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77,678
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34862
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Discharge summary
|
report
|
Admission Date: [**2180-10-15**] Discharge Date: [**2180-10-17**]
Date of Birth: [**2159-9-8**] Sex: M
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Alchohol intoxication and hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
Mr. [**Known lastname 79822**] is a 21 year old gentleman found unresponsive in
his dorm room. Per report, patient was drinking vodka last
night until ~5 am, and was found approximately 12 hours later by
friends in the prone position. Per EMS, the patient did have a
gag and responded to a sternal rub. In the [**Hospital1 18**] ED, VS were
98.4 72 116/72 8 100%?. He received 1 liter NS and narcan,
which he did not respond to. He was responsive to nasal
trumplet placement. A CTH and CT c-spine did not demonstrate
acute intracranial abnormality or fracture, and a CXR did not
demonstrate any acute cardiopulmonary process. Patient was
intubated for hypercarbic respiratory failure with an ABG of
7.29/54/401. Labs in the ED were otherwise notable for a lactate
of 3.1 and a CK of 4200.
Of note, the patient was a difficult intubation in the past for
elective surgery.
Past Medical History:
Unknown
Social History:
Unknown
Family History:
Unknown
Physical Exam:
Gen: Sedated and unresponsive
HEENT: Perrla, MMM, ETT in place
CV: Nl S1+S2
Pulm: CTAB
Abd: S/NT/ND +bs
Ext: 2+ dp b/l
Neuro: Sedated and unresponsive. Intermitently agitated when
propafol turned off.
Brief Hospital Course:
21 year old gentleman with no significant PMH admitted for
unresponsiveness secondary to alchohol intoxication, subsequent
hypercarbic resp failure s/p intubation.
<br>
1. Hypercarbic respiratory failure: Patient intubated for airway
protection and hypercarbic respiratory failure initially [**2-5**] to
severe etoh intoxication. Pt was quickly extubated and was
doing fine on room air. Repeat CXR was neg for acute changes.
<br>
2. EtOH intoxication: Patient with significant EtOH intoxication
with serum EtOH of 325 on admission. Following extubation, he
was maintained on a CIWA and social work was consulted.
-CIWA (though noted pt not a chronic abuser)
-S.W. saw pt and counselled him on etoh use. Pt denies any overt
signs of alcohol dependence (neg on CAGE questionairre) and also
denied any depression hx and denies SI/HI
<br>
3. Mild rhabdomyolysis: CK of >4000 and lactate of 3.1 likely
represents mild rhabdomyolysis in the setting of being prone for
~12 hours. Potassium within normal limits. Plan was to
continue IVF s but decided to leave AMA
<br>
4. Leukocytosis: Patient leukocytosis to 17.3 during admission,
likely due to chemical aspiration while unconscious but on
repeat was wnl and cxr was also neg.
<br>
5. Trauma: CTH and CT c-spine negative for acute intracranial
process or fracture.
-observe, no further interventions.
<br>
On day of transfer to floor, pt decided to leave AMA. Pt had
capacity to make decisions, was no longer intoxicated, did not
appear to be in withdrawal and realized that leaving the
hospital could be potentially fatal and decided to leave AMA
Medications on Admission:
Unknown
Discharge Medications:
none
Discharge Disposition:
Home
Facility:
Left AMA
Discharge Diagnosis:
Alcohol intoxication
Discharge Condition:
Left AMA
Discharge Instructions:
Left AMA
Followup Instructions:
Left AMA
|
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icd9cm
|
[
[
[]
]
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,573
| 153,271
|
1118
|
Discharge summary
|
report
|
Admission Date: [**2129-1-14**] Discharge Date: [**2129-1-19**]
Date of Birth: [**2070-7-15**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
EGD on [**2129-1-15**]
HD on [**2129-1-15**], [**2129-1-18**]
4 units of pRBCs transfusion
History of Present Illness:
History of Present Illness: 58 yo male with CAD s/p CABG in [**2125**]
([**2-27**] LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1) with subsequent
cath in [**2126**] showing patent grafts, ESRD on HD, COPD, who
presents with one day of constant left sided pleuritic CP
without associated sxs. The pain did not radiate down his arm
or to his jaw. No n/v/d at home. No bleeding in his stool. No
dizziness, fainting,lightheadedness.
.
In the [**Last Name (LF) **], [**First Name3 (LF) **] EKG revealed T wave inversions worse in I, AVL and
new in II. otherwise unchanged. He had a a troponin of 0.21
which is his baseline baseline. He was given nitro for pain
improvement. He was also given morphine with mod improvement. He
was found to have a HCT of 27.5 (baseline 40) and had guaiac
positive stool. He subsequently had a HCT of 21. GI was
notified and he was typed and crossed and transfused with blood
and given a dose of IV PPI. A D-Dimer was drawn and found to be
605 and he underwent a CTA prior to transfer to the MICU.
Past Medical History:
1) CAD: s/p CABG [**2-27**] LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1
[**2127-6-20**] cardiac cath: LMCA 40%, LAD mid 70%, LCx 60%, RCA
previously known proximal 99% occlusion; Patent grafts.
-- Stress [**2127-10-10**]: unchanged from [**2127-6-18**]; moderately
reversible inferolateral to inferior walls perfusion defects
with EF 44%
2) Type II DM (diet controlled) - HgbA1c 6.5 [**12/2126**]
--- retinopathy
--- nephropathy
--- neuropathy
3) HTN
4) Hyperlipidemia- last FLP [**7-/2126**] (TChol 100, LDL 39, HDL 44)
5) CHF: [**2-1**] Echo: unchanged from [**2127-10-14**]; [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated,
LVEF improved to 55% (from 35% 2 years prior), 1+ MR
6) PVD: s/p stent to bilateral CIAs (Genesis) and steft to [**Female First Name (un) 7195**]
- s/p POBA and atherectomy of L SFA [**2126-7-17**]
7) ESRD/HD - T/Th/Sat
8) COPD - pt denies this diagnosis
9) Tracheomalacia
10) C. diff colitis
11) UGI bleed [**2126-5-25**]: EGD showed non-bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Tear, gastropathy, and gastritis
-- s/p POBA and atherectomy of L SFA [**2126-7-17**]
12) RLL pneumonia
Social History:
patient is originally from [**Country 7192**] (moved here 16 years ago).
His wife and family are still over there. He travelled there
[**11-30**]. He lives alone, but his brother is nearby. He is on
disability. His sister-in law works @ [**Hospital1 18**] in housekeeping. No
tob, EtOH, illicits
Family History:
father d. CAD, mother and brother with [**Name (NI) 7199**].
Physical Exam:
T: 98.2 102/49 76 16 100% on 2L NC
General: Pleasant male
HEENT: JVP seen at angle of jaw
CV: Irregular rate, systolic murmur heard at apex and at LUSB,
radiates to carotids b/l
Lungs: crackles at bases, wheezy at right mid lung field
Abd: soft, nt, nd, +bs
Ext: trace edema, 1+ pedal pulses
Skin: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-28**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission LABs:
[**2129-1-14**] 11:35AM BLOOD WBC-7.0 RBC-2.85*# Hgb-9.5*# Hct-27.5*#
MCV-96 MCH-33.4* MCHC-34.7 RDW-14.3 Plt Ct-234
[**2129-1-14**] 06:25PM BLOOD WBC-5.8 RBC-2.32* Hgb-7.9* Hct-21.9*
MCV-94 MCH-34.0* MCHC-36.2* RDW-14.6 Plt Ct-203
[**2129-1-14**] 11:35AM BLOOD Neuts-79.9* Lymphs-10.9* Monos-5.7
Eos-2.7 Baso-0.6
[**2129-1-14**] 06:25PM BLOOD Neuts-70.4* Lymphs-19.3 Monos-6.7 Eos-3.3
Baso-0.3
[**2129-1-14**] 11:02PM BLOOD PT-12.1 PTT-26.7 INR(PT)-1.0
[**2129-1-14**] 05:00PM BLOOD D-Dimer-605*
[**2129-1-14**] 11:35AM BLOOD Glucose-112* UreaN-52* Creat-7.4*# Na-139
K-4.0 Cl-95* HCO3-31 AnGap-17
[**2129-1-14**] 11:35AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.7*
.
Other Labs:
[**2129-1-14**] 11:35AM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2129-1-14**] 05:00PM BLOOD CK-MB-3 cTropnT-0.18*
[**2129-1-14**] 11:02PM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2129-1-14**] 11:02PM BLOOD Lipase-19
[**2129-1-14**] 11:35AM BLOOD CK(CPK)-89
[**2129-1-14**] 05:00PM BLOOD CK(CPK)-69
[**2129-1-14**] 11:02PM BLOOD ALT-24 AST-33 LD(LDH)-338* CK(CPK)-75
AlkPhos-90 Amylase-129* TotBili-0.6
.
Discharge labs:
[**2129-1-19**] 06:20AM BLOOD WBC-7.0 RBC-4.01* Hgb-12.3* Hct-36.3*
MCV-90 MCH-30.7 MCHC-33.9 RDW-16.4* Plt Ct-194
[**2129-1-19**] 06:20AM BLOOD PT-11.6 PTT-25.4 INR(PT)-1.0
[**2129-1-19**] 06:20AM BLOOD Glucose-95 UreaN-40* Creat-6.8*# Na-140
K-3.9 Cl-97 HCO3-30 AnGap-17
[**2129-1-19**] 06:20AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.2
.
Microbiology:
[**2129-1-17**] 6:20 am SEROLOGY/BLOOD
**FINAL REPORT [**2129-1-19**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2129-1-19**]):
NEGATIVE BY EIA.
Reference Range: Negative.
.
EKGs in ED: Similar to baseline with nonspecific T wave
inversions in lateral leads, TWIs in II, AVL
.
EKG on arrival to MICU: Unchanged from prior
.
Studies:
CXR [**1-14**]: IMPRESSION: Stable small right effusion.
.
CTA Chest [**1-14**]:
1. No evidence of PE.
2. Right lower lobe atelectasis. Small associated right-sided
pleural effusion.
3. Several pulmonary nodules in right upper lobe not identified
on the prior CT of [**2126-7-28**]. Comparison with the most recent
CT of [**2128-1-30**] is recommended once this becomes
available for review. If these nodules were not present at that
time, a 3-month followup would be recommended to assess for
resolution.
.
EGD [**2129-1-15**]: Impression: Adherent blood clot in the lower third
of the esophagus and GE junction, possibly extending into the
stomach.
Ulcer in the cardia. Oozing of blood in the cardia (thermal
therapy, injection); No blood was seen in the duodenum; Blood in
the stomach
Brief Hospital Course:
Mr. [**Known lastname 7203**] is a 58 yo male with CAD s/p CABG in [**2125**] admitted
with chest pain in setting of HCT drop 10-15 pts from baseline.
His hospital course is summarized below by problem.
1 GIB: Patitent has a known history of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear,
admitted to MICU with a Hct drop (27-->21) in the setting of
chest pain. NG lavage was positive for frank blood on arrival to
MICU but HCT improved s/p 3 unit of PRBCs. GI performed and
upper endoscopy on [**1-15**] which showed a bleeding gastric ulcer
with was treated with electrocautery and epinephrine injection.
This stabilized the bleeding with out further blood per rectum.
Patient Hct remained stable >30, started on IV PPI [**Hospital1 **], and was
called out to the floor on [**2129-1-16**]. H. pylori serology was
checked and was negative. He remained HD stable on the floor
with [**Hospital1 **] Hct checks. His Hct remained mostly>30, with one
transient Hct drop to 27.3 on the night of [**2129-1-17**], which he
recieved an additional unit of pRBC, and his Hct remained stable
and above 30 post transfusion. GI was [**Name (NI) 653**], given his Hct
remained post transfusion and no overt bleeding, recommended
repeat EGD in 3 weeks post discharge. His ASA and Plavix was
held throughout his hospital course. Typically GI recommend ASA
and plavix held for at least 1 week post acute bleed. After
discussion with GI and his cardiologist (Dr. [**First Name (STitle) **]. Patient
was to restart 1 week after his acute bleed ([**2129-1-22**]), and 3
weeks after discharge. He was also transioned to PO protonix
[**Hospital1 **] prior to discharge.
2 ESRD: Patient is on the deceased donor kidney transplant list.
He currently dialyzes via a left brachiocephalic AV fistula
which is functioning well, and is on a T, Th, Sat HD schedule.
We continued him on that schedule, and he was dialysed on
[**2129-1-15**] (S) and [**2129-1-18**] (T), which we tolerated the HD well. He
was also maintained on Nephrocaps and Renagel (outpatient
regimen).
3 CAD: Patient has chronic CP in setting of muliti-vessel
disease s/p CABG. On ASA, Plavix at baseline. Admission EKG
without changes compared to his prior EKGs. Patient was ruled
out for MI x 3 sets (Trop ~0.2 which is around his baseline).
His ASA/Plavix was held given his acute GIB. His chest pain
resolved post EGD. After discussion with GI and his
Cardiologist (Dr. [**First Name (STitle) **], we continued to hold his ASA and
plavix during his stay. He will restart ASA 1 week after his
acute bleeding on [**2129-1-22**], and restart his plavix 3 weeks after
discharge. His antihypertensives was initially held post EGD at
the MICU. We gradually restarted him back on his home dosage of
betablocker, ACEI, Imdur in that order as tolerated. His BP
remained stable, and patient denied any symptoms of CP/SOB while
on the floor. He was to follow up with Dr. [**First Name (STitle) **] within 2 weeks
after discharge for further management of his CAD.
4 Incidental lung nodules of RUL on CT: Patient had a CT
initially to r/o PE given an elevated D-dimer. Incidental lung
nodules were found in his RUL. He was instructed to have a
follow-up Chest CT in 3 months to assess these nodules.
5 HTN: Longstanding. Initially, his antihypertensives was
held(ACE, BB, Imdur) given HCT lability. After pt was called
out to the floor, we gradually restarted his bb, ACEI, and Imdur
in that order. His BP remained well controlled in that regimen.
6 Type II DM: Pt. has diet-controlled DM as an outpatient. We
kept him on SSI and FSQID. His BS remained well controlled.
7 CHF: Stable during this admission no signs of volume overload
despite lg heart on CT. Echo in [**2-1**] unchanged from [**2127-10-14**];
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, LVEF improved to 55% (from 35% 2 years
prior), 1+ MR
8 PVD: His activity is still limited to walking 15 minutes after
which he develops pain in the lower legs and occasional chest
pain which responds to Nitroglycerin. He was able to ambulate
without difficulty on the floor.
9 FEN: NPO initially then advanced gradually to regular cardiac
and renal diet; repleted lytes prn
10 PPx: PPI [**Hospital1 **] (initially IV, then switched to PO); ambulating,
bowel regimen
11 CODE: FULL
Medications on Admission:
Atenolol 25 mg b.i.d.
Aspirin 81mg daily
Plavix 75 Daily
Imdur 30 mg Daily
Lipitor 80 mg Daily
Lisinopril 20 mg Daily
Renagel
Nephrocaps
.
Allergies: Cefepime
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
->pt was instructed to finish his atenolol pills he has at home,
and discuss with his PCP about switching to metoprolol given his
ESRD
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: please restart on
[**2129-1-22**].
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: Please
restart 3 weeks after discharge or instructed by Dr. [**Last Name (STitle) **]
[**Name (STitle) **] ( your cardiologist).
10. Outpatient Lab Work
Please check CBC [**2129-1-24**] prior to your next appointment time
with your PCP [**Last Name (NamePattern4) **] [**2129-1-25**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) Acute GI Bleed/Gastric ulceration
2) Acute blood loss anemia
3) Anemia of chronic disease
4) CAD s/p CABG, angina pectoralis
5) incidentally noted RUL pulmonary nodules, 3 month f/u rec'd
Secondary:
1) Hypertension
2) Severe pulmonary hypetension
3) Diastolic CHF
4) 2+ Mitral regurgitation
5) Type II DM - controlled with complications
6) arteriosclerosis, peripheral [**Date Range 1106**] disease, claudication
Discharge Condition:
afebrile, VSS, tolerating POs, and ambulate without difficulty
Discharge Instructions:
You had an acute upper GI bleed on admission, you underwent an
EGD on [**2129-1-15**], which reviewed an ulcer in the cardia. You also
received 4 units of pRBC during this admission, and your hct
stabilized.
.
Because of your acute bleeding, you were started on protonix
40mg PO twice a day, and you need to continue that until
instructed by your PCP or GI doctors.
.
We held your ASA and plavix. After discussing with the GI team
and Dr. [**First Name (STitle) **] (your cardiologist), you can resume ASA on
[**2129-1-22**], and tentatively resume your plavix three weeks after
discharge (discuss with Dr. [**First Name (STitle) **] during next appointment).
You will follow up with your PCP Dr [**Last Name (STitle) **] on [**2129-1-25**] 1:45pm for
Hct check to make sure it is stable. And you will have follow
up with Dr. [**First Name (STitle) **] [**2129-2-1**] at 3pm to discuss management of your
CAD, and when you can restart plavix. You will also have a
follow up EGD on [**2129-2-9**] at 9:30am with GI team, and a follow up
with GI fellow, Dr. [**Last Name (STitle) 3708**] who has been following you during this
admission on [**2129-2-22**] 1:30 to discuss further treatment and
management.
.
You should have a follow-up Chest CT in 3 months to assess some
incidentally noted nodules in your right upper lobe. These may
not be anything to worry about, but they may be an early
growth/tumor and should be followed. Please discuss this
finding during your next PCP [**Name Initial (PRE) 648**].
.
Please continue your HD T, Th and Sat as before.
.
If you experience any fevers, chills, chest pain, SOB,
dizziness, N/V, acute blood loss, or any medical conditions
concerning for you, please call your PCP or go to the emergency
room immediately.
.
Please make all of your appointments, and please take all of
your medications as prescribed.
Followup Instructions:
Please follow up with below appointment:
You PCP: [**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2129-1-25**] 1:40 (please have a CBC check prior to that
appointment, prescription given)
.
You cardiologist: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D.
Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2129-2-1**] 3:00
.
repeat EGD: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2129-2-9**] 9:30 ([**Hospital **] clinic will send you specific
instructions prior to this procedure)
.
GI follow up: Provider: [**Name10 (NameIs) 3708**] [**Name11 (NameIs) **], MD phone [**Telephone/Fax (1) 1983**]
Date/Time: [**2129-2-22**] 1:30 ( to discuss repeat EGD results)
.
You should have a follow-up Chest CT in 3 months to assess some
incidentally noted nodules in your right upper lobe. These may
not be anything to worry about, but they may be an early
growth/tumor and should be followed.
[**Last Name (un) 7213**] [**Last Name (un) 7214**] un pecho CT [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7215**] recordativa en 3 meses para
determinar alguno los n??????dulos incidentemente conocidos en tu
l??????bulo superior derecho. ??????stos no pueden ser cualquier cosa
preocuparse alrededor, [**Last Name (un) **] pueden ser un crecimiento/un tumor
tempranos y deben ser seguidas.
Completed by:[**2129-1-19**]
|
[
"285.21",
"518.89",
"250.40",
"403.91",
"V18.0",
"428.0",
"285.1",
"496",
"585.6",
"424.0",
"416.0",
"531.40",
"V17.3",
"V45.81",
"413.9",
"414.01",
"440.21",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"43.41",
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12134, 12140
|
6250, 10610
|
279, 372
|
12610, 12675
|
3606, 3606
|
14579, 15296
|
2943, 3005
|
10819, 12111
|
12161, 12589
|
10636, 10796
|
12699, 14556
|
4706, 6227
|
3020, 3587
|
15308, 16129
|
229, 241
|
428, 1427
|
3622, 4282
|
1449, 2613
|
2629, 2927
|
4294, 4690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,515
| 198,740
|
48304
|
Discharge summary
|
report
|
Admission Date: [**2157-5-24**] Discharge Date: [**2157-5-25**]
Date of Birth: [**2110-9-29**] Sex: F
Service:
In brief, the patient is a 46-year-old female with a
complicated medical history including lupus, dilated
cardiomyopathy, mitral regurgitation, aortic insufficiency
and peripheral vascular disease who presented to the [**Hospital1 **] [**First Name (Titles) 767**] [**Hospital3 **] Center with a
hematoma in her right medial thigh. In brief, the patient
underwent a femoral popliteal bypass graft in [**Month (only) 547**] and
returned postoperative day 8 with abdominal pain and was
found to have a perforated colon. She then underwent a
subtotal colectomy with an end ileostomy. Her course was a
little prolonged and the patient was eventually discharged to
[**Hospital3 **] on long term intravenous antibiotics
and Lovenox therapy.
Upon beginning physical therapy, the patient developed a
hematoma in her right thigh which was tender. [**First Name8 (NamePattern2) **]
[**Hospital1 78543**] report, her hematocrit dropped from approximately
30 to approximately 24. Thus, she was transferred here for
evaluation. Upon arrival to the Emergency Room, she was
tachycardic and slightly hypertensive from the 110s/50s down
to the 80s/40s. However, the patient did not complain of any
symptoms besides some tenderness in her thigh. She was
resuscitated over night with 2 units of blood and with fluid.
Her blood pressure in the a.m. resumed to 120s/50s and her
tachycardia resolved.
Upon electrocardiogram analysis, the patient was noted to
have some change in her precordial leads, specifically V3
through V6 which are likely due to lead placement.
Nevertheless, CK and troponins were sent which were
completely negative. In the a.m., the patient was afebrile
and hemodynamically stable. Her right thigh hematoma was
much resolved. A post transfusion hematocrit will be checked
prior to transfer, but the patient will likely be transferred
back to [**Hospital3 **] in the p.m. The
electrocardiogram changes on the V3 to V6 leads will also be
looked at by the cardiology team, but having already spoken
to her cardiology attending, these were most likely due to
lead placement. Also, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**], her nephrologist,
was also contact[**Name (NI) **] and is aware of her admission but does not
feel there are any acute renal issues at this time.
This is just a short discharge note for an overnight
admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36
D: [**2157-5-25**] 10:41
T: [**2157-5-25**] 10:48
JOB#: [**Job Number **]
|
[
"396.3",
"244.9",
"459.0",
"412",
"425.4",
"710.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,689
| 111,702
|
27753
|
Discharge summary
|
report
|
Admission Date: [**2103-5-30**] Discharge Date: [**2103-6-8**]
Date of Birth: [**2022-3-6**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin Hcl
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Mechanical Fall
Chronic Subdural Hematoma
Bilobar pneumonia
Repaired right eyebrow laceration
Right meacarpal fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is an 81 yo female with atrial fibrillation, schizophrenia,
mild dementia, who was initially transferred from [**Hospital **]
Hospital to [**Hospital1 **] for possible new SDH. On day of admission at her
nursing home, the patient had an unwitnessed fall. Per NH, she
got entangled in her sheets and fell to the ground. She was
found on the ground with laceration over her right eye and there
was noted to be a large amount of blood. She was sent to
[**Hospital1 **] ED via ambulance.
.
Head CT there showed a right subdural hematoma. She was given 1
gram of dilantin for ? seizure prophylaxis and 10 mg IV vitamin
K. She was then transferred via [**Location (un) **] to [**Hospital1 18**]. In route,
she received a total of 6 mg of ativan. Upon arrival to [**Hospital1 **], she
was intubated for airway protection as she was so sedated.
Repeat head CT done here showed a chronic subdural hematoma.
Neurosurgery and neurology were consulted and aside from an
upgoing toe on the left (thought to be due to chronic subdural)
they did not note any acute neurological issues.
.
CT scan of abd/pelvis/thorax also revealed a probable right
aspiration pneumonia and she was given 500 mg IV levaquin and
500 mg IV flagyl.
.
In speaking with the nursing home, pt is confused most of the
time. At baseline she is able to respond to name , speaks
"jibberish most of time," and doesn't make sense. She is able to
ambulate and feed herself but is totally dependent on ADLs. Upon
further questioning it was found that on [**2103-5-17**] at 10 pm, pt
fell and may have hit her head right side. She was on
anticoagulation with coumadin at that point and it was d/c'd.
She was not sent to the hospital at that time as vitals were OK
and neurological exam was reportedly intact. Also per NH, no
cough/fevers recently.
Past Medical History:
1. Atrial fibrillation- not on anticoagulation since fall as
above
2. Schizophrenia- s/p ECT. Hospitalized many times since age 28.
3. GERD
4. Dementia
Social History:
Lives in Resident Care NH ([**Telephone/Fax (1) 67707**]). Worked until 28 as a
clerk until first schizophrenia "attack." Never been married. No
children. Quit smoking last year ([**Location (un) 47**] [**Hospital1 **] for PNA); had
been "heavy smoker" ~ 2 ppd x many years; no EtOH; no drugs.
Family History:
NC
Physical Exam:
VS: T 97.7, BP 102/66, HR 96, RR 20, 94% 3.5 L (from 6L), Wt 158
lb
Gen: sleepy but arousable, speech incomprehensible
HEENT: pupils round and reactive b/l. op clear
CV: RRR. S1S2. No M/R/G
Lungs: coarse bs b/l. no focal ronchi
Abd: NABS. soft, NT, ND
Ext: no c/c/e. 2+ pulses
Neuro: demented, poorly follows commands, moving all extremities
Pertinent Results:
[**2103-5-30**] 04:25PM TYPE-ART RATES-[**11-1**] TIDAL VOL-560 PEEP-5
PO2-419* PCO2-42 PH-7.41 TOTAL CO2-28 BASE XS-2
INTUBATED-INTUBATED
[**2103-5-30**] 04:25PM LACTATE-1.5
[**2103-5-30**] 03:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2103-5-30**] 03:27PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2103-5-30**] 03:10PM LACTATE-2.8*
[**2103-5-30**] 11:15AM GLUCOSE-99 UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-29 ANION GAP-13
[**2103-5-30**] 11:15AM CK(CPK)-41
[**2103-5-30**] 11:15AM CK-MB-NotDone cTropnT-<0.01
[**2103-5-30**] 11:15AM ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-3.4
MAGNESIUM-2.2
[**2103-5-30**] 11:15AM WBC-10.0 RBC-4.79 HGB-12.7 HCT-36.7 MCV-77*
MCH-26.5* MCHC-34.5 RDW-15.1
[**2103-5-30**] 11:15AM NEUTS-82.5* LYMPHS-12.1* MONOS-5.0 EOS-0.2
BASOS-0.3
[**2103-5-30**] 11:15AM MICROCYT-2+
[**2103-5-30**] 11:15AM PLT COUNT-311
[**2103-5-30**] 11:15AM PT-12.5 PTT-22.7 INR(PT)-1.1
[**2103-5-30**] 11:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2103-5-30**] 11:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
..
Head CT without contrast [**2103-5-30**] prelim:
Rt chronic SDH extending across the entire convexity.
- Left frontal prominent extraaxial space
- No acute bleed
- Small vessel ischemic changes.
- Osseous findings consistent with Pagets
.
CT c-spine [**2103-5-30**]-C1 through T2 are visualized. There is no
evidence of acute fracture or malalignment of the cervical
spine. There are extensive degenerative changes ranging from
C4-C7 characterized by disc space narrowing, end plate sclerosis
and subchondral cyst formation and vacuum disc phenomena and
marginal osteophyte formation. Disc space narrowing is most
severe at
C5/6 and C6/7. Disc osteophyte complexes at C3/4 C5/6 and C6/7
moderately indent the spinal canal. The prevertebral soft
tissues are unremarkable. The patient is intubated. Limited
evaluation of the lung apices demonstrates apical scarring.
.
Chest AP ([**2103-5-30**])
1. Endotracheal tube and nasogastric tube in satisfactory
position, however, the endotracheal tube cuff is over-inflated.
2. Cardiomegaly and pulmonary edema.
.
CT orbit/sella ([**2103-5-30**])
1. Questionable mildly depressed nasal bone fracture with two
tiny 1-2 mm high- density foreign bodies in the adjacent soft
tissues in the nose.
2. Mottled appearance of the skull with mixed sclerotic and
lucent areas is suggestive of Paget disease. Further evaluation
with bone scan is suggested.
.
CT abdomen/pelvis ([**2103-5-30**])
1. No evidence for acute intrathoracic, intra-abdominal, or
intrapelvic injury including fracture, visceral laceration,
hematoma, free air, or free fluid.
2. Right lower lung lobe air space consolidation with soft
tissue density filling the bronchi to the right lower lung lobe.
This could represent tumor within the bronchi or mucoid
impaction. These findings could represent aspiration pneumonia
or a post-obstructive pneumonia. Right hilar lymphadenopathy
cannot be definitively excluded on this non-contrast scan. In
the non-acute setting, a contrast-enhanced scan could further
characterize this abnormality.
3. Enlarged pulmonary artery measuring 4.7 cm, which may be
secondary to pulmonary artery hypertension.
4. Large stool filled rectum measuring 28 x 10 cm. No evidence
for bowel dilatation proximal to this stool ball.
5. Multiple sclerotic lesions are of uncertain etiology and
should be further characterized with a bone scan in the
non-acute setting.
6. Multiple tiny hyperdense lesions of the right kidney which
are incompletely characterized. An ultrasound could further
evaluate these lesions.
7. Probable simple cyst in the mid pole of the left kidney.
8. Multiple prior rib fractures. No evidence for acute fracture.
.
Left shoulder AP/neutral ([**2103-5-30**]): No fracture.
.
Humerus films ([**2103-5-30**]): No fracture
Brief Hospital Course:
1. Respiratory- Initially intubated for airway protection in
setting of over sedation from both ativan (6 mg) and dilantin (1
g). Extubated, now saturating >94% on 3.5 L via NC.
Antipscyhotics held because of concern to for sedative effect.
Pt now titrated NC to 1.5 L and maintaining oxygen sat in low
90s range. [**Month (only) 116**] have element of atelectasis now that will
hopefully improve with increased activity. Titrate down oxygen
as tol with goal sat of 92-95%.
.
2. Pneumonia- On CT and CXR appears to have a RM/RL lobe PNA.
?aspiration vs [**Name (NI) 16630**]
Pt was on ceftriaxone and then once cleared to take po
medications changed to cefpodoxime. Today is day [**7-2**] of
antibiotics.
.
3. SDH- Appears chronic in nature. Reviewed by neurology/
neurosurgery. She did fall 2 weeks prior. She was given 1 g
dilantin at OSH. Now discontinued.
.
4. S/p fall- Seems completely mechanical in nature. Will need to
get more information regarding fall risk. PT eval.
.
5. ST depression- 1 mm STD in V2-V4; no old to compare with. [**Month (only) 116**]
be related to strain from RVR. CE's negative.
.
6. Afib- Heart rate has been elevated as patient has not been
able to consistently take rate related medications. [**Month (only) 116**] also be
secondary to hypovolemia. Now back on diet have restarted dig
and diltiazem. Should follow. Will not restart anticoagulation
with SDH and history of significant falls. This can be
addressed at [**Hospital1 1501**] as well as starting aspirin instead.
.
7. [**Name (NI) 3687**] Pt with schizophrenia requiring multiple
hospitalizations in the past. Has been sedate and comfortable
during this stay. No agitation. In the prior few days has not
taken good po. Unclear if behavioral or if she dislikes diet.
[**Month (only) 116**] consider restarting antipsychotics at [**Hospital1 1501**]. Unclear after
this fall what her new baseline level of function will be.
.
8. GERD- continue PPI per outpt dose.
.
9. F/E/[**Name (NI) **] Pt received swallow evaluation because of concern for
aspiration. Recommendations were for her to be on a pureed
solids and thin liquids diet. Aspiration precautions. Need to
encourage eating. If she continues to refuse, may need to
address with family other avenues to get her nutrition. Pt also
had episode of hypernatremia when not eating for a few days.
Responded to IVF of 1/2NS. Pt improved now.
.
10. Code Status: DNR/DNI. Discussed with pt's sister [**Name (NI) 4489**]
[**Name (NI) 2520**], her HCP.
Medications on Admission:
Digoxin 0.25 mg qday
MVI
Protonix 40 mg qday
Zyprexa 5 mg qam, 15 mg qhs
Trifluoperazine 5 mg QHS
Colace 100 mg [**Hospital1 **]
Bisacodyl 10 mg PR prn
Diltiazem 30 mg tid
Tylenol prn
Fleets prn
Guaifenesin prn
MOM prn
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 6 days.
6. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
resident care
Discharge Diagnosis:
Fall. Chronic Subdural Hematoma. Bilobar pneumonia.
Repaired right eyebrow laceration.
Right metacarpal fracture.
Discharge Condition:
Fair
Discharge Instructions:
Patient will need physical therapy to regain strength. Needs
full assist for ADLs at this point and encouragement in eating.
Should be seen by a doctor if develops fever.
Followup Instructions:
Patient should be followed up by physicians at her [**Hospital1 1501**].
|
[
"295.90",
"294.8",
"518.81",
"V58.61",
"815.02",
"276.0",
"852.21",
"873.42",
"507.0",
"530.81",
"998.12",
"E884.2",
"802.0",
"E939.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10553, 10593
|
7179, 9693
|
395, 401
|
10753, 10760
|
3119, 7156
|
10980, 11056
|
2737, 2741
|
9962, 10530
|
10614, 10732
|
9719, 9939
|
10784, 10957
|
2756, 3100
|
237, 357
|
429, 2233
|
2255, 2409
|
2425, 2721
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,361
| 153,131
|
42897
|
Discharge summary
|
report
|
Admission Date: [**2180-11-17**] Discharge Date: [**2180-12-14**]
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worst headache of her life
Major Surgical or Invasive Procedure:
[**2180-11-17**] Cerebral angiogram for coiling of R PCOMM aneurysm
[**2180-11-18**] R EVD placement
[**2180-12-3**] BRONCHIAL BALLOON DILITATION
[**2180-12-4**] IVCF
[**2180-12-4**] RIGHT VENTRICULOPERITONEAL SHUNT
[**2180-12-6**] TRACHEOSTOMY
[**2180-12-6**] BRONCHOSCOPY WITH TRACHEAL BIOPSY
[**2180-12-12**] UPPER ENDOSCOPY
History of Present Illness:
88 y/o female who developed a severe headache this morning
around 10am followed by malaise and sweating and episodes of dry
heaving. Taken to the hospital by her daughter. Transferred from
[**Hospital3 **] to [**Hospital1 18**] for further care.
Upon evaluation, patient is accompanied by her daughter who
helps
with the exam and translates for her. She is complaining of
posterior headache and nuchal pain and stiffness, denies chest
pain, SOB, visual changes.
Past Medical History:
HTN
Social History:
Lives with her daughter, Daughter denies knowledge of
Tobacco use.
Family History:
NC
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 2 [**Doctor Last Name **]: 3 GCS E: 4 V: Motor 6
O: T: BP: 160 /74 HR: 59 R O2Sats
Gen: Uncomfortable with a headache
HEENT: NCNT
Neck: Nuchal rigidity
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect, Spanish speaking
Orientation: Oriented to person, place, and date.
Language: Speech fluent Spanish
Cranial Nerves:
I: Not tested
II: Pupils righ 4mm, left 3mm and reactive. Visual fields are
full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-20**] throughout. No pronator drift
Sensation: Intact to light touch
On discharge -
she is afebrile / vss and has had a bm since peg placed
Neurologically she awakens easily and is attentive. Oriented to
herself, she follows commands. Her pupils are 4-2mm bilaterally/
EOMI/ face is symmetric and tongue is ML with some noted oral
thrush. She has some difficulty following commands but is
antigravity x all four extremities without noted deficit. There
is no obvious drift. Her Incisions to her scalp as well as her
peg site are all benign. Her trach is clean and dry without
acitive bleeding / oozing. She is incontinent of urine.
Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2180-11-17**]
1. Extensive subarachnoid hemorrhage, likely originating from 6
mm bilobed
right posterior communicating artery aneurysm.
2. Two tiny infundibula or aneurysms measuring 1-2 mm involving
the left PCom and possibly the left anterior choroidal artery.
3. Large superior mediastinal mass which may represent a
descending goiter, which should be further investigated once the
patient is clinically stable.
CT HEAD W/O CONTRAST [**2180-11-17**]
1. Interval placement of right-sided vascular coil.
2. Very minimal increase in ventricular size compared to most
recent prior
exam.
3. Extensive subarachnoid hemorrhage with blood layering in the
occipital
horns bilaterally.
ECHO:
EF 80%, Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CT HEAD W/O CONTRAST [**2180-11-19**]
Reduction in ventricular size. Somewhat caudal placement of
ventriculostomy catheter. Readjustment may be necessary.
CT Chest [**2180-11-20**]:
IMPRESSION:
1. Approximately 8-cm diameter heterogeneous mass arising from
the right lobe of thyroid gland and descending inferiorly into
the middle mediastinum with associated displacement and
narrowing of the trachea. The etiology of the mass is uncertain,
but could relate to a thyroid goiter. A neoplasm arising within
a goiter is also possible, particularly considering the presence
of right paratracheal lymph node enlargement below the level of
the mass.
2. Small right pleural effusion with adjacent right lower lobe
atelectasis.
3. Incompletely imaged 6.5-cm diameter left renal lesion is
probably a simple cyst but is incompletely imaged on this study
and cannot be fully
characterized.
CTA [**11-22**]:
IMPRESSION:
1. No infarct, extension of existing hemorrhage, or new
hemorrhage.
2. New left subdural hygroma overlying the frontoparietal
convexity.
3. The A1 branch of the right anterior cerebral artery exhibits
minimal
vasospasm, but remains widely patent.
CTA [**11-25**]:
IMPRESSION: Limited examination due to poor arterial
enhancement,
possible/equivocal vasospasm involving the right middle cerebral
artery in
segments M2 and M3, the left middle cerebral artery appears
patent, the
patient is status post coil embolization in the right internal
carotid artery.
Unchanged intraventricular hemorrhage and subarachnoid
hemorrhage with major
distribution of the blood on the right sylvian fissure. Slightly
more
prominent subdural hematoma and also midline shifting towards
the right as
described above.
[**2180-11-28**] Portable Head CT:
IMPRESSION:
1. New small hemorrhage into the pre-existing left subdural
hygroma, which is unchanged in size however.
2. Reduction in rightward shift of midline structures from 6 mm
to 2.5 mm.
3. Unchanged ventricular size with no evidence of hydrocephalus.
The amount of fluid being drained by the EVD catheter should be
monitored closely, as intracranial hypotension from overtly
aggressive CSF drainage is one possible cause of the spontaneous
left subdural hygroma.
4. Continued expected evolution of preexisting subarachnoid and
intraventricular blood collections.
[**2180-12-4**] Head CT:
IMPRESSION:
1. Stable left subdural fluid collection.
2. Minimal increase in ventricular size.
3. Continued redistribution and clearance of subarachnoid
hemorrhage.
4. Progressive fluid opacification of right mastoid air cells.
[**2180-12-4**] LENIS:
IMPRESSION:
1. Nonocclusive thrombus of the right common femoral vein. No
other
thrombosis identified within the deep venous system of the right
lower
extremity.
2. No DVT in left lower extremity.
[**2180-12-4**] Head CT:
IMPRESSION:
1. Interval EVD removal, and placement of VP shunt catheter with
tip in the right frontal [**Doctor Last Name 534**]. Mild improvement in ventricular
size.
2. Stable left subdural fluid collection, evolving subarachnoid
hemorrhage, and trace intraventricular hemorrhage with mild
rightward shift of left cerebral hemisphere and left lateral
ventricle.
3. Continued partial opacification of the right mastoid air
cells.
[**12-8**] Video Swallow: Swallowing videofluoroscopy was performed
in conjunction with the speech and swallow division. Attempt was
made to pass multiple consistencies of barium; however, the
patient was too lethargic to participate in the study. Upon the
administration of nectar thickened liquids, penetration was
seen. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric feeding tube was present.
[**12-11**] CXR
IMPRESSION: Right hemidiaphragmatic elevation with resultant
atelectasis,
perhaps a result of phrenic nerve paralysis secondary to the
large right
mediastinal mass.
Brief Hospital Course:
88 y/o F s/p WHOL presents to [**Hospital1 18**] for evaluation. A CT head
showed diffuse SAH. CTA was done which was suspicious for
aneurysm. Angiogram was done with coiling of R PCOM aneurysm.
Patient was transferred to ICU for close monitoring.
ICU Course:
On [**11-18**], an EVD was placed for developing hydrocephalus. She was
stable and was extubated on the morning of [**11-19**], but need to be
re-intubated that evening for hypoxemia. A chest x-ray revealed
an enlarged mass at the thyroid level. A CT of the chest was
done for further workup. CT confirmed a Thyroid mass, likely a
goiter causing tracheal compression and stenosis.
[**11-21**]: Thoracic surgery was consulted along with Intraventional
IP for possible tracheal stenting. We started to wean the EVD
raising it to 15 and subsequently to 20.
[**11-22**]: Interventional IP recommended EBUS via ET tube on [**11-23**].
Her EVD was clamped in the morning with no issue. On exam, it
was noted she had RUE weakness compared to left. A CTA head was
done which showed no vasospasm. A family meeting was held and
current diagnosis and plan were discussed.
[**11-24**]: EVD remains clamped, a CT of the head was performed which
revealed a left sided expanding CSF collection likely secondary
to hydrocephalus.Patient also underwent a baloon dilation of her
trachea in the operating room with interventional pulmonary.
[**11-25**]: CTA was performed that was questionable for mild
vasospasm, there were no changes made to her management given
that she remained clinically stable and continued to follow
commands in her primary language.
[**11-26**]: EVD opened after review of the prior CTA which showed in
increase in the extra axial CSF collection, with the intention
to repeat the study in two days to determine whether the patient
will need a shunt. The plan for extubation was postponed given
increased secretions.
On [**11-27**] & [**11-28**] the patient remained stable with her EVD at 15
and IVF at 100. CT head was done and this was stable.
On [**11-29**] a family meeting was held to discuss treatment plan.
On [**11-30**] patient was noted to be more awake. The plan was made
to place her VP shunt on Friday and ENT to resect the thyroid
mass on Monday. Her ceftaz was discontinued. She became febrile
overnight and was pancultured. Ceftaz was restarted.
On [**12-1**] the OR case was cancelled given she had been febrile.
CSF was sent, gram stain was negative. Her exam remained stable,
more awake, following commands x4, antigravity x4. Her foley was
changed out given her borderline UA.
Over the weekend, patient remained stable. She was pre-oped for
the OR on Monday for VP shunt placement.
On [**12-4**] a programmable VP shunt was placed without
complication. Resection of the thyroid mass was postponed.
Screening lower extremity ultrasound showed a DVT in the right
common femoral vein. Vascular surgery was consulted and an IVC
filter was placed by interventional radiology.
On [**12-5**] the surgical team reached a consensus that
thyroidectomy should be avoided if possible, and a trial of
extubation was indicated. Pt was given decadron for 24hrs, with
extubation planned for [**12-6**]. IP then saw patient [**12-5**] and felt
extubation was not indicated given the risk for airway
obstruction. On [**12-6**], it was decided she would go to the OR for
a flexible and rigid bronchoscopy with possible biopsy. At that
time if the airway appears too small, a trach would be done.
[**12-7**] Patient tolerated trach mask over night and was seen in
the morning by physicial therapy and was transferred to the
floor in stable neuro and pulmonary status. She was noted to
have a black tarry stool which was guaic positive so general
surgery was consulted. They recommended endoscopy at the time of
PEG placement.
[**12-8**] A video swallow was perfromed that indicated patient was
likely aspirating, general surgery was consulted for PEG
placement. Patient was found to have black tarry stools that
were guiac positive. A GI consult was obtained. Patient will
need an endoscopy and the plan is for the GI team to coordinate
the scope with the general surgery team to perform the study at
the same time as the PEG placement in the OR. Nimodipine was
discontinued as patient had completed 21 day course.
On [**12-9**] the patients trach site was noted to be bleeding so IP
was reconsulted for evaluation but no intervention was
necessary. The patient trach site & neurological status remained
stable for the next couple days. On [**12-12**] she went to the OR for
PEG tube placement and endoscopy. The PEG was placed without
complication and the endoscopy revealed no bleeding ulcers or
varicies.
On [**12-13**] she was again neurologically stable. Tube feedings were
initiated via the PEG tube. PT and OT recommended discharge to
acute rehab hospital.
Medications on Admission:
Enalapril 20mg daily, ASA 81 mg daily, Aledronate 70mg qweek
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
4. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): [**Hospital1 **]
PER GASTRENTEROLOGY REQUEST FOR COVERAGE.
10. HydrALAzine 10 mg IV Q8H SBP > 200
If aneurysm secured, SBP can be liberalized post angio to less
than 200
11. 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.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Subarachnoid hemorrhage
R PCOMM aneurysm
Respiratory failure
Hydrocephalus
Left sided hygroma
Thyroid mass
Fevers
Oral thrush
melanous stool
anemia requiring transfusion
Deep vein thrombosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for subarachnoid hemorrhage
from a posterior communicating artery aneurysm. This was
treated with coiling. You also required an external ventricular
drain and subsequent ventriculoperitoneal shunt. During your
stay a mass was noted in your neck. It was biopsied but the
results were non diagnostic meaning we still don't know what it
is. You had a tracheostomy to support your airway because of
this neck mass. You also had a feeding tube placed for
nutritional support. You had some blood in your stool during
your stay and received transfusions for this. You were seen by
the gastroenterology doctors. Their work up did not reveal a
source of your bleeding.
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 4 weeks with a MRI/MRA
([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
You will need to follow up with Dr. [**Last Name (STitle) **] of interventional
pulmonary for your trach, in 10 days to 2 weeks. Their office
phone number is [**Telephone/Fax (1) **] / they will also discuss the non
diagnostic biopsy results of your neck mass.
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks
of discharge.
Completed by:[**2180-12-14**]
|
[
"453.41",
"518.81",
"285.9",
"788.30",
"240.9",
"401.9",
"331.4",
"519.19",
"430",
"112.0",
"578.1",
"427.31",
"780.60",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.6",
"39.75",
"38.7",
"33.91",
"33.24",
"02.34",
"96.72",
"88.41",
"02.21",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
14421, 14468
|
8090, 12944
|
282, 612
|
14703, 14703
|
2985, 5951
|
17497, 18076
|
1235, 1240
|
13055, 14398
|
14489, 14682
|
12970, 13032
|
14884, 16555
|
16581, 17474
|
1255, 1594
|
216, 244
|
640, 1105
|
1781, 2966
|
7030, 8067
|
14718, 14860
|
1127, 1133
|
1149, 1218
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,920
| 132,168
|
47525
|
Discharge summary
|
report
|
Admission Date: [**2201-4-28**] Discharge Date: [**2201-5-9**]
Date of Birth: [**2127-12-13**] Sex: F
Service: Cardiothoracic surgery
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Patient is a 73 year-old woman
with known extensive coronary artery disease, diabetes
mellitus and hypertension who was sent to the emergency
department at [**Hospital1 69**] by her
primary care physician when she complained of substernal
chest pain radiating to her back. Patient had a cardiac
catheterization in [**2198-4-26**] which showed left main 50
percent stenosis, LAD 90 percent stenosis, D1 90 percent
stenosis, left circumflex and OM1 80 percent stenosis, RCA 70
percent stenosis, PDA 90 percent stenosis. She has had
intermittent symptoms but otherwise has remained stable. She
had a nuclear stress test on [**2201-4-4**] which revealed a
severe reversible defect inferiorly extending to the apex
with an ejection fraction of 48 percent.
On the day of admission patient was ambulating from the
bathroom when she noted sudden onset of right upper quadrant
tumor radiating to her chest and to Emergency Room back. She
denied any shortness of breath, diaphoresis, palpitations,
nausea or vomiting. She took two sublingual nitroglycerin
and felt better ten minutes after the pain had begun. She
has had these episodes in the past and patient was going to
her primary care physician for her routine visit who then her
referred her to the emergency department.
PAST MEDICAL HISTORY: 1) Coronary artery disease with three
vessel disease as above. 2) Hypertension. 3) Diabetes
mellitus type 2. 4) Hypercholesterolemia.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION: Included Protonix 40 mg p.o. q.d.,
isosorbide 120 mg p.o. q.d., Mavica 8 mg p.o. q.d.,
hydrochlorothiazide 25 mg p.o. q.d., Norvasc 10 mg p.o. q.d.,
Atenolol and Lipitor 20 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient lives with grown children. Denied
ETOH and tobacco or other drug use.
PHYSICAL EXAMINATION: Patient's temperature is 97, heart
rate 56, blood pressure 150/60, respiratory rate 24,
saturating 99% on room air. She is awake in no acute
distress. Pupil are equal, round and reactive to light.
Extraocular motor function intact. Moist mucous membranes.
Neck supple, no jugular venous distention. She does have a
left carotid bruit. Heart has regular rate and rhythm
without murmurs, rubs or gallops. Chest is clear to
auscultation. Abdomen is soft, nontender. Rectal is normal
sphincter tone, guaiac negative. Extremities warm
bilaterally. She is alert and oriented times three with
nonfocal examination.
LABORATORY EXAMINATION: Included white count of 4.8,
hematocrit of 32.9, platelets of 176. PT of 12.7, PTT 28.4,
INR of 1.1. Sodium 136, potassium of 3.8, chloride of 99,
bicarbonate 26, BUN 26, creatinine 1.0, glucose of 306, ALT
was 50, AST 60, alk phos 45, total bilirubin was 0.4, lipase
was 24. Percent of cardiac enzymes were 103, 69 a 68
respectively. Troponins were all less than 0.3.
Electrocardiogram: sinus bradycardia with rate of 53, normal
axis. There are new ST depressions in lead [**Street Address(2) 17297**]
elevations in V2 and V3.
Chest x-ray was within normal limits.
HOSPITAL COURSE: Patient is a 73 year-old woman with
extensive coronary artery disease who has refused coronary
artery bypass graft in the past. Patient was admitted by the
medicine team and was medically maximized on heparin drip and
nitroglycerin drip, Lopressor, Captopril and aspirin. The
patient though remaining hemodynamically stable continued to
have episodic chest pain on exertion with accompanied
electrocardiographic changes. She had a right upper quadrant
ultrasound which was negative to evaluate this right upper
quadrant pain which eventually was the presenting symptoms.
On hospital day number two patient went to cardiac
catheterization which showed stenosis of the RCA 70 percent,
right PDA 90 percent, right posterolateral 90 percent, left
main 80 percent, LAD 90 percent, diagonal 1 90 percent,
diagonal 2 90 percent, proximal circumflex 90 percent, OM1 90
percent, OM2 90 percent. Patient tolerated the procedure
well. Post catheterization patient developed another episode
of chest pain, this time associated with electrocardiographic
changes and positive cardiac enzymes. CPKs were 597, 636,
463 respectively with an accompaniment of troponin of 45.6.
She was maximized medical therapy including heparin,
nitroglycerin drip, beta blockade, ACE inhibitor, Plavix,
Integrulin. Patient continued to have episodic chest pain.
On hospital day five despite maximized medical therapy
patient's blood pressure began to decline from the 170s/60s
to 100s to 120s/40s to 60s. With this active ischemia
patient was transferred to the Cardiac Care Unit after
undergoing placement of intra-aortic balloon pump. In
addition, cardiothoracic surgery was consulted for evaluation
for coronary artery bypass graft. After discussion with the
patient and family patient has agreed to undergo the
procedure. Patient was scheduled for coronary artery bypass
graft. Patient remained hemodynamically stable in the
Cardiac Care Unit on intra-aortic balloon pump at 1:1
augmentation. Patient's Integrulin was stopped prior to the
planned procedure. Preoperative laboratories were
significant for a low platelet count for which she received a
five pack of platelets. PT and PTT were elevated for which
she received two units of fresh frozen plasma. On hospital
day seven patient went to the operating room where she
underwent coronary artery bypass graft time four by Dr. [**Last Name (STitle) 1537**]
and the cardiothoracic team. The grafts were LIMA to LAD,
SVG to diagonal 1, SVG to diagonal 2 and SVG to PDA. She
tolerated this procedure well and was transferred to the
cardiothoracic Intensive Care Unit with intra-aortic balloon
pump at 1:1, propofol drip, epinephrine drip, insulin and
Lidocaine. Postoperatively patient was weaned off all
sedation and was slowly slowly recovered neurologically.
Patient was weaned to extubation without incident. Patient
was weaned off all drips maintaining good cardiac index from
2.2 to 2.3. Patient's intra-aortic balloon pump was
discontinued on postoperative day number one with no events.
She remained hemodynamically stable. Chest tube output was
450 for the first 24 hours. Chest tube output appropriately
decreased but remained serosanguinous. Patient was stable
and on postoperative day number two patient developed atrial
fibrillation with controlled rate. She was started on
amiodarone. Her blood pressure remained in the 130s. She was
then transferred to the floor in stable condition, continuing
in rate controlled atrial fibrillation. She spontaneously
converted to sinus the same day and has remained in sinus
since. Her chest tubes were discontinued on postoperative
day number three without incident. Patient has been seen by
physical therapy and has currently reached a level 3 to 4
activity. Patient is tolerating regular diet. She did
suffer some nausea on postoperative day number three which
was controlled with Zofran. She has had her Foley removed
and she has voided spontaneously. The [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain in
the right leg wound from the vein harvest site has been
removed. Her wounds have remained clean, dry and intact.
Patient's laboratories have remained stable with a hematocrit
of 26, BUN of 16 and creatinine of .6. She has had no
further chest pain.
Of note, during work up prior to surgery patient had had
bilateral carotid studies which are significant for a right
carotid stenosis of the 80 to 99 percent and left carotid
stenosis of 79 percent. Vascular surgery was consulted and
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] vascular team evaluated patient and found
to have stable carotid artery disease. They will follow the
patient and will see the patient several weeks
postoperatively for carotid endarterectomy.
Patient's blood glucose levels have remained from the 100s to
an occasional high 200. She has been on insulin sliding
scale. There are no records of hypoglycemic medications.
Patient will e seen by [**Hospital **] Clinic physician for
recommendations of blood glucose control. Patient is stable
and now ready for discharge to rehabilitation.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft times four.
2. Diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE: Include Lopressor 25 mg p.o.
b.i.., Lasix 20 mg p.o. b.i.d. times seven days, KayCiel 20
mEq p.o. b.i.d. times seven days, Colace 100 mg p.o. b.i.d.,
ECASA 325 mg p.o. q.d., Protonix 40 mg p.o. q.d., Captopril
50 mg p.o. t.i.d., amiodarone 400 mg p.o. q.d., Plavix 75 mg
p.o. q.d., Tylenol 650 mg p.o. q. 4 hours p.r.n., Lipitor 20
mg p.o. q.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: Patient will follow up with Dr. [**Last Name (STitle) 1537**] in four week
in cardiothoracic clinic. Patient will follow up with Dr.
[**Last Name (STitle) **] her primary care physician in two weeks for adjustment
of medications. Follow up for hypertension and diabetes
control.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2201-5-9**] 11:28
T: [**2201-5-10**] 12:29
JOB#: [**Job Number **]
|
[
"433.10",
"458.2",
"410.91",
"250.00",
"401.9",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"36.15",
"88.53",
"36.14",
"37.23",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8457, 8631
|
8658, 9004
|
1710, 1935
|
3291, 8436
|
1676, 1683
|
9050, 9608
|
2055, 3273
|
173, 186
|
215, 1491
|
1514, 1652
|
1952, 2032
|
9029, 9038
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,767
| 122,301
|
2255
|
Discharge summary
|
report
|
Admission Date: [**2140-6-8**] Discharge Date: [**2140-6-17**]
Date of Birth: [**2059-9-13**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
tPA
History of Present Illness:
Code stroke information:
87 y.o. lady with PMH of HTN presented to ER after passing
out and having left side weakness after that. She was brought to
ER within 45 minutes of presentation. She had no signs of
recovery. Code stroke was called.
.
80 RHF with HTN and no other known PMH was brought to the ED for
evaluation of left sided weakness. Promptly code stroke was
called. She was last well seen around 1140 am. Her husband noted
around noon, that she was not moving the left side. he noted
that she was slurred and not her usual self. He called 911 and
she was brought to the ED.
In the ED, when she arrived, she was hemiparatic on the left
side and the arm was much weaker than the leg. She was slurring
her speech.
.
ICU admission:
80F w/ hx of HTN presented to ED after syncopal episode followed
by L-sided weakness and dysarthria. CT head showed no evidence
of hemorrhage or acute infarct. Pt was within 3-hour window for
tPA, and it was thus administered. After receiving approximately
half the tPA dose, she began to have gum bleeding. The tPA was
stopped for 10 minutes and then restarted to complete the entire
dose. Shortly thereafter the patient's L-sided weakness showed
some improvement; dysarthria continued.
En route to the SICU, the patient became bradycardic to the 30s,
lethargic, and showed worsening L-sided weakness and neglect
compared to that demonstrated in the ED. She was given a 1000cc
bolus of LR with improvement in heart rate to the 40s/low 50s
and mild improvement in her mental status. She underwent a STAT
non-contrast head CT, which showed no evidence of hemorrhage.
Past Medical History:
1. Hypertension.
2. Anemia.
3. Glaucoma.
4. Uterine Prolapse and pessery
5. ? dementia
6. Osteoporosis: Osteopenia.
Social History:
Lives with husband
Mobilises with cane outdoors
Retired assistant to nutrition department of. [**Hospital1 11900**]
Never smoked
Drinks 3 beers per day
Family History:
Mother - Stroke
Father - died old age
Brother - prostate ca
Brother - ca unspecified site
Sister - oesophageal ca
Physical Exam:
Code stroke/admission examination:
BP 135/90, HR 66, RR 14
Lungs: CTAB
CV: RRR
Abdomen is soft and nontemder to palpation.
Neurologic examination:
Patient is awake and alert, oriented to self and a year. Not
oriented to month. Patient has right gaze preference and is
neglecting left side, no signs of aphasia, speech is slurred.
CN: left hemianopia vs neglect, PERRL, EOMI, left facial droop,
tongue and uvula are midline.
Motor: Left arm 0/5, left leg [**3-15**], Right upper and lower
extremities are [**4-14**].
[**Doctor Last Name **] is decreased sensation on the left side to pin prick and
light touch.
DTR are decreased on the left, Plantar is mute.
Finger to nose is WNL
.
Discharge examination:
A+Ox3 GCS 15/15
[**3-15**] in proximal left upper limb weaker distally [**2-13**] in pyramidal
distribution. LLE weakness milder at 4-5/5 in pyramidal
distribution. Decreased sensation left arm/leg.
Good power in right side
Profound left facil droop with significnt dysrthria
Pertinent Results:
Admission labs:
[**2140-6-8**] 12:30PM BLOOD WBC-6.3 RBC-3.80* Hgb-11.2* Hct-33.8*
MCV-89 MCH-29.4 MCHC-33.1 RDW-13.7 Plt Ct-241
[**2140-6-8**] 03:57PM BLOOD Neuts-82.0* Lymphs-13.6* Monos-3.5
Eos-0.4 Baso-0.5
[**2140-6-8**] 01:30PM BLOOD PT-11.6 PTT-20.5* INR(PT)-1.0
[**2140-6-8**] 12:30PM BLOOD UreaN-26* Creat-1.3*
.
Other pertinent labs:
[**2140-6-8**] 12:30PM BLOOD Lipase-47
[**2140-6-8**] 12:30PM BLOOD cTropnT-<0.01
[**2140-6-10**] 10:17AM BLOOD %HbA1c-5.9 eAG-123
[**2140-6-10**] 04:16AM BLOOD Triglyc-67 HDL-68 CHOL/HD-2.7 LDLcalc-100
[**2140-6-10**] 04:16AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.0 Cholest-181
[**2140-6-8**] 12:51PM BLOOD Glucose-113* Lactate-1.7 Na-132* K-3.7
Cl-96* calHCO3-26
[**2140-6-16**] 5:05PM BLOOD Fibrinogen: 663
.
Discharge labs:
[**2140-6-17**] 05:30AM BLOOD WBC 5.6 RBC 3.04* Hgb 9.2* Hct 27.2* MCV
90 MCH 30.4 MCHC 34.0 RDW 13.8 Plt 339
[**2140-6-17**] 05:30AM BLOOD Glc 96 UreaN 15 Creat 0.9 Na 135 K 4.0 Cl
103 HCO3 23 An-gap 13
[**2140-6-17**] 05:30AM BLOOD Ca 8.8 PO4 3.7 Mg 1.9
.
.
Urine:
[**2140-6-8**] 03:57PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022
[**2140-6-8**] 03:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2140-6-8**] 03:57PM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE Epi-1
[**2140-6-12**] 02:25PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2140-6-12**] 02:25PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG
[**2140-6-12**] 02:25PM URINE RBC-2 WBC-30* Bacteri-FEW Yeast-NONE
Epi-2
[**2140-6-12**] 02:25PM URINE Mucous-RARE
.
.
Microbiology:
[**2140-6-8**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2140-6-8**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2140-6-10**] 12:04 am SWAB Source: Vaginal.
**FINAL REPORT [**2140-6-11**]**
YEAST VAGINITIS CULTURE (Final [**2140-6-11**]): NEGATIVE FOR
YEAST.
[**2140-6-12**] 12:59 pm SWAB Source: Vaginal.
**FINAL REPORT [**2140-6-13**]**
SMEAR FOR BACTERIAL VAGINOSIS (Final [**2140-6-13**]):
Indeterminate. Altered vaginal flora that does not meet
criteria for
diagnosis of bacterial vaginosis. If signs and/or symptoms
persist,
repeat testing may be warranted.
.
.
Cardiology:
ECG Study Date of [**2140-6-8**] 1:07:08 PM
Sinus rhythm with ventricular premature depolarizations.
Compared to the
previous tracing of [**2129-8-22**] frequent ventricular ectopic
activity is now
present.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 158 78 [**Telephone/Fax (2) 11901**] 24
.
ECG Study Date of [**2140-6-8**] 4:19:02 PM
Sinus bradycardia. Compared to the previous tracing ventricular
ectopic
activity is no longer present.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
40 188 76 494/459 53 12 28
.
ECG Study Date of [**2140-6-9**] 8:26:22 AM
Sinus bradycardia. Compared to the previous tracing there is no
significant
change.
TRACING #3
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
53 170 84 [**Telephone/Fax (2) 11902**]3
.
Portable TTE (Complete) Done [**2140-6-9**] at 3:26:24 PM
Conclusions
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
70%). Right ventricular chamber size and free wall motion are
normal. There are focal calcifications in the aortic arch. 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.
Compared with the findings of the prior study (images reviewed)
of [**2137-10-30**], findings are similar.
.
Portable TTE (Complete) Done [**2140-6-14**] at 3:14:19 PM
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or agitated saline
contrast at rest (maneuvers attempted but patient unable to
perform these effectively). Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No cardiac source of embolus identified. No evidence
of PFO or ASD. Simple atheroma in the thoracic aorta.
.
.
Radiology:
[**2140-6-8**] CTA-head/neck: A tiny amount of calcific plaque is
noted in the right carotid bulb. No significant stenosis is
noted in the left carotid circulation. Both vertebral arteries
are widely patent. No aneurysm greater than 3 mm is noted. No
areas of thrombosis or dissection are noted either.
.
[**2140-6-8**] CT-head perfusion: Elevated MTT in a moderately-large
right MCA territory consistent with an infarct in this region.
No intra-arterial thrombosis or evidence of dissection noted.
.
[**2140-6-8**] NCHCT: No intracranial hemorrhage. Subtle loss of
[**Doctor Last Name 352**]-white matter differentiation Right MCA region.
.
[**2140-6-8**] CXR: No acute intrathoracic process.
.
[**2140-6-9**]: Evolving right MCA-territory infarct with hemorrhagic
conversion.
.
[**2140-6-9**] MR HEAD W/O CONTRAST: Acute right middle cerebral
artery territorial infarct with blood products. No midline shift
or hydrocephalus
.
[**2140-6-11**] CT-head: Evolving right MCA infarction with hemorrhagic
conversion with blood products slightly more prominent.
Continued effacement of the right cerebral sulci and mass effect
on the right lateral ventricle.
.
[**2140-6-16**] CT-Chest/Abdomen/Pelvis: Preliminary report
Chest:
Enlarged heterogeneous thyroid can be eval by US if clin
indicated.
Bovine Ao arch.
Small hiatal hernia.
Mildly elevated R hemidiaphragm of indeterminate chronicity.
Abdomen:
Several locules of air w/fat stranding in ant abd wall, please
correlate for
recent SQ injection.
Mult intermediate-density renal cystic lesions, can be eval by
US if clin
indicated.
Moderate fecal loading.
Desc and sigmoid diverticulosis.
Calcified uterine fibroids + pessary.
Right iliopsoas bursitis, with 4.5 x 2.3 cm fluid collection.
Age-indet L1 compression fx with 60% loss of height, L1-2
degenerative
changes.
Brief Hospital Course:
Diagnoses:
Primary diagnoses:
Right middle cerebral artery stroke s/p rTPA etiology unclear
.
Secondary diagnoses:
CT-torso showed enlarged thyroid and intermediate density renal
cystic lesions
Bacterial vaginosis
Urinary tract infection
.
.
80 yo W with h/o HTN "passed out" per husband found to have R
gaze pref, L hemiparesis and dysarthria. She was brought to ED
within 45 minutes of presentation. She had no signs of recovery.
CT head did not shows any hemorrhage or signs of infarct, CTA
shows cut off in the right M2 segment, CT perfusion showed
increased MTT in the right hemisphere with decreased flow in the
area, perfusion volume mismatched with MTT. Code stroke was
called and patient received TPA. MRI showed an acute right
middle cerebral artery territorial infarct with blood products.
Patient was briefly in ICU and transitioned to the floor. Echo
showed EF 70%, focal calcifications in the aortic arch and mild
1+ MR. [**Name13 (STitle) **] had TEE [**2140-6-14**] which showed no cardiac source
of embolus identified with no evidence of PFO or ASD with
bubble. Fibrinogen was 633. As no cause for her stroke, she
proceeded to a CT-torso to rule out malignancy which showed
minimal abnormalities on preliminary read (formal read awaited
at time of writing) with heterogeneously enlarged thyroid and
intermediate density renal cystic lesions which should be
followed as an outpatient.
Patient had vaginal discharge and was found to have bacterial
vaginosis on review by OB/Gyn although swab was indeterminate.
She was treated with a 1 week course of metronidazole. She also
had evidence of a UTI and treated with po ciprofloxacin for 7
days. Her left sided weakness and neglect improved and her
dysarthria improved although fluctuates throughout the day with
persistent hemi-sensory loss. She was transferred to rehab on
[**2140-6-17**] and has neurology follow-up.
.
# R MCA infarct: Patient presented with left hemiparesis, right
gaze preference and dysarthria and found to have an acute left
MCA stroke on CT-perfusion and MRI imaging and as she was within
the time window received IV thrombolysis. She had a brief stay
in the ICU and was transferred to the floor. She worked with
PT/OT and speech and swallow. Her swallowing was impaired and
was upgraded to soft foods and thin liquids by discharge.
Work-up for the etiology of her stroke included echo and TEE
which showed no cardiac causes and fibrinogen was mildly
elevated at 633. Risk factors were addressed with HbA1c with
negative CEs, HbA1c 5.9%, chol 181 and LDL 100. Patient was
started on aspirin and simvastatin. BP was allowed to
auto-regulate and her anti-hypertensives were slowly
re-introduced. Clinically the patient has improving left
hemiparesis and neglect with still significant left facial
weakness. Dysarthria fluctuates during the day but has improved
and left hemisensory loss. As no cause for her stroke, she
proceeded to a CT-torso to rule out malignancy which showed
minimal abnormalities on preliminary read (formal read awaited
at time of writing) with heterogeneously enlarged thyroid and
intermediate density renal cystic lesions which should be
followed as an outpatient. She has neurology follow-up with Dr
[**Last Name (STitle) **] on [**2140-8-3**]. She should have o/p u/s to evaluate thyroid
and kidneys.
.
# HTN: Hypertensive in house and initially had
anti-hypertensives were held to allow auto-regulation.
Antihypertensives were slowly reintroduced and on discharge was
on home dose lisinopril and slightly reduced metoprolol
succinate at 100mg. She will need further uptitration of her
anti-hypertensives as an out-patient.
.
# Bacterial vaginosis: Patient has a pessary in place and was
noted to have foul-smelling vaginal discharge. She was seen by
OB/Gyn who cleaned/replaced pessary and noted fishy smelling
[**Doctor Last Name 352**]/white discharge and recommended treatment for BV. She was
treated with 1 week of oral metronidazole. BV swab
indeterminate. Per OB/Gyn, she should f/u as outpatient for next
cleaning of pessary in [**1-14**] months.
.
# UTI: Positive UA but in context of vaginal discharge. We
treated for complicated UTI with ciprofloxacin 7 days.
.
# Enlarged thyroid and renal cysts: CT-torso showed
heterogeneously enlarged thyroid and intermediate density renal
cystic lesions and should have ultrasound follow-up of both of
these as an out-patient.
.
.
.
Transitional issues:
We are awaiting formal report of CT-Torso as prelim findings are
in results section
Medications on Admission:
- lisinopril 40mg daily
- metoprolol succinate XR 125mg daily
- HCTZ 25mg daily
- alendronate 35mg weekly
- dorzolamide 2% 1 gtt OU [**Hospital1 **]
- latanoprost 0.005% 1 gtt OU qHS
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnoses:
Right middle cerebral artery stroke s/p rTPA etiology unclear
.
Secondary diagnoses:
Bacterial vaginosis
Urinary tract infection
CT-torso showed enlarged thyoid and intermediate density renal
cystic lesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure taking care of you during your stay at the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented after
passing out and you were found to have left sided weakness. You
were assessed by neurology in the ED and CT scanning showed
evidence of a stroke in the left side of the brain. You received
clot-busting therapy for the blood vessel that was blocked and
caused your stroke and you were transferred to the ICU for
monitoring. You were stable and transferred to the neurology
[**Hospital1 **]. You were assessed with an ultrasound of the heart
(echocardiogram) which was unremarkable and a further
echocardiogram with the use of an endoscopy showed no evidence
of clot in the heart. You had an MRI scan which showed similar
appearances and CT scans were stable. You also had swallowing
problems as a result of your stroke and you were placed on a
modified diet after review by speech and swallow specialists.
You had a CT scan of the body which showed some slight
enlargement of the thyroid gland and will have to have an
ultrasound as an out-patient to assess this and cysts (which can
be normal) within the kidneys which should also be assessed by
ultrasound as an out-patient. You were seen by PT and OT. You
were also fond to have vaginal discharge and were felt to have
bacterial vaginosis and and UTI. You were treated with
antibiotcs for these. Your symptoms were very slowly improving
and you were transferred to rehabilitation on [**2140-6-16**]. You have
follow-up with neurology as below.
.
Medication changes:
We DECREASED metoprolol to 100mg daily
We STOPPED hydrochlorothiazide
We STARTED simvastatin 40mg daily for cholesterol
We STARTED famotidine 20mg twice daily for stomach acid
We STARTED aspirin 325mg daily
We STARTED metronidazole 500mg three times daily for further 2
days for bacterial vaginosis
We STARTED ciprofloxacin 500mg twice daily for a further 2 days
for a urinary infection
We STARTED laxatives for contipation
Followup Instructions:
An appointment has been made for Dr [**Last Name (STitle) 11903**] out-patient
neurology clinic on Wednesday [**2140-8-3**] at 4pm, [**Hospital1 18**] [**Hospital Ward Name 5074**], [**Hospital Ward Name 23**] Center [**Location (un) **]. You can call to confirm on
([**Telephone/Fax (1) 7394**].
.
You should have an ultrasound of the thyroid and the kidneys as
an out-patient organised by your PCP.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"784.51",
"365.9",
"780.2",
"593.2",
"240.9",
"616.10",
"599.0",
"342.02",
"041.9",
"434.91",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
15135, 15205
|
10399, 10493
|
323, 328
|
15475, 15475
|
3425, 3425
|
17682, 18178
|
2292, 2407
|
15226, 15309
|
14928, 15112
|
15610, 17214
|
4191, 10376
|
2422, 2546
|
15330, 15454
|
14816, 14902
|
17234, 17659
|
264, 285
|
356, 1963
|
3441, 3746
|
3768, 4175
|
15490, 15586
|
2570, 3406
|
1985, 2107
|
2123, 2276
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,844
| 199,145
|
41674
|
Discharge summary
|
report
|
Admission Date: [**2108-7-17**] Discharge Date: [**2108-7-20**]
Date of Birth: [**2056-5-7**] Sex: M
Service: MEDICINE
Allergies:
Haloperidol / quetiapine
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Assault of staff member at [**Hospital1 **], concern for psychosis.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52yoM with h/o ?bipolar disorder and substance abuse presenting
from [**Hospital3 **] for concern for psychosis after
assaulting staff members at his facility.
.
The patient reportedly voluntarily presented to [**Hospital1 36497**] the day prior to admission for detoxification,
reporting he felt as though he were going to die and saying he
"needed help for substance abuse." He reportedly denied any
trauma or injury or recent illness upon arrival to the facility.
However, he then became assaultive and attacked staff members
at [**Hospital1 **] and was placed in 4 point restraints and sent to
the ED under section 21 for evaluation. There was a concern for
substance abuse given his prior history of benzodiazepine abuse,
and the patient reportedly endorsed recently filling a
prescription for Xanax although he did not give a history of
overdose.
.
In the ED, initial VS were: 99.0 103 143/93 16 99% RA
The patient has a history of hallucinations and history of
psychiatric disorder with psychosis, and was noted to have
visual and auditory hallucinations in the ED. He was A&Ox2 to
person and place per ED report. His exam was unremarkable and
his pupils were 3mm b/l and reactive, but given he looked volume
deplete, there was an initial concern for toxic syndrome.
Toxicology was consulted, and did not feel his presentation was
consistent with acute toxidrome. They recommended further
evaluation for possible benzo vs clonidine withdrawal and
recommended continued supportive care and CIWA. They felt
symptoms were consistent with psychosis rather than delerium,
and noted his anion gap acidosis.
.
The patient was given Ativan on a CIWA scale in the ED and
required increasing amounts of Ativan every 30 min to 1 hr for a
total of 14mg IV Ativan. He was also given Zyprexa 10mg IV x1.
His serum and urine tox screens were negative, including for
benzodiazepines. He had an elevated lactate of 3 initially,
which decreased to 1.5 after 3L NS. However, given his CIWA
requirement for agitation, hypertension, and tachycardia, he was
admitted to the MICU for frequent neuro checks. On transfer, VS
were: 97.9, 105,156/81,19,98% 2L and then 97.4-96-23 146/90 99%
.
On arrival to the MICU, the patient was agitated and psychotic
in four point leather restraints. He was responding to internal
stimuli, but was redirectable and interactive, able to follow
simple commands for brief periods of time. However, he was
unable to provide a coherent history or fully cooperate with his
physical exam. He denied pain or other complaints.
Past Medical History:
- h/o substance abuse, specifically benzodiazepine abuse
- h/o psychiatric disorder, bipolar disorder per [**Hospital1 **]
report
- Hepatitis C
Social History:
Tobacco: smokes 1 PPD
Alcohol: Denies, although reliability unclear.
[**Name2 (NI) 3264**]: Denies, although reliability unclear.
Family History:
unable to provide at the time of admission
Physical Exam:
ADMISSION PHYSICAL EXAM
General: Alert, A&Ox1-2 to person, time (year only), agitated
but redirectable and interactive, minimally cooperative, no
acute distress
HEENT: PERRL ~3mm b/l, sclera anicteric, MMM
Neck: Supple, JVP unable to be assessed, no cervical LAD
CV: Tachycardic, regular rhythm, normal S1/S2, no murmurs, rubs,
or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ DP pulses b/l, no clubbing,
cyanosis or edema
Neuro: Unable to be assessed given poor cooperation
.
Discharge Physical Exam:
Gen: Awake, alert, anxious. No acute distress. HEENT: EOMI,
PERRL. Sclerae anicteric. MMM, OP clear.
Neck: no LAD
CV: regular rate and rhythm, normal S1/S2, no murmurs, rubs, or
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abd: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
Ext: Warm, well perfused, 2+ DP pulses b/l, no clubbing,
cyanosis or edema. Right ring finger distal joint bruised and
swollen. No sign of injury to bone or joint. No fluid
collection, no drainage.
Skin: red peeling rash on trunk and face
Neuro: CN II-XII grossly normal. Motor and sensory function
intact.
Psych: pressured speech, no delusion or hallucination.
Agitated at times but redirectable.
Pertinent Results:
LABS:
On admission:
[**2108-7-17**] 12:05PM BLOOD WBC-11.0 RBC-4.43* Hgb-15.4 Hct-41.4
MCV-93 MCH-34.7* MCHC-37.1* RDW-13.9 Plt Ct-243
[**2108-7-17**] 12:05PM BLOOD Neuts-78.9* Lymphs-15.7* Monos-4.7
Eos-0.4 Baso-0.4
[**2108-7-17**] 12:05PM BLOOD Glucose-95 UreaN-11 Creat-0.9 Na-139
K-3.4 Cl-103 HCO3-17* AnGap-22*
[**2108-7-17**] 12:05PM BLOOD ALT-21 AST-22 AlkPhos-68 TotBili-0.4
[**2108-7-17**] 11:34PM BLOOD Calcium-8.4 Phos-1.4* Mg-1.7
[**2108-7-17**] 12:05PM BLOOD Osmolal-287
[**2108-7-17**] 11:34PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
[**2108-7-17**] 11:34PM BLOOD HCV Ab-POSITIVE*
[**2108-7-17**] 12:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2108-7-17**] 03:15PM BLOOD Lactate-3.0*
.
[**Hospital3 **]:
[**2108-7-18**] 02:31PM BLOOD Glucose-73 UreaN-4* Creat-0.8 Na-138
K-5.1 Cl-107 HCO3-18* AnGap-18
[**2108-7-19**] 05:54AM BLOOD Glucose-165* UreaN-5* Creat-0.8 Na-141
K-3.1* Cl-107 HCO3-25 AnGap-12
[**2108-7-17**] 12:05PM BLOOD ALT-21 AST-22 AlkPhos-68 TotBili-0.4
[**2108-7-17**] 12:05PM BLOOD Lipase-37
[**2108-7-18**] 05:09AM BLOOD Calcium-8.5 Phos-1.3* Mg-1.6
[**2108-7-18**] 02:31PM BLOOD Calcium-8.2* Phos-2.8 Mg-2.4
[**2108-7-17**] 12:05PM BLOOD Osmolal-287
[**2108-7-17**] 11:34PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
[**2108-7-17**] 12:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2108-7-17**] 11:34PM BLOOD HCV Ab-POSITIVE*
[**2108-7-17**] 03:15PM BLOOD Lactate-3.0*
[**2108-7-17**] 07:32PM BLOOD Lactate-1.5
[**2108-7-17**] 08:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
Discharge Labs:
[**2108-7-19**] 05:54AM BLOOD WBC-5.4 RBC-4.23* Hgb-14.1 Hct-39.9*
MCV-94 MCH-33.3* MCHC-35.4* RDW-13.1 Plt Ct-164
[**2108-7-19**] 05:54AM BLOOD Glucose-165* UreaN-5* Creat-0.8 Na-141
K-3.1* Cl-107 HCO3-25 AnGap-12
[**2108-7-20**] 09:20AM BLOOD Na-144 K-3.8 Cl-104
.
Microbiology: none
.
IMAGING:
ECG: Sinus tachycardia. Non-specific inferior T wave changes. No
previous tracing available for comparison.
.
CXR: Limited study. No gross pulmonary process identified.
Brief Hospital Course:
52yoM with h/o ?bipolar disorder and substance abuse presenting
from [**Hospital3 **] for concern for psychosis after
assaulting staff members at his facility, found also to have
anion gap ketoacidosis.
.
# Agitation: On admission, the patient was having visual and
auditory hallucinations and appeared to be responding to
internal stimuli. Urine and serum tox were negative. Given his
history of benzo abuse with a now negative tox screen, there was
concern that he was having benzo withdrawal. Toxicology was
consulted and felt his presentation was more consistent with
psychosis from his underlying psychiatric condition than
delerium, and did not feel his symptoms were consistent with
acute toxidrome from an ingestion. He was given benzodiazepines
and Zyprexa for control of his agitation and psychosis. He was
in 4-point restraints for periods. Psychiatry was consulted and
felt that his symptoms were more consistent with delirium (and
likely benzo withdrawal), perhaps with underlying depression
with psychosis. On their recommendation he was restarted on his
home psychiatric medications. By the third day of his admission
he was returned to his baseline mental status. He continued to
have episodes of perseveration, but was appropriate and
redirectable.
.
# Ketoacidosis / hypovolemia: On admission the patient was
found to have an anion gap of 19, bicarb of 17, and ketones in
his urine but normal glucose of 95. This was thought to be due
to alcoholic ketoacidosis vs. starvation ketosis. This was
likely secondary to poor po intake given recent psychosis and
substance abuse. Lactate was 3.0 on presentation, but this
normalized with 3L NS. He was given hydration, thiamine, folate
and multivitamin, and his anion gap returned to [**Location 213**].
.
# Right ring finger injury: At the time of floor transfer on
[**7-19**], the patient was found to have an injury at the
distal joint of the right ring finger. This was bruised and
swollen, but without fluid collection, drainage, or warmth. He
had full range of motion; exam not consistent with fracture. It
was likely secondary to injury incurred either at [**Hospital1 **] or
during his delirium. Treatment with compresses and Tylenol was
provided.
.
Transitional issues:
- Outpatient psychiatry follow-up for therapy and medication
management
- Follow finger injury to ensure resolution
Medications on Admission:
1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day.
4. doxepin 25 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
5. trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*20 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
3. alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*10 Tablet(s)* Refills:*0*
5. doxepin 25 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
Disp:*40 Capsule(s)* Refills:*0*
6. trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
7. desonide 0.05 % Cream Sig: One (1) Appl Topical TID (3 times
a day) as needed for axillary rash.
Disp:*qs 14 days* Refills:*0*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*10 Tablet(s)* Refills:*0*
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*10 Tablet(s)* Refills:*0*
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: benzodiazpine withdrawl
Secondary: right ring finger injury, depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 57994**],
It was a pleasure taking care of you at [**Hospital1 827**].
You were brought to the hospital after an incident at [**Hospital1 36497**]. You became confused and the staff was concerned for
your safety and the safety of their staff. When you came here,
you were having hallucinations. Given your blood tests, we were
concerned you were in withdrawl from benzodiazepines. You were
initially admitted to the ICU for close observation. After two
days you were recovering physically and were more aware of your
surroundings. You were transferred to a general medical floor.
.
During your stay, our Psychiatry team saw you several times.
They noted your improvement and felt you were safe to go home
from the hospital. They recommend following up with your
outpatient Psychiatrist, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within the next week
or two.
.
Please take all your medications as directed, and consult your
doctor before changing your medications (taking more, taking
less, stopping or starting). We have made no changes to your
psychiatric medications, but we recommend starting the
following:
- folic acid 1mg daily
- thiamine 100mg daily
- desonide 0.05% cream for your underarm rash (new medication)
.
Please follow-up with your primary care physician within one
week of your discharge to ensure you have fully recovered.
Please follow-up with your psychiatrist within two weeks for
further treatment.
Followup Instructions:
Please follow-up with your primary care physician within one
week of your discharge to ensure you have fully recovered.
[**Last Name (LF) **],[**First Name3 (LF) **]
Phone: [**Telephone/Fax (1) 74625**]
Please follow-up with your psychiatrist (Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
[**Telephone/Fax (1) 90595**]) within two weeks for further treatment. You have
an appointment with Dr [**Last Name (STitle) **] on [**8-11**], but should call to
get one earlier.
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65,164
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Discharge summary
|
report+addendum
|
Admission Date: [**2168-6-13**] Discharge Date: [**2168-6-23**]
Date of Birth: [**2095-2-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 yo M with ILD, OSA, presents from Siani with question of
repeat PNA in the setting of rapidly progressing interstitial
lung disease. Patient was discharged from the [**Hospital Ward Name **]
[**2168-5-28**] to [**Location (un) 511**] Siani following a long hospital course.
Briefly, patient was admitted to the VA [**2168-4-18**] for respiratory
distress, intubated [**2168-4-20**] and brought to the [**Hospital1 **] for a second
opinion on [**2168-5-9**]. He was found to have rapidly progressing
interstitial lung disease and underwent tracheostomy placement
[**2168-5-13**]. Course was complicated by bacterimia and he was
treated for a MDR klebsiella VAP with cefepime until [**6-2**] and
vancomycin until [**2168-5-30**]. While at rehab, patient was treated
for cdiff colitis.
Per report, patient has been declining since weekend with
increased secretions and increased respiratory rate. [**6-13**]
patient was found to have saturations in the 80s on vent,
breathing 30-40/min. Per EMS he improved slightly after being
taken off the vent and bagged while en route.
In the ED initial vitals at 16:10 98.2 114 113/65 36 99%.
Respiratory rate remained in the 40s, pulling large tidal
volumes, currently denies any pain or shortness of breath.
Lowest reported blood pressure in the ED was 90/45, which
recovered with 1L NS. Patient's highest temperature was 99.9.
CXR prelminary demonstrated new left-sided consolidation and
baseline interstitial lung disease. Patient was given 2g IV
cefepime, 1g vancomycin and 750mg levofloxacin. He was also
given 1g acetaminophen.
On arrival to the MICU, patient is still tachypnic with tidal
volumes in the 25L/min range. He denies any chest pain and is
in no acute distress. He states that at baseline he coughs
frequently, although denies any aspiration events. Patient is
extremely hard of hearing at baseline and is unable to
communicate well unless by lipreading.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Prostate Cancer s/p XRT and hormone Rx
PMR
Hypertension
Morbid Obesity
Type II DM
OSA - did not tolerate CPAP
Interstitial lung disease (UIP/IPF) but no definitive diagnosis
as never had bronch/bx, trach course as per HPI.
Social History:
Smoked until [**2145**] 90pkyrs, former EtOH use, No IVDU, retired
from truck driving, worked in Navy for 4 years, no known
asbestos exposure. Lived with wife in [**Name (NI) 112230**]. One son from
previous marraige.
Family History:
No CAD, no DM, No cancers
Physical Exam:
Admission PE:
Vitals: Temp = 98.2, HR = 114, BR = 113/65, RR = 36, O2sat = 99%
General: Alert, oriented, tachypnic
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP unable to see due to collar, no LAD
CV: tachycardic irregular rate/ rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Diminished at bases with crackles.
Abdomen: soft, non-tender, obese, Gtube present without
erythema, 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
Skin: per report: large decubitus ulcer, not visualized due to
patient discomfort.
Discharge exam:
General: Alert, oriented, tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP unable to see due to collar, no LAD
CV: tachycardic irregular rate/ rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Diminished at bases with crackles.
Abdomen: soft, non-tender, obese, Gtube present without
erythema, bowel sounds present, no organomegaly
GU: foley in place, flexiseal in place draining stool
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, 5/5 strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred, finger-to-nose intact
Skin: per report: large decubitus ulcer, not visualized due to
patient discomfort.
Pertinent Results:
[**2168-6-13**] 09:29PM TYPE-ART PO2-78* PCO2-46* PH-7.46* TOTAL
CO2-34* BASE XS-7
[**2168-6-13**] 04:53PM TYPE-[**Last Name (un) **] PEEP-5 PO2-64* PCO2-46* PH-7.45
TOTAL CO2-33* BASE XS-6 INTUBATED-INTUBATED
[**2168-6-13**] 04:44PM PO2-114* PCO2-42 PH-7.49* TOTAL CO2-33* BASE
XS-8 COMMENTS-GREEN TOP
[**2168-6-13**] 04:44PM LACTATE-2.5*
[**2168-6-13**] 04:43PM URINE HOURS-RANDOM
[**2168-6-13**] 04:43PM URINE UHOLD-HOLD
[**2168-6-13**] 04:43PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2168-6-13**] 04:43PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
[**2168-6-13**] 04:43PM URINE RBC-27* WBC-12* BACTERIA-MANY YEAST-NONE
EPI-0
[**2168-6-13**] 04:30PM GLUCOSE-178* UREA N-51* CREAT-0.9 SODIUM-141
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14
[**2168-6-13**] 04:30PM estGFR-Using this
[**2168-6-13**] 04:30PM cTropnT-<0.01
[**2168-6-13**] 04:30PM proBNP-4396*
[**2168-6-13**] 04:30PM WBC-12.7* RBC-2.83* HGB-7.9* HCT-25.9* MCV-91
MCH-28.1 MCHC-30.7* RDW-15.1
[**2168-6-13**] 04:30PM NEUTS-86.3* LYMPHS-8.3* MONOS-4.7 EOS-0.6
BASOS-0.1
[**2168-6-13**] 04:30PM PLT COUNT-362
[**2168-6-13**] 04:30PM PT-33.1* PTT-28.6 INR(PT)-3.2*
ECG
Baseline artifact. Atrial fibrillation with rapid ventricular
rate and
multifocal ventricular premature contractions. Left axis
deviation with left anterior fascicular block. Generally poor R
wave progression suggests prior anterior myocardial infarction.
Diffuse repolarization abnormalities in the limb leads. Compared
to the previous tracing of [**2168-5-19**] the rate is much faster and
now tachycardic. Ventricular ectopy is new. Depolarization and
repolarization abnormalities are similar.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
109 0 100 310/395 0 -43 44
CXR: [**2168-6-13**]
FINDINGS: The patient is status post tracheostomy, which
appears unchanged.
A PICC line terminates in the superior vena cava, as before,
inserted via
right-sided approach. The cardiac, mediastinal and hilar
contours appear
unchanged including widening of the vascular pedicle, perihilar
fullness, and cardiomegaly. A moderate-to-severe interstitial
abnormality suggests known interstitial lung disease without
significant change. This appearance includes confluent
opacification at the lung bases. Because of severe background
lung abnormality, it is difficult to exclude a superimposed
edema or pneumonia.
IMPRESSION: Similar severe widespread predominantly interstitial
opacification, most confluent at the lung bases; although there
is no definite change, subtle superimposed process could be
readily obscured by a severe background abnormality.
CXR: [**2168-6-14**]
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Low lung volumes with massive bilateral diffusely
distributed
reticular or reticulonodular opacities. The presence of small
pleural
effusions cannot be excluded. Tracheostomy tube is unchanged.
Moderate
cardiomegaly. No pneumothorax.
[**2168-6-13**] 04:30PM BLOOD proBNP-4396*
[**2168-6-13**] 04:30PM BLOOD WBC-12.7* RBC-2.83* Hgb-7.9* Hct-25.9*
MCV-91 MCH-28.1 MCHC-30.7* RDW-15.1 Plt Ct-362
[**2168-6-14**] 03:30PM BLOOD WBC-12.3* RBC-2.78* Hgb-7.7* Hct-25.2*
MCV-91 MCH-27.6 MCHC-30.5* RDW-15.2 Plt Ct-357
[**2168-6-16**] 05:00AM BLOOD WBC-11.4* RBC-2.68* Hgb-7.6* Hct-24.7*
MCV-92 MCH-28.2 MCHC-30.7* RDW-15.2 Plt Ct-333
[**2168-6-18**] 06:13AM BLOOD WBC-10.3 RBC-2.79* Hgb-7.7* Hct-25.3*
MCV-91 MCH-27.7 MCHC-30.5* RDW-15.4 Plt Ct-352
[**2168-6-20**] 04:59PM BLOOD WBC-13.5* RBC-3.14* Hgb-8.7* Hct-28.9*
MCV-92 MCH-27.6 MCHC-30.0* RDW-16.0* Plt Ct-425
[**2168-6-21**] 05:59AM BLOOD WBC-12.6* RBC-2.98* Hgb-8.2* Hct-27.6*
MCV-93 MCH-27.5 MCHC-29.7* RDW-16.3* Plt Ct-388
[**2168-6-22**] 02:57AM BLOOD WBC-16.0* RBC-3.19* Hgb-8.8* Hct-29.5*
MCV-92 MCH-27.7 MCHC-30.0* RDW-16.9* Plt Ct-411
[**2168-6-23**] 05:33AM BLOOD WBC-12.6* RBC-3.17* Hgb-9.0* Hct-29.2*
MCV-92 MCH-28.4 MCHC-30.8* RDW-17.1* Plt Ct-358
[**2168-6-14**] 04:46AM BLOOD PT-39.7* PTT-28.8 INR(PT)-3.9*
[**2168-6-15**] 06:26AM BLOOD PT-24.5* PTT-27.1 INR(PT)-2.3*
[**2168-6-17**] 06:07AM BLOOD PT-14.8* PTT-23.5* INR(PT)-1.4*
[**2168-6-22**] 02:57AM BLOOD PT-31.7* PTT-36.1 INR(PT)-3.1*
[**2168-6-21**] 05:59AM BLOOD PT-28.7* INR(PT)-2.8*
[**2168-6-22**] 02:57AM BLOOD PT-31.7* PTT-36.1 INR(PT)-3.1*
[**2168-6-23**] 05:33AM BLOOD PT-28.7* PTT-34.1 INR(PT)-2.8*
[**2168-6-20**] 04:59PM BLOOD Glucose-149* UreaN-30* Creat-0.7 Na-140
K-4.8 Cl-96 HCO3-39* AnGap-10
[**2168-6-21**] 05:59AM BLOOD Glucose-140* UreaN-30* Creat-0.8 Na-141
K-4.2 Cl-99 HCO3-38* AnGap-8
[**2168-6-22**] 02:57AM BLOOD Glucose-145* UreaN-30* Creat-0.8 Na-139
K-4.3 Cl-99 HCO3-36* AnGap-8
[**2168-6-23**] 05:33AM BLOOD Glucose-157* UreaN-32* Creat-0.9 Na-140
K-4.2 Cl-98 HCO3-36* AnGap-10
Brief Hospital Course:
73 yo M with ILD, OSA, presents from Siani with question of
repeat PNA in the setting of rapidly progressing interstitial
lung disease.
# Respiratory distress: Pt initially fit SIRS criteria with
tachypnea and leukocytosis. PNA was suspected by leukocytosis
and history of frequent cough, as well as potential aspiration
risk. PT was recently treated for MDR klebsiella VAP with
cefepime until [**6-2**] and vancomycin until [**2168-5-30**]. It appears that
the previous culture grew two strains of klebsiella, only one
was sensitive to cefepime, so it was possible that it was
incompletely treated. Also possible is PE, but less likely
given supratherapeutic INR. Pt's sputum culture grew Pseudomonas
and received 8 days of meropenem for presumed HCAP. Albuterol
and ipratropium MDIs were also given during course along with
Lasix diuresis. Pt's respiratory status improved throughout
sstay and tolerated 2 hour periods off of the ventilator by the
end of course. On the day on his planned discharge ([**6-22**]) he was
noted to have secretions which were thought to be [**12-31**] fluid
status. A CXR was performed which was slightly improved from
prior. Sputum Cx were sent, however there was low concern for
infection given he had finished his 8 day course of meropenem
the day prior. His lasix 40mg IV BID was restarted out of
concern for fluid overload. This was transitioned to 80mg PO BID
in anticipation of discharge. Electrolytes and weights should be
monitored and lasix dose should be adjusted.
Of note, on the day of discharge it was noted that his sputum
culture had grown Pseudomonas so [**Hospital 100**] Rehab was called and the
physician taking care of him there was personally advised to
continue Meropenem for a total of two weeks (with a planned stop
date of [**2168-6-30**]) in an effort to completely and optimally treat
this Pseudomonas.
Finally, there were multiple family meetings with the patient's
wife and the patient - he is aware that he is chronically
critically ill and that his likelihood of completely coming off
the ventilator is guarded at best; he (and his wife) elect to
continue pursuing rehab at this time, although the idea of
hospice was introduced during this hospitalization - neither he
nor his wife is ready to consider complete transition to
palliative care at this time.
# C-diff by report: Pt was found to be C. diff toxin positive at
previous hospitalization at OSH, and was continued on Flagyl at
[**Hospital1 18**] with flexiseal in place.
[**2168-7-5**] was the projected date to stop Flagyl (2 weeks
after completion of meropenem).
# Atrial fibrillation: Pt's CHADS2 score of 4, but
anticoagulation was held initially due to supratherapeutic INR.
Coumadin restarted once INR was below <2. Pt was rate controlled
with Metoprolol Tartrate 25 mg PO TID. His INR was difficult to
control likely due to antibiotic therapy and decreased hepatic
clearance. His warfarin was decreased to 2.5 and eventually held
for multiple doses given a supratheraputic INR. Today INR was
2.8 and warfarin can be restated at 2.5mg. INR should be
rechecked on [**2168-6-25**] and warfarin dose can be adjusted at that
time.
# Anemia: 28.6 at discharge on [**5-28**]. Unsure if this is anemia
of chronic disease versus occult bleed from elevated INR. Guaiac
stools were negative and no obvious acute bleeding was found
during MICU stay. Hematocrit remained stable.
# Polymyalgia rheumatica: Was previously treated with prednisone
15mg PO daily, but was never given PCP [**Name Initial (PRE) **]. We discontinued
hydroxycholoroquine in the setting of treating pneumonia along
with titrating down pt's prednisone from 15mg to 10mg PO daily.
Bactrim PCP prophylaxis was given.
# Type II DM: Pt was on MetFORMIN (Glucophage) 1000 mg PO BID,
Pioglitazone 30 mg PO DAILY and NPH 4 Units Breakfast, NPH 4
Units Dinner with ISS pre-admission. We continued pt on ISS and
serum glucose remained in mid 100s.
# History of hypothyroidism: TSH 2.0 from [**5-10**] and was on
Levothyroxine Sodium 300 mcg PO DAILY upon admission. Pt was
discharged on this dose with recommendations for follow-up on
TSH at rehab.
# Hyperlipidemia: unknown control. Pt was discharged on home
dose of Simvastatin 40 mg PO DAILY and Niacin 250 mg PO TID
# Right sided PICC: PICC line terminates in the superior vena
cava, as before, inserted via right-sided approach. Pt was
discharged with PICC.
# Tube feeds: G tube in place. Pt tolerated Isosource 1.5 Cal
Full strength at 70cc/hr.
# Rash in perianal area: Pt's decubitus wound was dressed with
following regimen: Cleanse area around flexiseal with foam
cleanser and pat dry. Apply criticade clear, then wrap xeroform
gauze around flexiseal.
# Med rec:
- Continue Acetaminophen 650 mg PO Q6H:PRN fever/ pain
- Hold Docusate Sodium 100 mg PO BID:PRN constipation
- Hold Senna 1 TAB PO BID:PRN constipation
- Hold ALPRAZolam 0.25 mg PO TID:PRN anxiety
- OxycoDONE (Immediate Release) 5 mg PO/NG Q8H:PRN pain
- Hold Albuterol-Ipratropium [**11-30**] PUFF IH Q2H:PRN dyspnea
Transitional Issues:
- Complete two weeks of Meropenem (last day [**2168-6-30**]) for
Pseudomonas treatment.
- Consider further Prednisone titration if his PMR symptoms are
adequately controlled on 10mg q24h - ideally would like to
titrate Prednisone off if possible.
- TSH level in 6 months for followup
- monitor INR while on coumadin
- DISCONTINUE Flagyl on [**2168-7-5**] (end of 2 week course for
C. diff)
- DNR. Discussion had with patient who does not wish to pursue
palliative care at this time.
- Monitor I&O while on lasix, adjust lasix dose as needed.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Location (un) 511**] Siani list.
1. Levothyroxine Sodium 300 mcg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Pioglitazone 30 mg PO DAILY
4. PredniSONE 15 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. NPH 4 Units Breakfast
NPH 4 Units Dinner
Insulin SC Sliding Scale using REG Insulin
9. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
10. Niacin 250 mg PO TID
11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
12. MetRONIDAZOLE (FLagyl) 500 mg PO Q 8H
13. Miconazole 2% Cream 1 Appl TP Q8H
to perianal area
14. Furosemide 20 mg IV BID
15. Loperamide 2 mg PO/NG Q8H
16. Albuterol-Ipratropium [**11-30**] PUFF IH Q6H
17. Metoprolol Tartrate 25 mg PO TID
18. CefePIME 1 g IV Q12H
19. Acetaminophen 650 mg PO Q6H:PRN fever/ pain
20. Docusate Sodium 100 mg PO BID:PRN constipation
21. Senna 1 TAB PO BID:PRN constipation
22. ALPRAZolam 0.25 mg PO TID:PRN anxiety
23. OxycoDONE (Immediate Release) 5 mg PO/NG Q8H:PRN pain
24. Lorazepam 0.5 mg IV Q8H:PRN anxiety
25. Albuterol-Ipratropium [**11-30**] PUFF IH Q2H:PRN dyspnea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever/ pain
2. Aspirin 81 mg PO DAILY
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
4. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 300 mcg PO DAILY
6. Lorazepam 0.5 mg IV Q4H:PRN anxiety
7. Metoprolol Tartrate 25 mg PO TID
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q 8H
9. Niacin 250 mg PO TID
10. Meropenem - restarted after d/c in communication with [**Hospital 100**]
Rehab (last day to be [**2168-6-30**])
10. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
11. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
12. Simvastatin 40 mg PO DAILY
13. Albuterol-Ipratropium [**11-30**] PUFF IH Q6H
14. Albuterol-Ipratropium [**11-30**] PUFF IH Q2H:PRN dyspnea
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Loperamide 2 mg PO Q8H
17. Miconazole 2% Cream 1 Appl TP Q8H
to perianal area
18. Senna 1 TAB PO BID:PRN constipation
19. Warfarin 2.5 mg PO DAILY16 Duration: 1 Doses
20. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
21. 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.
22. Furosemide 80 mg PO BID
23. Ipratropium Bromide MDI 6 PUFF IH QID
24. Albuterol Inhaler 6 PUFF IH Q4H:PRN dyspnea/ wheeze
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Ventilator associated pneumonia
Interstitial lung disease
Clostridium difficile colitis
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was our pleasure caring for you at the [**Hospital1 18**].
You were admitted to the [**Hospital1 69**]
for treatment of pneumonia. Your sputum cultures confirmed that
you had a pneumonia and you tolerated the 8 day course of
antibiotics very well. Your respiratory status improved during
your stay. You also had fluid in your lungs which made it
difficult for you to breate; we gave you diuretics to help
remove this fluid.
After several discussions, you decided to go back to rehab to
help you transition off the ventilator.
Followup Instructions:
You will be followed by the physicians at the rehabilitation
center.
Name: [**Known lastname 18425**],[**Known firstname **] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 18426**]
Admission Date: [**2168-6-13**] Discharge Date: [**2168-6-23**]
Date of Birth: [**2095-2-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12576**]
Addendum:
Clarification: This patient had SIRS on presentation due to a
ventilator associated pneumonia (due to Klebsiella). His SIRS
resolved with treatment of the pneumonia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 12580**] MD [**MD Number(2) 12581**]
Completed by:[**2168-8-18**]
|
[
"995.92",
"725",
"416.8",
"E879.8",
"427.32",
"244.9",
"008.45",
"707.22",
"V49.86",
"V58.65",
"518.84",
"707.05",
"V44.0",
"401.9",
"V85.37",
"250.00",
"997.31",
"E849.7",
"278.01",
"038.49",
"427.31",
"482.1",
"515",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
19628, 19853
|
9769, 14807
|
313, 319
|
18201, 18201
|
4789, 9746
|
18962, 19605
|
3196, 3223
|
16627, 17961
|
18071, 18180
|
15397, 16604
|
18376, 18939
|
3238, 4010
|
4026, 4770
|
14828, 15371
|
2295, 2694
|
263, 275
|
347, 2276
|
18216, 18352
|
2716, 2942
|
2958, 3180
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,049
| 127,809
|
24774
|
Discharge summary
|
report
|
Admission Date: [**2173-12-8**] Discharge Date: [**2173-12-11**]
Date of Birth: [**2115-8-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
ICD lead fracture
Major Surgical or Invasive Procedure:
ICD Lead extraction and new lead placement
Intubation
History of Present Illness:
58 yo male with hx of CAD s/p IMI, ischemic cardiomyopathy with
EF 25-30% and hx of VT controlled on quinidine presents with ICD
lead fracture. Pt had IMI in [**2159**]. In [**2170**] he had an ICD placed
for episode of Vtach. He then ad another episode of V-tach for
which his ICD fired 16 times and he underwent ablation. He was
started on sotalol, however failed this tx. He had another
episode of V-tach in [**7-13**] and was changed to quinidine in
[**2173-8-6**]. He has had no further episodes of VT since [**Month (only) 205**].
.
Most recently he was noted to have fluctuating RV lead impedance
and was scheduled for RV lead extraction tomorrow. His device
started beeping today and transmission showed greater impedance
([**2165**] ohms) therefore he was admitted for monitoring overnight.
He has not had inappropriate shocks and is not pacer dependent.
.
On review of systems, he states he has been feeling well lately.
He
denies any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. All of the other review of systems were
negative. The only recen medication changes were an increase in
his lasix to 60mg daily.
.
*** Cardiac review of systems is notable for absence of chest
pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. Coronary artery disease s/p inferoposterior MI with PTCA
[**2159**].
2. Left ventricular dysfunction with poor ejection fraction of
25-30%.
2. Nonsustained ventricular tachycardia with ICD 08/[**2170**].
3. Hypertension.
4. Hyperlipidemia.
5. Obstructive sleep apnea
6. H/o vitamin B12 deficiency. Last vitamin B12 level in
[**2171**]=418
7. Nephrolithiasis.
8. Peripheral neuropathy. He does not have known diabetes
mellitus.
9. Remote history of peptic ulcer disease.
10. GERD.
11. Status post tonsillectomy and adenoidectomy.
Social History:
Social history is significant for the presence of current
tobacco use (40 pack year history). There is no history of
alcohol abuse.Pt lives at home with his wife and daughter. [**Name (NI) **] is
on disability but still works part time in management for the
[**Location (un) 86**] retirement board.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father had atrial fibrillation.
Physical Exam:
VS - 98.2 124/85 74 18 96% on RA
Gen: Obese middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: trace pitting edema to mid-shin bilaterally. No femoral
bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2173-12-8**] 09:40PM BLOOD WBC-9.5 RBC-4.25* Hgb-13.5* Hct-37.8*
MCV-89 MCH-31.7 MCHC-35.6* RDW-14.6 Plt Ct-256
[**2173-12-8**] 09:40PM BLOOD PT-13.5* PTT-26.3 INR(PT)-1.2*
[**2173-12-8**] 09:40PM BLOOD Glucose-174* UreaN-16 Creat-1.1 Na-137
K-3.7 Cl-100 HCO3-28 AnGap-13
[**2173-12-8**] 09:40PM BLOOD CK(CPK)-186*
[**2173-12-9**] 07:20AM BLOOD CK(CPK)-221*
[**2173-12-10**] 04:41AM BLOOD CK(CPK)-201*
[**2173-12-8**] 09:40PM BLOOD CK-MB-5 cTropnT-<0.01
[**2173-12-9**] 07:20AM BLOOD CK-MB-21* MB Indx-9.5* cTropnT-0.14*
[**2173-12-10**] 04:41AM BLOOD CK-MB-12* MB Indx-6.0
[**2173-12-8**] 09:40PM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0
[**2173-12-9**] 06:28PM BLOOD Type-ART pO2-74* pCO2-43 pH-7.36
calTCO2-25 Base XS--1
Brief Hospital Course:
Summary of hospital course:
The patient is a 58 year old male with a history of CAD s/p IMI,
ischemic CM (EF 25-30%) with an ICD placement [**8-/2170**] (for NSVT,
EF <35% and inducible VT on EPS) VT s/p failed ablation on
quinidine, admitted to the floor for an ICD lead extraction. On
[**12-8**], telemetry showed sudden onset of a wide complex
tachycardia at 150. The patient was intially asymptomatic to the
episode, but began to feel nauseated. He denied any chest pain,
shortness of breath, palpitations, lightheadedness. He was
intially bolused with IV lidocaine 50mg x 2 without effect. He
was then bolused with 300mg IV amiodarone, and started on a
amiodarone gtt at 1mg/min, but remained in stable VT. The
patient was transferred to the CCU, had ATP pacing and started
on mixiline. He was taken to the OR [**2173-12-9**], the lead was
removed and a new ICD system was implanted in the left pectoral
region. He was a difficult intubation and had right upper lobe
collapse post procedure which later resolved spontaneously. He
was kept intubated overnight and extubated without trouble the
next day. A cardiac CT was peformed prior to discharge in
preparation for VT ablation procedure as an outpatient. He was
discharged on mexilitine and keflex to complete a 7 day course.
Medications on Admission:
1. Carvedilol 12.5mg Po BID
2. Niaspan 500mg qhs
3. Cymbalta 60mg daily
4. Diovan 80mg daily
5. Lasix 60mg daily
6. Lipitor 80mg daily
7. Allopurinol 150mg daily
8. Lorazepam 0,5mg q6h prn
9. ASA 325mg daily
10. Tylenol #3 1-2hr q6hr prn
11. Oxycodone 5mg q4h prn
12. Gabapentin 600mg TID< 900mg qhs
13. Colace 50mg prn
14. Melatonin 3mg daily
15. L-theanine 25mg daily
16. B-50
17. Fish oil
18. Mirapex
19. Magnesium 250mg daily
20. Quinidine 648mg TID
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
7. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
9. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
10. Melatonin 3 mg Tablet Sig: One (1) Tablet PO qhs ().
11. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO daily ().
12. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain .
15. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO HS (at bedtime).
16. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO Q8H (every 8 hours).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
18. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
19. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
20. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
ICD lead replacement and lead extraction
Ventricular tachycardia
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted for elective replacement of your ICD lead.
During your admission you went into ventricular tachycardia,
which was broken with electrical pacing. You are being started
on a new medication to help control your arrythmia. If you
experience GI upset or increase tremulations, you should call
Dr. [**Last Name (STitle) **]. If you experience any chest pain, shortness of
breath, or lightheadedness you should call your cardiologist or
go to the emergency room.
You are being started on antibiotics, which you should continue
for the next seven days.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet as instructed to prevent volume
overload.
.
Please stop smoking. This greatly increases your risk for heart
attack and stroke. Information was given to you on admission
regarding smoking cessation.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2173-12-17**]
11:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-1-21**] 3:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Known firstname **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2174-4-8**] 7:40
Completed by:[**2173-12-11**]
|
[
"272.4",
"414.8",
"327.23",
"414.01",
"428.0",
"428.42",
"996.04",
"V45.82",
"401.9",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.97"
] |
icd9pcs
|
[
[
[]
]
] |
8054, 8060
|
4531, 4531
|
334, 390
|
8169, 8208
|
3787, 4508
|
9129, 9572
|
2828, 2943
|
6320, 8031
|
8081, 8148
|
5842, 6297
|
8232, 9106
|
2958, 3768
|
4559, 5816
|
277, 296
|
418, 1939
|
1961, 2495
|
2511, 2812
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,278
| 140,817
|
5650
|
Discharge summary
|
report
|
Admission Date: [**2177-12-8**] Discharge Date: [**2177-12-15**]
Date of Birth: [**2122-10-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Moexipril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
[**2177-12-9**] AVR ( [**Street Address(2) 11688**]. [**Male First Name (un) 923**] mechanical)/septal myomectomy
History of Present Illness:
55 year old male with known biscuspid
aortic valve and aortic stenosis who was admitted to the [**Hospital1 18**]
for new onset atrial fibrillation and chest pain [**2177-9-10**]. He
underwent TEE guided expedited cardioversion and discharged on
warfarin and no antiarrhythmic. Since discharge issues have been
coumadin management and he notes edema at the end of the day
with
improvement in the morning. He continues with chest pressure
with
activity that resolves with rest occuring a few times a week.
He
is now admitted for surgery and heparin bridge.
Past Medical History:
hypertrophic cardiomyopathy
severe aortic stenosis secondary to bicuspid aortic valve
Hypertension
hyperlipidemia
diabetes mellitus - Type II
obstructive sleep apnea
kidney stones
Social History:
Never smoked. 1 - 2 drinks on the weekends. 1 large cup of
coffee daily. Works as an attorney. Lives at home and performs
all activities of daily living independently.
Family History:
Father died of MI in 50's. Had first MI at age 46. Mother died
of lung CA in 70's. No children with known heart disease
Physical Exam:
Pulse: 90 Resp: 20 O2 sat: 97% RA
B/P Right: 136/82 Left: 155/81
General no acute distress
Skin: Dry [X] intact [X] skin tags right shoulder
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] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema - trace
bilateral
LE Varicosities: None [x]
Neuro: alert and oriented x3 nonfocal
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: transmitted murmur bilateral
Pertinent Results:
Intra-op TEE [**2177-12-9**]
Pre CPB:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. There are simple atheroma
in the descending thoracic aorta.
The number of aortic valve leaflets cannot be determined. There
is severe aortic valve stenosis (valve area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
Moderate (2+) mitral regurgitation is seen. Excessive motion of
anterior leaflet chordae tendineae noted, this could represent a
ruptured chord or redundant chordae length.
Moderate [2+] tricuspid regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
Post CPB:
The patient is atrial paced.
The biventricular systolic function is preserved.
There is a mechanical valve in the aortic position with a peak
gradient of 34mmHg which is mechanically stable with good
leaflet excursion.
There is moderate mitral regurgitation with an eccentric
posteriorly directed regurgitation jet. The mitral valve
demonstrates systolic anterior motion. Sequential PWD through
the LVOT demonstrated step up of the peak velocity to 1.6m/s.
There is moderate tricuspid regurgitation.
The visible contours of the thoracic aorta are intact.
Dr. [**Last Name (STitle) **] was notified in person of the results.
Brief Hospital Course:
The patient was brought to the operating room on [**2177-12-9**]
where the patient underwent AVR(#23mm St. [**Male First Name (un) 923**] Mechanical
valve)and a Septal Myomectomy . Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Anticoagulation therapy was started with coumadin on [**2177-12-10**],
and Heparin intravenous therapy was started on [**2177-12-12**] until the
INR was >2.0. Chest tubes and pacing wires were discontinued
without complication. He did develop post-op a-fib and was
started on amiodarone. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD number 6, the patient
was ambulating freely, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged to
home with visiting nurses in good condition with appropriate
follow up instructions. Dr. [**Last Name (STitle) 1683**] will continue to manage
coumadin dosing.
Medications on Admission:
GLYBURIDE 1.25mg - one tablet once a day
METFORMIN 500mg - one tablet twice a day
SIMVASTATIN 20 mg - one Tablet by mouth once a day
VERAPAMIL 240 mg - one Tablet by mouth twice a day
WARFARIN 5mg - 1 tab 5x/wk; 1.5 tabs twice/wk
Antibiotic prophylaxis
MULTIVITAMIN 1 (One) Tablet by mouth once a day
Discharge Medications:
1. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
5. glyburide 2.5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 2 weeks, then 400mg daily x 1 week, then
200mg daily until further instructed.
Disp:*120 Tablet(s)* Refills:*0*
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
11. Coumadin 5 mg Tablet Sig: One (1) 1.5 PO once a day: take
7.5mg on Monday, Wednesday, and Friday.
Disp:*30 * Refills:*0*
12. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: take
5mg every Saturday, Sunday, Tuesday, and Thursday.
Disp:*30 Tablet(s)* Refills:*2*
13. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 2 weeks.
Disp:*45 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication mechanical aortic valve
Goal INR 2.5 -3.0
First draw [**2177-12-16**]
Results to Dr. [**Last Name (STitle) 1683**], phone [**Telephone/Fax (1) 22609**], confirmed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
s/p AVR/septal myomectomy
atrial fibrillation
hypertrophic cardiomyopathy
severe aortic stenosis with bicuspid valve
Hypercholesterolemia
hypertension
diabetes mellitus, type II
Obesity
Pulmonary artery hypertension
Sleep apnea - does not tolerate CPAP
Coronary artery disease
Gout
Kidney stones
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ bilateral lower extremities
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**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1504**] Thurs. [**2177-1-15**] 1pm
Cardiologist:Dr. [**Last Name (STitle) 696**] [**Telephone/Fax (1) 62**] Date/Time:[**2178-3-26**] 8:20
**Please also call for appointment with Dr. [**Last Name (STitle) 696**] in 3 weeks**
Primary Care Dr.[**Last Name (STitle) 1683**] [**2177-12-22**], 3:30pm [**Telephone/Fax (1) 22609**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechanical aortic valve
Goal INR 2.5 -3.0
First draw [**2177-12-16**]
Results to Dr. [**Last Name (STitle) 1683**], phone [**Telephone/Fax (1) 22609**], confirmed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Completed by:[**2177-12-15**]
|
[
"416.8",
"424.1",
"V17.3",
"401.9",
"272.0",
"746.4",
"327.23",
"425.4",
"250.00",
"427.31",
"274.9",
"V13.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"35.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7874, 7937
|
3926, 5362
|
307, 423
|
8277, 8463
|
2275, 3268
|
9387, 10289
|
1415, 1536
|
5714, 7851
|
7958, 8256
|
5388, 5691
|
8487, 9364
|
1551, 2256
|
252, 269
|
451, 1010
|
1032, 1213
|
1229, 1399
|
3278, 3903
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,413
| 164,138
|
31846
|
Discharge summary
|
report
|
Admission Date: [**2124-10-10**] Discharge Date: [**2124-10-20**]
Date of Birth: [**2048-12-3**] Sex: F
Service: SURGERY
Allergies:
Darvocet A500 / Percocet / Tape
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
cholangiocarcinoma
Major Surgical or Invasive Procedure:
[**2124-10-10**]
Exploratory laparotomy, resection of
extrahepatic biliary tree up to and beyond the bifurcation of
the right and left hepatic ducts, portal lymphadenectomy and
Roux-en-Y hepaticojejunostomy.
History of Present Illness:
75 y.o. female with long standing Ulcerative colitis who
presented with a few months of feeling poorly, 7 lb wt loss and
jaundice (t.bili up to 27). She was referred to [**Hospital1 18**] for ERCP
which showed a stricture and hilar mass. Brushings demonstrated
atypical cells and no malignancy. A biliary stent was placed and
the bilirubin trended down from 30 to 8.5. Subsequently, this
stent was removed in order to place a R and L hepatic duct PTC.
Imaging delineated a mass like lesion at the bifurcation of the
hepatic duct. She elected to undergo resection. A cardiac work
up was done. The Stress test was negative.
Past Medical History:
MI, CABG [**2100**] and [**2109**], GERD, osteoperosis, CSECx3, Appy, UC,
Anemia, Cariologist -- Dr [**Last Name (STitle) **] in [**Location (un) 1514**]
Social History:
Pt lives at home with her husband in [**Name (NI) 3844**]. Former
smoker quit in [**2100**]. Denies EtOH
Family History:
Sister with thyroid disease
Pertinent Results:
[**2124-10-10**] 08:50AM HGB-10.5* calcHCT-32
[**2124-10-10**] 08:50AM GLUCOSE-105 LACTATE-1.0 NA+-139 K+-3.3*
CL--101
Brief Hospital Course:
On [**2124-10-10**] she underwent exploratory laparotomy, resection of
extrahepatic biliary tree up to and beyond the bifurcation of
the right and left hepatic ducts, portal lymphadenectomy and
Roux-en-Y hepaticojejunostomy for cholangiocarcinoma. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see operative report for further
details. Intraoperative findings included a large hilar
cholangiocarcinoma involving primarily the bifurcation of the
hepatic duct. There was no evidence of carcinomatosis. The liver
was profoundly cholestatic and abnormal in appearance. There was
also a replaced accessory right hepatic artery coming off the
SMA behind the common bile duct, and the normally situated right
hepatic artery was
encased in tumor and thrombosed. Review of the frozensections
with the pathologist, and all 3 lymph nodes had evidence, on
further review, of mucinous-producing tumor
consistent with a cholangiocarcinoma, and there was also
microscopic tumor in both the right and left hepatic duct
proximal resection margins. The two PTCs were exchanged for 10
Fr. [**Location (un) 3825**] stents and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed behind the
biliary anastomosis.
Postop in PACU she was hypotensive, tachy to 130 (sinus tach)
with a temp of 101.4. The epidural was suspected as a cause for
hypotension and this was capped. She received IV fluid and
colloid without improvement. An ekg had questionable changes. A
Neo drip was started and the epidural removed. She was
transferred to the SICU for possible sepsis and further
management. WBC was 24. A swan ganz catheter was placed for
monitoring. Cardiac enzymes were done to rule out a cardiogenic
etiology for hypotension and Cardiology was consulted. A
Diltiazem drip was started and isosorbide was continued.
Vasopressin was added. Troponins were positive at 0.17 and 0.11.
She required multiple boluses of iv fluid. Urine output was low.
U/A and urine cultures were negative. Blood cultures were done
to rule out sepsis. Zosyn and cipro were added for possible
sepsis. These were changed to vanco and meropenum. Blood
cultures were negative. Bile cultures grew rare growth of gram
negative rods, staph coag negative, yeast and probable
enterococcus. WBC trended down. CXR were negative for pneumonia.
The swan ganz catheter was removed.
She was mildly confused and hallucinated. This was attributed to
dilaudid. Sedation was minimized. BP improved to 120/40 with
heart rate in the 70s. Diltiazem was changed to po, neo and
vasopressin were stopped. Lasix was started. Diet was slowly
advanced. The JP drained serosanuinous fluid and the two PTCs
drained bile.
She was transferred out of the SICU to the med-[**Doctor First Name **] unit where
she continued to improved each day. Mental status improved to
baseline. Appetite was fair and po intake was poor. Supplements
were ordered. Heart rate remained in the 70s (sinus). Abd was
soft. PT assessed her. She was independent with a rolling walker
and only required supervision on stairs. Tylenol was used for
pain control.
A cholangiogram was done on [**10-18**] demonstrating bilateral
biliary tubes migrated and dislodged and only opacification of
the subcapsular region was achieved. Bilateral tubes were
removed per Dr.[**Name (NI) 670**] requisition. The JP was removed on
[**10-19**] when the drainage was down to ~ 80cc/day.
[**Month/Year (2) 269**] services were arranged for home.
Labs on [**10-20**]: sodium 138, potassium 4.0, chloride 107, C02 27,
BUN 15, Creat 0.7, calcium 8.4, Mg 2.1, phos 2.9, wbc 8.4, h/h
9.2/33, plt 484, ast 57, alt 72, alk phos 318, t.bili 1.9 and
albumin 1.9.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] reviewed the pathology findings with the
patient and her family. Recommendations included chemotherapy.
Referral to an oncologist in N.H. was to be obtained after
speaking with Oncology from [**Hospital1 18**]. This was to be further
discussed on follow up outpatient visit. Please see path report
as follows:
Pathology Report
DIAGNOSIS:
I. Celiac lymph node (A): No carcinoma.
II. Calot lymph node (B-C): Metastatic adenocarcinoma with
signet ring cells.
III. Posterior common bile duct lymph node (D-E): Tiny focus of
metastatic adenocarcinoma, in permanent slide D. No tumor in the
original frozen sections.
IV. Peri-duct tissue (F): No tumor.
V. Bile duct (G-H): Invasive adenocarcinoma with perineural
involvement.
VI. Left duct margin (I-J): Invasive adenocarcinoma, involving
mucosa and wall.
VII. Right duct margin (K): Invasive adenocarcinoma, with
perineural involvement.
VIII. Gallbladder (L-N): Invasive adenocarcinoma at end of
cholecystic duct and adjacent soft tissue
IX. Small bowel (O-R): Segment of small intestine, within
normal limits.
Clinical: Cholangiocarcinoma.
Medications on Admission:
imdur 60 qd, cardizem 240 qd, ursodiol 300 TID, senna
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO three times a
day.
Disp:*60 Capsule(s)* Refills:*2*
2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO prn: q 6 hours as
needed for pain.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*1 bottle* Refills:*1*
4. DILT-XR 240 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
Disp:*30 Capsule,Degradable Cnt Release(s)* Refills:*2*
5. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Vicodin 5-500 mg Tablet Sig: [**12-28**] Tablet PO every eight (8)
hours.
Disp:*20 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
8. Imdur 60 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Month/Day (2) **] of [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Biliary strictures
biliary mass
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you experience
fever, chills, nauea, vomiting, jaundice, increased abdominal
pain/distension or increasing redness, bleeding, or drainage
from your incision.
Call office if you are changing the dressing over the abdominal
incision more than 3 times daily or if it has a foul odor/looks
bloody or greenish
No heavy lifting.
Follow up with your primary care physician to see if your
Cardizem dose needs to be changed.
You may shower.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 673**] Call to schedule an appointment
week of [**10-30**]
Completed by:[**2124-10-20**]
|
[
"995.91",
"V45.81",
"292.81",
"996.59",
"998.59",
"997.1",
"V15.82",
"156.1",
"196.2",
"E935.2",
"038.9",
"V18.19",
"412",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"40.3",
"51.37",
"97.55",
"51.22",
"51.69",
"38.93",
"87.54"
] |
icd9pcs
|
[
[
[]
]
] |
7626, 7746
|
1684, 6566
|
311, 521
|
7822, 7829
|
1537, 1661
|
8384, 8547
|
1489, 1518
|
6670, 7603
|
7767, 7801
|
6592, 6647
|
7853, 8360
|
253, 273
|
549, 1173
|
1195, 1350
|
1366, 1473
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,596
| 105,289
|
43752+43753
|
Discharge summary
|
report+report
|
Admission Date: [**2175-1-29**] Discharge Date: [**2175-2-10**]
Date of Birth: [**2100-3-19**] Sex: F
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Bleeding at right AV fistula site.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year old
female with end-stage renal disease secondary to IDDM and
hypertension; on hemodialysis every Monday, Wednesday and
Friday at the [**Location (un) **] Hemodialysis Unit. Her attending is
Dr. [**Last Name (STitle) **]. She was transferred to [**Hospital1 18**] for bleeding from her
AV fistula site. The first time was spontaneously. The second
time was secondary to the patient disturbing the dressing.
The bleeding was controlled in the ED with a stitch. She was
in her usual state of health, although had an extra
hemodialysis session for volume overload.
REVIEW OF SYSTEMS: No complaints, though the patient has
dementia.
PAST MEDICAL HISTORY: Significant for Alzheimer's with
vascular dementia, right AV fistula, post angioplasty, recent
admission in [**2174-12-1**] for mental status changes and
question encephalopathy and hypercalcemia.
PAST SURGICAL HISTORY: Cholecystectomy and a nephrectomy.
MEDICATIONS AT HOME: Aricept 10 mg p.o. at bedtime, aspirin
81 mg p.o. daily, Cozaar 100 mg p.o. daily, Norvasc 5 mg p.o.
daily, insulin daily, Zantac daily, Glucotrol 5 mg p.o.
daily, Renagel 2400 mg p.o. t.i.d., Nephrocaps 1 p.o. daily,
Sensipar 30 mg p.o. daily, hydralazine 100 mg p.o. q.a.m. and
50 mg at bedtime.
FAMILY HISTORY: Unable to obtain.
PHYSICAL EXAMINATION: Temperature 98.2, BP 148/78, heart
rate 75, respiratory rate 20, O2 saturation 100% on room air,
weight 139.8 pounds. She was alert and oriented x1. In no
acute distress. Lungs clear. Positive systolic murmur.
Regular rate and rhythm. Abdomen is soft and nontender with
positive bowel sounds. No lower extremity edema bilaterally.
Right upper extremity AV fistula is positive for thrill, and
this was palpable at the proximal aspect of the fistula.
LABORATORY DATA ON ADMISSION: White count was 7.3,
hematocrit 32.5, platelet count 174, creatinine 9.3, BUN 61,
with a potassium of 7.7 (which was hemolyzed), calcium was
9.7, magnesium 2.1, and a phosphorous of 5.
HOSPITAL COURSE: The patient was admitted for bleeding of
her AV fistula while in HD. This was stitched. She was taken
to the OR by Dr. [**First Name (STitle) **] [**Name (STitle) **]. The patient underwent an
excision and repair of right arm AV graft pseudoaneurysm with
a 6-mm PTFE jump graft. The patient tolerated the procedure
well and was extubated and transferred to the recovery room
in stable condition. Noted that it was okay to use the upper
arm portion of the AV graft for dialysis.
The patient was sent directly from the OR to dialysis. Her AV
fistula was cannulated on the upper without any problem. She
underwent hemodialysis without any problems; 0.5 liters were
ultrafiltrated.
The patient was admitted to the medical surgical unit after
hemodialysis. Noted that the patient was having mental status
changes. She appeared confused, only responded to painful
stimuli and sternal rub. She was shouting. Her O2 saturation
dropped to the mid 80s. She was put on an 02 nonrebreather.
ABGs were sent off as well as a full set of labs. O2
saturation improved to 100%. A central line was placed.
She was transferred to the SICU for monitoring. During
evaluation, the daughter was [**Name (NI) 653**]. It was noted that the
daughter stated that the patient's behavior was typical, that
she has dementia. She had a waxing and [**Doctor Last Name 688**] level of
consciousness. She received no sedation. Neurology was
consulted. A head CT was done. ABGs were done as well; pH was
7.39, pO2 420, pCO2 45. Head CT demonstrated no acute
intracranial hemorrhage, and the recommendations from
neurology included MRI/MRA to evaluate for stroke. They
recommended treating empirically with vancomycin and
ceftriaxone for infection, as it was felt that it was unsafe
to perform a LP due to a low platelet count and coagulopathy.
No antiepileptics were recommended. Of note, during
hemodialysis the patient had a low blood pressure of 70/40.
This responded to Trendelenburg position and a fluid bolus.
She is normally anuric. Her blood sugar was normal. The
patient was also transfused with 2 units of packed red blood
cells for a hematocrit of 20. Hematocrit increased to 28. The
patient was transferred back to the medical surgical unit.
Seizure was likely secondary to uremia. A temporary dialysis
catheter was placed in radiology as the right AV graft
thrombosed. The patient continued to receive hemodialysis via
the temporary catheter.
The patient returned on [**2-1**] to the OR for thrombectomy
of the right upper arm AV graft with fluoroscopy. The surgeon
was Dr. [**First Name (STitle) **] [**Name (STitle) **], assisted by Dr. [**First Name8 (NamePattern2) 30642**] [**Name (STitle) **]. The
patient received local with MAC. Impression included proximal
stenosis, and a venography was recommended with possible
dilatation of more proximal stenosis.
On [**2-2**], IR was unable to perform a venogram secondary
to the patient being uncooperative and agitated. This was
felt to be secondary to her dementia. She remained on IV
antibiotics for possible infectious etiology for seizure;
although this was less likely, this was a low probability.
The patient had episodes of semi appropriate responses and
answers to questions.
On [**2-6**], the patient underwent a right arm AV
fistulogram and a venogram via the right common femoral vein
catheter. A catheter was placed with the SVC that
demonstrated an approximately 2-cm occlusion extending from
the right brachiocephalic vein to the upstream portion of the
superior vena cava. Extensive venous collaterals were
demonstrated at the right upper chest, shoulder, and the
right upper arm. The recanalization of occlusion with a 0.035
glide wire was unsuccessful.
On [**2-8**], the patient underwent an MRI of the chest and
mediastinum to evaluate the left arm for future access to
rule out central stenosis. This study demonstrated a widely
patent left subclavian vein, internal jugular vein,
brachiocephalic vein, and superior vena cava. An occlusive
thrombus was noted within the right brachiocephalic vein with
partially occlusive thrombus in the right subclavian vein. No
flow was seen in the right internal jugular vein. Enhancement
of the vessel walls suggested subacute age, probably within 2
weeks. A 2.5-cm peripheral lung lesion with T2 hyperintense
center and rim enhancement was noted. Findings were noted to
be possibly related to infection; although given thrombus
seen within the central right veins, a septic emboli and
infarct were also amongst the differential diagnoses. The
differential diagnoses included neoplasm. After discussion of
MRI findings with the patient's daughter, a chest CT without
contrast was done to evaluate the left upper lobe lesion.
This was confirmed by CT. A left upper lobe peripheral
pleural based mass like opacity was noted. A small cavitation
was seen on the reformatted images. Given this rapid
development compared to a chest radiograph from [**2174-12-16**] a neoplasm seemed unlikely.
