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67,924
| 124,042
|
36115
|
Discharge summary
|
report
|
Admission Date: [**2175-6-7**] Discharge Date: [**2175-6-13**]
Date of Birth: [**2114-3-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
respiratory arrest, followed by cardiac arrest
Major Surgical or Invasive Procedure:
central line placement
arterial line placement
intubation
History of Present Illness:
61yo male who presents from a nursing home after a choking
episode causing respiratory, then PEA arrest. He reportedly has
a history of dysphagia (on chronic soft mechanical diet) and
COPD. The patient was in the cafeteria when he suffered a
choking event on a piece of steak. He went into respiratory
distress and EMS was called. On EMS arrival the patient was
breathing spontaenously but with difficulty and was diaphoretic.
During EMS transport the patient stopped breathing and lost
pulses. Per EMS initially in asystole. Underwent immediate CPR
and ACLS protocol with epi x3. No shocks. Total downtime 0min.
Total low flow 10min with ROSC. Intubated prior to arrival by
EMS, per report a steak peice was removed. No sedation given for
intubation. ECG on arrival showed inferior ST depressions and ST
depression V3-6. Patient was pulseless in narrow complex rhythm
initially. Chest compressions were continued for another one to
two minutes while access was obtained, airway secured, and on
repeat pulse check, patient had palpable pulses, blood pressure
at that time was 85 systolic. Patient began to gag
spontaneously, once hemodynamic stability was demonstrated (~15
minutes after ROSC), he was placed on sedation as he was
overbreathing the ventilator, though no other purposeful
movements in that brief interlude.
In the ED:
ETT was confirmed with direct laryngoscopy
EKG showed sinus tach, ns stw dep inferiolaterally
CXR showed some edema, ? rib fractures, possible aspiration, OG
tube placement was confirmed.
Vanc and Zosyn were given for aspiration pneumonia
He was guaiac negative
Shock ultrasound unrevealing of any immediately reversible signs
of shock
The post-arrest team was consulted, who said that cooling
indicated at this time, after head CT, which was grossly
negative
Pressures initially up to 130/60, then down with
Fentanyl and Versed for sedation
Has an 18G and 16G for access
Received about 2L of IV fluids
On arrival to the MICU, patient intubated and sedated. Unable to
obtain recent ROS. Per his court-appointed guardian, he has been
falling a lot, but is generally pretty happy-go lucky.
Completely conversant with good cognitive function. He was at
[**Hospital **] Hospital and no nursing home would accept without a
guardian, so he ended up with a guardian. They were never able
to discuss in any depth what he would want done if he were
critically ill. Was a 'go with the flow' type [**Male First Name (un) **], agreeable.
Per [**Hospital3 2558**], at baseline he is oriented to self only and
wheelchair bound. He has had problems with eating, and is
supposed to get a mechanical soft diet. He got antibiotics in
[**Month (only) 547**] but has otherwise been at baseline.
Past Medical History:
- R hip fracture [**2172**], c/b chronic hip pain
- Dysphagia
- spinal stenosis
- gait disorder s/p multiple falls, patient apparently not safe
to ambulate independently
- olecranon bursitis
- alcohol abuse
- Hepatitis B and C, no documentation of cirrhosis
- seizure disorder
- subdural hematoma
Social History:
Lives at [**Hospital3 2558**]. Never married, unknown religion.
- Tobacco: not documented
- Alcohol: reported history of alcholism
- Illicits: not documented
Family History:
unknown
Physical Exam:
admission exam
General: Intubated, paralyzed
HEENT: Sclera anicteric, pupils pinpoint and minimally
responsive
Neck: supple, JVP not elevated, no LAD
CV: distant, regular
Lungs: Clear to auscultation anteriorly
Abdomen: under cooling sheets, soft, non-distended
GU: foley in place
Ext: cool, 2+ pulses, no clubbing, cyanosis or edema
Neuro: intubated, sedated, paralyzed
Pertinent Results:
admission labs
[**2175-6-7**] 06:40PM BLOOD WBC-12.8* RBC-4.52* Hgb-14.2 Hct-45.5
MCV-101* MCH-31.4 MCHC-31.2 RDW-13.7 Plt Ct-273
[**2175-6-7**] 11:12PM BLOOD Neuts-86* Bands-5 Lymphs-5* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2175-6-7**] 11:12PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-1+ Burr-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2175-6-7**] 06:40PM BLOOD PT-14.1* PTT-56.3* INR(PT)-1.3*
[**2175-6-7**] 06:40PM BLOOD Fibrino-182
[**2175-6-7**] 06:40PM BLOOD Glucose-336* UreaN-22* Creat-1.1 Na-142
K-3.7 Cl-102 HCO3-17* AnGap-27*
[**2175-6-7**] 06:40PM BLOOD ALT-102* AST-142* CK(CPK)-122 AlkPhos-55
TotBili-0.4
[**2175-6-7**] 06:40PM BLOOD Lipase-74*
[**2175-6-7**] 06:40PM BLOOD cTropnT-<0.01
[**2175-6-7**] 06:40PM BLOOD CK-MB-3
[**2175-6-7**] 06:40PM BLOOD Albumin-3.8 Calcium-8.8 Phos-10.6* Mg-2.4
[**2175-6-7**] 06:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-6-7**] 06:50PM BLOOD Lactate-11.1*
[**2175-6-7**] 11:21PM BLOOD freeCa-1.05*
.
urine
[**2175-6-7**] 07:01PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.009
[**2175-6-7**] 07:01PM URINE Blood-SM Nitrite-NEG Protein-600
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2175-6-7**] 07:01PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
[**2175-6-7**] 07:01PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
micro
blood cultures with no growth to date at time of death
urine cultures no growth
[**2175-6-10**] 2:30 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2175-6-12**]**
GRAM STAIN (Final [**2175-6-10**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final [**2175-6-12**]):
RARE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
YEAST. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
imaging
CXR: ET and NG tube positioned appropriately. Diffuse pulmonary
opacities concerning for pulmonary edema versus diffuse
aspiration or
hemorrhage.
.
CT head
1. No acute intracranial process.
2. Mild global atrophy.
.
EEG
This is an abnormal continuous ICU monitoring study because
of severe diffuse encephalopathy initially with a marked
suppression and
burst pattern. This evolved into a much more frequent bursting
pattern
associated with systemic myoclonus and a continued severe
suppression of
electrical activity between these bursts. This is a pattern
compatible
with post-anoxic myoclonic seizure activity.
.
ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is an apical left ventricular aneurysm. Overall
left ventricular systolic function is severely depressed (LVEF=
25 %) secondary to extensive anteroapical akinesis with focal
apical dyskinesis. Only the basal segments of the left ventricle
display preserved contractile function. A moderate sized
crescent-shaped apical thrombus is seen in the left ventricle.
The right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with focal hypokinesis of
the apical free wall. The aortic valve is not well seen. There
is no aortic valve stenosis. 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 mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: extensive anteroapical left ventricular contractile
dysfunction with an apical aneurysm and apical thrombus
Brief Hospital Course:
80yo male with history of dysphagia, admitted after PEA arrest
in the setting of a choking episode. Patient completed cooling
protocol and found to have poor neurologic function. He was
subsequently transitioned to comfort measures only and passed
away on [**2175-6-13**].
# Acute respiratory failure/aspiration pneumonia: Patient
presented with acute respiratory failure in the setting of a
choking event. CXR showed evidence of underlying process
consistent with aspiration. On admission he was started on
vancomycin and zosyn. He was extubated on [**6-10**]. Antibiotics were
discontinued with transtion to comfort measures on [**6-11**].
