge and will be resumed at the
discretion of her PCP.
#HTN: On admission her BP was in the 170s. Her labetolol was
being held per the aspirin desensitization protocol at that
time.She received IV hydral as well as her home norvasc,isordil
and p.o hydral with good effect. Following her successful
aspirin desensitization, her labetolol was restarted and her BP
was maintained within the normal range.
.
# Anemia: Hct 29, baseline 33, trending down over last month.
Prior iron studies, hemolysis labs negative. Her hematocrit was
stable at 25-28 this admission and she had no evidence of
bleeding and this was presumed to be anemia of chronic disease.
Age appropriate malignancy screening should be performed as an
outpatient with screening colonoscopy.
.
Back Pain: She had a history of chronic back pain for which she
continued to receive lidoderm patch to upper/lower back,
oxycodone 5, tylenol 650 mg prn pain, neurontin 300mg q24
(renally dosed), ultram 50mg TID and a bowel regimen of senna,
colace and lactulose.
.
#Diabetes: On lantus, Novolog SS at home . She continued lantus,
1/2 dose while npo
and was on an insulin sliding scale with finger sticks. She
became nauseated in the am and was found to be hypoglyemic to
the 50s in the mid morning. She states that she never eats
breakfast and becomes very dizzy and diaphoretic every morning.
She received p.o and was encouraged to eat breakfast to avoid
these predictable cycles of hypoglycemia.
.
# h/o CVA: She had a large right-sided CVA in [**11/2128**] with rehab
until [**3-1**]. Has regained some function, mobilizing with
walker. She should resume physical therapy on d/c to rehab.
Medications on Admission:
plavix 75mg daily
lipitor 80 daily
ambien 10mg p.o QHS
lidocaine patch % change daily
isosorbide dinitrate 40mg p.o TID
lantus insulin 36U sc daily
amlodpine 10mg daily
labetolol 400mg p.o [**Hospital1 **]
zantac 150mg daily
nitroglycerin 0.3mg sublingual one tablets q5
tylenol 650mg p.o q 4 prn
senna 8.6 p.o [**Hospital1 **] prn
ativan 0.5mg TI.D prn anxiety
hydralazine 50mg q6
RISS
.
Meds on Transfer:
Lasix 20mg p.o daily
Ultram 50mg TID daily
Neurontin 300mg p.o TID
novolog insulin 6U premeal glucose >150
Lantus 30 u sc qhs
lidoderm patch one on shoulder, neck and one on lower back
lactulose 30mg [**Hospital1 **] prn constipation
zofran 4mg IV q6 PRN nausea
oxycodoen 5mg p.o Q6 PRN pain
pepcid 20mg p.o daily
tylenol 650mg q4 prn
hydralazine 50mg p.o q6
ativan 0.5 mg p.o TID prn anxiety
senna 8.6 p.o twice daily PRN constipation
nitro-stat 0.3mg s q 5 x 3 prn cp
labetolol 400mg p.o [**Hospital1 **]
isordil 40mg p.o TID
lipitor 80mg daily
ambien 10mg p.o qhs prn insomnia
plavix 75mg daily
Allergies: ASA: gets hives, SOB,
Compazine
.
Discharge Medications:
1. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for PRN INSOMNIA.
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for CHEST PAIN :
1 tablet every five minutes up to total of 3 tablets,then call
ambulance.
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain : please do not exceed
3000mg/day. Tablet(s)
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
12. Isosorbide Dinitrate 10 mg Tablet Sig: Four (4) Tablet PO
TID (3 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty (30)
units Subcutaneous at bedtime.
15. Insulin Aspart 100 unit/mL Cartridge Sig: sliding scale
units Subcutaneous dose to be determined by blood sugar.
16. Lactulose 10 gram Packet Sig: Three (3) mg PO twice a day as
needed for constipation.
17. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
18. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety: may cause sedation. Please do not
take with alcohol or perform activities that require
concentration while taking .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary
Aspirin Desensitization for aspirin allergy
.
Secondary
Two vessel coronary artery disease
Hypertension
Renal Failure
Diabetes
Discharge Condition:
stable, alert and oriented x 3, able to ambulate with walker.
Discharge Instructions:
You were admitted to the hospital because you required aspirin
desensitization and cardiac catheterization to explore the cause
of a heart attack that you had in [**Month (only) 956**]. Your catheterization
showed that you had disease in several of your heart blood
vessels. You will follow up with the cardiothoracic surgeon's in
one month who will evaluate whether a coronary artery bypass
should be performed but in the meantime your renal function
needs to improve and you will return to rehab for this purpose.
The following changes were made to your medications.
Aspirin 325mg daily (please take every day without fail or else
you will have to be admitted to the ICU again for
desensitization)
Lisinopril was held given her renal failure but should be
resumed when renal function improves by outpatient doctor.
Lasix was held and will be resumed by the outpatient doctor when
appropriate.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2129-4-25**] 2:20
Provider: [**Name10 (NameIs) 1947**] CLINIC (SB) Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2129-4-22**]
Cardiothoracic Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2129-5-16**] 1:15
11:15
|
[
"530.81",
"V58.67",
"278.01",
"438.20",
"414.01",
"250.00",
"584.9",
"410.72",
"428.32",
"403.10",
"285.9",
"585.9",
"V07.1",
"428.0",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.12",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
11586, 11657
|
4322, 8696
|
301, 326
|
11836, 11899
|
2912, 4226
|
12934, 13354
|
2304, 2334
|
9797, 11563
|
11678, 11815
|
8722, 9111
|
4243, 4299
|
11923, 12911
|
2349, 2893
|
238, 263
|
354, 1632
|
1654, 1977
|
1993, 2288
|
9129, 9774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,800
| 187,363
|
37825
|
Discharge summary
|
report
|
Admission Date: [**2104-9-10**] Discharge Date: [**2104-9-13**]
Date of Birth: [**2052-5-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Supraventricular Tachycardia
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
52M with no pmh reporting 12 days of increased abdominal girth
and 5 days of lower extremity swelling, presented to his PCP
today and found to have a supraventricular tachycardia to 140 on
ekg. He reports having a cough with yellow sputum which occurred
shortly before he noticed his increased abdominal size. he
denied ever feeling palpitations or chest pain, but did report
shortness of breath with the cough. he took robitussin and his
shortness of breath and cough resolved. Upon presentation to his
PCP and discovery of his supraventricular tachycardia, he was
brought to [**Hospital3 4107**] where he was given diltiazem 45mg IV
and metoprolol 7.5mg without effect. Bedside echo at the time
showed LVH with an ejection fraction of 10%.
.
He was transferred to [**Hospital1 18**] ED where vitals were 99.5 145 165/98
20 97%RA. He was given lopressor 5mg IV X1 without effect,
followed by adenosine 12mg which broke his rhythm and showed
atrial flutter with 4:1 block. His rate returned to 145. He
was placed on a nitro drip and given aspirin 325mg X1.
.
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.
Past Medical History:
hypertension
Social History:
-Tobacco history: cigars up to 2 weeks ago
-ETOH: drinks a pint of whiskey 4 nights weekly
Family History:
mother died in the 80's of "heart problems" for many years, she
was 65yo at the time.
Physical Exam:
VS: T= 98.9 BP= 170/90 HR= 139 RR=12 O2 sat= 93% 3L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP up to angle of jaw.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, obese, distended, pitting edema.
EXTREMITIES: 2+ pitting edema b/l.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2104-9-10**] 05:20PM CK-MB-6 proBNP-7235*
[**2104-9-10**] 05:20PM cTropnT-0.02*
[**2104-9-10**] 05:20PM ALT(SGPT)-55* AST(SGOT)-53* CK(CPK)-418* ALK
PHOS-68 TOT BILI-1.1
[**2104-9-10**] 05:20PM GLUCOSE-130* UREA N-19 CREAT-1.4* SODIUM-134
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-20* ANION GAP-18
[**2104-9-10**] 05:20PM WBC-9.8 RBC-4.49* HGB-14.6 HCT-44.6 MCV-99*
MCH-32.4* MCHC-32.7 RDW-14.1
[**2104-9-10**] CXR: IMPRESSION: Findings consistent with mild volume
overload. More confluent opacity in the lung bases may be due to
soft tissue attenuation, atelectasis, and/or focal pneumonia.
Repeat radiography following appropriate diuresis recommended to
assess for underlying infection. If clinically feasible,
consider PA and lateral views in the Radiology Suite for a more
sensitive evaluation. Cardiomegaly is also noted.
[**2104-9-10**] EKG: Atrial flutter with a ventricular rate of 139. Left
axis deviation. Marked J point elevation with early
repolarization in anterior precordial leads. Diffuse
non-diagnostic repolarization abnormalities elsewhere. No
previous tracing available for comparison.
[**2104-9-11**] TEE ECHO: The left atrial appendage emptying velocity is
depressed (<0.2m/s). A probable thrombus is seen in the left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is severely
depressed (LVEF= 15-20 %). Right ventricular chamber size is
normal. with moderate global free wall hypokinesis. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 30 cm from the
incisors. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Probable thrombus in left atrial appendage. Severely
depressed [**Hospital1 **]-ventricular systolic function.
Brief Hospital Course:
52M with no past medical history presenting with new onset
systolic congestive heart failure and atrial flutter with
alternating 4:1 and 2:1 block.
.
# Atrial Flutter: His atrial flutter may have begun nearly two
weeks ago when he first developed cough and increased abdominal
girth. He was initially in a 2:1 block with a HR in the
140s-150s and his cardiac enzymes were negative. His rhythm was
initially resistant to diltiazem drip and metoprolol. An
electrophysiology consult was obtained and the plan was to
proceed with TEE to rule out atrial clot prior to ablation of
the circuit. A TEE was performed which showed probable thrombus
in the left atrial appendage and the ablation was therefore
cancelled. He was then started on Metoprolol 75mg QID and
verpamil 60mg [**Hospital1 **] which managed to push his rhythm into 4:1
block with a HR in the 80s to 100s. He was also digoxin loaded,
but the digoxin was discontinued because he had 2 prolonged
pauses in his rhythm with the vagal stimulation of passing gas
and it was felt that digoxin was making this more pronounced.
For his left atrial appendage clot he was started on heparin IV
as a bridge to Coumadin. He will continue the bridging at home
with Lovenox and will have his INR measured on [**9-15**]. He
will follow-up with electrophysiology in 1 month as an
outpatient for repeat TEE and possible ablation if there is no
clot seen. Until then he will remain of metoprolol 150mg [**Hospital1 **]
and verpamil 60mg [**Hospital1 **] for rate control.
.
# Acute Systolic Congestive heart failure: He appears to have
predominantly right sided heart failure with absence of
crackles, along with presence of JVP, abdominal edema, and
increased abdominal girth. Echo showed EF=15-20%. BNP elevated
to 7000. Etiologies may include cardiomyopathy induced by
alcohol, viral infection from previous upper respiratory
infection, or tachycardia induced cardiomyopathy. He diuresed
well with Lasix 20mg IV.
.
# Hypertension: He was started on metoprolol and lisinopril.
.
# Coronary artery disease prevention: Will start on aspirin
81mg. Consider checking lipid profile with PCP as an outpatient.
.
CODE: Code status was confirmed as full.
.
COMM: [**Name (NI) 17**] [**Name (NI) **] (sister) [**Telephone/Fax (1) 84636**]
Medications on Admission:
None
Discharge Medications:
1. Outpatient Lab Work
Please measure INR, PT, PTT, [**Name (NI) **], K, Cl, CO2, BUN, Cr on [**9-15**].
Please fax results to office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18359**] at fax #
[**Telephone/Fax (1) 84637**].
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Verapamil 40 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours).
Disp:*90 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO Q
12H (Every 12 Hours).
Disp:*180 Tablet(s)* Refills:*2*
6. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Please have Na, K, Cl, CO2, BUN, Cr measured on [**9-29**]. Please
fax results to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 84638**] at [**Telephone/Fax (1) 18360**]
8. Lovenox 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous
every twelve (12) hours for 8 doses: Inject twice a day on [**9-14**].
Inject the morning of [**9-15**]. await results of labs on [**9-15**] before
administering further injections.
Disp:*8 syringe* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Flutter
Systolic Congestive Heart Failure
Left Ventricular Hypertrophy
Discharge Condition:
Good. ambulating. 95% on Room air. Lower extremity edema
present. Abdominal edema present.
Discharge Instructions:
You were admitted to the hospital with a rapid heart rhythm
called atrial flutter and congestive heart failure. You were
given medications to slow down your heart rate. You also
underwent a trans-esophageal echocardiograpy to evaluate for
presence of blood clots in your heart. Blood clots were
present, and it was decided to give you blood thinners named
coumadin and lovenox to allow disintegration of this clot. You
should continue these medications for 4 weeks. You should
return here to meet with the electrophysiologists in 4 weeks for
consideration of ablation totreat your atrial flutter. The
electrophysiologist will contact you to set up this appointment
in 4 weeks.
You will need to have labs drawn on [**Last Name (LF) 766**], [**9-15**] and
[**9-29**]. You will be given a prescription to have these
labs drawn. Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 84639**] office to arrange
this lab draw.
.
Please start taking aspirin 81mg PO daily
Please start taking metoprolol 150mg PO every 12 hours
Please start taking verapimil 60mg PO every 12 hours
Please start taking coumadin 4mg PO daily
Please start taking lovenox 100mg SC every 12 hours. Take this
medication until instructed otherwise by your primary care
doctor.
.
Please be sure to have your labs drawn on [**9-15**] and [**9-29**], and to
have these results faxed to your primary care doctor.
Followup Instructions:
Please call your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18359**] at [**Telephone/Fax (1) 18360**] to set up an
appointment for next week.
.
The electrophysiologists at [**Hospital1 18**] will contact you to set up an
appointment in 4 weeks.
Completed by:[**2104-9-14**]
|
[
"428.0",
"429.3",
"429.89",
"427.32",
"428.21",
"401.9",
"426.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8501, 8507
|
4868, 7155
|
343, 348
|
8629, 8723
|
2813, 4845
|
10183, 10482
|
1952, 2039
|
7210, 8478
|
8528, 8608
|
7181, 7187
|
8747, 10160
|
2054, 2794
|
275, 305
|
376, 1791
|
1813, 1827
|
1843, 1936
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,058
| 174,936
|
52856
|
Discharge summary
|
report
|
Admission Date: [**2177-8-21**] Discharge Date: [**2177-8-26**]
Date of Birth: [**2092-10-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84M with CAD s/p CABG/PCI (LIMA to LAD, SVG to OM1-OM2, SVG to
RCA), systolic and diastolic CHF s/p BiV-IVD (EF=40% in [**6-/2177**]),
ischemic CMP, VT s/p ablation, PAF who presents directly from
clinic for CHF exacerbation. Patient was recently admitted to
the CCU in [**6-/2177**] where he underwent successful VT ablation and
was also diuresed approximately 3 liters. His discharge weight
at that admission was 68.5 kg and dry weight according to prior
records is also approximately 68.5-69kg.
On [**2177-8-15**], he was referred for DCCV and had a TEE which was
negative for atrial thrombus. DCCV was unsuccessful at
restoring sinus rhythm after 300J and 360J external shocks as
well as 35J internal shock with brief return to NSR, but he
subsequently reverted back to Afib.
He reports that over the past 1-2 weeks, he has been feeling
more SOB and more tired. He has DOE after ambulating only a few
feet and reports that he has felt this way in the past when he
has had HF exacerbations. He denies any chest pain or
diaphoresis during this time. He states that he has been
compliant with all of his medications and denies any dietary
indescretions. No fevers or chills. His weight has increased a
few pounds from 152lbs at baseline to 155-156 over the past few
days. He has also been feeling dizzy for the past couple of
weeks and had a fall 3 days prior to admission. He struck his
right arm on the ground, denies head strike.
On arrival to the floor, patient reports ongoing fatigue and
some mild SOB at rest but denies any other complaints at this
time.
REVIEW OF SYSTEMS
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-Hypertension
-Dyslipidemia
-CABG: [**2157**] (LIMA-LAD, SVG-OM1-OM2, SVG-RCA)
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2165**] (SVG-RCA,
SVG-OM1-OM2), s/p PCI [**2167**] (Ultra stent to SVG-RCA)
-PACING/ICD: s/p BiV-pacer ([**Company 1543**] Concerto, originally
placed [**2167**], last gen change [**2173**])
- CHF (systolic and diastolic, [**12-26**] ischemic cardiomyopathy),
last LVEF 40% in [**6-/2177**]
- MR
- Atrial fibrillation, on coumadin
- slow VT s/p ablation [**6-/2177**]
- stage IV CKD
- Hypothyroidism
- BPH
- chronic anemia, receiving procrit through Dr.[**Name (NI) 109000**] office
- gout
- chronic low back pain
- migraine headaches
- colonic polyps
Social History:
Patient is a retired furniture businessman. He is married and
lives in [**Location 745**] with his wife. Two daughters (one deceased),
four grandchildren. Independent with ADLs, uses a cane at
baseline, minimal exercise tolerance.
# Tobacco: remote cigar use, no cigarettes
# Alcohol: none
# Illicit: none
Family History:
Mother had severe [**Name (NI) 59282**] leading to double amputations. Father
died of a MI at age 62.
Physical Exam:
Physical Exam on Admission:
VS: T=97.7 HR 70 (paced) BP 135/76 RR 14 SpO2 98%/RA
GENERAL: NAD, A&Ox3.
HEENT: NCAT. Sclera anicteric. Moist MM.
NECK: JVP difficult to assess.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur heard best at the
LLSB.
LUNGS: Trace crackles at the bases bilaterally, otherwise CTAB
ABDOMEN: Soft, NTND.
EXTREMITIES: 3+ pitting edema to the knee bilaterally
SKIN: Multiple ecchymoses on arms and chest.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Exam at disccharge:
98.6, 126/57, 71, 18, 94% on RA
General: alert, mildly confused per wife but aware of place,
time and reason for hospitalization
HEENT: JVD 4 cm above clavicle
CHEST: CLear bilat
CV: RRR
Abd; obese, NT, BM this am.
Extremeties: no edema, mult ecchymotic areas
Pertinent Results:
Labs on Admission:
[**2177-8-21**] 01:50PM BLOOD WBC-4.3 RBC-2.71* Hgb-9.6* Hct-29.0*
MCV-107* MCH-
35.5* MCHC-33.2 RDW-16.5* Plt Ct-110*
[**2177-8-21**] 01:50PM BLOOD PT-30.1* INR(PT)-2.9*
[**2177-8-21**] 01:50PM BLOOD UreaN-87* Creat-3.6* Na-135 K-4.7 Cl-93*
HCO3-31 AnGap-16
[**2177-8-21**] 01:50PM BLOOD ALT-10 AST-34 CK(CPK)-152 AlkPhos-91
TotBili-0.6
[**2177-8-21**] 08:09PM BLOOD CK(CPK)-38*
[**2177-8-21**] 01:50PM BLOOD CK-MB-4 cTropnT-0.08*
[**2177-8-21**] 08:09PM BLOOD CK-MB-4 cTropnT-0.06*
[**2177-8-21**] 01:50PM BLOOD Albumin-4.4 Calcium-8.8 Phos-4.8* Mg-2.4
[**2177-8-21**] 01:50PM BLOOD Osmolal-310
[**2177-8-21**] 01:50PM BLOOD TSH-1.6
Imaging:
[**2177-8-25**] CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant change in extent of the pre-existing right pleural
effusion. Unchanged are the areas of basal atelectasis on both
the right side and in the retrocardiac lung areas. Unchanged
appearance of the cardiac silhouette and the pacemaker devices.
Unchanged alignment of the sternal wires.
[**2177-8-22**] ECHO
The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed (LVEF = 35
%) secondary to severe hypokinesis/akinesis of the inferior and
posterior walls. The right ventricular free wall thickness is
normal. The right ventricular cavity is moderately dilated with
severe global free wall hypokinesis. There is moderate-to-severe
aortic valve stenosis (valve area 1.0 cm2) (possibly with
low-flow/low-gradient physiology). The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. [Due to acoustic shadowing, the
severity of tricuspid regurgitation may be significantly
UNDERestimated.] There is no pericardial effusion.
[**2177-8-21**]
IMPRESSION:
1. New right middle lobe collapse.
2. Stable right pleural effusion.
Discharge:
[**2177-8-26**] 06:20AM BLOOD WBC-6.3# RBC-2.86* Hgb-10.0* Hct-31.1*
MCV-109* MCH-35.1* MCHC-32.3 RDW-16.8* Plt Ct-155
[**2177-8-26**] 06:20AM BLOOD PT-14.5* PTT-36.2 INR(PT)-1.4*
[**2177-8-26**] 06:20AM BLOOD Glucose-94 UreaN-79* Creat-3.1* Na-143
K-3.9 Cl-97 HCO3-35* AnGap-15
Brief Hospital Course:
84M with CAD s/p CABG/PCI (LIMA to LAD, SVG to OM1-OM2, SVG to
RCA), systolic and diastolic CHF s/p BiV-IVD (EF=40% in [**6-/2177**]),
ischemic CMP, VT s/p ablation, PAF on warfarin who presents with
fatigue and DOE with evidence of volume overload and acute on
chronic systolic/diastolic heart failure.
Acute Issues:
# Acute on chronic systolic and diastolic heart failure
(EF=40%): Pt presented with dypsnea, especially with movement
was a major complaint. Etiology for CHF exacerbation was
unclear; no evidence of ischemia, non-compliance, dietary
indiscretions or infection. [**Month (only) 116**] be due to the fact that he was
in atrial fibrillation with loss of atrial kick. Recent
cardioversion was unsuccessful. On admission appeared mildly
volume overloaded with peripheral edema > pulmonary edema on
exam. Cardiac enzymes were trended with CK and CKMB flat and
minimal elevation of troponin to 0.08 in setting of acute on
chronic kidney disease. CXR showed new right middle lobe
collapse and stable pleural effusions without frank pulmonary
edema. The patient was 4 lbs above his dry weight. An 80 mg IV
lasix bolous was given and then patient started on 10mg/hr gtt.
Metolazone was also utilized to augment diuresis, and carvedilol
was continued. Patient was not on ACEi/[**Last Name (un) **] [**12-26**] poor renal
function. The patient was placed on 2g sodium diet, 1.5 L fluid
restriction, daily weights, and strict I/Os. Pt did well with
aggressive diuresis while the team closely followed electrolytes
and was weaned down on oxygen. Lasix gtt was discontinued on
[**8-22**] as Cr bumped and chemistries suggestive of contraction
alkalosis. Milrinone drip used temporarily to assess if dyspnea
and Cr would improve with increased contractility. As little
change was noted, milrinone was discontinued.
Given respiratory status improved with diuresis, the stable R
pleural effusion was not pursued. In addition, pt also underwent
incentive spirometry for the atelectasis which could be
visualized on radiographs. Pt was discharged on digoxin,
amiodarone, carvedilol and torsemide at home doses.
# Acute on chronic kidney disease: Recent baseline Cr is ~2.5,
over the past 1-2 weeks has been increasing to 3.0 and is 3.6 at
admission to the CCU. He appears volume overloaded on exam but
likely has decreased ECV with decreased renal perfusion.
Cautious diuresis as above. Home spironolactone was held. Urine
lytes were obtained that showed FeNa >2%, however hard to
analyze in setting of diuretics. FeUrea slightly > 35% and urine
osmos of 330 making ATN possible. Cr was trended and patient was
discharged with a Cr of 3.1.
Chronic Issues:
# CAD s/p CABG and PCI: No chest pain or diaphoresis, although
he does have worsening SOB and DOE which may represent angina
but seems less likely. ASA 81mg daily and carvedilol continued.
# Afib: Currently appears to be in Afib at admission with no
clear P waves on ECG. Also had recent ablation for VT.
Currently he is primarily V-paced with intermittent A-V pacing.
Rate well controlled. Home mexilitine 150mg daily, warfarin for
goal INR [**12-27**], and Coreg were continued. Warfarin as temporarily
held as thoracentesis of R pleural effusion was considered.
Given pt was saturating well on RA, it was decided not to pursue
tapping pleural effusion, and warfarin was restarted [**2177-8-25**],
the day before discharge. INR on discharge was subtherapeutic at
1.4.
# Anemia: Hct at baseline, he is on Procrit as an outpatient.
Procrit was continued. Hct was trended upwards after
administering Procrit and pt was discharged with Hct of 31.
# Hypothyroidism: Continued levothyroxine 100mcg PO daily.
Transitional Issues:
-WEIGHT AT DISCHARGE: 66.8kg (147lbs)
-consider Isordil and hydralazine for afterload reduction
-Pt is to f/u with cardiology
-Pt is to f/u with heme/onc
-Pt is to f/u with PCP after [**Name Initial (PRE) **]/c from ECF
-Pt expected length of rehab stay of < 30 days
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Allopurinol 100 mg PO DAILY
2. Amiodarone 400 mg PO DAILY
3. Calcitriol 0.25 mcg PO 2X/WEEK (WE,SA)
4. Carvedilol 12.5 mg PO BID
hold for SBP<100
5. Digoxin 0.0625 mg PO EVERY OTHER DAY
6. Finasteride 5 mg PO DAILY
7. fluticasone *NF* 220 mcg Inhalation [**Hospital1 **]
8. FoLIC Acid 1 mg PO DAILY
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Metolazone 2.5 mg PO 2X/WEEK (WE,SA)
11. Mexiletine 150 mg PO Q12H
12. Mirtazapine 7.5 mg PO HS
13. Spironolactone 12.5 mg PO DAILY
14. Torsemide 30 mg PO DAILY
15. Warfarin 2 mg PO DAILY16
16. Aspirin 81 mg PO DAILY
17. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg (1,500 mg)-400 unit Oral daily
18. Cyanocobalamin 1000 mcg PO DAILY
19. Docusate Sodium 100 mg PO BID
20. Fish Oil (Omega 3) 1200 mg PO BID
21. Pyridoxine 100 mg PO DAILY
22. Vitamin E 100 UNIT PO DAILY
Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. Amiodarone 400 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO 2X/WEEK (WE,SA)
5. Carvedilol 12.5 mg PO BID
hold for SBP<100
6. Cyanocobalamin 1000 mcg PO DAILY
7. Digoxin 0.0625 mg PO EVERY OTHER DAY
8. Docusate Sodium 100 mg PO BID
9. Finasteride 5 mg PO DAILY
10. Fish Oil (Omega 3) 1200 mg PO BID
11. FoLIC Acid 1 mg PO DAILY
12. Levothyroxine Sodium 100 mcg PO DAILY
13. Mirtazapine 7.5 mg PO HS
14. Pyridoxine 100 mg PO DAILY
15. Torsemide 30 mg PO DAILY
16. Vitamin E 100 UNIT PO DAILY
17. Warfarin 2 mg PO DAILY16
18. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg (1,500 mg)-400 unit Oral daily
19. fluticasone *NF* 220 mcg Inhalation [**Hospital1 **]
20. Atorvastatin 20 mg PO DAILY
21. Epoetin Alfa 3000 UNIT SC QTUTHSA (TU,TH,SA)
please give first dose today, and give qSat, [**Hospital1 **], Thurs
22. Mexiletine 150 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
stone instutute
Discharge Diagnosis:
Acute on Chronic systolic Congestive heart failure
Acute on Chronic Kidney Injury
Right pleural effusion
Coronary artery disease
Atrial Fibrillation
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 had an acute exacerbation of your congestive heart failure.
It is unclear what the cause of this is. You were admitted to
the CCU and given intravenous diuretics to remove the extra
fluid. Your weight at dicharge is 147 lbs. You also had an
effusion, an accumulation of fluid around your right lung. After
close monitoring, the decision was made to continue to monitor
it over time. Your kidney function worsened but is now almost
back to your normal level.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 1911**] if weight
goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
reschedule Papageourgiou
.
Department: CARDIAC SERVICES
When: THURSDAY [**2177-9-4**] at 1 PM
With: [**Name6 (MD) 1918**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2177-9-16**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2178-1-13**] at 1:15 PM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2177-8-26**]
|
[
"511.9",
"346.90",
"V45.09",
"427.31",
"584.9",
"403.90",
"274.9",
"V58.61",
"285.9",
"V45.81",
"272.4",
"585.4",
"244.9",
"428.43",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12607, 12649
|
6710, 9355
|
290, 297
|
12842, 12842
|
4444, 4449
|
13639, 14746
|
3492, 3595
|
11666, 12584
|
12670, 12821
|
10695, 11643
|
13018, 13616
|
3610, 3624
|
10423, 10669
|
10401, 10409
|
234, 252
|
325, 2454
|
4463, 6687
|
12857, 12994
|
9371, 10380
|
2476, 3150
|
3166, 3476
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,886
| 166,787
|
26173
|
Discharge summary
|
report
|
Admission Date: [**2166-1-2**] Discharge Date: [**2166-1-24**]
Date of Birth: [**2112-4-2**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Morphine / Rocephin / Tetracycline /
Penicillins / Strawberry / Coconut Flavor / Bee Pollens / Tape
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Transfer from [**Hospital3 10377**] Hospital for treatment of
tracheomalacia
Major Surgical or Invasive Procedure:
placement of G-J tube by interventional radiology
placement of Y stent in trachea
stoma revision and placement of tracheal stent w/ foam cuff
History of Present Illness:
53F with hx of severe spina bifida, kyphoscoliosis and chronic
atelectasis who is chronically vented who was transferred from
[**Hospital3 417**] for a rigid bronchoscopy. Pt was admitted to [**Hospital 64898**] in [**9-25**] for a trach change after it was
found that it was difficult to pass the suction catheter. A
bronchoscopy at that time showed granulation tissue causing a
30-40% obstruction of the posterolateral wall so she had a new
trach placed. On [**2165-12-25**], pt had a fiberoptic bronchoscopy with
another change of her tracheostomy tube. Apparently the ideal
length of trach tube was not available at the time so a #7
Shiley with a length of 88mm was placed. On [**12-29**], pt noted to go
into acute resp distres with decrease in her mental status. She
was placed on an ambu bag and brought to [**Hospital3 **] Med Ctr. There
an ABG revealed 7.16/115/281. She underwent an urgent
bronchoscopy which showed mucous plugging and granulation tissue
in and around the trachea. The granulation tissue was measured
at 3-44mm above the carina, obstructing the airway. The tube was
advanced through the obstruction and now rests 3cm above the
carina. Her ABG improved to 7.38/64/239 following the procedure.
Pt was transferred to [**Hospital1 18**] for rigid bronchoscopy and possible
trach repositioning.
.
Of note, pt has sputum from [**12-26**] growing acinetobacter [**Last Name (un) 36**] only
to amikacin and sputum from [**12-29**] growing morganella [**Last Name (un) 36**] to
amikcain, gentamicin and imipenem. She also had a urine cx from
[**12-29**] growing MRSA. It appears that she has been on Amikacin since
[**12-31**] and Vancomycin since [**1-1**]
Past Medical History:
* spina bifida, chronically vented
* severe kyphoscoliosis
* chronic atelectasis of left lung
* chronic ileus with placement of ileostomy
* hx of multiple PNAs,
* hx of multiple UTIs, most recently treated with amikacin
(completed on [**2165-12-20**])
* Renal insufficiency
* Anxiety
* Diabetes
Social History:
Lives at rehab facility, sister [**Name (NI) **] is next of [**Doctor First Name **], no hx
tobacco use
Family History:
NC
Physical Exam:
Exam: temp 96.2, BP 122/69, HR 61, R 31, O2 100% on vent
Vent: 400x14x5x0.35, PIP 35-37
Gen: sleeping
HEENT: MM dry
CV: RRR
Chest: clear, no wheezes
Abd: no BS detected, ostomy bag in place with prolapsed stoma,
nontender, +distended
Ext: thin extremities, trace edema, warm, 2+DP
Pertinent Results:
--G-J Tube Placement: Successful conversion of a percutaneous G
to GJ tube. The tip of the tube is now in the proximal jejunum.
The tube is ready for use.
--CT PELVIS W&W/O contrast ([**2166-1-16**]): No secondary signs to
indicate a vesicoenteric fistula. Oral contrast is not seen
extending into the bladder and infusion of contrast into the
bladder does not extend into the adjacent small bowel loops.
Persistent left-sided hydronephrosis and nephrolithiasis.
--URINE CULTURE ([**2166-1-18**]): MORGANELLA MORGANII sensitive to
gentamicin.
--Sputum & BAL ([**2166-1-14**] & [**2166-1-15**]): pseudomonas
--[**2166-1-7**]: FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA
[**2166-1-24**] 06:00AM BLOOD WBC-6.7 RBC-2.72* Hgb-8.1* Hct-23.5*
MCV-87 MCH-29.8 MCHC-34.5 RDW-15.3 Plt Ct-564*
[**2166-1-23**] 04:30AM BLOOD WBC-5.4 RBC-2.69* Hgb-7.8* Hct-23.5*
MCV-88 MCH-29.2 MCHC-33.3 RDW-15.5 Plt Ct-515*
[**2166-1-22**] 04:48AM BLOOD WBC-5.2 RBC-2.83* Hgb-8.4* Hct-25.2*
MCV-89 MCH-29.5 MCHC-33.2 RDW-15.5 Plt Ct-489*
[**2166-1-21**] 04:48AM BLOOD WBC-5.1 RBC-2.49* Hgb-7.0* Hct-20.8*
MCV-84 MCH-28.3 MCHC-33.8 RDW-15.1 Plt Ct-393
[**2166-1-20**] 03:45AM BLOOD WBC-5.1 RBC-2.55* Hgb-7.3* Hct-21.5*
MCV-84 MCH-28.7 MCHC-34.1 RDW-14.9 Plt Ct-327
[**2166-1-19**] 04:07AM BLOOD WBC-5.7 RBC-2.71* Hgb-7.7* Hct-22.9*
MCV-85 MCH-28.6 MCHC-33.8 RDW-15.1 Plt Ct-331
[**2166-1-18**] 12:40PM BLOOD Hct-23.1*
[**2166-1-18**] 03:45AM BLOOD WBC-6.1 RBC-2.61* Hgb-7.9* Hct-23.3*
MCV-89 MCH-30.3 MCHC-33.8 RDW-15.3 Plt Ct-333
[**2166-1-17**] 07:29PM BLOOD Hct-23.5*
[**2166-1-17**] 10:50AM BLOOD WBC-7.1 RBC-2.71* Hgb-8.1* Hct-24.3*
MCV-90 MCH-30.0 MCHC-33.4 RDW-15.3 Plt Ct-346
[**2166-1-16**] 02:55AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.0* Hct-29.1*
MCV-84 MCH-28.8 MCHC-34.4 RDW-15.2 Plt Ct-356
[**2166-1-15**] 02:48AM BLOOD WBC-6.7 RBC-3.30* Hgb-10.2* Hct-28.6*
MCV-87 MCH-31.1 MCHC-35.8* RDW-15.5 Plt Ct-310
[**2166-1-13**] 04:08AM BLOOD WBC-8.0 RBC-3.45* Hgb-10.3* Hct-30.4*
MCV-88 MCH-29.9 MCHC-34.0 RDW-15.2 Plt Ct-289
[**2166-1-16**] 02:55AM BLOOD Fibrino-667*
[**2166-1-24**] 06:00AM BLOOD Glucose-144* UreaN-17 Creat-0.8 Na-135
K-4.3 Cl-102 HCO3-21* AnGap-16
[**2166-1-21**] 04:48AM BLOOD Glucose-78 UreaN-14 Creat-0.5 Na-137
K-3.2* Cl-106 HCO3-22 AnGap-12
[**2166-1-20**] 03:45AM BLOOD Glucose-137* UreaN-15 Creat-0.5 Na-135
K-3.9 Cl-104 HCO3-22 AnGap-13
[**2166-1-19**] 04:07AM BLOOD Glucose-169* UreaN-16 Creat-0.6 Na-134
K-3.6 Cl-101 HCO3-22 AnGap-15
[**2166-1-17**] 10:50AM BLOOD Glucose-152* UreaN-19 Creat-0.6 Na-139
K-4.1 Cl-109* HCO3-17* AnGap-17
[**2166-1-15**] 02:48AM BLOOD Glucose-147* UreaN-28* Creat-0.5 Na-138
K-3.3 Cl-105 HCO3-19* AnGap-17
[**2166-1-14**] 03:33AM BLOOD Glucose-148* UreaN-34* Creat-0.6 Na-139
K-3.7 Cl-107 HCO3-21* AnGap-15
[**2166-1-13**] 04:08AM BLOOD Glucose-124* UreaN-38* Creat-0.6 Na-138
K-3.5 Cl-108 HCO3-18* AnGap-16
[**2166-1-24**] 06:00AM BLOOD Calcium-10.4* Phos-2.8 Mg-1.5*
[**2166-1-21**] 04:48AM BLOOD calTIBC-137* Ferritn-579* TRF-105*
[**2166-1-17**] 10:50AM BLOOD Hapto-332*
[**2166-1-11**] 03:18AM BLOOD Triglyc-231*
[**2166-1-24**] 06:00AM BLOOD Vanco-30.8
[**2166-1-23**] 04:30AM BLOOD Vanco-46.2*
[**2166-1-22**] 04:48AM BLOOD Vanco-56.3*
[**2166-1-22**] 04:48PM BLOOD Type-MIX pO2-38* pCO2-41 pH-7.34*
calHCO3-23 Base XS--3
[**2166-1-19**] 12:54PM BLOOD Type-ART pO2-92 pCO2-38 pH-7.35
calHCO3-22 Base XS--3
[**2166-1-7**] 11:59AM BLOOD Type-ART Rates-14/0 Tidal V-400 PEEP-5
FiO2-50 pO2-188* pCO2-32* pH-7.48* calHCO3-25 Base XS-1
-ASSIST/CON Intubat-INTUBATED
[**2166-1-6**] 11:06AM BLOOD Type-ART pO2-132* pCO2-39 pH-7.43
calHCO3-27 Base XS-2
[**2166-1-5**] 06:04AM BLOOD Type-ART Rates-14/ Tidal V-400 PEEP-5
FiO2-35 pO2-50* pCO2-42 pH-7.34* calHCO3-24 Base XS--2
[**2166-1-23**] 03:31PM BLOOD AMIKACIN- TEST
[**2166-1-22**] 11:26AM BLOOD AMIKACIN-16.1 MG/L(THERAPEUTIC RANGE
TROUGH=[**3-29**] PEAK=20-25)
[**2166-1-21**] 11:26AM BLOOD AMIKACIN- TEST
[**2166-1-19**] 11:30AM BLOOD AMIKACIN- TEST
[**2166-1-8**] 03:00AM BLOOD AMIKACIN- TEST
Brief Hospital Course:
1. Tracheal stenosis and malacia: Pt had developed granulation
tissue from chronic trach tube leading to periods of obstruction
and resp distress. On [**1-3**] pt underwent rigid bronchoscopy,
stoma revision, and placement of foam cuff. Unfortunately,
shortly thereafter there was occlusion due to significant
malacia and an ulcer on her posterior trachea causing collapse.
Because of this, on [**1-14**] pt was taken back to the OR for rigid
bronchoscopy, and had a Y stent placed. Since then, respiratory
status has remained stable on her chronic vent settings of AV
400x14x4x40%. Most recent bronchoscopy on [**1-22**] revealed some
thin secretions and otherwise clear airways and stent in good
position.
.
2. PNA: Pt was growing acinetobacter, MRSA and morganella in her
sputum [**Last Name (un) 36**] to mainly amikacin and had been started on amikacin
the week prior to admission at her rehab facility due to a
fever. Amikacin was discontinued on her arrival due to lack of
fever and leukocytosis. It was felt that pt is likely colonized
by these organisms. After a period of resp distress, she was
noted to have a fever to 101.5 with an increased WBC and on the
bronch, her airways appeared inflammed. She was thus restarted
on amikacin for a presumed pneumonia and received a 10 day
course. Two days after cessation of amikacin, pt spiked a temp
to 105.5 with tachycardia. She was restarted on vanc and
Amikacin and HR came down with fluids. She defervesced and bld
cx were NGTD. Sputum from BAL was growing pseudomonas only [**Last Name (un) 36**]
to Amikacin so she was continued on this antibiotic.
.
# UTI: Following the pt's fever spike to 105.5, her urine cx
grew out Morganella [**Last Name (un) 36**] to meropenem but given her PCN allergy,
she was continued on Amikacin x 10 days. Her urine appeared very
dark so there was concern for a fistula between her GI and GU
tract. A CT was done and showed no communication between the
two tracts.
.
# J-tube malfunction: Nursing noted that material injected into
the PEG was leaking back out at the opening surrounding the PEG
site. Gastograffin study shows that g tube was in the stomach
but leaking around the tube. A gastroenterology consult and
surgery consult were obtained. It was felt that material
injected through the G tube was not draining beyond the pylorus.
Also, surgery found that the tissue around the G-tube site was
gastric mucosa. Therefore, per surgical recommendation, a G-J
tube was placed so that pt could be fed with the J tube. A
small-bowel follow through after the G-J tube placement found
that contrast flowed nicely from jejunum to ostomy bag.
Continued clear drainage around G-J tube so IR replaced tube on
[**1-22**] with good result.
.
# Abdominal distension: Pt had intermittent distension of the
abdomen. Her ostomy was putting out stool and gas, however the
ostomy site would intermittently herniate out. A small bowel
follow through study was obtained to rule out obstruction and
showed normal flow of contrast through the GI tract, out through
the ostomy. She was restarted on her bowel meds and reglan.
Tubefeed residuals remained WNL and her ostomy output remained
good.
.
# Agitation/Mental Status: Pt had been placed on propofol prior
to admission to control her agitation while her trach tube was
unstable. Following placement of her Y-stent, her propofol was
discontinued and her agitation was controlled with ativan,
haldol, and low-dose fentanyl patch. ECG revealed QTc WNL even
with haldol. Decreased fent patch 50 mcg->25 mcg on [**1-22**]. On
this regimen, the patient remained alert, calm, and followed
simple commands. Can consider decreasing haldol further in
future.
.
# Diabetes Mellitus: glucose was stable on sliding scale
insulin.
.
# FEN: patient tolerated tube feeds well with good, guaiac
negative stool output from colostomy site.
.
# Prophylaxis: pt was maintained on SQ heparin, bowel regimen,
and pantoprazole throughout hospitalization.
Medications on Admission:
* albuterol q6hrs
* Amikacin
* digoxin 0.125mg qd
* Colace
* Esomeprazole 40mg qd
* Haldol 4mg q4hr
* Heparin SQ
* regular insulin sliding scale
* Solumedrol 20mg IV q12hrs
* Reglan 10mg IV tid
* MVI
* Nitro 1" q4hrs
* Paxil 10mg qd
* Vancomycin 1gm q12
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day): mouth care.
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**5-29**]
Puffs Inhalation Q4H (every 4 hours).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
5. Colace 60 mg/15 mL Syrup Sig: Fifteen (15) mL PO twice a day.
6. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for agitation.
7. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
8. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
9. Insulin Regular Human 100 unit/mL Solution Sig: AS DIR units
Injection ASDIR (AS DIRECTED): based on sliding scale.
10. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
13. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily): via G-J tube.
14. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) mL PO
BID (2 times a day): hold for loose stools.
15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): for skin breakdown.
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): for skin breakdown.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
18. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): consider discontinuing this
in future if patient's mental status remains at baseline and not
in pain.
19. Guaifenesin 100 mg/5 mL Syrup Sig: Sixty (60) ML PO BID (2
times a day).
20. Amikacin 250 mg/mL Solution Sig: Two [**Age over 90 1230**]y (250) mg
Injection Q24H (every 24 hours) for 7 days: PLease check
amikacin level everyday and aim for trough level of [**3-29**].
21. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: 1000 (1000)
mg Intravenous Q 24H (Every 24 Hours) for 7 days: Please check
vanco level everyday and dose only for level<15.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
traceal stenosis
tracheomalacia
pneumonia, acitinobacter
urinary tract infection, Morganella
spina bifida
kyphoscoliosis
ileostomy
renal insufficiency
diabetes mellitus
Discharge Condition:
stable on current vent settings
Discharge Instructions:
Please follow up with your physician at the rehab facility.
Followup Instructions:
Please follow up with your physician at the rehab facility.
Completed by:[**2166-1-24**]
|
[
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"741.90",
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icd9cm
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[
[
[]
]
] |
[
"96.04",
"99.15",
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"96.6",
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icd9pcs
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[
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2643, 2748
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,957
| 152,651
|
50674
|
Discharge summary
|
report
|
Admission Date: [**2137-3-19**] Discharge Date: [**2137-3-25**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] M with history of Afib, dCHF EF 55%, CAD s/p 3V-CABG, HTN,
DMII, PVD, HL presents from PCP office for severe fatigue and
cough over the last 2 weeks. He has a long standing (>2 year)
dry cough that became productive 2 weeks ago after grandkids,
who were sick with URI type symptoms, visited. He became more
drowsy, and had more DOE. He is able to cooks simple meals for
himself, but was becoming tired walking to bathroom for the past
few days. He also reported developing left side chest pain
yesterday- pleuritic, non-radiating. He reports having calf
pain, which has been going on for years.
In clinic, he was noted to be very drowsy, bradycardic, and
hypotensive so was referred to the ED. Baseline BP usually in
110-130s.
In the ED, initial vitals were 96.9 37 68/31 16 98%. He was
given 500cc bolus of IVF with marginal response in hemodynamics
to BP of 75/40. Peripheral dopamine was started with a good
increase in his HR and BP. CVL was subsequently placed.
Dopamine dosing was as high as 15, but was weaned to 5 by the
time he was transferred to the floor. Given his cough, he was
initially given a dose of levofloxacin and clindmycin. CXR was
a poor study.
He had recently been undergoing aggressive diuresis for leg
edema as an outpatient. His primary cardiologist had been
worried about primary bradycardia (was in 40-50's) and had
ordered an event monitor, which does not appear to have been
performed yet. At the time, there was also concern for TIA, so
MRI head was obtained which showed no vascular occlusion,
stenosis, or an aneurysm >3 mm.
Vitals prior to transfer were: 90, 130/60, 15, 98% 2-3L
On cardiac review of systems, he denies chest pain, dyspnea,
orthopnea, PND, syncope, presyncope, and palpitations. No other
pertinent positives on general review of systems
Past Medical History:
-CAD: Severe 3 vessel disease s/p 3v CABG [**2108**](SVG=>D1=>LAD,
SVG=>OM1=>OM3, SVG= >AM). SVG=>D1=>LAD was stented [**2128**]. Repeat
cath [**7-12**] showed inoperable disease. During admit [**10-12**], had CP
a/w some dynamic ST segment depressions in anterior leads,
medically managed with aspirin, plavix, ACE, imdur, and
betablocker. LVEF >55% on Echo done [**12/2131**]
-Incarcerated paraesophageal hernia s/p laparoscopic repair with
fundoplication in [**10-12**]; associated gastric outlet obstruction
resolved with surgical repair
-Lower gastrointestinal bleed secondary to hemorrhoids and
colonic polyps, admit [**2129-11-20**]
-Hypertension with mild symmetric LVH
-Afib, first noted post-op during [**10-12**] admission post op after
paraesophageal hernia repair, converted to NSR on 11/[**2131**]. Off
coumadin [**2-7**] significant bleeding issues.
-Hyperlipidemia
-Diabetes type II
-By MRI/MRA: left posterior parietal infarct, chronic
periventricular microvascular ischemic changes, moderate disease
resulting in 60-70% stenosis of the right precavernous and
cavernous ICA
-s/p bilateral carotid endarterectomy
-Peripheral vascular disease status post left toe amputation,
followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 105256**] of prostate cancer status post radiation therapy
-Cataracts
Social History:
No history of tobacco, no illicit drugs, no EtOH use. Walks
without a walker at home. Lives with his wife [**Name (NI) 1446**] and son
[**Name (NI) **] who is active in his care. Retired physical therapist,
musician and barber. Independent of ADLs except for showering.
Wife does the bills. He does his own medications and his son
supervises. 3 children, 3 grandchildren and 7 great
grandchildren. Last fell [**10-18**] and was admitted to [**Hospital 2940**]
Family History:
Father died at 78 due to probable MI. Mother died at 86 due to
probable MI.
Physical Exam:
On Admission:
94 82 133/63 81 16 98% on 4L
GENERAL: drowsy, Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple without elevation of JVP
CARDIAC: irregularly irregular RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. bilateral
crackles R>L on anterior lung exam
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
NEURO: AAOx3, CNII-XII intact, poor effort with exam. Moving all
extremities. sensation to LT symmetric.
On Discharge:
Vitals: 98.5 BP 126-135/63-71 HR 69-82 RR 18-20 98% RA
I's/O's: 8 - 120/500+1, 24 - [**Telephone/Fax (1) 105436**]+2BM
GENERAL: no acute distress
HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated
CHEST: Crackle base.
CV: S1 S2 Normal in quality and intensity, no murmurs rubs or
gallops
ABD: soft, non-tender, BS normoactive.
EXT: wwp, no edema. DPs, PTs 2+. Not able to palpate thrill in
fistula.
NEURO: 5/5 strength in U/L extremities. Speech clear, pt
answering questions appropriately.
SKIN: no rash
.
Pertinent Results:
On Admission:
[**2137-3-19**] 06:00PM BLOOD WBC-5.8 RBC-2.77* Hgb-8.2* Hct-24.2*
MCV-87 MCH-29.6 MCHC-33.8 RDW-16.4* Plt Ct-66*
[**2137-3-19**] 06:00PM BLOOD Neuts-75* Bands-3 Lymphs-14* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2137-3-21**] 03:05AM BLOOD WBC-8.7# RBC-3.58*# Hgb-10.3*# Hct-30.2*
MCV-84 MCH-28.9 MCHC-34.2 RDW-15.9* Plt Ct-69*
[**2137-3-21**] 03:05AM BLOOD Neuts-79* Bands-4 Lymphs-8* Monos-8 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2137-3-23**] 05:59AM BLOOD WBC-11.9*# RBC-3.63* Hgb-10.3* Hct-32.6*
MCV-90 MCH-28.5 MCHC-31.7 RDW-15.9* Plt Ct-84*
[**2137-3-19**] 06:00PM BLOOD PT-13.2* PTT-36.0 INR(PT)-1.2*
[**2137-3-19**] 06:00PM BLOOD Glucose-92 UreaN-67* Creat-2.2* Na-137
K-4.3 Cl-100 HCO3-23 AnGap-18
[**2137-3-19**] 06:00PM BLOOD ALT-45* AST-47* CK(CPK)-73 AlkPhos-121
TotBili-0.4
[**2137-3-19**] 06:00PM BLOOD CK-MB-8 cTropnT-0.06* proBNP-2261*
[**2137-3-19**] 06:00PM BLOOD Albumin-3.6 Calcium-9.1 Phos-5.1* Mg-2.2
[**2137-3-19**] 06:00PM BLOOD TSH-5.3*
[**2137-3-20**] 05:09AM BLOOD Cortsol-53.0*
[**2137-3-20**] 05:24AM BLOOD Type-ART pO2-68* pCO2-35 pH-7.41
calTCO2-23 Base XS--1
[**2137-3-20**] 02:51PM BLOOD Type-ART Temp-38.0 Rates-/14 FiO2-50
pO2-127* pCO2-32* pH-7.40 calTCO2-21 Base XS--3 Intubat-NOT
INTUBA Comment-CN
[**2137-3-20**] 05:07PM BLOOD Type-ART Temp-38.2 FiO2-50 pO2-110*
pCO2-38 pH-7.38 calTCO2-23 Base XS--1 Intubat-NOT INTUBA
Comment-C.N
[**2137-3-19**] 06:13PM BLOOD Lactate-1.2
Cardiac Enzymes:
[**2137-3-19**] 06:00PM BLOOD CK-MB-8 cTropnT-0.06* proBNP-2261*
[**2137-3-20**] 05:09AM BLOOD CK-MB-33* MB Indx-15.6* cTropnT-1.32*
[**2137-3-20**] 12:02PM BLOOD CK-MB-24* MB Indx-13.8* cTropnT-2.20*
[**2137-3-20**] 05:00PM BLOOD CK-MB-18* MB Indx-11.3* cTropnT-1.72*
[**2137-3-20**] 05:09AM BLOOD CK(CPK)-211
[**2137-3-20**] 12:02PM BLOOD CK(CPK)-174
[**2137-3-20**] 05:00PM BLOOD CK(CPK)-160
TTE [**2137-3-20**]:
Imaging:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the basal inferior and infero-lateral walls. The
remaining segments contract normally (LVEF = 55%). 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. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild mitral regurgitation is seen.There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior study dated [**2136-10-29**] (images
reviewed), the wall motion abnormalities described above were
present but not reported on the prior echocardiogram.
Brief Hospital Course:
HOSPITAL COURSE: [**Age over 90 **] M with Afib, dCHF EF 55%, CAD s/p 3V-CABG,
HTN, DMII, PVD, HL presents with severe fatigue and cough found
to be hypotensive to 60s and bradycardic to 30s due to sepsis
from pneumonia.
ACTIVE ISSUES:
#. Community-Acquired Pneumonia complicated by severe sepsis-
The patient presented to his primary care provider hypotensive
to 70's/30's, bradycardia to high 30's, and marketly lethargic.
He was urgently tranfered to the ED and was admitted to the CCU
for an inital diagnosis of cardiogenic shock given his
bradycardia. This is a patient of Dr. [**First Name (STitle) 437**] and the patient has
been priously bradycardic to the low 40's but minimally
symptomatic. On arrive to the ED he was bradycardic to as low as
the high 30's, but typically in the mid 40's/50's. Given a new
productive cough, opacities on chest x-ray, it was felt that the
hypotension and lethargy was likely related to pneumonia and
less likely due to a cardiogenic process. He was given
Levofloxacin in the ED. After transfer to the CCU, the patient
was increasing tachypnic and ABG was concerning for hypoxemic
respiratory failure. The patient was started on meropenem (given
penicillin allergy) and vancomycin. He was started on Bi-PAP.
He was also started on dopamine. Hypotension was likely due to
sepsis from pneumonia. He had been noted to be bradycardic in
recent past but this seems to be unrelated. TSH mildly elevated
but unlikely to be cause of his hypotension. Cortisol was
normal. However, pt improved with antibitoics and was copntinued
only on levofloxacin (days [**7-13**]). He improved dramatically, came
off pressors and face mask. we f/u blood cultures, but there has
been no growth to date. Legionella, MRSA, resp cultures were all
-ve. Pt was stable on RA at dc.
#. Bradycardia ?????? resolved with HR in 70-80s after resolutiuon of
pna.
INACTIVE ISSUES:
#. Afib - CHADS2 score of 6. However, she is not on coumadin
secondary to prior GI bleeds. On [**Month/Day (4) **] and plavix.
#. dCHF ?????? had not been on home betablocker given bradycardia. We
held betablocker and dc/ed the pt on home po lasix
#. CAD: Stable on medical therapy. We dc/ed pt on home [**Month/Day (4) **],
imdur, lisinopril, lasix, simva.
#. thrombocytopenia/anemia- The patient has a long standing
anemia likely secondary to anemia of chronic inflammation per
Hem-Onc records. The thrombocytopenia is new, which could be
related to septic physiology vs. MDS vs. other. Improved with
overall clinical stabilization.
#. type 2 DM- last A1c was 7.5 on sitagliptin at home. We
continued HISS in-house and dc/ed on home sitagliptin
.
# Elevated LFTs: They were elevated possibly due to hypotension,
and improved with mangment of pneumonia.
#. CKD, stage 3: baseline Cr 1.1-1.4. Cr stable at 1.7 on dc.
Dc/ed on home po lasix.
#.HL: we continued home simvastatin
#.PVD: Stable.
#. Code status: full
TRANSITIONAL ISSUES:
- may need to be abck on beta blocker if not bradycardic at some
point.
- outpatient repeat thyroid function studies
- outpatient repeat LFTs
Medications on Admission:
BRIMONIDINE 0.1 % Drops, both eyes [**Hospital1 **]
CLOPIDOGREL 75 mg daily
DORZOLAMIDE-TIMOLOL 2%-0.5%, both eyes [**Hospital1 **]
FOLIC ACID 1 mg daily
FUROSEMIDE 20 mg daily
GO2 PERSONAL FINGERTIP PULSE OXIMETRY
ISOSORBIDE MONONITRATE 60 mg daily
LATANOPROST 0.005 % topically qhs
LEUPROLIDE - Dosage uncertain
LISINOPRIL 7.5 mg daily
NITROGLYCERIN 0.4 mg SL prn
SIMVASTATIN 40 mg daily
SITAGLIPTIN 50 mg daily
ACETAMINOPHEN - 500 mg q6h prn pain
ASPIRIN 81 mg daily
CALCIUM CARBONATE-VITAMIN D3 500 mg (1,250 mg)-400 unit, 1
Tablet daily
MULTIVITAMIN 1 Tablet daily
PSYLLIUM 1 tsp daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Imdur 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet
Extended Release 24 hr PO once a day.
7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. leuprolide Intramuscular
9. sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day.
10. acetaminophen 500 mg Capsule Sig: One (1) Capsule PO every
six (6) hours as needed for pain.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit
Tablet Sig: One (1) Tablet PO once a day.
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. lisinopril 2.5 mg Tablet Sig: Three (3) Tablet PO once a
day.
16. nitroglycerin Sublingual
17. psyllium 1.7 g Wafer Sig: One (1) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Community Acquired Pneumonia
Diastolic Heart Failure
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr [**Known lastname 105255**],
It was a pleasure taking care of you here at the [**Hospital1 18**]. You
presented with a slow heart rate and low blood pressure and were
found to have a pneumonia. You were given a 7 day course of
antibitoics and you responded very well. You were discharged to
rehab in a stable condition. NO changes were made to your
medications.
Followup Instructions:
Department: NEUROLOGY
When: [**Hospital1 **] [**2137-4-1**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 8222**], MD [**Telephone/Fax (1) 2928**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2137-4-29**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PODIATRY
When: FRIDAY [**2137-5-3**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"V10.46",
"518.81",
"272.4",
"585.3",
"V45.81",
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"486",
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"403.90",
"785.51",
"428.0",
"995.92",
"V15.3",
"285.9",
"250.00",
"038.9",
"427.31",
"414.00",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12834, 12924
|
7870, 7870
|
230, 236
|
13041, 13041
|
5096, 5096
|
13619, 14608
|
3929, 4007
|
11596, 12811
|
12945, 13020
|
10981, 11573
|
7887, 8092
|
13224, 13596
|
4022, 4022
|
4554, 5077
|
10812, 10955
|
6558, 7847
|
179, 192
|
8108, 9750
|
264, 2093
|
9768, 10791
|
5111, 6540
|
13056, 13200
|
2115, 3436
|
3452, 3913
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,721
| 126,814
|
51587
|
Discharge summary
|
report
|
Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-12**]
Date of Birth: [**2088-8-2**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
40 y/o female with a hx of sarcoidosis (pulmonary manifestation)
on prednisone, chronic abdominal pain (chronic pancreatitis),
hypertension and hyperlipidemia. Patient presented to ED with
compliant of shortness of breath and abdominal pain. Patient
reports shortness of breath with exertion for the past 3 days -
her baseline is SOB with 1 flight of stairs but increased
recently to a couple of stairs. She decribes associated
palpitations and chest tightness. She denies lower extremity
edema. Does report PND and orthopnea since the diagnosis of
sacroid - no recent changes. Reports chest pain - but on further
questioning is "chest tightness" related to exertion/difficulty
breathing. She also describes a productive cough, mild sore
throat, chills and fever (reported to 100.0). Patient feels she
has a "cold but worse". Denies recent prolonged travel or leg
pain/swelling. She also reports eipgastric abdominal pain for
the past 2 days described as "burning/sharp" typical for
pancreatitis. She describes associated nausea, vomiting and
diarrhea. Patient reports he last drink was a couple days ago -
few glasses of wine. She has a history of fibroids but does not
feel this is fibroid pain (typically causes back pain).
On arrival to ED patient triggered for tachycardia 147 (sinus)
with blood pressure 143/95 and O2 sat 94% RA. Labs notable for
lipase 150, lactate 3.9, ETOH 318, and anion gap 21. Patient
reported abdominal pain, on exam tender in the epigastric region
and required 12 mg IV morphine and zofran. CT scan of abdomen
with massive fibroids with central necrosis otherwise no acute
pathology. CXR unremarkable. Patient given NEB treatments and
Vanc/Zosyn. Patient continued to be tachycardic (ranging
116-145) despite 4 L NS consequently is being admitted to the
ICU. Her vital signs on transfer are HR 126 BP 145/81 O2 sat 92%
2 L.
Of note patient is on a narcotics contract (percocet [**Hospital1 **]) for
chronic abdominal pain felt to be related to chronic
pancreatitis. Patient's last admission was [**4-/2141**] for acute
pancreatitis with a lipase of 177.
Past Medical History:
- Hypertension
- Chronic pancreatitis
- Sarcoid, diagnosed with skin biopsy, pulm involvement;
prednisone dependent, failed MTX [**1-31**] side effects
- Degenerative Joint Disease of the lower back
- Umbilical hernia
- Fibroids
- Irregular menses, ? premature ovarian failure
PSH: s/p Appendectomy
Social History:
Tobacco - denies.
EtOH - Occasional (last had 1 bottle of wine with boyfriend
several days ago).
Drugs - Denies.
Lives by self at home. Does not work; on disability.
Family History:
Mother with bronchitis, asthma, cervical cancer. Uncle and
grandfather with prostate cancer. Father had CAD. Mother has hx
of cervical cancer as well as
asthma/bronchitis (but is smoker). Has 3 living brothers, none
with known lung disease. Another brother died 6 years ago from
HIV.
Physical Exam:
On Admission:
VS: Temp: 97 BP: 143/111 HR: 128 O2sat: 97% 3 L (90% RA)
GEN: pleasant, comfortable, NAD
HEENT: anicteric, MMM, op without lesions, no supraclavicular or
cervical lymphadenopathy, no jvd.
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, tenderness periumbical and epigastric, no
masses or hepatosplenomegaly, no gaurding or rebound
EXT: no c/c/e
----
Discharge:
ABD: mildly tender in epigastrum
Pertinent Results:
Admission Labs [**2142-1-7**]
WBC-8.6 RBC-4.59 Hgb-13.3 Hct-38.4 MCV-84 MCH-28.9 MCHC-34.5
RDW-13.9 Plt Ct-410
Glucose-108* UreaN-25* Creat-1.2* Na-145 K-3.7 Cl-102 HCO3-22
AnGap-25*
ALT-34 AST-42* AlkPhos-98 TotBili-0.6 Lipase-148*
Lactate-3.9*
Discharge Labs
Glucose-86 UreaN-15 Creat-0.9 Na-135 K-3.0* Cl-98 HCO3-25
AnGap-15
ALT-27 AST-35 AlkPhos-74 TotBili-1.1
Lactate-0.8
TTE: No echocardiographic evidence of cardiac sarcoidosis.
Normal global and regional biventricular systolic function.
CT Abd/Pelvis:
1. Enlargement of massive fibroid uterus.
2. Small hiatal hernia.
3. Fat-containing periumbilical hernia.
LENIs: No evidence of DVT.
Brief Hospital Course:
1. Pancreatitis. Most likely alcohol related. Treated with
supportive care. At time of discharge, was tolerating oral
medications.
2. Fibroid uterus. CT scan demonstrated interval progression of
massive fibroids with areas of central necrosis. This was
associated with lactate of 3.9, which normalized with IVF. GYN
follow-up was scheduled.
3. Shortness of breath. Etiology unclear with possible viral
syndrome. No infiltrate on CXR to suggest PNA. Influenza swab
negative. Improved over stay with oxygen saturations remaining
>95% at rest and with exertion.
4. Tachycardia. Review of OMR reports chronic tachycardia. Per
notes patient's baseline HR 90-100, when sick/dehydrated
elevated to 130-140s. Most likely dehydrated due to acute
pancreatitis with possible component of alcohol ingestion /
withdrawal. Improved during hospitalization with HR in the 90s.
5. Acute renal failure. Prerenal. Improved with IVF.
6. Alcohol abuse. Monitored on CIWA; social work met with
patient and recommended outpatient therapy.
7. Sarcoid. Continued prednisone.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs inh q4-6 hrs as needed for shortness of breath
AMLODIPINE - 10 mg Tablet - one Tablet(s) by mouth daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff inh twice a day
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr -
one
Tablet(s) by mouth daily
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s)
by mouth twice a day
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth daily
SIMVASTATIN - 20 mg Tablet - one Tablet(s) by mouth daily
SUCRALFATE - (Prescribed by Other Provider) - Dosage uncertain
* percocet [**Hospital1 **] on narcotics contract.
* per patietn Bactrim MWF
Medications - OTC
CALCIUM CARBONATE - 500 mg Tablet, Chewable - 1 Tablet(s) by
mouth twice a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 400 unit Capsule - 1
Capsule(s) by mouth once a day Please substitute tablet
formulation for capsules
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-31**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. sucralfate Oral
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. calcium carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO twice a day.
10. ergocalciferol (vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
twice a day as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pancreatitis
2. Hypoxia
3. Acute renal failure
4. Acidosis
5. Fibroid with necrosis
6. URI
7. Sarcoidosis
8. Hypertension
9. Alcohol abuse
10. Hypokalemia
11. Umbilical hernia
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 multiple problems,
including pancreatitis and breathing difficulties. During your
stay, a CT showed that your fibroids have increased greatly in
size and are very large. We have made an appointment with
gynecology for this to be further evaluated.
Followup Instructions:
Please keep the follow appointments:
Gynecology:
Department: OBSTETRICS AND GYNECOLOGY
When: THURSDAY [**2142-1-18**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 106916**], MD [**Telephone/Fax (1) 2664**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2142-1-17**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2142-1-22**] at 4:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: MONDAY [**2142-1-22**] at 4:30 PM
|
[
"799.02",
"465.9",
"276.8",
"276.51",
"135",
"577.0",
"517.8",
"218.9",
"401.9",
"305.00",
"276.2",
"577.1",
"584.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7506, 7512
|
4405, 5462
|
297, 303
|
7734, 7734
|
3729, 4382
|
8196, 9139
|
2944, 3231
|
6464, 7483
|
7533, 7713
|
5488, 6441
|
7884, 8173
|
3246, 3246
|
238, 259
|
331, 2419
|
3260, 3710
|
7749, 7860
|
2441, 2743
|
2759, 2928
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,506
| 183,981
|
32844
|
Discharge summary
|
report
|
Admission Date: [**2123-6-28**] Discharge Date: [**2123-6-29**]
Date of Birth: [**2058-10-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Left Internal Carotid Artery stenosis, s/p stent
Major Surgical or Invasive Procedure:
Elective left ICA stent placement found to have an asymptomatic
90% stenosis.
History of Present Illness:
This is a 64 year old male with a history of hypertension,
hyperlipidemia, coronary artery disease who is status-post bare
metal stent to the Right Coronary Artery in [**11-7**] admitted for
elective left Internal Carotid Artery (ICA) stent placement. The
patient was found to have an asymptomatic 90% stenosis in the
proximal left internal carotid artery just distal to the
bifurcation on carotid duplex study on [**2123-6-9**] which was
performed for evaluation of a bruit noted on physical exam by
his outpatient cardiologist. The right side was without flow
abnormality.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- Coronary Artery Disease, status-post bare metal stent to RCA
in [**11-8**]
- Severe depression, followed by Dr. [**Last Name (STitle) 46739**] outpatient
- Status-post right total knee replacement
- History of disc disease L5-S1/chronic low back pain
- Carotid artery disease
- Anxiety
- Peripheral vascular disease- asymptomatic severe left internal
carotid artery disease.
Cardiac Risk Factors: -Diabetes, +Dyslipidemia, +Hypertension
Percutaneous coronary intervention, in 1217/07 anatomy as
follows:
The LMCA has 10% tapering at the origin. The LAD system has
several digonal arteries which has mild disease. The LCx system
gives off two moderate size OMs and only has mild disease. The
mid RCA and acute marginal are diffusely diseased up to 70% The
distal RCA is occluded with left to right collaterals supplying
the PDA territory.
PTCA and BMS to mid RCA.
Social History:
Social history is significant for the absence of current tobacco
use, history of 1.5 packs per day x 30+ years, quit [**11-8**]. There
is no history of alcohol abuse.
Family History:
His father had his first MI at age 59 and his mother had CABG x
5 at age 85.
Physical Exam:
VS: T 98.4, BP 124/76, HR 68, RR 14, O2 98% on RA
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple unable to assess JVP as is lying flat, no bruits
noted.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Neuro: CN 2-12 in tact, 5/5 strength in upper and lower
extremities symmetric BL
Pertinent Results:
Labs on admission:
[**2123-6-28**] 09:01PM BLOOD WBC-10.1 Plt Ct-235
[**2123-6-29**] 05:36AM BLOOD PT-13.3 PTT-26.4 INR(PT)-1.1
[**2123-6-28**] 09:01PM BLOOD Glucose-98 K-3.8 Cl-100 HCO3-27
[**2123-6-28**] 09:01PM BLOOD CK(CPK)-96
[**2123-6-28**] 09:01PM BLOOD Calcium-8.9 Mg-2.2
Labs on discharge:
[**2123-6-29**] 05:36AM BLOOD WBC-9.3 Hct-35.9* Plt Ct-221
[**2123-6-29**] 05:36AM BLOOD Glucose-108* UreaN-11 Creat-1.0 Na-140
K-4.5 Cl-102 HCO3-30 AnGap-13
[**2123-6-29**] 05:36AM BLOOD CK(CPK)-85
[**2123-6-29**] 05:36AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.3
Carotid ultrasound performed [**2123-6-9**] in [**Location (un) 620**]:
Peak velocities of 78/18 and 443/147 cm/sec on the right and
left, respectively. Left ICA/CCA 6.4.
CARDIAC CATH performed on [**2123-6-28**] demonstrated:
Abdominal aorta: type II arch w/o critical lesions
Carotid/vertebral arteries:
RCCA normal, ICA- no angiographic lesions, ICA fills ipsilateral
ACA and MCA w/cross filling of the LACA and partial filling of
the LMCA. LCCA is normal.
ICA- tubular 90% lesion w/some moderate ectasia. ICA- fills the
MCA primarily w/competitive filling of the ACA.
COMMENTS:
1. Access was obtained via the right femoral artery.
2. Aortogram demonstrated a Type II aortic arch.
3. Selective angiography of the right carotid artery obtained
by passing a Berenstein catheter into the of the right common
carotid artery demonstrated a widely patent external and
internal carotid artery with excellent cerebral runoff.
4. Selective angiography of the left carotid artery obtained by
passing a Berenstein catheter into the left common carotid
artery demonstrated a tight 90% stenosis of the internal carotid
just distal to the bifurcation.
5. Successful angioplasty and stenting of the left internal
carotid artery with an Acculink (7x40mm) bare metal stent
postdilated with a 5mm balloon. The stent was deployed with the
use of distal protection. Final angiography demonstrated no
angiographically apparent dissection, no residual stenosis and
normal flow throughout the vessel with improved cerebral blood
flow (see PTCA comments).
6. Successful closure of the right femoral arteriotomy site
with a 6F Angioseal closure device.
FINAL DIAGNOSIS:
1. Left internal carotid artery disease.
2. Successful stenting of the left internal carotid artery with
an Acculink bare metal stent with use of distal protection.
3. Successful closure of the right femoral arteriotomy site with
a 6F angioseal closure device.
Brief Hospital Course:
The patient is a 64 year old male with a history of
hypertension, hyperlipidemia, coronary artery disease found to
have asymptomatic 90% left internal carotid lesion on ultrasound
and is was admitted for elective left ICA stent placement.
The patient was stented with resulting normal flow throughout
the vessel with improved cerebral blood flow. No bruits noted on
exam.
The patient has coronary artery disease, status-post stent to
the RCA with no other occlusive disease identified on cath in
[**11-7**]. He was continued on ASPIRIN, PLAVIX, and STATIN. The
patient has normal LV/RV function on last ECHO [**11-7**] with an
ejection fraction of 60-65%.
He was maintained on his prior Cymbalta during his
hospitalization. The patient was followed on a CIWA scale for
signs of alcohol withdrawal but did not require any benzo.
Initially, his antihypertensives were while inpatient. These
were restarted prior to discharge with a stable blood pressure.
The patient was hemodynamically stable at discharge with plans
to follow up in one month with Dr. [**First Name (STitle) **].
Medications on Admission:
ASA 325 mg 1 tab daily
Plavix 75 mg 1 tab daily
Lipitor 40 mg 1 tab daily
Cymbalta 60 mg 1 tab daily
Clonazepam 0.5 mg 1 tab prn
Alprazolam 0.25 mg 1 tab prn
Vitamin C with rosehip 1000 mg 1 tab daily
Colace 100 mg daily q hs
Aleve 1-2 tabs prn
Miralax powder 2 teaspoons daily
Cardizem 120 mg 1 tab daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed.
8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
90% asymptomatic stenosis of left ICA
Seconday:
Coronary artery disease, status-post bare metal stent to RCA in
[**11-8**]
Severe depression, followed by Dr. [**Last Name (STitle) 46739**] outpatient
Status-post right total knee replacement
History of disc disease L5-S1/chronic low back pain
Carotid artery disease
Anxiety
Peripheral vascular disease- asymptomatic severe left internal
arotid artery disease.
Discharge Condition:
Stable, afebrile, back on home BP meds with stable BP
Discharge Instructions:
You were admitted for elective carotid artery stenting. A stent
was placed into your left internal carotis artery. you have to
continue taking plavix and aspirin until advised otherwise by
your doctor.
Please call your doctor or come to emergancy department if you
experience any neurological signs or symptoms.
Followup Instructions:
Cardiology:
Follow up with Dr. [**First Name (STitle) **] and [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 3100**]. On [**2123-7-27**]
and 9:30am. The office there can be reached at: [**Telephone/Fax (1) 62**].
Completed by:[**2123-6-29**]
|
[
"V70.7",
"V45.82",
"272.4",
"433.10",
"300.4",
"414.01",
"412",
"443.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"00.63",
"00.40",
"00.45",
"00.61",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
8406, 8412
|
6220, 7307
|
365, 444
|
8876, 8932
|
3718, 3723
|
9293, 9549
|
2667, 2745
|
7664, 8383
|
8433, 8855
|
7333, 7641
|
5935, 6197
|
8956, 9270
|
2760, 3699
|
277, 327
|
4018, 5918
|
472, 1576
|
3737, 3999
|
1598, 2467
|
2483, 2651
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,791
| 190,668
|
7438
|
Discharge summary
|
report
|
Admission Date: [**2135-10-20**] Discharge Date: [**2135-10-26**]
Date of Birth: [**2075-2-18**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Aspirin
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
R knee pain
Major Surgical or Invasive Procedure:
[**2135-10-20**]: R TKA
History of Present Illness:
HPI: The patient is a 60 yo F with long-standing history of R
knee pain, limited ROM and difficulties with activities of daily
living. The patient has met the clinical and radiographic
indications for joint arthroplasty and wished to proceed with
the above procedure. Prior to admission the patient has been
feeling well with no recent illness, no shortness of breath, no
chest pain and has been cleared medically for the surgical
procedure.
Past Medical History:
PMH: HTN, depression/anxiety, obesity (BMI 50), OSA
PSH: S/P L TKA [**2133**]. [**2132-10-23**] rotator cuff surgery
Social History:
She is of Polish origin, not working formally,
employed as a teacher, does not smoke, has not smoked in the
past, and does not drink.
Family History:
NC
Physical Exam:
comfortable, NAD
left knee demonstrates full extension to 0 of the left
knee, flexion to 135. Well healed incision. Her right knee
demonstrates a varus
alignment, extension to about 10 degrees, flexion to 90 degrees.
Pertinent Results:
none
Brief Hospital Course:
The patient was admitted and taken to the operating room by Dr.
[**First Name (STitle) **] where the patient underwent R TKA. The procedure was well
tolerated and there were no complications. Please see the
separately dictated operative report for details regarding the
surgery. The patient was subsequently transferred to the
post-anesthesia care unit in stable condition and transferred to
the floor later that day.
Overnight, the patient was placed on a PCA for pain control. IV
antibiotics were continued for 24 hours postoperatively for
prophylaxis.
The patient was placed in a CPM machine.
On postoperative day 1, Lovenox was started for DVT prophylaxis.
The patient was weaned off of the PCA onto oral pain
medications.
On postoperative day 2, the Foley catheter was removed without
incident. The surgical dressing was also removed, and the
surgical incision was found to be clean, dry, and intact without
erythema or purulent drainage.
During the hospital course the patient was seen daily by
physical therapy. Labs were checked both post-operatively and
throughout the hospital course and repleted accordingly.
On POD 3, she was noted to be somewhat somnolent and found to
have some swelling in her right leg. Her narcotics were
discontinued, and she received narcan which she responded well
to. She was sent for a lower ext doppler which was found to be
negative for DVT. That night, her urine output decreased and her
hct was 25, so she was given 2u PRBCs. She was also found to
have elevated creatinine.
On POD 4, she had persistent hypotension, and both medicine and
renal consults were obtained to address her acute renal failure,
her hypotension, and her mild confusion. Despite agressive
rehydration efforts, her SBP did not seem to respond, and
continued to be in the 70s/40s. As such, in discussion with the
consulting teams, she was transferred to the MICU for SBP
monitoring and for her ARF.
She received several liters of fluid that night, in addition to
1uPRBCs.
By POD 5, her blood pressure responded well to the 130s, her
creatinine had come down significantly, and she was making plent
of urine. She was called out to the floor from the MICU.
POD 6 she continued to do well, her urine output had improved
significantly and her creatinine was down to 0.9. Her blood
pressuree was running in the 120s. Her electrolytes were
repleted and foley was removed without incident.
The patient was discharged to inpatient rehab in stable
condition with written follow up instructions and detailed
precautionary guidance.
Medications on Admission:
Amitriptyline 75',Aripiprazole 5', Gabapentin 800''', Lisinopril
5', Trospium *NF* 60', oxycontin 20, percocet, Sertraline 100'
allergies: none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous once a day for 3 weeks.
3. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. Amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
9. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Trospium 60 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO qam ().
14. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 7168**]
Discharge Diagnosis:
R knee OA
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr. [**First Name (STitle) **], your primary care physician or report to
the ER if you have any nausea, vomiting, fever greater than
101.5, chest pain, shortness of breath, increased
pain/redness/drainage from your incision site,
numbness/tingling, or any other concerning symptoms. Also,
please notify your primary care physician of your recent
admission.
Take all medications as prescribed and resume home medications,
please take a stool softener if taking narcotic pain
medications, please taper down pain medication use as tolerated.
No driving nor operating heavy machinery while using narcotic
pain medications.
ANTICOAGULATION: Continue to take Lovenox shots for 21 days
after the date of surgery.
WOUND CARE: Keep your incision clean and dry. You can shower but
should not tub-bath or submerge your incision. Please place a
dry sterile dressing to the wound each day if there is drainage,
otherwise you can leave it open to air. If [**First Name (STitle) 27269**], nursing
should remove staples 14 days after surgery and place ?????? inch
uncut (long) steristrips over wound.
ACTIVITY FOR KNEE REPLACEMENTS: Weight bearing as tolerated.
VNA (after discharge to home): Home PT/OT, dressing changes as
instructed, and wound checks.
Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] PA in orthopedic clinic.
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2135-11-3**] 10:20
Physical Therapy:
WBAT RLE
Treatments Frequency:
wound checks, drsg [**Name5 (PTitle) **] if [**Name5 (PTitle) 27269**], PT
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 3996**] [**Last Name (NamePattern1) **], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2135-11-3**]
10:20
Completed by:[**2135-10-26**]
|
[
"401.9",
"458.9",
"327.23",
"V85.4",
"293.0",
"285.1",
"715.36",
"300.4",
"584.9",
"278.01",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.54"
] |
icd9pcs
|
[
[
[]
]
] |
5576, 5664
|
1391, 3940
|
296, 322
|
5718, 5727
|
1362, 1368
|
7338, 7536
|
1104, 1108
|
4135, 5553
|
5685, 5697
|
3966, 4112
|
5751, 6473
|
1123, 1343
|
7208, 7217
|
7239, 7315
|
245, 258
|
6485, 7190
|
350, 794
|
816, 936
|
952, 1088
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,239
| 124,212
|
26490
|
Discharge summary
|
report
|
Admission Date: [**2134-3-27**] Discharge Date: [**2134-4-2**]
Date of Birth: [**2069-3-26**] Sex: M
Service: MEDICINE
Allergies:
Ancef
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Colonoscopy
History of Present Illness:
64 y/o M with PMHx of Diastolic Heart Failure, OSA/Pulm HTN,
Severe COPD on home O2, Afib s/p AV-junction ablation and PCM
placement who presents with DOE and BRBPR. Pt first noted dark
stools 4 days PTA that he attributed to iron pills. However, his
BMs became loose, approx 2-3 episodes per day and he was taking
decreased po in an effort to decrease the diarrhea. On thursday
morning, he noticed BRB in his stool and underwear. His last
bloody BM was 3:30am today and his wife convinced him to go the
[**Name (NI) **] this afternoon.
.
In the ED, initial VS were: T 97.4 P 78 BP 101/46 R 18 Sats O2
97% on 6L sat. Initial labs revealed a hct of 13 and INR>21. Pt
had bright red blood on stool guiac and GI was consulted. Pt
received Vitamin K 10mg IV, Protonix 40mg IV, 1u FFP and had a
foley placed. Pt was placed on a NRB for femoral line placement
and first unit of prbcs was being transfused on transfer to
unit.
.
Pt was doing well on arrival, denying CP, nausea, abd pain, SOB.
He did report some orthostatic symptoms and DOE prior to
admission. He denied any emesis or hematemesis, though
developped some nausea after getting oral care in the unit.
Past Medical History:
s/p AV junction ablation & PCM
CHF (diastolic dysfxn) EF >55%.
Chronic bronchitis on 3L home O2 at all times (FEV1 58 %
predicted with ratio 112%)
Home OSA BiPAP settings are 18 and 11
HTN
Obesity
Severe Pulm HTN
CRI-baseline creat 1.3-1.8
Social History:
He is married and lives with wife. [**Name (NI) **] smoked 2 PPD x35 years and
quit 15 years ago. He drinks 1-2 beers/week. He worked full-time
as quality engineer(mechanical engineer) wearing oxygen to work,
has not worked since his hospitalization in [**Month (only) 205**].
Family History:
Father has DM, no heart disease in family, only his brother has
HTN.
Physical Exam:
Vitals: T: 96 BP: 101/43 P: 75 R:22 Sats 100% on 4L NC
General: Alert, oriented, pale but no acute distress
HEENT: Sclera anicteric, MM dry
Neck: supple, no LAD
Lungs: CTA lateral bases, no appreciable wheezes, rales, ronchi
CV: RRR, soft gr 2 SEM best heard over LUSB, no gallop
Abdomen: soft/obese, decreased bowel sounds, no rebound
tenderness or guarding, fluid wave present
Ext: chronic severe lower extremity edema +3 bilaterally &
venous stasis changes.
Pertinent Results:
[**2134-3-27**] 11:45PM HCT-15.7*
[**2134-3-27**] 11:45PM PT-25.9* PTT-40.5* INR(PT)-2.6*
[**2134-3-27**] 09:46PM HCT-14.9*
[**2134-3-27**] 06:50PM HCT-13.3*
[**2134-3-27**] 06:46PM PT-36.2* PTT-42.2* INR(PT)-3.8*
[**2134-3-27**] 01:05PM HGB-4.4* calcHCT-13
[**2134-3-27**] 12:20PM PT-150* PTT-55.3* INR(PT)->21.8*
[**2134-3-27**] 12:00PM GLUCOSE-130* UREA N-80* CREAT-2.3* SODIUM-143
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-19
[**2134-3-27**] 12:00PM estGFR-Using this
[**2134-3-27**] 12:00PM ALT(SGPT)-8 AST(SGOT)-14 ALK PHOS-82 TOT
BILI-0.5
[**2134-3-27**] 12:00PM LIPASE-86*
[**2134-3-27**] 12:00PM IRON-15*
[**2134-3-27**] 12:00PM calTIBC-295 FERRITIN-119 TRF-227
[**2134-3-27**] 12:00PM WBC-8.2# RBC-1.52*# HGB-4.1*# HCT-13.4*#
MCV-88 MCH-26.7* MCHC-30.3* RDW-24.1*
[**2134-3-27**] 12:00PM NEUTS-77.2* LYMPHS-18.3 MONOS-3.2 EOS-0.9
BASOS-0.4
[**2134-3-27**] 12:00PM PLT COUNT-207
[**2134-3-28**]
Erythema and ulceration in the gastroesophageal junction.
Erythema with a clean based ulceration with no bleeding, visible
vessel, or overlying clot was noted in the gastroesophageal
junction in the cardia. Erythema and erosion in the antrum
compatible with erosive gastritis. Otherwise normal EGD to
second part of the duodenum.
Brief Hospital Course:
Patient expired at 9:15 p.m. on [**2134-4-2**]. The day of [**2134-4-2**] was
eventful for a cardiac arrest around 10 a.m. with subsequent
ressucitation. Patient was intubated and hypotensive, requiring
three vasopressors, likely secondary to sepsis. Over the course
of the evening, he had multiple episodes of NSVT with
resolution. Around 9 p.m., he had another episode of VT that
was torsades de pointes in morphology. This degenerated into
VF. The patient expired shortly afterward. His family came to
the bedside at the time of torsades initiation. They declined
an autopsy.
The below represents a summary of the [**Hospital 228**] hospital course
prior to transfer to the [**Hospital Unit Name 153**]:
Assessment
64 y/o M with PMHx of Severe COPD, Diastolic Dysfunction and AVJ
ablation s/p PCM who presents with BRBPP, Hct of 13 and
supratherapeutic INR at 21.
.
# GI Bleed: Pt received 10 units of PRBCs and 5 units of FFP on
the 1st two days of presentation and had an inappropriate
increase in HCT from 13 to 24. Pt started on Octreotide
ggt/Protonix gtt per GI and treated with Cipro as empiric
therapy in the setting of GI bleed. Pt's coagulopathy improved
to 1.8 (also received Vitamin K 5mg PO for 3 days). EGD
revealed clean-based ulceration and evidence of gastritis but no
active source of bleeding. Ciprofloxacin was discontinued. Pt's
HCT remained stable after EGD but continued to have dark black
stools. Pt was prepped overnight on [**3-29**] for colonoscopy but
continued to have dark black stools. However, colonscopy was not
performed as anaesthsiologist was not available. Patient
continued to prep for the colonscopy, however this was
complicated by marked worsening of ascites and peripheral edema.
Given that patients hematocrit had remained stable and the
patient's volume overloaded state, the colonscopy was deferred
to a future date. His hematocrit remained stable...
.
# Coagulopathy: Pt on coumadin for atrial fibrillation. INR
improved from 21.8 to 1.8 after 5 units of FFP and vitamin K 5mg
PO for 3 days.
.
# Cirrhosis: Pt with cirrhosis, ascites, splenomegaly & portal
HTN seen on RUQ U/S performed in [**10-19**], pt appeared to be unaware
of this diagnosis. Pt did not have evidence of varices on EGD.
Hepatitis serologies were sent and were negative. [**Doctor First Name **] was
negative.Alpha-1 antitrypsin is pending at time of discharge.
With volumes resuscitation and bowel preparation, patient had
noteably worsening ascites and edema. He underwent large
volume....
# Diastolic Dysfunction: Pt was given lasix in between blood
products but was not aggressively diuresed given his significant
GI bleed. Home BP medications were held in the setting of
severe GI bleed.
.
# ARF: Likely pre-renal in etiology, hypovolemia secondary to
severe GI bleed. Initial Cr 2.7 but improved to baseline of 1.9
with aggressive resuscitation.
.
# FEN: NPO for colonoscopy.
.
# Prophylaxis: Pneumoboots, supratherapeutic INR, PPI
.
# Access: 2 PIVs
.
# Code: FULL CODE
.
# Communication: Patient and wife
.
Medications on Admission:
Coumadin as directed (1mg on wkds, 1.5 M-Th)
Diltiazem 120mg daily
Flovent [**Hospital1 **]
Lasix 80mg [**Hospital1 **]
Metoprolol 100mg daily
Spiriva daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2134-4-2**]
|
[
"E934.2",
"V46.2",
"560.1",
"E946.3",
"V15.82",
"E935.9",
"427.5",
"530.20",
"427.31",
"491.20",
"578.1",
"458.0",
"535.40",
"790.92",
"428.32",
"427.41",
"532.90",
"V45.01",
"416.8",
"427.1",
"584.5",
"038.9",
"428.0",
"327.23",
"785.52",
"571.5",
"285.1",
"572.3",
"789.59",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.71",
"45.13",
"96.04",
"38.91",
"38.93",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
7259, 7268
|
3967, 7023
|
292, 332
|
7315, 7320
|
2667, 3944
|
7372, 7405
|
2098, 2169
|
7231, 7236
|
7289, 7294
|
7049, 7208
|
7344, 7349
|
2184, 2648
|
225, 254
|
360, 1525
|
1547, 1788
|
1804, 2082
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,174
| 101,751
|
10478
|
Discharge summary
|
report
|
Admission Date: [**2180-5-3**] Discharge Date: [**2180-5-6**]
Date of Birth: [**2134-6-21**] Sex: M
Service: CTS
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 34589**] is a
45-year-old male with a past medical history remarkable for
chronic relapsing pericarditis secondary to severe variant
rheumatoid arthritis.
The patient has been experiencing severe pleuritic chest pain
which had been controlled on 10 mg of prednisone; however,
this had recently increased to 20 mg to control these
recurrent flares.
Since the symptoms stemming from the relapsing pericarditis
has required the use of prednisone while other symptoms such
as aching in the hands and feet have been well controlled on
colchicine and methotrexate, the Cardiothoracic Surgery
Service was consulted to evaluate this patient for
pericardiectomy.
PAST MEDICAL HISTORY:
1. Severe variant rheumatoid arthritis.
2. Gastritis.
3. History of Helicobacter pylori.
4. Status post back surgery.
MEDICATIONS ON ADMISSION: (Medications at home included)
1. Prednisone 7.5 mg p.o. once per day.
2. Methotrexate 15 mg p.o. every week.
3. Colchicine 0.6 mg p.o. twice per day
4. Duragesic patch 50 as needed.
5. OxyContin 40 mg p.o. four times per day as needed (for
pain).
6. Centrum.
7. Nexium.
8. Stool softeners.
ALLERGIES:
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratories as of [**2180-5-5**] revealed white blood cell
count was 10.5, hematocrit was 30.8, and platelets were 175.
Sodium was 143, potassium was 4.4, chloride was 107,
bicarbonate was 27, blood urea nitrogen was 11, creatinine
was 0.7, and blood glucose was 120. Magnesium was 2.3.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs with a temperature of 99.2, heart rate
was 80 (sinus), blood pressure was 140/72, respiratory rate
was 18, and oxygen saturation was 96% on room air. The
patient is a well-developed and well-nourished male in no
apparent distress. Sclerae were anicteric. Mucous membranes
were moist. No evidence of oral ulcers. No evidence of
cervical lymphadenopathy. Cranial nerves II through XII were
intact. The chest was clear to auscultation bilaterally.
The sternal dressing was intact. No evidence of extending
erythema. No serosanguineous drainage was noted. The
sternum showed no signs of click to palpation.
Cardiovascular examination revealed a regular rate and
rhythm. No murmurs, no rubs, and no click noted. The
abdomen was soft, nontender, and nondistended. Positive
bowel sounds. No evidence of inguinal lymphadenopathy. No
hepatosplenomegaly was noted. Extremity examination revealed
no evidence of edema. No rash was noted.
HOSPITAL COURSE: The patient is a 45-year-old male with a
long history of severe variant rheumatoid arthritis who
underwent a subtotal pericardiectomy for recurrent
pericarditis.
The patient's intraoperative course as well as postoperative
course were uncomplicated. The patient was taken to the
Cardiothoracic Surgery Recovery Unit immediately
postoperatively for close monitoring. The patient was
promptly extubated. The patient maintained good oxygen
saturations status post extubation and remained in a normal
sinus rhythm while maintaining good pressure without any
pressors.
By postoperative day two, the patient's condition continued
to advance; demonstrating ambulation greater than five
minutes without evidence of shortness of breath.
By postoperative day three, the patient achieved proper
physical therapy status criteria for discharge and the
decision was made to discharge the patient in good condition
from the hospital without services.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES: Status post subtotal pericardiectomy.
MEDICATIONS ON DISCHARGE:
1. Prednisone 7.5 mg p.o. once per day.
2. Aspirin 325 mg p.o. once per day.
3. Metoprolol 25 mg p.o. twice per day.
4. Fentanyl patch.
5. Oxycodone 80 mg p.o. twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was requested to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in four weeks after discharge.
2. The patient was to follow up with Dr. [**Last Name (STitle) 19634**] in one to
two weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 11079**]
MEDQUIST36
D: [**2180-5-5**]
T: [**2180-5-5**] 15:45
JOB#: [**Job Number 34590**]
cc:[**Numeric Identifier 34591**]
|
[
"714.30",
"423.8",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31"
] |
icd9pcs
|
[
[
[]
]
] |
3814, 3853
|
3879, 4060
|
1037, 2721
|
2740, 3693
|
4093, 4629
|
3708, 3792
|
163, 865
|
887, 1010
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,052
| 130,339
|
7861
|
Discharge summary
|
report
|
Admission Date: [**2152-1-7**] Discharge Date: [**2152-1-24**]
Date of Birth: [**2071-9-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
unremitting chest pain and abd pain out-of-proportion to exam
Major Surgical or Invasive Procedure:
. Exploratory laparotomy.
2. Small intestinal resection
History of Present Illness:
This was an 80-year-old man who
entered the hospital with a 1-day history of abdominal
discomfort. He had a known history of chronic bilateral chest
discomfort of which he also complained. He underwent an
initial CT scan of the abdomen which demonstrated a small
amount of free fluid, but no other obvious abnormality. It
was suggested that he had a larger amount of small intestine
than expected lateral to the ascending colon, potentially
suggestive of an internal hernia. The initial CT scan was
done without oral contrast. It had been performed in the
context of a CT angio of the chest to rule out aortic
dissection or embolus. His initial lactate was 1.1. A few
hours later while being observed, he complained of increased
pain. The lactate was found to be 4.8. A repeat CT scan with
contrast now showed an increased amount of free abdominal
fluid. He appeared to have an area of small bowel which was
somewhat dilated and thickened. Although his feeding vessels
were normal, the possibility of ischemic colitis, perhaps on
a mechanical basis such as a volvulus or internal hernia,
could not be discounted. Exploratory laparotomy was suggested
to the family and accepted by them.
Past Medical History:
headache, cerebellar CVA (ataxia), BPH, HTN, GERD, left foot
pain
Physical Exam:
NAD AOx3
CTA b/l
RRR
soft, mildly tender mildy distended hypoactive bowel sounds
no c/c/e
Pertinent Results:
[**2152-1-7**] 01:25PM BLOOD WBC-7.3# RBC-4.02* Hgb-13.4* Hct-37.9*
MCV-94 MCH-33.3* MCHC-35.3* RDW-13.4 Plt Ct-155
[**2152-1-9**] 03:17AM BLOOD WBC-4.6 RBC-2.93* Hgb-9.7* Hct-28.0*
MCV-96 MCH-33.1* MCHC-34.6 RDW-13.5 Plt Ct-116*
[**2152-1-11**] 04:50AM BLOOD WBC-4.6 RBC-2.78* Hgb-9.2* Hct-27.0*
MCV-97 MCH-33.0* MCHC-34.0 RDW-13.3 Plt Ct-125*
[**2152-1-18**] 02:57AM BLOOD WBC-6.0 RBC-2.51* Hgb-7.9* Hct-24.3*
MCV-97 MCH-31.5 MCHC-32.4 RDW-13.7 Plt Ct-204
[**2152-1-20**] 06:41PM BLOOD WBC-5.6 RBC-3.00* Hgb-9.5* Hct-27.9*
MCV-93 MCH-31.6 MCHC-33.9 RDW-15.1 Plt Ct-205
[**2152-1-22**] 03:45AM BLOOD Hct-30.8*
[**2152-1-7**] 01:25PM BLOOD PT-11.5 PTT-24.8 INR(PT)-1.0
[**2152-1-17**] 05:16AM BLOOD PT-12.0 PTT-73.3* INR(PT)-1.0
[**2152-1-19**] 05:50AM BLOOD PT-15.8* PTT-51.9* INR(PT)-1.4*
[**2152-1-20**] 02:50PM BLOOD PT-29.8* PTT-105.4* INR(PT)-3.1*
[**2152-1-24**] 05:00AM BLOOD PT-27.7* INR(PT)-2.9*
[**2152-1-7**] 01:25PM BLOOD Glucose-144* UreaN-19 Creat-0.9 Na-137
K-5.0 Cl-102 HCO3-25 AnGap-15
[**2152-1-11**] 04:50AM BLOOD Glucose-86 UreaN-19 Creat-0.6 Na-140
K-4.1 Cl-107 HCO3-27 AnGap-10
[**2152-1-18**] 02:57AM BLOOD Glucose-112* UreaN-20 Creat-0.6 Na-134
K-4.4 Cl-105 HCO3-27 AnGap-6*
[**2152-1-7**] 01:25PM BLOOD ALT-16 AST-22 CK(CPK)-56 AlkPhos-47
Amylase-126* TotBili-0.7
[**2152-1-7**] 01:25PM BLOOD Albumin-4.1 Calcium-9.8 Phos-1.2*# Mg-1.9
[**2152-1-13**] 11:30AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.6
[**2152-1-18**] 02:57AM BLOOD Calcium-7.9* Phos-3.3 Mg-2.0
[**2152-1-17**] 05:16AM BLOOD calTIBC-163* TRF-125*
[**2152-1-14**] 06:25AM BLOOD Triglyc-89
[**2152-1-7**] 04:57PM BLOOD Glucose-122* Lactate-0.9 K-4.2
[**2152-1-8**] 02:48AM BLOOD Lactate-3.6*
[**2152-1-8**] 05:46AM BLOOD freeCa-1.25
[**2152-1-16**] 03:48PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2152-1-16**] 03:48PM URINE RBC-0-2 WBC-0 Bacteri-FEW Yeast-NONE
Epi-0
CTA ABD W&W/O C & RECONS [**2152-1-7**] 1:57 PM
CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS
Reason: eval aorta
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with unremitting CP/ab pain
REASON FOR THIS EXAMINATION:
eval aorta
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Unremitting chest pain and abdominal pain, please
evaluate the aorta.
COMPARISON: [**2147-9-3**].
TECHNIQUE: CT angiogram of the chest, abdomen and pelvis to
evaluate for aortic dissection was reviewed. Multiplanar CT
reformations were obtained and reviewed.
CT CHEST WITH CONTRAST: There is no evidence for dissection. The
heart and great vessels of the mediastinum are unremarkable. The
lungs are clear. The pleura are normal. The soft tissues are
unremarkable. The thoracic aorta is calcified secondary to
atherosclerotic disease. The bronchi are patent to the
subsegmental level.
CT ABDOMEN WITH CONTRAST: There is an abnormal edematous loop of
small bowel in the right mid/upper quadrant with associated
edematous mesentery. There is also some trace free fluid in this
area. This abnormal loop of bowel lies lateral to the ascending
colon, and its superior mesenteric artery feeding branch has a
stretched appearance. This finding may represent internal small
bowel hernia. The remainder of the small bowel appears normal.
The liver, pancreas, spleen, and adrenal glands are normal. The
nephrograms are normal, but the expiratory state cannot be
evaluated. There is nonspecific non- pathologically enlarged
lymphadenopathy.
CT PELVIS WITH CONTRAST: Rectum, sigmoid colon, and large bowel
are unremarkable. The descending colon lies medial to the
abnormal loop of small bowel. There is no free fluid in the
pelvis. The prostate is enlarged. The bladder is normal. There
is no lymphadenopathy.
BONE WINDOWS: There is no evidence for fracture. Soft tissues
are unremarkable.
CT REFORMATIONS: The reformations again demonstrate no
dissection but an abnormal small bowel loop in the right
mid/upper quadrant.
IMPRESSION:
1. Abnormal edematous small bowel loop within the right
mid/upper quadrant susspicious for internal hernia with edema
(R/O strangulation - closed loop obstruction or volvulous)
Surgical consult is recommended. These findings were discussed
with Dr. [**Last Name (STitle) **] at the time of the study.
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: SMALL BOWEL.
Procedure date Tissue received Report Date Diagnosed
by
[**2152-1-7**] [**2152-1-8**] [**2152-1-12**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/stu
Previous biopsies: [**-4/2352**] ANAL POLYP.
[**-1/4138**] GI BX/da/ah.
DIAGNOSIS:
Small bowel segment:
Acute transmural hemorrhagic infarction of intestine and
adjacent mesentery.
There is mucosal infarction in the 3.5 cm margin.
The 3.0 cm margin shows no ischemic change.
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2152-1-16**] 11:00 PM
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: r/o PE.
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
80 year old man POD 9 SB resection, fever, received CT Abdomen
today on which there was a concern for possible PE.
REASON FOR THIS EXAMINATION:
r/o PE.
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 80-year-old man postop day 9, status post small bowel
resection, fever, received CT abdomen today where there was a
concern of PE.
COMPARISON: [**2152-1-7**] chest CTA and [**2152-1-16**]
abdominal CT.
TECHNIQUE: Multidetector axial images of the chest were obtained
without and with IV contrast. 100 cc Optiray. Multiplanar
reformatted images were obtained.
CT CHEST WITHOUT AND WITH IV CONTRAST: A filling defect is
observed in a left lower lobe subsegmental pulmonary artery and
extending into three of the branches consistent with pulmonary
embolism. No other pulmonary emboli are observed. The heart,
pericardium, and great vessels are stable, with coronary and
aortic calcifications again noted. Prominent mediastinal lymph
nodes are stable in appearance and calcifications are seen in
some of the nodes. There is no hilar or axillary
lymphadenopathy. There are small bilateral pleural effusions.
Associated dependent and bibasilar atelectasis is observed. The
visualized portions of the upper abdomen are stable. Hepatic
calcifications are identified. Vicarious excretion of contrast
is observed in the gallbladder.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. Subsegmental left lower lobe pulmonary embolism.
2. Small bilateral pleural effusions.
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2152-1-16**] 6:43 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: FEVER
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
80 year old man POD 9 from SB resection for infarction due to
volvulus. new fever to 102, wound erythema.