PLAN THIS HOSPITAL COURSE: The patient was evaluated by
physical therapy. PT recommended for strengthening and
safety. The patient's daughter called and noted that the
patient was unsafe at home. She was afraid to take the
patient home and wanted the patient to be placed in a nursing
home. Social service was consulted and followed along
closely. The patient has been living at [**Hospital3 2558**] and
did have a bed to return to. Throughout the remainder of this
hospital stay the patient was relatively cooperative. She did
have a one-to-one sitter. A one-to-one sitter was stopped
after her left groin temporary hemodialysis catheter was
removed. Her vital signs were stable. She continued on
vancomycin and ceftriaxone for empiric treatment for
meningitis; although this was felt to be low probability, and
her mental status changes were attributed to uremia and
dementia. An EEG was recommended by neurology. It was felt
that this could be done as an outpatient.
On physical exam, the patient's right upper extremity graft
site was open to air with sutures without any redness,
drainage or bleeding. She required assist with all areas of
ADL. Appetite was good. Blood sugars were controlled with her
regularly scheduled insulin.
DISCHARGE PLAN: The plan was to discharge to [**Hospital3 2558**]
on [**2175-2-10**] on the following medications.
DISCHARGE MEDICATIONS: Donepezil 5 mg p.o. at bedtime,
losartan 50 mg p.o. daily, amlodipine 5 mg p.o. daily,
hydralazine 25 mg p.o. q.6h., glipizide 5 mg p.o. b.i.d.,
enteric coated aspirin 81 mg p.o. daily, Zantac 150 mg p.o.
daily, Senna, Calcet 30 mg p.o. b.i.d., insulin sliding
scale, Colace 100 mg p.o. b.i.d., Thiamine 100 mg p.o. daily
(Thiamine was recommended by neurology for possible
Wernicke's encephalopathy).
DISCHARGE DIAGNOSES: Included end-stage renal disease,
diabetes, hypertension, dementia, left upper lung nodule,
right brachiocephalic occlusive thrombus, status post
creation of right upper extremity arteriovenous graft and
repair of right upper extremity arteriovenous fistula
pseudoaneurysm.
DISCHARGE FOLLOWUP: The patient was scheduled to follow up
with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2175-2-16**].
DISCHARGE CONDITION: Stable.
DISCHARGE LABORATORY DATA: Labs on [**2-9**] included a
white blood cell count of 8.2, hematocrit of 26.5, platelet
count of 255. Sodium 140, potassium 4.7, chloride 100,
bicarbonate 29, BUN 22, creatinine 4.9 and a glucose of 97.
CPK was drawn; this was 120. Calcium was 7.3, magnesium of
1.7, phosphorous of 3.1, albumin of 3.4. Vancomycin level on
[**2-2**] was 18.9.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2175-2-10**] 15:28:26
T: [**2175-2-10**] 16:53:52
Job#: [**Job Number 94023**]
Admission Date: [**2175-1-29**] Discharge Date: [**2175-2-10**]
Date of Birth: [**2100-3-19**] Sex: F
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Bleeding at right AV fistula site.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year old
female with end-stage renal disease secondary to IDDM and
hypertension; on hemodialysis every Monday, Wednesday and
Friday at the [**Location (un) **] Hemodialysis Unit. Her attending is
Dr. [**Last Name (STitle) **]. She was transferred to [**Hospital1 18**] for bleeding from her
AV fistula site. The first time was spontaneously. The second
time was secondary to the patient disturbing the dressing.
The bleeding was controlled in the ED with a stitch. She was
in her usual state of health, although had an extra
hemodialysis session for volume overload.
REVIEW OF SYSTEMS: No complaints, though the patient has
dementia.
PAST MEDICAL HISTORY: Significant for Alzheimer's with
vascular dementia, right AV fistula, post angioplasty, recent
admission in [**2174-12-1**] for mental status changes and
question encephalopathy and hypercalcemia.
PAST SURGICAL HISTORY: Cholecystectomy and a nephrectomy.
MEDICATIONS AT HOME: Aricept 10 mg p.o. at bedtime, aspirin
81 mg p.o. daily, Cozaar 100 mg p.o. daily, Norvasc 5 mg p.o.
daily, insulin daily, Zantac daily, Glucotrol 5 mg p.o.
daily, Renagel 2400 mg p.o. t.i.d., Nephrocaps 1 p.o. daily,
Sensipar 30 mg p.o. daily, hydralazine 100 mg p.o. q.a.m. and
50 mg at bedtime.
FAMILY HISTORY: Unable to obtain.
PHYSICAL EXAMINATION: Temperature 98.2, BP 148/78, heart
rate 75, respiratory rate 20, O2 saturation 100% on room air,
weight 139.8 pounds. She was alert and oriented x1. In no
acute distress. Lungs clear. Positive systolic murmur.
Regular rate and rhythm. Abdomen is soft and nontender with
positive bowel sounds. No lower extremity edema bilaterally.
Right upper extremity AV fistula is positive for thrill, and
this was palpable at the proximal aspect of the fistula.
LABORATORY DATA ON ADMISSION: White count was 7.3,
hematocrit 32.5, platelet count 174, creatinine 9.3, BUN 61,
with a potassium of 7.7 (which was hemolyzed), calcium was
9.7, magnesium 2.1, and a phosphorous of 5.
HOSPITAL COURSE: The patient was admitted for bleeding of
her AV fistula while in HD. This was stitched. She was taken
to the OR by Dr. [**First Name (STitle) **] [**Name (STitle) **]. The patient underwent an
excision and repair of right arm AV graft pseudoaneurysm with
a 6-mm PTFE jump graft. The patient tolerated the procedure
well and was extubated and transferred to the recovery room
in stable condition. Noted that it was okay to use the upper
arm portion of the AV graft for dialysis.
The patient was sent directly from the OR to dialysis. Her AV
fistula was cannulated on the upper without any problem. She
underwent hemodialysis without any problems; 0.5 liters were
ultrafiltrated.
The patient was admitted to the medical surgical unit after
hemodialysis. Noted that the patient was having mental status
changes. She appeared confused, only responded to painful
stimuli and sternal rub. She was shouting. Her O2 saturation
dropped to the mid 80s. She was put on an 02 nonrebreather.
ABGs were sent off as well as a full set of labs. O2
saturation improved to 100%. A central line was placed.
She was transferred to the SICU for monitoring. During
evaluation, the daughter was [**Name (NI) 653**]. It was noted that the
daughter stated that the patient's behavior was typical, that
she has dementia. She had a waxing and [**Doctor Last Name 688**] level of
consciousness. She received no sedation. Neurology was
consulted. A head CT was done. ABGs were done as well; pH was
7.39, pO2 420, pCO2 45. Head CT demonstrated no acute
intracranial hemorrhage, and the recommendations from
neurology included MRI/MRA to evaluate for stroke. They
recommended treating empirically with vancomycin and
ceftriaxone for infection, as it was felt that it was unsafe
to perform a LP due to a low platelet count and coagulopathy.
No antiepileptics were recommended. Of note, during
hemodialysis the patient had a low blood pressure of 70/40.
This responded to Trendelenburg position and a fluid bolus.
She is normally anuric. Her blood sugar was normal. The
patient was also transfused with 2 units of packed red blood
cells for a hematocrit of 20. Hematocrit increased to 28. The
patient was transferred back to the medical surgical unit.
Seizure was likely secondary to uremia. A temporary dialysis
catheter was placed in radiology as the right AV graft
thrombosed. The patient continued to receive hemodialysis via
the temporary catheter.
The patient returned on [**2-1**] to the OR for thrombectomy
of the right upper arm AV graft with fluoroscopy. The surgeon
was Dr. [**First Name (STitle) **] [**Name (STitle) **], assisted by Dr. [**First Name8 (NamePattern2) 30642**] [**Name (STitle) **]. The
patient received local with MAC. Impression included proximal
stenosis, and a venography was recommended with possible
dilatation of more proximal stenosis.
On [**2-2**], IR was unable to perform a venogram secondary
to the patient being uncooperative and agitated. This was
felt to be secondary to her dementia. She remained on IV
antibiotics for possible infectious etiology for seizure;
although this was less likely, this was a low probability.
The patient had episodes of semi appropriate responses and
answers to questions.
On [**2-6**], the patient underwent a right arm AV
fistulogram and a venogram via the right common femoral vein
catheter. A catheter was placed with the SVC that
demonstrated an approximately 2-cm occlusion extending from
the right brachiocephalic vein to the upstream portion of the
superior vena cava. Extensive venous collaterals were
demonstrated at the right upper chest, shoulder, and the
right upper arm. The recanalization of occlusion with a 0.035
glide wire was unsuccessful.
On [**2-8**], the patient underwent an MRI of the chest and
mediastinum to evaluate the left arm for future access to
rule out central stenosis. This study demonstrated a widely
patent left subclavian vein, internal jugular vein,
brachiocephalic vein, and superior vena cava. An occlusive
thrombus was noted within the right brachiocephalic vein with
partially occlusive thrombus in the right subclavian vein. No
flow was seen in the right internal jugular vein. Enhancement
of the vessel walls suggested subacute age, probably within 2
weeks. A 2.5-cm peripheral lung lesion with T2 hyperintense
center and rim enhancement was noted. Findings were noted to
be possibly related to infection; although given thrombus
seen within the central right veins, a septic emboli and
infarct were also amongst the differential diagnoses. The
differential diagnoses included neoplasm. After discussion of
MRI findings with the patient's daughter, a chest CT without
contrast was done to evaluate the left upper lobe lesion.
This was confirmed by CT. A left upper lobe peripheral
pleural based mass like opacity was noted. A small cavitation
was seen on the reformatted images. Given this rapid
development compared to a chest radiograph from [**2174-12-16**] a neoplasm seemed unlikely.
PLAN THIS HOSPITAL COURSE: The patient was evaluated by
physical therapy. PT recommended for strengthening and
safety. The patient's daughter called and noted that the
patient was unsafe at home. She was afraid to take the
patient home and wanted the patient to be placed in a nursing
home. Social service was consulted and followed along
closely. The patient has been living at [**Hospital3 2558**] and
did have a bed to return to. Throughout the remainder of this
hospital stay the patient was relatively cooperative. She did
have a one-to-one sitter. A one-to-one sitter was stopped
after her left groin temporary hemodialysis catheter was
removed. Her vital signs were stable. She continued on
vancomycin and ceftriaxone for empiric treatment for
meningitis; although this was felt to be low probability, and
her mental status changes were attributed to uremia and
dementia. An EEG was recommended by neurology. It was felt
that this could be done as an outpatient.
On physical exam, the patient's right upper extremity graft
site was open to air with sutures without any redness,
drainage or bleeding. She required assist with all areas of
ADL. Appetite was good. Blood sugars were controlled with her
regularly scheduled insulin.
DISCHARGE PLAN: The plan was to discharge to [**Hospital3 2558**]
on [**2175-2-10**] on the following medications.
DISCHARGE MEDICATIONS: Donepezil 5 mg p.o. at bedtime,
losartan 50 mg p.o. daily, amlodipine 5 mg p.o. daily,
hydralazine 25 mg p.o. q.6h., glipizide 5 mg p.o. b.i.d.,
enteric coated aspirin 81 mg p.o. daily, Zantac 150 mg p.o.
daily, Senna, Calcet 30 mg p.o. b.i.d., insulin sliding
scale, Colace 100 mg p.o. b.i.d., Thiamine 100 mg p.o. daily
(Thiamine was recommended by neurology for possible
Wernicke's encephalopathy).
DISCHARGE DIAGNOSES: Included end-stage renal disease,
diabetes, hypertension, dementia, left upper lung nodule,
right brachiocephalic occlusive thrombus, status post
creation of right upper extremity arteriovenous graft and
repair of right upper extremity arteriovenous fistula
pseudoaneurysm.
DISCHARGE FOLLOWUP: The patient was scheduled to follow up
with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2175-2-16**].
DISCHARGE CONDITION: Stable.
DISCHARGE LABORATORY DATA: Labs on [**2-9**] included a
white blood cell count of 8.2, hematocrit of 26.5, platelet
count of 255. Sodium 140, potassium 4.7, chloride 100,
bicarbonate 29, BUN 22, creatinine 4.9 and a glucose of 97.
CPK was drawn; this was 120. Calcium was 7.3, magnesium of
1.7, phosphorous of 3.1, albumin of 3.4. Vancomycin level on
[**2-2**] was 18.9.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2175-2-10**] 15:28:26
T: [**2175-2-10**] 16:53:52
Job#: [**Job Number 94023**]
|
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"250.40",
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"276.7",
"518.89",
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icd9cm
|
[
[
[]
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[
"39.49",
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icd9pcs
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[
[
[]
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19558, 20193
|
11610, 11629
|
19123, 19398
|
18698, 19101
|
17346, 18557
|
11294, 11593
|
11236, 11272
|
11652, 12118
|
10942, 10991
|
10269, 10305
|
19419, 19536
|
10334, 10922
|
12133, 12319
|
18574, 18674
|
11014, 11212
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
745
| 101,984
|
4857
|
Discharge summary
|
report
|
Admission Date: [**2199-6-13**] Discharge Date: [**2199-7-3**]
Date of Birth: [**2142-6-14**] Sex: M
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
male with history of type 1 diabetes, status post cadaveric
renal transplant 1?????? years prior to admission, who presented
to his primary care physician with fevers for the past week.
He had a low grade fever approximately one week prior to
admission and felt some chills. These symptoms subsequently
improved but returned on the day of admission and his
temperature was 101.5 at home. He was admitted directly to
medical service.
PAST MEDICAL HISTORY: Type 1 diabetes diagnosed at 14 years
of age, neuropathy. He uses leg braces and walker,
retinopathy. He is status post laser surgery three years
ago. Chronic end stage renal disease on dialysis from [**2194**]
to [**2192**]. History of peritonitis while on dialysis. He is
status post cadaveric renal transplant [**2197-10-25**]. He has
a history of acute rejection in [**2197-12-26**] treated with
OKT3, history of hip fracture in [**2198-2-24**] status post hip
arthroplasty at that time, history of hypertension, history
of hypercholesterolemia, chronic hiccups, coronary artery
disease, GERD.
MEDICATIONS: On admission, insulin NPH 25 units q a.m., 6
units q p.m., Regular insulin sliding scale, Rapamycin 2 mg
po q d, Prednisone 10 mg po q d, Lipitor 10 mg po q d, Lasix
20 mg po q d, Prograf 4 mg po bid, Reglan 10 mg po bid,
Prilosec 20 mg po bid, calcium 1500 mg po q d.
ALLERGIES: Penicillin causes nausea.
HOSPITAL COURSE: The patient was admitted to medical
service. His temperature on admission was 101.3, blood
pressure 140/70, heart rate 80 saturating 100% on room air.
His white count was 34, hematocrit 36.2, platelet count
291,000, sodium 137, potassium 5.1, chloride 101, CO2 20, BUN
43, creatinine 2 and blood sugar 346. His ALT was 75, AST
96, alkaline phosphatase 180, bilirubin 0.5. He underwent
chest x-ray which showed no signs of infiltrate. His abdomen
was nontender and non distended with no signs of peritoneal
irritation. The patient was placed on Zosyn empirically and
his white count started to come down. He underwent
ultrasound which showed stones and sludge in the gallbladder
and common bile duct and signs of cholecystitis. ERCP
consult was called and he underwent ERCP for diagnosis of
cholecystitis and cholangitis. Sphincterotomy was done during
ERCP and multiple stones and sludge were extracted
successfully. There were no remaining stones in the common
bile duct at the end of procedure. The patient was
maintained on Zosyn and he underwent interval cholecystectomy
on [**2199-6-19**]. An attempt to remove gallbladder
laparoscopically was made but the gallbladder was very
inflamed and the procedure had to be converted to open
cholecystectomy. He tolerated the procedure well without
complications. He did well initially postoperatively but
then he noticed to have an increased scleral icterus. His
LFTs were checked and his alkaline phosphatase was 671 with
bilirubin going up to 6.4. His amylase and lipase were
normal. His creatinine was also rising up to 2.2. He
underwent another ERCP which showed dilatation of CVD and
multiple blood clots in common bile duct along with one
yellow stone. The sphincterotomy site was bicapped for
possibility of bleeding from the sphincterotomy site and
double pigtail stent was placed into common bile duct for
drainage. After this ERCP bilirubin peaked at 7.4 with
alkaline phosphatase at 1100 and then started to slowly
decrease. White count at the time was ranging between 12 and
17. He was afebrile. His blood sugars were under good
control. He was tolerating regular diet. On post ERCP day
#4, the patient was noticed to be passing several stools with
blood clots. He became lightheaded and his hematocrit
dropped from 29 to 24 and urgent ERCP was done which showed
oozing from the sphincterotomy site with pulsating vessel on
the bottom and stent eroding injury in sphincterotomy. Due
to close proximity of the sphincterotomy site to pancreatic
duct, BICAP could not be applied anymore but the vessel was
injected with Epinephrine several times and seemed to stop.
The patient was admitted to surgical ICU for close
observation and serial hematocrits. He was transfused
several units of packed red blood cells around the ERCP but
then his hematocrits were stable. He was eventually
transferred back from the surgical ICU to regular floor and
his diet was slowly advanced. He tolerated this well. He
was discharged home on postoperative day #14. At the time of
discharge he was afebrile, stable, with heart rate of 73,
blood pressure 140/60, blood sugars were well controlled. On
the day of discharge his white count was 16.7, hematocrit
26.3 which was stable, platelet count 308,000, sodium 141,
potassium 4.1, chloride 104, CO2 26, BUN 20 and creatinine
1.3, glucose in the morning was 94. His FK levels were 16.3
on discharge.
DISCHARGE MEDICATIONS: Included Prednisone 5 mg po q d,
Prograf 4 mg po bid, Rapamycin 5 mg po q d, Norvasc 5 mg po q
d, Lopressor 50 mg po bid, Flomax 0.4 mg po q d, Calcium 1500
mg po q d, Prilosec, Lipitor, NPH insulin 25 units subcu q
a.m. and 6 units subcu q p.m. and iron supplements. He is
also taking Reglan and Colace.
FOLLOW-UP: He will follow-up with Dr. [**Last Name (STitle) **] on Monday
following discharge and with Dr. [**Last Name (STitle) **] from ERCP in two
months for removal of his stent.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Name8 (MD) 20287**]
MEDQUIST36
D: [**2199-7-4**] 10:25
T: [**2199-7-9**] 08:07
JOB#: [**Job Number 20288**]
|
[
"584.9",
"V64.4",
"285.1",
"576.1",
"998.11",
"576.8",
"E933.1",
"574.60",
"V42.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
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"51.88",
"51.85",
"51.87",
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icd9pcs
|
[
[
[]
]
] |
5052, 5803
|
1609, 5028
|
175, 640
|
663, 1591
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,814
| 141,996
|
52778
|
Discharge summary
|
report
|
Admission Date: [**2163-7-12**] Discharge Date: [**2163-7-20**]
Date of Birth: [**2079-1-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Bloody sputum for 5 days, post-bronchoscopy respiratory distress
Major Surgical or Invasive Procedure:
[**7-13**]: Bronchoscopy - only suction trauma visualized, no source
of bleeding found.
History of Present Illness:
Mr. [**Known lastname 108855**] is a very pleasant 84 y/o male with a h/o colon
cancer s/p resection and radiation, CAD s/p stents, systolic CHF
with EF 40-45%, dilated cardiomyopathy, afib, h/o cardiac arrest
and complete heart block now with pacer/AICD, and history of GI
bleed secondary to duodenal telangiectasia who is here from
rehab following evaluation of blood in his respiratory
secretions.
.
Mr. [**Known lastname 108855**] had a lengthy, complex, and recent admission to
the TICU which is summarized in brief. He had a fall on [**2163-6-23**],
leading to multiple rib fractures. He had L 1-10th rib frx, R
5-7th rib frx, L hemothorax decompressed by pigtail catheter,
and a L distal clavicle fracture. He was given a tracheostomy
and PEG tube after failed extubation and reintubation.
.
In rehab, the patient was noted to have blood tinged secretions
via his trach. A bronschoscopy was performed and reportedly saw
bleeding inside of his trachea with poor visualization. He was
transfused 2 unit pRBC and was transferred to [**Hospital1 18**]. Here, the
patient reports no resp distress. His wife stated that the pt
has been stable with no change in his respiration.
.
He underwent a bronchoscopy with our [**Hospital1 18**] group on [**7-13**], which
did not find an etiology of the bleed. Only suction trauma was
seen. Of note, he was receiving intermittent lasix and IVF for
hypernatremia prior to bronchoscopy. Post-procedure, he was
noted to be mildly tachypnic with RR 30s and was satting 88% on
15L NC. As such, he was transferred to the medical ICU for
closer monitoring. Of note, he is typically on 50% FIO2 with his
trach mask.
Past Medical History:
rectal cancer s/p removal and radiation ijn [**2157**]
CAD s/p stents
Complete heart block (now with pacer)
afib
h/o cardiac arrest (now with AICD)
systolic CHF (EF 40-45%)
fall with multiple rib fractures ([**2163-6-23**])
GI bleed
Social History:
Mr. [**Known lastname 108855**] lives in [**Location 745**] with his wife. They are currently
in the process of moving to an apartment. Per wife, Mr.
[**Known lastname 108855**] has been feeling stress/depressed about moving out of
their 42 year home. They have 2 children. He is a retired
computer science professor. [**First Name (Titles) **] [**Last Name (Titles) 22381**] smoked 5 cigars a day
for 30 years and quit in [**2150**] after his CVA. He drinks once or
twice a week. His wife says that even just a little alcohol
'affects him quite a bit' in changing his mood and makes 'him
sick'
Family History:
Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.
Physical Exam:
VS: T 101, BP:111/49, HR: 70, RR:19, O2:95% on 50% FiO2
General: NAD, resting comfortably and sleeping, arousable with
mild stimuli from sleep, no labored breathing
HEENT: NC, AT, no blood at trach opening or in oropharynx, MMM
Neck: no JVD, no LAD
Lungs: rhonchi throughout, diminished sounds at the bases
Heart: RRR, no M/R/G
Abdomen: soft, nontender, nondistended, normoactive bowel
sounds, PEG and ostomy in place, ostomy has brown stool
Skin: dry, hyperpigmentation of distal LE bilaterally; LUE seems
to be more swollen than RUE
Ext: bilateral lower extremities wrapped in dressing
NEURO: Coherent but sluggish, has episodic confusion. Can
verbalize some words through mask. CN II-XII intact, no motor or
sensory deficits on screening exam.
At discharge: same as above except
Gen: Arousable to verbal stimuli
HEENT: clear/tan secretions at trach site
Ext: LUE with swelling
Pertinent Results:
[**2163-7-12**] 02:15PM BLOOD WBC-10.4 RBC-3.05* Hgb-9.1* Hct-28.8*
MCV-95 MCH-29.9 MCHC-31.6 RDW-19.7* Plt Ct-273
[**2163-7-19**] 03:00AM BLOOD WBC-3.8* RBC-2.68* Hgb-8.0* Hct-25.5*
MCV-95 MCH-29.7 MCHC-31.2 RDW-17.1* Plt Ct-111*
[**2163-7-12**] 02:15PM BLOOD Neuts-80.6* Bands-0 Lymphs-8.4* Monos-9.6
Eos-0.6 Baso-0.6
[**2163-7-12**] 02:15PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-OCCASIONAL Stipple-OCCASIONAL
[**2163-7-12**] 02:15PM BLOOD PT-14.1* PTT-30.5 INR(PT)-1.2*
[**2163-7-15**] 05:37AM BLOOD PT-15.0* PTT-29.6 INR(PT)-1.3*
[**2163-7-12**] 02:15PM BLOOD Glucose-138* UreaN-63* Creat-1.1 Na-150*
K-4.8 Cl-108 HCO3-33* AnGap-14
[**2163-7-19**] 03:00AM BLOOD Glucose-130* UreaN-36* Creat-0.9 Na-141
K-5.1 Cl-105 HCO3-32 AnGap-9
[**2163-7-12**] 02:15PM BLOOD ALT-43* AST-38 AlkPhos-151* TotBili-1.0
[**2163-7-12**] 02:15PM BLOOD Lipase-523*
[**2163-7-12**] 02:15PM BLOOD proBNP-7598*
[**2163-7-19**] 03:00AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.4
[**2163-7-13**] 04:36PM BLOOD Type-ART Rates-/32 FiO2-100 pO2-60*
pCO2-48* pH-7.47* calTCO2-36* Base XS-9 Intubat-NOT INTUBA
Comment-TRACH MASK
[**2163-7-12**] 02:22PM BLOOD Lactate-1.1
.
Microbiology:
[**7-13**] Blood Cx: No growth
[**7-13**] Urine Cx: No growth
[**7-13**] Sputum Cx: Staph aureus coag +, sensitive to levofloxacin
[**7-13**] MRSA nasal screen: negative
.
Imaging:
[**7-16**] LUE doppler: No evidence of deep venous thrombosis in the
left upper extremity.
[**7-19**] CXR: Slightly rotated positioning. A tracheostomy tube is in
place. A left-sided dual-lead pacemaker is in place, with lead
tips over right atrium and right ventricle. There is moderately
severe cardiomegaly, with left lower lobe collapse and/or
consolidation. There is upper zone redistribution and diffuse
vascular blurring, suggestive of mild CHF. There is focal patchy
opacity in the left mid zone, which could reflect atelectasis or
a pneumonic infiltrate. There is a small left and possible
minimal right effusion. Minimal atelectasis right base. The hila
are enlarged.
Brief Hospital Course:
Mr. [**Known lastname 108855**] is a 84 y/o male with colon cancer s/p resection
and radiation, CAD s/p stents, systolic CHF with EF 40-45%,
dilated cardiomyopathy, afib, h/o cardiac arrest and complete
heart block now with pacer/AICD, and history of GI bleed
secondary to duodenal telangiectasia who is here from rehab for
hemoptysis. Of note, he had lengthy TICU hospitalization for L
1-10th rib fractures, R 5-7th rib fractures, a L hemothorax, a L
dist clavicle fracture, and he is s/p trach and peg.
.
# Hemoptysis: Mr. [**Known lastname 108855**] was noted to have blood tinged
secretions via his trach. An OSH bronschoscopy was performed and
reportedly saw bleeding inside the trachea with poor
visualization. He was transfused 2 units of pRBC and transferred
to [**Hospital1 18**]. Here, he reported no resp distress. He is status post
bronchoscopy with our pulmonary team on [**7-13**], which did not find
an etiology of the bleed. Only suction trauma was seen, and this
may be the primary etiology of his bloody tracheal secretions.
While the cause of his hemoptysis remains uncertain, his
hematocrits have remained stable and there are no signs of
continuing hemoptysis or active bleeding. Chemical DVT ppx was
held at time of discharge after he was HIT positive and given
risk of bleeding with suction trauma.
.
# Respiratory distress: His respiratory distress has
currentlyimproved. Post bronchoscopy, he was noted to be mildly
tachypnic with RR 30s and was 88% on 15L NC. A CXR showed
worsening pulmonary edema, and he received lasix with
improvement in PACU. He was transferred to the MICU for closer
monitoring. Of note, he was receiving intermittent lasix and an
IVF bolus prior to bronchoscopy. He is typically on 50% FIO2
with his trach mask. He was weaned from the ventilator, and was
continued on albuterol MDIs. He was also treated with vancomycin
and cefepime for HCAP, until his sputum Cx grew coag-positive
staph sensitive to levofloxacin. He was started on an 8-day
course of levofloxacin 750mg qday, of which the last dose will
be on [**7-21**]. Lasix 40mg PO daily was restarted on day of
discharge. This should be titrated as needed.
-We recommend keeping the patient on the ventilator (MMV)
overnight to decrease his work of breathing.
.
# Fever: The patient p/w low grade fever/temperature post
bronchoscopy. His fever curve was trended, and cultures were
sent. His urine and blood cultures showed no growth, while his
sputum culture grew coag-positive staph as mentioned above. He
was continued on levofloxacin.
.
# Anemia: His anemia was stable after 2u pRBC prior to transfer,
and his hematocrits remained stable. There was no further need
for transfusion.
.
# Asymetric swelling of LUE: His LUE was cooler than the RUE and
more swollen than the right, but still had good pulses. Although
his wife stated that his LUE has always been swollen, a doppler
of the LUE was obtained which showed no evidence of DVT. The
swelling appears to have reduced, although it still remains more
swollen than the RUE.
.
# Acute on chronic systolic CHF (40-45%): The initial physical
exam showed leg edema and his chest x-ray suggest mild CHF. He
was given 20mg of lasix in the PACU, and further diuresis was
not undertaken in the ICU. He was started on Lasix 40mg PO daily
(Previous home dose) on day of discharge. This should continue
to be monitored. He was given free water flushes through his G
tube for hypernatremia, which resolved during his stay.
.
# Low platelet count: His platelets fell from 273 on admission
to 107 prior to discharge. This drop was consistent with
heparin-induced thrombocytopenia, for which his heparin was
discontinued. This was confirmed as his heparin antibody from
[**2163-7-19**] was positive. His PLT count on [**7-19**] is 111. He was put on
pneumoboots for DVT prophylaxis given risk of bleeding with
suction.
-He should not be given heparin.
.
# Hypernatremia: As above, he was given free water flushes for
correction of his hypernatremia, which appears to have resolved.
Free water flushes were continued at time of discharge.
.
# Oral candidiasis: PO fluconazole was stopped prior to
discharge.
.
Only evidence of bleed is suection trauma in L maintstem
bronchus, needs to come back in 6 week from [**2163-7-13**] for rpt
bronch
Medications on Admission:
acetaminophen 975mg PO Q8H
carvedilol 3.125mg PO BID
Citalopram 20mg PO daily
docusate 100mg PO BID
ferrous sulfate 300mg PO daily
fluconazole 100mg PO Q12H
folic acid 1 mg po daily
lasix 40mg PO daily
gabapentin 300mg PO Q12H
heparin 5000U SC Q12H
lisinopril 2.5mg PO daily
MVI daily
omeprazole 20mg PO daily
protein supplement daily
albuterol inhaler 4 puffs Q2H prn wheezing
simethicone 80mg PO Q8Hprn
oxycodone 5-10mg po q4h prn
Discharge Medications:
1. acetaminophen 650 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every
eight (8) hours as needed for pain.
2. acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every
eight (8) hours as needed for pain.
3. carvedilol 3.125 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2
times a day).
4. citalopram 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
5. docusate sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: Ten (10) milliliters
PO BID (2 times a day).
6. ferrous sulfate 325 mg (65 mg iron) Tablet [**Month/Day/Year **]: One (1)
Tablet PO once a day.
7. folic acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
8. Lasix 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
9. gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO Q12H (every
12 hours).
10. lisinopril 2.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
11. multivitamin Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. protein supplement Packet [**Month/Day/Year **]: One (1) PO once a day.
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day/Year **]:
Four (4) Puff Inhalation q2hr as needed for SOB.
15. simethicone 80 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every eight
(8) hours.
16. oxycodone 5 mg/5 mL Solution [**Month/Day/Year **]: [**1-16**] PO Q4H (every 4
hours) as needed for tracheal pain.
17. levofloxacin 750 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily) for 2 days: Pt needs one dose on [**7-20**] and one dose on [**7-21**]
(in order to complete 8day course, day 1 was [**7-14**]).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Respiratory distress, now improved.
Tracheostomy requiring ventilation
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You initially came from your rehab after receiving a
bronchoscopy to evaluate your bloody sputum that you had had for
5 days. You received another bronchoscopy on [**7-13**], which did not
show any obvious source of bleeding. Afterwards, you had a fast
breathing rate and low oxygen saturation, so you were monitored
in the ICU. You received antibiotics for suspected pneumonia and
were on a ventilator machine at night. Your breathing and
overall status has improved, and you can be discharged to your
rehab in order to begin regaining your strength.
You were found to have an antibody against heparin products and
should avoid getting any further heparin products.
The following changes were made to your medications:
New: Levofloxacin 750mg daily, for 2 more days (dose on [**7-20**] and
[**7-21**])
Discontinued: Fluconazole, Heparin
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please keep the following appointments that you have with your
doctors:
Department: DERMATOLOGY AND LASER
When: THURSDAY [**2163-7-28**] at 2:45 PM
With: [**Name6 (MD) 13953**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
Department: CARDIAC SERVICES
When: MONDAY [**2163-8-8**] at 12:00 PM
With: [**Year (4 digits) 3941**] CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
.
Department: CARDIAC SERVICES
When: MONDAY [**2163-8-22**] at 1:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"112.0",
"482.41",
"428.23",
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icd9cm
|
[
[
[]
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] |
[
"96.6",
"96.72",
"33.21"
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icd9pcs
|
[
[
[]
]
] |
12836, 12902
|
6255, 10543
|
433, 523
|
13027, 13027
|
4154, 6232
|
14159, 15196
|
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|
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|
12923, 13006
|
10569, 11004
|
13205, 14136
|
3254, 4001
|
4015, 4135
|
329, 395
|
551, 2203
|
13042, 13181
|
2225, 2459
|
2475, 3071
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,143
| 192,589
|
21961
|
Discharge summary
|
report
|
Admission Date: [**2135-8-28**] Discharge Date: [**2135-9-7**]
Service: ORTHO
Allergies:
Codeine
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Left leg swelling/weakness
Major Surgical or Invasive Procedure:
I&D of left thigh hematoma
History of Present Illness:
81-year-old female patient transferred from Outside hopital, c/o
left thigh weakness,with a history of coronary artery disease
and DVT who was on
Coumadin. She developed worsening sciatica and eventually
lost motor strength in her left lower extremity associated
with the presence of a large hematoma at the subgluteal area
of her left buttock on CT/MRI, possibly accounting for some
sciatic
nerve compression and resulting in the paresthesias and
palsy.
Past Medical History:
DVT/PE
breast cancer
colon cancer
CAD s/p CABG
Social History:
TOB-denies
ETOH-denies
IVDA-denies
Physical Exam:
Gen:Comfortable/Alert
afebrile/vss
CV: tachy S1/S2
Lungs:CTA ant/lat
Abd:soft NT/ND
Ext:
LLE-intact quad strength, 0/5 [**Female First Name (un) **] at tibialis
anterior/[**Last Name (un) 938**]/Peroneal/gastroc.
decreased sensation lateral aspect of thigh. Positive
dopplerable DP/PT.
RLE: 5/5SAR at quads/knee/ankle sensaton intact throughtout.2+
pulses.
Pertinent Results:
[**2135-8-28**] 06:25PM PT-13.8* PTT-28.7 INR(PT)-1.2
Brief Hospital Course:
81-year-old female patient transfered from [**Hospital **] hospital c/o
left leg weakness with a history of coronary artery disease and
DVT who was on Coumadin with an INR of 6. She developed
worsening sciatica and eventually lost motor strength in her
left lower extremity associatedwith the presence of a large
hematoma at the subgluteal area of her left buttock, possibly
accounting for some sciatic nerve compression and resulting in
the paresthesias and palsy. The patient was admitted to the
Trauma Service and her anticoagulation status was reversed. A
CT and an MRI
revealed the presence of an extremely large hematoma immediately
deep to the gluteus maximus.
The patient was brought to the Operating Room for evacuation on
[**2135-8-29**] after her INR
was reversed to 1.2, please see op-note [**2135-8-29**], surgery went
without complicaions. Patient was brought back to the trauma ICU
for observation. Patient was then extubated without compliction
while in ICU, patient did have brief course of a-fib for which
lopressor was started. Plan for the patient was to restart
coumadin goal INR 1.5-2.0, CT of left leg to observe for
hematoma formation post-op, AFO to left lower leg, and follow
serial exams, follow hct. Patient continued to improved and was
transfered to the floor/orthopedic service on [**2135-9-2**]. Patient
was started on Levofloxacin on [**2135-9-5**] for UTI. Foley was d/c'ed
later that same day, however patient failed voiding trial and
foley was replaced. Foley was d/c'ed a second time [**2135-9-6**] and
patient again failed voiding trial. Urology was contact[**Name (NI) **] and
left recomendation to d/c to rehab with foley and follow-up in
clinic with Dr. [**Last Name (STitle) 770**].
Patient continued to do well througout course. Patien did gain
some [**Last Name (un) 938**]/FHL function in left leg. On day of discharge pain was
well controlled vital signs were stable, and INR was 1.4, hct
stable at 30.6.
Medications on Admission:
Coumadin
Lipitor
Toprol
Protonix
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime:
goal INR 1.5-2.0.
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] new [**Hospital **] rehab at [**First Name8 (NamePattern2) **] [**Hospital 11042**] Healthcare Center
Discharge Diagnosis:
Left thight hematoma
Discharge Condition:
stable
Discharge Instructions:
cont with Coumadin for anti-coagulation, goal INR 1.5-2.0,
please check INR 2x weekly, Please have HO adjust dose to meet
goal INR. Cont with physical therapy.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1005**] 10-14 days please call for appt.
[**Telephone/Fax (1) 4845**]. Please call this week for appt.
Please follow-up with Urology Dr. [**Last Name (STitle) 770**] 1week after discharge.
Please call this week for appt. [**Telephone/Fax (1) 2906**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2135-9-7**]
|
[
"599.0",
"V58.61",
"427.31",
"790.92",
"728.89",
"V10.3",
"V45.81",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"83.45",
"83.02",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4112, 4257
|
1347, 3304
|
239, 268
|
4322, 4330
|
1267, 1324
|
4538, 4989
|
3388, 4089
|
4278, 4301
|
3330, 3365
|
4354, 4515
|
890, 1248
|
173, 201
|
296, 753
|
775, 823
|
839, 875
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,672
| 140,814
|
11918
|
Discharge summary
|
report
|
Admission Date: [**2193-1-17**] Discharge Date:
Date of Birth: [**2131-3-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
male with a limited past medical history as per family who
was at the gym on the morning of admission working out and
was found to have syncope and arrest by bystanders. EMS was
called and the patient was brought back after asystole with
Epinephrine and Atropine and five shocks. The patient was
resuscitated for 15 minutes and then had stable blood
pressure and heart rate. The patient was started on Dopamine
and Lidocaine and transferred to [**Hospital **] [**Hospital 1459**] Hospital
where he was noted to have posturing. Head CT was done
showing questionable swelling but no bruits. There were
questionable ischemic changes on EKG. The patient was then
transferred to [**Hospital1 **]. While at the outside hospital, patient's
Dopamine was weaned off. The family could only provide a
limited history as the patient lives by himself.
PAST MEDICAL HISTORY: Arthritis.
PAST SURGICAL HISTORY: Unknown.
MEDICATIONS: On transfer, Aspirin, Heparin IV, Lidocaine IV.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Lives alone, never married, no children.
Smoking status unknown.
PHYSICAL EXAMINATION: Blood pressure 85/60, heart rate 85,
respirations 16. Head and neck exam, JVD 5 cm, no bruits,
intubated. Cardiac exam, normal S1 and S2, no murmurs, rubs
or gallops. Chest, coarse breath sounds with rhonchi.
Abdomen soft, nontender, good bowel sounds in all four
quadrants. Extremities, right and left upper extremity with
distal cyanosis, no palpable radial pulses bilaterally. Also
distal lower extremities with no palpable right or left PT or
DP pulses.
LABORATORY DATA: On admission white blood cell count 12.2,
hematocrit 40, platelet count 219,000, sodium 142, potassium
3.6, chloride 109, CO2 23, BUN 16, creatinine 1.3, CPK 305,
troponin .286, ABG with PH 7.15, CO2 49, O2 429 on 100% IMV
12/700. EKG showed sinus bradycardia with APC's and [**Street Address(2) 4793**]
elevation V2, [**Street Address(2) 4793**] depression in V3. Second EKG showed
normal sinus rhythm at 87 with inverted T waves in V3 through
V6. Chest x-ray reportedly showed mild CHF and cardiomegaly.
HOSPITAL COURSE:
1. Cardiovascular: The possible etiology of the patient's
acute asystole which the patient was in acute myocardial
infarction vs arrhythmia. The patient had no known history
of coronary artery disease but the family new very little
about the patient's past medical history. The patient did
not have elevated cardiac enzymes and no EKG changes to
suggest acute ischemia. The patient was placed on Heparin
for an acute coronary syndrome. After admission, the patient
experienced a seizure with tachypnea and tachycardia and
rapidly afterwards developed flash pulmonary edema. The
patient was given Morphine and Dilantin and his blood
pressure fell such that he required inotropic support with
Dopamine. Chest x-ray demonstrated interstitial edema with
perihilar haziness consistent with CHF. The patient was
treated with Lasix and supplemental oxygen. As he diuresed,
his oxygen requirements decreased and his Dopamine was weaned
down.
A TTE was obtained which demonstrated enlarged left atrium,
mildly decreased left ventricular function with an ejection
fraction of 40-45%, global mild hypokinesis with apical
anterior and septal hypokinesis, mildly dilated aortic root
with pulmonary hypertension. Given his relatively good
ejection fraction in conjunction with the patient's episode
of flash pulmonary edema, it was felt that he most likely
suffered diastolic as opposed to systolic heart dysfunction.
The Heparin drip was discontinued when the patient developed
a significant nasal bleed as well as questionable increasing
left groin hematoma. The patient was, however, continued on
Aspirin therapy and he was started on a beta blocker which
was slowly titrated up as tolerated over the hospital stay to
Lopressor 50 mg po bid and then switched over to once a day
beta blockers, Atenolol 25 mg po q d. Dopamine was also
weaned and the patient remained hemodynamically stable. The
patient was also started on an ACE inhibitor, Lisinopril 5 mg
po q d.
Consideration was given to catheterization to determine
whether or not the patient had coronary artery disease and it
was determined to revisit the issue once the patient's
neurological status had declared itself. The patient had no
events on telemetry over the hospital stay.
2. Pulmonary: The patient was intubated in the field and
was maintained on support over the first few hospital days.
ABGs demonstrated adequate oxygenation, ventilation. The
patient then suffered a flash pulmonary edema after a seizure
which was treated with increased FIO2 and diuresis. The
patient was started on Ceftriaxone and Flagyl for a presumed
aspiration pneumonia. The patient tried to wean off the
ventilator when he self extubated, then tolerated this
without difficulty. The patient was slowly weaned off
supplemental oxygen and ultimately required no oxygen. Chest
x-ray obtained during hospital course revealed no evidence of
remaining pulmonary edema. Furthermore, antibiotics were
discontinued.
3. Neuro: A neurological consult was obtained at admission
secondary to witnessed seizure at the time of admission. The
patient was thought to have suffered low cerebral perfusion
during asystolic event and CT scan demonstrated left mid
brain edema. The patient demonstrated posturing after his
admission seizure which slowly resolved over the hospital
stay. He was loaded with Dilantin and treated with 100 mg IV
tid. An EEG demonstrated diffuse swelling consistent with
encephalopathy but no epileptiform activity. Further
analysis over the next few days suggested the patient had a
70% chance of meaningful neurologic recovery. Over the
remainder of the hospital course the patient had significant
improvement in his neurological status in that he was no
longer posturing, started following commands, and could
answer questions. However, the patient was unable to swallow
during hospital stay. A nasogastric tube was initially
placed, and in prognosticating the time to full neurologic
recovery, a PEG tube was placed.
4. Renal: The patient's creatinine was mildly elevated at
the time of admission to 1.5. However, this quickly dropped
to within normal limits and the patient had good urine output
over hospital stay. Creatinine dropped to .9 towards the end
of admission.
5. Gastrointestinal: The patient was kept on Protonix for
GI prophylaxis. As the patient could not swallow, a
nasogastric tube was initially placed, followed by a PEG tube
in light of the fact that the patient's neurologic status
would not return to normal for awhile and would need such
means for nutritional support.
6. Infectious Disease: The patient was febrile with a
significant left shift and bandemia at the time of admission.
Blood and urine cultures showed no growth, chest x-ray did
not definitively suggest pneumonia, and no source of
infection could be found. However, the patient was started
on Ceftriaxone and Flagyl with the intent to complete a 7 day
course of treated presumed aspiration pneumonia. This course
was completed on [**2193-1-23**]. The patient then spiked a
temperature to 100.9. Cultures showed no growth thus far and
chest x-ray was negative. As the temperature persisted, a
lumbar puncture was obtained and was negative. In light of
all negative cultures, the only remaining possible etiology
was drug fever, possibly secondary to Dilantin. Dilantin was
discontinued and in place patient was placed on Depakote for
seizure prophylaxis, and after Dilantin was discontinued, the
patient was afebrile for remainder of hospital course.
7. Hematology: The patient was placed on Heparin initially
for an acute coronary syndrome. Heparin was discontinued
secondary to questionable groin hematoma and significant
nasal bleed associated with a drop in his hematocrit that
normalized without transfusion. Hemolysis labs and iron
studies were normal. Hematocrit remained stable for the
remainder of hospital course.
CONDITION ON DISCHARGE: Stable. Patient is being discharged
to rehab.
DISCHARGE MEDICATIONS: Atenolol 25 mg po q d, Lisinopril 5
mg po q d, enteric coated Aspirin 325 mg po q d, Heparin
subcu 5000 units q 12 hours, Lipitor 10 mg po q d, Prevacid
40 mg po q d, Depakote 250 mg po q d, Protonix 40 mg po q d,
Dulcolax 10 mg pr q 6 hours prn, Tylenol 650 mg po q 4-6
hours prn.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 2692**]
MEDQUIST36
D: [**2193-2-1**] 16:13
T: [**2193-2-1**] 16:17
JOB#: [**Job Number 37550**]
|
[
"780.39",
"411.89",
"787.2",
"348.1",
"780.6",
"507.0",
"416.8",
"E936.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"43.11",
"38.91",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
1207, 1225
|
8359, 8919
|
2340, 8262
|
1079, 1190
|
1331, 2323
|
143, 1020
|
1043, 1055
|
1242, 1308
|
8287, 8335
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,841
| 169,506
|
50893
|
Discharge summary
|
report
|
Admission Date: [**2200-5-23**] Discharge Date: [**2200-6-1**]
Date of Birth: [**2119-7-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2200-5-28**] Aortic valve replacement (21 mm CE pericardial magna
ease) Resection of left atrial appendage
History of Present Illness:
80 year old female with a history of Aortic Stenosis, followed
by echo. She also has Atrial Fibrillation and has a permanent
pace-maker. She is relatively active, and has noted increasing
dyspnea on exertion recently. Echo reveals [**Location (un) 109**] 0.9cm2. She
will be admitted for catheterization and pre-op workup.
Past Medical History:
Tachy-brady syndrome s/p ablation of atrial tachycardia and
single-chamber pacemaker implant ([**Company 1543**] Sigma) in 03/[**2190**].
EPS at that time showed multiple atrial tachycardias with
different morphologies (only 1 ablated) and also AF.
Atrial fibrillation diagnosed in [**2179**], initially paroxysmal
and treated with amiodarone, but currently permanent on rate
control and Coumadin for thromboembolic prophylaxis.
Aortic stenosis (severe with a valvular area of 0.9-1 cm2 and
a mean gradient of 23 mmHg by echo in 05/[**2199**]).
Hypertension.
Vascular disease including right carotid stenosis and left
subclavian stenosis.
History of right cerebellar embolic stroke in [**7-/2190**]
with no residual deficit.
Hyperlipidemia.
Hypothyroidism
Diverticulitis
Colon Cancer
multiple small bowel obstructions
temporary ileostomy with subsequent re-anastomosis
right rotator cuff repair x 2
hysterectomy
cholecystectomy
appendectomy
Social History:
Lives with: alone in senior housing, remains active
Occupation: retired hair dresser
Tobacco: denies
ETOH: denies
Family History:
father died of cancer at 60yo
mother died at 83 with diabetes and gangrene
sisters and brother with emphysema
brother died of renal failure
Physical Exam:
Pulse: 76 irregular Resp: 16 O2 sat: 99%RA
B/P Right: Left: 121/46
Height: Weight: 130lb
General: NAD, WGWN, appears much younger than stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur 3/6 systolic, loudest at
LSB, radiates to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] numerous well-healed surgical incisions
Extremities: Warm [x], well-perfused [x]
Edema: trace
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: NP Left:NP
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
radiation of cardiac murmur
Pertinent Results:
[**2200-5-23**] 05:30PM BLOOD WBC-3.6* RBC-3.70* Hgb-11.5* Hct-33.0*
MCV-89 MCH-31.1 MCHC-34.8 RDW-14.9 Plt Ct-189
[**2200-5-23**] 05:30PM BLOOD Plt Ct-189
[**2200-5-23**] 05:30PM BLOOD PT-30.5* PTT-34.8 INR(PT)-3.0*
[**2200-5-23**] 05:30PM BLOOD Glucose-98 UreaN-31* Creat-1.1 Na-144
K-3.8 Cl-106 HCO3-29 AnGap-13
[**2200-5-23**] 05:30PM BLOOD Albumin-4.7 Calcium-9.6 Phos-3.5 Mg-2.4
[**2200-5-23**] 05:30PM BLOOD %HbA1c-5.6 eAG-114
[**2200-5-23**] 05:30PM BLOOD TSH-1.7
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
No thrombus is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are severely thickened/deformed. 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. Moderate (2+) mitral regurgitation is seen. There is
a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) 914**] was
notified in person of the results on [**2200-5-28**] at 1000 am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Bioprosthetic
valve seen in the aortic position. It appears well seated and
the leaflets move well. Mean gradient is 10 mm Hg. Trivial
central aortic insufficiency is present. Aorta is intact post
decannulation. Mild mitral regurgitation persists. Mild
tricuspid regurgitation present.
Cardiac catheterization
1. Selective coronary angiography in this codominant system
revealed no
angiographically apparent coronary artery disease. The LM was
short with
slightly irregular angulation into LAD. The LAD had a hazy
ostial 30%
stenosis difficult to visualized; mid 40% at D1 and S1;
diffusely
diseased mid LAD involving origin of D2 to 25%; tortous distal
LAD prior
to wrapping around apex. The LCx had ostial 20% stenosis; small
ramus
intermedius branch; small OM1 followed by diffuse mid Cx 30%;
large
branching OM2, modest LPL and small LPDA arise from distal AV
groove Cx.
The RCA had diffuse luminal irregularities to 25% mid; mid and
distal
inferior septum supplied by large AM branch, with small basal
RPDA
arising from the distal AV groove RCA (which has a mild stenosis
just
after the take-off of the large AM).
2. Limited resting hemodynamics revealed mildly elevated
systemic
arterial pressure of 150/74mmHg.
3. Maximal hyperemia induced with iv adenosine over proximal
LAD, the
FFR was 0.95 with a 5mmHg gradient. Upon pullback of pressure
wire into
the guiding catheter, the Pd/Pa was 0.99-1.00.
FINAL DIAGNOSIS:
1. No angiographically-apparent flow-limiting CAD, although
atherosclerosis present.
2. Known severe aortic stenosis.
3. Negative pressure wire evaluation of the proximal/ostial LAD.
4. Angiograms reviewed with Dr. [**Last Name (STitle) **]. Additional plans per
Dr.
[**Last Name (STitle) **] and [**Doctor Last Name 914**].
5. Sheath to be removed when ACT <180 secs.
6. Reinforce primary preventative measures against CAD.
Brief Hospital Course:
She was admitted for heparin bridge, prehydration, and
preoperative testing. On [**5-26**] she underwent cardiac
catheterization as part of her preoperative workup. On [**5-28**] she
was brought to the operating room for aortic valve replacement
and resection of left atrial appendage. See operative report
for further details. She received cefazolin and vancomycin for
perioperative antibiotics. That evening she was weaned from
sedation, awoke neurologically intact and was extubated without
complications. Additionally she had anemia that she was
transfused for overnight. Post operative day one she was
started on betablockers, diuretics, and ace inhibitor. Later
that day she was transferred to the floor. Physical therapy
worked with her on strength and mobility. Chest tubes and
epicardial wires were removed per protocol. Coumadin was
started for atrial fibrillation. Her permanent pacemaker was
interrogated by the electrophysiology service. By
post-operative day four she was ready for discharge to rehab at
Newbridge on the [**Doctor Last Name **]. All follow-up appointments were
advised.
Medications on Admission:
Lasix 20 mg p.o. daily
Synthroid 0.05 mg p.o. daily
lisinopril 40 mg p.o. daily
Toprol 150 mg p.o. daily
omeprazole 20 mg p.o. daily
Crestor 20 mg p.o. daily
Coumadin 4mg, 6mg on Wed. and Mon. (last dose Wed. [**2200-5-21**])
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: eval for need of further diuresis at the end of treatment.
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 7 days.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Atrial fibrillation s/p LAA resection
Aortic stenosis s/p AVR
Hypertension
carotid stenosis
subclavian stenosis
Tachy-brady syndrome
History of right cerebellar embolic stroke Hyperlipidemia.
Hypothyroidism
Diverticulitis
Colon Cancer
multiple small bowel obstructions
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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) 914**] on [**6-24**] at 2pm
Cardiologist: Dr [**Last Name (STitle) **] in [**12-22**] weeks
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**3-25**] weeks [**Telephone/Fax (1) 8506**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2200-6-1**]
|
[
"401.9",
"287.5",
"V45.01",
"447.1",
"285.1",
"433.10",
"272.0",
"427.31",
"433.30",
"V10.05",
"414.01",
"V12.54",
"443.9",
"424.1",
"786.09",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"37.22",
"37.36",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10113, 10207
|
7462, 8578
|
328, 440
|
10520, 10675
|
2883, 6994
|
11599, 12107
|
1916, 2058
|
8855, 10090
|
10228, 10499
|
8604, 8832
|
7011, 7439
|
10699, 11576
|
2073, 2864
|
269, 290
|
468, 797
|
819, 1768
|
1784, 1900
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,565
| 155,495
|
47647
|
Discharge summary
|
report
|
Admission Date: [**2184-4-26**] Discharge Date: [**2184-4-29**]
Date of Birth: [**2118-1-17**] Sex: M
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Nausea, vomiting, diarrhea; admission to MICU with hypotension.
Major Surgical or Invasive Procedure:
Upper endoscopy.
History of Present Illness:
66 year-old male with past medical history of hypertension,
prostate cancer status post radiation, and osteoarthritis of the
left hip with chronic NSAID use presenting with nausea,
vomiting, and diarrhea for three days; admitted to MICU for
hypotension. The patient states his symptoms began at 1:00 AM
three days prior to admission with vomiting and diarrhea. The
patient felt improved the next day, then relapsed. He describes
having approximately [**2-29**] bowel movements/hour three days prior
to admission, then increased the next day where he spent the
majority of the day in the bathroom. He states he felt "hot" but
denies fevers. He had a small amount of blood-streaking of his
vomitus the morning of admission. He denies BRBPR or melena. He
had some crampy abdominal pain at first which is now resolved.
He estimates an approximately 15 pound weight loss over the last
few days. Had substernal burning chest pain earlier today
consistent with prior history of GERD, now resolved. He states
he had lightheadedness the day prior to admission with standing,
improved at this time. No recent antibiotics. Travel to Bahamas
and [**Location (un) 5770**]
.
In the ED, NG lavage negative. Pt found to have ARF - Cr 9.3
(baseline not known). Lactate 1.0. Pt rec'd levofloxacin 500mg
IV x1, flagyl 500mg IV x1, protonix 40mg IV x1, and NS 4.5 L. Pt
was going to go to floor, but then SBP dropped to 80s, and she
was transferred to MICU. Pt was guaiac positive in ED. Renal u/s
performed, which was normal, and Renal and GI services were
consulted.
Past Medical History:
1. Hypertension
2. Prostate cancer status post radiation therapy
3. Osteoarthritis of the left hip; status post right hip
replacement
Social History:
Lives at home with wife and cat. Denies current tobacco use, but
has a 30 pack-year smoking history. Occasional EtOH. No IVDU.
Has a PhD and specialized in management of natural disasters.
Recent travel to [**Location (un) 5770**] and Bahamas.
Family History:
Non-contributory.
Physical Exam:
VS: 99.2 113/59 92 27 98% RA
Gen: Well appearing, NAD
HEENT: PERRL, EOMI, OP clear, MMM
Neck: No cervical LAD, no JVD
CV: RRR, nl S1/S2, no m/r/g
Pulm: CTAB, no wheezes
Abd: Soft, distended, somewhat tympanitic, nontender, + BS
Ext: No c/c/e, 2+ distal pulses
Rectal: Guaiac positive in ED
Neuro: AAOx3
Pertinent Results:
[**2184-4-26**] 01:10AM GLUCOSE-119* UREA N-81* CREAT-9.3*
SODIUM-131* POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-14* ANION
GAP-29*
[**2184-4-26**] 01:10AM WBC-20.3*# RBC-4.96 HGB-15.8 HCT-45.0 MCV-91
MCH-31.8 MCHC-35.1* RDW-13.7
[**2184-4-26**] 01:10AM PLT COUNT-384
[**2184-4-26**] 01:10AM NEUTS-88.5* LYMPHS-5.4* MONOS-6.0 EOS-0
BASOS-0
[**2184-4-26**] 01:10AM PT-12.6 PTT-27.8 INR(PT)-1.1
[**2184-4-26**] 09:54PM GLUCOSE-87 UREA N-74* CREAT-5.1*# SODIUM-139
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-14* ANION GAP-20
.
Labwork on discharge:
[**2184-4-29**] 03:07AM BLOOD WBC-6.3 RBC-3.64* Hgb-11.3* Hct-32.5*
MCV-89 MCH-31.2 MCHC-34.9 RDW-13.3 Plt Ct-279
[**2184-4-29**] 03:07AM BLOOD Glucose-111* UreaN-15 Creat-0.8 Na-140
K-4.1 Cl-109* HCO3-25 AnGap-10
.
[**2184-4-26**] 12:15 pm STOOL CONSISTENCY: WATERY
FECAL CULTURE (Final [**2184-4-28**]): NO SALMONELLA OR SHIGELLA
FOUND. CAMPYLOBACTER CULTURE (Final [**2184-4-28**]): NO
CAMPYLOBACTER FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2184-4-27**]): NO
E.COLI 0157:H7 FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2184-4-28**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O VIBRIO (Final [**2184-4-28**]): NO VIBRIO FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2184-4-29**]): FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2184-4-28**] 4:30 am STOOL CONSISTENCY: WATERY Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2184-4-29**]): FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
CHEST (PORTABLE AP) [**2184-4-26**]
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Normal heart, lungs, hila, mediastinum, and pleural surfaces.
.
RENAL U.S. [**2184-4-26**]
IMPRESSION: The right kidney measures 10.4 cm. The left kidney
measures 10.9 cm. There is no evidence of obstruction or stones.
No mass or cyst was noted. The bladder contains a Foley catheter
and is not well distended.
.
ECG Study Date of [**2184-4-26**] 11:23:06 AM
Normal sinus rhythm, rate 74. Anteroseptal myocardial infarction
of
indeterminate age. Probable inferior wall myocardial infarction
of
indeterminate age. Compared to the previous tracing of [**2180-3-29**]
the sinus rate is slower.
Brief Hospital Course:
66 year-old male with nausea, vomiting and profound diarrhea
times three days presenting with hypotension, acute renal
failure, and guaiac positive stools.
.
1. Hypotension: The patient had transient hypotension to
systolic 80s in the Emergency Department responding to fluid
repletion. The hypotension was likely due to volume depletion
from gastrointestinal losses. The patient received
bicarbonate-[**Doctor First Name **] fluids to replace his bicarbonate losses from
the diarrhea. The patient's blood pressure subsequently remained
stable throughout admission. The patient ruled out for
myocardial infarction. There was initial concern for sepsis and
the patient was started on empiric levofloxacin and flagyl to
cover gastrointestinal bacteria. Chest x-ray and urinalysis were
negative for infection. Blood cultures were negative at the time
of discharge. Bacterial stool cultures and C. difficile toxin
were negative as above with viral cultures pending at the time
of discharge. Antibiotics were discontinued prior to discharge
as the patient remained afebrile and his history was consistent
with viral gastroenteritis.
.
2. Nausea, vomiting, diarrhea: The history was most consistent
with viral gastroenteritis (eg. Norovirus). He was volume
expanded as above. There was initial concern for sepsis and he
was started on empiric levofloxacin and flagyl to cover
gastrointestinal bacteria as above. Antibiotics were
discontinued prior to discharge as the patient remained afebrile
and the history was consistent with viral gastroenteritis.
Bacterial stool cultures were negative as above with viral
cultures pending at the time of discharge. The patient was
taking good PO prior to discharge.
.
3. Acute renal failure: This was likely prerenal from
gastrointestinal losses and NSAID use. He was volume expanded as
above. The patient was followed by Nephrology. There was no
evidence of acute tubular necrosis on urine sediment. SPEP and
UPEP were pending at the time of discharge. The patient's
ACE-inhibitor was held and the patient should discuss use of
this medication with his primary care physician. [**Name10 (NameIs) **] patient was
advised to discontinue NSAIDs.
.
4. Guaiac positive stools: Nasogastric lavage was negative in
the Emergency Department. His hematocrit remained stable within
expected limits for his volume expansion. He was evaluated by
Gastroenterology and upper endoscopy was performed. Endoscopy
revealed esophagitis, gastritis, and duodenitis likely due to
the patient's use of NSAIDs. The patient was started on
omeprazole twice daily per GI recommendations and advised to
discontinue NSAIDs and aspirin. The patient should schedule an
outpatient screening colonoscopy.
.
5. Left hip osteoarthritis: The patient was advised to
discontinue NSAIDs. The patient was treated with ultram with
good effect.
.
Code: Full
.
Disposition: Home
Medications on Admission:
1. Atenolol 100 mg daily
2. Flomax 0.4 mg daily
3. Ibuprofen 200-800 mg three times daily
4. Moexipril 15 mg daily
5. Simvastatin 20 mg daily
Discharge Medications:
1. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Gastroenteritis, likely viral
2. Acute renal failure
3. Esophagitis, gastritis, and duodentitis
4. Guaiac positive stools
.
Secondary:
1. Hypertension
2. Prostate cancer status post radiation therapy
3. Osteoarthritis of the left hip; status post right hip
replacement
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were hospitalized with gastroenteritis, likely viral. You do
not need to take antibiotics. You should take in at least one to
two liters of fluid per day to replace your gastrointestinal
losses. Please contact a physician if you are unable to take in
enough fluids.
.
You were hospitalized with acute renal failure. This was likely
due to inability to replace gastrointestinal losses. There is
likely a component of renal failure from taking motrin. You
should not take motrin or any other NSAIDs.
.
You were found to have blood in your stools. Your upper
endoscopy showed erosive esophagitis, gastritis, and
duodentitis, likely from NSAID use. You should not take any
NSAIDs or aspirin. You should take omeprazole twice daily. You
should call to schedule an outpatient colonoscopy as below.
.
You were given ultram to treat your hip pain. You should not
take any NSAIDs. You should contact your primary care physician
if you experience pain that is not relieved by ultram.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, nausea, vomiting, worsening
diarrhea, black stools or blood in your stools, inability to
take fluids, worsening hip pain that is not relieved by ultram,
or any other concerning symptoms.
.
Please take your medications as prescribed.
- You should take omeprazole 20 mg twice daily.
- You should take ultram 50 mg every 4-6 hours for hip pain. You
should not take aspirin, motrin or any other NSAID. You should
contact your primary care physician if you experience pain that
is not relieved by ultram.
- You should hold your moexipril for now and discuss restarting
this medication with your primary care physician.
.
Please keep your follow-up appointments as below.
Followup Instructions:
Follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9625**],
on Thursday, [**5-6**] at 10:00 am. Please call [**Telephone/Fax (1) 100663**] with
any questions or concerns.
.
Please call [**Telephone/Fax (1) 1983**] to schedule an outpatient colonoscopy
with Dr. [**First Name4 (NamePattern1) 1939**] [**Last Name (NamePattern1) 1940**].
.
Previously scheduled appointments:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10516**] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2184-5-7**] 2:20
|
[
"401.9",
"E935.9",
"V10.46",
"535.60",
"V43.64",
"530.81",
"V15.3",
"276.51",
"584.9",
"530.19",
"276.2",
"535.50",
"008.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
8575, 8581
|
4951, 7822
|
338, 357
|
8906, 8938
|
2727, 3260
|
10726, 11367
|
2369, 2388
|
8015, 8552
|
8602, 8885
|
7848, 7992
|
8962, 10703
|
2403, 2708
|
3274, 4928
|
235, 300
|
385, 1935
|
1957, 2092
|
2108, 2353
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,362
| 117,454
|
33063
|
Discharge summary
|
report
|
Admission Date: [**2179-5-21**] Discharge Date: [**2179-5-25**]
Date of Birth: [**2158-5-11**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Codeine
Attending:[**First Name3 (LF) 3129**]
Chief Complaint:
Hypertensive Emergency/Seizure/Hyperkalemia
Major Surgical or Invasive Procedure:
Hemodyalisis
History of Present Illness:
Ms. [**Known lastname 76867**] is a 20 year old female with MPGN s/p renal
transplant ([**7-13**]) and recurrent MPGN who was recently admitted
over the last few months for hypertensive emergency twice.
.
She started peritoneal dialysis and tried to do this at home
today. Around 3:30 pm she had a generalized seizure and was
found on the floor at home by her father, drooling and
nonverbal, and he called EMS. She was brought to the ED and had
a seizure in the ED as well witnessed by the ED staff and her
mother. She had quite elevated BP with SBP > 250 and a cough
over the last few days.
.
In the ED, she was hypertensive to 258/168. She was given
labetalol 10 iv x 2 then started on labetalol GTT. She was noted
to have a K of 7 so she was given bicarb, insulin, glucose, and
calcium. She had an additional generalized seizure in the ED.
She got 1 gram of vancomycin and 1 gram of ceftriaxone. She was
admitted to the ICU for emergent hemodialysis
Past Medical History:
) MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[**2175**]. Post
transplant pt was doing well, but had rising Cr for two year. In
[**6-/2178**] pt presented with uncontrolled BP requiring ICU
admission for Isradipine drip. Repeat biopsy showed a type 1
MPGN. Negative HepC,HepB,[**Doctor First Name **], and renal U/S from NMEC showed
stable AVF. Her creatinine peaked to 4's and she was started on
steroids, prograf and cellcept. In [**1-/2179**], she required 3
sessions of HD through a right upper chest catheter. Creatinine
slowly recovered to 3.2. Plasmapheresis was then initiated with
plan to then treat with Rituximab. She only underwent 3 sessions
of [**Year (4 digits) **]. She is now transferred her care to Dr. [**Last Name (STitle) **]
at [**Hospital1 18**] to an adult clinic.
2) Peripheral edema and abdominal striae [**1-9**] steroids
3) HTN [**1-9**] steroids and renal disease, multiple admissions for
Hypertensive emergency.
4) Hemolytic Anemia - was seen by heme/onc who felt it was [**1-9**]
to malignant hypertension.
5) Migraines
Social History:
Lives at home with [**Month/Day (2) **], brother and sister, college student
at [**Name (NI) 498**] [**Name (NI) 86**] in the health sciences. Denies ETOH, illicit
drugs, tobacco.
Family History:
No history of kidney disease, malignancy, heart disease, or
diabetes.
Physical Exam:
VS: T98.6 BP 196/132 P106 R29 98% 3L NC
GEN: eyes close, opens to voice, sedated
[**Name (NI) 4459**]: Pupils reactive direct and consentual biaterally. OP
clear, MMM
RESP: crackles all areas posteriorly
CV: RRR 2/6 SEM LUSB
CHEST: HD catheter in right chest wall
ABD: Soft NT/ND + BS no rebound or guarding. PD catheter in
place
EXT: Warm well perfused, no peripheral edema
SKIN: slight skin discoloration over right tibia
NEURO: moves hands and feet slightly to command. Opens eyes to
voice. Nonverbal.
Pertinent Results:
[**2179-5-21**] 04:30PM CALCIUM-10.0 PHOSPHATE-9.2* MAGNESIUM-2.0
[**2179-5-21**] 04:30PM estGFR-Using this
[**2179-5-21**] 04:30PM GLUCOSE-158* UREA N-54* CREAT-9.9*#
SODIUM-142 POTASSIUM-7.4* CHLORIDE-100 TOTAL CO2-21* ANION
GAP-28*
[**2179-5-21**] 04:37PM GLUCOSE-154* LACTATE-4.4* K+-7.0*
[**2179-5-21**] 04:37PM COMMENTS-GREEN TOP
[**2179-5-21**] 05:25PM PLT SMR-NORMAL PLT COUNT-185
[**2179-5-21**] 05:25PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-3+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-OCCASIONAL SCHISTOCY-1+
BURR-1+ TEARDROP-OCCASIONAL
[**2179-5-21**] 05:25PM NEUTS-96.8* BANDS-0 LYMPHS-1.7* MONOS-0.8*
EOS-0.5 BASOS-0.2
[**2179-5-21**] 05:25PM WBC-12.2*# RBC-3.56* HGB-10.7* HCT-33.8*
MCV-95 MCH-30.0 MCHC-31.6 RDW-22.9*
[**2179-5-21**] 05:25PM CALCIUM-9.9 PHOSPHATE-9.1* MAGNESIUM-1.9
[**2179-5-21**] 05:25PM GLUCOSE-261* UREA N-55* CREAT-10.1*
SODIUM-142 POTASSIUM-7.0* CHLORIDE-100 TOTAL CO2-24 ANION
GAP-25*
[**2179-5-21**] 05:48PM LACTATE-4.9*
[**2179-5-21**] 07:44PM PLT COUNT-177
[**2179-5-21**] 07:44PM WBC-14.3* RBC-3.66* HGB-10.9* HCT-34.8*
MCV-95 MCH-29.9 MCHC-31.4 RDW-22.1*
CT
NDICATION: 21-year-old woman status post seizure.
COMPARISON: None.
TECHNIQUE: Contiguous axial images of the cervical spine were
obtained without IV contrast. Sagittal and coronal
reconstructions were also obtained.
FINDINGS: No disc, vertebral or paraspinal abnormality is seen.
There is no sign of a fracture or abnormal alignment. While CT
is not able to provide intrathecal detail comparable to MRI, the
visualized outline of the thecal sac appears unremarkable.
The lung apices demonstrate multifocal, patchy airspace
opacities, worrisome for an infectious process, and are
incompletely evaluated on this study.
IMPRESSION: No acute abnormalities of the cervical spine. Patchy
airspace opacities seen at the lung apices, incompletely
evaluated. Please refer to dedicated chest radiograph obtained
[**2179-5-21**] at 1700 hours.
..
CT HEAD W/O CONTRAST
Reason: bleed?
[**Hospital 93**] MEDICAL CONDITION:
21 year old woman with ESRD on PD, sz and hypertensive today.
also with fall with seizure
REASON FOR THIS EXAMINATION:
bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 21-year-old woman with fall, seizure, and
hypertension today. History of ESRD on PD.
COMPARISON: Head CT of [**2179-4-27**].
TECHNIQUE: Contiguous axial images were obtained through the
brain. No contrast was administered.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect, shift of normally midline structures, or evidence of
major vascular territorial infarct. The ventricles and sulci are
normal in contour and configuration. There is no fracture and
the sinuses and mastoid air cells are well aerated. Soft tissues
are unremarkable.
IMPRESSION: No acute intracranial abnormalities.
.
========
CHEST (PORTABLE AP) [**2179-5-21**] 5:11 PM
CHEST (PORTABLE AP)
Reason: pna? pulm edema?
[**Hospital 93**] MEDICAL CONDITION:
21 year old woman with ESRD and seizure. recent cough.
REASON FOR THIS EXAMINATION:
pna? pulm edema?
HISTORY: 21-year-old woman with ESRD and seizures; ? pneumonia
or pulmonary edema.
FINDINGS: Single bedside AP examination labeled "supine at 1700
p.m." is compared with studies dated [**5-2**] and [**2179-5-3**]. The
overall appearance is dramatically worse, now with diffuse and
more confluent airspace opacity and lower lung volumes, which
could represent progressive pulmonary infection, pulmonary
edema, or both. The heart appears further enlarged with "water-
bottle" configuration, supporting a contribution of edema,
though there is no large pleural effusion. The right-sided
dual-lumen venous access device is unchanged.
Brief Hospital Course:
ASSESSMENT/PLAN: 21 year-old woman with with ESRD, h/o MPGN-type
1 s/p transplant now with recurrence in transplanted kidney,
recent transition to peritoneal dialysis admitted to MICU with
hyperkalemia, volume overload, hypertensive urgency, and
seizures
#MICU course: In the MICU, she was continue on labetalol drip
and was emergently dialized. Peritoneal fluid was sent on
admission and was negative for SBP. 14 WBC. Remained afebrile.
Labetalol drip was off at 11pm [**2179-5-21**]. All her oral BP meds
were started. She also received another dose of antibiotics but
after discussion with renal team it was determined to stop them
given no signs of infections. She has also cmplained of
intermittent headache while in the unit treated with dilauded
PRN. This am labs her K came back as 6.5. No EKG changes. It was
also discusssed with renal team not to give her any kayexalate
unles EKG changes.
# Headaches: per prior discharge summarys, patient with h/o of
headaches. They are not always related to her elevated BP.
Patient has a follow up appointment with neurology in [**Month (only) 205**] for
further evaluation.
.
# Hypertensive Emergency: BP currently well control with oral PO
meds when transfer to the floor.She was kept on losartan,
metoprolol, isradipine, hydralazine, clonidine and lisinopril.
Also after peritoneal dialysis was on board, her BP's improved.
.
# Hyperkalemia: on admission due to CKD. Electrolytes
disturbances were managed with HD.
.
# CKD: Upon transfer to the floor, her PD scheduled was
optimized. She had [**3-14**] dwells with 2.5% per day. Her weights
were followed closely. The day of discharge she had 1 HD
treatment with 2L off at the end. Her weight ~ 47kg.
Instructions wer given upon discharge to continue to peritoneal
dialysis at home.
.
# seizures - likely secondary to hypertensive emergency and
electrolyte imbalance. No new episodes since admission to MICU.
Head Ct negative on admission. Infectious work up remained
negative. Patient will have a follow up with neurology in [**Month (only) 205**].
.
# Hypoxia/volume overload : on admission secondary to being
unable to do her Peritoneal dialysis. Her oxygenation improved
after dyalisis was re-started.
.
# ? infection Peritoneal dialysis: Given seizures and low grade
temperatue on admission, there was a concern for infection upon
presentation. Peritoneal fluid analysis was negative for SBP. Cx
remained negative until discharge. Initial empiric antibiotic
therapy was discontinued.
.
Medications on Admission:
B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule
PO once a day.
Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Isradipine 2.5 mg Capsule Sig: Six (6) Capsule PO TID (3
times a day).
Losartan 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily)
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO three times
a day.
6. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO three times
a day.
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
8. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Thirty
(30) ML PO Q 8H (Every 8 Hours) for 1 days.
Disp:*1 bottle* Refills:*0*
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Sevelamer HCl 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*1 botttle* Refills:*0*
16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Emergency
Hyperkalemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted with high blood pressure, seizures and
elevated K
Please continue your dialysis as instructed by the renal team.
Please take all your blood pressure meds as prescribed.
If fevers, chills, nausea/vomit, worsening headache or any other
symptoms that may concern you, call your PCP or come to the
emergency department
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2179-6-8**] 7:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-6-17**] 1:20
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-7-22**] 9:40
Completed by:[**2179-5-27**]
|
[
"585.6",
"285.21",
"784.0",
"276.6",
"996.81",
"403.01",
"780.39",
"276.7",
"799.02",
"403.00",
"583.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
11964, 11970
|
7016, 9512
|
329, 344
|
12050, 12057
|
3237, 5289
|
12439, 12878
|
2624, 2696
|
10390, 11941
|
6259, 6314
|
11991, 12029
|
9538, 10367
|
12081, 12416
|
2711, 3218
|
246, 291
|
6343, 6993
|
372, 1327
|
1349, 2411
|
2427, 2608
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,709
| 147,614
|
26927
|
Discharge summary
|
report
|
Admission Date: [**2197-1-16**] Discharge Date: [**2197-1-31**]
Service: CARDIOTHORACIC
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2197-1-25**] AVR ( 23 mm CE Magna pericardial)/Resect. LAA
History of Present Illness:
Mrs. [**Known lastname 21212**] is an 85 year old female with a PMH significant for
severe AS, recently diagnosed AF, HTN, HLD, and possible COPD
who presents with progressive shortness of breath. The patient
presented to her PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**1-12**] complaining of [**4-20**] days
of palpitations and was found to be in AF with RVR. At that
time, her atenolol was increased and she was started on
coumadin. She then presented to her PCP today complaining of
progressively increasing shortness of breath and was sent to the
ED for further evaluation. Of note, the patient has had chronic
shortness of breath that is likely multifactorial in the setting
of deconditioning, possible mild COPD, and severe AS. She states
that at baseline, she can walk only from her bed to her bathroom
(15 feet) before developing dyspnea, and that this is worse in
the past few days. She also reports having gained approximately
2 lbs/month for the past year.
.
On initial presentation to the BIMDC ED, VS 98.3 124 127/88 20
94%RA. The patient had an ECG that demonstrated AF with RVR, a
CTA that was negative for PE or dissection, and a CXR that did
not demonstrate an acute cardiopulmonary process. She received
10 mg IV diltiazem and 30 mg po diltiazem, and was admitted to
[**Hospital Unit Name 196**] for further management.
.
Currently, the patient is resting comfortably without
complaints. Denies any CP/SOB, f/c/s, n/v/d, abd pain, HA,
palpitations, orthopnea, PND, diaphoresis, or pain radiating to
her jaw or shoulder or back.
.
ROS: Patient reports 3 months of expiratory wheezing. As above,
otherwise negative. Cardiac review of systems is notable for
absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
- Breast cancer s/p left mastectomy [**2180**]. Treated with tamoxifen
for five years. Negative nodes.No evidence of recurrence or
metastases.
- HTN
- HLD
- Possible mild COPD
- Osteoporosis
- Glaucoma
.
Past Surgical History:
[**2160**]-TAH/BSO (irregular bleeding)
[**2170**] right hip fracture, pinned.
[**2179**]-diverticulitis-resected with temporary colostomy,
reanastomosis
[**2180**]-left mastectomy.
[**2181**]-abdominal hernia repair.
[**2184**] right hip replacement.
[**2188**]-pelvic fracture.
[**2189**]-right arm fracture, open reduction, internal fixation.
[**2194**]-periprosthetic right hip fracture
.
Cardiac Risk Factors: Hypertension and hyperlipidemia
.
Cardiac History:
1. Aortic stenosis - Last [**Location (un) 109**] <0.8 cm2 ([**10/2196**]; mild AR), prior
in [**9-22**] [**Location (un) 109**] 0.8-1 cm2.
2. Atrial fibrillation - newly diagnosed on [**2197-1-12**].
Social History:
Widowed, moved from [**Location (un) **] to [**Hospital1 2436**], the Gables, in
[**9-20**]. Supportive children. Daughter is her healthcare proxy.
She prefers not to have any invasive treatment. Tobacco:
Ex-smoker, 22 years-[**12-17**] 1/2 packs per day. EtOH: One drink of
scotch nightly. Exercise: Senior exercise class.
Family History:
+ CVA (MGM age 78)
Physical Exam:
VS: 97.9 134/89 105 22 92%RA
Gen: Age appropriate female in NAD
HEENT: PERRL, EOMI, sclerae anicteric. MMM, OP clear without
lesions, exudate, or erythema. Neck supple without LAD.
CV: Irregular S1+S2, III/VI late peaking crescendo-descrescendo
systolic murmur throughout the precordium radiating to the
carotids. No pre-cordial heave. PMI not palpable. Unable to
assess JVP.
Pulm: Bibasilar crackles (L>R)
Abd: S/ND/ND +bs
GU: guaiac OB brown negative
Ext: No c/c/e. 1+ dp/pt bilaterally
Neuro: AOx3, CN II-XII intact.
Pertinent Results:
[**2197-1-16**] 11:50AM PT-16.7* INR(PT)-1.5*
[**2197-1-16**] 03:20PM PT-17.8* PTT-27.6 INR(PT)-1.6*
[**2197-1-16**] 03:20PM PLT COUNT-218
[**2197-1-16**] 03:20PM WBC-7.9 RBC-4.64 HGB-12.5 HCT-38.9 MCV-84
MCH-27.0 MCHC-32.2 RDW-15.6*
[**2197-1-16**] 03:20PM cTropnT-<0.01
[**2197-1-16**] 03:20PM CK(CPK)-73
[**2197-1-16**] 03:20PM GLUCOSE-152* UREA N-15 CREAT-0.7 SODIUM-136
POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-29 ANION GAP-1
[**2197-1-31**] 06:15AM BLOOD WBC-11.3* RBC-3.48* Hgb-9.5* Hct-29.5*
MCV-85 MCH-27.2 MCHC-32.1 RDW-15.6* Plt Ct-317
[**2197-1-31**] 06:15AM BLOOD Plt Ct-317
[**2197-1-31**] 06:15AM BLOOD PT-14.0* INR(PT)-1.2*
[**2197-1-31**] 06:15AM BLOOD Glucose-83 UreaN-12 Creat-0.5 Na-131*
K-4.2 Cl-91* HCO3-31 AnGap-13
[**2197-1-22**] 04:50AM BLOOD ALT-14 AST-21 AlkPhos-92 TotBili-0.7
[**2197-1-22**] 04:50AM BLOOD %HbA1c-5.7 eAG-117
[**2197-1-17**] 12:50PM BLOOD TSH-4.5*
Radiology Report CHEST (PORTABLE AP) Study Date of [**2197-1-27**] 1:40
PM
Final Report
INDICATION: 85-year-old woman status post AV replacement.
Evaluate for
pneumothorax status post line change over a wire.
COMPARISON: Multiple priors, most recent portable AP chest
radiograph
[**2197-1-27**] at 11:19 a.m.
FINDINGS: Right internal jugular line tip projects over the
cavoatrial
junction. There is no pneumothorax. No focal parenchymal opacity
suggesting pneumonia. There is no overt pulmonary edema. Minimal
atelectasis is once again noted in the retrocardiac region,
unchanged from radiograph obtained earlier on the same day.
Borderline cardiomegaly is once again noted, unchanged from the
radiograph obtained earlier today.
IMPRESSION: Right IJ tip is at the cavoatrial junction with no
evidence of
pneumothorax. Otherwise, no interval change since chest
radiograph obtained earlier today.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8575**] [**Name (STitle) 8576**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 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: 3.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Sinus Level: 2.1 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.6 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *85 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 60 mm Hg
Aortic Valve - LVOT diam: 1.8 cm
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Moderate LA enlargement. Depressed LAA emptying
velocity (<0.2m/s) Probable thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. PFO is present.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low
normal LVEF. [Intrinsic LV systolic function likely depressed
given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Normal aortic arch diameter. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild to moderate ([**12-17**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The rhythm appears to be atrial fibrillation. See
Conclusions for post-bypass data
Conclusions
Pre-bypass:
The left atrium is moderately dilated. The left atrial appendage
emptying velocity is depressed (<0.2m/s). A probable thrombus is
seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is low normal (LVEF 50-55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Right ventricular chamber
size and free wall motion are normal. There are complex
atheromas in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-17**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Post-bypass:
The patient is not receiving inotropic support post-CPB. There
is a bioprothestic valve well-seated in the aortic position with
good leaflet excursion. There is no paravalvular or
transvalvular regurgitation. There is a mean pressure gradient
of 5 mm Hg across the valve. The left atrial appendage has been
resected. Biventricular systolic function is preserved. All
other findings are consistent with the pre-bypass findings
except an easy detection of left to right PFO by color doppler
at rest. This was not seen in the preoperative period. There is
evidence of LAA ligation. All findings were communicated to the
surgeon.
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) **] [**2197-1-25**] 14:14
Radiology Report CAROTID SERIES COMPLETE Study Date of [**2197-1-23**]
9:03 AM
Final Report
HISTORY: An 85-year-old lady with critical AS, awaiting AVR.
TECHNIQUE: Evaluation of the bilateral extracranial carotid
arteries was
performed with B-mode, color and spectral Doppler ultrasound.
Mild-to-moderate amount of plaque was seen in the left internal
carotid artery and a mild amount of plaque was seen in the right
internal carotid artery, with B-mode ultrasound. On the right
side, peak systolic velocities were 55 cm/sec for the internal
carotid artery and 60 cm/sec for the common carotid artery. The
right ICA/CCA ratio was 1.0.
On the left side, peak systolic velocities were 112 cm/sec for
the ICA and 49 cm/sec for the CCA. The left ICA/CCA ratio was
2.3.
The right vertebral artery presented antegrade flow and the left
vertebral
artery could not be visualized.
COMPARISON: None available.
IMPRESSION:
1. Less than 40% stenosis of the right internal carotid artery.
2. 40-59% stenosis of the left internal carotid artery.
DR. [**First Name (STitle) **] [**Name (STitle) **]
Cardiology Report Cardiac Cath Study Date of [**2197-1-20**]
BRIEF HISTORY:
Mrs. [**Known lastname 21212**] is an 85 y/o woman with symptomatic critical aortic
stenosis
(mean gradient 55 mmHg, [**Location (un) 109**] 0.5 cm2) who declined OHS and
requested
percutaneous valvuloplasty.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.77 m2
HEMOGLOBIN: 11.9 gms %
**PRESSURES
RIGHT ATRIUM {a/v/m} -/23/20
RIGHT VENTRICLE {s/ed} 70/15/24
AORTA {s/d/m} 161/94/125
**CARDIAC OUTPUT
HEART RATE {beats/min} 105
RHYTHM ATRIAL FIBRILLATION
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
COMMENTS:
1- Arterial and venous access under US guided and placement of
8F
sheaths in the R CFA and R CFV.
2- Selective coronary angiography showed no
angiographically-apparent
coronary artery disease. The LMCA, LAD, LCX and RCA were all
patent.
3- Limited resting hemodynamic assessment showed elevated
right-sided
filling pressure with (mean RA 20 mmHg, RVEDP 24 mmHg). Despite
numerous
atempts, including using a J wire, we were unable to advance the
PA
catheter to the pulmonary arteries. The systemic arterial BP was
markedly elevated was 161/94 mmHg requiring IV NTG gtt. The RV
systolic
pressure was markedly elevated (70/15/24 mmHg).
4- Heparin (4000 units) was administered.
5- Despite prolonged attempts, using different catheters
(including 5F
Pigtail, AL1, JR2, AL2, AR2, and MP) we were unable to cross the
aortic
valve. The tight AS as well as extremely severe valve
calcifications, as
well as the dilated aortic root are potential reasons for this.
Notably,
the femoral, iliac and distal aorta had moderate tortuousity
making it
a little difficult to torque the catheters. The AL1 catheter was
the one
that appeared to provide best (although suboptimal) orientation.
6- Given the radiation dose, we opted to abort further
retrograde aortic
valvuloplasty.
7- We will consider trans-septal antegrade approach or surgical
AVR.
8- [**Hospital 66215**] medical therapy including continuing
anticoagulation
and cardioversion for AF.
9- If no trans-septal antegrade valvuloplasty or AVR is to be
done
next week, consider restarting warfarin. Otherwise, continue
heparin
gtt.
FINAL DIAGNOSIS:
1. No significant coronary artery disease
2. Severly elevated right-sided filling pressures (mean RAP 20
mmHg)
3. Unable to advance the PA catheter to the pulmonary arteries
but RV
pressure was elevated at 70/24 mmHg.
4. Moderate systemic arterial hypertension.
5. Dilated aortic root
6. Atrial fibrillation with rapid ventricular response
7. Moderately tortuous L CFA, L iliac and distal aorta
8. Markedly calcific aortic valve and significant mitral annular
calcifications
9- Patient not a candidate for percutaneous retrograde aortic
valvuloplasty.
10. Consider percutaneous antegrade aortic valvuloplasty via
trans-septal approach or surgical AVR next week
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **]
ATTENDING STAFF: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J.
Brief Hospital Course:
Mrs. [**Known lastname 21212**] is an 85 year old female with a PMH significant for
critical aortic stenosis, recently diagnosed atrial
fibrillation, hypertension, hyperlipidemia, who initially
presented with progressive shortness of breath consistent with
acute on chronic congestive heart failure. Etiology behind
exacerbation was secondary to new atrial fibrillation
significantly decreasing cardiac output causing florid heart
failure. Patient was gently diuresed with lasix. Her blood
pressures could not tolerate significant fluid removal and thus
significant diuresis was terminated. Volume status goal was net
-500 cc to 0 cc per day prior to surgery. She remained
comfortable on 2 Liters oxygen.
Patient initially opted against surgery due and valvuloplasty
was attempted. This was not successful as the catheter could not
be passed safely through the aortic valve. This was felt to be
due to the tight valve, the extremely severe valve
calcifications, as well as the dilated aortic root. It was
decided the definitive treatment for this patient was an aortic
valve replacement. Patient was taken to surgery [**2197-1-25**]. Please
see operative report for details in summary the patient had
aortic valve replacement with a 23-mm [**Doctor Last Name **] Magna Lifesciences
pericardial tissue valve, model number 3000TFX, serial number
[**Serial Number 66216**]. Resection of left atrial appendage. Her CARDIOPULMONARY
BYPASS TIME was 103 minutes with a CROSSCLAMP TIME of 80
minutes. She tolerated the operation well and was transferred
from the operating room to the cardiac surgery ICU in stable
condition. She remained hemodynamically stable in the immediate
post-op period and was weaned from sedation and extubated on the
morning after surgery. She continued to be hemodynamically
stable but remained in the ICu for pulmonary hygiene. All tubes
lines and drains were removed according to cardiac surgery
protocols. She was transferred from the cardiac surgery ICU to
the stepdown floor on POD3.
The remainder of her hospital course was uneventful. She was
transferred to rehab at [**Hospital 66217**] Rehab in [**Hospital1 2436**] on POD6.
Followup with Dr [**Last Name (STitle) **] in 4 weeks
Medications on Admission:
Albuterol MDI prn
Atenolol 50 mg po bid
Citalopram 20 mg daily
Fluticasone 50 mcg each nostril daily
Furosemide 10 mg/mL solution, 1 mL daily
Lisinopril 10 mg daily
Lorazepam 0.5 mg prn
KCl 25 meq daily
Ranitidine 150 mg po daily
Risedronate 35 mg po qweek
Simvastatin 20 mg daily
Travatan 0.004% drops
Coumadin 2 mg daily
ASA 81 mg daily - on hold since [**2197-1-12**]
Calcium 1500 mg daily
Vitamin D 800 units daily
Simethicone 80 mg QID prn
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QAC ().
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): 20mg [**Hospital1 **] x10 days then 20mg QD.
10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
13. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAC&HS.
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 4days then 400mg QD x7 days then 200mg QD.
15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
16. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) tx Inhalation Q6H (every 6 hours) as
needed for wheezing.
18. Warfarin 1 mg Tablet Sig: as directed to keep INR 2-2.5
Tablets PO DAILY (Daily) as needed for Afib: target INR 2-2.5
Home dose 2mg QD.
Discharge Disposition:
Extended Care
Facility:
Aberjona Nursing Center - [**Hospital1 2436**]
Discharge Diagnosis:
AS s/p AVR/resect. LAA
Atrial Fibrillation
chronic diastolic heart failure
Chronic Obstructive Pulmonary Disease
Hypertension
hypercholesterolemia
glaucoma
GERD/hiatal hernia
esophageal stricture
osteoporosis
osteoarthritis
depression
lumbar spinal stenosis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Sternal wound healing well, no drainage or erythema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
****WHEELCHAIR only for 10 weeks- may not use her routine walker
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) 914**] on [**2-28**] @1:15 [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) **] in [**12-17**] weeks
Cardiologist Dr. [**Last Name (STitle) **] in [**12-17**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Dental: f/u with your dentist to check vitality of tooth #30
with peri-apical xray after discharge.
Completed by:[**2197-1-31**]
|
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.33",
"35.21",
"39.61",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
19337, 19410
|
14900, 17112
|
243, 308
|
19712, 19712
|
4030, 13855
|
20599, 21102
|
3455, 3475
|
17607, 19314
|
19431, 19691
|
17138, 17584
|
13872, 14876
|
19934, 20576
|
2429, 3097
|
3490, 4011
|
184, 205
|
337, 2158
|
19726, 19910
|
2202, 2406
|
3114, 3439
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,916
| 174,115
|
21984
|
Discharge summary
|
report
|
Admission Date: [**2129-10-14**] Discharge Date: [**2129-10-24**]
Date of Birth: [**2066-4-17**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This patient is a 63-year-old
man with past medical history significant for diverticulitis
and ventral hernia repair with mesh who presented to the ER
at 2 a.m. with 12 hours of abdominal distention, nausea,
vomiting x1, and pain, which the patient described as being
more like fullness. He denied any fever or chills, chest
pain, or shortness of breath. These symptoms have not
happened previously.
PAST SURGICAL HISTORY: Notable for a colostomy and colonic
resection in [**2119**] for perforated diverticulitis, which was
subsequently reversed and a ventral hernia repair with mesh
in [**2127**]. The patient has also had a right total hip
replacement.
PAST MEDICAL HISTORY: Ankylosing spondylitis.
ALLERGIES: The patient has no known drug allergies.
CURRENT MEDICATIONS:
1. Hydrochlorothiazide 12.5 mg.
2. Toprol 50 mg.
3. Diovan 80 mg.
4. Piroxicam 20 mg for arthritis and the ankylosing
spondylitis.
SOCIAL HISTORY: The patient smokes one to two cigarettes per
week and is a social drinker.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.2 degrees,
pulse 86, blood pressure 125/99, respiratory rate 16, and
saturating at 97 percent on room air. Lungs are clear to
auscultation bilaterally. Heart is regular rate and rhythm.
Abdomen is soft and somewhat distended with diffuse mild
tenderness. The patient has no rebound. No evidence of
hernia. Rectal examination is without masses and guaiac
negative.
LABORATORY DATA: On transfer from the outside hospital,
white count 17.6, hematocrit of 48.1. Chem-7 within normal
limits, although notation is made of a creatinine of 1.2.
HOSPITAL COURSE: The patient was seen and examined by Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The initial plan on
his presentation was to place a nasogastric tube, make the
patient n.p.o., hydrate with IV fluids, and attempt
nonoperative management depending on the patient's clinical
course.
Later on that evening, however, it was felt that the patient
was appearing to have developed a complete obstruction and
the patient was taken to the operating room for an
exploratory laparotomy and extensive lysis of adhesions.
Please refer to the operative note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57554**]
for more details on that operation. Due to the patient's
history of ankylosing spondylitis and a very difficult
intubation, postoperatively, the patient was transferred to
SICU where he had a stable course without significant
incident.
On postoperative day two, [**2129-10-16**], the patient was
transferred to the floor. Vital sings were stable. Breath
sounds continued to be somewhat coarse. Physical examination
was otherwise unremarkable. The patient's wound was noted to
be clean, dry, and intact. The patient was encouraged to
ambulate as much as possible and was given aggressive
pulmonary toilet with regards to incentive spirometer use and
early ambulation. Pain control was managed with the patient-
controlled analgesia pump. On [**2129-10-18**], it was noted that
the patient's condition continued to improve. Note was made
of slight erythema at the left margin of his incision and the
abdomen was otherwise soft. No focal tenderness. Due to the
patient's improving clinical status, the nasogastric tube was
discontinued on [**2129-10-18**] and his diet was advanced to sips
and clear liquids. The Foley was taken out and the patient
continued to improve.
On [**2129-10-19**], the patient continued to improve, although it
was noted that he felt a slight bloating sensation even on
the clear sips and the patient's diet was not advanced
further that day. Late in the evening of [**2129-10-19**], in fact
at 12:30 a.m. on [**2129-10-20**], house staff was called to see the
patient for a ten-beat run of ventricular tachycardia on the
telemetry monitor. The patient was also complaining of left
shoulder pain that was focal and nonradiating. The patient
denied diaphoresis or shortness of breath, although he did
have a slight episode of nausea prior to the event. Note was
made of a significantly elevated blood pressure to 190/100,
other vital signs were unremarkable. The patient was given a
1 mg of morphine sulfate for pain control and an increased
dose of intravenous Lopressor. The patient's blood pressure
came down to 180/102. The patient was alert, somewhat
anxious, and was not diaphoretic. Heart was regular rate and
rhythm. Lungs were clear to auscultation. A 12-lead EKG was
performed and no change was appreciated from his EKG of
[**2129-10-15**]. Other measures initiated at that time were to
restart the patient on his home dose of Diovan, increase his
IV Lopressor dose to 10 mg q.6 h. He was started on aspirin
325 mg and was given an order for Nitro paste as necessary
and electrolyte check in the morning. Results of stat
chemistry showed a low magnesium of 1.4; this was
appropriately repleted; and on recheck, the patient's
magnesium rebounded to 2.6. The patient was once again made
n.p.o., although the NG tube was not replaced.
Throughout the day of [**2129-10-20**], the patient continued to do
well and tolerated limited p.o. intake. After being
initially n.p.o. that morning, he was seen and examined by
the attending once again. After this hypertensive event, his
blood pressures had stabilized to 165/91. His cardiac
enzymes were negative for infarction. The patient's diet was
gradually advanced; and on [**2129-10-23**], the patient was given a
regular diet, which he tolerated well. Also on [**2129-10-23**], the
patient had one bowel movement, which was considered an
encouraging sign of return of bowel function. He was
transitioned to entirely oral medicines. The patient
continued to do well throughout the day. On [**2129-10-24**], the
patient was once again feeling very well. His abdominal
examination was reassuring. The incision was noted to be
clean, dry, and intact. It was decided to discharge the
patient home in good condition.
DISCHARGE MEDICATIONS: The patient was discharged home on
his customary cardiac regimen of 50 mg Toprol XL q.d., 80 mg
of Diovan q.d., and 12.5 mg of hydrochlorothiazide q.d.
DISCHARGE INSTRUCTIONS: The patient was given instructions
to return to see Dr. [**Last Name (STitle) **] in one week for removal of the
staples.
DISCHARGE DIAGNOSES: Partial small bowel obstruction.
Ankylosing spondylitis.
Postoperative hypotension.
Postoperative volume depletion.
Acute hypertensive crisis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**]
Dictated By:[**Doctor Last Name 55789**]
MEDQUIST36
D: [**2129-10-24**] 14:00:28
T: [**2129-10-25**] 02:55:53
Job#: [**Job Number 57555**]
|
[
"998.2",
"401.9",
"427.1",
"276.5",
"560.81",
"997.1",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"38.91",
"38.93",
"46.73"
] |
icd9pcs
|
[
[
[]
]
] |
6602, 7013
|
6279, 6432
|
1813, 6255
|
6457, 6580
|
612, 846
|
969, 1105
|
185, 588
|
1234, 1795
|
869, 948
|
1122, 1219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,234
| 120,074
|
25241
|
Discharge summary
|
report
|
Admission Date: [**2153-7-30**] Discharge Date: [**2153-7-31**]
Date of Birth: [**2115-12-18**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
left foot cellulitis, Benzodiazepine overdose
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr. [**Known lastname **] is a 37 YOM with past medical history of bipolar
disorder, schizoaffective disorder, polysubstance abuse
including cocaine and heroin, previous admission [**5-26**] for
altered mental status, thought secondary to benzodiazepine
toxicity/overdose and polypharmacy requiring admission to the
ICU for unresponsiveness, who presented to the ED tonight
because of lethargy and ?cellulitis.
.
Last week the patient spilled hot water on his left foot and
developed increased redness, pain, and pus over the dorsum of
his foot. He denied fevers. He called [**Company 191**] on [**7-28**] and an appt
was booked for today, but he cancelled this appt. His PCA was
concerned about the foot and called EMS. When they arrived, the
pt was found to be lethargic, Ox2, and agitated and they found
multiple pills in a bag that were not prescribed to him. He was
then brought to the ED.
.
Of note, the patient has made frequent requests to [**Company 191**] for
narcotics in the setting of various injuries, and has a history
of being prescribed benzodiazepines from multiple different
providers. He was hospitalized in [**Month (only) **] for altered mental
status. Urine tox at that time was positive for benzos,
amphetamines, and cocaine. He was section'd 12 by psych and
admitted to ICU though he was not intubated. He had no signs of
withdrawal and at discharge a duel diagnosis program was
recommended to him.
.
In the ED, VS were: 98.9 102 121/83 16 99% RA. Exam notable for
somnolent, intermittantly arousable, and only minimally
responsive to pain. Pupils [**3-18**]; L dorsal apect of foot had a
2x2 inch area of ulceration with overlying pus?/eschar with
surrounding erythema. he did not have his pill bottles with
him. Labs showed WBC 19.4, Hct 38.9, positive benzos and
cocaine on tox screen, negative for barbituates, opiates,
amphetamines. UA showed 24 RBCs and 10 WBCs, 30 prot. Blood
cultures were drawn. The patient was intubated for altered
mental status. He was given propofol, 1 gm vancomycin, and 1 L
IVF. Wet to dry dressing was placed on his foot. CXR showed
left > right sided mild opacities. Toxicology was consulted who
recommended repeating the EKG Q 3 hrs. The patient was admitted
to the ICU for ventilator management and treatment of altered
mental status. He had a foot film on the way up to the unit.
.
On the floor, pt arrived sedated and intubated. He could not
follow commands.
.
Review of systems:
Unable to obtain
Past Medical History:
- h/o head trauma
- substance abuse
- bipolar disorder
- schizoaffective disorder
- hepatitis C genotype II, followed by Dr. [**First Name (STitle) 2643**]
- hyponatremia
- polysubstance abuse incluidng cocaine, heroine, trazodone
- chronic leukocytosis of unclear etiology
- history of splenectomy
.
PAST SURGICAL HISTORY:
1. Multiple trauma secondary to motor vehicle crash in [**2146**].
2. Bilateral rib fractures.
3. Jaw fracture, status post bilateral mandibular repair.
4. Status post splenectomy in [**2146**] secondary to motor vehicle
accident.
5. Right post tib-fib patellar repair.
6. Right shoulder surgery for dislocations, multiple times.
Social History:
(obtained per OMR record [**2-23**])
He is disabled secondary to his psychiatric illness and does not
currently work. He was incarcerated from [**2148**] to [**2150**] for
assault and battery. Is MSM. Smoked 1 pack per day since [**54**].
History of cocaine, heroin, marijuana. Denied etoh use for the
past 12 years.
Family History:
(per OMR)
DM in both grandparents.
Physical Exam:
Admission Exam:
Vitals: T: BP: 128/71 P: 66 R: 13 O2: 100%
CMV Assist, FiO2 100%, Tv 500, PEEP 5
General: sedated, does not follow verbal command, intubated
HEENT: Sclera anicteric, MMM, pupils reactive
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no rhales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-distended, bowel sounds present, no
hepatomegally
GU: foley
Ext: warm, well perfused, 2+ pulses, no edema. left dorsum of
foot 4cm by 6 cm depressed ulceration with fibrinous eschar, non
oozing on top. Mildly erythematous borders with erythema and
warmth extending to the toes, no fluctuence
Pertinent Results:
Admission Labs:
[**2153-7-30**] 10:35PM BLOOD WBC-19.4* RBC-4.33* Hgb-13.5* Hct-38.9*
MCV-90 MCH-31.1 MCHC-34.6 RDW-13.9 Plt Ct-399
[**2153-7-30**] 10:35PM BLOOD Neuts-57.0 Lymphs-30.7 Monos-6.8 Eos-4.7*
Baso-0.8
[**2153-7-30**] 10:35PM BLOOD Plt Ct-399
[**2153-7-30**] 10:35PM BLOOD Glucose-120* UreaN-7 Creat-0.7 Na-137
K-3.6 Cl-102 HCO3-27 AnGap-12
[**2153-7-30**] 10:35PM BLOOD ALT-78* AST-42* AlkPhos-94 TotBili-0.1
[**2153-7-30**] 10:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2153-7-30**] 10:46PM BLOOD Lactate-1.0
.
CXR [**2153-7-30**]
1. ETT ends approximately 5 cm above the level of the carina.
Recommend
advancing by 2 cm.
1. NG tube side port is near the GE junction. Recommend
advancing.
2. Mild asymmetric pulmonary edema, left greater than right.
.
Foot Xray [**2153-7-31**]: No radiographic evidence for osteomyelitis
Brief Hospital Course:
Mr. [**Known lastname **] is a 37 YOM with a history of polysubstance abuse and
polypharmacy who presented with worsening left lower foot
erythema after burn injury and was found to be altered and
unable to protect his airway in setting of likely toxic
ingestion and was intubated in the ED. Serial ECGs were
monitored without significant OTc prolongation. He was extubated
the morning after admission without difficulty. Pt described
having taken extra Lyrica in hopes of helping the pain from his
boot burn. He denied suicidal intention. Pt was given vanc
overnight for his foot which was concerning for cellulitis.
There was also the plan to get a heme consult to evaluate his
chronic leukocytosis. However, once extubated, the patient was
insistent on leaving the hospital. The risks and benefits of
leaving were discussed with the ICU team and psych, can both
felt the patient had the capacity to make the decision to leave.
Pt decided to leave the hospital against medical advice. He
states that he plans to make an appointment at [**Hospital **].
Medications on Admission:
ALPRAZOLAM [XANAX] 2 mg tab QID (not prescribed by PCP)
BUPROPION HCL 150 mg ER [**Hospital1 **] (not prescribed by PCP)
CLONAZEPAM 1 mg TID (not prescribed by PCP)
GABAPENTIN - 800 mg QID
IBUPROFEN - 800 mg TID PRN
LAMOTRIGINE 200 mg [**Hospital1 **] (not prescribed by PCP)
OMEPRAZOLE - 20 mg Qday
OXCARBAZEPINE [TRILEPTAL] dosage uncertain (not prescribed by
PCP)
POLYETHYLENE GLYCOL PRN
PREGABALIN [LYRICA] - 150 mg TID
PREGABALIN [LYRICA] - 75 mg TID PRN
RANITIDINE HCL - 300 mg QHS
SELENIUM SULFIDE - 2.5 % Suspension - 2 x a week
TEMAZEPAM [RESTORIL] 30 mg QHS
TRAMADOL - 50 mg QID (recently stopped)
TRIAMCINOLONE ACETONIDE - 0.05 % Ointment [**Hospital1 **] PRN
DOCUSATE SODIUM - 100 mg Qday
MULTIVITAMIN WITH MINERALS Qday
NICOTINE - 21 mg/24 hour Patch 24 hr - Qday
SENNOSIDES [SENNA] - 8.6 mg Qday
Discharge Medications:
left AMA
Discharge Disposition:
Home
Discharge Diagnosis:
left AMA
Discharge Condition:
left AMA
Discharge Instructions:
left AMA
Followup Instructions:
left AMA
|
[
"305.40",
"780.09",
"296.80",
"969.4",
"E854.3",
"945.22",
"070.70",
"E853.2",
"682.7",
"970.81",
"305.60",
"E924.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7491, 7497
|
5542, 6597
|
353, 365
|
7549, 7559
|
4643, 4643
|
7616, 7627
|
3915, 3952
|
7458, 7468
|
7518, 7528
|
6623, 7435
|
7583, 7593
|
3223, 3561
|
3967, 4624
|
2859, 2877
|
268, 315
|
393, 2840
|
4659, 5519
|
2899, 3200
|
3577, 3899
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,812
| 185,610
|
42200
|
Discharge summary
|
report
|
Admission Date: [**2193-3-9**] Discharge Date: [**2193-3-15**]
Date of Birth: [**2121-7-14**] Sex: F
Service: SURGERY
Allergies:
novacaine / Lanolin / wool / Biaxin / House Dust / pollen / cats
and dogs / Lidocaine / doxycycline / Zestril
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
left neck abscess
Major Surgical or Invasive Procedure:
[**2193-3-9**]: left neck abscess irrigation and drainage, wound vac
placement
[**2193-3-11**]: washout and primary closure of left neck wound
History of Present Illness:
71 year old female with a history of symptomatic 80% stenosis of
the left carotid artery s/p left carotid endarterectomy with
Dacron patch angioplasty on
[**2193-1-3**] (Dr. [**Last Name (STitle) 1391**]. Postoperatively patient had some mild
pulmonary edema likely due to acute diastolic heart failure and
was aggressively diuresed. She was discharged on [**2193-1-8**] and did
very well. She was seen in clinic by Dr [**Last Name (STitle) 1391**] on [**2193-2-15**] with
incision completely healed and plan for a followup ultrasound in
3 months. Patient presented to [**Hospital 91499**] Medical Center with
5-7 days of worsening left neck pain, swelling and erythema
around the left cervical incision. She has been having
significant chills and night sweats, and fevers up to 101 in the
ED. She denies any chest pain or shortness of breath and has
been having adequate O2 sats on room air.
Past Medical History:
Past Medical History: asthma, COPD, PNA, empyema LLL with
previous CT placement, hx stable pulmonary nodules, HTN,
paroxysmal afib, CAD s/p cath [**2192-11-17**] with non-occlusive
disease, LVEF 55-60% ([**11/2192**]), hyperlipidemia, GERD
Past Surgical History: oophorectomy, left CEA [**2193-1-3**]
Social History:
Remote history of smoking, no alcohol abuse. Lives alone, has
supportive son.
Family History:
Non contributory
Physical Exam:
Vitals: T 98.2, HR 72, BP 129/55, HR 18, O2 98% RA
Gen: A&O, NAD
HEENT: Neck supple. Incision and drain site c/d/i, no
hematoma/drainage/erythema
CV: RRR
Pulm: CTAB
Abd: S/NT/ND
Ext: w/d, no edema
Pulses: all palpable
Pertinent Results:
[**2193-3-9**] 01:40AM BLOOD WBC-16.0*# RBC-3.70* Hgb-11.8* Hct-34.4*
MCV-93 MCH-32.0 MCHC-34.3 RDW-15.4 Plt Ct-314
[**2193-3-14**] 07:15AM BLOOD WBC-10.9 RBC-3.48* Hgb-10.5* Hct-33.2*
MCV-95 MCH-30.2 MCHC-31.6 RDW-15.3 Plt Ct-407
[**2193-3-14**] 07:15AM BLOOD Glucose-87 UreaN-8 Creat-1.0 Na-140 K-4.6
Cl-104 HCO3-24 AnGap-17
[**2193-3-9**] 02:16PM BLOOD CK-MB-1 cTropnT-<0.01
[**2193-3-9**] 06:21AM BLOOD CK-MB-1 cTropnT-<0.01
[**2193-3-9**] 02:16PM BLOOD CK(CPK)-33
[**2193-3-9**] 06:21AM BLOOD CK(CPK)-24*
[**2193-3-14**] 07:15AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.8
[**2193-3-15**] 05:01AM BLOOD WBC-10.3 RBC-3.30* Hgb-10.0* Hct-31.0*
MCV-94 MCH-30.2 MCHC-32.1 RDW-15.2 Plt Ct-428
[**2193-3-15**] 05:01AM BLOOD Glucose-94 UreaN-13 Creat-1.1 Na-140
K-4.2 Cl-103 HCO3-28 AnGap-13
[**2193-3-15**] 05:01AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9
CTA neck ([**2193-3-9**]):
1. Fluid collection in the left side of the neck with
surrounding enhancement
extrinsic to the internal jugular vein, likely an abscess or a
hematoma.
Clinically correlate.
2. Intracranial CTA demonstrates chronic-appearing
occlusion with moyamoya vessels in the region of left middle
cerebral artery.
3. Neck CTA shows calcification at the bifurcation with patent
carotid and
vertebral arteries. Occluded left external carotid is seen with
distal
reconstitution.
4. No evidence of intracranial dural venous sinus thrombosis
visualized but
the superior sagittal sinus is only partially visualized.
5. Degenerative changes are seen in the cervical spine.
CXR ([**2193-3-11**]): In comparison with the study of [**3-9**], the
endotracheal tube tip lies approximately 4.5 cm above the
carina. Nasogastric tube extends to the distal stomach.
Opacification at the right base medially again could reflect
atelectasis or crowding of vessels. In the appropriate clinical
setting, the possibility of supervening pneumonia would have to
be considered. Minimal atelectatic changes are seen at the left
base. No vascular congestion.
Brief Hospital Course:
The patient was admitted to the Vascular Surgery Service. She
was taken urgently to the OR on [**2193-3-9**] for irrigation and
debridement with wound vac placement. She was kept intubated due
to concern for airway compromise and remained in the ICU for
monitoring. She was placed on Vancomycin and Zosyn. She remained
hemodynamically stable not requiring any pressors. She was taken
back to the OR on [**3-11**] for washout and primary closure with a
drain left in place. She was extubated on [**3-11**] without
difficulty. Cultures from the abscess grew Group A strep and her
antibiotic regimen was de-escalated to Penicillin G. An
Infectious Disease consult was obtained and they recommended
adding Clindamycin to cover toxin production. On POD #[**4-4**] she
was transferred out of the ICU to the VICU and her course
remained uncomplicated as follows:
Neuro: The patient remained neurologically intact throughout the
hospitalization. Her post-operative pain was controlled with
Ultram.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. She was maintained on her
home cardiovascular regimen.
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 POD# [**5-6**], 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. Her foley was removed POD #[**5-6**] and she was
voiding without difficulty. She developed non-bloody loose
stools after starting Clindamycin. C.diff Ag was negative x2. If
she continues to have loose stools now that the Clindamycin was
discontinued she will need further workup.
ID: Intitially she was placed on Vancomycin and Zosyn. Initial
WBC was 16 and this normalized post-operatively. Cultures from
the abscess grew Group A strep and her antibiotic regimen was
changed to Penicillin G. Sensitivities are pending. She
initially had a fever to 101 on POD #1 and cultures were sent.
Urine culture was negative x2 and blood cultures were negative
from [**2193-3-9**] with no growth to date on cultures from [**2193-3-12**].
Infectious disease was consulted and Clindamycin was added. They
recommended long-term antibiotic therapy and a PICC was placed
on [**2193-3-14**]. Under guidance from ID her antibiotic regimen was
changed to Ceftriaxone 2g daily. She will continue IV
antibiotics until she follows up with Dr. [**Last Name (STitle) 1391**] in 2 weeks at
which point a decision will be made to continue IV antibiotic or
transition to an oral regimen. She will follow up with
infectious disease and will have weekly CBC, BUN/Cr, and LFTs
sent to the [**Hospital **] clinic. She remained afebrile thereafter.
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; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin, H2
blocker, and Aspirin during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, voiding without difficulty,
and pain was well controlled. She was discharged to rehab and
will follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks for a post-operative
check in addition to follow up in the [**Hospital **] clinic.
Medications on Admission:
spiriva 18 mcg', advair 100mcg-50mcg 1 inh'', singular 10',
metoprolol 50'', hydroxyzine 10', allopurinol 300', ranitidine
150", celexa 40', azelastine 133mcg (0.1%) 2 sprays'', nasonex 2
sprays', ativan 0.25mg prn inability to sleep, amlodipine 2.5',
ASA 325'
Discharge Medications:
1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) dose Intravenous Q24H (every 24 hours) for 4 weeks. dose
7. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
9. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Nasonex 50 mcg/actuation Spray, Non-Aerosol Sig: One (1)
Nasal [**Hospital1 **] (2 times a day).
16. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. azelastine 137 mcg Aerosol, Spray Sig: Two (2) Nasal twice
a day.
18. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for itching: apply to perineum, avoid
mucosa.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
left neck abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for an abscess or infection in the neck. You
had this surgically drained and washed out. You were placed on
intravenous antibiotics and had a PICC line placed to continue
the antibiotics when you leave the hospital.
The staples were removed from the incision and steri-strips were
placed. You should leave this on for 7 days and they will fall
off on their own or you may remove them after 7 days.
You may shower and wash the incision gently with soap and water
then pat dry. No baths or pools for 2 weeks.
Please call your doctor or return to the ER for any of the
following:
*your neck becomes swollen or increasingly painful. The incision
becomes more red or pus drainage.
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.4 (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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**11-18**] lbs) until your follow up appointment.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks. Call his office at
[**Telephone/Fax (1) 1393**] to schedule that appointment. Dr. [**Last Name (STitle) 1391**] sees
patients in [**Location (un) 86**] as well as around the [**Location (un) 86**] area for your
conveinence.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2193-4-2**] 10:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2193-4-16**]
10:30
Completed by:[**2193-3-15**]
|
[
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"493.20",
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"530.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"86.28",
"96.58",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9888, 9981
|
4177, 7945
|
386, 531
|
10043, 10043
|
2163, 4154
|
12308, 12927
|
1892, 1910
|
8256, 9865
|
10002, 10022
|
7971, 8233
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10226, 12285
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1740, 1780
|
1925, 2144
|
329, 348
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559, 1454
|
10058, 10202
|
1498, 1717
|
1796, 1876
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,811
| 191,523
|
31619
|
Discharge summary
|
report
|
Admission Date: [**2173-7-21**] Discharge Date: [**2173-7-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Lower gastrointestinal bleeding
Major Surgical or Invasive Procedure:
embolization of a branch of the ileocolic artery
History of Present Illness:
83 year old woman with a history of recently diagnosed
diverticulosis, hypertension, chronic kidney disease, and
temporal arteritis who presents from OSH with brisk bleeding
from rectum since 8:30 PM [**2173-7-20**]. Her last normal BM was that
morning, and her last meal was 7:00pm that day. Reportedly
passed ~1L BRBPR. Associated syncopal episode at [**Hospital 2725**]
hospital. She has also had LLQ pain for the past several weeks
that prompted a CT 4 weeks ago that reportedly revealed the
diverticulosis. At the OSH ED, her BP was initially 100/50 P in
60's.. Hematocrit 31 (at 10pm on [**2173-7-20**]). She received 2 units
pRBC. Because she continued to have brisk bleeding from her
rectum, she was transferred to [**Hospital1 18**] ED for further management
while the second unit was running.
In ED at [**Hospital1 18**], BP intially 192/70, though was as high as
235/79--both in setting of nausea, P 76 but became bradycardic
-- she was noted to have continued BRBPR and hematocrit returned
at 24.5. An NG lavage was attempted but the patient became
bradycardic & vomitted (brown emesis, no frank blood) during
this procedure. P returned to [**Location 213**] spontaneously. Through the
ED course she continued to have brisk bleeding Her BP ranged
downward to the 100-110 range, P unchanged. Pt passed total of
800cc of BRBPR, 2 additional pRBC were given. She was also given
4 units of platelets because she was reported to be on plavix.
It was decided to send the patient to IR urgently for
embolization.
.
On further questioning, the patient reports she has never had
BRBPR. She does not recall ever having a colonoscopy.
.
Past Medical History:
(from ED & OSH records and daughter)
1) Diverticulosis seen on [**6-/2173**] CT scan
2) Hypertension (Baseline SBP 130s)
3) Anemia (Baseline ~35) on procrit
4) Chronic kidney disease, secondary to one non-functioning
kidney and hypertension (baseline & cause of CRI unclear)
5) Temporal arteritis on steroids
6) Hypercholesterolemia
7) PVD w/ h/o R foot pain and faint pulses
8) Status post surgery for ovarian cancer with peritoneal
seeding in [**2160**]--likely TAHBSO and peritoneal surgery.
9) Status post appendectomy
10) S/p cataract surgery
[**77**]) Spinal stenosis surgery in [**2166**].
Social History:
Lives alone in Senior Development Apartment, independent of
ADL's and active. Former manager of a free health care clinic.
Former smoker, 30 pack years, quit 15 years ago. Does not use
alcohol. Has son and daughter.
Family History:
Mother with HTN
Physical Exam:
T: 98 P 82 BP 187/99 RR 18 O2 97 on RA
Gen: WD/WN African American woman, fully oriented
Eyes: Anicteric, PERRL
Mouth: No lesions.
Neck: Supple
Lungs: CTA anteriorly
Cor: RRR, 3/6 systolic, [**2-13**] diastolic murmur, no gallops/rubs
Abd: S/NT/ND; +BS
Ext: No C/C/E; 2+ rad pulses b/l; 2+ PT pulse in L foot, not
palpable on R foot; LE warm b/l
Pertinent Results:
[**2173-7-22**] 04:40AM BLOOD WBC-9.8 RBC-2.80* Hgb-8.2* Hct-24.5*
MCV-87 MCH-29.4 MCHC-33.7 RDW-16.4* Plt Ct-184
[**2173-7-21**] 01:30AM BLOOD Neuts-79.7* Lymphs-16.3* Monos-3.5
Eos-0.3 Baso-0.1
[**2173-7-22**] 04:40AM BLOOD Glucose-122* UreaN-33* Creat-1.7* Na-141
K-4.5 Cl-112* HCO3-24 AnGap-10
[**2173-7-21**] 03:18PM BLOOD CK-MB-4 cTropnT-0.01
[**2173-7-22**] 04:40AM BLOOD Calcium-8.2* Phos-4.2 Mg-2.4
[**2173-7-21**] 09:47AM BLOOD Lactate-2.0
Mesenteric Angio and Embolization [**2173-7-21**]:
1. Active bleeding in the cecum from the branch of the
ileocolic artery.
2. Uncomplicated embolization of the bleeding branch of the
ileocolic artery with two microcoils with good angiographic
result.
Echo ([**2173-7-22**]):
Hyperdynamic LV w/ LVH (EF>75%)
mild LV diastolic dysfunction
mod LVOTO, no AS
CXR ([**2173-7-22**]):
no pulm edema
enlarged hilar b/l; ?PAH
Brief Hospital Course:
83 year old woman with diverticulosis, hypertension, and [**Hospital **]
transferred from OSH with LGIB. On admission, pt had placement
of 3 large bore IVs, pt was typed and screened. She had active
bleeding in cecum detected on angiography ([**2173-7-21**]). HD1, pt
successfully underwent embolization of ileocolic branch of SMA
per interventional radiology. Pt was transferred to the MICU in
hemodynamically stable condition, Hct 26.6. She initially c/o
nausea and abdominal pain, but symptoms resolved over time. Hct
trended down over 24hrs, with Hct 24.5 on [**2173-7-22**], and 1u pRBCs
was given. GI was consulted, and recommended outpatient f/u
with appt on [**2173-8-24**] for possible colonoscopy.
Pt was transferred to a regular medical floor on HD 2 after
stable HCT for 48 hours and having been hemodynamically stable.
She was transfused 1 unit PRBC's with appropriately increased
HCT to 30.1. She had not had a BM since embolization. HD 4 had
BM w/small amount BRBPR early in AM. HCTs stable at 30.9. Pt was
monitored for 48 hours after with stable HCT. Repeat BM on day
prior to discharge was with brown stool. Pt did not have signs
of bowel ischemia during this admission. Her plavix was held to
be restarted outpt.
.
With regard to her hypertension: Pt was hypertensive with SBP in
180s on arrival to MICU. Home BP meds held initially due to
concern for bleeding, but she was restarted on home Cozaar,
Clonidine, and Norvasc with good response. Atenolol was
initially held. EKG and cardiac enzymes did not suggest a
cardiovascular event.
Atenolol was restarted on HD 4 after pt was hemodynamically
stable throughout hospitalization and continued to be
hypertensive.
.
With regard to her Bradycardia: At OSH, pt was reported to have
become bradycardic during NG tube placement, likely due to vagal
reaction. She did not have any episodes of bradycardia during
this hospitalization.
.
With regard to her Acidosis: Plasma bicarbonate was 16
initially, likely due to GI loss and aggressive colloid and
crystalloid resuscitation (high salt load). Resolved HD 3.
.
With regard to her baseline Anemia, normocytic: chronic causes
likely from CRI and/or anemia of chronic disease on epo
outpatient. Monitored HCT, transfused as above.
.
With regard to her CKD: Cr 1.7 trended down to pt's baseline Cr
of 1.4 with transfusion and IVF.
.
With regard to her Temporal Arteritis: After embolization
procedure, pt was placed on fludrocortisone to substitute her
home prednisone regiment. She was switched back to home
prednisone 5mg po on [**2173-7-22**] and continued on this regiimen
during the rest of her hospitalization.
Medications on Admission:
1) Procrit
2) Plavix 75mg daily
3) Vytorin QPM
4) Clonidine 2mg QAM & 3QPM
5) Atenolol 12.5mg daily
6) Norvasc 10mg daily
7) Cozaar 100mg daily
8) Prednisone 5mg daily
9) Nephrocaps 1tab daily
10 Advair PRN
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
10. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Lower GI bleed
Hypertension
.
Secondary:
PVD
Discharge Condition:
The patient was discharged hemodynamically stable afebrile with
appropriate follow up.
Discharge Instructions:
You were admitted for a GI bleed. It is important that you avoid
medications like ibuprofen and continue to take pantoprazole, a
new medication for you. Your Plavix was stopped because of the
bleeding, this medication should be restarted outpatient when
you see your primary care doctor.
.
Please present to the hospital or call your primary care
provider if you have recurrence of your bleeding, black tarry
stools, chest pain/shortness of breath, fever/chills,
headache/dizzyness.
.
You will need to have a colonscopy in 1 month as recommended by
the GI doctors who saw [**Name5 (PTitle) **] while you were here. This is very
important.
Followup Instructions:
Please follow up with your PCP [**Name9 (PRE) **] [**Name9 (PRE) 74324**],[**Name9 (PRE) **] [**Telephone/Fax (1) 74325**]
within the next 2 weeks. Please do not re-start your Plavix
until you see your primary care doctor.
Please also follow up with your outpatient colonoscopy on
[**2173-8-24**]. Please call ([**Telephone/Fax (1) 2233**] with questions.
Please also follow up with your nephrologist Dr. [**Last Name (STitle) 74326**], a copy
of your discharge summary was faxed to his office.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
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293, 344
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,305
| 112,732
|
8322
|
Discharge summary
|
report
|
Admission Date: [**2190-11-12**] Discharge Date: [**2190-11-17**]
Date of Birth: [**2130-8-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Altered mental status after MVA
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
Please see MICU GREEN admission note for complete HPI. Briefly,
Pt is a 60 yo M with PMHx significant for Hep C cirrhosis c/b
esophageal varices, portal vein thrombus on coumadin, s/p TIPS,
who presented with progressive confusion after MVC. He was
brought by EMS to OSH, where he remained confused and was noted
to have coffee ground emesis. Ethanol level was negative. He
reportedly had a negative head CT and he was intubated for
airway protection and transferred to [**Hospital1 18**], where he was
admitted to the MICU. Hepatology consulted and pt was started
on octreotide, PPI, lactulose and cipro. Hct remained stable
and EGD was deferred. U/S showed stable TIPS, stable velocities,
and unchanged left portal vein thrombus. He had no further
evidence of upper GI bleed and was extubated earlier today. He
is now being transferred to the liver/kidney service for further
management
Past Medical History:
Hepatitis C cirrhosis: history of decompensation with a variceal
bleed in [**2188**] followed by TIPS placement. He is currently listed
as of [**10-29**]. No repeat EGD since TIPS.
Diabetes Mellitus
Hypertension
OSA, being evaluated for CPAP
Chronic back pain, off methadone, on codeine
Social History:
lives with wife and 2 kids 19 and 15 in lunenberg. smokes 1 PPD,
total of ~40pack year history smoking. Denies ETOH, IVDU. Per
pt., likely hepC exposure was through sexual contact
Family History:
h/o DM, no CAD
Physical Exam:
Vitals - T:98.5 BP:143/74 HR:67 RR: 21 02 sat: 97%RA
GENERAL: NAD, lying comfortably in bed
SKIN: warm, pink, numerous scabs over upper extrem b/l
HEENT: NCAT, MMM, no scleral icterus, OP clear, poor dentition
CARDIAC: RRR, nl S1, S2, II/VI soft systolic murmur radiating to
axilla
LUNG: diffusely rhonchorus b/l, partially clears with cough
ABDOMEN: soft, ND, ttp in epigastrium and RUQ (especially over
rt ribs), voluntary guarding, no rebound
EXT: no c/c/e, 2+ peripheral pulse b/l
NEURO: A&Ox2 (not oriented to time), + asterixis
Pertinent Results:
CBC:
[**2190-11-12**] 01:42PM BLOOD WBC-6.3 RBC-2.86* Hgb-9.2* Hct-25.5*
MCV-89 MCH-32.3* MCHC-36.3* RDW-16.4* Plt Ct-56*
[**2190-11-12**] 01:42PM BLOOD Neuts-91.6* Bands-0 Lymphs-4.7* Monos-2.8
Eos-0.7 Baso-0.1
[**2190-11-12**] 07:46PM BLOOD WBC-6.1 RBC-2.91* Hgb-9.6* Hct-26.2*
MCV-90 MCH-32.9* MCHC-36.6* RDW-16.4* Plt Ct-54*
[**2190-11-13**] 05:24AM BLOOD WBC-5.0 RBC-3.10* Hgb-9.9* Hct-28.2*
MCV-91 MCH-31.9 MCHC-35.1* RDW-16.6* Plt Ct-60*
[**2190-11-13**] 01:53PM BLOOD Hct-26.7*
[**2190-11-14**] 05:32AM BLOOD WBC-4.6 RBC-3.19* Hgb-10.5* Hct-28.9*
MCV-90 MCH-33.0* MCHC-36.5* RDW-16.5* Plt Ct-49*
[**2190-11-15**] 06:00AM BLOOD WBC-4.5 RBC-3.11* Hgb-9.9* Hct-27.9*
MCV-90 MCH-32.0 MCHC-35.6* RDW-16.9* Plt Ct-59*
[**2190-11-16**] 05:40AM BLOOD WBC-4.8 RBC-3.14* Hgb-10.2* Hct-28.1*
MCV-90 MCH-32.4* MCHC-36.2* RDW-16.0* Plt Ct-63*
[**2190-11-17**] 06:10AM BLOOD WBC-5.1 RBC-3.26* Hgb-10.5* Hct-29.2*
MCV-90 MCH-32.0 MCHC-35.8* RDW-16.1* Plt Ct-74*
Coags:
[**2190-11-12**] 01:42PM BLOOD PT-15.8* PTT-33.2 INR(PT)-1.4*
[**2190-11-13**] 05:24AM BLOOD PT-15.0* PTT-32.6 INR(PT)-1.3*
[**2190-11-14**] 05:32AM BLOOD PT-14.4* PTT-32.8 INR(PT)-1.2*
[**2190-11-15**] 06:00AM BLOOD PT-14.0* PTT-33.1 INR(PT)-1.2*
[**2190-11-16**] 05:40AM BLOOD PT-14.8* PTT-33.9 INR(PT)-1.3*
[**2190-11-17**] 06:10AM BLOOD PT-15.1* PTT-34.7 INR(PT)-1.3*
Chemistry/Glucose/Renal:
[**2190-11-12**] 01:42PM BLOOD Glucose-208* UreaN-23* Creat-1.7* Na-141
K-4.0 Cl-112* HCO3-20* AnGap-13
[**2190-11-13**] 05:24AM BLOOD Glucose-107* UreaN-24* Creat-1.8* Na-143
K-3.7 Cl-112* HCO3-21* AnGap-14
[**2190-11-13**] 05:24AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9
[**2190-11-14**] 05:32AM BLOOD Glucose-123* UreaN-22* Creat-1.7* Na-143
K-3.4 Cl-112* HCO3-21* AnGap-13
[**2190-11-14**] 05:32AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.7
[**2190-11-15**] 06:00AM BLOOD Glucose-165* UreaN-20 Creat-1.5* Na-144
K-3.5 Cl-110* HCO3-24 AnGap-14
[**2190-11-15**] 06:00AM BLOOD Albumin-3.5 Calcium-8.6 Phos-2.6* Mg-1.8
[**2190-11-16**] 05:40AM BLOOD Glucose-116* UreaN-18 Creat-1.4* Na-143
K-3.7 Cl-112* HCO3-23 AnGap-12
[**2190-11-16**] 05:40AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.6
[**2190-11-17**] 06:10AM BLOOD Glucose-117* UreaN-19 Creat-1.5* Na-143
K-3.7 Cl-109* HCO3-25 AnGap-13
[**2190-11-17**] 06:10AM BLOOD Albumin-3.4 Calcium-8.4 Phos-3.2 Mg-1.5*
LFTs:
[**2190-11-12**] 01:42PM BLOOD ALT-15 AST-28 AlkPhos-74 TotBili-0.9
[**2190-11-13**] 05:24AM BLOOD ALT-18 AST-36 LD(LDH)-282* AlkPhos-85
TotBili-1.1
[**2190-11-14**] 05:32AM BLOOD ALT-16 AST-33 LD(LDH)-270* AlkPhos-86
TotBili-0.9
[**2190-11-15**] 06:00AM BLOOD ALT-15 AST-35 LD(LDH)-281* AlkPhos-85
TotBili-0.9
[**2190-11-16**] 05:40AM BLOOD ALT-20 AST-32 LD(LDH)-275* AlkPhos-85
TotBili-0.9
[**2190-11-17**] 06:10AM BLOOD ALT-17 AST-28 LD(LDH)-272* AlkPhos-82
TotBili-1.0
Lactate:
[**2190-11-12**] 01:53PM BLOOD Lactate-2.3*
Urinalysis:
[**2190-11-12**] 08:44PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2190-11-12**] 08:44PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2190-11-12**] 08:44PM URINE RBC-9* WBC-2 Bacteri-FEW Yeast-NONE Epi-0
[**2190-11-12**] 08:44PM URINE Mucous-RARE
[**2190-11-12**] 01:42PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2190-11-12**] 01:42PM URINE Blood-LG Nitrite-NEG Protein-
Glucose-100 Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
[**2190-11-12**] 01:42PM URINE RBC-[**6-30**]* WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
Blood/Urine/CSF culture: No growth to date
Brief Hospital Course:
# AMS: The patient was believed to have hepatic
encephalopathy--potentially secondaryy to medication
non-compliance--as workup for other causes of altered mental
status was unrevealing. Upon arrival on the floor, the patient
was continued on lactulose and rifaximin. His home codeine was
held, so as to not exacerbate his altered state. He was
initially oriented to only person and place, but not date.