# s/p PEA arrest: The most likely etiology is hypoxemia in the
setting of choking episode. Patient had RoSC after 10 minutes of
low flow. Given [**Location (un) 2611**] coma score <10 after resuscitation,
patient met criteria for therapeutic cooling. He completed the
cooling protocol on [**6-8**] and was rewarmed on [**6-9**]. His post
arrest TTE showed depressed LVEF and an LV thrombus. No
anticoagulation was started.
# Coma post-cardiac arrest: at baseline he is orientated x 2.
Initially it was difficult to assess his neurologic status in
the setting of cooling and sedation. He was monitored for 48
hours after rewarming and discontinuation of sedation and
continued to be unresponsive with only some brainstem reflexes
on exam. He was monitored on continuous EEG which demonstrated
myoclonic epileptiform activity. The Neurology team was
consulted given concern for seizures. The EEG showed evidence of
severe, diffuse, and irreversible anoxic brain injury. He was
started on Keppra [**Hospital1 **] which was discontinued on transition to
comfort care.
# Goals of care: Given the information noted above, Mr. [**Known lastname **]
overall prognosis was grim and the likelihood of meaningful
neurologic recovery was negligible. A consensus between two
attending physicians and the MICU team was reached that Mr. [**Known lastname **]
did not have a change of meaningful neurologic recovery and
therefore aggressive care would not be appropriate in his case.
He was subsequently transitioned to comfort focused care. His
guardian was notified of this plan, and Mr. [**Known lastname **] was started on
palliative treatment with a morphine drip for comfort and ativan
for seizures. He was also given IV tylenol for fevers. Mr. [**Known lastname **]
died comfortably on [**2175-6-13**] at 12:34 AM.
Medications on Admission:
- Tylenol 1000mg [**Hospital1 **]
- Vicodin 1 tab QHS
- Bisacodyl 10mg rectally PRN constipation
- Milk of magnesia 30 MLs PRN constipation
- Fleet enedma PRN
- Cephalosporin (illegible) 500mg [**Hospital1 **] x 7 days, started [**2175-5-22**]
- Vitamin D 50,000 units Q weekly
- citalopram 10mg daily
- colace 200mg daily
- calcium carbonate 400mg [**Hospital1 **]
- senna 1 tab QHS
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
anoxic brain injury
s/p PEA arrest
s/p respiratory arrest
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
Completed by:[**2175-6-13**]
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,396
| 108,721
|
48379
|
Discharge summary
|
report
|
Admission Date: [**2150-2-9**] Discharge Date: [**2150-2-11**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
EU Critical [**Doctor Last Name **] ([**Numeric Identifier 101896**]) aka Ms. [**Known lastname 71492**] ([**Numeric Identifier 101897**]) is a
[**Age over 90 **]
year-old woman with a history of a fib (coumadin discontinued),
remote right parietal +/- right cerebellar stroke, and
Waldenstrom's macroglobulinemia who presented following a period
of unresponsiveness.
.
According to reports, the patient was last known well around 4pm
on the day of evaluation. After enjoying lunch with her family,
she became "unresponsive." Observers noted right eye deviation
before what sounds like horizontal nystagmus. EMS was called.
Apparently concerned the abnormal eye movements represented
seizure, the patient was given ativan 2 mg IV x 1. Blood
glucose
was 118. To protect her airway, the patient was given succ. and
then intubated at the scene. She was then transported to the
[**Hospital1 18**] for further evaluation and care.
Past Medical History:
Atrial fibrillation, no longer on Coumadin
Stroke with left sided deficit
Chronic kidney disease, stage III/IV, baseline Cr 1.5-1.8
Anemia of chronic disease
Systolic congestive heart failure, EF 45%
Waldenstrom Macroglobulinemia
Social History:
She lives at home and son is in the house. He is a lawyer. She
has 2 daughters, one in [**Name (NI) 6624**] and one in [**Name (NI) 311**]. No alcohol or
current smoking. She was an Opera singer for more than 30 years
with the [**Location (un) 86**] pops. She played piano before her stroke. She
now uses one hand to play the piano.
Family History:
Not related to her fall.
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T: nr P: 86 R: 18 BP: 148/87 SaO2: 100% intub
General: intubated sedated --> prop held for ten minutes
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
intubated
Cardiac: irreg irreg rhythm, normal S1 and S2.
Pulmonary: coarse breath sounds to auscultation bilaterally ant.
Abdomen: Round Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: does not open eyes to loud voice, sternal
rub
Cranial Nerves:
* I: Olfaction not evaluated.
* II: R 2.5--> 2mm, L 2.25--> 2 cm
* III, IV, VI: gaze conjugate; eyes stay midline with doll's eye
maneuver
* V, VII: corneals intact bilat
* VII: face grossly symmetric
* IX, X: gag intact
Motor:
* Tone: increased in LUE
Strength:
* Left Upper Extremity: withdraws purposefully from noxious
* Right Upper Extremity: extends into stimulus
* Left Lower Extremity: withdraws purposefully from noxious
* Right Lower Extremity: withdraws purposefully from noxious
Reflexes:
* Left: 2+ throughout Biceps, Triceps, Bracheoradialis, brisk
Patellar, 1+ Achilles
* Right: brisk thoughout Biceps, Triceps, Bracheoradialis,
Patellar, 1+ Achilles
* Babinski:mute bilaterally
Sensation:
* intact to noxious in all limbs
Pertinent Results:
[**2150-2-9**] 10:09PM GLUCOSE-249* UREA N-43* CREAT-1.7* SODIUM-136
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-21* ANION GAP-24*
[**2150-2-9**] 10:09PM ALT(SGPT)-14 AST(SGOT)-37 ALK PHOS-60 TOT
BILI-0.9
[**2150-2-9**] 10:09PM CK-MB-3 cTropnT-<0.01
[**2150-2-9**] 10:09PM ALBUMIN-3.5 CALCIUM-10.0 PHOSPHATE-3.8
MAGNESIUM-2.4 CHOLEST-119
[**2150-2-9**] 10:09PM %HbA1c-6.7* eAG-146*
[**2150-2-9**] 10:09PM TRIGLYCER-62 HDL CHOL-55 CHOL/HDL-2.2
LDL(CALC)-52
[**2150-2-9**] 10:09PM WBC-7.4 RBC-3.99* HGB-9.6* HCT-30.7* MCV-77*
MCH-24.1* MCHC-31.3 RDW-19.3*
[**2150-2-9**] 10:09PM PLT COUNT-133*
[**2150-2-9**] 05:58PM URINE HOURS-RANDOM
[**2150-2-9**] 05:58PM URINE HOURS-RANDOM
[**2150-2-9**] 05:58PM URINE GR HOLD-HOLD
[**2150-2-9**] 05:58PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-2-9**] 05:58PM TYPE-ART PO2-393* PCO2-27* PH-7.55* TOTAL
CO2-24 BASE XS-3
[**2150-2-9**] 05:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2150-2-9**] 05:58PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2150-2-9**] 05:58PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2150-2-9**] 04:36PM GLUCOSE-149* LACTATE-2.9* NA+-142 K+-4.0
CL--103 TCO2-26
[**2150-2-9**] 04:35PM UREA N-39* CREAT-1.6*
[**2150-2-9**] 04:35PM estGFR-Using this
[**2150-2-9**] 04:35PM LIPASE-82*
[**2150-2-9**] 04:35PM CALCIUM-10.3 PHOSPHATE-3.6 MAGNESIUM-2.5
[**2150-2-9**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-2-9**] 04:35PM WBC-6.1 RBC-3.57* HGB-8.9* HCT-27.2* MCV-76*
MCH-25.0* MCHC-32.8 RDW-20.1*
[**2150-2-9**] 04:35PM PT-15.4* PTT-24.5 INR(PT)-1.3*
[**2150-2-9**] 04:35PM PLT COUNT-180
[**2150-2-9**] 04:35PM PLT COUNT-180
[**2150-2-9**] 04:35PM FIBRINOGE-212
[**Known lastname **],[**Known firstname **] [**Age over 90 101898**] F 92 [**2058-1-23**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2150-2-9**] 6:34 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**2150-2-9**] 6:34 PM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS; CT BRAIN
PERFUSION Clip # [**Clip Number (Radiology) 101899**]
Reason: ? cva, basilar thrombosis
Contrast: OPTIRAY Amt: 110
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **]F w. unresponsiveness, intubated at scene w.
unresponsiveness, h/o CVA. pt is
receivinb nac and bicarb for kidney protection. please do
perfusion imaging as
well.