REASON FOR THIS EXAMINATION:
r/o intraperitoneal abscess.
CONTRAINDICATIONS for IV CONTRAST: None.
CT OF THE ABDOMEN
CLINICAL INDICATION: 80-year-old man with prior small bowel
resection for infarction due to volvulus. New fever to 102.
Wound erythema. Rule out intraperitoneal abscess.
COMPARISON: CT from [**2152-1-7**], is available for
comparison.
TECHNIQUE: Multidetector CT of the abdomen and pelvis was
performed from the base of the lungs to the symphysis pubis
after administration of oral contrast and 100 cc of Optiray.
RECONSTRUCTIONS: Multiplanar reformations including sagittal and
coronal reconstructions were performed in a 3D workstation and
were essential in evaluating the findings.
FINDINGS:
CT ABDOMEN: Visualized portions of the lung bases demonstrate
filling defects in segmental branches of the left lower lobe
pulmonary arteries. This is consistent with pulmonary embolism.
There are small bilateral pleural effusions. The liver is
homogeneous without focal lesions. A small hypodense area in the
upper aspect of the right lower lobe may represent segmental
biliary dilatation at this level. Spleen, pancreas, adrenal
glands, and extrahepatic biliary tree is normal. There is mild
distention of the gallbladder without gallbladder wall edema or
pericholecystic fluid. Small hypodensities are noted in the
right kidney likely representing cysts. The kidneys enhance
symmetrically and excrete contrast normally. There is no
evidence for hydronephrosis. There are no enlarged lymph nodes
in the abdomen. There is marked distention of the stomach
without dilatation of the proximal small bowel.
There is a small hiatal hernia status post laparotomy. There are
surgical changes in the anterior abdominal wall without fluid
collection.
CT PELVIS: The distal portion of the ureters are not well
opacified. There is no significant abnormality at this level.
The bladder is collapsed with a Foley catheter inside. Extensive
stool in the rectum and sigmoid colon. Contrast reached the
right colon. The visualized portion of the small bowel in the
abdomen and pelvis are normal. There is a small-to-moderate
amount of free fluid in the abdomen.
CT BONES: No lytic or sclerotic lesions are noted in the bones.
IMPRESSION:
1. Pulmonary embolism in the left lower lobe. A dedicated chest
CTA is recommended for further assessment of this finding.
2. Small bilateral pleural effusions and bibasilar atelectasis.
3. Mild-to-moderate amount of free fluid in the abdomen without
evidence for organized fluid collection.
4. No evidence for small-bowel obstruction or abnormal loops of
small bowel.
5. Marked distention of the stomach without dilatation of the
duodenum. This may represent gastroparesis. Clinical correlation
is recommended. Small hiatal hernia.
These findings were discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14135**] on [**1-16**] at 9 p.m.
BILAT LOWER EXT VEINS [**2152-1-17**] 3:44 PM
BILAT LOWER EXT VEINS
Reason: ? clot
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with LLL PE
REASON FOR THIS EXAMINATION:
? clot
DUPLEX ULTRASOUND OF BOTH LOWER EXTREMITIES.
INDICATION: Patient with lower lobe pulmonary embolism.
TECHNIQUE: Grayscale, color flow and pulse wave Doppler
insonation of the deep vessels of both lower extremities was
performed using dynamic compression maneuvers where appropriate.
COMPARISON: None. Reference is made to recent chest examination.
REPORT:
There is normal compressibility, augmentation, and respiratory
variation within the deep veins of both lower extremities. There
is no evidence of lower limb DVT. Significant arterial
calcification is noted in the common femoral arteries.
CONCLUSION:
Negative DVT study bilaterally.
Brief Hospital Course:
Patient was taken to the operating as described above, where
they found a volvulus of the small bowel requiring resection.
Patient was extubated in the OR, and taken to the recovery room
and then to the intensive care until for further monitoring
post-operatively. Patient's respiratory status was good and made
a quick recovery. Patient did well and was transferred to the
floor on POD2, still with an NGT and central line. NGT was dc'd
on POD4, and POD5 patient was started on clears. Physical
therapy worked with the patient and determined that the patient
could go home with services and home PT.
Patient was still experiences some abdominal pain and was
distended, so was made NO again on POD6 and started on TPN.
Awaited bowel function to return and continued course allowing
patient sips to drink for the next few days. Patient had an NGT
placed for 1 day with decent outpu on POD8 for an
ileus/increasing distension. Pateint had CT of abdomen on POD9
which showed a possible PE prompting a formal CTA chest showing
subsegmental LLL PEs. Also spiked a fever and noticed some
erythema by the incision and was started on kefzol. lower
extremity ultrasounds were negative for dvts. Patient was
immediately started on a heparin drip and made therapeutic.
Levoquin was then added after the inferior part of the wound
was opened for pus. Patient was started back on clears POD11 and
then advanced to regular diet on POD12. Patient then started
having multiple BMs, but had 3 negative C diff cultures.
Antibiotics were dc'd on POD14 after all final cultures were
negative for growth. Patient was started on coumadin on POD14,
and was therapeutic shortly thereafter and heparin was stopped.
Patient failed 3 voiding trials, so kept foley in until POD16,
when he finally voided with it out. All home meds were
restarted.
patient was discharged on POD17 in good condition with home VNA
for PT, dressing change, and INR checks which will be phoned to
his PCPs ofice. Patient will follow up with Dr [**Last Name (STitle) 519**] in 3 weeks
and has an appointment.
Medications on Admission:
Protonix, enalapril 5, ASA 81, Cardura 4, Celexa 20, Lumigan
0.03% [**Hospital1 **], timolol 0.5% [**Hospital1 **]
Discharge Medications:
1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
2. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic qHS ().
3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H
(Every 3 to 4 Hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
small bowel volvulus
Discharge Condition:
good
Discharge Instructions:
please seek medical attention if you expereience fever > 101.5,
severe nausea, vomitting, pain
no driving while on narcotic pain meds
may shower
need to have INR checked biweekly. have the VNA call Dr. [**Name (NI) 28326**] office with the results
Followup Instructions:
please folow up with Dr. [**Last Name (STitle) 519**] in clinic on [**2-14**] @ 9:45am.
Call ([**Telephone/Fax (1) 5323**] with any questions.
please follow up with Dr. [**Last Name (STitle) **] for INR check and also an
appointment in about 10 days. Her office will call you with a
time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2152-1-24**]
|
[
"998.59",
"415.11",
"600.90",
"557.0",
"560.2",
"401.9",
"997.4",
"560.39",
"438.84",
"530.81",
"560.1",
"682.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.62",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
15860, 15935
|
12547, 14607
|
338, 396
|
16000, 16007
|
1826, 3884
|
16309, 16758
|
14773, 15837
|
11815, 11843
|
15956, 15979
|
14633, 14749
|
16032, 16285
|
1716, 1807
|
237, 300
|
11872, 12524
|
424, 1612
|
1634, 1701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,146
| 181,745
|
51346
|
Discharge summary
|
report
|
Admission Date: [**2134-6-30**] Discharge Date: [**2134-7-7**]
Date of Birth: [**2065-5-31**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines / Penicillins
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 69 yo woman with metastatic gastric ca recently discharged
with hospice care returns with c/o fistula at previous ostomy
site. Her daughter noticed yesterday at her [**Name (NI) 1501**] that she had an
area of drainage adjacent to her ostomy site that was draining.
In the ED was noted to be hypotensive (SBP 60's improved to 70's
s/p 9L IVF). Lactate 4.4. She had no specific complaints but
felt tired. Despite DNR/DNI status decided on IVF and
antibiotics. She was started on vanco 1gm iv and levofloxacin
500mg iv. Initial UA negative, CXR with stable left pleural
effusion, abdominal XR unremarkable. UOP 200cc. She was admitted
to [**Hospital Unit Name 153**] for further management. On arrival she c/o thirst and
chills in the ED but denied fevers, HA, SOB, CP, cough, nausea,
vomiting, diarrhea, constipation, melena, BRBPR, dysuria.
Past Medical History:
Oncologic history: dates back to [**9-/2133**], when she presented
with symptoms of early satiety, epigastric fullness and weight
loss. An EGD with biopsies performed at that time revealed
poorly differentiated gastric cancer with a small component of
signet ring cells, as well as chronic mildly active H. pylori
astritis. She was initially offered EUS with possible evaluation
for surgery, but opted to pursue a second opinion at the [**Hospital1 2025**].
There, she reportedly underwent an exploratory laparotomy in
[**11/2133**], and her malignancy was deemed unresectable. She
additionally underwent J-tube placement while at the [**Hospital1 2025**]. She
declined other modalities of therapy, and was mostly followed by
her primary care physician over the following months. She was
admitted to [**Hospital1 18**] [**3-31**] to [**4-2**] with abdominal fullness with
evidence of new ascites. On [**2133-4-1**], approximately 6L of yellow
ascitic fluid were removed, and cytology revealed malignant
cells consistent with non small cell carcinoma, thought to be
most likely related to her known history of gastric cancer. S/p
peritoneal port [**4-26**], s/p j-tube removal [**4-26**] with persistant
high output from jtube site and metabolic alkalosis, on TPN
however this was stopped on admit [**5-27**] at husband and patient's
request. Concern expressed that daughter pushing for TPN but not
wanted by patient (see discharge summary [**2134-5-27**]).
.
Past Medical History:
1. Unresectable metastatic signet cell gastric carcinoma, poorly
differentiated
2. Hyperlipidemia (she denies this is a problem)
3. H. pylori gastritis diagnosed [**9-/2133**], not treated.
4. Chronic fatigue and anxiety
5. s/p J-tube insertion [**11-25**], re-inserted by IR [**2134-4-28**]
6. Ostomy (non-correctable [**1-22**] wound healing)
Social History:
She is married and lives in [**Location **] with her husband
[**Name (NI) **]. She is of Ashkenazi [**Hospital1 **] descent, is Russian but
speaks English. She formally worked as an aesthetician. She
denies alcohol or tobacco use. She has one daughter [**Name (NI) **] and
four grandchildren.
Family History:
Colon cancer in her father, and her sister died of gastric
carcinoma. Mother with CAD.
Physical Exam:
Physical Exam on arrival to the floor:
VITALS: T 97, BP 72/48, HR 90, RR 20, Sat 99% 2l NC
GEN: ill appearing, thin, pale woman
HEENT: mm slightly dry, sclear anicteric, conjunctiva pale, op
clear
NECK: JVP 6cm, no lad
RESP: slighlty decreased BS L>R base, no w/r/r
CV: RRR. Normal S1, S2. No murmur/rubs/gallops
GI: mild tenderness to palpation with voluntary guarding without
rebound LLQ, j tube site draining feculant material with
adjacent medial fisutla also draining; +BS
EXT: 2+ PE to mid-calf, no cyanosis/clubbing
Pertinent Results:
[**2134-6-30**]
WBC-11.4* RBC-3.33* HGB-8.8* HCT-27.2* MCV-82 MCH-26.5*
MCHC-32.4 RDW-17.6*
NEUTS-79* BANDS-4 LYMPHS-8* MONOS-5 EOS-0 BASOS-0 METAS-4*
MYELOS-0
PLT COUNT-180#
PT-15.2* PTT-32.2 INR(PT)-1.4*
GLUCOSE-99 UREA N-45* CREAT-1.8*# SODIUM-133 POTASSIUM-4.4
CHLORIDE-85*
TOTAL CO2-38* ANION GAP-14
CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-2.4
LACTATE-4.4*
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-
NEG UROBILNGN-NEG PH-9.0* LEUK-NEG
.
AXR: Limited single abdominal radiograph with a gasless abdomen.
There is no definite evidence of small- bowel obstruction.
Intra-abdominal free air cannot be assessed on this radiograph
.
CXR: 1. No parenchymal opacification is noted to suggest
pneumonia.
2. Slight increase in left pleural effusion, decreased right
pleural effusion.
3. PICC line in good position.
Brief Hospital Course:
A/P: 69 yo woman with metastatic gastric cancer recently d/c'ed
with hospice returned for hypotension and sepsis with drainage
from old ostomy site. She was admitted to the [**Hospital Unit Name 153**] and had
aggressive fluid resuscitation. Her blood pressure remained in
the 80's to 90's systolic range. She was started on antibiotics
and antifungals. She did not receive pressors or surgical
intervention as these were not consistent with her wishes for
care. She had CT to evaluate her ostomy drainage which
confirmed enterocutaneous fistula. She was started on TPN as
requested by her family and, eventually, by the patient as well.
In the last three days of hospitalization she gradually began
to decline, with increasing oxygen requirement, poor urine
output, and worsening mental status. Palliative care and social
work were involved. Antibiotics and TPN were discontinued and
she was made comfortable. She passed away on [**2134-7-7**] in the
presence of her family.
Medications on Admission:
ativan 0.5-1mg prn
dilaudid 2mg iv prn
tylenol prn
benedryl prn
compazine prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"197.6",
"511.9",
"276.8",
"569.69",
"151.8",
"569.81",
"038.9",
"995.92",
"272.4",
"263.9",
"584.9",
"518.0",
"785.52",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6018, 6027
|
4873, 5861
|
299, 305
|
6074, 6079
|
4005, 4850
|
6131, 6137
|
3358, 3446
|
5990, 5995
|
6048, 6053
|
5887, 5967
|
6103, 6108
|
3461, 3986
|
248, 261
|
333, 1180
|
2683, 3030
|
3046, 3342
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,025
| 179,095
|
47235
|
Discharge summary
|
report
|
Admission Date: [**2200-6-13**] Discharge Date: [**2200-6-22**]
Date of Birth: [**2144-11-5**] Sex: F
Service: MEDICINE
Allergies:
Latex / lisinopril
Attending:[**First Name3 (LF) 87302**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Lumbar puncture
Thoracentesis
left breast wound drainage
History of Present Illness:
55 yo F with breast cancer, HTN, DM2, presents with dyspnea on
exertion, orthpnea, and lower extremity edema.
She says her symptoms started 2 weeks ago, even before her
breast surgery, which was on [**2200-6-4**]. At that time, she
underwent left needle-localized lumpectomy, sentinel node
biopsy, and low axillary dissection. During the last couple of
weeks, her dyspnea has worsened. It is worse with exertion and
with lying flat. She has also noticed lightheadedness and has
needed to steady herself when walking. She has had a cough,
productive of yellow sputum. No hemoptysis. +bilateral ankle
swelling.
Due to wheezing, she was treated with albuterol as an
outpatient, but that did not seem to help. The symptoms became
worse over the past couple of days, leading the patient to
present to the ED.
In the ED, initial VS were: T 98.0 BP 103/73 HR 112 RR 16 Sat
97%/RA. Bedside ultrasound showed significant bilateral pleural
effusion without pericardial effusion. The patient was given
levofloxacin and vancomycin due to concern for infection.
Subsequently CTA showed PE. She was guaiac negative, but head CT
showed an abnormality for which the differential included
subarachnoid hemorrhage, so heparin was not started. The patient
was given 500 cc of normal saline. On transfer to the [**Hospital Unit Name 153**],
vital signs were 97.5 120 24 128/75 100%/2L.
On arrival to the MICU, the patient stated that her breathing
was improved.
Past Medical History:
diabetes mellitus, type 2
breast cancer (see below)
vitamin D deficiency
HTN
hyperlipidemia
obesity
low vision
congenital syphilis
Oncologic history:
-Breast cancer, stage IIB
-[**12-16**] Mammogram/ultrasound: Mass in left upper outer quadrant.
Hypoechoic solid, irreg., spiculated 2.5x2.1x2.4cm. Left axilla
with multiple hypoechoic nodules consistent with lymph nodes,
largest 1.7cm and 3.4cm.
-Pathology: Poorly differentiated invasive ductal carcinoma
without definite in situ or lymphatic vascular invasion.
Immunohistochemistry showed a negative estrogen and progesterone
receptor HER2/neu was 2+.
-[**2200-1-15**]: CT chest/abd/pelvis neg for malignancy
-[**2200-1-31**] - [**2200-3-14**]: 4 cycles of Adriamycin and Cytoxan
-[**2200-3-28**], [**2200-4-4**] and [**2200-4-11**] Taxol 80mg/m2 and Herceptin
-[**5-2**] Taxol 175/m2, herceptin (cycle #3)
-[**2200-5-16**] taxol/175/m2, herceptin C4
Social History:
Has 8 children.
Tobacco: Quit [**2186**]
EtOH: Quit 22 year ago.
Drugs: Quit 22 years ago.
Family History:
Daughter with breast cancer. No family history of venous
thromboembolism.
Physical Exam:
ADMISSION EXAM:
Vitals: HR 115 BP 117/66 Sat 96%
General: Alert, oriented, no acute distress
HEENT: Left eye cloudy, with chronic visual loss, MMM,
oropharynx clear, EOMI
Neck: supple
CV: Tachycardic. Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Decreased breath sounds at bilateral bases
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, trace bilateral LE edema
Neuro: Right pupil round and reactive. Left eye opacified
(chronic). EOMI, with end-gaze nystagmus in all directions of
gaze. Facial movement full, 5/5 strength upper extremities,
lower extremity movement symmetric but did not stress calves due
to possibility of DVT.
DISCHARGE EXAM:
Vitals: 97.4, 98/68 (90-100/60-80s), 100, 20, 97% on RA
General: Alert, oriented, no acute distress
HEENT: Left eye with congenital lid lag, MMM, EOMI
Neck: Supple
Axilla: Left axilla with area of swelling at surgical site,
surrounding erythema and induration
CV: Tachycardic, no m/r/g
Lungs: Decreased breath sounds at bases b/l, otherwise clear
without wheezes
Abdomen: +BS, soft, non-distended, no tenderness
Ext: Warm, well perfused, no pedal edema
Neuro: Right pupil round and reactive. Left eye opacified
(chronic).
Pertinent Results:
ADMISSION LABS:
[**2200-6-13**] 03:30PM WBC-5.1 RBC-3.88* HGB-11.3* HCT-35.8* MCV-92
MCH-29.0 MCHC-31.5 RDW-16.3*
[**2200-6-13**] 03:30PM NEUTS-68.6 LYMPHS-22.1 MONOS-5.5 EOS-3.1
BASOS-0.6
[**2200-6-13**] 03:30PM PLT COUNT-305
[**2200-6-13**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2200-6-13**] 03:53PM LACTATE-1.5
[**2200-6-13**] 03:30PM GLUCOSE-97 UREA N-10 CREAT-0.9 SODIUM-139
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-21* ANION GAP-15
CARDIAC LABS:
[**2200-6-13**] 03:30PM CK(CPK)-72
[**2200-6-13**] 03:30PM cTropnT-0.04*
[**2200-6-13**] 03:30PM CK-MB-2
[**2200-6-14**] 12:06AM BLOOD CK-MB-2 cTropnT-0.04*
[**2200-6-14**] 05:22AM BLOOD CK-MB-2 cTropnT-0.03* proBNP-684*
[**2200-6-14**] 04:16PM BLOOD CK-MB-2 cTropnT-0.02*
BODILY FLUIDS:
[**2200-6-14**] 01:14PM PLEURAL WBC-450* RBC-3550* Polys-5* Lymphs-68*
Monos-15* Eos-1* Atyps-2* Meso-2* Other-7*
[**2200-6-14**] 01:14PM PLEURAL TotProt-1.8 Glucose-94 LD(LDH)-74
Cholest-17 Triglyc-8
[**2200-6-14**] 05:28PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-1
Lymphs-77 Monos-22
[**2200-6-14**] 05:28PM CEREBROSPINAL FLUID (CSF) TotProt-19 Glucose-65
LD(LDH)-16
Herpes simplex PCR: negative
DISCHARGE LABS:
[**2200-6-22**] 04:48AM BLOOD WBC-4.1 RBC-3.68* Hgb-10.3* Hct-33.3*
MCV-91 MCH-28.1 MCHC-31.1 RDW-15.7* Plt Ct-287
[**2200-6-22**] 04:48AM BLOOD Glucose-88 UreaN-8 Creat-0.8 Na-138 K-3.8
Cl-100 HCO3-30 AnGap-12
[**2200-6-22**] 04:48AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.0
MICROBIOLOGY:
[**2200-6-15**] BLOOD CULTURE -NO GROWTH
[**2200-6-14**] CSF
GRAM STAIN (Final [**2200-6-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2200-6-17**]): NO GROWTH.
FUNGAL CULTURE (Final [**2200-7-4**]): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
[**2200-6-14**] PLEURAL FLUID
GRAM STAIN (Final [**2200-6-14**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
FLUID CULTURE (Final [**2200-6-18**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2200-6-20**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2200-6-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2200-6-13**] BLOOD CULTURE - NO GROWTH.
IMAGING:
# [**2200-6-13**] CXRay:
IMPRESSION: Bilateral moderate pleural effusions with adjacent
bibasilar
atelectasis and mild pulmonary congestion. Pneumonia cannot be
entirely
excluded in the right clinical setting.
# [**2200-6-13**] CTA chest:
IMPRESSION:
1. Left lower lobe segmental pulmonary embolism without
evidence of right
heart strain or pulmonary infarction.
2. Interlobular septal thickening is concerning for fluid
overload. Given the lack of nodularity, carcinomatosis seems
much less likely, but is hard to completely excluded.
3. Moderate bilateral pleural effusions, larger on the right
than the left. In conjunction with the septal thickening, these
are most likely secondary to fluid overload from CHF, although
malignant effusions cannot be completely excluded.
4. Bibasilar consolidations are likely atelectasis, although in
the proper clinical setting, infection cannot be excluded.
5. Subcutaneous air in the left breast, possibly extending to
the skin.
These are likely postoperative changes. Recommend clinical
correlation,
however, with direct inspection of the operative site.
6. Left axillary seroma.
7. Trace pericardial effusion.
# [**6-13**] CT head:
Abnormal gyriform hyperdensity in the left frontal lobe of
uncertain etiology in the setting of prior intravenous contrast
administration, but the differential diagnosis includes abnormal
enhancement associated with
leptomeningeal carcinomatosis, possibly with a parenchymal mass
or edema;
although unlikely, it is not possible to exclude hemorrhage.
Recommend an MRI for further evaluation.
# [**6-14**] Echo:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is severe global
left ventricular hypokinesis (LVEF = 25-30 %). No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated
with borderline mild global free wall hypokinesis. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**1-6**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is a small to moderate sized
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: Cardiomyopathy. Pericardial effusion. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers.
# [**6-14**] MRI w and w/o contrast:
CONCLUSION: Left frontal and right parietal enhancing lesions
appear most
likely to be subacute infarction, with the right parietal lesion
more recentthan the left frontal.
# [**6-14**] CTA head:
No vascular abnormalities detected on the head CTA. Left
frontal
enhancement and left mastoid opacification appear unchanged.
# [**6-16**] CXR
IMPRESSION: Moderate left and trace right pleural effusion with
likely mild pulmonary edema.
# [**6-20**] Left axillary U/S:
FINDINGS:
A focused left axilla ultrasound was performed in the in the
region of
concern. Two heterogeneous complex collections, which appear to
communicate, are identified in the anterior left axilla. The
1st more superior and superficial collection in subdermal
location, measures 5 cm in transverse and 2 cm deep. This
collection demonstrates several persistent foci of low-level
back and forth flow. A 2nd more inferior collection measures 7
x 6.5 cm. No Doppler flow is seen in this 2nd collection. The
collections are far removed from the left axillary artery.
IMPRESSION:
Two, apparently communicating, 5 and 7 cm complex fluid
collections in the left axilla may represent hematomas although
infection cannot be excluded. Flow into the more superior
collection may be due to mobile fluid or slow continued bleeding
(felt less likely). A contrast CT may be useful to evaluate for
continued bleeding, if clinically warranted, but venous bleeding
can be difficult to assess.
Brief Hospital Course:
55 yo female with hx breast cancer, HTN, DM2, who presented with
dyspnea on exertion, orthopnea, and lower extremity edema found
to have a PE, bilateral pleural effusions, and pericardial
effusion with new systolic CHF.
ACTIVE ISSUES:
# PE: Pt presented with DOE, orthopnea and cough, likely due in
part to new diagnosis of pulmonary embolism. In the [**Name (NI) **], pt was
guaiac negative, but head CT showed an abnormality for which the
differential included subarachnoid hemorrhage, so initiation of
heparin was deferred and pt was transferred to the [**Hospital Unit Name 153**].
Neurology was consulted and an LP was performed, which was
unrevealing for any infectious etiologies. Neurology felt it was
safe to start anticoagulation so she was started on Lovenox. Pt
was not interested in Coumadin monitoring so she was continued
on Lovenox. She had a TTE which was negative for any evidence of
right heart strain. She was quickly weaned off oxygen and was
satting in mid to high 90s on room air at time of discharge.
# systolic CHF: Because of new pleural effusions noted on chest
CT, TTE was performed which showed severe global left
ventricular hypokinesis with EF of 25% along with small
pericardial effusion (no tamponade), which was new from prior
echo at start of chemo therapy. The concern is that her new
diagnosis of CHF may have been secondary to chemotherapy she
received for recent diagnosis of breast cancer. Pt had a
therapeutic/diagnosis paracentesis performed, which was
transudative in nature. She was initially diuresed, but this was
complicated by hypotensive episodes. At time of discharge, pt
appeared euvolemic. She was started on Valsartan and low dose
aspirin and will follow up with cardiology as an outpatient.
Consider spironolactone and beta blocker once stable to
medically optimize, although anticipate cardiomyopathy may
reverse when Adriamycin is complete and these medications may
not be necessary. Her pleural fluid cytology was negative for
malignant cells.
# Axillary fluid collection: Pt was noted to have increasing
erythema, warmth and induration in left axilla at site of recent
breast drainage. Surgery was consulted and drained a small
collection of serosanguinous fluid. She was initially started on
Keflex for presumed cellulitis, however the patient was afebrile
and without leukocytosis so Keflex was discontinued. Her factor
X level was checked given that patient was on Lovenox and there
was concern that if she was supratherapeutic, it may be
contributing to bleeding within her recent surgical site.
However, her Lovenox dosing appeared adequate and her hct
remained stable. She had a left axillary ultrasound that did
show a communicating fluid collection so surgery drained more
fluid. At time of discharge, pain and induration had improved,
and pt will follow up with surgery as an outpatient.
# Brain MRI c/w infarcts: Because of abnormal head CT obtained
in the [**Last Name (LF) **], [**First Name3 (LF) **] MRI was obtained which showed several enhancing
lesions consistent with subacute infarcts. Neurology felt that
these were most likely embolic in nature. She had a TTE with
negative bubble study. She was continued on her pravastatin and
aspirin and will need a repeat MRI as an outpatient in [**1-6**]
months.
# neuropathy: Pt complained of recent onset lower extremity
tingling, concerning for chemotherapy induced neuropathy. She
was started on low dose gabapentin during this admission and
this can be increased as necessary as an outpatient.
CHRONIC ISSUES"
# Breast cancer: Staged as 2B s/p treatment with Adriamycin and
cyclophosphamide, Taxol, and weekly Herceptin, needle-localized
lumpectomy, sentinel node biopsy, and low axillary dissection
with pleural effusion negative for malignancy. Her further
chemotherapy options may be limited as pt appeared to develop
CHF in setting of active chemotherapy. She will follow up with
oncology as an outpatient.
# T2DM: Pt was on metformin at home, though this was held while
in house. Her blood sugar was controlled with insulin 75/25 as
well as sliding scale insulin. Her insulin dose was decreased
during this hospitalization given low blood sugars. Her
metformin was resumed on discharge.
# Depression: Continued bupropion
TRANSITIONAL ISSUES:
# Pt's hypercoagulable work up was pending at time of discharge
and should be followed as an outpatient.
# Pt will need a repeat outpt brain MRI in [**1-6**] months.
# She will need to establish care with cardiology as an
outpatient for continued adjustment of medications given her new
diagnosis of heart failure.
# Pt will need to follow with surgery regarding her left
axillary seroma.
Medications on Admission:
Losaratan 50mg Oral daily
Pravastatin 40mg Daily
Metformin 1000mg daily
Clobetasol 0.05% Topical PRN (eczema)
Insulin Lispro 75-25 KwikPen 18 units before breakfast and
dinner
(does not check her BG usually otherwise)
Buproprion 300mg XL daily
Herceptin - every 4 weeks infusion
Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous
every twelve (12) hours.
Disp:*60 syringes* Refills:*0*
2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. valsartan 40 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
4. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Disp:*1 inhaler* Refills:*0*
7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*0*
9. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Six (6)
units Subcutaneous twice a day.
10. aspirin 81 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*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY:
Pulmonary embolism
Congestive heart failure
SECONDARY:
breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 4427**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for shortness of breath. You
were found to have a pulmonary embolism (a blood clot in your
lungs) as well as congestive heart failure. This means that your
heart does not pump as effectively as it should.
You were noticed to have some bleeding into your left breast
where you had surgery.
Because of the blood clot, you will need to be on blood
thinners. We also changed some of your other medications for
your heart.
Please make the following changes to your medications:
# START lovenox 80 mg injections twice a day
# START valsartan 20 mg daily
# START omeprazole 40 mg daily
# START aspirin 81 mg daily
# START gabapentin 100 mg three times a day
# USE albuterol inhaler every 4 hours as needed for shortness of
breath
# STOP losartan
# DECREASE insulin 75-25 to 6 units in the morning and before
dinner. Please check your blood sugars 4 times a day, as your
insulin dose may need to be adjusted further.
Please continue all other medications as prescribed.
Followup Instructions:
Cardiology Appointment: Thursday, [**6-26**] at 1:30pm
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location:[**Hospital1 **]
[**Location (un) 4363**],
[**Location (un) 86**], [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 2258**]
PCP [**Name Initial (PRE) 648**]:[**Last Name (LF) 2974**], [**6-27**] at 10:40am
With:[**First Name11 (Name Pattern1) 2114**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2113**],MD
Location: [**Hospital1 641**]
Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 2115**]
Hematology/Oncology: [**Last Name (LF) 2974**], [**7-4**] at 11am
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**]
Location:[**Hospital1 **]
[**Location (un) 4363**], 4th fl
[**Location (un) 86**], [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 3468**]
Surgery Appointment:PENDING
With: Dr. [**First Name4 (NamePattern1) 69494**] [**Last Name (NamePattern1) 4048**]
Phone: [**Telephone/Fax (1) 100016**]
**We are working on a follow up appointment with Dr.[**Last Name (STitle) 4048**] in the
next week. You will be called at home with the appointment. If
you have not heard within 2 business days or have questions,
please call the number above. You should be seen this week.
You will also need to have a repeat MRI brain done as an
outpatient. Please discuss this with your primary care doctor.
Completed by:[**2200-7-4**]
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9,158
| 120,496
|
22612
|
Discharge summary
|
report
|
Admission Date: [**2160-5-30**] Discharge Date: [**2160-6-4**]
Date of Birth: [**2083-12-12**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Penicillins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Abdominal Pain and Nausea/Vomiting
Major Surgical or Invasive Procedure:
Pericardial Drainage
Right Heart Cath
Ultrasound guided thoracentesis
History of Present Illness:
76 y/o diabetic vasculopath (CAD/PVD/carotid stenosis), s/p VATS
[**2160-4-28**] for lung nodules, who p/w nausea/vomiting hypotension
after eating fried scallopps. Taken to [**Hospital3 7569**] where
she was found to have SBP of 70's refractory to 2.5L NS, also
noted mild epigastric pain. Lipase was 600 at [**Location (un) **], CT abd
done to eval for pancreatitis, which revealed pericardial
effusion. She did c/o light-headedness at OSH. Transferred to
[**Hospital1 18**] for eval for tamponade. In ED, SBP 70's and HR 70's, dop
gtt hung. Bedside TTE revealed small pericardial effusion with
no tamponade physiology. Fluid hung for presumed hypovolemic
hypotension. Her relative bradycardia was presumed [**2-27**] vagal vs
beta-blockade. In [**Hospital1 18**] ED, denied CP, SOB, palpitaitons,
presyncope or visual changes.
Past Medical History:
diabetes mellitus type 2 with associated retinopathy and
neuropathy
rectal bladder fistulae s/p colonic vesicular repair ([**2159-10-23**])
osteoarthritis
hyperlipidemia
coronary artery disease, single vessel by Cath LCx ([**2159-7-26**])
left carotid stenosis
"small" CVA (per pt - [**2159-7-26**])
s/p fem-opo bypass ([**2159-7-26**])
s/p TAH BSO
s/p cholecystectomy
Social History:
50 pack year tobacco, quit 25 yres ago
no alcohol
no illicit drugs
Family History:
non-contrib
Physical Exam:
Gen: A&O X 3, NAD
Heent: EOMI, PERRL, MM dry,
Neck: Flat veins on left. VATS scar anteriorly.
Heart: RRR no mrg. PMI normal.
Lungs: Clear
Abd: Soft, nt/nd. NABS
Ext: No c/c/e. Cool distal exteremities.
Neuro: Non-focal. No flap.
Pertinent Results:
ECHO ([**5-30**]): The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size
is normal. Overall left ventricular systolic function is low
normal (LVEF 50%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is a moderate sized pericardial effusion. The
effusion appears circumferential. There is brief right and left
atrial diastolic collapse,l but no abnormal respirophasic
changes in trans mitral or transtricuspid flow.
Cath ([**5-30**]):
1. Hemodynamic evaluation on entry revealed moderately elevated
right-sided pressures (mean RA was 13 and RVEDP was 15 mmHg),
mildly
elevated left-sided pressures (mean PCW was 17 mmHg), and
moderately
elevated pulmonary pressures (PA was 35/17 mmHg). The femoral
artery
pressure was 152/72 mmHg. There was a 21 mmHg pulsus paradoxus
observed
with respiration (152 - 131 mmHg). The RA pressure tracing
demonstrated
mild blunting of the Y decent. There was near equalization of
the
average diastolic pressures of the RA, RV, PA, and PCW
pressures.
2. The pericardial pressure on entry was elevated at 13 mmHg.
There
was entrainment of the RA and pericardial pressures confirming
tamponade
physiology.
3. After 300 cc of bloody pericardial fluid was removed,
hemodynamic
assessment was repeated. The mean RA pressure remained 13 mmHg.
The
pericardial pressure decreased to 3 mmHg. The femoral artery
pressure
increased to 192/76 mmHg. There was an 8 mmHg pulsus paradoxus
observed
with respiration (192 - 184 mmHg).
ECHO ([**6-2**]): The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild to moderate ([**1-27**]+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is a
small pericardial effusion. There are no echocardiographic signs
of
tamponade. Compared to the prior study (tape reviewed) dated
[**2160-5-30**], the
pericardial effusion appears smaller.
CXR ([**6-3**]): Resolution of left pleural effusion.
ECHO ([**6-3**]): No pericardial effusion.
[**2160-6-4**] 04:03AM BLOOD WBC-4.8 RBC-3.51* Hgb-10.5* Hct-31.4*
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.6 Plt Ct-265
[**2160-6-3**] 03:38AM BLOOD Neuts-68.4 Lymphs-20.3 Monos-6.6 Eos-4.1*
Baso-0.6
[**2160-5-31**] 04:06AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2160-6-4**] 04:03AM BLOOD Plt Ct-265
[**2160-6-4**] 04:03AM BLOOD PT-14.0* PTT-35.9* INR(PT)-1.3
[**2160-6-4**] 04:03AM BLOOD Glucose-125* UreaN-17 Creat-0.9 Na-138
K-3.9 Cl-105 HCO3-24 AnGap-13
[**2160-5-30**] 04:00AM BLOOD Glucose-216* UreaN-43* Creat-1.9* Na-143
K-3.9 Cl-111* HCO3-16* AnGap-20
[**2160-6-2**] 04:42AM BLOOD ALT-289* AST-226* LD(LDH)-244 AlkPhos-48
TotBili-1.5
[**2160-5-31**] 04:06AM BLOOD ALT-303* AST-724* CK(CPK)-405* AlkPhos-45
Amylase-41 TotBili-1.7*
[**2160-5-31**] 04:06AM BLOOD Lipase-34
[**2160-5-31**] 12:00PM BLOOD CK-MB-9
[**2160-5-31**] 04:06AM BLOOD CK-MB-13* MB Indx-3.2 cTropnT-0.74*
[**2160-5-30**] 08:17PM BLOOD CK-MB-14* MB Indx-3.6 cTropnT-0.68*
[**2160-6-4**] 04:03AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.9
[**2160-5-31**] 04:06AM BLOOD Albumin-2.9* Calcium-8.1* Phos-4.4#
Mg-1.8
[**2160-5-30**] 08:17PM BLOOD calTIBC-361 Ferritn-1437* TRF-278
[**2160-5-30**] 08:17PM BLOOD TSH-1.9
[**2160-5-31**] 09:18PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2160-5-31**] 04:06AM BLOOD RedHold-HOLD
[**2160-5-31**] 09:18PM BLOOD HCV Ab-NEGATIVE
[**2160-5-30**] 05:41AM BLOOD Lactate-3.4*
Brief Hospital Course:
76 y/o female vasculopath who p/w n/v, hypotension and
pericardial effusion.
* Diabetes: Continued RISS during this hospitalization. Can
restart actos as outpt.
* Episode of Afib: Had 5 sec episode of Afib on tele after
pericardial tap. Likely related to tap. However, she could
also have paroxysmal A-fib, therefore needs outpt holter, which
will be coordinated by Dr.[**Last Name (STitle) **].
* Hypotension: SBP in the 70's at admission. Multifactorial
in etiology. Tamponade, hypovolemia, and medication effect
contributors. After pericardial drainage, hypotension resolved.
Her anti-hypertensives were titrated up without problem. This
hypotension likely resulted in shock liver with transaminitis
that is now resolving. Her LFT's shouuld be followed as an
outpt.
* Pericardial Effusion: 300cc of frank blood removed on
pericardiocentesis. Likely [**2-27**] VATS. Cultures, gram stain and
cytology neg. Stopped draining after 24 hours. Re-ECHO shows
no reaccumulation.
* Pleural Effusion: Exudative. Also likely [**2-27**] VATS. Neg
culture, gram stain and cytology pending. Needs oupt
monitoring.
* Granulomatous Disease: Will d/w Dr.[**Last Name (STitle) 952**] about results of
pleural biopsy (?possible MAC). Tb negative. Per ID, no need
for inpatient w/u for MAC. Will f/u with [**Hospital **] clinic as outpt.
* Transaminitis: Neg [**Name (NI) 5283**] sono. Hep serologies neg. LIkely
[**2-27**] shock liver. Improving. Needs outpt f/u.
* CAD: Cont asprin. Changed atenolol to toprol. Started
statin. No acute issues..
Medications on Admission:
Actos 45 once daily, aspirin 325 once daily, atenolol 75 daily,
Tricor 1.45 once daily, Plavix 25 once daily, lisinopril 2.5
once daily, nitroglycerin sublingual, which she has only used
once since the stent, but unsure if she needed it; Nexium 40
once daily.
7
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Actos 45 daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Pericardial Tamponade
Pleural Effusion
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
If you have these symptoms, call your doctor or go to the ED:
- shortness of breath
- chest pain
- dizziness
- visual change
- palpitations
- severe belly pain
- fainting
Followup Instructions:
1. Please call [**Hospital **] clinic and follow up with Dr.[**Last Name (STitle) **] at [**Telephone/Fax (1) 10**]
2. Please follow up with Dr.[**Last Name (STitle) 952**] at ([**Telephone/Fax (1) 1504**].
3. Please follow up with Dr. [**Last Name (STitle) **]. She will see you within one
week.
4. Please call Dr.[**First Name (STitle) **] at ([**Telephone/Fax (1) 7236**] to schedule an
appointment for possible carotid stenting.
Completed by:[**2160-6-4**]
|
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|
[
[
[]
]
] |
[
"37.21",
"88.55",
"37.0",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
8931, 8999
|
6204, 7780
|
323, 395
|
9082, 9090
|
2047, 6181
|
9411, 9882
|
1758, 1771
|
8092, 8908
|
9020, 9061
|
7806, 8069
|
9114, 9388
|
1786, 2028
|
249, 285
|
423, 1264
|
1286, 1657
|
1673, 1742
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,077
| 156,316
|
12407+12408
|
Discharge summary
|
report+report
|
Admission Date: [**2170-6-21**] Discharge Date: [**2170-7-5**]
Date of Birth: [**2107-6-27**] Sex: M
(Last words - right pleural effusion) Continuation of discharge
summary:
Total parenteral nutrition was also started on this day. On
parenteral nutrition was continued. The patient's hematocrit
remained stable. The patient continued to do well, continued
on total parenteral nutrition and on postoperative day #11
the lateral [**Location (un) 1661**]-[**Location (un) 1662**] drain was discontinued. The
patient's hematocrit remained stable. Total parenteral
nutrition was discontinued on postoperative day #12 and on
postoperative day #13 the medial [**Location (un) 1661**]-[**Location (un) 1662**] drain was
time was 2.0. The ALT was 85 and the AST was 41. The
patient was discharged on this day to home to be followed up
in clinic with Dr. [**Last Name (STitle) **]. During his hospital course the
patient's immunosuppression regimen included Cellcept, a
methylprednisolone taper which was changed to p.o. Prednisone
and cyclosporine.
MEDICATIONS ON DISCHARGE:
Cyclosporine 150 mg p.o. b.i.d.
Prednisone 15 mg p.o. q.d.
Cellcept [**Pager number **] mg p.o. b.i.d.
Fluconazole 400 mg p.o. q.d.
Amlodipine 5 mg p.o. q.d.
Ergocalciferol 400 units p.o. q.d.
Calcium carbonate 500 mg p.o. b.i.d.
Valganciclovir 450 mg p.o. b.i.d.
Bactrim single strength one tablet p.o. q.d.
Percocet 5/325 one to two tablets p.o. q. [**4-14**] prn
Pantoprazole 40 mg p.o. q.d.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Discharge to home.
DISCHARGE DIAGNOSIS:
1. Status post orthotopic liver transplant
2. Hepatitis C
3. History of cirrhosis
4. History of hepatocellular carcinoma
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D., Ph.D.
Dictated By:[**Last Name (NamePattern1) 28534**]
MEDQUIST36
D: [**2170-8-12**] 17:17
T: [**2170-8-12**] 19:04
JOB#: [**Job Number 38595**]
Admission Date: [**2170-6-21**] Discharge Date: [**2170-7-5**]
Date of Birth: [**2107-6-27**] Sex: M
Service: TRANSPLANT SURGERY
Attending:[**Last Name (NamePattern4) 30250**]
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old
male with a history of hepatitis C since [**2158**], and grade IV
cirrhosis. The patient denies any symptoms of liver failure
essentially normal total bilirubin and albumin. In [**2169-4-9**], the patient was noted to have an increasing AFP and a
CT/MRI was obtained which demonstrated a lesion in the right
lobe of the liver. Biopsy confirmed this lesion to be a
hepatocellular carcinoma for which he underwent
radiofrequency ablation. The patient was subsequently
evaluated for liver transplant, found to be a suitable
PAST MEDICAL HISTORY:
1. Hepatitis C, cirrhosis, hepatocellular carcinoma.
2. Depression.
MEDICATIONS ON ADMISSION:
1. Interferon.
2. Wellbutrin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Preoperatively, the patient's
temperature was 99.2, heart rate 72, blood pressure 118/62,
respiratory rate 12, oxygen saturation 99% in room air. On
examination, the patient was a tanned middle age male with no
jaundice and no icterus. Pulmonary examination revealed
lungs that were clear to auscultation bilaterally. Cardiac
examination revealed a regular rate and rhythm. Abdominal
examination was soft, nontender, nondistended, no evidence of
hepatosplenomegaly. Rectal examination was guaiac negative
with normal tone. Extremities were unremarkable, warm and
well perfused. There were palpable dorsalis pedis and
posterior tibial pulses bilaterally.
LABORATORY DATA: On admission, white blood cell count was
2.9, hematocrit 41.1, platelet count 77,000. Sodium was 142,
potassium 4.0, chloride 107, bicarbonate 23, blood urea
nitrogen 9, creatinine 0.8. Prothrombin time was 13.0,
partial thromboplastin time was 33.0 and INR was 1.2. ALT
was 115, AST was 107, alkaline phosphatase was 140, total
bilirubin was 1.1 with a direct bilirubin of 0.5. Calcium
was 8.7, magnesium 1.6, phosphate 3.5. Urinalysis was
negative.
Electrocardiogram showed normal sinus rhythm at 77 beats per
minute, no ST changes.
Chest x-ray showed no infiltrates and no evidence for
congestive heart failure.
Cardiac workup included echocardiogram from [**2170-4-9**], which
showed an ejection fraction of 60 to 65%, normal valves.
Stress test from [**2170-4-9**], showed no ischemia.
Tissue typing samples were sent to [**Hospital6 15291**].
HOSPITAL COURSE: The patient was admitted and taken to the
Operating Room for orthotopic cadaveric liver transplant at
which time a left subclavian central venous pressure line was
also placed. The patient tolerated the procedure well and
was transferred to the SICU postoperatively. Please see the
operative note for details.
The patient arrived to the SICU intubated and sedated with
Propofol. At the postoperative check, the white blood cell
count was 6.0, hematocrit 35.8, platelet count 85,000. Total
bilirubin was 1.4, ALT 254, AST 615, and alkaline phosphatase
was 69. Lateral and medial [**Location (un) 1661**]-[**Location (un) 1662**] drains had been
placed in the operating room. One unit of platelets was
administered for a platelet count of 84,000 the evening
following the operation.
On postoperative day one, the patient was extubated and his
hematocrit remained stable. On postoperative day number two,
the patient was transferred to the floor. Total bilirubin
was noted to be elevated to 3.2 from 1.4 the previous day and
was thought to be likely secondary to preservation injury.
On postoperative day number three, the lateral [**Location (un) 1661**]-[**Location (un) 1662**]
drain was removed. Total bilirubin increased to 3.5, and an
ultrasound of the allograft liver was performed with no
evidence of thrombus. However, there was evidence of
hemostatic material and blood products present in [**Location (un) 6813**]
pouch.
On postoperative day four, a decreased hematocrit was noted
down to 18.7 from 27.5 previously. There was also found to
be increased output from the medial [**Location (un) 1661**]-[**Location (un) 1662**] drain which
remained in place. The patient was taken to the Operating
Room for exploration and on this day he received a total of
six units of fresh frozen plasma, two units of platelets, and
was transfused a total of five units of packed red blood
cells. In the Operating Room, bleeding was found at the
suprahepatic caval anastomosis which was oversewn and the
patient was transferred to the SICU postoperatively.
On postoperative day five from the original operation,
postoperative day one from the second, the patient was
extubated and he was given two units of packed red blood
cells and four units of platelets for a hematocrit of 28.6
and a platelet count of 54,000, respectively. An ultrasound
of the liver was obtained which showed normal flow and there
was simple fluid found in [**Location (un) 6813**] pouch which was not
consistent with hematoma.
On postoperative day six from the original procedure, the
patient was transferred to the floor somewhat hypertensive
but stable. On postoperative day seven, a duplex ultrasound
of the liver was obtained which showed normal flow. There
was a right pleural effusion found.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 28534**]
MEDQUIST36
D: [**2170-8-12**] 16:50
T: [**2170-8-12**] 19:05
JOB#: [**Job Number 38596**]
|
[
"070.51",
"155.0",
"401.9",
"511.9",
"998.11",
"571.5",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.12",
"50.59",
"99.15",
"54.12",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1583, 2135
|
1095, 1491
|
2838, 2909
|
4489, 7544
|
2932, 4471
|
2164, 2719
|
2741, 2812
|
1516, 1562
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,201
| 125,117
|
5984
|
Discharge summary
|
report
|
Admission Date: [**2125-2-4**] Discharge Date: [**2125-3-21**]
Date of Birth: [**2077-6-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Temperature of 103.4, chills and malaise after flushing PTC
drains the day before.
Major Surgical or Invasive Procedure:
orthotopic liver transplant [**2125-2-12**]
Hepatic artery repair [**2125-3-6**]
cholangiogram [**2125-3-16**], CTA
CT guided drainage of fluid collection above liver [**3-17**]
History of Present Illness:
47 y.o. male s/p living unrelated liver transplant [**2124-10-30**] c/b
hepatico
Physical Exam:
A&O, NAD, Lying in bed watching TV
VS: 98.2- 82-18, 112/62 98% RA 56.7kg
Jaundiced
CTAB
RRR, nl s1s2, no m/r/g
soft, NT, ND, +BS
PTC x2 R flank superior, no erythema, mod crusting, no drainage
JP x1 anterior abd wall, no erythema, biliary
1+pedal edema to ankle bilaterally
WWP
Pertinent Results:
[**2125-2-4**] 08:53PM PT-16.3* PTT-32.6 INR(PT)-1.7
[**2125-2-4**] 08:07PM GLUCOSE-139* UREA N-47* CREAT-3.0*
SODIUM-128* POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-18* ANION
GAP-19
[**2125-2-4**] 08:07PM ALT(SGPT)-56* AST(SGOT)-46* LD(LDH)-311* ALK
PHOS-1692* AMYLASE-47 TOT [**Month/Day/Year **]-21.8*
[**2125-2-4**] 08:07PM LIPASE-22
[**2125-2-4**] 08:07PM ALBUMIN-2.5* CALCIUM-8.1* PHOSPHATE-5.4*
MAGNESIUM-1.5*
[**2125-2-4**] 08:07PM FK506-2.6*
[**2125-2-4**] 08:07PM WBC-5.4 RBC-3.13* HGB-9.0* HCT-26.9* MCV-86
MCH-28.8 MCHC-33.4 RDW-19.1*
[**2125-2-4**] 08:07PM NEUTS-84* BANDS-6* LYMPHS-4* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2125-2-4**] 08:07PM PLT SMR-NORMAL PLT COUNT-246
[**2125-2-4**] 08:05PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-LG UROBILNGN-NEG PH-6.5 LEUK-NEG
[**2125-2-4**] 08:05PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2125-2-4**] 08:05PM URINE AMORPH-FEW
Brief Hospital Course:
Presented with temperature of 103, chills and malaise after
flushing biliary drains at home. He is s/p living donor liver
transplant [**2124-10-30**] for PSC complicated by bile leak requiring
hepaticojejunostomy with persistent bile leak requiring PTC
drains and hepatic artery stenosis requiring stent. LFTs
remained elevated secondary to failing liver transplant and he
was relisted for liver transplant. He was pan cultured and
started on Linezolid and Meropenum. CXR and urinalyis were
negative. Blood cultures were positive for klebsiella pneumoniae
and enterococcus faecum sensitive to Imipenum and linezolid. PTC
drainage was positive for klebsiella and enterococcus (VRE). ID
was consulted and daily blood cultures were done to ensure that
he was cleared for re-transplant if donor available. After 5
days of Meropenum, he was switched to Levaquin. A TTE was done
to rule out vegetation. This was negative. He was cleared for
liver transplant by ID.
On [**2125-2-11**] he received an orthotopic liver transplant. He
received Simulect, Cellcept and Solumedrol induction. In OR
6,500 ml of IVF, 8 units of FFP, 19 units of PRBC, 5 units of
platelets and 3units of cryoglobulin were given. Please refer to
operative report for further details. Post op duplex of liver
was normal with patent arterial and venous flow. AST and ALT
increased on POD 1. A liver duplex was done revealing patent
hepatic vasculature and IVC. Prograf was started on POD 1 and he
tolerated extubation. IV linezolid, levaquin were continued
postop. Caspofungin was started for empiric fungal coverage. He
was hypertensive with BP of 160/90s. Lasix was given. On POD 3
he was transfused for a hct of 28.9. FFP was given for INR >2.
Nitroglycerin and nipride were used for BP control. These meds
were tapered and lopressor was started. LFTs trended down and he
was transfered to the transplant unit on POD 7.
On POD 8 he received 2 units of platelets for plt count of 33. A
HIT was checked.This was negative. A cholangiogram was performed
revealing no evidence of biliary leak or intrahepatic ductal
dilatation, with smooth but slightly slow passage of contrast
through the biliojejunal anastomosis. The PTC was then capped.
On POD 10, he complained of abdominal distension. On exam his
abdomen was soft, non-tender with mild distension. A KUB
revealed no evidence of bowel obstruction or ileus. A dulcolax
was given with passage of a bm. He continued to complain of
right sided abdominal pain. This was treated with dilaudid 1mg
prn every three hours with relief. Nutrition was consulted and
calorie counts were done. On pod 11 he was still experiencing
abdominal distension after meals. He was made NPO and TPN was
started after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Picc line was placed. Dilaudid was
stopped. Clear liquids were restarted on POD 13 without any
nausea or vomiting. Diet was advanced. He still experienced post
prandial distension and RUQ discomfort radiating to right back.
Cellcept was stopped. Stools were sent for C.diff x3 for
complaints of diarrhea. All specimens were negative.
On [**3-1**] abdominal CT revealed 18.8 x 13.5 cm intra-abdominal
fluid collection and moderate intraabdominal ascites. A liver
duplex failed to identify right and left intrahepatic arteries.
A pigtail drain was placed into the fluid collection. This
drained 1000cc of ascites. On pod 22, alk phos increased to 238.
A repeat CT and ultrasound were done on POD 23. Duplex
demonstrated slow arterial waveforms. Angiography was attempted
with attempt to stent. A small amount of extravasation and
bleeding occurred [**Hospital 23567**] transfer to ICU for monitoring.
He was tranfused with PRBC. On [**2125-3-6**] he was taken to the OR
for revision of hepatic artery anastomosis. Refer to OR report.
POD 1 duplex demonstrated improved arterial flow.
Post op he did well with LFTs trending down. Abdominal
discomfort improved. Creatinine increased to 2.7. Prograf was
held for four doses. Creatinine decreased to 1.6. PT and OT were
consulted for strengthening. Diet was advanced and TPN stopped
when goal caloric intake was reached. JPs were removed without
incident. IV lasix was given for fluid retention. On POD 31/7 a
CTA to reconstruct the hepatic artery was performed as well as a
cholangiogram for an elevated alk phos of 287. This revealed 1.
A 2 cm long area of mild narrowing within the hepatic artery.
2. Multifocal areas of nonenhancing liver parenchyma consistent
with infarction.
3. Multiple collections of fluid within the anterior abdomen and
along the medial aspect of the liver, containing some gas and
high density material consistent with hematoma. Cholangiogram
demonstrated normal bile ducts with sluggish emptying without
biliary leak. Arterial and venous wave forms were normal.
On [**3-17**] a CT guided drainage of the superior fluid collection
was performed. Successful aspiration of approximately 125 cc of
serosangious fluid from hematoma in the left upper quadrant.
This did not appear grossly infected at the time of aspiration
but was sent for microbiology. On [**3-19**] a liver biopsy was
performed. This revealed mild cholestasis without rejection.
Aspirin and plavix were held on [**3-16**] until [**3-19**].
PT and OT evaluation deferred rehab. Patient was ambulatory and
safe for discharge to home. He is taking in adequate calories.
Vital signs have been stable. Weight trended down to 59.8kg with
minimal pedal edema. He will be discharged to home with capped
roux tube. Abdominal incision was well approximated and steri
stripped. Labs were as follows wbc 3.5, hct 27.3, sodium 138,
potassium 4.3, creatinine 1.2, ast 33, alt 82, alk phos 243,
t.[**Month/Year (2) **] 1.3 and prograf level 7.1. He will follow up weekly at
the transplant office. Twice weekly labs will be drawn at
[**Hospital6 8283**] with results fax'd to transplant
office.
Medications on Admission:
rapamune 4mg qd, MMF 500mg [**Hospital1 **], prednisone 15mg qd, bactrim ss 1
qd, protonix 40mg [**Last Name (LF) **], [**First Name3 (LF) **] 325mg qd, plavix 75mg qd, actigall
600mg [**Hospital1 **], regular insulin per sliding scale dialuadid 2mg prn
q8 hours
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
10. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO
3X/WEEK (MO,WE,FR).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ESLD s/p liver transplant [**2125-2-12**] complicated by hepatic artery
stenosis.
Hepatic artery repair [**2125-3-6**]
Discharge Condition:
stable
Discharge Instructions:
Call transplant office if fevers, chills, nausea, vomiting,
inability to take medications, jaundice, increased abdominal
pain or malaise.
Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk
phos, t.[**Month/Day/Year **], and trough prograf
Change dry sterile dressing over capped t.tube (roux tube) every
day. monitor for any bleeding/redness at insertion site.
No driving
no heavy lifting
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-3-21**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-3-28**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-4-4**] 11:00
Provider: [**Name10 (NameIs) 816**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 673**] Call to schedule appointment
Completed by:[**2125-3-21**]
|
[
"447.1",
"998.2",
"998.12",
"789.5",
"996.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91",
"00.93",
"54.19",
"39.59",
"87.54",
"99.04",
"99.15",
"50.59",
"00.14",
"50.11",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
9529, 9535
|
1980, 7883
|
395, 575
|
9698, 9706
|
1001, 1957
|
10153, 10949
|
8196, 9506
|
9556, 9677
|
7909, 8173
|
9730, 10130
|
700, 982
|
273, 357
|
603, 685
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,540
| 198,242
|
34238
|
Discharge summary
|
report
|
Admission Date: [**2197-3-26**] Discharge Date: [**2197-3-28**]
Date of Birth: [**2171-7-5**] Sex: M
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
asked to consult on atraumatic IPH, ? SAH
Major Surgical or Invasive Procedure:
Placement of extra-ventricular drain,
diagnostic angiogram
History of Present Illness:
: 28M who was playing soccer this afternoon when he had a
sudden onset HA and right sided weakness and collapsed. He was
taken to OSH where he was scanned and a significant IPH was
identified. He was intubated at the OSH for increasing
lethargy.
Past Medical History:
Unknown
Social History:
Unknown
Family History:
Non-contributory
Physical Exam:
On Arrival
T: afebrile BP:117/63 HR: 62 RR:20 O2Sats: 100% CMV
FiO2 100%
Gen: WD/WN Male
HEENT:Atraumatic, normocephalic
Pupils: 2mm, sluggish EOMs unable to assess
Extrem: Warm and well-perfused.
Neuro:
Mental status: Patient intubated and received vecuronium at
2:15pm for intubation. His pupils are 2mm, minimally reactive,
strong gag reflex, spontaneously moving all four extremities.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2mm to
1.5 mm bilaterally.
III-XII: unable to assess
Motor/Sensation: moving all extremeties
In AM on day of transfer:
Self extubated, PERRL 5-3 mm, EOMI, no pronator drift, tongue
midline, 5/5 strength bilateral upper and lower extremeties
Pertinent Results:
[**2197-3-26**] 03:00PM WBC-12.2* RBC-4.11* HGB-12.5* HCT-36.3*
MCV-88 MCH-30.4 MCHC-34.5 RDW-13.5
[**2197-3-26**] 03:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2197-3-26**] 03:00PM NEUTS-86.1* BANDS-0 LYMPHS-9.0* MONOS-3.8
EOS-0.7 BASOS-0.3
CT HEAD W/O CONTRAST [**2197-3-26**] 8:21 PM
CT HEAD W/O CONTRAST
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
26 year old man with ruptured AVM s/p angio
REASON FOR THIS EXAMINATION:
interval change
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: 26-year-old male with ruptured AVM status post
angio. Evaluate for interval change.
COMPARISON: [**2197-3-26**] at 15:30.
NON-CONTRAST HEAD CT: Large intraparenchymal hemorrhage in the
left occipitoparietal lobe measures 5.0 x 2.0 cm and dissects
into the left lateral ventricle. Blood is seen within both
lateral, third and fourth ventricles. Compared to the prior
exam, there is probably no significant change in the size of
large intraparenchymal hemorrhage, allowing for different
orientation of axial images.
Since the last exam, a ventricular shunt has been placed
terminating within the right lateral ventricle via a right
frontal approach. Although direct comparison is difficult from
prior exam given difference in orientation of the axial images,
there is probably slight decrease in the degree of ventricular
dilatation. High-attenuation material is seen within the sulci,
particularly along the left cerebral hemisphere, which may
represent subarachnoid blood, although delayed enhancement from
recent contrast study is possible.
There is no shift of normally midline structures. The [**Doctor Last Name 352**]-white
matter differentiation is intact. The basal cistern, in
particular the suprasellar is effaced.
Fluid is noted within the right maxillary sinus. The remainder
of the visualized paranasal sinuses and mastoid air cells remain
normally aerated. A right frontal scalp hematoma is present with
tiny locules of air within the subcutaneous tissues around the
ventricular shunt.
IMPRESSION:
1. Large intraparenchymal hemorrhage centered within the left
occipitoparietal lobe with blood dissecting into the lateral,
third and fourth ventricles. Compared to prior exam, there is no
significant change in the size of the intraparenchymal hematoma,
although there may be slightly increased amount of blood within
the ventricle.
2. Status post placement of a right frontal ventricular shunt
terminating within the right lateral ventricle with slightly
decreased size of the ventricles.
CTA HEAD W&W/O C & RECONS [**2197-3-26**] 3:16 PM
CTA HEAD W&W/O C & RECONS
Reason: eval aneurysm
[**Hospital 93**] MEDICAL CONDITION:
26 year old man with ICH/SAH
REASON FOR THIS EXAMINATION:
eval aneurysm
CONTRAINDICATIONS for IV CONTRAST: None.
CT ANGIOGRAPHY OF THE HEAD
HISTORY: CT angiography using a bolus enhancement technique.
PRELIMINARY REPORT: Provided by Dr. [**Last Name (STitle) **]. He indicated "large
left occipital temporal intraparenchymal hematoma with
surrounding edema. A large amount of intraparenchymal hemorrhage
is present in the ventricular system, which demonstrates some
degree of hydrocephalus involving the temporal horns. The source
of bleed is a large dural AVM in the left occipital region with
arterial source appearing to be the left posterior cerebral
artery and a large draining vein to the superior sagittal sinus,
possibly a vein of Trolard."
FINDINGS: The large left posterior temporal occipital
hemorrhage, with extensive intraventricular hemorrhage is seen.
There is moderate right and milder left-sided temporal [**Doctor Last Name 534**]
enlargement. There is no shift of normally midline structures.
The CT angiogram confirms the presence of a large vascular
malformation, which appears to be primarily of pial, rather than
dural origin. The major vascular feeder appears to be the left
posterior cerebral artery, although there may well be
contribution from distal branches of the left anterior cerebral
artery arising from the pericallosal division. The nidus of the
vascular malformation is situated along the superior aspect of
the hemorrhage. There is some lobulation of this nidus.
Certainly, an intranidal aneurysm cannot be entirely excluded on
the basis of this non-selective study. The major draining vein,
as noted by Dr. [**Last Name (STitle) **], appears to merge with the posterior
aspect of the superior sagittal sinus. However, its very
posterior location is not compatible with the designation of the
vein of Trolard. No other definite vascular abnormalities are
demonstrated.
CONCLUSION: Large pial-based arteriovenous malformation within
the left parietal- occipital region. Clearly, this malformation
requires superselective angiography for complete mapping of its
vascular supply, but especially for improved analysis of the
nidus for the presence of potential intranidal aneurysms.
CT HEAD W/O CONTRAST [**2197-3-27**] 10:20 AM
CT HEAD W/O CONTRAST
Reason: new hippus, ? worsening bleed/ ICP
[**Hospital 93**] MEDICAL CONDITION:
26 year old man with large ICH
REASON FOR THIS EXAMINATION:
new hippus, ? worsening bleed/ ICP
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Known large left intraparenchymal hemorrhage with
associated AVM and worsening hiccups. Evaluate for worsening
bleed or signs of increased intracranial pressure.
Comparison is made to multiple prior CTs dated [**2196-3-25**].
NON-CONTRAST HEAD CT
The overall size of the known left temporal-occipital
intraparenchymal hemorrhage has displayed no interval change,
with decreased blood noted within the ventricular system,
especially anteriorly. The positioning and appearance of the
right intraventricular drain is unchanged, as is the size of the
lateral, third, and fourth ventricles from most recent exam. The
amount of edema surrounding the intraparenchymal hemorrhage is
stable, with maintenance of [**Doctor Last Name 352**]-white differentiation in
remaining portions of the brain. No new regions of
intraparenchymal hemorrhage are identified. No significant
midline shift or signs of uncal herniation are noted. Soft
tissues and osseous structures are unremarkable.
Mild-to-moderate mucosal thickening involving the maxillary
sinuses bilaterally with partially aerosolized secretions is
again noted, with remaining paranasal sinuses and mastoid air
cells appearing well aerated.
IMPRESSION:
1. No interval change in size of left temporal-occipital
intraparenchymal hematoma. No CT findings to suggest
elevated/worsening intracranial pressure.
2. Interval decrease in amount of intraventricular hemorrhage
with degree of dilatation involving the temporal horns appearing
stable from most recent exam but improved from patient's
original CT examination prior to drain.
Brief Hospital Course:
The patient was admitted to the ICU from the ER to the
neurosurgical service. An EVD was placed for monitoring and
prevention of hydrocephalus. Dilantin was started for seizure
prophylaxis and nimodipine was started for vasospasm
prophylaxis. He was maintained on nafcillin for the drain. An
angiogram was obtained which showed a large AVM supplied by the
L PCA draining into SS sinus, also supplied by L ACA As
branches, no aneurysm noted. A post angio CT was stable. ON HD
2 his neurological exam was improving. He was also seen by the
neurology consult service. On HD#3 the patient pulled out his
own ET tube. His CVP was noted to range from [**11-23**] with the EVD
open at 20cm above the tragus. Arrangements were made for his
transfer to [**Hospital6 **] under the care of Dr.
[**Last Name (STitle) **] for further management of his large AVM.
Medications on Admission:
None
Discharge Medications:
1. Nitroprusside 25 mg/mL Solution Sig: One (1) as dir
Intravenous TITRATE TO (titrate to desired clinical effect
(please specify)).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO Q8H (every
8 hours).
4. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Phenylephrine HCl 10 mg/mL Solution Sig: One (1) Injection
TITRATE TO (titrate to desired clinical effect (please
specify)): SBP >110.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for HA.
10. Nafcillin 2 gm IV Q4H
continue while EVD in place
Discharge Disposition:
Extended Care
Discharge Diagnosis:
AVM
Discharge Condition:
Guarded to [**Hospital1 756**] ICU for further care.
Discharge Instructions:
You are being transferred to [**Hospital6 **] for further
treatment of your AVM brain lesion.
Followup Instructions:
Please follow up at the [**Hospital1 756**]
|
[
"796.4",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.03",
"88.41",
"02.2",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10197, 10212
|
8382, 9239
|
342, 402
|
10259, 10313
|
1536, 1923
|
10455, 10501
|
751, 769
|
9294, 10174
|
6631, 6662
|
10233, 10238
|
9265, 9271
|
10337, 10432
|
784, 1007
|
260, 304
|
6691, 8359
|
431, 679
|
1210, 1517
|
2255, 4220
|
1022, 1194
|
701, 710
|
726, 735
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,336
| 150,906
|
882
|
Discharge summary
|
report
|
Admission Date: [**2122-5-11**] Discharge Date: [**2122-5-17**]
Date of Birth: [**2038-11-13**] Sex: M
Service: MEDICINE
Allergies:
Serevent Diskus / Theraflu Multi Symptom
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
hematuria, weakness, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83-year old Russian-speaking male with a past
medical history of IDDM, asthma, AFib on coumadin, CAD s/p CABG
in [**2105**], diabetic ulcers, chronic venous stasis dematitis/severe
lower extremity edema follwoed by vascular service presenting
with hematuria, shaking in his R arm and hypotension and
tachycarida noted in the ED. History was obtained from son and
wife, who speak English, and are patient's primary caretakers.
[**Name (NI) **] has been declining since around [**Month (only) 1096**]; used to be able to
walk around and now needs assistance to transfer from bed to
chair, and has been mostly wheelchair bound. Patient was last
admitted in [**1-30**] for cellulitis in setting of his chronic lower
extremity edema. At that time he was experiencing shakes at
home, high fevers and on admission was noted to have L lower
extremity erythema. He was treated with a course of IV abx at
home (including course of zosyn, ceftriaxone for E. coli
bacteremia). He also was referred to podiatry and conservative
measures such as wound care, leg elevation and ACE wraps have
been used by his wife in order to decrease his chance of
infection, however he still has significant lower extremity
edema bilaterally.
.
Yesterday, his wife noted that the patient was urinating more
and then had bright red urine. He had never had this before. He
had associated L sided abdominal pain. Today he had a scheduled
podiatry followup appointment for wound debridement. No
purulence or drainage was noted from ulcers. Developed shaking
chills after this appointment and presented to the ED for chills
and for hematuria as his primary complaints. No fevers,
diarrhea, chest pain. He has had a dry cough, but this is
chronic and has been getting better (per family, related to
difficulty swallowing bt this has improved). Has also been
constipatied and his wife (who is a nurse and his primary
caretaker) manually disimpacted him on Saturday.
.
In the ED, initial vital signs were 97.8 131 88/45 18 95% RA. He
triggered soon after arrival for systolic BP in 80s and HR in
130s, and responded immediately to fluids. Baseline BP per the
wife who records multiple times per day is 80s-100s systolic.
Recieved vancomycin and zosyn after obtaining blood and urine cx
for concern for PNA with retrocardiac opacity noted on CXR. He
was also noted to have hematuria, foley cathter was placed and
initially urine was red with clots, but then ran clear wtihout
irrigation. Noted to have Cr elevated from baseline at 2.2,
microcytic anemia and INR 1.6 (on coumadin for Afib). Also
notedt o have transaminitis (AST 314, ALT 322), however specimen
was hemolyzed. VS on transfer afebrile, HR 87, 112/59, 22 100%
on RA. EKG with bundle branch block (old) and afib.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
IDDM
Chronic venous stasis dematitis L>R
Diabetic ulcers on heel and foot
Colon cancer(s/p L colectomy '[**07**])
CAD(s/p CABG '[**15**])
Right-sided heart failure
Afib(s/p ablation)
Gout
Asthma/Restrcitive Lung
CKD Stage III, baseline Cr 1.6-2.0
Social History:
Patient lives with his wife at home, she is a nurse and is his
primary caretaker. [**Name (NI) **] is dependent on ADLs. Uses a wheelchair.
Denies any history of smoking. Used to drink alcohol
occasionally but now he does not.
Family History:
lung cancer in father (smoker)
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, R conjunctival
injection and redness of lower eyelid (chronic)
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: 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 in place, red tinged, clear urine in bag, no clots,
pitting scrotal edema
Ext: warm, well perfused, 2+ pulses, 3+ pitting edema to thighs
bilaterally. R heel with ulcer on medial/plantar side 2 cm
diameter with yellow fibrotic tissue, no drainage or surrounding
erythema. L heel with 1 cm ulcer with deeper base and small
amount of bleeding, no drainage or surrounding erythema. More
superficial ulcer on posterior L ankle with no drainage or
erythema pink and granular, skin tears on medial aspect of L
calf
Pertinent Results:
Admission Labs:
[**2122-5-11**] 11:45AM BLOOD WBC-7.9 RBC-4.38* Hgb-10.7* Hct-34.4*
MCV-79*# MCH-24.4* MCHC-31.0 RDW-17.7* Plt Ct-117*
[**2122-5-11**] 07:30PM BLOOD WBC-6.7 RBC-4.25* Hgb-10.3* Hct-34.6*
MCV-82 MCH-24.3* MCHC-29.9* RDW-17.0* Plt Ct-109*
[**2122-5-12**] 04:35AM BLOOD WBC-4.7 RBC-4.14* Hgb-9.9* Hct-33.6*
MCV-81* MCH-24.0* MCHC-29.6* RDW-17.1* Plt Ct-112*
[**2122-5-11**] 11:45AM BLOOD Neuts-87.6* Lymphs-7.9* Monos-3.6 Eos-0.5
Baso-0.3
[**2122-5-11**] 11:45AM BLOOD Plt Ct-117*
[**2122-5-11**] 01:53PM BLOOD PT-18.0* PTT-29.3 INR(PT)-1.6*
[**2122-5-11**] 07:30PM BLOOD Plt Ct-109*
[**2122-5-12**] 04:35AM BLOOD Plt Ct-112*
[**2122-5-11**] 11:45AM BLOOD Glucose-135* UreaN-52* Creat-2.2* Na-137
K-5.7* Cl-97 HCO3-27 AnGap-19
[**2122-5-11**] 07:30PM BLOOD Glucose-119* UreaN-51* Creat-2.1* Na-139
K-4.1 Cl-99 HCO3-27 AnGap-17
[**2122-5-12**] 04:35AM BLOOD Glucose-119* UreaN-48* Creat-2.0* Na-142
K-3.6 Cl-102 HCO3-30 AnGap-14
[**2122-5-11**] 11:45AM BLOOD ALT-322* AST-314* TotBili-0.8
[**2122-5-11**] 07:30PM BLOOD ALT-312* AST-291* LD(LDH)-375* AlkPhos-74
[**2122-5-12**] 04:35AM BLOOD ALT-307* AST-262* LD(LDH)-271*
CK(CPK)-41* AlkPhos-72
[**2122-5-11**] 07:30PM BLOOD proBNP-[**Numeric Identifier 6041**]*
[**2122-5-11**] 11:45AM BLOOD Lipase-23
[**2122-5-11**] 11:45AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.2
[**2122-5-11**] 07:30PM BLOOD Albumin-3.1* Calcium-7.9* Phos-4.0 Mg-2.2
UricAcd-8.5*
[**2122-5-12**] 04:35AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.2
[**2122-5-11**] 07:30PM BLOOD PSA-8.4*
[**2122-5-11**] 11:45AM BLOOD Acetmnp-NEG
[**2122-5-11**] 11:55AM BLOOD Lactate-1.9
MICRO:
Sputum: GRAM STAIN (Final [**2122-5-12**]):
[**10-13**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
Urine: URINE CULTURE (Final [**2122-5-13**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
CHEST (PA & LAT) [**5-12**]:
Mild congestive heart failure with small bilateral pleural
effusions and pulmonary vascular congestion. Recommend repeat
radiograph
after diuresis to assess for resolution of retrocardiac
opacities which could represent LLL pneumonia.
Abdominal u/s [**5-12**]:
1. Main portal vein is patent.
2. Bilateral kidneys show evidence of thinning of the cortex.
3. Gallbladder wall thickening with mild gallbladder wall edema
likely
represents third spacing in setting of congestive cardiac
failure.
4. Small amount of ascites.
5. Splenomegaly.
Brief Hospital Course:
83 yo M with IDDM, asthma, AFib on coumadin, CAD s/p CABG in
[**2105**], diabetic ulcers, chronic venous stasis dematitis/severe
lower extremity edema followed by vascular service p/w hematuria
x 2 days and chills, hypotension and tachycardia following a
podiatry appointment for wound debridement.
Chills, hypotension and tachycardia was due to probable UTI with
urine culture growth of E coli. He completed 7 total days of
appropriate antibiotic therapy. It seems as though his
hypotension was a baseline blood pressure (at home per wife SBP
80-100) and his tachycardia was the major issue. Due to a h/o
bradycardia his nodal agents had been held. His toprol and
digoxin at low doses were restarted and his amiodarone 400mg po
daily was continued. His tachycardia resolved, his BP remained
80-100 systolic and was asymptomatic.
PERIPHERAL EDEMA, associated with ascites and pleural effusions:
all consistent with acute on chronic right sided heart failure.
he was restarted on his home dose of torsemide and diuresed
about net negative 2 liters the first day wtih clinical
improvement in volume status. It is possible he has a greater PO
fluid / salt intake at home or does not take his torsemide as
prescribed but he responded well to this dose. His I/O's were
even over the next 24 hours. He will continue on this but
should be weighed daily at home and his torsemide should be
adjusted based on his edema, weight and BUN/Cr.
CKD 3: creatinine remained stable around at baseline through
diuresis.
ATRIAL FIBRILLATION: As above restarted on nodal agents with
good effect. Coumadin continued at 2.5mg po daily with
therapeutic INR.
DM1 uncontrolled with renal and PVD comps, chronic diabetic foot
ulcer. The patient continued on his insulin regimen and will
follow-up with podiatry for further care.
DECREASED MOBILITY: subacute decline in mobility, patient has
been walking much less with a walker at home per his wife, PT
evaluated the patient and recommended rehab, which he and his
wife refused (as she had a bad experience involving the
development of pressure sores in the past) and instead PT
recommended he stay for [**1-22**] inpt PT sessions then be discharged
home w/ PT and VNA.
Medications on Admission:
allopurinol 100 mg daily
amiodarone 400 mg daily
potassium cl 20 meq daily
flomax 0.4 mg daily
sentyl ointment
nexium 40 mg daily
torsemide 100 mg [**Hospital1 **]
warfarin 2.5 mg daily
zolpidem 10 mg QHS PRN
Humulin N 100 unit/mL Suspension Sig: Thirty (30) units
Subcutaneous in AM: Take 10 units after dinner.
fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day)
erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day)
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. digoxin 125 mcg Tablet Sig: [**12-21**] Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
10. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
11. Humulin N 100 unit/mL Suspension Sig: as directed units
Subcutaneous twice a day: 30 units qam and 10 units after
dinner.
12. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic [**Hospital1 **] (2 times a day).
14. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Outpatient Lab Work
Please draw labs on Tuesday [**2122-5-19**].
PT [**Name (NI) 263**]
Chem 7 (Na, K, Bicarb, Cl, BUN, Cr, Glucose)
Please fax results to PCP [**Telephone/Fax (1) 6042**]
Discharge Disposition:
Home With Service
Facility:
Suburban Home Services
Discharge Diagnosis:
Primary Diagnosis:
Atrial fibrillation with rapid ventricular rate
Acute on chronic diastolic CHF
Urinary tract infection
.
DM1
CAD
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 with a rapid heart rate and chills. You were
found to have a urinary tract infection and you were found to
have fluid around your lungs and in your legs. You were treated
with antibiotics for urinary tract infection and you continue on
your home torsemide to remove fluid. Please weigh yourself daily
and call your doctor for any increase in weight by 3 lbs.
Please take your medications as prescribed and make your follow
up appointments.
MEDICATION CHANGES:
Please RESTART taking your METOPROLOL SUCCINATE (TOPROL XL) and
DIGOXIN. I have given you new prescriptions of these
medications at their new doses.
Followup Instructions:
Please see your primary care physician [**Name Initial (PRE) 176**] 4 weeks of your
discharge from the hospital: [**Last Name (LF) 585**],[**First Name3 (LF) 586**] L. [**Telephone/Fax (1) 589**]
Please see your cardiologist within 2 weeks of your discharge
from the hospital.
Department: PODIATRY
When: FRIDAY [**2122-6-5**] at 10:25 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"599.0",
"285.9",
"V45.81",
"585.3",
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"459.81",
"584.9",
"427.31",
"428.0",
"041.4",
"518.89",
"V10.05",
"707.14",
"414.00",
"250.72",
"V58.61",
"428.33"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12610, 12663
|
8276, 10478
|
334, 341
|
12839, 12839
|
5075, 5075
|
13677, 14296
|
4039, 4071
|
11026, 12587
|
12684, 12684
|
10504, 11003
|
13022, 13483
|
4111, 5056
|
13503, 13654
|
262, 296
|
3127, 3507
|
369, 3109
|
5091, 8253
|
12703, 12818
|
12854, 12998
|
3529, 3778
|
3794, 4023
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,972
| 167,704
|
3589
|
Discharge summary
|
report
|
Admission Date: [**2144-6-24**] Discharge Date: [**2144-6-25**]
Date of Birth: [**2092-5-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Small bright red blood in vomitus
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
52yoM with h/o HepC cirrhosis c/b varices presenting with
hematemsis. Patient receives most of his care at [**Hospital1 2025**]. He is
s/p TIPS with TIPS revision 6weeks ago. He was in his normal
state of health until DOA when he developed nausea. At about
5:30pm that night he had a "small amount" of hematemesis, less
than [**11-25**] cup. Hematemesis was associated with worsening of his
chronic RUQ pain, prompting presenation to [**Hospital1 18**] ED. In the ED
initial vitals T 99.5 HR 86 BP 130/65 RR 14 98%RA. Hct 30.7.
He received 1L NS, 40mg iv Protonix, and octreotide gtt
started. NG lavage was negative. In the ED his FS was 515 and
5units regular insulin given. Pt. admitted to MICU.
Past Medical History:
diabetes, hepatitis C cirrhosis on transplant list, tips proc
[**6-27**], chole [**9-27**], h/o nephrolithiasis, IV substance abuse
Social History:
SHx: homeless x6mos, on disability
Tob: 1/2ppd x 40yrs
EtOH: none, h/o abuse, quit 3yrs ago
Illicits: none, h/o abuse, ivdu last used [**2117**]
Family History:
NC
Physical Exam:
PE: T 98.0 HR 78 BP 118/60 RR 11 98%RA
Gen: alert, cooperative, NAD
HEENT: PERRL, anicteric, OP clear, MMM
Neck: supple, no LAD, JVP flat
CV: RRR, no mrg
Resp: CTAB
Abd: +BS, soft, ttp RUQ with guarding, no rebounding, no masses
Ext: no edema, 2+ DPs
Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout, no
asterixis
.
Pertinent Results:
EGD revealed no significant varices. No active bleeding seen.
Several small very minor esophageal erosions. Otherwise
negative EGD.
Brief Hospital Course:
# UGIB: Concerning for variceal bleed. DDx also includes
gastropathy, [**Doctor First Name 329**]-[**Doctor Last Name **], PUD. hemodynamically stable
- two 16-gauge piv were placed
- [**Hospital1 **] iv PPI started
- octreotide gtt started
- levofloxacin started in anticipation of EGD
- Type&screen
- serial hct's revealed stable Hct
- EGD was negative for any significant varices or bleeds, c/w
esophagitis. Pt kept on PPI, started on 1-week course of
sucralfate.
# HepC cirrhosis: c/b history of varices.
- Held lasix/spironolactone given concern for bleeding and
hypotension
- continue lactulose per outpt regimen 30ml QID
- restarted all outpt meds after nl EGD.
- will f/u with his hepatology team at [**Hospital1 2025**]
.
# TIIDM: hyperglycemia may be due to patient not taking
insulin this evening vs infection given c/o nausea. patient has
non-gap acidosis more consistent with GI losses than
ketoacidosis
- check UA
- continue NPH; 1/2 dose while NPO
- supplement with RISS
- restarted on original dose before discharge.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day). ML(s)
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO every eight (8)
hours for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Esophagitis
Minor upper GI bleed
Discharge Condition:
Good - Patient is tolerating oral intake, ambulating
independently, and has returned to his baseline condition.
Discharge Instructions:
Please continue taking your insulin, lactulose, lasix,
spironolactone, and protonix as prescribed. Take sucralfate 3
times per day for one week. If you have any further vomiting,
abdominal pain, bloody vomit, vomit that looks like coffee
grounds, or black/tarry stools, return to your doctor or the
emergency department.
Followup Instructions:
Follow up with hepatology service at [**Hospital1 2025**] as previously
scheduled.
Follow up with your PCP [**Last Name (NamePattern4) **] [**12-27**] days
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2144-6-25**]
|
[
"571.5",
"070.70",
"537.9",
"250.00",
"578.9",
"530.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
3592, 3598
|
1974, 3032
|
355, 361
|
3674, 3788
|
1816, 1951
|
4159, 4481
|
1440, 1444
|
3055, 3569
|
3619, 3653
|
3812, 4136
|
1459, 1797
|
282, 317
|
389, 1102
|
1124, 1257
|
1273, 1424
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,538
| 149,772
|
25441
|
Discharge summary
|
report
|
Admission Date: [**2186-6-25**] Discharge Date: [**2186-7-4**]
Date of Birth: [**2110-6-13**] Sex: M
Service: MEDICINE
Allergies:
Versed / Codeine / Haldol / Benzodiazepines
Attending:[**First Name3 (LF) 14961**]
Chief Complaint:
cc: fever, AMS
Major Surgical or Invasive Procedure:
PICC placement and removal
NGT placement x 2 and removal
History of Present Illness:
History of Present Illness: 76yo M with AF, LB dementia, h/o GIB
and recent right Tib/Fib fracture s/p ORIF who presented to ED
with fever, respiratory distress and altered mental status. Pt
intubated apon arrival to ED for protection of airway given AMS.
Per wife; Pt has had several days of worsening MS in setting of
not returning to baseline after recent orthopaedic procedure.
During this time has had low grade fevers without possible
source of infection. This AM was found to be febrile to 104 for
which he recieved a dose of CTx prior to transferring to [**Hospital1 18**]
ED. Per report wound has looked good and dressing changes
without alarm. No diarrhea. No N/V. Pt with h/o GIB but no
reported melena/BRBPR/Hematemesis.
.
ED Course: Initial VS-> 105, 100, 104/65, 15 96% NRM. Intubated
for AMS and inability to protect airway. Recieved
Vanc/Levo/Flagyl. Given fever, was triaged as per code sepsis.
Past Medical History:
1. Atrial fibrillation: not anticoag [**3-2**] falls
2. [**Last Name (un) 309**] body dementia: h/o hallucinations resulting in severe
agitation with h/o combative behavior, on quetiapine tid + prn
at rehab
3. H/o GI bleed: [**3-2**] esophageal erosions, on PPI
4. CVA: [**3-2**] PFO
5. recent TIB/FIB Fx s/p ORIF R ankle bimalleolar fx and IM nail
tibia fracture
Social History:
married, retired general surgeon, lives at [**Hospital 599**] nursing home,
was ambulating independently; h/o tobacco- 3ppd, quit 40y ago;
occ EtOH, no drugs
Family History:
NC
Physical Exam:
Physical Exam:
vitals- T 99.2, 103, 115/70, 19 100% [AC 600x12/5/100%]
.
General- Intubated and Sedated
HEENT- PERRL, anicteric, noninjected, ETT in place, MMM, right
nasal packing
Pulm- diffuse rhonchi
CV- irregularly irregular, 2/6 systolic murmur heard best at the
LLSB/apex
Abd- Soft, ND, no HSM, + bowel sounds x 4 quad.
Ext- RLE cast with anterior scar/staples. Incision c/d/i. No
obvious effusion but right medial knee warmer to touch than
left. Toes WWP b/l. LLE with no edema but venous stasis
changes, 2+ L DP pulse
Neuro- sedated, not following commands or opening eyes to
voice/tactile stimuls, moving all 4 extremities
Pertinent Results:
Labs:
[**2186-6-25**] 10:20AM BLOOD WBC-11.3* RBC-4.87 Hgb-11.9* Hct-35.5*
MCV-73* MCH-24.3* MCHC-33.4 RDW-19.3* Plt Ct-341#
[**2186-7-3**] 03:42AM BLOOD WBC-4.8 RBC-4.04* Hgb-9.9* Hct-31.4*
MCV-78* MCH-24.6* MCHC-31.6 RDW-21.7* Plt Ct-387
[**2186-6-25**] 10:20AM BLOOD Neuts-75.9* Lymphs-18.0 Monos-5.8 Eos-0.1
Baso-0.3
[**2186-6-25**] 10:20AM BLOOD Hypochr-1+ Anisocy-2+ Microcy-3+
[**2186-6-25**] 10:20AM BLOOD PT-13.8* PTT-25.3 INR(PT)-1.2*
[**2186-6-25**] 10:20AM BLOOD Plt Ct-341#
[**2186-6-30**] 06:10AM BLOOD PT-14.7* PTT-32.2 INR(PT)-1.3*
[**2186-7-3**] 03:42AM BLOOD Plt Ct-387
[**2186-6-25**] 04:19PM BLOOD ESR-10
[**2186-7-1**] 06:00AM BLOOD LMWH-0.31
[**2186-7-3**] 11:51PM BLOOD LMWH-PND
[**2186-6-25**] 10:20AM BLOOD Glucose-105 UreaN-27* Creat-1.2 Na-133
K-4.5 Cl-98 HCO3-22 AnGap-18
[**2186-7-3**] 03:42AM BLOOD Glucose-104 UreaN-15 Creat-0.7 Na-140
K-3.9 Cl-108 HCO3-26 AnGap-10
[**2186-6-25**] 10:20AM BLOOD ALT-40 AST-54* LD(LDH)-362* CK(CPK)-268*
AlkPhos-95 Amylase-75 TotBili-0.6
[**2186-6-25**] 10:20AM BLOOD Lipase-51
[**2186-6-25**] 10:20AM BLOOD CK-MB-1
[**2186-6-25**] 10:20AM BLOOD cTropnT-<0.01
[**2186-6-25**] 10:20AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.1
[**2186-6-29**] 05:40AM BLOOD Albumin-2.5* Calcium-7.7* Phos-2.5*
Mg-1.9
[**2186-7-2**] 06:15AM BLOOD Calcium-7.6* Phos-3.3 Mg-2.1
[**2186-7-1**] 06:00AM BLOOD Triglyc-43
[**2186-7-2**] 06:15AM BLOOD Triglyc-38
[**2186-6-28**] 03:35AM BLOOD TSH-0.90
[**2186-6-25**] 10:20AM BLOOD Cortsol-23.8*
[**2186-6-25**] 04:19PM BLOOD CRP-12.3*
[**2186-6-25**] 11:05AM BLOOD pO2-287* pCO2-31* pH-7.48* calHCO3-24
Base XS-1
[**2186-6-25**] 03:19PM BLOOD Type-ART Rates-16/ Tidal V-600 PEEP-5
FiO2-50 pO2-101 pCO2-31* pH-7.43 calHCO3-21 Base XS--2
[**2186-6-27**] 10:13AM BLOOD Type-ART Temp-38.1 Rates-/21 O2 Flow-3
pO2-114* pCO2-33* pH-7.42 calHCO3-22 Base XS--1 Intubat-NOT
INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2186-6-25**] 10:48AM BLOOD Lactate-2.2*
[**2186-6-25**] 03:19PM BLOOD Lactate-1.2
.
Micro:
Bl cx [**6-25**] - no growth; [**6-30**] x 2 - NGTD
U cx [**6-25**], [**6-30**] - no growth
[**2186-6-25**] 6:34 pm STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2186-6-27**]**
FECAL CULTURE (Final [**2186-6-27**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2186-6-27**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2186-6-26**]):
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). .
REPORTED BY PHONE TO K. ELDREKIN 1455 [**2186-6-26**].
[**2186-6-25**] 8:32 pm SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2186-6-28**]**
GRAM STAIN (Final [**2186-6-25**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2186-6-28**]):
RARE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
Imaging:
DVT [**2186-6-25**]:
No evidence of DVT. Examination of popliteal veins was
suboptimal see comments above.
.
CTA Chest [**6-25**]:
IMPRESSION:
1. Pulmonary emboli within right lower lobe segmental and
subsegmental arteries.
2. Bibasilar airspace opacities, right greater than left, which
are nonspecific and may represent atelectasis or aspiration.
Developing infarction in the right lower lobe cannot be fully
excluded.
3. Feeding tube with tip positioned in a large axial hiatal
hernia, directed cephalad.
4. Small right pleural effusion.
.
EKG [**6-25**]
Atrial fibrillation with a moderate ventricular response. Left
axis deviation with left anterior fascicular block. Probable old
lateral myocardial infarction. Compared to the previous tracing
of [**2186-6-14**] no significant diagnostic change.
.
TIB/FIB (AP & LAT) RIGHT PORT [**2186-6-27**] 10:19 AM
INTACT HARDWARE SPANNING ANATOMICALLY ALIGNED TIB/FIB FRACTURES
WITH NO PLAIN FILM EVIDENCE OF OSTEOMYELITIS. POPLITEAL
ATHEROSCLEROSIS.
.
PICC LINE PLACMENT SCH [**2186-6-30**] 1:48 PM
Successful placement of right basilic vein 44 cm double-lumen
PICC line with the tip in the SVC. The line is ready for use.
.
UNILAT UP EXT VEINS US RIGHT [**2186-7-1**] 9:24 AM
RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler
son[**Name (NI) 1417**] of the right internal jugular, subclavian, axillary,
and brachial veins were performed. The cephalic and basilic
veins were not visualized. Heterogeneous material is seen in the
proximal axillary vein which did not compress. There was limited
blood flow demonstrated. The internal jugular, subclavian, and
brachial veins demonstrated normal color flow and
compressibility. 1. Partially occlusive thrombus in the right
axillary vein. These findings were discussed with Dr. [**Last Name (STitle) **]
following the examination.
.
CHEST (PORTABLE AP) [**2186-7-2**] 7:26 AM
FINDINGS: The previously visualized NG tube is not seen on the
current film. Again noted is a hiatal hernia. There is patchy
volume loss in the left lower lung. The right lateral lung is
off the film. The right subclavian line is unchanged. This
finding was called to the floor at time of dictating this
report.
Brief Hospital Course:
Dr. [**Known lastname 63569**] is a 76 yo gentleman with Atrial fibrillation, LB
dementia, h/o GIB and recent right Tib/Fib fracture s/p ORIF who
presents with fever and AMS. [**Hospital **] hospital course by
problem is summarized below.
.
# Fever/Sepsis: SIRS/Sepsis criteria met by
tachycardia/fever/tachypnea and suspected source. No definitive
source at presentation but at risk for septic arthritis or
infected hardware especially given physical examination. Patient
triaged as per code sepsis and transferred to [**Hospital Unit Name 153**]. CTA
performed and showed RLL subsegmental PE. Ortho eval felt sepsis
not related to leg. Patient started on heparin gtt and continued
on broad spectrum antibiotics. Patient then noted to have a
rash, ?drug fever/rash, Tm 105, flagyl d/ced. Stool then came
back + for C.diff, flagyl restarted. Patient extubated and
sating on 3L NC. NGT fell out and replaced as well. Levo also
d/ced for ?drug rash. Patient changed to po vanco for ongoing
fevers thought to be [**3-2**] C.diff. Patient's MS slightly improved,
following commands. Patient transferred to medical floor in
stable condition. On the floor, patient continued to improve
initially slowly. He pulled out his NGT on [**7-2**] and it was not
replaced. Due to his improved mental status, swallowing pills
with thickened liquids was attempted by nursing and he seemed to
do well. He continued to fail his speech and swallow evaluations
however. After discussions with all teams involved, it was felt
that the patient would likely continue to aspirate and he would
be better off without an NGT or TPN for nutrition. He continues
to tolerate his pills crushed with thickened liquids. The hope
is that his diet will be advanced as he continues to improve. HE
has been afebrile for several days and is discharged on a course
of po flagyl/vanco to be continued for a 2 week course up to
[**2186-7-14**]. Of note, he was started of IV Vanco on [**6-30**] due to
persistent fevers and +MRSA in his sputum which seems to improve
his overall clinical course.
.
# AMS: Exacerbated by infection with underlying dementia. As Pt
became afebrile on antibiotics, MS cleared to baseline. Seroquel
held for depressed MS during this hospital stay.
.
# Hypotension: Transient in setting of sedation and intubation.
Received IVF upon admission. Maintained stable SBP 100's and
adequate CVP. No need for pressors. Currently stable.
.
# Afib. Well rate controlled off meds, transiently tachy to 160
however has been well rate controlled majority of time.
Lopressor prn for RVR.
.
# Mechanical Ventilation: Patient intubated for airway
protection. No difficulty with ventilation or oxygenation.
Patient self extubated while being weaned on pressure support.
Of note, patient is now confirmed DNR/DNI and DO NOT
HOSPITALIZE.
.
# PE/RUE DVT: Patient developed RLL segmental PE found on CTA
despite prophylaxis Lovenox. Then developed a partial thrombus
in the R axillary vein in the setting of PICC placement. Factor
Xa determined to be 0.3 (therapeutic range 0.6-1.0) while on 80
mg Lovenox [**Hospital1 **]. Patient to be discharged on 100 mg lovenox [**Hospital1 **]
with repeat Factor Xa pending. Patient was transiently on a
heparin gtt however will be maintained on Lovenox.
.
# H/O GIB: [**3-2**] esophageal erosions; at risk given
anticoagulation. Hct has remained stable despite guaiac positive
stools. Pt maintained on PPI.
.
# PD/Dementia: c/w seroquel
.
# FEN: Transiently on tube feeds then TPN, currently without
access for feeds, will take POs as tolerated despite aspiration
risk. Diet: ground, honey thickened asp precautions, S+S eval.
.
# PPx: HOB>30 deg, PPI, Lovenox -->f/up Factor Xa repeat level
.
CODE STATUS: DNR, DNI, DNH
Medications on Admission:
Acetaminophen 325-650 mg PO Q4-6H:PRN
Bisacodyl prn
Docusate prn
Heparin IV SS
Vit D
Vancomycin Oral Liquid 250 mg PO Q6H
Quetiapine Fumarate 25 mg PO BID
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
Metronidazole 500 mg PO TID
Levothyroxine Sodium 37.5
Lansoprazole Oral Suspension 30 mg NG [**Hospital1 **]
Discharge Medications:
1. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
4. Levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for agitation.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Lovenox 100 mg/mL Solution Sig: One (1) Subcutaneous twice a
day.
10. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every eight (8) hours for 14 days.
11. Outpatient Lab Work
Please check BMP and CBC on [**2186-7-6**]
12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 11 days.
13. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO four times
a day for 11 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
c.diff colitis
pulmonary embolus
R axillary vein thrombus
Dementia
A.fib
Chronic Aspiration
?MRSA pneumonia
Discharge Condition:
fair - stable
Discharge Instructions:
Continue medications as listed.
Followup Instructions:
Please schedule followup with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 719**].
Completed by:[**2186-7-4**]
|
[
"294.10",
"038.9",
"008.45",
"745.5",
"427.31",
"482.41",
"996.74",
"693.0",
"415.19",
"507.0",
"453.8",
"995.91",
"331.82",
"E930.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"99.15",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14122, 14194
|
8927, 12658
|
319, 378
|
14346, 14362
|
2577, 8904
|
14442, 14612
|
1902, 1906
|
13021, 14099
|
14215, 14325
|
12684, 12998
|
14386, 14419
|
1936, 2558
|
265, 281
|
434, 1324
|
1346, 1711
|
1727, 1886
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,099
| 194,038
|
25631
|
Discharge summary
|
report
|
Admission Date: [**2174-2-11**] Discharge Date: [**2174-2-15**]
Date of Birth: [**2118-10-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Pituitary macroadenoma
Major Surgical or Invasive Procedure:
[**2-11**] Transphenoidal Pituitary resection and lumbar drain
placement
History of Present Illness:
patient was recently admitted to [**Hospital1 18**] from [**2173-12-19**] - [**2173-12-21**] for
syncopal episode, found to have suprasellar mass on CT, and
confirmed to have 2.6 x 1.4 x 1.2 cm pituitary mass with some
focal hemorrhage infarction. She was seen by neurosurgery as an
inpatient, found to be neurologically intact and was discharged
to see endocrinology as an outpatient and further neurosurgical
evaluation. The patient missed her outpatient endocrine initial
appointment on [**2173-12-31**], and had cancelled neurosurgical follow
up. Multiple attempts to contact the patient went unanswered and
multiple messages were left (see OMR notes). When I spoke to the
patient today, she states that she was in "denial" and had fear
and apologizes for the lack of contact and follow up. During a
neuro-ophthalmology appointment on [**2174-1-26**], endocrinology was
contact[**Name (NI) **] and we were able to talk to patient to schedule
appropriate follow up and outpatient testing. The patient was
seen by neurosurgery in clinic on [**2174-1-27**], and
scheduled for surgery due to the size and location of the
lesion. She has intact visual fields as assessed by
neuro-ophthalmology. Her endocrine labs done in the past month
are consistent with a likely nonfunctioning pituitary
macroadenoma. Her gonadotropins are lower than would be expected
for her post-menopausal state, and her thyroid and cortisol axes
are intact. Her 1 mg
Dex-suppression test suppressed to 3 which does not completely
rule out Cushings. A normal IGF-1 level was done to rule out
Acromegaly. Her prolactin level was mildly elevated at 24.
She was electively admitted on [**2-11**] to undergo said procedure
Past Medical History:
Hypertension
Hypercholesterolemia
Depression/Anxiety
Roux-en-y gastric bypass in [**2170-8-18**].
Diabetic prior to gastric bypass
Pituitary Macroadenoma
Social History:
Separated with two grown children. Works at Stop and Shop in
[**Last Name (un) 33487**] as a Cashier. No smoking or alcohol.
Family History:
M: CAD. F: died of some type of heart disorder at age of 45, ?
CAD. Brother: MI at age 47. Maternal aunt: breast cancer. No
pituitary dysfunction or other endocrine problems in the family.
Physical Exam:
On discharge: Pt is awake, alert and oriented x3. Pupils are
equeal round react to light. Conjugate gaze. No nystagmus.
Headaches have been controlled with oral narcotic analgesics.
Speech is fluent and clear. No paraphrasic errors. Motor
strength is [**3-22**] throughout all muscle groups. There is no
tremor. She is tolerating all po food and fluids well and has
not had any residual nausea or vomiting. The prior drain site
is clean and dry. There is no bleeding or drainage from the
prior lumbar drain site. The patient has remained afebrile with
minimal nasal drainage and congestion.
Pertinent Results:
Labs On Admission:
[**2174-2-12**] 04:08AM BLOOD WBC-10.8# RBC-4.53 Hgb-12.7 Hct-37.8
MCV-84 MCH-28.1 MCHC-33.7 RDW-14.7 Plt Ct-263
[**2174-2-12**] 04:08AM BLOOD PT-12.8 PTT-25.9 INR(PT)-1.1
[**2174-2-12**] 04:08AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9
[**2174-2-11**] 10:47PM BLOOD Osmolal-298
Labs on Discharge:
Imaging:
Head CT [**2-11**]:
FINDINGS:
The sella is enlarged and measures 13.8 mm in AP diameter. Again
noted is a
heterogeneous mixed attenuation mass arising from the sella and
extending into the suprasellar region, best demonstrated on the
MRI that was concurrently performed. There is calcification of
the bilateral cavernous carotid arteries. The left carotid
artery is incompletely covered by bone (series 2, image 26). The
right carotid artery is completely covered by bone. The sphenoid
sinuses and sphenoethmoid recesses are clear. There is no
definite evidence for erosion of the clivus. The sphenoid sinus
septum inserts approximately 8 mm laterally from the right bony
carotid canal.
The bilateral maxillary antrum, frontal sinuses, and ethmoid air
cells are
clear. The nasal cavity is clear. There is slight septal
deviation to the
left. The bilateral OMUs are patent. The lateral wall of the
infundibulum is formed by the medial wall of the orbit. The
cribriform plates are asymmetric in height, the right one lower
than the left ([**Last Name (un) 36826**] type 1 classification). The visualized
portions of the brain parenchyma are unremarkable. There is a
focal area of hyperdensity of similar
attenuation to the skull likely representing a calcified
meningioma or
exostosis. There is no hypodensity in the underlying frontal
lobe to suggest edema.
IMPRESSION:
1. Pituitary mass with extension from the sella to the
suprasellar region
with no evidence of clival invasion.
2. Paranasal sinus anatomy as detailed above. Dehiscence of a
portion of the left bony carotid canal.
MRI Head [**2-11**]:
INDINGS: Images through the brain demonstrate no evidence of
acute infarct.
No mass effect or hydrocephalus is seen. No focal abnormalities.
Images through the sella demonstrate postoperative changes which
are new since the previous MRI examination of [**2174-2-11**]. Fluid and
high intensity material are seen within the sphenoid sinus and
the posterior nasal passage. This is likely related to packing
from surgery. A small amount of soft tissue changes are seen in
the sellar and suprasellar region with mild enhancement. The
majority of the soft tissue mass identified in the sellar and
suprasellar region has been resected. The subtle enhancing
lesions could be residual mass or due to some postoperative
enhancement.
IMPRESSION:
1. No evidence of acute infarcts or mass effect.
2. Postoperative changes within the sphenoid sinus and posterior
nasal
passage and in the pituitary region with high intensity packing
material. No hemorrhage. Although, high density material is seen
within the pituitary
fossa, No intracranial hemorrhage seen. Majority of the mass has
been removed with subtle enhancing soft tissues seen in the
suprasellar region with decreased mass effect on the optic
chiasm.
Brief Hospital Course:
Pt went to O.R. [**2174-2-11**] for a transsphenoidal pituitary tumor
resection as scheduled. She remained neurologically intact
(including visual acuity and visual fields). She had the
intraoperative lumbar drain removed on [**2174-2-15**] without event.
She has been closely monitored for change in neurologic status,
as well as for any evidence of Diabetes Insipidus or SIADH. She
has not displayed symptoms consistent with either. Endocrinology
has been following and guiding the Prednisone therapy and will
continue to do so as an outpt.
Medications on Admission:
Lisinopril 20 mg daily
Simvastatin 40 mg qhs
Wellbutrin 300 mg daily
Celexa 40 mg daily
Stool softener [**Hospital1 **]
Discharge Medications:
1. Outpatient Lab Work
Please have your Cortisol level drawn on the morning of your
appointment with Dr. [**Last Name (STitle) **]. Please make sure NOT TO TAKE
your prednisone prior to this level being drawn.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Prednisone Oral
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Bupropion 150 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
12. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary macroadenoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Continue Sinus Precautions for an additional two weeks. This
means, no use of straws, forceful blowing of your nose, or use
of your incentive spirometer.
?????? You have been discharged on Prednisone, take it daily as
prescribed.
?????? You are required to take Prednisone, an oral steroid, make
sure you are taking a medication to protect your stomach
(Prilosec, Protonix, or Pepcid), as this medication can cause
stomach irritation. Prednisone should also be taken with a
glass of milk or with a meal.
CALL YOUR DOCTOR 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.
?????? It is normal for feel nasal fullness for a few days after
surgery, but if you begin to experience drainage or salty taste
at the back of your throat, that resembles a ??????dripping??????
sensation, or persistent, clear fluid that drains from your nose
that was not present when you were sent home, please call.
?????? Fever greater than or equal to 101?????? F.
?????? If you notice your urine output to be increasing, and/or
excessive, and you are unable to quench your thirst, please call
your endocrinologist.
Please keep track of your headaches. You should notice
improvement daily. If they worsen please notify your surgeon.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with your
surgeon, Dr. [**First Name (STitle) **], to be seen in two months. You will need a CT
scan of the brain without contrast prior to your appointment.
??????You have an appointment scheduled with [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**],
M.D.(endocrinologist) Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2174-2-21**]
5:00. please call if you require directions or need to change
your appointment time.
Completed by:[**2174-2-15**]
|
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1,228
| 112,020
|
3209
|
Discharge summary
|
report
|
Admission Date: [**2178-5-8**] Discharge Date: [**2178-6-13**]
Service: ICU
CHIEF COMPLAINT: Decreased hematocrit, increased INR.
HISTORY OF THE PRESENT ILLNESS: The patient is an
84-year-old male who presented for outpatient ERCP and was
found to have a newly diminished hematocrit to 17 and newly
increased INR to 3.0. The patient had recently been
diagnosed with diabetes mellitus three months ago and started
on insulin. Approximately 3 1/2 weeks ago, the patient
developed dark urine and went to his primary care physician
who noted jaundice and had the patient go for a CT of the
abdomen where a mass in the head of the pancreas was seen.
The patient was scheduled for outpatient ERCP on the day of
presentation.
Upon presentation, he noted melenic dark black stools mixed
with some [**Male First Name (un) 1658**]-colored stools, fatigue, back pain, early
satiety and some decreased appetite. The patient was
admitted to the General Medical Service and Gastroenterology
was consulted for ERCP. The patient was evaluated and
concern for pancreatic carcinoma led to scheduling for an
ERCP. There was also concern for a possible biliary
obstruction given the elevated alkaline phosphatase of 1,818
and total bilirubin of 12.4 and so the procedure was also for
the purpose of decompression.
On the day after admission, the patient had received 2 units
of packed red blood cells and had a CT of the abdomen which
revealed a 3.2 cm mass in the head of the pancreas with clear
fat planes between the mass and all surrounding abdominal
organs with vascular structures intact with the exception of
the mass which abutted and possibly invaded the duodenum.
The SMV, portal vein, SMA, gastroduodenal artery and stomach
were all free from involvement. There was massive intra and
extrahepatic biliary ductal dilatation and pancreatic ductal
dilatation upstream to the pancreatic head mass. Incidental
finding of a small left renal cyst versus angiomyolipoma was
noted.
The patient had episodic desaturations to the low 70s to 80s
which improved to 90s with supplemental oxygen. Chest x-ray
done at one of the episodes revealed diffuse interstitial
opacities, raising a question of pulmonary edema versus
lymphangitic spread versus atelectasis with collapse versus
pneumonia. The patient received a trial of IV Lasix and
concern for ongoing clinical deterioration led to the
consideration for ICU level care.
On [**2178-5-10**], the patient was found to be very short of
breath, saturating mid 90s on a 100% nonrebreather. The
patient's white blood cell count was noted to continue to
rise into the mid 20s and his renal function was found to
decline with a creatinine of 2.2 concerning for ATN. There
was concern for evolving sepsis in the setting of biliary
obstruction and possible cholangitis. The patient had been
started on ceftriaxone and Flagyl for antibiotic coverage.
The patient was electively transferred to the ICU and
evaluated for emergent biliary decompression.
Infectious Disease was consulted and recommended that the
patient undergo treatment with Zosyn 2.25 grams IV q. eight
hours. The patient was admitted to the ICU. The patient's
hematocrit was noted to continue to be low and he was given 3
units of packed red blood cells along with vitamin K 10 mg
subcutaneously for an elevated INR. The patient's hypoxia
was thought to be secondary to multilobar pneumonia versus
evolving ARDS. There was concern about the need to intubate
preprocedure in order to enable the patient to undergo ERCP.
The patient's acute renal failure was thought secondary to
possible prerenal state in the setting of sepsis.
Renal was consulted for further evaluation of the patient's
acute renal failure and it was felt that the patient's acute
renal failure was secondary to acute interstitial nephritis
in the setting of treatment with Zosyn. The Zosyn was
discontinued and the patient underwent supportive care with
avoidance of nephrotoxins and discontinuation of the
patient's angiotensin receptor blocker.
At 7:35 p.m. on [**2178-5-10**], the patient was intubated for
progressive hypoxemia. The patient underwent emergent ERCP
which showed a giant ulcer in the posterior vault, evidence
of previous cholecystectomy, biliary stricture compatible
with known tumor in the head of the pancreas. The patient
was continued on broad spectrum antibiotics. There was
inability to place this biliary stent on the first attempt.
The patient returned to the ERCP Suite on [**2178-5-11**] and
sphincterotomy was performed with a coated walled stent
placed in the distal common bile duct. There was concern for
malignant ulcer in the posterior duodenal bulb, distal common
bile duct stricture consistent with the known tumor in the
head of the pancreas. Surgery was consulted for a possible
Whipple procedure; however, given the patient's current
clinical status at this time, no surgical intervention was
needed at the time.
The patient was followed by Renal who recommended the use of
diuretics for volume control. Cortisol levels revealed that
the patient did not have any evidence of adrenal
insufficiency. He transiently required pressors consisting
of Levophed but this was eventually able to be weaned off.
The patient was bronchoscoped for evaluation of pneumonia
versus ARDS. The patient's pancreatic and liver function
tests diminished after ERCP. The option of dialysis was
presented and the family elected not to partake of this. The
patient's volume was able to be controlled with intravenous
diuretics. The patient was ventilated with low tidal volumes
and increased respiratory rate per the ARDS net protocol.
An esophageal balloon was used to guide the patient's PEEP
requirement and this suggested ARDS as the patient had
increased chest wall and abdominal pressures. The patient's
ICU course was also complicated by hyponatremia which
warranted increased free water boluses. The patient required
an insulin drip for glycemic control which was worse in the
setting of infection. The patient underwent diuresis to try
to decrease the amount of FI02 that he was requiring.
By [**2178-5-23**], the patient showed improvement in his
ventilatory requirements as well as ability to come off
pressor agents. His acute renal failure continued to
improve. The Renal Service recommended a short steroid
course of prednisone to treat the patient's acute
interstitial nephritis. This was initiated with steady
improvement in the patient's creatinine which had reached a
high of 8.5. The patient developed some neutropenia which
was also felt to be due to a reaction of Zosyn. This
resolved spontaneously with discontinuation of the
medication. Also, in support of a reaction to Zosyn, the
patient developed a maculopapular rash. All of these
improved with the discontinuation of the drug.
The patient had been afebrile for a significant amount of his
ICU stay and around [**2178-5-21**], developed low-grade
temperature elevation and cultures were drawn. The patient
eventually grew MRSA from sputum, likely related to
ventilator-associated pneumonia. He was started on
vancomycin for treatment of this. Given the possible
presence of a drug reaction and some decreased urine output
and difficulty controlling the patient's volume, the patient
was diuresed with ethacrynic acid with good response. The
patient developed hematuria for which Urology consult was
obtained and this was thought to be secondary to ethacrynic
acid which is associated with gross hematuria and the patient
was diuresed further with Lasix in place of ethacrynic acid.
The patient developed a contraction alkalosis for which he
received Diamox with a good improvement. The patient's ARDS
was shown to resolve on serial chest x-rays. The patient
underwent weaning from the ventilator and his sedation was
changed from Ativan to propofol in the hope of achieving
sustained extubation.
On [**2178-6-4**], a family meeting was held with the plan to
discuss the need for reintubation after an extubation
attempt. The family elected to reintubate in the event of an
extubation failure. The patient was extubated successfully
on [**2178-6-4**]. He remained with a relatively high oxygen
requirement post extubation. He continued treatment for MRSA
pneumonia with vancomycin for a total course of ten days.
His acute renal failure resolved to a baseline creatinine of
1.4. As the patient was off sedation, his mental status
improved.
He developed oral lesions shortly after extubation which were
thought to be secondary to HSV.
The patient remained with tenuous respiratory status over the
next four days after extubation but did show slow but steady
improvement in his oxygen requirement.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus times 22 years.
2. Hypertension.
3. Hypercholesterolemia.
MEDICATIONS:
1. Humalog/Humulin sliding scale 17 units in the a.m., 8
units at h.s.
2. Lopressor 50 mg p.o. b.i.d.
3. Glyburide 5 mg p.o. b.i.d.
4. Cozaar 100 mg p.o. q.d.
5. Percocet p.r.n.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is married and did not smoke or
drink. He use to work as a truck manager for Ford Motors.
FAMILY HISTORY: The patient has a sister with diabetes and
chronic renal insufficiency. There is no history of
pancreatic malignancy in his family.
LABORATORY/RADIOLOGIC DATA: The patient had a white blood
cell count of 14.3 on admission with a hematocrit of 16.4 and
platelets of 341,000. His INR was 3.9. His ALT was 167, AST
221, total bilirubin 17.2, alkaline phosphatase 2,024,
amylase 28, total bilirubin 17.2 with a lipase of 233.
CT of the abdomen revealed a 3.2 cm mass in the head of the
pancreas, clear fat planes between the mass and all
surrounding abdominal organs and vascular structures with the
exception of the duodenum. SMV, portal vein, SMA,
gastroduodenal artery, and stomach were all free from
involvement. Massive intra and extrahepatic biliary ductal
dilatation was noted, pancreatic ductal dilatation upstream
of the pancreatic mass was noted. Small left renal cyst
versus angiomyolipoma was noted.
Chest x-ray revealed biapical pleural thickening, small
bilateral pleural effusion.
HOSPITAL COURSE: The patient was an 84-year-old male with a
pancreatic mass status post ERCP and stenting for biliary
obstruction with a complicated ICU course significant for
respiratory failure and acute renal failure.
1. PULMONARY: The patient underwent extubation on [**2178-6-4**]
and had ongoing difficulties with secretions and aspiration.
The patient oxygenated with steady improvement over the
course of several days postextubation. He was initially able
to be weaned to 4 liters of nasal cannula. His ARDS
continued to resolve on serial chest x-rays. He underwent
several bedside swallow evaluations which initially showed
severe aspiration but with time he was able to pass a bedside
swallow examination. ENT evaluated his vocal cords for vocal
cord dysfunction and he appeared to be able to protect his
airway. He completed a ten day course of vancomycin for MRSA
pneumonia. He continued to have aggressive pulmonary toilet
and continued to do well from a respiratory standpoint.
2. RENAL: The patient's acute renal failure resolved
completely to be better than baseline, creatinine of 1.4.
The patient's acute interstitial nephritis was thought to be
secondary to Zosyn. He completed a short course of steroids
which were tapered and continued to make adequate urine
output over the course of his admission.
3. NEUROLOGIC: The patient initially had depressed mental
status which was thought secondary to the heavy sedation
while intubated. As the sedation wore off, his mental status
cleared and he was able to participate in discussions of
level of care and was quite lucid and cooperative.
4. CARDIOVASCULAR: The patient did undergo an
echocardiogram which revealed LV ejection fraction of 70%,
mild diastolic dysfunction, no regional wall motion
abnormalities, normal right ventricular systolic function,
mild 1+ mitral regurgitation, moderate pulmonary
hypertension, moderate 2+ tricuspid regurgitation, and no
evidence of pericardial effusion. The patient had some
hypertension after extubation and was initially started on
Lopressor. His Lopressor dose was limited by bradycardia
while asleep at night and thus his Losartan was reinitiated
after his renal function improved. He was titrated up on his
Losartan to the maximal dose. The patient did have one run
of nonsustained ventricular tachycardia while in the ICU
limited to three beats. Given his normal ejection fraction
and no evidence of coronary artery disease on echocardiogram,
this was observed with telemetry. The use of beta blocker
will be helpful in limiting ventricular ectopy.
5. ENDOCRINE: The patient was maintained on a regular
insulin sliding scale and fingerstick blood sugar monitoring
for his diabetes mellitus. After extubation, he did not
require an insulin drip and was able to be maintained with
subcutaneous insulin.
6. GASTROINTESTINAL: The patient was with a pancreatic mass
concerning for pancreatic adenocarcinoma. Surgery was
reconsulted after the patient was extubated but continued to
feel that the patient was too deconditioned to undergo such a
significant abdominal surgery. Discussion was held with the
patient and his family including his son, [**Name (NI) **], and wife
and he elected not to consider surgery for his pancreatic
malignancy. It was stressed that based on the CT abdominal
findings of his recent examination that the tumor may be
resectable and Surgery confirmed this. Despite this
knowledge, the patient continued to wish to defer on surgery.
He was given the option to reconsider should he change his
mind.
Gastroenterology was consulted because of the patient's
intolerance of tube feeds after extubation. They felt that
it was possible that the patient had gastric outlet
obstruction secondary to a malignant ulcer versus extrinsic
compression from a pancreatic mass. The patient was
gradually able to tolerate p.o. alimentation and underwent a
video swallow examination which showed that he could tolerate
thin liquids with a chin tuck and ground solids. If he is
able to take adequate p.o. nutrition through this way, no
further workup was warranted. If the patient is not able to
nourish himself orally, a permanent enteric feeding tube
would need to be considered versus chronic total parenteral
nutrition. If PEG or PEG J tube were to be considered, the
patient may need to undergo upper GI series and esophagram to
evaluate the anatomy for possible placement of one of these
tubes. Multiple attempts were made to pass a NG tube in the
postpyloric position and were met with difficulty suggesting
the possibility of the pancreatic mass limiting the ability
to achieve a postpyloric tube even through interventional
radiology.
The patient's LFTs improved steadily throughout his
hospitalization.
7. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient
initially received tube feeds while intubated and then after
extubation was not able to tolerate even 10 cc an hour. He
was eventually able to pass a Speech and Swallow evaluation
and video swallow examination and Nutrition and Speech
Pathology aided in management of oral feeding. At the time
of this dictation, the patient was attempting to take in an
oral diet and if he fails this, consideration of an
alternative need for nutrition will need to be considered.
The patient also had his course complicated by hypernatremia
which was treated with free water boluses initially and then
IV D5W. It is hoped that the patient's hypernatremia will
improve as he begins to take more free water through oral
means.
8. PROPHYLAXIS: The patient was maintained on subcutaneous
heparin, Venodyne boots, and a proton pump inhibitor.
9. ACCESS: The patient has a left PICC line in place.
10. CODE STATUS: The patient was DNR, but okay to intubate
throughout most of his admission.
11. COMMUNICATION: Communication was maintained between the
patient's family including himself, his wife, and his son,
[**Name (NI) **].
12. HEMATOLOGIC: The patient had a stable crit in the low
30s throughout the ultimate dates of his ICU admission.
CONDITION AT TRANSFER: Stable.
DISCHARGE STATUS: The patient was discharged to
rehabilitation placement. The patient should be discharged
on 4 liters of supplemental oxygen nasal cannula.
MEDICATIONS AT DISCHARGE:
1. Losartan potassium 100 mg p.o. q.d.
2. Metoprolol 50 mg p.o. t.i.d.
3. Vancomycin 1 gram IV q. 24 hours to be continued for two
more days.
4. Protonix 40 mg p.o. q.d.
5. Heparin subcutaneously 5,000 units q. 12 hours.
6. Sarna lotion one application b.i.d. p.r.n.
7. Miconazole powder 2% one application b.i.d. p.r.n.
8. Desitin one application q.d. p.r.n.
9. Albuterol, Atrovent, MDI two puffs inhaled q. four hours.
10. Lacrilube ointment one application to each eye t.i.d.
p.r.n.
11. Acetaminophen 650 mg p.o. q. four to six hours p.r.n.
12. Clorhexadine gluconate 15 milliliters p.o. t.i.d. p.r.n.
13. Potassium chloride 60 mEq p.o. q.d. given in three
separate doses as 20 mEq p.o. t.i.d.
DIET: Thin liquids with chin tuck and ground solids. If the
patient is found aspirating on thin liquids, he should be
switched to nectar consistency liquids. His diet should be
[**First Name8 (NamePattern2) **] [**Doctor First Name **] diet.
DIAGNOSIS:
1. Pancreatic mass concerning for pancreatic adenocarcinoma.
2. Biliary obstruction secondary to pancreatic mass.
3. Adult Respiratory Distress Syndrome.
4. Aspiration.
5. Acute renal failure secondary to acute interstitial
nephritis from Zosyn.
6. Hypertension.
7. Diabetes mellitus type 2.
8. Hypernatremia.
9. Methicillin-resistant Staphylococcus aureus pneumonia.
10. Neutropenia and drug rash to Zosyn.
11. Coagulopathy.
12. Contraction alkalosis.
13. Toxic metabolic encephalopathy now resolved.
14. Giant ulcer in the posterior bulb of the duodenum.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2178-6-12**] 02:59
T: [**2178-6-12**] 19:12
JOB#: [**Job Number 15042**]
cc:[**Name8 (MD) 15043**]
|
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8748, 9089
|
9106, 9210
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,330
| 172,298
|
17490
|
Discharge summary
|
report
|
Admission Date: [**2132-10-9**] Discharge Date: [**2132-10-11**]
Date of Birth: [**2049-3-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
83 year old male with PMH of ESRD on HD and CHF presenting from
HD session with lethargic and hypotension. Patient was noted to
be hypotensive and lethargic on arrival at HD session and
throughout his treatment and was noted to have no urine output
(oliguric at baseline). He was given vanc and gent at HD and at
the end of the session sent to the ED.
.
On arrival to the ED his initial BP was 88/47 and he was noted
to be somnolent but responsive to voices. He was bolused with
IVF and briefly went up to a SBP of ~100 but then went back
down. An attempt to place an IJ line failed and during the
procedure he became bradycardic.
.
Levophed was started peripherally and a femoral line was placed.
He was then intubated. A CXR showed a RLL PNA and he was started
on levoquin. An EKG showed precordial depressions, II and aVF,
V4-V6, and a troponin was 0.08 (near baseline in setting of
ARF). Given an aspirin.
.
At the time of transfer his blood pressures were failing to
adequately respond to levo at 0.27. BPs were ~88/44 and he was
being given additional fluids. Last temperature in the ED was
100.0. FS was 147. He received a total of ~3L IVF in the ED.
.
On arrival in the ICU initial VS were BPs 70s/40s and HR 90s.
.
Review of systems:
unable to obtain
Past Medical History:
Diabetes mellitus type I, dx [**2096**]
Diabetic retinopathy
ESRD on HD
Secondary hyperparathyroidism
Anemia [**1-1**] ESRD
Nephrotic syndrome
CHF, EF 50% (last echo [**5-5**])
mild tricuspid and mitral regurgitation
Essential HTN
Alzheimer's dementia
Depression
BPH with urinary retention and chronic indwelling foley catheter
recurrent UTIs and hematuria followed by urology
Social History:
Lives in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], a nursing facility in [**Location (un) 538**].
Has 4 children, son [**Name (NI) 449**] [**Name (NI) **] is his primary caretaker. Was
active in his church. No alcohol or illicit drug use, quit
smoking cigars years ago. Wife passed away in [**2128**].
Family History:
Non-contributory
Physical Exam:
Vitals: T: 98.3 BP: 107/59 P: 97 R:23 O2: 97%/FiO2 100%
General: Alert, oriented, no acute distress
HEENT: dry MM
Neck: unable to appreciate elevated JVP
Lungs: Coarse breath sounds bilaterally but no focal crackles,
no wheeze
CV: RRR no R/G/M appreciated
Abdomen: soft, non-tender, slightly-distended, +bowel sounds, no
rebound/guarding
Ext: cold, weak pulses, no edema
Pertinent Results:
Admission Labs
[**2132-10-9**] 09:04PM TYPE-ART TEMP-36.1 RATES-16/4 TIDAL VOL-460
O2-100 PO2-461* PCO2-47* PH-7.38 TOTAL CO2-29 BASE XS-2
AADO2-219 REQ O2-44 -ASSIST/CON INTUBATED-INTUBATED
[**2132-10-9**] 08:40PM LACTATE-4.9*
[**2132-10-9**] 05:30PM cTropnT-0.08*
[**2132-10-9**] 05:30PM WBC-11.3*# RBC-4.81 HGB-13.0* HCT-42.5 MCV-89
MCH-27.1 MCHC-30.6* RDW-15.9*
[**2132-10-9**] 05:30PM NEUTS-75* BANDS-13* LYMPHS-2* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2132-10-9**] 05:30PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL
OVALOCYT-2+ TEARDROP-OCCASIONAL FRAGMENT-OCCASIONAL
[**2132-10-9**] 05:30PM PLT SMR-NORMAL PLT COUNT-344
[**2132-10-9**] 05:30PM PT-15.5* PTT-25.1 INR(PT)-1.4*
[**2132-10-9**] 05:14PM GLUCOSE-132* LACTATE-4.6* NA+-145 K+-3.5
[**2132-10-9**] 05:14PM HGB-13.5* calcHCT-41
[**2132-10-9**] 05:00PM GLUCOSE-134* UREA N-26* CREAT-2.9* SODIUM-141
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-26 ANION GAP-18
[**2132-10-9**] 05:00PM estGFR-Using this
[**2132-10-9**] 05:00PM ALT(SGPT)-19 AST(SGOT)-24 LD(LDH)-316*
CK(CPK)-39* ALK PHOS-101 TOT BILI-0.4
[**2132-10-9**] 05:00PM LIPASE-11
[**2132-10-9**] 05:00PM CK-MB-2
[**2132-10-9**] 05:00PM ALBUMIN-3.4*
.
Micro Data-
[**2132-10-10**] 12:54PM BLOOD Hct-36.1*
[**2132-10-10**] 04:24AM BLOOD WBC-6.8 RBC-4.30* Hgb-11.9* Hct-37.6*
MCV-88 MCH-27.7 MCHC-31.6 RDW-15.6* Plt Ct-224
[**2132-10-10**] 04:24AM BLOOD Plt Smr-NORMAL Plt Ct-224
[**2132-10-9**] 05:30PM BLOOD Plt Smr-NORMAL Plt Ct-344
[**2132-10-9**] 05:30PM BLOOD PT-15.5* PTT-25.1 INR(PT)-1.4*
[**2132-10-10**] 08:12PM BLOOD Glucose-194* UreaN-37* Creat-2.3* Na-141
K-5.5* Cl-104 HCO3-9* AnGap-34*
[**2132-10-10**] 12:54PM BLOOD Glucose-164* UreaN-35* Creat-2.3* Na-140
K-4.1 Cl-105 HCO3-16* AnGap-23*
[**2132-10-10**] 04:24AM BLOOD Glucose-177* UreaN-30* Creat-2.4* Na-143
K-2.9* Cl-107 HCO3-22 AnGap-17
[**2132-10-10**] 05:40PM BLOOD CK(CPK)-1079*
[**2132-10-10**] 09:37AM BLOOD CK(CPK)-669*
[**2132-10-10**] 04:24AM BLOOD CK(CPK)-386*
[**2132-10-10**] 05:40PM BLOOD CK-MB-21* MB Indx-1.9 cTropnT-0.20*
[**2132-10-10**] 09:37AM BLOOD CK-MB-14* MB Indx-2.1 cTropnT-0.19*
[**2132-10-10**] 04:24AM BLOOD CK-MB-12* MB Indx-3.1
[**2132-10-10**] 12:31AM BLOOD cTropnT-0.15*
[**2132-10-10**] 08:12PM BLOOD Calcium-7.9* Phos-7.7*# Mg-2.4
[**2132-10-10**] 12:54PM BLOOD Calcium-7.9* Phos-3.3# Mg-2.2
[**2132-10-10**] 04:24AM BLOOD Calcium-8.4 Phos-1.4*# Mg-1.5*
[**2132-10-10**] 05:40PM BLOOD Vanco-5.2*
[**2132-10-10**] 06:11PM BLOOD Type-ART Temp-36.4 PEEP-5 pO2-144*
pCO2-28* pH-7.17* calTCO2-11* Base XS--16 Intubat-INTUBATED
[**2132-10-10**] 01:06PM BLOOD Type-ART Temp-36.6 Tidal V-450 PEEP-5
FiO2-50 pO2-153* pCO2-33* pH-7.31* calTCO2-17* Base XS--8
Intubat-INTUBATED
[**2132-10-10**] 12:36PM BLOOD Type-MIX Temp-36.6 Comment-ORAL
[**2132-10-10**] 09:54AM BLOOD Type-ART Temp-37.3 Rates-16/24 Tidal
V-450 PEEP-5 FiO2-50 pO2-193* pCO2-40 pH-7.30* calTCO2-20* Base
XS--5 Intubat-INTUBATED
[**2132-10-11**] 12:25AM BLOOD Lactate-17.6*
[**2132-10-11**] 12:11AM BLOOD Lactate-14.9*
[**2132-10-10**] 06:11PM BLOOD Glucose-98 Lactate-9.5* Na-139 K-4.8
Cl-110
[**2132-10-10**] 01:06PM BLOOD Lactate-6.3*
[**2132-10-10**] 12:36PM BLOOD Glucose-294* Lactate-6.8*
[**2132-10-11**] 12:25AM BLOOD O2 Sat-81
[**2132-10-11**] 12:11AM BLOOD O2 Sat-98
[**2132-10-10**] 06:11PM BLOOD Hgb-10.7* calcHCT-32 O2 Sat-98
[**2132-10-10**] 12:36PM BLOOD O2 Sat-69
[**2132-10-10**] 08:32PM BLOOD freeCa-1.09*
[**2132-10-10**] 07:02PM BLOOD freeCa-1.11*
[**2132-10-10**] 06:11PM BLOOD freeCa-1.07*
.
Micro Data
[**10-9**] Blood Cx.
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS SP..
SENSITIVITIES PERFORMED ON CULTURE # 309-9780G
([**2132-10-9**]).
Anaerobic Bottle Gram Stain (Final [**2132-10-10**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final [**2132-10-10**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**10-9**]
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS SP.. PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ S
LEVOFLOXACIN---------- S
VANCOMYCIN------------ S
Anaerobic Bottle Gram Stain (Final [**2132-10-10**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**2132-10-10**] 12:26PM.
Aerobic Bottle Gram Stain (Final [**2132-10-10**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
.
[**10-10**] Blood cx. pending
.
MRSA- pending
.
Reports
[**10-10**] CT head
FINDINGS: There is no intracranial hemorrhage, edema, mass
effect, or
vascular territorial infarction. Ventricles and sulci are
enlarged,
reflecting parenchymal volume loss. Periventricular white matter
hypodensities indicate chronic microvascular infarction. There
is no
fracture. Mastoid air cells are clear. Paranasal sinuses are
also clear.
IMPRESSION: No acute intracranial abnormality.
.
[**10-10**] X Ray of abdomen
FINDINGS: One frontal radiograph of the abdomen and one left
lateral
decubitus film demonstrates stool in the ascending and sigmoid
colon with a
relative paucity of air within the bowel. On left lateral
decubitus film,
there are minimal air-fluid levels, a nonspecific finding. No
evidence of
free air or pneumatosis. Note, a right femoral venous catheter
as well as a
nasogastric tube with side port at the level of the GE junction;
could be
advanced 2-3 cm. Bilateral pleural effusions better evaluated on
chest x-ray
with a minimally evaluated right middle lobe opacity, possibly
representing
pneumonia or atelectasis. Visualized osseous structures are
unremarkable.
IMPRESSION: Nonspecific bowel gas pattern. No evidence of
obstruction.
.
[**10-10**] EKG
Regular narrow complex rhythm with variation in the ST segment
and the
T to R segment suggesting atrial activity. Other ST-T wave
abnormalities.
Since the previous tracing atrial activity is now less apparent.
ST-T wave
abnormalities are less prominent.
.
[**10-10**] ECHO
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. There is
severe regional left ventricular systolic dysfunction with
near-akinesis of the inferior/inferolateral walls. There is
moderate hypokinesis of the remaining segments (LVEF = 20-25%).
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The ascending aorta is mildly dilated. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. An eccentric, jet of
moderate (2+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Dilated and hypertrophied left ventricle with severe
regional and global systolic dysfunction. Dilated right
ventricle with moderate systolic dysfunction. Mild aortic
stenosis. Moderate mitral and tricuspid regurgitation. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2131-12-10**],
biventricular cavity sizes are larger and biventricular systolic
function has further decreased. Pulmonary pressure is higher.
.
[**10-9**] CXR
FINDINGS: Consistent with the given history, an endotracheal
tube has been
introduced with the distal tip approximately 5.2 cm from the
carina in
appropriate position. A nasogastric tube has also been placed.
The sidehole
projects at the GE junction. Lung volumes remain low. Blunting
of bilateral
costophrenic angles likely indicate effusions. There is
persistent volume
loss in the right middle lobe, with prominence of the right
hilum, possibly
due to the low lung volumes. The possibility of a right lower
lobe infiltrate
or possible aspiration cannot be excluded on the basis of this
examination.
.
[**10-9**] EKG
Supraventricular rhythm may be sinus. Left atrial abnormality.
ST-T wave
abnormalities. Mild Q-T interval prolongation. Since the
previous tracing
ST-T wave abnormalities may be less.
.
Brief Hospital Course:
83 year old gentleman with ESRD on HD, systolic CHF and DM
presented with likely septic shock.
.
# Shock: likely septic given leukocytosis w/bandemia, elevated
lactates, e/o PNA on CXR and mixed venous sat ~80%. Unable to
track CVP as CVL is femoral.Trended lactates
which were trending up during the admission. The patient's blood
pressure continued to decrease and required pressors for
support. At the time of death he was on Vasopressin,
Norepinephrine and Phenylephrine. Given Piperacillin-Tazobactam
and Vancomycin and grew sensitive ENTEROCOCCUS in his blood.
.
# Respiratory Failure: hypoxic respiratory failure in ED with
desats unclear how low. No hypercapnea on post-intubation
ABG.Continued mechanical ventilation on assist control until
time of death
.
# UGIB: bloody NG suctioning (coffee groups), unclear etiology,
no known h/o UGIB.
Active type and screened was maintained and Hct remained stable
around 36.
.
# EKG changes: STDs and mildly elevated trops in setting of
hypotension and CKI. Cards consulted, felt unlikely acute plaque
rupture, no need to heparinize, trended cardiac markers with
troponin trending up to 0.2, and receieved an echo which
showed biventricular cavity sizes are larger and biventricular
systolic function has further decreased.Continued aspirin 325mg
daily (already received)
.
# ESRD: on dialysis TuThSat, LUE AV graft s/p angioplasty [**8-7**]
and [**11-6**]. Renal was following patient at the time of death.
.
[**2132-10-10**]
Patient noted to be asystolic on telemetry. Went to assess
patient. No spontaneous breaths, no heart sounds, pupils not
reactive to light, no corneal reflex, no carotid pulse, no
withdrawal to painful stimulation. Time of death pronounced
[**2132-10-11**] at 01:45am. Immediate cause of death: cardiac arrest.
Chief cause of death: Sepsis. Other antecedent causes: End
stage renal disease. Family notified; will not be able to come
in tonight. Family would like to discuss before deciding on
autopsy. Attending notified.
Medications on Admission:
-Docusate Sodium 100 mg PO BID
-Citalopram 30 mg daily
-B Complex-Vitamin C-Folic Acid 1 mg daily
-Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet
PO QID (4 times a day).
-Donepezil 10 mg QHS
-Simvastatin 20 mg daily
-Tamsulosin 0.4 mg Capsule, SR 24 hr PO QHS
-Hydrocodone-Acetaminophen 5-500 mg [**12-1**] PO Q6H prn pain
-Lisinopril 20-40 mg Tablets, 1 tablet PO 4x/week in evening on
non-dialysis days
-Oxybutynin Chloride 2.5 mg [**Hospital1 **]
-Humalog 100 unit/mL Solution Sig: 1 inj SQ QID per ISS
-Novolin N 100 unit/mL suspension 1 inj SQ q8am and q5pm: 16
units at 8am daily; 4 units at 5pm daily.
Discharge Medications:
Patient passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient passed away
Discharge Condition:
Patient passed away
Discharge Instructions:
Patient passed away
Followup Instructions:
Patient passed away
|
[
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"250.51",
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"600.01",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.04",
"38.91",
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] |
icd9pcs
|
[
[
[]
]
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14297, 14306
|
11555, 13566
|
328, 340
|
14369, 14390
|
2821, 6439
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14458, 14480
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2396, 2414
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14414, 14435
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2429, 2802
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6840, 11532
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1611, 1630
|
277, 290
|
368, 1592
|
1652, 2032
|
2048, 2380
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,398
| 173,489
|
49006
|
Discharge summary
|
report
|
Admission Date: [**2138-3-3**] Discharge Date: [**2138-3-6**]
Date of Birth: [**2062-9-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
Symptomatic bradycardia.
Major Surgical or Invasive Procedure:
Pacemaker placement.
History of Present Illness:
Ms. [**Known lastname 8389**] is a 75 year-old woman with a history of CAD s/p
CABG, bovine AVR, DVT on lovenox, and endometrial cancer s/p XRT
who is transferred from [**Hospital 882**] hospital for management of
symptomatic bradycardia, syncope.
She was in usual state of health until the morning of [**2138-3-3**]
when she had syncope while walking to the cafeteria and fell to
the ground. She denied prodrome, SOB, lightheadedness or CP
prior to the event. She did not have loss of bladder or bowel
function (although she has some stool incontinence at baseline).
She denied any numbness or tingling, weakness, or amnesia. ROS
was otherwise negative for fever, chills, headache, cough,
dysuria, melena, BRBPR.
She initially presented to [**Hospital1 112**] where vitals in the ED were 96.0
HR 60 BP 141/79 RR 18 100% RA. Her exam and labs were
unrevealing. CXR was negative. Head CT showed 3-4 cm hematoma.
For reasons that are unclear, she was then transferred to the
[**Hospital1 882**].
At the [**Hospital1 882**], she developed bradycardia to the 30s which
was found to be sinus arrest with narrow junctional escape. Her
rate increased spontaneously without atropine and [**Hospital1 1516**] pads were
placed. Cardiology was consulted and recommended transfer to
[**Hospital1 18**] for EP evaluation. On arrival to [**Hospital1 18**], she had a 10
second symptomatic pause on tele while on [**Hospital1 1516**] and transfer to
CCU was requested. On arrival to the CVICU, she denied chest
pain and dyspnea but noted a dizziness and light-headedness
associated with her bradycardic episodes. During evaluation, she
had another 10 second pause in which she was unresponsive,
followed by spontaneous recovery.
Cardiac review of systems is notable for absence of chest
pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations.
Past Medical History:
- AVR, bovine [**8-5**]
- CAD s/p CABG [**8-5**]
- HTN
- HLD
- DVT (RLE, popliteal and femoral) [**7-7**], on lovenox
- Endometrial cancer s/p XRT [**1-7**]
- Hysterectomy
- Tonic clonic seizure thought to be [**12-31**] PRES
- Bilateral hearing aids
Social History:
Widowed x 5 years, lives in [**Location (un) 18293**]. Has two sons and
works as telphone operator in the state lab.
-Tobacco history: quit in [**2134**]
-ETOH: occasional
-Illicit drugs: none
Family History:
Father died of throat cancer. Mother died of CAD, sister with
[**Name (NI) 2481**] disease, HLD, HTN.
Physical Exam:
GENERAL: nad
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no jvd
CARDIAC: brady, normal S1, S2. 2/6 SEM
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles.
ABDOMEN: Soft, NTND. midline lower abdominal scar, well-healed.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: 2 + DP
Left: 2+ DP
Pertinent Results:
Laboratory Results on Admission
[**2138-3-3**] 10:57PM BLOOD WBC-6.2 RBC-3.87* Hgb-12.3 Hct-34.9*
MCV-90 MCH-31.8 MCHC-35.2* RDW-13.1 Plt Ct-150
[**2138-3-3**] 10:57PM BLOOD PT-12.0 PTT-26.6 INR(PT)-1.0
[**2138-3-3**] 10:57PM BLOOD Glucose-114* UreaN-19 Creat-0.7 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2138-3-3**] 10:57PM BLOOD ALT-152* AST-29 LD(LDH)-238 CK(CPK)-87
AlkPhos-184* TotBili-0.9
[**2138-3-3**] 10:57PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2138-3-4**] 08:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2138-3-3**] 10:57PM BLOOD Calcium-8.5 Phos-3.7 Mg-2.1
[**2138-3-3**] 10:57PM BLOOD TSH-0.42
Laboratory Data on Discharge
[**2138-3-6**] 06:45AM BLOOD WBC-4.9 RBC-3.80* Hgb-11.9* Hct-34.2*
MCV-90 MCH-31.2 MCHC-34.7 RDW-13.2 Plt Ct-159
[**2138-3-6**] 06:45AM BLOOD Glucose-89 UreaN-20 Creat-0.8 Na-142
K-4.7 Cl-108 HCO3-27 AnGap-12
[**2138-3-4**] 08:15AM BLOOD CK(CPK)-75
[**2138-3-6**] 06:45AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2
EKG [**3-4**]
Sinus bradycardia. Left axis deviation. Left anterior fascicular
block. No
previous tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
56 132 94 440/433 43 -45 19
Echocardiography [**3-4**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. A mechanical
aortic valve prosthesis is present. The transaortic gradient is
normal for this prosthesis. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CXR [**3-5**]
PROCEDURE: Chest PA and lateral.
REASON FOR EXAM: Assess for lead placement following placement
of pacemaker.
FINDINGS: The new atrial and ventricular pacing leads appear in
satisfactory position. Mild linear atelectases along the left
heart border may be chronic. Lungs are are clear. No pleural
effusion or pneumothorax. Heart size is top normal with previous
median sternotomy and aortic valve replacement.
IMPRESSION: No acute cardiopulmonary findings. Satisfactory
placement of atrial and ventricular pacing leads.
Brief Hospital Course:
Precis
Ms. [**Known lastname 8389**] is a 75 year-old woman with a history of CAD s/p
CABG, bovine AVR, DVT on lovenox, and endometrial cancer s/p XRT
who is transferred from [**Hospital 883**] hospital for management of
symptomatic bradycardia and syncope. Permanent pace-maker was
placed without complication. Bradycardia and sinus pause were
attributed to age-related conduction system degeneration.
Hospital Course by Problem
Bradycardia
On the day of admission, Ms. [**Known lastname 8389**] had a 10 second symptomatic
pause. Atropine (0.5 mg IV) was given and dopamine started with
no further pauses, but a subsequent bradycardic episode to 40s
BPMs. Atropine was again given (1 mg IV), however on this
occasion she was sleeping and it was unclear whether this
bradycardia was symptomatic. Various causes of this were
excluded including electrolyte disturbance, ischemia (enzymes
flat), hypothyroidism (TSH normal), attributed to senile
degeneration of the conduction system with possible contribution
by atenolol. On the following day, a permanent pacemaker was
placed (please see Dr.[**Name (NI) 17720**] note for further specification of
this device and settings). Chest x-ray films showed good lead
placement without physiologic or radiographic evidence of
complication. She will follow-up with Dr. [**First Name (STitle) **] on [**3-13**] at 12:30
[**Hospital 2274**] [**Hospital **] clinic. Lovenox was
Syncope
Attributed to bradycardia or sinus pause. No head injury was
sustained.
Hypertension
Ms. [**Known lastname 91893**] antihypertensives were held in the setting of
bradycardia and hypotension. After pacer placement and
restoration of good ventricular rates, Ms. [**Known lastname 91893**] blood
pressure remained within the normal range (80s to 130s).
Half-doses, relative to pre-admission, were given and HCTZ was
not restarted. These all may require up-titration after
discharge.
Deep Venous Thrombosis
Course of Lovenox was to be stopped in [**Month (only) 404**] this year and
was not. Therefore this medication was stopped prior to pacer
placement and not restarted. There was initially some confusion
about whether this was to continue indefinitely in the context
of endometrial cancer, but this was resolved by discussion with
her PCP.
Coronary Artery Disease
Post-CABG. No evidence of ischemia during the admission, based
on history, symptoms, EKG and enzymes. Statin was continued and
atenolol continued at half the pre-admission dose.
Endometrial cancer
Treated with XRT and hysterectomy. Non-active and no related
investigations or treatment during the admission.
Medications on Admission:
atenolol 100 mg po daily
simvastatin 80 mg po daily
lisinopril 40 mg po daily
loperamide 2 mg po daily prn
hctz 25 mg po daily
lovenox 90 mg po daily
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Loperamide 2 mg Tablet Sig: One (1) Tablet PO once a day.
3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 doses.
Disp:*2 Capsule(s)* Refills:*0*
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
sick sinus syndrome - bradycardia with 10 second pauses
Secondary diagnosis:
Hypertension
Deep vein thrombosis
Status post endometrial cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you fell. You were found to
have a slow heart rate with long pauses. You were given a
pacemaker which will prevent this from happening in the future.
You tolerated the procedure well. Please refrain from lifting
more than 5 pounds raising your left arm above your shoulder for
6 weeks. There are no restrictions on your right arm. Keep the
dressing dry for 4 days, after that you can remove the dressing
and take a shower, leaving the steristrips in place. Do not use
soap over the site. You can return to work after Dr. [**First Name (STitle) **] says
it is OK.
The following changes have been made to your medication list:
**START Keflex 500 mg every 6 hrs for 2 doses
** decrease lisinopril to 20 mg a day
** Decrease atenolol to 50 mg a day
** stop HCTZ (please talk to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 11370**]g)
** STOP Lovenox shots (please talk to your primary care doctor
about restarting)
Please follow up with your primary care doctor and your
cardiologist (see below).
It was a pleasure taking part in your care.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 30186**].
We have made an appointment for you on Wed, [**3-19**] at 12:10
pm. If this time does not work, please call [**Telephone/Fax (1) 3530**] to
reschedule.
Please also follow up with Dr. [**First Name (STitle) **] in cardiology. You have an
appointment scheduled for [**3-13**] at 12:30 at the [**Hospital1 2292**] office. Please call ([**Telephone/Fax (1) 66291**] for directions or
if you need to change this appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
|
[
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"401.9",
"V42.2",
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icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
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icd9pcs
|
[
[
[]
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9092, 9098
|
5749, 8369
|
338, 361
|
9304, 9304
|
3409, 5726
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10584, 11206
|
2770, 2873
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8570, 9069
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9119, 9119
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8395, 8547
|
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274, 300
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391, 2268
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9216, 9283
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9138, 9195
|
9319, 9431
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2290, 2543
|
2559, 2754
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,880
| 105,160
|
22799
|
Discharge summary
|
report
|
Admission Date: [**2188-11-27**] Discharge Date: [**2188-12-2**]
Date of Birth: [**2144-12-16**] Sex: M
Service: MEDICINE
Allergies:
Levaquin in D5W
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Unresponsiveness/hypoglycemia
Major Surgical or Invasive Procedure:
-Mechanical Ventilation
History of Present Illness:
This is a 43yoM with history MEN1 s/p splenectomy and subtotal
pancreatectomy who presents after being found unresponsive.
Patient was intubated on arrival to MICU so history was obtained
from partner. Pt apparently was feeling more depressed over last
2 weeks. Yesterday apparently pt and partner got into an
argument. Pt was last seen at 10am on [**11-27**]. Pt was contact[**Name (NI) **]
via phone at 12pm on [**11-27**]. Patient was then found at home at
730pm and was unresponsive. Blood sugar was taken which was
"critically low." EMS was called who also found pt with low
blood sugar. Pt was given amp of D50 as well as narcan without
improvement of MS and was then intubated for "airway
protection."
.
In [**Name (NI) **], pt was found to be continually hypoglycemic. Started on
D10 gtt. Head CT was negative. Pt admitted for further work-up
.
In MICU, pt was intubated/sedated continued on glucose drip
until blood sugars had normalized and patient's mental status
had improved. Post-extubation psychiatry was consulted given
patient's partner's concern for worsening of his depression a
sectioned 12 was placed and the patient was given a 1:1 sitter.
Patient now states that he had several appointments on the day
of admission adn was unable to eat and that was why his blood
sugar was low. Has had several episodes of hypoglycemia in the
past, but never this severe.
.
Review of systems: Patient currently feeling well with no HA,
dizziness, thirst, dysuria, change in bowel or bladder habits,
CP, SOB, abdominal pain nausea or vomitting.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. multiple endocrine neoplasia (type 1) - genetic testing
confirmed per medical records
2. metastatic gastrinoma, Zollinger-[**Doctor Last Name 9480**] syndrome
3. insulin dependent type 1 diabetes (diagnosed at age 16, h/o
DKA with hospitalizations)
4. stage II CKD (diabetic nephropathy) - baseline creatinine
1.4-1.6
5. s/p parathyroidectomy (x 3, [**2172**]-[**2176**]) with re-implantation
to arm
6. GERD/gastritis
7. unilateral right adrenalectomy (for pheochromocytoma with
adrencortical hyperplasia, [**11/2174**])
8. sub-total pancreatectomy (MD [**Location (un) 4223**] with pathology
demonstrating islet cell tumor, [**2174**])
9. s/p splenectomy ([**11/2174**])
10. depression
Social History:
He normally lives in [**Location 3615**], but has been staying with his
partner in [**Name (NI) 86**]. He smoked approximately two packs per week
from [**2172**] to [**2182**] and quit in [**2182**]. He denies any alcohol use.
He denies IV drug use. He does smoke marijuana regularly.
Family History:
His father had an [**Name (NI) 58955**] and subsequent gastrinoma. He denies
any other family history of malignancy.
Physical Exam:
Physical Exam on Arrival to MICU
General Appearance: No acute distress, Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: Soft, Bowel sounds present, Tender: mildly,
throughout
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
ON DISCHARGE:
Vitals: 97.3, 134/93, 70, 18, 16
I/O: NR
General: A and ox3
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: non-focal.
Pertinent Results:
[**2188-11-27**] 09:49PM BLOOD WBC-14.7*# RBC-4.50* Hgb-13.1* Hct-39.8*
MCV-88 MCH-29.1 MCHC-32.9 RDW-14.3 Plt Ct-393
ADMISSION LABS:
[**2188-11-27**] 09:49PM BLOOD Neuts-76.2* Lymphs-14.1* Monos-7.6
Eos-1.4 Baso-0.6
[**2188-11-27**] 09:49PM BLOOD PT-13.1 PTT-25.5 INR(PT)-1.1
[**2188-11-27**] 09:49PM BLOOD Glucose-16* UreaN-21* Creat-1.7* Na-143
K-3.9 Cl-110* HCO3-19* AnGap-18
[**2188-11-27**] 09:49PM BLOOD ALT-30 AST-33 AlkPhos-230* TotBili-0.2
[**2188-11-27**] 09:49PM BLOOD Calcium-10.2 Phos-2.5* Mg-1.9
[**2188-11-27**] 09:42PM BLOOD Lactate-2.7*
[**2188-11-27**] 09:49PM BLOOD Lipase-9
[**2188-11-28**] 01:23AM BLOOD TSH-0.54
[**2188-11-28**] 01:23AM BLOOD Cortsol-18.8
[**2188-11-28**] 01:23AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2188-11-28**] 12:48AM BLOOD C-PEPTIDE-PND
[**2188-11-27**]
- CT head w/o contrast: No acute intracranial hemorrhage, edema,
mass effect or major vascular territorial infarction. [**Doctor Last Name **]-white
matter differentiation is preserved. There is no shift of
normally midline structures. The ventricles and sulci are normal
in size and configuration. There is no fracture. Imaged
paranasal sinuses and mastoid air cells demonstrate mucus
retention cyst or polyp in the floor of the right maxillary
sinus is not completely imaged. Right parietal scalp lipoma is
again noted.
IMPRESSION: No acute intracranial process.
DISCHARGE LABS
[**2188-11-30**] 06:40AM BLOOD WBC-10.2 RBC-4.28* Hgb-12.2* Hct-37.5*
MCV-88 MCH-28.5 MCHC-32.5 RDW-14.4 Plt Ct-388
[**2188-12-1**] 06:33AM BLOOD Glucose-155* UreaN-20 Creat-1.7* Na-138
K-5.1 Cl-103 HCO3-26 AnGap-14
[**2188-11-29**] 03:34AM BLOOD ALT-20 AST-21 AlkPhos-210* TotBili-0.3
[**2188-12-1**] 06:33AM BLOOD Calcium-10.3 Phos-3.8 Mg-1.9
[**2188-11-28**] 01:23AM BLOOD TSH-0.54
[**2188-11-28**] 01:23AM BLOOD Cortsol-18.8
Brief Hospital Course:
43 yoM with history of severe depression, MEN 1a s/p
pancreatectomy who presents after unresponsive episode.
# Unresponsive episode: patient was found unconscious at home by
his partner, EMS was called and found to have a SBG in the 40s
was given dextrose and naracan, intubated and brought to the ED.
Patient was admitted to the ICU where he continued to recieve
dextrose gtt until alert enough for extubation 24 hours later.
Patient was transfered to the floor where he was followed by
[**Last Name (un) 387**] consult service and had his basal glargine titrated to 12
units QAM with a tighter humalog sliding scale. Thyroid,
coritisol and c-peptide (pending) were sent as patient had
history of MEN1 all of which were normal. Patient reports
hypoglycemia was unitentional and from forgetting to eat.
Psychiatry was consulted and felt patient lacked appropriate
insight into his illness and were concerned that his actions may
have been suicidial in intent. Patient was secontioned 12 and
was to be admitted to inpatient psychiatry. Patient was alert
and oriented and medically clear prior to transfer to
psycihatry.
.
# Leukocytosis: felt to be stress demargination and resolved by
MICU admission.
.
# Depression: Patient has signifcant history of depression under
outpatient management and past history of suicide attempts.
Psychiatry was consulted out of concern that patient's
hypoglycemia was intentional. Patient continues to have an
increased level of risk given his demonstrating impaired
judgment and impulsiveness resulting in serious medical
consequences, his previous history of suicide
attempt, ongoing unchanged psychosocial stressors, and expressed
concerns about safety outside of the hospital by his outpatient
providers. Patient was section 12'd and to be admitted to
inpaitent psychiatry.
.
# Diabetes: Patient was seen by inpatient [**Last Name (un) **] service and
had his basal galargine titrated to 12 units daily with an
uptitrated sliding scale. Paitent will continue to have [**Last Name (un) 387**]
consultation while in inpatient psychiatry and was medically
cleared for transfer to psychiatry. His most reccent sliding
scale was
Glargine 12 units SC every AM
Humalog sliding scale to as below:
Breakfast Lunch Dinner
71-110 4 5 5
111-150 5 6 6
151-200 7 7 7
[**Telephone/Fax (2) 58956**]51-400 9 9 9
>400 call your doctor
.
# Vomitting: patient with 2 episodes of vomitting intact food
several hours after eating post extubation. This was felt to be
from possible gastroperesis though patient without a known
history of these symptoms. He was treated with Zofran PRN with
good effect and medically cleared for inpatient psychiatric
admission.
.
# MEN1: patient with history of pheochromcytoma, gastrinoma and
hyperparathyroidism diagnosed as MEN1 syndrome status
post-pancreatectomy and spleenectomy. Patient has insulin
diabetes as discussed above as well as peristantly elevated
gastrin levels. he was maintained on his home regimen of
pantoparazole 40 mg [**Hospital1 **] with good effect and medically clear for
inpatient psychiatric admission.
.
# HYPOTHYROIDISM: secondary to idodine ablation of grave's
disease, stable on home regimen of levothyroxine 150 mcg for 9.5
doses weekly.
.
TRANSITIONAL ISSUES:
-patient is not on Ace/[**Last Name (un) **] for diabetic nephropathy due to
history of hyperkalemia - should followup as outpatient with his
nephrologist.
-consider having gastric emptying study to evaluate for
gastroperesis.
Medications on Admission:
Per OMR
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) in each
nostril daily Can decrease to 1 spray daily in each nostril once
symptoms controlled
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth daily at
bedtime
INSULIN GLARGINE [LANTUS] - (Dose adjustment - no new Rx) - 100
unit/mL Solution - 15 units SC every AM
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - per sliding
scale three times daily as directed
KETOTIFEN FUMARATE - 0.025 % Drops - 1 drop(s) in the affected
eye(s) twice a day as needed for allergy symptoms
LAMOTRIGINE - 100 mg Tablet - 1 Tablet(s) by mouth daily
LEVOTHYROXINE - 150 mcg Tablet - 9.5 Tablet(s) by mouth weekly
LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - [**7-23**] Capsule(s) by mouth up
to 6 times daily before meals and snacks as directed: 8 caps
before meals 6 before snacks
LORAZEPAM - 1 mg Tablet - 1.5 Tablet(s) by mouth four times
daily
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth twice a day - No Substitution
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia ; may take additional dose if needed after
one hour
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - to be
used as directed up to five times daily
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 3 Capsule(s)
by mouth daily; to replace previous Vit D prescriptions
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Ten (10) Capsule, Delayed
Release(E.C.) PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
4. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day)
as needed for anxiety.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 12 units daily in the AM.
9. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
13. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
15. insulin glargine 100 unit/mL Solution Sig: One (1) 1
Subcutaneous once a day: 12 units daily.
16. levothyroxine 75 mcg Tablet Sig: Three (3) Tablet PO 1X/WEEK
(SA).
17. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO
2X/WEEK (MO,WE).
18. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,FR).
19. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous
three times a day: CHANGE Glargine 15 units SC every AM to 12
units SC every AM
CHANGE Humalog sliding scale to as below:
Breakfast Lunch Dinner
71-110 4 5 5
111-150 5 6 6
151-200 7 7 7
[**Telephone/Fax (2) 58956**]51-400 9 9 9
>400 call your doctor.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
PRIMARY:
Hypoglycemia
SECONDARY:
-MEN-1 status post surgical excision of gastrinomas, parathyroid
resection, right adrenalectomy for pheochromocytoma, splenectomy
in [**2174**],
-type 1 diabetes,
-pancreatic insufficiency on enzyme supplements
-[**Doctor Last Name **] disease s/p radioiodine ablation
-Hypothyroidism
-cataracts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 58871**],
It was a pleasure taking care of you while you were in the
hospital. You were admitted for severe hypoglycemia requiring
intubation and a stay in the intensive care unit. Your blood
sugar was aggressively treated we were able to stabilize you and
discharge you from the ICU. You were seen by our diabetes
experts who have ajusted your sliding scale for better glucose
control. You were also seen by our psychiatrists who felt you
should be observed in the inpatient setting for the time being.
The following changes were made to your medications:
CONTINUE Fluticasone - 50 mcg 2 sprays(s) in each nostril daily
CONTINUE Gabapentin 300 mg before bed
CONTINUE Ketotifen 0.025% 1 drop(s) in the affected eye(s) twice
a day as needed for allergy symptoms
CONTINUE Lamotrigine 100 mg daily
CONTINUE Levothyroxine 150 mcg, 9.5 Tablet(s) by mouth weekly
CONTINUE Creon [**7-23**] Capsule up to 6 times daily before meals and
snacks as directed: 8 caps before meals 6 before snacks
CONTINUE Lorazeopam 1 mg - 1.5 Tablet(s) by mouth four times
daily
CONTINUE Pantoprazole - 40 mg Tablet, Delayed Release twice
daily
CONTINUE Trazodone 50 mg as needed for insomnia
CHANGE Glargine 15 units SC every AM to 12 units SC every AM
CHANGE Humalog sliding scale to as below:
Breakfast Lunch Dinner
71-110 4 5 5
111-150 5 6 6
151-200 7 7 7
[**Telephone/Fax (2) 58956**]51-400 9 9 9
>400 call your doctor
Followup Instructions:
Department: PSYCHIATRY
When: TUESDAY [**2188-12-2**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Department: [**Location (un) 1947**]
When: WEDNESDAY [**2188-12-3**] at 10:40 AM
With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2188-12-8**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"96.71"
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icd9pcs
|
[
[
[]
]
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13689, 13735
|
6302, 9651
|
308, 334
|
14109, 14109
|
4437, 4555
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15820, 16869
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2986, 3106
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3121, 3903
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9672, 9900
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1765, 1917
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239, 270
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362, 1745
|
4571, 6279
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14124, 14236
|
1939, 2664
|
2680, 2970
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,546
| 191,415
|
29133
|
Discharge summary
|
report
|
Admission Date: [**2127-3-31**] Discharge Date: [**2127-4-2**]
Date of Birth: [**2064-4-22**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Lamictal
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Multinodular goiter with microfollicular aspirate.
Major Surgical or Invasive Procedure:
Total thyroidectomy including substernal component via cervical
approach.
[**2127-3-31**] Re-intubation with mechanical ventilation
History of Present Illness:
62 yo F with h/o follicular adenoma, HTN, HLD, DVT x 3 on
coumadin, DM, ESRD s/p renal transplant presents after
successful total thyroidectomy for respiratory distress.
Patient presented for elective thyroidectomy this AM for an
enlarging goiter which on FNA was follicular adenoma, tolerated
procedure well and was intubated and extubated without
difficulty. She was extubated for a few minutes and about to be
transferred to the floor, however patient became acutely short
of breath with RR in 50s, worse than laying down, also BP
elevated to 180s-200s systolic. Patient given 10 mg IV
labetolol with improvement in BP, work of breathing not imrpoved
with 100% face mask so she was re-intubated with glidescope and
per anesthesiology noted right vocal cord dysfunction with
little movement in right vocal cord. No difficulty noted in the
surgery regarding visualization of recurrent laryngeal nerves.
Patient was also given 20 mg IV lasix given h/o HTN and lasix
use as outpatient, CXR was done and was concerning for possible
fluid overload as well. She had received 1000 mL in crystalloid
during procedure, urine output immediately following lasix and
placement of foley catheter was 700 mL, EBL 25 mL. She was
transferred to [**Hospital Unit Name 153**] for further workup of respiratory distress
and possible evaluation of vocal cord dysfunction.
On arrival to the ICU, pt is intubated and sedated, unable to
give further history.
Past Medical History:
Past Medical History:
follicular thyroid CA on FNA of thyroid nodules
Hypertension
Hyperlipidemia
Deep Vein Thrombosis x 3 on lifelong coumadin
arthritis
tremor
Diabetes Mellitus
obesity
osteopenia
ESRD s/p renal transplant [**2-27**] lithium use (new baseline Cr 1.08
[**1-6**])
bipolar disease
Past surgical history:
renal transplant [**2118**]
appendectomy
Left fistula attempt
Social History:
Former tobacco, quit [**2098**]
EtOH: 2 drinks/week
drugs: former, last used marijuana, cocaine, LSD in [**2093**]
Family History:
Father had skin cancer on his nose - type unknown, no fh of
thyroid cancer.
Physical Exam:
Vitals:98.4,78, 144/72, 18, 98 % room air
General:alert and oriented, no acute distress
HEENT:Sclera anicteric,oropharynx clear
Neck:soft,incision steri strips clean,dry, intact, no bleeding
Lungs:Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Cardiovascular: 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
Extremities:warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Pertinent Results:
[**2127-4-2**] 05:30AM BLOOD WBC-6.8 RBC-4.27 Hgb-12.2 Hct-37.1 MCV-87
MCH-28.6 MCHC-33.0 RDW-13.1 Plt Ct-163
[**2127-4-2**] 05:30AM BLOOD Glucose-139* UreaN-15 Creat-1.0 Na-137
K-3.7 Cl-101 HCO3-24 AnGap-16
[**2127-4-2**] 05:30AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.9
[**2127-4-1**] 02:22AM BLOOD tacroFK-4.3*
[**2127-3-31**] 11:37AM BLOOD WBC-9.7 RBC-4.30 Hgb-12.6 Hct-36.5 MCV-85
MCH-29.4 MCHC-34.5 RDW-13.3 Plt Ct-177
[**2127-3-31**] 11:37AM BLOOD Glucose-149* UreaN-17 Creat-1.0 Na-140
K-4.0 Cl-104 HCO3-25 AnGap-15
[**2127-3-31**] 08:15AM PT-11.7 INR(PT)-1.1
MICROBIOLOGIC DATA:
[**2127-3-31**] MRSA screen - pending
IMAGING STUDIES:
[**2127-3-31**] CHEST (PORTABLE AP) - An endotracheal tube terminates
5.8 cm above the carina. The lung volumes are low. Bibasilar
atelectasis is slightly worse, and central pulmonary vascular
engorgement is again seen without edema. There is no
pneumothorax, pleural effusion, or focal consolidation. ET tube
terminating 5.8 cm above the carina. Increased atelectasis since
[**25**] a.m.
Brief Hospital Course:
62F with h/o follicular adenoma, HTN, HLD, DVT x 3 on coumadin,
DM, ESRD s/p renal transplant who underwent a successful total
thyroidectomy developed respiratory distress with re-intubation
and was admitted to the [**Hospital Unit Name 153**] for acute respiratory concerns.Once
stabalized the patient was transferred to the floor on
postoperative day one.
# ACUTE RESPIRATORY DISTRESS - Patient developed respiratory
distress in the setting of recent surgical procedure (in the
PACU requiring re-intubation), concerning for acute pulmonary
edema given his elevated systolic BPs vs. a component of
diastolic dysfunction. Patient has strong history of DVTs in the
past and has been holding his anticoagulation in the setting of
surgery, so pulmonary embolus made the differential. Following
Lasix 20 mg IV x 1 with adequate urine output response, the
patient had improved oxygenations. Of note, there was some
question of right vocal cord paresis, but unilateral involvement
should not result in respiratory concerns. The patient improved
and actually self-extubated in the evening of [**2127-3-31**] without
re-intubation needs. Her oxygen saturations were stable.
# STATUS-POST TOTAL THYROIDECTOMY - Patient tolerated the
procedure well despite re-intubation concerns. Incision appeared
clean, dry and intact without fullness or evidence of bleeding.
East 1 surgery followed closely. Levothyroxine replacement was
started following the procedure and her calcium level was
closely monitored.
# RIGHT VOCAL CORD PARESIS - initially imaged during
reintubation after the surgery. Patient was evaluated by ENT the
next day which confirmed the finding, as well as some false
vocal cord edema and hemorrhages. She was evaluated by speech
and swallow and was cleared for regular diet. She will need to
follow up with ENT for further monitoring and management.
# ESRD STATUS-POST RENAL TRANSPLANT - We continued her home
dosing of Cellcept and Tacrolimus. Tacrolimus level was
reassuring.
# RECURRENT DEEP VENOUS THROMBOSUS HISTORY - Anticoagulation
held peri-procedurally. We resumed Coumadin in the AM on [**2127-4-1**].
# BIPOLAR DISORDER - Appeared stable. We continued her home
dosing of Clomipramine, Perphenazine, Buproprion, Clonazepam and
Abilify.
# HYPERTENSION - We continued her home dosing of Lasix and
Lisinopril following re-initiation of her PO intake.
Medications on Admission:
Warfarin 2.5 mg tabs (1.5 tabs mon and fri, 2 tabs sun, tue,
wed, thurs, sat, last dose was on [**2127-3-25**])
Lisinopril 5 mg Oral Tablet 1 tablet daily
Furosemide 20 mg Oral Tablet take 1 tablet daily
Tacrolimus (PROGRAF) 2 mg po BID
Mycophenolate Mofetil (CELLCEPT) 750 mg po twice daily
Aripiprazole (ABILIFY) 5 mg Oral Tablet 1 tab po qd
Oxcarbazepine (TRILEPTAL) 600 mg Oral Tablet 1 tab q hs
Perphenazine 4 mg Oral Tablet TAKE 1 TABLET by mouth AT BEDTIME
Clomipramine 2 tabs at night (likely 50 mg) but atrius records
state 75 mg po BID
Bupropion HCl XL (WELLBUTRIN XL) 300 mg Oral Tablet Extended
Release 24 hr 1 tab q am
Omega-3 Fatty Acids-Fish Oil (FISH OIL) 300-1,000 mg Oral
Capsule 1 by mouth four times daily
Calcium Carbonate 500 mg (1,250 mg) Oral Tablet twice daily
Docusate Sodium (COLACE) 100 mg Oral Capsule 3 tabs daily
Cholecalciferol, Vitamin D3, (VITAMIN D) 1,000 unit Oral Capsule
1 tablet daily
MULTIVITAMIN CAPSULE PO (MULTIVITAMINS) 1 TAB PO QD
Discharge Medications:
1. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
2. mycophenolate mofetil 200 mg/mL Suspension for Reconstitution
Sig: 750 mg PO BID (2 times a day).
3. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
4. bupropion HCl 150 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO QAM (once a day (in the morning)).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. perphenazine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: Three (3) Capsule PO HS
(at bedtime).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. clomipramine 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
14. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
Disp:*40 Tablet(s)* Refills:*0*
16. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO BID (2 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Multinodular goiter with microfollicular aspirate (left
substernal).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 70110**],
You had a successful total thyroidectomy, however shortly after
your surgery you developed respiratory distress and required a
brief stay in the ICU before being transferred to the floor the
following day. Due to concerns of possible vocal cord paralysis
you were evaluated by ENT and speech & swallow. You had bedside
speech & swallowing exam which you passed and your diet was
advanced to regular which was tolerated well. We have arranged
for you to follow-up with(Otolaryngology) for further evaluation
as an outpatient;your appointment is listed below.Please
continue to monitor your voice hoarseness which should improve
over the next few weeks. However if your symptoms worsen then
contact the office for advice.
Please resume all regular home medications, unless specifically
advised not to take a particular medication and take any new
medications as prescribed. Your home dose Coumadin was restarted
on [**2127-4-1**]. Continue to follow-up with your primary care
provider for your Coumadin dosing.You will be given a
prescription for narcotic pain medication, take as prescribed.
It is recommended that you take a stool softner such as Colace
while taking oral narcotic pain medication to prevent
constipation. Please get plenty of rest, continue to walk
several times per day, and drink adequate amounts of fluids.
You will be discharged home on thyroid medication Levothyroxine
and calcium supplement Tums, please take exactly as
prescribed.Please monitor for signs and symptoms of low calcium
such as numbness or tingling around mouth or fingetips. If you
experience any of these signs or symptoms you may take an extra
dose of Tums, however if symptoms continue please call Dr.
[**Last Name (STitle) **] office or go to emergency room.
Incision Care:
Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.You may shower and wash incisions with a mild soap
and warm water.Avoid swimming and baths until cleared by your
surgeon.Gently pat the area dry.You have a neck incision with
steri-strips in place, do not remove, they will fall off on
their own.
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:
Follow up with Dr. [**Last Name (STitle) **] in 1 month [**Telephone/Fax (1) 9**].
Follow-up with Dr. [**First Name4 (NamePattern1) 10827**] [**Last Name (NamePattern1) **] (Otolaryngology)on [**2127-4-17**],your appointment is scheduled for 11:30 AM.(please arrive
30 minutes early)[**Telephone/Fax (1) 2349**].[**Location (un) **] [**Apartment Address(1) **].
[**Location (un) 55**]
Completed by:[**2127-4-3**]
|
[
"250.00",
"428.33",
"733.90",
"401.9",
"296.80",
"272.4",
"V15.82",
"478.31",
"V12.51",
"V58.61",
"716.90",
"278.00",
"478.6",
"241.1",
"V12.55",
"V42.0",
"428.0",
"518.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"06.4",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9135, 9141
|
4179, 6550
|
330, 464
|
9254, 9254
|
3126, 3747
|
11765, 12180
|
2486, 2563
|
7578, 9112
|
9162, 9233
|
6576, 7555
|
9405, 11190
|
11205, 11742
|
2275, 2338
|
2578, 3107
|
239, 292
|
492, 1934
|
9269, 9381
|
1978, 2252
|
2354, 2470
|
3764, 4156
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,172
| 110,820
|
40287
|
Discharge summary
|
report
|
Admission Date: [**2100-11-9**] Discharge Date: [**2100-11-14**]
Date of Birth: [**2037-1-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Burning across chest
Major Surgical or Invasive Procedure:
[**2100-11-10**]
1. Emergency coronary artery bypass graft x4: Left
internal mammary artery to left anterior descending
artery and saphenous vein graft to ramus intermedius and
a saphenous vein sequential graft to obtuse marginal 1
and 2.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
63F with history htn and hyperlipidemia p/t OSH ED c/o chest
burning while mowing the lawn. She was admitted to [**Hospital **]
Hospital on [**11-6**] and had a NSTEMI with a peak troponin of 1.45.
Workup included cardiac cath which revealed three vessel
disease.
She also had an elevated creatinine when she presented (1.6)
which was new for her. A CXR revealed a 6-7 cm pulmonary nodule
in the RUL. She is transferred for surgical consideration.
Past Medical History:
Past Medical History:
hypertension
h/o hypertensive urgency [**2097**]- stress echo was negative for
ischemia at this time
hyperlipidemia
anxiety
s/p NSTEMI [**2100-11-6**]
Past Surgical History: s/p C section
Social History:
Lives with: husband
Occupation: retired
Tobacco: 1 1/2 packs per week
ETOH: denies
Family History:
mother with a-fib
sister with a-fib
Physical Exam:
Pulse: 65 Resp:18 O2 sat: 97% on RA
B/P Right: 136/77 Left:
Height: 65" Weight: 153lb
General:
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
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [] Edema
Varicosities: None [x]
Neuro: Grossly intact
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 Right: no Left: no
Pertinent Results:
[**2100-11-13**] 04:56AM BLOOD WBC-9.1 RBC-3.42* Hgb-10.3* Hct-28.8*
MCV-84 MCH-30.3 MCHC-35.9* RDW-14.4 Plt Ct-101*
[**2100-11-12**] 03:59AM BLOOD PT-14.3* PTT-26.9 INR(PT)-1.2*
[**2100-11-13**] 04:56AM BLOOD Glucose-120* UreaN-18 Creat-1.0 Na-140
K-4.0 Cl-106 HCO3-23 AnGap-15
[**2100-11-10**] Intra-op TEE
PRE-BYPASS No spontaneous echo contrast is seen in the body of
the left atrium. No atrial septal defect is seen by 2D or color
Doppler. 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.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is mild mitral valve
prolapse. Physiologic mitral regurgitation is seen (within
normal limits). The intra-aortic balloon tip is about 6 cm below
the distal aortic arch. Dr. [**Last Name (STitle) **] was notified in person
of the results in the operating room at the time of the study.
POST-BYPASS The patient is atrially paced. There is normal
biventricular systolic function. The thoracic aorta appears
intact after decannulation. No other significant changes from
the pre-bypass study
Brief Hospital Course:
The patient was transferred from an outside hospital where she
ruled in for NSTEMI on [**2100-11-6**]. She had ongoing chest pain,
received a balloon pump and was brought to the operating room on
[**2100-11-10**] where the patient underwent emergent CABG x 4 with Dr.
[**First Name (STitle) **]. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. Hydralazine was
started for hypertension and beta blocker titrated as tolerated.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. ACE inhibitor was not
started, as it was felt more important to titrate her beta
blocker for tachycardia. This can be initiated outpatient by
her cardiologist when appropriate. By the time of discharge on
POD 4 the patient was ambulating freely, the wound was healing
and pain was controlled with oral analgesics. The patient was
discharged to home in good condition with appropriate follow up
instructions.
Medications on Admission:
triamterene/HCTZ 37.5/25mg daily
lopressor 100mg daily
simvastatin 40mg hs
diltiazem CD 240mg daily
Diovan 80mg daily
alprazolam 0.25mg hs
lisinopril recently discontinued
Plavix - last dose: she received: [**11-7**]: 300 mg, [**11-8**]: 225 mg,
[**11-9**]: 75 mg
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
coronary artery disease
PMH:
hypertension
h/o hypertensive urgency [**2097**]- stress echo was negative for
ischemia at this time
hyperlipidemia
anxiety
s/p NSTEMI [**2100-11-6**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: 1+ edema bilateral LEs
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) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2100-12-6**] 1:00
Cardiologist Dr [**Last Name (STitle) 8579**] [**Telephone/Fax (1) 23882**] on [**12-7**] at 10:30am
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 1575**] S. [**Telephone/Fax (1) 13350**] in [**3-29**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2100-11-14**]
|
[
"410.71",
"401.9",
"427.1",
"414.01",
"272.4",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"37.61",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6290, 6361
|
3612, 5100
|
343, 654
|
6585, 6771
|
2192, 3589
|
7643, 8380
|
1484, 1522
|
5416, 6267
|
6382, 6564
|
5126, 5393
|
6795, 7620
|
1351, 1367
|
1537, 2173
|
282, 305
|
682, 1133
|
1177, 1328
|
1383, 1468
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,127
| 199,695
|
10460
|
Discharge summary
|
report
|
Admission Date: [**2109-10-6**] Discharge Date: [**2109-10-13**]
Date of Birth: [**2050-1-1**] Sex: F
Service: O-MED
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
female with recurrent squamous cell carcinoma of the bladder,
status post excision, status post chemotherapy and radiation
following local recurrence, who presented to [**Hospital1 346**] after a 3-week hospitalization in
[**Location (un) 34553**], [**State 108**] where she was with mental status changes
and renal failure. As per the patient's husband, the patient
presented to urologist in [**State 108**] about one month ago with
symptoms suggestive of a urinary tract infection with nausea,
and vomiting, fevers, and dark urine.
On [**9-9**] she had an ultrasound that was consistent
with bilateral hydronephrosis and ureteral obstruction. On
[**9-10**] the patient was admitted to [**Location (un) 34554**]
[**Hospital 107**] Hospital in [**Location (un) 34553**], [**State 108**] with decreased
functional status, fatigue, nausea, low-grade fevers, and
decreased colostomy output. The patient was found to have
evidence of colonic stool impaction and ileus and bilateral
hydronephrosis with a urinary tract infection. The ileus was
presumed to be secondary to urosepsis. Initially the patient
was treated with mineral oil and started on total parenteral
nutrition. She was transfused packed red blood cells and
treated with antibiotics. On [**9-11**] the patient became
increasingly disoriented, incoherent, and decreasing
responsive. She had a magnetic resonance imaging of the head
that was negative for metastatic disease. She had a CT of
the abdomen on [**9-11**] which showed dilated bowel loops
suggestive of obstruction with bilateral ectasia of renal
collecting septum. She had a repeat abdominal CT on
[**2109-10-2**] with new 5-cm soft tissue density in the
right pelvis with a question of abscess versus hematoma
versus neoplasm. On [**10-3**] a tagged red blood cell scan
was negative for localization to right upper quadrant and
right lower quadrant. As per the husband, the medical team
planned a biopsy of the soft tissue density, but the husband
decided to drive his wife back to [**Name (NI) 86**] for her care. He
does note her mental status has been poor for the last two to
three weeks but has had some days that are better than
others.
PAST MEDICAL HISTORY:
1. Squamous cell bladder carcinoma diagnosed on [**2109-1-30**]; stage IV with invasion into the paravaginal regional
and left vaginal wall. She is status post cystectomy and
lymph node dissection with ileal loop diversion and pelvic
exoneration. The patient had local recurrence in [**2108-12-31**] and was treated with cisplatin and radiation. She is
status post anterior exenteration with ileal conduit. She is
also status post rectovaginal fistula secondary to radiation
therapy, status post surgery.
2. Multiple sclerosis diagnosed in [**2074**].
3. History of urinary tract infections, positive for
pseudomonas.
4. History of sacral decubitus ulcer.
5. History of recurrent infection of ureteral drainage.
6. History of mitral valve prolapse.
7. History of chronic vaginal discharge.
MEDICATIONS ON ADMISSION: Medications per husband were
atenolol 25 mg p.o. q.d., Zoloft 50 mg p.o. b.i.d.,
Baclofen 10 mg p.o. b.i.d., diazepam 10 mg p.o. q.d.
MEDICATIONS ON TRANSFER: Medications on transfer from the
outside hospital were Protonix, OxyContin, Compazine, and
Percocet.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married. Lives part-time in
[**Location (un) 34553**] and part-time in [**State 350**]. Denies alcohol or
tobacco.
PHYSICAL EXAMINATION ON PRESENTATION: On admission
temperature 99.4, pulse 88, blood pressure 116/67, oxygen
saturation 96% on room air. The patient was awake,
responsive to some commands, had difficulty articulating her
responses, in no acute distress. Head, ears, nose, eyes and
throat revealed dry mucous membranes. No erythema or
exudate. Neck was supple. No jugular venous distention.
Cardiovascular was rapid, regular, a 2/6 systolic ejection
murmur at the left upper sternal border radiating to the
axilla. Lungs had decreased breath sounds at the bases
bilaterally with poor air movement, but no wheezes or
crackles. Abdomen was tense, distended, question of right
lower quadrant mass, positive bowel sounds, negative rebound
or guarding. Left colostomy with clear yellow urine, right
colostomy was empty. Negative costovertebral angle
tenderness. Extremities were flexed, contracted lower
extremities, trace pedal edema, and 2+ pedal pulses. Back
revealed sacral decubitus ulcer with wide base. No obvious
tracking or extension, packed with gauze. Neurologically,
pupils were equal, round, and reactive to light and
accommodation. The patient failed to follow commands,
grasped hands, and followed some commands. No focal weakness
was appreciated.
LABORATORY DATA ON PRESENTATION: On admission white blood
cell count of 26.2, hematocrit 34, platelets 248;
93% neutrophils, 4% lymphocytes, 2% monocytes.
Potassium 6.2, sodium 134, chloride 98, bicarbonate 23, blood
urea nitrogen 113, creatinine 3.5, glucose 80. Calcium 11
(corrected to 12.2), albumin 2.5, magnesium 1.9,
phosphorous 5.7. INR of 1.4. Urinalysis with 22 red blood
cells, no epithelial cells, small blood. Cultures were
pending.
RADIOLOGY/IMAGING: Electrocardiogram with a rate of 75,
regular rhythm, normal axis, no P-T, and no acute ST-T wave
changes.
HOSPITAL COURSE:
1. INFECTIOUS DISEASE: The patient with an elevated white
count and low-grade fever suggestive of acute infectious
process, likely urinary tract infection or pyelonephritis.
The patient was started on Zosyn. Later in her course when
she decompensated levofloxacin, Flagyl, and one dose of
vancomycin were added. This was for presumed
hospital-acquired pneumonia that led to some respiratory
failure.
2. FLUIDS/ELECTROLYTES/NUTRITION: The patient with a high
calcium likely secondary to renal failure and/or metastatic
disease. The patient was treated with fluids, Lasix, and
pamidronate. Also with hyperkalemia treated with Kayexalate
and insulin. These eventually normalized.
3. RENAL: The patient with acute-on-chronic renal
insufficiency. The patient with known bladder cancer. She
had a right pelvic mass that was re-evaluated on magnetic
resonance imaging that was thought to be recurrence of tumor.
She had a left percutaneous nephrostomy tube placed during
her hospital course. She also had a bone scan that showed no
metastatic disease to her bones.
4. HEMATOLOGY: The patient with initially elevated INR and
given vitamin K.
5. RESPIRATORY: The patient had respiratory decompensation
on [**2109-10-10**], with desaturations into the 80s on 100%
nonrebreather. During that time the patient was tachycardic
up to the 200s and with elevated blood pressure.
The patient required intubation and was transferred to the
Medical Intensive Care Unit. She was in the Medical
Intensive Care Unit for two days where she was stabilized and
additional antibiotic coverage was added. She was extubated
successfully and transferred back to the floor with a comfort
measures only status.
The patient expired on [**2109-10-13**] at 7:50 p.m. with
respiratory failure.
[**Name6 (MD) 6337**] [**Name8 (MD) **], M.D. [**MD Number(1) 6342**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2109-12-27**] 12:21
T: [**2109-12-31**] 07:19
JOB#: [**Job Number **]
|
[
"275.42",
"188.9",
"340",
"599.0",
"591",
"198.82",
"507.0",
"707.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.03",
"96.6",
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3223, 3358
|
5545, 7561
|
163, 2372
|
3384, 3524
|
2394, 3196
|
3541, 5527
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,261
| 105,163
|
7429
|
Discharge summary
|
report
|
Admission Date: [**2121-11-1**] Discharge Date: [**2121-11-6**]
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Cholangitis, sepsis, admitted to ICU for monitoring prior to
ERCP
Major Surgical or Invasive Procedure:
[**11-1**]: ERCP
History of Present Illness:
83 y/o male with history of choledocolithiasis in [**2113**] s/p ERCP
and sphincterotomy who presents with malasie and dark colored
urine x 5 days. He denies symptoms abdominal pain, n/v, chills,
cp, sob, dysuria. Denies weight loss, had poor appetite this
week. called his PCP after noticing the dark urine and was told
to go to OSH. He was evaluated at [**Hospital1 **] Ed which revealed
elevated LFT's, total bili 12.5, U/S with CBD dilation, sludge,
and distended gallbladder wall with pericholecystic fluid. Was
transfered to [**Hospital1 18**] for ERCP.
.
In ED was hypotensive 94/50 and febrile, requiring levophed
through a peripheral IV. He received 4L NS in ED, his BP
recovered and levophed was d/c'd. He got one dose unasyn and was
transfered to the [**Hospital Unit Name 153**] for monitoring prior to ERCP in AM.
Past Medical History:
1. CAD s/p CABG in [**2110**].
2. Billroth II gastrectomy in [**2077**].
3. ERCP on [**2114-4-12**].
4. Herniorrhaphy times two.
5. Hypertension
Social History:
SH: Lives in [**Location 27252**], MA with one of his 4 sons. Wife
passed away 10 years ago, has 9 children. Team photographer for
the [**Location (un) 86**] Red Sox.
Family History:
Non-contributory
Physical Exam:
VS T:99.8 HR:81 BP:118/62 O2sat 98%RA
GEN: A/O, nad, well appearing, jaundiced
HEENT: icteric sclera, sublingual icterus
CV: RRR s1, s2, 2/6 systolic murmur heard in axilla
RESP: CTA bl
ABD: soft, NT, ND, no masses. prior scars noted on abd and chest
EXT: + pulses distally, warm, no erythema or swelling
SKIN: icteric, no rashes
Pertinent Results:
CXR [**11-1**]: FINDINGS: There has been no significant change from
the patient's prior examination of [**2113**]. There is no new
infiltrate. Patient is status post a median sternotomy.
Cardiomediastinal contours are within normal limits. IMPRESSION:
No evidence of acute disease in the chest.
.
ERCP [**11-1**]: Sludge and CBD stones cleared. Tolerated procedure
well.
.
[**2121-10-31**] 08:40PM BLOOD Lactate-3.3*
[**2121-11-1**] 02:29AM BLOOD Lactate-3.4*
[**2121-11-3**] 07:00AM BLOOD calTIBC-127* VitB12-[**2104**]* Folate-6.7
Ferritn-790* TRF-98*
[**2121-10-31**] 08:30PM BLOOD Lipase-15
[**2121-10-31**] 08:30PM BLOOD ALT-194* AST-170* AlkPhos-394* Amylase-51
TotBili-9.6* DirBili-7.8* IndBili-1.8
[**2121-11-1**] 04:57AM BLOOD ALT-160* AST-135* LD(LDH)-242
AlkPhos-312* Amylase-57 TotBili-7.2*
[**2121-11-6**] 06:55AM BLOOD ALT-52* AST-51* AlkPhos-168* Amylase-38
TotBili-1.6*
[**2121-11-1**] 02:30AM BLOOD Glucose-102 UreaN-21* Creat-1.3* Na-135
K-4.0 Cl-106 HCO3-14* AnGap-19
[**2121-11-6**] 06:55AM BLOOD Glucose-95 UreaN-13 Creat-0.9 Na-137
K-3.6 Cl-105 HCO3-26 AnGap-10
[**2121-10-31**] 08:30PM BLOOD PT-15.1* PTT-27.9 INR(PT)-1.4*
[**2121-11-3**] 07:00AM BLOOD PT-12.3 PTT-26.9 INR(PT)-1.1
[**2121-10-31**] 08:30PM BLOOD WBC-12.3*# RBC-4.19* Hgb-12.4* Hct-36.6*
MCV-87 MCH-29.5 MCHC-33.8 RDW-14.9 Plt Ct-181
[**2121-11-1**] 05:32PM BLOOD WBC-17.1* RBC-4.46* Hgb-12.9* Hct-38.3*
MCV-86 MCH-29.0 MCHC-33.8 RDW-15.1 Plt Ct-114*
[**2121-11-6**] 06:55AM BLOOD WBC-8.3 RBC-3.65* Hgb-10.4* Hct-30.3*
MCV-83 MCH-28.5 MCHC-34.3 RDW-15.3 Plt Ct-190
.
Blood Cultures [**11-1**]
MORGANELLA MORGANII
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- 4 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
Hosptial Course, by Problem:
.
#Ascending Cholangitis/Choledocolithiasis: had ERCP with
sphincterotomy; stones and sludge removed. Needs f/u with PCP
for discussion of cholecystectomy.
.
#Bacteremia: blood cultures at OSH grew pan-S E coli. Pt
initially on Unasyn; however, patient spiked on the floor. CTX
added. Repeat blood cultures grew Morganelli (R) to Unasyn and
(S) to CTX. Was eventually transitioned to PO
Augmentin/Cefpodoxime. Will complete a total of a 10 day
course. ID consulted and agreed with plan.
.
#Anemia: Fe studies c/w Anemia of Chronic Disease. Remained
stable in house.
Medications on Admission:
Metoprolol 25mg po BID
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
1. Ascending Cholangitis
2. Choledocolithiasis
3. Morganella/E. Coli bacteremia
4. Anemia of Chronic Disease
Secondary Diagnoses
1. Hypertension
2. h/o CAD s/p CABG
3. h/o Billroth II
Discharge Condition:
stable, afebrile
Discharge Instructions:
Please contact Dr. [**Last Name (STitle) **] should you develop any worsening
abdominal pain, nausea, vomiting, diarrhea, fevers, chills,
sweats, or any other serious complaints.
Please take your antibiotics are prescribed for the next 5 days.
Followup Instructions:
Please call dr. [**Last Name (STitle) **] as soon as possible to make a follow-up
appointment.
|
[
"574.91",
"576.1",
"414.00",
"041.4",
"285.29",
"401.9",
"790.7",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
5139, 5145
|
4079, 4685
|
287, 305
|
5399, 5418
|
1917, 4056
|
5711, 5809
|
1532, 1550
|
4758, 5116
|
5166, 5378
|
4711, 4735
|
5442, 5688
|
1565, 1898
|
182, 249
|
333, 1162
|
1184, 1331
|
1347, 1516
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,585
| 184,466
|
45326+58807
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-9-8**] Discharge Date: [**2177-9-12**]
Date of Birth: [**2105-12-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Slurred speech and leg weakness
Major Surgical or Invasive Procedure:
Myelogram
History of Present Illness:
This is a 71 y/o with h/o dm, HTN, CAD s/p PTCA distal LAD
([**2177-7-31**]) who prsents to the ED with chest pain, worsening
shortness of breath and substernal chest pain.
.
Per ED and Neurology notes who spoke to son, patient was at her
usual state of health until waking up this am. She noted chest
pain an dshortness of breath. Later on , her son noticed she was
having slureed speech.
Patient reports that over the last couple of weeks, she was
feeling with decrease energy and intermittent left sided
headaches. This morniing, she woke up with slurred speech and
strange sensation on the left side of her face.
She denied any any difficulty with word finding or speech
comprenhension, no limb weakness or gait instability.
She also reports chest pain about [**6-18**] that was all over her
chest and was going to both arms. No pleuritic. She thought she
was having another [**Doctor Last Name **] attacck. She did not take anything for
it.
She denief any fevers, nasusea, vomit, chills, cough, diarrhea,
abdominal pain associated.
.
She currently feels 2/10 chest pain, and feels that her speech
is not back to baseline. She is oriented and coherent on her
speech.
.
In The ED vs: T 97, HR 68, BP 78-88; 92/37 RR 20on 2L NC. Code
stroke was initially called but cancelled given that her
presentation was more consistent with encephalopatic process.
she was also bradycardic to the 40's with low BP. She was given
glucagon 5 mg IV x1. She was also given Dextrose 50%, and
combivent nebs. 1.5 L of NS were given.
Past Medical History:
DM
HTN
OSA- uses BiPAP at home
Asthma- uses O2 at home
Restrictive lung disease on [**Name (NI) 96801**]
[**Name (NI) **] pt unable to ambulate, uses wheelchair
Hyperlipidemia
s/p cholecystectomy
s/p hysterectomy
Chronic back pain
Social History:
Lives alone in an appartment in [**Location (un) **], divorced. Currently
unemployed, Mass Health/Medicaid. Has an aide that comes every
day to help her with cleaning, dishes, etc. Denies ever
smoking, using Alcohol, or IV drugs.
Family History:
Mother died at age 80yo - had CAD, DM
Father passed away at age 89yo - had CAD
Physical Exam:
Vitals: T: P: 50 R:16 BP:95/45 SaO2:97 4 L
General: Awake, alert, NAD
HEENT: PEERLA, JVD difficult to appreciate. no lymphadenopathies
Pulmonary: + rhonchi and expiratory wheezing.
Cardiac: bradycardic, RRR.
Abdomen: soft, obes, non tender non distended. no masses noted.
Extremities: 1+ [**Location (un) **].
Skin: no rashes or lesions noted.
Neurologic: alert, oriented times 3, mild slrueed speech, tongue
midline, no ptosis. no pronator drift. + asterixix
Pertinent Results:
[**2177-9-8**] 11:26PM TYPE-ART PO2-63* PCO2-43 PH-7.38 TOTAL CO2-26
BASE XS-0
[**2177-9-8**] 05:00PM GLUCOSE-79 UREA N-33* CREAT-3.1*# SODIUM-137
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-25 ANION GAP-18
[**2177-9-8**] 05:00PM ALT(SGPT)-14 AST(SGOT)-21 LD(LDH)-254*
CK(CPK)-380* ALK PHOS-84 TOT BILI-0.3
[**2177-9-8**] 05:00PM cTropnT-0.06*
[**2177-9-8**] 05:00PM CK-MB-14* MB INDX-3.7
[**2177-9-8**] 05:00PM CALCIUM-9.2 PHOSPHATE-5.4*# MAGNESIUM-2.0
[**2177-9-8**] 05:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2177-9-8**] 05:00PM WBC-8.0 RBC-3.84* HGB-9.7* HCT-30.6* MCV-80*
MCH-25.2* MCHC-31.6 RDW-15.9*
[**2177-9-8**] 05:00PM NEUTS-76.4* LYMPHS-17.5* MONOS-3.3 EOS-2.7
BASOS-0.2
[**2177-9-8**] 05:00PM HYPOCHROM-3+ MICROCYT-1+
[**2177-9-8**] 05:00PM PLT COUNT-259
[**2177-9-8**] 05:00PM PT-12.5 PTT-24.7 INR(PT)-1.1
.
[**9-8**] CT head w/o contrast:
IMPRESSION: No mass effect or hemorrhage
.
[**9-8**] CXR
FINDINGS: Portable AP upright chest radiograph reviewed. The
lung volumes are low. There is diffuse opacification of both
lungs with more dense bilateral retrocardiac opacities. The hila
are hazy and the pulmonary vasculature are engorged. The left
costophrenic angle is not sharp and a small left pleural
effusion on this poor quality radiograph cannot be excluded.
IMPRESSION: Moderate CHF.
.
[**9-9**] Renal U/S no hydronephrosis
.
[**9-9**] CT C/T/L spine without contrast
FINDINGS: The study is severely limited due to patient body
habitus and a mild amount of motion artifact. Cord compression
cannot be excluded based on non-contrast study. Within the
limitations of the artifact, there are no large displaced
fractures. There is a large amount of degenerative change. At
C2-3, [**4-12**], there is no spinal canal stenosis.
At C5-6, there is a small posterior osteophyte with mild spinal
canal stenosis. There is a large osteophyte at the right side of
the vertebral body. C5-6, there is a moderate sized posterior
osteophyte which appears to cause at least a moderate spinal
canal narrowing. There are osteophytes at both uncovertebral
joints.
At C6-7, there is a small posterior osteophyte present. This
causes no significant canal narrowing.
As the patient's body habitus produces significant artifact
within the spinal canal, a disc or rather soft tissue masses
could easily cause spinal cord compression would not be
visualized on this study. An alternative way to evaluate the
central canal would be to obtain a CT myelogram.
IMPRESSION: Spinal cord compression cannot be excluded based on
a non- contrast CT with this amount of artifact. Multilevel
degenerative changes and osteophytes causing at least moderate
spinal canal narrowing at C5-6.
.
[**9-11**] Myelogram: IMPRESSION: Successful fluorographically guided
myelogram via the lumbar puncture at L3. No evidence of
significant central canal stenosis. For further detailed
findings, please refer to the CT myelogram of the same day.
Brief Hospital Course:
A/P: 71 y/o female with HTN, DM, hyperlipidemia, CAD, OSA,
Asthma
with slurred speech and LE weakness
.
#) Slurred speech, LE weakness. Still unclear etiology. Per
patient, this was resolving by the date of discharge. Had
negative CT scan of head. CT of spine showed spinal canal
narrowing at cervical, thoracic, and lumbar levels. CT after
myelograms shows severe stenosis at the thoracic level. Patient
refused the possiblity of neurosurgery.
.
#) CAD: CE neg X 2. No additional chest pain complaints once
transferred to the floor.
- Continued ASA, plavix, metoprolol, atorvastatin, added back
ACEI on last day (had been held secondary to ARF)
.
#) Bradycardia with escape rhythm: Resolved. Thought to be due
to BB overdose in the setting of renal failure. Now in sinus.
- monitored on Telemetry without events
- continued on low dose beta blocker
.
#) Wheezing: still unclear whether pulm edema or asthma or an
element of both. LVEF >55%.
- continued alb and ip nebs
.
#) OSA: continued on BiPAP.
.
#) ARF: Likley pre renal secondary to lasix as improved with
hydration. Renal u/s negative for hydronephrosis
- Cr 1.0 at discharge
- discharged on [**2-10**] dose of Lasix that she was taking on
admission: 40 mg po qd
.
#) DM: Continued on glyburide. Insulin sliding scale. Blood
sugars well-controlled on floor.
.
#) Microcytic Anemia: needs outpatient colonoscopy
.
#) FEN: Diabetic/Caradiac Diet
.
#) PPX: Heparin SC
.
#) communication [**Name (NI) **] son [**Name (NI) 2259**] [**Telephone/Fax (1) 96802**]
.
#) Dispo: home with home PT eval and prior services
Medications on Admission:
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Amitriptyline HCl 50 mg PO HS
Aspirin 325 mg PO DAILY
Atorvastatin 80 mg PO DAILY
Clopidogrel Bisulfate 150 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Fluticasone Propionate Nasal 2 SPRY NU DAILY
Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **]
Furosemide 80 mg PO DAILY
Gabapentin 600 mg PO TID
Glyburide 5mg [**Hospital1 **]
Ipratropium Bromide MDI 2 PUFF IH QID
Lisinopril 20 mg PO DAILY
Metoprolol 25 mg PO BID
Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
10. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times
a day.
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation four times a day.
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
13. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
sprays Nasal once a day: one spray in each nostril.
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
ALL CARE FAMILY SERVICES
Discharge Diagnosis:
Congestive Heart Failure
Spinal Stenosis
Bradycardia
Acute Renal Failure
DM2
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
Please take all medications as instructed. Your Metoprolol and
Furosemide doses have been changed.
If you experience any nausea, vomiting, lightheadedness, chest
pain, shortness of breath, or any other concerning symptoms
please seek medical attention immediately.
Followup Instructions:
Please follow-up with your PCP within the next week.
Provider: [**First Name8 (NamePattern2) 5257**] [**Last Name (NamePattern1) 5258**], [**Name12 (NameIs) 280**] Date/Time:[**2177-9-26**] 2:00
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2177-10-28**] 11:20
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2177-12-4**] 1:45
Name: [**Known lastname 400**],[**Known firstname 15394**] Unit No: [**Numeric Identifier 15395**]
Admission Date: [**2177-9-8**] Discharge Date: [**2177-9-12**]
Date of Birth: [**2105-12-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1775**]
Addendum:
It should be noted that Ms. [**Known lastname **] had severe nausea and
vomiting with a burning sensation up her spine and in her head
after the myelogram. She was treated with morphine and
compazine and the symptoms resolved within 8 hours after the
procedure.
Discharge Disposition:
Home With Service
Facility:
ALL CARE FAMILY SERVICES
[**First Name11 (Name Pattern1) 1034**] [**Last Name (NamePattern1) 1778**] MD [**MD Number(2) 1779**]
Completed by:[**2177-9-12**]
|
[
"E947.8",
"V45.82",
"250.00",
"414.01",
"278.01",
"403.91",
"723.0",
"272.4",
"584.9",
"427.89",
"327.23",
"787.01",
"428.0",
"715.90",
"493.90",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.21"
] |
icd9pcs
|
[
[
[]
]
] |
10987, 11203
|
6006, 7576
|
345, 356
|
9476, 9502
|
3001, 5983
|
9817, 10964
|
2423, 2503
|
8122, 9277
|
9376, 9455
|
7602, 8099
|
9526, 9794
|
2518, 2982
|
274, 307
|
384, 1903
|
1925, 2157
|
2173, 2407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,282
| 132,069
|
5524
|
Discharge summary
|
report
|
Admission Date: [**2114-5-15**] Discharge Date: [**2114-5-28**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
carcinoma of the rectum
Major Surgical or Invasive Procedure:
Exploratory laparotomy, lysis of adhesions (2.5
to 3 hours), low-low anterior resection with a
coloproctostomy with hand-sewn anastomosis and feeding
jejunostomy.
History of Present Illness:
86M referred with a carcinoma of the rectum which was thought to
be partially obstructing, but in fact as it turns out, it was
his diverticulosis which was
giving him the partial obstruction. His family noted that he had
begun to fail over the past year and that he had some rectal
bleeding. Colonoscopy showed a lesion which was advertised as 16
cm, but in fact was 10 cm. He had previously
had an abdominal aortic aneurysm and 2 hernias repaired with
mesh which made things somewhat difficult.
Past Medical History:
open chole, AAA repair, SB resection, intestinal obstruction,
LOA '[**06**], L inguinal hernia repair, eczema, hypothyroid
Social History:
married
20 pack-year h/o tobacco
-quit 6 years ago
3 glasses of wine q night
Family History:
non-contributory
Physical Exam:
[**2114-5-27**] per inpatient record:
98.5 64 146/72 18 94 RA
NAD
A and O x3
RRR no MRG
CTAB
soft, appropriately tender, +BS, ND
wound c/d/i
no c/c/e
Pertinent Results:
CBC
[**2114-5-16**] 06:30AM BLOOD WBC-5.4 RBC-4.42* Hgb-13.7* Hct-40.0
MCV-90 MCH-31.0 MCHC-34.3 RDW-14.0 Plt Ct-259
[**2114-5-17**] 02:15PM BLOOD WBC-7.1 RBC-3.42* Hgb-10.9* Hct-30.4*
MCV-89 MCH-31.9 MCHC-36.0* RDW-14.4 Plt Ct-170
[**2114-5-17**] 07:31PM BLOOD Hct-35.6*
[**2114-5-18**] 03:00AM BLOOD WBC-12.8*# RBC-3.65* Hgb-11.6* Hct-32.4*
MCV-89 MCH-31.7 MCHC-35.8* RDW-14.6 Plt Ct-189
[**2114-5-18**] 02:01PM BLOOD Hct-31.7*
[**2114-5-19**] 03:07AM BLOOD WBC-14.4* RBC-3.59* Hgb-11.2* Hct-31.9*
MCV-89 MCH-31.3 MCHC-35.2* RDW-14.6 Plt Ct-188
[**2114-5-20**] 04:28AM BLOOD WBC-11.1* RBC-3.52* Hgb-11.4* Hct-31.5*
MCV-90 MCH-32.3* MCHC-36.1* RDW-14.2 Plt Ct-200
[**2114-5-21**] 03:33AM BLOOD WBC-8.0 RBC-3.44* Hgb-10.9* Hct-30.7*
MCV-89 MCH-31.8 MCHC-35.6* RDW-14.1 Plt Ct-229
[**2114-5-22**] 06:05AM BLOOD WBC-8.7 RBC-3.58* Hgb-11.6* Hct-32.0*
MCV-89 MCH-32.4* MCHC-36.3* RDW-14.1 Plt Ct-289
[**2114-5-23**] 06:55AM BLOOD WBC-10.7 RBC-3.74* Hgb-11.5* Hct-33.8*
MCV-91 MCH-30.8 MCHC-34.0 RDW-14.0 Plt Ct-292
[**2114-5-24**] 04:21AM BLOOD WBC-6.3 RBC-2.67*# Hgb-8.0*# Hct-31.0*
MCV-116*# MCH-30.2 MCHC-25.9*# RDW-13.8 Plt Ct-212
[**2114-5-24**] 07:09AM BLOOD WBC-8.7 RBC-3.42*# Hgb-10.4*# Hct-31.4*
MCV-92# MCH-30.5 MCHC-33.2# RDW-14.0 Plt Ct-277
[**2114-5-26**] 06:41PM BLOOD WBC-8.0 RBC-3.39* Hgb-10.7* Hct-30.4*
MCV-90 MCH-31.5 MCHC-35.2* RDW-13.8 Plt Ct-354
Chemistries
[**2114-5-16**] 06:30AM BLOOD Glucose-94 UreaN-10 Creat-0.9 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
[**2114-5-17**] 02:15PM BLOOD Glucose-142* UreaN-7 Creat-0.8 Na-142
K-4.0 Cl-112* HCO3-21* AnGap-13
[**2114-5-18**] 03:00AM BLOOD Glucose-88 UreaN-10 Creat-0.9 Na-140
K-4.0 Cl-108 HCO3-24 AnGap-12
[**2114-5-19**] 03:07AM BLOOD Glucose-123* UreaN-19 Creat-0.8 Na-135
K-4.5 Cl-106 HCO3-23 AnGap-11
[**2114-5-20**] 04:28AM BLOOD Glucose-99 UreaN-19 Creat-0.7 Na-133
K-4.0 Cl-102 HCO3-23 AnGap-12
[**2114-5-21**] 03:33AM BLOOD Glucose-120* UreaN-20 Creat-0.6 Na-137
K-3.5 Cl-104 HCO3-26 AnGap-11
[**2114-5-22**] 06:05AM BLOOD Glucose-130* UreaN-21* Creat-0.7 Na-139
K-4.2 Cl-103 HCO3-27 AnGap-13
[**2114-5-23**] 06:55AM BLOOD Glucose-117* UreaN-21* Creat-0.7 Na-135
K-4.5 Cl-99 HCO3-29 AnGap-12
[**2114-5-24**] 07:09AM BLOOD Glucose-118* UreaN-23* Creat-0.7 Na-139
K-5.1 Cl-103 HCO3-30 AnGap-11
[**2114-5-24**] 11:00AM BLOOD Glucose-104 UreaN-24* Creat-0.6 Na-137
K-4.6 Cl-103 HCO3-28 AnGap-11
[**2114-5-26**] 06:41PM BLOOD Glucose-102 UreaN-26* Creat-0.8 Na-138
K-4.4 Cl-105 HCO3-25 AnGap-12
[**2114-5-27**] 07:56AM BLOOD Glucose-97 UreaN-23* Creat-0.7 Na-137
K-4.6 Cl-104 HCO3-25 AnGap-13
Coags
[**2114-5-28**] 04:35AM BLOOD PT-15.1* PTT-33.7 INR(PT)-1.4*
Brief Hospital Course:
Patient was admitted on [**2114-5-15**] with T3N0 recti-sigmoid
adenocarcinoma. He was taken to the operating room on [**2114-5-17**] by
Dr. [**Last Name (STitle) **] and the surgical staff for a Exploratory laparotomy,
lysis of adhesions (2.5 to 3 hours), low-low anterior resection
with a coloproctostomy with hand-sewn anastomosis and feeding
jejunostomy. Procedure was uncomplicated.
Post-operatively the patient did well, his pain was controlled
with an epidural.
On POD #1 he was out of bed, was given TPN, and made adequate
urine. His hematocrit remained stable. He was seen and evaluated
by radiation oncology. His JP drains continued to have
serosanguinous drainage. His dressings were clean, dry, and
intact. His pathology showed low grade adenocarcinoma with
negative margins and 0/12 lymph nodes and therefore was not a
candidate for XRT. He worked with physical therapy and made
progress. A condom catheter was used for his incontinence.
He was maintained on coumadin for DVT prophylaxis. On [**2114-5-23**] he
was started on amp/gent/flagyl. On [**2114-5-24**] he ambulated well
with PT, however with a decreased step length.
Patient had a gout flare during the admission and was started on
indomethacin 25mg PO TID.
By [**2114-5-26**] he was tolerating a soft diet and was passing flatus.
He moved his bowels on [**2114-5-27**] and his antibiotics were
discontinued.
On [**2114-5-28**] his JP drains were discontinued. His TPN was stopped.
His coumadin was also stopped. He tolerated a regular diet which
is to be supplemented by 30cc/hour of Impact with fiber cycled
overnight. He was started on iron treatment for his anemia and
Paxil for a depressed affect. His PICC line was discontinued.
His Indomethacin was changed to a PRN medication should he have
an another gout flare.
*Note: M.D. composing discharge summary was only inolved in the
care of the patient on [**2114-5-28**].
Medications on Admission:
flomax .4 mg qd
levothyr 50'
benicar 20qd
propranolol 20qd
hydrocortisone cream
Discharge Medications:
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Levothyroxine Sodium 50 mcg PO DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Metoclopramide 5 mg PO Q6H
Benicar *NF* 20 mg Oral daily hold for SBP<100
Metoprolol 12.5 mg PO BID hold for sbp <110, hr <55
Ferrous Sulfate 325 mg PO DAILY
Mineral Oil 15 ml PO QD
Pantoprazole 40 mg PO Q24H
Paroxetine HCl 20 mg PO DAILY
Hydrocodone-Acetaminophen 1 TAB PO Q4-6H:PRN
Psyllium 1 PKT PO BID
Tamsulosin HCl 0.4 mg PO HS
Insulin SC Sliding Scale
Discharge Disposition:
Extended Care
Facility:
The Clipper Home
Discharge Diagnosis:
rectosigmoid adenocarcinoma
Discharge Condition:
stable
Discharge Instructions:
[**Name8 (MD) **] M.D. for fevers, chills, nausea, vomitting, abdominal pain,
redness or drainage from wound, questions or concerns.
Continue tube feeds through feeding J-tube, cycled overnight
Impact w/ fiber at 30cc/hour.
Please flush J-tube w/ 30 ml water Before and after each
feeding.
Please check blood chemistries/electrolytes on [**2114-5-29**] and twice
weekly.
Please use venodynes to bilateral lower extremities at all
times.
Do not change dressing. Please leave dressing intact until
follow-up appointment.
Please check finger sticks QID.
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] next Wedneday [**2114-6-6**] at the
[**Hospital1 18**] general surgery clinic. Please call clinic to
schedule/confirm [**Telephone/Fax (1) 17478**].
Follow-up with primary care provider [**Last Name (NamePattern4) **] 1 week. Please call
clinic to schedule.
Completed by:[**2114-5-28**]
|
[
"562.10",
"424.1",
"998.11",
"568.0",
"244.9",
"564.09",
"275.3",
"293.9",
"274.9",
"154.0",
"V45.82",
"280.9",
"790.92",
"709.2",
"496",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.15",
"96.6",
"89.62",
"38.93",
"86.3",
"48.23",
"88.72",
"48.63",
"54.59",
"40.29",
"46.39",
"45.94",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6627, 6670
|
4088, 5991
|
285, 450
|
6742, 6750
|
1435, 4065
|
7354, 7729
|
1231, 1249
|
6122, 6604
|
6691, 6721
|
6017, 6099
|
6774, 7331
|
1264, 1416
|
222, 247
|
478, 975
|
997, 1121
|
1137, 1215
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,043
| 165,605
|
1717
|
Discharge summary
|
report
|
Admission Date: [**2157-5-27**] Discharge Date: [**2157-6-9**]
Date of Birth: [**2091-4-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Left Hemothorax
Major Surgical or Invasive Procedure:
[**2157-6-1**]: Video-assisted thoracoscopic surgery left hemothorax
evacuation, bronchoscopy with aspiration.
[**2157-6-1**]: Left-sided chest ultrasound, left-sided
pleuroscopy, pleural biopsies, talc pleurodesis, and Pleurx
catheter placement.
[**2157-6-1**]: Transthoracic ultrasound. Tube thoracostomy on the
left side.
History of Present Illness:
Pt is a 66M who is s/p L pleuroscopy, talc pleurodesis & pleurex
on [**2157-5-27**] for recurrent L pleural effusion. He was found to
have a hematocrit of 25 on the am
[**2157-5-31**], down from 39. Repeat HCT 12 hrs later was 19. He also
had L chest pain and LUQ pain. He was transferred to the MICU
for hypotension, transfused 3 units of PRCs. A CT torso was
obtained demonstrating a large L hemothorax.
His hemodynamics improved and HCT initially responded
appropriately. However, HCT dropped again this morning, and he
was transfused 2 additional units PRBCs without change in his
HCT from 24. The IP team placed a L 36 french chest tube
draining 700cc of blood. A repeat CT showed persistent large
hemothroax
and thoracic surgery was consulted for surgical management.
Past Medical History:
1) Ischemic Cardiomyopathy (EF15-20% at worst and started on
milrinone in [**2151**], last echo in [**2154**] with EF35-40%) s/p [**Hospital1 **]-V
Pacer/ICD ([**11-12**])
2) CAD/CABG [**2135**] (SVG-LAD-s/p stent in [**2148**], SVG-LCX(known
occlusion), LIMA to diag, SVG to RCA-known occlusion, stent to
LM into LCX)
3) DMII
4) CRI (Cr 1.3-1.8)
5) Anemia of Chronic Disease
6) HTN
7) Lichen Simplex Chronicus
8) h/o left subclavian vein occlusion
9) Hernia repair [**2151**]
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Cardiac History: CABG, in [**2145**] anatomy as above
Percutaneous coronary intervention, as above
Pacemaker/ICD placed in [**2151**]
Social History:
Lives with wife and daughters. [**Name (NI) **] five children and two
grandchildren. Born in [**Country 9819**] - has lived in USA for ten
years. Previous leather goods importer/exporter. Never smoked
cigs, drank ETOH or used recreational drugs.
Family History:
Brother had MI at 48. Mother had DM, CHF and MI and unknown age.
Father had CAD, but no MI.
Physical Exam:
VS: T 98.9 HR: 68 SR BP: 110/60 Sats: 98% RA
General: 66 year-old male with minimal understanding of English
but in no apparent distress.
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopath
Card: RRR
Resp: decreased breath sounds on left with faint crackles at
base. Right clear
GI: beign
Extr: Right arm no edema, Left 2+ edema. Bilateral knees with
mild edema
Skin: multiple areas of scattered hyperpigmentation of upper &
lower extremity
Incision: left VATs site with steri-strips. mild ooz
Neuro: non-focal
Pertinent Results:
[**2157-6-8**] WBC-9.5 RBC-3.39* Hgb-10.3* Hct-29.7* Plt Ct-325
[**2157-6-6**] Hct-29.8*
[**2157-6-5**] WBC-8.0 RBC-3.51* Hgb-10.6* Hct-31.1 Plt Ct-187
[**2157-6-4**] WBC-8.1 RBC-3.43* Hgb-10.5* Hct-29.9 Plt Ct-160
[**2157-6-3**] WBC-6.8 RBC-3.04* Hgb-9.2* Hct-25.8 Plt Ct-128*
[**2157-6-2**] Hct-28.6*
[**2157-6-8**] Glucose-141* UreaN-37* Creat-1.3* Na-133 K-4.5 Cl-99
HCO3-24
[**2157-6-7**] UreaN-33* Creat-1.3* Na-134 K-3.8 Cl-100 HCO3-26
[**2157-6-6**] Creat-1.1 K-4.1
[**2157-6-5**] Glucose-138* UreaN-20 Creat-1.0 Na-137 K-4.2 Cl-102
HCO3-27
[**2157-6-4**] Glucose-93 UreaN-20 Creat-1.0 Na-141 K-4.0 Cl-105
HCO3-28
[**2157-6-3**] Glucose-105 UreaN-22* Creat-1.0 Na-142 K-4.1 Cl-107
HCO3-27
[**2157-5-30**] Glucose-120* UreaN-43* Creat-1.5* Na-134 K-4.4 Cl-104
HCO3-20
[**2157-5-30**] Glucose-55* UreaN-45* Creat-1.5* Na-136 K-4.3 Cl-105
HCO3-20
[**2157-5-29**] Glucose-177* UreaN-46* Creat-1.6* Na-135 K-4.9 Cl-104
HCO3-19
[**2157-6-1**] CK-MB-26* MB Indx-7.7* cTropnT-0.29* CK-MB-39* MB
Indx-8.0
TropnT-0.43* CK-MB-19* MB Indx-10.4* cTropnT-0.09 cTropnT-0.05
[**2157-6-6**] JOINT FLUID Source: Knee LEFT KNEE.
GRAM STAIN (Final [**2157-6-6**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
[**2157-6-1**] TISSUE BLOOD CLOTS FROM LEFT CHEST.
GRAM STAIN (Final [**2157-6-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2157-6-4**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2157-6-7**]): NO GROWTH.
ACID FAST SMEAR (Final [**2157-6-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
[**2157-5-27**] 4:47 pm PLEURAL FLUID
GRAM STAIN (Final [**2157-5-27**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2157-5-30**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2157-6-2**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2157-5-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
CXR:
[**2157-6-8**] the left chest tube has been
removed. No evidence of pneumothorax. Otherwise, little change.
[**2157-6-7**] 1. The left basal pleural tube has been removed and
there is no pneumothorax or accumulation of appreciable pleural
fluid. Left lower lobe remains collapsed. Very small right
pleural effusion is present. Moderate
cardiomegaly unchanged.
2. Percutaneous epicardial pacer leads and transvenous right
atrial and right ventricular pacer defibrillator leads are
unchanged in their respective positions. Right lung is clear.
Mild-to-moderate cardiomegaly is unchanged.
[**2157-6-4**] One of the left apical chest tubes has been removed. No
significant pneumothorax is identified. The rest of the lines
and tubes are unchanged. There is a left retrocardiac opacity
which is unchanged. There is no signs for overt pulmonary edema.
[**2157-6-2**] There is slight increase in left basal atelectasis
which might be explained at least in part by low lung volumes
most likely due to termination of mechanical ventilation. The
pacemaker obscures part of the left hemithorax but within the
limitations of this study, no overt pneumothorax is
demonstrated. Small amount of subcutaneous air is seen in the
left chest wall. The lower left chest tube is seen, also
unchanged in location compared to the prior study. The right
lung is grossly unremarkable.
Chest CT
[**2157-6-1**] Large 16 x 15 x 14 cm left subpulmonic hemorrhage.
Small
hydropneumothorax.
Brief Hospital Course:
The patient had a left pleuroscopy, pleural biopsy, talc
pleurodesis and pleur ex catheter placed on [**5-27**] for recurrent L
pleural, by Interventional Pulmonology who admitted him. Pleural
fluid was lymphocytic exudate. He was found to have an HCT of 25
on [**5-31**], down from 35; repeat HCT 12 hours later was 19. At this
time he had some L chest and LUQ pain, lightheartedness. His
blood pressure was 70's systolic. He was transfused RBC for
acute blood loss anemia He was transferred to the MICU. CXR
showed increased left pleural effusion. CT of the chest showed
Large 16 x 15 x 14 cm left subpulmonic hemorrhage.
Anticoagulation was held. He was transfused FFP and pRBCs (acute
blood loss anemia). Interventional pulmonology placed a left 36
french chest tube which drained 600cc blood. Repeat chest CT
showed persistent large hemothorax. Thoracic surgery was
consulted for surgical management.
On [**6-1**], he was taken to the OR for L VATS hemothorax evacuation
and bronchoscopy with aspiration. He transferred to the SICU
intubated overnight and extubated the next day. He remained in
sinus rhythm and HCT was stable. He transferred to the 2 chest
tube were to suction with serous drainage. On [**6-4**] the basilar
chest tube was removed. The posterior apical was removed on
[**2157-6-5**]. He was followed by serial chest films which ed showed
a stable small left lower lobe effusion and atelectasis.
His oxygenation improved with oxygenation 98% RA.
Rheumatology saw him on [**2157-6-6**] for an acute flare of gout
bilateral knees. The right knee was tapped. He was started on
Prednisone 30mg for 5 days. They recommended to re-initiate
allopurinol at 100 mg daily as an outpatient in [**5-16**] weeks after
this flare resolves. Consider low-dose colchicine at 0.6 mg
every other day when allopurinol initiated. Should recheck uric
acid level after 3-4 weeks of treatment with allopurinol and up
titrate dose if level continues to be > 6.
Cardiology saw him for his ICD which functioned normally with
interrogation. They recommended holding Plavix and decrease
aspirin to 81mg daily.
He was seen by physical therapy who recommended STR.
Disposition: He transferred to [**Hospital1 **] and will follow-up with
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
atorvastatin 20 mg daily bumetanide 0.5 mg daily coreg 12.5 mg
[**Hospital1 **] plavix 75 mg daily digoxin 62.5 mcg daily imdur 30 mg qhs
lisinopril 2.5 mg daily asa 325 mg daily multivitamin daily
glimepiride 2 mg daily
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
8. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days: last dose [**2157-6-11**].
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: Start
[**2157-6-12**].
11. Regular Insulin Sliding Scale
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
61-160 mg/dL 0 Units 0 Units 0 Units 0 Units
161-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-240 mg/dL 4 Units 4 Units 4 Units 4 Units
241-280 mg/dL 6 Units 6 Units 6 Units 6 Units
281-320 mg/dL 8 Units 8 Units 8 Units 8 Units
321-360 mg/dL 10 Units 10 Units 10 Units 10 Units
12. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Left lower lobe effusion
Ishcemic cardiomyopathy with LVEF 25-30% in [**1-/2157**]; formerly
on home milrinone in [**2151**]; [**Hospital1 **]-V PPM/ICD placed [**2151**]
CAD with CABG in [**2135**] (LIMA-Diag, SVG-LCx, SVG-RCA, SVG-LAD;
LCx and RCA grafts known occluded), s/p stents to LM-LCx and
stent into SVG-LAD graft both in [**6-13**]; grade III/IV diastolic
dysfunction
DM2
CKD III (baseline creatinine 1.3 to 1.5) --> recent inpatient
creatinine values 1-1.1
Anemia (baseline Hct 38)
HTN
lichen simplex chronicus
h/o left subclavian vein occlusion
hernia repair [**2151**]
pulmonary hypertension (PA pressure 35/15 by RHC in [**3-/2156**])
h/o gout (right knee, 5 years ago, prior treatment with
allopurinol)
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 7769**] if experience increased
shortness of breath, cough or sputum production, chest pain
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2348**] [**6-21**] at 9:30 in
the [**Hospital Ward Name 121**] Building Chest Disease Center [**Hospital1 **] I.
Report to the [**Hospital Ward Name 517**] Clincal Center [**Location (un) **] Radiology
Department for a Chest X-Ray 45 minutes before your appointment
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Telephone/Fax (1) 250**] in [**5-16**] weeks for
restart of Allopurinol and uric acid levels.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2157-6-14**]
|
[
"285.21",
"V45.02",
"428.42",
"998.11",
"285.1",
"511.89",
"338.18",
"584.9",
"512.1",
"250.00",
"414.8",
"585.3",
"274.0",
"998.0",
"403.90",
"428.0",
"511.9",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.92",
"33.24",
"81.91",
"34.20",
"34.06",
"34.04",
"89.49"
] |
icd9pcs
|
[
[
[]
]
] |
10906, 10985
|
6801, 9125
|
335, 663
|
11749, 11765
|
3121, 4381
|
11963, 12624
|
2448, 2543
|
9397, 10883
|
11006, 11728
|
9151, 9374
|
11789, 11940
|
2558, 3102
|
5302, 6778
|
5152, 5268
|
280, 297
|
691, 1474
|
1496, 2168
|
2184, 2432
|
4413, 4795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,486
| 183,427
|
17715
|
Discharge summary
|
report
|
Admission Date: [**2151-2-10**] Discharge Date: [**2151-3-3**]
Date of Birth: [**2077-11-24**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: A 73-year-old man presented to
the [**Hospital1 69**] with complaint of
decreased level of consciousness earlier on [**2151-2-11**].
The patient complained of headache earlier that evening as
well. The patient became obtunded and presented at
First Health Alliance in [**Location (un) 16843**] for treatment. The
patient became less responsive over there and was transferred
to [**Hospital1 69**] for treatment.
PAST MEDICAL HISTORY:
1. Status post myocardial infarction five years ago.
2. Hypertension.
3. History of mastoid surgery.
MEDICATIONS:
1. Isosorbide.
2. Baby aspirin.
SOCIAL HISTORY: The patient lives with his wife, and is a
retired [**Name (NI) **]. The patient denies any alcohol use, but uses
tobacco.
PHYSICAL EXAMINATION: Patient's blood pressure is 219/103 on
presentation, pulse was 72. Patient was lethargic, was
awoken easily and followed commands. The patient was alert
to person and date, but not to place. Patient's pupils were
equal, round, and reactive to light. Patient's extraocular
movements were intact. Patient's lungs were clear bilaterally.
Patient's heart was regular, rate, and rhythm. Patient's abdomen
was soft, nontender, and nondistended. Patient had good bowel
sounds. Patient's extremities showed no edema. Patient had
no pronator drift. Patient's cranial nerve examinations were
grossly intact. Patient's motor examinations are normal.
The patient follows commands, had normal speech.
STUDIES: CT scan, showed a right intraventricular
hemorrhage, with bleeding also in the third and fourth
ventricle as well.
HOSPITAL COURSE: The patient was admitted to the
Neurosurgery/ICU service for management. The patient had
repeat head CT scan on [**2-12**], and the patient was
started on Nipride for blood pressure control. Patient's
blood pressure gradually returned to acceptable range. A
ventriculostomy drain to monitor intracranial pressure.
On [**2-23**], the patient had episodes of hypoxia.
Pulmonary consult was obtained. Patient was intubated for
hypoxia. Patient also had altered mental status, which was
contributed to possible meningitis. The patient was started
on Vancomycin and ceftriaxone.
Infectious Disease consult was also obtained, which
recommended patient continue with the Vancomycin and
ceftriaxone. Patient's CSF returned as Enterobacter
meningitis. The patient also has had a coagulase negative
Staphylococcus aureus growing in blood. Patient gradually
became septic and was made comfort measures only on [**2151-3-3**].
The patient expired on 5:25 pm on [**3-3**],medial [**2150**].
DISCHARGE CONDITION: Expired.
DISCHARGE STATUS: Morgue.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 1909**]
MEDQUIST36
D: [**2151-3-3**] 19:19
T: [**2151-3-4**] 05:55
JOB#: [**Job Number 49274**]
|
[
"320.82",
"038.11",
"412",
"431",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.04",
"02.2",
"01.18",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
2779, 3072
|
1766, 2757
|
923, 1748
|
174, 589
|
611, 759
|
776, 900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,449
| 185,812
|
34804
|
Discharge summary
|
report
|
Admission Date: [**2129-8-20**] Discharge Date: [**2129-8-28**]
Date of Birth: [**2105-9-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
right craniotomy for tumor resection
History of Present Illness:
Mr. [**Known lastname **] is a 23 y/o male in previously good health who was
moving boxes on [**2129-8-18**] when he noted gradual onset headaches
which were localized mostly to the left frontal portion of his
head. He took analgesics and noted some relief. He denies head
trauma, loss of consciousness, or other associated neurological
symptoms. After the pain improved, headache returned today
stronger than previously noted. He presented to OSH where head
CT revealed left parieto-occipital hyperdensity consistent with
acute hemorrhage. He was transferred to [**Hospital1 18**] ED for
neurosurgical evaluation.
Past Medical History:
none
Social History:
lives in apartment; denies tobacco or IVDU; social EtOH use
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM upon admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-20**] bilaterally EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-21**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally.
Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to 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 [**5-23**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On Discharge:
Neurological examination was non-focal. AOX3, EOMI, no pronator
drift. Full motor strength and sensation throughout upper and
lower extremities. Surgical incision was clean dry and intact.
Pertinent Results:
CT head [**2129-8-25**]:
FINDINGS: The patient is post left occipital craniotomy and
excision of the left posterior temporal occipital meningioma,
with expected degree of
pneumocephalus. There are tiny foci of high attenuation in the
postoperative bed, which may reflect presence of hemorrhage.
There is no hydrocephalus, shift of normally midline structures.
There is no mass effect or edema.
Left occipital craniotomy changes are evident on the bone
windows. Imaged
paranasal sinuses are pneumatized and well aerated.
IMPRESSION: Status post excision of left temporoparietal
meningioma, with
small foci of hemorrhage and expected postoperative changes.
[**2129-8-27**] 06:55AM BLOOD WBC-11.7* RBC-4.70 Hgb-14.1 Hct-39.8*
MCV-85 MCH-30.0 MCHC-35.4* RDW-12.4 Plt Ct-356
[**2129-8-27**] 06:55AM BLOOD Glucose-104 UreaN-7 Creat-0.6 Na-139
K-4.4 Cl-100 HCO3-27 AnGap-16
[**2129-8-27**] 06:55AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname **] is a 23 y/o male in previously good health who was
moving boxes on [**2129-8-18**] when he noted gradual onset headaches
which were localized mostly to the left frontal portion of his
head. He took analgesics and noted some relief. After the pain
improved, headache returned the following day with stronger
intensity, prompting his going to the ED for evaluation.
By CT an area of questionable mass was identified in the occiput
and further work-up was done and inclusive of MRI, CTA/V. An
angiogram was desired, however this was refused by the patient,
as he "didn't feel good about it". He went to the OR for
resection of this mass via a posteriorly placed incision, and
tolerated the procedure well. He was maintained in the ICU
overnight for monitoring, and transferred to [**Hospital Ward Name **] 11 floor
status to following day. He was evaluated by PT on POD#2, and
determined to be appropriate for home discharge, however the
patient continued to be hospitalized secondary to pain
Management issues. Narcotic agents were changed, and an
anti-spasmodic was added, which made a marked difference in pain
relief. On [**8-28**], he was discharged to home without further
physical therapy needs, and instructions to follow up as noted
previously in this document.
Medications on Admission:
None
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
5 days.
Disp:*5 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Phenytoin Sodium Extended 200 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 3 doses.
Disp:*3 Tablet(s)* Refills:*0*
6. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 3 doses.
Disp:*6 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
left parieto-occipital meningioma
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
??????Have a family member check your incision daily for signs of
infection
??????Take your pain medicine as prescribed
??????Exercise should be limited to walking; no lifting, straining,
excessive bending
??????You may wash your hair only after sutures have been removed
??????You may shower before this time with assistance and use of a
shower cap
??????Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
??????Clearance to drive and return to work will be addressed at your
post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
??????New onset of tremors or seizures
??????Any confusion or change in mental status
??????Any numbness, tingling, weakness in your extremities
??????Pain or headache that is continually increasing or not relieved
by pain medication
??????Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????Fever greater than or equal to 101?????? F
Followup Instructions:
Follow-up in Brain [**Hospital 341**] Clinic on the [**Location (un) 858**] of the [**Hospital Ward Name 5074**].
The appointment will be with [**Name6 (MD) 5005**] [**Last Name (NamePattern4) 5342**], MD
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2129-9-5**] 4:00pm.
You will have your sutures removed at that time as well.
Completed by:[**2129-8-28**]
|
[
"431",
"338.18",
"225.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
5894, 5900
|
3662, 4964
|
328, 367
|
5978, 6002
|
2708, 3638
|
7358, 7718
|
1138, 1156
|
5019, 5871
|
5921, 5957
|
4990, 4996
|
6026, 7335
|
1171, 1187
|
2497, 2689
|
280, 290
|
395, 1016
|
1692, 2483
|
1201, 1399
|
1414, 1676
|
1038, 1044
|
1060, 1122
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,191
| 182,909
|
48658
|
Discharge summary
|
report
|
Admission Date: [**2197-3-5**] Discharge Date: [**2197-3-8**]
Date of Birth: [**2132-10-6**] Sex: F
Service: MEDICINE
Allergies:
Effexor / Vicodin / Lisinopril / Valsartan
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Tongue swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64 yo F with a past history of HL, DM, and Htn who presents with
recurrent facial swelling. Patient was in her USOH when at 2 am
this morning she was awake listening to the radio and all of a
sudden she developed right sided tongue swelling without
associated dyspnea, stridor or difficulty with secretions. She
was listening to the R & B radio program hosted by [**First Name9 (NamePattern2) **] [**Doctor Last Name 3175**] (@
[**University/College **]) at the time of this event. Per the patient, these symptoms
feel exactly like her previous episodes of angioedema. In the
past, this reaction has been blamed on ace-i, [**Last Name (un) **] and green tea.
Her workup has included normal C3, elevated C4, normal C1
inhibitor protein. Patient denies any new medications, other
than the recent addition of clonidine to her medication regimen.
She reports no out of the ordinary foods, and today she ate
oatmeal, wheat toast and coffee for breakfast, skipped lunch,
and had a TV chicken dinner (which she reportedly tolerated well
several years ago when she had the same TV dinner). She reports
no rashes, no sick contacts, and no recent travel.
.
In the ED, patient was noted to have swelling of the right side
of the tongue. She received Solumedrol 125 mg IVx1, Ranitidine
10 mg x1, and Diphenhydramine 25 mg IV x1. On transfer, VS were
66, 157/65, 14, 97% RA.
.
In the MICU, patient reports that she is feeling better better
still feels that her tongue is swollen. She continues to deny
shortness or breath or difficulty managing her secretions.
.
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:
# Hypertension
# Hyperlipidemia
# Diabetes
# Depression
# Primary hypothyroidism
# Multinodular goiter
Social History:
The patient lives in [**Location 686**] with her granddaughter and her
son. She is currently on [**Social Security Number 102338**]social security. She denied smoking,
drinking or IVDU.
Family History:
Family History: No family history of [**Social Security Number **] or angioedema. She
has 2 brothers with DM. His sister had breast cancer and passed
away approximately ten years ago.
Physical Exam:
ADMISSION EXAM:
T: 97.8 BP: 171/75 P: 68 R: 21 O2: 97% RA
General: Alert, oriented, no acute distress
HEENT: Right sided tongue swelling, Sclera anicteric, MMM,
oropharynx clear
Neck: Somewhat cushingoid neck, supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2197-3-5**] 04:05AM BLOOD WBC-9.8 RBC-4.49 Hgb-11.5* Hct-35.2*
MCV-79* MCH-25.6* MCHC-32.6 RDW-13.3 Plt Ct-315
[**2197-3-5**] 04:05AM BLOOD Neuts-48.2* Lymphs-43.2* Monos-3.9
Eos-3.8 Baso-0.9
[**2197-3-5**] 04:05AM BLOOD Glucose-153* UreaN-27* Creat-1.7* Na-138
K-5.3* Cl-103 HCO3-20* AnGap-20
Brief Hospital Course:
HOSPITAL COURSE
This is a 64 year old lady with a history of HTN, HL, DM who
presented with recurrent tongue swelling. She was treated with
steroids, H2 blocker and antihistamine with total resolution of
her swelling. She was discharged on insulin for management of
hyperglycemia in the setting of prednisone.
.
ACTIVE ISSUES
#. ANGIOEDEMA: The patient presented with recurrent angioedema,
third admission since Decemeber. She was given prednisone,
famotidine, and benadryl with total resolution of her symptoms
within 24 hours of admission. She had no urticaria or
bronchospasm associated with her swelling, and did not develop
airway compromise. She was transferred from the ICU on HD 2.
Etiology of swelling remained unclear. Clonidine initially held
given only recently added medication. However, after refractory
hypertension, clonidine was restarted. She had only started her
clonidine after her prior two admissions for angioedema, and
after discussion with her outpatient endocrinologist, clonidine
is not frequently associated with angioedema. The patient has
had excellent workup thus far with normal C1 inhibitor levels
and relatively normal complement levels. There was possible
concern in past that green tea may be trigger, and patient did
report having green tea during day prior to admission. Her
prednisone taper was cut short one day of 5 given total
resolution of symptoms and hyperglycemia (40, 30, 20, 20, 10).
She was discharged on cetirizine and benadryl as needed with
close [**Month/Day/Year **] and PCP [**Last Name (NamePattern4) 702**].
.
# HYPERTENSION: History of difficult to manage hypertension
currently managed on amlodipine, hydralazine, clonidine and
imdur. Clonidine was initially held in the setting of angioedema
and concern that clonidine was only medication recently started.
The patient was subsequently noted to have persistently
elevated SBPs in the 150s-180s. Hydralazine uptitrated to 75mg
PO Q6H and Imdur increased to 60mg daily. Patient remained
hypertensive to 170s after regimen adjusted, and labetalol was
added for additional BP control. Ultimately as discussed above,
the patient was restarted on her home regimen with improvement
in her blood pressure management.
.
# DIABETES MELLITIS TYPE 2: Patient has previously been on
insulin, but was only on oral agents prior to admission. Oral
agents held and patient started on insulin sliding scale. Was
noted to have hyperglycemia with FSBS in 300s-400s, in setting
of being started on steroids for treatment of tongue swelling.
She was started on glargine without improvement in her blood
sugars. Ultimately, in setting or [**Last Name (un) **] and concern for
continuation of glyburide and persistently elevated blood sugars
despite prednisone taper, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes Center consult was
placed. The patient was started on 20 units of NPH in the
morning and an adjusted humulog sliding scale. Her glyburide
was discontined and she was started on glimepride given her
persistent kidney insufficiency. She will follow-up with [**Last Name (un) **]
Diabetes on the day following discharge.
.
# CKD: It appears her baseline since [**2194-12-18**] has been Cr of
1.2 to 1.9. Creatinine stably elevated around 1.7 on admission.
Glyburide was held and replaced with glimepride on discharge.
She has close follow up with PCP and [**Name9 (PRE) **] clinic and
Nephrology to discuss persisently renal insufficiency.
.
INACTIVE ISSUES
# DYSLIPIDEMIA: She was continued on atorvastatin.
.
# INSOMNIA: She was continued on clonazepam, trazodone as needed
for insomnia.
.
#. DEPRESSION: She was continued on nortriptyline.
.
TRANSITIONAL ISSUES
# Medical Management: Start NPH, Humulog and glimepride
# Follow-Up: [**Last Name (un) **], PCP, [**Name10 (NameIs) 9039**], Renal
# Code: Full
Medications on Admission:
CLONIDINE 0.1 mg po BID
AMLODIPINE 10 mg daily
ATORVASTATIN 80 mg daily
CLONAZEPAM - 0.5 -1 mg prn
FLUTICASONE [FLONASE] - 50 mcg Spray, 2 puff [**Hospital1 **]
GLYBURIDE - 2.5 mg daily
HYDRALAZINE - 50 mg Q6H
ISOSORBIDE MONONITRATE - 30 mg ER daily
NORTRIPTYLINE 50 mg qhs
TRAZODONE - 100 mg qhs
Tylenol prn
Aspirin 81 mg daily
CETIRIZINE 10 mg qhs
Discharge Medications:
1. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO QHS (once a day
(at bedtime)) as needed for insomnia.
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
6. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. cetirizine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching: swelling, itching,
rash.
14. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous in the morning for 14 days.
Disp:*qS * Refills:*0*
15. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous
three times a day: Use per attached insulin sliding scale.
Disp:*qS * Refills:*2*
16. Amaryl 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
17. Diabetic Insulin Syringe
Please provide patient with appropriate diabetic syringes for
management of her AM NPH dose and Humalog insulin sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Angioedema, Diabetes Mellitus Type 2
3. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for management of recurrent swelling in your
tongue. It is still unclear what the cause of these episodes
are. Please continue to follow-up in [**Hospital1 **] clinic for ongoing
work-up of these episodes.
Your blood sugars were again elevated in the setting of
prednisone. Because they were difficult to control using a
simple insulin sliding scale as you have used in the past, we
had our [**Hospital **] Clinic Diabetes specialists assist us. You were
started on NPH and a Humalog insulin sliding scale. In
addition, you continue to have worsening mild kidney disease. To
reflect your kidney function, your oral diabetes medication was
again changed, this time to glipizide. Please discuss these
changes with your primary care physician. [**Name10 (NameIs) **] scheduled an
outpatient follow up appointment at the [**Last Name (un) **] Diabetes Center
tomorrow to go over your diabetes control. Although we have
stopped your prednisone, it is likely that you will have
elevated blood sugars for several more days and will need to
take insulin during this time.
The following changes were made to your medication list:
1. START Amaryl 1mg at night
2. START NPH 20 units in the morning
3. START Humulog insulin sliding scale
Followup Instructions:
Department: DIV OF [**Last Name (un) **] AND INFLAM
When: MONDAY [**2197-3-13**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9703**], RNC [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: [**Last Name (un) **] Diabetes Center
When: Thursday [**3-9**]
At: 12:00 for registration
At: 12:30pm with [**Last Name (un) **] Vision for eye imaging (no dialation)
At: 1:00pm with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**] NP
At: 2:00pm with a Nurse Educator
Address: One [**Last Name (un) **] Place, [**Location (un) 86**], [**Numeric Identifier 718**]
Campus: OFF CAMPUS
Department: [**Hospital3 249**]
When: FRIDAY [**2197-3-10**] at 10:20 AM
With: [**Doctor First Name **] FERN, RNC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"250.02",
"E928.9",
"584.9",
"285.21",
"244.8",
"311",
"585.9",
"780.52",
"403.90",
"995.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9771, 9777
|
3852, 7699
|
316, 322
|
9877, 9877
|
3515, 3515
|
11307, 12363
|
2730, 2900
|
8099, 9748
|
9798, 9856
|
7725, 8076
|
10028, 11284
|
2915, 3496
|
1919, 2366
|
261, 278
|
350, 1900
|
3531, 3829
|
9892, 10004
|
2388, 2493
|
2509, 2698
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,607
| 143,183
|
19248+57032
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-4-10**] Discharge Date: [**2142-4-24**]
Date of Birth: [**2069-11-24**] Sex: M
Service:
ADMISSION DIAGNOSES:
1. Bile peritonitis.
2. Small bowel obstruction.
HISTORY OF PRESENT ILLNESS: This patient is a 72-year-old
male, who was recently admitted to [**Hospital3 **] Hospital from
[**2-21**] to [**2142-4-6**] for acute mesenteric ischemia
for which he had status post aortobifemoral bypass graft for
an occluded mesenteric vasculature with dead bowel. He also
underwent a massive small bowel resection with
jejunocolostomy during that hospital visit. This was
followed with ileocecectomy and ileocolostomy, and a
percutaneous cholecystostomy tube, a PEG/J tube and a left
subclavian Hickman for long-term TPN.
His previous hospital course was complicated by anastomotic
ulcer with significant bleeding. The bleeding had
subsequently subsided over a period of time. The patient was
then discharged to rehab after prolonged hospital course, but
now returns with significant dehydration, azotemia, sepsis,
abdominal pain, and a low-grade temperature of 100.3. He
also had leukocytosis, and on initial CT scan, there was
presumed small bowel obstruction at the small bowel - colon
anastomosis. Patient was brought in urgently for hydration
and exploratory laparotomy.
PAST MEDICAL HISTORY:
1. Acute mesenteric ischemia.
2. Anastomotic ulcer/bleed.
3. History of MRSA.
4. History of Enterobacter/Klebsiella septicemia.
5. Significant 60-pack year smoking history.
PAST SURGICAL HISTORY:
1. Aortobifemoral/superior mesenteric artery bypass graft.
2. Small bowel resection.
3. Left subclavian double lumen Hickman.
4. Status post ileocecectomy/ileocolostomy.
5. Status post cholecystostomy tube.
6. Status post PEG-J tube.
7. Remote status post vasectomy.
MEDICATIONS ON ADMISSION:
1. Levaquin 500 mg q.d.
2. Lopressor 12.5 mg b.i.d.
3. Ursodiol 300 mg t.i.d.
4. Protonix 40 mg b.i.d.
5. Loperamide 2 mg b.i.d.
6. Iron sulfate 5 mg b.i.d.
7. Morphine sulfate p.o. 10-15 mg q.4-6h. prn.
8. Mucomyst nebulizer.
9. Chlorhexidine 15 mg q.3h. prn.
10. Insulin-sliding scale.
ALLERGIES: No known drug allergies.
LABORATORY DATA ON ADMISSION: WBC 21.4, hematocrit 29.9,
platelets 247. Sodium 154, potassium 3.8, chloride 125,
bicarb 16, BUN 74, creatinine 1.8, glucose 72. ALT 96, AST
92, alkaline phosphatase 318. Amylase 23, total bilirubin
9.9, lipase 11.
CT of the abdomen and CT angiogram: Small bowel obstruction
with distention of the small bowel, edema of the small bowel
wall, most likely at the ileocolonic anastomotic site.
Distended gallbladder with gallbladder wall edema. Ascites.
Patent superior mesenteric artery graft.
HOSPITAL COURSE: Patient was admitted on [**2142-5-11**] and
immediately went to the operating room for an exploratory
laparotomy. In the OR, a exploratory laparotomy with a
midline incision was performed, along with a cholecystectomy,
and G tube placement. A small bowel resection with
jejunocolostomy was also performed, and a diagnosis of bile
peritonitis was confirmed in the OR. The patient tolerated
the procedure, remained in hypovolemic/septic shock following
the operation. He was transferred to the Surgical ICU for
further management of his hypovolemia, azotemia, and sepsis.
He was placed on broad-spectrum antibiotics including
vancomycin, levofloxacin, Flagyl, and fluconazole.
During his OR and initial ICU course, he received 8 units of
packed red blood cells, 4 units of FFP, and over 5 liters of
crystalloid. He had an estimated blood loss of 2 liters in
the OR. He was maintained on a Levophed drip. Over the next
couple of days, the patient was given massive fluid
resuscitation along with FFP and vitamin K. He was kept
intubated and sedated.
During his hospitalization, the Vascular Surgery service was
also made aware of his presence. They had formally evaluated
while in the Emergency Department, and followed him
throughout his hospital course. They felt that he
demonstrated no evidence of acute ischemia during his present
hospital course. This patient had blood cultures, sputum
cultures, and peritoneal cultures all which demonstrates
methicillin-resistant Staphylococcus aureus.
By [**4-15**], the patient was finally weaned off his
Levophed. He remained hemodynamically stable throughout the
rest of his ICU course. He was continued on broad-spectrum
antibiotics. Patient was also started on TPN with the help
of a nutritional consult. He was also started on tube feeds
and advanced slowly to a goal of 30 cc an hour of full
strength Impact with fiber.
On [**4-16**], the patient was started on diuresis of his
fluid overload. On [**4-17**], a right upper extremity
ultrasound was obtained for right upper extremity swelling.
This ultrasound demonstrated a nonocclusive thrombus of the
right internal jugular vein. The patient was started on a
Heparin drip of 400 units per hour with a goal of 40-60 PTT.
On [**4-19**], the patient developed diarrhea, Clostridium
difficile was sent, which returned negative. On [**4-20**],
the patient was finally extubated and patient was tolerating
goal tube feeds and CPM. He was transferred to the VICU on
[**2142-4-21**]. He received aggressive chest PT. He was
finally transferred to floor status on [**2142-4-23**], and
also underwent a second ultrasound, which did not reveal any
deep venous thrombus particularly of the right internal
jugular vein. His Heparin was stopped, and the patient was
also taken off all antibiotics by [**2142-4-23**].
A bedside swallow study was performed, and the patient was
determined to be a clear aspiration risk. As a result, he
was maintained at NPO status, and was continued on tube feeds
with a plan for long-term TPN. Home TPN service and Dr.[**Name (NI) 19165**] office was contact[**Name (NI) **] for future planning of home TPN.
Patient's Foley was also discontinued, and he successfully
passed his voiding trial. Physical Therapy and Occupational
Therapy were both consulted, and patient was screened for
rehab. Patient remained hemodynamically stable, and remained
afebrile throughout the rest of his hospital course. He was
set for discharge by [**2142-4-24**].
DISCHARGE STATUS: Rehab facility.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Bile peritonitis.
2. Small bowel obstruction status post small bowel resection.
3. Cholecystitis status post cholecystectomy.
4. Status post gastrostomy tube placement.
FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr. [**Last Name (STitle) **]
within two weeks. Patient is to call to make an appointment.
Patient is also to be followed up for video swallowing test
to assess for his aspiration potential within 2-3 weeks.
Patient is also to be setup for home TPN services.
DISCHARGE MEDICATIONS:
1. Ranitidine 150 mg b.i.d. per G tube.
2. Lopressor 25 mg b.i.d. per G tube.
3. Insulin-sliding scale.
4. Impact with fiber full strength tube feeds should run at
30 cc an hour.
5. TPN should entail the following volume [**2138**] cc/hour.
6. Amino acid 100 grams.
7. Dextrose 250 grams, 45 grams per day of fat.
8. Potassium chloride 30 mmol/L.
9. Potassium phosphate 30 mmol/L.
10. Magnesium sulfate 10 mmol/L.
11. Calcium gluconate 15 mmol/L.
12. Zinc 10 mg.
OTHER INSTRUCTIONS: Patient should remain NPO. He should
receive tube feeds at 30 cc an hour, and maintained with
daily TPN. All medications should be given through G tube or
by subq injection.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Name8 (MD) 3430**]
MEDQUIST36
D: [**2142-4-24**] 11:19
T: [**2142-4-24**] 11:20
JOB#: [**Job Number 52433**]
Name: [**Known lastname 9759**], [**Known firstname 4076**] Unit No: [**Numeric Identifier 9760**]
Admission Date: [**2142-4-10**] Discharge Date: [**2142-4-26**]
Date of Birth: [**2069-11-24**] Sex: M
Service:
ADDENDUM:
The patient stayed an extra two days beyond expected
discharge date. The patient was first screened at Wood, Inc
and they had rejected him because of concerns that the
patient would be at rehabilitation for an extended period of
time. He was then accepted at [**Hospital **] Rehabilitation.
During the interim, the patient also received two units of
packed red blood cells for a hematocrit of 26.0, which had
slowly but progressively decreased over the last week. It
was felt that the patient would benefit from a packed red
blood cell transfusion. Posttransfusion, hematocrit was
checked and this revealed a hematocrit of 34.0. The patient
would also be started on 325 mg Iron three times a day per J
tube. The patient will be going to [**Hospital **] Rehabilitation
on [**2142-4-26**]. The patient is to continue TPN orders daily and
to continue tube feeds at 30cc/hour.
[**First Name11 (Name Pattern1) 651**] [**Last Name (NamePattern4) 2749**], M.D. [**MD Number(1) 2750**]
Dictated By:[**Name8 (MD) 4548**]
MEDQUIST36
D: [**2142-4-26**] 10:29
T: [**2142-4-28**] 11:34
JOB#: [**Job Number 9761**]
|
[
"996.74",
"567.8",
"584.9",
"996.69",
"482.41",
"995.92",
"560.89",
"038.11",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.06",
"38.93",
"89.64",
"96.72",
"45.62",
"99.15",
"99.07",
"96.04",
"51.22",
"99.05",
"96.6",
"99.04",
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] |
icd9pcs
|
[
[
[]
]
] |
6263, 6270
|
6291, 6464
|
6801, 9137
|
1833, 2176
|
2709, 6241
|
1539, 1807
|
153, 203
|
232, 1320
|
2191, 2691
|
6489, 6778
|
1342, 1516
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,722
| 108,313
|
47413
|
Discharge summary
|
report
|
Admission Date: [**2147-9-7**] Discharge Date: [**2147-9-27**]
Date of Birth: [**2083-2-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / Metformin
Attending:[**First Name3 (LF) 4963**]
Chief Complaint:
Mental Status Changes
Major Surgical or Invasive Procedure:
- intubation
- central line placement
- a-line placement
History of Present Illness:
64 year old women with history of mental retardation, MRSA
pneumonia, bipolar disorder and CHF presenting with a five day
history weakness, tremors and altered mental status. She feels
her symptoms began three weeks ago when she was started on
metformin and glipizide for DM control. She was taken off these
medications three days prior to admission. She describes tremors
and a fear of falling which have left her bed bound for the last
five days. She feels generally weak and has been having diarrhea
and polyuria. Her po intake has also decreased over the last
week. Per her and her caregivers, she has been increasingly
confused and agitated as well. Her PCP recommended coming to the
ED for evaluation.
.
In the ED, vitals were 98.1, BP 101/57, HR 74, R 18, 96% RA. FS
was 118. Labs demonstrated Lithium level 2.2, hyperkalemia,
hyponatremia and acute renal failure. She was given kayexelate,
insulin and glucose for her hyperkalemia with slight improvement
to 6.0. She had a transient hypotensive episode to SBP 89/33 and
received a 500 cc bolus and 8 mg IV Decadron for presumed
adrenal insufficiency. She responded and did not require any
further BP support. She received levofloxacin, flagyl and
vancomycin given leukocytosis and relative hypotension and was
transferred to the MICU for furhter monitoring.
Past Medical History:
1) Asthma
- PFTs [**6-22**] FEV1 0.54 (27%), FVC 0.57 (21%), FEV1/FVC 130% c/w
restrictive defect
2) Mental retardation
3) ?temporal lobe epilepsy: this diagnosis has been questioned
in the past
4) h/o MRSA PNA requiring intubation [**6-22**]: Pt was found down in
respiratory failure; etiology was unclear, but possible
contributors included OSA-associated hypercapnia, aspiration,
and congestive heart failure
- [**8-23**] CTA (technically limited): No central/lobar PE.
Improvement in previously-noted opacities in right lung.
5) Obstructive sleep apnea:
- [**9-22**] sleep study with titration of CPAP to 19 cm with 4L O2.
6) Bipolar disorder: currently on lithium and Seroquel
7) Hypertension
8) [**Location (un) 3484**] disease: diagnosis is unclear
9) Osteoarthritis
10) GERD
11) h/o CHF:
- EF [**5-23**] (limited): [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 100312**] dilated, RA moderately dilated,
asc aorta mildly dilated, 1+ MR, mod pulm artery systolic HTN.
12) Morbid obesity
Social History:
Lives in [**Hospital3 **] in Brookeline with visiting services.
Ambulates with a walker. No tobacco, alcohol, or other drug use
Family History:
cancer NOS in mom and dad
no HTN
no DM
Physical Exam:
vitals: 147/72, 76, 20, 93% 2L
General: pleasant female, MR, a+o X 3, no distress
HEENT: RERRL, OP clear, EOMI
Neck: obese, nontender, FROM
Car: RRR no murmur
Resp: [**Month (only) **] BS bilat--ant/lat exam
Abd: obese, soft, nontender +BS
Ext: no edema, erythematous rash on left shin
Neuro: MAE, A+OX3, does not cooperate with exam
Pertinent Results:
[**2147-9-7**] 11:40PM POTASSIUM-6.0*
[**2147-9-7**] 11:30PM GLUCOSE-104 UREA N-57* CREAT-2.1* SODIUM-129*
POTASSIUM-6.4* CHLORIDE-96 TOTAL CO2-27 ANION GAP-12
[**2147-9-7**] 09:56PM COMMENTS-GREEN TOP
[**2147-9-7**] 09:56PM LACTATE-1.0
[**2147-9-7**] 09:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2147-9-7**] 09:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2147-9-7**] 09:40PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2147-9-7**] 09:40PM URINE HYALINE-[**2-20**]*
[**2147-9-7**] 07:30PM GLUCOSE-100 UREA N-60* CREAT-2.3* SODIUM-126*
POTASSIUM-6.2* CHLORIDE-93* TOTAL CO2-28 ANION GAP-11
[**2147-9-7**] 07:30PM estGFR-Using this
[**2147-9-7**] 07:30PM LITHIUM-2.2*#
[**2147-9-7**] 07:30PM WBC-11.2*# RBC-4.10* HGB-12.4 HCT-36.7 MCV-90
MCH-30.2 MCHC-33.7 RDW-17.0*
[**2147-9-7**] 07:30PM NEUTS-85.2* LYMPHS-11.5* MONOS-1.9* EOS-1.2
BASOS-0.1
[**2147-9-7**] 07:30PM PLT COUNT-299
Brief Hospital Course:
A/P: 64F h/o bipolar on lithium, MR, CHF, DM2, admitted with
ARF, hyperkalemia, hyponatremia, elevated lithium level, now
attempting to wean off vent.
.
# Hypercarbic respiratory failure: Pt with chronic respiratory
acidosis likely [**1-20**] OSA/pulmonary HTN, asthma. In setting of ARF
[**1-20**] diarrhea, poor PO, likely triggered inability to eliminate
H+ and related worsening uncompensated respiratory acidosis.
Goal pCO2 = 65, as pt is likely obligate rapid shallow breather
at baseline given obesity. Attempt wean to PS 8/PEEP 8, with
diuresis to improve respiratory mechanics.
- First few days of ICU admission pt. was maintained on home
regimen of CPAP while sleeping and nasal cannula / room air
while awake
- [**Hospital **] hospital day 4 pt. with increasing somnolence and
increased positive fluid balance as renal function worsened and
thus increased biPAP requirement -> pCO2 continued to climb and
pt. intubated. Pt. underwent slow wean over the next 2 weeks ->
coupled with return of renal function, subsequent diuresis, and
treatment of MSSA pneumonia -> pt. completed 14 day course of
Vancomycin as she has pcn allergy
- [**9-19**] extubated in am and doing well -> tolerating CPAP
overnight and NC during the day.
Pt reports being complaint at home with her nebulizer, CPAP as
well as O2 nasal canula. During the day she uses her O2 by NC
most of the time.
.
# Acute renal failure: Cr 1.3, with baseline 0.8-1.0.
- Cr elevated on admission and 18-24 hours later pt. stopped
making urine. Renal was consulted and initially pt did not
respond to lasix. During this time pt. given some fluids and
kidneys slowly recovered on their own. Pt. had Cr. back to
normal level and we started lasix -> now Cr stable at 1.3, pt.
making adequate amounts of urine and processing meds
appropriately
-Initially held further diuresis as overall fluid balance per
physical exam seemed to be even. Diuresis started with 20 mg
lasix PO on medical floor again as pt's renal function o
baseline. Pt need weekly check of her renal function as long as
Lithium treatment continues.
.
# Intermittent low - grade temps: vancomycin as above [**1-20**] sputum
MSSA. Completed full 5 day azithromycin course. pt. had central
venous line placed which was removed once 14 day course of vanco
was complete. She remained afebrile after above.
.
# Bipolar d/o: Titrated lithium per ARF, now at lithium 150mg
QHS, with quetiapine 100mg PO TID, quetiapine 350mg PO HS.
Lithium level was elevated on arrival - 2.0 and psych / renal
advised that HD was not needed for lithium. We held lithium
until level was <1.0 with return of renal function. Restarted
lithium and following daily levels. Pt. will need to follow-up
with primary psychiatrist for further medication alterations. Pt
needs 2-3 times weekly Lithium levels check until stabilized on
this regiment for 3-4 weeks,.
.
# CHF: continued with lasix 20 mg daily as above
.
# DM2: Continued on humalog insulin SS q6h. Pt. with history of
reaction to oral hypoglycemics. Pt refused taking oral
antidiabetic but is now agreeing to take glipizide 2.5 mg [**Hospital1 **].
Will need follow-up with PCP and further dose adjustment.
Uncertain about capacity to learn how to use insulin.
.
# Asthma: Continued on home regimen of albuterol and
ipratropium.
.
# Decubitus ulcer -> on air mattress for much of her icu stay.
sacral decub dressed daily - stage I.
.
# FEN: [**Doctor First Name **] diet
.
# Full code
Medications on Admission:
Metformin 500mg [**Hospital1 **]--stopped X 3 days
Glipizide 2.5mg [**Hospital1 **]--stopped X 3 days
Prilosec 20mg daily
Loperamide 4mg 4 times daily PRN
Seroquel 300mg TID + 350mg qHS
Lithium 150mg TID
Ibuprofen 600mg 4 times daily
Furosemide 20mg daily
Lisinopril 2.5mg daily
Folic Acid 1mg daily
Singular 10mg daily
Atrovent Neb 4 times daily
Pulmicort
Discharge Medications:
1. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. Quetiapine 100 mg Tablet Sig: 3.5 Tablets PO HS (at bedtime).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
solution Inhalation Q4H (every 4 hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) solution
Inhalation Q6H (every 6 hours) as needed.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. GlipiZIDE 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**]
Discharge Diagnosis:
- acute renal failure
- hypercarbic respiratory distress
- MSSA pneumonia
- CHF exacerbation
- h/o bipolar
- h/o diabetes
- h/o asthma
Discharge Condition:
- good
Discharge Instructions:
- you should take all medications as instructed
- some of your medications have been changed -> please note
these changes
- you need to follow-up with you primary care doctor in the next
week
chills, nasuea, vomiting, chest pain, shortness of breath,
inability to urinate or urinating more than normal, change in
mental status, or any other concern
Followup Instructions:
**it is very important for you to keep the following
appointments**
- you need to follow-up with your primary care doctor within one
week of discharge -> this is for post-hospitalization follow-up,
medication review, blood testing for medication levels, and
diabetes management.
- you need to follow-up with your primary psychiatrist within
one week of discharge for post-hospitalization eval and
medication adjustment.
.
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2147-11-20**] 12:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2147-11-20**] 12:00
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2147-11-20**] 11:40
|
[
"530.81",
"278.01",
"276.7",
"785.50",
"707.03",
"319",
"482.41",
"584.9",
"276.1",
"518.81",
"250.00",
"428.0",
"401.9",
"428.33",
"276.2",
"327.23",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"38.91",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9593, 9643
|
4353, 7802
|
314, 372
|
9822, 9831
|
3314, 4330
|
10228, 11091
|
2904, 2944
|
8210, 9570
|
9664, 9801
|
7828, 8187
|
9855, 10205
|
2959, 3295
|
253, 276
|
400, 1718
|
1740, 2742
|
2758, 2888
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,245
| 152,770
|
2290
|
Discharge summary
|
report
|
Admission Date: [**2194-10-8**] Discharge Date: [**2194-10-19**]
Date of Birth: [**2124-12-26**] Sex: F
Service: CARDIAC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 69-year-old
female with a past medical history significant for CAD,
status post MI times two, and three vessel CABG in [**2182**] who
presented to [**Hospital 12017**] [**Hospital 12018**] Hospital complaining of
substernal chest pain which awoke her from sleep. The
substernal chest pain lasted several hours and at the
Emergency Department the patient was found to have no
significant changes in EKG from her prior EKGs; however, she
was found to have elevated troponins with a maximum value of
24.49 and peak CK to 857 and peak CK MB value of 73.8. She
was sent to the cardiac catheterization laboratory for this
non ST elevation, elevated MI which showed a left ventricular
function with ejection fraction of 50% showing inferior wall
hypokinesis, patent saphenous vein graft to the occluded LAD
and occluded native LAD, occluded circumflex bypass graft
with multiple plaques and occluded dominant RCA graft of
multiple severe stenosis.
The patient was advised to undergo coronary artery bypass
graft at [**Location (un) 12017**] Regional and the patient and family
decided to come to [**Hospital1 **] [**Hospital1 **] for a second opinion. Also,
at her presentation at [**Location (un) 12017**] Regional, the patient had a
U/A finding that was consistent with UTI and was started on
levofloxacin.
PAST MEDICAL HISTORY:
1. Myocardial infarction times two, status post three vessel
CABG in [**2182**]; SVG to LAD, SVG to left circumflex, and SVG to
RCA.
2. History of abdominal aortic aneurysm, underwent
aortobifemoral bypass graft in [**2188**].
3. The patient has a history of peripheral vascular disease.
4. Hypertension.
5. Hypercholesterolemia.
6. Carotid artery disease. Latest study on [**2194-8-21**]
showed 25-49% stenosis of the right internal carotid assessed
to be stable and minimally changed from the prior study in
[**2193-6-8**].
7. Seizure disorder.
8. Past medical history of pyelonephritis as a child. The
patient has one functioning kidney.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft times three in [**2182**].
2. Aortobifemoral bypass graft in [**2188**].
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a long time smoker of 1 [**1-9**]
to 2 packs per day for approximately 45 pack year history.
FAMILY HISTORY: Significant for CAD and MI in the patient's
mother.
ADMISSION MEDICATIONS:
1. Lipitor 80 mg p.o. q.d.
2. Zetia 10 mg p.o. q.d.
3. Toprol XL 100 mg p.o. q.d.
4. Ecotrin 325 mg p.o. q.d.
5. Dilantin 400 mg p.o. q.d.
6. Altace 2.5 mg p.o. q.d.
7. Nitroglycerin paste p.r.n.
8. Provigil 100 mg p.o. q.d.
The patient was initially admitted to the Medicine Service
for a second opinion.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: T maximum
of 100.1, heart rate 67, blood pressure 141/67, respiratory
rate 18, saturating at 94% on room air. General: The
patient was alert and oriented times three, calm, without
apparent distress. Heart: Regular rate and rhythm. S1, S2,
I/VI systolic murmur appreciated. Chest: Clear to
auscultation except for mild crackles at the bases
bilaterally. Abdomen: Bowel sounds, soft, nontender,
nondistended. Neurologic: Cranial nerves II through XII
were grossly intact. No focal motor or sensory deficits
appreciated. Sensory: No cyanosis, no clubbing, no edema.
LABORATORY/RADIOLOGIC DATA: On admission, the white count
was 14.1 with neutrophils 71%, 10% bands, 40% lymphocytes,
hematocrit 43.5, platelets 229,000. Chemistries: Sodium
140, potassium 4.2, chloride 104, C02 25, BUN 13, creatinine
0.9, glucose 88, AST 59, ALT 19, alkaline phosphatase 179,
total protein 6.9 with an albumin of 3.7. PT/PTT 11.7/44.5
with an INR of 1.1. CKs initially on presentation to
[**Hospital 12017**] [**Hospital 12018**] Hospital was 803, 821, 857, 649 with MB
fraction of 76.1, 51.1, 73.8, and 55.8 respectively.
Troponin levels were 18.6, 6.24, 24.49, 24.38. The U/A
showed a few WBCs and a few bacteria, moderate blood.
Laboratories on admission to [**Hospital1 **] revealed a white count of
12.8, hematocrit 37.7, platelets 184,000. PT/PTT 12.0 and
42.0 with an INR of 1.0. Sodium 142, potassium 3.9, chloride
106, C02 25, BUN 13, creatinine 0.8, and glucose of 82. CKs
done at [**Hospital1 **] [**Hospital1 **] was 254 and 229 with an MB fraction of
87, troponin 1.24 and 1.24. The U/A done at [**Hospital1 **] [**Hospital1 **]
showed 0-2 WBCs and occasional bacteria, nitrates negative,
leukocyte esterase negative, protein 30, and RBCs [**11-27**].
EKG done at [**Hospital1 **] [**Hospital1 **] in comparison to prior EKGs showed a
new left bundle branch block.
HOSPITAL COURSE: Cardiology and Interventional Cardiology
staff were consulted and the cardiac catheterization films
from [**Hospital 12017**] Hospital were read with the saphenous vein
graft to LAD with 40% stenosis, saphenous vein graft to
RCA/PDA with 90% stenosis, saphenous vein graft to OM with
complete occlusion.
Th[**Last Name (STitle) 1050**] was referred to Cardiac Surgery for a redo CABG
and was evaluated and accepted for transfer to the Cardiac
Surgery Service. On [**2194-10-14**], the patient underwent a
redo CABG times three with LIMA to LAD, saphenous vein graft
to OM, and saphenous vein graft to PDA, bypassing occluded
disease of previous graft by Dr. [**Last Name (Prefixes) **]. Please see the
operative report for further details.
Immediately, in the postoperative settings, the patient was
transferred to the Cardiac Surgery Recovery Unit intubated
and on IV nitroglycerin drip with two mediastinal and one
left pleural chest tube, two ventricular and two atrial
epicardial pacing wires and an A line and a Swan-Ganz
catheter intact. Not too long after arrival to the CSIU, the
patient was successfully extubated without any problems and
did well on postoperative day number one without requiring
any need for epicardial pacing and was stable with
hemodynamic parameters. The Swan-Ganz catheter was
discontinued. The blood pressures were stable off of all
drips.
The patient was started on p.o. Lopressor on postoperative
day number one and did well enough that the chest tubes were
discontinued on postoperative day number two. On
postoperative day number three, she was transferred to the
regular floor.
On the floor, the patient did very well without any
postoperative arrhythmias, tolerated a regular diet. The
blood pressure was well controlled on p.o. agents and the
patient was well diuresed. The patient complained of mild
sternal incisional pain which was controlled with p.o.
Percocet.
On postoperative day number five, the patient was stable and
was transferred to a rehabilitation facility.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Transferred to rehabilitation.
DISCHARGE DIAGNOSIS:
1. Non ST elevated myocardial infarction.
2. Coronary artery disease.
3. Bypass graft thrombosis.
4. Hypertension.
5. Seizure disorder.
6. Peripheral vascular disease.
7. Smoking.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Dilantin 400 mg p.o. q.p.m.
3. Lipitor 80 mg p.o. q.d.
4. Percocet 5/325 mg one to two tablets p.o. q. four hours
p.r.n. pain.
5. Lasix 20 mg p.o. q. 12 hours.
6. Potassium chloride 20 mEq p.o. q. 12 hours.
7. Colace 100 mg p.o. b.i.d.
8. Milk of magnesia 30 mg p.o. q.h.s. p.r.n. constipation.
9. Zantac 150 mg p.o. q.d.
10. Tylenol 650 mg p.o. q. four hours p.r.n. pain.
11. Restoril 15 mg p.o. q.h.s. p.r.n. insomnia.
12. Zetia 10 mg p.o. q.d.
13. Ecotrin 325 mg p.o. q.d.
14. Zyban 150 mg p.o. q.a.m. times three days followed by
Zyban 150 mg p.o. b.i.d. for seven weeks.
FO[**Last Name (STitle) **]P: The patient is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
cardiologist, within the next two weeks and is to follow-up
with Dr. [**Last Name (Prefixes) **] within the next four weeks. The patient
was advised not to lift any heavy objects for the next four
weeks and must be cleared by Dr. [**Last Name (Prefixes) **] before beginning
any upper extremity exercises or any activities requiring
upper extremity exertion.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2194-10-19**] 11:09
T: [**2194-10-19**] 11:31
JOB#: [**Job Number 12019**]
cc: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern1) 1731**], M.D.
[**Hospital3 12020**] Care [**Location (un) 12021**] Port Country [**Hospital 731**] Rehab and
Nursing, [**Doctor Last Name 12022**], [**Location (un) 12021**] Port, [**Numeric Identifier 12023**],
[**Telephone/Fax (1) 12024**]
[**Hospital3 12020**] Care Skilled Nursing Rehabilitation
Facility, [**Location (un) 12021**] Port, [**Hospital1 756**] Manor Nursing and
Rehabilitation, [**Street Address(2) 12025**], [**Location (un) 12021**] Port,MA
|
[
"780.39",
"410.71",
"401.9",
"414.01",
"272.0",
"996.72",
"599.0",
"443.9",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2509, 2562
|
7200, 9125
|
6989, 7177
|
4856, 6883
|
2585, 2922
|
2204, 2366
|
2937, 4838
|
1529, 2181
|
2383, 2492
|
6908, 6968
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,685
| 156,950
|
48013
|
Discharge summary
|
report
|
Admission Date: [**2141-6-18**] Discharge Date: [**2141-7-5**]
Date of Birth: [**2079-5-4**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Chest pain, lightheadedness, dizziness, nausea, shortness of
breath.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is 62 y/o M with HTN who presents to ED with complaints of
chest pain. Pt was riding the T to a ballgame today when he had
a sudden urge to have a bowel movement. Pt went to a restroom
and was able to have a bowel movement, but then
developed severe knife-like chest pain which radiated to his
back. Pt also felt lightheaded, dizzy, nauseous, and short of
breath. No abd pain, diarrhea, or bright red blood per rectum.
Past Medical History:
PMH: HTN, arthritis
Social History:
No EtOH. Smokes 1 pack per day.
Family History:
Non-contributory
Physical Exam:
PE:
T 97.9 P 58 BP 186/93 R 18 SaO2 100%
Gen: no acute distress
Heent: no scleral icterus
Neck: supple
Lungs: clear
Heart: RRR
Abd: soft, nontender, nondistended
Extrem: no edema, 2+ femoral, popliteal, DP/PT pulses
bilaterally
Pertinent Results:
[**2141-6-18**] CXR: Prominence of the ascending aorta. Recommend
comparison with
cross-sectional imaging for evaluation of an aneurysm.
[**2141-6-18**] CTA torso:
1. Type B aortic dissection with evidence of end-organ vascular
compromise of the right kidney.
2. Aneurysmal dilatation of the ascending aorta, infrarenal
abdominal aorta, and right common iliac artery as above.
3. Fluid in the scrotum bilaterally, consistent with possible
hydrocele.
Recommend comparison to clinical examination.
[**2141-6-20**] CXR: New consolidation at both lung bases, and new small
bilateral pleural effusions are concerning for aspiration. Heart
size top normal. No
pneumothorax or evidence of central adenopathy.
[**2141-6-20**] Renal ultrasound:
1. No normal arterial waveforms seen in the right kidney or
right main renal artery. This is concordant with findings of
decreased end organ perfusion secondary to dissection seen on CT
dated [**2141-6-18**].
2. Normal arterial waveforms in the left main renal artery and
kidney,
although full evaluation was technically limited as above.
3. No hydronephrosis or renal stones identified.
[**2141-6-21**] Echo (TTE): The left atrium is elongated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). 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
arch is mildly dilated. The descending thoracic aorta is
moderately dilated. The abdominal aorta is moderately dilated. A
mobile density is seen in the descending aorta consistent with
an intimal flap/aortic dissection. The aortic valve leaflets (3)
are mildly thickened. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2141-6-21**] CXR: New bilateral mid zone mainly peripheral patchy
airspace change, most suggestive of pneumonia. Atypical
pulmonary edema, ARDS or pulmonary hemorrhage while considered
would be less likely. Given the rapid onset, aspiration must be
considered.
[**2141-6-22**] Carotid series: Right ICA stenosis <40%. Left ICA
stenosis <40
No evidence of carotid dissection.
[**2141-6-22**] Head CT: No acute intracranial process. Left maxillary
sinus mucosal disease.
[**2141-6-24**] Renal ultrasound:
1. No left renal hydronephrosis, nephrolithiasis or renal mass.
2. Normal arterial and venous flow to the left kidney.
Brief Hospital Course:
Pt is 62 y/o M with htn who presents to ED with complaints of
chest pain. Pt was riding the T to a ballgame today when he had
a sudden urge to have a bowel movement. Pt went to a restroom
and was able to have a bowel movement, but then
developed severe knife-like chest pain which radiated to his
back. Pt also felt lightheaded, dizzy, nauseous, and short of
breath. No abd pain, diarrhea, or bright red blood per rectum.
Came to ER. Vascular and Cardiac Surgery consulted.
[**6-17**] - [**6-19**], CTA torso: type B aortic dissection, true lumen in
upper abd near completely occluded, false lumen supplies celiac,
SMA, L renal, R kidney asymmetrically hypoperfused.
Pt [**Hospital 13434**] transfered to the CVICU for [**Last Name (un) **] BP control.
Initally started on IV Nipride and IV Labetolol to keep SBP less
then 140. Pt r/o for MI.
Pain control.
[**6-20**], Pt creatinine elevated. Because of this and original read
of CTA. Renal US R>L perfusion. nl size.
Labetolol/Nicardipine(IV), Norvasc PO added for BP control.
Pain control.
Renal Consulted for move of creatinine from 1.4 to 2.1, thought
to be due to decreased perfusion to Kidney, coupled with ATN
from contrast load. No need for HD at this time. Pt making good
urine.
[**6-21**] - [**6-23**], Pt feeling SOB, decrease sats to 80's recieved Neb
treatment. It was noticed the patient had a WBC of 23. Pt also
febrile. Pt pan cx'd. Likely culprit thought to be PNA or CHF by
CXR. Pt put on BIPAP. Could not tolerate, dropped O2 sats again.
Pt Intubated 2'resp.failure/P edema.
To note patient hallucinating and confused. Lookes like patient
was posturing. Head CT negative for sroke.
Social Consult
Labetolol/Nicardipine(IV), Bronchoscopy showed copius secretons,
Broad Spectrum Antibiotics started for PNA.
Pt also new onset Afib, BB started. Pt r/o for MI.
Gentle hydraton continued for creatinine of 3.9. Non oliguric
Pt cardioverted for Afib.
[**6-24**], Normal flow of L renal artery on duplex U/S, NSR afer
cardioversion. BP control. Labetolol/Nicardipine, Broad Spectrum
Antibiotics started for PNA.
[**6-25**], Extubated. restless, agitated. Labetalol GTT for BP
control. Pain control. Haldol for agitation. Folate and Thiamine
started, CIWA scale. Broad Spectrum Antibiotics started for PNA.
Labetolol/Nicardipine
[**6-26**], PP DHT, TF begun. fenanyl for pain, calmer. Creatinine
approves to 3.6, still non oliguric. Labetolol/Nicardipine(IV)
for BP control. Pain control. Broad Spectrum Antibiotics
[**6-27**], more awake. Ativan/haldol scheduled, Haldol for
breakthru. Psych saw. Pulled DHT out. Back to stomach,feeds
resumed. Labetolol/Nicardipine(IV) for BP control. Pain
control. Broad Spectrum Antibiotics. Psychiatry Consult.
[**6-28**] - [**6-29**], episodes of agitation. Ativan stopped-cont
haldol/Fentanyl, Labetolol/Nicardipine(IV) for BP control. Pain
control. DHFT replaced. Broad Spectrum Antibiotics. Creatinine
steadliy improves 3.2.
[**6-30**] - [**7-2**], more alert/awake. NTG off w/o change. HR 40s after
37.5 Lopressor TID. Clondine TD 0.3 added. Po hydralazine.
Weaned off IV antihypertensives. Starting to take PO. DHFT DC'd.
Creatinine now 3.0. Pt transfered to VICU from CVICU.
[**7-3**], PT consult. BP stable on PO, Clonodine patch switched over
to PO clonidine. Taking PO. Creatinine improves to 2.5.
[**7-4**], d/c'd Zosyn/Flagyl (finished abx course). d/c'd tele,
foley. Scheduled outpt PCP appt for BP mgmt.
[**7-5**], stable for DC
Medications on Admission:
Aspirin
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
9. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Type B aortic dissection
CHF acute systolic
Afib - resolved
ARF - Vascular compromise of right kidney
Discharge Condition:
Good
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* 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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
1. Follow-up with Dr. [**First Name4 (NamePattern1) 2398**] [**Last Name (NamePattern1) **] on [**2141-7-20**] at 3:30 p.m. in
the [**Hospital Ward Name 23**] Building, [**Location (un) **], Central Suite. Call the office
at [**Telephone/Fax (1) 250**] to confirm your appointment.
2. Follow-up to have your CT scan on [**2141-8-16**] at 8:45 a.m. Call
the office at [**Telephone/Fax (1) 327**] to confirm your appointment. Then you
will have your left renal ultrasound done on [**2141-8-16**] at 10:00
a.m. in Vascular [**Apartment Address(1) **], Vascular LMOB (NHB). Call the office at
[**Telephone/Fax (1) 1237**] to confirm your appointment. You will then see Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 1:00 p.m. in the LM [**Hospital Ward Name **] Bldg, [**Location (un) 442**],
Room 5B. Call the office at [**Telephone/Fax (1) 2625**] to confirm your
appointment.
3. Follow-up with Dr. [**Last Name (STitle) 914**] (Thoracic surgeon) in 3 months.
Call the office at [**Telephone/Fax (1) 170**] to schedule your appointment.
[**2141-8-3**] 09:00a [**Last Name (LF) **],[**First Name3 (LF) 177**] A., [**Hospital6 29**], [**Location (un) **]
RENAL DIV-CC7 (SB)
Completed by:[**2141-7-5**]
|
[
"518.81",
"305.1",
"486",
"584.5",
"401.9",
"441.02",
"427.32",
"348.39",
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.22",
"96.71",
"96.6",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
8633, 8691
|
4184, 7660
|
358, 365
|
8837, 8844
|
1218, 3927
|
9676, 10909
|
931, 950
|
7718, 8610
|
8712, 8816
|
7686, 7695
|
8868, 9653
|
965, 1199
|
250, 320
|
393, 821
|
3936, 4161
|
843, 865
|
881, 915
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,841
| 152,493
|
50894
|
Discharge summary
|
report
|
Admission Date: [**2200-6-12**] Discharge Date: [**2200-6-16**]
Date of Birth: [**2119-7-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Near syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 yo female s/p AVR (tissue)/LAA on [**5-28**], discharged to rehab on
[**6-1**] who was doing well until earlier this evening when she was
on the toilet trying to have a BM. Pt reports straining and
nearly losing consciousness. She developed SOB at that time
with dizziness and palpitations. Previously had only had DOE.
She
presented to ED in RAF 140-150's with SBP 80-100. CXR showed
CHF with bilateral effusions and bedside echo showed small
circumfrential pericaridal effusion. She was discharged on
Pradaxa for PAF and Lopressor was recently increased for
tachycardia. She is to be admitted for rate control, diuresis,
possible CV and formal echo to rule out tamponade.
Past Medical History:
Atrial fibrillation diagnosed in [**2179**], on Coumadin
Aortic stenosis s/p AVR(21 mm pericardial) resection of LAA
Tachy-brady syndrome s/p ablation of atrial tachycardia and
single-chamber pacemaker implant ([**Company 1543**] Sigma) in [**2-/2191**]
Hypertension
Hyperlipidemia
Hypothyroidism
Vascular disease including right carotid stenosis and left
subclavian stenosis
Right cerebellar embolic stroke in [**7-/2190**] no residual deficit.
Diverticulitis
Colon Cancer
Multiple small bowel obstructions
Past Surgical History
[**2200-5-28**] AVR (21 mm pericardial magna ease) resection of LAA
temporary ileostomy with subsequent re-anastomosis
right rotator cuff repair x 2
hysterectomy
cholecystectomy
appendectomy
Social History:
Lives with: alone in senior housing, remains active
Occupation: retired hair dresser
Tobacco: denies
ETOH: denies
Family History:
father died of cancer at 60yo
mother died at 83 with diabetes and gangrene
sisters and brother with emphysema
brother died of renal failure
Brief Hospital Course:
Ms [**Known lastname 25288**] was transfer to [**Hospital1 18**] ED on [**2200-6-12**] from rehab for a
syncopal episode, and was found to be in rapid atrial
fibrillation with congestive heart failure. While in the ED IV
lasix was given, Vancomycin 1 gm, Cefepime 2 gm and Levofloxacin
750 mg x 1 for possible pneumonia in setting of leukocytosis WBC
14. CXR showed bilateral effusions. She was admitted to the
CVICU. An echocardiogram was done which showed aortic valve
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. There is a
very small pericardial effusion. She was diuresed with IV lasix.
Interrogation of her pacer demonstrates no mode switching events
and ventricular high rate episodes are only afew secondly long
and occur ~once a week, but she is known to have chronic atrial
fibrillation. Per Dr. [**Last Name (STitle) 914**] amiodarone was discontinuation and
increased beta-blockers. Her heart rate improved. She had
multiple stools, c.diff was negative x 3. Infectious disease
was consulted and recommended a total of a 2 week course since
her symtpoms improved after treatment was inititated with flagyl
and vanco. Pradaxa was restarted for atrial fibrillation- No
coumadin per Dr. [**Last Name (STitle) 914**]. She has a low activity tolerance due
to deconditioning and post-op recovery. She was seen by physical
therapy and continued to make slow steady progress. She was
discharged back to [**Hospital3 4103**] on the [**Doctor Last Name **] on HD # 4.
Medications on Admission:
ASA 81 mg daily, Pradaxa 150 mg [**Hospital1 **] Lasix 20 mg daily Synthroid
50 mcg daily
Lisinopril 10 mg daily Lopressor 50 mg [**Hospital1 **] Prilosec 20 mg daily
Zocor 40 mg daily Dulcolax suppository Percocet 1-2 tabs po q 4
hrs
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
11. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day): for afib- no coumadin.
12. Zofran 8 mg Tablet Sig: One (1) Tablet PO q8hrs prn as
needed for nausea.
13. potassium chloride 20 mEq Packet Sig: One (1) Packet PO BID
(2 times a day) for 5 days.
14. furosemide 10 mg/mL Solution Sig: One (1) Injection once a
day for 5 days.
15. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 12 days: total of 2 week for empiric c-diff despite
neg cultures per ID.
16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 12 days: total of 2 week for empiric c-diff
despite neg cultures per ID.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Aortic stenosis s/p AVR (21 mm pericardial) resection of LAA,
[**2200-5-28**]
Tachy-brady syndrome s/p ablation of atrial tachycardia and
single-chamber pacemaker implant ([**Company 1543**] Sigma) in 03/[**2190**].
Atrial fibrillation diagnosed in [**2179**], initially paroxysmal
and treated with amiodarone, but currently permanent on rate
control and Coumadin for thromboembolic prophylaxis.
Hypertension.
Vascular disease including right carotid stenosis and left
subclavian stenosis.
History of right cerebellar embolic stroke in [**7-/2190**] with no
residual deficit.
Hyperlipidemia.
Hypothyroidism
Diverticulitis
Colon Cancer
multiple small bowel obstructions
PSH: temporary ileostomy with subsequent re-anastomosis
right rotator cuff repair x 2, hysterectomy cholecystectomy
appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
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:
[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2200-6-24**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2200-7-15**]
12:40
Please call to schedule the following:
Primary Care Dr. [**First Name4 (NamePattern1) 2808**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8506**] in [**3-25**] 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:[**2200-6-16**]
|
[
"V10.05",
"V42.2",
"V58.61",
"401.9",
"427.31",
"244.9",
"428.0",
"008.45",
"V12.54",
"V45.01",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5637, 5731
|
2102, 3707
|
323, 330
|
6573, 6729
|
7601, 8302
|
1937, 2079
|
3994, 5614
|
5752, 6552
|
3733, 3971
|
6753, 7578
|
270, 285
|
358, 1043
|
1065, 1789
|
1805, 1921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,320
| 152,752
|
42764
|
Discharge summary
|
report
|
Admission Date: [**2113-1-25**] Discharge Date: [**2113-1-26**]
Date of Birth: [**2064-6-10**] Sex: F
Service: NEUROSURGERY
Allergies:
morphine / IV Dye, Iodine Containing Contrast Media / Shellfish
/ Ancef / jalepeno peppers
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
L MCA aneurysm
Major Surgical or Invasive Procedure:
[**2113-1-25**] Embolization of Left MCA aneurysm
History of Present Illness:
Presents for elective angiogram for coiling of L MCA aneurysm
Past Medical History:
C-section x1, hysterectomy in [**2099**], gastric bypass surgery in
[**2105**], cervical cancer.
Social History:
Denies ETOH or tobacco use
Family History:
Daughter with aneurysm
Physical Exam:
On Discharge:
Nonfocal
Groin: clean/dry/intact, no hematoma, 2+ femoral pulse
2+ dorsalis pedis pulses b/l
Pertinent Results:
Head CT [**1-25**]: no acute hemorrhage, s/p coiling
Brief Hospital Course:
48 y/o F presents for elective angiogram for coiling of L MCA
aneruysm. She was taken to angiogram on 1.25 without any
complications. Patient was coiled successfully and then
transferred to the ICU for recovery and monitoring. She was also
placed on a heparin gtt. On [**1-26**], heparin gtt was discontinued
at 7am, groin incision was intact and patient was nonfocal. She
was discharge home after voiding, eating, and ambulating
appropriately.
Medications on Admission:
zantac
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 29 days.
Disp:*29 Tablet(s)* Refills:*0*
4. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-2**]
Tablets PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
left mca aneurysm / unruptured
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization / coil embolization only / no stent
placed
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily for 30 days only.
?????? 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 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
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? 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)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please call the office of Dr [**First Name (STitle) **] to be seen in one months
time at [**Telephone/Fax (1) **] / you WILL NOT need any imaging at that
time.
Completed by:[**2113-1-26**]
|
[
"278.01",
"V15.05",
"V10.41",
"437.3",
"V14.8",
"V15.08",
"327.23",
"V45.86",
"V85.42",
"V15.04",
"V14.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.75",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
1931, 1937
|
935, 1381
|
368, 420
|
2013, 2013
|
858, 912
|
4213, 4404
|
692, 716
|
1438, 1908
|
1958, 1992
|
1407, 1415
|
2164, 3271
|
3297, 4190
|
731, 731
|
745, 839
|
314, 330
|
448, 511
|
2028, 2140
|
533, 632
|
648, 676
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,721
| 173,757
|
41257
|
Discharge summary
|
report
|
Admission Date: [**2195-2-16**] Discharge Date: [**2195-2-19**]
Date of Birth: [**2127-5-31**] Sex: M
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Transfer from OSH for possible pontine infarct / basilar
occlusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 67 year-old ?-handed man with h/o HTN, CAD s/p CABG
in the [**2173**] who is transferred here to our ICU/Neurology
service
after a decline in his exam at the OSH ([**Hospital6 **]) and possible expansion [**2-16**] of a pontine hypodensity
seen on the admitting NCHCT from the previous day [**2-15**]. Although
both NCHCTs demonstrate multiple prior strokes including
bilateral occipital infarcts that appear subacute, he has no
known/documented prior history of stroke or Neurologic
disease/deficit. By history, he has been non-adherent with
medical follow-up and not taking any medications at home. He is
a
smoker and drinks at least four alcoholic beverages daily per
his
family/OSH notes.
He was last known to be in his USOH at home Saturday. On Sunday,
he did not answer phone calls from his daughter and was found
confused and dysarthric at home. He was taken by family to the
OSH, where his confusion imrpoved in the ED. He was moderately
hypertensive in the 150s-160s SBP, but VS were otherwise wnl.
Only mild lab abnormalities including Cr 1.3-->1.2, AST>ALT
(47/22), low albumin, low HDL, borderline leukocytosis (10.5,
85%
neutrophils). His exam was notable only for slurred speech and
confusion, and he was noted to be "moving all extremities
appropriately." His NCHCT revealed [**Hospital1 **]-occipital
hypodensities/strokes (subacute-appearing) on a background of
multiple prior infarcts/ischemic-[**Male First Name (un) 4746**] disease, and a
Left-paramedian pontine hypodense lesion. ECG showed LVH and e/o
old inferior infarct. He was started on ASA 325, metoprolol 50mg
tid, NG 1" paste, and a CIWA EtOH-w/drawal protocol, and a
Neurology consult was planned. His MS improved in the ED, and he
remained relatively stable, eating dinner the next day, sitting
up in bed, until around noon on the day of transfer ([**2-16**]) when
he
was noted to be increasingly dysartric and lethargic,
progressing
to tetraplegia. A Neurology consultant ([**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]) found
faint bilateral bruits L>R, dysconjugate [**Last Name (un) **] (R-eye out, both
down, Right facial droop, R>L ptosis, [**1-17**] purposeful movment of
the Left arm, Right arm extensor posturing, and triple-flex
responses in both LEs, brisk DTRs R>L, bilateral upgoing toes,
and no grimace to noxious stimuli. He started a heparin gtt
(with
bolus) out of concern for a widening basilar/pontine infarct,
recommended transfer here to [**Hospital1 18**] for MRI and possible [**Doctor First Name 10788**]
intervention, and offered the family/daughter a "guarded"
prognosis.
He arrived here untresponsive, with exam similar to what was
described above (see below), exhibiting intermittent brief
[**Last Name (LF) 89859**], [**First Name3 (LF) **] he was intubated by the ICU shortly after. We got a
CTA of the head and neck, which revealed complete Left-ICA
occlusion (preserved flow in L-MCA/ACA) and V4 segmental lack of
flow in the Left vertebral a, as well as overall
diminuitive/ratty-looking basilar/posterior circulation.
Incidentally, there was also a spiculated pulmonary nodule in
the
upper lobe of the Right lung c/f adenocarcinoma.
Past Medical History:
1. HTN
2. CAD s/p CABG in the [**2173**]
3. ?h/o PAD, fem bypass
4. ?h/o bilateral carotid endarterectomy
5. ?EtOH use/abuse (per family / OSH notes)
non-adherence to medical f/u and meds
Social History:
Significant for smoking history
Family History:
No hx of early strokes
Physical Exam:
Neurologic examination on admission:
Non-responsive to noxious stimuli. Does not follow commands.
CN exam revealed: Pupils midposition, 2.5mm sluggishly reactive
to light, but equal. No nystagmus. +doll's eyes/VOR. +corneals.
No blink to threat in any quadrant. +weak cough on tracheal
suctioning; did not elicit gag by moving ETT.
Sensory/motor exam revealed:
Left arm (moreso than right) responds to noxious stimulation
with
decorticate/extensor posturing.
Intermittent spontaneous/purposeful movement of RLE, no movement
of LLE other than triple-flexion withdrawal to noxious
stimulation.
DTRs: Diffusely brisk, with distal spread in Left>rt UE and
clonus of Left knee (not ankle). No ankle jerks.
Toes are up-going bilaterally.
Pt passed away on [**2195-2-19**]. see death note for exam.
Pertinent Results:
CT HEAD: The bilateral occipital large regions of parenchymal
hypodensity
have not significantly changed compared with the study performed
at the
outside institution just hours prior to this exam. Also, the
region of
hypodensity involving the central slightly to the left midbrain
and the small
focus of hypodensity within the right cerebellar hemisphere has
also not
significantly changed over the past few hours.
The ventricles and sulci are enlarged, likely representing
central and
cortical atrophy. There are subtle regions of diminished
attenuation within
the periventricular white matter, which likely represent the
sequela of
chronic small vessel ischemic disease. No other areas of
territorial regional
hypointensity are demonstrated with the exception of the
above-mentioned
bilateral PCA distribution and midbrain and right cerebellar
foci. There is
no evidence of intracranial hemorrhage. With the exception of
local mass
effect associated with the bilateral occipital regions of
hypodensity, there
is no evidence of shift of midline structures or herniation. The
visualized
portions of the intracranial V4 segments of the vertebral
arteries are heavily
calcified proximately.
The paranasal sinuses demonstrate minimal mucosal thickening
within the
inferior aspect of the right maxillary sinus.
CTA NECK: The visualized portions of the aortic arch straight
mild peripheral
calcified and non-calcified atheromatous plaque. The left common
carotid
artery and the innominate artery share a common origin. The
major cervical
artery origins at the arch do not demonstrate flow-limiting
stenosis, although
there is calcified and non-calcified atheromatous plaque
circumferentially
involving the artery walls resulting in mild-to-moderate
stenosis of the
proximal left subclavian artery and the small left common
carotid artery. The
origin of the right common carotid artery and the left vertebral
artery are
patent with normal caliber and post-contrast enhancement. There
is a moderate
stenosis of the origin and proximal right vertebral artery,
likely due to
atheromatous disease.
The common carotid arteries demonstrate circumferential
calcified and
noncalcified plaque with irregularity of the diameter without
flow-limiting
stenosis. The left carotid artery at the carotid bulb abruptly
terminates in
post-contrast enhancement without reconstitution consistent with
occlusion,
which extends to the supraclinoid left internal carotid artery.
There are
scattered foci of calcified atheromatous plaque along the
cervical right
internal carotid artery without flow-limiting stenosis.
The cervical vertebral arteries demonstrate scattered foci of
irregularity and
moderate stenoses due to calcified and non-calcified plaque with
the right
cervical vertebral artery appearing to be more extensively
involved.
CTA HEAD: As mentioned in the above section describing the
cervical vessels,
the left internal carotid artery is occluded to the supraclinoid
segment in
which is reconstituted likely the circle of [**Location (un) 431**] anatomy. The
right
intracranial internal carotid artery demonstrates scattered foci
of calcified
and non-calcified atheromatous plaque with up to moderate
stenosis in the
cavernous segments.
The anterior cerebral arteries and middle cerebral arteries
demonstrate normal
post-contrast enhancement and caliber.
The intracranial vertebral arteries demonstrate calcified and
non-calcified
atheromatous plaque. The right intracranial vertebral artery
demonstrates
severe stenoses and irregularities with a string of contrast,
short segment
from the origin of the right PICA to the basilar anastomosis.
The left
intracranial vertebral artery also demonstrates significant
calcified and
non-calcified atheromatous plaque with irregular stenoses along
its course.
At the midpoint of the left V4 segment, there is complete loss
of
post-contrast enhancement of the vessel with reconstitution of
the short
segment distal left vertebral artery to the anastomosis forming
the basilar
artery. The basilar artery is small and irregular in contour,
likely related
to atherosclerotic disease. The bilateral PCA arteries are
diminutive without
definite occlusion. Small posterior communicating arteries are
identified
bilaterally.
No evidence of aneurysm, arteriovenous malformation, or
arteriovenous fistula
is identified.
Brief Hospital Course:
Mr [**Known lastname 76536**] was admitted as an OSH transfer for posterior
circulation strokes. He had CT imaging done of the brain and
vessels which demonstrated multiple areas of infarct including
the brainstem and significant stenosis by calcifications and
plaques of various intracranial and extracranial vessels.
The family was made aware that should he survive this
hospitalization he would be left significantly impaired. They
decided to make him CMO after all family members had a chance to
visit with him.
Medications on Admission:
none
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
CMO: passed away
Discharge Condition:
Passed away
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2195-2-19**]
|
[
"V15.81",
"344.00",
"305.01",
"433.10",
"V45.81",
"434.91",
"784.51",
"401.9",
"414.00",
"V49.86",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9683, 9692
|
9083, 9600
|
354, 360
|
9752, 9765
|
4709, 4709
|
9817, 9943
|
3852, 3876
|
9655, 9660
|
9713, 9731
|
9626, 9632
|
9789, 9794
|
3891, 3914
|
247, 316
|
388, 3575
|
4718, 9060
|
3929, 4690
|
3597, 3787
|
3803, 3836
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,914
| 133,111
|
47815
|
Discharge summary
|
report
|
Admission Date: [**2106-5-26**] Discharge Date: [**2106-6-1**]
Date of Birth: [**2032-11-16**] Sex: M
Service: SURGERY
Allergies:
Ceftriaxone
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Post-operative hypotension, bleed
Major Surgical or Invasive Procedure:
Elective incisonal hernia repair.
History of Present Illness:
72 y/o M with history of hypertension, GERD, stage III colon
cancer s/p right colectomy in [**5-/2105**], now POD #1 s/p elective
incisonal hernia repair on [**5-26**] with component separatin and
mesh. The patient was in his usual state of health and presented
to the hospital for elective surgery.
Past Medical History:
HTN
arthritis
GERD
legally blind [**2-9**] retinitis pigmentosa
S/p R colectomy ([**2105**])
S/p hiatal hernia repair ([**2091**])
S/p surgical removal shrapnel ([**2056**])
Dermatologic cquamous cell carcinoma, anterior abdominal wall
([**2106**])
Social History:
Lives at home with wife. Is a retired military historian and a
psychologist in the federal court system. Is physically active,
participating in regular running, spinning, and water exercises.
Remote etoh abuse, last drink 22 years ago. Denies current or
past tobacco abuse.
Family History:
Father passed away from stroke at age 51. Sister with blindness.
No known cardiovascular disease or diabetes. No children.
Physical Exam:
T: 97.5 BP: 114/63 P: 73 R:13 O2:96% RA
General: Alert, oriented, NAD, pleasant
HEENT: Sclera anicteric, MMM, OP clear
Neck: supple, no JVD or LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, no M/R/G
Abdomen: softly distended. +hypoactive bowel sounds throughout.
Vertical midline incision scar underneath C/D/I dressing. No
rebound tenderness or guarding, mildly tender to deep palpation
around epigastrium
GU: Foley catheter in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2106-5-27**] 01:00PM BLOOD WBC-10.1# RBC-3.38* Hgb-10.7* Hct-32.1*
MCV-95 MCH-31.6 MCHC-33.2 RDW-14.8 Plt Ct-218
[**2106-5-28**] 05:10AM BLOOD WBC-6.7 RBC-2.88* Hgb-9.0* Hct-25.8*#
MCV-90 MCH-31.2 MCHC-34.9 RDW-15.0 Plt Ct-125*
[**2106-5-29**] 02:44AM BLOOD WBC-6.7 RBC-3.17* Hgb-10.5* Hct-28.3*
MCV-89 MCH-32.9* MCHC-37.1* RDW-15.4 Plt Ct-118*
[**2106-5-29**] 08:44AM BLOOD WBC-5.4 RBC-3.18* Hgb-9.9* Hct-27.8*
MCV-87 MCH-31.2 MCHC-35.7* RDW-15.4 Plt Ct-118*
[**2106-5-29**] 02:44AM BLOOD PT-13.7* INR(PT)-1.2*
[**2106-5-28**] 09:26PM BLOOD PT-13.3 PTT-26.0 INR(PT)-1.1
[**2106-5-28**] 12:06AM BLOOD PT-15.5* PTT-26.1 INR(PT)-1.4*
[**2106-5-28**] 05:10AM BLOOD Calcium-7.8* Phos-3.0 Mg-1.5*
[**2106-5-28**] 12:06AM BLOOD Hapto-110
[**2106-5-27**] 01:00PM BLOOD Osmolal-290
KUB [**2106-5-27**]: Multiple loops of dilated small and large bowel
may be compatible with an ileus in the setting of recent
surgery.
Brief Hospital Course:
The patient was admitted to the inpatient [**Hospital1 **] status post
incisional hernia repair with mesh and component separation. The
patient tolerated the procedure well however post-operative day
1 developed hypotension, low urine output, with a dropping
hematocrit, increased serous drainage from the [**Location (un) 1661**]-[**Location (un) 1662**]
drains placed in either side of the abdomen.On day of admission
to ICU, patient was noted to have BP of 87/61, at 4:25 pm. Hct
dropped from 32 to 26. He was also noted to have a moderate
amount of bloody JP drain output (328 cc R drain, 131 cc L
drain) over 24 hours. His urine output had also dropped to 0-10
cc/hr for most of the day. Got 3500 cc lactated ringers, and
1uPRBC ordered prior to transfer to [**Hospital Unit Name 153**]. Patient has one
peripheral IV. Has been off his home aspirin since [**5-21**]. Was on
subcu heparin.On the floor, the patient denied any symptoms,
including dizziness, lightheadedness, abdominal pain, nausea,
vomiting, palpations, dyspnea, or chest pain. Also denies
fevers, chills, or sweats. The patient was transferred from the
inpatient floor to the intensive care unit for further
monitoring.
[**Hospital Unit Name 153**] course:
# HYPOTENSION: BP stabilized after significant IVF resuscitation
and blood transfusions. Patient displayed no signs or symptoms
of sepsis. Good IV access was maintained throughout entire [**Hospital Unit Name 153**]
course. Home HCTZ, verapamil, and spironolactone were held.
Two units of blood were eventually transfused, and patient did
well; he was transferred back to the surgical floor without
complications.
# POST-OPERATIVE BLEED: Per attending surgeon, no blood loss
intra-operatively, no visceral organs punctured and no
significant blood vessels injured. Patient without known past
or current bleeding disorders. Hct dropped 32 -> 26; then
dropped further to 24 in setting of aggressive IVF
resuscitation. No recent coagulation studies seen in medical
records. Platelet count normal. As above, patient received 2
units of PRBCs. Coags were normal. ASA was held. On morning
after [**Hospital Unit Name 153**] transfer, patient had no signs or symptoms of bleeds
and blood pressure had normalized. Patient was transferred to
surgery floor.
# ACUTE KIDNEY INJURY/OLIGURIA: Given history of hypotension and
bleeding, concerning for perfusion-related kidney injury. [**Month (only) 116**]
also be in oliguric phase of ATN, given hypotension earlier
during admission and BUN:creatinine ratio < 20. FeNa 0.5
consistent with perfusion-related [**Last Name (un) **]. Patient was given IVF
and anti-hypertensives were held. Creatinine trended down to
1.1 after fluid resuscitation.
# HYPONATREMIA: Likely hypoosomolar, hypovolemic. Resolved with
IVF.
After the patient was medically stabilized he was transferred to
the inpatient [**Hospital1 **]. The remaining post-operative coarse was
uneventful and this laboratory values remained stable with a
hematocrit of 28.7 at discharge. 2 JP drains were removed from
right and left side of the midline incision and dressed
appropriately. The midline incision was intact with staples,
triple antibiotic ointment was applied and the area was covered
with a dry sterile gauze dressing. The patient was discharged
home with close visiting nurse follow-up.
Medications on Admission:
Allopurinol 300 mg PO daily
Atorvastatin 5 mg PO QHS
HCTZ 25 mg PO daily
Verapamil 240 mg PO daily
Ascorbic acid 500 mg PO daily
Aspirin 81 mg PO daily (last taken on [**5-21**])
Fish oil
Vitamin A 15,000 units daily
Vit B6 100 mg PO BID
Spironolactone 25 mg PO BID
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
2. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Incisional hernia following midline incision.
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 your repair of
incisional hernia with mesh and component separation technique.
The first day after your surgery you had some bleeding and you
were admitted to the intesive care unit for replacement of this
blood loss. You recovered well from this and the two drains in
your abdomen will be removed prior to your discharge. The drain
sites will be covered with bulky sterile gauze dressings and
tegaderms. These can be left in place until your follow-up or be
changed as needed by the visiting nurses. Because of your vision
impairment it is very important that you have the visiting
nurses look at the dressings on your abdomen daily and a family
member glance at these dressings throughout the day to be sure
that these dressings are clean dry and intact. If you notice
that the dressings become saturated with drainage or blood
please call Dr [**Last Name (STitle) 11639**] with any quesstions related to the
dressings. The midline incision line will be covered with triple
antibiotic ointment and covered with a protective dry sterile
gauze dressing. This should be left in place until your follow
up appointment with Dr. [**Last Name (STitle) **] which should be in 1 week.
If the gauze becomes dirty or soaked with drainage it may be
changed.
Please monitor your bowel function. If you notice that you are
unable to pass stool, become nauseated, vomit, or you notice
that your abdomen becomes more distended please seek medical
attention or if severe come to the emergency room. Please eat
small frequent meals and take adequate fluids. Please watch for
symptoms of dehydration such as dizziness, nausea, loss of
conciousness, dry mouth, rapid heart rate, or fatigue. These
could also be signs of bleeding, which we do not expect, but you
should watch for. Please call or go to the emergency room if
these symptoms are severe.
You may resume the medications your were taking prior to your
surgery. You have not been having pain, however if you do have
pain you may take extra strength Tylenol as written on the over
the counter bottle but do not take more than 4000mg of Tylenol
daily.
Followup Instructions:
Please call Dr.[**Name (NI) 10946**] office at ([**Telephone/Fax (1) 9011**] to make a
follow up appointment within one week.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-7-2**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2106-7-14**] 9:00
Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 6401**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2106-7-14**] 9:00
Completed by:[**2106-6-8**]
|
[
"553.21",
"401.9",
"362.74",
"276.7",
"287.5",
"584.5",
"790.01",
"369.4",
"788.5",
"998.11",
"276.1",
"E878.8",
"530.81",
"V10.83",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.61"
] |
icd9pcs
|
[
[
[]
]
] |
7164, 7222
|
2869, 6216
|
302, 337
|
7312, 7312
|
1930, 2846
|
9621, 10180
|
1245, 1369
|
6532, 7141
|
7243, 7291
|
6242, 6509
|
7463, 9598
|
1384, 1911
|
229, 264
|
365, 666
|
7327, 7439
|
688, 938
|
954, 1229
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,805
| 196,539
|
20674
|
Discharge summary
|
report
|
Admission Date: [**2110-3-28**] Discharge Date: [**2110-4-7**]
Date of Birth: [**2036-2-14**] Sex: M
Service: OMED
CHIEF COMPLAINT: Hypoxia.
HISTORY OF PRESENT ILLNESS: This is a 73-year-old male with
multiple medical problems including a history of COPD and
recent craniotomy with resection of a glioblastoma multiforme
in [**2110-1-20**], with initial XRT in [**2110-2-20**], who presented
to the ED last evening following XRT treatment with increased
shortness of breath and hypoxia. The patient states that
shortness of breath has been times one month since starting
chemo and XRT, which has gradually been worsening. He was
seen in clinic on [**2110-3-9**] with fatigue, decreased p.o., and
increased shortness of breath. At that point, temozolomide
was stopped and Dilantin was stopped. He had a chest x-ray,
which was negative. No cough, no orthopnea, no chest pain,
no nausea or vomiting, diarrhea or dysuria, no abdominal
pain, no fevers or chills. No sick contacts, and no recent
travel. In the ED, ABG showed 7.50/31/35 on room air. CTA
was negative for PE and nonspecific ground-glass opacities.
The patient was started on Bactrim and increased steroids for
question of PCP. [**Name10 (NameIs) **], ABGs with continued hypoxia with
increasing lactates, he was transferred to the unit for
closer monitoring.
PAST MEDICAL HISTORY: CAD status post CABG in [**2093**].
Right upper lobe resection secondary to abscess in [**2094**] later
found to be Aspergillus
Prostate cancer in [**2106**] status post XRT.
Left hip fracture.
Hyperlipidemia
Hypertension.
COPD.
Basal cell carcinoma on nose.
Right frontal glioblastoma multiforme status post resection
[**1-23**] with XRT on steroids.
MEDICATIONS AT HOME:
1. Keppra.
2. Decadron.
3. Cardizem.
4. Protonix.
5. Neurontin.
6. Lipitor.
7. Quinine 325.
8. Aspirin.
MEDICATIONS ON TRANSFER:
1. Albuterol and Atrovent nebulizers.
2. Tylenol p.r.n.
3. Regular insulin sliding scale.
4. Senokot.
5. Colace.
6. Heparin subcutaneous t.i.d.
7. Levofloxacin 500 once daily.
8. Quinine 325.
9. Atorvastatin 20 once daily.
10. Neurontin 300 once daily.
11. Diltiazem 300 once daily.
12. Protonix 40 once daily.
13. Bactrim 400 IV q.8.
14. Decadron 6 mg b.i.d.
15. Keppra 500 in a.m. and 1000 in p.m.
ALLERGIES: MORPHINE AND CODEINE CAUSE NAUSEA AND VOMITING.
PHYSICAL EXAMINATION: Vital signs: Afebrile. Blood
pressure 166/89, pulse 77, pulse ox 98 on 100 percent
nonrebreather. General: Mild shortness of breath, but is
able to speak in full sentences. HEENT: PERRLA. EOMI.
White coat on palate. Cardiovascular: S1, S2. Regular.
Pulmonary: Crackles left greater than right. Bronchial
breath sounds throughout. Abdomen: Soft, nontender, and
nondistended. Extremities: No clubbing, cyanosis, edema.
Neurologic: Grossly intact.
LABORATORY DATA: Laboratory on admission to the SICU, white
count 18.9, hematocrit 45, platelets 151, differential is 91
neutrophils, 2 bands, 5 lymphs. PT 12.4, INR 12.4.
Chemistry is sodium 131, potassium 4.3, chloride 96,
bicarbonate 21, BUN 30, creatinine 1.3, glucose 132, ALT 38,
AST 23, amylase 70, lipase 23, total bilirubin 0.4, alkaline
phosphatase 72, albumin 3.3. ABG pH 7.5, CO2 26, oxygen 50,
and lactate 4.6. Microbiology shows, induced sputum, no
growth to date, urine culture no growth to date, and blood
culture [**12-23**], no growth to date.
CTA from [**3-27**] shows no PA emphysematous changes, nonspecific
ground-glass opacity to both lungs consistent with infectious
or inflammatory disease or pulmonary edema.
Echocardiogram shows EF of 35 percent with akinesis and
thinning of anterior septal, inferior septum, inferior wall.
Normal PA pressures, no effusion, dilated left and right
atrium.
HOSPITAL COURSE: Hypoxia/respiratory failure: The patient
is admitted to SICU for further evaluation of his
hypoxia/respiratory failure. The patient had been
empirically treated for a possible pneumonia. Given his
history of malignancy and steroids, he was felt to be at
increased risk for PCP. [**Name10 (NameIs) **] was subsequently started on
Bactrim and was placed on increased doses of steroids.
Meanwhile, he was also treated for possible bacterial process
with broad spectrum antibiotics including Levaquin and
Ceftaz. The cause of the patient's respiratory demise
remained unclear throughout his hospital course. However, he
progressively worsened in terms of his oxygen requirements.
By [**4-1**], he was placed on BiPAP for increased respiratory
distress. When he was not continuing to improve and had an
increased hypoxia, he was emergently intubated on the evening
of [**2110-4-3**]. Initially, there were concerns about PCP as
mentioned above. Family and team were hesitant to
bronchoscope the patient secondary to requirements for
intubation. Initial discussions with the family stressed
that the patient and family would not be interested in
aggressive long-term measures such as intubation.
Ultimately, after the patient was intubated a bronchoscopy
was performed. Bronchoscopy stains were negative for PCP and
fungal cultures were pending. His sputum ultimately grew out
staph aureus and the patient was later changed to oxacillin.
Infectious disease was consulted for further evaluation. He
was placed on voriconazole empirically secondary to concerns
about occult infections with fungus. His condition failed to
improve, however. There were also some thoughts that
possibly CHF could be an etiology of the patient's hypoxia.
He was gently diuresed, but did not respond well, resulted in
hypotension and increased renal insufficiency. Family had
been offered a Swan at one point, but refused. Secondary to
the patient's response with hypotension and increased renal
insufficiency, CHF was not felt to be a large component of
his respiratory demise. Cardiothoracic surgery was consulted
for evaluation of a possible VATS for further evaluation of
the patient's pulmonary demise. Again, the family was not
interested in any aggressive measures. Later during end of
hospital course, the patient has spiked fever and since
sputum grew out staph, oxacillin was added for possible
ventilator associated pneumonia. At onset of the patient's
care in the ICU, the patient and family had expressed
reservations about long-term management on ventilators
particularly if situation was not promising. After multiple
discussions with family during the [**Hospital 228**] hospital course,
it was ultimately decided that the patient's prognosis was
extremely poor, especially given his unclear etiology of
respiratory demise in the setting of a known CNS malignancy.
It was decided that the patient would be extubated on [**4-7**],
in the evening. He expired several minutes later.
CHF: The patient had echo from [**3-28**], showing EF of 35
percent as mentioned above, the patient's respiratory demise
was unclear in etiology. There were some concern that CHF
may have been playing a role. However, the patient had less
than adequate response to diuresis involving hypotension and
renal insufficiency. Family had declined a Swan at one
point. Given the patient's persistent hypotension with
diuresis, it was felt that CHF was not the etiology for his
respiratory failure. His ACE was given cautiously secondary
to hypotension and renal failure.
CAD: The patient was maintained on aspirin and low-dose
Lipitor.
Hypotension: As mentioned above unclear in etiology. The
patient responded to IV fluids on several occasions. It was
felt that some of the hypotension may have been diuresed
induced.
Glioblastoma multiforme: The patient had been in the midst
of receiving XRT during his hospitalization. After his
respiratory status worsened, he was unable to continue with
further XRT. Ultimately, his poor prognosis involving his
respiratory failure and his glioblastoma multiforme was the
key factor in the patient's family deciding to withdraw care.
Thrombocytopenia: Unclear etiology. Heparin induced
antibodies were sent and still pending at the time of death.
Acute renal insufficiency: The patient developed mild renal
insufficiency with creatinines up to 1.5 and 1.6. It was
thought that possibly over-diuresis may have been the
possible culprit. Special care was used in order to renally
dose his medications.
DISPOSITION: As mentioned above, the patient failed to show
significant improvement throughout his hospital course and in
fact his oxygen requirements increased. After multiple
discussions with the family and primary ICU team, it was
decided to withdraw care of the patient and extubate him on
the evening of [**4-7**]. He passed away shortly at 08:32 in
the evening with the family at bed side.
DISCHARGE DIAGNOSES: Death.
Respiratory failure/hypoxia of unclear etiology.
Glioblastoma multiforme.
Transient hypotension.
Acute renal insufficiency.
Thrombocytopenia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55220**]
Dictated By:[**Last Name (NamePattern1) 11267**]
MEDQUIST36
D: [**2110-8-5**] 16:48:57
T: [**2110-8-6**] 04:13:02
Job#: [**Job Number 55221**]
|
[
"496",
"486",
"428.0",
"518.81",
"401.9",
"276.1",
"414.00",
"191.9",
"796.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"93.90",
"38.91",
"96.6",
"96.04",
"38.93",
"96.72",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8780, 9202
|
3810, 8758
|
1758, 1864
|
2405, 3792
|
154, 164
|
193, 1353
|
1889, 2382
|
1376, 1737
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,264
| 136,386
|
9919
|
Discharge summary
|
report
|
Admission Date: [**2127-5-5**] Discharge Date: [**2127-5-8**]
Date of Birth: [**2077-9-13**] Sex: M
Service:
CHIEF COMPLAINT: Melena.
HISTORY OF PRESENT ILLNESS: The patient is a 42 year old
male with a 25 year history of hepatitis C infection, child's
B cirrhosis, variocele bleed times one, status post TIPS one
and a half weeks ago, who presents with melena. The patient
reports that he was in his usual state of health until
approximately two weeks prior to the admission, at which time
he had hematochezia that led to the loss of approximately two
liters of blood, Medical Intensive Care Unit admission, and
emergent placement of TIPS following hemodynamic
stabilization. The patient was discharged from the hospital
feeling well until the day of admission, when he felt
lightheaded. He denies any syncope or fall, however, he
continued to feel dizzy. He had a bowel movement that was
melenic times two. Because before prior admission, he also
felt lightheaded, he decided to come to the Emergency Room.
The patient reports fatigue. He denies any easy bruising or
bleeding anywhere besides gastrointestinal tract. He denies
any shortness of breath, chest pain. He denies urinary or
upper respiratory symptoms. He denies nausea or vomiting,
fevers, constipation or diarrhea.
PAST MEDICAL HISTORY:
1. A 25 year history of hepatitis C infection contracted
secondary to intravenous drug abuse in [**2100**]. Genotype 1A,
diagnosed in [**2120**]. Treated with regulated Interferon as well
as Vibrovirin for 12 weeks with failure to eradicate the
virus. The patient is currently in a pilot study of
Interferon versus colchicine, and is on colchicine 0.6 mg
twice a day. Said his last viral load was 256,000.
2. Child's B cirrhosis with a biopsy in [**2126-7-21**],
showing Grade II to III inflammation.
3. Portal hypertension.
4. Gastropathy with esophagogastroduodenoscopy in [**2126-9-21**] showing abnormal vascularity of fundus in antrum and
in [**2126-12-21**], cirrhotic liver with portal
hypertension.
5. Non-suspicious liver mass, although patient has had
multiple nodules seen in his liver.
6. Grade I esophageal varices status post leak two weeks
prior to the admission.
SOCIAL HISTORY: The patient denies any alcohol since [**2120**].
He reports intravenous drug use in [**2100**], none since then.
The patient denies any tobacco use.
FAMILY HISTORY: Significant for coronary thrombosis in his
father.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lactulose.
2. Colchicine 0.6 mg twice a day.
3. Nadolol 60 mg p.o. q. day.
4. Aldactone 100 mg p.o. q. day.
5. Accupril 10 mg p.o. q. day.
6. Somata for sleep.
PHYSICAL EXAMINATION: On admission, vital signs 98.6 F. for
temperature; pulse 76; blood pressure 101/61; respiratory
rate 17; O2 saturation 98% on room air. In general, the
patient is alert and responsive in no apparent distress.
HEENT: Icteric sclerae and frenulum. No lymphadenopathy, no
thyromegaly, no jugular venous distention appreciated. Lungs
are clear to auscultation bilaterally. Heart: Regular rate
and rhythm with II/VI crescendo/decrescendo systolic murmur.
Abdomen soft, nontender, nondistended. No hepatosplenomegaly
appreciated. Extremities without edema or erythema. Skin
jaundiced. Rectal with dark stools, positive for heme.
Neurological: The patient is mildly anxious, alert and
oriented times three. Pupils are round and reactive to
light, 3 to 2 millimeters bilaterally. Extraocular movements
intact. The patient's sensation is intact. Facial movements
are intact. Hearing is intact bilaterally. Tongue protrudes
midline. Sternocleidomastoid and trapezius muscles intact.
LABORATORY FINDINGS: On admission, alpha-fetoprotein 12.3.
Chem-7 with sodium 136, potasium 4.1, chloride 101,
bicarbonate 25, BUN 31, creatinine 0.9, glucose 99. CBC
showed white count of 12.6 with 70 neutrophils, 17
lymphocytes, 7.5 monocytes, 4 eosinophils. Hematocrit 33.4
with three plus macrocytosis and two plus anisocytosis.
Platelet count 160.
ALT 53, AST 89, alkaline phosphatase 149, total bilirubin
3.5. INR 1.3. Urinalysis was pending.
HOSPITAL COURSE: In summary, the patient is a 49 year old
gentleman with a 25 year history of hepatitis C infection,
child's B cirrhosis, varicocele bleed and status post TIPS
one and a half weeks ago, presenting with melena, most likely
representing another upper gastrointestinal bleed.
While in the Emergency Room, the patient was seen by the GI
fellow and due to the fact that the patient was
hemodynamically stable, his melena subsided and hematocrits
remained at approximately 30, the decision was made not to
start Octreotide. Overnight, the patient's hematocrit
drifted from 33 to 28, and he was transfused one unit packed
red blood cells. He underwent an abdominal ultrasound to
evaluate the patency of the TIPS. The initial report noted
decreased velocity of the flow in the TIPS and thrombus in
IVC. A repeat ultrasound by Vascular Tech showed occlusion
of TIPS without IVC thrombus.
The patient was continued on his Protonix and all the
medications that could effect his blood pressure including
Nadolol and Aldactone were held. He was transfused another
unit of packed red blood cells on his way to Interventional
Radiology for revision of his TIPS.
The patient tolerated the procedure well. Overnight, he was
monitored in the Medical Intensive Care Unit and remained
hemodynamically stable. A repeat ultrasound revealed patent
TIPS with flow rate in the range of 65 to 127. There is
patent and appropriate direction flow in the portal vein,
hepatic vein and the hepatic arteries. Following additional
treatment with packed red blood cells the patient's
hematocrit remained at 32. He was restarted on his
outpatient medications with blood pressures in the 120s.
Prior to the discharge, the patient was seen by Dr. [**Last Name (STitle) **]
from Transplant Surgery. Possible renal splenic shunt
occlusion was considered due to lower flows than desired
through the TIPS. The patient is to have a follow-up
ultrasound in one week. Additionally, he is to follow-up
with his hepatologist and Dr. [**Last Name (STitle) **].
DISCHARGE DIAGNOSES:
1. Hepatitis C infection.
2. Child's B cirrhosis.
3. Portal hypertension.
4. Grade I esophageal varices status post TIPS revision.
5. Status post variceal bleed times two.
6. Status post transfusion of four units of packed red blood
cells.
MEDICATIONS ON DISCHARGE:
1. Lactulose.
2. Colchicine 0.6 mg p.o. twice a day.
3. Nadolol 50 mg p.o. twice a day.
4. Aldactone 100 mg p.o. q. day.
5. Accupril 10 mg p.o. q. day.
6. Sonata for sleep.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-899
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2127-5-8**] 13:51
T: [**2127-5-8**] 22:14
JOB#: [**Job Number 33255**]
|
[
"287.5",
"996.1",
"571.5",
"E878.8",
"070.51",
"456.20",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
2409, 2500
|
6239, 6486
|
6512, 6923
|
2526, 2696
|
4186, 6218
|
2719, 4167
|
143, 152
|
182, 1310
|
1332, 2222
|
2240, 2391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,881
| 177,273
|
11982+11983
|
Discharge summary
|
report+report
|
Admission Date: [**2190-12-22**] Discharge Date: [**2190-12-26**]
Date of Birth: [**2133-5-7**] Sex: M
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Syncope. Subsequent workup for the
syncopal episode revealed aortic disease.
HISTORY OF PRESENT ILLNESS: No previous cardiac history,
syncope in [**2190-7-7**]. Following the syncopal episode he
saw a neurologist, a neurosurgeon and finally a cardiologist.
A cardiac echocardiogram done from the cardiologist revealed
a normal ejection fraction and two mobile plaques in the
aortic arch more distal then the left subclavian.
PAST MEDICAL HISTORY: Significant for hypercholesterolemia,
hypertension and gastric reflux. He also has ruptured disc
for which he is awaiting surgery.
PAST SURGICAL HISTORY: Four mouth extractions, knee surgery
and a tonsillectomy.
MEDICATIONS PRIOR TO ADMISSION: Zestril 10 mg q.d., Lipitor
80 mg q.d., Plavix 75 mg q.d., Wellbutrin SR 150 mg b.i.d.,
Combivent inhaler q 6 hours, Ambien 10 mg q.h.s. and Roxicet
5/325 prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in an apartment with a
friend up three flights of stairs. Occupation, he is a
material manager. Tobacco use positive, down to five
cigarettes a day. ETOH use three drinks per day, more on the
weekends and occasional marijuana use.
PHYSICAL EXAMINATION PRIOR TO ADMISSION: Heart rate 102.
Blood pressure 163/88. Respiratory rate 22. Height 5'7".
Weight 160 pounds. General, male in no acute distress. Skin
few superficial lesions on his legs. HEENT is unremarkable.
Neck is supple with some decreased flexion. Chest is clear
to auscultation bilaterally. Heart regular rate and rhythm.
No murmur noted. Abdomen slightly distended, soft, nontender
with positive bowel sounds. Extremities are warm and well
perfuse. Left foot slightly pale compared with the right.
Varicosities none. Neurological grossly intact.
LABORATORY DATA: White blood cell count 9.3, hematocrit
39.4, platelets 314, PT 11.2, PTT 24.2, INR 0.9, sodium 139,
potassium 4.0, chloride 99, CO2 24, BUN 12, creatinine 1.0.
Chest x-ray no infiltrates or effusions. No pneumothorax.
HOSPITAL COURSE: The patient is a direct admission to the
Operating Room on [**12-22**]. At that time he underwent an
aortic arch endarterectomy. He tolerated the operation well
and was transferred to the Operating Room to the
Cardiothoracic Intensive Care Unit.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2190-12-24**] 10:32
T: [**2190-12-24**] 12:03
JOB#: [**Job Number 37688**]
Admission Date: [**2190-12-22**] Discharge Date: [**2190-12-26**]
Date of Birth: [**2133-5-7**] Sex: M
Service: CARDIOTHORACIC
CHIEF COMPLAINT: The patient had a syncopal episode in [**2189**].
Subsequent workup for the syncopal episode revealed aortic
disease.
HISTORY OF PRESENT ILLNESS: No previous cardiac history,
syncope in [**2190-7-7**]. Following the syncopal episode he
saw a neurologist, a neurosurgeon and finally a cardiologist.
A cardiac echocardiogram done from the cardiologist revealed
a normal ejection fraction and two mobile plaques in the
aortic arch more distal then the left subclavian.
PAST MEDICAL HISTORY: Significant for hypercholesterolemia,
hypertension and gastric reflux. He also has ruptured disc
for which he is awaiting surgery.
PAST SURGICAL HISTORY: Four mouth extractions, knee surgery
and a tonsillectomy.
MEDICATIONS PRIOR TO ADMISSION: Zestril 10 mg q.d., Lipitor
80 mg q.d., Plavix 75 mg q.d., Wellbutrin SR 150 mg b.i.d.,
Combivent inhaler q 6 hours prn, Ambien 10 mg q.h.s. and
Roxicet 5/325 prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in an apartment with a
friend up three flights of stairs. Occupation, he is a
material manager. Tobacco use positive, down to five
cigarettes a day. ETOH use three drinks per day, more on the
weekends and occasional marijuana use.
PHYSICAL EXAMINATION PRIOR TO ADMISSION: Heart rate 102.
Blood pressure 163/88. Respiratory rate 22. Height 5'7".
Weight 160 pounds. General, 57 year-old male in no acute
distress. Skin few superficial lesions on his legs. HEENT
is unremarkable. Neck is supple with some decreased flexion.
Chest is clear to auscultation bilaterally. Heart regular
rate and rhythm. No murmur noted. Abdomen slightly
distended, soft, nontender with positive bowel sounds.
Extremities are warm and well perfuse. Left foot slightly
pale compared with the right. Varicosities none.
Neurological grossly intact.
LABORATORY DATA: White blood cell count 9.3, hematocrit
39.4, platelets 314, PT 11.2, PTT 24.2, INR 0.9, sodium 139,
potassium 4.0, chloride 99, CO2 24, BUN 12, creatinine 1.0.
Chest x-ray no infiltrates or effusions. No pneumothorax.
HOSPITAL COURSE: The patient is a direct admission to the
Operating Room on [**12-22**] at which time he underwent an
aortic arch endarterectomy. Please see the Operating Room
report for full details. The patient tolerated the operation
well and was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit. At the time of transfer
the patient was in sinus rhythm at 93 beats per minute. His
mean arteriole pressure was 70. His CVP was 8. He was
transferred on intravenous Nipride and Propofol. The patient
did well in the immediate postoperative period. He was
weaned off of his Propofol, weaned from the ventilator and
extubated without incident. He remained hemodynamically
stable on the night of his surgery. He did remain on a
Nipride drip to control his blood pressure. On postoperative
day none the patient continued to do well. His Nipride drip
was weaned to off. His chest tubes were removed and he was
transferred from the Intensive Care Unit to the floor for
continued postoperative care and postoperative
rehabilitation.
Over the next several days he continued to do well. He was
restarted on his oral medications for blood pressure control.
His activity and diet were both advanced and it is
anticipated that on postoperative day four to five he will be
stable and ready for transfer home.
At this time the patient's physical examination is as
follows: temperature 99.7. Heart rate 108 sinus rhythm.
Blood pressure 132/74. Respiratory rate 20. O2 sat 92%.
Weight preoperatively 71.6 kilograms. On postoperative day
two at 74.9 kilograms. Laboratory data white count 15,
hematocrit 32.8, platelets 199, sodium 132, potassium 4.3,
chloride 102, CO2 29, BUN 12, creatinine 1.0, glucose 115.
Physical examination alert and oriented times three.
Conversant, moves all extremities. Respiratory clear to
auscultation bilaterally. Heart sounds regular rate and
rhythm. S1 and S2. No murmurs. Sternum is stable.
Incision with Steri-Strips open to air clean and dry.
Abdomen is soft, nontender, nondistended. Normoactive bowel
sounds. Extremities are warm and well perfuse with no
clubbing, cyanosis or edema.
MEDICATIONS ON DISCHARGE: Metoprolol 25 mg b.i.d., Lasix 20
mg q.d. times ten days, potassium chloride 20
milliequivalents q.d. times ten days, aspirin 325 mg q.d.,
Lipitor 80 mg q.h.s., Wellbutrin SR 150 mg b.i.d., Combivent
inhaler prn, Zestril 10 mg q.d. and Percocet 5/325 one to two
tabs q 4 hours prn.
CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Status post aortic arch end arterectomy.
2. Hypercholesterolemia.
3. Hypertension.
4. Gastric reflux disease.
5. Ruptured spinal disc.
6. Status post knee surgery.
7. Status post tonsillectomy.
It[**Last Name (STitle) 37689**]ticipated that the patient will be discharged to
home. He is to have follow up in the [**Hospital 409**] Clinic in two
weeks and follow up with Dr. [**Last Name (Prefixes) **] in one month. He is
also to have follow up with his primary care provider in
three to four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2190-12-24**] 10:47
T: [**2190-12-24**] 12:12
JOB#: [**Job Number 37690**]
|
[
"272.0",
"305.1",
"440.0",
"401.9",
"722.10",
"496",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.14",
"42.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7426, 8193
|
7101, 7405
|
4927, 7074
|
3503, 3562
|
3595, 3798
|
2853, 2972
|
3001, 3323
|
3346, 3479
|
3815, 4909
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,349
| 138,985
|
35371
|
Discharge summary
|
report
|
Admission Date: [**2119-1-20**] Discharge Date: [**2119-2-3**]
Date of Birth: [**2054-8-6**] Sex: F
Service: MEDICINE
Allergies:
Zosyn
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
evaluation by IP for cause of frequent intubations
Major Surgical or Invasive Procedure:
[**1-25**]: bronchoscopy
[**1-26**]: rigid bronchoscopy
[**1-30**]: transesophageal echocardiogram with cardioversion
History of Present Illness:
Ms. [**Known lastname 24630**] is a 64F with ESRD on HD, morbid obesity, afib,
tracheobronchiomalacia, multinodular goiter, and OSA referred to
[**Hospital1 18**] for possible IP intervention for ?tracheomalacia.
.
She had been having increased dyspnea and sputum production x 2
weeks prior to presentation to OSH along with nasal congestion,
but no fevers, chills, sweats. On [**1-16**] on way to HD session she
developed increased SOB and was taken to an OSH. There, she
developed increasing respiratory distress and was intubated. ABG
showed 7.27/56/334 on 100% O2. She became hypotensive to 60's
SBP following intubation requiring IVF resuscitation. She was
admitted to the OSH ICU for further care. Vancomycin and Zosyn
were started empirically on [**1-16**] for a possible pna. She was
extubated on [**1-17**], but had to be reintubated that day following
increased SOB that developed while she was getting a CT of her
chest to rule out PE or pneumonia. CTA apparently showed a small
right sided PE and she was started on heparin IV. On
reintubation, it was apparently difficult to pass an ET tube
through the vocal cords. A flexible bronchoscopy performed [**1-18**]
showed a normal trachea that was "somewhat collapsible" on
expiration, also observed in the "right and left
tracheobronchial tree". The RLL had a few retained secretions
and debris. No endobronchial lesions were observed. Her hospital
course was also notable for afib with RVR managed with IV
metoprolol. Patient underwent HD today prior to transfer to
[**Hospital1 18**].
.
On evaluation in the [**Hospital1 18**] MICU, she denies any pain. Her
breathing is "so-so" on the ventilator. She has recently had
some loose stools but denies any abdominal pain. Had fever to
101F today. Makes minimal amounts of urine, no dysuria. No
pleuritic chest discomfort, leg discomfort, history of DVT.
.
TRANSFER TO [**Hospital1 **]-CARDIOLOGY SERVICE:
This is a 64F with an extremely complicated hospitalization
lasting approximately 6 months who is being transered to the
[**Hospital1 1516**] Service for control of asypmtomatic atrial fibrillation
with rapid ventricular response to > 120/min that has been
difficult to control on the general medical floor.
.
In brief, she presented to an OSH with cellulitis that
progressed rapidly to sepsis in [**7-5**]. Her hospitalization was
complicated by acute renal failure for which she has been on HD
for several months and respiratory distress, possibly ARDS,
requiring intubation. She was difficult to wean from the
ventilator and remained intubated via tracheostomy until [**11-5**].
Throughout her hospitalization she was noted to be in Afib with
RVR. She was initially treated with Bblockers and started on
heparin drip and transitioned to warfarin. After extubation she
continued to have stridor and respiratory compromise. She was
transfered to [**Hospital1 18**] for management of presumed tracheamalacia.
Throughout her hospitalization at [**Hospital1 18**] (since [**2119-1-20**] to
transfer on [**2119-1-28**]) she has been in afib with RVR. Over the
past day her rate has been increasingly difficult to control.
During her initial MICU stay for tracheal debridement she had a
bronchospastic reaction to Bblockers and was transitioned to
diltiazem. She required increasing doses of PO diltiazem to the
max dose of 360mg PO daily in divided doses. On top of that she
received a total of 65mg IV in 12 hours and continued to be
tachycardic but asymptomatic assuming her baseline SOB is not
related to her afib with RVR (which may not be the case). She
was ultimately transfered to the [**Hospital1 1516**] Service for management of
Afib with RVR and possible cardioversion.
.
On the floor she is able to speak in short sentances [**1-30**] dyspnea
but reports that the is good for her from a respiratory
standpoint. She related her complicated history with the help of
her daughter as she was sedated and on a ventilator for much of
her hospitalization.
Past Medical History:
cellulitis with "fat necrosis" requiring skin grafting, c/b
sepsis
--hospitalized [**7-5**] prolongued vent had trach placed removed
[**12-5**]
atrial fibrillation on warfarin
--cultured (?source) Citrobacter braakii, Serratia marcescens,
Enterobacter
?OSA on CPAP no formal sleep study
ESRD on HD MWF has tunneled cath
multinodular goiter s/p biopsy
Morbid obesity
HTN
C difficile colitis
?retroperitoneal hematoma
peripheral neuropathy ?GBS following birth of 2nd child
left leg weakness
tracheomalatia
Chronic leg ulcers
Recurrent UTI
urinary stress incontinence
iron deficiency anemia
nephrolithiasis
Social History:
Nursing home resident at Summit Ridge. No smoking or EtoH.
Husband is a dermatologist. Prior to her severe illness this
summer she had been ambulating with a walker.
Family History:
noncontributory
Physical Exam:
Vitals 101.2 136 119/90 17 100% on AC 550/16/0.4/5
General Obese woman, intubated lying in bed, appearing somewhat
uncomfortable but in no acute distress
HEENT Sclera white, conjunctiva pink
Neck Unable to assess JVP secondary to large neck. Well-healed
trach scar at base of neck. +goiter
Pulm Lungs with rhonchi bilaterally, no wheezing
CV Irregular tachycardiac no murmurs appreciated
Chest R dialysis catheter in place no tenderness, erythema, or
exudate
Abd Obese +bowel sounds nontender large panus
Extrem Warm 2+ edema bilateral LE, well healing wounds medial
upper thighs, palpable distal pulses. Red rash R arm where BP
cuff had been located.
Neuro Alert and awake, able to write answers to questions on
whiteboard, no gross focal deficits
Pertinent Results:
[**2119-2-1**] 08:00AM BLOOD WBC-11.1* RBC-4.05* Hgb-11.8* Hct-38.3
MCV-95 MCH-29.2 MCHC-30.9* RDW-17.6* Plt Ct-345
[**2119-2-2**] 05:24AM BLOOD WBC-11.7* RBC-4.25 Hgb-12.4 Hct-40.5
MCV-95 MCH-29.2 MCHC-30.7* RDW-18.4* Plt Ct-324
[**2119-1-31**] 09:01AM BLOOD WBC-10.6 RBC-4.56 Hgb-13.3 Hct-43.3
MCV-95 MCH-29.1 MCHC-30.6* RDW-18.3* Plt Ct-370
[**2119-1-30**] 07:02AM BLOOD Neuts-79.9* Lymphs-13.8* Monos-3.3
Eos-2.7 Baso-0.4
[**2119-1-20**] 09:33PM BLOOD Neuts-77.4* Lymphs-13.6* Monos-4.8
Eos-3.6 Baso-0.5
[**2119-2-2**] 05:24AM BLOOD PT-21.4* PTT-40.8* INR(PT)-2.0*
[**2119-2-1**] 08:00AM BLOOD PT-24.4* INR(PT)-2.4*
[**2119-1-31**] 09:01AM BLOOD PT-21.9* PTT-60.3* INR(PT)-2.1*
[**2119-2-2**] 05:24AM BLOOD Glucose-96 UreaN-22* Creat-4.0*# Na-137
K-4.5 Cl-98 HCO3-27 AnGap-17
[**2119-2-1**] 08:00AM BLOOD Glucose-91 UreaN-29* Creat-5.7*# Na-138
K-4.6 Cl-98 HCO3-26 AnGap-19
[**2119-1-31**] 09:01AM BLOOD Glucose-112* UreaN-19 Creat-4.6*# Na-138
K-4.8 Cl-99 HCO3-27 AnGap-17
[**2119-1-21**] 09:21PM BLOOD CK(CPK)-38
[**2119-1-21**] 12:15PM BLOOD CK(CPK)-36
[**2119-2-2**] 05:24AM BLOOD Calcium-9.8 Phos-2.9 Mg-1.7
[**2119-2-1**] 08:00AM BLOOD Calcium-10.1 Phos-3.1 Mg-2.0
[**2119-1-31**] 09:01AM BLOOD Mg-2.1
[**2119-1-30**] 07:02AM BLOOD Calcium-9.9 Phos-3.6 Mg-1.7
Retics 0.7% ([**1-20**])
TIBC 170, b12 [**2047**], ferritin 1647, iron 24, folate 11.6
total cholesterol 228, HDL 50, LDL 128, TG 249
Hemoglobin a1c 4.9%
Echo [**2119-1-31**]
The left atrium is mildly dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No spontaneous echo contrast is seen in the left
atrial appendage. No spontaneous echo contrast or thrombus is
seen in the body of the right atrium or the right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
Echo [**1-21**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. The right atrial pressure is indeterminate.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. 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%). The
right ventricular cavity is mildly dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion. There is an anterior space
which most likely represents a fat pad.
[**1-26**] Tracheal Bx
Squamous and respiratory epithelium with acute inflammation,
necrosis, and focal granulation tissue formation.
[**1-30**] CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The left and right central venous access devices are
unchanged.
Improved transparency of the lung bases, unchanged moderate
cardiomegaly
without evidence of overhydration or pleural effusions. No focal
parenchymal opacity suggestive of pneumonia.
Microbiology data:
Stool: positive for Clostridium difficile on [**2119-1-30**]
MRSA screen negative on [**1-24**]
Sputum cx ([**1-23**]): oropharyngeal flora
Blood cx ([**1-20**]): negative
Brief Hospital Course:
Ms. [**Known lastname 24630**] is a 64F with multiple medical problems including
ESRD on HD, morbid obesity, afib, multinodular goiter, and OSA
who was transferred to [**Hospital1 18**] for IP eval for cause of frequent
intubations and concern for tracheobronchomalacia. Patient also
developed AFib with RVR and was started on Amiodarone and was
successfully DC cardioverted to sinus rhythm.
.
#. Respiratory failure: Likely multifactorial secondary to OSA,
obesity hypoventilation syndrome, CHF, volume overload from
ESRD, goiter and URI/bronchitis prior to transfer to OSH.
Tracheobronchomalacia may have been contributory to her
difficulties tolerating discontinuation of mechanical
ventilation, however less likely. Her pulmonary reserve is
limited given her morbid obesity. The patient underwent a
formal bronchoscopy by IP to determine if subglottic stenosis is
present and to determine degree of external compression by
goiter as she may require goiter removal. Cultures negative,
afebrile, no leukocytosis, therefore infectious process unlikely
to be a cause of respiratory failure. Did not start
antibiotics. Most likely contributing factor during admission
was excess volume, therefore patient underwent UF HD two days in
a row for volume removal. The patient was transferred with the
diagnosis of a PE, however according to our staff radiologist
evaluating the CT scan, it was determined that there was a very
small chance she actually had a PE thus was not anticoagulated
further; of note, she is on coumadin for A fib. She was being
treated with albuterol and ipratropium nebulizer treatments,
however albuterol was temporarily held given significant
tachycardia.
.
Pt was stable and able to be called out from MICU to floor on
[**1-24**]. The first night on floor, pt had frequent bursts of rapid
afib w/ rates >140. Her metoprolol was increased again to 87.5
QID which kept her HR usually under 120. On [**1-25**], went for
bronchoscopy that showed severe stenosis. Following the
procedure, she became stridorous, using accessory muscles to
breath, no wheezing. She was able to say approximately 4 to 5
words at a time. She was given an atrovent neb w/ little change
in symptoms. Given concern for laryngeal edema, she was given
dexamethasone. Attempted to give inhaled racemic epi but
pharmacy did not have. MICU consult was called and pt was
transferred back to MICU for further evaluation and treatment.
Patient was stabilized and evaluated by Interventional Pulmonary
and was transferred to cardiology service for AFib Management.
- She is set to follow up with IP here at [**Hospital1 18**] in 3 weeks
- As tachycardia issue has resolved, have reinitiated albuterol
nebs.
- Continue inhaled steroids, albuterol nebs, and atrovent nebs.
#. Atrial fibrillation w/ RVR: Resolved. Now in sinus rhythm,
status post TEE and cardioversion. Patient's rates were poorly
controlled on [**Hospital1 **] metoprolol when admitted. Given patient's
history of reactive airway disease, patient was switched to
diltiazem. Amiodarone drip was initiated and then patient was
transitioned to po load for help control AFib. Coumadin was
started as well, and patient's INR on discharge is 1.6. Patient
was successfully cardioverted into sinus rhythm and TEE did not
show any [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**].
- Continue Amiodarone 200 TID through [**2-3**]. On [**2-4**] transition to
Amiodarone 200mg [**Hospital1 **] for 14 days, and then daily thereafter.
- Continue Coumadin 2mg. INR on discharge is 1.6. Goal is [**1-31**].
Patient needs INR checked with dialysis until on a stable dose
of coumadin. Plan is for anticoagulation for at least one month
following cardioversion. The patient should discuss
discontinuation of coumadin with her cardiologist (to establish
care as outlined in d/c plan).
- Continue diltiazem 240mg daily
- Continue Lisinopril 2.5mg daily
- She should follow up with a cardiologist (Dr. [**Last Name (STitle) 10165**], as
recommended by her primary care physician) within two weeks of
discharge from [**Hospital1 18**]. The phone number for their office is
[**Telephone/Fax (1) 32501**].
#. ESRD on HD: Gets HD MWF as an outpatient. Renal followed
the patient during her stay. HD provided for volume removal.
- Continue Epo with HD
- Continue Zemplar 1 mg with HD
- she was dialyzed on [**2-3**] in the morning.
#. Anemia: Pt with reported anemia of iron deficiency but this
is an unlikely diagnosis given her ferritin of 1647. She likely
has a combination of anemia of renal disease and anemia of
chronic inflammation - tbe treatment of which is treatment of
the underlying disorder. She will earn only marginal benefit
from Epo given her high ferritin but we will continue with this
regimen.
- Continue FeSo4 325mg daily
- Continue Epo with HD
#. Anxiety: Continue zoloft, with ativan as needed.
# C Diff Diarrhea: Patient's diarrhea has resolved. Patient
has no s/sx of fever.
- Continue Metronidazole 500mg TID for 11 more days.
# Rash: Patient developed a rash on the left forearm one day
after initiation of metronidazole. She also noted a pruritic
rash in her bilateral antecubital areas. She was treated with
topical steroids with relief. The rash was not diffuse and it
resolved over the past two days, making systemic drug eruption
less likely.
Medications on Admission:
Zoloft 100
Metoprolol 125 [**Hospital1 **]
Ativan 0.5 prn
Albuterol
Coumadin ?5mg daily
Acidophilus
Dulcolax
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): with dialysis.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO As directed:
Three times daily (TID) (to finish [**2-3**]), then twice daily ([**Hospital1 **])
for 14 days starting [**2-4**], then daily thereafter.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
17. DILT-CD 240 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed: max 4 g daily.
21. Hydrocortisone 1 % Cream Sig: One (1) application Topical
three times a day as needed for itching.
22. Zemplar 2 mcg/mL Solution Sig: One (1) mcg Intravenous qhd:
with HD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] rehab hospital
Discharge Diagnosis:
Primary: tracheomalacia, atrial fibrillation with rapid
ventricular response
.
Secondary: End stage renal disease, hypertension, asthma
Discharge Condition:
Afebrile, vitals stable, sinus rhythm
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**].
.
You were admitted for management of your tracheomalacia, a
disorder of your trachea from prolonged intubation. You were
also found to have atrial fibrillation, a common arrhythmia of
the heart. We dilated and debrided your trachea. We also treated
you with medications and cardioversion for your atrial
fibrillation and you were successfully converted back to sinus
(normal) rhythm.
As a result, your metoprolol has been discontinued. You have
been started on a new medication, Cardizem 240mg daily that will
help control your heart rate and blood pressure. Additionally,
you have also been started on a medication called Amiodarone.
Please take this medication three times daily for the next two
days, and then twice daily for the following 14 days, and then
once daily thereafter. You have also been started on coumadin
and your INR is therapeutic. Your INR should be checked while
you are in Rehab.
While you were an inpatient, you developed diarreha caused by C
Diff. The treatment for this is metronidazole. Please continue
to take this medication for the next 12 days, three times daily.
You have also been started on a low dose of Lisinopril 2.5mg for
blood pressure control.
.
Please take your medications as prescribed. We have made several
changes.
.
Please attend your follow up appointments.
.
Please call your doctor or come to the nearest emergency room if
you experience chest pain, palpitations, shortness of breath,
passing out, bleeding, or other concerning symptoms.
Followup Instructions:
Please make an appointment to follow up with your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 80632**] in 1 month, so you can see her once you are discharged
from Rehab. Their number is [**Telephone/Fax (1) 80633**]
Please make an appointment to follow up with Dr. [**Last Name (STitle) 10165**], a
cardiologist that Dr. [**Last Name (STitle) 80632**] has recommended. Their group
can be reached at [**Telephone/Fax (1) 32501**]. Please make this appointment to
see them in the next 2 weeks.
Interventional Pulmonary
Please follow up with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] on Wednesday [**2-22**]
10am. Their office is at [**Hospital1 18**] [**Hospital Ward Name 517**], [**Hospital1 **] 116.
Please do not eat anything after midnight on [**2-22**], in case
the physicians choose to perform a bronchoscopy.
Completed by:[**2119-3-3**]
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61,030
| 193,011
|
5943
|
Discharge summary
|
report
|
Admission Date: [**2194-6-13**] Discharge Date: [**2194-6-25**]
Date of Birth: [**2119-8-13**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Darvon / Atenolol / Bactrim
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation on [**6-13**]
History of Present Illness:
74 year old female with CAD, dCHF, and CKD presented to an OSH
today after calling EMS complaining of severe shortness of
breath. On arrival to the ED the patient was found to be
tachycardic to 148, BP 140/58, 81% with EKG concerning for
possible VTach. Patient does have known LBBB at baselie. The
patient was emergently intubated for respiratory failure and was
given a 150J shock x1 for possible Vtach though rhythm strips
from the OSH were unavailable on transfer. In addition, the
patient was bolused with Amiodarone and started on an amiodarone
drip. A CXR showed diffuse bilateral pulmonary infiltrates so
the patient was also given a dose of ceftriaxone/azithromycin as
well as IV lasix for posisble fluid overload. A bedside TTE was
performed which, per report, showed a reduced EF of
approximately 30-35% at the OSH as well. Initial cardiac
enzymes were negative. An ABG shortly after intubation was
7.15/45/66/16/86% and she remained difficult to ventilate
requiring 100% FiO2 and PEEP 20. Given her continued acidosis
on the vent, the patient was given 1 Amp of sodium bicarb while
in the ED. Given the patient's complicated presentation, newly
reduced EF, and possible cardiogenic shock, the patient was
transferred to [**Hospital1 18**] MICU for further management and possible
intervention.
In the MICU, repeat TTE showed global LV systolic dysfunction w/
EF of 30%. Cardiac enzymes were trended and continued to rise,
last trop of 0.52, CK of 7559, MBI 1.6. She was initially
started on a heparin gtt due to concern for ACS, though this was
later thought to be more consistent with a metabolic
process/sepsis, and the heparin gtt was discontinued. Also, on
review, rhythm was most likely consistent with SVT w/ abberancy,
not VT. Amiodarone was discontinued.
.
Of note, patient had worsening of her chronic kidney disease
from a baseline creatinine of 1.5 up to 2.7 thought to be
secondary to hypoperfusion. She had a borderline UA at the OSH
showing protein and blood without ketones or glucose. Abdominal
US was performed to look at kidneys which were unremarkable.
.
She was also initiated on an insulin gtt due to persistently
elevated BS in the 400s and significant AG acidosis on
admission, now well controlled with a closed gap. No ketones or
glucosuria.
.
The patient was extubated on day 6 of hospitalization, and
developed flash pulmonary edema thereafter. Was placed on home
bipap regimen. Serial chest x-rays showed resolution of
infiltrates, although congestion present. Diuresis was started
with diuresis goals of 1 to 1.5 L. Hydralazine and isosorbide
were started. Echo was repeated on [**6-18**] and EF had improved to
55%. For CAD the patient was continued on aspirin, statin, and
metoprolol 75 mg tid. The white count improved, trending down
from 17.7 to 13. She completed a 7 day course of vanco and zosyn
for hospital acquired pneumonia. All cultured obtained at [**Hospital1 18**]
were negative, urine culture from OSH grew out E coli and
Klebsiella sensitive to cipro. Patient was afebrile. Following
antibiotic course, patient was re-cultured after antibiotics
were discontinued. Stool was sent for c-difficile.
The patient had several episodes of afib with RVR. Beta
blockers were titrated up to lopressor 75 mg TID for rate
control and amiodarone IV drip was restarted for further nodal
block. Was then switched to PO amiodarone 200 [**Hospital1 **] and was in
sinus rhythm. Acute renal failure also continued to resolve
with Cr near baseline (was 1.5). Was transfered to the floor
cardiology service for further management.
On review of systems was unattainable due to patient being
intubated.
Past Medical History:
1. Coronary artery disease s/p NSTEMI and Taxus stent to LAD in
[**2189**] in [**State 108**] and failed attempt to stent OM1 in [**2187**]
2. Hypertension.
3. Diabetes mellitus type 2 (last A1C 9.0 in [**2192-5-18**])
4. Hyperlipidemia.
5. Anemia with baseline hematocrit approximately 30.0.
6. Carotid stenosis.
7. Breast cancer, status post lumpectomy and radiation
therapy.
8. Chronic Diastolic CHF
9. Status post cholecystectomy.
10. Obstructive Sleep Apnea on CPAP at home
11. Bakere's cyst
12. Osteoarthritis
Social History:
The patient lives in [**Location 3146**] by herself. She smoked 0.5-1 ppd
for 30 years but quit 20 years ago. She does not currently
drink alcohol. She denies illicit drug use. Ambulates with
walker and needs assistance with ADLs.
Family History:
Father had stomach cancer and died of a MI at age 62. Her
mother had [**Name2 (NI) 499**] cancer and died in her 60s. She had two
brothers, one died of an MI at age 39, the other at age 65. She
has a sister who had breast cancer. She has three children, one
of whom is deceased. The other two children are healthy. She
has three healthy grandchildren.
Physical Exam:
Vital signs:
BP right arm: 116 / 85 mmHg supine
Weight: 114.2 kg
T current: 98.2 C
HR: 100 bpm
RR: 24 insp/min
O2 sat: 89 % AC 12/500/20/100%
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: WNL, ET tube in
place), (Teeth, gums and palette: WNL)
Neck: (Right carotid artery: No bruit), (Left carotid artery: No
bruit), (Thyroid / Neck: Right IJ in place)
Back / Musculoskeletal: (Chest wall structure: WNL)
Respiratory: (Effort: Mechanical Ventilation), (Auscultation:
Mild [**Hospital1 **] basilar crackles, no wheezes,good air movement)
Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL),
(Auscultation: S1: WNL, S2: physiologic, S3: Absent, S4:
Absent), (Murmur / Rub: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: Abnormal,
decreased), (Bruits: No), (Pulsatile mass: No),
(Hepatosplenomegaly: No)
Genitourinary: (Foley catheter with scant urine)
Extremities / Musculoskeletal: (Digits and nails: WNL), (Muscle
strength and tone: Unable to asses strength, tone normal),
(Edema: Right: 0, Left: 0), (Extremity details: No significant
lower extremity edema)
Pertinent Results:
[**2194-6-13**] 04:56PM WBC-20.1*# RBC-3.14* HGB-9.6* HCT-30.1*
MCV-96 MCH-30.7 MCHC-32.0 RDW-13.2
[**2194-6-13**] 04:56PM NEUTS-89* BANDS-1 LYMPHS-4* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2194-6-13**] 04:56PM ALT(SGPT)-117* AST(SGOT)-172* LD(LDH)-541*
CK(CPK)-1872* ALK PHOS-141* TOT BILI-0.6
[**2194-6-13**] 07:49PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-5.0 LEUK-MOD
[**2194-6-13**] 07:59PM PT-15.2* PTT->150* INR(PT)-1.3*
[**2194-6-13**] 09:00PM LACTATE-2.1*
[**2194-6-13**] 09:00PM TYPE-ART RATES-28/ TIDAL VOL-500 O2-80
PO2-197* PCO2-40 PH-7.31* TOTAL CO2-21 BASE XS--5 AADO2-341 REQ
O2-61 -ASSIST/CON INTUBATED-INTUBATED
[**2194-6-13**] 11:47PM CK-MB-120* MB INDX-1.6 cTropnT-3.54*
[**2194-6-13**] 11:47PM CK(CPK)-7559*
CXR [**2194-6-13**] - diffuse air space opacities in all four quadrants,
most extensive in RLL.
.
CXR [**2194-6-22**] - There is patchy airspace opacity in the right mid
and lower lobe as well as lingula and left upper lobe, not
appreciably changed from the prior study. Small right pleural
effusion persists. Mild cardiomegaly. Mediastinum within normal
limits. Mild biapical pleural thickening.
.
EKG: LBBB, sinus rhythm, no ischemic ST segment changes
.
TELEMETRY: Normal sinus rhythm, HR 70s
.
2D-ECHOCARDIOGRAM: Bedside TTE shows reduced EF ~ 30%, with
global hypokinesis. Moderate global left ventricular systolic
dysfunction. Mild right ventricular systolic dysfunction.
Minimal aortic stenosis. Moderate mitral and tricuspid
regurgitation. Mild pulmonary hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2191-5-4**], biventricul ar systolic function has
deteriorated.
.
2D Echo: [**2194-6-18**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%).
.
RUQ U/S: Prominent CBD of 9 mm which may relate to
post-cholecystectomy status, although CBD not visualized to
ampulla. If concern is high for
choledocholithiasis, MRCP is more sensitive. Small amount of
fluid in right upper quadrant.
.
Lower extremity Doppler: No left lower extremity DVT. Left
[**Hospital Ward Name 4675**] cyst.
.
OSH Culture DATA
[**2194-6-13**] - Urine Cx positive for >100,000 E.coli and Klebsiella
pneumonia - pansenstive E.coli and Klebsiella resistant only to
ampicillin and nitrofuratonin
.
Culture Data from [**Hospital1 18**] - Negative blood, urine, stool cultures.
C difficile toxin is negative.
.
Brief Hospital Course:
HOSPITAL COURSE:
.
74 year old female with known CAD, diastolic CHF, HTN, DM,
dyslipidemia, presents to OSH ED complaining of SOB, arrived in
extremus and respiratory failure requiring intubation,
tachycardic with likely SVT with aberrancy, new reduced EF,
leukocytosis, four quadrant air space opacities on CXR, and
relative hypotension concerning for distributive vs. cardiogenic
shock. Brief hospital course by problem list is as followers:
.
Coronary Disease: Has known CAD. Initial enzymes were negative.
After being transferred from OSH, CK rise seen from (1872 ->
7559) although very minimal CK-MB rise and troponins rose to ~3.
No ischemic EKG changes. MICU attributed troponin rise and CK
rise to cardioversion shock and demand ischemia in setting of
possible sepsis. Globally reduced EF was attributed at OSH to
acidosis/sepsis rather than ischemic cardiomyopathy. IV Heparin
was briefly started in the MICU for ACS, but then discontinued
once she ruled out. Aspirin and statin were continued on the
floor. Repeat Echo showed a markedly improved EF.
.
Congestive Heart Failure: Pt with history of diastolic CHF had
dramatically reduced EF on bedside TTE as above, mixed picture
ACS/sepsis and metabolic acidosis given lactate of 7.0 at OSH.
MAPs in mid 50's on arrival, but patient started on low dose
levophed overnight [**2111-6-12**] for low blood pressures and nadir of
74/38 after initation of fentanyl/versed for sedation. CVP on
arrival to CCU was 12. Central venous O2 sat 87 on admission
came up to 99%. Pt was given small 500 IVF bolus given for
relative hypotension in setting of CVP 12 with low urine output
ON after admission to MICU. CVP increased to 17 following 500 cc
IVF. Pt had cardiac stunning with low EF (30%), but on repeat
echo, her EF was markedly improved. Received IV lasix 80 mg
twice a day when transferred to floor. On day prior to
discharge, was switched from lasix to PO torsemide 40 mg [**Hospital1 **].
Improved oxygen saturations at 97% on RA at discharge, with
intermittent needs for 2 L oxygen on NC. Diuresing well on
torsemide, should be continued at rehab facility.
.
Atrial Fibrillation: At OSH was found to be tachycardic with
wide complex tachycardia felt to be SVT with aberrancy based on
12 lead EKG. Pt was shocked x 1 at OSH and loaded with
amiodarone upon transfer. Amidarone gtt was d/c upon admission
to ICU. She went into afib with RVR and cardiology was
consulted. She was amiodarone loaded and was subsequently
managed on metoprolol and amiodarone PO BID. While on floor,
she remained in normal sinus rhythm with HRs in the 60s - 70s.
.
Respiratory Failure: CXR showing diffuse fluffly pulmonary
infiltrates concerning for ARDS. In MICU was continued on A/C
mechanical ventilation with low tidal volume strategy and PEEP
to support increased lung resistance. She was diuresed
aggressively and successfully weaned from mechanical
ventilation. On the floor was diuresed and did well on room
air, saturating at 97% on room air with intermittent needs for 2
L O2.
.
ID: Possible sepsis given leukocytosis, with suspected urinary
source, though pulmonary source could also be present given
increased RLL infiltrate on CXR. Urine cultures were positive
at OSH for cipro-sensitive E coli and Klebsiella. Urine
legionella negative. Blood, stool, and urine cultures at [**Hospital1 18**]
negative. She completed a course of Abx for HAP and a cipro
course for her UTI. WBC trended down but still elevated at 13
at time of discharge. Patient has been afebrile.
.
Acute renal failure or chronic failure: Pt with baseline cr of
1.7, 2.0 at OSH earlier, trended down to 1.8-2.1 by end of
hospital stay, which is near her baseline. Original pathology
was felt to be pre-renal hypoperfusion in setting of severe
systemic illness and reduced EF.
.
Diabetes Mellitus: Pt with significantly elevated blood sugars
at OSH and on admission. Patient with history of type II DM and
at risk for hyperosmolar non-ketotic hyperglycemia, although
blood glucoses did not exceed 600 in CCU. Serum ketones were
followed and normal. Sugars were well-controlled on sliding
scale on the floor.
.
Metabolic Acidosis: Pt with large gap metabolic acidosis,
initial lactate at OSH 7. Pt was given 1 amp sodium bicarb at
OSH. Mechanical vent was set with increased respiratory rate for
hyperventilation, to compensate for the met acidosis. Improved
over course of stay to within normal limits.
.
Transaminitis: Pt with elevated transaminases on admission,
likely consistent with global critical illness and possibly
related to shock liver/hypoperfusion. LFTs and coags were
trended in the MICU and at baseline at discharge.
.
Access: Patient still has a PICC line in place. This will need
to be flushed with heparin daily in the rehab. Can be
discontinued when discharged to home from rehab.
.
Code: FULL
Medications on Admission:
Lipitor 80 mg po daily
Metoprolol 100 mg po BID
Cozaar 100 mg po daily
Tramadol 50 mg po BID
Lasix 40 mg po BID
Amlodipine 5mg po daily
[**Doctor First Name **] 60 mg po BID
Vicodin 1 tab Q6 prn pain
NKDA
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
3. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Cozaar 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for afib.
Disp:*60 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Check INR 2 days following discharge and titrate as
appopriate.
Disp:*30 Tablet(s)* Refills:*2*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
14. NPH 35/40
15. Humalog sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] sinani-[**Location (un) **]
Discharge Diagnosis:
1. Pneumonia
2. Sepsis
3. Congestive Heart Failure
4. Coronary Artery Disease
5. Diabetes Mellitus
6. Hypertension
Discharge Condition:
good
Discharge Instructions:
You were admitted with a complaint of shortness of breath to the
medical intensive care unit. They found that you probably had a
pnuemonia that made your short of breath. You were given
antibiotics for this. Further, the stress of pneumonia made
your heart struggle a little bit, making fluids back up from the
heart into your lungs. This probably also made you short of
breath. We've been giving you medications to take this fluid
away from your lungs. In addition, your heart was beating in a
rhythm that is called atrial fibrillation. You were put on a
medication to help slow down your heart rate and keep it
controlled in a normal rhythm. Because of these problems you'[**Name2 (NI) **]
experienced, we have started you on a few new medications that
you should continue to take at home.
1) torsemide 40 mg taken by mouth, twice a day: This medicine
is a water pill that helps keep the fluids off your lungs.
2) Amiodarone 200 mg by mouth twice a day - This helps keep your
heart from going into the rhythm we call atrial fibrillation.
3) Warfarin 2.5 mg a day - This medicine helps to thin your
blood so that you don't form clots. Your rehab should be
checking a lab test, called INR, on Thursday, Saturday, and
Monday of every week to make sure you are taking the right
amount of this medicine.
There are a few changes in dose we've made in a couple of your
medicines:
1) Omeprazole 40 mg twice a day - We increased this from
omeprazole 20 mg twice a day, because of your black stool. This
medicine helps to prevent you from bleeding in your stomach.
2) Metoprolol - We decreased this from 100 mg to 75 mg twice a
day.
We have discontinued one medication that you used to take at
home:
1) You no longer should take the lasix.
Please return to the ED if you have any chest pain, chest
pressure, shortness of breath, dizziness, fevers, or any other
concerning symptoms.
Followup Instructions:
1. You already have a follow-up appointment scheduled with Dr.
[**Last Name (STitle) 911**] in [**Month (only) **]. You have been placed on a wait list, so that
if a patient has a cancellation, they will call you so that you
can come in earlier.
2. At the rehab, please get the following labs checked:
[**2194-6-27**] - Check INR and adjust Coumadin accordingly to ensure
she is on appropriate dose. INR goal [**1-21**]. Currently is on 2.5
mg daily. INR on day of discharge ([**6-25**]/-0) is 2.5. Also check
creatinine to ensure she is at baseline (Cr 1.8-2.2).
Please check INR every other day starting [**6-27**], and adjust
coumadin appropriately to maintain INR of [**1-21**].
|
[
"V58.61",
"599.0",
"412",
"427.1",
"V45.82",
"276.2",
"427.31",
"785.52",
"414.01",
"715.36",
"250.00",
"518.81",
"041.4",
"276.1",
"038.9",
"995.92",
"486",
"584.9",
"428.0",
"585.9",
"428.33",
"V58.67",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"96.6",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15415, 15490
|
8972, 8972
|
315, 341
|
15655, 15661
|
6344, 8949
|
17599, 18294
|
4850, 5209
|
14081, 15392
|
15511, 15634
|
13852, 14058
|
8989, 13826
|
15685, 17576
|
5224, 6325
|
268, 277
|
369, 4033
|
4055, 4582
|
4598, 4834
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,495
| 159,606
|
22210
|
Discharge summary
|
report
|
Admission Date: [**2186-8-18**] Discharge Date: [**2186-8-28**]
Date of Birth: [**2120-1-31**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
.
HPI: History of Present Illness: Mrs. [**Known lastname **] is a 66 year
old female with history of rheumatic heart disease s/p MVR and
recent TVR, afib, severe tracheomalacia s/p trach/PEG, celiac
disease who was recently admitted to [**Hospital1 18**] from [**2186-8-13**] to
[**2186-8-18**] for management of diarrhea and fever. During this
admission the patient had a CT Abd/Pelvis revealing for colitis
and ascites. The patient was treated empirically for C. Diff
with Flagyl tid with report of significantly decreased diarrhea
on discharge although no stool cultures are available for
review. The patient underwent a 1.5L paracentesis this admission
with cell count consistent with SBP, culture negative, for which
the patient was treated with Ceftriaxone during hospitalization
and on discahrge. Finally, the patient additionally had sputum
cultures performed which revealed Stenotrephomonas for which the
patient was treated with Bactrim although this was discontinued
after 3 days given low clinical suspicion for pneumonia. The
patient's tube feeds were resumed with report of improved
adominal pain. A PICC line was placed on [**8-17**] for Abx use. Of
note, prior to this admission the patient additionally was
reported to have coag negative staph bacteremia-oxacillin
resistant. Blood cultures during this last hospitalization did
not reveal any growth, a TTE was performed which did not reveal
any obvious vegetations.
With regards to her remaining issues the patient was
continued on lasix and aldactone for management of her ascites.
The patient is suspected to have cirrhosis with portal
hypertension secondary to severe TR. She was otherwise
maintained on her outpatient [**Hospital 1902**] medical regimen. The patient is
now s/p trach/peg for severe tracheomalacia and significant
Right sided pleural effusion. She was noted to have a
respiratory alkalosis, often overbreathing the vent, noted to be
tolerating PS for several hours at a time of discharge.
.
The patient today at her facility was found to be hypotensive
with SBP in the 80s. She received 300cc bolus with improvement
of SBP to 103.
ED Course: Vitals T- none recorded. HR: 126 BP: 110/70
- In the ED blood and urine cultures obtained. The patient was
treated empirically with CTX, Vanc, Flagyl. A central line was
placed and the patient was started on Levophed for hypotension.
The patient was given 2U PRBCs.
Past Medical History:
-s/p cardiac cath [**2186-6-26**] for TVR procedure
-TVR/RA reduction surgery via right thoracotomy [**2186-6-28**] ( 33 mm
CE pericardial valve) c/b partial right lung collapse and
persistent hypoxia
-s/p bronch on [**2186-7-26**] showing moderate to severe tracheomalacia
and left mild bronchomalacia.
-s/p trach/PEG on [**2186-7-27**]
-Mitral valve replacement, [**2165**] on coumadin. Treatment for
rheumatic MS. h/o MV commissurotomy in [**2152**].
-Celiac sprue -does not have collagenous colitis with
negative biopsies done at the last colonoscopy Per Dr. [**Last Name (STitle) **]
[**Name (STitle) 57868**] Intolerance
-Elevated LFTs
-h/o AF prior to mechanical valve placement
-Cirrhosis with cardiogenic ascites and ansarca
Social History:
-Married 4 kids
-No current tobacco use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
on admission:
Physical Exam:
Vital Signs: T- 97.2 BP: 97/46 (.153 Levophed) HR: 126-127 afib
RR: 24-27 O2: 97% AC: 450 x 15 (sp 9) Fi2: 0.50 PEEP: 5
General: Patient is a chronically ill appearing female, with
buccal wasting but gross anasarca. Patient is with trach in
place, breathing relatively comfortably
[**Name (NI) 4459**]: NCAT, [**Name (NI) 3899**], PERRL. OP: MMM, poor dentition
Neck: Supple, no LAD, no JCD + left IJ
Chest: Course breath sounds diffusely on inspiration and
expiration. No obvious rales, very limited posterior exam
Cor: Irregular, systolic click throughout precordium. No obvious
regurgitant murmurs appreciated
Abdomen: Moderately to severely distended. 3+ edema. Firm
although not rigid, + pain with palpation of the left lower
quadrant, sense of fullness underneath with ? palpable
mass/phlegmon.
Rectal: Thin yellow stool in rectal vault, trace guaiac positive
Extremity: 4+ pitting edema to thighs, hyperpigmentation of LE.
DP not palpable secondary to anasarca
Foley: Foley in place draning brown feculent material with
visible debris
.
on discharge:
[**Name (NI) 4459**]: NCAT, [**Name (NI) 3899**], PERRLA, MMM
neck: supples
heart: irregular rhytm, nl rate
chest: anterior exam with clear breath sounds bilaterally
abdomen: soft, NT, ND, PEG tube
Ext: chronic venous stasis changes. 2 + B pitting edema
foley in place
Pertinent Results:
.
ECG: 120, Afib, RAD. QRS 130, +RBBB. Deep TWI V1-V4. Unchanged
from previous.
.
Imaging:
[**2186-8-18**]: Portable Chest -
IMPRESSION: Post-line placement, without pneumothorax.
Unchanged appearance of the chest with marked cardiomegaly and
bibasilar opacities most likely representing atelectasis,
however, pneumonia cannot be totally excluded especially in the
left lower lobe. Clinical correlation is recommended.
.
[**2186-8-12**]: CT Abdomen/Pelvis
IMPRESSION:
1. Multiple foci of intraperitoneal gas could be related to
recent
gastrostomy placement (when was this installed?) but
intraperitoneal
infection cannot be excluded. No evidence of extravasation of
oral contrast.
2. Wall thickening of the ascending colon and hepatic flexure.
This is a common finding in cirrhosis complicated by ascites.
However, it is pronounced enough to suggest possible underlying
colitis.
3. Cirrhosis. Significant increase in volume of ascites, which
is now large.
4. Extensive body wall edema.
5. Marked cardiomegaly and biatrial enlargement.
6. Moderate right pleural effusion and atelectasis of the base
of the right lower lobe. Small left pleural effusion.
.
Echocardiogram: [**2186-8-14**]
Conclusions:
The left atrium is markedly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. Mild
spontaneous echo contrast is seen in the body of the right
atrium. Left ventricular wall thicknesses and cavity size are
normal. There is moderate global left ventricular hypokinesis
(LVEF = 35-40 %). Right ventricular cavity size is increased
with free wall hypokinesis. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. A bileaflet mitral valve
prosthesis is present. The mitral prosthesis appears well
seated, with normal disc motion and transvalvular gradients.
Trivial mitral regurgitation is seen. The degree of mitral
regurgitation seen is normal for this prosthesis. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] A bioprosthetic tricuspid valve
is present. The tricuspid prosthesis appears well seated, with
normal leaflet motion and transvalvular gradients. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
#. Left RP Bleed - Pt presented with hypotension; Pt found to
have a large left RP hematoma on CT ABdomen. Pt was
aggressively rescusitated with 14 Units of RBCs and
cryoprecipitate and FFP. Pt was evaluated by surgery who felt
that she wouldn't need surgical intervention but more likely IR
embolization if she were to become hemodynamically unstable.
Patient did not require further treatment of the RP bleed and
her Hcts remained stable. She was restarted on IV heparin and
transitioned to coumadin for an INR goal of 2.5-3.5 and her Hct
remained stable during this transition phase.
.
#[**Name (NI) 27035**] Pt had culture of blood, urine, sputum, and
stool. Sent Stool for C. Diff Toxin A+B, A is negative on first
culture, toxin B still pending.
-Continue PO Vanc and PO Flagyl for C.Diff x14 days (from [**8-26**])
-Pt completed course of Ceftriaxone for presumptive SBP
.
#. ARF - Patient initially had increased Cr. This was thought to
be due to ATN from her GI bleed. Cr trended back to her baseline
upon discharge.
.
#Fluid Overload - Patient is currently positive 7 liters for her
length of stay. She has been diuresed with 80IV lasix and 5mg
metolazone as tolerated for daily I/O goals of -1L. Continues to
need diuresis.
.
#[**Name (NI) 57954**] - Pt had 10,000-100,000 yeast in urine after her
second foley change. She was treated in light of patients
symptoms of dysuria/rash as well as the relative risk of fungal
endocarditis given her MVR and TVR. She will be treated with a
14 day course of fluconazole 200mg which will finish on [**9-7**].
The interaction with Coumadin was noted, therefore the titration
of coumadin to goal was done slowly.
.
#. Afib with RVR - Initially with increased Hr, likely
exacerbated by levophed. Patient was continued on metoprolol
12.5mg TID. She is currently on heparin while she is titrated
up on her coumadin.
.
#.MVR and TVR - Anticoagulation was initially held because of RP
bleed. After bleed stable, she was started on a heparin gtt
while she was bridged back to her Coumadin. We are treating the
yeast infection to prevent the possibility of fungemia and risk
to valves.
.
# Hypernatremia: Na has trended up with diuresis. At time of
discharge, we were replacing her free water deficit with 200mL
of free H20 Q6 hours.
Medications on Admission:
Medications: at admission = Discharge Medications: [**2186-8-17**]
Metronidazole 500 mg PO tid
Ceftriaxone 2 g once daily x 8 days (10 day course)
Bactrim DS 160-800 mg: Tablet PO once a day
Colace 100mg PO bid
Furosemide 20 mg daily
Spironolactone 25 mg daily
Senna 1-2 Tablets PO BID
Calcium Acetate 667 mg tid with meals
Metoprolol Tartrate 25 mg PO bid
Aspirin 81 mg daily
Sertraline 50 mg daily
Albuterol-Ipratropium 103-18 mcg/Actuation 6puffs q 4 hours
Atorvastatin 10 mg daily
Ascorbic Acid 90 mg/mL dropn once daily
Famotidine 20 mg PO bid
Acetaminophen 160 mg/5 mL PO q 6 hr PRN
Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **]
Multivitamin 5ml PO daily
Warfarin 5 mg PO qhs
Lactulose 30ml PO tid
Heparin Porcine (PF) 10 unit/mL Solution: Weight based protocol
PT, PTT Goal 60-80 until INR 2.5-3.5.
Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Hypotension
Diarrhea
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1200 cc/d
Followup Instructions:
Please follow up with your pcp. [**Name10 (NameIs) 357**] call to make an
appointment
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**]
Completed by:[**2186-8-28**]
|
[
"276.3",
"V58.61",
"785.52",
"V44.1",
"276.0",
"789.5",
"038.9",
"567.23",
"518.83",
"428.0",
"427.31",
"519.19",
"285.1",
"572.3",
"112.2",
"008.45",
"V44.0",
"397.0",
"584.5",
"571.5",
"459.0",
"V43.3",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.6",
"99.07",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10719, 10791
|
7498, 9784
|
327, 333
|
10856, 10865
|
5113, 7475
|
11042, 11269
|
3638, 3720
|
9861, 10696
|
10812, 10835
|
9810, 9838
|
10889, 11019
|
3765, 4810
|
4824, 5094
|
276, 289
|
396, 2766
|
3750, 3750
|
2788, 3525
|
3541, 3622
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,811
| 126,022
|
5645
|
Discharge summary
|
report
|
Admission Date: [**2112-2-5**] Discharge Date: [**2112-2-10**]
Date of Birth: [**2055-3-10**] Sex: F
Service: ONCOLOGY MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 56 year old female
with metastatic nonsmall cell lung cancer admitted with
hypoxia and shortness of breath for approximately one week
and left sided chest pain. She presented with an oxygen
saturation of 83%, electrocardiographic changes consistent
with pericarditis, positive cardiac enzymes, and a sizeable
circumferential pericardial effusion (early tamponade).
Status post pericardial drainage.
HOSPITAL COURSE: Further workup revealed worsening
opacification in the left lower lobe, extrinsically
obstructing tumor compressing on the left bronchus. She was
treated with Zosyn for presumptive postobstructive pneumonia.
Her course was complicated by tachycardia, atrial flutter.
She was maintained on Amiodarone drip and converted to sinus
within 24 hours.
After ongoing discussions with the pulmonary team regarding
management of the endobronchial lesion, the patient decided
she did not want to be intubated (which would be required to
be perform an endobronchial procedure). Her code status
changed to DNR/DNI. She was maintained on steroids and
antibiotics until she further decompensated for a respiratory
standpoint. This further decompensation was attributed to
progression of her underlying carcinoma. In discussions with
the patient's family and partner, it was decided during this
terminal respiratory decompensation to proceed to comfort
care only. At that time, antibiotics and all other
aggressive measures were withdrawn. The patient expired at
2:00 p.m. on [**2112-2-10**].
PRIMARY CAUSE OF DEATH: Respiratory failure.
UNDERLYING CAUSE OF DEATH: Nonsmall cell lung carcinoma.
An autopsy was requested and refused by the patient's partner
and family. It was felt that it would not be in the
patient's best interest. Again, the time of expiration was
2:00 p.m. on [**2112-2-10**].
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 15108**], M.D. [**MD Number(1) 3282**]
Dictated By:[**Name8 (MD) 17844**]
MEDQUIST36
D: [**2112-2-10**] 15:49
T: [**2112-2-10**] 18:38
JOB#: [**Job Number **]
|
[
"799.0",
"427.31",
"198.5",
"198.89",
"162.8",
"486",
"285.9",
"423.8",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
603, 2248
|
174, 585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,568
| 129,848
|
54174
|
Discharge summary
|
report
|
Admission Date: [**2113-4-5**] Discharge Date: [**2113-4-11**]
Date of Birth: [**2047-6-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Influenza Virus Vaccine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**4-5**] Coronary Artery Bypass Graft x 2 (Left internal mammary
artery to left anterior descending artery, Saphenous vein graft
to posterior descending artery), Mitral valve repair
History of Present Illness:
65 yo F with severe MR referred for cardiac catheterization and
surgical evaluation.
Past Medical History:
Severe Mitral regurgitation
Coronary artery disease
s/p prior RCA stenting c/b ISR x 2, most recently with Cypher
stenting in [**2107-4-24**] for NSTEMI
Hypertension
Dyslipidemia
'[**05**]: post cath large retroperitoneal hematoma extending from the
right groin superiorly to the level of the lower pole of the
right kidney-->required 7 units PRBCs
Non sustained polymorphic VT s/p ICD [**2-24**]
Depression
History of panic attacks/anxiety, prior psychiatric admission
within
the past several years
Gastroesophageal reflux disease
Osteopenia
History of pulmonary nodules, followed by serial imaging
Glucose intolerance
History of H. pylori
Social History:
Retired, worked as hairdresser. Lives at home in [**Location (un) 3146**] with her
husband and 17 [**Name2 (NI) **] son. Pt smoked cigarettes x many years,
reports on-off history. Denies ETOH abuse.
Family History:
Father died at age 50 of an MI and "enlarged heart." Brother
with drug abuse. Mother had depression and panic attacks.
Physical Exam:
Pulse:55 Resp:18 O2 sat:
B/P Right:101/31 Left:106/43
Height: 5'0" Weight:170 lbs.
General: distressed, tearful at times
Skin: Dry [] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur systolic, apical
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 / moves 4 extremities
Pulses:
Femoral Right: drsg C/I/D Left: +
DP Right: + Left: +
PT [**Name (NI) 167**]: Left:
Radial Right: + Left: +
Carotid Bruit Right: (-) Left: (-)
Pertinent Results:
[**4-5**] Echo: The left atrium is moderately dilated. The left
atrium is elongated. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. The right ventricular cavity is mildly dilated with mild
global free wall hypokinesis. LVEF is 40 %, but is likely lower
given the severity of mitral regurgitation. There are simple
atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are moderately
thickened. At least moderate to severe eccebtric ([**1-25**]+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is A2 flail and possible
posterior restriction seen on the mitral valve. There is no
pericardial effusion.
[**2113-4-11**] 05:35AM BLOOD WBC-12.6* RBC-3.15* Hgb-9.8* Hct-29.4*
MCV-93 MCH-31.2 MCHC-33.5 RDW-14.3 Plt Ct-218
[**2113-4-5**] 02:50PM BLOOD WBC-21.6*# RBC-3.04* Hgb-9.6* Hct-28.1*
MCV-93 MCH-31.7 MCHC-34.3 RDW-13.9 Plt Ct-152
[**2113-4-11**] 05:35AM BLOOD Glucose-100 UreaN-25* Creat-0.7 Na-139
K-4.2 Cl-101 HCO3-27 AnGap-15
[**2113-4-6**] 02:54AM BLOOD Glucose-110* UreaN-19 Creat-0.8 Na-138
K-4.4 Cl-109* HCO3-22 AnGap-11
Brief Hospital Course:
Mrs. [**Known lastname 7958**] was a same day admission and on [**4-5**] she was
brought to the operating room where she underwent a coronary
artery bypass graft x 2 and mitral valve repair(Left internal
mammary artery grafted to Left anterior descending
artery/Saphenous vein grafted to Obtuse Marginal/Mitral Valve
Replacement #25mm [**Company 1543**] Mosaic Porcine).Cross Clamp time=
112 minutes/Cardiopulmonary bypass time =139 minutes. Please
see Dr[**Last Name (STitle) **] operative report for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Immediately postoperative a left
chest tube was inserted for a hemothorax. All vasoactive
infusions were weaned to off. She awoke neurologically intact
and was extubated on POD#1. All lines and drains were
discontinued in a timely fashion. Beta-blocker was optimized.
Due to Mrs.[**Doctor First Name 111028**] psychiatric history, postoperatively she
was often uncooperative and requiring very close monitoring. She
therefore remained in the CVICU until POD# 5 when she was more
appropriate/cooperative and it was deemed safe to transfer her
to the stepdown unit for further monitoring. The remainder of
her postoperative course was essentially uncomplicated. She
continued to progress and on POD #6 Dr. [**Last Name (STitle) **] cleared her for
discharge to rehab for further strength, endurance, and increase
in daily activities. All follow up appointments were advised.
Medications on Admission:
Benzonatate 100mg one capsule three times a day prn
Celexa 20mg one tablet three times a day
Plavix 75mg daily every morning
Lamictal 25mg one tablet every morning, two tablets every
evening
Lisinopril 10mg daily every morning
Lorazepam 1mg four times a day prn
Metoprolol Tartrate 50mg twice a day
Nitroglycerin 0.3mg SL as needed
Omeprazole 20mg daily every morning
Evista 60mg daily every morning
Simvastatin 20mg daily every evening
Triamterene-HCTZ 75-50mg one tablet daily every morning
Aspirin 325mg daily every morning
Discharge Medications:
1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
2. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/^temp.
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes/sob.
16. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
17. Citalopram 20 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
18. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
19. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
20. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
21. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
22. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
Severe Mitral regurgitation
Coronary artery disease
s/p prior RCA stenting c/b ISR x 2, most recently with Cypher
stenting in [**2107-4-24**] for NSTEMI
Hypertension
Dyslipidemia
'[**05**]: post cath large retroperitoneal hematoma extending from the
right groin superiorly to the level of the lower pole of the
right kidney-->required 7 units PRBCs
Non sustained polymorphic VT s/p ICD [**2-24**]
Depression
History of panic attacks/anxiety, prior psychiatric admission
within
the past several years
Gastroesophageal reflux disease
Osteopenia
History of pulmonary nodules, followed by serial imaging
Glucose intolerance
History of H. pylori
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incision dry
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks, please call for appointment #
[**Telephone/Fax (1) **]
Dr. [**Last Name (STitle) 12167**] in [**12-27**] weeks
Dr. [**Last Name (STitle) 410**] in [**11-25**] weeks
Completed by:[**2113-4-11**]
|
[
"428.0",
"530.81",
"414.01",
"V45.02",
"428.23",
"511.89",
"424.0",
"998.11",
"401.9",
"413.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"35.23",
"34.04",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7998, 8063
|
3793, 5285
|
309, 493
|
8748, 8754
|
2336, 3770
|
9067, 9305
|
1505, 1625
|
5862, 7975
|
8084, 8727
|
5311, 5839
|
8778, 9044
|
1640, 2317
|
250, 271
|
521, 608
|
630, 1273
|
1289, 1489
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,443
| 153,160
|
16994
|
Discharge summary
|
report
|
Admission Date: [**2153-5-17**] Discharge Date: [**2153-5-28**]
Date of Birth: [**2081-12-22**] Sex: F
Service: O-Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old right-
handed woman who had an episode of loss of consciousness at a
restaurant. The patient was noted to have a probable generalized
tonic-clonic seizure. The patient was taken to an outside
hospital, where she was intubated and loaded with Dilantin. The
patient underwent a head CT scan which disclosed a large left
frontoparietal subdural hematoma with mass effect and midline
shift.
The patient was transferred to [**Hospital1 188**], where she underwent emergent left craniotomy and
evacuation. The patient was found to have subdural mass.
Pathology found the mass to be consistent with central nervous
system lymphoma.
On [**2153-5-23**], the patient underwent a bone marrow biopsy. The
biopsy was negative for lymphoma. Postoperatively, the patient
was noted to have ST segment depressions in V3 through V6 and
troponin elevated to 1.4. The patient was also noted to have
electrocardiographic changes which were thought to be related to
rate related ST segment depression with digoxin effect.
The patient was seen by cardiology and her digoxin was
discontinued. The patient was started on a beta blocker and an
echocardiogram was done. The echocardiogram disclosed a normal
left ventricular ejection fraction, 1 to 2+ mitral regurgitation
and 3+ tricuspid regurgitation. The patient was transferred to
the oncology service for initiation of high-dose methotrexate.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Atrial fibrillation.
3. Asthma.
ALLERGIES: Sulfa drugs.
MEDICATIONS ON ADMISSION: Aspirin and digoxin; on transfer,
the patient was on Decadron 4 mg q.d., lansoprazole 15 mg
q.d., Dilantin 100 mg t.i.d., Lopressor 25 mg b.i.d.,
salmeterol one to two puffs b.i.d., regular insulin sliding
scale, albuterol inhaler p.r.n.
FAMILY HISTORY: The patient has a second cousin with Wilson's
disease and a sister with breast cancer.
SOCIAL HISTORY: The patient does not use tobacco or alcohol.
PHYSICAL EXAMINATION: On physical examination, the patient was a
pleasant female lying in bed in no acute distress. Vital signs:
Temperature 100.4, blood pressure 120/60, heart rate 80,
respiratory rate 20. Head, eyes, ears, nose and throat: Left
craniotomy scar, moist mucous membranes, oropharynx clear, pupils
equal, round, and reactive to light and accommodation,
extraocular movements intact. Neck: Supple, no jugular venous
distention. Cardiovascular: Irregularly irregular, S1 and S2, no
murmur, rub or gallop, II/VI systolic ejection murmur at the apex
radiating to the axilla. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, nontender, nondistended, positive
bowel sounds. Extremities: No cyanosis, clubbing or edema.
Neurologic examination: Alert and oriented times 3, cranial
nerves II through XII intact, exam otherwise nonfocal.
LABORATORY DATA: On transfer, white blood cell count was 17,
hematocrit 30.6, platelet count 190,000, BUN 11, and creatinine
0.6.
RADIOLOGIC DATA: MRI from [**2153-5-18**] disclosed an enhancing
left frontal extra-axial mass with mass effect, intracerebral
edema in the left frontal lobe. CT scan of the torso from [**2153-5-21**] showed no evidence of lymphadenopathy or masses within
the chest, abdomen or pelvis. Echocardiogram from [**2153-5-21**]
showed a left ventricular ejection fraction of 55%, mild
dilatation of the left and right atria, 1 to 2+ mitral
regurgitation, 3+ tricuspid regurgitation, no pericardial
effusions.
HOSPITAL COURSE: Events while on the neurosurgical service
were reviewed above. Hospital course while on the oncology
service will be reviewed below.
(1) Oncology: The patient underwent initiation of chemotherapy
with high-dose methotrexate. She underwent a lumbar puncture to
evaluate for the possibility of carcinomatous meningitis. The
patient was continued on steroids.
(2) Seizure prophylaxis: The patient was continued on Dilantin
and was maintained on seizure precautions.
(3) Atrial fibrillation: The patient was continued on a beta
blocker for rate control. Anticoagulation was held given her
recent neurosurgery.
(4) Asthma: The patient was continued on her inhalers.
(5) Gastrointestinal: The patient was continued on lansoprazole
and a bowel regimen.
(6) Endocrine: The patient was maintained on a regular insulin
sliding scale.
(7) Renal: The patient was well hydrated during the
administration of methotrexate due to the fact that methotrexate
can precipitate in renal tubules. Urine pH and methotrexate
levels were monitored.
(8) Skin: The patient was noted to have zoster neuralgia.
She was given Capsacin cream.
DISCHARGE CONDITION: Good.
DISPOSITION: To home.
FOLLOW-UP PLANS: The patient was instructed to follow up with
neurosurgery for placement of an Ommaya shunt so that she may
undergo intrathecal chemotherapy. We will also follow up
cerebrospinal fluid cytology. The patient is to follow up with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
DISCHARGE MEDICATIONS:
Capsacin cream.
Salmeterol inhaler 2 puffs b.i.d.
Lopressor 25 mg p.o.b.i.d.
Dilantin 100 mg p.o.t.i.d.
Decadron 4 mg p.o.b.i.d.
[**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**MD Number(1) 748**]
Dictated By:[**Numeric Identifier 47805**]
MEDQUIST36
D: [**2153-8-13**] 02:49
T: [**2153-8-13**] 14:59
JOB#: [**Job Number 47806**]
|
[
"518.81",
"493.90",
"432.1",
"202.81",
"438.89",
"427.31",
"458.2",
"401.9",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"03.31",
"96.71",
"99.25",
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
4802, 4833
|
1971, 2059
|
5178, 5579
|
1715, 1954
|
3643, 4780
|
2145, 2869
|
4851, 5155
|
169, 1584
|
2894, 3625
|
1606, 1688
|
2076, 2122
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,105
| 125,108
|
45952
|
Discharge summary
|
report
|
Admission Date: [**2195-9-12**] Discharge Date: [**2195-9-26**]
Date of Birth: [**2132-11-18**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nifedipine / Premarin / Morphine / Crestor /
Atorvastatin / Codeine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Failure to Thrive
Major Surgical or Invasive Procedure:
Echocardiogram (TEE, TTE)
MRI/MRA Head
CT Chest
CT Head, Sinus, Orbits
PICC
Carotid Evaluation
History of Present Illness:
62 year old woman with history of DM II, CAD s/p stent and MI,
HTN, hypercholesterolemia, prior R MCA infarct with residual
blindness, who was recently admitted to [**Hospital1 18**] from [**9-2**] to [**9-10**]
after she presented to the ED with fall and coffee ground
emesis. She was found to be in DKA felt to be possibly due to
UTI with pansensitive E. Coli, for which she was to complete 7d
course of cipro. She also developed UGIB and was found to have
candidal esophagitis on EGD and was started on fluconazole
treatment. She also had ST elevations in inferior leads on that
admission but ruled out for MI with enzymes. She was discharged
home on [**9-10**] (lives alone). Two days later, on [**9-12**] VNA found
her disheveled in bed, not having eaten for 2 days, concern that
apartment may have been broken into. Per notes, she normally is
able to pivot from bed to wheelchair, which was next to her bed,
but this time felt too weak and fatigued to do so, and also
couldn't see where her chair or phone was. In ER, FSBG 242, U/A
w/ 1000 glu, tr ketones, no acidosis/AG by chem 7. She was
re-admitted to the medicine service for further workup of
failure to thrive, safety at home.
On this admission, she said that her vision was blurry but
apparently
had this complaint before. Then she developed of a headache,
thought to be migraine. She had a head CT on [**9-13**] that revealed
new hypodensity in the right parieto-occipital region. Neurology
was consulted and an MRI showed multiple bilateral occipital
infarct. The work up for embolic source was initiated (carotid
US pending, TEE was recommended).
She was doing well on the floor, satting high 90's on RA - 2L NC
until 1am [**2195-9-16**]. Vitals at MN revealed T 98.9; 140/70; 75;
18; 93% on 2L. Shortly thereafter, the patient complained of
medications and when she returned about 15 minutes later, she
found the patient in respiratory distress. O2 sat 62% on RA. The
patient was placed on 5L NC and given Albuterol nebulizer for
audible wheezing. Then placed on 100% NRB (satting 90% on NRB;
ABG 7.36/58/60; lactate 1.0 on a NRB). Received Lasix 40 mg IV
once with good response. EKG done and showed no ischemic
changes. CXR showed diffuse bilateral pulmonary edema (new from
[**2195-9-13**]). In the [**Hospital Unit Name 153**], she was diuresed successfully. She had
a repeat MRI/MRA. Neuro continued to follow for her posterior
embolic strokes and recommend avoiding hypo/hypertension, good
glycemic control. She was also ruled out for MI with CEs (neg
CKs, flat tnts). TEE ruled out vegetation/other abnormality or
embolic source.
Past Medical History:
HTN
DMII
Hyperlipidemia
h/o CVA w/ residual L sided hemiparesis
CAD- w/ stent '[**86**] and '[**89**]
Asthma
Rheumatic fever
Femoral Bypass - [**1-15**] complication of most recent cath
Asthma - last hospitalization mult years ago, uses rescue
albuterol inhaler 1-2 times per week
migraine headaches - tx with vicodin or tylenol
Breast Cancer - node negative (surgery only, no chemo, no rad)
Degenerative Disk Disease
Osteoarthritis
Osteoporosis
GERD
Social History:
lives alone at home [**Location (un) 6409**]; wheelchair bound s/p CVA; no
h/o ETOH or tobacco use
Family History:
non-contributory
Physical Exam:
98.7, 150/100, 98, 22, 99% RA
Blind, decreased L zygoma swelling, - fluctuance
MMM
RRR, S1/S2
Soft, NT/ND, +BS
bibasilar crackles (less than prior)
warm, - CCE
alert
Pertinent Results:
[**2195-9-26**] 05:48AM BLOOD WBC-5.9 RBC-3.73* Hgb-10.4* Hct-31.6*
MCV-85 MCH-27.9 MCHC-32.9 RDW-14.4 Plt Ct-314
[**2195-9-26**] 05:48AM BLOOD PT-26.7* INR(PT)-2.7*
[**2195-9-26**] 05:48AM BLOOD UreaN-20 Creat-1.0 Na-143 K-4.0
[**2195-9-25**] 04:17AM BLOOD Glucose-89 UreaN-19 Creat-0.9 Na-147*
K-3.7 Cl-110* HCO3-30 AnGap-11
[**2195-9-25**] 04:17AM BLOOD TotBili-0.2
[**2195-9-15**] 02:39PM BLOOD CK(CPK)-56
[**2195-9-15**] 03:24AM BLOOD ALT-22 AST-27 CK(CPK)-68
[**2195-9-15**] 02:39PM BLOOD CK-MB-1 cTropnT-0.03*
[**2195-9-26**] 05:48AM BLOOD Phos-3.9 Mg-2.3
[**2195-9-25**] 04:17AM BLOOD Hapto-194
[**2195-9-17**] 07:20AM BLOOD Folate-9.3
[**2195-9-14**] 12:40PM BLOOD calTIBC-259* VitB12-477 Ferritn-566*
TRF-199*
CT SINUS/ORBIT: IMPRESSION:
1. Normal-appearing orbits bilaterally, without periorbital
edema, soft tissue stranding, or collection.
2. Stable near complete opacification of the left maxillary
sinus, with hyperdense and minimally enhancing material. While
these could represent chronic inspissated secretions, fungal
sinusitis cannot be excluded, and clinical correlation is
requested.
3. Bilateral occipital lobe hypodensities, unchanged.
4. Right thyroid nodule.
TEE: Conclusions:
1. No spontaneous echo contrast or thrombus is seen in the body
of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D,
color Doppler or saline contrast with maneuvers.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed. Inferior hypokinesis is
present.
3. The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen.
4. There is a small pericardial effusion.
5. No cardiac source of embolism seen.
6. Compared to the previous study of [**2195-9-22**], there is no
significant
change.
CT HEAD: IMPRESSION:
1) No intracranial hemorrhage. Stable multiple low-density
lesions within both parieto-occipital lobes, are stable from the
prior examination but new from the examination of [**2195-9-6**]. Further evaluation with MRI should be performed.
2) Chronic sinusitis of the left maxillary sinus versus fungal
sinusitis.
ECHO (TTE) Conclusions:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the
inferior wall. The remaining segments contract well. Right
ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated.
The aortic valve leaflets appear structurally normal with good
leaflet
excursion. There is no aortic valve stenosis. Trace aortic
regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral
valve prolapse. Mild to moderate ([**12-15**]+) mitral regurgitation is
seen. There is
mild pulmonary artery systolic hypertension. There is a small
pericardial
effusion. There are bilateral pleural effusions
MRA BRAIN: IMPRESSION:
Acute infarcts in bilateral PCA distribution.
Filling defects in bilateral PCA, left MCA, likely due to
embolic phenomena. These findings were discussed with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] by Dr. [**Last Name (STitle) **] on [**2195-9-17**] at 5:41 p.m.
MRI BRAIN: IMPRESSION: Multiple T2 hyperintense areas of slow
diffusion involving both cerebral hemispheres, likely within the
PCA distribution, consistent with embolic infarcts. Further
evaluation with MRA of the head and neck is recommended.
CAROTID DUPLEX: FINDINGS: Duplex evaluation was performed of
both carotid arteries. Minimal plaques identified.
On the right, peak systolic velocities are 74, 63, 80 in the
ICA, CCA, and ECA respectively. This is consistent with no
stenosis.
On the left, peak systolic velocities are 87, 73, 76 in the ICA,
CCA, and ECA respectively. This is consistent with no stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: No evidence of stenosis in either carotid artery.
Brief Hospital Course:
Stroke workup, including TEE, TTE (Bubble), carotid, MRA were
all negative for source of embolus.
Anemia was treated with transfusions with good response.
Brief periorbital edema was concerning for mucor, but resolved
spontaneously with negative CT imaging.
Pt had multiple episodes of hypoxia due to fluid overload, which
were treated with lasix IV with good response. Diuresis post
transfusion and all fluid containing medications was performed
with good result.
Insulin regimen was titrated by the [**Last Name (un) **] DM team.
Social work is critical, as patient's apartment was robbed while
she was in it, and was not a safe environment.
BP Control achieved to manage hypertension, with goal in the
130-145 range as recent acute CVA, per neurology with
hydralazine and lisinopril.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed for SOB, wheeze.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. Budesonide 0.25 mg/2 mL Solution for Nebulization Sig: Two
(2) ML Inhalation [**Hospital1 **] (2 times a day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Colesevelam 625 mg Tablet Sig: Three (3) Tablet PO bid ().
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-15**] Sprays Nasal
TID (3 times a day) as needed.
12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Ten
(10) ML Intravenous DAILY (Daily) as needed.
16. Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection Q
SHIFT: PICC.
17. Coreg 3.125 mg Tablet Sig: One (1) Tablet PO twice a day.
18. Lantus 100 unit/mL Solution Sig: Twenty Two (22) Units
Subcutaneous at bedtime.
19. RISS
See Enclosed RISS Sheet
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
CVA with residual blindness
CHF
Diabetes Mellitus
Hypertension
[**Female First Name (un) 564**] Esophagitis
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital for hypoxia, dyspnea if failure after
lasix
Continue on low salt diet, avoid drinking large quantities of
water
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2195-11-18**] 1:00
Provider: [**Name10 (NameIs) **] PROCEDURE Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2195-11-18**]
1:00
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 4283**] [**Last Name (NamePattern1) 10803**] [**Telephone/Fax (1) 250**] Call to schedule
appointment within 2 weeks
|
[
"276.51",
"438.20",
"357.2",
"428.40",
"250.80",
"V58.67",
"438.89",
"493.90",
"368.46",
"784.0",
"112.84",
"377.75",
"285.1",
"401.9",
"518.81",
"783.7",
"250.60",
"434.91",
"414.01",
"428.0",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"93.90",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10548, 10618
|
8140, 8933
|
357, 453
|
10769, 10775
|
3918, 5806
|
10959, 11376
|
3698, 3716
|
8956, 10525
|
10639, 10748
|
10799, 10936
|
3731, 3899
|
300, 319
|
481, 3091
|
5815, 8117
|
3113, 3565
|
3581, 3682
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,467
| 146,357
|
18391
|
Discharge summary
|
report
|
Admission Date: [**2134-11-24**] Discharge Date: [**2134-12-1**]
Date of Birth: [**2064-4-16**] Sex: M
Service: CARDIOTHORACIC SERVICE
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
gentleman who is status post colonic resection that developed
ST changes postoperatively. He ruled in for a myocardial
infarction and was transferred to [**Hospital6 649**] for cardiac catheterization which occurred on
[**2134-10-18**].
Catheterization report at that time showed three-vessel
disease with preserved ejection fraction. Please see
catheterization report for full details.
Summary of the catheterization showed serial 80% left
anterior descending lesion, subtotal left circumflex, and
right coronary artery with diffuse disease.
PAST MEDICAL HISTORY: Diabetes mellitus type 2. Colonic
carcinoma status post colonic resection.
MEDICATIONS ON ADMISSION: Glipizide 10 mg b.i.d., Metformin
500 mg t.i.d., Lopressor 50 mg p.o. b.i.d.
ALLERGIES: PENICILLIN.
LABORATORY DATA: On cardiac catheterization white count was
12.6, hematocrit 37, platelet count 275; sodium 129,
potassium 3.6, chloride 95, CO2 19, BUN 10; creatinine 0.9,
glucose 252, CK 403, MB 17.6, troponin I 8.8.
Electrocardiogram was sinus rhythm at a rate of 90 with a
left bundle branch block, Q-wave in lead [**Last Name (LF) 1105**], [**First Name3 (LF) **] depressions
in lead II, as well as V2-6.
PHYSICAL EXAMINATION: Vital signs: Height 5 ft 11 in,
weight 206 lbs. Heart rate 84, blood pressure 102/63,
respirations 24, oxygen saturation 100% on room air.
General: The patient was in no acute distress.
Neurological: He was alert and oriented times three. He
moved all extremities. Nonfocal exam. HEENT: Pupils equal,
round and reactive to light. Extraocular movements intact.
Anicteric, noninjected. Moist mucous membranes. Neck:
Supple. No lymphadenopathy. No thyromegaly. No jugular
venous distention. No bruits. Respiratory: Clear to
auscultation bilaterally. Cardiovascular: Regular, rate and
rhythm. S1 and S2. No murmur. Abdomen: Soft with a
healing midline scar with staples that were intact. No
erythema or drainage. Extremities: Warm and well perfused
with no clubbing, cyanosis, or edema. Pulses: Carotid 2+
bilaterally with no bruits. Femoral on the right at calf
site not palpable, on left was 2+. Radial 1+ bilaterally.
Dorsalis pedis and posterior tibial unpalpable bilaterally.
HOSPITAL COURSE: The patient was discharged to home
following cardiac catheterization. He returned as a
postoperative admission on [**2134-11-24**], at which time he
was admitted directly to the Operating Room for coronary
artery bypass grafting. Please see the operative report for
full details.
In summary the patient had a coronary artery bypass grafting
times four with LIMA to the left anterior descending,
saphenous vein graft to OM, saphenous vein graft to PL, and
saphenous vein graft to the posterior descending artery. The
patient tolerated the procedure well and was transferred from
the Operating Room to the Cardiothoracic Intensive Care Unit.
The patient did well in the immediate postoperative period.
His anesthesia was reversed. He was weaned from the
ventilator and successfully extubated. He remained
hemodynamically stable throughout the day and night of his
operation.
On the following morning, he remained on a minimal amount of
Neo-Synephrine to maintain an adequate blood pressure. Other
than that, the patient remained hemodynamically stable. His
chest tubes were left in on postoperative day #1 because of a
fair amount of drainage.
By postoperative day #2, the patient had weaned off from
Neo-Synephrine. His preoperative medications were restarted.
His chest tubes were removed. He was started on Lasix and
Lopressor, and he was transferred to the floor for continued
postoperative care and cardiac rehabilitation.
Over the next several days, the patient had an uneventful
postoperative course. With the assistance of the nursing
staff and Physical Therapy, his activity level was increased.
On postoperative day #7, it was decided that the patient was
stable and ready to be discharged to home.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature
99.2??????, heart rate 88, sinus rhythm, blood pressure 110/45,
respirations 18, oxygen saturation 95% on room air. Weight
preoperatively 94 kg, discharge 90.4 kg. General: The
patient was alert and oriented times three. He moved all
extremities and followed commands. Respiratory: Clear to
auscultation bilaterally. Cardiovascular: Regular, rate and
rhythm. S1 and S2. No murmur. Chest: Sternum stable.
Incision with staples, open to air, clean and dry. Abdomen:
Soft, nontender, nondistended. Normoactive bowel sounds.
Extremities: Warm and well perfused. He had 1+ edema
bilaterally. Left leg saphenous vein graft site with
Steri-Strips, open to air, clean and dry.
DISCHARGE LABORATORY DATA: White count 6.3, hematocrit 23.4,
platelet count 354; potassium 3.9, BUN 13, creatinine 0.8,
magnesium 2.0.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS: Metoprolol 50 mg b.i.d., Lasix 20 mg
q.d. x 10 days, Potassium Chloride 20 mEq q.d. x 10 days,
Aspirin 325 mg q.d., Glipizide 10 mg b.i.d., Metformin 500 mg
t.i.d., Niferex 150 mg q.d., Colace 100 mg q.d., Percocet
5/325 [**1-21**] q.4 hours p.r.n.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting times four with LIMA to the left anterior
descending, saphenous vein graft to the obtuse marginal,
saphenous vein graft to posterior descending artery, and
saphenous vein graft to PL.
2. Diabetes mellitus.
3. Colonic carcinoma status post colonic resection.
DISCHARGE STATUS: The patient is to be discharged home with
visiting nurse.
FOLLOW-UP: He is to have follow-up with Dr. [**Last Name (STitle) **] in one
month. Follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3613**]
[**Last Name (NamePattern1) 45877**] in [**3-23**] weeks. The patient is also to have
follow-up with Dr. [**Last Name (STitle) **] of the [**Hospital **] Clinic on [**12-13**]
for diabetes management.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Doctor Last Name 50644**]
MEDQUIST36
D: [**2134-12-1**] 14:04
T: [**2134-12-1**] 14:06
JOB#: [**Job Number 50645**]
|
[
"250.00",
"414.01",
"V10.05",
"410.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5116, 5366
|
5387, 6473
|
889, 1405
|
2454, 4187
|
4210, 5060
|
185, 762
|
785, 862
|
5085, 5092
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,584
| 151,740
|
7017
|
Discharge summary
|
report
|
Admission Date: [**2167-6-15**] Discharge Date: [**2167-7-23**]
Date of Birth: [**2129-9-29**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Bactrim / Compazine / Augmentin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
"my legs are swollen" x 2 weeks.
Major Surgical or Invasive Procedure:
Open Splenectomy [**2167-7-14**]
History of Present Illness:
37M with h/o HIV/AIDS (last CD4 12, VL 7000) with chronic
medical issues related to AIDS including diarrhea, sinusitis,
pancyotpenia, chronic fevers that are unchanged. Essentially, Mr
[**Known lastname 26240**] has experienced (chronic) BLE edema that has progressed
to a point where he was referred for inpatient management.
Recent w/u in [**Month (only) 116**] included Echo and LENIs that were
unremarkable; he was discharged on lasix to control anasarca. He
states that lasix is not as effective as it used to be (160
Qam and 80 Qpm). Pt relates that his ankles and area behind the
knees are sore and making ambulation difficult; this is related
only to this acute event. He states that when he stands, he can
almost feel the fluid rush to his feet. He has no orthopnea,
new SOB, CP, PND. Last echo in [**4-9**] with EF >55%, no diastolic
dysfxn. Received 120 IV lasix on arrival to floor with prompt
diuresis > 700 cc.workup demonstrated no evidence of CHF or
venous occlusion. He was finally d/c to home w/ lasix to
control his anasarca.
Past Medical History:
1. HIV/AIDS: dx [**2154**], last CD4 12, viral load 7000
2. H/O multiple OIs: PCP [**2156**], zoster, [**Female First Name (un) **] esophagitis,
oral leukoplakia, perioral condylomata
3. Chronic sinusitis treated w/ Ketec 60 day course, pt self d/c
abx recently
4. Polyneuropathy
5. Lipodystrophy
6. Pancytopenia: presumably [**1-7**] HIV marrow suppression, BM
biopsy [**2167-5-26**] w/ hypocellularity but no evidence of
microorganisms
7. H/O pneumococcal bacteremia [**5-8**]
8. Chronic LE edema x 3 months: ECHO [**4-9**] w/ EF>55%, no
diastolic dysfxn
9. Chronic diarrhea
10. C diff colitis dx [**4-9**], treated w/ flagyl
Social History:
Smokes, 10 pack-years, now [**2-6**] cigs/wk; no alcohol or
recreational drug use.
Family History:
NC
Physical Exam:
VS T 99.9, BP 128/66, HR 97, RR 16, O2 sat 97% RA
Gen: chronically ill appearing man, lying flat in bed in NAD
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM and no thrush,
evident lipodystrophy, no JVD, no LAD, neck supple
CV: reg s1/s2, no s3/s4/m/r
Pulm: CTA B, no wheezes or crackles
Abd: scaphoid, +BS, soft, NT, ND
Ext: warm, palpable DP B, 1+ pitting edema to knees B, venous
stasis changes over ankles B w/ no tenderness, no calf
tenderness
Neuro: a/o x 3, CN 2-12 intact, strength 5/5 throughout UE/LE B
Pertinent Results:
[**2167-6-14**] 10:30PM WBC-1.8* RBC-2.52* HGB-9.2* HCT-25.9*
MCV-103*# MCH-36.3* MCHC-35.4* RDW-21.5*
[**2167-6-14**] 10:30PM PLT COUNT-25*
[**2167-6-14**] 10:30PM GRAN CT-1400*
[**2167-6-14**] 10:30PM GLUCOSE-98 UREA N-20 CREAT-0.4* SODIUM-138
POTASSIUM-2.7* CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
[**2167-6-14**] 10:30PM ALT(SGPT)-10 AST(SGOT)-53* ALK PHOS-296* TOT
BILI-1.4
[**2167-6-14**] 10:30PM ALBUMIN-3.1* CALCIUM-8.4 PHOSPHATE-3.2
MAGNESIUM-1.8
[**2167-6-14**] 10:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2167-6-14**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2167-6-14**] 10:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2167-6-14**] 10:30PM URINE HYALINE-[**2-7**]*
CXR: prominent interstitial markings B, stable from prior
films; no focal opacities, no pleural effusions, no PTX
EKG: NSR @ 93 bpm, nl axis, nl intervals, no ST changes
Brief Hospital Course:
Mr. [**Known lastname 26240**] is a gentleman who expired on the surgical service
on [**2167-7-24**] of respiratory failure secondary to acute renal
failure and complications from advanced AIDS status-post open
splenectomy on [**2167-7-14**]. He was initially on the medical service
prior to his surgery. A brief summary of his hospital course is
follows:
Mr [**Known lastname 26240**] was admitted on [**2167-6-15**] for inpatient management of
his anasarca, chronic diarrhea, and chronic pancytopenia.
With regards to his HIV, his last CD4 12, viral load 7000.
Treated w/ HAART, home meds continued (abacavir, lamivudine,
zidovudine, enfuvirtide, ritonavir, dapsone for pcp [**Name9 (PRE) **],
famciclovir, fluconazole).
With regards to his anasarca, this was postulated to be
secondary to low oncotic pressure secondary to chronic
pancytopenia as well as lymphatic insufficiency. Albumin level
was checked several times, however, and was > 3, leading us to
consider a multi-factorial etiology for the edema. CT abdomen
was done to assess for retroperitoneal lymphadenopathy as a
source of venous occlusion, but it was negative. Echo on this
hospitalization revealed no significant change from the previous
study in [**4-9**], with EF >55%. Edema was managed initially with
high-dose lasix, and then with metolazone. Diuretics caused
only marginal improvement in LE edema, and caused the patient to
be hypovolemic and hyponatremic. Diuretics were discontinued
and patient was placed in compression stockings.
With regards to his diarrhea, the patient was found to have C.
diff positive stools and was started on a course of Flagyl for
treatment.
From an infectious disease standpoint, intermittent and chronic
low-grade fevers gave way to frank fever spikes on day 3 of
hospitalization, along with development of R ear pain and a
coincidentally positive sputum for AFB that was taken as an
outpatient. Cultures of nose and ear revealed GPC in pairs from
the sinus and pseudomonas from the ear. MRI ordered to assess
extent of pseudomonal infection (see below) indicated diffuse
(R>L) meningeal enhancement c/w menigitis. He was maintained on
several courses of empiric antibiotics, as well as IV acyclovir
possible HSV lesion in his ear. IV acyclovir course completed
prior to viral culture results. He developed acute R ear pain
with serosanguinous drainage early in this hospitalization, and
ENT was promptly consulted for input. ENT input regarding
mastoiditis indicates that no surgical intervention required
even if pt were appropriate candidate. He had one sputum
positive for AFB on [**2167-6-9**]. He was placed on resppiratory
precautions until 3 sets of negative sputums were obtained (no
sputum samples from this hospitalization have been positive).
He was treated empiracally for presumed MAC.
With regards this his pancytpoenia , this was postulated to be
initially to be secondary to his HIV marrow suppression. Recent
BM biopsy from [**5-10**] showed hypocellularity w/ no marrow
infection, though cultures had never been sent. Patient
experienced steady decline in cellular counts which prompted
reevaluation of initial hypothesis and data. Marrow showed viral
inclusion bodies (though there was no evidence of viral
organsims), and therefore, serologies for CMV and Parvovirus B19
were sent. He was treated with IVIG 1g/kg/day to treat possible
parvovirus and intiated on Procrit, 40,000 u/week. Surgery was
consulted and due to his severe thrombocytopenia, the decision
was made to procede with salvage splenectomy.
He underwent splenectomy via open technique on [**2167-7-14**] (please
see the operative note of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for full details).
Post-operatively, he initially did well and was extubated and
transferred out of the ICU by post-op day 3 and started on a
clear liquid diet. However, he began to have oliguric renal
failure and was transferred back to the ICU for close
monitoring. Within a day his renal failure became anuric and he
presented with an encephalopathic picture. Renal consultation
assessed the patient's renal failure as multifactorial in
nature, including HIV nephropathy, renal failure secondary to
amicar treatment for his MAC, and perioperative fluid changes.
He was emergently intubated for mental status changes
comprimising respiration. He was dialyzed for 4 consecutive days
starting on [**2167-7-19**], however there was marginal improvement in
his renal function. While is platelet counts did not drop
post-splenectomy, he continued to present with clinical bleeding
from his incision sites and it was presumed that his platelets
were poorly functional secondary to uremia. Hematology
recommended DDAVP and FFP which were given, as well as platelet
transfusions. On [**2167-7-24**] a family meeting was held and the
decision was made by the [**Hospital 228**] health care proxy to make him
comfort measures only. He was extubated and expired shortly
afterwards. His family members were present at his bedside.
Medications on Admission:
1. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
3. Famciclovir 250mg [**Hospital1 **] (2 times a day).
5. Abacavir-Lamivudine-Zidovudine 300-150-300 mg Tablet Sig: One
(1) Tablet PO BID (2 times a day).
6. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [**Hospital1 **] (2
times a day).
7. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Furosemide 160mg PO QAM, 80mg PO QPM
Discharge Disposition:
Expired
Discharge Diagnosis:
AIDS-related pancytopenia
Anuric Renal Failure
MAC
Sinusitis
Respiratory Failure
Mental Status Changes
Discharge Condition:
Expired
Completed by:[**2167-7-25**]
|
[
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icd9cm
|
[
[
[]
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[
"99.04",
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icd9pcs
|
[
[
[]
]
] |
9487, 9496
|
3791, 8833
|
337, 371
|
9642, 9680
|
2778, 3768
|
2223, 2227
|
9517, 9621
|
8859, 9464
|
2242, 2759
|
265, 299
|
399, 1452
|
1474, 2107
|
2123, 2207
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,133
| 156,033
|
48151
|
Discharge summary
|
report
|
Admission Date: [**2164-4-24**] Discharge Date: [**2164-4-28**]
Date of Birth: [**2108-12-6**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
HD
History of Present Illness:
This is a 55yo F w/hx of ESRD on HD (TTS), failed renal
transplant on prednisone, dCM EF 25%, Dm1 on lantus who presents
with hypoglycemia and associated encephalopathy. PEr patient
since leaving the hospital a week ago she has not felt her
normal self. She has been very fatigued (worse than normal) and
has had occasional episodes of nausea that resolve with sugar
free mints. The nausea is not necessarily associated with food,
movement, or medications. She has not been eating her usual
amount but says her appetite is not decreased and she does not
have abdominal pain, nausea, vomiting, bloody stools or black
stools. She reports that last night she was planning on eating
dinner and took her home dose of 3 units of lantus. Her family
then brought home chinese food which she doesnt like. She was
going to order herself something different but ended up falling
asleep and never ate anything.
This morning per the ED physicians her family found her to be
"not herself". Her FSBS at home was 40. Her family gave her some
glucose but per the Ed physicians her family says was not
herself even after taking glucose at home so they brought her to
the ED
.
In the ED, initial VS were: 95.4 59 140/85 18 94% RA. On exam
she appeared slow to respond compared to her usual baseline
according to family. Also c/o chronic discomfort between both
shoulders. A & O x3 but sleepy. Said she was just tired. CXR
revealed recurrence of her pleural effusion (tapped on last
admission).
.
She was admitted for HD given her hyperkalemia and for FSBS
monitoring. She was taken directly from the ED to HD.
.
vs on transfer: 60 141/92 16 96 2lnc.
.
On the floor, patient was receiving dialysis. She noted
continued chronic fatigue and says that although she was able to
work up until her recent admission she has not felt able to go
back since being discharged a week ago. She notes occasional
nausea that is relieved with mints. She denies fever, cough,
chills, abdominal pain, vomiting, diarrhea, constipation. She
does not make urine. She notes a 5kg weight gain and increased
peripheral edema.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest
pain. Denied vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits.
Past Medical History:
(per OMR)
s/p placement of right upper extremity arteriovenous graft
[**2162-10-19**]
-Type 1 DM, since age 20
-Dilated cardiomyopathy, EF 25% by echo [**4-/2164**]
-Hypertension
-ESRD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant- on HD T/T/S
-Hepatitis C, chronic, untreated
-Intracranial right ICA aneurysm, s/p clipping [**2159-5-16**]
-s/p C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**]
-s/p diskectomy at C6-C7 and fusion in [**2157**], with
instrumentation removal and reinsertion on [**2159-9-28**]
-Ulnar nerve impingement bilaterally
-S/p Rotator cuff repair
-s/p release of right carpal tunnel
-GERD
-Asthma as a child
-Sleep apnea, unable tolerate CPAP
-s/p right carpal tunnel release
-s/p rotator cuff repair
-Resting tremor
-h/o Pneumonia
-Anemia
-h/o CMV in [**2155**]
Social History:
Lives at home with her son, [**Name (NI) 101512**] and 4 grandchildren.
Smoked but quit many years ago. Previously drank ETOH socially
now does not drink at all. Was working up until admission [**4-16**].
Family History:
No history of renal or cardiac disease. All of her children and
grandchildren are healthy.
Physical Exam:
Vitals: T:95 (on HD) BP:132/84 P:60 R:20 O2: 100% on 2L NC
General: Alert, oriented X 3, no acute distress but does stop in
the middle of a sentence to catch her breath occasionally
HEENT: Sclera anicteric, [**Month/Year (2) 5674**], oropharynx clear
Neck: supple, JVP 4 cm above the clavicle when she is sitting at
90 degrees
Lungs: Clear to auscultation on left with diminished breath
sounds on the right. No wheezes, rales, or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
soft S3 gallop
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm 2+ pitting edema to knee
Neuro: A+OX3. Able to recite the days of the week backward.
Recalls her entire medical history, her son's cell phone number,
and all of her grandchildren's ages. Gait and strength not
assessed as patient is on HD. PERRL, face symmetric, tongue
midline.
Pertinent Results:
[**2164-4-24**] 10:40AM LACTATE-2.6*
[**2164-4-24**] 10:25AM GLUCOSE-246* UREA N-75* CREAT-6.8*
SODIUM-130* POTASSIUM-6.3* CHLORIDE-93* TOTAL CO2-20* ANION
GAP-23*
[**2164-4-24**] 10:25AM NEUTS-66.0 LYMPHS-24.1 MONOS-5.6 EOS-2.8
BASOS-1.5
[**2164-4-24**] 10:25AM PLT COUNT-300#
[**2164-4-24**] 10:25AM PT-15.5* PTT-27.0 INR(PT)-1.4*
CXR: Recurrence of right-sided pleural effusion (previously
tapped) and stable cardiomegaly.
Brief Hospital Course:
# PEA arrest: Pt had episode of AMS after returning from HD,
with hypotension prior to transfer. Attributed to hypovolemia
[**2-8**] HD. CODE was called and pt received CPR, 1LNS, 1mg Epi with
return of spontaneous circulation. She was transferred to the
MICU. She was unresponsive s/p arrest, and was cooled per
protocol. She was rewarmed per protocol. Shortly after being
rewarmed she went into PEA arrest. She was resuscitated and a
family meeting was held. After careful discussion with the
family she was made CMO. She passed [**Doctor Last Name 8196**] that night with her
family at her side.
Medications on Admission:
Per patient these medications have not changed since her
discharge <1 week ago.
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
3. hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
4. insulin glargine 100 unit/mL Solution Sig: 6 units qam, 3
units qpm . Subcutaneous .
5. insulin lispro 100 unit/mL Solution Sig: sliding scale .
Subcutaneous four times a day.
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. ranitidine HCl 15 mg/mL Syrup Sig: Seventy Five (75) mg PO
DAILY (Daily).
10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
12. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
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"518.81",
"996.81",
"403.91",
"070.70",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"38.93",
"96.71",
"39.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7165, 7174
|
5269, 5870
|
280, 285
|
7226, 7236
|
4807, 5246
|
7293, 7304
|
3773, 3866
|
7124, 7142
|
7195, 7205
|
5896, 7101
|
7260, 7270
|
3881, 4788
|
2418, 2664
|
228, 242
|
313, 2399
|
2686, 3533
|
3549, 3756
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
971
| 176,106
|
2868+55419
|
Discharge summary
|
report+addendum
|
Admission Date: [**2105-11-20**] Discharge Date: [**2105-11-27**]
Date of Birth: [**2030-11-10**] Sex: M
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: This is a 75 year-old male with
a history of multiple myeloma on thalidomide who was found in
the field having generalized tonic clonic seizures for 20
minutes. There was no family to provide history at this
time. He was given 4 mg of Ativan at the scene which broke
his generalized activity. He was still observed to have
bilateral abdominal convulsions and was then given 2 more mg
of Ativan. At this time, around 7:35 A.M. he arrived at the
[**Hospital1 69**] emergency department and
neurology was called. On initial observation he was
unresponsive to verbal and noxious stimuli and was noticed to
rhythmic abdominal contractions. He also had a mild right
eye deviation. He was immediately started on phenytoin and
500 mg was infused over ten minutes. To expedite the
infusion the remaining 500 mg was infused as Cerebryx. After
the Dilantin load his gaze was in primary position and there
were no longer any abdominal contractions. Stat laboratories
and blood cultures were drawn. The patient was started on
ceftriaxone after an initial rectal temperature of 102.5 was
confirmed. Pertinent history from the prior notes: "his
treatment initially included radiation to an L2 plasmacytoma,
as well as a full course of Melphalan and prednisone
completed on [**2104-4-1**]. Since that time he was treated with
pulse dexamethasone for approximately 11 months through the
end of [**8-29**]. His treatments also included Aranesp every two
weeks and Zometa every three weeks. At his last clinic visit
we did change Mr. [**Known lastname 13927**] therapy from pulse dexamethasone to
thalidomide at 100 mg daily. This was due to the fact that
Mr. [**Known lastname **] had been on dexamethasone for almost one year.
Prior to switching therapy a repeat bone marrow biopsy was
done on [**2105-8-4**] which revealed a hypercellular marrow with
involvement of known plasma cell myeloma as well as decreased
iron stores. There was no evidence of dyspoiesis. Mr. [**Known lastname **]
took approximately 19 days of thalidomide at 100 mg daily.
Since the thalidomide was started e was then started on
Ritalin for the side effects of slowness due to the
thalidomide.
PAST MEDICAL HISTORY: B12 deficiency with a peripheral
neuropathy, prostate cancer, PSA was 6.5 in [**7-28**],
conservative treatment was undertaken, peptic ulcer disease,
esophagogastroduodenoscopy consistent with gastritis,
multiple myeloma as above, hypertension and status post
appendectomy.
MEDICATIONS: Iron 325 mg daily, Zoloft 50 mg daily, vitamin
B12 2,000 mcg daily Roxicet p.r.n., folic acid 1 mg daily,
ranitidine 250 mg b.i.d., thalidomide 100 mg q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is widowed but is quite
independent in has activities of daily living and lives with
his family.
PHYSICAL EXAMINATION: Initially the patient was unarousable
and unresponsive to verbal and tactile stimulus. By the time
of discharge the patient was sitting up, alert, awake and
answering questions appropriately following simple commands.
Had no motor deficit, was without pronator drift and
otherwise has intact coordination.
LABORATORY STUDIES: The white count on [**11-26**] was 6.6,
hematocrit 33.3, the hematocrit has ranged from 25.6 to 33
throughout the hospital course. Platelet count 425, INR 1.0.
Urinalysis has been negative On [**11-25**]. However, it was
positive on [**11-21**]. The patient received [**Doctor Last Name **] days of
Bactrim. Cerebrospinal fluid: white count 0, red count 0.
Liver function tests: ALT 9, AST 27, alk phos 66, amylase
78, total bilirubin 0.6, troponin less than .01. Vitamin B12
919. The phenytoin level on [**11-27**] was 16.6. Initial tox
screen was negative. Total protein in the cerebrospinal
fluid 20, glucose 80. Urine cultures were no growth. MRSA
screens were negative. Blood cultures were no growth.
Cerebrospinal fluid gram stain and culture. The gram stain
was negative. The culture was contaminated with coagulase
negative staphylococcus, cryptococcal antigen negative,
fungal culture negative, viral cultures negative. Head CT
showed no hemorrhage, only some atrophy and old infract. MRI
of the head showed evidence of small vessel disease, no acute
infarct or abnormal enhancement. The video swallow on
[**2105-11-25**] showed no evidence of aspiration or penetration.
Cytology of the cerebrospinal fluid was negative for
malignant cells. EEG consistent with severe encephalopathy
or extensive bilateral subcortical disease. Beta activity
likely represents intercurrent medication effects. This can
be seen with benzodiazepines or barbiturates. No evidence of
ongoing seizure at this time.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for seizures. He was initially intubated and his
Dilantin level was titrated up to about 15. He remained
intubated for a couple of days until he self extubated. He
did well after this point and went to the floor. Once on the
floor he did remain somewhat lethargic with phenytoin level
of 20 to 21 as well as urinary tract infection. The urinary
tract infection was treated. He completed a course of three
days of Bactrim. The Dilantin dose was decreased to 250
b.i.d. and 100 t.i.d. to 100 t.i.d. The patient began to be
more alert and on discharge was nearly at his baseline.
However, his family noted that he did seem to be still
somewhat more lethargic than usual. He was discharged to
[**Location 13928**] in good condition on [**2105-11-27**].
His medication are Metoprolol 75 mg p.o. b.i.d., thiamin 100
mg p.o. q.d., vitamin B12 2,000 mcg p.o. q.d., ferrous
sulfate 325 mg p.o. q.d., multivitamin 1 capsule p.o. q.d.,
folic acid 1 mg p.o. q.d., Phenytoin 100 mg p.o. t.i.d.,
flumotidine 20 mg p.o. b.i.d.
The patient will follow up in neurology clinic with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**Last Name (NamePattern1) 10034**]
MEDQUIST36
D: [**2105-11-27**] 13:51
T: [**2105-11-27**] 15:03
JOB#: [**Job Number 13929**]
Name: [**Known lastname 2170**], [**Known firstname **] Unit No: [**Numeric Identifier 2171**]
Admission Date: [**2105-11-20**] Discharge Date: [**2105-11-27**]
Date of Birth: [**2030-11-10**] Sex: M
Service:
ADDENDUM TO HOSPITAL COURSE: It was felt that the patient's
seizures were caused by the combination of Ritalin and
thalidomide. These medications were discontinued and as
stated previously, the patient was started on Phenytoin for
prophylaxis.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 2172**]
Dictated By:[**Last Name (NamePattern1) 866**]
MEDQUIST36
D: [**2105-11-27**] 14:35
T: [**2105-11-28**] 04:39
JOB#: [**Job Number 2173**]
|
[
"203.00",
"E937.8",
"780.39",
"401.9",
"V10.46",
"599.0",
"E939.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"03.31",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6622, 7080
|
3004, 4855
|
174, 2347
|
2370, 2854
|
2871, 2981
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,819
| 135,454
|
6379
|
Discharge summary
|
report
|
Admission Date: [**2116-2-10**] Discharge Date: [**2116-2-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 yo Russian-speaking female with a history of dementia,
stroke, and hypertension was admitted from the emergency
department with respiratory distress and hypotension.
.
Per report from EMS, patient suddenly became unresponsive either
during or shortly after breakfast. Blood pressure decreased to
65/35 with pulse ox 86%. Patient was suctioned with some
improvement in her oxygenation. She was then transferred to the
[**Hospital1 18**] ED for further evaluation. Of note, patient was recently
started on influenza prophylaxis on [**2116-2-5**] with oseltamavir
75mg PO daily.
.
Upon admission to the ED, vital signs were temp 96.8, HR 112,
SBP 70s, RR 36-40, and 78% on NRB. her BP improved to 112/76
with IVF and O2 sat improved to 94% with suctioning and
combivent. Labs were notable for WBC 20 and Cr 1.2, She
received ipratropium nebs, albuterol nebs, methylprednisolone
125mg IV x 1, levofloxacin 1000mg x 1, metronidazole 500mg x 1,
and vancomycin 1g x 1. After discussion with family in the ED,
code status was confirmed as DNR/DNI.
.
Past Medical History:
CVA with residual L arm > leg weakness
HTN
CAD
Osteoarthritis
multiple UTI
Dementia
Rabbit Syndrome (TD)
Pseudoaphakia of both eyes
Macular degeneration
Delusional D/o
Social History:
lives in [**Hospital 100**] Rehab for past 3 years since her stroke. has
daughter with whom she has good relationship
Family History:
non-contributory
Physical Exam:
T 102 / HR 107 / BP 86/45 / RR 26 / Pulse ox 91% on NRB
Gen: NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-27**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
.
Pertinent Results:
[**2116-2-10**]
WBC 20.3 / Hct 47/7 / Plt 391
Na 145 / K 4.6 / Cl 104 / CO2 22 / BUN 47 / Cr 1.2 / BG 265
GFR 42
.
STUDIES:
CXR - [**2116-2-10**] - Vague increased opacities in the lung bases
bilaterally may be related to aspiration. PA and lateral views
would be helpful to further evaluate.
.
ECG - [**2116-2-10**] - sinus tachycardia at ~100 bpm, left axis
deviation
.
Blood & Urine Cx pending
[**2116-2-11**] 01:34AM URINE RBC-3* WBC-14* Bacteri-MANY Yeast-NONE
Epi-3
[**2116-2-11**] 01:34AM URINE Blood-SM Nitrite-POS Protein-300
Glucose-250 Ketone-15 Bilirub-LG Urobiln-1 pH-5.0 Leuks-NEG
[**2116-2-11**] 01:34AM URINE Color-Brown Appear-SlHazy Sp [**Last Name (un) **]->1.030
[**2116-2-11**] 01:34AM URINE Hours-RANDOM UreaN-134 Creat-94 Na<10
.
CT head
IMPRESSION: 1) There is no evidence of significant change in
comparison with the prior examinations.
2) Persistent and unchanged chronic microvascular ischemic
changes involving the subcortical and periventricular white
matter.
3) Stable appearance of old area of ischemia located in the
caudate nuclei and right basal ganglia.
4) Unchanged left temporal bone osteoma.
Brief Hospital Course:
89 yo Russian-speaking female with history stroke, hypertension,
and dementia was admitted with hypoxia and hypotension after
being found unresponsive at her skilled nursing facility. Per
discussion with family, would prefer to avoid any escalation of
care, continue ABx & IVFs, but no new lines, no other aggressive
measures.
.
1. Hypoxia: Etiology appears most likely secondary to either
aspiration pneumonia, aspiration pneumonitis, or pneumonia
secondary to either bacteria or viral etiology. Additional
possibility includes a reactive airway component given
expiratory wheezes heard diffusely on exam. No evidence of fluid
overload otherwise on exam. Additional possibilities include a
possible stroke or hemorrhage. Urine legionella neg & Influenza
DFA Neg.
Pt. demonstrated minimal recovery over ICU stay, no
vocalizations, high O2 requrement, worsening renal function, low
bp reqiring freqent fluid boluses. Was transferred to the
medical [**Hospital1 **], and I had a lengthy discussion of the goals of
care with dtr., who decided that she would want her mother to
get only comfort measueres. This was done, and the pt. died
three days later. She was comfortable, and required only
intermittant, low, doses of sublingual morphine to ensure
comfort.
Medications on Admission:
HOME MEDICATIONS: (from discharge summary from [**10-1**])
1. Venlafaxine 25mg PO bid
2. Galantamine 8mg PO bid
3. Olanzapine 2.5mg PO qhs
4. Nitroglycerin tabs prn chest pain
5. Gabapentin 200mg PO qhs
6. Lisinopril 20mg PO daily
7. Tylenol prn
8. Oseltamavir 75mg PO daily ([**Date range (1) 24645**])
9. Aspirin 81mg PO daily
10.Metformin 500mg PO bid
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"038.9",
"728.89",
"362.50",
"438.89",
"584.9",
"348.30",
"507.0",
"276.2",
"401.9",
"518.81",
"995.92",
"276.3",
"785.52",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5145, 5224
|
3441, 4706
|
270, 276
|
5276, 5286
|
2285, 3418
|
5343, 5354
|
1696, 1714
|
5112, 5122
|
5245, 5255
|
4732, 4732
|
5310, 5320
|
1729, 2266
|
4750, 5089
|
223, 232
|
304, 1352
|
1374, 1544
|
1560, 1680
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,063
| 185,511
|
52962
|
Discharge summary
|
report
|
Admission Date: [**2152-11-3**] Discharge Date: [**2152-11-9**]
Date of Birth: [**2080-7-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
[**Known firstname **] is a pleasant 73-year-old female who is status
post a motor vehicle collision where she was an unrestrained
driver last evening and she is complaining of neck pain and
right
upper extremity pain.
Major Surgical or Invasive Procedure:
C6-7 ACDF
c5-t1 LATERAL MASS SCREW FUSION.
History of Present Illness:
82 year old female sp MVA with Subluxation of C6-7 and humerus
fracture.
Past Medical History:
non-contributory
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
Exam upon discharge:
Patient is A&O x 3.
She is in a hard cervical collar with anterior and posterior
dressings clean, dry, and intact.
Motor: RUE is [**4-10**]. LUE is limited due to the humeral fx but her
grip is [**4-10**].
Bilateral lower extremities are [**4-10**].
Sensation is grossly intact.
No clonus.
Pertinent Results:
CT C-Spine:
1. C6-C7 bilateral interfacetal fracture-dislocation with
anterior
subluxation of C6 on 7.
2. Nondisplaced left C7 transverse process fracture that does
not appear to involve the transverse foramen.
3. Grade I anterolisthesis of C2 on 3 and C3 on 4, [**Last Name (un) 109167**] likely
degenerative in nature.
MRI is recommended to evaluate for cord or ligamentous injury.
Findings were discussed with Dr. [**First Name4 (NamePattern1) 1169**] [**Last Name (NamePattern1) **] at 8:15 p.m. on
[**2152-11-3**].
RT. Humerus X-Ray:
IMPRESSION: Comminuted impacted fracture of the proximal humerus
with
resultant varus angulation.
Brief Hospital Course:
Pt. was taken to the OR on HD# 4 for a C6-7 Anterior cervical
plated fusion with Illiac graft harvest, the second part of the
procedure consisted of a C5-T1 lateral mass screw fusion. On
POD#1 pt. had an episode of hypotension and was placed on Neo
for a brief period of time. Work up revealed a HCT of 20.0, and
the patient was transfused 2 units of PRBCs with an immediate
post transfusion HCT of 28. On POD#2 the crit was 27.4. The
patient did have significant pain that day but her medication
was adjusted and her pain decreased. On POD# her HCT was stable
at 27.6. She was evaluated by PT and OT who recommended rehab.
She was discharged on [**2152-11-9**].
Medications on Admission:
unknown
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Cervical Cubluxation, s/p 360 degree fusion.
Discharge Condition:
Stable
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? You are required to wear your cervical collar for 3 months
.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in 10 days from the date of your
surgery for a wound check.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 6 weeks.
??????You will need a CT-scan of the cervical spine prior to your
appointment, please have the office arrange this exam for you.
Completed by:[**2152-11-9**]
|
[
"805.06",
"812.01",
"E812.0",
"805.07",
"790.01",
"458.9",
"401.9",
"737.10",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"81.02",
"93.41",
"99.04",
"81.62",
"02.94",
"81.03",
"80.51",
"77.79"
] |
icd9pcs
|
[
[
[]
]
] |
3314, 3426
|
1764, 2428
|
491, 536
|
3514, 3523
|
1100, 1741
|
5397, 5819
|
729, 747
|
2486, 3291
|
3447, 3493
|
2454, 2463
|
3547, 5374
|
762, 762
|
232, 453
|
564, 639
|
661, 679
|
695, 713
|
783, 1081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,854
| 129,565
|
30298+57690
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-6-1**] Discharge Date: [**2146-6-8**]
Date of Birth: [**2066-10-19**] Sex: M
Service: MEDICINE
Allergies:
Bactrim DS / Levaquin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation with subsequent extubation
Bronchoscopy
Replacement of 14F nephrostomy cath via loop ileostomy
History of Present Illness:
Mr. [**Known lastname **] is a 79 year old man with ESRD who has not been feeling
well over the last couple of weeks. He had been prescribed
azithromycin as an oupatient. Reportedly, a recent dialysis
session took off more fluid than normal. Patient became
pre-syncopal. He later went to the [**Hospital6 18346**]. A
CXR showed bilateral infiltrates. He started taking ceftriaxone
for presumed pneumonia. He did not significantly improved.
Yesterday he went into AFib after HD. He remembers feeling
weak, pale, and being short of breath. He received IV metoprolol
and his rhythm converted to sinus. EKG showed ST depression in
lateral leads. He received a chest CTA which showed prominent
mucous plugging, complete blockage of R mainstem, collapse of
RLL. He was transferred to [**Hospital1 18**] for further management. He
arrived on a mediccal floor on a NRB. He was then sent to the
ED.
.
In the ED he was tachypneic, working to breathe, and denied any
chest pain. He was not short of breath and not moving any air on
the right. Trop was reportedly up to 1. He had a pH of 7.21 on
VBG. He was placed on Bipap prior to transfer to the floor. Also
of note he has [**Street Address(2) 4793**] elevations in V2 and V3. This was seen by
cardiology and felt possibly related to demand and there would
be no acute intervention. He was given vancomycin and cefepime.
.
On arrival to the MICU, he was able to speak in full sentences
and denied any pain.
Past Medical History:
*bladder cancer s/p neobladder
*prior UTI
*rectal cancer s/p abdominal-pelvic resection c/b pelvic abscess
formation
*right hydronephrosis with stent placement from nephrostomy
through kidney and into pt's ileal conduit
*hypertension
*GERD
*anemia of chronic disease
*CKD stage V, new baseline Cr around 6.6
Social History:
Pt is married and lives w/ wife. Rare EtOH; no tobacco or drugs.
Retired construction worker.
Family History:
Denies family hx of heart disease. Mother died in 60s of breast
cancer, father died in 80s, a brother died at 83 of colon
cancer.
Physical Exam:
Discharge physical exam:
Vitals: T 97.5 BP 134/61 (134-149/61-62) HR 88 RR 20 O2 Sat 97%
on 2L via NC
Weight 74.2kg
General: Patient sitting in bed during HD session with HOB
elevated in NAD
HEENT: EOMI. MMM.
Neck: Supple. No JVD.
CV: Regular rate and rhythm. 2/6 systolic murmur appreciated
throught the precordium
Lungs: Clear to auscultation bilaterally, anteriorly. No
crackles or wheezes appreciated. Nml work of breathing.
Abd: NABS+. Soft. NT/ND. Ileostomy with nephrostomy tube coming
out with blood-tinged present in the bag.
Ext: No pitting edema bilaterally. 2+ DPs.
Skin: Across the back, erythema scattered across the back.
Pertinent Results:
Admission labs:
[**2146-6-1**] 08:30PM BLOOD WBC-7.5 RBC-3.40* Hgb-10.3* Hct-33.1*
MCV-98 MCH-30.3 MCHC-31.0 RDW-14.3 Plt Ct-215
[**2146-6-1**] 08:30PM BLOOD Neuts-75.2* Lymphs-14.7* Monos-8.1
Eos-1.5 Baso-0.4
[**2146-6-1**] 08:30PM BLOOD PT-12.7* PTT-27.2 INR(PT)-1.2*
[**2146-6-1**] 08:30PM BLOOD Glucose-88 UreaN-55* Creat-6.4* Na-133
K-5.0 Cl-92* HCO3-27 AnGap-19
[**2146-6-1**] 08:30PM BLOOD Calcium-8.5 Phos-7.0*# Mg-1.9
Microbiology:
[**2146-6-1**] 8:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending)
[**2146-6-1**] 8:45 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending)
[**2146-6-2**] 12:02 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2146-6-4**]**
GRAM STAIN (Final [**2146-6-2**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2146-6-4**]):
RARE GROWTH Commensal Respiratory Flora.
[**2146-6-2**] 4:52 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2146-6-3**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2146-6-4**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2146-6-3**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2146-6-3**] 3:54 am BLOOD CULTURE Source: Line-CVL RIGHT HAND.
Blood Culture, Routine (Pending):
Cytology:
Bronchial lavage:
NEGATIVE FOR MALIGNANT CELLS.
Abundant neutrophils, scattered macrophages, and bronchial
cells.
Imaging:
Head CT:
FINDINGS: Presence of previous intravenous contrast slightly
limits the evaluation for small intracranial hemorrhage but
there is no large acute hemorrhage, edema, mass effect, or
territorial infarction. The sulci are mildly prominent,
consistent with age-related atrophy. _The visualized paranasal
sinuses, mastoid air cells and middle ear cavities are clear.
No acute skeletal abnormalities.
IMPRESSION: No acute intracranial process.
TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %) secondary to inferior and posterior wall
hypokinesis. The right ventricular free wall thickness is
normal. The right ventricular cavity is dilated with depressed
free wall contractility. The aortic root is mildly dilated at
the sinus level. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area 1.4
cm2). The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2141-7-6**], mild aortic stenosis, moderate left ventricular
contractile dysfunction, moderate pulmonary hypertension, and
significant right ventricular dilatation and hypokinesis are now
present.
Discharge labs:
[**2146-6-8**] 05:58AM BLOOD WBC-11.6* RBC-3.35* Hgb-10.2* Hct-33.2*
MCV-99* MCH-30.5 MCHC-30.8* RDW-14.1 Plt Ct-220
[**2146-6-8**] 05:58AM BLOOD Glucose-94 UreaN-26* Creat-5.0*# Na-136
K-4.7 Cl-97 HCO3-34* AnGap-10
[**2146-6-8**] 05:58AM BLOOD Calcium-8.5 Phos-3.6# Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname **] is a 79 year old man with ESRD on HD
Tues/Thurs/Saturday, HTN, bladder cancer s/p resection and
neobladder c/b multiple UTIs, rectal cancer s/p [**Month (only) **] c/b pelvic
abscesses, right hydronephrosis s/p ureteral stent and
nephrostomy tube placement who presented from OSH with shortness
of breath and transferred to the MICU for further management,
including intubation who is now extubated, found to have
decreased EF with posterior-inferior hypokinesis concerning for
missed cardiac event transferred to Cardiology service for
further management.
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MICU course:
Respiratory failure: Patient was empirically covered with
vancomycin and zosyn. A BAL was done and a large mucus plug was
suctioned. His fever curve trended down. CXR was consistent
with pulmonary edema rather than pneumonia, so he was run 3 L
negative on dialysis with improvement in his vent settings. He
was subequently successfully extubated. Antibiotics were
discontinued.
Systolic Dysfunction: Patient's troponins were elevated on
admission with TTE showing new inferoposterior hypokinesis,
consistent with acute coronary syndrome at some point in the
last several weeks. EF was 35%. He was on aspirin, atorvastatin
80, and metoprolol. ACE-I was initially held given low blood
pressures.
Atrial Fibrillation: Patient had very brief runs of atrial
fibrillation during dialysis the morning after admission.
End Stage Renal Disease: On Tuesday, Thursday, and Saturday
schedule. Patient was run in the unit negative 4 L with
improvement in respiratory function.
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Cardiology Floor course:
# Acute on chronic systolic heart failure with evidence of focal
hypokinesis: TTE showing EF of 35% with evidence of inferior and
posterior wall hypokinesis, which is concerning for a missed
coronary event. Given the patient's other co-morbidities, the
decision was made to medically manage the patient's presumed
CAD. He was started on 81mg aspirin, atorvastatin 80mg daily,
and metoprolol tartrate 25mg [**Hospital1 **], then transitioned to
metorpolol succinate 50mg daily. The patient's volume status was
trended clinically, and renal followed the patient. He was
euvolemic on day of discharge. The patient's weight on day of
discharge 74.2kg. ACEI was deferred due to persistently low
blood pressures
# Respiratory Failure: Extubated [**2146-6-3**]. Thought to be likely
secondary to pulmonary edema and inability to clear secretions
with mucus plugging leading to lobar collapse. Chest PT and
acapella were done during the patient's floor stay for chronic
bronchiectasis and should be continued on an outpatient basis.
Pending BAL studies will need to be follow-up upon discharge.
# Hypertension: Well-controlled, requiring no
anyti-hypertensives as an inpatient.
# Leukocytosis: The patient was noted to have a white count on
day of discharge of 11.7. Patient was afebrile with no
localizing symptoms concerning for infection. Leukocytosis was
attributed to stress reaction in the setting of recent
procedure.
OUTPATIENT ISSUES: Check CBC with next lab check at
hemodialysis to ensure that white count has resolved.
# Paroxysmal Atrial fibrillation: Patient has been in sinus
rhythm since ICU admission. No prior history of Atrial
fibrillation. CHADS-2 score of 4, placing patient at elevated
risk for stroke. He was monitored on telemetry and started on
metoprolol succinate 50mg daily. Coumadin was not started given
his other co-morbidities; the decision to initiate coumadin can
be readdressed as an outpatient with the patient's primary care
physician.
# Nephrostomy through kidney via patient's ileal conduit:
Interventional radiology replaced replacement of 14-French
nephrostomy cath via loop ileostomy. Patient will have follow-up
to be scheduled by Interventional radiology.
# End Stage Renal Disease on HD: Patient on Tues/Thurs/Sat HD,
which was continued through his cardiology floor course. Renal
consult service followed the patient through his
hospitalization. Nephrocaps were continued daily. Calcium
acetate was increased to 1000mg TID per renal recommendations in
light of elevated phosphorous.
OUTPATIENT ISSUES: Trend phosphorous with labs at
hemodialysis and consider decreasing calcium acetate if
phosphorous is lower.
# GERD: Resume omeprazole as an outpatient.
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================================================================
Transition of care:
--Check CBC with next lab check at hemodialysis to ensure that
white count has resolved.
--decision to initiate coumadin can be readdressed as an
outpatient upon discharge from rehab.
--Trend phosphorous with labs at hemodialysis and consider
decreasing calcium acetate if phosphorous is lower.
--Follow-up pending BAL studies and blood cultures.
--Interventional radiology follow-up.
FULL CODE
Medications on Admission:
--meprazole 20 mg Capsule, Delayed Release(E.C.) One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
--B complex-vitamin C-folic acid 1 mg Capsule One (1) Cap PO
DAILY (Daily).
--Calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH
MEALS)
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for Itching.
6. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Respiratory failure
Mucous plugging
Acute on chronic systolic heart failure
SECONDARY DIAGNOSIS:
End-stage renal disease
Paroxysmal atrial fibrillation
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:
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 69**].
You were hospitalized for respiratory failure secondary to
mucous plugs in your lungs and excess volume in your lungs. You
were intubated during your hospitalization and subsequently
exutabted. During your hosptialization, you were found to have
depressed pumping function of your heart, called systolic heart
failure, concerning for a missed heart attack. The decision was
made to medically manage you in light of your other [**Hospital 15774**]
medical issues.
You continued to have dialysis during this hospital admission.
Take all medications as instructed. Note the following
medication changes:
--*ADDED* Aspirin 81mg daily
--*ADDED* Atorvastatin 80mg daily
--*ADDED* Metoprolol succinate 50mg ONCE daily
--*NEW* Sarna lotion 1 application to the back three times daily
Ask your cardiologist whether you start coumadin as an
outpatient for your intermittent heart arrhythmia.
During this admission you also underwent nephrostomy tube
replacement by interventional radiology.
Keep all hospital follow-up appointments. Your [**Hospital 14776**]
hospital appointments are provided in a list for you.
Followup Instructions:
Department: RADIOLOGY CARE UNIT
When: MONDAY [**2146-6-20**] at 8:30 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: MONDAY [**2146-6-20**] at 10:00 AM
With: XSP WEST [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 12064**]
Admission Date: [**2146-6-1**] Discharge Date: [**2146-6-8**]
Date of Birth: [**2066-10-19**] Sex: M
Service: MEDICINE
Allergies:
Bactrim DS / Levaquin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2412**]
Addendum:
Discharge summary should read that the patient was discharged on
calcium carbonate 1000mg TID with meals as opposed to calcium
acetate 1000mg TID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 2414**]
Completed by:[**2146-6-8**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,974
| 145,550
|
30456
|
Discharge summary
|
report
|
Admission Date: [**2179-4-22**] Discharge Date: [**2179-4-29**]
Date of Birth: [**2116-12-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
L-Sided weakness
Major Surgical or Invasive Procedure:
[**2179-4-23**]: Right Crani for Mass resection/decompression
(Radiation Necrosis)
History of Present Illness:
Patient is a 62M known to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for metastatic melanoma
to the brain. He is s/p brain biopsy by Dr. [**Last Name (STitle) **], and
Cybernife
and WBR. During the last office visit at the BTC, it was
recommended that open craniotomy be pursued to decompress
intracranial lesion. The patient and his family elected to
continue their vacation plans to [**Doctor First Name 26692**], and have
surgery
when they returned.
On [**4-13**], Mr. [**Known lastname 72387**] was out walking when he suddenly "face
planted". Per his wife who witnessed the event, he appeared to
be having a seizure. EMS was called and he was taken to the
hospital. Imaging there revealed a punctate right thalamic
hemorrhage, however significant sub falcine herniation and
sulcal
effacement. Given these findings, and his newly resultant left
hemiplegia and neglect, he was transferred to [**Hospital1 18**] for
definitive care per the family's request.
Past Medical History:
Melanoma
Hypertension
Social History:
He lives with his spouse. There is no prior
history of smoking. He drinks about 24 ounces of beer per week.
He denies any recreational drug use.
Family History:
n/a
Physical Exam:
PHYSICAL EXAM:
O: BP:140/80 HR: 55 RR:18 O2Sats:97%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, left sclarea is contused. otherwise
atraumatic
Pupils: PERRL EOMs: impaired 6th nerve to the left gaze
in both eyes.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date(needs prompting
with day of the month).
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,4mm to
2mm bilaterally.
III, IV, VI: Extraocular movements are with defect to the left
lateral gaze (CN6)
V, VII: Facial there is a left facial droop.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue is somewhat atonic on the left side though without
gross deviation.
EXAM ON DISCHARGE:
The patient has continued left facial droop, left tongue
deviation, left hemineglect. His is oriented x 3 and pupils are
equally reactive to light.
Right side strength is 4-5/5. Sensation is intact bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2179-4-22**] 06:00PM PT-12.1 PTT-25.7 INR(PT)-1.0
[**2179-4-22**] 06:00PM WBC-17.9*# RBC-5.43 HGB-16.2 HCT-46.7 MCV-86
MCH-29.8 MCHC-34.6 RDW-12.0
[**2179-4-22**] 06:00PM CALCIUM-9.4 PHOSPHATE-3.3 MAGNESIUM-2.4
[**2179-4-22**] 06:00PM ALT(SGPT)-108* AST(SGOT)-41* LD(LDH)-425* ALK
PHOS-115 TOT BILI-0.8
[**2179-4-22**] 06:00PM GLUCOSE-129* UREA N-21* CREAT-0.8 SODIUM-136
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-28 ANION GAP-16
DISCHARGE LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2179-4-27**] 04:40AM 8.5 4.35 12.9 37.4 86 29.7 34.6 14.5 168
Na 137, Osm 291
IMAGING:
CT Head [**4-22**]:
IMPRESSION:
1. New right uncal herniation, with effacement of the right
perimesencephalic cistern and mass effect on the right cerebral
peduncle. Effacement of the right cerebral sulci and mass effect
on the right lateral ventricle is likely unchanged from MRI
[**2179-3-20**].
2. New punctate subcortical white matter hyperdense foci, which
may be
hemorrhage, measuring up to 8 mm.
3. Hyperdense 6 mm right frontal lesion, difficult to determine
whether this is a new finding from MRI [**2176-3-19**].
4. Extensive white matter hypoattenuation consistent with
edema/radiation
effect, likely similar to MRI, [**2179-3-20**], allowing for
differences in
technique.
MRI Head [**4-22**]:
1. Four new enhancing lesions, as described above, with marked
"blooming"
artifact consistent with blood products, melanin or both, with
stability size and appearance of the dominant enhancing lesion
and interval decrease in size of the adjacent "satellite"
lesion. Findings are consistent with
mixed-response to treatment.
2. Persistent confluent FLAIR-hyperintensity extending to, but
not including, the subcortical U-fibers with persistent mass
effect and decreased shift of the normally midline structures;
the appearance is consistent with radiation toxicity.
3. No acute infarction
MRI Head [**4-24**]:
1. Status post very recent right frontal craniotomy with
resection of the
dominant mass superficially located in the right frontal lobe;
however, there is persistent band-like enhancement at the
posterior and caudal margin of the resection cavity, highly
suspicious for residual tumor.
2. Separate discrete 8-mm enhancing focus in the right temporal
operculum,
unchanged.
3. At least four small enhancing foci with marked "blooming"
susceptibility artifact in the right frontal corona radiata and
forceps minor, as described, also unchanged and likely
representing metastases.
4. No definite hemorrhage or acute infarction elsewhere in the
brain
CT Head [**4-28**]:
1. Expansion of the mixed-density extra-axial collection
overlying the
surgical bed, now 11 mm (previously 6 mm).
2. Apparent increase in the fluid-filled surgical cavity, with
new dependent hyperdensity consistent with hemorrhage.
3. Similar to minimally increased leftward shift of midline
structures, now 9 mm. Degree of early/slight right uncal
herniation is unchanged from [**2179-4-23**].
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] under the Oncology team for
evaulation of his left hemiplegia. MRI revealed a region of
contrast enhancement in the right frontal lobe and extensive
surrounding edema. He was taken to the operating room on
[**2179-4-23**] for a R frontal craniotomy for lesion resection. The
preliminary pathology report was positive for radiation
necrosis.
His neurological exam remained stable and unchanged
post-operatively. He remained on the mannitol and dexamethasone
for the vasogenic edema. He had an MRI on [**4-24**] which revealed
persistent VG edema, but no new hemorrhage or infarct. He was
tapered off of the mannitol until [**4-29**], and the dexamethasone was
kept at 4mg Q 6. He was transferred to the floor on [**2179-4-26**],
and was seen by the physical therapists. They determined that
he met criteria for a rehab facility.
He was discharged to the rehab on [**4-29**].
Medications on Admission:
Initial medications:
Dexamethasone 6 mg IV Q6H, LeVETiracetam 1000 mg PO/NG [**Hospital1 **],
Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **], Hydrochlorothiazide 25 mg
PO/NG DAILY, Lisinopril 20 mg PO/NG
DAILY, Polyethylene Glycol 17 g PO/NG DAILY:PRN, Senna 1 TAB
PO/NG [**Hospital1 **]:PRN, Docusate Sodium 100 mg PO BID, Insulin SC Sliding
Scale, Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol,
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol, Famotidine 20
mg PO/NG [**Hospital1 **]
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 24402**], ME
Discharge Diagnosis:
Metastatic Melanoma, Brain Mass, Radiation Necrosis
Discharge Condition:
Neurologically Stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
*You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? 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.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**5-17**]
at 3:00 pm [**Hospital Ward Name 23**] 3 pm. The Brain [**Hospital 341**] Clinic is located on
the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **].
Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to
change your appointment, or require additional directions.
??????You will need an MRI of the brain. This will be done at 1:45 on
the same day as your appointment.
Completed by:[**2179-4-29**]
|
[
"348.5",
"198.3",
"787.21",
"V10.82",
"780.39",
"V15.3",
"197.0",
"196.3",
"530.81",
"401.9",
"198.89",
"348.4",
"437.8",
"E879.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"01.59",
"93.59",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8447, 8525
|
5982, 6910
|
337, 422
|
8621, 8643
|
2921, 2921
|
13878, 14489
|
1669, 1674
|
7456, 8424
|
8546, 8600
|
6936, 7433
|
8819, 8840
|
3392, 5959
|
1704, 1936
|
12047, 13855
|
281, 299
|
8852, 12020
|
450, 1442
|
2227, 2671
|
2690, 2902
|
2938, 3376
|
8658, 8795
|
1464, 1487
|
1503, 1653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,788
| 111,585
|
13171
|
Discharge summary
|
report
|
Admission Date: [**2127-12-24**] Discharge Date: [**2128-3-12**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea on exertion and weight gain
Major Surgical or Invasive Procedure:
[**1-7**] redo sternotomy, AVR(23 CE pericardial)/MVrepair(28mm CE
physio ring), aortic endarterectomy
[**1-28**] Trach & PEG
[**2128-2-6**] Sternal debridement
[**2-23**] Sternal debridement
[**2-25**] Sternal closure with plating
[**3-5**] RIJ Tunnelled dialysis catheter
History of Present Illness:
83 yoM w/ a h/o CAD initially admitted on [**12-17**] to OSH with a 15
lb weight gain over past 3 months. Dyspnea @ rest and pedal
edema upon presentation. Upon his hospitalization he developed
atrial flutter and has atrial flutter w/ tachycardia requiring
lopressor however while asleep at night his heart rate has been
slow to low 30s at times with 3 second pauses. Stress rates of
110-120s. Transferred to [**Hospital1 18**] for evaluation.
Past Medical History:
Coronary Artery Disease
Systolic heart failure
HTN
Atrial Flutter
Claudication
S/p nephrectomy for Left Renal Cell Carcinoma
Hypercholesterolemia
Gout
Social History:
Tobacco denies - quit many years ago
Rare ETOH
Lives alone
Family History:
Unknown
Physical Exam:
VS: BP 134/82 HR 109 RR 18 O2 95% 2L
GEN: NAD, AOx3
HEENT: JVP 10cm (but difficult to see)
CARD: tachycardia, regular rhythm, [**3-10**] early peaking systolic
cres decres murmur @ USB w/o radiation to the carotids
PULM: rales [**2-4**] way up on R, bronchial breath sounds [**2-4**] way up
on L side
ABD: Soft, NT, ND, no masses, BS+
EXT: WWP, 2+ pitting edema to thigh bilaterally symmetrical
Pertinent Results:
[**2128-3-12**] 12:22AM BLOOD WBC-15.1* RBC-2.81* Hgb-8.7* Hct-28.3*
MCV-101* MCH-31.0 MCHC-30.9* RDW-20.5* Plt Ct-222
[**2128-3-11**] 03:01AM BLOOD WBC-10.6 RBC-2.67* Hgb-8.6* Hct-27.0*
MCV-101* MCH-32.3* MCHC-31.9 RDW-20.5* Plt Ct-192
[**2128-3-12**] 12:22AM BLOOD PT-18.6* PTT-57.9* INR(PT)-1.7*
[**2128-3-11**] 11:04AM BLOOD PT-17.6* PTT-54.3* INR(PT)-1.6*
[**2128-3-12**] 12:22AM BLOOD Glucose-112* UreaN-28* Creat-2.2* Na-136
K-4.3 Cl-99 HCO3-26 AnGap-15
[**2128-3-11**] 03:01AM BLOOD Glucose-140* UreaN-37* Creat-2.7* Na-135
K-3.9 Cl-100 HCO3-22 AnGap-17
Brief Hospital Course:
He was admitted to the floor and diuresed. TEE on [**12-26**] showed
no thrombus and on [**12-26**] he underwent a flutter ablation. He
became hypotensive from diuresis and was started on dopamine and
tranferred to the CCU. Cardiac surgery was consulted for his
severe AS and MR. [**Name13 (STitle) **] was started on tube feeds for dysphagia. He
remained on a heparin drip. He had a VT arrest requiring CPR,
and recovered to rapid afib. He was started on amiodarone. He
was intubated electively, and cardiac cath was done and [**12-29**]
and graft to OM was stented. He was treated for a klebsiella
UTI. Repeat echo showed no improvement in EF after stent. He was
seen by renal for increasing creatinine however continued to
have good urine output with lasix and diuril. He was extubated
on [**1-1**]. He agreed to surgery, and on [**1-7**] was taken to the
operating room wher he underwent a redo sternotomy/AVR/MV Repair
and aortic endarterectomy. He became asystolic immediately post
op and was reopened with resolution and no findings. He was
transferred to the ICU in critical but stable condition on epi,
neo and propofol. He was given vancomycin periop as he was in
the hospital preoperatively. He was hypotensive overnight,
milrinone and pitressin were added, and he was transfused. His
pressors and vent were slowly weaned and he was diuresed. His
vasoactive drips were weaned to off and He was extubated on POD
#7. He had several runs of VT. He remained on heparin IV for
atrial fibrillation and Coumadin was held with plans for AICD.
He was started on a lasix drip, and required free water for
hypernatremia. On [**1-17**] he was reintubated for PCO2 of 90. AICD
placement was cancelled until patient is stabilized. After
multiple extubation attempts, on [**1-28**] a trach and were placed.
Diamox was added for diuresis. Coumadin was restarted. He
continued to progress and was able to tolerate trach collar
trials. Diuresis was stopped. EP was reconsulted in relation
to AICD and Mr. [**Known lastname 40177**] should follow up in one month with EP.
His distal incision began to drain serous fluid and it was
opened and packed. His trach was changed to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**] on [**2-5**]. His
sternum continued to open and He was taken to the operating room
on [**2-5**] for a sternal debridement and a VAC was placed. He
suffered a cardiac arrest in the operating room and was
resuscitated. He was started on 3 pressors and vanco zosyn and
flagyl. He was seen by nephrology for decreased urine output. He
was started on fluconazole for yeast in his sternal wound. He
was started on CVVH. He remained on multiple pressors. He
remained on full ventilator support, an dpressors for a number
of days. He stabilized hemodynamically, and weaned off
pressors. On [**2128-2-23**], he was again taken to the OR with Dr.
[**First Name (STitle) **] (plastic surgery) for a sternal debridement. He was
again returned to the OR for delayed sternal closure with
plating by Dr. [**First Name (STitle) **] on [**2128-2-25**]. He was able to tolerate
hemodialysis, no longer requiring CVVH, so he had a RIJ
tunnelled hemodialysis catheter placed on [**2128-3-5**] by Dr. [**Last Name (STitle) 816**].
He has remained hemodynamically stable, and is now ready to be
transferred to rehab for continued physical therapy, and
ventilator weaning. His Zosyn will be completed on [**2128-3-22**].
Fluconazole is to be lifelong. Daptomycin should continue for 4
week from start date of [**2128-3-11**].
Medications on Admission:
Metoprolol 100mg po daily
Lipitor 10mg po daily
Lasix 80mg po daily (patient is unsure if he takes lasix at
home)
Aspirin 81mg po daily
Cozaar 50mg po daily
Cilostozal 100mg po bid
Doxasosin 4mg po daily
Allopurinol 100mg daily
Discharge Medications:
1. Allopurinol 100 mg Tablet [**Date Range **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily): for stent .
3. Senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: Ten (10) PO BID (2
times a day).
5. Carvedilol 3.125 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2
times a day).
6. Aspirin 81 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Date Range **]: [**3-8**]
Puffs Inhalation Q6H (every 6 hours) as needed.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Lipitor 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Tablet(s)
10. Nephrocaps 1 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day.
11. Sertraline 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO once a day:
75 mg daily.
12. Zosyn 2.25 gram Recon Soln [**Last Name (STitle) **]: 2.25 Gms Intravenous every
eight (8) hours for 10 days: end date [**2128-3-22**].
13. Daptomycin 500 mg Recon Soln [**Month/Day/Year **]: 350 mg Intravenous every
other day for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Aortic Stenosis s/p avr
Mitral Regurgitation s/p MV repair
Acute on chronic systolic heart failure
PMH: HTN, Aflutter (s/p ablation [**12-26**]), Claudication, Chol,
Gout, CAD (s/p MI x 3)[**2112**], CHF (EF 20%)
PSH: CABG '[**12**], Lt Nephrectomy '[**99**], Rt knee [**Doctor First Name **] 70's
Discharge Condition:
Fair
Discharge Instructions:
Call with fever, or redness or drainage from incision.
[**Telephone/Fax (1) 170**]
Please monitor weight - systolic heart failure - monitor for
weight gain more than 2 pounds in one day or five in one week.
No baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon
Followup Instructions:
Dr. [**Last Name (STitle) 1637**] after discharge from rehab - please call to schedule
appointment [**Telephone/Fax (1) 14655**]
Dr. [**First Name (STitle) **] - [**Telephone/Fax (1) 170**] please call for appointment when
discharged from rehab
Dr. [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 285**]
Dr. [**First Name (STitle) 1075**] in [**Hospital **] clinic on [**2128-3-19**] at 10 am ([**Last Name (NamePattern1) **],
basement) Please call if need to reschedule [**Telephone/Fax (1) 457**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2128-3-12**]
|
[
"427.5",
"403.90",
"518.81",
"584.5",
"V45.73",
"997.1",
"414.01",
"038.9",
"785.51",
"785.52",
"414.02",
"112.89",
"427.32",
"424.0",
"427.1",
"458.29",
"272.0",
"427.31",
"V09.80",
"998.32",
"428.23",
"995.89",
"746.4",
"285.21",
"440.0",
"995.92",
"428.0",
"585.9",
"412",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"38.14",
"96.6",
"77.61",
"37.23",
"96.71",
"35.33",
"43.11",
"00.13",
"99.62",
"88.72",
"00.40",
"36.07",
"37.34",
"00.66",
"35.21",
"39.61",
"34.03",
"34.79",
"96.04",
"86.74",
"39.95",
"96.72",
"37.26",
"38.95",
"83.39",
"88.56",
"31.1",
"93.59",
"34.91",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
7564, 7594
|
2356, 5908
|
304, 580
|
7936, 7943
|
1769, 2333
|
8324, 8972
|
1327, 1336
|
6186, 7541
|
7615, 7915
|
5934, 6163
|
7967, 8301
|
1351, 1750
|
229, 266
|
608, 1060
|
1082, 1234
|
1250, 1311
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,626
| 166,653
|
13350
|
Discharge summary
|
report
|
Admission Date: [**2186-9-12**] Discharge Date: [**2186-9-25**]
Date of Birth: [**2125-1-28**] Sex: M
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p bike accident
Major Surgical or Invasive Procedure:
S/P posterior fusion of spine
S/P Oepn tracheostomy and PEG placement
S/PIVC filter placement
History of Present Illness:
61M found down in V fib arrest. Cardioverted X 1 back to sinus
rythm transfered in. Found to have a C2 burst fx and
quadraplegia.
Past Medical History:
Anemia
Depression, Cholinergic urticaria
Social History:
Married, lives with wife. Dentist
Family History:
None
Physical Exam:
Temp 99.7 HR 47 BP 110/67 RR 10 O2 100 on vent
PERRL EOMI
C collar on
CTA
SB no murmurs
S/NT/ND/ BS +
no edema
Pertinent Results:
[**2186-9-12**] 03:30PM ALT(SGPT)-49* AST(SGOT)-58* CK(CPK)-317* ALK
PHOS-25* AMYLASE-232* TOT BILI-0.7
[**2186-9-12**] 03:30PM CK-MB-6 cTropnT-<0.01
[**2186-9-12**] 03:30PM WBC-7.5# RBC-3.71* HGB-11.4* HCT-31.6* MCV-85
MCH-30.8 MCHC-36.2* RDW-13.0
[**2186-9-12**] 03:30PM PLT COUNT-143*
[**2186-9-12**] 10:55AM TYPE-ART TEMP-37.0 RATES-14/ TIDAL VOL-600
PEEP-5 O2-60 PO2-186* PCO2-44 PH-7.38 TOTAL CO2-27 BASE XS-0
INTUBATED-INTUBATED VENT-CONTROLLED COMMENTS-ORAL
[**2186-9-12**] 08:20AM CK(CPK)-367* AMYLASE-132*
[**2186-9-12**] 08:20AM CK-MB-5 cTropnT-<0.01
Brief Hospital Course:
Pt was admitted to the CCU on [**9-12**] for V fib arrest. Review of
his X rays revealed a C2 burst fx. Pt was transfered to the
Trauma Surgery service and Ortho spine, Neurosurgery, and
Neurology were consulted. Steriods and dilantin were given X 48
hrs, EEG was preformed which was normal. SBP was elevated above
140 using pressers in order to increase cerebral perfusion. Due
to his complete quadraplegia an IVC filter was placed to reduce
the risk of PE. He was given a full dourse of Levo/Flagyl for a
? of aspiration pneumonia. Tube feeds were started and quickly
advanced to goal. After a family discussion it was decided that
Dr. [**Last Name (STitle) 1327**] would stablize his spine and Dr. [**Last Name (STitle) **] would do a
tracheostomy and PEG at the same time. Also, minocycline was
started at the request of the family for spinal cord injury
treatment. Pt was noted to have a cuff leak on [**9-16**] and his ETT
tube was changed. Pt began to have temp spikes to 101.8 starting
on [**9-17**]. He was pan cultured and continued on abx. On [**9-18**] he
underwent a spinal fusion and trach/PEG. He tolerated the
procedure well and TF were restarted. He was easily advanced to
goal which he tolerated. He was weaned from his pressor and was
able to maintain an adequate SBP. He was kept on Kefzol after
surgery for prophylaxsis with a drain in place. This was changed
to Vanco after swabs showed he was colonized with MRSA. His CVL
was removed and his temp came down. Ophthalmology was consulted
because the pt complained of seeing floaters and he had a h/o
retinal detachment. His exam was found to be normal. Psychiatry
was also consulted as well as PT and OT. He was given 1U PRBC
for blood loss anemia. Speech and swallow was consulted and the
pt was able to pass his bedside swallow. Also he was able to
tolerate a Passy Muir Valve. He was given clear liquids for his
comfort while being continued on his tube feeds. He had an
episode of abd distention. KUB showed diffuse abd distention
with gas. Pt continued with normal BM and passing flatus. He was
found to have GPC in [**2-5**] blood cx and he was continued on Vanco
for this. His cultures grew Coag neg Staph however repeated
sputum cx grew MRSA and he continued to have fevers. It was
decided he would complete a 10 day course of Vanco, which was
started on [**9-20**] for his pneumonia.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*40 * Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
Disp:*40 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Minocycline HCl 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*60 * Refills:*2*
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*60 * Refills:*2*
8. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day.
Disp:*120 Tablet(s)* Refills:*2*
9. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. Vancomycin HCl 1250 mg IV Q12H
check trough/peak level after 3rd dose
Discharge Disposition:
Extended Care
Facility:
[**Hospital 40599**] Rehab.
Discharge Diagnosis:
C2 fx
Ventricular fibrilation arrest
Pneumonia
blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Passy-Muir valve with cuff down. Pt may have clear liquids for
comfort with cuff down.
Followup Instructions:
F/U with Dr. [**Last Name (STitle) 1327**]
F/U with Dr. [**Last Name (STitle) **] if neccesary
Completed by:[**0-0-0**]
|
[
"507.0",
"995.91",
"780.39",
"427.5",
"806.01",
"996.59",
"280.0",
"427.41",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.03",
"81.01",
"38.93",
"31.1",
"43.11",
"96.72",
"03.53",
"96.04",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
5142, 5196
|
1485, 3850
|
346, 442
|
5305, 5313
|
884, 1462
|
5448, 5570
|
732, 738
|
3905, 5119
|
5217, 5284
|
3876, 3882
|
5337, 5425
|
753, 865
|
289, 308
|
470, 601
|
623, 665
|
681, 716
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
990
| 184,231
|
44515
|
Discharge summary
|
report
|
Admission Date: [**2146-10-17**] Discharge Date: [**2146-10-24**]
Service: Medicine, [**Hospital1 139**] Firm
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
African-American female with a history of hypertension,
hypercholesterolemia, coronary artery disease,
cerebrovascular accident, abdominal aortic aneurysm, and
severe dementia who presents with a upper respiratory
infection initially to the [**Hospital6 733**] Clinic on
[**10-13**] and given azithromycin times five days. The
patient was otherwise, she was in her usual state of health.
On Saturday ([**10-15**]) in the evening, the patient was
noted to have a large hard stool with dark blood. On Sunday
morning, she had no blood in her diaper when changed but by
the evening (at 6 p.m.) she had a large blood clot and dark
blood saturating her diaper. The patient had no nausea,
vomiting, abdominal pain, or hematemesis.
In the Emergency Department, the patient's vital signs
revealed a heart rate of 77, her blood pressure was 132/44,
and her oxygen saturation was 97% on room air. Her
hematocrit was 27.8 (with a baseline of 35.3 in [**2146-10-15**]) with normal platelets and coagulations.
The patient was transfused 2 units of packed red blood cells.
A tagged red blood cell scan showed an active hepatic
flexure bleed. The patient went to angiogram for a possible
embolization and was found to have a total superior
mesenteric artery and internal mammary artery occlusion with
no possible embolization intervention. Her hematocrit was
stabilized after a total of 3 units of packed red blood cells
were transfused. She was watched in the Medical Intensive
Care Unit, and her hematocrit on [**10-18**] at 4 a.m. was 29%
and remained in that range on [**10-19**]. She continued to
ooze some blood from her rectal tube.
The patient's two daughters have expressed the desire for no
surgery or heroic measures. The patient's code status was to
remain do not resuscitate/do not intubate. The patient was
transferred to the floor initially for observation.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature was 96.7 degrees
Fahrenheit, temperature maximum was 96.7, her heart rate was
53 to 72, and her blood pressure was 135 to 167/48 to 58.
Generally, the patient was in no acute distress. She opened
her eyes and was moaning. She was not communicative but was
alert and at her baseline. Head, eyes, ears, nose, and
throat examination revealed the mucous membranes were moist.
There was no jugular venous distention. Cardiovascular
examination revealed a regular rate and rhythm. There was
[**2-17**] holosystolic murmur at the apex. Pulmonary examination
revealed the lungs were clear to auscultation bilaterally.
The abdomen was soft, nontender, and nondistended. There
were normal active bowel sounds. There was no
hepatosplenomegaly. The extremities were without edema. She
had contracture of all four extremities. Neurologically, she
had increased tone in her left upper extremity and left lower
extremity. She was moving all extremities well. Her
reflexes were equal bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed her white blood cell count was 10, her hematocrit
was 30, and her platelets were 132. The patient's sodium was
142, potassium was 4.4, chloride was 112, bicarbonate was 22,
blood urea nitrogen was 17, creatinine was 0.5, and her blood
glucose was 103. Her calcium was 8.2, her phosphate was 2.6,
and her magnesium was 2.1.
PERTINENT RADIOLOGY/IMAGING: A tagged red cell scan on
[**10-17**] showed an active hepatic flexure bleed.
Angiography revealed total occlusion of the superior
mesenteric artery and internal mammary artery with celiac
collateral feeding superior mesenteric artery territory. No
possible embolization.
An esophagogastroduodenoscopy on [**2144-4-6**] showed normal
esophagus, gastric, and duodenum.
A colonoscopy on [**2144-4-6**] showed multiple diverticula
in the entire colon, three polyps in the ascending colon
(status post polypectomy), and no active bleeding.
A chest x-ray showed cardiomegaly and increased interstitial
markings.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. GASTROINTESTINAL BLEED ISSUES: Gastrointestinal bleed
localized to the hepatic flexure with a tagged red blood cell
scan. The patient's was stabilized in the Intensive Care
Unit initially with a transfusion and was then transferred
out to the floor. She had total superior mesenteric artery
and internal mammary artery occlusion, and no embolization
was possible by angiography.
The family declined any surgery or other heroic measures, and
she continued to have bleeding after transfer out of the
Intensive Care Unit, requiring four to six transfusions per
day. The bleeding had slowed by [**10-24**]. After having a
family discussion with both of her daughters and the
attending, her daughters understood that she would likely
continue to bleed at home but there may be no other
noninvasive interventions possible in the hospital. Her
daughters understood this and elected to take her home.
2. CORONARY ARTERY DISEASE ISSUES: The patient with a
troponin leak. There were no electrocardiogram changes.
Initially, her hematocrit was kept around 30%, but the
patient remained transfusion dependent.
3. CONGESTIVE HEART FAILURE ISSUES: Congestive heart
failure was well compensated with an ejection fraction of
about 45%. The patient was gently hydrated during her
hospital stay and treated with packed red blood cells without
any evidence of fluid overload.
4. JOINT CONTRACTURE ISSUES: The patient had contractures
of all four extremities and was treated with physical therapy
as an inpatient.
5. HYPERTENSION ISSUES: The patient's blood pressure
medications were held in the setting of an active bleed.
6. CODE STATUS ISSUES: The patient remained do not
resuscitate/do not intubate during her hospital stay.
CONDITION AT DISCHARGE: Condition on discharge was guarded.
CODE STATUS ON DISCHARGE: The patient to remain do not
resuscitate/do not intubate, and her family understood her
risk at home of continued bleeding.
DISCHARGE STATUS: The patient was discharged to home in the
care of her two daughters.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] and was to call for an
appointment (telephone number [**Telephone/Fax (1) 250**]).
MEDICATIONS ON DISCHARGE: Pantoprazole 40 mg by mouth once
per day.
[**Name6 (MD) 3488**] [**Last Name (NamePattern4) 3489**], M.D. [**MD Number(1) 3490**]
Dictated By:[**Last Name (NamePattern1) 5819**]
MEDQUIST36
D: [**2147-1-11**] 08:26
T: [**2147-1-11**] 09:00
JOB#: [**Job Number 95372**]
|
[
"414.01",
"410.71",
"562.12",
"438.20",
"707.0",
"298.4",
"428.0",
"401.9",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
6531, 6839
|
6323, 6504
|
4247, 5995
|
6010, 6059
|
6074, 6288
|
149, 4213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,263
| 190,790
|
38108
|
Discharge summary
|
report
|
Admission Date: [**2153-6-20**] Discharge Date: [**2153-6-28**]
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin / Sulfa (Sulfonamide Antibiotics) /
Macrodantin
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Pacemaker implantation
Cardiac catheterization with bare metal stent to the diagonal
coronary artery
History of Present Illness:
[**Age over 90 **] yo with PMH of atrial fibrillation, ?SVT, Sjogren's disease,
systemic HTN, GERD, who presented to [**Hospital6 3105**]
on [**2153-6-18**] with left sided chest discomfort in the setting of
rapid heartbeat. Episode lasted approximately one hour. She has
had these episodes in the past, but they have usually lasted
only a few minutes. Patient was found to have ST elevations in
lateral leads (I and aVL) with ST depressions in aVR. CPK peaked
at 1261 and troponin of 54.56. Underwent cath at [**Hospital1 487**] which
demonstrated 80% stenosis of mid LAD, 100% occlusion of first
diag, 50% left main stenosis, 50% left circumflex, 70% stenosis
of PDA, LVEF of 35% with anterior and apical akinesis. Underwent
angioplasty and BMS to her first diagonal artery. Transferred to
[**Hospital1 18**] for CT [**Doctor First Name **] evaluation for possible CABG.
.
Pt is currently comfortable, she has no chest pain, shortness of
breath, or dizziness.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, [**Doctor First Name **] at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
atrial fibrillation
?SVT
Sjogren's disease
systemic HTN
GERD
.
.
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- History of supraventricular tachycardia, atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
- sjogren's syndrome
- GERD
Social History:
SOCIAL HISTORY: lives alone, has help with chores. has a nephew
who is involved but [**Name (NI) **] sometimes is reluctant to involve him.
-Tobacco history: None.
-ETOH: None.
-Illicit drugs: None.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Gen: alert, oriented, NAD
HEENT: supple, no JVD
CV: RRR, no M/R/G, distant HS. Left pacer site with drsg [**Name5 (PTitle) 767**]
[**Name5 (PTitle) **] [**Name5 (PTitle) 2729**] in lab, no evidence of ecchymosis or swelling
under dressing.
RESP: [**Month (only) **] BS right base only, left now clear
ABD: soft, NT/ND
EXTR: no peripheral edema.
NEURO: A/O
Extremeties: no edema
Pulses:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Pertinent Results:
[**2153-6-28**] 07:15AM BLOOD WBC-8.4 RBC-3.55* Hgb-10.0* Hct-30.3*
MCV-85 MCH-28.1 MCHC-32.9 RDW-14.3 Plt Ct-244
[**2153-6-20**] 11:51PM BLOOD WBC-7.8 RBC-3.84* Hgb-11.3* Hct-33.4*
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.8 Plt Ct-174
[**2153-6-27**] 07:05AM BLOOD PT-12.3 PTT-26.3 INR(PT)-1.0
[**2153-6-28**] 07:15AM BLOOD Glucose-117* UreaN-17 Creat-1.0 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
[**2153-6-20**] 11:51PM BLOOD Glucose-124* UreaN-24* Creat-1.1 Na-141
K-3.7 Cl-105 HCO3-25 AnGap-15
[**2153-6-22**] 07:30AM BLOOD CK(CPK)-123
[**2153-6-21**] 07:02AM BLOOD CK(CPK)-138
[**2153-6-20**] 11:51PM BLOOD CK(CPK)-182
[**2153-6-21**] 07:02AM BLOOD CK-MB-8 cTropnT-3.18*
[**2153-6-20**] 11:51PM BLOOD CK-MB-10 MB Indx-5.5 cTropnT-3.55*
[**2153-6-27**] 07:05AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
.
[**6-27**]/CXR:
The lead of the single-chamber pacemaker is terminating in the
right ventricle. Unchanged position of the left pectoral
generator.
Otherwise no change. Mild elevation of the left hemidiaphragm.
No pulmonary edema. No pleural effusions.
.
Brief Hospital Course:
[**Age over 90 **] yo with PMH of atrial fibrillation, ?SVT, Sjogren's disease,
systemic HTN, GERD, who presented to OSH with chest discomfort
in the setting of rapid heartbeat, found to have ST elevations
in lateral leads (I and aVL) with ST depressions in aVR. CPK
peaked at 1261 and troponin at 54.56. Found to have 3VD, s/p BMS
to her first diagonal artery. Transferred to [**Hospital1 18**] for EP
evealuation re: pacemaker for tachy-brady syndrome.
.
# STEMI/CAD: Underwent cath at [**Hospital1 487**] which demonstrated 80%
stenosis of mid LAD, 100% occlusion of first diag, 50% left main
stenosis, 50% left circumflex, 70% stenosis of PDA, LVEF of 35%
with anterior and apical akinesis. S/p BMS to first diagonal
artery. Pt was started on Plavix, lisinopril 15mg daily, and
Lipitor 80mg daily. Aspirin was increased to 325 mg daily.
Metoprolol 12.5mg [**Hospital1 **] was started once patient was no longer
having episodes of bradycardia; this can be converted to
metoprolol succinate 25mg daily on d/c. Lisinopril 15mg daily
was started prior to d/c. She did not have further episodes of
chest pain.
.
# Atrial fib: History of paroxysmal atrial fibrillation and ?
SVT.
- found to be bradycardic at OSH in response to lopressor. Also
noticed to be tachy-brady upon arrival to CCU, with rates
varying from the 40s to the 120s. Also with pauses > 5 seconds
at OSH. Patient went in to AF with RVR after transfer that was
terminated with 2.5mg metoprolol IV. EP was consulted and
recommended a pacemaker for tachy-brady syndrome. Pacer was
sucessfuly placed [**2153-6-27**]. Patient was not on coumadin at the
time of admission. It is unclear why her PMD felt coumadin was
contraindicated, but it was felt during hospital stay that pt
was a fall risk and the risk of coumadin would outweight the
benefit in her case, particularly given that she would need
Plavix and ASA after her stent. CHADS score 2. ASA was increased
to full dose. Amiodorone was started for rhythm control as
recommended by EP, and she is on metoprolol for rate control.
She will require a 5 gram load of amiodarone and should change
to 100 mg daily after her load of 400 mg daily for 13 days.
TFT's and LFT's should be checked and PFT's should be arranged
by her PCP.
.
# PUMP: Per OSH report, TTE [**12-31**] demonstrated LVEF 55%, 1+MR,
1+TR. Appears euvolemic on exam throughout hospital course. Pt
is on ACEi and long acting Bblocker.
.
# Dyslipidemia: continue lipitor as above.
.
# Hypertension: BP currently controlled on lisinopril and
metoprolol at time of d/c.
.
# Sjogren's syndrome: Stable.
.
# GERD: Famotidine continued given possible interaction between
PPIs and Plavix.
.
# BRBPR: Noted by nursing staff. Hct follwed serially and was
stable throughout hospital course. C diff was negative. There
was no more evidence of [**Month/Year (2) **] in stools per nursing at the
time of discharge. Consider colonoscopy as an outpatient.
.
# Leukocytosis: WBC 12. Pancultures sent, no source of infection
found. CXR showed no infiltrate. C diff toxin negative.
Leukocytosis resolved and patient afebrile at time of d/c.
.
Medications on Admission:
HOME MEDICATIONS:
- aspirin 81mg PO daily
- sotalol 40mg PO BID
- amlodipine 10mg PO daily
- colace 100mg PO daily
- SL NTG PRN
- omeprazole 20mg PO daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not stop taking or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr.
[**Last Name (STitle) **] tells you to. .
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
every 5 minutes X 3 [**Last Name (STitle) 4319**] PRN
.
6. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 13 days: Then decrease to 100 mg daily indefinitely.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Hold
SBP < 100.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Nursing and Rehab
Discharge Diagnosis:
Tachy/Brady syndrome
ST Elevation Myocardial Infarction
Atrial fibrillation with Rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack because of a rapid heart rate and needed
a bare metal stent to fix a blocked coronary artery. You were
transferred here for further treatment. We noticed that you had
pauses on telemetry and a pacemaker was placed. You will need to
come back in 1 week to check the pacer. You can take the
dressing off on Monday [**7-2**] and take a shower. No soaps or
creams to the pacer site. No lifting your left arm over your
head of lifting more than 5 pounds for 6 weeks.
Medication changes:
1. Stop taking Amlodipine, Colace and Omeprazole
2. Take famotidine to protect your stomach
3. Increase your aspirin to 325 mg to prevent strokes with your
atrial fibrillation.
4. Continue with the nitroglycerin as needed
5. Start taking amiodarone to control your heart rate and
rhythm.
6. Start taking Metoprolol to control your heart rate and rhythm
7. Start Atorvastatin to lower your cholesterol
8. Start taking Tylenol as needed for the pacer pain
9. Start taking Plavix daily to keep the stent from clotting off
and causing another heart attack. Do not stop taking Plavix
unless Dr. [**Last Name (STitle) **] tells you to.
Followup Instructions:
Department: Internal Medicine
Name: Dr. [**First Name (STitle) 487**] KIDD
When: Monday [**2153-7-2**] at 3 PM
Address: [**Street Address(2) **], [**Apartment Address(1) 85042**] [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 69547**]
Department: Cardiology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5423**]
When: Thursday [**2153-8-2**] at 3 PM
Location: [**Location (un) **] CARDIO
Address: [**Street Address(2) **], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 39854**]
Phone: [**Telephone/Fax (1) 5424**]
Department: CARDIAC SERVICES
When: THURSDAY [**2153-7-5**] at 10:00 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: CARDIAC SERVICES
When: MONDAY [**2153-8-13**] at 3:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2153-6-29**]
|
[
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"V45.82",
"530.81",
"578.9",
"414.01",
"427.81",
"427.31",
"410.51",
"272.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.82",
"37.71"
] |
icd9pcs
|
[
[
[]
]
] |
8353, 8413
|
3955, 7062
|
289, 392
|
8565, 8565
|
2887, 3932
|
9875, 11077
|
2312, 2427
|
7268, 8330
|
8434, 8544
|
7088, 7088
|
8716, 9201
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2442, 2868
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1955, 2018
|
7106, 7245
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9221, 9852
|
244, 251
|
420, 1755
|
8580, 8692
|
2049, 2079
|
1864, 1935
|
2111, 2296
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,859
| 124,447
|
30969
|
Discharge summary
|
report
|
Admission Date: [**2155-9-25**] Discharge Date: [**2155-9-27**]
Date of Birth: [**2097-6-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Ciprofloxacin / Percocet
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Left Parietal Mass
Major Surgical or Invasive Procedure:
Left parietal Craniotomy
History of Present Illness:
Pt was recently admitted on the neurology service for
uncontrollable leg movements. CT head showed a hemorrhage in
one of her known metastates. This was confirmed per MRI, which
did not show any visible foci that could explain the clinical
presentation. The event could have represented a simple partial
seizure. Brain tumor clinic recommended resecting her left
parietal mass.
Past Medical History:
metastatic renal cell
adult-onset diabetes, now insulin dependent, with resulting
neuropathy and retinopathy
Social History:
RN, not currently working (did direct obs for TB treatment).
Divorced with one daughter. H/o tobacco 1ppd x 40yrs, quit 6mo
ago. No EtOH or drug use. Enjoys quilting, sweing. HCPs are her
brother and daughter. She is full code but would not want to be
on sustained life-saving measures; she has discussed this with
her HCPs.
Family History:
mother died at age 78 of lung cancer, grandmother died age
[**Age over 90 **] of pancreatic cancer, aunt may have had abdominal cancer,
father w/ polycystic kidney disease, paternal grandmother died
of
DM in her 50s, ovarian cancer in multiple aunts. [**Name (NI) **] strokes,
seizures, migraines.
Physical Exam:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**]
backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] intact.
Recalls
[**3-8**] +1 with cue from item list given 1 week ago. No right-left
confusion. No evidence of neglect.
Cranial Nerves: Pupils equally round and reactive to light,
6->3mm bilaterally. No red desaturation. Visual fields are full
to confrontation. Extraocular movements intact bilaterally
without nystagmus. Sensation intact V1-V3. Facial movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. Sternocleidomastoid and trapezius full
strength bilaterally. Tongue midline, movements intact.
Motor: Normal bulk bilaterally. No observed myoclonus,
asterixis,
or tremor. No pronator drift.
[**Doctor First Name **] [**Doctor First Name **] [**Hospital1 **] WE FE FF IP H Q DF PF TE
R 5 4+ 5 5 5 5 5 5 5 5 5 4+
L 5 5 5 5 5- 5 5- 5 5 5 5 4+
Sensation: Intact to light touch. Decreased vibration R toe
worse
than L toe. Pinprick and cold sensation symmetric.
Reflexes: 1+ and symmetric in [**Hospital1 **], BR, decreased in [**Last Name (LF) **], [**First Name3 (LF) **],
achilles. Toes downgoing bilaterally.
Coordination: nl finger-nose-finger, very mildly inaccurate on
right finger-to-nose and heel-to-shin, slightly clumsy right
fine finger movements and [**Doctor First Name **]. Right pronator drift
Gait: Narrow based, steady. Able to tandem.
Romberg: Negative.
Pertinent Results:
[**2155-9-26**] 04:36AM BLOOD WBC-4.3 RBC-3.17*# Hgb-9.7*# Hct-27.5*
MCV-87 MCH-30.6 MCHC-35.3* RDW-22.4* Plt Ct-174
[**2155-9-26**] 04:36AM BLOOD Glucose-141* UreaN-15 Creat-0.7 Na-143
K-4.0 Cl-106 HCO3-30 AnGap-11
[**2155-9-25**] 05:32PM BLOOD Calcium-7.9* Phos-2.6* Mg-1.6
Brief Hospital Course:
Ms [**Known lastname 1024**] [**Last Name (Titles) 1834**] a left sided craniotomy without
complications. Post operatively she recovered in the PACU where
her BP was kept less than 140 and a head CT showed no sign of
hemorrhage. Neurologically she remained intact with possible
slight pronator drift. She was transferred to the regular floor
and was ambulating and tolerating a regular diet. Her MRI was
completed with minimal to no residual tumor observed. Her
steroids were weaned. PT was consulted and recommended patient
to be discharged home.
Medications on Admission:
ATIVAN 1 mg--1 (one) tablet(s) by mouth twice a day as needed
for nausea
COMPAZINE 5 mg--1 (one) tablet(s) by mouth every 4-6 hours as
needed for nausea
Insulin NPH Human Recomb 100 unit/mL--20 units twice a day
KEPPRA 500 mg--3 tablet(s) by mouth twice a day
PRILOSEC OTC 20 mg--one tablet(s) by mouth daily
PROZAC 40 mg--1 capsule(s) by mouth daily
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): please take this medication when you are taking
narcotic pain medications.
Disp:*60 Capsule(s)* Refills:*2*
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain / fever: Total acetaminophen dose must
be less than 4gm/24hrs. Tablet(s)
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 doses.
Disp:*2 Tablet(s)* Refills:*0*
9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO three times
a day for 3 doses: please start on [**2155-9-28**] for 1 (one) day.
Disp:*3 Tablet(s)* Refills:*0*
10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a
day: please start on [**2155-9-29**] and continue until your further
follow up. .
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Renal Cell Carcinoma with Brain Mets
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow up in brain tumor clinic within 2 weeks, please call
[**Telephone/Fax (1) 1844**] for appointment
Completed by:[**2155-9-27**]
|
[
"357.2",
"197.7",
"362.01",
"250.60",
"V10.52",
"250.50",
"197.0",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
5673, 5679
|
3460, 4015
|
308, 335
|
5760, 5784
|
3160, 3437
|
7119, 7255
|
1235, 1534
|
4417, 5650
|
5700, 5739
|
4041, 4394
|
5808, 7096
|
1549, 1549
|
250, 270
|
363, 744
|
1958, 3141
|
1564, 1942
|
766, 876
|
892, 1219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,873
| 151,475
|
33472
|
Discharge summary
|
report
|
Admission Date: [**2115-2-4**] Discharge Date: [**2115-2-11**]
Date of Birth: [**2038-1-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Ultrasound-guided placement of left pigtail catheter
History of Present Illness:
77F h/o diastolic CHF, CRI, recurrent pleural effusions,
transferred from [**Hospital6 5016**] on [**2115-2-4**] for further w/u
of persistent pleural effusions. Pt had undergone L
thoracentesis on [**2115-1-30**], which demonstrated nonmalignant
effusions with exudative protein count but otherwise
transudative markers. After the thoracentesis, pt became
hypoxic on RA, decreasing to 74% with slight improvement after
receivng 2-3L O2 NC.
.
On presentation to the ED after her thoracentesis, pt was
diagnosed with "reexpansion pulmonary edema," placed on BIPAP,
and received levofloxacin but switched to clindamycin on [**1-31**]
due to prolonged QT interval and concomitant sotalol use.
Subsequently, pt appeared to have developed flash pulmonary
edema on [**2-2**] to which she responded to furosemide 40 mg IV with
900 cc urine output, with oxygen saturation 94-95% on 50%
facemask. She later vomited x2, and then sotalol was held for
QTc 510 ms.
.
Pt was later transferred to [**Hospital1 18**] to undergo pleuroscopy in the
IP suite. During IP, pt desaturated to mid-70s on 5L NC after
being placed on her R side, and improved to mid-80s with
repositioning. She was then transferred to the MICU for closer
management, where she was treated with clindamycin for
presumptive asp PNA, and albuterol/ipratropium nebulizers. A
pigtail catheter was placed to drain L pleural effusion. CTA PE
was held given elevated creatinine. Pt's oxygen saturations
stabilized on 1L NC, and pt was transferred to the floor.
Past Medical History:
# COPD
# Chronic pleural effusions
--[**11-10**]: Transudative effusions s/p R thoracentesis
--[**2114-12-10**]: Transudative effusions s/p B thoracentesis
# CRI (baseline creat ~2.5) [**1-5**] hypertensive nephrosclerosis
# Diastolic CHF (EF 55%)
# MVP (3+ MR)
# Sick sinus syndrome s/p pacemaker
# HTN
# Anemia of chronic disease
# Hyperlipidemia
# Rheumatoid arthritis
# Osteoarthritis
# Osteoporosis
Social History:
# Professional: Retired nurse.
# Tobacco: Prior 20+ year smoking history.
# Alcohol: None.
Family History:
Noncontributory
Physical Exam:
VS: Temp 97.8, BP 160/59, HR 88, RR 25, O2sat 94 on 1L NC --> 88
on 1L NC when repositioned in bed
GEN: NAD
HEENT: PERRL, EOMI, anicteric, MMM, OP clear
NECK: No LAD, no JVD
RESP: Dullness to percussion and no breath sounds noted at
bilateral bases to ~1/2 up lung fields, B apices clear, no
wheezing
CV: RRR, S1 and S2, no m/r/g
ABD: Soft, ND, NT, BS+
EXT: W/W/P, no edema
Pertinent Results:
Notable labs:
.
[**2115-2-5**] 07:35AM BLOOD Glucose-111* UreaN-46* Creat-2.3* Na-136
K-4.3 Cl-100 HCO3-24 AnGap-16
[**2115-2-5**] 01:58PM BLOOD Type-ART pO2-51* pCO2-47* pH-7.38
calTCO2-29 Base XS-1 Intubat-NOT INTUBA
.
Imaging:
.
# OSH CT chest ([**1-30**]): Post left thoracentesis with considerable
edema in the lower half of the left lung felt to be related to
re-expansion. left upper lung and right lung are clear although
chronic changes are present. small amounts of residual bilateral
pleural fluid. less than 10% left sided pneumothorax.
.
# OSH CXR ([**1-31**]): Dense left lower lob infiltrate with patchy
right lower lobe infiltrate, left pleural effusion suspected.
.
# CHEST (PORTABLE AP) [**2115-2-6**] 5:27 AM
1. Status post left pigtail catheter placement in left upper
chest with new left-sided pneumothorax at the base.
2. More severe right-sided pleural effusion.
3. Stable increased retrocardiac opacity likely representing
compressive atelectasis.
.
# RENAL U.S. [**2115-2-7**] 3:27 PM: Small, symmetrical kidneys with
thin cortex. No hydronephrosis and no stones or solid masses.
Bilateral pleural effusion.
.
# CHEST (PORTABLE AP) [**2115-2-10**] 3:04 PM: Bilateral pleural
effusions, slightly increased with the greater portion of the
fluid loculated within the mid lung fields.
Brief Hospital Course:
77F h/o HTN, CRI [**1-5**] hypertensive nephropathy, diastolic CHF,
chronic pleural effusions, transferred to [**Hospital1 18**] from OSH to
undergo pleuroscopy, then transferred to MICU from IP suite
after hypoxia during aborted pleuroscopy, s/p pigtail catheter
to drain L pleural effusion, s/p talc pleurodesis, treated for
aspiration PNA, COPD, and CHF.
.
# Hypoxia: Pt became hypoxic after OSH thoracentesis, and again
later during attempted pleuroscopy at [**Hospital1 18**]. Hypoxia was
considered likely [**1-5**] underlying COPD, volume overload, chronic
pleural effusions, and aspiration PNA given history of vomiting
and report of opacity on CXR at OSH. Pt was administered
clindamycin for aspiration PNA, and albuterol/ipratropium
nebulizers for COPD. Pigtail cathether was placed to drain
effusions; L pneumothorax was then also noted, which resolved.
Pt completed clindaymycin x10 days for aspiration pneumonia,
with improvement in her respiratory status.
.
# Pleural effusions: Pt underwent talc pleurodesis at L pleura
per IP, with no further interventions anticipated.
.
# Diastolic CHF: Pt had known significant MR [**First Name (Titles) 151**] [**Last Name (Titles) 61935**] EF.
On transfer to floor from MICU, pt appeared euvolemic, with no
JVD and no peripheral edema. Pt's home regimen of furosemide 20
mg QOD, lisinopril 40 mg [**Hospital1 **] were continued.
.
# HTN: Pt was initially continued on home regimen of verapamil
240 mg daily and lisinopril 40mg [**Hospital1 **], and was restarted on
hydralazine 50 mg PO BID per home regimen upon transfer to the
floor. Given no known h/o ventricular or supraventricular
arrhythmias, as well as development of long QTc, sotalol was
discontinued permanently. Pt was started on HCTZ and metoprolol
50mg TID, to be uptitrated as an outpatient.
.
# UTI: Pt was noted to have a pan-sensitive E. Coli UTI, and was
started on ciprofloxacin x10 days given Foley instrumentation.
.
# Chronic renal insufficiency: Pt was noted to develop prerenal
ARF [**1-5**] poor PO and overdiuresis; this resolved after adequate
hydration.
.
# Hyperlipidemia: Pt continued on pravastatin 20mg PO daily, and
ASA 81mg daily.
.
# DNR/DNI
Medications on Admission:
Meds at home:
Sotalol 40 mg [**Hospital1 **]
Pravastatin 20 mg daily
Multivitamin
Furosemide 20 mg QOD
Lisinopril 40 mg [**Hospital1 **]
Hydralazine 50 mg [**Hospital1 **]
Verapamil 240 mg daily
Hydroxychloroquine 200 mg daily
Aspirin 81 mg daily
Caltrate
Oxygen via nasal cannula, 2 L
.
Medications on transfer to [**Hospital1 18**]:
Esomeprazole 40 mg IV daily
Hydralazine 50 mg PO q6h
Verapamil SR 240 mg PO daily
Hydroxychloroquine 200 mg PO daily
Aspirin 81 mg daily
Clindamycin 600 mg IV q8h
Alprazolam 0.5 mg PO prn
.
Meds on transfer to MICU:
Ondansetron
Pantoprazole 40 mg daily
Verapamil 240 mg daily
Plaquenil 200 mg [**Hospital1 **]
Clindamycin 600 mg IV q8h
Alprazolam 0.5 mg Qhs prn
Acetaminophen PRN
Heparin SC TID
.
Allergies: PCN / erythromycin
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 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. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q4H (every 4 hours) as needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
13. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
18. Ondansetron 4 mg IV Q8H:PRN
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
Hypoxia
Congestive Heart Failure (acute on chronic diastolic)
Chronic Pleural Effusions
COPD
Chronic Renal Insufficiency
Mitral Valve Prolapse with 3+MR
Hypertension
.
Secondary:
Sick Sinus Syndrome s/p pacer
Rheumatoid Arthritis
Anemia of Chronic Disease
Hyperlipidemia
Discharge Condition:
Stable, blood pressures still running high, actively uptitrating
metoprolol for further control.
Discharge Instructions:
You were admitted with hypoxia during pleuroscopy, and were
maintained with a pigtail catheter to drain a left sided pleural
effusion, and were treated for aspiration pneumonia, UTI, COPD,
and CHF.
.
During this admission, Sotalol was stopped. Please do not take
this medication anymore. Because you blood pressure was running
high, we increased your dose of metoprolol to 50 three times
daily on discharge, but this should be continued to be increased
to better control your blood pressure. Additionally, you will
remain on the following medications: lisinopril 40mg daily, HTCZ
25mg daily, hydralazine 50 mg PO Q6H for your blood pressure.
.
Additionally, you were noted to have hematuria on this
admission, which resolved by the time of discharge. We believe
that this was secondary to a UTI (catheter related), so you will
complete a 10 day course of ciprofloxacin for this (this will
also treat a presumed aspiration pneumonia as well).
.
Please return to hospital for fevers, shortness of breath, chest
pain or other symptoms that concern you.
Followup Instructions:
Please follow up with your primary care physician.
Completed by:[**2115-2-17**]
|
[
"E849.7",
"428.0",
"V45.01",
"V46.2",
"424.0",
"799.02",
"507.0",
"512.1",
"511.9",
"714.0",
"041.4",
"403.90",
"V15.82",
"E879.6",
"707.03",
"276.8",
"996.64",
"428.33",
"599.0",
"272.4",
"585.9",
"V64.1",
"E879.8",
"584.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
8773, 8911
|
4214, 6404
|
298, 352
|
9235, 9334
|
2878, 4191
|
10433, 10515
|
2451, 2468
|
7216, 8750
|
8932, 9214
|
6430, 7193
|
9358, 10410
|
2483, 2859
|
251, 260
|
380, 1900
|
1922, 2327
|
2343, 2435
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,630
| 193,154
|
23601
|
Discharge summary
|
report
|
Admission Date: [**2106-10-25**] Discharge Date: [**2106-11-12**]
Date of Birth: [**2054-5-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Biliary Bypass
Mesenteric Mass Biopsy
Segmental Left Colectomy with Primary Anastomosis
History of Present Illness:
Mr. [**Known lastname 60401**] is a 52-year-old gentleman who is
status post Whipple procedure in [**2105**] for pancreatic cancer.
He is from [**Country 3399**] and over the month prior to admission,
developed an increasing amount of abdominal pain and
jaundice. Prior to flying to the United States from [**Country 3399**], he
developed fevers and had some amount of emesis. He had
decreased bowel movements. A colonoscopy in [**Country 3399**] revealed an
adenocarcinoma of his descending colon. He presented to this
hospital as a direct admission on the [**3-25**]. He was
febrile to 101.0. His hematocrit was 24.9 and his white count
was 13,000. As mentioned, he is status post Whipple procedure
in [**2105-5-24**]. A CT scan was performed which revealed a mass
just anterior to the aorta as well as a dilated afferent limb
consistent with obstruction of that limb. The working
diagnosis prior to operation was recurrent tumor obstructing
his afferent limb. In addition, he has a colon mass which is
intermittently bleeding.
He also underwent chemoradiotherapy.
Past Medical History:
Ulcerative Colitis (Dx: [**2095**] with blood stools and C-scope, DCed
Rx 5 months ago; No Sx for 5 years), GERD, Hemorrhoids S/P
Surgery
s/p whipple for periamp adeno ca ([**2105**])
Social History:
He lives in [**State 350**], but regularly goes to [**Country 3399**] to see
his family, including his ex-wife. [**Name (NI) **] has two kids and ten
siblings. He currently smokes and has 35 p-y. He does not use
alcohol or drugs.
Family History:
His brother and sister have [**Name (NI) 2320**]. There is no billiary,
pancreatic or liver disease. No known CAs.
Physical Exam:
VS: 101.3, 90, 110/57, 16, 98%
HEENT: PERRLA, EOMI, anicteric, no cervical lymphadenopathy, no
JVD
Chest: CTA bilat.
CV: RRR, S1, S2, no murmurs
GI: aoft, nondistended, +epigastric and RUq pain, no peritoneal
signs, no [**Doctor Last Name 515**] sign
Ext: FROM all ext., no LE edema
Skin: warm, no rashes
Pertinent Results:
[**Numeric Identifier 49357**] CHANGE PERC TUBE OR CATH W/CONTRAST [**2106-11-2**] 7:34 AM
Reason: biliary obstruction
Contrast: OPTIRAY
CLINICAL HISTORY: Biliary obstruction.
The skin surrounding the skin exit site and tract were
infiltrated with approximately 8 cc of buffered 1% Xylocaine for
local anesthetic. The retention suture was cut. The catheter was
accessed using a 0.035-inch Bentson guidewire which was advanced
under fluoroscopic visualization uncoiling the retention pigtail
within the bowel. The catheter was then removed leaving the
guidewire in situ. Subsequently, a 7 French bright tip sheath
was advanced over the guidewire to the central right hepatic
duct. A pullback, over-the-wire cholangiogram was performed
which demonstrates free flow of the contrast column via the
dilated afferent limb to the ligament of Treitz. At the level of
the ligament of Treitz, this appears to be a blind ending
terminus. The new jejuno-jejunostomy described in the operative
note was not visualized. As such, the latter is presumed
occluded. There is no extravasation of contrast. Subsequently,
the 7 French bright tip sheath was then removed leaving the
guidewire in situ and exchanged for a new, 10 French
internal/external biliary drain. The distal segment was placed
within the afferent limb with the marker in a central right
hepatic duct. The catheter was secured using a 2-0 silk,
retention suture at the skin entrance site. This was reinforced
with a StatLock device. No complications were encountered
immediately. Estimated blood loss was minimal.
IMPRESSION:
1. Non-visualization of new jejuno-jejunostomy which is thus
presumed occluded.
2. Obstructed afferent limb, s/p Whipple procedure.
3. 10 French internal/external biliary drainage placed to
gravity drainage. see above.
CT ABDOMEN W/CONTRAST [**2106-11-2**] 5:10 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: eval for afferent loop obstruction
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
52 year old man s/ whipple now with obstructive [**Last Name (un) **], fevers, wbc
REASON FOR THIS EXAMINATION:
eval for afferent loop obstruction
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 52-year-old with history of prior pancreatic cancer
post-Whipple in [**2105**], history of colon cancer post-colonic
resection several days earlier. Now with obstructive symptoms
and fevers, assess for afferent loop obstruction.
COMPARISON: CT of [**2106-10-26**] and percutaneous cholangiogram done
the same day.
CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: Consolidation at
the left lung base has improved with atelectatic changes still
present. There is persistent consolidation of the right lung
base, though somewhat improved from the prior examination.
Bilateral pleural effusions are unchanged. Two small nodules
measuring roughly 2-3 mm are seen along the right minor fissure.
The patient is post-Whipple procedure. A transhepatic biliary
drainage catheter is seen traversing the right lobe of the liver
and terminating in a loop of jejunum. Mild left intrahepatic and
central intrahepatic ductal dilation is present along with
pneumobilia. There is an old afferent loop of jejunum seen which
does not contain oral contrast. There has been creation of a new
jejunal bypass loop from the region of small bowel where the
biliary drainage catheters terminate, coursing superiorly and
anteriorly in the transverse mesocolon just posterior to the
transverse colon, and apparently anastomosing in the region of
the gastrojejunostomy. Oral contrast material is seen in the
stomach and coursing freely into more distal loops of small
bowel. The oral contrast material seen in this new bypass loop
may be secondary to reflux from the gastrojejunostomy site.
There is a small amount of ascites. Numerous enlarged lymph
nodes seen in the peritoneum and retroperitoneum are unchanged.
The soft tissue mass anterior to the aorta is again visualized
and not significantly changed. There is no new intraabdominal
fluid collection. Diffuse stranding of the mesentery is present.
A small amount of free air is seen consistent with recent post-
surgical status. The spleen and adrenals, and right kidney are
normal. The left kidney demonstrates a delayed nephrogram and
mild pelvic fullness. The proximal left ureter is also slightly
dilated. It is visualized coursing inferior to the level of
retroperitoneal lymphadenopathy and in the region of the soft
tissue mass anterior to the aorta. The ureter is not clearly
visualized beyond this site.
CT OF THE PELVIS WITH ORAL AND IV CONTRAST: Patient has
undergone interval descending colonic resection, with the
anastomotic site seen in the left lower quadrant. The sigmoid
and rectum are unremarkable other than several diverticula in
the sigmoid. The bladder is distended. A tiny focus of air is
seen in the bladder, likely due to recent catheterization.
Prostate is normal. There is no free fluid or pathologic
lymphadenopathy in the pelvis.
Soft tissues demonstrate mild edema and stranding. Osseous
structures are unremarkable.
Coronal and sagittal reformatted images were imperative in
delineating and confirming the above findings.
IMPRESSION:
1. No obvious evidence of bowel obstruction. Contrast is seen in
the new jejunal bypass limb, possibly refluxing from the
gastrojejunostomy. No contrast is seen in the old afferent limb.
There are no dilated loops of small bowel.
2. Right lower lobe pneumonia.
3. Delayed nephrogram and mild hydronephrosis of the left
kidney, likely due to functional ureteral obstruction due to
lymphadenopathy in the retroperitoneum.
4. No significant change in the appearance of the soft tissue
mass anterior to the aorta and inferior to the superior
mesenteric artery. No change in mesenteric and retroperitoneal
lymphadenopathy.
Findings were discussed at approximately 3:00 p.m. with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] on [**2106-11-3**].
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 60402**],[**Known firstname **] [**2054-5-28**] 52 Male [**-6/3940**]
[**Numeric Identifier 60403**]
[**Doctor Last Name **].
[**Numeric Identifier 60404**] GALLBLADDER, DUODENAL JUNCTION, WHIPPLE.
[**Numeric Identifier 60405**] ERCP.
I. Mesenteric mass (A-B):
Metastatic adenocarcinoma.
II. Left colon (C-L):
Adenocarcinoma, see synoptic report.
Colon and Rectum: Resection Synopsis
MACROSCOPIC
Specimen Type: Colonic resection. Location: Left.
Specimen Size
Greatest dimension: 9.0 cm. Additional dimensions: 4.0
cm.
Tumor Site: Left (descending) colon.
Tumor configuration: Ulcerating.
Tumor Size
Greatest dimension: 5 cm. Additional dimensions: 3 cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: Low-grade (well differentiated).
EXTENT OF INVASION
Primary Tumor: pT4b: Tumor penetrates the visceral peritoneum.
Regional Lymph Nodes: pN1: Metastasis in 1 to 3 lymph nodes
(see note).
Lymph Nodes
Number examined: 10.
Number involved: 3.
Distant metastasis: PMX: Cannot be assessed.
Margins
Proximal margin:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 20 mm.
Distal margin:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 25 mm.
Circumferential (radial) margin:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 41 mm.
Lymphatic Small Vessel Invasion: Present. Extramural.
Venous (large vessel) invasion: Absent.
Perineural invasion: Present.
Tumor border configuration: Infiltrating.
ADDENDUM #1:
with REVISED DIAGNOSIS
1. Metastatic adenocarcinoma of the biliary tract, involving the
colon (transmural), mesenteric mass and pericolic lymph nodes.
.
2. Immunostains of the colonic tumor (slide E) are strongly
positive for both cytokeratins CK-7 and CK-20, with satisfactory
controls. This immunoprofile supports that the carcinoma is a
metastatic biliary tumor rather than a primary colonic lesion.
Note: The synoptic report for colon tumor (see above) is
rescinded. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 468**] was notified by e-mail on [**2106-11-4**].
ADDENDUM #2
Upon further review, the mesenteric mass (part I) was in the
mesenteric root whereas the colonic tumor (part II) was in the
proximal sigmoid area. Considering both the gross and histologic
features, it is not possible to completely distinguish whether
the colonic tumor is primary or metastatic. The case was
discussed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 468**] on [**2106-11-5**]..
Addendum added by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/hg
Date: [**2106-11-5**]
C1894 INT.SHTH NOT/GUID,EP,NONLASER [**2106-10-25**] 9:28 AM
Reason: place internal/external PTCs to decompress biliary tree.
th
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
52M with likely recurrent pancreatic cancer causing obstructive
jaundice & cholangitis
PROCEDURE AND FINDINGS: After injection of 5 cc of 1% lidocaine,
and using a 21-gauge needle that was introduced into the tenth
intercostal space in the mid axillary line in the right abdomen,
access was gained into the biliary duct from the right side,
after injection of contrast material. A 0.018 guidewire was then
advanced under fluoroscopic guidance into the site of
anastomosis, and the needle was then exchanged for an Accustick
sheath over the wire and its tip was positioned in the jejunum.
Cholangiogram was performed, demonstrated dilation of
intrahepatic biliary system, patent hepaticojejunostomy
anastomosis, but markedly dilated bowel loop. A 0.035 [**Last Name (un) 7648**]
wire was then advanced into the hepaticojejunostomy and the
Accustick sheath was removed and exchanged for a 8 French
internal external biliary catheter that was placed over the wire
with the loop formed in the bowel loop. The guidewire was then
removed. The catheter was secured to the skin, connected to the
bag and opened for external drainage. The patient tolerated the
procedure well. There were no immediate post-procedural
complications.
IMPRESSION:
1. Intrahepatic dilation of the biliary system.
2. Patent hepaticojejunostomy, but markedly dilated bowel loops.
3. Uncomplicated placement of percutaneous internal external
biliary drainage tube.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2106-10-25**] 1:35 AM
Reason: fever, RUQ abdominal pain, nausea, vomiting
COMPARISONS: Outside hospital CTs are not available. Studies
compared to CT abdomen of [**2105-5-6**] which is post-Whipple.
RIGHT UPPER QUADRANT ULTRASOUND: Per report, patient is status
post Whipple procedure and cholecystectomy. The liver is
diffusely coarsened without focal lesions with the exception of
a small simple cyst in the lateral left lobe. There is
intrahepatic biliary ductal dilatation and marked dilatation of
the extrahepatic common duct measuring up to 1.4 cm, extending
into a large cystic lesion which appears to be obstructing the
extrahepatic common duct. Per report from outside hospital CT,
this represents large necrotic nodal mass in the peripancreatic
region, though it is difficult to distinguish from obstructed,
nonperistalting small bowel at the anastomotic site on this
ultraound. It is difficult to accurately measure but is at least
7.5 x 6 x 6 cm. Right kidney demonstrates no evidence of
hydronephrosis. There is a single 1-cm echogenic lesion, likely
an AML but not well characterized.
IMPRESSION:
1) Large cystic mass vs. less likely dilated, nonperistalting
bowel at the biliary enteric anastomosis causing biliary
obstruction. Per correlation with the report from the outside
hospital CT from [**Country 3399**], there are large necrotic lymph nodes in
this region, which may be secondary to recurrence of the
patient's primary pancreatic cancer or metastatic disease from
the patient's suspected colon cancer. If there is any
uncertainty, a repeat CT could be performed.
2) Suboptimal evaluation of the liver. Single simple cyst in the
left lobe.
3) 1-cm echogenic lesion within the right kidney, likely an AML,
but again see recent outside hospital CT for confirmation.
Brief Hospital Course:
He was admitted to [**Hospital1 18**] on [**2106-10-25**]. He presented with recurrent
pancreatic cancer causing obstructive jaundice & cholangitis.
On [**2106-10-25**] He went for a Intrahepatic dilation of the biliary
system and had a patent hepaticojejunostomy, but markedly
dilated bowel loops. He then had an uncomplicated placement of
percutaneous internal external biliary drainage tube.
A CT on [**10-26**] showed Abnormal soft tissue density mass in the
pancreatic head surgical resection site, concerning for tumor
recurrence. It was decided to then proceed to the OR for
resection of this mass and a right colectomy. He tolerated the
procedure well. The Right internal/external biliary tube
drainage placed, and continues to be only route of bile
drainage.
.
Post-operatively he was NPO with IV fluids. His pain was well
controlled with an epidural. His diet was slowly advanced once
he had return of bowel function.
He then went for a Biliary tube check on [**2106-11-2**] that showed
non-visualization of new jejuno-jejunostomy which is thus
presumed occluded. An obstructed afferent limb, s/p Whipple
procedure. A 10 French internal/external biliary drainage placed
to gravity drainage.
Overall he was feeling better and his Total Bili was trending
down. The tube continued with external drainage. On POD 12, his
drain was capped and we monitored his LFT's for changes. His
LFT's continued to trend down with a TBili of 1.9 on [**2106-11-12**]
(Tbili was 7.1 on [**2106-11-3**]) and the drain therefore remained
capped and secured to his side.
Pertinent Cultures:
Blood cultures from [**10-25**] showed AEROMONAS SPECIES pan-sensitive.
Bile cultures from [**10-25**] showed ENTEROCOCCUS and from [**10-27**] showed
ESCHERICHIA COLI and ENTEROCOCCUS. Urine Cx from [**2106-11-2**] showed
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Medications on Admission:
theophylline
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*qs Tablet(s)* Refills:*2*
2. 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*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent Pancreatic Head Mass
Colon Cancer
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
Please resume all of your regular medications and take any new
medications as ordered.
Continue to walk several times per day.
Keep your drain covered with a gauze dressing and occlusive
dressing. Keep that area clean and dry.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in [**3-27**] weeks. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2106-11-17**] 9:00
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2106-11-17**] 9:00
Completed by:[**2106-11-15**]
|
[
"995.91",
"V10.09",
"153.2",
"530.81",
"038.49",
"196.2",
"576.1",
"576.2",
"996.59",
"197.6",
"198.89",
"199.1",
"556.9",
"560.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"51.94",
"87.51",
"51.98",
"45.75",
"54.23"
] |
icd9pcs
|
[
[
[]
]
] |
17340, 17398
|
14827, 16674
|
330, 420
|
17486, 17493
|
2444, 4399
|
17930, 18350
|
1988, 2104
|
16737, 17317
|
11532, 14804
|
17419, 17465
|
16700, 16714
|
17517, 17907
|
2119, 2425
|
276, 292
|
4548, 11495
|
448, 1518
|
1540, 1725
|
1741, 1972
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,391
| 160,880
|
55168
|
Discharge summary
|
report
|
Admission Date: [**2155-6-13**] Discharge Date: [**2155-6-15**]
Date of Birth: [**2091-4-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
bronchoscopy [**2155-6-13**]
History of Present Illness:
64M with PMH significant for
right-sided nonsmall celll lung cancer stage IIIb s/p
neoadjuvant
chemoradiation therapy with good response presented today with
dyspnea. He is s/p right upper lobectomy and wedge resection of
RLL on [**2155-5-23**] performed at [**Hospital **] Hospital. He was discharged
after an uneventful course but returned to the ED the next day
with dyspnea. A CXR revealed pneumothorax, and ultimately he
required two weeks of inpatient treatment. He was then
discharged on a pneumostat, and came up to [**Location (un) 86**] for vacation.
Last evening, he developed acute dyspnea. In the ED a portable
CXR was ordered and basic labs drawn.
Past Medical History:
right-sided nonsmall cell lung cancer stage IIIb s/p neoadjuvant
chemoradiation therapy with good response.
Social History:
Tobacco: Quit < 1 year ago, Alcohol: Heavy; beer daily time(s);
Recreational Drugs: None.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
T=98.6, HR=119 (sinus), 151/93, 16, 96% on 4L NC
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [ ] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[X] Abnormal findings: decreased respirations on right side
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
[**2155-6-13**] 11:00AM WBC-12.3* RBC-4.65 HGB-14.1 HCT-42.4 MCV-91
MCH-30.3 MCHC-33.2 RDW-13.8
[**2155-6-13**] 11:00AM NEUTS-91.7* LYMPHS-3.2* MONOS-4.8 EOS-0.2
BASOS-0.2
[**2155-6-13**] 11:00AM PLT COUNT-418
[**2155-6-13**] 11:00AM PT-10.8 PTT-30.9 INR(PT)-1.0
CXR: subcutaneous emphysema, pneumothorax, right-[**Hospital1 **] tracheal
deviation, no blunting of right costophrenic angle, no evidence
of effusion
Brief Hospital Course:
64M with PMH significant for right-sided nonsmall cell lung
cancer stage IIIb s/p neoadjuvant chemoradiation therapy with
good response presented to the hospital with
dyspnea. He is s/p right upper lobectomy and wedge resection of
RLL on [**2155-5-23**] performed at [**Hospital **] Hospital. In the ED a
portable CXR was ordered and basic labs drawn. His pneumostat
was switched to a Pleurovac to suction. A repeat CXR showing
improvement.
Given given his recent right upper lobectomy, there was concern
for a bronchial stump leak or bronchopleural fistula formation
responsible for his pneumothorax. So, he underwent bronchoscopy
to rule this out. The bronchoscopy showed a middle lobe
positional occlusion, likely due to kinking of the middle
bronchial stem as the middle lobe expanded in the absence of the
upper lobe. There was no evidence to suggest a bronchopleural
fistula or a bronchial stump air leak.
During his entire course, he was satting well and ambulating
without difficulty. Attempts to wean him down to waterseal were
successful. Finally, we placed him on pneumostat again, which
this time showed no air leak. A final CXR was negative for
increased pneumothorax, and he was discharged to home in stable
condition.
Medications on Admission:
1. Citalopram 20 mg PO DAILY
2. Lorazepam 1 mg PO Q4H:PRN anxiety
3. Oxycodone-Acetaminophen (5mg-325mg) [**12-16**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-16**] Tablet(s) by mouth
q4-6 hours Disp #*30 Tablet Refills:*0
4. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation 2 puffs [**Hospital1 **]
5. Albuterol Inhaler [**12-16**] PUFF IH Q6H
6. Aspirin 325 mg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 Capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*1
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Lorazepam 1 mg PO Q4H:PRN anxiety
3. Oxycodone-Acetaminophen (5mg-325mg) [**12-16**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-16**] Tablet(s) by mouth
q4-6 hours Disp #*30 Tablet Refills:*0
4. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation 2 puffs [**Hospital1 **]
5. Albuterol Inhaler [**12-16**] PUFF IH Q6H
6. Aspirin 325 mg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 Capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
small persistent air leak, right middle lobe bronchus collapse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after worsening shortness of breath
and right sided chest pain. You are now doing much better with
minimal intermittent sharp pain and no shortness of breath. Your
pigtail catheter is hooked back up to a pneumostat. You will be
seen by your thoracic surgeon in [**State 531**] in follow up tomorrow.
Please call your physician or go to the emergency department if
you develop worsening shortness of breath or chest pain or have
any symptoms that concern you.
Take percocet for pain control as needed.
Take colace as a stool softener as needed while taking
narcotics.
Do not drive while taking percocet.
Shower but do not bathe. Keep the insertion site of the pigtail
catheter clean and dry.
Followup Instructions:
Follow up with your thoracic surgery in [**State 531**].
Follow up with your primary care physician in [**Name9 (PRE) 531**].
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office as needed for follow up.
Division of Thoracic Surgery and Interventional Pulmonology
Department of Surgery
[**Hospital1 69**]
[**Hospital Ward Name 517**], [**Hospital Ward Name 121**] Entrance - [**Hospital1 **] Building, [**Apartment Address(1) **]
[**Street Address(2) 8667**]
[**Location (un) 86**] , [**Telephone/Fax (1) 112527**]
|
[
"162.9",
"V45.76",
"V15.82",
"518.0",
"512.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
6089, 6095
|
3650, 4898
|
286, 317
|
6202, 6202
|
3202, 3627
|
7113, 7663
|
1267, 1285
|
5506, 6066
|
6116, 6181
|
4924, 5483
|
6353, 7090
|
1315, 3183
|
239, 248
|
345, 1013
|
6217, 6329
|
1035, 1144
|
1160, 1251
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,623
| 160,216
|
4741
|
Discharge summary
|
report
|
Admission Date: [**2164-12-13**] Discharge Date: [**2164-12-22**]
Date of Birth: [**2093-7-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2164-12-17**] Three Vessel Coronary ARtery Bypass Grafting utilizing
left internal mammary artery to left anterior descending, and
vein grafts to obtuse marginal and posterior descending artery
History of Present Illness:
This is a 71 yo M w h/o HTN, CAD s/p multiple stents, asthma and
type 2 diabetes presents with CP 3 days after cardiac cath.
Patient states that he developed sharp pain in the center of his
chest, occurring at rest starting last night. He took 10 SL
nitro, and achieved relief of his pain after each dose, but
recurred again. He was able to go to sleep that night. He denied
any radiation of the pain to his neck or arms, or any associated
nausea, diaphoresis, or SOB associated with this chest pain. He
denies any positional component to his pain. He has no fevers,
chills, or productive sputum, but has had a dry cough recently.
He states that this is different from both his asthma and his
GERD, and is also unlike the shortness of breath and jaw
tightness he develops when going up stairs. He does not remember
whether this is his anginal equivalent. He was most recently
seen by his cardiologist for continuing anginal symptoms and at
that time was referred for a cath. This was performed 3 days
ago, and showed 3 vessel disease (LMCA w/80% distal stenosis,
LAD w/ 60% stenosis, distal LCx w/70% stenosis, first OM w/60%
stenosis, RCA 70% distal stenosis), and patient was scheduled
for CABG. In the ED, he received nitro SL and morphine IV with
relief of his pain. A first set of cardiac enzymes were
negative. His EKG showed minimal ST elevations <1mm in V3/V4,
and he was placed on a Heparin gtt and given BB, ASA, and
subsequently admitted for surgical revascularization.
Past Medical History:
Coronary artery disease, History of MI, History of PCI/stenting
to LAD in [**2161**], Hypertension, Hypercholesterolemia, Diabetes
Mellitus Type II, Asthma, Peripheral Neuropathy, Benign
Prostatic Hypertrophy - s/p TURP, Chronic Back pain - s/p
Laminectomy, Cervical Myelopathy, Penile Implant [**2158**]
Social History:
Mr. [**Known lastname 14502**] is originally from [**Male First Name (un) 1056**]. He emigrated to the
US in [**2116**]. urrently retired security officer at [**Location (un) 19930**]Hospital. Lives with second wife; no tobacco or alcohol; travels
to residence in [**Male First Name (un) 1056**] several times each year, last in
[**7-25**]; no ethanol since [**2159**]; no tobacco since [**2139**]. Incurred
injury to neck and back from job-related fall. He is currently
on disability. He has 6 children, 3 grandchildren and 1
great-grandchild.
Family History:
Mother died by suicide, Father with leg tumor; one sib with
cirrhosis, another with history of closed head injury; other
sibs with ethanol and tobacco use history. Had 3 brothers all
deceased, 1 brother that died from asthma, 1 from stroke and 1
died in an MVA.
Physical Exam:
VS: 98.0 BP 106/64 HR 48 RR 18 O2sat 97% 3L.
Gen: well appearing in NAD. Able to speak in full sentences.
heent: MMM. No oral ulcers. JVD flat.
neck: No carotid bruits.
cvs: RRR. No MRG.
chest: Diminished breath sounds. Expiratory wheezing bilaterally
in upper lobes.
abd: Soft, obese. Normoactive BS.
ext: No CCE. 2+DP/PT/radial pulses.
Discharge
VS temp 97.3 HR 93 SR B/P 105/81 RR 18 O2 Sat 98% 2lNC at rest
RA Sat 90 with Ambulation wt 84.9kg
Neuro Alert and oriented x3 nonfocal
Pulmonary: lungs clear to auscultation ant/post
Cardiac RRR no murmur/rub/gallop
Sternal inc midline healing scant amt serous drainage distal
end, no erythema, sternum stable
Leg: left EVH steristrips no erythema, no drainage
Ext warm pulses palpable, edema LE +1 L>R
Abd soft, nontender, nondistended
Pertinent Results:
[**2164-12-22**] 05:55AM BLOOD WBC-11.1* RBC-2.86* Hgb-9.0* Hct-25.9*
MCV-91 MCH-31.4 MCHC-34.7 RDW-12.8 Plt Ct-242
[**2164-12-19**] 02:46AM BLOOD WBC-24.5*# RBC-3.23* Hgb-10.1* Hct-29.4*
MCV-91 MCH-31.3 MCHC-34.4 RDW-13.0 Plt Ct-162
[**2164-12-13**] 02:50PM BLOOD WBC-9.9 RBC-4.14* Hgb-12.9* Hct-37.2*
MCV-90 MCH-31.2 MCHC-34.7 RDW-12.8 Plt Ct-227
[**2164-12-19**] 07:08PM BLOOD Neuts-85* Bands-0 Lymphs-8* Monos-4 Eos-2
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2164-12-13**] 02:50PM BLOOD Neuts-55.1 Lymphs-31.1 Monos-7.5 Eos-5.4*
Baso-0.9
[**2164-12-22**] 05:55AM BLOOD Plt Ct-242
[**2164-12-20**] 09:55AM BLOOD PT-13.1 PTT-28.9 INR(PT)-1.1
[**2164-12-13**] 02:50PM BLOOD Plt Ct-227
[**2164-12-14**] 05:55AM BLOOD PT-13.2* PTT-51.8* INR(PT)-1.2*
[**2164-12-22**] 05:55AM BLOOD Glucose-131* UreaN-26* Creat-1.4* Na-137
K-5.2* Cl-100 HCO3-30 AnGap-12
[**2164-12-19**] 07:08PM BLOOD Glucose-127* UreaN-23* Creat-1.6* Na-135
K-4.4 Cl-100 HCO3-26 AnGap-13
[**2164-12-13**] 02:50PM BLOOD Glucose-92 UreaN-25* Creat-1.3* Na-136
K-4.8 Cl-103 HCO3-26 AnGap-12
[**2164-12-19**] 02:46AM BLOOD ALT-25 AST-49* AlkPhos-70 Amylase-31
TotBili-1.0
Reason: evaluate for pneumonia
[**Hospital 93**] MEDICAL CONDITION:
71 year old man s/p cabg now with temps
REASON FOR THIS EXAMINATION:
evaluate for pneumonia
CHEST
HISTORY: CABG, fever, evaluate for pneumonia.
Two views. Comparison with the previous study of [**2164-12-19**]. There
is streaky density at the lung bases and in the left upper lobe
consistent with subsegmental atelectasis, as before. Blunting of
the posterior costophrenic sulci probably represents very small
pleural effusions. The patient is status post median sternotomy
and CABG. Mediastinal structures are unchanged. The bony thorax
is grossly intact.
IMPRESSION: Bilateral subsegmental atelectasis and possible
small bilateral pleural effusions. Status post median
sternotomy. No significant interval change.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was under
general anesthesia throughout the procedure.
Conclusions:
PRE-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. There is
severe regional
left ventricular systolic dysfunction with akinesis of the
anterior septum and
anterior wall.. The remaining left ventricular segments contract
normally.
Right ventricular chamber size and free wall motion are normal.
There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve
leaflets. The aortic valve leaflets (3) are mildly thickened.
There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is
no pericardial effusion.
POST CPB: LV systolic function globally improved on inotropic
support
(epinephrine). LVEF now 40 %. Akinetic anteroseptal mid and
apical segments.
Tivial MR [**First Name (Titles) **] [**Last Name (Titles) **] as described. TR is mild. The aortic contour is
intact post
decannulation.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2164-12-17**] 16:45.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr. [**Known lastname 14502**] was admitted to cardiology service. Cardiac enzymes
remained flat. Due to persistent chest pain at rest, he was
maintained on intravenous Heparin and Nitroglycerin. Plavix was
held in anticipation of surgery. His preoperative course was
otherwise unremarkable and he was cleared for surgery. On
[**12-17**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting. For additional surgical details, please see seperate
dictated operative note. Following the operation, he was brought
to the CSRU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated on postoperative day
one. He experienced bouts of atrial fibrillation which was
initially treated with intravenous Amiodarone. He remained
mostly in a normal sinus rhythm and continued to maintain stable
hemodynamics. On postoperative day two, he transferred to the
SDU. Beta blockade was advanced as tolerated. Plavix and Aspirin
were resumed. He remained in a normal sinus rhythm - no further
atrial arrhythmias. Patient was pan-cultured for postop fevers.
Workup revealed no growth to date. His postop course was
otherwise uneventful. He continued to make clinical improvements
and was eventually cleared for discharge to rehab on
postoperative day 5.
Medications on Admission:
Lovastatin 80 mg qD
Metformin 500 mg [**Hospital1 **]
Advair
Ranitidine 250 mg qD
Sulindac 200 mg qD
Toprol-XL 50 mg qD
Neurontin 400 mg [**Hospital1 **]
Plavix 75 mg qD
Roxicet 5/325 mg qD
Zetia 10 mg qDay
Lisinopril 10 mg qD
Imdur 30mg qD
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days. Tablet(s)
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 10 days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 10 days.
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Coronary artery disease - s/p CABG, Postop Paroxysmal Atrial
Fibrillation, Postop Fevers, History of MI, History of
PCI/stenting in [**2161**], Hypertension, Hypercholesterolemia,
Diabetes Mellitus Type II, Peripheral Neuropathy, Benign
Prostatic Hypertrophy - s/p TURP, Chronic Back pain - s/p
Laminectomy, Penile Implant [**2158**]
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 [**4-25**] weeks - call for appt
Dr. [**Last Name (STitle) **] in [**2-24**] weeks - call for appt
Dr. [**Last Name (STitle) 13965**] in [**2-24**] weeks - call for appt
Completed by:[**2164-12-22**]
|
[
"721.1",
"356.9",
"593.9",
"530.81",
"412",
"272.0",
"V45.82",
"401.9",
"414.01",
"250.00",
"493.90",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10173, 10246
|
7385, 8675
|
287, 486
|
10624, 10631
|
3993, 5154
|
11097, 11332
|
2906, 3169
|
8967, 10150
|
5191, 5231
|
10267, 10603
|
8701, 8944
|
10655, 11074
|
3184, 3974
|
237, 249
|
5260, 6915
|
514, 1997
|
7362, 7362
|
2019, 2325
|
2341, 2890
|
6925, 7328
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,818
| 189,492
|
52279
|
Discharge summary
|
report
|
Admission Date: [**2130-3-13**] Discharge Date: [**2130-3-15**]
Date of Birth: [**2055-12-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
right carotid stent
Major Surgical or Invasive Procedure:
Placement of right carotid artery stent (eV3 Protege Rx 7x40)
History of Present Illness:
74-year-old male with history of multiple TIA, CEA of left ICA
and failed attempt on right ICA secondary to hostile anatomy,
hypercholesterolemia, and continuing tobacco abuse presents for
carotid angiography and stenting with Dr. [**Last Name (STitle) 911**]. He is enrolled
in the Carotid Revascularization with eV3 Arterial Technology
Evolution Post Approval Study (Protocol Numer: 2007P-[**Numeric Identifier 108096**]).
Patient is a poor historian and has a poor memory at times. He
was seen by Dr. [**Last Name (STitle) 911**] in clinic in [**Month (only) 958**] and was told to stop
Atenolol and double metoprolol. He stopped atenolol but never
increased his metoprolol dosage. Per his daughter [**Name (NI) **] (nurse),
his memory is quite poor, and he is often non-compliant with
medications.
He underwent catheter placement in the right common carotid
artery via access in the right common femoral artery with
embolic protection as carotid stenosis was inaccessible by
attempted surgery with hostile neck from prior neck irradiation.
Total contrast used was 70 mL of omnipaque contrast.
On the floor, patient without complaints and desiring dinner. He
is AAOx2 (not to exact time - states [**2130-1-17**]). He can say the
days of the week backwards. He knows who the president of the
United States is.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: unknown
3. OTHER PAST MEDICAL HISTORY:
- multiple TIA, with deficit on left side of his body, without
CT evidence of stroke
- CEA of L, and attempt on R carotid with 90% stenosis, too
rostral to operate upon [**12-30**]
- Laryngeal CA s/p surgery and radiation with no recurrence
since [**2122**]
- Hypercholesterolemia
- active smoke, 40 - 60 py
- subdural hematoma after significant mechanical fall [**2127**]
Social History:
Occupation: retired
Drugs: Denies illicit drug usage
Tobacco: current tobacco usage, 40-60 pack-years history
Alcohol: Denies
Other:
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Tmax: 36.2 ??????C (97.1 ??????F)
Tcurrent: 36.2 ??????C (97.1 ??????F)
HR: 76 (73 - 81) bpm
BP: 189/80(122) {154/67(99) - 189/80(122)} mmHg
RR: 13 (9 - 16) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), Heart sounds rather
distant
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Diminished), (Left
DP pulse: Diminished), Pulses barely palpable. + by doppler
Respiratory / Chest: (Expansion: Symmetric), Globally course and
diminished
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person and place but NOT time,
Movement: Purposeful, Tone: Not assessed, LUE is 4+/5 compared
to RUE. Unable to assess RLE as had shealth in place.
Pertinent Results:
I. Imaging: CTA neck ([**2130-2-15**])
INDICATION: TIAs, carotid ultrasound revealed high-grade
stenosis on the right. The patient also has a history of
laryngeal carcinoma status post surgery and radiation a few
years ago according to a note by Dr. [**Last Name (STitle) 95245**], cardiology, dated
[**2130-2-15**].
COMPARISON: None available.
TECHNIQUE: After administering contrast intravenously, axial
images through the neck were obtained. Multiplanar reformatted
images and three-dimensional reconstructed images were made
available.
FINDINGS:
There is dense calcific arteriosclerosis of the aortic arch.
Both subclavian arteries show mild-to-moderate luminal
irregularity secondary to mixed plaque.
The bilateral common carotid artery shows similar findings.
The right common carotid artery has moderate luminal
irregularity at its origin secondary to calcific plaque. At the
level of C3, there is focal high-grade narrowing (70% luminal
narrowing) due to mixed plaque.
There is mild luminal irregularity of the right external carotid
artery.
There is mild-to-moderate luminal irregularity of the left
internal carotid artery secondary to mixed plaque with 40%
luminal narrowing. Similar changes are seen in the left external
carotid artery.
The right vertebral artery is occluded to the level of C5 where
there is thin reconstitution of flow. The right vertebral artery
luminal diameter progressively increases to the takeoff of the
PICA where it again tapers.
The left vertebral artery is occluded from its origin to the
level of C4 where there is a thin string of contrast. The lumen
remains attenuated throughout the remaining course of the left
vertebral artery, particularly the V3 and V4 segments where
there is calcific and soft plaque.
The partially visualized intracranial vessels are significant
for a severely atherosclerotic basilar artery which is likely
hypoplastic as well, with focal high-grade stenosis at its mid
portion.
Prominent bilateral posterior communicating arteries are
partially visualized.
A 1-cm diameter pocket of air just posterior to the right
submandibular gland is seen. In addition, there is diffuse
stranding of the fat of the right anterior neck within and
anterior to the carotid space. here is severe biapical pulmonary
scarring with severe underlying emphysema, partially visualized.
Mildly prominent mediastinal lymph nodes and heterogeneous
thyroid with subcentimeter hypodense nodules, some with
calcifications, are also seen.
IMPRESSION:
1. High-grade stenosis of the mid right internal carotid artery
at the level of C3.
2. Occlusion of both vertebral arteries from their origins to
the mid C2 segments with left greater than right distal disease
as well. The partially evaluated basilar artery is also severely
atherosclerotic.
3. Stranding along with a pocket of air in the right neck just
lateral to the hyoid bone. This may represent a fistula in the
setting of prior radiation, surgery and neck dissection.
Comparison with prior films and clinical correlation would be
helpful in further evaluating this finding.
4. The soft tissues of the esophagus and larynx are also mildly
edematous-appearing, likely post-radiation changes.
5. Severe biapical pulmonary scarring with underlying emphysema.
II. Labs
A. Admission
[**2130-3-13**] 09:44PM BLOOD WBC-8.0 RBC-4.08* Hgb-11.8* Hct-35.3*
MCV-87 MCH-28.8 MCHC-33.3 RDW-14.5 Plt Ct-303
[**2130-3-13**] 09:44PM BLOOD PT-13.2 PTT-30.5 INR(PT)-1.1
[**2130-3-13**] 09:44PM BLOOD Glucose-110* UreaN-12 Creat-1.0 Na-135
K-3.8 Cl-99 HCO3-26 AnGap-14
[**2130-3-13**] 09:44PM BLOOD Calcium-9.5 Phos-2.8 Mg-2.1
B. Discharge
[**2130-3-15**] 04:50AM BLOOD WBC-7.5 RBC-4.44* Hgb-12.8* Hct-38.9*
MCV-88 MCH-28.8 MCHC-32.9 RDW-14.2 Plt Ct-282
[**2130-3-15**] 04:50AM BLOOD PT-12.0 PTT-28.2 INR(PT)-1.0
[**2130-3-15**] 04:50AM BLOOD Glucose-90 UreaN-11 Creat-1.0 Na-137
K-3.6 Cl-99 HCO3-28 AnGap-14
[**2130-3-15**] 04:50AM BLOOD Calcium-10.4* Phos-2.9 Mg-2.2
Brief Hospital Course:
74-year-old male with history of multiple TIA, CEA of left ICA
and failed attempt on right ICA secondary to hostile anatomy
from prior neck irridation, hypercholesterolemia, and continuing
tobacco abuse presenting for right carotid stenting s/p
successful procedure.
# History of multiple TIAs
Patient has history of mulitple TIAs. He has deficit of slight
weakness on left side of his body without CT evidence of stroke.
CEA of left and attempt on R carotid with 90 % stenosis was too
rostral to operate upon in [**12-30**] secondary to prior neck
irridation for laryngeal cancer. CTA performed on [**2130-2-15**]
showing high grade stenosis of mid-right carotid artery at level
of C3. He status post successful stenting of right carotid
artery on [**2130-3-13**] with placement of Protege stent. Final
angiography revealed normal flow, no intracranial occlusion, no
dissection, and residual 30 % stenosis. He was transferred to
the cardiac care unit for invasive hemodynamic monitoring and
neuro checks per protocol. He briefly required a nitroglycerin
infusion for SBP > 180 but otherwise tolerated the procedure.
His right femoral cardiac cath site had a pre-procedure bruit
noted after the procedure as well in addition to a small
hematoma at discharge.
He was discharged on aspirin 325 mg PO qD indefinitely, plavix
75 mg PO qD for at least one month uninterrupted.
He will follow-up with his vascular surgeon. Dr.[**Name (NI) 5786**] office
will also schedule follow-up.
# Hypertension
Patient initially presented with SBP in 200s with subsequent
vagal reaction upon groin manipulation treated successfully with
atropine 0.5 mg and IV neosynephrine for approximately 5
minutes. As above, he was briefly on a nitroglycerin infusion in
the CCU for SBP 190.
He was continued on metoprolol 25 mg PO BID with lisinopril 10
mg PO qD, losartan 50 mg PO qD, and HCTZ 25 mg PO qD held given
contrast load. He was re-started on lisinopril 10 mg PO qD and
HCTZ 25 mg PO qD at discharge with losartan 50 mg PO qD held. He
will follow-up for a blood pressure check with his PCP, [**Name10 (NameIs) **] his
agents should be uptitrated as necessary on outpatient basis.
He will follow-up with his primary care doctor as listed for
further management.
# Chronic Kidney Disease, Stage 3 (MDRD GFR 59)
Etiology likely secondary to long-standing hypertension. Unknown
baseline without prior records. He was provided post-cath
hydration. He will have safety labs to assess renal function [**1-21**]
days after the procedure.
Creatinine at discharge was 1.
# Hypercholesterolemia
Last cholesterol panel on [**2130-2-15**] showing cholesterol 143, TG
254 (uncertain if fasting), HDL 41, LDL 51. He was continued on
simvastatin 20 mg PO qD.
# Incidental finding
CTA Neck dated [**2130-2-15**] showing stranding along with a pocket of
air in the right neck just lateral to the hyoid bone. This may
represent a fistula in the setting of prior radiation, surgery
and neck dissection. Comparison with prior films and clinical
correlation would be helpful in further evaluating this finding.
Etiology likely related to prior neck irridation.
# Rhythm: Patient was in NSR with ectopy throughout
hospitalization.
# Tobacco abuse
Patient in contemplative phase and endorses desire to smoke no
longer. He was offered smoking cessation advise in the hospital.
He should be offered continuing smoking cessation advice on
outpatient basis.
CODE: Full code (confirmed with patient and daughter)
COMM:
- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter), cell [**Telephone/Fax (1) 108097**]
- [**Name (NI) 2048**] [**Name (NI) **] (wife), home [**Telephone/Fax (1) 108098**]
# Transitions of care
- Advise secondary prevention of vascular disease. Of note, his
LDL is at goal and A1C is normal.
- Blood pressure check on [**2130-3-17**] with uptitration of agents or
re-initiation of agents (losartan) as needed and based on renal
function and potassium. Metoprolol could also be uptitrated if
pulse goal not met.
- Safety labs, namely creatinine and K after contrast exposure
and re-initiation of ACEi and HCTZ.
- Continued smoking cessation counseling
Medications on Admission:
HOME MEDICATIONS
(verified medication list with patient and daughter)
Metoprolol tartrate 25 mg PO BID
Folic Acid 0.4 mg daily
ASA 325 mg daily
Losartan 50 mg daily
Simvastatin 20 mg daily
HCTZ 25 mg daily
Lisinopril 10 mg daily
testoserone (dose unknown)
Vitamin D 400 units PO daily
Vitamin B1 250 mg PO daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. testosterone Transdermal
8. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
9. Vitamin B-1 250 mg Tablet Sig: One (1) Tablet PO once a day.
10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please check chemistry 7 panel including Cr and BUN at follow-up
appointment with primary care doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: right carotid stenosis
Secondary: dyslipidemia, hypertension, tobacco abuse, history of
transient ischemic attacks, history of laryngeal cancer status
post surgery and radiation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for placement of a right
carotid stent. The procedure went well, and you were
subsequently discharged.
You should also QUIT smoking. This will benefit your health.
Medication changes:
START plavix. Take this medication on a REGULAR BASIS for at
least the next month. Do not stop this medication unless
directed by Dr. [**Last Name (STitle) 911**].
CONTINUE taking aspirin 325 mg by mouth daily. Do not stop this
medication unless directed by Dr. [**Last Name (STitle) 911**].
STOP losartan 50 mg by mouth daily. We are re-starting your
blood pressure medications SLOWLY after hospitalization. You
will need to get a blood pressure check on [**Last Name (STitle) 2974**] and then visit
your doctor for a full appointment on Monday.
Followup Instructions:
*** Please visit Dr.[**Name (NI) 78012**] office in the morning for a blood
pressure check on [**Last Name (LF) 2974**], [**2130-3-17**] at 10:30 AM. ***
Name: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Address: [**State 8536**], [**Apartment Address(1) 8537**], [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 81613**]
Appointment: Monday [**2130-3-20**] 2:30pm
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 78958**]- Vascular Surgery
Address: [**Doctor Last Name 108099**] [**Location (un) 2624**], [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 78959**]
Appointment: Thursday [**2130-3-30**] 9:30am
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"V10.21",
"585.3",
"V12.54",
"272.0",
"403.90",
"433.10",
"V15.3",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"00.61",
"00.63",
"88.41",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
13622, 13628
|
8225, 12394
|
324, 388
|
13859, 13859
|
4190, 8202
|
14801, 15607
|
2948, 3031
|
12768, 13599
|
13649, 13838
|
12420, 12745
|
14010, 14210
|
3046, 4171
|
2353, 2362
|
14230, 14778
|
265, 286
|
416, 2258
|
13874, 13986
|
2394, 2777
|
2280, 2333
|
2793, 2932
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,247
| 142,525
|
9860
|
Discharge summary
|
report
|
Admission Date: [**2134-10-18**] Discharge Date: [**2134-10-21**]
Date of Birth: [**2078-6-15**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 56-year-old male with
a history of C7 paraplegia status post MVA in [**2119**], type 2
diabetes mellitus, hypertension, depression, nursing home
resident who was sent to the Emergency Room for increased
respiratory rate. The patient was initially seen at an
outside hospital on [**10-13**] for complaints of dyspnea, increased
respiratory rate and hypoxia. At the time the patient had
rales and rhonchi over his right middle lobe and he was sent
out with a prescription for 14 days of Flagyl. On the
morning of admission the patient was seen by plastic surgery
for debridement of his left leg ulcer. While there, the
patient was visibly tachypneic with a room air sat of 82%.
He was sent to the Emergency Room for evaluation. In the
Emergency Room the patient required escalating amounts of
oxygen supplementation, ultimately requiring 100% face mask
with sats in the 84-89% range. On physical exam he had
diffuse rales and cough with thick sputum. A chest x-ray
showed a left lower lobe infiltrate, all consistent with
pneumonia. In the Emergency Room he was given, in addition
to Flagyl, 1 gm of Vancomycin and 2 gm of Ceftriaxone IV.
PAST MEDICAL HISTORY: Hypertension, C7 paraplegia status
post MVA in [**2119**], depression, hepatitis B or hepatitis C,
type 2 diabetes mellitus, decubitus ulcers, gallstones.
ALLERGIES: No known drug allergies.
MEDICATIONS: Terazosin 5 mg q h.s., Vasotec 2.5 mg q day,
Dulcolax, Baclofen 10 mg tid, Albuterol, Flagyl 500 mg tid.
SOCIAL HISTORY: He has a history of IV drug use prior to
[**2119**]. He tested negative for HIV in [**2119**]. He is a nursing
home resident.
FAMILY HISTORY: Significant for diabetes mellitus.
PHYSICAL EXAMINATION: His temperature is 95.1, pulse 79,
blood pressure 148/87, respiratory rate 20, satting 88% on
four liters. Generally he is awake, alert, pleasant male
lying in bed in moderate distress with a face mask in place.
His head, eyes, ears, nose and throat exam, head is
normocephalic, atraumatic, pupils equal, round and reactive
to light, extraocular movements intact. Sclera is anicteric.
Mouth and oropharynx are clear without any erythema or
exudates but mucus membranes are moist. Cardiovascular exam,
regular rate and rhythm, normal S1 and S2, no murmurs, rubs
or gallops but diffuse rhonchi bilaterally with coarse breath
sounds. The left abdomen is soft, nontender, with mild
distention. He has no guarding or rebound. Extremities are
2+ bilateral lower extremity edema into the mid thigh. Left
leg is wrapped.
LABORATORY DATA: White cell count 15.3, hematocrit 34.6,
platelet count 509,000, sodium 130, potassium 5.6, is
hemolyzed, rechecked at 4.7, chloride 98, CO2 23, BUN 24,
creatinine 0.8, glucose 135. His ABG was 7.33/48/59 and 100%
face mask. Chest x-ray showed increased left lower lobe
infiltrate.
HOSPITAL COURSE: This is a 56-year-old man with a C7 spinal
cord injury, status post MVA in [**2119**], diabetes mellitus type
2, hypertension, who presented with peak oxygen saturations
with increased oxygen requirements, thick sputum as well as a
chest x-ray consistent with pneumonia.
1. Pulmonary: The patient's clinical presentation was
consistent with pneumonia. Given her C7 paraplegia and
impaired secretion clearance, he was initially admitted to
the medicine Intensive Care Unit. With his worsening hypoxia
on the day of admission, the team was concerned that the
patient would need to be intubated for possible aggressive
pulmonary toilet. The patient gradually improved on IV
antibiotics and was weaned off the oxygen and was transferred
to the medicine floor on hospital day three. In addition,
physical therapy and deep suctioning were done on the patient
in order to clear his secretions. He was also given
Albuterol and Atrovent nebulizers prn.
2. ID: The patient's elevated white cell count was thought
to be secondary to his pneumonia. On admission he was given
Flagyl and Ceftriaxone and he will be discharged with a
prescription for Flagyl and Levaquin to complete a 14 day
course of antibiotics.
3. Endocrine: The patient has a history of type 2 diabetes
mellitus. The patient was given [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet while he was in
the hospital and was placed on a sliding scale insulin. He
had no further endocrine issues.
4. GI: Initially the patient was NPO for possible
intubation. There was a question of whether or not the
patient had an appropriate gag reflex. He had a speech and
swallow study while he was in the medicine ICU. It was
determined that the patient was able to tolerate all
consistencies during the swallow trial and appeared to manage
dry solids without any difficulty.
5. Psych: A psychiatric evaluation was requested given the
concern at his nursing facility that he had been
confrontational and possibly depressed. Their evaluation of
the patient was that he was quite pleasant, positive and non
confrontational and very cooperative. He, at the time,
denied any depression and did not appear overtly depressed or
hopeless. They recommended a further psych evaluation when
he returns to [**Hospital1 8**] as needed.
6. Wound: His lateral left lower extremity has an 8 by 3 cm
open ulcer, pink at the base with minimal drainage. His
sacrum and upper thighs and buttocks have evidence of scar
tissue from previous skin breakdown. His left plantar
surface of the foot below the 4th and 5th toes have an opened
3 cm by 3 cm ulcer with 50% eschar and 50% pink face. The
wound care specialist recommended a first step mattress to
cleaning the wounds with saline and applying Duoderm wound
gel, and cover with normal saline moist dressing and DSD,
then cling wrap. They also recommended a nutrition consult
for protein calorie supplements.
DISCHARGE MEDICATIONS: Terazosin 5 mg q h.s., Vasotec 2.5 mg
q day, Dulcolax, Baclofen 10 mg tid, Albuterol prn, Flagyl
500 mg tid, Levofloxacin 500 mg po q day.
DISCHARGE DIAGNOSIS:
1. Pneumonia.
2. C7 paraplegia.
3. Depression.
4. Hypertension.
5. Type 2 diabetes mellitus.
6. Decubitus ulcers.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Doctor First Name 33119**]
MEDQUIST36
D: [**2134-10-21**] 10:51
T: [**2134-10-21**] 10:57
JOB#: [**Job Number 30114**]
|
[
"707.0",
"250.00",
"311",
"070.32",
"276.5",
"486",
"070.54",
"344.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1828, 1864
|
5986, 6126
|
6147, 6537
|
3028, 5962
|
1887, 3010
|
172, 1328
|
1351, 1665
|
1682, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,704
| 170,592
|
16553
|
Discharge summary
|
report
|
Admission Date: [**2107-1-14**] Discharge Date: [**2107-1-31**]
Date of Birth: [**2069-5-5**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: A 37-year-old female with a long
prior medical history of polysubstance abuse, depression,
anxiety/panic attacks, but no prior suicide gestures, and
attempts, and no prior history of mania or psychosis, who is
recently ([**2106-12-25**]) released from MCI after a one year
incarceration for possession of heroin.
On [**2107-1-2**], patient was found down in her mother's bathroom,
covered in vomit. She was taken to a hospital ([**Hospital **]
Hospital), where laboratories revealed positive opiates,
positive benzodiazepines, positive cocaine, and positive PCP.
[**Name10 (NameIs) **] was subsequently intubated for ARDS (secondary to
aspiration), and transferred to [**Hospital1 188**] when she was difficult/failed to wean from the
ventilator.
At [**Hospital1 69**], she was treated we
levofloxacin/clindamycin from [**Date range (3) 46987**] for
aspiration pneumonia as well as ceftazidime/vancomycin from
[**Date range (1) 46988**] for hospital acquired pneumonia. A
bronchoscopy done on [**1-10**] was negative. In addition, the
patient was initiated on TPN during her medical stay.
On her transfer to the floor, it was discontinued, and she
had been taking po. On [**2107-1-23**], the patient was extubated
without event. Since then, the patient has exhibited
visual/auditory hallucinations, tactile hallucinations which
had been waxing and [**Doctor Last Name 688**]. A psychiatry consult service has
been actively following the patient and providing
recommendations for this psychosis. The patient was then
transferred to the floor.
MEDICATIONS ON TRANSFER TO THE FLOOR:
1. Morphine 2 mg IV q4h.
2. Haldol 2.5 mg po q6h.
3. Ativan 1 mg IV q3h.
4. Protonix 40 mg po q24h.
5. Multivitamin one tablet po q day.
6. Folate 1 mg po q day.
7. Thiamine 100 mg po q day.
8. Nystatin 10 mL po qid.
9. Miconazole 2% cream [**Hospital1 **].
MEDICATIONS [**Hospital **] TRANSFER TO THE FLOOR:
1. Morphine 2-8 mg IV q2h prn.
2. Haldol 2.5 mg IV q2h prn.
3. Cogentin 1 mg IM q4h prn.
4. Colace 100 mg po bid prn.
5. Dulcolax 10 mg po/pr [**Hospital1 **] prn.
6. Tylenol 325-650 mg po prn.
VITAL SIGNS ON TRANSFER: Afebrile, heart rate 96-100, blood
pressure 110-120/70, respiratory rate 16, and O2 saturation
is 97% on room air.
PHYSICAL EXAMINATION: In general, she appeared preoccupied,
mumbling, talking to internal stimuli. HEENT: Pupils are
equal, round, and reactive to light, 3 mm bilaterally.
Extraocular movements are intact. Cardiovascular: Regular,
rate, and rhythm, no murmurs. Chest: Bilaterally clear to
auscultation with poor inspiratory effort, slight crackles at
the bases, likely atelectasis, no focal decreased breath
sounds or consolidations. Abdomen is soft, nontender,
nondistended, normoactive bowel sounds. No right upper
quadrant tenderness. Extremities: 1+ pitting edema.
Dorsalis pedis bilaterally palpable pulses. Left lower
extremity is greatly enlarged, much more so than the right
lower extremity. Her left lower extremity is nontender and
did not have any calf tenderness. Neurologic: Extraocular
movements are intact. Pupils are equal, round, and reactive
to light. Three mm constriction. Psychiatry: Oriented to
person only, tangential thought, illogical speech,
responding/acting on visual, auditory, as well as internal as
well as tactile stimuli.
LABORATORY DATA ON TRANSFER: [**2108-1-26**] - white count 11.6,
hematocrit 27.5, platelets 371. B12 is 1316, folate greater
than 20, TSH 2.9, triglycerides 132, ammonia 18, sodium 137,
potassium 4.4, chloride 100, bicarb 23, BUN 18, creatinine
0.5, glucose 102, calcium 9.2, phosphorus 4.9, magnesium 1.9,
albumin 3.5, ALT 246 (increased from 82 on [**1-24**]), AST 161
(increased from 74 on [**1-24**]), alkaline phosphatase 294
(increased from 209 on [**1-24**]), total bilirubin 0.4 stable.
Haptoglobin, hepatitis B serum antigen, hepatitis B serum
antibody, hepatitis B core antibody, hepatitis A antibody,
hepatitis C antibody were pending at the time of transfer to
the floor.
Chest x-ray on [**2107-1-24**] - Multifocal patchy opacities,
perihilar haziness, no definitive pleural effusions, or
pneumothoraces.
ASSESSMENT: A 37-year-old female status post extubation
after ARDS (secondary to aspiration pneumonia), following a
heroin overdose. Her delirium after extubation ([**2107-1-23**]),
x4-5 days and is currently on a benzodiazepine taper.
1. Aspiration pneumonia. The patient is status post a 10 day
treatment of antibiotics, and antibiotics ended on [**2107-1-22**].
No organism has been grown for this. She is breathing well.
Lungs are clear to auscultation bilaterally.
2. Cardiovascular: The patient had an electrocardiogram q am
while on Haldol. Had a three beat run of NSVT on [**2107-1-24**].
She was followed on Telemetry.
3. GI: Patient's LFTs were trending upward. Her LFTs
subsequently stabilized, thus right upper quadrant ultrasound
was not done.
4. Lower extremity edema. Her left lower extremity was
greatly edematous, much more so than the right side. Left
lower extremity noninvasive Doppler was obtained which showed
that she had echogenic material in the superficial and
popliteal veins. In addition, there was partial flow seen in
the proximal superficial femoral vein and the popliteal
veins, however, they were not compressible. The LENI
indicated that there was a partial thrombus at the level.
However, the official read said that there is a deep venous
thrombosis in the superficial femoral to popliteal veins.
The proximal superficial femoral vein and popliteal veins are
partially thrombosed, while the mid distal superficial
femoral veins are completely thrombosed. The patient was
started on Lovenox, and then was initiated on Coumadin for
appropriate anticoagulation.
5. Delirium. The patient continued to remain in delirium for
almost a week postextubation. The Psychiatry service
followed her closely, and they felt that her delirium was
resolving slowly, however, she remained disoriented and
nonsensical. When patient's mental status was clearing, we
discontinued her standing Haldol, and only had prn Haldol.
This was discussed with Psychiatry, the patient's need for
continued Haldol, and it was felt that this patient was not
likely need an antipsychotic after her mental status had
cleared for any long-term duration. The prn Haldol was just
for short term behavioral control.
6. Polysubstance abuse: Her taper of Ativan and Morphine was
continued very slowly, and decreased by approximately 20% per
day.
7. History of anxiety/panic disorder. The patient reports
her anxiety as well as panic disorder being controlled in the
past with Effexor. She was started on Effexor XR 37.5 mg po
qd for complaints of anxiety.
The patient was in her acute delirium on the floor, she had a
one to one sitter. This sitter stayed with the patient and
kept the patient oriented to person as well as place.
8. Hepatitis. Because the patient's LFTs were rising, but
then stabilized, hepatitis serologies were checked. These
serologies revealed a negative hepatitis B surface antigen,
negative hepatitis B surface antibody, negative hepatitis B
core antibody, negative hepatitis A antibody, positive
hepatitis C antibody. There is a question that the patient
did not remember being diagnosed with hepatitis C before, and
this was likely a new diagnosis for her. Patient was
instructed to followup with GI doctor as an outpatient, to
follow up his hepatitis. This was discussed with both the
patient and her mother prior to discharge.
9. Status post fall. On [**2107-1-28**] at 7 pm, patient became
entangled in her sheets. Her legs were wrapped up in the
sheets, and she was unable to become entangled. She
subsequently fell off the bed and hit her head on the floor.
Her last PTT was 88.9. In addition, as she fell, her left
PICC was pulled out. There is no obvious head or skull
fracture, or any open wounds on her head. A STAT CT scan of
the head without contrast was obtained, and the read was no
fractures, no intracranial bleed, it was a normal study.
10. Mobility: Physical Therapy consult was placed, and they
felt that the patient was functionally independent and was
cleared for discharge home. She was obviously deconditioned
after her prolonged MICU course, and she exhibited a rapid
increase in heart rate for a low level of activity. However,
this should resolve within the next 2-4 weeks if she was
compliant with her walking program. Physical Therapy cleared
her from a standpoint at which she could function at home.
DISPOSITION: The patient was discharged home with
prescriptions to have her INR checked q1-2 days, to keep her
INR therapeutic between [**3-14**]. She was arranged with PCP
followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She was also given a
psychiatric outpatient followup as well. She needs to be
continued on her Effexor. The patient was also given the
number for GI to followup for evaluation/plus-minus treatment
for her hepatitis C.
At the time of discharge, the patient had resolved change in
mental status secondary to polysubstance abuse, and she
exhibited no signs of delirium/mental status changes at all.
She is alert, awake, oriented x4. Pulmonary status was back
to baseline, status post her aspiration pneumonia/ARDS/status
post extubation.
ADDENDUM: Regarding the patient's left lower extremity deep
venous thrombosis, the patient was initially started on
Heparin. She was later changed from Heparin to Lovenox and
was bridged over on Lovenox until she became therapeutic on
Coumadin. Patient was therapeutic on Coumadin, and was to
have a Coumadin followup as an outpatient until she saw her
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-986
Dictated By:[**Last Name (NamePattern1) 14484**]
MEDQUIST36
D: [**2107-5-5**] 16:12
T: [**2107-5-6**] 07:39
JOB#: [**Job Number 46989**]
|
[
"305.90",
"507.0",
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"453.8",
"518.82",
"112.0",
"348.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.72",
"33.23",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
2416, 10205
|
155, 2393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,609
| 182,108
|
2324
|
Discharge summary
|
report
|
Admission Date: [**2104-1-24**] Discharge Date: [**2104-1-31**]
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Heparin Sodium
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 12122**] is a [**Age over 90 **] year-old man with a history of
hypertension, PVD, 2nd degree AVB, CVA, and chronic renal
insufficiency who was recently discharged from [**Hospital1 18**] to rehab on
[**1-12**] after an admission for urosepsis. He was gradually
recovering his strength, but approximately 3 days prior to this
admission he developed a mild, productive cough. However, per
the nurses at his rehab his lungs sounded clear; thus, he was
discharged as planned from rehab to his daughter's home on
[**2104-1-23**].
At home, Mr. [**Known lastname 12123**] cough worsened. The night prior to
admission he lay awake with coughing fits. PO intake was
unchanged (he voraciously ate lamb chops for dinner). The
morning of admission, he continued to cough, feel SOB, and VNA
noted T 100.4. Thus, he was referrred to the ED.
In the ED, initial VS T 100.4, HR 50, BP 158/43, RR 24, O2 83%
on RA, improving to 96% on NRB. Exam was notable for crackles at
the lung bases. Labs were notable for an improving creatinine,
stable Hct, and lactate of 3.5. CXR showed possible RML
infiltrate. He was given levofloxacin 750 mg IV x 1, cefepime 2G
IV x 1, and vancomycin 1 gm IV x 1 as well as 1L NS and admitted
to the MICU for further evaluation and treatment.
On admission to the MICU, patient complains of feeling thirsty
and of mild SOB when he talks. He states that his cough has
improved considerably since arrival at the hospital. He denies
chest pain, abdominal pain, nausea, vomitting, urinary symptoms,
change in mental status, or light-headedness. Review of systems
was otherwise negative.
Past Medical History:
-hypertension
-hyperlipidemia
-gout
-peripheral vascular disease
-stroke c residual L sided weakness
-macular degeneration
-depression
-renal insufficiency
-complete heart block s/p ppm
-recent admission for urosepsis [**12/2103**]
-mild AS
-AAA, 3.2 cm
Social History:
He lives with his daughter after being discharged from rehab
yesterday. At baseline he walks with a cane. No EtOH. Prior
smoker, quit 40 years ago.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Vitals: T: 97.2, BP 92/52, HR 96, RR 23, O2 92-95% on 3L NC
General: conversant, no distress, breathing comfortably
HEENT: dry mucous membranes
Neck: JVP flat
Lungs: bilateraly end-inspiratory basilar crackles, R basilar
rhonchi
CV: distant heart sounds, faint systolic mumur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no edema, warm, 2+ distal pulses,
Pertinent Results:
Admission Labs:
[**2104-1-24**] 12:00PM BLOOD WBC-9.7# RBC-3.88* Hgb-10.9* Hct-33.1*
MCV-85 MCH-28.0 MCHC-32.8 RDW-15.1 Plt Ct-300#
[**2104-1-24**] 12:00PM BLOOD Neuts-91.2* Lymphs-5.8* Monos-2.4 Eos-0.5
Baso-0
[**2104-1-24**] 12:00PM BLOOD Plt Ct-300#
[**2104-1-24**] 12:00PM BLOOD PT-12.0 PTT-28.3 INR(PT)-1.0
[**2104-1-24**] 12:00PM BLOOD Glucose-115* UreaN-23* Creat-1.5*# Na-145
K-4.0 Cl-107 HCO3-23 AnGap-19
[**2104-1-24**] 12:00PM BLOOD CK(CPK)-32*
[**2104-1-24**] 06:55PM BLOOD Type-MIX pO2-34* pCO2-33* pH-7.40
calTCO2-21 Base XS--3
Imaging:
[**2104-1-30**] V/Q Scan: Findings consistent with emphysema/COPD. There
is low likelihood of pulmonary embolism.
[**2104-3-30**] CXR: No change
[**2104-1-25**] CXR: No evidence of pulmonary edema or volume overload
after fluid resuscitation is demonstrated
[**2104-1-24**] CXR: No acute cardiopulmonary process. Calcified pleural
plaques.
Micro:
[**2104-1-24**] Ucx: NO GROWTH
[**2104-1-24**] Bcx x2: final results pending at time of discharge, but
are at no growth at 96 hours out.
[**2104-1-24**] MRSA screen: negative
[**2104-1-28**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: Results pending
at time of discharge
Brief Hospital Course:
A [**Age over 90 **] yo man with multiple medical problems presents with hypoxia
and fever, most likely an acute on chronic process.
# Intermittent hypoxia: The patient was admitted to the ICU and
treated for pneumonia initially with vancomycin, cefepime, and
levofloxacin given his intial precarious respiratory state. He
improved quickly and so cefepime was discontinued on the second
MICU day. Since MRSA screen [**2104-1-25**] was negative, vancomycin was
discontinued. Prior to discharge, patient was afebrile for
several days with non-produtive cough. Gauifenesin was added to
his medical regimen. At his time of discharge, the patient was
sating well in mid-high 90's on RA at rest and high 80s to low
90's while ambulating with occasional sats in the mid-80s. A
7-day course of levofloxacin was completed today [**2104-1-31**]. Given
a somewhat unclear etiology of hypoxia, a V/Q scan was done to
rule out pulmonary embolism. The V/Q scan revealed a low
likelihood of PE although did show signs of emphysema. His CXR
also showed plaques consistent with asbestosis exposure. He was
therefore scheduled for outpatient pfts shortly after discharge
as well as 2L NC to be used as needed with ambulation. His
albuterol was continued and we asked that he talk with his PCP
at his upcoming appointment about additional medications that
may be used to manage his lung disease depending on his PFT
results.
# Hypotension on admission: Borderline low blood pressure on
admission was likely due to pneumonia. Blood pressure quickly
improved after IVF in the ED. His antihypertensives were held.
By the time he was transferred to the floor, his SBP was in the
140s and his atenolol was restarted with normotension for
several days prior to discharge.
# Normocytic Anemia: No definitive etiology but HCT stable at
recent baseline of 25-28. He had normal iron studies and a
normal ferritin. Stool guaics were negative and patient was
without clinical evidence of bleeding. With CKD and low retic
count, most likely a result of low production state. We asked
that the patient follow up with his PCP for further management
planning.
# Chronic systolic heart failure: EF 40-45% on recent TTE. No
signs of volume overload on exam or by CXR on admission. On an
ACEI and BB.
# Chronic renal insufficiency: Creatinine improved since
discharge to baseline. Stable at 1.2 at time of discharge. There
is a poorly defined renal lesion see on ultrasound. Patient will
follow up with outpatient urology to discuss management and
treatment of this lesion.
# Gout: Patient experienced right big toe pain around the MTP
joint. Patient was started on colchicine in the hospital.
# Status post stroke: with residual right-sided weakness.
Aggrenox was continued during this admission.
# Coronary Artery Disease: No evidence of ischemia on admission.
Statin was continued. ACEI and beta blocker were held while
hypotensive and restarted when blood pressured stabilized to the
140s.
# History heparin sensitivity: Heparin SC at reduced dose was
started for DVT prophylaxis. PTT was followed.
# CODE: Patient and his daughter affirmed his desire to be
DNR/DNI and no invasive lines or procedures.
Medications on Admission:
Asirin 325 mg daily
Aggrenox 200mg-25mg [**Hospital1 **]
Crestor 40 mg daily
Atenolol 25 mg daily
Lisinopril 20 mg daily
Felodipine SR 10 mg daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aggrenox 200-25 mg Cap, Multiphasic Release 12 hr Sig: One
(1) Cap, Multiphasic Release 12 hr PO twice a day.
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day as needed for cold
symptoms.
6. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough.
Disp:*90 Capsule(s)* Refills:*0*
7. Pulmonary Rehab
Please provide patient with cardiopulmonary rehab on an
outpatient basis.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
10. Oxygen
Please provide patient with 2L continuous oxygen for
portability, pulse dose system as he has ambulatory sats of 84%
with a mild level of exertion.
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
as needed for gout. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3145**] Nursing Home - [**Location (un) 3146**]
Discharge Diagnosis:
Primary
Pneumonia
Hypoxia of unclear origin (determination pending COPD results)
Anemia
Secondary
Hypertension
Peripheral Vascular disease
Chronic renal insufficiency
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the [**Hospital 18**] hospital for pneumonia. You were
treated with antibiotics which you have completed. You are being
given a script for tessalon perles which may help with your
cough. You may also take mucinex/guaifenasin over-the-counter
for congestion.
Your oxygen level was low even after your infection was treated.
A scan was done to look for a blood clot in your lungs. The scan
suggested you DO NOT have a blood clot in your lungs but did
show some evidence of COPD and your chest X-ray showed some
evidence of asbestos-related disease. You have therefore been
set up to have pulmonary function tests done. In the meantime,
you should use oxygen at home with activity or if you feel short
of breath or tired.
Your felodipine was stopped. Since your aggrenox contains
aspirin, you can take a baby aspirin (81mg) rather than a full
strength aspirin. Please discuss whether or not you should
restart felodipine and full strength aspirin with Dr [**Last Name (STitle) **].
If your cough continues, please discuss with Dr [**Last Name (STitle) **] as
lisinopril may cause a dry cough.
The remainder of your medications are unchanged.
You were noted to have a lesion on one of your kidneys. It is
not clear what this is. An appointment was made for you to see a
urologist but you were still hospitalized when this appointment
was scheduled to take place. We were unable to make a follow up
appointment for you prior to discharge. We would like you to
call the urology office to schedule an appointment to take place
within the next month.
You were also found to have anemia. Your blood counts were low
but stable. Your labs suggested that your bone marrow may be
making less blood than would be expected. You should discuss
this, as well as checking your throid function and the results
of your pulmonary function tests, further with Dr [**Last Name (STitle) **] at your
follow up appointment as scheduled.
Followup Instructions:
Please call Dr [**Last Name (STitle) 770**] (Urology) to follow up on your renal
lesion. Phone:([**Telephone/Fax (1) 772**].
You are scheduled to have pulmonary function tests on Mon, [**2-4**] at 2pm. This is at the [**Location (un) 86**] [**Hospital1 18**], [**Hospital Ward Name 516**] Grysmish
building. To obtain a good study, please do not use any inhalers
for 12 hours prior to coming in for the study. Please call the
pulmonary function lab at ([**Telephone/Fax (1) 12124**] if you need to
reschedule this appointment.
Please follow up with Dr [**Last Name (STitle) **] on [**2104-2-13**] at 11:30 am.
Phone:[**Telephone/Fax (1) 1144**]. Please take the results of your pulmonary
function tests to this appointment and discuss them with Dr
[**Last Name (STitle) **].
You currently have a vascular surgery appointment scheduled with
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2104-4-16**] at 01:00p. Her office is located
at [**Location (un) **] ([**Location (un) 2352**], MA), [**Location (un) **]. Please call
her office if you would like to reschedule this appointment or
([**Telephone/Fax (1) 8343**] if you would like to see a vascular surgeon at
[**Hospital1 18**] in [**Location (un) 86**].
Completed by:[**2104-2-5**]
|
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"441.4",
"593.9",
"285.9",
"585.3",
"486",
"403.90",
"274.9",
"428.22",
"V15.82",
"799.02",
"V15.84",
"362.50",
"440.21",
"458.8",
"438.89",
"787.22",
"272.4",
"414.01",
"424.1",
"729.89",
"311",
"V45.01",
"428.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8627, 8713
|
4110, 5533
|
249, 255
|
8925, 8925
|
2912, 2912
|
11068, 12338
|
2363, 2445
|
7493, 8604
|
8734, 8904
|
7321, 7470
|
9105, 11045
|
2460, 2893
|
204, 211
|
283, 1904
|
2929, 4087
|
5547, 7295
|
8940, 9081
|
1926, 2182
|
2198, 2347
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,880
| 140,179
|
23669
|
Discharge summary
|
report
|
Admission Date: [**2135-7-4**] Discharge Date: [**2135-7-16**]
Date of Birth: [**2092-2-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
ETOH intoxication
Major Surgical or Invasive Procedure:
1. intubated
2. Through and through lip laceration repair
History of Present Illness:
43y/o M w/ ETOH abuse and recent admit here for same on [**3-12**],
today patient was found down on face on the sidewalk. Bystander
called 911, EMS brought patient to [**Hospital1 18**] ED. Here, per ED
resident, was noted to be aggitated and combative, noted to have
large through and through lac on upper lip, gurgling blood,
destated to 80's, was then intubated for airway protection.
Propofol was used for sedation. Received 2L NS in ED.
Past Medical History:
PMH:
1. Etoh abuse: History of "binge drinking" less than once per
week; multiple detox admissions and most recently finished 28
day rehab ~[**2-12**]; has a history of DTs, withdrawal seizures,
blackouts. Alcohol abuse for > 20 years.
2. H/o OD: 15 hospitalizations, most recently
in [**2135-1-8**]. He was at [**Doctor First Name 1191**] in late [**2134**], at [**Hospital 1263**]
Hospital [**Date range (2) 60513**], after a suicide attempt, and has also
been hospitalized at [**Hospital1 **]. Other suicide attempts include
OD two years ago, and OD on [**2135-3-14**] on alcohol, 100-150 mg
seroquel, and 4 ephedrine pills.
3. Neuropathy in legs b/l for several years.
4. Fatty liver: h/o elevated lfts
5. Pancytopenia [**2-9**] alcohol use
6. S/p L knee arthroscopy
Past Psych hx:
1. Bipolar d/o:
multiple psychiatric admissions, history of pill overdoses
(150mg
of seroquel and 4 amphetamine tabs)current treaters at [**Hospital1 12671**].
Patient's therapist at [**Last Name (LF) **], [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 60514**]). He
has been sent from [**Hospital1 **] to the ED many times, after arriving
intoxicated and threatening suicide. Sent to Norceg in
[**Location (un) 60515**] at one point, and per Mr. [**Last Name (Titles) **], the patient saved
up his meds there and later overdosed.
Social History:
SOH:
Adopted as an infant, and grew up in [**Location (un) 7581**], NY. Has
an adopted sister who lives in CT. Patient's adoptive mother is
alive and living in a nursing home in CT. Medical record
indicates history of sexual abuse by adopted father. [**Name (NI) **]
reports he graduated from SUNY [**Location (un) 60516**] with a degree in
business management. Worked at a tech firm for 14 years, and was
fired because of alcohol use. Reports he manages a restaurant
(Cosi). Had long relationship with partner of 21 years, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 60517**] ([**Telephone/Fax (1) 60518**], [**Telephone/Fax (1) 60519**]), which ended about one year
ago. Patient lives alone in [**Location (un) 538**], and has just kicked
out his roommate (who was using heroin).
Smokes tobacco, 1 ppd x 22 years. Started drinking alcohol at 22
yo, and reports he has had 23 detoxes. Longest sobriety was in
summer/[**2135**], when he had eight months of abstinence after
attending the Triangle Group, a program for gay addicts.
Reports history of withdrawal symptoms, withdrawal seizures,
and DT's, at a time when he was drinking up to "two gallons" of
alcohol daily.
Family History:
NC; patient adopted
Physical Exam:
T: 98.9 P: 113 BP: 153/104, R: 12 100% Vent: A/C
GEN: Patient sedated w/ propofol and intubated.
HEENT: multiple abrasion on his face with nose/lip-upper and
lower swelling, Pupils equal round and reactive to light, blood
found in oral cavity from lip lac, ETT in place
CV: Tachy, RR, no m/r/g
PULM:CTA b/l, no w/r/r
ABD: flat, round, BS present, soft, NT/ND
Ext: no c/c/e, vasc: DP/PT 2+ b/l
Neuro: sedated
Skin: multiple skin abrasions on face with upper lip lac.
Pertinent Results:
Serum tox: neg; Urine tox: pend; Serum Etoh: 402; Na: 145;
K:3.1; Cl: 98; Bicarb:22; BUN: 9; Cr:0.9; Glu: 124; AG: 25
WBC: 4.8; Hct: 44.3; Plt: 52; U/A: ket 15 o/w neg;
Brief Hospital Course:
# Alcohol withdrawal: The patient has a long history of alcohol
abuse including mutliple withdrawals complicated by delerium
tremens. Patient was treated with multivitamins, thiamine,
folate, and the CIWA scale. In addition, given his history of
severe withdrawals, patient was placed on a standing dose of 15
mg of Diazepam four times a day, which was then weaned down to
10 mg three times a day and then discontinued. Social work and
Psychiatry were both consulted but patient expressed disinterest
in entering a rehabilitation program. He has been of benzo with
out signs and symptoms for >48hours.
.
#Possible neck injury - GIven initial alterted mental status his
neck was not able to be cleared given risk secondary to his head
inury. He was placed in a c-collar for 14days. Repeat flex/ext
films showed no injury and patient was able to be sent home with
out collar.
.
# hypoxia: Patient was found to be gurgling blood on admission
from his impact with the sidewalk. His oxygen saturation went
down to the 80's and he was intubated for airway protection.
There was no evidence of aspiration on x-ray. He had an oxygen
requirement of 4 liters after extubation but was soon weaned
back to room air without difficulty. He did not have an
elevated white count and remained afebrile so no antibiotics
were started.
.
# Lip Lac: Repaired by plastic surgery in the OR with good wound
healing afterwards. Patient is to follow up in the plastic
surgery clinic 1 week after discharge.
.
# Bipolar disorder: Psychiatry raised the question of whether
the patient truly had bipolar disorder or if he had been
mis-diagnosed because of the effects of his long-term alcohol
abuse. Psychiatry followed him throughout his admission and
recommended his current regimine of psychiatric medications.
He has follow up in place.
.
# Thrombocytopenia: This was belived to be from the patient's
known cirrhosis/fatty liver. Abdominal ultrasound showed a
normal spleen and confirmed fatty infiltration of the liver.
Synthetic function remained intact. This was from ETOH induced
marrow suppression.
#diarrhea- resolved. c.diff negative. Had been on clindamycin
for lip lac.
Medications on Admission:
Neurontin 1800 mg tid
Depakote 1000 mg qhs
Remeron qhs prn insomnia
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 cap* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
4. Divalproex Sodium 500 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in
the morning)).
5. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig:
Three (3) Tablet, Delayed Release (E.C.) PO QHS (once a day (at
bedtime)).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day) for 1 weeks.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcoholwithdrawal
2. mechanical fall [**2-9**] alcohol intoxication
3. Neck pain
4. lower back pain
Discharge Condition:
patient ambulating and tolerating PO
Discharge Instructions:
Please follow up as indicated below.
Please take all medications as directed.
Returnt o the hospital if you have dizziness, fevers, chills,
nausea, vomiting, chest pain, abd pain, or any other concerning
symptoms.
Followup Instructions:
1. Follow up with platic surgery clinic this Friday for suture
removal. Call ([**Telephone/Fax (1) 23144**] to make an appointment.
2.Follow up with [**Hospital1 2177**] behavioral health.([**Telephone/Fax (1) 60520**]
Appt on [**2135-8-2**] at 1:45pm with Dr.[**Last Name (STitle) 60521**]
Appt on [**2135-8-4**] at 2 pm with [**First Name8 (NamePattern2) 8513**] [**Last Name (NamePattern1) 1024**].
[**Month (only) 116**] call [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD if needed for neck pain at [**Telephone/Fax (1) 7807**]
Go home to [**Last Name (un) 3952**] House today, [**Telephone/Fax (1) 60522**]. [**Female First Name (un) 7905**] knows this
and is expecting you. You must attend the partial psychiatric
program at [**Hospital1 1680**] HRI to continue living at [**Last Name (un) 3952**] House.
You have an appointment for intake at [**Hospital1 1680**] HRI on:
Monday, [**7-18**], 2:30 PM
[**Street Address(2) 4195**]
[**Location (un) **], MA
[**Telephone/Fax (1) 1691**]
If you continue to have fevers, shakes, chills, rigors, please
go to the emergency room or call your PCP. [**Name10 (NameIs) **] only your
prescribed medications.
Go home to [**Last Name (un) 3952**] House today, [**Telephone/Fax (1) 60522**]. [**Female First Name (un) 7905**] knows this
and is expecting you. You must attend the partial psychiatric
program at [**Hospital1 1680**] HRI to continue living at [**Last Name (un) 3952**] House.
You have an appointment for intake at [**Hospital1 1680**] HRI on:
Monday, [**7-18**], 2:30 PM
[**Street Address(2) 4195**]
[**Location (un) **], MA
[**Telephone/Fax (1) 1691**]
If you continue to have fevers, shakes, chills, rigors, please
go to the emergency room or call your PCP. [**Name10 (NameIs) **] only your
prescribed medications.
Completed by:[**2135-7-16**]
|
[
"303.91",
"356.9",
"E888.9",
"873.43",
"276.0",
"571.2",
"287.5",
"276.2",
"723.1",
"802.0",
"291.81",
"724.2",
"296.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"27.51",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7293, 7299
|
4191, 6359
|
332, 392
|
7446, 7484
|
3998, 4168
|
7748, 9582
|
3475, 3496
|
6477, 7270
|
7320, 7425
|
6385, 6454
|
7508, 7725
|
3511, 3979
|
275, 294
|
420, 864
|
886, 2251
|
2267, 3459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,269
| 135,064
|
37901
|
Discharge summary
|
report
|
Admission Date: [**2124-2-10**] Discharge Date: [**2124-2-14**]
Date of Birth: [**2067-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Lower GI bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Please see MICU admission note for full details. Briefly, this
is a 56 yo M h/o HCV cirrhosis with known grade II varices,
recurrent ascites, and encephalopathy who presented with BRBRR.
The patient has had multiple recent admission to the surgical
service including umbilical hernia repair and inguinal hernia
repair in the setting SBO. During his most recent hospitaliation
from [**Date range (1) 84740**], the pt noticed bright red blood associated with
bowel movements, and a GI consulted. Anoscopy performed on the
floor showed internal hemorrhoids. GI recommended an upper
endoscopy and colonscopy which was done on [**2124-1-31**]. Colonoscopy
was only performed to the ascending colon and demonstrated
friable bleeding mucosa and internal hemorrhoids. He was
instructed that he will still need a screening colonoscopy
outpatient since this was a limited study. An upper endoscopy
demonstrated esophageal varices, two of which were banded. The
patient has been doing well since discharge. He had been
constipated for the week prior, and took some fleets to good
effect.
The morning prior to admission he went to the bathroom and
noticed a significant amount of bright red blood. His wife then
drove him to the [**Name (NI) **] for further evaluation. He denied chest
pain, sob, dizziness, headache, syncope or presyncope.
.
In the ED, initial VS: 97.6, 102/66, 69, 100% on RA. . He was
given a total of 8mg of IV morphine for ongoing abdominal pain
d/t h/o chronic abdominal pain. He had a BM in the ED with a
large amout of BRB, but no melena.
.
General surgery was consulted who felt that there were no acute
surgical issues. Hepatology was called, who did not recommend NG
lavage, ocreotide, or any intervention at this time. He was
given 2L of NS. He was admitted to the MICU for further
evaluation.
.
In the MICU, he remained hemodynamically stable throughout his
ICU stay and his HCT was at baseline. He had one value that was
4 points lower than prior, but appeared to be an innacurate
value as further values were at baseline. Given 5mg vit K once.
Hepatology did not want to scope at this time since he was not
actively bleeding. 1 Liter paracentesis was performed which
showed no evidence of SBP.
.
On the floor, patient is hemodynamically stable and sitting in
bed quite comfortably. He denies any abdominal pain, chest pain,
shortness of breath, or any other symptom concerning to him.
Past Medical History:
- HCV cirrhosis c/b ascites with known grade II esophogeal
varices, hepatic encephalopathy, and splenomegaly
- hx of SBP
- Syphillis
- anemia
- h/o polysubstance abuse
- bilateral groin hernia
- s/p right inguinal s/p repair on [**2124-1-18**] in the setting of
SBO
- umbilical hernia repair [**2123-12-29**]
Social History:
Married and has 2 teenaged children. He is medically disabled.
History of cocaine and alcohol abuse, but says that he has
stopped all substances since President [**Last Name (un) 73989**] inauguration. *
As per transplant notes, patient is not a transplant candidate
[**2-22**] recurrent substance use
Family History:
Both parents have diabetes. His mother had CVA. He has 2
brothers who died of [**Name (NI) 27287**] complications
Physical Exam:
Vitals - T:98.4 BP:102/67 HR:70 RR:13 02 sat: 98% RA
GENERAL: Thin male, Alert and Oriented in No Acute Distress
HEENT: EOMI, PERRL, Oropharynx clear, MMM, sclera mildly icteric
NECK: No LAD, JVP not elevated
CARDIAC: RRR, No m/g/r
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: soft, NT, mildly distended. Negative fluid wave,
horizontal wound with staples in suprpubic area c/d/i; scar
around umbilicus closed and c/d/i
EXT: warm, well perfused, no edema
NEURO: CN 2-12 in tact; 5/5 strength in BUE/BLE, No asterixis
DERM: No rashes;
Pertinent Results:
Admission Labs:
[**2124-2-10**] 09:07PM HCT-26.7*
[**2124-2-10**] 04:19PM LACTATE-1.7
[**2124-2-10**] 02:54PM HCT-31.1*
[**2124-2-10**] 09:22AM LACTATE-2.2*
[**2124-2-10**] 09:15AM GLUCOSE-91 UREA N-13 CREAT-0.8 SODIUM-134
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-31 ANION GAP-8
[**2124-2-10**] 09:15AM WBC-7.5 RBC-3.72* HGB-11.2* HCT-33.9* MCV-91
MCH-30.0 MCHC-32.9 RDW-14.4
[**2124-2-10**] 09:15AM NEUTS-74.0* LYMPHS-10.9* MONOS-10.8 EOS-3.0
BASOS-1.3
[**2124-2-10**] 09:15AM PT-19.9* PTT-35.3* INR(PT)-1.8*
[**2124-2-10**] 09:15AM PT-19.9* PTT-35.3* INR(PT)-1.8*
Imaging:
CT Abdomen/Pelvis:
IMPRESSION:
1. Patient is status post right inguinal hernia repair. Left
inguinal hernia
is seen with herniation of antimesenteric border of loop of
sigmoid colon
without associated obstruction or bowel wall thickening
2. Cirrhotic liver, stable in appearance since recent
examination. Associated
portal hypertension with splenomegaly and ascites. Associated
bilateral
gynecomastia.
3. Cholelithiasis without secondary signs of cholecystitis.
Brief Hospital Course:
The patient is a 56 year old male with a history of HCV
cirrhosis with recently banded varrices and internal hemorrhoids
who presented with BRBPR.
.
# BRBPR: Patient had one large bloody bowel movement prior to
presentation in ED. Was hemodynamically stable upon arrival. Had
another bloody bowel movement in ED and was admitted to the MICU
for more careful monitoring. GI was consulted and since he was
not actively bleeding and maintained stable hematocrits with
adequate blood pressure, no intervention was performed. His
bleed was felt to be due to internal hemorrhoids seen in recent
colonoscopy. Patient also has evidence of esophageal varices
with recent banding, but this was not felt to be the source of
the bleed. He was transferred to the general medical floor and
he continued to remain hemodynamically stable. He had
intermittent bloody bowel movements, but his hematocrit remained
stable. He was discharged home with a plan for outpatient
colonoscopy [**2-18**].
# Abdominal Pain: Patient was complaining of abdominal pain
during admission. An abdominal CT scan showed no acute findings.
Surgery was consulted and felt this was likely from his known
inguinal hernias. He is s/p surgery and repair from early
[**Month (only) 404**]. Patient also had several bowel movements and denies
nausea/vomiting which suggested that this was not likely a small
bowel obstruction. Surgery felt nothing needed to be done and
he will follow up with Dr. [**Last Name (STitle) 816**] [**2-17**] for further evaluation.
Since patient did have ascites, a diagnostic paracentesis was
performed in the MICU where 1000 mL of ascitic fluid was
drained. This fluid showed no evidence of spontaneous bacterial
peritonitis to perhaps explain the abdominal pain.
# HCV cirrhosis: Has been complicated by decompensated ascites,
varices, and hemorrhoids. Stable with minimal evidence of
encephalopathy during admission. His lactulose was uptitrated
and he was continued on rifaximin. His spironolactone and lasix
were initially increased, but patient's blood pressure could not
tolerate. He was decreased back to his home dose of 100 mg
spironolactone daily and 40 mg lasix daily. He was also
continued on nadalol 20 mg [**Hospital1 **]. The Patient is currently being
evaluated by the liver service for possible transplant.
Medications on Admission:
1. Nadolol 20 mg Tablet PO BID
2. Rifaximin 400 mg Tablet TID
3. Spironolactone 100 mg PO DAILY
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H
5. Colace 100 mg twice a day
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID
9. Omeprazole 20 mg Capsule PO BID
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Sucralfate PO QID
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*3000 ml* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Glycerin (Adult) Suppository Sig: One (1) Suppository
Rectal PRN (as needed) as needed for hemorrhoids. Suppository(s)
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed) as needed for hemorrhoids.
Disp:*1 unit* Refills:*0*
11. Golytely 236-22.74-6.74 gram Recon Soln Sig: One (1) bottle
PO once for 1 doses: Please start drinking at 2 pm [**2-17**]. Please
drink 8 oz every 10 minutes until you finish the bottle.
Disp:*1 bottle* Refills:*0*
12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Hemorrhoidal Bleed
Hepatitis C Cirrhosis
Abdominal Hernias
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted because you had a lower GI bleed. You were
initially admitted to the ICU for close monitoring. Your
bleeding stopped and your blood counts were stable throughout
your admission. Gastroenterology was consulted and felt no
intervention needed to be done in the hospital. You should have
close follow up with this in the outpatient, as your colonoscopy
is scheduled for Friday, [**2124-2-18**]. The details of this are below.
We adjusted your medications and these changes are below.
You also complained of abdominal pain that you have had for
quite some time. A CT scan of your abdomen did not show anything
concerning. Surgery was consulted and felt it was from your
recent surgeries and nothing surgical needed to be done at this
point. About 1 Liter of fluid was drained from your belly. This
was tested for infection, as this could cause abdominal pain,
and it was negative for infection. You will follow up with Dr.
[**Last Name (STitle) 816**] for further management of this. The details of this are
below.
You Medication changes are:
Lactulose 30 ml three times a day. You should have at least [**3-24**]
bowel movements a day and if you do not, you should take more
lactulose.
Hydrocortisone 2.5% Cream; apply to rectal area as needed for
pain/inflammation
You are also scheduled for a colonoscopy Friday, [**2-18**]. You must
take the bowel prep prior to this procedure. You will start this
medication at 2 pm [**2-17**]. You should drink 8 oz of Go-Lytely
every 10 minutes until you finish the bottle. You should not eat
or drink anything after midnight prior to your procedure.
You should continue to take the rest of your home medications.
Followup Instructions:
You have the following appointments:
1. DR. [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD : GENERAL SURGERY
Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2124-2-17**] 10:30
This is your appointment to remove you staples.
2. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD (GASTROENTEROLOGY)
Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2124-2-18**] 10:30
GI [**Apartment Address(1) **] (ST-3)
This is for your colonoscopy.
3. You have an appointment with your primary care doctor
DR. [**First Name8 (NamePattern2) 1980**] [**Last Name (NamePattern1) **]
Friday, [**2-25**], 9:40am
PH [**Telephone/Fax (1) 250**]
[**Company 191**] [**Hospital Ward Name 23**] [**Location (un) **]
[**Location (un) **].
[**Location (un) 86**], [**Numeric Identifier **]
|
[
"458.29",
"276.1",
"456.21",
"305.90",
"608.86",
"550.90",
"455.2",
"571.5",
"276.2",
"070.54",
"572.3",
"285.9",
"458.9",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
9222, 9280
|
5202, 7519
|
330, 337
|
9392, 9392
|
4125, 4125
|
11234, 12111
|
3438, 3553
|
7975, 9199
|
9301, 9371
|
7545, 7952
|
9537, 11211
|
3568, 4106
|
276, 292
|
365, 2771
|
4142, 5179
|
9406, 9513
|
2793, 3103
|
3119, 3422
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,153
| 199,555
|
47755
|
Discharge summary
|
report
|
Admission Date: [**2173-9-1**] Discharge Date: [**2173-9-14**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
1. Change in behavior.
2. Bradycardia.
Major Surgical or Invasive Procedure:
1. Permanent pacemaker placement.
History of Present Illness:
Mr. [**Known lastname 75001**] is an 86 year-old male with a history of prior
stroke, hypertension and hyperlipidemia who presents with a
change in behavior.
Was seen by his PCP [**Last Name (NamePattern4) **] [**8-10**]. At that time, he had complaints of
palpatations. Cardiac exam showed a "regular rate and rhythm".
Per the family, the patient was in his usual state of health
until yesterday. Today, he was found unable to open the
microwave, walking around, rambling. He was walking with no
apparent weakness and no facial droop but his speech did not
make sense.
En route, EMS gave 0.5mg of atropine for a HR in the 30s.
In the ED, vitals showed a BP of 138/60 and a rate in the 30s.
Blood pressure never dipped below 117 systolic while the rates
remained in the 30s-40s. He was given aspirin and calcium
gluconate for an elevated potassium.
Neurology evaluated the patient and found a fluent aphasia which
was concerning for inferior MCA division stroke.
Past Medical History:
1. h/o right PICA stroke
2. h/o TIA in [**5-14**] (left weakness, slurred speech)
3. Hypertension
4. Hyperlipidemia (LDL 58, HDL 100 [**3-17**])
5. Hypothyroidism: h/o [**Doctor Last Name 933**], now hypothyroid
6. Chronic kindey disease (baseline mid 2s)
7. Anemia (baseline mid-high 30s): Normal iron studies in [**3-17**]
Social History:
Takes care of his wife, who is severely demented. No history of
tobacco, alcohol or drug use.
Family History:
Non-contributory.
Physical Exam:
Blood pressure was 128/49 mm Hg while seated. Pulse was 37
beats/min and regular, respiratory rate was 12 breaths/min and
the saturatoin was 97%. Generally the patient was well
developed, but thin. He had a fluent aphasia and would only
respond with "okay" and "sounds good".
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 3cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Cardiac exam revealed no thrills, lifts or palpable S3 or S4.
The heart sounds revealed a normal S1 and the S2 was normal.
There was a II/VI systolic murmur at the apex.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There was a faint carotid bruit on the left.
Inspection and/or palpation of skin and subcutaneous tissue
showed 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:
ADMIT LABS: [**2173-8-31**]
CBC:
WBC-6.3 RBC-3.94* Hgb-12.1* Hct-37.5* MCV-95 MCH-30.8 MCHC-32.4
RDW-15.1 Plt Ct-215
CHEMISTRIES:
UreaN-50* Creat-2.4* Na-140 K-5.7* Cl-102 HCO3-26 AnGap-18
TotProt-7.2 Albumin-4.4 Globuln-2.8 Calcium-9.4 Phos-3.7 Mg-2.7*
COAGS ([**9-1**]):
PT-12.2 PTT-26.1 INR(PT)-1.0
CARDIAC ENZYMES:
[**2173-9-1**] 02:20PM CK(CPK)-128
[**2173-9-1**] 09:28PM CK(CPK)-265* CK-MB-6 cTropnT-0.02*
[**2173-9-2**] 05:17AM CK(CPK)-580* CK-MB-8 cTropnT-0.06*
MISC:
[**2173-8-31**] PTH-133*
[**2173-9-8**] calTIBC-234* Ferritn-100 TRF-180*
[**2173-9-9**] VitB12-634 Folate-18.6 Hapto-215*
[**2173-9-9**] TSH-4.7*
CXR ([**2173-8-31**]):
1. Extensive left sided calcification of the pleura, which may
reflect prior asbestos exposure though asymmetry of the pleural
plaques would be unusual for asbestosis related disease of the
pleura. Another potential casue would be remote hemothorax or
resolved pleural empyema.
2. Patchy opacity of much of the left lung may be chronic though
asymmetric edema or airspace consolidation are possible.
CT HEAD ([**2173-9-1**]):
1. No hemorrhage, mass effect or edema.
2. Right maxillary sinus polyp/mucus-retention cyst, unchanged.
ECHO ([**2173-9-2**]):
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Torn mitral chordae are
present. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
VIDEO SWALLOW ([**2173-9-9**]):
Moderate dysphagia with extreme discoordination of the
oropharyngeal swallow. Aspiration of thin and nectar-thick
liquids after the swallow.
LOWER EXT US ([**2173-9-9**]):
No DVT.
CAROTID US ([**2173-9-9**]):
There is less than 40% stenosis within bilateral internal
carotid arteries.
Brief Hospital Course:
1. Temporal lobe stroke:
The patient's presentation of fluent aphasia was consistent with
the CT findings of a temporal lobe stroke. Regarding
etiologies, an acute bleed is unlikely given the CT. Low
cerebral blood flow in the setting of his bradycardia was a
possibility, as was a cardioembolic process. TEE showed a
patent foramen ovale, but lower extremity ultrasound did not
show evidence of DVT. As treatment, the patient was initially
anticoagulated with IV heparin; this was stopped on HD#2. He
was treated with PR aspirin given his inability to take crushed
aggrenox. To improved his HR, as a bridge to a PPM, IV
isoproterenol was used with good effect.
After stabilization, the patient's fluent aphasia resulting in
difficulties with communication. He was at time agitated,
requiring IV haldol. Psychiatry recommended standing zydis,
along with PRN doses. This was effective.
He will continue antiplatelet therapy with plavix and aspirin,
and follow up in stroke clinic.
2. Bradycardia:
EKG on admission showed a LBBB with 2:1 block and a ventricular
rate in the 30s. Once his rate increased, he showed a narrow
complex and a rate in the 70s. He likely has conduction disease
with intermitant block. A PPM was placed with good effect.
3. Swallow/Nutrition:
As the patient's diet was addressed, it became clear that he was
coughing with most ingestions. Given the fear of aspiration,
speech and swallow was consulted and felt there were soft signs
of aspiration with thin liquids, nectar-thick liquids, and
puree. A videoswallow showed moderate dysphagia with extreme
discoordination of the oropharyngeal swallow and aspiration of
thin and nectar-thick liquids after the swallow. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] free
water protocol was used and the patient improved with this. If
was felt that, if he is unable to maintain his nutrition &
hydration with PO intake alone, that consideration for PEG
placement would be appropriate. He should continue with
speech-language and swallwoing therapy at rehab.
4. Chronic kidney disease:
The creatinine on admission was sligthly above baseline. It
trended down over the intial days, then back up as his PO intake
was poor.
5. Anemia:
At the time of admission, hematocrit was 37.5. Trended down to
as low as 24.3 on [**9-8**] and rebounded to 27.9 on [**9-10**], without
intervention. Iron studies, B12, folate were not diagnostic.
He likely has underlying anemia from his CKD.
6. Hypertension:
Continued lisinopril.
7. Hyperlipids:
Continued simvastatin.
Medications on Admission:
1. Aggrenox 25-200mg [**Hospital1 **]
2. Levothyroxine 125mcg daily (had been 137, but he was not
taking this dose)
3. Lisinopril 20mg daily
4. Simvastatin 20mg daily
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**1-12**] Tablet, Rapid
Dissolve PO twice a day as needed for acute agitation.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*3*
10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**1-12**] Tablet,
Rapid Dissolve PO three times a day.
Disp:*45 Tablet, Rapid Dissolve(s)* Refills:*3*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Temporal lobe stroke; fluent aphasia
2. Bradycarda, s/p permanent pacemaker
Discharge Condition:
Hemodynamically stable. Fluent aphasia.
Discharge Instructions:
You were admitted after having a stroke and a low heart rate.
For the latter, a permanent pacemaker was placed. It will be
extremely important for you to follow-up with your primary care
provider and that you continue with occupational and speech
therapy.
Please be sure to take all your medications, as prescribed.
Seek medical attention at once if you develop
** lightheadedness or dizziness, chest discomfort or shortness
of breath, palpitations
** weakness or loss of sensation, especially if on one side of
your body, bloody or black stools, abdominal pain, or other
symptoms that worry you
Followup Instructions:
1. DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2173-10-12**] 2:30
2. [**Hospital 878**] clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1694**] Tuesday
[**11-2**] at 1:30
3. [**Last Name (LF) 1576**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**]-[**Doctor Last Name 1576**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2173-11-16**] 9:10
4. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2174-2-23**] 2:00
|
[
"434.91",
"403.90",
"285.21",
"585.9",
"427.89",
"272.4",
"244.9",
"426.3",
"426.13",
"438.11",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"88.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
9335, 9405
|
5584, 8148
|
256, 292
|
9537, 9580
|
3170, 3476
|
10227, 10838
|
1766, 1785
|
8366, 9312
|
9426, 9516
|
8174, 8343
|
9604, 10204
|
1800, 3151
|
3493, 5561
|
178, 218
|
320, 1290
|
1312, 1639
|
1655, 1750
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,191
| 180,271
|
39223
|
Discharge summary
|
report
|
Admission Date: [**2148-2-8**] Discharge Date: [**2148-2-12**]
Date of Birth: [**2080-1-5**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
transfer from OSH
Major Surgical or Invasive Procedure:
extubation
History of Present Illness:
per admitting resident note:
This HPI is obtained through records from OSH and daughter:
[**Name (NI) 72372**] [**Name (NI) **]: [**Telephone/Fax (1) 86817**].
68 yo RH man with a PMH remarkable for HTN, HLD, PVD s/p femoral
artery stent and LEFT CEA, CKD p/w sudden headache and
??????blindness??????.
He was last seen in her USOH today in the morning. He then
walked
upstairs (lives with his daughter) and started complaining of
inability to see and a ??????terrible headache??????. Unfortunately we
have no further description of his visual problems. The family
called 911 and he was taken to [**Doctor Last Name 1495**] [**Hospital1 107**].
Once at OSH: His 15:35 VS were 206/ 106 at 100 bpm with RR 24.
At
16:35 he was not responding to verbal commands. His eyes were
open and there was per OSH description a LEFT gaze deviation.
His
GCS was 10 per report. It then declined and he was intubated. He
received a a CT CNS w/o contrast which was unrevealing. His CBC
had a WBC of 18.6, but he was afebrile. Chem showed a glu of
184,
creat 2.0 and BUN 22. GFR 35. K+ was 3.2. I did not see a Mg or
Ca level. His EKG showed sinus tachycardia at 156 bpm with no
repol abnormalities.
Once at [**Hospital1 18**] her VS were 137/ 82, 88 bpm, RR 17 (overbreathing
the vent). Afebrile. He became agitated and received fentanyl
bolus and ativan 1 mg *2. He then became hypotensive and was
started on norepinephrine at 0.03 micrograms/ kg/ min. He
received a CT with CTA of his CNS and neck: my read: hypoplastic
LEFT vertebral. Patent vessels. No acute process.
He had recently been admitted for femoral artery stent (3 months
ago). Two and a half months ago he required readmission for
bowel
ischemia and subsequent surgery. After DC to rehab he returned
to
his daughter??????s a month ago. He is IADLs at baseline. He is FC.
ROS is negative otherwise.
Past Medical History:
- TIA - L arm numbness/weakness/confusion. [**10/2147**]
hospitalization
- HTN
- HL
- PAD, s/p LEFT open endarterectomy of ext.iliac, common femoral
and profunda femoris and angioplastiy of LEFT SFA w/ stenting on
[**2147-11-21**].
- Ischemic bowel s/p resection of 2 segm. of sm. bowel
([**Date range (1) 86818**] hospitalization c/b ARF [cr 4.1], anasarca [alb
0.9], fevers, b/l PNA).
- Tonsillectomy
- s/p CEA [**2140**]
Social History:
Widowed, has 7 children. Used to work as a truck driver, but has
not since recent hospitalizations. Independent in ADLs and
iADLs.
Tobacco - 1ppd 50+years
EtOH - denied
Drug use - denied
Obtained from family.
Family History:
Hx of early strokes (-)
Seizures (-)
CNS tumors (-)
Demyelinating conditions (-)
Autoimmune conditions (-)
Procoagulant conditions (-)
CAD (-)
Physical Exam:
Exam on admission:
Afebrile, normal temp. 140/ 80, 90 bpm. RR 17.
On vent, CMV RR 17
Sedated on fentanyl. Stopped 5 minutes ago.
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:
MS:
He is responsive to noxious stimuli: withdraws symm with all
limbs (and localizes)
CN: Brain stem reflexes : preserved:
Corneals + bl. Pupils 2 to 1.5 LEFT sluggishly, 2 to 1 on the
RIGHT. Dolls eyes +. No gaze deviation. No bobbing or Robbing.
No
nystagmus. NO facial asym.
Gag +.
Increased tone in bl legs.
DTR: 1+. Toes downgoing bl.
Exam at time of discharge:
Pertinent Results:
Labs on admission:
[**2148-2-8**] 06:30PM BLOOD
WBC-16.0* RBC-3.81* Hgb-11.1* Hct-33.0* MCV-87 MCH-29.2
MCHC-33.7 RDW-15.5 Plt Ct-311
[**2148-2-8**] 06:30PM BLOOD PT-12.6 PTT-20.5* INR(PT)-1.1
[**2148-2-9**] 02:53AM BLOOD Glucose-95 UreaN-27* Creat-2.0* Na-141
K-3.5 Cl-109* HCO3-24 AnGap-12
[**2148-2-8**] 06:30PM BLOOD CK(CPK)-36*
[**2148-2-9**] 11:03AM BLOOD CK(CPK)-59
[**2148-2-8**] 06:30PM BLOOD CK-MB-4 cTropnT-0.20*
[**2148-2-9**] 02:53AM BLOOD CK-MB-NotDone cTropnT-0.26*
[**2148-2-9**] 11:03AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2148-2-9**] 02:53AM BLOOD ALT-15 AST-23 CK(CPK)-50 AlkPhos-72
TotBili-0.3
[**2148-2-8**] 06:30PM BLOOD Calcium-8.1* Phos-6.9* Mg-1.5*
LIPID PROFILE
[**2148-2-9**] 02:53AM BLOOD Triglyc-166* HDL-24 CHOL/HD-6.3
LDLcalc-94
[**2148-2-8**] 06:30PM BLOOD
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
[**2148-2-9**] 02:53AM BLOOD TSH-0.91
Imaging:
CTA head and neck
IMPRESSION:
1. Hypodensity in the left parieto-occipital region and
bilateral cerebellar hemispheres. Infarcts cannot be excluded.
MRI would be more sensitive.
2. Extensive atherosclerosis of the aortic arch with numerous
ulcerations,
the largest being at the origin of the innominate artery.
3. 50-60% narrowing of the origin of the left common carotid
artery with
milder narrowing involving the origin of the right internal
carotid artery and proximal left vertebral artery as above.
MRI brain
IMPRESSION: Left parietooccipital, smaller right occipital,
bilateral
cerebellar abnormal signal suggestive of PRES in the appropriate
clinical
setting. Foci of subcortical signal abnormality in the frontal
lobes may be part of the same process.
Renal US
IMPRESSION:
1. No renal calculi or hydronephrosis.
2. Severely limited Doppler interrogation of the kidneys
bilaterally, without overt evidence for renal artery stenosis.
EEG Study Date of [**2148-2-9**]
IMPRESSION: This is a mildly abnormal routine EEG in the waking
and
drowsy states due to a mildly slow and disorganized background
consistent with mild encephalopathy. Medications, infection and
metabolic abnormalities are among the most common causes, but
posterior
circulation compromise could also contribute. There were no
focal,
lateralized or epileptiform abnormalities.
ECG Study Date of [**2148-2-9**] 10:41:30 AM
Sinus rhythm. Non-specific ST-T wave changes. Consider left
ventricular
hypertrophy. Compared to the previous tracing of [**2148-2-9**] no
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 180 88 [**Telephone/Fax (2) 86819**] 103
Brief Hospital Course:
68 yo RH man with TIA, HTN, HLD, PVD s/p L arterial
endarterectomy, SFA stent, ischemic coilitis s/p small bowel
resection, Left CEA and CKD presented with sudden headache,
visual loss and confusion. He had an an episode of
unresponsiveness in the OSH with LEFT gaze deviation and was
intubated. BP on arrival was 206/104 and fluctuated
significantly (SBP 74 - 206) while intubated. Given concern for
CVA patient was transferred to [**Hospital1 18**] for further care.
NEURO. Initial examination was non-focal on arrival. Based on
history suspicion was for PRES, occipital infarct from top of
basilar syndrome and hypertensive encephalopathy. He was loaded
with Keppra. MRI revealed multiple old lacunar strokes in R
thalamus and PVWMD and T2/FLAIR hyperintensities primarily in
subcortical L occiptal lobe, bilateral cerebelli consistent with
PRES.
He was extubated and blood pressure was well controlled (120 -
140s mmHg).
On HD1 he was awake and alert but remained
disoriented/encephalopathic.
EEG showed encephalopathy but was without evidence of seizure
activity; keppra was discontinued.
CV. EKG with TwI and flattening in lateral leads, episodes of
nausea/emesis w/o CP/SOB with flat CKs and troponin of 0.26
(peak). In setting of a hypertensive emergency, ARF was felt to
be due to demand/small subendocardial ischemia that was managed
medically. He was continued on Plavix, Metoprolol, Statin.
Hydralazine was used on prn basis.
PULM - patient was extubated on HD1. No respiratory issues were
noted during the hospitalization.
RENAL. Cr 2.0 on admission, per PCP [**Name9 (PRE) 2091**] with baseline Cr 1.4
prior to hospitalization for ischemic bowel, c/b anasarca, ARF
to 4.1 and PNA. However, last creatinine at rehab was 2.9
([**2148-1-8**]). UA showed proteinuria and RBCs with no casts.
Patient was treated with IVF for having had received IV contrast
at time of admission. Cr at time of discharge was 1.9 and this
is likely his new baseline. He was discharged on his home
medication of HCTZ.
Medications on Admission:
Plavix 75 qd.
HCTZ 12.5 mg qd
Amlodipine 10mg qd
metoprolol 50 XL qd.
Zocor 20 qhs.
Folic acid 1 mg qd.
Protonic 40mg
Multivitamin
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every twenty-four(24) hours.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Posterior Reversible Encephalopathy Syndrome
Hypertension
Hyperlipidemia
Chronic kidney disease
Discharge Condition:
He is awake and alert, with fluent speech and intact
comprehension. Visual fields where full on confrontation
testing, PERRLA. He has full strength in the deltoids, triceps,
and iliopsoas bilaterally.
Discharge Instructions:
You were admitted for evaluation of changes in your vision and
headaches. You did not have a stroke, but images of your brain
where suggestive of a process called PRES, which is likely
caused by high blood pressure in the setting of chronic kidney
disease.
We strongly recommend that you stop smoking. You should watch
your sodium intake, as this may contribute to your hypertension.
You are scheduled to see your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 2974**] at
10 am. You are also scheduled for follow up in the [**Hospital 86820**]
clinic in [**Month (only) 547**] with Dr. [**First Name (STitle) **].
Followup Instructions:
PCP: [**Name10 (NameIs) 86821**],[**Name11 (NameIs) 4912**] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 86822**]
You have an appointment scheduled for [**Telephone/Fax (1) 2974**], [**2148-2-16**]
at 10 am.
Neurology: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2148-3-25**] 1:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2148-2-12**]
|
[
"V12.54",
"403.90",
"580.9",
"443.9",
"V45.72",
"V15.82",
"518.82",
"437.2",
"E947.8",
"272.4",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9410, 9416
|
6585, 8612
|
332, 344
|
9556, 9761
|
4011, 4016
|
10451, 10941
|
2923, 3067
|
8795, 9387
|
9437, 9535
|
8638, 8772
|
9785, 10428
|
3082, 3087
|
275, 294
|
372, 2231
|
4030, 6562
|
3620, 3992
|
2253, 2679
|
2695, 2907
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,752
| 105,699
|
9961
|
Discharge summary
|
report
|
Admission Date: [**2204-12-13**] Discharge Date: [**2204-12-14**]
Date of Birth: [**2125-2-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**12-13**] intubation
[**12-13**] left femoral CVL
[**12-13**] left subclavian CVL
[**12-14**] arterial line
History of Present Illness:
Mr. [**Known lastname 26812**] is a 79 year old man with a history of metastatic
non-small cell lung cancer who presented to the ER today with
dyspnea for the past 2 days. He had recently undergone
thoracentesis on [**2204-11-29**] with 700 cc of fluid drained. He has
been on Bactrim for treatement of Moraxella found on BAL culture
on [**2204-11-29**].
In the emergency department, initial vitals: 97.7 88 132/52 28
90% 4L NC. US and CXR showed a large left-sided pleural
effusion. He was seen by IP who performed a thoracentesis at
the bedside which drained 2L of bloody fluid.
Post-thoracentesis CXR showed persistent collapse of left
hemithorax. He was treated emperically with Levofloxacin for
concern for infection. He was then admitted to the oncology
floor.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- known left lung pulmonary nodule since [**2199**], followed with
serial imaging.
- [**2204-11-8**] developed dyspnea with exertion, dry cough,
left sided chest discomfort and fatigue
- [**2204-11-4**]: imaging showed left-sided pulmonary mass,
mediastinal/hilar adenopathy, left pleural effusion and
impending left airway obstrcution
- [**Date range (3) 33359**]: admitted to [**Hospital1 18**] for evalution, CT
[**2204-11-29**] showed complete obstruction of the left upper lobe with
post obstructive upper lobe collpase with small to moderate left
pleural effuison, paraesophageal lymph node, mulitple
prevascular lymph nodes and aortopulmonary lymph nodes. There
was also a lytic lesion in the lateral aspect of the left 6th
rib and focal lucent area in the right T11 vertebra.
- [**2204-11-29**]: bronchoscopy and thoracentesis with 700 ccs of
ser-sanguinous fluid. The pleural fluid, lymph nodes stations
7, 4R, 4L and 11 showed adenocarchioma
post-obstructive pneumonia with Moraxella catarrhalis. He was
treated with supplemental oxygen and antibiotics (levofloxacin -
to complete the course within the next few days). Tumor cells on
pleural effusion cell block S11-[**Numeric Identifier 33360**] were positive for [**Last Name (un) **] 31,
B72.3 and CK7, and negative for CD68, TTF-1, p63, WT-1 and
calretinin.
- [**2204-12-7**]: PET scan showed FDG avid large left hilar tumor
causing compression of the left upper lobe bronchus with LUL
collapse, extensive FDG avid mediastinal adenopathy a loculated
moderate left pleural effusion and extensive FDG avid osseous
metastasis.
- [**2204-12-7**]: MRI Brain negative for brain mets
PAST MEDICAL HISTORY:
Hypertension
Hypercholesterolemia
CAD s/p CABG [**2192**], depressed EF per report
CKD with creatinine > 1.5
Nephrolithiasis [**2203**]
Hernia Repair
Social History:
Lives in [**Location (un) 5089**] with wife; previously in [**Location (un) **]. He
worked as a maintenance worker in various roles.Quit smoking at
age 42. Started smoking at age 12 and smoked 1 and [**12-10**] pack-per
day until age 42. This places him at an
approximate 45-pack-year history of smoking. The patient denies
chronic alcohol use/abuse. The patient denies significant
exposures to asbestos or chemicals in prior work. No exposure to
radiation.
Family History:
The patient's father died from unknown causes.
Mother died from sepsis (toxemia). There is no other history of
cancer in the family.
Physical Exam:
VS T97.1 BP 110/70 HR 85 RR20 92% on 4L
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: Decreased breath sounds on the left. Thoracentesis drain
in place with bloody fluid draining.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses
Pertinent Results:
LABS:
On admission:
[**2204-12-13**] 09:25AM BLOOD WBC-16.7* RBC-3.79* Hgb-10.7* Hct-32.0*
MCV-85 MCH-28.3 MCHC-33.5 RDW-13.8 Plt Ct-302
[**2204-12-13**] 09:25AM BLOOD Neuts-78.3* Lymphs-16.0* Monos-4.3
Eos-0.9 Baso-0.6
[**2204-12-13**] 09:25AM BLOOD PT-13.6* PTT-25.9 INR(PT)-1.3*
[**2204-12-13**] 09:25AM BLOOD Glucose-158* UreaN-47* Creat-2.3* Na-138
K-4.0 Cl-99 HCO3-23 AnGap-20
[**2204-12-13**] 09:13PM BLOOD ALT-51* AST-33 LD(LDH)-355* CK(CPK)-44*
AlkPhos-65 TotBili-0.2
During PEA arrest:
[**2204-12-13**] 09:13PM BLOOD WBC-13.6* RBC-2.96* Hgb-8.5* Hct-27.6*
MCV-93# MCH-28.8 MCHC-30.9* RDW-14.1 Plt Ct-232
[**2204-12-13**] 09:13PM BLOOD Neuts-50.3 Lymphs-43.2* Monos-5.1 Eos-0.9
Baso-0.5
[**2204-12-13**] 09:13PM BLOOD Glucose-309* UreaN-41* Creat-2.1* Na-136
K-4.0 Cl-110* HCO3-10* AnGap-20
[**2204-12-13**] 09:13PM BLOOD CK-MB-2 cTropnT-<0.01
[**2204-12-13**] 09:13PM BLOOD Albumin-2.3* Calcium-7.8* Phos-6.6*#
Mg-2.0
[**2204-12-13**] 09:18PM BLOOD Type-[**Last Name (un) **] pH-6.93* Comment-GREEN TOP
Post-arrest trends:
CBC
[**2204-12-13**] 10:16PM BLOOD WBC-14.0* RBC-2.64* Hgb-7.8* Hct-24.3*
MCV-92 MCH-29.5 MCHC-32.0 RDW-14.4 Plt Ct-186
[**2204-12-14**] 01:49AM BLOOD WBC-17.2* RBC-4.37*# Hgb-12.8*#
Hct-37.8*# MCV-87 MCH-29.3 MCHC-33.9 RDW-14.0 Plt Ct-209
[**2204-12-14**] 05:57AM BLOOD WBC-15.7* RBC-4.12* Hgb-11.9* Hct-35.4*
MCV-86 MCH-28.8 MCHC-33.6 RDW-14.1 Plt Ct-190
[**2204-12-14**] 02:56PM BLOOD WBC-16.7* RBC-4.11* Hgb-12.2* Hct-35.3*
MCV-86 MCH-29.8 MCHC-34.6 RDW-14.5 Plt Ct-178
Coags:
[**2204-12-13**] 10:16PM BLOOD PT-17.3* PTT-31.4 INR(PT)-1.6*
[**2204-12-14**] 01:49AM BLOOD PT-15.5* PTT-28.3 INR(PT)-1.5*
[**2204-12-14**] 05:57AM BLOOD PT-16.2* PTT-29.5 INR(PT)-1.5*
[**2204-12-14**] 02:56PM BLOOD PT-18.3* PTT-150* INR(PT)-1.7*
Chem 10:
[**2204-12-13**] 10:16PM BLOOD Glucose-253* UreaN-40* Creat-2.0* Na-139
K-3.2* Cl-111* HCO3-15* AnGap-16
[**2204-12-14**] 01:49AM BLOOD Glucose-254* UreaN-43* Creat-2.1* Na-141
K-3.9 Cl-109* HCO3-16* AnGap-20
[**2204-12-14**] 05:57AM BLOOD Glucose-287* UreaN-45* Creat-2.4* Na-139
K-4.3 Cl-106 HCO3-22 AnGap-15
[**2204-12-14**] 02:56PM BLOOD Glucose-162* UreaN-44* Creat-2.6* Na-140
K-3.9 Cl-107 HCO3-20* AnGap-17
[**2204-12-13**] 10:16PM BLOOD Calcium-8.2* Phos-8.9*# Mg-1.9
[**2204-12-14**] 01:49AM BLOOD Calcium-8.0* Phos-6.0*# Mg-1.6
[**2204-12-14**] 05:57AM BLOOD Albumin-2.4* Calcium-7.8* Phos-5.0*
Mg-1.6
[**2204-12-14**] 02:56PM BLOOD Calcium-7.9* Phos-4.9* Mg-1.5*
LFTS:
[**2204-12-13**] 10:16PM BLOOD ALT-114* AST-115* LD(LDH)-472* AlkPhos-54
TotBili-0.2
[**2204-12-14**] 01:49AM BLOOD ALT-231* AST-231* AlkPhos-90 TotBili-0.6
[**2204-12-14**] 05:57AM BLOOD ALT-205* AST-198* CK(CPK)-100 AlkPhos-83
TotBili-0.8
IMAGING:
[**12-13**] CT chest:
1. At least partially loculated large left pleural effusion,
stable in size
since [**2204-12-7**] study but progressed since [**2204-11-29**]. New
left pigtail catheter appears appropriately coiled deep within
the left
costophrenic angle.
2. Known left hilar mass causing left bronchial compression with
complete
collapse of the left upper lobe, stable, and near complete
collapse of the
left lower lobe, progressed since [**2204-11-29**].
3. Lytic lesions involving the left lateral sixth rib and
vertebral body T12,
most consistent with bony metastatic disease. Multiple other
bony sites of
disease are better evaluated on the [**2204-12-7**] PET-CT.
[**12-13**] post-intubation CXR:
The endotracheal tube is in standard placement. Large left
pleural effusion
developed in the setting of left upper lobe collapse is larger
now than it was
at 1:00 p.m. shifting the mediastinum further to the right and
collapsing the
remainder of the left lung as before. Nasogastric tube ends in
the stomach.
New right infrahilar consolidation is presumably atelectasis.
[**12-14**] Echo:
The left atrium is normal in size. The coronary sinus is dilated
(diameter >15mm). Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic (EF 75%). The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with severe global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload, with marked ventricular
interaction. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. The tricuspid regurgitation jet is eccentric. There is
severe pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. The main pulmonary
artery is dilated. The branch pulmonary arteries are dilated.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2204-11-30**], severe right ventricular pressure and
volume overload with marked ventricular interaction are now
present. Findings are consistent with acute-on-chronic right
ventricular strain.
[**12-14**] Bilateral LENIs:
IMPRESSION: Findings consistent with deep vein thrombosis within
the
Preliminary Reportbilateral popliteal and posterior tibial veins
and right peroneal vein.
Brief Hospital Course:
Mr. [**Known lastname 26812**] is a 79 year old man with a history of stage IV
NSCLC with recurrent pleural effusions and left-sided collapse
who presented for dyspnea and was s/p a thoracentesis with 2L
pleural fluid removed which was bloody.
Upon admission, he was sent immediately to radiology for CT
chest, and at that time was feeling dyspneic but was in no
distress. On arrival back up to the floors, he was found to be
hypoxic, and shortly thereafter lost his pulse. A code blue was
called. On arrival, chest compressions had been started. Rhythm
was analzyed and pt was found to be in PEA arrest. He was given
2 rounds of Epi 1mg with ~ 10mins of CPR, with recovery of
pulse. He was intubated and transferred to the unit.
On arrival to the ICU, VS were Temp 96.0 HR 104 BP 118/64 RR 23
O2 sat 67%. Vent settings CMV FiO2 100% Tv 550 RR 20 PEEP 5. Pt
appeared mildly uncomfortable and was started on
fentanyl/versed. Within a few minutes of arrival, he lost pulse
and was coded again. He was given 2 amps of bicarb, 1 calcium
gluconate, and 1mg Epi with return of pulse. He was transfused
PRBC's. His initial lactate during resuscitation returned at
10.8.
Bedside echo was performed and showed right sided volume
overload with underfilling of LV. Bedside bronchoscopy was
performed and showed severe extrinsic compression of left
bronchus from known hilar mass, but there were no secretions or
mucous plugs. He was also started on empiric vancomycin and
zosyn in case sepsis was playing any role in his acute decline.
He was aggressively resuscitated with IV fluids and
phenylephrine and norepinephrine were started to help support
blood pressures. He was also transfused 4 units of PRBCs for
6pt drop in Hct, and empiric anticoagulation was deferred. He
stabilized overnight on these supportive measures, and latate
trended down.
In the morning [**12-14**], Heparin gtt was started. Formal echo
confirmed rigth heart strain with under filling of the left
ventricle, and bilateral DVTs were found on LENIs. He required
uptitration on his pressors throughout the morning, suggesting
worsening shock. Though it was medically indicated due to his
hemodynamic instability, the team decided to speak with the
family first about goals of care prior to starting lysis
therapy. A family meeting was held with the patient's son [**Name (NI) **]
(HCP), daughter-in-law [**Name (NI) **], Dr. [**Last Name (STitle) **] from the ICU, Dr.
[**Last Name (STitle) **] from oncology, and the rest of the members of the ICU
team. Upon [**Last Name (STitle) **] discussion of all risks and benefits of
treatment and his overall poor prognosis, the family decided to
forgo clot lysis and change his management to comfort focused
care. He was started on a morphine drip, pressors were
withdrawn, and he was extubated. He passed away peacefully with
family at his side around 6:20 pm.
Medications on Admission:
Atorvastatin 40 mg PO daily
Lorazepam 0.5 mg PO BID PRN anxiety
Metoprolol 25 mg PO BID
Nifedipine XL 30mg PO daily
NTG 0.4 mg PO PRN chest pain
Omeprazole 20 mg PO daily
Aspirin 81 mg PO daily
Vitamin D 400 IU PO daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Stage IV lung cancer
PEA arrest
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
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"511.81",
"162.9",
"414.00",
"272.4",
"518.0",
"V66.7",
"198.5",
"V45.81",
"427.5",
"585.9",
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icd9cm
|
[
[
[]
]
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[
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"96.04",
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"96.71",
"38.91",
"38.93"
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icd9pcs
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[
[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,374
| 169,788
|
45108
|
Discharge summary
|
report
|
Admission Date: [**2109-3-5**] Discharge Date: [**2109-3-13**]
Date of Birth: [**2042-6-25**] Sex: F
Service: MEDICINE
Allergies:
Mevacor / Bactrim / Dilantin Kapseal / Naprosyn / Clindamycin /
Percocet / Quinine / Levofloxacin / Penicillins / Vicodin /
latex gloves / Morphine / optiflux / Warfarin / Phenytoin
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Right internal jugular line removal
Left internal jugular line insertion
History of Present Illness:
Ms. [**Known lastname 1968**] is a 66yo lady with Afib on Lovenox, ESRD on HD, dCHF,
HTN, DMII, restricitve lung disease on home O2, necrotizing
breast infections from Warfarin skin necrosis, admission 1 month
ago for hypoglycemia and pneumonia who was brought to the ED due
to mental status changes and is initially admitted to the MICU
due to hypotension.
.
Today she was taken to [**Known lastname 2286**] by EMS as usual. Initially she
was appropriate, but as the EMS ride continued, she began making
strange comments and ultimately became obtunded so they brought
her to the ED instead of HD.
.
In the ED, initial VS were: 98.2 68 121/36 24 100% 4L. She was
initially unresponsive except to noxious stimuli, but them
spontaneously became alert, interactive, and oriented x3. Knew
that she was brought to the hospital because she was "acting
funny in the ambulance, I guess." Labs were unremarkable except
Cr 5 (she is on HD). CXR suggested volume overload but could
not rule out pneumonia. During her evaluation, she again became
unresponsive except to noxious stimuli, with myoclonic jerks,
associated with SBP 50-60. Blood pressure improved to SBP 100
with 500cc IVF, and she became alert again. ABG did not suggest
hypercarbia. No suggestion of pneumonia, but there was concern
for leg infection so she was given Vanc/Zosyn. Given her
hypotension and periods of unresponsiveness, she was admitted to
the MICU. VS prior to transfer were: T 99, HR 68, BP 101/51,
RR22, 97%RA.
.
On arrival to the MICU, she is only reponsive tovigorous sternal
rub. Responds slowly to questions and falls asleep before
answering them fully. [**Known lastname 4273**] taking any pain medications today.
Past Medical History:
- CAD s/p Taxus stent to mid RCA in [**2101**], 2 Cypher stents to
mid LAD and proximal RCA in [**2102**]; 2 Taxus stents to mid and
distal LAD (99% in-stent restenosis of mid LAD stent); NSTEMI in
[**8-1**]
- CHF, LVEF >55% on echo in [**2107**]. 1+ MR
- Atrial fibrillation
- Hypertension
- Dyslipidemia: Chol: 171, LDL 92 in [**1-/2108**] on Pravastatin
- Multiple prior Syncope/Presyncopal episodes
- Type 2 DM on insulin, last A1c 8% in [**2107**]
- ESRD on HD since [**2107-2-28**] - [**Year (4 digits) 2286**] on MWF, and UF on
Thursday
- She had a left upper arm brachiocephalic AV fistula created
which did show some maturation, but the vein was found to be too
deep and too tortuous for use.
- PVD s/p bilateral fem-[**Doctor Last Name **] in [**2093**] (right), [**2100**] (left)
- restricitve lung disease last [**Year (4 digits) 1570**]'s of [**10-6**] consistent with
restrictive pattern. FEV1 = 71%, FVC = 68% FEV1/FVC = 105, on
home O2 3L
- title of COPD but most recent [**Date Range 1570**]'s showed reastrictive
pattern
- OSA- CPAP at home 14 cm of water and 4 liters of oxygen
- Morbid obesity (BMI 54)
- Crohn's disease - not currently treated, not active dx [**2093**]
- Depression
- Gout
- Hypothyroidism
- GERD
- Chronic Anemia
- Restless Leg Syndrome
- Back pain/leg pain from degenerative disk disease of lower L
spine, trochanteric bursitis, sciatica
- calciphylaxis
- warfarin skin necrosis
- invasive ductal breast cancer
Social History:
-Home: Lives at a Nursing Home ([**Location (un) 1036**] in [**Location (un) 620**]). Very
close with her sister [**Name (NI) **], HCP) and [**Initials (NamePattern4) 96407**] [**Last Name (NamePattern4) 96408**] [**Last Name (un) **].
-Tobacco: Quit smoking in [**2102**], smoked 2.5ppd x 40 years (100py
history).
-EtOH: [**Year (4 digits) **]
-Illicits: [**Year (4 digits) **]
Family History:
Sister: CAD s/p cath with 4 stents MI, DM
Brother: CAD s/p CABG x 4, MI, DM
Mother: died at age 79 of an MI, multiple prior, DM
Father: [**Name (NI) 96395**] MI at 60
She also has several family members with PVD
Physical Exam:
ADMISSION EXAM
Vitals: T: 97.1 BP: 116/62 P: 58 R: 14 O2: 96% 4L NC
General: Obese lady, snoring, not arousable except to deep
sternal rub, no respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Bradycardic, irregular, S1 and S2, no murmur
Lungs: End-expiratory wheezes bilaterally
Chest: b/l mastectomy sites with no erythema, no fluctuance
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present
GU: foley
Ext: very edematous legs (2+) up to thighs bilaterally with
chronic venous stasis; non-healing 2cm ulcers on left posterior
calf and left medial calf with serous drainage
Neuro: drowsy, localizes and withdraws to sternal rub or
peripheral noxious stimuli; 2+ brachial and patellar reflexes;
normal bulk and tone; intermittent myoclonic jerks
DISCHARGE EXAM:
Tele: 80-90s, A fib
VS: 98.0 110/78 95 22 95% on 3L
General: alert, oriented to person, place, events, fatigue in
appearance, pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to see due to body habitus
Resp: scattered expiratory wheeze, no rales or rhonchi,
occasional cough
CV: sounded irregular, distant heart sound, unable to appreciate
m/r/g
Abd: soft, NT, ND, BS+, obese, no tenderness
Ext: warm, dry, difficult to palpate DP/PT pulses bilaterally,
chronic stasis changes, + edema. right leg wrapped in gauze
Line: R tunnelled cath removed with resolving erythema, has L
tunnelled IJ cath now with dressing c/d/i
Pertinent Results:
ADMISSION LABS
[**2109-3-5**] 06:43PM TYPE-[**Last Name (un) **] PH-7.39
[**2109-3-5**] 06:43PM LACTATE-0.9
[**2109-3-5**] 06:43PM freeCa-1.01*
[**2109-3-5**] 05:48PM ALT(SGPT)-11 AST(SGOT)-14 LD(LDH)-135 ALK
PHOS-193* TOT BILI-0.2
[**2109-3-5**] 05:48PM ALBUMIN-2.8*
[**2109-3-5**] 05:48PM VIT B12-445
[**2109-3-5**] 05:48PM TSH-9.0*
[**2109-3-5**] 04:00PM GLUCOSE-176* UREA N-29* CREAT-4.9* SODIUM-136
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-30 ANION GAP-13
[**2109-3-5**] 04:00PM ALT(SGPT)-11 AST(SGOT)-15 LD(LDH)-175 ALK
PHOS-210* TOT BILI-0.2
[**2109-3-5**] 04:00PM ALBUMIN-3.1* CALCIUM-7.7* PHOSPHATE-3.1
MAGNESIUM-1.5*
[**2109-3-5**] 04:00PM DIGOXIN-2.5*
[**2109-3-5**] 04:00PM WBC-6.4 RBC-2.74* HGB-8.3* HCT-26.8* MCV-98
MCH-30.5 MCHC-31.1 RDW-16.0*
[**2109-3-5**] 04:00PM NEUTS-82.4* LYMPHS-8.0* MONOS-6.0 EOS-2.9
BASOS-0.6
[**2109-3-5**] 04:00PM PLT COUNT-214
[**2109-3-5**] 12:44PM PT-11.3 PTT-30.3 INR(PT)-1.0
[**2109-3-5**] 12:38PM PO2-103 PCO2-45 PH-7.42 TOTAL CO2-30 BASE
XS-3 COMMENTS-SOURCE NOT
[**2109-3-5**] 12:38PM LACTATE-1.7
[**2109-3-5**] 11:40AM GLUCOSE-200* UREA N-29* CREAT-5.0*#
SODIUM-138 POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-29 ANION GAP-18
[**2109-3-5**] 11:40AM estGFR-Using this
[**2109-3-5**] 11:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2109-3-5**] 11:39AM TYPE-[**Last Name (un) **] PO2-31* PCO2-60* PH-7.33* TOTAL
CO2-33* BASE XS-3 COMMENTS-GREENTOP
[**2109-3-5**] 11:39AM LACTATE-1.5
EEG [**2109-3-5**]:
IMPRESSION: This is an abnormal portable EEG due to the slow and
disorganized background indicative of a diffuse encephalopathy.
Infrequent sharp waves were seen in the bilateral frontal
regions, but
no clear electrographic seizures were seen. If clinical
suspicion for
seizures is high, prolonged bedside monitoring may be helpful
for
further diagnosis.
EKG [**2109-3-5**]:
Atrial fibrillation with a slow ventricular response. There are
tiny R waves in the anterior leads with a late transition
consistent with possible infarction. Non-specific ST-T wave
changes. Low voltage in the precordial leads. Compared to the
previous tracing of [**2109-1-16**] late transition is new.
CXR [**2109-3-5**]
IMPRESSION: Findings compatible with congestive failure.
Superimposed
pneumonia is not excluded.
HEAD CT [**2109-3-5**]
IMPRESSION: No acute intracranial process.
ECHO [**2109-3-6**]:
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and left
ventricular systolic function. Right ventricle not
well-visualized.
Compared with the prior study (images reviewed) of [**2107-2-10**],
estimated pulmonary artery pressure is lower.
EKG [**2109-3-7**]:
Atrial fibrillation and controlled ventricular response and
increase in rate as compared with previous tracing of [**2109-3-5**].
There is diffuse low voltage. The tracing is marred by wandering
baseline and baseline artifact. Prior anteroseptal myocardial
infarction. Diffuse non-specific ST-T wave flattening. Except
for the increase in rate, no diagnostic interim change.
CXR [**2109-3-9**]:
IMPRESSION: AP chest compared to [**2-3**] through [**3-5**]:
Moderately severe pulmonary edema has changed in distribution
but not in
overall severity since [**3-5**]. A small concurrent pneumonia
would not be appreciated. Small bilateral pleural effusions are
presumed. Moderate
cardiomegaly and mediastinal [**Month (only) 1106**] engorgement are unchanged,
and
recurrent.
Ultrasound R IJ Cath site [**2109-3-10**]:
IMPRESSION: Superficial thrombophlebitis of a right chest wall
vein.
DISCHARGE LABS:
[**2109-3-12**] 06:20AM BLOOD WBC-8.5 RBC-2.90* Hgb-8.8* Hct-27.9*
MCV-96 MCH-30.3 MCHC-31.5 RDW-16.3* Plt Ct-232
[**2109-3-12**] 06:20AM BLOOD Glucose-133* UreaN-19 Creat-2.9* Na-139
K-4.2 Cl-94* HCO3-29 AnGap-20
[**2109-3-12**] 06:20AM BLOOD Calcium-7.3* Phos-2.9 Mg-1.8
MICROBIOLOGY:
Blood cultures 2/7: negative
RPR [**3-5**]: non-reactive
Blood cultures 2/9, [**3-9**], [**3-10**], [**3-11**]: pending, no growth to date
at time of discharge
Wound culture R HD catheter site [**3-7**]: [**Female First Name (un) **] PARAPSILOSIS
(sensitive to fluconazole)
R IJ HD catheter tip culture [**3-7**]: no significant growth
R IJ catheter cuff culture [**3-8**]: CANDID PARAPSILOSIS
Brief Hospital Course:
66 yo F with AF on Lovenox given h/o necrotizing breast
infections from warfarin skin necrosis, ESRD on HD, T2DM,
restrictive lung disease on home O2, calciphylaxis who presented
with AMS, bradycardia, and hypotension in the setting of digoxin
toxicity, medication effects from narcotics and gabapentin, and
R IJ tunneled HD catheter infection.
.
#. Encephalopathy, bradycardia, and hypotension:
In the MICU: She has been known to be very somnolent in the
setting of opiate pain medication in the past. She was on
Oxycontin, Oxycodone, and Neurontin (which was not appropriately
dosed for an HD patient). She recalled asking for extra pain
meds the day PTA. Also, supratherapeutic Digoxin can cause
somnolence. CT head ruled out acute bleed. TSH was elevated.
Levothyroxine was continued at outpatient dose, as this can
occur in the setting of acute illness (will need repeat
outpatient testing once acute illness has resolved). After
holding her sedating meds overnight, she became alert and
oriented x3, interactive. She was transferred to the floor for
further management.
.
Upon review of the patient's records, it became clear that her
digoxin was accidentally doubled from 0.0625 to 0.125 mcg daily
during the prior admission in 1/[**2109**]. Digoxin toxicity level
trended to the normal range, and digoxin was not resumed since
she did not need it for rate control of her Afib during this
admission. Further history revealed that the patient had begun
taking gabapentin about 5 days prior to admission. She realized
it had been discontinued during a recent hospitalization, but
was not sure why, and she wanted to restart it. She also
reported taking increased amounts of oxycodone and oxycontin
prior to admission. Another potential cause of her presentation
was felt to be possible sepsis related to her R IJ tunnelled
line infection (see below). We held the gabapentin. We held
narcotics for several days, then resumed her oxycontin at home
dose and oxycodone at a lower dose, as she began to have
increased pain and possible withdrawal symptoms. Her pain was
well controlled on this regimen of oxycontin 20 [**Hospital1 **] and
oxycodone 5-10mg Q4h PRN pain. Per renal [**Hospital1 7219**], we
will discharge her on only oxycodone 5-10mg Q4h PRN pain. We
will discontinue oxycontin due to concerns about long acting
narcotics contributing to altered mental status. For concern of
sepsis, she was covered with vancomycin dosed at HD and
[**Last Name (LF) 96409**], [**First Name3 (LF) **] ID. This was transitioned to PO fluconazole
prior to discharge, as detailed below. Mental status remained
back to baseline on the medical floor. She had no further
hypotension or bradycardia after transfer out of the ICU.
.
#R IJ HD line infection and ESRD:
Typical HD schedule is T/Th/Sa. Patient's existing R IJ line
site was noted to be erythematous, tender, and with purulent
drainage. Blood cultures and swab cultures of the purulent
drainage were sent. Patient received HD on [**2109-3-8**] morning, IR
removed infected line [**2109-3-8**] afternoon. Per infectious disease,
patient was covered with vancomycin dosed at HD and [**Month/Day/Year 96409**]
daily after initial culture data showed yeast. Due to increased
pain, leukocytosis, and a left shift, ID recommended an U/S,
which revealed no evidence of an abscess. Blood cultures were
negative to date at time of discharge. Wound swab culture and
removed catheter cuff culture demonstrated [**Female First Name (un) **] PARAPSILOSIS
sensitive to fluconazole. Patient received new L IJ HD line on
[**2109-3-11**] morning and received HD [**2109-3-11**] afternoon. Vancomycin
and [**Month/Day/Year 96409**] were was discontinued and she was transitioned to
oral fluconazole. She will be discharged on fluconazole 200 mg
po daily to complete a total 14 day course of antifungal
therapy, last day will be [**2109-3-22**]. Her phosphate was low, so
PhosLo will be discontinued for now; renal may resume this at a
later date after discharge.
.
#Chest pain:
Patient complained of chest pain during the admission. Troponins
were 0.13 from baseline 0.06; CK MB flat. EKG showed A fib with
no evidence of ischemia. CXR was unchanged. Chest pain resolved
spontaneously.
.
#. Atrial Fibrillation.
Patient was in junctional escape rhythm in the MICU. After
transfer to the floor, she was in atrial fibrillation with rate
80s-90s on metoprolol 12.5 mg PO BID. If needed in the
outpatient setting, metoprolol dosing can be increased for
improved rate control. We held her digoxin for the duration of
the admission. Given history of warfarin skin necrosis, she was
maintained on home regimen of Lovenox qM/W/F.
.
#. Leg wounds: Resulted from calciphylaxis. Received wound care
consult during admission. Did not appear to be infected. Pain
control as discussed above.
.
#. Restrictive lung disease: Stable dyspnea throughout the
admission. She maintained good saturations on [**3-1**] L NC on the
floor, which is her home oxygen requirement. We continued her
home nebulizer treatments.
.
#. Type 2 DM, controlled, with complications: Stable.
Hypoglycemia has been an issue in the past, including recent
admission 1 month ago. She was covered with Humalog sliding
scale during the admission. Blood sugars remained in good
control.
.
#. h/o warfarin skin necrosis/infected breast wounds/invasive
ductal carcinoma. Necrosis was attributed to warfarin skin
necrosis 7/[**2108**]. Pathology revealed small area of invasive
ductal carcinoma on the mastectomy tissue. Per D/C summary on
[**2109-2-8**], patient had a discussion with her medical team, and
the decision at the time was not to pursue further
workup/staging/treatment given her comorbidities, significant
breast wound, and the small malignant size.
.
#. Depression: Continued home paroxetine.
.
#. Chronic anemia: Hct is near baseline. Monitored and Hct was
stable during admission.
.
#. CAD/CHF: Stable during the admission. Continued aspirin,
statin, beta blocker.
.
#. HLD: Continued statin.
.
#. Hypothyroidism:
Elevated TSH to 9.0, could be due to recent illness. Continued
home levothyroxine. Recommend outpatient repeat TSH to see if
dose of levothyroxine needs adjustment.
TRANSITIONAL ISSUES:
-Patient's code status was FULL code this admission.
-Patient should continue with HD as directed by her
Nephrologist.
-Patient needs repeat thyroid function testing in several weeks,
once acute illness has fully resolved. TSH elevated (9.0)
during this admission, and possible patient may need adjustment
of her levothyroxine dose.
-If patient continues to have ongoing nausea, would consider
gastric emptying study for further evaluation.
-Additional tapering of narcotics may help with nausea
-Continue po fluconazole through [**2109-3-22**]
-Holding digoxin. HRs controlled.
Medications on Admission:
Aspirin 81 mg daily
Digoxin 125 mcg daily
Metoprolol tartrate 25 mg TID
Enoxaparin 100 mg/mL Syringe subcutaneous Q M/W/F
Pravastatin 80 mg daily
Neurontin 600mg QPM
Oxycontin 20 mg [**Hospital1 **]
Oxycodone 15mg Q4H PRN
Levothyroxine 175 mcg daily
Aspart SS with breakfast, lunch, dinner
Omeprazole 40 mg daily
Allopurinol 100mg daily
Paroxetine HCl 40 mg daily
Albuterol sulfate 2.5 mg /3 mL (0.083 %) neb Q6H PRN
Ipratropium bromide 0.02 % neb Q6H
Cinacalcet 30 mg daily
PhosLo 1334mg TID w/meals
B complex-vitamin C-folic acid 1 mg daily
Folic acid 1 mg daily
Ascorbic acid 500 mg daily
Senna 8.6 mg QHS
Polyethylene glycol 3350 17 gram/dose daily PRN constipation
Bisacodyl 10mg PR PRN
Lactulose 10 gram/15 mL: 30mL PO daily PRN constipation
Recently stopped Nepro w/meals.
Discharge Medications:
1. senna 8.6 mg Capsule Sig: One (1) Tablet PO at bedtime as
needed for Constipation.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
5. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO once a day as needed for constipation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous MONDAY, WEDNESDAY, [**Hospital1 **] ().
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*180 Tablet(s)* Refills:*0*
15. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
17. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
18. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days: Take 9 days after discharge. Last day
[**2109-3-22**].
Disp:*10 Tablet(s)* Refills:*0*
19. lactulose 10 gram/15 mL (15 mL) Solution Sig: Thirty (30) mL
PO once a day as needed for constipation.
20. Humalog 100 unit/mL Solution Sig: As directed Subcutaneous
QACHS: As directed by sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Altered mental status
Digoxin toxicity
Infected [**Location (un) 2286**] line (yeast infection)
SECONDARY DIAGNOSES:
- Coronary artery disease
- Congestive heart failure, chronic
- Atrial fibrillation on Lovenox
- Hypertension
- Dyslipidemia
- Type 2 DM on insulin
- End stage renal disease on hemodialysis
- Peripheral [**Location (un) 1106**] disease
- Restricitve lung disease
- Obstructive sleep apnea
- Morbid obesity
- Crohn's disease
- Depression
- Gout
- Hypothyroidism
- Gastroesophageal reflux disease
- Chronic Anemia
- Restless Leg Syndrome
- Back pain/leg pain from degenerative disk disease,
trochanteric bursitis, sciatica
- Calciphylaxis
- Warfarin skin necrosis
- Invasive ductal breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 1968**],
You were admitted to the hospital with altered mental status, a
slow heart rate, and low blood pressure. You initially went to
the medical intensive care unit for one night and were then
transferred to the medical floor for further management. We
think that the altered mental status, slow heart rate, and low
blood pressure were due to high levels of digoxin, high doses of
sedating medications (including gabapentin, oxycontin, and
oxycodone), and/or due to the infection of your [**Known lastname 2286**] line.
We stopped your home digoxin, decreased the dose of your
metoprolol, and stopped your gabapentin. Your mental status
returned to [**Location 213**] and your blood pressure and heart rate
returned to [**Location 213**] range. We resumed some of your home pain
medications after a few days, which helped with your pain and
did not cause further change in your mental status.
We found that you had an infection of the [**Location 2286**] line. You
were seen by the kidney and infectious disease doctors. We gave
you antibiotics for a potential bacterial infection and
anti-fungal medication for potential fungal infection.
Interventional radiology doctors removed your [**Name5 (PTitle) 2286**] line and
put in a new one a few days later. The culture from the [**Name5 (PTitle) 2286**]
line grew a yeast. We switched you to an oral medication for
this yeast, which you will continue for 9 days after discharge.
You did not have any evidence of a bloodstream infection.
For your atrial fibrillation, we stopped your digoxin and
continued you on a lower dose of metoprolol. Your heart rate
remained in good control. We continued your home lovenox for
anticoagulation. You can discuss changing your atrial
fibrillation medications with your outpatient cardiologist.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
We made the following changes to your medications:
-STOPPED gabapentin
-STOPPED folic acid. This is because your other medicines also
contain folic acid.
-CHANGED metoprolol to 12.5 mg tab, take 1 tab by mouth two
times a day. This is for your atrial fibrillation. We reduced
the dose because your heart rate was too low when you came into
the hospital.
-STOPPED digoxin. This is because your digoxin was too high when
you came into the hospital and your heart rate remained in
control during the hospitalization.
-STARTED fluconazole 200 mg tab, take 1 tab by mouth daily for 9
days. This is for the fungal infection.
-CHANGED oxycodone to 5 mg tab, take [**1-28**] tab by mouth every 4
hours as needed for pain. This was reduced because of your
altered mental status.
-STOPPED oxycontin. This is because it can cause altered mental
status.
-STOPPED PhosLo. This was stopped because your phosphorus
levels were too low. Your doctors [**Name5 (PTitle) **] restart this medication
in the future.
Please continue to take all other medications as prescribed.
Please attend the follow-up appointments listed below.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2109-3-25**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
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] |
[
"38.95",
"86.05",
"39.95"
] |
icd9pcs
|
[
[
[]
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] |
19810, 19887
|
10239, 16437
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464, 539
|
20661, 20661
|
5906, 9517
|
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|
4164, 4378
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17065, 17847
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|
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20045, 20640
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5233, 5887
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16458, 17039
|
22792, 23856
|
403, 426
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567, 2272
|
20676, 20813
|
2294, 3749
|
3765, 4148
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,315
| 131,643
|
46749
|
Discharge summary
|
report
|
Admission Date: [**2169-1-8**] Discharge Date: [**2169-3-19**]
Date of Birth: [**2109-4-19**] Sex: M
Service: SURGERY
Allergies:
Augmentin / Clindamycin / Sulfa (Sulfonamides) / Heparin Agents
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
[**2169-1-8**]: Exploratory laparotomy, closure of small bowel
perforation
History of Present Illness:
The patient is a 59 year-old male well known to the transplant
service. He has a history of HCV with cirrhosis with a mass in
segment 6 & 7 status post resection on [**2168-12-23**]. His
postoperative course was significant for increased JP output
prior to d/c and constipation resolved with suppositories and
enemas. He reports that he has been recovering well at home but
has not had much of an appetite. Beginning last night, he began
to have increasing weakness to the point that he was unable to
get-up from a chair without help this morning. This morning he
was attempting to stand from a chair and was unable to. He
denies fevers, chills, nausea, vomiting, chest pain, or
shortness-of-breath, but his abdomen has increased in size
significantly since discharge. He has continued to have bowel
movements and have flatus after discharge. He most recent bowel
movement was a few days prior to presentation and that he
usually has bowel movements daily.
Past Medical History:
HCV and cirrhosis
Waldenstrom's lymphoma
hyperthyroidism
GERD
history of depression
appendectomy in [**2151**] for ruptured appendix
right hand surgery in [**2159**].
hernia repair in [**2161**]
Social History:
Married with one child
Currently not working/ disabled
Family History:
mother died in her 80s, had RA
father died in his 90's, Pagets disease
Physical Exam:
Vitals: 96.6 90 139/42 20 97% room air
RRR
CTA bilaterally
soft, distended, mildly diffusely tender, hypoactive bowel
sounds.
incision erythematous at surperior portion and lateral portion
Pertinent Results:
On Admission: [**2169-1-8**]
WBC-18.5* RBC-3.98* Hgb-12.3* Hct-38.7* MCV-97 MCH-31.0
MCHC-31.9 RDW-14.3 Plt Ct-325
PT-28.0* PTT-42.6* INR(PT)-2.8* Fibrino-227
Glucose-29* UreaN-52* Creat-4.1*# Na-129* K-5.8* Cl-88* HCO3-14*
AnGap-33*
ALT-27 AST-54* AlkPhos-112 Amylase-41 TotBili-2.8* Lipase-12
Albumin-2.7* Calcium-8.5 Phos-9.0*# Mg-2.1
.
[**2169-3-19**]
[**2169-3-19**] 04:38AM BLOOD WBC-6.8 RBC-2.71* Hgb-8.8* Hct-28.6*
MCV-105* MCH-32.2* MCHC-30.6* RDW-15.8* Plt Ct-125*
[**2169-3-19**] 04:38AM BLOOD PT-44.8* PTT-108.3* INR(PT)-5.0*
[**2169-3-19**] 04:38AM BLOOD Glucose-137* UreaN-120* Creat-2.8* Na-138
K-5.6* Cl-112* HCO3-17* AnGap-15
[**2169-3-19**] 04:38AM BLOOD ALT-66* AST-304* LD(LDH)-262* AlkPhos-64
TotBili-6.8*
[**2169-3-19**] 08:14AM BLOOD Type-ART pO2-73* pCO2-54* pH-7.06*
calTCO2-16* Base XS--15 Intubat-INTUBATED
[**2169-3-19**] 08:14AM BLOOD Glucose-43* Lactate-7.6*
.
RADIOLOGY
[**3-19**] CXR:
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with now with hypoxia and neurological changes
REASON FOR THIS EXAMINATION:
? acute change in cardiopulmonary process
PORTABLE CHEST [**2169-3-19**] AT 01:45
COMPARISON STUDY: [**2169-3-17**]
CLINICAL INFORMATION: Hypoxia, neurological changes.
FINDINGS:
Endotracheal tube terminates at thoracic inlet. Nasogastric tube
terminates at the gastroesophageal junction. There are bilateral
pigtail pleural catheters, unchanged in position. Bilateral
pleural effusions are essentially unchanged. There is bibasilar
atelectasis. Heart is mildly enlarged. There is continued
mild-to-moderate congestive failure. There is increased
opacification of bilateral lungs which may also reflect an
element of pneumonia.
IMPRESSION:
1. Unchanged pigtail catheters and pleural effusions
bilaterally.
2. Mild-to-moderate congestive failure.
3. Increased opacification of bilateral lungs which could
reflect pneumonia.
...
[**3-18**] CT A/P:
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval
worsening of the consolidation at the right lung base. The
loculated right-sided pleural effusion appears unchanged. There
is also worsening of the atelectatic changes at the left lung
base. The patient is status post drainage tube placement in the
left side of the chest. There has been interval development of
tree-in-[**Male First Name (un) 239**] opacities of the right middle [**Male First Name (un) 3630**], which is very
concerning for aspiration pneumonia. The heart and great
vessels appear unchanged. The nasointestinal tube is in the
standard position.
There has been interval decrease in the size of collection at
the hepatic resection site which now measures 45 x 61 mm
compared to the prior study when it measured 78 x 55 mm. The
remainder of the liver has normal appearance. The spleen and
adrenal glands have normal appearance. Both kidneys contain
multiple hypodense lesions which are too small to characterize.
Moderate amount of ascites in the peritoneal cavity is
unchanged. The stomach, duodenum and loops of small bowel and
large bowel appear normal. The oral contrast is noted within
the ascending and transverse colon up to the rectum with no
evidence of obstruction. The colon is mildly distended which may
be related to the use of hypertonic oral contrast. The aorta
shows sign of calcification. No pneumoperitoneum is detected. No
pathologically enlarged mesenteric or retroperitoneal or pelvic
or inguinal nodes are noted.
CT OF THE PELVIS WITHOUT IV CONTRAST: The urinary bladder,
distal ureters, the rectum, and sigmoid colon have normal
appearance.
BONE WINDOWS: No concerning lytic or sclerotic lesion is
identified.
IMPRESSION:
1. No acute intra-abdominal process to explain the patient's
symptoms.
2. Interval development of tree-in-[**Male First Name (un) 239**] opacities within the
right middle
[**Last Name (LF) 3630**], [**First Name3 (LF) **] interval complete opacification of both lung apices are
very
concerning for aspiration.
3. Unchanged ascites in the abdomen and pelvis.
4. Interval decrease in the size of fluid collection at the
resection bed.
5. Unchanged loculated pleural effusions bilaterally.
...
[**3-18**] CT Head:
FINDINGS: No edema, masses, mass effect, hemorrhage, or major
vascular
territorial infarction is noted. The ventricles and sulci are
normal in
course and configuration. Left maxillary sinus demonstrates
mild mucosal
thickening. The remainder of the paranasal sinuses and mastoid
air cells are clear. No fracture is noted.
IMPRESSION: No acute intracranial pathology, including no
hemorrhage.
NOTE AT ATTENDING REVIEW: There is a slightly hypodense,
irregularly
marginated region within the left lentiform nucleus area, and
possibly
additional low density in the left periatrial region. These
findings are not specific in etiology, but could be areas of
infarction. Follow-up MR scan is needed to more completely
assess this finding. Infection is an alternative diagnosis,
particularly if the patient is immunosuppressed. Information
relayed to staff caring for the patient this morning ([**2169-3-19**]).
...
[**3-15**] Renal US:
RENAL SON[**Name (NI) **]: This is a technically limited study, with the
right kidney measuring approximately 12 cm and the left kidney
measuring approximately 11.7 cm. There is no evidence of
hydronephrosis or obstructing stone. 1.5 cm rounded anechoic
structure in the mid pole of the left kidney is not fully
characterized given the limitations of the study and likely
reflects a simple cyst, and unchanged from [**2167-12-21**].
Foley catheter is present within the bladder, which is grossly
unremarkable.
IMPRESSION: No evidence of hydronephrosis.
...
[**3-6**] Liver US:
FINDINGS: The abdomen again demonstrates a large amount of
ascites. The left lower quadrant was marked for paracentesis to
be done by the clinical staff.
No focal masses are identified in the liver and there is no
biliary dilatation. A subhepatic collection is again identified
which measures 5.8 x 6.8 x 2.7 cm. This appears to be stable in
size from the prior exam.
Color Doppler and pulse Doppler waveforms were obtained. There
is non- occlusive thrombus again identified within the main
portal vein. Flow within the main portal vein continues to be
hepatofugal. Hepatofugal flow is also identified in both the
right and left portal veins. Appropriate flow is seen in the
main hepatic artery and in the hepatic veins.
IMPRESSION: 1) Stable appearing non-occlusive thrombus of the
main portal vein. Flow within the main portal vein, right
portal vein and left portal vein continues to be hepatofugal.
2) Large amount of ascites. The left lower quadrant was marked
for paracentesis to be performed by the clinical staff. 3)
Stable appearing 6.8 cm subhepatic collection.
...
[**2-22**] Liver US:
FINDINGS: Doppler ultrasound demonstrated subtotal occlusive
thrombus within the main portal vein extending into the right
branch. Minimal flow is seen within the portal vein, which is
again noted to be reversed in direction, similar to [**2169-2-15**]. The left portal vein is not well assessed. The hepatic
artery and veins are patent with appropriate waveforms. Ascites
is demonstrated.
IMPRESSION: Subtotal occlusive thrombus and reversal of flow
within the main portal vein extending into the right branch,
similar to prior exam from [**2169-2-15**].
...
[**2-6**] CT A/P:
CT OF THE CHEST WITHOUT IV CONTRAST: There is no axillary,
mediastinal, or hilar lymphadenopathy. Small lymph nodes are
seen particularly in the mediastinum that do not meet CT
criteria for pathologic enlargement. They measure 0.6 cm in
short axis. There are small bilateral pleural effusions. The
patient is status post catheter placement into the right pleural
space and the right pleural effusion is thus significantly
decreased in size. There is a moderate right pneumothorax.
There is improvement in the reticular opacities in the left
upper [**Month/Day (4) 3630**] with near-complete resolution. There are new areas
of patchy opacities in the lower lobes bilaterally most
consistent with atelectasis.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Again noted is a fluid
collection at the resection margin. This currently measures 8.0
x 6.2 cm (previously 7.1 x 4.9 cm) and is thus increased in
size. The spleen is normal in size. The pancreas is
unremarkable. The adrenal glands and left kidney are
unremarkable. In the right kidney there is a 1.3-cm hypodense
lesion that is not fully characterized on this examination.
There is no retroperitoneal lymphadenopathy. A moderate amount
of ascites is seen throughout the abdomen. This is increased
when compared to the prior examination. Oral contrast is seen
reaching the splenic flexure. There is no definite evidence of
bowel wall thickening. Some jejunal loops do not contain a
large amount of oral contrast and the appearance may be due to
underfilling. Similarly the ascending colon is not fully
distended with oral contrast. There is no free intraperitoneal
air. There is extensive emphysema around the left lateral
posterior chest wall as well as the abdominal wall.
CT OF THE PELVIS WITHOUT IV CONTRAST: Air is identified in the
bladder which also contains a Foley catheter. There is a
moderate amount of free fluid in the pelvis. Again this is
increased from the prior study. There is no pelvic
lymphadenopathy. There is increased soft tissue stranding
throughout the abdomen and pelvis which is also worsened
compared to the prior examination.
IMPRESSION:
1. No acute intra-abdominal process to explain the patient's
symptoms.
2. Increase in the amount of ascites in the abdomen and pelvis
as well as generalized anasarca.
3. Increase in size of the fluid collection at the resection
margin. Image- guided aspiration of this collection could be
performed if superinfection is of concern.
4. Moderate right pneumothorax following insertion of a pigtail
catheter. The previously noted large right pleural effusion is
significantly decreased in size. Extensive emphysema along the
right lateral and posterior chest wall.
...
[**2-2**] CT A/P:
IMPRESSION:
1. Interval progression in a right pleural effusion, which is
now large in size, causing near complete collapse of the right
lung.
2. Interval increase in ascites, which is moderate amount.
3. Slight interval increase in a fluid collection in the
hepatic
segmentectomy bed.
4. Slight interval improvement in left upper [**Month/Day (4) 3630**] reticular
opacity, which may be related to resolving edema.
...
[**1-8**] CT A/P:
IMPRESSION:
1. Limited study secondary to lack of IV and oral contrast.
2. Cirrhotic-appearing liver, status post resection of the
right [**Month/Day (4) 3630**], with post-surgical appearance of the operative site.
3. New large amount of perihepatic and abdominal ascites,
tracking into the pelvis; note that ascites has not been present
pre-operatively.
4. Large amount of pneumoperitoneum, possibly post-operative in
nature, though this appears larger than expected, some three
weeks following hepatic resection; perforation of hollow viscus
or infection (ie. SBP) with gas- forming organism cannot be
excluded.
5. Distended loops of small bowel; however, no definite
evidence of obstruction or secondary sign of bowel ischemia.
6. Small amount of gas seen within the bladder. Correlate with
recent instrumentation or catheterization. Otherwise, cystitis
should be considered.
Brief Hospital Course:
59 y/o male who is s/p segment VI/VII liver resection on [**12-24**]
who now presents with increased weakness.
CT of Abdomen gave the following findings:
-Cirrhotic-appearing liver, status post resection of the right
[**Month (only) 3630**], with post-surgical appearance of the operative site.
-New large amount of perihepatic and abdominal ascites, tracking
into the pelvis; note that ascites has not been present
pre-operatively.
-Large amount of pneumoperitoneum, possibly post-operative in
nature, though this appears larger than expected, some three
weeks following hepatic resection; perforation of hollow viscus
or infection (ie. SBP) with gas- forming organism cannot be
excluded.
-Distended loops of small bowel; however, no definite evidence
of obstruction or secondary sign of bowel ischemia.
Paracentesis showed WBC [**Numeric Identifier 4395**] with 88% polys with culture
growing Coag + Staph aureus. Patient was started on Vanco and
Meropenem.
Additionally on [**2169-1-8**] the patient was taken to the OR by Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with a pre-op diagnosis of perforated Viscus and a
post op diagnosis of perforated small bowel. In summary per Dr
[**Last Name (STitle) **] "he had approximately 6 liters of cloudy slightly
yellowish ascites. In the distal jejunum there was a small 2 mm
simple perforation midway between the mesentery and anti-
mesenteric border of the small bowel. There was no
fibrinopurulent debris around this area. It was a clean opening
in the small bowel. There was no evidence of any foreign body.
There were no adhesions in the abdomen. There was no obvious
explanation for the perforation. This was well
down in the midportion of the abdomen well away from the
incision. There were no other abnormalities in this area."
Please see the operative note for further surgical detail.
Mr. [**Known lastname **] had a prolonged postoperative course with multiple
transfers to the SICU for respiratory distress, fluid overload,
and sepsis. In summary briefly, he was noted to have rising
LFTs and bilirubin prompting a liver ultrasound on [**2-15**] which
showed a portal vein thrombus. At that time he was having blood
in his stools and was not started on anticoagulation. Over the
next several weeks his mental status slowly waxed and waned. He
was maintained on subcutaneous heparin for DVT prophylaxis, TPN
was started for some time for nutrition, a nasoduodenal tube
was placed in IR for enteral feeding, and he was maintained on
broad spectrum antibiotics for possible pneumonia. He underwent
a total of 3 paracenteses for abdominal distention and ascites.
Over the past week he had developed acute renal failure with his
creatinine rising. A renal ultrasound showed no hydronephrosis.
On [**2169-3-18**] Mr. [**Known lastname **] was noted to have some vomiting and his tube
feedings were stopped at this point. That evening he was noted
to become less responsive, unarousable, and hypoxic. He was
emergently intubated after which he became hypotensive requiring
levophed. A CT scan of the head, chest, abdomen, and pelvis was
done showing likely aspiration event. Over the course of the
night his hypoxia worsed, his pressor requriement increased. On
labs his liver enzymes, bilirubin, coagulation factors, and
creatinine all began rising. In discussion with the patients
family and Dr. [**Last Name (STitle) **] the decision was made to make the patient
CMO. He was extubated and the levophed was discontinued. He
expired shortly afterwards.
Medications on Admission:
celexa 20', levoxyl 75', nadolol 20', protonix
Discharge Disposition:
Expired
Discharge Diagnosis:
Hepatocellular carcinoma
Portal vein thrombosis
Liver failure
Perforated jejunum
Acute renal failure
Aspiration
Hypothyroidism
Discharge Condition:
Expired
Discharge Instructions:
Patient expired
Followup Instructions:
family has request an autopsy
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2169-3-19**]
|
[
"427.1",
"276.1",
"998.2",
"995.91",
"507.0",
"997.3",
"242.90",
"571.5",
"584.9",
"512.1",
"789.59",
"511.9",
"V10.07",
"250.00",
"572.4",
"070.54",
"E870.0",
"038.9",
"998.59",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.73",
"96.6",
"34.91",
"34.04",
"99.15",
"88.64",
"38.91",
"54.91",
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17128, 17137
|
13480, 17031
|
330, 407
|
17308, 17318
|
2012, 2012
|
17382, 17570
|
1710, 1784
|
2966, 3029
|
17158, 17287
|
17057, 17105
|
17342, 17359
|
1799, 1993
|
282, 292
|
3058, 6158
|
435, 1402
|
6167, 13457
|
2026, 2929
|
1424, 1621
|
1637, 1694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,778
| 186,443
|
37078
|
Discharge summary
|
report
|
Admission Date: [**2196-10-12**] Discharge Date: [**2196-10-14**]
Date of Birth: [**2144-6-26**] Sex: F
Service: SURGERY
Allergies:
Codeine / Penicillins / Sulfa (Sulfonamide Antibiotics) / Iodine
Containing Agents Classifier / Ketorolac / Tetracycline
Analogues / Erythromycin
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Tranisent Bilateral Vision Loss associated with Right Upper
Extremity Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PER ADMITTING RESIDENT:
52 yo RHW who experienced transient loss of vision in both
eyes at 1 pm, she stated that she could not see "a glimmer of a
shadow in both eyes for 5 minutes." This was followed by sharp
pain in her right arm with tingling, and a feeling of weakness,
she called 911, and she was taken to [**Hospital **]. She did
not notice weakness in her right leg. She has never had symptoms
like this previously. At [**Hospital 15405**], she had an MRI of the brain
and MRA of the head and neck, which demonstrated multiple small
infarcts and a left carotid artery stenosis. Since finding out
this news, Ms [**Known lastname 83578**] has been tearful. At [**Hospital 15405**] she
received a heparin bolus and heparin gtt at 6.8 cc/hr. She has
never had symptoms such as these previously. She felt light
headed during her symptoms, and in the ER, she developed a dull
bifrontal headache. The day prior to these symptoms, she had
nausea. Otherwise, the rest of her neurological and systemic
symptoms review was unremarkable.
Past Medical History:
PMH
Rheumatoid arthritis
OA
Fibromyalgia
Chronic pain syndrome
PE in [**2169**] secondary to the OCP
.
PSH
6 surgeries s/p MVA: C6-7 fusion, 3 shoulder surgeries (1 R, 2
L), L TKR
TAH (for menorrhagia)
Appendicectomy
Adenoidectomy
Tonsillectomy
Social History:
- Unemployed
- Lives alone
- divorced
- has son, daughter weekends
.
HABITS:
TOBACCO - 1ppd x 33 years
ETOH - denies
REC - denies
Family History:
Mother - COPD
Father - urothelial ca, CAD
Physical Exam:
ON ADMISSION:
T-97.8 BP-98/70 HR-92 RR-18 O2Sat-98%
Gen: Lying in bed, anxious, poor dentition
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple. Left
carotid bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
NIH SS:2
1a. Level of Consciousness: 0
1b. LOC questions: 0
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 1
7. Limb ataxia: 0
8. Sensory: 0
9. Best language: 0
10. Dysarthria: 0
11. Extinction and inattention: 0
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
DOW backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] intact.
Registers [**2-16**], recalls [**12-19**] in 5 minutes. No right left
confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Fundoscopy reveals normal optic discs bilaterally.
Vision corrected with glasses is 20/20 bilaterally. Visual
fields
are full to confrontation. Extraocular movements intact
bilaterally, no nystagmus. Sensation intact V1-V3. Facial
movement symmetric. Hearing intact to finger rub bilaterally.
Palate elevation symmetrical. Sternocleidomastoid and trapezius
normal bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Right pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R +4 +4 5 +4 +4 +4 +4 +4 +4 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, and vibration throughout.
Pinprick reduced in the right arm and right leg, more so in the
right arm. Proprioception reduced in the right fingers, but not
in the right foot. No extinction to DSS
Reflexes:
+2 and symmetric throughout.
Right Babinski
Coordination: finger-nose-finger ataxic on the right, heel to
shin slower on the right, RAMs slow and clumsy on the right.
Gait: Narrow based, steady.
Romberg: Positive
Pertinent Results:
WBC-12.9* RBC-4.64 HGB-14.0 HCT-41.1 MCV-89 MCH-30.2 MCHC-34.1
RDW-15.6*
GLUCOSE-89 UREA N-3* CREAT-0.6 SODIUM-141 POTASSIUM-4.0
CHLORIDE-108 TOTAL CO2-24 ANION GAP-13
SED RATE-32*
PT-12.9 PTT-44.0* INR(PT)-1.1
CK-MB-NotDone cTropnT-<0.01
TSH-1.3
.
Modifiable Risk Factors for Stroke:
TRIGLYCER-85 HDL CHOL-40 LDL(CALC)-97
%HbA1c-5.8
.
IMAGING:
.
Transthoracic Echocardiogram ([**2196-10-12**]):
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion
.
Carotid Duplex ([**2196-10-12**]):
pending
.
Chest X-ray ([**2196-10-12**]):
IMPRESSION: No acute intrathoracic process
Brief Hospital Course:
Ms. [**Known lastname 83578**] is a 52 year-old right-handed female smoker with
a past medical history including Rheumatoid Arthritis who
presented to [**Hospital6 302**] [**2196-10-12**] with right upper
extremity weakness following transient bilateral vision loss.
Neuroimaging demonstrated multiple occipital lobe and deep white
matter infarcts in teh setting of left internal carotid artery
stenosis. A heparin drip was started and the patient was
transferred to the [**Hospital1 18**] for further care. She was admitted to
the stroke service from [**2196-10-12**], then transfered to [**Month/Day/Year **]
surgery.
.
NEURO
Upon her arrival to the [**Hospital1 18**], the heparin drip was continued
with a goal PTT of 50 to 70. As an MRA performed at [**Hospital3 **]
demonstrated significant carotid artery stenosis, carotid duplex
studies were performed to confirm the finding. The imaging
showed carotid artery stenois
.
CVS
A [**Hospital3 1106**] surgery consult was requested to evaluate the utility
and feasbility of a carotid endarterectomy. The team
recommended CEA. She recieved thiss. It was uncomplicated
.
RHEUM
The pre-existing RA regimen of methotrexate, plaquenil, and
folate was continued while the patient was in the hospital.
.
CODE
Full
Medications on Admission:
percocet 10/325 mg 1 tab po q6h prn pain + qhs prn pain
alprazolam 0.5 mg po q 12h
fosamax 70 mg po q Wednesday
methotrexate 2.5 mg tabs - 6 tabs (15 mg) po q Tuesday
plaquenil 200 mg po bid
folic acid 1 mg po daily
ambien 10 mg po qhs
.
ALLERGIES:
codeine
Penicillin
sulfa
ketorolac
tetracycline
erythromycin
iodine contrast dye
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO twice
a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every
Wednesday).
7. Methotrexate Sodium 2.5 mg Tablet Sig: One (1) Tablet PO once
a day: as directed by PCP, [**Name10 (NameIs) **] not known.
8. Glucocom Lancets Misc Sig: One (1) Miscellaneous three
times a day.
Disp:*1 Glucocom Lancets * Refills:*2*
9. Glucostix Test Strip Sig: One (1) In [**Last Name (un) 5153**] three times a
day.
Disp:*1 Strip* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
carotid artery stenosis
Discharge Condition:
stable
Discharge Instructions:
Division of [**Last Name (un) **] and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision:
?????? It is normal to have some swelling and feel a firm ridge along
the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call [**Last Name (un) 1106**] surgeon??????s office
4. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2196-11-16**] 11:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2196-11-16**] 12:00
Completed by:[**2196-10-14**]
|
[
"433.11",
"714.0",
"458.29",
"715.90",
"V43.65",
"338.4",
"V12.51",
"305.1",
"729.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"38.12"
] |
icd9pcs
|
[
[
[]
]
] |
8440, 8446
|
5902, 7168
|
486, 492
|
8514, 8523
|
4390, 5879
|
11433, 11745
|
1987, 2031
|
7550, 8417
|
8467, 8493
|
7194, 7527
|
8547, 10838
|
10864, 11410
|
2046, 2046
|
368, 448
|
520, 1555
|
3155, 4371
|
2060, 2411
|
2777, 3139
|
2435, 2762
|
1577, 1824
|
1840, 1971
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,856
| 145,827
|
3543
|
Discharge summary
|
report
|
Admission Date: [**2199-9-27**] Discharge Date: [**2199-10-3**]
Date of Birth: [**2116-7-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2199-9-27**] - Coronary bypass grafting x4 with left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from aorta to the first obtuse
marginal coronary artery; reverse saphenous vein single graft
from the aorta to the second obtuse marginal coronary artery; as
well as reverse saphenous vein single graft from aorta to distal
right coronary artery. Resection of left atrial appendage.
History of Present Illness:
Mr. [**Known lastname 4295**] is a 83 year old male with a 2 month history of
dyspnea on exertion. He was referred for cardiac catheterization
after echo showed depressed LV function with an ejection
fraction of 20-25%. Echocardiogram also notable for [**1-18**]+ mitral
regurgitation, moderate tricuspid regurgitation and moderate
pulmonary hypertension. Subsequent cardiac catheterization was
significant for left main and three vessel disease. He is now
admitted for surgical revascularization.
Past Medical History:
Coronary Artery Disease, Ischemic Cardiomyopathy
Silent MI
Hypertension
GOUT
Type 2 diabetes - diet controlled
GERD
Hypertriglyceridemia
Duodenal ulcer/GI bleeding
Asthma/Asbestosis
Squamous Cell CA
Mild Depression
Right inguinal hernia repair
Colonic polyps
Industrial Accident with crushed/fractured pelvis
Bell's palsy
Chronic pain s/p pelvic fracture/crushing injury
Mild arthritis/knees
Social History:
-Tobacco history: Prior smoking history 30 years ago.
-ETOH: Rare glass of wine.
-Illicit drugs: Denies.
He lives in [**Location **] MA with his wife [**Name (NI) 2127**]. Previously worked
in a candy factory and was also an iron worker.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:81 Resp: 16 O2 sat:
B/P Right:165/88 Left:
Height:5'6" Weight:162 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] No Murmur, frequent skipped beats
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema Right 1+ Left none
Varicosities: None [x]
Neuro: Grossly intact[x] A&Ox3, MAE, follows commands
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 1+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2199-9-27**] Intraop TEE:
PRE-BYPASS: The left atrium is dilated. Moderate to severe
spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). A patent foramen ovale is present.Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe regional left
ventricular systolic dysfunction in mid to apical segments and
especially in the RCA territory. There is moderate to severe
global left ventricular hypokinesis (LVEF = 20 %). Overall left
ventricular systolic function is severely depressed (LVEF= 20
%). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. 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. The mitral valve leaflets do not fully coapt.
There is moderate thickening of the mitral valve chordae.
Moderate (2+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
[**2199-10-2**] Discharge Chest X-ray, PA and Lat:
Moderate enlargement of the cardiac silhouette is stable since
preoperative study and small right pleural effusion has been
present throughout. There is no pulmonary edema. Extremely heavy
asbestos-related pleural calcification obscures large areas of
the lung. Mediastinum has a stable and unremarkable
postoperative appearance. Atherosclerotic calcification in the
aorta and innominate artery is very heavy.
Bloodwork:
[**2199-10-3**] WBC-8.7 RBC-2.98* Hgb-8.4* Hct-26.4* RDW-16.1* Plt
Ct-222
[**2199-10-1**] WBC-8.5 RBC-3.06* Hgb-8.6* Hct-26.5* RDW-15.4 Plt
Ct-163
[**2199-9-30**] WBC-9.8 RBC-2.98* Hgb-8.4* Hct-25.5* RDW-14.9 Plt
Ct-116*
[**2199-9-29**] WBC-9.5 RBC-3.02* Hgb-8.6* Hct-25.8* RDW-14.4 Plt
Ct-97*
[**2199-9-28**] WBC-9.8# RBC-3.04*# Hgb-8.5*# Hct-25.6* RDW-14.5 Plt
Ct-129*
[**2199-10-3**] PT-21.1* INR(PT)-2.0*
[**2199-10-2**] PT-19.4* INR(PT)-1.8*
[**2199-10-1**] PT-15.1* INR(PT)-1.3*
[**2199-9-28**] PT-16.1* PTT-36.9* INR(PT)-1.4*
[**2199-10-3**] Glucose-123* UreaN-34* Creat-1.4* Na-140 K-4.6 Cl-103
HCO3-26
[**2199-10-1**] Glucose-111* UreaN-39* Creat-1.4* Na-141 K-3.8 Cl-101
HCO3-28
[**2199-9-30**] Glucose-100 UreaN-35* Creat-1.3* Na-139 K-3.6 Cl-101
HCO3-29
[**2199-9-29**] Glucose-128* UreaN-26* Creat-1.1 Na-135 K-4.7 Cl-104
HCO3-22
[**2199-9-28**] Glucose-75 UreaN-25* Creat-0.8 Na-139 K-4.4 Cl-109*
HCO3-23 [**2199-10-1**] 04:50AM BLOOD Mg-1.9
Warfarin doses:
[**2199-10-3**] - 1mg
[**2199-10-2**] - 2mg
[**2199-10-1**] - 2mg
[**2199-9-30**] - 2mg
Brief Hospital Course:
Mr. [**Known lastname 4295**] was admitted to the [**Hospital1 18**] on [**2199-9-27**] for surgical
management of his coronary artery disease. He was taken to the
the operating room where he underwent coronary artery bypass
grafting to four vessels as well as resection of his left atrial
appendage. Please see operative note for details.
Postoperatively he was taken to the cardiac surgical intensive
care unit. On postoperative day one, he awoke neurologically
intact and was extubated. He developed atrial fibrillation as
well as non-sustained ventricular tachycardia which was treated
with Amiodarone. Given his low ejection fraction and ventricular
ectopy, the electrophysiology service was consulted. It was
initially decided that if his ejection fraction remained below
40% 2 months after surgery by echoacrdiogram, then a primary
prevention AICD would be placed. Given his poor ejection
fraction, Warfarin anticoagulation was initiated with a goal INR
between 1.5 - 2.5. On postoperative day three, he was
transferred to the step down unit for further recovery. He was
gently diuresed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. Despite his poor ejection
fraction he was unable to be started on an ACE-I due to a
systolic blood pressure in the 90s. Prior to discharge, EP study
was performed and negative for inducible sustained ventricular
arrhythmias. Therefore AICD was not recommended at this time
with recommendations to advance beta blockade as tolerated. By
post-operative day six, he was medically cleared for discharge
to home. Prior to discharge, arrangements were made and
confirmed with Dr. [**Last Name (STitle) 12872**] for outpatient management of
Warfarin.
Medications on Admission:
albuterol MDI 2 puffs prn, atenolol 50mg daily, econazole
1%cream PRN, gemfibrozil 600mg twice daily, HCTZ 25mg daily,
prilosec 20mg daily PRN
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. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*2*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 2 pills (400mg total) daily for one week, then decrease to
1 pill (200mg total) ongoing.
Disp:*60 Tablet(s)* Refills:*2*
10. Coumadin 2 mg Tablet Sig: 0.5 Tablet PO once a day: take as
directed by the office of Dr. [**Last Name (STitle) **] phone [**Telephone/Fax (1) 1579**]
Fax: [**Telephone/Fax (1) 11038**]. INR to be drawn on [**2199-10-7**]. INR goal for
low EF is 1.5 to 2.5. .
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
INR to be drawn on [**2199-10-3**]. Lab results to be sent to the
office of Dr. [**Last Name (STitle) **] phone [**Telephone/Fax (1) 1579**]
Fax: [**Telephone/Fax (1) 11038**]. INR goal for low EF is 1.5 to 2.5.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] homecare
Discharge Diagnosis:
Coronary artery disease, s/p CABG
Chronic Systolic Congestive Heart Failure, LVEF 20-25%
Postop Nonsustained Ventricular Tachycardia(EP study negative)
Postop Atrial Fibrillation - resolved
Mitral Regurgitation
Tricuspid Regurgitation
History of silent MI
Hypertension
Type II DM - diet controlled
Dyslipidemia
Discharge Condition:
Good
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) INR to be followed by the office of Dr. [**Last Name (STitle) **] phone
[**Telephone/Fax (1) 1579**] Fax: [**Telephone/Fax (1) 11038**]. INR to be drawn on [**2199-10-7**].
INR goal for low EF is 1.5 to 2.5. Plan confirmed with Dr.
[**Last Name (STitle) **] on [**10-2**].
8) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 171**] in [**2-19**] weeks.
Please follow-up with Dr. [**Last Name (STitle) **] in 8 weeks. [**Telephone/Fax (1) 62**]
INR to be followed by the office of Dr. [**Last Name (STitle) **] phone
[**Telephone/Fax (1) 1579**]
Fax: [**Telephone/Fax (1) 11038**]. INR to be drawn on [**2199-10-3**]. INR goal for
low EF is 1.5 to 2.5. Plan confirmed with Dr. [**Last Name (STitle) **] on
[**10-2**].
Please call above providers to schedule appointment.
Scheduled appointments:
Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2199-12-10**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], DPM Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2199-12-18**] 8:40
Completed by:[**2199-10-3**]
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icd9cm
|
[
[
[]
]
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[
"37.26",
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"37.36",
"36.15",
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icd9pcs
|
[
[
[]
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1746, 1990
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,599
| 109,516
|
45618
|
Discharge summary
|
report
|
Admission Date: [**2196-6-6**] Discharge Date: [**2196-6-15**]
Date of Birth: [**2109-11-12**] Sex: M
Service: NEUROSURGERY
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
status post fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 86 year old male who was walking and fell off a 3ft
ledge, witnessed by family, no Loss of consiousness per family.
Patient was taken to an OSH and
transferred to [**Hospital1 18**] when head CT showed a very small occipital
ICH. On transfer, he was agitated and was intubated in the [**Hospital1 18**]
ER. Neurosurgery was consulted for further management.
Past Medical History:
CAD s/p CABG x4 in [**2176**]
Moderate aortic stenosis (1.0 cm2)
Marginal Cell Lymphoma (dx [**1-14**], asymptomatic, observing)
Hearing loss
PUD
Left eye loss now with prosthesis
S/P kidney stones
Inguinal hernia repair x 2
Spinal stenosis
Anxiety
S/P rotator cuff
BPH, s/p TURP, recurrent BPH
Social History:
He is married with two grown sons, lives with his wife who
is handicapped. No VNA services at home. Former worker at GE
then started his own contracting business, during which he had
known asbestos exposure. At baseline, high functioning and
physically active, walking and takse care of his sick wife. Does
not drive, has family members of grocery services bring food
home but able to take care of daily ADLs independently.
-Tobacco history: denied
-ETOH: denied
-Illicit drugs: denied
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
O: T: 99.4 BP: 147/91 HR: 78 R 16 O2Sats 96%
Gen: Intubated/ sedated. Facial lacerations, bilateral
periorbital ecchymosis. C-collar on.
Neuro:
Patient just intubated/ sedated. Per ER- prior to intubation
patient was moving all 4 ext purposefully.
Sedation held x 5-10 min.
No EO, BUE localizes to noxious, BLE withdraw briskly. Some
spont
mvmt of BLE noted. No commands. R pupil 3-2 mm, no left eye. +
[**Month/Year (2) **]/ gag.
On the day of discharge:
VS: T98.4, HR 66, BP 139/76, RR 20, 97% on RA
GEN: elderly male sitting in bed in NAD
HEENT: multiple healing scabs on face, L eye sewn shut
CV: RRR
PULM: mild rhonchi anteriorly throughout, improved with [**Month/Year (2) **]
ABD: soft, NT, ND
EXT: trace edema at ankles bilaterally
NEURO:
MS - when questions are written down for him, he is AAOx3. He
is very hard of hearing and so cannot understand spoken
questions. He follows simple commands, speech is fluent, no
dysarthria, comprehension is intact when instructions are
written or mimicked.
CN - L eye missing, R eye EOMI, R eye 3->2mm and brisk, face
symmetrical, facial sensation intact, tongue midline
MOTOR - MAEE, and when asked to do strength exam with written
instructions and mimicking he is at least 5-/5 troughout.
SENSORY - intact to LT throughout
COORDINATION - able to reach accurately bilaterally
GAIT - deferred
Pertinent Results:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2196-6-5**]
11:38 PM
IMPRESSION:
1. Endotracheal tube tip approximately 3.6 cm above the carina.
2. Calcified pleural plaques.
3. Engorged left upper lobe pulmonary vessels, which suggest
mild left sided heart failure.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2196-6-6**]
12:13 AM
IMPRESSION:
1. 12 x 6 mm left occipital parenchymal or subarachnoid
hemorrhage, unchanged compared to prior outside exam given
differences in technique.
2. Facial fractures, partially imaged, better seen on outside
hospital facial bone CT.
CT head [**2196-6-6**]
1. 13 x 8 mm left occipital hemorrhagic focus is most consistent
with
subarachnoid hemorrhage, less likely intraparenchymal
hemorrhage, and appears stable compared to the most recent prior
study of 10 hours prior.
2. Stable small subdural hematoma along the posterior left falx
cerebri.
3. Multiple facial fractures better assessed on the facial bone
CT from
outside hospital on [**2196-6-5**].
4. Stable osteolytic lesion in the left occipital bone unchanged
from MRI of [**2194-12-22**].
ECG [**2196-6-7**]
Sinus rhythm. Left bundle-branch block with a single narrow
complex beat.
Since the previous tracing left bundle-branch block has recurred
except for the one narrow beat. The rate is faster. Narrow beat
is after an atrial premature beat. Clinical correlation is
suggested.
CXR [**2196-6-7**]
As compared to the previous radiograph, the patient has been
extubated. The pre-existing post-surgical material after CABG
and the
pre-existing pleural calcifications are unchanged. There is no
evidence of
pneumothorax. Borderline size of the cardiac silhouette without
evidence of pulmonary edema. In the interval, the ventilation of
the lung appears to have slightly improved. No larger pleural
effusions. Moderate tortuosity of the thoracic aorta, no
evidence of chest wall lesions.
CXR [**2196-6-8**]
Pulmonary vascular congestion is improving. Borderline
cardiomegaly is
chronic. Multiple pleural calcifications should not be mistaken
for pulmonary abnormalities. No large scale atelectasis or
evidence of pneumonia. The patient has had median sternotomy and
coronary bypass grafting. No pneumothorax.
CXR [**2196-6-9**]
No acute cardiopulmonary process.
CXR [**2196-6-12**]
Compared to the prior exam, there has been a mild increase in
the
size of the heart with pulmonary vascular redistribution and
volume loss at both bases. Again seen are granulomas and
calcified pleural plaques,
sternotomy wires, and mediastinal clips.
IMPRESSION: Fluid overload.
[**2196-6-13**]
Improvment in pulmonary edema.
[**2196-6-13**] Video Swallow
No aspiration or penetration seen. For details and
recommendations, please refer to speech and swallow note in OMR.
[**2196-6-14**] Bilateral LENIs: negative
ADMISSION LABS:
[**2196-6-6**] 12:00AM BLOOD WBC-15.5*# RBC-4.33* Hgb-12.6* Hct-40.0
MCV-92 MCH-29.0 MCHC-31.5# RDW-14.0 Plt Ct-324
[**2196-6-6**] 12:00AM BLOOD Neuts-86.0* Lymphs-11.2* Monos-2.3
Eos-0.3 Baso-0.2
[**2196-6-6**] 12:00AM BLOOD PT-11.2 PTT-28.1 INR(PT)-1.0
[**2196-6-6**] 12:00AM BLOOD Glucose-157* UreaN-26* Creat-1.3* Na-132*
K-4.6 Cl-99 HCO3-21* AnGap-17
[**2196-6-6**] 12:00AM BLOOD ALT-15 AST-27 AlkPhos-74 TotBili-0.3
[**2196-6-6**] 12:00AM BLOOD Lipase-34
[**2196-6-6**] 12:00AM BLOOD cTropnT-<0.01
[**2196-6-6**] 12:00AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.1 Mg-1.6
[**2196-6-6**] 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-6-6**] 01:53AM BLOOD Type-ART Rates-/20 pO2-369* pCO2-33*
pH-7.45 calTCO2-24 Base XS-0 Intubat-INTUBATED
DISCHARGE LABS:
[**2196-6-14**] 04:55AM BLOOD WBC-10.2 RBC-3.66* Hgb-10.7* Hct-34.2*
MCV-93 MCH-29.2 MCHC-31.3 RDW-14.4 Plt Ct-301
[**2196-6-14**] 04:55AM BLOOD Glucose-137* UreaN-17 Creat-0.8 Na-140
K-3.0* Cl-104 HCO3-30 AnGap-9 (K was repleted after this result)
[**2196-6-14**] 04:55AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.7
Brief Hospital Course:
This is a 86 year old male who was walking and fell off a 3ft
ledge, witnessed by family the patient was transfered here from
an outside hospital on [**2196-6-6**]. Upon transfer, the patient was
aggitated and intubated in the [**Hospital1 18**] ED. A head Ct was
performed and consistent small occipital hemorhage and bilateral
Lefort 1 fracture.
Right medial orbital wall fx,Nasal fx with moderate deviation.
The patient was admitted to the TSICU.
In the morning of [**2196-6-6**], the patient continued to be
intubated and was weaned from sedation the ventilator was weaned
as tolerated. a NCHCT was performed and was found to be stable.
Plastic surgery consulted on the patient and recommended
conservative management which included:Unasyn and Dc on
Augmentin for a week total, Once extubated, limit diet to full
liquids and soft solids only to prevent lefort fragment
displacement,HOB elevation,Cool pack to face,Sinus precautions
once extubated, soft diet for 4 weeks when awake, Follow up in
[**Hospital **] clinic with chief on Friday. Plastic surgery reduced the
nasal fx at bedside and placed nasal packing to stay in place
for 48-72 hours.
[**6-7**], patient removed his nasal packing, has a nasal splint in
place. He remains stable on examination. C-spine was cleared. On
[**6-8**], he was transferred to the floor.
On [**6-9**], patient was febrile to 102, cultures were sent and a CXR
was ordered. On [**6-9**] started Cipro for UTI, which he completed on
[**6-15**]. The medicine service started following this patient. They
recommended following his lab work and a speech and swallow exam
Serial chest X-rays showed fluid overload and he was diareses
with Lasix. This improved on [**6-13**].
On [**6-12**] he was re-evaluated by medicine for delirium, this
improved on [**6-13**] and he passed his video swallow. He was on sinus
precautions and a soft diet for his facial fractures.
On [**6-14**] he was c/o leg pain, so he had bilateral LENIs which were
negative. He was then able to be safely sent to rehab.
Medications on Admission:
Flonase 50mcg 2 sprays per nostril daily
Aricept 5mg QHS
Vit D [**2184**] units daily
Colace 100mg [**Hospital1 **]
Flomax 0.4mg daily
ASA 81mg daily
Celexa 10mg daily
Ferrous Sulfate 325mg daily
MVI
Prilosec 20mg [**Hospital1 **]
Zocor 40mg daily
Vit B12 250 mcg daily
Proscar 5mg QHS
Discharge Medications:
1. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Vitamin D3 2,000 unit Tablet Sig: One (1) Tablet PO once a
day.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever/HA.
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Cipro I.V. 200 mg/20 mL Solution Sig: Four Hundred (400) mg
Intravenous Once for 1 doses: Last dose to complete course
should be on [**6-15**] at 4pm.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehabilitation & [**Hospital **] Care Center - [**Location (un) **]
Discharge Diagnosis:
left occipital IPH
R medial orbital wall fracture
Nasal bone fracture
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
You are to be on a soft diet due to facial fractures for one
month from your accident. Also maintain sinus precautions: no
nose blowing, no straws.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? You may have Heparin SC and Aspirin.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
SINUS PRECAUTIONS: NO STRAWS, NO NOSE BLOWING, ELEVATE HEAD OF
BED WHEN POSSIBLE
We made the following changes to your medications:
1) We STOPPED your FLONASE because of your nasal fractures.
2) We STARTED you on SUBCUTANEOUS HEPARIN three times a day.
You will only need this medication while you are at rehab.
3) We STARTED you on TYLENOL 325-650mg every 4 hours as needed
for pain.
4) We STARTED you on IV CIPRO. Your last dose will be [**6-15**] at
4pm.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in four weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Follow up in [**Hospital **] clinic with chief on Friday [**2196-6-17**] at
10:00am.
Please contact Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 6331**] reagarding appt location
as they need to ensure appropriate assistance is available for
the patient.
|
[
"389.9",
"414.00",
"V45.81",
"276.69",
"V49.87",
"E884.9",
"200.30",
"424.1",
"802.4",
"V45.78",
"585.3",
"300.00",
"802.0",
"715.90",
"600.00",
"853.01",
"780.09",
"599.0",
"802.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.71",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10705, 10819
|
6995, 9035
|
357, 364
|
10937, 10937
|
3025, 5845
|
12602, 13204
|
1601, 1619
|
9372, 10682
|
10840, 10916
|
9061, 9349
|
11115, 12222
|
6663, 6972
|
1649, 3006
|
12251, 12579
|
300, 319
|
392, 762
|
5862, 6646
|
10952, 11091
|
784, 1080
|
1096, 1585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,017
| 114,250
|
35171
|
Discharge summary
|
report
|
Admission Date: [**2130-6-24**] Discharge Date: [**2130-7-14**]
Date of Birth: [**2048-11-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Ciprofloxacin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain, Palpitations
Major Surgical or Invasive Procedure:
-Aortic valve replacement with a 21 mm [**Doctor Last Name **]
pericardial tissue valve, model number 3300 TFX.
-Coronary artery bypass grafting x1 with the saphenous
vein graft to the right coronary artery.
History of Present Illness:
Pt is an 81 y/o F with PMHx significant for HTN, DM, Afib,
asthma, and aortic stenosis who is being transferred from [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 4117**] for further management of her critical aortic stenosis.
She initially presented to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4117**] on [**2130-6-21**] with chest
pain ("heaviness"), palpitations, lightheadedness, headache, and
diaphoresis. She also experienced left hand numbness at that
time. On presentation, she was noted to be afebrile with a HR in
the 80's. She underwent an echo, which showed critical AS ([**Location (un) 109**]
0.6 cm2, gradient of 73 mmHg), moderate pHTN,and LVEF was 60%.
Cardiac surgery was consulted for surgical correction.
Past Medical History:
- Aortic stenosis
- HTN
- Chronic Back Pain
- GERD
- DM
- Anxiety
- Depression
- Afib on coumadin
- Hemorrhoids
- ?Asthma
- Epistaxis
- S/p Appendectomy
- S/p Hysterectomy
- S/p Cataract Sx
- Several episodes of bursitis
- 2 sinus surgeries
- Knee surgery, unspecified
Social History:
Lives alone. Has a homemaker that helps around the appt;
daughter in law visits frequently. No alcohol. Remote tobacco
use (quit 30 years ago). Worked at [**Company 2676**] in electronics.
Family History:
Breast cancer in mother. [**Name (NI) 3495**] dz and DM in siblings.
Physical Exam:
(Admission Exam)
VS - T 97.6, BP 124/59, HR 66, RR 18, 95% on RA, FS 156
GENERAL - 81 y/o F in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM
NECK - supple, no JVD, AS murmur radiating to carotids
CV: Irregular, rate ~80s, 3/6 systolic murmur with
LUNGS - CTA bilaterally, non-labored respirations, no accessory
muscle use, good air movement
ABDOMEN - BS present, soft, NT/ND, no masses or HSM
EXTREMITIES - WWP, ankles appear full but no pitting edema, 2+
DP pulses
SKIN - No rashes or lesions noted
Pertinent Results:
[**2130-7-13**] 07:10AM BLOOD WBC-18.8* RBC-3.95*# Hgb-10.5*#
Hct-31.1*# MCV-79* MCH-26.7* MCHC-33.9 RDW-18.1* Plt Ct-335
[**2130-6-25**] 05:30AM BLOOD WBC-13.8* RBC-4.42 Hgb-10.5* Hct-33.6*
MCV-76* MCH-23.8* MCHC-31.3 RDW-17.7* Plt Ct-367
[**2130-7-13**] 07:10AM BLOOD PT-12.4 INR(PT)-1.0
[**2130-6-25**] 05:30AM BLOOD PT-21.4* PTT-26.5 INR(PT)-2.0*
[**2130-7-13**] 07:10AM BLOOD Glucose-163* UreaN-26* Creat-1.2* Na-131*
K-3.8 Cl-92* HCO3-30 AnGap-13
[**2130-6-25**] 05:30AM BLOOD Glucose-129* UreaN-24* Creat-1.1 Na-140
K-4.8 Cl-100 HCO3-34* AnGap-11
[**2130-7-1**] 07:20AM BLOOD ALT-20 AST-31 LD(LDH)-287* AlkPhos-115*
TotBili-0.3
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 80274**]
(Complete) Done [**2130-7-10**] at 10:45:59 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2048-11-26**]
Age (years): 81 F Hgt (in): 64
BP (mm Hg): 120/60 Wgt (lb): 184
HR (bpm): 60 BSA (m2): 1.89 m2
Indication: aortic valve stenosis
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2130-7-10**] at 10:45 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *42 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 28 mm Hg
Aortic Valve - LVOT diam: 1.8 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Moderate to severe spontaneous echo contrast in the
body of the LA. Depressed LAA emptying velocity (<0.2m/s) Cannot
exclude LAA thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Normal
aortic arch diameter. Focal calcifications in aortic arch.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
Critical AS (area <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The rhythm appears to be atrial fibrillation.
patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. The left atrial appendage emptying velocity
is depressed (<0.2m/s). A left atrial appendage thrombus cannot
be excluded. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
complex atheromas seen in the thoracic descending aorta.
The aortic valve leaflets (3) are moderately thickened. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Dr..[**Doctor Last Name **] was notified in person of the results on Mrs. [**Known lastname 303**]
before surgical incision.
POST-BYPASS:
Normal RV systolic function.
LVEF 50%. No regional wall motion abnormalities.
Intact thoracic aorta.
Minimal MR.
The aortic b ioprosthesis is intact and functioning well.
Residual mean gradient is 12 mm of Hg.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2130-7-12**] 11:36
Brief Hospital Course:
81 y/o F with PMHx significant for HTN, DM, chronic Afib-on
Coumadin, asthma, and aortic stenosis who was transferred to
[**Hospital1 18**] for further management of her critical aortic stenosis.
She underwent preoperative testing which included cardiac
catheterization. This was complicated by postprocedure
pseudoanuerysm that was corrected with thrombin injection by IR.
In addition, a right apical neural sheath tumor was found
incidentally during pre-operative evaluation. Neurosurgery team
was consulted and believed changes to be chronic in nature with
no need to delay AVR/CABG. Patient will undergo MRI as an
outpatient with follow up with Dr. [**Last Name (STitle) 739**].
Ms.[**Known lastname 80275**] preoperative chest CT also revealed hepatic
fibrosis,and hepatology was consulted for evaluation, management
and recommendations before surgery for AVR. No intervention was
required.
[**Last Name (un) **] was also consulted preoperatively for glucose control
recommendations, and followed postoperatively as well.
On [**2130-7-10**] Ms.[**Known lastname **] was taken to the operating room and
underwent an Aortic valve replacement with a 21 mm [**Doctor Last Name **]
pericardial tissue valve, model number 3300 TFX/Coronary artery
bypass grafting x1 with the saphenous vein grafted to the right
coronary artery. Please refer to Dr[**Doctor Last Name **] operative report for
further details. She tolerated the procedure well and was
transferred to the CVICU for further invasive monitoring. She
was intubated and sedated, requiring Propofol and Phenylephrine.
She awoke neurologically intact and was extubated
postoperatively without incident. All lines and drains were
discontinued in a timely fashion. She weaned off pressors and
Beta-blocker/Statin/Aspirin, and diuresis was initiated. POD#2
she was transferred to the floor for further monitoring.
Anticoagulation was resumed with Coumadin for her chronic Atrial
fibrillation.
Physical Therapy was consulted for evaluation of strength and
mobility. The remainder of her postoperative course was
essentially uneventful. On POD#4 she was cleared by Dr.[**Last Name (STitle) **] for
discharge to [**Hospital 38**] Rehabilitation in [**Location (un) 1110**]. All follow up
appointments were advised.
Medications on Admission:
- Lantus 20 units qAM, 60 units qHS
- Advair 250/50 1 puff [**Hospital1 **]
- Metformin 500 mg [**Hospital1 **]
- Restoril 30 mg qHS
- Zoloft 100 mg daily
- HCTZ 25 mg daily
- Lisinopril 10 mg daily
- Ativan 1 mg HS
- Digoxin 0.125 mg daily
- Neurontin 600 mg qHS
- Toprol XL 50 mg TID
- Colace
- Senna
- Prevacid 30 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHS (once a
day (at bedtime)): home dose 600mg qhs.
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
14. Warfarin 1 mg Tablet Sig: as directed for Afib Tablet PO
Once Daily at 4 PM: goal INR 2.0-2.5.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: check BMP in 2 days - if elevated may need to chnage to
diamox until at pre-op weight.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days: while on lasix.
17. Lantus 100 unit/mL Solution Sig: Fifty (50) units SQ
Subcutaneous once a day: Usual dose is 20 units qam and 60 units
qhs
.
18. regular insulin
based on qid sliding scale finger stick
19. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Start when Creatinine stable.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
- Aortic stenosis (valve area 0.5 cm2)
-Aortic valve replacement with a 21 mm [**Doctor Last Name **]
pericardial tissue valve, model number 3300 TFX.
2. Coronary artery bypass grafting x1 with the saphenous
vein graft to the right coronary artery.
Secondary:
Hypertension
Aortic Stenosis
Diabetes Mellitus
Atrial Fibrillation on coumadin
?Asthma
GERD
Irritable Bowel Syndrome
Stress incontinence
h/o fainting spells dating back to childhood
Iron deficiency anemia
Chronic back pain
Anxiety/Depression
Bursitis
Epistaxis
Hemorrhoids
Past Surgical History:
s/p appendectomy
s/p hysterectomy
s/p cataract surgery
s/p sinus surgery x2
s/p left knee surgery
- Hypertension
- Type II diabetes mellitus
- Atrial fibrillation
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema: 1+
bilat LE edema
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of sternal wound.
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
please take all of your medications as prescribed and follow up
with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) **], [**First Name3 (LF) **] appointment was arranged for Wednesday, [**8-9**] at 1pm
Please call to schedule appointments with your
Primary Care: PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] [**Telephone/Fax (1) 60570**] in [**2-4**] weeks
Cardiologist: Dr. [**First Name (STitle) **] [**Doctor Last Name 2194**] in [**2-4**] weeks
Your pre-operative workup revealed a neural sheath tumor located
at the top of your right lung. We consulted the neurosurgery
team who believed this change to be chronic in nature requiring
no immediate intervention. After you recover from surgery, you
will have an MRI with follow up with Dr. [**Last Name (STitle) 739**] of
Neurosurgery as an outpatient. Plaese call and schedue a
Neurosurgery appointment with Dr.[**Last Name (STitle) 739**] in 3 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 for Coumadin ?????? indication-Atrial Fibrillation
Goal INR: 2.0 -2.5
Completed by:[**2130-7-14**]
|
[
"416.8",
"493.90",
"V58.61",
"239.2",
"424.1",
"401.9",
"442.3",
"997.2",
"E879.0",
"338.29",
"571.5",
"V58.67",
"E849.7",
"280.9",
"300.4",
"427.31",
"564.1",
"724.5",
"414.01",
"530.81",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"36.11",
"37.23",
"88.56",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12368, 12513
|
7751, 10024
|
321, 539
|
13293, 13537
|
2478, 7728
|
14542, 15750
|
1845, 1915
|
10400, 12345
|
12534, 13084
|
10050, 10377
|
13561, 14519
|
13107, 13272
|
1930, 2459
|
256, 283
|
567, 1331
|
1353, 1623
|
1639, 1829
|
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