Within 2-3 days, however, the patient was fully oriented and his
mental status was much clearer. He was discharged with clear
instructions to take his medications as directed. He was also
clearly instructed to not drive.
# Upper GI bleed: Reported at outside hospital. At [**Hospital1 18**], he was
hemodynamically stable, and did not have hematemesis or
hemoptysis. He was continued on a PPI and his home propanolol.
His hematocrit was generally stable, and slowly improved during
the admission. He remained stable on the floor for several days,
then underwent upper endoscopy, which revealed portal
hypertensive gastropathy and duodenitis. No interventions were
performed.
# Pain control: The patient complained of right side and RUQ
pain when palpated directly, but did not appear excessively
uncomfortable at any time. Chest x-rays revealed a healing rib
fracture. His home codeine, taken for low back pain, was held
for mental status. He was given lidocaine transdermal patches at
the site of his pain, with moderate analgesic effect.
# Hypertension: The patient did not come to the floor on an
anti-hypertensive regimen, and was started on amlodipine 5 mg
daily. This was increased to 10 mg daily on the day of
discharge.
# Diabetes Mellitus: Patient's blood glucose well controlled on
his home dose of lantus and sliding scale
# CRI: Creatinine was at baseline on the day of discharge
# History of portal vein thrombosis: Stable by ultrasound on
admission. The patient's warfarin was held given concern for
upper GI bleed at the outside hospital
Medications on Admission:
codeine 60 mg q4 hrs
glipizide ER 20mg PO daily
Metformin 500 mg TID
Lantus 22 units qhs
lactulose 30 mg TID
Prilosec 40mg PO daily
paroxetine 20mg PO daily
warfarin 5 mg daily
Propranolol 80mg PO daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
[**Hospital1 **]:*60 Tablet(s)* Refills:*0*
2. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H
(every 4 hours).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical 12 hours on, then
twelve hours off as needed for pain.
[**Hospital1 **]:*10 Adhesive Patch, Medicated(s)* Refills:*0*
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
[**Hospital1 **]:*180 Tablet(s)* Refills:*0*
7. Lantus 100 unit/mL Solution Sig: Twenty Two (22) Units
Subcutaneous at bedtime.
8. Propranolol 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: Two (2)
Tablet Extended Rel 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic encephalopathy
.
Hepatitis C cirrhosis
Diabetes Mellitus
Hypertension
Obstructive sleep apnea
Discharge Condition:
Awake, alert, oriented. Medically stable for discharge home.
Discharge Instructions:
Mr [**Known lastname **],
.
You were transferred to the intensive care unit at [**Hospital1 18**] for
mental status changes, following your motor vehicle accident.
There was concern that you may have been confused while driving.
You were also noted to have some blood in your vomit at the
other hospital, so there was also some concern that you may have
had an internal bleed.
.
You were transferred to the liver/kidney floor where you
underwent an upper endoscopy, which did not reveal any
significant bleeding in your esophagus, stomach, or intestine.
You recovered from the procedure without any difficulty, and
were medically stable to be discharged home.
.
We made the following changes to your medications:
-Please take AMLODIPINE 10 mg by mouth DAILY for blood pressure
-Please take RIFAXIMIN 200 mg by mouth THREE TIMES DAILY
-Please use LIDOCAINE transdermal patches over your ribs for
pain relief
.
Please keep your appointment in the [**Hospital1 **] clinic [**12-8**] @
2:40 PM. Please call [**Telephone/Fax (1) 673**] if you need to reschedule the
appointment.
.
Please call your doctor or return to the Emergency Department if
you experience any severe abdominal pain, nausea, or vomiting,
or if you have any blood in your vomit. Please keep your
scheduled follow up appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2190-12-8**] 2:40
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2191-1-5**]
11:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2191-1-5**] 1:40
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,226
| 105,929
|
34000
|
Discharge summary
|
report
|
Admission Date: [**2195-8-2**] Discharge Date: [**2195-8-7**]
Date of Birth: [**2116-12-21**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
dyspnea and altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78 yo F with Afib on coumadin, CHF (EF 55-60 [**2192**]), stroke, CAD
(MI [**2182**]), HTN and asthma p/w mental status changes and dyspnea.
History is limited by pt's mental status. Per nurse [**First Name (Titles) **] [**Name (NI) 78493**] pt is usually A&O x3. This morning she was agitated
and having increased dyspnea. Given Nebs @ 12:00 and Ativan
without relief. Transported to hospital by EMS for further
evaluation. Of note, patient's baseline weight is 168lbs (which
she was close to at discharge on [**2195-6-3**]) and today is 198.8lbs.
Patient is additionally having back pain.
.
In ED VS were 97.5 72 110/72 20 97% RA. CBC significant for WBC
of 11.8, hct 35.2. Chem7 significant for Cr 2.4 (baseline
1.0-1.2, [**5-/2195**]), UA negative, lactate 1.2, INR 3.3. BNP [**2141**]
(increased from 827 on [**5-/2195**]), trop neg X1, LFTs WNL. Blood
cultures drawn. Given Naloxone for AMS because of history of
recently being started on oxycodone- did not help mental status.
CXR showed mild pulmonary edema. Head CT prelim read showed no
acute changes.
.
On transfer, pt's vitals were: 98.4 Tc rectally, HR 67, BP
126/58, RR 22, 99%2L NC. On the floor, the patient is confused
and not appropriately answering questions. Unable to get good
HPI. Patient's only complaint is her lower back pain.
Past Medical History:
CAD s/p MI [**2182**]
Atrial fibrillation on coumadin
h/o stroke [**2177**] left PCA and right superor MCA infarcts
diastolic CHF, EF 55-60% in [**12-31**]
Hypertension
Hypercholesterolemia
Pulmonary hypertension
Asthma
Allergic rhinitis
GERD
Social History:
The patient lives alone in senior housing at Springhouse in JP,
but lives 2 blocks away from her daughter. She moved here from
[**Male First Name (un) 1056**] many years ago.
She has never smoked, does not drink EtOH, or use illicit drugs.
Family History:
There is family history of hypertension and asthma.
Physical Exam:
Admission PE:
VS: 96.5, 106/53, 65, 18, 97%RA
General: easily arousable and wakeful, but incoherent and not
answering question, A&OX2, NAD
HEENT: PERRLA. MMM.
NECK: No LAD, JVP 6-7cm. Neck supple.
Cardiovascular: Irregularly irregular. Normal S1/S2. [**1-25**]
systolic murmur. No gallops/rubs.
Pulmonary: CTAB, no wheezes, rales, rhonchi. Equal breath sounds
bilaterally, good air exchange.
Abd: Soft, NT, minimally distended, +BS. No HSM.
Extremities: WWP, no cyanosis/clubbing, 3+ edema. DPs, PTs 2+.
Skin: No rash, ecchymosis, or lesions.
Neuro/Psych: confused, and not cooperating with interview. Only
repeating interpreter's questions and thanking her.
Discharge PE:
Brief Hospital Course:
78 yo F with Afib on coumadin, CHF (EF 55-60 [**2192**]), CVA, CAD (MI
[**2182**]), HTN and asthma initially admitted to medical floors with
mental status changes and dyspnea. became somnolent on [**8-5**],
found to have respiratory acidosis, presumed CO2 narcosis,
transferred to CCU for bipap on [**8-6**].
.
Patient with known diastolic CHF and history of CAD/MI is
presenting with dyspnea, a 30lb weight gain, satting 97% on RA.
CXR and physical exam shows mild pulmonary edema suggestive of
fluid overload, likely due to CHF exacerbation. Ruled out for
ACS with 2 sets of trops. ECG unchanged from baseline. Patient
does not appear to be infected- no productive cough or signs of
consolidation on exam, CXR did not show evidence of
consolidation. Pt was aggressively diuresed, developed
contraction alkalosis and on [**8-5**] became somnolent. Abg at this
time revealed hypercarbic respiratory failure. Echo was
performed which showed aortic stenosis, mild MR, 3+ TR, and
moderate pulmonary hypertension. She was transferred to the CCU
on [**8-6**] for Bipap and after 3 hrs self d/ced bipap mask,
somnolence resolved. O2 sats were normal on RA. However, pt
became increasingly agitated overnight and by morning of [**8-7**] O2
saturations dipped into 80s and SBP went into 190s. Concern for
flash pulmonary edema, but CXR looked unchanged from baselines.
Blood pressures improved on nitro gtt, and bipap was restarted.
Pt's O2 saturations initially improved on BIPAP but after
several hours she became hypoxic again. Pt was being prepared
for intubation, pt's next of [**Doctor First Name **] was contact[**Name (NI) **] the decision was
made to make pt [**Name (NI) 835**]. She continued to deteriorate and next of
[**Doctor First Name **] made decision to make pt [**Name (NI) 3225**]. She was given ativan and IV
morphine and expired at 16:02 on [**2195-8-7**].
.
Medications on Admission:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for prn breakthrough pain.
4. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
10. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for dizziness.
11. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed for constipation or gas
pains.
16. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
30 min prior to lasix.
17. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Diphenhist 25 mg Capsule Sig: One (1) Capsule PO at bedtime
as needed.
19. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
20. azelastine 137 mcg Aerosol, Spray Sig: One (1) spray Nasal
once a day.
21. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for wheezing, sob.
22. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for SOB.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"493.00",
"V12.54",
"414.01",
"424.1",
"428.33",
"724.5",
"300.4",
"530.81",
"416.8",
"584.9",
"412",
"V58.61",
"276.3",
"V49.86",
"293.0",
"428.0",
"518.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6918, 6927
|
2981, 4868
|
336, 342
|
6974, 6979
|
7031, 7037
|
2214, 2268
|
6889, 6895
|
6948, 6953
|
4894, 6866
|
7003, 7008
|
2283, 2943
|
2958, 2958
|
263, 298
|
370, 1673
|
1695, 1940
|
1956, 2198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,798
| 133,311
|
40648
|
Discharge summary
|
report
|
Admission Date: [**2193-6-10**] Discharge Date: [**2193-6-18**]
Date of Birth: [**2107-5-18**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
L SDH
Major Surgical or Invasive Procedure:
Left Sided Craniotomy for Subdural Hematoma Evacuation
History of Present Illness:
[**Known lastname 63347**] is a 86 yo man with baseline dementia, CAD, TIAs,
s/p endovascular repair of AAA. His baseline functional status
is
not well known.
He presents from [**Hospital3 26615**] hospital after being admitted there
on [**6-9**] with worsening confusion and walking difficulty. There,
a
CT showed a left parietal SDH, approx 1cm in depth. At first,
family wanted supportive care for this, however, they later
changed their mind and opted for transfer to a tertiary care
facility so pt was transferred here.
Past Medical History:
1. Dementia
2. CAD
3. TIAs
4. s/p endovascular repair of AAA.
Social History:
Lives at home. No Tob, EtOH use
Family History:
Mother with stroke
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro: Opens eyes to voice. Cannot reliably follow simple
commands. Mumbles incomprehensibly with some dysarthria. Pupils
2
to 1mm. face symmetric. Moving all extremities anti-gravity with
perhaps some mild R arm weakness.
Pertinent Results:
CT Head [**2193-6-10**] 9:20 PM
IMPRESSION: Unchanged moderate left subdural hematoma with acute
and
non-acute blood products. Associated mass effect on the brain is
relatively mild due to extensive cerebral atrophy, but mild
rightward shift of normally midline structures is present.
CT Head [**2193-6-11**] 8:33 AM
IMPRESSION: Unchanged moderate left subdural hematoma with acute
and nonacute blood products. Unchanged associated mass effect.
CT Head Post-OP [**6-13**]
The study is slightly limited secondary to patient motion. The
patient is status post left parietal craniotomy. There is a
large volume of subcutaneous gas along the left side of the
cranium and a small amount of pneumocephalus with gas seen
subjacent to the craniotomy site as well as anteriorly
bilaterally. The left subdural hematoma has been evacuated and
now there is only a trace amount of subdural blood and fluid
remaining. There is no new intracranial hemorrhage or vascular
territorial infarction. The degree of mass effect of the left
subdural fluid is also decreased as expected. Ventricles and
sulci are enlarged, reflecting parenchymal volume loss. Note is
made of periventricular white matter hypodensity indicating
chronic microvascular infarction. Punctate calcifications in the
basal ganglia are bilateral. Note is made of dense
atherosclerotic vascular calcification.
Brief Hospital Course:
86 y/o M with baseline dementia and on anticoagulation presents
s/p multiple falls with Left SDH. He was transferred from OSH
for further neurosurgical intervention. Patient was admitted to
ICU for monitoring. Serial Head CTs were stable and patient was
transferred to the step down unit with a plan His mental status
improved greatly over 2 days and in the morning on [**6-12**] he was
alert, attentive and following commands. He went to the
operating room on the afternoon of [**6-13**] for evacuation of his
SDH. He toelrated the procedure wellm, was extuabted in the OR
and trasnferred to the PACU for further monitoring. His post-op
Head CT should expected changes and on the morning of 5.20 he
was downgraded to floor status and stayed in the PACU overnight
and then trasnferred to SICU in stable condition. He had an
uncomplicated ICU course. He was transferred to floor in stable
condition. He was found to have a low dilantin level and was
re-bolused. His most recent phenytoin level was 9.9.
PT/OT/speech and nutrition were consulted. He was started on
calorie counts. His mental status although sporadic remained
stable during his floor course.
Now DOD, he is afebrile, VSS, and neurologically stable. He is
tolerating an oral diet although marginal PO intake and voiding
spontaneously. His incision is clean, dry and intact. He is
set for discharge to rehab in stable condition and will
follow-up with Dr. [**Last Name (STitle) **] accordingly.
Medications on Admission:
1. Nitro paste
2. Lisinopril 20mg daily
3. Zofran 4mg PRN
4. Protonix 40mg daily
Discharge Medications:
1. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H
(every 6 hours) as needed for chest pain.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Left SDH
hypokalemia
dysarthria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? 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 were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this on until follow-up with Dr. [**Last Name (STitle) **]
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed
?????? 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, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2193-6-18**]
|
[
"781.94",
"443.9",
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"414.01",
"294.8",
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"716.90",
"432.1",
"276.8",
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] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
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] |
icd9pcs
|
[
[
[]
]
] |
6003, 6075
|
2914, 4384
|
315, 372
|
6151, 6151
|
1527, 2891
|
8037, 8398
|
1079, 1100
|
4516, 5980
|
6096, 6130
|
4410, 4493
|
6302, 8014
|
1115, 1508
|
269, 277
|
400, 928
|
6166, 6278
|
950, 1014
|
1030, 1063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,837
| 142,118
|
53367
|
Discharge summary
|
report
|
Admission Date: [**2158-3-14**] Discharge Date: [**2158-3-25**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Pain, nausea, emesis
Major Surgical or Invasive Procedure:
Exploratory laparotomy, Extensive lysis of adhesions, and Small
bowel resection on [**2158-3-17**]
History of Present Illness:
The patient is an 85 y/o F with PMHx significant for HTN, COPD,
and DJD, who was admitted to the surgical service on [**2158-3-14**]
with abdominal pain, nausea, and bilious emesis. She reports
that these symptoms began 5 days prior to her presentation. They
were waxing and [**Doctor Last Name 688**] in nature. At the time of presentation,
she had not had a bowel movement in approximately 3 days.
.
On presentation to the ED, the patient had an NGT tube placed
for decompression in the setting of a suspected SBO. She was
admitted to the surgical service, where she was monitored for
several days. When her symptoms did not improve over several
days, the patient was brought to the OR for ex lap. During her
ex lap this afternoon, she was found to have a segemnt of small
bowel that was adhered to the mesh from a previous hernia
repair. She underwent resection of this segment of small bowel
as well as lysis of other adhesions. Her surgical procedure was
ultimately longer than planned (3.5 hours). She also reportedly
did not get as much fluid resuscitation as she should have
during surgery. As a result, she developed hypotension in the
intra- and post-operative period. UOP was reportedly low
(0-30/hr in the PACU). She was given albumin (32.5 gm total),
bolused 2L LR, and started on LR at 150 cc/hr. SBP was
reportedly in the 90's in the PACU (baseline in the 140's). She
is now admitted to the [**Hospital Unit Name 153**] for monitoring of her blood pressure
overnight.
.
On arrival to the [**Hospital Unit Name 153**], the patient's VS were T: 96.2 BP: 105/55
P: 91 R: 20 O2: 91% on 3LNC. She complained of abdominal pain
and nausea. She denied any chest pain or shortness of breath.
She reported that she did feel very thirsty. She denied any
other complaints. She reported that her last BM was last Sunday;
she also denied passing flatus. She described her emesis as
biliary.
Past Medical History:
Past Medical History (per pt, [**Name (NI) **], and surgery admit note):
- HTN
- COPD
- DJD
- Osteoporosis
- Psoriasis
- Varicose veins with chronic varicose dermatitis
.
Past Surgical History:
- cholecystectomy via a midline exlap
- incisional hernias s/p repair at [**Hospital **] Hospital reportedly
by Dr. [**Last Name (STitle) **]
- cataract surgery left eye
- excision of a vocal cord polyp
Social History:
Remote smoking history; quit ~20 years ago. Admits to occasional
alcohol use. Retired. Used to work in sales.
Family History:
Reports cancer in her father (unknown type). Daughter died of
lung cancer. Does not report any other family history.
Physical Exam:
Vitals: T: 96.2 BP: 105/55 P: 91 R: 20 O2: 91% on 3LNC
General: Alert; NAD; oriented to person, place, and time
HEENT: NC/AT; Sclera anicteric; Dry MM; some submandibular LAD
bilaterally; JVP not elevated
Lungs: Non-labored breathing; lungs CTA anteriorly with
diminised breath sounds in the lower lung fields; no wheezes or
rhonchi noted
CV: RRR; No murmurs, rubs, or gallops appreciated
Abdomen: Diffuse mild tenderness to palpation; surgical site
present with dressing intact in the the midabdomen; no masses
appreciated; minimal BS present
GU: Foley present
Ext: Cool; no cyanosis; no significant pitting LE edema; 2+ DP
pulses present bilaterally
Neuro: Alert; oriented x 3; grossly non-focal
Pertinent Results:
[**2158-3-14**] 01:05PM GLUCOSE-119* UREA N-29* CREAT-1.5* SODIUM-138
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-30 ANION GAP-18
[**2158-3-14**] 01:05PM ALT(SGPT)-16 AST(SGOT)-15 ALK PHOS-97 TOT
BILI-1.0
[**2158-3-14**] 01:05PM LIPASE-20
[**2158-3-14**] 01:05PM ALBUMIN-4.8 PHOSPHATE-4.0 MAGNESIUM-1.8
[**2158-3-14**] 01:05PM WBC-12.0* RBC-5.60* HGB-16.8* HCT-49.3*
MCV-88 MCH-30.1 MCHC-34.2 RDW-15.5
[**2158-3-14**] 01:05PM NEUTS-85.8* LYMPHS-10.1* MONOS-3.6 EOS-0.2
BASOS-0.4
[**2158-3-14**] 01:05PM PLT COUNT-232
[**2158-3-14**] 01:05PM PT-12.9 PTT-22.4 INR(PT)-1.1
.
[**3-14**] KUB: IMPRESSION: Findings are consistent with early small
bowel obstruction.
.
[**3-14**] CT abd/pelvis:IMPRESSION:
1. High-grade small-bowel obstruction with transition point at
the anterior
abdominal wall surgical wound, without discrete mass seen, may
be secondary to
adhesions.
2. Indetermiante splenic hypodensities, can be further evaluated
by MRI or
ultrasound.
3. 1.5 x 0.7 cm duodenal lipoma.
4. Colonic diverticulosis with no evidence of acute
diverticulitis.
5. Moderate-large hiatal hernia.
Brief Hospital Course:
85 y/o F with PMHx significant for HTN, COPD, GERD, DJD, a/w
SBO, now s/p ex-lap with bowel resection and lysis of adhesions.
Admitted to the [**Hospital Unit Name 153**] from the PACU for monitoring in the setting
of post-operative hypotension.
.
# Hypotension: Likely dehydration in the setting of SBO and
recent surgery. UOP and BP responded well to fluid boluses.
Boluses were continued PRN to maintain UOP. Her home
antihypertensive regimen was held. No pressors were ever
needed.
.
# SBO, s/p Bowel Resection and Lysis of Adhesions: Patient
presented with abdominal pain and N/V. She was found to have an
SBO and was brought to the OR for bowel resection and LOA.
Morphine PCA for pain control. Immediately post-operatively she
was oliguric and hypotensive requiring admission to the [**Hospital Unit Name 153**].
It was determined that this was secondary to inadequate fluid
resuscitation. She responded appropriately to fluid
resuscitation. She was admitted to the floor. She did have an
ileus which resolved. She was started on cipro/flagyl for
empiric coverage of bowel sources of infection which was
completed after a 7 day course. By the time of discharge she
was tolerating regular diet and her pain was controlled on PO
meds.
.
# COPD: She is not on home oxygen. Her home respiratory
medications include albuterol, symbicort, and theophylline. She
was continued on albuterol. Advair was started to replace
symbicort while in house. Theophylline was also on hold and
would likely be restarted.
.
# UTI: Urine culture was growing E.coli sensitive to cipro. She
was continued on cipro.
.
# H/o Hypertension: On amlodipine/benazepril, atenolol, and
furosemide at home. Holding home antihypertensive and ASA
regimen for now given hypotension and recent surgery.
#DVT: [**2158-3-23**] pt found to have unilateral RUE swelling.
Underwent RUE US which demosntrated extensive DVT extending from
the subclavian to the basilic vein. She was started on coumadin
for anticoagulation on [**2158-3-24**]. INR was monitored and dose
adjusted appopriately. She will need follow up with her Primary
care provider and coumadin clinic for continued treatment.
.
# Hyperlipidemia: Home lovastatin on hold, likely restart on
discharge.
.
# Psych: Patient was reportedly on alprazolam, oxazepam, and
sertraline at home. These meds have been on hold while patient
in house and can likely be restarted on discharge.
.
#. GERD- Continued home PPI.
.
#. Code: Confirmed full code
.
#. Communication: Patient; HCP is granddaughter
Medications on Admission:
- albuterol 90 q6hrs prn
- alprazolam .25 TID prn
- amlodipine benazepril [**4-6**] daily
- atenolol 100 daily
- symbicort 160/4.5 [**Hospital1 **]
- lasix 20 daily
- lovastatin 30 daily
- oxazepam 30 daily prn
- kcl 20 daily
- robitussin
- sertraline 50 daily
- theophylline 600 daily
- tylenol
- asa 81 daily
- calcium 600 daily
- ergocalciferol 1000 daily
- ?omeprazole
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-19**] Inhalation Q6H (every 6 hours) as needed
for sob wheeze.
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5
Tablets PO DAILY (Daily).
15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM: adjust dose based on INR, follow up with coumadin clinic
and PCP.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] [**Hospital1 1501**]
Discharge Diagnosis:
1. Small bowel obstruction secondary to adhesions and
incarceration to previously placed Marlex mesh.
2. Oliguria
3.Urinary tract infection
4. Right upper extremity DVT
5. Post operative ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Call if fever >101 F. Call if signs of wound infection
including increased redness and foul smelling discharge. Call
if chest pain, shortness of breath. Call with any questions or
concerns.
Followup Instructions:
Please call Dr.[**Name (NI) 10946**] clinic to schedule follow up
appointment in [**11-19**] weeks.
Follow up with coumadin clinic (call to schedule) for your
anticoagulation with coumadin. Patient will need close follow
up with PCP for this as well.
|
[
"458.29",
"996.74",
"401.9",
"E878.1",
"496",
"041.4",
"788.5",
"599.0",
"530.81",
"453.81",
"560.81",
"715.90",
"733.00",
"996.59",
"E878.8",
"E879.8",
"560.1",
"696.1",
"272.4",
"997.4",
"E870.8",
"998.2",
"453.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"45.62",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9642, 9759
|
4837, 7372
|
279, 380
|
9998, 9998
|
3718, 4814
|
10391, 10647
|
2867, 2985
|
7795, 9619
|
9780, 9977
|
7398, 7772
|
10174, 10368
|
2518, 2723
|
3000, 3699
|
219, 241
|
408, 2302
|
10013, 10150
|
2324, 2495
|
2739, 2851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,376
| 150,252
|
50162
|
Discharge summary
|
report
|
Admission Date: [**2196-9-3**] Discharge Date: [**2196-9-6**]
Date of Birth: [**2116-1-15**] Sex: M
Service: MEDICINE
Allergies:
Omeprazole/Lansoprazole / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80M PMH metastatic lung cancer, 100 pack-year smoking history
presenting with acute on chronic dyspnea. The patient complains
of increasing DOE progressing to SOB at rest over the past few
days. The patient complains of prominent wheezing and cough
with increased production of dark brown/blood-tinged sputum.
The patient also complains of intermittent left-sided squeezing
chest pain, both at rest and with exertion, radiating to the
back at times, lasting seconds to minutes. No associated
nausea, diaphoresis. Denies fevers, chills, LE swelling/pain.
.
In the ED, VS T 99.9 HR 123 BP 137/63 RR 26 O2sat 97% NRB.
Patient received levofloxacin 750 mg PO x 1, zosyn 2.25 mg IV x
1, combivent nebulizer x 1, albuterol nebulizers x 2, solumedrol
125 mg IV x 1, ativan 1 mg IV x 1. The patient's oxygen
saturation improved to 94% on 6L NC with the above therapies.
.
Review of systems: As above. Positive for "abdominal spasm."
Negative for melena, hematochezia, dysuria, hematuria. ROS
otherwise negative in detail.
Past Medical History:
1. Pulmonary sarcomatoid carcinoma metastatic to right leg
2. Paroxysmal atrial fibrillation
3. Benign prostatic hypertrophy
4. Status post cholecystectomy [**2178**]
5. Gastritis
6. Colonic polyps
7. Anxiety
8. Cataracts
Social History:
Lives in [**Location **] with his wife in an apartment. Children and
grandchildren local. Speaks Yiddish and Russian. Long history of
alcohol use, with periodic decreases and increases in use (per
PCP [**Name9 (PRE) **] notes). Quit smoking 20 years ago, but has a 100
pack-year history.
Family History:
No h/o lung cancer. He has a brother with [**Name2 (NI) 499**] cancer. He has
a daughter with thyroid cancer, and a cousin with [**Name2 (NI) 499**] cancer.
Physical Exam:
VITAL SIGNS: T 98.0 BP 157/69 HR 128 RR 31 O2sat 94% 6L
GENERAL: Alert, oriented, cooperative male in no mild
respiratory distress.
HEENT: Scleara anicteric. Right pupil asymmetric but reactive,
left pupil symmetric and reactive. Mucous membranes are moist,
oropharynx clear.
NECK: Supple, no masses, no cervical or supraclavicular
lymphadenopathy, no thyromegaly.
CARDIOVASCULAR: Irregularly irregular, normal S1, S2, no rubs,
murmurs or gallops.
LUNGS: Moderate air flow, expiratory wheezes throughout,
increased expiratory phase, bronchial breath sounds left lung,
decreased breath sounds at bases bilaterally.
ABDOMEN: Soft, nontender, nondistended with positive bowel
sounds, no hepatosplenomegaly.
EXTREMITIES: No edema. Well healed right leg mass with no
residual deficits at this time.
NEUROLOGIC: Grossly intact.
Pertinent Results:
Imaging:
CXR [**2196-9-3**]:
1. Interval increase in size of multiple pulmonary metastases.
2. Interval increase in size of bilateral pleural effusions.
.
CTA CHEST [**2196-9-3**]: no pulmonary embolism or aortic dissection.
Calcifications are noted within the coronary arteries. There is
no
pericardial effusion, though fluid extends superiorly within the
pericardial recess. A prominent left supraclavicular lymph node
mass, not present on the prior exam, measures 2.7 x 3.3 cm.
Mediastinal lymph nodes are not enlarged. Lung windows
demonstrate marked progression of metastatic disease. Existing
lesions have increased dramatically in size, and there are
multiple new nodules. For example, previous dominant nodule
along the left pleural margin now measures 5.1 cm, previously
2.5 cm. Nodule at the right cardiophrenic recess measures 4.4
cm, previously 1.8 cm. Nodule at the esophageal hiatus has grown
markedly extending inferiorly and displacing the aorta to the
left, measuring approximately 7.9 cm, previously 2.4 cm. Many
lesions have become confluent, particularly at the right lung
base. The patient is status post left upper lobectomy with
volume loss in the left lung. Intramural peripheral thrombus in
the thoracic aorta without aneurysm is unchanged. There is no
evidence of osseous metastasis.
.
PFT [**2196-2-22**]
FVC 58%Pred
FEV1 72%Pred
FEV1/FVC 123%Pred
TLC 69%Pred
.
ON ADMISSION
[**2196-9-3**] 08:38PM BLOOD WBC-11.4* RBC-3.08* Hgb-8.6* Hct-27.0*
MCV-88 MCH-27.8 MCHC-31.8 RDW-14.5 Plt Ct-247
[**2196-9-3**] 08:38PM BLOOD Neuts-93.5* Lymphs-5.5* Monos-0.8*
Eos-0.1 Baso-0.1
[**2196-9-3**] 02:20PM BLOOD PT-12.6 PTT-27.6 INR(PT)-1.1
[**2196-9-3**] 02:20PM BLOOD Glucose-137* UreaN-24* Creat-1.2 Na-142
K-4.5 Cl-102 HCO3-24 AnGap-21*
[**2196-9-3**] 02:20PM BLOOD ALT-18 AST-18 LD(LDH)-279* CK(CPK)-46
AlkPhos-133* Amylase-21 TotBili-0.3
[**2196-9-4**] 04:33AM BLOOD CK-MB-4 cTropnT-0.02*
[**2196-9-3**] 08:38PM BLOOD CK-MB-4 cTropnT-0.03*
[**2196-9-3**] 02:20PM BLOOD cTropnT-0.05*
[**2196-9-3**] 02:20PM BLOOD Albumin-3.8 Calcium-9.7 Phos-3.1 Mg-2.0
[**2196-9-3**] 04:50PM BLOOD Lactate-1.9
[**2196-9-3**] 03:03PM BLOOD Hgb-9.7* calcHCT-29
Brief Hospital Course:
80 year-old man with history of metastatic lung cancer, 100
pack-year smoking history, presented with acute on chronic
dyspnea.
.
# Respiratory distress: Diffuse wheezes on exam. CXR revealed
innumerable pulmonary masses, perihilar opacities, pleural
effusions. CTA showed no PE. Dyspnea was likely due to a
combination of infection, cancer progression, COPD exacerbation.
He received solumedrol IV and prednisone taper, fluticasone,
ipratropium, Xopenex, diuretics, and levofloxacin. His symptoms
improved to dyspnea only with movements. He was still on 2L NC
of O2 on discharge. He was sent home with prenisone taper, nebs,
and levofloxacin x 8 more days.
.
# Chest pain: Patient had episodes of chest pain. MI was ruled
out. Pain resolved by discharge.
.
# Abdominal pain: chronic stomach spasm. He was put on diazepam.
No pain at time of discharge.
.
# Paroxysmal atrial fibrillation: Patient unaware in AF; last
documented in [**3-28**]. CHAD2 score 1 for age. He was continued on
metoprolol for rate control and was started on ASA 325 mg for
anticoagulation, with warfarin to be considered as outpatient.
He was put on Xopenex instead of albuterol.
.
# Anemia: Likely anemia of chronic disease. No recent
chemotherapy. No signs or symptoms of bleeding.
.
# Chronic kidney disease: Unclear etiology. Creatinine at
baseline.
.
# Metastatic lung cancer: Rapidly progressive on imaging. He was
continued on amitriptyline, tylenol for pain. Home with hospice
care.
.
# Code: DNR/DNI
Medications on Admission:
Amitriptyline 50 mg QD, doxazosin 2 mg QD, metoprolol 37.5 mg
TID, clonazepam 0.5 mg [**Hospital1 **], tylenol PRN, senna, colace,
albuterol PRN.
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
4. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 10 days.
Disp:*15 Tablet(s)* Refills:*0*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
6. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
10. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain, spasm.
Disp:*90 Tablet(s)* Refills:*0*
11. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: 1-2 MLs
Inhalation Q4H (every 4 hours) as needed for SOB, wheeze.
Disp:*1 bottle* Refills:*0*
12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
Take 60 mg on [**9-6**] mg on [**9-7**] and [**9-8**], 40 mg on [**9-9**]
and [**9-10**], 30 mg on [**9-11**] and [**9-12**], 20 mg on [**9-13**] and [**9-14**],
10 mg on [**9-15**] and [**9-16**].
Disp:*40 Tablet(s)* Refills:*0*
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. morphine sulfate Sig: 2-20 mg Sublingual q 1 hour as needed
for pain.
Disp:*30 ml of 20mg/ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary diagnoses: lung cancer, pneumonia, congestive heart
failure
Secondary diagnoses: paroxysmal atrial fibrillation, benign
prostatic hypertrophy, gastritis, anxiety
Discharge Condition:
Stable, but still dyspneic with some movements, on supplement
O2.
Discharge Instructions:
You presented to [**Hospital1 18**] with shortness of breath. Your shortness
of breath was likely due to exacerbation of your chronic
shortness of breath due to a combination of possible infection,
fluid in your lungs, and progression of your lung cancer. Your
symptoms improved with antibiotic, steroids, and medications to
remove some fluid from your lungs. You are sent home with
nursing care. Please take all your medications as instructed.
Please call your physician or go to the nearest Emergency Room
if you develop fevers > 101F, chills, worsening shortness of
breath, chest pain, chest pressure, palpitations, dizziness, or
any other symptom that concerns you.
Followup Instructions:
Please go to the following appointments:
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2196-9-13**] 12:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2196-9-15**] 11:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2196-9-15**]
11:30
|
[
"428.0",
"518.84",
"427.31",
"491.21",
"285.21",
"198.89",
"486",
"790.29",
"585.9",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8739, 8817
|
5173, 6663
|
325, 331
|
9032, 9100
|
2977, 5150
|
9819, 10259
|
1949, 2108
|
6859, 8716
|
8838, 8907
|
6689, 6836
|
9124, 9796
|
2123, 2958
|
8928, 9011
|
1247, 1382
|
266, 287
|
359, 1228
|
1404, 1627
|
1643, 1933
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,572
| 141,317
|
39027
|
Discharge summary
|
report
|
Admission Date: [**2153-3-12**] Discharge Date: [**2153-5-8**]
Date of Birth: [**2074-11-30**] Sex: M
Service:
This is a re-dictation of a discharge summary in a somewhat
delayed fashion following nothing able to be located. Mr.
[**Known lastname 9449**] was a 78-year-old gentleman status post extended
right colectomy on early [**Month (only) 956**] with an ileum to left colon
anastomosis at an outside hospital. There, postoperatively
he developed a troponin leak and acute renal insufficiency
which was thought to be prerenal and atrial fibrillation. He
then was transferred at the request of the surgeon there with
an essentially an acute abdomen, respiratory at failure
requiring urgent intubation. After initial stabilization and
resuscitation, and evaluation in the ICU, he was taken to the
OR for exploratory laparotomy with a leak at the ileocolonic
anastomosis was identified and feculent peritonitis. He
underwent resection of the anastomosis with an end ileostomy
and [**Last Name (un) **] gastrostomy. The placement of a G-tube additionally
.
Subsequent to that, he had a long course with many issues
with wound care requiring ultimately complicated vac and a
variety of pouches, multiple debridements of the wound care.
With retention sutures in place, the wound was more difficult
to manage and he did develop skin erosions as well during
this time. Postoperatively, he also developed a leak from
his G-tube site requiring with leaking from the JP requiring
a long period of being n.p.o. He was on TPN. He had a
prolonged ICU stay with intubation because of his risk for
respiratory status. He was ultimately extubated from that
but continued to be not mentating at his preoperative level.
He then in early [**Month (only) 547**] developed acute arterial ischemia of
the right lower extremity and required a right femoral
embolectomy and repair of the right common femoral artery by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] and following that, he required continued
intubation and because of his long course, family discussions
were held in which he was ultimately made a CMO on [**2143-5-8**] and he expired on [**2153-5-8**] at 3:50 p.m. as noted
already on the Fulmar chart. His family was appropriately
notified.
DISCHARGE STATUS: Expired.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 71138**]
Dictated By:[**Last Name (NamePattern4) 79676**]
MEDQUIST36
D: [**2153-10-19**] 10:26:32
T: [**2153-10-19**] 11:13:07
Job#: [**Job Number 86542**]
|
[
"584.9",
"E879.8",
"577.0",
"995.92",
"276.8",
"041.86",
"276.2",
"567.29",
"998.31",
"536.42",
"789.59",
"E878.3",
"707.22",
"530.81",
"V45.81",
"496",
"348.30",
"401.9",
"V12.54",
"E878.2",
"442.3",
"427.31",
"998.59",
"997.1",
"038.11",
"V53.32",
"518.5",
"410.71",
"999.31",
"707.03",
"997.4",
"287.5",
"276.0",
"444.22",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"86.28",
"97.02",
"88.72",
"96.04",
"38.08",
"86.22",
"43.19",
"46.20",
"96.6",
"45.73",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,593
| 155,879
|
51097
|
Discharge summary
|
report
|
Admission Date: [**2113-8-7**] Discharge Date: [**2113-8-26**]
Date of Birth: [**2057-12-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
Right shoulder pain x 3 days, cough, SOB x 6 months
Major Surgical or Invasive Procedure:
Left septic wrist debridement and washout on [**2113-8-10**] and repeat
procedure on [**2113-8-25**].
History of Present Illness:
55 yo lady with multiple medical problems including HIV,
[**Year (4 digits) **] [**Year (4 digits) 106114**] pneumonitis, pulmonary HTN, ESRD on HD,
cardiomyopathy and emphysema on O2 at home who presents with
right shoulder pain and worsening cough/SOB for 6 months.
.
Right shoulder pain: started 3 days ago. Sudden onset. Not
provoked by any activity, no h/o trauma or any other event that
may have precipitated this pain.
.
Cough/SOB: This has been chronic, apparently at least six
months, but the frequency and severity of cough has increased.
The patient has a subconjunctival hemorrhage in the left eye
from the coughing. Cough is productive of white, non-bloody
sputum. Pt also states "i had pneumonia 3 weeks ago, but I
handled it on my own." Patient does endorse increasing dyspnea
on exertion, and states that she uses several pillows and feels
that she has more
swelling in her legs than usual. The patient was on prednisone
for her LIP, but this was discontinued about 6-7 months ago. Pt
reports chills for the past several days.
.
Denies chest pain, N/V, diarrhea, weight loss. No recent history
of incarceration or other exposure risk for TB although son has
been incercerated. No hx of oppotunistic infections.
.
In [**Name (NI) **], pt with T 101. Joint injected with bupicivaine with
moderate relief. Pt then received HD. On return to the medical
floor, she develop severe left wrist pain--contralateral to her
original left shoulder pain. Plastics was consulted and
attempted drainage of the wrist with no success. MICU consulted
for worsened tachycardia (130 from admission HR of 110 which may
be her baseline) and worsening tachypnea. ABG surprisingly
7.36/48/86 despite tachypnea. At that time, pt reached her TMAX,
102.0. Shortly thereafter, 1 of 4 (anaerobic) bottles grew GPC.
Past Medical History:
- HIV ([**2113-7-20**] CD4 257, VL <48)
- ESRD on HD MWF
- HTN
- Severe pulmonary HTN
- Cardiomyopathy [**12-10**] LVEF 31%, severe MR/TR
- [**Month/Year (2) 106113**] [**Month/Year (2) 106114**] pneumonitis (LIP) followed by Dr. [**Last Name (STitle) **]
[**Last Name (STitle) **] at [**Hospital1 2177**] ([**Telephone/Fax (1) 7799**] #6564
- Anemia of chronic disease
- AVNRT diagnosed at [**Hospital1 2177**]
- Recent vaginal bleed s/p conization
- HCV - untreated
- Asthma/COPD
- C-section
- R knee surgery
- Ovarian cysts removed
Social History:
She lives in [**Location 669**] with her 18 year old son. She has three
sons and one daughter. She quit smoking on [**2112-2-3**].
She has a 30-40 pack year smoking history. She has used "every
drug" including cocaine. Last drug use was three years ago. She
has never used IV drugs. She has a history alcohol abuse
and has been sober for six years. She has a history of
homelessness and has lived in shelters, most recently within the
past five years. She has never been incarcerated but her son has
been. She is currently medically handicapped and unemployed for
many years.
Family History:
Her mother is living in her 70s and had a stroke, hypertension
and diabetes. Her uncle died of kidney disease. She never met
her father. [**Name (NI) **] sister was killed in a motor vehicle crash. Her
children are healthy. Her daughter has a single kidney.
Physical Exam:
Vitals: 97.6 (98.6), 139/91 (93-160/59-90), 110 (96-110), 22,
98% 2L
Gen: Asleep, easy to arouse, no acute distress
HEENT: Left eye with subconjunctival hemorrhage, unchanged;
icteric b/l
CV: RRR no murmur appreciated
Pulmonary: CTA b/l
Abd: Obese, distended, +BS, mild epigastric tenderness
Ext: Peripheral edema 1+ b/l LE, LUE with clean wound dressing
Neuro: AOx3
Pertinent Results:
[**2113-8-7**] 08:30PM TYPE-ART PO2-86 PCO2-48* PH-7.36 TOTAL CO2-28
BASE XS-0
[**2113-8-7**] 08:30PM GLUCOSE-83 LACTATE-1.1 NA+-141 K+-4.1 CL--101
[**2113-8-7**] 08:30PM O2 SAT-94
[**2113-8-7**] 08:30PM freeCa-1.17
[**2113-8-7**] 01:38AM LACTATE-1.6
[**2113-8-7**] 01:30AM GLUCOSE-84 UREA N-27* CREAT-7.8*# SODIUM-135
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-26 ANION GAP-16
[**2113-8-7**] 01:30AM estGFR-Using this
[**2113-8-7**] 01:30AM ALT(SGPT)-18 AST(SGOT)-46* LD(LDH)-311* ALK
PHOS-107 TOT BILI-1.1
[**2113-8-7**] 01:30AM LIPASE-26
[**2113-8-7**] 01:30AM CRP-7.7*
[**2113-8-7**] 01:30AM WBC-4.5 RBC-4.57 HGB-11.3* HCT-40.4 MCV-89
MCH-24.7* MCHC-27.9* RDW-21.4*
[**2113-8-7**] 01:30AM NEUTS-67.3 LYMPHS-19.4 MONOS-7.7 EOS-4.6*
BASOS-1.1
[**2113-8-7**] 01:30AM PLT COUNT-117*
[**2113-8-7**] 01:30AM PT-17.1* PTT-40.4* INR(PT)-1.5*
[**2113-8-7**] 01:30AM SED RATE-23*
----------
C. diff negative [**8-12**] and [**8-14**]
----------
HIDA [**2113-8-13**]
IMPRESSION: Markedly abnormal hepatobiliary scan with no uptake
of DISIDA into the liver during 78 minutes of imaging. This
finding is compatible with severe hepatic dysfunction. Due to
the hepatic dysfunction, the biliary system cannot be evaluated.
----------
Radiology Report CHEST (PORTABLE AP) Study Date of [**2113-8-15**]
11:29 AM
CHEST RADIOGRAPH
INDICATION: Hemoptysis, evaluation for changes.
COMPARISON: [**2113-8-14**].
FINDINGS: As compared to the previous radiograph, the
pre-existing
right-sided pleural effusion shows a slightly different
distribution but
appears to be overall unchanged. The subtle suprabasal opacity
in the left
lung could have minimally increased in extent. Other opacities
are not
visible. Moderate cardiomegaly with signs of mild to moderate
pulmonary
overhydration. No evidence of left-sided pleural effusion.
----------
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2113-8-14**]
12:47 AM
CONCLUSION:
The findings of adrenal hyperenhancement and renal
hypoenhancement are
nonspecific but suggest possible infarction or ischemia to these
organs.
As the proximal arteries appear unremarkable and there is no
overt evidence of
significant arteriosclerosis, hypotension must be considered.
Nonspecific dilatation of the small bowel, possibly reflecting
ileus.
No additional findings. Of note, there is joint space narrowing
at L4-L5.
This is felt secondary to degenerative disc disease rather than
discitis.
----------
Radiology Report CT ABD W&W/O C Study Date of [**2113-8-20**] 3:02 PM
IMPRESSION:
1. Homogeneous enhancement of the pancreas.
2. Mild stigmata of cirrhosis.
3. Small fat-containing ventral abdominal hernia.
----------
EGD Report Tuesday, [**2113-8-22**]
Impression: There were no varices seen in the esophagus.
Abnormal mucosa in the stomach (biopsy, biopsy)
Otherwise normal EGD to third part of the duodenum
----------
PATHOLOGY EXAMINATION: [**2113-8-22**]
DIAGNOSIS:
Gastric mucosal biopsies, two:
A. Fundus: Superficial fragment of fundic mucosa with no
diagnostic abnormalities recognized.
B. Antrum: Antral mucosa with regenerative changes suggestive
of chemical injury.
----------
ENDOSCOPIC U/S [**2113-8-24**]
EUS: Pancreas parenchyma showed changes c/w moderate chronic
[**Year (4 digits) **].
Pancreatic duct was normal. Bile duct was normal, without
stones.
Brief Hospital Course:
In short, patient is a 55 yo lady with multiple medical problems
including HIV (CD4 257), [**Year (4 digits) **] [**Year (4 digits) 106114**] pneumonitis,
pulmonary HTN, ESRD on HD, cardiomyopathy and emphysema on O2 at
home who presented initially with right shoulder pain and
worsening cough, SOB for 6 months. She was initially admitted
on [**2113-8-7**] and has had a protracted hospital course.
.
She was found to have MSSA bacteremia, for which she was treated
with cefazolin. Her shoulder pain had improved, but she had
developed left wrist pain which was found to be a septic joint
and s/p wash out with ortho on [**2113-8-10**]. Also, during her
hospitalization, she had difficulty maintaining her BPs,
especially for dialysis, and initially it was felt that she
potentially had an infection of her AVF (imaging did not suggest
any thrombus/source of infection there). It is thought that the
infection was [**3-6**] to her left wrist septic joint - her cultures
have since cleared with therapy. She also had difficulty with
respirations, and it was thought to be secondary to increased
narcotics use, and improved once she was switched from IV to PO
narcotics. Her LFTs gradually improved, but she now has a
persistently elevated amylase/lipase of unclear etiology. It is
thought that this may be secondary to her HAART therapy, since
her CT of her pancreas did not show any significant
abnormalities. MRCP cannot be done given her renal failure.
Also, during this hospitalization, she had black stool, guaiac
positive.
.
# MSSA bacteremia: Likely explanation for her fevers. 2 sets of
blood cx positive on [**2113-8-7**], not since. Risk factors for staph
include recurrent hospitalizations, HD, HIV, distant prior staph
bacteremia. Started on Vanco and later switched to Nafcillin.
Gentamycin was added on [**2113-8-12**]. Neg echo. Gent was d/c'd.
Treating with Cefazolin. s/p PICC. Per ID, if TEE negative would
treat 4 weeks. If no TEE would treat 6 weeks (D1= [**8-14**]); however
pt. would not cooperate for TEE. Also outpatient ID f/u with
weekly CBC, CRP, ESR, LFTs, BMP. ID signed off.
.
# Hypotension: Was showing septic physiology and was on
dopamine, later weaned off, started Levophed; weaned off and
responded to steroids. After 24 hours off of steroids, they
were stopped. Intent to try pt. on Midodrine but since she
refused and BP was stable with it, it was also d/c'd. Pt.'s BPs
were stable when transferred out of ICU and continued to be
stable on the floor. Patient's home Sildenafil was held b/c of
persistent hypotension episodes. Patient normotensive on floor
and BP was not much of an issue.
.
# Left wrist pain: Felt to be septic joint [**3-6**] MSSA bacteremia.
Went to OR for debridement and washings on [**2113-8-10**]. Pain has
been well controlled on Percocet and with patient in
sling/splint during hospitalization. OT reconsulted and saw
patient on [**2113-8-22**] now that she had improved wrist function.
Patient still complained of pain and had mild drainage from
wound site on [**2113-8-25**], when hand re-evaluated and brought to
OR for repeat wash-out procedure. Pus not visualized during
operation however, and site irrigated and closed.
.
# Right shoulder pain. On exam, low suspicion for septic joint
and pain resolved fairly quickly. Ortho was consulted; managed
with sling and pain control.
.
# Cough/SOB: Resolved quickly. Most likely dx seems to be
progression of her serious underlying lung pathology. No hx of
oppotunistic infections. Prelim CT chest c/w emphysematous
changes. At this point, low suspicion for TB as PPD negative.
F/u swab negative. Was continued on albuterol/ipratropium and
resolved and pt. on home oxygen requirement at conclusion of ICU
stay. Patient without symptomatic complaints when on hospital
floor.
.
# ESRD: Pt was continued on HD three times per week. Renal was
following and meds were dosed appropriately.
.
# Tachycardia: Felt to be a response to infection, but per outpt
and inpt notes, she is chronically tachycardic and may have
baseline HR in 110s. Sinus on 12 lead. Plan to restart home
beta blocker after HD (Toprol XL 25 daily). This had been
stopped because of hypotension. Restart with renal permission.
.
# Cardiomyopathy/CHF, EF 30%: Patient's BB was held; should be
started on ACEi/[**Last Name (un) **] in the future if BP can tolerate.
.
# [**Last Name (un) **] Pneumonitits/Pulmonary hypertension: Sildenafil
was held becuse of hypotension; should be restarted when BPs
more stable.
.
# Asthma/COPD: was continued on Iprotrop.
.
# HIV ([**2113-7-20**] CD4 257, VL <48): was continued on HAART meds and
bactrim ppx.
.
# Coagulopathy: INR elevated in past but not to this range. ? if
related to liver enzymes/HCV
.
# HCV: has not been treated. Hepatology has no new recs. Stated
HCV viral load will not affect current management
.
# Transaminitis: Imaging of RUQ done [**3-6**] increased abd pain and
rising t. bili. HIDA scan ordered and surgery consulted. Gent
added to Abx regimen on [**2113-8-12**] but d/c'd per ID. Bili, amylase
still elevated however pt. had refused MRCP and since AST and TB
trending down and renal function would not tolerate dye, with
increased amylase to the 1000s, hepatology was consulted, the
pt. had a normal CT pancreas study, and ID confirmed that such
an increase would also affect her lipase. At transfer from ICU,
still unclear etiology. Liver enzymes down trended while on the
floor. Etiology thought likely due to cholelithiasis causing a
brief elevation of liver enzymes.
.
# Erosive gastritis: Patient had melena with guiaic positive
stool during hospitalization on the floor. EGD [**2113-8-22**] showed
blood collection, questional source but likely erosive
gastritis. Differential also included epistaxis (hx of
epistaxis: risk factors including elevated INR [**3-6**] poor liver
fx. ALT, AST may be normal [**3-6**] poor residual fx). EGD negative
for esophagitis, PUD. Patient treated with [**Hospital1 **] PPI for erosive
gastritis with careful monitoring of Hct.
.
# Elevated amylase, lipase; [**Hospital1 **]: Etiology unclear, but
patient has risk for gallstone, autoimmune ([**Hospital1 **]
[**Hospital1 106114**] pneumonitis, HCV/HIV), and/or drug-induced
[**Hospital1 **] (HAART). Gallstone [**Hospital1 **] likely given
initial elevation of T bili, cholelithiasis. CT pancreas without
any obvious abnormalities. MRCP to visualize pancreatic ducts
unlikely given renal failure. EUS obtained [**2113-8-24**] showing
changes consistent with chronic [**Year (4 digits) **] but no gallstones.
Outpatient surgery follow up for elective cholecystectomy is
recommended.
.
# CT suggestive of adrenal infarction. Endo stated that adrenal
response normal, if relatively adrenal insufficient can try
stress dose steroids without fluid bolus or pressors. This was
not an issue throughout hospitalization.
.
# Foot pain and leg weakness: Unlikely gout given recent
steroids. Unlikely sepsis given not febrile and no change in WBC
and bilateral. Actually completely improved as of [**8-18**]. Put in
for PT consult.
.
# Hemoptysis: Likely worsened by coagulopathy. Had black tarry
stools [**8-19**]. Monitored H/H, INR and sxs and patient was stable.
GI endoscope am [**8-22**].
.
# Dispo: Because of prolonged bedrest and left wrist mobility
will likely need inpatient rehabilitation before she can go
home. discharged to rehab
Medications on Admission:
Metoprolol Succinate XL 25 mg
Acetaminophen 325-650 mg PO Q6H:PRN pain
Nephrocaps 1 CAP PO DAILY
Calcitriol 0.5 mcg PO EVERY OTHER DAY Tues, Thurs, Sat
Quetiapine Fumarate 25 mg PO QMOWEFR 45 min prior to HD
Cinacalcet 30 mg PO DAILY
Raltegravir 400 mg PO BID
Etravirine 200 mg PO BID
Sildenafil Citrate 50 mg PO TID
Fexofenadine 60 mg PO DAILY:PRN Hay fever
Guaifenesin-CODEINE Phosphate [**6-11**] mL PO Q6H:PRN cough
Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR
Heparin 5000 UNIT SC TID
sevelamer HYDROCHLORIDE 1600 mg PO TID W/MEALS
LaMIVudine 50 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
3. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
4. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for hay fever.
7. Etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough .
11. Cefazolin 1 gram Recon Soln Sig: Two (2) Injection qMoWe
for 4 weeks: Please take until last day [**2113-9-21**].
12. Cefazolin 1 gram Recon Soln Sig: Three (3) Injection qFr
for 4 weeks: Please take until last day [**2113-9-21**].
13. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO once a day.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for constipation.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) as needed for constipation.
17. Oxycodone-Acetaminophen 5-500 mg Capsule Sig: One (1) Tablet
PO every 6-8 hours as needed for pain.
18. Outpatient Lab Work
Please draw CBC, CRP, ESR, LFTs, BMP weekly from [**2113-8-23**]
([**2113-8-30**], etc) and fax results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 106119**].
Discharge Disposition:
Extended Care
Facility:
radius of [**Location (un) **]
Discharge Diagnosis:
Primary diagnoses:
- MSSA bacteremia
- Septic wrist at the radial carpal joint and mid carpal joint
- Erosive gastritis
- [**Location (un) **]
- Transaminitis
- ESRD on HD
- HIV on HAART
Secondary diagnoses:
- HIV ([**2113-7-20**] CD4 257, VL <48)
- ESRD on HD MWF
- HTN
- Severe pulmonary HTN
- Cardiomyopathy [**12-10**] LVEF 31%, severe MR/TR
- [**Month/Year (2) 106113**] [**Month/Year (2) 106114**] pneumonitis (LIP) followed by Dr. [**Last Name (STitle) **]
[**Last Name (STitle) **] at [**Hospital1 2177**] ([**Telephone/Fax (1) 7799**] #6564
- Anemia of chronic disease
- AVNRT diagnosed at [**Hospital1 2177**]
- Recent vaginal bleed s/p conization
- HCV - untreated
- Asthma/COPD
- C-section
- R knee surgery
- Ovarian cysts removed
Discharge Condition:
Afebrile, in good condition, ambulating, alert and oriented x3,
tolerating PO intake.
Discharge Instructions:
You were admitted to the hospital on [**2113-8-7**] for right shoulder
pain and shortness of breath. During your hospitalization, we
found out that you had an infection in your blood. You are being
treated on an antibiotic for this infection (your blood cultures
have been negative, but it may be bacteria on your heart valve
due to previous drug use, and you will be taking the antibiotic
until [**2113-9-21**]). Also during this hospitalization, we found
that you had bacteria in your left wrist. We took you to an
operation on [**2113-8-10**] to clean out the wrist. The wrist
continued to have infection and you were taken back for a repeat
operation on [**2113-8-25**]. We also found that you were bleeding
from your stools during this hospitalization. We put a scope
down your throat to look at your stomach and found generalized
inflammation that was likely causing the bleeding. We also found
out that the enzymes that we use to monitor for inflammation of
the pancreas were elevated. We did procedures including a CT
scan and endoscopic ultrasound which showed changes consistent
with chronic [**Year (4 digits) **].
Changes to your home medications include:
Calcitriol: We discontinued this medication.
Cincalcet: We discontinued this medication.
Sildenafil: We discontinued this medication because of your low
blood pressure in the hospital.
If you should experience signs of infection such as fever
greater than 101, chills, sweats, or chest pain, trouble
breathing, palpitations, dizziness, fatigue, or any other
medically concerning symptoms, please call your doctor or 911 or
go to the emergency room.
Followup Instructions:
Please keep the following appointments which have been made for
you:
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Surgery
Date and time: [**9-7**] At 12:30pm
Location: [**Street Address(2) 106120**]
Phone number: [**Telephone/Fax (1) 8792**]
Special instructions: You are going to see surgery because the
GI doctors [**Name5 (PTitle) 2985**] your [**Name5 (PTitle) **] was due to the gallstones in
your gallbladder. You have been recommended to talk with surgery
about an elective cholecystectomy.
MD: [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Specialty: Infectious Disease
Date and time: [**9-13**] at 9:30am
Location: [**Hospital **] Community Health Center
Phone number: [**Telephone/Fax (1) 3581**]
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Gastroenterology- for Endoscopy
Date and time: [**10-2**] at 11:30am arrival for 12:30pm
procedure
Location: [**Hospital Ward Name 1950**] [**Location (un) 470**]
Phone number: [**Telephone/Fax (1) 463**]
Special instructions if applicable: Instructions will be mailed
for endoscopy preparation.
Please call the hand clinic at [**Telephone/Fax (1) 3009**]. You need to make an
appointment for follow-up from your surgery on [**2113-8-25**]. Please
make this appointment to be within 2-3 weeks.
Completed by:[**2113-8-29**]
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64,185
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37859
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Discharge summary
|
report
|
Admission Date: [**2164-7-7**] Discharge Date: [**2164-7-8**]
Date of Birth: [**2087-2-15**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left hemiparesis, transferred here from OSH with
"hyperdense R MCA sign."
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
Patient is a 77 year old man with afib (NOT on coumadin) and
cancer who was last seen normal at 11:45am by his wife. At
[**Name2 (NI) **],
she heard a thud and discovered him slumped over. EMS
transported the patient to [**Hospital **] Hospital.
There, he was noted to be in afib, to have left hemiparesis, and
to be hypertensive to SBP = 210. He was given nitropaste and
diltiazem. NCHCT apparently showed "hyperdense R MCA sign,"
though we are not able to view these images directly. Patient
did not receive ivTPA (which I presume is because he has distant
history of cerebral hemorrhage) and was transferred to [**Hospital1 18**] for
further care.
Here, NIHSS = 23 at 5:45pm
LOC 1
Questions 2
Commands 0
Gaze 1
Visual fields 2
Face 2
Motor 3 + 3 = 6
Ataxia 0
Sensory 2
Language 3
Dysarthria 2
Extinction/inattention 2
ROS:
Wife says patient has had no recent complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG: 5 vessel CABG ten years ago at [**Hospital3 **],anatomy
unknown
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Unresectable cholangiocarcinoma diagnosed in [**12/2163**] who has
been receiving gemcitabine chemotherapy for this disease with
plans for initiation of cisplatin in the near future
Parotid Cancer noted [**4-25**] being considered for palliative
radiation
parotid gland raising the possibility that he had a second
primary parotid tumor.
Hypertension
Status post cerebral hemorrhage 20 years ago
Peptic ulcer disease complicated by GI bleeding
Diverticulitis
Chronic renal insufficiency
Hidradentis suppurativa
Mastoid bone operation at age 5
Social History:
Mr. [**Known lastname 84682**] is married and lives with his wife. [**Name (NI) **] is a
former smoker, quitting 20 years ago. He used to smoke a pack a
day for 40 years. He denies illicit drug use, reports
occasional alcohol use. He has no children. He is retired and
used to work in sales. He also used to be in the Marine Corps.
Family History:
His mother died from bone cancer at age 66. His father died at
age 62 from either a myocardial infarction or a stroke. His
maternal grandmother died from liver cancer at an unknown age.
He has no siblings.
Physical Exam:
Exam: T 98.5 BP 157/82 HR 72 Afib RR 10 O2Sat 100% face mask
Gen:
Lying in bed, appears agitated. HEENT: Lots of secretions from
the nose. CV: Irregularly irregular but no murmurs/gallops/rubs
Lung: Clear anteriorly Abd: +BS, soft, nontender Ext: No edema
Neurologic examination: Mental status: Awake and alert - follow
motor commands including opening eyes and showing R thumb,
wiggling R toes and sticking tongue out. Frequent groaning only
-nonverbal otherwise. Cranial Nerves: L pupil larger than R (L
6mm and R 4mm) - reactive but not brisk. L facial droop. Eyes
cross midline. Blinks to visual threat on R only. Motor: Normal
tone on R but decreased tone on L. Moves R arm and leg
anti-gravity with some resistance but does not move the L.
Extensor posturing to noxious stim on LUE only. No adventitious
movements. Sensation: Intact to noxious stim. Reflexes: 2s on R
biceps and patellar but none for L. Toes are upgoing
bilaterally.
Pertinent Results:
CT
1. Right MCA territory infarction with cerebral edema and a new
right basal ganglia intraparenchymal hemorrhagic transformation,
with
significant subfalcine herniation, effacement of the suprasellar
cisterns and
uncal herniation. There is no transtentorial herniation at this
time.
2. Small amount of intraventricular hemorrhage and entrapment of
the left
lateral ventricle.
3. New air-fluid levels in the sphenoid sinuses can represent
acute
sinusitis. Clinical correlation is recommended. Aerosolized
mucosal
thickening in the maxillary sinuses.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Patient was admitted with large left MCA stroke. He was
admitted to the ICU and needed to be intubated on arrival. The
following morning the patient was noted to have a blown R pupil
and was extensor posturing in all extremities. On a repeat head
CT scan he was noted to have a large hemorrhage in the area of
the MCA. Prognosis was discussed with family and the decision
to withdraw care was made. The patient expired on [**2164-7-8**].
Medications on Admission:
1. Lasix 10
2. Percocet
3. Lisinopril 5
4. Metoprolol 25mg [**Hospital1 **]
5. KCl 24/16
6. Prochlorperazine 10 QID
7. Allopurinol 150mg daily
8. Xanax 0.25mg [**Hospital1 **]
9. Amlodipine/Benazepril [**6-25**]
10. Dexamethasone 4mg [**Hospital1 **]
11. Diltiazem 120mg
12. CoQ
13. Thiamine
14. ASA 81mg daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
L MCA stroke
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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1333, 1389
|
2092, 2432
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,059
| 107,397
|
48188
|
Discharge summary
|
report
|
Admission Date: [**2126-12-29**] Discharge Date: [**2127-1-1**]
Date of Birth: [**2065-11-22**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Clindamycin / Celery / apple / bees
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Malfunctioning tracheostomy
Major Surgical or Invasive Procedure:
1. Revision of tracheostomy. Flexible bronchoscopy ([**2126-12-29**])
2. PICC line placement ([**2126-12-30**])
History of Present Illness:
60F w/ hx of COPD, PAH w/ cor pulmonale, right-sided CHF, CKD
s/p tracheostomy on [**12-25**]. She presents from rehab facility with
a few hours of low tidal volume. Over the past several months
she has undergone prolonged course with several hospitalizations
including a recent admission from [**Date range (1) 49798**] for shortness of
breath thought initially to be pneumonia but eventually
attributed to COPD exacerbation as opposed to infection. Due to
respiratory failure she underwent a tracheostomy on [**12-25**]. She
otherwise has denied any fever, chills, headache, cough, chest
pain, abdominal pain, nausea or vomiting.
Past Medical History:
1. Morbid obesity (s/p gastric bypass)
2. Obstructive sleep apnea (noctural BiPAP 18/15, home oxygen
requirement of 3-4L via nasal cannula)
3. Obesity hypoventilation syndrome
4. Severe pulmonary artery hypertension (attributed to OSA)
5. Cor pulmonale (right heart failure attributed to severe
pulmonary hypertension)
6. Asthma
7. Osteoarthritis (bilateral knee involvement)
8. Diastolic heart failure (2D-Echo [**1-/2124**] showing LVEF 70-80%,
PAP 64 mmHg)
9. Chronic kidney disease (stage III-IV, baseline creatinine
1.8-2.2)
10. Rosacea
11. Hypertension
12. Iron deficiency anemia
11. s/p ventral hernia repair with mesh and component separation
([**5-/2119**])
12. s/p gastric bypass surgery ([**2113**])
13. s/p debridement of anterior abdominal wall and complex
repair ([**6-/2119**])
Social History:
Patient lives at home with disability services. She has 2 adult
children. She notes no toabcco use, rare alcohol use currently
but notes a former heavy alcohol history in the distant past.
She denies recreational substance use.
Family History:
Notable for diabetes mellitus in her mother and sister,
hypertension in siblings, mother and throughout the maternal
family as well as kidney disease.
Physical Exam:
On admission:
Vitals: 99.9 88 122/82 12 100% at 60% fio2
GEN: A&O 3, Moving all four extremities
HEENT:NCAT, Anicteric sclera, mucus membranes moist
Neck: Tracheostomy tube in place, site c/d/i with cuff up. no
evidence of subcutaneous emphysema. However most of her Tv is
come out through her mouth. She is only getting Tv of 105 to
150's, while she is set for 400.
CV: RRR no m/r/g
PULM: Clear to auscultation but diminished breath sound at the
bases b/l
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
LABORATORY
On admission:
WBC-10.2 RBC-3.06* Hgb-8.6* Hct-28.9* MCV-95 MCH-28.0 MCHC-29.6*
RDW-16.3* Plt Ct-298
Neuts-88.4* Lymphs-7.3* Monos-3.6 Eos-0.5 Baso-0.1
PT-12.2 PTT-28.3 INR(PT)-1.1
Glucose-159* UreaN-38* Creat-1.1 Na-147* K-3.7 Cl-99 HCO3-40*
AnGap-12
Calcium-7.8* Phos-2.5* Mg-1.7
Glucose-159* UreaN-38* Creat-1.1 Na-147* K-3.7 Cl-99 HCO3-40*
AnGap-12
ART pO2-134* pCO2-63* pH-7.39 calTCO2-40* Base XS-10
On discharge:
WBC-7.1 RBC-2.94* Hgb-8.2* Hct-27.2* MCV-93 MCH-27.8 MCHC-30.1*
RDW-16.8* Plt Ct-267
Glucose-114* UreaN-29* Creat-0.8 Na-148* K-2.8* Cl-111* HCO3-32
AnGap-8
Calcium-6.4* Phos-1.9* Mg-1.5*
IMAGING
CXR, pre-op ([**2126-12-29**]):
1. Tracheostomy cannula above the level of the clavicles within
the upper
trachea but rotated and potentially malpositioned.
2. No acute cardiopulmonary process.
CXR, post-op ([**2126-12-30**]):
A tracheostomy tube is in place, the tip lies approximately 16
mm above the carina. This appears to represent a change in the
tracheostomy tube compared with earlier the same day ([**2126-12-29**] at
9:59 a.m.). The cardiomediastinal silhouette is prominent but
unchanged. Some patchy opacity in the left greater than right
suprahilar regions is unchanged. Some bibasilar atelectasis is
also unchanged. Prominent pulmonary artery is again noted in
this individual with history of pulmonary arterial hypertension.
Left wrist plain films ([**2126-12-30**]):
1. No obvious fracture. If there has been significant trauma and
wrist pain persists, then followup radiographs in [**7-8**] days
could help to assess for resorption about an occult fracture.
2. Widening and ? slight offset at the distal radioulnar joint.
This could represent a post-traumatic finding, though it is of
indeterminate acuity.
3. Possible soft tissue swelling, best assessed by physical
exam.
4. First CMC and triscaphe joint degenerative changes.
Brief Hospital Course:
60F admitted on [**2126-12-29**] for tracheostomy malfunction. The patient
was taken to the operating room and, under direct laryngoscopy,
was found to have a dislodged tracheostomy. The tracheostomy
was replaced with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**] tracheostomy piece without
complication. The patient was subsequently admitted to the ICU
for ventilator management and close monitoring.
On hospital day #2 the patient was weaned off the ventilator to
trach collar. Given her poor IV access, a PICC line was placed.
She was transfused 1 unit PRBC for hematocrit 24.7, with
subsequent increase to 29.1. Her anemia was attributed to
anemia of chronic disease given she had no evidence of active
bleeding. Her transfusion was given in conjunction with IV
Lasix to avoid exacerbation of her congestive heart
failure/pulmonary edema. She complained of left wrist pain, for
which plain films were obtained. No fracture was identified.
Given her history of gout, her home allopurinol was restarted
once enteral access was obtained.
On hospital day #3 the patient went to IR for post-pyloric
advancement of a Dobhoff tube. Nutrition was consulted with
recommendations for Replete with fiber tube feedings at a goal
of 55cc/hour. She continued to remain stable from a hemodynamic
and respiratory standpoint and was deemed appropriate for
discharge back to rehab.
Medications on Admission:
- sildenafil 20mg TID
- aspirin 81mg daily
- fluticasone 110mcg inhaled [**Hospital1 **]
- home oxygen 3-4 L/min N/C
- albuterol 90mcg HFA Q6hrs prn wheezing/SOB
- albuterol 2.5mg nebulized Q4hrs prn SOB
- allopurinol 300mg daily
- metolazone 5mg [**Hospital1 **]
- ISS QID
- acetaminophen 500mg Q6hrs prn pain
- ferrous sulfate 300mg daily
- metronidazole 1% gel topically daily
- docusate 100mg [**Hospital1 **]
- bisacodyl 10mg daily
- PEG 17g powder daily
- heparin SQ TID
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours.
2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours.
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
5. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. metolazone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
9. Roxicet 5-325 mg/5 mL Solution Sig: [**5-8**] ml PO every six (6)
hours as needed for pain.
Disp:*400 ml* Refills:*0*
10. simethicone 40 mg/0.6 mL Drops, Suspension Sig: Eighty (80)
mg PO four times a day as needed for indigestion.
11. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg/5 mL
Elixir Sig: Five (5) ml PO three times a day.
12. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Five
(5) ml PO once a day.
13. Miralax 17 gram/dose Powder Sig: Seventeen (17) grams PO
once a day.
14. Insulin
Per insulin sliding scale worksheet.
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] Rehab
Discharge Diagnosis:
1. Malfunctioning tracheostomy
2. Hypercarbic respiratory failure
3. Acute Kidney Injury
4. Cor pulmonale
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:
We appreciated the opportunity to partipate in your care at
[**Hospital1 18**]. As you transition to your extended care facility we
wanted to highlight several ongoing issues with your care:
1. Physical therapy: please work each day with the physical
therapy team. This will increase your strength and improve your
lung function.
2. Abdominal pain: your pain is similar to the chronic pain you
experienced prior to admission. The medical team has contact[**Name (NI) **]
your GI doctor to discuss your hospitalization, but you should
also schedule a follow up appointment with your GI doctor within
the next several weeks to further evaluate and manage your
chronic abdominal
pain.
3. Obstructive sleep apnea: while you are on the vent you will
receive respiratory support while you are both awake and asleep.
When you are weaned from the vent you will need to continue
using your bipap machine while you are asleep. This is very
important as sleep apnea contributes to worsening of your
pulmonary function and heart failure.
4. Rehab course: we believe you are now ready to continue
rehabilitation from your illness at an extended care facility.
Please keep in mind that you were very sick while in the
hospital, and recovery may be prolonged despite not needing to
remain in the hospital at this time. To help guide what types of
things should prompt calling your primary care physician or
returning to the hospital, please refer to the information
listed below.
Followup Instructions:
1. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3029**] at
the following appointment that has been scheduled for you:
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time: [**2127-1-14**] 10:20
2. Please follow up with the acute care surgery clinic in 2
weeks. Your appointment is [**2127-1-9**] at 2pm in the [**Hospital Ward Name **]
Office building at [**Hospital1 18**]. You can call [**Telephone/Fax (1) 600**] for any
questions.
3. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-2-3**]
9:50
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"585.4",
"278.01",
"428.32",
"695.3",
"403.90",
"V85.41",
"274.01",
"493.20",
"428.0",
"250.00",
"V45.86",
"518.83",
"278.03",
"285.29",
"715.36",
"V46.2",
"519.02",
"327.23",
"E878.3",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"38.97",
"96.71",
"96.6",
"33.21",
"97.23"
] |
icd9pcs
|
[
[
[]
]
] |
8301, 8352
|
4901, 6302
|
338, 452
|
8502, 8502
|
2991, 3003
|
10175, 10982
|
2195, 2347
|
6830, 8278
|
8373, 8481
|
6328, 6807
|
8678, 8873
|
2362, 2362
|
8891, 10152
|
3425, 4878
|
271, 300
|
480, 1115
|
3018, 3410
|
8517, 8654
|
1137, 1933
|
1949, 2179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,887
| 107,748
|
15627
|
Discharge summary
|
report
|
Admission Date: [**2156-10-8**] Discharge Date: [**2156-10-13**]
Date of Birth: [**2107-3-3**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 49-year-old male who
presented with chest pain and palpitations to an outside
hospital. He had a positive stress test at that time, and
was transferred to [**Hospital1 69**] for
catheterization. Catheterization showed left main disease
and preserved left ventricular function.
PAST MEDICAL HISTORY: Significant for anxiety, hypertension,
obesity.
MEDICATIONS ON ADMISSION: Atenolol 25 mg by mouth once
daily, aspirin 325 mg by mouth once daily, vitamin E, vitamin
C.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: He was afebrile. His vital signs were
stable. His neck was supple, with no bruits. His lungs were
clear to auscultation bilaterally. His heart was regular
rate and rhythm, with no murmurs, gallops or rubs. His
abdomen was soft, nontender, nondistended, bowel sounds
present. Extremities were warm and well perfused, with no
cyanosis, clubbing or edema.
LABORATORY DATA: White count 6.5, hematocrit 40, platelet
count 213. Sodium 138, potassium 4.1, chloride 105,
bicarbonate 26, BUN 11, creatinine 0.9, glucose 106. PT
12.8, PTT 22.7, INR 1.1.
HOSPITAL COURSE: The patient was planned to have a coronary
artery bypass graft. Due to his left main disease, the
patient was taken to the operating room on [**2156-10-9**], where a
coronary artery bypass graft x 2 was performed. The patient
was transferred to the CSRU postoperatively, and did well.
He was extubated and continued to improve. The patient was
started on beta blockers and lasix, and his chest tubes were
removed. He continued to improve. His Foley was removed,
and the patient was transferred to the floor.
Physical Therapy was consulted at that time for ambulation
and for evaluation of his cardiac rehabilitation potential.
They felt that he would do quite well and, do to his age,
could function well. It was suggested at that time and
decided that the patient would be able to be discharged home.
The patient did well, and was transferred to the floor on
[**2156-10-11**], and continued to improve. His wires were removed on
[**2156-10-12**], and his Lopressor was increased. On [**2156-10-12**], he was
also cleared by Physical Therapy.
The patient was discharged on [**2156-10-13**] in stable condition.
DISCHARGE MEDICATIONS:
1. Motrin 600 mg by mouth every six hours as needed
2. Xanax 0.5 by mouth three times a day as needed
3. Lopressor 50 mg by mouth twice a day
4. Percocet one to two tablets by mouth every four hours as
needed
5. Aspirin 325 mg by mouth once daily
6. Colace 100 mg by mouth twice a day
7. Zantac 150 mg by mouth twice a day
8 Potassium chloride 20 mEq by mouth twice a day
9. Lasix 20 mg by mouth twice a day
DISCHARGE DIAGNOSIS:
1. Anxiety
2. Hypertension
3. Coronary artery disease status post coronary artery
bypass graft x 2
4. Obesity
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: He is instructed to follow up with
Dr. [**Last Name (Prefixes) **] in four weeks and with his primary care
physician in one to two weeks, and with his cardiologist in
two to four weeks.
The patient is discharged home in stable condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 10459**]
MEDQUIST36
D: [**2156-10-12**] 23:32
T: [**2156-10-13**] 00:53
JOB#: [**Job Number 45145**]
|
[
"414.01",
"300.00",
"278.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.53",
"88.56",
"36.11",
"36.15",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
2423, 2842
|
2863, 3532
|
549, 682
|
1278, 2400
|
705, 1260
|
160, 450
|
473, 522
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,800
| 156,641
|
12487
|
Discharge summary
|
report
|
Admission Date: [**2143-11-29**] Discharge Date: [**2143-12-24**]
Date of Birth: [**2079-7-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
ischemic left leg
Major Surgical or Invasive Procedure:
[**2143-11-30**]: Left guillotine below-knee amputation.
[**2143-12-3**]: Debridement of necrotic muscle from the left calf and
completion of left below-knee amputation
[**2143-12-9**]: Left guillotine above-knee amputation, above-knee
amputation
fasciotomy.
[**2143-12-16**]:Debridement of left above-knee amputation wound.
[**2143-12-20**]: Revision and closure of left above knee amputation.
History of Present Illness:
This 64 y/o man with hx of CAD, multiple prior PCI/stents to
LCX/OM last in [**2135**], Ischemic cardiomyopathy with EF of 30% and
extensive PAD s/p failed PCI S/P fem-[**Doctor Last Name **] bypass in [**2142**]
presented to ED on [**2143-11-28**] with LLE ischemia for the last 2
days. Brought to angio and found to have thrombosed left common
femoral artery to below the knee popliteal artery bypass graft.
A thrombolysis catheter was placed with tPA infusion that has
since proved to be futile in relieving occulsion. The following
morning, [**2143-11-29**], Pt had chest pressure and was found to have
trop of 8.14 at 2AM By 5am it had trendned down to 8.08. Ekg
showing mild diffuse ST depressions. CK consistently rose from
231-->310-->1747 with MB concurrently going from
6.7--->6.7-->19.6. CK index actually trended down from 2.9 to
2.2 to 1.1.
.
Patient was taken to cath lab and found to have 100% thrombotic
stenosis within the prior Lcx stent. Was transferred to [**Hospital1 18**]
for LBKA and possible PCI
.
Prior to going o the cath lab the decision was made to not
attempt to revascularize the patient's LCx secondary to risk of
complications and lack of benefit.
.
Patient was admitted to the CCU for medical management and
monitoring with plan to go to OR the following morning. Labs on
admission to the CCU were significant for CK of >19,000.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: PTCA [**2128**] to LPLB with
stenting for restenosis, [**1-/2135**] stenting to proximal LCX
complicated by distal edge dissection requiring distal stenting
and subsequent rescue stenting into jailed OM complicated by
stent thrombosis requiring rheolytic thrombectomy and subsequent
residual distal LCX/LPDA T.O. [**9-/2135**] PCI with stneting of Pcx
and OMi1
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
PVD
Social History:
-Tobacco history: 45 Pack years, still smoking 1ppd
-ETOH: None
-Illicit drugs: None
.
Family History:
Heart disease, Cancer
Physical Exam:
Admission Exam
VS: T=97.7 BP=134/68 HR=107 RR=22 O2 sat= 95%
GENERAL: 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
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g.
LUNGS: CTA BL
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Right leg is WWP. Left leg is cold, mottled and
pulsless from the tibial tuberosity distally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP doppler PT 2+
Left: Radial 2+ DP 0 PT 0
Discharge Exam:
VSS afebrile
Gen: Alert and oriented x3; normal mood and affect
Card: RRR, no m/r/g
Lungs: CTA bilat
Abd: Soft +bs, no m/t/o
Extremities: R PICC line. L AKA stump c/d/i without erythema or
drainage ; RLE warm and well perfused
Pulses: Right fem-palp dp/pt palp
Left fem-palp; AKA
Pertinent Results:
Portable TTE (Complete) Done [**2143-11-29**] at 10:24:31 PM
FINAL
Left Ventricle - Ejection Fraction: 20% to 25%
There is mild symmetric left ventricular hypertrophy. Suboptimal
image quality precludes accurate assessment but there is severe
regional left ventricular systolic dysfunction with akinesis of
the inferior and inferolateral walls.The anterior septum has
relatively normal function. The other walls are not well seen..
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened without
significant stenosis. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). The pulmonary artery systolic pressure could not
be determined. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Severe regional LV systolic dysfunction with severe
hypokinesis/akinesis of at least the inferior and inferolateral
walls. No pathologic valvular abnormality seen.
[**2143-11-29**] 7:22 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2143-12-2**]**
MRSA SCREEN (Final [**2143-12-2**]): No MRSA isolated.
[**2143-12-8**] 10:37 am URINE Source: Catheter.
**FINAL REPORT [**2143-12-9**]**
URINE CULTURE (Final [**2143-12-9**]): NO GROWTH.
[**2143-12-9**] 9:50 am BLOOD CULTURE
**FINAL REPORT [**2143-12-15**]**
Blood Culture, Routine (Final [**2143-12-15**]): NO GROWTH.
Time Taken Not Noted Log-In Date/Time: [**2143-12-9**] 4:40 pm
SWAB LEFT LATERAL THIGH.
**FINAL REPORT [**2143-12-13**]**
GRAM STAIN (Final [**2143-12-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2143-12-11**]):
ENTEROBACTER CLOACAE. RARE 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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2143-12-13**]): NO ANAEROBES ISOLATED.
Log-In Date/Time: [**2143-12-9**] 8:15 pm
SWAB BK SPECIMEN.
**FINAL REPORT [**2143-12-23**]**
GRAM STAIN (Final [**2143-12-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2143-12-11**]):
ENTEROBACTER CLOACAE. HEAVY GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 38750**]([**2143-12-9**]).
BACILLUS SPECIES; NOT ANTHRACIS. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2143-12-13**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2143-12-23**]):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
Log-In Date/Time: [**2143-12-9**] 8:18 pm
TISSUE LEFT LATERAL THIGH.
**FINAL REPORT [**2143-12-23**]**
GRAM STAIN (Final [**2143-12-9**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2143-12-12**]):
REPORTED BY PHONE TO DR.[**Last Name (STitle) 38751**],[**First Name3 (LF) **] ([**2143-12-10**]) AT 1314.
ENTEROBACTER CLOACAE. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 38750**]([**2143-12-9**]).
ANAEROBIC CULTURE (Final [**2143-12-13**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2143-12-23**]): NO FUNGUS ISOLATED.
[**2143-12-13**] 10:13 pm URINE Source: Catheter.
**FINAL REPORT [**2143-12-15**]**
URINE CULTURE (Final [**2143-12-15**]):
YEAST. >100,000 ORGANISMS/ML..
[**2143-12-14**] 11:05 am SWAB Source: L AKA amp site.
**FINAL REPORT [**2143-12-18**]**
GRAM STAIN (Final [**2143-12-14**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2143-12-16**]):
ENTEROBACTER CLOACAE. 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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2143-12-18**]): NO ANAEROBES ISOLATED.
[**2143-12-14**] 11:06 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2143-12-15**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2143-12-15**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2143-12-16**] 12:05 pm TISSUE LEFT AKA WOUND.
**FINAL REPORT [**2143-12-20**]**
GRAM STAIN (Final [**2143-12-16**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2143-12-19**]):
ENTEROBACTER CLOACAE. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
310-9315B
[**2143-12-14**].
ANAEROBIC CULTURE (Final [**2143-12-20**]): NO ANAEROBES ISOLATED.
[**2143-12-16**] 12:09 pm SWAB LEFT MEDIAL AKA WOUND.
**FINAL REPORT [**2143-12-20**]**
GRAM STAIN (Final [**2143-12-16**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2143-12-19**]):
ENTEROBACTER CLOACAE. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
310-9315B
[**2143-12-14**].
ANAEROBIC CULTURE (Final [**2143-12-20**]): NO ANAEROBES ISOLATED.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2143-12-24**] 05:15 4.2 2.91* 8.9* 25.5* 88 30.7 34.9 13.8 565*
Source: Line-picc
[**2143-12-23**] 04:00 4.3 2.85* 8.6* 25.2* 88 30.1 34.1 14.0 522*
Source: Line-PICC
[**2143-12-21**] 04:51 6.1 3.12* 9.4* 27.0* 87 30.2 34.9 14.5 543*
Source: Line-PICC
[**2143-12-20**] 10:43 9.9 3.67* 10.7* 31.3* 85 29.1 34.1 14.6 632*
[**2143-12-20**] 05:59 9.7 3.34* 9.9* 29.1* 87 29.5 33.9 14.4 596*
Source: Line-PICC
[**2143-12-19**] 05:45 5.9 3.21* 9.8* 28.4* 88 30.4 34.3 14.4 590*
Source: Line-PICC
[**2143-12-18**] 22:25 27.5*
Source: Line-PICC
[**2143-12-18**] 05:32 7.7 2.69* 8.2* 24.5* 91 30.6 33.7 14.3 633*
Source: Line-PICC
[**2143-12-17**] 03:15 9.1 3.21* 9.8* 29.1* 91 30.6 33.7 14.2 622*
Source: Line-picc
[**2143-12-16**] 14:39 10.0 3.36* 10.2* 30.6* 91 30.3 33.3 14.1
734*
Source: Line-PICC
[**2143-12-16**] 01:39 7.1 3.42* 10.6* 30.8* 90 31.0 34.4 14.2 693*
Source: Line-picc
[**2143-12-15**] 07:09 11.0 3.75* 11.5* 34.1* 91 30.7 33.7 14.3
753*
[**2143-12-13**] 06:30 11.7* 3.76* 11.5* 34.5* 92 30.5 33.2 14.3
802*
[**2143-12-12**] 05:56 12.7* 3.26* 10.1* 29.8* 91 30.9 33.8 14.4
798*
Source: Line-art
[**2143-12-11**] 05:50 15.1* 3.26* 10.0* 28.9* 89 30.5 34.4 14.4
660*
Source: Line-art
[**2143-12-10**] 12:59 14.0* 3.19* 9.8* 28.4* 89 30.6 34.3 14.4
646*
Source: Line-aline
[**2143-12-10**] 03:20 12.6* 2.87* 8.8* 25.6* 89 30.5 34.3 13.9
693*
Source: Line-aline
[**2143-12-9**] 15:40 14.7* 3.27* 9.9* 28.9* 88 30.3 34.3 13.7
706*
[**2143-12-9**] 08:25 15.9* 2.99* 9.0* 27.4* 92 30.2 33.0 13.4
851*
[**2143-12-8**] 09:20 17.5* 3.04* 9.4* 27.1* 89 30.8 34.6 13.1
671*
[**2143-12-6**] 06:45 13.8* 3.17* 9.7* 28.6* 90 30.7 34.0 12.9
569*
[**2143-12-5**] 07:00 11.2* 3.18* 9.7* 28.5* 90 30.4 33.9 12.9
590*
[**2143-12-4**] 07:10 8.4 3.18* 10.1* 28.6* 90 31.6 35.2* 12.9
483*
[**2143-12-3**] 18:46 11.3* 3.31* 10.6* 28.8* 87 31.9 36.6* 12.9
430
Source: Line-a line
[**2143-12-3**] 07:05 10.3 3.44* 10.7* 29.9* 87 31.1 35.7* 12.9
373
[**2143-12-2**] 08:05 10.8 3.83* 11.9* 34.3* 89 31.1 34.8 12.6 375
[**2143-12-1**] 19:03 32.3*
[**2143-12-1**] 15:40 9.2 3.75* 11.7* 32.9* 88 31.2 35.6* 12.9 290
[**2143-12-1**] 04:42 8.0 3.90* 11.8* 34.0* 87 30.4 34.8 13.1 266
Source: Line-aline
[**2143-11-30**] 15:08 8.9 3.85* 11.8* 34.4* 89 30.8 34.5 12.9 248
Source: Line-aline
[**2143-11-30**] 04:53 10.1 4.30* 13.5* 37.7* 88 31.3 35.7* 13.2
252
[**2143-11-29**] 19:22 9.6 4.24* 13.0* 37.0* 87 30.7 35.1* 13.4 243
Source: Line-art line
[**2143-11-29**] 16:10 10.5 4.26* 13.3* 37.1* 87 31.2 35.8* 13.4
243
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2143-12-24**] 05:15 120*1 4* 0.4* 137 3.9 103 28 10
Source: Line-picc
[**2143-12-23**] 04:00 177*1 7 0.6 134 4.3 98 30 10
Source: Line-PICC
[**2143-12-22**] 05:00 136*1 7 0.5 134 4.3 98 31 9
Source: Line-picc
[**2143-12-21**] 04:51 169*1 8 0.5 130* 4.5 96 29 10
Source: Line-PICC
[**2143-12-20**] 10:43 182*1 7 0.6 132* 4.8 99 27 11
[**2143-12-20**] 05:59 157*1 8 0.5 131* 4.5 98 29 9
Source: Line-PICC
[**2143-12-19**] 05:45 133*1 9 0.5 131* 4.3 98 29 8
Source: Line-PICC
[**2143-12-17**] 03:15 163*1 9 0.6 135 4.4 103 26 10
Source: Line-picc
[**2143-12-16**] 17:57 154*1 10 0.6 133 4.3 103 24 10
Source: Line-picc
[**2143-12-16**] 01:39 152*1 10 0.5 135 4.2 102 25 12
Source: Line-picc
[**2143-12-15**] 07:09 144*1 9 0.6 134 4.6 100 27 12
[**2143-12-13**] 06:30 142*1 11 0.6 133 4.6 98 27 13
[**2143-12-12**] 06:16 162*1 12 0.6 131* 4.7 100 25 11
Source: Line-art
[**2143-12-11**] 05:50 146*1 12 0.5 136 4.5 101 27 13
Source: Line-art
[**2143-12-10**] 03:20 173*1 19 0.6 137 3.9 100 31 10
Source: Line-aline
[**2143-12-9**] 15:40 247*1 20 0.7 136 4.2 99 27 14
[**2143-12-9**] 08:25 208*1 21* 0.7 134 4.4 95* 30 13
[**2143-12-8**] 09:20 185*1 29* 0.8 132* 5.1 93* 27 17
[**2143-12-6**] 06:45 154*1 14 0.8 132* 4.8 95* 27 15
[**2143-12-5**] 07:00 130*1 13 0.7 131* 4.8 95* 28 13
[**2143-12-4**] 07:10 147*1 20 0.8 134 4.4 98 28 12
[**2143-12-3**] 18:46 120*1 19 0.9 136 4.0 103 24 13
Source: Line-a line
[**2143-12-3**] 07:05 145*1 15 0.6 134 4.3 98 26 14
[**2143-12-2**] 08:05 160*1 17 0.6 135 4.1 98 26 15
[**2143-12-1**] 15:40 213*1 16 0.8 133 4.3 99 26 12
[**2143-12-1**] 04:42 198*1 16 0.7 136 4.4 102 27 11
Source: Line-aline
[**2143-11-30**] 15:08 20 0.7 137 3.6 100 29 12
Source: Line-aline
[**2143-11-30**] 04:53 228*1 19 0.9 135 3.9 96 27 16
[**2143-11-30**] 00:44 234*1 19 0.9 134 3.8 97 27 14
[**2143-11-29**] 19:22 311*1 19 0.9 135 4.0 98 25 16
Source: Line-art line
[**2143-11-29**] 16:10 285*1 19 0.9 136 4.0 99 24 17
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2143-12-22**] 05:00 2211
Source: Line-picc
[**2143-12-21**] 04:51 11 22 57 0.8
Source: Line-PICC
[**2143-12-20**] 10:43 2741
[**2143-12-10**] 12:59 432*1
Source: Line-aline
[**2143-12-10**] 03:20 53* 102* 916*1 124 3.2*
Source: Line-aline
[**2143-12-9**] 15:40 2050*1
[**2143-12-9**] 00:35 2593*2
[**2143-12-8**] 18:15 2835*1
[**2143-12-8**] 10:15 2888*1
[**2143-12-7**] 06:05 2903*3
[**2143-12-6**] 10:50 3675*1
[**2143-12-4**] 08:40 1835*1
[**2143-12-4**] 07:10 55* 84* 55 0.8
[**2143-12-4**] 02:23 2821*1
[**2143-12-3**] 18:46 5014*1
Source: Line-a line
[**2143-12-2**] 08:05 5790*1
[**2143-12-1**] 15:40 6846*1
[**2143-12-1**] 04:42 8359*4
Source: Line-aline
[**2143-11-30**] 15:08 [**Numeric Identifier 38752**]*1
Source: Line-aline
[**2143-11-30**] 04:53 [**Numeric Identifier 38753**]*5
[**2143-11-30**] 00:44 [**Numeric Identifier 38754**]*5
[**2143-11-29**] 19:22 [**Numeric Identifier 38755**]*1
Source: Line-art line
[**2143-11-29**] 16:10 74* 265* [**Numeric Identifier 38756**]*1 55 19 1.0 0.3 0.7
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2143-12-22**] 05:00 2 0.15*1
Source: Line-picc
[**2143-12-21**] 04:51 0.18*1
Source: Line-PICC
[**2143-12-20**] 10:43 0.22*2
[**2143-12-10**] 12:59 5 0.50*1
Source: Line-aline
[**2143-12-10**] 03:20 4 0.60*1
Source: Line-aline
[**2143-12-9**] 15:40 3 0.53*1
[**2143-12-9**] 00:35 4 0.58*1
[**2143-12-8**] 18:15 4 0.62*1
[**2143-12-8**] 10:15 5 0.67*1
[**2143-12-7**] 06:05 6 1.04*1
[**2143-12-6**] 10:50 8 0.96*1
[**2143-12-6**] 06:45 9 0.90*1
[**2143-12-5**] 07:00 13* 1.08*1
[**2143-12-4**] 08:40 7 1.44*1
[**2143-12-4**] 07:10 1.43*1
[**2143-12-4**] 02:23 9 1.51*1
[**2143-12-3**] 18:46 14* 0.3 1.71*1
Source: Line-a line
[**2143-11-30**] 04:53 91* 0.3
[**2143-11-30**] 00:44 98* 0.3
[**2143-11-29**] 19:22 91* 0.4 1.91*1
Source: Line-art line
[**2143-11-29**] 16:10 90* 0.5 2.02
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2143-12-24**] 05:15 7.3* 3.3 1.6
Source: Line-picc
[**2143-12-23**] 04:00 8.2* 2.9 1.6
Source: Line-PICC
[**2143-12-22**] 05:00 7.8* 2.8 1.9
Source: Line-picc
[**2143-12-21**] 04:51 8.1* 2.6* 1.6
Source: Line-PICC
[**2143-12-20**] 10:43 9.1 3.9 1.5*
[**2143-12-20**] 05:59 8.1* 2.5* 1.7
Source: Line-PICC
[**2143-12-19**] 05:45 8.2* 2.7 1.7
Source: Line-PICC
[**2143-12-17**] 03:15 8.3* 3.2 1.9
Source: Line-picc
[**2143-12-16**] 17:57 7.7* 3.0 1.6
Source: Line-picc
[**2143-12-16**] 01:39 7.6* 2.2* 1.9
Source: Line-picc
[**2143-12-15**] 07:09 8.4 2.5* 1.9
[**2143-12-13**] 06:30 8.3* 2.3* 1.8
[**2143-12-12**] 06:16 8.0* 2.5* 1.7
Source: Line-art
[**2143-12-10**] 03:20 7.8* 2.8 1.9
Source: Line-aline
[**2143-12-9**] 15:40 8.0* 3.7 1.8
[**2143-12-9**] 08:25 8.8 3.6 2.1
[**2143-12-8**] 09:20 8.9 3.6 2.3
[**2143-12-4**] 07:10 8.9 3.6 2.0
[**2143-12-3**] 18:46 8.2* 4.2 2.2
Source: Line-a line
[**2143-12-3**] 07:05 8.7 3.4 1.8
[**2143-12-2**] 08:05 8.8 2.8 2.0
[**2143-12-1**] 15:40 8.3* 3.0 2.0
[**2143-12-1**] 04:42 8.0* 1.8* 2.0
Source: Line-aline
[**2143-11-30**] 04:53 8.1* 2.5* 2.0
[**2143-11-30**] 00:44 8.2* 2.7 2.3
[**2143-11-29**] 19:22 8.0* 2.5* 1.7
PITUITARY TSH
[**2143-12-17**] 17:13 0.98
Brief Hospital Course:
64 year old man with long history of CAD, PVD and smoking
presented to OSH with ischemic LLE secondary to thrombosed
fem-[**Doctor Last Name **] bypass and found to have troponin elevation and coronary
cath consistent with remote cardiac event in prior 5 days.
Underwent a thrombolysis procedure w/ TPA infusion at OSH.
However, no improvement to LLE ischemia and continued to worsen.
Transfered to [**Hospital1 18**] for further evaluation. Put on heparin gtt,
seen by Vascular and found to have non salvagable left foot. He
was taken for L Guillotine BKA on [**2143-11-30**]. He had nectotic
tissue at the base of his amputation site and was taken back to
the OR on [**12-3**] where he had Debridement of necrotic muscle from
the left calf and completion below-knee amputation. He was
monitored closely in the VICU and subsequently developed
necrosis of the distal skin of the below-knee amputation. This
was noted to progress with blistering and
therefore was planned for above-knee amputation. Between the
time of morning rounds and operation in the early afternoon, he
was noted to have some erythema and bogginess extending up the
lateral aspect of the thigh. He then underwent Amputation,
guillotine, above-knee amputation fasciotomy on [**12-9**]. A wound
VAC was subsequently placed and his wound was monitored closely.
He had mulitple sets of wound cultures and tissue cultures which
ultimately grew ENTEROBACTER CLOACAE. He was seen by ID and
placed on meropenem, which should be given through [**2143-12-30**]. On
[**12-16**] he was taken back to the OR for debridement of left
above-knee amputation wound. A dry sterlile dressing was placed,
and the next day a VAC was again put on the open wound. On [**12-20**]
he was taken for revision and closure of left above knee
amputation. He tolerated the procedure well. He remained in the
VICU for several days with close monitoring. He worked with PT,
tolerated a regular diet and voided without difficulty. On [**12-24**]
he was deemed stable for discharge to rehab.
.
# CORONARIES: 100% occulusion of LCx stent. Did not
revascularize as evidence does not piont to an improvement in
outcomes in revascularizing the stent. Continued medical
management of CAD with ASA, plavix, BB and statin and ACE I.
.
# PUMP: Previous EF reportedly 30%, now 20-25%. Patient is at
risk for post infarct structural/functional complications. Echo
reported severe regional LV systolic dysfunction with severe
hypokinesis/akinesis of at least the inferior and inferolateral
walls, consistent with his Left circ stent occlusion.
.
# RHYTHM: NSR. Would benefit from ICD outpatient given EF<35%.
Pt told he should follow up with cardiology outpatient regarding
this matter.
.
# Ischemic leg: Pt with ischemic left leg. Vascular surgery
performed left BKA, complicated by necrotic tissue requiring
multiple debridements and ultimately an AKA. His wound is closed
and healing nicely at this time.
.
#Creatinine Kinase: CK peaked at 33,000 in the setting of
ischemic leg. No signs of renal failure. Pt was hydrated to
protect kidneys. CK dropped after BKA.
.
#DM: Held oral agents and continued home Lantus with ISS on
admission. Should resume home regimen at discharge and be
followed up by PCP/endocrinologist.
.
HTN: Switched atenolol to metoprolol given initial risk of [**Last Name (un) **]
in setting of elevated CK and leg ischemia. Should remain on
metoprolol at discharge and f/u with cardiology
.
#HLD: continued statin
.
#ID: Meropenem 1gram q8h thru [**2143-12-30**]. PICC line should be
d/c'd after last dose. F/U in [**Hospital **] clinic [**2144-1-31**] 9am
Medications on Admission:
Atenolol 25mg QD
Plavix 75 mg QD
Glyburide 5mg QD
Lantus 30U QHS
Lisinopril 10mg QD
Metformin 1000mg QD
Actos 30mg QD
Simvastatin 40mg QD
Warfarin 2.5mg [**1-19**] tab QD
Aspirin 81mg QD
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for muscle spasm.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q12H (every 12 hours).
11. morphine 15 mg Tablet Sig: One (1) Tablet PO Q 3H PRN () as
needed for pain.
12. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
13. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
14. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. heparin (porcine) 5,000 unit/mL Solution Sig: Five (5)
thousand units Injection TID (3 times a day).
16. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
17. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
19. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
20. glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
21. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
22. Outpatient Lab Work
Please check CBC, LFTs, Chem 7 on [**12-27**].
23. D/C PICC LINE
After last meropenum dose on [**2143-12-30**]
24. Heparin Flush 10 unit/mL Kit Sig: Two (2) ml Intravenous
every six (6) hours as needed for line flush: PICC, heparin
dependent: Flush with 10mL Normal Saline followed by Heparin as
above daily and PRN per lumen. .
25. meropenem 1 gram Recon Soln Sig: One (1) gram Intravenous
every eight (8) hours for 7 days: through [**2143-12-30**]. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
- Thrombosed left fem-[**Doctor Last Name **] bypass with no viable left foot
- Necrotic infected left below-knee stump.
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:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Discharge Instructions:
.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 for 4-6 weeks. You should
keep this amputation site elevated when ever possible.
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).
.New pain, numbness or discoloration of your foot or toes.
.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.
.No heavy lifting greater than 10 pounds for the next 14 days.
.Try to keep leg elevated when able.
.BATHING/SHOWERING:
.You may shower immediately upon coming home. No bathing. 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:
.We have stopped your coumadin; you do not to be on this for
your graft since you have had an amputation. We have changed
your beta blocker from atenolol to metoprolol. You will be
given a new prescription for pain medication, which can be taken
every three (3) to four (4) hours only if necessary. Also, you
will be on IV antibiotics through ecember 13th for the infection
you had. After you finish the antibiotic, your PICC line may be
removed.
.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 vascular 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 keep your follow-up visit. This should be scheduledprior
to your discharge.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
Vascular Surgery:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD
[**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2144-1-9**] 9:15
Infectious Disease:
Dr. [**Last Name (STitle) 2324**] [**Name (STitle) 2323**]
[**2144-1-31**] 09:00a
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
ID WEST (SB)
Please make appointment with your cardiologist and pcp [**Last Name (NamePattern4) **] [**1-19**]
weeks after discharge from rehab.
Completed by:[**2143-12-24**]
|
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icd9cm
|
[
[
[]
]
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[
"84.17",
"84.15",
"83.14",
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icd9pcs
|
[
[
[]
]
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25982, 26079
|
19808, 23426
|
334, 731
|
26244, 26244
|
3874, 19785
|
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|
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26259, 26396
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|
2712, 2801
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,866
| 164,680
|
32653
|
Discharge summary
|
report
|
Admission Date: [**2126-10-9**] Discharge Date: [**2126-10-22**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is an 85 year old male, admitted for multiple
rib, pelvic and scapular fractures after falling down 7 front
steps while trying to pick up a package and the newspaper on
[**2126-10-9**]. He remembers the events leading up to the fall, but
does not recall anything afterwards. He was found unconscious in
a pool of blood after approximately 15 minutes by his daughter,
who called an ambulance. He has a history of multiple falls due
to unsteady gait, but never resulting in injuries of this
severity. Pt was transferred from OSH to [**Hospital1 **] for evaluation.
Past Medical History:
1) CLL - diagnosed in [**2120**], treated with oral chemotherapy
2) SCC - treated with radiation in [**2126-4-19**], resulted in right
facial nerve palsy
3) Right retinal artery stroke - approx. 20 years ago, resulted
in lower altitudinal visual field defect
4) Peripheral neuropathy of lower extremities - believed to be
secondary to chemotherapy
5) End stage renal failure - secondary to chemotherapy
6) L4-L5 intervertebral disc herniation
Social History:
SH: Former contractor. Retired in [**2120**] due to diagnosis of CLL.
Married with children.
Denied ETOH, Tobacco, Drug use
Family History:
No family history of parkinson's disease or other neurologic
disease. Father died at age 86 of MI, mother died at age 40.
Physical Exam:
On [**2126-10-16**]
VITAL SIGNS: T 97.3, BP 131/41, RR 22, SaO2 97% on humidified
tent mask
GEN: Elderly male, lying in bed. Appears much more comfortable
than prior exams.
HEENT: NCAT, Rt eye with reddened/swollen conjunctiva.
RESP: Anterior exam only - CTA bilaterally no w/c/r. Good air
movement. Can take deep breaths on command.
COR: Distant heart sounds, but RRR
ABD: Soft, non-distended, nontender, no masses, no guarding, BS
+.
GU: Foley in place - scrotal swelling significantly decreased.
EXT: Decreasing edema from prior exams.
Skin: Bilateraly heels with cracking [**12-21**] dry skin. No skin
breakdown. Significant erythema, tenderness, and skin breakdown
around scrotum
NEURO: Will open eyes to voice. Lethargic. Follows 1 step
commands. Oriented to self, place "hospital", and year. Thinks
it is [**Month (only) 1096**]. Does not recall fall down stairs. Rt sided
facial droop (old). Mild dysarthria (believed to be old).
Pertinent Results:
[**2126-10-9**] 08:56PM URINE RBC-[**4-28**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0
[**2126-10-9**] 08:56PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
The patient was admitted to the hospital on [**2126-10-9**]. He had
entensive imaging which included the following studies:
[**10-9**]: R scapula: comminuted fracture through the body of the
scapula. There are associated right lateral rib fractures of the
third, fourth, and fifth ribs
[**10-9**] CT pelvis: Nondisplaced right iliac fracture, which
extends to the SI joint without diastasis of the joint. No
additional fractures seen. Hematoma in the right gluteus muscles
extending into the flank and into the right upper thigh. Right
paracolic gutter hematoma with free fluid in deep pelvis and
presacral area.
[**10-11**] CT head: Bifrontal extra-axial fluid collections which may
represent prominent CSF spaces due to bifrontal atrophy, but
bilateral chronic subdural hematomas or cystic hygromas cannot
be excluded.
#Orthopedic Injuries:
Given his multiple fractures, he was admitted to the hospital
for pain control since his orthopedic injuries were deemed
non-operative by orthopedic surgery. His right arm was kept in a
sling early on and he was seen by PT and OT. His current
disposition is to be full weight bearing of his RUE and touch
down weight bearing of his right leg.
#Acute on Chronic Renal Insuffciency:
The patient is known to have ESRD likely secondary to
chemotherapy. His Cr was 1.5 on presentation and peaked at 2.5
on HD3. His pottasium peaked on admission at 7.5 and lowered to
a normal level by HD3. His pottasium was controlled by
kayexelate, fluids, and lasix. He was seen by the nephrology
service who thought his acute on chronic renal insufficiency was
likely due to a contrast nephropathy
#Hypoxia:
The patient was at known increased risk for splinting and
pulmonary pathology given his multiple rib and sternal
fractures. Consequently, incentive spirometry was greatly
encouraged as well as the implementation of chest PT, pulmonary
toilet, and standing narcotics for pain control. On HD7, the
patient developed worsening respiratory distress and increasing
oxygen requirements as well as worsening delerium. He was then
transferred tot he ICU where he had an inital oxygen saturation
of 96% on 4L NC. His aggressive pulmonary toilet was continued
there with increased suctioning and chest PT. Within 48 hours,
his respiratory and mental status had greatly improved such that
he was transferred back to the floor without subsequent
complication. He currently has an oxygen saturation of 98% on
RA.
#Delerium:
Likely causes of delirium include infection, medication, and
sleep-deprivation. The patient's symptoms steadily improved as
his pain was better controlled and his renal insuffiency was
improved. Currently he is A and O x 3 and functioning at his
baseline mental status per family members.
Medications on Admission:
ARtificial tears 1.4% providone QID, B12, glucosamin 500, vit C
500, ASA 81', Ca carbonate 650'', citalopram 40', amitriptyline
10', loratadine 10', darboepoetin [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] 200mg/.4 mlq2wks,
amlodipine 5mg', fosinoprl 20 mg', vicodin 2 tabs TID,
omeprazole 20', ocuvite preservision 2 [**Hospital1 **], penlac nail ',
e-mycin eye oint QID
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: per SS
Injection ASDIR (AS DIRECTED).
2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Ocuvite PreserVision Oral
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-20**]
Drops Ophthalmic PRN (as needed).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: [**11-20**] PO BID (2 times a
day).
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4-6H () as needed.
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
17. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
19. HydrALAzine 10 mg IV Q4-6H:PRN SBP>160
Hold for SBP<159
20. Metoprolol 10 mg IV Q4H:PRN SBP>160
21. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
22. Darbepoetin Alfa In Polysorbat 200 mcg/0.4 mL Syringe Sig:
One (1) Injection every 2 weeks, on Saturday: Please give this
Saturday.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] Court
Discharge Diagnosis:
Scapula body comminuted fracture
3rd, 4th, 5th lateral rib fractures
Nondisplaced right iliac fracture
Acute on chronic renal insufficiency-resolved
Delerium-resolved
Discharge Condition:
good
Discharge Instructions:
Please return to the hospital if you have fever, shortness of
breath, chest pain, fever, or any concnerns.
Please take your medications as directed including finishing a 5
day course of cipro for a urinary tract infection.
Please follow the recommendations of the physcial therapists in
terms of rehabilitation from your multiple fractures.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics, in 4 weeks. Call
[**Telephone/Fax (1) 1228**] for an appointment. Inform the office that you will
need a CT scan of her pelvis and right scapula for this
appointment.
Please follow up with trauma clinic. Call [**Telephone/Fax (1) 6429**] for an
appointment.
|
[
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"E880.9",
"V44.1",
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icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7863, 7919
|
2861, 3489
|
271, 278
|
8130, 8137
|
2622, 2838
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8528, 8853
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1523, 1647
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7940, 8109
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5628, 6023
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8161, 8505
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1662, 2603
|
223, 233
|
306, 897
|
3498, 5602
|
919, 1364
|
1380, 1507
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,620
| 119,318
|
879
|
Discharge summary
|
report
|
Admission Date: [**2200-12-13**] Discharge Date: [**2200-12-22**]
Date of Birth: [**2141-8-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 6013**] is a 59 year-old male with schizophrenia, dementia,
COPD, unspecified CHF, seizure disorder, current smoker, and
recent pneumonia treated with levofloxacin ([**9-17**]) admitted from
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home and Rehab ([**Name8 (MD) 4134**], RN; [**Telephone/Fax (1) 6014**])
with shortness of breath and hypoxia. Per EMS notes, patient
yelled for help at 0500 and found to have oxygen saturation 70%;
T 98.7; BP 117/75; HR 118; RR 24. Nebulizer with minimal
improvement. NRB started with oxygen saturation improved to over
90%. Noted to be rhonchorous at bases bilaterally. No LOC. No
seizure activity. Per discussion with nursing staff at facility,
patient without chest pain, fevers, chills, myalgias, nausea,
vomiting, diarrhea. At baseline has productive cough. Also with
SOB at baseline, needs daily nebs. No known OSA.
Of note, received pneumovac [**2199-11-4**], seasonal flu vac [**2200-10-20**].
Normal oxygen saturation 90-91% on RA; 93-94%RA after nebulizer
treatment.
In the ED, 98 114 121/79 24 97%NRB. Patient unable to provide
history. Physical exam notable for tachypnea, diffuse rhonchi;
appeared dry. Laboratory data significant for leukocytosis to
18.3 with left-shift, mild hypernatremia (146), first set
cardiac markers WNL, and lactate 1.9. CXR reportedly with
possible left basilar infiltrate. Given IVF, nebs, levofloxacin
750mg IV x1, vancomycin 1gm IV x1, and solumedrol 125mg IV x1.
On transfer to ICU, RR improved to 24, 93% on 4L NC, HR in
110's, normotensive.
On arrival to the ICU, patient reports feeling well. Complains
of shortness of breath. Not able to recall events this morning.
Reports chronic cough, nonproductive. Denies chest pain, back
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
difficulty with urination, dysuria.
Past Medical History:
- Seizure disorder; last seizure [**9-17**]
- Dementia
- Paranoid schizophrenia
- Alcohol seizures and delirium tremens in [**2174**]
- Positive PPD in [**2181-1-8**] (12cm wheel), no treatment
- Asthma
- COPD; severe; on chronic prednisone; continues to smoke
- CHF unspecified
- s/p right THR for osteoarthritis
- Anxiety
- Cataract
- Chronic rhinitis
Social History:
Long-term resident of [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home and Rehab.
Largely wheel-chair bound. Continues to smoke - quantity
unknown. No current alcohol or illicit drug use.
Family History:
Non-contributory
Physical Exam:
99.6; 109; 143/78; 24; 90% 6L NC + shovel mask
General: Alert, comfortable
HEENT: Sclera anicteric, dry mucous membranes
Neck: Supple, no appreciable JVD
Lungs: Nonlabored; diffuse expiratory wheezes, rhonchi; no
crackles appreciated
CV: Tachycardic; normal S1/S2; no murmurs appreciated
Abdomen: Obese; hypoactive bowel sounds; diffuse abdominal
tenderness to palpationl; no rebound tenderness/guarding
Ext: Warm, well-perfused; radial and DP pulses 2+; no lower
extremity edema
Neuro: Will not cooperate with exam; AOx1 (person only); able to
move all extremities
Pertinent Results:
ADMISSION LABS [**2200-12-13**]:
[**2200-12-13**] 07:15AM WBC-18.3* Hgb-16.0 Hct-48.0 Plt Ct-306
[**2200-12-13**] 07:15AM Neuts-85.3* Lymphs-9.9* Monos-3.8 Eos-0.5
Baso-0.4
[**2200-12-13**] 07:15AM Glucose-131* UreaN-23* Creat-0.7 Na-146* K-4.8
Cl-99 HCO3-31 AnGap-21*
[**2200-12-13**] 07:15AM CK(CPK)-47 CK-MB-NotDone cTropnT-<0.01
[**2200-12-13**] 07:31AM BLOOD Lactate-1.9
ABG
[**2200-12-13**] 03:21PM Type-ART pO2-63* pCO2-55* pH-7.45 calTCO2-39*
Base XS-11
CE Trend:
[**2200-12-13**] 07:15AM CK(CPK)-47 CK-MB-NotDone cTropnT-<0.01
[**2200-12-13**] 05:38PM CK(CPK)-19* CK-MB-NotDone
[**2200-12-14**] 01:22AM CK(CPK)-24* CK-MB-2 cTropnT-<0.01
UA:
[**2200-12-14**] 05:35PM Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2200-12-14**] 05:35PM Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2200-12-14**] 05:35PM RBC-11* WBC-<1 Bacteri-NONE Yeast-NONE Epi-0
MICROBIOLOGY:
[**2200-12-13**] BCx: negative
[**2200-12-14**] DFA: negative
[**2200-12-14**] UCx: negative
STUDIES:
[**2200-12-13**] CXR:
Patchy opacity noted at the left lung base obscuring the left
costophrenic angle. Please correlate with subsequent CT chest
[**2200-12-13**] CT chest:
1. No pulmonary embolism.
2. Atelectasis at the base of the left lower lobe.
3. Emphysema.
[**2200-12-15**]
STUDY: AP abdominal radiograph and left lateral decubitus
abdominal
radiograph.
COMPARISON: None.
FINDINGS: Gas and stool is seen throughout the colon. There are
no dilated
loops of small bowel, nor are there any air-fluid levels. No
pneumoperitoneum
is seen. A left total hip arthroplasty is seen without evidence
of failure or
loosening. Opacity seen in the left lower lobe is concerning for
an
infiltrate.
IMPRESSION:
1. No evidence of obstruction or perforation.
2. Left lower lobe infiltrate.
[**2200-12-17**]
UPRIGHT AP VIEW OF THE CHEST: Mild enlargement of the heart is
unchanged in
comparison to prior exam. There is an ill-defined new right
upper lobe
opacity, consistent with clinical suggestion of aspiration. The
previously
seen left lower lobe opacity has slightly increased in density
on the current
exam. The remaining areas of the lungs are clear. Hilar and
mediastinal
contours are relatively unchanged.
IMPRESSION: New right upper lobe opacity, and increased left
lower lobe
opacity compatible with clinical suggestion of aspiration with
concern for
pneumonia.
The study and the report were reviewed by the staff radiologist.
[**2200-12-18**]
STUDY: Video oropharyngeal swallow studies; multiple
consistencies of barium were administered under fluoroscopic
observation in conjunction with the speech and swallow division.
FINDINGS: Barium passed freely without evidence of obstruction.
Penetration was noted with thin liquids and nectar. One episode
of silent aspiration was noted with thin liquids. For more
details, please see the speech and swallow division note in the
online medical record.
IMPRESSION: Penetration with thin liquids and nectar; one
episode of silent aspiration with thin liquids.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
59M with schizophrenia, COPD on chronic steroids, unspecified
HF, current smoker admitted from nursing home for COPD
exacerbation.
1. Acute Exacerbation of COPD: The patient's baseline oxygen
saturation in low 90s, likely secondary to known severe COPD. He
was admitted to the ICU given his presentation of hypoxia with
02 sat's in the 70s. There was originally a question of whether
he had a PNA given his LLL consolidation but only atelectasis
was seen on CTA. No PE was noted. He remained afebrile. He was
treated for a COPD flare with nebulizers, azithromycin, the
course now completed, and steroids with improvement. He was
transferred to the floor. He was noted to be choking up with
feeding.A video swallow study showed that he had had some
silent aspiration. A subsequent CXR showed a RUQ infiltrate
indicating a pneumonia, which may have had some contribution
from aspiration. Given his poor dentition, and given that he
developed this aspiration during his hospitalization this was
treated as a HCAP. He was treated with vancomycin and zosyn with
effect. He will have a total antibiotic course of 8 days. He
will also undergo a two week steroid taper. He had already
received the pneumoccal vaccine and seasonal flu vaccine. The
H1N1 is still not available to inpatients at [**Hospital1 18**] thus this was
not given. He had needed supplemental oxygen during his
hospitalization, but was discharge on room air.
2. ? Aspiration:He was noted to have had some choking during
feeding. He had a bedside swallow evaluation which showed that
he was having some silent aspiration.
Pureed solids, with nectar prethickened liquids were
recommended, and he tolerated this regimen well with no further
episodes of choking during feeding.
3. Rash: He had a blanching erythematous rash involving
bilateral thighs to upper calves. This was felt likely to be
physiologic livedo reticularis and likely benign.
4. Urinary Incontinence: He continued to have urinary
incontinence which is his baseline. Condom catheters were used
during this hospitalization.
5. Abdominal Pain: pt was diffusely TTP on admission. However
his abdomen remained soft, with no evidence rebound/guarding. A
KUB was negative. His abdominal pain resolved following
passing of a large BM.
6. Hypotension: He had been initially hypotensive in the ICU. He
did not need pressors. His blood pressures remained within
normal limits on the floor. He continued to recieve his home
lasix.
9. EKG changes: He did not have any chest pain, however given
his pulmonary presentation he got an EKG and he was ruled out
for MI by enzymes. He did have some TW inversion in I, aVL with
improvement to flattening on repeat EKG. Also with flattening in
v1/v2 compared to baseline EKG from 16 years ago.
10. Seizure disorder: Last seizure reportedly [**9-17**].
- Continue divalproex and phenobarb per home regimen
11. Chronic rhinitis:
- Continued fluticasone per home regimen
12. GERD: He was initially on omeprazole at home. Given that he
was on high dose steroids, and all his medications had to be
crushed or dissolvable, he was switched to dissolvable
lansoprazole.
13. Paranoid schizophrenia, general anxiety disorder: He was
continued on olanzapine per home regimen.
14. Smoker: unknown how many PPD
-recieved the nicotine patch
Medications on Admission:
- Depakote 2500mg PO QHS
- Prednisone 10mg PO daily
- Omeprazole 20mg PO daily
- Furosemide 40mg PO BID
- Docusate 200mg PO daily
- Acetaminophen 1000mg PO TID
- Trazodone 50mg PO QHS
- Fluticasone nasal daily
- Duoneb TID
- Gabapentin 200mg PO TID
- Levocarnitine 1gm PO BID (dietary supplement)
- EC ASA 325mg PO daily
- Thiamine 100mg PO daily
- MVI
- Phenobarbital 60mg PO daily; 30mg PO QHS
- Olanzapine 20mg PO QHS
- Senna 1 tab PO QHS
- Lorazepam 1 tab PO Q4 hours PRN agitation
Discharge Medications:
1. Divalproex 500 mg Tablet Sustained Release 24 hr [**Month/Year (2) **]: Five
(5) Tablet Sustained Release 24 hr PO HS (at bedtime).
2. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
4. Fluticasone 50 mcg/Actuation Spray, Suspension [**Month/Year (2) **]: One (1)
Spray Nasal DAILY (Daily).
5. Gabapentin 100 mg Capsule [**Month/Year (2) **]: Two (2) Capsule PO TID (3
times a day).
6. Thiamine HCl 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
7. Levocarnitine 330 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO BID (2
times a day).
8. Multivitamin Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
9. Lorazepam 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for Anxiety: please do not drink alcohol or
perform activities that require a fast reaction time when taking
this medication. may cause sedation. .
10. Olanzapine 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO HS (at
bedtime).
11. Nicotine 14 mg/24 hr Patch 24 hr [**Month/Year (2) **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
12. Furosemide 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times
a day).
13. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
14. Prednisone 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day
for 3 days: from [**2200-12-23**] to [**2200-12-24**].
Disp:*2 Tablet(s)* Refills:*0*
15. Prednisone 20 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO once a day
for 2 days: from [**2200-12-25**]- to [**2200-12-26**].
Disp:*4 Tablet(s)* Refills:*0*
16. Prednisone 10 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO once a day
for 2 days: from [**2200-12-29**] to [**2200-12-30**].
Disp:*6 Tablet(s)* Refills:*0*
17. Prednisone 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day
for 2 days: [**2200-12-29**] to [**2200-12-30**] .
Disp:*2 Tablet(s)* Refills:*0*
18. Prednisone 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day
for 2 days: [**2200-12-31**] to [**2201-1-1**].
Disp:*2 Tablet(s)* Refills:*0*
19. Prednisone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day for
2 days: [**2201-1-2**] to [**2201-1-3**].
Disp:*2 Tablet(s)* Refills:*0*
20. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Month/Day/Year **]: One (1) Intravenous Q8H (every 8 hours) for 2 days.
Disp:*6 doses* Refills:*0*
21. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1)
Intravenous Q 12H (Every 12 Hours) for 2 days.
Disp:*4 doses* Refills:*0*
22. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
23. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) nebulizer treatment Inhalation Q4H
(every 4 hours).
Disp:*90 nebulizer treatment* Refills:*0*
24. Phenobarbital 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QPM (once
a day (in the evening)).
25. Phenobarbital 30 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QAM (once
a day (in the morning)).
26. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
27. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) breathing
treatments Inhalation Q4H (every 4 hours).
Disp:*90 breathing treatments* Refills:*0*
28. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q2H (every 2 hours) as
needed for Shortness of breath, wheezing.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary
COPD exacerbation.
.
Secondary
Pneumonia
Dementia
Schizophrenia
Discharge Condition:
stable, good, baseline mental and ambulatory status, sating
90-93% on room air.
Discharge Instructions:
You were admitted to the hospital because you were having
difficulty with your breathing. You were found to have a
pneumonia as well as a COPD flare. You were treated with
antibiotics for your pneumonia, and nebulizer treatments helped
your pneumonia.
You also developed difficulty with swallowing. A swallow study
was done which showed that you may be having some silent
aspiration.
.
The following changes were made to your medications .
Prednisone with taper.
Zosyn 4.5 mg IV Q8 hours for 2 days.
Vancomycin 1g every 12 hours for 2 days.
Lansoprazole 30mg once a day.
Aspirin 325 daily
Ipatropium Bromide nebulizers every four hours as needed
Albuterol Sulphate nebulizer treatment every four hours as
needed
.
We discontinued the omeprazole.
Followup Instructions:
POOR,[**Doctor First Name 6015**] D.
Address: [**Doctor Last Name 6016**], [**Location (un) 6017**],[**Numeric Identifier 6018**]
Phone: [**Telephone/Fax (1) 6019**]
Fax: [**Telephone/Fax (1) 6020**]
|
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icd9cm
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[
[
[]
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[
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2644, 2867
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,430
| 156,778
|
23755
|
Discharge summary
|
report
|
Admission Date: [**2172-8-16**] Discharge Date: [**2172-8-21**]
Date of Birth: [**2124-12-23**] Sex: F
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
epigastric pain, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 year old female with no known history of diabetes, presented
to [**Hospital1 18**] ED with several days of lower abdominal pain and
vomiting which began the night before. She also reported poor
appetite for several weeks, with increased thirst and increased
urine output. She has no history of diabetes personally, but has
a strong history of diabetes in her family. She has not measured
any fevers at home, but reports feeling subjectively feverish
occasionally for the past several days. Denies any loss of
consciousness, she was brought into the ED by her family today.
She also reports a month-long history of severe pain in her
lower back and legs - started suddenly in early [**Month (only) 216**], with no
known trauma or inciting injury. She first noticed pain in her
left hip and lower back, which has worsened to include the rest
of her left leg and her right hip and leg as well. Her PCP has
been working up this issue and has ordered an MRI which the
patient reports was normal. She also underwent cortisone shot
and possibly epidural injection about 3 weeks ago to her lower
lumbar spine. She reports that the back pain intensified after
getting these injections. She reports walking now with a cane.
She is only able to ambulate short distances.
.
In the ED, initial vs were: T=98 P=119 BP=139/82 R=20 O2=100%
The patient was given regular insulin 10 units IV, and started
on an insulin drip, 7 units per hour. Mental status remained
stable. After 3 hours her glucose had decreased from 826 to 440.
Overall she received 1.6 liters of NS in the ED.
.
In the ICU she reports feeling quite fatigued. She remains quite
thirsty. Reports back pain and achy pains throughout her lower
extremities, especially with palpation.
.
.
Review of systems:
(+) Per HPI, +mild nausea
Denies weight loss or gain. No chest pain or shortness of
breath. Does report worsening vision over the past 2 months.
Past Medical History:
** Nephrolithiasis, s/p ESWL procedure
** asthma - never hospitalized
** diverticulitis
Social History:
Married, lives with husband. [**Name (NI) 1403**] as a bus driver for the [**Company 2318**],
though she has not worked for the past month due to severe
back/leg pain. Does not smoke, denies alcohol or drug use.
Family History:
Multiple family members with diabetes, including her mother whom
she reports died from diabetes.
Physical Exam:
Vitals: T:98.6 BP:141/92 P:106 R:19 O2:99% on 1LNC
General: Sleepy appearing, but alert and oriented, conversant.
HEENT: Sclera anicteric, mucous membranes dry, 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-distended, + bowel sounds. Tender to
palpation in epigastrium, but no rebound tenderness or guarding.
Back: focal spinal tenderness in L1-2 region.
Ext: Warm, well perfused, 1+ pulses.
Neuro: CN intact, reports diffuse pain throughout both lower
extremities sensation and motor function grossly intact, but
exam limited by patient cooperation - reports pain with any
touch or movement.
Pertinent Results:
[**2172-8-16**] 02:00PM BLOOD WBC-15.0*# RBC-5.98*# Hgb-15.0 Hct-52.7*#
MCV-88 MCH-25.1* MCHC-28.5*# RDW-13.0 Plt Ct-296
[**2172-8-16**] 08:28PM BLOOD WBC-18.9* RBC-4.38# Hgb-11.5*# Hct-36.4#
MCV-83 MCH-26.1* MCHC-31.5# RDW-12.8 Plt Ct-193
[**2172-8-17**] 05:00AM BLOOD WBC-13.6* RBC-3.79* Hgb-9.9* Hct-30.6*
MCV-81* MCH-26.0* MCHC-32.2 RDW-12.4 Plt Ct-168
[**2172-8-20**] 06:35AM BLOOD WBC-7.3 RBC-4.18* Hgb-10.7* Hct-34.0*
MCV-82 MCH-25.5* MCHC-31.3 RDW-13.1 Plt Ct-166
[**2172-8-21**] 06:22AM BLOOD WBC-7.8 RBC-4.07* Hgb-10.3* Hct-32.2*
MCV-79* MCH-25.3* MCHC-32.0 RDW-13.1 Plt Ct-197
[**2172-8-16**] 02:00PM BLOOD Neuts-90.1* Lymphs-7.2* Monos-2.0 Eos-0.2
Baso-0.5
[**2172-8-16**] 08:28PM BLOOD ESR-8
[**2172-8-17**] 05:00AM BLOOD ESR-0
[**2172-8-16**] 02:00PM BLOOD Glucose-801* UreaN-24* Creat-1.6* Na-135
K-5.7* Cl-95* HCO3-6* AnGap-40*
[**2172-8-16**] 05:00PM BLOOD Glucose-472* UreaN-21* Creat-1.1 Na-144
K-3.7 Cl-112* HCO3-6* AnGap-30*
[**2172-8-16**] 10:36PM BLOOD Glucose-388* UreaN-11 Creat-0.7 Na-144
K-3.1* Cl-119* HCO3-9* AnGap-19
[**2172-8-17**] 02:15AM BLOOD Glucose-260* UreaN-8 Creat-0.7 Na-143
K-2.8* Cl-119* HCO3-15* AnGap-12
[**2172-8-18**] 06:18AM BLOOD Glucose-320* UreaN-6 Creat-0.6 Na-140
K-3.4 Cl-108 HCO3-21* AnGap-14
[**2172-8-21**] 06:22AM BLOOD Glucose-182* UreaN-10 Creat-0.6 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
[**2172-8-17**] 05:00AM BLOOD CK(CPK)-28
[**2172-8-16**] 02:00PM BLOOD ALT-37 AST-15 CK(CPK)-37 AlkPhos-140*
TotBili-0.2
[**2172-8-16**] 02:00PM BLOOD Lipase-24
[**2172-8-16**] 02:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2172-8-16**] 05:00PM BLOOD Calcium-9.9 Phos-2.6* Mg-2.7*
[**2172-8-16**] 10:36PM BLOOD Albumin-3.0* Calcium-7.0* Phos-0.9*#
Mg-1.8
[**2172-8-17**] 12:42PM BLOOD Calcium-8.2* Phos-1.9* Mg-2.2
[**2172-8-20**] 06:35AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
[**2172-8-21**] 06:22AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.2 Iron-94
[**2172-8-21**] 06:22AM BLOOD calTIBC-226* Ferritn-400* TRF-174*
[**2172-8-17**] 12:42PM BLOOD %HbA1c-12.6*
[**2172-8-16**] 05:00PM BLOOD Acetone-POS Osmolal-343*
[**2172-8-16**] 10:36PM BLOOD Osmolal-317*
[**2172-8-17**] 02:15AM BLOOD Osmolal-300
[**2172-8-17**] 05:00AM BLOOD TSH-0.71
[**2172-8-16**] 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2172-8-17**] 02:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.0
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2172-8-16**] 02:08PM BLOOD Glucose-826* Lactate-6.7* Na-143 K-5.2
Cl-104
[**2172-8-16**] 05:19PM BLOOD Glucose-440* K-3.9
[**2172-8-17**] 05:25AM BLOOD Lactate-1.5
[**2172-8-16**] 02:08PM BLOOD freeCa-1.32
[**2172-8-17**] 05:25AM BLOOD freeCa-1.26
[**2172-8-17**] 12:42PM BLOOD GLUTAMIC ACID DECARBOXYLASE-Test
[**2172-8-17**] 12:42PM BLOOD C-PEPTIDE-Test
[**2172-8-17**] 12:42PM BLOOD VITAMIN D [**12-29**] DIHYDROXY-Test
[**2172-8-16**] 04:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.032
[**2172-8-16**] 04:00PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2172-8-16**] 04:00PM URINE RBC-[**2-6**]* WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2172-8-16**] 06:41PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2172-8-17**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2172-8-16**] URINE URINE CULTURE-FINAL INPATIENT
[**2172-8-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**Known lastname **],[**Known firstname **] [**Medical Record Number 60670**] F 47 [**2124-12-23**]
Radiology Report CHEST (PA & LAT) Study Date of [**2172-8-16**] 2:59 PM
[**Last Name (LF) **],[**First Name8 (NamePattern2) 2620**] [**Last Name (NamePattern1) **] EU [**2172-8-16**] 2:59 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 60671**]
Reason: eval for pna
[**Hospital 93**] MEDICAL CONDITION:
47 year old woman with CP and hyperglycemia
REASON FOR THIS EXAMINATION:
eval for pna
Final Report
INDICATION: 47-year-old female with chest pain and
hyperglycemia. Evaluate
for pneumonia.
COMPARISON: [**2171-8-26**].
EXAMINATION: Chest, PA and lateral views: The lungs are clear
without focal
opacity or pleural effusions. There is no pneumothorax. The
heart size is
normal. The mediastinal silhouette, hilar contours, and
pulmonary vasculature
are unremarkable.
IMPRESSION: No acute intrathoracic abnormality.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 60670**] F 47 [**2124-12-23**]
Radiology Report PANCREAS US Study Date of [**2172-8-19**] 2:08 PM
[**Last Name (LF) **],[**First Name3 (LF) **] E. MED CC7A [**2172-8-19**] 2:08 PM
PANCREAS US Clip # [**Clip Number (Radiology) 60672**]
Reason: Please eval pancreas for any abnormalities
[**Hospital 93**] MEDICAL CONDITION:
47 year old woman with new onset diabetes. Please eval
pancreas for any
abnormalities
REASON FOR THIS EXAMINATION:
Please eval pancreas for any abnormalities
Provisional Findings Impression: MBue WED [**2172-8-19**] 3:23 PM
Normal-appearing pancreas.
Final Report
HISTORY: 47-year-old female with new onset diabetes. Question
pancreatic
abnormality.
COMPARISON: CT dated [**2170-10-5**].
FINDINGS: A limited ultrasound examination of the pancreas was
performed.
Evaluation of portions of the pancreatic head and tail are
limited. The
visualized pancreas is normal in appearance with no focal
abnormalities
identified. The pancreatic duct is not dilated. There is no free
fluid in the
abdomen.
IMPRESSION:
Normal-appearing pancreas. Limited visualization of portions of
the pancreatic
head and tail.
Brief Hospital Course:
47 year old female with history of asthma and nephrolithiasis
presenting with hyperglycemia, signifcant lactic acidosis, and
laboratory and clinical evidence of hypovolemia.
.
#Hyperglycemia: Given hyperglycemia in the setting of a
ketonemia/ketonuria, gap acidosis and elevated serum osm this
most likely represented DKA and thus newly diagnosed diabetes.
Significant hemoconcentration and ARF suggestive pt at least [**5-11**]
liters negative. Patient received aggressive fluid
resuscitation and was started on insulin gtt. [**Last Name (un) **] was
consulted and patient switched to sq insulin regimen. At the
time of transfer out of the MICU, BS was 141. Electrolytes were
followed closely and potassium/phosphate were aggressively
repleted. On transfer to the medical floor the patient BS
remained elevated, up to 300s, requiring increasing insulin
doses. Her lantus dose was 46 units on discharge and ISS for
coverage.
.
# Gap Acidosis: Likely related to a combination of lactic acid
and ketonemia. Improved with insulin gtt and fluid resucitation.
At the time of transfer from the MICU, lactate was 1.5. Workup
for lactic acidosis as below.
.
# Lactic acidosis - Thought to be secondary to severe
hypovolemia in the setting of significant osmotic diuresis from
hyperglycemia. No source of infection was found as X ray was
clear, UA/urine cx benign. Blood cultures were negative. WBC was
elevated, possibly due to reactive leukocytosis and it resolved
after lactic acidosis resolved.
.
# ARF: Likely related to significant hypovolemia. Cr improved
from 1.6 to 0.6 with fluid rescucitation. It remained in the
normal range there after.
.
# Back/hip pain: Patient presented with back and hip pain that
had started 3 weeks prior to admission. The patient was
initially treated with narcotics with little effect. Patient
then was empirically started on gabapentin with improvement of
her pain. As the pain improved with gabapentin the pain was
thought to be neuropathic in origin. She was discharged with
instructions to increase her dose of gabapentin to 300 TID for
better pain control.
.
# Leukocytosis - Initial WBC 15.0 on hemoconcentrated sample,
repeat WBC 18.9. WBC was 13.6 on date of MICU transfer. This was
thought to be a reactive process as no source of infection was
identified and it resolved without intervention.
.
# Epigastric pain- likely secondary to stomach upset, vomiting
over the past 2 days. LFTs and lipase normal. She was given
anti-emetics and maalox PRN and was tolerating a diet upon
transfer out of the MICU. On the medical floor the patient's
epigastric pain resolved and she was able to tolerate PO.
.
# Asthma - Not currently taking any medications, no inhaler use
for the past year.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
2. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) for 2 days: take 200 mg gabapentin on Saturday [**8-22**]
and Sunday [**8-23**]. Thereafter, take 300 mg gabapentin daily.
Disp:*12 Capsule(s)* Refills:*0*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day: Start taking daily on Monday, [**8-24**].
Disp:*90 Capsule(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
5. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: One (1) 46
Subcutaneous at bedtime.
Disp:*5 pens* Refills:*2*
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Humalog 100 unit/mL Cartridge Sig: As directed Units
Subcutaneous four times a day: Please use per insulin sliding
scale.
Disp:*12 cartridges* Refills:*2*
9. Lancets Misc Sig: One (1) lancet Miscellaneous four times
a day.
Disp:*1 box* Refills:*2*
10. Blood Sugar Diagnostic Strip Sig: One (1) strip In [**Last Name (un) 5153**]
four times a day.
Disp:*1 box* Refills:*2*
11. Insulin Syringe 1 mL 29 x [**12-6**] Syringe Sig: One (1) syringe
Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
12. Glucometer
Please provide patient with one glucometer for blood glucose
testing.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Diabetes
Peripheral Neuropathy
Discharge Condition:
excellent
Discharge Instructions:
You presented to the [**Hospital1 18**] ED with 2-3 days of headaches, nausea
and vomiting. You also had a month long history of excessive
thirst and urination, as well as signiifcant pain in your lower
back and both legs. On arrival in the ED, your blood sugar was
significantly elevated (826) and you were very dehydrated. We
gave you 8L of fluid and insulin which helped to improve your
symptoms and normalize your blood sugars.
You were diagnosed with diabetes and we have started you on an
insulin regimen to control your blood sugars, in consultation
with the [**Hospital **] clinic. It is very important that you take your
insulin as directed and check your blood sugars 3-4 times daily.
We will provide you with additional documentation of how and
when to take your insulin and check your sugars. It is also very
important that you continue to follow up with the [**Hospital **] clinic,
as they will be responsible for modifying your insulin dosing
when necessary.
For your leg pain, we obtained the MRI records from the outside
hospital which showed that you don't appear to have impingement
of a nerve. We believe your leg pain is most likely the result
of diabetes' effect on the nerves in your leg, something known
as a diabteic neuropathy. We will continue you on neurontin, a
medicine for diabetic neuropathy, as your leg pain has improved
during your visit. Please continue to followup with [**Last Name (un) **] and
your PCP with regards to your leg pain. We have also made an
appointment with an opthamologist as you were having some
complaints of blurry vision and diabetes can also affect your
vision.
While you were here, we made the following changes to your
medications:
1.
If you develop lightheadedness, weakness, severe headaches or
fainting episodes, have someone adminster you some sugar
containing food/drink and have them bring you to the hospital.
These symptoms can be caused by taking too much insulin and
dropping your blood sugars. In addition, if you develop
worsening leg pain, vision changes, or any other concerning
symptoms, please come back to the ED.
Followup Instructions:
Please keep the following appointments:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP). Date and time: [**2172-9-2**] 6:00pm.
Location: [**Street Address(2) 60673**], [**Street Address(1) **] MA. Phone number:
[**Telephone/Fax (1) 34469**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28224**] ([**Last Name (un) **] Educational Instructor). Date and time:
[**2172-9-14**] 9:00am-1:00am. Location: [**Last Name (un) 3911**] [**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 2384**]
Special instructions if applicable: This is required by [**Last Name (un) **].
It is an educational class. They will provide lunch.
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 60674**] (Ophthalmology). Date and time: [**9-14**]
at 2pm
Location: [**Hospital **] Clinic. Phone number: [**Telephone/Fax (1) 60675**]
Dr. [**Last Name (STitle) 978**] ([**Last Name (un) **]). Date and Time: [**1193-8-25**] AM.
Location: [**Hospital **] Clinic. Phone number: [**Telephone/Fax (1) 60675**].
|
[
"724.5",
"285.9",
"250.13",
"729.5",
"276.52",
"493.90",
"584.9",
"784.0",
"355.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13352, 13410
|
9057, 11782
|
313, 319
|
13504, 13516
|
3510, 7263
|
15660, 16723
|
2611, 2709
|
11837, 13329
|
8223, 8312
|
13431, 13431
|
11808, 11814
|
13540, 15637
|
2724, 3491
|
2107, 2254
|
248, 275
|
8344, 9034
|
347, 2088
|
13450, 13483
|
2276, 2366
|
2382, 2595
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,238
| 131,745
|
41980+58489+58490
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2161-10-24**] Discharge Date: [**2161-10-28**]
Date of Birth: [**2115-3-6**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2161-10-27**] Conventional Cerebral Angiogram with coiling
History of Present Illness:
46 year old white male who was transferred from OSH after CTA
revealed Acomm / ACA bifurcation aneurysm. LP here at [**Hospital1 18**]
reveals only 4 RBC in the
4th tube. The pt is visibly uncomfortable and reports that he
does have a history of headaches but this is different. He
reports that he was sitting in a car smoking marijuana 2 days
ago
and he had abrupt onset of a severe headache. He rated this
pain
a 12 on a scale of [**12-15**]. He reports that it subsided a little
and then last night he had another severe headache and then went
to the OSH. He reports history of head trauma [**2160-3-6**] with
subsequent EDSI and trigger pt injections via pain management.
He does see his PCP [**Name Initial (PRE) 30449**]. He was told he had lung nodules
for which he had PET imaging but does not need any more imaging
for 6 months.
He denies nausea vomiting potophobia phonophobia.
Past Medical History:
lung nodules
corrective foot surgery at 10 yrs old
Social History:
Lives with brother for now. Is on disability from
being a truck driver. Has a 60+ pack yr history of tobacco use.
no EtOH x 2 yrs. He is clean of heroine and cocaine x 11 yrs.
He later revealed during his hospital stay that he was victim of
sexual abuse by his adoptive father.
Family History:
NC
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 1 GCS 15
O: T: af BP:98.2 108/63 HR:64 R14 O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT:NCAT Pupils: [**2-4**] EOMis
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3to2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-9**] throughout. No pronator drift
Sensation: Intact to light touch,
Toes downgoing bilaterally
On Discharge:
A&Ox3
PERRL
EOMs intact
Motor full
Pertinent Results:
MRI/A BRAIN and NECK [**10-24**]
FINDINGS: The study is compared with the prompting CTA ([**Hospital 39437**]
Hospital), performed roughly 17.5 hours earlier. As on the
non-enhanced
portion of that examination, the axial FLAIR sequence is
entirely
unremarkable, with no finding to suggest subarachnoid
hemorrhage. Similarly, the GRE sequence demonstrates no evidence
of intra- or extra-axial hemorrhage with a solitary 3-mm focus
of "blooming" susceptibility artifact in the region of the
lateral aspect of the left leaflet of the tentorium cerebelli,
perhaps representing an incidental dural calcification (though
difficult to confirm on the CT). There is no focus of slow
diffusion to suggest an acute ischemic event and the principal
intracranial vascular flow voids are preserved (see MRA, below),
including those of the dural venous sinuses. There is no
space-occupying lesion, and the sella, parasellar region and
remainder of the skull base and orbits are unremarkable. There
is minor mucosal thickening involving the anterior ethmoidal air
cells, bilaterally, with the included paranasal sinuses and
mastoid air cells, otherwise grossly clear.
Corresponding to the findings on the CTA, there is normal
flow-related
enhancement in the included intracranial portions of both
internal carotid and proximal and middle and an anterior
cerebral arteries, with normal symmetric arborization of MCA
branches and no significant mural irregularity or flow-limiting
stenosis. However, there is an anomalous appearance to the
anterior communicating artery complex, particularly the junction
of the ACom vessel and the A1 and A2 segments of the right ACA.
Emanating from this site is a rounded saccular aneurysm
measuring roughly 4.5 mm, directed inferiorly and somewhat
laterally (6:79-82). The MIP reconstructions demonstrate that
this lesion has a relatively long and broad neck, and its dome,
a bilobed appearance. This process is associated with a markedly
hypoplastic A1 segment of the contralateral ACA, as on the CTA.
There is also likely a small, 1.5-2.0mm aneurysm originating at
the junction of the left ACA and the ACom and directed
anterolaterally (6:83-84).
The appearance of the remainder of both anterior cerebral
arteries is
unremarkable. There is normal flow-related enhancement in the
distal
vertebral arteries, with markedly dominant right and hypoplastic
left vessel, as well as the basilar and bilateral superior
cerebellar and posterior cerebral arteries robust right and
diminutive left posterior communicating vessels are seen with no
aneurysm larger than 3 mm involving the posterior circulation.
There is a bulbous "patulous" appearance to the basilar tip with
likely small infundibula at the origins of all four of its
terminal branches.
The dedicated fat-saturated sequences demonstrate no crescentic
or other
pathologic T1-hyperintensity associated with the cervical
portions of the
vertebral or carotid arteries to specifically suggest intramural
hematoma
related to vascular dissection. There is only limited depiction
of the aortic arch. However, the common, internal and external
carotid arteries demonstrate normal course, caliber, contour,
and both flow-related and contrast enhancement from their
origins to the level of the skull base, with no significant
mural irregularity, flow-limiting stenosis or evidence of
dissection. Similarly, though the vertebral arterial origins are
poorly
demonstrated, these vessels otherwise demonstrate normal course,
caliber,
contour, and flow-related and contrast enhancement through the
vertebrobasilar junction, with no significant mural
irregularity, flow-limiting stenosis, or evidence of dissection.
IMPRESSION:
1. No evidence of subarachnoid or other intracranial hemorrhage,
or other
acute intracranial process.
2. Markedly abnormal appearance to the anterior communicating
artery complex with a large 4.5-mm bilobed saccular aneurysm
with relatively long and broad neck, originating from the
junction of the right ACA and the ACom vessel and directed
inferiorly.
3. Likely very small, less than 2-mm aneurysm originating at the
junction of the left ACA and the ACom vessel, directed
anterolaterally.
4. Unremarkable cervical MRA with no evidence of vertebral or
carotid
dissection.
[**10-27**] CXR
HISTORY: Pre-operative.
FINDINGS: No previous images. There is hyperexpansion of the
lungs
suggesting underlying chronic pulmonary disease. However, no
acute pneumonia, vascular congestion, or pleural effusion.
Brief Hospital Course:
Patient presented to the emergency department at [**Hospital1 18**] as a
transfer from an OSH where he was found to have an incidental
finding of an ACOMM aneurysm. He was evalauted in the emergency
department and had a lumbar puncture with 4 red blood cells in
tube#4. He was admitted to the neurosurgery service and had an
MRI/A of the Brain and an MRA of the neck to r/o dissection. He
was found to have an ACOMM aneurysm with no evidence of rupture
or vessel dissection. On the evening of [**10-24**] he was threatening
to leave AMA and after discussion with our team agreed to stay.
He recieved valium for anxiety/agitation with good effect. He
had significant pain issues which required high dose pain
medication and continued to threaten to leave. Chronic pain was
calledto assist in his management. Neurontin was started. He
was brought down for cerebral angiogram with coiling on the
22nd. The case was uneventful and he was recovered in the ICU x
24 hours. R ACOMM and R MCA was noted and patient will return
for elective clipping. On [**10-28**], patient was nonfocal on
examination, eating and voiding appropriately. He was discharged
home to return for elective clipping next week.
Medications on Admission:
baclofen 10mg po bid / 20 mg at HS
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*1 box* Refills:*2*
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior Communicating Artery Aneurysm
Headache
Nicotine withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a headache and found to
have an Anterior Communicating Artery Aneurysm (unruptured)
which was treated by placement of coils.
Angiogram with Embolization Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
- You will require a follow-up appointment in 6 months with Dr
[**First Name (STitle) **]. You can make this appointment by calling [**Telephone/Fax (1) 1669**].
You will require an MRI/MRA of the brain with Dr [**First Name (STitle) **] protocol
at that time.
Completed by:[**2161-10-28**] Name: [**Known lastname **],[**Known firstname 801**] Unit No: [**Numeric Identifier 14366**]
Admission Date: [**2161-10-24**] Discharge Date: [**2161-10-28**]
Date of Birth: [**2115-3-6**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 40**]
Addendum:
Please refer to discharge instruction for changes made.
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior Communicating Artery Aneurysm
Headache
Nicotine withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a headache and found to
have an Anterior Communicating Artery Aneurysm (unruptured).
Angiogram Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
- You are scheduled for an elective clipping of your aneurysm on
Tuesday Novemeber 29, [**2160**].
If there are further questions or concerns, please call the
neurosurgery office at [**Telephone/Fax (1) 8659**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2161-10-28**] Name: [**Known lastname **],[**Known firstname 801**] Unit No: [**Numeric Identifier 14366**]
Admission Date: [**2161-10-24**] Discharge Date: [**2161-10-28**]
Date of Birth: [**2115-3-6**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 40**]
Addendum:
Diagnosis: ACOMM aneurysm and L ACA aneurysm
Major Surgical or Invasive Procedure:
[**2161-10-27**] Diagnostic cerebral angiogram
Brief Hospital Course:
Please see d/c summary for full hospital course-
addendum: Patient was taken to angio for a planned coiling of
the ACOMM aneurysm; however, the coils were unable to stay in
place so the coiling was aborted. The patient was extubated and
monitored in the ICU overnight. He was discharged [**10-28**] with
plans to return electively on [**11-3**] for clipping of the ACOMM
aneurysm. The L ACA aneurysm is too small for treatment and we
will continue to follow.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2161-11-5**]
|
[
"437.3",
"300.00",
"338.29",
"355.9",
"292.0",
"V15.41",
"784.0",
"305.1",
"V64.3",
"715.36"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
15814, 15955
|
15330, 15791
|
15258, 15307
|
12307, 12307
|
2900, 7394
|
14449, 15220
|
1694, 1698
|
8704, 9046
|
12216, 12286
|
8644, 8681
|
12458, 13507
|
13533, 14426
|
1713, 1911
|
2844, 2881
|
268, 278
|
408, 1303
|
2163, 2830
|
12322, 12434
|
1325, 1378
|
1394, 1678
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,067
| 131,483
|
54229
|
Discharge summary
|
report
|
Admission Date: [**2201-2-7**] Discharge Date: [**2201-2-19**]
Date of Birth: [**2121-8-10**] Sex: M
Service: MEDICINE
Allergies:
Haldol / Neurontin / Vancomycin
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
Shortness of breath
Dizziness
Lethargy
Hypotension
Major Surgical or Invasive Procedure:
Left subclavian central line
Arterial line placement
History of Present Illness:
79 yo male with CHF (EF 35%), ESRD on HD presents with
complaints of dizziness and general malaise starting in the AM.
Denies fevers,chills, SOB, cough, rhinorrhea, dysuria, or
diarrhea. In ambulance to hospital,pt was hypotensive with SBP
in 80's. Taken to OSH and transferred here for further care.
Past Medical History:
Chronic Afib
CHF with EF 35-40%, RV dysfunction
s/p AoVR '[**84**] secondary to rheumatic heart disease
DMII, HbA1C 6.3 in [**1-21**]
H/O UGIB secondary to gastritis/AVM
ESRD on HD
CD s/p MI s/p CABG
Gout
[**Last Name (un) 309**] Body Dementia
H/0 hypotension
Social History:
lives with wife
[**Name (NI) 3106**] veteran on disability x 18 years
Distant 5 yr history of tobacco use
occ ETOH use
Family History:
no cardiac disease
Physical Exam:
100.6 84/56-->89/44 99-100 21 100% on 3L
CVP 22-30
Gen: lying in bed in no acute distress
HEENT: poor dentition, dry mm
Neck: supple, RIJ
CV: [**Last Name (un) 3526**], irreg +mech click
Chest: bibasilar crackles; right scl tunneled catheter
Abd: soft, distended, NT/BS
Ext: +L>r edema; left toe amputation, chronic venous stasis
Pertinent Results:
[**2201-2-7**] 11:58PM GLUCOSE-138* UREA N-63* CREAT-5.3* SODIUM-133
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-20* ANION GAP-24*
[**2201-2-7**] 11:58PM WBC-10.8 RBC-6.06 HGB-12.6* HCT-41.4 MCV-68*
MCH-20.7* MCHC-30.4* RDW-17.8*
[**2201-2-7**] 11:58PM NEUTS-91.9* BANDS-0 LYMPHS-4.9* MONOS-2.8
EOS-0.4 BASOS-0.1
[**2201-2-7**] 11:58PM PLT SMR-NORMAL PLT COUNT-302
[**2201-2-7**] 02:39PM LACTATE-1.5
[**2201-2-7**] 02:00PM DIGOXIN-0.9
[**2201-2-7**] 02:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG
EKG: afib, normal axis, poor RWP, flat TW III avF
CXR: cardiomegaly with small right effusion
Brief Hospital Course:
Pt was admitted to MICU for further evaluation and treatment of
hypotension. Pt had a history of hypotension in the past in the
setting of ESRD, however, he had never been symptomatic. In the
setting of peristent hypotension, pt was initially started on
Levophed and Dopamine. Chest radiographs indicated CHF. In
addition to CHF, patient had significant amount of abdominal
ascites which appeared to be increasig in size. CVVH was started
for additional fluid removal from CHF. Pt was able to maintain
pressures, and pressors were discontinued early in the course.
Pt responded well to CVVH-->HD. Pt, however, continued to have
low grade fevers from a gram positive bacteremia, and increasing
INR most likely secondary to antibiotic use in setting of
sepsis, despite being taken off anticoagulants.
Throughout the course, pt had fluctuating blood pressures, going
down to SBP 50's during HD. Although pt continued to mentate
well initially, pressors were again started with gentle fluid
boluses to maintain pressures. At this point, a new set of blood
cultures came back positive for GNR etiology unknown, possibly
from infected fluid from abdominal ascites. The focus of care
was now on managing pressures in the setting of septic
physiology. Pressors were continued with gentle hydration.
It was thought at this time by the family, with the patient
persistently pressor dependent with now, altered mental status,
that the patient be made CMO. Pt expired on [**2201-2-19**] in the early
morning.
Medications on Admission:
Pantoprazole
Sevelamer
Digoxin
Donepezil
Allopurinol
[**Last Name (un) **]/Ipratrop
Epo
Coumadin
Discharge Medications:
none
Discharge Disposition:
Expired
Facility:
[**Hospital1 69**]
Discharge Diagnosis:
Pt expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"250.00",
"331.82",
"790.92",
"V45.81",
"V43.3",
"427.31",
"038.3",
"789.5",
"414.00",
"995.91",
"276.5",
"567.2",
"294.10",
"403.91",
"428.0",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"39.95",
"38.91",
"38.93",
"54.91",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
3917, 3956
|
2240, 3741
|
342, 396
|
4010, 4019
|
1553, 2217
|
4072, 4080
|
1161, 1181
|
3888, 3894
|
3977, 3989
|
3767, 3865
|
4043, 4049
|
1196, 1534
|
252, 304
|
424, 726
|
748, 1009
|
1025, 1145
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,002
| 138,167
|
5698
|
Discharge summary
|
report
|
Admission Date: [**2115-10-17**] Discharge Date: [**2115-10-23**]
Date of Birth: [**2052-7-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Difficulty breathing, increase in Angina.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 63M with PMH CAD s/p 3V CABG in [**2107**], most recent cath
this month [**9-30**] with stent of LMCA to LCx and angioplasty of
OM. Prior to that admission pt had initially presented to
[**Hospital 882**] hospital with complaints of worsening dyspnea and
angina over past 8 months. Had reported a week of dry cough and
pharyngitis. During his recent stay pt remained afebrile with a
white count WNL. He is now presenting with complaints of R sided
intermitted chest pain, orthopnea and fatigue. First set of
cardiac enzymes are negative. CXR appears unchanged from prior
with with possible RML PNA. CTA chest significant for R pleural
effusion and RML PNA vs atelectasis. WBC nl. EKG no significant
change from prior.
Past Medical History:
Depression 20 years
Erectile dysfunction
Angina
hyperlipidemia
IDDM
CAD (CABG 3vd), 6 stents; last Cath [**9-22**]
Ulcerative colitis
HTN
Social History:
Married. Patient is a optometrist who has been under a great
deal of stress, related to his health inhibiting his ability to
work. 5 year smoking history in 20s. No history of etoh abuse.
No iv drugs
Family History:
mom with CAD, CABG in her 60's.
Family history of premature coronary artery disease, DM, HTN,
Hyperlipidemia
Physical Exam:
VS - Temp 97.0 BP 139/65 HR 78, RR 18, 100% 2L oxygen,
Gen: middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral
Neck: large, neck hard to examine, supple, no meningismus,
Difficult to assess JVP.
CV: PMI small and displaced laterally. RRR, Distant Heart
Sounds. normal S1, S2. No murmurs, no rubs
Chest: Dull to percussion and auscultation bilat up post [**12-20**]
bilat. Abd: Soft, NTND. No HSM or tenderness. No abdominial
bruits.
Ext: 1+ edema bilaterally, up to ankle. Feet decreased
temperature, minimal hair, no ulcers noted
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2115-10-17**] 08:50AM BLOOD WBC-8.8 RBC-4.60 Hgb-12.2* Hct-37.9*
MCV-82 MCH-26.6* MCHC-32.3 RDW-16.4* Plt Ct-216
[**2115-10-17**] 05:50PM BLOOD PT-14.3* PTT-95.5* INR(PT)-1.3*
[**2115-10-17**] 08:50AM BLOOD Glucose-237* UreaN-24* Creat-1.1 Na-138
K-4.4 Cl-101 HCO3-29 AnGap-12
[**2115-10-18**] 12:00PM BLOOD ALT-29 AST-37 CK(CPK)-211* AlkPhos-51
TotBili-0.6
[**2115-10-17**] 08:50AM BLOOD CK(CPK)-98
[**2115-10-17**] 03:50PM BLOOD CK(CPK)-93
[**2115-10-18**] 12:25AM BLOOD CK(CPK)-168
[**2115-10-19**] 02:30AM BLOOD CK(CPK)-406*
[**2115-10-19**] 07:08AM BLOOD ALT-32 AST-55* CK(CPK)-371* AlkPhos-62
TotBili-0.9
[**2115-10-19**] 07:08AM BLOOD CK-MB-12* MB Indx-3.2 cTropnT-0.65*
[**2115-10-19**] 02:30AM BLOOD CK-MB-13* MB Indx-3.2 cTropnT-0.47*
[**2115-10-18**] 12:00PM BLOOD CK-MB-6 cTropnT-0.16*
[**2115-10-18**] 12:25AM BLOOD CK-MB-8 cTropnT-0.14*
[**2115-10-17**] 03:50PM BLOOD cTropnT-0.03*
[**2115-10-19**] 07:08AM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.1 Mg-2.1
[**2115-10-17**] 10:25AM BLOOD Lactate-1.3
.
TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with inferolateral akinesis/hypokinesis. Overall
left ventricular systolic function is mildly depressed (LVEF= 55
%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2115-9-30**],
the regional wall motion abnormality was present previously
although not reported. There is no aortic regurgitation detected
in either study.
.
CTA CHEST
1. Multifocal pneumonia with associated reactive lymph nodes.
2. No pulmonary embolus or aortic dissection.
3. Bilateral pleural effusions; cannot exclude infected pleural
effusions as there is enhancement of the adjacent pleural
surfaces.
4. Degenerative change of thoracic spine and DISH.
5. Calcification in gallbladder, which may be within the wall,
should be further evaluated by non- urgent ultrasound.
.
Brief Hospital Course:
63M with CAD s/o CABG with recent stent in LCx [**9-22**] who
presents with shortness of breath and flash pulmonary edema in
setting of diastolic heart failure.
.
Brief Hospital Course:
.
# Pulmonary
Patient presented without fever or leukocytosis. CTA was
negative for PE, however it was positive for multifocal
pneumonia and bilateral pleural effusions. He was started on
levofloxacin for presumed community acquired pneumonia. He
twice experienced acute SOB associated with severe HTN (SBP
200s) and was found to have flash pulmonary edema in the setting
of diastolic heart dysfunction. His overlying pneumonia was
thought to contribute to this decompensation as well. He was
transferred to the MICU for management. He underwent diuresis
and his BP was controlled. His pulmonary status responded well
to these interventions and he was transferred to the cardiology
service. Repeat chest imaging showed a stable right middle lobe
nodule opacification. Infectious disease and pulmonary were
consulted to comment on CT chest findings in the setting of
atypical presentation of infection (no leukocytosis, fever,
productive cough). ID recommended a battery of infectious
disease studies including fungal and atypical infectious causes
of pneumonia as well as immunodeficiency workup (HIV testing).
A PPD was placed on [**2115-10-22**] on the right forearm. Pulmonary
considered the lesion to be a polymicrobial abscess and
recommended a prolonged course of PO antibiotics with repeat
imaging w/ CT and outpatient pulmonary follow up. He was
scheduled for repeat CT scan prior to his pulmonary appointment.
He was stable on room air for several days prior to discharge,
albiet with a mild cough worse at night.
.
# CAD
Patient with known severe CAD with recent stenting in [**Month (only) 359**]
[**2114**] to LCx and POBA to OM2. Initial evaluation of cardiac
enzymes was negative, however after the episode of flash
pulmonary edema and HTN his troponins and CK-MB increased. This
was considered a NSTEMI due to demand ischemia and he was
started on heparin drip in addition to his home medications.
After his enzymes trended down the heparin drip was
discontinued. He was also started on a nitroglycerin patch to
help alleviate anginal sxs. Upon discharge he was free of
exertional CP and dyspnea. He will follow up with his
cardiologist several weeks after discharge. A repeat stress
test was recommended and ordered to be completed prior to his
next appointment with cardiology.
.
# PUMP: Diastolic CHF / HTN
Patient has known diastolic chronic CHF. As mentioned, he
likely experienced flash pulmonary edema in setting of
tachycardia, hypertension, pneumonia and mild fluid overload.
His lasix dose was doubled to [**Hospital1 **]; his K and creatinine remained
stable. Other home medications were continued.
.
# IDDM
Home [**Hospital1 **] NPH was continued, however he experienced a few AM low
AM sugars. His PM NPH dose was decreased to 39 units with
resolution. However, given his liberalized diet @ home, he will
continue on his regular 42 units [**Hospital1 **] at home.
.
# Ulcerative Colitis:
Continued 5-ASA.
.
# Depression/Anxiety
Continued Clonazepam and Escitalopram. Clearly this is an
ongoing issue for him and likely is playing a role in his
ongoing debilitation. It was recommended that he continue his
weekly group therapy and consult a private therapist if needed.
.
#Disposition
The patient's family was concerned about Mr. [**Known lastname **] returning
home given the disrepair and clutter in the home, in addition to
a stressful relationship between the wife and husband. PT and
OT were consulted as was social work. The patient did not meet
criteria for rehabilitation; it was recommended that the PCP
continue to work with the patient and his family regarding this
issue. Documentation was provided to apply for disability as
well.
.
He was started on nitroglycerin patch. He will take antibiotics
for 3-4 weeks until his pulmonary follow up. He will also see
his cardiologist and get a stress test in the interim. On
discharge the patient was ambulating on room air without
assistance and free of shortness of breath and / or chest pain.
Medications on Admission:
Mesalamine 1200mg [**Hospital1 **]
Escitalopram 10mg
Amlodipine 5mg daily
Clonazepam 0.75 QHS
Ranolazine 500mg [**Hospital1 **]
Atorvastatin 80mg daily
NTG SL prn
Lisinopril 30mg daily
Ezetimibe 10mg daily
Clopidogrel 75mg daily
Metoprolol Succinate 100mg [**Hospital1 **]
Aspirin 325mg daily
Humalog 42 Units [**Hospital1 **]
Furosemide 40mg daily
Discharge Medications:
1. Stress Test
Exercise MIBI
Please have this test approximately 1 week before your
appointment with Dr. [**Last Name (STitle) **]
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
4. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO BID (2 times a day).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*qs Tablet, Sublingual(s)* Refills:*0*
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Nitroglycerin 0.3 mg/hr Patch 24 hr Sig: One (1) patch
Transdermal DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA): Apply in the morning
and remove before bedtime.
Disp:*30 patch* Refills:*1*
13. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day) for 7 days.
Disp:*qs * Refills:*0*
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
16. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
17. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
Subcutaneous twice a day: Use as directed.
18. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 30 days.
Disp:*120 Tablet(s)* Refills:*0*
19. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 30 days.
Disp:*240 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
-CAD
-Pneumonia, atypical vs abscess
Secondary:
-Diastolic congestive heart failre, chronic
Discharge Condition:
Breathing improved; still w/ occasional cough, free of chest
pain
Discharge Instructions:
You were admitted to the hospital with shortness of breath. You
were found to have uncontrolled blood pressure and excess fluid
in your lungs. During the hospitalization you were also found
to have damage to your heart (heart attack - NSTEMI). Your
blood pressure was controlled and your medication regimen was
improved. You are now taking several new medications:
nitroglycerin patch and two antibiotics - cefpodoxime and
clindamycin. The dose of your lasix was also increased to 40 mg
TWICE a day. Lastly, you were also found to have pneumonia, for
which you were treated with an antibiotic.
.
A nodular opacification was also found on your chest x-ray. You
were scheduled to see a pulmonologist for follow up of this.
BEFORE this appointment (several days prior) please get a chest
CT scan at the [**Hospital3 **] Medical Center. Call radiology ([**Telephone/Fax (1) 18969**] with any questions.
.
Also, have your PPD read (right forearm) w/ your PCP [**Name Initial (PRE) 503**]
([**2115-10-24**]).
.
You will also need to keep your appointment with Dr. [**Last Name (STitle) **].
Prior to this appointment we recommend that you get a stress
test to further evaluate your heart disease. Lastly, Dr. [**Last Name (STitle) **]
will should set you up with post-heart attack rehabilitation as
an outpatient.
.
If you experience any of the following please return to the
hospital or call your doctor: fever, chills, chest pain,
shortness of breath, palpitations, blood sputum production,
rash, swelling of the tongue or throat.
Followup Instructions:
Please keep the below appointments:
Please have CT scan before going to see pulmonology:
CT SCAN [**11-12**] : Call radiology ([**Telephone/Fax (1) 6713**] with any
questions.
.
-Pulmonary
Arrive 7:30AM please
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2115-11-15**] 7:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2115-11-15**] 8:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING
Date/Time:[**2115-11-15**] 8:00
.
-CARDIOLOGY
Dr. [**Last Name (STitle) **] [**2118-11-18**]:30am in [**Last Name (un) 5869**]
|
[
"272.4",
"486",
"556.9",
"428.33",
"401.9",
"410.71",
"V45.81",
"428.0",
"413.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11298, 11355
|
4856, 8867
|
315, 322
|
11500, 11568
|
2321, 4647
|
13153, 13911
|
1471, 1583
|
9266, 11275
|
11376, 11479
|
8893, 9243
|
11592, 13130
|
1598, 2302
|
234, 277
|
350, 1077
|
1099, 1238
|
1254, 1455
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,866
| 149,180
|
10339
|
Discharge summary
|
report
|
Admission Date: [**2143-9-30**] Discharge Date: [**2143-10-3**]
Service: NEUROSURGERY
Allergies:
Penicillins / Gentamicin / Bacitracin / Hydrochlorothiazide /
Chlorothiazide
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
S/p Mechanical Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
s/p mechanical fall
Past Medical History:
Chromic Lymphocytic Lymphoma
Hypertension
Hyperlipidemia
Depression
Osteoarthritis
Chronic low back and hip pain, avascular necrosis of right hip
Chronic bilateral knee pain
s/p right elbow fracture
s/p ORIF right hip [**2137**]
Peripheral Vascular Disease s/p bilat bypass grafts
Social History:
She currently lives alone. Denies any drug use. Quit smoking 15
years ago and only occasional alcohol use.
Family History:
n/a
Physical Exam:
On Admission:
O: T: 96.8 BP: 149/ HR: 79 R O2Sats
Gen: WD/WN, comfortable, NAD, L. parietal hematoma, L. upper lip
laceration
HEENT: Pupils: PERRLA EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-17**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Normal finger-to-nose
Toes downgoing bilaterally
On Discharge:
AOx3, PERRL 3/2mm bilaterally. EOMI intact. Full strength and
sensation throughout upper and lower extremities. Resolving
ecchymotic areas on left facial and lip areas. Chief complaint
upon discharge is ongoing headache(states no worse than
admission)
Pertinent Results:
Non-Contrast Head CT(on admission):
FINDINGS: There is subarachnoid hemorrhage, with hemorrhage in
the cortical sulci in the right frontal and temporal lobes, as
well as hemorrhage within the right sylvian fissure. No
significant mass effect is identified. No other foci of
hemorrhage are seen. There is no shift of normally midline
structures. The ventricles and sulci are normal in caliber and
configuration, without hydrocephalus. There is no acute major
vascular territorial infarction. Mild mucosal thickening is seen
within the maxillary sinuses bilaterally. Additionally, there is
a large soft tissue swelling and hematoma overlying the left
maxillary sinus. However, no fracture is identified.
Non-Contrast Head CT([**10-1**]):
FINDINGS: There is hypoattenuating material seen layering within
the cortical sulci at the right frontal and temporal lobes as
well as within the right sylvian fissure. This represents
subarachnoid hemorrhage and is stable when compared to the
previous examination of [**2143-9-30**]. There is no new focus
of hemorrhage seen on the current study.
There is no mass, mass effect, displacement of the normal
midline anatomy, or infarction. The ventricles and sulci are
normal in caliber and configuration.
There is mild mucosal thickening in the maxillary sinuses
bilaterally.
There is no fracture seen.
Ct of C-Spine([**9-30**]):
CONCLUSION:
1. No acute fracture with extensive degenerative change and
osteophyte
formation along with disc space narrowing at multiple levels in
the cervical spine.
2. Wedge compression of the superior end plate of T2 with
sclerosis of the
end-plate suggestive of subacute or chronic injury.
Labs on Admission:
[**2143-9-30**] 02:45PM BLOOD WBC-43.8* RBC-4.50 Hgb-12.9 Hct-40.0
MCV-89 MCH-28.6 MCHC-32.2 RDW-15.6* Plt Ct-269
[**2143-9-30**] 02:45PM BLOOD Neuts-27* Bands-0 Lymphs-68* Monos-2
Eos-2 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2143-9-30**] 02:45PM BLOOD PT-14.0* PTT-26.3 INR(PT)-1.2*
[**2143-9-30**] 02:45PM BLOOD Glucose-94 UreaN-37* Creat-1.0 Na-138
K-4.2 Cl-103 HCO3-22 AnGap-17
[**2143-9-30**] 02:45PM BLOOD Calcium-9.0 Phos-4.2 Mg-2.2
Labs on Discharge:
[**2143-10-2**] 06:40AM BLOOD WBC-43.2* RBC-3.86* Hgb-11.2* Hct-34.1*
MCV-88 MCH-29.0 MCHC-32.9 RDW-15.3 Plt Ct-256
[**2143-10-2**] 06:40AM BLOOD PT-13.7* PTT-25.4 INR(PT)-1.2*
[**2143-10-2**] 06:40AM BLOOD Glucose-110* UreaN-15 Creat-0.7 Na-141
K-3.7 Cl-105 HCO3-26 AnGap-14
[**2143-10-2**] 06:40AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0
[**2143-10-1**] 04:40AM BLOOD Phenyto-15.2
Brief Hospital Course:
Patient was admitted to the NSURG service on [**9-30**] after
sustaining a mechanical fall while at home and striking the
right side of the body. She was taken to [**Hospital1 18**] after she was
found to have a right traumatic SAH. She was initially admitted
to the ICU to closer monitoring. On HD#2, a repeat non-contrast
head CT was performed and deemed to be stable. She was then
discharged to the floor. She continued to complain of a headache
throughout her hospitalization. Per her report, the headache has
been stable, and not worsening. Also on HD#2 she was evaluated
by physical therapy for home safety and potential disposition.
Secondary to physical therapy's evaluation; Ms. [**Known lastname **] was
determined to be appropriate for rehab disposition. Due to Ms.
[**Known lastname 34327**] insurer's requirements, this was not able to occur until
HD#3. On [**10-3**], she was discharged to her rehab facility as
above.
Medications on Admission:
Metoprolol, Lasix, Plavix, Paxil, Lescol, Fosamax,
multivitamins, calcium, and vitamin D.
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
7. Pre-Hospitalization Meds
Please resume all of your pre-hospitalization medications.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] center
Discharge Diagnosis:
Right Traumatic SAH
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2143-10-3**]
|
[
"311",
"401.9",
"E885.9",
"272.4",
"715.90",
"V43.64",
"724.2",
"873.43",
"200.10",
"852.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"27.51"
] |
icd9pcs
|
[
[
[]
]
] |
6828, 6882
|
4926, 5863
|
308, 315
|
6946, 6970
|
2387, 4054
|
8005, 8268
|
810, 815
|
6004, 6805
|
6903, 6925
|
5889, 5981
|
6994, 7982
|
830, 830
|
2115, 2368
|
249, 270
|
4524, 4903
|
343, 364
|
1374, 2101
|
4068, 4505
|
1135, 1358
|
386, 668
|
684, 794
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,055
| 122,724
|
42160
|
Discharge summary
|
report
|
Admission Date: [**2128-9-27**] Discharge Date: [**2128-10-4**]
Date of Birth: [**2046-11-9**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Ventricular tachycardia
Major Surgical or Invasive Procedure:
cardiac catheterization with no interventions
History of Present Illness:
81F with DM2, HTN, history of stroke on plavix, dementia
transferred from [**Hospital1 1516**] for closer monitoring in setting of
possible VTach. Pt in usual state of health until yesterday.
Some SOB ascending stairs to bed last night, Daughter then heard
gurgling noise and noted pt to be difficult to arouse from
sleep, pt was confused and diaphoretic when awoken - pt stated
she was in "deep sleep". Of note, clear fluid on shirt and
sheets thought to be from mouth, but reported to not look like
vomit. ? syncope. EMS called, taken to [**Hospital3 4107**] where
troponin I 0.72, BNP 369, Creatinine 1.6, EKG NSR with sub-mm ST
elevations in III and aVF and reciprocal sub-mm depression in I
and aVL. CXR with no acute process. Recieved ASA 324mg and
heparin gtt, transferred to [**Hospital1 18**] for cath. This am,
experienced 30s run of VT, self-limited. Now with persistant
tachycardia, EP consulted and not sure if VT vs other
tachyarrhythmia - recommend transfer to CCU for further
monitoring. Remained asymptommatic throughout.
.
She reports she is comfortable and never had any chest
discomfort or shortness of breath. Per son who accompanies her,
patient has baseline lower extremity edema, 2 pillow orthopnea
that is unchanged, and stable DOE w/ stairs. Has remote history
of fainting.
.
On review of systems, s/he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable as above and for absence of
chest pain, paroxysmal nocturnal dyspnea, palpitations.
.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension
2. OTHER PAST MEDICAL HISTORY:
Hypertension
Diabetes mellitus type II, on insulin
H/o stroke
Dementia (baseline oriented x2)
Osteoperosis
PVD
CKD - creatinine 1.8 in [**6-/2128**]
Social History:
Lives w/ daughter in [**Name (NI) 5110**]. Is from [**Location (un) **] and moved here
many decades ago. Son is HCP/POA.
-Tobacco history: No current tobacco use. Smoked rarely in
remote past.
-ETOH: None currently. Rare in past.
-Illicit drugs: Never
Family History:
Unknown
Physical Exam:
VS: T= 97.5 BP= 67/50 HR= 123 RR= 21 O2 sat= 97%RA
.
DATE: GENERAL: NAD. Oriented x2. Appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear.
NECK: Supple, no LAD. JVP minimally elevated above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. tachycardic, regular, normal S1, S2. No m/r/g. No thrills,
lifts. no gallop.
LUNGS: Resp were unlabored, no accessory muscle use. bibasilar
wet crackles, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. +BS.
EXTREMITIES: trace bilateral LE edema to ankle, No c/c.
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:
[**2128-9-27**] 05:49AM PT-11.7 PTT-24.0 INR(PT)-1.0
[**2128-9-27**] 05:49AM PLT COUNT-292
[**2128-9-27**] 05:49AM NEUTS-65.1 LYMPHS-29.8 MONOS-3.1 EOS-1.5
BASOS-0.6
[**2128-9-27**] 05:49AM WBC-7.4 RBC-3.43* HGB-10.5* HCT-30.2* MCV-88
MCH-30.7 MCHC-34.9 RDW-13.0
[**2128-9-27**] 05:49AM CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-2.2
[**2128-9-27**] 05:49AM CK-MB-4 cTropnT-0.43*
[**2128-9-27**] 05:49AM CK(CPK)-73
[**2128-9-27**] 05:49AM estGFR-Using this
[**2128-9-27**] 05:49AM GLUCOSE-166* UREA N-29* CREAT-1.6* SODIUM-140
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
[**2128-9-27**] 12:00PM PTT-61.7*
[**2128-9-27**] 04:55PM CK-MB-3 cTropnT-0.43*
[**2128-9-27**] 04:55PM CK(CPK)-63
.
Cardiac Cath [**2128-9-29**]
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated 3 vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting disease. The LAD had a
90%
mid-vessel stenosis, and was otherwise diffusely disease. The
D1 had an
80% stenosis. The LCx had 80% stenosis at the origin, and OMB2
was
totally occluded and filled by left-to-left collaterals. The
RCA was
totally occluded proximally and filled via left-to-right
collaterals.
2. Resting hemodynamics revealed mildly elevated left- and
right-sided
filling pressures with an LVEDP of 20mmHg and an RVEDP of
16mmHg. There
was no gradient across the aortic or mitral valve. There was
mild
pulmonary venous hypertension with a PA pressure of 37/19 and a
normal
PVR. Cardiac output was preserved at 5.5 L/min with an index of
3.2
L/min/m2.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Preserved cardiac output.
3. Mildly elevated left- and right-sided filling pressures
.
[**2128-9-27**]
echo
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
near akinesis of the basal inferior wall and distal halves of
the septum and anterior wall. The apex is mildly aneurysmal and
akinetic. The remaining segments contract normally (LVEF = 30-35
%). No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild to moderate
([**1-11**]+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is an anterior space
which most likely represents a prominent fat pad.
.
IMPRESSION: Normal left ventricular cavity size with extensive
regional systolic dysfunction c/w multivessel CAD. Mild-moderate
mitral regurgitation.
.
Brief Hospital Course:
81F with history of previous stroke, DM and dementia admitted
with likely NSTEMI now with tachyarrythmia concerning for VT.
.
# NSTEMI/CAD: no known history, multiple risk factors. q's in
III and aVF concerning for history of MI. elevated troponin of
0.43, CK WNL. Pt went for cardiac cath which showed extensive
3VD. Goals of care discussion occured with pt and family and it
was determined not to pursue CABG. Pt was continued on ASA,
plavix, metoprolol, lisinopril and atorvastatin.
.
# CHF: On presentation to CCU, pt was found to have bibasilar
crackles on exam, however, no oxygen requirement and minimal
swelling in LE. Pt was given one dose of lasix 10mg IV and
diuresed appropriately. At time of discharge, she was not
requiring any diuretic. She was discharged on lisinopril and
metoprolol.
.
# RHYTHM: Pt was in stable monomorphic VT on transfer to CCU.
Etiology is likely secondary to scarring from previous event.
Pt was initially started on metoprolol 5mg IV and then lidocaine
bolus and drip. She converted to 1st degree heart block. On
[**9-30**] started amio 200TID for 14 days of loading, then 300 qday 4
weeks then 200mg qday. EP was consulted and determined that pt
is not a good candidate for EP study given age and prior goals
of care discussion.
.
# HTN - Pt was continued on metoprolol. At time of discharge,
she was taking lisinopril and metoprolol.
.
# Diabetes - on lantus at home. Was put on ISS during
hospitalization.
.
Transitional:
- Pt will need f/u care with Dr. [**Last Name (STitle) 8098**] per son's request for
management of CHF and CAD, unsuccessful attempt was made to
schedule before discharge
- DNR/DNI status initiated during this hospital stay
- Please check Chem-7 and CBC on Thursday [**10-7**]
- Please check fingersticks for one week with humalog sliding
scale, d/c after one week if FS consistantly < 150.
- Pt may need to transition to permanant 24 hour care according
to son.
Medications on Admission:
Plavix 75 mg daily
Metoprolol Succinate 25 mg daily
Lantus 10 units SC daily
Vitamin B
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as
needed for insomnia.
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) for 4 days: Change to 300 mg daily for 4 weeks, last day
[**11-4**], then change to 200 mg daily thereafter. .
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day.
9. multivitamin Capsule Sig: One (1) Capsule PO once a day.
10. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Severe coronary artery disease
Ventricular tachycardia
Acute systolic congestive heart failure
Diabetes
Hypertension
Dementia
History of stroke
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 had a heart attack and needed a cardiac catheterization to
assess for blockages in your coronary arteries. There were
severe blockages found but none of the blockages were amenable
to treatment with balloons or stents. Instead, we have started
you on medicine to try to prevent the blockages from getting
worse. You had a irregular heart rhythm called ventricular
tachycardia, this was treated with a medicine called amiodarone
and it has not returned. Your heart is weak after the heart
attack. Weigh yourself every morning, call Dr. [**Last Name (STitle) 8098**] if weight
goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start aspirin to prevent another heart attack
2. Start lisinopril to help improve your heart function
3. STart trazadone to help you sleep
4. Start amiodarone to prevent ventricular tachycardia
5. Start atorvastatin to lower your cholesterol
6. STart calcium and vitamin D to treat your osteoporosis
7. STart a multivitamin to add to your diet.
Followup Instructions:
CV: A call was made to Dr.[**Name (NI) 39204**] office at [**Location 91435**], [**Numeric Identifier 34093**]
Phone: ([**Telephone/Fax (1) 20481**]
Please call the office to schedule an appt
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icd9pcs
|
[
[
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|
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328, 376
|
9746, 9746
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,270
| 120,750
|
52946
|
Discharge summary
|
report
|
Admission Date: [**2139-1-27**] Discharge Date: [**2139-2-10**]
Date of Birth: [**2070-6-4**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old
woman with a history of hypercholesterolemia and migraine
headaches who developed a severe headache at work followed by
confusion. Her coworkers called 911.
In the Emergency Room at [**Hospital6 2561**], the patient
had a 10 to 20 second tonic-clonic seizure which resolved
with Ativan. The patient was transferred to [**Hospital1 346**] intubated for a magnetic resonance
imaging and increased lethargy. Prior to intubation the
patient was awake, alert, and oriented times two. The
magnetic resonance imaging showed a left parietal mass and
surrounding edema; similar to a CT scan done at [**Hospital6 **]. The patient was loaded with Dilantin and started
on Decadron.
PAST MEDICAL HISTORY: Also a past medical history of
depression, asthma, migraine headaches (with right-sided
migraines daily times years with visual changes).
MEDICATIONS ON ADMISSION: Dilantin 100 mg three times daily,
subcutaneous heparin, Protonix by mouth, Decadron 6
intravenous q.6h., and atorvastatin 10 mg once daily.
ALLERGIES: The patient has an allergy to PENICILLIN.
SOCIAL HISTORY: The patient is married and has nine
children. No tobacco or ethanol in her past.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
afebrile, the heart rate was 71, the respiratory rate was 18,
the blood pressure was 126/54, and the oxygen saturation was
100 percent. In general, the patient was sedated and
intubated. HEENT revealed the pupils were equal, round, and
reactive to light. No scleral icterus. The neck was supple.
The lungs were clear bilaterally. Heart revealed a regular
rate and rhythm. No murmurs. The abdomen was soft,
nontender, and nondistended. There were positive bowel
sounds. The extremities revealed no clubbing, cyanosis, or
edema. There were 2 plus pulses. Neurologic examination
revealed the patient was sedated. She was moving all
extremities. She withdrew to pain.
RADIOLOGY STUDIES: A head computer tomography and magnetic
resonance imaging showed a left parietal mass with
surrounding edema.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Neurosurgery Service. The patient was extubated in the
Emergency Room prior to being admitted. The patient was
admitted to the Intensive Care Unit for close neurologic
observation and transferred to the regular floor the
following day.
The patient was seen by Neurology/Oncology who recommended
either biopsy or surgery to confirm the diagnosis. The
patient remained neurologically stable. She was seen by
Physical Therapy and Occupational Therapy. She was seen by
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] on [**2139-2-2**] and prepared for surgery.
On [**2139-2-4**] the patient underwent a left parietal
craniotomy for excision of a tumor. The patient was kept
overnight in the Recovery Room. She was following commands.
She was neurologically stable. She was transferred to the
regular floor on postoperative day one. She did spike a
temperature to 102.5. She was awake and alert. Her speech
was intact. She was moving all four extremities
spontaneously. She had no drift.
She had a magnetic resonance imaging postoperatively that
showed good excision of the mass. She developed a rash
postoperatively and was seen by Dermatology who felt that
this more likely due to Dilantin. She also spiked a
temperature again to 103. She was seen by the Infectious
Disease Service who felt that she could potentially have
meningitis, but the patient and her family refused a lumbar
puncture. The patient was stated on linezolid by mouth 600
mg twice daily for two weeks and ceftazidime 2 grams
intravenously q.8h. for two weeks. She also developed herpes
simplex sores in her mouth and was started acyclovir 400 mg
by mouth three times per day for five to seven days.
The patient was seen by Physical Therapy and Occupational
Therapy and felt to require a short rehabilitation stay
prior to discharge to home. Her neurologic status remained
stable throughout her hospital stay, and her vital signs were
stable. She was afebrile at the time of discharge.
MEDICATIONS ON DISCHARGE:
1. Acyclovir 400 mg by mouth q.8h. (times one week).
2. Quetiapine fumarate 25 mg by mouth at bedtime.
3. Decadron 2 mg by mouth q.8h. (for two days) and then down
2 mg twice daily and stay at that dose.
4. Bisacodyl 10 mg by mouth once daily as needed.
5. Plexal 10 mg p.r. at bedtime as needed.
6. Senna one tablet by mouth twice daily as needed.
7. Heparin 5000 units subcutaneously twice daily.
8. Calcium carbonate 500 mg by mouth four times per day.
9. Linezolid 600 mg by mouth q.12h.
10. Ceftazidime 2 grams intravenously q.8h.
11. Hydromorphone 2 mg by mouth q.4.h. as needed.
12. Levetiraetam 750 mg by mouth twice daily.
13. Sarna lotion one application topically to her rash
four times daily as needed.
14. Triamcinolone acetonide 0.1 percent cream topically
to the rash twice daily for 14 days (which started on
[**2139-2-6**]).
15. Lorazepam 0.5 mg by mouth q.12h. as needed.
16. Colace 100 mg by mouth twice daily.
17. Pantoprazole 40 mg by mouth q.24h.
18. Atorvastatin 10 mg by mouth once daily.
19. Tylenol 650 mg by mouth q.4.h. as needed.
CONDITION ON DISCHARGE: The patient's condition was stable
at the time of discharge.
DISCHARGE FOLLOWUP: She will follow up in the Brain [**Hospital 341**]
Clinic in two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2139-2-10**] 11:38:30
T: [**2139-2-10**] 12:09:17
Job#: [**Job Number 109147**]
|
[
"054.9",
"780.6",
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"998.89",
"272.0",
"E936.1",
"191.3",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
4340, 5463
|
1059, 1256
|
2250, 4314
|
5572, 5909
|
164, 870
|
893, 1032
|
1273, 2221
|
5488, 5551
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,516
| 126,907
|
22504
|
Discharge summary
|
report
|
Admission Date: [**2117-9-22**] Discharge Date: [**2117-10-11**]
Date of Birth: [**2079-8-26**] Sex: F
Service: HPB
HISTORY OF PRESENT ILLNESS: The patient is a 38 year old
female with Child's B cirrhosis with 2 to 3 month history of
right upper quadrant pain in her abdomen, chills, night
sweats, rigors, pain radiating to her back, also associated
with occasional nausea and emesis. She is a patient with
well known severely symptomatic chronic cholecystitis with
proven stone disease by ultrasound and CAT scan. She is also
an alcoholic, known to be actively drinking in the recent
past. She has been on an outpatient detoxification for the
last two weeks in order to prepare for her upcoming
gallbladder removal and the possibility of withdrawal
symptoms. This patient has been in close contact with Dr.
[**Last Name (STitle) **] during this time, discussing the danger of possible
operations. Dr. [**Last Name (STitle) **] has also discussed this surgery at
length with the patient's family stating the ramifications of
possible surgery in the background of liver disease, her
being a Child's B cirrhotic. The patient also has history of
cocaine abuse, but states she has not currently had any for
the last 10 years.
PHYSICAL EXAMINATION: The patient was afebrile with a heart
rate of 90, blood pressure 100/69, and was breathing at 95
percent oxygen on room air with a weight of 115 lbs. She was
noted to be somewhat cachectic appearing with mild jaundice
of her sclerae. Heart was in regular rate and rhythm. Lungs
were clear to auscultation bilaterally. Abdomen was slightly
distended with normal bowel sounds. There is some tenderness
in the right upper quadrant. No rebound or guarding. Liver
edge was not palpable at this time. Her spleen has been
removed. Extremities were warm to the touch. Pulses were 2+
bilaterally and there was no edema noted.
HOSPITAL COURSE: This patient with chronic cholecystitis was
admitted for an open cholecystectomy with the patient
accepting the risk of mortality and morbidity of this
procedure in the background of her liver disease. This has
been discussed again at length with the patient and her
family. The patient's risk as a Child's B cirrhotic was
detailed at length. The patient was encouraged to prepare for
this procedure nutritionally and to avoid alcohol in the
period leading up to it, and enrolled in an alcoholic
detoxification program in preparation for this procedure and
on [**2117-9-22**], was admitted to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **] for open cholecystectomy for chronic
cholecystitis with cholangiogram to be performed.
During the procedure the patient's gallbladder was removed
without complication and a cholangiogram was performed. There
was no evidence of obstruction of the ducts, of further stone
disease or filling defects. It was determined there was no
common bile duct pathology at this time. The patient had [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 406**] drain placed at this time as well in the right upper
quadrant and the patient was transferred to the Post
Anesthesia Care Unit in stable condition following an
extubation. There had been no complications
intraoperatively. The patient's blood loss was approximately
50 ml during this operation and there was a central venous
catheter also placed.
In the immediate postoperative period the patient complained
of some pain at the operative site. Her vital signs were
stable at this point. She was afebrile at 96.5 degrees
Fahrenheit with a heart rate of 60 and blood pressure of
121/72, and with a urine output was approximately 50 per hour
over the last couple of hours in the immediate postoperative
period. She was started on intravenous fluids, pain
medication and she was transferred to the floor at this time.
On postoperative day 1 the patient began to have slight drops
in her blood pressure into the high 80's over the high 50's
with heart rate of up to 107. Hematocrit was checked at this
time and found to be 28.1. The patient was placed on urine
output check every 2 hours and vital signs every 2 hours and
frequent checks. The patient was also given albumin several
times during this period receiving 25 grams, with decreased
urine output in addition to boluses of lactated Ringer's
solution of 500 ml at a time with the patient continuing to
have low urine output. The patient also was complaining of
itching during this time and was receiving Benadryl. Later
in the evening of postoperative day 1 the patient's oxygen
saturations dropped to 78 percent with 2 liters of nasal
cannula. This had to be increased to 6 liters to obtain
saturations of greater than 90 percent.
On postoperative day 2, [**2117-9-24**], the patient at
this time had now received 4 doses of albumin, 4 boluses of
500 ml of lactated Ringer's solution and was placed on face
mask for decreased oxygen saturations. She was doing
somewhat better with her pain better controlled at this time
and she was not having any nausea or vomiting. She was
afebrile during this time and her vital signs were 98.9,
temperature maximally over the last 24 hours. The patient
was started on clear liquids which she managed to tolerate.
The patient on the second postoperative day also received 2
units of packed red blood cells. The patient was given
lactulose at this time and was allowed to advance her diet as
tolerated.
On postoperative day 3, the patient had another episode of
desaturation to 76 percent on room air after having gradual
onset of dyspnea with blood pressure of 92/60 at this time,
heart rate piling to the 115 to 120 as maximum. Chest x-ray
was performed and it was read as having some pulmonary edema
with small pleural effusions bilaterally. The patient was
given Lasix 40 mg intravenous x 1 at this time. The patient
was continued on a non-breathable mask. Serial examinations
were performed and it was determined that the patient would
likely have to move to a more monitored setting or possibly
be intubated in a short period of time. The patient was also
placed on aggressive pulmonary toilet during this time and on
postoperative day 3, the patient was moved to the Post
Anesthesia Care Unit due to her pulmonary edema. She had
increased ascites with elevated hemidiaphragms on chest x-ray
with small bilateral pleural effusions and the fact that
aspiration pneumonia could not be ruled out at this time. It
was determined that the patient would benefit from this more
monitored setting. During this time the patient's white count
went up to 20.2.
On [**2117-9-25**], hospital day No. 4, postoperative day No. 3,
the patient was started on levofloxacin and Flagyl. The
patient was cultured throughout. The patient was get daily
hematocrit checked and have pathology following the patient,
and the patient continued to receive doses of albumin. Later
in the day on [**2117-9-25**], the house officers were
called to the bedside for increasing respiratory failure and
decreased urine output with recent output of 7 cc per hour.
Chest x-ray was repeated that showed significant white-out of
her right lung. Arterial blood gases showed numbers of 7.30,
79, 46, 24, and negative 3 with CVP and 22 to 24. The
patient was in fact labor breathing with respiratory rate
between 25 and 32. There were significant right sided
crackles anteriorly and posteriorly on auscultation. The
patient was diuresed at this point with Lasix 120 mg x 1, and
the patient improved somewhat at this time. The patient's
CVP improved between 9 and 10 liter in the day with chest x-
ray as mentioned above showing significant right lung white
out.
On [**2117-9-26**], another chest x-ray was performed that
now showed bilateral infiltrates and the plan was now to
actively intubate the patient. This was performed in the Post
Anesthesia Care Unit. Chest x-ray confirmed placement.
On postoperative day 5, a left subclavian Cordis and
pulmonary artery catheter were placed. Secondary to an
infected line and the need for invasive hemodynamic
monitoring vancomycin was added at this time. On
postoperative day 5, [**2117-9-27**], the patient was
being ventilated effectively. She was now being treated for
gram positive cocci septicemia and was on vancomycin,
levofloxacin and Flagyl at this time for any possible
pulmonary process as well and on [**2117-9-27**], the
patient was also on Levophed at this time for pressure
support. The patient was also full coded at this time. Her
bilirubin at this time was 2.8 total with an INR of 2.5.
On [**2117-9-28**], postoperative day No. 6, the patient
was now on propofol as well. She has having more adequate
urine output during this time. Antibiotics were continued.
Nutrition began to assess the patient during this time who
recommended tube feeds to meet nutritional goals. On
[**2117-9-28**], the patient's total bilirubin was 7.6
with an INR of 1.9 and her temperature maximally over the
last 24 hours was up to 101.7 degrees Fahrenheit.
On [**2117-9-29**], postoperative day 7, the patient was
noted to be improving slightly and seemingly less septic.
She was ventilated adequately at this time and was receiving
Nepro for tube feeds and was being advanced as tolerated with
Levophed also being used as tolerated. Cultures have been
followed carefully. The patient was continued on Actos
during this time as well.
On postoperative day 8, her white blood cell count at this
time on [**9-30**] was 24.6. It had increased over the
last several days. Her central line was again changed over a
wire for fear of previous one being an infectious source.
On [**2117-10-1**], postoperative day 9, the patient's
white blood cell count increased again to 28.6. The patient
was ventilated. The patient was now off of Levophed at this
point and tube feeds were switched from Nepro to Impac and
antibiotics were continued.
On [**2117-10-2**], postoperative day No. 10, our goal at
this time was to wean pressure support and to try CPAP.
On [**2117-10-3**], postoperative day 11, the patient was
still intubated. The patient was again off of Levophed at
this time and was receiving doses of albumin. The patient
was worked up for heparin induced thrombocytopenia at this
time. All tests came back negative. HIT antibody was
negative and the patient was restarted on heparin. White
blood cell count was now up to 31.5. The patient was now
noted to be losing significant amounts of fluid out of her
ascites and her wound. Our goal at this time was to keep up
with her fluid requirements.
On [**2117-10-4**], postoperative day 12, the patient had
now been activated and was tolerating well. She was noted to
be generally stable except for having a significant ascites
of late and was noted to have a case of ARDS. Ascitic fluid
was sent at this time for culture and sensitivity. CT chest
scan had been negative on [**2117-10-1**], for any signs
of abscess.
On [**2117-10-5**], postoperative day 13, her NG tube was
discontinued and she continued to have a drainage from her
incision. She again received 500 ml bolus for tachycardia
and blood pressure during this time. The patient began to
have improved oral intake also during this time and tube
feeds were stopped. Her PTT at this point was 41.3 and her
heparin was back down to 2 doses a day.
On [**2117-10-6**], the patient was transferred to the
floor, Surgical Intensive Care Unit without difficulty. She
was noted to be doing well with her pain well controlled.
She was now out of bed and ambulating. Her examination
revealed still some ascitic fluid draining from her wound.
This was cared for at this point by an ostomy nurse and
physical therapy began to evaluate the patient at this time
and determined that the patient will be safe for discharge to
home after one to two more follow up visits. They
recommended ambulating 3 times a day for the patient.
On [**2117-10-7**], postoperative day 15, the patient
continued to progress well and was without complaints at this
point. Her electrolytes were being repleted. Accordingly
magnesium and potassium have been given as needed. The
patient was now receiving spironolactone 50 mg qd and she was
noted to be at this point turning the corner after a distinct
postoperative decompensation.
On [**2117-10-8**], postoperative day 16, the patient was
again without complaint. She was taking more by mouth at
this time. Calorie counts had been started and the patient
was restarted as well on Nadolol. Vancomycin was stopped
during this time. Special nursing was consulted for her
wound site and how to go about gathering her ascitic fluid.
On [**2117-10-8**], physical therapy had signed off on the
patient and said that the patient was safe to go home though
calorie counts were still not satisfactory. The patient
received 26 grams of protein and 487 calories on [**2117-10-7**], postoperative day 15. On postoperative day 16, the
patient was encouraged to get at length on the importance of
improving her nutritional status. Social work and addiction
consults were sought and their input was appreciated.
On [**2117-10-10**], postoperative day 18, the patient was
continued on Levofloxacin and Flagyl and was noted to be
doing well, and increasing her oral intake. Calorie counts
began to dramatically improve during this time as well as her
protein intake. The plan was to continue the patient on
Aldactone and restrict sodium to prevent excess fluid
accumulation and to monitor her phage output. Her calorie
intake over the previous 24 hours was approximately 1200,
protein 90 grams.
On [**2117-10-11**], postoperative day 19, antibiotics had
been stopped and the patient was afebrile with temperature
maximally of 98.4 degrees over the last 24 hours. She was
still putting out significant amount of ascitic fluid but was
falling down somewhat clearing out approximately 1 liter over
24 hours at this time out of her wound into the bag. The
patient was noted to be stable at this time. The patient was
able to be discharged home with visiting nursing assistance.
The patient was stable on examination and was fully aware of
the plans for follow up and for her care at home and for the
importance of abstaining from alcohol and taking all her
medications according to the plan set out for her.
DISCHARGE INSTRUCTIONS: The patient was to be discharged
home with visiting nurse assistance daily to take special
care of her wound site and ascites drainage. The [**Hospital 228**]
medical doctor is aware. She is to come to Emergency Room if
having increasing abdominal pain, fevers, chills, nausea,
vomiting, increasing drainage or redness about the wound or
if there are any questions or concerns.
FINAL DIAGNOSIS:
1. Child's B cirrhosis.
2. Chronic severe symptomatic cholelithiasis.
3. Aspiration pneumonia.
4. Acute respiratory distress syndrome.
5. Sepsis.
6. Alcoholism.
7. Major surgical or invasive procedures - open
cholecystectomy with cholangiogram, intubation subclavian
Cordis and pulmonary artery catheter placement with
multiple changes.
RECOMMENDATIONS: Follow up - the patient to be seen by Dr.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, on [**2117-10-29**], at 10:30 a.m.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po qd.
2. Spironolactone 100 mg po qd.
DISPOSITION: The patient to be discharged home with visiting
nurse assistance.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2117-11-23**] 22:16:46
T: [**2117-11-24**] 02:10:18
Job#: [**Job Number 58432**]
|
[
"303.01",
"518.5",
"287.5",
"789.5",
"571.2",
"574.10",
"038.10",
"507.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"96.72",
"96.6",
"99.04",
"96.04",
"38.93",
"99.07",
"93.90",
"87.53",
"51.22",
"51.51"
] |
icd9pcs
|
[
[
[]
]
] |
15338, 15753
|
1917, 14375
|
14798, 15315
|
14400, 14781
|
1274, 1899
|
166, 1251
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,408
| 138,971
|
6650
|
Discharge summary
|
report
|
Admission Date: [**2163-6-13**] Discharge Date: [**2163-6-16**]
Date of Birth: [**2117-3-31**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Vancomycin / Keflex / Biaxin / Percocet
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Chest burning
Major Surgical or Invasive Procedure:
Left femoral line placement
History of Present Illness:
46yo F with Type 1 DM on insulin pump presented to [**Last Name (un) **] with
"chest burning" noted to have hyperglycemia 600s, elevated anion
gap. Pt recently admitted to [**Hospital3 **] in [**Location (un) 7661**] for similar
presentation 2 weeks ago. Pt describes chest pain substernal
radiating to neck and top of arms, but not down arms. Lasted [**11-28**]
hours. No associated SOB, V, diaphoresis. In ED, given NTG and
Mylanta, feels Mylanta made pain better. Patient feels that pain
is most likely heartburn. She states she was on Nexium in past,
which was not helping her anymore. At [**Hospital3 **] she had
negative persantine stress test and enzymes. She had a small
bowel follow through which was normal and a normal endoscopy.
She was started on reglan (but told only to take as needed) and
PPI (but also told to take as needed?) She does not recall the
name of the new medication.
ROS: + episode of N earlier today. No sweats. No F/C. No sore
throat. No dysuria, vaginal discharge. no diarrhea. no sore
throat/ cough.
Of note, ? if pump is working. Last night, when she primed the
pump, she had difficulty with it and had to prime it at least 3
times. Apparently, the pump has not been checked at [**Last Name (un) **] in
last 2 weeks.
Patient also describes subjective sensation of food getting
stuck in stomach after she eats and then passing quite a bit
later.
Past Medical History:
DM Type 1 with renal and eye manifestations followed by Dr.
[**First Name (STitle) **]; last HbA1C 10.9% 1/05
Hypercholesterolemia
Goiter, unspec
abdominal bruit - [**2162-8-25**]- CT abd/pelvis: CA++ mesenteric art.No
sig CA++ in aorta or renal art. No aortic aneurysm.
s/p cholecystectomy
Social History:
Recently moved to [**Location 9583**] from [**Location (un) 6981**], MA. Her
endocrinologist at [**Last Name (un) **] is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**]. No tobacco,
rare EtOH. Is a stay at home mom. [**Name (NI) **] 2 [**Name2 (NI) 25400**] 9, 12.
Family History:
No family h/o CAD. Mom-high cholesterol. Dad- prostate CA.
Physical Exam:
VS: T 98.4 HR 110 BP 131/36 RR 18 O2 99% RA
Gen: well-appearing thin F NAD, alert and oriented x 3.
HEENT: PERL. EOMI. no scleral icterus.
CV: RRR. Nl S1, S2. + SEM loudest at LUSB radiating to carotids
b/l, back.
Lungs: CTAB
Abd: active BS. soft. ND. + audible aortic bruit. tender
suprapubically and ? diffusely to percussion. no renal artery
bruit.
no rebound or guarding. insulin pump site without erythema or
tenderness.
Extr: no edema. DP 2+ b/l.
Neuro: strength intact throughout. light touch intact. pinprick
not tested.
Groin: Left femoral line in place
Pertinent Results:
On admission [**2163-6-13**]:
.
pH 7.4, glu (venous) 603, lactate 2.2
WBC 9.4, Hgb 14, Hct 39.5, Plt 183
Na 131, K 5.2, Cl 91, HCO3 18, BUN 27, Cr 1.3, Glu 613, AG 22
.
Cardiac enzymes x2 - NEGATIVE
.
U/A: pH 5.0, glucose 1000, ketones 50; no leukoctyes or
nitrite.
.
EKG: sinus tach at 100bpm, normal axis; flattened TW III and TWI
V1; ? slight ST depression in II, III, avF, V6 (EKG from [**11/2156**]
largely unchanged)
.
CXR, PA and lateral: Flattened diaphragms, with flaring between
ribs, and a small heart. No focal infiltrates or consolidations.
Clear costophrenic angles bilaterally.
.
serum hCG: negative
.
On discharge:
WBC 5.8, Hgb 11.0, Hct 31.5, Plt 153
Na 141, K 4.0, Cl 113, HCO3 24, BUN 15, Cr 0.8, Glu 124, AG 4
Fe 45, TIBC 205, Ferritin 112, TRF 158
Ca 7.8, Ph 2.7, Mg 1.8
.
Echo: ([**First Name8 (NamePattern2) **] [**Last Name (un) **] notes).
[**2161-12-16**]- Normal LV function >55%, 1+MR [**First Name (Titles) **] [**Last Name (Titles) **]
Brief Hospital Course:
46yo female with type I DM complicated by retinopathy and
nephropathy who presents in DKA with burning chest pain that
radiated to her neck and arms bilaterally. Likely cause of her
DKA was insulin deficiency [**12-29**] a pump malfunction.
.
1. DKA - She was admitted to the [**Hospital Unit Name 153**] and placed on IVF of NS at
500cc/hr overnight. She was also started on an insulin gtt per
the [**Last Name (un) **] protocol. By morning, she had closed her anion gap
and was actually becoming hypoglycemic. Her IVF were switched to
D5NS and her insulin gtt was held until her fingersticks came
back to normal. Her insulin gtt was then restarted at a basal
rate to match her typical rate on her insulin pump. [**Last Name (un) **]
consulted to check her insulin pump and found that she had
bubbles in the line which was likely blocking the flow of
insulin. Unfortunately, the patient was unable to see the
bubbles due to her retinopathy. It was decided to d/c the
insulin gtt and place the patient on glargine 20u at 5pm and a
humalog sliding scale in a ratio of 1:15g carbohydrates, as the
patient is educated in carb counting. The patient did not feel
comfortable administering injections due to her deformed R hand
and her inability to see the numbers on the syringes well.
Because of this, it was decided to keep her overnight and
discharge her prior to her [**Last Name (un) **] appointment where her insulin
pump will be reattached.
.
2. Chest pain - She ruled out for MI by negative cardiac enzymes
x2 and no EKG changes. She had a negative persantine stress test
and normal ECHO per patient 2 weeks ago at [**Hospital6 5016**]
in [**Location (un) 7661**]. It was felt to be GERD/gastroparesis and patient was
started on a PPI or H2 blocker (she can't remember the name). in
hospital, she felt that her GERD symptoms were improved with
Mylanta and pantoprazole. She may benefit from gastric motility
studies as an outpatient.
.
3. Anion gap metabolic acidosis - Her anion gap was originally
22, but came down to 4. She likely became hyperchloremic due to
aggressive fluid resuscitation, so IVF were stopped and the
patient was encouraged to continue taking POs.
.
4. Hyperkalemia - Resolved with treatment of her DKA. Was 4.0 on
discharge.
.
5. ARF - Also resolved with treatment of her DKA. Her Cr was 1.3
on admission, but came down to 0.8 which is her baseline. The
bump in her Cr was likely prerenal in origin.
.
6. Anemia - Her Hct was normal on admission, but decreased to
31.4 with hydration. Iron studies were sent and are suggestive
of an anemia of chronic disease. We recommend follow-up with her
PCP for this.
.
7. FEN - She was on a diabetic diet throughout her admission.
She was encouraged to take PO fluids rather than IVF. She had
bathroom privileges throughout her admission and a foley
catheter was never placed. She did complain of mild suprapubic
pain while admitted. If suprapubic pain does not improve, her
PCP may consider straight catheterization or diagnostic studies
to r/o urinary retention/autonomic dysfunction due to her DM. UA
and urine cx were negative for infection.
.
8. Access - L femoral line was placed in the ED per patient
request. It was left in throughout the course of her admission.
She has had 11 surgeries and now has a deformed R hand [**12-29**] an
infiltrated IV and thrombophlebitis in the past, so she is
reluctant to have peripheral lines.
.
9. Ppx - She used pneumoboots while in bed. Heparin was not
indicated as pt was ambulating to commode. Was also given PPI +
Maalox. Bowel regimen to prevent constipation.
.
10. Code status - FULL
.
11. Dispo - To home, with close follow-up by [**Last Name (un) **].
Medications on Admission:
1. Humalog insulin pump. 0.7 U/hr 12 AM to 7 AM ; 0.8 U/ hr 7AM
-12 AM
2. Prinivil 10mg 1 once a day
3. Lipitor 10mg 1 once a day
4. Advair [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Diabetic ketoacidosis
2. Anemia
Secondary diagnosis:
1. Diabetes mellitus type 1 complicated by retinopathy,
nephropathy
2. Hypercholesterolemia
3. h/o goiter
4. h/o abdominal bruit
Discharge Condition:
Stable, with FS in 160s-200s and anion gap of 4.
Discharge Instructions:
Please call your PCP if you develop any of the following
symptoms: dizziness, sweating, lightheadedness, chest pain,
burning or tightness, shortness of breath, nausea or vomiting,
or with any other troublesome symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 174**] on Thursday, [**6-17**] at 11am and
with [**First Name8 (NamePattern2) 7905**] [**Last Name (NamePattern1) **] at 1pm.
Please set up follow-up with your PCP [**Last Name (NamePattern4) **] [**11-28**] weeks for your
reflux disease and possible gastroparesis. You may benefit from
a gastric motility study, if you have not had that already. You
also have a slight anemia which should be followed by your PCP.
[**Name10 (NameIs) 2172**] CXR also shows signs of hyperinflation. This should be
compared to old films by your PCP as your PCP may recommend
pulmonary function tests as an outpatient.
|
[
"250.41",
"285.29",
"276.2",
"583.81",
"276.7",
"V45.85",
"362.01",
"584.9",
"250.51",
"530.81",
"250.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7931, 7937
|
4052, 7724
|
324, 353
|
8186, 8236
|
3061, 3679
|
8504, 9156
|
2402, 2462
|
7958, 7958
|
7750, 7908
|
8260, 8481
|
2477, 3042
|
3693, 4029
|
271, 286
|
381, 1764
|
8034, 8165
|
7977, 8013
|
1786, 2078
|
2094, 2386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,575
| 188,641
|
46420
|
Discharge summary
|
report
|
Admission Date: [**2153-8-23**] Discharge Date: [**2153-8-25**]
Date of Birth: [**2078-9-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
right chest tube insertion
epidural anesthesia
arterial line insertion
History of Present Illness:
79F with h/o dimentia fell in the shower without loss of
consciousness. Presented to [**Hospital1 18**].
Past Medical History:
recent diagnosis of sacral shingles c/b urinary retention,
currently with indwelling Foley, followed by urology
HTN
NIDDM
depression
CAD s/p MI '[**39**]
cholecystectomy
hypercholesterolemia
hypoacusis
chronic h/a ?migraines
legally blind L >R x 7 yrs
L cataract sx
R eye retinal detachment
carpal tunnel in L wrist, no sx, followed by plastics
Social History:
rPt is a retired travel [**Doctor Last Name 360**], widowed, has 3 children, lives
alone in [**Location (un) 55**], previously independent of ADLs until
recent episode of shingles. Former smoker for 50 yrs, [**11-29**] PPD.
No EtOH or illicits.
Family History:
non-contributory
Physical Exam:
Expired
Pulses
no respirations
pupils not reactive to light
Pertinent Results:
[**2153-8-23**] 06:00AM BLOOD WBC-13.0* RBC-3.84* Hgb-11.8* Hct-33.9*
MCV-88 MCH-30.8 MCHC-34.9 RDW-15.3 Plt Ct-379
[**2153-8-25**] 05:05AM BLOOD WBC-11.6* RBC-1.95* Hgb-6.1* Hct-18.3*
MCV-94 MCH-31.0 MCHC-33.1 RDW-15.0 Plt Ct-141*
[**2153-8-25**] 04:51AM BLOOD WBC-12.0* RBC-2.33* Hgb-7.2* Hct-21.8*
MCV-93 MCH-30.8 MCHC-33.0 RDW-15.2 Plt Ct-174
[**2153-8-24**] 03:40AM BLOOD WBC-10.1 RBC-3.10* Hgb-9.4* Hct-28.4*
MCV-92 MCH-30.3 MCHC-33.1 RDW-15.4 Plt Ct-303
[**2153-8-23**] 09:10PM BLOOD WBC-8.1 RBC-3.12* Hgb-9.4* Hct-28.0*
MCV-90 MCH-30.3 MCHC-33.7 RDW-15.8* Plt Ct-262
[**2153-8-23**] 06:00AM BLOOD Neuts-87.4* Lymphs-9.3* Monos-2.8 Eos-0.3
Baso-0.2
[**2153-8-25**] 05:05AM BLOOD PT-16.9* PTT-103.4* INR(PT)-1.5*
[**2153-8-24**] 03:40AM BLOOD PT-11.8 PTT-22.8 INR(PT)-1.0
[**2153-8-23**] 06:00AM BLOOD PT-11.3 PTT-19.1* INR(PT)-0.9
[**2153-8-25**] 05:05AM BLOOD Glucose-198* UreaN-41* Creat-1.6* Na-143
K-4.4 Cl-117* HCO3-12* AnGap-18
[**2153-8-25**] 04:51AM BLOOD Glucose-230* UreaN-43* Creat-1.6* Na-142
K-4.6 Cl-113* HCO3-12* AnGap-22*
[**2153-8-24**] 03:40AM BLOOD Glucose-151* UreaN-45* Creat-1.5* Na-140
K-4.7 Cl-108 HCO3-25 AnGap-12
[**2153-8-23**] 09:10PM BLOOD Glucose-89 UreaN-46* Creat-1.5* Na-137
K-4.6 Cl-105 HCO3-26 AnGap-11
[**2153-8-23**] 06:00AM BLOOD Glucose-207* UreaN-40* Creat-1.2* Na-138
K-4.4 Cl-103 HCO3-24 AnGap-15
[**2153-8-25**] 04:51AM BLOOD CK(CPK)-296*
[**2153-8-24**] 01:50PM BLOOD CK(CPK)-182*
[**2153-8-24**] 03:40AM BLOOD CK(CPK)-176*
[**2153-8-23**] 09:10PM BLOOD CK(CPK)-154*
[**2153-8-23**] 05:20PM BLOOD CK(CPK)-177*
[**2153-8-23**] 06:00AM BLOOD CK(CPK)-214*
[**2153-8-25**] 04:51AM BLOOD CK-MB-8 cTropnT-0.02* proBNP-5113*
[**2153-8-24**] 01:50PM BLOOD CK-MB-7 cTropnT-0.03*
[**2153-8-23**] 09:10PM BLOOD CK-MB-4 cTropnT-0.03*
[**2153-8-23**] 05:20PM BLOOD CK-MB-5 cTropnT-0.02*
[**2153-8-23**] 06:00AM BLOOD cTropnT-<0.01
[**2153-8-25**] 05:05AM BLOOD Calcium-6.0* Phos-7.7* Mg-1.8
[**2153-8-25**] 04:51AM BLOOD Calcium-6.6* Phos-8.4*# Mg-2.0
[**2153-8-24**] 03:40AM BLOOD Calcium-8.0* Phos-4.5 Mg-1.7
[**2153-8-23**] 09:10PM BLOOD Calcium-8.6 Phos-4.6* Mg-1.9
[**2153-8-23**] 06:00AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.6
[**2153-8-24**] 03:40AM BLOOD TSH-2.3
[**2153-8-25**] 05:15AM BLOOD Type-ART pO2-134* pCO2-41 pH-7.05*
calTCO2-12* Base XS--19
[**2153-8-25**] 04:57AM BLOOD Type-[**Last Name (un) **] pO2-92 pCO2-49* pH-7.04*
calTCO2-14* Base XS--17
[**2153-8-25**] 04:16AM BLOOD Type-ART pO2-25* pCO2-74* pH-7.14*
calTCO2-27 Base XS--6
[**2153-8-25**] 04:57AM BLOOD Lactate-9.3*
Brief Hospital Course:
74F s/p fall at home on [**8-22**] presented to [**Hospital1 18**] with left sided
chest pain. CT revealed left rib fractures [**9-9**]. Initially
admitted to the surgical floor for observation. On [**8-23**] epidural
anesthesia placed for pain relief. Patient triggered with
bradycardia, BP in 80, low urine output and was unresponsive.
Patient given fluids, atropine and transferred to TSICU for
further observation. Cardiology was consulted for
recommendations with her history or coronary disease. Epidural
turned off and placed on oral pain medication. Patient's heart
rate, BP, and urine output improved with fluids in TSICU. In
addition, mental status improved as well. Patient was
transferred to medical service on [**8-25**] to help manage her many
medical comorbidities. Shortly after transfer, patient was
found to be tachypneic with labored breathing and complained of
nausea and vomiting. Stat X-ray showed diffuse right lung
oppacity. There was concern of hemothorax due to recent
thoracic epidural insertion. Thoracic surgery consulted for
possible decompression. Patient had a PEA shortly after the
consult was requested and chest compressions were started
immediately. Chest tube was inserted and drained 1L blood.
Patient was revived and blood was transfused. After discussing
the events with the son, the son expressed that his mother would
not want heroic measures and would like comfort measure only.
Patient was kept comfortable and patient expired on [**8-25**] 6:25
am. Medical examiner was notified and protocol was followed.
Medications on Admission:
n/c
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
left rib fracture
right hemothroax
respiratory arrest
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2153-12-1**]
|
[
"250.00",
"807.03",
"414.01",
"427.5",
"401.9",
"311",
"272.0",
"366.9",
"E935.9",
"E849.0",
"E885.9",
"530.81",
"294.8",
"346.90",
"458.0",
"426.11",
"412",
"361.9",
"427.89",
"369.4",
"860.2",
"305.1",
"389.9",
"276.51",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"99.04",
"03.90",
"34.04",
"38.91",
"99.63",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
5496, 5505
|
3845, 5413
|
322, 394
|
5602, 5611
|
1292, 3822
|
5664, 5827
|
1177, 1195
|
5467, 5473
|
5526, 5581
|
5439, 5444
|
5635, 5641
|
1210, 1273
|
274, 284
|
422, 529
|
551, 897
|
914, 1161
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,515
| 195,745
|
34042
|
Discharge summary
|
report
|
Admission Date: [**2145-6-11**] Discharge Date: [**2145-7-8**]
Date of Birth: [**2070-6-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
AVR(#23CE Magna)MVR(#29StJude Epic)CABGx1(SVG-PDA)[**7-2**]
History of Present Illness:
Mr. [**Known lastname 78566**] is a 74 year old male with history of HTN,
hyperlipidemia, DM2, aortic stenosis and PVD who presented
initially to an OSH on [**2145-6-6**] with complaints of fever,
headache, and arthralgias. Patient was initially felt to have
viral meningitis, and was treated broadly with antibiotics. He
is unclear about his history. Per his daughter, patient called
her on [**Name (NI) 1017**] and she thought he had dysarthria, and called
ambulance to take to ER. Patient had a head MRI which was
negative. Prior to this, patient had been fatigued, napping more
frequently for the past week. He had no weight loss, fevers. He
does have chronic neck pain.
At the OSH, patient was febrile to 103.9 with a leukocytosis
with bandemia, and blood cultures were positive for staph
aureus, and patient was placed on vancomycin, and subsequently
transitioned to oxacillin. Diagnostic studies, including LP,
CXR, UA, MRI spine, and TTE were negative for a source of
infection. He was also noted to have thrombocytopenia. Last
night, patient developed rigors and oxygen desaturation to 88%
on 4L and ruled in for ischemia. He was felt to have had an
anteroseptal MI based on EKG and elevation in troponin. He was
also in atrial fibrillation with RVR and was placed on
diltiazem.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. He
denies cough. He notes fevers and chills. He notes exertional
buttock or calf pain.
*** Cardiac review of systems is notable for absence of chest
pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.***
Past Medical History:
Diabetes mellitus type 2
Dyslipidemia
Severe aortic stenosis (Echo [**8-9**] at OSH: EF 65%, [**Location (un) 109**] 0.9, Peak
gradient 70)
Peripheral arterial disease
Hypertension
Pancreatitis, alcoholic
S/p tonsillectomy.
Hx alcohol abuse
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Cardiac History: No hx CABG, cardiac catheterizations,
pacemaker/ICD placement.
Social History:
Social history is significant for the absence of current tobacco
use. He quit tobacco 30 years prior, but smoked 1 ppd prior to
this. There is remote history of alcohol abuse in his 20s. He
now drinks 2-3 drinks/day. Retired English teacher. Lives alone.
Daughters nearby and very involved.
Family History:
Family history is significant for mother with CVA, father died
of unknown cause. Children with hypertension, hyperlipidemia.
Sister with [**Name (NI) 4522**] disease.
Physical Exam:
VS: T 97.5, BP 125/70 HR 108, RR 27, O2 96% on 4L
Gen: NAD. Diaphoretic.
HEENT: NCAT. Sclera anicteric. Pupils asymmetric but reactive,
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa.
Neck: Supple with JVP of 10 cm.
CV: PMI located in 5th intercostal space. 2/6 systolic ejection
murmur at RUSB with radiation into carotids. No thrill. No rubs
or gallops.
Chest: No chest wall deformities, scoliosis or kyphosis.
Bilateral expiratory wheezing. Dull at bases bilaterally.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. No
[**Last Name (un) 1003**] lesions or Osler nodes.
Pulses: 2+ DP/PT/carotid/radial. No bruits.
Neuro: CN intact. 5/5 strength bilaterally. Symmetric reflexes
at patella. Sensation to LT intact. Tangential. Appears
intermittently confused. Alert to self.
Pertinent Results:
[**6-11**] Head CT: There is no evidence of hemorrhage, edema, mass,
mass effect, or infarction. The ventricles and sulci are normal
in size and configuration. There is mild periventricular white
matter hypodensity, most consistent with chronic small vessel
ischemic disease. There is no fracture. Mild mucosal thickening
is seen in the bilateral maxillary sinuses. Bilateral cavernous
carotid artery calcification is noted.
[**6-14**] CT of Chest/Abd/Pelvis: 1. Multiple mediastinal lymph nodes
which are likely reactive. 2. Extensive aortic valve, coronary
artery, and aortic calcifications. 3. Aneurysmal dilatation up
to 3 cm of the infrarenal abdominal aorta. 4. Bilateral pleural
effusions. 5. Emphysematous changes with peripheral ground-glass
opacities in the upper lobes, which may represent an
inflammatory or infectious process. No frank consolidation
identified. 6. Splenic infarct. 7. Air within bladder.
Differential diagnosis includes recent instrumentation versus
UTI. 8. This examination was not tailored for venous evaluation
but there is suggestion of thrombus (hypodensity) within the
right common femoral vein. Ultrasound is recommended if
clinically indicated.
[**6-15**] Cardiac MR: 1. There was a 14x12 mm mass in the left atrium
attached to/involving the base of the posterior mitral valve
leaflet. There was mild enhancement of the mass during first
pass perfusion of Gd-DTPA. Given the location, clinical history,
and mild contrast uptake, the mass most likely is a valvular
vegetation, but cannot fully exclude a primary tumor (e.g.
atrial myxoma). 2. Normal left ventricular cavity size with
normal regional systolic function. The LVEF was mildly decreased
at 51%. The effective forward LVEF was moderately decreased at
38%. 3. Normal right ventricular cavity size and systolic
function. The RVEF was normal at 54%. 4. Mild aortic
regurgitation. Moderate mitral regurgitation. Mild pulmonic
regurgitation. Mild tricuspid regurgitation. 5. Moderate aortic
stenosis. 6. The indexed diameters of the ascending and
descending thoracic aorta were normal. The main pulmonary artery
diameter index was mildly increased. 7. Biatrial enlargement. 8.
A note is made of moderate bilateral pleural effusions, aortic
atherosclerosis, a pre-tracheal lymph node, and possible
tracheomalacia.
[**6-25**] Head MRI: Numerous small foci of acute infarction as
described above, consistent with embolic infarction. Infection
within these small foci cannot be excluded based on the current
study. No evidence of abscess is seen.
[**6-29**] CNIS: Less than 40% right ICA stenosis. 40-59% left ICA
stenosis.
[**7-2**] Echo: Pre Bypass: The left atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch and the descending aorta.
Focal calcification is seen at the ST junciton, There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is a large vegetation
on the mitral valve, encompassing the majority of the posterior
leaflet and impeding flow into the left ventricle. There is a
minimally increased gradient consistent with trivial mitral
stenosis. Trace to Mild (1+) mitral regurgitation is seen. Post
Bypass: Patient is on epinepherine 0.02 mcg/kg/min,
[**Last Name (LF) 78567**], [**First Name3 (LF) **], then later only A paced. Biventricular
function is preserved, LVEF >55%. There is a 29 [**First Name8 (NamePattern2) **] [**Male First Name (un) **] epic
in the mitral position (per surgeon). Bioprotsthesis has a mean
gradient 9, peak 13 mm Hg with CO 7.1 post bypass. No
perivalvular leaks seen. There is a 23 [**Doctor Last Name **] Magna (per
surgeon) in the aortic position. The bioprosthesis has no
perivalvular leaks, peak gradients 9, mean 7 mm Hg with CO 7.1
post bypass. An asd is appreciated with flow from left to right
which was not apparent pre-bypass. Aortic contours are intact.
Remaining exam is unchanged. All finidings discussed with
surgeons at the time of the exam.
[**7-6**] CXR: In comparison with the study of [**7-5**], there is little
change in the moderate right pleural effusion. The aberrant left
PICC line has been removed. Enlargement of the cardiac
silhouette persists as does bibasilar atelectatic change,
especially in the retrocardiac region.
[**2145-6-11**] 08:01PM BLOOD WBC-15.2* RBC-4.86 Hgb-13.6* Hct-37.6*
MCV-77* MCH-27.9 MCHC-36.1* RDW-14.3 Plt Ct-141*
[**2145-6-26**] 05:26AM BLOOD WBC-9.2 RBC-3.46* Hgb-9.4* Hct-27.6*
MCV-80* MCH-27.1 MCHC-33.9 RDW-16.1* Plt Ct-396
[**2145-7-3**] 01:18AM BLOOD WBC-24.0* RBC-3.15* Hgb-9.0* Hct-25.3*
MCV-80* MCH-28.6 MCHC-35.6* RDW-16.5* Plt Ct-334
[**2145-7-8**] 04:43AM BLOOD WBC-9.4 RBC-2.81* Hgb-8.0* Hct-23.2*
MCV-83 MCH-28.4 MCHC-34.4 RDW-16.7* Plt Ct-323
[**2145-6-11**] 08:01PM BLOOD PT-12.2 PTT-28.0 INR(PT)-1.0
[**2145-6-25**] 05:30AM BLOOD PT-14.5* PTT-35.5* INR(PT)-1.3*
[**2145-7-4**] 12:11AM BLOOD PT-17.1* PTT-38.5* INR(PT)-1.5*
[**2145-6-11**] 08:01PM BLOOD Glucose-153* UreaN-16 Creat-0.8 Na-140
K-3.6 Cl-105 HCO3-25 AnGap-14
[**2145-6-30**] 03:17PM BLOOD Glucose-104 UreaN-13 Creat-1.1 Na-138
K-3.5 Cl-100 HCO3-28 AnGap-14
[**2145-7-8**] 04:43AM BLOOD Glucose-132* UreaN-18 Creat-1.3* Na-136
K-2.8* Cl-102 HCO3-26 AnGap-11
[**2145-6-11**] 08:01PM BLOOD ALT-72* AST-74* LD(LDH)-294* CK(CPK)-34*
AlkPhos-109 TotBili-1.4
[**2145-7-6**] 07:30PM BLOOD ALT-14 AST-25 AlkPhos-62 Amylase-69
TotBili-0.5
[**2145-7-6**] 07:30PM BLOOD Albumin-2.5* Calcium-7.7* Phos-4.1 Mg-2.2
Brief Hospital Course:
Mr. [**Name14 (STitle) 78568**] presented with MSSA bacteremia consistent with
endocarditis. He was also admitted for NSTEMI and was treated
medically with heparin, ASA, Statin and betablocker. Cardiac
cath was deferred due to endocarditis/bacteremia. One week into
his admission, Mr. [**Known lastname 78566**] developed chest pain associated with
dynamic ST changes and was taken to the cath lab. He is now
status post cardiac cath, which found a filling defect of the
distal LAD not intervened upon based on its location. He also
has a chronic 80% mid-RCA occlusion. No intervention was done,
as decision was for CABG. He continued on nafcillin. TEE and
Cardiac MR showed a vegetation on the Mitral Valve. He has had
recurring fevers while in the hospital. Repeat CT scan of
Chest/ABD/Pelvis was done which showed increasing splenic
infarct but no signs of abscess formation. Patient's daughter
stated that her father had mild mental status changes and was
not at his baseline. A CT scan of the brain was done which was
negative. This was followed up by an MR of the brain which
showed several small infarcts, which are likely due to septic
emboli from the vegetation on the mitral valve. Cardiac surgery
the patient and given the findings on MR he was taken to the
operating room on [**2145-7-2**] where he underwent a CABG x 1, MVR
and AVR. He was transferred to the ICU in stable condition on
epinephrine, neo and propofol. He was extubated post op. His
creatinine rose and his lasix was held. PICC line was placed. He
remained in the ICU for pulmoanry toilet. He was transferred to
the floor on POD #4. Creatinine improved and lasix was
restarted. IV antibiotics should continue for 6 weeks from [**7-4**].
Medications on Admission:
CURRENT MEDICATIONS (on transfer):
Acetaminophen 650 mg q6h
Aspirin 81 mg po qd
Diltiazem 5 mg/hr IV gtt
Insulin SS
Magnesium oxide 400 mg qd
Metoprolol 50 mg [**Hospital1 **]
Oxacillin 2 gm IV q4h (start [**2145-6-9**])
Protonix 40 mg po qd
Simvastatin 40 mg qhs
Albuterol nebs prn
Bisacodyl prn
Docusate prn
Zofran prn
HOME MEDICATIONS:
Enalapril 20 mg [**Hospital1 **]
Metoprolol 50 mg [**Hospital1 **]
Crestor 20 mg qhs
Hydrochlorothiazide 25 mg qd
Metformin 500 mg [**Hospital1 **]
Lipitor ? mg qhs
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
11. 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.
12. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO TID
(3 times a day) as needed.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 1
weeks.
15. Nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous
Q4H (every 4 hours) for 6 weeks: through [**8-15**].
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 1
weeks: then reassess need for diuresis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] and Islands
Discharge Diagnosis:
Endocarditis s/p Aortic and Mitral Valve Replacement
NSTEMI s/p cardiac cath with filling defect of LAD, 80% RCA s/p
Coronary Artery Bypass Graft x 1
MV endocarditis, AS, MR, CAD, DM2, HTN, PAD, Alcoholic
pancreatitis, chronic neck pain, Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage to incision or weight gain
more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
[**Last Name (LF) 24690**],[**First Name3 (LF) **] H [**Telephone/Fax (1) 78569**] in 2 weeks
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] [**Numeric Identifier 78570**] in 2 weeks
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2145-8-11**] 11:30
Completed by:[**2145-7-8**]
|
[
"434.11",
"724.5",
"410.11",
"723.1",
"421.0",
"414.01",
"356.9",
"427.31",
"414.2",
"593.81",
"444.89",
"250.00",
"584.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.56",
"35.23",
"88.72",
"36.11",
"35.33",
"39.61",
"37.22",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
13805, 13892
|
9921, 11645
|
327, 389
|
14187, 14193
|
4010, 4021
|
14504, 14932
|
2896, 3064
|
12200, 13782
|
13913, 14166
|
11671, 11993
|
14217, 14481
|
3079, 3991
|
12011, 12177
|
280, 289
|
417, 2165
|
4030, 9898
|
2187, 2571
|
2587, 2880
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,675
| 195,182
|
22836
|
Discharge summary
|
report
|
Admission Date: [**2114-11-8**] [**Month/Day/Year **] Date: [**2114-11-28**]
Date of Birth: [**2058-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Azithromycin / Lipitor
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of breath and tachypnea
Major Surgical or Invasive Procedure:
Intubation started on [**11-12**]
History of Present Illness:
56 yo female with ESRD s/p renal [**Month/Year (2) **] in [**2108**] who
presented with shortness of breath and tachypnea for about 2
weeks, accompanied by subjective fevers and chills, decreased
appetite, productive cough with hemoptysis. Has lost 20#
(intentionally) since the summer, but then regained it.
Past Medical History:
Fulminant liver failure [**1-5**] likely caused by Azithromycin
Hypertension
End-stage renal disease s/p living related donor in [**2108**]
Depression
Dyslipidemia
Nephrolithiasis
Melasma
Social History:
Married with 5 children. Lives at home with husband, daughter
and grandchildren. She moved from [**Country 5737**] in [**2098**] and last
visited in [**Month (only) **]. She denies any cigarette use, and quit
alcohol, though she used to abuse alcohol. No IVDU. While in
[**Country **], she lived on a farm for 3 years-- exposure to many
domestic farm animals. She does not recall any skin rashes or
febrile illnesses during that period. She does not know if she
received the BCG vaccine as a child.
Family History:
No history of liver or renal disease. Five brothers and father
were killed in [**Country **]. Mother had stroke. Sister alive and
well.
Physical Exam:
On admission:
Vitals: T: 97.6 BP: 136/84 P: 84 R: 30 O2: 95RA
General: She appeared uncomfortable and was tachypnic
HEENT: MMM
Neck: supple, JVP not elevated, no LAD
Lungs: She diffuse wheezes and decreased breath sounds
bilaterally worse in the right.
CV: tachycardic, regular, no m/r/g, S1/S2 appreciated
Abdomen: soft, non-tender, slightly 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
On [**Country **]:
Vitals: Tc 98.4 BP 137/73 (128-156/72-82) HR 80 (63-80) RR 18
O2 sat 98%RA
GEN: A & O x 3, NAD
HEENT: EOMI, sl dry MM
NECK: Supple, no LAD
PULM: CTAB, no wheezes or crackles
CARD: RRR, nl S1, nl S2, II/VI systolic murmur at LLSB
ABD: Soft, BS+, non-tender
EXT: 1+ pitting edema of upper and lower extremities
SKIN: No rashes
NEURO: Patient alert and oriented x 3, diffuse muscle weakness
without focal findings
Pertinent Results:
Renal US [**11-25**]:
IMPRESSION:
1. No neighboring fluid collections.
2. Segmental arterial resistive indices ranging from 0.73 to
0.85.
Previously, this ranged from 0.72 to 0.76. Diastolic arterial
flow is redemonstrated.
3. Better defined, echogenic bands at the base of the pyramids
may reflect small calcifications.
TTE [**11-10**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with
infero-lateral hypokinesis. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2114-4-6**],
infero-lateral hypokinesis is now appreciated. The degree of MR
has slihgtly increased.
TTE [**2114-11-17**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is a very small
pericardial effusion.
Compared with the prior study (images reviewed) of [**2114-11-10**],
left ventricular systolic function is improved (previously low
normal), the severity of mitral regurgitation is reduced
(previously mild) and the heart rate is now higher.
LUE ultrasound [**11-11**]:
IMPRESSION: No evidence of DVT in the left upper extremity.
Renal Echo: [**11-9**]
IMPRESSION: Persistent mild-moderate hydronephrosis of the
transplanted
kidney. Minimal increase in the resistive indices throughout the
transplanted kidney.
CT Chest: [**11-8**]
1. Multifocal ground glass opacities and airspace consolidation.
The
differential diagnosis includes multifocal pneumonia, most
likely pyogenic
though atypical organisms are also in the differential given a
history of
immunosuppression.
2. Central adenopathy, likely reactive.
EKG [**11-9**] Sinus rhythm. Diffuse non-specific inferior and
anterolateral ST segment changes. Compared to the previous
tracing of [**2114-4-4**] the findings are similar.
On admission:
[**2114-11-8**] 09:30AM BLOOD WBC-12.0*# RBC-3.01* Hgb-9.0* Hct-27.3*
MCV-91 MCH-29.9 MCHC-33.0 RDW-13.8 Plt Ct-477*
[**2114-11-8**] 09:30AM BLOOD Neuts-85.0* Lymphs-10.0* Monos-3.8
Eos-0.7 Baso-0.5
[**2114-11-8**] 09:30AM BLOOD PT-13.1 PTT-30.6 INR(PT)-1.1
[**2114-11-13**] 06:38PM BLOOD Ret Aut-1.7
[**2114-11-21**] 03:47AM BLOOD Fibrino-376
[**2114-11-8**] 09:30AM BLOOD Glucose-127* UreaN-26* Creat-2.1* Na-128*
K-7.3* Cl-104 HCO3-11* AnGap-20
[**2114-11-8**] 10:24AM BLOOD LD(LDH)-277*
[**2114-11-9**] 06:15AM BLOOD ALT-6 AST-9 LD(LDH)-265* AlkPhos-78
TotBili-0.4
[**2114-11-9**] 05:50PM BLOOD proBNP-[**Numeric Identifier 59030**]*
[**2114-11-14**] 04:21AM BLOOD CK-MB-3 cTropnT-0.03*
[**2114-11-14**] 03:55PM BLOOD CK-MB-4 cTropnT-0.03*
[**2114-11-9**] 06:15AM BLOOD Calcium-7.9* Phos-3.4# Mg-1.1* Iron-17*
[**2114-11-9**] 06:15AM BLOOD calTIBC-147* Hapto-437* Ferritn-503*
TRF-113*
[**2114-11-13**] 06:38PM BLOOD Hapto-263*
[**2114-11-18**] 09:42PM BLOOD Hapto-141
[**2114-11-8**] 09:27PM BLOOD Osmolal-284
[**2114-11-18**] 12:02PM BLOOD Cortsol-17.0
[**2114-11-9**] 08:35PM BLOOD [**Month/Day/Year **]-NEGATIVE B
[**2114-11-9**] 08:35PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2114-11-15**] 04:05PM BLOOD PEP-NO SPECIFI IgG-396* IgA-264 IgM-84
IFE-NO MONOCLO
[**2114-11-15**] 04:05PM BLOOD C3-115 C4-46*
[**2114-11-9**] 06:15AM BLOOD tacroFK-3.8*
[**2114-11-8**] 09:32AM BLOOD Lactate-1.7
On [**Month/Day/Year **]:
[**2114-11-28**] 06:10AM BLOOD WBC-7.1 RBC-2.97* Hgb-8.9* Hct-27.3*
MCV-92 MCH-30.1 MCHC-32.7 RDW-17.8* Plt Ct-287
[**2114-11-28**] 06:10AM BLOOD Glucose-81 UreaN-58* Creat-2.6* Na-135
K-5.0 Cl-106 HCO3-21* AnGap-13
[**2114-11-28**] 06:10AM BLOOD Calcium-8.8 Phos-5.6* Mg-1.7
[**2114-11-8**] 11:08AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2114-11-8**] 11:08AM URINE Blood-SM Nitrite-NEG Protein->300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
[**2114-11-8**] 11:08AM URINE RBC-0-2 WBC-[**2-2**] Bacteri-FEW Yeast-NONE
Epi-[**2-2**]
[**2114-11-8**] 11:08AM URINE CastHy-0-2
[**2114-11-9**] 09:26PM URINE Eos-NEGATIVE
[**2114-11-15**] 06:16PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
[**2114-11-14**] 11:18PM URINE HISTOPLASMA ANTIGEN-Test
[**2114-11-12**] 06:18PM OTHER BODY FLUID Polys-83* Lymphs-4* Monos-13*
[**2114-11-17**] 03:32PM STOOL CLOSTRIDIUM DIFFICILE TOXIN, PCR-
Negative
Microbiology:
Blood Culture, Routine (Final [**2114-11-14**]): NO GROWTH.
Legionella Urinary Antigen (Final [**2114-11-9**]): NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2114-11-9**] 6:29 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2114-11-9**]):
[**9-24**] PMNs and >10 epithelial cells/100X field.
LEGIONELLA CULTURE (Final [**2114-11-16**]): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Final [**2114-11-26**]): GRAM STAIN OF THIS SPECIMEN
INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND
INVALIDATES RESULTS.
ACID FAST SMEAR (Final [**2114-11-9**]): NO ACID FAST BACILLI SEEN ON
CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Respiratory Viral Culture (Final [**2114-11-11**]): No respiratory
viruses isolated.
Respiratory Viral Antigen Screen (Final [**2114-11-9**]): Negative for
Respiratory Viral Antigen.
[**2114-11-12**] 6:18 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2114-11-13**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2114-11-15**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final [**2114-11-20**]): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2114-11-14**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2114-11-26**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2114-11-13**]): NO ACID FAST BACILLI SEEN ON
CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
ASO Screen (Final [**2114-11-13**], performed at Lab): < 200 IU/ml
PERFORMED BY LATEX AGGLUTINATION.
CMV Viral Load (Final [**2114-11-16**]): CMV DNA not detected.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2114-11-18**]): Feces
negative for C.difficile toxin A & B by EIA.
URINE CULTURE (Final [**2114-11-22**]): NO GROWTH.
Brief Hospital Course:
56 yo female with ESRD s/p renal [**Month/Day/Year **] in [**2108**] who
presented with shortness of breath and tachypnea, found to have
pneumonia.
.
# Hypoxemic respiratory failure: A chest CT was obtained and
consistent with pneumonia. She was started on broad spectrum abx
including Vanco, Cefepime, Flagyl and Levo. She triggered twice
for for tachypnea to RR of 40s and hypoxia with an O2
requirement of 4L to sat mid-90s, also fever to 101.8, and still
tachypneic. She was started on steroids and TMP-SMX for possible
PCP. [**Name10 (NameIs) **] was seen on the floor by MICU consult. She was
tachypneic to ~30, satting 100% on 4L, SOB with minimal exertion
but not in acute respiratory distress. R lung with crackles.
Patient noted feeling a little better after nebs, but overall
decline over past day. She was transferred to the MICU. There
she had 2 episodes of shortness of breath with tachypnea and
desaturation that improved wtih nebulizers however on [**11-12**] she
was intubated for respiratory distress. Due to difficulty with
ventilation given metabolic acidosis, 02 desaturation and pt
fighting the vent, the decision was made to paralyze the patient
on [**11-13**] which greatly improved her ventilation. Over the next
week attempts were made to take her off of paralysis however she
would become asynchonous and desat. A TTE was performed on TTE
that was essentially normal (LVEF > 55 %). On [**11-19**] a steroid
taper was started as we no longer felt we needed to treat for an
inflammatory compenent and that her issue now with being weaned
from the vent was due to pulmonary edema. On [**11-18**] her paralytic
was stopped and she remained off paralytics. On [**11-21**] she was
extubated. She continued to do well satting at 100% on 3L. She
was called out to the floor where she remained stable with no
resp distress until d/c to rehab. Oxygen saturation was 90s on
room air. She had generalized muscle weakness due to paralytics
and steroids that she had been given; there were no focal neuro
deficits. She worked with PT/OT and was discharged to rehab.
.
# Acute on chronic renal Failure s/p renal [**Month/Year (2) **]: Pt's
creatinine on admission was 2.1 which climbed to 5.5 on [**11-12**].
An Intrinsic renal process such as ATN was most concerning,
given the fact that patient's creatinine didn't improve with
fluids, though admittedly only received 1.3L. Renal ultrasound
w/o showed e/o moderate hydronephrosis of transplanted kidney.
The patient was started on CVVH on [**11-12**] for fluid management
and acidosis treatment. Renal was unable to place dialysis line
given stenosis beyond Left IJ so the patient was sent to IR for
line placement. Bactrim and acei were d/c'd given ARF. On [**11-15**]
CVVH was stopped due to good UOP, good acid base status and
improving creatinine however was restarted on [**11-16**] for
oliguria. She continued to have fluid taken off via CVVH as her
pressures tolerated it. On [**11-20**] CVVH was d/c'd again. Her UOP
did well and her creatinine was stable. Lasix gtt was started
with resulting good UOP. For her anti-rejection meds, MMF was
restarted on [**11-22**] and she was continued on her prednisone at a
higher dose and tacrolimus. Bactrim was discontinued due to her
acute on chronic renal failure. She was started on sevelamer.
Cr was 2.6-2.7 by time of [**Month/Year (2) **] and she was discharged with
close follow-up with her renal [**Month/Year (2) **] doctor.
.
# Nongap Metobolic Acidosis: The patient was admitted with pH of
7.29. Initially thought to be due to an RTA vs component of
diarrhea. Her metabolic acidosis continued to worsen and was
7.15 on [**11-13**]. She was intubated on [**11-12**] and was paralyzed on
[**11-13**] in light of her metabolic acidosis and O2 desaturations
and fighting the vent. Once she was paralyzed her metabolic
acidosis improved and she maintained a normal pH for the rest of
her stay in the ICU.
.
# Anemia: The patient was admitted with Hct 22-23 from baseline
27-32 (and admission CBC suggestive of hemoconcentration). The
patient had no clear signs of bleeding. Her Hct was 18.9 on
[**11-11**], and was given 1U PRBC. No signs of bleeding were found
and Hct appropriately bumped. On [**11-18**] she had a Hct drop from
27.2 to 21.2 and was transfused 1U PRBC. Her Hct appropriately
bumped and no cause of bleeding or evidence of DIC were found.
Her Hct remained stable for the remainder of her hosptial
course.
.
# Hypotension: The patient was intermittently hypotensive
requiring intermittent levophed. Her low pressures occured when
we were trying to remove fluid while she was on CVVH. When her
pressures were low, we kept her even and once they stabilized,
continued to take off fluid as we felt pulmonary edema was a
large cause of what was keeping her on the vent. By the time she
was extubated, her pressures had stabilized and she became
hypertensive (see below).
.
# Hypertension: Once extubated, pt became hypertensive. Her home
medications of metoprolol and amlodipine were restarted. Her
lisinopril was held given renal failure. After transfer to the
floor from the ICU, she had low BPs on the floor and amlodipine
was discontinued and metoprolol was decreased to half her home
dose. She should follow-up with her PCP regarding when to
restart these meds.
Medications on Admission:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. 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.
[**Hospital1 **] Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
5. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
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. 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.
12. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Inhalation twice a day.
13. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours) as needed for anxiety: Hold for sedation or RR < 12.
14. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
15. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: See sliding scale .
16. Outpatient Lab Work
Please check tacrolimus levels every 3 days and fax results to
[**Hospital1 **] renal clinic; Phone: [**Telephone/Fax (1) 673**]
Fax: [**Telephone/Fax (1) 21335**]
17. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
18. epoetin alfa 10,000 unit/mL Solution Sig: One (1) ml
Injection once a week: Give every Wednesday.
[**Telephone/Fax (1) **] Disposition:
Extended Care
Facility:
St [**Hospital **] Hospital Rehabilitation Unit - [**Location (un) 8117**], NH
[**Location (un) **] Diagnosis:
Primary:
Hypoxemic respiratory distress
ATN
Secondary:
Hx of renal [**Location (un) **]
HTN
Anemia
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Location (un) **] Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with shortness of breath and required intubation. Your
respiratory status improved with iv lasix to take fluid out of
your lungs and with antibiotics for a possible pneumonia you may
have had. You were also treated for acute kidney injury with
dialysis. You will need close follow-up with your kidney
[**Location (un) **] doctors [**First Name (Titles) **] [**Last Name (Titles) **]. You will be transferred to
a rehab center where you will work with physical/occupational
therapy to regain your strength as you had weakness from the
paralytics and steroids that were given to help you breathe.
The following changes were made to your medications:
1) Bactrim was stopped due to renal failure
2) Lisinopril was stopped due to renal failure
3) Prednisone was increased to 5mg daily
4) Amlodipine 10mg daily was stopped (please discuss restarting
this with your doctor if your blood pressure starts to increase)
5) Metoprolol tartrate 100mg twice a day was reduced to 50mg
twice a day (please discuss restarting this with your doctor if
your blood pressure starts to increase)
6) Aspirin 325mg daily was started
7) Diazepam 5mg every 8 hours as needed for anxiety was started
8) Sevelamer 800mg twice a day was started
9) Omeprazole was changed to pantoprazole 40mg twice a day
10) Tacrolimus was increased to 2mg twice a day
11) Gemfibrozil was stopped due to renal failure
12) Ezetimibe was stopped due to renal failure
13) Epoetin Alfa 10,000 once a week (Wednesdays) was started
Followup Instructions:
You have the following appointment scheduled for you:
Department: [**Last Name (Titles) **] CENTER
When: TUESDAY [**2114-12-4**] at 2:00 PM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital Ward Name **] CENTER
When: FRIDAY [**2115-1-4**] at 10:40 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2114-11-28**]
|
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28,180
| 156,141
|
33697
|
Discharge summary
|
report
|
Admission Date: [**2113-1-29**] Discharge Date: [**2113-2-22**]
Date of Birth: [**2030-4-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Bronchoscopy [**2113-1-31**]
IP placed tracheostomy [**2113-2-16**]
CVL placement
History of Present Illness:
This is an 82 year old man with history of complicated course
after GI bleed with colectomy, respiratory failure, temporary
dialysis, vent/trach, who was admitted from home with confusion.
He was discharged from rehabilitation in mid [**Month (only) **], and had
been overall doing well and steadily improving regarding his
strength and ADL's. Over the last few days preceding
presentation, however, he had been confused and had intermittent
hallucinations regarding aliens. He also noted poor sleep and
multiple falls in the days proceeding admission.
His only medication change was recent initiation of escitalopram
treatment for depression. He was on 5 mg starting on [**1-2**], and
increased to 10 mg on [**1-16**] which he took for one week. His
daughter was concerned that this was making him somnolent, and
decreased him back to 5 mg. The confusion happened after the
decrease from 10 to 5. He has had prior episodes of
hallucinations previously when he has had confusion.
.
ROS otherwise positive for some difficulty swallowing recently.
Otherwise, no cough, no changes in ostomy output. Single
episode of indigestion. Otherwise negative.
Past Medical History:
1) LGIB [**2112-3-29**] - course complicated by need for subtotal
colectomy, anastamotic leak requiring revision, Afib with RVR,
MRSA PNA/Klebsiella Bacteremia, ARF requiring CVVHD, PE and
stroke
2)HTN
3)Hyperlipidemia
4)DM2 diet controlled
5) Afib with RVR: Patient has refused anticoagulation
6) Stroke
-Left parietal subcortical infarct [**2112-4-28**]
-probable subacute R posterior temporal and occipital as well
7)History of PE at OSH
8) History of throat cancer s/p resection + xrt '[**89**]
9) s/p empyema w/ CT drainage
10) legally blind right eye secondary to injury
11) Sleep apnea
12) Known aspiration and failed swallow study (patient self
d/c'd enteric feeding tube and accepted risks of aspiration
w/family approval)
Past Surgical History
Hemorrhoidectomy
Appendecetomy
Rt hernia operation
S/P Colectomy c/b anastomotic leak requiring revision
Social History:
The patient is widowed. He previously lived alone independently
in [**Location (un) 686**] although more recently has been living with his
daughter after a prolonged rehabilitation course. He previously
worked for [**Doctor Last Name **] milk as a machinist. Has three involved
daughters. [**Name (NI) **] a total of 5 children, 11 grandchildren.
Family History:
None known.
Physical Exam:
Exam on Admission:
T 98.7, BP 152/66, HR 81, RR 18, O2 Sat 96% on 1L
Gen: In NAD.
HEENT: PERRL, EOMI. No scleral icterus. No conjunctival
injection. Mucous membranes dry. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: Decreased breath sound left base. Otherwise CTA
bilaterally, no wheezes, rales, rhonchi. Normal respiratory
effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: Large abdominal wound, healed by secondary intent.
Colostomy with brown stool. Otherwise, soft, NT, ND, NABS, no
HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3, CN II-XII intact. Active
hallucinations. Follows all commands. Globally weak.
Skin: No rashes or ulcers. Left great toenail split.
Ecchymoses back.
Psychiatric: Appropriate.
GU: normal penis, scrotum, no foley.
Pertinent Results:
[**2113-1-29**] 09:30AM WBC-10.5# RBC-3.71* HGB-10.8* HCT-32.7*
MCV-88 MCH-29.2 MCHC-33.1 RDW-15.3
[**2113-1-29**] 09:30AM NEUTS-80.2* LYMPHS-15.6* MONOS-3.0 EOS-1.0
BASOS-0.2
[**2113-1-29**] 09:30AM PLT COUNT-189.
[**2113-1-29**] 09:30AM PT-12.0 PTT-26.9 INR(PT)-1.0
.
[**2113-1-29**] 09:30AM GLUCOSE-83 UREA N-31* CREAT-1.4* SODIUM-141
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-32 ANION GAP-10
.
[**2113-1-29**] 09:30AM CK(CPK)-45
[**2113-1-29**] 09:30AM cTropnT-0.09*
.
[**2113-1-29**] 10:20AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2113-1-29**] 10:20AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2113-1-29**] 10:20AM URINE RBC-[**6-7**]* WBC->50 BACTERIA-MOD YEAST-MOD
EPI-0-2 TRANS EPI-[**3-2**]
.
[**2113-1-29**] 09:43AM LACTATE-0.7
.
EKG: NSR 72, nl axis, LVH, no change from prior.
.
CXR: IMPRESSION: Persistent small left effusion. ?? early CHF
-- Recommend clinical correlation.
.
Head CT: No edema, masses, mass effect, hemorrhage or major
vascular territorial infarction is noted. The ventricles and
sulci are mildly prominent consistent with involutional changes.
The hypoattenuating foci within the left frontoparietal region,
right thalamus and the brainstem most likely represents old
lacunar infarct and appear unchanged compared to the prior study
with the one in the right thalamus being more conspicuous on the
present study. The visualized part of the paranasal sinuses and
mastoid air cells are clear. The calcification of the cavernous,
carotids and vertebral artery are noted. No obvious acute
fractures are noted.
.
L spine xray: DJD.
.
CT C spine: DJD. No subluxation. Canal narrowing at C6-7.
Preliminary read.
Brief Hospital Course:
82 yo man presenting to the hospital with altered mental status
and hallucinations and then transferred to the ICU for worsening
hypoxia and mental status. Course complicated by hypercarbic
respiratory failure, multiple failed extubation attempts, and
eventual need for trach placement.
#. Hypoxic respiratory failure/Pneumonia: The patient initially
presented to the [**Hospital Unit Name 153**] for hypoxic respiratory failure in the
context of new infiltrates, most dramatic in the left lower
lobe. The patient proceeded to bronchoscopy which noted
intermittent collapse of the left lower lobe with thick
secretions and bronchomalacia. This was cleared and the BAL
grew MRSA. The patient remained afebrile but given infilitrate
and isolation of an organism (the same organism also grew on
sputum culture) he was treated with fourteen days of vancomycin
for MRSA pneumonia (course extended due to rather severe
presentation). After his first two nights in the intensive care
unit the patients hypoxia resolved and he never had oxygenation
problems thereafter.
#. Hypercarbic respiratory failure: The patient had progressive
hypercarbic respiratory failure after his bronchoscopy leading
to increased somonolence. This eventually required intubation.
The patient was rapidly weaned to minimal settings but failed
extubation twice due to progressive hypercarbia. Unfortunately,
this did not resolve with treatment of pneumonia, pulmonary
edema, and other reversible factors. A neurology consult was
attained and it was determined that he had a diffuse
polyneuropathy and that neuromuscular weakness was the primary
reason for his failure to extubate. Because this etiology was
not reversible in the short term, a tracheostomy tube was placed
and he was able to tolerate a trach collar with intermittent
placement on pressure support ventilatory settings. A
Passy-Muir valve was placed on [**2113-2-21**].
#. Pulmonary edema: Patient had evidence of pulmonary edema on
presentation and was intermittently diuresed with lasix during
his three week ICU stay. It was thought to be secondary to
hypoalbuminemia given a normal ECHO in [**2-6**] (normal LV systolic
and diastolic function). He responded well to lasix 20 mg IV
boluses and may need lasix chronically to optimize his fluid
status.
#. Altered mental status: Patient exhibited evidence of
delirium, with waxing and [**Doctor Last Name 688**] levels of awareness and
intermittent visual hallucinations. These episodes were thought
to be secondary to infection, respiratory failure, insomnia, and
disorientation from a prolonged hospital stay. His insomnia
responded well to seroquel 25 mg po qhs.
#. History of Afib: Patient remained in normal sinus rhythm
during his hospitalization. He was continued on metoprol and
started on amlodipine for hypertension. Of note, he is not
currently anticoagulated nor receiving aspirin despite his
history of CVA per his choice, likely because of his history of
a massive GI bleed.
#. Hypertension: Patient was continued on metoprolol and
started on amlodipine on [**2113-2-8**].
#. Chronic kidney disease: Patient has a baseline creatinine of
1.4-1.5 and generally remained in this range during his hospital
stay. His medications were renally dosed.
#. Arterial line erythema: Patient had some erythema at the
site of his right radial artery A-line and this was removed.
His blood cultures remained negative but he received two doses
of vancomycin empirically.
#. Anemia: Hct near baseline of 25-27 and remained stable.
#. Pyuria: Patient has with leukocyte esterase and pyuria on UA
but culture only growing yeast. This is most likely a
contaminant. Coude foley placed on [**2113-2-7**] by urology, and
patient will follow-up with urology as an outpatient (Dr.
[**Last Name (STitle) 986**] to evaluate his ability to void without the foley.
# FEN: Patient had a post-pyloric Dobhoff placed and was
continued on tube feeds (Fibersource HN).
# PPx: Patient was given heparin SC and continued on
pantoprazole.
# Communication: W/ [**Name (NI) **], HCP.
Medications on Admission:
Lopressor 25, 12.5
Metamucil
Lactobacillus
Nasonex
Prilosec
Discharge Medications:
1. Psyllium Packet [**Name (NI) **]: One (1) Packet PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: One (1)
Injection TID (3 times a day).
3. Metoprolol Tartrate 25 mg Tablet [**Name (NI) **]: 0.5 Tablet PO BID (2
times a day).
4. Amlodipine 5 mg Tablet [**Name (NI) **]: Two (2) Tablet PO DAILY (Daily).
5. Miconazole Nitrate 2 % Powder [**Name (NI) **]: One (1) Appl Topical QID
(4 times a day) as needed.
6. Acetaminophen 325 mg Tablet [**Name (NI) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for agitation/insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 10353**] TCU
Discharge Diagnosis:
Primary:
1. MRSA Pneumonia
2. Hypercapnic/hypoxic respiratory failure
3. Atrial fibrillation
4. Hypertension
4.
Discharge Condition:
Good
Discharge Instructions:
You were admitted because of shortness of breath. We diagnosed
you with pneumonia and helped support your breathing with a
breathing tube. We ultimately had to place a tracheostomy tube
to assist your breathing because your chest wall muscles were
weak.
Followup Instructions:
Urology:
Scheduled Appointments :
Provider UROLOGY UNIT, Dr. [**First Name8 (NamePattern2) **] [**Known firstname 805**]. Phone:[**Telephone/Fax (1) 164**]
Date/Time:[**2113-3-1**] 9:30
Completed by:[**2113-2-22**]
|
[
"584.9",
"V12.54",
"250.00",
"518.81",
"348.30",
"518.4",
"272.4",
"427.31",
"V10.9",
"585.9",
"511.9",
"356.9",
"482.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"33.24",
"33.21",
"38.93",
"38.91",
"96.71",
"96.72",
"96.04",
"96.6",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
10614, 10666
|
5566, 7883
|
336, 420
|
10823, 10830
|
3781, 4788
|
11135, 11352
|
2879, 2892
|
9763, 10591
|
10687, 10802
|
9679, 9740
|
10854, 11112
|
2907, 2912
|
275, 298
|
448, 1606
|
4798, 5543
|
2926, 3762
|
7899, 9653
|
1628, 2496
|
2512, 2863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,268
| 170,030
|
44307
|
Discharge summary
|
report
|
Admission Date: [**2137-6-20**] Discharge Date: [**2137-6-28**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 14062**]
Chief Complaint:
ascities, lower extremity edema, weight gain
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
87M with ischemic cardiomyopathy (LVEF 30%), atrial fib/flutter,
DM2, extensive EtOH Hx (last drink 6 mo ago) who was seen in [**Hospital 191**]
clinic for progressive weight gain (baseline 175-180 lbs),
ascites, leg edema with SOB beginning ~1 wk ago. He notes
increased PO intake of canned soups at that time and regularly
eats hotdogs and deli meats. baseline activity is ambulating 30
steps; now minimal ambulation before SOB. Pt missed his ACE-I
dose yesterday but reports taking medications reliably. Has 2
pillow orthopnea, now uses 3 pillows. Denies any CP, fever,
nausea, vomiting.
Pt was most recently in the hospital in [**3-31**] for CHF
exacerbation. He was d/ced on coumadin at that time for planned
cardioversion after 1 month of anticoag. However, he presented
to the ED on [**2137-5-1**] with hematuria and was found to have INR of
9 so coumadin was stopped by his PCP.
Pt had a single episode of emesis of clear fluid in the ED,
another episode of reportedly blood-tinged vomitus, and then
~200cc maroon-colored emesis on the floor. Pt reports epigastic
"burning" since the last episode of emesis, non-radiating.
Denies abdom pain, LH, palpitations, BRBPR, or melena.
Pt was transferred to the [**Hospital Unit Name 153**] for closer monitoring where he
had another emesis of dark brown liquid (~200CC). Pt was started
on IV PPI. Given 1 unit of FFP. RUQ ultrasound showed moderate
ascites, enlarged spleen (15.6cm), splenorenal shunt, consistent
with portal hypertension; no ultrasonographic evidence of
cirrosis. EGD was performed which showed a Dieulafoy lesion in
the fundus which was cauterized, blood in stomach, esophagitis.
Serial hematocrits remained stable (29-30). Aspirin and plavix
were held. Antihypertensives initially held, but restarted on
low dose bb. Pt was hemodynamically stable. Total blood products
during hospitalization: 1 unit FFP, 1 unit PRBC. Pt was given
Vit K for elevated INR. Alpha feto protein was normal at 2.3.
Admission CXR without evidence of CHF. Echocardiogram on [**6-21**]
showed EF 45-50%, pulmonary hypertension, [**1-6**]+ MR, 3+ TR,
dilated RV with systolic/diastolic dysfunction c/w RV overload.
Pt was diuresed on [**6-23**] with po and IV Lasix.
Past Medical History:
-CHF: EF 30% global HK, biatrial enlargement, LVH 1.3cm, 1+MR,
2+TR
-CAD: large reversable mod severe inferior wall defect by pMIBI
[**4-9**]; refused PCI [**4-9**] admission but was considering outpt cath
-essential thrombocytosis, followed by Dr. [**First Name (STitle) **], on hydroxyurea
-Atrial fibrillation: was on coumadin but d/ced by PCP [**Last Name (NamePattern4) **] [**4-9**]
due to elevated INR
-HTN
-DM2, on insulin
Social History:
Denies tobacco use. Extensive EtOH x 50 yrs, last drink 6 mo
ago. Lives alone. Has girlfriend. [**Name (NI) **] visiting nurse. Cooks for
self (mostly canned food).
Family History:
N/C
Physical Exam:
(at admission)
T 98.2, HR 60, BP 123/60, Sat 99% RA
Gen: nad, breathing comfortably
Skin: C/D/I, no spider angiomata, no caput medusa, no palmar
erythema
HEENT: OP clear, dry MM, sclera somewhat yellow, EOMI
Heart: S1S2, irreg irreg, 3/6 SEM @ apex
Lungs: bibasilar crackles, good air movement
Abd: +fluid wave, decreased BS, soft, NT
Groin: scotal edema
Extrem: 3+ pitting edema to hip, chronic venostasis changes, no
erythama or warmth, no UE asterixis
Neuro: A&Ox3, fluent speech, follows commands, moving all
extremities
Pertinent Results:
Laboratory studies:
-WBC 5.8, Hct 29.9 (from 31.4, 14 hrs before), Plt pending
-BUN/creat 26/1.2 -> 26/1.3; other chem-7 WNL
-BNP 6692 in ED
ALT-13 AST-23 LD(LDH)-303* CK(CPK)-54 AlkPhos-167* TotBili-1.8*
DirBili-0.6* IndBili-1.2 Lipase-27
AFP-2.3
Albumin-3.1* Calcium-8.7 Phos-2.8 Mg-2.0
.
-ECG: Aflutter @ 60 bpm, variable 1:1 to 1:3 flutter, low
voltages
.
Radiology:
-CXR: decreased right pleural effusion, no clear evidence of
CHF, no PTX or infiltrate.
.
-Abdominal ultrasound
IMPRESSION:
1. Splenomegaly, splenorenal shunt and ascites. The findings
indicate portal hypertension, and in fact, there is alternating
flow within the main portal vein.
2. The liver is slightly heterogeneous in echotexture, without
definite ultrasonographic evidence of cirrhosis.
3. Probable hemangiomas within the liver.
.
Echocardiogram:
Conclusions:
1.The left atrium is normal in size. The left atrium is
elongated. The right
atrium is markedly dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly
depressed. [Intrinsic left ventricular systolic function may be
more depressed
given the severity of valvular regurgitation.]
3.The right ventricular cavity is moderately dilated. Right
ventricular
systolic function appears depressed. There is abnormal diastolic
septal
motion/position consistent with right ventricular volume
overload.
4.The aortic root is mildly dilated. The ascending aorta is
mildly dilated.
5.The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation
is seen.
6.The mitral valve leaflets are moderately thickened. Mild to
moderate ([**1-6**]+)
mitral regurgitation is seen.
7. Moderate to severe [3+] tricuspid regurgitation is seen.
There is moderate
pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
.
Periotoneal fluid:
WBC-28* RBC-3038* Polys-35* Lymphs-19* Monos-30* Macroph-5*
Other-11*
TotPro-4.3 Glucose-145 LD(LDH)-103 Albumin-2.2
.
Cytology:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, lymphocytes and neutrophils.
Brief Hospital Course:
87M with ischemic cardiomyopathy admitted w/periph edema and
ascites secondary to right heart failure. On admission pt
developed bloody emesis and found to have Dieulofoy lesion;
monitored in [**Hospital Unit Name 153**] and transferred to the floor. Hospital course
by issues as follows:
.
# Hematemesis: Etiology secondary to Dieulafoy lesion seen on
EGD [**2137-6-21**]. Initially received FFP and Vitamin K. Stable HD.
Slight decreased in hct to 28.7. Pt was transfused a total of
one unit for transfusion goal of 30 given his history of CAD.
Hct has remained stable. Aspirin and Plavix which was initially
held were restarted on [**6-24**]. Pt was continued on [**Hospital1 **] PPI.
.
# Burning Epigastric Pain: Per pt, started after 2nd episode of
emesis. Etiology was most likely secondary to emesis. DDx also
included anginal equivalent, PUD, pancreatitis, and other bowel
process. ECG w/o signif ST/TW changes. Card enzymes flat x3.
Epigastric pain resolved. Pt was continued on [**Hospital1 **] ppi.
.
# Elevated INR: Unclear etiology. Based on Abd U/S does not
appear to have cirrhosis. [**Month (only) 116**] be secondary to nutritional
deficiency. Given FFP x1 and Vit K without significant
improvement in INR
.
# Ascites/abnormal abd U/S: Most likely related to CHF and fluid
overload. AFB normal. Given the question of malignant etiology
paracentesis was performed on [**6-25**]. Ascites fluid was negative
for SBP, SAAG 0.8 (not portal hypertension). Culture data was
negative. Cytology did not found any malignant cells.
.
# CHF: Pt was in decompensated right heart failure at admission
by exam & labs. Unclear etiology of acute episode, but possible
dietary indiscretion. Doubt ischemia-related or rhythm-related
given flat card enzymes and stable ECG/tele. Echocardiogram
showed an EF of 45-50% (likely less than this, given severe
valvular abnl). Pt maintained a stable respiratory status. Lasix
was initially held in setting of GIB, but was restarted on home
lasix dose.
.
# CAD: Pt has a P-MIBI in [**2-9**] w/large, predominantly
reversible, moderately severe defect but pt has deferred cath x2
while in hospital for CHF in [**2-9**] & [**4-9**] (but apparently would
consider as outpt). Initially ASA and Plavix were held, then
restarted. ACE-I was held, but restarted on [**6-26**]. Pt was
continued on a statin and low dose bb.
.
# Rhythm: Pt is in atrial fib/flutter, rate controlled. Coumadin
was previously stopped by PCP for bleeding complications. Pt was
rate-controlled with BB.
.
# DM2: Pt is on insulin @ home. Insulin and ISS were continued.
.
# Essential thrombocytosis: Increasing over last several months.
Pt was continued on home dose of hydroxyurea with folate.
Medications on Admission:
-ASA 325 mg po qd
-folate 1mg po qd
-hydroxyurea 500mg po qd
-lasix 160mg po qam/80mg qpm
-insulin 70/30, 16 unit qam
-Lipitor 40mg po qd
-Plavix 75mg po qd
-lisinopril 10mg po qd
-Toprol XL 100mg po qd
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Insulin 70/30 70-30 unit/mL Suspension Sig: Sixteen (16)
units Subcutaneous qam.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Upper Gastrointestinal Bleed
Gastric Dieulafoy's Lesion
Systolic Congestive Heart Failure
Ascites
Atrial Fibrillation
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L per day
Please continue your regular medications.
Followup Instructions:
1. Please follow up with Dr. [**First Name (STitle) **] in [**1-6**] weeks.
2. You can also follow up with [**First Name4 (NamePattern1) 7306**] [**Last Name (NamePattern1) 7307**] of
gastroenterology in [**2-8**] weeks. You can call [**Telephone/Fax (1) 1954**] for an
appointment.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5004**] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 14063**]
|
[
"427.31",
"537.84",
"289.9",
"428.21",
"250.00",
"V58.67",
"401.9",
"414.01",
"286.9",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"44.43",
"54.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9905, 9963
|
5888, 8592
|
273, 302
|
10125, 10133
|
3770, 5865
|
10355, 10804
|
3205, 3210
|
8845, 9882
|
9984, 10104
|
8618, 8822
|
10157, 10332
|
3225, 3751
|
189, 235
|
330, 2550
|
2572, 3007
|
3023, 3189
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,477
| 117,466
|
45286
|
Discharge summary
|
report
|
Admission Date: [**2185-6-16**] Discharge Date: [**2185-6-27**]
Service:
CHIEF COMPLAINT: Melena intraoperatively complication from
plastic surgery.
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
female with diabetes mellitus Type 2 complicated by end-stage
renal disease on hemodialysis, history of retinopathy
(legally blind) hypertension, hypercholesterolemia, status
post cerebrovascular accident, peripheral vascular disease,
who is admitted to the [**Hospital1 69**]
Plastic Surgery service on [**2185-6-16**] for incision and drainage
of a left hand abscess.
The patient initially admitted [**2185-5-28**] for left hand
abscess with gram positive bacteria and underwent incision
and drainage on [**2185-5-29**]. The patient was discharged on
Vancomycin. The patient was seen in [**Hospital 3595**] Clinic on [**6-7**]
and had a 6 cm area of necrotic tissue over the dorsum of the
hand with edema more proximal to this area that was warm.
The patient was admitted to the [**Hospital1 188**] on [**2185-6-16**] and underwent a second incision and
drainage and Vac placement and started on Cefazolin
intravenous.
On admission the patient had a crit of 35 with baseline 35 to
40. Following incision and drainage the patient was given
Percocet for pain control, noted to have some tiny confusion
and the Percocet was discontinued and the patient was started
on Toradol, received 60 mg intramuscular on [**6-18**] mg
intramuscular on [**2185-6-19**], 30 mg on [**2185-6-20**]. On [**6-22**] the
patient was found to have decreased flow through the
Permacath at hemodialysis. The patient was given TPA in both
ports. At dialysis the patient complained of stomach pain
and hematocrit was drawn that showed it was 30 down from 35
on admission. The patient was subsequently transferred to
the MICU on [**2185-6-23**]. The patient had initially gone to the
O.R. for a skin flap with a full thickness skin graft to the
left hand. The patient received 15 mg intramuscular of
Toradol preop. Following the procedure the patient passed
approximately 250 cc's of melanotic stool. Crit at the time
was 23.5 at 11 AM and 20.3 at 3 PM. The patient remained
hemodynamically stable with heart rates in 70's to 90's and
blood pressure of 100 to 160/40 to 60. Anesthesia placed a
left IJ for central venous access and the patient received
approximately 700 cc's of intravenous fluids
intraoperatively. In the Post Anesthesia Care Unit the
gastrointestinal team was consulted and
esophagogastroduodenoscopy performed which was normal
(bilious material in the stomach, no signs of bleeding).
Recommended colonoscopy following transfusion. The labs were
drawn postoperatively showing platelets of 255, BUN 107 up
from 51 from [**2185-5-23**], an INR of 1.7 and a PTT of 55.1. The
patient was subsequently given DDAVP. At 7:15 PM the patient
passed approximately 200 cc's of melena and was subsequently
transferred to the medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus times 50 years,
complicated by end-stage renal disease on hemodialysis,
complicated by retinopathy, legally blind, complicated by
neuropathy.
2. Hypertension.
3. Hypercholesterolemia.
4. Dementia.
5. Status post cerebrovascular accident with left sided
residual weakness and right sided weakness.
6. Hypothyroidism.
7. Peripheral vascular disease.
8. Status post total abdominal hysterectomy for fibroids.
9. Status post right knee surgery.
10. Gout.
11. Scoliosis progressive.
12. Hip "fusion" with back pain requiring narcotics.
The patient has no known coronary artery disease.
MEDICATIONS ON ADMISSION:
1. Synthroid 150 mg p.o. q day.
2. Neurontin 300 mg p.o. q day.
3. Aspirin 81 mg q day.
4. Norvasc 10 mg p.o. q day.
5. Timolol eyedrops 0.5%
6. Renagel
7. Ultram.
8. Colace.
9. Lisinopril.
ALLERGIES: Codeine, question renal failure.
PHYSICAL EXAMINATION: Temperature 97.7, heart rate 84, blood
pressure 125/37, respiratory rate 14, sating 95% on three
liters. General: Awake but drowsy, answers questions
appropriately, well nourished in no apparent distress. The
patient having periods of apnea greater than 20 seconds.
Head, eyes, ears, nose and throat anicteric sclera,
oropharynx benign. Cardiovascular: Regular rate and rhythm.
No murmurs, rubs or gallops. Lungs: Clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended,
positive bowel sounds. Extremities: No edema, nonfunctional
arteriovenous fistula in the right upper extremity and left
upper extremity.
LABORATORY: On [**2185-6-22**] white count 14.8, hematocrit 20.3,
potassium 5.1, BUN 107, creatinine 7.3, CPK 34, Troponin
0.11.
Electrocardiogram is normal sinus rhythm at 75 beats per
minute, normal axis and intervals, no acute ST changes, no
changes when compared to previous Echocardiogram.
Chest x-ray for left IG placement. Heart normal size. No
pneumothorax. Right upper lobe opacity stable compared to
previous chest x-ray. Recommend follow-up CT scan.
Microbiology: Wound cultures left hand from [**6-16**] no growth.
HOSPITAL COURSE:
1. Gastrointestinal bleed: During the hospital course
hematocrit declined 35 to 30 to 24 on day of transfer. The
patient went for skin graft of the left hand. After the
procedure the patient passed 250 cc's of melena as before
though remained hemodynamically stable with a repeat crit of
20. Underwent an esophagogastroduodenoscopy which was
negative with transfer to the TCU for monitoring. The
patient was typed and crossed, matched for four units with a
goal crit of 30. Protonix was started 40 mg intravenous q
day for gastrointestinal prophylaxis and aspirin and
non-steroidal anti-inflammatory drugs were held off. The
recommendation was to move further with a colonoscopy for
further evaluation of the gastrointestinal bleed however, in
the MICU there was a long discussion with the patient's two
health care proxies and they felt that the patient did not
want to have invasive procedures done including colonoscopy
and angiography, said that the patient often declined medical
care and would not wish to have invasive procedures done now.
They were given information regarding the procedure,
benefits and risks including the possibility of finding a
source of bleeding that is relatively easily treatable. They
said they would like her to have more done but do not want to
go against the relatives wishes, they hope that with time she
will be able to wake up more and more and to make the final
decision for herself. They understand she could have a life
threatening bleed in the meantime and she could expire.
Given the patient's multiple comorbidities and the quality of
life and her wishes the decision was to withdrawal invasive
procedures appears reasonable. If she did re-bleed she would
be transfused with packed red blood cells only and provide
supportive care. This was discussed with the MICU team and
the decision was to transfer the patient to the Medicine
service on the floor and the patient was transferred on
[**2185-6-26**].
After the family meeting and made DNR/DNI no colonoscopy was
to be done to diagnose the source of gastrointestinal bleed.
On the Medicine Team her crit remained stable and she
continued to refuse colonoscopy and a type cell scan with
angio. Serial crits were followed. Her hematocrit was
stabilizing at 26.9.
2. Coagulations, heme. There was an initial increase of her
INR of unclear reasons throughout to be done due to it being
drawn from the Heparin site and the patient was status post
Vitamin K reversal and now had stable INR at 1.3. On the
floor she was continued to follow and no obvious pathology
was found.
3. End-stage renal disease. The patient continued to have
hemodialysis during hospital stay. She was continued on
Nephrocaps with the Renal Team following and repletion of K
and subsequent following of her creatinine which was 8.0 at
discharge.
4. Elevation of Troponin T. Likely thought to be due to
decreased renal clearance as per the Renal Team. The patient
did not have any acute electrocardiogram changes and no chest
pain and there is consideration of repeating the Troponin T
after hemodialysis to follow. Otherwise there was no
significant medical changes that needed to occur.
5. Endo. The patient with hypothyroid and diabetes
mellitus. Levothyroxine was continued in the house as is
regular insulin sliding scale. Fingersticks were monitored
closely.
6. Plastic surgery and hand. The patient's arm was kept
elevated, dressing changes were done q day. Ancef 1 gram
intravenous q 48 hours was continued.
7. Pain. The patient was maintained on Hydrocodone and
Acetaminophen 1 tab p.o. q 6 hours while in house.
8. FEN. The patient was unable to take p.o's and
intravenous meds were continued.
9. Hypertension. Elevation of her blood pressure given the
stable hematocrit, after transfer to the floor the patient
was restarted on her anti-hypertensive meds and titrated as
needed Amlodipine and Captopril.
10. Prophylaxis. The patient was given a proton pump
inhibitor for gastrointestinal, pneumo boots were in place.
11. Access. The patient has a left IJ in position placed on
[**2185-6-23**].
12. Code: DNR/DNI.
13. Disposition: On the day of discharge [**2185-6-27**] the
patient refused transfusion of packed red blood cells after a
crit of 26.0 from 29.1 was noted. The patient also refused
all meds and requested desire to go home alone with health
care proxies. The attending was [**Name (NI) 653**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and plan was for patient to be discharged on current
inpatient meds with hemodialysis three times a week at her
current location with follow-up with Plastic Surgery and
continued antibiotics changed from Ancef to Keflex p.o. with
follow-up with the PCP.
14. Pulmonary nodule seen on a recent chest x-ray and will
be required to follow-up with CT scan as an outpatient.
CONDITION ON DISCHARGE: Fair. Patient requested to go home.
DISCHARGE STATUS: Poor. Patient refusing blood transfusion
and all in house medications. Requesting desire to go home
and leave along with [**Hospital 228**] health care proxies.
DISCHARGE DIAGNOSIS:
1. Gastrointestinal bleed (melena)
2. Escharotomy.
3. Left hand abscess status post full thickness skin
graft from the abdomen to the left hand and
VAC placement on left hand dorsum.
FOLLOW-UP PLANS: The patient to follow-up with Plastic
Surgery provider, [**Name10 (NameIs) 648**] has been made for 7/25/0 after
the regular dialysis [**Name10 (NameIs) 648**].
Primary care provider with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to be followed
with an [**Last Name (NamePattern1) 648**] within two weeks, call [**Telephone/Fax (1) 16315**].
Continue to go to weekly dialysis appointments as you have
done prior to this admission.
DISCHARGE MEDICATIONS:
1. Levothyroxine 150 mcg q day.
2. Folic Acid.
3. Vitamin B Complex 1 mg capsule q day.
4. Calcium carbonate 1000 mg three times a day with meals.
5. Lisinopril 5 mg q day.
6. Cephalexin 250 mg q 12 hours.
7. Amlodipine 5 mg one tab q day.
8. Pantoprazole 40 mg q day.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 96753**]
Dictated By:[**Last Name (NamePattern1) 11210**]
MEDQUIST36
D: [**2185-8-1**] 15:55
T: [**2185-8-1**] 16:02
JOB#: [**Job Number 96754**]
|
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icd9cm
|
[
[
[]
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[
"39.95",
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icd9pcs
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[
[
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|
10270, 10465
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5116, 10003
|
3923, 5099
|
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|
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|
191, 2976
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,724
| 193,509
|
4786
|
Discharge summary
|
report
|
Admission Date: [**2102-3-9**] Discharge Date: [**2102-3-16**]
Date of Birth: [**2052-3-1**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Propofol Analogues / Lactose / caffeine / Iodine /
Glucocorticoids,Systemic Classifier / Amoxicillin / msg / IV
Dye, Iodine Containing / broth
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
metastatic clear cell carcinoma to the anterior floor of mouth
Major Surgical or Invasive Procedure:
anterior floor of mouth resection, reconstruction with split
thickness skin graft
History of Present Illness:
49-year-old male who has a history of metastatic renal cell
carcinoma. Recently, he was noted to have a firmness in the
anterior floor of mouth and was seen by an oral surgeon who
apparently partially resected it. The specimen was not oriented
and the margins were not commented on. However, the diagnosis
from the Center for Oral Pathology in [**Location (un) **] was that of
metastatic malignant clear cell neoplasm consistent with renal
cell carcinoma. He presents today for recommendations
concerning
further management of this lesion. At this time, he is not
having any odynophagia or dysphagia. He is able to move his
tongue normally. He has had no submandibular swelling.
Apparently, he did have a stone in the left submandibular duct
some time ago and underwent some form of surgery for this. He
has had no oral cavity bleeding.
Past Medical History:
Past Oncologic History:
- [**8-/2097**]: p/w abd discomfort found to have 6 cm mass in the left
kidney, and 3 low attenuation cystic lesions of the liver. CT
chest with lung nodule felt likely to be a nerve sheath tumor.
- [**8-/2097**] left nephrectomy by Dr. [**Last Name (STitle) 9125**]. Pathology revealed
clear cell histology with tumor size 6.5 cm and tumor limited to
the kidney, firm and grade 2. Regional lymph nodes were not
submitted. Margins were uninvolved by invasive carcinoma.
- [**9-/2097**] VATS resection of left extrapleural nodule. Pathology
revealed metastatic renal cell carcinoma. Followup CT scan
showed no evidence of disease
- [**2100-4-21**] CT torso, revealed several intramuscular
enhancing lesions bx with metastatic renal cell carcinoma
- [**5-/2100**] cycle 1, high-dose IL-2
- [**10/2100**]: 3-month torso CT on [**2100-11-9**], revealed stability of
3 lesions and resolution of 2 intermuscular nodules, felt
consistent with delayed response to IL-2
- [**12/2100**]: cycle 2 IL2
- CT [**2101**]: stable lung nodules and no further disease
progression
Other Past Medical History:
IBS
Gastritis
Lactose Intoelrance
Generalized anxiety disorder
CKD baseline Cr 1.3
Social History:
From [**Location (un) **]. Composer and teaches piano. Former smoker. Rare
EtOH. Married no children.
Family History:
CAD s/p CABG, HTN in father.
Physical Exam:
AVSS
NAD
Braething comfortably
No stridor
Mild tongue edema, greatly improved since admission
Skin graft healing well
Skin graft donor site with xeroform on it
Brief Hospital Course:
The patient was admitted to the otolaryngology service on
[**2102-3-9**] after undergoing a anterior floor of mouth resection
with split thickness skin graft recon with attending Dr.
[**Last Name (STitle) 1837**]. The patient tolerated the procedure without
intra-operative complications. Please refer to the operative
note for full operative detail. Due to noted tongue edema, the
patient was kept intubated over the night of POD0. He was
monitored in the ICU for airway protection and stabilization.
The morning following his procedure, he passed his RISB and was
extubated successfully. He endorsed anxiety and some throat
pain, however he maintained his oxygenation and cleared his
secretions well. He bloody secretions that began to resolved
over the course of the next 24 hours, and his pain was well
controlled. His oxygenation was 95-99% on RA. He was stable for
the floor and transferred to the ENT service on the floor.
While on the floor, he was kept on antibiotics until the
intraoral bolster was removed on POD6. His diet was advanced to
clears on POD6 and ground consistency solids on POD7 per speech
and swallow recommendations. Until that point, his nutrition
had been maintained with tube feeds. The remainder of the
hospital course was relatively unremarkable and the patient was
discharged in stable condition, ambulating, and voiding
independently and with adequate pain control on oral analgesics.
The patient was given explicit instructions to follow-up in
clinic with Dr. [**Last Name (STitle) 1837**] next week.
Medications on Admission:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, fever.
5. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
metastatic clear cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Please call or go to emergency room if fever greater than
101.5, if
increased redness or discharge from wound or around drain site,
if
numbness/weakness, if short of breath, if you notice leg
swelling, if
increased pain uncontrolled by pain medications, or for any
other
concerning symptoms.
-[**Month (only) 116**] shower; Do not get the skin graft donor site dressing
(xeroform) wet.
-Please do not drive or consume alcohol while taking narcotics.
-Please follow up with your primary care provider concerning
hospitalization.
-Please resume all home medications unless instructed otherwise.
-xeroform on the skin graft donor site will peel off on own.
Can trim it as needed
Followup Instructions:
f/u with Dr. [**Last Name (STitle) 1837**] in 1 week
Completed by:[**2102-3-16**]
|
[
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icd9cm
|
[
[
[]
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[
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"26.99",
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icd9pcs
|
[
[
[]
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5307, 5313
|
3020, 4563
|
470, 554
|
5389, 5389
|
6243, 6327
|
2790, 2821
|
4823, 5284
|
5334, 5368
|
4589, 4800
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5541, 6220
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2836, 2997
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368, 432
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582, 1429
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5404, 5517
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2566, 2651
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2667, 2774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,752
| 128,342
|
39170
|
Discharge summary
|
report
|
Admission Date: [**2191-1-20**] Discharge Date: [**2191-2-2**]
Date of Birth: [**2122-5-13**] Sex: M
Service: MEDICINE
Allergies:
Atenolol / Atorvastatin / Carbamazepine / Chlorhexidine /
Codeine / Fentanyl / Oxycodone / Propoxyphene / Demerol
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
ICD firing
Major Surgical or Invasive Procedure:
Attempted VT tract ablation
Percutaneous Coronary Intervention
History of Present Illness:
68M with h/o CAD (prior MIs, CABG, CHF), COPD on baseline O2,
CRI, DM, IACD placed for afib/VT in [**2-14**], presents for VT storm
with multiple ICD firings.
.
Pt was recently admitted to [**Hospital 1263**] Hospital for ICD firing on
[**1-15**], discharged [**1-17**] after restarting amiodarone. Pacer was
interogated and showed afib.
.
After discharge pt was repeatedly shocked at home, on the way to
the ED and in the ED for VT. He reports no SOB, palpitations,
fevers/chills or CP but feels chest heaviness, heat wave, and
clammy prior to firings. Pt reports many waves of heat, only
some (about a dozen) resulting in shock. On arrival pt afebrile,
A-paced at 70, with BP 120/60s. Pt was ruled out for MI with CEs
neg x 2, Cr at baseline at 1.7. Dig level was checked after dose
and was 1.9. Pt was bolused and started on amio gtt and most
recent VT and shock was at 3am on [**2191-1-20**]. He also received IV
ativan, and 5mg IV dilaudid.
.
ROS: Currently pt denies SOB, CP, palpitations, abd pain, back
pain.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: CAD, MIx2
-CABG: 3V [**2174**]
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2184**]
-PACING/ICD: [**2-14**]
3. OTHER PAST MEDICAL HISTORY:
-COPD on home O2.
-Afib
-CRI
-OSA
-Diabetes with peripheral neuropathy
-BPH
-kyphoplasty L1-3, C5-6 fusion, chronic lower back pain
-systolic CHF EF 25-30% in [**2188**]
-diverticulosis
-GERD
-lacunar CVA [**2178**]
Social History:
works as security guard, daughter is nurse (previously CCU)
-Tobacco history: Has not smoked in last year.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
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 (dry). No
xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Well healed sternal scar.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Decreased BS at R base.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Palpable DPs and PTs.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2191-1-21**] 04:55AM BLOOD WBC-7.6 RBC-4.37* Hgb-12.4* Hct-39.2*
MCV-90 MCH-28.3 MCHC-31.6 RDW-14.5 Plt Ct-251
[**2191-1-23**] 01:02AM BLOOD WBC-12.0* RBC-3.90* Hgb-11.2* Hct-35.1*
MCV-90 MCH-28.7 MCHC-31.8 RDW-14.7 Plt Ct-183
[**2191-1-28**] 04:16AM BLOOD WBC-8.1 RBC-3.61* Hgb-10.3* Hct-33.2*
MCV-92 MCH-28.6 MCHC-31.1 RDW-15.0 Plt Ct-215
[**2191-2-2**] 07:45AM BLOOD WBC-12.0* RBC-3.41* Hgb-10.3* Hct-31.6*
MCV-93 MCH-30.1 MCHC-32.6 RDW-15.4 Plt Ct-298
[**2191-1-25**] 04:37AM BLOOD Neuts-70 Bands-0 Lymphs-7* Monos-21*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2191-1-21**] 04:55AM BLOOD PT-13.1 PTT-27.1 INR(PT)-1.1
[**2191-1-24**] 05:46PM BLOOD PT-14.7* PTT-71.9* INR(PT)-1.3*
[**2191-2-2**] 07:45AM BLOOD PT-14.4* PTT-27.7 INR(PT)-1.2*
[**2191-1-20**] 11:26PM BLOOD Glucose-173* UreaN-36* Creat-2.1* Na-138
K-4.5 Cl-99 HCO3-31 AnGap-13
[**2191-1-22**] 06:37AM BLOOD Glucose-94 UreaN-39* Creat-1.9* Na-136
K-5.1 Cl-101 HCO3-26 AnGap-14
[**2191-1-23**] 01:02AM BLOOD Glucose-108* UreaN-50* Creat-2.5* Na-134
K-4.7 Cl-100 HCO3-21* AnGap-18
[**2191-2-2**] 07:45AM BLOOD Glucose-83 UreaN-87* Creat-1.8* Na-137
K-4.5 Cl-102 HCO3-28 AnGap-12
[**2191-1-27**] 09:05PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2191-1-28**] 04:16AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2191-1-27**] 09:05PM BLOOD CK(CPK)-45*
[**2191-1-24**] 10:55AM BLOOD D-Dimer-6615*
[**2191-1-27**] 03:00AM BLOOD Vanco-10.0
[**2191-1-23**] 01:42AM BLOOD Type-ART pO2-299* pCO2-46* pH-7.35
calTCO2-26 Base XS-0
[**2191-1-29**] 06:58PM BLOOD Type-ART pO2-86 pCO2-46* pH-7.34*
calTCO2-26 Base XS--1
[**2191-1-23**] 01:42AM BLOOD Glucose-116* Lactate-0.8
[**2191-1-23**] 01:42AM BLOOD freeCa-1.13
[**2191-1-21**] CCATH: FINAL DIAGNOSIS: 1. Three vessel coronary artery
disease. 2. Patent LIMA-LAD. 3. Successful PCI of the LCX/OM
with drug-eluting stent.
[**2191-1-22**] CXR: Asymmetric CHF. An underlying infectious infiltrate
in the right lower lung cannot be excluded.
[**2191-1-26**] TTE: The left atrium is normal in size. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with basal to mid
inferolateral and inferior akinesis. Views are suboptimal so
regional wall motion could not be fully assessed. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. An eccentric,
posteriorly directed jet of at least moderate (2+) mitral
regurgitation is seen. Mitral regurgitation is not fully
visualized. The tricuspid valve leaflets are mildly thickened.
There is no pericardial effusion.
[**2191-1-27**] CT chest: 1. Moderate, mostly loculated, right pleural
effusion and small, dependent freely layering left pleural
effusion. 2. Dense opacity at right lung base adjacent to
pleural effusion likely
represents atelectasis and less likely focal infection. 3.
Bilateral ground-glass opacities with septal thickening and
bronchial wall
thickening likely represent hydrostatic edema, but viral
pneumonia may
produce a similar pattern. 4. Mediastinal lymphadenopathy with
the largest lymph node conglomerate located subcarinally.
Although potentially related to hydrostatic edema or infection,
given the large size of the subcarinal lymph nodes, there is
concern for malignancy. Followup CT in 6 weeks after treatment
of the patients acute conditoin is recommended. 5. Two nodular
foci in the right upper lobe may represent focal areas of
infection and less likely malignant lung nodules. These may also
be reassessed at the follow up CT scan. 6. Small amoung of
ascites is noted. Hypodense lesion in the upper pole of the left
kidney likely represents a cyst.
Brief Hospital Course:
68M with MMP presents with VT storm and ICD firing, transferred
from outside hospital for EP ablation.
.
# Ventricular Tachycardia:
Patient presented from outside hospital with VT storm, initially
thought to be of ischemic etiology due to scar tissue. TSH and
digoxin level were within normal limits. Patient had been
loaded on amiodarone at outside hospital and was continued on
amiodarone drip at 0.5mg/hr and beta blocker on presentation to
[**Hospital1 18**]. On the night of admission, patient had frequent runs of
NSVT, longest 15 beats, which started while he was sleeping.
While awake, patient reported feeling a sensation of "warmth"
during some of these runs of NSVT. He was started on low dose
metoprolol (both patient and daughter do not recall reason for
listed atenolol allergy) and amiodarone drip dose was increased
to 1mg/hr, after which frequency of NSVT runs decreased quickly.
During attempted EP ablation of VT tract the next morning,
Electrophysiology team was able to map out patient's left
ventricle and felt that VT was coming from right ventricle.
Patient reported having chest pain during EP procedure, so the
procedure was cut short, and patient was sent for Cardiac
Catheterization with the presumption that his VT may have been
of ischemic etiology. The patient had a PCI of the LCX/OM with
drug-eluting stent, however, felt that this wasn't in the right
location to be causing his VT. The patient had no further runs
of VT and no further EP procedure was done. If he develops VT in
the future he may need his right ventricle mapped to look for a
focus of the VT. The patient will follow up with Dr. [**Last Name (STitle) **] as
an outpatient.
# Shortness of Breath:
Patient experienced worsening shortness of breath during
hospitalization, likely multifactorial. He presented with two
weeks of worsening productive cough and was treated for Right
lower lobe pneumonia with broad spectrum antibiotics; only
normal oropharyngeal flora grew from his sputum culture.
Patient appears to have long history of hospitalizations for
COPD and CHF exacerbations with prolonged courses of recovery.
He was found to have a right sided pleural effusion on admission
to [**Hospital1 18**]; he was noted to have had this effusion in the past
which was previously drained and found to be transudative.
Effusion appeared to be loculated on lateral decubitus films
taken during this hospitalization. Patient's O2 requirement
increased post EP and Cath procedures. He was thought to have
aspirated during the EP procedure, so flagyl was added to his
antibiotic regimen. Pulmonary embolism was considered but felt
to be of low suspicion. Lower extremity ultrasound was negative
for DVTs bilaterally. Ultimately, he was treated for COPD
exacerbation with steroids, despite minimal wheezing on exam,
after which his symptoms improved. He was discharged home with
services on oxygen (which he had prior to this hospitalization).
# COPD Exacerbation:
Patient has prior smoking history, intermittently requires O2 at
home, usually with CHF exacerbations. He has had multiple known
exacerbations for CHF and COPD in the past with prolonged
recovery. His oxygen requirement was variable with up to 6L NC
and a face tent. He was started on IV methylprednisolone and
then prednisone taper. His oxygen requirement decreased to 4L
NC. He will follow up with his PCP post discharge for further
management. He was discharged with Advair.
# Coronary Artery Disease:
Patient was ruled out for MI at the outside hospital, and EKG
was without evidence of acute ischemia. Patient was continued on
home aspirin, statin, plavix, and beta blocker. Patient was sent
to Cath lab immediately after having chest pain in the EP lab.
Cardiac Catheterization showed three vessel coronary artery
disease, 100% stenosis of mid LAD but patent LIMA-LAD graft, and
significant disease in the Left Circumflex. The left circumflex
had 90% proximal stenosis before the origin of the AV branch and
an 80% stenosis after the AV and before OM1, and was totally
occluded distally. A Drug-eluting stent was placed in the
proximal-mid Circumflex. The
SVG-PDA and SVG-OM were known occluded and were not looked at.
A femoral bruit was noted post procedure, not known to be old,
but femoral ultrasound showed no pseudoaneurysm or fistula.
Patient did have a couple of episodes of chest pain in the day
post catheterization with no EKG changes; he noted that the
chest pain was similar to pain he experiences at home sometimes
for which he does nothing.
# Hypertension:
Blood pressure was well controlled during hospitalization. He
was discharged on his home low dose of tamsulosin, metoprolol.
He will follow up with his primary care physician for further
management.
# Hyperlipidemia:
He was continued on Zetia/Simvastatin.
# Afib: Well rate controlled, currently A paced. On no
anticoagulation although CHADS score is 6. He was continued on
aspirin and plavix.
# CRI: At baseline 1.7. He was given mucomyst prior to cardiac
catheterization.
# Diabetes:
Patient was continued on basal glargine plus an insulin sliding
scale during this hospitalization. His blood sugars were
elevated while on steroids for COPD exacerbation.
# BPH:
He was continued on his home meds.
Medications on Admission:
Lisinopril 2.5mg PO daily
Lasix 40mg PO QOD (last on [**2191-1-20**])
KCl 10mEq QOD
Lantus 30U qhs
Novolog 10U TID
Proscar 5mg PO daily
Flomax 0.4mg PO daily
Paroxetine 30mg PO daily
Plavix 75mg Po daily
Digoxin 0.125mg Po daily
ASA 81mg PO daily
Zetia 10mg PO daily
Simvastatin 20mg PO daily
Omeprazole 20mg PO daily
Amiodarone 400mg PO daily
Colace 100mg PO daily
Senna 8.6mg Po at bedtime
Ambien 5mg Po qhs prn
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
10. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-12**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain:
Take 3 minutes apart, if you still have chest pain after 3
tablets, call 911.
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
17. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO every four (4) hours as needed for cough.
18. Novolog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous three times a day: before meals per sliding scale
attached.
19. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days: Take on [**2-3**] and [**2-4**].
20. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 days: take on [**2-5**] and [**2-6**].
21. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Take on [**2-7**] and [**2-8**].
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Ventricular Tachycarida
Coronary Artery Disease
Acute on Chronic congestive heart failure, ACEi held due to
increased creatinine.
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
YOu had ventricular tachycardia while you were at home which
required the addition of more amiodarone and metoprolol. We were
not able to complete an ablation at this time because of chest
pressure during the ablation. A cardiac catheterizaion showed
blockages in your left circumflex artery that were opened with 2
drug eluting stents. It is very important that you take your
Plavix and aspirin every day for at least one year and possibly
longer. Do not stop taking Plavix for any reason unless Dr.
[**Last Name (STitle) **] tells you not to.
Medication changes:
1. Start Plavix to keep the stents open
2. Increase aspirin to 325 mg daily
3. Stop taking Omeprazole and digoxin
4. Start taking Ranitidine instead of Omeprazole
5. Stop taking Lisinopril and Lasix for now
6. Stop taking Potassium supplements until you restart your
lasix.
7. Decrease your lantus to 20 unit for now, you have a humalog
sliding scale that you can use. You may need to decrease the
Lantus as your prednisone dose decreases.
8. Start taking Prednisone for you COPD. You will take 30 mg for
2 days, then 20 mg for 2 days, then 10 mg for 2 days, then d/c.
9. Decrease your amiodarone to 300 mg daily
10. Start taking Advair twice daily to help your breathing.
.
A CT scan of your chest showed that you had some enlarged lymph
nodes in your chest. You also had some nodules in your right
upper lung lobe. You should get another CT scan of your chest
in 6 weeks time.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if your weight
goes up more than 3 lbs in 1 day or 6 pounds in 3 days.
.
You cannot drive until after you see Dr. [**Last Name (STitle) **] on [**3-3**]
and he tells you it is OK to do so.
Followup Instructions:
Primary Care and Pulmonology:
[**Last Name (LF) **],[**First Name3 (LF) **] W. Phone: [**Telephone/Fax (1) **] Date/time: Friday [**2-11**] at 11:15 am.
.
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] I. Phone: [**Telephone/Fax (1) 8725**] Date/time: [**3-3**]
at 2:20pm.
.
|
[
"530.81",
"250.60",
"585.9",
"584.9",
"724.2",
"600.00",
"428.0",
"507.0",
"458.9",
"414.02",
"414.01",
"427.1",
"428.23",
"403.90",
"V45.4",
"491.21",
"272.4",
"786.50",
"357.2",
"427.31",
"338.29",
"562.10",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.45",
"88.72",
"37.22",
"37.26",
"00.40",
"37.27",
"93.90",
"36.07",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
14718, 14774
|
6724, 11980
|
384, 448
|
14986, 14986
|
2937, 4617
|
16860, 17150
|
2093, 2208
|
12444, 14695
|
14795, 14965
|
12006, 12421
|
4634, 6701
|
15134, 15679
|
2223, 2918
|
1598, 1704
|
15699, 16837
|
334, 346
|
476, 1494
|
15001, 15110
|
1735, 1952
|
1516, 1578
|
1968, 2077
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,451
| 129,396
|
29964+57673
|
Discharge summary
|
report+addendum
|
Admission Date: [**2152-1-18**] Discharge Date:
Date of Birth: [**2083-2-25**] Sex: M
Service: VSU
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This 68 year-old gentleman with
abdominal pain x 6 weeks with sudden onset associated with
eating, occurs 15 minutes post eating and lasts several
hours. Partially relieved with Darvocet. The patient had a
diagnostic work-up at an outside hospital for mesenteric
ischemia which was positive.
REVIEW OF SYSTEMS: Positive for weight loss, nausea,
vomiting, diarrhea, shortness of breath. He denies chest pain
or night sweats. The patient now is admitted for
prehydration prior to undergoing mesenteric ischemic
revascularization.
PAST MEDICAL HISTORY: Peripheral vascular disease, status
post angioplasty and stenting of the right lower extremity in
[**2143**]. Vessel angioplastied is now known. History of
hypertension, controlled.
PAST SOCIAL HISTORY: The patient is a 12 pack per week beer
drinker. History of copious alcohol use previously. One and
1/2 packs per day times 55 years smoking, which is current.
FAMILY HISTORY: Positive in the father for liver disease.
Mother myocardial infarction and breast cancer.
MEDICATIONS ON ADMISSION: Atenolol 100 mg daily,
hydrochlorothiazide 25 mg daily.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs 97.6; 65; 18; blood
pressure 124/86; oxygen saturation 90% on room air. General
appearance: Alert, white male, in no acute distress. HEENT:
Unremarkable. Lungs are clear to auscultation. Heart is
regular rate and rhythm without murmur, rub or gallop.
Abdomen is soft, mildly distended. Mild tympany in the right
lower quadrant. There are no bruits. Rectal exam was
deferred. Extremity examination shows non palpable
Dopplerable DP and PT bilaterally. Right femoral is
palpable. Left femoral is nonpalpable.
HOSPITAL COURSE: The patient was admitted to the vascular
service. Nutritional service was requested to see the patient
in anticipation of postoperative nutritional needs. The
patient was IV hydrated and began on IV heparin with serial
PTT monitored for a goal PTT of 60 to 70. The patient
proceeded to surgery on [**2152-1-20**] and underwent an aorta
bifemoral bypass graft with a reimplantation of the inferior
mesenteric artery and an aorta to superior mesenteric artery
bypass graft. The patient tolerated the procedure well and
was transferred to the PACU extubated but did require
reintubation. The patient was transferred to the surgical
intensive care unit the following day for vent support for
respiratory failure. The patient was transfused and
aggressive pulmonary care was instituted.
On postoperative day number 2, it was noted that his platelet
counts were in the 25 range. The heparin was discontinued. He
was started on Fondopain-RX. His PA line was converted to a
central line. A hip panel was sent and results returned as
negative. It was also noted that the patient had an elevated
white count and Vancomycin and Zosyn were instituted. A
chest x-ray was obtained on [**1-23**], secondary to increasing
white count. The chest x-ray showed right lower lobe changes,
probably consistent with multi-focal pneumonia. Nutrition
recommended to start tube feeds. This was held secondary to
his respiratory status. On [**1-24**], postoperative day number 4,
patient required a CIWA scale for postoperative agitation and
combativeness. On [**1-26**], the TPN was instituted. On [**2152-1-28**],
the patient did have a bowel movement with the use of a
suppository. His white count continued to be elevated at
13.9. On [**1-29**], the white count continued to increase. The
right groin showed a serosanguineous drainage. A VAC dressing
was applied. The central line was changed over a wire. Tube
feeds were held secondary to his elevated white count and
abdominal distention. CT of the abdomen was obtained which
showed a filling defect in the SMA distal to the graft which
they felt was thrombus with some thickening of the small
bowel. Intravenous heparin was restarted. Amylase was
obtained which was 109 and lactate was .8. General surgery
was consulted for the possibility of abdominal exploration
and bowel resection. They felt that the patient could be
managed conservatively. The patient developed hypercarbia
with a C02 of 72, requiring reintubation. He was
bronchoscoped which showed right lower lobe collapse and
atelectasis. The antibiotics were continued. His tube feeds
were started on [**1-31**]. Head CT was obtained which showed
subacute right temporal parietal occipital lobe changes which
were consistent with old infarcts per neurology service. CT
of the abdomen was obtained and it showed the graft was
patent.
The patient had a second bronchoscopy done and his
antibiotics were restarted. The patient had a third
bronchoscopy which showed clear secretions with mucus
plugging times one. Venous studies were negative for DVT. On
[**2-3**], the patient was extubated and new CVL was placed via new
stick. On [**2-4**], sedation was weaned. His aspirin was restarted
and he was reintubated secondary to aspiration. His white
count continued to rise. He required neo for hemodynamic
support. This was weaned overnight and Flagyl was begun
empirically for questionable C. Diff. The cultures eventually
were determined to be negative and the Flagyl was
discontinued. On [**2-5**], the patient had an episode of atrial
fibrillation which was confirmed with Lopressor. CT of the
abdomen was repeated secondary to increasing white count
which showed a low attenuation and peri-aortic fluid. The
right renal artery showed changes, questionable infarct and
the white count began to show improvement. On [**2-8**], the
patient underwent a PEG and trache procedure. His tube feeds
were restarted on [**2-9**]. His chest x-ray showed a left lower
pneumonia. His TPN was discontinued. On [**2-12**], he had
elevated LFTs and they felt this was related to pancreatitis
postoperatively. Fluconazole was started for a yeast UTI and
his Zosyn was discontinued on [**2-13**]. On [**2-14**], his tube feeds
were readjusted for abdominal distention and high residuals.
Tobramycin inhalation was begun for gram negative rods found
in his sputum. LFTs have been slowly improving but amylase
remained elevated at 450. On [**2-15**], the patient's LFTs
continued to improve. His amylase and lipase continued to
improve. The patient was transferred to the VICU for
continued care. His Vancomycin, fluconazole and Tobramycin
were discontinued on [**2-15**]. On [**2-16**], a PICC line was placed.
Physical therapy will evaluate the patient. He will require
rehab at the time of discharge. Patient will be discharged to
rehab when medically stable and bed available.
DISCHARGE MEDICATIONS: Iproprium bromide aerosol puffs q. 4
hours. Albuterol 90 mcg actuation aerosol, 1 to 2 puffs q. 4
hours. Fluconazole nitrate powder 2% to affected areas t.i.d.
Fluconazole actuation and aerosol 2 puffs b.i.d.. Medium
chain triglycerides 30 cc b.i.d.. Metoprolol 37.5 mg b.i.d.
Ranitidine 150 mg b.i.d.. Montelukast 10 mg daily.
Erythromycin 500 mg liquid daily. Aspirin 325 mg extended
release daily. Heparin flush to PICC line 2 cc IV daily and
prn followed by 10 cc of normal saline, followed by 2 cc of
100 units U of heparin, i.e. 200 units of heparin each lumen
daily and prn.
DISCHARGE DIAGNOSES:
1. Mesenteric ischemia.
2. Postoperative thrombocytopenia; HIT negative, resolved.
3. Postoperative nicotine withdraw, resolved.
4. Postoperative delirium confusion. Head CT with old
temporal parietal occipital infarcts.
5. Postoperative pneumonia, treated.
6. Postoperative SMA thrombus improved, anticoagulated.
7. Postoperative hypercarbia, status post bronchoscopy.
8. Postoperative aspiration reintubation for respiratory
failure.
9. Postoperative atrial fibrillation, converted with
Lopressor.
10. Postoperative right groin seroma.
11. Postoperative aspiration, treated.
12. Postoperative failure to thrive.
13. PEG with tube feeds.
MAJOR SURGICAL PROCEDURES:
1. Aorta bifemoral with reimplantation of the [**Female First Name (un) 899**], aorta,
SMA bypass on [**1-18**].
2. Right groin VAC dressing application starting on
[**2152-1-29**].
3. CVL change over wire on [**2152-1-29**].
4. Bronchoscopy on [**1-30**] and [**2152-2-1**].
5. PEG/trache on [**2152-2-8**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2152-2-16**] 11:22:52
T: [**2152-2-16**] 11:51:30
Job#: [**Job Number 71554**]
Name: [**Known lastname 2578**],[**Known firstname **] M Unit No: [**Numeric Identifier 12021**]
Admission Date: [**2152-1-18**] Discharge Date: [**2152-2-23**]
Date of Birth: [**2083-2-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
[**2152-2-17**] speech/swallow service consulted for pessiemeyer trach.
patient tolerating trach. Will scheduale viedo-swallow for
assesment of silent aspiration.
[**2-18**]/assement of viedo swallow, no aspiration may advance to
ground solids and thin liquids. advance to regular when patient
has his dentures
[**2152-2-23**] tube feed converted to cycling. discharged to rehab.
stable
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) 42**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2152-2-23**]
|
[
"287.5",
"112.2",
"401.9",
"276.2",
"427.31",
"518.0",
"557.0",
"486",
"293.0",
"305.1",
"518.5",
"440.22",
"305.00",
"571.2",
"557.1",
"577.0",
"349.82",
"998.13",
"250.00",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"33.24",
"96.6",
"39.26",
"93.59",
"96.72",
"38.93",
"39.25",
"31.1",
"39.59",
"96.04",
"99.15",
"43.11",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
9481, 9720
|
1123, 1214
|
7403, 9458
|
6796, 7382
|
1241, 1336
|
1901, 6772
|
1359, 1883
|
497, 716
|
138, 155
|
184, 477
|
739, 928
|
945, 1106
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,856
| 157,076
|
6919
|
Discharge summary
|
report
|
Admission Date: [**2198-2-8**] Discharge Date: [**2198-2-22**]
Date of Birth: [**2116-2-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Wheezing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 81 yo man with history of GERD s/p fundoplication,
HTN, Charcot-[**Doctor Last Name **]-Tooth disease who presents to the Emergency
Department with worsening shortness of breath. Patient states
that for the past 2-3 weeks he has had worsening shortness of
breath. Patient describes this as wheezing which can last
'through the night'. These episodes can occur when walking to
the bathroom or at rest. He has never had wheezing before. He
denies any recent, chest pain, palpitations, nausea, vomiting,
radiating pain, peripheral edema, PND, orthopnea. He does sleep
with 2+ pillows but he does this for his GERD. He also denies
any recent abdominal pain, diarrhea, dysuria, urinary frequency.
In the ED, initial vs were: T 98.1, HR 53, BP 165/93, RR 24.
Patient was given ASA 325 mg, NS IVF at 100cc/hr. Patient had an
acute episode of hypoxia requirng BIPAP. He was given Solumedrol
125 mg IV, Levaquin 750 mg, Ceftriaxone 1 gm IV. ECG done which
showed ? q waves in V1,V2. Cardiac biomarkers were drawn and
Troponin-T was elevated at 0.34 with normal CK of 62. Heparin
gtt was started for concern of acute coronary syndrome. Patient
sent for CTA, which was negative for pulmonary embolus, but
showed ? bibasilar consolidations consistent with aspiration vs
atelectasis. Patient then went into atrial fibrillation with
rapid ventricular response and was given diltiazem 10 mg IV x 1
then started on a diltiazem gtt. He ws also given Lopressor 5 mg
IV without resolution of tachycardia. Lasix 10 mg IV also given
in ED. Patient required BIPAP for 1 hour in ED and was then
placed on face tent O2.
Past Medical History:
GERD s/p fundoplication [**2175**]
Hypertension
Charcot-[**Doctor Last Name **]-Tooth Disease (hereditary motor and sensory
neuropathy (HMSN) or peroneal muscular atrophy)
Pancreatitis
Laminectomy
Social History:
Retired. Denies tobacco, EtOH or illicit drug use
Family History:
Uncles with CAD
Physical Exam:
General: Alert, oriented elderly Caucasian man in mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: +crakles at both bases, no wheezing
CV: irregular 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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs
[**2198-2-8**] 03:00PM BLOOD WBC-3.9* RBC-3.40* Hgb-10.8* Hct-30.8*
MCV-91 MCH-31.8 MCHC-35.1* RDW-17.3* Plt Ct-183
[**2198-2-8**] 03:00PM BLOOD PT-14.3* PTT-28.4 INR(PT)-1.2*
[**2198-2-8**] 03:00PM BLOOD Glucose-115* UreaN-33* Creat-0.8 Na-140
K-4.4 Cl-100 HCO3-31 AnGap-13
[**2198-2-8**] 03:00PM CK(CPK)-62 cTropnT-0.34*
[**2198-2-8**] 10:50PM CK(CPK)-40 cTropnT-0.25*
[**2198-2-9**] 02:28AM CK-MB-4 cTropnT-0.23*
[**2198-2-9**] 10:15AM CK(CPK)-55
[**2198-2-10**] 02:08AM CK(CPK)-50 CK-MB-NotDone cTropnT-0.46*
[**2198-2-10**] 10:03AM CK(CPK)-75 CK-MB-NotDone cTropnT-0.48*
[**2198-2-10**] 06:31PM CK(CPK)-49 CK-MB-NotDone cTropnT-0.57*
[**2198-2-9**] 06:07PM BLOOD proBNP-[**Numeric Identifier 26053**]*
[**2198-2-9**] 02:28AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.5 Cholest-118
[**2198-2-9**] 02:28AM BLOOD Triglyc-63 HDL-36 CHOL/HD-3.3 LDLcalc-69
[**2198-2-10**] 10:03AM BLOOD calTIBC-204* VitB12-1104* Folate-12.3
Ferritn-478* TRF-157*
[**2198-2-9**] 02:28AM BLOOD TSH-0.94
[**2198-2-13**] 08:13AM BLOOD %HbA1c-5.5
Discharge Labs
[**2198-2-22**] 07:30AM BLOOD WBC-3.0* RBC-3.09* Hgb-9.3* Hct-27.0*
MCV-87 MCH-30.0 MCHC-34.3 RDW-18.3* Plt Ct-163
[**2198-2-22**] 07:30AM BLOOD PT-36.9* PTT-50.0* INR(PT)-3.9*
[**2198-2-22**] 07:30AM BLOOD Glucose-104 UreaN-18 Creat-1.0 Na-140
K-4.5 Cl-101 HCO3-32 AnGap-12
[**2198-2-15**] 06:00AM BLOOD ALT-22 AST-28 LD(LDH)-256* AlkPhos-93
TotBili-0.4
[**2198-2-10**] 10:03AM BLOOD calTIBC-204* VitB12-1104* Folate-12.3
Ferritn-478* TRF-157*
[**2198-2-15**] 09:59AM URINE RBC->50 WBC-[**6-13**]* Bacteri-MOD Yeast-NONE
Epi-0-2
[**2198-2-9**] 03:54AM URINE RBC-201* WBC-31* Bacteri-FEW Yeast-NONE
Epi-0
Micro
Blood cultures x 4, urine cx, sputum cx no growth
EKG: Irregular rate and rhythm, T wave flattening I-III. T wave
inversions V1-V5. qwaves V1-V2.
CXR [**2198-2-8**]
Study is limited by lordotic positioning. Heart size is within
normal limits given technique. The mediastinal silhouette is
within normal limits. Pulmonary vascularity is normal. Lungs are
clear. No effusion or pneumothorax detected however the extreme
left costophrenic angle not included on this radiograph.
Numerous surgical clips are present within the upper abdomen
from nissen procedure.
CTA Chest [**2198-2-8**]
No thoracic aortic dissection is identified. No filling
defects within the pulmonary arteries to suggest acute pulmonary
embolism. There are no pathologically enlarged axillary,
mediastinal or hilar lymph nodes per CT size criteria. A small
pericardial effusion is present. Moderate coronary artery
calcifications.
Evaluation of the lungs demonstrates bibasilar consolidations,
right greater than left with impacted endobronchial secretions
and peribronchial thickening. A trace left pleural effusion is
noted.
Evaluation of the upper abdomen is limited; however, evidence
of a laparoscopic Nissen with multiple surgical clips noted.
There is herniation of the proximal portion of the laparoscopic
Nissen consistent with a small hernia.
No suspicious lytic or sclerotic lesions identified. At the
T11/T12 vertebral bodies, there is severe intervertebral body
disc space narrowing and vacuum phenomenon. Significant
sclerosis of these vertebral bodies present with erosion at the
endplates.
CT Abdomen/Pelvis [**2198-2-18**]
There is a trace pericardial effusion vs. pericardial
thickening that is unchanged from the recent CTA of the chest of
[**2-8**]. There remains evidence of bibasilar aspiration, with
patchy bibasilar opacities, flecks of barium in the medial right
lower lobe, and bronchial wall thickening. Opacities have
actually improved since [**2-8**]. The small herniation of the
laparoscopic Nissen at the thorax is unchanged from [**2-8**]
as well.
Images in the abdomen and pelvis are degraded by streak
artifact due to high-density material in the colon, and due to
multiple clips near the gastroesophageal junction. The
non-contrast appearance of the liver, gallbladder, pancreas, and
adrenal glands are unremarkable. The spleen is mildly enlarged,
measuring about 14.1 cm in diameter.
Kidney and urologic evaluation is quite limited for technical
reasons already described. There is no hydronephrosis. No
calculi are seen in the kidneys.
No mass lesions are detected, though the evaluation is
incomplete without IV contrast. The stomach is moderately
distended. Small bowel loops are unremarkable. Barium is
retained throughout the colon. No free air or free fluid in the
abdomen is visualized. Air is seen in the left anterior
abdominal wall subcutaneous tissues, possibly related to
injection. Hyperdense material is seen in the musculature of the
left paramedian anterior abdominal wall, possibly representing
calcified suture. Inside the left anterior abdomen there is a
tubular dense structure just anterior to the stomach oriented in
a craniocaudal direction, which may represent a calcified
vessel.
CT OF THE PELVIS WITHOUT IV CONTRAST: Detail is markedly
obscured due to streak artifact from bowel contrast. There is a
Foley catheter within the bladder, and air within the bladder
likely related to instrumentation. There are calcifications in
the prostate, mild. The rectum is filled with stool and is
otherwise unremarkable. No free fluid in the pelvis, and no
pathologically enlarged pelvic or inguinal nodes.
BONE WINDOWS: There are advanced degenerative changes of the
lumbar spine. The patient is post-bilateral L4-5 and partial S1
laminectomies. There is intervertebral disc space narrowing at
all levels, multiple Schmorl's nodes, large anterior
osteophytes, and degenerative endplate changes.
Barium esophagram [**2198-2-12**]
Evaluation of chest radiographs performed one day prior shows
multiple surgical clips projecting over the epigastric and left
upper abdominal regions. The patient was positioned upright at
approximately 80 degrees, in the left posterior oblique
position. During the initial swallow of thick barium, oral
contrast was seen not only descending the esophagus, but also
the trachea, predominantly into a right lower lobe bronchus,
with a trace amount also seen within the left bronchus. Views of
the esophagus show no gross abnormality. However, the study was
very limited as no further contrast was administered.
Video Swallow [**2198-2-13**]
Oral bolus formation, AP tongue movement, and oral transit times
were within functional limits. Bolus control was mildly reduced
with intermittent premature spillover with thin and nectar thick
liquids. No significant oral cavity residue remained after the
swallow. During the pharyngeal phase, there was mild delay in
swallow initiation with liquids. Once started, palatal
elevation, laryngeal elevation, and epiglottic deflection were
complete. Laryngeal valve closure was mildly reduced. Pharyngeal
transit was timely with mild reduced bolus propulsion. Mild
amount of residue remained within the valleculae and piriform
sinuses after swallowing all consistencies. However, the patient
cleared the residue with spontaneous repeat swallows. Esophageal
sphincter opening was mildly reduced at the height of the
swallow. The patient was seen to aspirate before, during and
after the swallow once during administration of thin liquids
using a straw due to premature spillover and swallow delay.
Aspiration was silent and cued coughs were ineffective at
clearing the aspirate.
IMPRESSIONS: Mild-to-moderate oropharyngeal dysphagia, with
aspiration seen before, during, and after the swallow due to
premature spillover, swallow delay, and residue in the piriform
sinuses. While aspiration with thick liquids was not reproduced
today, the patient aspirated on thin liquids. Both episodes
occurred during consecutive sips of liquid.
For further treatment techniques and dietary recommendations,
please refer to speech and swallow pathology note on CareWeb.
Echo [**2198-2-9**]
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
severe hypokinesis/akinesis of the distal 2/3rds of the anterior
septum and anterior wall and distal inferior wall. There is an
apical left ventricular aneurysm. The remaining segments
contract normally (LVEF = 30-35 %). No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild-moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with apical
aneurysm and extensive regional dysfunction c/w CAD (mid-LAD
distribution). Moderate mitral regurgitation. Pulmonary artery
systolic hypertension. Dilated ascending aorta.
P-MIBI [**2198-2-14**]:
Left ventricular cavity size is mildly enlarged, and does not
enlarge further with stress. Rest and stress perfusion images
reveal a moderate-severity fixed mid/distal anterior and
anteroseptal wall defect and a severe fixed apical defect. Gated
images reveal akinesis of the apex with mild global hypokinesis.
The calculated left ventricular ejection fraction is 35%.
PFTs [**2198-2-22**]
FEV1 2.13, FVC 3.53, FEV/FVC 60% MMF 0.95
TLC 4.83 FRC 2.84 RV 2.07
Although the reduced TLC is consistent with a mild restrictive
ventilatory defect, TLC may be underestimated due to a
suboptimal SVC maneuver. There is a mild to moderate gas
exchange defect. There are no prior studies available for
comparison.
Brief Hospital Course:
81 yo man with history of GERD s/p fundoplication, Hypertension,
Charcot [**Doctor Last Name **] Tooth disease with acute on chronic aspiration
pneumonitis/pneumonia, now with acute on chronic systolic heart
failure, elevated troponin consistent with NSTEMI.
# Acute on chronic aspiration pneumonia/Respiratory Distress:
Improved after initial MICU stay. Patient has signs of acute on
chronic aspiration on CT chest, with concern for pneumonia given
consolidation on CT scan. Aspiration is likely secondary to
known GERD. He also has evidence of pulmonary edema on CXR with
a BNP of >16,000 so CHF also a contributer. Tracheomalacia is
being worked up as an outpatient. Patient had required
intermittent BIPAP initially but he remained off BiPAP after
24-48 hours. He was treated with 7 day course of Levofloxacin.
Oxygen saturations remained mid 90s prior to discharge off
supplemental oxygen. He had no further complaints of shortness
of breath. He was initially diuresed with Lasix 20-40mg PO daily
but this was discontinued since patient appeared euvolemic with
borderline low BPs as discussed below. He had PFTs prior to
discharge since was started on Amiodarone. He should maintain
aspiration precautions with PO intake as instructed in dietary
discharge instructions.
# NSTEMI: Patient had NSTEMI on admission with T wave
flattening I-III, T wave inversions V1-V5. He was treated with
aspirin as well as heparin gtt for NSTEMI and atrial
fibrillation. NSTEMI likely secondary to demand ischemia in
setting of tachycardia. Anticoagulation was then transitioned to
Coumadin with lovenox bridge. He was also started on statin. He
was initially on beta blocker but this was held seocndary to
bradycardia with HR 50s as well as initial concern for
bronchospasm. Given his comorbidities, he was not felt to be a
good candidate for CABG (as multivessel CAD was likely given his
LV systolic heart failure). A conservative risk stratification
strategy was undertaken, and a pharmacological stress test
showed moderate fixed mid/distal anterior and anteroseptal
defect, and severe fixed apical defect. As no objective evidence
of residual post-infarct ischemia was found, revascularization
was not pursued, and his CAD was treated medically.
# Atrial Fibrillation/Flutter: Patient with no prior history of
atrial fibrillation. It was thought that initial episode was
secondary to aspiration pneumonia, but he had recurrent episode
in hospital and was transferred back to CCU where he was started
on amiodarone. Per their report, he was not interested in an
ablative procedure. He remained in sinus rhythm after being
started on amio with no further episodes of SVT. He was
initially maintained on metoprolol 12.5 mg [**Hospital1 **] but this was
discontinued secondary to bradycardia. Regarding Coumadin
dosing, he was started on Coumadin 2 mg daily. This was changed
to 1 mg daily on [**2198-2-18**] since INR rapidly became therapeutic
and can interact with amiodarone. On [**2198-2-22**], INR 3.9 so
Coumadin held. He should have close daily monitoring of INR to
determine when to restart Coumadin (at 0.5-1mg daily). Goal INR
[**2-6**] for atrial fibrillation as well as LV aneurysm on echo. He
will complete [**Hospital1 **] dosing of amiodarone x 7 days (4 more days)
after [**2-22**] then should continue daily dosing.
# Acute systolic heart failure: Patient with acute LV systolic
heart failure (LVEF 30-35%) with no previous data in our system.
We attempted to optimize a heart failure regimen with low dose
lisinopril, beta blocker, and Lasix. However, he had poor PO
intake in house with hypotension with SBP 90s which dropped to
80s when we tried to reinitiate these meds. He was also
bradycardic HR 50s-60s. Would recommend adding back captopril
6.25 mg TID as BP tolerates. If he tolerates ACE-I, would then
consider adding Imdur. Will also need daily assessment of volume
status and oxygen saturations to determine if needs diuresis.
# GERD: Continued on PPI. Dr. [**First Name (STitle) 679**] following. Dr. [**First Name (STitle) 679**] would
like to perform endoscopy after cardiac issues have resolved.
# Hematuria: Patient developed hematuria on admission with
presumed Foley trauma in the setting of anticoagulation. Urine
cytology was negative. CT urogram was performed but was
nondiagnostic. He was continued on continuous bladder irrigation
which was titrated to light pink urine then clamped on [**2198-2-21**].
He had voiding trial on [**2198-2-22**] which he passed. He will follow
up with urology.
Code: Full
Medications on Admission:
Omeprazole 20 mg daily
ASA 81 mg daily
Motilium 10 mg daily
Levothyroxine 75 mcg daily, recently stopped
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 days: After 5 days, please change to once daily
dosing.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO three times a
day: Please hold for SBP<90.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses
Aspiration Pneumonia
Atrial fibrillation/flutter
Non ST elevation myocardial infarction
Coronary artery disease
Acute left ventricular systolic heart failure
Braydcardia
Hypotension
Hematuria
Secondary Diagnosis
Gastroesophageal reflux with prior fundoplication
Hypertension
Charcot-[**Doctor Last Name **]-Tooth Disease
Discharge Condition:
Hemodynamically stable, afebrile, voiding without difficulty,
hematuria resolved
Discharge Instructions:
You were admitted to the hospital with pneumonia and a fast and
irregular heart rate. This caused increased demand on your heart
and you had a small heart attack. Your pneumonia was treated
with antibiotics. Your irregular rhythm was treated with a
medication called amiodarone. We also started you on a blood
thinning medication called coumadin to prevent strokes which can
happen with irregular heart rhythyms. You will need to have
blood levels monitored very closely while you are on coumadin.
We tried treating you with medications for your heart disease
but were limited by your slow heart rate and low blood pressure.
While you were in the hospital, you also had blood in your
urine, most likely from being on blood thinning medications. You
had a foley catheter which was irrigating your bladder which was
discontinued on [**2198-2-22**] and you voided without difficulty prior
to discharge.
We made the following changes to your home medications
1. We icnreased your aspirin to 325 mg daily
2. We increased your omeprazole to twice daily dosing
3. We added captopril which should be slowly added to your
medications regimen as your blood pressure tolerates. If your
blood pressure tolerates, you should take 6.25 mg three times
daily. If your systolic blood pressure is still >95, you should
also add Imdur or a beta blocker as determined by your
outpatient physician.
4. We added Coumadin. You were initially on 2mg daily, then 1 mg
daily. We held your coumadin on [**2198-2-22**] and you will need to
have your INR checked to determine when to restart it. Goal INR
[**2-6**].
Followup Instructions:
Please follow up with urology. You have an appointment with Dr.
[**Last Name (STitle) **] [**Last Name (STitle) **] [**Name (STitle) 766**] [**3-5**] at 10:30am. Their clinic is located in
[**Hospital Ward Name 23**] Bldg at [**Hospital1 18**] on the [**Location (un) 470**]. Call [**Telephone/Fax (1) 921**] if you
have any questions regarding this appointment.
Please follow up with Dr. [**First Name (STitle) 437**] regarding your heart failure.
You have an appointment with him on [**3-19**] at 11am. Their
office is located in the [**Hospital Ward Name 23**] Building ont he [**Location (un) 436**].
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 1040**] Date/Time:[**2198-2-20**]
4:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 682**] Call to schedule appointment
[**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339
|
[
"867.0",
"427.31",
"410.71",
"428.23",
"599.70",
"577.1",
"285.29",
"280.9",
"E928.9",
"414.01",
"V58.61",
"428.0",
"401.9",
"427.32",
"356.1",
"414.8",
"507.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17858, 17937
|
12662, 17205
|
323, 329
|
18320, 18402
|
2773, 12639
|
20038, 21063
|
2271, 2288
|
17360, 17835
|
17958, 18299
|
17231, 17337
|
18426, 20015
|
2303, 2754
|
275, 285
|
357, 1967
|
1989, 2187
|
2203, 2255
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,387
| 129,649
|
26792
|
Discharge summary
|
report
|
Admission Date: [**2172-5-15**] Discharge Date: [**2172-5-24**]
Date of Birth: [**2123-9-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Recurrent right pleural effusion
Major Surgical or Invasive Procedure:
1. Right thoracoscopy
2. Right thoracotomy with partial lung decortication
3. Talc pleurodesis
4. Flexible bronchoscopy
History of Present Illness:
Ms. [**Known lastname 58457**] is a 48 year old woman with hepatitis C induced
cirrhosis. She developed a large right effusion over a year ago
and was treated with a PleurX catheter with continuous drainage.
She was referred for further management at that time. She
underwent a thoracoscopy with partial lung decortication and a
mechanical as well as talc pleurodesis. Postop course was
complicated by a Staph aureus pleural infection. Ultimately she
had a reasonably good result but recently has had progressive
dyspnea once again and was found to have recurrence of her right
sided pleural effusion. CT imaging demonstrated a fibrothorax as
well and trapped lung.
After long discussions about a high risk of recurrence and
the fact that she needs a liver transplant, she decided she did
not want to continue to live dyspneic as she is and is willing
to move forward with surgery, understanding that there is a high
risk of
recurrence. Due to the fact that she has a high PT it was
elected not to place an epidural. Her BUN and creatinine were
elevated preoperatively. Her hepatologist, Dr. [**First Name (STitle) **], felt this
was due to her aggressive diuresis. He felt it was okay to move
forward with surgery.
Past Medical History:
1. Hep C with variceal bleed s/p band
2. 30ppy Tobacco
3. h/o EtOH use
4. recurrent pleural effusion. Pleurx catheter placement and
management of recurrent pleural effusion. s/p VATS decort,
pleurodesis [**2170**]
Social History:
Lives alone in 2 story home, bed and bath upstairs. 30ppy
smoking history.
Family History:
father - COPD
Pertinent Results:
Post-op:
[**2172-5-15**] 12:29PM WBC-7.6 RBC-3.85* HGB-11.4* HCT-33.1* MCV-86
MCH-29.7 MCHC-34.5 RDW-13.6
[**2172-5-15**] 12:29PM PLT COUNT-117*
[**2172-5-15**] 12:29PM GLUCOSE-143* UREA N-48* CREAT-1.4* SODIUM-134
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-11
[**2172-5-15**] 12:29PM CALCIUM-8.2* PHOSPHATE-3.5 MAGNESIUM-2.0
.
MICRO:
[**2172-5-15**] 9:15 am PLEURAL FLUID RIGHT PLEURAL FLUID.
GRAM STAIN (Final [**2172-5-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2172-5-18**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2172-5-21**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
PATHOLOGY:
DIAGNOSIS:
Right pleural tissue:
Fibrous tissue with extensive foreign body giant cell reaction
with associated polarizable foreign material.
Focal reactive mesothelial hyperplasia.
Small fragment of lung parenchymal tissue.
No malignancy identified.
Cytology:
DIAGNOSIS: Pleural fluid, right:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes, monocytes, macrophages and rare mesothelial
cells.
.
IMAGING:
[**5-15**] CXR:
CLINICAL HISTORY: Status post decortication on the right chest.
CHEST: Post-op chest shows position of two chest tubes on the
right side in satisfactory position and resolution of the
pre-operative right effusion. Blunting of the right costophrenic
angle is present. No pneumothorax is identified. The left lung
is clear, some atelectasis is seen on the right side.
IMPRESSION: Chest tubes in satisfactory position. Resolution of
effusions. No pneumothorax.
.
[**5-16**] CXR:
IMPRESSION: AP chest compared to [**5-15**] and 2 at 5:39 a.m.:
Lung volumes only mildly lower following tracheal extubation.
Right pleural tube is unchanged in position. Little if any right
pleural effusion has accumulated, and there is no pneumothorax.
Heart size normal. Right basal atelectasis is more pronounced.
Left lung grossly clear. Subcutaneous emphysema in the right
neck has increased and needs to be followed to exclude a
communication between the pleural space and subcutaneous
tissues.
Gaseous distention of the stomach persists. Heart size normal.
.
[**5-17**] CXR:
Single portable radiograph of the chest demonstrates no interval
change in the three right-sided chest tubes seen on [**2172-5-16**].
There is a small right-sided pneumothorax, slightly more
conspicuous than seen previously. Right basilar atelectasis
persist. Left lung is clear. No left-sided pleural effusion.
Trachea is midline. Subcutaneous emphysema is again noted. No
consolidation is evident.
.
[**5-18**] CXR:
IMPRESSION: AP chest compared to [**5-15**] through [**5-17**]:
Low lung volumes suggest this film was taken at suboptimal
inspiration accounting for worsening atelectasis in the region
of surgery at the base of the right lung. There is no
appreciable right pneumothorax. A small amount of right pleural
thickening or fluid along the lateral costal pleural surface is
stable. Small left pleural effusion is new or newly apparent and
there is increasing atelectasis at the left base. The upper
lungs are grossly clear, the heart is normal size, and the
mediastinum midline. Subcutaneous emphysema in the right chest
wall and right neck is stable.
.
[**5-20**] CXR:
CHEST PA AND LATERAL: Cardiac, mediastinal and hilar contours
are within normal limits. Pulmonary vasculature is unremarkable.
The appearance of the right chest is stable with three chest
tubes in place. Two of the chest tubes appear somewhat acutely
angulated. Right lateral lower lung opacities are again
identified. Adjacent subcutaneous emphysema is improved. The
left lower lobe atelectasis and possible small effusion is
improved. Osseous and soft tissue structures are unremarkable.
IMPRESSION: Slight interval improvement in post-operative
appearances.
.
[**5-21**] CXR:
HISTORY: Right thoracotomy and decortication.
3 chest tubes are present in the hemithorax as previously
demonstrated with subcutaneous emphysema in the right chest
wall. No pneumothorax. Pleural effusion or thickening is present
in the right costophrenic region and focal asymmetric pleural
density at the right lung apex, unchanged. Atelectasis at the
right lung base. The left lung remains clear.
.
[**5-22**] CXR:
Portable AP chest radiograph compared to [**2172-5-21**].
One of the two right chest tubes has been removed, the lower
one. Minimal apical pneumothorax is still present. No
significant change in the right pleural thickening/effusion and
atelectasis of the adjacent lung is demonstrated. The rest of
the lung is unremarkable. The cardiomediastinal silhouette is
stable. No increase in pleural effusion is demonstrated.
IMPRESSION: Minimal residual apical pneumothorax on the right.
No change after discontinuation of one of the chest tubes.
Brief Hospital Course:
Ms. [**Known lastname 58457**] was admitted on [**2172-5-15**] after a decortication and
mechanical pleurodesis. For details of the procedure please see
the operative report. Of note, the procedure was unable to be
completed thoracoscopically necessitating a right thoracotomy.
She tolerated the procedure well and was admitted to the SICU
postoperatively intubated. 2 chest tubes and a tunneled pleurex
catheter were left in place postoperatively. Both chest tubes
were placed to suction with an air leak noticed immediately.
She was extubated without difficulty on POD1. Post operatively
she was noted to be tachycardic with a heart rate ranging from
115-130. This was noted to be a sinus tachycardia and as her
blood pressure was stable and she was not hypoxic it was felt to
be secondary to pain and hypovolemia. She continued to be
tachycardic after adequate volume resusciation, but she
continued to have significant difficulties with pain control.
Once her pain was stablized on her home regimen of oxycontin and
lamotrigine the tachycardia resolved. Postoperatively her renal
function was stable with a creatinine of 1.4 initially on POD1.
She was restarted on her lasix but her aldactone was held. She
was also started on salt tabs and a fluid restriction once
adequate resuscitated for hyponatremia (sodium as low as 128).
This remained stable throughout her hospital stay and she was
restarted on aldactone on POD 6. Both chest tubes remained on
suction postoperatively for several days in order to ensure full
expansion and adhesion formation of the right lung. The air
leak resolved after several days and the CT output was minimal
at the time of removal. One CT was removed on POD 7 and the
second was removed on POD 8 with only a small, stable apical
pneumothorax noted after removal. After removal of the second
chest tube, the pleurex catheter was attached to pleurovac on
suction. At the time of discharge on POD9 the pleurex catheter
was capped and her pain was adequately controlled. She was
ambulating without difficulty and tolerating a regular diet.
Medications on Admission:
1. Maphyton 10mg qDay
2. Lactulose 2mg/day
3. Slow Mag 64mg [**Hospital1 **]
4. Oxycontin 80mg q8hours
5. Lamotrigine 100mg [**Hospital1 **]
6. Lasix 60mg qDay
7. Protonix 40mg qDay
8. Spironolactone 200mg qDay
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
Discharge Diagnosis:
Recurrent right pleural effusions
Hepatitis C
Discharge Condition:
Good
Discharge Instructions:
Call your doctor [**First Name (Titles) **] [**Last Name (Titles) 5162**] greater than 101F, chills, worsening
chest pain not controlled by pain medication, shortness of
breath, worsening redness/discharge from incisions or other
symptoms concerning to you.
You may remove the dressings tomorrow, [**5-25**]. You may place a
bandaid over the CT sites if there is any drainage present. Do
not remove the steristrips, they will fall off on their own.
You will be discharged home with a pleurex catheter in place.
You may shower tomorrow after the dressing is removed. Cover
the catheter when showering. Do not tub bathe or swim while the
pleurex catheter is in place. No heavy lifting, greater than 15
lbs, for 4 weeks. Do not drive while taking narcotic pain
medication.
Drain the pleurex catheter once a day.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 952**], call office for an appointment.
([**Telephone/Fax (1) 1504**].
Follow up with your hepatologist, Dr. [**First Name (STitle) **] in [**1-18**] weeks.
Follow up with your primary care doctor in [**1-18**] weeks.
Completed by:[**2172-5-24**]
|
[
"998.81",
"571.2",
"785.0",
"511.0",
"303.93",
"518.0",
"070.70",
"V64.42",
"530.81",
"511.9",
"276.1",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.51",
"33.22",
"34.09",
"34.92"
] |
icd9pcs
|
[
[
[]
]
] |
9866, 9923
|
6969, 9058
|
361, 487
|
10013, 10020
|
2114, 2764
|
10885, 11175
|
2080, 2095
|
9319, 9843
|
9944, 9992
|
9084, 9296
|
10044, 10862
|
2797, 6946
|
289, 323
|
515, 1733
|
1755, 1971
|
1987, 2064
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,892
| 153,259
|
16025
|
Discharge summary
|
report
|
Admission Date: [**2114-12-7**] Discharge Date: [**2114-12-12**]
Date of Birth: [**2073-4-21**] Sex: M
Service: UROLOGY
Allergies:
Aloe / Levaquin / Tape / Penicillins
Attending:[**First Name3 (LF) 824**]
Chief Complaint:
left renal stone
Major Surgical or Invasive Procedure:
Percutaneous nephrolithotomy
History of Present Illness:
41M with MS, neurogenic bladder, h/o drug resistant UTIs,
underwent percutaneous nephrolithotomy/nephrolithotripsy today.
Urology team noted frank pus in the collecting system, and given
his history resistant UTIs, started broad spectrum antibiotics
and requested ICU monitoring. He is only able to give a limited
history due to MS; details are from the medical record.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, vision changes,
headache, rash or skin changes.
Past Medical History:
multiple sclerosis
neurogenic bladder s/p suprapubic catheter
multiple urinary tract infections with multi-drug resistant
organisms
Social History:
Married, lives with wife. no tobacco, no illicits.
Family History:
Non-contributory.
Physical Exam:
Vitals: T:98.7 BP:136/97 HR:101 RR:20 O2Sat:97% 2L
GEN: Well-appearing, well-nourished, white male
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: L nephrostomy tube draining blood urine, suprapubic
catheter draining clear urine. Soft, NT, ND, +BS, no HSM, no
masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. Gait not tested but wheelchair bound at baseline.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2114-12-7**] 07:07PM GLUCOSE-98 UREA N-13 CREAT-0.9 SODIUM-139
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
[**2114-12-7**] 07:07PM WBC-10.5 RBC-5.15 HGB-14.4 HCT-42.5 MCV-83
MCH-28.0 MCHC-34.0 RDW-14.8
[**2114-12-7**] 07:07PM PT-12.9 PTT-36.9* INR(PT)-1.1
Laboratories: Urine sent at time of nephrostomy placement was
frank pus per urology team, culture pending.
Brief Hospital Course:
41 year-old male with MS and history of urosepsis with multidrug
resistant organisms, now s/p L perc nephrostomy and lithotripsy,
admitted for ICU monitoring due to concern over purulent urine
in collection system/high risk of urosepsis.
# s/p nephrostomy:
given history of urinary tract infections and high risk after
manipulation, will cover broadly with abx, ie vancomycin 1gm
q12hrs and ceftazidime 1gm q8hrs
- blood culture if spikes fever
- f/u intra-op urine culture from collection system
- urinary analgesics and antispasmodics recommended by urology
- prn morphine for post-procedure pain
# MS: Not currently active; continue home baclofen for pain
control
# FEN: npo except meds for now, adat; maintenance IVF with D5
1/2NS until taking adequate pos; check and replete lytes
# Access: PIV
# PPx: home famotidine, heparin sub-q, bowel regimen
# Code: full
[**2114-12-7**]:
- Sinus tach to 129
- Spiked to 101.1, asymptomatic, bps stable
Transferred to floor on POD 1
The patient was admitted to Dr.[**Name (NI) 825**] Urology service after
percutaneous nephrolithotripsy. No concerning intraoperative
events occurred; please see dictated operative note for details.
He patient received peri-operative antibiotic prophylaxis with
ceftazidime and vancomycin. CT scan identified some residual
nephrolithisis. An ID consult was called for assistance with his
antibiotic regimen and he had a midline placed for antibiotics.
On POD 3 nephrostommy tube was removed. He was having leakage
from his nephrostomy tube site and a stitch was placed. His
urine was clear yellow without clots from his suprapubic tube.
He remained afebrile throughout his hospital stay. At discharge,
patient's pain well controlled with oral pain medications,
tolerating regular diet. He was discharged with 2 weeks of IV
ceftazadime and oral bactrim. He is given explicit instructions
to f/u with Infectious disease and to have a repeat urine
culture and urinalysis after his 2 week course of antibiotics.
He is to call Dr. [**Last Name (STitle) 770**] for follow-up and removal of his
nephrostomy tube site stitch
-
Medications on Admission:
baclofen 20mg 5 times a day
oxybutynin 10mg qhs
famotidine 20mg [**Hospital1 **]
MVI
Vit C tid
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO 5X/D ().
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)).
5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for consitpation.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
10. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
Disp:*1000 ML(s)* Refills:*0*
11. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous every
eight (8) hours.
Disp:*90 syringes* Refills:*0*
12. Ceftazidime 2 gram Recon Soln Sig: Two (2) grams recon soln
Injection Q12H (every 12 hours) for 10 days.
Disp:*40 grams recon soln* Refills:*0*
13. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
left renal stone
Discharge Condition:
stable
Discharge Instructions:
- resume medications
- antibiotics x 10 day
- urinalysis and urine culture after completion of antibiotics
- follow up with Infectious disease and Urology in [**1-9**] weeks
Followup Instructions:
1. Infectious disease in 2 weeks
2. Dr. [**Last Name (STitle) 770**] in [**1-9**] weeks
Completed by:[**2114-12-12**]
|
[
"427.89",
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"596.54",
"340"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.32",
"59.8",
"55.21",
"55.04"
] |
icd9pcs
|
[
[
[]
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6215, 6270
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2585, 4690
|
313, 343
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6330, 6338
|
2178, 2562
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4835, 6192
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6291, 6309
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4716, 4812
|
6362, 6537
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1338, 2159
|
257, 275
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371, 1064
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1086, 1219
|
1235, 1288
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,546
| 128,101
|
36447
|
Discharge summary
|
report
|
Admission Date: [**2104-7-14**] Discharge Date: [**2104-7-28**]
Date of Birth: [**2028-5-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
membramous glomerulonephritis
anasarca
Major Surgical or Invasive Procedure:
CVVH
History of Present Illness:
76 yo M with MGN, CKD, and hypothyroidism presents with
anasarca, RUE erythema and weakness. Patient is followed by
nephrologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] since [**2103-10-7**], who received a
phone call today . Patient had a biopsy in [**2104-4-5**] and was
started on prednisone. He was seen [**2104-7-8**] and was started on
Cytoxan the following day. Of note, he was admitted for similar
complaints in [**2104-6-5**] at [**Location (un) 620**]. His lasix was initially
held, and then restarted prior to discharge. At that time Cr was
3.4 on discharge.
.
Patient was in his USOH when he developed weakness, reduced po
intake, and total body pain last week within 1 day of starting
Cytoxan. At baseline, he ambulates with a walker, but he was so
tired on Friday that he could barely walk with in home PT.
Patient also reports reduced po intake since that time. Patient
reports some dyspnea with exertion, but no chest pain or
palpitations. Patient also reports a brief episode of abdominal
pain yesterday which lasted less than one minutes, was sharp and
periumbilical. Since then he has had no abdominal pain, and
denies nausea, vomitting, diarrhea. Also of note, patient
slipped and fell on his right wrist 3 weeks ago and developed
erythema in that area since last week. He was started on
bacitracin cream, and denies fevers, chills and tender
lymphadenopathy.
.
In the ED, patient was afenrile and noted to have diffuse
ansarca and RUE erythema the wrist. CT head was normal. CXR
showed no acute process. CT abdomen showed ascites and
cholethiasis. Patient received Cefazolin 1 g IV x1. On transfer,
VS were 98.9, 109, 132/71, 16, 100% on unclear amount of oxygen.
Past Medical History:
1. Membranous glomerulonephritis recently diagnosed, on
steroids, started cytoxan 8 days ago
2. CKD, stage 3 to 4.
3. Hypoalbuminemia / Anasarca.
4. Hypertension.
5. Bipolar disorder followed by psych.
6. spinal stenosis.
7. Hypothyroid.
8. Anemia of chronic disease.
9. Hyperlipidemia.
10. Elevated blood sugar while on steroids but his A1c was 5.9.
Social History:
Originally from [**Country 7192**]. Came to the US in [**2068**]. Lives in [**Location **] with his wife and son. Denies smoking, ethanol and IVDU. No
known chemical exposures. He is a retired minister. At baseline
uses a walker.
Physical Exam:
Vitals: T: 98.3 BP: 117/70 P: 104 R: 20 SaO2: 100% 4L
General: Tired appearing, Awake, alert, NAD, pleasant,
appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: pitting edema, soft, NT, ND, normoactive bowel sounds,
no masses or organomegaly noted
Extremities: 4+ pitting edema in all 4 extremities; 4x4 cm
eruthema at right wrist with small 2cm laceration which is well
healing
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Genital: extensive testicular swelling, non-tender
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x3 Cranial nerves II-XII intact. No
abnormal movements noted. No deficits to light touch throughout.
Pertinent Results:
[**2104-7-14**] 06:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2104-7-14**] 06:30PM URINE RBC-[**5-15**]* WBC-[**2-8**] BACTERIA-FEW
YEAST-NONE EPI-[**2-8**]
[**2104-7-14**] 06:30PM URINE GRANULAR-0-2 HYALINE-[**10-25**]*
[**2104-7-14**] 03:35PM GLUCOSE-95 LACTATE-1.1 NA+-138 K+-3.8
CL--113*
[**2104-7-14**] 03:35PM HGB-9.9* calcHCT-30
[**2104-7-14**] 03:30PM GLUCOSE-103* UREA N-61* CREAT-2.9* SODIUM-136
POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-15* ANION GAP-13
[**2104-7-14**] 03:30PM ALT(SGPT)-22 AST(SGOT)-18 CK(CPK)-36* ALK
PHOS-59 TOT BILI-0.2
[**2104-7-14**] 03:30PM CK-MB-3 cTropnT-0.04*
[**2104-7-14**] 03:30PM CALCIUM-7.0* PHOSPHATE-3.8 MAGNESIUM-2.8*
[**2104-7-14**] 03:30PM LITHIUM-1.2
[**2104-7-14**] 03:30PM WBC-6.9# RBC-2.97* HGB-9.5* HCT-29.7*
MCV-100* MCH-32.1* MCHC-32.1 RDW-16.9*
[**2104-7-14**] 03:30PM NEUTS-93.1* LYMPHS-5.5* MONOS-0.9* EOS-0.4
BASOS-0.1
[**2104-7-14**] 03:30PM PLT COUNT-214
[**2104-7-14**] 03:30PM PT-12.6 PTT-30.5 INR(PT)-1.1
[**7-14**] CT head: No acute intracranial process
[**7-14**] CT abd/pelvis:
1. Body wall edema, ascites, pleural effusions raise concern for
fluid
overload.
2. Cholelithiasis without evidence of cholecystitis.
3. Diverticulosis without evidence of diverticulitis.
[**7-16**] Renal U/S: No evidence of renal vein thrombosis
[**7-18**] RUE Duplex: Distal right brachial vein DVT. Remainder of
the upper extremity
veins, and the more proximal aspects of the right brachial vein
remain patent.
[**7-21**] CT abd/pelvis:
1. Subacute or chronic right retroperitoneal and psoas
hematomas. No
evidence for acute bleeding based on noncontrast examination.
2. Bilateral moderate pleural effusions with secondary
atelectasis.
Superinfection not excluded
3. Cholelithiasis.
[**7-23**]: RUE Duplex: Improvement in nonocclusive distal brachial
vein thrombus
Brief Hospital Course:
# Acute on chronic renal failure: Patient with progressively
worsening MGN with Cre from 2.2->3.9 this admission. Patient
failed Lasix drip for diuresis so was transferred to the MICU
for CVVH. He was thought to be a total 30 kg up from dry
weight. We started CVVH on Mr. [**Known lastname **], who tolerated it well.
We were able to dialyze a total of 15 kg off while in the MICU.
For the treatment of the MGN, we followed renal recs which were:
- complete 3 days of solumedrol 500 mg IV daily
- 50 grams of albumin IV daily concentrated
- cytoxan was restarted (with Bactrim ppx), then discontinued as
it was felt to be contributing to his generalized weakness on
admission, and renal advised that he would likely need
hemodialysis in the future and cytoxan would not reverse his
renal failure
- avoid nephrotoxins, renally dose all medications
- worried that pt is not absorbing PO lasix [**1-8**] gut edema, so
bumex added and titrated up, tolerated well.
- also, pt used to be on lithium, however as per renal, lithium
is associated with MGN, so pt taken off this med.
- UE venograms were done for possible future fistula placement.
- Finally, renal would also like a colonoscopy as an outpatient,
as they are worried there is a malignancy that could account for
the rapid progression of his MGN.
- As per renal, hepatitis serologies and a PPD was placed -
negative.
Unfortunately, CVVH had to be stopped after two days as the pt
had a Hct drop to 17 (rechecked and real). Please see below for
further explanation. After stopping, renal felt he could go
toward HD and UF, no longer requiring ICU level care. Renal
communicated with the patient's outpatient nephrologist, who
will see the patient after discharge and continue to monitor
labs. The patient will likely need hemodialysis in the future
and his outpatient nephrologist is aware and will discuss this
possibility with the patient and his family as it becomes
necessary.
.
# Altered Mental Status: Thought secondary to multifactorial
issues. Cultures were drawn and infectious etiology was
essentially ruled out. Also possible is his baseline behavioral
disorder which required lithium and risperdone.
- The pt was started on empiric abx, which were d/c'ed after he
stayed afebrile with no leukocytosis.
- changed psych meds to risperidone 1 mg PO BID, which has
worked well for him in the MICU.
- pt also has h/o neurocysticercosis. neuro thought very
unlikely that pt has reactivation as cysts have already formed
and pt's mental status improved on risperdal.
.
# Anemia (chronic and acute): Pt has chronic anemia thought [**1-8**]
many reasons: CKD vs. GIB vs. anemia of chronic disease vs.
cytoxan marrow suppression. iron studies sent which were
consistent with anemia of chronic disease. We continued EPO per
renal recs. He is guaiac positive, however has never had BRBPR
or evidence of brisk GI bleed, so GI was not consulted.
In terms of the acute bleed, the pt was anticoagulated for his
RUE DVT with a heparin gtt and was supratherapeutic by PTT (goal
of 60-80). His Hct dropped to 17 acutely and he was transfused
three units of PRBC. A CT Abd/Pelvis revealed an RP hematoma.
Vascular surgery was consulted who thought that if the pt is
unstable, IR should be consulted for urgent intervention.
We also transfused him prn (2 units today with a Hct of 22),
maintained an active type and screen, trended his Hcts (Q6H in
the setting of the acute bleed), and continued EPO. His hct
remained stable after transfusion until discharge. (see below)
.
# Hypothyroidism: An endocrine c/s was called who recommended
that we increase the dose to 175 mcg PO. A recheck of his TFTs
showed that we were going in the right direction.
- A TSH check is put in for tomorrow ([**7-23**]) as requested by
endo.
.
# Behavioral disorder: Pt is on lithium and risperidone as an
outpatient.
- Lithium d/c'ed given possible contribution to MGN.
- Risperidone started 1 mg POBID which has worked well for him
now.
.
# RUE erythema: thought [**1-8**] cellulitis, however a RUE US showed
a basilic vein DVT. We had started anticoagulation, but again,
stopped given his RP bleed. Given the risks associated with his
retroperitoneal bleed, and the fact that we were unable to use
lovenox because of his renal failure, the decision was made to
avoid anticoagulation at this time. This can be addressed again
in the future once the patient is far enough out from his
retroperitoneal bleed that rebleeding is not a risk.
Medications on Admission:
#Cytoxan 100 mg daily
# Risperdal 1 mg daily
# Fenofibrate 54 mg daily
# Lasix 80 mg daily
# Levothyroxine 150 mcg daily
# Lithium 150 mg daily
# Lorazepam 0.5 m g daily
# Aspirin 81 mg daily
# Docusate 200 mg daily
# Ergocalciferol 400 mg daily
# Pyridoxine B-6 100 mg daily
# Senna 4 capusles daily
# Fenofibrate 54 mg daily
# Risperdal 1 mg daily
Discharge Medications:
1. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week for 8 weeks.
Disp:*8 Capsule(s)* Refills:*0*
2. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) mL Injection
MWF (Monday-Wednesday-Friday).
Disp:*10 mL* Refills:*2*
4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Bumetanide 0.5 mg Tablet Sig: Three (3) Tablet PO q am.
Disp:*90 Tablet(s)* Refills:*2*
8. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
Disp:*1 bottle* Refills:*2*
10. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. Fenofibrate 54 mg Tablet Sig: One (1) Tablet PO once a day.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
14. Outpatient Lab Work
Please draw labs on [**2104-7-29**] and fax results to [**Telephone/Fax (1) 82575**]
(PCP). Labs to check: Chem-10, CBC
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Membranous glomerulonephropathy
Anasarca
Retroperitoneal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for total body fluid overload because of your
kidney failure. We used a machine to take a lot of the fluid
off and changed some of your medications to increase your urine
output. It is possible that you might need dialysis in the
future as your kidney failure is permanent and the fluid may
reaccumulate.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Please call the office number listed below to book an
appointment for 3-4 days after your hospital discharge.
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 28634**]
Department: Nephrology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
When: Tuesday [**2104-8-5**] at 10 AM
Location: [**Hospital3 82576**] MEDICINE PROGRAM
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 71231**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2104-7-28**]
|
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|
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icd9pcs
|
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11952, 12001
|
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|
352, 359
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|
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|
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5,535
| 180,510
|
9075
|
Discharge summary
|
report
|
Admission Date: [**2130-12-21**] Discharge Date: [**2131-1-23**]
Service: MEDICINE
Allergies:
Prednisone / Cortisone
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
diarrhea and fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is an 80 year old man with likely c.diff pan colitis.
He reports a liquid stools without blood or melena up to 7 times
in a day despite taking Imodium up to 4 pills a day. Less than a
week prior to admission, Mr. [**Known lastname **] finished a course of
levaquin, started for CAP.
Of note, patient admitted in [**Month (only) 404**] for influenza, although he
had received the vaccine, and was sent out to rehab. The patient
has had diarrhea since he was hospitalized in [**Month (only) **], but it
is worse lately, now described as caramel colored.
Mr. [**Known lastname **] states that morning of admission he had a 45 minute
period of nonradiating substernal chest pain while at rest that
was relieved by one SLNG. It was not accompanied by
N/V/diaphoresis/palpitations/HA. In the past he reported PND,
but he states that he no longer has it. He denies DOE,
peripheral edema, or orthopnea.
ROS: He also reports anorexia and now some nausea with dry
heaves. No fever, chills, sweats.
Past Medical History:
CAD
-1 vd; LAD 50-60% prox at first septal perf, 1st septal branch
60%; RCA 80% prox; RI 80% prox
-no perfusion defects by MIBI ([**1-19**])
CHF
-LVEF <20% with global HK and no focal segmental abnormalities
PAF (prior hx of LV thrombus now resolved)
HTN
Hyperlipidemia
COPD, mild with FEV1 83% pred
Psoriasis
Community acquired pneumonia (recurrent over last 2-3 years)
Iron deficiency anemia with hx GI bleed
CRI (baseline creatinine 2.0-2.5)
Macular degeneration
s/p left hip replacement
Hard of hearing
hypothyroidism
Social History:
Retired fireman captain. lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], he has several
children in the area, has good social support. 2-3 episodes of
smoke inhalation. 55-75 pack years tobacco hx quit in [**2123**]. no
alcohol. no illicit drugs.Patient has been finding it
increasingly difficult to care for himself at home, his children
also have concerns. The patient is adamant about not moving in
with one of his children although they have offered. He would
like to improve his functional status so he can remain
independent at home.
Family History:
noncontrib
Physical Exam:
T 97.1, HR 89, BP 115/52, RR 16 O2 sat 94% on RA
Gen: pleasant and cooperative, thin
HEENT: MMM, PERRLA, JVD 7 cm
Cor: RRR no murmurs
Pulm: CTAB no crackles
Abd: +BS, very tender to mild palpation, + rebound, no guarding
Ext: WWP, DP 2+ bilaterally, strength 5/5 bilaterally upper
extremities, left lower extremity with 4/5 hip flexor, right
with 5/5 strength, hands with thenar atrophy
neuro: CN II-XII individually tested and intact but left side of
face very slightly drooping
Pertinent Results:
EKG: paced
Labs: WBC 31.1, Troponin 0.10, Creatinine 2.6
CT abdomen: effusion at lung base, diffuse abnormality of colon
from splenic flexure to rectum but also around cecum showing
diffuse wall edema consistent with c.diff pan-colitis, liver
with multiple lesions consistent with simple cysts, muliple
diverticuli in colon, left sided hip prosthesis, DJD in right
hip, aorta with multiple atheroma
CXR: mild fluffy opacities consistent with pulmonary edema
Brief Hospital Course:
Mr. [**Known lastname **] is an 80 year old man with c.difficile pancolitis, in
the setting of recent levofloxacin use. He also presented a
troponin leak from likely demand ischemia. Recently, he had a
normal TSH ruling out hyperthyroidism as an etiology and a
virtual colonoscopy that showed no colonic lesions though there
was poor visualization of the descending colon and no
intraabdominal masses or other pathology.
1. C. diff pancolitis
In terms of his colitis, Mr. [**Known lastname 31337**] stool was negative for
toxin A on several occasional but positive for c.difficile toxin
B. He had multiple bowel movements per day, usually OB positive,
and he even had an episode of melena. He was made NPO and
started on PO vancomycin and IV flagyl in additional to morphine
and tylenol for pain. He was followed by surgery and GI but it
was felt that there were no indications for intervention since
he's a poor surgical candidate and colonoscopy could potentially
perforate the colon.
He continued to improve with diarrhea resolving. He remained on
po vancomycin for this infection. He will complete a course of
po vancomycin for about two months in
total.
2. VRE UTI/Bacteremia
Mr. [**Known lastname **] made progress in his recovery until he spiked a
fever. His blood cultures grew 4/4 bottles of VRE on [**1-11**] and
4/4 bottles on [**1-12**]; he was started on linezolid. He appears to
have seeded his blood from his urine where his urine culture
grew out 10,000 colonies of VRE [**1-6**]. His PICC was pulled. He
had a TTE to r/o evidence of endocarditis. Of note, he had an
AICD placed in [**11-22**]. THe TTE did not show any evidence of
endocarditis. He then underwent a TEE which showed no evidence
of endocarditis.
- An initial CT abd/pelvis on admission raised the possibility
of intravesical air as a sign of entero-vesical fistula (which
might explain the VRE uti and subsequent bacteremia
- A f/u CT abd/pelvis was done with rectal contrast to evaluate
for this possibility. While the rectal contrast did not reach
high enough to directly visualize a potential fistula, there was
no evidence of intra-vesical air on this study, making a fistula
less likely.
*** will f/u with Dr. [**First Name (STitle) **] in ID
- plan 4 weeks of po linezolid 600 [**Hospital1 **] (start date of [**1-13**] -
first date of negative cultures)
- f/u with Dr. [**First Name (STitle) **] on [**2-9**] at 9:30 AM
- will f/u with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**] after d/c
*** will need f/u TEE.
*** will need weekly CBC to follow for cytopenias with linezolid
therapy.
3. Chronic renal insufficiency:
Mr. [**Known lastname **] has chronic renal insufficiency, with a baseline
1.7-2.0. He was initially thought to be prerenal from CHF
combined with contrast induced ARF. Within 3 days of admission,
he became oliguric and hypotensive. He was sent to the MICU
where he was fluid resuscitated with 8 liters. His hypotension,
oliguria, and acute renal failure resolved within a few days. He
was transferred back to the floor, where he was effectively
diuresed without precipitating a rise in creatinine.
Creatinine on discharge was 1.5; lasix and ACE-I were held on
account of
bump in crn from 1.2 to 1.5
4. Troponin leak:
Mr. [**Known lastname **] had a troponin leak which was thought to be secondary
to congestive heart failure. He has an EF of < 20%, and was
initially started ASA, with continuation of his statin. His
Lisinopril and metoprolol were initially discontinued, as he was
hypotensive. They were both restarted once he stabilized.
5. Urinary retention:
Mr. [**Known lastname **] has urinary retention. Once his foley was pulled, he
was able to urinate. The Tamsulosin was continued.
6. Hypothyroidism:
For his hypothyroidism, the levothyroxine was continued.
7. COPD:
For his COPD, he was continued on
albuterol/ipratropium/fluticasone MDIs in addition to nebulizer
treatments. He no longer required oxygen by the end of his stay.
8. Oral candidiasis:
Mr. [**Known lastname **] had oral candidiasis in addition to urinary [**Female First Name (un) **].
He was treated with one dose of fluconazole and nystatin swish
and swallow.
Medications on Admission:
Allergies: prednisone
Medications: toprol xl 50, synthroid 25, lipitor 20, lisinopril
5, furosemide 20, protonix 40, MVI, coenzyme Q, SLNTG
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*3 inhalers* Refills:*2*
2. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*21 Tablet(s)* Refills:*0*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*30 Tablet(s)* Refills:*2*
5. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-19**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*3 inhalers* Refills:*2*
12. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
13. Vancomycin HCl 250 mg Capsule Sig: Two (2) Capsule PO three
times a day for 1 months: 500mg TID for one month, then 500mg
[**Hospital1 **] for 2 wks, then 500mg qD for two weeks.
Disp:*264 Capsule(s)* Refills:*0*
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
16. Outpatient Lab Work
Weekly CBC - send results to primary care md
17. Outpatient Lab Work
ESR/crp - send results to primary care md
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
VRE uti/bacteremia
c difficile colitis
CHF, EF 20%
CAD s/p MI
s/p placement of AICD
s/p left femoral fracture
chronic renal insufficiency with baseline creatinine 1.3
COPD
h/o urinary retention
major depression
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: 1500 cc
[**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 7186**] of breath, bright red blood per rectum,
fevers, chills, cough, increased diarrhea.
Continue to take your regular medications, as well as four weeks
of the antibiotic linezolid. You will also take a long course
of the antibiotic vancomycin.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-2-12**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2131-1-15**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2131-1-22**] 1:30
Infectious disease clinic - Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Friday [**2-9**]
at 9:30 AM.
|
[
"787.91",
"599.0",
"403.91",
"455.2",
"790.7",
"296.20",
"428.20",
"280.9",
"584.5",
"008.45",
"112.0",
"276.5",
"562.10",
"041.04",
"414.01",
"263.9",
"V45.02",
"428.0",
"V45.82",
"496",
"V09.80",
"696.1",
"244.9",
"788.20",
"414.8",
"458.9",
"578.1",
"556.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"00.14",
"38.93",
"99.15",
"88.01",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10019, 10108
|
3471, 7713
|
250, 256
|
10363, 10369
|
2989, 3448
|
10865, 11525
|
2462, 2474
|
7904, 9996
|
10129, 10342
|
7739, 7881
|
10393, 10842
|
2489, 2970
|
192, 212
|
284, 1302
|
1324, 1851
|
1867, 2446
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,901
| 118,273
|
12638+56382
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-1-28**] Discharge Date: [**2200-2-14**]
Date of Birth: [**2142-10-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
female transferred from [**Hospital 1727**] Medical Center to Dr.[**Name (NI) 37249**] service for care of dry gangrenous digits. Her
current condition is secondary to purpura fulminans, a
complication of Pneumococcal sepsis in late [**2199-12-14**].
The patient is asplenic predisposing her to Pneumococcal
sepsis. She is now stable and in need of Plastic and
Vascular Surgery care. She has increased pain issues. She
has finished a course of intravenous antibiotics and is now
on Clarithromycin prophylactically.
PAST MEDICAL HISTORY:
1. Asthma.
2. Hypercholesterolemia.
3. Glaucoma.
4. Asplenia.
MEDICATIONS ON TRANSFER:
1. Tazolol.
2. Ranitidine.
3. Clarithromycin.
4. Fluoxetine.
5. Singulair.
6. Protonix.
7. Pilocarpine.
8. Lumigan.
9. Prednisone.
10. Solu-Medrol MDI.
11. Senna tablets.
12. Triamcinolone MDI.
13. Diazepam.
14. Lasix p.r.n..
15. Dilaudid PCA.
16. Maalox.
17. Reglan.
18. Percocet.
19. Slo-[**Hospital1 **].
20. Heparin drip.
ALLERGIES: Penicillin and sulfa drugs.
PHYSICAL EXAMINATION: Upon admission, vital signs stable;
afebrile. The patient is a pleasant middle-aged lady in no
apparent distress. Lungs are clear to auscultation, normal
sinus rhythm, no murmurs. Chest wall has old ecchymosis over
the anterior chest wall, no induration, nontender. Upper
extremities have numbness left and right hands, right worse
than left. They are insensate. There is no motor function.
Bilateral palpable radial and ulnar pulses. Lower
extremities mummified left and right distal foot, all toes
involved. Entire sole of foot, left and right, dry
gangrenous. Dorsum of the foot is edematous but does not
have dry gangrene on the left or the right. Necrotic skin
over the soles extending over the Achilles tendon area on the
left and the right, pretibial edema and ecchymosis, tender.
Femoral, popliteal and dorsalis pedis pulses palpable
bilaterally. Sensation is intact up to the middle of the
forefoot on the dorsum on the left and the right. No
sensation or motor function of the toes. Sensation and motor
function of the ankle is intact.
LABORATORY: Upon admission, white count 18.3, hematocrit
31.3, platelets 778. Sodium 136, potassium 5.1, chloride 98,
bicarbonate 26, BUN 12, creatinine 0.5, glucose 169.
Coagulation: PT is 13.1, PTT 89.9 and INR is 1.2.
HOSPITAL COURSE: The patient was admitted to the Plastic
Surgery Service and was under the care of Dr. [**Last Name (STitle) 13797**].
Chronic Pain Service, Hematology Service, Infectious Disease
and Vascular Surgery followed the patient closely.
Psychiatric consultation was also obtained secondary to the
severity of the situation.
The patient was taken to the Operating Room on Tuesday,
[**2-4**], for bilateral below the knee amputations as well
as right hand amputation, left small ring finger amputation,
left partial middle finger amputation, and a free-flap to the
left first web site.
On postoperative course, the patient was admitted to the SICU
for a few days as ventilation was needed secondary to a large
dose of narcotics, hemodynamic monitoring as well as q. one
hour free-flap checks. She was transferred to the Floor a
few days later after being successfully extubated and her
pain was well controlled.
Infectious Disease eventually switched her antibiotic dosing
to Vancomycin for a few days and then eventually to p.o.
Vantin. Her free-flap continued to be viable with good
pulses and her wounds all remained clean, dry and intact with
no signs of infection.
Her pain was managed by the Chronic Pain Service and she was
eventually well controlled with 120 mg p.o. three times a day
of MS Contin, 35 to 45 mg p.o. q. three to four hours of
MSIR, Neurontin 300 mg p.o. three times a day. Infectious
Disease recommended that she have the Prevnar Conjugated
Pneumococcal Vaccine as well as the HIB and Meningococcal
vaccine which she was given on the day of discharge and she
should be followed closely by Infectious Disease after
discharge in order to continue her Pneumococcal vaccination
series.
The Infectious Disease team also pursued a coagulopathy
work-up as well as immunodeficiency evaluation. No positive
results to date. They recommend that she get a second
pneumococcal vaccine in four to eight weeks after her first
vaccine and four weeks after that, an unconjugated vaccine.
She had an echocardiogram to rule out endocarditis which was
negative. The patient was eventually discharged to a
rehabilitation facility in [**State 1727**] and will be following up
with Plastics and Vascular Surgery Clinics.
DISCHARGE DIAGNOSES:
1. Status post bilateral below the knee amputations.
2. Right hand amputation.
3. Left digit amputation with a free-flap to the first web
space secondary to purpura fulminans.
DISCHARGE MEDICATIONS:
1. MS Contin 115 mg three times a day.
2. Zofran 2 to 4 mg intravenous q. eight hours.
3. Neurontin 300 mg p.o. three times a day.
4. MSIR, 30 to 45 mg p.o. q. three to four hours.
5. Nystatin Powder to the buttock area with each incontinent
episode.
6. Dulcolax p.r.n. 10 mg q. day.
7. Colace 100 mg p.o. twice a day.
8. Vantin 200 mg p.o. q. 12 hours.
9. Ambien 5 to 10 mg p.o. q. h.s. p.r.n.
10. Triamcinolone MDI, four puffs twice a day.
11. Solu-Medrol MDI, two puffs twice a day.
12. Senna tablets 2 mg p.o. twice a day.
13. Dilantin 0.005%, one drop o.s. q. h.s.
14. Betaxolol 0.25%, one drop o.s. twice a day.
15. Varmonadine 0.2% solution, one drop o.s. twice a day.
16. Singulair 10 mg p.o. q. h.s.
17. Pantoprazole 40 mg p.o. q. day.
18. Multi-vitamin, one tablet p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. Dressings changes q. day with Xeroform and Kerlix q. day.
2. Follow-up with Plastic Surgery Clinic in one to two
weeks; call [**Telephone/Fax (1) 274**].
3. Follow-up with Dr. [**Last Name (STitle) **] from Vascular Surgery in one to
two weeks.
4. Follow-up with Infectious Disease p.r.n.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D. [**MD Number(1) 19096**]
Dictated By:[**Doctor Last Name 32927**]
MEDQUIST36
D: [**2200-2-14**] 11:54
T: [**2200-2-14**] 12:21
JOB#: [**Job Number 13331**]
Name: [**Known lastname 7052**], [**Known firstname **] Unit No: [**Numeric Identifier 7053**]
Admission Date: [**2200-1-28**] Discharge Date: [**2200-2-19**]
Date of Birth: Sex: F
Service: /
ADDENDUM: [**First Name8 (NamePattern2) 1693**] [**Known lastname **] is a woman who was admitted to the
hospital on [**2200-1-28**], transferred from [**Hospital 4488**] Medical Center
for extremity gangrene.
A complete discharge summary was dictated through [**2200-2-14**].
She stayed in the hospital from [**2200-2-14**] until [**2200-2-19**],
awaiting a bed to become available for her up in [**State 4488**].
There is nothing of significance that happened during this
portion of the hospital course and reference should be made
to the full Discharge Summary previously dictated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7054**], M.D. [**MD Number(1) 7055**]
Dictated By:[**Last Name (NamePattern4) 7056**]
MEDQUIST36
D: [**2200-6-18**] 18:35
T: [**2200-6-19**] 14:50
JOB#: [**Job Number 7057**]
|
[
"285.9",
"139.8",
"785.4",
"286.6",
"V45.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.15",
"84.01",
"86.62",
"96.71",
"84.04",
"03.90",
"84.02"
] |
icd9pcs
|
[
[
[]
]
] |
4777, 4957
|
4980, 5778
|
2529, 4756
|
5802, 7477
|
1226, 2511
|
161, 710
|
824, 1203
|
732, 799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,921
| 185,095
|
28770
|
Discharge summary
|
report
|
Admission Date: [**2157-9-2**] Discharge Date: [**2157-9-16**]
Date of Birth: [**2085-7-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Pravachol / Questran / Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2157-9-6**] - MVR(31mm Mosaic porcine)/CABGx4(LIMA->LAD, SVG->Diag,
OM, RCA)
History of Present Illness:
The patient is a 72 year old male who was transferred from
[**Hospital6 1109**] following admission for chest pain
while playing golf and had non specific ST changes (troponin
111, CK 2502 peaks), ruled in for non ST elevation myocardial
infarction. Went for cardiac catherization at [**Hospital1 **] which
showed three vessel coronary artery disease (100% diagonal 80%
left anterior descending, and 100% right coronary artery).
Past Medical History:
CAD
Obesity
Hypercholesterolemia
MR
[**First Name (Titles) 21463**]
[**Last Name (Titles) **]
s/p PTCA
s/p Ventrial hernia repair
Polymyalgia rheumatica
Social History:
Lives with wife
[**Name (NI) 1139**]: 15 pack year history - quit 5 years ago
Alcohol: 2-3 beers per week
Family History:
Unknown
Physical Exam:
Admission:
Vitals: Blood pressure 134/65, Heart Rate 108, Respiratory Rate
20, Oxygen Saturation 100% on room air, Temperature 96.8 Weight
92.6 kilograms
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds, old incision
healed
Ext: [**1-10**]+ edema, groin site clean dry and intact no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2157-9-2**] 08:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2157-9-2**] 08:33PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2157-9-2**] 08:58PM PT-12.1 PTT-23.5 INR(PT)-1.0
[**2157-9-2**] 08:58PM WBC-8.3 RBC-5.13 HGB-13.5* HCT-40.6 MCV-79*
MCH-26.4* MCHC-33.3 RDW-17.0*
[**2157-9-2**] 08:58PM GLUCOSE-337* UREA N-22* CREAT-1.0 SODIUM-136
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-28 ANION GAP-14
[**2157-9-16**] 06:50AM BLOOD WBC-8.1 RBC-4.96 Hgb-12.8* Hct-39.3*
MCV-79* MCH-25.9* MCHC-32.6 RDW-16.7* Plt Ct-294
[**2157-9-16**] 06:50AM BLOOD Plt Ct-294
[**2157-9-16**] 06:50AM BLOOD Glucose-152* UreaN-25* Creat-1.1 Na-138
K-4.3 Cl-97 HCO3-30 AnGap-15
[**2157-9-5**] Carotid Duplex U/S
Mild atherosclerotic changes bilaterally with less than 40%
stenosis of the internal carotid arteries on both sides. This is
a baseline examination at the [**Hospital1 18**].
[**2157-9-3**] ECHO
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. There
is severe
regional left ventricular systolic dysfunction. Overall left
ventricular
systolic function is severely depressed. Tissue velocity imaging
E/e' is
elevated (>15) suggesting increased left ventricular filling
pressure
(PCWP>18mmHg). Resting regional wall motion abnormalities
include thinned and aneurysmal basal inferior/inferolateral
wall, mid inferior
hypokinesis/akinesis, akinetic mid to distal septum, and apical
akinesis/hypokinesis. Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is an anterior space which
most likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
[**2157-9-15**] ECHO
Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity size. There is severe global left ventricular
hypokinesis. Overall left
ventricular systolic function is severely depressed.
3. The ascending aorta is mildly dilated.
4. The aortic valve leaflets (3) are mildly thickened.
5. A bioprosthetic mitral valve prosthesis is present. The
mitral prosthesis appears well seated, with normal leaflet
motion and transvalvular gradients.
6. Compared with the prior study (images reviewed) of [**2157-9-6**],
the mitral prosthetic valve is new.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2157-9-2**] for further
management of his coronary artery disease. He was worked-up in
the usual preoperative manner by the cardiac surgical service.
Heparin was continued for anticoagulation. A carotid duplex
ultrasound was performed which showed mild atherosclerotic
changes bilaterally with less than 40% stenosis of the internal
carotid arteries bilaterally. An echocardiogram was performed
which showed his ejection fraction to be 25%, no mitral valve
regurgitation and an inferior basal aneurysm. The cardiology
service was consulted for assistance with the management of his
ischemic [**Date Range **]. Carvedilol, aspirin, ace inhibition and
statin therapy were started. As Mr. [**Known lastname 16643**] hematocrit fell, a
cause of his anemia was explored. A tagged red blood cell scan
was negative for an active bleed. The gastrointestinal service
was consulted. A colonoscopy was notable for only diverticula
and hemorrhoids. An esophageal duodenoscopy was notable for
angioectasia which was cauterized and gastritis. Mr. [**Known lastname **] was
subsequently cleared for surgery. On [**2157-9-6**], Mr. [**Known lastname **] was
taken to the operating room where he underwent coronary artery
bypass grafting to four vessels and a mitral valve replacement
using a 31mm mosaic porcine valve. Please see operative note for
details. An intra-aortic balloon pump was placed for poor
hemodynamics. An initial attempt was made to place the balloon
in the left groin which failed. The left groin thus needed to be
explored with repairs made to the femoral artery. The balloon
was then placed in the right groin. Postoperatively he was taken
to the cardiac surgical intensive care unit for monitoring. He
required multiple pressors and blood products for postoperative
bleeding. Amiodarone was started for ectopy. Over the next
several days, Mr. [**Known lastname **] slowly weaned from pressors, the
balloon pump and sedation. On [**2157-9-14**], Mr. [**Known lastname **] was
successfully extubated. He developed atrial fibrillation which
was treated with amiodarone and beta blockade. He initially had
some confusion however cleared appropriately. He was gently
diuresed towards his preoperative weight. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. On postoperative day seven, Mr. [**Known lastname **]
was transferred to the step down unit for further recovery. He
remained in normal sinus rhythm. A repeat echocardiogram showed
his ejection fraction to be 20%. Mr. [**Known lastname **] continued to make
steady progress and was discharged home on postoperative day
ten. He will follow-up with Dr. [**Last Name (STitle) 1290**], his cardiologist and
his primary care physician as an outpatient.
Medications on Admission:
Verapamil SR 240mg daily, Aspirin 81mg daily, Imdur ER 30mg
daily, Prilosec 20 mg daily, Fish oil, Folic Acid, Calcitrate
950mg daily, Vitamin C, Vitamin E, Metformin 500mg twice a day,
Prednisone 5mg in am and 3mg in pm, Lipitor 10mg daily,
Allopurinol 300mg daily, Xanax prn ,
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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. 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*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week then 400mg QD x1 wk then 200mg QD.
Disp:*60 Tablet(s)* Refills:*2*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
10 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Calcitrate 950 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Prednisone 1 mg Tablet Sig: Five (5) Tablet PO q AM: Take 3
mg PO q PM.
Disp:*240 Tablet(s)* Refills:*2*
14. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 1280**]
Discharge Diagnosis:
s/p Mitral Valve Replacement (#31 Mosaic porcine) Coronary
Artery Bypass Graft (Left internal Mammary Artery to left
anterior descending, saphenous vein graft to diagonal, saphenous
vein graft to obtuse marginal, saphenous vein graft to right
coronary artery)Intra aortic balloon pump
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or
swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Dr [**First Name (STitle) **] [**Name (STitle) **] in [**1-10**] weeks
Dr [**Last Name (STitle) 69523**] in [**2-11**] weeks
Dr [**Last Name (STitle) 1290**] in 4 weeks
See your urologist in [**1-10**] weeks.
Completed by:[**2157-9-21**]
|
[
"998.11",
"785.51",
"V45.82",
"537.83",
"725",
"V58.65",
"414.8",
"285.1",
"424.0",
"272.0",
"410.71",
"427.31",
"428.0",
"414.01",
"562.10",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.59",
"39.61",
"35.23",
"37.61",
"36.15",
"45.23",
"36.13",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
9479, 9530
|
4537, 7372
|
331, 412
|
9859, 9866
|
1744, 4514
|
10069, 10309
|
1188, 1197
|
7701, 9456
|
9551, 9838
|
7398, 7678
|
9890, 10046
|
1212, 1725
|
281, 293
|
440, 872
|
894, 1049
|
1065, 1172
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,796
| 166,225
|
31915
|
Discharge summary
|
report
|
Admission Date: [**2140-9-16**] Discharge Date: [**2140-9-16**]
Date of Birth: [**2121-10-17**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**Known firstname 2297**]
Chief Complaint:
Alcohol intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
18 year old male, previously healthy, brought in by ambulance
after friends found him "very drunk." He was playing a drinking
game with his friends the night prior to admission and it is
estimated that he drank [**2-28**] of a liter of vodka/15 shots. He
was found somnolent/passed out by his friends and EMS was
called.
.
In the ED, his vitals were: 96.7, 152/80, 108, 24, 96% RA. His
alcohol level was 231, but the patient was pale, diaphoretic and
difficult to arouse, raising the concern that there was another
substance involved, but urine and serum tox screens were
otherwise negative. He began to vomit and did not have a gag
reflex therefore, he was intubated for airway protection.
Past Medical History:
None
Social History:
BU sophomore, rare tob, no drug use, reports drinking once every
2 weeks. Average [**10-10**] shots per outing. Began drinking at 15.
CAGE 0/4.
Family History:
None
Physical Exam:
general: well developed, well nourished young adult, no
distress, alert and oriented, remembers the events of the night.
HEENT: EOMI, PERRL, OP clear
Neck: JVP at 8 cm H2O
Car: RRR
Resp: CTAB
Abd: s/nt/nd/nabs
Ext: mild swelling left ankle, no erythema, not painful
Neuro: follows commands, moves all extremities
Pertinent Results:
[**2140-9-16**] 02:55AM URINE HOURS-RANDOM
[**2140-9-16**] 02:55AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2140-9-16**] 02:55AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2140-9-16**] 02:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2140-9-16**] 02:30AM GLUCOSE-120* UREA N-14 CREAT-1.1 SODIUM-142
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-20
[**2140-9-16**] 02:30AM estGFR-Using this
[**2140-9-16**] 02:30AM ASA-NEG ETHANOL-231* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-9-16**] 02:30AM WBC-12.8* RBC-5.29 HGB-16.7 HCT-48.0 MCV-91
MCH-31.5 MCHC-34.7 RDW-12.5
[**2140-9-16**] 02:30AM NEUTS-66.7 LYMPHS-28.3 MONOS-3.1 EOS-0.5
BASOS-1.5
[**2140-9-16**] 02:30AM PLT COUNT-389
.
CXR: Endotracheal tube with tip approximately 4 cm above the
carina. Nasogastric tube should be advanced to ensure that the
most proximal side port is within the stomach.
.
CT head: No evidence of acute intracranial hemorrhage
.
Left ankle Xray: No evidence of acute fracture or dislocation
Brief Hospital Course:
The patient was brought to the MICU and successfully extubated.
He was easily transitioned to room air and was eating and
ambulating prior to discharge. He met with the social worker
prior to discharge to discuss his alcohol use. He was
discharged home.
Medications on Admission:
None
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol intoxication
Discharge Condition:
Stable, on room air, tolerating diet.
Discharge Instructions:
You were admitted with alcohol intoxication to the degree that
you required a breathing tube to support your breathing. You
were successfully extubated and were doing well at discharge.
Followup Instructions:
PCP as needed
|
[
"305.00",
"518.81",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3177, 3183
|
2780, 3036
|
317, 324
|
3248, 3288
|
1606, 2637
|
3523, 3540
|
1252, 1258
|
3091, 3154
|
3204, 3227
|
3062, 3068
|
3312, 3500
|
1273, 1587
|
257, 279
|
352, 1047
|
2646, 2757
|
1069, 1075
|
1091, 1236
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,256
| 135,032
|
43399
|
Discharge summary
|
report
|
Admission Date: [**2109-4-2**] Discharge Date: [**2109-6-13**]
Date of Birth: [**2055-8-22**] Sex: F
Service: COLORECTAL SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-old
woman with a complex medical history remarkable for multiple
past surgeries and hospitalizations for enterocutaneous
fistulae. She first developed fistulae approximately seven
years ago following an exploratory laparotomy for small bowel
obstruction and incisional hernia repair. She has had
numerous hospitalizations since then with recurrence of her
fistulae. In [**2108-11-23**], she noted a breakdown of the
skin around her most recent fistulae and was admitted to
[**Hospital3 1443**] Hospital for exploratory laparotomy, lysis
of adhesions, and resection of her enterocutaneous fistulae
along with small bowel resection.
On that admission, she developed a fluid collection that was
percutaneously drained and remarkable for E. coli, MRSA, and
VRE. In early [**Month (only) 1096**], she was readmitted to [**Hospital3 1442**] for new onset of bilious drainage from the lower
part of her surgical incision and subcutaneously transferred
to [**Hospital1 18**] on [**2109-2-5**] for further management of her
fistulae. She was evaluated at this time and not felt to be
a good surgical candidate. At this time, it was decided to
improve the patient's nutritional status with TPN and then
bring her back for surgical intervention when she was
physically stronger.
After discharge from [**Hospital1 18**], on [**2109-2-18**], she
subsequently returned to [**Hospital3 1443**] on [**2109-2-26**] with
fevers. Her hospital course there was significant for
intermittent drainage from her wound which grew out E. coli.
Her antibiotics were changed at that time to Levaquin and
doxycycline secondary to pancytopenia. She was transfused 2
units of packed red blood cells for a hematocrit of 22
without any evidence of GI bleed. She has taken no oral
intake except for ice chips for several months now.
On [**2109-4-2**], she was transferred from [**Hospital3 1443**] to
[**Hospital1 18**] for further management of her enterocutaneous fistulae.
PAST MEDICAL HISTORY:
1. Enterocutaneous fistulae.
2. Splenomegaly.
3. Portal hypertension.
4. Thrombocytopenia.
5. Multiple DVTs requiring [**Location (un) 260**] filter placement.
6. Gastric ulcer.
7. Severe MVA at age 17.
PAST SURGICAL HISTORY:
1. Status post appendectomy at age two.
2. Cholecystectomy [**21**] years ago.
3. Multiple exploratory laparotomies.
4. Exploratory laparotomy with lysis of adhesions, as
described above in [**11-24**] with small bowel resection and
resection of fistulae.
ADMISSION MEDICATIONS:
1. TPN.
2. Levofloxacin 500 mg IV q.d.
3. Doxycycline 400 mg IV b.i.d.
4. Colace.
5. Dilaudid.
6. Vistaril.
7. Tylenol.
8. Regular insulin sliding scale.
9. Milk of magnesia.
ALLERGIES:
1. IV dye.
2. Compazine.
3. Benzodiazepines.
4. Local anesthetics except for Marcaine.
5. Betadine.
6. Sulfa.
SOCIAL HISTORY: The patient denied alcohol use. The patient
is a smoker.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.9, pulse 85, blood pressure 134/58, respirations 20, 02
saturation 98% on room air. General: The patient was alert,
comfortable. HEENT: The head was normocephalic, atraumatic.
Neck: Supple. The patient was anicteric. Lungs: Clear to
auscultation bilaterally. Heart: Regular rate and rhythm
with a III/VI holosystolic murmur. Abdomen: Obese, soft,
nondistended, tender lower abdomen with erythema surrounding
the incision. Also noted is a dry old drainage site in the
lower abdomen with ulceration. Extremities: Without
clubbing, cyanosis or edema.
HOSPITAL COURSE: The patient was admitted to the Colorectal
Surgery Service where she was continued on Levaquin and
doxycycline and was prepared for surgery. On [**2109-4-4**],
she was taken to the Operating Room, right colorrhaphy, small
bowel resection, ventral hernia repair with mesh, excision of
mesh from previous hernia, and placement of a gastrostomy tube
lysis of
adhesions were performed. She tolerated the procedure in
guarded condition and was taken to the Intensive Care Unit
for close monitoring.
Intraoperatively, she received 7 units of FFP, 6 units of
packed red blood cells, and 1 unit of platelets. In the
Intensive Care Unit, she was kept intubated overnight. She
received TPN for nutritional support. She was treated with
perioperative beta blockade and received antibiotic coverage
with Levaquin, doxycycline, vancomycin, and Flagyl. She
received several fluid boluses immediately postoperatively
for oliguria. She was extubated on postoperative day number
one.
On postoperative day number two, she was transfused 2 units
of packed red blood cells for a hematocrit of 25. Her
antibiotics were changed to Levaquin, Flagyl, and linazolid
for concern of VRE. Her pain was controlled with a Dilaudid
PCA.
On [**2109-4-9**], she remained afebrile and her antibiotics
were discontinued. On [**2109-4-12**], the patient remained
stable, however, she experienced no return of bowel function.
A CT scan was performed at that time which was suggestive of
a small bowel obstruction. Also noted was a significant
amount of ascites.
On postoperative day number 11, [**2109-4-15**], the JP was
discontinued. Her condition was stable and she was
transferred to the floor. However, her white blood cell
count was noted to be elevated. Cultures from her urine
revealed yeast and she was started on fluconazole. Her CVL
was changed also at this time. On [**2109-4-18**], the patient
developed shaking chills and tachycardia. She was found to
have dark green drainage from the base of her wound. Upon
further exploration of the wound, a fascial defect was found.
She was transferred to the Intensive Care Unit and started on
broad spectrum antibiotics on [**2109-4-19**]. A CAT scan of her
abdomen revealed a large left upper quadrant fluid
collection. Interventional percutaneous drainage of this
collection was performed which produced 300 cc of bloody
fluid. Cultures from this fluid grew [**Female First Name (un) 564**], Enterococcus,
Pseudomonas, and methicillin-resistant Staphylococcus aureus.
She was covered with Zosyn, vancomycin, Flagyl, and
fluconazole for these organisms. C. difficile toxin was
checked and found to be positive which was covered by the
Flagyl therapy.
Her condition stabilized in the Intensive Care Unit. She
remained afebrile and her vital signs remained stable.
However, she continued to have worsening liver dysfunction
and thrombocytopenia. Her abdominal wound incisions were
opened with a large superior wound with fistulae drainage
from the superior most portion of the wound. A smaller
inferior wound opened as well. The wounds were aggressively
treated with dressing changes and an ostomy appliance was
constructed over the fistulae drainage to keep the open
wounds clean.
She was transferred back to the floor on [**2109-4-24**]. Due to
her continued increased bilirubin levels, a Hepatology
consult was requested. NUmerous discussions with the hepatology
team and the liver transplant service were held "off-line" with
the effort to further brainstorm possible treatments as well as
etiology. It was felt that this was likely due
to cirrhosis with portal hypertension of unclear origin.
Hepatitis screen was negative. Ultrasound performed on
[**2109-4-27**] revealed flow through the hepatic veins, artery, and
portal vein. She was started on Actigall out of
consideration of possibility of cholestasis as cause of her
liver dysfunction. She was also started on Aldactone for
management of her ascites.
She was taken for an MRI on [**2109-4-30**] which she was unable to
tolerate due to claustrophobia and the procedure had to be
aborted. On [**2109-5-2**], her fluconazole and Zosyn were
discontinued out of the possibility of antibiotic medication
causing her liver dysfunction. However, her bilirubin
continued to increase and by [**2109-5-3**] it was up to 16.
Ultrasound was repeated at this time which revealed a nodular
liver consistent with cirrhosis, ascites, reversed flow
through the right and main portal veins, decreased flow
versus thrombus in the left portal vein and no evidence of
ductal dilatation.
On this day, her G tube also fell out during transport. She
was taken to Interventional Radiology but the tube was unable
to be replaced. Given the ultrasound results, the Hepatology
Service requested a liver biopsy be performed for tissue
diagnosis of the cause of her cirrhosis. This issue became
readdressed several times over the next few weeks and each
time the patient declined the liver biopsy. The patient also
developed several episodes over the next subsequent two weeks
of spontaneous bleeding from her abdominal wound which were
managed with Gelfoam and sutures. Her INR was approximately
2 or greater during this time. She was also not started on
any anticoagulation for her possible left portal vein
thrombus as she was autoanticoagulated.
By postoperative day number 40, [**2109-5-15**], she continued to
have high output from her fistulae. She was started on
Octreotide. On [**2109-5-16**], she developed a fever. Wound
cultures grew out Pseudomonas which was resistant to Levaquin
and ciprofloxacin. She was thus restarted on Zosyn.
On [**2109-5-20**], she was transfused 2 units of packed red blood
cells for a hematocrit of 21. On [**2109-5-22**], due to her
continued severe illness, after lengthy discussions with the
patient and her family, it was decided to make her DNR/DNI.
On [**2109-5-25**], the patient developed fevers up to 103.2. Blood
cultures were taken and her CVL was also changed over a wire
and the line tip was sent for cultures. These cultures were
positive for methicillin-resistant Staphylococcus aureus and
she was restarted on her vancomycin therapy. This line was
eventually discontinued completely and a new line was placed
on [**2109-5-28**] after pretreating the patient with FFP and
platelets.
Over the next two days, the patient had somewhat worsening
respiratory status. The chest x-ray revealed worsening CHF.
Her respiratory status improved with IV Lasix. On [**2109-5-30**],
the issue of liver biopsy was readdressed. The patient
consented to the procedure and was pretreated with FFP and
platelets. However, she refused the procedure again prior to
the biopsy.
On [**2109-5-31**], she had been afebrile for several days and her
vital signs had stabilized. Her antibiotics were
discontinued at this time and she had no further fevers for
the remainder of her hospital course.
On [**2109-6-5**], her code status was readdressed. Her bilirubin
had increased to the 30s but had stabilized. She otherwise
remained ill but stable. It was decided at this time to make
her a full code. By [**2109-6-13**], the patient continued to
remain stable. Her wounds were granulating and continued to
be changed with wet-to-dry dressing changes. Her fistulae
output remained high but stable. She continued to receive
TPN for nutritional supplementation. She was felt stable at
this time for discharge to a rehabilitation facility.
PHYSICAL EXAMINATION AT DISCHARGE: Vital signs: Temperature
98.4, pulse 82, blood pressure 118/44, respirations 18, 02
saturation 100% on room air. Heart: Regular rate and
rhythm. Lungs: Clear to auscultation bilaterally. Abdomen:
Soft with mild wound tenderness, nondistended with active
bowel sounds. Two open wounds were observed, the larger
superior wound with increasing granulation tissue. There was
a fistula at the superior portion of the wound with ostomy
appliance in place for collection of the output. Smaller
inferior wound is noted as well with good granulation tissue.
The extremities were without clubbing, cyanosis or edema.
DISCHARGE MEDICATIONS:
1. Dilaudid 1-2 mg subcutaneously q. three to four hours
p.r.n.
2. Oxybutynin 5 mg p.o. b.i.d.
3. Iron gluconate 300 mg p.o. q.d.
4. Protonix 40 mg IV q.d.
5. Trazodone 25 mg p.o. q.h.s. p.r.n.
6. Octreotide 100 micrograms subcutaneously q. eight hours.
7. Artificial tears one to two drops O.U. p.r.n.
8. Guaifenesin [**6-1**] mils q. six hours p.r.n.
9. Sodium chloride nasal spray one to two sprays q.i.d.
p.r.n.
10. Spironolactone 200 mg p.o. q.d.
11. Hydroxyzine 25 mg IM t.i.d. p.r.n.
12. Ursodiol 300 mg p.o. t.i.d.
13. Miconazole powder 2% one application q.i.d. p.r.n.
14. Zofran 4 mg IV q. six hours p.r.n.
15. Tylenol 650 mg p.o./p.r. q. four to six hours p.r.n.
16. Regular insulin sliding scale; glucose 0-150 0 units;
151-200 2 units; 201-250 4 units; 251-300 6 units; 301-350 8
units; 351-400 10 units; greater than 400 12 units.
DIET: The patient is n.p.o., taking only medications and ice
chips. The patient is on total parenteral nutrition for
support.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: The patient is to be discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post enterocutaneous fistula repair on [**2109-4-4**]
with left colon resection, left colon colorrhaphy, small
bowel resection, ventral hernia repair with mesh, excision of
previous mesh, G tube placement, extensive lysis of
adhesions.
2. Recurrence of fistula on [**2109-5-14**].
3. Hepatic failure of unclear etiology.
4. Chronic total parenteral nutrition.
5. Personality disorder (Psychiatric Eval - untreatable)
[**Last Name (NamePattern4) 1889**], M.D. [**MD Number(1) 1890**]
Dictated By:[**Name8 (MD) 12370**]
MEDQUIST36
D: [**2109-6-12**] 03:23
T: [**2109-6-12**] 17:09
JOB#: [**Job Number 93405**]
|
[
"571.5",
"428.0",
"287.5",
"789.5",
"008.45",
"569.81",
"570",
"996.62",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"38.93",
"54.59",
"43.19",
"89.64",
"45.79",
"99.15",
"54.91",
"46.75",
"53.61",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
12910, 12999
|
11904, 12888
|
13020, 13681
|
3739, 11249
|
2703, 3016
|
2419, 2680
|
11264, 11881
|
3128, 3721
|
2185, 2396
|
3033, 3113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,100
| 135,812
|
6094+55724
|
Discharge summary
|
report+addendum
|
Admission Date: [**2139-1-12**] Discharge Date: [**2139-2-10**]
Date of Birth: [**2074-8-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Reason for ICU Transfer: Initiation of XRT for NSCLC, Hypoxemic
Respiratory Failure
Major Surgical or Invasive Procedure:
XRT
Bronchoscopy & Biopsy
History of Present Illness:
Please refer to prior admit note from [**2139-1-12**], pulmonary consult
note on [**2139-1-14**], MICU Green Note [**1-17**] for full details.
.
Briefly, 64M with h/o lung ca s/p left pneumonectomy ([**2125**],
unknown CA), more recently had w/u of recurrent R lung mass
(unrevealing medisastinoscopy and paraceliac LN biopsy ([**7-17**]) at
[**Hospital1 112**].
.
[**2138-1-12**] [Floor]: Pt presented ED on [**2139-1-12**] for with productive
cough, low grade temps, worsening dyspnea, and tachypnea.
Treated with Levo/Clinda for post-obstructive RLL PNA>
.
[**Date range (1) 23890**] [Floor, ICU, Floor, Bronch, ICU]: CT scan revealed
R hilar cavitating mass with evidence of tree and [**Male First Name (un) 239**] opacities
of the right lung. Pt subsequently tachypnea to 30s and
transfered to MICU Green. Clinda/Levo was changed to PCN to
treat for actinomyces. Pt subsequently called back out to floor
and underwent Bronch that showed near occlusion of the RUL
bronchus by mass and endobronchial bx and transbronchial FNA
performed. Pt desatted to 80% and remained intubated, transfered
back to the MICU.
.
[**Date range (1) 23891**]: [ICU] Pt placed on Levophed. On [**1-18**] underwent
repeat Chest CT and started on Vanc/Cefepime/Cipro. Pt given
increasing doses of IV Lasix and later placed on Dobutamine to
assist with diuresis. ([**1-19**]) Micafungin, Flaygl added as PCN and
Cipro d/c'd. ([**1-20**]) Vanc d/c'd as the pt underwent a rigid/flex
bronch that revealed poorly differentiated NSCLC. Today the
patient was consulted by Heme-Onc where numerous options were
presented to the patient (XRT, chemo). The pt initially decided
against XRT, but later reversed his decision and is now being
transfered to the [**Hospital Ward Name 516**] to undergo XRT. Prior to transfer
the pt was hypotensive, started back on Levophed and given IV
Bolus.
.
ROS: congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY: (per admit note)
# Lung Ca s/p Left Pneumonectomy - first dx [**2125**] s/p radiation
therapy (no tissue diagnosis known) followed by thoracics (Dr
[**Last Name (STitle) 17041**] at [**Hospital1 112**] - being evaluated for new right hilar mass s/p
mediastinoscopy with biopsy without evidence of malignancy of
note; sputum culture [**7-17**] with actinomyces
# HTN
# NIDDM2
# HL
# Pituitary Microadenoma
# Testicular Hypofunction
# Obesity
# Angioedema after a dental procedure with negative RAST for l
Social History:
The patient quit smoking ten years ago but has a 25 pack [**Female First Name (un) **]
history. He drinks rarely. He is a retired cook. No known
asbestos exposures or occupational exposures. He lives alone. No
illicit drug use.
Family History:
Mother died at age 38 secondary to ovarian carcinoma. Father
died at age 84 secondary to "heart trouble." He had hypertension
as well. The patient reports a positive history of malignancy in
other family members of unknown types. The patient has four
siblings, all of whom are in reasonably good health.
Physical Exam:
on Arrival to [**Hospital Unit Name 153**]
Vitals - T: 99.4 125/94 BP: HR: RR: 02 sat:
Gen: Intubated, NAD, responding to questions appropriately,
follows commands
CV: RRR
Lungs: Scattered rhonci on right
Abd: Soft, normal BS. Nontender
Ext: 1+ edema
Neuro: A/O x 3; intubated, responding to voice
.
LABS: See below.
Pertinent Results:
[**2139-1-12**] 08:20PM PLT COUNT-338
[**2139-1-12**] 08:20PM NEUTS-69.9 LYMPHS-21.3 MONOS-5.9 EOS-2.5
BASOS-0.5
[**2139-1-12**] 08:20PM WBC-6.3 RBC-4.26* HGB-12.3* HCT-38.2* MCV-90
MCH-28.9 MCHC-32.2 RDW-14.2
[**2139-1-12**] 08:20PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-1.7
[**2139-1-12**] 08:20PM CK-MB-NotDone
[**2139-1-12**] 08:20PM cTropnT-<0.01
[**2139-1-12**] 08:20PM CK(CPK)-77
[**2139-1-12**] 08:20PM estGFR-Using this
[**2139-1-12**] 08:20PM GLUCOSE-70 UREA N-13 CREAT-1.1 SODIUM-140
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-33* ANION GAP-13
[**2139-1-12**] 08:35PM PT-14.0* PTT-33.7 INR(PT)-1.2*
CT chest: [**2139-1-13**]
1. Right lower lobe cavitary mass, with associated right hilar
bulky
lymphadenopathy, highly concerning for recurrent bronchogenic
malignancy.
Either the right lower lobe mass, or multiple stations of
lymphadenopathy in the mediastinum would be amenable to
bronchoscopic biopsy.
2. Extensive peribronchiolar tree-in-[**Male First Name (un) 239**] opacities, small
nodular and
ground-glass opacities throughout the right upper lobe, and to a
lesser degree in the right middle and lower lobes. Findings
suggest a superimposed infectious process. Infection involving
the cavitary mass in the right lower lobe superior segment could
also be considered, along with superinfection of a preexisting
cavitary mass.
3. Subtle thickening of interlobular septae in portions of the
right upper lobe and superior segment right lower lobe,
worrisome for lymphangitic carcinomatosis.
4. Necrotic-appearing 3 cm left adrenal nodule and enlarged
1.6 cm left
paraaortic node worrisome for metastatic disease.
5. Secretions and debris in the left mainstem bronchial stump
may be acting as a nidus for infection.
Cytology:
Right main stem mass, transbronchial needle aspirate: ATYPICAL.
Clusters of atypical stripped nuclei and focal necrosis in a
background of reactive bronchial epithelial cells, (see note.)
Note: The atypical nuclei are stripped of their cytoplasm
and display regular nuclear contours, vesicular chromatin and
large prominent nucleoli. Please also refer to the concurrent
endobronchial biopsy S10-964.
Right mainstem bronchus, endobronchial biopsy: Poorly
differentiated carcinoma
TTE:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is moderately dilated with depressed free wall
contractility. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. The aortic
root is mildly dilated at the sinus level. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is severe pulmonary artery
systolic hypertension. There is no pericardial effusion
[**2139-1-18**]:
1. No evidence of endoluminal filling defects to indicate
pulmonary embolus. However, multiple areas of progressive
narrowing and at least one occlusion of pulmonary arterial
branches by the infiltrative right hilar mass likely contribute
to the described symptoms of pulmonary arterial hypertension.
2.Interval development of multiple foci of consolidation and
peribronchiolar opacities in the right middle and upper lobe
concerning for progressive multifocal pneumonia. Findings were
called to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
3. Mild-to-moderate right pleural effusion.
4. Diffuse adenopathy and infiltrative mass involving the
right middle and upper lobe with progressive obstruction of the
bronchi and pulmonary
vasculature.
5. Changes of left pneumonectomy.
6. Enhancing nodule with central hypodensity adjacent to or
within the left adrenal gland is consistent with either
metastatic involvement of lymph node or adrenal gland.
[**2139-1-20**] Pathology:
Right bronchus intermedius mass (for frozen section),
endobronchial biopsy (A): Poorly differentiated carcinoma.
Right bronchus intermedius mass, endobronchial biopsy (B):
Poorly differentiated carcinoma.
[**2139-2-5**] Cardiac cath:
1. No significant coronary artery disease.
2. No central pulmonary embolism.
3. Moderate pulmonary arterial hypertension.
4. Elevated right-sided filling pressures.
[**2139-2-5**] TTE: Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 70%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with severe global free wall
hypokinesis. There is no mitral valve prolapse. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2139-1-17**], the findings are similar.
Brief Hospital Course:
64 yo male with h/o lung ca s/p left pneumonectomy, DM2, HTN,
admitted for fever, dyspnea and productive cough. Experienced
hypoxic respiratory failure during bronchoscopy, requiring
intubation. He was found to have partial occlusion of RUL
bronchus, and biopsy of lung revealed NSCLC. A stent was placed
in his bronchus intermidius. He was eventually extubated. He was
treated with antibiotics for post-obstructive pneumonia, and
also received XRT for his lung CA. He transiently required
vasopressors for hypotension, believed to be [**2-10**] vagal response
during intubation and, later, XRT. He developed chest pain with
EKG findings concerning for myocardial ischemia. Cardiac
catheterization revealed no coronary lesions. Pain was further
managed with morphine. The patient was seen by palliative care,
and goals of care were shifted towards comfort measures. He was
discharged to a long-term facility for hospice care.
Medications on Admission:
cabergoline 0.25mg twice a week
lipitor 10mg daily
viagra prn
metoprolol SR 200mg daily
lisinopril 40mg daily
glyburide 5mg daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough .
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebs Inhalation Q2H (every 2 hours) as
needed for SOB.
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY PRN () as needed
for pain: Leave on for 12 hours, then take off for 12 hours.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO DAILY
(Daily).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-8 Puffs Inhalation Q4H (every 4 hours).
9. Morphine 15 mg Tablet Sustained Release Sig: [**1-10**] Tablet
Sustained Releases PO Q4H (every 4 hours) as needed for pain.
10. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal EVERY 3 DAYS (Every 3 Days).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary: Hypoxic respiratory failure
Secondary: Pericarditis
Acute Kidney Injury
Diabetes Mellitus
Discharge Condition:
Comfortable.
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Mr. [**Known lastname **],
You were admitted to the hospital for fever, shortness of breath
and sputum production. You had chest pain and underwent cardiac
catheterization; your chest pain was ultimately believed to be
due to inflammation of the lining around your heart. You
required mechanical ventilation for a period of time, but you
were eventually able to breathe on your own. Our palliative care
specialists met with you to discuss further goals of care.
Medications not directed at comfort (e.g. shots for insulin and
blood thinners) were discontinued. You are being discharged to a
hospice facility where you can be made maximally comfortable.
Your further medication regimens will be specifically geared
towards your comfort.
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Name: [**Known lastname **],[**Known firstname 4049**] Unit No: [**Numeric Identifier 4050**]
Admission Date: [**2139-1-12**] Discharge Date: [**2139-2-10**]
Date of Birth: [**2074-8-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
Supplemental oxygen was added to discharge medications
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 163**] - [**Location (un) 164**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2139-2-10**]
|
[
"518.89",
"584.5",
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"E879.2",
"511.9",
"401.9",
"250.00",
"997.5",
"427.31",
"E849.7",
"486",
"278.00",
"799.02",
"518.81",
"E879.8",
"458.29",
"162.8",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.27",
"96.04",
"96.05",
"37.23",
"33.24",
"32.01",
"92.29",
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"96.72",
"38.93",
"88.43"
] |
icd9pcs
|
[
[
[]
]
] |
12940, 13183
|
8944, 9871
|
406, 433
|
11381, 11394
|
3953, 8921
|
12325, 12917
|
3294, 3599
|
10052, 11141
|
11258, 11360
|
9897, 10029
|
11564, 12302
|
3614, 3934
|
283, 368
|
461, 2473
|
11408, 11540
|
2495, 3033
|
3049, 3278
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,503
| 160,967
|
33429
|
Discharge summary
|
report
|
Admission Date: [**2161-7-6**] Discharge Date: [**2161-7-22**]
Date of Birth: [**2100-3-21**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents / lisinopril
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
MVC trauma
Major Surgical or Invasive Procedure:
ORIF left tibia [**2161-7-10**], ex-fix LLE [**2161-7-7**]
History of Present Illness:
Mr. [**Known lastname 77557**] was a restrained passenger in special needs [**Doctor Last Name **] that
crashed into stationary garbage truck. He presented to the [**Hospital1 18**]
ED with a right eyelid hematoma, blood in nasopharynx, obvious
lower ext fracture, bilat knee abrasions. He was responding to
commands in the ED but minimally verbal (but was able to state
his name).
Past Medical History:
PMH: Down syndrome, CHF, OSA, gout, atrial fibrillation, h/o
bilateral DVT, asthma, hypothyroidism, pulmonary embolus
PSH: none
[**Last Name (un) 1724**]: centrum, econazole', allopurinol 100", synthroid 125',
diovan, lasix 20', miconazole, amiodarone 100 mg qod, advair,
aspirin 325', omeprazole 40'
Social History:
Lives in a group home for individuals with special needs. Has a
sister who visits him and who lives in [**State 531**].
Pertinent Results:
Imaging:
[**2161-7-6**] CT Head: r front cont/IPH/SAH, Temp sm SAH
[**2161-7-6**] CT C-Spine degenerative changes most pronounced at
C5-C6 with posterior disc osteophyte complex causing moderate
canal narrowing
[**2161-7-6**] CT C/A/P Lproximal clavicular fx, r 1st rib fx
[**2161-7-6**] B/l knee xr: 1. Comminuted intra-articular fracture of
the proximal left tibia with left fibular head fracture as well.
2. hondrocalcinosis suggestive of CPPD.
[**2161-7-6**] Left tibial xr: 1. Tibial soft tissue swelling with
proximal tibial and fibular fractures, better assessed on the
accompanying knee radiographs.
[**2161-7-6**] CT maxillofacial: 1. Dislocated left TMJ with possible
mandibular head fracture. ?chronic. 2. [**Doctor Last Name 25971**] of hyperdensity in
the right orbit could reflect calcification versus fracture
versus foreign body. Right periorbital and preseptal hematoma
without retrobulbar extension. 3. Left intraconal lesion, likely
a hemangioma, can be further assessed with MRI with contrast.
[**2161-7-7**] AM: CT head: int increase R IPH, evolution R SAH
[**2161-7-7**] PM: CT head: min interval change
[**2161-7-8**] MRI C-spine: Degenerative changes. Mild prominence of
canal at C6/7 w/o acute cord injury
[**2161-7-8**] R knee plain film: Small-to-moderate lipohemarthrosis,
suggesting fracture
[**2161-7-11**]: CT RLE - no fx line despite sm joint effusion
[**2161-7-13**]: Head CT - Stable hemorrhagic contusion of the right
inferior frontal lobe. Decreased in amount of scalp swelling.
Resolving small hematoma in the left orbit. Small fracture of
the temporal bone adjacent to the temporomandibular joint.
Status post mastoidectomy
[**2161-7-13**] x2: CXR - mod to severe pulm edema, atelectasis, mod
stable cardiomegaly
[**2161-7-14**]: CXR - *WET READ* worsening pulm edema, L pleural
effusion v consolidation
[**2161-7-15**]: TTE - Mild LV hypokinesis w/ low normal LV systolic
function. Moderate to severe MR w/ rheumatic appearing mitral
leaflet and prolapse of the posterior leaflet. Borderline pulm
HTN. ASD w/ L to R shunting at rest.
Brief Hospital Course:
In brief, on imaging on initial evaluation, he was found to have
a Left TMJ dislocation, a left proximal clavicular fracture, a
right posterior first rib fracture, left upper and lower lobe
opacities (possibly secondary to aspiration), a
periorbital/preseptal right hematoma, a right frontal lobe
contusion, a small right frontal SAH, a left proximal tibial
fracture, a right frontal intraparenchymal hemorrhage and a left
parafalcine subdural hemorrhage.
He was admitted to TSICU for frequent neuro checks and repeat
head CTs. He was taken to the operating room by orthopedics on
[**2161-7-7**] for an ex-fix of his left lower extremity which was
subsequently open reduced and internally fixated on [**2161-7-10**]. He
had some difficulty w/somnolence during post-op period as well
as apnea and resultant hypoxia in the setting of dilaudid for
pain. He gradually improved in mental status as narcotis were
weaned and was transferred to floor on HD 6.
He was returned to the TSICU on HD 8 after hypoxia to 80s on
floor. CXR on the evening prior to re-admit to TSICU showed
stable moderate pulm edema. He was intubated, further diuresed,
bronched and continued on antibiotics. He was ultimately
extubated without incident.
At time of discharge, he was afebrile, tolerating a honey
thickened liquid diet (after a video swallow eval). Largely
immobile, he will need continued physical therapy needs.
By systems:
Neuro: Head polytrauma as noted above. Serial head CTs were
done which were initially stable then improving. Neurosurgery
recommends follow up in early [**Month (only) **] with a noncontrast head
CT. Please see discharge instructions for further info. His
mental status improved with time. His c-collar was cleared on
HD 3 after a spinal MRI did not show evidence of spine defects.
He was dosed intermittently for seroquel for insomnia and
tolerated it well. Ophthalmology was consulted for the
periorbital trauma and stated injuries were non-operative.
CV: Was initially on pressors then weaned. Subsequently
restarted on pressors on readmission to the ICU. His pressor
drips were weaned without incident but he was started on
midodrine for a couple days to support his systolics in the 90s.
He tolerated it well and was eventually weaned from it without
issue. At time of discharge he was hemodynamically stable, off
all forms of pressors for several days with no active issues. Of
note, he was on amiodarone per baseline for paroxysmal afib.
This was stopped on [**7-16**] after a few brief episodes of
bradycardia and overall normal heart rate. This was discussed
with his PCP who recommended discontinuation until follow-up
with him (PCP) at which point he will determine its
recontinuation based on discussion with his outpatient
cardiologist.
Resp: Initially intubated for operating room trips and extubated
without incident. There was some concern for aspiration early
on but this did not manifest or become a major issue. Upon
transfer to the floor on HD 6 he was doing overall quite well
then suddenly became hypoxic in the setting of pulling off his
supplemental O2 but also had bilateral rhonchi and a worsening
CXR. Secretions were cleared with a bronchoscopy and after
several more days of diuresis and careful management of his
fluid status (PRN lasix), he was extubated on [**7-20**] without
incident. Of note, please see ID section for additional info,
his BAL from [**7-15**] was shown to grow MSSA and he was started on
levofloxacin for an 8 day course - last day to be [**2161-7-23**]. He
was treated with albuterol and ipratropium nebs q6h and as
needed during this hospitalization.
GI: Failed multiple speech and swallow evals early in his
hospitalization. This was attributed to his mental status and
somnolence. Ultimately he tolerated POs (especially during his
transfer to the floor). He was NPO on readmit to the ICU due to
intubation and respiratory issues, then after extubation failed
a swallow eval but passed a video swallow the subsequent day and
was cleared for honey thickened liquids with aspiration
precautions and with supervised feeds. Lansoprazole (home
regimen) for stress ulcer prophylaxis.
GU/FEN: Initially low UOP. FeUrea showed pre-renal picture, was
fluid resuscitated as appropriate. Had a foley catheter which
was replaced when appropriate. By time of discharge was making
excellent urine with no active renal issues. During the
hospitalizaton he had some issues with hypernatremia, with Na as
high as 153. His maintainance fluids were switched to D5W and
his sodium was normal for the final 9 days of his
hospitalization (139 on discharge). Home dose lasix 20 mg PO
(crushed)was started and we recommend its continuation.
Heme: He was started on fondaparinux (heparin allergy) for
routine DVT prophylaxis in the setting of long bone fractures.
We recommend that he continue on DVT prophylaxis while at rehab,
preferably fondaparinux.
He received several units of blood early in the hospitalization
in the postoperative period after his orthopedic procedures. He
was additionally transfused as needed to keep his Hct at or
above 25 given his cardiac history. Regarding his need for
coumadin -- this was discussed with his PCP who made it clear
that long-term anticoagulation was no longer indicated and he
was not continued on this medication while in the hospital.
ID: Mr. [**Known lastname 77557**] had a pneumonia and UTI on this hospitalization.
Was initially on ancef, then antibiotics were empirically
broadened to a regimen which included vancomycin, cefepime and
ceftriaxone. BAL and urine culture from [**7-15**] grew MSSA and
pseudomonas, respectively, both sensitive to levofloxacin. His
other antibiotics were discontinued; he was started on an 8 day
course of levofloxacin. He should receive levofloxacin until
and including [**2161-7-23**].
Musculoskeletal: Othopaedic polytrauma as noted. Was taken to
the OR twice by ortho surgery - they recommend f/u in clinic and
touch-down weight bearing on the LLE. Has [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6587**] brace -- to
be unlocked only when working w/ PT, no brace needed in bed. No
intervention for clavicular fracture. Please see discharge
paperwork for follow-up information. Oromaxillofacial surgery
evaluated TMJ and mandible with subsequent no indication for
operative intervention.
Endocrine: Known hypothyroidism, stable, continued home dose 125
synthroid and recommend its continuation upon discharge. For
Vitamin D deficiency, started on repletion of 50,000 units
qweekly x 6 weeks (1st dose 8/9; dose Qwednesday x 6 -- i.e.
needs 4 more doses at rehab and beyond).
TLD: Has a right IJ central line placed [**2161-7-10**].
Medications on Admission:
[**Last Name (un) 1724**]: centrum, econazole', allopurinol 100", synthroid 125',
diovan, lasix 20', miconazole, amiodarone 100 mg qod, advair,
aspirin 325', omeprazole 40'
Discharge Medications:
1. senna 8.6 mg Tablet [**Last Name (un) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. fondaparinux 2.5 mg/0.5 mL Syringe [**Last Name (un) **]: 2.5 mg
mg Subcutaneous DAILY (Daily).
3. docusate sodium 50 mg/5 mL Liquid [**Last Name (un) **]: One Hundred (100) mg
PO BID (2 times a day).
4. bisacodyl 10 mg Suppository [**Last Name (un) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. ergocalciferol (vitamin D2) 50,000 unit Capsule [**Last Name (un) **]: One (1)
Capsule PO 1X/WEEK (WE) for 4 weeks.
6. glucagon (human recombinant) 1 mg Recon Soln [**Last Name (un) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. levothyroxine 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb
neb Inhalation Q2H (every 2 hours) as needed for SOB/wheezing.
10. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob/wheezing.
11. furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. acetaminophen 1,000 mg/100 mL (10 mg/mL) Solution [**Last Name (STitle) **]: 1000
(1000) mg Intravenous Q6H (every 6 hours) as needed for
fever/pain.
13. dextrose 50% in water (D50W) Syringe [**Last Name (STitle) **]: One (1) amp
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
14. levofloxacin in D5W 750 mg/150 mL Piggyback [**Last Name (STitle) **]: Seven
[**Age over 90 1230**]y (750) mg Intravenous Q24H (every 24 hours) for 1
days: Please stop after [**7-23**] dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Orthopedic polytrauma (including TMJ dislocation, nondisplaced
mandibular fracture, left clavicular fracture, right posterior
first rib fracture, left proximal tibial fracture), head trauma
with hemorrhage (right frontal contusion, right frontal
intraparenchymal hemorrage, left parafalcine SDH, small right
frontal SAH)
Discharge Condition:
Mental Status: Clear and coherent with baseline deficits due to
Down's syndrome
Level of Consciousness: Alert and interactive.
Activity Status: Touch-down weight bearing on LLE. Out of Bed
with assistance to chair or wheelchair.
Discharge Instructions:
You were admitted after a motor vehicle collision in which you
were a passenger. You suffered multiple injuries including to
your head, collar bone, and leg. The orthopedic surgeons took
you to the OR to fix bone injuries. You were also treated for a
pneumonia and urinary infection while admitted. You need two
more days of antibiotics which will be continued at the rehab
hospital. You have recovered well and are being discharged to a
rehab hospital to help you regain your full strength.
Followup Instructions:
Follow-up in [**Hospital 2536**] Clinic in 2 weeks. Call [**Telephone/Fax (1) 600**] to
schedule the appointment.
Follow up with orthopaedic surgery, Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 1228**],
in 2 weeks.
Followup with neurosurgery in 2 weeks with a repeat CT without
contrast. Please call [**Telephone/Fax (1) 1669**] to schedule the appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2161-7-22**]
|
[
"272.0",
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"823.12",
"801.11",
"E813.1",
"599.0",
"482.41",
"V12.51",
"274.9",
"493.90",
"327.23",
"995.91",
"428.0",
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"427.31",
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"758.0",
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"807.01",
"830.0",
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"851.81",
"038.9",
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"268.9",
"810.01",
"276.0",
"285.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"84.72",
"78.17",
"78.67",
"79.06",
"96.72",
"33.24",
"96.04",
"38.97",
"96.6",
"86.59",
"79.36",
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] |
icd9pcs
|
[
[
[]
]
] |
12179, 12249
|
3351, 10084
|
296, 356
|
12614, 12614
|
1253, 1277
|
13390, 13897
|
10308, 12156
|
12270, 12593
|
10110, 10285
|
12870, 13367
|
246, 258
|
384, 769
|
2359, 3328
|
12629, 12846
|
791, 1096
|
1112, 1234
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,968
| 146,944
|
26844
|
Discharge summary
|
report
|
Admission Date: [**2110-4-18**] Discharge Date: [**2110-4-26**]
Service: MEDICINE
Allergies:
Ace Inhibitors / Captopril / Penicillins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
found unresponsive by daughter
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
86 yoM with largely unknown past medical history, found down on
kitchen floor by daughter [**4-17**]. EMS activated, per records
found patient unresponsive with no pulse, WCT ?VT noted.
Patient was given defibrillation x1, noted "sinus tachycardia"
120 bpm post cardioversion. Recorded SBP 86/p.
In [**Hospital1 18**] ER, patient subsequently urgently intubated secondary
to respiratory distress. ER concern for sepsis given
hypotension, leukocytosis, and possible pneumonia, so "code
sepsis" activated with placement of central venous lines,
obtainment of cultures, and administration of antibiotic
(vanc/levo/zosyn).
Patient given total 8 L IVF in ER, MAP ~65, started on
norepinephrine vasopressor for hemodynamic support. Transferred
to [**Hospital Unit Name 153**] for further therapy, arriving intubated and sedated.
Per family, patient complained of "cold-like" symptoms for 5
days prior to admission. Last contact 2 days before being found
down.
Meds (in ER): Vancomycin 1g, Zosyn, Levofloxacin, Decadron 6 mg
IV.
Past Medical History:
Largely unknown. Per ER, patient living alone, no current
medical issues.
Social History:
Lives alone, fully functional, family in area.
Family History:
Non contributory
Physical Exam:
PE: T 99.7, BP 124/82, P96, R14
Gen: Sedated,
CV: S1 S2 with no MRG
Lungs: Rare wheezes bilateral anterior fields
Abd: Soft, NT/ND
Ext: 1+ bilateral pitting edema
Neuro: Moves all extremities, reacts to painful stimuli. No
signs of trauma.
Pertinent Results:
CXR:
Endotracheal tube is terminating approximately 5 cm above the
carina. Nasogastric tube is coursing down below the left
hemidiaphragm, and terminating in right upper quadrant. Cardiac
and mediastinal contours are within normal limits for age, given
the positioning. Right costophrenic angle is not included.
Patchy opacities are seen in bilateral lower lobes, which may
represent atelectasis versus aspiration.
IMPRESSION: Tubes and lines as described above. Bibasilar patchy
opacities, representing atelectasis or aspiration.
.
Head CT:
IMPRESSION:
1. No evidence of hemorrhage.
2. There is white matter hypodensity near the trigone of the
left lateral ventricle without extension to the [**Doctor Last Name 352**] matter that
may represent sequela from chronic small vessel disease.
3. Left thalamic and caudate lacunar infarcts.
.
Repeat CXR: FINDINGS: The cardiomediastinal silhouette is
stable. Again seen are bilateral basilar parenchymal opacities,
which demonstrate no significant change compared to prior
examinations. There are likely small bilateral pleural
effusions.
IMPRESSION:
1. Slight improvement in bilateral basilar pulmonary opacities,
right more prominent than left with differential diagnosis
including aspiration versus pneumonia.
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2110-4-24**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Blood Cultures: negative
Urine Cultures: negative
.
C1 esterase inhibitory assay: pending at time of discharge
[**2110-4-17**] 08:00PM BLOOD WBC-14.7* RBC-4.51* Hgb-14.6 Hct-43.2
MCV-96 MCH-32.5* MCHC-33.9 RDW-13.6 Plt Ct-272
[**2110-4-23**] 05:36AM BLOOD WBC-23.0*# RBC-4.37* Hgb-14.3 Hct-40.8
MCV-93 MCH-32.6* MCHC-35.0 RDW-14.3 Plt Ct-514*
[**2110-4-26**] 07:40AM BLOOD WBC-18.8* RBC-4.36* Hgb-14.6 Hct-40.9
MCV-94 MCH-33.4* MCHC-35.7* RDW-14.5 Plt Ct-644*
[**2110-4-25**] 07:40AM BLOOD Neuts-82* Bands-1 Lymphs-12* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-3*
[**2110-4-21**] 05:25AM BLOOD Ret Aut-0.6*
[**2110-4-25**] 07:40AM BLOOD Glucose-145* UreaN-33* Creat-1.0 Na-142
K-4.0 Cl-104 HCO3-29 AnGap-13
[**2110-4-20**] 05:05AM BLOOD ALT-30 AST-54* AlkPhos-52 TotBili-0.5
[**2110-4-18**] 02:12AM BLOOD ALT-29 AST-104* LD(LDH)-363* AlkPhos-50
TotBili-1.3
[**2110-4-17**] 08:00PM BLOOD cTropnT-0.35*
[**2110-4-18**] 06:06AM BLOOD CK-MB-124* MB Indx-9.5* cTropnT-3.36*
[**2110-4-18**] 02:07PM BLOOD CK-MB-110* MB Indx-8.8* cTropnT-3.37*
[**2110-4-21**] 05:25AM BLOOD calTIBC-156* VitB12-406 Folate-5.0
Hapto-357* Ferritn-1171* TRF-120*
[**2110-4-23**] 05:36AM BLOOD Triglyc-213* HDL-20 CHOL/HD-8.9
LDLcalc-115
[**2110-4-18**] 06:06AM BLOOD TSH-5.4*
[**2110-4-22**] 04:33AM BLOOD C4-34
[**2110-4-17**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2110-4-17**] 08:12PM BLOOD Glucose-376* Lactate-5.3* Na-141 K-4.1
Cl-101 calHCO3-21
[**2110-4-18**] 05:28AM BLOOD Lactate-2.6*
[**2110-4-18**] 02:24AM BLOOD freeCa-1.03*
Brief Hospital Course:
86 yoM with unknown past medical history presents after being
found unresponsive by family member. [**Name (NI) **] had prodrome of
cold-like symptoms per report. It is unclear what was the
precipitant of the profound weakness / loss of consciousness,
but concern exists for cardiac etiology in addition to infection
/ sepsis. The patient was not "down" for long (likely << 24h)
given absence of profound volume depletion, minimal CK
elevation. No evidence of trauma. He was initially transferred
to the ICU for treatment. Hospital course is discussed by
problem.
.
ID - Blood cultures were drawn, negative for growth. Given the
patient's low grade temperature elevation and leukocytosis, as
well as the history of "cold-like" symptoms experienced by
patient, pneumonia was thought to be the most likely source of
infection. An initial CXR demonstrated an early PNA consistent
with aspiration, so he was started on empiric coverage with
vancomycin/levofloxacin/Flagyl. The patient went into
respiratory distress secondary to sepsis/pneumonia, and the
patient required intubation. He was later successfully
extubated. The patient rapidly improved and his lactate
normalized. His antibiotic coverage was narrowed to
Levofloxacin only and finished a seven day course prior to
discharge.
.
CV - Possible arrhythmic impetus (VT, less likely VF given
period on floor) in setting of unknown history of vascular
disease. An EKG demonstrates LBBB, which could be chronic and
indicate significant CAD. Given his NSTEMI, with troponin up to
>3.0 and an index of 8, cardiology was consulted for further
recommendations. Given that the patient was shocked,
hypotensive, and septic; this may have all contributed to the
troponin elevation. He underwent an echocardiogram with report
as follows: 1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity
size. Overall left ventricular systolic function is difficult to
assess but is
probably moderately depressed. Overall left ventricular systolic
function
cannot be reliably assessed.
3. The aortic root is mildly dilated.
4. The aortic valve leaflets are severely thickened/deformed.
There is
probably mild to moderate aortic valve stenosis.
5. The mitral valve leaflets are mildly thickened. There is
moderate
thickening of the mitral valve chordae. At least mild (1+)
mitral
regurgitation is seen. The mitral regurgitation jet is
eccentric. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly
underestimated.]
He was started on a beta-blocker, aspirin, high dose Statin, and
an ACE inhibitor for medical management. In addition, a heparin
drip was administered for 48 hours. However, a few hours after
the second dose of Captopril, the patient developed severe
angioedema with lip and tongue swelling. The patient was given
Epi, Benadryl, IV steroids and ranitidine immediately, and
anesthesia was consulted for possible intubation, as well as the
ICU team. The patient was transferred back to the ICU for
airway monitoring, but was able to be medically managed without
intubation. Allergy service was consulted, and felt that this
was consistent with an ACE-I allergy rather than a C-1
deficiency. The C-1 assay was sent to rule out deficiency, with
the results still pending at the time of discharge. The
patient's PCP was [**Name (NI) 653**], and a follow-up appointment with an
outside cardiologist was arranged prior to discharge. He was
also started on Norvasc to help optimize his blood pressure
control.
.
Renal- He was initially in acute renal failure, with a
creatinine of 1.8 on admission. Although his baseline was
unknown, it resolved to 1.1. His Foley was discontinued, and he
urinated without difficulty. A microalbumin was sent, which was
negative, therefore initiating [**First Name8 (NamePattern2) **] [**Last Name (un) **] was deferred by now.
According to the allergy service, there is some risk of allergy
with [**Last Name (un) **], although very low.
.
Endocrine- Given that he had a history of "borderline" diabetes,
he was monitored with FS QID and covered with an ISS,
particularly in the setting of steroids for angioedema. A free
T4 was normal, and a urine for microalbumin shows alb/creatinine
ratio 27.6.
.
Heme- He was found to have anemia, normocytic, hct since
admission 33-38, then improved to 40. He was guaiac negative,
and iron studies were consistent with anemia of chronic disease.
.
He was evaluated by PT and was cleared for a home discharge with
services. His PCP was [**Name (NI) 653**] prior to discharge, and the
patient was scheduled for a follow-up appointment within one
week of discharge.
Medications on Admission:
excedrin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
vna carenetwork
Discharge Diagnosis:
Principal:
1. Multilobar Pneumonia.
2. Septic Shock.
3. Wide Complex Tachycardia NOS.
4. Non ST Elevation Myocardial Infarction.
5. Acute ACE-I Angioedema with Airway Compromise.
6. Acute Renal Failure.
7. Left Thalamic and Caudate lacunar infarcts - chronic.
Secondary:
1. Diabetes Mellitus Type II.
2. Chronic Kidney Disease Stage I.
3. Hypercholesterolemia.
4. Hypertension.
5. Psoriasis.
Discharge Condition:
Good
Discharge Instructions:
We have started you on four new medications for your heart.
Please continue to take these and all of your medications as
instructed. Please call your doctor or return to the hospital
if you develop chest pain, difficulty breathing, fevers or
chills.
You develop a severe allergic reaction called angioedema when
you take a medication called ACE inhibitors. Please refrain
from ever taking this type of medication.
Followup Instructions:
1. You have a scheduled appointment with Dr. [**Last Name (STitle) 66070**] at [**Hospital 1411**]
Medical Associates on Monday [**4-28**] at 14:15. It is important
that you go to this appointment.
2. You will also need follow-up with a cardiologist. We have
scheduled an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiologist) at
[**Hospital 1411**] Medical Associates (his office is next to Dr.[**Name (NI) 66071**]
office) on [**5-5**] at 09:15 in the morning. Please call his
office at [**Telephone/Fax (1) 66072**] if you have any questions.
|
[
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"250.02",
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"410.71",
"584.9",
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"428.0",
"403.91",
"285.29",
"427.89",
"995.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10064, 10110
|
4822, 9513
|
277, 290
|
10547, 10554
|
1833, 2367
|
11018, 11615
|
1531, 1549
|
9572, 10041
|
10131, 10526
|
9539, 9549
|
10578, 10995
|
1564, 1814
|
207, 239
|
318, 1352
|
2376, 4799
|
1374, 1451
|
1467, 1515
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,125
| 103,452
|
5221
|
Discharge summary
|
report
|
Admission Date: [**2147-1-2**] Discharge Date: [**2147-1-9**]
Date of Birth: [**2089-4-7**] Sex: F
Service: OME
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
female with a history of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease and
metastatic renal cell carcinoma being admitted for cycle one,
week one high dose IL2 therapy. Her oncologic history began
in [**2130**], when she was diagnosed with bilateral renal masses
consistent with renal cell carcinoma and underwent bilateral
partial nephrectomy. She did well until [**2139-9-9**], when
disease progression was noted in her right kidney and a liver
lesion was noted. Needle biopsy of the liver lesion
confirmed metastatic renal cell carcinoma. She received IL2
and Interferon phase III protocol with stable disease. She
underwent resection of an isolated thyroid met in [**2141-12-9**], and had radiofrequency ablation of renal masses in
[**2142**], [**2143**], and [**2144**]. Recent scans revealed progression of
disease in her liver and an enlarging mass in her left
kidney. She was planned for high dose IL2, but developed
pyelonephritis/urosepsis and was hospitalized from
[**2146-12-14**], through [**2146-12-19**], for intravenous fluids and
intravenous antibiotics. She has recovered well and
completed her last antibiotic dose this morning. Her MG has
returned to 100 percent. She is now being admitted for cycle
one, week one high dose IL2 therapy.
PAST MEDICAL HISTORY: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease.
History of seizures.
Recent urosepsis.
History of hemangioma, status post cerebellar resection times
two.
Hypothyroidism.
ALLERGIES: Levofloxacin causes a rash.
MEDICATIONS ON ADMISSION:
1. Levoxyl 50 mcg p.o. daily.
2. Phenobarbital 64.8 mg p.o. three times a day.
3. Fosamax 70 mg p.o. weekly.
PHYSICAL EXAMINATION: General reveals a well appearing
middle age female in no acute distress. Vital signs revealed
temperature 97.8 heart rate 68, respiratory rate 20, blood
pressure 136/83, oxygen saturation 96 percent in room air.
Head, eyes, ears, nose and throat is normocephalic and
atraumatic. Sclera anicteric. The mucous membranes are
moist without lesions. The neck is supple, no jugular venous
distention. Lymph nodes - No cervical, supraclavicular,
axillary or bilateral inguinal lymphadenopathy. Heart is
regular rate and rhythm, S1 and S2, without murmurs, rubs or
gallops. The chest is clear to percussion and auscultation
bilaterally. Abdomen is soft, positive bowel sounds,
rounded, soft, nontender, no hepatosplenomegaly or masses.
Extremities revealed no lower extremity edema. Skin intact
without breakdown. On neurologic examination, the patient is
alert and oriented times three. Speech clear and fluent.
She is moving all extremities well with strength 5/5.
LABORATORY DATA: On admission, white blood cell count 5.0,
hemoglobin 15.0, hematocrit 45.4, platelet count 323,000.
Blood urea nitrogen 26, creatinine 1.2. Sodium 136,
potassium 4.3, chloride 101, CO2 30, ALT 15, AST 18, LDH 138,
CK 24, alkaline phosphatase 156, total bilirubin 0.2, albumin
3.7, calcium 9.3, phosphorus 3.6, magnesium 1.9, uric acid
6.6. INR 1.0.
HOSPITAL COURSE: The patient was admitted for high dose IL2
therapy. Her admission weight was 56 kilograms and she
received Interleukin2 600,000 international units per
kilogram equaling 33.6 million units intravenously q8hours
times fourteen planned doses. During this week, she received
thirteen of fourteen doses with dose number four held related
to hypotension and hypoxia. Side effects initially included
chills improved with Demerol and nausea improved with Ativan.
She developed an erythematous pruritic skin rash treated with
topical lotion, as well as diarrhea improved with Lomotil.
On treatment day number five, she developed mild dyspnea on
exertion with oxygen saturation in the high 90s in room air
and examination consistent with small pleural effusions with
dullness at bilateral bases without crackles. She received
dose number thirteen of IL2 at approximately 3:00 p.m. and
three hours later became hypotensive requiring the initiation
of Dopamine. She developed crackles on her pulmonary
examination and was subjectively short of breath and 20 mg of
intravenous Lasix was given. She was started on Neo-
Synephrine to help support her blood pressure. She developed
mild chest pain and underwent electrocardiogram revealing
probable supraventricular tachycardia. Given need for
maximum doses of Dopamine and Neo-Synephrine with systolic
blood pressure remaining in the 80 range, she was transferred
to the Medical Intensive Care Unit for further management and
monitoring.
In the Medical Intensive Care Unit, she was fluid
resuscitated and cultured to rule out infection as a source
of her hypotension. She was maintained on Dopamine and Neo-
Synephrine for blood pressure support. During her initial
hypotension on seven [**Hospital Ward Name 1826**], she was also noted to be
hypoxic with an oxygen saturation in the mid 80s, markedly
improved with oxygen by face mask. She initially remained in
supraventricular tachycardia but ruled out for myocardial
infarction by CK and troponin. She was maintained overnight
in the Medical Intensive Care Unit with vasopressor support
slowly weaned. By the evening of [**2147-1-7**], her blood
pressure had stabilized and she had been weaned completely
off Neo-Synephrine. Her systolic blood pressure was
maintaining over 90 on Dopamine. Her oxygen saturation was
in the 90s in room air. She had spontaneously converted to
normal sinus rhythm after transfer to the Medical Intensive
Care Unit. Her Dopamine was successfully weaned down and was
discontinued early in the morning of [**2147-1-8**]. She
underwent echocardiogram on [**2147-1-9**], revealing left
ventricular wall thickness, cavity size and systolic function
to be normal with a left ventricular ejection fraction
greater than 55 percent. Regional left ventricular wall
motion normal. There was mild pulmonary artery systolic
hypertension and a small pericardial effusion without
echocardiographic signs of tamponade.
Laboratory abnormalities during this week included creatinine
rise to 2.6, improved to 2.1 on the day of discharge;
hyperbilirubinemia with a peak bilirubin of 3.8, improved to
1.7 on the day of discharge; metabolic acidosis with a
bicarbonate low at 16, improved to 25 on the day of
discharge; and an elevated alkaline phosphatase with peak
alkaline phosphatase [**Location (un) 1131**] of 383 on the day of discharge.
She had no transaminitis during her hospitalization. She
developed mild INR elevation on [**2147-1-7**], improved the next
day to 1.1 after Vitamin K administration, and she had no
evidence of myocarditis based on enzymes or echocardiogram.
She was mildly anemic with a hemoglobin of 12.1 and
hematocrit of 35.1 without need for packed red blood cell
transfusion. She was thrombocytopenic with a platelet count
low of 27,000 on the day prior to discharge which had
improved to 36,000 on the day of discharge. She had no
evidence of bleeding throughout her hospitalization. She
required intermittent electrolytes repletion throughout her
hospitalization. By [**2147-1-9**], she had recovered
sufficiently from side effects to allow for discharge to
home. She had significant weight gain of approximately
thirty pounds during her hospitalization. Her blood cultures
drawn during her Medical Intensive Care Unit stay were
negative. Her central line tip was sent for culture upon
discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with her husband.
DISCHARGE INSTRUCTIONS: The patient is to notify us for
persistent fever, chills or fluid retention.
MEDICATIONS ON DISCHARGE:
1. Nystatin 5 cc p.o. four times a day.
2. Keflex 500 mg p.o. twice a day times five days.
3. Ranitidine 150 mg p.o. twice a day p.r.n. nausea, acid
stomach or while taking nonsteroidals.
4. Lomotil one to two tablets p.o. q6hours p.r.n. diarrhea.
5. Compazine 10 mg p.o. q6hours p.r.n. nausea.
6. Ativan 1 mg p.o. q6hours p.r.n. nausea, anxiety or for
sleep.
7. Benadryl 25 to 50 mg p.o. q6hours p.r.n. pruritus.
8. Tylenol p.r.n.
9. Ibuprofen p.r.n.
10. Lasix 20 mg p.o. four times a day times five days or
until achieves baseline weight.
</DISCHARGE DIAGNOSIS>
Metastatic renal cell carcinoma, status post high dose IL2
therapy complicated by hypotension and hypoxia.
[**First Name11 (Name Pattern1) 449**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**MD Number(1) 21348**]
Dictated By:[**Last Name (NamePattern1) 18853**]
MEDQUIST36
D: [**2147-1-13**] 16:11:51
T: [**2147-1-14**] 12:10:55
Job#: [**Job Number 21349**]
cc:[**Numeric Identifier 21350**]
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Discharge summary
|
report
|
Admission Date: [**2132-7-14**] Discharge Date: [**2132-7-25**]
Date of Birth: [**2069-11-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Keflex / Latex
Attending:[**First Name3 (LF) 2006**]
Chief Complaint:
hypoxia, shortness of breath
Major Surgical or Invasive Procedure:
intubation
bronchoscopy and BAL
Arterial line
Double Lumen PICC
History of Present Illness:
This patient is a 62 year old female who complains of HYPOXIA.
Patient from rehab, tx from [**Hospital3 13313**] with Shortness
of breath (SOB) and hypoxia. She s/p right ankle surgery this
past week, on levaquin for pneumonia post op (started a week
ago, still on levoquin). She had a sudden worsening of
respiratory distress today with saturations in the 80s. Chest
x-ray at outside hospital shows infiltrates worse on the left
side. She is on Coumadin but INR only 1.7. Her outside doctor
he confirmed with her that she is DNR/DNI and currently refuses
intubation. 97% O2 saturations on non-RB. Given nebs X 3 en
route.
.
As per OMR note from Infectious disease (ID, OPAT), "she had
recent admission was for right foot hardware infection s/p
removal of external fixation device, found to have line-related
blood stream infection (Vancomycin resistant enterococcus - VRE,
CoNS), right foot osteomyelitis with VRE, ESBL Klebsiella, and
staph aureus (with hardware in place), urinary tract infection
(UTI) with ESBL klebsiella and possible PNA. Additionally,
patient has significant antibiotic allergies to penicillin (PCN)
and sulfa. PICC line was removed, subsequent cultures were
drawn. Recommended endocarditis eval bc of VRE, CoNS BSI.
Transthoracic echo (TTE) was negative for vegetations. For
treatment, ID recommended daptomycin for VRE blood stream
infection and daptomycin + meropenem for osteomyelitis; and
meropenem for UTI (ESBL klebsiella). Because the patient has
osteomyelitis with hardware in place, she requires indefinite
suppression, the VRE was sensitive to levofloxacin and will be
the [**Doctor Last Name 360**] for longterm oral suppression after pt completes 6-wk
course with daptomycin and meropenem. However, the meropenem was
stopped on [**7-6**] transiently and was re-instated on [**7-8**]."
.
In ED, initial vitals were: 96.7 94 124/76 24 97%
Non-Rebreather.
Exam was significant for b/l rhonchi no wheezing, no splinter,
rle in caste, neurovascular compromise, b/l edema noted. Labs
were significant for Hct of 25 baseline of 25-28, INR of 1.8.
Patient underwent Xray "multifocal PNA" per read. Patient was
given Vancomycin and meropenem. Patient was not seen by any
consults. Patient was admitted for multifocal PNA. Vitals prior
to transfer 97, 88, 134/72, 25, 95% NRB, 3 PIV.
.
On the floor, she appears to be comfortable.
.
Review of systems:
(+) Per HPI
Past Medical History:
DM c/b neuropathy
Charcot foot
chronic lower back pain,
spinal stenosis, s/p lumbar laminectomy/fusion 4 years ago
s/p I+D rt foot [**7-/2131**]
Hepatitis C
Depression
Hypertension
Obstructive Sleep Apnea on CPAP
Asthma
Social History:
-Retired nurse. Lives with parents.
-tobacco: quit smoking 7 months ago
-alcohol: none
-Drugs: none
Family History:
Diabetes
Physical Exam:
Admission Physical exam
Vitals: T: 97 BP:129/67 P:86 R: 18 O2: 95%
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
Discharge Physical exam
T 98.0, HR 81, BP 150/70, RR 20, 97%RA
General: A&Ox3, NAD resting comfortably in bed smiling,
minimally hoarse voice
HEENT: Sclera anicteric, dry MM, oropharynx clear
Lungs: CTA b/l, no wheezes or rhonchi, good expansion, no use of
accessory muscles
CV: 2/6 systolic murmur, regular rhythm, S1S2, no rubs or
gallops
Abdomen: soft, ND, NT, +BS, no rebound, no guarding
Ext: no e/c/c, 2+ peripheral pulses, spint and ace bandage of
right foot up to midcalf. Sensation and movement intact in toes
of right foot.
Pertinent Results:
Labs at admission:
[**2132-7-14**] 03:00PM BLOOD WBC-7.0# RBC-3.02* Hgb-8.0* Hct-25.3*
MCV-81* MCH-26.6* MCHC-32.6 RDW-14.8 Plt Ct-341
[**2132-7-14**] 03:00PM BLOOD Neuts-77.5* Lymphs-14.5* Monos-4.5
Eos-3.2 Baso-0.5
[**2132-7-14**] 03:00PM BLOOD PT-19.4* PTT-48.8* INR(PT)-1.8*
[**2132-7-14**] 03:00PM BLOOD Glucose-165* UreaN-14 Creat-0.9 Na-139
K-3.8 Cl-101 HCO3-31 AnGap-11
[**2132-7-14**] 03:00PM BLOOD ALT-25 AST-29 AlkPhos-270* TotBili-0.4
[**2132-7-14**] 03:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-1691*
[**2132-7-14**] 03:00PM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9
Micro:
[**2132-7-16**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-PRELIMINARY; LEGIONELLA CULTURE-PRELIMINARY;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; NOCARDIA
CULTURE-PRELIMINARY; ACID FAST SMEAR-PRELIMINARY; ACID FAST
CULTURE-PRELIMINARY INPATIENT
[**2132-7-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-7-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-7-16**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2132-7-14**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2132-7-14**] URINE URINE CULTURE-FINAL INPATIENT
[**2132-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-7-14**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE};
Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2132-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2132-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
Imaging:
CT chest [**7-15**]
INDICATION: 62-year-old woman with diabetes and diabetic
nephropathy and
hypoxia, to rule out pulmonary embolism.
TECHNIQUE: Contrast enhanced CT of thorax was performed using
the standard
department protocol to evaluate pulmonary embolism. Contiguous
axial images
at 5 mm and 2.5 mm slice thickness were reviewed concurrently
with coronal and
sagittal reformats. Comparison was made with limited available
sections from
a prior abdominal CT dated [**2132-6-24**].
FINDINGS:
PULMONARY ARTERY: The study is technically adequate for
evaluation of
pulmonary embolism. The main pulmonary artery proximal to
bifurcation
measures 3.9 cm in caliber and is enlarged suggestive of
pulmonary artery
hypertension. No filling defects seen within the main, lobar,
segmental and subsegmental branches to suggest pulmonary
embolism. No right heart strain or septal bulge.
LUNGS AND AIRWAYS: Central airways are patent till subsegmental
level.
Extensive multifocal pneumonic consolidation seen bilaterally
relatively
sparing the lower lobes basal segments. No areas of cavitation
seen within the
consolidation. Bilateral simple pleural effusions are minimal.
There is no
pneumothorax.
MEDIASTINUM: Multiple enlarged lymph nodes are seen in the
mediastinum and
the bilateral hilum, for example a precarinal lymph node
measures 1.9 x 1.4 cm
(4:14), right hilar node 13 x 10 mm (4:30) and a left hilar node
1.5 x 1.1 cm
(4:22). Heart is normal size without pericardial effusion.
ABDOMEN: The study is not tailored for evaluation of abdomen;
however,
limited views revealed partially imaged 4.0 x 5.4 cm lesion of
fluid
attenuation located in the lesser sac. This lesion is better
characterized on
the prior abdomen CT dated [**2130-6-25**] and kindly refer to
the
corresponding CT.
BONES: No bone lesion suspicious for malignancy or infection.
IMPRESSION:
1. There is no CT evidence of pulmonary embolism.
2. Extensive multifocal pneumonia involving both lungs.
3. Multiple enlarged mediastinal and hilar lymph nodes.
Findings were discussed with Dr. [**Last Name (STitle) **] over the phone on [**7-15**], [**2131**] at 5
p.m.
Echo [**7-15**]
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2132-6-25**], no
change.
EKG [**7-14**]
Sinus rhythm. No significant change compared to the tracing of
[**2132-6-29**]
CXR [**7-14**]
FINDINGS: Extensive opacification in the lungs bilaterally along
with
fullness of the hila and enlarged cardiomediastinal silhouette
concerning for
moderate-to-severe pulmonary edema. However slight asymmetry in
the opacities
could suggest infectious component. Left-sided PICC line is seen
with distal
tip not well seen, but possibly within the mid SVC. There is no
pleural
effusion or pneumothorax identified.
IMPRESSION:
1. Moderate-to-severe pulmonary edema worsened since the prior
studies.
2. PICC tip not well seen, possibly within the mid SVC.
Discharge labs:
[**2132-7-25**] 05:35AM BLOOD WBC-4.5 RBC-3.52* Hgb-9.4* Hct-27.5*
MCV-78* MCH-26.7* MCHC-34.2 RDW-16.6* Plt Ct-239
[**2132-7-19**] 04:02AM BLOOD Neuts-69.1 Bands-0 Lymphs-17.1* Monos-3.8
Eos-9.9* Baso-0.1
[**2132-7-25**] 05:35AM BLOOD Glucose-138* UreaN-19 Creat-1.1 Na-134
K-3.6 Cl-96 HCO3-27 AnGap-15
[**2132-7-23**] 04:12AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.1
[**2132-7-21**] 04:26AM BLOOD ANCA-NEGATIVE B
[**2132-7-23**] 04:28AM BLOOD Type-ART pO2-88 pCO2-45 pH-7.50*
calTCO2-36* Base XS-9
Brief Hospital Course:
Reason for admission: hypoxia and shortness of breath
62 yo female with diabetes, diabetic neuropathy and right sided
Charcot foot, status post (s/p) reconstruction and external
fixation, with recent right foot infection with hardware
infection/removal complicated by osteomyelitis, urinary tract
infection(UTI) and PICC line infection on daptomycin/meropenem,
and recent "PNA" at rehab on levofloxacin, presenting with
sudden onset of shortness of breath (SOB) with pulmonary
congestion and possible multifocal pneumonia (PNA).
.
Active Issues:
.
# Hypoxia: Had hypoxia during last admission, satting in 70s on
RA, then 84% on 6L NC. Albuterol, ipratropium nebs and
non-rebreather mask given then with O2 saturation recovered to
high 90s. She was diuresed and weaned off Lasix at discharge. On
review of her records, it seems that she had lasix as part of
her meds until [**5-12**], at which time she was not discharged on it.
Pt was continued on home meropenem, and started vancomycin
(concern for methicilin resistant staph aureus, MRSA, PNA) and
levofloxacin (concern for atypical PNA and VRE coverage). Her
daptomycin was held with concern for possible eosinophilic
pneumonia. Transthoracic echo (TTE) with bubble study was
obtained showing EF of 55%, otherwise normal. Patient was
intubated for bronchoscopy on [**7-16**] and remained intubated until
AM of [**7-22**] when she self-extubated on decreased sedation (for
planned extubation later that day). Bronchoscopy was done to
evaluate for eosinophilic pneumonia but there were minimal
eosinophils on BAL. She continued to improve clinically off
antibiotics (abx) for PNA given negative cultures (abx continued
for osteomyelitis). Patient transferred to the medicine floor
where her vital signs remained stable, she was breathing on room
air with lungs clear to auscultation bilaterally.
.
# Right foot/line/urinary tract infection: On [**2132-6-20**], she had
partial hardware/frame removal. Wound culture swab grew staph
aureus and klebsiella sensitive to gentamycin and meropenem.
Pin culture grew out klebsiella, staph aureus, and enterococcus
sensitive to daptomycin, gentamycin and bactrim. She also had
line infection- enterococcus and coagulase negative staph aureus
grew from PICC line culture on prior admission, which was pulled
on [**2132-6-23**]. Culture positive only from PICC line draw, not
peripheral draw or PICC tip. TTE was obtained on [**2132-6-25**], which
showed no evidence of endocarditis. She had evidence of a
klebsiella UTI, though this may be [**12-19**] colonization. Per ID
recommendation, she was started on [**Last Name (un) 2830**]/dapto, which pt started
[**2132-6-23**]. Podiatry recommended reimaging with xray prior to
discharge and planned to replace cast [**2132-7-17**]. On this admission,
patient was changed to Meropenem, Vancomycin, and Levofloxacin
given possibility of Dapto causing eosinophilic pneumonia.
Coverage was narrowed to [**Last Name (un) **] and Levo, at Infection disease
consult's suggestion. Podiatry was consulted who recommended a
new [**Hospital1 **]-valve, non-weight bearing cast for her right foot.
Patient remained afebrile with stable vital signs on the floor
and looked remarkably well. Plan is for her to follow up with
podiatry in 4 days to reassess weight bearing status. From an
infection stand point, she will need 4 additional weeks of IV
antibiotics ([**Last Name (un) 2830**] and levo).
.
#. Diminished hearing - Noted on admission, unclear etiology,
possibly secondary to medication toxicitiy, possibly lasix,
antibiotics also a consideration. Patient without current
complaints. Can consider audiology f/u as an outpatient.
.
#. Eosinophilia - unclear what etiology of this is, considered
allergic reaction to daptomycin, has since been discontinued.
Also consideration of latex allergy.
.
Chronic Issues:
.
# History of right upper quadrant pain: thought to be biliary
colic. Issue was not aggressively evaluated in the hospital. An
outpatient GI follow up appointment was made, which she can
consider or arrange an elective cholecystectomy in the future
should she choose to pursue that.
.
# Diabetes mellitus type II: Patient was on insulin sliding
scale during admission (using latex free insulin, Novolog) and
gabapentin was continued for neuropathic pain
.
# Hypertension: Blood pressure medications were held duing ICU
stay. Patient was given several doses of lasix for duiresis.
Blood pressure 150/70 on discharge. Can restart home
amlodipine.
.
# Low back pain - managed over admission with home fentanyl
patch, oxycodone prn. Patient additionally on a bowel regimen
and having BMs.
.
# Depression: outpatient regimen was continued - venlafaxine and
bupropion.
.
# Hypothyroid: home dose of levothyroxine was continued.
.
# Obstructive sleep apnea - on CPAP at home.
.
# Anxiety: Patient's home ativan was continued.
.
Transitional Issues:
Patient is returning to her previous rehabilitation facility,
[**Hospital 10478**] rehab, which is affiliated with her long term living
facility. The IV antbiotics can be given there. She will need
to be followed up with podiatry at [**Hospital1 18**] early next week.
Medications on Admission:
- aspirin 81 mg PO DAILY.
- polysaccharide iron complex 150 mg PO DAILY.
- amlodipine 10 mg PO DAILY.
- lorazepam 0.5 mg PO BID (2 times a day)
- levothyroxine 200 mcg PO DAILY
- oxycodone 15 mg Tablet PO Q4H PRN pain (held)
- fentanyl 50 mcg/hr Patch every 72 hours
- simvastatin 20 mg PO QHS
- gabapentin 300 mg PO QAM
- gabapentin 600 mg PO QPM
- venlafaxine 225 mg PO DAILY.
- Wellbutrin XL 300 mg ER 24 hr PO once a day.
- trazodone 500 mg Tablet PO HS PRN insomnia.
- senna 8.6 mg Tablet PO DAILY
- docusate sodium 100 mg PO once a day PRN constipation.
- bisacodyl 10 mg PR DAILY PRN constipation.
- acetaminophen 650 mg PO once a day as needed for pain.
- Milk of Magnesia PO once a day as needed for constipation.
- Fleet Enema 19-7 gram/118 mL once a day PRN constipation
- Novolin 70/30 suspension 25 units Subcutaneous qAM.
- Novolin 70/30 Suspension 20 units Subcutaneous qPM.
- insulin lispro as directed Subcutaneous as directed.
- meropenem 1 gram IV Q8H
- daptomycin 800 mg IV Q24H
- Vitamin D3 50,000 UI po qWEEK
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. polysaccharide iron complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
3. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. trazodone 100 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime) as needed for insomnia.
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO PRN (as needed) as needed for constipation.
13. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
16. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO every [**2-20**]
hours as needed for pain.
17. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
18. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed.
19. Vitamin D 5,000 unit Tablet Sig: One (1) Tablet PO once a
week.
20. Novolin 70/30 100 unit/mL (70-30) Suspension Sig: One (1) 25
units Subcutaneous once a day.
21. Novolin 70/30 100 unit/mL (70-30) Suspension Sig: One (1) 20
units Subcutaneous at bedtime.
22. meropenem 1 gram Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 4 weeks: last dose on [**2132-8-27**].
23. Outpatient Lab Work
Please check CBC with differential, BMP, LFT, CK, ESR, CRP
weekly starting on [**2132-7-28**]. Please fax results to the
Infectious Disease RN at ([**Telephone/Fax (1) 4591**]. Call ([**Telephone/Fax (1) 21403**] with
any questions.
24. levofloxacin 25 mg/mL Solution Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous once a day for 4 weeks: last dose on
[**2132-8-27**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 13316**]Healthcare Center - [**Hospital1 10478**]
Discharge Diagnosis:
Primary Diagnosis:
Multifocal Pneumonia
Pulmonary congestion
Right Foot osteomyelitis with ESBL kelbsiella, MRSA, VRE
Secondary diagnosis:
DM c/b neuropathy
Charcot foot
chronic lower back pain,
spinal stenosis, s/p lumbar laminectomy/fusion 4 years ago
s/p I+D rt foot [**7-/2131**]
Hep C
depression
HTN
OSA on CPAP
asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 87206**],
You were admitted to the hospital because you were having
shortness of breath and difficulty getting oxygen into your
blood. You had several chest xrays and a CT scan of your chest
that showed a multifocal pneumonia as well as fluid in your
lungs, both of which were causing you to have difficulty
breathing. Because of this, if was felt that you should be
intubated. You were given lasix (a duiretic) to get the fluid
out of your lungs as well as antibiotics to treat the pneumonia
in your lungs in addition to the infection in your foot and in
your blood. You improved clinically, no longer needed to be
intubated and are now stable for discharge to rehab with
intravenous antibiotics to treat your infections, and follow up
with podiatry for your foot.
Please continue your home medications as prescribed.
The follwing changes were made to your home medications:
- STOP taking Daptomycin.
- CONTINUE to take the Meropenem IV 3 times per day until
[**2132-8-27**].
- START Levofloxacin IV once per day for until [**2132-8-27**].
- you will need to have weekly labs checked, with results faxed
to the infectious disease office
Dear Ms. [**Known lastname 87206**],
You were admitted to the hospital because you were having
shortness of breath and difficulty getting oxygen into your
blood. You had several chest xrays and a CT scan of your chest
that showed a multifocal pneumonia as well as fluid in your
lungs, both of which were causing you to have difficulty
breathing. Because of this, if was felt that you should be
intubated. You were given lasix (a duiretic) to get the fluid
out of your lungs as well as antibiotics to treat the pneumonia
in your lungs in addition to the infection in your foot and in
your blood. You improved clinically, no longer needed to be
intubated and are now stable for discharge to rehab with
intravenous antibiotics to treat your infections, and follow up
with podiatry for your foot.
Please continue your home medications as prescribed.
The follwing changes were made to your home medications:
- STOP taking Daptomycin.
- CONTINUE to take the Meropenem IV 3 times per day until
[**2132-8-27**].
- START Levofloxacin IV once per day for until [**2132-8-27**].
- you will need to have weekly labs checked, with results faxed
to the infectious disease office
Followup Instructions:
Department: PODIATRY
When: MONDAY [**2132-7-28**] at 11:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2132-7-29**] at 1:30 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2132-8-11**] at 10:10 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"713.5",
"276.3",
"327.23",
"311",
"724.2",
"401.9",
"493.90",
"389.9",
"250.60",
"288.3",
"428.0",
"518.81",
"486",
"730.27",
"E947.9",
"E930.8",
"V09.91",
"070.70",
"V45.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.24",
"93.90",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
19328, 19417
|
10662, 11193
|
353, 418
|
19786, 19786
|
4338, 10128
|
22328, 23277
|
3225, 3235
|
16913, 19305
|
19438, 19438
|
15857, 16890
|
19962, 20853
|
10145, 10639
|
3250, 4319
|
22042, 22305
|
15560, 15831
|
2833, 2847
|
285, 315
|
11208, 14500
|
446, 2814
|
19578, 19765
|
19457, 19557
|
19801, 19938
|
14516, 15539
|
2869, 3091
|
3107, 3209
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,060
| 195,456
|
16845+56806
|
Discharge summary
|
report+addendum
|
Admission Date: [**2161-7-14**] Discharge Date: [**2161-7-23**]
Date of Birth: [**2083-2-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Right LE ulceration with dry gangrene sceondary to ischemia
Major Surgical or Invasive Procedure:
1. Left CEA
2. R fem-AT bypass
History of Present Illness:
78 yM with rt foot ischemia with with dry gangrenous ulceration
secondary to heel pressure during hospitalization for
MI/CHF/CABG"Sx1 [**3-18**] Patient with known aorto-iliac and femoral
disease s/p ABF [**1-10**] returns for angio and possible surgery.
Past Medical History:
PVd,Dm2,neuropathy,retinopathy s/pOS laser ,hypelipdemia,CVA w
residual left side weakness [**2140**], polycythemia [**Doctor First Name **] s/p
phlebotomy,CAD,s/pMIwCHF,s/pCABG"SLima-lad,GBstones s/p
ccy,prostate ca s/p radium seeds
Pertinent Results:
[**2161-7-21**] 05:08AM BLOOD WBC-16.0* RBC-3.54* Hgb-10.8* Hct-32.1*
MCV-91 MCH-30.5 MCHC-33.7 RDW-19.4* Plt Ct-192
[**2161-7-20**] 03:48AM BLOOD WBC-14.9* RBC-3.43* Hgb-10.9* Hct-31.2*
MCV-91 MCH-31.7 MCHC-34.9 RDW-19.1* Plt Ct-175
[**2161-7-19**] 06:19PM BLOOD Hct-32.8*
[**2161-7-19**] 02:53AM BLOOD WBC-13.5* RBC-3.11* Hgb-9.7* Hct-26.8*
MCV-86 MCH-31.1 MCHC-36.1* RDW-18.8* Plt Ct-126*
[**2161-7-18**] 01:20PM BLOOD WBC-11.1* RBC-3.30* Hgb-10.0* Hct-29.4*
MCV-89 MCH-30.4 MCHC-34.2 RDW-18.2* Plt Ct-112*
[**2161-7-18**] 04:00AM BLOOD WBC-14.6* RBC-3.18* Hgb-9.8* Hct-28.7*
MCV-90 MCH-30.8 MCHC-34.1 RDW-19.9* Plt Ct-193
[**2161-7-17**] 04:57AM BLOOD WBC-12.0* RBC-3.34*# Hgb-10.1*#
Hct-30.1*# MCV-90 MCH-30.3 MCHC-33.7 RDW-19.6* Plt Ct-191
[**2161-7-16**] 05:49PM BLOOD WBC-11.1* RBC-2.54* Hgb-7.7* Hct-23.9*
MCV-94 MCH-30.4 MCHC-32.2 RDW-19.5* Plt Ct-190
[**2161-7-16**] 12:44PM BLOOD WBC-12.5* RBC-2.89* Hgb-8.8* Hct-27.2*
MCV-94 MCH-30.4 MCHC-32.3 RDW-19.4* Plt Ct-219
[**2161-7-16**] 05:40AM BLOOD WBC-11.8* RBC-3.29* Hgb-10.0* Hct-30.9*
MCV-94 MCH-30.4 MCHC-32.3 RDW-19.6* Plt Ct-215
[**2161-7-15**] 06:05AM BLOOD Hct-34.7*
[**2161-7-14**] 05:05PM BLOOD WBC-16.3* RBC-3.79*# Hgb-11.5* Hct-36.3*
MCV-96# MCH-30.2# MCHC-31.6 RDW-19.5* Plt Ct-305
[**2161-7-21**] 05:08AM BLOOD Plt Ct-192
[**2161-7-21**] 05:08AM BLOOD PT-13.8* PTT-58.4* INR(PT)-1.2*
[**2161-7-20**] 03:48AM BLOOD Plt Ct-175
[**2161-7-20**] 03:48AM BLOOD PT-14.0* PTT-47.3* INR(PT)-1.2*
[**2161-7-19**] 02:53AM BLOOD Plt Ct-126* LPlt-1+
[**2161-7-19**] 02:53AM BLOOD PT-15.7* PTT-37.2* INR(PT)-1.4*
[**2161-7-18**] 01:20PM BLOOD Plt Ct-112*
[**2161-7-18**] 01:20PM BLOOD PT-16.3* PTT-47.9* INR(PT)-1.5*
[**2161-7-18**] 04:00AM BLOOD Plt Ct-193
[**2161-7-18**] 04:00AM BLOOD PT-14.4* PTT-50.8* INR(PT)-1.3*
[**2161-7-17**] 04:57AM BLOOD Plt Ct-191
[**2161-7-17**] 04:57AM BLOOD PT-13.8* PTT-30.7 INR(PT)-1.2*
[**2161-7-16**] 12:44PM BLOOD Plt Ct-219
[**2161-7-16**] 12:44PM BLOOD PT-14.8* PTT-127.4* INR(PT)-1.3*
[**2161-7-16**] 05:40AM BLOOD Plt Ct-215
[**2161-7-16**] 05:40AM BLOOD PT-13.6* PTT-32.9 INR(PT)-1.2*
[**2161-7-14**] 05:05PM BLOOD Plt Ct-305
[**2161-7-14**] 05:05PM BLOOD PT-12.8 PTT-27.6 INR(PT)-1.1
[**2161-7-21**] 05:08AM BLOOD Glucose-106* UreaN-22* Creat-1.3* Na-135
K-3.9 Cl-100 HCO3-28 AnGap-11
[**2161-7-20**] 03:48AM BLOOD Glucose-48* UreaN-18 Creat-1.3* Na-135
K-3.6 Cl-102 HCO3-27 AnGap-10
[**2161-7-19**] 02:53AM BLOOD Glucose-66* UreaN-16 Creat-1.3* Na-134
K-4.6 Cl-104 HCO3-25 AnGap-10
[**2161-7-18**] 01:20PM BLOOD Glucose-167* UreaN-17 Creat-1.1 Na-133
K-3.4 Cl-102 HCO3-22 AnGap-12
[**2161-7-18**] 04:00AM BLOOD Glucose-164* UreaN-23* Creat-1.3* Na-135
K-3.7 Cl-100 HCO3-25 AnGap-14
[**2161-7-17**] 04:57AM BLOOD Glucose-71 UreaN-25* Creat-1.3* Na-138
K-3.9 Cl-102 HCO3-29 AnGap-11
[**2161-7-16**] 12:44PM BLOOD Glucose-139* UreaN-27* Creat-1.3* Na-141
K-4.4 Cl-107 HCO3-26 AnGap-12
[**2161-7-16**] 05:40AM BLOOD Glucose-105 UreaN-29* Creat-1.4* Na-138
K-4.5 Cl-101 HCO3-30 AnGap-12
[**2161-7-19**] 06:03AM BLOOD CK(CPK)-161
[**2161-7-18**] 10:20PM BLOOD CK(CPK)-182*
[**2161-7-18**] 01:20PM BLOOD CK(CPK)-53
[**2161-7-19**] 06:03AM BLOOD CK-MB-5 cTropnT-0.04*
[**2161-7-18**] 10:20PM BLOOD CK-MB-6 cTropnT-0.05*
[**2161-7-18**] 01:20PM BLOOD CK-MB-NotDone cTropnT-0.04*
Brief Hospital Course:
78 yM with rt foot ischemia with with dry gangrenous ulceration
secondary to heel pressure during hospitalization for
MI/CHF/CABG"Sx1 [**3-18**] Patient with known aorto-iliac and femoral
disease s/p ABF [**1-10**] returns for angio and possible surgery.
Patient was admitted and pre-hydrated for an angiogram. Angio on
[**2161-7-15**] revealed [**7-15**] angio: patent aobifem, occluded sfa, [**Doctor Last Name **]
disease, patent distal AT. AT & peroneal runoff. The patient
also had a carotid US which revelaed 80-99% stenosis of his left
carotid aretery. On [**2161-7-16**] Mr. [**Known lastname 47487**] was consented, prepped,
and brought down to the operating room for surgery.
Intra-operatively, he was closely monitored and remained
hemodynamically stable. He tolerated the procedure well without
any difficulty or complication. Post-operatively, he was
extubated and transferred to the PACU for further stabilization
and monitoring. He was noted to have a left neck hematoma, and
was given 2u of PRBC for a HCT of 23. He was then transferred
to the VICU for further recovery. On the floor, he remained
hemodynamically stable with his pain controlled. His Vitals
remained stable and his diet was advanced. On [**2161-7-19**] he
returned to the OR for a R fem-AT bypass. The patient was
monitored intraoperatively with a PA catheter and remained
stable. HE tolerated wht procedure without complication and was
transferred to the PACU then ICU pos-op due to hypotension
requiring pressor support. On POD #1 he remained stable and was
transferred to the VICU. He received 2u PRBC's. His blood
pressure was kept under tight control and diuresis was begun on
POD #2. On POD #3 the patient's PA catheter and CVL were
removed. His labs remained stable with the exception of a
slightly elevated WBC, which he had on admission, and he was
OOB. A PT consult was obtained, and his diet was advanced. His
pain was control on PO pain medications. The patient had a
palpable RLE graft and pulses on doppler. The patient continued
to progress well and was cleared for home with [**Last Name (un) **] PT. His labs
remained stable, and on POD #4 he was discharged to home with
VNA/PT. He will be partial weight bearing on his RLE for
essential distances until followup. He will be sent on a 10 day
course of bactrim. He will followup with Dr. [**Last Name (STitle) 1391**] in [**3-14**]
weeks.
Medications on Admission:
omeprazole 20mgm ',hydroxeurea 500mgm tabs2 q sunday,tab 1
M-Sat,lipitor10mgm',coreg6.25mgm(1/2tab) ",folic acid
1mgm',lasix40mgm',albuterol MDI prn,protonix 40mgm ',plavix
75mgm',asa81mgm'cingular 10mgmHS ,darvocet prn
70/30 humelin insulin 39units qam, 30 units q supper
Discharge Medications:
1. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO 1X/WEEK
([**Doctor First Name **]).
2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 6X/WEEK
(MO,TU,WE,TH,FR,SA).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
15. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: Thirty
Nine (39) u Subcutaneous QAM.
16. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: Thirty
(30) u Subcutaneous QPM.
17. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
home health
Discharge Diagnosis:
Left carotid stenosis
Right lower extremity vascular insufficiency
Discharge Condition:
Stable
Discharge Instructions:
[**Name8 (MD) **] M.D. if fever > 101.5, headache, vision changes, nausea,
vomiting, chest pain, shortness of breath, redness or drainage
from incision, numbness in foot/leg. You may shower and pat
incision dry with a towel, but not tub baths or swimming for 2
weeks. Leave steri-strips in place until they fall out. You may
take a regular diet. Resume all home medications. Do not drive
while taking narcotics. You may walk essential distances with
partial weight bearing on your left leg. Do not hang your leg
over the side of the bed - keep it elevated while seated and in
bed.
Followup Instructions:
Please call Dr.[**Name (NI) 1392**] office to schedule a followup in 2
weeks. [**Telephone/Fax (1) 1393**].
Please f/u with your PCP [**Last Name (NamePattern4) **] [**2-10**] weeks.
Completed by:[**2161-7-23**] Name: [**Known lastname 8782**],[**Known firstname 651**] Unit No: [**Numeric Identifier 8783**]
Admission Date: [**2161-7-14**] Discharge Date: [**2161-7-23**]
Date of Birth: [**2083-2-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
see d/c dx
Discharge Disposition:
Home With Service
Facility:
home health
Discharge Diagnosis:
congestive heart failure, systolic/diastolic
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2161-7-27**]
|
[
"440.24",
"433.10",
"250.60",
"V58.67",
"357.2",
"998.12",
"V10.46",
"428.0",
"238.4",
"V45.81",
"707.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"00.40",
"39.29",
"99.04",
"88.42",
"88.47",
"88.72",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
9876, 9918
|
4268, 6658
|
374, 407
|
8603, 8612
|
969, 4245
|
9241, 9853
|
6982, 8427
|
9939, 10142
|
6684, 6959
|
8636, 9218
|
275, 336
|
435, 692
|
714, 950
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,402
| 140,418
|
2633
|
Discharge summary
|
report
|
Admission Date: [**2154-1-17**] Discharge Date: [**2154-1-24**]
Date of Birth: [**2084-3-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Aleve
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Dark Maroon stools
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Capsule Study
History of Present Illness:
69yo F with ESRD on HD, CAD, DM, HTN, CHF who was recently
admitted with decreased Hct and chest pain. During the
admission, the pt received an EGD which demonstrated GAVE
(watermelon stomach) s/p APC (Argon Laser). She received 2units
of PRBCs during the previous admission. The pt also has a
history of colonic polyps from c-scope in [**2152**] s/p polypectomy.
The pt reports she has been feeling well since her last
admission. The pt had been tolerating PO diet without
difficulty. She had a "normal" BM this AM which was described
as [**Doctor Last Name 352**] in color, formed, without blood clots or streaks or any
odor. She subsequently had two BM at 14:00 and 16:00 which were
described as maroon colored, watery stools with significant
blood in the bowel. The pt has not had a BM since that time.
During this time, the pt admits to some amount of LH and
dizziness, especially with change in position. However she
denies any chest pain, palpitations, sob, falls, HA, change in
vision, numbness, weakness, tingling or loc. She also denies
any abdominal pain, n/v or change in diet/appetite. No f/c/r,
however the pt admits to occasional night sweats and occurs only
after HD. The night sweats are significant enough to force her
to change her pajamas and sheets. The pt denies any weight
change. The pt denies any recent use of NSAIDS.
.
In the ED, 2x pIV were placed, the pt was given protonix 40mg
IVx1 and she was given 1 unit or PRBC. The pt also received a
NGL which was found to be negative. (no blood with suction and
neg lavage). GI was consulted from the ED who recommend NPO
overnight and bowel prep tomorrow for EGD/Colonoscopy the
following day. Renal was also consulted in the ED and has
arranged for the pt to remain on her usual Mon, Wed, Fri
schedule of HD.
Past Medical History:
1. Type 2 diabetes mellitus complicated by nephropathy and
neuropathy.
2. ESRD on HD since [**November 2153**]
3. CAD: suspected by stress test in [**2153-5-22**], not reperfused.
4. CHF: TTE on [**2153-11-1**]. It showed a LVEF of 60 to 70% with 3+
MR and 2+ TR.
5. Anemia: Felt to be multifactorial from ESRD and also guiac
positive. Pt had a colonoscopy on [**2153-8-7**] significant for two
nonbleeding polyps in the sigmoid colon. She also had an EGD on
the same date which was significant for erythema, edema, and
erosion in the antrum compatible with gastritis in addition to
erythema in the proximal bulb compatible with duodenitis. No
bleeding was noted. EGD has since demonstated GAVE on 2'[**53**].
6. Occult GI bleed [**7-/2153**] with studies as above
7. Gout
Social History:
Pt lives alone in an [**Hospital3 **] community. She has a
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 13222**]. Son lives close by and helps
mother. [**Name (NI) **] ETOH, tobacco, or drugs.
Family History:
[**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. She has no
family history of CAD.
Physical Exam:
VS in ED: Tc: 98.9, HR: 104 -> 111 sitting up, BP: 141/60 -> 154
systolic, RR: 20, SaO2: 100% (orthostatics measured while
getting 1 unit of PRBCs).
GEN: well nutritioned elderly AA female in NAD, comfortable, no
accessory muscle use, conversing fluently in full sentences.
HEENT: EOMI, anicteric, mmm, op clear
NECK: no appreciable JVD
CV: tachycardia, s1, s2, ?1/6 SEM
CHEST: CTA bilaterally
ABD: obese, soft, NT, ND, BS+, ventral hernia
RECTAL: External non-bleeding hemorrhoids, brown guaiac positive
stool.
EXT: L UE fistula with thrill.
NEURO: A+O x3, strength 5/5 bilaterally in UE, LE not tested.
Gait not assessed.
Pertinent Results:
EGD [**2154-1-10**]:
Esophagus: Normal mucosa.
Stomach: Linear streaks of erythema of the mucosa with contact
bleeding and in a watermelon distribution was noted in the
antrum. These findings are compatible with GAVE. An Argon-Plasma
Coagulator was applied for hemostasis successfully.
Duodenum: Normal mucosa was noted from the duodenum to the
proximal jejunum. There were no blood or any bleeding lesions.
Impression: Erythema in the antrum compatible with GAVE s/p APC
.
EGD [**2154-1-22**]:
Impression: Erythema and congestion in the duodenal bulb
consistent with duodenitis. Erythema and congestion in the
antrum compatible with GAVE
Small angioectasias in the jejunum without evidence of bleeding
Recommendations: Protonix 40 mg Twice daily
Capsule endoscopy
.
Colonoscopy [**2154-1-22**]:
Impression: Scant stool mixed in with prep liquid in the colon
Findings do not explain bleeding.
Recommendations: Source of bleeding not identified, recommend
capsule endoscopy
.
LABS:
At discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2154-1-24**] 06:30AM 6.1 2.97* 9.5* 29.0* 98 32.1* 32.8 20.2*
247
At Admission:
[**2154-1-17**] 05:35PM 7.1 2.30* 7.4* 22.3*1 97 32.1* 33.2 21.1*
173
.
At discharge:
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2154-1-24**] 06:30AM 71 10 2.8*#1 142 4.2 105 30 11
At admission:
[**2154-1-17**] 05:35PM 140* 43* 4.1* 138 4.0 97 30 15
Brief Hospital Course:
69yo F with ESRD on HD, CAD, DM, HTN, CHF who was recently
admitted with anemia and found to have GAVE on EGD presents with
marroon stools.
.
#. Anemia: The pt has baseline anemia that is multifactorial
(secondary to Renal failure as well as iron deficiency from
prior GIB). However this acute [**Month (only) **] in Hct (29 at discharge in
[**2154-1-11**] to 22 in ED), is most likely secondary to GIB. As to
the source of the GIB, this is most likely LGIB given the neg NG
Lavage and maroon colored stools, however her history of GAVE is
concerning for a possible UGIB. Although the pt is currently
hemodynamically stable without any evidence of orthostatics, we
will observe in MICU for concern of UGIB. She had received
1UPRBC in ED. MICU course of 1 day-pt was HD stable throughout
course, received 2UPRBC for HCT 24.2 during HD. Pt was called
out to floor the following day. Medicine floor course
uncomplicated. Pt remained HD stable. Remained on PPI [**Hospital1 **]. Per
GI EGD/[**Last Name (un) **] essentially unremarkable and did not account for
bleeding during this admission. Given findings and EGD/[**Last Name (un) **],
proceeded with capsule study.
Further work up included checking hemolysis labs (LDH, T-bili),
which were normal. She was continued on Epo and Fe supplements
per HD. No further blood transfusions were needed, she remained
HD stable throughout her admission.
2. CV:
A. Coronaries: No signs or sx of acute ischemia including ECG
without acute changes.
Pt was noted to have PVCs on tele with few episodes of short
6beat runs of NSVT, however pt was asymptomatic throughout these
episodes. Electrolytes were repleted carefully, no ischemic
changes noted on EKG. Pt's BB was re-initiated on [**1-21**] in
setting of HTN and stable GIB. Lipitor was continued. No aspirin
given pt's allergy history and GIB.
B. Pump: The pt has hx of CHF with preserved EF of 60-70% per
echo on [**2153-11-1**] suggesting diastolic dysfxn. Pt currently
appears euvolemic. Pt did not have any syptoms or signs of CHF
exacerbation during this admission.
C. Rhythm: NSR to sinus tach.
She did not develop any dysrhythmias and remained stable, well
rate controlled on her BB.
3. ESRD: on HD since [**November 2153**]
renal followed pt throughout course, HD MWF. Continued
nephrocaps, calcium acetate, Epo
5. Gout: R finger pain- Her pain was well controlled, per
finger films c/w tissue edema, no evidence of fracture.
Continued allopurinol and colchicine renally dosed. She was also
given oxycodone for 5 days upon discharge until she could follow
up with her primary care physician.
Medications on Admission:
Allopurinol 100mg QOD
Metoprolol 75mg [**Hospital1 **]
Atorvastatin 80mg daily
MVI daily
Calcium Acetate 667mg TID w/meals
B-complex w/vitamin C
Folic Acid 1mg daily
Pantoprazole 40mg Q12
Camphor-Menthol0.5% appl topical daily
Conjugated Estrogens 0.3mg daily
Bisacodyl 10mg PRN
Glipizide 2.5mg daily
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO q6hPRN.
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
12. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day: Pls take with the
other Toprol XL pill.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GAVE
Anemia
Gout
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1.5L per day.
.
Please take all your medications as directed and keep all your
follow up appointments.
--Please note the following changes in your medications:
-you were given oxycodone for your finger pain
-your were started on Toprol XL 75 mg daily for your blood
pressure
.
If you have chest pain, are short of breath, notice bright red
blood per rectum or maroon/black colored stools call your
physician or go to the emergency room.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2154-2-4**] 1:30
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2154-2-4**] 1:30
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Hospital1 7975**] FAMILY PRACTICE Date/Time:[**2154-2-12**]
9:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2154-1-24**]
|
[
"250.40",
"357.2",
"537.83",
"585.5",
"274.9",
"428.32",
"250.60",
"403.91",
"285.1",
"397.0",
"424.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"44.43",
"45.13",
"45.19",
"45.23",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9722, 9779
|
5387, 7989
|
294, 326
|
9840, 9848
|
3961, 4942
|
10451, 10973
|
3196, 3301
|
8340, 9699
|
9800, 9819
|
8015, 8317
|
9872, 10428
|
3316, 3942
|
5194, 5364
|
236, 256
|
354, 2153
|
2175, 2950
|
2966, 3180
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,303
| 171,069
|
32771
|
Discharge summary
|
report
|
Admission Date: [**2102-5-7**] Discharge Date: [**2102-5-21**]
Service: MEDICINE
Allergies:
Penicillins / Codeine / Vicodin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain and SOB
Major Surgical or Invasive Procedure:
patient expired [**5-21**].
History of Present Illness:
87 year old male with h/o CAD s/p CABG, Afib, SSS s/p PPM, CHF
with EF 35%, moderate-severe AS, HTN, HL, and prostate cancer
who presented on [**5-3**] to [**Hospital3 **] with worsening SOB
found to have an [**Hospital 39700**] transferred to [**Hospital1 18**] for cardiac cath,
and now transferred to CCU in setting of worsening respiratory
distress and [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing.
.
He reports over a month of shortness of breath which worsened in
the few days prior to admission and was associated with
worsening peripheral edema. He had previously increased his
home lasix dose but this did not improve his breathing. His
weight increased 10 pounds over one week prior to admission with
substantial peripheral edema. He then developed nausea and
vomiting and presented to the ED at [**Location (un) **]. At the time of
admission to OSH he denied any chest pain. He did endorse
recent diarrhea. He also endorsed 3 pillow orthopnea and severe
PND.
.
On admission to [**Location (un) **], Troponin I was 0.19 with CPK of 65.
Creatinine was elevated to 1.6. Cardiology was consulted and he
was treated with IV lasix with improvement in his SOB and lower
extremity edema. Creatinine improved to 1.2 throughout his
stay. His troponin I initially downtrended to 0.13. Yesterday
he had an episode of recurrent chest pain with transfer from
chair to bed that lasted 15 minutes and resolved without
intervention. Troponin I then trended up to 0.42 with unchanged
CK. He was loaded with 300mg Plavix this morning. He was not
given lovenox or a heparin gtt given anemia Hct to 28-30. He
was chest pain free on transfer. He was also started on digoxin
at the OSH for his CHF and was also started on amiodarone.
Vitals on transfer: 96.4, 108/68, 60 paced, 99% 2LNC. He was
transferred for cardiac catheterization Tuesday.
.
While at [**Hospital1 18**] today, he went to cardiac catheterization; prior
to procedure he became very nauseous and endorsed difficulty
breathing. His breathing difficulty was noted to consist of
periods of apnea associated with rapid, short breaths, thought
to be consistent with [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing. Troponins were
stable and EKG did not reveal any new changes. Given
respiratory distress, he was transferred to the CCU for further
management.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. All of the other review of systems were
negative. Cardiac review of systems is notable for absence of
syncope or presyncope.
Past Medical History:
Cardiac Risk Factors: Diabetes, + Dyslipidemia, + Hypertension
Cardiac History:
CAD s/p CABG X 5 and multiple PCI. performed at [**Hospital 58921**] center on [**2088-6-17**], LIMA to LAD, SVG to PDA and RCA, SVG
to diagonal and SVG to OM. (OSH records obtained during [**4-/2102**]
hospitalization)
Paroxysmal Atrial Fibrillation, not felt to be a candidate for
Coumadin
Moderate to Severe AS: peak gradient 28, mean gradient 15, AV
area 0.6cm2
Sick sinus syndrome s/p PPM with generator change in [**2098**]
Chronic systolic and diastolic congestive heart failure, in
[**3-18**] TTE showed EF 35%, worse than one year ago and new focal
areas of distal septal and inferoposterior hypokinesis (althoguh
TTE reports states global hypokinesis)
Other Past History:
COPD, not on home O2
Osteoarthritis
Hyperlipidemia
Prostate cancer, treated with finasteride, previously on lupron,
never had surgery. Followed by Dr. [**Last Name (STitle) 76317**] at [**Hospital3 25357**].
Rheumatoid arthritis, on methotrexate and prednisone with
continued significant pain
Hypothyroidism
Lymphoma, states he has had it 3 times, the most recent being 3
years ago when he received radiation (low grade follicular
lymphoma per OSH records, last radiation [**2099**])
Anemia
H/o GI bleed - per OSH records, "Lower GI bleed of unknown
source"
TTE [**2102-3-14**] at [**Hospital3 **]: (Full report in scanned records)
1. LVH, paradoxical septal motion, global hypokinesis, ejection
fraction 35-40%
2. Probable severe aortic stenosis with a peak gradient of 50,
mean gradient of 30, which given his degree of left ventricular
dysfunction likely represents critical aortic stenosis. The
calculated aortic valve area by continuity equation is 0.7cm2.
3. Moderate to severe mitral regurgitation
4. Moderate to severe tricuspid regurgitation
5. Pulmonary hypertension with pulmonary systolic of 45-50mm
6. Moderate pulmonary insufficiency
7. Biatrial enlargement
8. Pacing wire, right ventricle
Social History:
Lives in an [**Hospital3 **] facility (Meadows in [**Location (un) **]).
Previous smoker x 20 years but quit 40 years ago. Smoked cigars
and pipes mainly, but started with cigarettes. Denies any
current alcohol use, but used to drink wine with dinner. No
other drugs. Has son in [**Name (NI) 1468**], MA. Daughter in [**Name2 (NI) 108**].
Family History:
Mother had emphysema. Father had ?[**Name2 (NI) 499**] cancer or ?prostate
cancer. There is no family history of premature coronary artery
disease or sudden death.
Physical Exam:
VS: 96.6 100/50 60 22 92%2L
Gen: Awake, alert, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa
Neck: Supple with elevated JVP to the temple.
CV: Regular rate with substantial amount of ectopy. Loud
crescendo-decrescendo systolic murmur heard at LUSB and systolic
murmur heard at apex.
Chest: Respirations were unlabored without accessory muscle use.
Fine rales at the bases bilaterally with mild bronchial breath
sounds in left midlung.
Abd: Soft, with palpable liver in epigastrium. Nontender and
slightly protuberant. Abd aorta not enlarged by palpation.
Extremities: 2+ peripheral edema to the knees on the left, to
the shins on the right. Left 4th digit with swelling and
discoloration around the nail and severe pain with palpation.
Gauze in place between toes. Also mild erythema up to center of
the dorsum of his right foot, no tenderness to palpation of that
area.
Pertinent Results:
OSH LABS:
OSH [**5-3**]: WBC 4.7, Hgb 10.5, Hct 30.4, Plt 104, Na 136, K 4.4,
Cl 102, Bicarb 23, BUN 56, Crt 1.4, Gluc 103, BNP 1810, Lipase
47, Troponin I 0.16, Ca 8.9, U/A ngative for infection
Digoxin 0.30 [**5-5**]
CK and Troponin Trend:
[**5-3**] 15:08 CPK 65 Troponin 0.16
[**5-3**] 22:45 CK 51 Troponin 0.15
[**5-4**] 06:30 CK 40 Troponin 0.19
[**5-4**] 13:13 CK 45 Troponin 0.16
[**5-5**] 06:00 CK Troponin 0.13
[**5-6**] 07:20 CK 48 Troponin 0.19
[**5-6**] 12:33 CK 49 Troponin 0.23
[**5-6**] 20:30 CK 52 Troponin 0.27
[**5-7**] 05:00 CK 51 Troponin 0.42
Hct Trend:
[**5-3**] Hct 30.4
[**5-4**] Hct 29.5
[**5-5**] Hct 26.5
[**5-6**] Hct 29.3
[**5-6**] Hct 29.2
Creatinine Trend
[**5-3**] 1.4
[**5-4**] 1.4
[**5-5**] 1.3
[**5-6**] 1.2
[**5-7**] 1.2
Admission Labs:
[**2102-5-7**] 04:55PM WBC-4.4 RBC-3.15* HGB-10.1* HCT-31.0* MCV-98
MCH-32.1* MCHC-32.6 RDW-17.3*
[**2102-5-7**] 04:55PM PLT COUNT-133*
[**2102-5-7**] 04:55PM PT-14.2* PTT-29.3 INR(PT)-1.2*
[**2102-5-7**] 04:55PM CALCIUM-8.5 PHOSPHATE-2.9 MAGNESIUM-1.8
[**2102-5-7**] 04:55PM CK-MB-NotDone cTropnT-0.15*
[**2102-5-7**] 04:55PM CK(CPK)-59
[**2102-5-7**] 04:55PM GLUCOSE-112* UREA N-31* CREAT-1.2 SODIUM-136
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
.
[**2102-5-8**] CXR
Cardiac silhouette is enlarged. There is calcification of the
thoracic aorta. Median sternotomy wires and multiple surgical
clips are seen in the
mediastinum. There is a dual-lead right-sided pacemaker. Lungs
are grossly
clear without focal consolidation, pleural effusions, or overt
pulmonary
edema. There is tortuosity of thoracic aorta. Degenerative
changes of the
AC joints and spine are noted.
.
[**2102-5-8**] Foot xray
No prior studies for comparison. There is severe end-stage
osteoarthritic changes of the first MTP joint with complete loss
of joint
space and large spurs. Vascular calcifications are also seen.
There are no
signs for acute fractures or dislocations. Extensive vascular
calcifications are present. There are no destructive bony
changes to indicate radiographic evidence for osteomyelitis. If
there is high clinical concern, MRI could be performed. No soft
tissue gas is seen.
.
[**2102-5-10**] Abd u/s;
Nonspecific bowel gas pattern. Air is seen in the distal
sigmoid
and rectum.
.
[**2102-5-11**] Echo:
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is
10-20mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is severe regional left ventricular systolic
dysfunction with akinesis of the inferior and inferolateral
walls. There is an inferobasal left ventricular aneurysm.
Overall left ventricular systolic function is severely depressed
(LVEF= XX %). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is markedly dilated
with moderate global free wall hypokinesis. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. There is critical aortic valve stenosis (valve area
<0.8cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is moderate thickening of
the mitral valve chordae. Severe (4+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. Severe
[4+] tricuspid regurgitation is seen. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] The pulmonic valve leaflets
are thickened. Significant pulmonic regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction. Markedly dilated right ventricle with depressed
systolic function. Severe aortic stenosis (calculated by
continuity equation, low cardiac output). Severe mitral
regurgitation. Severe tricuspid regurgitation. Severe pulmonic
regurgitation.
.
[**2102-5-11**] CT head:
No acute intracranial process
.
[**2102-5-13**] KUB:
IMPRESSION: Probable ileus. No evidence of obstruction
.
[**2102-5-15**] CXR:
1. Mild-to-moderate cardiomegaly without pulmonary edema, but
unchanged mild vascular congestion.
2. Small bilateral pleural effusions with associated basilar
atelectasis.
Brief Hospital Course:
87 year old male with h/o CAD s/p CABG, Afib, SSS s/p PPM, CHF
with EF 35%, moderate to severe AS, HTN, HL, and prostate cancer
who presented on [**5-3**] to [**Hospital3 **] with SOB, [**Hospital 39700**]
transferred to [**Hospital1 18**] for cardiac cath who had worsening
respiratory distress prior to catheterization.
.
# Shortness of breath: Component pulmonary edema and
[**Last Name (un) 6055**]-[**Doctor Last Name **] respirations. Patient was diuresed. Sleep consult
was done. Per sleep recs started diamox and scopolamine .
Started Ultimately patient became DNR/DNI and wanted hospice
with goal being comfortable breathing which was achieved with
low doses of morphine and ativan po as needed at onset of
respiratory distress. Patient went into respiratory distress
overnight [**5-20**], not responding to po or iv morphine. He was
started on a morphine drip and passed [**5-21**].
.
#. CAD: Likely had NSTEMI in setting of recent demand from CHF
with troponin elevations, however patient decided against
intervention. Patient was initially medically managed but then
medications tapered once goals of care were addressed and
decision for hospice was made. See above, patient expired [**5-21**].
.
#. Aortic Stenosis: Has known severe aortic stenosis. No acute
intervention planned based on patient wishes. See above, patient
expired [**5-21**].
Medications on Admission:
ASA 81mg po daily
Lasix 40mg po bid, recently increased from 40mg po daily
Simvastatin 10mg po daily
Atenolol 25mg po bid
Fosamax 35mg po qweek on Saturdays
Vitamin C 500mg po daily
Calcium with Vitamin D 1 tab po bid
Finasteride 5mg po daily
Folic acid 1mg po daily
Glucosamine 500mg po bid
Synthroid 100mcg po daily
Methotrexate 7.5mg po weekly on Wednesdays
MVI 1 tab po daily
Prilosec 20mg po bid
Zofran 4mg po q8h prn nausea
Prednisone 5mg po daily
Terazosin 2mg po daily
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired [**5-21**].
Discharge Condition:
patient expired [**5-21**].
Discharge Instructions:
patient expired [**5-21**].
Followup Instructions:
patient expired [**5-21**].
Completed by:[**2102-5-21**]
|
[
"428.0",
"185",
"714.0",
"V45.81",
"401.9",
"V45.01",
"272.4",
"584.9",
"530.81",
"716.90",
"V64.1",
"202.80",
"414.01",
"427.31",
"244.9",
"496",
"410.71",
"416.8",
"424.1",
"428.43"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12944, 12953
|
11055, 12417
|
256, 285
|
13024, 13053
|
6622, 7388
|
13129, 13187
|
5448, 5615
|
12974, 13003
|
12443, 12921
|
13077, 13106
|
5630, 6603
|
198, 218
|
313, 3076
|
10727, 11032
|
7404, 10718
|
3098, 5071
|
5087, 5432
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,380
| 147,340
|
32484
|
Discharge summary
|
report
|
Admission Date: [**2195-10-31**] Discharge Date: [**2195-11-7**]
Date of Birth: [**2125-8-27**] Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Tunneled HD line placement
Hemodialysis
History of Present Illness:
70yo M with h/o CKD stage V, obesity, PVD (s/p right fem-[**Doctor Last Name **]
bypass), HTN, HLD and BPH presented originally for worsening
somnolence and confusion. Patient has been preparing to
initiate HD and is being evaluated for a transplant. He has an
AVG placed 5 months prior, but it has not matured. The patients
family was concerned about his worsening mental status,
prompting their visit to the ED. In the ED, the patient was
noted to be SOB and confused. His troponins were elevated but
he was not felt to have ischemic EKG changes. He was admitted
to the MICU out of concern for volume overload and possible need
for urgent HD.
The dialysis team evaluated the patient and felt that HD was not
needed urgently. The MICU evaluated him for possible infectious
etiology. The patient was not reporting sx or febrile, but
given his overall status, he was was started on CTX/levo for
?PNA given the concerning findings on his CXR. He was also
noted to be in afib, which is believed to be a new finding for
the patient. The patient was started on heparin gtt and has
been rate controlled on his own.
He was eventually started on HD (day 1: [**2195-11-2**]) via a tunneled
line. Following his first session, his mental status began to
improve. He is currently mentating well and has remained
afebrile and HD stable. He is to be transferred to the fluid
for further management. Currently, the patient reports feeling
well. He is tired but has no other compliants. He is preparing
for his second HD today.
Past Medical History:
PAST MEDICAL HISTORY:
-DM with retinopathy,
-HTN,
-PVD - right fem-[**Doctor Last Name **] bypass,
-Obesity,
-BPH - s/p TURP,
-Prior bladder stones,
-Smoker,
-Hypercholesterolemia.
-Necrotizing fasciitis of the abdominal wall approx 30yrs ago.
Social History:
He is currently retired, used to sell hot dogs and used to work
for the [**Company 2318**]. Currently, lives with his wife, has a 50-pack-year
history of 1 pack per day smoking, still smokes the same amount.
Alcohol, extremely rarely, 1 beer in a year. No history of any
drug use in the past.
Family History:
There is no family history of any chronic kidney disease or
hypertension. His mother had a history of angina and passed
away at the age of 74. His father died of lung cancer. He has
2 sisters who are reportedly healthy and a brother who recently
got diagnosed with diabetes. He has 4 children aged 43 to 50,
who are healthy except for asthma. He has 11 grandchildren and
one great grandchild and another great grandchild on the way.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: Afebrile, 132/61, 100, 20, 92% on RA
GENERAL: Well appearing M/F who appears stated age. Comfortable,
appropriate and in good humor.
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. No HSM or
tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees. HD Tunneled cath dressing c/d/i, site
nontender/nonerythematous (right SC), AV fistula on left forarm
with thrill, scar is heeling well.
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.8, 117/51, 67, 20, 99% on 1L
GENERAL: Well appearing, alert/oriented and calm
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple, difficult to assess JVP given body habitus.
CARDIAC: Given habitus, heart sounds are quiet (c/w prior).
Fib, nl s1s2, no mrg appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. minimal crackles in b/l bases.
ABDOMEN: Distended but Soft, non-tender to palpation. No HSM or
tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees. HD Tunneled cath dressing c/d/i, some
dried blood, site nontender/nonerythematous (right SC), AV
fistula on left forarm with thrill, scar is heeling well. PPD
negative (left forearm)
Pertinent Results:
Admission Labs-
[**2195-10-31**] 11:29AM BLOOD WBC-6.4 RBC-3.42* Hgb-10.1* Hct-33.0*
MCV-96 MCH-29.6 MCHC-30.8* RDW-15.1 Plt Ct-139*
[**2195-11-1**] 09:54AM BLOOD PT-13.2* PTT-31.5 INR(PT)-1.2*
[**2195-10-31**] 11:29AM BLOOD Glucose-147* UreaN-120* Creat-7.0*#
Na-142 K-4.1 Cl-105 HCO3-22 AnGap-19
[**2195-10-31**] 11:29AM BLOOD ALT-23 AST-16 AlkPhos-75 TotBili-0.2
[**2195-10-31**] 11:29AM BLOOD Albumin-4.2 Calcium-9.3 Phos-6.9* Mg-2.0
[**2195-11-3**] 09:45AM BLOOD calTIBC-251* Ferritn-113 TRF-193*
[**2195-11-5**] 08:50AM BLOOD %HbA1c-7.1* eAG-157*
[**2195-11-1**] 02:44AM BLOOD TSH-2.0
[**2195-11-3**] 09:45AM BLOOD PTH-327*
[**2195-11-3**] 09:45AM BLOOD 25VitD-24*
[**2195-11-2**] 10:13AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2195-11-2**] 10:13AM BLOOD HCV Ab-NEGATIVE
[**2195-10-31**] 04:55PM BLOOD Type-ART pO2-77* pCO2-64* pH-7.17*
calTCO2-25 Base XS--6
[**2195-10-31**] 11:34AM BLOOD Lactate-0.5
Cardiac Enzymes-
[**2195-10-31**] 11:29AM BLOOD CK-MB-14* cTropnT-0.33*
[**2195-10-31**] 05:43PM BLOOD CK-MB-12* MB Indx-10.1* cTropnT-0.31*
[**2195-11-1**] 01:11AM BLOOD CK-MB-10 MB Indx-10.3* cTropnT-0.32*
[**2195-11-4**] 07:20PM BLOOD CK-MB-9 cTropnT-0.44*
Discharge Labs-
[**2195-11-7**] 07:00AM BLOOD WBC-6.6 RBC-3.13* Hgb-9.2* Hct-29.8*
MCV-95 MCH-29.4 MCHC-30.9* RDW-14.5 Plt Ct-123*
[**2195-11-7**] 07:00AM BLOOD PT-14.8* PTT-32.4 INR(PT)-1.4*
[**2195-11-7**] 07:00AM BLOOD Glucose-93 UreaN-65* Creat-5.4* Na-138
K-4.0 Cl-97 HCO3-28 AnGap-17
[**2195-11-5**] 08:50AM BLOOD ALT-29 AST-24 AlkPhos-63 TotBili-0.2
[**2195-11-7**] 07:00AM BLOOD Calcium-9.2 Phos-5.5*# Mg-1.9
[**2195-11-4**] 05:56PM BLOOD Type-ART pO2-72* pCO2-60* pH-7.34*
calTCO2-34* Base XS-3
Studies-
-pCXR ([**2195-10-31**]): AP portable chest radiograph. Exam is limated
by portable technique, low lung volumes and body habitus. There
is apparent elevation of the left hemidiaphragm. Bibasilar
opacities may be due to atelectasis and overlying soft tissues
with small efusions not excluded. The cardiomediastinal
silhouette is prominent but likely accentuated for reason above.
Old, potentially post traumatic changes seen at the lateral
right clavicle.
-NCHCT ([**2195-11-4**]): No evidence of hemorrhage, mass effect, or
acute infarction.
-CXR ([**2195-11-4**]): Moderate right pleural effusion accounts for
most of the radiodensity at the base of the right hemithorax.
Pulmonary edema, if present, is minimal. Caliber of the upper
mediastinum has not changed since [**10-31**] and could be due
either to mediastinal fat deposition or dilated mediastinal
veins. The heart is top normal size, exaggerated by mediastinal
fat.
-AV Fistulogram ([**2195-11-5**]): Preliminary Report
Left AV fistulagram demonstrating :
1. Multiple early filling collateral venous pathways between the
cephalic vein and the basilic vein.
2. Two foci of possible minimal bandlike stenosis (<15%) in the
cephalic vein at the level of the femoral head of uncertain
hemodynamic significance.
3. Variant anatomy with bifurcation of the cephalic vein 6cm
proximal to its junction with the subclavian vein. Again this
may be contributing to mild flow limitation.
4. The central veins appear to be widely patent.
5. Widely patent arterial anastamosis on ultrasound.
The above findings would be amenable to percutaneous venoplasty
to see if this reduces flow into the cephalic to basilic
collaterals.
Brief Hospital Course:
70yo male with pmhx of ESRD on HD, DM, presenting for somnolence
with plan for next week initiation of HD.
ACUTE CARE
#) Somnolence:
Felt to likely be [**3-12**] uremia, although likely exacerbated by
possible infection or hypercarbia. The patient presented with
asterixis and a significantly elevated BUN. He was started on
HD via a tunneled line on [**2195-11-2**] and his mental status
gradually cleared. He was treated empirically for PNA given
concerning findings on CXR. He received a 7 day course of
CTX/levofloxacin. The patient was noted to be acidotic with
elevated CO2, which partially improved over his hospital course.
He likely retains CO2 given his body habitus and likely
previously undiagnosed OSA. He was not confused or altered upon
discharge.
#) ESRD:
The patient had a tunneled line placed and he had initiation of
HD on [**2195-11-2**], which gradually lead to the improvement of his
mental status. His last HD session at [**Hospital1 18**] was Friday,
[**2195-11-6**]. His next session is to be Monday, [**2195-11-9**] in the out
patient setting. His AV fistula was noted to be patent, but
with present collaterals. He was evaluated by the surgery team,
who plan to ligate them in the future. In the mean time, he is
to continue HD via his temp tunneled line. His HBV/HCV panel
and PPD were negative. He may benefit from HBV vaccination as
an outpatient.
#) Afib:
The patient was noted to be in Afib without RVR in the ED. The
patient has no known h/o of afib. He was initially started on a
heparin gtt given his CHADS score of > 2. The cardiology team
evaluated the patient and felt that his day to day CVA risk was
not elevated enough to warrant the heparin ggt. The recommended
the initiation of warfarin and a low dose of a betablocker.
#) Troponinemia:
The patient had an elevated and slightly uptrended troponin. He
denied chest pain and his EKG was without evidence of ischemia.
Likely [**3-12**] ESRD, although there is a possibly that he has
underlying CAD. The cardiology team recommended the
consideration of an outpatient stress test.
#) DM:
HgA1c 7.6% in [**Month (only) 205**] and 7.1% on this admission. He had an
episode of hypoglycemia with a documented FS os 36. His insulin
requirements are likely going to change given the initiation of
HD. The [**Last Name (un) **] team was consulted for their recommendations and
assistance with his insulin regimen. His insulin needs should
be monitored going forward as it will likely continue to change
as he adjusted to HD.
#) Hypoxia:
The patient was noted to have a new oxygen requirement. This
was felt to be likely to be multifactorial and [**3-12**]
#) PVD:
Patient was continued on his home plavix. Aspirin was d/c per
cardiology recommendations given the initiation of warfarin and
desire to avoid triple anticoagulation.
#) HTN:
Stable. Cont home amlodipine, losartan
#) HLD:
Stable. Cont home atorvastatin
#) Depression:
Cont home sertraline. Of note, the patient and his family
reported significant anxiety while in the hospital. He may
benefit from antianxiety medications, but of note, because
sedated from lorazepam 0.5 mg po x1.
TRANSITIONS IN CARE
# Code: Full (confirmed with wife)
# ESRD: Patient to have HD MWF. He will require ligation of
collateral at his AVF before it can be used. This was not able
to be done while in house.
# Cards: Has been started on warfarin and metoprolol. Will need
monitoring of his INR. Also may benefit from outpatient ETT.
ASA has been d/c.
# DM: His insulin regimen has been downtitrated given episodes
of hypoglycemia as an in patient. This should continue to be
monitored.
# Pulm: Patient has elevated CO2 and likely undiagnosed OSA. He
would likely benefit from outpatient sleep studies.
# Psych: Patient and family reporting significant anxiety, may
benefit from medication adjustments.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Losartan Potassium 50 mg PO DAILY
hold for SBP < 90
2. Calcium Carbonate 500 mg PO TID
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
hold for SBP < 90, HR <55
5. HydrALAzine 10 mg PO BID
hold for SBP < 90, HR <55
6. Atorvastatin 10 mg PO DAILY
7. Glargine 46 Units Breakfast
Glargine 20 Units Bedtime
Novolog 8 Units Breakfast
Novolog 8 Units Lunch
Novolog 8 Units Dinner
8. Furosemide 80 mg PO DAILY
hold for SBP < 90, HR <55
9. Torsemide 40 mg PO DAILY
hold for SBP < 90
10. Multivitamins 1 TAB PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Sertraline 100 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
hold for SBP < 90, HR <55
2. Atorvastatin 10 mg PO DAILY
3. Calcium Carbonate 500 mg PO TID
4. Clopidogrel 75 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
hold for SBP < 90
7. Torsemide 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 2 tablet(s) by mouth
TID w/meals Disp #*180 Tablet Refills:*0
12. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch daily Disp #*30 Unit
Refills:*0
13. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
14. Outpatient Lab Work
Please draw PT and INR on Monday [**2195-11-9**]. Ok to draw at
dialysis.
-Please fax the results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43785**] at [**Telephone/Fax (1) 6808**].
-ICD-9: 427.31
15. Sertraline 100 mg PO DAILY
16. traZODONE 50 mg PO HS:PRN sleeplessness
RX *trazodone 50 mg 1 tablet(s) by mouth HS Disp #*30 Tablet
Refills:*0
17. Glargine 20 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL Injection 20 Units
before BKFT; 10 Units before BED; Disp #*3 Vial Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL Up to 6 Units per
sliding scale four times a day Disp #*2 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Uremia secondary to end stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 75792**],
It was a pleasure taking part in your care during this
hospitalization. You were admitted when you were found to be
confused and sleepy. You were treated for a pneumonia and
started on dialysis. We hope you continue to recover.
We are coordinating for oxygen to be delivered to your home
later today.
Please review the attached medication list carefully. You are
now taking a medication known as warfarin. This medication needs
to be carefully monitored, especially when you are first
starting to take it. You need to have a level drawn on Monday
at dialysis. The prescription is also included. Please note:
your insulin doses have also changed. We are also sending you
out on a medicine called Trazodone to help you sleep.
Followup Instructions:
Please attend your regularly scheduled dialysis sessions.
You should also contact your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 43785**] ([**Telephone/Fax (1) 31019**]) and schedule an appointment with him in
[**2-9**] weeks. You should plan to discuss your breathing and your
heart rate.
The office of Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] from transplant surgery will
contact you to set up an appointment to get surgery to ligate
the collaterals around your fistula. If they do not call on
Monday to schedule, please contact them at ([**Telephone/Fax (1) 3618**] to
schedule an appointment.
|
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"38.95",
"88.49",
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icd9pcs
|
[
[
[]
]
] |
14517, 14566
|
8101, 11972
|
284, 326
|
14663, 14663
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4695, 8078
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15609, 16322
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2483, 2923
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12831, 14494
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14587, 14642
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11998, 12808
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14814, 15586
|
2938, 3838
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3860, 4676
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234, 246
|
354, 1886
|
14678, 14790
|
1930, 2154
|
2170, 2467
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,002
| 100,978
|
53742
|
Discharge summary
|
report
|
Admission Date: [**2165-7-2**] Discharge Date: [**2165-7-10**]
Date of Birth: [**2097-3-13**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Posterior thoracolumbar fusion
History of Present Illness:
Ms. [**Known lastname **] has undergone a previous lumbar fusion in [**Month (only) **] of
[**2164**]. Unfortunately, she has displaced her instrumentation and
requires revision thoracolumbar fusion with instrumentation.
Past Medical History:
1. Status post left BKA in [**2150**] due to osteomyelitis (performed
at [**Hospital1 2025**])
2. Hypertension
3. Hypothyroidism
4. Hyperlipidemia
5. Lung nodules
6. Osteoporosis
7. Hx of Squamous and basal cell carcinomas
8. Chronic low back pain secondary to L5-S1 disc bulge
9. Status post left thumb CMC arthroplasty as well as left MP
joint volar plate advancement.
10. s/p hysterectomy
11. s/p L5-S1 ant/post fusion laminectomy
12. s/p kyphoplasty
13. s/p right ORIF patella
Social History:
The patient worked as a nurse practitioner until [**2159**] when she
developed back pain. She is single and lives with her sister.
She has never been pregnant. She smokes half a pack of
cigarettes a day. She has tried to quit. Has smoked for "many"
years and was unable to quantify. She does not drink alcohol.
She exercises regularly with a personal trainer.
Family History:
Sister with osteoarthritis of the back and hips.
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
LLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
RLE- BKA; otherwise sensation intact.
Pertinent Results:
[**2165-7-8**] 12:50PM BLOOD WBC-8.0 RBC-4.00* Hgb-11.7* Hct-34.6*
MCV-86 MCH-29.2 MCHC-33.8 RDW-13.2 Plt Ct-262
[**2165-7-6**] 06:50AM BLOOD WBC-9.0 RBC-3.91*# Hgb-11.5*# Hct-33.8*#
MCV-86 MCH-29.4 MCHC-34.0 RDW-13.8 Plt Ct-189
[**2165-7-5**] 06:20AM BLOOD WBC-11.9* RBC-2.86* Hgb-8.6* Hct-25.2*
MCV-88 MCH-29.9 MCHC-34.0 RDW-12.8 Plt Ct-212
[**2165-7-4**] 06:45AM BLOOD WBC-11.5*# RBC-3.38* Hgb-9.9* Hct-30.3*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.0 Plt Ct-281
[**2165-7-2**] 08:08PM BLOOD WBC-6.3# RBC-3.82* Hgb-11.1* Hct-33.3*
MCV-87 MCH-29.0 MCHC-33.2 RDW-12.9 Plt Ct-250
[**2165-7-8**] 12:50PM BLOOD Glucose-101* UreaN-6 Creat-0.3* Na-135
K-4.1 Cl-97 HCO3-28 AnGap-14
[**2165-7-7**] 03:21AM BLOOD Na-134 K-3.5 Cl-97
[**2165-7-6**] 06:50AM BLOOD Glucose-120* UreaN-6 Creat-0.4 Na-133
K-3.6 Cl-99 HCO3-27 AnGap-11
[**2165-7-5**] 05:35PM BLOOD Na-134 K-4.8 Cl-102
[**2165-7-5**] 06:20AM BLOOD Glucose-100 UreaN-9 Creat-0.4 Na-133
K-3.7 Cl-100 HCO3-27 AnGap-10
[**2165-7-8**] 12:50PM BLOOD Calcium-9.0 Phos-5.1*# Mg-1.8
[**2165-7-6**] 06:50AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.6
[**2165-7-5**] 06:20AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.6
[**2165-7-3**] 11:59AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2165-7-2**] and taken to the Operating Room for a T9 to L3 posterior
fusion with instrumetation and removal of previous segmental
instrumentation. Please refer to the dictated operative note for
further details. The surgery was without complication and the
patient was transferred to the PACU in a stable condition.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were given per standard protocol.
Initial postop pain was controlled with a PCA. Postoperative HCT
was low and she was transfused PRBCs with good effect. A
bupivicaine epidural pain catheter placed at the time of the
posterior surgery remained in place until postop day one. A
medicine consult was obtained due to her previous diagnosis of
SIADH and her lengthy stay in the MICU. Recommendations were
followed from the Medical service. She was kept NPO until bowel
function returned then diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#3. She was fitted with a TLSO
brace. Physical therapy was consulted for mobilization OOB to
ambulate. Hospital course was otherwise unremarkable. On the day
of discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
gabapentin
trazodone
simvastatin
amlodipine
synthroid
lidocanie patch atenolol
fluoxetine
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Levothyroxine 75 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*60 Adhesive Patch, Medicated(s)* Refills:*2*
10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical TID (3 times a day).
Disp:*1 tube* Refills:*2*
12. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*2*
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
14. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Hardware failure
Post-op acute blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: Revisison POSTERIOR
thoracolumbar fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Pneumatic boots
TLSO for ambulation, may be out of bed to chair without.
Treatments Frequency:
Site: Lumbar back
Description: surgical incision
Care: Leave OTA, assess for s&s of infection
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days.
Completed by:[**2165-8-14**]
|
[
"996.49",
"564.00",
"272.4",
"V49.75",
"733.00",
"285.1",
"253.6",
"244.9",
"788.29",
"E878.1",
"733.13",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"81.63",
"78.69",
"84.52",
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] |
icd9pcs
|
[
[
[]
]
] |
6612, 6671
|
3345, 4749
|
328, 361
|
6764, 6771
|
2131, 3322
|
8993, 9074
|
1509, 1559
|
4889, 6589
|
6692, 6743
|
4775, 4866
|
6795, 6883
|
1574, 2112
|
8745, 8852
|
8874, 8970
|
6919, 7112
|
279, 290
|
7148, 7615
|
7627, 8727
|
389, 612
|
634, 1116
|
1132, 1493
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,618
| 192,175
|
37070
|
Discharge summary
|
report
|
Admission Date: [**2193-9-18**] Discharge Date: [**2193-9-27**]
Date of Birth: [**2119-3-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
abdominal pain, hematochezia
Major Surgical or Invasive Procedure:
Gastroscopy, exploratory laparotomy with lysis
of adhesions, and small bowel resection.
History of Present Illness:
74 yo male w/ h/o esophageal CA s/p esophagogastrectomy was not
feeling well last night, couple pf episodes of bilious vomiting,
abdominal pain and nausea. Went to [**Hospital3 **] where he
vomited 2L of BRB. Intubated ther. CT scan showed dilated
jejunum/duodenum w/ pneumatosis proximally suggesting ischemic
bowel. He was transferred here for further management.
Past Medical History:
Past Medical History:
IDDM, gastroparesis, HTN, depression, esophageal cancer,
esophageal stricture
Past Surgical History: Esophagogastrectomy. /hand surgery
Social History:
dairy farmer, former smoker (quit 4 yrs ago)
married, lives with wife
Family History:
non-contributory
Physical Exam:
Physical Exam:
Vitals: HR 130s BP 130/70mmHg intubated on the vent
GEN: Sedated
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, Tenderness possibly in the upper
abdomen
but patient sedated so not a good exam. no rebound or guarding,
Prominent epigastric pulsation
DRE: Not done
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2193-9-18**] 07:38PM WBC-11.5* RBC-3.95* HGB-13.3* HCT-40.4
MCV-102* MCH-33.8* MCHC-33.0 RDW-14.0
[**2193-9-18**] 07:38PM NEUTS-83* BANDS-13* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2193-9-18**] 07:38PM PT-14.1* PTT-21.9* INR(PT)-1.2*
[**2193-9-18**] 07:38PM PLT SMR-NORMAL PLT COUNT-230
[**2193-9-18**] 07:38PM GLUCOSE-216* UREA N-24* CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-15
[**2193-9-18**] 07:38PM ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-51 TOT
BILI-1.0
[**2193-9-18**] 07:38PM LIPASE-45
[**2193-9-19**] 11:36 am BRONCHOALVEOLAR LAVAGE RIGHT MIDDLE LOBE.
**FINAL REPORT [**2193-9-22**]**
GRAM STAIN (Final [**2193-9-19**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2193-9-22**]):
Commensal Respiratory Flora Absent.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
[**2193-9-19**] 10:56 am BRONCHOALVEOLAR LAVAGE RIGHT LOWER
LOBE.
GRAM STAIN (Final [**2193-9-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): COLUMNAR EPITHELIAL CELLS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2193-9-22**]):
Commensal Respiratory Flora Absent.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
306-0506O
[**2193-9-19**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2193-9-20**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2193-9-18**] CXR : 1. Endotracheal tube in standard position, 4.3 cm
above the carina.
2. Increase in bibasilar opacification for which differential
includes
aspiration or pneumonia.
[**2193-9-19**] CXR post bronch : AP single view of the chest has been
obtained with patient in sitting semi-upright position.
Comparison is made with the next preceding supine chest
examination obtained 10 hours earlier during the same day. The
patient remains intubated, the ETT in unchanged position. Heart
size is stable and not significantly enlarged. Change in
patient's position accounts for the more visible blunting of the
lateral pleural sinuses indicative of some moderate amount of
pleural effusions. No new parenchymal infiltrates are
identified. The previously described multifocal densities,
however, persist and are most marked in the right lung base as
well as in the lateral portion of the left upper lung field. The
latter infiltrate was clearly not present on the preceding chest
examination of [**9-18**] and thus is new. Otherwise, again
evidence of COPD with emphysematous appearance of the lung
bases, but no evidence of pneumothorax in the apical area.
Surgical clips in neck area as well as hilar area as before.
[**2193-9-20**] Cardiac echo : The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 70%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**2193-9-25**] PA & Lat CXR :
In comparison with the study of [**9-23**], the nasogastric tube
has
been removed. Central catheter extends to the mild to lower
portion of the
SVC. Cardiac silhouette is within upper limits of normal in
size. Diffuse
prominence of interstitial markings again may be consistent with
the clinical diagnosis of fluid overload. Areas of patchy
opacification in the perihilar and basilar regions could reflect
asymmetric edema or possibly superimposed aspiration. Small
right and moderate left pleural effusions are seen.
Brief Hospital Course:
Mr. [**Name13 (STitle) **] was evaluated by the Acute Care service in the
Emergency Room and based on his CT scan and history he was taken
to the Operating Room urgently for an exploratory laparotomy for
possible ischemic bowel. See formal Operative note for specific
details. He was found to have a small bowel obstruction with
significant dilatation of the proximal small bowel and a
stricture at the J tube site. He tolerated the procedure well
and returned to the SICU in stable condition.
He remained intubated and fully ventilated and his hemodynamics
were stable. He required some background neo synephrine while
fluid resuscitation continued and he also had some pre renal
azotemia with a creatinine of 1.6 which resolved with fluid
resuscitation.
Due to his chest xray findings of multilobar pneumonia and many
secretions, he underwent bronchoscopy and BAL specimen revealed
Ecoli and Klebsiella. His antibiotics were broadened prior to
these results but tapered to Zosyn alone after the sensitivities
returned. He underwent vigorous pulmonary toilet and was
eventually able to be weaned and extubated on [**2193-9-21**].
Following transfer to the Surgical floor he continued to make
good progress. His bowel function was slow to return but finally
he had flatus on post op day # 5. His nasogastric tube was
removed and he eventually began a clear liquid diet. That was
gradually increased to regular over the next 24 hours and he
tolerated it well. His abdominal wound was healing well and his
pain was well controlled. He was voiding sufficiently and his
creatine was normal. His antibiotics were stopped on [**2193-9-27**].
Due to his prolonged hospitalization and ICU stay he was
evaluated by the Physical Therapy service who determined that he
wound benefit from a short term rehab prior to his return home
for to increase his mobility and endurance and to continue with
pulmonary toilet.
Medications on Admission:
Lisinopril 5mg qd
Lopressor 12.5 [**Hospital1 **]
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for coughing.
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
small bowel obstruction
pneumonia
acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-13**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed at rehab on [**2193-10-2**]
Followup Instructions:
Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment
in [**2-6**] weeks.
Completed by:[**2193-9-27**]
|
[
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"482.82",
"V10.03",
"401.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"45.62",
"45.13",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
10194, 10306
|
7410, 9326
|
343, 433
|
10404, 10404
|
1579, 4775
|
12440, 12586
|
1117, 1135
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10327, 10383
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977, 1014
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4958, 7387
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4811, 4922
|
275, 305
|
461, 829
|
10419, 10563
|
874, 953
|
1030, 1101
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,019
| 124,165
|
17003
|
Discharge summary
|
report
|
Admission Date: [**2174-7-5**] Discharge Date: [**2174-7-31**]
Date of Birth: [**2148-1-31**] Sex: F
Service: OMED
Allergies:
Vancomycin / Ambisome
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
MMUD allo-BMT in [**5-10**]
s/p intubation and extubation
History of Present Illness:
Ms. [**Known lastname 47828**] is a 26 y.o. female with resistant and progressive
AML diagnosed [**3-9**]. She is s/p 2 cycles of 7 + 3 with
recurrence. She then underwent reindunction with 7+3 with MMUD
allo-BMT c/b abdominal abcess, CHF, respiratory distress 2ndary
to fluid overload, or less likely, pneumonitis (due to CMV+ or
capillary leak syndrome), hyperbili, and renal failure. Pt's
renal failure and hyperbili resolved. Was treated primarily for
CHF with lisinopril and Lasix PRN. EF is 25-30% on last ECHO.
Off Hi-flow mask and Sats >93% on 6LNC-->5LNC
Pt admitted from clinic after presented with one day of abd
cramping, vomiting and diarrhea. CMV serologies positive. No
fevers at home, but spiked fever on admission. Pancultured and
CXR done. Started on Gancyclvir on [**7-5**].
Past Medical History:
AML dx [**3-9**] s/p 7+3 x 2 c/b typhlitis/appendicitis.
Pertinent Results:
[**2174-7-4**] 09:30AM GLUCOSE-111* UREA N-10 CREAT-0.8 SODIUM-139
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
[**2174-7-4**] 09:30AM ALT(SGPT)-30 AST(SGOT)-25 LD(LDH)-333* ALK
PHOS-104 TOT BILI-1.5 DIR BILI-0.7* INDIR BIL-0.8
[**2174-7-4**] 09:30AM ALBUMIN-3.2* CALCIUM-8.8 MAGNESIUM-2.1
[**2174-7-4**] 09:30AM CYCLSPRN-517*
[**2174-7-4**] 09:30AM PLT COUNT-99*
Brief Hospital Course:
1) AML: treated with mismatched allo BMT. +75 days. She was
transfusion dependent throughout her hospital course, for plt
and Hct with parameters for plt transfusion for Plt<10 or Plt<20
if bleeding. Her hospital course was complicated a number of
issues as follows;
2) ID: CMV positive serologies with diarrhea, now resolved. [**7-7**]
started on ganciclovir and IVIG. Switched over to
valgancyclovir after decreased CMV [**Month/Day (4) 18617**] load. Will check
weekly [**Month/Day (4) 18617**] load. Last checked [**7-25**] (-). Vanco trough due
tonight. Flagyl d/c'd [**7-26**]. Jaw pain with tender right lower
tooth, written for oxycodone; CT mandible negative. Oxycodone
5mg for pain.
3) Pneumonia/pneumonitis: CXR on [**7-5**] showed diffuse infiltrates
in RML, RLL and LUL. ID consult followed the patient throughout
her course. A BAL done [**7-6**] was neg for PCP. [**Name10 (NameIs) **] cultures were
negative. She completed 14d. course of vanco/zosyn (started
[**2174-7-12**]). At discharge, she remained on vanco. Switched over to
prednisone 30mg po qd for GVHD pneumonitis.
4) Pericardial effusion: found on CT [**7-6**]. Pt has had in past
but has increased and is now large effusion with brief R atrial
collapse. Serial TTE showed no change.
5) CHF: severe L venrtricular hypokenesis [**2-7**] chemo and BMT. In
the ICU, she had respiratory distress and intubation [**2-7**] fluid
overload vs. capillary leak/pneumonitis; After daily diuresis
in the MICU and then only as needed on the floor, the patient
had rapid improvement, suggesting that the largest component of
the respiratory distress was volume overload. EF has improved
to 55% on most recent echo with smaller pericardial effusion.
Weaned captopril because of renal insufficiency. Ordered lasix
prn as one-time orders only as necessary because the patient was
very sensitive to volume changes.
6) Renal: Increased Creatinine secondary to diuresis and
decreased intravascular volume. Decreased captopril to 6.25 tid
with resolving creatinine.
7) Hx of abd abcess with gram neg bacteremia. Pt did not have
surgery. No further abdominal complaints on floor. No signs of
GI GVHD during remainder of hospital course.
8) FEN: Nutrition consulted for low PO's and felt that pt had
enuogh POs to not require TPN. Now eating actively. Foley d/c'd
[**2174-7-26**], AM.
9) PT/OT. Physical therapy consulted and rec'd home with PT
secondary to poor balance.
Discharge Medications:
Treatments
-----------------
Hickman care per Critical Care Systems Protocol
Cyclosporine infusion pump at 84 mg/day, continuous infusion.
Oral Medications
Captopril 6.25mg po tid
Saline mouth rinses qid
Prednisone 30mg po qd
Immodium 2 mg po q6hrs
Sodium Fluoride (Dental gel) 1 appl tp [**Hospital1 **]
Valgancyclovir 450mg po bid
Bactrim DS 1 tab po 3 times per week (Mon, Wed, Fri)
Voriconazole 200mg po q12
Nystatin oral suspension 5cc po qid
Ursodiol 300mg po bid
Pantoprazole 40mg po q24h
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
AML (diagnosed [**3-9**]) s/p MMUD allo-BMT in [**5-10**].
cytomegalovirus infection complicated by volume overload or
pneumonitis)
Acute renal failure
Graft vs. Host Disease
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:
Followup Instructions:
1. With the treatment nurse at 9:30am in clinic at the [**Hospital Ward Name 23**]
Building on the [**Location (un) **].
2. In clinic with Dr. [**First Name (STitle) 1557**] on Tuesday at 10:00am in clinic at
the [**Hospital Ward Name 23**] Building on the [**Location (un) **].
|
[
"518.81",
"484.1",
"482.41",
"996.85",
"276.2",
"428.0",
"205.00",
"577.0",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24",
"96.04",
"99.04",
"99.15",
"89.61",
"99.05",
"96.71",
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
4679, 4731
|
1685, 4135
|
295, 355
|
4950, 4957
|
1279, 1662
|
5124, 5407
|
4158, 4656
|
4752, 4929
|
4981, 5101
|
236, 257
|
383, 1179
|
1201, 1260
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,676
| 106,048
|
916
|
Discharge summary
|
report
|
Admission Date: [**2119-10-31**] Discharge Date: [**2119-11-5**]
Date of Birth: [**2072-1-20**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 47 year old male with HIV( last CD4 301 [**8-7**]),
ESRD on PD, dilated cardiomyopathy (EF 30%) who presents with
cough and SOB. Patient notes being in his usual state of health
until ~ 2 am this morning when he awoke with severe cough and
SOB. He notes chronic SOB x 3-4 months but does note feel this
was significantly worse recently. He notes chronic cough due to
cigarette smoking but did not note significant change in his
cough until waking up the morning of admission. Since the
coughing began this am it has been productive of frothy white
sputum. Denies any blood or other colors. He notes fevers and
chills for months but no changes recently. Denies any recent
travel or sick contacts. [**Name (NI) **] denies any significant LE swelling.
He denies orthopnea or PND. He has not taken any of his HAART
regimen or Bactrim ppx for the last month as he ran out of
prescriptions. The only medications he has been taking are
cinacalcet, clonidine, and sevelamer.
.
In ED, 98.6, 177/134, 116->140, 20, 100% RA(?). Exam notable for
bibasilar crackles and wheezes. Labs remarkable for leukocytosis
to 11,600, anemia with Hct of 26, . ABG on RA was 7.45/35/60.
Lactate 1.8->1.2. BUN/Cr 68/16.5. CXR showed diffuse ground
glass opacities. Head CT was unremarkable with the exception of
mastoid opacification. ECG showed sinus tach to 140s. He
received azithromycin 500 mg po, bactrim DS 1 tab po, 60 mg of
po prednisone, 1 gram of IV ceftriaxone, atrovent nebulizer,
benzonatate 100 mg, morphine 4 mg IV, ativan 2 mg IV, and reglan
5 mg IV. CTA showed no evidence of PE but did show diffuse
infiltrates, consolidations, and moderate edema.
.
ROS was positive as above. In addition, he does note a HA
beginning this am. He denies any vision changes, numbness, or
weakness. He does not make any urine at baseline. He has been
doing his PD regularly and his last ultrafiltrate this morning
was ~990 cc. He denies any chest pain, abdominal pain, diarrhea.
He notes constipation and has not had a BM in several days. He
denies any nausea, vomiting.
Past Medical History:
HIV with a CD4 360 in [**2118-7-19**], viral load 45,900 at that time
End-stage renal disease secondary to HIV nephropathy. on PD
Anemia
Secondary hyperphosphatemia.
Sickle cell trait.
Polysubstance abuse - including cocaine
Dilated cardiomyopathy (last EF 30% on [**4-5**])
HTN
Atrial fibrillation following cocaine use.
Social History:
-Cocaine use; last use 4d ago
-h/o EtOH abuse; 1 drink a month now
-smokes 1 PPD x 35 yrs
-works as a waiter
-lives with friends
-receives care and medications through [**Hospital6 **]
Center.
Family History:
Significant for ethanol abuse in the mother as well as diabetes
and multiple myeloma. Negative for renal disease.
Physical Exam:
Vitals - T: 98.3 BP: 133/99 HR: 95 RR: 20 02 sat: 96% RA
GENERAL: NAD/ comfortable
HEENT: EOMI, PERRL, OP - no exudate, no erythema, JVD not
appreciated
CARDIAC:no m/r/g appreciated, nl S1, S2
LUNG: decreased BS at bases bilaterally, CTA-B/L
ABDOMEN: slightly distended, NT, soft, PD catheter in place
EXT: no c/c/e
NEURO: non-focal
SKIN: no rashes noted
Pertinent Results:
Admission:
[**2119-10-31**] 02:30PM BLOOD WBC-11.6*# RBC-2.67* Hgb-9.1* Hct-26.0*
MCV-97 MCH-34.2* MCHC-35.2* RDW-14.6 Plt Ct-437
[**2119-10-31**] 02:30PM BLOOD Neuts-79.6* Lymphs-11.7* Monos-7.1
Eos-1.3 Baso-0.4
[**2119-10-31**] 09:04PM BLOOD PT-13.1 PTT-31.0 INR(PT)-1.1
[**2119-10-31**] 02:30PM BLOOD WBC-11.6* Lymph-12* Abs [**Last Name (un) **]-1392 CD3%-83
Abs CD3-1162 CD4%-18 Abs CD4-253* CD8%-61 Abs CD8-850*
CD4/CD8-0.3*
[**2119-10-31**] 02:30PM BLOOD Glucose-90 UreaN-68* Creat-16.5*# Na-138
K-3.6 Cl-98 HCO3-28 AnGap-16
[**2119-10-31**] 09:04PM BLOOD ALT-13 AST-37 LD(LDH)-447* CK(CPK)-1224*
AlkPhos-94 TotBili-0.3
[**2119-10-31**] 09:04PM BLOOD CK-MB-22* MB Indx-1.8 cTropnT-0.24*
[**2119-11-1**] 03:45AM BLOOD CK-MB-23* MB Indx-1.3 cTropnT-0.23*
[**2119-11-1**] 01:14PM BLOOD CK-MB-33* MB Indx-1.1 cTropnT-0.22*
[**2119-11-2**] 06:40AM BLOOD CK-MB-43* MB Indx-1.0 cTropnT-0.25*
[**2119-10-31**] 09:04PM BLOOD Albumin-3.0* Calcium-9.4 Phos-5.3*
Mg-1.4*
[**2119-11-2**] 06:40AM BLOOD calTIBC-191* Ferritn-300 TRF-147*
[**2119-10-31**] 09:04PM BLOOD HIV Ab-POSITIVE
[**2119-10-31**] 09:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2119-10-31**] 04:34PM BLOOD pO2-60* pCO2-35 pH-7.45 calTCO2-25 Base
XS-0
[**2119-10-31**] 02:34PM BLOOD Lactate-1.8
[**2119-10-31**] 04:34PM BLOOD Lactate-1.2
[**2119-10-31**] 04:34PM BLOOD O2 Sat-88Test
[**2119-11-5**] 06:10AM BLOOD WBC-5.5 RBC-2.79* Hgb-9.4* Hct-26.9*
MCV-96 MCH-33.6* MCHC-34.8 RDW-15.9* Plt Ct-464*
[**2119-11-5**] 06:10AM BLOOD Neuts-51.6 Bands-0 Lymphs-32.1
Monos-11.4* Eos-4.4* Baso-0.6
[**2119-11-3**] 06:25AM BLOOD PT-13.0 PTT-31.8 INR(PT)-1.1
[**2119-11-5**] 06:10AM BLOOD Glucose-114* UreaN-75* Creat-16.8* Na-135
K-3.4 Cl-93* HCO3-24 AnGap-21*
[**2119-11-5**] 06:10AM BLOOD CK(CPK)-720*
[**2119-11-4**] 06:05AM BLOOD CK(CPK)-1247*
[**2119-11-3**] 06:25AM BLOOD CK(CPK)-2352*
[**2119-11-1**] 01:14PM BLOOD CK(CPK)-3127*
[**2119-11-1**] 03:45AM BLOOD CK(CPK)-1824*
[**2119-11-5**] 06:10AM BLOOD Calcium-8.0* Phos-5.8* Mg-1.9
[**2119-11-2**] 06:40AM BLOOD calTIBC-191* Ferritn-300 TRF-147*
Result Reference
Range/Units
COCAINE/METABOLITES NONE DETECTED SEE BELOW
NG/ML
REP. LIMIT 20
ANALYSIS BY ENZYME-LINKED IMMUNOSORBENT ASSAY ([**Doctor First Name **]).
Test Result Reference
Range/Units
COCAINE AND METABOLITES TNP REP. LIMIT 20
NG/ML
CONFIRMATION (COCAINE)
FOLLOWING ORAL OR NASAL INTAKE OF 2 MG/KG: UP TO 200 NG/ML.
Test Result Reference
Range/Units
COCAETHYLENE TNP REP. LIMIT 20
NG/ML
(COCAINE/ETHANOL BY-PRODUCT)
BENZOYLECGONINE (COCAINE TNP REP. LIMIT 50
DEGRADATION PRODUCT)
**FINAL REPORT [**2119-11-4**]**
Rapid Respiratory Viral Antigen Test (Final [**2119-11-2**]):
Respiratory viral antigens not detected.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for the direct detection of
respiratory
viruses in specimens; interpret negative result with
caution..
Refer to respiratory viral culture for further
information.
VIRAL CULTURE (Final [**2119-11-4**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
[**2119-11-2**] 4:01 pm SPUTUM Site: INDUCED Source: Induced.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2119-11-3**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
GRAM STAIN (Final [**2119-11-1**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2119-11-1**]):
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2119-11-2**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
ACID FAST SMEAR (Final [**2119-11-2**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2119-11-1**] 2:40 pm Influenza A/B by DFA
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2119-11-1**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2119-11-1**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2119-11-1**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
Blood Culture, Routine (Final [**2119-11-6**]): NO GROWTH.
Imaging:
CXR [**11-3**]
IMPRESSION: Improvement of the right upper lobe opacification.
Given short
time interval of clearance suggests aspiration. Otherwise,
diffuse
ground-glass opacities bilaterally are similar in appearance.
CXR [**11-2**]
IMPRESSION: Focal progression of disease in the right upper lobe
and
bilateral pleural effusions (more clearly seen on chest CT)
favor a general
bacterial infection over PCP.
ECHO [**11-1**]
The left atrium is dilated. There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis
(LVEF = 30-35 %). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**11-30**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2118-4-8**],
the aorta does not appear as dilated on the current study. The
other findings are similar.
CTA [**10-31**]
IMPRESSION:
1. Extensive bilateral airspace opacification, with severe
consolidation in
right upper lobe, less extensive consolidation in the left upper
lobe, and
diffuse ground- glass opacity in the lower lobes bilaterally.
These findings
suggest an advanced infectious process such as PCP or CMV
pneumonia, less
likely bacterial pneumonia.
2. No evidence of pulmonary embolism.
3. Moderately extensive mediastinal and hilar lymphadenopathy,
likely
reactive to the pulmonary process.
4. Mild pulmonary edema and small pleural effusions.
CXR [**10-31**]
IMPRESSION: Diffuse air space opacification, which may represent
pulmonary edema or diffuse pneumonia (including PCP).
CT Head [**10-31**]
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect. MRI is more
sensitive
for detection of intracranial malignancy.
2. Near complete opacification of the right mastoid air cells.
Please
correlate clinically for evidence of otitis media or
mastoiditis.
Brief Hospital Course:
47 year old male with HIV(CD4 301), ESRD on PD, dilated
cardiomyopathy(EF 30%) here with diffuse pulmonary ground glass
opacities, consolidations, and pulmonary edema.
# SOB/hypoxia:
The day of admission the patient awoke with cough and SOB that
had acutely worsened. He noted 3-4 months of SOB prior. He
reportedly had a lot of salt over the [**Holiday 1451**] holiday and
missed some of his lisinopril doses. Of note, he has not had
his HAART or Bactrim ppx for the last month as he ran out of
prescriptions. He states he has been doing his PD regularly. In
the ED he was notable for bibasilar crackles and wheezes with
labs significant for leukocytosis of 11,600, anemia with Hct of
26. ABG on RA was 7.45/35/60. Lactate 1.8->1.2. BUN/Cr 68/16.5.
CXR showed diffuse ground glass opacities. Head CT was
unremarkable with the exception of mastoid opacification. ECG
showed sinus tach to 140s. He received azithromycin 500 mg po,
bactrim DS 1 tab po, 60 mg of po prednisone, 1 gram of IV
ceftriaxone, atrovent nebulizer, benzonatate 100 mg, morphine 4
mg IV, ativan 2 mg IV, and reglan 5 mg IV. CTA showed no
evidence of PE but did show diffuse infiltrates, consolidations,
and moderate edema. He was transferred to the MICU due to his
respiratory status.
.
In the MICU, the patient was initially treated with Bactrim and
steroids. ID was consulted and an induced sputum was sent for
PCP and DFA for [**Holiday **] was also sent, that eventually returned
negative. Given the fact that the likelihood of PCP was low
given that CD4 > 250. Bactrim and steroids were stopped, and he
conitued on IV ceftriaxone and azithromycin for CAP. Nephrology
also followed the patient for his PD and fluid was taken off.
CHF regimen also changed to carvedilol and stopped CCB. His
respiratory status improved. The patient continued to improve
and completed a 10 day course of antibiotics for CAP with
azithro and cefpodoxime. He also had repeat PCP and legionella
that was negative. Additionally, viral screen showed was
negative.
# Tachycardia: The patient was previously noted to have sinus
tachycardia on ECG. Given acute presentation, MI was on the list
of potential etiologies however ECG and enzymes were not
consistent with this picture. There is question whether he has
been compliant with his diltiazem, as he was both tachycardic
and hypertensive on presentation. Given his cardiomyopathy his
CCB was changed to carvedilol. A serum cocaine tox show was
negative.
#Elevated CK: The patient's CK continued to trend upward during
his admission. The cause was thought to potentially be due to
infectious insult vs. sickle cell trait (elevated LDH at
baseline as well). The patient's CK trended upwards to 4170 on
[**11-2**]. The CK then trended down and was 720 on discharge.
.
# HTN: Persistently hypertensive during admission, and was
continued on his clonidine. The patient's ciltiazem was
discontinued and he was started on coreg.
.
# Dilated cardiomyopathy: The patient's CE were negative. An
ECHO was performed this admission had showed an EF of 30-35%.
The patient was started on coreg. The patient should have
follow-up with cardiology.
# HIV: ID consulted for this morning. Patient has been
non-compliant with medications in the past, His CD4 count was
251 on admission. His HAART was held given that he had not been
taking the medications in the last month. He has no h/o OI and
was not started on ppx. He was restarted on his HAART regimen
on [**11-5**] and also started on Bactrim ppx.
# ESRD: The patient was followed by renal and continued on
peritoneal dialysis.
# Hyperparathyroidism: Thought to be secondary to renal disease,
on cinecalcet. Patient noted not being compliant with this
medication at times as well (due to insurance issues).
.
# Anemia, The patient's baseline hct high 20s - low 30s, highly
variable. He has a h/o sickle cell trait. There was no evidence
of bleed, or hemolysis (although LDH is elevated, but this is
chronic). His Hct was trended throughout the admission.
.
# FEN: advance diet as tolerated
.
# PPx: heparin sc. PPI.
# ACCESS: PIV, 18G x 2.
# CODE: FULL, confirmed with patient
# COMM: [**Name (NI) **] [**Name (NI) 6183**] (aunt) [**Telephone/Fax (1) 6184**]. [**Name (NI) 6185**] [**Name (NI) 1726**] (friend)
[**Telephone/Fax (1) 6186**]
Medications on Admission:
RITONAVIR 100 mg once a day (not taken for 1 month)
ZIDOVUDINE 300 mg once a day (not taken for 1 month)
FOSAMPRENAVIR 1400 mg once a day (not taken for 1 month)
LAMIVUDINE 50 mg daily (not taken for 1 month)
TENOFOVIR DISOPROXIL FUMARATE 300 mg Tablet q week (not taken
for 1 month)
DILTIAZEM SR 240 mg daily (not taken for 1 month)
TRIMETHOPRIM-SULFAMETHOXAZOLE 400 mg-80 mg once a day (not taken
for 1 month)
OMEPRAZOLE 20 MG DAILY prn
LACTULOSE 30 mL prn
CINACALCET 60 mg [**Hospital1 **]
CLONIDINE 0.1 mg [**Hospital1 **]
SEVELAMER 3 pills with each meal
Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
10. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
Disp:*60 Tablet(s)* Refills:*2*
11. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QFRI (every Friday).
Disp:*4 Tablet(s)* Refills:*2*
12. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*90 Capsule(s)* Refills:*2*
13. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
14. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
15. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
16. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
17. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Community Aquired Pneumonia
Seconday:
HIV
End-stage renal disease
Dilated cardiomyopathy (last EF 30% on [**4-5**])
hyperparathyroidism
Anemia
Secondary hyperphosphatemia
HTN
Atrial fibrillation
Sickle cell trait
s/p R inguinal hernia repair [**5-7**]
Discharge Condition:
stable, ambulating, satting well on room air
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
your lung. You were treated with antibiotics and improved. You
were continued on antibiotics for a total of 10 days. Your
respiratory status improved and you felt much better. You were
ruled out for PCP, [**Name10 (NameIs) **], and other infectious diseases.
You were also restarted on your HAART and Bactrim for PCP
[**Name Initial (PRE) 6187**].
Please follow the medications prescribed below.
New Medications:
1) Bactrim SS 1 tab daily
2) Flonase
3) Restart your HAART therapy as previous:
RITONAVIR 100 mg once a day
ZIDOVUDINE 300 mg once a day
FOSAMPRENAVIR 1400 mg once a day
LAMIVUDINE 50 mg daily
TENOFOVIR DISOPROXIL FUMARATE 300 mg Tablet q week
4) Nicotine patch
5) Azithromycin 10 days total
6) Cefpodoxine 10 days total
7) Carvedilol 6.25mg [**Hospital1 **]
8) Calcitriol 0.5mcg
Your Diltiazem was discontinuned.
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**11-30**] weeks
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 798**]
Please follow up with the [**Hospital **] [**Hospital **] Clinic
Telephone: [**Telephone/Fax (1) 5972**]
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2119-11-20**]
9:00
Completed by:[**2119-11-8**]
|
[
"403.91",
"486",
"282.5",
"425.4",
"588.81",
"585.6",
"285.21",
"582.9",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
17768, 17774
|
11035, 15336
|
291, 298
|
18080, 18127
|
3483, 7933
|
19358, 19840
|
2975, 3092
|
15947, 17745
|
17795, 18059
|
15362, 15924
|
18151, 19335
|
3107, 3464
|
8313, 11012
|
7969, 8279
|
232, 253
|
326, 2402
|
2424, 2748
|
2764, 2959
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,016
| 181,942
|
3773
|
Discharge summary
|
report
|
Admission Date: [**2106-2-7**] Discharge Date: [**2106-2-12**]
Service: MEDICINE
Allergies:
Morphine
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization w/ DES in SVG -> RCA, RPDA and RPL
branch vessels
Cardiac catheterization w/ DES to LAD
History of Present Illness:
Mr. [**Known lastname 11386**] is an 82yo M w/ PMH of CAD s/p 2 MIs and CABG in [**2096**]
who presented to OSH today after developing "shakes" at home
while getting dressed. Denies overt chest pain, but states he
had chest discomfort [**6-12**], starting in his chest and radiating
to his shoulders bilaterally. + diaphoresis, but no jaw pain or
SOB. Has not had any prior episodes of angina since his CABG. No
n/v. Called his daughter after onset of sx, then called EMS. Was
taken by EMS to NWH where he had an EKG performed which showed
profound ST elevations in II, III, avF, V3-V6 with reciprocal ST
depressions in aVL, aVR, V1, and V2. He received atropine x1 for
bradycardia and was then started on integrillin, heparin gtt,
plavix and IVF. He was then tx to [**Hospital1 18**] cath lab where he
underwent emergent cardiac cath.
.
ROS: denies f/c/HA/dizziness/lightheadedness/URI
sx/cough/GERD/chest
pain/palpitations/SOB/n/v/d/constipation/dysuria. + frequent
urination. Denies any prior episodes of angina since CABG. Able
to do daily activities. States he was walking 1 mi/day prior to
weather getting colder.
Past Medical History:
PMH:
-CAD
---MI ([**2-/2096**], [**3-/2096**])
---CABG ([**3-/2096**])
-HTN
-Hypothyroid
-Prostate CA
-Asthma
-Arthritis
-colonoscopy [**11/2100**]
.
PSH:
-thoracic hiatal hernia repair [**2080**]
-torn left rotator cuff [**8-/2093**]
-CABG [**3-/2096**]
-TURP, radiation [**6-/2097**]
-right iliac artery aneurysm [**8-/2097**]
-left knee cartilage repair [**2-/2099**]
-right groin exploration, lymph node disection (benign) [**5-/2100**]
-hemmoroidectomy [**11/2100**]
-left total knee replacement [**11-4**]
-left inguinal hernia repair
-bilateral carpal tunnel repair
-right bicep repair
-gallbladder removal
-torn right knee cartilage repair
-right thumb repair
-bilateral trigger finger repair
Social History:
Lives alone in [**Location (un) 745**]. Is widowed. Has one daugther, no
grandchildren. Worked as a plumber for 45 yrs. No tob, EtOH
currently. States he quit smoking when he was in school. Was in
the Army, spent time overseas in [**Country 6171**] in [**2044**]. Has one tattoo
from his time in the service.
Family History:
NC
Physical Exam:
VS - T 98.4, BP 124/75, HR 75, RR 14, sats 100% on 2L O2 by nc
Gen: WDWN elderly male, lying flat s/p sheath removal, in NAD.
HEENT: Sclera anicteric, MM dry.
CV: RR, normal S1, S2. No m/r/g.
Lungs: Faint crackles at bases bilaterally, no wheezing/rhonchi.
Abd: Soft, NTND. + BS. No masses, no HSM.
Ext: No c/c/e. Cool, dry. PT/DP 2+ on L, dopplerable on R.
Sheath/PA cath are in place in R groin. Dsg c/d/i.
Skin: No rashes.
Neuro: CN II-XII grossly intact.
Pertinent Results:
Labs on admission:
WBC 8.2, Hgb 10.7*, Hct 31.3*, MCV 89, Plt 196
PT 13.3*, PTT 35.6*, INR(PT) 1.2*
Na 139, K 4.6, Cl 104, HCO3 22, BUN 39, Cr 1.9, Glu 108, Mg 1.9
ABG: pO2-62* pCO2-48* pH-7.36 calHCO3-28 Base XS-0
.
Cardiac enzymes:
[**2106-2-7**] 01:10PM BLOOD CK(CPK)-225, CK-MB-13*, MB Indx-5.8,
TropT-0.09*
[**2106-2-7**] 05:28PM BLOOD CK(CPK)-5712*, CK-MB->500, TropT->25.00
[**2106-2-7**] 10:18PM BLOOD CK(CPK)-5145*, CK-MB-438*, MBI-8.5*,
TropT->25.00
[**2106-2-8**] 03:51AM BLOOD CK(CPK)-3906*, CK-MB-263*, MBI-6.7*,
TropT->25.00
[**2106-2-8**] 06:20PM BLOOD CK(CPK)-2196*, CK-MB-91*, MBI-4.1,
TropT-22.6*
[**2106-2-9**] 06:25AM BLOOD CK(CPK)-1335*, CK-MB-37*, MBI-2.8,
TropT-19.25*
.
Labs on discharge:
WBC 5.8, Hct 27.1, MCV 90, Plt 197
Na 142, K 4.4, Cl 104, HCO3 28, BUN 36, Cr 2.0, Glu 102
Ca 8.5, Mg 2.1, Ph 3.3
.
Imaging:
ECG [**2106-2-7**]:
Sinus rhythm, first degree A-V block, marked left axis deviation
Acute inferolateral myocardial infarct, possible posterior
myocardial infarct
Intervals Axes
Rate PR QRS QT/QTc P QRS T
73 218 92 368/393.57 50 -46 86
.
CATH [**2106-2-7**]:
1. Three vessel coronary artery disease.
2. Patent SVG--> LAD and SVG--> D1.
3. Occluded SVG--> RCA.
4. Elevated left sided filling pressures.
5. Preserved cardiac index/output.
6. Acute inferior myocardial infarction, managed by acute ptca.
PTCA of SVG--> RCA, RPDA adn RPL branch vessels.
.
ECHO [**2106-2-8**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is moderately to severely
depressed with global hypokinesis and akinesis of the inferior
and infero-lateral walls. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size is normal. There
is moderate global right ventricular free wall hypokinesis. The
aortic root is mildly dilated. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
.
CATH [**2106-2-10**]:
1. Limited selective coronary angiography demonstrated single
vein
graft disease. The SVG-RCA demonstrated no angiographically
apparent,
flow-limiting disease including the native vessel distal to the
touchdown which was involved with the STEMI. The SVG-diagonal
was
without angiographically apparent, flow-limiting disease. The
SVG-LAD
had an ostial 70% lesion.
2. Limited resting hemodynamics revealed central hypertension
with
blood pressure of 182/93 mmHg.
3. Successful placement of 3.0 x 18 mm Cypher drug-eluting stent
in
the ostial SVG-LAD. Final angiography demonstrated no residual
stenosis, no angiographically apparent dissection, and normal
flow (See PTCA Comments).
.
FINAL DIAGNOSIS:
1. Single vein graft stenosis.
2. Central hypertension.
3. Successful placement of drug-eluting stent in SVG-LAD.
.
Brief Hospital Course:
82yo M w/ STEMI now s/p cath with DES to R RCA/PDA. Plan is to
go back to cath for stent to LAD today.
.
# ISCHEMIA: Mr. [**Known lastname 11386**] already had elevated cardiac enzymes on
presentation to the CCU, with inferior and lateral ST elevations
on his EKG. On catheterization, it was found that one of his
grafts, the SVG -> distal RCA, had 100% occlusion at distal
anastomosis involving both PDA and PL branch bifurcation. A DES
was placed in the r-PDA and the r-PL had a balloon angioplasty,
with restoration of TIMI 3 flow. He was on intregrillin for 18
hours post-cath. Post-cath, he had residual ST elevations in the
inferior and lateral leads and persistent chest pain, though it
was much improved from the pain he had on admission. His cardiac
enzymes peaked on [**2106-2-7**], with CK of 5712, CKMB >500, MBI 8.5,
and troponins of >25. He was initially on a nitro gtt, but that
was weaned off as his blood pressure was low. He had no change
in his pain off the nitro gtt. His chest pain resolved on its
own on HD #[**Street Address(2) 16957**] elevations still persisted. He was
started on ASA, plavix, bblocker, ACE-i, and a statin. Based on
the results of his first catheterization, it was decided to
repeat a catheterization on [**2106-2-10**] and to stent his LAD graft
(which had a 70% ostial stenosis). He received mucomyst and
bicarb prior to his second catheterization for his chronic renal
insufficiency (Cr was 2.2). He tolerated the second
catheterization well. There were no groin complications from
either cath and he was able to be discharged home, with close
follow-up with his cardiologist, Dr. [**Last Name (STitle) 16958**].
.
# PUMP: Mr. [**Known lastname 11386**] had an ECHO on [**2106-2-8**] which showed his EF to be
30%, down from LVEF of >55% in [**4-7**] (on an ECHO from his PCP's
office). The ECHO showed that he has akinetic inferior and
inferolateral walls and global LV and RV hypokinesis.
Immediately after his MI, he had a lot of ectopy, including
multiple runs of NSVT (as long 20 beats) and AIVR. However, the
ectopy improved over time and he remained mostly in NSR
throughout the remainder of his hospital stay. A discussion
about an AICD was deferred as his ectopy improved and it was
felt that his EF may improve with resolution of his acute event.
He received IVF post-catheterization and tolerated it well,
without any evidence of volume overload. His BUN and Cr actually
rose slightly, to 40/2.2, which may have been prerenal as he was
not taking in good PO's. He was again given post-cath hydration
after his second catheterization and his Cr improved to 2.0. He
was started on an ACE-inhibitor and bblocker for his ACS as well
as his heart failure and tolerated them both well, without any
side effects. They were changed to once-daily dosing prior to
discharge.
.
# RHYTHM: He was monitored on telemetry throughout his entire
hospital course. Immediately after his first catheterization
(which was peri-MI), he had a significant amount of ectopy, with
up to 20 beats of VT and multiple episodes of AIVR, but the
ectopy improved over time. He remained in NSR for the remainder
of his hospital course.
.
# DELIRIUM: Mr. [**Known lastname 11386**] [**Last Name (NamePattern1) 16959**] at night. He was given zydis SL,
ativan and ambien in attempts to help him sleep, but none
worked. He was eventually given seroquel 25mg PO QHS which
helped him sleep and prevented him from sundowning.
.
# ASTHMA: Mr. [**Known lastname 11386**] was diagnosed w/ asthma several years ago and
states that he uses albuterol INH q6 at home. He was continued
on that regimen here, despite the fact that he had no wheezing
or shortness of breath. He was able to maintain stable O2 sats
on RA at rest and while ambulating prior to discharge.
.
# CRI: Mr. [**Known lastname 11386**] has chronic renal insufficiency, with a baseline
Cr of 1.8 to 2.2. His Cr on admission was 1.9 and remained
within his normal range throughout his hospital stay. He was
given post-cath hydration after both procedures as well as
mucomyst and IVF with bicarb prior to his second
catheterization. His Cr on discharge was 2.0.
.
# BLOOD in STOOL: He was seen to have stool streaked w/ blood on
HD #1. His Hct was monitored and remained stable despite
receiving IVF. It was felt that the blood-streaked stools were
likely due to hemorrhoids in the setting of anti-platelet
therapy. He had no further episodes throughout his stay.
.
# FEN: He was given a cardiac, heart healthy diet. He received
IVF after both catheterizations, as well as IVF with bicarb
prior to his 2nd procedure. His electrolytes were checked daily
and were repleted prn to keep K >4 and Mg >2.
.
# ACCESS: Peripheral IV x2
.
# PPX: Heparin SC. PPI. Bowel regimen.
.
# CODE: FULL
.
# DISPO: To home.
.
# F/U: PCP is [**First Name8 (NamePattern2) 1313**] [**Last Name (NamePattern1) 16958**]
Medications on Admission:
-synthroid 75 mcg daily
-metoprolol tartrate 25 mg twice daily
-aspirin 325 mg daily
-norvasc 5 mg daily
-nitro-dur 7.5 mg patch/24 hr
-astelin nasal spray 2 sprays/nostril twice daily
-prilosec 20 mg daily
-albuterol 2 puffs 4x daily
-ditropan 1 tab PO QD
-citracel TID
-nitro tabs prn
-HCTZ 12.5mg PO QD
-lipitor 10mg PO QD
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Azelastine 137 mcg Aerosol, Spray Sig: [**1-4**] sprays Nasal [**Hospital1 **]
(2 times a day).
9. Ditropan 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Acute inferior STEMI
.
Secondary diagnosis:
Chronic renal insufficiency
HTN
Hypothyroid
h/o prostate CA
Asthma
Arthritis
Discharge Condition:
Good. Patient is afebrile, hemodynamically stable with o2 sats >
95% on room air.
Discharge Instructions:
1. Please call your PCP or go to the nearest ER if you develop
any of the following symptoms: fever, chills, chest pain,
pressure or discomfort, shortness of breath, difficulty
breathing, nausea, vomiting, leg swelling or numbness, or any
other worrisome symptoms.
.
2. Please take all your medications. It is very important that
you take your aspirin and plavix EVERY DAY. If you find you can
not take these medications for any reason, you must call your
doctor immediately. These medications help keep your stents
open.
.
3. You will no longer be taking the following medications:
nitro-dur, norvasc, and hydrochlorothiazide.
.
4. Please follow-up with Dr. [**Last Name (STitle) 16958**] as directed below.
.
5. You will have [**Hospital1 **] VNA services visit you at your house to
help see what additional needs may be needed during your
recovery from your heart attack.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 16958**] on [**2106-3-1**] at
1:45pm. Please call his office if you have any questions or
concerns. His number is [**Telephone/Fax (1) 16960**].
.
2. Please follow up with your primary care doctor within one to
two weeks for follow up.
|
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"244.9",
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] |
icd9cm
|
[
[
[]
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[
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"00.45",
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icd9pcs
|
[
[
[]
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12654, 12712
|
6305, 11180
|
234, 348
|
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3065, 3070
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1520, 2223
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2239, 2549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,178
| 188,927
|
9959
|
Discharge summary
|
report
|
Admission Date: [**2123-9-16**] Discharge Date: [**2123-9-19**]
Date of Birth: [**2065-9-16**] Sex: F
Service: MEDICINE
Allergies:
Sulfur / Morphine Sulfate
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
Endoscopy with biopsies
History of Present Illness:
57F with a history of hypertension, pancreatitis,
STEATOHEPATITIS, GASTROESOPHAGEAL REFLUX who presntes with 5
days worth of nausea and vomiting.
This morning, when she woe up, she fell otu of bed and ays that
her right leg "gave out." She denied feeling any chest pain,
palpitations, lightheadeness or dizziness, and denies any loss
of conciounsness. She also says that she did not hit her head,
but did land profoundly on her right flank.
.
She sayt aht for hte past five days, she ahs been vomiting [**1-28**]
times with non-bloody, bilious emesis, with potentially small
flexs of blood. She also endorses having diarrhea for the past
few days, 3-4 episodes a day, aagain without blood, and that
does not interrupt her sleep.
.
She does endorsed a sick contact at work, who had these symptoms
of N/V/diarrhea 2 weeks ago. She denies any medication changes
recently. She does endorse decreased PO intake. On her review of
systems, she is positive for couhing up white spuutm since last
night, rhinorrhea after vomiting, shrotness of breath after
vomiting, nausea dn vomiting and diarrhea as described above.
.
In the ED inital vitals were, 98 116 149/74 20 100%. She was
given 4 mg Zofran x 2, 2 mg Lorazepam x 3, Thiamine 200 mg,
Folic acid 1 mg. 3 L NS, 1 L hanging.
.
.
Of note, she was admitted in [**2120-9-25**] to the MICU with
what was at the time felt to be alcohol/starvation acidosis,
hwere she was found to have acute pancreatitis with
peri-pancreatitic stranding, and fatty liver. Her N/V at that
time was though to be consistent with opioid withdrawal given 6
weeks of standing oxycodone 10 mg q 4 hours. She also had a
tranaminitis at the time, which was thought to be secondary to
alcohol.
Past Medical History:
OBESITY
HYPERLIPIDEMIA
HYPERTENSION
STEATOHEPATITIS
GASTROESOPHAGEAL REFLUX
PANCREATIC MASS
ALLERGIC RHINITIS
CERVICAL SPINAL STENOSIS
ANKLE FRACTURE, REQUIRING SURGICAL FIXATION
Social History:
Patient lives with her wife, [**Name (NI) **]. [**Name2 (NI) 1403**] as an optician. Former
smoker, quit 10 years ago (smoke 1/2-1 PPD for 10 years). Last
Drink tuesday 9 pm 15 drinks week
Family History:
NC
Physical Exam:
Admission:
Vitals: T: 97.7 BP: 146/111 P: 87 R: 23 O2: 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA
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; large R
flank eccymoses
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, patient has L facial droop
secondary to prior surgery
.
DISCHARGE PHYSICAL:
98.8, 150/88, 72, 18, 98RA
-comfortable appearing, NAD
-ambulating without difficulty
-abdomen non-tender, non-distended
-lungs clear to auscultaion
-alert and oriented x3, conversant
-no edema
Pertinent Results:
[**2123-9-16**] 10:10AM BLOOD WBC-9.5# RBC-3.45* Hgb-11.5* Hct-33.6*
MCV-97 MCH-33.2* MCHC-34.2 RDW-13.1 Plt Ct-199
[**2123-9-16**] 10:10AM BLOOD Neuts-92.7* Lymphs-3.8* Monos-3.0 Eos-0.4
Baso-0.2
[**2123-9-16**] 10:10AM BLOOD PT-12.5 PTT-24.9 INR(PT)-1.1
[**2123-9-16**] 10:10AM BLOOD Glucose-76 UreaN-26* Creat-1.4* Na-141
K-4.3 Cl-88* HCO3-14* AnGap-43*
[**2123-9-16**] 10:10AM BLOOD ALT-140* AST-185* AlkPhos-47 TotBili-1.1
[**2123-9-16**] 10:10AM BLOOD Lipase-27
[**2123-9-16**] 01:01PM BLOOD Calcium-8.1* Phos-3.6 Mg-1.3*
[**2123-9-16**] 08:10PM BLOOD Calcium-8.1* Phos-1.5* Mg-1.1* Iron-46
[**2123-9-16**] 08:10PM BLOOD calTIBC-257* VitB12-614 Folate-GREATER TH
Ferritn-802* TRF-198*
[**2123-9-16**] 08:10PM BLOOD Acetone-SMALL Osmolal-298
[**2123-9-16**] 01:01PM BLOOD Osmolal-310
[**2123-9-17**] 03:33AM BLOOD TSH-3.5
[**2123-9-16**] 10:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-9-16**] 09:17PM BLOOD Type-ART pO2-86 pCO2-23* pH-7.47*
calTCO2-17* Base XS--4
[**2123-9-16**] 09:17PM BLOOD Lactate-1.0
[**2123-9-16**] 12:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2123-9-16**] 12:00PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
[**2123-9-16**] 12:00PM URINE CastHy-32*
[**2123-9-16**] 12:00PM URINE Eos-NEGATIVE
[**2123-9-16**] 10:10PM URINE Hours-RANDOM UreaN-533 Creat-74 Na-88
K-33 Cl-98
[**2123-9-16**] 10:10PM URINE Osmolal-592
[**2123-9-16**] 12:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
CT Torso:
1. Superior anterior endplate compression fracture of L1 is of
indeterminate age but new from [**2121-10-24**]. There is evidence of a
healed fracture of the right lateral fifth rib. No other
fractures are identified.
2. No definite evidence of intra-abdominal trauma.
3. Thickening of the esophageal wall is noted without evidence
of rupture. Endoscopy would be recommended as an outpatient for
further evaluation.
4. Thickening of the wall of the second and third portions of
the duodenum
with mild adjacent stranding, concerning for duodenitis which
may be
infectious, inflammatory or although post-traumatic cause can
not be entirely excluded in the setting of trauma.
5. Multinodular thyroid gland is incidentally noted. A followup
ultrasound
would be recommended on an outpatient basis.
6. Indeterminate hypodensity in segment [**Doctor First Name **] of the liver. A
followup
ultrasound or MRI would be recommended for further evaluation.
.
ecg: Sinus tachycardia with minor non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2120-11-13**]
heart rate is somewhat increased. Otherwise, there is no
significant change.
.
GI BIOPSIES PENDING AT DISCHARGE
.
EGD:
Abnormal mucosa in the esophagus (biopsy)
Erythema, congestion and granularity in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
.
MRSA NASAL SWAB POSITIVE, NO OTHER MICRO DATA
.
DISCHARGE LABS
[**2123-9-17**] 03:33AM BLOOD WBC-5.7 RBC-2.80* Hgb-9.5* Hct-26.9*
MCV-96 MCH-34.1* MCHC-35.6* RDW-13.3 Plt Ct-118*
[**2123-9-17**] 03:11PM BLOOD Hct-29.0*
[**2123-9-18**] 06:45AM BLOOD WBC-4.6 RBC-3.18* Hgb-10.6* Hct-31.3*
MCV-99* MCH-33.2* MCHC-33.7 RDW-13.4 Plt Ct-130*
[**2123-9-18**] 06:45AM BLOOD Glucose-92 UreaN-6 Creat-0.8 Na-140 K-3.6
Cl-101 HCO3-27 AnGap-16
[**2123-9-19**] 06:30AM BLOOD Glucose-89 UreaN-6 Creat-0.7 Na-139 K-3.7
Cl-104 HCO3-26 AnGap-13
[**2123-9-17**] 03:33AM BLOOD ALT-86* AST-110* CK(CPK)-330* AlkPhos-38
TotBili-0.8
[**2123-9-18**] 06:45AM BLOOD ALT-75* AST-80*
[**2123-9-18**] 06:45AM BLOOD Calcium-8.5 Phos-1.4* Mg-1.7
[**2123-9-19**] 06:30AM BLOOD Calcium-9.1 Phos-2.2* Mg-1.6
[**2123-9-16**] 08:10PM BLOOD calTIBC-257* VitB12-614 Folate-GREATER TH
Ferritn-802* TRF-198*
.
hepatitis serologies pending
Brief Hospital Course:
57F with a history of hypertension, pancreatitis,
steatohepatitis, and GERD who presented with 5 days of nausea
and vomiting in the setting of poor nutrition and excess alcohol
consumption. Found to have a marked metabolic acidosis initially
requiring admission to the MICU. This was likely due to the
combined effects of alcohol and starvation--it resolved with IV
fluids. EGD was notable for esophagitis and duodenitis. Her
hospital course is further summarized below by major issues.
She presented in acute renal failure which resolved with
admisistration of IVF and was attributed to hypovolemia. Her
Anion-gap (positive ketones) metabolic acidosis was attributed
to starvation and alcoholic ketoacidosis--this also resolved
promptly with IVF.
She did have some sick contacts, so her nausea and vomitting
could have been secondary to viral gastroenteritis, but more
likely they were a consequence of her acidosis or
esophagitis/duodenitis.
She received thiamine and folate repleteion for her history of
alcoholism and poor nutrtion. She did not diplay nay signs or
symptoms of alcohol withdrawal during this admission. She
states she will not drink again. She required aggressive oral
and IV electrolyte repletion.
Transaminitis was attributed to alcohol consumption, but viral
hepatitis serologies are pending at the time of discharge.
Her lisinopril was initially held in the MICU, but restarted on
the medical floor prior to discharge. Her fibrate was held
during the admission and at the time of discharge because of her
resolving transaminitis.
Several incidental findings were noted on a CT of the torso that
will require oupatient follow-up:
1. a superior anterior endplate compression fracture: She will
need outpt bone denisometry as this is suspicious for
osteoporosis.
2. liver lesion: needs either MRI or US for further evaluation.
3. multinodular thyroid goiter: requires ultrasound for further
evalaution.
The patient was advised to follow-up with her PCP this week.
Medications on Admission:
Tricor 145 mg Daily
Lisinopril 20 mg Daily
Lorazepam 0.5 mg Q8H as needed (last filled [**Month (only) 956**])
Discharge Medications:
1. fenofibrate nanocrystallized 145 mg Tablet Sig: One (1)
Tablet PO once a day: HOLD THIS MEDICATION UNTIL YOU SEE DR.
[**Last Name (STitle) **].
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
5. sucralfate 1 gram Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*1*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
7. Calcium 500 + D Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Metabolic Acidosis: Alcoholic and starvation ketoacidosis
Acute Renal Failure
Esophagitis
Duodenitis
Hypertension, poor control
Alcohol abuse
Transaminitis
Hyperlipidemia
Hypophosphatemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 24344**],
You were initially very ill and required admission to the
medical intensive care unit. Alcohol and lack of food altered
the electolyte composition and acidity of your blood. This
resolved with IV fluids, food, and electrolyte supplementation.
You had an endoscopy performed which revealed erosions (ulcers)
in your esophagus and inflammation in your duodenum. Biopsies
were taken and you have been prescribed two medications to block
stomach acid and promote healing. You should avoid taking
aspirin and medications known as NSAIDS such as aleve, motrin,
ibuprofen, and advil among others.
It is important that you abstain from alcohol, particularly now
so your stomach can heal. You should continue to hold
fenofibrate until Dr. [**Last Name (STitle) 5263**] has checked your liver enzymes an
ensured that they have normalized.
Followup Instructions:
Please call [**Telephone/Fax (1) **] to schedule an appointment with Dr.
[**Last Name (STitle) 5263**] this week. She is aware of your hospitalization and has
access to the relevant records.
Please call [**Telephone/Fax (1) **] to schedule an appointmet with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within the next two weeks. If he is unavailable,
please make an appointment with any other gastroenterologist in
that department. Dr. [**Last Name (STitle) 5263**] can assist you if you have
difficulty making this appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2123-9-20**]
|
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icd9cm
|
[
[
[]
]
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[
"45.16"
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icd9pcs
|
[
[
[]
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7192, 9191
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302, 329
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10268, 10268
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,247
| 131,903
|
15729+56685+56687
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2122-1-10**] Discharge Date: [**2122-2-5**]
Date of Birth: [**2059-1-8**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Motrin / Nsaids / Aspirin
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
seizure, subsequent transfer to MICU for angioedema
Major Surgical or Invasive Procedure:
Thrombectomy by IR
PEG placement - converted to G-J tube
Tracheostomy
Chest Tube placement/removal
History of Present Illness:
62 y.o. F with h/o ESRD on HD, s/p failed kidney transplant on
prograf, h/o DVT (associated with HD catheter) - on coumadin,
who was admited to neurology service ([**1-10**]) after experiencing
becoming unresponsive due to presumed seizure during her
scheduled HD (at OS facililty). Patient subsequently transfered
to MICU in the morning of [**1-11**] after she was found to be severely
hypertensive to 220/120 with tachycardia to 130s, elevated K,
and continued seizure activity - unresponsiveness.
.
Patient during initial presentation was found "catatonic",
tracking but not able to speak or follow comands. No active
convulsions were noted. She was spontaneously moving her all
extremities equally. Patient was felt to have nonfluent aphasia
with mouth twitching and left gaze palsy that resolved with
adminstration of ativan. CT head showed no evidence of acute
stroke, no tPA was administered as she was felt more likely to
have a seizure. Patient was also loaded with dilantin at that
point (1 gm). She was continued on Dilantin 100 mg IV q8; An
extra 700 mg and 300 mg IV dose was give @ 7 pm [**1-10**]. Patient was
subsequently given Kayexcalate and CaGluconate, insulin and D50
for hyperkalemia and peaked T waves @ 2 am. She was given about
1L NS overnight as well. In the morning, patient was
unresponsive to vocal commands, but gesturing to noxiuos
stimuli. Her angioedema including lip and eye swelling appeared
to have worsened over last 12 hours. She initially appeared to
be protecting her airway. A nasal trumpet was inserted and she
was bagged on her way to the MICU. Patient was also given 2 mg
Ativan @ 7 am; Of note her FS was 35 @ 4 pm [**1-10**] as well, and
went to 143 after D50 amp. (It was 63 upon ED presentation).
Patient also had respiratory acidosis with likely worsening
transcellular shift of potassium. Patient was subsequently
hypertensive to 220/110 upon arrival, with HR in 120s,
responding only to noxious stimuli with impressive angioedema.
Patient was subsequently intubated using Rocuronium with 7.5
ETT, moderate to severe vocal edema noted. Patient with
transient desaturation to 60s with quick recovery upon bagging.
Patient was given 10 mg of IV labetalol for BP 220/110 during
intubation, subsequently after IV propofol was started,
rocuronium and intubation patient's SBP dipped to 60s, it
improved to 90-100s over next 10 minutes after 300 cc of NS
bolus. Post-intubation Xray was showed ETT 4 cm above coryna
with large sided PTX and CT surgery was called.
Past Medical History:
1. Diabetes mellitus.
2. End-stage renal disease secondary to diabetes mellitus s/p
failed dual extended-criteria donor renal transplant (BK virus
nephropathy)
3. Hemodialysis.
4. Hypertension.
5. Hyperlipidemia.
6. Thrombosis of bilateral IVJ (catheter placement)-- DVT
associated with HD catheter RUE on anticoagulation (Coumadin)
9. Osteoarthritis.
10. Arthritis of the left knee at age nine, treated with ACTH
resulting in secondary [**Location (un) **]. She was diagnosed with rheumatic
fever.
11. Multiple admission with altered MS recently ([**10-13**]) - with
recent extensive neurological workup revealing multifocal
etiology likely due to HD fluid/electrolyte shifts, ? uremia
prior to HD, also component of vascular dementia. Recent PNA.
.
Past Surgical History:
1. Kidney transplant in [**2119**] b/l in RLQ
2. Left arm AV fistula for dialysis.
3. Removal of remnant of AV fistula, left arm.
4. Catheter placement for hemodialysis.
5. Low back surgery (unspecified
Social History:
The patient smokes half a pack of cigarettes a day for the last
20 years. She does not drink alcohol or has ever experienced
with recreational drugs, has no tattoos. The patient has had
transfusions in [**2119**] and [**2120**]. The patient is a homemaker. The
patient has experienced economic problems lately.
Family History:
Mother and sister with diabetic mellitus.
Kidney failure in mother, sister
Physical Exam:
PE: intubated, sedated, NAD
VS: T 98.0 BP 120/83 HR 97 RR 20, 100% AC 100% 500 x 20 5
General: sedated, comfortable
HEENT: large distended neck veins
PEERL to light from 2 mm to 1 mm, anicteric
large protuberant tongue, and swelling of the lips
neck: no JVD, supple
CV: +s1s2 RRR 2/6 systolic murmur, no R/G. +L.sided tunnel cath
no erythema, C/D/I.
PULM: B/L AE no w/c/r
ABD: +bs, soft, NT, ND
EXT: no C/C/ trace edema 2+pulses
NEURO: AAOx3, CN 2-12 intact, motor [**5-11**] UE and LE, sensation
intact to LT, prioprioception intact, 1+ reflexes throughout,
cerebellar function intact, gait intact.
.
Discharge PE:
On trach - using trach mask at times
VS: T 99.4 BP 104/63, HR 110, RR 20, O2 100%
General: comfortable, clear trach secretions
HEENT: supple
neck: no JVD, supple
CV: +s1s2 RRR 2/6 systolic murmur, no R/G.
PULM: B/L AE no w/c/r
ABD: +bs, soft, NT, ND, G-J tube in place.
EXT: no C/C/ trace edema 2+pulses, R-groin hematoma resolving.
NEURO: AAOx3, CN 2-12 intact, motor [**5-11**] UE and LE
Pertinent Results:
CXR:
as above in HPI
.
EKG:
NSR @ 88, nl axis; no STE in precorrdial leads; markedly reduced
voltage compared to prior
.
[**1-10**] EEG:
IMPRESSION: This is an abnormal portable EEG in the waking and
sleeping
states due to the disorganized background, initially [**7-14**] Hz, but
later
interrupted by prolonged bursts of moderate amplitude
generalized mixed
theta and delta frequency slowing with a bifrontal predominance.
Findings are consistent with an encephalopathy, which suggests
bilateral
subcortical or deep midline dysfunction. Medication, metabolic
disturbances and infection are among the common causes of
encephalopathy. Of note, the superimposed faster beta frequency
rhythm
likely represents medication effect. No clearly epileptiform
features
were noted and no electrographic seizures were seen.
.
Head CT [**1-10**]:
IMPRESSION:
1. No evidence of hemorrhage or infarct. Normal CT perfusion
study.
2. No evidence of occlusion or flow-limiting stenosis in the
vessels of the head or neck.
3. Old infarcts in the deep [**Doctor Last Name 352**] matter as described above.
.
[**1-11**] UE US:
IMPRESSION:
1. No definite flow seen within either the right or left
internal jugular vein, likely chronically thrombosed as
previously reported. The venous flow seen in vessels medial to
the carotid arteries, bilaterally, likely represent flow within
prominent collateral vessels.
2. Abnormally sluggish and "to-and-fro" flow seen within the
subclavian veins, bilaterally, more evident on the right than
the left. In this setting, these findings raise the possibility
of more central (ie. SVC), perhaps partially occlusive, venous
thrombosis.
3. Thrombosis of the right cephalic vein, while brachial vein is
patent.
COMMENT: Depending on patient's overall condition and the state
of the patient's renal function and timing of dialysis, further
evaluation with possible CT venography, MR venography with time-
of-flight images (as gadolinium may be interdicted), or
radionuclide pertechnetate venous flow- study may provide
further information.
.
[**1-11**] SVC gram:
IMPRESSION:
1. Bilateral upper extremity venograms demonstrating relatively
stable appearance of complete thrombosis of the distal right
subclavian and right brachiocephalic vein with extensive venous
collaterals.
2. Interval progression of thrombosis of the left upper
extermity veins with complete occlusion extending from the left
mid axillary vein to the the left brachiocephalic vein,
supported by extensive venous collaterals.
3. Delayed opacification with contrast identified centrally of
the azygous vein and superior vena cava, although assessment of
these vessels is limited secondary to the poor bolus of contrast
from extensive thoracic collateral veins. Partial
occlusion/thrombosis of the superior vena cava is likely. (IR
unable to visualize much of the dye as the canulation of IJ's
would not allow the dye to progress to SVC due to presumed more
proximal obstruction)
[**1-13**] EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
Routine
sampling and spike and seizure detection programs demonstrated a
poorly
organized posterior dominant interrupted by prolonged bursts of
bifrontally predominant generalized delta frequency slowing,
consistent
with a moderate encephalopathy. This suggests dysfunction of
bilateral
subcortical or deep midline structures. Medications, metabolic
disturbances, and infection are among the common causes of
encephalopathy. An isolated interictal sharp wave discharge was
noted
via the automated algorithms in the left temporal region, with
phase
reversal at T3, suggesting a potential focus for
epileptigenesis. There
were no prolonged or sustained discharges and no electrographic
seizures
were noted.
.
CT Abd/Pelvis [**2122-2-3**]
Slight decrease in size of right medial thigh compartment and
obturator
internus hematomas, no new hematoma formation. 2-cm long thin
linear metallic foreign body within lumen of jejunum of unclear
significance. Findings
discussed with Dr. [**Last Name (STitle) 45311**] at 10:15PM [**2122-2-3**]. MPOWELL [**Numeric Identifier 45312**].
Brief Hospital Course:
63 y.o. F with h/o ESRD on HD, s/p failed b/l kidney
transplants, who presented from OSH with unresponsiveness
witness facial twiching/seizure at the end of her HD session,
subsequent unresponsiveness, hyperkalemia, hypertension, and
failure to protect her airway due to angioedema resulting in
intubation and subsequent L sided pneumothorax.
.
# Pneumothorax - Patient did have a transient 20 second hypoxic
episode to Sats of 60s that quickly reocvered. She continued to
oxygenate well. Her CT was draining minimally. The subsequent
repeat CXR showed L lung reexpansion. CT to be d/c once patient
is extubated. Thoracics service placed the CT at bedside and
followed the patient during her hospital course
.
# Respiratory failure, angioedema - patient was intubated due to
angioedema. The intubation was medium complexity with moderate
swelling of visual cords visualized. Patient required use of a
bouje, with a subsequent 7.0 ETT reinsertion after 6.5 was
placed initially. She did have a brief episode of desaturation
to 60s for 20 seconds that improved with ventilation. Patient's
course was complicated by PTX as described above. Patient was
initially started on steroids, benadryl and famotadine was it
was unclear whether her angioedema was due to dilantin (24 hours
prior to ICU transfer) or CT dye allergy vs SVC syndrome. After
obtaining UE ultrasound and the swelling of the neck along with
UE swelling. Patient was subsequently taken off steroids after
2 days and was continued on heparin gtt. Patient underwent SVC
gram for possible definitive diagnosis of SVC clot, however the
study was limited due to failure of progression of the dye to
the SVC from the SCL due to several likely obstructions. Per IR
thrombectomy would have been a very technically difficult
procedure. Patient with good pulmonary mechanics after
improvement in her likely VAP as described below but continues
to have no cuff leak, thus suggesting persistent vocal cord
edema. On [**1-17**] patient was also noted to have opacification of
L lung on the Xray suggesting diffuse alveolar process or
possible lung collapse or plugging. There was no mediastinal
shift or air to suggest new PTX. Heparin drip was continued.
She was eventually extubated on [**1-19**] but reintubated on [**1-20**] for
increased stridor and concern for loss of airway. She got a
tracheostomy on [**1-21**] and PEG on [**1-23**]. Her secretions decreased
and she had an adequate cough reflex, sufficient for management
on the floor.
.
SVC syndrome/multiple upper extrmity clots. She had a
thrombectomy for this on [**1-23**]. She was bridge from heparin to
coumadin, and is now on coumadin 5mg daily with a therapeutic
INR.
.
# Hypotension - initial hypotension was felt to be due to
pneumothorax and propofol, antihypertensive medications received
during intubation. It quickly resolved with 250 cc NS bolus and
patient in a few hours required antihypertensives to keep her
SBP <200. On [**1-15**] patient patient suddently became hypotensive
after pulmonary toileting along with tachypnea and tachycardia.
Patient responded to 250 cc NS bolus again with improvement in
her BP with SbP to 110s and MAPs > 65. There was no evidence of
new re-expended tension pneumothorax. It was felt to be due to
possible VAP and she was started on broad spectrum antibiotics
as below. Patient hypotensive again on [**1-30**], after HD. resolved
with lying flat and 1 unit prbcs.
.
# VAP - patient's secretions worsened on [**1-14**], and she became
transiently hypotensive on [**1-15**] AM. She was started on broad
spectrum antibiotics - Vanco/Zosyn. Her cultures remained
negative and her sputum Cx was felt to be contaminated and did
not grow out pulmonary pathogens. Her WBC was elevated but
improved after institution of antibiotics. Patient was off
steroids x 2 days during the leukocytosis increase, thus making
demargination less likely. She completed an 8 day course of
vancomycin and Zosyn with no microbe isolated.
.
# Seizures - Patient initially presented with facial twitching
in the ED, that improved with ativan and was felt to be
consistent with a clinical seizure. Thus she was loaded with
dilantin and was admited to neurology service. However, further
review of her EEG failed to caputre true epileptiforms and her
presentation was felt to be consistent with toxic metabolic
encephalpathy that may have precipitate a seizure especially
with hyperkalemia. Patient remained without any clinical signs
of seizure while in ICU on propofol, she was mentating and
interacting on [**1-17**]. Her EEG also did not show any new siezure
activity. Neurology service was following the patient and
decided that she did not need additional antiseizure medication.
.
Rt femoral hematoma: Patient had femoral line placed on [**1-15**] on
rt side. after being called out to the floor on [**1-25**], she
started c/o of severe rt groin pain. hematoma was palpated, no
bruits. An u/s showed a large hematoma in the thigh. Her Hct had
been trending down since the placement of the line, so a CT was
done to assess for retroperitoneal hematoma. The obutrator
internis muscle was slight enlarged, consistent with small
retropertineal bleed. No acute drop in Hct. She did have 1 unit
PRBCs for hct of 23. She was also intermittently with low grade
fever, which may have been from the hematoma. Hematoma steadily
resolved and repeat imaging showed no progression.
.
# Foreign Body - CT scan of the abdomen performed for abdominal
pain demonstrated a small jejunal foreign body 2cm in length.
Interventional radiology was contact[**Name (NI) **] who felt the foreign body
was related to the placement of the G-J tube and stated that
there is a small cap associated with the J-tube that normally
breaks off and is passed in the stool. After discussion with IR
and surgery it was felt that there was no need for intervention
at this time, and that the object should pass on its own without
difficulty. If desired, repeat imaging at a point in the near
future could be obtained to follow the passage of the cap, but
was not felt to be necesarry at this time.
.
# ESRD - s/p renal transplant; patient with 2 failed kidney
transplants in LLQ; she does not need to be on tacrolimus
anymore. HD continued.
.
# h/o b/l IJ thrombosis - on coumadin at home, but not
therapeutic. Heparin gtt while in house, transitioned to
coumadin.
.
# DM - RISS, of note hypoglycemic during initial ED presentation
to 30s.
.
# Hypertension - initially hypertensive to 220s during ED and
ICU presentation. She was eventually converted to amlodipine
10mg daily, captopril 12.5mg TID, and metoprolol 25mg TID with
room to increase as tolerated.
.
# Atrial fibrillation - on [**1-19**] she had an episode of unstable
atrial fibrillation which produced blood pressures in the 60's
systolic; she was cardioverted x 1 with good response. Briefly
on amiodarone and remained in sinus thereafter. Currently
anticoagulated with coumadin.
.
# Hyperlipidemia - lipitor 20 mg daily
.
# Depression - Zoloft 100 mg daily
.
# R femoral TLC placed on [**1-15**] in IR, after failed attempts x 3
by bedside, know IJ occlusions with slow subclavian flow and
likely SVC occlusion.
Medications on Admission:
Norvasc 10 mg Daily
Lipitor 20 mg Daily
Metoprolol 75 mg PO BID
HCTZ 25 mg Daily
Prilosec 20 mg
Renal Cap PO QD
Cinacalcet 90 mg Daily
Thrimethoprim 400 mg PO QD ?
Lanthanum 1000 mg PO TID w/meals
Coumadin 2 mg Sun/Tue/[**Doctor First Name **]/Sat; 5 mg M/W/F
Folate/Thiamine
Zoloft 100 mg Daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Doctor First Name **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Doctor First Name **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Doctor First Name **]: [**1-7**] PO BID (2 times a
day).
4. Cinacalcet 30 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO DAILY
(Daily).
5. Thiamine HCl 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
6. Sertraline 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
7. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Month/Day (2) **]: as
directed Subcutaneous qACHS: As per sliding scale.
8. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
[**1-7**] Inhalation Q6H (every 6 hours) as needed.
11. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Day (2) **]: One (1) Cap
PO DAILY (Daily).
13. Warfarin 2.5 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO QHS (once a
day (at bedtime)).
14. Trazodone 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO ONCE (Once) for 1
doses.
15. Morphine 10 mg/mL Solution [**Month/Day (2) **]: 1-2 mg Intravenous Q2H
(every 2 hours) as needed.
16. Heparin (Porcine) in D5W 10,000 unit/100 mL Parenteral
Solution [**Month/Day (2) **]: as per sliding scale Intravenous IV infusion: As
per sliding scale, target range PTT 60-85.
17. Captopril 12.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO three times
a day: Hold on day of HD, and for SBP < 100.
Discharge Disposition:
Extended Care
Facility:
Radius
Discharge Diagnosis:
Primary:
SVC syndrome
Diabetes mellitus.
Seizure
Pneumothorax
anaphylaxis
Thrombosis of bilateral IJV (catheter placement)-- DVT
associated with HD catheter RUE on anticoagulation
.
Secondary:
Diabetes
End-stage renal disease secondary to diabetes mellitus s/p
failed dual kidney transplant
Hypertension.
Hyperlipidemia.
Osteoarthritis.
Discharge Condition:
Stable, on coumadin, cleared to eat by speech and swallow once
she finds her dentures.
Discharge Instructions:
You were admitted to the hospital intially with seizure like
activity, and developed swelling in your throat, which required
you to be intubated. You course was further complicated by
deflation of your lung and pneumonia. This swelling is most
likely caused by SVC syndrome, which is the backing up of your
blood because of clots in your veins.
.
You are to continue taking coumadin daily for the rest of your
life to ensure you have no further blood clots. At this time,
you do not need to take medications to prevent seizures. You
should avoid dilantin in the future as it may have caused some
of your neck swelling.
.
Please call your PCP or return to the hospital if you experience
more face, upper extremity swelling, sudden shortness of breath,
chest pain or any other concerning symptoms.
Followup Instructions:
Please f/u with your PCP [**Last Name (NamePattern4) **] [**2-8**] weeks.
.
ENT -- Please f/u with ENT for your tracheostomy in [**3-10**] weeks
([**Telephone/Fax (1) 6213**].
.
Please f/u in 1 month with inteventional radiology to repat an
angiogram of your arm veins. Phone # ([**Telephone/Fax (1) 45313**]
.
Below are
your existing appointments:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2122-5-4**] 1:20
------------
Please continue to monitor INR until consistently therapeutic
([**2-8**]). Please continue heparin for 48 hours after patient
becomes therapeutic on coumadin and then discontinue.
Please continue to monitor INR at a regular interval in the
future.
Name: [**Known lastname **],[**Known firstname 8328**] Unit No: [**Numeric Identifier 8329**]
Admission Date: [**2122-1-10**] Discharge Date: [**2122-2-5**]
Date of Birth: [**2059-1-8**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Motrin / Nsaids / Aspirin / Dilantin
Attending:[**First Name3 (LF) 417**]
Addendum:
Captopril dose on discharge adjusted to 6.25mg TID from 12.5mg
TID. To be held on dialysis days.
Discharge Disposition:
Extended Care
Facility:
Radius
[**Name6 (MD) **] [**Last Name (NamePattern4) 424**] MD [**MD Number(1) 425**]
Completed by:[**2122-2-5**] Name: [**Known lastname **],[**Known firstname 8328**] Unit No: [**Numeric Identifier 8329**]
Admission Date: [**2122-1-10**] Discharge Date: [**2122-2-5**]
Date of Birth: [**2059-1-8**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Motrin / Nsaids / Aspirin / Dilantin
Attending:[**First Name3 (LF) 417**]
Addendum:
Discussion with IR attending regarding the foreign body in the
jejunum. Again, it was felt that the foreign body might be
related to the G-J tube placement and a normal consequence of
the procedure. Less likely but also possible was that it
represents some other swallowed foreign body. In any event,
felt it was reasonable to observe and consider re-imaging down
the road if the patient becomes symptomatic, or has any symptoms
suggestive of a bowel obstruction. No specific reimaging
required at this time.
Discharge Disposition:
Extended Care
Facility:
Radius
[**Name6 (MD) **] [**Last Name (NamePattern4) 424**] MD [**MD Number(1) 425**]
Completed by:[**2122-2-5**]
|
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41,217
| 163,724
|
38899
|
Discharge summary
|
report
|
Admission Date: [**2165-3-25**] Discharge Date: [**2165-4-4**]
Date of Birth: [**2104-2-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
STEMI, vfib arrest
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
61 y/o M who while working at [**Hospital1 778**] started complaining of
substernal chest pain. EKG at the park showed STEMI, he received
aspirin 325 mg, and he was transported to the [**Hospital1 18**]. Initial
systolic BP at [**Hospital1 778**] was in the 90s. While enroute, he lost his
pulse and arrested. He underwent CPR for approximately one to
two minutes prior to arriving in the ED. He was intubated. In
the ED, he was in Vfib. At that time he received 2 shocks. He
also received epinephrine and atropine x1 dose each. He also
received one dose of amiodarone. A pulse was obtained and a
systolic blood pressure in the 90s. He was started on levophed
and dopamine prior to cath. He went into afib and then sinus
tachycardia.
.
In the ED, initial vitals were unobtained as patient in wide
complex rhythm without a pulse. See above for code sequence.
.
He was taken directly to the cath lab. In the cath lab, he had
proximal LAD occlusion with residual mid and distal disease, had
placement of 2 promus stents in proximal LAD, 2 cipher stents
distally. Placed on integrillin and heparin. Stopped integrillin
and heparin b/c had petechiae on legs b/l. He did have hypoxia,
which was due to ventilator malfunction and cuff [**Last Name (LF) 3564**], [**First Name3 (LF) **] he was
reintubated in the cath lab. By the end of the procedure, he was
weaned off the dopamine and levophed. During cath CO=9, CI=4.5.
Required a large amount of sedation for the cath. Had arterial
sheath in, large bore so pulled in lab. A femoral swan catheter
remained in place.
.
In the lab, he received an amiodarone gtt, dopamine gtt,
levophed gtt, propofol gtt, bolus of succinylcholine and
vecuronium, bolus of versed, bolus of heparin and integrilin and
plavix 600 mg. The dopamine and levophed were weaned prior to
transfer.
.
ROS and specifically, cardiac review of systems could not be
obtained as patient intubated and sedated. While in the CCU,
patient dropped BP's to 70's systolic (also in the setting of
sedation), and required levophed briefly. An arterial line was
placed. Was weaned overnight.
Past Medical History:
None/unknown
Social History:
Formerly homeless, now living in an apartment. Works at [**Hospital1 778**]
park in food service. Smoker, tox screen on admission negative.
Family History:
Unknown
Physical Exam:
GENERAL: WDWN male who is sedated and intubated.
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: Unable to assess JVP due to body habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB in anterior
fields.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. +petechiae on LE b/l.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
NEURO: Posturing, PERRLA
ACCESS: Right femoral CVL/Swan, Left radial Aline
Pertinent Results:
Labs on admission:
[**2165-3-25**] 11:20PM WBC-21.2* RBC-5.25 HGB-14.6 HCT-44.0 MCV-84
MCH-27.9 MCHC-33.3 RDW-13.6
[**2165-3-25**] 11:20PM NEUTS-92.0* LYMPHS-4.9* MONOS-2.6 EOS-0.1
BASOS-0.3
[**2165-3-25**] 11:20PM PLT COUNT-285
[**2165-3-25**] 10:54PM GLUCOSE-271* LACTATE-3.2*
[**2165-3-25**] 08:30PM ALT(SGPT)-28 AST(SGOT)-39 CK(CPK)-91 ALK
PHOS-88 TOT BILI-0.7
[**2165-3-25**] 08:30PM LIPASE-31
[**2165-3-25**] 08:30PM PT-13.4 PTT-19.5* INR(PT)-1.1
[**2165-3-25**] 08:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2165-3-26**] 01:13AM BLOOD CK-MB-198* MB Indx-12.7* cTropnT-5.59*
[**2165-3-26**] 05:38AM BLOOD CK-MB-239* MB Indx-13.5* cTropnT-4.76*
[**2165-3-26**] 11:00AM BLOOD CK-MB-279* MB Indx-16.1* cTropnT-4.62*
[**2165-3-27**] 04:31AM BLOOD CK-MB-251* MB Indx-22.7*
Micro:
[**2165-3-30**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2165-3-30**] URINE URINE CULTURE-PENDING INPATIENT
[**2165-3-30**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2165-3-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY INPATIENT
[**2165-3-30**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2165-3-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2165-3-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2165-3-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2165-3-28**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {BACILLUS SPECIES; NOT ANTHRACIS}; Aerobic
Bottle Gram Stain-FINAL INPATIENT (thought to be contaminant)
[**2165-3-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2165-3-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2165-3-26**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
Imaging:
C Cath ([**2165-3-25**])
COMMENTS:
1- Coronary angiography in this right dominant system
demonstrated one
vessel disease. The LMCA ahd RCA had no angiographically
apparent
disease. The LAD was proximally occluded. The LCx had mild
diffuse
disease without angiographically significant stenoses.
2- Resting hemodynamics demonstrated elevated right sided
filling
pressures with RVEDP 18mmHg. The PCWP was elevated at 21mmHg.
There was
mild pulmonary arterial systemic hypertension with PASP 39mmHg.
The
cardiac index was preserved at 4.2 L/min/m2. The systemic
arterial blood
pressure was normal with SBP 119mmHg and DBP 72mmHg.
3- Successful primary angioplasty of the LAD with placement of 4
DESs:
two overlapping Promus DESs to the culprit lesion at proximal
LAD
(3.0x18 and 3.0x8 mm) and two overlapping Cypher DESs to the mid
LAD
(3.0x13 and 3.0x8 mm) with excellent results (see PTCA Comments)
4- Successful closure of the RCFA (arteriotomy) with a 6F
Angioseal.
FINAL DIAGNOSIS:
1- One vessel coronary artery disease.
2- Elevated right sided filling pressures and PCWP.
3- Preserved cardiac index.
4- Successful primary angioplasty to the LAD with two Promus DES
to mid
vessel (culprit lesion)
5- Successful PTCA and stenting of the mid LAD with two Cypher
DESs
6- Successful closure of the RCFA (arteriotomy) with a 6F
Angioseal
Echo ([**2165-3-26**]):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. A left ventricular mass/thrombus cannot be excluded.
Right ventricular chamber size is normal. with focal hypokinesis
of the apical free wall. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is severe mitral annular calcification. Mild (1+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
CXR:
No evidence of acute focal pneumonia, though there may be mild
retrocardiac atelectatic changes.
CT head:
1. Left parietal hypodensity with loss of [**Doctor Last Name 352**]-white matter
differentiation concerning for acute or early subacute infarct.
2. No intracranial hemorrhage.
Brief Hospital Course:
61 y/o M who presented with substernal chest pain, STEMI and
Vfib arrest.
.
# Cardiogenic Shock: On admission, patient in cardiogenic shock
from STEMI with Vfib arrest. Had elevated filling pressures in
the lab, CO 9 and CI 4.5. Intially had required levophed and
dopamine to maintain BP's, weaned off within hours of leaving
the lab. Found to have multiple tight lesions in LAD. BP
improved after PTCA and stents.
.
# Coronary Artery Disease: Patient with STEMI, proximal LAD
occlusion with residual mid and distal disease, had placement of
2 promus stents in proximal LAD, 2 cipher stents distally.
Started on Atorvastatin 80mg daily, Plavix 75mg [**Hospital1 **] x 1 week
then 75mg daily, ASA 325mg daily. Metoprolol Succinate
uptitrated to 200 mg daily to maintain lower resting HR.
.
# Acute Systolic Dysfunction, EF 40%: Echo following cath showed
low EF to 20% and wall motion abnormalities as above. Patient
started on heparin gtt, added on BB and ACEi as well. Did not
require diuresis as euvolemic on exam. EF improved to 35-40% by
discharge. Coumadin started for near akinetic apex, goal INR [**12-26**]
with INR 2.8 at discharge on [**4-4**]. Pt will get INR checked on
[**4-5**] at Dr.[**Name (NI) 86313**] office and further instructions on daily
coumadin dose.
.
# RHYTHM: Patient s/p Vfib arrest, now in NSR. Continued on
Amiodarone drip initially, then easily weaned off. Uptitrated
Metoprolol Succinate to goal HR of 60's-70's.
.
# HYPOXIC RESPIRATORY FAILURE: Patient noted to desat in the
cath lab, thought to be in the setting of cuff [**Name (NI) 3564**] and
ventilator malfunction. Difficulty in weaning off the vent given
mental status, and required Presidex to be started before this
could be successfully done. Two days after intubation, patient
w/ copious sputum, fever to 101.8, and ?infiltrate on CXR,
prompting treatment for Ventilator associated pneumonia with
Vancomycin and Zosyn. Completed 5 day course IV with no further
fevers or leukocytosis. Dry cough thought secondary to ACEi use,
changed to [**Last Name (un) **] with improvement of cough.
******CT Chest: there was a 1cm pulmonary nodule found in the
Right upper lobe. Rec repeat CT chest done in 3 months as an
outpatient to follow-up on this lesion.
.
# Acute Mental status changes: Patient underwent cooling
protocol s/p Vfib arrest. Also noted to be quite agitated before
being weaned off ventilator, possibly from alcohol withdrawal.
Neuro consulted, felt this to be most c/w encephalopathy. Mental
status cleared completely before discharge and pt was evaluated
and cleared by OT/PT.
.
# Left parietal stroke: Patient noted to have left parietal
stroke on head CT following catheterization. Thought to be
cardioembolic in nature. Maintained on heparin gtt, ASA, plavix.
No residual defecits noted at discharge.
.
# Social Status: pt lives alone in small room above the Veterans
homeless shelter in Government Center. He pays rent and works [**Hospital1 63740**] during the baseball season selling hot dogs. His job
requires lifting and standing so pt was told not to return to
work until after he sees Dr. [**Last Name (STitle) **] on [**4-16**]. He has no
family contact but reports many friends. Smokes approx 16
cigs/day and drinks 5-6 beers/day. he was told that quitting
tobacco and ETOH will be crucial to his continued recovery. He
has had no primary care and never took any prescriptions.
Doesn't cook, heats up frozen and packaged food in the
microwave. Extensive teaching was done about heart disease,
medications, low salt diet and importance of follow-up,
especially for coumadin. Pt exibited limited understanding and
will need continued teaching. [**Hospital 119**] Homecare will see pt at
home and close f/u was made prior to discharge.
Medications on Admission:
None
Discharge Medications:
1. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 6 weeks.
Disp:*45 Patch 24 hr(s)* Refills:*1*
5. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 2 weeks.
Disp:*14 patches* Refills:*0*
6. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*0*
11. Outpatient Lab Work
Please check your Warfarin (coumadin) level on Friday [**4-5**]
during your appt with Dr. [**Last Name (STitle) 10747**]. Results to Dr. [**Last Name (STitle) 10747**] at
[**Telephone/Fax (1) 798**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY: ST-elevation myocardial infarction
SECONDARY:
Hypertension
Tobacco Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure being involved in your care, Mr. [**Known lastname 86314**].
You came to the hospital after suffering a massive heart attack
and a cardiac arrest while you were working at [**Hospital1 778**]. You had 4
drug eluting stents placed in the coronary arteries that were
blocked. You also had a stroke around the same time. You
received antibiotics for pneumonia and finished the 5 day course
before leaving. Your heart is wek after the heart attack and we
have started new medicines to prevent another heart attack and
help your heart recover. It is extremely important to take these
medicines every day, even if you feel OK.
.
New Medicines:
1. Aspirin and Plavix: blood thinners to take every day, no
matter what. These medicines keep the stents from clotting off
and prevent another heart attack. Do not stop taking Plavix or
aspirin unless Dr. [**Last Name (STitle) **] tells you to.
2. Simvastatin: medicine to lower your cholesterol levels. Take
every day at night. You will need to get blood tests in 6 weeks
to check your liver function.
3. Metoprolol: a medicine to lower your heart rate and help your
heart recover from the heart attack.
4. Warfarin (Coumadin): a medicine to thin your blood and
prevent blood clots that can lead to another stroke. You will
need to get your blood checked frequently to make sure the level
is not too high or too low. Dr. [**Last Name (STitle) 10747**] will tell you how much
coumadin to take every day. Do not take your Warfarin on
[**2165-4-4**].
5. Ranitidine (Zantac): a medicine to protect your stomach from
the blood thinners
6. Nicotine patch: to use to decrease cravings for cigarettes.
Use the 14 mg patch for 6 weeks, then the 7 mg patch daily for 2
weeks, then discontinue.
7. Losartan to lower your blood pressure and help your heart
recover from the heart attack.
.
** On your CT Chest, there was a 1cm pulmonary nodule found in
the Right upper lobe. You should have a CT chest done in 3
months as an outpatient to follow-up on this lesion.
.
Please weigh yourself every day and call Dr. [**Last Name (STitle) **] if you gain
more than 3 pounds in 1 day or 6 pounds in 3 days.
Followup Instructions:
Primary care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10747**], MD [**Location (un) **], [**Hospital6 **] Center, [**Last Name (un) 86315**], [**Location (un) 86**] Phone: [**Telephone/Fax (1) 798**] Date/Time: Friday [**4-5**] at 12:30pm.
.
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time: Tuesday [**4-16**]
at 10:20pm.
.
** On your CT Chest, there was a 1cm pulmonary nodule found in
the Right upper lobe. You should have a CT chest done in 3
months as an outpatient to follow-up on this lesion.
Completed by:[**2165-4-4**]
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26,868
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Discharge summary
|
report+addendum
|
Admission Date: [**2163-3-23**] Discharge Date: [**2163-4-5**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 y.o. woman w/ PMH significant for DM, ESRD, initially
presenting from dialysis w/ substernal chest pain. The pain felt
tight, like pressure in the middle of her chest. It was not
associated with radiation to her arms or jaw, was not associated
with nausea, or diaphoresis. The patient reports having this
pain frequently, however, she reports never having been
hospitalized for the pain. However, the patient was admitted
last week with the same chief complaint. Apparently, the patient
is sensitive to fluid shifts given her HOCM, and this is the
precipitant of her chest pain. Her chest pain is non-exertional
in nature. She denies SOB, orthopnea, PND. She denies fever. She
reports having a productive cough, without hemoptysis. She
denies palpitations, lightheadedness, or headache. She denies
brbpr, or melena.
.
In the ED:her vitals were 97.3 126/92 130s 20 100%2L. ekg showed
ST depressions. Troponins positive 0.18. She received lopressor
5mg IV X1, some IVF, and SL nitro. Her pain resolved.
Past Medical History:
PMH:
- Hypertension
- Diabetes
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- GERD
- Hypercholesterolemia
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Paroxysmal atrial flutter, s/p failed ablation
- Peptic ulcer disease
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
.
PSurgH:
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
Social History:
Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker.
Family History:
Her father died in his 90's and mother at the age of 102.
Patient unable to specify cause of death. She has one living
sister and 6 sisters and one brother who passed away. Her family
history is significant for coronary artery disease, cancer, and
diabetes.
Physical Exam:
Vitals: T:97.9 P:91 BP:137/60 R:18 SaO2:92% 2L
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, left pupil unresponsive EOMI without
nystagmus, no scleral icterus noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs crackles at bases bilaterally
Cardiac: irregular, nl. 3/6 systolic murmur at RUSB.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: fistula w/ palpable thrill on left upper extremity.
b/l bka. radial pulse 2+ b/l
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Pertinent Results:
[**2163-3-23**] 10:00AM WBC-7.6 RBC-3.60* HGB-10.5* HCT-35.0* MCV-97
MCH-29.3 MCHC-30.1* RDW-17.6*
[**2163-3-23**] 10:00AM NEUTS-77.2* LYMPHS-16.3* MONOS-5.1 EOS-1.0
BASOS-0.4
[**2163-3-23**] 10:00AM GLUCOSE-140* UREA N-16 CREAT-3.4*# SODIUM-145
POTASSIUM-5.6* CHLORIDE-102 TOTAL CO2-29 ANION GAP-20
.
Rib Films ([**2163-3-30**])
No fracture. Persistent CHF. Right-sided PICC unchanged.
.
Echo ([**2163-3-24**])The left atrium is moderately dilated. There is
severe symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Left ventricular systolic
function is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are moderately thickened. There is severe mitral annular
calcification. There is moderate functional mitral stenosis
(mean gradient 9 mmHg) due to mitral annular calcification.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion.
IMPRESSION: Severe symmetric LVH with a small cavity and
hyperdynamic systolic function. Minimal resting LVOT
obstruction. Moderate functional mitral stenosis. Moderate
pulmonary hypertension.
.
Head CT ([**2163-4-4**])
FINDINGS: There is no evidence of hemorrhage, mass,
hydrocephalus, shift of normally midline structures, or major
vascular territorial infarction.
Periventricular [**Known lastname **] matter hypodensities are consistent with
mildly severe small vessel ischemic disease. A hyperdensity in
the left frontal lobe in the suprasellar region may represent
partial volume averaging or a small meningioma. Tiny
calcifications are again noted in the basal ganglia. A punctate
calcification along the sulci in the right parietal region is
unchanged. There is no fracture. The visualized paranasal
sinuses and the mastoid air cells are well aerated.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Mildly severe small vessel ischemic disease.
3. Hyperdensity in the left frontal lobe in the suprasellar
region may
represent partial volume averaging versus a small meningioma.
Attention to
this region is recommended on followup imaging.
Brief Hospital Course:
The patient was initially admitted for an episode of SSCP
following her usual dialysis. She has had this pain before and
was recently admitted for CP. She denied radiation, nausea,
diaphoresis, palps, SOB with her pain. This pain has been
attributed to her HOCM due to fluid shifts during her dialysis.
She otherwise denied F/C, HA, lightheadedness.
.
Following admission, her hospital course was uneventful until
about 1AM on HD1. At that time, the patient awoke agitated and
complaining of SOB. 02 96% on 5L NC and lungs with crackles per
report. She then quickly developed more difficulty breathing and
became somnolent. Code blue was called. BP of 90s systolic, FS
71. She subsequently became more somnolent and became
bradycardic. She lost per pulse and PEA arrest was called. Chest
compressions were initiated. She was given 1mg atropine with
improvement in her HR to 100s, 110/50->170s. Pt was also given
CaCL, HC03, insulin/D50 for presumed hyperkalemia given previous
K 5.6 (hemolyzed). A R femoral CVL was placed. The patient was
intubated and transferred to the MICU. In the MICU, she improved
rapidly with supportive care and was extubated. The precise
cause of her respiratory failure and PEA arrest were unable to
be determined, although fluid shifts related to HD, perhaps with
associated metabolic derrangments were strongly suspected. The
pt was transferred to the general medical floor on [**2163-3-31**].
.
On the floor, the pt remained stable. Her medication regimen was
optimized. HD was continued. Her continued treatment by problem
included the following:
.
Hypertension: The pt required IV labetalol for hypertensive
urgency twice during her admission, however her BP stabilized as
her overall status improved. Metoprolol, diltiazem and
lisinopril, along with hemodialysis, were continued.
.
Obstructive cardiomyopathy: An echo performed during the pt's
admission confirmed mild to moderate resting left ventricular
outflow tract obstruction. This was attributed to long-standing
hypertensive heart disease. Based on this finding and the pt's
clinical course, it is felt that she is very sensitive to fluid
shifts, particularly as may occur during HD. The pt's ASA, BB
and ACEi were continued. Tight BP and heart rate control were
maintained as best as possible. Cardiology was involved in the
pt's clear. Caution should used in giving the patient agents
that will reduce pre-load or afterload as doing this may worsen
the patient's outflow tract obstruction.
.
Chest Pain: The pt complained of very frequent chest and arm
discomfort during much of her hospital stay. Her initial chest
pain was thought to be related to her obstructive cardiac
physiology. Multiple ECGs were checked and did not show
abnormalities compared to baseline; she was ruled out for MI at
the beginning of her course by biomarkers. Following her
cardiac arrest, which included chest compressions, the patient
developed more persistent central, non-radiating chest pain that
was worse with movement. The chest pain was reproducible on
exam. It is thought that the pain is musculoskeletal in origin
from the trauma sustained during the chest compressions. Rib
films were negative for fracture. The pt had some relief with
Tylenol, though low dose oxycodone was more effective. There
was a reluctance to use narcotics, as it was thought these may
alter the pt's mental status. However, she did seem to tolerate
2.5mg of oxycodone.
.
Mental status changes: The pt was noted by providers and family
members to be slightly off her mental baseline. Her neuro exam
was consistently non-focal. A work-up for delirium, include two
UAs, TSH, Folate, B12 and RPR testing was unrevealing. A head CT
was obtained on the day prior to discharge which showed small
vessel ischemic changes but no acute findings. Ultimately it was
thought that the pt's altered mental status may have been the
result of anoxic injury that occurred during her cardiac arrest.
.
ESRD: Three times weekly hemodialysis was continued during the
pt's stay. She was followed by the renal team. Sevelemer and
Nephrocaps were continued. At future HD sessions, the pt be
premedicated with beta blocker and will not have more than 1 kg
of fluid removed to help maintain her hemodynamics in the
setting of her obstructive cardiac physiology.
.
PAF/Flutter: The pt's HR was well-controlled on diltiazem and
metoprolol. Anticoagulation with Coumadin was continued. ***At
the time of discharge, the pt's INR was elevated at 4.4, and
thus her Coumadin was being held.*** Close monitoring of the INR
over the next few days is highly suggested.
.
Hyperlipidemia: Simvastatin 40 mg QHS was continued.
.
PVD: Aspirin was continued.
.
DM: The pt's home insulin was continued with a sliding scale.
Her blood sugar remained under good control.
.
Glaucoma: The pt's home eye drops were continued.
.
GERD/PUD: Ranitidine was continued.
Medications on Admission:
Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID
Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
Aspirin 81 mg Tablet daily
Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID with
meals
Warfarin 3 mg daily
Simvastatin 40 mg Tablet daily
Ranitidine HCl 150 mg Tablet once daily
Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
four times daily
Metoprolol Tartrate 50 mg [**Hospital1 **]
Diltiazem HCl 120 mg Capsule
Insulin NPH Human 16 units QAM
Discharge Medications:
1. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen
(16) units Subcutaneous with breakfast every morning.
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
4. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO qAM.
9. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
10. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
11. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day: To be given every day, including dialysis
days.
12. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
13. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
14. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Humalog 100 unit/mL Cartridge Sig: sliding scale units
Subcutaneous four times daily; with meals and at bedtime:
Standard sliding scale with coverage beginnig with 2 units at
150 and increasing by 2 units for every 50 point increase in BS.
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
17. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: One (1) neb Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
18. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
19. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q 24H (Every 24 Hours)
as needed for pain.
21. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
***This medication was being held at the time of discharge due
to an elevated INR.***.
22. dialysis
Pt's next hemodialysis scheduled for [**2163-4-6**] at 6:15 AM at
[**Location (un) **] in [**Location (un) **], MA.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
hypertension
kidney disease on dialysis
hypercholesterolemia
GERD
peripheral vascular disease
glaucoma
atrial flutter
diabetes
s/p cardiac arrest
Discharge Condition:
Vitals stable, improved overall.
Discharge Instructions:
-You were admitted with chest pain. Testing has not identified a
precise cause for this, however we do not believe it due to a
problem with your heart. During your stay, your hospital course
was complicated by a cardiac arrest that required treatment in
the ICU. You underwent CPR and were on a breathing machine for a
short period. Following the CPR, you developed more persistent
chest pain, which we think was due to the chest compressions.
Again, there was not clear evidence for a heart attack as the
cause of your pain.
You have now recovered and are going to a rehab facility to help
regain your strength.
-It is important that you continue to take your medications as
directed. On this admission, lisinopril was added and metoprolol
was increased to better control your blood pressure.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please call Dr.[**Name (NI) 51374**] office at [**Telephone/Fax (1) 250**] to schedule
a follow-up appointment when you are discharged from rehab.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2163-5-18**] 10:40
Name: [**Known lastname **],[**Known firstname 194**] Unit No: [**Numeric Identifier 17893**]
Admission Date: [**2163-3-23**] Discharge Date: [**2163-4-5**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 16607**]
Addendum:
Code Status: full code
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16608**] MD [**Last Name (un) 16609**]
Completed by:[**2163-4-5**]
|
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"427.5",
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"518.4",
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"403.01",
"276.7",
"272.4",
"786.50",
"518.81",
"585.6",
"530.81",
"440.20",
"780.97",
"588.81",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.60",
"96.04",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15597, 15830
|
5682, 10570
|
325, 331
|
13775, 13810
|
3301, 5659
|
14868, 15574
|
2244, 2504
|
11230, 13489
|
13606, 13754
|
10596, 11207
|
13834, 14845
|
3187, 3282
|
2519, 3091
|
275, 287
|
359, 1364
|
3106, 3170
|
1386, 1974
|
1990, 2228
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,183
| 156,528
|
47353
|
Discharge summary
|
report
|
Admission Date: [**2137-3-13**] Discharge Date: [**2137-3-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83yo man with DM, HTN, MI with RCA stenting in [**2127**] and recent
STEMI 3 weeks ago with BMS stent complicated by cardiogenic
shock and VT/Vfib requiring defibrillation/pacing for heart
block. During that admission, cardiac angiography found him to
have completely occluded proximal LAD, 80% occlusion of the Lcx
and complete proximal occlusion of the RCA with distal flow from
collaterals. The LAD lesion was opened by angioplasty and a bare
metal stent was placed. During the procedure the patient became
hypotensive with episodes of V Tach and V fib requiring multiple
cardioversions, managed with amiodarone. He then experienced
chest pain at rest on [**2137-3-1**] which on repeat cath was shown to
be from LAD instent thrombosis, managed by PTCA. His Troponin
peaked at 23.5. ECHO at the beginning of the admission showed
cardiogenic shock with EF 20%, 3+ MR, and septal and
anterolateral ventricular akinesis. He required dopamine and
levophed, which was weaned after a few days. Metoprolol was
started and titrated. He was also fluid overloaded, managed by
lasix. He was discharged on amiodarone, coumadin, Toprol, lasix,
plavix, and aspirin. He was d/c'd to [**Hospital1 **] of [**Location (un) 55**]
Today, he presents with SOB x a few days, mild dull SSCP. No
diaphoresis, N/V. Increased LE edema, PND, DOE. In ED,
presenting vitals of 96.5, HR 71, BP 132/83 24, 98% on 8L. EKG
with concern of Qs and ST elevations anteriorly. Trop of 1 (way
down from before), CXR showed volume overload. He was CP free
after nitroglycerine and morphine. He was given 80 lasix in the
ED and initially was to be sent to floor but became tachypneic,
agitated with hypoxia to 80s on NC, placed on BIPAP, with
improvement of sats to 100s. Pt. 7.42/38/154 on 50% BIPAP. In
ED, non-invasive BPs marginal, so pt. given 1.25L IVFs. Art
line placed, which showed 40 pt. difference between NBP and art
line. Nitro gtt initiated, additional 40mg lasix given with
total of 2L UO in ED. Pt. remained on BIPAP for tachypnea on
transfer to ICU.
Past Medical History:
# Myocardial Infarction [**1-/2137**], s/p cath with PTCA and 2 stents
placed in proximal LAD. C/B cardiogenic shock and VT requiring
defibrillation/pacing for heart block
# Myocardial Infarction with two stents placed in the RCA in
[**2127**].
# RLE DVT [**3-1**]
# Diabetes: HA1c 6.4% on [**11-30**]. High grade proteinuria X 1yr.
# Hypertension
# Hypercholesteremia
# Asthma
# CRF: Cr 1.8 in [**10/2136**], acute worsening after [**2-1**] MI,
baseline now approx 2.5-2.8
Social History:
Social history is significant for: smokes [**1-27**] cigarettes a day.
Lives with his wife.
Family History:
No family history of early coronary disease or stroke and no
family history of sudden cardiac death.
Physical Exam:
VS - afebrile, BP 145/63 on nitro gtt, HR 79, RR 26, 100% on 40%
BIPAP at 8/5, 96%/4L NC
Gen: WDWN middle aged male, very anxious. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, JVP not assessed
CV: PMI nondisplaced. RR, distant HS, almost absent S1, nl S2.
No m/r/gs noted. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. sl.
tachypneic, no accessory muscle use. decreased BS at bases R>L,
with overlying rales and I and E wheezes above
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: 3+ pitting edema to kness. No femoral bruits.
Skin: stasis dermatitis on R, no ulcers, scars, or xanthomas.
large ecchymoses on R forearm
Neuro: AA&Ox3, CN II- XII intact, FS all 4 ext. nl sensation to
LT. reflexes not tested
.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
guaiac negative
Pertinent Results:
[**2137-3-15**] 05:25AM BLOOD WBC-9.5 RBC-3.56* Hgb-9.3* Hct-29.3*
MCV-82 MCH-26.2* MCHC-31.9 RDW-15.9* Plt Ct-315
[**2137-3-13**] 05:29PM BLOOD PT-64.3* PTT-41.0* INR(PT)-7.8*
[**2137-3-13**] 04:45PM BLOOD Glucose-64* UreaN-65* Creat-2.8* Na-140
K-4.5 Cl-103 HCO3-27 AnGap-15
[**2137-3-13**] 04:45PM BLOOD CK(CPK)-41
[**2137-3-14**] 12:14AM BLOOD CK(CPK)-120
[**2137-3-14**] 08:23AM BLOOD CK(CPK)-41
[**2137-3-13**] 05:29PM BLOOD cTropnT-1.05*
[**2137-3-14**] 12:14AM BLOOD CK-MB-5 proBNP-[**Numeric Identifier 97228**]*
[**2137-3-14**] 12:14AM BLOOD cTropnT-0.86*
[**2137-3-14**] 08:23AM BLOOD CK-MB-NotDone cTropnT-0.87*
[**2137-3-13**] 04:45PM BLOOD Calcium-9.0 Phos-4.5 Mg-2.2
[**2137-3-14**] 01:55AM BLOOD Type-ART FiO2-50 pO2-154* pCO2-38 pH-7.42
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
CXR:
There is stable moderate cardiomegaly. The aorta is calcified
and tortuous. There is pulmonary vascular congestion and
diffusely increased interstitial linear opacities. Bilateral
pleural effusions are identified.
IMPRESSION: Moderate CHF.
ECG:
Sinus rhythm. Left atrial abnormality. Prior anteroseptal
myocardial
infarction. Compared to the previous tracing of [**2137-3-4**] right
bundle-branch block is no longer recorded. There is further
evolution of acute anterolateral myocardial infarction. Followup
and clinical correlation are suggested.
ECHO [**2137-3-18**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is top normal/borderline dilated. There is an apical
left ventricular aneurysm with near akinesis of the distal half
of the ventricle (LVEF <20%). No masses or thrombi are seen in
the left ventricle. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal. with moderate global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-26**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2137-2-21**],
pulmonary artery systolic hypertension is now identified. The
severity of mitral regurgitation was slightly overestimated on
the prior study, but is slightly reduced today (may be related
to the lower systemic pressure).
Discharge labs:
[**2137-3-20**] 07:55AM BLOOD WBC-8.4 RBC-3.82* Hgb-10.0* Hct-31.0*
MCV-81* MCH-26.2* MCHC-32.2 RDW-16.4* Plt Ct-302
[**2137-3-20**] 07:55AM BLOOD PT-20.6* PTT-27.4 INR(PT)-1.9*
[**2137-3-20**] 07:55AM BLOOD Glucose-134* UreaN-90* Creat-2.9* Na-138
K-3.9 Cl-95* HCO3-31 AnGap-16
[**2137-3-14**] 12:14AM BLOOD CK-MB-5 proBNP-[**Numeric Identifier 97228**]*
[**2137-3-20**] 07:55AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.3
Brief Hospital Course:
Patient is a 83 yo male with CAD, DM, HTN, CRI, with recent MI
and EF of 20%, who presents with likely acute CHF exacerbation.
.
#. CAD: s/p complicated admission with 2 anterior MIs, second
from instent thrombosis, two cardiac catheterizations,
cardiogenic shock, vfib/vt, and fluid overload. Currently CP
free. His troponins are much decreased compared to discharge,
trending down, and CKs flat, likely [**1-26**] ARF. Ruled out for ACS
by 3 sets of down trending cardiac biomarkers. EKG unchanged
from prior. No signs of new ischemia. The patient was changed to
carvedilol for better CHF management and continued on his [**Month/Day (2) **],
plavix, statin. He will follow up with Dr. [**Last Name (STitle) **].
.
#. Pump: The patients symptoms were likely from fluid overload
in setting of depressed cardiac function and depressed EF. LVEF
20% by echo with 3+ and septal and anterolateral ventricular
akenesis. Repeat echo showed LVEF <20% with global akinesis and
apical aneursym. Acute on chronic CHF exacerbation less likely
[**1-26**] ischemia given negative biomarkers. Started on 80mg PO bid
lasix one day prior to admission by Dr. [**Last Name (STitle) **]. An admission CXR
showed moderate pulmonary edema and a BNP was >[**Numeric Identifier 6085**]. The
patient was initially controlled by a nitro gtt and BIPAP but
both of these were rapidly turned off upon arrival to the ICU.
He was begun on a lasix drip with good results and with
significant further diuresis with addition of diuril 250mg iv
bid. His O2 was slowly weened down and he was . He was
discharged on oral regimen consisting of lasix 80mg PO bid. His
weight upon discharge was 76.8. He should have his weight
measured at rehab and further lasix or diuril administered if it
increases >1kg. He should be on coumadin for the apical
aneurysm with goal INR [**1-27**] for 6 months. If necessary, can
increase lasix dose or add diuril to his regimen. We elected
not to add aldactone given renal insufficiency.
.
He received perfusion thallium study on day of d/c to evaluate
viability and to determine if he needs outpt. cardiac
catheterization. Results pending on discharge and will be
followed up by Dr.[**Name (NI) 26896**] office.
.
#. Rhythm: The patient had a history of vfib/vt during last
admission and was sent home on coumadin and amiodarone. His
initial INR was elevated at 7.8 so his coumadin was held and his
INR was allowed to drift down. He was continued on his
amiodarone 200mg PO daily.
.
# Acute on chronic renal failure: Cr baseline 2.5-2.8 which may
represent a new baseline for patient after multiple caths/code
at last admission when Cr peaked at 4.4. Creatinine was 1.8
prior to that. Creatinine transiently elevated to 3.5 but felt
to be spurious as repeat 2hrs later was 2.8. Cr was at baseline
upon discharge. Continued phoslo with meals givenn continued
elevated phosphate
.
#. DM: held oral hypoglyemics in house and discontinued upon
discharge given renal failure. He was maintained on sliding
scale insulin that we will provide to transferring facility
.
#. HTN: switched from metoprolol to carvedilol, SBP 96-121 on
day prior to discharge.
.
#. DVT diagnosed [**3-2**]. He was admitted with supratherapeutic
INR. Coumadin held until drifted down to 2.0. It was restarted
at 2.5mg (previously on 5mg) but was 1.8 two days later, so dose
was increased to 4mg. INR should be monitored at rehab with
goal [**1-27**]. He should stay on anticoagulation for 6 months (both
for DVT and apical aneurysm)
.
# anxiety: continue qhs lorazepam and PRN. anxiety does seem to
contribute to patient's shortness of breath. On day of
discharge some subjective shortness of breath seemed to resolve
with NC without O2.
.
# BPH: continue tamsulosin
# pt. discharged to [**Hospital **] rehab MACU
Medications on Admission:
1. Atorvastatin 80 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Aspirin 325 mg PO DAILY
4. Glipizide 5 mg PO twice a day.
5. RISS
6. Senna 1 tab [**Hospital1 **] PRN
7. Ipratropium-Albuterol 2 puff [**Hospital1 **] PRN
8. Ferrous Sulfate 325 mg PO DAILY
10. Nitroglycerin 0.3 mg PRN
11. Lorazepam 0.5 mg PO HS PRN
13. Amiodarone 200 mg PO once a day:
14. Toprol XL 25mg PO daily
15. Clopidogrel 75 mg PO DAILY
16. Coumadin 5 mg PO at bedtime
17. Lasix 80 mg PO BID
18. Tamsulosin 0.4 mg PO HS
19. trazadone 50 qhs
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once
Daily at 16): dose may need adjustment.
16. Ipratropium-Albuterol 0.5-2.5 mg/3 mL Solution for
Nebulization Sig: 1-2 puffs Inhalation twice a day as needed for
shortness of breath or wheezing.
17. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous qidachs: see attached sliding scale sheet.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
congestive heart failure (acute systolic)
DVT on anticoagulation
Coronary artery disease
Diabetes Mellitus type II
anxiety disorder
Discharge Condition:
good, satting >95% on RA, tolerating pos
Discharge Instructions:
You were admitted with an exacerbation of your congestive heart
failure.
This was treated with diuretics which helped reduce the fluid
you had accumulated. You should limit your fluid intake to less
than 1 liter per day and avoid all high sodium foods (keeping
sodium intake <2grams).
Please followup with Dr. [**Last Name (STitle) **] regarding further management of
your heart problems.
Weigh yourself daily and call Dr.[**Name (NI) 26896**] office if you gain
more than 2lbs.
Please seek medical attention if you experience chest pain,
fevers, shortness of breath, or any other new or concerning
symptoms.
Please take all medications exactly as prescribed.
Followup Instructions:
We have arranged a follow-up appt with Dr. [**Last Name (STitle) **] on [**2140-4-1**]:40 at 330 [**Location (un) **] [**Location (un) 436**]. Please call Dr.[**Name (NI) 26896**]
office at [**Telephone/Fax (1) 4022**] if you need to reschedule.
You also have the following appointment which you should attend
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2137-4-4**]
1:00 (nephrology)
|
[
"V45.82",
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"428.21",
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"410.92",
"V12.51",
"250.00",
"585.9",
"414.01",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13065, 13131
|
7180, 10987
|
282, 288
|
13316, 13359
|
4221, 6725
|
14069, 14552
|
2984, 3086
|
11555, 13042
|
13152, 13295
|
11013, 11532
|
13383, 14046
|
6741, 7157
|
3101, 4202
|
223, 244
|
316, 2360
|
2382, 2858
|
2874, 2968
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,458
| 180,635
|
24607
|
Discharge summary
|
report
|
Admission Date: [**2176-4-17**] Discharge Date: [**2176-4-24**]
Date of Birth: [**2140-12-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
fevers, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
35 yo M with h/o EtOH cirrhosis with acites and grade I varcies
admitted with fever abn abd pain with L perinephric iatrogenic
hematoma. Had admission in [**Month (only) 547**] where protienuria and hematuria
was noted therefore followed up in nephrology clinic and had a
kidney bx on [**4-16**]. The night following the biopsy, the patient
developed nausea, vomiting and a fever. CT showed left
perinephric hematoma near the biopsy site as well as colonic
thickening.
.
In the emergency department, a diagnostic paracentesis was
performed which demonstrated 30cc of ascites. Analysis of the
fluid shows spontaneous bacterial peritonitis. In the ED, he was
started on treatment with amp/gent/flagyl and recieved 8 L NS
for systolic hypotension.
Past Medical History:
cirrhosis
hepatitis c
etoh abuse
thrombocytopenia
hematuria
grade I varices
renal failure
Social History:
s/p incarceration, IVDU , h/o alcohol abuse, +tobacco.
Physical Exam:
VS: T 97.6 HR 87 (80-96) BP 132/75 (95-127/57-75) RR 17 (15-20)
Sat 93% RA (93-97%)
Gen: WN/WD young man in bed in NAD.
HEENT: OP clear, MMM, PERRL
CV: nl s1/s2, no m/r/g RRR
Pul: CTA b/l, no wheezes
Abd: Distended, slightly tender, +BS, no rebound or guarding.
Ext: W/WP, no edema, pneumoboots in place
Neuro: A&Ox3, sleepy but arousable.
Pertinent Results:
[**2176-4-17**] 04:10PM WBC-8.6 RBC-3.88* HGB-12.9* HCT-36.3* MCV-94
MCH-33.3* MCHC-35.6* RDW-13.7
[**2176-4-17**] 04:10PM NEUTS-87.5* BANDS-0 LYMPHS-8.1* MONOS-4.0
EOS-0.3 BASOS-0.1
[**2176-4-17**] 04:10PM PLT COUNT-61*
[**2176-4-17**] 04:23PM LACTATE-3.5*
[**2176-4-17**] 11:00PM OTHER BODY FLUID WBC-3850* RBC-400* POLYS-87*
LYMPHS-1* MONOS-12*
[**2176-4-17**] 11:00PM OTHER BODY FLUID TOT PROT-0.3 GLUCOSE-110
ALBUMIN-LESS THAN
CT [**4-17**]
1) Hematoma surrounding the lower pole of the left kidney,
without mass effect.
2) Cirrhosis, with ascites.
3) Cholelithiasis.
4) Splenomegaly.
5) Highly edematous wall in the ascending and transverse colon
in particular, which is nonspecific but can be seen in
cirrhosis. No definite pneumatosis, although the presence of
thickened haustral folds makes it difficult to fully exclude.
Brief Hospital Course:
A/P: 35M w/ etoh cirrhosis, ascites admitted after iatrogenic
hematoma, SBP.
1) Hematoma: acute blood loss anemia post-operatively from
kidney biopsy in renal clinic. We followed hematacrit which was
stable until he had additional drop on [**4-19**] which was likely due
to his blood loss from hematuria. CT w/o contrast was repeated
which showed stable perinephric hematoma.
2) Cirrhosis: hepatology consulted. Albumin was given per SBP
protocol 1.5gm/kg day 1, 0.5 gm/kg day 3. We re-started lasix,
aldactone [**4-20**] for control of his ascites.
3) Spontaneous Bacterial Peritonitis: probable post-op fever
secondary to seeding of peritoneum versus possible colonic
translocation. Initial paracentesis showed peritoneal fluid
with a diff that suggested SBP, but peritoneal fluid culture was
negative. Note that this culture was taken after antibiotics
were started. Imipenem was given in the MICU due to the
severity of patient's presentation but was discontinued [**4-22**] and
changed to levaquin for an additional 7 day course. Following
the levaquin, he will be changed to SBP prophylaxis with cipro
thereafter.
He had persistent low grade temps in 99.5 range and so he was
sent for ultrasound guided tap (wbc 300 from 3000s. gram stain
neg). Temp was 100.8 on discharge and this was attributed to the
reabsorbtion of the perinephric hematoma.
4) ETOH abuse: by history, but per patient his last drink was
>1mo earlier. Pt was monitored by CIWA scale but did not
require any benzodiazepams.
5) F/E/N: full diet as tolerated.
Medications on Admission:
aldactone 100qd
lasix 40qd
nadolol 20qd
protonix 40
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Transdermal
once a day: DO NOT SMOKE WITH THIS PATCH.
Disp:*14 patches* Refills:*0*
8. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day: Please
start after finishing your levofloxacin medicine.
Disp:*30 Tablet(s)* Refills:*2*
9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Spontaneous bacterial peritonitis
perinephric hematoma
cirrhosis
Discharge Condition:
Stable, afebrile. Pt had two paracenteses. The second
paracentesis showed a major decrease in white blood cells.
Discharge Instructions:
Call your doctor and go to the emergency room immediately if you
have fevers >101, worsening abdominal pain, back pain, chest
pain, feel dizzy, lightheaded, have problems breathing,
shortness of breath, or any other health concern.
Please monitor your temperatures and take it several times a
week. [**Name8 (MD) **] MD immediately or go to the emergency room if it is
higher than 101.4.
Please take your medications as directed.
Please go to your appointments below.
Followup Instructions:
1) Please call [**Telephone/Fax (1) 250**] to make an appointment to see Dr.
[**First Name (STitle) **] within 1 week for follow up.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2176-5-22**] 9:30Provider: [**First Name11 (Name Pattern1) **]
[**Last Name (NamePattern1) 7128**], MD Where: LM [**Hospital Unit Name 7129**] CENTER
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2176-5-22**] 9:30
|
[
"070.70",
"E878.8",
"458.9",
"567.8",
"583.9",
"303.91",
"599.7",
"287.5",
"571.2",
"573.8",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
5264, 5270
|
2551, 4098
|
341, 347
|
5379, 5493
|
1684, 2528
|
6010, 6548
|
4200, 5241
|
5291, 5358
|
4124, 4177
|
5517, 5987
|
1323, 1665
|
277, 303
|
375, 1122
|
1144, 1236
|
1252, 1308
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,418
| 136,717
|
34423+57949
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-4-7**] Discharge Date: [**2200-4-12**]
Date of Birth: [**2139-8-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 922**]
Chief Complaint:
Increasing fatigue, dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p bilateral thoracotomies/mini-maze
History of Present Illness:
60 year old male with complicated medical history who had about
18 months of paroxysmal atrial fibrillation. He was initially
treated with coumadin but had a fall with severe facial
hematoma. He has been deemed a fall risk and thus not an ideal
candidate for coumadin therapy.
Past Medical History:
Paroxysmal atrial fibrillation
Morbid obesity
s/p gastric bypass surgery
s/p ruptured gall bladder
s/p cholecystectomy
Neuropathy/gait instability
Prostate cancer s/p radiation therapy
Psoriatic arthritis
Diabetes type 2
Sleep apnea
Social History:
Retired school principal who lives with his wife. Denies any
history of tobacco or alcohol use.
Family History:
Non-contributory
Physical Exam:
General: obese, gait somewhat unsteady
Skin: multiple psoriatic patches over entire face/body
HEENT: PERRLA, Extra occular movements intact.
Neck: supple, full range of motion.
Lungs clear to auscultation bilaterally
Heart: irregular, normal S1S2.
Abdomen: soft and nondistended with normoactive bowel sounds.
Obese, well healed scars.
Extremities: warm, well perfused with 2+ bilateral lower
extremity edema
Pertinent Results:
[**2200-4-12**] 03:16AM BLOOD WBC-4.8 RBC-3.82* Hgb-11.8* Hct-35.0*
MCV-92 MCH-31.0 MCHC-33.8 RDW-14.3 Plt Ct-87*
[**2200-4-7**] 07:08PM BLOOD WBC-3.1* RBC-4.32* Hgb-13.3* Hct-39.9*
MCV-92 MCH-30.9 MCHC-33.4 RDW-14.5 Plt Ct-81*
[**2200-4-12**] 03:16AM BLOOD Plt Ct-87*
[**2200-4-11**] 04:30AM BLOOD Plt Ct-81*
[**2200-4-12**] 03:16AM BLOOD Glucose-80 UreaN-31* Creat-0.9 Na-143
K-3.7 Cl-109* HCO3-27 AnGap-11
[**2200-4-7**] 07:08PM BLOOD Glucose-164* UreaN-14 Creat-0.9 Na-143
K-4.3 Cl-109* HCO3-25 AnGap-13
[**2200-4-7**] 07:08PM BLOOD ALT-20 AST-28 LD(LDH)-225 AlkPhos-102
TotBili-1.4
[**2200-4-7**] 07:08PM BLOOD %HbA1c-5.1
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 157**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 79136**] (Complete)
Done [**2200-4-9**] at 3:11:28 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**Known firstname 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2139-8-24**]
Age (years): 60 M Hgt (in): 76
BP (mm Hg): 140/70 Wgt (lb): 246
HR (bpm): 78 BSA (m2): 2.42 m2
Indication: Bilateral thorcascopic mini m aze procedure
ICD-9 Codes: 427.31
Test Information
Date/Time: [**2200-4-9**] at 15:11 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: Limited Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Aorta - Ascending: *3.5 cm <= 3.4 cm
Findings
Limited esophageal views were done due to the prior gastric
bypass surgery in this patient.
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
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. The rhythm appears to be atrial
fibrillation. Results were personally reviewed with the MD
caring for the patient.
Conclusions
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. The right atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified
in person of the results on Mr.[**Known lastname **] prior to surgery start.
Post LAA ligation, no LAA was visualized by 2D and 3D.
Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
?????? [**2193**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mr [**Known lastname **] was worked up and brought into the operating room as
an outpatient. He was prepped and draped in the usual manner and
underwent a bilateral thoracotomy/min-maze procedure. Please see
operative note for full details. Post-operatively he was
admitted to the cardiovascular intensive care unit for invasive
hemodynamic monitoring. He was weaned and extubated on
post-operative day one. That same day he was transferred to the
step down unit. Physical therapy was consulted to work on
strength and balance. He continued to progress and was ready for
discharge on post-operative day 3.
Medications on Admission:
Celexa 40 mg po daily
Flomax 0.4 mg po QHS
ASA 81 mg po daily
Metoprolol 25 mg po BID
Digoxin 0.25 mg PO daily
Pepcid AC 150 mg po BID
Levitra 10 mg po PRN
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical TID (3 times a day).
11. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
12. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day).
13. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days: Please take one pill twice daily for 4 days,
then one pill once daily for 3 days.
Disp:*11 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p bilateral thoracotomies/mini-maze
Paroxysmal atrial fibrillation
hypertension
diabetes mellitus type 2
psoriatic arthritis
sleep apnea
prostate cancer s/p x-ray therapy
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. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr. [**Last Name (STitle) 32772**] in 1 week please call for appointment
Dr. [**Last Name (STitle) 36026**] in [**1-21**] weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2200-4-12**] Name: [**Known lastname 12808**],[**Known firstname 33**] JR Unit [**Name2 (NI) **]: [**Numeric Identifier 12809**]
Admission Date: [**2200-4-7**] Discharge Date: [**2200-4-12**]
Date of Birth: [**2139-8-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 1543**]
Addendum:
After discharge the patient was notified that Losartan was not
covered under his insurance plan. Lisnopril was substituted for
Losartan. A prescription was called in Lisinopril 10mg QD.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**Known firstname 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2200-4-14**]
|
[
"278.00",
"696.0",
"781.2",
"311",
"456.21",
"285.9",
"250.00",
"511.9",
"355.9",
"327.23",
"427.31",
"V10.46",
"782.3",
"571.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.91",
"37.33",
"37.27",
"45.13",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9997, 10197
|
5528, 6136
|
358, 398
|
8461, 8468
|
1551, 5505
|
8980, 9974
|
1089, 1107
|
6343, 8166
|
8265, 8440
|
6162, 6320
|
8492, 8957
|
1122, 1532
|
279, 320
|
426, 704
|
726, 960
|
976, 1073
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,835
| 152,336
|
37433
|
Discharge summary
|
report
|
Admission Date: [**2197-2-8**] Discharge Date: [**2197-2-13**]
Date of Birth: [**2129-4-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD)
History of Present Illness:
Mr. [**Known lastname **] is a 67 year-old man with a history of DM, CAD,
large infrarenal AAA with bilateral large common iliac
aneurysms, s/p right hypogastric coiled embolization on
[**2197-1-17**], who presents with hematemesis and is admitted to the
MICU for further management.
.
He was recently discharged on [**2-3**] after presenting with ARF and
[**1-17**] after presenting with Fournier's Gangrene/periurethral
abscesses requiring operative debridment. During this
hospitalization, he also underwent coil embolization of the
right hypogastric artery. He was doing well at home until today
when he had an episode of bright red hematemsis with clots this
morning. He also had a 3 bowel movements with bright red blood
and associated with light-headedness but no abdominal pain or
chest pain. He presented to his PCP and was referred to the ED.
.
In the ED, vital signs were initially: 86 87/46 20 100%ra. Hct
on arrival was 22 from a baseline of 30. BPs improved with 4L
IVFs and he was transfused 2u prbc, 2u ffp, and 1 unit of
platelets. NG lavage positive for dark blood but no coffee
grounds and he had brb per rectum. He was also given
pantoprazole 80 iv x 1 and a gtt was started. He complained of
CP initially which improved with morphine 2mg iv x 2 and blood
transfusion. His EKG demonstrated anterior-lateral precordial TW
flattening consistent with ischemic changes per cardiology. Abd
CT was negative for aorto-enteric fistula and he was admitted to
the MICU for further management.
Past Medical History:
- large infrarenal AAA with b/l large common iliac aneurysms
- Urethral abscess
- DM
- HTN
- CAD s/p PCI
- R hypogastric coiled embolization on [**2197-1-17**]
- suprapubic urinary catheter placement [**2197-1-10**]
- per pt has Hx of "stenting" of vessel after left arm pain, but
does not believe stent in heart, thinks in arm.
Social History:
Lives at home with wife and is retired. Quit smoking two months
ago; previously 1 ppd x 50 years. No drugs.
Family History:
Colon cancer in father
Physical Exam:
VS: 98 96 107/65 100%2L
GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
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. BUE
[**5-24**], and BLE [**5-24**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.
Pertinent Results:
Admission labs:
[**2197-2-8**] 02:30PM BLOOD WBC-12.1*# RBC-2.39*# Hgb-7.1*#
Hct-22.0*# MCV-92 MCH-29.7 MCHC-32.3 RDW-16.2* Plt Ct-205
[**2197-2-8**] 02:30PM BLOOD UreaN-47* Creat-1.6* Na-138 K-5.6*
Cl-109* HCO3-21* AnGap-14
[**2197-2-8**] 09:29PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2197-2-9**] 05:38AM BLOOD CK-MB-4 cTropnT-0.03*
[**2197-2-9**] 06:07PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2197-2-8**] 09:29PM BLOOD CK(CPK)-35*
[**2197-2-9**] 06:07PM BLOOD CK(CPK)-22*
[**2197-2-8**] 09:29PM BLOOD Calcium-7.6* Phos-3.9 Mg-1.7
.
Discharge labs:
[**2197-2-13**] 12:06PM BLOOD WBC-10.9 RBC-4.31* Hgb-12.4* Hct-36.9*
MCV-86 MCH-28.7 MCHC-33.5 RDW-15.4 Plt Ct-145*
[**2197-2-13**] 12:06PM BLOOD Glucose-285* UreaN-24* Creat-1.4* Na-137
K-4.3 Cl-99 HCO3-29 AnGap-13
[**2197-2-12**] 09:55AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.7
ECG [**2197-2-8**]:
Sinus rhythm. Tracing may be within normal limits but unstable
baseline makes assessment difficult. Since the previous tracing
of [**2197-2-2**] there is probably no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
81 144 70 356/392 72 42 86
CT Abdomen/Pelvis [**2197-2-8**]:
CT ABDOMEN WITH CONTRAST: The imaged portions of the lung bases
reveal a 7-mm subpleural nodule in the right lower lobe (3:11).
Additionally, note is made of scattered nodules in the left
lower lobe, though these latter show
indistinct margins suggesting that they may be inflammatory or
infectious in etiology. The imaged cardiac apex is notable for
mitral annular
calcification.
The spleen, adjacent splenule, pancreas, gallbladder, adrenal
glands, kidneys, liver are unremarkable. The stomach contains a
nasogastric tube. There is no retroperitoneal or mesenteric
lymphadenopathy.
CT PELVIS WITH CONTRAST: A suprapubic catheter ends the urinary
bladder is
unchanged. The prostate is notable for diffuse calcifications
which are also unchanged. The rectum and colon are unremarkable.
There is no free gas or fluid in the pelvis. There is no pelvic
or inguinal lymphadenopathy.
CT ANGIOGRAM: The suprarenal aorta is normal in caliber. The
infrarenal
aorta is notable for diffuse aneurysmal dilation. A small
intimal flap is
seen in the proximal part of the suprarenal aorta (3:70). More
distally, just above the level of the aortic bifurcation, the
aorta measures 74 x 69 mm in cross-sectional area and is notable
for a large amount of mural thrombus. Aneurysmal dilation with
thrombus is also present in the common iliac arteries
bilaterally, the most severe on the right with a total dimension
of the vessels 91 x 83 mm, similar to that seen previously. The
patient is status post embolization of the right internal iliac
artery, a finding which is unchanged from the recent comparison
CT. Both external iliac arteries opacify normally with arterial
contrast. There is no evidence of aortoenteric fistula.
OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic
lesion.
Degenerative changes are present throughout the lumbar spine.
There is also mild degenerative change in the sacroiliac joints
bilaterally.
IMPRESSION:
1. Large infrarenal and bilateral common iliac arterial
aneurysms, appearing similar to those characterized recently.
There is no evidence of aortoenteric fistula.
2. Focal nodule in the right lower lobe and inflammatory
appearing nodules in the left lower lobe. In the absence of high
risk for pulmonary malignancy, would recommend followup with a
dedicated CT of the chest in six months. In the presence of
these risk factors, would recommend followup with a dedicated CT
of the chest in three months.
CXR [**2197-2-9**]:
FINDINGS: Interval extubation and removal of nasogastric tube
and central
line with no evidence of pneumothorax. Mild pulmonary vascular
congestion. No new areas of consolidation to suggest an acute
infectious pneumonia.
EGD [**2197-2-8**]:
Findings:
Esophagus:
Excavated Lesions: A single non-bleeding 5 mm ulcer was found in
the gastroesophageal junction.
Stomach:
Mucosa: Mosaic appearance of the mucosa was noted in the fundus
and stomach body. These findings are compatible with possible
portal hypertensive gastropathy.
Duodenum:
Excavated Lesions: A single acute cratered 3 cm ulcer was found
in the proximal bulb and anterior bulb. A clot suggested recent
bleeding and there were two vissible vessels. 2 2.5
cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied for hemostasis
with success. A gold probe was applied for hemostasis
successfully to anterior vissible vessel. Two endoclips were
successfully applied for the purpose of hemostasis to posterior
vissible vessel.
Impression: Mosaic appearance in the fundus and stomach body
compatible with possible portal hypertensive gastropathy
Ulcer in the proximal bulb and anterior bulb (injection, thermal
therapy, endoclip) Ulcer in the gastroesophageal junction
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
Mr. [**Known lastname **] is a 67 year-old man with a history of a large
infrarenal AAA with bilateral large common iliac aneurysms, s/p
right hypogastric coiled embolization on [**2197-1-17**], who presents
with hematemesis.
.
# GI Bleed: On arrival to the ICU patient was hemodynamically
stable. An urgent EGD was performed with intubation and
anesthesia. This demonstrated two large bleeding duodenal
ulcers which were injected with epinephrine, cauterized and
endoclips were applied. He received an additional 4 units of
PRBC before, during and after the procedure. General surgery and
interventional radiology were consulted regarding management of
his UGIB, and did not recommend further intervention as
hemostasis was achieved by EGD. He was kept in the unit for
close clinical monitoring. He continued to have melena, but it
was thought this represented residual blood from his initial
bleed. His hematocrit was 22 on arrival to the MICU, after a
total of seven units PRBC, his repeat hematocrit was 29. He was
called out to the medical floor on [**2197-2-11**]. His PPI was
converted from a drip, to [**Hospital1 **] dosing IV to [**Hospital1 **] dosing orally.
His diet was gradually advanced. He experienced no further
episodes of bleeding, and his hematocrit remained stable. On
discharge, he was prescribed treatment for H. pylori, as well as
a [**Hospital1 **] ppi.
.
# CAD s/p PCI: Patient initially experienced chest pain, it was
considered likely that this represented demand ischemia in the
setting of anemia. Myocardial infarction was ruled out by EKG
and serial troponins and cardiac enzymes. Patient was continued
on his statin, but aspirin was held in the setting of an active
bleed.
.
# Infrarenal AAA with b/l common iliac aneurysms: CT scan
demonstrated no evidence of aorto-enteric fistula. Vascular
surgery was consulted and followed throughout his stay. Patient
has a scheduled intervention for his AAA with vascular surgery.
.
# Periurethral Abscesses: Patient had recent periurethral
abscesses requiring operative debridement and suprapubic urinary
catheter placement [**2197-1-10**]. He was continued on his outpatient
10 day course of levofloxacin, which he completed [**2197-2-12**]. His
suprapubic catheter functioned appropriately well, and the
surgical site was healing well.
.
# Hypertension: Blood pressure medications were initially held
in the setting of an acute bleed. On discharge, he was
restarted on his home dose of metoprolol.
.
# Diabetes Mellitus: Patient was treated with a humalog sliding
scale throughout his hospitalization.
.
# Lung nodule: Focal nodule in the right lower lobe and
inflammatory appearing nodules in the left lower lobe. In the
absence of high risk for pulmonary malignancy, would recommend
followup with a dedicated CT of the chest in six months. In the
presence of these risk factors, would recommend followup with a
dedicated CT of the chest in three months.
Medications on Admission:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet daily
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Hyoscyamine Sulfate 0.125 mg Tablet Sig: One (1) Tablet PO
four times a day: prn for bladder spasms.
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
Please begin taking pantoprazole once you have finished the
[**Month/Day/Year **].
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Succinate 25 mg PO daily
5. [**Month/Day/Year **] 500-500-30 mg Combo Pack Sig: One (1) PO twice a day
for 14 days.
Disp:*qs pack* Refills:*0*
6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Duodenal Ulcer
Upper Gastrointestinal Bleed
Abdominal Aortic Aneurysm
Discharge Condition:
Stable, alert and oriented to person, place and time, ambulating
without assistance.
Discharge Instructions:
You were admitted for bloody stools. Upper endoscopy
(esophagogastroduodenoscopy or EGD) was performed and found a
bleeding ulcer in your stomach. Injections, cauterization and
clips were placed to stop the bleeding. You were given 8 units
of packed red blood cells. Since this procedure, your blood
count levels have remained stable.
The following changes were made in your medications:
- Please START [**Hospital **], take as directed on the package, twice
daily for 14 days.
- While taking the [**Last Name (LF) **], [**First Name3 (LF) **] not take protonix (pantoprozole).
Once you are finished with the [**First Name3 (LF) **], you can continue taking
the pantoprazole as prescribed.
- Please STOP taking aspirin until you speak with Dr.
[**Last Name (STitle) **], or Dr. [**Last Name (STitle) 66738**].
Please continue with all other medications as you were before.
Please review all changes in your medications with your primary
care physician.
Followup Instructions:
Please follow up with the following appointments:
MD: Dr. [**First Name (STitle) **] [**Name (STitle) 66738**]
Specialty: Internal Medicine-Primary Care
Date/ Time: [**2197-2-27**] 1:30pm
Location: [**Last Name (NamePattern1) 84131**], [**Location (un) 2251**] MA
Phone number: [**Telephone/Fax (1) 49449**]
Provider: [**Name10 (NameIs) **] RM 2
[**Name10 (NameIs) **]-PREADMISSION TESTING
Date/Time:[**2197-2-15**] 10:00
You are scheduled for surgery for your abdominal aortic
aneuurysm:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **]
Time: 10:00 am, Date [**2197-2-20**]
Vascular Surgery
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 10314**], MD
Specialty: Gastroenterology
[**Hospital Unit Name 1825**] [**Location (un) 453**] - [**Hospital1 18**] [**Hospital Ward Name 516**] - [**Location (un) **].
[**Location (un) 86**], MA
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2197-3-8**] 1:30
Provider: [**Name10 (NameIs) **] UNIT
Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2197-3-15**] 10:00
|
[
"572.3",
"414.01",
"285.1",
"287.5",
"276.2",
"441.4",
"250.00",
"532.40",
"518.89",
"608.83",
"597.0",
"403.90",
"585.3",
"537.89",
"V45.82",
"531.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
12242, 12300
|
8017, 10966
|
326, 361
|
12414, 12501
|
3101, 3101
|
13510, 14544
|
2390, 2414
|
11604, 12219
|
12321, 12393
|
10992, 11581
|
12525, 13487
|
3649, 7994
|
2429, 3082
|
275, 288
|
389, 1895
|
3117, 3633
|
1917, 2248
|
2264, 2374
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,251
| 134,898
|
34788
|
Discharge summary
|
report
|
Admission Date: [**2166-6-9**] Discharge Date: [**2166-6-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain and shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 yr old male with ESRD on hemodialysis MWF who is s/p cath at
[**Hospital3 **] [**3-4**] showing moderate aortic stenosis and tight 90%
ostial CX-into LM and 50-60% lad, 80% om1 and 70-80% diag. He
was treated medically and now presents to [**Hospital3 **] this w/e with
chest pain/heart failure. He presented to Caritas Good-[**Male First Name (un) **] on
[**2166-6-8**] with left sided chest pain that started on the day of
admission. The pain lasted 15 minutes and resolved with 1 SL
nitroglycerin. Also of note, he has had several weeks of
hemoptysis with increasing sputum production. His initial EKG
was unchanged with his LBBB. His initial cardiac enzymes were
positive. He was started on antibiotics, a nitroglycerin drip,
and heparin drip and admitted. His initial chest xray was read
as pulmonary edema. He developed worsening respiratory distress
and hypoxia requiring NRB facemask. An ABG at that time was
7.35/44/71 (on 100% NRB). He was dialyzed for 3.1 kg on [**2166-3-9**].
Following his dialysis session he required neosynephrine gtt. .
A follow-up hematocrit was 22.3 which was down from admission
from 28.7% he received 1 unit of PRBCs. A left groin TLC was
placed on [**2166-3-10**] given his poor venous access.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
*** Cardiac review of systems is notable for absence of chest
pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
ESRD on HD
Hypertension
hyperlipidemia
moderate aortic stenosis
remote stroke
anemia
BPH
.
Cardiac Risk Factors: -Diabetes, +Dyslipidemia, +Hypertension
Social History:
lives with wife who is his HCP. no cigarettes, drugs or EtOH.
Family History:
nc
Physical Exam:
upon arrival to CCU
VS: afebrile , BP 95/50, HR 80, RR 23, O2 95% on 5L FM
Gen: chronically ill eldery male in NAD, resp or otherwise.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. right eye blind, Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
Neck: Supple with JVP elevated
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles at bases
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. left femoral central line
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2166-6-9**] 01:25PM WBC-9.1 RBC-2.67* HGB-8.2* HCT-25.3* MCV-95
MCH-30.7 MCHC-32.4 RDW-19.7*
[**2166-6-9**] 01:25PM PLT COUNT-157
[**2166-6-9**] 01:25PM GLUCOSE-108* UREA N-50* CREAT-5.3* SODIUM-142
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-26 ANION GAP-17
[**2166-6-9**] 01:25PM CK(CPK)-310*
[**2166-6-9**] 01:25PM CK-MB-8
[**2166-6-8**] @805am sinus @95. LBBB no significant concordant or
discondant changes
CXR -
1. Severe bilateral pulmonary edema and cardiomegaly consistent
with cardiac etiology.
TTE (emergent, limited study) - Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis/akinesis. (LVEF =<<20 %). The right
ventricular cavity is markedly dilated with severe global free
wall hypokinesis/akinesis. There is no pericardial effusion
Brief Hospital Course:
In brief, the patient is an 84 year old man with hx of ESRD on
HD, CAD, moderate AS who presented to an outside hospital with
chest pain and shortness of breath and found to have NSTEMI and
pulmonary edema. The patient was transfered to [**Hospital1 18**] for
further management while on supplemental O2 and single
vasopressor. Upon arrival in the CCU the patient was breathing
comfortably and mentating normally with stable O2sats on
moderate flow face mask. Over the next hour the patient
developed rapidly progressing hypotension requiring initiation
of a second vasopressor. The patient suddenly developed PEA
arrest and CPR was begun immediately. Multiple rounds of
epinephrine and atropine were given. No shockable rhythm
developed. There was no pericardial tamponade seen on emergent
bedside TTE. During intubation, marked bloody sputum was seen
coming from the endo-tracheal tube. The family, including the
patient's wife and healthcare proxy, were updated of the
situation. The family was invited into the room during
resuscitative attempts. After discussing the likely outcome
despite the efforts, the family indicated that the resuscitative
attempts should stop. The patient was pronounced dead. The
family was offered counseling by the medical, nursing, social
work, and clergical staff. The family declined autopsy.
Medications on Admission:
Home Medications:
proscar 5 mg daily
coreg 40 mg daily
coreg ER 200 mg daily
renagel 800 mg tid/meals
imdur 90 mg daily
omeprazole 20 mg daily
fish oil 1 capsule daily
aspirin 81 mg daily
.
Medications on transfer:
imdur
neosynephrine gtt
heparin gtt
coreg 12.5 mg [**Hospital1 **] (held)
aspirin 325 mg daily
plavix 75 mg daily (first dose on[**2166-6-8**])
colace 100 mg [**Hospital1 **]
nexium 40 mg daily
proscar 5 mg daily
imdur 90 mg daily
levofloxacin 500 mg q48hr (start [**2166-3-9**])
renagel 800 mg TID/meals
simvastatin 40 mg daily
tylenol 325-650 mg q4prn
mylanta 30 mL q4prn
robitussin 200mg tidprn
serax 10 mg qhsprn
.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac arrest
non-ST elevation MI
pulmonary edema
Discharge Condition:
deceased
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"403.91",
"424.1",
"427.5",
"585.6",
"285.9",
"410.71",
"514"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
6161, 6170
|
4106, 5447
|
294, 300
|
6264, 6274
|
3261, 4083
|
6325, 6330
|
2371, 2375
|
6132, 6138
|
6191, 6243
|
5473, 5473
|
6298, 6302
|
2390, 3242
|
5491, 5663
|
220, 256
|
328, 2099
|
5688, 6109
|
2121, 2276
|
2292, 2355
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,711
| 103,050
|
38538
|
Discharge summary
|
report
|
Admission Date: [**2134-6-15**] Discharge Date: [**2134-6-25**]
Date of Birth: [**2072-7-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Optiray 300 / Keflex /
Ciprofloxacin
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
[**2134-6-21**]: Percutaneous pinning right SI joinig
History of Present Illness:
Ms. [**Known lastname **] is a 62 y.o. female unrestrained driver presents
[**6-15**] after high speed MVC (45-50mph), patient was ejected via
driver's side window and landed 15-20 feet away. No LOC. Patient
was flown from the scene via [**Location (un) **] to [**Hospital1 18**] for further
evaluation.
Past Medical History:
(1) IDDM type 2
(2) DVT, PE, and pulmonary infarct (greater than 20 years ago)
(3) Lumbar disc herniations
(4) osteoarthritis
(5) COPD
Social History:
no tobacco, drugs; occ ETOH
Family History:
NC
Physical Exam:
VITAL SIGNS: tmax ([**6-22**]):100.0 tc:98.7 bp:117/77 hr:95 (92-106)
rr:14, 98%NC
PHYSICAL EXAM
GENERAL: Obese female sitting in chair in NAD
HEENT: MMM, no pharyngeal erythemia, no lymphadenopathy, No
conjunctival pallor. Non icteric sclera. PERRLA
CV: Tachycardic, Normal S1, S2. RRR No murmurs, rubs or [**Last Name (un) 549**].
Difficult to assess JVP.
PULM: CTA BL, no wheezes, no ronchi
ABD: Obese. Soft, NT, ND. No HSM
EXTREMITIES: Multiple ecchymoses on extremities, including right
anticubitis, and left forearm, and right calf which patient
reports are from trauma. Right hand with healing laceration and
stitches in place, no drainage, no erythemia.
SKIN: ecchymosis over right hip
NEURO: A&Ox3. Appropriate. CN II_XII grossly intact.
Pertinent Results:
[**2134-6-15**] 01:15PM BLOOD WBC-10.6 RBC-4.19* Hgb-12.7 Hct-38.5
MCV-92 MCH-30.4 MCHC-33.0 RDW-13.2 Plt Ct-278
[**2134-6-15**] 01:15PM BLOOD PT-13.1 PTT-23.1 INR(PT)-1.1
[**2134-6-15**] 11:10PM BLOOD Glucose-172* UreaN-18 Creat-0.7 Na-139
K-4.0 Cl-103 HCO3-25 AnGap-15
[**2134-6-15**] 11:10PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8
.
[**2134-6-16**] 04:30AM BLOOD WBC-11.8* RBC-3.61* Hgb-11.2* Hct-32.5*
MCV-90 MCH-31.1 MCHC-34.5 RDW-13.0 Plt Ct-227
[**2134-6-17**] 07:30AM BLOOD WBC-12.3* RBC-3.04* Hgb-9.4* Hct-27.9*
MCV-92 MCH-30.9 MCHC-33.6 RDW-13.1 Plt Ct-155
[**2134-6-20**] 12:50PM BLOOD WBC-7.5 RBC-2.86* Hgb-9.0* Hct-26.6*
MCV-93 MCH-31.4 MCHC-33.8 RDW-13.9 Plt Ct-189
[**2134-6-22**] 06:10AM BLOOD WBC-7.9 RBC-2.64* Hgb-8.1* Hct-24.8*
MCV-94 MCH-30.6 MCHC-32.6 RDW-14.6 Plt Ct-108*
[**2134-6-22**] 01:30PM BLOOD WBC-9.2 RBC-2.77* Hgb-8.5* Hct-26.8*
MCV-97 MCH-30.7 MCHC-31.7 RDW-14.1 Plt Ct-193#
[**2134-6-22**] 04:15PM BLOOD WBC-9.1 RBC-2.64* Hgb-8.2* Hct-25.1*
MCV-95 MCH-31.2 MCHC-32.8 RDW-13.7 Plt Ct-181
[**2134-6-23**] 04:20PM BLOOD WBC-7.3 RBC-2.92* Hgb-9.0* Hct-27.4*
MCV-94 MCH-30.9 MCHC-33.0 RDW-14.7 Plt Ct-265
[**2134-6-24**] 06:40AM BLOOD WBC-7.7 RBC-2.86* Hgb-8.7* Hct-26.8*
MCV-94 MCH-30.3 MCHC-32.4 RDW-15.3 Plt Ct-279
[**2134-6-25**] 06:50AM BLOOD WBC-8.4 RBC-3.08* Hgb-9.0* Hct-29.0*
MCV-94 MCH-29.2 MCHC-31.0 RDW-15.3 Plt Ct-359
[**2134-6-16**] 04:30AM BLOOD Glucose-158* UreaN-18 Creat-0.6 Na-136
K-3.9 Cl-105 HCO3-26 AnGap-9
[**2134-6-17**] 07:30AM BLOOD Glucose-153* UreaN-17 Creat-0.6 Na-137
K-4.2 Cl-101 HCO3-30 AnGap-10
[**2134-6-22**] 06:10AM BLOOD Glucose-191* UreaN-13 Creat-0.4 Na-132*
K-4.0 Cl-99 HCO3-28 AnGap-9
[**2134-6-25**] 06:50AM BLOOD Glucose-166* UreaN-16 Creat-0.5 Na-133
K-4.0 Cl-96 HCO3-30 AnGap-11
[**2134-6-15**] 01:15PM BLOOD Lipase-19
IMAGING:
CT HEAD
EXAM: CT head exam dated [**2134-6-15**].
COMPARISON: None.
CLINICAL INFORMATION: 62-year-old female in an MVC.
TECHNIQUE: Contiguous 5-mm axial images were acquired of the
head without the
use of intravenous contrast, and these were reformatted in the
coronal and
sagittal planes.
FINDINGS: There is no intracranial hemorrhage. There is no mass
effect or
midline shift. The ventricles and sulci are normal in size and
configuration.
[**Doctor Last Name **]-white differentiation is preserved. The orbits are
unremarkable.
Visualized soft tissue structures are normal in appearance. The
mastoid air
cells are clear. The visualized paranasal sinuses are clear.
Incidental note
is made of hyperostosis frontalis.
IMPRESSION: No acute intracranial injury.
.......................................................
EXAM: CT of the torso.
COMPARISON: None.
CLINICAL INFORMATION: 63-year-old female involved in motor
vehicle collision.
TECHNIQUE: 5-mm axial images were acquired of the chest, abdomen
and pelvis.
Intravenous contrast was not administered due to history of
anaphylactic
reaction. Images were reformatted in the coronal and sagittal
planes.
FINDINGS:
CHEST: The lungs are clear, with the exception of minimal
bibasilar
atelectasis. While limited by lack of intravenous contrast,
there is no
evidence of injury to the thoracic aorta. No pericardial
effusion is seen.
The heart is normal in size and configuration. Incidental note
is made of
coronary artery calcifications. There are fractures of the left
fourth
through eighth ribs laterally, additionally with anterior
fractures of the
sixth and seventh ribs anteriorly. No pneumothorax is seen.
There is no
pleural effusion. The central airways appear patent.
ABDOMEN: While limited by lack of intravenous contrast, the
liver, spleen,
pancreas, gallbladder, adrenals, and kidneys are unremarkable.
No
intraperitoneal free fluid is seen. The small bowel and its
mesenteries
appear unremarkable.
PELVIS: There is a comminuted fracture of the right hemisacrum,
posterior
iliac spine, and inferior and superior pubic rami. Hematoma is
seen within
the pelvis in the area of these fractures, which measures 4.5 x
7 cm at the
right ischium. Additionally, there are distracted fractures of
the right
transverse processes of L4 and L5. The bladder is deviated to
the left by
hematoma but otherwise demonstrates no evidence of injury. The
uterus is
normal in appearance. The colon is significant for
diverticulosis, with no
evidence of diverticulitis.
BONES: The thoracolumbar spine is significant for flowing
osteophytes along
the anterior thoracic spine, consistent with DISH. There is
degenerative
disease of the lumbar spine with vacuum phenomenon and disc
space narrowing,
most significant at the L5-S1 level. Alignment is preserved. A
posterior
disc osteophyte complex at the L2-3 level causes moderate
central canal
narrowing.
IMPRESSION:
1. Comminuted fractures of the right hemisacrum, right posterior
iliac spine,
and right superior and inferior pubic rami. Pelvic hematoma
surrounds these
fractures. Additionally, there are right L4 and L5 transverse
process
fractures.
2. Left-sided fourth through eighth rib fractures, with no
evidence of
pneumothorax.
3. While limited by lack of intravenous contrast, there are no
other injuries
identified of the chest, abdomen or pelvis.
.......................................................
EXAM: CT of the C-spine.
COMPARISON: None.
CLINICAL INFORMATION: 62-year-old female involved in a motor
vehicle
collision.
TECHNIQUE: Contiguous 2.5-mm axial images were acquired of the
cervical
spine, and these were reformatted in the coronal and sagittal
planes.
FINDINGS: There is no fracture, and alignment is preserved. The
prevertebral
soft tissues are normal in appearance. There is multilevel disc
space
narrowing, most prominent at C5-6, where a posterior disc
osteophyte complex
mildly narrows the central canal. Facet joint, and uncovertebral
joint
hypertrophy narrow the neural foramina at multiple levels, most
severely on
the right at the C5-6 level. The visualized lung apices are
clear. The
thyroid and soft tissues of the neck are unremarkable.
IMPRESSION:
1. No evidence of acute injury to the cervical spine.
2. Multilevel degenerative change, with mild narrowing of the
central canal
at the C5-6 level. If there is concern for cord injury, an MRI
would be
helpful for the evaluation of this.
.......................................................
HISTORY: Right percutaneous SI joint pinning.
Fluoroscopic assistance provided to the surgeon in the OR
without the
radiologist present. Seven spot views obtained. These
demonstrate steps
related to placement of screws across the right SI joint and
right sacral ala.
Correlation with real-time findings and when appropriate
conventional
radiographs are recommended for full assessment. Fluoro time not
recorded on
the electronic requisition.
.......................................................
EXAM: Bilateral lower extremity ultrasound to rule out DVT.
CLINICAL INFORMATION: 61-year-old female with history of
peristent
tachycardia, prior pelvic surgery, question lower extremity DVT.
COMPARISON: None.
FINDINGS: Real-time [**Doctor Last Name 352**]-scale and color Doppler son[**Name (NI) 493**]
evaluation of
bilateral common femoral, superficial femoral, and popliteal
veins was
performed. There is normal compressibility, color flow, and
augmentation seen
throughout. Color flow is also seen in the peroneal veins in the
proximal
calves bilaterally. There is limited evaluation of the posterior
tibial
veins.
IMPRESSION: No evidence of deep venous thrombosis in bilateral
lower
extremities.
.......................................................
V/Q scan
RADIOPHARMACEUTICAL DATA:
8.2 mCi Tc-[**Age over 90 **]m MAA ([**2134-6-22**]);
40.3 mCi Tc-99m DTPA Aerosol ([**2134-6-22**]);
HISTORY: increased oxygen requirement and tachycardia after hip
surgery
INTERPRETATION:
Perfusion images obtained with Tc-[**Age over 90 **]m MAA in 8 views show a
defect in the
superior segment of the left lower lobe and a partial defect in
the superior
portion of the basal segments of the left lower lobe. There is
also an overall
decrease in perfusion in the left lobe when compared with the
right lobe.
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in the same 8
views demonstrate
a defect in the same region, partially matching the perfusion
defects.
Chest x-ray (portable film from [**2134-6-21**]) shows possible new
retrocardiac
opacity and blunting of left costophrenic sulcus.
In view of her prior history of pulmonary embolism, these
findings may represent
chronic changes; however acute embolus cannot be excluded.
The above results are consistent with an indeterminate
likelihood for acute
pulmonary embolism.
IMPRESSION: Indeterminate likelihood for acute pulmonary
embolism. The perfusion
defects may be chronic and related to her prior pulmonary
embolism. If clinical
suspicion remains, a CT pulmonary angiogram using gadolinium may
be warranted
.
.
.
.
.
.
.
.
.
.
.
................................................................
HISTORY: 61-year-old female with multiple traumatic injuries
after MVC, now
with oxygen requirement and tachycardia after hip surgery,
concerning for
pulmonary embolism.
COMPARISON: CT torso from [**2134-6-15**]. V/Q scan was also performed
on [**2134-6-22**].
TECHNIQUE: MDCT axial imaging was performed through the chest
initially using
low-dose technique during full inspiration prior to
administration of IV
contrast, and then after administration of IV contrast. Axial
images were
displayed using 5- and 2.5-mm collimation. Coronal and sagittal
reformations
as well as bilateral oblique maximal-intensity projection images
were then
obtained on a separate workstation.
Due to the patient's reported history of prior reaction to CT IV
contrast, the
study was performed after uneventful intravenous administration
of 50 mL of IV
gadolinium-DTPA.
CTA CHEST WITH IV GADOLINIUM: Unfortunately, due to multiple
technical
factors including timing of the contrast bolus and timing of the
CT table,
post-contrast images show insufficient opacification of the
pulmonary arteries
for diagnosis of pulmonary embolism. The pulmonary artery and
aorta are of
normal caliber. Mitral annular calcifications are noted. There
is no
pericardial effusion. Multiple mediastinal nodes are
subcentimeter, not
meeting size criteria for adenopathy.
Multiple both anterior and posterolateral left rib fractures are
redemonstrated, with stranding noted in the overlying soft
tissues, but no
pneumothorax or subcutaneous gas. There is moderate left pleural
effusion
which measures fluid density, with secondary compressive
atelectasis of the
left lower lobe, sparing only the anterior basal segment.
The central airways are patent to the subsegmental levels. On
the right,
there are dependent atelectatic changes. Additionally, there are
multiple
small peripheral ground-glass opacities in the right upper,
right middle, and
right lower lobes, which were not present on [**2134-6-15**].
No focal abnormality is demonstrated within the visualized upper
abdomen on
this exam not tailored for subdiaphragmatic diagnosis.
Degenerative changes
are redemonstrated in the thoracic spine.
IMPRESSIONS:
1. Multiple anterior and posterolateral left rib fractures
redemonstrated.
Moderate left pleural effusion, with associated left lower lobe
atelectasis.
2. Non- diagnostic study for pulmonary embolism.
3. New small peripheral ground-glass opacities in the right
upper, right
middle, and right lower lobes are nonspecific. While infection
is possible,
location and morphology raise the possibility of small areas of
infarction in
setting of clinical suspicion for PE.
Findings and recommendations were discussed in detail with Dr.
[**First Name8 (NamePattern2) 2092**] [**Last Name (NamePattern1) **]
over the phone at 3:30 p.m., who states that the patient reports
her prior
contrast reaction consisted of hives and lightheadedness. If
this can be
confirmed, then CTA after pre-medication may be considered.
Otherwise, a non-
contrast, flow-related MRA study would be recommended.
...................................
Brief Hospital Course:
Ms. [**Known lastname **] presented to the [**Hospital1 18**] on [**2134-6-15**] via [**Hospital **]
transfer from the scene of her MVC where she was ejected. She
was found to have a right hemi sacral and iliac fracture, pubic
rami fractures and multiple left sided rib fractures, 4-8th rib
fractures, with 6th and 7th ribs fractured in two places, and a
right transverse process fractures, L4 and 5. She was admitted
to the TICU for observation and serial hematocrits. On [**2134-6-16**]
she was transferred to the floor. She was taken to the
operating room on [**2134-6-21**] and underwent a percutaneous pinning
of her right hemisacral fracture. She toleratd the procedure
well, was extubated, and transferred to the floor. her pain was
well controled with dilaudid 6mg. She will need follow up with
[**Hospital1 18**] ortho clinic for revaluation 2 weeks after discharge and
to remove the stitches on her right hand.
.
# Tachycardia: patient was observed to be persistently
tachycardic to the 120's despite adequate fluid resussitation
and a stable hematocrit. Medicine was consulted. The patient
states that she has been 'known to have a higher heart rate' but
is unsure how high her rates have been. Given immobility after
surgery and history of DVT/PE (28 years ago) concern for
pulmonary embolism was elevated. Lower ext dopplars were
negative for DVT. She was sent for a V/Q scan which was
equivical and followed up with a CTA with gadolinium (given hx
anaphalaxis to contrast). The study was incomplete and unable to
rule in or out PE. Discussed these findings with the patient and
the need for repeat imaging, and she refused repeat scan.
Discussed with her the importance of diagnosing and treating PE
to prevent respiratory distress, cardiac compromise and death.
She acknowledges these risks and declines repeat imaging. Given
recent surgery and equivical studies she was not anticoagulated
and is being discharged in lovanox 40mg [**Hospital1 **] for 4 weeks for DVT
prophylaxis post surgery.
.
# Pneumonia: patient developed productive cough while in the
hospital. Initially, there was concern for hospital acquired
pneumonia and she was started on vancomycin/zosyn. After a two
day course of abx, she reported having had the cough prior to
admission and she was switched to augmentin (given allergy to
fluroquinolones and cephalosporins) and azithromycin. She will
complete a 7 day course of antibiotics.
Medications on Admission:
Iinsulin sliding scale
Metformin 500mg Daily
Lantus 50 Units daily
Flexaril 20mg daiy
Albuterol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day). Tablet, Chewable(s)
5. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO ONCE (Once)
for 4 days. Tablet(s)
6. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q 8H (Every 8 Hours) for 4 days.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Cyclobenzaprine 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous once a day.
10. Humalog 100 unit/mL Solution Sig: asdir Subcutaneous asdir:
At Breakfast/lunch/dinner/bed time:
Below 120: no coverage
120-159 4 Units
160-199 6 Units
200-239 8 Units
240-279 10 Units
280-319 12 Units
.
11. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: One (1)
Tablet PO three times a day.
12. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO
Q6H (every 6 hours) as needed for itching.
13. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain: Hold for sedation, hold for rr<12.
Disp:*30 Tablet(s)* Refills:*0*
14. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. ML(s)
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] rehab [**Hospital1 **] NH
Discharge Diagnosis:
s/p MVC
Right acetabular fracture
Left sided rib fractures, [**3-4**], with 6th and 7th ribs fx in 2
places
Right transverse process fractures, L4 and 5
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:
Ms. [**Known lastname **],
As you know, you were admitted to the hospital with pelvic and
rib fractures after your motor vehicle accident on [**2134-6-15**].
You were treated by our orthopedic surgeons who put a pin into
your pelvis to hold the bone in place. As we discussed, the
broken ribs will take six to ten weeks to heal, you will need to
use pain as your guide regarding your activity level.
Orthopedics recommends that you ontinue to touchdown weight
bearing on your right leg.
.
You were found to have pneumonia and are being treated with
antibiotics (Amoxicillin-Clavulanic and Azithromycin). You will
need to continue to take the anti biotics for four days after
you are discharged from [**Hospital1 18**].
Continue your lovenox injections as instructed for a total of 4
weeks after surgery
Please take all medication as prescribed
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
.
Please follow up with your PCP 2-4 weeks after discharge
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Hospital **] MEDICAL CENTER
Address: [**Doctor Last Name 80300**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 66328**]
Phone: [**Telephone/Fax (1) 63696**]
|
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66,083
| 114,322
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41966+58488
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-7-28**] Discharge Date: [**2132-8-5**]
Date of Birth: [**2079-11-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Mitral valve repair (26 [**Doctor Last Name **] Ring- SN893344,Model 5200),
Ligation left atrial appendage, Coronary artery bypass graft
x1(Saphenous vein graft to obtuse marginal) [**2132-7-30**]
History of Present Illness:
This 52 year old white male was visiting the US from [**Country **]
presented with three days of intermittent chest pain,weakness
and fatigue. An echocardiogram in the ED revealed a partially
flail posterior mitral leaflet with 2+ regurgitation. Cardiac
surgery was consulted for evaluation of surgical correction.
Past Medical History:
Hyperlipidemia
Hypothyroid
s/p thyroid cancer and surgical removal
Social History:
He lives in [**Country **] with his wife, and works as an accountant. He
is visiting his son.
-Tobacco history: quit 30 yrs ago (smoked 1ppd/5 yrs)
-ETOH: 12 drinks/wk
-Illicit drugs: none
Family History:
Mother died at age 62 of CAD, father died of alzheimers. Brother
recently had a stroke.
Physical Exam:
Pulse:108 Resp:16 O2 sat:100/RA
B/P 165/88
Height: Weight:184#
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x- throidectomy scar] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade _3/6 heard across
precordium, loudest at left axilla
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right: radiating Left: Radiating
Pertinent Results:
INTRAOP TEE: [**2132-7-30**] PRE-BYPASS: No spontaneous echo contrast is
seen in the body of the left atrium or left atrial appendage.
There is bowing of the interatrial septum suggesting increased
left atrial pressures. The interatrial septum does not appear
aneurysmal. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. There is partial P2 mitral leaflet flail.
An eccentric, anterior directed jet of moderate to severe (3+)
mitral regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The C-[**Month (only) **] distance is 2.9 cm,
with a [**Doctor Last Name **]/PL ratio of 1.7. There is a trivial/physiologic
pericardial effusion.
POST-BYPASS: The patient is status post mitral valve repair.
There is a well-positioned annuloplasty ring in the mitral
position. No mitral regurgitation or paravalvular leak is seen.
There is no mitral stenosis with a mean gradient of less than 5
mmHg. Biventricular function is unchanged. There is trace aortic
regurgitation. There is no evidence of systolic anterior motion
of the mitral valve or left ventricular outflow tract
obstruction ([**Male First Name (un) **]/LVOTO). The ascending aorta, aortic arch, and
descending thoracic aorta are intact.
CXR: [**2132-8-3**]: Cardiac silhouette is within normal limits. A
valve replacement is seen. There is a small left-sided pleural
effusion. There is some atelectasis at the lung bases, which is
stable since the previous study. No pneumothoraces are seen.
There are no signs for overt pulmonary edema.
[**2132-7-28**] 07:25PM BLOOD WBC-9.5 RBC-4.74 Hgb-14.8 Hct-40.8 MCV-86
MCH-31.2 MCHC-36.3* RDW-13.0 Plt Ct-304
[**2132-8-4**] 07:00AM BLOOD WBC-9.0 RBC-2.89* Hgb-9.0* Hct-25.7*
MCV-89 MCH-31.0 MCHC-34.9 RDW-13.4 Plt Ct-460*
[**2132-7-28**] 07:25PM BLOOD PT-12.6 PTT-23.7 INR(PT)-1.1
[**2132-7-30**] 03:27PM BLOOD PT-15.2* PTT-35.3* INR(PT)-1.3*
[**2132-7-28**] 07:25PM BLOOD Glucose-107* UreaN-18 Creat-1.0 Na-138
K-5.9* Cl-103 HCO3-26 AnGap-15
[**2132-8-4**] 07:00AM BLOOD Glucose-137* UreaN-21* Creat-0.8 Na-137
K-4.3 Cl-99 HCO3-32 AnGap-10
[**2132-7-29**] 07:15AM BLOOD Phos-3.8 Mg-2.2
[**2132-8-2**] 07:15AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 90917**] presented to the ED the day prior to planned surgery
with pain. Enzymes were negative and on [**7-30**] he was taken to the
Operating Room and underwent a Mitral valve repair and Coronary
artery bypass grafting x 1. CARDIOPULMONARY BYPASS TIME:120
minutes. CROSSCLAMP TIME: 93 minutes. He tolerated the procedure
well and was transferred to the CVICU, intubated and sedated in
critical but stable condition. He was weaned from low dose Neo
Synephrine, awoke neurologically intact and was extubated the
night of surgery. All lines and drains were discontinued per
protocol. He was started on Beta blockers/Aspirin/Statin,
diuresed and transferred to the floor on POD #1. Physical
Therapy was consulted to evaluate mobility and strength. Of note
his rhythm was in a first degree AV block/accelerated
junctional, continued on low dose beta blockers (this was
present on day of discharge as well). Stable HCT 24 and was
started on iron. He continued to progress and the remainder of
his hospital course was essentially uneventful. He was cleared
for discharge to home with VNA services on post-op day six with
the appropriate medications and follow-up appointments.
Medications on Admission:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO daily
except fridays.
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO QFRI
(every Friday).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. mupirocin 2 % Ointment Sig: One (1) application Topical twice
a day for 5 days: Please apply to your nose twice daily for 5
days, starting [**2132-7-26**].
8. temazepam 7.5 mg Capsule Sig: One (1) Capsule PO Once, the
night before your surgery for 1 days.
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
Disp:*40 Tablet(s)* Refills:*0*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
4. 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*
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO Q FRIDAY
().
Disp:*5 Tablet(s)* Refills:*2*
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily): take with OJ.
Disp:*30 Tablet(s)* Refills:*2*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Senna-S 8.6-50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
12. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO PO daily
except Fridays.
Disp:*30 Tablet(s)* Refills:*2*
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hotel Recovery
Discharge Diagnosis:
Coronary Artery disease s/p Coronary artery bypass graft x 1
Mitral regurgitation s/p Mitral Valve Repair
Past medical history:
Hyperlipidemia
h/o thyroid cancer s/p thyroidectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right- healing well, no erythema or drainage.
Edema: [**12-16**]+
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) 914**] ([**Telephone/Fax (1) 170**]) on [**2132-9-2**] at 2pm in the
[**Hospital Unit Name 91090**] [**Last Name (NamePattern1) **], [**Hospital Unit Name **]
Echocardiogram and CXR prior to office visit - [**2132-8-19**] at 11AM
Phone:[**Telephone/Fax (1) 62**], Clinical center [**Location (un) 470**]
Cardiologist: Dr. [**Last Name (STitle) **] to arrange. Office will contact you
with appointment date and time.
Please call to schedule appointments with: Primary Care doctor
in [**Country **] on return.
**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:[**2132-8-5**] Name: [**Known lastname 14361**],[**Known firstname 14362**] Unit No: [**Numeric Identifier 14363**]
Admission Date: [**2132-7-28**] Discharge Date: [**2132-8-5**]
Date of Birth: [**2079-11-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1543**]
Addendum:
Please note, the partial flail mitral valve leaflet was caused
by ruptured chordae tendineae.
Discharge Disposition:
Home With Service
Facility:
Hotel Recovery
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2132-9-15**]
|
[
"429.5",
"424.0",
"560.1",
"429.89",
"272.4",
"414.01",
"411.1",
"244.0",
"V10.87"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"37.36",
"35.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10816, 11020
|
4662, 5856
|
319, 517
|
8453, 8687
|
1981, 4639
|
9527, 10793
|
1173, 1262
|
6630, 8162
|
8251, 8357
|
5882, 6607
|
8711, 9504
|
1277, 1962
|
269, 281
|
545, 861
|
8379, 8432
|
967, 1157
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,684
| 151,425
|
52571
|
Discharge summary
|
report
|
Admission Date: [**2177-12-10**] Discharge Date: [**2177-12-19**]
Date of Birth: [**2123-1-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
CABG x3 [**2177-12-15**] (LIMA to LAD, SVG to RAMUS, SVG to OM)
History of Present Illness:
Mr. [**Known lastname **] is a 54y/o gentleman with HTN, HLD, and CAD with
recent workup for chest pain revealing LAD and L. Main disease,
who presents after markedly positive stress test and is admitted
for corony bypass grafting.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
-hypertension
-hyperlipidemia
-OSA, on CPAP
-CAD: LAD disease s/p DES, L. main disease
-s/p minimal-change disease/membranous glomerulonephritis (had
presented with edema, Cr rise, but now in remission with Cr
~1.0)
Social History:
He is married and a research fellow at the [**University/College **] [**Doctor Last Name **] School of
Management. He does not smoke. He exercises 5-10 hours per week.
He is on a weight reduction diet.
Family History:
There is a possible family history of hypertension and a family
history of coronary artery disease. His mother is alive and his
father is deceased. His father underwent two prior CABG
procedures at age 52 and 66.
Physical Exam:
ADMISSION PHYSICAL EXAM:
231# 72"
VS: T=98 BP=145/85 HR=66 RR=20 O2 sat=100%RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate. Very apprehensive about needles.
HEENT: NCAT. EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa.
NECK: Supple, obese, unable to appreciate any JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, obese but nondistended. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS
[**2177-12-11**] 02:55AM BLOOD WBC-8.6 RBC-4.39* Hgb-12.0*# Hct-35.6*
MCV-81* MCH-27.4 MCHC-33.8 RDW-14.1 Plt Ct-249
[**2177-12-11**] 02:55AM BLOOD Glucose-99 UreaN-16 Creat-1.1 Na-143
K-4.3 Cl-105 HCO3-32 AnGap-10
[**2177-12-11**] 02:55AM BLOOD Calcium-9.5 Phos-4.7* Mg-2.1
[**2177-12-11**] 02:55AM BLOOD ALT-31 AST-26 AlkPhos-69 TotBili-0.6
[**2177-12-12**] 02:01AM BLOOD PT-12.8 PTT-52.3* INR(PT)-1.1
[**2177-12-11**] 02:55AM BLOOD %HbA1c-6.3* eAG-134*
[**2177-12-12**] 09:40AM BLOOD VitB12-357
Discharge Labs.
[**2177-12-18**] 04:50AM BLOOD WBC-10.8 RBC-2.90* Hgb-7.7* Hct-23.5*
MCV-81* MCH-26.6* MCHC-32.9 RDW-14.0 Plt Ct-205
[**2177-12-18**] 04:50AM BLOOD Plt Ct-205
[**2177-12-15**] 03:00PM BLOOD PT-13.7* PTT-26.8 INR(PT)-1.2*
[**2177-12-18**] 04:50AM BLOOD Glucose-117* UreaN-19 Creat-1.0 Na-138
K-3.9 Cl-99 HCO3-31 AnGap-12
[**2177-12-17**] 04:50AM BLOOD Mg-2.0
EXERCISE STRESS ECHO [**2177-12-10**]:
IMPRESSION: marked ischemic ECG changes with 2D
echocardiographic evidence of inducible ishemia at achieved
workload; transient ischemic dilatation of the left ventricle
was noted
EKG [**2177-12-11**]:
Sinus rhythm. Non-diagnostic Q waves in leads I and aVL. Since
the previous tracing of [**2169-9-13**] no significant change.
.
CARDIAC CATH [**2177-12-12**]:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated left main and proximal LAD coronary artery disease.
The
LMCA had 80% distal stenosis. The LAD had 70-80% ostial and
diagonal
branch disease. The LCx had no angiographically apparent
flow-limiting
disease. The ramus was a large vessel with minor
irregularities. The
RCA was a small but dominant vessel with no angiographically
apparent
flow limiting disease.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures.
.
CAROTID ULTRASOUND [**2177-12-12**]:
Impression: Right ICA <40% stenosis.
Left ICA <40% stenosis.
Echo:[**12-15**]
Pre CPB:
The left atrium is moderately dilated.
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen.
Trivial mitral regurgitation is seen.
Post CPB:
The cardiac output is 6.6L/min with atrial pacing at 80bpm.
The biventricular systolic function is preserved.
There is mild tricuspid regurgitation.
The visible contours of the thoracic aorta are intact.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2177-12-17**]
12:57 PM
[**Hospital 93**] MEDICAL CONDITION: 54 year old man s/p CABG
FINDINGS: In comparison with the study of [**12-16**], there has been
removal of
all the monitoring and support devices. No evidence of
pneumothorax. Left
basilar atelectatic change persists.
Brief Hospital Course:
Mr. [**Known lastname **] is a 54y/o gentleman with HTN, HLD, and CAD who has
had a workup for ongoing atypical chest pain that has revealed
left main and LAD disease, with a markedly positive stress test
and recent cath on [**12-12**] showing 90% left main disease. Referred
for CABG and underwent surgery with Dr. [**Last Name (STitle) **] on [**12-15**] after
preop w/u completed. Transferred to the CVICU in stable
condition on titrated phenylephrine and propofol drips.
Subcutaneous air appeared in neck; bronchoscopy done without
evidence of mucosal injury. Kept intubated overnight and was
extubated early on POD #1 and transferred to the floor to begin
increasing his activity level. Gently diuresed toward his preop
weight. Chest tubes and pacing wires removed per protocol.
Continued to make goopd progress and was cleared for discharge
to home with VNA on POD #4. f/u with Dr [**Last Name (STitle) **] in 3 weeks.
Medications on Admission:
ASPIRIN 325mg daily
PRASUGREL 10 mg daily
VALSARTAN [DIOVAN] - 160 mg daily
ATORVASTATIN [LIPITOR] - 80 mg daily
TOPROL XL - 25mg daily
LORAZEPAM - 0.5 mg PRN anxiety
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
8. potassium chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*25 Tablet(s)* Refills:*0*
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
coronary artery disease, s/p CABG x3, s/p DES [**9-26**]
hypertension
hyperlipidemia
obstructive sleep apnea
nephrotic syndrome (renal bx shows min. disease, some features
of membranous glomerulonephritis)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with dilaudid
Anxiety managed with Ativan
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **] [**Hospital Ward Name **] 2A Thursday [**1-1**] @ 1:30 pm
Cardiologist:Dr. [**Last Name (STitle) **] [**Name (STitle) **] [**1-13**] @ 10:40 AM
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 2204**] in [**4-21**] weeks [**Telephone/Fax (1) 2205**]
**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:[**2177-12-19**]
|
[
"414.01",
"458.29",
"V45.82",
"581.1",
"327.23",
"272.4",
"998.81",
"300.00",
"E878.2",
"784.42",
"411.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"33.22",
"88.56",
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8475, 8561
|
5823, 6749
|
318, 384
|
8811, 9059
|
2784, 5250
|
9899, 10469
|
1637, 1853
|
6966, 8452
|
5579, 5800
|
8582, 8790
|
6775, 6943
|
9083, 9876
|
1893, 2765
|
272, 280
|
412, 1161
|
1183, 1401
|
1417, 1621
|
5260, 5542
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,756
| 153,914
|
53451+59526
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-1-13**] Discharge Date: [**2174-1-17**]
Date of Birth: [**2123-8-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Compazine / Keflex
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
[**1-13**]: Exploration and decompression or right cerebello-pontine
angle mass
History of Present Illness:
[**Known firstname 12589**] [**Known lastname **] is a 50-year-old right-handed man with complaints of
vertigo since [**2173-11-28**]. He had nausea but no vomiting. He
presented to the emergency room at [**Hospital1 1170**]. MRI imaging on [**2173-11-30**] showed a right cerebellopontine
angle mass. He underwent a steretactic biopsy of this lesion
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2173-12-6**] and the pathology showed
grade I meningioma. He did well after surgery and his vertigo
was well controlled. He did have some right sided neck pain.
Past Medical History:
1. Hx of sarcoidosis - diagnosed by pulmonary nodule biopsy in
[**2166**]; normal f/u's including optho.
2. Sleep apnea - not on CPAP for claustrophobia but on NC at
bedtime
3. Depression
4. BPH
5. Asthma
6. GERD
7. hx of bacterial meningitis 10 yrs ago - no seizures and not
immunocompromised.
8. Central serous retinopathy
9. herniarraphy
Social History:
Lives alone - works for [**Hospital1 18**] under admitting. Denies
smoking or illicit drug use. Rare EtOH. Full code.
Family History:
Father died of retinal/liver cancer in his late 40's, mother
alive.
Physical Exam:
On Discharge: awake and alert, oriented to self, place, date,
motor strength 5/5 in all extremities, PERRL bilaterally,
extraocular movements intact, incision clean dry and intact, no
pronator drift, no clonus, ambulating without difficulty in
halls
Pertinent Results:
[**2174-1-17**] 05:50AM BLOOD WBC-5.9 RBC-4.52* Hgb-13.0* Hct-37.9*
MCV-84 MCH-28.8 MCHC-34.4 RDW-14.3 Plt Ct-205
[**2174-1-17**] 05:50AM BLOOD PT-11.2 PTT-23.6 INR(PT)-0.9
[**2174-1-17**] 05:50AM BLOOD Glucose-97 UreaN-19 Creat-0.8 Na-140
K-4.1 Cl-103 HCO3-30 AnGap-11
[**2174-1-17**] 05:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3
MR [**Name13 (STitle) 430**] [**2174-1-14**]
Status post partial resection of invasive mass at the right
cerebellomedullary angle, with post-operative changes and
unchanged mass
effect.
MR [**Name13 (STitle) 430**] [**2174-1-13**]
Extra-axial mass centered in the right cerebellomedullary angle
and extending into the right jugular foramen and right
hypoglossal canal,
stable since the prior studies.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] and was taken to the OR with Dr.
[**Last Name (STitle) **] on [**2174-1-13**]. He underwent an exploration and decompression
of a right cerebello-pontine angle mass. He was extubated after
the procedure and taken to the ICU post-operatively. He remained
stable overnight. On [**1-14**] he was neurologically intact with the
exception of a mild dysconjugate gaze thought to be related to
manipulation of the cerebellum. Transfer orders for the step
down unit were ordered. His neuro checks were liberalized to
Q2hrs.
He remained stable on the floor with resolution of his
disconjugate gaze noted on [**2174-1-16**]. He was seen by PT and OT on
[**2174-1-17**] and was cleared to go home with PT services. He was
discussed in Brain Tumor Conference and appropriate follow up
was arranged.
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaled every 6 hours as
needed for shortness of breath
BUPROPION HCL [WELLBUTRIN SR] - (Prescribed by Other Provider)
-
100 mg Tablet Sustained Release - 1 Tablet by mouth twice daily
BUSPIRONE - (Prescribed by Other Provider) - 10 mg Tablet - 2
Tablet(s) by mouth twice daily
DEXAMETHASONE - (Prescribed by Other Provider) - 2 mg Tablet -
1
Tablet(s) by mouth every eight (8) hours
ELOCON - 0.1% Cream - APPLY TO AFFECTED AREA ONCE DAILY AS
NEEDED.
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth daily
FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - 50 mcg
Spray, Suspension - 1 spray intranasal once a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Dose adjustment - no
new Rx) - 250 mcg-50 mcg/Dose Disk with Device - 1 puff inhaled
daily rinse mouth after use
LORAZEPAM - 1 mg Tablet - [**12-18**] Tablet(s) by mouth at bedtime Take
night of sleep study
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
PHENYTOIN SODIUM EXTENDED - (Prescribed by Other Provider) -
100
mg Capsule - 1 Capsule(s) by mouth three times a day
TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg
Capsule, Sust. Release 24 hr - 1 Capsule by mouth daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
7. Buspirone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-18**]
Tablets PO Q6H (every 6 hours) as needed for pain: CAUTION Not
to exceed more than 4gm APAP in 24h.
Disp:*40 Tablet(s)* Refills:*0*
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
13. Prednisone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 1 days.
Disp:*4 Tablet(s)* Refills:*0*
14. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for
3 days.
Disp:*6 Tablet(s)* Refills:*0*
15. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
meningioma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**6-25**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2-14**] at
9:30 am. 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:[**2174-1-17**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 18029**]
Admission Date: [**2174-1-13**] Discharge Date: [**2174-1-17**]
Date of Birth: [**2123-8-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Compazine / Keflex
Attending:[**First Name3 (LF) 599**]
Addendum:
Of note, during this hospitalization the patient had problems
with urinary retention post-operatively requiring straight
catheterization.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2174-2-16**]
|
[
"327.23",
"788.20",
"530.81",
"362.41",
"780.4",
"278.00",
"600.00",
"225.2",
"311",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"02.12",
"02.05",
"01.24",
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
12865, 13008
|
2637, 3488
|
291, 373
|
6505, 6529
|
1881, 2614
|
11511, 12842
|
1525, 1596
|
4848, 6421
|
6471, 6484
|
3514, 4825
|
6553, 6574
|
1611, 1611
|
1625, 1862
|
9680, 11488
|
244, 253
|
6586, 9653
|
401, 1005
|
1027, 1370
|
1386, 1509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,526
| 179,596
|
365
|
Discharge summary
|
report
|
Admission Date: [**2161-3-2**] Discharge Date: [**2161-3-8**]
Date of Birth: [**2089-11-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
s/p suboccipital craniotomy for tumor resection and biopsy
History of Present Illness:
71F with NSCLC, HTN, hypercholesterolemia, admitted with
refractory nausea/vomitting since starting Tarceva. She denies
abdominal/chest pain, SOB, diarrhea/constipation or problems
w/bladder incontinence. She does have unsteadiness of gait as
well as trouble using her right hand.
Past Medical History:
1. NSCLC: prior w/u at [**Hospital1 112**]/[**Company 2860**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3273**])- lung
nodules found on preop CXR [**6-14**], CT showed RLL nodule c/w
primary lung cancer and multifocal bronchoalveolar carcinoma,
PET/CT showed FDG-avid R lung nodule and mediastinal/pericardial
LAD, s/p bronch/mediastinoscopy with mediastinal LN dissection
with path showing NSCLC-adenoca; sought 2nd opinion at [**Hospital1 18**]
([**Doctor Last Name 3274**]/[**Doctor Last Name 1058**]), s/p 2 cycles of Taxol and carboplatin from
[**Date range (1) 3275**], s/p 4 cycles Navelbine on [**2165-9-14**], CT chest [**2-16**]
showed interval worsening of lung metastases and LAD, started
Tarceva ?[**2-20**]
2. Hypertension
3. Hypercholesterolemia
4. Degenerative joint disease
Social History:
She is a former smoker of half to one pack a day
for 20 to 30 years, but she quit about 20 years ago. She does
not have significant amount of passive smoking exposure, no
asbestos exposure, and rare social drinking.
Family History:
Positive for cardiac or vascular disease, but no
cancer. She has a possible history of amoxicillin allergy,
although it is not clear whether this was poor tolerance, and
she
has taken penicillin in the past without difficulty. She has a
daughter who is a physician and who comes with her to the visit
along with her son-in-law. She worked as a bookkeeper in an
electrical company in the past.
Physical Exam:
T:96.9 BP:140/78 HR:64 RR:20 O2Sats:95% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-13**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, heel to shin
(+) Romberg
Pertinent Results:
[**2161-3-2**] 09:10PM WBC-11.9* RBC-5.25 HGB-15.3 HCT-44.5 MCV-85
MCH-29.2 MCHC-34.4 RDW-16.7*
[**2161-3-2**] 09:10PM NEUTS-70.0 LYMPHS-24.3 MONOS-4.0 EOS-1.3
BASOS-0.5
[**2161-3-2**] 09:10PM ANISOCYT-1+ MICROCYT-1+
[**2161-3-2**] 09:10PM PLT COUNT-406
[**2161-3-2**] 09:10PM GLUCOSE-97 UREA N-34* CREAT-0.8 SODIUM-133
POTASSIUM-7.7* CHLORIDE-98 TOTAL CO2-26 ANION GAP-17
[**2161-3-2**] 09:10PM estGFR-Using this
[**2161-3-2**] 09:10PM ALT(SGPT)-33 AST(SGOT)-97* ALK PHOS-109
AMYLASE-111* TOT BILI-0.6
[**2161-3-2**] 09:10PM LIPASE-81*
[**2161-3-2**] 09:10PM CALCIUM-9.6 PHOSPHATE-4.4 MAGNESIUM-2.4
MRI head:
1. Enhancing mass in the right cerebellar hemisphere, with mass
effect as described above, most consistent with a metastatic
lesion. No additional mass/abnormal enhancement.
2. Old lacune in the left caudate nucleus and a nonspecific T2
hyperintensity in the right frontal lobe, likely post-traumatic
or chronic small vessel ischemic change.
3. Mucosal changes in the right sphenoid sinus.
CT abdomen/pelvis:
1. No evidence of intra-abdominal metastatic disease.
2. A 9-mm hypoattenuating liver lesion is likely a cyst but
should be
monitored closely on followup exams.
3. New small bilateral pleural effusions with adjacent
atelectasis.
4. Large paraesophageal hernia.
5. Stable pericardial lymph node.
Brief Hospital Course:
# Nausea and vomiting: Concerning presentation for brain
metastasis. Tarceva d/c'd on thursday of last week w/continued
N/V as well as unsteadiness of gait
# NSCLC: further treatment plans per Dr. [**Last Name (STitle) 3274**] and [**Doctor Last Name 1058**]
- hold Tarceva
- CT head as above
# Code status: DNR/DNI
On [**3-4**], the patient came from the [**Hospital Ward Name **] to the SICU on
the west. She underwent preop evaluation and surgery was
scheduled for [**3-5**] with Dr. [**Last Name (STitle) 548**]. She had a very successful
surgery with no reported complications. Please see the
operative note for full details. She went back to the ICU for
24 hours and then came to the floor. Physical therapy saw her
and had no major issues with her progression. She plans to say
with her daughter for several days to recuperate. The patient
will see neuro oncology and Dr. [**Last Name (STitle) 548**] next week and will be on a
course of steroids for the unforeseeable future.
Medications on Admission:
[**Doctor First Name **] 60MG [**Hospital1 **]
FLONASE 50 mcg 2 sprays ou qd
LIPITOR 10 MG qd
PRILOSEC 40 mg qd
Discharge Medications:
1. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) for 2 days.
Disp:*12 Tablet(s)* Refills:*0*
2. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO twice a
day for 2 days: Start this dose after taking 3mg TID.
Disp:*8 Tablet(s)* Refills:*0*
3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day:
Once you have finished taking 3mg [**Hospital1 **], take 2mg [**Hospital1 **] until
directed by MD otherwise.
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: Please take this medication as long as
you are taking percocet. .
Disp:*60 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
cerebellar mass
Discharge Condition:
neurologically stable
Discharge Instructions:
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
* Please continue all of your preadmission medications that you
were on before coming into the hospital.
?????? 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:
Need to follow-up with oncologist for 9-mm hypoattenuating liver
lesion which is likely a cyst but needs to be watched.
PLEASE RETURN TO THE OFFICE IN 7 DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) 548**] TO BE SEEN IN 1 WEEK.
YOU WILL NOT NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT
CONTRAST
Completed by:[**2161-3-8**]
|
[
"715.98",
"272.0",
"V15.82",
"401.9",
"197.3",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
6766, 6772
|
4780, 5776
|
335, 396
|
6832, 6856
|
3421, 4757
|
8296, 8712
|
1796, 2193
|
5938, 6743
|
6793, 6811
|
5802, 5915
|
6880, 8273
|
2208, 2453
|
279, 297
|
424, 706
|
2705, 3402
|
2468, 2689
|
728, 1545
|
1561, 1780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,926
| 104,122
|
38626
|
Discharge summary
|
report
|
Admission Date: [**2198-3-29**] Discharge Date: [**2198-4-4**]
Date of Birth: [**2143-8-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Found unresponsive
Major Surgical or Invasive Procedure:
Mechanical ventilation
Intubation
History of Present Illness:
Mr. [**Known firstname 85836**] [**Known lastname 1005**] is a 54 yo man with a history of DM,
polysubstance abuse, HCV, liver cirrhosis, and gastric ulcer who
was BIBA to [**Hospital3 **] ED after being found unresponsive on his
bed by his roommate with needles scattered around him. He had
not been seen for 2 days. EMS was called and administered
Narcan on arrival with with minimal improvement.
At [**Hospital3 **], the pt was febrile to 105.4, for which he
received tylenol. He was again given narcan without improvement
so was intubated. On AC with 400/20/5/100%, ABG was
7.29/27/463. WBC 18.4 (83%N), Hct 39.5. Na 150, K 5.6, Cl 117,
HCO3 14, BUN 76, Cr 3.1, anion gap 27. AST 101, ALT 38, AP 112,
TB 1.8. CK 2431, CK-MB 9.5, Trop 1.98 (nl <0.3). U/A with
[**10-27**] WBC and RBC, 3+ bact, + epis, ketones, [**1-12**] hyaline casts.
Tox screen was neg. EKG without peaked T waves, ST dep in
lateral leads, old q waves in inferior leads. CT head neg but
could not exclude mild cerebral edema due to motion artifact.
CXR with question of RML infiltrate, and as there was concern
for meningitis given his AMS, he was given vancomycin 1gm,
ceftriaxone 2gm. He received a total of 4L NS IVF.
In our ED, initial VS were: T 101, P 131, BP 119/65, R 48, O2
sat 100% on AC 760/?/5/100%. ABG 7.25/33/81/15. FSG 128. Pt
was not sedated but was minimally responsive to painful stimuli.
Pupils reactive. BS rhonchorous b/l. No e/o trauma. Noted to
have melena; OG tube here without any hematemesis. Lactate 4.6.
WBC 22.6. Bcx drawn. CXR without obvious infiltrate but
question of R paratracheal stripe. An LP was not done because
of INR 3. Patient was given tylenol 650mg pr and abx coverage
broadened to metronidazole 500mg IV and cefepime for pseudomonal
coverage. He received 1 L NS. On transfer to MICU, VS: T 101
(rectal), P 134, BP 112/70, RR 47, O2sat 100% on vent, CPAP
15/5, FiO2 100%.
Review of OSH records shows that pt was admitted from [**Date range (1) 85837**]
for LLE cellulitis and hematoma d/t trauma from fall; no acute
fractures. During that hospital course, he did have a work-up
for abdominal pain. CT abd ruled out pancreatitis with an
abnormal duodenal finding; EGD showed severe duodenitis and
small esophageal varices. He was started on pantoprazole 40mg
[**Hospital1 **]. There were concerns about drug-seeking behavior although
pt was discharged with 30 tabs of oxycodone due to recent
trauma.
Review of systems: Unable to elicit
Past Medical History:
(Per OSH records; daughter confirms diabetes and "liver disease"
as well as addictions to alcohol, heroin and possible meth)
DM
GERD
Left leg cellulitits
Left leg ecchymosis/hematoma
Thrombocytopenia
Hepatitis C
Hepatic cirrhosis c/b encephalopathy, small gastric varices
Polysubstance abuse
H/o anasarca
Stasis dermatitis
Gastric ulcer (biopsy from EGD on [**2198-3-23**] negative for stain for
H. pylori)
Social History:
Unable to elicit from patient. Has two adult daughters who live
in [**Name (NI) 74122**], PA as well as a son in [**Name2 (NI) **] who is in jail. Daughter
[**Name (NI) 50269**] can be contact[**Name (NI) **] at [**Telephone/Fax (1) 85838**] (home), [**Telephone/Fax (1) 85839**]
(cell), or [**Telephone/Fax (1) 85840**] (cell) Lives with a roommate (contact
info unknown). Not currently employed. Polysubstance abuse
history including alcohol and heroin, possibly other drugs as
well per daughter.
Family History:
Unknown
Physical Exam:
Vitals: T 99.7, P 133, BP 124/71, RR 48, O2sat 99 on PS 10/5
General: Obtunded, tachypneic, using accessory muscles of
respiration
HEENT: Sclera anicteric, intubated, +OG tube
Neck: Supple, JVP not elevated, no LAD
Lungs: Coarse rhonchi b/l
CV: Tachycardic, regular rhythm, normal S1 + S2, unable to
appreciate m/r/g
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: Warm, well perfused, 2+ pulses, venous
Neuro: Pupils reactive b/l, unable to elicit corneal/gag
reflexes or cough w/ suctioning, nl tone, no asterixis, small
withdrawal to pain in all extremities except LUE, pronating
response to DTR, toes equivocal (?upgoing on left) to Babinski.
Pertinent Results:
LABS ON ADMISSION:
[**2198-3-29**] 01:25AM URINE EOS-NEGATIVE
[**2198-3-29**] 01:25AM URINE RBC-[**2-9**]* WBC-[**5-17**]* BACTERIA-FEW
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2198-3-29**] 01:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-100 KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2198-3-29**] 01:25AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2198-3-29**] 01:25AM FIBRINOGE-215
[**2198-3-29**] 01:25AM PT-30.3* PTT-50.1* INR(PT)-3.0*
[**2198-3-29**] 01:25AM PLT COUNT-69*
[**2198-3-29**] 01:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL BURR-1+ TEARDROP-OCCASIONAL BITE-OCCASIONAL
[**2198-3-29**] 01:25AM NEUTS-92* BANDS-1 LYMPHS-3* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2198-3-29**] 01:25AM WBC-22.6* RBC-3.53* HGB-10.7* HCT-32.8*
MCV-93 MCH-30.5 MCHC-32.8 RDW-17.8*
[**2198-3-29**] 01:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2198-3-29**] 01:25AM URINE GR HOLD-HOLD
[**2198-3-29**] 01:25AM URINE OSMOLAL-460
[**2198-3-29**] 01:25AM URINE HOURS-RANDOM
[**2198-3-29**] 01:25AM URINE HOURS-RANDOM UREA N-471 CREAT-108
SODIUM-19 PROT/CREA-2.0*
[**2198-3-29**] 01:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2198-3-29**] 01:25AM PEP-AWAITING F IgG-1430 IgA-728* IgM-151
[**2198-3-29**] 01:25AM TSH-0.57
[**2198-3-29**] 01:25AM OSMOLAL-346*
[**2198-3-29**] 01:25AM calTIBC-224* VIT B12-GREATER TH
FOLATE-GREATER TH HAPTOGLOB-<5* FERRITIN-585* TRF-172*
[**2198-3-29**] 01:25AM TOT PROT-5.6* ALBUMIN-2.4* GLOBULIN-3.2
CALCIUM-7.5* PHOSPHATE-5.3* MAGNESIUM-1.8 IRON-53
[**2198-3-29**] 01:25AM CK-MB-17* MB INDX-0.6 cTropnT-0.26
[**2198-3-29**] 01:25AM LIPASE-47
[**2198-3-29**] 01:25AM ALT(SGPT)-55* AST(SGOT)-231* LD(LDH)-684*
CK(CPK)-2749* ALK PHOS-95 TOT BILI-1.3
[**2198-3-29**] 01:25AM estGFR-Using this
[**2198-3-29**] 01:25AM GLUCOSE-109* UREA N-77* CREAT-3.1*
SODIUM-154* POTASSIUM-3.9 CHLORIDE-126* TOTAL CO2-11* ANION
GAP-21*
[**2198-3-29**] 01:34AM LACTATE-4.6*
[**2198-3-29**] 01:34AM TYPE-ART TEMP-40.0 RATES-/50 TIDAL VOL-760
PEEP-5 O2-100 PO2-81* PCO2-33* PH-7.25* TOTAL CO2-15* BASE
XS--11 AADO2-613 REQ O2-98 INTUBATED-INTUBATED VENT-SPONTANEOU
[**2198-3-29**] 02:55AM RET MAN-4.2*
[**2198-3-29**] 02:55AM FDP-40-80*
[**2198-3-29**] 02:55AM HCT-32.0*
[**2198-3-29**] 02:55AM AMMONIA-20
[**2198-3-29**] 03:47AM TYPE-ART TEMP-37.3 RATES-/47 TIDAL VOL-640
PEEP-5 O2-90 PO2-497* PCO2-22* PH-7.34* TOTAL CO2-12* BASE
XS--11 AADO2-135 REQ O2-32 INTUBATED-INTUBATED VENT-SPONTANEOU
[**2198-3-29**] 07:44AM PT-31.7* PTT-45.7* INR(PT)-3.2*
[**2198-3-29**] 07:44AM PLT COUNT-45*
[**2198-3-29**] 07:44AM WBC-15.7* RBC-3.16* HGB-9.9* HCT-29.7* MCV-94
MCH-31.2 MCHC-33.2 RDW-18.0*
[**2198-3-29**] 07:44AM CALCIUM-7.8* PHOSPHATE-6.8* MAGNESIUM-1.7
[**2198-3-29**] 07:44AM CK-MB-26* MB INDX-1.0 cTropnT-0.20*
[**2198-3-29**] 07:44AM CK(CPK)-2698*
[**2198-3-29**] 07:44AM GLUCOSE-201* UREA N-85* CREAT-3.9*
SODIUM-150* POTASSIUM-4.4 CHLORIDE-122* TOTAL CO2-9* ANION
GAP-23*
[**2198-3-29**] 08:00AM LACTATE-6.2*
[**2198-3-29**] 08:00AM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2198-3-29**] 11:45AM PLT COUNT-50*
[**2198-3-29**] 12:05PM LACTATE-6.0*
[**2198-3-29**] 12:05PM TYPE-[**Last Name (un) **] TEMP-38.1 PO2-263* PCO2-20* PH-7.34*
TOTAL CO2-11* BASE XS--12 INTUBATED-INTUBATED VENT-CONTROLLED
[**2198-3-29**] 02:34PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-476*
POLYS-18 LYMPHS-35 MONOS-47
[**2198-3-29**] 04:41PM FIBRINOGE-184
[**2198-3-29**] 04:41PM PT-24.6* PTT-42.0* INR(PT)-2.4*
[**2198-3-29**] 04:42PM PLT COUNT-42*
[**2198-3-29**] 04:42PM HCT-24.4*
[**2198-3-29**] 04:42PM CALCIUM-7.5* PHOSPHATE-4.8*# MAGNESIUM-1.8
[**2198-3-29**] 04:42PM CK(CPK)-1838*
[**2198-3-29**] 04:42PM GLUCOSE-368* UREA N-89* CREAT-4.1* SODIUM-144
POTASSIUM-3.1* CHLORIDE-116* TOTAL CO2-14* ANION GAP-17
[**2198-3-29**] 04:54PM O2 SAT-99
[**2198-3-29**] 04:54PM LACTATE-4.7*
[**2198-3-29**] 04:54PM TYPE-ART PO2-141* PCO2-22* PH-7.51* TOTAL
CO2-18* BASE XS--2
[**2198-3-29**] 08:15PM PT-26.2* PTT-40.8* INR(PT)-2.5*
[**2198-3-29**] 08:15PM PLT COUNT-36*
[**2198-3-29**] 08:15PM HCT-24.3*
[**2198-3-29**] 08:15PM CALCIUM-7.4* PHOSPHATE-4.4 MAGNESIUM-1.8
[**2198-3-29**] 08:15PM CK(CPK)-1608*
[**2198-3-29**] 08:15PM GLUCOSE-264* UREA N-89* CREAT-4.2* SODIUM-144
POTASSIUM-3.2* CHLORIDE-116* TOTAL CO2-17* ANION GAP-14
========
MICROBIOLOGY:
- [**2198-3-29**] Blood culture - PENDING **
- [**2198-3-29**] Blood culture - PENDING **
- [**2198-3-29**] Blood culture - PENDING **
- [**2198-3-29**] MRSA screen - no MRSA isolates
- [**2198-3-29**] Urine culture - no growth
- [**2198-3-29**] Urine legionella antigen - negative
- [**2198-3-29**] RPR - non-reactive
- [**2198-3-29**] CSF: gram stain - negative; culture - no growth; viral
culture - PENDING **
- [**2198-3-30**] Sputum: > 25 PMNs, < 10 epithelial cells, 1+ GPC in
pairs/chains; culture: ESCHERICHIA COLI - sensitivities:
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
- [**2198-3-30**] Bacterial stool studies (incl. Yersinia, E. coli) -
negative
- [**2198-3-30**] C. difficile toxin - negative
- [**2198-3-31**] Urine culture - negative, final
- [**2198-3-31**] Sputum: > 25 PMNs, < 10 epithelial cells, no
microorganisms; culture - Gram negative rods, sparse
- [**2198-3-31**] Blood culture - PENDING, no growth to date
- [**2198-3-31**] Blood culture - PENDING, no growth to date
========
IMAGES/STUDIES:
- [**2198-3-29**] ECG: Sinus tachycardia and respiratory variation in
QRS complex suggesting dyspnea. No previous tracing available
for comparison.
- [**2198-3-29**] ECG: Sinus tachycardia. Compared to the previous
tracing of [**2198-3-29**] no diagnostic interim change.
- [**2198-3-29**] CXR portable: SINGLE FRONTAL PORTABLE CHEST
RADIOGRAPH: The endotracheal tube terminates approximately 5.8
cm above the carina. The NG tube terminates in the first portion
of the duodenum. There is appearance of widening of upper
mediastinum, likely secondary to mediastinal lipomatosis. The
lungs are clear. There is no pneumothorax or pleural effusions.
The cardiac silhouette is normal. The hilar contour and
pulmonary vasculature are within normal limits. The underlying
osseous structures are normal. A rounded lucency in the right
lateral lung is likely atelectasis. There is no radiographic
evidence of acute displaced rib fracture. IMPRESSION: No
pneumothorax or pleural effusion. No acute displaced rib
fracture. Recommend follow-up with upright view to better assess
the mediastinum when the patient can tolerate it.
- [**2198-3-29**] Liver/GB ultrasound: FINDINGS: The liver is coarsened
and echogenic, consistent with cirrhosis. There are no focal
lesions and there is no biliary dilatation. The common duct
measures 5.5 mm at the porta hepatis. The gallbladder is
unremarkable, without shadowing stones or sludge. The main
portal vein is patent, with normal direction of flow. The
pancreas is not visualized due to overlying bowel gas. The
spleen is enlarged, measuring 17.1 cm. The right kidney measures
12.0 cm, and the left kidney measures 13.1 cm. The kidneys are
unremarkable bilaterally, without focal lesion or
hydronephrosis. There is no ascites. The visualized abdominal
aorta and IVC are unremarkable. There is loculated fluid in the
anterior right pleural space. IMPRESSION: 1. Cirrhosis, without
focal lesion. 2. Splenomegaly. 3. Loculated fluid in the
anterior right pleural cavity.
- [**2198-3-30**] TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). There is a
trivial/physiologic pericardial effusion. No vegetation seen
(cannot definitively exclude).
- [**2198-3-30**] ECG: Normal sinus rhythm. Diffuse T wave flattening
throughout the tracing. Compared to the previous tracing of
[**2198-3-29**] patient's rhythm has changed from sinus tachycardia at a
rate of 132 to normal sinus rhythm at a rate of 72. Diffuse T
wave flattening is more prominent on this tracing. Consider
electrolyte abnormality.
- [**2198-3-30**] CXR portable: SINGLE PORTABLE CHEST RADIOGRAPH:
Retrocardiac opacity, new since one day prior, most likely
represents atelectasis and less likely pneumonia. Also new is a
small left pleural effusion. The right lung is clear. Mild
cardiomegaly is unchanged. Fullness of central vascular markings
is suggestive of mild volume overload or cardiac decompensation.
There is no pneumothorax. Tubes and lines are in stable
positions since one day prior. IMPRESSION: 1. New left lower
lobe atelectasis, less likely pneumonia. 2. New small left
pleural effusion. 3. Mild volume overload versus cardiac
decompensation.
- [**2198-3-31**] EEG: Report PENDING **
- [**2198-3-31**] CXR portable:FINDINGS: As compared to the previous
radiograph, there is minimal improvement with partial resolution
of the pre-existing left retrocardiac atelectasis. Overall, the
ventilation of the lung parenchyma has slightly improved.
Unchanged size of the cardiac silhouette. No focal parenchymal
opacity suggesting pneumonia. No larger pleural effusions. No
pneumothorax. The size of the cardiac silhouette is at the upper
range of normal.
- [**2198-4-1**] EEG: Report PENDING **
- [**2198-4-1**] CXR portable: FINDINGS: As compared to the previous
radiograph, the three monitoring and support devices are in
unchanged position. Unchanged borderline size of the cardiac
silhouette without evidence of pulmonary edema. The pre-existing
retrocardiac atelectasis has mostly resolved. No evidence of
newly appeared focal parenchymal opacities suggesting pneumonia.
No pleural effusions.
- [**2198-4-2**] EEG: Report PENDING **
- [**2198-4-2**] CXR portable: As compared to the previous radiograph,
there is no relevant change. The monitoring and support devices
are in unchanged position. Unchanged size of the cardiac
silhouette, unchanged absence of focal parenchymal opacities
suggesting pneumonia. No visualization of pleural effusions.
- [**2198-4-3**]: FINDINGS: In comparison with the study of [**4-2**], the
monitoring and support devices remain in place. Some
indistinctness of pulmonary vessels raises the possibility of
elevated pulmonary venous pressure. No evidence of acute focal
pneumonia or pleural effusion.
-MRI ([**4-2**]): IMPRESSION:
1. Diffuse bilateral subacute ischemic changes consistent with a
global
anoxic brain injury.
2. Sinus and mastoid disease as described above, the activity of
which is to be determined clinically.
3. Old left frontal lobe infarction.
------
Brief Hospital Course:
51 yo man with a h/o diabetes mellitus II, polysubstance abuse
(alcohol and heroin), HCV, cirrhosis, small esophageal varices,
duodenitis/gastritis presenting with unresponsiveness.
# Unresponsiveness, most likely from anoxic brain injury: The
patient was found unresponsive, intubated at OSH ED for airway
protection. There was concern for intoxication given finding of
needles but tox screens negative. Pt also recently discharged
with short course oxycodone despite concerns of drug seeking
behavior; pupils noted to be pinpoint by EMS but minimal
response to Narcan. Given IV drug use, concern that pt may have
endocarditis with embolic showering, though TTE negative and no
acute intracranial event seen on OSH CT head. The patient was
started on Vancomycin and cefepime for treatment of possible
meningitis, though lumbar puncture was not indicative of a CNS
infection. Metabolic reasons for unresponsiveness included
hepatic encephalopathy, hypernatremia, hyperglycemia, and
low-grade uremia which were all treated. B12, TSH and RPR were
normal. Neurology consulted on the patient and diagnosed him
with anoxic brain injury likely due to hypotension and later
confirmed through a MRI. Prior to extubation, the patient seemed
more responsive. He was extubated and able to understand
commands with limited verbalization. His speech sounded
dysarthric.
# Respiratory failure: The patient required intubation and
mechanical ventilation for inability to protect his airway
secondary to his unresponsiveness. He was continued on pressure
support ventilation and was extubated without difficulty.
# Seizure disorder: The patient was found to have a subclinical
seizure disorder on EEG, most likely secondary to his anoxic
brain injury. The patient was started on Keppra and uptitrated
to 1000 mg [**Hospital1 **]. He was also loaded with fosphenytoin per
neurology recommendations. He will continue on Keppra and has
neurology followup. Final EEG [**Location (un) 1131**] was pending on discharge.
# E. coli pneumonia: The patient presented with fever and was
initially broadly covered with vancomycin, cefepime, acyclovir
and flagyl. Sputum culture revealed E.coli and antibiotics were
narrowed with a course of 7 days for IV cefepime.
# E. coli urinary tract infection: The patient was found to have
a E. coli UTI which was treated with 7 days of IV cefepime.
# Acute renal failure: The patient presented with a Cr to 4.9
(baseline unknown). Nephrology felt that it was most likely due
to acute tubular necrosis (secondary to pre-renal from
hypoperfusion). Rhado (CKs elevated on admission) might have
also played a role. With time, the patient's creatinine contined
to improve and he continued to produce adequate urine output.
# Upper GI bleed: The patient was noted to have black tarry,
guaiac positive stools. His EGD report from OSH was obtained
which showed small esophageal varices and gastritis/duodenitis.
Per his OG tube, he did not have active hematemesis. He was
initially started on PPI and octreotide drips. He required 4
units of pRBCs. Since he did not have any evidence of blood per
OG tube, it was concluded that he did not have a brisk bleed and
his initial bleed was likely due to his gastritis/duodenitis.
His hematocrit remained stable over the last couple days of his
hospitalization and did not need any transfusions. He will
continue on PPI. Baseline Hct unknown.
# Hypernatremia: The patient presented with hypernatremia,
likely due to decreased PO intake. The patient was started on
free water to treat his deficit. He was continued on
maintainence fluids of D5 [**12-9**] normal saline for poor PO intake.
# Type II Diabetes mellitus: The patient has a history of
diabetes mellitus. His home glipizide was held and he was
started on an insulin drip with tubefeeds due to hyperglycemia.
His insulin regimen was later switched to 18 units of humalog
[**Hospital1 **] with a sliding scale. He will likely need further titration
based on nutritional requirements.
# Anion gap metabolic acidosis: The patient presented with an
anion gap metabolic acidosis with elevated lactate. Toxic
ingestion on differential but serum tox negative and renal
consult felt that the AG metabolic acidosis was unlikely. With
IV hydration, improved renal function and treatment of
underlying issues, his anion gap metabolic acidosis improved.
# Polysubstance abuse: The patient has a history of narcotics
and alcohol abuse. It remains unclear on how his addictions
played into his clinical presentation and course. He did not
receive any benzodiazepine doses for alcohol withdrawal and he
is out of the window for any withdrawal symptoms.
# Coronary artery disease with demand ischemia: At OSH, CK,
CK-MB, and trop all elevated; EKG with ST depressions. Here, CK
remains elevated but trop improving with resolution of ST
depressions. [**Month (only) 116**] represent demand in setting of tachycardia,
exacerbated by renal failure. Possible that CK elevation may
also reflect muscle breakdown as may have been nonresponsive for
up to 2 days before being found. Echo without any wall motion
abnormalities and normal left ventricular EF>55%.
# Cirrhosis: The patient has hepatic cirrhosis complicated by
encephalopathy and small gastric varices. The etiology of his
cirrhosis is presumably hepatitis C and alcohol. Initially his
transaminases were elevated, likely due to liver hypoperfusion,
but continued to trend downward. His total bilirubin was 2.7 on
discharge. He has evidence of synthetic dynsfunction, though not
compensated. Further details pertaining to his liver disease
were not available during this hospitalization.
# Coagulopathy: The patient was noted to have an INR elevated to
3.0. He received Vitamin K with improvement. His continued
elevated INR is likely due to his underlying cirrhosis.
# Thrombocytopenia: Pt w/ history thrombocytopenia per OSH
records. Pt also with anemia but DIC unlikely with nl
fibrinogen. Probably splenic sequestration in setting of
cirrhosis.
# Hepatitis C: No current issues.
# Nutrition/fluids: Pureed diet. Fluids of D51/2 normal saline
at 75 cc/hr for maintainence while low PO intake
# Prophylaxis: DVT: pneumoboots, GI: PPI
.
# Access: Right internal jugular. Will need a PICC line for
access since IV nurse unable to find peripheral IV.
Medications on Admission:
Doxazosin 2mg qhs
Tiotropium 1 cap daily
Omeprazole 20mg daily
Lasix 40mg [**Hospital1 **]
Ipratropium/albuterol 1 puff qid
Glipizide ER 10mg [**Hospital1 **]
MVI daily
Oxycodone 15mg q6h
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-9**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
2. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. Levetiracetam 500 mg/5 mL Solution Sig: 1000 (1000) mg
Intravenous [**Hospital1 **] (2 times a day).
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for goal 3 BM daily.
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
9. Humalog 100 unit/mL Cartridge Sig: Eighteen (18) units
Subcutaneous twice a day: Hold dose when NPO.
10. Humalog 100 unit/mL Cartridge Sig: see comment Subcutaneous
at meals and bedtime: per attached sliding scale.
11. D5 %-0.45 % Sodium Chloride Parenteral Solution Sig:
Seventy Five (75) cc/hr Intravenous continuous.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
-respiratory failure
-anoxic brain injury
-acute renal failure
.
Secondary:
-upper gastrointestinal bleed
-seizure disorder not otherwise specified
-liver cirrhosis
-hepatic encephalopathy
-esophageal varices
-gastritis, duodenitis
-diabetes mellitus
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted because you were found unresponsive. You
required mechanical ventilation to help you breath. You were
found to have injuries to your brain from low oxygen and
subsequent sub-clinical seizures. You also had a problem with
your kidneys called renal failure, which started to recover at
the end of your hospitalization. You also had a pneumonia and
urinary tract infection which were treated with antibiotics.
.
Your medications have changed:
-start pantoprazole
-stop omeprazole
-stop oxycodone
-stop lasix
-stop doxazosin
-stop glipizide
-start humalog insulin
Followup Instructions:
You have the following appointments scheduled:
.
Physician: [**Name10 (NameIs) **],[**Name11 (NameIs) 4739**] MD, neurology
Date/Time: [**2198-5-9**] at 1:30 pm
Location: [**Hospital Ward Name 23**] Building, [**Location (un) **] neurology, [**Hospital1 771**], [**Location (un) 830**], [**Location (un) 86**], [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 2528**]
|
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81,245
| 124,037
|
45608
|
Discharge summary
|
report
|
Admission Date: [**2200-3-27**] Discharge Date: [**2200-4-11**]
Date of Birth: [**2132-7-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Demerol
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Femur Fracture
Major Surgical or Invasive Procedure:
Joint aspiration ([**2200-3-28**])
Right femoral head resection, irrigation, debridement,
arthrotomy ([**2200-3-31**])
Placement of Tobramycin/Vancomycin cement spacer ([**2200-3-31**])
History of Present Illness:
History of Present Illness: The patient is a 67 y/o woman with a
PMH of MRSA BSI [**6-4**] with L2-L3 discitis/osteomyelitis and
pelvic abscess, treated with 4 months of IV vancomycin, with
recurrence of BSI and osteomyelitis after discontinuation of
therapy, requiring L2/L3 debridment and allograft presenting
with non-traumatic femur fracture. The patient was treated with
vancomycin [**11-7**]- [**1-29**] after
improvement in her inflammatory markers. The patient reported
onset of R hip pain starting [**3-3**]. R hip and L-spine x-rays were
obtained on [**3-7**] which did not show evidence of a new fracture
or hardware loosening. She was started on 300 mg t.i.d.
gabapentin by her PCP without improvement. She reports receiving
an epidural injection on Monday without relief of symptoms. AP
Pelvis/Right Hip was done which demonstrated a displaced femoral
neck fracture and she was referred to the ED.
.
On arrival to the ED, initial vitals: T 98.8 HR 51 BP 174/80 RR
16 O2 100% on RA. She was evaluated by [**Last Name (un) **] and CT pelvis
performed demonstrating a acute mildly-comminuted R femoral
subcapital fracture. No lesion to suggest underlying pathologic
fracture. She was given a total of 12mg IV morphine for pain
control. She is being admitted to the medical service for
evaluation prior to surgical intervention of fracture.
.
On arrival to the medical floor, the patient complains of R hip
pain. States she is otherwise feeling well overall.
Past Medical History:
- Multiple admissions for partial SBO
- MRSA bloodstream infection ([**5-/2199**])
--- BCx + [**Date range (1) 97263**]
--- TTE [**2199-5-27**] neg (no TEE)
- L2-L3 discitis/osteomyelitis, suspected MRSA
--- MRI = L2-L3 discitis/osteomyelitis, w/ psoas abscess
--- Intra-pelvic abscesses, suspected MRSA
--- Vancomycin [**Date range (1) 97264**]
--- TMP/SMX [**9-23**] - ?
- MRSA bloodstream infection, infected RUE DVT ([**2199-4-10**])
- L5-S1 lumbar spine fusion with hardware ([**2192**])
- Thrush
- LUE DVT
- Ovarian cancer
--- dx [**2175**]; stage IV, metastatic to liver only
--- TAH-BSO, [**2175**]
--- tx chemo (adriamycin) and XRT
- Chemotherapy-associated dilated cardiomyopathy
- Small bowel obstruction; radiation enteritis; chronic abd pain
multiple admissions, with surgical mgmt
- iron deficiency anemia
- Hyperlipidemia
- Chronic kidney disease
- hyperthyroidism
ablation
- tonsillectomy, adenoidectomy
- appendectomy
- xerophthalmia, lagophthalmos, thyroid orbitopathy
- depression, fibromyalgia
Social History:
Used to work as outpatient RN 3 days/week
No significant tobacco, EtOH, illicit drug use
Family History:
Cancer, heart disease in several family members
Physical Exam:
Admission Exam:
Vitals: T 97.3, HR 50, BP 179/84, RR 18, O2 92% on RA.
Gen: pleasant elderly female in NAD
HEENT: MMM, OP clear
CV: RRR, nl S1/S2, no MRG
PULM: CTAB, no WRR
ABD: soft, NT/ND, NABS
BACK: well-healed lumbar surgical scar, no TTP
MSK: R hip no discoloration, no warmth, unable to test strength
and ROM secondary to pain
Neuro: no gross motor or sensory deficits
Discharge Exam:
GEN: Caucasian Female laying down in bed in NARD.
CV: S1, S2, no murmurs, gallops or rubs, RRR
PUL: CTA bilaterally
ABD: Mildly tenderness to palpation in lower quadrants, soft,
normoactive BS x 4.
EXT: Rt hip wound shows staples with good approximation and no
purulent drainage. No edema noted.
Pertinent Results:
[**2200-4-10**] 09:58AM BLOOD WBC-10.0 RBC-2.99* Hgb-8.7* Hct-26.7*
MCV-89 MCH-29.1 MCHC-32.6 RDW-15.8* Plt Ct-391
[**2200-4-8**] 06:00AM BLOOD WBC-15.1* RBC-3.28* Hgb-9.4* Hct-27.6*
MCV-84 MCH-28.6 MCHC-34.0 RDW-16.4* Plt Ct-347
[**2200-4-7**] 10:45AM BLOOD WBC-15.8* RBC-3.27* Hgb-9.3* Hct-27.9*
MCV-85 MCH-28.3 MCHC-33.2 RDW-16.4* Plt Ct-320
[**2200-4-6**] 09:06AM BLOOD WBC-19.7* RBC-3.47* Hgb-9.9* Hct-29.8*
MCV-86 MCH-28.7 MCHC-33.4 RDW-16.0* Plt Ct-360
[**2200-4-5**] 06:13AM BLOOD WBC-26.9* RBC-3.27* Hgb-9.3* Hct-28.1*
MCV-86 MCH-28.6 MCHC-33.2 RDW-16.0* Plt Ct-367
[**2200-4-4**] 07:35AM BLOOD WBC-20.6* RBC-2.68* Hgb-7.7* Hct-23.1*
MCV-86 MCH-28.8 MCHC-33.4 RDW-16.3* Plt Ct-450*
[**2200-4-2**] 11:30PM BLOOD WBC-25.5* RBC-3.05* Hgb-8.9* Hct-25.8*
MCV-85 MCH-29.1 MCHC-34.4 RDW-16.3* Plt Ct-434
[**2200-4-1**] 10:50AM BLOOD WBC-31.2*# RBC-3.35* Hgb-9.3* Hct-28.9*
MCV-86 MCH-27.7 MCHC-32.1 RDW-16.1* Plt Ct-450*
[**2200-3-31**] 09:29PM BLOOD WBC-16.4* RBC-3.33* Hgb-9.2* Hct-28.7*
MCV-86 MCH-27.6 MCHC-32.0 RDW-16.3* Plt Ct-434
[**2200-4-1**] 10:50AM BLOOD WBC-31.2*# RBC-3.35* Hgb-9.3* Hct-28.9*
MCV-86 MCH-27.7 MCHC-32.1 RDW-16.1* Plt Ct-450*
[**2200-3-31**] 09:29PM BLOOD WBC-16.4* RBC-3.33* Hgb-9.2* Hct-28.7*
MCV-86 MCH-27.6 MCHC-32.0 RDW-16.3* Plt Ct-434
[**2200-3-31**] 05:40AM BLOOD WBC-21.4* RBC-4.24 Hgb-12.2 Hct-36.2
MCV-85 MCH-28.8 MCHC-33.8 RDW-16.3* Plt Ct-503*
[**2200-3-30**] 06:50AM BLOOD WBC-16.5* RBC-3.55* Hgb-10.3* Hct-30.4*
MCV-86 MCH-28.9 MCHC-33.8 RDW-16.0* Plt Ct-443*
[**2200-3-29**] 06:15AM BLOOD WBC-18.5* RBC-3.54* Hgb-10.2* Hct-29.7*
MCV-84 MCH-28.8 MCHC-34.3 RDW-16.3* Plt Ct-531*
[**2200-3-28**] 05:35AM BLOOD WBC-16.9* RBC-3.58* Hgb-10.4* Hct-30.8*
MCV-86 MCH-29.2 MCHC-34.0 RDW-16.2* Plt Ct-493*
[**2200-3-27**] 06:54PM BLOOD WBC-18.4*# RBC-4.09* Hgb-11.2* Hct-34.8*
MCV-85 MCH-27.3 MCHC-32.1 RDW-16.2* Plt Ct-529*
[**2200-4-7**] 10:45AM BLOOD Neuts-89.5* Lymphs-7.2* Monos-2.6 Eos-0.5
Baso-0.2
[**2200-4-5**] 06:13AM BLOOD Neuts-90.9* Lymphs-4.0* Monos-4.9 Eos-0.2
Baso-0
[**2200-4-11**] 09:00AM BLOOD Glucose-91 UreaN-23* Creat-1.3* Na-136
K-4.0 Cl-108 HCO3-20* AnGap-12
[**2200-4-10**] 09:58AM BLOOD Glucose-93 UreaN-22* Creat-1.2* Na-137
K-3.6 Cl-110* HCO3-18* AnGap-13
[**2200-4-8**] 06:00AM BLOOD Glucose-87 UreaN-29* Creat-1.3* Na-136
K-3.9 Cl-106 HCO3-18* AnGap-16
[**2200-4-7**] 10:45AM BLOOD Glucose-104* UreaN-30* Creat-1.4* Na-134
K-3.6 Cl-106 HCO3-17* AnGap-15
[**2200-4-6**] 09:06AM BLOOD Glucose-86 UreaN-27* Creat-1.4* Na-130*
K-3.7 Cl-101 HCO3-17* AnGap-16
[**2200-4-5**] 06:13AM BLOOD Glucose-92 UreaN-38* Creat-1.6* Na-133
K-3.8 Cl-105 HCO3-18* AnGap-14
[**2200-4-4**] 07:35AM BLOOD Glucose-86 UreaN-39* Creat-1.9* Na-132*
K-4.3 Cl-100 HCO3-18* AnGap-18
[**2200-4-2**] 11:30PM BLOOD Glucose-101* UreaN-32* Creat-1.6* Na-131*
K-3.9 Cl-100 HCO3-18* AnGap-17
[**2200-4-1**] 10:50AM BLOOD Glucose-104* UreaN-36* Creat-1.8* Na-132*
K-5.0 Cl-102 HCO3-19* AnGap-16
[**2200-3-31**] 05:40AM BLOOD Glucose-94 UreaN-28* Creat-1.5* Na-131*
K-4.7 Cl-96 HCO3-21* AnGap-19
[**2200-3-30**] 06:50AM BLOOD Glucose-79 UreaN-31* Creat-1.3* Na-133
K-4.8 Cl-104 HCO3-19* AnGap-15
[**2200-3-29**] 06:15AM BLOOD Glucose-98 UreaN-33* Creat-1.6* Na-129*
K-4.1 Cl-101 HCO3-21* AnGap-11
[**2200-3-28**] 05:35AM BLOOD Glucose-101* UreaN-36* Creat-1.6* Na-133
K-4.6 Cl-103 HCO3-17* AnGap-18
[**2200-3-27**] 06:54PM BLOOD Glucose-80 UreaN-36* Creat-1.7* Na-134
K-4.8 Cl-103 HCO3-19* AnGap-17
[**2200-4-11**] 09:00AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.5*
[**2200-4-10**] 09:58AM BLOOD Calcium-7.5* Phos-2.4* Mg-1.4*
[**2200-4-8**] 06:00AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.6
[**2200-4-4**] 12:42PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2200-4-4**] 12:42PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2200-4-4**] 12:42PM URINE RBC-5* WBC-3 Bacteri-MOD Yeast-MANY
Epi-<1 TransE-<1
Brief Hospital Course:
67 y/o woman w10ith a PMH of MRSA BSI [**6-4**] with L2-L3
discitis/osteomyelitis and pelvic abscess, treated with 4 months
of IV vancomycin, with recurrence of BSI and osteomyelitis after
discontinuation of therapy, requiring L2/L3 debridement and
allograft presenting with non-traumatic femur fracture.
##. Right femoral subcapital frature: Ms. [**Known lastname 97260**] was referred
on [**3-27**] from her PCP's office after a complaint of right hip
pain and and x-ray showing a displaced femoral neck fracture. In
the ED she underwent a CT scan of her pelvis which showed
mildly-comminuted R femoral subcapital fracture. She was
evaluated by the Orthopaedic service and admitted to the
medicine service with Infectious disease and Orthopaedic
consulting. She was initially started on Vancomycin given her
MRSA history and her joint was aspirated and notable for 36K WBC
and 96% polys with rare growth of MSSA. On [**3-31**] she had a
cement Vancomycin/Tobramycin spacer placed in her right hip and
femoral head resection. She developed diarrhea and was found to
have +C. Diff on [**4-5**]. Per ID recommendations her antibiotics
were changed from Vancomycin IV to Daptomycin IV. She will need
to continue this antibiotic 330mg intravenous every 48 hours for
6 weeks (her last dose will be [**2200-5-19**]). She has an appointment
to see her Infectious Specialist Dr. [**Last Name (STitle) 111**] on [**2200-4-18**], during
this appointment he will determine whether she will need a
longer course of Daptomycin.
- recommend continuing Daptomycin IV 330mg every 48hours for at
least 6 weeks, last dose of the antibiotic will be [**2200-5-19**]
- recommend following up with Dr.[**Name (NI) 97268**] appointment on
[**2200-4-18**] at 1100
- recommend continuing Methadone 2.5mg twice a day with Dilaudid
2-4mg every 3 hours PRN for breakthrough pain
- recommend following up with Orthopaedic appointment, physical
therapy
##. C. Diff Associated Diarrhea: Pt during hospitalization ntoed
to have numerous bowel movements and tested positive on C. Diff
toxin assay for C. Diff,
gastroenterology were consulted for regimen length. Per
Gastroenterology recommendations Ms. [**Known lastname 97260**] will need to be on
Vancomycin PO every 6 hours, this will need to continued for 2
weeks after the Daptomycin is stopped with no taper. If her last
course of Daptomycin remains scheduled on [**2200-5-19**] her
Vancoymcin PO course will end [**2200-6-2**].
- recommend continuing PO Vancomycin 250mg every 6 hours until 2
weeks after her last Daptomycin
##. Urinary Tract Infection: During hospitalization pt was noted
to have a urinary tract infection on [**2200-3-29**] and completed a
course of Ciprofloxacin. Subsequent urine culture showed no
bacterial growth.
##. Renal Insufficiency: Pt has a history of renal insufficiency
with a baseline Creatine ranging from 1.3-1.5 since [**Month (only) 1096**]
[**2198**]. During hospitalization pt did develop acute on chronic
insufficiency from a combination of pre-renal and allergic
interstitial nephritis (urine was positive for urine
Eosinophils). Cause of AIN not entirely clear though
Ciprofloxacin was suspected, however Creatinine improved with
intravenous fluid.
##. Hypothyroidism: Patient was continued on her home regimen of
synthroid 150mcg daily
##. Hyperlipidemia: Pt was continued on home regimen of
Simvastatin 40mg at bedtime.
##. Depression: Pt was continued on her home regimen of
Sertraline.
##. Nutrition: Pt was continued on a Regular diet with Resource
Breeze supplementation every breakfast, lunch and dinner.
Anticipated length of stay less than 30 days
Medications on Admission:
Amlodipine 2.5 mg Tablet 1 Tablet(s) by mouth DAILY (Daily)
Butorphanol Tartrate 10 mg/mL Spray, Non-Aerosol [**1-30**] sprays(s)
intranasally q 4 hours as needed for PRN one nare only.
Alternate nares every other dose.
Carvedilol 25 mg Tablet one Tablet(s) by mouth twice daily
Diphenoxylate-Atropine [Lomotil] 2.5 mg-0.025 mg Tablet 1
Tablet(s) by mouth four times a day
Gabapentin 100 mg Capsule [**12-28**] Capsule(s) by mouth three times a
day ( start with 100 qhs and increase slowly)
Hydrocodone-Acetaminophen 5 mg-500 mg Tablet [**12-28**] Tablet(s) by
mouth QID prn (max 8/day)
Levothyroxine 150 mcg Tablet 1 Tablet(s) by mouth once a day
Lipase-Protease-Amylase [Ultrase MT 18] 333 mg (18,000
unit-[**Unit Number **],500 unit-[**Unit Number **],500 unit) Capsule, Delayed Release(E.C.) 3
Capsule(s) by mouth three times a day
Lorazepam 0.5 mg Tablet 1 Tablet(s) by mouth every 6-8 hours as
needed for anxiety
Omeprazole [Prilosec] 40 mg Capsule, Delayed Release(E.C.)
1 Capsule(s) by mouth once a day
Sertraline [Zoloft] 100 mg Tablet 1 Tablet(s) by mouth once a
day Simvastatin 40 mg Tablet 1 Tablet(s) by mouth once a day
(Not Taking as Prescribed: on hold in recovery)
Ergocalciferol (Vitamin D2) [Vitamin D] 1,000 unit Tablet 1
Tablet(s) by mouth once a day
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
8. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
12. Methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
13. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): please continue for 2 additional weeks after last
Daptomycin dose.
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 10973**]y (330)
Recon Soln Intravenous Q48H (every 48 hours): Last dose of
antibiotic will be [**2200-5-19**] unless prolonged course is
recommended by Dr. [**Last Name (STitle) 111**] during ID appointment.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Right subcapital femur fracture secondary to infection
Right Septic Hip (MSSA on Daptomycin) with spacer placement,
femoral head resection
Clostridium Difficile Colitis
UTI (treated with Ciprofloxacin)
Hypertension
Hypothyroidism
Hyperlipidemia
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 initially admitted to the hospital with a fracture of
one of your bones that we think was due to an infection. Whilst
in the hospital you were seen by the Orthopaedic and Infectious
Disease team who followed you during your hospital stay. You
were found to have an infection in your hip and were prescribed
intravenous antibiotics, you were also went to the operating
room to have a spacer placed in your right hip.
Prior to leaving the hospital you were diagnosed with having an
intestinal infection called Clostridium Difficile and were
started on oral antibiotics.
We STARTED several new medications:
1. Please start taking Daptomycin 330mg IV every 48hours for at
least 6 weeks ([**2200-5-19**]). You will see Dr. [**Last Name (STitle) 111**] who will be
able to clarify if you need a longer course of antibiotics.
2. Please start taking Vancomycin 250mg by mouth every 6 hours,
you will stop this medication 2 weeks after you finish your
Daptomycin medication.
3. Please start taking Methadone 2.5mg by mouth twice a day
4. Please start taking Dilaudid 2-4mg by mouth as needed for
pain every 3 hours
5. Please take the Lidocaine patch every day
6. Please take Pancrelipase 5,000units three times a day with
meals
We CHANGED some of your old medications:
1. Please start taking 5mg Amlodipine daily instead of 2.5mg.
We STOPPED some of your old medications:
1. Please stop taking Gabapentin
2. Please stop taking Hydrocodone-Acetaminophen
Followup Instructions:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2200-4-18**] at 11:00 AM
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: ORTHOPEDICS
When: THURSDAY [**2200-5-1**] at 10:00 AM
With: [**Year (4 digits) **] XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SPINE CENTER
When: THURSDAY [**2200-5-1**] at 10:20 AM
With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3736**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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"783.7",
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"711.05",
"584.9",
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"585.9",
"820.09",
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icd9cm
|
[
[
[]
]
] |
[
"77.65",
"81.91",
"38.93",
"84.56",
"77.85"
] |
icd9pcs
|
[
[
[]
]
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14388, 14460
|
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|
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|
14749, 14749
|
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14925, 16384
|
3228, 3604
|
3620, 3917
|
262, 278
|
560, 2002
|
14764, 14901
|
2024, 3041
|
3057, 3148
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,800
| 156,129
|
46364
|
Discharge summary
|
report
|
Admission Date: [**2162-5-13**] Discharge Date: [**2162-5-17**]
Date of Birth: [**2096-5-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66M with severe COPD, chronically trached (capped), on 2L O2 at
baseline who presents with tachypnea. The patient was found to
be tachypneic and diaphoretic at his group home. When EMS was
called he was 82% on 2L, and came up to 99% on NRB. Denied chest
pain, abdominal pain, headache.
.
.
Notably, he had a recent MICU admission from [**Date range (1) 98536**] for COPD
exacerbation and pneumonia. Sputum cultures grew out Strep
pneumoniae, and the patient was treated with Ceftriaxone and
Levofloxacin. He was discharged on a steroid taper.
.
In the ED, initial vs were: 97.2 91 151/77 32 100% 15L NRB. Exam
was notable for coarse rales on the L, green sputum around the
trach site, and accessory muscle use. EKG was without ST segment
changes. Blood cultures and a sputum culture were sent. CXR was
obtained. Patient was given Albuterol nebs x3, Ipratropium nebs
x3, Prednisolone 125mg IV x1, wtihout much relief. He was also
given Vancomycin 1g, Levofloxacin 500mg, and Ceftriaxone 1g.
Respiratory was called, and the patient was ventilated. Vitals
prior to transfer were T98 HR 91 BP 133/52 99% on facemask,
awaiting mechanical ventilation. With onset of mechanical
ventilation and sedation (2mg IV midazolam), the patient briefly
became hypotensive to 60s/40s. He was found to be autopeeping at
15. He received 2L IV fluids, and was briefly taken off the
ventilator, with resolution of hypotension. BPs prior to
transfer were 95-112/56-58. He was started on 0.15 peripheral
levophed.
.
.
.
On the floor, the patient is resting comfortably. He denies any
chest pain. He has had chills overnight, and only felt badly
yesterday. He states that 2 days ago, he felt completely well.
Denies cough or sputum production.
.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
- COPD: FEV1 23% predicted ([**2160**]), FEV1/FVC 28% predicted ([**2160**])
home 2L O2. Trach placed in [**2162-1-6**].
- Secondary Pulmonary Hypertension (TR Gradient 51-66 mm Hg on
ECHO
[**2159-9-18**])
- Schizophrenia
- Hx GI bleeding
- Mental Retardation
- s/p tonsillectomy
- s/p trach
Social History:
Lives in [**Location **], unknown if alone. On disability since [**2149**]
for mental health issues. Has home nurse visit every morning and
evening. Reports ~50 pack-year smoking denies current smoking.
Denies any ETOH/drug use.
Family History:
Non-contributory
Physical Exam:
Admission Exam:
Vitals: T: 97.6 BP: 121/77 P: 63 R: 16 O2: 100% on AC FiO2 of
100%, PEEP 5, Vt 400 RR 16
General: Alert, oriented, trach in place. No acute distress
[**Year (4 digits) 4459**]: Sclera anicteric, MMM, oropharynx clear. Trach in place,
with purulent secretions around trach site.
Neck: supple, JVP not elevated, no LAD
Lungs: Poor air movement. Faint end expiratory wheezes. No
crackles or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
At discharge, same as above except:
[**Year (4 digits) 4459**]: Trach in place and capped, no secretions
Lungs: moderate air entry, minimal wheezes
Pertinent Results:
Admission Labs:
[**2162-5-13**] 07:20AM PLT COUNT-318
[**2162-5-13**] 07:20AM NEUTS-74.5* LYMPHS-20.7 MONOS-3.9 EOS-0.6
BASOS-0.3
[**2162-5-13**] 07:20AM WBC-13.9*# RBC-4.32* HGB-13.1* HCT-40.6
MCV-94 MCH-30.3 MCHC-32.3 RDW-13.3
[**2162-5-13**] 07:20AM cTropnT-0.01
[**2162-5-13**] 07:20AM estGFR-Using this
[**2162-5-13**] 07:20AM GLUCOSE-156* UREA N-48* CREAT-1.0 SODIUM-149*
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-48* ANION GAP-6*
[**2162-5-13**] 07:37AM freeCa-1.19
[**2162-5-13**] 07:37AM LACTATE-0.9
[**2162-5-13**] 07:37AM TYPE-[**Last Name (un) **] RATES-/40 O2-100 PO2-192* PCO2-101*
PH-7.27* TOTAL CO2-48* BASE XS-14 AADO2-440 REQ O2-74
INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
[**2162-5-13**] 08:30AM URINE MUCOUS-FEW
[**2162-5-13**] 08:30AM URINE HYALINE-4*
[**2162-5-13**] 08:30AM URINE RBC-2 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
[**2162-5-13**] 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2162-5-13**] 08:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2162-5-13**] 10:58AM URINE GR HOLD-HOLD
[**2162-5-13**] 10:58AM URINE HOURS-RANDOM
[**2162-5-13**] 11:27AM TYPE-ART RATES-/16 TIDAL VOL-400 PEEP-5 O2-70
PO2-223* PCO2-78* PH-7.26* TOTAL CO2-37* BASE XS-5 -ASSIST/CON
INTUBATED-INTUBATED
[**2162-5-13**] 05:00PM PT-13.1 PTT-26.5 INR(PT)-1.1
[**2162-5-13**] 05:00PM PLT COUNT-270
[**2162-5-13**] 05:00PM WBC-10.6 RBC-3.92* HGB-11.8* HCT-36.7* MCV-94
MCH-30.0 MCHC-32.0 RDW-13.5
[**2162-5-13**] 05:00PM CALCIUM-7.9* PHOSPHATE-2.3* MAGNESIUM-1.7
[**2162-5-13**] 05:00PM GLUCOSE-203* UREA N-35* CREAT-0.8 SODIUM-141
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-32 ANION GAP-11
Discharge Labs:
Micro:
BLOOD CULTURE [**2162-5-13**] x 2: NGTD
SPUTUM CULTURE [**2162-5-13**]:
[**2162-5-13**] 7:43 am SPUTUM SPUTUM VIA TRACHEOSTOMY.
**FINAL REPORT [**2162-5-15**]**
GRAM STAIN (Final [**2162-5-13**]):
[**11-30**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2162-5-15**]):
HEAVY GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
URINE CULTURE [**2162-5-13**] : negative
URINE LEGIONELLA [**2162-5-13**]: negative
INFLUENZA A + B [**2162-5-13**]: negative
SPUTUM CULTURE [**2162-5-13**]:
[**2162-5-13**] 4:41 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2162-5-15**]**
GRAM STAIN (Final [**2162-5-14**]):
THIS IS A CORRECTED REPORT ([**2162-5-14**]).
Reported to and read back by DR. [**Last Name (STitle) **], R ([**Numeric Identifier 20879**]) ON
[**2162-5-14**]
AT 15:09.
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
PREVIOUSLY REPORTED ([**2162-5-13**]) AS:.
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2162-5-15**]):
SPARSE GROWTH Commensal Respiratory Flora.
Imaging:
CXR [**2162-5-13**]: Cardiac contour is unremarkable. Bilateral hilar
prominence is stable. There is no focal consolidation within the
lungs concerning for pneumonia. There is slight prominence and
haziness of the pulmonary vasculature. No pleural effusion or
pneumothorax. Tracheostomy is in place. IMPRESSION: Minimal
central vascular engorgement with minimal pulmonary vascular
congestion. Stable hilar prominence.
Brief Hospital Course:
Mr. [**Known lastname 79627**] is a 66 yo M with a history of severe COPD,
chronically trached, who presents with hypoxia and tachypnea
likely due to a COPD exacerbation.
ACTIVE PROBLEMS:
1. DYSPNEA/TACHYPNEA/ACUTE RESPIRATORY FAILURE: He presented
with hypoxia and tachypnea, with desaturations to 82% at his
rehab that rebounded with NRB. He has severe underlying COPD
and had recently undergone MICU treatment of pneumonia within
the past month. He was placed on vanco/levaquin/ceftriaxone for
suspected HCAP. COPD was aggressively managed with IV steroids,
standing ipratroprium and albuterol nebulizers, and the above
antibiotics. CXR revealed no sign of infiltrate. He was placed
on mechanical ventilator for elevated AAD02 and CO2 retention.
He ruled out for flu and legionella. His sputum culture from
[**2162-5-13**] revealed a polymicrobial gram stain with gram negative
and positive rods, and gram positive cocci in pairs and chains,
however the culture revealed only sparse growth of commensal
respiratory flora. Vancomycin and ceftriaxone were stopped on
[**2162-5-15**], and he will continue a 8 day course of levofloxacin
based on previous culture data growing strep pneumo from last
hospitalization. He came off the vent on [**2162-5-13**] and tolerated
pressure support. His trach was capped [**2162-5-14**], which he
tolerated well, though he rested on pressure support overnight
per the primary teams recommendation given his severe COPD. He
may need nightly resting on the vent, though this decision may
depend on his performance at rehab as his trach is capped for
longer periods. It may also be wise to consider nocturnal BiPAP.
He will complete a ten day steroid taper. He completed 5 days
of levaquin on [**2162-5-17**].
2. ACUTE HYPOTENSION: He became hypotensive to 60s/40s upon
starting sedation and mechanical ventilation on admission. He
received IVF x2L and was placed on levophed gtt, which was
weaned during his second hospital day. He maintained his blood
pressures thereafter.
3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE: Severe, with FEV1/FVC
28% on 2L home 02. Exacerbated, as above. [**Month (only) 116**] benefit from
nightly resting on pressure support.
INACTIVE PROBLEMS:
4. SCHIZOPHRENIA: no issues, continued zyprexa 7.5mg [**Hospital1 **]
PENDING TESTS AT DISCHARGE: Blood cultures [**2162-5-13**] x 2
TRANSITIONAL CARE ISSUES:
- prednisone taper as follows: 40mg daily through [**2162-5-18**], then
30mg x3 days, 20mg x3 days, 10 mg x2 days, 5mg x 2 days.
- consideration for nightly rest on vent or BiPAP
Medications on Admission:
1. Zyprexa 7.5 mg Tab 1 Tablet(s) by mouth once a day
2. Multivitamins with Minerals Tab 1 Tablet(s) by mouth once a
day
3. Advair Diskus 500 mcg-50 mcg/Dose for Inhalation 1 puff(s)
inhaled twice a day
4. Spiriva with HandiHaler 18 mcg & inhalation Caps 1 capsule
inhaled once a day
5. Albuterol Inhaler 2 puffs q4h PRN wheezing
6. Aspirin 81 mg po daily
7. Tylenol 325 mg po q6h PRN pain
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day/Year **]:
1-2 Puffs Inhalation every four (4) hours as needed for
wheezing.
2. olanzapine 5 mg Tablet [**Month/Day/Year **]: 1.5 Tablets PO twice a day.
3. prednisone 10 mg Tablet [**Month/Day/Year **]: per schedule below Tablet PO
once a day: 4 tabs/day through [**2162-4-17**], then 3 tabs/day for 3
days. 2 tabs/day for 3 days. 1 tab/day for 2 days. 0.5 tab/day
for 2 days, then STOP (10 days total taper).
Disp:*22 Tablet(s)* Refills:*0*
4. aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Month/Day/Year **]:
One (1) capsule, inhaled Inhalation once a day.
6. Advair Diskus 500-50 mcg/dose Disk with Device [**Month/Day/Year **]: One (1)
Inhalation twice a day.
7. Tylenol 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every six (6)
hours as needed for pain.
8. multivitamin with minerals Tablet [**Month/Day/Year **]: One (1) Tablet PO
once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY DIAGNOSES: Acute respiratory failure secondary to
exacerbation of chronic obstructive pulmonary disease.
SECONDARY DIAGNOSES: schizophrenia
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 Mr. [**Known lastname 79627**],
You were admitted to the hospital with difficulty breathing,
which was likely caused by worsening of your COPD, and maybe a
pneumonia. We treated you with strong antibiotics, nebulizer
treatments, and steroids, and you improved. You also were placed
on a mechanical ventilator to help rest your breathing muscles,
which also helped you recover. You may find that nightly rest on
a ventilator may be beneficial to you, though this possibility
may be further explored at rehab.
The following changes were made to your medications
- START prednisone, in a tapered fashion as included with your
medication list
Please continue all other meds as previously prescribed
It was a pleasure caring for you, Mr. [**Known lastname 79627**].
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1022**], at [**Telephone/Fax (1) 250**] when you return
from rehab to follow up.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
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"518.81",
"416.8",
"V55.0",
"V58.65",
"295.90",
"458.29",
"E937.8",
"V46.2",
"V15.82",
"319",
"491.21",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
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11972, 12043
|
7888, 10203
|
323, 329
|
12237, 12237
|
3972, 3972
|
13208, 13462
|
3093, 3111
|
10900, 11949
|
12064, 12179
|
10485, 10877
|
12413, 13185
|
5703, 7865
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3126, 3953
|
12200, 12216
|
10218, 10253
|
2097, 2513
|
264, 285
|
10279, 10459
|
357, 2078
|
3988, 5686
|
12252, 12389
|
2535, 2829
|
2845, 3077
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,604
| 178,435
|
46447
|
Discharge summary
|
report
|
Admission Date: [**2195-5-24**] Discharge Date: [**2195-5-26**]
Date of Birth: [**2123-10-9**] Sex: M
Service: Neurology
IDENTIFYING DATA: A 71-year-old ambidextrous male
transferred the Intensive Care Unit with a right basal
ganglia and thalamic hemorrhage.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 13448**] is a 71-year-old
ambidextrous, though mainly left handed, male who was in his
usual state of health until the morning of [**5-24**]. He
awoke and was doing some work at his desk when he leaned over
to get some papers and fell to the ground secondary to left
sided weakness. He could not do anything with the left arm
at all and had some movement of the left leg. He could not
bear weight on the left leg. He lay on the ground for a few
hours until his son came home and called 911. He denied any
headaches, nausea, vomiting, numbness or tingling. He stated
that he thought he had double vision intermittently, but
could not be more specific. The double image was of objects
seen side to side, but he could not say if any particular
direction of gaze made this worse. He was seen in the
Emergency Department by the neurology and stroke service
where his exam was notable for a right gaze preference, left
homonymous hemianopia versus left hemi-spacial visual
neglect, a left facial droop, flaccid left arm with strength
in all muscle groups except for minimal movement of the
fingers and 4 to 4+/5 strength in left hip flexion and
hamstrings. There was minimal left foot dorsiflexion. There
was extinction to double .............. stimulation on the
left. An MRI revealed a 2 cm right sided basal ganglia bleed
with some extension to the thalamus. His blood pressure
initially was 190/110, so he was admitted to the Intensive
Care Unit for intravenous labetalol and frequent neurologic
checks. He did well over the first night with rapidly
improved strength in the left arm. He no longer had any
complaints of diplopia. He was therefore transferred to the
neurology floor for further care.
PAST MEDICAL HISTORY:
1. Hypertension for at least five to six years, but he
stopped taking Norvasc six months ago secondary to
presyncopal feeling.
2. Known right ICA stenosis
3. Status post left carotid endarterectomy - unclear if this
was symptomatic or not. Performed by Dr. [**Last Name (STitle) 1476**] in [**2189**].
4. Status post coronary artery bypass graft in [**2191**]
5. Possible hypercholesterolemia
MEDICATIONS: No medications at home. Aspirin and Norvasc
prescribed in the past. Labetalol drip in the MICU
transitioned to po Lopressor 25 mg tid.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: More than 50 pack year smoker, drinks one to
two cans of beer per day, works as a doorman a few days per
week and lives with his wife. [**Name (NI) **] has seven children and four
grandchildren.
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 130/80, heart rate 70s,
temperature 98??????.
HEAD, EARS, EYES, NOSE AND THROAT: Head was normocephalic,
atraumatic.
NECK: Supple without bruits.
CARDIOVASCULAR: Regular rate and rhythm with no murmurs.
LUNGS: Clear to auscultation.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: Warm without cyanosis, clubbing or edema.
NEUROLOGIC: He was alert, oriented and attentive. He was
able to do the months of the year backwards without
difficulty. Language was fluent with intact naming, [**Location (un) 1131**],
repetition and comprehension. Praxis was normal and there
was no right left confusion. Cranial nerve exam: The right
pupil was 1.5 mm, left 2 mm. Both were reactive to light.
Visual fields were full, though he explores the left
hemi-space less and requires encouragement to look to the
left. Extraocular movements revealed some limitation of
vertical gaze with both up and down gaze. There was some
improvement to down gaze with vestibular ocular reflex
(tilting head backwards). Smooth pursuit was interrupted by
saccades when pursuing to the right. Saccadic eye movements
were hypometric to the left. There is a flattened nasolabial
fold on the left. Sensation was intact in the face. Tongue
and palate movements were normal. Sternocleidomastoid and
trapezius were full. Bulk and tone were full. There was a
left pronator drift and isolated asterixis of the left hand,
as well as occasional myoclonic movements of the left hand.
Strength was [**3-12**] in the left deltoid, 5-/5 triceps, 4+/5
finger extensors and hand intrinsics. Strength was full in
the left lower extremity and muscle groups on the right were
full. Reflexes were 3+ on the left, 2+ on the right in both
the arms and legs. There was a withdrawal response to
plantar stimulation with the left foot, but right plantar
reflex was flexor. Pinprick was mildly decreased in a patchy
distribution over the left arm and leg. Joint position sense
was intact throughout. Vibration was decreased to the knees
bilaterally. Rapid alternating movements and fine finger
movements were slow on the left. There was some dysmetria
out of proportion to weakness with finger to nose testing on
the left arm.
MRI revealed acute hemorrhage in the right basal ganglia
extending into the thalamus. There was changes of small
vessel disease. There was absence of flow signal in the
right intracranial internal carotid artery with markedly
diminished flow signal within the right middle cerebral and
anterior cerebral arteries.
LABS: White blood count 8, hematocrit 34, BUN 21, creatinine
1.9, albumin 3.3. Liver function tests were within normal
limits.
HOSPITAL COURSE: In summary, Mr. [**Known lastname 13448**] is a 71-year-old
man with untreated hypertension over the last six months. He
presented with an acute right basal ganglia bleed with some
extension to the thalamus. This location favored a
hypertensive etiology. His symptoms rapidly improved as
documented by his initial exam (stated in the history of
present illness) compared to his exam the next day upon
transfer to the neurology floor. He remained stable with
blood pressures in the range of 130 to 160. His goal blood
pressure at this point should now be between 120 to 150 mmHg.
Further drops of blood pressure acutely would not be prudent,
particularly in the setting of pre-existing right internal
carotid artery occlusion. In roughly two to three weeks, the
patient should be restarted on aspirin. He was seen by
physical therapy who felt that he was an excellent
rehabilitation candidate. Therefore, accommodations will b.e
made to transfer the patient to an acute rehabilitation
setting.
DISCHARGE MEDICATIONS:
1. Thiamine 100 mg po qd
2. Folate 1 gm po qd
3. Lopressor 25 mg po tid, to hold for a systolic blood
pressure less than 140
4. Zantac 150 mg po bid
5. Colace 100 mg po bid
6. Tylenol prn
DISCHARGE DIAGNOSES:
1. Right basal ganglia
2. Thalamic presumed hypertensive hemorrhage
3. Left sided residual ataxic hemiparesis
Please note that arrangements will need to be made for new
outpatient primary care upon discharge from the
rehabilitation setting.
[**Last Name (LF) **],[**First Name3 (LF) **] J.S. 13-244
Dictated By:[**Name8 (MD) 98668**]
MEDQUIST36
D: [**2195-5-26**] 13:07
T: [**2195-5-26**] 14:25
JOB#: [**Job Number **]
|
[
"305.1",
"414.01",
"401.9",
"V45.81",
"431",
"433.10",
"V15.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6829, 7290
|
6613, 6808
|
5588, 6590
|
2888, 5570
|
311, 2047
|
2069, 2659
|
2676, 2873
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,743
| 172,903
|
32379+57800
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-1-24**] Discharge Date: [**2141-1-31**]
Date of Birth: [**2068-8-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 1267**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2141-1-24**] Coronary Artery Bypass Graft x 4 (LIMA to Diag, SVG to
LAD, SVG to Ramus, SVG to OM)
History of Present Illness:
72 y/o male with known coronary artery disease s/p recent stent.
In [**12-24**] presented to [**Hospital1 18**] with a GI bleed. At that time
cardiac surgery was consulted for possible surgical
revascularization.
Past Medical History:
Myocardial Infarction s/p PCI/Stent, Hypertension,
Hypercholesterolemia, Peptic Ulcer Disease, Upper GI Bleed
Social History:
no tob, alcohol, drugs
Family History:
NC
Physical Exam:
VS: 61 16 128/72 5'7" 69.9kg
Gen: WD/WN male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, Carotid bruits
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, superficial varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**1-26**] CXR: No pneumothorax. Mild residual left basal atelectasis
but overall re-aeration of the lungs.
[**1-24**] Echo: PRE-BYPASS: No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine. 1.
Biventricular function is preserved.
2. Aorta is intact post decannulation. 3. Other findings are
unchanged
[**2141-1-29**] 07:20AM BLOOD
WBC-14.6* RBC-3.10* Hgb-9.4* Hct-27.1* MCV-88 MCH-30.5 MCHC-34.8
RDW-14.1 Plt Ct-229
[**2141-1-24**] 03:39PM BLOOD
PT-14.7* PTT-42.1* INR(PT)-1.3*
[**2141-1-27**] 06:45AM BLOOD
Glucose-120* UreaN-21* Creat-1.0 Na-136 K-3.7 Cl-100 HCO3-28
AnGap-12
[**2141-1-27**] 11:47AM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2141-1-26**] 3:25 AM
CHEST (PORTABLE AP)
COMPARISON: [**2141-1-24**].
FINDINGS: In the interval, an air collection in the pectoral
muscle, left has developed. A small air collection is also seen
in the lateral aspect of the soft tissues surrounding the left
hemithorax. Very small left-sided pneumothorax (1-2 mm). Subtle
atelectasis at the left lung base. No parenchymal opacities
suggestive of pneumonia. The size of the cardiac silhouette has
slightly increased as compared to the previous examination.
However, the endotracheal tube has been removed in the meantime.
The Swan- Ganz catheter has also been removed. All other devices
are still in place.
IMPRESSION: Status post removal of the endotracheal tube and the
Swan-Ganz catheter. Subtle air collection in the pectoral
muscles and in the left chest wall. Minimal pneumothorax, left.
Slight enlargement of the cardiac silhouette in the interval.
Otherwise, no relevant changes.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Test Information
Date/Time: [**2141-1-24**] at 12:47 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW209-9:4 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Normal aortic arch diameter. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine.
1. Biventricular function is preserved.
2. Aorta is intact post decannulation.
3. Other findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2141-1-24**] 15:22
Brief Hospital Course:
On day of admission Mr. [**Known lastname **] was brought directly to the
operating room where he underwent a coronary artery bypass graft
x 4. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later on op day he was weaned from
sedation, awoke neurologically intact and extubated. He did
require post-op blood transfusion secondary to low HCT. On
post-op day two his chest tubes were removed and he was started
on beta blockers and diuretics. And gently diuresed towards his
pre-op weight. On post-op day three his epicardial pacing wires
were removed and he was transferred to the telemetry floor for
further care. His medications were adjusted for maximum
hemodynamics. Physical therapy worked with patient during
post-op course for strength and mobility. And on post-op day 4
he was discharged home with VNA services and the appropriate
follow-up appointments.
To note pt did go into atrial fibrillation. Pt converted with
amio bolus. On Dc pt is in NSR. No anticoagualtion was started.
Pt also had a pnuemomediastinum on CXR post CT DC. This is
stable
Medications on Admission:
Lipitor, Aspirin, Lisinopril, Lopressor, Protonix, Plavix
(stopped [**1-20**])
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:*1*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
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:*1*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): take amiodarone 400 mg tid x 1 week, then 400 mg [**Hospital1 **] x 1
week, then 400 mg po qd x 1 week, then 200 mg po qd.
Disp:*180 Tablet(s)* Refills:*4*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Myocardial Infarction s/p PCI/Stent, Hypertension,
Hypercholesterolemia, Peptic Ulcer Disease, Upper GI Bleed
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
[**Hospital Ward Name 121**] 6 for wound check in 2 weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-18**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-19**] weeks
Dr. [**Known firstname **] [**Last Name (NamePattern1) **] in 4 weeks
Completed by:[**2141-1-29**] Name: [**Known lastname 861**],[**Known firstname **] Unit No: [**Numeric Identifier 12406**]
Admission Date: [**2141-1-24**] Discharge Date: [**2141-1-31**]
Date of Birth: [**2068-8-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 4551**]
Addendum:
The pt. had bradycardia and atrial fibrillation. His Lopressor
was decreased and Amiodorone was eventually d/c'd. He also had
subcutaneous emphysema with a pneumo mediastinum and was
followed with chest xrays. He continued to progress and
remained in SR in the 60s. He was discharged to home on POD#7
in stable condition.
Pertinent Results:
[**2141-1-30**] 07:05AM BLOOD WBC-14.5* RBC-3.39* Hgb-10.1* Hct-30.4*
MCV-90 MCH-30.0 MCHC-33.4 RDW-14.3 Plt Ct-331
[**2141-1-30**] 07:05AM BLOOD Glucose-111* UreaN-26* Creat-1.1 Na-134
K-4.3 Cl-97 HCO3-27 AnGap-14
RADIOLOGY Final Report
CHEST (PA & LAT) [**2141-1-30**] 11:24 AM
CHEST (PA & LAT)
Reason: evaluate pneumomediastinum
[**Hospital 5**] MEDICAL CONDITION:
72 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate pneumomediastinum
REASON FOR EXAMINATION: Followup of a patient after CABG.
PA and lateral upright chest radiograph compared to [**2141-1-29**].
The cardiomediastinal contour is unchanged. The
pneumomediastinum with air overlying the contour of the aortic
arch is unchanged. Slight interval decrease in left apical
pneumothorax is demonstrated with grossly unchanged appearance
of the subcutaneous chest wall emphysema, left greater than the
right and subcutaneous emphysema within the neck tissues. Left
pleural effusion is small, unchanged also seen within the
fissure.
DR. [**First Name4 (NamePattern1) 10279**] [**Last Name (NamePattern1) 12407**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12408**]
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:*1*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
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:*1*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 313**], [**Location (un) 42**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Myocardial Infarction s/p PCI/Stent, Hypertension,
Hypercholesterolemia, Peptic Ulcer Disease, Upper GI Bleed
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 4294**] at
([**Telephone/Fax (1) 2092**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
[**Hospital Ward Name **] 6 for wound check in 1 week
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-18**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-19**] weeks
Dr. [**Known firstname 255**] [**Last Name (NamePattern1) 256**] in 4 weeks
[**Known firstname **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**]
Completed by:[**2141-1-31**]
|
[
"285.9",
"272.0",
"790.92",
"E878.2",
"530.81",
"250.00",
"410.12",
"414.01",
"998.81",
"558.9",
"V45.82",
"427.89",
"427.31",
"V58.63",
"414.8",
"401.9",
"V12.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"99.04",
"39.61",
"99.05",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
13672, 13746
|
6154, 7309
|
331, 433
|
13966, 13973
|
11085, 11426
|
14715, 15169
|
864, 868
|
12320, 13649
|
13767, 13945
|
7335, 7415
|
13997, 14692
|
883, 1164
|
281, 293
|
11521, 12297
|
11462, 11492
|
461, 675
|
697, 808
|
824, 848
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,103
| 119,812
|
3045
|
Discharge summary
|
report
|
Admission Date: [**2143-2-1**] Discharge Date: [**2143-2-12**]
Date of Birth: [**2100-6-26**] Sex: M
Service: Plastic Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 42-year-old
gentleman with a history of rheumatic fever, who
approximately three nights prior to admission developed
difficulty breathing, jumping out of his bed and landing on
his left lower extremity in what he described as a strange
fashion and twisting his left leg. Was able to bear weight
shortly after, but had sharp penetrating pain.
On the day of admission, he came into the Emergency Room
because of fever without any shortness of breath, chest pain,
nausea, vomiting, upper respiratory symptoms, urinary
symptoms, or diarrhea.
PHYSICAL EXAMINATION: On examination, the patient had a
temperature of 103.2 and on examination, his left thigh was
noted to have erythema superior and lateral to the knee. A
left knee effusion without any breaks in the skin.
The patient was also noted on admission to have a white count
of 21.5. The rest of his laboratories were normal.
Patient was admitted to the Medicine Service at the time,
however, General Surgery was consulted that same night.
Concern was indicated by the General Surgery team that the
patient likely had fasciitis and the patient was subsequently
taken to the operating room for biopsy versus debridement.
A left knee aspirate was also performed by Orthopedics team
indicating approximately 60 cc of pus aspirated.
The patient was subsequently transferred to the Surgical
Intensive Care Unit after the I&D was performed. The patient
on [**2143-2-3**] developed worsening redness on his affected
left thigh, and was subsequently taken to the operating room
for an open incision and drainage of his left thigh. After
surgery was performed, the patient was transferred back to
the Intensive Care Unit.
On [**2143-2-6**], the patient was taken back to the operating
room by the Plastic Surgery team for further I&D of the left
thigh with washout. The patient was transferred back to the
floor at regular floor at that time. Wound VAC was placed on
[**2143-2-6**]. He was continued on penicillin per ID
recommendations for type A Strep from his wound.
On [**2143-2-7**], the patient started physical therapy which he
tolerated well. A VAC change was also performed on
[**2143-2-8**], which the patient tolerated without difficulty.
On the day of discharge, [**2143-2-12**], the patient was stable,
was ambulating with assistance. Urination and defecation was
normal. He had been stable on wound VAC.
DISCHARGE STATUS: Home with VNA services and PT.
DISCHARGE DIAGNOSES: Fasciitis and myositis status post
irrigation, drainage, and debridement.
DISCHARGE MEDICATIONS:
1. Aspirin 325 po q day.
2. Percocet 1-2 tablets po q4-6h.
3. Penicillin G potassium 4 milliunits IV q4h given via PICC
line that the patient received on his final day in the
hospital.
FOLLOWUP: Follow up was scheduled with Dr. [**Last Name (STitle) **] in two
weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2647**], M.D. [**MD Number(1) 2648**]
Dictated By:[**Last Name (NamePattern1) 1752**]
MEDQUIST36
D: [**2143-2-11**] 17:23
T: [**2143-2-14**] 13:05
JOB#: [**Job Number 14500**]
|
[
"729.1",
"728.86",
"711.06"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"80.26",
"80.86",
"83.14"
] |
icd9pcs
|
[
[
[]
]
] |
2638, 2713
|
2736, 3315
|
749, 2616
|
172, 726
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,967
| 129,131
|
18246
|
Discharge summary
|
report
|
Admission Date: [**2116-3-2**] Discharge Date: [**2116-3-5**]
Date of Birth: [**2063-10-29**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 53 year old female
with a past medical history significant for melanoma
diagnosed in [**2115-3-28**], status post excision and radiation
therapy, Type 2 diabetes, and tobacco use who presented on
[**2116-3-2**] for repair of a scalp wound.
PAST MEDICAL HISTORY:
1. Melanoma.
2. Type 2 diabetes for three years.
3. Obesity.
4. Tobacco use.
ALLERGIES: Penicillin (rash).
MEDICATIONS: Metformin 500 mg p.o. b.i.d.
SOCIAL HISTORY: Tobacco use, less than one pack per day for
25 years, and ethanol use occasionally.
FAMILY HISTORY: Mother with hypertension, father with [**Name2 (NI) 499**]
cancer, and cousin with Type 2 diabetes.
PHYSICAL EXAMINATION: The patient is afebrile with vital
signs stable, in no acute distress. Lungs are clear to
auscultation. Heart sounds are regular with regular rate and
rhythm. Abdomen is benign. Postoperative large skin defect
on the scalp.
HOSPITAL COURSE: The patient was taken to the Operating Room
the same day for repair of scalp defect. Tissue expander was
removed. The patient also had a split thickness skin graft
placed to cover the wound. There were no complications. The
patient tolerated the procedure well. After surgery the
patient was taken to the Recovery Room where she was noted to
require 4 liters of oxygen by nasal cannula and 40% shovel
mask to maintain saturations in the high 90s. Therefore, she
was transferred to the Intensive Care Unit for over night
observation. The next day the patient was able to wean off
of the nonrebreather mask and her saturations remained in the
range of 93 to 95% on 4 liters of nasal cannula. The patient
was then transferred to the floor on postoperative day #1
where she was able to tolerate a regular diet, was ambulatory
and the pain was well controlled with Tylenol with Codeine.
The patient has receive preoperative antibiotics and she was
maintained on Vancomycin 1000 mg intravenously q. 12 hours as
prophylaxis for two drains. The [**Hospital 228**] hospital course
had been unremarkable, and therefore on hospital day #3, the
patient's drains were removed and she was discharged home
with visiting nurse services for dressing changes b.i.d.
Since the patient was allergic to Penicillin she was
discharged home with a five day course of Clindamycin after
removal of her drain and Vancomycin was discontinued. The
patient should follow up with Dr. [**First Name (STitle) **] in his office;
telephone number was provided to the patient to schedule a
follow up appointment.
DISCHARGE DIAGNOSIS:
1. Scalp wound.
2. Diabetes.
3. Melanoma diagnosed status post excision and radiation.
4. Tobacco abuse.
DISCHARGE CONDITION: Good.
DISPOSITION: Home with visiting nurses.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2116-3-5**] 10:51
T: [**2116-3-5**] 11:05
JOB#: [**Job Number 50363**]
|
[
"V10.82",
"997.3",
"250.00",
"401.9",
"518.0",
"996.52",
"414.00",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"86.74",
"86.69"
] |
icd9pcs
|
[
[
[]
]
] |
2820, 3127
|
709, 810
|
2689, 2799
|
1080, 2668
|
833, 1062
|
159, 410
|
432, 590
|
607, 692
|
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