REASON FOR THIS EXAMINATION:
? cva, basilar thrombosis
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: JKSd MON [**2150-2-9**] 7:47 PM
1. thrombus of left MCA and ACA with corresponding large infarct
of the
entire left MCA and ACA territory. No mismatch present on
perfusion between
CBV and CBF to suggest a penumbra. basilar artery patent. no
acute hemorrhage.
Final Report
EXAMINATION: CTA head and neck with CT perfusion of the brain.
INDICATION: Unresponsive.
COMPARISON: [**2150-2-9**] non-contrast head CT.
TECHNIQUE: Initially, non-contrast head CT was performed.
Subsequently,
contrast was administered intravenously and serial axial images
through the
head and neck were obtained in the arterial phase. CT perfusion
was also
performed of the brain as per protocol.
FINDINGS:
NON-CONTRAST HEAD CT:
There is a large infarction involving the left MCA and ACA
territories with
loss of [**Doctor Last Name 352**]-white matter differentiation, and diffuse edematous
changes with
effacement of adjacent sulci and of the left lateral ventricle.
In addition,
there is right parietal encephalomalacia, compatible with remote
infarct.
There is no evidence of hemorrhage.
CTA NECK:
The aortic arch has mild calcific arteriosclerosis with no
stenosis of the
great vessel origins. The right brachiocephalic, left common
carotid and left
subclavian have separate origins off the arch.
The bilateral common, external, and cervical right internal
carotid arteries
have regions of minimal calcific arteriosclerosis, but no
flow-limiting
stenosis. The vertebral arteries have no flow-limiting stenosis.
There is
mild calcific arteriosclerosis of the left vertebral artery
origin. The left
vertebral artery is dominant. The proximal left internal carotid
artery is
unremarkable. There is mild tapering of the left high cervical
internal
carotid artery.
CTA HEAD:
There is a thin linear filling defect within the petrous and
remaining
intracranial left internal carotid artery. This extends through
the carotid
siphons, the supraclinoid left carotid. The lumen of the
communicating segment
then quickly tapers with low-density filling defect extending
from the left
lateral wall, and occluding this vessel just proximal to its
bifurcation and
just distal to the left posterior communicating artery origin
which is patent.
The left MCA and ACA are occluded from their origin with
minimal, faint
peripheral filling of M2 and M3 branches.
The right intracranial carotid has mild calcific
arteriosclerosis, with no
evidence of flow-limiting disease. The right anterior
communicating artery
and branches are patent. No anterior communicating artery is
identified.
The posterior circulation is unremarkable.
The examination is otherwise significant for left greater than
right maxillary
sinus mucosal thickening; the left-sided maxillary thickening is
contiguous
with a carious left maxillary premolar. In addition, there is
patchy
opacification of the left mastoid air cells and degenerative
osseous changes.
There is mild right greater than left pleural/parenchymal
pulmonary scarring
and mild mediastinal adenopathy, partially visualized. There are
heterogeneous thyroid nodules with calcifications as well. An
endotracheal
tube terminates in the mid thoracic trachea.An esophageal tube
is partially
visualized.
CT PERFUSION:
There is markedly increased mean transit time and decreased
blood flow and
decreased blood volume within the left MCA and ACA territories,
with no
evidence of significant penumbra.
IMPRESSION:
1. Dissection of the left internal carotid artery at the
craniocervical
junction. The dissection flap extends through the petrous
carotid and carotid
siphon, and leads to occlusion of the left MCA and ACA and
distal left
internal carotid artery just proximal to its bifurcation. It is
difficult to
determine which is the true and false lumen. The left posterior
communicating
artery is patent and arises just proximal to the occlusion.
2. No other flow-limiting stenosis.
3. Associated infarction of the left MCA and ACA territories
with no evidence
of significant penumbra.
4. Chronic right parietal lobe infarct.
Brief Hospital Course:
Ms. [**Known lastname 71492**] is a [**Age over 90 **] year-old woman with a history of a fib
(coumadin discontinued), remote right parietal +/- right
cerebellar stroke, and Waldenstrom's macroglobulinemia who
presented following a period of unresponsiveness and was found
to
have evidence of occlusion of the distal left ICA, left ACA and
MCA with
corresponding regions of stroke on CT/CTA brain. CTP
demonstrated no
appreciable penumbra in the left MCA and ACA region. Although
the official radiology read of the CTA was left ICA dissection
starting in the left petrous canal and extending to the distal
left ICA as well as the MCA and ACA, given her history of atrial
fibrillation, the Neurology team thought that cardioembolism as
a result of afib was the most probable diagnosis.
The morning following her admission to [**Hospital1 18**], the patient's
situation was discussed with the son. [**Name (NI) **] was told that she had a
devastating stroke that had caused complete ischemia of the left
ACA and MCA territories. This stroke severity is associated with
a very high morbidity and mortality. Even if she survived this
event, she would have global aphasia, be unable to move or feel
the right side of her body, have loss of vision in a right
homonymous hemianopsia pattern. She would require a tracheostomy
and a PEG tube. She would require 24/7 nursing care. He agreed
that she should be DNR. He wanted to keep her intubated until
her family could arrive from Europe to say goodbye to her.
The following day she had difficulty maintaining her pressures
and pressors were initiated. The following morning her son was
attempted to be notified multiple times. She went asystolic.
With a DNR order, she was not resusitated and she expired.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
6. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO twice a day.
7. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
Disp:*100 ML(s)* Refills:*2*
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
stroke
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2150-2-12**]
|
[
"342.90",
"428.22",
"733.13",
"416.8",
"V49.86",
"585.3",
"428.0",
"273.3",
"V66.7",
"434.01",
"368.46",
"427.31",
"285.29",
"784.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12937, 12946
|
10040, 11794
|
272, 278
|
12996, 13006
|
3271, 5637
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1863, 1889
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13030, 13040
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|
1926, 2376
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220, 234
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5896, 6680
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306, 1241
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2502, 3252
|
6689, 10017
|
2416, 2486
|
2401, 2401
|
1263, 1496
|
1512, 1847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,595
| 154,747
|
30013
|
Discharge summary
|
report
|
Admission Date: [**2115-5-17**] Discharge Date: [**2115-5-23**]
Date of Birth: [**2061-6-9**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Levaquin
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Worsening cough, abnormal chest CT
Major Surgical or Invasive Procedure:
Bronchoscopy [**2115-5-18**]
Platelet transfusion of two units [**2115-5-18**]
History of Present Illness:
Patient is a 53 year old with history of refractory lymphoma
status post matched unrelated non-myeloablative allogenic stem
cell transplant, who presents with worsening cough and CT chest
findings.
.
He has had a dry cough and hoarse voice over the last several
weeks, and completed a course of azithromycin approximately one
week ago, at which time a CT of the chest was completed. He
presented to clinic on [**2115-5-17**] for Rituxan therapy, and was
noted to have worsening of his cough. Pulmonary function tests
and a repeat chest CT were obtained as noted below concerning
for 'infectious etiology'. He has not had any sputum production,
fevers, or shortness of breath. Based on CT findings and concern
for worsening infectious process, he was admitted for
bronchoscopy to guide further management and treatment.
.
Review of systems:
ROS:
No fevers, chills, sweats. He has had a dry cough for
approximately 3-4 weeks, as noted above. No chest pain,
palpitations, difficulty breathing, dyspnea on exertion, PND,
orthopnea, hemoptysis, headaches, congestion, sore throat,
difficulty swallowing. Hoarseness of his voice as improved. No
N/V/D/C, abdominal pain. No GU symptoms. Weight has been stable;
his appetite has been "fair."
Past Medical History:
Oncologic History:
Patient underwent matched unrelated non-myeloablative allogenic
stem cell transplant with fludorabine and Cytoxan on [**2114-11-15**].
He was diagnosed with grade II follicular lymphoma in [**2112**] after
presenting with lymphadenopathy of the neck. His lymphoma was
resistant to multiple courses of chemotherapy, and he then
underwent transplant in [**2114**].
.
His post-transplant course was complicated by tooth abscesses
requiring extractment. While on antibiotics after extractment,
he developed rashes, which were felt to be secondary to GVHD or
drug-related. He also had several bouts of CMV viremia with
colonic involvement causing diarrhea, which improved with
Valcyte, however he had difficulty tolerating this medication
secondary to reduced cell counts. He has had repeated difficulty
with rashes, and had another skin biopsy in [**3-/2115**] that finally
confirmed GVHD of the skin. Over this time, he has been treated
with steroids and had improvement of his rashes, however again
has had recurrences of his CMV. He was most recently admitted
last month for fevers and worsening cough, work-up for which was
unrevealing.
His primary oncology team has been using PUVA treatment for this
while attempting to taper his steroids.
.
Other Past Medical History:
1. Follicular lymphoma as noted above.
2. CMV viremia, colitis
3. GVHD of skin and liver
4. Left inguinal hernia
5. Borderline positive Hepatitis B core antibody
6. Hypertension
7. Hyperglycemia while on steroids
Social History:
Patient is married and has three children. He formerly worked as
an electrician. He does not smoke or drink alcohol.
Family History:
There is no family history of lymphoma or other hematologic
diseases.
Physical Exam:
Vitals:
Temperature 98.7, Blood pressure 100/82, Heart rate 89,
Respiratory rate 20, 98% on room air. Pain 0/10.
General: Well appearing male resting comfortably in bed, NAD,
pleasant, occasional dry cough.
HEENT: NC/AT, clear oropharynx without any exudates or lesions,
moist mucous membranes. No scleral icterus or conjunctival
pallor. Mild conjunctival injection.
Neck: Supple.
Lungs: Bibasilar rales, right greater than left, good
air-movement, no accessory muscle use, no wheezes.
Cardiac: RRR, S1, S2, no m/g/r
Abdomen: Soft, NT, ND, +BS, no splenomegaly, liver edge palpable
Extr: Warm, no edema
Skin: Darkened-violet and smoky in appearance, some areas of
circular hypopigmentation along arms. No clear discrete lesions.
Port nontender, no erythmea.
Neuro: A&Ox3, no focal deficits, gait steady and narrow-based
Psych: Pleasant, appropriate
Pertinent Results:
[**2115-5-17**] 10:55AM PT-12.1 PTT-25.9 INR(PT)-1.0
[**2115-5-17**] 09:50AM GLUCOSE-201* UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2115-5-17**] 09:50AM estGFR-Using this
[**2115-5-17**] 09:50AM ALT(SGPT)-191* AST(SGOT)-65* LD(LDH)-492* ALK
PHOS-482* TOT BILI-0.9 DIR BILI-0.5* INDIR BIL-0.4
[**2115-5-17**] 09:50AM ALBUMIN-3.6 CALCIUM-8.8 PHOSPHATE-2.5*
MAGNESIUM-1.8
[**2115-5-17**] 09:50AM WBC-3.0* RBC-3.15* HGB-9.2* HCT-29.9* MCV-95
MCH-29.2 MCHC-30.7* RDW-18.2*
[**2115-5-17**] 09:50AM NEUTS-73* BANDS-2 LYMPHS-14* MONOS-3 EOS-8*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2115-5-17**] 09:50AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SCHISTOCY-1+ TEARDROP-1+
[**2115-5-17**] 09:50AM PLT SMR-VERY LOW PLT COUNT-50*
.
CT Chest [**2115-5-17**]:
MPRESSION:
1. New infection predominantly involving the right lower lobe
and the right middle lobe, but with some involvement of right
middle lobe and left lower lobe, radiologically consistent with
mycoplasma haemophilus influenza or viral infection.
2. Right apical and upper lobe findings which might represent
post-radiation changes, correlation with clinical history is
recommended.
3. Subpleural right upper lobe nodule, series 4, image 75, 4.5
mm in diameter, stable since [**2114-11-7**]. Several adjacent
smaller subpleural pulmonary nodules are seen, 4:76, 4:79, all
stable since the same period of time.
Brief Hospital Course:
53 year old male with past medical history of refractory
follicular lymphoma, status post allogenic stem cell transplant
complicated by GVHD of the skin and CMV viremia, who presented
with worsening cough and CT findings.
.
# Cough, CT chest findings: Given the CT chest findings and his
long-standing immunosuppressive therapy, there was concern for
infectious process, or GVHD of the lung. He was afebrile and
hemodynamically stable, and had recently completed a course of
azithromycin, so no antibiotics were started until after the pt
could undergo bronchoscopy. This procedure was performed and an
in doing so the pt became transiently hypotensive, hypoxemic and
tachycardic. He was transferred to the ICU for monitoring where
his hemodynamics improved with supportive care. Cultures from
his BAL demonstrated MSSA and Pseudomonas. The pt was treated
with vancomycin and Zosyn, then transitioned to Zosyn only based
on sensitivities. With antibiotic therapy his condition rapidly
improved. He will complete a total of a 14 day course. B-glucan
and galactomanan were sent and were negative.
.
# GVHD: Patient has known GVHD of both skin and liver. He was
continued on his home immunosuppressives of prednisone and
neoral [**Hospital1 **]; prednisone was decreased to 20 mg daily. The pt will
have outpt follow-up for further skin care.
.
# Lymphoma: Patient is on maintenance Rituxan therapy as
outpatient. His home prophylaxis with posaconazole was
continued. He receives pentamidine as outpatient monthly.
.
# Hypertension: Patient's home antihypertensives were held after
he became hypotensive; these were able to be restarted prior to
discharge.
.
# History of borderline HBV: Viral load on [**5-15**] was negative.
Valganciclovir dose was reduced to 450 mg given his neutropenia;
lamivudine was continued.
Medications on Admission:
- Calcitriol 0.25 mcg daily
- Clobetasol 0.05% cream [**Hospital1 **]
- Clonidine 0.1 mg [**Hospital1 **]
- Neoral 50 mg [**Hospital1 **]
- Erythromycin Ointment 5mg/gram 0.5 inch strip each eye QHS
- Folic acid 1 mg daily
- Lamivudine 100 mg daily
- Nifedipine SR 60 mg daily
- Pantoprazole 40 mg daily
- Pentamidine inhaled monthly (last dose [**2115-5-31**])
- Posaconazole 200mg/5mL TID
- Prednisone 30 mg
- Saliva substitute TID
- Valcyte 900 mg daily
- Monthly IVIG
- Multivitamin
- Petrolatrum ointment
- Vitamin E 400 units daily
Discharge Medications:
1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Posaconazole 200 mg/5 mL Suspension Sig: Five (5) mL PO TID
(3 times a day).
7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*90 tabs* Refills:*6*
10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
12. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 grams Intravenous Q8H (every 8 hours) for 10 days.
Disp:*QS grams* Refills:*0*
13. Filgrastim 300 mcg/mL Solution Sig: One (1) injection
Injection once a day for 3 days.
Disp:*3 injection* Refills:*0*
14. Petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed.
15. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO once a day.
16. Valcyte 450 mg Tablet Sig: One (1) Tablet PO once a day.
17. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary diagnosis:
- Cough
Secondary diagnoses:
- Graft-versus-host disease
- Lymphoma
Discharge Condition:
Pneumonia improved. Vitals stable on room air. Ambulating at
baseline.
Discharge Instructions:
You were admitted for further work up of cough and findings on
your CT scan. You underwent bronchoscopy for further evaluation.
You were also monitored in the intensive care unit for a short
time. You were found to have pneumonia and we have treated you
for that; you will continue on antibiotics at home.
.
Please contact Dr. [**First Name (STitle) **], your primary care physician, [**Name10 (NameIs) **] go to
the emergency room if you experience any worsening cough,
difficulty breathing, chest pain, palpitations, difficulty keep
down food or drink, fevers above 100.0, or other concerning
symptoms.
Followup Instructions:
You will follow-up in the [**Hospital Ward Name 1826**] 7 outpatient clinic each day
for the next four days. This is to get your filgrastim injection
and check your progress. You will follow-up with Dr. [**First Name (STitle) **] on
Wednesday, [**5-29**].
|
[
"202.80",
"486",
"996.85",
"E878.0",
"287.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"38.93",
"33.24",
"33.27"
] |
icd9pcs
|
[
[
[]
]
] |
9837, 9889
|
5792, 7608
|
322, 403
|
10020, 10093
|
4299, 5769
|
10746, 11005
|
3344, 3415
|
8196, 9814
|
9910, 9910
|
7634, 8173
|
10117, 10723
|
3430, 4280
|
9958, 9999
|
1271, 1666
|
248, 284
|
431, 1252
|
9929, 9937
|
2979, 3193
|
3209, 3328
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,986
| 109,355
|
1783
|
Discharge summary
|
report
|
Admission Date: [**2195-7-15**] Discharge Date: [**2195-7-24**]
Date of Birth: [**2126-12-3**] Sex: M
Service: SURGERY
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Complicated ventral incisional recurrent hernia.
Major Surgical or Invasive Procedure:
[**2195-7-15**]: Exploratory laparotomy, extensive lysis of adhesions,
small bowel resection and enteroenterostomy, component
separation, and ventral hernia repair
History of Present Illness:
Patient is a 68 y/o very pleasant gentleman with a symptomatic
ventral bulge. This was after a previous repair with mesh.
Imaging showed a complicated hernia with diastasis. Combined
surgery with plastics with a component separation was planned.
Past Medical History:
Past Medical History:
1.HCV
bx [**2192**]: grade 2 inflamm, stage 4 fibrosis; type 1B;
2.Peripheral neuropathy
3.Hypertension
4.History of sigmoid colon cancer
- s/p sigmoid colectomy and no further rx [**2185**]
5. Osteoarthritis
Past Surgical History:
1. Sigmoid colectomy [**2185**]
2. Cholecystectomy [**2179**]
3. Multiple incisional ventral hernia repairs
4. bilateral inguinal hernia repair on [**1-19**] and [**2-20**]
5. lysis of adhesions for SBO and Tru-Cut liver biopsy [**10-20**]
Social History:
domestic partner, [**Name (NI) **] [**Name (NI) **]. He used to live in [**Location (un) 10054**] and developed programs for patients with HIV. He is
currently a writer. He does not smoke cigarettes and does not
drink any alcohol. Former smoker, 25 py, quit 30 yrs ago. He
does [**Doctor First Name **] [**Doctor First Name **] every day and has done so
for the last 25 years.
Family History:
Lung cancer and his father who died, a brother died of diabetes,
his mother has cardiac problems and her older age, GF NHL
Physical Exam:
On Discharge:
VS: 98.2, 89, 120/76, 18, 96% RA
Gen: NAD
CV: RRR
Lungs: CTAB
Abd: Midline abdominal incision with occlusive dressing c/d/i.
JP drains x 2 to bulb suction.
Pertinent Results:
[**2195-7-15**] 09:20PM SODIUM-138 POTASSIUM-4.0 CHLORIDE-101
[**2195-7-15**] 09:20PM MAGNESIUM-1.6
[**2195-7-15**] 09:20PM HCT-28.6*
[**2195-7-14**] 12:10PM GLUCOSE-93 UREA N-11 CREAT-0.9 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2195-7-14**] 12:10PM estGFR-Using this
[**2195-7-14**] 12:10PM ALT(SGPT)-36 AST(SGOT)-44* LD(LDH)-196 ALK
PHOS-104 TOT BILI-1.0
[**2195-7-14**] 12:10PM TOT PROT-7.8 ALBUMIN-4.6 GLOBULIN-3.2
[**2195-7-14**] 12:10PM HCT-34.1*
[**2195-7-14**] 12:10PM PLT COUNT-211
[**2195-7-14**] 12:10PM PT-14.3* PTT-30.9 INR(PT)-1.2*
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation of the aforementioned problem. On [**2195-7-15**], the
patient underwent exploratory laparotomy, extensive lysis of
adhesions, small bowel resection x2 and enteroenterostomy, which
went well without complication (reader referred to the Operative
Note for details). In the PACU, recovery was complicated by
altered mental status and agitation. Patient was transferred in
ICU for observation and treatment. Patient was NPO with an NG
tube, on IV fluids and antibiotics, with a foley catheter and a
JP x 2 drains in place, and Morphine IV for pain control. In ICU
patient was stabilized to his baseline and was transferred to
the floor to continue recovery. The patient was hemodynamically
stable.
.
Post-operative pain was initially well controlled with Morphine
IV, which was converted Morphine PCA. Patient has a history of
chronic pain and he use multiple opioids at home to control his
pain. During on Morphine PCA patient pain was continue to be
high, chronic pain service was consulted and their
recommendations were implemented with good result. When patient
tolerated PO, he was converted to oral pain medication, he was
started on home regiment with Oxycodone IR for breakthrough
pain. Patient was consulted by nutritionist and was started on
TPN on POD # 5 for nutritional support. The NG tube was
discontinued on POD# 7, and the patient was started on sips of
clears on POD# 8. Diet was progressively advanced as tolerated
to a regular diet by POD# 9. The foley catheter was discontinued
at midnight of POD# 4. The patient subsequently voided without
problem.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Amlodipine 5', Clonidine 0.2''', Marinol 10'' prn for pain,
lisinopril 40', ritalin 10''', zofran 8''', oxycontin SR 20, 20,
40, protonix 40', trazodone 75 qhs, effexor 75', colace,
magnesium, milk thistle
Discharge Medications:
1. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day) as needed for nausea.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
7. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO HS (at bedtime).
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 15 days.
Disp:*60 Tablet(s)* Refills:*0*
11. 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*
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Complicated ventral incisional recurrent hernia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-22**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2195-8-3**] 9:00
.
Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2195-8-5**]
11:00
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2195-8-25**] 11:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2998**]
Date/Time:[**2195-8-10**] 9:45
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD ([**Street Address(2) 10055**].
[**Location (un) **] [**2195-7-30**] 11:30
Completed by:[**2195-7-24**]
|
[
"401.9",
"571.5",
"E870.0",
"568.0",
"070.70",
"553.21",
"728.84",
"V10.05",
"356.9",
"998.2",
"307.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.51",
"38.93",
"45.91",
"99.15",
"45.61",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
6591, 6650
|
2652, 5111
|
327, 493
|
6743, 6743
|
2035, 2629
|
8733, 9487
|
1705, 1830
|
5368, 6568
|
6671, 6722
|
5137, 5345
|
6894, 7473
|
7488, 8710
|
1050, 1291
|
1845, 1845
|
1859, 2016
|
238, 289
|
521, 768
|
6758, 6870
|
812, 1027
|
1307, 1689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,904
| 125,754
|
28333
|
Discharge summary
|
report
|
Admission Date: [**2155-9-4**] Discharge Date: [**2155-10-3**]
Date of Birth: [**2100-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
referred for evaluation of posterior mediastinal mass
Major Surgical or Invasive Procedure:
T3-9 Laminectomies
Bronchial aspirate, CT-guided biopsy.
History of Present Illness:
This is a 55y.o. man with a significant smoking history and COPD
who presented to an OSH with fatigue, 40lb wt loss since [**Month (only) **],
weakness, and back pain; he was found to have a large posterior
mediastinal mass concerning for malignancy, possibly lymphoma.
Patient had failed a CT-guided biopsy in the past.
Transferred to Medicine from Thoracic service after patient
failed attempted EUS with biopsy. Main issues were pain
management and respiratory optimization; in addition, he was
extremely weak and unable to walk.
The patient's symptoms began as back pain in [**2155-5-8**] when
he was diagnosed with compression fractures of his spine after
lifting boxes. Since that time the patient has had diffuse,
vague pains in his chest, back and abdomen. More recently, over
the past 3-5 weeks the patient has developed signficant loss of
appetite and a 40 lb weight loss.
.
ROS: Denies significant new HA, blurred vision, diplopia, CP,
SOB, edema, dizziness, lightheadedness, nausea, vomiting,
abdominal pain, diarrhea, consitpation, urinary symptoms.
Past Medical History:
COPD, 80 pk/yr smoker
Hypercholesterolemia
s/p Appendectomy
Hernias, s/p multiple repairs with current umbilical hernia
Sebaceous cysts
Lipomas
s/p Arthroscopic knee surgery
Social History:
>1ppd x40 yrs
Separated from wife 4 months ago after 35 years of marriage.
Family History:
Mother with DM and died of colon CA at 64
Father with emphysema
Physical Exam:
VS 98.9 134/66 78 18 96%4L
Gen: Ill appearing man older than stated age.
Integumentary: No rashes.
HEENT: PERRL. Red oral mucosa appearing raw.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Congested breath sounds in mid and lower lung fields
bilaterally.
Abd: Distended. Soft. Mild diffuse tenderness.
Ext: No edema. Peripheral pulses in lower extremities intact.
Neuro: A&Ox3. Lethargic.
Pertinent Results:
[**2155-9-3**] 09:00PM GLUCOSE-134* UREA N-21* CREAT-0.7 SODIUM-137
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2155-9-3**] 09:00PM CALCIUM-10.9* PHOSPHATE-3.6 MAGNESIUM-1.9
[**2155-9-3**] 09:00PM WBC-11.6* RBC-3.67* HGB-10.5* HCT-31.3*
MCV-85 MCH-28.5 MCHC-33.4 RDW-19.7*
[**2155-9-3**] 09:00PM PT-12.6 PTT-22.3 INR(PT)-1.1
[**2155-9-3**] 09:41PM LACTATE-1.2
[**2155-9-4**] 09:40AM ALBUMIN-2.9* CALCIUM-10.9* PHOSPHATE-3.7
MAGNESIUM-2.2
.
CT chest ([**2155-9-3**]):
Large heterogeneous posterior mediastinal mass, abutting the
carina from its posterior aspect, and involving the aorta and
the spine. The differential diagnosis is broad, in that the
appearance is not entirely typical for any single process. It
may represent a primary lung or esophageal cancer, or perhaps
lymphoma. Infection cannot be excluded, however, although the
bony structures appear intact, arguing again epidural abscess.
Bacterial or tuberculous infection is also possible, the latter
perhaps less likely due to the lack of evidence for it
elsewhere. Severe emphysema. Bibasilar opacities, most
suggestive of atelectasis. Probable involvement of the esophagus
by the mass. Mediastinal lymphadenopathy. Vague stranding about
the mesentery and pancreatic regions. This appearance is
nonspecific. It does not appear to focus distinctly on the
pancreas, but it may be helpful to correlate with pancreatic
enzymes. Multiple lower thoracic and lumbar compression
fractures.
.
CT head ([**2155-9-3**]): No evidence of acute intracranial process
.
Chest Xray ([**2155-9-3**]): Widened mediastinum, which is consistent
with the history of a mediastinal mass. Probable bibasilar
atelectasis or scarring.
Brief Hospital Course:
A/P: 55 y.o. man with history of smoking, COPD with multiple
constitutional complaints and large posterior mediatinal mass
concerning for malignancy.
.
# mediastinal mass: highly concerning for malignancy. There was
considerable difficulty obtaining tissue for diagnosis. The
patient had a broncial aspirate which grew strep viridans and
oral flora and a CT-guided biopsy that revealed only
inflammatory cells. The patient was started on Unasyn on
[**2155-9-14**] for a planned total of 4 weeks. While awaiting
pathologic diagnosis, the patient developed acute neurologic
symptoms including a mid-thoracic sensory deficit and lower
extremity weakness. He underwent emergent multi-level thoracic
laminectomy for spinal cord decompression. Tissue from this
procedure eventually revealed myeloma. BM biopsy confirmed
multiple myeloma with a posterior mediastinal plasmacytoma. The
patient was initiated on pulse steroid therapy, decadron 40 mg
QD x4 days to be repeated for a total of 3 weeks. He developed
steroid-induced hyperglycemia for which he was covered with a
regular insulin sliding scale. The patient is to follow-up with
Dr. [**First Name (STitle) **] of oncology for further management. Future
treatment options include thalidomide, chemotherapy and
radiation to the plasmacytoma. The patient was not started on
chemo agents due to the above described viridans superinfection.
The patient will likely not be eligible for radiation for [**3-13**]
weeks after his neurosurgical intervention.
.
# Infectious. The strep viridans from the mediastinal mass
initially raised the question as to whether this was an abscess
or a neoplasm with a superinfection. Differential diagnosis
included mediastinal abscess and/or vertebral osteomyelitis. As
noted above, he will complete a 4 week course of Unasyn via a
PICC line.
.
# Spinal cord compression. The patient developed acute
neurologic symptoms secondary to cord compression during the
course of his initial evaluation. He underwent emergent
laminectomy of multiple thoracic levels for cord compression. At
the time of discharge, the patient has persistent bilateral
lower extremity weakness worse in the proximal distribution with
a sensory deficit to the mid thoracic level. All staples have
been removed. The patient requires a wound check and
neurosurgical follow-up as scheduled within 2 weeks. The patient
is to get out of bed with the TLSO spinal brace always in place.
The patient continues to require a foley catheter due to
incontinence.
.
# Pain management. The patient had significant pain secondary to
the myeloma as well as post-operatively. He was followed by the
Chronic Pain Service. The patient had been on a dilaudid PCA
pump but was transitioned to an oral regimen. At one point he
received an intrathecal dilaudid injection with some relief; he
discussed placement of an intrathecal pump with his family but
deferred for now. At the time of discharge, he was managed with
a lidocaine patch, standing MS Contin, standing methadone and
dilaudid PO for breakthrough pain.
.
# Hypercalcemia. This was most consistent with hypercalcemia of
malignancy. This improved with IV NS and pamidronate. He should
be administered 90mg pamidronate IV q 3-4 weeks.
.
# Anemia of chronic disease. The patient received transfusions
with appropriate response and Hct stabilized.
.
# Sacral decubitus skin breakdown. The patient developed sacral
skin breakdown after developing incontinence secondary to cord
compression. He requires continued wound care.
.
# Emphysema. Stable. The patient developed a 2-3L supplemental
oxygen requirement thought secondary to baseline lung disease,
exacerbated by his posterior mediastinal mass as well as the
post-operative state. The patient received albuterol and
ipratropium nebs.
.
# Constipation. Likely secondary to high dose narcotics. The
patient requires an aggressive bowel regimen.
.
# History of compression fractures. Stable. Secondary to
underlying disease. The patient may require future
vertebroplasty for further treatment.
.
# Hypercholesterolemia. Stable. The patient was continued on his
home regimen of Vytorin.
Medications on Admission:
Vytorin 10/20 QD
Pain meds, most recently morphine, prior to that percocet,
vicodin as well as various muscle relaxants in the past,
including tramadol.
Discharge Medications:
1. Outpatient Lab Work
Blood draw: ESR and CRP to be drawn once per week.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) scale
Injection ASDIR (AS DIRECTED) as needed for During steroid
administration.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day).
13. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
16. Megestrol 40 mg/mL Suspension Sig: Two (2) PO DAILY
(Daily).
17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
18. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
QD ().
19. Methadone 10 mg/mL Concentrate Sig: Three (3) PO Q8H (every
8 hours).
20. Dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO DAILY
(Daily) for 2 days.
21. Dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO once a day
for 4 days: Please administer from [**2155-10-11**] to [**10-14**], [**2154**].
22. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q8H (every 8 hours).
23. Hydromorphone 2 mg Tablet Sig: Five (5) Tablet PO Q2H (every
2 hours) as needed for breakthrough pain.
24. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
25. Ampicillin-Sulbactam [**1-8**] g Recon Soln Sig: Three (3) grams
Injection Q8H (every 8 hours): Continue until [**2155-10-15**].
26. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
27. Pamidronate 90 mg Recon Soln Sig: Ninety (90) mg Intravenous
Q3-4Weeks: To be repeated q3-4 weeks (last on [**2155-9-30**]).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
multiple myeloma
strep viridians vertebral osteomyelitis
spinal cord compression
hypercalcemia of malignancy
chronic obstructive pulmonary disease
Discharge Condition:
alert and cognitively intact; hemodynamically stable; tolerating
po though appetite poor; unable to reposition himself in bed or
get up without assistance
Discharge Instructions:
Take all medications as prescribed.
.
Attend all follow-up appointments.
.
Neurosurgery: Watch incision for redness, drainage, bleeding,
swelling any discharge, fever greater than 101.5 call Dr [**Name (NI) 14232**] office. No heavy lifting greater than 10lb. Have weekly
ESR and CRPs
Should wear TLSO whenever out of bed.
Followup Instructions:
Dr. [**First Name (STitle) 1557**] (Oncology): Tuesday, [**2155-10-14**] 12:00AM.
[**Last Name (un) 469**] 7, [**Hospital3 **] Hospital.
.
Dr. [**Last Name (STitle) **] (Neurosurgery): Tuesday , [**2155-10-14**] 10:00AM.
[**Last Name (NamePattern1) 439**], [**Hospital3 **] Hospital.
.
Dr. [**Last Name (STitle) **] (Primary Care): Schedule an appointment to
establish primary care at [**Telephone/Fax (1) **].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"780.79",
"203.80",
"251.8",
"338.3",
"E932.0",
"780.57",
"737.41",
"041.09",
"788.39",
"733.13",
"530.3",
"305.1",
"285.22",
"272.0",
"496",
"324.1",
"336.3",
"275.42",
"730.08",
"564.00",
"707.03",
"203.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"03.90",
"88.73",
"33.27",
"96.6",
"45.13",
"38.93",
"96.04",
"88.72",
"41.31",
"34.25",
"99.05",
"99.07",
"96.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10892, 10964
|
4046, 8170
|
367, 426
|
11154, 11311
|
2325, 4023
|
11682, 12217
|
1827, 1893
|
8374, 10869
|
10985, 11133
|
8196, 8351
|
11335, 11659
|
1909, 2306
|
274, 329
|
454, 1520
|
1542, 1718
|
1734, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,358
| 154,616
|
22538
|
Discharge summary
|
report
|
Admission Date: [**2167-7-25**] Discharge Date: [**2167-8-10**]
Date of Birth: [**2115-9-4**] Sex: M
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right intracerebral hemorrhage
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Central line placement
History of Present Illness:
Patient is a 51 year-old right-handed man with a history of
untreated HTN, hep A/B w/?cirrhosis, EtOH use who presented to
OSH with large R frontal bleed.
Per medical records, pt w/HA for several weeks, taking ASA. On
[**2167-7-25**], awoke at 5am with severe HA not relieved by ASA and was
brought to [**Hospital3 17162**] ED. There, he had left facial droop,
slurred speech and altered mental status, and he was intubated
for airway protection. SBP 150-170. Emergent head CT showed a
large right frontal/basal ganglia bleed with extension into
ventricles, and 3-5 mm of midline shift (per report) and he was
transferred to [**Hospital1 18**] for further management. Started on
dilantin and mannitol during med flight.
On arrival in our ED, BP 176/66, peaked at 224/118, with low of
87/60. Neuro exam with sluggish pupils, 3.5mm on left, 2.5 mm on
right, swollen left optic disc, left facial droop, right corneal
reflex, moving right arm and leg spontaneously, extensor
posturing to pain except localizes on right upper extremity.
Labs with platelets of 88k and INR 1.6. [**Hospital1 **] pressure was
controlled with nipride drip, given additional mannitol,
sedated. Also given FFP and vitamin K for elevated INR,
platelets for goal >100k. Had witnessed seizure activity in ED,
and given additional dilantin, and then admitted to the neuro
ICU.
Past Medical History:
1. Untreated hypertension
2. Hypercholesterolemia
3. Hepatits A and B, with ?cirrhosis
4. Alcoholism
Social History:
Lives in [**Location (un) 5503**], works as technician. Smokes 1.5 packs per
day, unknown how long. Drinks EtOH, unknown how much. Smokes
marijuana, unknown how much. ?other drugs.
Family History:
Non-contributory
Physical Exam:
T 95.6 HR 97 BP 173/88 RR 22 100% intubated
General: intubated
HEENT: no carotid bruit
CV: rrr, no murmur
Chest: clear to auscultation bilaterally
ABD: soft, nontender
eXt: no clubbing, cyanosis or edema
Neuro
intubated, grimaces to sternal rub
Pupil 3.5 on left and 2.5 on right, left fundus showing swollen
optic disc (unable to see right fundus). Sluggish pupil reaction
to light bilaterally. No blink to visual threat bilaterally. No
doll's but has right corneal reflex. Left facial droop.
Positive
gag.
Moves right arm and leg spontaneously
increase tone in lower extremities
Localizes pain in right arm but extensor postures with rest of
extremities.
Reflex: [**2-11**] in upper extremities and right lower extremity; left
lower extremity 2+/4. Toes upgoing bilaterally.
Pertinent Results:
WBC-3.8 HGB-14.4 HCT-43.1 MCV-96 PLT-89
NEUTS-84.0* LYMPHS-12.6* MONOS-2.1 EOS-0.5 BASOS-0.7
PT-15.6* PTT-31.8 INR(PT)-1.6
Na-141 K-3.7 Cl-104 HCO3-27 BUN-9 Cr-0.7 Gluc-234*
URINE SP [**Last Name (un) 155**]-1.019 [**Last Name (un) 3143**]-LG NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG RBC-0-2 WBC-0 BACTERIA-NONE
ABG: PO2-165* PCO2-65* PH-7.28* TOTAL CO2-32*
CK(CPK)-119 CK-MB-4 cTropnT-<0.01
Head CT: 4.5 x 6 x 6 cm right basal ganglia bleed with extension
into right ventricle, 3rd, and 4th ventricle. there is some
increasing size of lateral ventricle compared to outside
hospital CT which had showed 4x5x6 cm bleed
CTA: No definite intracranial aneurysm noted. Tiny aneurysms
cannot be excluded.
Brief Hospital Course:
1. Intracranial hemorrhage: Neuro exam was initially stable, or
slightly improved, with some spontaneous movements on right
side, withdrawal to pain RUE, RLE, LLE and extensor LUE. After
48 hours, mannitol was discontinued, but later that day patient
became less reponsive. Repeat head CT had worsening edema and
mannitol was restarted. Despite elevated osmolarity, remained
with significant edema on CT, and remained comatose with minimal
responsiveness. [**Last Name (un) **] pressure was maintained with systolic
pressures less than 160 to minimize any further bleeding.
Dilantin was used for seizure prophylaxis.
Initially, attempts were made to maintain INR<1.4,
platelets>100k, but this had to be stopped secondary to
respiratory failure (see below).
2. Respiratory failure: Given large bleed and elevated
INR/decreased platelets, pt was aggressively transfused over his
first 2-3 days in the ICU. On [**7-28**], he developed worsening
hypoxemic respiratory failure and chest x- ray showed severe
bilateral pulmonary edema, consistent with TRALI vs ARDS.
Therefore, transfusions were held. Pulmonary status slowly
improved, and pt was satting well on 40% O2. though he continued
to have problems managing his secretions.
3. Fever/ID: Since admission, pt was spiking fevers. Urine
cultures were positive for E coli and Klebsiella, both sensitive
to levofloxacin. Depsite adequate treatment, pt has continued to
spike fevers of unclear etiology. Flagyl was added [**7-31**] for ETT
secretions that looked like tube feeds. Other contributors to
fever imclude sinusitis and pancreatitis
4. Pancreatitis: Amylase and lipase were checked on [**8-4**] to see
if pancreatic encephalopathy could be contributing to patient's
coma. Lipase was elevated to 300, etiology unclear as
triglycerides were ~150. Tube feeds were held and intravenous
fluids increased. He did not respond to pressing on his
epigastric area with signs of pain.
5. Presumed cirrhosis: Patient with long alcohol history, with
coagulopathy on admission, presumed secondary to cirrhosis.
However, LFTs unremarkable except for elevated bilirubin.
Abdominal ultrasound showed liver with normal echotexture, no
ascites, splenomegaly with questionable portal hypertension.
6. CV: TTE shows EF>55%, minimal RV free wall HK, 1+ MR. [**Name13 (STitle) **]
pressure was controlled with IV agents to keep MAP<130.
Despite continued care, patient remained comatose. After
multiple long discussions with the family, they decided to make
patient comfort measures only. He was extubated and made
comfortable. He died from cardiac arrest at 7am on [**2167-8-10**].
Medications on Admission:
Aspirin
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
funeral home
Discharge Diagnosis:
Large intracranial hemorrhage, complicated by coma
Transfusion-associated acute lung injury causing hypoxemic
respiratory failure
Coagulopathy
Urinary tract infection with E. coli and Klebsiella
Pancreatitis
Sinusitis
Presumed cirrhosis
Hypertension
Anemia
Alcohol abuse
Discharge Condition:
Dead
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"518.5",
"599.0",
"276.0",
"070.30",
"331.4",
"428.0",
"303.91",
"431",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6439, 6478
|
3729, 6352
|
340, 402
|
6792, 6798
|
2953, 3398
|
6851, 6950
|
2117, 2135
|
6410, 6416
|
6499, 6771
|
6378, 6387
|
6822, 6828
|
2150, 2934
|
270, 302
|
430, 1779
|
3407, 3706
|
1801, 1903
|
1919, 2101
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,661
| 131,771
|
26070
|
Discharge summary
|
report
|
Admission Date: [**2117-5-21**] Discharge Date: [**2117-6-16**]
Date of Birth: [**2061-11-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
abdominal distention
Major Surgical or Invasive Procedure:
1. Paracentesis x2
2. Ultrasound-guided targeted biopsy of segment VIII liver
lesion
3. Orthotopic deceased donor liver transplant, portal vein to
portal vein anastomosis, common bile duct to common bile duct
anastomosis without a T-tube, common hepatic artery donor to
proper hepatic artery
recipient, venovenous bypass, resection of portion of the right
diaphragm.
History of Present Illness:
55 y.o. male with ESLD on liver transplant list who presented to
liver clinic with worsening abdominal distension and
encephalopathy and was referred for admission. One week ago he
developed increasing abdominal pain, back pain, and diarrhea.
He was admitted to an OSH where he was treated with IV CTX for 3
days, then discharged on cipro for 3 days as outpatient, he
finished his cipro yesterday. Since his discharge he has had
increasing abdominal distention and pain leading to a
therapeutic 2.5 L paracentesis yesterday at his PCP's office
which was consistent with SBP.
At home he has had increasing confusion, intermittent
fevers/chills, increased itching, poor PO intake, and decreased
urine output. He has been taking his medications as prescribed
and has had ~ 4 BMs per day with one dose of lactulose daily.
.
He currently denies SOB, cough, abd pain, N/V/D.
Past Medical History:
Cirrhosis - on transplant list
HTN
Meningioma s/p resection
GERD
Social History:
Lives with partner [**Name (NI) **] here with him today. + tobacco
Family History:
NC
Physical Exam:
Vit - 98.4 110/52 65 18 94% RA
Gen - very pleasant middle aged male, resting in bed, NAD
HEENT - NC/AT, sclera icteric, EOMI, PERRLA, MM dry, mild thrush
on buccal mucosa
Neck - no LAD
CV - RRR, [**2-15**] SM at LUSB, nl s1, s2
Pulm - CTAB, no w/c/r, good breath sounds
Abd - + BS, mild distention, mild tenderness to palpation on RUQ
and RLQ, + tympanic
Ext - trace peripheral edema, 2+ radial pulses
Neuro - alert and appropriate, no asterixis, slow speech
Skin - ecchymoses on B forearms with areas of excoriation and
dryness
Pertinent Results:
[**2117-5-21**] 02:05PM BLOOD WBC-9.1# RBC-2.95* Hgb-11.3* Hct-31.9*
MCV-108* MCH-38.3* MCHC-35.4* RDW-17.5* Plt Ct-109*
[**2117-5-27**] 05:10AM BLOOD WBC-6.0 RBC-2.45* Hgb-9.3* Hct-25.9*
MCV-106* MCH-37.9* MCHC-35.7* RDW-17.7* