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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
21,522
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|
28458
|
Discharge summary
|
report
|
Admission Date: [**2198-7-8**] Discharge Date: [**2198-7-16**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
[**2198-7-10**] Rigid bronchoscopy, flexible bronchoscopy, and metallic
covered Ultraflex stent placement 40 mm x 20 mm.
[**2198-7-10**] Flexible and rigid bronchoscopy with endotracheal stent
placement.
[**2198-7-11**] Ultrasound-guided right-sided therapeutic thoracentesis.
History of Present Illness:
This history has been obtained from OSH reports. This is a [**Age over 90 **]
year-old female who presented to [**Hospital3 934**] Hospital with
worsening shortness of breath for
6-7 weeks. Despite medical treatment from her PCP, [**Name10 (NameIs) **] symptoms
continued to worsen. On [**7-6**], the patient went to answer the
phone and got significantly short of breath. The patient also
complained of tachycardia and palpitations at that time. Patient
denied coughing, chest pain, abdominal pain, arm or leg pain and
urinary symptoms on initial presentation. The patient was
transferred to [**Hospital1 18**] because she has a metal tracheal stent that
was placed here in [**2197**].
Past Medical History:
Cervical Trachaelmalacia s/p Stent
Congestive Heart Failure, atrial fibrillation, s/p pacemaker
Rectal prolapse, bronchitis, anemia, syncope, left humeral
fracture, pulmonary hypertension, constipation, cataracts,
osteoarthritis, CAD with stent, goiter
Social History:
Lives alone in [**Location (un) 1439**]. Widowed (husband died at age 82). Denies
tobacco, EtOH, or drug use
Family History:
Non-contributory
Physical Exam:
VS: T 97.9 HR: 85-90's Afib BP: 110/54 RR 20 Sats: 96% RA
at rest, 92-96% 1L with ambulation
Wt 80.0 kg
General: [**Age over 90 **] year-old female sitting in chair no apparent
distress
Neck: supple no lymphadenopathy
Card: irreg
Resp: decresased breath sounds throughout with faint crackles R
[**2-16**], left base
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Skin: scattered isolated 2-6 mm erytematous papules, central
adherent dry crust, on face, chest, abdomen,low back and
buttocks arms, & legs
Neuro: non-focal
Pertinent Results:
[**2198-7-12**] WBC-11.6* RBC-3.32* Hgb-10.1* Hct-30.0 Plt Ct-272
[**2198-7-8**] WBC-8.1 RBC-3.47* Hgb-10.4* Hct-31.5* Plt Ct-233
[**2198-7-11**] Neuts-88.1* Lymphs-5.5* Monos-6.2 Eos-0.1 Baso-0.1
[**2198-7-13**] Glucose-99 UreaN-25* Creat-0.9 Na-144 K-3.4 Cl-107
HCO3-31
[**2198-7-8**] Glucose-122* UreaN-23* Creat-0.9 Na-140 K-4.4 Cl-109*
HCO3-20
[**2198-7-12**] CK(CPK)-48
[**2198-7-12**] CK-MB-NotDone cTropnT-0.01 proBNP-[**Numeric Identifier 26054**]*
[**2198-7-13**] Calcium-9.7 Phos-2.5* Mg-2.0
[**2198-7-11**] PLEURAL FLUID GRAM STAIN (Final [**2198-7-11**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
[**2198-7-10**] SPUTUM Endotracheal. FINAL REPORT [**2198-7-12**]**
GRAM STAIN (Final [**2198-7-10**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2198-7-12**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
[**2198-7-10**] 3:50 am MRSA SCREEN Site: RECTAL FINAL REPORT
[**2198-7-12**]
MRSA SCREEN (Final [**2198-7-12**]): No MRSA isolated.
[**2198-7-8**] 4:18 pm URINE FINAL REPORT [**2198-7-10**] NO GROWTH.
Echocardgiogram: [**2198-7-11**]
The left atrial volume is markedly increased (>32ml/m2). The
right atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. There is mild to moderate regional left
ventricular systolic dysfunction with severe
hypokinesis/akinesis of the septum and hypokinesis of the
anterior wall. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. Ejection Fraction 35-40%
IMPRESSION: Moderate focal LV systolic dysfunction. Diastolic
dysfunction. Mild aortic regurgitation.
CHEST (PORTABLE AP) [**2198-7-13**]
FINDINGS: In comparison with the study of [**7-11**], there is no
interval change. Small bilateral pleural effusions are again
seen in this patient with a tracheal stent in place. Enlargement
of the cardiac silhouette with vascular prominence and pacemaker
device.
Brief Hospital Course:
Mrs. [**Known lastname 47716**] was transferred to the SICU from [**Hospital3 934**]
Hospital intubated [**2198-7-6**] for progressive SOB. On HOD #1 she
was seen by dermatology for puritis who recommended to keep skin
moist with emollients, such as Eucerin. On HOD #2 she had
Flexible bronchoscopy was performed through the endotracheal
tube. On HOD #3 she went to the operating room and underwent
successful Rigid bronchoscopy, flexible bronchoscopy, and
metallic covered Ultraflex stent placement 40 mm x 20 mm. She
was transferred back to the SICU and extubated without
difficulty. [**Last Name (un) **] was seen by Speech and swallow for mild
difficulty with mastication [**3-17**] edentulous state, but otherwise
did not have any overt signs of aspiration. They recommended a
PO diet of thin liquids and ground consistency solids and pills
whole with apple sauce. She tolerated this without difficulty.
Later that evening she transferred to the floor but developed
respiratory distress and was transferred back to the SICU. She
responded to diuretics, nebulizers and aggressive pulmonary
toileting. She was found to be in atrial fibrillation and her
beta-blockers were increased. An echocardiogram was performed
(see report). The right pleural effusion was drained for 600cc.
Her hypoxemia improved and she was transferred back to the
floor. She was seen by physical therapy who recommended rehab.
Her oxygen saturation were 96% on RA at rest, and 92-96% on 1
Liter via nasal cannula. She was discharged to rehab on POD #6.
She will follow-up with Dr. [**Last Name (STitle) **] in 4 weeks.
Medications on Admission:
Zoloft 12.5mg daily, lasix 20mg [**Hospital1 **], lopressor 25mg tid, asa
81mg daily, famotidine 20mg [**Hospital1 **], coumadin as directed
Discharge Medications:
1. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Sertraline 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
Cervical Trachaelmalacia s/p Stent [**6-21**]
Trachael bronchomalacia s/p metallic stent [**2197**]
Congestive Heart Failure, atrial fibrillation, s/p pacemaker
Rectal prolapse, bronchitis, anemia, syncope, left humeral
fracture, pulmonary hypertension, constipation, cataracts,
osteoarthritis, CAD with stent, goiter
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Initials (NamePattern4) 5070**] [**Last Name (NamePattern4) **] if experience: fever > 101 or chills,
increased cough or shortness of breath or any other symptoms
that concern you.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 10084**] [**2198-8-14**] 10am for
bronchoscopy in the chest disease center [**Hospital Ward Name **] building [**Hospital1 **]
one. Do not eat or Drink after midnight the day before.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 911**] [**Telephone/Fax (1) 59456**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2198-7-17**]
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25,509
| 109,775
|
5807
|
Discharge summary
|
report
|
Admission Date: [**2156-5-24**] Discharge Date: [**2156-5-30**]
Date of Birth: [**2098-4-2**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
known coronary artery disease, status post multiple PCIs in
the past, had a recent positive stress echocardiogram and was
referred for a cardiac catheterization. This revealed severe
3-vessel disease with 70% proximal LAD lesion, 90%
circumflex, 80% mid RCA, and an EF of 58%. He was then
referred for coronary artery bypass graft surgery.
PAST MEDICAL HISTORY: Status post multiple PCIs,
hypercholesterolemia, nephrolithiasis, status post
appendectomy, status post cholecystectomy, type 2 diabetes.
The patient also has Parkinson disease.
MEDICATIONS AT HOME: Aspirin 81 mg daily, Lopressor 50 mg
b.i.d., Glucotrol XL 5 mg daily, Glucophage 500 mg a.m. and
100 mg p.m., Zestril 2.5 mg daily, Zocor 20 mg daily,
Sinemet, Lodosyn 25 mg q.i.d.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He works as a mechanic. He never smoked. He
does not drink. He has no history of recreational drug use.
PREOPERATIVE LABORATORY DATA: White blood count of 5.6,
hematocrit of 35.1, platelets of 114. INR of 1.1, PTT of
28.9. Sodium of 135, potassium of 4.7, chloride of 103,
bicarbonate of 29, BUN of 29, creatinine of 1.2, glucose of
221. His LFTs were normal. His UA was negative.
RADIOLOGIC STUDIES: His preoperative chest x-ray showed no
evidence of acute cardiopulmonary process.
Cardiac catheterization results were mentioned in the HPI.
PHYSICAL EXAMINATION ON ADMISSION: He was a well-appearing
58-year-old male in no acute distress. Neurologically, he was
grossly intact. A tremor was noted of the left hand. No
carotid bruits. His heart rate was regular in rate and
rhythm. Positive S1 and S2. No clicks, rubs, murmurs, or
gallops. His lungs were clear to auscultation bilaterally.
His abdomen was soft, nontender, and nondistended. Positive
bowel sounds. The extremities revealed the groin saphenous
vein site was clean and dry without hematoma. His legs were
warm without edema or varicosities. He had positive DP and PT
pulses bilaterally.
HOSPITAL COURSE: After discussion with the patient he was
consented for bypass surgery the following day. On [**2156-5-25**] he was brought to the operating room and underwent
coronary artery bypass graft x 4 with a LIMA to the LAD,
saphenous vein graft to diagonal, saphenous vein graft to
ramus and OM sequence. Please refer to the OP note for full
surgical details. The patient tolerated the procedure well.
Cardiopulmonary bypass time was 75 minutes. Cross-clamp time
was 49 minutes.
Following the procedure the patient was transferred to the
CSICU with a CVP of 11, heart rate of 80, A paced. He was
being titrated on Neo-Synephrine currently at 0.8 mcg/kg/min,
propofol, and insulin. Later that day propofol was weaned.
The patient became less sedated, and he was awake, alert, and
followed commands. He was extubated. The extubation went
well. He was neurologically intact, and there were no
deficits, and he was responding to all commands.
On postoperative day #1, beta blockade and diuresis were
started per protocol. His chest tubes were removed. He was
hemodynamically stable. Later that day he was transferred to
the telemetry floor on [**Hospital Ward Name 121**] Two. On postoperative day #2, he
appeared to be doing well. He was continuing to get out bed
and ambulate good. His Foley was removed. On postoperative
day #3, his epicardial pacing wires were removed. He appeared
to be doing well in his postoperative course, getting out of
bed. His physical exam was unremarkable. His labs were
stable. On postoperative day #4, once again the patient
appeared to be well. He was complaining of shoulder and back
pain which were resolved with typical pain medication. His
physical exam was unremarkable, and he was still getting out
of bed well and continued using inspiratory spirometer. On
postoperative day #5, once again the patient had a pretty
unremarkable postoperative course. He was at level 5. His
labs were stable. His physical exam was unremarkable. His
lungs were clear. His heart was regular in rate and rhythm.
His sternum was stable. The incision was clean, dry, and
intact. His blood glucose did remain to be high; and
therefore [**Last Name (un) **] was consulted before the patient's
discharge, and he will follow up in the [**Hospital **] Clinic for
diabetic management as an outpatient.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: He was discharged to home with VNA
services.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft x 4 on [**2156-5-25**].
2. Hypercholesterolemia.
3. Nephrolithiasis.
4. Diabetes.
5. Parkinson disease.
6. Status post multiple percutaneous coronary interventions.
7. Status post appendectomy.
8. Status post cholecystectomy.
DISCHARGE FOLLOWUP: He was recommended to follow up with Dr.
[**Last Name (STitle) 70**] in 6 weeks, follow with the cardiologist in 2
weeks, and with PCP [**Last Name (NamePattern4) **] 1 week.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg p.o. daily.
2. Ranitidine 150 mg p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d.
4. Carbidopa/levodopa 50/200 mg 1 daily.
5. Lodosyn 25 mg take 2 p.o. q.i.d.
6. Carbidopa/levodopa 25/250 mg p.o. q.i.d.
7. Glipizide 5 mg p.o. daily.
8. FeSO4 300 mg p.o. daily.
9. Vitamin C 500 mg p.o. b.i.d.
10. Multivitamin p.o. daily.
11. Dilaudid 2 mg 1 to 2 tablets p.o. q.4h. p.r.n. (for
pain).
12. Metformin 500 mg p.o. daily.
13.
Metformin 500 mg 2 tablets p.o. daily.
14. Lopressor 50 mg 1-1/2 tablets p.o. b.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 11830**]
MEDQUIST36
D: [**2156-6-23**] 14:27:07
T: [**2156-6-24**] 18:16:10
Job#: [**Job Number 23067**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
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2182, 4487
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761, 988
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4931, 5107
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164, 537
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1589, 2164
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560, 739
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1005, 1574
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4512, 4519
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,458
| 182,671
|
32738
|
Discharge summary
|
report
|
Admission Date: [**2170-2-15**] Discharge Date: [**2170-2-28**]
Date of Birth: [**2091-10-30**] Sex: F
Service: MEDICINE
Allergies:
Allopurinol / Erythromycin Base / Percocet / Tetracycline
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
Lumbar puncture under fluouroscopy, attempted lumbar punctures
at bedside
History of Present Illness:
Pt is a 78 yo F with PMH significant for HTN, recent ankle
fracture and c/o LLE weakness with a recent complicated hospital
course since mid-[**2169-12-23**]. Now being transferred to OMED
for new dx of Small Cell Lung Cancer.
Originally admitted to an OSH [**1-7**] after a fall with a left
ankle fracture. Discharged to a nursing home, noted to have UTI
treated with cipro. Subsequently returned to the OSH with
confusion and was noted to have hyponatremia with (NA 122) in
setting of dehydration. Also noted to have some right hand
weakness and advised for outpt neuro f/u. Admitted to East
hospital service on [**2-2**] with PNA, UTI and SIADH. Had LE
weakenss seen by neuro had multilevel DJD and sent to rehab.
Weakness progressed at rehab.
Sent back to [**Hospital1 18**] on [**2-15**] due to weakness in all limbs. EMG
done showed diffuse axonal pattern c/w neuropathy. LP showed
somewhat elevated protein (cytology sent). Given findings,
question of neoplasm raised. CT of chest subsequently performed
and found lung mass w/ nodal mets. Also suspicious lesions in
kidney and liver. Question of small cell lung CA raised.
Oncology and IP were consulted. Ultimately obtained tissue for
pathology on [**2170-2-15**]. Pathology returned [**2-19**] with new dx of
Small Cell Lung Ca. Patient was been fluid restricted given
SIADH and sodium improved.
Briefly transferred to medicine [**2170-2-20**] for further management.
At time of transfer patient c/o continued weakness. Only focal
complaint is perirectal discomfort (has a decubitus ulcer).
Now transferred to OMED service for intitiation of therapy for
new cancer diagnosis. Beyond history as surmarized above,
patient c/o recent bout of somonlence x 3 day. She also has
persistent low back pain [**2-24**] to ulceration and is willing to try
low dose narcotics to help this. Denies any other symptoms of
infectious process though did have some increased bowel
frequency several days. No diarrhea currently F/ch/N/V.
Past Medical History:
Left ankle fracture [**2170-2-2**], s/p cast
Weakness thought related to polyradiculopathy (as above)
SIADH - had been thought related to ILD
Cataracts
Interstitial lung disease
Hypertension
Diverticulitis
Gout
s/p tonsillectomy
s/p appy
s/p cholecystectomy
s/p colon resection
s/p ovarian cyst removal
Rotator cuff injury
Bilateral carpal tunnel syndrome
Lumbar radiculopathy
Chronic lumbar spondylosis
Social History:
Lived at home alone prior to hospitalizations. Now comes from
rehab. No alcohol or drugs. Smoked in the past. Music teacher,
retired.
Family History:
Father with gastric cancer; mother died at 88 of cancer (unknown
type)
Physical Exam:
Physical Examination:
Vitals: Tm 98.6 HR 92 BP 141/76 RR 18 96% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Attention: Able to recite [**Doctor Last Name 1841**] backwards.
Registration intact.
Recall: [**2-25**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors. No apraxia,
no
neglect. [**Location (un) **] intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Full strength at neck flexors and extensors. No
fasciculations.
[**Doctor First Name **] Tri Bic WE FE FF IP HE HipAd HipAb Q H DF PF [**Last Name (un) 938**]
R 5 5 5 5 4+ 4+ 3 4+ 4 4 4 4 2 4 2
L 5 4 4+ 4+ 4+ 4+ Cast on left lower leg.
Sensation: Decreased propriception and vibration to upper and
lower extremities. Some decrease in cold and PP to right lower
extremity.
Reflexes: B T Br Pa Ac
Right 0 0 0 0 0
Left 0 0 0 0 0
Toes downgoing bilaterally.
Coordination: Slow finger-nose-finger; slower heel to shin in
proportion with weakness
Gait: Unable to sit or walk.
Pertinent Results:
Admission Labs:
7.9 > 10.8 < 494
31.0
N:87.1 L:9.7 M:2.2 E:0.9 Bas:0.2
Lactate:1.3
125 88 11 98 AGap=11
---------------
4.2 30 0.6
estGFR: >75 (click for details)
PT: 13.0 PTT: 34.4 INR: 1.1
EKG [**2170-2-15**] - Sinus rhythm. Borderline left axis deviation.
Possible left anterior fascicular block. No previous tracing
available for comparison.
LP performed under fluouro [**2-17**]:
WBC 6->2
RBC 1430->267
prot 78
gluc 70
cytology pending
CHEST XRAY AT ADMISSION [**2-15**]:
COMPARISON: Chest radiographs [**2170-2-6**], [**2170-2-3**], and [**2170-2-2**].
Chest X-ray
1. Improvement in left upper lung opacity seen [**2170-2-6**] with
small residual nodular density persisting. Findings could
reflect residual infection. Continued surveillance is suggested
to assure resolution. Alternatively, this could be further
evaluated on a non-emergent basis with chest CT.
2. Abnormal mediastinal contour with marked convexity of the
aorticopulmonary window has not appreciably changed compared to
the recent radiograph. While this could represent enlargement of
the pulmonary artery, underlying lymphadenopathy or mass is
possible. This could also be further evaluated with chest CT.
CT chest without contrast and reconstructions [**2170-2-16**]:
1. Multiple left upper lobe nodules with large left mediastinal
nodal conglomerate centered within the AP window with
obstruction of the left anterior and apicoposterior upper lobe
bronchi. This is consistent with a primary lung carcinoma with
nodal metastases, with small cell carcinoma most likely.
2. Exophytic right upper pole renal lesion measuring 2.1 cm in
greatest axial dimension. This lesion is concerning for renal
cell carcinoma, however, a complex (proteinaceous vs hemorragic)
cyst is also within the differential. MRI would be preferred for
definitive characterization.
3. Hypodense lesion within segment VIII of the liver, not
compatible with a simple cyst. Further evaluation with MRI is
recommended at which time the renal lesion can be assessed too.
4. Emphysema and pulmonary fibrosis without a classic pattern.
FDG TUMOR IMAGING (PET-CT) [**2170-2-23**]
1. FDG avid nodule in the right upper lobe with SUV max of 10.3
consistent with primary site of lung cancer. Adjacent intensely
FDG avid right lung nodule also consistent with lung cancer.
2. Large FDG avid conglomerated mass centered in the region of
the AP window with lobulated borders consistent with lymph node
metastases.
3. FDG avid liver lesion consistent with metastatic
disease activity.
4. FDG avid bony involvements of T2, T11, L1 vertebrae, right
scapula and left femoral neck consistent with metastatic
disease.
HIP UNILAT MIN 2 VIEWS LEFT [**2170-2-26**] 2:12 PM
No previous images. Two views show no convincing evidence of
lytic lesion in the region of the left hip. However, substantial
bone destruction is required before this can be identified on
plain radiographs.
[**2170-2-28**] 10:34AM COMPLETE BLOOD COUNT
White Blood Cells 5.3 K/uL
Red Blood Cells 3.79* m/uL
Hemoglobin 11.1* g/dL
Hematocrit 33.3* %
MCV 88 fL
MCH 29.4 pg
MCHC 33.4 %
RDW 13.5 %
[**2170-2-28**] 10:34AM RENAL & GLUCOSE
Glucose 102 mg/dL
Urea Nitrogen 35* mg/dL
Creatinine 0.7 mg/dL
Sodium 134 mEq/L
Potassium 4.0 mEq/L
Chloride 100 mEq/L
Bicarbonate 26 mEq/L
Anion Gap 12 mEq/L
Brief Hospital Course:
78 yof with a recent ankle fracture and a complicated course
including hyponatremia (SIADH) and polyaxonal neuropathy
concerning for paraneoplastic syndrome noted to have a chest
mass on CT with new dx of Small Cell Lung Cancer.
# Small Cell Lung Cancer, Metastatic - Given CT chest findings
there was initial concern for metastatic lung cancer. Pathology
of lung biopsy verified small cell. Given initial presentation
of weakness, it was presumed that neuro findings were likely
explained by paraneoplastic syndromes. Upon discharge her
paraneoplastic work-up was positive for Anti-[**Doctor Last Name **] and Anti-Ri was
still pending. After an initial evaluation by the medicine
service, she was transferred to Oncology for initiation of
chemotherapy and consideration of radiation. An MRI was then
obtained for staging which revealed a liver lesion suspicious
for metastatic spread. The images, however, were nondiagnostic.
PET Scan [**2-23**] confirmed metastatic lesions in her liver and
[**Last Name (un) 2043**] involvement at T2, T11, L1, R scapula & L femoral neck.
Findings were discussed with Ms. [**Known lastname **] and she decided to
proceed with chemotherapy. She was not a candidate for
radiation given metastatic presentation. Prior to discharge,
she completed 3 days of etoposdie/carbaplatin and tolerated it
well.
# Weakness - Neurology was actively involved in care during
hospitalization. Paraneoplastic syndrome was the presumed
etiology of her weakness given characteristic EMG findings.
Paraneoplastic work-up revealed positive Anti-[**Doctor Last Name **] antibodies.
Anti-Ri antibodies were pending on discharge. Have begun
treating Small Cell as above. Should continue PT/OT in rehab
and work on endurace and strength training.
# Urinary retention - Prior to this hospitalization, had been
treated with antibiotics for UTIs, however, most recent culture
from [**2-16**] without growth. Had foley removed twice during
inpatient stay but failed to urinate so foley was reinserted.
Likely due to urethral spasm following foley removal. Opted to
not remove again during stay while she was so weak given concern
for skin breakdown with incontinency. Upon discharge would
recommend voiding trial in the days directly following discharge
as the foley represents a potential source of infection.
# S/p ankle fracture. Transferred while in a cast. Per patient,
had planned for follow-up with her original orthopedist four
weeks post-fracture. While inpatient had been 6+ weeks.
Obtained initial x-ray which was nondiagnostic given cast. Cast
was subsequently removed for better imaging with replacement of
substitute cast. Per orthopedics, should continue with
touch-down weight bearing as tolerated. Should follow-up with
outpatient orthopedist in [**1-24**] weeks following discharge.
Patient should be assisted in establishing this appiontment upon
discharge. Should also continue PT/OT in rehabiliation
facility.
# History of loose stools - Early during hospital course.
Thought to be due to colchicine as no infectious etiology was
identified (C.diff negative). Continued on bowel regimen PRN.
Colchicine was then held, but restarted prior to discharge given
concern for gout flair. Patient did not have further loose
stools.
# Decubitus ulcers - Wound care consulted and provided
recommendations. Improved dramatically with KinAir bed. Will
continue this at rehabilitation facility.
# Hypertension- Continued lisinopril with holding parameters.
# Gout- Continued colchicine initially, but then briefly
discontinued given concern of loose stools. No evidence of
active flares but pt feels one 'coming on'. Restarted
colchicine suspected flair.
# Left Hip Pain - Known lesions in left femoral neck. Obtained
plain film to assess for structural stability. Negative for a
lytic lesion, but would have to have significant decortication
to see on plain film. Follow-up as indicated. Would recommend
continued pain medications prior to PT.
# Hyponatremia- Resolved with fluid restriction (likely from
SIADH). Continue on 1.2L fluid restriction.
# Thrush- Noted on transfer to Oncology. Patient states she was
previously treated.
Continued with good oral care and Nystatin QID PRN.
Medications on Admission:
Lisinopril 5 mg PO DAILY
Acetaminophen 500 mg PO Q6H
Multivitamins 1 CAP PO DAILY
Calcium Carbonate 500 mg PO BID
Pantoprazole 40 mg PO Q24H
CefePIME 2 gm IV Q24H
Senna 1 TAB PO BID:PRN
Colchicine 0.6 mg PO DAILY
Docusate Sodium 100 mg PO BID
Vancomycin 1000 mg IV Q 24H
Enoxaparin Sodium 40 mg SC QD
Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Hold for loose stools.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day): [**Month (only) 116**] discontinue when patient
becomes more ambulatory.
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP < 90 .
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Neb Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain: Hold for sedation or RR < 12 .
15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. [**Doctor First Name **]-Air Bed
For patient while continued weakness, may change to regular bed
once paraneoplastic syndrome improves
17. Outpatient Occupational Therapy
To evaluate and treat
18. Outpatient Physical Therapy
To evaluate and treat
19. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Small Cell Lung Cancer
Secondary: Left ankle fracture, gout, hypertension,
paraneoplastic syndrome
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted with weakness and recent ankle fracture.
Further evaluation revealed metastatic Small Cell Lung Cancer.
You were treated with chemotherapy. Neurology and orthopedics
were also involved in your care given your weakness and broken
ankle. You are now being discharged to a extended care facility
for further rehabilitation.
Followup Instructions:
You should call your original orthopedic physician and [**Name9 (PRE) 702**]
with them in [**1-24**] weeks following discharge from [**Hospital1 18**].
You need to have a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**],
Oncology, in the next 3-4 weeks following discharge. The
oncology office is aware of this and attempting to schedule this
appointment. Please have your rehabilitation support staff
call: ([**Telephone/Fax (1) 21188**] to confirm this appointment.
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,404
| 165,209
|
43695
|
Discharge summary
|
report
|
Admission Date: [**2181-9-3**] Discharge Date: [**2181-9-6**]
Date of Birth: [**2105-6-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Altered mental status, fevers
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Ms. [**Known lastname 93921**] is a 76 y.o. F with schizophrenia and tardive
dyskinesia, admitted with lethargy and fever.
.
The patient was recently admitted to [**Hospital1 18**] from [**8-16**] - [**2181-8-30**]
for altered mental status with inability to respond to questions
or follow commands as well as fevers to 102 at [**Doctor Last Name **] House.
During this hospitalization, patient developed fever to 104.
Treated for UTI. Continued to have fever through UTI treatment
and worked up with CT head, MRI head, MRI C-spine, CT torso with
contrast, LP x 2, multiple blood cultures without evidence of
infection. ID, neurology, psychiatry, and heme-onc were all
consulted. Medication fever and NMS considered but felt unlikley
given persistence of fever off medication and normal CK/no
rigidity. [**Last Name (un) 18183**] evaluation, including thyroid and adrenal axis,
were normal. Initially, covered with broad spectrum abx and then
3 days prior to discharge, abx stopped. PPD placed on [**8-29**], to
be read [**9-1**]. The patient was discharged on [**2181-8-30**] to [**Doctor Last Name **]
House.
.
In the ED, initial VS: T 98.0 (Tmax 102 R) HR 80 BP 130/78 RR 12
99%. Labs, including blood cultures, were sent. UA negative.
Given 2.5 L NS. CXR, CT head, EKG, and LP completed. Given
cefepime 2gm IV x 1 and vancomycin 1 gm IV x 1, ampicillin
ordered but not given. Per ED resident, pt was noted to become
bradycardic to 30s, but did not believe it as he was counting
pulse at same time and it was in 60s. Atropine at bedside.
.
Currently, pt does not respond to verbal stimuli.
Past Medical History:
Schizophrenia
Tardive Dyskinesia
Urinary incontinence
h/o dysarthria
Social History:
Worked in a bank lending credit. No smoking, no alcohol, never
married, no children.
Family History:
Aunt with uterine cancer.
Physical Exam:
Vitals - T: 97.2 BP: 120/90 HR: 64 RR: 23 02 sat: 94% 2 L NC
GENERAL: elderly F with L facial twitching
HEENT: anicteric, does not respond to verbal stimuli, unable to
examine OP, no cervical LAD
CARDIAC: RRR, nl S1, S2, II/VI SEM at LLSB
LUNG: CTAB, but poor inspiratory effort
ABDOMEN: NDNT, soft, NABS
EXT: no c/c/e
NEURO: obtunded, bilateral upper extremities pose in mid-air,
rigidity in upper extremities, doees not respond to verbal
stimuli
DERM: no rashes noted
Pertinent Results:
[**2181-9-3**] 09:27PM URINE HOURS-RANDOM UREA N-1276 CREAT-110
SODIUM-87 POTASSIUM-42 CHLORIDE-70
[**2181-9-3**] 09:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2181-9-3**] 09:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
[**2181-9-3**] 09:27PM URINE RBC-1 WBC-9* BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2181-9-3**] 09:27PM URINE HYALINE-1*
[**2181-9-3**] 09:27PM URINE MUCOUS-RARE
[**2181-9-3**] 09:27PM URINE EOS-POSITIVE
[**2181-9-3**] 06:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-67*
GLUCOSE-86
[**2181-9-3**] 06:00PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-3* POLYS-0
LYMPHS-93 MONOS-7
[**2181-9-3**] 06:00PM CEREBROSPINAL FLUID (CSF) WBC-10 RBC-38*
POLYS-1 LYMPHS-93 MONOS-6
[**2181-9-3**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2181-9-3**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2181-9-3**] 02:35PM POTASSIUM-4.1
[**2181-9-3**] 02:35PM GLUCOSE-135* UREA N-75* CREAT-1.7*
SODIUM-155* CHLORIDE-115* TOTAL CO2-29
[**2181-9-3**] 02:35PM ALT(SGPT)-80* AST(SGOT)-50* CK(CPK)-103 ALK
PHOS-72 TOT BILI-0.4
[**2181-9-3**] 02:35PM LIPASE-37
[**2181-9-3**] 02:35PM ALBUMIN-3.6 CALCIUM-10.7* PHOSPHATE-4.2
MAGNESIUM-3.1*
[**2181-9-3**] 02:35PM ALBUMIN-3.9 CALCIUM-10.6* PHOSPHATE-4.6*
MAGNESIUM-3.2*
[**2181-9-3**] 02:35PM PT-14.2* PTT-21.9* INR(PT)-1.2*
[**2181-9-3**] 02:21PM GLUCOSE-137* UREA N-75* CREAT-1.8*
SODIUM-156* POTASSIUM-4.2 CHLORIDE-116* TOTAL CO2-27 ANION
GAP-17
[**2181-9-3**] 02:21PM WBC-15.1* RBC-4.78 HGB-13.4 HCT-41.9 MCV-88
MCH-28.0 MCHC-32.0 RDW-14.0
[**2181-9-3**] 02:21PM NEUTS-77.2* LYMPHS-16.1* MONOS-4.7 EOS-1.1
BASOS-0.9
[**2181-9-3**] 02:21PM PLT COUNT-523*
[**2181-9-4**] 03:43AM BLOOD WBC-12.9* RBC-4.04* Hgb-11.4* Hct-35.8*
MCV-89 MCH-28.2 MCHC-31.9 RDW-13.8 Plt Ct-330
[**2181-9-5**] 05:50AM BLOOD WBC-12.3* RBC-4.22 Hgb-11.6* Hct-36.7
MCV-87 MCH-27.4 MCHC-31.5 RDW-13.6 Plt Ct-336
[**2181-9-6**] 06:25AM BLOOD WBC-11.6* RBC-4.09* Hgb-11.9* Hct-35.6*
MCV-87 MCH-29.0 MCHC-33.3 RDW-13.7 Plt Ct-288
[**2181-9-3**] 02:35PM BLOOD PT-14.2* PTT-21.9* INR(PT)-1.2*
[**2181-9-4**] 03:43AM BLOOD PT-13.9* PTT-23.8 INR(PT)-1.2*
[**2181-9-5**] 05:50AM BLOOD PT-12.1 PTT-25.7 INR(PT)-1.0
[**2181-9-5**] 05:50AM BLOOD Plt Ct-336
[**2181-9-4**] 03:43AM BLOOD Glucose-226* UreaN-57* Creat-1.0 Na-148*
K-3.0* Cl-113* HCO3-28 AnGap-10
[**2181-9-4**] 04:31PM BLOOD Glucose-114* UreaN-45* Creat-0.8 Na-147*
K-3.9 Cl-113* HCO3-27 AnGap-11
[**2181-9-4**] 05:04PM BLOOD Na-146*
[**2181-9-5**] 05:50AM BLOOD Glucose-167* UreaN-37* Creat-0.8 Na-142
K-3.5 Cl-108 HCO3-25 AnGap-13
[**2181-9-6**] 06:25AM BLOOD Glucose-128* UreaN-21* Creat-0.6 Na-140
K-3.8 Cl-103 HCO3-27 AnGap-14
[**2181-9-3**] 02:35PM BLOOD ALT-80* AST-50* CK(CPK)-103 AlkPhos-72
TotBili-0.4
[**2181-9-4**] 03:43AM BLOOD ALT-55* AST-27
[**2181-9-5**] 05:50AM BLOOD Calcium-9.4 Phos-1.9* Mg-2.2
[**2181-9-6**] 06:25AM BLOOD Calcium-9.2 Phos-2.3* Mg-2.1
CSF- HSV PCR- negative
MRSA SCREEN (Final [**2181-9-6**]): No MRSA isolated.
URINE CULTURE (Final [**2181-9-5**]): NO GROWTH.
CSF;SPINAL FLUID ([**2181-9-3**] 6:00 pm)
GRAM STAIN (Final [**2181-9-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
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 [**2181-9-6**]): NO GROWTH.
Chest X-ray ([**9-3**])- IMPRESSION: Low lung volumes, but no acute
cardiopulmonary abnormality
CT head IMPRESSION:
1. No acute intracranial abnormality.
2. Chronic small vessel ischemic change.
Brief Hospital Course:
MICU COURSE
The patient was readmitted with altered mental status. She was
found to be hypernatremic that was corrected with intravenous
infusions of D5W. She had an EEG that was pending at time of
call-out.
FLOOR COURSE
The patient was transferred to the floor on [**2181-9-3**] from the
MICU.
#. Fevers, lethargy, altered mental status- Her mental status
continued to improve with the correction of her electrolytes.
Her sodium on admission to the hospital was 155. Down to 148 on
transfer to floor. She did receive 2L of D5W in the MICU given
her hypernatremia and fluid deficit. Her mental status improved
daily- was able to answer questions with more than just a
yes/no. This is her baseline over the last few months. Her WBC
count trended down daily and was 11.5 on discharge (15.1 on
admission). The patient remained afebrile throughout her time
on the floor.
.
She did just have a full FUO work-up on previous admission from
[**Date range (1) 93924**]. All that was found was a UTI, for which she was
treated for appropriately. The MICU team performed an LP on
[**9-3**]- CSF studies did not show an acute process. Cytology
studies were added and are pending. Urine cultures were
negative and blood cultures have no growth to date. All drugs
that could possibly cause drug fever were held. EEG did not
show any seizure activity. CT head did not show any acute
intracranial abnormality only chronic small vessel ischemic
change. Mental status is back to baseline.
.
#. Fever- Patient remained afebrile throughout her stay on the
floor. Cultures have no growth to date. She has just undergone
extensive FUO work-up here last week with no clear etilogy
except for UTI. WBC trended down and there was no signs of
infection on labs or examination.
.
#. Acute renal failure- Admitted with Cr of 1.8. Patient was
found to have a fluid deficit and was given 2L D5W. Creatinine
trended down each day and was .8 on discharge. Patient had good
UOP throughout hospitalization.
.
#. Hypernatremia- Admitted with sodium of 155. Could have been
contributing factor to patient's AMS. She received 2L of D5W
(at 100mls/hr). Sodium was monitored regularly and trended down
throughout her stay. Upon discharge, sodium was within normal
limits at 140. Patient's mental status back to baseline.
.
#. Nutrition- Patient seen and evaluated by nutrition. NG tube
placed on [**9-3**] and patient started on tube feeds. She pulled
the tube on [**9-4**] AM. Speech and swallow was consulted for
evaluation given her improved mental status and cleared patient
was thin fluids with pureed solids (1:1 sitter) and crushed
pills with purees. She tolerated her diet well.
.
# Schizophrenia- Patient was not on any psychiatric medications
on admission so these were not given to her while she was here.
.
# PPX: Heparin 5000U TID, bowel regimen
.
# ACCESS: PIV
.
# CONTACT: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25237**] [**Telephone/Fax (1) 93925**] (attempted to contact, but
no answer)
Medications on Admission:
Colace 100 mg po BID
Heparin 5000 units SQ TID
Aspirin 81 mg po daily
Polyethylene glycol 17 gm po daily prn constipation
Senna 8.6 mg po BID
Chlorthalidone 25 mg po daily
Lisinopril 5 mg po daily
Tylenol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection three times a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
4. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
once a day as needed for constipation.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
6. Chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Lethargy, altered mental status- resolved, fevers
Secondary: Schizophrenia, tardive dyskinesia
Discharge Condition:
Good. Vital signs stable. Afebrile x 48 hrs
Discharge Instructions:
You were admitted for fever and lethargy. You had just been
admitted to [**Hospital1 18**] for similar symptoms from [**8-16**] to [**8-30**] and had
an extensive work-up for your fevers. They found that you had a
urinary tract infection and were treated appropriately. Once
you got back to the [**Hospital3 2558**], you continued to have fevers
and mental status changes, so you were readmitted to the
hospital. While here, we repeated some of the test you had just
had performed. In addition, we performed some newer tests-
those results are still pending. You remained afebrile while on
the floor and your mental status improved. Upon discharge you
were stable and back at your baseline.
No medication changes were made to your regimen. Please
continue your medications as your physician at the [**Name9 (PRE) 7137**] orders them to be taken.
Please be sure to follow-up with your providers as listed below.
You will be provided medical care while at [**Hospital3 2558**], as
well.
Please return to the emergency department or call your provider
for chest pain, shortness of breath, lightheadedness, or for any
other symptoms which are medically concerning to you.
Followup Instructions:
You will be provided medical care at the [**Hospital3 2558**]. Dr.
[**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) 4321**], or one of the physicians at the at [**Hospital3 2558**]
will see you. They will also arrange for you to be seen by a
psychiatrist.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2181-9-6**]
|
[
"295.90",
"584.9",
"787.21",
"276.0",
"333.82",
"332.0",
"780.60"
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icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.6"
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icd9pcs
|
[
[
[]
]
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10366, 10436
|
6502, 9526
|
342, 360
|
10587, 10634
|
2728, 6479
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11862, 12292
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9785, 10343
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10457, 10566
|
9552, 9762
|
10658, 11839
|
2237, 2709
|
273, 304
|
388, 1983
|
2005, 2076
|
2092, 2179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,596
| 104,252
|
37398
|
Discharge summary
|
report
|
Admission Date: [**2119-7-13**] Discharge Date: [**2119-7-18**]
Date of Birth: [**2053-11-10**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / ceftriaxone / tuberculin ppd skin test
Attending:[**First Name3 (LF) 16115**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 65 year old female with history of multiple
sclerosis, dementia, neurogenic bladder with indwelling foley,
right staghorn calculus, left obstructing UVJ stone with
nephrostomy tube presented from [**Hospital1 1501**] with worsening lethargy and
no output from nephrostomy tube for the two days prior to
admission. The patient was also reported to have been satting at
77% on NBR when EMS arrived. The patient has been admitted three
times in the past year with urosepsis.
In the ER, the patient was febrile to 102.8 and tachycardic. She
had a leukocytosis to 16.4. Her foley catheter was exchanged and
foul-smelling urine emerged. She had numerous excoriations
within and around her vagina and decubitus ulcers on her sacrum.
The nephrostomy tube was encrusted, and when cleaned, purulent
discharge emerged. She also had erythema and fluctuance with
expressible pus around the nephrostomy site. The patient was
given vancomycin, aztreonam, and flagyl. She was transferred to
the MICU with a systolic pressure of 85 on peripheral low-dose
levophed.
Past Medical History:
Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
- wheelchair at baseline, lives in nursing home
- has no use of her lower extremities, sometimes spastic
movements
- bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past
[**Last Name (un) 8304**] Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral Decub
LE spasticity
Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **]
Social History:
Lives in nursing home for last 4 [**First Name3 (LF) 1686**]. Husband is HCP, lives
with one of their daughters. [**Name (NI) **] daughter married and lives
in the area. Nonambulatory and in wheelchair at baseline,
dependent for transfers and some of ADLs. Has no use of lower
extremities at baseline. On pureed thickened liquids at rehab.
-Tobacco: started at age 20, quit about 15yrs ago
-ETOH: social, occasional, per husband
-[**Name (NI) 3264**]: none
Family History:
No family members with Multiple Sclerosis.
Physical Exam:
Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Physical Exam on Discharge
VS: RR16-18
Gen: Debilitated female in no acute distress
HEENT: EOMI with horizontal nystagmus, MMM
CV: RRR, no m/g/r
Resp: anterolateral exam limited, CTAB, no w/r/r
GU: Foley, nephrostomy in place, clear yellow urine
Neuro: unable to assess due to pt dementia/decompensation
MSK: unable to assess due to pt dementia/decompensation
Pertinent Results:
Abdominal XR ([**7-13**]): The left percutaneous nephrostomy tube is
in similar position
compared with prior imaging. If the patient continues to have
symptoms and clinical concern exists for malposition of tube, a
dedicated antegrade nephrostomy tube study would be recommended.
.
LABS ON ADMISSION
[**2119-7-13**] 09:35AM BLOOD WBC-16.4*# RBC-4.08* Hgb-11.5* Hct-37.5
MCV-92 MCH-28.2 MCHC-30.6* RDW-16.1* Plt Ct-533*#
[**2119-7-13**] 09:35AM BLOOD Neuts-87.6* Lymphs-7.8* Monos-4.2 Eos-0.2
Baso-0.2
[**2119-7-13**] 09:35AM BLOOD PT-31.0* PTT-43.6* INR(PT)-3.0*
[**2119-7-13**] 09:35AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-144
K-3.9 Cl-108 HCO3-25 AnGap-15
[**2119-7-13**] 09:35AM BLOOD cTropnT-<0.01
[**2119-7-13**] 09:35AM BLOOD CK-MB-2
[**2119-7-13**] 09:35AM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.4 Mg-2.1
[**2119-7-13**] 10:14AM BLOOD Lactate-2.3*
.
LABS ON DISCHARGE
lab draws were discontinued due to patient and husband's wishes
for comfort measures only.
Brief Hospital Course:
The patient is a 65 year old female with history of MS,
dementia, neurogenic bladder with indwelling foley, b/l calculi
s/p left nephrostomy presenting with fatige and found to have
urosepsis.
.
ACUTE ISSUES
#Urosepsis:
The patient has long history of urinary tract infections with
MDR organisms including ESBL e. coli and pseudomonas due to her
abnormal anatomy. She has been considered for lithotripsy of
left UVJ stone in past but thought to be high risk due to
cardiac co-morbidities. The patient also has a staghorn calculus
in the right kidney. She presented febrile to 102.8 and with
systolic pressure in the 80s. Patient was found to have
foul-smelling urine from foley and purulent material emanating
from nephrostomy tube in the ER. She was started on low-dose
peripheral levophed and transferred to the MICU. She was started
on meropenem for likely ESBL E. coli and vancomycin. A Dobhoff
tube was inserted and the patient was started on tube feeds. A
goals of care discussion was had with the patient's husband, and
it was decided that the patient would seek comfort measures only
(see below). The patient was transferred to the floor for
continued management despite low pressures. On the floor she
remained clinically stable without the need for pressure
support. Her antibiotics were discontinued upon discharge.
.
#Goals of care:
The goals of care were discussed with the patient and husband in
both the ICU and the general medicine floor. After a long
discussion, it was decided that the patient would be continued
on IV antibiotics and tube feeds while inpatient. On the floor,
the patient removed her Dobhoff tube, and it was decided with
the husband not to reinitiate it. The patient's husband wished
to keep patient comfort at the forefront, but wanted to continue
interventions until the patient either declined or discontinued
them herself. Palliative care was consulted and it was planned
that the patient would return to her longterm care facility for
hospice services. IV antibiotics were discontinued, as they
would require PICC placement, which would not have been
consistent with pt and husband's goals of care. She was
discharged without antibiotics.
.
[**Month/Day/Year **] ISSUES
#Multiple sclerosis:
Long history of MS (14 years), quite debilitated, now
experiencing dementia. The patient's home baclofen and
cyclobenzaprine were continued while inpatient.
.
#COPD:
The patient had a history of COPD with nknown baseline status.
It was reported that the patient uses home O2 at unknown rate.
She was continued on her ipratropium and fluticasone at home
doses and she was given O2 by nasal canula as needed.
.
#Depression:
Patient has [**Month/Day/Year **] depression and has been on SSRI at home.
This was continued while inpatient.
.
TRANSITIONAL ISSUES
- Hospice care to be initiated once patient at [**Location (un) 583**] [**Hospital1 1501**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Hospital1 1501**] documentation.
1. Sertraline 100 mg PO DAILY
2. Baclofen 10 mg PO BID
3. carBAMazepine *NF* 300 mg Oral [**Hospital1 **]
4. Cyclobenzaprine 10 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. methenamine hippurate *NF* 1 gram Oral [**Hospital1 **]
8. Simvastatin 20 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain
10. Bisacodyl 10 mg PR DAILY:PRN constipation
11. cranberry ext-C-L. sporogenes *NF* [**Medical Record Number 18595**] mg-mg-million
Oral daily
12. Docusate Sodium 100 mg PO BID
13. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Morphine Sulfate (Concentrated Oral Soln) 5-15 mg PO Q2H:PRN
pain
2. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO DAILY:PRN
agitation
3. Acetaminophen 1000 mg PO Q8H:PRN pain
4. carBAMazepine *NF* 300 mg Oral [**Hospital1 **]
5. cranberry ext-C-L. sporogenes *NF* [**Medical Record Number 18595**] mg-mg-million
Oral daily
6. methenamine hippurate *NF* 1 gram Oral [**Hospital1 **]
7. Sertraline 100 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Bisacodyl 10 mg PR DAILY:PRN constipation
10. Baclofen 10 mg PO BID
11. Cyclobenzaprine 10 mg PO BID
12. Docusate Sodium 100 mg PO BID
13. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
14. Ipratropium Bromide Neb 1 NEB IH Q6H
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House Rehab & Nursing Center
Discharge Diagnosis:
Primary diagnoses:
Urosepsis
L UVJ calculus causing obstruction s/p nephrostomy
Neurogenic bladder s/p indwelling foley catheter
Secondary diagnoses:
Multiple sclerosis
Advancing dementia
Discharge Condition:
Mental status: responds to questions, limited speech
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted with infections in your urinary tract that
causes your blood pressure to be low. You were given antibiotics
and feedings by tube while you were here. You, your husband, and
the medical team discussed your goals of care. It was decided
that we would make you as comfortable as possible before
discharging you back to [**Location (un) 583**] House.
You are being discharged to a nursing facility. Please follow-up
with the physician there or your PCP.
Completed by:[**2119-7-19**]
|
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icd9cm
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318, 325
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 154,098
|
22415
|
Discharge summary
|
report
|
Admission Date: [**2131-7-27**] Discharge Date: [**2131-8-3**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Prochlorperazine
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Back pain, hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Mrs. [**Known lastname **] is a 26 yo F with DMI
and multiple admissions for DKA who presents with back pain and
hyperglycemia. She has had chronic back pain since an MVA in
[**2124**] that intermittently comes and goes, and for which she
states she takes 'her mother's percocet' but is not prescribed
anything by her PCP. [**Name10 (NameIs) **] noticed worsening onset of her back
pain this morning ([**5-10**], non-radiating, no neurologic deficits,
no saddle anesthesia). She also noticed that her fingersticks
were higher than normal, as she was about 240s without eating,
and then progressed to 'critical high' on her glucometer (at
baseline, she states her FS range from 150s-280s after meals).
Also noticed some increased polyuria over the past 2 days. She
reports taking her insulin as directed, and reports her Lantus
was recently increased from 22->28->30 U QHS by a physician at
[**Name9 (PRE) 22652**] Corner Dr. [**First Name (STitle) 1255**], and her Aspart sliding scale has
remained the same. Has been seen by [**Last Name (un) **] in the past but did
not follow up since 2/[**2130**]. She denies missing any doses. No
localizing infectious symptoms such as fever, chills, chest
pain, SOB, abdominal pain, diarrhea, dysuria, or rash. She
endorses nausea and vomiting only upon admission to the ED, when
she vomited 3 times. Her back pain and her critically high FS
resulted in her presentation to the ED.
.
In the ED, initial vs were: 98.5 139 151/93 16 100% on RA. She
triggered for tachycardia in triage, which was accompanied by
nausea and vomiting. Patient was given Zofran 2 mg IV x2,
Dilaudid 0.5 mg IV x2 for her back pain and promethazine 25 mg
IV x1. Received 3 L of IVFs total, and was receiving NS with 20
mEQ of K on transfer. Labs notable for FS of 726, Cre of 1.3,
Chem-7 slightly hemolyzed with K of 6.2 (4.9 on repeat), Na 132,
initial AG of 21. U/A spilling glucose, +ketones, [**5-10**] RBCs. WBC
of 6.5. Insulin gtt (6 U bolus and 6 U/hr) was started. VS were
98.6 103 127/87 18 100% on RA with FS of 253 prior to transfer,
so insulin gtt was stopped prior to floor transfer.
.
On the floor, patient is walking and talking, but endorses back
pain and states she is hungry and wants to eat. Her nausea and
vomiting have improved. FS was 206. Patient appeared
disinterested in giving history about her diabetes and only
interested in pain medication for her back
Past Medical History:
-Diabetes Type I: diagnosed age 16 in [**2120**] after her first
pregnancy. Most recent Hgb A1C 10.9 % ([**8-9**])
- Previous admissions for nausea/vomiting with h/o esophagitis
and with concern for diabetic gastroparesis on metoclopramide
- Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**]
- Stage I diabetic nephropathy
- Anxiety/panic attacks
- Depression
- Hyperlipidemia
- S/P MVA [**5-4**] - lower back pain since then. Per patient,
received oxycodone from her primary provider.
[**Name Initial (NameIs) **] [**Name Initial (NameIs) 58252**]
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
- Genital Herpes
Social History:
She was born and raised in [**Location (un) 669**] but currently lives in her
own apartment near [**University/College 5130**] with her son, who is 8 years
old. Her son is currently staying with her aunt. She has family
nearby who help out. She is planning on going to school to be a
medical assistant. She denies tobacco, alcohol or illicit drug
use.
Family History:
Her grandmother had type II diabetes. No family history of
inflammatory bowel disease.
Physical Exam:
Upon admission:
General: AA female, no acute distress, affect flat and downward
gazing during most of history
[**University/College 4459**]: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +vertical incision well healed with overlying keloid;
soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: no TTP spinally or paraspinally. CNs [**1-12**] intact. [**4-4**]
strength in upper and lower extremities. 2+ reflexes in
patellar, achilles tendons. sensation grossly intact BL.
cerebellar fxn intact. gait WNL.
Upon discharge:
Vitals: T: 99.6 BP: 156/102 P: 126 R: 20 O2: comfortable on RA
General: Alert, oriented, no acute distress
[**Month/Day (1) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, 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: CNs2-12 intact, motor function grossly normal
Pertinent Results:
[**2131-7-27**] 08:00PM URINE HOURS-RANDOM
[**2131-7-27**] 08:00PM URINE UCG-NEGATIVE
[**2131-7-27**] 08:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2131-7-27**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2131-7-27**] 08:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2131-7-27**] 08:00PM URINE RBC-[**5-10**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2131-7-27**] 07:34PM GLUCOSE-GREATER TH K+-4.9
[**2131-7-27**] 07:30PM GLUCOSE-753* UREA N-19 CREAT-1.3* SODIUM-132*
POTASSIUM-6.2* CHLORIDE-91* TOTAL CO2-21* ANION GAP-26*
[**2131-7-27**] 07:30PM HCG-<5
[**2131-7-27**] 07:30PM WBC-6.6# RBC-4.24 HGB-12.3 HCT-38.1 MCV-90
MCH-29.0 MCHC-32.2 RDW-14.3
[**2131-7-27**] 07:30PM NEUTS-67.8 LYMPHS-27.9 MONOS-3.2 EOS-0.5
BASOS-0.5
[**2131-7-27**] 07:30PM PLT COUNT-223#
[**7-28**]
FINDINGS: PA and lateral views of the chest demonstrate no focal
consolidation, effusion, or pneumothorax. There is no evidence
of congestive
heart failure. Cardiomediastinal silhouette is normal. Bony
structures are
intact. There is no free air below the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
[**2131-7-28**] 01:03AM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-49* pH-7.37
calTCO2-29 Base XS-1
[**2131-7-30**] 06:09AM BLOOD TSH-0.48
[**2131-7-31**] 09:52AM BLOOD ALT-15 AST-17 LD(LDH)-200 AlkPhos-69
Amylase-130* TotBili-0.9
[**2131-7-31**] 09:52AM BLOOD Lipase-17
[**2131-8-1**] 03:43AM BLOOD Glucose-262* UreaN-2* Creat-0.7 Na-136
K-3.4 Cl-103 HCO3-23 AnGap-13
[**2131-8-3**] 06:00AM BLOOD WBC-5.8 RBC-3.88* Hgb-11.1* Hct-34.3*
MCV-88 MCH-28.7 MCHC-32.5 RDW-14.8 Plt Ct-204
[**2131-8-3**] 06:00AM BLOOD UreaN-5* Creat-0.8 Na-137 K-3.9 Cl-104
HCO3-23 AnGap-14
[**2131-8-3**] 06:00AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.6
[**2131-7-30**] 06:09AM BLOOD TSH-0.48
[**2131-8-3**] 06:00AM BLOOD Free T4-PND
Brief Hospital Course:
26 yo female with history of Type 1 DM, chronic back pain
admitted with hyperglycemia likely a repeat episode of DKA.
Multiple admissions for DKA (at least 8 in [**2129**] and 2 since
[**2130**]). Inciting etiologies are unclear as patient states she is
taking her insulin at home and recently had her dose uptitrated
by her PCP, [**Name10 (NameIs) **] medication non-compliance is likely the
main issue (not taking many of the medications she was
discharged on back in [**5-/2131**], lost to f/u with [**Last Name (un) **] since
2/[**2130**]). The patient states that any acute increase in her back
pain triggers DKA. No chest pain or EKG changes to indicate
evidence of MI. She was found to have a UA positive for UTI with
no symptoms, and she was treated with Ciprofloxacin. She was
seen by [**Last Name (un) **] during her stay. They recommended an increased
dose of Lantus at 35 units daily.
Throughout her stay, she had persistent tachycardia and
hypertension during the day that normalized overnight. Etiology
unclear, but may be related to chronic back pain and persistent
anxiety/agitation. Moreover, she has had tachycardia similar to
this during her previous admission. Back pain was unchanged on
exam and related to MVA 6 years prior. No neurological deficit
or signs of infection. Tachycardia responded somewhat to fluid
boluses, anxioltics, and analgesics. She was seen by psychiatry.
Zoloft was restarted when she began tolerating PO intake. A TSH
was normal at 0.48.
Additionally, her course was complicated by nausea and vomiting
of unclear etiology. She was treated with zofran and reglan
prior to meals, which greatly decreased her nausea, vomiting,
and bloating. She reports history of diabetic gastroparesis but
had a normal gastric emptying study in [**11-8**]. She was eating a
normal diet without issue on the final two days of her
admission.
Medications on Admission:
Lantus 30
Novolog 1:14 [**Doctor Last Name **] for every 40 over 140 FSBS
Zoloft 100
Lorazepam
ASA 81
Protonix 40
Reglan occaisionally
MVI
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO q8h prn as
needed for anxiety.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
6. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
7. Novolog 100 unit/mL Solution Sig: 1:14 units Subcutaneous
qidachs: 1:14 [**Doctor Last Name **] coverage for every 40 units >140 finger stick.
8. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO qidachs:
Please stop this medication immediately if you notice any signs
of lip smacking, facial abnormalities or facial muscle spasms.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
because of Diabetic Ketoacidosis. You were treated with insulin
aggressively until your sugars and your blood chemistries
returned to [**Location 213**] values. We gave a lot of IV fluids to
rehydrate you as you were severely dehydrated. We restarted
your home insulin regimen, and made sure to pretreat you with
zofran (antinausea) and reglan (for gut motility) before your
meals. You were discharged once you were back on your home
insulin and able to take meals by mouth.
There were no changes made to your medications. The following
medications that you take were on your last discharge summary
however were not continued after this discharge because you
stated that you were no longer taking them:
-zofran
-exetimibe
-trazadone
-thiamine
-aspirin
Please discuss with your primary care physician if you should
continue these medications.
Followup Instructions:
You are scheduled for a follow up appointment with your NP at
[**Last Name (un) **] on [**2131-8-8**] at 8:30AM. If you need to change
this appointment, please call ([**Telephone/Fax (1) 2384**] to reschedule.
Also, you have an appointment with your PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **], [**First Name3 (LF) **]
Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 58270**]
Phone: [**Telephone/Fax (1) 58261**]
Appointment: Tuesday, [**8-21**], 7:45PM
|
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"338.29",
"599.0",
"240.9",
"427.89",
"300.01",
"583.81",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10374, 10380
|
7422, 9298
|
311, 317
|
10446, 10446
|
5425, 7399
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3894, 3983
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9487, 10351
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10401, 10425
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9324, 9464
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10597, 11491
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3998, 4000
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247, 273
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4825, 5406
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374, 2772
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4014, 4809
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10461, 10573
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2794, 3505
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3521, 3878
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,715
| 189,090
|
4253+55559
|
Discharge summary
|
report+addendum
|
Admission Date: [**2115-11-18**] Discharge Date: [**2115-11-29**]
Date of Birth: [**2066-6-12**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 15373**]
Chief Complaint:
Witnessed seizures.
Major Surgical or Invasive Procedure:
Femoral line placement.
History of Present Illness:
This is a 49year old man with a past medical history
significant for epilepsy and heavy alcohol abuse who presented
with at least 3 seizures. Apparently, earlier in the day, he was
"found down" outside with frostbite, and covered with urine and
feces on hands and feet. He was taken to [**Hospital1 2025**], where he was also
noted to be intoxicated. He stayed there to "sober up," was
given
500mg po of dilantin and prescription for 100mg tid - and then
sent out to a shelter - the [**First Name9 (NamePattern2) 18479**] [**Doctor Last Name **] House. While at the
shelter, he was sitting on a chair, and then noted to have a GTC
seizure and fell off the chair and hit his head. EMS brought him
to the ED - there are no other details regarding Mr.[**Known lastname **]
whatsoever except OMR note per psychiatry service back in [**2108**]
when he was admitted here for alcohol and klonopin overdose. On
arrival in ED, he had 2 witnessed 30 sec. GTC seizures per the
ED
physicians and was given 2mg of ativan x1. He was then intubated
for airway protection as well, and after intubation meds, was
given versed for "biting on tube/agitation."
Past Medical History:
1. h/o epilepsy x 9 years, maybe secondary to #2 below, but also
multiple alcohol withdrawl seizures.
2. h/o hallucinations, "little people" and "crawling feelins"
during alcohol withdrawl
3. h/o "brain tumor removal" at [**Hospital1 2025**] 9 years ago
4. h/o EtOH and drug abuse
5. h/o suicide attempt - patient denies
6. h/o "coma in [**2106**]" after tumor removal
Social History:
Homeless, Native American. +h/o heavy alcohol
use, uses gallan vodka a day. "smokes like a chimney" Past
marajuana and cocaine (but as of [**2108**], had quit). Never married,
no kids, not working.
Family History:
Father was [**Name2 (NI) 18480**], mom died of "brain tumor" 3 yrs ago.
Physical Exam:
General Exam:
Vitals: afebrile BP:wnl P:70-80s R: 14
Gen: dissheveled
Head: bruises on face, non-icteric, MMM
Neck: supple, no LAD, no carotid bruits
Ext: no edema nor rashes
Neurological Exam:
Mental Status:
Awake, alert, cooperative and attentive. Memory impaired to
recent but not distant past. Speech is fluent without
paraphasic
errors. Anomia to high/mod frequency items. There is no
neglect. Positive globellar, slight snout, no grasp.
Cranial Nerves:
II. visual fields intact to confrontation.
pupils normal, round and reactive to light, no rAPD
III, IV, VI. Extraocular movements intact and without nystagmus,
normal VOR, pursuit is smooth
V, VII. Normal facial sensation. No facial droop. Strength full
and symmetric.
VIII. Hearing intact to finger rub bilaterally
IX, X, XII. Normal oropharyngeal movemement. Tongue midline
without fasciculations. Sternocleidomastoid and trapezius normal
bilaterally
Motor:
Normal bulk and tone.
No tremor
No pronator drift or slowing of RAMs.
Full strength throughout the upper and lower extremities.
Sensory:
Decreased to pp and proprioception in a stocking distribution.
Reflexes:
Tri [**Hospital1 **] Br Pat Ach Toes
L 1 2 2 2 +/- down
R 1 2 2 2 +/- down
Coordination: Without dysmetria, intact to FNF and HTS.
Performed hand mirroring task well with little overshoot.
Gait: Narrow, normal based. Initiation normal with normal
stride. slightly impaired tandem gait tandem gait. Romberg sign
absent.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2115-11-20**] 11:00AM 6.6 3.60* 11.5* 32.9* 92 32.1* 35.0 13.8
102*
BASIC COAGULATION PT PTT Plt Ct INR(PT)
[**2115-11-20**] 11:00AM 102*
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2115-11-17**] 10:42PM 257
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2115-11-20**] 06:15AM 80 6 0.7 140 4.4 105 24 15
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2115-11-19**] 03:15AM 13 30 55 70 0.7
CPK ISOENZYMES CK-MB cTropnT
[**2115-11-18**] 07:33PM 2 <0.011
1 <0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2115-11-21**] 05:40AM 4.0 41*1
Moderately Hemolyzed
1 HEMOLYSIS FALSELY ELEVATES IRON
HEMATOLOGIC calTIBC VitB12 Folate Ferritn TRF
[**2115-11-21**] 05:40AM 294 676 GREATER TH1 103 226
Moderately Hemolyzed
1 GREATER THAN 20.0
PITUITARY TSH
[**2115-11-18**] 04:13AM 0.971
1 NEW METHOD AS OF [**2114-3-26**]
NEUROPSYCHIATRIC Phenyto
[**2115-11-21**] 05:40AM 15.1
Moderately Hemolyzed
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
[**2115-11-18**] 09:09PM NEG1 NEG2 NEG NEG NEG NEG
1 NEG
NEW UNITS IN USE AS OF [**2108-2-6**]
2 NEG
NEW UNITS IN USE AS OF [**2108-2-6**]: 80 (THESE UNITS) = 0.08 (% BY
WEIGHT)
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP O2 O2 Flow pO2 pCO2 pH
calHCO3 Base XS Intubat
[**2115-11-18**] 05:45AM ART 38.3 14/ 600 5 40 112* 51* 7.44 36*
8 ASSIST/CON1 INTUBATED
1 ASSIST/CONTROL
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2115-11-18**] 05:45AM 1.3
CALCIUM freeCa
[**2115-11-18**] 05:45AM 1.04*
Brief Hospital Course:
The patient was initially admitted to the Neurology Intensive
Care Unit for seizure work up. The patient was started on a CIWA
protocol, monitored for signs and symptoms of alcohol
withdrawal/DTs, started on MVI, thiamine, folate, B12, loaded on
Dilantin and then continued on maintanence Dilantin 100mg po
tid. Once the patient's mental status improved, he was extubated
without complications.
A CT of the head showed: There is no acute intracranial
hemorrhage, mass effect, or shift of the normally midline
structures. There is a large area of malacic change involving
the left temporal [**Doctor Last Name 534**] and also the left frontal region.
[**Doctor Last Name **]/white matter differentiation is otherwise grossly
preserved. The ventricles and sulci appear normal in size and
configuration. The structures are notable for a left
frontotemporal craniotomy defect. There is no evidence of acute
fracture. There is mucosal thickening of the ethmoid air cells
as well as a small amount of fluid in the left sphenoid sinus.
A CT of the Cervical Spine showed no vertebral fracture:There is
no evidence of acute fracture or malalignment. Vertebral body
heights are preserved. There are multilevel degenerative
changes, with bridging osteophytes at C2/3 and C4/5. The spinal
canal appears patent.
There is evidence of diffuse idiopathic skeletal hyperostosis
A Chest XR showed: No acute cardiopulmonary disease. No evidence
of traumatic injury to the chest.
An initial CBC revealed low hemoglobin and hematocrit, likely
the result of chronic liver disease and malnutrition. The
patient also had a low platelet count consistent with chronic
alchol dependence.
While in the ICU, the patient's pulse and blood pressure
remained stable and he had no further seizures. The patient did
spike a temperature and blood cultures, UA/UCx, and Sputum were
sent. The patient's UA was not suspicious for infection. UCx
grew out pansensitive enterococcus and Sputum cultures grew out
gram positive cocci coag +. However, for the remainder of the
hospitalization, the patient remained afebrile and had no
dysuria, cough or other signs of infection. Given the risk of
lowering seizure threshold with antibiotics and the lack of
clinical evidence of infection, the patient was not started on
antibiotics. Blood cultures remained negative throughout the
hospital course.
After 2 days in the ICU, the patient was transferred to the [**Hospital Ward Name 121**]
5 General Neurology [**Hospital1 **] in stable condition. On the unit, the
patient was written for a taper of Librium for alcohol
withdrawal. He was given one day of Librium 50mg po qid,
followed by one day of Librium 25mg po qid. The patient showed
no signs of tremor, elevated pulse or blood pressure or
hallucinations. He had no new seizures. The patient's femoral
line was removed without any complications.
The patient was continued on MVI, Folate, and Thiamine. The
patient's Dilatin level was checked and found to be in the
therapeutic range (15.1). A discussion was had with the patient
in which the importance of continuing to take Dilantin and to
stop drinking alcohol for prevention of future seizures was
explained. The patient stated that he understood this risk. He
reported that he was not interested in getting involved in
Alcholics Anonymous at this time because he wanted to handle his
alcohol recovery on his own. The patient, however, did state
that he has a goal of attaining one year of sobriety and wished
to return to the [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 11009**] Home.
Medications on Admission:
Folic Acid, Dilantin
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 tablets* Refills:*0*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] Health Care Center
Discharge Diagnosis:
Primary Diagnosis: Generalized Clonic-Tonic Seizure
Secondary Diagnoses: Alcohol Dependence, Seizure disorder, s/p
cranietomy for brain tumor resection, anemia
Discharge Condition:
Good.
Discharge Instructions:
Go to an emergency room if you experience an new seizures
(abnormal movements), have sudden onset of weakness, numbness,
tingling sensations, sudden changes in vision or speech.
Followup Instructions:
The patient was instructed to call Dr.[**Name (NI) 11858**] office at
[**Telephone/Fax (1) 541**] to schedule an appointment to follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**] in the General [**Hospital 878**] Clinic.
Name: [**Known lastname **],[**Known firstname 33**] Unit No: [**Numeric Identifier 2986**]
Admission Date: [**2115-11-18**] Discharge Date: [**2115-11-29**]
Date of Birth: [**2066-6-12**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2987**]
Chief Complaint:
Generalized Tonic-Clonic Seizure.
Major Surgical or Invasive Procedure:
Femoral line placement.
History of Present Illness:
This is a 49year old man with a past medical history
significant for epilepsy and heavy alcohol abuse who presented
with at least 3 seizures. Apparently, earlier in the day, he was
"found down" outside with frostbite, and covered with urine and
feces on hands and feet. He was taken to [**Hospital1 2239**], where he was also
noted to be intoxicated. He stayed there to "sober up," was
given
500mg po of dilantin and prescription for 100mg tid - and then
sent out to a shelter - the [**First Name9 (NamePattern2) 2988**] [**Doctor Last Name **] House. While at the
shelter, he was sitting on a chair, and then noted to have a GTC
seizure and fell off the chair and hit his head. EMS brought him
to the ED - there are no other details regarding Mr.[**Known lastname **]
whatsoever except OMR note per psychiatry service back in [**2108**]
when he was admitted here for alcohol and klonopin overdose. On
arrival in ED, he had 2 witnessed 30 sec. GTC seizures per the
ED
physicians and was given 2mg of ativan x1. He was then intubated
for airway protection as well, and after intubation meds, was
given versed for "biting on tube/agitation."
While in ICU, was on CIWA scale but did not require any benzos.
BP, HR stable but was febrile to 101.4. Continued on dilantin.
Past Medical History:
1. h/o epilepsy x 9 years, maybe secondary to #2 below, but also
multiple alcohol withdrawl seizures.
2. h/o hallucinations, "little people" and "crawling feelins"
during alcohol withdrawl
3. h/o "brain tumor removal" at [**Hospital1 2239**] 9 years ago
4. h/o EtOH and drug abuse
5. h/o suicide attempt - patient denies
6. h/o "coma in [**2106**]" after tumor removal
Social History:
Homeless, Native American. +h/o heavy alcohol
use, uses gallan vodka a day. "smokes like a chimney" Past
marajuana and cocaine (but as of [**2108**], had quit). Never married,
no kids, not working.
Family History:
Father was [**Name2 (NI) 2989**], mom died of "brain tumor" 3 yrs ago.
Physical Exam:
Vitals: Tm afebrile (spiked to 101.4 on admission [**11-18**]),
140-146/76-80 (stable), HR 82-93, 18, 98% RA
Gen: disheveled, poor hygiene, poor dentition
HEENT: bruise on left forehead, left forehead post surgical
indentation, no LAD or thyroid nodules
Chest: CTA bilat
CV: RRR without mur
Abd: soft, NT
Extrem: erythematous and slightly edematous hands, feet
bilaterally, several abrasions on feet but no exudates, well
perfused
Mental status: awake, alert, conversant, oriented to
person/place/time although initially gave wrong answers "[**2015**] I
mean, [**2115**]", "age 29 no, 49". Good attention, names days of
week
backwards. No right/left mismatch. Speech is fluent with good
comprehension, repitition, naming. Unable to read secondary to
poor vision per patient. No neglect. Registration [**3-6**], recall
[**1-5**].
Cranial Nerves:
I: deferred
II: Visual acuity: 20/200 OU. Visual fields: full to
left/right/upper/lower fields. Fundoscopic exam: unable to
visualize. Pupils: 3->1 mm, consenual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus or ptosis.
V: facial sensation intact over V1/2/3 to light touch.
VII: symmetric smile
VIII; hearing intact to finger rubs
IX, X: Symmetric elevation of palate.
[**Doctor First Name 2237**]: SCM and trapezius [**5-8**] bilaterally
XII: tongue midline without atrophy or fasciulations.
Sensory: Normal sensation to light touch, pinprick, position
sense.
Motor: Normal bulk, tone. No fasciculations or drift. No
adventitious movements.. Strength:
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF Toe
Reflexes: Bic BR Tri Pat Ach Toes
RT: 2 2 2 1 1 down
LEFT: 2 2 2 1 1 down
Coordination: Very minimal dysmetria on finger-to-nose.
Gait: Did well on tandem walking.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2115-11-24**] 05:20PM 4.1 3.89* 12.1* 34.9* 90 31.3 34.8 13.8
325#
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2115-11-24**] 05:20PM 22* 4 18 19* 2 0 35* 0 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2115-11-24**] 05:20PM NORMAL1 NORMAL NORMAL NORMAL NORMAL
NORMAL
1 NORMAL
MANUALLY COUNTED
BASIC COAGULATION PT PTT Plt Smr Plt Ct INR(PT)
[**2115-11-24**] 05:20PM 325#
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2115-11-17**] 10:42PM 257
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2115-11-20**] 06:15AM 80 6 0.7 140 4.4 105 24 15
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2115-11-19**] 03:15AM 13 30 55 70 0.7
CPK ISOENZYMES CK-MB cTropnT
[**2115-11-18**] 07:33PM 2 <0.011
1 <0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2115-11-21**] 05:40AM 4.0 41*1
Moderately Hemolyzed
1 HEMOLYSIS FALSELY ELEVATES IRON
HEMATOLOGIC calTIBC VitB12 Folate Ferritn TRF
[**2115-11-21**] 05:40AM 294 676 GREATER TH1 103 226
Moderately Hemolyzed
1 GREATER THAN 20.0
PITUITARY TSH
[**2115-11-18**] 04:13AM 0.971
1 NEW METHOD AS OF [**2114-3-26**]
NEUROPSYCHIATRIC Phenyto
[**2115-11-26**] 05:05AM 11.4
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
[**2115-11-18**] 09:09PM NEG1 NEG2 NEG NEG NEG NEG
1 NEG
NEW UNITS IN USE AS OF [**2108-2-6**]
2 NEG
NEW UNITS IN USE AS OF [**2108-2-6**]: 80 (THESE UNITS) = 0.08 (% BY
WEIGHT)
LAB USE ONLY Prblm RedHold
[**2115-11-22**] 11:10AM PND
NO PURPLE RECEIVED. CAD NOT DONE
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP O2 O2 Flow pO2 pCO2 pH
calHCO3 Base XS Intubat
[**2115-11-18**] 05:45AM ART 38.3 14/ 600 5 40 112* 51* 7.44 36*
8 ASSIST/CON1 INTUBATED
1 ASSIST/CONTROL
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2115-11-18**] 05:45AM 1.3
CALCIUM freeCa
[**2115-11-18**] 05:45AM 1.04*
Brief Hospital Course:
This is an addendum to this [**Hospital 1325**] hospital course.
The patient was planned for discharge to the [**First Name9 (NamePattern2) 2990**] [**Doctor Last Name 2991**]
House on Friday [**2115-11-22**]. However, the previous evening, the
patient had a temperature spike. Blood cultures were taken,
which ultimately grew out MRSA Staph aureus. The same microb was
isolated from the pus collected the wound at the site of the
extraction of the patients femoral line, as well as from the tip
of the patient's femoral line catheter.
The patient was stated on IV Vancomycin and oral Levofloxacin
for treatment of his bacteremia. The patient had a PICC line
placed because the IV therapy was unable to place a new IV after
multiple attempts. The patient was planned to continue a 2 week
course of IV Vancomycin and then to do a surveillance blood
culture to make sure the patient's bacteremia had cleared.
The patient had a TTE prior to discharge to r/o bacterial
endocarditis, given his cultures positive for MRSA.
Clinically, the patient remained afebrile for the remainder of
his hospital course. He was started on Zonagram with the plan to
ultimately taper off his Dilantin and increase his Zonagram as
the sole anti-epileptic drug for his seizure disorder.
The patient had no neurological changes or seizures during the
remainder of his hospital course. He manifested no signs of
alcohol withdrawl and completed a Librium taper. He was not
given any further bezodiazepines once completing his Librium
taper.
The patient was then D/C'd to the [**Hospital3 2992**] Skilled Nursing
Facility in [**Location (un) 2993**], MA for completion of his antibiotic
course.
Medications on Admission:
The patient had a prescription for dilantin from [**Hospital1 2239**].
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 tablets* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Dilantin 100 mg Capsule Sig: Three (3) Capsule PO once a day:
Brand name only.
5. Dilantin 30 mg Capsule Sig: One (1) Capsule PO once a day:
Brnad name only.
6. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous
every twelve (12) hours for 2 weeks: Patient started Vancomycin
IV on [**2115-11-26**] and is to complete a 2 week course.
9. Trazodone HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Health Care Center
Discharge Diagnosis:
Primary Diagnosis: Generalized Clonic-Tonic Seizure
Secondary Diagnoses: Alcohol Dependence, Seizure disorder, s/p
cranietomy for brain tumor resection, anemia, bacteremia
Discharge Condition:
Good.
Discharge Instructions:
Go to an emergency room if you experience an new seizures
(abnormal movements), have sudden onset of weakness, numbness,
tingling sensations, sudden changes in vision or speech.
Followup Instructions:
Call Dr.[**Name (NI) 2994**] office at [**Telephone/Fax (1) 2995**] to schedule an
appointment to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the General
[**Hospital 2996**] Clinic at [**Hospital1 **] after you are
discharged.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2997**] MD [**MD Number(1) 2998**]
Completed by:[**2115-11-27**]
|
[
"291.81",
"599.0",
"790.7",
"303.01",
"920",
"263.9",
"345.10",
"041.11",
"E884.2",
"V09.0",
"V60.0",
"305.1",
"996.62",
"571.3",
"281.9",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
19736, 19798
|
17024, 18698
|
10954, 10980
|
20014, 20021
|
14837, 17001
|
20247, 20677
|
12904, 12976
|
18820, 19713
|
19819, 19819
|
18724, 18797
|
20045, 20224
|
12991, 13427
|
19892, 19993
|
2453, 2453
|
10881, 10916
|
11008, 12279
|
13848, 14818
|
19838, 19871
|
13442, 13832
|
12301, 12671
|
12687, 12888
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,609
| 107,158
|
48465
|
Discharge summary
|
report
|
Admission Date: [**2183-1-8**] Discharge Date: [**2183-1-10**]
Date of Birth: [**2125-1-18**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 58 year old female
with a history of coronary artery disease and multiple stents
complicated by thrombosis and restenosis who last underwent
cardiac catheterization at [**Hospital6 2910**] in
[**2182-4-30**] at [**Hospital6 **] for right coronary artery
restenosis. The area was dilated, complicated by dissection,
treated with Cypher drug-eluding [**Hospital6 **] and metal [**Hospital6 **]. In
[**2182-5-30**] the patient had recurrent angina, now occurring on
a daily basis, worse with exertion. There was pain lying
flat, so using four pillows at home. Presenting MIBI with
fixed anteroseptal defect and reversible inferior and
inferoseptal defect, now admitted to CMI for catheterization.
At catheterization right coronary artery arthrectomy placed
complicated by right coronary artery perforation, treated
with [**Year (4 digits) **]. Echocardiogram without pericardial effusion. No
symptoms now, also a large right inguinal hematoma.
ALLERGIES: Sulfa, Plavix, Codeine.
CURRENT MEDICATIONS AT HOME: Aspirin 81, Monopril 40 q.h.s.,
Metformin 1000 b.i.d., Pravachol 40 q.h.s., Verapamil 240
q.h.s., Lexapro 20 q.h.s., NPH 30, q. AM, 30 q.h.s., Humalog
10 q. dinner, Ambien 10 q.h.s., Ticlid 250 b.i.d., Zantac 150
b.i.d., Lasix 20 q. AM, Nitroglycerin prn.
PAST MEDICAL HISTORY: 1. Diabetes; 2.
Hypercholesterolemia; 3. Hypertension; 4. Coronary artery
disease, right coronary artery [**Year (4 digits) **] in [**2179**], [**2179-12-1**]
[**Last Name (un) **]/stenting right coronary artery, [**2181-5-16**], 80%
right coronary artery and [**Year (4 digits) **] restenosis, status post [**Year (4 digits) **]
complicated by thrombosis treated with a [**Last Name (LF) **], [**2182-4-30**]
positive angina, positive ETT MIBI, in-[**Year (4 digits) **] restenosis, to
[**Hospital6 **], stenosis dilated, Cypher [**Hospital6 **] and metal
[**Hospital6 **] placed; 5. Obesity; 6. Status post bladder suspension
surgery; 7. Left frozen shoulder; 8. Depression; 9. Hiatal
hernia; 10. Gastritis; 11. Tonsillectomy; 12. Bilateral
carpal tunnel release; 13. Arthroscopic left knee surgery.
SOCIAL HISTORY: Married, quit smoking tobacco ten years ago.
FAMILY HISTORY: Father died at 71 with coronary artery
disease. Grandfather died at 52 with a history of coronary
artery disease. Uncle with coronary artery bypass graft in
his 50s.
PHYSICAL EXAMINATION: Vital signs, temperature 97.7, heart
rate 98, respirations 13, 94% on room air saturations, blood
pressure 141/71. General: Obese and pleasant female, in no
acute distress. Head, eyes, ears, nose and throat:
Extraocular movements intact, pupils equal, round and
reactive to light and accommodation. Mucous membranes, moist
and pink. Neck: No jugulovenous distension appreciated.
Pulmonary: Clear to auscultation bilaterally. Abdomen:
Large, round, soft, nontender, nondistended. Bowel sounds
present. Cardiovascular: Regular rate and rhythm, no
murmurs, rubs or gallops appreciated. Extremities: Left
hand with petechiae, lower extremities with no cyanosis,
clubbing or edema.
LABORATORY DATA: Diagnostic studies reveal electrocardiogram
interpretation, sinus rhythm with left bundle branch block.
Echocardiogram: [**2183-1-8**], preliminary
echocardiogram showed no minimal pericardial effusion, no
evidence of tamponade. Repeat echocardiogram, [**2183-1-10**], no occlusions, limited study, no carotid doppler study
performed. The left atrium is normal in size. Left
ventricular wall thickness was normal. Left ventricular size
cavity size is normal. Overall left ventricular systolic
function is moderately depressed. Overall left ventricular
systolic function is moderately depressed. Resting regional
wall motion abnormalities include septal, anterior akinesis.
Though, the views are limited, it appeared that the inferior
wall was akinetic. There was a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs or tamponade. Compared to the
previous report of [**2183-1-9**], effusion has not
changed. The ejection fraction appears worse than previously
reported. Previous study is not available for review.
Ejection fraction of 35% to 40%. Cardiac catheterization
[**2183-1-8**]: 1. Left ventriculography revealed an
ejection fraction of 46% with mild global hypokinesis. There
was no mitral regurgitation. 2. Selective coronary
angiography revealed a right dominant system. The left main
coronary artery, left anterior descending and left circumflex
were angiographically normal. The right coronary artery had
a 70% stenosis. The neostented gap was seen on the
previously placed proximal image stents. There was 90%
restenosis placed on the initially placed mid [**Year (4 digits) **]. There
was a 60% restenosis on the distal Cypher [**Year (4 digits) **]. There was
minimal disease of the posterior descending artery,
percutaneous transluminal coronary angioplasty site. 3. At
the end of the procedure right heart catheterization was
performed to rule out tamponade. The right-sided filling
pressures were normal. The preliminary capillary wedge
pressure was 12 mm of mercury. The left ventricular end
diastolic pressure was elevated about 30 mm of mercury.
Cardiac index depressed at 2.2 liters/min meter squared. 4.
Successfully stenting of right coronary artery was performed
with 3 by 5 by 33 mm Cypher drug-eluding [**Year (4 digits) **], complicated
initially by vertebra entrapment, perforation and dissection
of the artery. Final diagnosis: 1. One vessel coronary
artery disease; 2. Moderate systolic and diastolic
ventricular dysfunction; 3. Ventricular right coronary
artery. Hemodynamics: Right atrium 12/9/9, right ventricle
28/10, pulmonary artery 28/16/21, pulmonary capillary wedge
15/13/12, left ventricle 163/30, aorta 163/78, cardiac output
4.4, cardiac index 2.2, SVR 1836, PVR 164. ETT date, [**2182-9-23**], affixed anteroseptal defect, inferior/inferior
septal staining with reperfusion, ejection fraction of 34%.
Laboratory data on [**2183-1-4**], sodium 141, potassium
4.3, chloride 102, bicarbonate 26, BUN 21, creatinine 0.8,
INR 0.9, white blood count 9.3, hematocrit of 36.8, decreased
down to 33 and platelets 276. Peak CKMB 10.
HOSPITAL COURSE: 1. Cardiovascular - The patient was
brought up to the Coronary Care Unit for closer monitoring in
light of the patient's dissection and perforation of the
right coronary artery. The patient was placed on Telemetry
and serial hematocrits were monitored q. 4 hours and q. 6
hours and then q. 12 hours. The patient's hematocrit dropped
from 33 to 31.7 at which point the patient was transfused 1
unit of packed red blood cells with an inappropriate bump and
the patient's hematocrit of 30.7. The patient was then given
a second unit of packed red blood cells with an appropriate
increase to 34.2. The patient's hematocrit subsequently
remained stable and increased to a predischarge hematocrit of
36.7. The patient was started on Aspirin, kept on
Ticlopidine, started on Aspirin, low dose beta blocker and
ACE inhibitor. ACE inhibitor and beta blocker were not
started on the day of admission in Coronary Care Unit until
there was evidence that the patient was hemodynamically
stable. Once, hemodynamic stability was demonstrated, the
patient was started on low dose beta blocker, ACE inhibitor
and titrated up as tolerated. TTE worse than at bedside and
repeated several days after to evaluate for cardiac
tamponade. The patient at no point throughout the stay
showed any indication of pericardial tamponade. The
patient's TTE showed an ejection fraction of 35% to 40%. The
patient was in normal sinus rhythm throughout the entire stay
with episodic episodes of ectopy. The patient ultimately in
the Cardiac Catheterization Laboratory had a Cypher [**Year (4 digits) **]
placed in the right coronary artery. The patient was kept
within the Coronary Unit for one day and subsequently was
transferred to the floor the following day.
2. Hematoma - The patient developed a large right inguinal
hematoma which remained stable, nontender the remainder of
the stay. There was evidence of a small left groin hematoma
as well which did not increase in size. Both hematomas
receded 20 to 30% prior to discharge.
3. Depression - The patient will be restarted on an
outpatient medication regimen on the day of discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Unstable angina
2. Percutaneous coronary intervention to right coronary
artery
3. Aneurysm of coronary vessel
4. Right coronary artery in-[**Year (4 digits) **] restenosis
5. Right coronary artery perforation
DISCHARGE MEDICATIONS:
1. Aspirin 325 once a day
2. Metformin 1000 mg twice a day
3. Lexapro 20 mg q.h.s.
4. Insulin NPH 30 units twice a day
5. Ticlopidine 250 mg twice a day
6. Insulin, LysPro 10 units, PPN with thinner
7. Zantac 150 mg twice a day
8. Lasix 20 mg once a day
9. Metoprolol tartrate, 50 mg tablet, [**1-31**] tablet p.o. twice
a day
10. Pravachol 40 mg tablet q.h.s.
11. Monopril 20 mg tablet q.h.s.
12. Me
FOLLOW UP:
1. Please follow up with primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 30623**] [**Last Name (NamePattern1) **] in one to two weeks. Call to make an
appointment at [**Telephone/Fax (1) 30837**].
2. Please follow up with Dr. [**Last Name (STitle) **], Cardiology on Monday
[**2-10**], at 9:20 AM, [**Last Name (NamePattern1) 102032**]:
[**Telephone/Fax (1) 5003**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 53716**]
Dictated By:[**First Name3 (LF) 102033**]
MEDQUIST36
D: [**2183-1-11**] 23:07
T: [**2183-1-12**] 06:08
JOB#: [**Job Number 102034**]
|
[
"410.91",
"794.39",
"998.2",
"414.01",
"250.00",
"278.00",
"998.12",
"401.9",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"36.07",
"36.01",
"39.64",
"88.56",
"99.04",
"37.23",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
2359, 2528
|
8891, 9302
|
8650, 8868
|
6438, 8566
|
5704, 6420
|
1184, 1441
|
9313, 9991
|
2551, 5686
|
159, 1162
|
1464, 2279
|
2296, 2342
|
8591, 8629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,864
| 149,239
|
634
|
Discharge summary
|
report
|
Admission Date: [**2158-1-31**] Discharge Date: [**2158-2-4**]
Date of Birth: [**2111-2-7**] Sex: F
Service:
ADMITTING DIAGNOSIS: Pelvic mass.
POSTOPERATIVE DIAGNOSIS: Ovarian cancer.
HISTORY OF THE PRESENT ILLNESS: The patient was admitted for
with symptoms of bloating. The patient's workup revealed a
large pelvic mass that was suspicious for ovarian cancer.
PAST MEDICAL HISTORY: Significant for migraines.
PAST SURGICAL HISTORY: Noncontributory.
PAST OBSTETRICAL HISTORY: Noncontributory.
HOSPITAL COURSE: The patient was admitted for an exploratory
laparotomy, TAH/BSO, peritoneal washings, omentectomy, and
debulking, and pelvic lymph node dissection. The estimated
blood loss of the procedure was 250 cc. The procedure was
uncomplicated. The patient's
postoperative course was complicated by an episode of
respiratory arrest believed to be related to narcotic
sensitivity. The patient had received in total 3 mg of
morphine IV and 4 mg of Dilaudid IV and then 4 mg of Dilaudid
subcutaneously. A code was called. The patient's airway was
immediately secured and she was immediately bagged. Narcan
was given IV and the patient responded well with a vigorous
respiratory effort.
The patient was transferred to the MICU for closer monitoring
and at that time was started on a Narcan drip. The patient
did well for the remainder of the night and the Narcan drip
was then discontinued in the early morning. The patient's
pain control overnight was managed with a dose of p.o.
Percocet early in the morning.
The patient was called out of the MICU on postoperative day
number one and transferred to the regular Postsurgical Floor.
The patient's pain control was initially controlled with
Percocet and then transitioned to Toradol and then finally
after a consultation with the Pain Service was transitioned
to Flexeril 10 mg t.i.d. and Motrin 600 mg q. six hours. In
addition, Physical Therapy consult was obtained to provide
assistance with the patient in ambulation and mobility.
The patient's urine output was adequate throughout her
hospitalization/postoperative course. She began tolerating
p.o. on postoperative day number one. On postoperative day
number one, she also began ambulating. The patient's Foley
was discontinued and she was voiding spontaneously. Her
vital signs remained stable for the remainder of the
hospitalization. Her abdominal examination had positive
bowel sounds and was appropriately tender. Her incision
remained clean, dry, and intact. The patient will be
discharged to home on a full diet with Flexeril 10 mg t.i.d.
and 600 mg of Motrin q. six hours, simethicone 80 mg q. eight
hours.
DISPOSITION: The patient will be discharged to home.
CONDITION ON DISCHARGE: Good. The patient will have home
VNA to assess her postoperative course.
FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) 1022**] in
approximately one months time.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4871**]
Dictated By:[**Name8 (MD) 4872**]
MEDQUIST36
D: [**2158-2-4**] 01:04
T: [**2158-2-6**] 12:56
JOB#: [**Job Number 4873**]
|
[
"197.6",
"518.81",
"458.2",
"285.9",
"198.1",
"198.82",
"197.5",
"183.0",
"E935.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.25",
"54.4",
"65.61",
"68.4",
"40.29"
] |
icd9pcs
|
[
[
[]
]
] |
541, 2723
|
459, 523
|
146, 384
|
407, 435
|
2748, 3217
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,353
| 143,725
|
20682
|
Discharge summary
|
report
|
Admission Date: [**2165-12-7**] Discharge Date: [**2165-12-11**]
Date of Birth: [**2123-9-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Gentamicin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
right flank pain, nausea/ vomiting
Major Surgical or Invasive Procedure:
Placement of RIJ line and temporary pacing wire
History of Present Illness:
42 yo M w/ h/o IDDM with gastroparesis, CRI (BL Cr [**8-14**] 1.5),
HTN, ?nephrolithiasis who p/w 2d of n/v and 2 weeks of R flank
pain. He states that he developed pain in his R flank 2 weeks
ago, sharp, nonradiating, though he injected himself too high
location with insulin. It got worse over last week and he went
to [**Hospital **] Hosp ED where he was diagnosed with 7 mm R kidney
stone. He saw GU in [**Location (un) **] 5 days ago who informed him that
either the stone would be passed, or he would receive
lithotripsy. One day PTA he had severe n/a, unable to hold down
po's except some jello. Overnight he has worsening of his flank
pain to [**8-20**] with n/v which continued into this morning. He came
to the ED due to not being able to tolerate pos. He denies
passing stone, hematuria,dysuria, BRBPR, melena, f/c. + small
amt of diarrhea yesterday which resolved. He normally has n/v
from gastroparesis, but states the pain is different. In ED he
received 12 mg morphine, 2-4 mg dilaudid, anzemet, and toradol
with minimal effect on his pain. CT of abdomen with po contrast
only was negative for stones, hydronephrosis, or other
abnormalities. He was admitted for poor po tolerance and pain
control.
Past Medical History:
1. IDDM, HbA1C 8.3
2. Gastroparesis
3. CRI with BL Cr 2.1
4. HTN
5. Anemia
6. Nephrolithiasis
7. Neuropathy
8. S/p facial cellulitis with recent ICU admit to [**Location (un) **]
9. S/p L4-5 osteomyelitis from foot ulcer
Social History:
Married, lives with wife. [**Name (NI) **] EtOH, denies tob or IVDU.
Family History:
+DM
Physical Exam:
VS: T 96.6, BP 157/93, P 77, RR 12, FS 115
Gen: NAD, thin, pale
HEENT: PERRL, EOMI, O/P with white tongue coating
CV: RRR, nl S1, S2 without m/r/g
Pulm: CTA bilat
Back: Mild TTP at R flank
Abd: +bs, s/NT, no HSM
Extr: No edema, braces, +foot drop
Pertinent Results:
Labs on admission:
[**2165-12-6**] 07:26PM WBC-8.83 RBC-4.35* HGB-12.6* HCT-38.0* MCV-87
MCH-28.8 MCHC-33.0 RDW-17.3* PLT COUNT-409
GLUCOSE-92 UREA N-31* CREAT-2.5* SODIUM-139 POTASSIUM-5.1
CHLORIDE-108 TOTAL CO2-22 ANION GAP-14; ALT(SGPT)-22
AST(SGOT)-22 ALK PHOS-113 AMYLASE-33 TOT BILI-0.4
U/A: BLOOD-SM; PROTEIN-500; GLUCOSE-1000; otherwise neg,
RBC-[**3-15**]* WBC-0 BACTERIA-RARE YEAST-NONE EPI-0
[**12-6**] ABDOMEN CT WITHOUT IV CONTRAST: 1. No stones and no
hydronephrosis.
2. Small pericardial effusion.
Brief Hospital Course:
1. R Flank pain - patient presented with right flank pain.
Given his recently diagnosed nephrolithiasis, urinalysis and
pain were thought consistent with probable nephrolithiasis.
Patient had been diagnosed with a 7mm renal calculi on CT at an
outside hospital the previous week. Given his new symptoms,
further imaging was obtained here. A CT scan of the abdomen was
done, which in fact revealed no abdominal abnormalities,
including no stones, hydronephrosis, or other pathologies in his
right kidney. Given his negative CT, and poor pain control
despite large quantities of morphine, the etiology of his pain
was unclear. Over the course of the hosp stay, patient's pain
was reasonably controlled with pain medication. Pt stated
further that he has developed chronic back pain since
development of L4-5 discitis from an infected foot ulcer. The
patient did not experience any fevers or leucocytosis during the
hospitalization to suggest chronic discitis or osteo. His
primary care physician will be able to follow his flank pain
further as an outpatient; by the time of discharge his pain was
well controlled on PO percocet.
2. Bradycardia: The patient was about to be discharged when he
developed pre-syncopal symptoms. Dizzy and lightheaded,
although mentating. Found to have pulse 33, SBP 66. EKG showed
no p-waves, and junctional escape rhythm in 30s. His pulse had
been in the 60s earlier in the day, w/ stable BP, and a previous
EKG showing normal sinus rhythm. He was emergently given
atropine and dopamine, without any increase in his heart rate.
His BP remained in the 70s/40s. [**Hospital **] transferred to MICU,
where right IJ was placed. Atrial pacing attempted, but atria
unresponsive despite multiple attempts at capture. Ventricular
pacer was then successfully placed with capture. Paced at 80,
with marked improvement in BP. Bedside echo showed no
abnormality. His labs then returned, which were remarkable for
K of 6.6 (previously 4.9 in the am), creatinine of 3.2 (from
2.5), and calcium 7.3 (from 8.3). Received kayexalate, bicarb,
calcium gluconate, and insulin, with normalization of
electrolytes. Subsequently recovered sinus nodal activity with
heartrate in 60s, and no longer required pacing. Pacemaker
discontinued, and he remained hemodynamically stable.
Etiology of bradycardia unclear. [**Name2 (NI) 55232**] due to hyperkalemia,
which can cause atrial standstill. His conduction disorder did
resolve with correction of his electrolytes. His nodal agents
(labetalol and diltiazem) were initially held, but labetalol 100
mg [**Hospital1 **] was then added back, and then patient remained in sinus
rhythm.
3. Hyperkalemia - In setting of bradyarrhythmia, found to have
elevated potassium of 6.6 (from 4.9). Likely due to ARF, as his
creatinine also bumped.
4. ARF - Pt with CRI, per note from outside hosp on [**8-14**],
baseline Cr 1.5. Likely due to DM & htn, & had recent ARF [**2-11**]
gentamycin toxicity. At admission, creatinine elevated at 2.5,
where it initially remained stable. U/a unremarkable for infx.
Aggressively hydrated, given concerns for dehydration. He then
developed ARF in setting of bradyarrhythmia. ARF of unclear
etiology - likely ATN given prolonged hypotension in setting of
bradycardia. Concern for mild dehydration at admission, but no
documented hypotension. His nephrolithiasis could also have
contributed, although no stone nor obstruction/hydropnephrosis
seen on abdominal CT the previous day. Renal was consulted, who
recommended start an ACE or [**Last Name (un) **] as an outpt once his creatinine
returned to baseline.
5. Nausea/vomiting - initially presented with n/v, likely due to
pain & nephrolithiasis. He also has diabetic gastroparesis,
which may have contributed to his symptoms. Following his
bradycardic episode, he developed prolonged QT, and his reglan
and erythromycin were held. He then developed increased n/v.
Treated symptomatically with anti-emetics. Once his cardiac
issues resolved, he was restarted on Reglan with much
improvement in N/v. EKG was normal following reinstitution of
reglan, and he was told to d/c the erythromycin which can cause
QT prolongation.
6. Anemia - patient carries diagnosis of anemia, but unclear
etiology or baseline. Likely due to CRI, and is on epo as
outpatient. Iron studies sent, which showed anemia of chronic
disease. Hematocrit did initially drop, but it was thought that
the initial value was hemoconcentrated, and that the subsequent
range of 32-33 represented his true baseline. Subsequent
hematocrits stable.
7. HTN - At admission, initially well-controlled on home regimen
of cardizem, labetalol, and catapres. These were held in
setting of hypotension. With resolution of bradyarrhthmia, he
became hypertensive & tachycardic. He was restarted on
clonidine, & hydralazine and amlodipine.
On day 3 of hospital stay, pt developed orthostatic hypotension
(170's lying, 90's standing). This was thought to be secondary
to autonomic insufficiency, deconditioning after lying in bed
for several days, and dehydration. Hydralazine was stopped and
he was switched to labetalol 100 mg PO BID. He remained stable
on this regmine and did not develop any further episodes of
orthostasis.
8. DM - Blood sugars well-controlled at admission, no evidence
of DKA. Given his initial nausea/vomiting, halved NPH insulin
with sliding scale insulin coverage. While in the ICU, briefly
placed on insulin gttp. Following transfer back to floor,
transitioned back to home regimen of NPH & SSI.
7. Depression - Continued effexor. Social work consult obtained
given patient's wife expressed considerable anxiety over pt's
health and hx of depression.
Medications on Admission:
1. Insulin AM: 8u NPH, 4-6Reg, PM: NPH 4-6U
2. Catapres 0.1 po bid
3. Reglan 10 mg po tid
4. Epo 40,000 qweek
5. Flexeril 5 mg po tid prn
6. Labetalol 300 mg po bid
7. Cardizem CD 120 mg po bid
8. Erythromycin 333 mg po tid
9. Effexor XL 75 mg po qd
10. Dilaudid and percocet, per [**Location (un) 535**] (pt did not
volunteer this)
Discharge Medications:
1. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
2. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Labetalol HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
5. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
6. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
Pt was told to restart his home dose of NPH once he was taking
full PO's.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary
1. Flank pain - ?nephrolithiasis.
2. Acute Renal Failure.
3. Hyperkalemia w/ bradyarrhythmia and shock.
4. Orthostatic Hypotension.
5. Ataxia and deconditioning.
Secondary:
1. Diabetes Mellitus.
2. Gastroparesis
3. Chronic Renal Failure.
4. Hypertension.
5. Peripheral Neuropathy.
6. Bilateral Foot Drop.
7. Depression.
8. S/P L4-L5 diskitis/osteomyelitis [**3-/2164**]
9. Anemia.
Discharge Condition:
- stable to home with services
Discharge Instructions:
- Take medications as directed. Continue to take your usual
insulin regimine if you are eating.
- Follow up as scheduled with Dr. [**Last Name (STitle) 55233**] to have your blood
pressure checked.
- Call your doctor or go to emergency room for increased pain or
any new pain, nausea, vomiting, fevers, chills, difficulty
urinating, or other concerning symptoms.
Followup Instructions:
Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 55233**], in one week. Call on
[**2165-12-16**] to schedule an appointment.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 55234**] [**Telephone/Fax (1) 55235**]
|
[
"592.0",
"285.9",
"272.0",
"376.33",
"736.79",
"584.9",
"427.89",
"403.91",
"275.41",
"276.2",
"311",
"458.0",
"250.60",
"250.40",
"780.2",
"536.3",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78"
] |
icd9pcs
|
[
[
[]
]
] |
9847, 9910
|
2787, 8495
|
318, 368
|
10343, 10375
|
2243, 2248
|
10787, 11040
|
1956, 1961
|
8878, 9824
|
9931, 10322
|
8521, 8855
|
10399, 10764
|
1976, 2224
|
244, 280
|
396, 1610
|
2262, 2764
|
1632, 1854
|
1870, 1940
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,600
| 181,986
|
16848+16849+56759
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2176-11-8**] Discharge Date: [**2176-12-26**]
Date of Birth: [**2126-1-22**] Sex: M
Service: CARDIOTHORACIC SURGERY
ADMITTING DIAGNOSIS: Type A dissection.
DISCHARGE DIAGNOSIS: Type A dissection.
PROCEDURES PERFORMED:
1. Repair of type A dissection with supracoronary hemiarch
II graft 28 mm and resuspension of the aortic valve on
[**2176-11-8**].
2. Percutaneous tracheostomy placement.
3. Percutaneous endoscopic gastrostomy tube.
4. Hemodialysis catheter placement.
HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old
male with a past medical history significant for hypertension
who was transferred to [**Hospital6 256**]
after he presented to an outside hospital with weakness in
his lower extremities. The patient fell, and upon evaluation
was found to have a type A aortic dissection. The patient
was transferred to [**Hospital6 256**], was
found to be in shock. A TE was done which revealed an aortic
dissection as well as an aortic insufficiency.
HOSPITAL COURSE: NEUROLOGY: The patient had a complicated
postoperative neurologic course. He had decreased function
of his bilateral lower extremities postoperatively. This was
thought to be secondary to spinal cord ischemia; the
patient's spinal arteries were most likely involved in his
abdominal resection which was not repaired.
On [**2176-12-17**], the patient underwent a CT of his head
which was negative. On [**2176-12-18**], he underwent an EEG
as he was having what were thought to be seizures. The EEG
was essentially negative. It was then decided that given
what was thought to be seizure activity while positioning the
patient in a sitting position, that this was actually a
reaction to postural hypotension.
The patient also underwent an MRI of his TL spine on [**2176-12-20**] which was negative as well. The patient was
initially intubated for many weeks and was confused. After
approximately one month in the ICU, he began to wake up and
regain his normal mental status. He worked with PT and did
regain some motion of his lower extremities.
On [**2176-12-25**], he underwent an MRI/MRA of his brain
which revealed linear focus in his left cerebellar hemisphere
of late subacute chronic hemorrhage. This was not thought to
be acute in nature but given the patient's anticoagulation on
heparin and Coumadin. Neurology was reconsulted. At the
time of dictation, there was no further recommendations.
At the patient's time of discharge, he was fully awake,
alert, conversant, and appropriate with some motor function
in his bilateral lower extremities.
CARDIOVASCULAR: The patient had somewhat of a labile
postoperative cardiovascular course as his blood pressure was
rather labile. He was at first maintained on a Nipride drip
to keep his blood pressure under tight control given his
hemiarch II graft repair. Gradually, the patient was
transitioned over to p.o. antihypertensives; Lopressor and
Labetalol were used, and slowly he was transitioned over to
p.o. Lopressor which controlled the patient's blood pressure
and heart rate. He had no other cardiovascular issues
throughout his hospital course. On discharge, he was on 150
mg of Lopressor b.i.d. Of note, this may be changed and an
addendum will be dictated if there is a change in his
medications at discharge.
Of note, the patient underwent a TE on [**2176-12-10**] which
revealed a normal EF and no vegetations. This was done for
concern of the patient's spiking of temperatures. He also
underwent an MRI of his chest on [**2176-12-19**] which
showed some old blood in the mediastinum; however, this was
thought to be consistent with postoperative changes.
RESPIRATORY: The patient underwent a percutaneous
tracheostomy on [**2176-11-22**] because of his failure to
wean from the ventilator. His respiratory course was
somewhat prolonged and arduous as well. He had bouts of
tachypnea and failure to wean from the ventilator.
On [**2176-12-5**], he underwent a CTA because of his hypoxia
which revealed bilateral pulmonary emboli. He was started on
a heparin drip and Coumadin was begun on [**2176-12-18**].
The patient slowly weaned from the ventilator and was
tolerating room air.
On [**2176-12-21**], the tracheostomy was discontinued and
the patient was able to vocalize without problems. His
saturations were 95-100 on room air.
RENAL: Postoperatively, the patient had severely elevated
CKs in the range of 44,000. He went into acute renal
failure. This was thought to be secondary to the involvement
of his renal arteries and his abdominal aortic dissection.
Renal consult was obtained and ultimately the patient was
placed on hemodialysis for oliguria, rising creatinine, and
potassium. Slowly, the patient began to have minimal urine
output and on [**2176-12-13**] hemodialysis was discontinued
as the patient was making large amounts of urine on his own
and his creatinine ultimately did normalize. He had no
further renal issues towards the end of his hospital stay.
GASTROINTESTINAL: The patient received a percutaneous
endoscopic gastrostomy on [**2176-11-29**] given his prolonged
hospital course. He did tolerate tube feeds but given the
fact that he progressed well and was able to vocalize and his
tracheostomy was removed, a bedside swallow evaluation was
done which he passed and he was started on liquids.
The patient also underwent a barium swallow given his vagal
episodes. This was normal. On discharge, the patient was
tolerating a regular diet. Also, of note, the patient
underwent an abdominal CT on [**2176-12-5**] as he had some
slight abdominal pain. This was negative. On [**2176-12-19**], he underwent a right upper quadrant ultrasound looking
for a source for his persistent fevers. This was negative as
well.
HEMATOLOGY: The patient was transfused several times
throughout his hospital course. Given his bilateral
pulmonary embolism, he was started on a heparin drip on
[**2176-12-5**] and was transitioned over to Coumadin on
[**2176-12-18**] as it was deemed that he would not need a
permanent hemodialysis catheter and would not need further
operative intervention. His goal INR was to be approximately
2.
VASCULAR: Initially the patient was followed by the Vascular
Surgery Team as there was concern that his lower extremities
were ischemic secondary to an area extended to his iliacs
bilaterally. The patient's feet remained warm with
Dopplerable signals.
A discussion was had regarding repair of his abdominal aortic
aneurysm. However, given his tenuous clinical status and the
fact that he was beginning to progress it was decided not to
repair this aneurysm or to bypass his lower extremities.
ENDOCRINE: The patient was initially on an insulin drip
changed over to a sliding scale. This was gradually
withdrawn. The patient underwent a cortisol stim test as a
workup for his fevers. This was negative as well.
INFECTIOUS DISEASE: The patient was persistently febrile
throughout his hospital course spiking on almost a daily
basis. He was started on vancomycin for coagulase-negative
Staphylococcus on his right IJ catheter tip and he was also
started on Zosyn for gram-negative rods in his sputum.
He then grew out Pseudomonas in his urine which was resistant
to everything except Imipenem. He was switched to vancomycin
and Imipenem. Antibiotics were then discontinued as he began
to have a rash over his whole entire body and Infectious
Disease was concerned that this was a drug-related reaction.
His rash did improve somewhat.
Given the concern for infection of his graft, Cardiothoracic
Surgery strongly urged to continue antibiotics given the fact
that the patient had a rising white count to 22,000 and
continued to spike fevers. The patient was started on Cipro
and Zosyn for Pseudomonas in his sputum and urine. The
patient grew out
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2176-12-26**] 04:19
T: [**2176-12-26**] 18:16
JOB#: [**Job Number 47491**]
Admission Date: [**2176-11-8**] Discharge Date: [**2177-1-8**]
Date of Birth: [**2126-1-22**] Sex: M
Service:
ADDENDUM: The patient's main issue since the last discharge
summary are as follows. The patient was transferred to the
floor on [**2176-12-27**], without significant events. On his floor
stay, the patient continued to spike intermittent
temperatures while being covered with Zosyn and gentamicin.
As per Infectious Disease, the patient eventually defervesced
and the antibiotics were stopped per Infectious Disease's
initial consult recommendation of ten days of antibiotic
coverage empirically.
The patient remained afebrile after stopping the antibiotics
and subsequently had no more fevers. The patient also
tolerated having his Foley removed, and voided spontaneously
on his own.
The patient's main issues in the days prior to discharge
remained with his anticoagulation balance, with a goal INR
being about 2.0 for his history of pulmonary emboli. In
addition, the patient had some sacral decubitus ulcers which
were cared for by our Wound Care Team.
The patient on the day of discharge continued to be afebrile,
tolerating a regular diet, and quite comfortable. He had no
acute issues and his INR on the day prior to discharge was
1.8.
MEDICATIONS ON DISCHARGE:
1. Zinc sulfate 220 mg q.d.
2. Vitamin C 500 mg q.d.
3. Lopressor 150 mg b.i.d.
4. Coumadin 3 mg q.d.
5. Colace 100 mg b.i.d.
6. Neutra-Phos two packets t.i.d.
7. Albuterol inhaler one to two puffs q. six hours p.r.n.
8. Nystatin suspension 5 ml b.i.d. p.r.n.
9. Tylenol 325 mg q. 4-6 hours p.r.n.
DISCHARGE CONDITION: Stable, nonambulatory. The patient has
some minimal motion of his lower extremities but is
essentially bed bound. He is working on transfers to a
chair. The patient could feed himself.
DISPOSITION: [**Country 4194**].
DIET: Ad lib.
DISCHARGE INSTRUCTIONS: The patient will require aggressive
physical therapy, nursing, and wound care. Wound care is as
follows: To the sacral area (bilateral buttocks) cleanse
area with gentle wound cleanser, pat dry with sterile gauze,
apply Duoderm gel to all open areas, cover with dry gauze and
then cover with absorbant cover sponge. Avoid taping to
skin. Stomal wafers have been used as areas to apply tape
to. Duoderm is also an alternative. We have also been using
no-sting baby wipes to protect areas surrounding open
ulceration. The patient also has ulcerations on the left
shin and top of foot which are being observed at this time.
The patient will require a PEG gastrostomy tube maintenance
daily. The patient's physical therapy regimen should work on
regaining any possible strength or coordination of the lower
extremities as well as simply working with the ability to
transfer to a chair with a goal of being able to transfer to
wheelchairs.
The patient should follow-up with his cardiologist in [**Country 4194**]
for adjustment of his medications and possible need for
diuresis. At the time of discharge, the patient did not need
any diuresis and was seen to have minimal to no peripheral
edema.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2177-1-8**] 07:45
T: [**2177-1-8**] 20:31
JOB#: [**Job Number 47492**]
Name: [**Known lastname 8584**], [**Known firstname 8585**] Unit No: [**Numeric Identifier 8586**]
Admission Date: [**2176-11-8**] Discharge Date: [**2176-12-26**]
Date of Birth: [**2126-1-22**] Sex: M
Service: Cardiothoracic Surgery
ADDENDUM: This is a continuation of a Discharge Summary
which was cut off midway.
INFECTIOUS DISEASE ISSUES CONTINUED: The patient was changed
to ciprofloxacin and Zosyn for Pseudomonas in his sputum and
urine. On the 23rd, the patient grew out Pseudomonas from
his hemodialysis catheter which was removed. He was then
started on low-dose gentamicin and Zosyn. Gradually his
fever curve decreased, and his white blood cell count slowly
normalized.
Given the patient's history of living in [**Country 8138**], a parasite
and malaria workup was undertaken which was negative thus
far.
DERMATOLOGIC ISSUES: The patient had a decubitus ulcer which
was treated conservatively, as it was only a stage I ulcer.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was to be discharged home to
[**Country 8138**].
NOTE: A short Addendum will be dictated prior to his
discharge given any changes in his status. Also, his
medications on discharge will be dictated as well.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**]
Dictated By:[**Last Name (NamePattern1) 3831**]
MEDQUIST36
D: [**2176-12-26**] 14:22
T: [**2176-12-26**] 19:25
JOB#: [**Job Number 8587**]
|
[
"415.11",
"041.7",
"424.1",
"518.81",
"707.0",
"401.9",
"441.1",
"584.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"33.21",
"38.45",
"38.95",
"39.61",
"97.23",
"35.11",
"43.11",
"39.95",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
9798, 10038
|
219, 1019
|
9468, 9776
|
1037, 9442
|
10063, 12561
|
12576, 13159
|
177, 197
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,644
| 120,121
|
44228
|
Discharge summary
|
report
|
Admission Date: [**2140-5-13**] Discharge Date: [**2140-5-22**]
Date of Birth: [**2092-10-11**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 47-year-old woman who
presents for a preoperative admission for a cadaveric kidney
transplant. The patient was started on dialysis in [**2140-1-6**]. The patient has a longstanding history of polycystic
kidney disease.
PHYSICAL EXAMINATION: The patient has vitals of temperature
97.6, blood pressure of 77/37, heart rate of 82, a
respiratory rate of 18, and saturation of 99% on room air.
The patient was in no acute distress in terms of general
exam. Her cardiac was regular rate and rhythm. S1 and S2 were
appreciated. No murmurs, rubs, or gallops. The chest exam was
clear to auscultation bilaterally. There were no rales. There
were no rhonchi. There was no wheezing. There was no egophony
or whispered pectoriloquy. On abdominal exam, the patient was
nontender. She was nondistended. Her abdomen was soft. Bowel
sounds were appreciated in the right lower quadrant. There
was a peritoneal dialysis catheter. The patient's extremities
were not cyanotic. They were not edematous. The patient had
2+ pulses bilaterally. The lower extremities were warm and
well perfused. Capillary refill was within 2 seconds. On
neurologic examination, the patient was alert, awake, and
oriented x3. On cranial nerve exam, cranial nerves II-XII
were grossly intact.
LABORATORY DATA: The pertinent labs on admission included a
white blood cell count of 7.0, hematocrit 36.6, and platelet
count 305. The serum sodium was 140, the potassium was 4.0,
the chloride was 95, the CO2 was 28, the BUN was 47, and the
creatinine was 15.9. The calcium was 9.9. The phosphorus was
5.4. The INR was 1.1. The PT was 13. The PTT was 24.7.
The patient's EKG was normal sinus rhythm.
The chest x-ray showed no cardiopulmonary process.
HOSPITAL COURSE: On [**2140-5-13**], the patient was admitted
for preoperative workup and evaluation for a cadaveric kidney
transplant. She was made NPO after midnight. Her preoperative
workup was complete. She was scheduled for a renal transplant
in the morning.
In the morning of [**2140-5-14**], the patient went to the
operating room for a cadaveric renal transplant. The patient
was consented. Her tissue typing was sent off to [**Hospital6 8866**] and she underwent a transplant. Please the
operative report for further details of the operational
procedure.
Postoperatively, the patient stayed in the PACU area for 3-4
hours. She was doing fine there and was transferred to the
regular hospital floor. On her postop check later that night,
the patient was doing well. Her pain was well controlled. She
was to be weaned from dopa in the PACU prior to be
transferred to the floor which she was, and there were no
real issues when the patient got to the floor.
On postop day #1, the patient was doing fine. She experienced
some episodes of hypotension that required some boluses of
normal saline a few times. Her urine output was somewhere
between 30 cubic centimeters and 60 cubic centimeters per
hour roughly. On postop day #1 in the day, the patient was
transferred to the SICU for what was routine sort of a
dopamine drip so that her blood pressure could be titrated to
a systolic pressure of above 100 and her urine output could
increase comfortably to 100 cubic centimeters per hour.
On postoperative day #2, the patient was doing very well. She
was continued on IV fluids. Her urine output had been
excellent overnight. Her dopamine IV was titrated down to 1.5
from 2, and she was doing very well. She got a dose of
Thymoglobulin that day and an echocardiogram was obtained
just to check for any kind of cardiac wall motion
abnormalities. That echocardiogram was negative.
On postoperative day #3, the patient continued to do well.
Her dopamine was titrated down to 1. Her urine output was
good. We continued to try to wean off dopamine. Her K-Lyte
was increased to 4 mg b.i.d. The patient was followed
throughout the hospital course by renal transplant medicine
who helped very diligently in her care.
On postoperative day #4, the patient again did very well. She
was making good urine output. She was still on a dopamine
drip, but she was doing very well. The plan was to transfer
her to the floor and that was to be discussed with the team
since she was doing so well.
The patient, in the unit, continued to do very well. She was
tolerating her diet. She was up and around, walking around.
On postoperative day #5 and #6, she really had no complaints
other than she wanted to get back up to the floor. On
postoperative day #6, she was transferred to the regular
hospital floor and she was doing very well. She was
comfortable.
On postoperative day #7, she continued in that same light on
the floor with close monitoring of her blood pressure. She
was out of bed. She was walking around. Her urine output had
maintained above 50-60 cubic centimeters an hour, and her
Prograf level was evaluated with labs daily.
On postoperative day #8, the patient was deemed ready to go
home. She was given a followup on the following day for all
of her labs to be reassessed by the transplant team. She went
home on an FK level of 7 and 7. She was given very strict
instructions as to some of the diarrhea that she had been
having towards her final day and she was started on 500 mg of
Flagyl prior to leaving. She was told that, if that tailed
off, she would be able to stop the Flagyl. Otherwise, she
could continue that. Two of her C. difficile samples that
were sent the final 2 days of her hospital stay were
negative, but we are awaiting for the third one. We just had
her continue on her Flagyl.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: End-stage renal failure secondary to
polycystic kidney disease.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.24h.
2. Nystatin suspension 5 mL p.o. 4 times daily
3. Colace 100 mg p.o. b.i.d.
4. Diphenhydramine 25 mg at bedtime p.r.n.
5. Valacyclovir 450 mg p.o. every other day.
6. Percocet 5/325 mg 1-2 tabs p.o. q.4-6h. p.r.n. pain, 30
tablets.
7. Ambien 5 mg p.o. at bedtime, 20 tablets.
8. Fludrocortisone acetate 0.1 mg p.o. t.i.d.
9. Mycophenolate mofetil 500 mg p.o. 4 times daily.
10. Flagyl 500 mg p.o. t.i.d. for 10 days.
11. Tacrolimus 7 mg p.o. b.i.d.
12. Potassium chloride 10 mEq p.o. once a day.
13. Bisacodyl 10 mg suppository at bedtime p.r.n.
FOLLOWUP PLANS: The patient's followup plans are to followup
with transplant medicine the following day, on [**2140-5-23**], for labs. She has additional followup with Dr. [**Last Name (STitle) **]
on [**2140-5-26**], at 2:40 PM. She also has followup with Dr.
[**Last Name (STitle) **] on [**2140-5-30**], at 3:00 PM, and with Dr. [**First Name (STitle) **]
on [**2140-6-9**], at 9:20 AM.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Last Name (NamePattern1) 18027**]
MEDQUIST36
D: [**2140-5-23**] 05:38:25
T: [**2140-5-23**] 13:41:03
Job#: [**Job Number 94882**]
|
[
"753.12",
"276.8",
"458.9",
"305.1",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"54.98",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
5738, 5776
|
5886, 7153
|
5798, 5863
|
1922, 5716
|
437, 1904
|
184, 414
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,024
| 170,446
|
14077
|
Discharge summary
|
report
|
Admission Date: [**2162-2-17**] Discharge Date: [**2162-2-23**]
Date of Birth: [**2103-10-26**] Sex: M
Service: Cardiothoracic
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
male with a history of diabetes, hypertension, and
hypercholesterolemia who presented after having a positive
stress test to [**Hospital1 69**] for
workup.
For the last several months the patient has had axillary pain
with exertion which is relieved with rest. The pain has not
increased in frequency or intensity in the last few months.
He denies any radiation, shortness of breath, diaphoresis,
nausea, and vomiting with these symptoms.
He had an electrocardiogram done in the clinic which appeared
abnormal, and this led to a exercise tolerance test. The
stress test demonstrated electrocardiogram changes with ST
changes in the anterior leads, and the patient was admitted
to [**Hospital1 69**] for further
evaluation.
PAST MEDICAL HISTORY: (Past Medical History significant
for)
1. Type 2 diabetes.
2. Hypertension.
3. Hypercholesterolemia.
MEDICATIONS ON ADMISSION: Medications on admission included
Avandia 4 mg p.o. q.d., Glucophage 850 mg p.o. t.i.d.,
Accupril 10 mg p.o. q.d., Pravachol 40 mg p.o. q.d.,
enteric-coated aspirin 325 mg p.o. q.d.
SOCIAL HISTORY: He denies any tobacco or alcohol use. The
patient is an engineer and lives with his wife.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination the patient was in no acute distress.
Temperature was afebrile, pulse of 72, blood pressure
of 140/72, respiratory rate of 18, satting at 96% on room
air. Alert and oriented times three. Pupils were equal,
round, and reactive to light. Extraocular movements were
intact. Neck was supple. No lymphadenopathy. He had a
clear chest bilaterally. He had a regular rate and rhythm
with no murmurs, rubs or gallops. His abdomen was soft and
nontender, with positive bowel sounds. He had no clubbing,
cyanosis or edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission included a white blood cell count of 10.6,
hematocrit of 36.4, platelets of 339. PTT of 27, PT of 13,
INR of 1.2. Sodium of 145, potassium of 4.7, chloride
of 106, bicarbonate of 25, blood urea nitrogen of 18,
creatinine of 1, glucose of 136.
RADIOLOGY/IMAGING: Electrocardiogram revealed normal sinus
rhythm at 93, poor R wave progression, normal axis, T wave
inversions in V4 through V6.
HOSPITAL COURSE: The patient was admitted to the C-MED
Service where he underwent a cardiac catheterization. A
middle right coronary artery 95% stenosis, middle left
anterior descending artery 80% stenosis, first diagonal with
40% stenosis, proximal circumflex with 60%. There was an
estimated ejection fraction of 37%.
The patient was then evaluated by Cardiothoracic Surgery. He
was then taken to the operating room where he underwent a
coronary artery bypass graft times four with a left internal
mammary artery to left anterior descending artery, radial
segment to the obtuse marginal and first diagonal, and a
reversed saphenous vein graft to the right coronary artery.
The patient tolerated the procedure well and was transferred
to the Coronary Care Unit where he remained hemodynamically
stable. He was weaned off of pressors and did well
overnight.
On postoperative day one, the patient was transferred to the
floor. Chest tube was discontinued. The patient was stable
overnight.
On postoperative day two, he had an episode of rapid atrial
fibrillation. The patient was converted back to sinus rhythm
after intravenous Lopressor was given. After bolus of
150 mg, he was started on amiodarone 400 mg p.o. t.i.d. which
he was to complete for one week and following the standard
taper course. He has remained in sinus rhythm since the
initial episode.
The patient has otherwise remained afebrile and stable. The
wound remained clean, dry, and intact. The patient has had
an elevation of his potassium of up to 6. His supplemental
potassium chloride was discontinued, and the patient
potassium appropriately dropped to 5.4. The patient has been
able to void. He was tolerating a cardiac/diabetic diet and
was ambulating with an activity level of V with Physical
Therapy. The patient was stable and is now ready for
discharge.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft times four.
2. Diabetes mellitus.
3. Atrial fibrillation.
4. Hypertension.
5. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE: (Medications on discharge
included)
1. Glucophage 850 mg p.o. t.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Lopressor 25 mg p.o. b.i.d.
4. Accupril 10 mg p.o. q.d.
5. Pravachol 40 mg p.o. q.d.
6. Lasix 20 mg p.o. b.i.d. times seven days.
7. Folate 1 mg p.o. q.d.
8. Amiodarone 400 mg p.o. t.i.d. (until [**2162-2-27**]; the
patient will then take 400 mg p.o. b.i.d. from [**2-28**] to
[**2162-3-7**]; then the patient will take 400 mg p.o. q.d.
starting on [**2162-3-8**]).
9. Avandia 4 mg p.o. q.d.
10. Percocet 5/325 one to two tablets p.o. q.4h. p.r.n.
11. Colace 100 mg p.o. b.i.d.
CONDITION AT DISCHARGE: The patient was discharge in stable
condition.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) 1537**] in four weeks and follow up with Dr. [**First Name (STitle) **] in two
to three weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2162-2-23**] 12:46
T: [**2162-2-23**] 15:14
JOB#: [**Job Number 41986**]
|
[
"272.0",
"401.9",
"414.01",
"794.31",
"V10.83",
"250.00",
"427.31",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"99.29",
"88.53",
"99.69",
"88.56",
"37.22",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
4333, 4508
|
4535, 5144
|
1117, 1300
|
2477, 4312
|
5159, 5263
|
162, 175
|
5285, 5722
|
204, 961
|
985, 1090
|
1317, 2458
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,153
| 116,191
|
13187
|
Discharge summary
|
report
|
Admission Date: [**2148-3-27**] Discharge Date: [**2148-3-28**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
woman with a history of hypertension and peripheral vascular
disease who presented to her primary care physician in
[**2147-11-25**] with a complaint of cough and chest
tightness. The symptoms persisted and the patient had a
chest x-ray done on [**2148-3-6**], which showed a large right
sided [**Location (un) 21851**] in the paratracheal region.
On review of systems, the patient reports slow progression of
exertional dyspnea, fatigue, anorexia and hemoptysis times
several weeks. The patient presented to the Emergency Room
on [**2148-2-26**], with significant worsening of dyspnea,
wheezing and cough. CT scan was done which showed a large
right upper lobe mass extending into the mediastinum, 7.2
centimeters by 7.7 centimeters, associated with right upper
lobe collapse. There was extensive right hilar and
sub-carinal lymphadenopathy with an 8 millimeter nodular
density in the right posterior middle lobe and small right
pleural effusion.
The patient was discharged and had an outpatient bronchoscopy
performed which showed tumor invasion in the distal tracheal,
right main-stem bronchus was patent at that time. Unable to
do biopsy secondary to patient coughing, discomfort and
difficulty visualizing the bronchus. Repeat bronchoscopy was
done on [**2148-3-15**], which showed complete obstruction of the
main stem bronchus. Biopsies taken indicated poorly
differentiated carcinoma infiltrating bronchial sub-mucosa.
The patient was admitted on [**2148-3-16**], to [**Hospital3 20445**] for worsening shortness of breath. The patient was
started on Solu-Medrol which was subsequently changed to
Prednisone. The patient underwent a staging work-up with
abdominal CT scan which showed no metastases. The patient
was sent for mapping to initiate XRT to large lung mass.
While lying flat, the patient became more dyspneic with
increasing coughing and obvious cyanosis. The patient
underwent an emergency CT scan which showed progression of
disease and compression of the trachea and main [**Last Name (un) 2435**]
bronchus. The patient was sent to [**Hospital1 190**] for emergent XRT and then sent back to
[**Hospital3 1196**] for chemotherapy. The patient
received one cycle of Carboplatin and Taxol on [**2148-3-24**],
and has had a total of five cycles of XRT (last cycle on
[**2148-3-22**]).
The patient reportedly developed increasing cough with
periods of bronchospasm and cyanosis despite increasing doses
of steroids, nebulizer treatments and heated face mask. The
patient was referred to [**Hospital1 69**]
for stenting of her trachea and right main stem bronchus.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Severe peripheral vascular disease on Coumadin status
post bilateral femoral-popliteal bypass in [**2127**].
3. Status post left below the knee amputation in [**2128**]
secondary to obstructing clot and left foot ischemia.
4. In [**2140**], the patient underwent a redo right axillary
shunt to lower extremity bypass which was complicated by
postoperative pulmonary embolus treated with Coumadin and IVC
filter placement.
5. Non-small cell lung cancer as above.
The patient's Oncologist is Dr. [**Last Name (STitle) 6099**] and Dr. [**First Name8 (NamePattern2) 3551**] [**Last Name (NamePattern1) 8631**].
Her Pulmonologist is Dr. [**Last Name (STitle) 40217**].
MEDICATIONS AT HOME:
1. Coumadin 2 mg p.o. q. h.s.
2. Maxzide.
MEDICATIONS ON TRANSFER:
1. Diltiazem 60 mg p.o. q. day.
2. Albuterol and Atrovent nebulizers q. four hours.
3. Decadron 4 mg intravenous q. four hours.
4. Levaquin 250 mg p.o. q. day.
5. Robitussin and Tessalon Pearls p.r.n.
SOCIAL HISTORY: The patient is widowed for seven years.
She has three children. She lives independently and
ambulates with a cane. She has 40 pack year history of
smoking; quit in [**2127**].
PHYSICAL EXAMINATION: Temperature 98.6 F.; blood pressure
134/60; pulse 110; saturation of 93% on five liters. In
general, the patient was alert and oriented times three.
Cardiovascular: The patient was tachycardic with no
appreciable murmurs, rubs or gallops. Lungs: Bronchial
breath sounds, left greater than right. Abdomen: Obese,
nontender, not distended, normal bowel sounds. Extremities:
Left below the knee amputation. No cyanosis, clubbing or
edema.
LABORATORY: On admission, white blood cell count 25.0,
hematocrit 32.3, platelets 185. Sodium 129, potassium 5.1,
BUN 39, creatinine 0.9, albumin 2.8, calcium 8.5, magnesium
2.1.
HOSPITAL COURSE: The patient is an 80 year old woman with
poorly differentiated non-small cell lung cancer admitted
with compression of the trachea and right main stem bronchus
by a large right upper lobe tumor.
On hospital day one, the patient underwent a rigid
bronchoscopy with findings of the right upper lobe occluded
by tumor; in addition, distal trachea had a near total
obstruction by tumor. The patient underwent placement of a
stent to the distal trachea and right main stem bronchus.
Repeat bronchoscopy was performed on hospital day number two,
which showed stents to be patent and in good position.
Distal airways were patent as well and mild to moderate
secretions were noted bilaterally.
Post-procedure, the patient maintained O2 saturations of 93
to 98% on a 50% face mask (this was her O2 requirement on
admission). The patient was subsequently transitioned to
shovel mask with three liters nasal cannula, again
maintaining her saturations above 93%. The patient did note
subjectively improvement in shortness of breath
post-procedure. The patient was continued on humidified
oxygen, standing Albuterol and Atrovent nebulizers q. four
hours. In addition, the patient was given Lidocaine
nebulizers to help with continued cough. In addition, the
patient was continued on Decadron to help decrease
inflammation in the bronchus and was continued on
prophylactic antibiotics with Levaquin and Flagyl
post-procedure.
MEDICATIONS AT THE TIME OF DISCHARGE:
1. Diltiazem 60 mg p.o. q. day.
2. Heparin 5000 units subcutaneously twice a day.
3. Decadron 4 mg intravenously q. four hours.
4. Protonix 40 mg p.o. q. day.
5. Levaquin 500 mg p.o. q. day.
6. Flagyl 500 mg p.o. q. eight hours.
7. Albuterol and Atrovent nebulizers q. eight hours.
8. Lidocaine nebulizers 2.5 cc. of 1% Lidocaine q. one hour
p.r.n.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged back to
[**Hospital3 1196**] for continuing care.
DISCHARGE DIAGNOSES:
1. Non-small cell lung cancer with compression of trachea
and main stem bronchus status post stent placement.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2148-3-28**] 13:02
T: [**2148-3-28**] 13:26
JOB#: [**Job Number 40218**]
|
[
"162.3",
"401.9",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
6604, 6992
|
4631, 6448
|
3488, 3533
|
3986, 4613
|
124, 2754
|
3558, 3765
|
2776, 3467
|
3783, 3962
|
6473, 6583
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,051
| 132,432
|
8979
|
Discharge summary
|
report
|
Admission Date: [**2129-2-7**] Discharge Date: [**2129-3-5**]
Date of Birth: [**2057-11-15**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Flumazenil
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Transfer from OSH for ERCP.
Major Surgical or Invasive Procedure:
ERCP on [**2129-2-14**].
History of Present Illness:
HPI: 71 y/o female with PMH significant for atrial fibrillation,
CAD, St. [**Male First Name (un) 1525**] mitral valve replacement, and sclerosing
cholangitis admitted from OSH for an ERCP. Pt was in her normal
state of health until [**1-28**] when she noted that she felt more
"shakey" than usual. As the day progressed, the pt's family
noted that her movements were very slowed and she was not
thinking as clearly as normal. They wanted to take the pt to the
hospital but she initially declined. However, late that evening,
the pt was too weak to lift herself off of the toilet and fell
into the tub. Did not actually go to the ground but scraped her
leg so family called EMS to take her to the hospital.
At the time of admission to [**Hospital6 28728**] Center, the pt
was noted to be very lethargic and mildly confused. Admission
blood cultures at the OSH grew 4:4 bottles of enterococcus. This
was sensitive to ampicillin, chloramphenicol, genta,
tetracycline, and vancomycin. In addition, her WBC count was
elevated at [**Numeric Identifier 6085**]. Pt was placed on aldactone, unaxyn, and
gentamycin. ID and GI were consulted. A TEE was done that did
not show any vegitations so the gentamycin was discontinued at
that time. An abdominal US at this time was negative for
cholycystitis but showed cirrhosis and mild ascities. There was
a question of an intraparenchymal stone on the US. Blood
cultures from [**2-1**] were negative. Pt had three negative
cultures for C diff on [**1-30**] and [**1-31**]. Today's labs at the OSH
were significant for: WBC 12.9, Hct 36.5, Na 136, K 4.1,
chloride 106, bicarb 21, BUN 33, creatinine 1.2. Pt is now
transferred to [**Hospital1 18**] to receive an ERCP to evaluate for
strictures given her history of sclerosis cholangitis and
positive bacteremia.
In ROS, pt reports that she is feeling well at this time. No CP
or palpiations. No SOB. No abdominal pain, nausea, or vomiting.
She reports that she has a fairly good appetite. Has not noted
any blood in her stools. Is anxious to work with PT as she does
not want to "loose ground" in her progress.
Past Medical History:
1. Sclerosing cholangitis- Pt reports that this was diagnosed
approximately 10 years ago. She is followed by Dr. [**First Name (STitle) 572**] here at
[**Hospital1 18**].
2. S/P St. [**Male First Name (un) 1525**] mitral valve replacement following an episode
of MV endocarditis. Was done at [**Hospital1 112**] on [**2128-9-30**]. Pt is
anticoagulated on coumadin with a goal INR of 2.5 to 3.5.
3. H/O paroxysmal atrial fibrillation- This was found when pt
went to OSH for elective laminectomy on [**2128-8-24**]. At that
time, pt was treated with amioadarone, sotalol, and
cardioversion. It is unclear if pt has had episodes of atrial
fibrillation since her cardioversion.
4. [**Name (NI) **] Pt is s/p a non Q wave MI in 09/[**2127**]. Cath at that time
was negative per notes.
5. Depression
6. H/O acute mitral valve staph aureus endocarditis in the
setting of a line sepsis during [**8-/2128**] hospital course. Pt had
a large associated pericardial effusion. Pt also had posterior
annular abscess s/p debridement and patch.
7. Heparin induced thrombocytopenia in [**9-/2128**]
8. H/O acute renal failure requiring CVVH in 10/[**2127**]. Renal
function subsequently returned to baseline.
9. S/P pacemaker palcement for bradycardia and AV block on
[**2128-10-28**]
10. H/O GI bleed secondary to an AVM and/or portal hypertensive
gastropathy as seen on EGD and colonoscopy by Dr. [**First Name (STitle) 572**] in
01/[**2128**].
11. CHF with diastolic dysfunction
12. Ruptured disc at L4-L5
13. H/O multiple spinal compression fractures
14. H/O hepatic encephalopathy
15. Old left frontal watershed infarct- Likely secondary to
hypotension.
Social History:
Pt is a retired administrator. She lives with her daughter. [**Name (NI) **]
[**Name (NI) 5656**] is also very involved and is her health care proxy.
Widowed from husband 25 yrs ago
Tob - Hasn't smoked for 25 years, [**12-19**] ppd x 15 years
Etoh - Occ has 1 glass wine at dinner
No IVDU
Pt smoked [**12-19**] PPD for 15 years but quit 25 years ago. Rare ETOH.
No drug use.
Family History:
Pt's older and younger brothers both had lymphoma. Unclear what
medical conditions her parents had.
Physical Exam:
Gen- Pleasant lady resing in bed. NAD. Alert and oriented x3.
HEENT- NC AT. PERRL. EOMI. Anicteric sclera. MMM. No lesions in
the oropharynx.
Neck- Supple. No cervical or supraclavicular lymphadenopathy.
Cardiac- RRR. Loud mechanic S2 click that is loudest at the
apex. II/VI SEM at base. No carotid bruits.
Pulm- CTAB.
Abdomen- Soft. Moderately distended. NT. Positive bowel sounds.
No hepatosplenomegaly.
Extremities- No c/c/e. 2+ DP pulses bilaterally. Healing
abrasion on right lower extremity below knee from fall at home.
Neuro- Alert and oriented x3. CN II-XII intact. 4/5 strength in
upper and lower extremities bilaterally.
Pertinent Results:
LIVER ULTRASOUND ([**2129-2-7**])
1) There are probably two intraductal stones in the right lobe
of the liver.
2) Hypoechoic lesion in segment 2 of the liver is unchanged when
compared to the prior study and is concerning. Recommend MRI of
the liver for further evaluation.
3) The portal vein is not well identified and there are
diminutive vessels in its region. This could represent cavernous
transformation of the portal vein secondary to thrombosis.
4) Moderate amount of ascites.
5) Edematous gallbladder most likely secondary to
hypoalbuminemia.
Brief Hospital Course:
MICU Course:
On [**2-17**], patient developed severe diarrhea and leukocytosis. She
spiked a temp to 103.5 and WBC to 28. Her hematocrit also
dropped from 31.6 to 25.3. Her SBP also decreased to mid-70s.
The pt did not have any symptoms of lightheadedness or abdominal
pain. After her BP failed to respond to IVF managment, she
satisfied the criteria for the sepsis MUST protocol. A sepsis
code was called, and she was evaluated and transferred to the
[**Hospital Unit Name 153**] for further BP management.
Blood pressure- Initially, patient received dopamine, continous
normal saline and pRBCs until BP stabilized. She was weaned off
pressors after three days and BP is well controlled.
Sepsis/ID- She has [**2-18**] blood cultures for enterobacter. Urine
cultures and U/A was negative. WBC stabilized and she remained
afebrile. C. diff assay x3 negative. CT abdomen consistent with
colitis. She was empirically treated with levofloxacin, flagyl,
ceftazidine and vancomycin. These were all discontinued and she
was started on Imipenem/cilastin on [**2-21**]. Notably, she has a
recent history of positive blood cultures ([**2-7**]) at an OSH
([**Location (un) 1121**]) for enterococcus bacteremia. Sensitive to CTZ -
treated for 2 week course, ended on [**3-4**], AF, stable,
surveillance cx. negative.
Hematologic- During her [**Hospital Unit Name 153**] course, she received a total of 5
units pRBCs and FFP to maintain her hematocrit. Her hematocrit
was followed serially and eventually stabilized, at which point
Coumadin was restarted in setting of heparin induced
thrombocytopenia and [**Hospital3 9642**] mitral valve replacement. On
floor, required one unit of prbc, then stable hct, guaiac neg.
stools.
1. Sclerosing cholangitis- Pt presents to [**Hospital1 18**] from OSH for
ERCP. Liver ultrasound revealed likely intraductal stone and
stable hypoechoic lesion. Patient was scheduled to get ERCP,
but her INR was 2.2 on transfer. Due to her history of St.
Jude's valve, atrial fibrillation, and also a history of HIT,
decision was made to start renally dosed Lepirudin while
coumadin was held and INR was reversed. Lepirudin was chosen
over argatroban because of her underlying liver disease. INR
was lowered to 1.4 using vitamin K, and pt underwent successful
ERCP and sphincterotomy with extraction of sludge on [**2-14**] after
holding Lepirudin since midnight. Lepirudin was re-started 6 hr
post-ERCP after discussing the risk of post-procedure bleed and
valve thrombosis with the ERCP fellow and a hematology fellow.
Patient was started on ampicillin since the admission and will
complete a 14 day course for enteroccal bacteremia. The source
of infection was thought to be from the intraductal stone.
Treated as above.
2. [**Name (NI) **] Pt with 4/4 blood clutures from OSH growing enterococcus
sensitive to ampicillin. Blood cultures from [**2-1**] were
negative. TEE at OSH was negative for vegetation. Abdominal US
did not show any cholangitis or cholecystitis. Stool was
negative for C diff. UAs at the OSH did not show infection. At
this time, pt is afebrile and WBC count was normal at OSH this
morning. As stated above, the source of infection was thought to
be from the intraductal stone. She remained afebrile and WBC
remained within normal limit. Treated as above. Diarrhea
diminished over stay, was given oral Vancomycin emperically for
C Diff, toxin A neg X 4, Toxin B sent, pending on [**3-4**] - will
continue oral vanco emperically until this negative. Had flex
sig that was neg for pseudomembranes, but had two small polyps.
After d/c her c dif toxin b returned negative, and her PO vanco
was discontinued.
3. [**Hospital3 9642**] mitral valve- Pt is normally anticoagulated on
coumadin with a goal INR of 2.5 to 3.5. As stated above, pt was
bridged with Lepirudin peri-ERCP and Coumadin was re-started
until therapeutic. Sent home on alternating days dosing of 2 mg
then 1 mg warfarin with f/u check of INR in three days.
4. Liver lesion: Abdominal ultrasound from [**12-22**] and [**2129-2-7**]
showing stable hypoechoic lesion. She is being followed by Dr.
[**First Name (STitle) 572**] who suggested close monitoring at this time.
5. Depression- She was continued on citalopram.
Medications on Admission:
Allergies:
1. IV contrast
2. [**Name (NI) 31150**] Pt has a history of heparin induced thrombocytopenia
.
Medications on transfer:
1. Ampicillin 2 gm IV Q6H
2. Spironolactone 100 mg daily
3. Lasix 20 mg daily
4. Coumadin 2.5 mg daily
5. Ursodiol 300 mg [**Hospital1 **]
6. Pantoprazole 40 mg daily
7. MVT 1 tab daily
8. Citalopram 10 mg daily
9. Ferrous sulfate 300 mg TID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Prochlorperazine 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed.
Disp:*15 Tablet(s)* Refills:*0*
9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 tube* Refills:*2*
10. 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*
11. Vancomycin HCl 250 mg Capsule Sig: Two (2) Capsule PO every
six (6) hours for 14 days.
Disp:*112 Capsule(s)* Refills:*0*
12. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day).
Disp:*60 Packet(s)* Refills:*2*
13. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*0*
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO QOD:
Alternate dosing: 2 mg po QD every other day; take 1 mg po qd on
the other days (example: Monday 2 mg; Tuesday 1 mg; Wednesday 2
mg; Thursday 1 mg; etc.).
Disp:*15 Tablet(s)* Refills:*2*
17. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO QOD:
Every other day, alternating with 2 mg on the other days.
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
1) ERCP for billiary ductal stone
Secondary diagnoses:
2) Enterococcal bacteremia
3) Sclerosing cholangitis
4) Paroxysmal atrial fibrillation
5) St. [**Male First Name (un) 1525**] mitral valve with h/o s. aureus endocarditis [**9-20**]
6) Depression
7) Liver Mass - unknown significance
8) Cirrhosis with mild hepatic dysfunction
9) Heparin Induced Thrombocytopenia, Antibody positive
10) Chronic renal insufficiency/failure, with history of ARF
requiring CVVHD in past
11) Probable Osteoporosis
Discharge Condition:
Stable
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all follow up appointments.
3. Seek medical attention for fevers, chills, chest pain,
shortness of breath, abdominal pain, nausea, vomiting, bleeding
from the procedure site, or any other concerning sympoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Where: LM [**Hospital Unit Name 22399**] Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2129-4-22**] 10:00
You have a mass in your liver that needs close follow-up. Dr.
[**First Name (STitle) 572**] is aware as are you of this condition. Please see him to
further discuss possible evaluation and management of this
condition.
|
[
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"599.0",
"V12.59",
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"571.5",
"428.0",
"280.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"88.72",
"51.85",
"54.91",
"48.23"
] |
icd9pcs
|
[
[
[]
]
] |
12782, 12857
|
5889, 10135
|
315, 341
|
13419, 13427
|
5312, 5866
|
13746, 14165
|
4543, 4644
|
10558, 12759
|
12878, 12878
|
10161, 10267
|
13451, 13723
|
4659, 5293
|
12953, 13398
|
248, 277
|
369, 2469
|
12897, 12932
|
10292, 10535
|
2491, 4135
|
4151, 4527
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,925
| 104,276
|
19481
|
Discharge summary
|
report
|
Admission Date: [**2194-12-28**] Discharge Date: [**2195-1-8**]
Date of Birth: [**2172-11-19**] Sex: F
Service: Medicine, [**Hospital1 139**] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old
female with no significant past medical history who was
transferred here from an outside hospital after a Tylenol PM
overdose.
The patient was in her usual state of health until the day
prior to admission when she had a "fight" with her boss at
work. She was seen wondering about the house at
approximately 11 p.m. speaking nonsensically by her father
who encouraged her to go to sleep. She was then discovered
on the day of admission at 1 p.m. in her bedroom and
unresponsive by her father.
Emergency Medical Service transported her to [**Hospital **]
Hospital. It was subsequently discovered that she had
ingested approximately one and a half bottles of Tylenol PM.
At the outside hospital, the patient received 2 gram of
ceftriaxone. She had a negative head computed tomography.
She was intubated for altered mental status. A serum
toxicology screen revealed a Tylenol level of over 200. The
patient was given 140 mg/kg of N-acetylcysteine and charcoal
followed by nasogastric lavage and bicarbonate. Nasogastric
lavage was occult-blood positive and rectal examination was
guaiac-positive. She was then transferred to [**Hospital1 346**] for further management in out
Medical Intensive Care Unit.
PAST MEDICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Diet pills that the patient
purchased over the internet. She is not clear exactly what
they were.
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: The patient reportedly drinks alcohol
socially. She uses tobacco socially. She does have a
history of cocaine use; per her cousin she quit last year.
No history of intravenous drug use. She works in a health
club. Her parents are divorced. She lives with her father.
She has some recreational Percocet use in the last year.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 96.2
degrees Fahrenheit, her heart rate was in the 120s, her blood
pressure was 93 to 116/57 to 63, she was on pressure support
ventilation of 20/5/40% with a rate of 21 and a tidal volume
of 880. Her oxygen saturation was 97% to 99% on room air.
In general, the patient was an obese, sedated, and intubated
woman. Skin showed pressure shores on her left forearm and
left hip. Head, eyes, ears, nose, and throat examination
revealed pupils were 5 mm and minimally reactive to light.
She had charcoal around her mouth. Neck examination revealed
a large smooth bulge on the right side with no
lymphadenopathy. Cardiovascular examination revealed
tachycardia; otherwise regular. Pulmonary examination was
clear. The abdomen was obese but soft and nontender. There
were positive bowel sounds. Extremity examination revealed
no edema. There were strong bilateral radial pulses. There
was normal capillary refill in her left arm and fingers. On
neurologic examination, the patient was sedated and
intubated. She had absent deep tendon reflexes in her
patellar and Achilles. Her toes were upgoing bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 26.9 (differential with 84% neutrophils, 10%
bands, 3% lymphocytes, and 3% monocytes), her hematocrit was
52.8, and her platelets were in the 300s. Her INR was 3.2,
her prothrombin time was 22, and her partial thromboplastin
time was 35.8. Chemistry-7 revealed her sodium was 141,
potassium was 4.7, chloride was 113, bicarbonate was 6, blood
urea nitrogen was 10, creatinine was 0.9, and her blood
glucose was 186. Her anion gap was 22. Her calcium was 8,
her phosphate was 3.2, and her magnesium was 2.2.
Alanine-aminotransferase was 291, her aspartate
aminotransferase was 312, her lactate dehydrogenase was 276,
creatine kinase was 39,700. Her alkaline phosphatase was 92.
Her total bilirubin was 2. Her albumin was 4.3. Her Tylenol
level was 706. Serum osmolalities were 314. Her lactate was
13.5. Acetone was negative. Ethanol was negative.
Urinalysis revealed a specific gravity of 1.025, large blood,
30 protein, 250 glucose, 27 red blood cells, 27 white blood
cells, and a few bacteria.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a
narrow complex tachycardia and R prime in V1.
IMPRESSION: The patient is a 22-year-old female status post
a suicide attempt with a large number of Tylenol PM who
presented with an altered mental status requiring intubation
with severe anion gap metabolic acidosis, coagulopathy, liver
enzyme abnormalities, leukocytosis, rhabdomyolysis, and left
arm compression.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. TOXICOLOGIC ISSUES: The patient presented with both a
Tylenol and Benadryl overdose.
The Tylenol overdose was treated with an infusion of
N-acetylcysteine at 17.5 mg/kg per hour to decrease any
further toxicity to the liver and kidneys. Additionally, the
patient underwent urgent hemodialysis in an effort to
decrease the Tylenol level given that it was over 700 on
presentation to [**Hospital1 69**] which
was at least 20 hours after ingestion. N-acetylcysteine was
continued until the patient's liver enzymes had normalized to
be below 1000.
For the Benadryl overdose, the patient was treated
supportively with benzodiazepines as needed for agitation
from the anticholinergic effects of the Benadryl.
The remaining toxicology screens for possible other
substances ingested were negative.
2. LIVER ISSUES: The patient's liver enzymes and
coagulation times were carefully monitored to determine liver
function. Her alanine-aminotransferase peaked at
approximately 12,000. Her aspartate aminotransferase peaked
at about 8500. Additionally, the patient's INR peaked at
approximately 10. Her bilirubin peaked at approximately 12.
All were consistent with her being in hepatic failure.
The patient was evaluated by the Liver Transplant team on the
day of arrival. During her hospital course, she was in fact
placed on the transplant list. However, her liver function
began to recover and is in fact nearing normal currently.
Thus, she did not need a liver transplant. Currently, her
INR is 1.3. Her bilirubin is 3. Her liver enzymes are
nearly normal.
3. RENAL ISSUES: Initially, the patient's kidney function
was normal. She underwent emergent hemodialysis for
decreasing the Tylenol level. However, several days into her
hospital course, the patient developed decreased urine output
and with an increasing urine sodium; concerning for acute
tubular necrosis secondary to Tylenol toxicity. The patient
was therefore restarted on hemodialysis for her acute renal
failure through a right femoral Quinton catheter. The
patient tolerated this very well. Over her hospital course,
the patient's kidney function began to recover. By the time
of discharge she had excellent urine output of over 2 liters
of urine per day, and her creatinine was starting to
normalize without hemodialysis. Her creatinine went from 6.6
on [**1-7**] to 6 on [**2195-1-8**]. Her kidney
function will need to continue to be followed daily for the
next several days after discharge to insure that it continues
to recover.
4. RHABDOMYOLYSIS ISSUES: Rhabdomyolysis likely secondary
to her prolonged time down on her left side. The patient was
treated with vigorous hydration to prevent renal failure
secondary to elevated myoglobin levels. Her creatine kinases
normalized while she was in the hospital.
5. COAGULOPATHY ISSUES: The patient's initial coagulopathy
on presentation to the outside hospital was likely secondary
to direct effects of Tylenol on Factor VII. However, she
subsequently developed a significant coagulopathy secondary
to her renal failure. The patient received multiple units of
fresh frozen plasma while she was in the hospital to correct
her coagulopathy for procedures and other line placements.
Additionally, she received multiple doses of vitamin K. By
the time of discharge, her INR was 1.3.
6. LEFT RADIAL NERVE PALSY ISSUES: Initially, when the
patient presented she had left arm swelling. There was
concern for a possible compartment syndrome.
The Orthopaedic Service was consulted and felt that she did
not show signs of compartment syndrome after she was
extubated, and her mental status had improved, neurologic and
motor testing on her left arm revealed decreased thumb
extension and abduction which was consistent with a left
radial nerve palsy which was likely from compression. The
Orthopaedic Service recommended a wrist splint to prevent
thumb flexion contractors, and she was to follow up with Dr.
[**Last Name (STitle) **] in the Hand Clinic one to two weeks after discharge.
7. SUICIDE ATTEMPT ISSUES: The patient had no known prior
history of depression or suicide attempts. She was
maintained with a one-to-one sitter for her entire in the
hospital.
Once the patient was extubated and was able to speak, the
Psychiatry Service was involved in her care. They are
arranging for her to receive inpatient psychiatric treatment
now that her medical issues have nearly resolved.
8. ANION GAP METABOLIC ACIDOSIS ISSUES: The patient
initially presented with a severe anion gap metabolic
acidosis which was most likely secondary to a lactic acidosis
which was most likely from a combination of the
rhabdomyolysis and the fact that her liver was failing and
was not effectively clearing lactate.
The patient was treated with fluids containing bicarbonate,
and the metabolic acidosis resolved over the first several
days she was in the hospital.
9. ALTERED MENTAL STATUS ISSUES: On presentation, the
patient's altered mental status was likely secondary to her
large ingestion of Benadryl. Her mental status improved as
she cleared over the first several days.
10. ASPIRATION PNEUMONIA ISSUES: The patient came in with
an elevated white blood cell count and began spiking fevers.
Chest x-rays and computed tomography scans were consistent
with aspiration pneumonia. The patient was treated with a
10-day course of levofloxacin and Flagyl with resolution of
her sputum production and fevers as well as improvement in
her white blood cell counts.
11. ANEMIA ISSUES: The patient was noted to develop a
decrease in her hematocrit while she was here in the
hospital. Her hematocrit on admission was most likely
hemoconcentrated. Nevertheless, while she was in here toward
the end of her hospital course, her hematocrit levels were
consistently in the 27 to 31 range. The etiology of this are
currently unclear as iron studies, B12, and folate studies
were pending at the time of this dictation. Although, given
her age and the fact that she was menstruating, this was most
likely reflective of an iron deficiency anemia. If the
laboratories are consistent with this, the patient will be
started on iron daily.
At the time of this dictation, the [**Hospital 228**] medical issues
have largely resolved or are near resolution. Her only
current outstanding issues is her kidney failure; which, at
this time, appears to be progressing toward resolution with a
decrease in her creatinine today. The patient will need her
kidney function to be followed daily for at least the next
several days, but at this time we do not expect that she will
need any further hemodialysis. Therefore, she is medically
stable to go to an inpatient psychiatric facility.
CONDITION AT DISCHARGE: Condition on discharge was improved.
The patient currently denies any suicidal ideation.
DISCHARGE STATUS: To inpatient psychiatric facility.
DISCHARGE DIAGNOSES:
1. Suicide attempt by Tylenol overdose.
2. Fulminant hepatic failure secondary to Tylenol toxicity;
nearly resolved.
3. Acute renal failure secondary to Tylenol toxicity
requiring hemodialysis; resolving.
4. Left radial nerve compression injury.
5. Rhabdomyolysis; resolved.
6. Anemia.
7. Aspiration pneumonia; resolved.
8. Anion gap metabolic acidosis; resolved.
9. Mental status changes; resolved.
10. Coagulopathy; resolved.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg by mouth once per day.
2. Calcium carbonate 1000 mg by mouth three times per day
(with meals); to be continued as long as phosphate is
elevated.
3. Robitussin DM 5 mL to 10 mL by mouth q.4h. as needed.
4. Cepacol lozenges as needed.
5. Ferrous sulfate 325 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Inpatient
Psychiatry, and upon discharge from the psychiatric facility
was to follow up with outpatient Psychiatry as they direct.
2. The patient was also instructed to follow up with Dr. [**Last Name (STitle) **]
for her left hand and thumb weakness. The patient was to
call telemetry [**Telephone/Fax (1) 4845**] to schedule an appointment in
approximately one to two weeks; she was to continue wearing
the wrist splint until then to prevent flexion contractures.
3. Finally, the patient was instructed to follow up with her
primary care physician upon discharge to further assess her
renal function and make sure that it has returned to [**Location 213**].
4. Additionally, while the patient is at the psychiatric
facility she should have a Chemistry-10 checked daily for the
next several days until her renal function normalizes or is
nearly normal; at which point she should have it checked
every three days for approximately one more week.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 8978**]
MEDQUIST36
D: [**2195-1-8**] 14:33
T: [**2195-1-8**] 15:30
JOB#: [**Job Number 52902**]
|
[
"584.9",
"707.0",
"E950.4",
"507.0",
"570",
"276.2",
"E950.0",
"963.0",
"965.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.95",
"38.93",
"96.04",
"99.15",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1651, 1688
|
11691, 12138
|
12164, 12470
|
1533, 1633
|
12503, 13782
|
4768, 11509
|
11524, 11669
|
197, 1437
|
1461, 1506
|
1705, 4733
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,843
| 197,572
|
54665
|
Discharge summary
|
report
|
Admission Date: [**2111-6-29**] Discharge Date: [**2111-7-9**]
Date of Birth: [**2040-2-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
71 yo M w/ PMH DM, OSA, and COPD initially presented to St.
[**Hospital 6783**] Hospital with SOB requiring transfer to [**Hospital1 18**] MICU for
higher level of care. Pt with chronic COPD at baseline reliant
on 4.5L O2 by NC at home and Spiriva, Advair and Albuterol nebs.
He had increasing dyspnea over past few months, most notably in
the past few days. SOB is present at rest and worsened with
exertion, however he denies chest pain. Cough productive of
small amounts of white sputum. No hemoptysis. No fever, night
sweats or notable change in weight. No dysphagia. Yesterday he
found himself gasping for air, for which he called his PCP who
suggested ambulance transfer to [**Hospital2 **] [**Hospital3 6783**].
In [**Name (NI) **] pt's vitals: T:98.7, BP 160/66, HR 77, R 16, SaO2 96% on
6L NC. Pt thought to have stridor on exam in addition to
rhonchi and wheezes bilaterally. CXR showed right suprahilar
mass with left tracheal deviation. CT chest with contrast
showed large paratracheal mediastinal 7cm necrotic mass with
airway and SVC effacement. Basic lab work: Chemistry: Sodium
136, K 4.7, Cl 97, Bicarbonate 30, BUN 19, Creatinine 1.0,
glucose 193, calcium 8.8. Hematology: Hemoglobin 12.6,
hematocrit 39.3, WBC 10.7, platelets 201. CK 188, troponins
negative, BNP 312. Urinalysis, glucosuria. Pt given IV
azithromycin, IV methylprednisolone 125mg and nebulization
treatment. Foley placed.
On arrival to the MICU, vitals T:98.2 BP:154/73 P:87 R:20 O2:
97% on 6L NC. Pt alert and oriented x3 with labored breathing
and frequent coughing.
Past Medical History:
-diabetic mellitus
-diabetic neuropathy and retinopathy
-HTN
-Hyperlipidemia
-COPD, requiring 4.5L continuous oxygen at home
-Obesity
-OSA
-Osteoporosis
-Berrylium exposure (tested positive on multiple blood tests)
Social History:
Social History: He is a retired metal worker in a factory with
significant Berrylium exposure. He lives at home with wife.
Former alcoholic, has not drank in 29 years. Former smoker 1.5
ppd for over 50 yrs, quit 4 years ago. Denies illicits
Family History:
Significant for diabetes, HTN, and CAD.
Physical Exam:
Admission exam:
Vitals: T:98.2 BP:154/73 P:87 R:20 O2: 97% on 6L NC
General: Obese man wearing glasses. Alert, oriented, in mild
distress [**1-29**] frequent coughing. NC in place.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Rhonchi throughout with inspiratory and expiratory
wheezes heard bilaterally. No rales.
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, +1 edema to
mid calf. Right lower leg with wound at lateral aspect.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
Discharge Exam:
Pt expired.
Pertinent Results:
Admission Labs:
[**2111-6-29**] 11:17PM BLOOD WBC-14.8* RBC-4.49* Hgb-13.8* Hct-42.4
MCV-94 MCH-30.7 MCHC-32.5 RDW-12.6 Plt Ct-242
[**2111-6-29**] 11:17PM BLOOD PT-13.0* PTT-29.9 INR(PT)-1.2*
[**2111-6-29**] 11:17PM BLOOD Fibrino-757*
[**2111-6-29**] 11:17PM BLOOD Glucose-224* UreaN-20 Creat-1.0 Na-139
K-4.9 Cl-98 HCO3-28 AnGap-18
[**2111-6-29**] 11:17PM BLOOD Calcium-9.1 Phos-3.3 Mg-2.1
Micro data:
[**7-1**] bronchial washings: no organisms
blood cultures and urine cultures were all no growth
DIAGNOSIS: EBUS-TBNA, Paratracheal mass:
POSITIVE FOR MALIGNANT CELLS,
consistent with poorly differentiated non-small cell
carcinoma; see note.
[**2111-6-29**] 11:17PM GLUCOSE-224* UREA N-20 CREAT-1.0 SODIUM-139
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-28 ANION GAP-18
[**2111-6-29**] 11:17PM WBC-14.8* RBC-4.49* HGB-13.8* HCT-42.4 MCV-94
MCH-30.7 MCHC-32.5 RDW-12.6
[**2111-6-29**] 11:17PM FIBRINOGE-757*
MRSA SCREEN (Final [**2111-7-3**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
The lung volumes are normal. The lung bases on the left and
right
show linear opacities with air bronchograms, most likely
consistent with
atelectasis. However, a presence of pneumonia cannot be
excluded.
No other lung parenchymal abnormalities. In the mediastinum
however, there is
increased density, notably in the right paratracheal
compartment, associated
with substantial narrowing of the lower third of the trachea and
distortion of
both the right and left main bronchus. Right and left main
bronchus are also
narrowed. To clarify the morphologic situation, notably for
exclusion of a
central malignancy, CT should be performed.
No pulmonary edema. Normal size of the cardiac silhouette. No
pleural
effusions.
Sinus rhythm. Left atrial abnormality. Early R wave progression.
Single wide
complex beat, probable ventricular premature beat but consider
atrial premature beat with aberration. No previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 152 86 388/416 21 36 50
Brief Hospital Course:
71 yo M with oxygen dependent COPD, obstructive sleep apnea,
diabetes mellitus presenting with shortness of breath found to
have large central mediastinal mass with airway effacement as
per outside hospital radiology report.
Active Issues:
# Squamous cell lung carcinoma: Patient initially presented to
outside hospital with hypoxia secondary to paratracheal
mediastinal mass, which on pathology was poorly differentiated
squamous cell carcinoma. Radiation oncology and oncology were
consulted for further management. Patient received XRT while
admitted but due to continued hypoxia and respiratory failure,
poor progress and overall poor prognosis (see below) the family
decision was to focus on comfort, and patient extubated and
expired quietly and peacefully in the presence of family
members.
# Hypoxia: Patient with progressive increase in dyspnea at rest
over past few days increasing his baseline home 02 requirement.
Most likely secondary to necrotic paratracheal mediastinal mass
with airway effacement that was seen on CT from outside
hospital. Interventional pulmonary team consulted and rigid
bronchoscopy done on [**2111-7-1**], along with biopsy of lung mass.
After procedure he returned to the ICU with diffculty managing
secretions and was intubated. Patient was extubated the
following morning, however was intubated again due to difficulty
in managing secretions resulting in hypercarbia. Pathology
returned as poorly differentiated squamous cell lung carcinoma
and patient was transferred to [**Hospital Unit Name 153**] for radiation of lung mass.
Patient remained intubated for his entire [**Hospital Unit Name 153**] course without
ability to safely extubate. After multiple discussions with
patient's family, family clearly endorsed patient's clearly
expressed wishes to avoid long-term life support, including
mechanical ventilation, and tracheostomy was not acceptable to
patient. Focus of care was shifted to comfort. The patient was
extubated, and quietly and peacefully expired in the presence of
family members.
# Cellulitis: Patient with traumatic skin tear on R lower
extremity on admission, which appeared to be erythematous and
indurated on hospital day 2, a change from admission exam. He
was started on vancomycin for coverage of cellultis which
continued until patient death.
# ATN: Patient developed increased Creatine with muddy brown
casts in urine consistent with ATN. Medications were renal dosed
and nephrotoxic medications were held.
Chronic Diagnoses
#Diabetes mellitus: Held home meds and placed on sliding scale
insulin.
#HTN: Initially held home meds and blood pressure was managed
with IV and PO meds.
#Hyperlipidemia: continued home simvastatin 40mg daily
Transitional Issues
Pt expired.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient [**Name (NI) **].
1. Metoprolol Tartrate 25 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Furosemide 40 mg PO DAILY
Hold for SBP <100
4. Lisinopril 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. 70/30 74 Units Breakfast
70/30 56 Units Dinner
7. Spiriva HandiHaler 1 CAP IH DAILY
8. Advair Diskus (250/50) 1 INH IH [**Hospital1 **]
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
Discharge Medications:
None. Pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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"250.60",
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"162.3",
"V87.09",
"362.01",
"357.2",
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
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icd9pcs
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[
[
[]
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8180, 8653
|
8811, 8820
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3309, 3322
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264, 285
|
5639, 8154
|
363, 1937
|
3357, 5375
|
1959, 2176
|
2208, 2438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,497
| 137,565
|
985
|
Discharge summary
|
report
|
Admission Date: [**2151-3-8**] Discharge Date: [**2151-3-15**]
Date of Birth: [**2071-11-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Prim card: [**First Name8 (NamePattern2) 1026**] [**Doctor Last Name 6522**]
Intervent: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
.
cc:[**CC Contact Info 6523**].
HPI: Pt is a 79yo male h/o of aortic stenosis (asymptomatic) and
recently discovered adenocarcinoma of the colon (by colonoscopy
in [**1-4**]) presenting for aortic valvuloplasty and pre-op L heart
cath for resection of adenoCA of mid-ascending colon on Tuesday
AM by Dr.[**Name (NI) 1482**] service.
.
OMR note from [**2-25**] states pt was doing well with no sx of CHF.
An echocardiogram on [**2151-2-18**] showed progression of aortic
stenosis with aortic valve area falling from 0.9 to 0.6
centimeters squared between
last year and this year. The LVEF had decreased from 50% to
35-40%. There was severe hypokinesis at the anterior septum.
There was mild to moderate MR. Compared with [**2150-1-29**], LV
systolic function was diminished and aortic stenosis thought to
have progressed.
.
R heart cath and L heart cath was performed in addition to the
valvuloplasty. C.O. 4.25 baseline, 4.15 s/p intervention; CI
2.14, 2.12 s/p intervention. Hemodynamics showed baseline mean
aortic valve gradient ~35mm Hg with calculated [**Location (un) 109**] 0.69cm2.
Mildly elevated left-sided filling pressures. LV gram was not
performed. L heart cath revealed left dominant system:
LMCA: dual ostia of LAD and LCx from aorta
LAD: 50% ostial, otherwise normal
LCX: normal
RCA: normal.
After interventon (balloon valvuloplasty, mean aortic valve
gradient reduced to 30mmHg wtih calculated [**Location (un) 109**] of 0.8cm2.
.
Pt was Admitted to [**Hospital Unit Name 196**] for post valvuloplasty care.
.
Meds: aspirin 325 mg po daily, protonix 40 mg po daily, senna
one [**Hospital1 **] prn, tylenol prn, colace 100 mg po bid, iron.
.
PMH:
-aortic stenosis
-adenocarcionoma of colon
cscope in [**2151-2-18**] showed tumor in mid asceding colon,
angioextasias, bx showed adenocarcinoma. Pt has had a 50lbs
weight lost hx over past 2 yrs.
-Zenkers diverticulum s/p surgical repair by [**Last Name (un) 6520**] [**4-3**]
-h/o splenomegaly and thrombocytosis
-Anemia iron deficiency--baseline 31-32%
-Bilateral inguinal hernia repair 35 years ago as well as repair
of a right inguinal hernia in [**2146**]
-Decreased hearing
-Esophageal stenosis diagnosed several years ago at the [**Hospital1 **], but chose not to undergo surgical
procedure.
-History of pulmonary asbestosis diagnosed by CT scan in [**2142**]
-History of a jejunal microperforation diagnosed by barium
swallow in [**2144**]
-Left rotator cuff partial tear
-Manic depression/anxiety
.
FMH:
Has one brother with [**Name (NI) 6521**] and other c [**Name (NI) 2481**] Disease
Doesn't remember parents illness
.
Social: currenlty lives with daughter after wife hospitalized.
former smoker, no etoh.
.
Admission PE:
Physical Exam:
VITALS: 98.0 95/66 HR 102-106 18 99%RA
GENL: cachectic, pale, pleasant appearing frail man in NAD
HEENT: anicteric, mmm, pale conjunctiva, JVP not elevtated
CV: tachy, [**5-6**], harsh, late-peaking systolic m, radiated to
carotids, no RG, warm extremities, ? pericardial rub. radial
pulses 1+ b/l
RESP: CTAB without crackles or wheeze
ABD: scaphoid, s/nt/nd, hyperactive bs, no bruit, +splenomegaly,
no CVA tenderness
Groin: sheath removed, no hematoma, no bruits auscultated
EXTREM: cap refill <3 sec, trace pedal edema
.
Labs (see below)
.
Studies:
.
Cardiac cath [**2151-3-8**]
COMMENTS:
1. Selective coronary angiography in this right dominant
patient
revealed mild single vessel disease. The LMCA was absent as
there were dual ostia for the LAD and LCX. The LAD had a 50%
ostial lesion but was otherwise angiographically normal
including branch vessels. The LCX and dominant RCA were
angiographically normal.
2. Resting hemodynamics revealed normal right sided filling
pressures with very mild elevation of left sided filling
pressure with PCWP and LVEDP of about 15mmHG. The cardiac index
was slightly low at 2.17. There was no step up in oxygen
saturations from SVC to PA.
3. Baseline trans aortic gradient was measured at mean of
35mmHG
corresponding with [**Location (un) 109**] of .69cm2.
4. After valvuloplasty the mean gradient fell to 30mmHG with
[**Location (un) 109**] of
.8cm2.
5. Aortic valvuloplasty was performed using a 20 x 60 mm balloon
and a 22 x 50 mm balloon. Following balloon valvuloplasty, the
aortic valve gradient decreased to 30 mmHg with a calculated
valve area of 0.8 cm2.
FINAL DIAGNOSIS:
1. Mild single vessel CAD in LAD
2. Critical Aortic stenosis at baseline which improved slightly
after
valvuloplasty
3. Low cardiac index with slightly elevated left sided filling
pressures.
4. Successful balloon aortic valvuloplasty.
.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.96 m2
HEMOGLOBIN: 10.1 gms %
REST
**PRESSURES
RIGHT ATRIUM {a/v/m} 5/10/5
RIGHT VENTRICLE {s/ed} 32/6
PULMONARY ARTERY {s/d/m} 32/15/24
PULMONARY WEDGE {a/v/m} 19/19/15
LEFT VENTRICLE {s/ed} 134/14 140/14
AORTA {s/d/m} 95/59/75 107/66/82
**CARDIAC OUTPUT
HEART RATE {beats/min} 86 91
RHYTHM SINUS SINUS
O2 CONS. IND {ml/min/m2} 125 125
CARD. OP/IND FICK {l/mn/m2} 4.25/2.17 4.15/2.12
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1318
PULMONARY VASC. RESISTANCE 169
REST
**VALVULAR STENOSIS
AORTIC VALVE GRADIENT {mmHg} 35 30
AORTIC VALVE AREA {sq-cm} .69 .8
**% SATURATION DATA (NL)
SVC LOW 57
PA MAIN 54
AO 96
**ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N 21
.
Echo [**2151-2-18**]: There is moderate regional left ventricular
systolic dysfunction with global hypokinesis with more severe
hypokinesis of the anterior septum. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated. The ascending aorta is mildly dilated. The aortic valve
leaflets are moderately thickened. There is moderate to severe
aortic valve stenosis with a valve area of 0.6cm. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-1**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. EF has
decreased from 50% to 30-40%
Echo data: (excerpt)
Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.8 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *3.9 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 61 mm Hg
Aortic Valve - Mean Gradient: 39 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 (nl >= 3.0 cm2)
.
EKG on admission: HR 108. Sinus rhythm with ventricular and
atrial premature beats. First degree A-V heart block.
Non-specific ST-T wave changes. LVH.
.
Impression: 79 yo male with critical aortic stenosis and
adenocarcinoma of the colon admitted to [**Hospital Unit Name 196**] service post aortic
valvuloplasty going to colon resection in AM with Dr. [**Last Name (STitle) **].
.
#Cardiovascular: Aortic stenosis. S/P "moderately successfull"
valvuloplasty with increasing [**Location (un) 109**] and slightly improved
hemodynamics.
Ischemia: no critical lesions identified, but the patient does
have 50% ostial LAD lesion. Patient is not and has not been
symptomatic. No Dx of CAD in the past. no coronary
interventions were made.
-continue ASA
-no need for plavix since no intervention
-consider starting statin after the colorectal surgery
Pump: EF decreased on recent echo from 50% to 30-40%
(pre-valvuloplasty). BP borderline at 95/66. Tenous
hemodynamics [**3-4**] aortic stenosis. Pt not on BB or ACEI.
-hold off starting BB and ACE [**3-4**] tenous hemodynamics
-gentle fluids Ok of BP lowers below 90s
-getting PRBC transfusion
Rhythm: pt has a baseline h/o baseline asymptomatic first degree
AV block. 1 episode of degeneration to Wenchebach, asx, HR of
99. ? reason, may be [**3-4**] manipulation during valvuloplasty?
-cont to monitor tele, mostly in 1st degree AV block
-hold BB, nodal agents
-atropine at bedside if symptomatic bradycardia
-if degenerateds into Mobitz I type II, call EP for
consideration of pacemaker placement
.
#GI: colorectal adenocarcinoma/bleeding polyp. Pt scheduled for
resection tomorrow AM by Dr.[**Name (NI) 1482**] service.
-NPO after MN for surgery
.
#Heme: iron deficiency anemia. h/o recent GI bleed in the past
requiring 7u of PRBCs. Hct on admission was 31.6, but post cath
Hct was 27.4.
-type and x-match 2 units
-X-fuse 1 U prbcs
-more on call to the OR.
-will hold iron supplements
.
FEN: sips of clears, then NPO after MN. IVF NS at 75cc/hr x 1L
PPx: pneumatic boots, PPI
Code:FULL
Dispo: to GI [**Doctor First Name **] service tomorrow AM.
Major Surgical or Invasive Procedure:
aortic valvuloplasty, laproscopic right colectomy
History of Present Illness:
HPI: Pt is a 79yo male h/o of aortic stenosis (asymptomatic) and
recently discovered adenocarcinoma of the colon (by colonoscopy
in [**1-4**]) presenting for aortic valvuloplasty and pre-op L heart
cath for resection of adenoCA of mid-ascending colon on Tuesday
AM by Dr.[**Name (NI) 1482**] service.
.
OMR note from [**2-25**] states pt was doing well with no sx of CHF.
An chocardiogram on [**2151-2-18**] showed progression of aortic
stenosis with aortic valve area falling from 0.9 to 0.6
centimeters squared between last year and this year. The LVEF
had decreased from 50% to 35-40%. There was severe hypokinesis
at the anterior septum. There was mild to moderate MR. Compared
with [**2150-1-29**], LV systolic function was diminished and aortic
stenosis thought to have progressed.
.
R heart cath and L heart cath was performed in addition to the
valvuloplasty. C.O. 4.25 baseline, 4.15 s/p intervention; CI
2.14, 2.12 s/p intervention. Hemodynamics showed baseline mean
aortic valve gradient ~35mm Hg with calculated [**Location (un) 109**] 0.69cm2.
Mildly elevated left-sided filling pressures. LV gram was not
performed. L heart cath revealed left dominant system: LMCA:
dual ostia of LAD and LCx from aorta LAD: 50% ostial, otherwise
normal LCX: normal
RCA: normal. After interventon (balloon valvuloplasty, mean
aortic valve gradient reduced to 30mmHg wtih calculated [**Location (un) 109**] of
0.8cm2.
Past Medical History:
PMH:
-Zenkers diverticulum s/p surgical repair by [**Last Name (un) 6520**] [**4-3**],
-h/o splenomegaly and thrombocytosis,
-Anemia iron deficiency--baseline 31-32%,
-Bilateral inguinal hernia repair 35 years ago as well as repair
of a right inguinal hernia in [**2146**],
-Decreased hearing,
-Esophageal stenosis diagnosed several years ago at the [**Hospital1 **], but chose not to undergo surgical
procedure.
-History of pulmonary asbestosis diagnosed by CT scan in [**2142**],
-History of a jejunal microperforation diagnosed by barium
swallow in [**2144**],
-Left rotator cuff partial tear
-Manic depression/anxiety.
Social History:
-Iron
-ASA
-Zoloft
-Advil. He takes not more than 2 qd for arthritis
Family History:
Family
Has one brother [**Initials (NamePattern4) **] [**Name (NI) 6521**] and other c [**Name (NI) 2481**] Disease
Doesn't remember parents illness
Physical Exam:
Physical Exam:
VITALS: 98.0 95/66 HR 102-106 18 99%RA
GENL: cachectic, pale, pleasant appearing frail man in NAD
HEENT: anicteric, mmm, pale conjunctiva, JVP not elevtated
CV: tachy, [**5-6**], harsh, late-peaking systolic m, radiated to
carotids, no RG, warm extremities, ? pericardial rub. radial
pulses 1+ b/l
RESP: CTAB without crackles or wheeze
ABD: scaphoid, s/nt/nd, hyperactive bs, no bruit, +splenomegaly,
no CVA tenderness
Groin: sheath removed, no hematoma, no bruits auscultated
EXTREM: cap refill <3 sec, trace pedal edema
Pertinent Results:
[**2151-3-8**] 09:24PM BLOOD WBC-4.6 RBC-3.39* Hgb-9.1* Hct-27.8*
MCV-82 MCH-27.0 MCHC-32.9 RDW-17.2* Plt Ct-599*
[**2151-3-8**] 01:15PM BLOOD Glucose-92 UreaN-18 Creat-0.7 Na-140
K-4.9 Cl-104 HCO3-26 AnGap-15
[**2151-3-8**] 03:38PM BLOOD Type-ART pO2-112* pCO2-36 pH-7.50*
calHCO3-29 Base XS-5
Brief Hospital Course:
The patient was admitted on [**2151-3-8**] for a pre-operative aortic
balloon valvuloplasty (please see cardiology note for details).
On [**2151-3-9**] the patient underwent a laproscopic right colectomy by
Dr. [**Last Name (STitle) **] (please see operative note for details). The
operation went well with no complications. On POD 0, the
patient spiked a temperature of 102.4, which was determined to
be from atelectasis as his wounds looked and chest X-ray looked
good. Blood and urine cultures were subsequently negative.
Vancomycin, gentamycin and flagyl were started empirically
because of his recent valvuloplasty. On POD 1, he required 1.5
liters in fluid boluses for hypotension (SBP in the 70's to
80's). He seemed to respond and his urine output was
outstanding at over 100 cc/ hour. However, that night he
developed tachycardia to the 130's-140's and hypotension to
80/55. He was assymptomatic, however an EKG showed A-flutter vs
A-fibrillation. He was subsequently transferred to the surgical
ICU. The cardiology service was consulted and responded
immediately and cardioverted the patient. Afterwards he was
hemodynamically stable. Amiodarone was started at 200 mg PO
TID. Consideration was given to heparinize the patient, however
cardiology did not feel the need to do so given that he
responded well to the amiodarone and cardioversion and did not
experience any more atrial fibrillation. Gentamycin was
discontinued. On POD 2, he continued to require fluid boluses
to keep his SBP above 90. On POD 3, he was started on clears.
He did not require any more fluid boluses. Antibiotics were
discontinued as he was afebrile with a normal WBC. On POD 4, he
was started on a regular diet which he tolerated well. His IV
was heparin locked. His central line was discontinued.
Physical therapy saw and evaluated the patient and determined
that he was fit to go to his daughter's house with services and
not to rehabillitation. On POD 6, he continued to do well and
was discharged home on an amiodarone taper.
Medications on Admission:
Meds: aspirin 325 mg po daily, protonix 40 mg po daily, senna
one [**Hospital1 **] prn, tylenol prn, colace 100 mg po bid, iron.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks: please start on [**2151-3-19**].
Disp:*28 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: please start after 2 weeks of taking amiodarone
200mg PO BID.
Disp:*14 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation for 2 weeks.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
colon cancer, atrial fibrillation, aortic stenosis
Discharge Condition:
good
Discharge Instructions:
Please call or come to the ED with any fevers > 101, nausea,
vomiting, abdominal pain, chest pain, rapid heart rate, or any
other concerning symptoms. Please take your amiodarone taper as
directed. Please do not drive while taking pain medication.
Please continue home physical therapy to build up youy strength.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up
appointment in [**8-9**] days ([**Telephone/Fax (1) 6524**]).
Please call Dr. [**Last Name (STitle) 1016**] tomorrow to schedule a follow-up for your
atrial fibrillation.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2151-4-20**] 3:30
Completed by:[**2151-3-15**]
|
[
"518.0",
"427.31",
"997.3",
"414.01",
"997.1",
"280.9",
"153.6",
"458.29",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"45.73",
"37.23",
"35.96",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
15287, 15344
|
12194, 14233
|
8899, 8951
|
15439, 15446
|
11875, 12171
|
15809, 16234
|
11150, 11301
|
14413, 15264
|
15365, 15418
|
14259, 14390
|
4790, 6760
|
15470, 15786
|
11331, 11856
|
274, 3135
|
8979, 10400
|
6774, 8861
|
10422, 11047
|
11063, 11134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,872
| 156,328
|
46514
|
Discharge summary
|
report
|
Admission Date: [**2149-7-29**] Discharge Date: [**2149-8-6**]
Date of Birth: [**2107-7-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
intubation for airway protection
History of Present Illness:
Mr [**Known lastname 98789**] is 42 a year-old male with a PMH of alcohol abuse,
seizure disorder, traumatic brain injuries requiring multiple
craniotomies in [**2145**] with apparent memory deficit who was found
with a generalized seizure. The length of the seizure is unknown
but 25min after EMS was called and the pt stopped seizing
spontaneously. Per report of his group home, the patient may
not have been takin his meds. He was febrile to 102F, desated to
80s and was intubated in the field with concern for an
aspiration. He was brought to [**Hospital1 18**] and admitted to the ICU.
Past Medical History:
-EtOH abuse
-Seizure disorder
-h/o traumatic brain injury requiring multiple craiectomies in
[**2145**] - with memory deficit
-Subdural hematoma - [**2145**]
-asthma
-hepatis C
-anxiety
-bipolar
Social History:
Mr. [**Known lastname 98789**] lives [**Street Address(1) 29735**] Inn, has visiting nurse to
help him with his medications. He has had a significant history
of EtOH use, reports AA has been helpful to him in the past and
plans to go back.
He reports he has not smoked in 3 weeks (somewhat concurrent
with his hospitalization), previously was about [**12-17**] pack per day
of cigarettes and per report has stopped using other drugs such
as cocaine. He has a sister who knows him well, but who is not
able to see him often.
Family History:
He has a sister who lives in western [**Name (NI) **] who is well.
Otherwise, no family history obtainable from the patient due to
memory deficits.
Physical Exam:
At Admission
General: intubated
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: Scars on abdomen, erythematous on the back
.
Neurologic examination:
-Mental Status: off sedation patient opens eyes to noxious and
then immediately closes them. Did not follow commands. However
had purposeful movements on the left.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk.
III, IV, VI: roving eye movements; slow random predominantly
horizontal conjugate eye movements
No V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
.
-Motor: spontaneous movement on the left upper extremity and
right lower extremity.
-Sensory: withdraws to noxious on the left (upper and lower).
minimal withdraw on the right lower. flicker of withdraw on the
right upper
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally (likely secondary to
heavily calused feet
________________________________________________________________
At Discharge:
GENERAL - NAD, alert sitting up in bed
HEENT - NC/AT, EOMI, sclerae mildly icteric, dry MM, OP clear
NECK - supple, no JVD
LUNGS - CTAB, mild crackles at bases bilaterally
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - numerous ecchymoses, jaundiced
NEURO - A&Ox3, though slow responses, unable to remember home
street address, strength 5/5
Pertinent Results:
Admission Labs:
.
[**2149-7-29**] 08:30AM BLOOD WBC-8.4 RBC-4.33* Hgb-14.4 Hct-41.7
MCV-96 MCH-33.4* MCHC-34.6 RDW-13.3 Plt Ct-112*
[**2149-7-29**] 08:30AM BLOOD Neuts-77.0* Lymphs-18.5 Monos-3.3 Eos-0.9
Baso-0.3
[**2149-7-29**] 08:30AM BLOOD PT-11.8 PTT-23.4 INR(PT)-1.0
[**2149-7-29**] 08:30AM BLOOD Glucose-161* UreaN-12 Creat-1.4* Na-140
K-4.7 Cl-97 HCO3-15* AnGap-33*
[**2149-7-29**] 08:30AM BLOOD ALT-191* AST-175* LD(LDH)-309*
CK(CPK)-544* AlkPhos-70 TotBili-0.9
[**2149-7-29**] 08:30AM BLOOD Lipase-112*
[**2149-7-29**] 08:30AM BLOOD Calcium-8.8 Phos-5.9*# Mg-1.9
.
[**2149-7-29**] 08:55AM BLOOD Lactate-12.6*
[**2149-7-29**] 04:25PM BLOOD Lactate-1.4 Na-135
.
CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0 LYMPHS-33
MONOS-67 PROTEIN-67* GLUCOSE-101
GRAM STAIN (Final [**2149-7-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
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 [**2149-8-1**]): NO GROWTH.
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2149-8-5**]):
No Herpes simplex (HSV) virus isolated.
[**7-29**] Blood cx negative
[**8-3**] Blood cx no growth (final result on [**8-9**])
[**8-3**] Urine cx negative
[**8-5**] C.diff negative
.
Liver testing:
.
[**2149-7-30**] 04:08PM BLOOD ALT-4091* AST-8031* LD(LDH)-2780*
CK(CPK)-[**Numeric Identifier 98790**]* AlkPhos-68 TotBili-4.4* DirBili-3.4* IndBili-1.0
[**2149-7-30**] 09:43AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2149-7-30**] 04:08PM BLOOD AMA-NEGATIVE
[**2149-8-5**] 05:50AM BLOOD HIV Ab-NEGATIVE
.
Drug/tox screen:
.
[**2149-7-29**] 08:30AM BLOOD Phenoba-LESS THAN Phenyto-<0.6*
Lithium-LESS THAN Valproa-LESS THAN
[**2149-7-29**] 08:30AM BLOOD ASA-NEG Ethanol-NEG Carbamz-LESS THAN
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Discharge labs:
[**2149-8-6**] 06:25AM BLOOD WBC-5.6 RBC-3.92* Hgb-13.1* Hct-38.4*
MCV-98 MCH-33.3* MCHC-34.0 RDW-14.6 Plt Ct-245
[**2149-8-6**] 06:25AM BLOOD PT-12.5 INR(PT)-1.1
[**2149-8-6**] 06:25AM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-133
K-4.0 Cl-98 HCO3-24 AnGap-15
[**2149-8-6**] 06:25AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.8
[**2149-8-6**] 06:25AM BLOOD ALT-454* AST-118* CK(CPK)-212 AlkPhos-93
TotBili-6.3*
[**2149-7-31**] 02:03AM BLOOD Lipase-41
.
Imaging:
.
[**2149-7-29**] Head CT w/o contrast
IMPRESSION:
1. No evidence of acute intracranial process.
2. Stable post-surgical changes as described above.
3. Stable left frontal lobe and left temporal lobe
encephalomalacia with
corresponding ex vacuo dilatation of the frontal [**Doctor Last Name 534**] of the
left lateral
ventricle, likely sequela of prior trauma.
[**2149-7-30**] Abd U/S
IMPRESSION:
1. Significant asymmetric gallbladder wall edema without
associated
gallbladder wall distention, stones or pericholecystic fluid.
Given degree of gallbladder wall edema and lack of distention,
these findings are suggestive of acute hepatitis.
2. Doppler assessment of the hepatic vasculature shows patency,
appropriate waveforms and directionality of flow.
[**2149-7-30**] CXR
FINDINGS: Low lung volumes accentuate the cardiac silhouette and
bronchovascular structures, limiting assessment of the
cardiovascular status of the patient. A questionable area of
confluent opacity has developed in the left retrocardiac region,
and could be confirmed or excluded by repeat a radiograph with
improved inspiratory level. Lungs are otherwise grossly clear,
and there is no pleural effusion or pneumothorax.
[**2149-8-5**] CXR
FINDINGS: Upright PA and lateral views of the chest show slight
decrease in a small right pleural effusion. Cardiomediastinal
and pulmonary structures are unremarkable. Again seen are
multiple rib fractures. No pneumothorax.
IMPRESSION: Slight decrease in small right pleural effusion
Brief Hospital Course:
Mr [**Known lastname 98789**] is 42 a year-old male with a PMH of alcohol abuse,
seizure disorder, traumatic brain injuries requiring multiple
craniotomies in [**2145**] with apparent memory deficit who was found
with a generalized seizure believed secondary to alcohol
withdrawal.
.
He received a loading dose of keppra in the ED. An LP was
performed in the ED found to be negative for infection, tox
screen was negative and antiseizure med levels were
undetectable. He was found to have a lactate of 12.6 which
improved with IVF, and he was started on folate, thiamine and a
multivitamin. He awoke with [**Initials (NamePattern4) **] [**Doctor Last Name 555**] paralysis and was
extubated the evening of admission. Head imaging showed no cause
of seizure, so seizure was believed to be secondary to alcohol
withdrawal and the patient was started on CIWA scale, restarted
on home keppra and encouraged to abstain from alcohol use. He
had no further seizures in the hospital.
.
He was started on Vanc and cefepime for a HCAP for continuing
fevers to 101 and a retrocardiac opacity noted on CXR. Blood cx
and urine cx were negative. He was switched to ceftriaxone and
azithromycin for CAP, and finished a 5 day course on [**8-4**], no
respiratory symptoms or O2 requirement during course. On repeat
CXR he was found to have a small resolving right pleural
effusion upon finishing abx, no evidence of loculations. It was
thought likely this effusion was secondary to inflammation
associated with acute hepatic injury and regeneration.
The first day of admission he was noted to have greatly elevated
LFTs, CK, INR and Tbili. (ALT/AST in the [**2137**], INR 1.7s, bili
to 9). His LFTs, INR and Tbili trended down through his hospital
course, with a negative abd U/S for cholestasis. He was found to
have Hep C, but negative for Hep B, Hep A, AMA and HIV.
Hepatology was consulted and suggested that the damage was
secondary to ischemic injury superimposed on chronic liver
disease from alcohol and hep C. His CK also trended down with
IVF, and Cr returned to baseline.
.
He was somnolent secondary to benzo use per CIWA scale in the
context of liver injury. By discharge he was at baseline mental
status (some confusion, AOX3) per report of sister.
.
TO DO:
Repeat LFTs, INR, bilirubin for continuing downward trend.
Chest X-ray should be repeated in 1 month to follow up right
pleural effusion, with diagnostic tap if persistent.
Medications on Admission:
1 mvi qday
colace 100 [**Hospital1 **]
nicoderm patch
keppra 1000 [**Hospital1 **]
b complex 100 1 tab daily
folic acid 1 mg daily
trazadone 175 mg HS
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
Disp:*60 tab* Refills:*2*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Nicoderm CQ 21 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day.
Disp:*30 patch* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Nizhoni VNA
Discharge Diagnosis:
Primary Diagnoses
Seizure secondary to alcohol withdrawal
Acute liver injury
Acute Kidney Injury secondary to rhabdomyolysis
Secondary Diagnoses
Seizure disorder
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 98789**],
It was a pleasure taking care of you. You were admitted to the
hospital after having a seizure after you stopped drinking
alcohol. While you were here, you were found to have some damage
to your liver which we believe was due to longterm damage from
an infection (hepatitis C), alcohol use, as well as in the short
term a lack of oxygen to your liver. You improved during your
hospitalization but it is very important that you continue to
not drink and take your anti-seizure medications regularly.
There were no medication changes during this hospitalization.
Followup Instructions:
Name: Dr. [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 98791**]
Location: [**Hospital1 2177**] INTERNAL MEDICINE
Address: [**Location (un) **], 5TH FL, Suite B, [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 11463**]
Appointment: Wednesday [**2149-8-13**] 9:00am
*This is a follow up appointment of your hospitalization. You
will be reconnected with your primary care physician after this
visit.
Department: LIVER CENTER
When: THURSDAY [**2149-8-21**] at 10:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2149-8-8**]
|
[
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"286.9",
"303.90",
"285.9",
"275.2",
"276.2",
"296.80",
"275.3",
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] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
10848, 10890
|
7585, 10016
|
311, 346
|
11097, 11097
|
3646, 3646
|
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|
1744, 1893
|
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10042, 10194
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|
5605, 7562
|
2450, 3182
|
1908, 2243
|
3196, 3627
|
264, 273
|
374, 967
|
3662, 5589
|
11112, 11223
|
2267, 2268
|
989, 1185
|
1201, 1728
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,299
| 143,829
|
47061
|
Discharge summary
|
report
|
Admission Date: [**2165-9-9**] Discharge Date: [**2165-10-3**]
Date of Birth: [**2101-8-14**] Sex: F
Service: SURGERY
Allergies:
Codeine / Shellfish
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Recurrent diverticulitis
Major Surgical or Invasive Procedure:
Laparoscopic partial left colectomy with takedown
of splenic flexure; laparotomy, partial colectomy, washout and
temporary abdominal closure; repeated washout, closure, end
colostomy
History of Present Illness:
Mrs. [**Known lastname 7346**] is a 64 year-old female with 7 episodes of
diverticulitis for which she has been hospitalized over the past
decade, 4 episodes within the past
year. She presented after her most recent episode in [**Month (only) **] of
this year for which she completed 2 weeks of antibiotics. She
had avoided surgery for this condition previously but does
request surgical removal of the offending bowel as she does not
want to endure further attacks.
Past Medical History:
Diverticulosis, recurrent diverticulitis, Osteoarthritis,
Osteopenia, Uterine Fibroids, S/P total hysterectomy in [**2150**],
Stable lung nodule, HOH/tinnitus [**2157**], Genital Herpes,
Musculoskeletal disorder, Achilles tendonitis, plantar fasciitis
Social History:
Married, lives in [**Location (un) 538**] with her husband; occasional
alcohol (1-2x/week); remote tobacco use, quit 30 years ago,
denies illicit drug use.
Family History:
Father: CAD father in 80's
Mother: breast cancer
No history of inflammatory bowel disease
Physical Exam:
On presentation:
General appearance: globally orientated, awake, alert
Heent: PERRLA,
Heart: RRR, no M/R/G
Lungs: CTAB
Abdomen: soft, nontender, nondistended, scars c/w prior surgery
Musculoskeletal: within normal limits, warm, well perfused.
Skin: warm, dry
Lymphadenopathy: not present
Anoderm/gluteal area: within normal limits
Tone: normal rectal tone
Mass: None
Hemorrhoid: None
Pertinent Results:
[**2165-9-9**] 02:14PM SODIUM-142 POTASSIUM-4.8 CHLORIDE-104
[**2165-9-9**] 02:14PM MAGNESIUM-2.1
[**2165-9-9**] 02:14PM HCT-38.2
[**2165-9-10**] 05:10AM BLOOD WBC-12.1*# RBC-3.75* Hgb-11.9* Hct-36.1
MCV-96 MCH-31.7 MCHC-32.9 RDW-13.6 Plt Ct-274
[**2165-9-18**] 10:42PM BLOOD WBC-15.7* RBC-4.32# Hgb-13.0# Hct-39.1#
MCV-90 MCH-30.1 MCHC-33.3 RDW-17.8* Plt Ct-382
[**2165-9-19**] 09:11PM BLOOD WBC-16.2* RBC-3.07* Hgb-9.5* Hct-27.0*
MCV-88 MCH-30.9 MCHC-35.1* RDW-17.8* Plt Ct-340
[**2165-9-21**] 04:20AM BLOOD WBC-17.5* RBC-2.69* Hgb-8.2* Hct-24.4*
MCV-91 MCH-30.5 MCHC-33.5 RDW-16.6* Plt Ct-401
[**2165-9-22**] 04:08AM BLOOD WBC-18.1* RBC-2.44* Hgb-7.4* Hct-22.1*
MCV-91 MCH-30.5 MCHC-33.6 RDW-15.9* Plt Ct-466*
[**2165-9-28**] 05:36AM BLOOD WBC-10.0 RBC-2.61* Hgb-8.2* Hct-23.6*
MCV-91 MCH-31.6 MCHC-34.9 RDW-15.7* Plt Ct-594*
[**2165-9-29**] 04:39AM BLOOD WBC-9.4 RBC-2.62* Hgb-8.2* Hct-24.0*
MCV-92 MCH-31.3 MCHC-34.1 RDW-15.7* Plt Ct-491*
[**2165-9-20**] 05:59AM BLOOD PT-13.8* PTT-28.3 INR(PT)-1.2*
[**2165-9-22**] 04:08AM BLOOD PT-13.3 PTT-30.4 INR(PT)-1.1
[**2165-9-10**] 05:10AM BLOOD Glucose-131* UreaN-8 Creat-0.6 Na-140
K-4.6 Cl-104 HCO3-27 AnGap-14
[**2165-9-17**] 05:10AM BLOOD Glucose-123* UreaN-15 Creat-0.5 Na-148*
K-3.5 Cl-106 HCO3-31 AnGap-15
[**2165-9-20**] 06:45PM BLOOD Glucose-131* UreaN-14 Creat-0.8 Na-141
K-3.5 Cl-105 HCO3-27 AnGap-13
[**2165-9-29**] 04:39AM BLOOD Glucose-123* UreaN-22* Creat-0.9 Na-141
K-4.0 Cl-107 HCO3-26 AnGap-12
[**2165-9-27**] 04:43AM BLOOD ALT-13 AST-16 AlkPhos-61 TotBili-0.5
[**2165-9-10**] 05:10AM BLOOD Calcium-7.9* Phos-4.3 Mg-2.1
[**2165-9-19**] 03:41PM BLOOD Calcium-7.3* Phos-6.0* Mg-2.1
[**2165-9-29**] 04:39AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
PORTABLE ABDOMEN Study Date of [**2165-9-15**] 7:09 AM
There is a nasogastric tube with distal tip and side port in the
body of the stomach. This is appropriately sited. Lower lung
fields are clear. There is no free air underneath the
hemidiaphragm. The visualized bowel gas pattern is unremarkable.
Surgical clips are seen within the right upper abdomen.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2165-9-18**] 4:15 PM
1. Abnormal pelvic collection immediately superior to the
anastomotic site
containing air, fluid and contrast compatible with a component
of enteric
leak. Enhancing pseudo wall formation and components of
enhancing adjacent
peritoneum. This collection contains an abnormal loop of distal
colon, which has an appearance suggestive of extensive
pneumatosis with concern overall for ischemia/necrosis of this
distal colonic segment.
2. There is a separate collection demonstrated along the left
paracolic
gutter, containing air and fluid measuring 2.7 x 1.8 cm (series
2: image 31).
CT ABD & PELVIS WITH CONTRAST Study Date of [**2165-10-1**] 2:24 PM
IMPRESSION:
1. At the site of old colostomy, note is made of hyperdense
packing material and a small drain. No surrounding fluid
collections or inflammatory changes to suggest infection.
2. Fluid and air collection adjacent to the left kidney
measuring 3.3 cm x
2.1 cm. There are no definite signs of infection at this time
and given small size, the collection is not amenable to drain
placement although could be aspirated
3. Stable perisplenic fluid collection.
4. Patient is status post sigmoidectomy with splenic flexure
takedown and
second colostomy placement in left lower quadrant. No evidence
of associated infection or obstruction with second colostomy.
5. Small left pleural effusion with adjacent compressive
atelectasis.
Brief Hospital Course:
Ms. [**Known lastname 7346**] is a 64 year old woman with recurrent sigmoid and
descending diverticulitis status-post elective lap partial left
colectomy on [**2165-9-9**]. The patient did well
post-operatively until [**2165-9-10**] when prior to being advanced to a
regular diet, she vomited, requiring nasogastric tube placement.
The patient was managed conservatively for a post-operative
ileus. On [**2165-9-12**] the patient was noted to be passing flatus and
having bowel movements however, continued to have 1000cc from
the nasogastric tube. Clamping trials were attempted and she
eventually passed her clamping trial and the nasogastric tube
was removed. Her diet was advanced from clears to regular. The
patient was doing well, she was ambulating the inpatient unit
and voiding on her own. The patient was accessed multiple times
and stated that she was feeling improved as each day passed, her
pain was managed with pain medications by mouth. The
[**Location (un) 1661**]-[**Location (un) 1662**] drain had been removed from the lower left
quadrant, and was noted to drain a moderate amount of sero-sang
fluid and was sutured closed. The patient complained of moderate
pain in this area, but i caused her minimal distress. On
[**2165-9-18**], the patient ambulated to the bathroom and was noted by
the nursing staff to be draining foul smelling maroon/brown
liquid. This was promptly evaluated by the surgical team, and
the drainage was noted to be malodorous, this was concerning for
stool. The suture was removed and the wound drained a large
amount of this liquid, the site was controlled with an ileostomy
appliance. The patient was in stable condition. She was sent for
a CT scan of the abdomen and pelvis with the intention of ruling
out a fistula. The CT scan in fact showed ischemia/necrosis of
this distal colonic segment. The patient was taken emergently to
the operating room for Laparotomy, partial colectomy, washout
and temporary abdominal closure. After this procedure, the
patient was transferred intubated to the [**Hospital Unit Name 153**].
[**Hospital Unit Name 153**] Course as documented by [**Hospital Unit Name 153**] team:
Regarding her initial ICU stay, she spent 5 days in the ICU for
higher-level care requiring sedation, Lasix drip for diuresis
after receiving much intra-operative fluid as well as for
anticipated closure of her abdominal wound. She was extubated on
POD#3 after her initial resection and wash-out on [**9-18**],
then taken back on [**9-20**] for repeated wash-out, abdominal
wound closure and end-colostomy. She was successfully extubated
again the next day; her pain was controlled with IV Dilaudid.
While in the ICU, her urine output would drift to low 20s, but
would respond with albumin and gentle IV fluids. Her hematocrit
also trended downwards from a pre-operative hematocrit of 27 to
22, with a transfusion threshold of less than 21. However, the
patient's hematocrit began to normalize soon thereafter with no
required transfusions. It was thought that the downward trend
was partially from hemodilution secondary to her intra-operative
resuscitation. She was weaned off of propofol with good pain
control on IV dilaudid with excellent oxygen saturations on 2L
nasal cannula. The patient was transferred to the floor on POD#2
from her abdominal closure and end-colostomy.
By system,
Neurologic: the patient received good pain control
post-operatively after her original laparoscopic sigmoidectomy,
and subsequent ex-laparotomy, wash-outs and closure with
end-colostomy. She received IV dilaudid and PCA with frequent
titration of propofol and fentanyl after her ex-laparotomy and
closure with end-colostomy. As noted, she was successfully
extubated after her three operations and after transfer to the
floor, received good pain control with IV dilaudid and later
transitioned to oral pain medications.
Cardiovascular: the patient received several liters of fluid
peri-operatively for her ex-laparotomy and washouts; for both
maintenance of diuresis and anticipated abdominal closure, she
was placed on lasix drip in the interim for a goal diuresis of
1-2L. She also received albumin boluses amidst diuresis as
needed for urine output and maintenance of an acceptable MAP;
her SBP largely remained within the 90s with no pressor
requirements. She did not experience any significant
cardiovascular issues throughout her admission; vital signs,
urine output and intake were continuously monitored during her
ICU stay.
Pulmonary: as mentioned, the patient was extubated after
laparotomy on [**2165-9-18**] to CPAP then face mask within 24 hours
with excellent oxygen saturations. She was weaned to nasal
cannula, and upon transfer to the floor was maintaining
excellent oxygen saturations on 2-4L nasal cannula. She was
weaned to room air and tolerated it very well and did not have
an oxygen requirement or any other pulmonary issues during the
remainder of her hospitalization.
GI: As noted in the operative report and as found on abdominal
CT on [**2165-9-18**], there was necrosis of the colon in the setting
of recent sigmoid/descending colectomy with splenic flexure
takedown. Given the polymicrobial nature of fluid collection in
her previous JP site, broad spectrum antibiotics consisting of
vancomycin, Zosyn and flagyl were immediately started. She is
now status-post removal of the necrotic tissue with washout,
abdominal closure and end-colostomy, which is healing well with
good output.
.
# Anemia- Hct trended down yesterday to 22, has been stably
there over past day. This is likely [**2-27**] post-op and will
transfuse for <21. Hcts are being followed [**Hospital1 **].
Output from various drains is being closley monitored.
.
# Hypernatremia. Patient??????s Na of 148 may be due to hypovolemic
hypernatremia and dehydration. Pt received 500cc D5W bolus.
.
# Leukocytosis: Elevated WBC, but has been stable over the last
few days. Is likely post-op inflammation. Pt is broadly covered
with vanc/Zosyn/flagyl given abdominal flora as above. Will need
to follow up cultures, although unlikely to get more data given
polymicrobial flora.
Post-operative course after transfer from [**Hospital Unit Name 153**] to inpatient
Floor.
The patient was transferred to the inpatient floor with
nasogastric tube in place, right lower quadrant sump dran and
left lower quadrant penrose drain left in place in old JP drain
site. Her NGT output remained consistently high, in the first
post-operative days, greater than 1-1.5L per day, which
prolonged its placement; however, it was removed as soon as
output decreased to an acceptable range with successful clamped
NGT trial and decreased residuals. The patient tolerated the
clamping trial, and was successfully advanced to a regular diet
within 2-3 days. She was started on continuous TPN with PICC
placement five days post-operatively for additional
supplementation, and was weaned from TPN as her diet was
advanced. On the floor the patient progressed well and continued
to participate in her care and maintained her conditioning. On
[**2165-10-2**] the sump drain was removed and the site was closed with a
suture. The midline wound was noted to have some erythema and
drainage and the superior aspect of the wound was opened and
packed with a wet to dry saline dressing, this was monitored
closely by the inpatient nurses. Because of purulent appearing
drianage from the left lower quadrant penrose [**Last Name (LF) **], [**First Name3 (LF) **] CT of
the abdomen/pelvis was preformed on [**2165-10-1**] which did not show an
intraabdominal process. On [**2165-10-2**] all intravenous antibiotics
were discontinued and the patient was started on a 14 day course
of Augmentin which she was to complete as an outpatient. On
[**2165-10-3**] the patient was stable and ready for discharge. She was
discharged home in stable condition with visiting nursing
services arranged.
Medications on Admission:
Ca-carbonate-Vit D3, Multivitamin
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 10 days: Please do not drink alcohol or
drive a car while taking this medication. .
Disp:*40 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): do not drink alcohol while taking this medication, do
not take more than 4000mg of tylenol daily.
4. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 13 days.
Disp:*26 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent diverticulitis
Discharge Condition:
Mental status: alert, awake, cooperative with plan of care.
Ambulatory status: walking independently without assistance.
Discharge Instructions:
You were admitted to the hospital for surgery to address your
recurrent diverticulitis. You initially underwent a laparoscopic
sigmoidectomy on [**2165-9-9**]. However, you had some nausea
within the first few post-operative days and and NGT
([**Last Name (un) **]-gastric tube that goes into your stomach to drain fluid)
was placed within the first few days. It was noted on the 9th
day after your surgery that you had some feculent material
coming from your older drain site on your left side--a CT scan
of your abdomen showed that there was feculent material and no
perfusion to your left colon. You were then taken to the
operating room to remove this part of your colon and to remove
any feculent material; you underwent another operation in two
days to close your abdominal wound with the placement of 2
drains and a colostomy.
Since then, you have been recovering well. Your colostomy has
been producing gas and appropriate output, and you have been
tolerating your diet. You were initially given TPN (nutrition
through the IV) to provide nutrition in the interim before you
were progressed to a regular diet. Your pain was well
controlled, and you could ambulate well on a daily basis.
Colostomy care:
You have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. You should have [**1-27**]
bowel movements daily. If you notice that you have not had any
stool from your stoma in [**1-27**] days, please call the office. You
may take an over the counter stool softener such as colace if
you find that you are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if you notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for bulging or signs
of infection listed above. Please care for the ostomy as you
have been instructed by the wound/ostomy nurses. You will be
able to make an appointment with the ostomy nurse in the clinic
a few days after surgery. You will have a visiting nurse at home
for the next few weeks helping to monitor your ostomy until you
are comfortable caring for it on your own. Please call Dr. [**Name (NI) 38196**] office if you are starting to notice symptoms of
constipation for advice.
Please monitor your abdominal function closely. If you notice
any of the following symptoms please call the office: nausea,
vomiting, increased abdominal pain, increased abdominal
distension, constipation, or inability to tolerate food or
liquids.
Wound care:
You have a long vertical incision on your abdomen that is closed
with staples. Part of this incision is opened (in the top
portion) and must be changed twice daily with saline moist to
dry dressings as you will be instructed by the visiting nurses
and floor nurses. The care of this wound will change when you
are seen in clinic. This incision can be left open to air or
covered with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. You also
have a small opening in your left lower abdomen where the
Penrose drain once was, this should be clensed in the shower
with warm water and covered with a gauze dressing and changed as
needed. The site in the right lower quadrant where the sump dran
was placed is closed with a suture and this can be covered with
a dry sterile dressing and monitored for infection as the other
incisions will be. Please monitor the incision for signs and
symptoms of infection including: increasing redness at the
incision, opening of the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever.
You will have VNA nurses to help with your ostomy and wound
care: please refer to the ostomy handouts per your ostomy
teaching while in the hospital for further details. Regarding
your abdominal incision, please apply wet to dry dressings daily
until your follow-up with Dr. [**Last Name (STitle) 1120**] in clinic, who will then
recommend any changes. Your VNA nurses will also be able to help
with dressing changes in the beginning until you are comfortable
doing so on your own.
You may shower, let the warm water run over the incision line
and pat the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**]. You may gradually increase
your activity as tolerated but clear heavy exercise for [**3-29**]
weeks.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1120**] in [**3-29**] weeks; you may call her
office at [**Telephone/Fax (1) 160**] to schedule an appointment.
Please call the wound-ostomy nurse clinic to make a follow-up
appointment to review your wound care and care of your
colostomy.
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-27**] weeks to discuss your
recent hospitalization.
Completed by:[**2165-10-3**]
|
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"733.90",
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"285.1",
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"997.4",
"557.0",
"560.1",
"568.0",
"562.11",
"536.3",
"998.11",
"998.2",
"E870.8",
"275.41",
"276.0"
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icd9cm
|
[
[
[]
]
] |
[
"17.35",
"45.75",
"46.11",
"99.15",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
14157, 14215
|
5512, 13420
|
303, 488
|
14284, 14284
|
1966, 5489
|
19944, 20385
|
1452, 1543
|
13504, 14134
|
14236, 14263
|
13446, 13481
|
14431, 17315
|
1558, 1947
|
239, 265
|
17327, 19921
|
516, 987
|
14299, 14407
|
1009, 1262
|
1278, 1436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,699
| 144,228
|
11642+11663
|
Discharge summary
|
report+report
|
Admission Date: [**2169-7-4**] Discharge Date: [**2169-7-13**]
Date of Birth: [**2108-4-24**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
right-handed gentleman who had a fall six to eight weeks
prior to admission and was brought to [**Hospital3 35151**] where an MRI showed a cord compression at the C1-C2
level. The patient was transferred to [**Hospital1 190**], was evaluated by Dr. [**Last Name (STitle) 1327**], and was
discharged to rehabilitation with follow up for surgery. The
patient was admitted on [**2169-7-4**] for surgery on [**2169-7-5**].
The patient has a long-standing history of rheumatoid
arthritis and cervical myelopathy secondary now to this
periodontoid mass and pannus with CMJ compression. There was
also an intrinsic cord signal abnormality of C1 and C2.
PHYSICAL EXAMINATION: On admission physical examination he
was awake, alert and oriented x 3 with fluent speech. His
temperature was 97.9, blood pressure 116/70, heart rate 61,
respiratory rate 18, saturations 96% on room air. His
deltoids were 4- on the right, 4 on the left, biceps 4- on
the right, 4 on the left, triceps 4- on the right and 4 on
the left, wrist extension was 4- on the right, 4+ on the
left, wrist flexion was 4 and 4 on the left and right, grasp
4- on the right, 4+ on the left, intrinsics were 2 and 2, IPs
were 4 on the right, 4+ on the left, quads 4+ bilaterally,
hamstrings 4 bilaterally, ATs 5 on the right, 4 on the left,
extensor hallucis longus 4+ on the right, 4+ on the left, and
plantar-flexion was 4+ bilaterally. His reflexes were 3+
throughout. He had negative Hoffmann. Sensation was
decreased to light touch in his lower extremities. He was
admitted for a preoperative evaluation.
HOSPITAL COURSE: On [**2169-7-5**] he was taken to the operating
room and underwent a transoral resection of the odontoid and
associated rheumatoid pannus, and cervico-occipital fusion
without intraoperative complications. Postoperatively the
patient was intubated and monitored in the intensive care
unit. His vital signs were stable. He was following
commands, opening his eyes, moving his hands. His pupils
were equal, round and reactive to light. His extraocular
movements were full. He localized to light touch in all four
extremities with movement by commands. His reflexes were 2
on the right side, 1 on the left in the knees, 4+ at the
ankles. Smile was symmetric. His vital signs were stable
and he was afebrile.
Postoperatively his motor examination was 3+ in the triceps,
4- in the biceps bilaterally, 4- in the triceps bilaterally,
4 in the wrist extension, 4 in the wrist flexion on the right
and 4+ on the left. His IPs were 4+ bilaterally, quads 4,
hamstrings 4, ATs 4+, gastrocnemius 4+ and extensor hallucis
longus 4+ bilaterally.
He was extubated on [**2169-7-7**] which he tolerated. He was
moving all extremities, ............... 4+/5 bilaterally in
the upper extremities, he had antigravity strength. His
vital signs remained stable. He continued to have a Hemovac
drain in place.
He was evaluated by physical therapy. His Hemovac drain was
discontinued on [**2169-7-9**] and the patient was transferred to
the regular floor on [**2169-7-8**]. He was seen by physical
therapy and occupational therapy and found to require a short
rehabilitation stay prior to discharge to home. He was
started on clear liquids on [**2169-7-10**] and then to full regular
diet on [**2169-7-12**], which he tolerated well, requiring frequent
pain medication for posterior neck and posterior head pain.
His other vital signs have remained stable.
DISCHARGE MEDICATIONS:
1. Percocet 1-2 tablets p.o. q. 4 hours p.r.n.
2. Famotidine 20 mg p.o. b.i.d.
3. Metoprolol 12.5 mg p.o. b.i.d.
4. Flexeril 10 mg p.o. t.i.d. p.r.n.
5. Heparin 5,000 units subcutaneous q. 12 hours.
6. Nicotine 21 mg topically q. day.
7. Tylenol 650 p.o./p.r. q. 4-6 hours p.r.n.
CONDITION ON DISCHARGE: Stable with incision line clean, dry
and intact.
FOLLOW-UP PLANS: He should follow up with Dr. [**Last Name (STitle) 1327**] in one
week for staple removal.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2169-7-13**] 09:49
T: [**2169-7-13**] 10:08
JOB#: [**Job Number 36920**]
Admission Date: [**2169-7-4**] Discharge Date: [**2169-7-14**]
Date of Birth: [**2108-4-24**] Sex: M
Service: #58
HISTORY OF PRESENT ILLNESS: This is a 62 year-old right
handed male who had fallen six to eight weeks previous to
admission and was brought to an outside hospital where an MRI
done showed cord compression. The patient felt weak and
unable to move.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern4) 36958**]
MEDQUIST36
D: [**2169-7-14**] 09:46
T: [**2169-7-14**] 10:11
JOB#: [**Job Number 36959**]
|
[
"401.9",
"533.90",
"720.0",
"E935.9",
"721.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.01",
"99.15",
"38.93",
"77.89",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3657, 3938
|
1783, 3634
|
862, 1765
|
4031, 4524
|
4553, 5043
|
3963, 4013
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,540
| 178,449
|
54772
|
Discharge summary
|
report
|
Admission Date: [**2141-7-5**] Discharge Date: [**2141-8-3**]
Date of Birth: [**2114-4-7**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Compartment syndrome
Major Surgical or Invasive Procedure:
[**2141-7-5**] Left lower and upper extremity fasciotomies
[**2141-7-10**] Left lower extremity debridement, Left medial thigh
closure
[**2141-7-14**] Left lower extremity debridement
[**2141-7-21**] Left lower extremity debridement
History of Present Illness:
27M presents to an OSH with significantly increasing left lower
extremity pain, numbness and tingling. Patient reports passing
out at home two days ago,
after drinking, and waking up one day prior to admission, with
numbness and tingling in the left foot. He reports increasingly
worsening pain, with loss of function and sensation. He also
reports a painful rash which started in the left lower extremity
extended upward into the groin and abdomen. There are also some
blisters on this rash. He reports otherwise being in his usual
state of health.
Past Medical History:
IV drug abuse, bilateral inguinal hernias as a child
Social History:
IV drug use, theough denies for the past six months, occasional
alcohol, half a pack a day of tobacco.
Family History:
negative for any vascular history
Physical Exam:
Vital Signs: Temp: 98.2 RR: 18 Pulse: 91 BP: 167/96
Neuro/Psych: Oriented x3, Affect Normal, abnormal: Appears in
moderate discomfort.
Neck: No masses, Trachea midline.
Skin: No atypical lesions.
Heart: Regular rate and rhythm, abnormal: Negative for any
murmur.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound.
Extremities: No femoral bruit/thrill, abnormal: Left lower leg
with edemetous anterior compartment and fasciotomies on the
medial and lateral sides. Moderate tenderness to palpation.
Minimal tenderness passive motion. 10 x 4 cm erythematous patch
on the lateral lower leg. Scattered blistering.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
LUE Radial: P.
RLE Femoral: P. Popiteal: P. DP: P. PT: P.
LLE Femoral: P. Popiteal: P. DP: N. PT: D.
Pertinent Results:
[**2141-7-6**] 07:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2141-7-6**] 07:00PM BLOOD HCV Ab-POSITIVE*
Cardiovascular Report ECG Study Date of [**2141-7-5**] 4:39:10 PM
Sinus tachycardia. Peaked P waves with rightward P axis
consistent with right atrial abnormality. Low limb lead voltage.
Delayed precordial R wave
transition. No previous tracing available for comparison.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
113 154 80 294/386 65 33 41
[**2141-7-5**] LENIES
IMPRESSION: No evidence of deep venous thrombosis in the left
or right lower extremities. On the left, the popliteal vein is
narrowed due to overlying soft tissue swelling; however, is
patent.
8.28.2 CXR
FINDINGS: As compared to the previous radiograph, the patient
has received a new double-lumen central venous catheter over a
left-sided approach. The tip projects over the right atrium,
there is no evidence of complications, notably no pneumothorax.
All pre-existing monitoring and support devices, including the
endotracheal tube and tunneled hemodialysis line, has been
removed.
CBCs
[**2141-8-3**] 07:15AM BLOOD WBC-6.0 RBC-3.00* Hgb-8.7* Hct-26.2*
MCV-87 MCH-28.9 MCHC-33.1 RDW-13.3 Plt Ct-538*
[**2141-8-2**] 06:55AM BLOOD WBC-6.9 RBC-3.18* Hgb-9.4* Hct-27.6*
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.4 Plt Ct-573*
[**2141-8-1**] 07:10AM BLOOD WBC-6.7 RBC-3.05* Hgb-8.9* Hct-26.9*
MCV-88 MCH-29.1 MCHC-33.1 RDW-13.4 Plt Ct-515*
[**2141-7-31**] 07:05AM BLOOD WBC-6.5 RBC-3.08* Hgb-8.9* Hct-26.9*
MCV-88 MCH-29.0 MCHC-33.1 RDW-13.3 Plt Ct-502*
[**2141-7-30**] 03:14AM BLOOD WBC-5.3 RBC-3.26* Hgb-9.6* Hct-28.8*
MCV-88 MCH-29.3 MCHC-33.2 RDW-13.5 Plt Ct-450*
[**2141-7-28**] 04:01AM BLOOD WBC-5.3 RBC-2.98* Hgb-8.8* Hct-26.3*
MCV-88 MCH-29.7 MCHC-33.6 RDW-13.5 Plt Ct-424
[**2141-7-27**] 05:40AM BLOOD WBC-4.9 RBC-3.27* Hgb-9.5* Hct-28.9*
MCV-88 MCH-29.1 MCHC-33.0 RDW-13.5 Plt Ct-437
[**2141-7-26**] 03:04AM BLOOD WBC-4.2 RBC-3.06* Hgb-8.9* Hct-26.5*
MCV-87 MCH-29.1 MCHC-33.6 RDW-14.0 Plt Ct-402
[**2141-7-25**] 03:37AM BLOOD WBC-8.1 RBC-3.56* Hgb-10.3* Hct-31.3*
MCV-88 MCH-29.0 MCHC-32.9 RDW-14.1 Plt Ct-539*
[**2141-7-24**] 07:07AM BLOOD WBC-6.2 RBC-3.24*# Hgb-9.4*# Hct-28.3*
MCV-87 MCH-28.9 MCHC-33.2 RDW-14.5 Plt Ct-424
[**2141-7-23**] 07:05AM BLOOD Hct-27.4*
[**2141-7-22**] 04:55PM BLOOD Hct-27.0*#
[**2141-7-22**] 06:18AM BLOOD WBC-7.4 RBC-2.40* Hgb-7.2* Hct-21.3*
MCV-89 MCH-30.2 MCHC-34.0 RDW-13.9 Plt Ct-449*
[**2141-7-21**] 05:55PM BLOOD Hct-24.7*
[**2141-7-21**] 06:17AM BLOOD WBC-8.7 RBC-2.46* Hgb-7.2* Hct-21.5*
MCV-87 MCH-29.1 MCHC-33.4 RDW-13.9 Plt Ct-398
[**2141-7-20**] 06:35AM BLOOD WBC-11.5* RBC-2.86* Hgb-8.4* Hct-24.5*
MCV-86 MCH-29.2 MCHC-34.0 RDW-14.1 Plt Ct-423
[**2141-7-19**] 06:50AM BLOOD WBC-11.0 RBC-2.88* Hgb-8.5* Hct-24.8*
MCV-86 MCH-29.7 MCHC-34.4 RDW-14.4 Plt Ct-460*
[**2141-7-18**] 05:15AM BLOOD WBC-14.8* RBC-3.21* Hgb-9.5* Hct-27.1*
MCV-85 MCH-29.5 MCHC-34.9 RDW-14.6 Plt Ct-522*
[**2141-7-17**] 07:25AM BLOOD WBC-17.3* RBC-3.30* Hgb-9.8* Hct-28.3*
MCV-86 MCH-29.6 MCHC-34.5 RDW-14.7 Plt Ct-468*
[**2141-7-16**] 06:45AM BLOOD WBC-17.2* RBC-3.10*# Hgb-9.0*# Hct-26.6*#
MCV-86 MCH-28.9 MCHC-33.8 RDW-14.9 Plt Ct-345
[**2141-7-15**] 06:04AM BLOOD WBC-16.8* RBC-2.41* Hgb-6.9* Hct-20.1*
MCV-83 MCH-28.7 MCHC-34.4 RDW-15.3 Plt Ct-351
[**2141-7-14**] 02:08PM BLOOD WBC-17.5* RBC-2.78* Hgb-8.1* Hct-23.2*
MCV-84 MCH-29.1 MCHC-34.9 RDW-15.1 Plt Ct-423
[**2141-7-14**] 02:38AM BLOOD WBC-17.8* RBC-3.03* Hgb-8.7* Hct-25.3*
MCV-83 MCH-28.7 MCHC-34.4 RDW-15.1 Plt Ct-329
[**2141-7-13**] 03:07PM BLOOD WBC-14.6* RBC-3.20* Hgb-9.1* Hct-26.6*
MCV-83 MCH-28.6 MCHC-34.3 RDW-14.7 Plt Ct-302#
[**2141-7-12**] 08:50PM BLOOD WBC-12.9* RBC-3.03* Hgb-8.5* Hct-24.9*
MCV-82 MCH-28.2 MCHC-34.3 RDW-14.7 Plt Ct-197
[**2141-7-12**] 03:59AM BLOOD WBC-11.4* RBC-3.04* Hgb-8.6* Hct-25.3*
MCV-83 MCH-28.4 MCHC-34.2 RDW-13.7 Plt Ct-179
[**2141-7-11**] 04:57AM BLOOD WBC-10.6 RBC-3.03* Hgb-8.5* Hct-25.2*
MCV-83 MCH-28.2 MCHC-33.9 RDW-13.5 Plt Ct-208
[**2141-7-10**] 01:03PM BLOOD WBC-9.9 RBC-3.29* Hgb-9.6* Hct-27.4*
MCV-83 MCH-29.3 MCHC-35.2* RDW-13.3 Plt Ct-174
[**2141-7-10**] 03:52AM BLOOD WBC-11.9* RBC-3.55* Hgb-10.1* Hct-29.7*
MCV-84 MCH-28.4 MCHC-33.9 RDW-13.5 Plt Ct-183
[**2141-7-9**] 04:05AM BLOOD WBC-12.0* RBC-3.94* Hgb-11.4* Hct-33.4*
MCV-85 MCH-28.9 MCHC-34.2 RDW-13.3 Plt Ct-229
[**2141-7-8**] 03:56AM BLOOD WBC-9.8 RBC-4.24* Hgb-12.2* Hct-35.2*
MCV-83 MCH-28.8 MCHC-34.7 RDW-12.9 Plt Ct-210
[**2141-7-7**] 03:56AM BLOOD WBC-8.7 RBC-4.28* Hgb-12.5* Hct-35.9*
MCV-84 MCH-29.2 MCHC-34.8 RDW-13.0 Plt Ct-182
[**2141-7-6**] 02:36AM BLOOD WBC-11.9* RBC-4.32* Hgb-12.5* Hct-36.0*#
MCV-83 MCH-28.9 MCHC-34.7 RDW-12.9 Plt Ct-185
[**2141-7-5**] 10:51PM BLOOD WBC-8.2# RBC-3.46*# Hgb-10.0*# Hct-28.7*#
MCV-83 MCH-28.8 MCHC-34.8 RDW-12.9 Plt Ct-186
[**2141-7-5**] 03:55PM BLOOD WBC-23.2* RBC-5.93 Hgb-16.8 Hct-50.1
MCV-85 MCH-28.3 MCHC-33.5 RDW-12.9 Plt Ct-310
Basic Metabolic Profiles
[**2141-8-3**] 07:15AM BLOOD Glucose-87 UreaN-15 Creat-1.5* Na-138
K-4.7 Cl-97 HCO3-38* AnGap-8
[**2141-8-2**] 06:55AM BLOOD Glucose-86 UreaN-16 Creat-1.6* Na-138
K-4.4 Cl-98 HCO3-36* AnGap-8
[**2141-8-1**] 07:10AM BLOOD Glucose-83 UreaN-13 Creat-1.4* Na-141
K-3.9 Cl-100 HCO3-36* AnGap-9
[**2141-7-31**] 07:05AM BLOOD Glucose-97 UreaN-14 Creat-1.4* Na-142
K-3.9 Cl-103 HCO3-33* AnGap-10
[**2141-7-30**] 03:38PM BLOOD Glucose-101* UreaN-16 Creat-1.5* Na-143
K-4.3 Cl-103 HCO3-35* AnGap-9
[**2141-7-30**] 03:14AM BLOOD Glucose-85 UreaN-18 Creat-1.6* Na-142
K-3.8 Cl-103 HCO3-32 AnGap-11
[**2141-7-29**] 02:00PM BLOOD Na-142 K-3.8 Cl-104
[**2141-7-29**] 02:57AM BLOOD Glucose-94 UreaN-21* Creat-1.7* Na-140
K-3.7 Cl-103 HCO3-30 AnGap-11
[**2141-7-28**] 01:15PM BLOOD UreaN-26* Creat-1.8* Na-143 K-3.8 Cl-104
[**2141-7-28**] 04:01AM BLOOD Glucose-111* UreaN-32* Creat-1.9* Na-140
K-4.1 Cl-103 HCO3-33* AnGap-8
[**2141-7-27**] 05:40AM BLOOD Glucose-102* UreaN-40* Creat-2.6* Na-138
K-4.6 Cl-100 HCO3-27 AnGap-16
[**2141-7-26**] 03:04AM BLOOD Glucose-104* UreaN-42* Creat-2.8* Na-139
K-4.5 Cl-101 HCO3-33* AnGap-10
[**2141-7-25**] 03:37AM BLOOD Glucose-110* UreaN-41* Creat-3.2* Na-136
K-4.3 Cl-98 HCO3-29 AnGap-13
[**2141-7-24**] 07:07AM BLOOD Glucose-94 UreaN-35* Creat-3.1* Na-137
K-4.7 Cl-97 HCO3-31 AnGap-14
[**2141-7-23**] 07:05AM BLOOD Glucose-99 UreaN-28* Creat-3.1*# Na-138
K-4.3 Cl-99 HCO3-32 AnGap-11
[**2141-7-22**] 06:18AM BLOOD Glucose-97 UreaN-55* Creat-5.0* Na-133
K-3.9 Cl-96 HCO3-29 AnGap-12
[**2141-7-21**] 06:17AM BLOOD Glucose-98 UreaN-46* Creat-4.3*# Na-131*
K-4.3 Cl-93* HCO3-31 AnGap-11
[**2141-7-20**] 06:35AM BLOOD Glucose-130* UreaN-89* Creat-6.8*#
Na-128* K-4.6 Cl-90* HCO3-27 AnGap-16
[**2141-7-19**] 06:50AM BLOOD Glucose-105* UreaN-67* Creat-5.7*#
Na-127* K-4.7 Cl-90* HCO3-29 AnGap-13
[**2141-7-18**] 05:15AM BLOOD Glucose-94 UreaN-115* Creat-8.3* Na-125*
K-5.5* Cl-86* HCO3-22 AnGap-23*
[**2141-7-17**] 09:07PM BLOOD Glucose-86 UreaN-109* Creat-8.1* Na-125*
K-5.8* Cl-86* HCO3-23 AnGap-22*
[**2141-7-17**] 04:10PM BLOOD Glucose-85 UreaN-101* Creat-7.6* Na-121*
K-5.5* Cl-85* HCO3-20* AnGap-22*
[**2141-7-17**] 07:25AM BLOOD Glucose-90 UreaN-94* Creat-7.4*# Na-127*
K-5.3* Cl-87* HCO3-24 AnGap-21*
[**2141-7-16**] 06:45AM BLOOD Glucose-89 UreaN-76* Creat-5.5*# Na-129*
K-4.4 Cl-91* HCO3-27 AnGap-15
[**2141-7-15**] 06:04AM BLOOD Glucose-99 UreaN-93* Creat-6.9*# Na-126*
K-5.5* Cl-91* HCO3-25 AnGap-16
[**2141-7-14**] 02:08PM BLOOD Glucose-91 UreaN-122* Creat-8.6* Na-127*
K-5.9* Cl-91* HCO3-22 AnGap-20
[**2141-7-14**] 02:38AM BLOOD Glucose-85 UreaN-110* Creat-7.9* Na-127*
K-5.3* Cl-89* HCO3-23 AnGap-20
[**2141-7-13**] 03:07PM BLOOD Glucose-89 UreaN-92* Creat-7.0*# Na-129*
K-4.9 Cl-90* HCO3-25 AnGap-19
[**2141-7-12**] 08:50PM BLOOD Glucose-92 UreaN-64* Creat-4.9*# Na-130*
K-4.1 Cl-93* HCO3-25 AnGap-16
[**2141-7-12**] 03:59AM BLOOD Glucose-100 UreaN-98* Creat-7.1*# Na-129*
K-4.2 Cl-90* HCO3-25 AnGap-18
[**2141-7-11**] 04:57AM BLOOD Glucose-93 UreaN-62* Creat-5.0* Na-131*
K-4.3 Cl-92* HCO3-26 AnGap-17
[**2141-7-10**] 01:03PM BLOOD Glucose-99 UreaN-66* Creat-6.0* Na-133
K-4.9 Cl-94* HCO3-25 AnGap-19
[**2141-7-10**] 03:52AM BLOOD Glucose-90 UreaN-61* Creat-5.9* Na-131*
K-4.9 Cl-91* HCO3-27 AnGap-18
[**2141-7-9**] 05:05PM BLOOD Na-129* K-5.5* Cl-92*
[**2141-7-9**] 10:49AM BLOOD Na-129* K-5.8* Cl-93*
[**2141-7-9**] 04:05AM BLOOD Glucose-96 UreaN-49* Creat-5.7* Na-134
K-5.9* Cl-94* HCO3-28 AnGap-18
[**2141-7-8**] 05:48PM BLOOD Na-132* K-5.9* Cl-94*
[**2141-7-8**] 03:56AM BLOOD Glucose-100 UreaN-39* Creat-4.9* Na-134
K-5.7* Cl-96 HCO3-26 AnGap-18
[**2141-7-7**] 09:20PM BLOOD Na-133 K-5.4* Cl-97
[**2141-7-7**] 10:53AM BLOOD Glucose-100 Na-128* K-5.3* Cl-96 HCO3-28
AnGap-9
[**2141-7-7**] 03:56AM BLOOD Glucose-100 UreaN-35* Creat-3.9* Na-127*
K-5.4* Cl-97 HCO3-26 AnGap-9
[**2141-7-7**] 12:23AM BLOOD Na-128* K-4.9 Cl-99
[**2141-7-6**] 05:08AM BLOOD Glucose-79 Na-130* K-5.1 Cl-96
[**2141-7-6**] 02:36AM BLOOD Glucose-70 UreaN-55* Creat-4.7* Na-132*
K-5.3* Cl-98 HCO3-23 AnGap-16
[**2141-7-5**] 10:51PM BLOOD Glucose-260* UreaN-55* Creat-4.4* Na-131*
K-5.3* Cl-100 HCO3-23 AnGap-13
[**2141-7-5**] 10:00PM BLOOD Glucose-104* UreaN-56* Creat-4.5* Na-135
K-5.3* Cl-101 HCO3-22 AnGap-17
[**2141-7-5**] 07:35PM BLOOD Glucose-78 UreaN-56* Creat-4.8* Na-131*
K-6.9* Cl-101 HCO3-19* AnGap-18
[**2141-7-5**] 03:55PM BLOOD Glucose-91 UreaN-53* Creat-5.0* Na-130*
K-7.2* Cl-92* HCO3-22 AnGap-23*
Calcium, Magnesium, Phosphorus
[**2141-8-3**] 07:15AM BLOOD Calcium-9.9 Phos-4.0 Mg-2.1
[**2141-8-2**] 06:55AM BLOOD Calcium-10.0 Phos-3.6 Mg-2.1
[**2141-8-1**] 09:50PM BLOOD Calcium-10.5*
[**2141-8-1**] 07:10AM BLOOD Calcium-10.3 Phos-3.2 Mg-1.8
[**2141-7-31**] 07:05AM BLOOD Calcium-11.6* Phos-3.5 Mg-2.0
[**2141-7-30**] 03:38PM BLOOD Calcium-12.1* Phos-3.2 Mg-1.9
[**2141-7-30**] 03:14AM BLOOD Calcium-12.3* Phos-4.0 Mg-1.4*
[**2141-7-29**] 02:00PM BLOOD Calcium-12.7*
[**2141-7-29**] 02:57AM BLOOD Calcium-12.8* Phos-4.3 Mg-1.6
[**2141-7-28**] 01:15PM BLOOD Calcium-13.6* Phos-5.4* Mg-1.6
[**2141-7-28**] 04:01AM BLOOD Calcium-13.6* Phos-6.2* Mg-1.8
[**2141-7-27**] 01:00PM BLOOD Calcium-13.8*
[**2141-7-27**] 05:40AM BLOOD Calcium-14.2* Phos-7.4* Mg-1.8
[**2141-7-26**] 03:04AM BLOOD Albumin-2.4* Calcium-12.3* Phos-6.8*
Mg-2.0
[**2141-7-25**] 03:37AM BLOOD Calcium-11.4* Phos-7.1* Mg-2.1
[**2141-7-24**] 07:07AM BLOOD Calcium-10.3 Phos-6.5* Mg-2.0
[**2141-7-23**] 07:05AM BLOOD Calcium-9.2 Phos-5.0* Mg-2.0
[**2141-7-22**] 06:18AM BLOOD Calcium-8.2* Phos-5.8* Mg-2.2
[**2141-7-21**] 06:17AM BLOOD Calcium-8.1* Phos-5.4*# Mg-2.2
[**2141-7-20**] 06:35AM BLOOD Calcium-8.0* Phos-8.2* Mg-2.3
[**2141-7-19**] 06:50AM BLOOD Calcium-7.1* Phos-7.5*# Mg-2.2
[**2141-7-18**] 05:15AM BLOOD Calcium-7.0* Phos-10.7*# Mg-2.3
[**2141-7-17**] 07:25AM BLOOD Calcium-7.9* Phos-8.9* Mg-2.3
[**2141-7-16**] 06:45AM BLOOD Calcium-7.5* Phos-7.6* Mg-2.2
[**2141-7-15**] 06:04AM BLOOD Calcium-7.0* Phos-8.2*# Mg-2.2
[**2141-7-14**] 02:08PM BLOOD Calcium-7.1* Phos-10.1*# Mg-2.4
[**2141-7-14**] 02:38AM BLOOD Calcium-7.7* Phos-8.5*# Mg-2.4
[**2141-7-13**] 03:07PM BLOOD Calcium-7.8* Phos-6.9*# Mg-2.4
[**2141-7-13**] 11:58AM BLOOD Albumin-2.3* Iron-47
[**2141-7-12**] 08:50PM BLOOD Albumin-2.6* Calcium-6.9* Phos-4.9*#
Mg-2.2
[**2141-7-12**] 03:59AM BLOOD Calcium-7.2* Phos-6.8* Mg-2.6
[**2141-7-11**] 04:57AM BLOOD Calcium-7.2* Phos-6.6*# Mg-2.4
[**2141-7-10**] 01:03PM BLOOD Calcium-6.9* Phos-8.6* Mg-2.5
[**2141-7-10**] 03:52AM BLOOD Calcium-7.1* Phos-7.7* Mg-2.4
[**2141-7-9**] 05:05PM BLOOD Mg-2.3
[**2141-7-9**] 04:05AM BLOOD Calcium-7.3* Phos-8.5*# Mg-2.4
[**2141-7-8**] 05:48PM BLOOD Mg-2.0
[**2141-7-8**] 03:56AM BLOOD Calcium-7.4* Phos-5.7* Mg-1.9
[**2141-7-7**] 09:20PM BLOOD Mg-1.9
[**2141-7-7**] 10:53AM BLOOD Calcium-7.6*
[**2141-7-7**] 03:56AM BLOOD Albumin-1.9* Calcium-7.8* Phos-4.2#
Mg-1.7
[**2141-7-6**] 04:34PM BLOOD Calcium-6.2*
[**2141-7-6**] 11:54AM BLOOD Calcium-5.9*
[**2141-7-6**] 02:36AM BLOOD Calcium-6.5* Phos-6.7* Mg-2.2
[**2141-7-5**] 10:51PM BLOOD Calcium-5.8* Phos-6.0*# Mg-2.1
[**2141-7-5**] 03:55PM BLOOD Albumin-3.3* Calcium-7.4* Phos-7.7*
Mg-2.8*
[**2141-8-3**] 08:31AM BLOOD freeCa-1.31
[**2141-8-2**] 07:32AM BLOOD freeCa-1.31
[**2141-8-1**] 10:21PM BLOOD freeCa-1.37*
[**2141-7-31**] 07:19AM BLOOD freeCa-1.43*
[**2141-7-30**] 02:23PM BLOOD freeCa-1.56*
[**2141-7-29**] 02:18PM BLOOD freeCa-1.64*
[**2141-7-29**] 03:09AM BLOOD freeCa-1.63*
[**2141-7-28**] 01:24PM BLOOD freeCa-1.59*
[**2141-7-28**] 04:06AM BLOOD freeCa-1.79*
[**2141-7-27**] 09:54AM BLOOD freeCa-1.84*
[**2141-7-10**] 01:11PM BLOOD freeCa-0.92*
[**2141-7-9**] 05:16PM BLOOD freeCa-0.93*
[**2141-7-9**] 04:27AM BLOOD freeCa-0.95*
[**2141-7-9**] 12:11AM BLOOD freeCa-0.93*
[**2141-7-8**] 05:57PM BLOOD freeCa-0.92*
[**2141-7-8**] 04:05AM BLOOD freeCa-0.97*
[**2141-7-7**] 09:27PM BLOOD freeCa-1.00*
[**2141-7-7**] 04:13AM BLOOD freeCa-1.01*
[**2141-7-7**] 12:35AM BLOOD freeCa-1.08*
[**2141-7-6**] 05:19AM BLOOD freeCa-1.04*
[**2141-7-6**] 02:44AM BLOOD freeCa-0.93*
[**2141-7-5**] 10:59PM BLOOD freeCa-0.84*
[**2141-7-5**] 09:15PM BLOOD freeCa-1.02*
[**2141-7-5**] 08:52PM BLOOD freeCa-0.87*
HIV/hepatitis viral titers
[**2141-7-26**] 12:55PM BLOOD HIV Ab-NEGATIVE
[**2141-7-6**] 07:00PM BLOOD HCV Ab-POSITIVE*
[**2141-7-6**] 07:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
toxicology on admission
[**2141-7-5**] 03:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
This patient is a 27-year-old gentleman who two days prior to
admission was found down by his mother for an indeterminate
period of time, but felt greater than 10 hours, secondary to
narcotic abuse and alcohol intoxication. On presentation to the
ER he had an elevated CK of greater than 160,000 and a
creatinine of 5 and a cool mottled left foot with absent Doppler
signals and no motor sensation below-the-knee. It was felt he
had developed a compartment syndrome in the setting of likely
being in the same position for several hours and was brought
urgently to the OR for left lower extremity fasciotomies.
Cardiovascular
He had a fasciotomy done for his compartment syndrome. He
required subsequent debridements (three) where necrotic muscle
in the lateral compartment was heavily debrided. It was felt he
suffered severed, likely irreparable damage to his superficial
peroneal nerve. His deep peroneal nerve, on the other hand,
recovered somewhat with respect to sensation. His tibial nerve
was less clear, but at least some sensation was present during
his stay over the medial plantar branch cutaneous distribution.
He never recovered motor function during his stay. He will have
his sutures removed in two weeks time w/ Dr. [**Last Name (STitle) **] as an
outpatient. At this time, he will also discuss the possibility
of a skin graft for the fasciotomy sites. During his stay, his
edema over the left lower extremity was controlled with
furosemide.
Renal
Upon admission he was found to have a severely elevated CK. His
creatinine was also elevated, and so he was diagnosed with acute
renal failure secondary to rhabdomyalysis. The renal service
was consulted for management of his severe rhabdomyolysis, and
subsequent anuric - oliguric [**Last Name (un) **], hyperkalemia,
hyperphosphatemia and hypocalcemia. Hemodialysis was immediately
initiated to remove myoglobin. He was aggressively volume
resuscitation until euvolemic requiring intubation and CVP
monitoring in the ICU. Over time his renal function improved.
He was last dialyzed on [**2141-7-22**]. On discharge, his urine output
was 2L/day with cr 2.8 and BUN 43. During his stay he also
developed critical hypercalcemia and non-critical
hyperphosphatemia. He was sequestered with phosphate binders to
prevent calciphylaxis. He was also flushed with high flow
normal saline fluids to clear the calcium. He was given
furosemide at increased dosage during this time to control the
subsequent edema in his left lower extremity. His calcium
eventually returned to within normal range. He will need to be
followed closely by the nephologists at the [**Hospital1 **].
Pain
Pain remain controlled throughout his stay. He was seen by
chronic pain service on the day of discharge and was put on a
finalized regimen of gabapentin 600 mg TID, oxycodone SR 20 [**Hospital1 **],
and oxycodone 5-10 mg every 6 hours. He is to follow up with
his primary care provider for further management of his pain
issues.
Social
Mr. [**Known lastname 20825**] has no insurance, and as such we began the process
of obtaining insurance. From a disposition perspective, he will
go to [**Hospital **] rehabilitation.
Medications on Admission:
1. Methadone 5 mg PO DAILY
Discharge Medications:
1. Gabapentin 600 mg PO TID
2. Methadone 5 mg PO DAILY
3. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
4. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
5. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Compartment Syndrome
Acute Renal Failure
Rhabdomyolysis
Hypercalcemia
Hyperphosphatemia
Sinus tachycardia
Chronic Pain - does not require follow up with our pain clinic
Anemia requiring transfusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital secondary to pain, swelling
and decreased circulation to your right lower extremity You
were diagnosed with compartment syndrome and fasciotomies
(opening of the skin) were performed to relieve the pressure in
your left leg. Your kidneys were also noted to be failing
related to the severe muscle damage from the lack of
circulation. You were started on dialysis. Your kidney
function had since returned and we stopped hemodialysis. You
kidney function is slowly returning and will be closely
monitored. We noticed damaged muscular tissue in the open areas
on your calves which required you to return to the OR several
times for debridement. You also had elevated levels of calcium,
which we corrected with high flow fluids. You recovered well,
but we will continue to monitor your calcium levels daily. You
will follow up with us in two weeks time, where we will discuss
options for your leg including possible plastic surgery to graft
the open area.
Followup Instructions:
You have two follow up appointments.
1.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD
Phone:[**Telephone/Fax (1) 1237**] (please call for directions)
Date/Time:[**2141-8-10**] at 11:15AM
2. You have a follow up appointment with renal with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4920**] on Thursday, [**8-17**], at 2:30 pm. You will also see
Dr. [**Known firstname 122**] [**Last Name (NamePattern1) 96416**] during this time.
Location: [**Hospital1 18**] [**Hospital Ward Name 121**] [**Location (un) 453**] in West [**Hospital **] Clinic
Phone Number: [**Telephone/Fax (1) 721**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18672**], M.D.
Date/Time:[**2141-8-17**] 2:30
|
[
"276.1",
"285.9",
"V16.0",
"427.89",
"305.1",
"584.5",
"729.72",
"458.21",
"276.7",
"996.73",
"E879.1",
"338.29",
"305.50",
"275.3",
"275.41",
"728.88",
"276.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"96.6",
"83.45",
"83.09",
"38.97",
"38.95",
"39.95",
"38.93",
"96.71",
"93.57"
] |
icd9pcs
|
[
[
[]
]
] |
19090, 19163
|
15610, 18794
|
321, 556
|
19405, 19405
|
2257, 15587
|
20601, 21365
|
1355, 1391
|
18872, 19067
|
19184, 19384
|
18820, 18849
|
19581, 20578
|
1406, 2238
|
261, 283
|
584, 1139
|
19420, 19557
|
1161, 1217
|
1233, 1339
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,069
| 162,449
|
5789
|
Discharge summary
|
report
|
Admission Date: [**2179-2-27**] Discharge Date: [**2179-3-10**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
PICC placement
CT-guided FNA biopsy of vertebral disc
Left knee arthrocentesis
Left knee arthrotomy, irrigation and debridemen with complete
synovectomy and replacement of tibial liner component
History of Present Illness:
The patient is an 86 year-old man with a history of coronary
artery disease, hypercholesterolemia, hypertension, elevated PSA
with recent prostate biopsywho was transferred from [**Hospital3 1280**]
with a diagnosis of septic diskitis at T9-T10 and enterococcal
bacteremia. Approximately one month prior to admission to the
outside hospital on [**2179-2-21**], the patient had undergone a
prostate biopsy for a nodule. About three weeks later, he
developed a UTI and was treated with a course of levofloxacin.
Several days later, he developed acute back pain when he
attempted to rise from his bed and had difficutly standing. The
pain spread across his back and radiated down his leg. He
describes the pain as sharp, and was relieved by "pain pills."
He notes that the pain has migrated between his back and various
LE joints (bilaterally) since the pain began. He has had a low
grade temp and elevated ESR at 150. MRI revealed increased T2
signal disc T9-T10, CT guided bx revealed no evidence of
malignancy or infection, and cultures were negative. Initial
blood cultures were negative, but on fourth day 1 bottle grew
enterococcus Patient had initially been treated with
levofloxacin, then was changed to vancomycin when enterococcus
grew from culture. The patient has had significant pain
requiring narcotics. At the outside hospital the patient was
also found to be in renal failure with creatinine 2.5.
.
Evaluation at outside hospital:
- Abdominal CT without contrast: no AAA, extensive degenerative
joint disease of the lumbar spine
- Bone scan [**2-19**]: DJD
- MRI; enhancement of the T9-10 disk, suspicious for diskitis
- CK normal (concern for possible rhabdomyolysis after recent
statin use)
- Renal U/S (limited exam)-2.6cm parapelvic cyst at upper pole
of R kidney. No hydro or nephrolithiasis
Past Medical History:
- Coronary artery disease with Left bundle branch block
suggestive of old MI
- Hypercholesterolemia-started on pravastatin approx. 2 months
ago, discontinued after several weeks secondary to myalgias and
weakness.
- Hypertension
- Elevated PSA
- Prostate nodule with recent biopsy approx. 1 month ago
- s/p R shoulder [**Doctor First Name **], hardware later removed
- s/p bilat knee arthroplasty, revision of L knee hardware [**11-14**]
- Normal colonoscopy [**2177**]
- Osteoarthritis
Social History:
SHx: Married, lives with his wife who is in reasonably good
health. Served in WW-II, then worked as a mechanic and
supervisor until retirement.
Habits: 100 pack-year tobacco history, quit 21 years ago, ETOH:
1 vodka [**Doctor Last Name 6654**] nightly before dinner, no other drugs.
Family History:
NC
Physical Exam:
Gen: Elderly male, appears to be in pain
VS: 98.4 / 90 / 128/57 / 22 / 100% on 2L nc
HEENT: Sclera anicteric, conjunctiva pink. PERRL. MM dry, OP
clear.
Neck: Supple, no LAD, no thyromegaly
Cor: Tachycardic, regular rhythm, 2/6 systolic murmur best
appreciated at the R sternal border, radiating to the clavicles
Lungs: R lung CTA, L lung with focal crackles in L base, with
occasional expiratory wheeze
Abd: Soft, NT, ND, no organomegaly
Rectal: Normal tone, no saddle anesthesia
Ext: WWP, 1+ pitting edema in feet and shins bilaterally.
Well-healed surgical scars over both knees. Left knee is
erythematous, warm, swollen with extensive swelling of the
pre-patellar bursa.
Neuro: A&O x 3, CN intact. UE strength 5/5, LE strength 5/5
proximally and distally. Toes downgoing bilaterally. DTRs not
elicited. Sensation to light touch intact bilat LE.
Pertinent Results:
Blood cultures negative x4
Urine culture negative
.
MRI of T Spine [**2179-3-1**]:
Signal within the disc space on the T2- and STIR-weighted
sequences at T9-10 consistent with discitis at this level.
.
MRI of L Spine [**2179-3-3**]:
There is a focus of abnormal signal intensity in the left
anterior aspect of the L4/5 disk and a small area of diskitis
cannot be completely excluded, although the typical soft tissue
and marrow abnormalities are absent. There is severe stenosis of
the spinal canal at L5/S1 from a disk bulge, disk space and
facet osteophytes and ligamentum flavum hypertrophy. There is
severe stenosis of the left foramen. Milder stenosis is seen at
L3/4 and L4/5.
.
TEE [**2179-3-3**]: Conclusions:
LVEF>55%. No masses or vegetations see. [**1-11**]+ aortic
regurgitation, 1+ mitral regurgitation.
Brief Hospital Course:
Mr. [**Known lastname 23000**] presented with weakness for several weeks, with
subsequent development of sudden severe back pain radiating down
his legs. The back pain was located in the lumbar area. Also on
admission he had an inflammed left knee (s/p knee replacement
several years ago). MRI shows enhancement of T9-10 disk space,
T4-5 space, and severe stenosis at L5-S1. FNA of T9-10 negative
for organisms, PMNs, malignant cells. L knee washed-out and
liner replaced by ortho for suspected infection. Enterococcus
grew from 1/4 bottles on blood cx at OSH, but all subsequent
cultures have been negative to date.
.
1. Back Pain and Weakness: MRI of T spine at [**Hospital3 1280**] had
revealed abnormal enhancement of the T9-10 disk space,
consistent with diskitis. However, the patient reported that MRI
of L spine showed severe stenosis at L5-S1, the level of the
patient's back pain. Also on MRI, there is abnormal enhancement
of T9-10 and L4-5, which possibly represents diskitis. FNA of T
spine lesion has not yielded any organism, although infection
probably can't be excluded as patient had been treated with
antibiotics for more than a week when biopsies were taken.
Regardless, Ortho-Spine felt surgery is not indicated currently
for diskitis. ID consulted for medical management (see below).
Overall, the patient's LE weakness has been improving. It is
likely related to stenosis as L5-S1. Ortho-spine consultant
recommends continued PO pain medications for now, with possible
epidural steroids in future once infections resolved. Patient
should follow-up with ortho spine in [**2-12**] weeks. Pt followed by
PT with improvement in mobility.
.
2. Diskitis/bacteremia: At [**Hospital3 1280**], 1 of 4 bottles from a
blood culture grew enterococcus after several days. No blood
cultures at [**Hospital1 18**] grew organisims. As the patient is allergic to
penecillins (unknown type of rash 50 years ago), he was started
on vancomycin at the outside hospital for enterococcus
bacteremia. It was unclear if the bacteremia was related to the
diskitis, as only one of four bottles grew organisms, and
therefore a work-up for other sources was undertaken, including
TTE/TEE (no vegetations seen), chest x-ray, urine culture. The
patient had also recently had a prostate biopsy approx. 1 month
before that was complicated by a UTI, so there was also concern
for gram negative source of diskitis. Thus, the patient was
treated with a course of IV Ciprofloxacin in addition to the
Vancomycin. An abdominal CT was also performed, which ruled-out
abscess. ID was consulted for recommendations for therapy. Given
likely need for long-term antibiotics for infected knee hardware
as well as need for good enterococcus coverage, ID recommended
desensitization so patient could be treated with ampicillin.
Allergy was consulted who gave recommendations for
desensitization protocol, which patient underwent in the ICU
overnight with no complications. The vancomycin was stopped and
patient was continued on ampicillin, which he will need for 6
weeks (PICC line in place). He will follow-up at the [**Hospital **] clinic
for recommendations concerning possible longer-term oral
antibiotic coverage given his knee hardware; this decision will
be made in conjunction with either [**Hospital1 **] orthopedics (Dr.
[**Last Name (STitle) 1005**] or [**Hospital1 2025**] orthopedics (Dr. [**Last Name (STitle) 23001**] ) depending on patient
preference.
.
3. L knee swelling: On admission, the patient's L knee was red
and warm with significant swelling. There was marked swelling of
the pre-patellar bursa. The patient is s/p knee replacements
bilaterally, with a recent revision of his L knee hardware in
[**2178-11-10**]. Given his exam, there is concern for joint
infection. Ortho consulted and performed arthrocentesis, which
had a leukocytosis but no organisms (though patient on
antibiotics). He was taken to the OR for wash-out of grossly
infected knee and replacement of liner. On gram stain from the
OR, there were no organisms, 2+ PMNs. Post-operatively, the
patient did well with PT [**Name (NI) 11030**] on left leg). ID was consulted
for recommendations about antibiotics (see above).
.
3. Pain control: Initially on morphine PCA, then switched to
tylenol with oxycodone as needed.
.
4.Renal insufficiency: Cr stable around 2.0 during
hospitalization. Appears to be chronic from outside records from
[**Hospital3 1280**]. Needs outpatient work-up. No NSAIDs given renal
function. Renally dose all meds.
.
5. Anemia: Baseline HCT from [**11-14**] was 37.6. Iron studies
consistent with anemia of chronic inflammation. no signs of
active bleeding.
.
6.CAD: Stable. LBBB on EKG unchanged from previous studies. ASA
81mg and Lopressor 12.5mg [**Hospital1 **]
.
7. Prostate hypertrophy/elevated PSA: Stable, to be followed as
outpatient. Continue Tamsulosin 0.4 mg daily
.
8. FEN: Was frequently NPO for procedures (maintained on IVF).
Nutrition consult recommended Boost TID. Cardiac diet.
.
9.Prophylaxis: lovenox, IS, protonix, bowel regimen.
.
10. Code: FULL
.
11. Communication: PCP is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12300**] in [**Location (un) 1110**] ([**Telephone/Fax (1) 23002**]).
Wife is [**Name (NI) **] [**Name (NI) 23000**] ([**Telephone/Fax (1) 23003**]).
Medications on Admission:
Meds on transfer:
- ASA 81
- Toprol XL 25
- Vanco 1g qd
- Flomax 0.4mg qd
- heparin 5000U subQ tid
- Protonix 40 qd
- Flexeril 5 q 8
- PCA with dilaudid
- MVI qd
- Senekot 2 tabs po bid
- tyelnol 650 q 6h prn
- restaril 7.5mg qHS prn insomnia
- dulcolax 10mg qd
- colace 100 [**Hospital1 **]
- MOM 30cc qid
- Dilaudid 1-3mg SC q 2-4h prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Septic left knee
Diskitis T9-10
Spinal stenosis L5-S1
Enlarged prostate
Bacteremia at referring hospital (enterococcus)
Chronic renal insufficiency
Anemia of chronic disease
Discharge Condition:
Good
Discharge Instructions:
Take all medications as directed.
Call a nurse or doctor or go to the ER for difficulty breathing,
chest pain, fever over 101.5F, vomiting, abdominal pain,
worsening pain or swelling in your knee, new weakness or
tingling in your legs, bladder or bowel incontinence, numbness,
or any other concerns.
Followup Instructions:
You need to have weekly lab work (CBC, BUN, Creatinine, LFTs),
and the results should be faxed to the Infectious Disease clinic
at [**Telephone/Fax (1) 1419**].
Your knee staples need to be removed in [**5-16**] days; your
rehabilitation center can arrange this. Call Dr. [**Last Name (STitle) 23001**]
(Orthopedics at [**Hospital1 2025**]) for a follow-up appointment for your knee
in [**2-13**] weeks. Or, if you prefer, you can follow-up with Dr.
[**Last Name (STitle) 1005**] [**Name (STitle) 23004**] at ([**Telephone/Fax (1) 2007**].
Call Dr. [**Last Name (STitle) **] (Orthopedics-Spine) at ([**Telephone/Fax (1) 2007**] for a
follow-up appointment for your back in [**2-12**] weeks.
You have an appointment with Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 2716**] (Infectious
Disease, [**Telephone/Fax (1) 457**]) on [**4-12**] at 9:30am.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"272.0",
"412",
"401.9",
"722.93",
"996.66",
"584.9",
"V43.65",
"585.9",
"711.06",
"396.3",
"724.02",
"414.01",
"397.0",
"600.00",
"790.7",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.72",
"81.91",
"81.55",
"38.93",
"80.39"
] |
icd9pcs
|
[
[
[]
]
] |
10515, 10660
|
4823, 10127
|
229, 425
|
10878, 10885
|
3981, 4800
|
11234, 12204
|
3092, 3096
|
10681, 10857
|
10153, 10153
|
10909, 11211
|
3111, 3962
|
180, 191
|
453, 2264
|
2286, 2775
|
2791, 3076
|
10171, 10492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,574
| 189,995
|
3705
|
Discharge summary
|
report
|
Admission Date: [**2180-10-19**] Discharge Date: [**2180-10-29**]
Date of Birth: [**2106-4-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
coronary artery disease, aortic stenosis
Major Surgical or Invasive Procedure:
[**2180-10-19**] Coronary artery bypass grafts (LIMA-OM,RIMA-RCA), Aortic
valve replacement (27mm [**Company 1543**] tissue)
[**2180-10-20**] Thrombectomy of left lower extremity common femoral
artery to peroneal artery bypass vein graft, serial arteriogram
of the left lower extremity, balloon angioplasty of the left
femoral artery to peroneal artery bypass graft x4, balloon
angioplasty of the distal anastamosis at distal AT/DP.
History of Present Illness:
74 yo Spanish speaking male who was hospitalized for elective
resection of Right CFA aneurysm and revision of R CFA to
peroneal bypass graft in [**Month (only) 205**]. On hospital day 2, he developed a
GIB on Heparin gtt and GI was consulted. Pt underwent
colonoscopy which revealed small polyps and radiation proctitis.
An echo revealed critical aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] 0.8cm2 and
catheterization
revealed 3VD. Pt was discharged home to recover from GIB, but
re-presented to ED in early [**Month (only) 216**] with another GIB. He
underwent a flexible sigmoidoscopy, which showed a large rectal
ulcer in the area of the prior APC treatment. Given his iron
deficiency anemia, he also underwent an upper endoscopy which
was
unrevealing. He was recently seen in [**Hospital **] clinic and underwent a
capsule study with small bowel follow through which was normal.
He is now scheduled for a sigmoidoscopy tomorrow morning for
surgical clearance. Mr. [**Known lastname **] has noticed more exertional
chest pain recently and has been using nitroglycerin more
frequently. He is scheduled for surgery [**2180-10-19**]. Cardiac
Catherization:[**2180-8-10**] [**Hospital1 18**]: Right dominant system LM:no CAD
LAD:50% where D1 branched off and D1 was small with 80% [**Last Name (un) 2435**].
LCx:90% in the distal prox region prior to branching off of
large OM RCA:70% [**Last Name (un) 2435**] in mid region of vessel. The posterior
lateral
branch had an 80% [**Last Name (un) 2435**] in mid region and a subbranch of PL had a
70% stenosis at its origin
Past Medical History:
coronary artery disease
aortic stenosis
peripheral vascular disease
gastroesophageal reflux disease
hypertension
hyperlipidemia
h/o prostate disease
s/p coronary artery stenting
Social History:
Spanish speaking. He is married and lives with his wife. [**Name (NI) **]
continues to smoke [**4-30**] cigs/day, h/o 1ppd since age 15. Denies
EtOH for years, but history of heavy drinking. Denies drug use.
Family History:
Brother died of colon CA at age 70. No sudden cardiac death.
Physical Exam:
Pulse: 63 Resp: 14
B/P Right: 155/58 Left: 151/58
Height: 62" Weight: 165
General: WDWN in NAD
Skin: Dry, warm, intact. Multiple well healed incisions on right
UE and Bilateral LE.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric. Full dentures.
Neck: Supple [X] Full ROM [X] no JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, N1 S1-S2, III/VI SEM, I-II/VI diastolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: multiple well healed incisions. 2+ LE Edema
Neuro: A+Ox3, walks with cane. No focal deficits
Pulses:
Femoral Right: 1 Left: 1
DP Right: Trace Left: Trace
PT [**Name (NI) 167**]: Trace Left: Trace
Radial Right: 1 Left: 1
Carotid Bruit Right: Transmitted Left: transmitted
Pertinent Results:
[**2180-10-18**] 11:20AM URINE RBC-<1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2180-10-18**] 11:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2180-10-18**] 11:20AM PT-13.2 PTT-33.6 INR(PT)-1.1
[**2180-10-18**] 11:20AM PLT COUNT-348
[**2180-10-18**] 11:20AM WBC-8.1 RBC-3.74* HGB-9.2* HCT-30.5* MCV-82
MCH-24.8*# MCHC-30.3* RDW-16.1*
[**2180-10-18**] 11:20AM %HbA1c-5.8
[**2180-10-18**] 11:20AM TOT PROT-7.6 ALBUMIN-4.7 GLOBULIN-2.9
[**2180-10-18**] 11:20AM ALT(SGPT)-14 AST(SGOT)-16 LD(LDH)-215 ALK
PHOS-118* AMYLASE-65 TOT BILI-0.6
[**2180-10-18**] 11:20AM UREA N-16 CREAT-1.0 SODIUM-142 POTASSIUM-4.4
CHLORIDE-104 TOTAL CO2-29 ANION GAP-13
[**2180-10-18**] 11:20AM GLUCOSE-106*
ECHO:
PRE-CPB:1. The left atrium is moderately dilated. No spontaneous
echo contrast is seen in the left atrial appendage. A left
atrial appendage thrombus cannot be excluded.
2. A patent foramen ovale is present.
3. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic
regurgitation is seen.
7. The mitral valve appears structurally normal with trivial
mitral regurgitation.
8. There is a trivial/physiologic pericardial effusion.
9. An epiaortic scan showed simple atheroma in the areas of the
perfusion cannula site and the cross clamp site.
POST-CPB: On infusion of [**Last Name (LF) **], [**First Name3 (LF) **] pacing. Well-seated
bioprosthetic valve in the aortic position. Trivial AI, no
paravalvular leak. Preserved LV systolic function. LVEF= 55%.
Aortic contour is normal post decannulation.
Radiology Report CHEST (PA & LAT) Study Date of [**2180-10-26**] 10:58
AM
Final Report
INDICATION: 74-year-old male with AVR and CABG. Evaluate for
interval change.
PA and lateral chest radiograph compared to [**2180-10-24**]
showed mild
generalized improved ventilation with decrease left basilar
atelectasis.
Small bilateral pleural effusions persist. Moderate-to-severe
cardiomegaly is unchanged with no evidence of overhydration.
Postoperative widening of the new mediastinum status post
sternotomy is unchanged. Right IJ central venous catheter has
been removed. There is no pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Brief Hospital Course:
Patient was admitted directly to the operating room where he had
an Aortic valve replacement andc coronary bypass grafting.
Please see operative report for details. In summary he had an
AVR(#27 [**Company 1543**] Mosaic tissue valve and CABG x2 with LIMA-LAD
and RIMA-RCA. His bypass time was 134 minutes with a crossclamp
of 94 minutes. A right femoral arterial line was placed in the
Operating Room through a prior graft. He tolerated the
operation well, and was transferred from the operating room to
the cardiac surgery ICU in stable condition.
Vascular surgery was consulted (they were familiar with him from
his prior procedure) and the femoral line was maintained with a
heparin infusion overnight. Postoperatively CXR showed right
upper lobe collapse and he subsequently underwent a
bronchoscopy. Repeat CXR after bronchoscopy revealed good
aeration of the right upper lobe. On POD 1 the Doppler signal
to the left lower extremity was abscent. Vascular surgery opted
to take him to the Operating Room to evaluate the flow, and a
thrombectomy of left lower extremity common femoral artery to
peroneal artery bypass vein graft, balloon angioplasty of the
left femoral artery to peroneal artery bypass graft, and balloon
angioplasty of the distal anastamosis at distal AT/DP. See
operative note for full details. Right arterial line was pulled
in the Operating Room by the vascular team without incidence.
He was continued on heparin gtt and started on Coumadin. On
post operative #2 he developed respiratory distress and
acidosis, a surgical consult was requested out of concern that
he might be developing an acute abdominal process. He had
increasing abdominal distention, his hematocrit had trended down
and he was reintubated, swan ganz catheter was placed.
Abdominal cat scan was negative for any acute process. He
developed non-oliguric acute tubular nephrosis at this time and
creatinine peaked at 2.7. His diuretics were discontinued and
his creatinine was back down to baseline (1.1) at the time of
discharge. He remained hemodynamically stable after
resuscitation and was extubated the following day. Chest tubes
and pacing wires were removed per cardiac surgery protocol. He
was transferred to the floor on post operative day 4. He went
into rapid atrial fibrillation at that time and started on an
amiodarone bolus and drip and Lopressor was increased. He
converted to sinus rhythm and remained in sinus for 24 hours
prior to discharge. He was started on warfarin to which he was
extremely sensitive. His INR rose from 1.5 to 9.9 after two
doses 4mg on day1 and 1mg on day2. He received FFP to correct
this and warfarin was held for 2 days. He was slightly confused
and all narcotics were discontinued and he cleared. He was pain
free at the time of discharge. He was continued on Coumadin for
anticoagulation for vascular issues and his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] will
follow INR levels. The goal INR [**2-29**]. VNA services are to call
INR results to [**Telephone/Fax (1) 1792**]. He was discharged home on post
operative day # 10 in stable condition.
Medications on Admission:
[**Last Name (un) 1724**]:ASA 325mg/D,Atenolol 100mg/D,Citalopram 10mg/D,Clonazepam
1mg qHS,atorvastatin 10mg/D,HCTZ 25mg/D,Lisinopril 40mg/D,
Nifedipine SR 90mg/D,Nitro SL 0.3 mg PRN chest pain,Omeprazole
20mg/D ,Fe 325mg/D
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. Omeprazole 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*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
Disp:*1 inhaler* Refills:*1*
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*1*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
11. Hydrochlorothiazide 12.5 mg Capsule Sig: [**1-28**] Capsule PO
DAILY (Daily).
Disp:*25 Capsule(s)* Refills:*2*
12. Warfarin 1 mg Tablet Sig: As directed by Dr. [**First Name4 (NamePattern1) 1790**]
[**Last Name (NamePattern1) 1789**] Tablet PO DAILY (Daily): Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**]
([**Telephone/Fax (1) 1792**])
goal INR 2-3.0.
Disp:*60 Tablet(s)* Refills:*2*
13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
INR check [**10-30**] with results faxed to
Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**] ([**Telephone/Fax (1) 1792**]) goal INR 2-3.0.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
coronary artery disease
aortic stenosis
peripheral vascular disease
s/p coronary artery bypass x2, aortic valve replacement
gasroesophageal reflux disease
hyperlipidemia
hypertension
h/o prostate cancer
s/p coronary artery stenting
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**] in [**1-28**] weeks ([**Telephone/Fax (1) 1792**])
Dr. [**Last Name (STitle) 3407**] in 2 weeks
VNA to call INR results into Dr[**Name (NI) 14025**] office for coumadin
dosing instructions Fax [**Telephone/Fax (1) 15418**]
Please call for appointments
Completed by:[**2180-10-29**]
|
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icd9cm
|
[
[
[]
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[
"96.04",
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icd9pcs
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[]
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12119, 12176
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362, 798
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12451, 12458
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10159, 12096
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12197, 12430
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2953, 3741
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282, 324
|
826, 2433
|
2455, 2634
|
2650, 2860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,808
| 108,605
|
48818
|
Discharge summary
|
report
|
Admission Date: [**2181-10-17**] Discharge Date: [**2181-11-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Respiratory arrest
Major Surgical or Invasive Procedure:
Intubation (in the field prior to admission)
PICC line placement [**10-22**]
History of Present Illness:
[**Age over 90 **]F vasculopathic female with h/o dementia, non-verbal at
baseline, DM2, PVD s/p bilateral AKAs, who presented from her NH
on [**10-17**] after being found in respiratory distress. She was noted
to have a fever to 102 (axillary) and O2 sat to 82%RA. EMS was
called. En route she was noted to have a sat of 80% on NRB. By
report, tube feeds were suctioned from her airway. She was
confirmed full code and pt was intubated. In the ED, she had a
low-grade temp of 99.4 (temporal), hemodynamically stable,
intubated, ABG noted to be 7.39/33/412. On exam she had equal
and reactive pupils and bilateral breath sounds. Stat labs were
significant for anemia to 26, renal failure with Cr 1.7, and
lactate of 4.5. Tox screen positive for barbiturates, c/w pt's
home med regimen. CXR revealed no obvious infiltrate. EKG showed
NSR, with 1mm ST elevations in V2-V4. Blood cultures were drawn
and patient was given vanc/levo/clinda for presumptive
HC-associated aspiration PNA. She was then admitted to the ICU.
.
MICU course:
-BP was initially low on arrival to the ICU (92/40) with poor
UOP but quickly came up with fluid boluses, with SBP mainly in
the 150-180s for the past 3 days. BP meds have been uptitrated.
-She was covered initially with vanco/zosyn empirically for
HCAP. She was pan-cultured and sputum cx revealed MSSA.
Extubated on [**10-19**].
-There was initial concern for possible ACS as the cause of her
respiratory distress given slight ST elevations in precordial
leads V2-4, and initial trop elevation to 0.39. Trop has trended
down to 0.30 and CK peaked at 364.
-Creatinine has been stable 1.7-2.0, unknown baseline.
-Developed transaminitis--> seen by hepatology who felt most
likely etiology to be ischemic, recommended discontinuing hydral
(as can be hepatotoxic) and maintaining MAP at 90+ for adequate
hepatic perfusion.
.
Her mental status is now felt to be at baseline, which is
non-responsive. She is satting well on 2L nasal cannula. She is
being called out to the floor.
Past Medical History:
# peripheral vascular disease status post AKA bilaterally
# diabetes mellitus type 2
# hypertension
# dementia
# seizure disorder
# right DVT in [**2173-8-10**]
# Anemia
# s/p G-tube
Social History:
The patient is a resident at [**Hospital3 2558**]. At baseline, she
has dementia and is nonverbal. She is dependent on all ADLs.
Mobility is limited to a recliner with assistence. There is no
history of smoking or tobacco.
Family History:
NC
Physical Exam:
VS: 98.0 77 92/40 14 100%
Gen: intubated and sedated elderly AA female
HEENT: OP clear, adentulous, MM slightly dry, surgical pupils
PERRL
Neck: No JVD, no LAD
Cor: RRR no m/r/g
Pulm: CTAB
Abd: obese, soft, NTND, G tube site+BS,
Extrem: bilateral AKAs, stump sites appear normal without e/o
erythema or inflammation
Skin: no rashes noted
Neuro: sedated, does not follow commands. Dolls eye intact.
Pertinent Results:
=======
Labs
=======
[**2181-10-31**] 07:10AM BLOOD WBC-10.9 RBC-3.04* Hgb-8.6* Hct-24.7*
MCV-81* MCH-28.4 MCHC-34.8 RDW-18.2* Plt Ct-369
[**2181-10-30**] 07:00AM BLOOD WBC-10.5 RBC-2.98* Hgb-8.6* Hct-24.3*
MCV-82 MCH-28.9 MCHC-35.4* RDW-18.0* Plt Ct-317
[**2181-10-28**] 05:52AM BLOOD WBC-11.9* RBC-3.40* Hgb-10.0* Hct-27.9*
MCV-82 MCH-29.3 MCHC-35.8* RDW-18.0* Plt Ct-290
[**2181-10-27**] 06:10AM BLOOD WBC-11.9* RBC-2.92* Hgb-8.4* Hct-23.8*
MCV-81* MCH-28.8 MCHC-35.5* RDW-18.0* Plt Ct-268
[**2181-10-26**] 04:59AM BLOOD WBC-13.8* RBC-3.27* Hgb-9.2* Hct-27.0*
MCV-83 MCH-28.2 MCHC-34.2 RDW-16.8* Plt Ct-253
[**2181-10-25**] 05:29AM BLOOD WBC-13.1* RBC-3.40* Hgb-9.5* Hct-28.2*
MCV-83 MCH-27.8 MCHC-33.5 RDW-16.8* Plt Ct-229
[**2181-10-24**] 07:00AM BLOOD WBC-11.6*# RBC-2.98* Hgb-8.2* Hct-24.8*
MCV-83 MCH-27.6 MCHC-33.1 RDW-16.9* Plt Ct-210
[**2181-10-23**] 06:00AM BLOOD WBC-7.4 RBC-3.23* Hgb-8.9* Hct-27.1*
MCV-84 MCH-27.5 MCHC-32.8 RDW-16.2* Plt Ct-196
[**2181-10-22**] 07:00AM BLOOD WBC-7.1 RBC-3.40* Hgb-9.6* Hct-28.6*
MCV-84 MCH-28.3 MCHC-33.6 RDW-15.7* Plt Ct-195
[**2181-10-21**] 07:35AM BLOOD WBC-6.2 RBC-3.11* Hgb-8.5* Hct-26.5*
MCV-85 MCH-27.4 MCHC-32.1 RDW-14.8 Plt Ct-148*
[**2181-10-20**] 01:58AM BLOOD WBC-7.1 RBC-2.67* Hgb-7.4* Hct-22.5*
MCV-84 MCH-27.7 MCHC-32.9 RDW-14.5 Plt Ct-140*
[**2181-10-19**] 03:13AM BLOOD WBC-8.0 RBC-2.77* Hgb-7.7* Hct-23.1*
MCV-84 MCH-27.9 MCHC-33.3 RDW-15.2 Plt Ct-140*
[**2181-10-18**] 07:10PM BLOOD WBC-9.8 RBC-3.00* Hgb-8.4* Hct-24.9*
MCV-83 MCH-28.0 MCHC-33.6 RDW-15.3 Plt Ct-138*
[**2181-10-18**] 02:47AM BLOOD WBC-11.0 RBC-2.69* Hgb-7.7* Hct-22.9*
MCV-85 MCH-28.5 MCHC-33.4 RDW-15.2 Plt Ct-146*
[**2181-10-17**] 04:26PM BLOOD WBC-10.1 RBC-2.98* Hgb-8.3* Hct-26.1*
MCV-88 MCH-27.8 MCHC-31.8 RDW-14.7 Plt Ct-172
[**2181-10-17**] 12:45PM BLOOD WBC-7.8 RBC-3.03* Hgb-8.6* Hct-26.2*
MCV-87 MCH-28.4 MCHC-32.8 RDW-14.5 Plt Ct-202
[**2181-10-31**] 07:10AM BLOOD Glucose-150* UreaN-89* Creat-4.5* Na-132*
K-3.3 Cl-93* HCO3-25 AnGap-17
[**2181-10-30**] 07:00AM BLOOD Glucose-85 UreaN-87* Creat-4.4* Na-130*
K-3.3 Cl-92* HCO3-25 AnGap-16
[**2181-10-28**] 05:52AM BLOOD Glucose-84 UreaN-91* Creat-4.2* Na-127*
K-4.2 Cl-91* HCO3-22 AnGap-18
[**2181-10-27**] 06:10AM BLOOD Glucose-126* UreaN-91* Creat-4.0* Na-126*
K-4.5 Cl-90* HCO3-22 AnGap-19
[**2181-10-26**] 04:59AM BLOOD Glucose-187* UreaN-85* Creat-3.7* Na-126*
K-4.6 Cl-91* HCO3-22 AnGap-18
[**2181-10-25**] 05:29AM BLOOD Glucose-165* UreaN-80* Creat-3.3* Na-125*
K-4.7 Cl-94* HCO3-21* AnGap-15
[**2181-10-24**] 07:00AM BLOOD Glucose-155* UreaN-73* Creat-3.2* Na-131*
K-4.5 Cl-99 HCO3-22 AnGap-15
[**2181-10-23**] 06:00AM BLOOD UreaN-64* Creat-2.5* Na-134 K-4.4 Cl-101
HCO3-23 AnGap-14
[**2181-10-22**] 07:00AM BLOOD Glucose-202* UreaN-51* Creat-1.8* Na-136
K-3.8 Cl-103 HCO3-24 AnGap-13
[**2181-10-21**] 07:35AM BLOOD Glucose-136* UreaN-44* Creat-1.6* Na-137
K-3.1* Cl-104 HCO3-23 AnGap-13
[**2181-10-20**] 01:58AM BLOOD Glucose-133* UreaN-46* Creat-1.7* Na-139
K-3.8 Cl-107 HCO3-23 AnGap-13
[**2181-10-19**] 03:13AM BLOOD Glucose-76 UreaN-49* Creat-1.9* Na-138
K-4.2 Cl-106 HCO3-23 AnGap-13
[**2181-10-18**] 02:47AM BLOOD Glucose-148* UreaN-49* Creat-2.0* Na-137
K-4.6 Cl-105 HCO3-22 AnGap-15
[**2181-10-18**] 02:47AM BLOOD Glucose-174* UreaN-49* Creat-2.1* Na-133
K-6.7* Cl-103 HCO3-23 AnGap-14
[**2181-10-17**] 04:26PM BLOOD Glucose-334* UreaN-42* Creat-1.9* Na-131*
K-5.7* Cl-100 HCO3-20* AnGap-17
[**2181-10-31**] 07:10AM BLOOD ALT-95* AST-31 AlkPhos-61 TotBili-0.7
[**2181-10-30**] 07:00AM BLOOD ALT-108* AST-29 LD(LDH)-318* AlkPhos-58
TotBili-0.6
[**2181-10-28**] 05:52AM BLOOD ALT-141* AST-33 AlkPhos-62 TotBili-1.2
[**2181-10-27**] 06:10AM BLOOD ALT-162* AST-34 AlkPhos-60 TotBili-1.3
[**2181-10-26**] 04:59AM BLOOD ALT-218* AST-46* AlkPhos-73 TotBili-1.8*
[**2181-10-25**] 05:29AM BLOOD ALT-277* AST-62* AlkPhos-75 TotBili-1.7*
[**2181-10-24**] 07:00AM BLOOD ALT-347* AST-92* AlkPhos-74 TotBili-1.6*
[**2181-10-23**] 06:00AM BLOOD ALT-504* AST-157* AlkPhos-85 TotBili-1.5
[**2181-10-22**] 07:00AM BLOOD ALT-840* AST-383* LD(LDH)-347* AlkPhos-94
TotBili-1.3
[**2181-10-21**] 07:35AM BLOOD ALT-1342* AST-1027* LD(LDH)-498*
AlkPhos-84 TotBili-1.3
[**2181-10-20**] 01:58AM BLOOD ALT-2245* AST-3656* LD(LDH)-2530*
AlkPhos-66 TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2181-10-19**] 03:13AM BLOOD ALT-783* AST-1611* AlkPhos-63 Amylase-33
TotBili-0.3
[**2181-10-18**] 02:47AM BLOOD CK(CPK)-322*
[**2181-10-18**] 02:47AM BLOOD CK(CPK)-364*
[**2181-10-18**] 12:12AM BLOOD CK(CPK)-310*
[**2181-10-17**] 04:26PM BLOOD ALT-35 AST-162* LD(LDH)-565* CK(CPK)-250*
AlkPhos-81 Amylase-79 TotBili-0.1
[**2181-10-18**] 02:47AM BLOOD CK-MB-6 cTropnT-0.30*
[**2181-10-18**] 02:47AM BLOOD CK-MB-6 cTropnT-0.31*
[**2181-10-18**] 12:12AM BLOOD CK-MB-6 cTropnT-0.35*
[**2181-10-17**] 04:26PM BLOOD CK-MB-6 cTropnT-0.39*
[**2181-10-20**] 01:58AM BLOOD Hapto-300*
[**2181-10-17**] 04:26PM BLOOD calTIBC-300 Ferritn-1825* TRF-231
[**2181-10-26**] 04:59AM BLOOD TSH-0.17*
[**2181-10-28**] 05:52AM BLOOD T3-37* Free T4-0.55*
=======
Micro
=======
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2181-10-29**]):
Feces negative for C.difficile toxin A & B by EIA.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2181-10-25**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
RESPIRATORY CULTURE (Final [**2181-10-20**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. HEAVY GROWTH.
Please contact the Microbiology Laboratory ([**7-/2479**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
=======
Radiology
=======
CXR - [**10-17**] - The endotracheal tube is seen in situ with its tip
approximately 12 mm from
the carina. This should be withdrawn. The lungs are low volume,
most likely
due to poor inspiratory effort. There is atelectasis at the left
lung base
with a probable area of consolidation. Followup to clearance is
recommended.
CXR [**10-18**] - Moderate enlargement of the cardiac silhouette has
progressed, with worsening left atrial enlargement, mild
pulmonary edema and vascular engorgement, new small-to-moderate
left and small right pleural effusion. Left lower lobe is fully
opacified, probably atelectasis. Mediastinal contour is now
bulging at the level of the AP window and pulmonary artery. This
could be due to pulmonary arterial dilatation alone, but
possibility of aortic aneurysm or mediastinal adenopathy is
raised, particularly since the right hilus is not enlarged.
With the chin down, the tip of the ET tube rests less than a
centimeter from the carina, 3 cm below optimal placement. No
pneumothorax.
CXR [**10-20**] - Interval extubation. Slight worsening of left
pleural effusion and adjacent retrocardiac opacity which may be
due to atelectasis or infectious consolidation. Minimal haziness
at right base may reflect motion artifact, but small pleural
effusion or focal right basilar parenchymal process could
produce a similar appearance.
CXR [**10-22**] - The right PICC line was inserted with its tip
terminating in the right atrium approximately 3 cm below the
cavoatrial junction. The cardiomediastinal silhouette is
unchanged including cardiomegaly and bulging of the main
pulmonary artery. There is additional worsening of the left
upper lobe opacity that might represent developing pneumonia.
The bilateral pleural effusions are small, unchanged.
CXR [**10-24**] - IMPRESSION: Little overall change except for slight
pulling back of the PICC line.
Abd u/s - [**10-20**] - IMPRESSION: Patent hepatic vasculature with
appropriate flow.
=======
Neurology
=======
EEG - Markedly abnormal portable EEG due to the very low
voltage
and slow background. This indicates a widespread and moderately
severe
encephalopathy. Medications, metabolic disturbances, infection,
and
anoxia are among the most common causes, but this tracing cannot
specify
the etiology. There were no areas of prominent focal slowing,
and there
were no epileptiform features, including at the times of
clinically
noted abnormal movements.
Brief Hospital Course:
# Respiratory failure / MSSA Pna: DDx includes aspiration
pneumonitis vs aspiration PNA, ACS, PE, PTX, infection/sepsis,
medications/overdose, hypoglycemia or seizure. ACS ruled out
with biomarkers trending down, no elevated CKMB, no acute ECG
changes. She did not have relative hypoxia nor [**Name (NI) **] gradient on
ABGs. Initial fever concerning for infxn so started empirically
on Vanc/Zosyn for possible HCAP although afebrile here.
Extubated [**10-19**] and satting well on 2L nasal cannula. Has sputum
gram stain showing 4+ MSSA so Vanco changed to Nafcillin and
Zosyn DC'd. Patient lost IV access on [**10-28**] and was transitioned
to Nafcillin to complete her 14 day couorse of antibiotics.
Blood cultures were persistently negative.
.
# Change in mental status: Pt has longstanding dementia. Pt's
baseline mental status prior to this hospital stay was saying
[**2-11**] words at a time and holding family's hands.Since her stay in
the ICU, pt only withdraws to painful stimuli, but has
occasionally opened her eyes for family members. EEG negative
for nonconvulsive status epelepticus. Worsening mental status
likely [**2-10**] to multiple etiologies, including infection, acute
renal failure, anoxic encephalopathy, hepatic encephalopathy and
worsening baseline dementia. Likelihood of recovering baseline
mental status considered very minimal at this time. Likelihood
for recovery of baseline mental status given multiple medical
issues is considered very unlikely.
# Elevated LFTs: On presentation her LFTs were ALT 32, AST 165.
LFTs were rechecked due to a mildly elevated INR which was
attributed to nutritional deficiency. The followup set of LFTs
was AST 783 ALT 1611, and [**10-20**] were 2245/3656. Liver was
consulted and recommended RUQ US with Dopplers which was done
and was normal with no thrombus. Etiology thought to be shock
liver secondary to hypotension. LFTs trended down over the
course of admission.
# Acute renal failure / Hyponatremia: Renal function worsened
over the course of admission and was oliguric for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1644**] period
of time. The likely etiology was pre-renal azotemia and ATN from
hypotension. Although patient was on naficillin, urine eos were
negative. Family chose not to pursue dialysis. Given
hyponatremia and totaly body overload, patient was diuresed with
Lasix which improved both the serum sodium and body edema.
Patient was also free water restricted with minimal tube feed
volumes. In addiion, urine output improved immensely on lasix.
However, the Cr worsened despite improved urine ouput. Once
total body edema improved, lasix were stopped in the hope that
this would help decrease serum Cr.
.
# UTI: Pt had worsening leukocytosis and UA suspicious for
infection, but urine cx was negative. Pt was treated empirically
with Ciprofloxacin for 7 days.
.
# vaginal yeast infection: on day of discharge pt was noted to
have vaginal yeast infection and was started on miconidazole
cream for an anticipated 7 days
.
#. DM2: Patient continued on NPH with ISS
#. PVD: Stumps appear clean.
#. Anemia - unknown baseline. Normocytic. Iron studies c/w
anemia of chronic disease. Also Guaiac positive. HCts stable.
# HTN ?????? Patient was continued on metoprolol and amlodipine.
Lisinopril was held in the setting of ARF. Patient remained
persistently hypertensive, but systolic BPs into the 170s were
tolerated given concern that patient might be septic and desire
to maintain liver and kidey perfusion given above problems.
[**Name (NI) **] was discharged on this two drug regimen.
.
# Seizure disorder: Pt has prior hx of seizure d/o. EEG
negative. Phenobarbital dosed by level.
# FEN: TF's at 30 cc/hr via PEG tube, replete lytes prn
.
# Code/Family Meeting: During this admission, patient required
intubation and agressive care. Patient was made DNR/DNI as of
[**10-24**] by HCP, in agreement with the rest of the patient's
family. Multiple family meetings were held once the patient was
transferred from the ICU to the floor. Family appreciated the
gravity and irreversibility of the patient's situation. Given
the patient's renal failure, family decided not to pursue
dialysis and not to pursue PICC line access for IV care once
patient self d/cd her line. Family chose a "comfort oriented"
plan that includes no escalation of care, no HD, and no ICU
transfer. A palliative care consult was requested to help
organize Hospice care at the [**Hospital3 **], which family
considers "patient's home". They understand that hospice care
will mean more volunteer time, more nursing assessment, and
additional health aide time.
.
# Communication:
-- Daughter [**Name (NI) 8392**] [**Telephone/Fax (1) 102571**]
-- Daughter [**Name (NI) 2563**] [**Telephone/Fax (1) 102572**]
Medications on Admission:
Avandia 4 mg p.o. b.i.d.
sliding scale insulin
Insulin 16 NPH q.p.m.
Dulcolax p.r.n.
MoM
tylenol
artificial tears
senna
FeSo4 325 [**Hospital1 **]
Phenobarbital 90 mg p.o. daily
Hyoscyamine 0.125 tid
Lopressor 150 mg p.o. b.i.d.
tube feeds per G-tube
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Last Name (STitle) **]: One
(1) Appl Ophthalmic PRN (as needed).
3. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) nebulizer Inhalation every twelve (12)
hours.
Disp:*10 bottles* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: Two (2)
Tablet, Sublingual Sublingual QID (4 times a day).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
8. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: Sixteen
(16) units Subcutaneous once a day.
Disp:*1 bottle* Refills:*2*
9. Scopolamine Base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) patch
Transdermal every seventy-two (72) hours as needed for oral
secretions.
10. Tylenol 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every 6-8 hours as
needed for pain.
11. Morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 3-10 mg PO q4h:PRN as
needed for pain.
Disp:*50 ml* Refills:*0*
12. Phenobarbital 30 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO every
seventy-two (72) hours: please dose by serum drug level if
possible.
Disp:*30 Tablet(s)* Refills:*2*
13. Miconazole Nitrate 2 % Cream [**Last Name (STitle) **]: One (1) Appl Vaginal Q 24H
(Every 24 Hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
MSSA pneumonia
Shock liver
Acute renal failure
Hyponatremia
Urinary tract infection
Secondary:
# peripheral vascular disease status post AKA bilaterally
# diabetes mellitus type 2
# hypertension
# dementia
# seizure disorder
# right DVT in [**2173-8-10**]
# Anemia
Discharge Condition:
Stable, afebirle
Discharge Instructions:
You were admitted for a pneumonia requiring antibiotic therapy.
Your hospital course was complicated by injury to your liver,
likely from your low blood pressure as a consequence of the
infection in your lung. You improved on IV antibiotics. You also
developed failure of your kidneys. This was felt to be secondary
to your low blood pressure. The decision was made not to pursue
dialysis. You are being discharged back to [**Hospital3 **] with
Hospice care. Your medications will be continued as below.
Please return to the hospital if you have any shortness of
breath, worsening cough or any other concerning symptoms.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 5762**] as needed.
Completed by:[**2181-11-2**]
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
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[
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12534, 16549
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2419, 2604
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2620, 2845
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,236
| 109,787
|
52422
|
Discharge summary
|
report
|
Admission Date: [**2194-8-24**] Discharge Date: [**2194-8-28**]
Date of Birth: [**2112-2-19**] Sex: F
Service: MEDICINE
Allergies:
Belladonna Alkaloids
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
AMS, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 108328**] is an 82 year old female with MDS, Crohn's disease,
CAD s/p NSTEMI, CRI, h/o DVT with saddle embolus on weekly
lovenox due to h/o GIBs, h/o breast cancer, on home O2 who
presents with dyspnea, AMS. Of note, patient was discharged 6
days ago with left upper extremity DVT from PICC and subsequent
port placement.
.
In ED, patient presented solmnolent with marked tachypnea from
ambulance. ABG 7.21/80/76 given baseline pCO2 60 patient was
started on BiPAP. CXR with effusions, but unclear if any
consolidation. Mildly positive UA, minimal urine output. Patient
was started on Vanc/Zosyn and given methylpred 125mg
empirically. Patient with troponin at baseline. K noted to be
7.0: 60 gm kayexelate enema (with no significant bowel
movement), amp D50, 10 unit insulin iv, albuterol/ipratropium
nebs, and 1 gm calcium gluconate. EKG no peaked Ts, QRS 130
which is baseline and no other concerning ST/T changes. Patient
repeat K pending. Renal aware of K+ but given EKG felt no need
for urgent HD. Given recent left upper extremity DVT, patient
got 60 mg lovenox in ED as has not gotten today. Unable to get
PE CTA given renal failure. Minimal improvement on BiPAP in
terms of mental status. Current vitals: temp afebrile by rectal,
BP 140/40s, HR 50s, O2sat 97% on bipap 8/5, 2LNC.
.
Event prior to transfer: SBP 70s suddenly, and SBP improved 100s
off BiPAP, still sinus brady. Patient slightly more awake now
off BiPAP, getting 500 ml bolus. ABG just prior 7.27/68/74.
.
Upon arrival to MICU, patient somnulent off BiPAP. Patient
placed back on BiPAP and want unable to answer questions.
Daughter provided the following history. Daughter reports since
discharge from hospital patient has been weak, not interested in
eating, and intermittently very somnulent. Daughter reports her
mother is [**Name2 (NI) 18248**] and then not confused. [**Name2 (NI) 108329**] describes 2
episodes of confusion this week in the setting of document
hypoxia to 70s, that resolved upon increasing oxygen. Daughter
reports mother [**Name (NI) **] hot w/o fever by thermometer, and w/o chills.
Over the week the daughter has noted she issues with oxygenation
and has changed her O2 between 1.5 to 3LNC. Usually her mother
is only on O2 at night, but has been on it continuously since
just prior to last hospitalization. Daughter has been giving her
Bactrim and vitamins to help. She also gave her mother [**Doctor Last Name **]
yesterday, because she wanted her to retain water and was
concerned she was becoming dehydrated. Daughter reports
increased UOP earlier in the week followed by minimal urine
output today. Early on day of admission patient called out to
daughter and reports not seeing well and wanting to get out of
bed. Per daughter, these are symptoms of hypercarbia in her
mother. Daughter also report mother has had non-productive
cough, but without coughing after eating. Per daughter [**Name (NI) **] [**Name2 (NI) **]
check was K =5.3 from VNA labs.
.
Review of systems: (+) Per HPI. Daughter reports ongoing groin
rash.
Past Medical History:
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, now off Lovenox as well for GIB
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-dHF with EF 60-70%
-s/p CY 10 yrs ago
-s/p Lumpectomy 13 yrs ago
Social History:
[**Year (4 digits) 595**] speaking only. Married; lives with her daughter [**Name (NI) 108329**],
[**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. [**Name (NI) 108329**] is the caretaker
for both of her parents. Has daily visiting nurse at home.
Family History:
Non-contributory
Physical Exam:
Initial MICU exam:
General Appearance: Thin
Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Conjunctiva
pale, conjugate gaze
Head, Ears, Nose, Throat: Normocephalic, on BiPAP
Lymphatic: No(t) Cervical WNL
Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t)
Systolic)
Peripheral [**Name (NI) **]: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : ), anterior, lateral
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: 1+ edema, Left: 1+ edema, legs wrapped in
ACE bandages
Skin: Warm, Rash: in groin erythematous.
Initial floor exam:
Vitals: 99.2 72 140/58 22 93% 0.5LNC
Gen: pleasant elderly woman lying in bed, in NAD
[**Name (NI) 4459**]: NC/AT, EOMI, MMM, supple neck
CV: RRR, normal S1S2, no m/r/g
Lungs: CTA b/l, decreased breath sounds, no rales/wheezing
appreciated
Abd: soft, nt, nd, +bs, no masses
Ext: 2+ edema in all extremities, +distal pulses
Pertinent Results:
Labs on Admission: [**2194-8-24**]
WBC-5.9 RBC-2.41* Hgb-8.5* Hct-27.3* MCV-114* RDW-23.9* Plt
Ct-244
Neuts-51.8 Lymphs-36.6 Monos-8.3 Eos-2.6 Baso-0.8
PT-10.5 PTT-22.3 INR(PT)-0.9
Glucose-115* UreaN-31* Creat-1.9* Na-140 K-7.0* Cl-105 HCO3-34*
AnGap-8
Calcium-8.7 Phos-4.1 Mg-2.7*
ALT-7 AST-11 CK(CPK)-16* AlkPhos-103 TotBili-0.3
Lipase-61*
proBNP-4081*
.
.
Micro:
[**2194-8-24**] Blood cultures: pending
[**2194-8-24**] Urine culture: URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
.
Other Studies:
[**2194-8-24**] EKG: Possible wandering atrial pacemaker or irregular
sinus bradycardia with premature atrial contractions and first
degree A-V block. Right bundle-branch block. Non-specific ST-T
wave changes. Compared to tracing #1 no significant change.
[**2194-8-24**] CXR: 1. Moderate left and small right pleural effusions.
2. Left retrocardiac opacity, atelectasis and/or consolidation.
[**2194-8-24**] CT Head w/o: No acute intracranial pathology. Stable
encephalomalacic changes as described. However, MRI would be
more sensitive for [**Month/Day/Year 2742**] of acute infarct if clinical
concern warrants.
[**2194-8-25**] Echo: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild pulmonary artery systolic
hypertension. Mild mitral regurgitation. Compared with the prior
study (images reviewed) of [**2194-4-8**], the estimated pulmonary
artery systolic pressure is now lower. The right ventricular
cavity is also smaller/now normal.
[**2194-8-25**] Left arm U/S: 1. Deep vein thrombosis is identified in
one of the two brachial veins. Flow within the axillary vein
appears to be normal on today's exam. 2. Stable appearing
hematoma in the left upper arm.
[**2194-8-26**] CXR: The Port-A-Cath catheter tip is in superior SVC.
The left retrocardiac consolidation which is most likely a
combination of atelectasis and pleural effusion is unchanged.
Infectious superimposed process cannot be excluded. There is
interval worsening of [**Month/Day/Year 1106**] engorgement with currently
[**Month/Day/Year 1106**] engorgement seen in the perihilar areas bilateral.
There is no pneumothorax. The patient is after cholecystectomy
Brief Hospital Course:
This is an 82 year old female with MDS, Crohn's with multiple GI
bleeds, CAD s/p NSTEMI, CKD, h/o DVT/saddle embolus on daily
Lovenox, breast ca, on home O2 only at night secondary to
non-compliance with bipap, admitted for altered mental status
and dyspnea.
.
#. AMS. The patient was admitted to the MICU with lethargy and
confusion which the daughter felt was due to hypercarbia. Upon
arrival to MICU, the patient was somnolent off BiPAP and
improved after being placed back on BiPAP. Ever since her last
admission, the daughter reports that the patient has been weak,
not interested in eating, and intermittently very somnolent. She
was found to have a questionable retrocardiac pneumonia on CXR
and a UTI. Her AMS resolved after antibiotic coverage and her
ABG returned to her baseline on nasal cannula prior to leaving
the ICU. She was treated empirically for HAP and UTI with
vanco, cefepime, and ciprofloxacin starting on [**8-24**] in the MICU.
Her antibiotics were modified to cefepime only for a total of a
10 day course to be completed at home. Blood cultures were
negative on discharge and urine culture was positive for
enterobacter sensitive to cefepime.
.
#. Dyspnea. She is slightly dyspneic at baseline, but was
satting well on room air prior to discharge. Her current chest
imaging does not have a clear infiltrate and just shows interval
worsening of [**Month/Year (2) 1106**] engorgement in bilateral perihilar areas
which may be secondary to fluid overload. Cefepime alone would
also provide good lung coverage in case the patient has a
non-focal pneumonia. She does have a history of PE, but no RV
strain was seen on ECHO on admission. She will most likely need
some gentle diuresis with her home dose of Lasix 10mg. She will
continue on her stress dose steroid [**Month/Year (2) 15123**] that was started in
MICU, and per the daughter's request will be tapered back slowly
by 5mg every 2 days down to her 20mg chronic dose after
discharge.
.
#. Hyperkalemia. This seems to be a chronic issue. Her Bactrim
was switched to atovaquone as Bactrim can sometimes contribute
to hyperkalemia. Her potassium had remained stable without
intervention over the two days prior to discharge.
.
#. Anemia. She was transfused 2 units [**8-26**] which appropriately
increased her hematocrit from 23.5 to 31.3. Her hematocrit
remained stable thereafter. Her stools were guaiac negative.
Her monthly B12 shot was administered [**2194-8-25**] and she was
continued on daily folic acid.
.
#. LUE DVT. Last ultrasound was done on [**2194-8-25**] which revealed
a stable hematoma and upper extremity DVT. She continued daily
Lovenox 60mg and her hematocrit was followed closely.
.
#. MDS. She has transfusion dependent disease and she was
transfused to keep her hematocrit greater than 23. Her PCP
prophylaxis was switched from Bactrim to Atovaquone.
.
#. Crohn's disease. Her home mesalamine was continued and her
steroids were stress dosed. She will be tapered back to her
20mg home dose slowly.
.
#. CAD s/p NSTEMI. She is not on ASA secondary to her history
of multiple GI bleeds. She was continued on her beta blocker.
.
#. Chronic b/l LE edema/venous stasis. Her home trimacinolone
cream was continued PRN as well as intermittent Lasix 10mg PRN.
.
#. GERD. She was maintained on daily pantoprazole 40mg during
the admission.
.
#. CKD - Her baseline creatinine is around 2 and was 1.9 on the
day of discharge. She will be continued on weekly Epogen 40,000
units as an outpatient, but was given 10,000 units on a
Monday/Wednesday/Friday schedule as an inpatient.
.
#. Fungal groin rash. Miconazole QID was given during admission.
Medications on Admission:
Folic Acid 1 mg daily
Mesalamine 1200 mg TID
Bone Reenforcement (MVI/Ca/D/Mg/vitC)
Trimethoprim-Sulfamethoxazole 80-400 mg every other day -- took
daily for 10 days for UTI prior to last hospital presentation
and has been taking almost daily since discharge from last
hospitalization for subj fevers.
Ciprofloxacin 250 mg [**Hospital1 **], taken PRN for diarrhea, last taken [**3-4**]
wks ago
Epoetin Alfa 40,000 unit/mL weekly
Miconazole Nitrate 2 % Powder TID:PRN rash
Omeprazole EC 20 mg daily
Lasix 10mg daily:PRN leg swelling - got tues or wed this past wk
Cyanocobalamin 1,000 mcg/mL INJ monthly - due this week
Triamcinolone Acetonide 0.025 % Cream to affected area [**Hospital1 **]
Prednisone 20 mg daily
Lovenox 60 mg INJ daily - got Wed-Fri, missed Mon/Tues due to no
supply, missed Sat/Sun as not feeling well and daughter worried
about giving
Metoprolol Tartrate 12.5 mg prn SBP >130 (daughter checks at
home) last given saturday.
Discharge Medications:
1. Cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q24H
(every 24 hours) for 6 doses.
Disp:*6 grams* Refills:*0*
2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 ML(s)* Refills:*0*
3. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
Disp:*30 ML(s)* Refills:*0*
4. Sodium Chloride 0.9 % 0.9 % Solution Sig: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
Disp:*60 ML(s)* Refills:*0*
5. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q24H (every 24 hours).
6. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical DAILY (Daily) as needed for to lower extremities.
7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin.
9. Epoetin Alfa 10,000 unit/mL Solution Sig: 40,000 units
Injection once a week.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day as
needed.
12. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Portacath care
Portacath supplies
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
18. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) MLs PO DAILY
(Daily).
Disp:*300 MLs* Refills:*2*
19. Prednisone 10 mg Tablet Sig: Take 55mg for 2 days, 50mg for
2 days, 45mg for 2 days, 40mg for 2 days, 35mg for 2 days, 30mg
for 2 days, 25mg for 2 days, then continue with 20mg daily
Tablet PO once a day.
Disp:*QS Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Pneumonia
urinary tract infection
altered mental status
Secondary diagnoses:
-h/o hyperkalemia
-PICC associated left upper extremity DVT and hematoma [**5-8**]
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, on weekly lovenox due to prior UGIB, recently [**8-18**]
increased to daily lovenox for upper extremity DVT.
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**] AND chronic diastolic congestive heart
failure: EF 60-70%
-CRI w baseline Cr 1.4-1.7
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
[**Hospital1 2742**] of altered mental status. You were found to have a
pneumonia, urinary tract infection and a high potassium level.
Your potassium levels were treated and have remained stable. At
first you were extremely somnolent and were cared for in the
intensive care unit where you were treated with broad spectrum
antibiotics to cover a pneumonia as well as a urinary tract
infection. Your mental status improved with oxygen and
antibiotics. For your congestive heart failure, please weigh
yourself every morning, call your primary care doctor if your
weight > 3 lbs. You should continue to dose Lasix as needed to
take off any extra fluid. Please adhere to a 2 gm sodium and
low potassium diet.
The following changes have been made to your medication regimen:
-You will take 6 more doses of Cefepime 1 gram IV daily
-You will [**Hospital1 15123**] your prednisone dose as directed by 5mg every 2
days back down to 20mg daily
-You will take atovaquone 1500mg daily
-You will stop taking Bactrim
Please keep all of your follow-up outpatient medical
appointments.
Please seek medical care for any concerning symptoms such as
confusion, fevers, chills, vomiting, increased shortness of
breath, chest pain, or bloos in your stool.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
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"414.01",
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"276.7",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14385, 14460
|
7662, 11327
|
305, 311
|
15238, 15257
|
5377, 5382
|
16601, 16793
|
4288, 4306
|
12321, 14362
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14481, 14538
|
11353, 12298
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15281, 16578
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4321, 5358
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14559, 15217
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3339, 3391
|
241, 267
|
5843, 7639
|
339, 3319
|
5396, 5814
|
3413, 3986
|
4002, 4272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,744
| 121,556
|
50975
|
Discharge summary
|
report
|
Admission Date: [**2179-4-19**] Discharge Date: [**2179-5-9**]
Date of Birth: [**2107-3-28**] Sex: M
Service: [**Doctor Last Name **]
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old man
with multiple medical problems including cirrhosis secondary
to Amiodarone, aortic valve replacement (St. [**Male First Name (un) 1525**]), atrial
fibrillation, and pleural effusions who presents with a
general feeling of malaise, weakness and shortness of breath.
The patient has felt "terrible," for the past week though he
can not put his finger on why. He has noted dyspnea on
exertion for several weeks, worse over the past week. His
review of systems is also positive for cold and taros
diarrhea. He denies fevers, chills, sweats, nausea, vomiting
and diaphoresis. He denies chest pain, jaw pain or anginal
equivalent. He denies abdominal pain with diarrhea which he
describes as dark. The diarrhea has been persistent over
several months. Review of systems is also positive for
decreased p.o. intake over the past week but no paroxysmal
nocturnal dyspnea or orthopnea. The patient came to the
Emergency Department for further evaluation, found to be
bradycardia in the 30s with INR of 6.2. Of note, the patient
was recently started on Digoxin in [**Month (only) 958**] for rapid atrial
fibrillation. With respect to his INR the patient's Coumadin
has been changed recently to 7.5, alternating with 10.
PAST MEDICAL HISTORY: 1. Cryptogenic cirrhosis felt to be
secondary to Amiodarone; 2. Grade 2 esophageal varices; 3.
Aortic valve replacement in [**2166**] for aortic stenosis; 4.
Atrial fibrillation; 5. Type 2 diabetes; 6. Meningioma
status post resection; 7. Gout; 8. Recurrent pleural
effusions, transudative; 9. Anemia; 10. History of
ventricular tachycardiac arrest; 11. Diverticulitis; 12.
Hypertension; 13. Status post right hip replacement.
ALLERGIES: Amiodarone.
MEDICATIONS ON ADMISSION: Dilantin 200 mg b.i.d., 100 mg
q.h.s., Aldactone 25 mg q.d., Lasix 40 mg q.d., Glyburide 10
q. AM, 5 q. PM, Metformin 500 b.i.d., Lexapro 15 q.d.,
Allopurinol 100 q.d., Protonix 40 q.d., Propranolol 30
b.i.d., Iron 325 q.d., Coumadin 10.5/10, Diltiazem
extended release 240 q.d., Digoxin 0.25 q.d.
SOCIAL HISTORY: The patient is married with five children.
He is a retired machinist. He has a 40 pack year smoking
history, quit 40 years ago.
PHYSICAL EXAMINATION: On examination the patient's
temperature is 96.4, pulse 62 range 30s to 40s, blood
pressure 152/55, respiratory rate 18, sating 99% on room air.
In general he is a pleasant man in no acute distress. Mucous
membranes are moist. Pupils equal, round and reactive to
light and accommodation. His jugular venous pulse was detected
at 10 cm.
Lungs, decreased breath sounds at the right base to [**1-8**] the
way up, and normal left lung examination. His heart was
rhythm, bradycardiac and regular with mechanical S2 and II/VI
systolic ejection murmur at the right upper sternal border.
The abdomen was distended with normoactive bowel sounds. He
was mildly tender in the right upper quadrant, liver edge was
at the costal margin and dull to percussion around one-third
of the way up. Extremities had 1+ pitting edema.
LABORATORY DATA: Laboratory data included white count of 7.8
with a normal differential, hematocrit 30.0 which is his
baseline. Platelets 132. Sodium 141, potassium 5.0,
chloride 107, bicarbonate 3, BUN 30, creatinine 1.1, glucose
173. His calcium was 9.5, magnesium 2.3, phosphorus 2.8.
His PTT was 37.3, INR 6.2. His Digoxin level was 2.9. AST
40, ALT 29, total bilirubin .6, alkaline phosphatase 142. He
had a chest film that showed a right pleural effusion that
was associated with right lower lobe collapse.
HOSPITAL COURSE: 1. Cardiovascular - The patient had two
problems as far as cardiovascular examination over the course
of his admission. Tthe first was bradycardia, likely secondary
to medication toxicity, predominantly Digoxin. The patient
had neural agents on top of the Digoxin and it was likely due
to toxicity that lead to his bradycardia. The patient had
both his Propranolol, Diltiazem and Digoxin withheld on
admission,
and had a cardiology consult on the second day of admission.
They recommended waiting until the Digoxin level was less
than .9 and then cardioverting. This was attempted, however,
within several hours the patient went back into atrial
fibrillation, and so he was rate-controlled with medication over
the rest of
his admission. He was initially just kept on the Propranolol
which was later changed over to Metoprolol. Later in the
hospital course he developed congestive heart failure.
Unfortunately he
went back into atrial fibrillation with rapid ventricular
response, so he was maintained on both Metoprolol and high
levels of Diltiazem with success.
The [**Last Name **] problem was
congestive heart failure, occurring after
transjugular intrahepatic portosystemic shunt (TIPS) procedure.
Two days following TIPS, the patient developed severe dyspnea and
tachypnea,
yet did not have any clear evidence for hypoxia, requiring
just 2 lpm O2; however, it was felt that he was likely in
right heart failure with a potential of heart component. He
was initially diuresed with minimal success, and was then
changed to a Nitroglycerin drip and transferred to the
Medical Intensive Care Unit. He had a Swan-Ganz catheter
placed which showed both left and right heart failure. At
the time he developed acute renal failure, and so he was not
diuresed for several days. He was improved symptomatically
and he was transferred back to the floor. He was stable off
diuretics for several days, however, again went into
pulmonary edema, was again diuresed, this time with more
success. At the time of dictation, however, he is not
requiring any further diuretics and he is on 2 liters O2.
2. Hematology - The patient has a supratherapeutic INR that
is likely considered poor absorption from decreased p.o.
intake and diarrhea. He was given gentle Vitamin K and
started on heparin while he was subtherapeutic towards the
end of his admission. After multiple procedures, the patient
was restarted on Coumadin with a goal INR of 2.5 to 3.
3. Pleural effusions - The patient had a pleural effusion,
likely hepatic hydrothorax. Once he was off
Coumadin, he was taken for thoracentesis under ultrasound
guidance. He had 1.5 liters of transudative taken off. There
were no complications from this, and
the patient felt better symptomatically.
4. Gastrointestinal - The patient over his
admission developed a drop in hematocrit that was likely
secondary to a gastrointestinal bleed. Gastroenterology
consult was obtained who recommended going to
esophagogastroduodenoscopy. The endoscopy showed Grade 3
varices which were worse compared to the previous as well as
portal hypertensive gastropathy. The decision at this point
was made to consult the liver service, given the
complications of portal hypertension. The liver service
recommended increasing his diuretics and ultimately a
transjugular intrahepatic portosystemic shunt procedure. The
patient underwent a transjugular intrahepatic portosystemic
shunt procedure which was initially uncomplicated, as they were
able to effectively reduce his portal pressures. As
mentioned above the patient developed complications from this
procedure including acute renal failure and congestive heart
failure that were managed initially in the Intensive Care
Unit and then later on the floor. More to the point, however,
the patient also developed encephalopathy within two days of
completing the transjugular intrahepatic portosystemic shunt
procedure. While on balance, it was felt the potential
benefit was to reduce the risk of having a lethal variceal
bleed, the family understood that one consequence and
complication of the transjugular intrahepatic portosystemic
shunt procedure was encephalopathy. Unfortunately, the
patient's encephalopathy did progress, likely multifactorial
towards the end of his admission. He was treated with
Lactulose around the clock as well as lactulose enemas with
minimal effect. Ultimately, the patient had an infection
which was precipitating and worsening his encephalopathy.
At the time of this dictation, he is being treated prn with
Lactulose. The patient in the past has expressed a wish not
to have diarrhea if at all possible (see below), but was treated
with Lactulose prn.
5. Infectious disease - The patient had no evidence of
infection for several weeks, however, towards the end of his
admission, he spiked a fever to 101.8. Blood cultures were
drawn. The patient was empirically started on Vancomycin and
Levofloxacin. The cultures are negative at the time of this
dictation, but presumptive infection from unknown source likely
precipitated and worsened his encephalopathy.
6. Code status - The patient over the course of his
admission slowly and steadily worsened in terms of his mental
status from various medical complications. The patient had
expressed a very clear wish to his family that he not go on a
ventilator or have cardiopulmonary resuscitation, if it would
only improve his quality of life. The patient was made
Do-Not-Resuscitate, Do-Not-Intubate in accordance with their
wishes. Unfortunately, the patient's condition continued to
deteriorate and after a family meeting in which the wishes of
the patient were made clear, the patient was made
Comfort-Measures-Only.
At the time of this dictation the medications he is still on
including the Diltiazem and the Metoprolol are primarily for
his comfort and then he goes into rapid atrial fibrillation
and has worsening congestive heart failure. In addition, the
patient's family was adamant that he stay on the Coumadin
prophylaxis for prosthetic valve, their belief being that
removing the Coumadin, and risking thrombosis, was too active a
mechanism of demise.
CONDITION ON DISCHARGE: Poor.
DISCHARGE STATUS: To hospice.
DISCHARGE DIAGNOSIS:
1. Digoxin toxicity.
2. Congestive heart failure.
3. Supratherapeutic INR.
4. Hepatic hydrothorax.
5. Cirrhosis.
6. Portal hypertension.
7. Esophageal varices.
8. Portal gastropathy.
9. Hepatic encephalopathy.
10. Type 2 diabetes.
11. Gastrointestinal bleed.
DISCHARGE MEDICATIONS;
1. Atrovent 1 nebulizer q. 6 hours.
2. Coumadin 10 mg q.d.
3. Tylenol 100 mg q. 6 hours prn.
4. MSIR 5 mg p.o. q. 4 hours prn.
5. Dilantin 200 b.i.d., 100 q.h.s.
6. Ativan .5 to 2 mg p.o. q. 4 hours prn seizure.
7. Diltiazem 120 mg p.o. q.i.d.
8. Metoprolol 25 mg p.o. b.i.d.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Last Name (NamePattern1) 7693**]
MEDQUIST36
D: [**2179-5-7**] 18:18
T: [**2179-5-7**] 19:26
JOB#: [**Job Number 105920**]
|
[
"584.9",
"428.0",
"511.8",
"572.2",
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"427.31",
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] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.62",
"34.91",
"39.1"
] |
icd9pcs
|
[
[
[]
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10017, 10864
|
1947, 2246
|
3774, 9932
|
2416, 3756
|
184, 1437
|
1460, 1920
|
2263, 2393
|
9957, 9996
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,688
| 144,761
|
37937
|
Discharge summary
|
report
|
Admission Date: [**2140-8-15**] Discharge Date: [**2140-8-18**]
Date of Birth: [**2065-11-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
RV pacemaker lead malfunction
Major Surgical or Invasive Procedure:
Right Ventricle Lead extraction and ICD replacement with St.
[**Male First Name (un) 923**]
History of Present Illness:
75 year old female with h/o long QT, cardiac arrest while
vacationing in [**Country 12649**]. Had ICD placement in [**2133**], placement of a
new RV lead in [**2134**] because of diaphragmatic pacing, second
arrest in [**2134**] in the setting of Biaxin administration,
generator replacement in [**12/2138**], presented for RV pacing lead
extraction after RV impedence increased to 1000 ohms last week.
Found to have fractured lead.
.
Cardiac arrest occurred while she was vacationing in [**Location (un) 84790**]
in [**2134**] in the setting of drinking large quantities of tonic
water (quinine). She had 5 separate episodes of "arrest" prior
to ICD placement in Malaga. The patient had another arrest in
the US in the setting of Biaxin administration. Pacemaker
placed in [**Country 12649**]. No episodes of cardiac arrests since placement
in [**2134**].
.
The patient had normal device checks in device clinic until last
month when she was found to have elevated impedence of 1900 0hms
in RV lead. Later readings were normal. However, 1.5 weeks ago
whe called clinic because her pacemaker was "beeping" and was
found to have impedence of 100 ohms on [**Male First Name (un) **] transmission. It
was determined that she required a new lead.
.
ICD and pacemaker lead from [**2133**] were removed (atrial lead still
in place). New ICD lead placed under general anesthesia. The
patient had 250cc of blood loss during the procedure and was
mildly hypotensive. 0.5-0.8cm pericardial effusion present
during procedure- no change in size. Admitted to CCU. Upon
transfer, patient stable with vitals signs as follows: T- 98, P-
97, BP- 128/62, RR- 14, SaO2- 100% on NC
.
The patient reports that on presentation she is asymptomatic.
There is no chest pain, shortness of breath, palpitations,
nausea, vomiting, abdominal pain, headache, dizziness,
lightheadedness, diaphoresis, dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-PACING/ICD: s/p ICD in [**2133**]; in [**12/2138**], generator change to
St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **].
3. OTHER PAST MEDICAL HISTORY:
Cardiac Arrest (as above) s/p ICD
COPD / Asthma (patient unsure) for 15 years, can climb 1 flight
of stairs without stopping
Hypertension
Hyperlipidemia
Ectopic Pregnancy (remote history)
Social History:
retired chemist; worked at [**University/College **] for many years, states make have
had exposure to many chemical fumes; Lives with husband.
-Tobacco history: None, but second hand smoke from her father
who was a heavy smoker
-ETOH: Rarely
-Illicit drugs: None
Family History:
Father with a MI in early 60s, lung cancer, eventually died on
CVA in his 80s. 2 paternal uncles with sudden death (cause
unknown) in their 60s.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T- 98, P- 97, BP- 128/62, RR- 14, SaO2- 100% on NC
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVD.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased breath sounds
at the bases, otherwise CTAB.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: Trace to 1+ edema. No c/c. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Echo [**2140-8-15**]: No atrial septal defect is seen by 2D or color
Doppler. 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. No thoracic
aortic dissection is seen. There is no aortic valve stenosis. No
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen.
.
Moderate [2+] tricuspid regurgitation is seen. The tricuspid
regurgitation jet is eccentric and may be underestimated. TR is
directed toward the CS, with possible restriction of the septal
leaflet.
.
There is a small pericardial effusion measuring 0.6 to 0.9 cm in
thickness, this was stable throughout the procedure and also at
the end of the procedure. There are no echocardiographic signs
of tamponade.
.
CXR portable [**2140-8-15**]: No previous images. A dual-channel
pacemaker device is in place with the leads extending in the
region of the apex of the right ventricle and the right atrium.
Mild hyperexpansion of the lungs suggests underlying chronic
pulmonary disease. The cardiac silhouette is essentially within
normal limits with no evidence of vascular congestion or pleural
effusion.
.
Labs on admission:
WBC 6.3, Hb 10.7, Hct 33.1, plt 189
Na 142, K 3.5, Cl 107, bicarb 26, BUN 26, Cr 1.1, glu 96
.
Labs on discharge:
WBC 6.8, Hb 8.9, Hct 28.2, plt 174
Na 141, K 4.7, Cl 110, bicarb 24, BUN 19, Cr 1.0, glu 109
Brief Hospital Course:
75 y/o F with h/o long QT and cardiac arrest s/p ICD placement,
s/p placement of a new RV lead in [**2134**] because of diaphragmatic
pacing, s/p second arrest in [**2134**] in the setting of Biaxin
administration, s/p generator replacement in [**12/2138**], presents
with RV lead malfunction.
.
# RV lead extraction - Extraced RV ICD and RV pacer lead and
implanted new single coil ICD lead and replaced the St. [**First Name4 (NamePattern1) 923**]
[**Last Name (NamePattern1) **] ICD. Post-procedure patient had a
small pericardial effusion measuring 0.6 to 0.9 cm in thickness,
this was stable throughout the procedure and also at the end of
the procedure. There were no echocardiographic or clinical signs
of tamponade. Repeat echo on [**2140-8-16**] showed stable/resolving
pericardial effusion. Estimated blood loss 250 cc, but per
report, procedure was slightly more complicated than expected.
Patient did have Hct which dropped from 33.1 to 28.2 then 26.6
(given 1 unit pRBC with appropriate rise). She was also given 1
unit of pRBC when her Hct went from 29.7 to 27.5, with
appropriate rise. Her physical exam showed small hematoma near
site of procedure and mild eryhema in L arm and L breast region,
for which patient received 2 doses of vancomycin and PO keflex
(to complete total 7 day course). Patient did not have any
events on telemetry. CXR after lead revision did not show
complications of lead implantation, no pneumothorax. Patient is
to follow-up with Dr. [**Last Name (STitle) 84791**] in device clinic in 1 week.
ICD site care reviewed with patient as follows: Please look at
the site daily and note if there is more swelling, tenderness or
redness. Call Dr. [**Last Name (STitle) **] for any of those symptoms or if you
develop a fever. Keep the site covered with a dry dressing. No
pools or baths or showers for one week. Do not lift your left
arm over your head for 6 weeks. Keep your left arm on 2 pillows
while you are sitting or lying down to decrease the swelling.
.
# Hypotension - after lead implantation and in setting of oral
antihypertensives, patient's systolic blood pressure went to the
low 70s. Patient was bolused 500 cc x 2 and SBP to 90s-100s.
Lisinopril and torsemide were held during this period. No mental
status changes or sx throughout the event. Her systolic blood
pressure remained in the 90s-100s throughout her
hospitalization, which, per patient, is her baseline. Her urine
and blood cx were negative. On discharge, home lisinopril dose
was decreased to 10 mg daily. Torsemide dose was decreased to
10 mg daily. Metoprolol dose was decreased to 12.5 mg twice
daily.
.
# h/o Cardiac Arrest s/p ICD placement - no events since [**2134**].
RV lead extraction as above. No events on telemetry. Pt was
continued on torsemide, metoprolol, lisinopril once blood
pressures were above sbp 100.
.
# h/o COPD / Asthma - stable per patient. Continued on Advair
discus [**Hospital1 **], Singulair daily, Spiriva daily, Albuterol prn.
.
# h/o Hypertension - outpatient regimen metoprolol, lisinopril,
torsemide. In setting of hypotensive episode, as noted above,
the above medications were initially held, then started at 1/2
dose.
.
# h/o Hyperlipidemia - continued on outpatient regimen of
simvastatin 20mg daily.
.
# Pain - moderate pain at procedure site. Received fentanyl
during procedure and before arriving to floor. Continued on
morphine 2-4mg IV q2hr PRN pain. Pt discharged on vicodin prn.
Medications on Admission:
Metoprolol 25mg [**Hospital1 **]
Lisinopril 20mg daily
Torsemide 20mg daily
Simvastatin 20mg daily
Advair Diskus 250/50 [**Hospital1 **]
Singulair 10mg daily
Spiriva Diskus one cap daily
Iprastopium Br Nasal Spray - qAM PRN
Albuterol inhaler PRN - 1 use over the past month
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath.
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain.
9. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours: Do not take with Tylenol.
Disp:*12 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Please check Hct and chem 7 on Tuesday [**8-23**]. Call results
to Dr. [**Last Name (STitle) 5980**] at [**Telephone/Fax (1) 5985**]
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Lead extraction and ICD replacement
Low grade fevers
Hypotension
Acute on Chronic Blood loss Anemia
Discharge Condition:
stable
hct 28
Creat 1.0
Discharge Instructions:
You had a right ventricle lead extraction, replacement and a new
ICD device placed. You developed a hematoma in your left breast
area and required a unit of blood. We held your lisinopril and
torsemide because your blood pressure was low. You have had a
mild fever, all of your cultures have been negative.
.
ICD site care:
1. Please look at the site daily and note if there is more
swelling, tenderness or redness. Call Dr. [**Last Name (STitle) **] for any of
those symptoms or if you develop a fever.
2. Keep the site covered with a dry dressing. No pools or baths
or showers for one week. Do not lift your left arm over your
head for 6 weeks. Keep your left arm on 2 pillows while you are
sitting or lying down to decrease the swelling.
3. You will be seen in the device clinic in 1 week, Dr.
[**Last Name (STitle) **] will see you then.
.
Medication changes:
1. Lisinopril: please decrease your dose to 10 mg daily
2. Torsemide: please decrease your dose to 10 mg daily
3. Cephalexin: to prevent infection at the ICD site, take for a
total of 1 week.
4. Metoprolol: please decrease your dose to 12.5 mg twice daily
5. Vicodin: a narcotic medicine with tylenol to use for your
pacer site pain if the tylenol is not working well enough.
.
Please check your blood pressure at home and call Dr. [**Last Name (STitle) 5980**] if you
notice your blood pressure top number is less than 90 and you
feel dizzy. He will help you adjust your medicines.
You should make an appt to get a colonoscopy as you may be
losing small amounts of blood in your stool.
Please call Dr. [**Last Name (STitle) 5980**] or Dr. [**Last Name (STitle) 37933**] if you have any chest pain,
trouble breathing, abdominal pain, fevers, chills, cough or any
other unusual symptoms.
Followup Instructions:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2140-8-23**] 2:30 Dr.
[**Last Name (STitle) **] will see you at this appt.
Cardiology:
[**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 5980**], MD Phone:[**Telephone/Fax (1) 5985**] Date/time: [**9-1**] at
1:00pm.
Completed by:[**2140-8-19**]
|
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icd9cm
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,127
| 193,258
|
38481
|
Discharge summary
|
report
|
Admission Date: [**2175-5-16**] Discharge Date: [**2175-5-20**]
Date of Birth: [**2100-11-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
aortic valve replacement (25mm tissue)
History of Present Illness:
History of Present Illness: This is a 74 year old male with
known
aortic stenosis who presents with worsening shortness of breath.
Recent echocardiogram confirmed severe aortic stenosis and
cardiac cath showed moderate three vessel disease. Given the
above results, he was referred for cardiac surgical
intervention.
Currently he denies chest pain, syncope or palpitations.
Past Medical History:
Aortic Stenosis/Coronary Artery Disease
- Chronic Diastolic Heart Failure
- Diabetes Mellitus
- Hypertension
- Dyslipidemia
- Multiple myeloma - Currently in remission
Past Surgical History
- Rod placed in left ankle following fracture.
Social History:
Race: Caucasian
Last Dental Exam: Yearly
Lives with: Wife in [**Location 9583**], MA
Occupation: Retired
Tobacco: 40 pack year history. quit last [**2174-1-30**].
ETOH: None or rare use
Family History:
Family History: None that is significant for heart disease
Physical Exam:
Pulse: 82 SR Resp: 22 O2 sat: 96% RA
B/P Right: 128/74 Left: 111/70
Height: 75" Weight: 317
General: WDWN In NAD
Skin: Dry, warm and intact
HEENT: PERRLA [X] EOMI [X], NCAT, Sclera anicteric, OP benign.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, normal S1-S2, Highpitched IV/VI SEM best heard at
right upper sternal border. Radiates to carotids.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Trace LE Edema
Varicosities: Varicosities at right knee and below. Left dilated
but appears suitable.
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 Transmitted vs. Bruit (B)
Pertinent Results:
ECHO
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
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. There are three
aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). 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.[**Last Name (STitle) **] was notified in person of the results on Mr.[**Known lastname 111**]
before surgical incision.
POST-BYPASS:
The aortic bioprosthesis is well seated and functioning well.
The mean gradient is less than 5 mm of Hg. Thoracic aorta is
intact.
Preserved biventricular systolic function. LVEF 50%.
Trivial MR.
Rest of the findings similar to prebypass.
[**2175-5-19**] 05:15AM BLOOD WBC-4.6 RBC-2.52* Hgb-8.4* Hct-24.8*
MCV-98 MCH-33.4* MCHC-34.0 RDW-15.5 Plt Ct-158
[**2175-5-20**] 06:00AM BLOOD Glucose-112* UreaN-22* Creat-1.1 Na-137
K-4.0 Cl-103 HCO3-27 AnGap-11
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2175-5-16**] where the patient underwent Aortic
valve replacement with 23-mm
Biocor Epic tissue heart valve.
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 on no inotropic or vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. 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 home in good condition with appropriate
follow up instructions.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
LISINOPRIL-HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider)
- 20 mg-12.5 mg Tablet - 1 Tablet(s) by mouth twice a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth twice a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN [ASPIR-81] - (Prescribed by Other Provider) - 81 mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a
day
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- 1,000 mg Capsule - 1 Capsule(s) by mouth twice a day
Discharge Medications:
1. 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*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or fever .
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
all care
Discharge Diagnosis:
Aortic stenosis/CAD,- Chronic Diastolic Heart failure
,NIDDM,HTN,dyslipidemia,
Multiple myeloma - Currently in remission,s/pORIF LT ankle fx.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:
Dr. [**Last Name (STitle) **] [**2175-6-15**] at 1:30pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 85630**] [**Telephone/Fax (1) 83705**] in [**12-3**] weeks
Cardiologist Dr [**Last Name (STitle) 5017**] in [**12-3**] weeks
Completed by:[**2175-5-20**]
|
[
"401.9",
"V45.89",
"272.4",
"428.0",
"285.9",
"250.00",
"287.5",
"428.32",
"203.01",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6780, 6819
|
3547, 4657
|
342, 383
|
7005, 7217
|
2186, 3524
|
8056, 8442
|
1284, 1328
|
5707, 6757
|
6840, 6984
|
4683, 5684
|
7241, 8033
|
1343, 2167
|
283, 304
|
439, 787
|
809, 1048
|
1064, 1252
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,504
| 192,740
|
37275
|
Discharge summary
|
report
|
Admission Date: [**2175-10-30**] Discharge Date: [**2175-11-2**]
Date of Birth: [**2130-7-23**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
BRBPR/hematochezia
Major Surgical or Invasive Procedure:
EGD - esophagogastroduodenoscopy
History of Present Illness:
45 yo male with PMH of severe MV accident 20 yrs ago s/p
transfusion with subsequent hep C infection who presented to
[**Hospital 1562**] Hospital on [**2175-10-29**] with an upper GI bleed. Pt
reports epigastric hunger pain on [**2175-10-27**]. These pains
continued on and off. Then on [**10-29**] in the AM he had a few sips
of coffee which tasted funny. He went outside for a smoke at
which point he felt severe nausea, dizziness, and the urge to
deficate. He then had a large episode of BRBPR. 2 hrs later he
had another episode of BPBPR. He went back to bed but later woke
up dizzy. He then presented to [**Hospital 1562**] hospital. On arrival to
the OSH HR was 140s, SBP 90s. His original HCT per the physician
who signed out to me was 37 and it dropped to 24. The pt
received 4 units af blood and bumped his HCT to 32. HCT on
arrival here is 35. Baseline HCT is unknown. Pt was orthostatic
by HR. He underwent endoscopy at [**Hospital1 1562**] that reportedly showed
a proximal duodenum clot which they felt was the site of
bleeding. Given that the clot was at a difficult angle, they
were unable to intervene on the clot. A second clot was noted at
the GE junction which was not actively bleeding and there was
question of a irregular mucosa suggesting malignancy below the
clot. His last BM was [**10-29**]. On admit he complained of [**2176-5-13**]
lower abd pain. He states he had this pain at the OSH and it was
helped by morphine. He was monitored in the ICU for
approximately 12 hours, with stable hct, vital signs
(orthostatics negative) and no further stools, so was
transferred to the medical floor. He has no complaints
currently, denies dizziness, lightheadedness, chest pain, SOB,
n/v, hematuria, dysuria.
ROS: Pruritic rash on bilateral lower extremities with scattered
areas of ulceration for the past month for which he has not
sought medical care or tried medications. He can not identify
any new lotions, meds, soaps etc that may have caused them. He
does note recently moving back in with his [**Date Range **] who have 2
dogs but feels they do not have ticks or fleas. Otherwise, 10
point review of systems negative except as noted above.
Past Medical History:
Hep C (interferon) no h/o cirrhosis or varices, s/p IFN
treatment 12 years ago
PSH:
-Left inguinal hernia repair many yrs ago
-Hiatal hernia repair
-Exploratory laparotomy in setting of MVA 20 yrs ago
Social History:
-Currently lives in [**Hospital1 27663**]. Truck driver.
-etoh 4-5 drinks q 1-2 months
-current smoker 1 PPD >20 yrs
-denies past current illicit drug use
Family History:
Fa: HTN, DM and colon ca diagnosed at 65 yo.
Physical Exam:
VS: T 98.2 HR 80 BP 112/63 RR 16 Sat 94% RA
Gen: Well appearing man in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, asterixis absent, speech fluent
Integument: Scattered 5mm ulceartions with excoriations on B LE,
no palmar erythema, spider angiomas, warm, moist, no rash or
ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
Admit labs:
CBC: WBC-10.9 HGB-12.2* HCT-35.3->31.7->33.1 MCV-89 RDW-14.0 PLT
COUNT-174
Coags: PT-11.9 PTT-23.8 INR(PT)-1.0
LFT's: ALT(SGPT)-17 AST(SGOT)-17 LD(LDH)-164 ALK PHOS-67 TOT
BILI-0.6
BMP: GLUCOSE-84 UREA N-10 CREAT-0.7 SODIUM-137 POTASSIUM-4.0
CHLORIDE-106 TOTAL CO2-25 ALBUMIN-3.6 CALCIUM-8.5 PHOSPHATE-2.7
MAGNESIUM-2.2
EGD report:
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Segmental erythema of the mucosa was noted in the
pre-pyloric region and antrum. These findings are compatible
with gastritis.
Protruding Lesions A fungating and ulcerated mass with stigmata
of recent bleeding of malignant appearance was found at the
cardia. The scope traversed the lesion. Cold forceps biopsies
were performed for histology at the cardia. Prominent folds,
possible varices in the fundus and cardia.
Duodenum:
Mucosa: Segmental erythema and friability of the mucosa with
contact bleeding were noted in the duodenal bulb compatible with
duodenitis.
Impression: Erythema and friability in the duodenal bulb
compatible with duodenitis
Erythema in the pre-pyloric region and antrum compatible with
gastritis
Varices at the fundus and cardia
Mass in the cardia (biopsy)
Brief Hospital Course:
The pt is a 45 yo male with h/o hep C with hemodynamically
significant upper GI bleeding.
1. Upper GI bleed with gastric mass: Endoscopy at OSH showed a
proximal duodenum clot and GE junction clot, unable to be
intervened on there so transferred here for repeat EGD. His Hct
was stable here 33-34 and he did not require additional blood
product at our hospital. GI team performed an EGD which showed
a gastric mass with stigmata of recent bleeding (no current
bleeding) as well as signs of duodenitis and gastritis.
Biopsies were taken and he will f/u closely with GI. He also
will have an endoscopic ultrasound next week to better define
the mass. He will continue PPI [**Hospital1 **].
2. Hep C: Pt with hep C from blood transfusion but reports not
active infection. No known varices or cirrhosis. Has taken
interferon in the past
- Hep C viral load was negative
- liver U/S showed fatty liver, no clear signs of cirrhosis,
patent portal flow
- There were possibly some signs of varices on EGD, though no
signs on liver U/S. Per GI recs, he will also f/u with liver
clinic.
3. Alchohol use: Variable reports of etoh use, currently states
rare.
no signs of EtOh withdrawal here
4. Lower extremity lesions/rash: Possibly related to insect
bites? they do not currently look active, excoriations from
prior scratching
Full code.
EMERGENCY CONTACT: [**Name (NI) 6961**] [**Name2 (NI) **] and [**Name (NI) **] [**Name (NI) 7173**], father [**Name (NI) **] can
make medical decisions for him if he cannot [**Telephone/Fax (1) 83896**]
Medications on Admission:
At home:
Tylenol prn
On transfer from [**Hospital1 1562**]:
-albuterol 0.083% q2 hrs prn
-morphine 1mg q 1 hr prn
-protonix gtt
-Tylenol 650mg po prn
-Zofran 4mg q 4h rs prn
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper gastrointestinal bleed
Gastric mass
Acute blood loss anemia resolved
Secondary:
Hepatitis C
Discharge Condition:
good
Discharge Instructions:
Please seek immediate medical attention/return to ER if you
develop persistent nausea, vomiting, bloody or black vomit,
bloody or dark stools, abdominal pain, lightheadedness, fever >
101.
Please keep your appointments as below for the endoscopic
ultrasound, your PCP, [**Name10 (NameIs) **] liver and GI clinics.
Followup Instructions:
Endoscopic ultrasound with Dr. [**First Name (STitle) **] [**Name (STitle) **] this coming
Monday [**11-6**] at 2 PM. Please arrive at the [**Hospital Ward Name **]
[**Hospital3 **] Hospital, [**Location (un) **] [**Hospital Ward Name 1950**] at 1 PM unless you hear
differently from Dr.[**Name (NI) 15832**] office. They should also call
you Monday morning. Their number is [**Telephone/Fax (1) 13246**]. You should
not eat anything after midnight the night before. OK to have
ice chips Monday morning.
MD: Dr. [**First Name8 (NamePattern2) 3065**] [**Last Name (NamePattern1) **]
Specialty: PCP
Date and time: Friday, [**11-10**] at 1:45pm
Location: [**Hospital Ward Name 83897**], [**Hospital1 **],[**Numeric Identifier 27861**]
Phone number: [**Telephone/Fax (1) 78221**]
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]
Specialty: Gastroenterology
Date and time: Wednesday, [**11-15**] at 10:15am
Location: [**Hospital Unit Name 83898**], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 682**]
MD: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: Gastroenterology
Date and time: Wednesday, [**11-22**] at 3:30pm
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 452**] Bldg [**Location (un) **], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 463**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2175-11-2**]
|
[
"305.1",
"285.1",
"578.1",
"E906.4",
"070.70",
"916.4",
"151.0",
"782.1",
"535.60",
"456.8",
"535.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7130, 7136
|
5169, 6711
|
288, 323
|
7279, 7286
|
3957, 5146
|
7649, 9156
|
2936, 2982
|
6936, 7107
|
7157, 7258
|
6737, 6913
|
7310, 7626
|
2997, 3938
|
230, 250
|
351, 2524
|
2546, 2748
|
2764, 2920
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,927
| 155,015
|
3044
|
Discharge summary
|
report
|
Admission Date: [**2199-12-28**] Discharge Date: [**2200-1-3**]
Date of Birth: [**2151-11-20**] Sex: M
Service: NEUROLOGY
Allergies:
Morphine
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
48 yo right-handed man with cerebral metastasis from renal
cell Ca, followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1729**]. Had been on Keppra for
seizure prophylaxis and recently hospitalized at OMED from
[**2199-11-20**] to [**2199-11-22**] after a first episode generalized seizure
and subsequently started on Dexamethasone, which has been
weaning
off since the end of [**Month (only) **], given side-effects including mood
swings, insomnia, weight gain and bloating and most recent
gadolinium-enhanced head MRI, as compared to his prior head MRI
from [**2199-11-12**], revealed shrinkage of his mesial left frontal
metastasis from 14 cm to 9 cm; there was also less cerebral
edema
in the adjacent brain.
Today he has a 15-min seizure witnessed by family that started
with L arm and L leg jerking and progressed to GTC sz. He was
given 4 mg Ativan by EMS and intubated with 100 mg Succ, 20 mg
Etomidate, and 10 mg Vecuronium. He was loaded with Dilantin and
given Decadron 10 mg iv; he had a NCHCT that showed a 7 mm L
parietal bleed and so was transferred here, where at 22h18 he
received Propofol 20 mcgs followed by infusion of 10mcg/kg/min,
as well as 10 mg Vec for repeat head CT at 23h05.
Mr. [**Known lastname 14495**]??????s neurological problem began on [**2198-4-28**] when
he
developed a headache and difficulty using his left arm, as well
as progressing left leg weakness that caused an unsteady gait.
His headache, weakness and poor coordination increased
over the next few days, and co-workers encouraged him to seek
medical care. On [**2198-5-4**] he presented to the [**Hospital1 18**]
Emergency Department where an MRI revealed a 1.8 X 1.4 cm mass
in
the right frontal parietal area that suggested a solid tumor. On
that same day he was taken to the OR by Dr. [**Last Name (STitle) **], who
performed
a resection of the right frontoparietal tumor. Pathology
revealed
metastatic clear cell carcinoma consistent with renal cell
carcinoma. The patient subsequently had an abdominal CT on [**2198-5-7**] which indicated a mass on the left kidney with a
central
area of necrosis. There was also evidence of multiple pulmonary
nodules bilaterally and two discrete lesions noted in the liver
that were too small to fully
characterize on the CT scan. On [**2198-8-16**] he had a radical left
nephrectomy, cholecystectomy, omentectomy and exploration of the
retroperitoneum. He had post-operative complications of
confusion related to pain medication and a bowel obstruction --
both resolved. He is also s/p Cyberknife radiosurgery to the
resection cavity on [**2198-6-6**] to 1,600 cGy, s/p dendritic cell
tumor fusion vaccine protocol, s/p a biopsy of the right
parietal
surgical cavity on [**2199-9-3**] by Dr. [**Last Name (STitle) **], and s/p Cyberknife
radiosurgery to a left parasagittal metastasis to 2,200 cGy on
[**2199-9-27**].
Past Medical History:
Presented [**4-/2198**] with headache and clumsiness, found to have
brain mass, subsequently found to have renal cancer with
pulmonary mets. [**2198-5-4**]: Resection of a solitary brain
metastasis from the right
parietal brain suggestive of clear cell carcinoma by [**First Name8 (NamePattern2) **]
[**Doctor Last Name **]. [**2198-6-6**] underwent 1600 cGY Cyberknife radiosurgery to
the resection cavity. [**8-/2198**] underwent radical left nephrectomy,
cholecystectomy, and omentectomy for renal cell carcinoma (renal
vein invasion; subsequently found to have pulmonary mets). [**8-20**]
found to have new Rt-sided weakness and found to have new brain
masses; [**2199-9-3**] stereotactic bx ws non-diagnositic; [**2199-9-27**]
underwent cyberknife to L parasagital metastasis (2200 cGy).
Current discussion is for resection.
.
PMH:
1. Hypertension
2. L-inguinal hernia, s/p surgery
3. RCC metastatic to brain, lung and liver
4. s/p Radical left nephrectomy [**8-19**]
5. s/p Open cholecystectomy [**8-19**]
6. s/p Omentectomy [**8-19**]
7. s/p right craniectomy [**4-19**]
Social History:
Prior heavy EtoH abuse (12pk daily); after cancer dx in [**4-19**]
about 6pk weekly
No tob
No IVDU
family contact is his sister [**Name (NI) 1494**] [**Name (NI) 14498**], [**Telephone/Fax (1) 14499**]
Family History:
Non-contributory
Physical Exam:
Intubated, sedated on Propofol infusion and recently paralyzed
with Vecuronium for CT scan
T 97.8, HR 100, BP 118/86, RR 18, O2 sat 100% RA,
Gen: cushingoid, intubated, on ventilator
HEENT: mmm, no carotid bruit, neck supple
CVS: RRR, N S1 & S2, no murmur
Lungs: CTAB
Abdomen: bowel sounds present, soft, distended, tympanic to
percussion
Extremities: trace edema at the ankles.
NEURO:
His pupils were pinpoint and sluggishly reactive, no
oculocephalic or corneal reflex elicited, face symmetric. Tone
nml, reflexes were trace throughout. Initially did not respond
to
noxious [**Doctor First Name **], but then started to withdraw to noxious stim
purporsefully and symmetrically, opening eyes to voice,
mouthing.
Pertinent Results:
[**2199-12-28**] 10:43AM ALBUMIN-3.5
[**2199-12-28**] 10:43AM PHENYTOIN-10.5
[**2199-12-28**] 06:15AM PHENYTOIN-10.0
[**2199-12-28**] 02:47AM GLUCOSE-138* UREA N-21* CREAT-1.0 SODIUM-141
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-18
[**2199-12-28**] 02:47AM PHENYTOIN-<0.6*
[**2199-12-28**] 02:47AM WBC-7.9 RBC-3.99* HGB-13.4* HCT-37.2* MCV-93
MCH-33.6* MCHC-36.1* RDW-14.7
[**2199-12-28**] 02:47AM PLT COUNT-168
[**2199-12-28**] 02:47AM PT-13.8* PTT-21.5* INR(PT)-1.2*
[**2199-12-27**] 10:30PM GLUCOSE-179* UREA N-23* CREAT-1.1 SODIUM-140
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
[**2199-12-27**] 10:30PM estGFR-Using this
[**2199-12-27**] 10:30PM PHENYTOIN-<0.6*
[**2199-12-27**] 10:30PM WBC-7.9 RBC-4.08* HGB-13.5* HCT-38.4* MCV-94
MCH-33.0* MCHC-35.1* RDW-14.9
[**2199-12-27**] 10:30PM NEUTS-85* BANDS-1 LYMPHS-11* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2199-12-27**] 10:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+
STIPPLED-1+ TEARDROP-1+
[**2199-12-27**] 10:30PM PLT SMR-LOW PLT COUNT-150
[**2199-12-27**] 10:30PM PT-12.5 PTT-22.1 INR(PT)-1.1
[**2199-12-27**] 10:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2199-12-27**] 10:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-12-27**] 10:30PM URINE RBC-1 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-1
NCHCT [**2199-12-27**]: There is a tiny 2-mm focus of hyperdensity near
the left vertex.
There are areas of vasogenic edema, in the left frontal as well
as right
parietal lobe, significantly decreased in extent, compared to
the prior
study of [**2199-11-20**]. There are craniotomy changes in the right
parietal bone.
The [**Doctor Last Name 352**]-white matter differentiation is preserved. The
ventricles and sulci
are normal in configuration.
The imaged paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION:
1. Tiny focus of hyperdensity left frontal lobe near vertex due
to chronic blood products in previously noted metastasis on MRI
of [**2199-12-9**].
2. Interval decrease in extent of left frontal and right
parietal vasogenic
edema. Status post craniotomy.
[**2199-12-28**]: MRI of the brain.
CLINICAL INFORMATION: Patient with metastatic disease with
question of new
lesion in the left frontal convexity region on the recent CT,
for further
evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility
and diffusion
axial images were obtained before gadolinium. T1 axial,
sagittal and coronal
images were obtained following the administration of gadolinium.
Comparison
was made with the previous MRI of [**2199-12-9**].
FINDINGS: A small enhancing metastatic lesion is identified at
the right
posterior frontal convexity region at the site of abnormality
seen on CT. This
has slightly decreased in size and enhancement compared to the
prior study
with decrease in surrounding edema. In addition, a small area
of enhancement
is identified adjacent to the craniotomy site in the right
parietal
cortical/subcortical region, which has also decreased in size
since the
previous study with decrease in edema. There are no areas new
areas of
enhancement identified. There is no mass effect seen, midline
shift
identified or hydrocephalus noted.
IMPRESSION: Since the previous MRI of [**2199-12-9**], the left
frontal convexity
lesion has decreased in size with decrease in enhancement and
surrounding
edema. The right parietal lesion has also decreased in size
with decrease in
edema. No definite new lesions are seen. No acute infarcts are
identified.
EEG [**2199-12-28**]: Reportedly showed frequent right frontocentral
sharps, right slowing without repitition or seizure activity;
official read pending.
Brief Hospital Course:
48 yo man with metastatic renal cell Ca, on Keppra for seizure
prophylaxis, who has been weaning off dexamethasone for his
cerebral metastasis and presented with a L focal seizure that
secondarily generalized. He was found to have right parietal
bleed on a head CT from [**Hospital 1474**] Hospital, where he was
intubated. Also has a left posterior frontal lesion. He was
loaded with Dilantin and received Decadron 10 mg iv prior to
transfer here on [**12-28**]. He was brought to the ICU for further
monitoring. The patient was extubated [**12-29**] and had a code
purple for agitation that day as well, for which he received
ativan and zyprexa. Psychiatry followed the patient after this
clinical development. We will discharge the patient with
standing seroquel 50mg at HS and an Rx for PRN seroquel as well.
We will discontinue the home ativan usage. He was continued
on decrementing doses of dexamethasone until he was switched to
prednisone 4mg daily on [**2200-1-2**]. He was stable on keppra and
dilantin with no further sezures. EEG reportedly showed
frequent right frontocentral sharps, right slowing without
repitition or seizure activity. The patient was still both
intermittently confused and somnolent, but did follow basic
commands and was oriented to place.
1. Unexplained tachycardia since 11 pm [**12-29**]. It was possible
that the patient remained anxious and tachycardic (does not
appear significantly dry or in pain), but we wanted to rule out
other medical issues. Checked an EKG (sinus tachy, left axis
deviation) and enzymes (all negative). The possibility for PE
in a patient with malignancy is a real possibility and we
checked a d-dimer (it turned out > 500). CT with contrast was
negative for PE but demonstrated increased diameter of the
patient's lung masses. We held the patient's HCTZ and increased
the dose of the metoprolol. The patient was less tachycardic
over the last 24 hours of admission, including longer periods
with normal heart rate.
2. Oncology: The patient's primary medical (Dr. [**Last Name (STitle) 1729**]and
neuological (Dr. [**Last Name (STitle) 724**] oncologist were informed of her
admission. The patient will follow up with his medical
oncologist on [**2200-1-21**]. We will make a follow up
appointment with Dr. [**Last Name (STitle) 724**].
3. Low Grade fevers: The patient had a mildly positive UA on
initial check but we felt that it more than likely represented
bacturia without pyuria. As such we stopped the antibiotics
(bactrim) that were started briefly and checked another UA that
revealed no infection.
Medications on Admission:
-Atenolol 25 mg 1.5 tab Qday
-Benadryl 25 mg po PRN for allergies
-Dexamethasone 4 mg po Qday weaning (current dose down to 1 mg)
-Prilosec 20 mg po BID
-Hydrochlorothiazide 12.5 mg po Qday
-Keppra 1000 mg po BID
-Ativan 0.5 mg Q6hrs PRN for anxiety
-Tylenol 325 mg Q4-6 hours PRN for headache.
Discharge Medications:
1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
3. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Dilantin Extended 100 mg Capsule Sig: Four (4) Capsule PO at
bedtime.
Disp:*120 Capsule(s)* Refills:*2*
5. Outpatient Lab Work
Dilantin level
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Brain Metastases.
Discharge Condition:
Vital signs are stable. Patient has no obvious neurological
sequela of his brain mets. He came in on keppra and low dose
dex and will be discharged on keppra, dilantin and 4mg/day dex.
Discharge Instructions:
Please take your medications as prescribed.
Please follow up with your appointments as documented below.
Please return to the hospital if you should have any symptoms
that are concerning to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2200-1-21**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7706**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2200-1-21**] 1:30
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2200-2-10**]
1:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
Completed by:[**2200-1-3**]
|
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icd9cm
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[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,728
| 161,401
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7004
|
Discharge summary
|
report
|
Admission Date: [**2201-5-22**] Discharge Date: [**2201-5-27**]
Date of Birth: [**2137-6-18**] Sex: M
Service: MEDICINE
Allergies:
Quinolones / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Back pain, aml, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
63 y/o with lung cancer with diffuse metastases, including to
the brain, bone and spine as well as hypercalcemia presents with
acute on chronic back pain and altered mental status. According
to patient's partner, Mr. [**Known lastname **] has not done well since being
discharged from [**Hospital1 18**] on [**2201-5-14**], after he was admitted with
bilateral DVTs. She reports that his mental status has worsened
subce then, especially over the last two days, characterized by
him making less sense over the last week intermittently.
According to the partner, the patient is generally able to
answer yes and no questions without problems, but is not able to
hold a conversation. This has become more pronounced over the
last week. He's also been complaining of more pain, mostly in
his lower back and scapular area. He was seen by his oncologist,
Dr. [**Last Name (STitle) **], on the day prior to admission, where he was noted to
be alert and oriented x 3 with appropriate mood and affect.
There has been some increase in white sputum production, as well
as complaints of dysuria on the day of admission. Patient also
reported a headache earlier in the day to his partner. [**Name (NI) **] has
had a rash that was first noted during his last hospital
admission, and thought to be due to Bactrim, upon which this
medication was stopped. His new medications include lovenox for
his bilateral DVTs.
.
In the ED, initial vital signs were 97.4 118 155/106 18 100% RA.
Patient did not have imaging of his back after discussion with
oncology (no red flags) Patient reportedly was all over the bed
complaining of pain, and over her ED course received total 4 mg
IV dilaudid for pain control. He also received leveitracetam
1000 mg and phenytoin 100 mg for seizure prophylaxis. He also
received lorazepam 4 mg total. Patient was noted to be
tachycardic to 140's while in pain, but was in sinus rhythm. He
was hypercalcemic to 13.7 on admission, which came down to 11.4
after receiving 2.5 liters of IVFs. Patient received a Zometa
injection the day prior to admission in oncology clinic. It was
decided to admit the patient to the ICU for pain control. Vitals
prior to transfer were 119 165/85 99%RA 99.8.
.
On the floor, partner denies fevers or chills, incontinence, or
new focal weakness or numbness. According to the ED signout,
there were no red flags on neuro exam, and imaging was not
required. Patient spiked a fever to >103F upon reaching the
floor, with a heart rate in the 130s. According to partner,
patient is significantly more altered since arriving at the ED.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. Metastatic non-small-cell lung cancer as above.
2. Known history of low back pain.
3. Benign prostatic hypertrophy.
4. Hyperlipidemia.
5. History of nephrolithiasis.
6. Status post hernia repair.
7. Bilateral LE DVT (R. above knee, L. below knee) [**2201-5-12**]
.
ONCOLOGIC HISTORY:
-- [**2-/2201**] cough and decreased stamina.
-- [**2201-4-24**] presented to [**Hospital1 18**] ED where chest x-ray disclosed
right middle lobe opacities.
-- [**2201-4-24**] Chest CT revealed a 3.6 x 3 x 3.7 cm rounded
hypodense
mass obstructing the right middle lobe bronchus causing near
complete right middle lobe collapse. There was also associated
bronchial wall thickening and enlarged right hilar nodes up to
13
mm. Given the concerning lung finding, he also underwent CT
abdomen and pelvis on the same date, which disclosed innumerable
peripherally enhancing liver lesions as well as multiple small
lytic osseous metastases throughout the skeleton without
evidence
of pathologic fracture.
-- [**2201-4-25**] MRI brain for seizure revealed multiple foci of
abnormal enhancement within the supra and infratentorial region,
with the largest lesion in the right frontal lobe measuring 1.5
cm.
-- [**2201-4-28**] liver biopsy with metastatic adenocarcinoma staining
positive for CK7 and TTF-1 with focal CK20 positivity and was
negative for CK5/6.
-- [**2201-5-1**] bone scan with diffuse bony mets
-- [**2201-5-1**] began WBRT for planned 3000 cGy over 10 fractions.
-- [**2201-5-12**] completed WBRT
-- [**2201-5-12**] admitted with b/l LE DVT, began Lovenox
.
Social History:
Lives with his longtime partner, [**Name (NI) **] [**Name (NI) 17543**], and they have
been together for over 30 years.
Work/income: He manages two properties and does some stock
trading on the side.
Tobacco: He smoked half a pack per day from ages 20 to 40,
giving him a 10-pack-year history, quitting over 20 years ago.
Alcohol: A prior history of heavy alcohol use, quitting six
years ago.
Diet and exercise: Follows a healthy balanced diet.
Exposures: No known asbestos exposure.
Family History:
per OMR
twin brother died of a coronary occlusion and his
older brother died at age 38 of AIDS. His father died of
coronary disease at age 58 and mother of breast cancer at age
84.
Physical Exam:
ICU Admission Physical Exam:
VS: T 99 HR 77 BP 120/64 SaO2 98% 2L
I/O +1.8L per 24hrs
GEN: AOx1 (does not know month/ day, hospital name), NAD
HEENT: R pupil 2mm, L pupil 3mm, equally reactive. dry oral
mucosa. no LAD. no JVD. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: erythematous blanching rash over chest, extremithies
Neuro: A+O x [**12-28**], able to follow only simple commands, recall
0/3 words after 5min. CNs II-XII intact. 5/5 strength in U/L
extremities. DTRs 2+ BL. sensation intact to LT, cerebellar fxn
intact although difficulty following commands(FTN, HTS).
.
On discharge:
GEN: AOx2 (does not know month/ day,) intermittently confused,
NAD
HEENT: R pupil 2mm, L pupil 3mm, equally reactive. MMM. no LAD.
no JVD. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: erythematous blanching rash over chest, ext
Neuro: A+O x [**12-28**], able to follow commands; CNs II-XII intact.
5/5 strength in U/L extremities. DTRs 2+ BL. sensation intact to
LT, cerebellar fxn intact although difficulty following
commands(FTN, HTS).
Pertinent Results:
Admission Labs:
[**2201-5-21**] 11:02AM [**Month/Day/Year 3143**] WBC-8.6 RBC-4.65 Hgb-14.2 Hct-39.7*
MCV-86 MCH-30.5 MCHC-35.7* RDW-14.4 Plt Ct-100*
[**2201-5-22**] 12:00PM [**Month/Day/Year 3143**] WBC-7.3 RBC-4.47* Hgb-13.4* Hct-38.8*
MCV-87 MCH-29.9 MCHC-34.4 RDW-15.2 Plt Ct-101*
[**2201-5-22**] 12:00PM [**Month/Day/Year 3143**] Neuts-60.6 Lymphs-16.6* Monos-7.5
Eos-14.4* Baso-0.9
[**2201-5-21**] 11:02AM [**Month/Day/Year 3143**] Plt Ct-100*
[**2201-5-22**] 12:00PM [**Month/Day/Year 3143**] Plt Ct-101*
[**2201-5-21**] 11:02AM [**Month/Day/Year 3143**] Gran Ct-5740
[**2201-5-22**] 03:20AM [**Month/Day/Year 3143**] Glucose-108* UreaN-22* Creat-0.8 Na-133
K-4.1 Cl-100 HCO3-26 AnGap-11
[**2201-5-22**] 12:00PM [**Month/Day/Year 3143**] UreaN-23* Creat-1.0
[**2201-5-21**] 11:02AM [**Month/Day/Year 3143**] ALT-125* AST-54* AlkPhos-540* TotBili-1.0
[**2201-5-21**] 11:02AM [**Month/Day/Year 3143**] Albumin-3.9 Calcium-13.7* Phos-4.6*
[**2201-5-22**] 03:20AM [**Month/Day/Year 3143**] Calcium-12.3* Phos-3.8 Mg-1.6
[**2201-5-22**] 12:00PM [**Month/Day/Year 3143**] Phenyto-2.4*
[**2201-5-22**] 12:03PM [**Month/Day/Year 3143**] pH-7.39
[**2201-5-22**] 12:03PM [**Month/Day/Year 3143**] Glucose-85 Lactate-2.6* Na-136 K-4.2
Cl-95*
[**2201-5-22**] 12:03PM [**Month/Day/Year 3143**] freeCa-1.46*
.
On Discharge:
[**2201-5-26**] 06:50AM [**Month/Day/Year 3143**] WBC-6.7 RBC-3.74* Hgb-10.9* Hct-31.6*
MCV-85 MCH-29.2 MCHC-34.6 RDW-15.2 Plt Ct-139*
[**2201-5-26**] 06:50AM [**Month/Day/Year 3143**] Glucose-81 UreaN-12 Creat-0.7 Na-139
K-3.9 Cl-106 HCO3-23 AnGap-14
[**2201-5-26**] 06:50AM [**Month/Day/Year 3143**] ALT-140* AST-84* AlkPhos-518* TotBili-1.2
[**2201-5-26**] 06:50AM [**Month/Day/Year 3143**] Calcium-7.8* Phos-1.4* Mg-1.7
.
Micro:
.
[**Month/Day/Year **] Cultures ([**5-26**]) pending at time of discharge:
.
[**Month/Day (4) **] Culture, Routine (Final [**2201-5-28**]): NO GROWTH.
.
URINE CULTURE (Final [**2201-5-23**]): NO GROWTH.
.
CHEST (PORTABLE AP) Study Date of [**2201-5-22**] 2:41 PM
FINDINGS: A central right middle lobe lung mass is again
demonstrated and has been more fully imaged on prior CT imaging.
Adjacent to this area are poorly defined parenchymal opacities
as well as interstitial septal thickening and reticulation
throughout the right lung. A questionable area of confluent
opacity is also identified below the right clavicle. Left lung
is grossly clear allowing for motion artifact.
IMPRESSION:
Worsening opacities in the right lung, many of which are in
close proximity to a known right middle lobe lung mass.
Differential diagnosis includes pulmonary infection, aspiration
and lymphangitic spread of tumor.
Brief Hospital Course:
63 y/o male with non-small cell lung cancer with brain, bone and
spinal metastases, hypercalcemia who presented on [**5-22**] with
acute on chronic back pain and altered mental status initially
admitted to the intensive care unit, later transferred to OMED
for continued management.
.
# Fever: Pt spiked to 103 upon reaching the ICU. There reports
of dysuria and headache on review of systems, both new symptoms.
There is no focality on exam to suggest infectious source.
Urinalysis was not suggestive of infection. Patient had rash on
anterior chest, likely from Bactrim, which could represent
source of fever, although it would be atypical that this started
this far from ceasing the medication. Other etiologies include
deep venous thrombosis and underlying malignancy. Cultures in
house with no growth to date and decision made to discontinue
prior to discharge. Patient off antibiotics for 3days prior to
discharge without fever.
.
# Altered mental status: According to wife, on admission patient
was far off from baseline, although patient does seem reportedly
have some baseline confusion. Possible etiologies include fever,
infection, hypovolemia, hypercalcemia, medication effect, given
the narcotics and benzodiazepines that were given while in the
ED, and brain metastases related to his underlying malignancy.
Infectious work-up negative.
Pt mental status slowly improved in ICU and the floor after
treatment of hypercalcemia. Patient intermittently confused on
the floor. At time of discharge new baseline patient AX0 x1-2
with ability to follow commands.
.
#. Pain control: As outpatient pain regimen included MS Contin
and Morphine IR however dosing insufficient and pain poorly
controlled. Per health care proxy, pain control is most
important, even if it means decline in mental and respiratory
status. Pt was given IV dilaudid PRN for pain, continued home
dose of MS Contin. At time of discharge patient on Morphine SR
45mg TID with IR 15-30 for breakthrough control with pain well
controlled. On day of discharge patient underwent first session
of palliative XRT.
OUTPATIENT ISSUES:
-- Plan to complete palliative XRT as well as chemotherapy
-- Uptitration of pain meds as needed
.
# Metastatic non-small cell lung cancer with known brain mets.
Patient is s/p whole body radiation therapy. Patient continued
on daily dexamethasone in setting of brain mets and radiation.
Plan after discussion between patient, HCP and primary
oncologist is to proceed with outpatient chemotherapy for
palliative measures and prolongation of life span.
.
# Goals of care: Patient's code status was changed to DNR/DNI on
admission to ICU with goals to avoid invasive procedures
including LP. Discussed goals with wife [**Name (NI) **], brother, and
patient who would like to focus on symptoms of pain. Discussed
with them the palliative aspects of chemothearpy, and the
potential for improving quality of life. At time of discharge
patient with plan to undergo palliative XRT and chemotherapy.
.
# Hypercalcemia: Likely related to malignancy. On admission, Ca:
13. Albumin 3.9. Level decreased from 13-->11 with IVFs. Patient
is s/p Zometa injection at oncology clinic on [**5-21**].
Hypercalcemia improved, and ultimately normalized by time of
discharge after bisphosphonate treatment and aggressive IV
hydration.
.
# History of deep venous thrombosis. Patient had recently been
admitted for in [**4-/2201**] for bilateral DVTs during which he was
started Lovenox. Patient was continued on lovenox 60 mg SC q12h
in house.
.
# Benign prostatic hypertrophy. intially home dose tamsulosin
held; restarted when patient able to safely to take PO meds
.
.
# Code - DNR/DNI, confirmed with HCP
# Communication: [**Name (NI) **] [**Name (NI) 17543**], HCP, [**Telephone/Fax (1) 26219**]
Medications on Admission:
Atorvastatin 10 mg PO daily
Dexamethasone 4 mg PO daily
Enoxaparin 60 mg SC q12h
Folic acid 1 mg PO daily
Glipizide 2.5 mg PO daily
Levetiracetam 1500 mg [**Hospital1 **]
Morphine IR 15 mg PO q4h PRN pain
MS Contin 15 mg PO BID
Omeprazole 20 mg PO daily
Ondansetron 8 mg PO q8h PRN nausea
Phenytoin 100 mg PO TID
Prochlorperazine 5-10 mg PO q6h PRN nausea
Tamsulosin 0.4 mg PO daily
Acetaminophen [**Telephone/Fax (1) 1999**] mg PO q6h PRN fever, pain
Cholecalciferol 400 units PO daily
Docusate 100 mg PO BID
Miconazole powder 1 appl to groin PRN daily
Discharge Medications:
1. phenytoin 100 mg/4 mL Suspension Sig: One (1) PO three times
a day: 100mg PO three times daily.
2. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please
apply to shoulder daily.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
6. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. morphine 15 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*0 Tablet, Rapid Dissolve(s)* Refills:*0*
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
Disp:*10 packets* Refills:*0*
10. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for pain.
13. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for no BM x 2 days.
16. morphine 15 mg Tablet Extended Release Sig: Three (3) Tablet
Extended Release PO every eight (8) hours.
Disp:*90 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Metastatic Non-Small Cell Lung Cancer
Hypercalcemia
.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr [**Known lastname **] it was a pleasure taking care of you.
.
You were admitted to [**Hospital1 18**] for evaluation of confusion as well
as pain control. Your confusion was thought likely secondary to
high calcium levels, inadequate pain control as well as known
brain metastatis. After correction of your calcium and treatment
of your pain your mental status improved.
.
Of note you also developed an rash while hospitalized which was
thought secondary to a Bactrim Allergy. You were treated
symptomatically with drugs/lotions to combat the itch. Continue
using this over the counter medications (ie sarna lotion) as
needed.
.
At time of discharge the plan is to return home with services
with plan for future radiation and chemotherapy.
.
CHANGES TO YOUR MEDICATIONS:
To treat your pain:
1. START taking MORPHINE 15mg Sustained Release Tablets. Take
three tablets three times daily
2. START taking MORPHINE 15mg-30mg Immediate Release every four
hours as needed for pain.
.
** While taking narcotic pain medication continue taking an
aggressive bowel regimen as these medications can result in
constipation**
** Also these medication have the potential to cmake you sedated
so avoid driving or operating any machinery while taking this
pain regimen.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2201-5-28**] at 10:00 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: MONDAY [**2201-6-8**] at 1:55 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2201-6-8**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INTERNAL MEDICINE
When: TUESDAY [**2201-6-2**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2201-5-29**]
|
[
"275.42",
"198.3",
"V66.7",
"V58.61",
"V15.3",
"288.3",
"272.4",
"V12.51",
"600.00",
"788.1",
"E931.0",
"197.7",
"780.60",
"693.0",
"198.5",
"162.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
15654, 15711
|
9356, 10303
|
343, 349
|
15818, 15818
|
6671, 6671
|
17290, 18613
|
5074, 5257
|
13744, 15631
|
15732, 15797
|
13166, 13721
|
16005, 16755
|
5301, 6024
|
7988, 9333
|
16784, 17267
|
266, 305
|
377, 2952
|
6687, 7974
|
15833, 15981
|
2996, 4556
|
4572, 5058
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
96
| 170,324
|
21229
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 56203**]
Admission Date: [**2156-3-31**]
Discharge Date: [**2156-4-29**]
Date of Birth: [**2116-10-2**]
Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 39-year-old gentleman,
who sustained a 30-foot fall, hitting a porch prior to
landing on the ground. There was no loss of consciousness,
and the patient arrived in the Trauma Bay complaining of a
chest pain on arrival. He was noted to have a massive
bleeding from his oropharynx and became hypotensive to the
60s. He was emergently intubated, and a right femoral cordis
was placed. His blood pressure improved with a fluid
resuscitation, and his chest x-ray was clear. He had good
saturations after intubation. A DPL was performed given his
hypotension as an unknown source that was positive after
instillation of 1 L of saline. He was also noted to have a
left upper extremity open fracture. He was taken emergently
to the operating room for exploration.
PAST MEDICAL HISTORY: Unknown.
PAST SURGICAL HISTORY: Unknown.
ALLERGIES: No known drug allergies.
MEDICATIONS: None known.
SOCIAL HISTORY: Unknown.
PHYSICAL EXAMINATION: Initial physical exam: Heart rate was
88, blood pressure 82/palpations, and 02 saturation 90
percent. The patient had an unstable face with a lip
laceration and blood in his oropharynx. GCS of 15. Pupils
equal, round, and reactive with TMs clear. Heart: Regular
rate and rhythm. S1 and S2. Chest: Clear to auscultation
bilaterally. Sternum stable with no crepitus. Abdomen is
soft, nontender, and nondistended. Rectal was guaiac
negative with a normal prostate and normal tone. Back showed
no step-offs or lacerations. Pelvis was stable. Left
forearm with an open fracture unstable with a 2 plus radial
pulse. Right arm question dislocation, and left and right
lower extremities are without deformities.
LABORATORY DATA: White blood cell count 8.1, hematocrit
38.9, and platelets 244,000. Chemistry-7: Sodium 143,
potassium 4, chloride 104, and bicarbonate 29. PT was 12.2,
PTT 19.4, INR 1.0, fibrinogen 199, and lactate was 3.5. ABG:
pH was 7.38, pCO2 43, pO2 232, bicarbonate 26, and base
deficit minus 2. UA was moderate blood and urine tox
negative. Initial films: Chest x-ray negative and pelvis
negative. Left forearm showed an ulnar fracture with radial
head displacement. Left shoulder was negative. Left wrist
was negative. Right shoulder, a nondisplaced fracture of the
greater tuberosity. A right humeral neck fracture that was
nondisplaced and impacted. CT of the head: Frontal
contusion, small temporal bleed, frontal sinus fracture of
the anterior and posterior table, and Le [**Location 56204**] fracture.
CT of the C-spine was negative. CT of the chest showed
bilateral pneumothoraces, right greater than left, with a
right upper lobe collapse and a sternal fracture.
BRIEF HOSPITAL COURSE: As per HPI, Mr. [**Known lastname 20598**] was taken
emergently to the operating room for exploration. On
entering the abdomen, they found a laceration of the
transverse mesocolon, splenic decapsulation, liver
laceration, and multiple colonic deserosalizations. The
splenic decapsulation was repaired, as were the serosal
injuries to the colon. The transverse mesocolon was
repaired, as was the liver laceration. The Orthopedic
Surgery team then came into the operating room for washout
and closed reduction of his left Monteggia fracture of the
radial head without long-arm splinting. He remained
hemodynamically stable throughout the procedure without
hypothermia. Of note, prior to this, because of the known
intracranial hemorrhage with hemodynamic instability,
Neurosurgery was called for bolt placement. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ICP
monitor was placed with pressures in the 10 to 13 range. He
was also placed on IV Ancef perioperatively. He was then
taken to the Trauma ICU where several consults were obtained,
including an Ophthalmology consult regarding his orbital wall
fractures. They did not identify any entrapment on CT and
recommended outpatient followup. He had subsequent bilateral
chest tubes placed and a subclavian line placed on return to
the ICU. He was seen by Oromaxillofacial Surgery regarding
his facial fractures and was taken to the operating room on
[**2156-4-12**] for open reduction and internal fixation of his mid
face fractures. Of note, he had a large laceration of his
eyebrow/nasal region that had been closed on the day of
admission. Of note, because of his multiple facial injuries
and his deteriorating respiratory status over the course of
his ICU stay, he ended up developing Pseudomonas in his
urine. A tracheostomy was performed on [**2156-4-7**]. He also
had an IVC filter placed on [**2156-4-12**] after bilateral lower
extremity ultrasound revealed a right common femoral vein
nonocclusive thrombus. A CTA of the chest to evaluate for
pulmonary embolus was negative, but was a poor quality study.
He was subsequently additionally started on a heparin drip.
However, there was difficulty in making him therapeutic, and
a Hematology consult was obtained. However, he was deemed to
have no identifiable hematologic problem and was eventually
maintained on goal PTT. Coumadin was subsequently started.
He was maintained on antibiotics for the Pseudomonas in his
sputum. He did continue to spike temperatures during his ICU
stay and required frequent suctioning and aggressive
pulmonary toilet to manage his copious secretions. After
recovering from his last operation, which was the ORIF of his
facial fractures, he was finally transferred to the floor on
[**2156-4-20**]. Due to the fact that he was now a candidate for
anticoagulation, Vascular Surgery was re-consulted and his
IVC filter was removed. He was then placed on Lovenox for
anticoagulation purposes. He was able then to ambulate with
physical therapy. However, he continued to have a very poor
p.o. intake. We strongly encouraged p.o., and he stabilized
his intake and was cleared by Speech and Swallow and was
deemed stable for discharge to home from that standpoint. He
was also placed on a Passy-Muir valve, which he tolerated
well. He defervesced, and his antibiotics were stopped, and
he remained without any further infectious issues. His
mental status improved, and he was able to follow commands,
and he was oriented x 3. Once his mental status had
improved, his C-spine was clinically cleared and his C-collar
was removed. He was followed up by Orthopedic Surgery, who
revised his cast after doing repeat films of his left upper
extremity. He continued to progress well, and he was deemed
stable for discharge to home on postoperative day numbers 29
and 17, which was also hospital day number 30.
DISCHARGE DIAGNOSES: Status post fall with multiple
injuries, including:
Mesocolic laceration.
Splenic laceration.
Liver laceration.
Colonic deserosalization x 3.
Le [**Location 56204**] fracture with fractures of the anterior and
posterior table of the frontal sinus.
Open left ulnar fracture with radial head dislocation.
Dislocated right shoulder reduced with greater tuberosity
fracture nondisplaced.
Status post exploratory laparotomy.
Status post open reduction and internal fixation of the left
ulna.
Status post tracheostomy placement.
Respiratory failure with ventilator-associated pneumonia,
resolved.
Right common femoral vein deep vein thrombosis.
Status post inferior vena cava filter placement and removal.
Status post bronchoscopy.
DISCHARGE MEDICATIONS:
1. Lovenox 90 mg subcutaneously q.12h.
2. Percocet 1 to 2 p.o. q.4-6h. p.r.n.
3. Peridex mouthwash p.r.n.
4. Colace 100 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Improved.
DISCHARGE STATUS: The patient will be discharged to home
with services.
DISCHARGE INSTRUCTIONS: The patient should keep his left arm
cast on and leave tracheostomy capped, right arm, to have a
full range of motion and weightbearing as tolerated. Keep
left arm elevated and use saline drops in both eyes p.r.n.
FOLLOWUP: Follow up with the Trauma Clinic in 2 weeks, with
[**Company 191**] associate, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in 2 weeks, with [**Hospital3 56205**] Center in 2 weeks, and with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from
Orthopedic Surgery in 2 weeks, and with Oromaxillofacial
Surgery on [**2156-5-10**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**]
Dictated By:[**Last Name (NamePattern1) 13030**]
MEDQUIST36
D: [**2156-6-21**] 08:21:01
T: [**2156-6-21**] 13:45:06
Job#: [**Job Number 56206**]
|
[
"453.8",
"V46.1",
"807.2",
"851.81",
"865.09",
"518.5",
"482.1",
"860.4",
"864.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.75",
"96.72",
"76.92",
"50.61",
"79.32",
"38.7",
"96.04",
"41.95",
"31.29",
"79.62",
"01.18",
"76.74"
] |
icd9pcs
|
[
[
[]
]
] |
2907, 6791
|
6813, 7554
|
7577, 7714
|
7849, 8726
|
1040, 1115
|
1189, 2883
|
1165, 1173
|
208, 983
|
1006, 1016
|
1132, 1142
|
7739, 7824
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,295
| 107,149
|
52080
|
Discharge summary
|
report
|
Admission Date: [**2155-4-12**] Discharge Date: [**2155-4-19**]
Date of Birth: [**2098-2-15**] Sex: F
Service: MEDICINE
Allergies:
Cefepime
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypotension, neutropenic fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 107792**] is a 57-year-old woman with relapsed AML following
a matched unrelated donor bone marrow transplant in [**7-/2154**] for
therapy related AML, now s/p DLI on [**2154-11-23**]. Subsequently,
she had increasing numbers of blast in both the peripheral blood
and the marrow and just finished a course of decitabine last
week with ANC 340.
.
She had been at home in good health and was actually seen in
clinic by Dr. [**Last Name (STitle) 410**] on [**2155-4-11**]. His note at that time reported
"She has no new complaints. She has had to receive platelets on
occasion and may need somered cells but otherwise does not
really have any significant dyspnea on exertion, shortness of
breath, and certainly no bleeding. She has been able to walk
around the [**Doctor Last Name **] at [**University/College 107793**]with her husband without
any significant problems. She has had no evidence of infection,
no fevers, no night sweats, no weight loss, no cough, dyspnea on
exertion, or shortness of breath. No chest pain. She is having
no bowel problems. She feels the rash on her face and arms that
is stable, not any worse, not any better. She is now on 4 mg of
Medrol every day because of her elevations in liver function
studies and her skin rash, all felt to be secondary to some GVH
after her DLI."
.
On the day of admission, she woke up feeling lethargic. She also
had one presyncopal episode with LHD, diaphoresis, but no LOC.
She did subsequently have emesis (non-bloody, non-bilious X1)
after breakfast. She took her temp at home and was 101 and came
to ED. Per patient, no sick contacts, travel to FLA 1 month ago.
She just went down on medrol from 6mg to 4mg last Wednesday (3
days prior to admission). ROS otherwise negtaive. NO HA, vision
changes, cough, rhinnorhea, sore throat, N, abd pain, diarrhea,
dysuria, new rash, CP, SOB.
.
In ED, 101.2; HR 155; BP 73/64; RR 16; 97% RA. She received
3LNS, blood cx drawn from line and peripheral, Vanc X 1, Zosyn X
1. Upon discussion with BMT team and given low plts, no CVL was
placed. Patient was mentating well the won a game of scrabble
throughout all of this.
.
Upon arrival to [**Hospital Unit Name 153**], she is feeling at baseline with no
complaints. T100.9; dynomap BP 85/64 (but on manual repeat
96/70); HR 125; RR 22; 98%RA.
.
During her [**Hospital Unit Name 153**] stay, pt received additional 4L fluid with no
significant increase in her SBP; pt, however, remained
asymptomatic. Pt was noted to have a fever of 102.2 and was
cultured.
Past Medical History:
AML s/p unrelated donor BMT on [**2154-11-23**]
Possible graft vs host skin reaction
S/p breast CA in [**2151**]
Positive PPD in the past, mother worked in TB sanitarium and s/p
INH treatment in the 70's.
Social History:
Denies EtOH, tobacco or drug use. Lives with her husband. [**Name (NI) **] 2
children. Mother with "heart disease" at an elderly age.
Family History:
Father died of unknown cause. Mother alive at [**Age over 90 **] years of age -
recently had diagnosis of "heart disease."
Physical Exam:
PE: 100.9 125 96/70 22 98% RAO2 Sats
Gen: well appearing, frail, but in good spirits
HEENT: dried brownish crust on tongue, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: skin hypopigmentation over face (old per patient)
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-8**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
LINES: insertion site clean, no exudate
Pertinent Results:
CXR: IMPRESSION: No acute cardiopulmonary process
.
U/A: negative
Brief Hospital Course:
57F h/o relapsed AML s/p transplant, DLI, with febrile
neutropenia.
.
# Febrile neutropenia: The patient was initially treated
broadly with vancomycin and Zosyn (cefepime allergy) given her
hypotensive presentation. Blood and urine cultures drawn before
antibiotic administration were negative after 5 days. No further
cause of her fever could be identified. She had no further
localizing symptoms and all other cultures, including a
c.difficile sample , were negative. A CT scan of her abdomen
showed no areas of possible infection. Her fever did not recur
after the first 24 hours of her admission and at the time of
discharge she had been afebrile and feeling well for greater
than 5 days. She completed a 7 day course of IV vancomycin and
Zosyn. She was then switched to IV vancomycin and PO cipro and
observed for 24 hours. She remained afebrile. She will be
discharged on IV vancomycin, to be administered at home, and PO
cipro to be continued while her ANC is low. Further extension of
this course will be determined by her primary oncologist, Dr.
[**Last Name (STitle) 410**].
.
# Hypotension: The patient responded well to fluid boluses and
upon presentation to the floor, was normotensive. She was
initially treated with stress dose steroids given the concern
for possible adrenal insufficiency, however these were rapidly
weened back to her normal home dose with no adverse effects on
her blood pressure
.
# AML: The patient was post decitabine treatment day + 7 on
admission. The patient remained neutropenic with an ANC of 0
during this admission. He WBC continued to rise with an
increasing blast percentage to approximately 80%. Initially, her
hydrea was held but restarted prior to discharge at 1 gram daily
in order to try and control her increased WBC count. She
required intermittent platelet and PRBC infusions. She will
present in 2 days to the 7F clinic for a count check and follow
up in 3 days with her primary oncologist. Further treatment
options will be discussed then.
.
# Depression: Continued on Sertraline with good effect.
.
# CODE: FULL
Medications on Admission:
Acyclovir - 400 mg Q8H
Fluconazole - 100 mg daily
Folic Acid - 1 mg daily
Hydroxyurea [Hydrea] 1 gram daily
Lorazepam PRN
Methylprednisolone 4mg daily
Sertraline - 75 mg daily
Bactrim DS - 800 mg-160 mg Tu/Th/Sat
.
ALLERGIES: Cefepime
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
3. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID, 3X/WEEK ().
6. Methylprednisolone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed.
8. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 10 days.
Disp:*20 gram* Refills:*0*
10. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours).
11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO three
times a day as needed.
12. Sodium Chloride 0.9 % 0.9 % Solution Sig: Three (3) ML
Injection once a day as needed: For hickman line care.
Disp:*1000 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Acute myelogenous leukemia
Fever of unknown source
Discharge Condition:
all vital signs stable, afebrile for >72hrs
Discharge Instructions:
You were admitted with fevers and neutropenia. We could find no
cause for your fevers but they were likely related to your low
white blood cell count. You will need to continue to take IV
vancomycin and oral ciprofloxacin when you return home. The IV
company will assist you in setting this up. You will follow up
with Dr. [**Last Name (STitle) 410**] to decide about possible further treatment.
Please ask him about the duration of your antibiotics at that
appointment. We have increased your dose of Hydrea to 1 gram
daily to attempt to keep your white blood cell count under
control. We have made no other modifications to your
medications.
Please take all your medications as prescribed.
Please call your doctor or return to the emergency room if you
experience fever >100.5, chills, diarrhea, nausea, vomitting,
pain, shortness of breath or any other symptom that concerns
you.
Followup Instructions:
Provider: [**Name Initial (NameIs) 455**] 4-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2155-4-21**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2155-4-22**] 2:00
|
[
"780.6",
"288.00",
"284.1",
"V42.82",
"205.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7675, 7727
|
4199, 6275
|
307, 314
|
7822, 7868
|
4109, 4176
|
8802, 9066
|
3272, 3396
|
6562, 7652
|
7748, 7801
|
6301, 6539
|
7892, 8779
|
3411, 4090
|
237, 269
|
342, 2877
|
2899, 3105
|
3121, 3256
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,489
| 100,313
|
30957
|
Discharge summary
|
report
|
Admission Date: [**2128-4-17**] Discharge Date: [**2128-4-21**]
Date of Birth: [**2063-11-19**] Sex: M
Service: MEDICINE
Allergies:
Seroquel / Ibuprofen / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 M rehab resident with history of DM2, ESRD on HD, CHF, HTN,
AFIB, was picked up in ambulance to go to HD today and patient
became acutely SOB and confused, repeatedly calling out for his
brother [**Name (NI) **], and ambulance was diverted to [**Hospital1 18**] ED. HD was
skipped today; last HD was on Thurs.
.
In the ED, patient had labored breathing but normal VS, T 97.0,
75, 106/52, 20, 99% 2Lnc. ABG: 7.69 / 15 / 127 / 19. Serum HCO3
15. CXR negative with no pulmonary edema, no infiltrate. CTA
chest negative. CT head negative. EKG with no previous shows
severe AFIB, Q waves II, III, F, V1-V3, IVCD. CK 17, Trop 0.34
likely from renal disease.
.
In the ED, patient was yelling for [**Doctor Last Name **] and yelling for the
nurse, alternating between getting agitated and calming down.
TSH pend. Serum tox negative for ASA. Had two blood cxs from PIV
and one blood cx from HD cath. Concern for performing LP since
patient has large sacral decub. Gets HD at [**Hospital3 5097**] TThS.
Received Haldol 5 IV, Ceftriaxone 2g IV, Vanco 1g IV, Acyclovir
800 IV over 1 hr, Ativan 1 mg IV.
.
Labs from [**2128-4-13**]: K 5.0, BUN 60, Ca 9.4, Phos 3.2, Albumin 2.5,
TG 197, Fluid gains 2.2 kg, weight 146.7 kg.
Past Medical History:
DM2
ESRD on HD TThS
CHF
HTN
AFIB
L BKA
Social History:
No ETOH, no smoking, no IVDU.
Family History:
Unknown.
Physical Exam:
ADMISSION EXAM:
97.7 / 139/92 / 101 / 24 / 100% 1Lnc
GEN: Delirious, calling out for [**Doctor Last Name **] and nurse, right hand
shaking tremor, obese
HEENT: Cannot assess JVD, 2 mm minimally reactive, OP dry with
poor dentition
LUNGS: Rhonchorous bilaterally
HEART: Irregularly irregular
ABD: Soft, +BS, ND NT, obese. PEG tube in place.
EXTR: 4+ pitting edema
NEURO: [**4-10**] motor
.
.
DISCHARGE EXAM:
AF BP 143/66 P 66 RR 20 O2: 100% 2L NC
GEN: Alert and oriented, cooperative, appropriate
HEENT: PERRL, EOMI. OP with MMM and poor dentition
NECK: Cannot assess JVD due to body habitus.
LUNGS: Distant breath sounds bilaterally, good air movement.
CHEST: Left SCL HD line in place
HEART: Irregularly irregular
ABD: Soft, +BS, ND/NT, obese. PEG tube in place.
EXTR: 2+ pitting edema
NEURO: [**4-10**] motor
Pertinent Results:
[**2128-4-17**] 03:10PM PT-12.3 PTT-31.6 INR(PT)-1.1
[**2128-4-17**] 03:10PM WBC-9.1 RBC-4.50* HGB-12.9* HCT-38.7* MCV-86
MCH-28.7 MCHC-33.4 RDW-19.3*
[**2128-4-17**] 03:10PM NEUTS-71.6* BANDS-0 LYMPHS-21.7 MONOS-2.6
EOS-2.5 BASOS-1.6
[**2128-4-17**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-4-17**] 03:10PM TSH-2.7
[**2128-4-17**] 03:10PM ACETONE-SMALL
[**2128-4-17**] 03:10PM CALCIUM-9.6 PHOSPHATE-2.5* MAGNESIUM-1.7
[**2128-4-17**] 03:10PM CK-MB-3
[**2128-4-17**] 03:10PM cTropnT-0.34*
[**2128-4-17**] 03:10PM LIPASE-10
[**2128-4-17**] 03:10PM ALT(SGPT)-25 AST(SGOT)-20 CK(CPK)-17* ALK
PHOS-376* AMYLASE-17 TOT BILI-0.2
[**2128-4-17**] 03:10PM GLUCOSE-91 UREA N-47* CREAT-4.4* SODIUM-138
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-15* ANION GAP-23
[**2128-4-17**] 03:31PM LACTATE-2.4* K+-4.0
[**2128-4-17**] 05:11PM TYPE-ART TEMP-37.2 O2-100 O2 FLOW-2.5
PO2-127* PCO2-15* PH-7.69* TOTAL CO2-19* BASE XS-1 AADO2-589 REQ
O2-94 INTUBATED-NOT INTUBA
.
CXR [**4-17**]: Findings consistent with increased volume status, but
no overt pulmonary edema.
.
CTA chest [**4-17**]: 1. No evidence for pulmonary embolus or other
explanation for shortness of breath.
2. Incidentally noted 4-mm left lower lobe pulmonary nodule for
which a one-year followup is recommended in the absence of known
malignancy.
.
CT head [**4-17**]: There is no intracranial hemorrhage. The
ventricles, cisterns, and sulci are prominent secondary to brain
atrophy. There is no mass effect or shift of normally midline
structures and [**Doctor Last Name 352**]-white matter differentiation is preserved.
Periventricular white matter hypodensities are the sequelae of
small vessel infarction. There is atherosclerotic disease of the
cavernous carotids. The visualized paranasal sinuses are clear.
.
EKG: AFIB 65, demand pacing, Q waves II, III, F, V1-V3, IVCD.
.
[**2128-4-17**] 3:10 pm BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Final [**2128-4-21**]):
BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE.
bld cx [**4-17**], [**4-19**], [**4-20**]: NGTD
.
[**2128-4-18**] 10:22 am SACRAL SWAB
GRAM STAIN (Final [**2128-4-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Final [**2128-4-20**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH.
GRAM NEGATIVE ROD #1. RARE GROWTH.
GRAM NEGATIVE ROD #2.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
[**2128-4-18**] 2:54 pm BKA stump SWAB
**FINAL REPORT [**2128-4-20**]**
GRAM STAIN (Final [**2128-4-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2128-4-20**]):
CITROBACTER KOSERI. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity testing available on
request.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER KOSERI
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 R
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
64 M rehab resident with history of DM2, ESRD on HD, CHF, HTN,
and AFIB who presented with with acute mental status change on
the way to HD, found to have acute respiratory alkalosis and
metabolic acidosis, as well as GNR bacteremia. Hospital course
by problem below:
.
#. GNR sepsis: He had an episode of hypothermia, hypotension,
and GNR bacteremia. Most likely source is sacral decubitus
ulcer. Repeat blood cultures were no growth to date. Initial
culture is preliminarly B.fragilis. Wound swabs were sent for
culture, as well as MRSA screens. He was covered broadly with
renally-dosed vanco, zosyn, and gent (gram positives and double
coverage for pseudomonas). His wound grew citrobacter,
resistant to piperacillin. He was switched to ciprofloxacin,
and should continue a total 14 day course of antibiotics.
.
# Mental status change: This was thought to be due to infection
as above, acute on chronic psychiatric symptoms, and alkalosis
with pH 7.69. Repeat blood gas was significantly improved.
Serum tox screen was negative; due to baseline anuria, urine tox
screen was not able to be obtained. LP was deferred due to
sacral ulcer overlying site. His valproate level was 22, but
the medication is given for agitation and mood disorder. Psych
was [**Month/Day/Year 4221**] for agitation and recommended haldol IV prn. His
mental status improved by discharge.
.
# Respiratory alkalosis: This was noted on admission, and was
thought to be due to compensation for metabolic acidosis,
question from uremia vs. sepsis. Repeat blood gas was improved.
.
# ESRD on HD: Patient with anion gap metabolic acidosis on
admission. This improved with hemodialysis. He was last
dialyzed on [**4-21**].
.
# DM2: He was continued on his outpatient lantus and glargine.
.
# HTN: Metoprolol was held in house due to hypotension. On
discharge he was hypertensive, and this was restarted with hold
parameters.
.
# AFIB: He received metoprolol for rate control. The patient
is not on coumadin because he does not want frequent blood
draws. He is also s/p pacer.
.
# Wound Care: The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] re his stage
IV ulcers. He is to receive wound care as an outpatient, and
frequent repositioning.
.
# PEG: His PEG tube material was hemooccult positive. He was
continued on [**Hospital1 **] PPI. He is to continue receiving daily
flushes, although he is no longer relying on tube feeds for
adequate pos.
.
# LLL Lung nodule: 4 mm nodule was found incidentally on CT
scan. The radiologists recommended one-year follow-up.
.
#. FEN: He was given a renal, diabetic, cardiac diet.
.
#. PPX: PPI, heparin sc, bowel regimen
.
#. CODE: He is DNR/[**Hospital 24351**] hospice care only but with exception of
dialysis per paperwork and discussion with Dr. [**Last Name (STitle) 53939**] at
[**Hospital 228**] nursing home.
.
#. COMMUNICATION: Brother [**Name (NI) 73171**] [**Name (NI) **]: [**Telephone/Fax (1) 73172**]. Brother
[**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 73173**]. ?Power of attorney [**First Name8 (NamePattern2) **] [**Known lastname **]:
[**Telephone/Fax (1) 73174**]
.
#. ACCESS: HD cath in LIJ, pacer on R chest
Medications on Admission:
NPH insulin 10 units sc QAM, 8 units sc Q4:30 pm
Fentanyl 50 mcg patch and 25 mcg patch
Reglan 5 per PEG TID prn
Tylenol #3 2 tabs [**Hospital1 **]
Colace
Vitamin C 500 [**Hospital1 **]
Metoprolol 12.5 [**Hospital1 **]
Valproic acid 250 via PEG Q8H
Ativan 0.5 QHS
Nephrocaps daily
ASA 81 daily
Nexium 40 daily
Heparin sc
NTG sl prn
Albuterol prn
Ativan 0.5 Q4H prn
MOM
Dulcolax prn
Fleet prn
Tylenol #3 prn
.
ALLERGIES:
Bactrim, Motrin, Seroquel
Discharge Medications:
1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Valproic Acid 250 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous QHD
for 4 doses: last given on [**4-21**].
14. Gentamicin 40 mg/mL Solution Sig: One (1) Injection QHD
(each hemodialysis) for 4 doses: last given on [**4-21**].
15. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
unit Subcutaneous four times a day as needed: per sliding scale.
16. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
four times a day as needed for pain.
17. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: Hold for SBP <100 or P <60.
19. Insulin Glargine 100 unit/mL Solution Sig: One (1) unit
Subcutaneous twice a day: Given 10 units QAM and 8 units QPM.
20. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
1. altered mental status
2. gram negative rod bacteremia
....
3. sacral decubitus ulcer - stage IV
4. ESRD on HD
5. DM2
6. HTN
7. AFib
Discharge Condition:
afebrile, oriented, alert
Discharge Instructions:
You were hospitalized for altered mental status. You were found
to have bacteria in your blood, and were started on antibiotics
for this. You underwent hemodialysis on [**4-19**] and [**4-21**].
.
Please call the [**Hospital1 18**] micro lab tomorrow for exact speciation of
organisms at [**Telephone/Fax (1) 73175**].
Followup Instructions:
to be arranged after discharge from acute rehab
|
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icd9cm
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,597
| 164,706
|
52540
|
Discharge summary
|
report
|
Admission Date: [**2201-7-29**] Discharge Date: [**2201-8-5**]
Date of Birth: [**2147-8-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
None
MRI head showed cortical atrophy and pronounced cerebellar
atrophy.
History of Present Illness:
53 year old man with EtOH abuse, HBV, HCV, chronic pancreatitis,
s/p L nephrectomy, presents with R flank pain x one week,
burning in nature, constant, [**8-31**] in severity. Notes dysuria,
nausea, vomiting, chills, and diarrhea. Denies polyuria,
epigastric pain. Reports having fallen off a wall previously
resulting in persistent heel pain. On exam, the patient appears
uncomfortable. Exam is variable between examiners, alternately
with and without R CVA tenderness, epigastric pain, LLQ
tenderness. There is no point tenderness or ecchymoses on his
feet. EtOH level was 328. Labs were otherwise unremarkable. CXR
showed no change from previous film. CT showed no
nephrolithiasis, no hydronephrosis, stable fatty liver. The
patient was given a banana bag, magnesium, and ketorolac and
morphine. He was admitted for CIWA and because he can't walk.
Also of note, the patient states that he seized this morning,
according to his friends and that he seizes about 3 times per
week when withdrawing from alcohol.
On ROS: admits to chills, but denies fevers, chest pain,
hematochezia, hematemesis. He admits to dyspnea that is improved
with albuterol. He's been nauseated with dry heaves but no
vomitting.
Past Medical History:
1. H/o chronic abdominal pain, likely [**12-24**] chronic pancreatitis
2. Hepatitis B
3. Hepatitis C
4. s/p L nephrectomy and tail of pancreas resection after stab
wound [**2173**]
5. s/p appendectomy
6. asthma
7. h/o IVDU (cocaine/heroin)
8. EtOH abuse w/ history of DT's, withdrawals, seizures.
9. H/o thrombocytopenia
10. Seizure disorder, untreated
11. Left arm laceration (severed palmeris longis); [**11-26**]
Social History:
Homeless. +EtOH (18 beers per day and 1 pint vodka per day on
average). Weekly marijuana. No current IVDU but h/o cocaine
and heroin use. Smokes 1.5-2 ppd x40years.
Family History:
Father - DM2, renal failure, alcoholic cirrhosis
Mother - [**Name (NI) **] cancer
Physical Exam:
T 97.9 HR 90 BP 128/64 RR 20 97% on RA
Gen: looks uncomfortable lying on stretcher, trembling
HEENT: dry MM, poor dentition
Neck: no LAD
Cor: RRR, no murmurs
Pulm: crackles at bases bilaterally
Back: normal excursion
Abd: hyperactive BS, soft but guarding and TTP on RUQ and LUQ
but not in lower abdomen, could not eval liver secondary to
guarding
Ext: WWP, strength 4/5 upper and lower extremities but poor
effort, very tremulous, DP, PT, radial 2+ bilaterally, heels TTP
but no ecchymosis or edema
Derm: multiple tatoos
Pertinent Results:
[**2201-7-29**] 04:35PM GLUCOSE-101 UREA N-6 CREAT-0.8 SODIUM-130*
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-22 ANION GAP-16
[**2201-7-29**] 04:35PM ALT(SGPT)-175* AST(SGOT)-293* LD(LDH)-318*
ALK PHOS-113 AMYLASE-76 TOT BILI-0.8
[**2201-7-29**] 04:35PM LIPASE-85*
[**2201-7-29**] 04:35PM CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-1.5*
[**2201-7-29**] 04:35PM ASA-NEG ETHANOL-348* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2201-7-29**] 04:35PM WBC-4.9# RBC-3.48* HGB-11.5* HCT-33.2* MCV-96
MCH-33.0* MCHC-34.6 RDW-13.2
[**2201-7-29**] 04:35PM NEUTS-59.3 LYMPHS-34.7 MONOS-4.6 EOS-1.3
BASOS-0.1
[**2201-7-29**] 04:35PM PLT COUNT-85*#
[**2201-7-29**] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
CXR: Cardiac and mediastinal silhouettes remain unchanged and
unremarkable in appearance. Vascular calcification of the aortic
arch is again seen. No evidence of pneumonia, pleural effusion,
or pneumothorax. Healing rib fracture of the left 7th rib at the
posteriolateral aspect is again appreciated. No other rib
fractures are identified. No significant change in comparison to
examination of [**2201-6-14**].
IMPRESSION:
1. No evidence of acute cardiopulmonary disease.
2. Healing left 7th rib fracture.
CT abdomen: 1. Stable appearance of the liver with hepatomegaly,
fatty infiltration, and unchanged heterogeneous perfusion.
2. Cholelithiasis and small amount of pericholecystic fluid. No
CT evidence of gallbladder wall edema.
3. Single right kidney with no stones, hydronephrosis, or
evidence of abscess.
MRI head: IMPRESSION: Diffuse cortical atrophy with pronounced
cerebellar atrophy. No focal lesions.
RUQ US IMPRESSION:
1. Cholelithiasis with no evidence of acute cholecystitis.
2. Fatty infiltration of the liver.
XRAY FEET IMPRESSION:
1. No significant interval change since the previous study. No
evidence for acute fracture or dislocations.
2. There is again seen a triangular-shaped radiopaque foreign
density dorsal soft tissues projecting over the right second
metatarsal head.
[**8-1**] Blood Cx (3/4 bottles Positive):
AEROBIC BOTTLE (Final [**2201-8-4**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
Brief Hospital Course:
BRIEF OVERVIEW:
53 year old man with abdominal pain, likely secondary to
alcoholic hepatitis vs. chronic alcoholic pancreatitis, EtOH
withdrawal, and heel pain. He was admitted for CIWA and w/u of
R flank pain. He was found to have very high CIWA needs on the
floor, receiving 10mg Valium q1h plus a 60mg load on admission.
He had films of his feet due to continued pain in his heels that
were neg for fx. CT showed a fractured L rib but no abcess.
Liver was expanded. Flank pain was thought to be due to refered
rib fx pain, enlarged liver, and chronic pancreatitis. He had a
MRI due to his hx of sz that showed diffuse cortical and
profound cerebellar atrophy without other deficit. After 36
hours of this, the nursing needs were thought to be too high and
the pt was tx'd to the unit. In the process of transfer, the pt
spiked a temp to 103 and was cx'd. [**1-23**] grew out pan-sensitive
MSSE. In the meantime, the pt was not treated with abx - vanco
was started when his cultures turned positive. He was called
out from the [**Hospital Unit Name 153**] after his valium needs had decreased and he
was being tx'd with vanco. When sensitivities returned, vanco
was changed to oxacillin. PT was consulted and found no deficit
that would improve with rehab. The pt was given crutches. He
refused detox and [**Hospital **] rehab programs. He was discharged in
stable condition.
COURSE BY SYSTEM:
# R flank/abdominal pain: This was thought to be due to his
enlarged liver stretching the capsule vs pancreatitis secondary
to alcohol vs referred pain from a L rib fracture. Amylase was
normal and lipase slightly elevated at 85. AST was about 2x ALT.
The patient has only one kidney (on the right), so it was felt
important to protect this kidney. However, UA and UCx were
negative throughout the hospital course. The patient had no
signs of pyelonephritis and CT showed no hydronephrosis nor
other kidney changes. He did have mild cholecystitis. This was
thought, in the end, to be another source of his pain. He was
initially started on a liquid diet and advanced as he tolerated
it. Toradol was used for pain control initially, but in the
[**Hospital Unit Name 153**] it was changed to Tramadol. This was continued in addition
to NSAID for the remainder of the hospital course and the pt was
provided with prescriptions for a short course of tramadol after
discharge.
# EtOH withdrawal: On admission, the patient had [**Known firstname **] tremors,
hyperacusis, photophobia, startle response and hypertension as
well as diaphoresis. Given his symptoms and his history of
delerium tremens/ seizures, he was given 20mg of valium q1 hour
for 3 hours after which he was changed to a q1 hour CIWA scale
with diazepam. He had an MRI given his history of sz both while
drinking and while withdrawing. The MRI showed only atrophy,
particularly in the cerebellum. The patient was given banana
bags, MVI/folate/and thiamine starting in the ED and continuing
throughout the hospital course. He was also discharged on MVI,
thiamine, folate. He was seen by the addiction service and
refused detox/rehab throughout his hospital course. After 1.5
days, the patient had not decreased his CIWA needs and he was tx
to the unit because of the continued high nursing needs. In the
unit he did well (had infection as below) and was tapered off of
his diazepam. When he returned to the floor, he required no
valium at all.
## Fevers: The patient spiked to 103 on the floor during his
[**Hospital Unit Name 153**] transfer. Blood cultures were pending for 3 days during
which the pt was in the unit. During this time he had no fevers
and was not treated with antibiotics. When blood cultures
returned [**1-23**] coag neg staph, he was started on vancomycin. No
source was identified. After one day on the medical floor,
sensitivities were returned and the MSSE was found to be
oxacillin sensitive. The patient was changed to dicloxacillin
with the plan to tx for 10d course. All blood cx after the [**1-23**]
positive ones remained negative.
# hyponatremia: The patient came in to the hospital euvolemic
but with hyponatremia. He was given NS IVF to correct his
hyponatremia. It corrected with this intervention. To better
understand the reason for his hyponatremia, urine lytes were
sent on admission. His urine sodium was low, suggesting that he
had a dilute urine in the face of hyponatremia. His history of
drinking at least a case and a half of beer per day without
eating made the most likely diagnosis beer potomania.
Hyponatremia was not an issue thereafter.
# h/o asthma: some fine crackles on exam. Albuterol inhaler was
continued. There were no issues at this hospitalization.
# heel pain: x rays to eval for fracture were negative. PT
consult felt that while he was somewhat unsteady on his
crutches, he had no rehab potential as his unsteadiness was
likely due to his permanent cerebellar damage. He was observed
to ambulate safely with crutches. Toradol was used for pain
control initially, but in the [**Hospital Unit Name 153**] it was changed to Tramadol.
This was continued in addition to NSAID for the remainder of the
hospital course and the pt was provided with prescriptions for a
short course of tramadol after discharge.
# anemia - This was mild and stable and was likely due to marrow
suppression from etoh, wbc also low.
# dispo: Pt refused alcohol rehab and detox, and was not a PT
candidate. He was discharged home. He lives under a bridge in
[**Location (un) **] square. He was established with an appt at [**Company 191**]. He
also sees a physician who does homeless health. This physician
was emailed to make him aware that the pt would be back on the
street.
Medications on Admission:
none
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Beer Potomania
Heel Pain NOS
Intoxication
Uncomplicated Withdrawal
Seizure disorder
Alcoholic Cortical Atrophy
Discharge Condition:
Stable, able to bear wt, no signs of impending DT's or seizure,
tolerating liquids.
Discharge Instructions:
You were admitted to the hospital for intoxication and because
of your inability to walk. You had x-rays of your feet. There
are no fractures. You should continue to walk with crutches
until you are able to bear weight on your feet.
.
You were given an MRI because you have seizures - it showed some
damage to your brain that could be from heavy alcohol
consumption. You will be given information about detoxification
programs that you can go to if you would like to quit drinking.
.
Dr.[**Name (NI) 5118**] knows that you will be discharged today and will
follow up with you.
.
You have an appointment at the [**Hospital Ward Name 23**] Building for primary care
with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**2201-8-17**] at 2:30. Please call if you
need to cancel or change your appointment: [**Telephone/Fax (1) 250**].
.
If you develop increasing foot pain, fevers, inability to eat or
drink water, or other worrisome symptoms, you should seek
immediate medical attention.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2201-8-17**] 2:30
Completed by:[**2201-8-8**]
|
[
"070.54",
"V60.0",
"493.90",
"719.47",
"291.0",
"577.1",
"287.4",
"303.91",
"780.39",
"790.7",
"276.1",
"571.1",
"070.30"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12361, 12367
|
5900, 11629
|
330, 405
|
12522, 12608
|
2921, 5877
|
13662, 13870
|
2281, 2364
|
11684, 12338
|
12388, 12501
|
11655, 11661
|
12632, 13639
|
2379, 2902
|
274, 292
|
433, 1638
|
1660, 2078
|
2094, 2265
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,112
| 146,735
|
5494
|
Discharge summary
|
report
|
Admission Date: [**2176-10-31**] Discharge Date: [**2176-11-7**]
Date of Birth: [**2110-7-26**] Sex: F
Service: MEDICINE
Allergies:
Captopril
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
cardiac cath
History of Present Illness:
66-year-old woman with type 1 diabetes x (HbA1c 7.6 in [**8-7**],
complicated by neuropathy, retinopathy, and
severe Charcot foot deformities), peripheral vascular disease
status post right popliteal-->DP bypass from [**6-6**], two-vessel
coronary disease status post mid RCA stent in 2/99 (3.5 x 16 mm)
with recent cardiac catheterization on [**2175-8-7**] demonstrating
diffuse coronary disease (detailed below), hyperlipidemia and
multiple sclerosis. She presented on [**10-31**] AM with lethargy,
vomiting, weakness, and critically high blood sugars (700s). She
also complained of feeling lightheadedness, with dull, crampy
epigastric pain for 2 days. No CP or SOB.
.
Unable to complete ROS.
.
.
In the ED, initial vitals were T 97.9 BP 99/44 HR 80 RR 14. EKG
showed ST elevations inferiorly, with ST depressions laterally.
Code STEMI was called. Patient received ASA, heparin gtt, and
plavix 600mg x1. However, she was severely nauseated, and
vomited immediately thereafter.
.
In the cath lab, she was hypotensive (SBP 60s). She had 90%
stenosis of RCA. Bare metal stent placed to mid RCA. She was
started on dopamine gtt and got 1.5L IV fluids. IABP was
inserted without complications. She also got 10 units of regular
insulin in the cath lab.
.
On transfer to the floor, blood sugar was 774. Venous sheath was
still in place.
Past Medical History:
Secondary progressive MS, Sx onset [**8-/2167**], Dx [**4-1**], previously on
Avonex [**Date range (1) 22207**] but discontinued because of continued
progression and major impairments related to diabetes
Neurogenic bladder S/P suprapubic sling [**12-5**]
Mild cognitive dysfunction
Essential tremor
History of syncope
Type 1 diabetes mellitus over 40 years, c/b retinopathy and
neuropathy with Charcot joints, also diabetic amyotrophy, on
insulin pump
Hypertension
Dyslipidemia
CAD s/p PTCA (stent) to mid RCA [**3-/2166**]
s/p bladder suspension surgery for stress incontinence
Chronic anemia
S/P IOL implantation for cataracts [**12-5**] and [**1-4**]
PVD s/p right BKPop-DP Bypass Graft [**2174-6-23**]
Sebhorrheic dermatitis
Depression
Social History:
Please see HPI for further social history. She
lives at home alone, but receives some assistance from a friend
who lives upstairs. She has used a wheelchair for the past 3
years. She denies cigarette, EtOH, or illicit drug use.
Family History:
Her second cousin has MS. [**Name13 (STitle) 3495**] disease runs in
her mother's side of the family. Mother died of MI at age 80;
Father had epilepsy.
Physical Exam:
Pt expired
Pertinent Results:
[**2176-11-7**] 04:07AM BLOOD WBC-22.4* RBC-2.96* Hgb-9.4* Hct-28.7*
MCV-97 MCH-31.7 MCHC-32.7 RDW-14.2 Plt Ct-362
[**2176-10-31**] 11:35AM BLOOD Neuts-87.3* Lymphs-9.4* Monos-3.2 Eos-0
Baso-0.1
[**2176-11-7**] 04:07AM BLOOD Plt Ct-362
[**2176-11-7**] 04:58PM BLOOD Glucose-439* UreaN-40* Creat-0.9 Na-133
K-4.5 Cl-92* HCO3-30 AnGap-16
[**2176-11-1**] 04:35AM BLOOD CK(CPK)-[**2152**]*
[**2176-11-1**] 04:35AM BLOOD CK-MB-44* MB Indx-2.2
[**2176-11-7**] 04:58PM BLOOD Calcium-7.8* Phos-3.7 Mg-2.4
[**2176-11-7**] 11:55AM BLOOD Type-ART Temp-38.2 Rates-/20 FiO2-50
pO2-72* pCO2-47* pH-7.43 calTCO2-32* Base XS-5 Intubat-NOT
INTUBA Vent-SPONTANEOU Comment-HI FLOW
[**2176-11-6**] 08:25PM BLOOD Lactate-1.1
[**2176-11-6**] 08:25PM BLOOD O2 Sat-92
[**2176-10-31**] 08:15PM BLOOD freeCa-1.15
CT Chest [**11-7**]
Brief Hospital Course:
Mrs [**Known lastname 22204**] is a 66-year-old woman with type 1 diabetes (HbA1c 7.6
in [**8-7**], complicated by neuropathy, retinopathy, and severe
Charcot foot deformities), peripheral vascular disease status
post right popliteal-->DP bypass from [**6-6**], two-vessel coronary
disease status post inferior STEMI with bare metal stent placed
to RCA, who was initially transfered to the cardiac ICU
intubated, on pressors, with balloon pump in place. She was
eventually able to be weaned off the balloon pump and
ventilator, however she showed worsening respiratory status
shortly thereafter with increasing oxygen demand and increased
work of breathing. On day 6 of her admission, she developed a
spontaneous pneumothorax which made postive pressure ventilation
difficult without re-intubation. On day 7 of her admission, her
CXR showed widespread bilateral airspace opacities which were
worse on the left side than previous images. Family meeting was
held to discuss the patient's worsening resp status and she was
changed to DNR/DNI status by her HCP. [**Name (NI) **] PCP was notified as
well. On the evening of day 7, she desated to the 80s and
became hemodynamically unstable. Her family was called and pt
passed at 1049pm with brother & sister at bedside.
Medications on Admission:
1. Citalopram 40 mg po bid
2. Dextroamphetamine 5 mg po qam
3. Aspirin 325 mg po daily
4. Gabapentin 300 mg po bid
5. Oxcarbazepine 150 mg po bid
6. Metoprolol Tartrate 25 mg po bid
7. Simvastatin 40 mg po qhs
8. Docusate Sodium 100 mg po bid
9. Senna 8.6 mg po bid PRN constipation
10. Primidone 150 mg po bid
11. Cholecalciferol (Vitamin D3) [**2167**] unit po daily
12. Folic Acid 1 mg po daily
13. Multivitamin po daily
14. Oxybutynin Chloride 5 mg po bid
15. Diclofenac Sodium 75 mg po bid
17. Vesicare 10 mg po daily
18. Insulin pump
19. Miralax po daily
20. Meclizine 25 mg po daily
21. Clobetasol 0.05 % PRN itching
22. Protopic 0.1 % Ointment Topical twice a day
23. Desonide 0.05 % Cream Topical twice a day
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"416.8",
"713.5",
"041.12",
"250.63",
"362.01",
"357.2",
"250.73",
"285.9",
"V45.82",
"250.13",
"785.51",
"690.10",
"596.54",
"401.9",
"512.8",
"414.01",
"507.0",
"428.0",
"518.5",
"311",
"443.81",
"410.21",
"428.31",
"340",
"V58.67",
"250.53",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.40",
"00.45",
"88.72",
"37.23",
"88.56",
"37.61",
"96.6",
"00.66",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
5792, 5801
|
3722, 4996
|
287, 301
|
5848, 5858
|
2890, 3699
|
5910, 5916
|
2691, 2844
|
5764, 5769
|
5822, 5827
|
5022, 5741
|
5882, 5887
|
2859, 2871
|
232, 249
|
329, 1665
|
1687, 2429
|
2445, 2675
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,997
| 162,226
|
1375
|
Discharge summary
|
report
|
Admission Date: [**2144-1-8**] Discharge Date: [**2144-1-28**]
Date of Birth: [**2093-9-15**] Sex: M
Service: [**Hospital1 212**]
CHIEF COMPLAINT: Epigastric pain, transferred from outside
hospital.
HISTORY OF PRESENT ILLNESS: This is a 50 year old male with
a history of type 2 diabetes mellitus since [**2136**], on insulin,
hypercholesterolemia, hypertension, who presents with a two
day history of epigastric pain. He presented to [**Hospital3 418**] Hospital and was admitted to [**Hospital3 417**]
Hospital on [**2144-1-3**], with this two day history of epigastric
pain. He denied any nausea, vomiting, diarrhea or anorexia.
At the outside hospital, he was diagnosed with acute
pancreatitis, presumably alcohol related (he states he drinks
two to four beers a day) with laboratory studies notable for
an amylase of 1900, a lipase of 413 and triglycerides of 56.
He did not have any significant gallbladder or prior
gastrointestinal disease. At [**Hospital3 417**] Hospital, he
improved with bowel rest and vigorous intravenous fluid
hydration but he continued to have abdominal pain, distention
and fevers two days prior to admission to [**Hospital1 346**]. A CT scan was repeated which
showed pancreatitis with necrosis. An ultrasound was
performed which did not reveal any stones or ductal
dilatation. He was then initiated on Imipenem one day prior
to admission and was noted to have a white blood cell count
of 16.0, a hematocrit of 43.0. Repeat CT scan performed two
days prior to admission revealed an area of low attenuation
consistent with necrosis that was new compared to a CT scan
done three days prior as well as evidence of bilateral
pleural effusions and consolidation at both lung bases. He
was transferred to [**Hospital1 69**] for
further management of his necrotic pancreas as well as his
increasing oxygen requirement and dyspnea. Arterial blood
gases on presentation revealed a pH 7.47, 29 and 64 on four
liters nasal cannula.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus.
2. Hyperlipidemia.
3. Hypertension.
SOCIAL HISTORY: The patient reports two to four beers per
day. He has two children and works for [**Company 8328**].
FAMILY HISTORY: Significant for diabetes mellitus in his
mother and father had cancer of unknown type.
MEDICATIONS ON TRANSFER FROM OUTSIDE HOSPITAL:
1. Imipenem 500 mg intravenous q6hours.
2. Levofloxacin 500 mg intravenous once daily.
3. Labetalol drip.
4. Ativan p.r.n.
5. Demerol p.r.n.
6. TPN.
MEDICATIONS AS OUTPATIENT:
1. Lipitor 10 mg p.o. once daily.
2. Accupril 40 mg p.o. once daily.
3. NPH 25 units at night.
4. Prandin 4 mg p.o. three times a day.
PHYSICAL EXAMINATION: On examination, the patient is
afebrile, blood pressure 168/85, heart rate 126, respiratory
rate 35, oxygen saturation 96% on four liters nasal cannula.
In general, the patient appeared tachypneic and in no acute
distress. Head, eyes, ears, nose and throat examination -
Mucous membranes are dry. Extraocular movements are intact.
The pupils are equal, round, and reactive to light and
accommodation. Neck is supple, jugular venous distention at
six to seven centimeters. Chest examination revealed
decreased breath sounds at the bases with dullness to
percussion bilaterally one half way up, right greater than
left. Cardiovascular examination - S1 and S2, regular rate
and rhythm with S3. Abdomen - No rebound tenderness.
Tenderness on palpation, distended, decreased bowel sounds,
tympanitic, no hepatosplenomegaly. Extremities - no
cyanosis, clubbing or edema. Neurologically, the patient is
alert, oriented times three. Cranial nerves II through XII
are intact grossly.
LABORATORY DATA: White blood cell count 16.7, hematocrit
33.5, platelet count 229,000. Prothrombin time 13.2, INR
1.2, partial thromboplastin time 28.2. Sodium 137, potassium
3.7, chloride 107, CO2 20, blood urea nitrogen 13, creatinine
0.7, glucose 272, AST 41, ALT 21, CK 883, alkaline
phosphatase 87, amylase 79, total bilirubin 1.2, lipase 109.
Albumin 2.9, calcium 8.0, magnesium 1.7, phosphorus 1.8.
Urinalysis revealed glucose greater than 1000 and trace
ketones. Urine sodium 117, urine creatinine 37, urine
osmolality 488.
Chest x-ray revealed bilateral pleural effusions, left
greater than right. No consolidation. Vasculature
unremarkable. Echocardiogram revealed left atrium normal
size, right atrium normal size, mild left ventricular
hypertrophy, ejection fraction 55%.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE:
1. Necrotizing pancreatitis - The patient was admitted to
the Intensive Care Unit for acute management of his acute
pancreatitis. He continued with total parenteral nutrition
as well as Imipenem and remained NPO. He was aggressively
treated with intravenous hydration. Gastrointestinal and
surgery consultations were obtained to further assist in
management of his necrotic pancreatitis. A CT scan was
performed on hospital day number one and revealed a 3.9 by
7.8 centimeter fluid attenuation replacing the body of the
pancreas as well as a large amount of fat stranding within
the mesentery. The patient continued to spike fevers through
imipenem and on hospital day number three, he experienced
epigastric and abdominal distention and a nasogastric tube
was placed for decompression. The patient was noted on
hospital day number four to have an increase in his
leukocytosis to 30.0 as well as a decrease in his hematocrit
to 25.0. A CT of the abdomen was repeated which did not show
any change in his necrotic pancreas as well as no evidence of
thrombosis or aphthous formation. Blood cultures obtained
throughout this time remained negative and the patient
continued to spike temperature to 101 degrees while on
Imipenem. Surgery declined surgical action at this time. On
hospital day number six, his diet was advanced to clear and
his pancreatitis remained stable. He was transferred out of
the Intensive Care Unit on hospital day number seven.
Clinically, his epigastric pain continued to improve. His
amylase and lipase continued to down trend to normal limits.
His fever curve was overall down trending with negative
cultures. His Morphine PCA was discontinued and he completed
a three week course of Imipenem. A repeat CT scan of the
abdomen on hospital day number fifteen revealed a slight
interval increase in size of the large pseudocyst. He was
continued to be medically managed. On hospital day number
sixteen, a CT guided aspiration of the pancreatic pseudocyst
was performed which did not reveal any infectious growth
including bacterial and fungal. His diet was again increased
to full liquids which he tolerated well. An attempt was made
for soft solids, nonfat diet, which the patient experienced
epigastric gas and slight distention at which time his diet
was reversed back to full liquids with resolution of his
epigastric gas. It was felt that the patient was amenable to
tolerating a full liquid diet with very slow advancement of
his diet and with appropriate follow-up, it was felt that
this patient was clinically stable to be discharged home with
follow-up appointments with the Gastroenterology service for
evaluation of the etiology of his pancreatitis. Upon
initiation of a full liquid diet during his hospital course,
his total parenteral nutrition was decreased and eventually
discontinued secondary to adequate intake. The patient
continued to exhibit increased elevations in his liver
function tests. The overall trend of his liver function
tests was down trending, however, he did not exhibit return
to normal limits. He is to follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**], for further evaluation and monitoring of
his liver function tests.
2. Fungemia - It was noted on hospital day number fifteen
that the patient spiked a temperature to 103.9 while on
Imipenem. Blood cultures were drawn including fungal
isolates which revealed growth of [**Female First Name (un) 564**] parapsilosis.
Acute infectious disease was consulted for further management
of his fungal infection and Amphotericin 45 mg q24hours was
initiated with resolution of his fevers. His PICC line was
removed upon identification of his Candidemia and clinically
the patient remained afebrile after initiation of
Amphotericin. Upon further consultation with the infectious
disease service, it was felt that he was suitable for an oral
regimen of antifungal treatment and was started on
Fluconazole 400 mg p.o.once daily for a three week course of
antifungal treatment. He was also given a follow-up
appointment with Dr. [**First Name (STitle) 3640**] for further evaluation.
Ophthalmology consultation was also obtained to rule out
[**Female First Name (un) 564**] endophthalmitis and ophthalmology did not see any
evidence of ocular involvement. He was also instructed to
follow-up with the ophthalmologist in approximately three to
four weeks for further evaluation.
3. Hyperglycemia - The patient was noted to have difficult
to control blood sugar throughout his hospital course. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consultation was obtained for management of his
hyperglycemia and he was started on a course of Lantus with
regular insulin for sliding scale. His blood sugar was
gradually controlled and he was eventually switched back to
Repaglinide 4 mg p.o. three times a day with meals and was to
continue on his usual regimen of NPH 10 units in the morning
and 15 units at evening. He was instructed to call the
[**Hospital **] Clinic for follow-up with his blood sugar.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with follow-up appointments with
the [**Hospital **] Clinic, Dr. [**Last Name (STitle) **], on [**2144-2-19**], at
1:20 p.m., follow-up with Infectious Disease Clinic, Dr.
[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3640**], on [**2144-2-17**], at 11;00 a.m., follow-up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] on [**2144-1-31**], at 1:15 p.m.,
follow-up with his ophthalmologist in three to four weeks.
MEDICATIONS ON DISCHARGE:
1. Fluconazole 400 mg p.o. once daily.
2. Accupril 40 mg p.o. once daily.
3. Insulin 10 units NPH q.a.m. and 15 units NPH q.p.m.
4. Prandin 4 mg p.o. three times a day with meals.
DISCHARGE DIAGNOSES:
1. Necrotic pancreatitis with pseudocyst.
2. Hyperglycemia.
3. Fungal Candidemia.
4. Insulin dependent diabetes mellitus.
5. Hypertension.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2144-2-20**] 17:34
T: [**2144-2-22**] 13:33
JOB#: [**Job Number 8329**]
|
[
"577.2",
"511.9",
"560.1",
"276.2",
"112.89",
"276.3",
"518.0",
"996.62",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"54.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
2223, 2681
|
10418, 10826
|
10212, 10397
|
4537, 9643
|
2704, 4520
|
165, 218
|
247, 1984
|
2006, 2086
|
2103, 2206
|
9668, 10186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,416
| 102,966
|
41943
|
Discharge summary
|
report
|
Admission Date: [**2183-11-5**] [**Month/Day/Year **] Date: [**2183-11-26**]
Date of Birth: [**2123-10-28**] Sex: M
Service: MEDICINE
Allergies:
Benzodiazepines
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Found unresponsive
Major Surgical or Invasive Procedure:
Right internal jugular vein central venous catheter placement
-[**2183-11-5**]
Intubated prior to admission
History of Present Illness:
The patient is a 60yo M with history of CHF, COPD, DM who was
brought to an outside hospital after bieng found down and was
transferred here for management of shock and respiratory
failure.
.
He was found unresponsive at home by his wife. She reported that
he had increasing lethargy over the several weeks prior and
seemed normal his morning but wa unresponsive around 3pm. At
that time blood glucose was 41. He was given 1 amp D50 by EMS.
After an additional amp of D50 and blood glucose 195, his mental
status was still poor. He was also hypothermic with temperative
93 and he was taken to [**Hospital3 2783**]. His initial vitals
there were T 92.2 BP 105/60, HR 56, RR 12, O2 90. A head CT was
negative. A CXR there was concernign for fluid overload. An echo
showed EF 10-15%. He was intubated for concern for mental
status. The initial impression was that he was in cardiogenic
shock and he was started on a heparin gtt and given PR ASA
before transfer here.
.
On arrival here, his CXR was felt to be consistent with
pneumonia and heparin was stopped and he was given cefepime and
levofloxacin. Glucose was still low at 56 and he was given 1amp
D50. He arrived with peripheral dopamine. This was weaned off
initially but blood pressure trended down and a R IJ was placed
and levophed started. On transfer, VS were 97/59, 57, 15, 99%
vent FiO2 100%, PEEP 5, tv 528
Past Medical History:
CHF
Depression
COPD
GERD
Hyperlipidemia
DM
s/p R BKA
Social History:
- Tobacco: 1ppd
- Alcohol: denies
- Illicits: denies
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
General Appearance: Overweight / Obese
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : )
Abdominal: Soft, Distended
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+, right BKA
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
[**Hospital3 **] exam: unchanged except for as below:
Weight at [**Hospital3 **] (after duiresis): 121kg
Lungs: mild crackles at the lung bases bilaterally, improved
Extremities: Left BKA, 1+ edema on right LE
HEENT: ET and OG tubes removed
Pertinent Results:
[**2183-11-5**] 06:45PM BLOOD WBC-5.2 RBC-3.26* Hgb-9.4* Hct-30.4*
MCV-93 MCH-28.8 MCHC-30.9* RDW-19.8* Plt Ct-355
[**2183-11-5**] 06:45PM BLOOD PT-20.6* PTT-150* INR(PT)-1.9*
[**2183-11-5**] 06:45PM BLOOD Glucose-58* UreaN-42* Creat-1.8* Na-141
K-3.3 Cl-110* HCO3-19* AnGap-15
[**2183-11-5**] 06:45PM BLOOD ALT-29 AST-28 AlkPhos-106 TotBili-1.5
Imaging:
-CXR ([**11-5**]) - Low-lying ET tube. Retraction by at least 1.5 cm
is advised. Advancement of NG tube result in more optimal
positioning. Scattered bilateral pulmonary opacities are
concerning for multifocal pneumonia, less likely pulmonary
edema. Findings D/w Dr. [**Last Name (STitle) 19409**].
-TTE ([**11-6**]) - The left atrium is moderately dilated. Late
saline contrast is seen in left heart suggesting intrapulmonary
shunting. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 25 %)
secondary to akinesis of the posterior and lateral walls and of
the apex, and hypokinesis of the inferior free wall. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. At least
moderate [2+] tricuspid regurgitation is seen by color flow
Doppler. However, the inferior vena cava spectral Doppler signal
suggests that the tricuspid regurgitation could actually be 3+
or 4+. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
-Renal US ([**2183-11-7**]) - 1. Markedly limited examination secondary
to poor acoustic windows. No gross evidence of hydronephrosis.
2. Doppler examination was unable to be performed.
-CT head ([**2183-11-12**]) - 1. No acute intracranial process. 2.
Apparent lucency through the right frontal bone, upon
correlation with coronal and sagittal reconstructions, is felt
to likely represent a suture, less likely nondisplaced fracture.
Clinical correlation may be helpful.
-CXR ([**2183-11-19**]) - In comparison with study of [**11-16**], the patient
has taken a slightly better inspiration and the monitoring and
support devices have been removed except for the left subclavian
catheter. There is continued enlargement of the cardiac
silhouette with mild elevation of pulmonary venous pressure,
though this is substantially decreased from the previous study.
-Video swallow ([**2183-11-21**]) - Aspiration with thin liquids. For
complete report, please see speech and swallow note in OMR.
[**Month/Day/Year **] labs:
[**2183-11-26**] 07:20AM BLOOD WBC-5.6 RBC-3.03* Hgb-8.7* Hct-27.8*
MCV-92 MCH-28.8 MCHC-31.4 RDW-17.3* Plt Ct-425
[**2183-11-26**] 07:20AM BLOOD Glucose-44* UreaN-62* Creat-3.2* Na-146*
K-3.5 Cl-100 HCO3-34* AnGap-16
[**2183-11-26**] 07:20AM BLOOD Calcium-9.2 Phos-5.3* Mg-2.1
Brief Hospital Course:
60M with chronic systolic CHF (EF=25%), T2DM who p/w AMS,
bilateral opacities on CXR.
# Metabolic encephalopathy - Most likely result of hypoglycemia
and subsequent pneumonia. Unlikely from stroke given normal
head CT and lack of focal deficits. He was weaned off
midazolam, but remained significantly altered. He has had
prolonged delirium with benzos in the past. He was started on
seroquel 50mg TID with little improvement. His sedation was
switched to Precedex with relatively little change. Extubation
was attempted [**11-12**] but the patient was very altered and
agitated, eventually requiring re-intubation. With time his
mental status improved, and after extubation [**11-16**] his mental
status had cleared. Seroquel was stopped. We held additional
sedating medications and MS improved. He was noted to have
periods where he was sleepy while on the floor, this usually
occurred after he didn't wear CPAP overnight and improved when
he was compliant with this therapy.
# Septic shock - Most likely [**2-12**] pneumonia, ? community acquired
vs. aspiration. He was started on broad spectrum antibiotics,
levofloxacin/cefepime/vancomycin. His medication was dosed
renally and for CVVH. He underwent bronchoscopy on [**11-6**] which
showed thick purulent sputum. Urine legionella was negative.
BAL grew only yeast, which was not treated as the patient is
immunocompetent. Patient was treated for 8 days and abx were
stopped. He subsequently had a fever but was hemodynamically
stable. Cultures were negative. His R IJ was replaced by a PICC
line. The patient was afebrile x72hrs prior to leaving the ICU.
On the floor, he remained afebrile and hemodynamically stable.
# Multifocal pneumonia - Differential includes community
acquired vs. aspiration. He was covered broadly with cefepime,
vancomycin and levofloxacin. Treated for total of 8 days given
the severity of his pneumonia, as above. Speech and swallow
after extubation found that he could eat normal solids and
nectar pre-thickened fluids. Re-evalution with a video swallow
showed silent aspiration of thin liquids. At [**Month/Year (2) **], he has
only been cleared for nectar thick liquids and will need further
assessment by speech and swallow at rehab.
# Hypoxic respiratory failure - Most likely [**2-12**] pneumonia.
Intubated while in the ICU, successfully weaned and satting well
on RA at [**Month/Day (2) **].
# Acute on chronic systolic HF - EF was noted to be 25-30% over
the last few years per outside record. Repeat echocardiogram
confirmed systolic heart failure. Cardiac enzymes were mildly
elevated but also in the setting of ARF. Trial of dobutamine
was used during his initial MICU stay, but was not found to be
helpful. Diuresis was held given septic shock. He was
subsequently duiresed upon arrival to the floor. [**Month/Day (2) **]
weight was 121kg. He will be discharged on Lasix 80mg PO bid.
He is still thought to be total-body fluid overloaded and should
continue to diurese net negative. Unfortunately, he does not
know his dry weight. He should have daily fluid inputs and
outputs measured, as well as daily weights. He should also have
outpatient discussion about AICD.
# Acute on chronic renal failure - Most likely [**2-12**] ATN based on
urine lytes and sediments and poor forward flow given sCHF and
septic shock. Nephrology evaluated patient as he became anuric.
Received CVVH via a Left IJ dialysis catheter for 3 days,
finishing the evening [**11-9**]. Afterwards he received one session
of intermittent dialysis before his urine output improved and he
was able to be diuresed with doses of 80mg IV lasix. It remains
unclear what his new baseline creatinine will be. At [**Month/Year (2) **],
Cr has mildly improved to 3.5. His [**Month/Year (2) **] weight is 121kg.
He will follow-up with nephrology after [**Month/Year (2) **] and did not
require further hemodialysis on the floor. He was also started
on acetazolimide for persistent metabolic alkalosis with an
elevated bicarbonate level.
# Transaminitis. Thought to be secondary to congestive
hepatopathy. Resolved at [**Month/Year (2) **].
# Type 2 diabetes on insulin - Found to be hypoglycemic at
presentation, requiring D10. Improved with tube feeds, and
transitioned to regular sc insulin. At [**Month/Year (2) **], he will be
continued on Lantus and sliding scale insulin. His PO intake
had been very variable and we significantly decreased his Lantus
this admission. He will likely need this titrated as his PO
intake improved over time.
# Depression - He was continued on zoloft. Cymbalta was held
given ARF.
# COPD - Not on oxygen prior to admission, at [**Month/Year (2) **] he is
breathing comfortably on room air and maintaining sats. He did
not have significant wheezing during this admission. He was
continued on his home Advair and Spiriva.
# GERD - Continued on home PPI.
# Hyperlipidemia. Simvastatin was initially held. As
transaminitis improved, simvastatin and ezetimibe were restarted
#Code status during this admission - FULL CODE
#Transitional issues -
-Will need weekly Chem-10 to measure electrolytes given poor
renal function, particulary phosphate.
-A urinalysis and urine culture was sent prior to [**Month/Year (2) **],
this will need to be followed-up as an outpatient.
-Lisinopril and spironolactone were held during this admission
given his acute on chronic renal failure, these medications
should be re-considered at his follow-up nephrology appointment
as they are important for systolic CHF.
-Will need ongoing evaluation by speech and swallow for
aspiration with thin liquids
-Should continue to wear CPAP at night for OSA, will need a
machine at home after [**Month/Year (2) **] from rehab
-Will follow-up with nephrology regarding his acute on chronic
kidney disease
-Will need his insulin titrated after [**Month/Year (2) **], PO intake has
been variable and he is on significantly less Lantus than at
admission
-monitor for serotonin syndrome given cymbalta/zoloft
combination
-Continued diuresis with measurement of I/Os and daily weights.
-Discussion about AICD.
-OT follow up to improve functioning of his hands.
Medications on Admission:
Zoloft 100 mg Tab Oral 1.5 Tablet(s) Once Daily, at bedtime
Lantus 70 units Solution(s) Twice Daily (every 12 hrs)
Nizoral 2 % Shampoo Topical 1application Shampoo(s) twice weekly
lisinopril 5 mg Tab Oral 1 Tablet(s) Once Daily
Cymbalta 60 mg Cap Oral 1 Capsule, (E.C.)(s) Once Daily, at
bedtime
Coreg 6.25 mg Tab Oral 1 Tablet(s) Once Daily
simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
Lasix 40 mg Tab Oral 1 Tablet(s) Once Daily
Novolin R 2-10 units Solution(s) sliding scale coverage
Spiriva Once Daily
Advair Diskus 250 mcg-50 mcg/dose Twice Daily
Zetia 10 mg Tab Oral 1 Tablet(s) Once Daily
Aldactone 25 mg Tab Oral 1 Tablet(s) Once Daily
Plavix 75 mg Tab Oral 1 Tablet(s) Once Daily
Neurontin 800 mg Tab Oral 1 Tablet(s) Three times daily
aspirin 81 mg Tab Oral 1 Tablet(s) Once Daily
Vitamin D -- Unknown Strength 1 tab Capsule(s) Once Daily
One Daily Multivitamin Tab Oral 1 Tablet(s) Once Daily
omeprazole 20 mg Tab Twice Daily
folic acid 1 mg Tab Oral 1 Tablet(s) Once Daily
Unisom 25 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
[**Month/Year (2) **] Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain: Not to exceed 4000mg per
day.
3. albuterol sulfate 1.25 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation every 4-6 hours as needed for
shortness of breath or wheezing.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. ezetimibe 10 mg Tablet Sig: One (1) Tablet 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. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection three times a day: Need for ongoing DVT
prophylaxis to be re-assessed by rehab physicians.
13. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous twice a day.
14. insulin lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous three times a day: 151-200 = 2 units
201-250 = 4 units
251-300 = 6 units
301-350 = 8 units
351-400 = 10 units
>400 = [**Name8 (MD) 138**] MD.
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
17. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
18. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
19. multivitamin Tablet Sig: One (1) Tablet PO once a day.
20. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
21. Vitamin D-3 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
22. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
23. acetazolamide 250 mg Tablet Sig: One (1) Tablet PO twice a
day.
24. Outpatient Lab Work
Weekly chem-10 at rehab
[**Name8 (MD) **] Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
[**Location (un) **] Diagnosis:
Primary diagnoses:
Multifocal pneumonia
Respiratory failure
Acute on chronic systolic heart failure
Acute kidney injury
Secondary diagnoses:
Type 2 diabetes
Hyperlipidemia
COPD
Depression
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
Dear Mr. [**Known lastname 91050**],
It was a pleasure taking care of you during your admission to
[**Hospital1 18**] for pneumonia, CHF and kidney failure. You initially
presented after being found unresponsive. Your blood sugar was
low and you were given sugar. It was also found that you had a
severe pneumonia and you were treated with antibiotics. You
were also on a ventilator. Because of the infection and sepsis,
your blood pressure was low and you required pressors to
maintain your blood pressure. During this time when your blood
pressure was low, your kidneys were injured and you temprarily
required dialysis. Your kidney function has not returned to
[**Location 213**] and you will see a kidney doctor [**First Name (Titles) **] [**Last Name (Titles) **].
You will be discharged to a rehab facility to get your strength
back. You will follow-up with the kidney doctors as [**Name5 (PTitle) **] as
your PCP.
The following changes were made to your medications:
START acetazolomide 250mg by mouth twice daily
START calcium acetate 1334mg by mouth three times daily with
meals
START albuterol 1 nebulizer inhaled every 4-6 hours as needed
for wheezing or shortness of breath
CHANGE insulin glargine 25 units subcutaneous twice daily
CHANGE gabapentin 300mg by mouth twice daily
CHANGE Lasix 80mg by mouth twice daily
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2183-12-2**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"414.01",
"348.1",
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"276.3",
"286.9",
"305.1",
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"584.5",
"278.00",
"428.0",
"496",
"285.9",
"263.0",
"250.82",
"995.92",
"530.81",
"428.23",
"707.13",
"348.31",
"038.9",
"V49.75",
"V49.87",
"272.4",
"276.2",
"V58.67",
"507.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"96.6",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5978, 12140
|
310, 419
|
2886, 5955
|
17450, 17813
|
1985, 2003
|
12166, 15646
|
2043, 2867
|
15819, 15868
|
15678, 15798
|
252, 272
|
15900, 15900
|
16087, 17427
|
447, 1818
|
15915, 16052
|
1840, 1895
|
1911, 1969
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,133
| 156,426
|
42542
|
Discharge summary
|
report
|
Admission Date: [**2156-3-19**] Discharge Date: [**2156-3-26**]
Date of Birth: [**2093-9-7**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Ampullary mass
Major Surgical or Invasive Procedure:
[**2156-3-19**]:
1. Pyloric-preserving pancreaticoduodenectomy.
2. Placement of fiducials.
History of Present Illness:
The patient is a delightful 62 year-old gentleman who, despite
feeling well, recently became jaundiced. His jaundice prompted
evaluation with CT and ERCP. He underwent placement of a plastic
stent and biopsy of the ampullary mass,
which he reported to me was consistent with cancer. The patient
was referred to Dr. [**First Name (STitle) **] for surgical evaluation. He CT was
reviewed and demonstrates a sizeable
ampullary mass, without evidence of vascular or distant
metastases. Dr. [**First Name (STitle) **] discussed with the patient possible Whipple
procedure. Aftre all risks, benefits and possible outcomes were
explained the patient, he was scheduled for elective Whipple
resection on [**2156-3-19**].
Past Medical History:
GERD, coronary artery disease (stented x2, most recently with
DES, no current angina), hypertension, high cholesterol.
Social History:
He has a 60 pack-year smoking history, but has since quit. He
drinks alcohol rarely.
Family History:
Mother (dementia), father (lung cancer), brother (congenital GI
disease). No family history of any GI/pancreatic malignancy.
Physical Exam:
On Discharge:
VS: 98.0, 80, 124/71, 14, 93% RA
GEN: NAD
CV; RRR, no m/r/g
ABD: Obese, soft, NT/ND. Bilateral subcostal incision open to
air with staples and c/d/i. RLQ old JP site with occlusive
dressing and c/d/i.
Extr: Warm, no c/c/e
Pertinent Results:
[**2156-3-19**] 08:00PM BLOOD WBC-13.0*# RBC-2.31*# Hgb-7.4*#
Hct-21.0*# MCV-91 MCH-31.8 MCHC-35.0 RDW-13.8 Plt Ct-186
[**2156-3-25**] 07:08PM BLOOD Hct-28.5*
[**2156-3-23**] 06:05AM BLOOD Glucose-123* UreaN-14 Creat-0.9 Na-146*
K-3.7 Cl-111* HCO3-29 AnGap-10
[**2156-3-23**] 06:05AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.3
[**2156-3-25**] 07:08PM ASCITES Amylase-6
[**2156-3-20**] EKG:
Normal sinus rhythm. Left axis deviation consistent with left
anterior
hemiblock. Right bundle-branch block.
[**2156-3-21**] ABD CT:
IMPRESSION:
1. Status post Whipple procedure with expected post-surgical
changes. No
evidence of intra-peritoneal or retro-peritoneal hemorrhage.
Please note
study is not timed to assess for GI bleed.
2. Bilateral pleural effusions with adjacent compressive
atelectasis.
3. Mild edema within the wall of the ascending colon, which is
not clearly
identified on the prior study. This may represent an
inflammatory or
infectious process.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 92061**],[**Known firstname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 3947**] [**2093-9-7**] 62 Male [**Numeric Identifier 92062**]
[**Numeric Identifier 92063**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **]. SCHMOLZE/mtd
SPECIMEN SUBMITTED: Metal Stent, Jejunum, Distal Duodenum and
Diverticulum, Whipple Specimen, Ciliac Node, bile duct content.
Procedure date Tissue received Report Date Diagnosed
by
[**2156-3-19**] [**2156-3-19**] [**2156-3-24**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl
DIAGNOSIS:
1. Pancreas, bile duct, and duodenum, Whipple resection (A-Q):
- Ampullary adenocarcinoma, moderately differentiated; see
synoptic report.
- Six of fifteen lymph nodes involved by metastatic carcinoma
([**7-9**]).
2. Metal stent: For gross examination only.
3. Jejunum, resection (R-T): Segment of small intestine,
within normal limits.
4. Distal duodenum, resection (U-V): Segment of small
intestine, within normal limits.
5. Lymph node, celiac, excision (W): One lymph node with no
malignancy identified (0/1).
6. Bile duct content (X): Bile.
AMPULLA OF VATER Ampullectomy, Pancreaticoduodenectomy (Whipple
Resection) Synopsis
Staging according to American Joint Committee on Cancer Staging
Manual -- 7th Edition, [**2153**]
MACROSCOPIC
Specimen Type: Pancreaticoduodenectomy (Whipple resection).
Other Organs Received: Duodenum, Common bile duct, Jejunum.
Tumor Site: Intra-ampullary, peri-ampullary, papilla of Vater
(junction of ampullary and duodenal mucosa), duodenal wall and
pancreas.
Tumor Size: Greatest dimension: 3 cm. Additional dimensions: 2
cm x 2 cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma (not otherwise characterized).
Histologic Grade: G2: Moderately differentiated.
MICROSCOPIC EXTENSION
Primary Tumor (pT): pT4: Tumor invades peripancreatic soft
tissues or other adjacent organs or structures.
Regional Lymph Nodes (pN): pN1: Regional lymph node
metastasis.
Lymph Nodes
Number examined: 16.
Number involved: 6.
Distant metastasis: pMX: Cannot be assessed.
MARGINS
Pancreaticoduodenal Resection Specimen:
Proximal Mucosal Margin (Gastric or Duodenal): Uninvolved by
invasive carcinoma.
Distal Margin (Distal Duodenal or Jejunal): Uninvolved by
invasive carcinoma.
Pancreatic Retroperitoneal (Uncinate) Margin: Uninvolved by
invasive carcinoma.
Bile Duct Margin: Margin uninvolved by invasive carcinoma.
Distal Pancreatic Resection Margin: Margin uninvolved by
invasive carcinoma.
Distance from closest margin: 1.5 mm.
Specified margin: Retroperitoneal.
Lymphovascular Invasion: Present.
Perineural Invasion: Present.
Additional Pathologic Findings: Dysplasia/adenoma of ampullary
mucosa; Pancreatic Intraepithelial Neoplasia I.
Clinical: Periampullary mass.
Brief Hospital Course:
The patient with newly diagnosed ampullary mass was admitted to
the Pancreaticobiliary Surgical Service on [**2156-3-19**] for elective
Whipple. On [**2156-3-19**], the patient underwent pylorus-preserving
pancreaticoduodenectomy (Whipple) and placement of fiducials,
during case large, old hematoma, found in duodenum at previous
stent site. Patient received 3 units of pRBC for postop HCT of
21. (Subsequently pt reported preoperative rectal bleeding.)
Post transfusion HCT was 23.9. Post operatively patient was
given another 4 units of pRBC (total 7) and transferred in ICU
for observation on POD # 1. In ICU patient was stable, he was
weaned off pressors and his HCT remained low stable 25-26.
Abdominal CT scan was negative for evidence of bleeding, and
patient was transferred to the floor in stable condition. His
post op recovery was followed the Whipple Clinical Pathway.
Post-operative pain was initially well controlled with epidural,
which was converted to oral pain medication when tolerating
clear liquids. The NG tube was discontinued on POD#3, and the
foley catheter discontinued at midnight of POD#4. The patient
subsequently voided without problem. The patient was started on
sips of clears on POD#4, which was progressively advanced as
tolerated to a regular diet by POD#7. JP amylase was sent in
the evening of POD#6; the JP was discontinued on POD#7 as the
output and amylase level were low.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated.
At the time of discharge on [**2156-3-26**], the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. His HCT was 28.5 and
patient was recommended to follow up with his PCP to recheck
HCT. Staples will be removed during his clinic appointment on
[**2156-3-31**]. The patient was discharged home without services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
aspirin 81', gemfibrozil 600', zantac, atenolol 75', zocor 40'
Discharge Medications:
1. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
6. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Locally advanced ampullary adenocarcinoma, moderately
differentiated.
2. Upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-3**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
You will have follow up appointment on [**3-31**] in Dr.[**Name (NI) 5067**]
clinic at [**Location (un) 620**] for staples removal. Dr.[**Name (NI) 5067**] office will
contact you with time of the appointment and other instructions.
.
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2156-4-7**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 2998**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Please follow up with Dr. [**Last Name (STitle) **] (PCP) in [**2-27**] weeks after
discharge
Completed by:[**2156-3-26**]
|
[
"414.01",
"458.29",
"562.02",
"V45.82",
"156.2",
"530.81",
"272.0",
"401.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.7"
] |
icd9pcs
|
[
[
[]
]
] |
9046, 9052
|
5841, 8228
|
317, 410
|
9187, 9187
|
1812, 5818
|
10444, 11136
|
1414, 1541
|
8342, 9023
|
9073, 9166
|
8255, 8319
|
9338, 9916
|
9931, 10421
|
1556, 1556
|
1570, 1793
|
263, 279
|
438, 1152
|
9202, 9314
|
1174, 1295
|
1311, 1398
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,555
| 194,577
|
41809
|
Discharge summary
|
report
|
Admission Date: [**2144-8-9**] Discharge Date: [**2144-9-3**]
Date of Birth: [**2110-8-5**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
victim of multiple gunshot wounds
Major Surgical or Invasive Procedure:
[**2144-8-9**]:
Exploratory laparotomy :
Compartment releases of left lower extremity (lateral,
anterior, posterior, and deep posterior).
Application of negative pressure dressing, left lower
extremity.
Irrigation and debridement of multiple open wounds, left
lower extremity.
Compartment release of right thigh anterior and
posterior compartments
[**2144-8-26**]: OR
PROCEDURES:
1. Irrigation and debridement of skin, subcutaneous tissue,
fascia, muscle and bone.
2. Complex closure of right thigh wound.
3. Complex closure of left medial leg wound.
4. Split-thickness skin graft of left lateral leg wound (5
x 18 cm).
5. Exploration of left deep peroneal nerve
History of Present Illness:
The patient is an unidentified male who
is likely in his 30's Spanish-speaking male who was shot
multiple
times prior to being brought by EMS to the trauma bay here.
Initial trauma evaluation revealed him to be tachycardic with
multiple gunshot wounds, including one to his left posterior
flank. Some of the wounds were actively oozing.
FAST examination at the time of initial evaluation was positive,
and he became acutely hypotensive with systolic pressure in the
70s, despite fluid boluses and eventual transfusion. Given the
distribution of gun shot wounds, hypotension, and FAST
examination, exploratory laparotomy was warranted in an emergent
fashion, and as such consent was waived for the procedure.
Past Medical History:
PMH: none
PSH: none prior to current admission
Social History:
Unknown
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION upon admission: [**2144-8-9**]
HR: 134 BP: 115/70 Resp: 21 O(2)Sat: 100 Normal
Constitutional: uncomfortable, in pain, GCS 14
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact; nares normal,
TM intact, no hemotympanum
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Tachycardic Rate and Rhythm, Normal first
and second heart sounds
Abdominal: Soft, Nontender, Nondistended; FAST equivocal,
abnormal LUQ
Pelvic: pelvis stable
Rectal: no gross blood
Extr/Back: R posterior thigh with wound, R thigh swelling,
tournequet applied; numerous GSW to back, L and R buttock,
midline spine in mid back and above anus, anterior and
posterior thigh on L and R, L flank
pulses intact bilateral LE
Neuro: moving all extremities
Psych: awake, alert, in pain
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2144-8-29**] 05:40 5.9 2.94* 8.6* 25.8* 88 29.4 33.5 14.9 454*
[**2144-8-24**] 06:55AM BLOOD WBC-6.8 RBC-3.04* Hgb-9.1* Hct-26.9*
MCV-89 MCH-29.9 MCHC-33.8 RDW-15.1 Plt Ct-457*
[**2144-8-23**] 06:10AM BLOOD WBC-7.4 RBC-2.97* Hgb-9.0* Hct-25.8*
MCV-87 MCH-30.2 MCHC-34.7 RDW-15.4 Plt Ct-484*
[**2144-8-22**] 12:45PM BLOOD WBC-9.2 RBC-2.91* Hgb-8.8* Hct-25.7*
MCV-88 MCH-30.4 MCHC-34.4 RDW-15.4 Plt Ct-470*
[**2144-8-17**] 01:35PM BLOOD WBC-23.3*# RBC-3.73* Hgb-11.6* Hct-32.6*
MCV-87 MCH-31.0 MCHC-35.5* RDW-15.7* Plt Ct-564*#
[**2144-8-9**] 06:03PM BLOOD Hct-26.2*
[**2144-8-9**] 07:50AM BLOOD WBC-21.0*# RBC-4.22* Hgb-12.6* Hct-36.6*
MCV-87 MCH-30.0 MCHC-34.5 RDW-15.3 Plt Ct-215
[**2144-8-9**] 04:30AM BLOOD WBC-8.9 RBC-4.36* Hgb-13.2* Hct-38.3*
MCV-88 MCH-30.2 MCHC-34.4 RDW-15.0 Plt Ct-264
[**2144-8-22**] 12:45PM BLOOD Neuts-78.6* Lymphs-13.5* Monos-4.5
Eos-3.0 Baso-0.5
[**2144-8-19**] 03:59AM BLOOD Neuts-79* Bands-0 Lymphs-17* Monos-1*
Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2144-8-25**] 06:10AM BLOOD PTT-52.3*
[**2144-8-25**] 12:16AM BLOOD PTT-44.3*
[**2144-8-24**] 05:35PM BLOOD PTT-22.8
[**2144-8-24**] 12:35AM BLOOD PTT-63.7*
[**2144-8-22**] 12:45PM BLOOD Plt Ct-470*
[**2144-8-22**] 06:30AM BLOOD Plt Ct-484*
[**2144-8-22**] 06:30AM BLOOD PTT-74.2*
[**2144-8-14**] 01:30AM BLOOD PT-11.7 PTT-22.1 INR(PT)-1.0
[**2144-8-13**] 01:29AM BLOOD PT-11.7 PTT-23.7 INR(PT)-1.0
[**2144-8-9**] 04:30AM BLOOD PT-12.4 PTT-20.2* INR(PT)-1.0
[**2144-8-9**] 05:15AM BLOOD Fibrino-115*
[**2144-8-9**] 04:30AM BLOOD Fibrino-203
[**2144-8-24**] 06:55AM BLOOD Glucose-95 UreaN-19 Creat-1.2 Na-139
K-4.2 Cl-105 HCO3-23 AnGap-15
[**2144-8-23**] 06:10AM BLOOD Glucose-92 UreaN-19 Creat-1.5* Na-138
K-4.5 Cl-104 HCO3-26 AnGap-13
[**2144-8-22**] 12:45PM BLOOD Glucose-116* UreaN-25* Creat-1.9* Na-136
K-4.1 Cl-103 HCO3-23 AnGap-14
[**2144-8-22**] 06:30AM BLOOD Glucose-94 UreaN-27* Creat-2.4*# Na-140
K-4.1 Cl-106 HCO3-24 AnGap-14
[**2144-8-9**] 07:50AM BLOOD Glucose-131* UreaN-12 Creat-0.8 Na-137
K-5.1 Cl-111* HCO3-19* AnGap-12
[**2144-8-9**] 04:30AM BLOOD UreaN-13 Creat-1.3*
[**2144-8-14**] 01:30AM BLOOD CK(CPK)-1345*
[**2144-8-13**] 01:29AM BLOOD CK(CPK)-2132*
[**2144-8-11**] 01:35AM BLOOD CK(CPK)-4651*
[**2144-8-24**] 06:55AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.3
[**2144-8-23**] 06:10AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.5
[**2144-8-22**] 12:45PM BLOOD Calcium-8.4 Phos-4.2 Mg-2.6
[**2144-8-23**] 06:10AM BLOOD Osmolal-287
[**2144-8-22**] 07:25PM BLOOD Vanco-17.6
[**2144-8-14**] 07:07AM BLOOD Vanco-11.4
[**2144-8-9**] 04:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-8-13**] 09:33PM BLOOD Type-ART pO2-87 pCO2-38 pH-7.50*
calTCO2-31* Base XS-5
[**2144-8-12**] 01:35AM BLOOD Type-ART pO2-108* pCO2-49* pH-7.41
calTCO2-32* Base XS-4
[**2144-8-11**] 02:08PM BLOOD Type-ART pO2-146* pCO2-44 pH-7.39
calTCO2-28 Base XS-1
[**2144-8-9**] 08:07AM BLOOD Type-ART Temp-36.0 Tidal V-450 PEEP-5
pO2-198* pCO2-42 pH-7.27* calTCO2-20* Base XS--7 -ASSIST/CON
Intubat-INTUBATED
[**2144-8-9**] 05:47AM BLOOD Type-ART Temp-36 Rates-14/ Tidal V-750
FiO2-80 pO2-69* pCO2-39 pH-7.31* calTCO2-21 Base XS--6 AADO2-466
REQ O2-79 Intubat-INTUBATED Vent-CONTROLLED
[**2144-8-9**] 05:18AM BLOOD Type-ART pO2-151* pCO2-51* pH-7.22*
calTCO2-22 Base XS--7 Intubat-INTUBATED Vent-CONTROLLED
[**2144-8-9**] 04:49AM BLOOD pO2-34* pCO2-58* pH-7.19* calTCO2-23 Base
XS--7 Comment-GREEN TOP
[**2144-8-18**] 03:10AM BLOOD Lactate-2.0
[**2144-8-9**] 05:47AM BLOOD Glucose-138* Lactate-3.1* Na-137 K-3.9
Cl-113*
[**2144-8-9**] 05:18AM BLOOD Glucose-144* Lactate-4.3* Na-137 K-3.9
Cl-111
[**2144-8-9**] 04:49AM BLOOD Glucose-194* Lactate-6.8* Na-141 K-3.2*
Cl-103
[**2144-8-9**] 05:47AM BLOOD Hgb-11.2* calcHCT-34 O2 Sat-93
[**2144-8-12**] 01:35AM BLOOD freeCa-1.10*
[**2144-8-11**] 02:08PM BLOOD freeCa-1.01*
[**2144-8-9**]: chest x-ray:
IMPRESSION: No acute cardiothoracic process on chest x-ray.
[**2144-8-9**]: CTA chest:
Comminuted left proximal fibula fracture with osseous and
bullet fragments with no opacification of the left peroneal
artery, posterior tibialis artery and anterior tibialis artery
distally and without reconstitution of flow. The expected course
of the peroneal and posterior tibialis arteries lies along the
fracture and bullet fragments and vascular injury cannot be
excluded.
Compartment syndrome is also of particular concern. A fasciotomy
was
subsequently performed.
2. Bullet fragments in the left lower lobe without evidence of
pneumothorax.
3. Bibasilar lung opacities.
4. Comminuted left greater trochanteric fracture with adjacent
bullet
fragments.
5. Post-surgical findings following exploratory laporotomy.
[**2144-8-12**]: EKG:
Sinus tachycardia, rate 140. Minor ST-T wave abnormalities
likely due to heart rate. No previous tracing available for
comparison.
[**2144-8-17**]: Chest x-ray:
FINDINGS: As compared to the previous radiograph, the right
central venous access line has been removed. There is mild
decrease in extent of the pre-existing signs suggesting
pulmonary edema. Unchanged cardiomegaly at low lung volumes.
Mild retrocardiac atelectasis but no evidence of pneumonia.
[**2144-8-18**]: cat scan of abdomen and pelvis:
IMPRESSION:
1. Comminuted fracture of the left greater trochanter (300B:84)
with adjacent bullet fragments.
2. Resolution of pneumoperitoneum since [**2144-8-9**].
3. Bibasilar atelectasis is improved since [**2144-8-9**].
4. Fat stranding along the ventral abdominal wall incision
extending into the anterior peritoneal fat appears increased
since [**2144-8-9**] and may indicate post surgical changes versus
infectious process. There is no evidence of associated focal
fluid collections.
5. Clot is seen within the right common femoral vein, new since
the prior
examination.
[**2144-8-10**]:
[**2144-8-10**] 3:33 am BLOOD CULTURE Source: Line-arterial.
**FINAL REPORT [**2144-8-16**]**
Blood Culture, Routine (Final [**2144-8-16**]):
BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final [**2144-8-10**]):
Reported to and read back by [**Last Name (un) **] [**Doctor Last Name 12729**] @ 1855 [**2144-8-10**].
GRAM POSITIVE ROD(S) CONSISTENT WITH CLOSTRIDIUM OR
BACILLUS SPECIES.
[**2144-8-10**] 2:30 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2144-8-12**]**
GRAM STAIN (Final [**2144-8-10**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2144-8-12**]):
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
[**2144-8-18**] 5:39 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2144-8-24**]**
Blood Culture, Routine (Final [**2144-8-24**]): NO GROWTH.
[**2144-8-26**] 9:28 pm BLOOD CULTURE
**FINAL REPORT [**2144-9-1**]**
Blood Culture, Routine (Final [**2144-9-1**]): NO GROWTH
[**2144-8-26**] 11:48 pm URINE Source: CVS.
**FINAL REPORT [**2144-8-29**]**
URINE CULTURE (Final [**2144-8-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION
[**2144-8-27**] 6:50 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
Brief Hospital Course:
34 year old gentleman brought intubated from scene after
sustaining multiple GSWs immediately prior to arrival. On
arrival, patient was found to be hemodynamically stable and was
noted to have approximately 12 entry/exit wounds involving the
back (thorax and lumbar region)and lower extremities. During
secondary survey, patient became hypotensive and was immediately
brought to the operating room for exploratory laparotomy. By
report, laparotomy revealed no abdominal visceral injury and no
evidence of intraperitoneal or retroperitoneal hematoma. During
the procedure, he was given 3 units of PRBCs and approximately 5
L of crystalloid. Despite this resuscitative effort, he remained
hypotensive and phenylephrine drip was started. His abdomen was
closed and given his lower extremity penetrating trauma, he was
brought immediately to CT for a CTA C/A/P with LE runoff. While
this study revealed no majory thoracic or abdominal vascular
injury, it did demonstrate likely vascular injury with lack of
opacification distal to the knee. He was admitted to the TSICU
for further monitoring.
Neuro: He was initally intubated and sedated. Once his sedation
was weaned, he experienced episodes of delerium, associated with
dilaudid dosing, and was changed to oxycodone. When not
delirious, he had episodes of anxiety related to his shooting,
for which both social work and psychiatry were consulted. He was
started on seroquel for his delirium.
CV: He had issues with sinus tachycardia while in the ICU,
possibly related to anxiety. He was started on a beta-blocker
with improvement in his heart rate.
Pulm: He was kept intubated post-operatively and weaned from the
vent on [**8-12**]. His pulmonary status was routinely monitored and
did not require intervention.
FEN/GI: He was kept NPO/IVF after his ex-lap and lower extremity
surgeries. Once extubated and awake, he was started on a clear
liquid diet and advanced as tolerated.
GU: A foley catheter was placed in the ED, and was kept in place
for urine output monitoring in the ICU.
Heme: His hematocrit was 38.3 on admission, and dropped to a
nadir of 22.6. He was transfused PRBC's when appropriate, and
his hematocrit responded appropriately.
ID: Two blood cultures drawn in the ED grew gram-positive rods,
for which he was treated with vancomycin. A sputum culture grew
GNR's and was treated with zosyn.
He was transferred to the surgical floor on [**2144-8-14**]:
He continued to have episodes of delirium and visual
halllucinations. A Spanish interpreter was sought for
re-orientation to his surroundings. A psychiatrist and social
worker were also consulted. Plastic surgery was consulted
regarding closure of the fasciotomies of his lower extremities.
Vac dressing changes to lower extremities continued every 3 days
by Orthopedics. As his health status gradually progressed,
physical and occupational therapy was consulted regarding his
mobility and recommendations made for ambulating.
His vancomycin and zosyn were discontinued on HD #8. At this
time, he became increasingly agitated, refusing to take his
anti-psychotic medications. Security and psychiatry were
notified and restraints applied. Because there was concern for
evolving sepsis, he was transferred back to the intensive care
unit on HD #9. At the same time, he was found to have an
elevated white blood cell count and fever. He resumed the
vancomycin and zosyn. He underwent a cat scan of his abdomen
which was negative for an abdominal abscess, but did show a
right femoral vein DVT for which he was started on lovenox. His
anti-coagulation regimen was changed to heparin infusion per
Plastic surgery in anticipation of his upcoming wound closure.
His agitation and delirium gradually resolved on zyprexa and
seroquel and on HD #11 he returned to the surgical floor.
His vancomycin and zosyn were discontinued on HD #16. His white
blood cell count normalized and his fever abated. His heparin
infusion was discontinued on HD #17 in preparation for his
return to the operating room for skin grafts to his lower
extremities.
He was taken to the operating room on HD #17 for complex closure
of right thigh wound and left leg wound, split-thickness skin
graft of left lateral leg wound, and exploration of left
peroneal nerve. The operative course was stable with minimal
blood loss. The peroneal nerve was found to be intact. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**]
drain and vac dressing were applied to the left leg during the
operative procedure. Both the vac and [**Doctor Last Name **] drain were
discontinued on HD #22. His post-operative course was
uneventful. His heparin infusion continued along with daily
dosing of coumadin. His heparin infusion was discontinued on
[**8-31**] when his INR reached 1.7 and he has been on daily coumadin
dosing. He has been evaluated by physical therapy and cleared
for discharge home. He is preparing for discharge to his
uncle's after dressings changes have been reviewed with the
family. He has instructions to follow up with Plastic Surgery,
the acute care service, orthopedics and with the coumadin
clinic. He has been assigned a health care provider in [**Name9 (PRE) 191**] and
will follow up in the coumadin clinic.
[**2144-9-3**]: PT=25.4, INR=2.4
Coumadin 5 mg given prior to discharge [**2144-9-3**]....discussed with
providers in coumadin clinic. Given script for 5mg tablets (
which were split by nurse to 2.5 mg)
Medications on Admission:
none
Discharge Medications:
1. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day) as needed for dry eyes.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation .
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
5. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q
8H (Every 8 Hours).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: may cause increased sedation.
Disp:*20 Tablet(s)* Refills:*0*
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for dyspepsia.
8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for pruritis.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gms PO DAILY (Daily) as needed for constipation.
10. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, fevers.
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
12. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*20 Tablet(s)* Refills:*0*
13. coumadin 5 mg tablet s po........dosing as per coumadin
clinic #5......no refills ( tablets have been split)
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: multiple gun-shot wounds: GSW back, L of midline
GSW above sacrum
GSW L flank
GSW R buttock
GSW L medial thigh
comminuted left fibular fracture
bilateral fasciotomies
exploratory laparotomy
R LLE close,LLE musto5cmfibbreak,LLElatSTSG,VAC dressing
Left common peroneal nerve neuropathy
femoral DVT
LLL bullet frat (no PTX)
b/l lung contusions
Discharge Condition:
Spanish speaking:
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 after you received multiple
gun shot wounds to your back and lower extremities. You were
taken to the operating room for an exploratory lapartomy and
incisons were made to release the swelling in the right thigh.
You were monitored in the intensive care unit after your
procedure. After your vital signs stabilized, you were
transferred to the surgical floor. You returned to the operating
room where you had skin grafts to the left leg and placement of
a vac dressing. The vac dressing was removed and you are now
having dressing changes to your left leg. Your vital signs have
stablized and you are now preparing for discharge to a relatives
home where you can further regain your strength and mobility.
Dress your skin graft sites with xeroform daily. DO NOT SCRUB
them while in the shower. Take great care to ensure that
nothing rubs on the grafts as they are quite fragile. Skin
graft donor site open to air. Please cover donor site and left
lower extremity in plastic when you shower.
Please apply small xeroform gauze to wounds on back and lower
extremities and cover with dressing daily
Please report the following:
*increased reddness from wound sites
*increased drainage frm wound sites
*fever
*chills
*abdominal pain
*increasing size of abdomen
*drainage from abdominal wound
*opening of abdominal wound
*increased pain in right leg
*inability to move toes right foot
*numbness toes right foot
*any new symptom that concerns you
Followup Instructions:
Please follow up with the acute care service in 2 weeks. You
can schedule this appointment 24 hours after discharge by
calling # [**Telephone/Fax (1) 600**].
Please call ([**Telephone/Fax (1) 36264**] for a follow up appointment in one
week with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] (plastic surgery).
Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3535**] on [**9-3**] at 3:20 pm in the [**Hospital Ward Name 23**] building, [**Location (un) 453**]
atrium. The telphone number is # [**Telephone/Fax (1) 90799**]. Prior to your
appointment, you will need to have lab work done. Please report
to the [**Location (un) **] of the Sharpiro building for your lab work.
Please follow up with Dr.[**Name (NI) 8091**] nurse practitioner, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in 2 weeks. You can schedule your appointment by
calling # [**Telephone/Fax (1) 1228**].
Completed by:[**2144-9-3**]
|
[
"E922.9",
"E935.2",
"958.4",
"790.7",
"861.32",
"276.7",
"958.92",
"788.20",
"285.1",
"453.41",
"427.89",
"879.4",
"823.31",
"877.0",
"292.81",
"956.3",
"879.2",
"276.1",
"861.31",
"309.81",
"276.3",
"820.30",
"890.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"79.66",
"96.71",
"86.59",
"83.09",
"86.69",
"83.45",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17394, 17400
|
10364, 15830
|
333, 1015
|
17795, 17813
|
2756, 10294
|
19508, 20568
|
1865, 1869
|
15885, 17371
|
17421, 17774
|
15856, 15862
|
17996, 19485
|
1884, 1907
|
10341, 10341
|
260, 295
|
1044, 1754
|
1922, 2737
|
17828, 17972
|
1776, 1824
|
1840, 1849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,378
| 155,393
|
54388+54389+54390
|
Discharge summary
|
report+report+report
|
Admission Date: [**2157-3-29**] Discharge Date: [**2157-4-2**]
Date of Birth: [**2082-6-6**] Sex: M
Service:
NOTE: Dictation ended after 0.20 minutes.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 6284**]
MEDQUIST36
D: [**2157-4-5**] 11:44
T: [**2157-4-5**] 11:49
JOB#: [**Job Number 111337**]
Admission Date: [**2157-3-29**] Discharge Date: [**2157-4-2**]
Date of Birth: [**2082-6-6**] Sex: M
Service:
NOTE: Dictation ended after 0.59 minutes.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 6284**]
MEDQUIST36
D: [**2157-4-5**] 11:46
T: [**2157-4-5**] 11:50
JOB#: [**Job Number 111338**]
Admission Date: [**2157-3-29**] Discharge Date: [**2157-4-2**]
Date of Birth: [**2082-6-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 74-year-old male with
no known past medical history who presented with one week of
gait ataxia at an outside hospital concerning for
cerebrovascular accident. The patient was subsequently
scheduled for MRI later in the day.
In route to MRI appointment, the patient developed the
gradual onset of indigestion symptoms while drinking a
nonalcoholic beverage. He arrived to the MRI facility where
the symptoms resolved, and the patient developed the sudden
onset of severe aching back pain located between the shoulder
blades. He also reported associated shortness of breath,
chest pain, light-headedness and worsening gait.
Planned MRI was deferred due to new concern for an aortic
dissection. The patient was then transferred to the [**Hospital6 1760**] Emergency Room for further
evaluation.
PHYSICAL EXAMINATION: Vitals signs: In the [**Hospital6 1760**] Emergency Room, vital signs
were notable for a heart rate above 80, blood pressure 180/90
in both arms, no hypoxia. General: The patient appeared
uncomfortable due to pain. Lungs: Clear to auscultation
bilaterally. Heart: Regular without murmurs. Abdomen:
Soft, nontender, nondistended. No bruits. Neurological:
Notable for bilateral upgoing Babinski, otherwise nonfocal.
Extremities: Distal pulses nonpalpable bilaterally, but
detected by Doppler.
LABORATORY DATA: Chest x-ray showed no acute cardiopulmonary
process, and the mediastinum was within normal limits.
Subsequent CTA revealed a descending aortic dissection
originating just distal to the left subclavian artery
terminating proximal to the celiac artery. Of note, multiple
cavitary lesions were also noted on CTA in left lung.
Differential diagnosis included malignancy, vasculitis,
versus infectious process.
Electrocardiogram showed no evidence of acute changes, only
old Q-waves in the inferior leads.
Diagnosis of a type B aortic dissection was made, and the
patient was started on an Esmolol drip in the Emergency Room
for heart rate and blood pressure stabilization.
The patient was subsequently transferred to the floor and
switched to Labetalol drip and Captopril p.o. During the
[**Hospital 228**] hospital course, heart rate and blood pressure
stabilized with target heart rate in the 60s, systolic blood
pressure in the 120s.
The symptoms of back pain recurred on hospital day #3.
Repeat MRI was done to evaluate for worsening dissection;
however, MRI confirmed a thrombosed false lumen without
progression of the dissection. Radiology recommended repeat
CT or MRI in [**Doctor Last Name **] months to reevaluate dissection.
Pulmonary was consulted for pulmonary lesions found on CTA
who recommended no immediate intervention and repeat CT in
two months. On hospital day #5, the patient was
considered stable for discharge.
DISCHARGE DIAGNOSIS: Type B aortic dissection.
DISCHARGE MEDICATIONS: Zestril 40 q.d., Labetalol 300
t.i.d., Aspirin 325 q.d., Atorvastatin 10 q.d.
FOLLOW-UP: Repeat chest and abdominal CT in three months and
chest CT in two months.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-255
Dictated By:[**Last Name (NamePattern1) 111339**]
MEDQUIST36
D: [**2157-4-5**] 12:49
T: [**2157-4-5**] 13:03
JOB#: [**Job Number 111340**]
|
[
"412",
"V45.82",
"401.9",
"441.01",
"276.5",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
3904, 4300
|
3853, 3880
|
1868, 3831
|
1036, 1845
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,331
| 114,467
|
48244
|
Discharge summary
|
report
|
Admission Date: [**2125-4-4**] Discharge Date: [**2125-5-29**]
Date of Birth: [**2070-4-5**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
1) Bedside incision and drainage, right hand [**2125-4-4**]
2) Operative incision and drainage, right hand [**2125-4-12**]
3) Arthroscopic wash out, bilateral shoulders [**2125-5-11**]
4) Percutaneous pigtail drainage of mid thoracic paravertebral
abscess under radiographic guidance [**2125-4-18**]
5) Left PICC, placed [**2125-4-30**], repositioned [**2125-5-18**]
History of Present Illness:
54 F with Crohn's disease on prednisode and Remicade, receiving
TPN through a PICC, admitted to an outside hospital on [**4-3**]
with two weeks of right hand swelling, fevers, and chills. At
the OSH emergency department, she was ill-appearing,
hypotensive, and afebrile, with a leukocytosis to 22 with 15%
bandemia and 70% polys; her creatinine was 1.7. She was
admitted to the MICU at the OSH where she was given stress dose
steroids, empiric vancomycin and levofloxacin, 4L IVF, and blood
cultures drawn. An ultrasound guided drainage of the right hand
was performed, expressing a small amount of pus that was sent
for gram stain and culture; Gram stain showed 2+ gram positive
cocci. Four of four blood cultures grew gram positive cocci, as
well. She subsequently developed respiratory distress overnight
with an arterial blood gas of 7.2/14.5/95 and was intubated.
Chest X-ray at the OSH was consistent with ARDS vs volume
overload. An MRI of the right hand showed no definite fluid
collection.
.
An attempt at a right subclavian central catheter prior to
transport failed, and a right femoral line was placed instead.
She received versed and vecuronium and was transported to [**Hospital1 18**]
by [**Location (un) 7622**].
Past Medical History:
Crohn's, longstanding on remicade, 5mg prednisone
short bowel syndrome
TPN through PICC
Rheumatoid arthritis
Social History:
Lives at home with husband
[**Name (NI) **] EtOH, IVDA.
Family History:
non-contributory
Physical Exam:
100.9 130 104/53 31 100% on AC500X22 w/PEEP 8 and FIO2 1
Intubated, sedated
MMD, PERRL
RLL crackles, DTP
Tachy, I/VI HSM @ apex; site of multiple R subclav attempts
evident but clean
soft, nt, nd, +BS
WWP X 4; R hand swollen; R fem line c/d/i; multiple stick sites
evident
Not responding to commands, pain
Pertinent Results:
Admission laboratories:
[**2125-4-4**] 02:13PM BLOOD WBC-26.7* RBC-3.78* Hgb-11.0* Hct-32.8*
MCV-87 MCH-29.1 MCHC-33.5 RDW-15.2 Plt Ct-235
[**2125-4-4**] 02:13PM BLOOD Neuts-90.3* Bands-0 Lymphs-7.5*
Monos-1.7* Eos-0.1 Baso-0.4
.
[**2125-4-4**] 02:13PM BLOOD Glucose-151* UreaN-37* Creat-0.9 Na-143
K-3.6 Cl-116* HCO3-15* AnGap-16
[**2125-4-4**] 02:13PM BLOOD Albumin-2.2* Calcium-7.6* Phos-6.5*
Mg-1.6
.
[**2125-4-4**] 02:13PM BLOOD PT-14.0* PTT-42.1* INR(PT)-1.2*
[**2125-4-4**] 02:13PM BLOOD Fibrino-576* D-Dimer-8768*
.
[**2125-4-4**] 02:13PM BLOOD ALT-25 AST-55* LD(LDH)-257* CK(CPK)-175*
AlkPhos-276* TotBili-3.7*
.
[**2125-4-4**] 04:43PM BLOOD Type-ART Temp-38.3 pO2-75* pCO2-42
pH-7.06* calHCO3-13* Base XS--18 Intubat-INTUBATED
.
Discharge laboratories:
[**2125-5-28**] 05:00AM BLOOD WBC-8.5 RBC-3.26* Hgb-9.0* Hct-27.8*
MCV-85 MCH-27.8 MCHC-32.5 RDW-17.9* Plt Ct-521*
.
[**2125-5-29**] 05:17AM BLOOD Glucose-105 UreaN-26* Creat-0.7 Na-136
K-4.2 Cl-104 HCO3-23 AnGap-13
[**2125-5-29**] 05:17AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9
.
Other relevant laboratories:
[**2125-4-17**] 03:53AM BLOOD ESR-135*
[**2125-4-16**] 03:02AM BLOOD CRP-149.6*
.
[**2125-5-4**] 05:44AM BLOOD Cortsol-20.4*
.
Relevant Studies:
CHEST - PORTABLE AP ([**2125-4-16**]): Poorly defined nodular opacities
in right upper and left mid lung zones, concerning for septic
emboli or fungal infection.
.
CT CHEST W/CONTRAST ([**2125-4-16**]): The heart and great vessels are
unremarkable. A single right axillary lymph node measures 1 cm.
There are no other pathologically enlarged mediastinal lymph
nodes. The airways are patent bilaterally. There is a small
right pleural effusion with associated atelectatis. Lung windows
revea severe emphysematous changes. There are multiple
bilateral, scattered varying- sized rounded and irregular
non-cavitating focal pulmonary opacities, predominantly with a
peripheral location. In the left posterior paraspinal
musculature just deep to the trapezius muscle extending
inferiorly from the C1 level , there is a rim enhancing
multiloculated fluid collection concerning for abscess. In the
region of the lower thoracic spine there is an apparent
encapsulated prevertebral fluid collection adjacent to the right
pleural effusion, and with low but slightly higher [**Doctor Last Name **] density
than the free pleual effusion. No gas is present within this
effusion but The vertebral bodies at this level (probable T8.9
and 10) demonstrate a mixed sclerotic/ lytic pattern and
findings are concerning for osteomyelitis.
.
MR [**Name13 (STitle) **] T-SPINE W &W/O CONTRAST ([**2125-4-17**]): There are signs
of extensive osseous abnormality of the mid thoracic spine with
a prevertebral collection associated with bone and interspace
abnormality. This is most suspicious for infection and abscess
formation. There is also an adjacent pleural effusion, and
extension of an infectious process into this space should be
considered. An area suspicious for large abscess collection is
also identified in the subcutaneous musculature of the posterior
back extending from roughly C7, 8 cm inferiorly into the
thoracic region, to about T5. Abnormality at the C1-2 junction
is also identified and though this could represent degenerative
change, but infection cannot be excluded in this location.
.
TEE ([**2125-4-17**]): No spontaneous echo contrast is seen in the body
of the left atrium or right atrium. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function appears preserved (LVEF>55%), however transgastic views
were not obtained. Right ventricular systolic function also
appears preserved. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. No mitral valve abscess is seen.
Trivial mitral regurgitation is seen. There is no abscess of the
tricuspid valve. No vegetation/mass is seen on the pulmonic
valve.
.
CT OF THE CHEST WITH IV CONTRAST ([**2125-5-22**]): Pulmonary arteries
appear well opacified and there is no evidence of acute
pulmonary embolism. Heart and great vessels appear unremarkable.
Again seen are several mediastinal lymph nodes, however, none
appear to meet CT criteria for pathological enlargement. There
is no evidence of pathologically enlarged hilar or axillary
lymphadenopathy. There has been interval improvement of
previously seen small right-sided pleural effusion. Again seen
are diffuse emphysematous bullous changes bilaterally. Three
poorly-defined peripheral opacities are present in the right
lung. The opacity seen on series 3, image 39, does not appear
significantly changed from prior study. New linear/nodular
opacities seen on series 2, image 34, possibly represents
atelectasis. Also seen is a smaller irregular peripheral
opacity, best seen on series 3, image 55. Peripheral opacity in
the left lung (series 3, image 49) appears improved compared to
prior study. Again seen is a paraspinal abscess collection
anterior to the mid thoracic region. Small amount of fluid is
again seen, decreased compared to [**4-16**]. Compared to [**4-28**], the
fluid collection is likely not significantly changed to slightly
larger in size. Soft tissue inflammation is also seen in this
area. Again seen is destruction of the T7 through T9 vertebral
bodies.
.
CT OF THE ABDOMEN WITH IV CONTRAST ([**2125-5-22**]): The liver,
pancreas, spleen, adrenal glands, and kidneys appear unchanged.
The bile duct measures 9 mm, not changed from prior study. There
is no evidence of free fluid or free air within the abdomen.
Scattered mesenteric lymph nodes again seen, however, none
appear to meet CT criteria for pathologic enlargement.
.
CT OF THE PELVIS WITH IV CONTRAST ([**2125-5-22**]): The rectum and
sigmoid appear unremarkable. Small amount of air is noted within
the bladder, correlate with recent catheterization. Small area
of enhancement again noted within the left psoas muscle,
previously described as abscess, not significantly changed from
prior study.
.
BONE WINDOWS ([**2125-5-22**]): Again seen is destruction of the T7
through T9 vertebral bodies. Degenerative changes also again
noted within the spine, most notably at the L5 level.
.
Microbiology:
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- 1 I
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
Brief Hospital Course:
1) Sepsis/disseminated infection: Patient was transferred from
OSH for sepsis thought secondary to a hand infection. An initial
incision and drainage of the right hand abscess had been
performed at the OSH. Here, she was started on vancomycin with
gentamycin at synergistic dosing for gram positive cocci on
outside hospital cultures. She was aggressively resuscitated
with IV fluids, with Levophed for additional pressure support.
She received a course of Xigris and stress dose steroids. When
cultures showed MSSA on HD #2, vancomycin was changed to
nafcillin. Gentamycin was stopped after 5 days of synergistic
dosing. She was weaned off of pressor support by HD #4 and
remained hemodynamically stable thereafter, although she
remained intubated on mechanical ventilation to facilitate
operative debridement of her right hand osteomyelitis.
.
Although she subsequently remained hemodynamically stable, she
continued to be febrile. There was concern for line infection.
Her chronic PICC for home TPN was removed at the outside
hospital. Left and right internal jugular central catheters
placed since admission were removed, as well as her arterial
line. A new left subclavian catheter was placed. However, she
continued to remain febrile.
.
A transesophageal echocardiogram was performed, which showed no
evidence of endocarditis. A chest X-ray showed pulmonary
nodules, prompting a follow up CT of the chest. This showed
nodular opacities consistent with septic emboli. In addition, it
showed two fluid collections, one involving the vertebral bodies
of T8-T10, and another in the left paraspinal muscles extending
inferiorly from C7. A CT of the abdomen and pelvis showed a left
iliopsoas abscess.
.
The orthopaedic spine team was consulted, and an MRI of the
spine was obtained for further delineation of these lesions. The
MRI confirmed osteomyelitis of the T9 vertebra, and showed a
fluid collection abutting the spine in addition to a fluid
collection subcutaneously on the back. The orthopaedic spine
service recommended a conservative approach with CT guided
drainage of the paraspinal fluid collection. The infectious
diseases team agreed with a strategy of attempting to treat each
locus of infection discretely and attempt drainage. However at
this point, the infection appeared fairly disseminated and there
was some concern that the infection would be difficult to
eradicate. The pulmonary nodules were felt to not be accessible
by bronchoscopy, and not large enough for percutaneous drainage.
The left iliopsoas abscess was likewise felt not to be amenable
to drainage. These concerns were shared with the patient and the
family. The patient underwent successful CT guided drainage of
the superficial abscess on the back, in addition to the
paraspinal fluid collection (with a pigtail catheter left in
place for drainage).
.
She was called out to the floor where she continued to be
febrile. Plans were made for CT guided drainage of the
parascapular abscess. However, the scan showed no drainable
fluid in the parascapular region. The T8-T10 paraspinal fluid
collection was persistent, but slightly improved. Incidentally,
however, it showed bilateral shoulder effusion. Orthopaedics
performed a joint aspirate, which returned grossly cloudy fluid,
with 41k WBCs and a negative gram stain. She was taken to the
operating room for bilateral shoulder washouts, which she
tolerated well.
.
She subsequently defervesced, and was afebrile x 1 week prior to
discharge. She was discharged with plans for an indefinite
course of nafcillin.
.
2. Pain control: She was initially placed on a morphine PCA for
pain control, but had difficulty operating the PCA. She was
changed to a fentanyl patch with IV Dilaudid boluses for
breakthrough. IV Dilaudid was transitioned to PO Dilaudid prior
to discharge. On discharge, her pain was well controlled on 25
mcg/hr fentanyl patch with 8mg PO Dilaudid Q2h for breakthrough
pain.
.
3. Respiratory failure: The patient had developed respiratory
failure at the OSH and arrived on mechanical ventilation. This
was thought secondary to non-cardiogenic pulmonary edema in the
setting of sepsis. Her ventilator settings were weaned, and she
was clinically ready for extubation several days after
admission. However, she remained intubated for an additional [**12-11**]
days because of planned hand surgery by plastic surgery. She was
extubated successfully on the following day, although her
respiratory status remained tenuous. She was reintubated on [**4-17**]
for a TEE and again successfully extubated on [**4-17**] after the TEE.
Her respiratory status was stable through the remainder of her
course on the floor.
.
4. Crohns: She was given a short course of stress dose steroids
on arrival, as described above, and subsequently put on 4mg IV
Solu-Medrol QD. She was transitioned back to her home regimen of
prednisone 5 mg PO QD prior to discharge. She was maintained on
TPN throughout her hospitalization for short gut syndrome. It
was initially run by continuous infusion, but was transitioned
to a cycled regimen over 12 hours prior to discharge. Her Crohns
was otherwise stable, without any complaints of abdominal pain.
5. Cardiac: She had a mild troponin T leak ~ 0.7, with a peak
CK-MB of 95. This was felt to be demand related in the setting
of sepsis. An initial TTE showed a depressed EF. However, this
recovered on subsequent TEEs.
.
6. Anemia: Patient had a stable anemia with iron studies
consistent with chronic inflammation.
.
7. Tachycardia: Patient was noted to be persistently tachycardic
during hospitalization. This was confirmed to be sinus by ECG,
and thought most likely multifactorial from anxiety, pain, and
her hypermetabolic state from infection. In addition to
treatment of her underlying infection and pain control described
above, she was given anxiolytics as needed. CT was negative for
PE.
.
8. Acidosis/hyperkalemia: The patient was noted to have a
metabolic acidosis on admission. This corrected spontaneously
over the subsequent several days. However, as the acidosis
resolved, she developed a significant hypokalemia, with
potassium levels down to 2.4. There were no ECG changes.
Potassium was repleted aggressively over the following several
days, with subsequent resolution.
.
Prophylaxis: She received heparin in her TPN for DVT
prophylaxis.
.
Code status was confirmed to be full.
Medications on Admission:
remicaide
prednisone 5 mg
Discharge Medications:
1. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) gram
Intravenous Q4H (every 4 hours).
Disp:*2 week supply* Refills:*2*
2. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch Transdermal
Q72H (every 72 hours).
Disp:*10 Patch(s)* Refills:*0*
3. Hydromorphone 8 mg Tablet Sig: One (1) Tablet PO Q2-4h as
needed.
Disp:*100 Tablet(s)* Refills:*0*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
MSSA Sepsis
Septic pulmonary emboli
Left ileopsoas abscess
T9 paraspinal abscess with T7-9 vertebral osteomyelitis
- s/p percutaneous pigtail drain
Parascapular abscess
Right hand abscess
- s/p open irrigation and debridement
Crohns Disease
Discharge Condition:
Stable
Afebrile
Discharge Instructions:
1) Continue your medications as prescribed
- You were started on an antibiotic called naficillin for
multiple infections in your body. You need to continue this
until you have back surgery, and likely for 6 weeks afterwards.
2) Follow up as directed below.
3) Call if any of your wounds looks worse, has worsened redness
or pain, discharge, if you have chest pain, difficulty
breathing, nausea, fevers, chills, or any other concerns.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] (orthopaedics) for your shoulders on
[**2125-6-7**] at 10:00am
- Call [**Telephone/Fax (1) 1228**] if you have questions or need to
reschedule.
Follow up with Dr [**Last Name (STitle) **] (orthopaedic spine) [**2125-7-5**] at
11:00am
- His coordinator will try to get you an earlier appointment.
If possible, they will contact you at home.
- Call [**Telephone/Fax (1) 1228**] if you have questions or need to
reschedule.
Follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (ID) on [**2125-6-15**] at 9:00am.
- Call [**Telephone/Fax (1) 457**] if you have questions or need to
reschedule.
Follow up with Dr [**Last Name (STitle) 5385**] in Plastic Surgery Hand Clinic on
[**2125-6-5**] at 9am.
- Call [**Telephone/Fax (1) 5343**] if you have questions or need to
reschedule.
You asked to transfer your primary care here to the [**Hospital1 18**], and
were scheduled for an appointment with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital 191**]
clinic Atrium Suite on [**2125-6-26**] at 1:30pm
- You need to call your insurance company to change your listed
PCP.
[**Name Initial (NameIs) **] After you change your PCP, [**Name10 (NameIs) 138**] the clinic at [**Telephone/Fax (1) 250**] to
request referrals for the specialists listed above. You will
need these referrals before you see any of the specialists.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2125-5-30**]
|
[
"579.3",
"682.3",
"V58.65",
"682.2",
"584.9",
"285.29",
"518.5",
"682.4",
"569.81",
"567.31",
"720.9",
"730.04",
"711.01",
"730.08",
"V55.2",
"038.11",
"995.92",
"996.1",
"785.52",
"555.9",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.73",
"88.72",
"83.95",
"38.93",
"81.91",
"99.15",
"96.72",
"00.17",
"99.04",
"82.29",
"86.04",
"80.11",
"00.11"
] |
icd9pcs
|
[
[
[]
]
] |
16438, 16487
|
9212, 15586
|
286, 655
|
16774, 16792
|
2498, 9189
|
17277, 18837
|
2135, 2153
|
15662, 16415
|
16508, 16753
|
15612, 15639
|
16816, 17254
|
2168, 2479
|
240, 248
|
683, 1914
|
1936, 2046
|
2062, 2119
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,883
| 186,860
|
29324
|
Discharge summary
|
report
|
Admission Date: [**2181-12-21**] Discharge Date: [**2181-12-25**]
Date of Birth: [**2112-2-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest discomfort
Major Surgical or Invasive Procedure:
CABG X 5 (LIMA > LAD, SVG > Diag,OM1,OM2,PDA) on [**2181-12-21**]
History of Present Illness:
69 yo M with exertional symptoms, +ETT, referred for cardiac
cath which showed 3VD. Then referred for surgiocal evaluation.
Past Medical History:
arthritis
HTN
spondylosis
HOH
anemia
L TKR
appy
bilat cataract surgery
cranial surgery post MVA as a child
Social History:
retired office worker
quit cigar smoking3-4 years ago
[**2-5**] scotch/day
Family History:
NC
Physical Exam:
NAD HR 54 RR 20 BP 224/77
NAD
Lungs CTAB
RRR, no M.R.G
Abd benign, well healed appy scar
R groin s/p cath C/D/I
No carotid bruits
Pertinent Results:
[**2181-12-25**] 06:45AM BLOOD WBC-5.1 RBC-2.97* Hgb-10.2* Hct-28.5*
MCV-96 MCH-34.2* MCHC-35.7* RDW-12.9 Plt Ct-221
[**2181-12-25**] 06:45AM BLOOD Plt Ct-221
[**2181-12-21**] 03:07PM BLOOD PT-16.2* PTT-36.6* INR(PT)-1.5*
[**2181-12-25**] 06:45AM BLOOD Glucose-101 UreaN-9 Creat-0.7 Na-140
K-4.4 Cl-101 HCO3-30 AnGap-13
[**2181-12-23**] 05:08AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-133
K-5.0 Cl-102 HCO3-24 AnGap-12
Brief Hospital Course:
He was taken to the operating room on [**2181-12-21**] where he
underwent a CABG x 5. He was transferred to the SICU in critical
but stable condition.He was extubated and weaned from his
vasoactive drips later that day. He was transferred to the floor
on POD #1. He did well postoperatively, he had no problems with
arrhythmias and he was easily diuresed. He was discharged home
on POD #4.
Medications on Admission:
motrin, carisprodol, lisinopril, atenolol, apap, lipitor,
[**Last Name (LF) 4532**], [**First Name3 (LF) **], MVI, [**Doctor First Name 130**], isosorbide mononitrate.
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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(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*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. 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*
7. 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*
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Soma 350 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD
HTN
chronic low back pain
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no lifting > 10# for 10 weeks
no creams, lotions or powders to any incisions
Followup Instructions:
with Dr. [**Last Name (STitle) **] in [**5-9**] weeks
with Dr. [**Last Name (STitle) **] in [**3-9**] weeks
with Dr. [**Last Name (STitle) 17025**] in [**3-9**] weeks
Completed by:[**2181-12-26**]
|
[
"401.9",
"V43.65",
"724.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.14",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3300, 3355
|
1421, 1812
|
350, 418
|
3429, 3436
|
979, 1398
|
3608, 3807
|
809, 813
|
2030, 3277
|
3376, 3408
|
1838, 2007
|
3460, 3585
|
828, 960
|
283, 312
|
446, 571
|
593, 701
|
717, 793
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,457
| 192,627
|
1579
|
Discharge summary
|
report
|
Admission Date: [**2152-11-24**] Discharge Date: [**2152-11-28**]
Date of Birth: [**2085-5-14**] Sex: M
Service: NEUROSURGERY
Allergies:
House Dust
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Dizziness, blurred vision, sellar mass
Major Surgical or Invasive Procedure:
[**11-24**] Right Sided Craniotomy for Mass resection
History of Present Illness:
This a 67 years old right handed man with a past medical history
of CAD s/p CABG, A.fib, and subdural hematoma s/p a left
frontoparietal craniotomy who presented to the [**Hospital1 18**] Brain Tumor
Center for the evaluation of dizziness, blurred vision and a
mass
in the tuberculum sella. Patient reports a history of dizziness
and blurred vision which started about 3 months ago. Patient
described this dizziness as feeling unsteady when trying to
ambulate. He denies any vertigo, hearing loss or palpitation. He
associates this symptom as starting after he tried to lose
weight
by dieting. Symptoms happen in the midmornings and these
symptoms
tend to fluctuate.
He also reports blurred vision mainly in his right eye. He had
right eye surgery for cataract removal 3 years ago and now has
an
implant. He denies any blindness or diplopia. He also reports
headaches which are diffused. These headaches are transient and
last last about 5 minutes. The do not happen everyday. He saw
his
PCP who tried him on motion sickness medications with no
benefits. He then saw Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9192**], a neurologist [**2152-7-19**]
who ordered an MRI/brain [**2152-7-24**] which showed a mass in the
tuberculum of the sella.
Past Medical History:
1.Atrial fibrillation
2.Heart Disease s/p mechanical valve
3.COPD
4.GERD
5.CAD s/p CABG
6.Subdural Hematoma s/p left frontoparietal craniotomy
7.Right eye cataract s/p right eye implant.
8.Anxiety
Social History:
He is divorced. He is also retired as a high school teacher and
electrician. He smoked for 50 years and quite in [**2148**]. He denies
any alcohol or illicit drugs use.
Family History:
Mother had CAD and colon CA in her mid 70's. Father had COPD.
Physical Exam:
Temperature: 96.6 Blood pressure: 131/78 Pulse: 72 Respiration:
18 Oxygen saturation: 95%/RA.
Neurological Examination:
Patient is alert, awake and oriented times 3. His Karnofsky
Performance Score is 100. He is awake, alert, and oriented
times
3. There is no right/left confusion or finger agnosia. His
calculation ability is intact. His language is fluent with good
comprehension, naming, and repetition. Recent recall is intact.
Cranial Nerve Examination: His pupils are equal and reactive to
light, 4 mm to 2 mm bilaterally. Extraocular movements are
full.
Funduscopic examination reveals pale disk on the right eye and
sharp disk margin on the left. His face is symmetric. Facial
sensation is intact bilaterally. His hearing is intact
bilaterally. His tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: He does not have a drift. His muscle
strengths are [**6-8**] at all muscle groups. He has cogwheel
ridigity
on activation. His reflexes are +3 bilaterally. His toes are
downgoing. Sensory examination is intact to touch and
proprioception. Coordination examination does not reveal
dysmetria. His gait examination was normal.
On general examination, the oropharynx is clear, the
lungs are clear, the heart is regular. The legs are without
edema
or tenderness. Healed wound of the left leg with signs of tibia
fracture.
On Discharge:
A&Ox3
full motor
Pertinent Results:
[**11-24**] MRI Brain with and without contrast: IMPRESSION:
Presurgical planning evaluation for a homogeneously enhancing
mass arising from the planum sphenoidale as detailed above.
[**11-24**] CT head noncontrast: Postoperative changes in the form of
right frontal and temporal craniotomy and pneumocephalus in
bilateral frontal region and right temporal region. Mild
intraventricular hemorrhage in occipital horns of bilateral
lateral ventricles which is likely post operative.
[**11-25**] MRI BRain with and without contrast:
1. Post-surgical changes with right-sided craniotomy and an
extra-axial fluid collection, measuring approximately 1.8 cm
with displacement of the right frontal lobe and shift of the
midline structures towards the left side by 5 mm. Hemorrhagic
components are noted within the fluid collection related to the
recent procedure.
2. Interval resection of the previously noted tumor in the
sellar/suprasellar
regions with minimal enhancement along the dura likely related
to
post-surgical changes. Significant improvement in the previously
noted mass effect on the optic chiasm.
Brief Hospital Course:
Patient presented electively on [**11-24**] for a right sided
craniotomy for tumor resection. he toelrated the procedure well,
was extubated in the operating room, and was transferred to the
intensive care unit post-operatively for frequent neuro checks
and SBP control less than 140. POstop head CT demonstratd no
hemorrhage. Postoperatively he was started on dexamethasone 4mg
IV Q6 hours.
On POD 1 [**11-25**] he was transfered to the regular floor. POstop
MRI was performed that demonstrated good resection of the mass.
He advanced his diet and began to mobilize. In the evening on
POD1 and on POD2 he was slightly confused and became agitated
requiring temporary restraints and Haldol 1mg IV x1 dose on
[**11-26**].
By [**11-27**] his exam was greatly improved and he no longer required
restraints. The Dexamethasone was tapered rapidly as it was
felt to cause psychosis.
On [**11-28**], patient remained stable, he was discharged to rehab.
Medications on Admission:
advair, albuterol, dizaepam, digoxin, MVI, omeprazole, crestor,
warfarin, zolpidem, spiriva
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/headache.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for headache.
6. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
8. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for sleep.
9. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
14. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day) for 3 days.
20. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 days.
21. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
22. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day) for 7 days.
23. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12 hrs ()
for 4 doses.
24. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q 24 hrs ()
for 2 doses.
25. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12 HRS ()
for 4 doses.
26. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
27. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8971**] Rehabilitation Center (at [**Hospital6 8972**])
- [**Location (un) 8973**]
Discharge Diagnosis:
right subfrontal brain mass
right visual [**Last Name (un) 8491**] cut
CAD
CABG
Mechanical heart valve
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
****You may restart coumadin on [**2152-11-29**]***
You were admitted to the hospital for removal of a brain mass.
You underwent this procedure without incident. Your vision
remains altered in your right eye and we will be getting formal
testing for you in 8 weeks time. You were started on Dilantin
for seizure prophylaxis, this [**Last Name (un) **] transitioned over to Keppra
which is easier for you to manage as an out patient as you do
not need to follow laboratory levels. Your steroids were weaned
slowly.
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**8-13**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You will need an appointment to be seen at the brain tumor
clinic. You will be contact[**Name (NI) **] with time and date of your
scheduled appointment. 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.
Completed by:[**2152-11-28**]
|
[
"427.31",
"530.81",
"E878.8",
"432.1",
"V49.87",
"300.00",
"V45.81",
"998.11",
"V43.3",
"496",
"414.00",
"192.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
8337, 8458
|
4760, 5714
|
316, 372
|
8605, 8605
|
3627, 4737
|
11450, 12320
|
2088, 2151
|
5856, 8314
|
8479, 8584
|
5740, 5833
|
8756, 11427
|
2166, 3575
|
3589, 3608
|
238, 278
|
400, 1665
|
8620, 8732
|
1687, 1886
|
1902, 2072
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,202
| 151,960
|
34056
|
Discharge summary
|
report
|
Admission Date: [**2115-5-12**] Discharge Date: [**2115-6-11**]
Date of Birth: [**2051-4-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Paraplegia
Major Surgical or Invasive Procedure:
1. Laminectomy T8, T12.
2. Decompression with resection of epidural abscess.
3. Incision and debridement skin to bone.
4. Biopsies for Pathology and Microbiology including
vertebral bone.
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 64-year-old male who is undergoing treatment
for multiple abscesses. Specifically, he previously presented to
[**Hospital1 69**] in [**2115-4-4**] and was found
to have a thoracic epidural abscess as well as abscesses in his
chest, empyema. He underwent operative treatment of both of
these collections. Infectious disease consult helps to direct
his care and ultimately he was discharged with intravenous
nafcillin treatment to a rehab center. On [**2115-5-11**], he was
transferred back from his rehab center to [**Hospital1 **]
Hospital with, by report, unilateral leg weakness. An MRI was
performed as an outpatient that morning which demonstrated a
large epidural compressive collection. On evaluation in the
emergency department, the patient exhibited no lower extremity
motor function bilaterally. He exhibited a mid thoracic sensory
level circumferentially. He did not demonstrate any voluntary
sphincter contraction but he did have sacral sensation intact.
Past Medical History:
1) Bipolar D/o
2) Hypothyroidism
3) DMII
4) Hyperlipidemia
5) Asthma
6) Depression
Social History:
Tob: Remote 30 pkyr hx; quit 20 yrs ago. No etoh. +Marijuana
use. No IVDU or other IV injection use. Retired; former
electrician. Lives with son, daughter-in-law and grandson.
Family History:
Father DM2
Mother CAD
Physical Exam:
On Admission:
PE: 99.8 107/85 98 18 97RA
NAD. Awake and alert. Oriented to person only. Follows only some
commands. Appears confused.
Anicteric. OP clear. MMM.
Diminished BS R base, otherwise fairly clear. No w/r/r.
Incision healing well. No drainage from wound.
Soft. NT. ND. +BS.
Unable to move BLE. 5/5 strength BUE. Unable to assess
sensation,
as patient's mental status is altered.
.
On Discharge:
He was alert, oriented x3. His neurological function was still
the same with complete loss of LE motor and sensory function
bilaterally.
Pertinent Results:
[**2115-5-12**] 05:00PM WBC-12.2* RBC-3.63* HGB-10.3* HCT-31.2*
MCV-86 MCH-28.3 MCHC-32.9 RDW-14.8
[**2115-5-12**] 05:00PM NEUTS-80.5* LYMPHS-13.3* MONOS-4.6 EOS-1.4
BASOS-0.2
[**2115-5-12**] 05:00PM PLT COUNT-678*
[**2115-5-12**] 05:00PM GLUCOSE-125* UREA N-8 CREAT-0.9 SODIUM-132*
POTASSIUM-3.5 CHLORIDE-94* TOTAL CO2-28 ANION GAP-14
[**2115-5-12**] 05:00PM CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2115-5-12**] 05:11PM LACTATE-1.3 K+-3.3*
[**2115-5-12**] 05:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2115-5-12**] 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2115-5-12**] 07:25PM PT-14.5* PTT-30.8 INR(PT)-1.3*
[**2115-6-10**] 06:15AM BLOOD WBC-9.6 RBC-3.53* Hgb-10.4* Hct-31.0*
MCV-88 MCH-29.4 MCHC-33.5 RDW-17.0* Plt Ct-801*
[**2115-6-3**] 04:27AM BLOOD Neuts-71.8* Lymphs-19.9 Monos-4.4 Eos-3.5
Baso-0.4
[**2115-6-3**] 05:22AM BLOOD PT-14.4* PTT-25.4 INR(PT)-1.3*
[**2115-6-10**] 06:15AM BLOOD Glucose-87 UreaN-12 Creat-1.0 Na-136
K-4.4 Cl-100 HCO3-27 AnGap-13
[**2115-6-4**] 05:55AM BLOOD ALT-15 AST-33 AlkPhos-241* TotBili-0.4
[**2115-6-7**] 09:35AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0
[**2115-6-4**] 05:55AM BLOOD VitB12-538 Folate-5.8
[**2115-6-4**] 05:55AM BLOOD TSH-21*
[**2115-6-4**] 05:55AM BLOOD T4-2.6*
.
MR C/T/L Spine [**2115-5-13**]
1. Spondylodiscitis of the cervical spine at the C4/5 level with
prevertebral and paraspinal phlegmon formation. Since [**4-11**],
there has been formation of a new tiny right ventral epidural
abscess, but without compression of the cord.
2. Post-surgical changes of the thoracic spine as described
above with
extensive circumferential epidural enhancing tissue within the
surgical site which may represent granulation tissue versus
epidural phlegmon. There is a small epidural abscess at the T7
level posteriorly which is compressing the cord.
3. There is subtle T2 hyperintensity in the cord at the surgical
site which may represent edema related to compression due to the
epidural process versus cord ischemia/infarct from
thrombophlebitis.
4. Changes suggestive of right pleural empyema and right lower
lobe
pneumonia.
5. Degenerative changes of the lumbar spine with no evidence of
spondylodiscitis.
6. There is edema and enhancement of the lumbar posterior
paraspinal muscles which may represent myositis versus
denervation injury.
.
MR C/T/L Spine [**2115-6-6**]
1. Findings consistent with discitis/osteomyelitis at C4-5
level, no evidence of intraspinal abscess.
2. Evaluation of the mid and lower thoracic spine is markedly
compromised by hardware artifact.
3. Complex right pleural collection, better evaluated on recent
chest CT.
.
CT Chest [**2115-5-13**]
1. Extensive discitis/osteomyelitis with severe bony destruction
at the T9-T10 level.
2. T10 vertebral body/pedicle fractures which may be unstable.
3. Complex right hydropneumothorax with multiple foci of gas and
loculations. Small uncomplicated left pleural effusion.
4. Left upper lobe ground-glass opacity. Although this most
likely
represents a benign focus of inflammation, a six- month followup
is
recommended to ensure resolution as more unlikely alternatives
such as BAC
cannot be definitively excluded.
.
CT Chest [**2115-6-6**]
1. Extensive discitis/osteomyelitis with severe bony destruction
at the T9-
T10 level.
2. T10 vertebral body/pedicle fractures which may be unstable.
3. Complex right hydropneumothorax with multiple foci of gas and
loculations. Small uncomplicated left pleural effusion.
4. Left upper lobe ground-glass opacity. Although this most
likely
represents a benign focus of inflammation, a six- month followup
is
recommended to ensure resolution as more unlikely alternatives
such as BAC
cannot be definitively excluded.
.
Pleural Fluid Cytology:
NEGATIVE FOR MALIGNANT CELLS.
.
LE USG [**2115-5-15**]
No evidence of DVT in the bilateral lower extremities
Brief Hospital Course:
64 year old male who previously presented to [**Hospital1 771**] in [**2115-4-4**] and was found to have a
thoracic epidural abscess as well as abscesses in his chest,
along with empyema. He underwent operative treatment of both of
these collections. Infectious disease consult helps to direct
his care and ultimately he was discharged with intravenous
nafcillin treatment to a rehab center.
On [**2115-5-11**], he was transferred back from his rehab center
to [**Hospital1 **] Hospital with, by report, unilateral
leg weakness. An MRI was performed as an outpatient that morning
which demonstrated a large epidural compressive collection. On
evaluation in the emergency department, the patient exhibited no
lower extremity motor function bilaterally. He exhibited a mid
thoracic sensory level circumferentially. He did not demonstrate
any voluntary sphincter contraction but he did have sacral
sensation intact.
1. Epidural abscess:
he had epidural abscess compressing his cord centrally and had
emergent revision decompression and abscess removal from T8-12.
After surgery, he underwent further evaluation with MRI scans of
C,T,& L spine as well as chest CT for evaluation of his previous
empyema. These did note further worsening consolidations in his
C spine as well. CT showed osteomyelitis at T9-10 as well as
complex right hydropneumothorax with multiple foci of gas and
loculations. Thoracic surgery & infectious disease were
consulted. He was maintained on fluconazole & nafcillin per ID
recommendations. (nafcillin 2gm iv q4 since last admission -
present, fluconazole 400 iv q24 from [**5-18**] - [**6-2**].) Cultures were
monitored. Postoperatively, he did have some return of sensation
in bilateral lower extremities but continued to have complete
paralysis of the lower extremities. The patient needs
Nafcicillin to be continued for a total of 8 weeks after the
last surgical debridement ([**5-21**]). Repeat blood cultures have
all not shown any growth. A repeat MRI of spine on [**6-6**] showed
discitis/osteomyelitis at C4-5 level but no evidence of
intraspinal abscess.
2. Osteomyelitis:
T9-10 vertebral bodies were noted to have severe bony
destruction on CT exam of Mr. [**Known lastname 78598**] chest. It was discussed
with thoracic surgery that a two level corpectomy would be
performed to stabilize Mr. [**Known lastname 78598**] spine. Mr. [**Known lastname **] was taken to
the OR for a anterior/posterior throacic fusion. This was a
staged procedure. On [**5-23**] he underwent MRI of cerivcal spine
which showed no changes. Decision was made that no further
surgery was needed.
3. Empyema:
Imaging revealed a RLL empyema. 2 chest tubes were placed on the
right by thoracic surgery. On [**5-28**] a Left thoracentesis was
performed by IP, which drained 750 of pleural fluid. On [**5-31**] a
CT-chest was performed which showed increased air/gas basally in
the Right lung. The chest tubes were again tPA'ed on [**6-1**] to
help drain the loculated collections. His chest tube was taken
out on [**6-4**]. A repeat CT Chest on [**6-6**] showed slight increase in
air/gas within complex right-sided hydropneumothorax with
decreased size of small nonhemorrhagic layering left-sided
pleural effusion. It was decided by thoracic surgery not to
perform any further procedures for this.
4. Candidemia:
Blood cultures on [**5-14**] revealed [**Female First Name (un) **] albicans and patient was
started on fluconazle. Subsequent blood cultures showed no
fungal growth. ID was consulted and the patient was continued
on fluconazole until [**6-2**].
5. Ventilator Associated Pneumonia:
The patient continued to have low grade fevers and increased WBC
after his corpectomy surgery. A BAL was performed on [**5-19**] and
the culture grew serratia marcescens. The patient was treated
for VAP with 8 days (completed [**5-29**]) of cipro per ID.
6. Type II Diabetes:
his metformin and Januvia were held while in the hospital. His
blood sugars were in the 100s-220s. He was maintained on NPH and
ISS; his NPH was titrated while he was in the hospital.
7. Delerium:
Pt is A+O to place and month and year, and appears less drowsy
during exam. Has self-D/C'd chest tube, PICC line and PIV
(multiple times). TSH 21, Vit B12 and folate wnl. Likely
residual delirium from surgery/infection, hypothyroidism may be
a contributor. Giatrics was consulted.
- per geriatrics consult, avoid sedating medications and
restraints
- mitt on opposite hand of PIV
- was on Baclofen transiently but was stopped [**1-5**] delirium
8. Hypothyroidism:
he has history of hypothyroidism with unknown baseline thyroid
function. His Levothyroxine dose was increased while in
hospital. His TSH and Free T4 should be checked in 4 weeks after
discharge from [**Hospital1 18**].
9. DVT prophylaxis:
An IVC filter was placed on [**5-16**] due to his need for prolonged
hospitalization and inability to anticoagulate in the setting of
immediate postoperative period. He was also later started on
heparin SC TID.
Medications on Admission:
Medications at Rehab prior to admission:
Fluticasone 110 mcg/ 2 puffs daily
Albuterol INH [**12-5**] puff every 4-6 hours
Aripiprazole 40 mg PO daily
Lexapro 30 mg PO daily
Lipitor 40 mg PO daily
Fenofibrate 145 mg PO daily
Januvia 50 [**Hospital1 **]
Metformin 1000 [**Hospital1 **]
Nafcillin IV 2g IV q 4
Metoprolol 50 [**Hospital1 **]
Combivent neb treatment q 6 hours
Levothyroxine 137 mcg daily
Colace/Senna/Bisacodyl/MgCitrate bowel regimen
Dilaudid 2 mg PO q4H prn pain
Discharge Medications:
1. Outpatient Lab Work
Weekly Labs:
CBC, LFT's, BUN, Createnine
Results to fax to Infectious Disease [**Telephone/Fax (1) 432**]
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
5. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
9. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
15. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
16. Ondansetron 4 mg IV Q8H:PRN
17. Nafcillin 2 gram Recon Soln Sig: One (1) Intravenous every
four (4) hours: Started on [**5-21**] for total of 8 weeks to end on
[**7-21**].
18. Insulin Regimen
NPH and Sliding scale (attached)
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
1. Space-occupying epidural collection T6-T12.
2. Thoracic spinal cord injury.
3. Previous epidural abscess.
Discharge Condition:
Stable to extended care facility
Discharge Instructions:
You will need to continue your IV nafcillin until [**7-16**]. You
will also need weekly laboratory tests, including CBC, HCT/Hb,
LFTs, and BUN/Creatinine, T bili, ALT/AST/ALK PHOS and fax the
results to ID Nurse Practitioner at [**Telephone/Fax (1) 432**]. You will
follow-up with Dr. [**Last Name (STitle) 438**] on [**7-8**].
.
Please follow up with all other appointments as recommended
below.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1007**] (Spine surgery) at one week from
the date of discharge. You can call [**Telephone/Fax (1) **] to make this
appointment.
.
Please follow up with Dr. [**Last Name (STitle) 438**] (Infectious Disease) on
[**2115-7-8**]. You can call [**Telephone/Fax (1) 457**] to make this appointment.
.
Please follow up with your primary care doctor
Completed by:[**2115-6-11**]
|
[
"510.9",
"995.91",
"999.31",
"730.08",
"E879.8",
"722.72",
"244.9",
"512.1",
"112.5",
"496",
"324.1",
"344.1",
"296.80",
"378.10",
"731.3",
"482.83",
"511.1",
"707.03",
"041.11",
"250.02",
"293.0",
"289.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"81.04",
"84.51",
"77.69",
"81.62",
"33.24",
"34.04",
"34.91",
"03.09",
"80.99",
"38.7",
"77.79",
"96.6",
"81.63",
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] |
icd9pcs
|
[
[
[]
]
] |
13605, 13685
|
6410, 11423
|
292, 486
|
13838, 13873
|
2456, 6387
|
14318, 14739
|
1849, 1873
|
11951, 13582
|
13706, 13817
|
11449, 11928
|
13897, 14295
|
1888, 1888
|
2299, 2437
|
242, 254
|
514, 1531
|
1902, 2285
|
1553, 1638
|
1654, 1832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,258
| 148,188
|
47386
|
Discharge summary
|
report
|
Admission Date: [**2133-8-26**] Discharge Date: [**2133-9-11**]
Date of Birth: [**2057-8-2**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Weakness and Lethargy
Major Surgical or Invasive Procedure:
PICC line placed RUE
Wound debridement of LLE ulcers
History of Present Illness:
In brief, [**Known firstname **] is a 76 yo F who has complex infectious history
who presents to [**Hospital1 18**] for 1 week of progressive weakness and
lethargy. In summary of her infectious history, she had a CABG
in [**1-30**] c/b LE cellulitis at site of venous harvest (Linezolid),
dehiscense of her sternal wound s/p pec flap [**2133-2-12**], readmitted
[**4-1**] for non-healing sternal wound s/p debridement, cultures
grew [**Female First Name (un) 564**] Torulopsis and CONS, discharged on 6 weeks
Vanco/Micafungin showed clinical improvement, [**5-15**] she lost IV
access and Vanco switched to Linezolid/Fluconazole. [**6-1**]
readmitted for sternal plate removal and wound closure, bone
cultures grew C.Albicans, she was also found to have UTI treated
with Cefepime, discharged home with Daptomycin for CONS Cx in
[**Month (only) 116**]. Dapto switched to Linezolid on [**2133-7-15**] for rising eos and
finally discontinued on [**7-21**]. Also of note, she was recently
treated with Cipro for UTI and then Augmentin for another UTI at
[**Hospital1 **]. She has a complex medical hsitory as well which is
significant for A.Fib on Coumadin, Type II DM, Primary Biliary
Cirrhosis.
.
Patient is unable to give a good history as she is falls asleep
frequently during examination but per report: she was sent to
the ED today from [**Hospital3 **] for worsening lethargy. She
reports progressive weakness over several weeks, usually gets
around fine with a wheelchair but over past week has been
requiring a motorchair to get around, she has also described
shortness of breath and more rapid breathign. In the ED, initial
VS 97.2 58-87 105/66-121/57 18 97-100% on RA. Significant labs
included Cr of 1.5, Hct 23.4, INR 3.3. Bicarb was 10 with gap of
22. lactate was 2.0. U/A showed trace leuks, 2WBCs. She was
guaiac negative.
.
Currently, the patient is very groggy and appears chronically
ill. She frequently falls asleep during questioning and she is
difficult to understand as her voice is soft and appears
labored. When she is more aroused she is oriented x 3,
mentatintg well and is able to relay her history.
.
On ROS, the patient reports losing 70 lbs since her CABG in
[**Month (only) **], + SOB x weeks, no CP, occasional N/V, recent profuse
diarrhea - [**1-23**] xs per day, last episode was Monday. She denies
fevers/chills and denies abdominal pain.
Past Medical History:
1. Right total knee and hip replacements [**2130**]
2. Left superficial temporal artery biopsy [**2131**]
3. Coronary artery bypass grafting x3 with left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to the marginal branch of the posterior descending artery
followed by plating x 5 in [**2133-1-20**]
4. Sternal wound separation s/p readvancement of pectoralis
flaps
and reclosure of sternal wound [**2133-2-12**]
5. Chronic atrial fibrillation on Coumadin, diagnosed [**2123**]
6. Stable primary biliary cirrhosis
7. Type II diabetes
8. Hypothyroidism
9. Polymyalgia rheumatica diagnosed [**3-31**], On Prednisone
10. Hypercholesterolemia
11. Osteoarthritis
12. Vulvar cancer [**2129**] s/p vulvectomy at [**Hospital1 2025**] (no chemo or
radiation)
13. Urinary incontinence s/p vulvectomy
14. H/O nephrolithiasis
15. Chronic lower extremity edema r/t lymphedema
16. H/O Urosepsis
17. Arthritis left knee
Social History:
Prior to her recent hospital stays, the patient had lived in
[**Location 1268**], MA with her husband; former smoker - quit at age
40, no illicits; drinks etoh socially.
She was the director of nursing at [**Hospital1 18**] on staff for 30 years
Family History:
Ms. [**Known lastname 100278**] sister died last year at age 71, S/P CABG at age
39, redo CABG at age 49, and peripheral bypass. Her father had
a myocardial infarction at age 50 and died at age 76 from a
ruptured abdominal aortic aneurysm.
Physical Exam:
GENERAL: NAD, lethargic but arousable, chronically
ill-appearing, obese, deeply breathing, trails off when talking
and frequently falls asleep
HEENT: PERRL, pale conjunctiva, OP clear, dry MM
NECK: Supple, no JVD, no LAD
HEART: RRR w/ frequent premature beats, sustained S1, no MRG,
CHEST: sternal wound is bandaged, appears to be healing well
LUNGS: CTA bilat, no r/rh/wh; deeply breathing
ABDOMEN: obese, Soft/NT/ND, no rebound/guarding, +BS
EXTREMITIES: obese legs, distal wounds are bandaged, pressure
ulcers on posterior legs are very tender, Feet are warm. She has
a foul smelling, pressure ulcer on posterior left leg: there is
central necrosis with non-viable tissues surrounded by red,
swollen skin but without evidence of frank cellulitis. there is
also a larger, foul smelling pressure ulcer over left lateral
thigh with central non-viable-tissues surrounded by swollen/red
skin but does not appear to be frank cellulitis. Her hands are
cold bilaterally and her fingers appear mottled. She has
multiple areas of frank skin break down over arms and under
breasts.
NEURO: AOx3, lethargic, CNs II-XII grossly intact, moving all
extremities
Pertinent Results:
Admission Labs:
[**2133-8-26**] 08:10PM BLOOD WBC-14.9* RBC-2.50*# Hgb-7.2*# Hct-23.4*
MCV-93 MCH-28.7 MCHC-30.8* RDW-17.0* Plt Ct-508*
[**2133-8-26**] 08:10PM BLOOD Neuts-78.9* Lymphs-14.0* Monos-2.5
Eos-3.8 Baso-0.7
[**2133-8-26**] 08:10PM BLOOD PT-33.0* PTT-37.1* INR(PT)-3.3*
[**2133-8-26**] 08:10PM BLOOD Ret Man-2.1*
[**2133-8-26**] 08:10PM BLOOD Glucose-113* UreaN-34* Creat-1.5* Na-143
K-3.9 Cl-111* HCO3-10* AnGap-26*
[**2133-8-26**] 08:10PM BLOOD ALT-4 AST-9 LD(LDH)-134 CK(CPK)-35
AlkPhos-136* TotBili-0.1
[**2133-8-26**] 08:10PM BLOOD CK-MB-3 cTropnT-0.06* proBNP-2799*
[**2133-8-26**] 08:10PM BLOOD Albumin-2.4* Calcium-9.0 Phos-3.3 Mg-1.9
[**2133-8-26**] 08:10PM BLOOD D-Dimer-503*
[**2133-8-26**] 08:10PM BLOOD TSH-30*
[**2133-8-26**] 08:16PM BLOOD Lactate-2.0
Lethargy Work Up:
[**2133-8-26**] 08:10PM BLOOD WBC-14.9* RBC-2.50*# Hgb-7.2*# Hct-23.4*
MCV-93 MCH-28.7 MCHC-30.8* RDW-17.0* Plt Ct-508*
[**2133-8-26**] 08:10PM BLOOD Ret Man-2.1*
[**2133-8-26**] 08:10PM BLOOD Glucose-113* UreaN-34* Creat-1.5* Na-143
K-3.9 Cl-111* HCO3-10* AnGap-26*
[**2133-8-26**] 08:10PM BLOOD Albumin-2.4* Calcium-9.0 Phos-3.3 Mg-1.9
[**2133-8-27**] 12:51PM BLOOD calTIBC-122* VitB12-1275* Folate-4.7
Ferritn-1494* TRF-94*
[**2133-8-26**] 08:10PM BLOOD TSH-30*
[**2133-8-28**] 05:30AM BLOOD Free T4-0.90*
[**2133-8-27**] 04:51AM BLOOD freeCa-1.38*
Anion Gap Work Up:
[**2133-8-29**] 11:46AM BLOOD PARATHYROID HORMONE RELATED PROTEIN-WNL
[**2133-8-27**] 12:51PM BLOOD BETA-HYDROXYBUTYRATE-Negative
[**2133-8-27**] 04:51AM BLOOD Lactate-1.0
[**2133-8-26**] 08:10PM BLOOD ASA-NEG Acetmnp-NEG
[**2133-8-28**] 04:00PM BLOOD PEP-POLYCLONAL
[**2133-8-27**] 12:51PM BLOOD Acetone-NEGATIVE Osmolal-303
[**2133-8-26**] 09:35PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2133-8-26**] 09:35PM URINE Hours-RANDOM UreaN-453 Creat-89 Na-32
K-55 Cl-LESS THAN
[**2133-8-31**] 11:20AM URINE Hours-RANDOM UreaN-327 Creat-54 Na-90
K-32 Cl-63 HCO3-LESS THAN
[**2133-8-26**] 09:35PM URINE Osmolal-433
[**2133-8-28**] 07:10PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
[**2133-9-3**] 05:54PM URINE ORGANIC ACID-PND
Anion Gap Trend: (Received Bicarb after work up negative and AG
unchanged)
[**2133-8-26**] 08:10PM BLOOD Glucose-113* UreaN-34* Creat-1.5* Na-143
K-3.9 Cl-111* HCO3-10* AnGap-26*
[**2133-8-29**] 06:38AM BLOOD Glucose-77 UreaN-19 Creat-1.1 Na-145
K-3.9 Cl-117* HCO3-11* AnGap-21*
[**2133-9-2**] 05:16AM BLOOD UreaN-12 Creat-1.1 Na-147* K-4.2 Cl-118*
HCO3-14* AnGap-19
[**2133-9-6**] 05:57AM BLOOD Glucose-115* UreaN-11 Creat-1.0 Na-137
K-3.7 Cl-108 HCO3-21* AnGap-12
[**2133-9-9**] 05:45AM BLOOD Glucose-93 UreaN-8 Creat-1.2* Na-139
K-3.8 Cl-109* HCO3-18* AnGap-16
[**2133-8-27**] 4:23 pm SWAB Source: Left Medial Lower leg.
ADD-ON FROM [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40906**](FAX) FOR GRAM STAIN [**2133-8-28**]
@1014.
**FINAL REPORT [**2133-8-30**]**
GRAM STAIN (Final [**2133-8-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2133-8-30**]):
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ =>16 R
C.Diff Toxin Negative
C.Diff PCR Negative
BCx Negative x2
BCx NGTD x2
UCx Negative x2
Discharge Labs:
********************
Reports:
CXR [**2133-8-26**]: PA AND LATERAL VIEWS OF THE CHEST: Cardiac
silhouette is minimally enlarged, though unchanged. Mediastinal
and hilar contours are also unchanged. There is no pleural
effusion or pneumothorax. A right peripherally inserted central
catheter has been removed.
CTA [**2133-8-26**]: No pulmonary embolism. No acute intrathoracic
process
CXR [**2133-9-9**]: FINDINGS: In comparison with the study of [**8-27**],
there is little change and no evidence of acute pneumonia.
Central catheter remains in place
Ulcer Biopsies Pending:
Brief Hospital Course:
[**Known firstname **] is a 76 yo F who has complex infectious history including
a CABG with post-op course c/b sternal wound infections. She has
been living in a nursing facility and has experienced recurrent
pressure ulcer infections and UTIs who presents to [**Hospital1 18**] for 1
week of progressive weakness and lethargy.
# Lethargy: Lethargy is most likely multifactorial from
infectious process, anemia, opiate use and compounded by
metabolic disturbance and increased work of breathing. For
infection, she was started on Vancomycin and Zosyn, after wound
culture grew Pseudomonas she was narrowed to Zosyn only. The
Zosyn was continued for nearly two weeks when it was
discontinued because of worsening diarrhea and without a change
in her clinical status. For her anemia she was transfused 1 unit
PRBCs with improvement in her metabolic alkalosis (see below)
but without a sustained improvement in her crit. Her Metabolic
disturbances were worked up as below and her clinical status did
not improve much other than correcting her anion gap with bicarb
supplementation. Hypothyroidism was considered and TSH, FT4 were
drawn which were compatable with hypothyroidism and her
synthroid was increased to 250mcg/day, again without significant
improvement in her clinical status.
#Acid/Base Distubrance: When she was admitted she had a profound
anion gap with a HCO3 of 10; her pH of 7.38 suggested there were
3 processes occuring. She had an anion-gap metabolic acidosis
(AG=26), when corrected for AG it appears she had a superimposed
non-gap metabolic acidosis. In addition, the patient's CO2 was
too low for a respiratory compensation and instead suggested a
primary respiratory alkalosis in addition to respiratory
compensation. Serum tox was negative for Salicylates, patient
was a nurse in her career and she was transferred from [**Hospital **]
Hospital: Methanol, Ethanol or Paraldehyde toxicity would be
extremeley unlikely, she does not take INH and in addition her
gap remained open >1week and it would have been expected that
any ingestion would have cleared in that time. Her urine was
negative for ketones, blood acetone and beta-hydroxybutyrate
were negative as well. BUN was 34, lactate was 1.0 and so
uremia/lactic acidosis not cause of her gap either. There was no
serum osmolar gap and her urine lytes suggested she was not
renally wasting bicarb (Ubicarb <1). She was trasfused 1 unit
PRBCs and started on Vanc/Zosyn for sepsis criteria (LE ulcers
infectios source) and her primary respiratory alkalosis
resolved. She did have diarrhea on presentation which after
giviing IVF and Loperamide/Lomotil her primary non-gap resolved
as well. Renal was consulted for ongoing AG Acidosis of unclear
etiology though the anions remained elusive, she was repleted
with 1.5amps bicarb in 1 unit D5W x6L and her gap closed with
bicarbs returning to low 20s. When bicarb supplementation was
stopped her gap began opening again. Currently the source of her
unmeasured anions is unclear, Urine organic acids are pending.
# Leukocytosis: Patient had multiple sources for infections and
a complex infectious history. During this hospitalization the
most likely source of infection waslikely pressure ulcers on LLE
and Left later thigh. Urinalysis was negative, BCx negative,
C.Diff toxin negative x2 and C.Diff PCR negative, CXR and PE did
not suggest PNA and sternal wound appears to be improved from
prior. LLE ulcer grew rare Pseudomonas and so Vancomycin
discontinued and Zosyn continued. Zosyn was continued for nearly
2 weeks without improvement in her clinical status and without a
downtrending WBC count (remained around [**9-1**]). Wound was
consulted for wound care and plastics followed patient for LLE
wound debridement.
# Anemia: Patient presented with an 8 pt Hct drop since [**7-21**],
though her baseline was uncertain. She did have a primary resp
alkalosis on admission with subjective SOB. She was transfused 1
unit PRBCs with improvement in primary resp alk but continued
deep breathing (compensation for met acid). Her iron studies
were consistent with anemia of chronic disease and she had a
reticulocyte count which was not appropriate for her level of
anemia. She was continued on iron and MVI.
# [**Last Name (un) **]: Patient admitted with an elevated creatinine of 1.5. Her
baseline was unclear as there are multiple Creatinines in OMR
>1.5 but it appears her last admission Creatinine 0.8-1.1. Per
OPAT notes her creatinine has been uptitrating at [**Hospital1 **].
BUN:Cr >20 but urine lytes also suggeted intrinsic kidney injury
and so she likely had an aspect of pre-renal etiology in
addition to intrinsic [**Last Name (un) **]. Lasix were held and IVF given and she
showed improvement in her renal function to a creatinine of 0.9.
CHRONIC STABLE CONDITIONS:
# Afib: During admission she was in sinus with frequent
premature beats. INR supratherapeutic at 3.3. Coumadin was held
and she remained at supratherapeutic levels for 1 week until
vitamin k was given for wound debridement. Metoprolol was
continued but because she remained hypotensive throughout
admission it was largely held.
# CAD s/p CABG: BNP elevated and EKG with TWF laterally on
admission. Continued aspirin as low probability Anion-gap is
salicylate toxicity (Salicylates negative on admission).
# Chronic sternal wound: Continued fluconazole (renally dosed).
Plastics debrided wound and placed a sternal wound vac which was
continued for ***
# DM: HISS, given reports of recent lows at [**Hospital1 **]
# PBC: continued ursodiol
# Hypothyroidism: Part of lethargy work up she was found to have
a TSH of 30 and a FT4 of 0.9. Synthroid was increased from
200mcg to 250mcg daily
# GERD: Continued omeprazole
# depression: Continued Wellbutrin, remeron
.
# diarrhea: Chronic on admission, C.Diff toxin and PCR negative.
Thought to be antibiotic related as it worsened with Zosyn and
improved after Zosyn discontinued. Loperamide and Lomotil given
for symptomatic relief.
# End of life events: Pt was transferred to MICU on [**9-8**]. She
was started on norepinephrine, and then phenylephrine for
refractory hypotension. A-line and central line was placed. NG
tube was placed for nutrition. Pt had increased requirement for
pressor support. She continued to decline despite broad
antibiotics, including vancomycin IV, metronidazole, vancomycin
PO, meropenem, and micafungin and supportive care including two
pressors. Family meeting was held on [**9-11**], and given her acute
decompensation despite aggressive managment from [**2043-9-8**], the
consensus decision was made to transition her to CMO. The
patient's husband, Dr. [**Last Name (STitle) 100282**] [**Known lastname 5699**], made this decision in
concert with the medical team as he felt it best reflected the
patient's wishes. She was subsequently transitioned to comfort
care. Pt deceased at 18:09 on [**9-11**]. Family was present at
that time. Autopsy was offered and Dr. [**Known lastname 5699**] accepted.
Nurse [**Known lastname 5699**] and her family were all sincerely thanked for her
numerous and significant contributions to our hospital and
informed that we will mourn her loss as well.
Medications on Admission:
MEDICATIONS (according to [**Hospital1 **] records)
oxycodone 5 mg q3h prn
zofran 4 mg PO prn
tramadol 50 mg q8h
lasix 20 mg qday
wellbutrin SR 100 mg QAM
compazine 10 mg QAM
Colace
Ferrous Sulfate 325 mg qday
LVTX 200 mcg qday
Aspirin 81 mg qday
Ursodiol 300 mg [**Hospital1 **]
Dulcolax 10 mg qAM
Remeron 7.5 mg hs
Tylenol 1g q8h
Fluconazole 400 mg qday
metoprolol 25 mg qday
HISS
Coumadin given 0.5 mg on [**8-26**] and to be given [**8-30**]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory distress, sepsis, altered mental status
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
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icd9cm
|
[
[
[]
]
] |
[
"38.91",
"86.69",
"86.28",
"38.97",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17726, 17735
|
10010, 17201
|
322, 376
|
17830, 17839
|
5457, 5457
|
17892, 17899
|
4030, 4273
|
17697, 17703
|
17756, 17809
|
17227, 17674
|
17863, 17869
|
9407, 9987
|
4288, 5438
|
261, 284
|
404, 2777
|
5473, 9391
|
2799, 3751
|
3767, 4014
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,275
| 164,563
|
1697
|
Discharge summary
|
report
|
Admission Date: [**2194-8-26**] Discharge Date: [**2194-9-26**]
Date of Birth: [**2122-1-13**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Tracheostomy [**2194-9-16**]
Bronchoscopy [**2194-9-10**]
Past Medical History:
Atrial fibrillation (on Coumadin)
Coronary Artery Disease
Ulcerative Colitis w/ colostomy
Hypertension
Pacemaker
CVA [**2191**] w/ right sided weakness
Cataracts, s/p cataract surgery
s/p TURP
Social History:
Lives with wife; +ETOH use
Family History:
Noncontributory
Pertinent Results:
[**2194-8-26**] 08:10PM GLUCOSE-126* UREA N-9 CREAT-0.8 SODIUM-135
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
[**2194-8-26**] 08:10PM CALCIUM-8.2* PHOSPHATE-2.1* MAGNESIUM-1.9
[**2194-8-26**] 08:10PM WBC-6.5 RBC-3.68* HGB-11.6* HCT-32.5* MCV-88
MCH-31.5 MCHC-35.6* RDW-13.6
[**2194-8-26**] 08:10PM PLT COUNT-207
[**2194-8-26**] 08:10PM PT-15.0* PTT-31.3 INR(PT)-1.5
[**2194-8-26**] 02:56PM TYPE-ART TEMP-36.6 RATES-14/ TIDAL VOL-550
PEEP-5 O2-100 PO2-416* PCO2-39 PH-7.41 TOTAL CO2-26 BASE XS-0
AADO2-279 REQ O2-52 -ASSIST/CON INTUBATED-INTUBATED
[**2194-8-26**] 09:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2194-8-26**] 09:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CT C-SPINE W/O CONTRAST [**2194-8-26**] 9:59 AM
CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: 72 male s/p fall down 20 stairs
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with
REASON FOR THIS EXAMINATION:
72 male s/p fall down 20 stairs
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATIONS: Fall down 20 stairs.
TECHNIQUE: Noncontrast cervical spine CT.
COMPARISON: None.
NOTE: This study was initially performed on [**2194-8-26**].
Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9768**] at the time this
study was performed, but the study was not dictated until the
morning of [**2194-8-27**], due to PACS malfunction.
NONCONTRAST CERVICAL SPINE CT: There are minimally displaced and
comminuted fractures through the left C7 and T1 transverse
processes. The margins do not appear to extend into the foramina
transversaria. Positioning limits assessment of alignment due to
extreme head tilting to the right, but this is likely the best
obtainable secondary to intubation and nasogastric tube
placement. Allowing for the limitations, the vertebral bodies
are normal in height and normally aligned. There is no
atlantoaxial subluxation. The lateral masses of C1 articulate
normally about the odontoid process. Prevertebral soft tissue
swelling cannot be excluded secondary to intubation. Extensive
carotid arterial calcifications are present in the bulb regions
bilaterally. Biapical lung scarring and mild bronchiectasis are
present.
Also noted is sclerosis and opacification of the visualized left
mastoid air cells and mastoid tip, likely chronic inflammatory
disease.
IMPRESSION: Minimally displaced, comminuted fractures of the
left C7 and T1 transverse processes. No evidence of extension
into the foramina transversaria.
CT HEAD W/O CONTRAST [**2194-8-26**] 9:42 AM
CT HEAD W/O CONTRAST
Reason: bleed?
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with intraparenchymal bleed s/p fall
REASON FOR THIS EXAMINATION:
bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Intraparenchymal hemorrhage after fall. Assess for
hemorrhage.
TECHNIQUE: Non-contrast head CT.
COMPARISON: No prior studies are available. By report, the
patient has an outside study. Should this become available, an
addendum will be issued to this report following the comparison
with the outside examination.
NOTE: This study was initially performed on the morning of
[**8-26**], and is being dictated on the morning of [**8-27**]
due to PACS malfunction. Findings were called to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9768**]
on the morning of [**8-26**].
NON-CONTRAST HEAD CT: There is a small amount of hemorrhage
within the occipital horns of both lateral ventricles, right
greater than left. Located within the atrium of the right
lateral ventricle is an 18 x 10 mm nodular area of increased
density which is separate from the choroid plexus. There is no
evidence of surrounding edema. There is diffuse brain atrophy
and chronic microvascular infarction throughout the white
matter. There is a remote right frontal infarct. There is no
evidence of subarachnoid hemorrhage or acute major vascular
territorial infarction. The ventricles do not appear dilated
relative to the sulci, and there is no shift of normally midline
structures. There is no skull fracture. There is opacification
of the posterior nasal cavity and nasopharynx but an NG tube is
present, and the patient is intubated. Opacified and sclerotic
left mastoid air cells are noted.
IMPRESSION:
1. Small amount of intraventricular hemorrhage.
2. Ovoid 18-mm density within the atrium of the right lateral
ventricle. This could represent either an atypically located
blood clot or an intraventricular mass, and further evaluation
with contrast-enhanced MRI of the brain, when clinically
feasible, is recommended.
Results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9768**] in the early
afternoon on [**2194-8-26**].
CT HEAD W/O CONTRAST [**2194-9-19**] 12:34 PM
CT HEAD W/O CONTRAST
Reason: altered mental status
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with
REASON FOR THIS EXAMINATION:
altered mental status
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 72-year-old male with altered mental status.
TECHNIQUE: Axial noncontrast CT scans of the brain were
obtained.
Comparison is made to a previous study from [**2194-9-1**].
FINDINGS:
There are numerous areas of decreased attenuation in the
periventricular and subcortical white matter of both cerebral
hemispheres, indicating chronic microvascular infarction. There
is also an old right frontal lobe cortical infarction. A small
right occipital lobe chronic infarction is also evident. There
is a small amount of blood layering in both lateral ventricles,
and this has decreased since the previous study. The size and
shape of the ventricles is unchanged. No new hemorrhage is
observed.
There is opacification of the mastoid air cells, greater on the
left than the right. There is some fluid or mucosal thickening
in the ethmoid and sphenoid sinuses.
IMPRESSION: No new cortical territorial infarction or hemorrhage
is identified. There is decreased intraventricular blood,
compared to the previous study, and there are no signs of
hydrocephalus.
CHEST (PORTABLE AP) [**2194-9-17**] 9:10 AM
CHEST (PORTABLE AP)
Reason: Fever, f/u infiltrte
[**Hospital 93**] MEDICAL CONDITION:
72yo M with rib fx s/p trauma, failure on previous CXR, now with
fever.
REASON FOR THIS EXAMINATION:
Fever, f/u infiltrte
HISTORY: Trauma, congestive heart failure, fever, pneumonia.
Portable supine chest radiograph shows improvement in edema
compared to studies from four and five days earlier with no
significant radiographic change in right upper lobe
consolidation consistent with pneumonia. Some interstitial edema
still persists, but there is no central pulmonary vascular
congestion. Cardiac size is unchanged. The amount of fluid
layering at the apices and the pleural spaces appear slightly
decreased. Multiple left-sided rib fractures are seen.
Supporting tubes and lines are in unchanged position and the
patient has a single lead pacemaker projected on the left.
Calcification is seen at both carotid bifurcations.
CONCLUSION: Improvement in congestion from edema with no
worsening, but no significant improvement, in the right upper
lobe pneumonia. Supporting lines and tubes in unchanged
position.
Brief Hospital Course:
Admitted to TSICU for subarachnoid hemorrhage and multiple
spinal fractures. Intubated and sedated for desats on [**2194-9-1**].
Evaluated by neurosurgery and deemed stable on [**2194-8-27**]. CT
head remained stable for SAH. Evaluated by orthopedic spine
surgeons with recommendations for soft c-collar for comfort. In
TSICU, developed MRSA pneumonia with question of aspiration,
treated Zosyn--> vanc/levo--> then 2 week course of Linazolid
with resolution of fevers and decreased pulmonary secretions.
[**2194-9-16**]: Tracheostomy performed without complication. Patient
tolerated decreasing ventillary support. Mental status improved
with the discontinuation of his bensodiazapines. Failed swallow
study x 2 in early [**Month (only) **]. Decision to continue Dobhoff at
rehab given continued clinical improvement and his poor
candidacy for G/J tube.
Communicating by speech s/p PMV placement. Continued in [**Location (un) 2848**]-J
for comfort per orthopedics. Stable during his course on the
surgical [**Hospital1 **]. Occasionally required Haldol/ativan at night for
agitation. Progressed adequately with physical/occupational
therapy, however was noted to develop an early bilateral upper
extermity contracture at the elbows and wrists.
Serial CT head revealed decreased blood through [**2194-9-19**].
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Lisinopril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
4. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): Last dose [**2194-9-25**].
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for consitpation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p Fall
Subarachnoid hemorrhage w/ bilateral intraventricular hemorrhage
Left T1 transverse process fracture
C7 & T1 mimimally displaced transverse process fracture
Left rib fractures [**3-27**]
Discharge Condition:
Stable
Discharge Instructions:
You must continue to wear your cervical collar for the next 4
weeks (through [**10-16**]).
Follow up with Trauma in [**1-17**] weeks after your discharge.
Followup Instructions:
Call [**Telephone/Fax (1) 6439**] to schedule appointment in Trauma Clinic in
[**1-17**] weeks.
Follow up with Dr. [**Last Name (STitle) **] after your discharge from
rehabilitation
Call [**Telephone/Fax (1) 9769**] to schedule an appointment with Orthopedics
for late [**Month (only) **].
|
[
"437.0",
"805.2",
"853.06",
"401.9",
"805.07",
"482.41",
"428.0",
"599.0",
"719.41",
"507.0",
"518.5",
"E880.9",
"807.08",
"V44.3",
"V45.01",
"V09.0",
"V58.61",
"V45.3",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"96.6",
"00.17",
"96.71",
"96.72",
"38.91",
"33.23",
"31.1",
"96.04",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
10149, 10196
|
7957, 9285
|
294, 354
|
10436, 10445
|
666, 1576
|
10648, 10940
|
630, 647
|
9308, 10126
|
6918, 6990
|
10217, 10415
|
10469, 10625
|
246, 256
|
7019, 7934
|
4119, 5569
|
376, 570
|
586, 614
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,585
| 175,850
|
37402
|
Discharge summary
|
report
|
Admission Date: [**2135-1-6**] Discharge Date: [**2135-3-1**]
Date of Birth: [**2055-1-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
malaise
Major Surgical or Invasive Procedure:
bone marrow biopsy
intrathecal chemo-therapy
pheresis line placement
Ommaya IT Port placement
History of Present Illness:
79 year old gentleman from transferred from [**Hospital 1562**] Hospital
with a new diagnosis of ALL. States previously with only
surgeries and mild GERD, but had developed severe, progressive
fatigue and malaise for about one week. He denies any other
localizing symptoms such as fever, sore throat, cough, chills,
myalgias, arthralgias, dyspnea, or chest pain. He was given
empiric antibiotics without any change in his progressive
fatigue by his primary care earlier this week. Given the lack of
improvement he presented to an OSH ED earlier today. ED labs
notable for profound leukocytosis with WBC 140.1k, 90% blasts,
6% PMNs, 2%bands, 2% lymphs, Hgb 11.6, Hct 34%, Plts 89k. He was
also quite hypokalemic with potassium of 2.0 (repleted with 40
mEq of KCl via IV fluids) and had a creatinine of 2.67 (unknown
baseline). A nasal swab was negative for influenza A and B. He
was transferred to the [**Hospital1 18**] ED for presumed acute leukemia.
In the ED the patient's vital signs were initially temp 97.5, hr
80, bp 136/65, rr 15, and breathing 94% on room air. CXR showing
possible left side pneumonia and U/A showed many bacteria.
Past Medical History:
s/p CCY
s/p Hernia repair
h/o perforated gastric ulcer with surgical management
peptic ulcer disease
Social History:
Smoked a pipe infrequently many years ago. Denies alcohol or
drug
use. Lives with his daughter and son-in-law on [**Hospital3 **]. Stays
active with hunting and fishing. Built his own house out of
logs.
Family History:
No known malignancies; daughter has had recent "heart trouble".
Physical Exam:
VS: 99.1, 110/58, 78, 22, 98/RA
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: No JVD, neck supple
CHEST: Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES: No peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact.
Pertinent Results:
LABS ON ADMISSION:
[**2135-1-6**] 08:40PM BLOOD WBC-138.3* RBC-3.71* Hgb-10.8* Hct-31.6*
MCV-85 MCH-29.3 MCHC-34.3 RDW-17.0* Plt Ct-89*
[**2135-1-6**] 08:40PM BLOOD Neuts-9* Bands-0 Lymphs-5* Monos-1* Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0 Blasts-84* Other-0
[**2135-1-6**] 08:40PM BLOOD PT-19.2* PTT-30.5 INR(PT)-1.8*
[**2135-1-6**] 08:40PM BLOOD Fibrino-113*
[**2135-1-7**] 01:29AM BLOOD FDP-80-160*
[**2135-1-13**] 12:00AM BLOOD Gran Ct-434*
[**2135-1-6**] 08:40PM BLOOD Glucose-128* UreaN-23* Creat-2.9* Na-143
K-2.6* Cl-106 HCO3-23 AnGap-17
[**2135-1-6**] 08:40PM BLOOD ALT-107* AST-115* LD(LDH)-2975*
CK(CPK)-37* AlkPhos-115 TotBili-0.5
[**2135-1-6**] 08:40PM BLOOD Lipase-16
[**2135-1-6**] 08:40PM BLOOD cTropnT-0.03* proBNP-748
[**2135-1-6**] 08:40PM BLOOD Calcium-8.3* Phos-3.6 Mg-1.7
UricAcd-22.7*
[**2135-1-6**] 09:02PM BLOOD D-Dimer-GREATER TH
[**2135-1-10**] 04:21AM BLOOD Hapto-100
[**2135-1-7**] 05:41AM BLOOD freeCa-0.85*
KEY LABS ACROSS ADMISSION:
COMPLETE BLOOD COUNTS
[**2135-1-6**] 08:40PM BLOOD WBC-138.3* RBC-3.71* Hgb-10.8* Hct-31.6*
MCV-85 MCH-29.3 MCHC-34.3 RDW-17.0* Plt Ct-89*
[**2135-1-7**] 07:50AM BLOOD WBC-47.3* RBC-3.19* Hgb-9.4* Hct-27.3*
MCV-86 MCH-29.5 MCHC-34.4 RDW-16.2* Plt Ct-46*
[**2135-1-10**] 04:21AM BLOOD WBC-2.4* RBC-2.48* Hgb-7.4* Hct-21.8*
MCV-88 MCH-29.8 MCHC-33.8 RDW-15.9* Plt Ct-17*
[**2135-1-13**] 08:00PM BLOOD WBC-0.8* RBC-2.50* Hgb-7.3* Hct-21.5*
MCV-86 MCH-29.3 MCHC-34.1 RDW-15.5 Plt Ct-67*
[**2135-1-22**] 12:00AM BLOOD WBC-0.2* RBC-2.99* Hgb-9.2* Hct-25.3*
MCV-85 MCH-30.8 MCHC-36.3* RDW-14.2 Plt Ct-11*
[**2135-2-3**] 12:45AM BLOOD WBC-0.1* RBC-3.05* Hgb-9.1* Hct-25.8*
MCV-84 MCH-29.9 MCHC-35.4* RDW-13.4 Plt Ct-7*#
[**2135-2-6**] 12:20AM BLOOD WBC-0.3* RBC-3.12* Hgb-9.1* Hct-26.0*
MCV-84 MCH-29.3 MCHC-35.1* RDW-13.4 Plt Ct-23*
[**2135-2-8**] 12:00AM BLOOD WBC-0.3* RBC-3.17* Hgb-9.4* Hct-26.5*
MCV-84 MCH-29.8 MCHC-35.5* RDW-13.7 Plt Ct-31*
[**2135-2-11**] 12:00AM BLOOD WBC-1.0*# RBC-2.99* Hgb-8.7* Hct-25.3*
MCV-85 MCH-29.1 MCHC-34.4 RDW-14.3 Plt Ct-91*
[**2135-2-14**] 12:30AM BLOOD WBC-2.6*# RBC-3.29* Hgb-9.4* Hct-27.9*
MCV-85 MCH-28.5 MCHC-33.7 RDW-15.0 Plt Ct-129*
[**2135-2-17**] 12:28AM BLOOD WBC-4.0 RBC-2.97* Hgb-9.0* Hct-25.8*
MCV-87 MCH-30.2 MCHC-34.7 RDW-15.6* Plt Ct-155
[**2135-2-18**] 12:00AM BLOOD WBC-3.0* RBC-3.04* Hgb-9.3* Hct-26.7*
MCV-88 MCH-30.5 MCHC-34.7 RDW-16.1* Plt Ct-164
[**2135-2-19**] 12:00AM BLOOD WBC-2.6* RBC-3.03* Hgb-9.3* Hct-26.4*
MCV-87 MCH-30.6 MCHC-35.1* RDW-16.5* Plt Ct-159
[**2135-2-20**] 12:00AM BLOOD WBC-3.4* RBC-3.05* Hgb-9.5* Hct-27.1*
MCV-89 MCH-31.0 MCHC-34.8 RDW-16.6* Plt Ct-158
[**2135-2-21**] 12:00AM BLOOD WBC-5.3# RBC-2.86* Hgb-9.0* Hct-25.3*
MCV-88 MCH-31.4 MCHC-35.5* RDW-16.9* Plt Ct-138*
[**2135-2-22**] 12:40AM BLOOD WBC-8.7# RBC-3.05* Hgb-9.3* Hct-27.2*
MCV-89 MCH-30.6 MCHC-34.4 RDW-17.1* Plt Ct-129*
[**2135-2-23**] 12:15AM BLOOD WBC-5.0 RBC-2.52* Hgb-7.8* Hct-22.7*
MCV-90 MCH-30.9 MCHC-34.3 RDW-17.5* Plt Ct-117*
[**2135-2-25**] 12:00AM BLOOD WBC-3.1* RBC-3.09* Hgb-9.5* Hct-26.9*
MCV-87 MCH-30.6 MCHC-35.1* RDW-17.5* Plt Ct-143*
[**2135-2-27**] 12:05AM BLOOD WBC-3.3* RBC-2.87* Hgb-8.9* Hct-25.6*
MCV-89 MCH-30.8 MCHC-34.6 RDW-17.1* Plt Ct-122*
[**2135-2-28**] 12:05AM BLOOD WBC-5.5# RBC-3.08* Hgb-9.5* Hct-27.0*
MCV-88 MCH-30.9 MCHC-35.3* RDW-17.2* Plt Ct-120*
[**2135-3-1**] 01:10AM BLOOD WBC-3.8* RBC-2.96* Hgb-9.2* Hct-26.6*
MCV-90 MCH-31.2 MCHC-34.7 RDW-17.5* Plt Ct-102*
MICROBIOLOGY:
All Urine and Blood Cultures were negative or NGTD at the time
of discharge.
LABS ON DISCHARGE:
130 102 14
-----------< 109
3.4 26 0.9
9.2
3.8 > ---- < 102
26.6
anc: 2770
inr: 1.3
ldh: 178
IMAGING:
CHEST RADIOGRAPHS:
[**2135-1-6**] CXR: Subtle opacity at the left lung base is concerning
for developing infection.
[**2135-1-31**]: Interval increase in small left pleural effusion. No
focal consolidation.
[**2135-2-27**]: Patchy opacities at the right lung base and in left
retrocardiac
area appear similar to the recent study, and may reflect very
slowly resolving pneumonia considering appearance on prior CTA
of the chest of [**2135-2-10**]. An area of adjacent linear
atelectasis at right base has slightly improved. No new areas of
consolidation are identified.
ECHOCARDIOGRAMS:
[**2135-1-7**] ECHO: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. The
right ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
[**2135-2-14**]: The estimated right atrial pressure is 0-10mmHg. There
is moderate global left ventricular hypokinesis (LVEF = 30 %).
RV with depressed free wall contractility. There is a small to
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade. Compared with the prior
study (images reviewed) of [**2135-2-11**], the pericardial effusion
appears slightly smaller (still mainly anterior). LV systolic
function appears slightly lower.
[**2135-3-1**]: The left atrium and right atrium are normal in cavity
size. The estimated right atrial pressure is 0-5 mmHg. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is globally depressed (LVEF=
25 %). No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size is normal. with mild global free
wall hypokinesis. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of [**2135-2-14**], the pericardial effusion has resolved.
Left ventricular systolic function is similar (was overestimated
on the prior study).
OTHER STUDIES:
[**2135-1-7**] Renal U/S: No evidence of hydronephrosis. 3-mm
non-obstructing left renal stone and left parapelvic cyst.
[**2135-1-7**] CT Head w/out Contrast: 1. No intracranial hemorrhage
or edema.
2. Prominence of the bifrontal CSF spaces, which may be due to
parenchymal
atrophy or chronic subdural hygromas.
[**2135-1-12**] Bilateral Upper Extremity U/S: No DVT.
PATHOLOGY
Pathology Examination
SPECIMEN SUBMITTED: BONE MARROW (1 JAR)
[**2135-2-17**] [**2135-2-18**] [**2135-2-23**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**]/ttl
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS: HYPERCELLULAR MARROW FOR AGE WITH MILD DYSPOIESIS AND
LEFT-SHIFTED MYELOPOIESIS, SEE NOTE.
Note: Blasts comprise 5% of aspirate differential. Review of
marrow core biopsy shows focal interstitial areas with
left-shifted maturation and clusters of immature cells. Of
note, the patient's original blast phenotype was CD34-, CD117-
precluding further immunohistochemical characterization of these
immature cells. The morphologic differential diagnosis includes
residual disease versus recovering hematopoiesis. By
immunohistochemistry, CD34 highlights rare scattered
interstitial myeloblasts, which are less than 5% of marrow
cellularity. A CD4 stain highlights scattered small lymphoid
cells without definite staining in immature cells. CD117
staining shows several interstitial clusters of immature myeloid
precursors, overall comprising 20% of marrow cellularity. The
latter may be indicative of recovering left-shifted
hematopoiesis.
Please correlate with clinical and cytogenetic findings. If
clinically indicated, a re-biopsy to assess interval change may
be contributory.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are
decreased in number, are normochromic, with anisopoikilocytosis
including echinocytes, acanthocytes, microcytes, and
dacryocytes. The white blood cell count appears decreased.
Platelet count appears normal; large forms are seen.
Differential count shows 79% neutrophils, 6% bands, 3%
monocytes, 11% lymphocytes, less than 1% eosinophils, 1%
basophils.
Aspirate Smear:
The aspirate material is adequate for evaluation and consists of
several cellular spicules. The M:E ratio is 2.6. Erythroid
precursors are normal in number and show overall normoblastic
maturation; rare erythroid precursor with asymmetric nuclear
budding is seen. Myeloid precursors appear normal in number and
show full spectrum maturation. Megakaryocytes are present in
normal number; occasional abnormal megakaryocytes with
disjointed nuclei are seen.
Differential shows: 5% Blasts, 3% Promyelocytes, 11% Myelocytes,
10% Metamyelocytes, 22% Bands/Neutrophils, 2% Plasma cells, 27%
Lymphocytes, 20% Erythroid.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation, and consists of
a 1.1 cm core biopsy of trabecular bone. Overall cellularity is
estimated to be 50%. The M:E ratio estimate is normal.
Erythroid precursors are normal in number and exhibit mildly
megaloblastic maturation. Myeloid elements are normal in number
with complete maturation to neutrophils noted in some areas.
However, focally maturation is markedly left-shifted with
interstitial clusters of immature mononuclear cells noted.
Megakaryocytes are present in normal numbers, and are focally
tightly clustered.
A non-paratrabecular lymphoid aggregate comprised of
predominantly small lymphocytes is present, and accounts for 5%
of the marrow cellularity.
Cytogenetics studies: see separate report
Flow cytometry studies: see separate report
Cytogenetics Report BONE MARROW - CYTOGENETICS Procedure Date of
[**2135-2-18**]
Specimen Type: BONE MARROW - CYTOGENETICS
Date and Time Taken: [**2135-2-17**] 5:30 PM Date Processed: [**2135-2-18**]
KARYOTYPE: 47,XY,+8[2]/46,XY[18]
INTERPRETATION:
Two of 20 metaphases contained an extra chromosome 8
(TRISOMY 8).
Small chromosome anomalies may not be detectable using the
standard methods employed.
Cytogenetics Report FLUID,OTHER Procedure Date of [**2135-2-14**]
Date and Time Taken: [**2135-2-14**] TIME NOT NOTED Date Processed:
[**2135-2-14**]
Requesting Physician: [**Name (NI) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Location: INPATIENT
FISH evaluation for a chromosome 8 aneuploidy was attempted
with the Vysis CEP 8 DNA Probe (chromosome 8 alpha
satellite DNA) at 8p11.1-q11.1. However, there were an
insufficient number of cells in the specimen. The FISH
analysis could not be performed.
Brief Hospital Course:
80 year old gentleman with minimal PMH admitted as a transfer
from an outside hospital with new diagnosis of AML and concern
for tumor lysis and evolving DIC.
# AML: Newly diagnosed with complications of DIC, tumor lysis
syndrome and acute renal failure on admission. Initially treated
with leukopheresis, hydration, hydroxyurea and rasburicase, then
developed worsening renal failure and was transferred to the ICU
for CVVH as discussed below. After discussion with the patient
and family, it was decided that he will recieve chemotherapy. He
completed a 7 day course of azacitidine and received gentuzumab
on day 8 which he tolerated well with an appropriate response in
his counts. CNS involvement of his AML is discussed below.
# CNS/Leptomeningeal Involvement of CML: During the patient's
course he complained of back and leg pain that were thought to
be due to neurologic involvement of his AML. He had a MRI head
which revealed leptomeningeal involvement. He received 4 courses
of IT chemotherapy via LP (MTX x2, Cytarabine x2). A family
meeting was held and it was decided that the patient would
continue to receive IT chemotherapy. An Ommaya port was placed
by neurosurgery and used for IT chemotherapy. At the time of
discharge the patient had had 2 rounds of IT MTX and 1 round of
IT cytarabine. Arrangements were made for the patient to be seen
by Dr. [**First Name8 (NamePattern2) 15139**] [**Last Name (NamePattern1) 22114**] at [**Hospital3 3583**]. Last treatment of IT
chemo was cytarabine on [**2135-2-25**].
# Neutropenic Fevers: His neutropenic course was complicated by
persistent fevers due to pneumonia. He received a prolonged
course of cefepime, vancomycin, metronidazole and micafungin. He
became afebrile ~7 days prior to his counts returning to normal
levels. Once he was no longer neutropenic his cefepime and
vancomycin were discontinued and metronidazole and micafungin
continued.
# PNA: Neutropenic course with pneumonias as discussed above,
treated with cefepime and flagyl. After resolution of his
neutropenia the patient was afebrile for several weeks. He
developed low grade fevers again shortly before discharge and a
repeat CXR showed possible ongoing vs slowly resolving PNA. A
7-day course of levoquin was started and continued at discharge.
# Tumor Lysis Syndrome: Patient presented with elevated uric
acid, LDH and acute renal failure. S/p Rasburicase on [**2135-1-7**] x
1 for hyperuricemia. Initially was treated with Allopurinol,
Hydroxyurea, Rasburicase and Leukopheresis. WBC initially
improved but DIC & tumor lysis were noted to be worsening. He
also had increased O2 requirement which was thought to be likely
multifactorial related to leukemic infiltrate, volume overload,
and question of a LLL pneumonia for which patient has been
receving vancomycin and cefepime. Patient had been having
relative hypotension on the floor with blood pressures in the
80s to 90s for which patient was triggered twice on floor
yesterday, though these have responded well to small (250 mL)
fluid bolus x 2.
# Acute Renal Failure: likely due to leukostasis effects from
elevated WBC and TLS. Urine cultures were NGTD x 2. Renal u/s
with no evidence of hydronephrosis. 3-mm non-obstructing left
renal stone and left parapelvic cyst. Patient received CVVH (as
above). After CVVH his renal function returned to [**Location 213**] and he
had no further issues with renal failure.
# Hyperphosphatemia: On [**1-8**] the patient was transferred to the
[**Hospital Unit Name 153**] when it was noted that his phosphate level was 11.9 and
nephrology thought that urgent dialysis was appropriate. Patient
was also noted to have hypocalcemia as discussed below.
# Hypocalcemia: with hyperphosphatemia as above. Transient
numbness as noted during episode of hypocalcemia. Corrected
serum calcium fell to 7 and ionized calcium was 0.71. Treated
with calcium gluconate.
# Heart Failure/Pericardial effusion: Patient's EF was 60% prior
to chemotherapy. During his course patient was found to be in
mild respiratory distress with a RR in the 30s. A CTA was done
which again revealed pneumonia but no PE. A TTE was done to
evaluate for tamponade and the patient was found to have
developed a moderate loculated pericardial effusion but had no
signs of tamponade. His EF was found to be 40-45% on this study.
His respiratory distress subsequently resolved without new
interventions. A repeat TTE was done to evaluate his pericardial
effusion and this was found to be stable, but his EF was now
30%. Cardioglogy was consulted and it was decided to treat with
maximal medical therapy for new heart failure.
- a repeat echo was performed on [**2135-3-1**], results of which were
pending at the time of discharge
# Hypoactive Delirium: During his hospital course the patient
was found to less interactive and shuttered. This was initially
thought to be due to depression. A psychiatry consult was
obtained and they concluded that the patient had developed a
hypoactive delirium. He was then started on low dose zyprexa and
this resolved. Ritalin was started with good initial affect, and
the patient was briefly noted to be significantly more alert and
participatory, although this change did not seem to last more
than one day. His ritalin dose might be titrated up if this
continues to be an issue.
# Transient Numbness: During hospitalization patient was noted
to have perioral numbness, numbness of left face and left hand,
and some concern for left facial droop. Head CT showed no acute
abnormality. His parasthesias abated with treatment of his
hypocalcemia.
# Coagulopathy: This was [**2-22**] underlying DIC secondary to acute
leukemia and tumor lysis syndrome. Patient was provided support
with cryo and FFP. He had no issues with bleeding and his DIC
resolved.
# Transaminitis: Mild, likely due to leukemia, leukostatic
effects. No h/o infectious exposure or mediation effect
(Tylenol, etc). It subsequently resolved.
COPY OF DISCHARGE SUMMARY TO BE SENT TO:
[**First Name8 (NamePattern2) 15139**] [**Last Name (NamePattern1) 22114**], MD
[**Location (un) 81195**]
[**Location (un) 3320**], [**Numeric Identifier 40624**]
([**Telephone/Fax (1) 84082**]
Fax: [**Telephone/Fax (1) 84083**]
Medications on Admission:
Omeprazole
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**]
Drops Ophthalmic PRN (as needed) as needed for eye irritation.
2. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
4. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a
day (in the morning)).
5. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO QNOON ().
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Saliva Substitution Combo No.2 Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center- [**Location (un) 11792**]
Discharge Diagnosis:
AML
Hypoactive Delirium
PNA
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 69**]. You were originally
admitted to the hospital with elevated blood counts. We
performed bone marrow biopsy and found that you had acute
leukemia. We found that your kidneys were overwhelmed by the
leukemia, which we had to help you with a form of hemodialysis.
Your kidney recovered after a period of time. We provided you
with supportive care and transfusions of red blood cells and
plaletes. We also started you on chemotherapy which we injected
into your central nervous system. We started you on a medication
called ritalin (methylphenidate) to help stimulated your mood
and your appetite. Finally, we started you on a course of
antibiotics for a pneumonia which you had developed.
We have changed several of your medications during your stay.
Please take all of your medications exactly as prescribed.
Please follow up with the following doctors [**First Name (Titles) 3**] [**Last Name (Titles) 8757**] below.
Followup Instructions:
[**First Name8 (NamePattern2) 15139**] [**Last Name (NamePattern1) 22114**], MD
[**Location (un) 81195**]
[**Location (un) 3320**], [**Numeric Identifier 40624**]
Phone: ([**Telephone/Fax (1) 84082**]
Appointment:
Friday, [**3-4**], 9:40AM
|
[
"205.00",
"275.3",
"584.5",
"E933.1",
"288.03",
"428.21",
"486",
"276.8",
"286.6",
"427.31",
"428.0",
"423.9",
"275.41",
"293.0",
"277.88",
"780.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"39.95",
"99.72",
"38.93",
"41.31",
"01.28",
"03.92",
"99.25",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
20930, 21009
|
13424, 19648
|
287, 383
|
21080, 21080
|
2474, 2479
|
22289, 22533
|
1916, 1981
|
19709, 20907
|
21030, 21059
|
19674, 19686
|
21261, 22266
|
1996, 2455
|
240, 249
|
6001, 13401
|
411, 1554
|
2493, 5981
|
21094, 21237
|
1576, 1679
|
1695, 1900
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,577
| 120,675
|
47809
|
Discharge summary
|
report
|
Admission Date: [**2127-12-7**] Discharge Date: [**2127-12-17**]
Date of Birth: [**2063-4-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Oversew of colonic deserosalization.
History of Present Illness:
64 year old female who presents with sudden onset of
periumbilical pain that started early this morning at around
5AM. Abdominal pain is mid abdomen with no radiation; relieved
by pain meds and no definite aggravating factors. Associated
nausea and vomiting ~6 times. Bilious; no blood. Denies any
fevers, chills. Bowel movements this morning; flatus last night.
Past Medical History:
- ovarian cancer, diagnosed in [**2109**] and treated with TAH BSO and
6 runs of chemotherapy complicated by deep vein thrombosis in
left lower extremity and was on coumadin briefly
- bladder cancer, diagnosed in [**2114**] and treated with cystecomy
and ileal conduit and stoma
- documented to have chronic anemia of unknown etiology
- pt. reported last colonoscopy 5 years ago with no abnormal,
she did have polyp removed during colonoscopy 10 years ago but
was not sure if malignancy was found.
-osteoporosis
PSYCHIATRIC HISTORY:
Patient has a diagnosis of "psychotic disorder" and has been
treated by her primary care provider successfully with
thorazine. She does not see any therapists or psychiatrists at
this time. She saw Dr. [**Last Name (STitle) 100898**] in therapy 1x/mo for 6yrs
until she changed her insurance in [**Month (only) 547**]. She reports trying
Zoloft for a short time in [**2111**] but did not mention results.
Hospitalizations: [**2111**] - "[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Accomodations"
[**2110**] - [**Hospital1 336**]
[**2092**] - [**Hospital1 **] [**Hospital1 **] 4
Patient reports 1 prior suicide attempt in [**2084**] when she
"stopped eating and wearing warm clothes and stayed out all
night, everything to excess." She was then hospitalized for
pneumonia, no history of hurting herself.
Social History:
Born in Mission [**Doctor Last Name **] and raised in [**Location (un) 669**], one of 11 children
(10 per OMR). She reports 7 living (OMR notes say 6) and all
except two sisters are in the [**Name (NI) 86**] area. Lives alone. Remote
smoker, no drugs/etoh
Family History:
She had ten siblings. Malignancy in the family: Deceased Sister:
ovarian ca
Sister: breast cancer Brother : Ca brain Brother: Liver cancer
Father: Prostate cancer; Mother's sister had schizophrenia.
Physical Exam:
Constitutional: Comfortable
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds
Abdominal: Diffuse tenderness to palpation. No guarding or
rebound tenderness to palpation. Abdomen nondistended, Soft.
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
[**2127-12-7**] 02:45PM URINE HOURS-RANDOM
[**2127-12-7**] 02:45PM URINE GR HOLD-HOLD
[**2127-12-7**] 02:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2127-12-7**] 02:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM
[**2127-12-7**] 02:45PM URINE RBC-0-2 WBC-[**4-18**] BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2127-12-7**] 02:11PM K+-4.1
[**2127-12-7**] 02:02PM GLUCOSE-129* UREA N-28* CREAT-1.4* SODIUM-144
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-26 ANION GAP-14
[**2127-12-7**] 12:30PM GLUCOSE-137* UREA N-31* CREAT-1.4* SODIUM-143
POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-28 ANION GAP-16
[**2127-12-7**] 12:30PM ALT(SGPT)-13 AST(SGOT)-32 ALK PHOS-75 TOT
BILI-0.3
[**2127-12-7**] 12:30PM LIPASE-55
[**2127-12-7**] 12:30PM CALCIUM-9.6
[**2127-12-7**] 12:30PM WBC-6.3# RBC-3.65* HGB-10.6* HCT-32.6* MCV-89
MCH-29.2 MCHC-32.7 RDW-13.9
[**2127-12-7**] 12:30PM NEUTS-87.4* LYMPHS-9.4* MONOS-2.4 EOS-0.5
BASOS-0.3
[**2127-12-7**] 12:30PM PLT COUNT-190
[**2127-12-8**] Abdominal CT w/ contrast: 1. High-grade small-bowel
obstruction, with dilation of the mid small bowel up to 3.4 cm.
The proximal and distal small bowel are decompressed and two
closely approximated transition points are seen in the
mid-abdomen, concerning for a closed loop obtruction, possibly
secondary to either internal hernia or
adhesion. While there is associated wall edema, mesenteric
fluid, and
adjacent ascites, there is no pneumatosis or portal venous air
identified to definitively suggest ischemia.
2. Status post right nephroureterectomy and radical cystectomy,
with
unremarkable appearance of urostomy in the right lower quadrant.
No definite evidence of metastatic disease. Small nodular
density at the left lung base is stable, though attention on
followup is warranted.
3. Stable 4 mm hypodensity within the body of the pancreas,
unchanged.
4. IVC filter in standard position.
[**2127-12-12**] EKG: Sinus rhythm with sinus arrhythmia. Borderline low
limb lead voltage. Diffuse non-specific ST-T wave abnormalities.
Compared to the previous tracing of [**2127-12-8**] findings are
similar.
Brief Hospital Course:
Ms. [**Known lastname 20400**] presented to the Emergency Department on [**2127-12-7**] with complaints of sudden onset abdominal pain at the
umbilical level associated with nausea and vomiting and not
relieved with over the counter pain medication. An abdominal
x-ray was obtained, which indicated a small bowel obstruction.
Therefore, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube was placed and the patient was
transferred to the general surgical [**Hospital1 **] for management.
On hospital day #1 the patient developed worsening abdominal
pain. Additionally, an abdominal CT scan had beeb obtained,
which revealed a high grade small bowel obstruction. Given the
worsening abdominal exam and the results of the CT scan, the
patient was brought to the operating room, where an exploratory
laparotomy, lysis of adhesions and oversew of colonic
deserosaliazation was performed. There were no adverse events
in the operating room; please see the operative note for
details. Pt was extubated, taken to the PACU until stable, then
transferred to the surgical intensive care unit for close
observation.
On hosptial day #2 the patient remained stable, was weaned from
the ventilator and extubated. She was subsequently transferred
to the general surgical [**Hospital1 **] for further management.
Neuro: The patient was alert and oriented throughout her
hospitalization; pain was initially controlled with intravenous
Dilaudid. The patient reported complete resolution of pain by
post-operative day #5 and did not require pain medication for
the remainder of her hospitalization.
CV: The patients vital signs were routinely monitored. She
became hypertensive in the intensive care unit with a systolic
blood pressure in the 160s. Additionally, she had 8 beats of
non-sustained ventricular tachycardia on post-operative day #4.
She was maintained on intravenous metoprolol which was initiated
in the intensive care unit and continued until post-operative
day #8; her blood pressure and heart rate remained within
acceptable limits without metoprolol administration.
Pulmonary: The patient tolerated extubation postoperatively
without difficulty and maintained appropriate oxygen saturation
levels throughout her admission.
GI/GU/FEN: She was initially NPO with IV fluids and a
[**Last Name (un) **]-gastric tube, which was removed on post-operative day #4.
Diet was advanced sequentially, which was well tolerated,
however, oral liquid and solid intake was initially suboptimal.
Nutritional supplements were then provided with each meal with
improved overall oral intake; she will continue this regimen at
home to optimize her nutritional status Patient's intake and
output were closely monitored, and IV fluid was adjusted when
necessary; electrolytes were routinely monitored and repleted as
necessary.
ID: The patient's white blood cell counts and fever curves were
monitored routinely throughout her admission and did not show
any signs of intrabdominal or wound infections.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; she was encouraged to
get up and ambulate as early as possible.
Rehab: Given her prolonged hospital course and operation, a
physical therapy consult was requested. She was evaluted on
post-operative day #8 and deemed safe for discharge home without
additional physical therapy requirements.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding via her urostomy tube, and pain was
well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Risperidone 1 mg Tab QPM
Vitamin D 800 unit Tab daily
Calcium 1200 mg Chewable Tab daily
Discharge Medications:
1. risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. calcium 500 mg Tablet Sig: 2.5 Tablets PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-23**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3201**] to make a follow-up
appointment for Friday, [**2127-12-26**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2127-12-12**] 3:30
Completed by:[**2127-12-18**]
|
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"V10.05",
"298.9",
"427.1",
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"V10.43",
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"733.00",
"789.59",
"560.2",
"V10.52",
"V10.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
9580, 9586
|
5342, 9204
|
330, 422
|
9654, 9654
|
3145, 5319
|
11275, 11594
|
2526, 2726
|
9343, 9557
|
9607, 9633
|
9230, 9320
|
9805, 11252
|
2741, 3126
|
276, 292
|
450, 815
|
9669, 9781
|
837, 2235
|
2251, 2510
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,664
| 180,551
|
37201
|
Discharge summary
|
report
|
Admission Date: [**2162-1-10**] Discharge Date: [**2162-1-19**]
Date of Birth: [**2087-9-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
History of Present Illness:
Mr. [**Known lastname 2643**] is a 74 year old man with a recent diagnosis of
squamous cell cancer of the head and neck. He was living in a
nursing home for the past month after a fall at home. He was
agitated on the morning of admission ([**1-10**])and pulled out his
foley. Had bleeding from his penis and was sent to the ED, but
en route, became unresponsive. Prior to this admission, was
conversant and had a normal mental status. One week ago, he was
discharged after a new diagnosis of neck cancer.
.
On arrival to [**Location (un) 620**], was in afib with RVR with rates to 170s;
cardioversion was attempted and not successful. Had a temp to
104.5 rectally and started on vanco, flagyl, levaquin. Was
hypotensive and started on levophed, neosynephrine, and
vasopressin and intubated. Received a total of 8L IVF's at
[**Location (un) 620**] as well as stress dose steroids. When OG tube placed,
had 100 cc coffee ground output. At OSH, lactate 8.5, wbc 19.8,
hct 37.
.
Was transferred to [**Hospital1 18**] ED where patient had R IJ CVL placed.
Pressors were titrated up slightly, but then stable. CT scan of
the chest showed a left sided pneumonia. He spontaneously
converted to NSR. EKG showed <1MM STE in V2 and V3; cards
rcommended ASA for now and no futher anticoagulation.
.
Patient was transferred to the ICU where he was initially
treated with broad spectrum antibiotics. CTA of his chest showed
no PE, but after volume resuscitation demonstrated a massive LUL
pneumonia. Patient was treated with a course of
vancomycin/cefepime. Self extubated on morning of [**2162-1-13**].
Vasopressors were weaned off as of 10am on [**2162-1-13**]. Stress dose
steroids were discontinued as no concern for adrenal
insufficiency.
.
At time of transfer to the floor, last VS were:
T96.7 HR 96-110 A. Fib, BP 108/73, RR 26, O2 95% 2L NC.
UOP: 100-150cc/hr
LOS Fluid Balance +11 Liters
Last 24 Hours: Negative 800cc
Past Medical History:
-colon cancer 10 yrs ago?
-new diagnosis of metastatic neck cancer 1 wk ago, has pulmonary
nodules concerning for mets but no other known metastatic sites.
Current plan is not definite but considering palliative
chemo/xrt vs. hospice.
-hypothyroidism
-BPH
Social History:
History of etoh abuse per notes. Unknown tobacco history.
Unknown drug history. He was living independently until recent
admission for neck mass. He has been at a nursing home since
that time with no recent alcohol consumption.
Family History:
non-contributory
Physical Exam:
Hr 99, BP 109/55, RR 26, 95% 2L NC
Gen - comfortable, NAD
HEENT: NCAT, o/p with large mass in right side, dried blood
Neck supple
Lungs decreased b/s biaterally at bases and in LUL.
Heart Irregular, mildly tachycardic, no murmurs noted
Abd: soft NTND
ext: wwp. no c/c/e
Neuro: AOx2 - know is at hospital but not sure of date and which
hospital. moves all extremities, CN II-XII grossly intact.
Pertinent Results:
[**2162-1-10**] 11:25AM BLOOD WBC-16.5* RBC-3.35* Hgb-10.6* Hct-31.0*
MCV-92 MCH-31.6 MCHC-34.2 RDW-14.3 Plt Ct-218
[**2162-1-10**] 06:45PM BLOOD WBC-27.2*# RBC-4.08* Hgb-12.8* Hct-38.6*
MCV-95 MCH-31.4 MCHC-33.2 RDW-14.9 Plt Ct-215
[**2162-1-11**] 01:59AM BLOOD WBC-25.4* RBC-3.72* Hgb-11.5* Hct-35.4*
MCV-95 MCH-30.9 MCHC-32.4 RDW-15.0 Plt Ct-154
[**2162-1-12**] 04:42AM BLOOD WBC-24.7* RBC-3.57* Hgb-11.2* Hct-32.3*
MCV-91 MCH-31.5 MCHC-34.8 RDW-14.5 Plt Ct-126*
[**2162-1-13**] 02:52AM BLOOD WBC-16.1* RBC-3.27* Hgb-10.1* Hct-30.0*
MCV-92 MCH-31.0 MCHC-33.7 RDW-15.1 Plt Ct-103*
[**2162-1-14**] 04:05AM BLOOD WBC-11.4* RBC-3.58* Hgb-11.0* Hct-32.8*
MCV-92 MCH-30.8 MCHC-33.7 RDW-14.9 Plt Ct-108*
[**2162-1-15**] 07:00AM BLOOD WBC-8.4 RBC-3.65* Hgb-11.3* Hct-32.7*
MCV-90 MCH-31.0 MCHC-34.6 RDW-14.6 Plt Ct-125*
[**2162-1-16**] 11:49AM BLOOD WBC-8.9 RBC-3.54* Hgb-11.1* Hct-32.4*
MCV-92 MCH-31.4 MCHC-34.3 RDW-15.5 Plt Ct-150
[**2162-1-17**] 06:15AM BLOOD WBC-8.4 RBC-3.75* Hgb-11.3* Hct-34.5*
MCV-92 MCH-30.2 MCHC-32.8 RDW-15.7* Plt Ct-172
[**2162-1-10**] 11:25AM BLOOD PT-19.1* PTT-39.9* INR(PT)-1.7*
[**2162-1-15**] 07:00AM BLOOD PT-12.9 PTT-26.6 INR(PT)-1.1
[**2162-1-10**] 06:45PM BLOOD Glucose-198* UreaN-19 Creat-1.0 Na-141
K-3.8 Cl-113* HCO3-16* AnGap-16
[**2162-1-12**] 04:42AM BLOOD Glucose-121* UreaN-19 Creat-0.6 Na-138
K-4.2 Cl-112* HCO3-19* AnGap-11
[**2162-1-14**] 04:05AM BLOOD Glucose-87 UreaN-9 Creat-0.5 Na-150*
K-2.6* Cl-113* HCO3-29 AnGap-11
[**2162-1-15**] 07:00AM BLOOD Glucose-111* UreaN-6 Creat-0.5 Na-147*
K-3.2* Cl-107 HCO3-31 AnGap-12
[**2162-1-16**] 11:49AM BLOOD Glucose-114* UreaN-9 Creat-0.5 Na-142
K-2.9* Cl-105 HCO3-30 AnGap-10
[**2162-1-17**] 06:15AM BLOOD Glucose-156* UreaN-10 Creat-0.5 Na-142
K-4.0 Cl-107 HCO3-26 AnGap-13
[**2162-1-10**] 11:25AM BLOOD CK(CPK)-755*
[**2162-1-10**] 06:45PM BLOOD ALT-89* AST-174* CK(CPK)-1026* AlkPhos-81
TotBili-0.9
[**2162-1-11**] 01:59AM BLOOD ALT-120* AST-209* CK(CPK)-743* AlkPhos-66
TotBili-0.5
[**2162-1-12**] 04:42AM BLOOD CK(CPK)-289*
[**2162-1-14**] 04:05AM BLOOD CK(CPK)-152
[**2162-1-15**] 07:00AM BLOOD CK(CPK)-82
[**2162-1-10**] 11:25AM BLOOD CK-MB-14* MB Indx-1.9 cTropnT-0.35*
[**2162-1-10**] 06:45PM BLOOD CK-MB-24* MB Indx-2.3 cTropnT-0.31*
[**2162-1-11**] 01:59AM BLOOD CK-MB-23* MB Indx-3.1 cTropnT-0.31*
[**2162-1-12**] 04:42AM BLOOD CK-MB-14* MB Indx-4.8 cTropnT-0.44*
[**2162-1-14**] 04:05AM BLOOD CK-MB-4 cTropnT-0.30*
[**2162-1-15**] 07:00AM BLOOD CK-MB-NotDone cTropnT-0.31*
[**2162-1-10**] 06:45PM BLOOD Albumin-2.7* Calcium-6.1* Phos-3.2
Mg-1.5*
[**2162-1-14**] 04:05AM BLOOD Calcium-8.4 Phos-1.7* Mg-1.6
[**2162-1-17**] 06:15AM BLOOD Calcium-8.0* Phos-4.0# Mg-2.0
[**2162-1-10**] 11:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2162-1-10**] 11:52AM BLOOD Rates-/16 Tidal V-500 PEEP-5 FiO2-100
pO2-106* pCO2-40 pH-7.28* calTCO2-20* Base XS--7 AADO2-582 REQ
O2-94 -ASSIST/CON Intubat-INTUBATED
[**2162-1-12**] 08:47AM BLOOD Type-ART Temp-37.4 Rates-/19 PEEP-0
FiO2-40 pO2-107* pCO2-35 pH-7.40 calTCO2-22 Base XS--1
Intubat-INTUBATED Vent-SPONTANEOU Comment-PRESSURE S
[**2162-1-10**] 11:47PM BLOOD Lactate-4.2*
[**2162-1-12**] 08:47AM BLOOD Lactate-1.9
[**2162-1-19**] 05:33AM BLOOD WBC-8.2 RBC-3.39* Hgb-10.1* Hct-31.5*
MCV-93 MCH-29.8 MCHC-32.0 RDW-15.8* Plt Ct-223
[**2162-1-19**] 05:33AM BLOOD Glucose-84 UreaN-7 Creat-0.5 Na-142 K-3.3
Cl-109* HCO3-28 AnGap-8
[**2162-1-19**] 05:33AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9
[**2162-1-18**] 06:26AM BLOOD Triglyc-128 HDL-32 CHOL/HD-5.1
LDLcalc-105
[**2162-1-18**] 06:26AM BLOOD TSH-26*
[**2162-1-19**] 05:33AM BLOOD T4-6.1
[**2162-1-18**] 06:26AM BLOOD Vanco-16.4
Imaging
[**2162-1-10**]
CT Chest/Abdomen
1. Complete consolidation of the left lower lobe without
significant volume loss, consistent with massive pneumonia.
Right lower lobe infiltrate. Given distribution, aspiration is
suspect as etiology. Small bilateral pleural effusions.
2. No pulmonary embolism or acute aortic pathology. Significant
atherosclerotic disease.
3. Simple cholelithiasis. [**Doctor First Name **] mesentery, nonspecific.
4. Appearance of thickened bladder wall in a partially collapsed
bladder,
incompletely assessed. Recommend clinical correlation to exclude
cystitis or urinary tract infection.
[**2162-1-10**] CT Head
1. No acute intracranial hemorrhage or major vascular
territorial infarct.
2. Expansile, sclerotic bony lesion centered in the sphenoid
bone, likely
bone metastasis.
3. Global atrophy with chronic microvascular ischemic disease.
[**2162-1-14**] ECHO
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-10mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with anteroseptum and anterior
wall hypokinesis. Overall left ventricular systolic function is
mildly depressed (LVEF= 40 %). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a small
pericardial effusion. The effusion appears circumferential.
IMPRESSION: Mild regional left ventricular systolic dysfunction.
Very small pericardial effusion.
[**2162-1-14**]
Catheter Placement
IMPRESSION: Successful fluoroscopically guided repositioning of
a right upper extremity PICC line. The catheter tip is in the
superior vena cava, and the catheter is ready for use.
[**2162-1-15**]
Video Swallow
SWALLOWING VIDEO FLUOROSCOPY: Oropharyngeal swallowing
videofluoroscopy was performed in conjunction with the speech
and swallow division. Multiple consistencies of barium were
administered.
Barium passed freely through the oropharynx and esophagus
without evidence of obstruction.
There is no gross aspiration or penetration. For full details,
please refer to speech and swallow division note in OMR.
[**2162-1-16**] CXR
PA and lateral upright chest radiograph was compared to [**1-14**], [**2161**].
The right PICC line tip is at the level of cavoatrial junction.
There is a combination of left lower lobe consolidation with
left pleural effusion that overall appears to be improved since
[**2162-1-14**]. There is also overall improvement of pulmonary
edema, but the asymmetric appearance of the left basal
consolidation is concerning for infection. Another asymmetric
area in more diffuse manner is in the right upper lobe that also
might be consistent with partial resolution of pulmonary edema
versus infectious process.
[**2162-1-19**] 05:33AM BLOOD WBC-8.2 RBC-3.39* Hgb-10.1* Hct-31.5*
MCV-93 MCH-29.8 MCHC-32.0 RDW-15.8* Plt Ct-223
[**2162-1-19**] 05:33AM BLOOD Glucose-84 UreaN-7 Creat-0.5 Na-142 K-3.3
Cl-109* HCO3-28 AnGap-8
[**2162-1-19**] 05:33AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9
[**2162-1-18**] 06:26AM BLOOD Triglyc-128 HDL-32 CHOL/HD-5.1
LDLcalc-105
[**2162-1-18**] 06:26AM BLOOD TSH-26*
[**2162-1-19**] 05:33AM BLOOD T4-6.1
[**2162-1-18**] 06:26AM BLOOD Vanco-16.4
[**2162-1-18**] Doppler of lower extremities
IMPRESSION: No deep venous thrombosis in the lower extremities
bilaterally.
Brief Hospital Course:
Mr. [**Known lastname 2643**] is a 74 year old man with a recent diagnosis of a
squamous cell head/neck cancer who was transferred to [**Hospital1 18**] with
septic shock from pneumonia.
.
# Pneumonia: He had an extensive pneumonia visible on CT scan
when he presented. He required three pressors and intubation. He
was treated empirically with vancomycin and cefepime. There was
no growth in any of the sputum or blood cultures. He received
periodic chest xrays to monitor the radiographic improvement of
his pneumonia. On discharge he had received a total of 9 days of
vancomycin and 10 days of cefepime. He will continue on
levofloxacin to complete a total course of 14 days. He will
need a follow-up CT chest in [**5-18**] weeks to ensure resolution of
infiltrate.
.
# Thromobocytopenia: Mr. [**Known lastname 2643**] had a decrease in his platelets
during admission of 50%. All heparin products were stopped. A
pf4 test was cancelled because he did not meet criteria for
testing. His platelets gradually increased as he began to
clinically improve. There were multiple reasons for his
thrombocytopenia including sepsis, bleeding, and drug effect.
Platelet count on discharge was 223.
.
# Atrial fibrillation with RVR: A. fib likely a response to
sepsis. As he clinically improved he returned to [**Location 213**] sinus.
.
# NSTEMI/Demand: Troponin peaked at 0.44 and CK at 1026 and MB
at 24. Elevation in enzymes thought likely related to increased
demand/sepsis/atrial fibrillation. Started on beta-blockers to
reduce cardiac workload. He was not started on aspirin initially
out of concern for bleeding given his presentation of coffee
ground emesis, which was likely to be blood from is SCC in his
mouth. He was started on a statin and discharged on aspirin. A
f/u TTE revealed an EF 40% and mild anterior wall hypokinesis.
.
# Squamous cell cancer: Patient has a squamous cell cancer. His
outpatient oncologist was contact[**Name (NI) **]. [**Name2 (NI) **] was in the middle of a
workup to determine treatment vs. palliation. He was scheduled
to be evaluated by radiation oncology, if he is a candidate. He
was not started on any treatment as an inpatient given his
pneumonia. The mass was bleeding during his stay in the ICU. The
area was packed with afrin soaked guaze. This was likely causing
his coffee ground emesis. His Hct has been stable. He needs to
follow up with his outpatient oncologist Dr. [**Last Name (STitle) 22956**].
.
# Bleeding from foley: Patient initially presented with bleeding
after self-removal of foley. His urine had trace blood after
removal. He had no difficulty urinating.
.
# Hypothyroidism: He was continued on his current dose of
levothyroxine. TSH was 26 but fT4 was normal at 6. No changes
were made to his dose of levothyroxine. He will need follow up
TSH in 4 weeks.
.
# Delerium: Patient was AxOx1 when discharged from the ICU. He
was delirious from sepsis and ICU. His foley and telemetry were
discontinued to decrease delirium triggers. He slowly improved
with reorientation and is now A&O x3 on discharge.
.
# Hypernatremia: Had been hypernatremic to 150 from poor PO
intake. he was placed on IVF and with improved PO intake, this
resolved to 142 on discharge.
.
# History of ETOH abuse: Records noted a history of alcohol
abuse. The extent of this was unknown. He was given folic acid,
thiamine, and multivitamin.
.
# Swallow evaluation: Patient was evaluated by speech and
swallow given the mass in his mouth. He failed a bedside swallow
evaluation. However, a video swallow showed no aspiration. He
was placed on a diet of ground solids and thin liquids. He took
his pills whole in puree or nectar thick liquids. He received
ensure plus for supplementation. Speech and swallow should
continue to assess him.
.
# Access: Right PICC
.
# Communication: [**Name (NI) 53767**] [**Name (NI) **] HCP
# Code: DNR per health care proxy. [**Name (NI) **] was ok to reintubate.
Medications on Admission:
Colace 200 mg daily
Lovenox 40 mg daily
Folic Acid 1 mg daily
Lactulose 20 gm daily
Levoxyl 100 mcg daily
MVI tab daily
Flomax 0.4 mg daily
Thiamine 100 mg daily
Zyprexa 2.5 mg daily
Mylanta PRN
Senna 8.6 PRN
Trazodone 25 mg tid PRN
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnosis: Pneumonia
Secondary Diagnosis:
Squamous Cell cancer of the head and neck
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the hospital with pneumonia. When you came
to the hospital, you required a breathing tube to help you
breathe. We gave you several antibiotics to help treat your
pneumonia.
Because you were so sick, you could not receive any treatment
for the cancer of your mouth. It is important to follow up with
your oncologist to see if radiation therapy would be helpful.
Followup Instructions:
Please follow up with your oncologist Dr. [**Last Name (STitle) 22956**] within 2 weeks.
She will arrange for an outpatient PET scan to assess the
extent of your cancer. She will also reschedule your
appointment with radiation oncology. Her clinic number is
[**Telephone/Fax (1) 83767**].
Please follow up with your primary care physician in one week.
|
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50,643
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55027
|
Discharge summary
|
report
|
Admission Date: [**2137-5-12**] Discharge Date: [**2137-5-24**]
Date of Birth: [**2059-1-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Found Down
Major Surgical or Invasive Procedure:
[**2137-5-22**] PROCEDURE:
1. Posterior cervical C1 laminotomy.
2. Posterior cervical C2 superior laminotomy and medial
facetectomy for removal of intraspinal extradural
abscess.
3. Spinal cord monitoring.
4. Insertion and removal of [**Location (un) 976**]-[**Doctor Last Name 3012**] tongs.
5. Biopsy of bone
6. Biopsy and cx of soft epidural soft tissue phlegmon.
History of Present Illness:
Mr. [**Known lastname 3236**] is a 78 year-old man with gout, HLD, HTN, Afib and
dementia who presents in the setting of being found down at his
home. Patient was not seen or spoken to since for 7 days and
when patient did not answer phone call yesterday, his family
became concerned. Patient has underlying dementia and lives at
home alone with family visiting regularly.
In the ED, initial VS were 160 154/92 20 80%RA (w/bad pleth
with 115 PaO2 on ABG). Labs were notable for WBC 14.8, HCT 53.3,
PLTs 167, INR 13.0, PTT 58.6, Fibrinogen 731, ALT 19, AST 80,
Lip 29, Tbili 1.5, Alb 3.2, Na 141, K6.6 that corrected to 4.2
with 2L NS, HCO3 25, Cr 1.2, CK 692 that rose to 739 after 2L NS
and Lactate 2.9, ABG 7.46/33/115. UA notable 99 RBC, 8 WBC and
many Bact. Patient was never hypoxic. Guaiac negative. Patient
was also noted to have a swollen and edematous left arm. LUE
U/S, CXR, CT head were reassuring. CT C-spne identified wideding
of the C1-occipital codyle joint and high density material near
the dens. Patient received tetanus toxoid vaccine for laceration
to left side of face. Patient also received 3L NS IV, metoprolol
5mg IV x2 for Atrial fibrillation and ceftriaxone 1g IV for UTI.
Given concern for compartment syndrome in LUE the patient was
admitted to MICU for further monitoring. Vitals signs on
transfer were 115 129/89 20 100% on 2L NC
On arrival to the MICU, the patient appeared comfortable and
was oridented x3 and ansering question approriately although
still confabulating (patient stated that his wife was in the
hospital, when in fact his wife has passed away).
Past Medical History:
- Afib w/ RVR
- Gout
- HTN
- HLD
- CHF
- Back pain (?Sciatica)
Social History:
Widower, no children, no living siblings
Mostly attended to by sister-in-laws and nephew
Smoked cigars x 50 years
Occasional EtOH
Family History:
No known history of malignancy, heart disease or diabetes
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
General: Alert and oriented x3 but confabulating, no acute
distress
HEENT: 4cm laceration to left scalp. Sclera anicteric, dry
mucous membranes, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic and irregular, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in palce draining dark urine
Ext: Warm, well perfused, 2+ pulses at BL radial and DP pulses,
no edema
Left arm was warm, 2+ radial pulse, not tense, no pallor
although is mildly painful to palpation.
Neuro: grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge Exam:
O: T 96.7 BP 140/84 HR 75 RR 18 99% RA
General: Awake and alert. Mental status waxes and wanes. AAOx1,
but has some insight into the fact that he can't remember the
date
HEENT: 1 cm raised nodule at distal eyebrow with dried blood,
conjunctiva clear, MMM, oropharynx clear
Neck: in c-collar
CV: irregularly irregular, no murmurs, rubs, gallops appreciated
Lungs: CTAB anteriorly and laterally
Abdomen: soft, NT/ND, no HSM, no rebound or guarding
Ext: Dry erythematous fingers worse on left hand with scaling.
Moist onchyomycosis between the toes. WWP. mild LE edema. 2+
distal pulses bilaterally.
Neuro: CN: intact; Motor: strength equal between the right and
left upper and lower extremities. Sensation intact throughout;
downgoing babinski
Pertinent Results:
LAB RESULTS ON ADMISSION:
[**2137-5-12**] 06:15PM BLOOD WBC-14.8* RBC-5.09 Hgb-17.5 Hct-53.3*
MCV-105* MCH-34.4* MCHC-32.8 RDW-14.2 Plt Ct-167
[**2137-5-12**] 06:15PM BLOOD PT-125.6* PTT-58.6* INR(PT)-13.0*
[**2137-5-12**] 06:15PM BLOOD UreaN-61* Creat-1.2 Na-141 K-6.6* Cl-103
HCO3-25 AnGap-20
[**2137-5-12**] 06:15PM BLOOD ALT-19 AST-80* CK(CPK)-692* AlkPhos-93
TotBili-1.5
[**2137-5-12**] 06:15PM BLOOD Lipase-29
[**2137-5-12**] 07:50PM BLOOD CK-MB-14* MB Indx-1.9
[**2137-5-12**] 07:50PM BLOOD cTropnT-0.04*
[**2137-5-12**] 11:44PM BLOOD CK-MB-12* MB Indx-2.0 cTropnT-0.05*
[**2137-5-13**] 05:14AM BLOOD CK-MB-9 cTropnT-0.03*
[**2137-5-12**] 06:15PM BLOOD Albumin-3.2*
[**2137-5-12**] 11:44PM BLOOD Albumin-3.1* Calcium-8.8 Phos-2.7 Mg-2.3
[**2137-5-12**] 09:48PM BLOOD D-Dimer-1826*
[**2137-5-12**] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2137-5-12**] 06:27PM BLOOD Type-ART pO2-115* pCO2-33* pH-7.46*
calTCO2-24 Base XS-0
[**2137-5-12**] 08:02PM BLOOD Lactate-2.9* K-4.1
[**2137-5-12**] 06:27PM BLOOD Hgb-17.2 calcHCT-52
Studies:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2137-5-12**] 6:07
PM
IMPRESSION: Limited study, however, no acute intrathoracic
process
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2137-5-12**]
6:08 PM
IMPRESSION: No acute intracranial process. High density material
near the
dens is better characterized on concurrent neck CT, however,
additional
imaging is recommended.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2137-5-12**]
6:09 PM
IMPRESSION:
1. No acute fracture.
2. Widening of the atlanto-occipital joint. High density
material seen near the dens may represent pannus and degernative
changes, however given trauma setting, the presence of blood
products is not excluded. MR is recommended for further
characterization.
3. Multilevel degenerative changes as described above.
Radiology Report UNILAT UP EXT VEINS US LEFT Study Date of
[**2137-5-12**] 8:49 PM
IMPRESSION: No DVT in the left upper extremity
Cervical spine MRI without contrast [**5-13**]:
1. Increased distance between the dens and the clivus with
extensive pre-, anterior and posterior para-vertebral, and
circumferential epidural soft tissue at C2 level causing
moderate spinal canal narrowing and deforming the spinal cord
with minimal edema in the cord. While these can relate an
inflammatory component along with degenerative
changes,associated post-traumatic changes and superimposed
hemorrhage/hematoma cannot be completely excluded.
Post-contrast sequences- axial T1 post ; sag T1 post contrast
with fat
sequences, axial GRE seq. including from clivus and Diffusion
sequences for cord can be helpful for better characterization
and to differentiate the etiology. If any priors are made
available, comparison can be made. Given the possible
instability, apprporiate c. spine precautions to be taken. Edema
in the posterior spinous soft tissues from C2-C5 level
with/without injury to the ligaments.
2. Multilevel multifactorial degenerative changes noted in the
cervical spine with moderate canal stenosis at C3/4, C5/6 and
C6/7 level.
Radiology Report MR CERVICAL SPINE with and without contrast
[**5-14**]:
4:52 PM
IMPRESSION:
1. Extensive homogenously enhancement in the pre-vertebral,
para-vertebral, and circumferential epidural soft tissue, and
peripherally enhancing posterior epidural collection at C2 level
causing moderate spinal canal narrowing and deforming the spinal
cord. These likely represent post traumatic changes with
epidural hematoma. However, the possibility of infection with
epidural abscess cannot be ruled out. There is no intrinsic
signal abnormality within the spinal cord.
2. Circumferential enhancement of the epidural soft tissues from
C1 to C6
level.
3. Edema in the dens and posterior spinous soft tissues from C2
to C5 levels.
4. High T2 signal intensity in the left vertebral artery at the
level of
C1/C2, suggesting slow flow, however thrombosis/disection of
this vessel
cannot be completely excluded, correlation with MRA and FAT/SAT
sequences is recommended.
5. Multilevel multifactorial degenerative changes noted in the
cervical spine with moderate canal stenosis at C3-C4, C5-C6 and
C6-C7 levels.
MRI C spine [**5-20**] - no significant change from prior, with
persistant enhancement and likely vertebral artery thrombosis.
CT abdomen/pelvis [**5-16**]:
IMPRESSION:
1. No evidence of intra-abdominal infection. No drainable
fluid collection.
2. Bilateral pleural effusions with adjacent atelectasis.
3. Abdominal aortic aneurysm to 4.0 cm with small focal
dissection within the aneurysm sac.
4. Mild anasarca.
ECHO [**5-16**] - IMPRESSION: No valvular vegetations seen. Symmetric
left ventricular hypertrophy with normal global and regional
left ventricular systolic function. Mildly dilated right
ventricle with normal global systolic function. Mild mitral
regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
MICROBIOLOGY:
[**5-12**] BLOOD CULTURES: MSSA AND PSEUDOMONAS
REPEAT BLOOD CULTURES 5/7, [**5-14**], [**5-15**], [**5-17**]: NEGATIVE
[**5-19**] BLOOD CULTURES: COAG NEG STAPH
[**5-16**] C DIFF: NEGATIVE
[**5-23**] WOUND SWAB: PAN SENSITIVE PSEUDOMONAS
DISCHARGE LABS:
[**2137-5-24**] 04:41AM BLOOD WBC-12.7* RBC-3.16* Hgb-10.7* Hct-32.3*
MCV-102* MCH-33.9* MCHC-33.1 RDW-14.3 Plt Ct-216
[**2137-5-24**] 04:41AM BLOOD PT-12.9* PTT-24.1* INR(PT)-1.2*
[**2137-5-24**] 04:41AM BLOOD Glucose-125* UreaN-15 Creat-0.7 Na-135
K-3.7 Cl-96 HCO3-32 AnGap-11
[**2137-5-24**] 04:41AM BLOOD Calcium-8.4 Phos-2.1* Mg-2.0
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 78M with gout,
HLD, HTN, Afib and dementia who presents in the setting of being
found down at his home admitted s/p fall with left arm fullness,
suprathrapeutic INR and elevated CK.
ACUTE ISSUES
# FALL -> Patient was found down by nephew with evidence of head
injury with left forehead laceration which did not require
suturing. Initial CT head and CXR were reassuring. Unlikely
ACS given negative cardiac enzymes. UA was positive, so CTX was
started initially, but culture was negative. CT neck was
obtained given the fall and there was concern for possible
hematoma, which was confirmed by subsequent MRI (see below for
details). His blood culture returned positive with MSSA and
Pseudomonas (see below for details), which can certainly lead to
a fall, although mechanical fall cannot be excluded as it was
not witnessed. Of note, patient does have history of falls per
his family. We were unable to determine the cause of the fall.
# C2 Hematoma/Abscess -> Initial CT Head was without acute
abnormalities. CT C-spine identified widening of the
C1-occipital codyle joint and high density material near the
dens, suggesting hematoma vs degenerative changes. MRI c-spine
was recommended for further evaluation. MRI c-spine on [**5-12**]
showed C2 hematoma. Ortho spine recommended q1 hr neuro checks
and repeat MRI in 24 hours. There was concern that the hematoma
could be infected as patient had been bactermic with MSSA and
pseudomonas. He was continued on cefepime. Patient was also
noted to develop some mild LUE and LLE weakness while in the
MICU. Repeat MRI on [**5-14**] showed a stable hematoma. Ortho spine
recommended repeat MRI in [**2-8**] days with c-collar, q4 hrs neuro
checks. During this time, patient remained afebrile, with a
stable neuro exam. Repeat MRI on [**5-17**] showed a stable hematoma
with concern for possible abscess. Repeat MRI on [**5-20**] showed
stable hematoma/abscess that was not improving with antibiotics,
so ortho decided that surgical intervention was needed to
resolve the lesion. Patient underwent drainage of abscess on
[**2137-5-22**] with removal of infected material. There were no
complications. Cultures from the procedures showed pseudomonas.
ID recommended IV antibiotics for 6-8 weeks from date of
surgery. Patient did well after surgery, recovered well,
without complications. Instructions to stay in the c-collar all
the time, except for 15-20 minutes with supervision for shaving,
eating, etc. Spinal cord is stable. Collar maintains stability
of infected region. No neuro changes.
# Bacteremia, MSSA and Psudomonas -> Initial blood cultures on
[**5-12**] were positive for pansensitive pseudomonas and MSSA. Source
unknown. Subsequent blood cultures were negative. Patient
continued to have low grade fevers over the first few days.
Source of the infection remained unknown. CT abdomen showed no
intrabdominal source. TTE showed no evidence of vegetations.
He was initially treated with vancomycin and cefepime, but was
narrowed to cefepime once sensitivities came back. WBC count
trended slightly up during week two of his hospitalization.
Blood cultures were sent and on [**5-19**] were positive for CoNS,
likely contamination. Patient remained afebrile. See above for
management of abscess. Will need 6-8 weeks of IV cefepime.
# Likely rhabdomyolysis -> Noted to have elevated CK on
admission, likely result of the fall and being on the ground for
unclear amount of time. Patient's CK was noted to be elevated
to 692 on admission that after 2L of NS rose to 739. Although
not 5 times the upper limit of normal, it is concerning that the
CK did not down trend afer 2L NS fluid bolus suggestive of
onging muscle destruction. Evaluation in the ED was concerning
for LUE compartment syndrome, although concerning findings are
not present on MICU evaluation. LUE ultrasound similarly did not
identify LUE DVT. Patient was given fluid boluses during
initial part of MICU stay until CK started to trend down. CK
trended down and resolved during hospital admission. Cre
remained normal.
# Left arm swelling -> Initially concerning for compartment
syndrome given the trauma. However, LUE is noted to be warm,
with good radial pulse, and without palor. Pain is ilicited in
LUE, although mostly along sites of skin injury. No finding to
suggest long bone fracture, although no X-rays of LUE were
obtained in the ED. Exam remained negative for compartment
syndrome. Swelling resolved over the course of the admission.
Patient did not develop additional pain or focal neurologic
findings in the left arm.
# Coagulopathy [**2-7**] Supratherapeutic INR -> Patient's INR on
admission was 13.0. Most recent INR from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] was 3.3
on [**2137-5-8**]. It is possible that patient's INR is elevated in
the setting of acute infection. Additionally, the patient may
have taken additional warfarin [**2-7**] to confusion and underlying
dementia. Alternatively, poor nutritional vitamin K may have
predispoded the patient develop a suprathrapeutic INR. The
latter is suggested by the fact that the patient did have an INR
of 14.0 that developed from one month to the next at [**Hospital1 **] in 11/[**2136**]. Given the hematoma found in the C-spine,
he was aggressively reversed with vitamin K and FFPs. Patient
was reversed with oral vitamin K x 2 followed by IV vitamin K
and 4 units of FFP. INR remained within normal range during the
hospitalization. Several times, it began to trend up again, and
was reversed with PO vit K.
# Thrombocytopenia -> Patient's platelet count dropped over
initial few days of admission, and then recovered, likely due to
infection.
# Atrial fibrillation on warfarin -> The patient was noted to be
in rapid atrial fibrillation to the 160s in the ED. Tachycardia
was thought to be partly due to volume depletion He received 3L
NS and 5mg IV metoprolol x2. It is also likely that the patient
missed his home dose of atenolol. He was switched to
metoprolol, which was uptitrated during MICU course. HR remained
elevated in the 90s-120s. We uptitrated his metoprolol to 75 mg
q8hrs with good improvement in his HR to the 60-80s. Remained in
afib throughout the hospitalization. We held his warfarin due to
concerns for bleeding regarding the C2 hematoma. Warfarin
should be re-started on [**5-27**], at a low dose and let INR trend up
slowly.
# Acute encephalopathy-> Based on his presentation, patient was
thought to have likely delirium on dementia. SW was consulted.
Safety issues were discussed with patient's HCP given the loss
of his life line (phone was not plugged in), elevated INR with
unclear etiology (? nutritional deficiency, taking excessive
dose, etc). He continued to have a waxing and [**Doctor Last Name 688**] mental
status throughout the course of his hospital stay. Possible
causes of delirium were addressed. Infection was treated.
Hemodynamic status was optimized.
# Chronic diastolic CHF, without exacerbation -> Patient has a
history of dCHF (EF >55% per ECHO [**5-17**]). Abd CT showed small
bilateral pleural effusions that may be evidence of slight
volume overload; although no evidence of LE edema and only mild
crackles on exam. Clinicaly euvolemic. He been positive 8L in
the MICU due to volume depletion and lasix had been held. Lasix
was restarted, and patient remained clinically euvolemic.
# Hypertension -> Ramipril, HCTZ, and Lasix were held initially
in the setting of volume depletion. Beta blocker was continued
but switched from atenolol to metoprolol. Patient remained
hypertensive with SBPs in the 170s-180s throughout the early
hospital stay. We uptitrated his HCTZ, ramipril, and metoprolol
with good improvement in BP to SBPs in the 140s-150s.
# Gout -> Allopurinol was initially held but reintroduced as his
renal function improved and volume repleted
CHRONIC ISSUES:
# HLD -> held atorvastatin. Can re-start as outpatient.
# Back pain - Hold tramadol in the setting of acute confusion.
Received tylenol prn for pain.
# Abdominal Aortic Aneuysm -> Abdominal CT noted a 4 cm aneurysm
with a small dissection within the aneuyrsm sac. Will need
outpatient follow-up. Does not need surgical intervention at
this time.
TRANSITIONAL ISSUES:
1. Abdominal aortic aneurysm: 4 cm, seen on abdominal CT. Will
need follow up monitoring
Medications on Admission:
- Tramadol 100 mg TID
- Atenolol 50 mg daily
- Klor-Con M20 40 mEq daily
- Atorvastatin 10 mg QHS
- Allopurinol 300 mg QOD
- Furosemide 20 mg daily
- Ramipril 10 mg [**Hospital1 **]
- HCTZ 12.5 mg daily
- Warfarin 3 mg Sun, Tue, [**Last Name (un) **], Sat - 4 mg Mon, Wed, Fri
Discharge Medications:
1. Allopurinol 300 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Ramipril 15 mg PO BID
hold if SBP < 100
4. Acetaminophen 325-650 mg PO TID
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. CefePIME 2 g IV Q8H
7. Docusate Sodium 100 mg PO BID
8. Hydrochlorothiazide 25 mg PO DAILY
hold for SBP<100 and inform H.O.
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Fluocinonide 0.05% Ointment 1 Appl TP [**Hospital1 **]
12. Lactic Acid 12% Lotion 1 Appl TP ASDIR
13. Multivitamins 1 TAB PO DAILY
14. Vitamin D [**2125**] UNIT PO DAILY
15. Metoprolol Succinate XL 225 mg PO DAILY
16. Atorvastatin 10 mg PO HS
17. Warfarin 2 mg PO DAILY16
START DATE [**5-27**]
18. Outpatient Lab Work
Chem 7, LFT's and CBC weekly on Mondays.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Epidural Abscess
Bacteremia
Supratherapeutic INR
Thrombocytopenia
Atrial Fibrillation
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 3236**],
You were admitted to the hospital after you were found on the
floor in your apartment. You were found to have bacteria in
your blood, and were started on antibiotics. This was thought
to be due to an infection in your spine. You underwent surgery
of your spine to help treat the infection. You will need to
continue antibiotics for 6-8 weeks from the date of your
surgery.
We adjusted your medications while you were in the hospital.
Please make the following changes to your medications:
CHANGE Ramipril to 15 mg twice daily
STOP taking Atenolol
RE-START Coumadin 2 mg on [**5-27**]
START taking Cefepime 2 grams through the IV every 8 hours
START taking Metoprolol Succinate 225 mg daily
START taking Hydrochlorothiazide 25 mg daily
Followup Instructions:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2137-6-7**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2137-6-24**] at 10:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SPINE CENTER
When: WEDNESDAY [**2137-6-5**] at 9:30 AM
With: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], NP [**Telephone/Fax (1) 8603**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"348.39",
"274.9",
"E888.9",
"336.1",
"428.32",
"324.1",
"287.5",
"294.20",
"790.7",
"584.9",
"427.31",
"428.0",
"790.92",
"873.42",
"728.88",
"041.11",
"041.7",
"V58.61",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.94",
"38.93",
"83.21",
"81.03",
"81.62",
"77.49",
"03.4",
"02.95"
] |
icd9pcs
|
[
[
[]
]
] |
19445, 19565
|
9833, 17774
|
315, 692
|
19708, 19708
|
4199, 4211
|
20694, 21691
|
2572, 2632
|
18583, 19422
|
19586, 19687
|
18281, 18560
|
19893, 20395
|
9471, 9810
|
2647, 2661
|
3435, 4180
|
18163, 18255
|
20424, 20671
|
264, 277
|
720, 2321
|
4226, 9455
|
19723, 19869
|
17791, 18142
|
2343, 2408
|
2424, 2556
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,995
| 118,677
|
45940
|
Discharge summary
|
report
|
Admission Date: [**2174-2-11**] Discharge Date: [**2174-2-16**]
Date of Birth: [**2107-9-11**] Sex: F
Service: MEDICINE
Allergies:
Gantrisin / Lactose
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Hyperglycemia, insulin drip
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 yo woman with type I DM, esrd [**2-19**] recently discharged [**2-8**]
after coag-neg staph line infection, presents to ED after fall
with left femoral neck fracture and hyperglycemia to >900. Due
for HD tomorrow.
.
While in the ED, the patient had a negative CT head/C-spine,
recieved IVF, bicarb, insulin for hyperglycemia/hyperkalemia.
Also recieved levaquin and ceftriaxone given fever, h/o recent
bacteremia/line infxn. Blood and urine cultures were drawn.
.
Upon arrival to the MICU, the patient was alert and answered
questions appropriately. She was resting comfortably. She was
given 500cc NS and continued on her insulin drip.
Past Medical History:
1. DM type 1 x 35 years. Previous admissions for DKA and
hypoglycemic episodes. Her DM is complicated by peripheral
neuropathy, proliferative retinopathy (left eye blindness), and
nephropathy. Followed at [**Last Name (un) **].
2. Chronic renal failure: Appears [**2-19**] to DM and Cr has been 5
over past few months. On hemodialysis. Followed by Dr. [**Last Name (STitle) **].
3. CAD - NSTEMI [**10-24**] in the setting of hospitalization for DKA,
Nuclear stress test [**8-24**]: P-MIBI, without fixed or reversible
defects, normal wall motion. EF 72%.
4. Hypertension
5. History of osteomyelitis, status post left transmetatarsal
amputation.
6. History of herpes zoster of left chest in [**2163**].
7. Bezoar, disclosed on UGI series [**7-/2166**].
8. Achalasia
9. Carpal Tunnel Syndrome
Social History:
She lives at home with her son, who is mentally retarded. Past
history of EtOH use. Ex-smoker, quit in [**2154**]. Previously smoked
for 8yrs. No history of illicit drug use
Family History:
Mother - DM
Sister - breast ca, DM
Brother - HTN
[**Name (NI) 2957**] - SLE, d. renal failure
Physical Exam:
VS:
GEN: chornically ill appearing, but in no acute distress
HEENT: dry mucus membranes, left eye shut
CV: regular no murmus, gallops, rubs
RESP: CTA ant
ABD: soft, NT/ND, no masses
EXT: warm, decreased pulses, dry black toes on right foot
Pertinent Results:
============
LABORATORIES
============
LABORATORIES ON ADMISSION:
[**2174-2-11**] WBC-6.0 (NEUTS-81.0 LYMPHS-15.0 MONOS-3.5 EOS-0.3
BASOS-0.2)
HGB-9.0 HCT-32.8 MCV-96 PLT COUNT-179
[**2174-2-11**] 02:15PM SODIUM-128 POTASSIUM-5.3 CHLORIDE-88 TOTAL
CO2-27 GLUCOSE-993 UREA N-33 CREAT-4.9 CALCIUM-9.0
PHOSPHATE-7.2 MAGNESIUM-2.4
[**2174-2-11**] PT-14.5 PTT-29.8 INR(PT)-1.3
[**2174-2-11**] LACTATE-1.6
[**2174-2-11**] 04:00PM GLUCOSE-695
[**2174-2-11**] 09:00PM GLUCOSE-418
.
CARDIAC ENZYMES
[**2174-2-11**] 12:15PM CK(CPK)-87 CK-MB-NotDone cTropnT-0.05
[**2174-2-12**] 04:18AM CK(CPK)-48 cTropnT-0.06
.
VANCOMYCIN LEVELS
[**2174-2-15**] Vanco-35.7
[**2174-2-14**] Vanco-17.5OTHER LABORATORIES
[**2174-2-13**] TSH-1.0 Free T4-0.89
.
LABORATORIES UPON DISCHARGE
[**2174-2-16**] WBC-12.0 (Neuts-81.0 Lymphs-15.0 Monos-3.5 Eos-0.3
Baso-0.2) Hgb-9.3 Hct-32.6 MCV-93 Plt Ct-169
[**2174-2-16**] Na-141 K-4.6 Cl-101 HCO3-24 UreaN-22 Creat-4.5
Glucose-152
.
=========
[**Month/Day/Year 706**]
=========
[**2174-2-11**] CXR: No acute Process.
.
[**2174-2-11**] CT-Head: No acute intracranial process.
.
[**2174-2-11**] CT-Neck: 1. No acute fracture or malalignment.
2. Left thyroid nodules, recommend correlation with physical
exam findings.
.
[**2174-2-11**] XR Femur: Acute left femoral neck fracture with varus
angulation. No other fractures identified.
.
[**2174-2-11**] CT LLE:
FINDINGS: Comparison is made to radiographs of the left hip from
the same day. There is a fracture involving the subcapital
portion of the left proximal femur. The femoral neck is
displaced slightly anteriorly in relation to the femoral head.
There is a small amount of intraarticular hemarthrosis. There
are no bony fragments between the femoral head in the joint
space.
.
[**2174-2-14**] HIP 1 VIEW IN O.R. 2:33 PM
A single intraoperative radiograph of the left hip is submitted.
The patient is status post left hip hemiarthroplasty and there
are multiple staples present. No evidence of fracture is seen.
Please refer to the operative report for full findings.
============
MICROBIOLOGY
============
[**2174-2-14**] Pathology Tissue: Left Hip Femoral Head. PENDING
.
[**2174-2-11**] URINE WBCCLUMP-FEW RBC-0-2 WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**6-28**] BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
.
[**2174-2-11**] URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE Epi-[**6-28**]
WBC Clm-FEW
Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015 Blood-MOD Nitrite-NEG
Protein-30 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG
pH-7.0 Leuks-MOD
.
[**2174-2-11**] 11:40 am URINE CULTURE (Final [**2174-2-13**]): MIXED
BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION. Site: CATHETER.
.
[**2174-2-15**] URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.015 Blood-LG
Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.0 Leuks-MOD URINE RBC-[**3-23**] WBC->50 Bacteri-MANY
Yeast-MANY Epi-0-2
.
[**2174-2-15**] 4:47 pm URINE CULTURE (Pending) Source: Catheter.
Brief Hospital Course:
# LEFT FEMORAL NECK FRACTURE S/P REPAIR
The patient had a left femoral neck fracture secondary to a
mechanical fall. No evidence of syncope was elicitied per
history and myocardial infarction ruled out as precipitating
cause of fall (see above cardiac enzymes). Left hip
hemiarthroplasty was preformed on Monday [**2174-2-14**] by orthopedic
surgery, Dr. [**Last Name (STitle) 1005**] attending. Post-operatively, her pain
was controlled with a morphine and then a dilaudid PCA. On the
day of discharge, PCA was discontinued and pain controlled with
dilaudid PO. As discussed below the patient is on hemodialysis
and had an episode of hypotension on morphine PCA; per renal
dilaudid is a better choice for pain control in a hemodialysis
patient as dilaudid is less renally cleared than other agents.
She was pain free upon transfer to rehab on POD #2 on dilaudid
PO. She is scheduled for outpatient followup in orthopedics
clinic in 2 weeks. Per orthopedics, patient is weight bearing
as tolerated and should work with physical therapy at rehab.
For post-operative prophylaxis, orthopedics recommends 4 weeks
of anticoagulation post-operatively. Lovenox was not a good
choice for the patient as she in on hemodialysis. Coumadin was
chosen for anticoagulation with a goal INR 2.0-2.5 per
orthopedics; we are bridging the patient with subcutaneous
heparin until INR is therpeutic on coumadin and subcutaneous
heparin should be discontinued once INR is therapeutic on
coumadin. Ms. [**Known lastname **] is not a good candidate for home
subcutaneous heparin secondary to administration difficulties;
INR should be followed daily and coumadin dose adjusted as
needed at rehab.
.
# UTI:
Ms. [**Known lastname **] had a grossly positive urinalysis on admission (see
results section above); she is on HD and produces a small amount
of urine daily (~200 cc/day). Historically, the patient has a
history of citrobacter (resistant to ciprofloxacin and
cephalosporins) and E. Coli (pan-sensitive) recurrent UTIs and
citrobacter infections in the past has been resistant to
ciprofloxacin. Most recently, UTIs have been [**10-25**] Citrobacter
freundii (resistant to cephalosporin, ciprofloxain; sensitive to
imipenem, tobramycin, cefepime), and [**10-24**] E. Coli
(pan-sensitive). No culture data was available during this
admission for current UTI; empiric abx choice was discussed with
ID and renal consultants. Upon discharge, the plan was to
extend ciprofloxacin abx course for a total of 14 days (D1:
[**2174-2-13**]) as repeat UA on the day prior to discharge was
positive. The ciprofloxacin should be dosed renally at 500 mg
daily with Tuesday, Thursday, Saturday doses given after HD so
as they are not cleared during dialysis. The patient remained
afebrile prior to discharge. Of note, her WBC did rise the AM
of discharge but was likely due to post-surgical inflammation.
WBC should be repeated at rehabilitation if the patient begins
to show signs and symptoms of infection.
.
#. RECENT HEMODIALYSIS LINE INFECTION
Continued Vanco per HD as per discharge instructions (discharge
[**2174-2-8**]) from last admission for HD line infection. Per renal
team, final vancomycin dose will be [**2174-2-19**].
.
#. ESRD
The patient is on hemodialysis on Tuesday, Thursday, Saturdays
and normally receives HD in [**Location (un) **]. She had one episode of
hypotensin after dialysis on [**2174-2-15**] while she was on the
morphine PCA after 2 L ultrafiltrate was removed. She was given
a bolus of IVF (250 cc) and her morphine PCA switched to
dilaudid and her hypotension improved. Dilaudid is less renally
cleared and less likely to cause hypotension in an HD patient.
Her sevelamer was increased to 1600 mg TID with meals for better
control of her phosphorus. Epogen was continued per outpatient
regimen. Vancomycin was provided with HD as above for a prior
HD line infection.
.
#. HYPERGLYCEMIA/DIABETES MELLITUS
Sugars continue not to be optimized on subcutaneous insulin with
values over 200 and episodic hypoglycemia. [**Last Name (un) **] was
consulted. Sliding scale was provided and lantus was continued
at 5 units every night, which was lower than home dose
peri-operatively. Her glargine dose will need to be adjusted at
rehabilitation with closely monitoring of finger stick blood
sugars. Outpatient followup with her [**Last Name (un) **] provider is
recommended to optimize her blood glucose control.
.
#. THYROID NODULES
Thyroid nodules (left lobe) were incidentally found on CT
c-spine. Free T4 slightly decreased and TSH within normal
limits. Outpatient thyroid ultrasound is recommended as
outpatient for further workup.
.
#. EVALUATION OF OSTEODYSTROPHY RELATED TO ESRD/ EVALUATION FOR
OSTEOPOROSIS:
Recommend outpatient DEXA scan in setting of renal disease and
recent hip fracture.
Bone specimen was sent during surgery and sent to pathology for
review to evaluate for renal osteodystrophy; results to be
followed up as an outpatient.
.
#. FULL CODE
Medications on Admission:
Atorvastatin 80mg po daily
Aspirin 325 mg po dails
sevelemer 800mg po TID
Loperamide 2mg QId prn
Lisinopril 20mg po Qday
Metoprolol 25mg po Qday
Glargine 10mg po QHS
Insulin aspart QID sliding scale.
ALL: Gantrisin / Lactose
Discharge Medications:
1. DEXA SCAN
Outpatient DEXA SCAN
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Lantus 100 unit/mL Solution Sig: Five (5) Subcutaneous once
a day.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day). Tablet(s)
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Insulin Glargine 100 unit/mL Solution Sig: Five (5)
Subcutaneous at bedtime.
19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: On hemodialysis days (Tuesday,
Thursday, Saturday), please give antibiotic dose after dialysis.
20. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
21. Insulin Aspart 100 unit/mL Solution Sig: AS DIRECTED PER
SLIDING SCALE Subcutaneous QACHS: AS DIRECTED PER SLIDING
SCALE.
22. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous HD
PROTOCOL for 2 doses: FINAL DOSE WILL BE [**2174-2-19**]. INDICATION:
HD LINE INFECTION.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary
1. Mechanical Fall
2. Left femoral neck fracture
3. Hyperglycemia
.
Secondary
1. Diabetes mellitus, type I
2. Peripheral neuropathy
3. Proliferative retinopathy
4. Diabetic nephropathy
5. Coronary artery disease
6. Hypertension
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to the hospital after a fall. You were found
to have a left femoral neck fracture (hip fracture). Left hip
replacement surgery was performed to repair your hip fracture
and your pain was well controlled at discharge.
.
Please keep all followup appointments.
.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
.
==================
MEDICATION CHANGES
==================
.
1. Metoprolol tartrate was increased to 37.5 mg [**Hospital1 **].
2. Sevelamer was increased to 1600 mg TID with meals.
3. Lantus decreased to 5 mg daily. This dose may need to be
adjusted as an outpatient.
4. Post-operative anticoagulation was begun with coumadin 5 mg
daily. Please continue subcutaneous heparin three times daily
until the patient is therpeutic on coumadin (goal INR 2.0-2.5).
Please continue anticoagulation for 4 weeks post-operatively.
(Left hip arthroplasty [**2174-2-15**]).
Followup Instructions:
1. Please PCP: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern1) 93528**], MD [**Telephone/Fax (1) 250**] in [**1-19**] weeks after
discharge. Her next available appointment has been scheduled for
you on Tuesday, [**2174-3-22**] at 11:20 AM; please call her
office for to see if she has any availabilities prior to this
appointment.
.
2. ORTHOPEDICS followup after your hip surgery: Tuesday,
[**2174-3-1**] at 10:00 AM for x-rays and then an appointment
nurse [**First Name8 (NamePattern2) 3639**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 97819**] at 10:20 AM. ([**Telephone/Fax (1) 15940**].
[**Hospital Ward Name 23**] Building, [**Location (un) **], at [**Hospital1 1170**].
.
3. Please followup with your [**Last Name (un) **] provider as an outpatient
within 1-2 weeks to optimize your blood sugar control. Phone:
([**Telephone/Fax (1) 3537**]
===========================================
REMINDER, PREVIOUSLY SCHEDULED APPOINTMENTS
===========================================
1. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2174-3-2**]
2:45
.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2174-2-18**] 3:15
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"585.6",
"E885.9",
"250.51",
"458.21",
"820.8",
"357.2",
"362.01",
"414.01",
"599.0",
"250.61",
"250.41",
"V45.1",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
12830, 12885
|
5536, 10525
|
307, 313
|
13165, 13200
|
2379, 2431
|
15076, 16492
|
2008, 2103
|
10801, 12807
|
12906, 13144
|
10551, 10778
|
13224, 15053
|
2118, 2360
|
240, 269
|
341, 983
|
2445, 5513
|
1005, 1800
|
1816, 1992
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,729
| 140,334
|
39532
|
Discharge summary
|
report
|
Admission Date: [**2150-9-30**] Discharge Date: [**2150-10-4**]
Date of Birth: [**2084-5-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2150-9-30**]: Mitral valve Repair with 30 mm CE PhysioRing II
History of Present Illness:
66 yo male with known mitral regurgitation with complaints of
chest discomfort and increasing dyspnea on exertion. He
presented for cardiac catheterization to further evaluate MR,
coronary anatomy, and cardiac surgery evaluation. Cardiac
Catheterization on [**2150-8-31**] showed severe MR, EF 60% and clean
coronaries.
Cardiac Echocardiogram on [**2150-8-5**] at OSH showerd EF 60%,
moderate MR, flail
mitral valve with ruptured chords noted in LA. Aortic root and
ascending aorta are dilated measuring up to 42mm,tr TR. He
presented as same day admission for mitral valve repair
Past Medical History:
Hypertension
Congestive Heart Failure
Mitral Regurgitation
GERD
hematuria
mild anemia
Bilateral ankle fractures after falling off scaffolding s/p
surgical repair
Social History:
Race:Caucasian, speaks English, primary language Portuguese
Last Dental Exam:[**2150-4-23**]
Lives with:wife
Occupation:Retired
Tobacco:Denies
ETOH:1 glass of wine daily
Family History:
Brother s/p CABG
Physical Exam:
Pulse:65 Resp:16 O2 sat:100%Ra
B/P Right: 144/87 Left:151/98
Height:5'5" Weight:173LBS (78.5KG)
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur III/VI SEM
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
Pulses:
Femoral Right: Dressing Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right/Left: transmitted murmur
Pertinent Results:
[**2150-10-2**] 03:00AM BLOOD WBC-11.1* RBC-3.66* Hgb-10.6* Hct-30.2*
MCV-82 MCH-28.9 MCHC-35.1* RDW-14.4 Plt Ct-88*
[**2150-10-2**] 03:00AM BLOOD Glucose-105* UreaN-25* Creat-1.0 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-14
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2150-9-30**] where the patient underwent mitral
valve repair with 30 mm CE PysioRing II. 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 on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. He
was hypertensive postoperatively and on a Nicardipene drip and
weaned off this on post operative day 1 with titration of oral
antihypertensives. He had 3 short bursts of rapid atrial
fibrillation on post operative day 1 and was started on
Amiodarone drip. This was transitioned to po Amiodarone without
any further episodes of afib. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with visiting nurse services in good
condition with appropriate follow up instructions.
Medications on Admission:
Ibuprofen 800mg po PRN
Lisinopril-HCTZ
Omeprazole 40mg po daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Mitral regurgitation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Edema - Trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**10-22**] at 1:15pm [**Telephone/Fax (1) 170**]
Cardiologist:Dr [**Last Name (STitle) **] on [**10-28**] at 9:30
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 6700**] in [**4-27**] weeks [**Telephone/Fax (1) 6699**]
**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:[**2150-10-4**]
|
[
"787.02",
"428.0",
"530.81",
"427.31",
"401.9",
"429.5",
"287.5",
"424.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
5144, 5199
|
2363, 3816
|
341, 408
|
5264, 5438
|
2122, 2340
|
6279, 6825
|
1410, 1429
|
3931, 5121
|
5220, 5243
|
3842, 3908
|
5462, 6256
|
1444, 2103
|
282, 303
|
436, 1020
|
1042, 1206
|
1222, 1394
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,561
| 199,972
|
24510
|
Discharge summary
|
report
|
Admission Date: [**2186-8-29**] Discharge Date: [**2186-9-11**]
Date of Birth: [**2108-5-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2186-8-29**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] Tissue)
History of Present Illness:
This is a 78 year old male with significant vascular history who
was diagnosed with Aortic Stenosis in [**12-13**]. More recently he has
noted to have worsening dyspnea on exertion and fatigue. Repeat
Echo showed worsening Aortic Stenosis and he was referred for
surgical intervention.
Past Medical History:
Aortic Stenosis
Mitral and Tricuspid Valve Regurgitation
Hyperlipidemia
Hypertension
Peripheral Vascular Disease
s/p Left Fem-[**Doctor Last Name **] bypass x 2,
Atrial Fibrillation
Congestive Heart Failure
Chronic Kidney Disease
Chronic Obstructive Pulmonary Disease
Anemia
Hyperparathyroidism
s/p Toe amputations
s/p Pleurectomy
s/p Cataract surgery
Social History:
Quit smoking 30yrs ago after 60pk/yr hx.
Rare ETOH.
lives with his wife
Family History:
noncontributory
Physical Exam:
T 98.3 BP 146/54 P 55 RR 20 100% on RA
General: Pleasant to speak with. Answers questions appropriately
Neuro:
Chest: Lungs clear to asucultation bilaterally
Cardiac: Slow rate, no murmurs, rubs, or gallops appreciated
Sternal incison: no drainage or erythema. Stable.
Abdomen: soft, nontender. No rebound or guarding. Normoactive
bowel sounds
Extremities: warm with 1+ edema
Pertinent Results:
[**8-29**] Echo: PREBYPASS: 1. The left atrium is moderately dilated.
No spontaneous echo contrast or thrombus is seen in the left
atrial appendage. No atrial septal defect of PFO is seen by 2D
or color Doppler. 2. Left ventricular wall thicknesses and
cavity size are normal. Regional left ventricular wall motion is
normal. 3. Right ventricular chamber size and free wall motion
are normal. 4. 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. 5. The
aortic valve leaflets are moderately thickened. There is severe
aortic valve stenosis (area <0.8cm2). 6. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. 7. The tricuspid valve leaflets are
normal appearing. Mild (1+) tricuspid regurgitation is seen. 8.
There is no pericardial effusion. 9. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**2186-8-29**] at 859. POSTBYPASS: 1. Patient
is on epinephrine and phenylephrine 2. Left ventricular function
remains unchanged. 3. A well seated, well functioning
bioprostetic valve is seen in the aortic position. The mean
gradients is 24 mmHg 4. Aortic contour is smooth after
decannulation. 5. Dr. [**Last Name (STitle) **] notified of these findings at
1148.
[**2186-9-11**] 06:10AM BLOOD WBC-13.6* RBC-2.98* Hgb-8.6* Hct-26.8*
MCV-90 MCH-28.9 MCHC-32.2 RDW-15.7* Plt Ct-289
[**2186-8-29**] 12:00PM BLOOD WBC-16.7* RBC-2.47*# Hgb-7.3*# Hct-21.8*#
MCV-88 MCH-29.7 MCHC-33.7 RDW-16.4* Plt Ct-153
[**2186-9-11**] 06:10AM BLOOD PT-28.5* INR(PT)-2.9*
[**2186-8-29**] 07:00AM BLOOD PT-14.1* PTT-28.9 INR(PT)-1.2*
[**2186-9-11**] 06:10AM BLOOD Glucose-81 UreaN-49* Creat-3.2* Na-142
K-4.3 Cl-115* HCO3-19* AnGap-12
[**2186-8-29**] 01:55PM BLOOD UreaN-40* Creat-3.1* K-5.5* Cl-114*
HCO3-21*
[**2186-9-7**] 04:47AM BLOOD ALT-12 AST-28 LD(LDH)-297* AlkPhos-98
Amylase-45 TotBili-0.7
[**2186-8-30**] 12:49AM BLOOD ALT-11 AST-39 LD(LDH)-236 AlkPhos-37*
TotBili-0.5
Radiology Report CHEST (PA & LAT) Study Date of [**2186-9-8**] 9:47 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2186-9-8**] SCHED
CHEST (PA & LAT) Clip # [**0-0-**]
Reason: evaluate right lobe collapse
[**Hospital 93**] MEDICAL CONDITION:
78 year old man s/p AVR
REASON FOR THIS EXAMINATION:
evaluate right lobe collapse
Provisional Findings Impression: JRld [**Name2 (NI) **] [**2186-9-8**] 10:49 AM
Improved right lower lobe aeration, improved fluid overload.
Small bilateral
pleural effusions, greater on the right, are unchanged.
Final Report
REASON FOR EXAM: Evaluate right lower lobe collapse.
Improved right lower lobe aeration, minimally improved fluid
overload. Small
bilateral pleural effusions, greater on the right side, are
unchanged.
Cardiomegaly is stable. Mediastinal wires are aligned. No
pneumothorax.
jr
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: [**Last Name (NamePattern4) **] [**2186-9-8**] 8:51 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 61954**]Portable TTE
(Focused views) Done [**2186-9-8**] at 3:48:29 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2108-5-31**]
Age (years): 78 M Hgt (in): 67
BP (mm Hg): 105/60 Wgt (lb): 175
HR (bpm): 56 BSA (m2): 1.91 m2
Indication: Left ventricular function.
ICD-9 Codes: 402.90, V42.2, 424.1, 424.0
Test Information
Date/Time: [**2186-9-8**] at 15:48 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**Name2 (NI) **] L.
[**Hospital1 **], RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W052-0:49 Machine: Vivid [**6-11**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.7 cm <= 5.0 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *17 < 15
Aortic Valve - Peak Velocity: *2.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *22 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 11 mm Hg
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 4.00
Mitral Valve - E Wave deceleration time: 221 ms 140-250 ms
TR Gradient (+ RA = PASP): *27 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.
RIGHT VENTRICLE: RV not well seen.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR gradient. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild [1+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - bandages, defibrillator pads or
electrodes. Suboptimal image quality - body habitus.
Conclusions
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size and global systolic function (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. A bioprosthetic aortic
valve prosthesis is present. The leaflets are not well-seen, but
the transaortic gradient is normal for this prosthesis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Normally
prosthetic transvalvular gradients. Mild mitral regurgitation.
Mild pulmonary hypertension.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2186-9-8**] 16:47
STUDY: MRI and MRA brain, MRA neck.
INDICATION: 78-year-old male status post aortic valve
replacement with
altered mental status.
COMPARISON: CT head without contrast, [**2186-8-30**].
TECHNIQUE: Sagittal T1, axial FLAIR, axial T2, axial GRE, and
diffusion-
weighted imaging was performed. Axial 2D time-of-flight imaging
was performed
of the neck and circle of [**Location (un) 431**]. Rotational reformatted images
were prepared
and reviewed. No IV contrast was administered secondary to poor
intravenous
access.
MRI BRAIN: Study is limited by blooming artifact obscuring the
right frontal
and parietal lobes on gradient recalled echo and diffusion
sequences secondary
to probable support device overlying the patient. Punctate foci
of slow
diffusion are present within the right frontal lobe, left
temporal lobe, and
bilateral occipital lobes most consistent with tiny embolic
infarctions. A
more gyriform pattern of slow diffusion is present along the
posterior left
precentral gyrus (11:19,20). The right frontal and parietal
lobes are not well
evaluated given artifact.
No mass, shift of normally midline structures, hydrocephalus, or
evidence of
acute hemorrhage is identified. The orbital regions are within
normal limits.
A 1.9-cm mucus retention cyst is present within the left
maxillary sinus.
Fluid is present within the right mastoid air cells.
MRA CIRCLE OF [**Location (un) **]: There is a hypoplastic versus congenitally
absent left
A1 segment. Therefore, both anterior cerebral arteries are
supplied by the
right A1. No aneurysms or other vascular anomalies are
identified.
MRA NECK: Study is suboptimal since the patient was not able to
recieve
intravenous gadolinium contrast material. There is mild stenosis
at the origin
of the left ICA. The left external carotid artery is not
detected. The right
internal and external carotid systems are within normal limits.
The vertebral
arteries appear unremarkable.
IMPRESSION:
1. Tiny probably embolic infarctions involving the right frontal
lobe, left
temporal lobe and bilateral occipital lobes. Gyriform pattern of
infarction
involving the left prefrontal gyrus.
2. Mild stenosis of the left ICA at the origin. Left external
carotid artery
is not visualized suggesting occlusion although study is
suboptimal given lack
of contrast material.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 4391**]
DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
Approved: SUN [**2186-9-3**] 2:45 PM
Brief Hospital Course:
Mr. [**Known lastname 40800**] was admitted on [**8-29**] after undergoing all
pre-operative work-up as an outpatient. On the day of admission
he was brought directly to the operating room where he underwent
an Aortic Valve Replacement. Please see operative report for
surgical details. He weaned from bypass on Propafol and
neosynephrine. He was transferred to the CVICU for postoperative
monitoring.
He weaned from pressors and required NTG for elevated blood
pressure by POD 1. He remained stable from a cardiovascular
standpoint but sufferd a tonic-clonic seizure in the morning of
[**8-30**]. This resolved without intervention and an emergent CT scan
demonstrated old subacute strokes involving the Left pons. MRI
obtained once pacing wires removed, showed probable embolic
infarctions involving the right frontal lobe, left temporal
lobe, and bilateral occipital lobes. As result patient had
weakness or right hand and lower extremity. Neuro was consulted
and recommended coumadin and follow up of left carotid stenosis
in [**2-9**] months.
Patient required several bronchoscopies for right middle lobe
pneumonia while in the CVICU. On [**2186-9-7**] patient was on the
floor and noted to have absent breath sounds in the right lung
fields. Chest x-ray showed right lung collapse. Patient was
started on Pulozyme nebulizers [**Hospital1 **], chest PT. By the end of
[**9-7**], pt was moving air in the right lung fields and stated
improvement in breathing. Serial chest x-rays showed continued
improvement.
Patient was noted to have motteling of legs worse than pre-op.
An echocardiogram was obtained on [**9-8**] that showed LVEF greater
than 55%, bio-prosthetic aortic valve appeared normal.
His renal function had returned to his baseline on the am of
[**9-11**]. INR trended down to 2.9 from the previous day at 3.1.
Medications on Admission:
Actonel 35mg QW, Advair 250/50 1 puff [**Hospital1 **], Atenolol 25mg QD,
Detrol LA 4mg QOD, Ferrous Sulfate 325mg QD, Paxil 40mg QD,
Protonix 40mg QD, Zocor 20mg QD, Terazosin 2mg QHS, Procrit prn,
Floranex 2 tabs [**Hospital1 **], Sodium Bicarb 650mg TID, Zemplar 1 Capsule
QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*0*
7. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM as needed for AFIB: Coumadin being held until INR <2.5.
Disp:*30 Tablet(s)* Refills:*0*
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
10. Tolterodine 2 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*120 * Refills:*0*
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed.
Disp:*60 * Refills:*0*
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis
s/p Aortic Valve Replacement
Mitral and Tricuspid Valve Regurgitation Hyperlipidemia,
Hypertension
Peripheral Vascular Disease
s/p Left Femoral popliteal bypass x 2
Atrial Fibrillation
Congestive Heart Failure
Chronic Kidney Disease
Chronic Obstructive Pulmonary Disease
Anemia
Hyperparathyroidism
s/p Toe amputations
s/p left leg hematoma evacuation
s/p Pleurectomy
s/p Cataract surgery
post operative cerebrovascular accident
Discharge Condition:
Good
Discharge Instructions:
shower daily and pat incisions dry
no lotion, creams, or powders on any incision
no driving for one month and until off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 5017**] in [**1-8**] weeks
Dr. [**Last Name (STitle) **] in [**12-7**] weeks
Completed by:[**2186-9-11**]
|
[
"584.9",
"434.91",
"427.31",
"285.9",
"997.02",
"403.90",
"397.0",
"486",
"V49.72",
"496",
"997.39",
"428.0",
"780.39",
"997.1",
"396.2",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"33.23",
"96.04",
"96.71",
"35.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15036, 15106
|
11167, 13002
|
298, 389
|
15594, 15600
|
1617, 3890
|
15885, 16059
|
1184, 1201
|
13331, 15013
|
3930, 3954
|
15127, 15573
|
13028, 13308
|
15624, 15862
|
1216, 1598
|
239, 260
|
3986, 11144
|
417, 704
|
726, 1079
|
1095, 1168
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,888
| 170,830
|
41489
|
Discharge summary
|
report
|
Admission Date: [**2131-6-18**] Discharge Date: [**2131-6-25**]
Date of Birth: [**2056-8-20**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2131-6-18**]: Endovascular Aortic Aneursym Repair
[**2131-6-20**]: Left femoral thrombectomy
History of Present Illness:
74-year-old female who was diagnosed with infrarenal abdominal
aortic aneurysm that has now reached greater than 5 cm. Due to
risk of rupture, she
was consented for repair of the aneurysm and the anatomy is
amenable to endograft exclusion.
Past Medical History:
CAD w/ coronary stent, HTN, COPD, CHF, Hypercholesterolemia, DM
PSH: Mastoid, abdominal Hernia repair
Social History:
She is divorced & lives by herself
Family History:
non contributory
Physical Exam:
On discharge:
Temp- 98.9
BP- 118/47
HR- 70
RR- 16
SpO2- 98%
GEN - Alert and oriented, WDWN female in NAD
CVS- RRR
RS- CTA bilat
ABD- soft, BS+, no M/T/O
EXTR- bilateral groins c/d/i, without hematoma;
Pulse exam- bilateral femoral and popliteal = palpable;
bilateral DP & PT doppler signals
Pertinent Results:
[**2131-6-18**] 12:44PM BLOOD WBC-9.1 RBC-3.38* Hgb-10.4* Hct-30.9*
MCV-92 MCH-30.9 MCHC-33.7 RDW-14.3 Plt Ct-253
[**2131-6-18**] 05:40PM BLOOD WBC-14.0*# RBC-3.20* Hgb-10.2* Hct-28.5*
MCV-89 MCH-31.7 MCHC-35.6* RDW-14.2 Plt Ct-268
[**2131-6-19**] 01:16AM BLOOD WBC-13.2* RBC-3.32* Hgb-10.0* Hct-30.4*
MCV-92 MCH-30.1 MCHC-32.8 RDW-14.5 Plt Ct-270
[**2131-6-20**] 02:00AM BLOOD WBC-9.0 RBC-2.76* Hgb-8.5* Hct-25.1*
MCV-91 MCH-31.0 MCHC-34.1 RDW-14.4 Plt Ct-176
[**2131-6-20**] 08:34AM BLOOD WBC-11.1* RBC-2.93* Hgb-9.5* Hct-26.6*
MCV-91 MCH-32.4* MCHC-35.7* RDW-14.5 Plt Ct-177
[**2131-6-21**] 01:45AM BLOOD WBC-12.0* RBC-2.97* Hgb-9.4* Hct-26.5*
MCV-90 MCH-31.8 MCHC-35.6* RDW-14.6 Plt Ct-186
[**2131-6-21**] 02:47PM BLOOD WBC-10.3 RBC-3.19* Hgb-9.9* Hct-28.4*
MCV-89 MCH-31.0 MCHC-34.8 RDW-15.0 Plt Ct-186
[**2131-6-22**] 05:43AM BLOOD WBC-9.0 RBC-3.13* Hgb-9.8* Hct-28.7*
MCV-92 MCH-31.2 MCHC-34.1 RDW-15.1 Plt Ct-234
[**2131-6-23**] 03:59AM BLOOD WBC-7.7 RBC-3.11* Hgb-9.7* Hct-28.8*
MCV-93 MCH-31.3 MCHC-33.8 RDW-15.1 Plt Ct-265
[**2131-6-24**] 04:13AM BLOOD WBC-8.1 RBC-3.12* Hgb-9.9* Hct-28.4*
MCV-91 MCH-31.8 MCHC-35.0 RDW-14.9 Plt Ct-266
[**2131-6-18**] 12:44PM BLOOD Glucose-216* UreaN-19 Creat-1.0 Na-136
K-5.2* Cl-107 HCO3-23 AnGap-11
[**2131-6-18**] 05:40PM BLOOD Glucose-156* UreaN-19 Creat-1.2* Na-134
K-4.9 Cl-105 HCO3-22 AnGap-12
[**2131-6-19**] 01:16AM BLOOD Glucose-166* UreaN-18 Creat-1.1 Na-138
K-5.1 Cl-105 HCO3-22 AnGap-16
[**2131-6-19**] 09:45PM BLOOD Na-136 K-4.0 Cl-105
[**2131-6-20**] 02:00AM BLOOD Glucose-101* UreaN-12 Creat-0.8 Na-133
K-3.7 Cl-102 HCO3-26 AnGap-9
[**2131-6-20**] 08:34AM BLOOD Glucose-114* UreaN-12 Creat-0.8 Na-135
K-4.3 Cl-104 HCO3-26 AnGap-9
[**2131-6-20**] 03:07PM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-135
K-4.2 Cl-101 HCO3-26 AnGap-12
[**2131-6-21**] 01:45AM BLOOD Glucose-153* UreaN-17 Creat-0.8 Na-136
K-4.1 Cl-102 HCO3-25 AnGap-13
[**2131-6-21**] 02:47PM BLOOD Glucose-151* UreaN-19 Creat-1.0 Na-132*
K-3.8 Cl-97 HCO3-29 AnGap-10
[**2131-6-21**] 10:44PM BLOOD Glucose-109* UreaN-21* Creat-1.0 Na-136
K-3.9 Cl-101 HCO3-28 AnGap-11
[**2131-6-22**] 05:43AM BLOOD Glucose-111* UreaN-19 Creat-1.0 Na-134
K-3.8 Cl-98 HCO3-29 AnGap-11
[**2131-6-23**] 03:59AM BLOOD Glucose-72 UreaN-24* Creat-0.9 Na-137
K-3.9 Cl-100 HCO3-29 AnGap-12
[**2131-6-24**] 04:13AM BLOOD Glucose-91 UreaN-25* Creat-1.0 Na-133
K-4.3 Cl-98 HCO3-28 AnGap-11
[**2131-6-18**] 12:44PM BLOOD Calcium-7.6* Phos-5.0* Mg-1.7
[**2131-6-18**] 05:40PM BLOOD Calcium-7.9* Phos-4.3 Mg-2.0
[**2131-6-19**] 01:16AM BLOOD Calcium-7.7* Phos-3.6 Mg-2.1
[**2131-6-20**] 08:34AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.3
[**2131-6-20**] 03:07PM BLOOD Calcium-7.8* Phos-3.3 Mg-2.2
[**2131-6-21**] 01:45AM BLOOD Calcium-7.5* Phos-3.0 Mg-2.1
[**2131-6-21**] 02:47PM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1
[**2131-6-21**] 10:44PM BLOOD Calcium-8.1* Phos-2.7 Mg-1.8
[**2131-6-22**] 05:43AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.2
[**2131-6-23**] 03:59AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.9
[**2131-6-24**] 04:13AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.1
[**2131-6-20**] 3:07 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2131-6-23**]**
MRSA SCREEN (Final [**2131-6-23**]): No MRSA isolated.
CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Study Date of
[**2131-6-19**] 10:23 PM
IMPRESSION:
1. Aortobiliac stent grafting, with postoperative air in
aneurysm sac, and no evidence of endoleak.
2. Diffuse atherosclerosis with 2-cm occlusion of distal right
SFA, 5-cm
occlusion of proximal left CFA, attenuated bilateral ATs, and
nonvisualized
left DP.
3. 3-mm nonobstructing left renal stone.
Brief Hospital Course:
The patient was admitted to the surgery service for evaluation
and treatment.She was stable from a cardiovascular standpoint
during the initial surgery. However, in the immediate post
operative period she became hypotensive and tachycardic. She
required inotropic support and mechanical ventilation. A swan
ganz catheter was placed to help monitor her cardiac status and
volume status more accurately. She was then transferred to the
Cardiovascular ICU where she was weaned off the inotropes and
then extubated. She started complaining of pain in the left leg
and foot and did not have any dopplerable signals in the DP or
the PT. A CT angio of the lower extremities was done that showed
2-cm occlusion of distal right SFA, 5-cm occlusion of proximal
left CFA. She was then taken to the OR and left common femoral
thrombectomy was done. Post operatively, she had dopplerable
signals in the left DP & PT. She was then transferred to the
unit where she was extubated.
Neuro: The patient received dilaudid with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CVS: In the immediate postoperative period after the EVAR, she
became hypotensive and was on inotropic support. There were no
changes in her EKG and her cardiac enzymes were negative. She
was weaned off the inotropes and did well. After the second
surgery, she was in sinus rhythm with frequent PACs. She was
given IV lopressor and was briefly put on a diltiazem drip to
control the rhythm. SHe was transitioned back to her oral
regimen and her Metoprolol dose was increased with resolution of
the arrythmia and good tolerance of the med. She is discharged
on the new dose.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout this hospitalization.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF.
The patient's diet was advanced when appropriate, which was
tolerated well.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely and she showed no signs of infection
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely.She required 3 units of packed RBCs in the post
operative period and is discharged with a stable H/H.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without difficulty, and pain was well
controlled.
Medications on Admission:
metoprolol 25 [**Hospital1 **], Glyburide 2.5 [**Hospital1 **], Metformin 850 [**Hospital1 **], Lasix
40 [**Hospital1 **],Fluoxetine 20, simvastatin 20, lisinopril 2.5, asa 325,
plavix 75, Nitroglycerin SL prn, Calcium acetate 500
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*50 Tablet(s)* Refills:*2*
11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual q5min x 3 doses as needed for chest pain: stat ekg
12. calcium acetate 667 mg Tablet Sig: One (1) Tablet PO once a
day.
13. check blood pressure twice daily
may resume lisinopril 2.5 mg daily if SBP consistenly >120
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Abdominal Aortic Aneurysm ; left common femoral thrombotic
arterial occlusion.
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:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**3-15**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**5-16**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Please call Dr[**Hospital **] clinic at [**Telephone/Fax (1) 43906**] to schedule an
appointment with him in 10 days.
Completed by:[**2131-6-25**]
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24,510
| 187,360
|
6638
|
Discharge summary
|
report
|
Admission Date: [**2195-1-22**] Discharge Date: [**2195-1-30**]
Date of Birth: [**2150-1-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
45 year old male with history of CHF woke up this morning
vomiting black/red vomitus with chest pain. Also having tan
diarrhea. He says he has had episodes similar to this in the
past. He initially presented to [**Hospital 8125**] Hospital. There he was
given ASA, NTG for his chest pain, EKG was unchanged, got
Reglan, Morphine. His cardiac enzymes came back positive so he
was transfered here for further evaluation. He had 1 unit PRBCs
hanging on arrival to ED. On arrival BP 165/98 and pulse 72.
In the ED he was given 40mg IV protonix and 10mg SC Vitamin K.
He notes that he has had increasing LE edema over several weeks.
He currently notes upper abdominal pain. He has back pain
consistent with his baseline where he sustained an injury. He
denies nausea or chest pain at this time. He says he is pretty
sleepy all the time and is not currently worse than normal.
He was admitted in [**2194-1-21**] with nausea and vomiting an EGD
was performed as he was having some coffee ground emesis. The
EGD showed 4 AVMs that were cauterized, a duodenal polyp with
normal pathology, and a small [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear.
Past Medical History:
Diabetes mellitus, type 1 complicated by episodes of DKA and
Gastroparesis
PVD s/p osteo of the 5th MTP s/p surgery [**9-23**]
History of hematemesis after vomiting (EGD [**8-24**] with
esophagitis, duodenitis, barrett's esophagous and bx with
[**Female First Name (un) **]).
Candidal Esophagitis
Anemia
Peripheral neuropathy
Duodenitis
CHF - dilated cardiomyopathy with EF 30-35%
Hypothyroidism
? Esophageal varices (per OSH records)
Recent MI (per OSH records)
Social History:
He lives with his brother and is separated from his current
wife. [**Name (NI) **] has children from previous marriage. He Smokes 1 pack
per day for 30 years. He uses cocaine about 2-3 times per month,
the last time was the Thursday prior to this admission. He
denies alcohol use.
Family History:
His mother had an MI at the age of 54, and his father has
diabetes.
Physical Exam:
Physical Exam 95.5 170/94, P 80, RR 20, 100% on RA
Gen: a and o times 3, very pale appearing
HEENT: PERRL, pale conjunctiva, OP clear, MMM, erythema around
eyes
Neck: no lymphadenopathy
Lungs: clear to auscultation bilaterally
CV: RRR, nl S1S2, no murmers
Abd: epigastric tenderness to palpation, decreased bowel sounds,
no rebound or guarding
Ext: 3+ edema to mid shin
Pertinent Results:
From OSH: HCT 28.9 from 34 on [**2195-1-14**], PLT 306, WBC 13.3
Troponin T 0.08, INR 0.7
.
EKG: NSR, nl axis, T wave flattening similar to prior, no
ischemic changes.
CXR: clear with no effusions
KUB and upright: no air fluid levels
.
[**2195-1-22**] 11:56PM TYPE-ART PO2-167* PCO2-36 PH-7.32* TOTAL
CO2-19* BASE XS--6
[**2195-1-22**] 11:56PM LACTATE-1.2
[**2195-1-22**] 10:58PM GLUCOSE-153* UREA N-55* CREAT-1.5* SODIUM-137
POTASSIUM-4.4 CHLORIDE-113* TOTAL CO2-16* ANION GAP-12
[**2195-1-22**] 10:58PM ALT(SGPT)-82* AST(SGOT)-20 LD(LDH)-280*
CK(CPK)-165 ALK PHOS-285* TOT BILI-0.7
[**2195-1-22**] 10:58PM CK-MB-17* MB INDX-10.3* cTropnT-0.05*
[**2195-1-22**] 10:58PM ALBUMIN-2.0* CALCIUM-7.7* PHOSPHATE-4.0
MAGNESIUM-1.4*
[**2195-1-22**] 10:58PM TSH-8.5*
[**2195-1-22**] 10:58PM FREE T4-1.1
[**2195-1-22**] 10:58PM WBC-12.0*# RBC-3.29*# HGB-10.0*# HCT-27.6*
MCV-84 MCH-30.4 MCHC-36.1* RDW-14.6
[**2195-1-22**] 10:58PM PLT COUNT-227#
[**2195-1-22**] 08:27PM HGB-11.9* calcHCT-36
[**2195-1-22**] 08:20PM HCT-32.3*#
[**2195-1-22**] 08:20PM PT-10.8 PTT-20.9* INR(PT)-0.9
[**2195-1-22**] 07:32PM WBC-4.2 RBC-1.42*# HGB-4.2*# HCT-12.7*#
MCV-89 MCH-29.8 MCHC-33.3 RDW-14.6
[**2195-1-22**] 07:32PM NEUTS-86.2* BANDS-0 LYMPHS-8.9* MONOS-4.3
EOS-0.5 BASOS-0.3
[**2195-1-22**] 07:32PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL BURR-1+
[**2195-1-22**] 07:32PM PLT SMR-LOW PLT COUNT-112*
[**2195-1-22**] 07:32PM PT-22.7* PTT-54.8* INR(PT)-2.2*
.
Echo:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left
ventricular cavity size is normal. There is moderate to severe
global left
ventricular hypokinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal. Right ventricular systolic
function is borderline normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal.
Significant pulmonic regurgitation is seen. The main pulmonary
artery is dilated. The branch pulmonary arteries are dilated.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade.
.
Abdominal US with Doppler:
Normal echogenicity of the liver with patent hepatic
vasculature. Decrease in the amount of ascites seen within the
abdomen since the prior examination. Right pleural effusion. A
spot was not marked for paracentesis given the minimal amount of
fluid.
.
CXR:
1. Left subclavian line tip in the mid SVC, without
pneumothorax.
2. Right basilar atelectasis versus aspiration.
Brief Hospital Course:
45 year old male with history of DM, CHF, esophagitis presenting
to [**Hospital1 18**] with coffee ground emesis, NSTEMI, pna/pleural
effusions, elevated LFTs, nephrotic syndrome.
.
# Nausea, vomiting, abdominal pain:
In ED, there was a question of coffee ground emesis. He was
given anzemet and reglan with minimal relief. A CT scan was
negative for appendicitis. He
declined nasogastric tube placement. His symptoms were
consistent with gastroparesis, especially since his pain
improved with reglan. He had right flank tenderness and right
upper quadrant tenderness with rebound. An RUQ ultrasound
showed a normal gallbladder with no evidence of stones. An
upright chest x-ray showed no evidence of free air. An
abdominal plain film was negative for obstruction and free air.
He was kept NPO and maintained on IV fluids and a PPI.
His symtoms were unlikely cardiac in nature since he ruled out
for an MI by serial enzymes. Head MRI was negative for a
cerebellar lesion that could contribute to nausea and vomiting.
He required the addition of erythromycin in addition to his
antiemetic regimen to control his nausea and vomiting. He then
tolerated a gastric emptying study that showed rapid emptying of
gastric contents within one hour.
.
# Upper GIB:
It was suspected that patient's coffee ground emesis was due to
prior AVMs vs. Gastritis vs. [**Doctor First Name **]-[**Doctor Last Name **] tear. In the MICU,
GI was consulted but because of his stable clinical condition,
did not feel that he needed to have EGD urgently, especially in
the setting of a NSTEMI. In the MICU, the patient received 1U
PRBC, and remained hemodynamically stable. He was on protonix
gtt and then [**Hospital1 **], Hct goal was >28 in setting of NSTEMI.
.
He was sent to the medical floor on [**2195-1-25**], and remained stable
till 2:40 AM and then had 240cc of hematamesis. Patient's SBP
at the time 170 and HR 20. GI was called, and pt returned to
the MICU. The next AM, he was scoped and initially found to
have esophagitis and a bleeding artery. Initially, epinephrine
injections were attempted to try to stop the bleeding but were
unsuccessful. Thus, he required banding, which stopped the
bleeding. His Hct was checked Q6 hours thereafter and were
stable. Hence, he was called out again on [**2195-1-26**] to the floor.
Antihypertensives were held in the setting of the GIB; the
carvedilol was restarted on [**2195-1-26**]. ASA was held because of
UGIB and in the setting of banding clips. Patient was
discharged on Carvedilol. Lisinopril or [**Last Name (un) **] was not added per
renal, since K and Cr were increased.
.
# NSTEMI:
This was diagnosed at the OSH, and could be secondary to demand
in setting of GIB. Cardiac enzymes were negative x3. EKGs
daily were unchanged from previous. Patient was chest pain free
throughout admission, both in the MICU and on the floor.
.
# Elevated LFTs:
ALT, AST, AP, LDH increased from 80s to 500s to 200s within 4
days. LFTs were also elevated during time in the MICU.
Hypotension did not occur during the patient's MICU time.
Medical records from [**Hospital3 **] showed that patient had been
worked up for elevated LFTs in the past, and nothing had been
found as an explanation (other than cocaine positive on urine
screen). Patient was asymptomatic. RUQ US with doppler was
wnl, lipid panel was wnl. The amount of ascites in the abdomen
decreased over several days. Patient must return for ERCP on
Monday, [**2195-2-2**], to assess for biliary sludge that may be
causing acute obstruction.
.
# Pleural effusions:
Bilateral pleural effusions we noted on CT Chest. Thoracentesis
removed 1 L of serous fluid that was conistent with an
transudate, likely secondary to CHF and
nephropathy.
.
# Pneumonia:
An area of opacity was noted on his initial chest x-ray, and it
became more pronounced after hydration. He was maintained on IV
antibiotics, levofloxacin and metronidazole, for probable
aspiration pneumonia. He remained afebrile during
his hospital course.
.
# Anemia:
He was found to be anemic on initial presentation, and his
hematocrit dropped with hydration. Because of his coffee ground
emesis in the ED, there was concern for an upper GI bleed. An
EGD showed 4 AVMs that were cauterized, a duodenal polyp that
had normal pathology, and a small [**Doctor First Name 329**]-[**Doctor Last Name **] tear. There was
no evidence of active bleeding. He remained hemodynamically
stable without a drop in his hematocrit. Studies were
consistent with hemolysis, and he was Coomb's negative. Iron
studies were consistent with anemia of chronic disease.
.
# Type I diabetes:
While he was NPO, he was maintained on half of his usual NPH
dose and an insulin sliding scale. He never had evidence of
DKA. Once he was able to tolerate solid food, he was
transitioned to an aggressive insulin sliding scale with
additional NPH. The patient was discharged and told to continue
his home regimen of insulin.
.
# Anasarca:
The etiology is likely secondary to congestive heart failure and
nephrotic syndrome. He was aggressively diuresed during this
admission, which resulted in a marked decrease in his edema.
.
# Nephrotic syndrome:
His protein to creatinine ration was in the nephrotic range,
which is consistent with diabetic nephropathy. A 24 hour urine
protein showed yield a total protein of abour 5g/day. Due to
the rapidly progressive proteinuria, a renal biopsy was
performed. He will follow-up with Dr. [**Last Name (STitle) **] to discuss the
results of the biopsy. Patient's albumin 1.7, causing anasarca.
Renal consult suggested Lasix 40 PO QD and starting ACE when K
is wnl.
.
# CHF:
An echocardiogram showed that he has a dilated cardiomyopathy
with and ejection fraction of 30-35%. He was gently diuresed to
remove over 10 pounds during the hospital stay. He was placed
on Lasix 40 PO QD on discharge.
.
# Hypothyroidism:
His TSH was found to be elevated to 5.9 in the setting of a T3
of 36 and a T4 of 1.1. He was started on IV synthroid (37.5
mcg) for probably subclinical hypothyroidism, and was discharged
on synthroid 75 PO QD. He will need outpatient TFTs.
.
6. FEN: He was kept NPO with maintenance fluids until he was
able to tolerate solid foods. On hospital day 4, he was
transitioned to clears, which he tolerated well. He was then
transitioned to a full diabetic, heart-healthy, low sodium diet.
His electrolytes were repleted as needed.
.
7. Code: Full
#. Contact - [**Name (NI) 25368**] ([**Telephone/Fax (1) 25369**]
Medications on Admission:
Insulin, HISS, NPH 7 at night, 7 in AM
Lisinopril 10 mg PO daily
Reglan 10mg PO QID
Protonix 40mg daily
Coreg 12.5mg daily
Vicodin prn
Toprol XL 50mg (told to stop taking this)
Hydralazine 10mg daily
Lomotil prn
? Lasix and Levothyroxine (not in medication bag but was on them
at last visit)
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*100 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Synthroid 75 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
GIB
Possible passed gallstone
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1L
If you have these symptoms, call your physician or go to the ER:
- fevers/chills
- shortness of breath
- belly pain
- nausea/vomiting
- diarrhea
- bloody stool or black stool
You must call Mass Health at 1-[**Telephone/Fax (1) 25370**] and change your PCC
to [**Hospital6 733**] or [**Hospital1 18**]. You may not be able to be
seen by Dr.[**First Name (STitle) **] until you have done this. Please do this
within 3 days.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 162**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2195-2-16**]
3:30
YOU MUST come back this MONDAY for ERCP. Go to [**Hospital Ward Name 516**],
[**Hospital Ward Name 1950**] 4.
Completed by:[**2195-1-30**]
|
[
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"443.9",
"250.41",
"507.0",
"244.9",
"581.81",
"410.71",
"530.10",
"569.85",
"276.2",
"578.9",
"250.61",
"536.3",
"530.82",
"285.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"99.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
13225, 13231
|
5779, 12303
|
327, 333
|
13305, 13312
|
2818, 5756
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|
2343, 2412
|
12646, 13202
|
13252, 13284
|
12329, 12623
|
13336, 13886
|
2427, 2799
|
276, 289
|
361, 1539
|
1561, 2026
|
2042, 2327
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,657
| 121,592
|
13526
|
Discharge summary
|
report
|
Admission Date: [**2146-11-23**] Discharge Date: [**2146-11-25**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil / Hydralazine
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
High Blood Sugar, Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Presented with additional episode c/w gastroparesis and DKA;
states that he is compliant with his DM regimen and does well
for awhile until he has another hurdle. Last A1C was > 9 which
is not consistent with the glycemic control stated by the
patient. Has been having nausea and vomiting over the past [**2-10**]
days and continued to feel worse until he knew he had to come to
the ED for additional evaluation and treatment. Denies any
fevers/chills/sweats but has been having abdominal pain, nausea,
and vomiting.
Past Medical History:
-DM type I since age 19, followed at [**Last Name (un) **]. Complicated by
nephropathy, neuropathy, gastroparesis, retionpathy. Prior
episodes of DKA and hospitalization.
-ESRD on HD T/Th/S: right arm fistula, [**Location (un) **] [**Location (un) **], dry
weight 73kg
-Hypertension
-Nonischemic cardiomyopathy with EF 30-35%
-Anemia: felt to be due to both iron deficiency and advanced CKD
-Depression
-Pulmonary hypertension
-Migraines
Social History:
-Home: Lives with his GF. Mother lives in the area as well.
-Tobacco: trying to quit; has relapsed and smokes 1 pack per
week or week and a half
-EtOH: previously drank heavily (30-40 drinks/week) but has not
used alcohol since [**2144-11-14**]
-Illicits: Denies other drugs.
Family History:
Paternal GF had DM2 but nobody with DM1. Hypertension in a few
family members.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7 160/100 94 12 97%
General: Alert, oriented, in mild-moderate distress d/t
abdominal pain
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, TTP in mid-epigastrum, 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. Functioning AV fistula in R arm.
Neuro: Awake and alert. Oriented. Moving all extremities.
.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.7 125/85 72 18 100%
General: Alert, oriented, no apparent distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no r/r/w
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM, no gallops
Abdomen: soft, slightly distended, bowel sounds present, no
rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Functioning AV fistula in R arm with +thrill.
Neuro: Awake and alert. Oriented.
Pertinent Results:
ADMISSION LABS:
[**2146-11-23**] 08:05AM BLOOD WBC-8.9 RBC-3.75* Hgb-11.8* Hct-34.4*
MCV-92 MCH-31.4 MCHC-34.3 RDW-14.2 Plt Ct-278
[**2146-11-23**] 08:05AM BLOOD Neuts-85.8* Bands-0 Lymphs-8.2* Monos-5.6
Eos-0.2 Baso-0.3
[**2146-11-23**] 08:05AM BLOOD Plt Ct-278
[**2146-11-23**] 08:05AM BLOOD Glucose-397* UreaN-39* Creat-9.1*# Na-136
K-5.9* Cl-88* HCO3-26 AnGap-28*
[**2146-11-23**] 08:05AM BLOOD ALT-24 AST-34 AlkPhos-146* Amylase-139*
TotBili-1.2
[**2146-11-23**] 11:25AM BLOOD CK(CPK)-145
[**2146-11-23**] 08:05AM BLOOD CK-MB-3 cTropnT-0.27*
[**2146-11-23**] 11:25AM BLOOD CK-MB-3 cTropnT-0.25*
[**2146-11-23**] 06:36PM BLOOD CK-MB-3 cTropnT-0.24*
[**2146-11-23**] 08:05AM BLOOD Lipase-62*
[**2146-11-23**] 08:05AM BLOOD Albumin-4.6 Calcium-10.1 Phos-6.5* Mg-1.9
[**2146-11-23**] 10:14AM BLOOD Lactate-2.0
[**2146-11-23**] 01:03PM BLOOD K-5.2*
.
DISCHARGE LABS:
[**2146-11-24**] 03:12AM BLOOD WBC-6.1 RBC-3.15* Hgb-9.8* Hct-29.5*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.1 Plt Ct-182
[**2146-11-24**] 03:12AM BLOOD Plt Ct-182
[**2146-11-24**] 03:12AM BLOOD Glucose-160* UreaN-52* Creat-10.8* Na-135
K-5.9* Cl-92* HCO3-29 AnGap-20
[**2146-11-24**] 03:12AM BLOOD Calcium-8.7 Phos-7.0* Mg-1.7
.
IMAGING:
CXR:
IMPRESSION: No acute cardiopulmonary process. Stable
mild-moderate
cardiomegaly.
Brief Hospital Course:
DC SUMMARIES:
Brief course: DM1 c/b gastroparesis, ESRD on HD, neuropathy, HTN
who is admitted with 2 days of nausea and vomiting and found to
have hyperglycemia and gap acidosis most likely due to DKA, gap
has closed glycemic control regained, abdominal pain resolved.
.
Active issues:
# DKA: The patient has a h/o of recurrent episodes of DKA and
presents now with similar Sx to prior admissions. Unknown
exacerbating factor although may be related to the patient's
chronic gastroparesis and his N/V over the past 2 days. Also
consider viral URI vs. PNA given the patient's recent productive
cough which has since resolved. The patient reports good
compliance with medications although has been non-compliant in
the past. Other forms of gap acidosis less likely as lactate is
normal and patient was dialyzed yesterday. Is 2 kilos below dry
weight on admission. Pt had insulin gtt in MICU, with
subsequent hypoglycemia. AG closed. He was transitioned to SC
insulin with normalization of blood sugars.
- FS QID, diabetic diet
- ISS
- SW consult given concern for repeated episodes and medication
non-compliance
- [**Last Name (un) **] saw the patient and made minor adjustments to his
sliding scale, will follow him as an outpatient
.
# Uncontrolled hypertension: The patient was hypertensive on
arrival with BPs up to 200 systolic while here. Most likely
etiology is poor compliance/absorption of home medications given
recent N/V. Also started on a [**Last Name (un) 40899**] patch recently but does
not have on here which may lead to rebound HTN. BP improved in
MICU and continued to have good pressure control on the floor.
- continue home anti-hypertensives amlodipine, carvedilol,
[**Last Name (un) 40899**], lisinopril, stable
.
#. Elevated troponin - Patient with troponin elevated to 0.27
(0.25 on repeat). Has been elevated to these levels on prior
admission in early [**2146-10-8**]. Most likely due to renal
failure and inability to clear trops. Less likely ACS as no
ischemic changes on ECG or active CP.
-baseline, no need to cycle enzymes
.
# End stage renal disease: renal failure [**2-9**] to DM. HD schedule
on [**Last Name (LF) **], [**First Name3 (LF) **], Sat. Last dialyzed today in MICU. Will have regular
dialysis tomorrow.
- continue HD per schedule
- appreciate renal recs
- continue home sevelamer and Nephrocaps.
.
Transitional care:
1. CODE: Full
2. Medication changes: [**First Name8 (NamePattern2) **] [**Last Name (un) **], no other changes or additions
3. Follow-up: with PCP and [**Name9 (PRE) **]
4. Pending studies/labs: Blood Cultures drawn [**2146-11-23**]; NGTD
Medications on Admission:
Medications - Prescription
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule - one
Capsule(s) by mouth once a day
CARVEDILOL - 25 mg Tablet - 2 Tablet(s) by mouth twice a day
[**Month/Day/Year **] - 0.2 mg/24 hour Patch Weekly - apply as directed
weekly
GLUCAGON (HUMAN RECOMBINANT) [GLUCAGON EMERGENCY] - 1 mg Kit -
use as directed for low blood sugar or passing out
HYDROMORPHONE - 4 mg Tablet - 1 Tablet(s) by mouth twice a day
as needed for severe pain 28 day supply
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100
unit/mL Solution - 18 units every morning Daily
INSULIN LISPRO [HUMALOG PEN] - (Prescribed by Other Provider) -
100 unit/mL Insulin Pen - Sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **]
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - Use as directed one
hour prior to dialysis three times a week
LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth once a day
METOCLOPRAMIDE - 5 mg Tablet - 1 Tablet(s) by mouth three times
a day as needed for Abdominal discomfort Please take 30 minutes
before meals.
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth Daily
ONDANSETRON - 4 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
every eight (8) hours as needed for Nausea
SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 1 Tablet(s) by
mouth TID with meals
SILDENAFIL [VIAGRA] - 100 mg Tablet - 0.5 (One half) Tablet(s)
by mouth Daily as needed for Sexual activity Take [**1-9**] tablet 1
hour before sexual activity.
SUMATRIPTAN SUCCINATE - 25 mg Tablet - 1 Tablet(s) by mouth ONCE
[**Month (only) 116**] repeat in 2 hours if no effect.
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth daily
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH TEST] - Strip - To be used
four times daily
DEXTROSE [GLUCOSE GEL] - 40 % Gel - [**1-9**] Gel(s) by mouth for
blood sugar < 60 If blood sugar < 60, take [**1-9**] gels and recheck
blood sugar in 30 minutes to one hour.
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE ULTRA-FINE] -
30 gauge X [**1-9**]" Syringe - Use up to four times daily as directed
[1 mL]
LANCETS [ONE TOUCH ULTRASOFT LANCETS] - Misc - 1 Misc(s) four
times a day or as directed
Discharge Medications:
1. amlodipine 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
2. [**Month/Day (2) 40899**] 0.2 mg/24 hr Patch Weekly [**Month/Day (2) **]: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. sevelamer carbonate 800 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. ondansetron 4 mg Tablet, Rapid Dissolve [**Month/Day (2) **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*0*
6. insulin glargine 100 unit/mL (3 mL) Insulin Pen [**Month/Day (2) **]: Eighteen
(18) units Subcutaneous with breakfast.
7. insulin lispro 100 unit/mL Solution [**Month/Day (2) **]: per sliding scale
units Subcutaneous with meals: please follow your sliding scale.
8. B complex-vitamin C-folic acid 1 mg Capsule [**Month/Day (2) **]: One (1) Cap
PO DAILY (Daily).
9. Glucagon Emergency 1 mg Kit [**Month/Day (2) **]: One (1) Kit Injection ONCE
as needed for hypoglycemia.
10. hydromorphone 4 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day
as needed for severe pain.
11. lidocaine-prilocaine 2.5-2.5 % Cream [**Month/Day (2) **]: as directed
Topical one hour prior to dialysis three times a week.
12. metoclopramide 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO three
times a day as needed for abdominal discomfort: take 30 minutes
prior to meals.
13. carvedilol 25 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO twice a day.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day (2) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day: 30 minutes before
a meal.
15. lisinopril 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
16. Viagra 100 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO once a day as needed
for sexual activity: Take 1 hour before sexual activity.
17. sumatriptan succinate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO
ONCE as needed for headache: may repeat x1 in 2 hours if no
effect.
18. docusate sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO twice
a day.
19. dextrose 40 % Gel [**Month/Day (2) **]: [**1-9**] gels PO blood sugar < 60: If
blood sugar less than 60, take [**1-9**] gels and repeat blood sugar
in 30 minutes.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Diabetic Ketoacidosis
Gastroparesis
Secondary Diagnoses:
Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 21822**],
It was a pleasure taking care of you. You were admitted for
elevated blood sugars and abdominal pain - in your case you were
in diabetic ketoacidosis and required admission to the intensive
care unit. Your blood sugars were controlled in the hospital
and you were seen by the [**Last Name (un) **] Diabetes Center staff who
adjusted your insulin regimen.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
The following medications were changed during this admission:
You have NO NEW MEDICATIONS
We are NOT STOPPING ANY MEDICATIONS
CHANGE your insulin regimen as directed by [**Last Name (un) **] Diabetes
Center
.
Please continue all other medications you were taking prior to
this admission.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) 7208**] [**Last Name (NamePattern4) **], MD
Specialty: Endocrinology
When: Wednesday [**11-30**] at 3pm
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Department: [**Hospital3 249**]
When: FRIDAY [**2146-12-2**] at 9:00 AM
With: [**Name6 (MD) 10160**] [**Name8 (MD) 10161**], NP [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] [**Hospital Ward Name **] Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a nurse practioner as part of your
transition from the hospital back to your primary care provider,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. After this visit, you will see Dr. [**Last Name (STitle) **] in follow up.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2146-12-8**]
|
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"250.53",
"346.90",
"V58.67",
"357.2",
"285.21",
"790.5",
"280.9",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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11625, 11631
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4299, 4571
|
347, 354
|
11773, 11773
|
2991, 2991
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|
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382, 903
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11788, 11900
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925, 1366
|
1382, 1661
|
2450, 2972
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,680
| 108,343
|
47367
|
Discharge summary
|
report
|
Admission Date: [**2178-12-17**] Discharge Date: [**2179-1-9**]
Date of Birth: [**2111-4-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2178-12-17**]:
1. Exploratory laparotomy.
2. Reduction of internal volvulus of the small bowel.
3. Small-bowel resection with primary anastomosis.
History of Present Illness:
67 year old man with [**Hospital 100256**] medical problems including DM
type 2, [**Hospital3 9642**] mechanical [**Hospital3 1291**], Ascending aorta repair with
graft CAD s/p CABG,hx of VF arrest s/p AICD [**2175**] who presents
with acute onset severe abdominal pain at 10am yesterday AM.
States was previosly feeling well, tolerating POs and having
regular BMs when this started. Never had pain like this before,
[**10-3**] diffuse, crampy. + nausea, no vomiting. Last BM
yesterday, normal, no blood. Denies Diarrhea. No fevers or
chills. In the Emergency Department, he was noted to be
hypotensive, started on vasopressors, received 3L IVF with
labored breathing and thus intubated in ED. He was admitted to
to the SICU.
Past Medical History:
CAD s/p CABGx3 [**2168**]
- h/o VF arrest [**6-30**] s/p ICD placement; required explantation
for MRSA pocket infection with reimplantation [**10-31**], s/p lead
removal [**4-2**]
- mechanical [**Last Name (LF) 1291**], [**First Name3 (LF) **]. [**Male First Name (un) 1525**], [**2168**]
- ascending aorta repair c graft [**4-/2169**]
- CHF (EF 20% per TTE [**2178-8-19**])
- high grade CoNS bacteremia in [**2-2**] c/b high grade CoNS, VRE
bactermia while on vancomycin [**3-2**], s/p 4 weeks daptomycin and
explantation of ICD leads
- pseudomonas UTI [**6-2**] s/p cefepime x 14 days, now pseudomonas
UTI [**8-2**] s/p meropenem x 14 days
- R lateral foot ulcer s/p debridement s/p zosyn x 14 days
- DM2 c/b neuropathy
- Hep C (dx [**4-2**], 2.38 million IU/ml. Seen by Hepatology, [**2178-7-30**]
note emphasizes deferring IFN/ribavirin tx for now given
infections, etc.)
- HTN
- HLP
- PVD s/p L BKA [**7-27**]
- hypothyroidism
- h/o opiate dependence, ?benzo dependence
- acute on chronic SDH, [**8-30**]
- h/o R scapula fx
- h/o MRSA elbow bursitis, [**5-1**]
- h/o closed bimalleolar fx s/p repair, removal of hardware [**6-26**]
Social History:
Lives in [**Location (un) **], though has been in rehab for much of the
past few months. Former cab driver. Social history is
significant for the current tobacco use of 40 pack years. There
is no history of alcohol abuse or recreational drug use. Lives
with common-law wife of 35 years who is a home health aid.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
VS: T96.0 66 80/50 24 100% facemask
GEN: ill appearing man, sleepy, answering questions with
difficulty
HEENT: Sclera anicteric. MMdry
CV: irregular irregular
LUNGS: Labored breathing. Diffuse bilateral rales
ABDOMEN: distended, diffusely tender with rebound and guarding
RECTAL: trace guaiac pos
.
At Discharge:
AVSS/afebrile.
GEN: Well in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: Irregularly irregular
ABD: Midline incision with steri-strips c/d/i. Lower aspect
incisional wound 5cm x 3cm x 2cm granulating, clean. Wet-to-dry
packing [**Hospital1 **]. BSX4. Appopriately tender to palpation along wound,
otherwise soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3.
Pertinent Results:
On Admission:
[**2178-12-17**] 12:15AM PT-48.6* PTT-61.5* INR(PT)-5.2*
[**2178-12-17**] 12:15AM PLT COUNT-158#
[**2178-12-17**] 12:15AM NEUTS-90.2* LYMPHS-5.2* MONOS-4.0 EOS-0.4
BASOS-0.2
[**2178-12-17**] 12:15AM WBC-8.2 RBC-3.68* HGB-8.5* HCT-28.7* MCV-78*
MCH-23.1* MCHC-29.7* RDW-19.7*
[**2178-12-17**] 12:15AM URINE GR HOLD-HOLD
[**2178-12-17**] 12:15AM CALCIUM-6.7* PHOSPHATE-2.6* MAGNESIUM-1.7
[**2178-12-17**] 12:15AM LIPASE-15
[**2178-12-17**] 12:15AM ALT(SGPT)-25 AST(SGOT)-33 LD(LDH)-196 ALK
PHOS-59 TOT BILI-0.4
[**2178-12-17**] 12:15AM GLUCOSE-228* UREA N-40* CREAT-1.2 SODIUM-139
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
[**2178-12-17**] 12:44AM LACTATE-2.2*
[**2178-12-17**] 04:30AM PT-21.6* PTT-41.8* INR(PT)-2.0*
[**2178-12-17**] 04:38AM LACTATE-2.9*
[**2178-12-17**] 04:45AM PT-24.2* PTT-43.7* INR(PT)-2.3*
[**2178-12-17**] 06:11AM freeCa-1.04*
[**2178-12-17**] 06:11AM HGB-9.2* calcHCT-28
[**2178-12-17**] 06:11AM GLUCOSE-223* LACTATE-3.9* NA+-137 K+-4.2
CL--103
[**2178-12-17**] 07:58AM PT-19.1* PTT-42.3* INR(PT)-1.7*
[**2178-12-17**] 07:58AM PLT COUNT-212
[**2178-12-17**] 07:58AM WBC-14.8*# RBC-3.85* HGB-9.3* HCT-30.6*
MCV-80* MCH-24.1* MCHC-30.4* RDW-19.2*
[**2178-12-17**] 07:58AM CALCIUM-7.6* PHOSPHATE-2.4* MAGNESIUM-2.2
[**2178-12-17**] 07:58AM CK-MB-NotDone cTropnT-0.03*
[**2178-12-17**] 07:58AM GLUCOSE-230* UREA N-43* CREAT-1.6* SODIUM-140
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-21* ANION GAP-17
.
Prior to Discharge:
[**2179-1-7**] 06:29AM BLOOD WBC-4.4 RBC-3.21* Hgb-9.0* Hct-27.7*
MCV-86 MCH-28.0 MCHC-32.5 RDW-22.5* Plt Ct-119*
[**2179-1-7**] 06:29AM BLOOD Plt Ct-119*
[**2179-1-7**] 06:29AM BLOOD Glucose-157* UreaN-16 Creat-0.8 Na-132*
K-4.3 Cl-91* HCO3-34* AnGap-11
[**2179-1-7**] 06:29AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.8
[**2179-1-8**] 04:20AM BLOOD PT-26.4* PTT-48.8* INR(PT)-2.6*
.
IMAGING:
[**12-17**] CXR Interval worsening of mild pulmonary edema. Moderate
bibasilar atelectasis in the setting of low lung volumes.
[**12-17**] CT abd: Findings concerning for mesenteric ischemia with
portal venous air, with focus of air seen in mesentery centered
about loops of small bowel in the right mid abdomen with air
circumferentially surrounding the lumen suggestive of
pneumatosis and associated mesenteric stranding (301B:18-27).
Vascular event may represent etiology, though swirling
configuration suggests internal hernia.
[**12-18**] CXR improved basilar aeration. CVl well placed
[**12-20**] CXR New b/l poorly defined pulmonary opacities, some w/
nodular configuration.
[**12-20**] CXR Interval increase in diffuse widespread airspace
consolidation, ?ARDS.
[**12-21**] multifocal pneumonia. Co-existing ARDS is also possible.
[**12-21**] lung CT
[**12-21**] Head CT
[**12-28**]: Echo: EF 20-25%, PCWP>18, [**12-26**]+ MR, dilated LV, global
hypokinesis
[**1-2**] CXR: Worsening pulmonary edema. Evidence for bilateral
pleural
effusions, which may have increased as well.
[**1-4**] CXR:Mild-to-moderate pulmonary edema has improved since
[**1-2**]
[**1-5**] CXR: Cardiomegaly, bilateral pleural effusions and
atelectasis,
overall appearing minimally changed.
.
MICROBIOLOGY:
[**12-17**] Sputum MRSA Mod growth.
[**12-18**] Bcx: Staph coag neg 1/2 bottles
[**12-19**] BAL MRSA
[**12-20**] Sputum: MRSA, sparse GNR
[**12-23**] BAL: MRSA
[**12-24**] BAL: Negative
[**12-26**] C diff neg
[**12-30**] Catheter tip neg
.
PATHOLOGY:
[**2178-12-17**] SPECIMEN SUBMITTED: ILEUM.
DIAGNOSIS:
Ileum, Segmental resection:
1. Ischemic enteritis with focally transmural necrosis and
associated serositis.
2. One unremarkable resection margin; opposite resection margin
with mucosal ischemic changes and acute inflammation of the
superficial submucosa.
Clinical: Ischemic bowel, acute abdomen.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known lastname **], [**Known firstname **]", the medical record number and "ileum." It
consists of a segment of small bowel measuring 92 cm in length
and 3 cm in average diameter. A portion of mesentery is
attached to the small bowel that measures 2 x 4 x 3 cm. The
specimen is not oriented. The mesentery is unremarkable. The
serosa of the bowel is focally erythematous and dusky looking.
There are two staples measuring 3.7 and 5.2 cm. The specimen is
opened along the antimesenteric surface to reveal fecal material
and blood within the lumen. The mucosa in the central portion of
the bowel measuring 34 cm in length is erythematous, brown and
dusky looking. No masses or polyps are identified. No
perforation site is identified. The bowel wall within the
affected area measures up to 0.2 cm in thickness. Normal
looking bowel measures up to 0.4 cm in thickness. The specimen
is represented in cassettes as follows: A = 5.2 cm stapled
margin, B = 3.7 cm staple margin, C = section of affected bowel,
D = transition between effected and normal bowel, E-G = fat.
Brief Hospital Course:
The patient with multiple medical problems was admitted to the
General Surgical Service on [**2178-12-17**] for evaluation of an acute
abdomen likely from ischemic bowel. He was admitted to the
SICU. He was made NPO, started on IV fluids, a foley catheter
and CVL were placed, empiric IV Vancomycin and Zosyn were
started, and he was given Fentanyl IV PRN for pain and Valium
for sedation. He was emergently brought to the Operating Room,
where he underwent exploratory laparotomy, reduction of internal
volvulus of the small bowel, and small-bowel resection with
primary anastomosis(reader referred to the Operative Note for
details). He was found to have ischemic bowel with obstruction,
peritonitis, and an internal volvulus of the small bowel.
He was returned to the SICU for post-operative care.
.
SICU/TICU EVENTS [**2178-1-17**] - [**2178-12-29**]:
[**12-17**] 1 u PRBC, 750 LR intraop, to ICU post op. On neo and epi.
Transfused 1 u for hct 28. Febrile to 101.
[**12-17**] pm - spike to 101.2, decreasing pressor requirements and
lactate. Pan-Cxs sent.
[**12-18**] Left subclavian placed. Bloody guiac + BM overnight. HCT
drifting down. GPC on blood culture 1/2 bottles [**12-18**] .
[**12-19**]: Bronch and BAL.Abx started after BAL
[**12-20**]: Low uop. Large heparin requirement given FFP 2 untis for
? atIII def. PS trial failed changed back to rate. TPN started.
[**12-21**]: Concern for depressed mental status in AM. Concern for
septic emboli to brain/eyes/lungs. Mental status improved in PM
w/o intervention except for holding of propofol. Also concern
for pt's high need of heparin to stay in therapeutic level.
Peripheral smear sent.LENI negative.
[**2178-12-22**]: Bedside TTE w/ hyperdynamic LV, FeNa 0.2%, given 3
Unit of Blood,He Had melanotic stool, but HD stable, started on
D5W at 30cc/h, Creatine improving. acutely became diaphoretic
sat down to 88% pt labored and desynchronous with ventilator,
tachycadic high BP w/ Map 110, tachycardic 120, CVP 26. Patient
had flush PE lasix bolus given, patient sedated, ABG improved
[**12-27**] - Extubated [**12-26**] PM, started on BiPAP. Back on Lasix gtt,
started Carvedilol, started bridge to Coumadin. Re-intubated due
to fluid reaccumulation
[**12-29**]: Extubated. Doing well.
[**12-30**] PICC placed
[**1-2**]: to TICU for resp distress, Bipap responsive, cardiac diet
now, restarted carvedilol, ace, aldactone, required bipap o/n
after brief desat
[**1-3**] Bipap during the day and extra Lasix 20mg IV x1, negative
for the day, Bipap overnight, held coumadin x 1 for INR 5.8
[**1-4**]: Opening of abdominal wound. Held coumadin for INR 5.7.
[**1-5**]: started glargine, removed foley, restarted coumadin 3mg.
[**1-6**]: Coumadin reduced to 2mg.
.
[**Hospital Ward Name **] 9 EVENTS:
On [**2179-1-6**], the patient was transfered to the inpatient floor.
He arrived on a Diabetic/low sodium regular diet, oral
medications, voiding without assitance, with IV Linezolid and
Meropenem continued. Coumadin was continued, and monitored
closely to maintain a therapeutic goal range of 2.5-3.5. The INR
on [**2179-1-8**] was 2.6.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient's blood sugar was monitored regularly throughout the
stay; Lantus and sliding scale insulin was administered as
indicated. Labwork was routinely followed; electrolytes were
repleted when indicated.
.
At the time of discharge on, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
diabetic/low sodium regular diet, ambulating with assistance,
voiding without assistance, and pain was well controlled. He
was discharged to an extended care facility for rehabilitation
and nursing care. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
.
Services Consulted during admission: Infectious Disease,
Otolaryngology, Cardiology, Pulmonary, Social Work, Physical
Therapy, and Occupational Therapy.
Medications on Admission:
Amiodarone 200 mg DAILY
Atorvastatin 40 mg DAILY
Polyethylene Glycol 3350 17 gram/dose [**Hospital1 **]
Amitriptyline 10 mg HS
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Captopril 25 mg TID
Lactulose 30 Q8H (every 8 hours) as needed for constipation.
Aspirin 81 mg Daily
Lorazepam 0.5 mg Q4H as needed for anxiety
Levetiracetam 500 mg QHS
Gabapentin 400 mg Q8H (
Warfarin 5 mg Daily
Oxycodone 5 mg Q4H as needed for pain.
Acetaminophen 500 mg q8 hours as needed for pain
Bisacodyl 10 mg [**Hospital1 **] prn
Albuterol Sulfate 90 mcg 2 Puffs IH Q6H prn
Ipratropium Bromide 17 mcg/Actuation QID (
Meropenem 500 mg q6
Spironolactone 25 mg DAILY
Torsemide 20 mg [**Hospital1 **]
Metolazone 5 mg [**Hospital1 **]
Metoprolol 12.5 mg [**Hospital1 **]
Potassium Chloride 20 mEq once a day
Insulin Glargine 40 units Subcutaneous at bedtime
Insulin Lispro per sliding scale
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY at 16:00:
St. [**Male First Name (un) 1525**] mechanical [**Male First Name (un) 1291**]; INR goal 2.5-3.5.
9. Ondansetron 4 mg IV Q8H:PRN nausea
10. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q6H (every 6
hours) as needed for pain.
11. Ativan 0.5 mg Tablet Sig: [**12-26**] Tablet(s) (give SL) PO every
6-8 hours as needed for Anxiety.
12. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Torsemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Metolazone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
16. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
17. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO at
bedtime.
18. Neurontin 400 mg Capsule Sig: One (1) Capsule PO three times
a day.
19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
20. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
21. Captopril 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
22. Insulin Lispro 100 unit/mL Solution Sig: 4-22 units
Subcutaneous As directed per Humalog Insulin Sliding Scale.
23. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
24. Medication:
Morphine Sulfate 2-4 mg IV Q6H:PRN Breakthrough Pain Only
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Ischemic bowel.
2. Bowel obstruction.
3. Peritonitis.
4. Internal volvulus of small bowel.
5. Multifocal pneumonia
.
Secondary:
1. CAD
2. History of VF arrest [**6-30**] s/p ICD placement
3. Mechanical St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] on Coumadin prophylaxis INR Goal
2.5-3.5)
4. CHF (EF 20%)
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:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-3**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
*The lower incision wound will be cared for by your nurse. Car
is a wet-to-dry dressing changed twice daily.
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Please call ([**Telephone/Fax (1) 2828**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) **] (Surgery) in 2 weeks.
.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2179-1-27**] 1:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. (PCP) Date/Time:[**2179-1-29**] 11:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2179-2-23**] 10:15
Completed by:[**2179-1-8**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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] |
15805, 15884
|
8560, 12677
|
328, 480
|
16274, 16274
|
3604, 3604
|
21012, 21627
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2745, 2860
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13618, 15782
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15905, 16253
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12703, 13595
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16451, 17124
|
17140, 20989
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2875, 2875
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3202, 3585
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274, 290
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508, 1239
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3619, 8537
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16288, 16427
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1261, 2399
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2415, 2729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,829
| 140,048
|
46546+58915
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-2-4**] Discharge Date: [**2174-2-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
LLE pain/swelling
Major Surgical or Invasive Procedure:
left femoral hemodialysis line
hemodialysis x 4 days
s/p embolization of inferior epigastric artery
EGD
s/p IVC filter
History of Present Illness:
83 y.o. female with CHF and gout p/w Left LE pain. She was in
her USOH (living with her son, somewhat independent) until [**2-2**]
at midnight when she noted acute onset of Left calf pain. She
went back to sleep but then awoke with severe calf pain and
erythema. She also notes erythema and warmth of uncertain
duration.
In the ED an U/S was (+) for DVT and she was started on heparin
along with one dose of unasyn for cellulitis.
Past Medical History:
## HTN
## Gout
## Depression
## Osteoporosis
## [**12-19**] + AR, 1+MR [**First Name (Titles) **] [**Last Name (Titles) **] [**2171**]
## ?Afib (not anticoagulated) on Digoxin
Social History:
Lives with son in [**Name (NI) 3915**], MA
No EtOh
No Tob (quit 10 y.a.)
Family History:
Father: brain tumor
Physical Exam:
On presentation:
T: 99.5, BP:163/65, HR:84, RR:20, O2:98RA
On the floor:
T: 101.2 BP: 116-118/42 68-71 18 94%RA
Gen: NAD. A/O x 3. Knows some current events.
HEENT: PEARLA. EOMI. OP: several caps on teeth
CV: Non-displaced PMI. III/VI diastolic murmur at RUSB with
radiation to carotids.
Pulm: CTA b/l
ABD: Nt/ND/soft
Ext: Left LE 2+ edema. + TTP over calf. no palpable cord. Warm,
Skin: Patchy erythema L>>R. More marked over plantar surfaces
b/l, venous stasis changes and several echymoses bilat
Neuro: motor [**4-21**] aside from hip flexors which are [**2-19**]. Full
A/PROM
CN II-XII GI. Gait: not observed
Pertinent Results:
[**2174-2-3**] 10:22PM GLUCOSE-98 UREA N-62* CREAT-1.8* SODIUM-136
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-29 ANION GAP-14
[**2174-2-3**] 10:22PM WBC-13.5* RBC-4.20 HGB-12.5 HCT-36.5 MCV-87
MCH-29.8 MCHC-34.3 RDW-14.8
[**2174-2-3**] 10:22PM NEUTS-87.0* BANDS-0 LYMPHS-7.4* MONOS-4.0
EOS-1.3 BASOS-0.2
[**2174-2-3**] 10:22PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2174-2-3**] 10:22PM PLT COUNT-463*
[**2174-2-3**] 10:22PM DIGOXIN-1.0
[**2174-2-3**] 10:22PM GLUCOSE-98 UREA N-62* CREAT-1.8* SODIUM-136
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-29 ANION GAP-14
[**2174-2-3**] 10:46PM LACTATE-1.4
[**2174-2-4**] 07:35AM WBC-12.8* RBC-3.64* HGB-10.7* HCT-31.1*
MCV-86 MCH-29.3 MCHC-34.2 RDW-14.8
[**2174-2-4**] 07:35AM PLT COUNT-373
c diff neg x 2 (3rd pending)
[**Last Name (un) **] cx [**2-14**]: neg
sputum cx [**2-14**]: mod OP flora
H pylori: positive
blood cx 2/17,24,25: no growth
LENI: Nonocclusive thrombus, left common femoral-popliteal
veins.
EGD [**2174-2-11**]:
Grade IV esophagitis in the middle third of the esophagus and
lower third of the esophagus.
Large hiatal hernia.
Erythema, congestion and friability in the whole stomach
compatible with gastritis.
Congestion, erythema and friability in the duodenal bulb
compatible with duodenitis.
KUB [**2174-2-12**]:
There is gas present throughout the colon with some retained
contrast in the right colon. There are gas filled loops of
nondilated small bowel. Soft tissue density in right flank,
presumably related to known hematoma. Overall appearance is
unchanged since the prior film of [**2174-2-10**].
Renal U/S [**2174-2-15**]: No hydronephrosis or renal calculi.
Angiogram/embolization [**2174-2-11**]:
FINDINGS: There are diffuse atherosclerotic changes in the
abdominal aorta
and iliac arteries with extensive tortuosity of the iliac
arteries
bilaterally. There is no evidence of active extravasation on
aortogram with selective injection of the contrast material into
the right external iliac artery and right inferior epigastric
artery. Gelfoam slurry for embolization of the right inferior
epigastric artery until complete stagnation of flow.
IMPRESSION:
1) No evidence of acute extravasation.
2) Prophylactic embolization of the right inferior epigastric
artery using
gelfoam slurry.
CT abd [**2174-2-8**]:
IMPRESSION:
1) Large right rectus sheath hematoma measuring 22.3 x 14.0 x
8.3 cm. Oblong collection of arterial attenuation blood medially
within the hematoma, which by Doppler, represents focal ectasia
of a branch of the inferior epigastric artery. An additional
fluid/contrast level is present more laterally within the
hematoma, which demonstrates CT evidence of active
extravasation.
2) Very distended gallbladder with a 6-mm calcified stone in
gallbladder neck or proximal cystic duct. No CT evidence of
acute cholecystitis. Continued clinical followup recommended.
3) Two rounded low-attenuation cystic structures in the tail of
the pancreas. The findings are nonspecific and could be sequelae
of prior pancreatitis, but IPMT cannot be excluded.
CXR [**2174-2-18**]:
The cardiac silhouette is mildly enlarged. There is upper zone
vascular
redistribution, but there is no overt evidence of pulmonary
edema. Small
pleural effusions are noted bilaterally, and the right pleural
effusion may have an associated subpulmonic component.
Labs on d/c:
hct 34.5, creatinine 2.4, sodium 130, wbc 12.1
Brief Hospital Course:
A/P: 83 yo F w/ h/o htn, gout, CRI, and depression a/w LLE DVT
for which she was anticoagulated but unfortunately developed a
rectus abd sheath hematoma and coffee ground emesis while on
anticoag so underwent embolization of inferior epigastric artery
and IVC filter.
# DVT: Likely [**1-19**] decreased mobility and venous insufficiency.
Pt was placed on a heparin drip and 5 mg coumadin was started
once PTT was in the goal range of 60-80 and stopped once pt's
INR was therapeutic (goal INR [**1-20**]). Unfortunately, while on
anticoagulation, patient developed a right rectus sheath
hematoma w/ concurrent hct drop. She was transfused and
underwent inferior epigastric artery embolization to control the
bleeding. Her coumadin was reversed and an IVC filter was placed
([**2174-2-11**]) for management of her DVT.
# LE cellulitis: Initially, pt was started on oxacillin as she
has no h/o DM and no bites/water exposure to suggest need for
broader coverage. However, her cellulitis did not improve and
her WBC climbed. She was switched to unasyn, again without
improvement, suggesting MRSA cellulitis. Vanco was started with
improvment clinically and with a decreased WBC. She is now
completing a total of 14 days levo/flagyl to cover both her
cellulitis and aspiration PNA and has been doing well.
# acute oliguric RF
Patient p/w baseline creatinine 1.8 on admission. Unfortunately,
in the setting of 2 IV contrast studies in addition to prerenal
insult due to acute bleeding, patient suffered acute oliguric
renal failure. Renal was consulted and suspect ATN. Due to
worsening uremia (causing AMS) decision was made to place a left
femoral temporary dialysis catheter. Patient underwent 4 HD
sessions and is much improved. Her HD line was pulled on [**2174-2-19**]
after her urine output returned to approx 1 L qd and her
creatinine was consistently improving. Plan to continue to
follow chem 10 and monitor i's/o's at rehab w/ plan for
follow-up with Dr. [**Last Name (STitle) 98846**] or Dr. [**Last Name (STitle) **] of nephrology if
creatinine does not return to baseline 1.8 by the end of her
rehab stay.
# GIB:
In addition to a rectus sheath hematoma, patient developed
coffee ground emesis while on anticoag. She underwent an EGD
this admission which showed grd IV
esophagitis/gastritis/duodenitis. Of note, serum H pylori was
positive so she is being tx w/ flagyl, amox, and [**Hospital1 **] ppi x 14
days total. No NSAIDs. Hct has been stable for days.
# Hypoxia
Patient developed an O2 reqmt over her hospital stay. CXR showed
RML and RLL infiltrates concerning for aspiration. Antibx were
broadened from vanc to levo/flagyl to cover aspiration PNA given
patient also demonstrating a rising wbc. She will continue on
these antibx through [**2174-2-24**]. She is due for a swallow
evaluation today prior to d/c though she is on a regular diet w/
no episodes of coughing and f/u CXR only remarkable for mild
volume overload. Prior to d/c she was stable on room air. We are
encouraging incentive spirometry qh.
# Right Rectus Sheath Hematoma:
Patient developed this hematoma in the context of
anticoagulation for her DVT. She is now s/p inf epigastric
artery embolization by IR to control her bleeding and her hct
has been stable since [**2-12**] w/o transfusions.
# PAF:
No h/o anticoagulation. Currently not anticoagulated due to r/o
bleeding. On digoxin as outpatient, started on BB as inpatient
w/ good rate control and bp stable.
# AS:
Mod AS in [**2171**]. LVEF > 65% in '[**71**]. Asxic this admission. Restart
ACE +/- lasix as outpatient when creatinine back to baseline.
# PPX: PPI, bowel reg, no anticoag due to hematoma
# FEN:
swallow eval to r/o aspiration prior to d/c
cardiac diet
# Code: Full.
# Communication: Niece [**Female First Name (un) 72029**] [**Telephone/Fax (1) 98847**]
# dispo: to rehab following completion of swallow eval
Medications on Admission:
ASA
MVI
Colchicine
Dig 125
lasix 40
Lisinopril 20
Vit A/D
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Can be started [**2174-3-2**].
Disp:*90 Tablet(s)* Refills:*2*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours)
for 8 days.
Disp:*16 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: Reduce to once
daily dosing after 10 days of taking this medication twice per
day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 8 days.
Disp:*8 Capsule(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold if you are having diarrhea.
Disp:*14 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 4 days: through [**2174-2-24**].
Disp:*2 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 days: through [**2174-2-24**].
Disp:*8 Tablet(s)* Refills:*0*
12. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of the [**Location (un) 1121**] - [**Location (un) **]
Discharge Diagnosis:
Acute oliguric renal failure
Left lower extremity cellulitis
deep vein thrombosis
Helicobacter pylori gastritis
Aspiration pneumonia
Right rectus sheath hematoma
Iron deficiency anemia
Secondary dx:
## HTN
## Gout
## Depression
## Osteoporosis
## [**12-19**] + AR, 1+MR [**First Name (Titles) **] [**Last Name (Titles) **] [**2171**]
## ?Afib
Discharge Condition:
good: stable on room air, good urine output
Discharge Instructions:
Please call your doctor or return to the emergency room for any
fever/chills, worsening leg redness/warmth, or swelling, acute
shortness of breath, or any other concerning symptoms you may
have.
Followup Instructions:
Please follow-up with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] at the appointment listed
below to discuss restarting your asa, coumadin, and ace
inhibitor:
[**Doctor Last Name **],MCCN MCCN-ADULT MEDICINE (PRIVATE) Where: ADULT MEDICINE
UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**], [**Numeric Identifier 9121**]
Phone:[**Pager number **] Date/Time:[**2174-3-10**] 11:00 Phone: [**Telephone/Fax (1) 1144**]
Please follow-up with Dr. [**Last Name (STitle) 98848**] or Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 60**]
if your creatinine does not return to 1.8 by the end of your
rehab stay.
Name: [**Known lastname 10298**],[**Known firstname 8547**] Unit No: [**Numeric Identifier 15778**]
Admission Date: [**2174-2-4**] Discharge Date: [**2174-2-21**]
Date of Birth: [**2090-8-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 211**]
Addendum:
Rehab concerned re: ? dx schizophrenia. I have contact[**Name (NI) **]
patient's PCP and she states that Ms. [**Known lastname **] does not have a
formal dx of schizophrenia. PCP is concerned she may be
depressed but Ms. [**Known lastname **] refuses to see a psychiatrist. Of
note, patient's son claims that Ms. [**Known lastname **] has schizophrenia
and has told Ms. [**Known lastname 15779**] PCP that she was on a number of psych
medications when he was younger. This has not been confirmed.
However, patient's son is followed by Dr. [**Last Name (STitle) 3812**] ([**Telephone/Fax (1) 15780**])
for dx schizophrenia.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of the [**Location (un) 95**] - [**Location (un) 102**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**]
Completed by:[**2174-2-21**]
|
[
"276.5",
"041.86",
"728.89",
"286.9",
"535.51",
"535.61",
"682.6",
"599.0",
"427.31",
"453.42",
"428.0",
"530.10",
"507.0",
"280.0",
"403.91",
"453.41",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"99.04",
"38.93",
"38.7",
"38.95",
"39.95",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
13390, 13644
|
5340, 9215
|
278, 399
|
11389, 11434
|
1839, 5317
|
11677, 13367
|
1167, 1189
|
9323, 10880
|
11022, 11368
|
9241, 9300
|
11458, 11654
|
1204, 1820
|
221, 240
|
427, 860
|
882, 1060
|
1076, 1151
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,509
| 148,301
|
24868
|
Discharge summary
|
report
|
Admission Date: [**2115-9-20**] Discharge Date: [**2115-10-23**]
Date of Birth: [**2086-12-31**] Sex: M
Service: NEUROSURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
27yo Hispanic M who was visiting a handicapped, known-drug
suppliers apartment earlier today when an unknown young
gentleman
entered the residence and shot the patient in the back
bilaterally to shoulders, left thigh and right
parietal-occipital
region of skull.
Major Surgical or Invasive Procedure:
placement of intracranial pressure monitor - now out
tracheosotomy / bronchoscopy [**2115-10-2**]
EGD [**10-7**]
PEG [**10-15**]
IVC filter [**10-17**]
History of Present Illness:
27yo Hispanic M who was visiting a handicapped, known-drug
suppliers apartment earlier today when an unknown young
gentleman
entered the residence and shot the patient in the back
bilaterally to shoulders, left thigh and right
parietal-occipital
region of skull.
Past Medical History:
PMH: None on admission
MED: Denies use of OTC, prescription medications
ALL: HIT (+)
SH: Patient uses marijuana, last use the morning of admission,
lives with girlfriend. [**Name (NI) **] [**Name2 (NI) 8003**] speaking, works as a painter
FH: Non-contributory
Social History:
SOCHx: Patient uses marijuana, last use the morning of
admission,
lives with girlfriend. [**Name (NI) **] [**Name2 (NI) 8003**] speaking, works as a painter
Family History:
FH: Non-contributory
Physical Exam:
on admission
VS: T `HR-49 BP-140/94 RR-18 Sat-100% NRB
PE: Per Trauma H&P
GEN Alert/NAD
HEENT Two wounds to right parietoccipital skull region
Neck C-spine collar, trachea midline, no crepitus
Chest CTA B
ABD soft, NTND, no injuries
EXT warm, well-perfused, no C/C/E, hole in left thight lateral
to and proximal to knee
Back Two lacs to left shoulder, 1 lac to right shoulder both
over scapulas, no scapular deformities
Neuro
MS: alert and oriented. Answering questions, follows commands.
Speech fluent.
GCS 14
Moves all extremitites.
Left eye esotropia. Nystagmus to right. Question of dysconjugate
gaze? Pt. reports that he can see "only a little" but is not
cooperative with formal visual field testing.
LAB:
Na 141
K 3.5
Cl 109
CO2 19
BUN/Cr 14/1.0
Glu 192
WBC 8.8
RBC 34.5
Plt 210
PT/INR/PTT 13.3/1.2/24.5
Pertinent Results:
[**2115-9-20**] 05:30PM WBC-17.5*# RBC-3.71* HGB-11.1* HCT-29.9*
MCV-81* MCH-30.0 MCHC-37.2* RDW-13.1
[**2115-9-20**] 05:30PM PT-13.2 PTT-26.0 INR(PT)-1.2
[**2115-9-20**] 11:29AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2115-9-20**] 11:29AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2115-9-20**] 11:29AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2115-9-20**] 11:29AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2115-9-20**] 11:10AM AMYLASE-79
[**2115-9-20**] 11:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEGATIVE barbitrt-NEGATIVE tricyclic-NEGATIVE
[**2115-9-20**] 11:10AM WBC-8.8 RBC-4.22* HGB-12.3* HCT-34.5* MCV-82
MCH-29.3 MCHC-35.8* RDW-12.9
[**2115-9-20**] 11:10AM PT-13.3 PTT-24.5 INR(PT)-1.2
[**2115-10-9**] 02:54AM BLOOD WBC-20.5* RBC-3.14* Hgb-9.0* Hct-26.3*
MCV-84 MCH-28.6 MCHC-34.2 RDW-15.9* Plt Ct-636*
[**2115-10-4**] 09:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2115-10-4**] 09:10AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2115-10-4**] 09:10AM URINE RBC-[**2-16**]* WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2115-10-1**] 03:47PM URINE CastHy-0-2
[**2115-10-9**] 10:52AM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-37*
Polys-PND Lymphs-PND Monos-PND
[**2115-10-9**] 10:52AM CEREBROSPINAL FLUID (CSF) WBC-12 RBC-386*
Polys-PND Lymphs-PND Monos-PND
[**2115-10-9**] 10:52AM CEREBROSPINAL FLUID (CSF) TotProt-30 Glucose-63
[**2115-10-8**] 11:09 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2115-10-8**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2115-10-8**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
RADIOLOGY Final Report
BILAT LOWER EXT VEINS PORT [**2115-10-8**] 10:00 AM
BILAT LOWER EXT VEINS PORT
Reason: BILATERAL SWELLING. R/O DVT
[**Hospital 93**] MEDICAL CONDITION:
28 year old man with fevers
REASON FOR THIS EXAMINATION:
r/o dvt
INDICATION: 28-year-old man with fever.
COMPARISON: None.
FINDINGS: [**Doctor Last Name **] scale and color Doppler examination of the deep
veins of both thighs and posterior knees demonstrates normal
compressibility, color flow, respiratory variation, and
augmentation. There is no sign of intraluminal thrombus.
IMPRESSION: No DVT.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2115-10-8**] 11:42 AM
CHEST (PORTABLE AP)
Reason: eval s/p bronch
[**Hospital 93**] MEDICAL CONDITION:
26 year old man with high resp rate and lot of secretions
REASON FOR THIS EXAMINATION:
eval s/p bronch
INDICATION: Tachypnea and secretions; status post bronchoscopy.
PORTABLE AP CHEST: Comparison is made to examination performed
10 hours earlier. Tracheostomy tube, enteric tube, and right
subclavian central venous catheter remain in stable position. Of
note, right subclavian central venous catheter remains within
the proximal right atrium. In the interval, there has been
improvement of previously evident diffuse bilateral multifocal
air space opacities, with bibasilar opacities persisting. There
are no definite pleural effusions. No pneumothorax is
identified.
IMPRESSION: Interval placement in diffuse bilateral airspace
opacities, consistent with resolving pulmonary edema. Persistent
bibasilar air space opacities are noted.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2115-10-7**] 10:25 PM
CT HEAD W/O CONTRAST
Reason: please eval interval change in intracranial hemorrhage
[**Hospital 93**] MEDICAL CONDITION:
28 year old man s/p gunshot to head
REASON FOR THIS EXAMINATION:
please eval interval change in intracranial hemorrhage
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Evaluate interval change and intracranial
hemorrhage.
COMPARISON: [**2115-9-21**].
TECHNIQUE: Noncontrast head CT.
CT OF THE BRAIN WITHOUT IV CONTRAST: Again, seen are multiple
bone fragments within the brain parenchyma in the right parietal
lobe and soft tissues secondary to the gunshot wound. Since the
examination of [**2115-9-21**], there has been evolution of
multiple hemorrhagic foci within the right temporal and parietal
lobes. There is, however, increase in hypodensity within the
anterior aspect of the right temporal lobe consistent with edema
or infarction, and stable hypodensity within the posterior
aspect of the right temporal lobe and parietal and frontal lobes
consistent with stable edema in these areas.
Although the images are limited by motion artifact, no definite
new intracranial hemorrhage is identified. There is near
complete resolution of the small amount of blood previously seen
in the posterior [**Doctor Last Name 534**] of the left lateral ventricle. The
tentorial subdural hematoma is poorly visualized.
There is continued compressive mass effect upon the right
lateral ventricle and mild right to left subfalcine shift,
somewhat improved from prior study. A left frontal burr hole is
new in the interval since the examination of [**9-21**], and
there is hypodensity within the subjacent brain parenchyma
likely due to prior placement and removal of a transcalvarial
device such as a bolt. No evidence of foramen magnum or
transtentorial herniation is seen.
A tiny focus of pneumocephalus is again seen within the frontal
[**Doctor Last Name 534**] of the right lateral ventricle.
Bone windows demonstrate new burr hole in the left frontal
cranium and continued osseous fragments within the brain
parenchyma and subcutaneous tissues on the right at the site of
gunshot wound injury. There is opacification of the left
maxillary sinus. Bilateral mastoid air cells are opacified.
IMPRESSION:
1. Continued evolution of blood products at the site of
contusion within the right parietal and temporal lobes with no
new acute intracranial hemorrhage identified.
2. Slight increase in edema within the anterior aspect of the
right temporal lobe and stable edema within the posterior right
temporal lobe and right parietal and posterior frontal region at
the site of contusion.
3. Interval placement of a burr hole in the left frontal region
with hypodensity in the adjacent left frontal lobe.
4. No evidence of herniation. Mild right to left shift and
compressive mass effect upon the right lateral ventricle are
probably unchanged.
RADIOLOGY Final Report
PORTABLE ABDOMEN [**2115-10-6**] 2:27 PM
PORTABLE ABDOMEN
Reason: upright
[**Hospital 93**] MEDICAL CONDITION:
28 year old man with decreasing Hct, r/o perforation
REASON FOR THIS EXAMINATION:
upright
UPRIGHT ABDOMEN RADIOGRAPH, [**2115-10-6**]:
CLINICAL INDICATION: Decreasing hematocrit. Evaluate for
perforation.
Comparison is made to a chest radiograph performed approximately
15 minutes earlier.
There is no evidence of free intraperitoneal air. Within the
imaged portion of the chest, there is a bilateral lower lobe
predominant alveolar process affecting the left lung to a
greater degree than the right, and most likely due to bilateral
pneumonia. Given the history of decreasing hematocrit, pulmonary
hemorrhage should also be considered in the appropriate clinical
setting.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SUN [**2115-10-6**] 7:57 PM
Neurophysiology Report EEG Study Date of [**2115-10-1**]
OBJECT: 26-YEAR-OLD MAN WITH ANOXIC BRAIN INJURY DUE TO GUNSHOT
IN
HEAD. PATIENT DEVELOPED JERKING MOVEMENT AND TWITCHING ACTIVITY.
REFERRING DOCTOR: DR. [**First Name (STitle) 742**] [**Name (STitle) **]
FINDINGS:
ABNORMALITY #1: There are frequent bursts of sharp slow wave
discharges
over the right parietal region with phase reversing at T4 and
spreading
to the entire right posterior quadrant.
ABNORMALITY #2: There are intermittent single sharp and slow
wave
discharges over the left frontal region.
ABNORMALITY #3: The background is slow in the [**5-21**] Hz frequency
range
and disorganized. In addition, there are bursts of generalized
slowing
in the 5 Hz theta frequency range.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed due to the patient's
clinical
condition.
INTERMITTENT PHOTIC STIMULATION: Was not performed because this
was a
portable study.
SLEEP: The study shows wakefulness progressing to stage I sleep.
CARDIAC MONITOR: Tachycardic sinus rhythm with a rate of 108
bpm.
IMPRESSION: This is a markedly abnormal portable EEG obtained in
wakefulness progressing to drowsiness due to the presence of
frequent
sharp and slow wave discharges over the right posterior quadrant
with
phase reversing around P4 and single sharp and slow wave
discharges over
the left frontal region. In addition, the background is slow and
disorganized with bursts of generalized slowing in the theta
frequency
range. The first two abnormalities suggest a
subcortical/cortical
dysfunction over the right posterior quadrant and left frontal
region
and are consistent with an increased risk of seizure activity.
The
second abnormality represents a deep, midline subcortical
dysfunction
and is consistent with a mild encephalopathy. A tachycardia was
noted.
INTERPRETED BY: [**Last Name (LF) 96**],[**First Name3 (LF) 125**] H.
Date: Monday, [**2115-10-7**] Endoscopist(s): [**Name6 (MD) **]
[**Name8 (MD) 9890**], MD
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Patient: [**Known firstname **] [**Known lastname 13370**]
Ref.Phys.:
Birth Date: [**2086-12-31**] (28 years) Instrument: GIF 160 Gastroscope
ID#: [**Numeric Identifier 62566**] ASA Class: P2
Medications: Midazolam 2mg
Glucagon 1mg
Fentanyl 50 micrograms
Indications: Melena
Coffee grounds emesis
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
Conscious sedation anesthesia. The patient was placed in the
left lateral decubitus position and an endoscope was introduced
through the mouth and advanced under direct visualization until
the second part of the duodenum was reached. Careful
visualization of the upper GI tract was performed. The procedure
was not difficult. The patient tolerated the procedure well.
There were no complications.
Findings: Esophagus: Normal esophagus.
Stomach:
Contents: Clotted blood (coffee grounds) was seen in the
fundus.
Mucosa: Diffuse erythema, congestion and friability of the
mucosa with stigmata of recent bleeding were noted in the fundus
and GE junction.. These findings are compatible with gastritis.
Excavated Lesions Multiple non-bleeding erosions were noted in
the antrum.
Duodenum: Normal duodenum.
Impression: Erythema, congestion and friability in the fundus
and GE junction. compatible with gastritis
Erosions in the antrum
Blood in the fundus
Recommendations: Protonix 40 mg IV BID
Transfusion support.
Check H.pylori serology
Additional notes: The attending physician was present during the
entire procedure.
Brief Hospital Course:
This 28 y/o hispanic male was brought in through the emergency
department on [**2115-9-20**] for GSW to the head and chest regions. He
was awake in the emergency room with a GCS of 14 on arrival -
his intubation was elective for control of airway and impending
need for management of intracranial pressure. he did admit to
decreased visual accuity on addmission and inability to see
examiners. He c/o N/V and neck pain on arrival.
He was seen and admitted by the trauma team. originally it was
thought that the pt would require placement of an ICP monitor
after he arrived in the ICU however he was very purposeful when
off sedation. We chose to follow his exam closely. On [**2115-9-21**]
after his exam revealed a loss of spontaneous movement on the
LUE and LLE it was determined that he would benefit from an ICP
monitor as well as an external ventricular drain. (LEFT EVD,
RIGHT ICP). ICP's were 30-35 on placment of the monitor. The
EVD was placed but the CSF was not pulsatile - therefore it was
thought that all CSF was drained/compressed by swelling - the
ICP monitor was then placed. Appropriate antibiotics were
started for drain/wound coverage. Dilantin levels were followed
and serial CT's were obtained during this time. After ICP
monitr was placed - pt was placed in a pentobarb coma. His
prognosis was very poor at this time. [**2115-9-23**] HCT drop to 25.9
- an anemia workup was instituted - some of the drop was thought
to be due to fluid volume resusitation. Mannitol was started on
[**2115-9-21**]. The family was updated continuously on all events and
wished to move forward with aggressive treatments.
Pt was seen and evaluated by Nutritional services for caloric
intake needs.
On [**2115-9-24**] NS intern was called to see pt for R dilated pupil.
Mannitol was given as scheduled. Pupils were non reactive for
intern at R - 5mm, and L 4mm. Pt on pentobarb coma - no
corneals, gag or motor response to pain at that time. Mannitol
was increased to 50gms q 4 hours. No neurosurgical intervention
at that time.
On [**2115-9-25**] his exam remined poor and his pupils were now
dilated to 8mm bilaterally and non reactive - He was excibiting
signs of [**Doctor Last Name **] death and a family meeting was arranged. ICP
remained in the 30's. Pentobarb was d/c'd for evaluation. His
exam remained unchanged for 5 days - His ICP monitor was D/C'd
on [**2115-9-30**] with ICPs now ranging from 12-33. His pupils on
this day were dilated however they were reactive and he is now
overbreathing the ventilator. Mannitol wean begins. Plan now
for trach and peg as soon as able. [**2115-10-1**] pt with fever of
102.1 and it was thought that he may have had a seizure
overnight - his head was rotated to the side with shoulder and
head twitching. An EEG was obtained - see "results" section for
EEG results. No obvious indication of seizure activity noted
and actually his dilantin wean is starting today [**2115-10-9**]. On
the 18th it was also noted that the pt had a drop in plts. and
he was determined to be HIT +. His heparin was d/c'd.
He was seen by Thoracic surgery on the 18th after he developed
pneumomediastinum after a line change. CT chest recommended
with further recs to follow CT results.
Tacheostomy and bronchoscopy were performed on [**2115-10-2**].
Levaquin was started for pneumonia (fever source). His exam
slowly improved to eyes being open and RUE movement to noxious,
LLE with poor withdrawal. RLE without movement on the 21st.
HCT dropping once again on the 23rd. Surgical conult was
obatined. Transufusions and GI consult were obtained under the
recs of surgery (required 5 units of PRBC over 5 day). GI
consult and EGD done - revealed stress ulcers.
He was seen and evaluated by GI for dropping HCT on [**2115-10-7**].
Pt had had melenous stools as well as coffee ground emesis. Pt
had an EGD Date: Monday, [**2115-10-7**] was performed. The
patient tolerated the procedure well. There were no
complications. Impression: Erythema, congestion and friability
in the fundus and GE junction. compatible with gastritis
Erosions in the antrum Blood in the fundus
Recommendations: Protonix 40 mg IV BID Transfusion support.
Check H.pylori serology
On [**10-9**] his exam is greatly improved - he is following commands
consistently and briskly - he had fever to 102.9 and is now
being recultured including a spinal tap. He also had an abd US
[**2115-10-9**] which was normal, however his lipase was elevated to
696. Felt to have pancreatitis and was treated conservatively
by surgical team. Pt with no further evidence of GI bleed up to
present time. Cont to spike fevers on [**10-31**]- All
cultures were negative with the exception of sputum which showed
staph coag positive and gram negative rods; Cxr showed
multilobar pneumonia treated with Oxacillin (start [**10-11**]; stop
[**10-25**]). Also treated with 7 days of Levaquin. TTE showed no
vegetation. On [**10-13**] pt transferred to neuro step down with
significant neurological improvement-- awake, alert, following
commands, MAE and oriented x2.
[**10-15**] Failed speech & swallow exam and Gtube was placed on [**10-15**]
without complications.
Tube feeds advanced to goal over 24 hours without difficulty.
Speech and Swallow should be retested in 14 days.
[**10-18**] IVC Filter placed without complication.
Cont to work with PT/OT daily; max assist with transfers.
Using passey-muir valve and speaking in [**Month/Day (4) **]; tolerating
well.
[**10-22**] Trach dc'd
Medications on Admission:
no prescription med use on admission
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed.
3. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
5. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
10. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
12. Oxacillin Sodium 2 g Recon Soln Sig: One (1) Injection
every six (6) hours for 2 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
s
s/p GSW to head and chest
pancreatitis
gastritis/severe bleeding from upper and lower GI tract
pneumomediastinum secondary to line change
Discharge Condition:
neurologically stable / improved
Discharge Instructions:
DC cotton Gtube sutures [**10-24**]; DC oxacillin after last dose on
[**10-25**]. Please call office or return for any neurological change.
Aggressive PT/OT. Please call for any redness, drainage or
signs of infection from occipital wound.
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 739**] in one month after discharge
with CT scan of brain - please call [**Telephone/Fax (1) **]
Patient will need formal Ophthomology exam and formal visual
field testing
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2115-10-23**]
|
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icd9pcs
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59,603
| 119,198
|
46513
|
Discharge summary
|
report
|
Admission Date: [**2165-6-23**] Discharge Date: [**2165-6-27**]
Date of Birth: [**2086-9-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfur / Lisinopril
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo female with history of PSP, HTN, and HL who had a syncopal
episode at home found to have a UTI and hypotension in the ED.
She was sitting on her chair at home today when she told her
aide she wanted to have a bowel movement. Her diaper already had
a bowel movement in it, but she stood to pivot to the commode.
She became weak in the knees and unresponsive to her caregiver's
verbal commands so she had her lay down until 911 arrived. There
was no seizure acitivity. She denies presyncopal symptoms. There
was no head strike and she was mentating appropriately when she
layed down. There EMS noted a SBP of 80's.
Of note, she denies fevers at home but reports taking tylenol
for pain. She has coughing fits when she does not pay attention
to carefully chewing and swallowing but has not had one
recently. She reports dysuria with a history of frequent UTI's.
She has seen multiple urologists and is currently on cranberry
tabs and nitrofurantoin [**Hospital1 **]. She has had multiple falls in the
past, but the last one was approximately two years ago. Her
daughter notes that 80% of her falls are a result of UTI's with
subsequent weakness.
In the ED, initial vitals were 59 80/47.
-total 3L IVF given
-guaiac negative
-UA: positive
-CXR: vascular congestion
-received levofloxacin in the ED
Prior to transfer, VS were afeb 90 16 95/53 95%on 2L.
On arrival to the MICU, she reports right upper arm pain and
left ankle pain.
Past Medical History:
Progressive supranuclear palsy, repeat falls, now
wheelchair-bound
Left optic nerve atrophy, diminished visual acuity
Hypertension
Hypercholesterolemia
H/o hyperparathyroidism
Gastroesophageal reflux disease
Chronic UTIs
Nephrolithiasis
Osteoarthritis
Recurrent dermatitis
Hiatal hernia
Osteoporosis
Anxiety
Depression
Left rotator cuff tear
s/p repair of fractured pelvis - [**2160-8-5**]
s/p bilateral knee replacements
s/p corneal transplant
s/p dental extractions under general anesthesia - [**9-/2163**]
Social History:
Widowed, lives in own home w/24-hr care. Has involved son and
daughter. Used to work within the house during her younger
years. Quit smoking >25 yrs ago. Occaisional glass of wine.
Family History:
No cardiac FH.
Physical Exam:
ON ADMISSION:
Vitals: 98.7 96 105/57 16 94% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, 3/6 SEM located at LLSB
Lungs: Bibasilar crackles
Abdomen: +BS, soft, non-tender, mildly distended, no
organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, erythematous round erosion on left lateral malleous,
smaller round erythematous erosion on lateral left foot
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
ON DISCHARGE:
VS - T 98.9F, BP 122/66, HR 69, RR 16, O2 Sat 95% on 2L NC
GENERAL - Elderly woman in NAD
HEENT - Keeps the left eye closed
LUNGS - Lungs are clear to auscultation bilaterally in anterior
lung fields
HEART - RRR, NL S1-S2, 3/6 systolic murmur
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
NEURO - CN 2-12 grossly intact
Pertinent Results:
Labs upon admission:
[**2165-6-23**] 01:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2165-6-23**] 01:00PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
[**2165-6-23**] 01:00PM URINE RBC-15* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-0
[**2165-6-23**] 12:45PM LACTATE-1.6
[**2165-6-23**] 12:30PM GLUCOSE-136* UREA N-31* CREAT-1.0 SODIUM-139
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15
[**2165-6-23**] 12:30PM cTropnT-0.02*
[**2165-6-23**] 12:30PM CALCIUM-8.0* PHOSPHATE-4.0 MAGNESIUM-1.7
[**2165-6-23**] 12:30PM WBC-8.3 RBC-3.87* HGB-11.0* HCT-34.1* MCV-88
MCH-28.5 MCHC-32.3 RDW-14.7
[**2165-6-23**] 12:30PM NEUTS-71.0* LYMPHS-17.8* MONOS-6.7 EOS-3.3
BASOS-1.2
[**2165-6-23**] 12:30PM PLT COUNT-348
[**2165-6-23**] 12:30PM PT-12.4 PTT-26.4 INR(PT)-1.1
Labs on discharge:
[**2165-6-26**] 07:20AM BLOOD WBC-8.5 RBC-3.78* Hgb-10.9* Hct-33.3*
MCV-88 MCH-28.8 MCHC-32.7 RDW-15.1 Plt Ct-307
[**2165-6-26**] 07:20AM BLOOD Glucose-92 UreaN-21* Creat-0.8 Na-139
K-4.6 Cl-102 HCO3-29 AnGap-13
[**2165-6-26**] 07:20AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.0
Micro:
URINE CULTURE (Final [**2165-6-26**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SECOND
MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of 2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- 8 R <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- 0.5 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- =>512 R =>512 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- 4 R <=1 S
Images:
[**2165-6-23**] CXR: small right sided pleural effusion, left base
opacity, cardiomegaly, low lung volumes, bibasilar atelectasis
[**2165-6-23**] EKG: NSR at 70, NA, NI, q wave in III, TWI in 3 and aVF
[**2165-6-23**] tele strips: 30 second run of narrow complex tachycardia
Brief Hospital Course:
78 yo female with history of PSP, HTN, HL, and recurrent UTI's
who presents with episode of weakness found to have urosepsis.
# Sepsis: On admission she met SIRS criteria of tachycardia and
leukocytosis with left shift with clear evidence of UTI on UA.
Multiple prior UTI's in the past including klebsiella resistant
to nitrofuantoin, cipro, bactrim, augmentin, and cefazolin;
pansensitive pseudomonas; and ecoli resistant to bactrim and
ampicillin. She responded well to IVF rehydration and remained
HD stable following admission to the ICU, and subsequently while
on the floor. Urine on this admission grew kelbsiella, sensitive
to ciprofloxacin. She was transitioned from ceftriaxone to PO
cipro successfully. She was instructed to complete a 7 day
course of cipro, and then to re-start her prophylactic
Nitrofurantoin thereafter. Additionally, she was restarted on
her home dose of cranberry tabs upon discharge.
# Syncope: Most likely secondary to hypovolemia in the setting
of UTI. Differential also included SVT or other arrhythmia.
Troponin was minimally elevated on admission (0.02), but
patient's story did not support ACS. No additional episodes of
syncope while in the hospital.
# Tachycardia: Run of tachyarrythmias on tele while in the ICU,
may be secondary to tachybrady syndrome in setting of
hypovolemia or atenolol withdrawal. Atenolol was restarted in
the ICU. She did not have any additional episodes of tachycardia
once transferred to the floor. She was maintained on her home
regimen of atenolol.
# Acute Kidney Injury: Increased BUN to creatinine ratio on
admission. Likely prerenal in the setting of infection. Received
3L of IVF in the ED. Patient's serum creatinine had improved
with hydration, and was within normal limits on discharge.
# Right upper arm pain: Recent PICC in right upper arm as most
likely cause of this pain. Pain was well controlled with tylenol
on this admission.
# Decubitus ulcers: Stage 2 on sacrum and Stage 1 on left ankle
were present on admission. Wound care was performed by nursing.
# Normocytic anemia: Likely secondary to anemia of chronic
disease. Hematocrit at baseline.
# Progressive Supranuclear Palsy: No active issues on this
admission. Continued carbidopa-levodopa, gabapentin, and
tylenol. Outpatient diet modifications were followed in light of
patient's history of aspiration. Pt worked with physical therapy
who supervised her safe transfer from bed-to-chair with her home
health aid and a walker.
# HTN: She was hypotensive in the setting of sepsis, but
following administration of aggressive IVF in the ED, she
remained normotensive in the ICU and on the floor. Once she was
HD stable, she was maintained on her home regimen of atenolol
and Avapro.
# HL: No active issues on this hospitalization. She was
maintained on her home dose of ezetemibe
# Depression: No active issues on this admission. She was
maintained on her home dose of escitalopram
==================================
TRANSITIONS OF CARE:
-Pending studies: Blood cultures (drawn on [**2165-6-23**]; no growth to
date of discharge of [**2165-6-27**])
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Carbidopa-Levodopa (25-100) 1 TAB PO TID
2. Gabapentin 100 mg PO BID
3. Gabapentin 200 mg PO HS
4. Atenolol 25 mg PO DAILY
5. Escitalopram Oxalate 30 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Acetaminophen 1000 mg PO Q8H:PRN pain
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE [**Hospital1 **]
9. HydrOXYzine 30 mg PO BID
10. HydrOXYzine 20 mg PO DAILY
at noon
11. Avapro *NF* (irbesartan) 150 mg Oral daily
12. Omeprazole 20 mg PO DAILY
13. Ezetimibe 10 mg PO DAILY
14. Nitrofurantoin (Macrodantin) 100 mg PO BID
15. Nystatin 100,000 UNIT VG DAILY:PRN irritation
16. Vitamin D 1000 UNIT PO DAILY
17. cranberry *NF* 500 mg Oral daily
18. Docusate Sodium 100 mg PO BID
19. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Avapro *NF* (irbesartan) 150 mg Oral daily
5. Carbidopa-Levodopa (25-100) 1 TAB PO TID
6. Docusate Sodium 100 mg PO BID
7. Escitalopram Oxalate 30 mg PO DAILY
8. Ezetimibe 10 mg PO DAILY
9. Gabapentin 100 mg PO BID
10. Gabapentin 200 mg PO HS
11. HydrOXYzine 30 mg PO BID
12. HydrOXYzine 20 mg PO DAILY
at noon
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE [**Hospital1 **]
16. Vitamin D 1000 UNIT PO DAILY
17. Ciprofloxacin HCl 500 mg PO Q12H
[**2165-6-23**] is first day of abx
RX *ciprofloxacin 500 mg 1 Tablet(s) by mouth twice a day Disp
#*5 Tablet Refills:*0
18. cranberry *NF* 500 mg Oral daily
19. Nystatin 100,000 UNIT VG DAILY:PRN irritation
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8930**] Home Care
Discharge Diagnosis:
Primary: Sepsis secondary to a Urinary Tract Infection
Secondary: Progressive supranuclear palsy
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were hospitalized because you have a bacterial infection in
your urine. Additionally, you were found to be hypotensive (low
blood pressure), and you were initially admitted to the ICU.
Your blood pressure improved after getting IV fluids, and you
were started on antibiotics for treatment of your urinary tract
infection. You were transfered out of the ICU, and your symptoms
continued to improve.
It was a pleasure taking care of you.
Please note that the following changes have been made to your
medications:
1. Please take ciprofloxacin 500 mg by mouth twice a day for the
next three days
2. Please stop taking Nitrofurantoin. Please resume taking this
medication as prescribed once you have completed your course of
treatment with ciprofloxacin.
Followup Instructions:
Department: GERONTOLOGY
When: WEDNESDAY [**2165-7-3**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Urology
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
When: Dr. [**Last Name (STitle) **] [**Last Name (STitle) 3726**] is working on a follow up appointment for
you in [**9-7**] days after your hospital discharge. You will be
called by the office with your appointment date and time. If you
have not heard from the office in 2 business days please call
the number listed below.
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 3RD FL, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 921**]
Department: RADIOLOGY
When: MONDAY [**2165-7-15**] at 1:45 PM [**Telephone/Fax (1) 10164**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Hospital 1422**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: GERONTOLOGY
When: MONDAY [**2165-7-22**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: TUESDAY [**2165-11-12**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 31415**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2165-6-28**]
|
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icd9cm
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11273, 11273
|
3537, 3544
|
12265, 14011
|
2518, 2534
|
10162, 10987
|
11096, 11252
|
9293, 10139
|
11451, 12242
|
2549, 2549
|
3176, 3518
|
254, 263
|
4421, 6145
|
335, 1772
|
3558, 4402
|
11288, 11427
|
9155, 9267
|
1794, 2304
|
2320, 2502
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,102
| 123,024
|
19148
|
Discharge summary
|
report
|
Admission Date: [**2199-7-22**] Discharge Date: [**2199-7-24**]
Date of Birth: [**2123-12-6**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Macrobid
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Swelling of neck & tongue
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is a 75 yo Spanish speaking M w/ DM, CAD, diastolic
CHF, prostate CA admitted with angioedema. He reports having
acute onset of tongue swelling that started yesterday evening
that woke him up from sleep. This swelling was associated with
shortness of breath. He called 911 and received benedryl 50 mg
IV during EMS transport. He had these symptoms previously when
he was admitted in [**Month (only) 116**] with angioedema. His symptoms were
thought to be seconadry to his ACEI and or macrobid. He reports
that he still takes his ACEI as he was told that he may continue
it as long as he does not have further symptoms. In the ED he
was noted to have the following VS 97.7 HR 73 115/63 RR 16
97% 4L He received Solumedrol 125 mg IV, benadryl 25 mg IV and
pepcid 20 mg IV. He was seen by anesthesia in ED and felt to be
improving with the above regimen. He is being admitted to the
MICU for airway protection. He currently feels that his
breathing is improved. He notes that his swelling is
persistent. He believes that he has been started on a new
medication called cordura (doxazosin), but per review of OMR, he
has been on this medication for some time.
Review of systems is negative for fevers, chills, palpitations,
cough, chest pain, abdominal pain, nausea, vomitting and
diarrhea.
Past Medical History:
Adenocarcinoma of the prostate- biopsy [**2199-6-24**] ([**Doctor Last Name **] 9+10
prostate cancer recently started on casodex will be transitioned
to lupron)
Benign Prostatic Hypertrophy s/p TURP with GreenLight [**10-8**]
COPD
Low back pain
Type II Diabetes - not on insulin
Diastolic Congestive Heart Failure - echo [**2197**] with EF 55%,
resting regional wall motion abnormalities include basal
inferior akinesis.
Coronary Artery Disease: Mild, reversible inferior wall defect
on stress MIBI [**6-5**]
Hypertension
GERD
Obstructive Sleep Apnea on CPAP (intermittently)
Migraine Headaches
Hypercholesterolemia
Social History:
The patient has never smoked. He previously used alcohol but
quit many years ago. He is married and lives with his wife. [**Name (NI) **]
previously worked in aggriculture but is now retired.
Family History:
His mother is deceased and had heart disease. His father is
also deceased but had no health problems to the patient's
knowledge.
Physical Exam:
PE: T 97.7 BP 110/60 HR 69 RR 17 O2Sat 98
Gen: elderly male sitting comfortably in bed
HEENT: MMM, poor dentition, tongue swelling, difficult to
visualize further in OP. No stridor
Neck: no jvd
CV: rrr, no murmurs
Resp: CTA bilaterally, poor effort
Abd: obese, soft, nt/nd, bs normoactive
Ext: WWP, 1+ bilateral edema
Pertinent Results:
[**2199-7-22**] 04:28AM GLUCOSE-95 UREA N-54* CREAT-3.2*# SODIUM-131*
POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-19* ANION GAP-20
[**2199-7-22**] 04:28AM WBC-9.9 RBC-3.66* HGB-9.7* HCT-29.3* MCV-80*
MCH-26.7* MCHC-33.3 RDW-13.2
[**2199-7-22**] 04:28AM NEUTS-66.9 LYMPHS-23.9 MONOS-6.5 EOS-2.3
BASOS-0.4
Discharge Labs:
[**2199-7-24**] 05:45AM BLOOD Glucose-93 UreaN-35* Creat-1.2 Na-139
K-4.8 Cl-107 HCO3-23 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname **] is a 75 year old with a history of prior angioedema
admitted with another episode of angioedema, possibly secondary
to ACEI.
1)Angioedema: Patient presented with tongue and lip swelling. He
has a history of angioedema on the past but has remained on
Lisinopril for several months now. He has also undergone testing
for C1 esterase inhibitor, which was negative. On admission to
the MICU, the ace-inhibitor was stopped as well as his
Doxazosin. The latter unlikely caused his symptoms. He was
started on IV steroids, H2 blocker, and benadryl. His swelling
improved after 24 hours. He was asymptomatic while on the floor.
We discussed with the patient that the Lisinopril was likely
reponsible for his angioedema and apologized for placing him
back on the medication on his previous discharge. A translator
was present for this discussion.
2)UTI: He is currently being treated for ESBL e.coli UTI with
Meropenem. He was discharged on Ertapenem for his last 3 days of
therapy.
3)Acute on chronic renal failure: Likely pre-renal since his
creatinine improved with IVFs. His diuretic regimen was held.
Lasix and Metolazone were restarted without incident prior to
discharge.
4)Type 2 DM: Patient is on Metformin at home. The decision was
made to stop this regimen given that the patient intermittently
goes into acute renal failure and the risk for lactic acidosis.
He was placed on an insulin sliding scale.
5)CAD: Continued on ASA and BB
6)Hyperlipidemia: Continued on statin
7)CHF: His outpatient regimen of Lasix & Metalozone were held in
the setting of acute renal failure. They were restarted before
discharge.
8)Prostate Cancer: The patient had no acute issues during this
stay. He has appointments next week to follow up with Oncology.
We attempted to schedule a bone scan but were not able to
coordinate it on this stay.
Medications on Admission:
Albuterol MID
Atorvastatin 40mg PO daily
Fluticasone-Salmeterol MDI
Montelukast 10mg PO daily
Omeprazole 20mg PO daily
Tiotropium Bromide MDI
Aspirin 81mg PO daily
Fluoxetine 20mg PO daily
Lisinopril 10mg PO daily
Metoprolol Succinate 50mg PO daily
Furosemide 40mg PO daily
Metolazone 10mg PO daily
Doxazosin 2mg PO BID
Gabapentin 100mg PO BID
Ertapenem 1 gram PO daily
Metformin 500mg PO BID
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln
Injection daily () for 3 doses: Last Dose 7/26.
Disp:*3 Recon Soln(s)* Refills:*0*
14. PICC Line
Please pull PICC line after last dose
15. PICC Care
PICC Line Care: per NEHT Protocol, Saline & Heparin Flushes
16. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
1. Angioedema
2. Acute Renal Failure
3. UTI
Secondary Diagnoses:
1. Prosate Cancer
2. Asthma
3. Hypertension
4. Hyperlipidemia
Discharge Condition:
Good.
Discharge Instructions:
You have been admitted to the hospital with Angioedema--swelling
of a the throat and tongue. While you were here you admitted to
the Intensive Care Unit.
Please continue your antibiotics until Saturday [**7-27**].
Please DO NOT take Lisinopril.
Please return to the ED for difficulty breathing, shortness of
breath or any other medical complaint.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23551**], MD Phone:[**Telephone/Fax (1) 447**]
Date/Time:[**2199-7-30**] 11:00
Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2199-7-30**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2199-7-30**] 2:20
|
[
"530.81",
"584.9",
"327.23",
"272.0",
"599.0",
"250.00",
"272.4",
"185",
"585.9",
"041.4",
"428.0",
"428.32",
"995.1",
"496",
"403.90",
"E942.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7185, 7243
|
3469, 5335
|
307, 315
|
7434, 7442
|
3026, 3330
|
7840, 8304
|
2541, 2672
|
5778, 7162
|
7264, 7328
|
5361, 5755
|
7466, 7817
|
3347, 3446
|
2687, 3007
|
7349, 7413
|
242, 269
|
343, 1672
|
1694, 2312
|
2328, 2525
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,250
| 111,201
|
46849
|
Discharge summary
|
report
|
Admission Date: [**2206-8-24**] Discharge Date: [**2206-9-3**]
Date of Birth: [**2132-5-30**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Fall, Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 1007**] is a 74 y/o F with a h/o COPD on 4L O2 during day and
6L O2 at night, pulmonary hypertension, obesity hypoventilation,
dCHF (EF > 55% in [**8-/2205**]), anxiety and multiple recent
hospitalizations for dyspnea, thought to be due to her
underlying untreated OSA and obesity hypoventilation syndrome,
who presented from home s/p a "fall". She was working with two
health aides when she felt weak and was lowered to the floor and
was unable to get up so EMS was called. She initially
complained of two days of productive cough, worsening shortness
of breath and subjective fever/chills.
In the ED, initial vs were: 97, 70, 144/61, 14, 94% on her home
4L nasal cannula. There was initial concern that she was
somewhat somnolent so she was given narcan 0.4mg x 1 with some
improvement in her MS. She refused to undergo a head CT and the
ER physicians felt she understood the risk of her refusal. She
had a CXR that was read as improved mild pulmonary vascular
congestion, no focal consolidation or infiltrate. Her EKG was
A.flutter at 73, consistent with prior. Labs were notable for a
PCO2 of 56, [**Known lastname **] count of 4.1, which is down from 6.1 two days
ago, lactate of 2.2. Despite her negative CXR and normal [**Known lastname **]
count, there was concern for PNA so she was given cefepime,
levofloxacin, with plans to give vancomycin as well and admitted
to the ICU since she has baseline poor respiratory status. At
the time of transfer her VS were: 88, 137/79, 24, 94% on 4LNC,
per report with no increased work of breathing.
.
On arrival to the MICU her initial VS were: 96.5, 86, 126/69,
22, 92% on 6LNC. Her current weight is 257lbs and weight on
discharge was recorded to be 263.5lbs. She complained of
shortness of breath that is unchanged from her baseline and
feeling tired. As there did not appear to be any acute process,
she was transferred to the floor.
Prior to transfer, she had a panic attack and on further
discussion notes that she has had progressive anxiety.
Pallitaive care had recommended morphine prn which was just
recently started. The patient's anxiety worsens her breathing.
She is however, amenable to pulmonary rehab and further
treatment of her anxiety.
ROS: see hpi She denied any associated n/v/d, abdominal pain,
chest pain, palpitations, HA, changes in her vision. She does
endorse continued orthopnea, PND multiple times per week and
possibly an increase in her LE edema. She says that her cough
is the same as it has been since her recent discharge from [**Hospital1 18**]
on [**2206-8-20**] with a presumed viral URI. 10 point ROS otherwise
negative.
Past Medical History:
- COPD
- obesity
- unspecified hypoxemia
- CNS lymphoma c/b CVAs x3 (posterior circulation) and seizure
d/o
- history of SAH while on coumadin
- diastolic heart failure
- coronary artery disease
- atrial fibrillation
- hypertension
- hyperlipidemia
- severe OSA (did not tolerate CPAP in the past)
- primary hyperparathyroidism/25-vit D deficiency c/b
nephrolithiasis
- toxic multinodular goiter with subclinical hyperthyroidism
- neovascular glaucoma c/b right eye blindness
Social History:
- Smoking: Denies current smoking. Heavy smoker in the past quit
in [**2175**]. About 3 ppd for 30 years
- EtOH: Denies.
- Illicits: Denies.
- Home: Lives at [**Hospital3 **] facility and recently enrolled
in home hospice. At baseline, able to
transfer to and from chair without support; able to bath self;
able to feed and dress self. Cooking/food provided at [**Hospital **]. Uses a wheelchair to get around.
- Work: Not working. Retired ob/gyn nurse.
Family History:
Father - Esophageal problems (unsure of the specifics),
[**Name (NI) 5895**]
Mother - Bradycardia, AAA
3 brothers all passed away: -Diabetes and heart attacks
Sister: healthy
Physical Exam:
Admisssion Physical Exam:
VS 35.8 86 126/69 22 92% NC 6L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
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:
[**2206-8-24**] 09:46PM WBC-4.1 RBC-4.90 HGB-13.1 HCT-42.8 MCV-87
MCH-26.7* MCHC-30.6* RDW-18.8*
[**2206-8-24**] 09:46PM NEUTS-66.0 LYMPHS-23.7 MONOS-5.4 EOS-3.7
BASOS-1.2
[**2206-8-24**] 09:46PM PLT COUNT-320
[**2206-8-24**] 09:46PM GLUCOSE-96 UREA N-17 CREAT-1.0 SODIUM-139
POTASSIUM->10 CHLORIDE-102 TOTAL CO2-31
[**2206-8-24**] 09:46PM CK(CPK)-233*
[**2206-8-24**] 09:46PM cTropnT-<0.01
[**2206-8-24**] 09:46PM CK-MB-4
[**2206-8-24**] 09:57PM LACTATE-2.2* K+-8.9*
[**2206-8-24**] 11:12PM K+-3.5
[**2206-8-24**] 09:57PM TYPE-[**Last Name (un) **] PO2-33* PCO2-56* PH-7.36 TOTAL
CO2-33* BASE XS-3
.
Microbiology:
blood cultures ([**8-24**]): [**1-14**] bottle coag neg staph
[**8-26**] cultures no growth.
Imaging:
CXR ([**8-24**]): UPRIGHT AP VIEW OF THE CHEST: There is continued
moderate cardiomegaly. Lung volumes remain low. The mediastinal
and hilar contours are stable. Mild pulmonary vascular
congestion persists, but may be mildly improved when compared to
the prior study. Linear atelectasis in the right lung base is
unchanged. No large pleural effusion or pneumothorax is
identified. IMPRESSION: Persistent mild pulmonary vascular
congestion, perhaps slightly improved compared to the prior
study. No new focal consolidation.
.
CXR ([**8-25**]): FINDINGS: In comparison with study of [**8-24**], there
is continued mild pulmonary vascular congestion. Poor definition
of the hemidiaphragms suggests possible small effusions and
atelectasis in a patient with low lung volumes.
.
Head CT [**8-25**]: FINDINGS: Again noted is encephalomalacia in the
left cerebellum (image 3:3)
and right occipital lobe (image 3:8), unchanged. There is no
acute
intracranial hemorrhage, edema or mass effect. There is no
evidence of
enhancing intraaxial or extraaxial lesions. The ventricles and
sulci remain
prominent, compatible with age-related global atrophy.
No lytic or sclerotic bone lesions suspicious for malignancy are
seen.
Thickening of the right maxillary sinus walls is again seen,
likely sequela of
prior chronic sinusitis.
IMPRESSION:
No evidence of new intracranial abnormalities. MRI would be more
sensitive
for evaluating the status of intracranial malignancy and for
detecting a
seizure source, if clinically warranted.
Brief Hospital Course:
Ms. [**Known lastname 1007**] is a 74 y/o F with a complicated PMH that includes
chronic hypoxemia on home oxygen (4L during the day and 6L at
night), untreated OSA, obesity hypoventilation syndrome,
pulmonary hypertension and multiple recent admissions who
presents after an episode of weakness at home with anxiety and
shortness of breath
.
#Dyspnea
# Chronic hypoxemia
#Obstructive sleep apnea
#Obesity hypoventilation syndrome
#Pulmonary hypertension
It is unclear if this is a true change from her baseline, as
most of her complaints seem to be chronic and she has frequent
dyspneic attacks which are closely correlated with anxiety
attacks as well. Her cough is unchanged from a recent
admission and she is afebrile, with no leukocytosis or CXR
findings that would support a pneumonia as the cause of her
dyspnea. Her current weight is 257lbs, which is 6lbs less than
her recent discharge weight ([**8-20**]) which also makes a component
of HF and volume overload less likely. No wheezing on exam.
Some notes indicate that she has COPD but pulmonary notes show
FEV1/FVC of 70% without significant obstruction. She was
continued on albuterol/atrovent nebs. She has baseline severe
OSA but does not tolerate CPAP.
She has seen palliative care on a prior admission and also has
recently enrolled in home hospice. She was continued on liquid
morphine prn and benzodiazepine for anxiety. (is on Xanax as an
outpt, and we increased its availability prn).
#) Anxiety: Based on prior admissions, anxiety appears to play a
substantial role in her sensation of dyspnea. She was continued
on xanax prn (increased availability to tid prn) and we
communicated with her outpatient psychiatrist and PCP regarding
her care. Her psychiatrist was ok with starting a long acting
benzodiazepine if needed but the pt did not require this. We
were also cautious about doing this because as her pulmonary
physician has noted, she has substantial sleep apnea and is
prone to CO2 retention. Her psychiatrist also mentioned that if
needed in the future, her seroquel could be titrated up for
anxiety. She advised against starting an SSRI because the pt
reportedly had some manic symptoms many years on SSRI.
.
#) CAD: Given her acute presentation, cardiac enzymes were sent
and negative. Continue home ASA, statin. ACEi was changed to
[**Last Name (un) **]. She does not appear to be on b-blocker at baseline/home.
.
#) Atrial fibrillation: Not on anticoagulation, only on ASA
despite CHADS>2, currently well rate controlled.
.
#)Hypertension: Currently normotensive on home regimen, continue
home amlodipine. ACEi was changed to [**Last Name (un) **] while in the ICU for
?dry cough.
.
#)Hyperlipidemia: Continue home simvastatin
.
#)Severe OSA: Continues to refuse CPAP, so will continued on
supplemental oxygen overnight.
.
#)Primary hyperparathyroidism: Continue home sensipar
.
#)Neovascular glaucoma c/b right eye blindness: Continue home
eye drops
#) Thrush: [**Month (only) 116**] be related to steroid inhaler use. Given
Nystatin swish and swallow and now appears resolved
.
#) Pannus fungal infection: Per prior documentation is stable,
continue miconazole powder QID.
.
#) Neuro: The patient has a known seizure disorder (complication
from CNS lymphoma). She was continued on lamictal 225mg daily.
Head CT was re-ordered as the patient does not remember the
events prior to admission, results showed no acute changes.
.
Disposition: her assisted facility has expressed significant
concerns about her safety at home, and she was evaluated by
physical therapy who recommended rehab stay. She is being
discharged to skilled nursing facility for rehab but will need
to be reassessed while there. It is possible she will not be
able to return to independent living.
.
Medications on Admission:
1. morphine 15 mg: 0.5 Tablet Q4H as needed for dyspnea,
anxiety.
2. alprazolam 0.25 mg QHS prn insomnia.
3. ipratropium bromide 0.02 % every six (6) hours as needed for
shortness of breath or wheezing.
4. amlodipine 10mg Daily
5. atropine 1 % Drops: One drop twice a day Right eye.
6. cinacalcet 30 mg [**Hospital1 **]
7. fluticasone 50 mcg: One Spray Nasal [**Hospital1 **]
8. furosemide 60 mg [**Hospital1 **]
9. lisinopril 5 mg DAILY
10. omeprazole 20 mg DAILY
11. simvastatin 40 mg at bedtime.
12. brimonidine 0.15 %: One Drop Ophthalmic [**Hospital1 **]
13. timolol maleate 0.5 %: One drop Ophthalmic twice a day.
14. aspirin 81 mg DAILY
15. docusate sodium 100 mg [**Hospital1 **]
16. miconazole nitrate 2 % Cream: twice a day as needed for as
needed for rash
17. guaifenesin 100 mg/5 mL Liquid Sig: 5-10 mLs every six hours
as needed for cough.
18. lamotrigine 200 mg once a day, take with 200mg for total of
225.
19. lamotrigine 25 mg once a day take with 200mg for total of
225.
20. quetiapine 25 mg: 1.5 Tablets HS
21. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
22. Cepacol Sig: One tab every four hours as needed for sore
throat.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
UNITS Injection TID (3 times a day).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. atropine 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
4. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
8. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
12. lamotrigine 200 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily): total 225 mg daily.
13. lamotrigine 25 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: total 225 mg daily.
14. quetiapine 25 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
15. Senna Concentrate 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2
times a day) as needed for constipation.
16. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. alprazolam 0.25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) as needed for anxiety.
19. Cepacol Sig: One (1) LOZENGE Mucous membrane every [**6-18**]
hours as needed for cough.
20. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
21. morphine 10 mg/5 mL Solution Sig: 5-10 MG PO Q4H (every 4
hours) as needed for shortness of breath or pain.
22. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as
needed for dyspnea.
23. ipratropium bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for dyspnea.
24. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
25. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Hypoxemia
Acute on chronic dyspnea
Obstructive sleep apnea
Obesity hypoventilation syndrome
Pulmonary hypertension
Anxiety disorder
Secondary:
Chronic diastolic CHF
Coronary artery disease
Hypertension
Discharge Condition:
condition: stable
mental status: alert, lucid
ambulatory status: wheelchair bound
Discharge Instructions:
You were admitted with shortness of breath, anxiety, cough, and
somnolence (now resolved). Your evaluation did not show any
signs of pneumonia or new [**Last Name **] problem. Your shortness of
breath was treated with nebulizers, morphine as needed, and anti
anxiety medications.
Please continue to take your medications as prescribed,
including the morphine as needed for shortness of breath.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2206-9-12**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PSYCHIATRY
When: TUESDAY [**2206-9-23**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5750**], 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: PULMONARY FUNCTION LAB
When: FRIDAY [**2206-10-24**] at 11:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V85.41",
"427.31",
"V49.86",
"365.63",
"401.9",
"799.02",
"276.0",
"278.03",
"414.01",
"V46.2",
"348.30",
"327.23",
"428.32",
"202.80",
"496",
"112.0",
"V15.82",
"416.8",
"428.0",
"300.01",
"278.00",
"345.90",
"110.5",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14484, 14567
|
7060, 10842
|
347, 353
|
14814, 14832
|
4759, 4759
|
15343, 16287
|
4018, 4194
|
12137, 14461
|
14588, 14793
|
10868, 12114
|
14922, 15320
|
4235, 4740
|
281, 309
|
381, 3029
|
4775, 7037
|
14847, 14898
|
3051, 3528
|
3544, 4002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,232
| 163,009
|
3546
|
Discharge summary
|
report
|
Admission Date: [**2172-6-3**] Discharge Date: [**2172-6-17**]
Date of Birth: [**2117-1-4**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfonamides
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Paracentesis
Upper endoscopy
History of Present Illness:
55 year old female with previously well-compensated HCV
cirrhosis and recent decompensation with ascites, admitted with
abdominal distension, fevers at home and increased LFT's at a
recent clinic visit. In the ED, she had a diagnostic
paracentesis that showed 20,000 RBC, 1050 WBC with 5% PMN's.
Given her clinical presentation she was admitted for empiric
therapy for SBP with ceftriaxone. Her CXR and UA showed no sign
of infection. Blood cultures and urine culture were sent.
Review of sytems:
(+) Per HPI
(-) Denies 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:
# HCV cirrhosis c/b diuretic resistant ascites, non-responder to
treatment
- HCV genotype 1: s/p Rebetron x 3 months in [**2160**]; nonresponder
- biopsy in [**1-1**]: III fibrosis with macrovesicular steatosis
involving 10% to 20% of the biopsy, mild bile duct proliferation
with focal epithelial damage and rare associated neutrophils and
minimal iron deposition and Kupffer cells, grade 2 inflammation
# S/p open CCY [**1-1**] c/b hematoma and recurrent ascitic drainage
# Endometriosis
Social History:
Lives with boyfriend, currently on medical leave from job in a
tax office. Smokes [**12-25**] cigarettes/ day. Denies ETOH or
recreational drug use
Family History:
No family history of liver disease. Mother with a history of
cholelithiasis.
Physical Exam:
ADMISSION:
Vitals: T: 98 BP: 86/57 P:87 R:15 18 O2:100% RA
General: Alert, oriented, no acute distress, chronically ill
appearing
Skin: Jaundice
HEENT: Sclera icteric, dry mm, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, soft, with mild TTP throughout, +
hepatomegally. RUQ
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE:
Vitals: 97.2 96/52 84 18 94%RA
General: jaundiced female, laying comfortably in bed, NAD
HEENT: +icterus
Neck: no JVD
Lungs: CTA b/l, no wheezes, rales, rhonchi
CV: RRR, no murmurs, rubs, gallops
Abdomen: BS+ moderately distended, soft, nontender, no
guarding/rebound
Ext: WWP, 2+ edema. Symmetric 2+ DP/PT pulses
Skin: +Jaundice
Neuro: AOx3. no asterixis
Pertinent Results:
Admission Labs
[**2172-6-3**] 02:40PM BLOOD WBC-4.9 RBC-3.27* Hgb-11.8* Hct-34.2*
MCV-105* MCH-36.0* MCHC-34.4 RDW-16.5* Plt Ct-123*
[**2172-6-3**] 02:40PM BLOOD Neuts-71* Bands-2 Lymphs-17* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2172-6-3**] 02:40PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-2+
Target-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**]
[**2172-6-3**] 02:40PM BLOOD PT-16.1* PTT-30.3 INR(PT)-1.4*
[**2172-6-3**] 02:40PM BLOOD Glucose-107* UreaN-15 Creat-0.8 Na-132*
K-4.1 Cl-96 HCO3-30 AnGap-10
[**2172-6-3**] 02:40PM BLOOD ALT-111* AST-244* AlkPhos-80 TotBili-7.0*
DirBili-5.3* IndBili-1.7
[**2172-6-3**] 02:40PM BLOOD Albumin-3.6
[**2172-6-3**] 06:40PM BLOOD Lactate-1.3
Urine Studies
[**2172-6-3**] 06:05PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.012
[**2172-6-3**] 06:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-6.5 Leuks-NEG
[**2172-6-3**] Culture: GRAM POSITIVE BACTERIA. >100,000
ORGANISMS/ML.. [Alpha hemolytic colonies consistent with alpha
streptococcus or Lactobacillus sp.]
Ascitic Fluid Studies
[**2172-6-5**] 10:04AM ASCITES WBC-745* RBC-5475* Polys-3* Lymphs-85*
Monos-7* Eos-1* Mesothe-2* Macroph-2*
[**2172-6-5**] 10:04AM ASCITES TotPro-2.9 Glucose-101 LD(LDH)-77
Albumin-2.4
[**2172-6-3**] 09:58PM OTHER BODY FLUID WBC-1050* RBC-[**Numeric Identifier 389**]* Polys-5*
Lymphs-65* Monos-5* Mesothe-2* Macro-23*
[**2172-6-3**] Culture - no growth
IMAGING:
[**2172-6-4**] Abd CT:
1. Stable small nonhemorrhagic pleural effusion with compressive
atelectasis on the left.
2. Increased size of simple intra-abdominal ascites as compared
to [**2172-2-2**].
3. No evidence of intrahepatic mass.
4. No intra- or retro-peritoneal hemorrhage.
5. Interval resolution of anterior abdominal wall subcutaneous
collection.
[**2172-6-4**] CXR:
Continued opacification at the left base consistent with
atelectasis and small effusion.
Brief Hospital Course:
55yo female w HCV cirrhosis, previously compensated with recent
decompensation after [**12/2171**] cholecystectomy, being worked up for
transplant, admitted with presumed SBP for antibiotic therapy.
#SBP: The patient was admitted with fevers, increased abdominal
distension. In the ED, she had a diagnostic paracentesis that
showed 20,000 RBC, 1050 WBC with 5% PMN's. Given the patient's
clinical picture, she was started on empiric CTX for presumed
SBP. On the floors the patient was persistently hypotensive
(SBP in the 80s), requiring transfer to the MICU. RUQ U/S and
CT abdomen did not reveal any obvious signs of intra-abdominal
bleeding. Given concern for possible GI source of infection, the
patient was started on broad-spectrum coverage with
Vancomycin/CTX/flagyl.
Given her improved clinical status, and negative ascites
cultures, her vancomycin and cipro were discontinued on [**6-8**] and
[**6-9**]. She remained on Zosyn to cover possible SBP as well as
HCAP (see below).
#DIC: During her MICU stay, the patient was noted to have low
fibrinogen, high INR, low haptoglobin, and positive FDPs. This
was thought to be related to her liver failure vs. early DIC in
the setting of infection. Her DIC labs, as well as her hct and
plt count were trended and remained stable for the remainder of
her hospitalization.
.
#PNA: Initially, during her ICU course, the patient developed
worsening respiratory status. Given radiologic findings, this
was thought to be related to fluid overload vs. compressive
atelectasis [**12-24**] ascites vs pneumonia. She underwent a second
paracentesis, during which 800 cc of fluid was removed. Her
respiratory status did not improve. On Day 3 of admission, the
patient's antibiotic regimen was broadened to
Vancomycin/zosyn/ciprofloxacin to provide better HCAP. Her
respiratory symptoms began to improved. Her vancomycin and
cipro were stopped as discussed above, and the patient was
continued on pip-tazo to cover possible SBP as well as HCAP.
The patient completed an 8d course of antibiotics and was weaned
off supplemental O2. She remained with mild residual cough
improved with PRN benzonatate.
.
#HCV Cirrhosis: The patient was being worked up for a transplant
prior to her admission. During this hospitalization,
pretransplant serologies were sent off. An EGD was performed on
this hospitalization, demonstrating no varices. The patient
will follow up as an outpatient for mammogram, pap smear, and
PFTs. During this hospitalization, she had a mild rise in LFTs,
thought to be [**12-24**] to zosyn, which resolved after discontinuation
of the zosyn.
.
#Hematemesis: After placement of dobhoff tube, pt had single
episode of emesis with several small blood clots. Dobhoff was
pulled and NGtube was placed for gastric lavage, which did not
demonstrate further signs of active bleeding. The patient's
hematocrit remained stable during this time. At this time,
there was low suspicion for a GI bleed, however given the
patient's cirrhosis, it was decided to send her for an EGD. The
EGD did not reveal any varices or signs of bleeding. A dobhoff
tube was placed post-pylorically to reinitiate tube feeding.
#Nutrition: Patient reported poor appetite and weight loss over
the year prior to her admission. As per nutrition consult, a
Dobhoff tube was placed and tube feeds were initiated. On
discharge the patient was educated on usage and maintenance of
the feeding pump and tube.
Medications on Admission:
- Fluticasone-Salmeterol [Advair Diskus]: not currently using
- Furosemide 40 mg Tablet
- Levonorgestrel [Mirena]
- Potassium Chloride
- Spironolactone 75 mg Tablet daily
- Ursodiol 600 mg [**Hospital1 **]
- Calcium Carbonate-Vitamin D3 600 mg-400 unit Tablet 2 Tablet
[**Hospital1 **]
- Magnesium [Magtab] 84 mg Tablet SR 2 tabs daily
Discharge Medications:
1. Fluticasone-Salmeterol Inhalation
2. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*0*
3. Levonorgestrel Intrauterine
4. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
Disp:*45 Tablet(s)* Refills:*0*
5. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
6. Calcium Carbonate-Vitamin D3 600-400 mg-unit Tablet Sig: Two
(2) Tablet PO twice a day.
7. Magtab 84 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO once a day.
8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Sepsis with spontaneous bacterial peritonitis and
pneumonia
Secondary: Hepatitis C cirrhosis
Cough
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - occasionally requires assistance
or aid (walker or cane).
Discharge Instructions:
Ms [**Known lastname **],
You were admitted to the hospital for increasing abdominal pain
and fluid accumulation. You were found to have low blood
pressure and infections, and were sent to the ICU for a period
of time. You received antibiotics for your infections, and your
vital signs stabilized. You were seen by our liver transplant
surgeons and your transplant evaluation was started. You had
feeding tubes placed in your nose to help increase your
nutrition, so that you will remain strong. You should continue
eating normally as well, as best as you can. You will continue
taking the tube feeds at home. Please keep your appointments and
take your medications as directed.
.
The following changes were made to your medications:
-Increased furosmide to 60 mg daily
-Increased spironolactone to 150 mg daily
-Started omeprazole 20 mg daily. You should continue taking this
because there was chronic inflammation seen in your stomach,
when you underwent upper endoscopy.
You were recorded as taking potassium supplements prior to
coming to the hospital. You have not been receiving daily
potassium supplementation while in the hospital, and your levels
have been generally normal. You therefore do not need to take
daily potassium tablets at this time but you should have your
level checked by your physician at your next visit--furosemide
and spironolactone can affect your potassium levels.
Followup Instructions:
We have made the following appointments for you:
1) Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2172-7-3**] 09:00. Liver transplant surgery clinic. [**Hospital Unit Name 3269**], [**Location (un) **]
2)Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2172-6-25**] 11:30.
Please call to reschedule if you cannot keep these appointments.
Other previously scheduled appointments:
Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2172-6-22**] 3:30
|
[
"567.23",
"038.9",
"287.5",
"276.1",
"570",
"578.0",
"786.2",
"286.6",
"783.7",
"571.5",
"486",
"789.59",
"995.92",
"782.4",
"535.10",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.08",
"54.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9628, 9686
|
4952, 8399
|
294, 325
|
9839, 9839
|
2930, 4929
|
11456, 12136
|
1922, 2000
|
8786, 9605
|
9707, 9818
|
8425, 8763
|
10035, 11433
|
2015, 2911
|
243, 256
|
852, 1224
|
353, 834
|
9854, 10011
|
1246, 1741
|
1757, 1906
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,153
| 116,042
|
33010
|
Discharge summary
|
report
|
Admission Date: [**2153-12-19**] Discharge Date: [**2153-12-28**]
Date of Birth: [**2084-5-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Reason for consult: R frontal hemorrhage
Major Surgical or Invasive Procedure:
stereotactic R frontal mass biopsy
History of Present Illness:
HPI: 69 yo RH male with MS, DM, HTN, HL, s/p CABG ("quintuple")
in [**2147**], defribillator placement who presents with 2 days of
worsening dysarthria and L sided weakness (baseline - flaccid
paralysis of LE bilaterally). Pt awoke with symptoms and with
worsening function, he presented to OSH - [**Location (un) **]/[**Location (un) 1459**].
There, CT demonstrated 2x3 cm hemorrhage lesion concerning for
underlying mass. pt was then transferred to [**Hospital1 18**].
Past Medical History:
PAST MEDICAL HISTORY:
DM, HTN, HL, CAD
MS: dx 10 yrs ago by Dr. [**Last Name (STitle) 76767**] in [**Location (un) **]. has not followed
up 2/2 insurance reasons. baseline wheel chair bound
hx of trigeminal neuralgia on left
Social History:
SOCIAL HISTORY:
lives with wife in [**Name (NI) **]. >10 PPD tob hx (stopped in [**2114**]). no
EtOH, no IVDA. used to be attendent for handicapped individual
before MS diagnosis
Family History:
FAMILY HISTORY:
no HTN, no CA
Physical Exam:
EXAM
VS: T 97 HR 88 BP 153/92 RR 16 Sat 95 % on 2L NC
PE: General NAD
HEENT AT/NC, MMM no lesions
Neck Supple, no bruits
Chest CTA B
CVS RRR, no m/r/g
ABD soft, NTND, + BS
EXT no C/C/E, no rashes or petechiae
NEUROLOGICAL
MS: waxes/wanes with intermittent confusion most likely from
decadron,
cooperative, following commands.
General: alert,interactive
Orientation: waxes/wanes, mostly oriented to person, place,
date, situation
Speech/[**Doctor Last Name **]: fluent w/o paraphasic errors but with slow
responses; simple
and complex command-following w/o L/R
confusion. Repetition, naming intact. perseverative "i don't
want to talk to psychiatry"
Calculations: 7 quarters = $1.75
CN:
II,III: difficulty keeping eyes open, VFFTC, pupils 4-2 mm
bilaterally to light, optics discs sharp and flat
III,IV,V: EOMI, eyelids half mast. Normal saccades/pursuits
V: sensation decreased on left
VII: Facial strength decreased on left, decreased nasolabial
fold
VIII: hears finger rub bilaterally
IX,X: voice slightly thickened, palate elevates symmetrically
[**Doctor First Name 81**]: SCM/trapezeii [**5-5**] bilaterally
XII: tongue protrudes midline without atrophy or fasciculation
Motor: Normal bulk and tone in UE. decreased tone in LE.
occasional faciculations of LE bilaterally
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
2 4- 4- 4 4 5-
Reflex:
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 4+/clonus Extensor
R 2 2 2 2 4+ clonus Extensor
Sensation: No extinction of DSS.
Coordination: Finger-nose-finger without dysmetria on R
Gait: not testing
Pertinent Results:
Color
Yellow Appear
Clear SpecGr
1.020 pH
6.5 Urobil
1 Bili
Neg
Leuk
Sm Bld
Lg Nitr
Neg Prot
Tr Glu
Neg Ket
Tr
RBC
[**11-20**] WBC
21-50 Bact
Many Yeast
None Epi
0
CTA w/wo contrast [**2153-12-19**]
IMPRESSION:
1. Unchanged 3-cm right frontal intraparenchymal hematoma with
surrounding vasogenic edema, without evidence of feeding artery
or draining veins suggestive of AVM or AVS.
2. No significant abnormality in intracranial anterior and
posterior circulation.
3. Atherosclerotic disease of the bilateral carotid arteries and
right vertebral artery.
4. Small left vertebral artery with no flow in V3 and V4
segment, suggestive of prior dissection or occlusion . Further
evaluation by MRA or CTA of the neck is recommended on
outpatient basis.
5. Extensive sinus disease with prior endoscopic surgery and
sinus-nasal polyposis.
IMAGING:
CT brain: 1. 2.9-cm right frontal intracranial hemorrhage,
likely related to underlying mass lesion with small component of
subarachnoid hemorrhage. There is moderate surrounding edema
and
minimal mass effect.
2. Evidence of prior infarction in the left occipital lobe.
3. Moderate cranial atrophy.
4. Evidence of prior left occipital craniotomy.
5. Extensive sinonasal polyposis.
CTA with contrast: Hemorrhagic mass in right high frontal lobe
is
unchanged in appearance - no tangle of vessels to suggest an
AVM.
Major vessels of COW patent.
[**12-26**]
IMPRESSION: No pathologic ehnacement with stable right frontal
parenchymal hemorrhage and decreased right subarachnoid
hemorrhage since [**2153-12-20**].
[**2153-12-28**] 06:20AM BLOOD WBC-7.6 RBC-4.19* Hgb-13.6* Hct-39.8*
MCV-95 MCH-32.5* MCHC-34.2 RDW-13.6 Plt Ct-297
[**2153-12-28**] 06:20AM BLOOD WBC-7.6 RBC-4.19* Hgb-13.6* Hct-39.8*
MCV-95 MCH-32.5* MCHC-34.2 RDW-13.6 Plt Ct-297
[**2153-12-28**] 06:20AM BLOOD PT-13.8* PTT-26.1 INR(PT)-1.2*
[**2153-12-28**] 06:20AM BLOOD Plt Ct-297
[**2153-12-28**] 06:20AM BLOOD Glucose-116* UreaN-22* Creat-1.1 Na-142
K-3.6 Cl-108 HCO3-23 AnGap-15
[**2153-12-28**] 06:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
[**2153-12-28**] 06:20AM BLOOD Carbamz-4.3
[**2153-12-28**] 06:20AM BLOOD Phenyto-9.0*
Brief Hospital Course:
69 yo male with MS, HTN, DM, HL who presents with R frontal
hemorrhage, with concern for underlying mass. He was admitted to
the ICU for 72 hours followed with serial head CTs and CTA that
did not show any source for the bleed.
On [**2153-12-21**] patient underwent a R frontal mass biopsy, pathology
prelimary showed reactive tissue no tumor however at this
writing the pathology is not completely confirmed.
Post-operatively he had slight confusion, which improved over a
couple of days. On [**2153-12-28**] he is alert and oriented x 3,
reports leg pain with prolonged sitting in one position. Pain is
controlled when repositioned and also with oral pain meds
Mr. [**Known lastname **] diet was advanced and pt tolerated diet well, he
is voiding without any difficulties.
His exam remains stable - his right upper extremity motor is
full, [**5-5**]; he does not have any movement in left upper
extremity, and no movement in bilateral lower extremities. His
dysarthia is slowly improving. His staples were removed on
discharge the site was clean and dry no redness.
Mr. [**Known lastname 4223**] will follow up with Dr. [**Last Name (STitle) **] in two weeks. Pt and
significant other agrees with plan.
Medications on Admission:
MEDICATIONS:
metformin 1000 [**Hospital1 **]
simvastatin 20 QD
amiodarone 200 QD
metoprolol 50 [**Hospital1 **]
neurontin 300 QID
tegretol 200 QID
avandia 8 mg QD
lisinopril 10 QD
lasix 20 QD
flovent 110 mcg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
5. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. 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*
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Please use stool softeners as long as
you use pain meds.
Disp:*60 Tablet(s)* Refills:*0*
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
14. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO every
eight (8) hours for 1 days: three tablests every eight hours on
[**2153-12-28**]; use two tablest every eight hours [**Date range (3) 76768**];
use 1 tablet every eight hours [**2153-12-31**] - [**2154-1-1**], then stop.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
R frontal hemorrhage
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 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:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 2 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITH CONTRAST
Completed by:[**2153-12-28**]
|
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48,388
| 156,310
|
18570
|
Discharge summary
|
report
|
Admission Date: [**2157-8-21**] Discharge Date: [**2157-10-24**]
Date of Birth: [**2099-12-5**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Lisinopril
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
abdominal pain, distention, constipation
Major Surgical or Invasive Procedure:
[**2157-8-22**]: sigmoid colectomy + diverting ileostomy
[**2157-9-6**]: Flexible bronchoscopy with bronchoalveolar lavage
and therapeutic aspiration
[**2157-9-12**]: ex-lap, removal of mesh from previous hernia repair,
abdominal washout
[**2157-9-13**]: emergent exlap, hematoma evacuation, abdominal packing,
temporary closure
[**2157-9-14**]: exlap, removal of packing, closure fascia
[**2157-9-15**]: perc trach
[**2157-9-19**]: exlap, hematoma evacuation, closure of leak site at
anastamosis
[**2157-9-22**]: left index finger amputation
[**2157-9-26**]: pigtail catheter placement for L pleural effusion
[**2157-9-29**]: bronchoscopy, removal of mucous plugging
[**2157-9-30**]: bronchoscopy, removal of mucous plugging
[**2157-10-17**]: bronchoscopy, removal of mucous plugging
History of Present Illness:
57 year old man with 3 day history of intermittent, crampy,
diffuse abdominal pain, belching, lack of appetite. Denies BM
or flatus x3 days. Reports taking only water and ensure PO x3
days. Recent admissions for perforated diverticulitis c/b blood
stream infection (PORPHYROMONAS SPECIES) from [**Date range (1) **]. On
discharge, plan was for colectomy per Dr. [**Last Name (STitle) **] on [**2157-9-13**].
Patient
reports thin, nonbloody stools since discharge.
Past Medical History:
(1) Splenectomy in [**2151-11-24**] when he had resection of a
benign pancreatic mass at [**Hospital1 2025**].
(2) Thrombocythemia: 800,000 - 1,000,000. No clotting or
bleeding. bone marrow biopsy on [**2153-3-1**] consistent with
myeloproliferative disorder (polycythemia [**Doctor First Name **])...as well as an
abnormal karyotype with deletion 20q in 3 out of 20 metaphases
increasing his risk of hypercoagulability.
(3) Immune-mediated granulomatous disease. He is followed by Dr.
[**Last Name (STitle) 50954**] at [**Hospital1 112**].
(4) Hypertension.
(5) Chronic renal insufficiency of unclear etiology.
(6) High-risk adenocarcinoma of the prostate treated with
radical prostatectomy on [**2151-5-31**], with no evidence of disease
recurrence since that time. Path revealed granulomas.
(7) Diabetes mellitus (no recent A1C).
(8) Gastritis, detected on EGD in [**2153-6-30**].
(9) In [**5-31**], he developed a perianal abscess with bacteremia.
(10) h/o thrombophlebitis in left leg
(11) uveitis
(12) C4-C5 radiculopathy
(13) HLD
(14) HTN
(15) recurrent autoimmune pericarditis
(16) h/o benign pancreatic cyst s/p resection
Social History:
Lives with wife, has grown children. Works as a trial attorney.
Family History:
Pancreatic Cancer
Physical Exam:
In ED at presentation:
VS: 97.4 78 165/109 18 100RA pain [**8-2**]
Gen: NAD, AOx3
HEENT: MMM, trachea midline, neck supple
CV: +S1, +S2 no murmurs/rubs/gallops
Pulm: Lungs clear to auscultation bilaterally
Abd: Softly distended, tympanitic. Minimal TTP throughout. No
focal tenderness. No rebound, no guarding. +bowel sounds
Rectal: guaiac neg
Extremities: warm, no edema, +DP and radial pulses
Pertinent Results:
[**2157-8-21**] CT ABDOMEN W/CONTRAST 1. Increased large bowel dilation
from the cecum to the junction of the descending and sigmoid
colon, with transition point noted in the left lower quadrant at
the junction of the sigmoid colon with the descending colon, in
a region which has been chronically inflammed by diverticulitis
as noted on prior studies. Additionally, at the transition
point, there is an intramural sinus tract/abscess containing air
and fluid, measuring up to 2-cm. Findings are compatible with an
inflammatory colonic stricture from prior diverticulitis
resulting in upstream large bowel obstruction. Please note that
an underlying colonic mass is considered unlikely given recent
negative
colonoscopy in 6/[**2156**]. 2. Normal small bowel. 3. No free air or
pneumatosis. 4. Trace intrapelvic free fluid, new since the [**7-13**], [**2156**] examination. 5. Status post distal pancreatectomy and
splenectomy, with left upper quadrant splenosis. 6. Status post
prostatectomy with unchanged left pelvic side wall soft tissue
nodule which remains suspicious for recurrence. 7. Unchanged
4-mm left lower lobe nodule.
[**2157-8-21**] 03:40PM WBC-4.4 RBC-3.71* HGB-9.8* HCT-31.8* MCV-86
MCH-26.5* MCHC-30.9* RDW-22.7*
[**2157-8-21**] 03:40PM NEUTS-78* BANDS-0 LYMPHS-15* MONOS-5 EOS-1
BASOS-0 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-3*
[**2157-8-21**] 03:40PM PT-57.8* PTT-37.2* INR(PT)-6.5*
[**2157-8-21**] 03:40PM GLUCOSE-194* UREA N-31* CREAT-1.6* SODIUM-139
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2157-8-21**] 09:16PM LACTATE-1.0
[**2157-8-21**] 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2157-8-21**] 03:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2157-8-21**] 03:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2157-8-21**] 03:40PM URINE HYALINE-[**2-25**]*
[**8-25**] AXR: dilated loops of small bowel with air in the colon
[**8-25**] Barium Enema: No gross contrast extravasation.
[**8-27**] ECHO: EF 40%, ascending aorta is mildly dilated. AV leaflets
mildly thickened
[**8-29**] CT A/P: Moderate volume ascites, more dense fluid pelvis.
Tiny focus of extraluminal density is noted near anastomosis -
leak.
[**8-30**] IR US: Feculent material drained
[**9-2**] Echo: mild LVH, EF>55%, no vegetations seen on valves
[**9-3**] CT torso: marked interval decrease in intra-abdominal fluid
collection, left basilar atelectasis, left pleural effusion
[**9-4**] RUE U/S: Prelim- DVT in basillic/ axillary not traveling to
IJ
[**9-7**] CT A/P, CTA chest - Segmental PE in the right upper and
middle lobe. Bilateral lower lobe, left greater than right
atelectasis and given heterogeneity, likely superimposed small
amount of aspiration or infection. Segmental bronchiolar
secretion/mucus plugging in the right lower lobe. New
pneumatosis in dilated loops of bowel in the right upper
quadrant without bowel wall thickening at these sites,
mesenteric or portal venous gas. This may be benign pneumatosis
in thisopatient on steroids and ventilated, but correlation and
follow up to exclude ischemix injury is recommended. Similar
overall appearance of non-loculated ascites, slight decrease in
the left lower quadrant fluid despite left mid abdominal pigtail
catheter
being partially withdrawn
[**9-7**] RUQ US: gallstones inside contracted GB, no evidence of
cholecystitis
[**9-8**] Echo: LVEF>55%, AV and MV leaflets are mildly thickened.
[**9-8**] Ext US: Right brachial vein contains echogenic material
[**9-12**] Liver US: Gallstones, cavernous transformation of the
portal vein and perihepatic ascites as previously shown on [**9-7**].
[**9-13**] CXR: Complete whiteout of L hemithorax.
[**9-28**] Chest, Abd, Pelvic CT: 1. Bilateral lower lobe pleural
effusions with adjacent atelectasis and bronchial plugging.
Right lower lobe heterogeneity of enhancement in regions of
atelectasis may result from regions of superimposed infection or
infarction. 2. Segmental PE in the right upper and middle lobes
remains unchanged in comparison to prior study. Filling defect
in the right IJ vein may represent residual fibrin sheath from
prior catheter. 3. Left-sided peritoneal enhancement along the
retroperitoneal lining which may be representative of infection
or inflammation, without loculated abscess. 4. Vague
heterogeneity in hepatic density - some of which may relate to
sequellae from previously described microabscesses, suggest
attention on followup or further characterization by MRI if
indicated. 5. Residual left hydropneumothorax with pigtail
catheter in situ.
[**10-9**] CXR: LLL and/or consolidation unchanged. Question
layering left effusion. Patchy opacity in right cardiophrenic
region slightly worse. Dobbhoff tube unlikely to have passed
pylorus.
[**10-16**] CT Chest/Abd/pelvis: No intraabdominal source of fever.
[**10-16**] CTA chest: 1. No evidence of organized abscess.
2. Hypodense nodule along the left obturator internus adjacent
to the site of surgical clips from prior prostatectomy.
Attention to this area should be paid on followup imaging.
[**10-19**] AP chest compared to [**Date range (1) 51011**]: Left lower lobe is still
collapsed, accompanied by moderate left pleural effusion. New
heterogeneous opacification at the base of the right lung is
concerning for bronchopneumonia. No pneumothorax. Feeding tube
ends in the upper stomach. Tracheostomy tube in place.
Brief Hospital Course:
[**2157-8-22**]: sigmoid colectomy + diverting ileostomy
[**2157-9-6**]: Flexible bronchoscopy with bronchoalveolar lavage
and therapeutic aspiration
[**2157-9-12**]: ex-lap, removal of mesh from previous hernia repair,
abdominal washout
[**2157-9-13**]: emergent exlap, hematoma evacuation, abdominal packing,
temporary closure
[**2157-9-14**]: exlap, removal of packing, closure fascia
[**2157-9-15**]: perc trach
[**2157-9-19**]: exlap, hematoma evacuation, closure of leak site at
anastamosis
[**2157-9-22**]: left index finger amputation
[**2157-9-26**]: pigtail catheter placement for L pleural effusion
[**2157-9-29**]: bronchoscopy, removal of mucous plugging
[**2157-9-30**]: bronchoscopy, removal of mucous plugging
[**2157-10-17**]: bronchoscopy, removal of mucous plugging
The pt was admitted on [**2157-8-21**] with a large bowel obstruction.
He was taken to the OR on [**2157-8-22**] for an exploratory
laparotomy with sigmoid colectomy and diverting ileostomy for
diverticular stricture. His postop course was complicated by
retroperitoneal bleed, pulmonary embolism, RUE DVT, pseudomonal
pneumonia, need for tracheostomy, recurrent mucous plugging, as
well as significant pain and musculoskeletal spasm issues. He
required numerous operative procedures as outlined above as well
as a prolonged stay in the ICU. By the end of his
hospitalization, he was able to sit at the edge of the bed, was
taking PO using chin tuck as recommended by the Speech and
Swallow therapists and was taken off of his tube feeds.
Neuro: Pt had post-operative pain which was treated with various
pain medications throughout his complicated course. He has
experienced significant deconditioning and will require
aggressive physical therapy in order to regain his previous
functional status. The weakness in all extremities is improving.
He also experienced issues with pain and muscle spasms issues
and was seen by the Chronic Pain Service. He is currently doing
well on his regimen of Tylenol, Fent patch, Neurontin,
tizanidine, ativan, with oxycodone or dilaudid for breakthrough.
Slow weaning of his narcotics should take place over time with a
goal to have him off narcotics over the next few weeks to
months.
CV: The patient had episodes of hypertension treated with beta
blockers and hydralazine but also tachycardia and hypotension
related to his bleeding episodes. At discharge, he was on
metoprolol 25 [**Hospital1 **]. Most likely due to the placement of a L
radial arterial line, the patient had ischemia to his L index
finger, the tip of which ultimately necrosed, requiring
amputation by the Hand Service. His last Echo showed an EF of
>55%.
Pulm: The patient's postoperative course was very difficult from
a pulmonary perspective. He ultimately required tracheostomy on
[**9-15**] by Dr. [**Last Name (STitle) **] and has since been weaned back down to
trach collar/Passy-Muir valve and has tolerated this well. He
also had a PE treated with hep gtt, argatroban gtt, and
transitioned to warfarin prior to discharge. Earlier in his
hospital course, he required numerous bronchoscopies in order to
reinflate his lungs (mostly the left lung) and remove clinically
significant mucous plugs. Prior to his discharge, he had been
stable from a respiratory perspective. He will hopefully move
towards decannulation as his overall functional status recovers.
GI: The patient underwent sigmoid colectomy with primary
reanastamosis and diverting loop ileostomy. On one of his
takebacks, a small area of leak was noted on the back side of
his anastamosis, which was sutured. His ostomy is currently
functioning well and he should hopefully be able to undergo
takedown after he is able to be sufficiently rehabilitated. He
required TPN for a significant portion of his stay, was then
transitioned to enteral feedings per Dobhoff, and ultimately was
able to begin taking POs and his Dobhoff was removed prior to
discharge.
GU: At the patient's admission, his Cr was elevated, but has
since returned to [**Location 213**] and remained there (0.8-0.9) over the
last few weeks. However, due to the patient's chronic steroid
use for his sarcoidosis, he experienced a relative steroid
deficiency (specifically aldosterone with hyponatremia and
hyperkalemia) requiring treatment with fludrocortisone. He was
then slowly weaned off the fludrocortisone without issue.
Heme: Earlier in his hospital course, there was concern for HIT,
which ultimately came back negative. Thus, he was maintained on
a heparin gtt, which was then switched to argatroban due to this
concern. He was found to have a RUE DVT complicated by pulmonary
embolism and he was ultimately transitioned to warfarin (which
he was also on preoperatively for his polycythemia [**Doctor First Name **]). He
also required two takebacks to the OR for intraperitoneal
hemorrhage with clot evacuation. He was also restarted on his
hydroxyurea with alternating hydroxyurea doses of 500mg and 1000
mg every other day.
ID: The [**Hospital 228**] hospital course was complicated by VRE sepsis,
as well as a pseudomonal ventilator associated pneumonia,
requiring treatment with broad spectrum antibiotics. His
antibiotic treatments are summarized as follows: vancomycin
([**Date range (1) 29441**]), meropenem ([**Date range (1) 51012**] ), fluconazole ([**Date range (1) 51013**]),
flagyl ([**8-26**]- [**9-1**], [**Date range (1) 51014**]), Linezolid (9/8-10-11), ceftaz
([**9-16**] - [**9-29**]), cipro ([**Date range (1) 51015**]), cefepime ([**Date range (1) 51016**]),
vanc/cipro/zosyn ([**Date range (1) 51017**]). He has been off abx since [**10-18**].
Endo: He was maintained on a sliding scale throughout his
hospital stay. He also had the issue with aldosterone deficiency
as noted above.
Wound: The patient's wound is currently being treated with a
V.A.C. device. He also has two JPs which will be removed by Dr.
[**Last Name (STitle) **] at some point in the future.
Medications on Admission:
Hydroxyurea 1000mg Mon/Tues/Wed/Thurs/Fri, 500mg Sat/Sun
Prednisone 10', Warfarin 10'/7.5', Glargine 20qHS, Lispro per
sliding scale, Omeprazole 20', Prednisolone 1% gtt OS",
Simvastatin 40', alendronate 70 [**Last Name (LF) 51018**], [**First Name3 (LF) **] 81', MVI
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln [**First Name3 (LF) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. acetaminophen 325 mg Tablet [**First Name3 (LF) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
3. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for COUGH.
5. prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
Two (2) Puff Inhalation QID (4 times a day).
7. hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**12-25**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
9. sodium polystyrene sulfonate 15 g/60 mL Suspension [**Month/Day (2) **]:
Fifteen (15) grams PO Q6H (every 6 hours) as needed for K
greater than 5.4.
10. metoprolol tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
11. insulin lispro 100 unit/mL Cartridge [**Month/Day (2) **]: One (1) sliding
scale Subcutaneous every six (6) hours: per sliding scale.
sliding scale
12. tizanidine 2 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times a
day).
13. gabapentin 300 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO HS (at
bedtime).
14. fentanyl 50 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
15. warfarin 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO daily, adjust
per INR
16. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Month/Day (2) **]:
15-30 MLs PO QID (4 times a day) as needed for
discomfort/nausea.
17. oxycodone-acetaminophen 5-325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
18. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (2) **]:
Four (4) Puff Inhalation Q6H (every 6 hours) as needed for
Wheezing.
19. hydroxyurea 500 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO Q48H,
GIVEN ON ALTERNATE DAYS AS OTHER DOSE ().
20. hydroxyurea 500 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO Q48H;
GIVEN ON ALTERNATE DAYS AS OTHER DOSE ().
21. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
22. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
23. lorazepam 2 mg/mL Syringe [**Month/Day (2) **]: 0.5 mg Injection HS (at
bedtime) as needed for anxiety. mg
24. ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day (2) **]: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
diverticular stricture with large bowel obstruction
adrenal insufficiency
respiratory failure requiring tracheostomy
diabetes mellitus
sarcoidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with a large bowel obstruction
secondary to a stricture in your colon from your diverticulitis.
You had a long hospital course described in your discharge
summary and are being discharged to a rehab facility to help you
get stronger and back to your baseline level of functioning.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD,PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2157-10-27**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2157-11-3**] 2:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2158-2-2**] 11:00
Please call Dr.[**Name (NI) 6218**] office at ([**Telephone/Fax (1) 15665**] in order to
schedule a follow up appointment in 2 weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
|
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icd9cm
|
[
[
[]
]
] |
[
"84.01",
"38.93",
"45.76",
"54.0",
"54.91",
"38.91",
"54.25",
"34.91",
"00.14",
"96.56",
"96.04",
"33.23",
"88.72",
"99.15",
"96.72",
"83.39",
"46.79",
"33.21",
"46.20",
"31.1",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
18110, 18186
|
8831, 14762
|
343, 1129
|
18377, 18377
|
3332, 8808
|
18892, 19581
|
2879, 2898
|
15081, 18087
|
18207, 18356
|
14788, 15058
|
18553, 18869
|
2913, 3313
|
263, 305
|
1157, 1626
|
18392, 18529
|
1648, 2781
|
2797, 2863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,519
| 155,768
|
34488
|
Discharge summary
|
report
|
Admission Date: [**2181-12-4**] Discharge Date: [**2181-12-8**]
Date of Birth: [**2109-7-1**] Sex: M
Service: MEDICINE
Allergies:
Methotrexate / Imuran / Remicade
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
weak/fatigue
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
This is a 72 year-old male with a history of UC on chronic
prednisone and MTX, scheduled for elective colectomy this am. He
was in his usual state of health until c yesterday when he
started experiencing worstening fatigue and weakness. He had no
po intake through out most of the day and in the evening had a
very low glucose level (?) and some chills, he had taken his
insulin but not eaten anything. He did not do anything about
this but lay down to sleep. This am he felt too weak to drive to
hospital by himself and called EMS to bring him for his surgery
to be done by Dr. [**Last Name (STitle) **], [**First Name3 (LF) **]. Upon arrival EMS recorded
a blood pressure of 60/40, FS 118, got fluid and upon arrival in
ED SBP of 80-90, he was given 5 L fluid with some minimal
response response, central line was placed, Levophed was
started. Tmax of around 100, current vitals HR 70 BP 96/53 RR 22
O2 95% 4L NC
He was given stress dose Hydrocortisone, Zosyn, Vanco, Aspirin
(for possible st depression in V2-V4)
.
ROS: positive for shortness of breath, cough since 3 wks and
post nasal drip, Z-pack for 5 days w/o improvement, than got
nasal spray for post nasal drip. feels thurstyThe patient denies
any fevers, chills, weight change, nausea, vomiting, abdominal
pain, diarrhea, constipation, melena, hematochezia, chest pain,
, orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
UC since [**2172**], in remission until last year, had Imuran and
Remicade trial in the past, of Imuran and MTX since [**Month (only) 216**] and
Of Remicade sice [**Month (only) 116**] due to intolerance, and on chronic
prednisone 30 mg, last dose this am, no pcp prophylaxis,
DM type 2
HTN
HC
Possible silent MI, cath and Echo in [**Month (only) 404**], no stenting, not
on Aspirin due to low platelets, no bleeding history
h/o prostatitis
Social History:
30 years 1 ppd smoking stopped 14 years ago, alcohol couple
times a month, lives with wife near [**Name2 (NI) **], retired school
superintendent
Family History:
N/C
Physical Exam:
Vitals: 97.5 117/73 18 73 92%4Lnc
Pain: 0/10
Access: L PIV
Gen: nad, occ cough
HEENT: anicteric, o/p clear
CV: RRR c ectopy, no m appreciated
Resp: CTAB with improved bibasilar crackles, no wheezing
Abd; soft, obese, nontender, +BS
Ext; no edema
Neuro: A&OX3, grossly nonfocal
Skin: worsened petechia scattered over upper arms/back
psych: appropriate
Pertinent Results:
White count 3.6-->2.4-->1.6->2.5
hgb stable 9s
plt count 56->40->30-->43
LDH, hapto, Tbili normal, retic 2.3
PTT normal, INR 1.3-1.5
Chem panel: BUN 19-->29, creat 0.8 stable.
BNP 4085, trops 0.04, 0.03, 0.02
.
UA blood, otw negative, Ucx negative
blood Cx [**12-4**] X4 NTD
Sputum >10epi, contamination
Sputum for PCP X2 negative
MRSA screen pending
.
.
Imaging/results:
.
EKG: NSR with frequent ectopy. Initially had lateral STDs
(sepsis), resolved
.
CXR #1: R>L lower lobe consolidation
CXR #2: increased RLL consolidation and R>L basilar Atx and mild
pulm edema
CXR #3: stable RLL consolidation, improved pulm edema
.
CT chest noncontrast [**12-6**] 1. Right lower lobe pneumonia.
2. Possible underlying small airway disease involving right
lung.
2. No evidence of congestive heart failure.
.
.
CT a/p noncontrast [**12-6**] Scattered mesenteric nodes do not meet
criteria for pathologic enlargement. No evidence of bowel
obstruction or other acute abdominal process.
.
.
Echo [**12-4**]: mild LV dilation, mild LVH and LAE, DD, mild
depressed LVEF 40-50%, AK of basal/inf/post and HK
midvent/inf/post walls, mild RV dilation and free wall HK.
.
Echo repeat [**12-7**]: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal for the
patient's body size. There is an inferobasal left ventricular
aneurysm. There is mild regional left ventricular systolic
dysfunction with basal inferior and inferolateral akinesis and
mid inferior and inferolateral hypokinesis. Overall left
ventricular systolic function is mildly depressed (LVEF= 45-50
%). The estimated cardiac index is normal (>=2.5L/min/m2). Left
ventricular diastolic function cannot be reliably assessed. The
right ventricular cavity is mildly dilated with mild global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2181-12-4**],
the findings are similar.
Brief Hospital Course:
72 year old male with h/o ulcerative colitis on chronic steroids
awaiting colectomy, pancytopenia [**2-10**] ?MTx, CAD s/p MI, with
recent viral cough X 3 weeks was admitted to MICU [**12-4**] with
sepsis. He was found to have RLL PNA, s/p 5L IVF/pressors,
vanc/ceftriaxone/levaquin in MICU, sepsis resolved. He remained
afebrile. He did not grow organisms on sputum culture, but did
well when Abx were decreased to Levaquin alone. His urine
legionella was negative. Repeat imaging showed a persistant RLL
infiltrate and he continued to require O2. He was discontinued
home on O2 (3-4L) for a short time.
.
He received stress/replacement dose steroids for several days,
but plan for rapid taper to baseline 30mg over next 4-5 days. He
had baseline pancytopenia, thought to be secondary to Mtx (no
BMB) for which he was followed as an outpatient by OSH
hematologist (Dr. [**Last Name (STitle) **]. His platelet count decreased to 30,
with increased petechiae, and hematology was consulted. He was
placed on neutropenic precautions briefly. His peripheral smear
was reviewed and did not show evidence of schistocytes. His
counts were monitored, and medications including heparin were
discontinued. H (vanc, H2B, heparin) and counts improved on own,
though he remains pancytopenic.
.
An echo was done on admission in the setting of sepsis which a
mildly reduced EF 40-50% and multiple WMA, but trops negative.
He has a h/o CAD s/p MI with cath [**1-16**] w/o intervention, likely
old changes and some acute depression in setting of sepsis. He
is asked to f/u with his cardiologist to get clearance prior to
colectomy, which is obviously delayed for the time being. Repeat
echo was done prior to discharge and showed preservation of his
ejection fraction, with evidence of persistent inferobasal left
ventricular aneurysm, unchanged from prior echocardiograms.
Given his preserved ejection fraction and lack of thrombus seen
on echo, decision was made not to start anticoagulation.
.
Finally, has h/o BPH with frequent symptoms and developed acute
urinary retention for which foley was placed. Finasteride was
started as well with a plan for a voiding trial in [**5-15**] days by
home nursing or PCP. [**Name10 (NameIs) **] he fails his voiding trial, he should
have a urology referal placed by his PCP.
.
Has baseline diarrhea [**2-10**] UC, but some increased stools near
discharged, which resolved by day of discharge. Given multiple
issues, he was set up with home VNA services (respiratory,
nursing, PT and he plans on staying with his daughter for a few
days to recover. He will need close follow up with his PCP,
[**Name10 (NameIs) 2085**], and hematologist.
Medications on Admission:
Medications:
Lantus 50 QHS
Humalog SS
Lisinopril 5
Coreg 6.25 [**Hospital1 **]
Simvastatin 40
Flomax 0.4
Flexseed oil
MV
B complex
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Lantus 100 unit/mL Solution Sig: Fifty (50) Units
Subcutaneous at bedtime.
5. Insulin Aspart 100 unit/mL Solution Sig: 20-25 Units
Subcutaneous three times a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
8. Home oxygen
3L at rest and 4L with exertion.
Portal pulse dose system
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
11. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day:
50mg [**12-8**] and [**12-9**]
40mg [**12-10**] and [**12-11**]
30mg after. .
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing
for 7 days.
Disp:*1 inhaler* Refills:*0*
13. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
RLL PNA, hypoxia
Pancytopenia (neutropenia/leukopenia, anemia, thrombocytopenia c
petechia)
Abnormal echo, mild heart failure
Acute urinary retention, foley placement
Discharge Condition:
GOOD
Discharge Instructions:
You were admitted with R lower lung pneumonia for which you were
treated with antibiotics, you will complete a course of levaquin
as directed.
You will go home on oxygen for a few days/weeks and your doctor
or home nursing will follow this.
You blood counts were also very low and you were seen by
hematology service. Please follow up with Dr. [**Last Name (STitle) **] to discuss
this further and to monitor your counts as you may need a bone
marrow biopsy in the future.
You need to follow a prednisone taper as follows: 50mg for [**12-8**]
and [**12-9**], then 40mg [**12-10**] and [**12-11**], then back to 30mg per day.
Remember to clarify with your doctor whether you need "stress"
replacement doses for the surgery since you have been on
steroids for very long. Also you should be on Calcium +vit D
since you have been on steroids, to protect your bones.
Your colectomy (surgery) will be delayed until you medical
issues are stable.
You had an abnormal echocardiogram while you were here and very
sick. There were some changes that are likely old and some
changes that are likely in setting of you being very sick. But,
you did NOT have a heart attack. You should give your results to
your cardiologist so that he can clear you to proceed with the
surgery. You were started back on your heart medications (coreg,
statin, lisinopril).
You had acute urinary retention in setting of your underlying
BPH and acute illness, we placed another foley catheter which
will remain for approximately 5days until a decatherization
trial by your doctor or home nursing. You will keep the flomax
but since you have symptoms even before this admission, you were
also started on finasteride.
You were set up with home VNA services for respiratory care,
foley care, PT, nursing.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 79244**] [**Name (STitle) **] ([**Telephone/Fax (1) 79245**]
after discharge in [**1-10**] weeks.
You should have your Foley discontinued in about 5 days with a
voiding trial.
Please also make appointments with your surgeon for your
colectomy after your acute issues are over.
Please make appointments with Dr. [**Last Name (STitle) **] (heme/onc) and your
cardiologist in 1week after discharge.
|
[
"600.01",
"284.1",
"556.9",
"486",
"401.9",
"995.92",
"V58.65",
"414.01",
"428.0",
"250.00",
"V15.82",
"788.20",
"782.7",
"785.52",
"038.9",
"V58.67",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9251, 9300
|
5099, 7765
|
305, 329
|
9511, 9518
|
2916, 5076
|
11335, 11821
|
2521, 2526
|
7946, 9228
|
9321, 9490
|
7791, 7923
|
9542, 11312
|
2541, 2897
|
253, 267
|
357, 1878
|
1900, 2342
|
2358, 2505
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,601
| 124,983
|
36849
|
Discharge summary
|
report
|
Admission Date: [**2146-7-16**] Discharge Date: [**2146-7-26**]
Date of Birth: [**2075-6-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain radiating to mid scapular pain associated with lower
extremity weakness and numbness. Type A dissection found on CT
scan at OSH
Major Surgical or Invasive Procedure:
Redo sternotomy/Aortic Valve Resuspension/Replacement of
Ascending Aorta and Hemiarch/Reimplantation of Saphenous vein
graft x2(vein to vein)for proximal graft-[**2146-7-16**]
History of Present Illness:
71 year old male presents to OSH complaining of chest pain
radiating mid scapular with associated lower extremity numbness
and weakness.
Past Medical History:
s/p CABG '[**33**],RA,hyperlipidemia, chronic thrombocytopenia
Social History:
+tobacco, quit 20 years ago
lives with wife
retired
Family History:
noncontributory
Physical Exam:
On Admission
VS:T:96/P:68/BP:92/38,RR:18/O2SAT=97%
HEENT:At/NC,EOMI,PERRL
Lungs:CTA
CVS:RRR
ABD:benign
Extr: No C/C/E
Pertinent Results:
[**2146-7-26**] 06:20AM BLOOD WBC-14.6* RBC-3.31* Hgb-10.1* Hct-30.4*
MCV-92 MCH-30.5 MCHC-33.2 RDW-14.6 Plt Ct-466*
[**2146-7-16**] 09:27AM BLOOD WBC-15.3* RBC-4.05* Hgb-13.1* Hct-37.5*
MCV-93 MCH-32.3* MCHC-34.9 RDW-14.6 Plt Ct-138*
[**2146-7-23**] 02:03AM BLOOD PT-12.9 PTT-25.6 INR(PT)-1.1
[**2146-7-16**] 09:27AM BLOOD PT-15.8* PTT-43.8* INR(PT)-1.4*
[**2146-7-26**] 06:20AM BLOOD Glucose-88 UreaN-41* Creat-1.3* Na-140
K-3.4 Cl-104 HCO3-21* AnGap-18
[**2146-7-16**] 09:27AM BLOOD Glucose-90 UreaN-27* Creat-1.3* Na-146*
K-3.6 Cl-113* HCO3-22 AnGap-15
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83231**] (Complete)
Done [**2146-7-16**] at 6:22:23 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2075-6-13**]
Age (years): 71 M Hgt (in):
BP (mm Hg): 90/40 Wgt (lb):
HR (bpm): 80 BSA (m2):
Indication: acute aortic dissection, CABG [**52**] years ago
ICD-9 Codes: 441.00, 424.1
Test Information
Date/Time: [**2146-7-16**] at 18:22 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 #: 2009AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Sinus Level: *4.1 cm <= 3.6 cm
Aorta - Ascending: *4.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Findings
Emergency aortic dissection. This patient has two [**Medical Record Number 83232**]. The
first [**Medical Record Number 83233**] changed by the admission in the middle of the
exam. There are two studies uploaded for this patient.
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
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: Moderately dilated aortic sinus. Focal calcifications in
aortic root. Mildly dilated ascending aorta. Ascending aortic
intimal flap/dissection.. Aortic arch intimal flap/dissection.
Descending aorta intimal flap/aortic dissection.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Moderate
to severe (3+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. 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. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
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.
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 moderately dilated at the sinus level. The
ascending aorta is mildly dilated.
A mobile density is seen in the ascending aorta consistent with
an intimal flap/aortic dissection extending all the way to the
lowest descending thoracic aorta visualized by TEE. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Moderate to severe (3+) aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results on Mr. [**Known lastname 9220**]
before incision
POST-BYPASS: (patient is on 0.02 mcg/kg/min of epinephrine, 0.15
mcg/kg/min of levophed and 4 units/hr of vasopressin
Normal left ventricular function. EF 55%.
Mild dilatation of the right ventricle with normal function.
Aortic valve is intact after resuspension and has no AI.
Mild MR [**First Name (Titles) **] [**Last Name (Titles) **].
The ascending aortic tube graft is intact.
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) **] [**2146-7-20**] 12:57
?????? [**2140**] CareGroup IS. All rights reserved.
Brief Hospital Course:
[**7-16**] Mr.[**Known lastname 9220**] was taken to the operating room and underwent a
Redo sternotomy/Aortic Valve Resuspension/Replacement of
Ascending Aorta and Hemiarch/Reimplantation of Saphenous vein
graft x2(vein to vein)for proximal graft. Cross clamp time= 123
minutes. Cardiopulmonary bypass time=169 minutes. Circulatory
arrest with cerebral perfusion time=23 minutes. Please refer to
Dr[**Doctor Last Name 14333**] operative report for further details. He
tolerated the procedure well and was transferred to the CVICU in
critical but stable condition requiring multiple pressors to
optimize cardiac output. He awoke neurologically intact and was
extubated on POD#2. All drips were weaned to off. Beta-blocker
and diuresis was initiated. All lines and drains were
discontinued in a timely fashion. Rheumatology was consulted
for his RA and recommendations regarding his medications, as he
is enrolled in a clinical study, and Hematology was consulted
for his chronic thrombocytopenia. POD#4 he went into atrial
fibrillation and was treated medically with Amiodarone and
converted to sinus rhythm. Noninvasive ventilation was utilized
for increasing tachypnea. Mr.[**Known lastname 9220**] required aggressive
pulmonary hygiene and continuous diuresis, prolonging his stay
in the CVICU. He continued to progress, was no longer requiring
BIPAP and was transferred to the step down unit on POD#7 for
further monitoring. Physical therapy consulted and evaluated.
The remainder of his postoperative course was essentially
uneventful. On POD#10 he was cleared by Dr.[**Last Name (STitle) **] for
discharge to rehab. All follow up appointments were advised.
Medications on Admission:
HOME MEDICATIONS: methotrexate 20 mg weekly, prednisone 15 mg
qAM, hydroxycholoquine 200 mg, sulfasalazine 1000 mg [**Hospital1 **] or
placebo, etanercept 15 mg weekly (Thursday), aspirin 81 mg,
metoprolol 12.5 mg, simvastatin 20 mg, naproxen 500 mg [**Hospital1 **],
alendronate 70 mg, B12 1000 mcg, folate 1 mg, omeprazole 20 mg,
cyclobenzaprine 10 mg TID
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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea/wheezing.
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for temp.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: Than reassess need to continue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Type A Aortic dissection
s/p redo sternotmy/AV resuspension/replacement of Ascending
Aorta and hemiarch.Reimplantation of SVGx2
CAD-s/p CABG 15yo
RA
Thrombocytopenia
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Name (NI) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**Last Name (STitle) 48985**], PCP [**Last Name (NamePattern4) **] 1 week please call for appointment
Cardiologist in [**2-22**] weeks please call for appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2146-7-26**]
|
[
"401.9",
"441.01",
"714.0",
"287.5",
"518.5",
"E878.8",
"427.31",
"997.1",
"414.00",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.91",
"38.45",
"39.49",
"39.61",
"96.71",
"35.11"
] |
icd9pcs
|
[
[
[]
]
] |
9935, 10014
|
6451, 8117
|
459, 637
|
10224, 10231
|
1145, 6428
|
10742, 11121
|
975, 992
|
8527, 9912
|
10035, 10203
|
8143, 8143
|
10255, 10719
|
1007, 1126
|
8162, 8504
|
281, 421
|
665, 804
|
826, 890
|
906, 959
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,695
| 170,595
|
49478
|
Discharge summary
|
report
|
Admission Date: [**2135-3-17**] Discharge Date: [**2135-3-28**]
Date of Birth: [**2050-3-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Bright red blood per ostomy
Major Surgical or Invasive Procedure:
Esophagoduodenoscopy
Colonoscopy
Blood Transfusion (1 unit)
Fresh frozen plasma transfusion (2 units)
History of Present Illness:
84 y/o F with hx of COPD, HTN, hyperlipidemia and recent
perforated sigmoid diverticulitis on [**1-5**] s/p ex lap, sigmoid
colectomy with [**Doctor Last Name 3379**] at [**Hospital1 **]. She was transferred to
[**Hospital1 18**] surgical service on [**2135-1-17**] after her course was
complicated by respiratory failure with persistent L lower lung
collapse, acute renal failure and altered mental status. While
in the surgical ICU from [**1-17**] to [**2-17**], she was found to have
pulmonary abscesses and started on vanco, zosyn and cipro. She
improved hemodynamically, but has slow recovery of mental
status. She had a trach and PEG tube placed for failure to wean
of ventilator. A pneumothorax occurred after CVL placement and
a CT was placed. During the admission, she also had unexplained
neutropenia and a BM biopsy. For diarrhea, she was empirically
treated for c.diff, although no cultures were positive.
.
She was recently seen in ED at OSH for possible pneumonia and
treated with unknown abx at that time at rehab. Was not
admitted. Also talking with rehab, she is on a course of IV
flagyl for c.diff. She in on day [**12-20**] today.
.
Today she presents from rehab with bright red blood per her
colostomy for the last 48 hours. Also had some blood sputum
through her tracheostomy per report. Her family is with her and
notes that the last few days she seems more tired than usual but
otherwise well. No nausea, vomiting, abdominal pain. Stool is
maroon. No stool output from her pouch.
.
In the ED, initial vs were: T98.4, 116/71, hr 110, r 12, 98% on
PS 5/5 with 60% FiO2. She was given cipro 400 mg IV x1 in the
ED. Her prior PICC site was very erythematous. Her PICC had
been removed at rehab the day prior to admission. She had a CXR
without new cardiopulmonary abnormalities; her trach was in
place. An NG lavage was attempted but unsuccessful via NG tube.
She had a lavage through her PEG tube which was negative. She
had [**Last Name (un) 17993**]-maroon stool in her bag. Her vitals on transfer were
P 113, BP 108/60, R 20, 94% on above vent settings. She had 2
peripheral IVs for access.
.
On the floor, she is awake and arousable, but not able to talk
because of her trach. She nods. She nods no to having no pain.
Otherwise yes/no review of systems was negative as listed
below. Her weight has been stable, although she is being
diuresed for fluid overload from previous admission. She does
have decubitus ulcers.
Past Medical History:
# Perforated Diverticulitis s/p sigmoid Colectomy with [**Doctor Last Name 3379**]
pouch at [**Hospital3 4107**] [**1-5**]
# Tracheostomy, ventilator dependent
# h/o ARDS
# h/o pulmonary abscess
# h/o encephalopathy, likely metabolic
# h/o neutropenia
# h/o C.diff
# Presyncopal episodes
# Hypertension
# Hyperlipidemia
# h/o electrolyte disorders
# Hypothyroidism
# Asthma/COPD
Social History:
Presents from rehab.
Family History:
Unable to obtain
Physical Exam:
General Appearance: ventilated, sedated, edematous
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: trach in place, no erythema
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Bowel sounds present, nontender, well healed
scars; Gtube in place with mild surrounding erythema; colostomy
bag in place with maroon stool
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Musculoskeletal: Unable to stand
Skin: Cool, Rash: decubitus ulcers on buttock, stage two; R
antecubital fossa with erythema and skin breakdown and opne PICC
site with serosanginous fluid
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2135-3-17**] 12:50PM PT-19.8* PTT-33.4 INR(PT)-1.8*
[**2135-3-17**] 12:50PM WBC-8.9# RBC-3.38* HGB-10.1* HCT-32.8*
MCV-97# MCH-29.8 MCHC-30.7* RDW-20.6*
[**2135-3-17**] 12:50PM GLUCOSE-130* UREA N-60* CREAT-0.5 SODIUM-135
POTASSIUM-6.3* CHLORIDE-103 TOTAL CO2-29 ANION GAP-9
[**2135-3-17**] 01:06PM LACTATE-1.9 K+-4.9
[**2135-3-17**] 03:00PM URINE HYALINE-[**11-26**]*
[**2135-3-17**] 03:00PM URINE BLOOD-TR NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2135-3-17**] 03:00PM URINE RBC-0-2 WBC-20* BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2135-3-17**] 06:31PM TSH-0.35
[**2135-3-17**] 06:31PM ALBUMIN-1.7* CALCIUM-7.6* PHOSPHATE-3.5
MAGNESIUM-1.9
[**2135-3-17**] 06:31PM CK-MB-2 cTropnT-0.09*
[**2135-3-17**] 06:31PM ALT(SGPT)-33 AST(SGOT)-84* LD(LDH)-207
CK(CPK)-23* ALK PHOS-1093* TOT BILI-1.1
Brief Hospital Course:
#) GI bleeding: Continued to have grossly bloody output per
ostomy on HD1. Was transfused 1U pRBCs on HD2 when hematocrit
dropped from 29 --> 26.6 and patient was tachycardic and
hypotensive (SBP in 80s). Hct remained stable at 29-31 for
duration of hospitalization and no more bloody output per
ostomy. EGD showed friable gastric and esophageal mucosa but no
active bleeds. Colonoscopy showed ulcers and erythema concerning
for infectious colitis vs. ischemic colitis. Biopsy results
still pending at time of discharge. CT abdomen showed thickening
of bowel near hepatic flexure consistent with colitis, and a
small amount of free intraperitoneal air that could be
consistent after colonoscopy. Surgery followed patient and
deemed her issues could be managed without surgery. She was
treated empirically for c. difficile colitis with IV flagyl and
vancomycin. C. difficile toxin negative x3. She was started on
protonix 40mg [**Hospital1 **] for friable gastric mucosa seen on EGD, and
will complete a 14-day course of IV flagyll and PO vancomycin
after completing a course of cefepime for her UTI. [**4-13**] should be
the last day of antibiotics. Stool cultures, ova and parasites,
and pathology from colonoscopy pending.
#) Hypotension: on arrival to MICU, patient was hypotensive
(SBPs to high 70s) and tachycardic to 100-110. Felt to be
secondary to hypovolemia. She was bolused 3.5L normal saline and
transfused 1U overnight, which improved her blood pressure. In
the setting of hypotension, her home lopressor dose was
initially held. Subsequently had two brief episodes of
hypotension (SBP to 70s) which responded to 500-1000ml boluses
of normal saline.
#) Atial fibrillation with Rapid ventricular response: on HD3
patient developed elevated heart rate to 140s and was found to
be in atrial fibrillation with rapid ventricular response. She
was rate controlled with diltiazem 10mg IV x1 and then loaded
with digoxin. She converted and remained in sinus rhythm for the
remainder of her ICU stay. In the setting of atrial
fibrillation, her levothyroxine dose was decreased from 200mcg
to 175mcg (she was felt to be slightly therapeutic on
levothyroxine as her TSH was 0.35). Her home lopressor dose
(6.25mg [**Hospital1 **]) was continued when blood pressure permitted.
#) Right arm erythema: at former PICC site. Picc was removed at
rehab and she was treated with IV vancomycin and IV cefepime for
presumed cellulitis. Erythema improved over the course of the
hospitalization. Blood cultures from [**3-17**] showed [**1-10**] positive
for coagulase negative staphaureus, and cultures from [**3-18**] and
[**3-19**] showed no growth. It was thought that the positive tube was
due to a contaminant. As she remained afebrile without a white
count, her IV vancomycin was discontinued after six days of
treatment. Cefepime was continued for treatment of pseudomonas
UTI.
#) Urinary tract infection: urine culture grew pseudamonas
sensitive to cefepime but resistant to ciprofloxacin. Started on
cefepime.
#) Chronic ventilator dependence: patient remained on
CPAP/pressure support with intermittent trache-mask trials and
work with respiratory support. On HD8, O2 saturation dropped to
89%. Her oxygen saturation normalized with increasing FiO2.
Concern for worsening of known chronic left-sided
hydropneumothorax, although stat chest X-ray showed no changes.
A PE CTA showed no evidence of PE but left lower lung collapse
and bilateral pleural effusions which was thought to be chronic.
Interventional pulmonology was consulted and felt that tapping
left-sided fluid was unlikely to yield any clinical benefit.
#) Mood: patient noted to be frustrated and sad/tearful on
admission. Psychiatry consulted, noted that it was difficult to
assess for depression given her baseline poor mental status, and
did not recommend starting her on anti-depressants.
#) Sacral decubitus ulcer: wound care consult obtained and wound
was maintained Q3D dressing changes, hydrogel to coccyx ulcer,
cover sacral ulcer wtih Mepilex.
#) Hypothyroidism: TSH was measured at 0.35 on admission. Given
baseline tachycardia and subsequent episode of atrial
fibrillation with RVR, levothyroxine dose was decreased from
200mcg PO QD to 175mcg QD. Needs out-patient thyroid function
tests.
#) Pulseless Arrest and Expiration: On [**3-28**] the patient went
into a PEA cardiac arrest and a code was called. Chest
compressions were begun. A pulse was eventually regained however
she remained profoundly bradycardic. Per family discussion a
decision was made to change her code status to DNR/DNI and to
withdraw further care. A member of the clergy was brought in to
provide for the patient and her family's spiritual needs. The
patient expired shortly thereafter.
Medications on Admission:
# Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: per sliding
scale sliding scale Injection ASDIR (AS DIRECTED).
# Levothyroxine 200 mcg QD
# Albuterol 4 puffs q6h
# Atrovent 4 puffs q6h
# Metoprolol 6.25mg q12h
# Lasix 20mg [**Hospital1 **]
# Nexium 40mg IV q12h
# Flagyl 500mg q8h begun [**3-5**] for 14-day course for C. diff
# Zinc Oxide--apply to sacral/coccygeal area q8h
# Tylenol 650 q4h PRN
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"401.9",
"707.22",
"276.3",
"999.31",
"276.51",
"V44.0",
"707.03",
"511.9",
"276.6",
"272.4",
"707.23",
"V44.3",
"041.12",
"682.3",
"518.0",
"V44.1",
"599.0",
"518.83",
"493.20",
"244.9",
"707.05",
"041.7",
"285.1",
"348.30",
"008.45",
"V46.11",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"45.13",
"96.6",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
10546, 10555
|
5303, 10050
|
343, 446
|
10602, 10607
|
4421, 5280
|
10659, 10757
|
3402, 3420
|
10518, 10523
|
10576, 10581
|
10076, 10495
|
10631, 10636
|
3435, 4402
|
276, 305
|
474, 2946
|
2968, 3348
|
3364, 3386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,119
| 163,628
|
2831
|
Discharge summary
|
report
|
Admission Date: [**2177-5-1**] Discharge Date: [**2177-5-2**]
Date of Birth: [**2141-5-4**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Progressively worsening shortness of breath for 3 days
Major Surgical or Invasive Procedure:
Pericardial drain placement
History of Present Illness:
This 35-year-old female with a history of widely metastatic
colon cancer to lung and liver developed progressively worsening
shortness of breath for 3 days. Due to the advanced stage of
malignanacy, she was discharged to hospice and recieved
palliative chemo and radiation recently for pain and spinal cord
compression. However, she has had difficulty accepting her
teminal disease and since then has been on and off hospice.
During the past 3 days, she experienced shortness of breath with
progression. No fever, cough, chest pain or extremity swelling
is noted. And the day of admission, she woke up and felt like
she couldn't breathe so her family called the EMS.
On her way to the ED, her oxygen saturation was 82% under room
air and increased to 93% with non-rebreathing bag. At the ED,
she was in respiratory distress and could not speak in full
sentances. The vital signs were 97.6 120 160/105 22 93% with
NRB. Physical exam showed rales over her lung bileterally.The
chest x-ray revealed a large pleural effusion and cardiomegaly.
A bedside echo demonstrated a large pericardial effusion with
matressing of the right ventricle and her pulsus was 20.
Cardiology was consulted and recommended pericardial drainage in
the cath lab. IP was consulted as well and recommended
drainage. She was given 750cc of normal saline to increase her
pre-load. Given her immunocompromised status, she recieved
vancomycin and levofloxacin for potential pneumonia. Her labs on
transfer to the cath lab were: 114 155/108 35 99% NRB. Per the
ED she was full code.
Past Medical History:
1. PPD positive -
had some treatment with INH, unclear if full course.
2. Metastatic colon cancer:
underwent left colectomy with end-to-end anastomosis on
[**2173-9-1**] followed by 2 months of FOLFOX and capecitabine.
Found to have metastatic disease in 09/[**2173**]. FOLFOX was started
on [**2174-9-7**]. Has since been on various chemo regimen including
Bevacizumab, oxaliplatin, fluorouracil,cetuximab Irinotecan .
.
palliative radiation therapy to paravertebral soft tissue from
[**Date range (3) 13812**], with 3000 cGy of radiation.
.
started on mitomycin/capecitabine on [**2176-12-31**]. She progressed on
this therapyand required admission in [**2-21**] for a pain crisis.
During this hospitalization she was found to have left lower
extremity weakness and paresthesias and imaging demonstrated
progression with cord compression. She had been previously
radiated extensively to the area. She was started on steroids
with some improvement of the neurologic findings and received a
short course of Cyberknife. She also had radiation to the L-S
spine.
She was discharged with home hospice to begin after the
radiation
therapy.
.
Last chemo:
Cycle #: 4 Day 1: [**2177-3-4**] Cycle end: [**2177-3-24**] Mitomycin-+
Capecitabine
.
Last radiation:
palliative radiation therapy to her sacral spine [**2177-4-1**] -
[**2177-4-9**]
.
Medications:
Dexamethasone 4 mg Tablet [**Hospital1 **]
Erythromycin with ethanol 2 % Gel apply to face twice a day
Megestrol 400 mg/10 mL (40 mg/mL) 2 tsp daily
Methadone 10 mg Tablet 2 Tablet(s) q8
Morphine 30 mg Tablet 3 tabs q4-6 prn
Morphine sulfate 20 mg/ml 2-20mg q1h prn pain
Nystatin 100,000 unit/mL 5 ml by
Ranitidine HCl 150 mg [**Hospital1 **]
Bisacodyl 5 mg 2 tabs daily
Docusate sodium 100 mg [**Hospital1 **]
Multivitamin
Senna 8.6 mg Tablet [**Hospital1 **]
.
Allergies: NKDA
Social History:
occupation: pre-school teacher
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
3 siblings.
One older brother with type 1 DM deceased in motorcycle
accident.
23 y/o sister & 33 y/o brother are healthy.
Physical Exam:
General: cachectic, diaphoretic, tachypnic and dyspneic, unable
to finish sentence, A+O X3
HEENT: temporal waisting, PERRLA, Sclera anicteric, dryish MM,
oropharynx oterwise clear
Neck: supple, JVP not elevated, no LAD
Lungs: reduced air entery to the left compared to right, coarse
crackles across all left lung fields, finer crackles over ri9ght
base
CV: Rapid RR, S1 + S2, systolic murmur [**1-19**] max at mid LUSB, no
no rubs or gallops
Abdomen: distended but soft, non-tender, hard non uniform mass
in LLQ, no flank dullness. bowel sounds present, no rebound
tenderness or guarding, no organomegaly per percussion
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pulses: radial, DP, TP faint bilaterally
Pertinent Results:
[**2177-5-1**] 08:25AM WBC-10.1 RBC-3.00* HGB-9.7* HCT-28.2* MCV-94
MCH-32.2* MCHC-34.4 RDW-20.7*
[**2177-5-1**] 08:25AM NEUTS-93.3* LYMPHS-2.9* MONOS-3.5 EOS-0.1
BASOS-0.2
[**2177-5-1**] 08:25AM PLT COUNT-168
[**2177-5-1**] 08:25AM GLUCOSE-128* UREA N-18 CREAT-0.4 SODIUM-122*
POTASSIUM-4.5 CHLORIDE-86* TOTAL CO2-22 ANION GAP-19
[**2177-5-1**] 08:25AM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-2.0
[**2177-5-1**] 08:25AM cTropnT-<0.01
[**2177-5-1**] 09:00AM PT-17.6* PTT-32.0 INR(PT)-1.6*
[**2177-5-1**] 08:25AM OSMOLAL-263*
[**2177-5-1**] 10:10AM Pericardial fluid
WBC-305* RBC-[**Numeric Identifier 13813**]* POLYS-88* LYMPHS-5* MONOS-4* OTHER-3*
TOT PROT-4.7 GLUCOSE-120 LD(LDH)-976 ALBUMIN-3.1
[**2177-5-1**] 11:39AM Areterial blood gas
PO2-66* PCO2-39 PH-7.41 TOTAL CO2-26 BASE XS-0 with nasal
cannula
[**2177-5-1**] 11:45AM URINE HOURS-RANDOM
UREA N-1652 CREAT-127 SODIUM-43 POTASSIUM-65 CHLORIDE-47
COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.029
[**2177-5-1**] 12:00PM
WBC-13.9* RBC-3.15* HGB-9.9* HCT-30.0* MCV-95 MCH-31.6 MCHC-33.1
RDW-20.9*
PLT COUNT-187
GLUCOSE-118* UREA N-16 CREAT-0.4 SODIUM-125* POTASSIUM-4.8
CHLORIDE-88* TOTAL CO2-24 ANION GAP-18
ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-2.0
PT-16.4* PTT-23.7 INR(PT)-1.4*
ALT(SGPT)-26 AST(SGOT)-43* LD(LDH)-1508* ALK PHOS-369* TOT
BILI-0.9
Brief Hospital Course:
This is a 35 year old female with end stage colon cancer with
diffuse mets who presented from home on [**5-1**] with gradually
worsening SOB and was found to have a large paricardial effusion
and white out of left lung. She underwent pericardial drainage
of exudative fluid and was subsequently admitted to the cardiac
intensive care unit. On admission she was found to be
significantly tachycardic and dyspnic with hypoxia. Pulmonary
team was consulted and performed bed-side ultrasound which
demonstrated a small amount of pleural fluid which was felt to
insufficient to explain her degree of dyspnea. Her dyspnea and
hypoxia were rather felt to be attributable to extended
malignant involvement of her lung possibly worsened by
post-obstructive lung infection. It was thus reasoned that
pleural fluid drainage will have no theraputic or palliative
benefit.
.
After discussion with the patient, her family and the
out-patient oncologist decision was made to focus on comfort
measures only and code status was changed to DNR/DNI. Palliative
care services were consulted and patient was treated overnight
with Lorazepam and opioid drips for maximal comfort.
.
On [**5-2**] in the AM the house officer was called to the patient??????s
room, her mother and the mother??????s 2 sisters were at the bedside.
She was found to be without spontaneous breathing or pulse with
fixed dilated pupils. Death was pronounced at 09:00 AM. Cause
of death was hypoxic respiratory failure which complicated her
end stage metastatic colon disease.
Medications on Admission:
Dexamethasone 4 mg Tablet [**Hospital1 **]
Erythromycin with ethanol 2 % Gel apply to face twice a day
Megestrol 400 mg/10 mL (40 mg/mL) 2 tsp daily
Methadone 10 mg Tablet 2 Tablet(s) q8
Morphine 30 mg Tablet 3 tabs q4-6 prn
Morphine sulfate 20 mg/ml 2-20mg q1h prn pain
Nystatin 100,000 unit/mL 5 ml by
Ranitidine HCl 150 mg [**Hospital1 **]
Bisacodyl 5 mg 2 tabs daily
Docusate sodium 100 mg [**Hospital1 **]
Multivitamin
Senna 8.6 mg Tablet [**Hospital1 **]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased secondary to hypoxic respiratory failure complicated
with end stage metastatic colon disease
Discharge Condition:
Deceased
Discharge Instructions:
None- deceased
Followup Instructions:
None- deceased
Completed by:[**2177-5-2**]
|
[
"511.9",
"253.6",
"799.4",
"518.81",
"423.9",
"423.3",
"197.0",
"336.3",
"197.7",
"486",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
8287, 8296
|
6214, 7747
|
356, 385
|
8443, 8453
|
4843, 6191
|
8516, 8560
|
3942, 4065
|
8258, 8264
|
8317, 8422
|
7773, 8235
|
8477, 8493
|
4080, 4824
|
262, 318
|
413, 1972
|
1994, 3826
|
3842, 3926
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,462
| 114,208
|
39011
|
Discharge summary
|
report
|
Admission Date: [**2153-5-30**] Discharge Date: [**2153-6-11**]
Date of Birth: [**2102-1-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
left heart catheterization,coronary angiogram
coroanry artery bypass grafts x3(LIMA-LAD,SVG-ramus,SVG-PDA)
[**2153-6-5**]
History of Present Illness:
This 51 year old white male presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital
with chest pain where he ruled in for a myocardial infarction by
enzymes (trop 0.39). He was transferred to [**Hospital1 18**] for cardiac
catheterization which revealed severe three vessel coronary
artery disease. Surgical evaluation was requested.
Past Medical History:
coronary artery disease
s/p coronary artery bypass grafts
Hypertension
Hyperlipidemia
s/p coronary angioplasty
Hepatitis C with cirrhosis
h/o alciohol induced seizures
Depression
Chronic back pain
Scoliosis
benign prostatic hypertrophy
h/o gastrointestinal bleed
Carpal Tunnel Syndrome
s/p left total hip replacement
Social History:
Lives with:sister
Occupation:on disability
Tobacco:+ 70 pk year, down to 3 cigs/day on Chantix
ETOH:H/o ETOH abuse, sober x7 years
Recreational drugs: denies
Family History:
Father died of "[**Last Name **] problem" age 45, had
rheumatic fever
Physical Exam:
Admission:
Pulse:72 Resp: 20 O2 sat:
B/P Right:194/117 Left: 177/108 (prior to cath)
Height:6'3" Weight:195lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 0 Varicosities +
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2153-6-11**] 04:40AM BLOOD WBC-9.4 RBC-3.18* Hgb-9.1* Hct-28.3*
MCV-89 MCH-28.6 MCHC-32.1 RDW-15.5 Plt Ct-305
[**2153-6-10**] 05:45AM BLOOD WBC-9.8 RBC-3.32* Hgb-9.5* Hct-30.1*
MCV-91 MCH-28.4 MCHC-31.4 RDW-15.3 Plt Ct-263
[**2153-6-11**] 04:40AM BLOOD UreaN-15 Creat-0.9 K-4.1
[**2153-6-10**] 05:45AM BLOOD UreaN-19 Creat-0.9 K-4.5
[**2153-6-8**] 09:31AM BLOOD Glucose-151* UreaN-21* Creat-1.0 Na-141
K-4.0 Cl-105 HCO3-24 AnGap-16
Brief Hospital Course:
The patient was evaluated and cleared by the hepatology service
with Child's Class A Cirrhosis. He underwent the routine
preoperative evaluation. Mr.[**Known lastname 1661**] was brought to the
Operating Room on [**2153-6-5**], where he underwent coronary artery
bypass x 3. See operative note for details. He weaned from
bypass on Neo Synephrine and Propofol infusions. He weaned from
pressors and the ventilator easily and was begun on beta-
blockers and diuresed towards his preoperative weight as usual.
Physical therapy worked with him, however, he was appropriate
for rehab prior to returning home. Wounds were clean and dry
and healing. Pacer wires and CTs had been removed per protocol.
His pain was well controlled on oral analgesics. POD# 6 He was
cleared for discharge to [**Hospital **]Rehabilitation for
further increase in strength and mobility. All follow up
appointments were advised.
Medications on Admission:
Clonidine patch 0.2 qTues
Celexa 60mg po daily
MS Contin 60mg po TID
MSIR 30mg po TID PRN pain
Plavix 75mg po daily
Keppra 500mg po BID
Folate 1mg po daily
Doxepin 10mg po qHS
Coreg 25mg po BID
Lisinopril 10mg po daily
Simvastatin 80mg po daily
Varenicline 0.5mg po daily
ASA 81mg po daily
Calcium Carbonate 500mg +Vit D
Colace 100mg po BID
Ferrous Sulfate 65mg po daily
Magnesium Oxide 400mg po daily
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Varenicline 0.5 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. Morphine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO three times a day.
6. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO once a day: Q
Thursady.
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day.
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever or pain.
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
20. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32944**] Village & Rehabilitation Center - [**Location (un) 32944**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
Hypertension
Hyperlipidemia
s/p percutaneous coronary interventions
Hepatitis C with cirrhosis
h/o alcohol induced seizures
Depression
Chronic back pain
Scoliosis
benign prostatic hypertrophy
h/o gastrointestinal bleed
Carpal Tunnel Syndrome
s/p laeft total hip replacement
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]), on [**2153-7-23**] at 1pm
Please call to schedule appointments
Primary Care: Dr. [**First Name (STitle) **],[**First Name3 (LF) 30129**]-[**Doctor First Name **] ([**Telephone/Fax (1) 28612**]) in [**2-3**] weeks
Cardiologist: Dr. [**Last Name (STitle) 86515**] [**Name (STitle) 82705**] ([**Telephone/Fax (1) 65733**]) in [**2-3**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2153-6-11**]
|
[
"401.9",
"305.1",
"600.00",
"V45.82",
"272.4",
"996.72",
"V43.64",
"410.71",
"345.90",
"E878.1",
"571.2",
"414.01",
"496",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.61",
"36.15",
"37.22",
"88.56",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5613, 5725
|
2546, 3455
|
289, 413
|
6101, 6570
|
2087, 2523
|
7272, 7966
|
1343, 1415
|
3908, 5590
|
5746, 6080
|
3481, 3885
|
6594, 7249
|
1430, 2068
|
238, 251
|
441, 810
|
832, 1151
|
1167, 1327
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,901
| 124,298
|
49837
|
Discharge summary
|
report
|
Admission Date: [**2187-11-26**] Discharge Date: [**2187-12-4**]
Date of Birth: [**2129-10-22**] Sex: M
Service: General Surgery
HISTORY OF PRESENT ILLNESS: The patient with a history of
multiple debridements for peripancreatic abscess and necrosis
who was noted to have a colocutaneous fistula as well as
colonic stricture. He wished to have this corrected. Also,
he did not have his gallbladder removed.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
on [**11-26**] and underwent a cholecystectomy, an ileostomy
creation, and a colocolostomy, and partial colectomy.
Postoperatively, he was admitted to the Trauma Surgical
Intensive Care Unit. On examination, he had a blood pressure
of 110/50 and a pulse of 100. His temperature was 99.6. He
was sedated and moved all four extremities. His chest was
clear to auscultation bilaterally. He had a regular rate and
rhythm. His abdomen was soft and nontender. He had mucosa
at the ileostomy, and the extremities were warm. He was
sedated with propofol and was seen by stoma therapy. He
actually improved after his operation.
On [**11-29**], his abdomen was mildly distended. The pain
control continued to be extremely important. He did complain
at one point of some chest pain. On [**11-30**], sips were
started, and his ileostomy began to work. His diet was
advanced so that by [**12-3**] he was noted to have a
methicillin-resistant Staphylococcus aureus wound infection.
Total parenteral nutrition was stopped. He was able to
tolerate food.
On postoperative day eight, which was [**12-4**], he was
discharged to home with follow up with [**Hospital6 1587**] on an outpatient basis.
DISCHARGE STATUS: Discharge status was improved.
DISCHARGE DIAGNOSES: Colonic fistula, colonic stricture, and
pancreatitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern4) 12891**]
MEDQUIST36
D: [**2188-2-12**] 12:51
T: [**2188-2-12**] 18:26
JOB#: [**Job Number 104131**]
|
[
"568.0",
"276.6",
"577.0",
"458.29",
"560.39",
"557.1",
"562.10",
"285.1",
"567.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.75",
"54.59",
"00.14",
"99.15",
"38.93",
"46.01",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
1757, 2089
|
463, 1736
|
175, 433
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,529
| 125,635
|
7180
|
Discharge summary
|
report
|
Admission Date: [**2137-5-30**] Discharge Date: [**2137-6-11**]
Date of Birth: [**2066-3-3**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 71 year-old gentleman
with known history of coronary artery disease, peripheral
vascular disease who presented to an outside hospital on
[**2137-5-25**] with epigastric and throat discomfort times four
hours with associated shortness of breath. Patient was found
to have a hematocrit of [**Street Address(2) 26651**] depressions in V2 through
V6. Chest x-ray was consistent with mild congestive heart
failure. Patient underwent a CT scan to rule out leak of his
previous aortic abdominal aneurysm repair which was within
normal limits. Patient was transfused three units of packed
red blood cells and was found to be guaiac negative. Patient
ruled in for a non-ST elevation myocardial infarction with a
peak troponin of .16. Patient was transferred to [**Hospital1 346**] for cardiac catheterization.
PAST MEDICAL HISTORY: 1) Paroxysmal atrial fibrillation. 2)
Hypertension. 3) Peripheral vascular disease. 4) Status
post aorto-[**Hospital1 **]-femoral bypass. 5) Status post right femoral
tibial bypass. 6) Status post abdominal aortic aneurysm
repair. 7) Coronary artery disease. 8) Status post PTCA
stent to the RCA and LAD in [**2132**]. 8) Status post
appendectomy. 9) Gastroesophageal reflux disease. 10) Gout.
11) Mild bilateral renal artery stenosis. 12) Bilateral
carotid stenosis. 13) Hyperlipidemia. 14) Benign prostatic
hypertrophy. 15) Status post transurethral resection of
prostate.
ALLERGIES: Penicillin and sulfa.
PREOPERATIVE MEDICATIONS:
1. Digoxin 0.25 mg p.o. q day.
2. Zestril 10 mg p.o. q day.
3. Norvasc 5 mg p.o. b.i.d.
4. aspirin 81 mg p.o. q day.
5. Gemfibrozil 300 mg p.o. b.i.d.
6. Coumadin 2.5 mg alternating with 2.0 mg.
7. Allopurinol 300 mg p.o. q day.
8. Isordil 60 mg p.o. q day.
9. Sotalol 40 mg p.o. b.i.d.
10. Protonix 40 mg p.o. b.i.d. on transfer.
11. Lipitor 40 mg p.o. q day.
12. Lexapro 10 mg p.o. q day.
SOCIAL HISTORY: Patient is an animal pharmacist and he is an
active smoker with a greater than 50 pack year history.
HOSPITAL COURSE: She was admitted to the [**Hospital1 346**] on [**5-30**] and was taken to the
cardiac catheterization laboratory. Cardiac catheterization
showed 20 percent left main stenosis, 60 to 90 percent LAD
occlusion, patent RCA stent. Patient was referred to cardiac
surgery for operative management. Due to patient's anemia
a GI consult was obtained for work up. Patient underwent an
esophagogastroduodenoscopy on [**6-3**] which was normal without
any evidence of pathology in the esophagus, stomach or the
small bowel to the third part of the duodenum. The GI service
recommended that patient have colonoscopy as an elective
procedure after coronary artery bypass. Patient had carotid
ultrasound which showed 60 to 69 percent stenosis of the
right internal carotid artery with only mild plaque in the
left internal carotid artery. Patient was taken to the
operating room by Dr. [**Last Name (STitle) **] on [**6-5**] for coronary artery
bypass graft times two, LIMA to LAD and saphenous vein graft
to diagonal. Total cardiopulmonary bypass time was 45
minutes, crossclamp time 33 minutes. Please see operative
note for further details. Patient was transported to the
Intensive Care Unit in stable condition. Patient had stable
hemodynamics, was weaned and extubated from mechanical
ventilation on the first postoperative night, required
antihypertensives. Patient was started on Sotalol on
postoperative day one and patient was transferred from the
Intensive Care Unit to the regular part of the hospital.
Upon arrival to the floor the patient was found to be in
atrial fibrillation while he had been in sinus rhythm
postoperatively. Patient was given intravenous doses of
Lopressor with adequate heart rate control. Patient was
started back on his Coumadin for anticoagulation but as
patient continued to have atrial fibrillation with a rapid
ventricular response an electrophysiology consult was
obtained and the electrophysiology recommendation was to
continue the Sotalol and sent home with [**Doctor Last Name **] of Hearts
Monitor. Patient began ambulating with physical therapy.
Patient continued to be in atrial fibrillation which she
tolerated well, was asymptomatic. Patient's pacing wires
were removed without incident on postoperative day number
three. Patient completed level 5 physical therapy. Patient
continued on heparin infusion and started Coumadin for
anticoagulation for the atrial fibrillation. Over the next
couple of days patient's basal heart rate began slowly
increased and electrophysiology service which had been
following the patient recommended starting low dose Lopressor
for heart rate control. Patient was started on Lopressor
12.5 mg p.o. b.i.d. with improvement in patient's heart rate
from 120 to 130/80 to 90. Patient also had some episodes of
ventricular bigeminy and occasional couplets and triplets.
This improved with the addition of Lopressor. By
postoperative day number six patient's INR had reached 1.8
and patient had reached level five and had stable heart rate
and blood pressures. Discussions with Dr. [**Last Name (STitle) **] and the
patient was cleared for discharge home.
CONDITION ON DISCHARGE: Maximum temperature 99.3, pulse 94
in atrial fibrillation, blood pressure 118/60, respiratory
rate 16 on room air, oxygen saturation 97 percent.
Neurologically patient is awake, alert and oriented times
three, nonfocal. Heart is irregularly irregular without rub
or murmur. Respiratory - breath sounds are clear
bilaterally. Abdomen is soft, nontender, nondistended,
positive bowel sounds. Patient is tolerating regular diet
and having normal bowel movement. Sternal incision - the
staples are intact. The sternum is stable. There is no
erythema or drainage. Left leg vein harvest site
Steri-Strips are intact. There is no erythema or drainage.
Bilateral lower extremities pulses are Dopplerable dorsalis
pedis and posterior tibial which are equal bilaterally.
Extremities are mildly cool but same as preoperatively per
patient. Patient's weight on [**6-11**] is 91 kilograms.
Preoperatively patient weighed 90 kilograms.
LABORATORY DATA: White blood cell count 7.3, hematocrit
26.8, platelet count 515. Sodium 138, potassium 4.1,
chloride 99, bicarb 28, BUN 12, creatinine 0.8.
Patient is being discharged to home in stable condition.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q day times seven days.
2. Potassium chloride 20 mEq p.o. q day times seven days.
3. Colace 100 mg p.o. b.i.d.
4. Enteric coated aspirin 81 mg p.o. q day.
5. Dilaudid 2 to 4 mg p.o. q 4 hours p.r.n.
6. Allopurinol 300 mg p.o. q day.
7. Nicotine patch 14 mg transdermally q day.
8. Protonix 40 mg p.o. q day.
9. Oxycontin 10 mg p.o. b.i.d. times three days, then 10 mg
p.o. q day times three days and then discontinue.
10. Lipitor 80 mg p.o. q day.
11. Sotalol 40 mg p.o. t.i.d.
12. Lopressor 12.5 mg p.o. b.i.d.
13. Niferex 150 mg p.o. q day.
14. Coumadin 2.5 mg on [**6-11**]. Patient is to have his PT/INR
drawn by the visiting nurse on [**6-12**] with results called to
Dr.[**Name (NI) 13176**] office.
Patient is to be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor
with daily asymptomatic recordings to Dr.[**Name (NI) 13176**] office for
two weeks. Patient is to follow up with Dr. [**Last Name (STitle) 13175**] in the
office in one to two weeks. Patient is to follow up with Dr.
[**Last Name (STitle) 26652**] in the office in one to two weeks and patient is to
follow up with Dr. [**Last Name (STitle) **] in three to four weeks. Patient is
to return to Far 2 on [**6-19**] for wound check and staple
removal.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Peripheral vascular disease.
4. Atrial fibrillation.
5. Iron deficiency anemia.
6. Status post esophagogastroduodenoscopy which was
negative.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2137-6-11**] 17:27
T: [**2137-6-11**] 17:30
JOB#: [**Job Number 26653**]
|
[
"443.9",
"410.71",
"427.31",
"401.9",
"414.01",
"305.1",
"280.9",
"274.9",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"89.60",
"36.11",
"39.61",
"36.15",
"37.22",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6535, 7844
|
7865, 8369
|
2192, 5336
|
1651, 2055
|
159, 977
|
1000, 1625
|
2072, 2174
|
5361, 6512
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,304
| 149,739
|
45705
|
Discharge summary
|
report
|
Admission Date: [**2131-5-7**] Discharge Date: [**2131-5-11**]
Date of Birth: [**2072-5-20**] Sex: F
Service: UROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
white female first seen by Dr. [**Last Name (STitle) 261**] on [**2131-4-19**], for
evaluation of a 5.1 centimeter mass in the upper pole of her
left kidney first noted on CT of the abdomen on [**2131-4-12**].
The CT was performed in response to symptoms of diarrhea. A
question of Crohn's disease was high on the list because of
her known history of Sjogren's syndrome. No evidence of
metastases were noted on chest, abdomen and pelvic CT and
confirmed by MR. The patient is now being admitted for left
laparoscopic nephrectomy. There is no history of urinary
tract infection, gross hematuria, smoking history or family
history of genitourinary cancer. Hemoglobin 14.4, alkaline
phosphatase 113. Torso CT and MR showed a 5.1 centimeter
mass upper pole of the left kidney, single LRA with negative
lymph nodes and adrenals. Right kidney appears OK.
PAST MEDICAL HISTORY:
1. Idiopathic thrombocytopenic purpura treated with steroids
last in [**2129**].
2. Deep vein thrombosis.
3. Hyperlipidemia.
4. Irritable bowel syndrome.
5. Total abdominal hysterectomy, bilateral
salpingo-oophorectomy for endometriosis.
6. Fibromyalgia.
7. Positive rheumatoid factor, Sjogren's syndrome.
8. Anserine bursitis.
9. Chondrocalcinosis.
10. Renal cell carcinoma.
11. Cholecystectomy.
MEDICATIONS ON ADMISSION:
1. Elavil.
2. Lipitor.
3. Clonazepam.
4. Neurontin.
5. Tramadol.
6. Imodium.
7. Currently Ciprofloxacin ear drops for an otitis externa.
PHYSICAL EXAMINATION: In general, the patient is a well
appearing female in no acute distress. Head, eyes, ears,
nose and throat examination - No masses and no bruits. The
chest is clear to auscultation bilaterally. Cardiovascular
is regular rate and rhythm. The abdomen is soft, flat,
nontender. Extremities - no cyanosis, clubbing or edema.
Neurologic examination is intact.
HOSPITAL COURSE: The patient was admitted on [**2131-5-7**], and
taken directly to the operating room where a hand assisted
laparoscopic left nephrectomy was performed. The patient
initially tolerated the procedure well and was sent to the
recovery room. After a few hours in the recovery room, the
patient was sent to the regular urology floor. The patient
received three doses of perioperative Kefzol. She received a
Morphine PCA. She was left NPO and had a nasogastric tube
placed to suction and a Foley catheter in place.
In the evening of the day of her surgery, the patient became
excessively somnolent and experienced a drop in oxygen
saturation. It was determined that her ensuing hypercarbia
and hypoxia secondary to hypoventilation was caused by
narcotic overdose. The patient received a number of doses of
Narcan to reverse the effects of the narcotics.
The patient was transferred to the Intensive Care Unit for
closer care. On Intensive Care Unit, the patient did fairly
well recovering from her narcotic overdose within the next
approximately twelve hours or so. The rest of the time the
patient was alert and progressively improved. She did
complain of a decrease in hearing bilaterally.
It was determined by ENT consultation that the patient had
otitis media. They told her to continue using her
Ciprofloxacin drops for her otitis externa and to use
decongestant and suggested that the otitis media would
improve when the nasogastric tube was removed.
It was also decided while in the Intensive Care Unit that the
patient would be scheduled for a sleep study after discharge
to be evaluated for sleep apnea as a possible exacerbating
factor for her hypoventilation hypercarbic hypoxic episode
the night of her surgery.
Over the course of the next few days, the patient started to
pass gas and her nasogastric tube and Foley catheter were
removed at the appropriate times. She started a regular diet
which she appeared to tolerate well. She also was able to be
started on some Percocet which she tolerated well.
It is now [**2131-5-10**], and the patient is in good condition.
She is being discharged. She is to follow-up with Dr. [**Last Name (STitle) 261**]
in approximately two weeks. She is to go for her sleep study
evaluation on Sunday night. She is being sent home with
Percocet for pain. She is also being sent home with Colace
to insure that her stools remain soft. She is also being
told to continue her home medications including her
Ciprofloxacin drops for her ears. She is also being told to
take Sudafed and Aspirin as needed to dry up her head
secretions. She should avoid strenuous activity. She should
not drive while on pain medications. She may shower although
should not take baths. She may observe a regular diet.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2131-5-10**] 15:16
T: [**2131-5-14**] 10:41
JOB#: [**Job Number **]
|
[
"287.3",
"518.0",
"189.0",
"428.0",
"710.2",
"382.9",
"714.0",
"285.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
1505, 1650
|
2051, 5090
|
1673, 2033
|
164, 1050
|
1072, 1479
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,429
| 134,299
|
24438
|
Discharge summary
|
report
|
Admission Date: [**2135-9-27**] Discharge Date: [**2135-10-7**]
Date of Birth: [**2087-2-17**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Ampicillin / Betadine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Lumbar pain
Major Surgical or Invasive Procedure:
Thoracolumbar anterior posterior spinal fusion
History of Present Illness:
Pt has a histiry of scoliosis with chronic back pain.
Past Medical History:
Scoliosis. HTN
Social History:
lives at home in [**State 2690**]. Married
Family History:
n/c
Physical Exam:
NAD Afebrile. VSS. Pt is moving extremities upon command.
Pertinent Results:
[**2135-10-7**] 05:38AM BLOOD Hct-30.5*
Brief Hospital Course:
Pt had thoracotomy [**2135-9-27**]. Pt had attempted posterior
thoracolumbar fusion T10-L5 severe blood loss encountered
surgery aborted. Pt admitted to the SICU for fluid
resuscitation. Surgery was completed [**10-3**]. Last post op course
uneventful.
Medications on Admission:
5. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO qd ().
6. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Estradiol 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for temp.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
const.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for breakthrough pain.
5. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO qd ().
6. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Estradiol 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Scoliosis. Degenerative disc disease
Discharge Condition:
good
Discharge Instructions:
keep incision clean and dry
Physical Therapy:
No heavy lifting greater than 15 lbs. No bending/twisting.
Ambulate atleast TID
Treatments Frequency:
Change dressing daily. Turn patient every 2 hours when in bed
Site: Left flank/lumbar
Type: Surgical
Dressing: Gauze - dry
Change dressing: qd
Followup Instructions:
7 days with Dr [**Last Name (STitle) 363**] [**Telephone/Fax (1) 3573**]
Completed by:[**2135-10-7**]
|
[
"401.9",
"285.1",
"721.2",
"733.00",
"244.9",
"458.29",
"998.11",
"733.90",
"518.0",
"737.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"38.93",
"03.90",
"99.05",
"84.51",
"99.07",
"81.04",
"99.00",
"96.71",
"81.08",
"84.52",
"99.04",
"77.79"
] |
icd9pcs
|
[
[
[]
]
] |
2410, 2480
|
706, 960
|
298, 347
|
2561, 2568
|
642, 683
|
2914, 3018
|
544, 549
|
1314, 2387
|
2501, 2540
|
986, 1291
|
2592, 2620
|
564, 623
|
2638, 2718
|
2740, 2891
|
247, 260
|
375, 430
|
452, 468
|
484, 528
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,626
| 126,832
|
43822
|
Discharge summary
|
report
|
Admission Date: [**2137-10-17**] Discharge Date: [**2137-10-20**]
Date of Birth: [**2067-6-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Attending Info 90680**]
Chief Complaint:
Increased edema and dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70M with CAD s/p NSTEMI and PCI to the RCA, T2DM, HTN, HLD, and
COPD who presents with dyspnea and worsening edema. The patient
reports that abaout 2 - 3 days ago he began to feel SOB more
than baseline. This AM around 4 AM he awoke feeling "radically"
SOB and felt very air hungry. It did not improve in about an
hour at which time he decided to come to the ED. He reports that
he has also noticed an increased amount of swelling in his lower
extremities bilaterally over the last couple of days. The
patient denies substernal CP, however does report a feeling of a
pulled muscle over his left lower ribs a couple days ago. The
patient also endorses a subjective fever (feeling warm) and some
mild chills over the past 2 days. He denies cough, congestion,
muscle/joint pains, and dysuria. He also denies N/V/D. The
patient denies orthopnea (but uses 2 pillows for comfort). He
also denies PND other than this AM. He reports medication
compliance and eats a heart healthy low sodium diet.
Of note, BP was well controlled at 126/78 during recent Atrius
outpatient visit on [**2137-10-15**].
He was previously admitted in [**5-/2137**] with edema and dyspnea and
was found to have an NSTEMI. During that admission, he was
found to have 95% lesions in the RCA and LCx, he received a DES
to the RCA and POBA to the LCx after being declined for [**Year (4 digits) **].
He was also found to have mildly elevated intracardiac pressures
and pulm HTN that admission with mean PAP of 28 and mean PCWP of
16. Subsequently he was admitted two separate times in [**7-/2137**]
with visual distubances and concern for CVA, it was thought he
had small embolic strokes after PCI but no new CVA was found on
repeat MRI.
In the ED, initial vitals were 88 179/81 28 100% on BiPAP.
Labs and imaging significant for proBNP of 2106 (no prior for
comparison). Initial trop was 0.03, ABG was 7.36/46/70/27 on
BiPAP.
Patient given Lasix 20mg IV, started on a nitro gtt. He was
subsequently weaned off of BiPAP prior to transfer to the CCU.
Vitals on transfer were 98 72 141/55 18 100% off BiPAP.
On arrival to the floor, patient reports that he feels SOB, but
it is much improved. He denies CP and has no other symptoms.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of 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 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,
orthopnea, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-[**Year (4 digits) **]: None
-PERCUTANEOUS CORONARY INTERVENTIONS: High-risk PCI [**5-/2137**] with
DES to the mid-RCA and POBA to the LCx
-s/p NSTEMI [**4-/2137**]
-mild pulm HTN (PASP=45mmHg on [**4-/2137**] RHC)
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-COPD
-embolic stroke s/p PCI
-h/o pan-resistent Klebsiella UTI, tx with Colistin c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
-Carotid Artery Stenosis (bilateral 60-69%)
Social History:
The patient lives at an assissted living place called [**Location (un) **]. He reports that he has nurses to help with his
medications and people help to prepare his meals.
Former technician for [**Company 22957**].
- Tobacco history: Smoked 2.5 PPD x 36 years, quit smoking in
[**2121**]
- ETOH: denies
- Illicit drugs: denies
Family History:
- Mother: CAD - MI in early 70s
- Brother: MI in early 60s, died of gastric cancer
- Brother: MI in 40s, died of pancreatic cancer
- Sister: MI in 60s
- Father: brain cancer
Physical Exam:
Physical Exam on Admission:
VS: T=97.9 BP=151/64 HR=78 RR= 18 O2 sat= 97% on 3L NC
GENERAL: WDWN 70 y/o in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry mucous
membranes.
NECK: Supple with JVP of [**9-16**] cm.
CARDIAC: distant heart sounds, normal RRR, normal S1, S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. Crackles about 1/3 up bilaterally,
decreased at bases bilaterally (R>L).
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c. 2+ pedal edema, 1+ [**1-7**] shins, and trace to
knees.
SKIN: Signs of venous stasis dermatitis over LE bilaterally no
ulcers. Thickened toenails bilaterally.
Neuro: CN II - XII intact (slightly asymetric smile, Left UE
with distal 4/5 strength, otherwise UE [**5-11**] bilaterally, right LE
5/5 strength, left LE 4/5 strength, sensation to light touch in
tact, downgoing toe on Babinski
Physical Exam on Discharge:
VS: T 98.1, BP 135/68, HR 72, RR 18, 98% O2 sat on RA
I/O: [**0-0-**]
No tele events
General: sleeping supine/flat, easily arousable and in NAD
Neck: no JVD
Lungs: CTAB, easy work of breathing, no accessory muscle use
CV: RRR, normal S1 and S2, no m/r/g
Abd: soft, NTND, + BS
Ext: no LE edema, warm and well perfused
Pertinent Results:
Labs on Admission:
[**2137-10-17**] 06:30AM BLOOD WBC-13.9*# RBC-3.41* Hgb-10.7* Hct-31.6*
MCV-93 MCH-31.6 MCHC-34.0 RDW-14.0 Plt Ct-252
[**2137-10-17**] 06:30AM BLOOD Neuts-81.4* Lymphs-10.2* Monos-5.0
Eos-3.1 Baso-0.3
[**2137-10-17**] 06:30AM BLOOD PT-11.7 PTT-35.0 INR(PT)-1.1
[**2137-10-17**] 06:30AM BLOOD Glucose-157* UreaN-19 Creat-1.1 Na-141
K-3.5 Cl-106 HCO3-23 AnGap-16
[**2137-10-17**] 03:30PM BLOOD CK(CPK)-78
[**2137-10-17**] 03:30PM BLOOD Mg-1.9
[**2137-10-17**] 06:48AM BLOOD Type-ART Rates-/27 PEEP-5 pO2-70*
pCO2-46* pH-7.36 calTCO2-27 Base XS-0 Intubat-NOT INTUBA
[**2137-10-17**] 06:33AM BLOOD Lactate-0.8
Cardiac Labs:
[**2137-10-17**] 06:30AM BLOOD proBNP-2106*
[**2137-10-17**] 06:30AM BLOOD cTropnT-0.03*
[**2137-10-17**] 03:30PM BLOOD CK-MB-4 cTropnT-0.04*
[**2137-10-17**] 03:30PM BLOOD CK(CPK)-78
Labs on Discharge:
[**2137-10-20**] 05:42AM BLOOD WBC-8.2 RBC-3.06* Hgb-9.5* Hct-28.9*
MCV-94 MCH-31.0 MCHC-32.8 RDW-14.4 Plt Ct-227
[**2137-10-20**] 05:42AM BLOOD Glucose-123* UreaN-27* Creat-1.3* Na-143
K-4.0 Cl-108 HCO3-24 AnGap-15
[**2137-10-20**] 05:42AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.9
Studies/Images:
EKG [**2137-10-17**]: Sinus rhythm. Minor lateral ST-T wave
abnormalities which are slightly more pronounced compared with
previous tracing of [**2137-7-26**].
CXR [**2137-10-17**]: IMPRESSION: Moderate interstitial pulmonary edema
and pulmonary vascular engorgement reflecting cardiac
decompensation.
ECHO [**2137-10-18**]: The left atrium and right atrium are normal in
cavity size. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with inferior and basal
inferolatearl hypokinesis. The remaining segments contract
normally (LVEF = 45%). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2137-5-14**], the
findings are similar.
Brief Hospital Course:
70M with a h/o CAD s/p NSTEMI and PCI to the RCA, T2DM
(A1c=6.8%), HTN, HLD, and COPD who presents with dyspnea and
worsening edema.
# Pulmonary edema: Patient does not appear to have chronic
systolic heart failure prior to admission and last EF from
[**5-/2137**] was 45-50%. CXR on admission consistent with pulmonary
edema likely secondary to dCHF exacerbation and BNP elevated to
2100 (no comparison in records). Patient initially required
BiPAP in the ED although was able to be weaned to nasal cannula
prior to arrival to the CCU after diuresis and afterload
reduction. The patient recieved 20mg IV lasix in the ED and
responded well making good urine. His symptoms had significantly
improved upon arrival at CCU. To rule out ischemic cause cardiac
enzymes were trended and did not indicate ischemic cause. The
patient was initially on nitro gtt for afterload reduction. He
was successfully weaned from this on HOD 2 and continued on home
hydralazine (however dosing to q8 vs. [**Hospital1 **]) and home isordil dose
increased. The patient was diuresed with additional 20mg IV
lasix on HOD 2 again with good response. He was then started on
PO lasix at 20 mg. Repeat ECHO on this admission showed EF 45%
and was largely unchanged from ECHO in [**Month (only) 116**].
# CAD s/p PCI: [**2137-5-7**] BMS to RCA and angioplasty to LCx.
Currently he does not endorse any anginal symtoms prior to this
episode of dyspnea. Cardiac enzymes flat without signs of acute
ischemia. Home ASA, plavix, and coreg were continued.
# Leukocytosis: Patient with leukocytosis on admission. He was
afebrile throughout hospitalization. Patient with h/o
pan-resistant ESBL Klebsiella UTI and urine reported to be
cloudy in the ED. Patient endorses low grade subjectvive fever
and mild chills. No other localizing signs of infection. UA was
sent and showed moderate leukocytes, few bacteria, and 16 WBC.
Urine culture again showed 10,000 - 100,000 resistant klebsiella
as before, however patient was asymptomatic. Treatment was not
initiated, however if patient becomes symptomatic, spikes fevers
will need treatment. Patient was afebrile and asymptomatic
throughout hospitalization. Blood cultures were with NGTD on
discharge, final pending. WBCs normalized on HOD2 and were most
likely reactive in the setting of his pulmonary edema.
# HTN: Initially on nitro gtt, successfully weaned on HOD 2.
Home Coreg, amlodipine, hydralazine, and isordil were continued.
As above the dose of isordil was increased and hydralazine dose
equivalent but changed to q8 hour dosing vs. [**Hospital1 **].
# COPD: Patient not on controler medications as an outpatient.
Ipratropium and albuterol nebs were written for prn, however
patient did not require in the hospital.
# T2DM: (A1c=6.8%). Home lantus at 12 units daily was conitnued.
Home januvia was held and patient was managed with humalog ISS.
# HLD: Continue atorvastatin 80mg
Transitional Issues:
- Blood culture with NGTD - f/u final
- Urine culture that showed resistant Klebsiella (10,000 -
100,000), which patient has had in past. Pt asymptomatic, no
leukocytosis, and afebrile. No treatment initiated. Will need to
follow up re: if symptoms begin or if becomes febrile may need
treatment in the future.
- Patient to follow up with [**Location (un) 2274**] cardiologist.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Doctor Last Name 9231**] pharmacy.
1. Januvia *NF* (sitaGLIPtin) 50 mg Oral daily
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Simethicone 80 mg PO TID
8. HydrALAzine 75 mg PO Q12H
9. Isosorbide Dinitrate 20 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. Sodium Bicarbonate Dose is Unknown PO BID
12. traZODONE 50 mg PO HS:PRN insomnia
13. Acetaminophen 650 mg PO Q6H:PRN pain
14. Aspirin 81 mg PO DAILY
15. Glargine 12 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Carvedilol 25 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. Glargine 12 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
8. Simethicone 80 mg PO TID:PRN indigestion
9. traZODONE 50 mg PO HS:PRN insomnia
10. HydrALAzine 50 mg PO Q8H
Hold for SBP <100
RX *hydralazine 50 mg 1 tablet(s) by mouth Three Times per day
Disp #*90 Tablet Refills:*0
11. Isosorbide Dinitrate 30 mg PO TID
hold for SBP<100
RX *isosorbide dinitrate 30 mg 1 tablet(s) by mouth Three times
per day Disp #*90 Tablet Refills:*0
12. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
13. Docusate Sodium 100 mg PO BID
14. Januvia *NF* (sitaGLIPtin) 50 mg Oral daily
15. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure
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 due to shortness of breath
from fluids on your lungs in the setting of high blood pressure
causing worse congestive heart failure. We removed some of the
fluid and controlled the blood pressure. We have obtained
follow-up with your cardiologist. Please take your medications
as prescribed. Please follow a low salt diet.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Cardiology F/U at [**Location (un) 2274**] [**Location (un) **] on [**2137-10-23**]. Please call to
obtain a time. Also, Dr. [**Last Name (STitle) 2257**] will call after he schedules
another appointment.
Department: RADIOLOGY
When: MONDAY [**2137-10-28**] at 10:00 AM
With: VASCULAR STUDY [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2137-11-13**] at 3:00 PM
With: [**Doctor Last Name **] [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROLOGY
When: TUESDAY [**2137-12-3**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2137-10-21**]
|
[
"414.01",
"428.0",
"272.4",
"250.00",
"403.90",
"459.81",
"496",
"V15.82",
"V45.82",
"412",
"585.9",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12908, 12965
|
7996, 10905
|
333, 340
|
13049, 13049
|
5542, 5547
|
13669, 14775
|
3955, 4130
|
12033, 12885
|
12986, 13028
|
11331, 12010
|
13200, 13646
|
4145, 4159
|
3136, 3371
|
5205, 5523
|
10926, 11305
|
266, 295
|
6386, 7973
|
368, 3028
|
5561, 6367
|
13064, 13176
|
3402, 3594
|
3050, 3116
|
3610, 3939
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,326
| 195,509
|
20741
|
Discharge summary
|
report
|
Admission Date: [**2173-2-17**] Discharge Date: [**2173-2-18**]
Date of Birth: [**2097-7-14**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
75 yo female with h/o HTN, Hypercholesterolemia, DM, CAD s/p
CABG and MI, CHF, PVD, CVA who was transferred to ICU after R
carotid stent.
Major Surgical or Invasive Procedure:
[**Name (NI) **] PTCA and stent
History of Present Illness:
75 yo F who was admitted to ICU for BP control s/p R carotid
stent. Her symptoms began in [**9-/2172**] when she had ptosis,
dysarthria and facial asymmetry. SHe was started on aggrenox in
addition to the [**Year (4 digits) 4532**] that she was already taking for presumed
PVD. DUring past few mos she has had pain down L arm mainly
while sleeping.
Past Medical History:
HTN, Hypercholesterolemia, DM, CAD s/p CABG [**2168**] and MI, CHF,
PVD, CVA, aortoiliac reconstruction, bliateral SSA
reconstruction, tremor of head, osteoproosis, AAA, prolapsed
bladder repair, wrist fx, shoulder fx, arthritis, carotid
stenosis, vertebral stenosis, Admission in [**2170**] for pulmonary
edema requiring intubation, Left superficial femoral vein DVT
dx'd by CT in [**April 2172**], AAA
Social History:
former tobacco, former ETOH (quit 17 years ago)
Physical Exam:
97.2, 116-160/72-100, 54-67, 24-34, 100%RA
GENL: pleasant F in NAD
HEENT: PERL, EOMI, full VF, OP clear, tongue midline, palatal
elevation equal, muscles of facial exp in tact, no LAD, no JVD
CV: RRR, + systolic murmur at LLSB
Lungs: CTA
Abd: soft, NT, ND, nl BS
Ext: no edema, 1+ pedal pulses
Neuro: A&Ox3, strength equal in UE at [**Hospital1 **] 4+/5, tri 4+/5, finger
ext [**6-18**], slight intention tremor with FTN, Calves [**6-18**], toes ext
[**6-18**]
Pertinent Results:
[**1-/2173**] Carotid U/S
Significant right-sided plaque with an 80-99% carotid stenosis.
Of note, this extends fairly distally in the cervical internal
carotid artery. On the left, there is moderate plaque with a
40-59% carotid stenosis, and findings that may be consistent
with aortic arch or left common carotid artery disease.
Brief Hospital Course:
75 yo F with h.o PVD, CAD, bl carotid stenosis s/p R ICA stent.
1. Carotid Stenosis: s.p [**Country **] intervention. Neuro exam at
baseline. Post procedure care included neosynephrine to keep
SBP120-180. Patient did not require this after 10 p.m. just
after the procedure. Continue [**Last Name (LF) 4532**], [**First Name3 (LF) **]. Gave small iv fluid
bolus to help increase SBP. Hold antihypertensives.
2. HTN: Holding antihypertensives. Restart as outpatient the day
after discharge.
3. HYperchol: Continued Lipitor
4. PVD: Continued [**First Name3 (LF) 4532**], started [**First Name3 (LF) **]
5. H/O CHF: Follow exam, gentle hydration. Likely slightly dry
post-procedure.
6. PPX: pneumoboots
7. Dispo: Patient was discharged to home to follow up with Dr.
[**First Name (STitle) **] as an outpatient. She is to restart blood pressure
medications the day after discharge.
Medications on Admission:
Fosamax 70mg every Tuesday
Lasix 40mg daily
Lipitor 10mg daily
Potassium 20meq daily
Metoprolol 50mg [**Hospital1 **]
Imdur 30mg daily
[**Hospital1 **] 75mg daily
Xanax 0.5mg HS
Paxil 20mg daily
Metformin 1000mg before supper
Lisinopril 5mg daily
Calcium supplement, Vitamin D and MVI 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO at bedtime.
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Please
start on [**2173-2-19**].
11. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day: please restart on [**2173-2-19**].
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
please restart on [**2173-2-19**].
14. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home
Discharge Diagnosis:
Carotid stenosis s/p carotid stent
Discharge Condition:
stable
Discharge Instructions:
Please call your physician or return to the hospital if you
experience chest pain, shortness of breath, nunbness, weakness,
visual changes, problems with speaking or other concerning
problems.
Please restart your blood pressure medications (Metoprolol,
Imdur, Lasix and lisinopril tomorrow).
Followup Instructions:
Please schedule follow-up appointment with Dr. [**First Name (STitle) **] in 1
month.
Please schedule follow-up in neurology clinic in the next month.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2173-8-31**] 3:30
Completed by:[**2173-2-18**]
|
[
"250.00",
"272.0",
"428.0",
"401.9",
"V45.81",
"414.00",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"00.45",
"00.40",
"00.61",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
4555, 4561
|
2166, 3049
|
408, 441
|
4640, 4649
|
1810, 2143
|
4990, 5327
|
3391, 4532
|
4582, 4619
|
3075, 3368
|
4673, 4967
|
1328, 1791
|
230, 370
|
469, 820
|
842, 1248
|
1264, 1313
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,276
| 150,132
|
3964
|
Discharge summary
|
report
|
Admission Date: [**2199-12-26**] Discharge Date: [**2200-1-1**]
Date of Birth: [**2139-12-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 60 year-old female with a history of metastatic breast
CA to lungs, bone who presents with progressive altered mental
status. Per family, she has been progressively lethargic over
the past 4-5 days. She has had decreased PO intake, not taking
her meds like usual, less alert and oriented. She was recently
started on Xeloda and took her first dose yesterday. Family was
concerned about dehydration and brought her into the ED for
evaluation.
In the ED, initial vitals were T 99.6, BP 168/111, HR 94, RR 97%
on 2L. She was alert and oriented to herself, able to recognize
family, and thought that she was at [**Hospital 745**] Hospital. She
appeared dry and overall weak. No leukocytosis but mild left
shift. Lactate 5.5. CXR unchanged with partial lingular
collapse, L hilar mass and associated streaky opacity. She was
covered broadly with vanco and cefepime. BP rose to a peak of
204/133. She was given 5 IV metoprolol x 2 with minimal response
(--> 180s/120s). Head CT revealed new vasogenic edema in b/l
occipital lobes as well as new hypodensity in the bilateral
cerebellum, thalami and corona radiata. She was given decadron
10mg and 3L NS. The OMED fellow was called and recommended admit
to [**Hospital Unit Name 153**] for close monitoring.
On arrival to the [**Hospital Unit Name 153**], her BP was 160-170s/100-120s. She
complained of pain "all over". Received hydral 10mg IV x 1 and
was then started on a labetalol drip. Also received morphine for
pain.
ROS: Limited [**2-2**] pt's mental status. Complains of pain all over
but cannot localize. Denies SOB.
Past Medical History:
Onc History (per prior notes):
- Pt noted neck mass [**4-9**]; at this time also had mammogram (as
had hx of breast lump 10 yrs prior) which demonstrated mass in
left breast.
- Core needle biopsy disclosed infiltrating poorly
differentiated carcinoma; histologic grade III; with necrosis,
probably lymphatic invasion, and possible DCIS
- ER neg, PR neg, Her-2/neu neg
- CT torso showed multiple enlarged left axillary nodes, several
right lower lobe lung nodules
- Bone scan showed no evidence of bony metastases
- FNA of left cervical node demonstrated malignant cells,
consistent with metastatic carcinoma (similar in morphology to
those on her recent breast biopsy)
- Commenced dose-dense Cytoxan/Adriamycin C1D1 [**2199-5-17**];
completed Cycle 4 [**2199-7-11**]
- Taxol/Avastin started; last dose (C3D15) was [**2199-11-8**]
- T8 transverse process biopsied [**2199-10-16**], demonstrated to have
malignant carcinoma cells c/w primary
Additional Past Med Hx:
1. as above, recent admission for bronchitis
2. atrial tachycardia
3. UTIs/pyelonephritis
Social History:
The patient lives in [**Location 745**], [**State 350**] and works as a
systems analyst. She is the vice president at a bank. She lives
with her significant other, [**First Name4 (NamePattern1) **] [**Name (NI) 17565**], and her daughter
[**Name (NI) **]. The patient is a former smoker. She quit 25 years ago
after a two to five-pack-year history. She previously drank two
alcoholic beverages per day.
Family History:
The patient states that she has three sisters, all of whom are
in good health. Her mother died in her 90s from a stroke. Her
mother had one sister who may have developed breast cancer in
her 70s. The patient's father died from heart disease. He had
one sister who died at age 17 from appendicitis. The patient is
not aware of any other family members with a diagnosis of breast
or ovarian cancer. She is not of Ashkenazi [**Hospital1 **] descent.
Physical Exam:
Vitals: T: 98.8 BP: 160/112 HR: 93 RR: 21 O2Sat: 97% on 2L-->96%
on RA
GEN: cachectic female, appears uncomfortable, intermittently
lying still and then writhing on the bed, tachypneic
HEENT: EOMI, PERRL (4-->2 mm), sclera anicteric, no epistaxis or
rhinorrhea, dry MM, small tannish plaques on the hard palate, no
thrush
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: tachy, regular, 2/6 systolic murmur at the apex, normal S1
S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: drowsy but arousable, oriented to person but not place or
time. difficult to assess her orientation as patient is too
exhausted to cooperate with exam. Moves all 4 extremities.
Plantar reflex downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
CHEST (SINGLE VIEW) Study Date of [**2199-12-26**]:
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: Allowing for patient
position and rotation, there is no change in partial collapse of
the lingula and an associated streaky opacity emanating from the
left hilum. There is diffuse interstitial abnormality most
likely related to lymphangitic spread of carcinomatosis. No
other focal consolidation is identified, and there has been no
interval development of pleural effusion. The cardiomediastinal
contour is unchanged. Osseous structures are unremarkable.
IMPRESSION: No change in collapse of lingula most likely due to
left hilar mass, and associated lymphangitic carcinomatosis.
CT HEAD W/O CONTRAST Study Date of [**2199-12-26**]:
IMPRESSION:
1. New right greater than left occipital vasogenic edema.
Recommend evaluation with gadolinium-enhanced MR to exclude
intracranial metastasis when patient is able to co-operate with
an exam.
2. No acute intracranial hemorrhage.
3. Worsening of sinus disease.
EEG Study Date of [**2199-12-27**]:
IMPRESSION: Abnormal EEG due to the slow disorganized background
and bursts of generalized slowing. These findings indicate a
widespread encephalopathy affecting both cortical and
subcortical structures. Medications, metabolic disturbances, and
infection are among the most common causes. There were no areas
of prominent focal slowing, but encelphalopathies may obscure
focal findings. There were no epileptiform features.
MRA BRAIN W/O CONTRAST Study Date of [**2199-12-27**]:
IMPRESSION:
1. Limited and incomplete study due to motion artifact. Multiple
bilateral
FLAIR hyperintensities that could represent PRESS given the
patient's history and pattern of distribution. A repeat study
with gadolinium is recommended when feasible.
2. Very limited MRA of the circle of [**Location (un) 431**] demonstrated
questionable right MCA stenosis and poor visualization of the
basilar artery.
3. Cannot evaluate for metastatic disease to the brain.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2199-12-27**]:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Progression of lymphangitic carcinomatosis.
3. Progressive infiltrative soft tissue in the left hilum with
worsening distal atelectasis.
4. Progression of liver metastases.
CHEST (PORTABLE AP) Study Date of [**2199-12-28**]:
IMPRESSION:
Persistent lymphangitic carcinomatosis, unchanged.
Left hilar opacity, more prominent than seen previously. Finding
again represents lingular atelectasis and is likely slightly
worse in the interval.
LABORATORY RESULTS:
[**2199-12-26**] 12:48PM BLOOD WBC-5.3 RBC-5.26 Hgb-14.3 Hct-41.1
MCV-78* MCH-27.2 MCHC-34.8 RDW-20.0* Plt Ct-108*#
[**2199-12-29**] 04:39AM BLOOD WBC-4.8 RBC-4.27 Hgb-11.1* Hct-34.4*
MCV-81* MCH-26.0* MCHC-32.2 RDW-20.8* Plt Ct-47*
[**2200-1-1**] 04:30AM BLOOD WBC-6.1 RBC-3.85* Hgb-10.3* Hct-32.1*
MCV-83 MCH-26.7* MCHC-32.1 RDW-21.5* Plt Ct-41*
[**2199-12-26**] 12:48PM BLOOD Glucose-105 UreaN-27* Creat-0.8 Na-137
K-3.8 Cl-96 HCO3-26 AnGap-19
[**2199-12-26**] 12:48PM BLOOD ALT-122* AST-398* CK(CPK)-257*
AlkPhos-433* TotBili-0.9
[**2199-12-26**] 12:46PM BLOOD Glucose-102 Lactate-5.5* Na-138 K-3.8
Cl-94* calHCO3-25
[**2199-12-29**] 04:39AM BLOOD Glucose-115* UreaN-36* Creat-0.8 Na-146*
K-4.0 Cl-111* HCO3-24 AnGap-15
[**2200-1-1**] 04:30AM BLOOD Glucose-114* UreaN-21* Creat-0.7 Na-141
K-4.5 Cl-110* HCO3-25 AnGap-11
MICROBIOLOGY:
[**2199-12-31**] MRSA SCREEN MRSA SCREEN-FINAL (NO GROWTH)
[**2199-12-26**] URINE URINE CULTURE-FINAL (NO GROWTH)
[**2199-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
[**2199-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
Brief Hospital Course:
# Altered mental status / Metastatic breast CA:
At presentation was though to be Posterior Reversible
Encephalopathy Syndrome (PRES) or metastatic disease to brain.
PRES was considered given patient history of recent hypertension
in setting of receiving cisplantin, a possible trigger of PRES.
Neurology was consulted and felt that MRI/MRA would help to
confirm PRES and possibly rule out metastatic disease to brain
causing her AMS. MRI would have also been useful to rule out a
stroke cause by a hypercoaguable state. MRI of brain on
[**2199-12-27**] reveals inability to evaluate for metastatic disease
in setting of imaging motion artifact. No sign of infection. EEG
consistent with ??????widespread encephalopathy affecting both
cortical and subcortical structures??????. No epileptiform activity
seen. Labetalol drip was started in hopes that controlling blood
pressure to keep patient normotensive would allow for potential
resolution of AMS if PRES was the culprit. On [**2199-12-31**], Dr.
[**Last Name (STitle) 19**] (patient's primary oncologist) stopped by to see patient
and family and outcome of his meeting was a request to reconsult
neurology for further prognostic information for PRES as well as
potential benefit for repeat MRI. Neurology was contact[**Name (NI) **] on
[**2199-12-31**] and they felt that the time course and prognosis of
PRES was too variable to be able to provide family with concrete
information in goals of care discussion. MRI tech revealed on
[**2199-12-31**] that repeat MRI could not be re-attempted without
intubation and sedation with anesthesia present as patient??????s
mental status and movement is incompatible with repeat imaging.
Dr. [**Last Name (STitle) 19**] was notified of this in an email evening of [**2199-12-31**].
Dr. [**Last Name (STitle) 19**] had a repeat discussion with the family in light of the
new information from neurology and inability to perform MRI.
Patient was made comfort measures only (CMO) on morning of
[**2200-1-1**] and IV fluids and anti-hypertensives were
discontinued. Morphine drip was started and was titrated to
patient comfort and RR of < 15. Patient died in afternoon of
[**2200-1-1**] in presence of her family members.
Medications on Admission:
Xeloda (took first dose on the night prior to admission)
Metoprolol 100mg PO daily
Lansoprazole 30mg PO daily
Ativan 1-2mg PO qHS
Zofran 8mg PO q8 prn
Compazine 10mg PO q8 prn
Tussionex 5ml PO BID
Cyclobenzaprine 5mg PO q8 prn
Acetaminophen-Codeine 300-30mg 1 tab PO q6h prn pain
Discharge Medications:
discharge to death
Discharge Disposition:
Expired
Discharge Diagnosis:
Immediate cause of death: Cardiopulmonary arrest, unspecified
Proximate cause of death: Metastatic Breast Cancer
Discharge Condition:
discharge to death
Discharge Instructions:
discharge to death
Followup Instructions:
discharge to death
Completed by:[**2200-1-2**]
|
[
"V15.82",
"799.02",
"348.39",
"174.9",
"V87.41",
"V15.3",
"276.0",
"401.9",
"V66.7",
"348.5",
"E933.1",
"287.4",
"197.0",
"197.7",
"198.5",
"196.3",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11078, 11087
|
8491, 10704
|
337, 343
|
11243, 11263
|
4804, 8468
|
11330, 11378
|
3474, 3926
|
11035, 11055
|
11108, 11222
|
10730, 11012
|
11287, 11307
|
3941, 4785
|
276, 299
|
371, 1955
|
1977, 3033
|
3049, 3458
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,571
| 145,943
|
5276
|
Discharge summary
|
report
|
Admission Date: [**2176-2-29**] Discharge Date: [**2176-3-1**]
Date of Birth: [**2095-3-29**] Sex: M
Service: MEDICINE
Allergies:
Keflex
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Hematoma s/p procedure
Major Surgical or Invasive Procedure:
Stenting of the Right Superficial Femoral Artery
History of Present Illness:
80M with h/o HTN, HL, CAD, DM, presented for elective PTA and
stenting of right femoral/SFA, complicated by large hematoma
requiring ICU monitoring.
.
Pt with lower extremity pain with rest and activity and open
ulcers bilaterally since [**Month (only) **]/[**Month (only) 1096**]. Also reported swelling,
rednes and scaliness. Pt referred for angiography after ABI on
left was 1.66, left CFA and SFA were biphasic on doppler, left
popliteal , DP and PT were monophasic.
.
Procedure was successful to RSFA (ballooned and stented) but
complicated by tear of branch of common femoral mid procedure
causing large hematoma. An angioseal was placed, protamine
given, pressure held on large hematoma. No aneurysm suspected.
.
ROS: Dizzy at baseline, denies SOB, CP, palpitation,
lightheadedness. Back pain at center, behind umbilicus.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: CAD s/p LAD stenting in [**2163**]. Most recent
ETT [**11-25**]: no ischemia. LVEF 63%.
3. OTHER PAST MEDICAL HISTORY:
-- Possible AAA. [**2175-4-10**] u/s: difficult study, no aneurysm
seen.
-- atrial fibrillation on Coumadin
-- PVD
- [**2176-2-19**] noninvasive study: RLE: moderate to severe
atherosclerotic disease. Evidence of severe RSFA stenosis and/or
occlusion. Right ABI 0.31. LLE: Evidence for left SFA stenosis
and/or occlusion. ABI 1.66.
-[**2176-2-20**] CT of pelvis and LE: right SFA mid vessel occlusion.
Left popliteal artery focal 70% calcific stenosis at the level
of
the patella.
-- Gout
-- Insomnia
-- Vitamin B12 deficiency
-- COPD
-- Tremor, unsteady gait s/p fall [**9-25**] with fractured right ribs
(has refused to see neurologist)
-- [**2166**], [**12-26**]: cellulitis
-- lumbar spondylosis
-- chronic back pain with possible compression fractures s/p
fall
-- full thickness right rotator cuff tear
-- Cataracts s/p surgery
Social History:
Patient is widowed and lives alone. He has five
children. He has a history of multiple falls. He does not use a
cane or a walker.
Tobacco: Patient smoked for approximately 45 years. Quit
approximately 15 years ago.
ETOH: None
Family History:
Mother died of CHF at age 66
Physical Exam:
GENERAL: WDWN male in NAD. Oriented x3. Frustrated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, dry mucus membranes
NECK: JVP not elevated
CARDIAC: irregular rhythm, rate 50s
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Left large groin hematoma with dark
ecchymosis, no tenderness
SKIN: Back with no bruising or signs of retroperitoneal
bleeding
Pertinent Results:
[**2176-2-29**] 09:42PM BLOOD WBC-9.5 RBC-3.91* Hgb-11.7* Hct-35.0*
MCV-90 MCH-29.8 MCHC-33.3 RDW-16.7* Plt Ct-143*
[**2176-3-1**] 06:11AM BLOOD WBC-10.7 RBC-3.85* Hgb-12.0* Hct-34.9*
MCV-91 MCH-31.1 MCHC-34.3 RDW-17.1* Plt Ct-158
[**2176-2-29**] 08:15AM BLOOD PT-14.4* INR(PT)-1.2*
[**2176-2-29**] 09:42PM BLOOD Glucose-109* UreaN-28* Creat-1.4* Na-139
K-4.1 Cl-99 HCO3-31 AnGap-13
[**2176-3-1**] 06:11AM BLOOD Glucose-100 UreaN-25* Creat-1.3* Na-142
K-4.0 Cl-101 HCO3-31 AnGap-14
[**2176-2-29**] 09:42PM BLOOD CK(CPK)-65
Cardiology Report Cardiac Cath Study Date of [**2176-2-29**]
FINAL DIAGNOSIS:
1. Peripheral artery disease.
2. Successful PTA and stenting of the RSFA with a 8.0x60mm
Zilver stent
that was postdilated with a 6.0x20mm Viatrac balloon. Final
angiography
revealed no residual stenosis, no angiographically apparent
dissection
and good distal flow (see PTA comments).
3. Successful deployment of angioseal closure device.
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2176-2-29**]
3:40 PM
PRELIMINARY REPORT
Large subcutaneous hematoma extending from the left groin access
site
inferiorly to the superior medial thigh, and superiorly to the
left iliac
crest. No retroperitoneal blood
Radiology Report FEMORAL VASCULAR US LEFT Study Date of [**2176-3-1**]
9:06 AM
No pseudoaneurysm identified in the left groin. A limited
examination was performed due to the large infiltrative hematoma
in the left
groin. No discrete collection identified.
Brief Hospital Course:
Mr. [**Known lastname 13469**] is an 80 year old male with history of hypertension,
hyperlipidemia, CAD, diabetes, who presented for elective
percutaneous transluminal angioplasty and stenting of right
superficial femoral artery, complicated by large hematoma
requiring ICU monitoring.
# Left Groin Hematoma:
Patient was transfused two units of pRBCs, after which his
hematocrit remained stable. His coumadin was held in the
setting of bleed, but his aspirin and plavix were continued in
the setting of recent stenting. Left groin ultrasound ruled out
aneurysm and AV fistula, and noncontrast CT scan ruled out
retroperitoneal bleed. CT scan showed extent of large hematoma
in subcutaneous tissue.
# Peripheral Vascular Disease:
Right Superficial Femoral Artery was successfully stented by
Interventional Cardiology. The patient was noted to have
complication of large left hematoma at the site of entry for the
procedure. After the procedure, the patient's right foot was
noted to have strong dorsalis pedis pulse and was warm, well
perfused, while the left foot felt colder in comparison with
dopplerable pulses.
.
# Hypertension:
Home dose of metoprolol was held overnight in order to monitor
hemodynamic status more effectively and in setting of
bradycardia with ventricular rates in 50s; metoprolol was
restarted prior to discharge. Patient may benefit from an ACE
inhibitor for renal and cardiac protection in the setting of
diabetes and heart disease if there are no contraindications to
its use in him.
.
# Hyperlipidemia:
Lipid panel was last checked in the [**Hospital1 18**] system in [**2163**], and
lipids appear to have been well controlled at that time.
Patient was continued on home dose atorvastatin during this
hospitalization.
.
# Coronary Artery Disease:
Patient was continued on aspiring, plavix, statin. His
metoprolol was held overnight to monitor his hemodynamic status
and was restarted prior to discharge.
.
# Chronic renal insufficiency:
Patient presumed to have chronic renal insufficiency because
creatinine in [**2163**] in [**Hospital1 18**] system was 1.2, though patient may
have had acute issue at that time elevating creatinine; current
baseline renal function unclear. Creatinine 1.4 prior to
angiography, stable at 1.3 prior to discharge. Creatinine
should be closely monitored after contrast load for procedure in
the setting of renal insufficiency.
.
# Diabetes Mellitus:
Patient's metformin was held during hospitalization and is to be
restarted the day after discharge. His blood sugars were
monitored, and he was placed on an insulin sliding scale during
this hospitalization.
.
# Atrail Fibrillation:
Patient is on coumadin at home, which was held overnight in the
setting of bleed and restarted the next day when hematoma was
found to be stable. Patient remained in slow atrial
fibrillation, rates in 50s during this hospitalization, likely
with some vagal response from groin hematoma. Metoprolol was
held in the setting of already slow rate.
.
# COPD:
Home Advair was continued.
.
# Gout:
Patient was continued on home dose allopurinol.
Medications on Admission:
ALLOPURINOL 300 mg by mouth once a day
ATORVASTATIN 40 mg by mouth every evening
FLUTICASONE-SALMETEROL 250 mcg-50 mcg 1 puff twice a day
FUROSEMIDE 20 mg on M/W/F, 2 tablets all other days
GABAPENTIN 300 mg by mouth daily
L-METHYLFOLATE-VIT B12-VIT B6 2 mg-2.8 mg-25 mg by mouth daily
METFORMIN 500 mg by mouth twice a day
METOPROLOL TARTRATE 25 mg by mouth twice a day
OMEPRAZOLE 20 mg by mouth every morning
WARFARIN 6 mg by mouth every evening, last dose [**2176-2-23**] pre
angiogram
ASPIRIN 325 mg by mouth daily
CYANOCOBALAMIN 1,000 mcg by mouth daily
VIT C-VIT E-COPPER-ZNOX-LUTEIN [PRESERVISION] 226 mg-200 unit-[**Unit Number **]
mg-0.8 mg-34.8 mg by mouth twice a day
VITAMIN A-VITAMIN C-VIT E-MIN [OCUVITE] by mouth twice a day
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).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation once a day.
8. Furosemide 20 mg Tablet Sig: as directed Tablet PO once a
day: please take 20mg (1 tab) on Mon, Wed, Fri, please take 40mg
(2 tabs) on Tue, [**Last Name (un) **], Sat, Sun.
9. L-Methylfolate-Vit B12-Vit B6 2.8-2-25 mg Tablet Sig: One (1)
Tablet PO once a day.
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Vit C-Vit E-Copper-ZnOx-Lutein 226-200-5 mg-unit-mg Capsule
Sig: One (1) Capsule PO twice a day.
14. Vitamin A-Vitamin C-Vit E-Min Tablet Sig: One (1) Tablet
PO twice a day.
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain for 15 doses.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. hematoma
2. PVD
Secondary Diagnoses:
1. Atrial fibrillation
2. COPD
3. Lumbar spondylosis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Dear Mr. [**Known lastname 13469**],
You were admitted to the hospital after a procedure to stent an
artery in your right leg because you had a lot of bleeding into
your left groin that we wanted to monitor. We transfused you
with two units of blood and monitored you overnight to make sure
your blood counts were stable and you did not continue to bleed.
Your blood counts were stable and you were discharged home. You
should not take your coumadin for the next three days. You will
be contact[**Name (NI) **] by Dr. [**Last Name (STitle) **] on Monday. If you do not hear from
him by noon on Monday please call him at [**Telephone/Fax (1) 8725**]. Please
discuss restarting your coumadin at this appointment. Also,
please discuss whether an ACE inhibitor would be beneficial.
The following changes have been made to your medications:
- Stop coumadin until your appointment with Dr. [**Last Name (STitle) **] on
Monday**
- START plavix 75mg by mouth daily - please do not stop taking
this for any reason. Only your cardiologist should stop this
medication.
- Stop Omeprazole - as this medication interacts with plavix
- START famotidine 20mg by mouth daily
Please be sure to keep all of your followup appointments.
Please seek medical attention if you experience any symptoms
concerning to you.
Followup Instructions:
Please be sure to keep all of your followup appointments.
You will be contact[**Name (NI) **] by Dr.[**Name (NI) 8716**] office on Monday
[**2176-3-4**]. If you do not hear from his office by noon please call
them at [**Telephone/Fax (1) 8725**] and schedule an appointment immediately.
|
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icd9cm
|
[
[
[]
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[
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288, 339
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10133, 10133
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2283, 2511
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,268
| 112,410
|
41321
|
Discharge summary
|
report
|
Admission Date: [**2178-12-9**] Discharge Date: [**2178-12-15**]
Date of Birth: [**2105-4-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Ventricular tachycardia
Major Surgical or Invasive Procedure:
VT-ablation
Arterial line placement and removal
History of Present Illness:
73 yo M with nonischemic cardiomyopathy, ventricular tachycardia
s/p VT ablation and AICD, who was admitted to [**Hospital 794**] Hospital
for multiple AICD shocks on [**2178-12-6**], now transferred for repeat
VT-ablation.
.
At [**Hospital 794**] Hospital, he was started on amiodarone and lidocaine
drip, which decreased his heart rate. He then underwent a
right-sided catheterization, which showed muliple vessel disease
and had PCI to the LAD/LCx. The procedure was uncomplicated.
This morning, patient again went into sustained monomorphic
ventricular tachycardia. He was thus transferred to [**Hospital1 18**] for
repeat VT-ablation.
.
Patient reports that when he has VT, he experiences
palpitations, diaphoresis, and weakness. Recently, he had these
symptoms at the end of [**Month (only) **] and was hospitalized at [**Hospital **]
Hospital from [**10-19**] - 11/31, when he was treated with potassium
and plan was to consider upgrading his ICD to biventricular
pacing. He was discharged home and then had repeated symptoms on
[**10-6**].
.
Of note, patient had his ICD placed approximately 8 years ago,
but had recurrent VTs. He underwent VT ablation by Dr. [**Last Name (STitle) **]
in [**2172**] but continued to have VTs. He was then succesfully
medically managed with amiodarone for 3 years, but had to stop
due to hepatic toxicity. Since then, he has been shocked "more
than 50 times", including one episode where he had an induced
ICD firing, presumably for slow VT.
.
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.
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, or syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2179-10-7**] with 3 stents
placed to LAD and LCx.
- PACING/ICD: VT storm s/p AICD and ablation [**2179**] in [**Location (un) 86**]
- Cardiomyopathy, EF 20%
- Myocardial infarction in [**2154**]
3. OTHER PAST MEDICAL HISTORY:
- COPD
- Hypothyroidism
- Abdominal aortic aneurysm repair with stent
- Eczema
- Multiple hemorrhoidectomies
Social History:
Patient lives alone. He is independent for all ADLs, continues
to drive.
- Tobacco history: ~75 pack year history, quit 7 years ago
- ETOH: Occasional beer but used to drink heavily.
- Illicit drugs: None
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Extensive history of cancers.
Physical Exam:
Physical exam on discharge:
VS: <<<<<<<<<< >>>>>>>>>
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Soft heart sounds, RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4. ICD in left chest.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Right post-cath side
no hematoma, no bruits.
SKIN: eczematous changes in finger nails and elbows
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
1. Labs on admission:
[**2178-12-9**] 01:13AM BLOOD WBC-8.6 RBC-4.06* Hgb-12.3* Hct-35.5*
MCV-88 MCH-30.2 MCHC-34.6 RDW-13.5 Plt Ct-262
[**2178-12-9**] 01:13AM BLOOD PT-12.6 PTT-26.3 INR(PT)-1.1
[**2178-12-9**] 01:13AM BLOOD Glucose-104* UreaN-23* Creat-0.9 Na-135
K-4.2 Cl-101 HCO3-23 AnGap-15
[**2178-12-9**] 01:13AM BLOOD ALT-12 AST-22 LD(LDH)-224 AlkPhos-98
TotBili-0.5
[**2178-12-9**] 01:13AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.3 Mg-2.1
[**2178-12-9**] 01:13AM BLOOD TSH-0.11*
[**2178-12-9**] 01:13AM BLOOD Free T4-1.4
.
2. Labs on discharge:
<<<<<<<<<<<< >>>>>>>>>>
.
3. Imaging/diagnostics:
- Echocardiogram ([**2178-12-9**]): The left atrium is mildly dilated.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is moderate to
severe regional left ventricular systolic dysfunction with
near-akinesis of the distal [**11-23**] of the left ventricle and global
hypokinesis in the remaining segments. A left ventricular
mass/thrombus cannot be excluded. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion.
IMPRESSION: Dilated left ventricular cardiomyopathy with
near-akinesis of the distal [**11-23**] of the left ventricle and global
hypokinesis in the remaining segments. Mild mitral
regurgitation.
.
- CXR ([**2178-12-9**]):
Heart is moderately enlarged, but there is no pulmonary edema or
even vascular congestion and the hila are normal size. No
pleural effusion or evidence of central adenopathy. Lungs clear.
Transvenous right atrial pacer lead follows the expected course.
A transvenous right ventricular pacer defibrillator lead ends
closer to the midline than we generally see but cannot be more
carefully localized without a lateral view.
.
- CXR ([**2178-12-10**]):
ICD leads remain in standard position. Cardiomediastinal
contours are unchanged. Lungs and pleural surfaces are clear.
.
Brief Hospital Course:
73 yo M with recurrent ventricular tachycardia despite ablation
and AICD, cardiomyopathy, CAD s/p PCI, COPD, hypothyroidism,
treated with dofetilide and repeat VT-ablation.
.
# Ventricular tachycardia: Pt admitted for initiation of
dofetilide ggt which was maintained for 3 days eventually being
decreased to 250mcg q12h. However, on HOD 2 he developed VT
into the 140s, with sBP in the 110s-120s. Received lidocaine
bolus, placed on gtt, and ativan. Broke after 5 minutes and did
not require firing of ICD. He subsequently went for ventricular
substrate ablation the following day (see report). After the
procedure his antiarrhythmic therapy was changed to mexilitine
150mg q8h and quinidine was started at 324mg TID. Dofetalide
was d/c'd. Of note When arterial sheath was being pulled, he
became transiently hypotensive to 60s, got 1 amp of atropine and
recovered. He remained hemodynamically stable for the remainder
of admission, but was noted to have occasional runs of 20-40
beats of vtach during which he remained asymptomatic. He was
discharged on mexilitine 150 TID and quinidine 324mg TID.
.
# Fever: Febrile to 102 on admission. Influenza swabs sent, came
back positive. Patient remianed on droplet precautions. He
remained afebrile throughout admission.
.
# Cardiomyopathy: Repeat echocardiogram here confirmed EF of
25-30%, with severe regional left ventricular systolic
dysfunction, near-akinesis of distal [**11-23**] of the LV and global
hypokinesis. He diuresed well and remained euvolemic on home
dose 20 mg PO Lasix.
.
# CAD s/p stent: History of MI in [**2154**] with anteriolateral
distribution on EKG, consistent with catheterization finding of
LAD, LCX stenosis. Patient has been asymptomatic and cardiac
enzymes at OSH were not elevated. Underwent uncomplicated
catheterization with three stents placed in the LAD and LCX.
Discharged on aspirin and plavix.
.
# Hypothyroid: TSH low at 0.11 (0.14 at OSH) and T4 appropriate
at 1.4. Just started on new lower dose of levothyroxine 50 mcg
three days ago so do not expect TSH to change dramatically. Kept
on same dose.
.
# HTN: Currently normotensive on Carvedilol and Losartan.
Increased carvedilol to 6.25 [**Hospital1 **].
.
# HLD: Lipid panel at OSH showed good control on home medication
of Cholestipol. Held during admission as was non-formulary. To
be continued at discharge.
Medications on Admission:
-Synthroid 88mcg qd
-Carvedilol 3.125 mg [**Hospital1 **]
-Aspirin 325 mg qd
-Losartan 25 mg qd
-MAgnesium oxide 400mg [**Hospital1 **]
-Klonopin 1.0 mg qd
-Colestipol 1 mg [**Hospital1 **]
-Lasix 20 mg po daily
-Vitamin D
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
5. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
10. quinidine gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. cholestipol Sig: One (1) tab once a day.
13. Outpatient Lab Work
Check Chem-10 for [**2178-12-22**]. Please fax results to:
Dr. [**First Name (STitle) **] [**First Name (STitle) 49514**]: [**Telephone/Fax (1) 89952**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ventricular Arrythmia
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital because of a persistent fast
rhythm called ventricular tachycardia and because your ICD went
off multiple times. You had a procedure called an ablation and
the settings on your ICD/pacemaker were adjusted. You also had
new stents placed in the arteries supplying blood to your heart.
Because of this, YOU NEED TO TAKE PLAVIX EVERY DAY. DO NOT
STOP PLAVIX FOR ANY REASON UNTIL YOU SPEAK WITH YOUR
CARDIOLOGIST FIRST.
.
We made the following changes to your medications:
STARTED Plavix 75 mg once a day
STARTED Quinidine 324 mg 3 times a day
STARTED Mexiletine 150 mg three times a day
INCREASED Carvedilol to 6.25 mg [**Hospital1 **]
Please note your follow up appointments below with Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) 49514**]. We have also include a prescription for
bloodwork to be done [**2178-12-22**] with the results to be faxed to Dr.
[**Last Name (STitle) 49514**].
It was a pleasure taking care you during your hospital stay.
Followup Instructions:
Please make an appointment to see your PCP in the next [**11-22**]
weeks.
Cardiology appointment with Dr. [**First Name (STitle) **] [**First Name (STitle) 49514**]
[**2178-12-31**] at 2:15 PM
[**Street Address(2) 85853**], [**Location (un) 796**], RI
([**Telephone/Fax (1) 85855**]
Department: CARDIAC SERVICES
When: FRIDAY [**2179-1-1**] at 1 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"695.3",
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] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.34",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
10346, 10352
|
6467, 8833
|
328, 377
|
10451, 10451
|
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|
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|
405, 2351
|
4175, 4684
|
10466, 10578
|
2728, 2838
|
2373, 2425
|
2854, 3062
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,275
| 131,938
|
53864+53888+53889
|
Discharge summary
|
report+report+report
|
Admission Date: [**2105-4-30**] Discharge Date: [**2105-5-6**]
Service:
ADDENDUM: Prior to discharge the patient was ambulated. She
continued to desat to 89% on room air while ambulatory. It
was recommended that she be discharged home on 2 to 3 liters
of home oxygen. The patient's family continued to wish her
to go home. They will consider outpatient pulmonary rehab.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2105-5-6**] 01:24
T: [**2105-5-6**] 13:31
JOB#: [**Job Number 100501**]
Admission Date: [**2105-4-30**] Discharge Date: [**2105-5-6**]
Date of Birth: Sex: M
Service: ACOVE
ADMITTING DIAGNOSIS: Respiratory distress.
HISTORY OF PRESENT ILLNESS: Patient is an 83-year-old woman
who was previously admitted to the Medical Intensive Care
Unit in [**Month (only) 404**] for bilateral pneumonia that was complicated
by adult respiratory distress syndrome. Patient was
discharged to pulmonary rehabilitation on home 02 and did
well. She was discharged from rehabilitation and went home.
She continued to do well at home and followed up by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], her pulmonologist. At that time, she seemed to be
doing well. The week prior to admission the patient noted
that she was developing a cough and chest discomfort. She
then developed fevers to 101 and a cough productive of
sputum. She developed shortness of breath on minimal
exertion. Patient had previously taken gammaglobulin
monthly, but stopped taking this when her IgG levels remained
in the normal range off therapy.
Patient is status post splenectomy and has received
appropriate prophylaxis. Patient noted decreased po intake
in the two days prior to admission. She presented to her
primary care physician on the day of admission complaining of
shortness of breath with a respiratory rate in the 40s and an
oxygen saturation of 90% on room air. The patient proceeded
to the Emergency Department where she received a dose of
Ceftriaxone, azithromycin, as well as albuterol and Atrovent
nebulizers. At that time, her blood pressure was in the high
80s to low 90s. She was given one liter of normal saline and
her blood pressure increased to 110. Patient notes that her
grandson was [**Name2 (NI) **] approximately one week prior to her
admission with a cough and upper respiratory tract infection
symptoms.
PAST MEDICAL HISTORY:
1. Brain meningioma.
2. CLL in [**2094**], transformed to NHL, status post CHOP.
3. Hypogammaglobulinemia.
4. Colon cancer status post hemicolectomy (Stage 3, T3N1M0).
5. Motor vehicle accident, status post splenectomy.
6. SVC clot in [**2104**] in setting of indwelling central line.
7. Pneumonia complicated by adult respiratory distress
syndrome in [**2105-1-28**].
8. Ejection fraction greater than 60%, mild mitral
regurgitation and mild pulmonary hypertension on an
echocardiogram from [**2105-1-28**].
MEDICATIONS ON ADMISSION: Advair, aspirin, Vioxx, Fosamax.
Last pneumovax two to three years ago.
ALLERGIES: Morphine causes vomiting.
SOCIAL HISTORY: The patient is a nonsmoker, nondrinker. She
lives with her daughter.
PHYSICAL EXAM ON ADMISSION: The temperature is 101.7. Blood
pressure 103/44. Heart rate 103. Respiratory rate 26-35,
saturating 93% on two liters by nasal cannula. Patient is in
mild respiratory distress. She is using her accessory
muscles. Her skin is warm and dry. She has a surgical left
pupils. The mucous membranes are moist. There is no scleral
icterus. The jugular venous distention is 8-9 cm below the
[**Doctor Last Name **] angle. There is no lymphadenopathy in the head or
neck. The neck is supple. The heart is regular. S1, S2 are
normal. There is no murmurs, rubs or gallops. The lungs
have crackles at the bases, [**1-30**] of the way up the back. The
abdomen is soft, nontender, nondistended. Bowel sounds are
present. There is 1+ pitting edema of the extremities
bilaterally. There is no calf tenderness. She is alert.
LABORATORIES: The white blood cell count is 20.7, hematocrit
40.6, platelet count 460,000. Sodium 128, potassium 3.9,
chloride 98, bicarbonate 20, BUN 13, creatinine 0.5, glucose
92, EBV of 7.42/40/117 on four liters nasal cannula.
An electrocardiogram showed normal sinus rhythm at a rate of
95. There is left axis deviation. There are normal
intervals. There is a left atrial enlargement. There are no
ST-T wave changes.
Chest x-ray shows bilateral infiltrates in the lingula, left
lower lobe, right lower lobe with baseline in interstitial
pattern. There are no pleural effusions.
Blood cultures were drawn.
COURSE IN THE HOSPITAL: The patient was initially admitted
to the Medical Intensive Care Unit for treatment of her
pneumonia. Her course in the hospital will be discussed by
system:
1. Pulmonary: The patient was admitted for treatment of
pneumonia. Blood cultures as well as sputum cultures were
taken. These remained negative. Patient was treated with a
seven day course of levofloxacin as she defervesced and her
white cell count decreased. A pulmonary consult was obtained
as the patient's chest x-ray was suggestive of an
interstitial pulmonary process and possibly interstitial lung
disease. The patient had improved when she was started on
antibiotic, however, at the same time, she was also given a
few days of steroids to treat her adrenal insufficiency. It
was unclear which the patient had responded too. The
Pulmonary Service felt that the patient's CT scan of the chest
demonstrated a flocal infiltrate, esp. in the RML area,
superimposed on changes consistent with resolving ARDS. It was
decided not continue the patient on steroid treatments
at this time. The patient's outpatient pulmonologist, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], conferred on the plan and will consider CXR in one
month with CT chest follow up in [**3-31**] months.
2. Adrenal insufficiency: The patient was noted to be
adrenally insufficient. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stem test was performed. The
patient's cortisol went from 15 to 19. She was therefore
treated with 4 days of hydrocortisone. The patient will
require a follow-up [**Last Name (un) 104**] stem test in approximately four
weeks after discharge.
3. Hyponatremia: The patient was noted to be hyponatremic
on admission. This was felt to be secondary to decreased po
intake. Her FeNA was 0.1% suggestive of prerenal condition.
The patient was hydrated with resolution.
4. Cardiovascular: The patient was ruled out for myocardial
infarction with serial enzymes. She had no electrocardiogram
changes. Her chest pain was thought to be secondary to her
pulmonary process.
5. Left back pain: The patient complained of left back pain
while in the hospital. During a CT of her chest to assess
for lung disease, it was noted that she had nine rib
fractures on the left, as well as two rib fractures on the
right. Upon further questioning, the patient's family
noted that she fell at home one month prior to admission w/o
dizziness, CP, or head trauma. The patient was treated with
oxycodone but tolerated this poorly, then Ultram, Tylenol and
ibuprofen prn for her pain.
6. Hyperglycemia: The patient was put on a regular insulin
sliding scale while she was on steroids as her blood sugars
increased. The hyperglycemia resolved after steroids were
discontinued.
7. Hematology/Oncology: The patient has a history of CLL
and hypogammaglobulinemia. This was not an issue during her
stay in house.
8. Gastrointestinal: The patient was kept on a proton pump
inhibitor while in the hospital.
9. Osteoporosis: The patient was maintained on Fosamax
while in the hospital.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Adrenal insufficiency.
3. Hypotension.
4. Steroid induced diabetes.
5. Rib fractures.
6. History of pneumonia complicated by adult respiratory
distress syndrome in [**2105-1-28**].
7. History of brain meningioma.
8. History of CLL.
9. History of hypogammaglobulinemia.
10. History of colon carcinoma, status post hemicolectomy.
11. History of motor vehicle accident, status post
splenectomy.
12. History of SVC clot in [**2104**].
13. Ejection fraction greater than 60%, mild mitral
regurgitation, mild pulmonary hypertension in an
echocardiogram from [**2105**].
DISCHARGE MEDICATIONS:
1. Tylenol 325-650 mg po q. 4h prn.
2. Protonix 40 mg po q.d.
3. Aspirin 325 mg po q.d.
4. Ibuprofen 400 mg po q. 8h prn.
5. Oxycodone 5 mg po q. 3h prn.
6. Fosamax 70 mg po q. Tuesday.
7. Advair 2 puffs b.i.d.
DISCHARGE FOLLOW-UP: It was felt that the patient would
benefit from pulmonary rehabilitation prior to being
discharged home. However the patient's family wished her to
go direclty home. The patient was cleared by physiotherapy. She
will follow-up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
She will also continue to be followed by her outpatient
pulmonologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2105-5-6**] 01:17
T: [**2105-5-6**] 13:08
JOB#: [**Job Number 110550**]
Admission Date: [**2105-4-30**] Discharge Date: [**2105-5-7**]
Service: ACOVE
ADDENDUM: On the planned day of discharge, the patient
developed some nausea and vomiting. This was felt to be
secondary to oxycodone. The patient's pain regimen was
changed to Tylenol, ibuprofen, and Ultram as needed. The
patient tolerated this well, and her nausea and vomiting
subsided. The patient also developed some diarrhea on the
planned day of discharge. The diarrhea resolved within 24
hours. The patient's white blood cell count decreased from
16 to 12. The patient remained afebrile.
DISCHARGE DISPOSITION: The patient was discharged home with
her family without services.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Adrenal insufficiency.
3. Rib fractures.
4. Other admission diagnoses.
MEDICATIONS ON DISCHARGE:
1. Tylenol 325 mg to 650 mg p.o. q.4h. as needed.
2. Protonix 40 mg p.o. once per day.
3. Aspirin 325 mg p.o. once per day.
4. Ibuprofen 400 mg p.o. q.8h. as needed.
5. Fosamax 70 mg p.o. every Tuesday.
6. Advair 2 puffs b.i.d.
7. Ultram 50 mg p.o. q.4-6h. as needed.
8. Home oxygen 2 liters to 3 liters as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to continue to be followed by her primary
care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]).
2. The patient was also to follow up with her outpatient
pulmonologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]).
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2105-5-7**] 14:08
T: [**2105-5-7**] 14:12
JOB#: [**Job Number 110551**]
|
[
"251.8",
"807.09",
"255.4",
"515",
"486",
"E932.0",
"518.82",
"427.31",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.96"
] |
icd9pcs
|
[
[
[]
]
] |
10225, 10292
|
10313, 10406
|
8576, 10201
|
10432, 10756
|
3137, 3249
|
10789, 11374
|
884, 2570
|
3366, 7941
|
832, 855
|
2592, 3110
|
3266, 3351
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,538
| 198,510
|
13343
|
Discharge summary
|
report
|
Admission Date: [**2191-11-17**] Discharge Date: [**2191-11-21**]
Date of Birth: [**2110-3-23**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
dizziness, cardioversion X2
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 81 yom with h/o ischemic cardiomyopathy EF 15% s/p
BiV pacer in [**2185**] and h/o NSVT who presents with 4 days of
progressive lightheadedness and 2 episodes of ICD cardioversion.
He says dizziness begain 4 days PTA lasting 5-10 seconds, [**1-4**]
hrs apart. He thought it was due to coumadin and went to the
hospital Monday to have coumadin level checked. Sx continued
and on day of admission they were every few minutes happening
hundreds of times throughout the course of the day. He went to
[**Hospital6 **] where he underwent CT head and
carotid u/s which were unremarkable. He was monitored on
telemetry where he had no abnormal events, despite "hundreds" of
episodes of light headedness. He was discharged at 4pm. At
4:15, he was in the car with his wife where he again felt light
headed and felt an "explosion in his chest", continued to feel
dizzy and felt a second "explosion". He had no syncopal events.
He returned to the ED vs were 180/89 156 18 97RA and was
noted to be in NSVT. ECG showed demand pacing with multiple
PVCS. Rightward Axis. LBBB qith QRS of 190. Another ECG
showed 6 beat NSVT. Per preliminary interrogation reqport:142
FVT/ VTs since 2 pm today. Had some failed ATP- most successful,
atleast 2 shocks on rhythms > 185. He was started on amio bolus
of 150mg and started on 1mg/kg at 5:30pm. He was transferred to
[**Hospital1 18**] shortly afterwards.
On arrival, pt was hemodynamically stable. He was alert,
oriented, and responding to questions. Vital signs were 97.8
120/50 82 18 95%RA. ECG again showed significant ectopy. No
ischemic changes.
Of note, pt is generally quite active with daily exercise
routine and many hobbies. ICD was last interrogated [**2191-5-2**]
which showed multiple episodes of NSVT. Per Dr.[**Name (NI) 1565**]
note, he was on amiodarone at that time. Unclear for what
duration he was continued on amio.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- S/P BiV ICD placement in [**2185**]([**Company 1543**] [**First Name9 (NamePattern2) **] [**Last Name (un) 24119**] device
placed with epicardial LV lead given poor intracardiac coronary
sinus anatomy), s/p generator change in [**2188**]
- Ischemic Cardiomyopathy with an EF of 15%
- NSVT
-Atrial fibrillation
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**2166**]: PTCA of RCA,
[**2169**]: cath-no critical disease,
[**2176**]:stent x 2 to OM, [**2177**]: s/p cath OM stents occluded,
[**8-/2184**]: s/p IMI s/p two stents to RCA (3.0 x 13 mm Velocity
Hepacoat stent proximally placed and a 3.0 x 28 mm Bx Velocity
Hepacoat stent to the mid vessel),
[**2185**]: s/p cath no critical disease,
[**2190**]: s/p cath no intervenable dz, diffusely diseased LMain and
LCx
-PACING/ICD: S/P BiV ICD placement [**2185**] with epicardial lead
placement via left anterior thoracotomy, generator change in
[**2188**]
3. OTHER PAST MEDICAL HISTORY:
Anxiety
Arthritis
Neuropathy
Social History:
He has been married for 55 years and lives on the [**Location (un) **]. He
has two daughters and one son. His son is currently battling
non-[**Name (NI) **]??????s lymphoma. He does not smoke or drink alcohol. He
is a retired sheriff. His three children are his proxys.
Family History:
His mother died at age 72 of a heart attack.
Physical Exam:
VS: 97.8 120/50 82 18 95%RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI displaced laterally. 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, bibasilar rales.
No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ PT 2+
Left: Carotid 2+ Femoral 2+ PT 2+
Pertinent Results:
ADMSSION LABS [**2191-11-17**]:
[**2191-11-17**] 08:43PM WBC-10.6# Hgb-14.0 Hct-41.2 Plt Ct-245
[**2191-11-17**] 08:43PM Neuts-72.4* Lymphs-21.7 Monos-2.7 Eos-2.8
Baso-0.3
[**2191-11-17**] 08:43PM PT-22.1* PTT-30.0 INR(PT)-2.1*
[**2191-11-17**] 08:43PM Glucose-152* UreaN-29* Creat-1.6* Na-140 K-4.0
Cl-107 HCO3-24 AnGap-13
[**2191-11-17**] 08:43PM ALT-21 AST-28 CK(CPK)-125 AlkPhos-36*
TotBili-0.7
[**2191-11-17**] 08:43PM CK-MB-5 cTropnT-0.05* proBNP-1797*
[**2191-11-17**] 08:43PM Calcium-9.3 Phos-2.6* Mg-2.0
[**2191-11-17**] 08:43PM TSH-3.8
[**2191-11-17**] 08:43PM Digoxin-0.7*
STUDIES:
[**2191-11-17**] CXR:
There is no pulmonary edema. Heart is top normal size, no
pleural effusion is present. The transvenous right atrial pacer
and right ventricular pacer
defibrillator lead are in standard placements. A percutaneous
pair of
epicardial leads is present, but there connections are unclear
[**2191-11-18**] ECHO:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is severe global left ventricular hypokinesis (LVEF = 20
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion.
There is marked postextrasystolic augmentation of left
ventricular ejection fraction andf stroke volume, indicating the
presence of significant myocardial contractile reserve.
DISCHARGE LABS [**2191-11-21**]:
[**2191-11-21**] 05:52AM WBC-9.9 Hgb-13.6* Hct-40.4 Plt Ct-225
[**2191-11-21**] 05:52AM PT-26.9* PTT-31.2 INR(PT)-2.6*
[**2191-11-21**] 05:52AM Glucose-113* UreaN-31* Creat-2.0* Na-140 K-4.4
Cl-105 HCO3-28 AnGap-11
[**2191-11-21**] 05:52AM Calcium-8.6 Phos-2.6* Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname **] is an 81 year old man with h/o of ischemic heart
disease, and CMY EF 15% with BiV pacer and ICD, p/w VT storm.
# CORONARIES: H/o ischemic disease with multiple stents. No
revascularabile disease as of [**2190-12-2**]. Pt not having ischemic
sx currently or recently. Pt was kept on ASA, BB, Lipitor. ACEi
was held [**1-3**] to renal failure - can be restarted as an
outpatient.
# PUMP: Pt has h/o generally well controlled cardiomyopathy.
He appeared to be mildly volume overloaded based on pulmonary
edema, but not requiring oxygen. He was diuresed gently with IV
Lasix and will be discharged on home dose of Lasix 20mg PO
daily.
# RHYTHM: The patient was admitted with VT storm, s/p
defibrillation by his ICD x2. He had ectopy on arrival, which
decreased with Amiodarone. He was bolused with Amio 150mg and
started on a drip, then transitioned to PO for Amio loading. He
will be discharged on Amio taper: 400mg PO TID x 4 days, 400mg
PO BID x 7 days, 400mg PO daily x 7 days, 200mg PO daily
ongoing. He should also continue his beta blocker and warfarin
for underlying atrial fibrillation. Warfarin was decreased to 4
mg daily, as his INR increased to 2.6 during hospitalization,
likely interaction with Amiodarone. Digoxin was decreased to
every other day dosing [**1-3**] to renal failure. TSH and LFTs were
WNL. Pt should have TFTs, LFTs, and PFTs followed up as an
outpatient as he has been started on Amiodarone.
# ACUTE ON CHRONIC RENAL FAILURE: Pt has a baseline creatinine
of 1.6, increased to 2.3 during hospitalization. Urine lytes
consistent with prerenal etiology, likely [**1-3**] to poor forward
flow. The patient's Cr improved to 2.0 with gentle diuresis. He
will be discharged on his home dose of Lasix and should have his
creatinine followed up in [**1-4**] days. ACEi and Digoxin were held
[**1-3**] to ARF: ACEi can be restarted as an outpatient after Cr is
followed up. Digoxin was restarted on discharge at lower dose.
# Htn: BP well controlled during hospitalization. Continued BB.
ACEi can be restarted as outpatient.
# DM - Pt had well controlled sugars while hospitalization on
insulin sliding scale. Will be discharged on home dose of
glyburide.
Medications on Admission:
ASA 81
Carvedilol 12.5mg [**Hospital1 **]
Digoxin 0.125 daily
Tricor 145mg daily
Nexium 40mg daily
Ascorbic Acid 500mg daily
Lasix 20mg daily
Glyburide 1.25mg daily
Lisinopril 5mg evening
Coumadin 5mg evening
Remeron 30mg qhs
Lipitor 10mg qhs
Tylenol 1gm qhs
Lorazepam 1-2mg qhs
Xanex 0.5mg q6h prn
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
3. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Ascorbic Acid 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
9. Remeron 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO at bedtime.
11. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
12. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*0*
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO see
instructions below: please take 2 tablets three times a day for
4 days, then 2 tablets twice daily for 7 days, then 2 tablets
once daily for 7 days, then 1 tablet once daily ongoing.
Disp:*100 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Please have your creatinine and INR checked in [**1-4**] days. Please
call results to your primary care doctor, Dr. [**Last Name (STitle) **] Phone:
[**Telephone/Fax (1) 29822**]. Fax: [**Telephone/Fax (1) 40589**]
15. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
at bedtime.
16. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Association
Discharge Diagnosis:
Primary Diagnosis:
Ventricular Tachycardia storm
acute on chronic renal insufficiency
Secondary Diagnosis:
chronic systolic congestive heart failure s/p ICD placement
Discharge Condition:
hemodynamically stable, alert and oriented x 3
in normal sinus rhythm
Discharge Instructions:
Mr. [**Known lastname **],
You were admitted to the hospital with an abnormal heart rhythm
called ventricular tachycardia, causing your ICD device to shock
you into a normal rhythm repeatedly. We treated you with a
medication called amiodarone, that should prevent you from going
into ventricular tachycardia in the future. For the duration of
your stay in the hospital, your heart rhythm remained normal.
While you were in the hospital we also noticed that your kidney
function had deteriorated from it's baseline. We watched your
kidney function carefully and stopped your lisinopril, a
medication that can sometimes harm the kidneys. By the time of
discharge, your kidneys were improving, but they will need to be
followed by your physician.
The medication amiodarone interacts with some of the other
medications that you take. Most importantly, amiodarone can
interfere with your blood thinning medication, coumadin. As a
result we have decreased your dose of coumadin to 4 mg and your
INR will need to be watched carefully by your outpatient
physician in the future. In addition, your primary care doctor
should follow your thyroid, lung and liver function tests while
on this medication.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please make the following changes to your medication regimen:
1. Decrease your dose of tricor from 145mg daily to
2. Please decrease your dose of digoxin from 1 pill every day to
1 pill every other day
3. Please decrease your dose of coumadin to 4 mg daily
4. Please stop your lisinopril. Ask your primary care
physician about restarting this medication once your kidney
function has improved
4. Please continue to take amiodarone according to the
following schedule
- take 400 mg (2 pills of 200mg) three times daily for 4 more
days
- take 400 mg (2 pills of 200mg) twice daily for one week
- take 400 mg (2 pills of 200mg) once daily for one week
- take 200 mg once daily ongoing
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
within 1-2 weeks. The office should contact you with an
appointment time, but please call [**Telephone/Fax (1) 29822**] if you do not
hear from from them by Wednesday.
Please follow up with your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at
1:00pm on [**2191-12-14**]. Call ([**Telephone/Fax (1) 32215**] with any questions.
Please follow up with the device clinc for your regular
semi-annual appointment in [**2192-1-30**]. Call ([**Telephone/Fax (1) 8793**] to
schedule an appointment
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
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|
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73,375
| 150,561
|
46544
|
Discharge summary
|
report
|
Admission Date: [**2137-1-28**] Discharge Date: [**2137-2-11**]
Date of Birth: [**2053-3-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ceftriaxone / Opioids-Morphine & Related / Amlodipine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain and dyspnea with minimal exertion
Major Surgical or Invasive Procedure:
[**2137-2-1**]
Aortic valve replacement with a 25-mm Mosaic tissue valve.
Aortic root enlargement with bovine pericardial patch.
Coronary artery bypass grafting x3(LIMA-LAD,SVG-OM1,SVG-LPDA)
History of Present Illness:
This 83 year old male with documented aortic stenosis and
coronary disease. he was scheduled for elective surgery . Hehad
continued angina despite nitrates and was admitted to the [**Hospital1 1516**]
service for this. He reports that he has been having
progressively worsening exertional chest pain and SOB for
several months. He first noted the symptoms prior to his cath in
10/[**2136**]. On [**Holiday **] eve he had an episode of pain at rest,
which prompted him to seek further intervention.
Past Medical History:
Coronary artery disease
Aortic Stenosis
Renal artery stenosis (Genesis stent placed [**8-/2128**])
Renal insufficiency (baseline creatine= 1.7-1.9)
Hypertension
Hyperlipidemia
Diabetes Mellitus
Gastroesophageal reflux disease
Gout
Benign Prostatic Hypertrophy
S/p Bladder Cancer [**2129**]
s/p Sigmoidectomy [**2117**]
s/p Right knee replacement [**2134**]
s/p Bilateral Cataracts
s/p Tonsillectomy as a child
Social History:
Race:caucasian
Last Dental Exam:1 month ago\
Lives with:lives in a retirement community, his wife is in a
nursing home with [**Name (NI) 11964**]
Occupation:retired pharmacist
Tobacco:quit 45 years ago, history of smoking 2-3ppd x23 years
ETOH:denies
Family History:
non-contributory
Physical Exam:
Admission:
Pulse:51 Resp:16 O2 sat:100/RA
B/P Right:170/51 Left:167/58
Height:5'8" Weight:200 lbs
General: Pleasant elderly male in no acute distress. Lying
supine, post cardiac cath.
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] - teeth in fair condition
Neck: Supple [x] Full ROM [x] - no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema trace
Varicosities: None [x]
Neuro: alert and oriented x3. CN 2-12 grossly intact, 5/5
strength, no focal deficits noted
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit: soft transmitted murmurs noted bilaterally
Pertinent Results:
[**2137-2-1**] Echo: 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. Left ventricular wall
thicknesses and cavity size are normal. Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Mild to moderate ([**1-13**]+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion.
[**2137-2-11**] 04:14AM BLOOD WBC-5.6 RBC-3.40* Hgb-10.1* Hct-29.9*
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.5 Plt Ct-234
[**2137-2-10**] 04:12AM BLOOD WBC-5.7 RBC-3.35* Hgb-10.0* Hct-29.4*
MCV-88 MCH-29.7 MCHC-33.9 RDW-14.7 Plt Ct-215
[**2137-1-28**] 12:05AM BLOOD WBC-4.4 RBC-3.51* Hgb-10.7* Hct-30.8*
MCV-88 MCH-30.5 MCHC-34.8 RDW-14.9 Plt Ct-145*
[**2137-2-11**] 04:14AM BLOOD PT-26.2* INR(PT)-2.5*
[**2137-2-10**] 04:12AM BLOOD PT-27.7* INR(PT)-2.7*
[**2137-2-9**] 01:45PM BLOOD PT-32.6* INR(PT)-3.3*
[**2137-2-9**] 06:36AM BLOOD PT-31.8* PTT-34.1 INR(PT)-3.2*
[**2137-2-8**] 06:01AM BLOOD PT-19.3* PTT-28.6 INR(PT)-1.8*
[**2137-2-7**] 11:50AM BLOOD PT-12.7 PTT-25.4 INR(PT)-1.1
[**2137-2-11**] 04:14AM BLOOD UreaN-72* Creat-2.7* Na-139 K-4.0 Cl-98
[**2137-2-10**] 04:12AM BLOOD UreaN-72* Creat-2.7* Na-141 K-3.7 Cl-99
[**2137-2-9**] 06:36AM BLOOD Glucose-132* UreaN-72* Creat-2.7* Na-144
K-3.6 Cl-103 HCO3-29 AnGap-16
[**2137-2-5**] 04:59AM BLOOD Glucose-137* UreaN-49* Creat-2.4* Na-140
K-4.3 Cl-106
[**2137-2-4**] 02:27AM BLOOD Glucose-111* UreaN-46* Creat-2.9* Na-139
K-4.3 Cl-104 HCO3-27 AnGap-12
[**2137-1-31**] 06:00AM BLOOD Glucose-128* UreaN-50* Creat-2.3* Na-141
K-4.9 Cl-106 HCO3-25 AnGap-15
[**2137-1-28**] 12:05AM BLOOD Glucose-119* UreaN-46* Creat-2.2* Na-137
K-5.0 Cl-107 HCO3-20* AnGap-15
Brief Hospital Course:
His chest CT on a previous admission showed a 14 x 9 mm ground
glass nodule in the right lower lobe. Thoracic Surgery was
consulted regarding the lung nodule and recommended follow up in
several months with no need to delay surgery now. Following
several days of optimal medical management, he was brought to
the Operating Room on [**2137-2-1**] where he underwent an aortic valve
replacement and coronary artery bypass graft. Please see
operative note for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition on Neo Synephrine, Epinephrine
and Propofol infusions. He was seen by the renal service for
his renal insufficiency. Pressors wer eweaned to off and he was
extubated on POD #3, and gently diuresed toward his preop
weight. Chest tubes and pacing wires removed per protocol.
He transferred to the floor on POD #4 to begin increasing his
activity level. Electrophysiology was consulted for postop
atrial fibrillation with conversion pauses. Amiodarone was
stopped per theri recommendation. Coumadin was started on POD
#6. Metolazone was added on POD #7 to facilitate diuresis. His
renal numbers remained stable for days and at discharge the
Lasix was changed to an oral form for an additional week of
diuresis. The gola INR is 2-2.5 for atrial dysrhythmia and will
be managed by the rehabilitation facility. He was discharged to
[**Hospital 98844**] Rehab on [**2137-12-11**].
Appointments for follow up were made as appropriate.
Medications at discharge were as noted.
Medications on Admission:
Valsartan 320 mg by mouth daily
Aspirin 162 mg PO daily
Simvastatin 20 mg PO daily
Metoprolol succinate 25 mg PO daily
Isosorbide mononitrate 30 mg PO TID
Tamsulosin 0.4 mg PO QHS
Lantus 30 units SC QHS
Humalog [**7-21**] at breakfast, [**9-24**] at lunch, [**10-24**] at dinner
Amoxicillin 500 mg PO TID (chronic suppression for prosthetic
joint)
Allopurinol 100 mg PO daily
Trazodone 50 mg PO QHS PRN insomnia
Esomeprazole 40 mg PO daily
Peri-Colace (8.6/50 mg) 1 tab PO QHS PRN constipation
Miralax 17 gram PO daily
Multivitamin 1 tab PO daily
Discharge Medications:
1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) 17
gm dose PO DAILY (Daily).
3. simvastatin 40 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day) for 1 months.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. metolazone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 7 days: 1/2 hour before Lasix dose.
7. Lopressor 50 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO three times a day.
8. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
9. warfarin 1 mg Tablet [**Last Name (STitle) **]: as directed Tablet PO Once Daily at
4 PM: Goal INR 2-2.5.
10. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Lasix 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for 7
days.
12. allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. amoxicillin 500 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO three
times a day.
14. insulin glargine 100 unit/mL (3 mL) Insulin Pen [**Last Name (STitle) **]: Thirty
(30) units Subcutaneous HS.
15. Humalog KwikPen 100 unit/mL Insulin Pen [**Last Name (STitle) **]: as directed
Subcutaneous AC & HS: 120-160:4units SQ AC only//
161-200:6units SQ AC,4units HS//
201-240:8units AC,6units HS//
241-280:10units AC,8units HS//.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Coronary artery disease
Aortic Stenosis
s/p Coronary artery bypass graft x 3 and Aortic Valve
replacement
paroxysmal atrial fibrillation
Renal artery stenosis (Genesis stent placed [**8-/2128**])
chronic Renal insufficiency (baseline creatine= 1.7-1.9)
Hypertension
Hyperlipidemia
insulin dependent Diabetes Mellitus
Gastroesophageal reflux disease
Gout
Benign Prostatic Hypertrophy
S/p Bladder Cancer [**2129**]
s/p Sigmoidectomy [**2117**]
s/p Right knee replacement [**2134**]
s/p Bilateral Cataract extraction
s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right and Left - healing well, no erythema or drainage.
Edema:trace. Minor skin tears legs and chest from tape
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication postop A Fib
Goal INR 2.0-2.5
First draw .................
Results to phone fax ..............
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2-28**] at 1:15 PM
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 34547**] on [**2-26**] at 10:45 AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 71192**] in [**4-16**] 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 postop A Fib
Goal INR 2.0-2.5
First draw : [**2-12**]
Completed by:[**2137-2-11**]
|
[
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"V58.67",
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"274.9",
"428.0",
"250.00",
"414.01",
"530.81",
"276.7",
"518.89",
"428.31",
"584.5",
"287.5",
"416.8",
"V43.65",
"427.31",
"272.4",
"585.3",
"424.1",
"403.90",
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icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.12",
"38.93",
"38.14",
"39.61",
"00.40",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8687, 8717
|
4734, 6281
|
364, 557
|
9293, 9573
|
2704, 4711
|
10641, 11347
|
1803, 1821
|
6878, 8664
|
8738, 9272
|
6307, 6855
|
9597, 10618
|
1836, 2685
|
280, 326
|
585, 1086
|
1108, 1519
|
1535, 1787
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,392
| 182,760
|
6692
|
Discharge summary
|
report
|
Admission Date: [**2196-11-18**] Discharge Date: [**2196-11-27**]
Date of Birth: [**2116-3-28**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Darvocet-N 100
Attending:[**First Name3 (LF) 6578**]
Chief Complaint:
progessive mental status change
Major Surgical or Invasive Procedure:
burr hole procedure, chest tube.
History of Present Illness:
Pt is a 80 yo female w/ PMhx sig for ESRD on HD, DM II, HTN, PAF
on coumadin who p/w decline in mental status for ~ 2 weeks. Pt
accompanied to ED by son who provided majority of history. Pt
is a nursing home resident and 1 month ago she fell backwards
striking the left posterior aspect of her head on a sink. She
did not lose consciousness with this event. Over the last two
weeks she has had personality change, increased lethargy, and
agitation. Apparently, at baseline she reads the newspaper
everyday and is very alert, pleasant, and conversant. Due to
concerns for her continued decline, she was brought to an OSH
where she was found to have multiple SDH and subsequently
transferred to [**Hospital1 18**] for further management.
Past Medical History:
DM II,
ESRD on HD,
HTN,
h/o epidural abscess,
h/o vertebral osteomyelitis and diskitis,
CHF, EF 25% in [**2189**] but 55% in [**2193**]
no CAD from cath in [**2189**]
Social History:
Lives in nursing home.
non smoker, no ETOH, no IVDU. Son visits regularly.
Family History:
non contributory
Physical Exam:
Vitals: T 98.6; BP 159/76; P ; RR 20; O2sat 98 4L
.
General: lying in bed, anxious appearing
HEENT: NCAT, dry mmm
Neck: supple
Pulmonary: CTA b/l
Cardiac: irreg irreg, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurologic:
Mental status: alert, and oriented to hospital, month, year -
4005. Unable to say MOYB. Fluent speech. Adequate
comprehension. Shows left thumb. Repetition intact. Registers
[**2-25**], Recalls 0/3 at five minutes. No right/left mismatch.
[**Location (un) **] intact. No apraxias/neglect.
.
Cranial Nerves:
I: Not tested
II: Visual fields full. PERRL, 4-->2mm with light. Optic discs
sharp.
III, IV, VI: EOMI, fatiguable end gaze nystagmus b/l
V, VII: facial sensation intact, face strength intact
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk. Normal tone
.
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF
RT: 5 4+ 5 5 5 5 4+ 5 5 5 5 5
LEFT: 5 5 5 5 5 5 5 5 5 5 5 5
.
Sensation: Decreased proprioception/vibration in feet b/l.
Intact to light touch, pinprick. No extinction to double
simultaneous stimulation.
.
Reflexes: Bicep T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally.
.
Coordination: FNF intact.
.
Gait: not tested
Pertinent Results:
[**2196-11-18**] 09:00PM PT-17.3* PTT-30.6 INR(PT)-2.1
[**2196-11-18**] 04:00PM GLUCOSE-157* UREA N-25* CREAT-4.3* SODIUM-139
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16
[**2196-11-18**] 04:00PM WBC-5.3 RBC-4.16* HGB-12.5 HCT-37.9 MCV-91#
MCH-29.9# MCHC-32.9 RDW-15.9*
[**2196-11-18**] 04:00PM ALBUMIN-3.7
[**2196-11-18**] 04:00PM PLT COUNT-105* LPLT-1+
[**2196-11-18**] 04:00PM NEUTS-81.1* LYMPHS-11.8* MONOS-4.4 EOS-2.3
BASOS-0.4
[**2196-11-18**] 04:00PM PT-18.8* PTT-29.7 INR(PT)-2.5
HEAD CT [**2196-11-18**]
Several multicompartmental chornic subdural collections are seen
surrounding the right cerebral hemisphere. Adjacent to the right
temporal [**Doctor Last Name 534**], a focus of hyperdensity may indicate an acute
component. Additionally, an old chronic subdural hematoma is
seen in the left parietal region. There is mass effect on the
right lateral ventricle, and shift of the central septum
pellucidum to the left, by 9 mm indicating subfalcine
herniation. The normal fourth ventricle is not clearly seen,
concerning for inferior herniation. The basilar cisterns are
preserved. The surrounding soft tissue and osseous structures
are unremarkable.
HEAD CT [**2196-11-20**];POST-OP
Interval decrease in the subdural collection adjacent to the
right temporal region. Markedly decreased mass effect on the
right temproal lobe. The remaining extra- axial collections and
the brain parenchyma are unchanged. No new areas of hemorrhage
are identified.
Brief Hospital Course:
80 year old-female presented to ER with progresive mental status
decline after sustainign a fall at the nursing home a month ago.
Patient admitted to Neuro ICU for close monitoring. Pateint's
INR 2.5 reversed with Vitamin K, FFP. Pateint received 1000mg of
dilantin then continued with maintanence dose. Patient taken to
OR on [**2196-11-19**] electively for a right sided burr hole for
subdural hematoma, acute on chronic, right greater than left,
with right to left midline shift. She underwent general
endotracheal anesthesia by the anesthesia team. The patient was
hemodynamically stable on induction. Of note, the patient is
post hemodialysis the day of surgery. She taken ot the operating
room with corrected coagulations of INR of 1.3, but a PTT of 77
for which she received 2 units of FFP intraoperatively. There
were no intraoperative complications, and the blood loss was
minimal. Post operatively INR goal is less then 1.4. Serial Head
CT remained stable.
Patient has been followed by renal service, continues to have
her hemodialysis regularly. Breast service consulted for right
breast "peau d'orange" on physical exam to evaluate.Her last
mammograms were from [**2189**], [**2181**] has been normal.
-----
After transfer to the floor, pt was found to be unresponsive by
nursing. Asystole on monitor. She expired on [**2196-11-26**].
Discharge Disposition:
Expired
Discharge Diagnosis:
subdural hematoma
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2196-11-27**]
|
[
"427.31",
"852.21",
"250.00",
"294.8",
"512.8",
"434.11",
"585.6",
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"217",
"276.0",
"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"34.04",
"39.95",
"01.31",
"34.91",
"99.60",
"38.93",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5832, 5841
|
4457, 5809
|
320, 354
|
5902, 5911
|
2948, 4434
|
5967, 6006
|
1425, 1443
|
5862, 5881
|
5935, 5944
|
1458, 1737
|
249, 282
|
382, 1125
|
2051, 2929
|
1752, 2035
|
1147, 1315
|
1331, 1409
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,743
| 102,439
|
23727
|
Discharge summary
|
report
|
Admission Date: [**2134-4-6**] Discharge Date: [**2134-6-4**]
Date of Birth: [**2071-1-2**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
Thoracentesis
Sub-clavian central line placement
Intubation
R radial Arterial line placement
History of Present Illness:
HPI:
The patient is a 63 yoF w/ h/o Type II DM, HTN presents from OSH
w/ abd pain, N/V/D. Her symptoms started w/ nausea while eating
dinner at ~ 8 p.m, associated w/ diaphoresis. She vomited
several times(non-bilious, non-bloody) then developed severe,
constant diffuse abdominal pain, radiating to back. She then
developed diarrhea, ~ 5 episodes loose, no BRBPR or melena. She
presented to [**Hospital3 **] where an Abd CT c/w acute
pancreatitis w/ lipase >80K and amylase 789. No recent travel,
no recent viral illnesses/URI symptoms. No h/o prior similar
symptoms; no h/o GB disease
*
In ED T 98.2, HR 99, bp 160/96. resp 20, 94% 2L.
Past Medical History:
PMHx
1) HTN
2) Type II DM: controlled w/ diet and exercise
3) Rosacea
4) s/p tonsillectomy
5) TAH: for cervical cancer
Social History:
SHx: Lives alone, no tobacco use, (+) EtOH (2 glasses of wine
several times a week), no other drug use. Works/volunteers w/
homeless. Has two sons [**Name (NI) 449**] and [**Name (NI) **] who are both very
involved in her care.
Family History:
FHx: uterine/cervical cancer on Father's side, breast cancer on
mother's side. F MI [**84**] yrs
Physical Exam:
T 98.2, HR 99, bp 160/96. resp 20, 94% 2L.
Gen: Pleasant obese female laying in bed. NAD
HEENT: no icterus
JVP: not elevated
CV: tachycardic, nml S1,S2 no m/r/g
Lungs: Bibasilar crackles
Abdomen: decreased bowel sounds. equisite diffuse tenderness
with rebound present.
Extremities: 2+ DPP with no edema
Neuro: A&O x 3. pleasant conversant, able to obey commands,
appropriate.
Pertinent Results:
*
Brief Hospital Course:
As above, Ms [**Known lastname 60613**] presented to [**Hospital1 18**] on [**4-6**] from OSH for
evaluation/treatment of severe acute pancreatitis of unknown
etiology. It was evident that she was quite sick, and she was
admitted to the ICU for close monitoring. Aggressive fluid
resuscitation was intiated as central and arterial lines were
placed. She began to experience respiratory distress and
required intubation with ventilatory support. A post-pyloric
feeding tube was placed and she was started on tubefeeds. TPN
was initiated, as well. CT demonstrated severe necrotizing
pancreatitis, in addition to multiple pulmonary nodules
worrrisome for metastatic disease. She was started on imipenem
for prolphylaxis to prevent infected necrotizing pancreatitis.
Ms. [**Known lastname 60613**] remained in the ICU for several weeks requiring
ventilatory support, and fluid resuscitation to prevent
worsening of her pancreatitic necrosis. She experienced
frequent loosse stools and C. Diff cultures returned positive
and she was started on flagyl. Repeat CT scans revealed the
development of a giant pseudocyst. She eventually was weaned
from ventilatory support and extubated, which she tolerated
well. She developed a biliary stricture and on [**5-4**], she
[**Month/Year (2) 1834**] a PTC with internal/external biliary catheter
placement, which seemed to relieve her obstruction well. She
was eventually transferred to the floor in stable condition. On
[**2134-5-18**], Ms. [**Known lastname 60613**] [**Last Name (Titles) 1834**] open drainage of her giant
pancreatic pseudocyst with gostostomy tube placement and
jejunosotmy tube placement (see Op Note), which she tolerated
reasonably well. After recovery in the PACU, she was
transferred to the floor in stable condition. She would remain
stable post-operatively. Physical began to help her out of bed
and ambulate. It should be noted that her ability to ambulate
has progressed slowly, and she will continue to need extensive
physical therapy in rehab. Her bowel function was slow to
return and she again was started on TPN. Eventually tubefeeds
were started and advanced to goal. She began to experience fever
with a rising WBC and repeat CT revealed an abscess in the left
paracolic gutter; on [**5-27**], the abscess was subsequently drained
by IR and pigtail catheter was placed for further drainage. Ms
[**Known lastname 60613**] would continue to remain stable, and progress slowly from
this serious illness that she has suffered. She was advanced to
a regular diet, which she has tolerated well. Her tubefeed were
cycled, then stopped. She has continued to have loose stools,
but repeat C. diff cultures are negative x 3. On [**6-4**], she was
discharged to rehab in stable condition for extended care.
Medications on Admission:
Meds: no herbal medications.
1) Accupril 20 mg PO daily
2) Folic acid
3) MV1
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Elixir Sig: Six [**Age over 90 1230**]y (650)
mg PO Q4-6H (every 4 to 6 hours) as needed for fever or pain.
2. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) UNITS
Subcutaneous HS (at bedtime).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
9. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash on buttocks.
12. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
16. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
17. Insulin Regular Human Injection
18. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
21. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Acute necrotizing pancreatitis
Giant Pancreatic pseudocyst
C. diff colitis
Biliary stricture
Discharge Condition:
Stable
Discharge Instructions:
Please return to the emergency room if you experience severe
abdominal pain, nausea vomiting, severe fever or chills, chest
pain or shortness of breath.
Followup Instructions:
Please follow up CT lung nodules with repeat scan
Follow up with Dr. [**Last Name (STitle) **] in [**2-11**] weeks after your discharge
from the hospital
|
[
"452",
"569.5",
"799.0",
"518.89",
"285.9",
"041.04",
"576.2",
"572.3",
"V10.41",
"552.1",
"276.0",
"599.0",
"577.0",
"568.0",
"250.00",
"401.9",
"518.0",
"518.81",
"E878.8",
"577.2",
"695.3",
"511.9",
"996.69",
"008.45",
"537.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.01",
"99.15",
"54.59",
"38.93",
"46.39",
"43.19",
"53.49",
"87.51",
"52.09",
"51.10",
"38.91",
"51.98",
"34.91",
"54.91",
"96.6",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7001, 7071
|
2010, 4803
|
303, 398
|
7208, 7216
|
1984, 1987
|
7417, 7575
|
1472, 1571
|
4931, 6978
|
7092, 7187
|
4829, 4908
|
7240, 7394
|
1586, 1965
|
228, 265
|
426, 1066
|
1088, 1210
|
1226, 1456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,477
| 157,596
|
12777
|
Discharge summary
|
report
|
Admission Date: [**2158-11-9**] Discharge Date: [**2158-11-15**]
Date of Birth: [**2081-4-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Diltiazem
Attending:[**Doctor First Name 1402**]
Chief Complaint:
bradycardia and hypotension
Major Surgical or Invasive Procedure:
Endo-tracheal intubation
Central line placement
History of Present Illness:
77m with HTN, paroxysmal afib, CHF with lvh and preserved EF,
PUD presented to VA urgent care on [**11-9**] with three days of
increasing dyspnea on exertion, orthopnea, and LE edema, with no
chest discomfort or palpitations. He was found there to be
afebrile with bp 115/72, hr 130, rr 20, and spo2 97%ra; his
lungs had bibasilar rales, and his periphery showed 1+ edema.
His ECG showed afib and flutter with pvc's, and a CXR showed
CHF. He was given diltiazem 20mg IV once, prompting a transition
to a-flutter in the 80's, with his bp dropping to 60's-70's. He
was given NS and then a dopamine drip. He became minimally
responsive so was intubated. On dopamine, his bp came up to the
120's and hr back up to the 130's, and he was transferred for
further management. In [**Hospital1 18**] ED, he was given calcium and
glucagon with little response, remaining hypotensive, so he was
cardioverted with 50 joules, resulting in sinus bradycardia. His
bp was in the 90's on a low dose of a norepi gtt (changed from
dopa for tachycardia and ectopy).
Past Medical History:
PMH:
-HTN
-Paroxysmal atrial fibrillation-flutter
-CHF with preserved EF of 55%, mod concentric hypertrophy, mild
AR and PR on [**5-/2156**] echo
-Cath at VA [**5-/2156**] with no flow limiting lesions, RA 25, PCWP
32, per VA discharge summary
-PUD
-CRI, baseline 1.4
-Prostate ca s/p prostatectomy
-DJD
-PTSD
.
PSH:
-L hip replacement [**2149**]
Social History:
SocHx: He is married, and his wife is paraplegic. He smoked 1ppd
for around 40-50 years, quit in [**2121**]'s. He stopped drinking
etoh in [**2131**]'s. He denies any illicit drug use. He used to
enjoy travelling around the US and was particularly fond of the
Niagra region.
Family History:
He is not aware of any family history of heart disease, CVA,
HTN, or DM.
Physical Exam:
PE: t- 98.1, bp 118/70, hr 62, rr 16, spo2 98%
gen- elderly male, sedated and intubated, chronically
ill-appearing
heent- anicteric, op with mmm
neck- impressively engorged ej's, ij tough to eval as on back,
no lad, no thyromegaly
cv- rrr, s1s2, no m/r/g
pul- moves air well, appears comfortable on vent, no w/r/r
abd- soft, nt, nd, nabs, hepatomeg (4cm below lower rib), well
healed scars, dark thin plaques over lower abdomen
extrm- 2+ pitting edema in le, warm/dry
nails- no clubbing, no pitting/color changes/indentations
neuro- sedated, perrl, moves extrm
Pertinent Results:
[**2158-11-9**] 04:30PM PLT COUNT-195
[**2158-11-9**] 04:30PM NEUTS-49.9* LYMPHS-43.2* MONOS-5.0 EOS-1.6
BASOS-0.3
[**2158-11-9**] 04:30PM WBC-8.2 RBC-3.58* HGB-11.5* HCT-33.1* MCV-93
MCH-32.2* MCHC-34.8 RDW-13.8
[**2158-11-9**] 04:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-11-9**] 04:30PM ALBUMIN-2.9* CALCIUM-7.9* PHOSPHATE-3.1
MAGNESIUM-2.0
[**2158-11-9**] 04:30PM CK-MB-4
[**2158-11-9**] 04:30PM cTropnT-0.06*
[**2158-11-9**] 04:30PM LIPASE-20
[**2158-11-9**] 04:30PM ALT(SGPT)-34 AST(SGOT)-52* CK(CPK)-146 ALK
PHOS-58 AMYLASE-73 TOT BILI-0.6
[**2158-11-9**] 04:30PM estGFR-Using this
[**2158-11-9**] 04:30PM GLUCOSE-173* UREA N-25* CREAT-1.6* SODIUM-142
POTASSIUM-3.1* CHLORIDE-111* TOTAL CO2-20* ANION GAP-14
[**2158-11-9**] 09:12PM O2 SAT-98
[**2158-11-9**] 09:12PM LACTATE-1.9
[**2158-11-9**] 09:12PM TYPE-ART TEMP-34.4 RATES-14/2 TIDAL VOL-600
PEEP-5 O2-80 PO2-205* PCO2-27* PH-7.40 TOTAL CO2-17* BASE XS--5
AADO2-355 REQ O2-62 INTUBATED-INTUBATED VENT-CONTROLLED
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *7.0 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.6 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.15 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 20% (nl >=55%)
Aorta - Valve Level: *4.1 cm (nl <= 3.6 cm)
Aorta - Ascending: *4.4 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 0.6 m/sec (nl <= 2.0 m/sec)
TR Gradient (+ RA = PASP): *31 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal
interatrial
septum. No ASD by 2D or color Doppler. The IVC is >2.5cm in
diameter with no
change with respiration (estimated RAP >20 mmHg).
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Severe global
LV hypokinesis. No LV mass/thrombus. No resting LVOT gradient.
No VSD. TSI
demonstrates no significant LV dyssynchrony with no significant
delay in peak
systolic contraction between opposing walls.
RIGHT VENTRICLE: Mildly dilated RV cavity. RV function
depressed.
AORTA: Moderately dilated aortic sinus. Moderately dilated
ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild to moderate
([**11-21**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate
[[**11-21**]+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: The end-diastolic PR velocity
is increased
c/w PA diastolic hypertension.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions:
The left atrium and right atrium are moderately dilated. No
atrial septal
defect is seen by 2D or color Doppler. There is moderate
symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is
severe global left ventricular hypokinesis. No masses or thrombi
are seen in
the left ventricle. There is no ventricular septal defect.
Tissue
synchronization imaging demonstrates no significant left
ventricular
dyssynchrony. The right ventricular cavity is mildly dilated.
Right
ventricular systolic function appears depressed. The aortic root
is moderately
dilated athe sinus level. The ascending aorta is moderately
dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**11-21**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly
thickened. There is mild pulmonary artery systolic hypertension.
The
end-diastolic pulmonic regurgitation velocity is increased
suggesting
pulmonary artery diastolic hypertension. There is a
trivial/physiologic
pericardial effusion.
IMPRESSION: Severely depressed LVEF.
cxr [**2158-11-9**]
FINDINGS: AP single view of the chest obtained with patient in
supine position demonstrates the presence of an ETT terminating
in the trachea some 6 cm above the level of the carina. The
inflated cuff distends the trachea locally by some millimeters.
An NG tube has been placed seen to reach below the diaphragm. No
pneumothorax is present. Diffuse perivascular haze is noted on
this portable examination and the patient appears to be in
pre-edema state. Density in left lower lobe area is noted,
obliterating the contour of the descending aorta as well as the
central portion of the left diaphragm indicative of
atelectasis-infiltrate. Further followup recommended.
Brief Hospital Course:
77m with htn, afib/flutter, chf with preserved ef, prostate ca
s/p prostatectomy who presented with sx of increasing volume
overload, was found to be in aflutter, and became bradycardic
and hypotensive following administration of IV diltiazem
requiring pressors and intubation.
.
#Shock/Pump -- His original presenting hypotension was felt to
be mixed type in nature, with distributive component likely from
the diltiazem (he has had this same response to the same drug in
[**6-/2156**], with similar presenting symptoms) and a cardiogenic
component from baseline heart failure with loss of supportive
tachycardia. No evidence of sepsis (no fever, tachypnea,
leukocytosis, or evidence of infection). His baseline cortisol
was normal. Improvement came with resolution of the calcium
channel blocker's effect, decreasing both the vasodilation and
negative chronotropy. By the second day of the admission he'd
actually returned to his usual hypertensive state, and his
anti-hypertensive medications were slowly re-introduced.
Following this, spironolactone was added both for his CHF and
for its potentially salubrious effect on cardiac remodeling,
done with an eye towards the subseuqently discussed
dysrhythmias.
.
In addition to this, we felt he appeared volume overloaded,
consistent with his presenting symptoms. He had peripheral
edema, elevated JVP, and hypoxemia to the low 90's-high 80's on
room air. As such, the cardiology team actively diuresed the
patient with furosemide 40mg intravenously on days [**1-23**] with a
good response (nearly 1-1.5 liters negative per day) with a good
response in both peipheral edema and room air sats (both at rest
and ambulatory). To further investigate, a surface echo was
performed with the results above, most significantly an EF of
20%. This was felt to probably be due to a tachycardia mediated
cardiomyopathy, as he seems to be fairly insensitive to his
tachyarrhythmias. He was cathed at the VA in [**2155**] without
flow-limiting lesions. His regimen was changed around to
include lisinopril, metoprolol xl, spironolactone, and
furosemide. He was instructed to weigh himself daily and adhere
to a two gram sodium diet.
.
#Atrial flutter, fib, and tachycardia -- Probably the cause of
his low EF, he was found to be in aflutter with a rapid
ventricular response at presentation. This was first treated
with diltiazem, causing the bradycardia and hypotension, then
eventually cardioverted with 50 joules. Following this, he
primarily remained in sinus rhythm with occasional runs of
atrial tachycardia and rare 3-4 beat runs of non-sustained
ventricular tachycardia. The option of a flutter ablation was
discussed with the patient, but he declined. As such, he was
started on amiodarone and warfarin. The risks and benefits were
discussed of both medications, and the patient understood,
saying he'd continue taking the medications and would be seen
regularly by his pcp for all requisite lab work. He remained
primarily in sinus for the rest of the admission. His
occasional atrial tachycardia episodes (hear rate around
110-120) were asymptomatic and without other hemodynamic
consequences. The plan for the amiodarone is to continue it at
400mg daily for a total of 14 days (to finish [**2158-11-27**]) then
transition to 200mg daily.
.
#Respiratory failure -- Seems to have been mainly from
unresponsiveness with a smaller contribution from pulmonary
edema, more of a not breathing than couldn't breath situation.
He was easily extubated on day two, with intially low O2 sats
(80's-90's) on room air that rapidly improved with diuresis. By
the time of transfer, he was high 90's on room air both at rest
and with ambulation.
.
#Renal failure -- He seems to have some componenet of chronic
renal insufficiency, based on his Cr of 1.4 in [**2155**]. At
admission, his Cr was 1.6, but rapidly increased to 2.6. This
was likely due to ATN from his pressor-dependent hypotension as
well as pressor use. His cr slowly improved over the following
days. Once stable, more active diuresis and ace-inhibiton was
initiated with ongoing improvement in his creatinine. On the
day of transfer, his Cr bumped back up to 2.3. This was felt to
be multifactorial in nature; the prime reason was felt to be
over-diuresis, so furosemide was held ([**2158-11-14**]), with plans
to allow him to re-equilibrate, then start oral furosemide.
Other reasons included an increased lisinopril dose, so on [**11-14**]
his dose was lowered from 10mg to 5mg and amiodarone
intitiation, which blocks tubular secretion of creatinine, thus
causing the apperance of renal failure with no actual changes in
glomerular filtration.
.
#Metabolic acidosis -- Mainly non-gap with a slight gap
component. With high chloride, likely was originally
hyperchloremic from agressive NS resuscitation. Following this,
the acidosis is probably from renal failure with poor acid
excretion. It has been stable and is felt that this will
improve; the plan was, should he begin to become progressively
acidemic from renal failure, to add in oral Bicitra. However,
as he's been stable, this was thought to be unlikely.
.
#Anemia --- His hct was 40 in [**2155**]. There was no obvious source
of blood loss. The anemia was stable and is likely a combination
of CRI, hypervolemia, and ACD. This theory was borne out by iron
studies.
.
#Hyperglycemia -- Unclear if stress response, glucagon received
in ED, D5 fluid carrying his meds. His A1c was only 5.9, and it
was felt he could get formal fasting blood glucose tested as an
outpatient for glucose intolerance and consideration of starting
an oral [**Doctor Last Name 360**].
.
#Code -- Remained full throughout admission
.
#Communication: wife and [**Name2 (NI) 802**]. Please call wife ([**Last Name (un) **])
first. [**Telephone/Fax (1) 5759**]. or [**Telephone/Fax (1) 39399**].
Medications on Admission:
Meds:
-ASA 81mg daily
-Metoprolol XL 150mg daily
-Simvastatin 80mg daily
-Lisinopril 20mg daily
-Nifedipine SA 120mg daily
-Ranitinde 150mg daily
Also:
Amiodarone 200qd
Celexa 10qd
Colace 100bid
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): 3 tabs daily for 6 days, two tabs daily for 7 days,
200mg daily thereafter.
Disp:*60 Tablet(s)* Refills:*0*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO at bedtime.
Disp:*90 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Heparin drip as bridge until warfarin becomes therapeutic
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
-Hypotension with shock
-Sinus bradycardia
-Atrial flutter with rapid ventricular response
-Atrial fibrillation
-Atrial tachycardia
-Congestive heart failure with EF of 20%
-Respiratory failure requiring intubation
-Acute renal failure from ATN
Secondary:
-HTN
-Paroxysmal atrial fibrillation-flutter
-CHF with preserved EF of 55%, mod concentric hypertrophy, mild
AR and PR on [**5-/2156**] echo
-Cath at VA [**5-/2156**] with no flow limiting lesions, RA 25, PCWP
32, per VA discharge summary
-PUD
-CRI baseline 1.4
-Prostate ca s/p prostatectomy
-DJD
-PTSD
Discharge Condition:
-stable, afebrile, ambulatory, breating well on a nasal cannula;
HR ranging from 80-120 (sinus to aflutter, occasional atrial
tachycardia)
Discharge Instructions:
Weigh yourself every morning, call your doctor if your weight
increases by more than 3 lbs.
Adhere to 2 gm sodium diet
.
You have recovered for an episode of low blood pressure and a
fast heart rate (atrial flutter) for which your medications have
been adjusted.
.
You have suffered from respiratory failure as a result of your
congestive heart failure. You had an endo-tracheal tube placed.
It has been removed without any complications.
.
You are being transferred to the VA. After discharge, please be
sure to have follow-up appointments with your PCP and
cardiologist.
.
You are being discharged on a blood thinner to prevent strokes
and will need to have labs checked weekly to make sure the
medication is working appropriately.
Followup Instructions:
.
2) Please establish care with a cardiologist at the VA, your PCP
will help arrange this
|
[
"458.29",
"V10.46",
"403.90",
"E942.4",
"276.2",
"585.9",
"518.81",
"428.0",
"425.4",
"584.5",
"285.21",
"427.31",
"427.32",
"785.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.17",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14855, 14903
|
7688, 13551
|
314, 364
|
15507, 15648
|
2792, 7665
|
16433, 16526
|
2121, 2195
|
13797, 14832
|
14924, 15486
|
13577, 13774
|
15672, 16410
|
2210, 2773
|
247, 276
|
392, 1438
|
1460, 1809
|
1825, 2105
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,154
| 187,744
|
32518
|
Discharge summary
|
report
|
Admission Date: [**2101-2-24**] Discharge Date: [**2101-4-29**]
Date of Birth: [**2030-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**2101-2-24**] Placement of left sided pigtail catheter
[**2101-3-1**] Flex bronchoscopy
[**2101-3-4**] PEG, Tracheostomy, Flex Bronchoscopy
History of Present Illness:
This is a 71M who was initially referred to Dr. [**Last Name (STitle) **]
following a thoracotomy demonstrating RUL adenocarcinoma
invading
the chest wall, followed by 3 months of carboplatin and Taxol
with Avastin. He underwent a second thoracotomy with RUL
lobectomy and en bloc R chest wall resection (ribs [**3-9**]) with
[**Doctor Last Name 4726**]
Tex chest wall reconstruction and decortication of the RML and
RLL with Dr. [**Last Name (STitle) **] on [**2100-12-21**]. His postoperative course was
complicated by a bronchopleural fistula and Serratia VAP for
which he took cipro x 14 days. On [**2101-1-13**], he was re-admitted
with R empyema and partial dehiscence of the chest wall patch.
On [**1-18**], he underwent R VATS with drainage, decortication, and
removal of patch. Postoperatively, his three chest tubes were
converted to empyema tubes. He was discharged on vancomycin and
fluconazole on [**2101-2-11**]. Since discharge, he has returned twice
for desaturations. Both times, his vitals were stable and his
CXR unchanged; he was thus sent home with regular follow up in
clinic. On [**2101-2-23**], he began c/o SOB. In transit to [**Hospital1 18**], EMS
noted HR 30 and apneic. He was intubated at [**Hospital 882**] Hospital
then transferred directly to the TSICU. Thick purulent
secretions were noted. He then underwent bronchoscopy which
demonstrated thin secretions in the trachea and proximal b/l
bronchi.
Past Medical History:
PMH:
Traumatic blindness (left eye)
Hypertension
Alcohol-induced gastric ulcers (alcohol-free x20yr)
Lung CA, R chest wall ([**4-11**]), s/p carboplatin, taxol with
avastin
h/o serratia marascens VAP
PSH:
s/p appendectomy, date unknown
[**2100-12-22**]: Bronchoscopy, Reoperative right thoracotomy with right
upper lobectomy and en bloc right chest wall resection (ribs 3,4
and 5) with [**Doctor Last Name 4726**]-Tex chest wall reconstruction and decortication
of right middle and right lower lobes.
.
[**2100-12-25**]: Flexible bronchoscopy with therapeutic aspiration and
bronchoalveolar lavage.
.
[**2100-12-26**], [**2100-12-27**], [**2100-12-28**], [**2101-1-19**]:
Flexible bronchoscopy with therapeutic aspiration.
.
[**2101-1-13**]: Right sided thoracentesis under ultrasound guidance.
Social History:
Lives with wife
EtOH: {x}N { }Y Quit
Tobacco: {x}N { }Y Quit 20 years ago
Drugs: {x}N { }Y Amount:
Married: { } N {x}Y
Occupations: Construction worker
Exposures: Asbestos, chemical / construction materials
Diabetes: N
Immunodeficiency: N
Cancer: Y
Family History:
Notable for cerebral hemorrhage. Father with lung cancer.
Brother with gastric cancer and another brother with emphysema.
Sister with cystic fibrosis.
Physical Exam:
98.5 73 120/63 16 100% AC 0.6/450 x 14/5
Gen: intubated, arousable to voice
CVS: RRR
Pulm: coarse breath sounds diffusely, CTs with purulent output,
incisions c/d/i
Abd: soft, NT, ND, +BS
Ext: no c/c/e
Pertinent Results:
WBC 10.6, Hct 24.5, plt 313; Na 142, K 5.6, Cl 109, bicarb 30,
BUn 31, Cr 1.4, glu 146, Ca 8.5, Mg 1.6, P 5.4; PT 12.8, INR
1.1;
ALT 15, AST 13, AP 143, t.bili 0.2, LDH 185, [**Doctor First Name **] 57, lip 30;
vanc
32.8; lactate 0.7; 7.21/80/161/34/1
CXR: largely unchanged from [**2-14**] and [**2-21**], persistent pleural
effusions
Bronchoscopy: thin secretions in trachea and b/l proximal
bronchi
Brief Hospital Course:
Neuro: patient was kept under light sedation for comfort while
intubated with propofol. His pain was initially controlled with
prn fentanyl. Eventually his propofol was weaned and he was
switched to a regimen of prn morphine and ativan. He was then
switched to PO roxicet and ativan down his PEG tube after this
was placed. We attempted to keep his sedation minimal and only
adminstered when he was agitated or requiring sedation for a
procedure.
During the hospitalization, delirium was persistent. Psychiatry
and geriatrics consultations were obtained. Treatment w/
multiple agents, including haldol, Remeron, and Zyprexa were
tried. On [**2101-4-28**], head CT was obtained, showing marked
predominantly vasogenic edema spread diffusely within both
cerebral hemispheres, right cerebellum, and possibly within the
brainstem with at least two focal hyperdense lesions noted
within the left periventricular white matter and left basal
ganglia. These findings were consistent with widespread
metastatic disease.
CV: An Echo was done at admission which demonstrated normal
systolic function. EKG showed normal sinus rhythm without
evidence of ischemic. He was continued on beta blockade. He
was given prn doses of hydralazine and diltiazem for HTN or
tachcardia. During the last week of his hospitalization,
intermittent bradycardia was documented while changing his
anti-hypertensive regimen. Electrophysiology consult was
obtained, and bradycardia was thought to be due to excess beta
blockade.
Pulm: He was maintained on the vent initially with
assist-control. He underwent bronchoscopy on [**2101-2-24**]. He was
found to have secretions in the trachea and b/l main stem
bronchi, BAL was performed. He decompensated later that day and
there was a question of plugging vs. atelectasis. A CT chest
was done which showed a moderate left pleural effusion. A left
sided pigtail catheter was placed by IP for this effusion. This
tube continued to put out a decent amount of fluid, averaging
about 1000cc per day. He was rebronched on [**2101-2-26**] for RLL
colapse and found to have a mucus plug and moderate to thick
secretions in the RML and RLL bronchi. His BAL grew out
Serratia that was pansensitive. On [**2101-3-1**] extubation was
attempted, but the patient failed and had to be reintubated.
The patient was taken to the OR for an open tracheostomy on
[**2101-3-4**]. 8 French portex cath was placed without complications.
The rest of his pulmonary course included multiple
bronchoscopies for removal of mucous plugs. He was always
attempted on trach collar on the days when it was deemed he
could tolerate it. Initially, he was only able to achieve [**3-8**]
hours of trach collar before tiring. Currently, he can [**Last Name (un) 1815**] up
to 12 hrs unless he has accumulated secretions requiring serial
bronchoscopy for pul tiolet. It was decided he would need vent
rehab after discharge. His left pigtail was removed after
resolutionneeded to be changed to a pleur-ex and this was done
by IP prior to d/c. His empyema tubes cont to be backed out
until they were completely out. The middle tube fell out
spontaneously prior to D/C.
Throughout his admission, patient had heavy secretions,
requiring frequent tracheal suctioning and chest PT, as well as
intermittent bronchoscopy. Pt was transferred to floor [**4-7**]. Pt
required brief transfer to ICU for hypoxia due to mucus plugging
[**4-16**] but transferred back to floor the following day. To help
patient clear the mucus, tracheostomy was downsized to #6
fenestrated uncuffed.
GI: he was kept NPO for the entire hospital course. Maintained
on GI prophylaxis with PPI.
FEN: He was started on TFs at admission. His nutritional status
was not improving all that well, and it was decided it would be
a long time before he would be able to take anything PO,
therefore a PEG was placed at the time of trach. His PEG feeds
were advanced to goal where he remained for his hospital course.
Nutrition labs were obtained weekly.
Renal: Pt was found to be in prerenal azotemia and acute tubular
necrosis, peaking at Cr 4.6. Nephrology was consulted and CVVH
was initiated. Later, pt tolerated HD. Pt regained renal
function and last HD was [**2101-4-20**].
ID: Patient was found to have pneumonia, BAL growing out
Serratia marcescens on admission. Pt was treated w/ Vancomycin,
Cefepime and fluconazole w/ clearing of BAL. During this
admission, another episode of pneumonia was documented w/ BAL
growing out Serratia, Acinetobacter and Enterobacter. This was
treated w/ Meropenem, followed by Ciprofloxacin.
On the evening of [**2101-4-28**], patient was found to be in sudden
respiratory arrest. Code Blue called. Inner cannula was removed,
tracheostomy suctioned, and pt was ventilated by Ambu bag. Pt
went into PEA arrest but converted to unstable narrow complex
tachycardia after epinephrine. Amiodarone was given. Given
hemodynamic instability, pt was cardioverted x1 200J w/ return
of sinus rhythm. Pt was emergently transferred to TSICU.
Bronchoscopy showed thick secretion, which was cleaned out.
Tracheostomy was exchanged for #8 cuffed non-fenestrated. During
the morning of [**2101-4-29**], pt was noted to have dilated R pupil w/o
corneal or gag reflex. STAT head CT showed uncal herniation and
cerebellar tonsil herniation.
Given the morbid situation, a family meeting was held. Family
decided on CMO. Patient was removed from vent support, and
started on morphine gtt. Patient was pronounced dead on 3:25pm,
[**2101-4-29**], with family at bedside. After lengthy discussion, wife
declined post-mortem examination.
Medications on Admission:
atenolol 100', doxazosin, Lasix 20', lisinopril 20"
.
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Discharge Diagnosis:
right hydrothorax after RUL lobectomy, en bloc R CW resection
(ribs [**3-9**]), [**Doctor Last Name 4726**]-Tex reconstruction and removal, RML/RLL
decortication, s/p trach & PEG
IMMEDIATE CAUSE OF DEATH: CARDIOPULMONARY ARREST
OTHER CAUSE OF DEATH: metastatic lung cancer
Discharge Condition:
expired
Completed by:[**2101-4-29**]
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64,153
| 145,014
|
3274
|
Discharge summary
|
report
|
Admission Date: [**2162-9-24**] Discharge Date: [**2162-9-28**]
Date of Birth: [**2116-12-26**] Sex: F
Service: MEDICINE
Allergies:
Ativan
Attending:[**Last Name (NamePattern1) 15287**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 45 year old woman with hx of ESRD [**1-28**] to T1DM,
neuropathy, retinopahty, CAD, HTN, HLD, Hypothyroidism and a
recent admission for diabetic coma, now presented to ED after
missing several sessions of dialysis with altered mental state.
Per ED report, patient noted to be altered by her neighbors who
called 911 after noticing that she is not herself, only oriented
to self. ED initially concerned for sepsis vs DKA, got
vanc/cefepime. Given calcium gluconate, insulin bolus/drip,
renal was consulted, given the fact that she has a large anion
gap. Renal told to hold insulin. Renal will take pt to HD this
AM for elevated K and Glucose. Patient improved. BP is 120/130s
systolic, satting 100% on RA, afebrile. Lactate of 4.1, but not
getting more fluids given crackles on exam.
In the ED, initial VS were: obtunded, 100.0 90 179/149 20 100%.
Past Medical History:
-ESRD [**1-28**] T1DM; on HD since [**8-/2157**]
- Type 1 diabetes mellitus complicated by neuropathy,
retinopathy, and nephropathy
- Coronary Artery Disease with perfusion defect
- Hypertension
- Hyperlipidemia
- Right Charcot Foot
- s/p Left Toe Amputation
- Hypothyroidism
Social History:
Lives alone, not currently working (on disability). Does not
smoke.
Family History:
mom- DM, CAD, stroke, dad - CAD, MGM -HF
Physical Exam:
General: obtunded, moaning, but responds
HEENT: Sclera anicteric, MMM, eyes closed, not cooperating with
exam
Neck: supple, JVP not elevated, no LAD
CV: S1 + S2, no murmurs
Lungs: mild crackles at bases
Abdomen: soft, distended, non-tender, bowel sounds present, no
organomegaly
Ext: warm, well perfused,
Discharge physical exam:
Vitals: 98.6, 60's, 140's-180's/70's-80's, 18, 98%RA
Gen: WD/WN, NAD
HEENT: EOMI, no scleral icterus, MMM
Cardio: RRR, no m/r/g, no pedal edema
Lungs: CTAB
ABD: soft, NT/ND, +BS
Ext: No c/c/e
Pertinent Results:
admission labs:
[**2162-9-24**] 03:35AM BLOOD Plt Ct-146*
[**2162-9-24**] 03:35AM BLOOD WBC-4.3 RBC-4.10* Hgb-10.9* Hct-36.4
MCV-89 MCH-26.7* MCHC-30.1* RDW-16.1* Plt Ct-146*
[**2162-9-24**] 08:25AM BLOOD WBC-3.9* RBC-3.67* Hgb-10.0* Hct-31.3*
MCV-85 MCH-27.3 MCHC-32.0 RDW-16.1* Plt Ct-130*
[**2162-9-25**] 03:34AM BLOOD WBC-2.8* RBC-3.83* Hgb-10.3* Hct-32.3*
MCV-84 MCH-26.8* MCHC-31.8 RDW-16.5* Plt Ct-128*
[**2162-9-24**] 08:25AM BLOOD Glucose-738* UreaN-127* Creat-12.4*
Na-122* K-6.2* Cl-80* HCO3-16* AnGap-32*
[**2162-9-24**] 09:47AM BLOOD Glucose-443*
[**2162-9-24**] 02:00PM BLOOD Glucose-143* UreaN-65* Creat-8.1*#
Na-131* K-4.2 Cl-91* HCO3-26 AnGap-18
[**2162-9-24**] 10:31PM BLOOD Glucose-178* UreaN-72* Creat-9.2* Na-130*
K-5.1 Cl-93* HCO3-23 AnGap-19
[**2162-9-25**] 05:30PM BLOOD Glucose-114* UreaN-32* Creat-5.4*# Na-134
K-3.9 Cl-95* HCO3-28 AnGap-15
[**2162-9-26**] 06:18AM BLOOD Glucose-252* UreaN-40* Creat-6.6*# Na-133
K-4.2 Cl-95* HCO3-28 AnGap-14
[**2162-9-24**] 08:25AM BLOOD Osmolal-349*
[**2162-9-24**] 09:35AM BLOOD Osmolal-328*
[**2162-9-24**] 09:47AM BLOOD Osmolal-321*
[**2162-9-24**] 11:05AM BLOOD Osmolal-305
[**2162-9-24**] 10:15AM BLOOD Type-MIX pH-7.40 Comment-GREEN TOP
[**2162-9-24**] 05:55AM BLOOD Type-[**Last Name (un) **] pO2-68* pCO2-37 pH-7.27*
calTCO2-18* Base XS--8 Comment-GREEN TOP
[**2162-9-26**] 05:26PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-5* Polys-8
Lymphs-58 Monos-34
[**2162-9-26**] 05:26PM CEREBROSPINAL FLUID (CSF) TotProt-24
[**2162-9-24**] 3:35 am BLOOD CULTURE
REPORTED BY FAX TO STATE OF MASS LABORATORY ON [**2162-9-26**] @
09:02AM.
**FINAL REPORT [**2162-9-27**]**
Blood Culture, Routine (Final [**2162-9-27**]):
LISTERIA MONOCYTOGENES.
Reported to and read back by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @
14:46PM ON
[**2162-9-25**]. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
LISTERIA MONOCYTOGENES
|
AMPICILLIN------------<=0.12 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2162-9-24**]):
Reported to and read back by DR. [**Last Name (STitle) **]. GROMSKI ON [**2162-9-24**] AT
2335.
GRAM POSITIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2162-9-25**]): GRAM
POSITIVE ROD(S).
[**2162-9-24**] 9:56 am BLOOD CULTURE Source: Venipuncture 2 OF 2.
Blood Culture, Routine (Preliminary):
LISTERIA MONOCYTOGENES.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 15288**]
FROM [**2162-9-24**].
Anaerobic Bottle Gram Stain (Final [**2162-9-27**]): GRAM
POSITIVE ROD(S).
[**2162-9-26**] 5:26 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final [**2162-9-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
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 (Preliminary): NO GROWTH.
Sinus tachycardia. Non-specific ST-T wave changes. Compared to
tracing #1
T wave peaking is no longer present at a faster rate and ST-T
wave changes are
new.
TRACING #2
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 160 84 348/432 82 45 85
CXR [**2162-9-24**]
FINDINGS: The lungs are well inflated. There are conspicuous
interstitial
markings and [**Month/Day/Year 1106**] cephalization with bilateral hilar
engorgement. Of note,
hilar lymphadenopathy documented in recent CT is also
contributing to the
hilar conspicuity. Moderate cardiomegaly appears slightly
worsened than in
prior exam although AP projection hinders accurate comparison.
There is no
pleural effusion or pneumothorax.
IMPRESSION: Moderate pulmonary edema in the setting of moderate
cardiomegaly.
CXR [**2162-9-25**]
IMPRESSION:
1. Interval increase in lung volumes with some improvement in
the pulmonary
vascularity suggesting a resolving interstitial edema. However,
there is
persistent pulmonary venous hypertension and some residual
interstitial
prominence. In addition, linear opacity in the left mid lung
may represent
scarring or subsegmental atelectasis. The heart remains
enlarged. Overall
mediastinal contours are stable, although the hila remain
prominent likely
related to known bilateral hilar lymphadenopathy seen on CT
dated [**2162-8-3**].
No large pleural effusions. No pneumothorax is appreciated.
DISCHARGE LABS
[**2162-9-26**] 06:18AM BLOOD WBC-2.4* RBC-3.78* Hgb-10.0* Hct-32.4*
MCV-86 MCH-26.5* MCHC-30.9* RDW-16.0* Plt Ct-111*
[**2162-9-28**] 05:45AM BLOOD WBC-3.1* RBC-4.10* Hgb-10.9* Hct-36.3
MCV-89 MCH-26.5* MCHC-29.9* RDW-15.8* Plt Ct-142*
[**2162-9-28**] 05:45AM BLOOD Neuts-63 Bands-0 Lymphs-18 Monos-12*
Eos-4 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2162-9-27**] 08:00AM BLOOD Glucose-220* UreaN-60* Creat-8.6* Na-134
K-4.3 Cl-97 HCO3-22 AnGap-19
[**2162-9-28**] 05:45AM BLOOD Glucose-449* UreaN-29* Creat-5.7*# Na-137
K-4.3 Cl-93* HCO3-35* AnGap-13
[**2162-9-28**] 05:45AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1
[**2162-9-27**] 08:00AM BLOOD Vanco-11.1
Brief Hospital Course:
Assessment and Plan: 45 Year old woman with PMH significant for
type I DM resulting in ESRD, missed several dialysis sessions,
also here with fevers.
# Listeria bacteremia: Pt with 2/2 blood cultures from admission
with listeria. Based on ID recs, pt had LP to r/o CNS
involvement given altered mental status on admission. Cultures
to date from LP are negative. Clinically she had been improving
well with treatment of cefepime and vancomycin, then narrowed to
ampicillin based on sensitivities. Based on preliminary negative
culture in CSF, will d/c pt on 4 weeks total of vancomycin to be
received at dialysis per ID recs.
-f/u LP culture results, if positive will need ampicillin
-will d/c on vancomycin at dialysis with goal levels 15-20, for
a total of 4 weeks to end [**10-22**]
#Altered mental state - likely uremia/hyperglycemia, LP for
listeria NGTD so listeria less likely. Her blood cultures grew
listeria. Patient's mental state improved following dialysis
sessions.
#ESRD: missed HD before admission, dialyzed during her stay.
This is appropriate given multiple electrolyte derangements that
would likley improved with HD. She is currently active on the
kidney-pancreas transplant list for over ~1800 days. Her
transplant workup is generally up-to-date, although she needs an
updated stress test and Pap smear. She had several sessions of
dialysis while inpatient and her mental state, as well as her
electrolyte abnormalities (anion gap acidosis, hyperkalemia,
hyperglycemia) improved.
- continue HD as scheduled (M/W/F)
#Diarrhea. Per patient has improved with no BM since morning of
[**2162-9-27**]. Tried to obtain stool for c. diff and culture but no
further bowel movements. Diarrhea was likely due to listeria and
resolved with treatment.
#Pancytopenia - HgB is at baseline at 10.9, likely depressed [**1-28**]
renal failure. However, WBC of 3.1 (improving from nadir of 2.4
on [**2162-9-26**]) and platelets of 142 (also improving from nadir of
111 on [**2162-9-26**]) remain unexplained. This would be an unusual
effect of listeria. Med effects also in the differential,
however she remains on vanc and ampicillin and her counts are
recovering.
-f/u CBC as outpatient
#Hyperkalemia - likely secondary to no HD, stable s/p HD
#Diabetes: Pt admitted in DKA with anion gap of 40, now off
insulin drip on home regimen
- Continue home lantus and humalog
Chronic Issues:
#Hypothyroidism: Continue levothyroxine
#CAD: continued on her home aspirin and statin medications.
-Restarted beta blocker
#HTN
-Restarted home medications
#GERD:
-Her home PPI was continued with no complaints of GERD
#Charcot foot/nephropathy:
-Percocet for pain was ordered and there were never complaints
for untreated pain
TRANSITIONAL ISSIUES:
1. LISTERIA BACTEREMIA -
-f/u LP culture results, if positive will need ampicillin
-will d/c on vancomycin at dialysis with goal levels 15-20, for
a total of 4 weeks to end [**10-22**]
-f/u CBC as outpatient as patient was pancytopenic (as above)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Atorvastatin 10 mg PO DAILY
2. Doxazosin 8 mg PO BID
take morning dose at 7 or 8:00am
3. Epoetin Alfa 0 UNIT IV Frequency is Unknown Start: HS
4. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 200 mcg PO DAILY
1 tablet daily except sunday take 2
6. Levothyroxine Sodium 50 mcg PO DAILY
daily except sunday take 2 tabs
7. Metoprolol Tartrate 25 mg PO TID
take am dose at 7-8:00am
8. Nortriptyline 25 mg PO HS
9. Oxycodone-Acetaminophen (5mg-325mg) [**12-28**] TAB PO Q6H:PRN pain
10. Pantoprazole 40 mg PO Q24H
11. sevelamer HYDROCHLORIDE *NF* 3-5 tablets Other with meals
12. Valsartan 160 mg PO BID
13. Aspirin 81 mg PO DAILY
14. [**Doctor First Name **]-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral
daily
Discharge Medications:
1. Valsartan 320 mg PO QHS
RX *valsartan [Diovan] 320 mg 1 tablet(s) by mouth at bedtime
Disp #*28 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Doxazosin 8 mg PO BID
take morning dose at 7 or 8:00am
5. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Levothyroxine Sodium 200 mcg PO DAILY
1 tablet daily except sunday take 2
7. Metoprolol Tartrate 25 mg PO TID
take am dose at 7-8:00am
8. Oxycodone-Acetaminophen (5mg-325mg) [**12-28**] TAB PO Q6H:PRN pain
9. Pantoprazole 40 mg PO Q24H
10. Levothyroxine Sodium 50 mcg PO DAILY
daily except sunday take 2 tabs
11. Epoetin Alfa 0 UNIT IV ONCE Duration: 1 Doses
12. Nortriptyline 25 mg PO HS
13. [**Doctor First Name **]-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral
daily
14. sevelamer HYDROCHLORIDE *NF* 3-5 tablets OTHER WITH MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Listeria Sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 15281**],
You were admitted to our intensive care unit with confusion,
likely due to missing several dialysis sessions, DKA and a blood
infection. We found that you have an infection called listeria.
Because of this, you will need to be treated with vancomycin at
dialysis for 3 weeks. Your blood pressure was also slightly high
here. You should talk about about this with the doctors [**First Name (Titles) **] [**Name5 (PTitle) 12069**].
The following changes were made to your medications:
You will be given vancomycin with your dialysis tomorrow. You
will need vancomycin until [**10-22**]. You will need to have
levels of vancomycin checked, with goal trough 15-20. You will
take valsartan 360mg once daily at bedtime instead of 160mg
twice daily. You should take your morning dose of metoprolol
and doxazosin between 7-8am instead of waiting until 10am.
Please follow up with your primary care doctor as well this
week.
Followup Instructions:
Department: PAIN MANAGEMENT CENTER
When: THURSDAY [**2162-9-30**] at 10:50 AM
With: [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] NP
Specialty: Endocrinology
When: Thursday [**9-30**] at 1:30pm
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: TUESDAY [**2162-10-5**] at 3:10 PM
With: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: RADIOLOGY
When: THURSDAY [**2162-10-14**] at 8:00 AM
With: RADIOLOGY [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2163-2-22**] at 11:00 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"272.4",
"027.0",
"995.91",
"276.7",
"250.43",
"284.19",
"250.53",
"585.6",
"V49.83",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12409, 12415
|
7613, 9996
|
299, 306
|
12475, 12475
|
2208, 2208
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|
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10013, 10618
|
1220, 1499
|
1515, 1586
|
5450, 7590
|
1992, 2189
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,955
| 197,971
|
46877
|
Discharge summary
|
report
|
Admission Date: [**2121-7-4**] Discharge Date: [**2121-7-12**]
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / aspirin
Attending:[**Last Name (un) 32349**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F with a complicated past medical history including recent
diagnosis of ulcerative colitis who is transferred from [**Hospital1 **] given concern for intramural hematoma of the descending
thoracic aorta. She was in her usual state of health until
approximately six hours ago when she experienced acute onset
back pain between her scapulas. She denied any other symptoms at
the
time including shortness of breath. When she arrived at [**Hospital1 **] her blood pressure was 200/120 which was managed with
labetalol and nitroglycerin. Despite improvement in her blood
pressure, her symptoms did not improve. Non-contrast CT scan was
obtained which showed intramural hematoma in the descending
thoracic aorta. Given these findings the patient was transferred
to [**Hospital1 18**] and urgent vascular surgery consult was obtained.
At [**Hospital1 18**] Mrs. [**Known lastname **] complained of persistent nausea with
associated emesis but denies back and abdominal pain at this
time. She is not short of breath. At home she is able to
ambulate without difficulty though she has appreciated and been
worked up for peripheral neuropathy.
Past Medical History:
- HTN
- Cataracts surgery - Both eyes
- Ulcerative colitis - 2.5 yrs of symptoms prior to diagnosis.
Not currently on any UC medications
- Osteoporosis
- Hx of upper GI bleed - s/p MVA 3yrs ago and presumed [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] tear. Took advil and aspirin for fractured sternum.
Received 5 unit transfusion.
- Fall history - In addition to recent fall, pt fell [**2-16**] yrs
ago.
- Hyperplastic polyps
- Basal and squamous cell carcinomas
- Hiatal hernia - Complicated by GERD
- Rhinitis
- Benign breast cysts
Social History:
Ms. [**Known lastname **] lives alone in [**Location (un) 5481**] independent living.
She is a former social worker and guidance couselor.
She has two daughters, [**Name (NI) **] lives nearby.
She is able to dress, take her meds, pay her bills.
Tobacco: None.
Alcohol: None.
Recreational Drugs: None.
Pt lives by herself in [**Location (un) 5481**] independent living. She was
widowed 1.5 yrs ago after 62 yrs of marriage, which has led to
some depression as per pt's daughter's report. She was a former
social worker and guidance counselor. She has two daughters, one
of whom ([**Name (NI) **]) lives nearby. She has an active social life, and
many friends. She is able to dress, take her medications, pay
bills, use a phone, drive, shop, and cook on her own without
assistance. She has a 40 pack yr history, and quit 14 yrs ago.
She drinks alcohol socially on occasion, but has never had any
problems with drinking. She does not use any recreational drugs.
She eats one meal a day cooked at her facility, and prepares 2
meals a day herself. She walks with a cane outside of her
facility, but does not need one at home. She was able to walk
1/2-1 mile before her recent fall; since then she has been able
to walk at least several hundred feet.
Family History:
Mother had TIAs and dementia. Father had MI at 45, died of
heart disease. 2 living brothers, one with hx of lung, "head"
cancers, one with heart problems. Distant relatives w/ hx of
IBD (Crohn's). No hx of colon cancer or DM.
Physical Exam:
ADMISSION:
Physical exam:
VS t 98.9 bp 152/83 hr 80 rr 24 sPo2 94% ra
GEN Alert, oriented X4, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM wheezing and questionnable rales at bases, no rhonchi
CV RRR normal S1/S2, 2/6 systolic murmur heard at LUSB, no rg
ABD soft NT distended normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, trace-1+ edema L > R, no
c/c
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE:
Physical exam:
VS t 98.1 bp 131/53 (130-160/50-60s) yesterday 110-170/50-60, hr
81 rr 18 sPo2 95% on 2L
GEN Alert, oriented X4, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM wheezing and questionnable rales at bases, no rhonchi
CV RRR normal S1/S2, 2/6 systolic murmur heard at LUSB, no rg
ABD soft NT distended normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, trace-1+ edema L > R, no
c/c
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS:
[**2121-7-4**] 06:45PM GLUCOSE-142* UREA N-32* CREAT-1.2* SODIUM-141
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-29 ANION GAP-14
[**2121-7-4**] 06:45PM CK-MB-4
[**2121-7-4**] 06:45PM HCT-34.7*
[**2121-7-4**] 03:32AM LACTATE-2.0
[**2121-7-4**] 03:05AM WBC-12.5* RBC-4.36 HGB-13.1 HCT-39.8 MCV-91
MCH-30.1 MCHC-32.9 RDW-14.3
[**2121-7-4**] 03:05AM NEUTS-87* BANDS-0 LYMPHS-9* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
DISCHARGE LABS:
[**2121-7-11**] 07:45AM BLOOD WBC-10.4 RBC-4.19* Hgb-12.4 Hct-37.5
MCV-90 MCH-29.6 MCHC-33.0 RDW-14.5 Plt Ct-326
[**2121-7-11**] 07:45AM BLOOD Glucose-135* UreaN-30* Creat-1.1 Na-137
K-3.5 Cl-94* HCO3-34* AnGap-13
[**2121-7-11**] 07:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0
[**2121-7-9**] 12:35PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2121-7-9**] 12:35PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2121-7-9**] 12:35PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
Urine cultures:
URINE CULTURE (Final [**2121-7-11**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
IMAGING:
[**7-3**] EKG:
Sinus rhythm. Non-specific ST-T wave changes. No previous
tracing available for comparison.
[**7-3**] CTA chest, abd/pelvis:
1. 13 cm type B acute intramural hematoma with a penetrating
ulcer.
2. 3.8 x 3.6 cm abdominal aortic aneurysm.
3. Severe stenosis of the left common iliac artery.
The study and the report were reviewed by the staff radiologist
There is a type B intramural hematoma with a small penetrating
ulcers
described above. A 3.8 x 3.6 cm infrarenal abdominal aortic
aneurysm has
increased in size compared to [**2115**].
A severe stenosis is noted in the left common iliac artery at
its origin.
[**7-6**] CXR:
REASON FOR EXAMINATION: Crackles.
Portable AP radiograph of the chest was reviewed in comparison
to [**2121-7-3**].
There is interval development of moderate to severe interstitial
pulmonary edema. Cardiomediastinal silhouette is unchanged.
Thickening of the aortic arch is consistent with known
intramural hematoma.
The study and the report were reviewed by the staff radiologist.
[**7-8**] CXR:
INDICATION: [**Age over 90 **]-year-old woman with shortness of breath.
Evaluate for
pneumonia, heart failure.
Comparison is made to prior examination of [**2121-7-6**]. There is
cardiomegaly which is unchanged. In comparison to the prior
study there has been an increase in haziness of the pulmonary
vasculature as well as small patchy opacities in the right lower
lobe. Small bilateral pleural effusions are also present
however are stable.
IMPRESSION: Worsening CHF with interstitial and possibly
intra-alveolar
edema.
Brief Hospital Course:
ACUTE ISSUES:
# Aortic dissection/Back Pain/HTN:
Ms. [**Known lastname **] was transferred to [**Hospital1 18**] from an OSH where she had
been admitted to the ED complaining of mid scapular pain. She
received a torso CT scan without IV contrast which revealed an
intramural hematoma of the descending thoracic aorta. Cardiac
and Vascular Surgery services were both consulted upon arrival
to the [**Hospital1 18**] and the CT scan was repeated with contrast. This
revealed a 13 cm type B acute intramural hematoma with a
penetrating ulcer, a 3.8x3.6 cm AAA and severe stenosis of the
left common iliac artery. She was hypertensive between 150 and
200 systolic upon presentation to the ED and was started on an
Esmolol drip. An EKG revealed NSR. She was admitted to the SICU
uunder the care of the Vascular team. An arterial line was
placed for BP management. She was started on a labetalol/esmolol
drip to titrate to a BP between 100 and 120 and she was made
NPO. It was decided that she was not a surgical candidate so she
was given a regular diet which she tolerated well. On HD 3 she
received lasix and was transitioned to PO hydralazine for BP
management. Her BPs were uncontrolled on HD4 and she was given
PO metoprolol as well as IV. Overnight she was hypertensive to
the 160s-180s which was improved with lopressor, hydralazine and
nitropaste. At discharge, her BPs were reasonably well controled
in 130s/50s, but she had had a few SBPs > 140s. Thus at
discharge she was uptitrated on metoprolol tartrate to to 75
[**Hospital1 **], also taking Lisinopril 40 po QD adn lasix 40 PO qd. She was
discontinued on her HCTZ in the hospital.
# UTI: During hospitalization, UCx returned positive for
coag-negative staph. Pt was started on Augmentin for 3d course
to treat UTI.
# Delirium: Pt became acutely delirius one night in the hospital
with psychotic features. She believed that people working in the
hospital were random people from off the street. This occurred
in the setting of having been given ativan, and also taking home
ambien. Geriatric recommended that benzodiazepines be avoided in
this pt and discontinued ambian for now. She tolerated 12.5
seroquel qhs for sleep well.
# Dyspnea: Pt has AS, and therefore with high afterload with
elevated SBPs may have caused her to have flash pulm edema. With
diuresis with lasix 40mg PO QD, dyspnea improved.
# Constipation: Pt agressively given bowel regimen with miralax,
ducusate, biscodyl
CHRONIC ISSUES:
# Hyperlipidemia: stable and cont home pravastatin
TRANSITION ISSUES:
[ ] complete 3d Augmentin for UTI stopping ABX after [**2121-7-14**]
dose
[ ] f/u BP control, to ensure SBPs <140s
[ ] Determine need for Seroquel PRN HS as an outpatient for
agitation/confusion.
[ ] Needs follow-up chest x-ray to follow-up on resolution of
pulmonary edema.
[ ] Pt needs CTA chest and abdomen prior to follow-up appt with
vascular on [**2121-8-13**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Zolpidem Tartrate 6.25 mg PO HS:PRN insomnia
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Pravastatin 20 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Gas Relief Extra Strength *NF* (simethicone) 125 mg Oral
QID:prn gas
9. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Pravastatin 20 mg PO DAILY
5. Gas Relief Extra Strength *NF* (simethicone) 125 mg Oral
QID:prn gas
6. Vitamin B Complex 1 CAP PO DAILY
7. Amoxicillin-Clavulanic Acid 875 mg PO Q12H Duration: 3 Days
8. Furosemide 40 mg PO DAILY
hold for sbp <100
9. Polyethylene Glycol 17 g PO DAILY
10. Metoprolol Tartrate 50 mg PO TID
hold for sbp < 100 or HR < 60
11. Quetiapine Fumarate 12.5 mg PO QHS:PRN agitation
12. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Primary Diagnosis: type B thoracic aortic dissection with
intramural hematoma
Secondary Diagnosis: hypertension
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 Mrs. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**] in [**Location (un) 86**]. You were admitted with back pain and
were found to have a problem with your aorta (a major blood
vessel that carries blood to your body) called an aortic
dissection, which is a tear in the wall of the blood vessel. You
were evaluated by the surgery team but the decision was made to
manage your problem with medications instead of surgery. The
main treatment is to control your blood pressure. Your blood
pressure medications were changed during your hospitalization
(see below).
.
You have been confused while in the hospital. To prevent that
from happening in the future, we have stopped your Ambien. To
help you sleep, we started you on a new medication, called
quietiapine.
.
Finally, we found that you had a urinary tract infection while
you were in the hospital which we treated with an antibiotic.
.
The following medication changes have been made:
- STOP taking Ambien
- STOP taking metoprolol succinate 25mg daily
- STOP taking hydrochlorothiazide 25mg daily
- START taking metoprolol tartrate 50mg three times daily
- START taking furosemide 40mg daily
- START taking senna and miralax for your constipation
- START taking Augmentin 500mg twice per day through [**2121-7-14**]
You should follow up with your rehab center regarding whether to
continue taking quetiapine at night.
Please follow up with the Wellness Center, with Dr. [**Last Name (STitle) 1391**],
and Dr. [**Last Name (STitle) **].
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: WELLNESS CENTER [**Location (un) **]
Address: 1 [**Doctor First Name 15**] POND DR, [**Location (un) **],[**Numeric Identifier 45899**]
Phone: [**Telephone/Fax (1) 5483**]
***The center will visit you within a few days of being home
from the hospital
Name: [**Last Name (LF) 1391**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Address: [**Doctor First Name **] STE 5C, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1393**]
Appointment: Wednesday [**2121-8-13**] 10:00am
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2121-10-9**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2121-7-14**]
|
[
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"041.10",
"440.8",
"518.4",
"733.00",
"V15.88",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12130, 12246
|
8120, 10572
|
267, 274
|
12402, 12402
|
4648, 4648
|
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|
3316, 3546
|
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|
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|
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|
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|
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12286, 12345
|
12417, 12554
|
10588, 11029
|
1478, 2037
|
2053, 3300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,568
| 150,775
|
27885
|
Discharge summary
|
report
|
Admission Date: [**2106-7-12**] Discharge Date: [**2106-7-16**]
Date of Birth: [**2057-11-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
chest pain.
Major Surgical or Invasive Procedure:
cardiac cath with stent placement at Framinham [**Hospital3 1280**].
History of Present Illness:
48 y/o Portugese speaking male pmhx significant for htn, DMII,
hypercholesterolemia, CAD with MI three years prior presenting
from [**Location (un) 47**] [**Hospital3 1280**] after L circumflex stent placement
for STEMI.
Pt presented to [**Hospital3 1280**] with left arm pain, sob, and chest
pain. 12 lead EKG demonstrated St elevations lat. leads. Upon
cath, Lcirc 100% occluded, 80% PDA, 91% RCA. Unable to balloon
RCA, PDA. tight diagnol also found, in addition to RCA and PDA
lesions. IABP placed. After cath records report pt to be
complaining of chest pain. Pt sent to [**Hospital1 18**] for repeat cath,
receiving ASA, plavix, integrillin.
Past Medical History:
MI [**2103**] - no interventions per patient.
Htn
Hypercholesterolemia
DMII
Social History:
38 pack/ yr smoking hx. Denies alcohol or illicit drug use
Family History:
Father with MI in 60's
hx of htn, diabetes in family
Physical Exam:
vitals- 97.2, 71, 145/88, 13, 100% 2L NC
General-male in no acute distress laying flat on bed with son at
bedside
[**Name (NI) 67943**], no injection, mucous membranes moist
CV-diminished heart sounds, Regular rhythm, no murmurs noted
Abdomen-soft, non tender, non distended
Lungs-Clear anteriorly
extr-warm well perfused, 1+ DP pulses. no C/C/E
Pertinent Results:
[**2106-7-12**] 07:47PM WBC-14.4* RBC-5.82 HGB-15.1 HCT-43.2 MCV-74*
MCH-25.9* MCHC-34.9 RDW-14.1
[**2106-7-12**] 07:47PM CK-MB-329* MB INDX-6.4* cTropnT-15.30*
[**2106-7-12**] 07:47PM CK(CPK)-5163*
EKG [**2106-7-13**] Normal sinus rhythm. RSR' pattern in lead V1,
probable normal variant.
Cath- [**2106-7-10**]- Lcirc 100% occluded, 80% PDA, 91% RCA. Unable to
balloon RCA, PDA. tight diagnol also found, in addition to RCA
and PDA lesions.
.
TTE [**2106-7-13**]:
LA: normal in size. No atrial septal defect is seen by 2D or
color Doppler. LV: wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is mildly depressed
with lateral wall hypokinesis (on some views basal inferior
appears hypokinetic as well). EF 40-45%. No masses or thrombi
are seen in the left ventricle. RV: chamber size and free wall
motion are normal.
Aortic valve: leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. No aortic valve
stenosis. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
48 y/o male with STEMI, s/p cath and stent placement in L circ,
with residual stenosis apparently in the Ramus intermedius after
PTCA, chest pain free off aortic balloon pump, with stable BP in
100's/70's in CCU.
.
Cath at outside hospital performed on [**2106-7-10**] with L circ 100%
occluded, 80% PDA, 91% RCA. Unable to balloon RCA, PDA. tight
diagnol also found, in addition to RCA and PDA lesions. The pt
was referred to [**Hospital1 18**] as he had continued to have chest pain
despite the interventions, however at [**Hospital1 18**] pt denied any chest
pain/pressure. Films were reviewed with interventionalists and
pt appeared to have sufficient TIMI flow past tight Diag s/p
POBA. Therefore no acute indication for further intervention was
found. Pt was continued on ASA, BB, plavix, statin, ACE-I
started to decrease afterload. Integrillin x 18 hours and hep
gtt. Metoprolol was increase to 50 mg qd for better bp control.
Pump- TTE demonstrated EF of 40 to 45% with lat wall HK but
otherwise normal. Intra-aortic balloon pump d/c'd on [**2106-7-13**] as
pt had appropriate hemodynamics. No valvular disease by echo.
Maintained on telemetry. Stable throughout admission until
discharge with no intervention needed.
Medications on Admission:
Medications on transfer:
Aspirin 325
Atorvastatin 80
Clopidogrel Bisulfate 75
Eptifibatide 2 mcg/kg/min IV drip
Heparin SC
Insulin sliding scale
Oxycodone-Acetaminophen 1-2 tabs prn
Medications prior to admission:
Brazilian medications
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*1*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold if SBP<100.
Disp:*60 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual q 5 minutes as needed for chest pain: up to three
tablets if no relief call 911.
Disp:*30 tab* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation MI, with L circumflex stent placement and possible
residual stenosis in the ramus intermedius.
Discharge Condition:
stable
Discharge Instructions:
Please continue to take all medications and attend all follow-up
appointments as directed. You MUST take aspirin and plavix every
day without missing a dose since you have had a stent. If you
miss a dose, you are at risk of having a severe heart attack.
If you have any chest pain, shortness of breath or any other
concerning symptoms, please call your doctor immediately or go
to the emergency room.
Followup Instructions:
Cardiology follow- up with Dr. [**Last Name (STitle) 6254**], Heart Center [**Hospital 3856**].
[**7-29**], 9:00 AM. If questions or to confirm, call [**Telephone/Fax (1) 6256**]
Primary Care follow up with Dr. [**Last Name (STitle) 67944**], [**Hospital1 67945**].
Wellness Center [**Location (un) **]. Tuesday [**8-10**]. Will call pt with
earlier date if possible. Questions or to confirm. Please call
[**Telephone/Fax (1) 12295**]
|
[
"272.0",
"412",
"414.01",
"410.91",
"V17.3",
"250.00",
"305.1",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.44",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
5145, 5151
|
2824, 4054
|
328, 399
|
5303, 5312
|
1707, 2801
|
5762, 6201
|
1270, 1325
|
4342, 5122
|
5172, 5282
|
4080, 4080
|
5336, 5739
|
1340, 1688
|
4295, 4319
|
277, 290
|
427, 1077
|
4105, 4263
|
1099, 1177
|
1193, 1254
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,785
| 141,864
|
46490
|
Discharge summary
|
report
|
Admission Date: [**2167-9-24**] Discharge Date: [**2167-10-7**]
Date of Birth: [**2087-10-1**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Gangrenous R foot
Major Surgical or Invasive Procedure:
Right below knee amputation [**2167-9-29**]
Left femoral central venous line placement
History of Present Illness:
80 yo male with history of a failed right lower extremity bypass
graft presented with ischemic rest pain and gangrene of the
right forefoot. No further revascularization options were
available. Pt has extensive cardiac history including CAD and
Afib on coumadin.
Past Medical History:
1. CHF: diastolic & systolic HF with CRI, EF 40-45% in [**1-13**] and
[**5-14**]
2. CAD s/p 2V-CABG [**2161**]
3. CVA: ([**2154**]) 3-4 days of slurred speech and right facial droop
without residual symptoms. s/p CEA (documented however patient
without memory of this procedure)
4. HTN
5. Hyperlipidemia
6. IDDM (retinopathy, nephropathy, neuropathy)
7. NSVT
8. Afib
9. PVD s/p R fem-[**Doctor Last Name **] ([**2154**]), R 2nd toe amputation, gangrene L
1st toe s/p amp ([**10-11**]), angio with L SFA stenosis & ratty AT
([**12-11**]), CABG x 2, LLE AT angioplasty ([**6-2**])
10. CRI (b/l around 2.9-3.1)
11. Colon ca s/p hemicolectomy
12. H/o diverticulosis
13. H/o angioectasia in stomach w/UGIB [**3-/2161**] and again [**7-/2166**]
14. Prostate ca (dx'd [**2150**]): s/p orchiectomy ([**2150**]), TURP ([**2153**])
& pelvic XRT ([**2155**]) with radiation 'proctopathy'.
15. Iron deficiency anemia on bone marrow aspirate ([**2157**])
16. Interstitial lung disease w/mediastinal LAD & a negative
CMA. (Differential diagnosis included burned out sarcoidosis
versus interstitial pulmonary fibrosis versus malignancy.) s/p
flexible bronchoscopy and cervical mediastinoscopy with biopsies
([**5-9**])
17. Left cataract surgery
[**77**]. UGIB [**2-7**] angioectasia ([**3-8**], [**7-13**], [**5-14**])
19. CEA
20. Cervical mediastinoscopy with biopsies ([**5-9**])
Social History:
Social history is significant for the absence of current tobacco
use; he has a remote history of tobacco use but quit in his 20s.
There is no history of alcohol abuse or illicit drug use.
Patient is widowed and transferred from [**Hospital3 1186**]. He is a
retired foreman for [**Company 2676**].
Family History:
Father: DM, alcohol related death
Mother: DM,passed away giving birth to 22nd child
Daughter: macular degeneration
Physical Exam:
GEN: NAD, pleasant.
HEENT: MMM. Pupils are equal, round, and reactive to light.
Extraocular muscles are intact. Oropharynx is clear. Mucous
membranes are dry. No oropharyngeal erythema or exudate.
Neck: Supple without lymphadenopathy.
CV: RRR. No m/r/g.
LUNGS: Clear anteriorly.
ABD: +BS. Soft, NTND. No HSM.
EXT: RLE BKA, left lower extremity is dressed post-surgically
but appears more edematous than the right lower extremity.
Pertinent Results:
[**2167-10-7**] 10:20AM BLOOD WBC-7.9 RBC-3.60* Hgb-9.5* Hct-29.6*
MCV-82 MCH-26.4* MCHC-32.1 RDW-21.0* Plt Ct-109*#
[**2167-10-7**] 09:26AM BLOOD WBC-7.7 RBC-3.59* Hgb-9.6* Hct-29.8*
MCV-83 MCH-26.7* MCHC-32.2 RDW-21.0* Plt Ct-114*#
[**2167-10-6**] 05:25AM BLOOD WBC-6.7 RBC-3.35* Hgb-8.8* Hct-27.9*
MCV-83 MCH-26.1* MCHC-31.4 RDW-21.2* Plt Ct-54* PT-19.8*
PTT-40.0* INR(PT)-1.8*
[**2167-10-5**] 03:19AM BLOOD WBC-6.5 RBC-3.57* Hgb-9.2* Hct-29.9*
MCV-84 MCH-25.8* MCHC-30.9* RDW-20.4* Plt Ct-81*
[**2167-10-4**] 02:17AM BLOOD WBC-8.1 RBC-3.51* Hgb-9.2* Hct-28.5*
MCV-81* MCH-26.2* MCHC-32.3 RDW-21.4* Plt Ct-55* PT-20.5*
PTT-39.4* INR(PT)-1.9*
[**2167-9-29**] 04:00PM BLOOD WBC-8.1 RBC-3.02* Hgb-7.8* Hct-24.2*
MCV-80* MCH-25.8* MCHC-32.2 RDW-21.3* Plt Ct-99*
[**2167-9-29**] 06:08AM BLOOD WBC-6.4 RBC-3.25* Hgb-8.1* Hct-26.9*
MCV-83 MCH-24.9* MCHC-30.1* RDW-19.9* Plt Ct-77*
[**2167-9-28**] 04:20AM BLOOD WBC-7.0 RBC-3.45* Hgb-8.7* Hct-28.3*
MCV-82 MCH-25.1* MCHC-30.7* RDW-19.6* Plt Ct-141*
[**2167-9-27**] 02:28AM BLOOD WBC-6.7 RBC-3.53* Hgb-8.7*# Hct-28.9*
MCV-82 MCH-24.7* MCHC-30.1* RDW-19.3* Plt Ct-102*
[**2167-9-26**] 02:09AM BLOOD WBC-8.0 RBC-2.86* Hgb-6.9* Hct-23.3*
MCV-81* MCH-24.2* MCHC-29.8* RDW-19.1* Plt Ct-108*
[**2167-9-25**] 09:10PM BLOOD WBC-9.1 RBC-3.27* Hgb-7.6* Hct-25.7*
MCV-79* MCH-23.2* MCHC-29.6* RDW-20.4* Plt Ct-139*
[**2167-9-25**] 11:30AM BLOOD WBC-8.7 RBC-3.18* Hgb-7.4* Hct-24.6*
MCV-78* MCH-23.3* MCHC-30.1* RDW-20.2* Plt Ct-120*
[**2167-9-24**] 08:51PM BLOOD WBC-9.1 RBC-3.56* Hgb-8.4* Hct-27.6*
MCV-78* MCH-23.6* MCHC-30.3* RDW-20.2* Plt Ct-111* PT-40.1*
PTT-49.3* INR(PT)-4.4*
[**2167-10-1**] 04:04AM BLOOD Neuts-85.1* Bands-0 Lymphs-9.8* Monos-4.4
Eos-0.5 Baso-0.1
[**2167-10-7**] 10:20AM BLOOD Glucose-136* UreaN-19 Creat-2.8* Na-136
K-3.9 Cl-97 HCO3-30 AnGap-13 Calcium-7.3* Phos-3.1 Mg-1.9
[**2167-10-6**] 05:25AM BLOOD Glucose-90 UreaN-13 Creat-2.3* Na-137
K-3.8 Cl-101 HCO3-31 AnGap-9 Calcium-7.7* Phos-2.1* Mg-1.8
[**2167-10-5**] 03:19AM BLOOD Glucose-161* UreaN-19 Creat-2.6* Na-134
K-3.9 Cl-100 HCO3-29 AnGap-9
[**2167-10-4**] 02:17AM BLOOD Glucose-81 UreaN-15 Creat-2.0* Na-135
K-4.2 Cl-101 HCO3-29 AnGap-9 Calcium-7.5* Phos-1.9* Mg-1.9
[**2167-10-3**] 05:08AM BLOOD Glucose-58* UreaN-24* Creat-2.6* Na-139
K-3.5 Cl-104 HCO3-29 AnGap-10
[**2167-10-2**] 04:20PM BLOOD UreaN-23* Creat-2.7* Na-138 K-3.4 Cl-101
HCO3-28 AnGap-12
[**2167-10-2**] 05:08AM BLOOD Glucose-224* UreaN-24* Creat-2.5* Na-140
K-3.6 Cl-103 HCO3-30 AnGap-11
[**2167-9-25**] 11:30AM BLOOD Glucose-111* UreaN-29* Creat-2.6* Na-141
K-3.8 Cl-103 HCO3-30 AnGap-12 Calcium-8.0* Phos-4.0 Mg-1.9
[**2167-9-24**] 08:51PM BLOOD Glucose-71 UreaN-22* Creat-2.5* Na-143
K-4.0 Cl-106 HCO3-27 AnGap-14 Calcium-8.4 Phos-3.3 Mg-1.9
[**2167-9-30**] 02:08AM BLOOD ALT-15 AST-23 CK(CPK)-119 AlkPhos-84
TotBili-1.4
[**2167-9-26**] 02:09AM BLOOD ALT-16 AST-22 AlkPhos-120* Amylase-22
TotBili-0.9
[**2167-9-26**] 02:09AM BLOOD Lipase-15
[**2167-9-30**] 02:08AM BLOOD CK-MB-6 cTropnT-0.17*
[**2167-9-29**] 05:16PM BLOOD cTropnT-0.15*
BLOOD [**2167-9-25**] 11:30AM BLOOD UricAcd-4.9
[**2167-9-24**] 08:51PM BLOOD [**2167-9-29**] 06:08AM BLOOD TSH-3.1
[**2167-10-1**] 03:57PM BLOOD Cortsol-33.7*
[**2167-10-1**] 03:21PM BLOOD Cortsol-30.6*
[**2167-10-1**] 02:53PM BLOOD Cortsol-21.2*
[**2167-10-7**] 10:20AM BLOOD Vanco-10.9
[**2167-10-5**] 03:19AM BLOOD Vanco-11.4
[**2167-10-2**] 05:08AM BLOOD Vanco-10.1
[**2167-9-30**] 10:00AM BLOOD Vanco-6.7*
[**2167-9-28**] 04:20AM BLOOD Vanco-4.5*
[**2167-10-7**] 05:26AM BLOOD Digoxin-1.6
[**2167-10-6**] 05:25AM BLOOD Digoxin-1.7
[**2167-10-3**] 05:08AM BLOOD Digoxin-1.1
[**2167-9-28**] 04:20AM BLOOD Digoxin-1.0
Brief Hospital Course:
Pt was admitted on [**2167-9-24**] for a gangrenous R foot.
Vanc/Cipro/Flagyl was started for possible infection.
Nephrology was consulted to continue the pt's MWF hemodialysis
regimen. The hospitalist service was consulted for the pt's
altered mental status who recommended to continue broad-spectrum
antibiotic coverage, check a head CT and to d/c coumadin. On
[**2167-9-26**], the pt began passing maroon-colored stools. The pt Hct
dropped, but he remained asymptomatic with stable BPs. GI was
consulted.
On [**2167-9-28**], cardiology performed a stress test on the pt and
recommended b-blockade. On [**2167-9-29**], cardiology designated the
pt as high risk, but no cardiac revascularization was indicated.
Later, on [**2167-9-29**], the right BKA performed. The pt was
transferred to the VICU postoperatively. The pt was slow to
wean from the vent. After weaning, the pt required
phenylephrine. On [**2167-9-30**], the pt was transferred to the CVICU
due to GI bleed. Pt was transfused with FFP and PRBC.
Ceftazidime, vancomycin, and flagyl were continued. Pt was
weaned off pressors on [**2167-10-3**]. On [**2167-10-4**], once the pt's INR
decreased, the pt underwent EGD/colonscopy which demonstrated
angioectasia. On [**2167-10-5**], the pt was transferred to the VICU.
On [**2167-10-6**], cardiology visited the pt to evaluate abnormal
telemetry. Cardiology recommended that digoxin be held until
dig level <1.0. Physical therapy evaluated the pt and
recommended rehab s/p discharge. On [**2167-10-7**], cardiology
evaluated the pt again. Telemetry continued to demonstrate
ectopy including NSVT. Amiodarone and metoprolol were
continued. Renal requested that BP meds be held on the AM of HD
days. On [**2167-10-7**], as the pt was stable to transfer to acute
rehab, he was discharged with followup.
Medications on Admission:
Bisacodyl 5 mg PRN constipation
Prilosec OTC 20 mg q day
Simvastatin 10 mg q day
Plavix 75 mg q day
Digoxin 0.125 mg PO EVERY OTHER DAY Start
Coumadin varied
Cymbalta 30 mg QHS
Tramadol 25 mg TID
Metoprolol 12.5 [**Hospital1 **]
Tramadol 50 mg q 4 hours
Torsemide 100 mg q day and QHS
Senna 8.6 mg TID
Tylenol 325 2 tabs PRN
Ferrous sulfate 324 mg q day
Colace 100 mg q day
Humalog SS
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. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
[**Hospital1 21013**]).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO QHS (once a day (at [**Hospital1 21013**])).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day): Hold until Digoxin level is <1.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Insulin Glargine 100 unit/mL Cartridge Sig: 10 Units
Subcutaneous With breakfast.
14. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: At breakfast, lunch, dinner. For
blood sugar 61-109 - 0 units; 110-130 - 2 units; 131-150 - 4
units; 151-180 - 6 units; 181-210 - 8 units; 211-240 - 10 units;
>240 [**Name8 (MD) 138**] MD.
[**First Name (Titles) **] [**Last Name (Titles) 21013**], for blood sugar 61-109 - 0 units; 110-130 - 0 units;
131-150 - 0 units; 151-180 - 2 units; 181-210 - 4 units; 211-240
- 6 units; >240 [**Name8 (MD) 138**] MD.
15. Outpatient Lab Work
Please obtain Digoxin levels daily until level <1; at that time
restart Digioxin .0625 every other day
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Right foot gangrene, s/p R BKA
Discharge Condition:
Improved
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid restriction
DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION
.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
.
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
.
No driving until cleared by your Surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your leg wound(s) .
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
.
Do not drive a car unless cleared by your Surgeon.
.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with [**Name8 (MD) 1106**] problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2167-11-4**] 10:15
Completed by:[**2167-10-7**]
|
[
"427.1",
"707.20",
"272.4",
"428.42",
"578.9",
"250.40",
"250.60",
"707.14",
"285.21",
"428.0",
"V10.46",
"331.0",
"585.6",
"515",
"357.2",
"294.10",
"362.01",
"427.31",
"250.50",
"707.05",
"583.81",
"403.91",
"V10.05",
"V45.81",
"440.24"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.15",
"39.95",
"38.93",
"99.07",
"45.13",
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
10873, 10939
|
6662, 8498
|
286, 375
|
11014, 11025
|
2983, 6639
|
16548, 16722
|
2397, 2513
|
8933, 10850
|
10960, 10993
|
8524, 8910
|
11049, 12911
|
2528, 2964
|
229, 248
|
12923, 15848
|
15871, 16525
|
403, 668
|
690, 2063
|
2079, 2381
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,782
| 113,985
|
50193+59243
|
Discharge summary
|
report+addendum
|
Admission Date: [**2115-9-11**] Discharge Date: [**2115-11-18**]
Date of Birth: [**2041-10-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Barrett's esophagus
Major Surgical or Invasive Procedure:
thorascopic laparoscopic esophagogastrectomy, feeding
jejunostomy [**2115-9-11**]
percutaneous tracheostomy [**2115-10-12**]
History of Present Illness:
73 y/o male with history of Barrett's esophagus with high grade
dysplasia on recent biopsy. Patient also complains of
regurgiation, but no weight loss.
Past Medical History:
1) atrial fibrillation - s/p ETOH ablation and pacemaker
placement, on coumadin
2) GERD
3) hypertrophic cardiomyopathy (idiopathic hypertrophic
subaortic stenosis) recent ejection fraction of 64%
4) osteoarthritis
5) s/p total knee replacement
6) Barrett's esophagus
7) prostate CA
8) hypertension
9) hypercholesterolemia
Social History:
lives with wife, retired truck driver, has three grown children,
no tobacco ETOH or other drug use
Family History:
no family history of psychiatric disease or substance abuse
Physical Exam:
VS: 96.6 82 123/57 20 97%
General: NAD, looks well
Chest: clear to auscultaton bilaterally
Heart: RRR
Abdomen: soft, non-tender-nondistended
Ext: wwp, no edema
Pertinent Results:
[**2115-9-11**] 09:39PM GLUCOSE-150* UREA N-28* CREAT-1.0 SODIUM-136
POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-18* ANION GAP-17
[**2115-9-11**] 09:39PM CALCIUM-7.2* PHOSPHATE-3.7# MAGNESIUM-1.2*
[**2115-9-11**] 09:39PM WBC-12.8* RBC-3.28*# HGB-10.6*# HCT-29.0*#
MCV-89 MCH-32.4* MCHC-36.6* RDW-13.0
[**2115-9-11**] 09:39PM PLT COUNT-182
[**2115-9-11**] 09:39PM PT-16.2* PTT-32.4 INR(PT)-1.7
[**2115-11-15**] 06:40AM BLOOD WBC-10.5 RBC-3.32* Hgb-10.1* Hct-29.3*
MCV-88 MCH-30.3 MCHC-34.3 RDW-14.6 Plt Ct-386
[**2115-11-15**] 06:40AM BLOOD Glucose-133* UreaN-34* Creat-0.8 Na-139
K-4.6 Cl-102 HCO3-32* AnGap-10
[**2115-10-1**] 10:00AM BLOOD ALT-19 AST-19 AlkPhos-84 Amylase-66
TotBili-0.7
[**2115-11-15**] 06:40AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9
[**2115-10-29**] 02:30AM BLOOD calTIBC-231* VitB12-951* Folate-14.0
Ferritn-260 TRF-178*
[**2115-11-12**] 04:34AM BLOOD TSH-7.4*
[**2115-11-12**] 04:34AM BLOOD T4-5.6 T3-78* calcTBG-0.95 TUptake-1.05
T4Index-5.9
[**2115-11-6**] 02:30AM BLOOD Digoxin-1.4
[**2115-11-18**] 06:21AM BLOOD PT-18.0* INR(PT)-2.0
Brief Hospital Course:
This is a brief hospital course organized by systems. Overall
patient had an uncomplicated laparoscopic/thoracoscopic
esophagogastrectomy and feeding jejunostomy that was complicated
by a pseudomonas pneumonia requiring prolonged intubation,
antibiotics and chest tubes; atrial fibrillation requiring
diltiazem drip; as well as persistent delirium. At the time of
discharge delirium, pneumonia, and atrial fibrillation had
resolved. Patient spent 41 consecutive days in surgical
intensive care unit and 50 total days in the SICU.
1)GI: Patient underwent laparoscopic/thoracoscopic
esophagogastrectomy and feeding jejunostomy on the day of
admission. Procedure went well without complications. Patient
went to SICU for close monitoring following the procedure.
Flexible esophagoscopy on [**2115-10-15**] showed patent anastomosis
with no area of breakdown
2) Respiratory: Intubated following surgery. Initially unable to
extubate due to thick sputum and increased secretions. Then
extubation continued due to pseudomonas pneumonia. CT scan [**9-17**]
showed RLL and LL consolidation and bilateral pleural effusion.
A left chest tube was placed on [**2115-9-24**] for respiratory distress
and persistent left sided pleural effusion and removed on
[**2115-10-1**]. Attempt at extubation [**2115-10-1**] failed. Patient remained
intubated with endotracheal tube 21 days until [**2115-10-2**] at which
time a percutaneous tracheostomy was placed. Right chest tube
placed on [**2115-10-5**] for a pleural effusion. Patient weaned from
ventilation and trach mask placed successfully on [**2115-10-13**]
(POD#31).
Patient readmitted to SICU on [**2115-10-30**] (POD#49) for respiratory
distress. Ventilation restarted and bronchoscopy was performed.
Chest CT demonstrated no acute change. Patient again weaned
quickly to trach collar and transferred back to floor [**2115-11-7**]
(POD#57).
Tracheostomy downsized to #6 on [**2115-11-14**] (POD#64) and
decannulated completely on [**2115-11-18**].
3) Psychiatric: Began getting agitated and receiving PRN Haldol
on [**2115-9-16**]. Subsequently increased to 4mg TID on [**2115-9-17**].
Haldol stopped and Seroquel started on [**2115-10-10**] (POD#29) for
continued agitation. Upon transfer to floor patient remained
very agitated, disoriented, and unable to sleep. Psychiatry was
consulted on [**2115-10-28**](POD#47) and formally diagnosed patient with
delirium and recommended checking TSH, B12, folate, and head CT.
All of these tests were unremarkable except for TSH which showed
patient to be hypothyroid. Sensorium began to clear on the night
of [**2115-11-14**] (POD#64) with patient no longer requiring a sitter
and increasing orientation. Psychiatric evaluation on [**2115-11-18**]
(POD#68) confirmed that patient had a delirium, multifactorial
etiology, that had resolved. They recommended continued 150 mg
[**Date Range **] Seroquel with possible wean starting next week.
4) Fluids/Electrolytes/Nutrition: Trophic tube feeds with Impact
begun on [**2115-9-13**] via J-tube. Feeds advanced without difficulty
to 3/4 strength impact with fiber at a rate of 100ccs/hour.
Bedside swallowing evaluations on [**2115-10-24**] demonstrated
aspiration of thin and thick liquids and video swallow test also
showed patient to be at risk for aspiration. Subsequent
oropharyngeal videofluoroscopy swallowing evaluation on [**2115-11-8**]
confirmed these findings.
5) Urogenital: Foley pulled out by patient on POD#62 ([**2115-11-12**])
and remained out until discharge. Patient is occasionally
incontinent of urine, but this incontinence was improving at the
time of discharge.
6) Cardiac: Developed atrial fibrillation in the early
post-operative period which was treated with diltiazem gtt and
Lopressor. Cardiology was consulted. Diltiazem drip was able to
provide good rate control. Patient developed prolonged QT most
likely secondary to Haldol and had at least one run of
non-sustained ventricular tachycardia. Coumadin restated on
[**2115-10-10**]. Diltiazem continuous infusion stopped on [**2115-10-9**]
(POD#29) and digoxin added on [**2115-10-11**] (POD#30).
Patient had episode of lateral wall ischemia and RBBB on
[**2115-11-2**] POD#52 with small rise in troponin. Cardiology,
however, believed that patient suffered only mild
heart damage. Echocardiogram demonstrated ejection fraction of
greater than 55%.
7) ID: Initially on cefazolin and Flagyl as post-operative
prophylaxis. Changed to Zosyn on [**2115-9-14**] for pseudomonas
positive sputum cultures on [**9-13**] and [**9-14**] with gentamycin
added on [**2115-9-18**]. Sputum cultures continued to grow
pseudomonas on [**2115-9-23**] and bronchoalveolar lavage culture from
[**2115-9-26**] also grew pseudomonas. Vancomycin added on [**2115-9-17**] for
high WBC count and concern about a wound cellulitis and
discontinued on [**2115-9-30**]. Flagyl was started on [**9-21**] empirically
for possible C. difficile colitis and was subsequently stopped
on [**2115-9-24**] following three negative C. difficile stool toxin
tests. Gentamycin was discontinued on ID's recommendation on
[**2115-10-13**] (POD#32) and Zosyn was discontinued on [**2115-10-21**]
(POD#40) after 38 days following negative gram stain of pleural
fluid.
Vancomycin and meropenem were restarted on [**2115-10-30**] (POD#50)
empirically for respiratory distress. Vancomycin discontinued
after seven days and Meropenem after 8 days.
8) Tubes/Lines/Drains: Patient had multiple central lines,
arterial lines, PICC lines, chest tubes, and JP drains. At the
time of discharge all tubes, lines and drains were removed
excepted the J-tube. The PICC line was discontinued immediately
prior to discharge.
9) Ophthalmology: Consulted on [**2115-11-14**] for blurry vision.
Vision 20/20 in one eye and 20/25 in the contralateral eye.
Patient diagnosed with dry eyes. Lubricating eye drops and warm
compresses recommended.
1)) Endocrine: Patient diagnosed with hypothyroidism and started
on Synthroid on [**2115-11-14**] (POD#64). Case was discussed informally
with endocrinology.
Medications on Admission:
amoxicillin 500mg, atrovaststin 40mg [**Date Range 6089**], flomax 4mg [**Date Range 6089**], lasix
20mg QD, prevacid 30mg QD, proscar 5mg [**Name (NI) 6089**], sonata [**Name (NI) **],
traimcinlone 4 puffs [**Hospital1 **], verapamil 120mg TID, Warfarin 2mg qd,
Zetia 10mg qd
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
2. Calcium Carbonate 1250 mg/5 mL Suspension Sig: 1000 (1000) mg
PO TID (3 times a day).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule,
Delayed Release(E.C.)(s)
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO [**Hospital1 6089**]
().
7. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO [**Hospital1 6089**] ().
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO [**Hospital1 6089**] ().
9. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
13. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
14. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs
Miscell. Q4-6H (every 4 to 6 hours).
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-23**]
Puffs Inhalation Q4H (every 4 hours) as needed.
18. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb
Inhalation Q4H (every 4 hours) as needed. Neb
19. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
20. Quetiapine Fumarate 100 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime): Via J-Tube. Tablet(s)
21. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-23**]
Drops Ophthalmic PRN (as needed).
22. Insulin Regular Human 300 unit/3 mL Syringe Sig: sliding
scale sliding scale Subcutaneous four times a day.
23. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses: Please check INR frequently at least [**Month/Day (2) 6089**],
with goal INR 2-2.5, as patient is not stabilized on this
regimen.
24. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed. ML(s)
25. Papain Powder Sig: [**9-11**] Miscell. PRN (as needed): to
J-tube as needed if to clear obstructed J-Tube. ML(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Barrett's esophagus
pseudomonas pneumonia
pleural effusion
delirium
atrial fibrillation
hypothryoidism
Discharge Condition:
Good
Discharge Instructions:
Please continue keeping the patient NPO until it is determined
via swallow study that he is not aspirating. Please give
patient tube feeds of Impact with fiber at 3/4 strength at
100ccs/hour cycled from 24:00 to 10:00, check resdiual q4h and
hold fro residual >100mL. Please flush q12h with 30ccs water.
Please change dressing over tracheostomy and j-tube once per
day. Other incisions may be left open to air.
Please have patient take all prescribed medications.
Please have patient follow-up with Dr. [**Last Name (STitle) **] as directed.
Followup Instructions:
Please follw-up with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] of general surgery
in two weeks. Call ([**Telephone/Fax (1) 1483**] for appoinment and
directions.
Name: [**Known lastname **],[**Known firstname 1500**] Unit No: [**Numeric Identifier 17027**]
Admission Date: [**2115-9-11**] Discharge Date: [**2115-11-18**]
Date of Birth: [**2041-10-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 203**]
Addendum:
Please note patient's tracheostomy was NOT decannulated and a
number 6 french tracheostomy remains in place. Please also note
that patient is chronically in atrial fibrillation, however, he
has adequate rate control and is anticoagulated. Also note that
tube feeds are being changed to full strength Impact with fiber
given at 100cc/hour cycled over 18 hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2115-11-18**]
|
[
"425.4",
"482.1",
"244.9",
"V45.01",
"780.52",
"V43.65",
"511.9",
"518.5",
"682.2",
"230.2",
"530.85",
"427.31",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.56",
"34.91",
"99.04",
"33.22",
"96.6",
"43.99",
"99.07",
"31.1",
"34.04",
"40.3",
"46.39",
"33.24",
"38.91",
"44.12"
] |
icd9pcs
|
[
[
[]
]
] |
13191, 13417
|
2462, 8537
|
336, 464
|
11622, 11628
|
1380, 2439
|
12222, 13168
|
1124, 1185
|
8864, 11381
|
11497, 11601
|
8563, 8841
|
11652, 12199
|
1200, 1361
|
277, 298
|
492, 646
|
668, 992
|
1008, 1108
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,859
| 118,564
|
8108
|
Discharge summary
|
report
|
Admission Date: [**2180-4-6**] Discharge Date: [**2180-4-20**]
Date of Birth: [**2152-9-9**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 28912**] is a 27-year-old HIV
positive male who presented with fevers, chills, headache to
the Emergency Room. The patient was in his usual state of
health until last week while being on vacation in [**Location (un) 28913**]. He developed throbbing frontal occipital headache
eyes and dry mouth and the headache was alleviated only
slightly with ibuprofen. About one day later, the patient
developed diffuse myalgia, began having shaking chills, and
noted an intense erythema over both legs and injected
conjunctivae and sclerae. These symptoms persisted over
three days and patient returned from vacation. At home, he
noted a temperature of 103.9 and came to the Emergency
On review of systems, the patient had not had any headache as
above before, is not photophobic, but does complain of a
stiff neck. He did not have any visual disturbances,
photophobia, nasal congestion, sore throat, oral ulcers or
odynophagia. He does complain of mild shortness of breath
over several months but is unable to quantify this in more
detail and shortness of breath did not limit him in daily
activities. He does complain of a cough. He is not
complaining of nausea or vomiting, chronic fevers. He does
complain of tarry loose stools, twice to three times per day,
otherwise, has no urinary symptoms. He cannot recall any
exposure to wild plants and animals or travels to exotic
rural settings. He does not recall when his last PPD was
done.
PAST MEDICAL HISTORY: HIV was diagnosed in [**2171-2-25**].
Until then, he had a stable CD4 count in the mid 300s and
never had any opportunistic infections or AIDS defining
illnesses until now. He was in no previous HAART. Two weeks
ago, CD4 count was 171, his viral load 200,000 and was
started on Bactrim for Pneumocystis carinii prophylaxis.
2. Status post auricle cyst excision.
MEDICATIONS PRIOR TO ADMISSION: Bactrim, acyclovir.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a single homosexual young man
who at the moment has no current partners and is not sexually
active. He denies alcohol or intravenous drug abuse. He is
employed as a coordinator for a program for the Pediatric
Justice Department, working with HIV positive kids. He is
also a part-time veterinarian technician. Recently, his
travel history included a stay in [**Location (un) 5953**] last week and
a stay in D.C. last month, Phoenix last year. At home, he
has three cats.
PHYSICAL EXAMINATION: His temperature was 99.6. Blood
pressure 116/62. Pulse 93. Respiratory rate 19. 02
saturation on room air 98%. In general, he is an awake,
alert and oriented young man, looks slightly uncomfortable
and is coughing. His pupils are equally round and reactive
to light. He has some conjunctival and scleral injection on
both eyes. No oral lesions. His neck exam reveals post
cervical tender lymphadenopathy and supple meningismus.
Auscultation of his heart revealed regular rate and rhythm,
no murmurs, gallops or friction rubs. Auscultation of the
lungs reveals scattered inspiratory crackles in the right
post mid lung field. The abdomen is soft, nontender,
nondistended and only shows slight right upper quadrant
tenderness on deep palpation. Bowel sounds are normal active
over all four quadrants. There is no edema and his
extremities show no cyanosis or clubbing. The skin on his
back and on both legs proximally shows a diffuse erythema
with no open ulcerations, no desquamations and no petechial
purpura like appearance. On neurological exam, he is alert
and oriented times four. Muscle strength 5/5 throughout.
LABORATORIES ON ADMISSION: White blood cell count 2.3,
hematocrit 37, platelet count 133,000. Differential is 57
polymorphonucleocytes, 35 lymphocytes, 6 monocytes, 1
eosinophil. MCV is 85, sodium 136, potassium 3.4, chloride
102, HCO3 25, BUN 9, creatinine 0.9, glucose 92.
COURSE OF HOSPITAL STAY: To rule out meningitis, a head CT
was performed showing no acute intracranial process. A
lumbar puncture revealed 2 white blood cells, no red blood
cells, protein of 31, glucose of 53 in cerebrospinal fluid.
Because of his shortness of breath and to rule out pneumonia
as the source of his symptoms, a chest x-ray was performed
showing no cardiopulmonary process. The next day, his cough
increased as well as his shortness of breath, and he became
hypoxic. His 02 saturation dropped to 85% on five liters.
Another chest x-ray was done showing now an acute
interstitial and valvular pulmonary edema. The heart size
now was borderline with diffuse interstitial pulmonary edema.
Predominantly perihilar air space opacities and small
bilateral pleural effusions. Induced sputums were performed
and the patient was started on intravenous Bactrim and
prednisone for a possible PCP infection and levofloxacin for
any community-acquired pneumonia. An echocardiogram was also
performed showing an ejection fraction of over 65% with
normal left ventricular wall thickness, cavity size and
systolic function.
As the patient continued to worsen and became increasingly
hypoxic, he was transferred to the Medical Intensive Care
Unit on day two of his hospital stay. Blood cultures, urine
cultures, stool cultures were obtained, but were all
negative. The patient was also feeling increasingly anxious
and was given morphine, pantoprazole, zolpidem, and heparin.
On day three of his hospital stay, the patient had to be
intubated due to increasing hypoxia and respiratory distress.
Another chest x-ray now showed a worsening in aeration. The
previously noted pulmonary edema, which had predominated in
the central lung zone, appeared to have extended into more
peripheral portions of both hemithoraces. It was consistent
with adult respiratory distress syndrome and possibly
superimposed pneumonia. The patient was sedated through
Fentanyl, lorazepam and also received nicotine.
On day five of his hospital stay, hematocrit dropped to 26.7.
He had not stooled and laboratory findings were not
significant for hemolysis; therefore, an abdominal CT scan
was performed to rule out retroperitoneal bleeding. The CT
showed evidence of bilateral pneumonia aspiration, mild
pleural effusions, but no focal consolidations and no
retroperitoneal bleeding. To identify the source of his
infection, a bronchoalveolar lavage was performed but viral
culture was negative. Influenza antigens A and B were
negative. Respiratory syncytial virus [**Doctor Last Name 360**] was negative.
No acid fast bacillus in the smear was detected. No
polymorphonuclears and sparse oropharyngeal flora could be
seen. Fungal culture was negative. Legionella culture was
negative and PCP was negative. The sputum showed only sparse
oropharyngeal growth. Cerebrospinal fluid culture was
negative for cryptococcal antigen fungus. The HIV viral load
was 343. Serology was as follows: EBV: VCA, IgG antibody
positive. EBNA IgG antibody negative. VCA, IgM antibody
negative. Toxoplasma IgG antibody equivocal. CMV IgG
antibody 385 AU/ml. Hepatitis A antibody negative. IgG
indeterminate, IgM negative, IgA negative. HBS antigen
negative. HBS antibody positive. HBV antibody negative.
HCV antibody negative. HIV antibody positive.
Stool cultures showed no ova or parasites. No
Cryptosporidium, no Giardia, no polymorphonucleocytes. C.
difficile was repeatedly negative. As Bactrim has been
described to be associated with adult respiratory distress
syndrome, Bactrim was discontinued on day five of hospital
stay. Within the next three days, the patient improved,
still had fevers, but could be put on a spontaneous breathing
ventilator on day eight of his hospital stay and extubated on
day nine. The skin signs markedly improved and his 02
saturation on hospital day nine was now 98% on four liters of
oxygen/nasal cannula.
On day ten of his hospital stay, the patient developed
withdrawal symptoms consisting of agitation, hallucinations
and tachypnea, which could be attributed to the high doses of
Fentanyl he had received.
The patient was transferred to the Medicine Floor on day ten
of his hospital stay. A chest x-ray showed no significant
changes to previous ones. The patient remained to be anxious
and agitated. He also still had hallucinations and an oral
thrush could be observed and treated with Nystatin. He
continued to have diarrhea, but his stool cultures remained
negative. Blood cultures were drawn and were still pending.
On day 12 of his hospital stay, the patient was started on
Dapsone for PCP prophylaxis, but the patient developed a rash
on both arms and the back again. As Dapsone is known to show
a cross reactivity to Bactrim in [**10-20**]%, Dapsone was
discontinued. Patient continued to have fevers and further
blood cultures were drawn which are still pending.
On day 14 of his hospital stay, all medications except
prednisone and the nicotine patch were discontinued. The
patient was seen by Physical Therapy and started to walk
around the floor. Diarrhea seemed to have gotten better.
His temperatures remained at low grade. On day 15 of his
hospital stay, the patient was discharged. Blood cultures
will have to be followed up with Dr. [**Last Name (STitle) **], with whom he
has an appointment within two weeks and a Infectious Disease
Consult for starting of HAART and PCP [**Name Initial (PRE) 1102**]. His
medications on discharge are Nystatin and nicotine patches.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Last Name (NamePattern4) 28914**]
MEDQUIST36
D: [**2180-4-21**] 02:24
T: [**2180-4-21**] 02:43
JOB#: [**Job Number 14476**]
|
[
"693.8",
"042",
"507.0",
"285.9",
"112.0",
"E931.0",
"E931.8",
"518.81",
"E930.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"39.93",
"38.91",
"99.15",
"03.31",
"33.23",
"96.56",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2051, 2110
|
2641, 3786
|
163, 1628
|
3801, 9865
|
1652, 2018
|
2127, 2618
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,361
| 134,284
|
33512
|
Discharge summary
|
report
|
Admission Date: [**2189-2-25**] Discharge Date: [**2189-3-13**]
Date of Birth: [**2130-8-9**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr. [**Known lastname 77702**] is a 58-year-old man with a history of
hypertension and DM who presents with dysarthria and left sided
weakness and was found to have a right thalamic bleed. He was in
his USOH at 11:30 pm last night when he was out shoveling snow
and developed sudden-onset dizziness, headache, and left-sided
heaviness. When he first felt the headache, he went to sit down,
but felt himself starting to fall to the left. He did sit down
without falling, but when he tried to get up he was unable to
walk.
He was initially taken by EMS to [**Hospital3 **], where initial
BP was 207/100. CEs negative. Head CT showed right thalamic
intraparenchymal hemorrhage, 2.7 x 2.6 cm. He was placed on a
nitroglycerin gtt and transported to [**Hospital1 18**] ED.
He denies current headache ("I feel much better"), loss of
vision, blurred vision, diplopia, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denied difficulties
producing or comprehending speech.
On review of systems, he denied recent fever or chills. No
night
sweats or recent weight loss or gain. 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. Denied rash.
Past Medical History:
HTN
DM2
Social History:
No tobacco, alcohol, or illicits. Lives in [**Hospital1 189**] with
wife and 2 kids. Originally from [**Country 16465**].
Family History:
Parents passed away long ago, one of malaria.
Physical Exam:
Vitals: T: 98.0 P: 73 R: 9 BP: 132/89 (on nitroglycerin gtt)
SaO2: 95%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes noted.
Neurologic:
-Mental Status: Alert but keeps eyes closed for most of
interview, oriented x 3. Markedly dysarthric, difficult to
understand more than 50%. He is able to relate history.
Attentive, names [**Doctor Last Name 1841**] backward with errors, but completes task.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able
to name high frequency objects. Able to follow both midline and
appendicular commands. Pt. was able to register 3 objects and
recall [**3-16**] at 5 minutes. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5mm and brisk. Fundi were not well visualized.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation diminished to pinprick over left.
VII: Right NLF flattening.
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk. Flaccid in left UE. No adventitious
movements noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 0 0 0 0 2 1 4- 5 3 1 4
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Complete loss of sensation to all modalities in left
UE. Diminished to all modalities in left LE.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor on the left, flexor on the right.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS on right. Unable to perform on left.
-Gait: Unable to perform.
Pertinent Results:
[**2189-2-25**] 01:16PM CK(CPK)-154
[**2189-2-25**] 01:16PM CK-MB-2 cTropnT-<0.01
[**2189-2-25**] 09:53AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2189-2-25**] 09:53AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2189-2-25**] 05:00AM PT-12.8 PTT-26.7 INR(PT)-1.1
[**2189-2-25**] 04:00AM GLUCOSE-298* UREA N-18 CREAT-1.3* SODIUM-139
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-30 ANION GAP-11
[**2189-2-25**] 04:00AM CK-MB-2 cTropnT-<0.01
[**2189-2-25**] 04:00AM CALCIUM-9.0 PHOSPHATE-2.6* MAGNESIUM-2.0
[**2189-2-25**] 04:00AM WBC-10.6 RBC-4.91 HGB-13.5* HCT-38.5* MCV-79*
MCH-27.5 MCHC-35.0 RDW-13.1
[**2189-2-25**] 04:00AM NEUTS-81.6* LYMPHS-13.3* MONOS-3.0 EOS-1.6
BASOS-0.5
[**2189-3-3**] 06:05AM BLOOD WBC-9.7 RBC-4.63 Hgb-12.0* Hct-35.0*
MCV-76* MCH-26.0* MCHC-34.5 RDW-13.2 Plt Ct-278
[**2189-3-3**] 06:05AM BLOOD Glucose-125* UreaN-20 Creat-1.3* Na-142
K-3.3 Cl-105 HCO3-27 AnGap-13
[**2189-2-25**] 01:16PM BLOOD CK(CPK)-154
[**2189-3-1**] 10:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2189-3-1**] 10:10AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-150 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2189-3-1**] 10:10AM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
02/13/08/ 03:58AM Head CT without contrast:
IMPRESSION: Large right thalamic hemorrhage with probable
intraventricular extension. Findings are compatible with the
patient's history of hypertensive urgency.
[**2189-2-25**] 06:40AM Head CT without contrast:
IMPRESSION: No interval change in right thalamic hemorrhage.
Brief Hospital Course:
The patient was found to have a large right thalamic hemorrhage
with probable intraventricular extension. Findings are
compatible with the patient's history of hypertensive urgency.
Serial CT scans confirmed a stable hemorrhage. Neurologic exam
significantly improved during stay in ICU with increased
strength in LLE ([**4-17**]+ in all flexors) and 2-3/5 in all extensors
of LUE. Strength gradually improved once he was transferred to
the floor with 4/5 strength in an UMN pattern.
Pt required nicardipine gtt with intermittent labetalol to keep
BPs within desired range in the ICU. Patient was started on
enalapril (with hx of DM) with improved BP control, allowing the
patient to come off of nicardipine gtt. The enalapril was
increased and the labetolol was increased to 600mg [**Hospital1 **]. His
pressure rose again despite this regimen and norvasc 10mg daily
was added.
He was noted to have elevated blood sugars. He was started on
glyburide 5mg [**Hospital1 **]. He was maintained on an insulin sliding
scale.
He had a fever briefly after transfer to the floor, but he never
had a treatable source despite cultures and studies. As such he
was not treated and the fever spontaneously resolved. He has
not been febrile for 5 days prior to discharge.
The physical therapists were consulted and felt that the patient
could use a stay at a rehabilitation facility.
Medications on Admission:
he used to take "something that had 1000 in it" but stopped
that months ago
Discharge Medications:
1. Glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose
Subcutaneous ASDIR (AS DIRECTED).
3. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
5. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q6H
(every 6 hours) as needed: For systolic blood pressure greater
than 160.
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
R thalamic bleed.
Discharge Condition:
Vital signs stable. Pateint has left hemiparesis.
Discharge Instructions:
Please take your medications as prescribed.
Please follow up with your appointments as documented below.
Please seek medical care if you have concerning symptoms. These
include, but are not limited to, weakness, gait instability.
BP should be monitored
Followup Instructions:
Please call [**Telephone/Fax (1) 250**] to book an appointment with a new PCP.
[**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2189-4-14**] 10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
|
[
"431",
"781.3",
"523.9",
"729.89",
"780.6",
"401.9",
"521.00",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8007, 8080
|
5866, 7251
|
335, 341
|
8141, 8193
|
4200, 5843
|
8497, 8834
|
1911, 1959
|
7378, 7984
|
8101, 8120
|
7277, 7355
|
8217, 8474
|
3099, 4181
|
1974, 2494
|
276, 297
|
369, 1723
|
2509, 3082
|
1745, 1755
|
1771, 1895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,839
| 120,118
|
48979
|
Discharge summary
|
report
|
Admission Date: [**2102-5-11**] Discharge Date:[**2102-5-15**]
Date of Birth: [**2040-1-1**] Sex: M
Service: [**Hospital Unit Name 153**]
This is an initial Discharge Summary from the dates of [**2102-5-11**] until [**2102-5-14**]. A subsequent Discharge Summary
addendum will follow.
HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old
male with known metastatic prostate cancer to the liver and
bone who was recently discharged from the [**Hospital1 346**] after a lower gastrointestinal bleed
thought to be radiation prostatitis and hemorrhoids, status
post Vergon laser treatment. He subsequently had progressive
difficulty with swallowing at home and through to have
worsening mucositis. He had a PICC line laced to facilitate
total parenteral nutrition given his poor p.o. intake. He
now presents after having worsened mucositis with some
associated shortness of breath, increasing cough. In the
emergency department he was found to be tachycardic with an
elevated respiratory rate, systolic blood pressures in the
high 90s as well as a lactate of 8.0 and medical criteria for
sepsis protocol. In the emergency department a right
internal jugular was placed. He was given 8 liters of normal
saline and a unit of packed red blood cells, given
ceftriaxone and cefepime as well as Vancomycin and
Azithromycin given his neutropenic status and he was admitted
to the Intensive Care Unit.
PAST MEDICAL HISTORY: 1) Prostate cancer with known
metastasis to the liver and bone. Status post radiation
therapy treated with Zoladex, treated with Taxotere times two
cycles, last on [**5-4**]. 2) Hypertension. 3) History of GI
bleed secondary to radiation prostatitis, status post Argon
laser treatment [**4-24**] and 20.
ALLERGIES: Patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Include finasteride 5 once a day,
Protonix 40 once a day, Percocet p.r.n., Megace 40 once a
day, Flomax .8 h.s., Lidocaine swish and swallow.
INITIAL PHYSICAL EXAMINATION: Temperature of 100.8, pulse
120, blood pressure range of 95/40 to 104/43, respiratory
rate 22, satting 100 percent nonrebreather. Physical
examination - general appearance - patient sitting upright,
cachectic, in respiratory distress with notable respiratory
secretions. Head and neck examination: notable for severe
mucositis involving soft palate and tongue. Neck notable for
hematoma around the left internal jugular site. Neck supple,
no jugular venous distention noted. Lungs: Patient did not
take deep inspirations, no wheezes noted. Some decreased
breath sounds at the bases. Cardiac examination:
tachycardic, mild systolic ejection murmur somewhat difficult
to assess given respiratory secretions. Abdomen: positive
bowel sounds, somewhat distended and tympanic, no rebound
noted. Extremities: 2 to 3+ pitting edema on the right
lower extremity, 2+ pitting edema of the left lower
extremity, right greater than left.
LABORATORY DATA: Initial laboratories notable for white
count of 1.7 with a differential of 16 percent neutrophils, 4
percent bands, 28 percent lymphocytes, 28 percent monos.
Hematocrit of 24.0 and platelets of 114. Coags notable for
INR of 2.0. Chem-7: sodium of 143, potassium 3.6, chloride
110, bicarb 15, BUN and creatinine 29 and 1.2, glucose of 59,
anion gap of 18, calcinotic phos of 6.4, 1.9 and 1.6.
Elevated liver function tests and AST of 176, ALT of 33.
Chest x-ray showing no evidence of pneumonia with some small
bilateral pleural effusions. EKG: sinus tachycardia with no
acute changes.
HOSPITAL COURSE:
1. Sepsis: Patient was placed on sepsis protocol although
his elevated lactates are likely in part due to his known
liver metastasis and tachycardia possibly related to severe
pain related to his worsening mucositis. After aggressive
intravenous hydration he remained hemodynamically stable and
was subsequently afebrile taken off the sepsis protocol.
During his hospital stay his white blood cell count continued
to increase. He was no longer neutropenic and became
afebrile. The source of his infection was not identified and
his cultures remained negative at which time his antibiotics
were discontinued.
2. Hematology oncology: Patient was continued on
finasteride and was initially given vitamin K for elevated
INR. Some mild schistocytes on smear with some elevated
fibrin degradation products, however, did not have evidence
of EIC on subsequent laboratories. Oncology followed the
patient during his stay in the Intensive Care Unit. Again it
was discussed with the family the patient had an extremely
poor prognosis given his known metastatic disease.
3. Mucositis/pain control: Patient has severe mucositis and
was no longer able to take p.o. He was placed on a morphine
PCA as well as Lidocaine swish and swallow and other mouth
care with significant improvement in his discomfort.
4. Code status: Although the exact etiology of the
patient's current infection was somewhat unclear, it was
related to the family that his long term prognosis was
extremely poor given his extensive need for pain control. It
was felt by patient's family that further aggressive measures
should not be taken, that the patient should be comfort
measures only. All life sustaining medications were
discontinued as well as his TPN. Patient was given morphine
and other medications to provide comfort. A subsequent
dictation addendum will follow explaining the rest of the
[**Hospital 228**] hospital course.
KO,[**Name8 (MD) 6337**] M.D.12-871
Dictated By:[**Last Name (NamePattern1) 6289**]
MEDQUIST36
D: [**2102-5-14**] 21:00
BT: [**2102-5-14**] 21:29
JOB#: [**Job Number 102840**]
|
[
"789.5",
"995.92",
"458.0",
"198.5",
"038.9",
"276.2",
"197.7",
"288.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.94",
"38.93",
"99.15",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
1832, 1983
|
3569, 5704
|
2006, 3552
|
336, 1424
|
1447, 1805
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,771
| 185,291
|
61
|
Discharge summary
|
report
|
Admission Date: [**2173-8-27**] Discharge Date: [**2173-9-10**]
Date of Birth: [**2095-6-20**] Sex: M
Service: MEDICINE
Allergies:
Cozaar
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
78 yo male with ESRD came in with abdominal pain
Major Surgical or Invasive Procedure:
Ultrasound-guided percutaneous cholecystostomy with
no immediate complications. 8-French catheter was left in situ
in satisfactory position.
PICC line placement
Percutaneous cholecystostomy tube removal by patient
History of Present Illness:
78 year old male who is status post exploratory laparotomy,
lysis of adhesions, and reduction of small bowel volvulus in
[**6-/2173**] by Dr [**First Name (STitle) **] was admitted with
diffuse abdominal pain for one month. He had a CT scan and RUQ
US that showed cholilithiasis thickened wall and [**Doctor Last Name 515**] sign.
Past Medical History:
- DM
- HTN
- Dyslipidemia
- Laser surgery to both eyes
- Bilateral cataracts
- ESRD on dialysis MWF
- Atrial flutter/atrial fibrillation s/p ablation. He is
reportedly not on anticoagulation because of renal insufficiency
and concern for high risk of bleeding.
- s/p pacemaker placement with history of tachy-brady syndrome
- Prostate cancer, diagnosed 12 years ago s/p orchietctomy and
hormone therapy
- Renal cell cancer, s/p right nephrectomy
- Secondary hyperparathyroidism
- Small bilateral pleural effusions noted on [**2172-1-17**]
admission, no longer noted on recent chest x-ray from [**2172-9-24**]
- Percutaneous thrombectomy of his left forearm AV graft,
fistulogram,
arteriogram, and a balloon angioplasty of multiple venous
outflow
stenoses and angioplasty of the arteriovenous graft anastomosis
in [**2172-6-16**]
-s/p surgical removal of upper GI obstruction per patient
Social History:
Retired foundry worker who lives at home in [**Location (un) 669**] with his
wife. Stopped smoking cigarettes over 20 years ago, smoked
intermittently for years before that, but has difficulty
quantifying use. Has not had alcohol in over 20 years, drinking
only socially prior to that time. Denies a history of drug use.
Family History:
Family History:
States that his siblings are healthy, but unsure on health of
other family members
Physical Exam:
Exam at admission:
Vital Signs: T 97.4 HR 86 BP 104/42 RR 18 O2 Sat 100
General: No acute distress
Cardiovascular: Regular rate and rhythm
Respiratory: Clear to auscultation bilaterally
Abdomen: midline incision well healed. No erythema. Soft,
diffusely tender, nondistended, no tap tenderness
.
Pertinent Results:
Labs on Admission:
[**2173-8-27**] 08:05PM WBC-9.2 RBC-3.63* HGB-10.3* HCT-33.4* MCV-92
MCH-28.2 MCHC-30.8* RDW-15.9*
[**2173-8-27**] 08:05PM ALT(SGPT)-62* AST(SGOT)-43* ALK PHOS-87 TOT
BILI-0.6
[**2173-8-27**] 08:05PM PT-14.8* PTT-37.6* INR(PT)-1.3*
[**2173-8-27**] 08:22PM LACTATE-2.0 K+-5.3
WBC trend:
[**2173-8-27**] 08:05PM BLOOD WBC-9.2
[**2173-8-28**] 06:35AM BLOOD WBC-8.6
[**2173-8-29**] 06:15AM BLOOD WBC-10.3
[**2173-8-30**] 04:50AM BLOOD WBC-12.6*
[**2173-8-31**] 07:00AM BLOOD WBC-12.3*
[**2173-9-1**] 06:10AM BLOOD WBC-10.6
[**2173-9-2**] 05:55AM BLOOD WBC-11.8*
[**2173-9-3**] 01:43AM BLOOD WBC-11.5*
[**2173-9-4**] 08:25AM BLOOD WBC-13.3*
[**2173-9-5**] 04:28AM BLOOD WBC-11.9*
[**2173-9-6**] 04:54AM BLOOD WBC-11.8*
[**2173-9-7**] 04:03AM BLOOD WBC-11.5*
[**2173-9-8**] 07:30AM BLOOD WBC-11.5*
[**2173-9-9**] 04:18AM BLOOD WBC-9.5
[**2173-9-10**] 07:00AM BLOOD WBC-10.3
CT Abdomen
Cholilithiasis; Status post right nephrectomy; Diverticulosis of
the colon without signs of diverticulitis, Right
small-to-moderate pleural effusion and small pleural effusion on
the left.
RUQ US
Evidence of cholecystitis.
FLUID CULTURE (Final [**2173-9-2**]):
ESCHERICHIA COLI. Resistant to all organisms except E Coli
MRSA screen ([**2173-9-1**]): negative
Blood cultures with NO GROWTH: [**2173-8-27**] x2, [**2173-8-31**] x2, [**2173-9-1**],
[**2173-9-6**], [**2173-9-7**].
CT Head [**2173-8-31**]
1. Continued evolution of previously identified left posterior
temporal/occipital lobe infarction manifest as increased
hypodensity since
[**9-23**].
2. Increased opacification of the right frontal sinus with
high-density (67 [**Doctor Last Name **]) material possibly representing inspissated
secretions, although fungal colonization could have this
appearance also.
3. No acute intracranial hemorrhage
ECHO [**2173-9-1**]
There is moderate global left ventricular hypokinesis (LVEF =
30%).
Dilated and hypertrophied left ventricle with moderate global
systolic dysfunction. Mild right ventricular systolic
dysfunction. Mild to moderate aortic regurgitation. Moderate to
severe mitral regurgitation. Mild pulmonary hypertension.
Carotid Series U/S ([**2173-9-2**]):
Right ICA stenosis <40%.
Left ICA stenosis <40%.
Possible intracranial carotid stenosis as above. Clinical
correlation and
posssible CTA warranted
NCHCT ([**2173-9-3**]):
1. No evidence of acute hemorrhage or shift.
2. Chronic small vessel ischemic changes.
3. Old left PCA infarct.
RUQ Ultrasound [**2173-9-7**]:
1. Decreased volume of the gallbladder as compared to prior
study with
edematous wall and gallstones. Cholecystitis cannot be excluded.
The
gallbladder is not amenable to percutaneous drainage at this
time due to lack of sufficient distention.
2. Unchanged 1-cm gallbladder wall polyp versus tumefactive
sludge.
3. Slightly complex intra-abdominal ascites. Right-sided pleural
effusion.
4. Pneumobilia.
HIDA scan ([**2173-9-7**]): Serial images over the abdomen show uptake
of tracer into the hepatic parenchyma. The gallbladder does not
fill. Tracer activity noted in the small bowel at 18 minutes.
There is no evidence of bile leak.
Right Upper Extremity U/S ([**2173-9-9**]): No deep venous thrombosis
in right upper extremity.
Chest X-ray ([**2173-9-9**]): PICC line terminating in mid portion of
SVC. No significant interval change since [**2173-9-2**]. No
pneumothorax. Stable chest findings.
Brief Hospital Course:
78 yo M with a history of HTN, DM2, CKD, prior CVA, Afib s/p
perc chole for cholecystitis, with biliary cultures growing MDR
E.coli. Hospital course complicated by altered mental status
most likely secondary to delirium (although a new CVA cannot be
excluded), admission to SICU because and brief episode of
hypotension at dialysis in the setting of Afib with RVR. Each of
the problems addressed during this hospitalization are described
in detail below:
Delirium: Throughout the hospital course, the patient was
confused. On [**2173-9-1**], the patient was noted to have worsening
of mental status and was evaluated by Neurology with a concern
for a possible CVA given INR subtheraputic for procedure.
Non-contrast head CT was performed which showed no acute
intracranial bleed and old PCA infarct. However, a new CVA
could not be excluded and MRI could not be performed as the
patient has a pacemaker. However, neurological exam remained
stable and no new focal neurological deficits were noted.
Confusion and agitation was believed to be secondary to delirium
of infectious etiology and long hospitalization. At some points
during hospitalization, the patient became more agitated and
exhibited paranoid ideation. He ended up pulling out his
percutaneous chole tube (see below). He was started on
Seroquel 12.5mg daily per psychiatry recs. EKGs were closely
monitored for QT prolongation. The patient's agitation and
paranoid ideation have resolved prior to discharge, mental
status somewhat improved. He no longer required restraints. The
plan is for the patient to continue on Seroquel 12.5 mg QHS.
Statin is continued. He may be given additional 12.5mg doses of
Seroquel up to a total of 37.5mg daily.
Cholecystitis: Patient was admitted with a diagnosis of acute
Cholecystitis for which he got a percutaneous cholecystostomy
tube. Biliary cultures grew out multi- drug resitant E. coli,
which was sensitive to Meropenem. The patient was started on
Meropenem, with a plan to complete a two week course (Day 1 =
[**2173-9-1**], last day [**2173-9-14**]). He had a PICC tube placed in his
right arm for antibiotic delivery. At the time of discharge, the
PICC is in mid-portion of superior vena cava but chest X-ray,
can can be used as a midline for antibiotic delivery. The
patient pulled out his percutaneous chole tube on [**2173-9-8**] while
his was agitated. At that point, the patient was evaluated by
surgery. HIDA scan was performed, which showed no gallbladder
filling, but no evidence of bile leak, and RUQ U/S, which did
reveal persistent edema in gallbladder, but insufficient fluid
to replace a drain. Abdominal exam continued to be benign with
was with some right upper quadrant tenderness, but no guarding
or rebound tenderness. White blood cell counts remained stable.
On admission, the patient with mild transaminitis, which
resolved after percutaneous chole placement. The patient
remained stable with no signs concerning for peristent
cholecystitis or sepsis. The patient will follow-up with his
surgeon Dr. [**Last Name (STitle) **] for elective cholecystectomy 2 weeks after
discharge.
Afib with RVR: s/p ablation in the past. The patient had an
episode of atrial fibrillation with RVR with hypotension during
hemodialysis session early during admission. The patient was
evaluated by EP service and Echocardiogram was performed, which
revealed no new wall motion abnormalities. Cardiac biomarkers
were negative for a myocardial infarction, Troponins were stably
elevated due to the patient's ESRD. The patient's heart rates
and blood pressures remained stable during the rest of the
admission. We continued amiodarone 100mg po daily during this
admission. We continued rate control with Metoprolol 12.5mg po
bid with holding parameters for hypotension and bradycardia.
Later in hospitalization course, EKG showed normal sinus rhythm,
with LVH and LAD. ST segment changes likely due to
repolarization abnormality. The patient was monitored on
Telemetry and remained chest pain free throughout this
admission. Given history of atrial fibrillation with embolic
strokes, the patient was re-started on anticoagulation with
Coumadin after percutaneous cholecystostomy with the goal INR of
[**1-19**]. At the time of discharge, Coumadin was held for 2 days for
supratherapeutic INR. On the day of discharge, INR is 2.6 and
the patient should be restarted on 3mg of Coumadin nightly. The
patient also was evaluated by carotid ultrasound, which revealed
bilateral carotid stenosis of <40%.
Diabetes mellitus type 2: BG currently remained under control
during this admission. We monitored blood glucose QID and
continued the patient on sliding scale.
Hypertension: Per neurology recommendations, systolic blood
pressure goal was 150-160 to assure sufficient brain perfusion
as the stroke could not be ruled out. There was some difficulty
accurately measuring BP accurately because of AV fistula on left
arm, PICC in right arm, thighs and calves have not yielded
consistent BPs.
We continued Metoprolol 12.5 [**Hospital1 **].
ESRD on dialysis: The patient is on dialysis on Mondays,
Wednesdays and Fridays, last HD in the morning on Friday,
[**2173-9-10**]. He has tolerated HD without complications.
Nutrition: The patient failed speech and swallow while with
Altered Mental Status early during hospitalization course.
Dubhoff tube was placed (but was not post-pyloric). As the
mental status improved, the patient passed speech and swallow,
and was upgraded to ground solids, thin liquids prior to
discharge. Nutrition recommended supplementation with Ensure.
At the time of discharge, the patient's calorie counts have
remained low (300's per day), but the patient has been able to
tolerate PO intake and has complained about the taste of the
food. We recommend no dietary restriction to facilitate PO
intake. Given low calorie counts, the patient is being
discharged with a Dobhoff tube in place as he may need
resumption of his tube feeds if he does not take sufficient PO
intake. He will need to be monitored closely by calorie counts.
Anemia: The patient with normocytic anemia, with worsening
during this admission. The presentation is most consistent with
anemia of chronic disease. Hematocrit remained stable at at the
time of discharge. The patient was Guaiac negative prior to
discharge.
Wound care: The patient has a Stage II sacral decubitous ulcer
on his buttocks. Mepilex dressing was applied and should
continue to be applied upon discharge.
Recommendation is to cleanse with commercial wound cleanser and
change dressing every three days or as needed.
ACCESS: PICC on (placement date [**9-2**]). Per CXR on [**2173-9-9**], tip
in mid-portion of SVC, and may be used for antibiotic delivery.
Of note, the patient had a rectal swab that was positive for VRE
during this admission.
Medications on Admission:
Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain .
2. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale
Subcutaneous four times a day.
3. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: check
inr 3x/week
goal 2-2.5.
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day.
8. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for sbp <110 or HR <60
Discharge Medications:
1. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 4 days.
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
7. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): See sliding scale.
8. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal [**1-19**].
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**] [**Location (un) 686**]
Discharge Diagnosis:
Primary: Cholecystitis, Delirium, Atrial Fibrillation
Secondary: Diabetes mellitus type 2, hypertension, dyslipidemia,
prior stroke.
Discharge Condition:
Vitals stable, oxygen saturation over 95% on room air, improved
mental status
Discharge Instructions:
You were admitted to the hospital because you developed
abdominal pain. You were found to have inflammation of your
gallbladder known as cholecystitis. A drainage tube was placed
surgically into your gallbladder to drain the infected biliary
fluid. You biliary fluid was infected with a bacterium that is
resistant to many types of antibiotics. You were started on a
strong antibiotic called Meropenem that is given by IV for your
gallbladder infection. You will need to take this antibiotic
for a total of 2 weeks. You also had an episode of low blood
pressure during dialysis due to your atrial fibrillation with an
increased heart rate. This resolved and has not recurred.
During your hospitalization, you became confused and agitated,
likely because of your infection. This condition is known as
Delirium. You were seen by Neurology to evaluate whether you
had suffered a new stroke. At this point, it is not certain
whether or not you had a new stroke. As you were agitated and
pulled out your drainage tube, you had to be restrained. You
were also seen by Psychiatry doctors and started on Seroquel for
your agitation. At the time of discharge, you are less agitated
but still occasionally confused. It is possible for your
confusion to last a few weeks even after your infection has been
treated.
At the time of discharge, your mental status is improving and
you are less confused. You pain is under control, and you are
able to tolerate a pureed diet.
We made several changes to your medications:
1. You will need to complete a course of Meropenem mg every 12
hours. Your last day of antibiotic treatment will be [**2173-9-14**].
2. You have been started on Seroquel, 12 mg at night for your
delirium. This medication may be stopped at some point in the
future depending on your mental status. You should be
reevaluated by your physician in the next week to determine
whether this should be continued.
3. Please take your other medications as directed.
You have a follow-up appointment with your surgeon Dr. [**Last Name (STitle) **]
(see below).
Should you develop fevers, worsening abdominal pain, nausea,
vomiting, worsening confusion or increased confusion, or any
other concerning symptoms, please call your Primary Care Doctor
or return to the Emergency Department.
Followup Instructions:
You have an appointment with your Surgeon Dr. [**Last Name (STitle) **] as
follows:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Transplant Center, Surgeon
Date and time: [**2173-9-23**] 3:10pm
Location: [**Last Name (NamePattern1) 439**] [**Hospital Unit Name **] [**Location (un) **]
Phone number: [**Telephone/Fax (1) 673**]
You should also call your primary care doctor Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**]
after you are discharge from rehabilitation facility to schedule
an appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Completed by:[**2173-10-1**]
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32,005
| 190,385
|
43783
|
Discharge summary
|
report
|
Admission Date: [**2152-10-3**] Discharge Date: [**2152-10-7**]
Date of Birth: [**2070-4-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
7 Units Packed Red Blood Cells, 2 units FFP, 1 unit Platelets
Colonoscopy and endoclips
History of Present Illness:
This is an 82yoM with DM2, vascular dementia, afib on coumadin,
h/o GI bleed on coumadin (had one in [**2148**] requiring clip in
colon and 2nd bleed in [**2149**] with no source found) who presents
to ED with lightheadedness. Has had black stool for indetermine
time however on iron supplementation. Per daughter, pt more
confused and unsteady on feet. Has been less active over last
few days. Yesterday was found to have red blood with clots in
underwear. Per daughter, thought pt was unsteady on feet so
brought patient into ED.
.
In ED, initial VS: 98.6 86 138/86 16 100%. Exam significant for
melena on rectal but negative NG lavage. Labs significant for
Hct of 17.1 (down from baseline of low-mid 30s), Cr of 1.9 (last
Cr was 1.4), INR of 4.6, and TropT of 0.04. Also had lateral ST
depressions in V4-V6. C/o LH but no SOB/CP. Received 10mg vit K
IV and protonix 80mg. One unit of pRBCs was hung. No FFP was
given.
.
In unit, patient appeared well and in NAD. Endorsed SOB over
last few days but no CP or abdominal pain. Also endorsed
unsteadiness.
.
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 dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
1. Vascular cognitive impairment
2. Hypercholesterolemia
3. Type 2 diabetes complicated by diabetic neuropathy,
ophthalmologic issues, and chronic kidney disease - The patient
is followed by podiatry and ophthalmology.
4. Hypertension
5. Mitral regurgitation
6. Atrial fibrillation - The patient is followed in cardiology
clinic by Dr. [**Last Name (STitle) 120**].
7. Status post DVT - [**2140**]
8. Status post GI bleeding in the setting of Coumadin - [**1-/2149**]
and 3/[**2149**].
9. Barrett's esophagus - The patient is followed by Dr.
[**Last Name (STitle) **]
with regular EGDs. He did have his regular follow up EGD on
[**2149-1-27**] with the repeat EGD during his hospitalization in
03/[**2149**].
10. Gout
11. Iron deficiency anemia
12. Known blood pressure differential left greater than right
13. Retinal bleed of the left eye - The patient is followed at
[**Location (un) 86**] Ophthalmologic.
14. Glaucoma
15. Status post basal cell carcinoma - 6/[**2148**]. The patient is
followed regularly by dermatology.
16. BPH
17. Hemorrhoids
18.. Osteoporosis
PAST SURGICAL HISTORY: per OMR
- Status post bilateral cataract removal
- Status post appendectomy
- Status post removal of basal cell carcinoma
Social History:
The patient's daughter [**Name (NI) **] continues to live with him. This is
going quite well. No alcohol or tobacco. He does not utilize an
assistive device for ambulation. He walks for exercise it the
weather is okay.
Family History:
Negative for premature CAD, HTN, lipid abnormaltiy.
Not pertinent to GI bleed
Physical Exam:
Physical Exam on arrival to MICU:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, conjunctival
pallor
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregularly irregular, II/VI systolic murmur nonradiating
Abdomen: soft, non-tender, obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ radial and DP pulses, no clubbing,
cyanosis or edema
Physical Exam on Discharge:
Afebrile 148-160s/54-70s BP, 60s-80sHR, 18R, 99% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate,
interactive and in good humor
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, non-tender, JVP up to angle of mandible
LUNGS - non-labored, no accessory muscle use. Very fine
bibasilar crackles
HEART - RRR S1 S2 clear and of good quality [**2-20**] holosytolic
murmur heard best over mitral area, though heard throughout
precordium
ABDOMEN - Distended but soft, NT, good bowel sounds throughout
EXTREMITIES - B/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 1+ (baseline per patient)
NEURO - Awake, alert and interactive
Pertinent Results:
[**2152-10-3**] 07:30AM BLOOD WBC-4.2 RBC-1.69*# Hgb-5.3*# Hct-17.1*#
MCV-101*# MCH-31.5 MCHC-31.2 RDW-15.8* Plt Ct-170
[**2152-10-3**] 07:30AM BLOOD Neuts-76.1* Lymphs-20.0 Monos-3.8 Eos-0.1
Baso-0.1
[**2152-10-3**] 07:30AM BLOOD PT-44.4* PTT-35.1* INR(PT)-4.6*
[**2152-10-3**] 07:30AM BLOOD Glucose-256* UreaN-74* Creat-1.9* Na-139
K-5.1 Cl-111* HCO3-16* AnGap-17
[**2152-10-3**] 02:35PM BLOOD CK(CPK)-96
[**2152-10-3**] 07:30AM BLOOD cTropnT-0.04*
[**2152-10-3**] 02:35PM BLOOD CK-MB-4 cTropnT-0.05*
[**2152-10-3**] 09:09PM BLOOD CK(CPK)-106
[**2152-10-3**] 09:09PM BLOOD CK-MB-5 cTropnT-0.09*
[**2152-10-4**] 07:42AM BLOOD CK(CPK)-99
[**2152-10-4**] 01:13AM BLOOD cTropnT-0.08*
[**2152-10-4**] 07:42AM BLOOD CK-MB-5 cTropnT-0.08*
[**2152-10-3**] 02:35PM BLOOD Calcium-8.3* Phos-4.5 Mg-2.3
[**2152-10-5**] 03:06AM BLOOD WBC-6.3 RBC-2.94* Hgb-9.3* Hct-29.3*
MCV-100*# MCH-31.6 MCHC-31.7 RDW-16.6* Plt Ct-148*
[**2152-10-3**] 10:10AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
[**2152-10-3**] 10:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2152-10-3**] 10:10AM URINE Hours-RANDOM UreaN-893 Creat-70 Na-48
K-44 Cl-34
[**2152-10-3**] 10:10AM URINE Osmolal-555
ECG [**2152-10-3**]
Atrial fibrillation, average ventricular rate 74. Non-specific
intraventricular conduction delay. Persistent ST-T wave changes
are present in the lateral leads raising a question of
myocardial ischemia. Clinical correlation is suggested. There
is no interval change.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 0 124 430/454 0 -28 51
CXR [**2152-10-3**]
Portable erect radiograph of the chest was obtained. The lungs
are
clear bilaterally with no evidence of consolidation or effusion.
Accounting for patient rotation, the trachea appears midline and
the cardiomediastinal silhouette is normal with evidence of
stable cardiomegaly. Mild mitral annulus calcification is noted.
There is no pneumothorax. Bony structures and soft tissue are
unremarkable.
IMPRESSION: No acute intrathoracic process.
EGD [**2152-10-4**]
Findings: Esophagus:
Mucosa: Tongue of salmon mucosa was seen at GE junction
consistent with known Barrett's.
Stomach:
Mucosa: Small patchy areas of abnormal mucosa were seen
throughout the whole stomach. These may represent areas of
intestinal metaplasia.
Protruding Lesions A single 7 mm polyp was found in the fundus
by the GE junction with some slight abnormal mucosa overlying
it.
Duodenum: Normal duodenum.
Other findings: Bile seen in duodenum without any blood.
Impression: Abnormal mucosa in the esophagus consistent with
known Barrett's Abnormal mucosa in the stomach. [**Month (only) 116**] represent
intestinal metaplasia related to H. pylori. Polyp in the
fundus. Bile seen in duodenum without any blood. Otherwise
normal EGD to third part of the duodenum
Recommendations: No source of the patient's GI bleeding was seen
on EGD.
Patient should have a repeat EGD to assess areas of abnormal
mucosa for biopsy and for follow up of Barrett's esophagus.
Colonoscopy [**2152-10-4**]
Findings:
Protruding Lesions Several sessile polyps visualized in cecum
randing from 3-4 mm. No bleeding noted from polyps.
Excavated Lesions Multiple non-bleeding diverticula with large
openings were seen in the sigmoid colon and descending colon.
Diverticulosis appeared to be severe.
Other Fresh bleeding noted from two localized points in the
proximal ascending colon. The surrounding and underlying mucosa
was normal without underlying lesion although suspect
Dieulafoy's lesion. Old dark blood seen in the remainder of the
colon. Three endoclips were successfully applied for the
purpose of hemostasis to the two localized points. No active
bleeding visualized after clip placement. Terminal ileum with
bilious output. No clotted or red blood visualized.
Impression: Fresh bleeding noted from two localized points in
the proximal ascending colon. The surrounding and underlying
mucosa was normal without underlying lesion although suspect
Dieulafoy's lesion. Old dark blood seen in the remainder of the
colon. (endoclip)
Diverticulosis of the sigmoid colon and descending colon
Terminal ileum with bilious output and without bleeding.
Polyps in the colon
Otherwise normal colonoscopy to terminal ileum
Recommendations: Small polyps in cecum. Diverticulosis. Active
bleeding from two localized points in the proximal ascending
colon appear to be the source of bleeding. Likely Dieulafoys
lesion. Three endoclips placed at site with no further bleeding.
Recommend continued ICU monitor, trend hct, with IR and surgery
aware in the event of recurrent active bleed.
Hct Trend s/p Colonoscopy and clips:
[**2152-10-4**] 02:18PM BLOOD Hct-29.5*
[**2152-10-4**] 07:02PM BLOOD Hct-28.7*
[**2152-10-5**] 03:06AM BLOOD WBC-6.3 RBC-2.94* Hgb-9.3* Hct-29.3*
MCV-100*# MCH-31.6 MCHC-31.7 RDW-16.6* Plt Ct-148*
[**2152-10-5**] 06:00PM BLOOD Hct-30.9*
[**2152-10-6**] 06:15AM BLOOD WBC-5.9 RBC-3.16* Hgb-9.9* Hct-30.0*
MCV-95 MCH-31.2 MCHC-32.9 RDW-16.3* Plt Ct-153
[**2152-10-7**] 05:39AM BLOOD WBC-5.6 RBC-2.95* Hgb-9.4* Hct-27.0*
MCV-91 MCH-31.9 MCHC-34.9 RDW-16.5* Plt Ct-128*
Discharge Labs:
[**2152-10-7**] 05:39AM BLOOD WBC-5.6 RBC-2.95* Hgb-9.4* Hct-27.0*
MCV-91 MCH-31.9 MCHC-34.9 RDW-16.5* Plt Ct-128*
[**2152-10-7**] 05:39AM BLOOD Glucose-200* UreaN-26* Creat-1.2 Na-139
K-3.9 Cl-109* HCO3-23 AnGap-11
[**2152-10-7**] 05:39AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9
Brief Hospital Course:
82yo M with history afib on coumadin, history of GI bleed
presenting with LH found to have profound anemia (Hct 17) [**1-19**] GI
Bleed.
# Lower GI Bleed, [**1-19**] suspected colonic Dieulafoy's lesion.
Patient was found to have low Hct down to 17 in presentation.
He received 10 mg vitamin K and protonix in the ED. Over the
course of his stay in the MICU, he received total of 7 units of
pRBC, 2 unit of FFP, 1 unit of platelets. Goal Hct was 30
because of V4-6 STD on EKG. In addition, his warfarin, beta
blocker, ACE inhibitor were held. He remained hemodynamically
stable while in the MICU. He underwent both EGD and colonoscopy
on [**2152-10-4**] which found non-bleeding mucosal change consistent
with Barrett's and an ascending colonic AVM x2 which was clipped
with 3 endoclips with resolution of bleeding. His Hct remained
stable while in the MICU post endoscopic intervention. On
arrival to the floor patient remained hemodynamically stable and
in fact was hypertensive throughout rest of admission. His
ACE-I, Spironolactone, HCTZ were restarted and patient was
switched from home Atenolol, which was being held, to Metoprolol
25mg because of renal insufficiency. He had no further episodes
of GIB and his diet was advanced to regular. He tolerated foods
well and was asymptomatic throughout duration of stay.
# CAD. Had lateralized EKG changes with STD in the V4-6 area
and mildly elevated troponin up to 0.09. However, CK and CKMB
stable. No cardiac symptoms. This was most likely from
underlying CAD in the setting of blood loss to Hct 17. ASA,
lisinopril, atenolol were held initially, though restarted per
above. Simvastatin was continued. His primary care physician
was made aware. On floor he did not require transfusions as his
Hct remained stable around 30.
# A.Fib. Patient remained rate controlled off atenolol in
setting of GIB. Warfarin and ASA were stopped and INR was
reversed with vitamin K and FFP. His PCP and cardiology were
informed. When transferred to the floor his aspirin was
restarted and atenolol changed to Metoprolol because of renal
insufficiency. He was not restarted Coumadin nor is he being
discharged on Coumadin. Should readdress Coumadin as an
outpatient and the risks of stroke given CHADS2 score=4 should
be weighed against the risk of rebleeding
# Acute Renal Failure. Unclear baseline however last Cr 1.4
prior to admission. Most likely pre-renal given profound anemia
from LGIB. ACE inhibitor was held while in the MICU. It
improved with transfusion. On floor ACE-I was restarted and his
creatinine continued to improve 1.2 prior to discharge, BUN
improved as well. Atenolol was switched to Metoprolol given
renal insufficiency.
# Dyspnea. Patient was subjectively dyspnic on admission. This
was most likely related to anemia. He Appeared
euvolemic-hypovolemic on arrival and was not hypoxic.
Respiratory status was stable while in the MICU and no lasix was
given. Dyspnea improved with PRBC transfusions.
# T2DM. His oral hypoglycemic was held in the MICU. He was
given HISS while hospitalized. Discharged back on Glipizide
# Hypertension. Normotensive while anemic, when GIB resolved he
was consistently hypertensive. Antihypertensives were held in
the MICU and restarted as above.
# Glaucoma: continued home drops
TRANSITIONAL ISSUES:
- Patient is not being discharged on Coumadin. Should readdress
this at a further date regarding the risk of stroke, given
CHADS2 of 4, against the bleeding risk of coumadin given his 3
prior bleed.
- Metoprolol 25mg PO BID was restarted instead of Atenolol 100mg
Daily because of renal insufficiency. Should reassess BP control
on Metoprolol and titrate up accordingly.
Medications on Admission:
per OMR
ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
ATENOLOL - 100 mg Tablet - 1 Tablet(s) by mouth at bedtime
DORZOLAMIDE-TIMOLOL [COSOPT] - (Prescribed by Other Provider) -
0.5 %-2 % Drops - 1 drop eyes twice a day
FUROSEMIDE - 40 mg Tablet - 0.5 (One half) Tablet(s) by mouth
every other day
GLIPIZIDE - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth twice a day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 2 Capsule(s) by mouth once a day
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
SPIRONOLACTON-HYDROCHLOROTHIAZ - 25 mg-25 mg Tablet - 1
Tablet(s)
by mouth qAM
TERAZOSIN - (Prescribed by Other Provider) - 10 mg Capsule - 1
Capsule(s) by mouth at bedtime
WARFARIN - 5 mg Tablet - [**12-19**] Tablet(s) by mouth once a day dose
as directed by INR
ASCORBIC ACID - 500 mg Tablet - 1 Tablet(s) by mouth daily
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D] - 600 mg (1,500
mg)-200 unit Tablet - 1 Tablet(s) by mouth three times a day
FERROUS SULFATE - (Prescribed by Other Provider: [**Name10 (NameIs) **] MD) - 325
mg
(65 mg Iron) Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s)
by mouth daily
Discharge Medications:
1. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. calcium carbonate-vitamin D3 600 mg(1,500mg) -200 unit Tablet
Sig: One (1) Tablet PO three times a day.
6. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. spironolacton-hydrochlorothiaz 25-25 mg Tablet Sig: One (1)
Tablet PO QAM.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
11. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
12. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
14. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
15. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Active:
- GI Bleed
- Atrial Fibrillation anticoagulated on admission
- Prior GIBs while on Coumadin
.
Chronic:
- HTN
- HLD
- CAD
- Anemia
- Barrett's Esophagus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 94074**],
It was a pleasure meeting you and treating you during this
hospitalization. You were admitted to [**Hospital1 827**] with a severe GI bleed which required you to be
monitored in the MICU. You received multiple transfusions and
has a colonoscopy which showed the site of bleeding. The site
was clipped and your bleeding resolved. Because the bleeding
occurred while you were taking Coumadin the medication was held
and you were given vitamin k to reverse the anticoagulation. You
are being discharged in stable condition with a blood count
which has been stable for several days. You are being discharged
without coumadin and this should be re-addressed by your primary
care physician.
.
The following chages to your medications were made:
- STOP Coumadin. This is being stopped because this is your 3rd
GI bleed while you have been on Coumadin. Coumadin should be
readdressed by your primary care physician.
[**Name Initial (NameIs) **] STOP Atenolol. This was stopped because we are changing the
medication to Metoprolol
- START Metoprolol 25 mg take by mouth twice per day. This is
for your blood pressure and hear rate control from your A.Fib.
Followup Instructions:
Department: GERONTOLOGY
When: TUESDAY [**2152-10-10**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: GERONTOLOGY
When: MONDAY [**2152-11-6**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: TUESDAY [**2153-1-9**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"45.43",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
16667, 16725
|
10259, 13559
|
308, 398
|
16929, 16929
|
4707, 9942
|
18284, 19142
|
3367, 3446
|
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|
16746, 16908
|
13978, 15399
|
17080, 18261
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9959, 10236
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|
3461, 3979
|
4007, 4688
|
13580, 13952
|
1502, 1857
|
265, 270
|
426, 1483
|
16944, 17056
|
1879, 2966
|
3129, 3351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,586
| 194,720
|
5203
|
Discharge summary
|
report
|
Admission Date: [**2149-6-19**] Discharge Date: [**2149-6-24**]
Date of Birth: [**2126-2-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Suicide attempt
Major Surgical or Invasive Procedure:
Femoral line placement
History of Present Illness:
Patient is a 24 year old woman with a history of prior suicide
attempts who presented to the ED with a suicide attempt. Patient
reports that at 9 pm she bought 3 bottles of 325 mg aspirin. She
took 200-250 tablets. The group home staff where she lives were
suspicous and called 911. When she arrived at the ED she was
alert and oriented and complained of nausea. Aspirin level was
39. ABG 7.42/32/151 and serum bicarbonate was 19. She was given
50 meq of sodium bicarbonate, charcol and dolasetron and started
on a bicarbonate drip. A repeat ASA level was 100 and chem 7 had
a bicarbonate of 16 with an AG of 28.
Patient was admitted to the MICU and dialyzed for such high ASA
levels until level lowered to 16. HD catheter removed from R
groin on [**6-20**]. Removal complicated by large hematoma and
hematocrit drop from 37 to 26. Baseline Hct appears to be closer
to 33. CT abdomen negative for retroperitoneal bleed. Patient
was then transferred out of the unit.
Currently, patient feels tired. Denies HA, abdominal pain. Groin
is somewhat tender. Pt does not have plans to harm herself
currently. C/o thirst.
Past Medical History:
Depression
PTSD
Eating disorder
Borderline PD
Asthma
Social History:
Per [**Name (NI) **], pt was born in [**Location (un) 5622**] and moved soon after to
[**Hospital1 1559**], MA with her mother and two older sisters. [**Name (NI) **] mother
was an alcoholic who was verbally abusive to the patient. The
patient had been sexually abused. She was removed from the care
of her mother along with her sister at the age of five. She then
lived with her aunt and several [**Doctor Last Name **] homes. She also began to
attempt suicide several times and had to admitted to psychiatric
inpatient hospitals. She has lived in several group homes and
long- term hospitals; including [**Location (un) 2498**], and most recently the
[**Hospital1 **] for two years. She has no contact with her father.
Family History:
Mother-alcoholism; sisters-behavioral problems
Physical Exam:
VS: T 97.1 HR 121 BP 106/56 RR 24 O2 sat 100% I/O 1000/1500
Gen: Thin, diaphoretic, restless, moving in the bed, sleepy.
Wakes to voice. Cannot state where she is. Says it is [**Month (only) 205**].
Knows she took "a lot of pills." slurred speech.
HEENT: Pupils dilated 4mm and slowly reactive to 3mm. EOMI.
sclera anicteric, MM dry.
Neck: No LAD, JVD or thyromegly.
CV: Regular and tachycardic with no m/r/g
Lungs: CTA bilaterally
Abd: soft, NT, ND no BS, no hepatosplenomegly.
ext: No clubbing, cyanosis or edema.
Neuro: Moves all extremities. Reflexes 2+ bilaterally. Follows
commands.
Skin: multiple scars on arms, legs, abdomen.
Psych: soft voice, poor eye contact.
Pertinent Results:
138 104 13 / 73 AGap=19
-------------
4.0 19 1.1 \
ALT: 18 AP: 49 Tbili: 0.1 Alb: 4.8
AST: 31
[**Doctor First Name **]: 114
Serum ASA 39
Serum EtOH, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
Acetone:Neg
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
88
7.1 \ 12.1 / 363
------
35.4
N:54.4 L:37.3 M:4.0 E:4.2 Bas:0.2
PT: 13.3 PTT: 29.0 INR: 1.2
.
pH 7.42 pCO2 32 pO2 151 HCO3 21 BaseXS -2
.
CT OF THE ABDOMEN: The lung bases are clear. Visualized heart
and pericardium appear unremarkable. Lack of intravenous
contrast limits assessment of intraabdominal organs. The liver,
gallbladder, adrenal glands, spleen, and pancreas appear
unremarkable. The kidneys appear symmetric without evidence of
hydronephrosis. No dilated loops of bowel are identified. No
pathologic mesenteric or retroperitoneal lymphadenopathy is
identified. No free air or free fluid is seen in the abdomen.
CT OF THE PELVIS: A Foley catheter is seen within the bladder
lumen, as well as non-dependent air. The uterus, adnexa, and
rectum appear unremarkable. There is no evidence of
retroperitoneal hematoma. There is a small amount of stranding
in the right groin. A pressure dressing appears to overlie the
right groin.
The osseous structures demonstrate no concerning lytic or
sclerotic lesions.
IMPRESSION: No evidence of retroperitoneal hematoma.
.
EKG: Sinus rhythm
Diffuse nonspecific T wave abnormalities
Since previous tracing of [**2148-11-4**], diffuse T wave changes
present
Brief Hospital Course:
23 yo female with a history of depression, PTSD, and borderline
personality disorder who was admitted with an aspirin overdose,
c/b metabolic acidosis and respiratory acidosis.
.
Patient had an aspirin overdose of approximately 200 pills, with
peak aspirin level of 127. Patient was emergently hemodialyzed
for her aspirin overdose to which she responded well. She also
received charcoal and was started on a bicarbonate drip. Patient
was followed by toxicology. Her metabolic acidosis and
respiratory alkalosis was monitored closely by serial ABGs and
normalized over the course of 24 hours. Patient's aspirin level
was negative.
.
Patient had a femoral line placed for dialysis. Patient had a
groin hematoma at the site. She was also noted to have a >10
point hematocrit drop. Patient had a CT scan performed for RP
bleed which was negative. She had a hematocrit that then
stabilized, and had no further drops over the next 72 hours.
Patient was also noted to have an elevated amylase and lipase,
thought to be secondary to a salicylate induced pancreatitis.
She complained of nausea. She had no epigastric tenderness to
palpation. Patient was tolerating pos and did not require pain
medications. Her amylase and lipase trended downward.
.
Patient was seen by psychiatry as an inpatient, and was
recommended to have a 1:1 sitter. She was restarted on Lamictal
for mood stabilization. She was also placed on antidepressants
with fluoxetine and Klonopin. Patient refused all her doses of
her medications, stating that she could not tolerate pills. She
was felt to be severely depressed, and patient was transferred
to inpatient psychiatry for further management.
Medications on Admission:
topamax 50 daily
clonazepam 0.5 mg [**Hospital1 **] prn anxiety
albuterol 2 puffs 4 times a day as needed
acetaminophen 325 2 tabs q 6 prn
Ibuprofen 600 q 6 prn
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for agitation, anxiety.
3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
1. Acute aspirin overdose with respiratory alkalosis and
metabolic acidosis
2. Suicide attempt
3. Depression
4. Pancreatitis
5. Acute blood loss anemia
Discharge Condition:
Stable for inpatient psychiatry admission
Discharge Instructions:
If you develop increased abdominal pain, nausea, vomiting,
fevers, or chills call your primary care doctor or go to the
emergency room.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 5263**] in [**1-6**] weeks. The number to
call to make the appointment is [**Telephone/Fax (1) 17826**].
|
[
"965.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6940, 6983
|
4644, 6308
|
330, 354
|
7179, 7223
|
3085, 4621
|
7407, 7566
|
2329, 2378
|
6520, 6917
|
7004, 7158
|
6334, 6497
|
7247, 7384
|
2393, 3066
|
275, 292
|
382, 1497
|
1519, 1574
|
1590, 2313
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,479
| 106,878
|
49731
|
Discharge summary
|
report
|
Admission Date: [**2179-6-21**] Discharge Date: [**2179-6-29**]
Date of Birth: [**2124-6-21**] Sex: F
Service: SURGERY
Allergies:
Tetracycline / Dilaudid (PF) / Pravastatin
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Crohn's disease with enterocutaneous fistula
Major Surgical or Invasive Procedure:
completion colectomy and end ileostomy
History of Present Illness:
Pt with complex Crohn's disease, previous hernias and hostile
abdomen has new entercutaneous fistulae from active disease in
her colostomy. Entire colon with some level of disease
activity. Patient presents for surgical management with
completion colectomy, fistula takedown, and end ileostomy
Past Medical History:
- Crohn's Disease (diagnosed [**2167**]) c/b fistulas, sigmoidectomy,
SBOs
- Atrial fibrillation since [**2173**]
---> DCCV x3 at [**Hospital1 **]
---> Cardioversion [**5-19**] at [**Hospital1 18**]
- Nonsustained Ventricular Tachycardia
- Benign Multinodular Goiter (followed by Dr. [**Last Name (STitle) **]
- s/p Cervical cancer
- GERD
- Paraspinal cyst (followed by Dr. [**Last Name (STitle) 575**]
- Pulmonary lesions
- Mediastinal mass (stable on MRI)
- Portal vein clot
- Arthritis
- Anxiety
Social History:
- Married, living with her family in [**Location (un) 47**]
- Previously worked as physical therapist
- Tobacco: Smoked intermittently in college, but no recent use
- EtOH: Denies
- Illicit Drug Use: Nil.
Family History:
- Father: UC, esophageal cancer
--- Paternal aunt with [**Name (NI) 4522**]
- Mother: Basal & squamous cell carcinoma
- Grandmother developed afib at 80 years of age
- Maternal grandmother: lung cancer
- [**Name (NI) **] diagnosed with IBD at age 14
Physical Exam:
At time of discharge:
VS: afebrile, vital signs stable
Gen: NAD, alert and oriented x3
CV: irregular rate, rhythm, nl S1, S2
Resp: CTAB
Abd: soft, appropiately tender, non-distended, ostomy pink with
gas, green liquid stool in bad
Inc: wide staples, serous drainage from midline of incision.
Ext: 1+ bilat LE edema
Pertinent Results:
[**2179-6-22**] 05:05AM BLOOD WBC-12.5* RBC-2.85* Hgb-8.6* Hct-28.2*
MCV-99* MCH-30.3 MCHC-30.7* RDW-14.3 Plt Ct-391
[**2179-6-22**] 05:05AM BLOOD Glucose-151* UreaN-21* Creat-1.0 Na-135
K-5.6* Cl-102 HCO3-28 AnGap-11
[**2179-6-22**] 04:00PM BLOOD Na-135 K-5.9* Cl-100
[**2179-6-22**] 05:05AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.5
[**2179-6-21**] 06:10PM BLOOD Calcium-8.1* Phos-3.6 Mg-1.1*
[**2179-6-21**] 06:10PM BLOOD Digoxin-2.5*
[**2179-6-29**] 05:00AM BLOOD WBC-11.8* RBC-2.71* Hgb-8.2* Hct-26.4*
MCV-97 MCH-30.1 MCHC-30.9* RDW-14.9 Plt Ct-442*
[**2179-6-27**] 11:35AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-139 K-4.4
Cl-104 HCO3-24 AnGap-15
Brief Hospital Course:
Patient was admitted following completion colectomy with end
ileostomy. She tolerated the procedure well. An extensive lysis
of adhesions was performed, and an NG tube was placed in the OR.
She was transferred to the floor. Overnight she was NPO and her
heart rate in the setting of atrial fibrillation was controlled
with IV metoprolol. Her pain was controlled with IV pain
medications.
On POD #1 her digoxin level was found to be elevated at 2.5 and
her digoxin dose was held. She had tachycardia with ambulation
and her IV metoprolol was increased. She was kept NPO and her NG
tube was kept in place. She did not have flatus. Her PCA was
increased with improved pain control. Her K+ was elevated at 5.6
and was found to be 5.9 on re-check in the PM. An EKG showed
chronic digoxin changes.
On POD #2 the patient remained NPO, with NGT in place. Patient's
foley catheter was removed.
On POD #3 the patient's NGT was removed. The patient was started
on sips and advanced to clear liquids. Patient restarted on
digoxin. Patient with anxiety -> controlled by ativan.
On POD #4 the patient was started on a clear liquid diet. Her
ostomy began to put out gas and stool.
On POD #5 the patient was started on a regular diet. The patient
became tachycardic to the 140's. She was restarted on her home
lopressor and her heart rate returned to [**Location 213**].
On POD #6 the patient was restarted on coumadin at her home dose
of 4mg.
On POD #7 the patient was restarted on her home medications.
Patient was started on immodium 2mg [**Hospital1 **] for high ostomy output.
At time of discharge on POD 8 the patient was tolerating a
regular diet. Her pain was controlled on oral pain medication,
she was ambulating without assitance, voiding without
difficulty.
Medications on Admission:
calcium, lantus 36u qAM, codeine 60", advair 250-50 1 puff",
humira 40mg every other week, humalog sliding scale, vitamin B12
1000mcg', tylenol prn, lorazepam 2''', diltiazem ER 360',
lisinopril 20', simvastatin 5', omeprazole 20', digoxin 250',
imodium 2", metoprolol 100", iron 325', coumadin 4', metformin
500", folic acid 400 mcg'
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
3. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
4. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
10. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. folic acid 1 mg Tablet Sig: Five (05) Tablet PO DAILY
(Daily).
12. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for anxiety.
13. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. Lantus 100 unit/mL Solution Sig: Thirty Six (36) units
Subcutaneous once a day.
16. insulin lispro 100 unit/mL Insulin Pen Sig: per home sliding
scale Subcutaneous per home regimen.
Discharge Disposition:
Home With Service
Facility:
VNA Caregroup
Discharge Diagnosis:
Crohn's Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a completion colectomy
and end ileostomy. You have recovered from this procedure well.
Samples from your colon were taken and this tissue has been sent
to the pathology department for analysis. You will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact you [**Name2 (NI) 19605**] these
results they will contact you before this time. You have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth.
You have an incision on your abdomen that is closed with
staples. This incision can be left open to air or covered with a
dry sterile gauze dressing if the staples become irritated from
clothing. The staples will stay in place until your first
post-operative visit at which time they can be removed in the
clinic, most likely by the office nurse. Please monitor the
incision for signs and symptoms of infection including:
increasing redness at the incision, opening of the incision,
increased pain at the incision line, draining of
[**Known lastname **]/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated.
You will be prescribed a small amount of the pain medication.
Please take this medication exactly as prescribed. You may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
You have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. You must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
you find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
[**Last Name (STitle) 3639**] can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if you notice
your ileostomy output increasing, take in more electrolyte drink
such as gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If you notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for buldging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic. You will have a visiting
nurse at home for the next few weeks helping to monitor your
ostomy until you are comfortable caring for it on your own.
Followup Instructions:
Call the colorectal surgery office to make an appointment for
follow-up two weeks after surgery with the colorectal surgery
outpatient nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP. At that
appointment you will be set up with an appointment for your
second post-operative check.
Call [**Telephone/Fax (1) 160**] to make this appointment.
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2179-7-12**]
2:00
Provider [**Name9 (PRE) 1382**] [**Name9 (PRE) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2179-8-16**] 11:50
Provider GI [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2179-8-23**] 10:30
Completed by:[**2179-7-1**]
|
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icd9cm
|
[
[
[]
]
] |
[
"46.01",
"54.59",
"45.83"
] |
icd9pcs
|
[
[
[]
]
] |
6340, 6384
|
2745, 4508
|
347, 388
|
6443, 6443
|
2077, 2722
|
10585, 11390
|
1474, 1726
|
4893, 6317
|
6405, 6422
|
4534, 4870
|
6594, 10562
|
1741, 2058
|
263, 309
|
416, 712
|
6458, 6570
|
734, 1235
|
1251, 1458
|
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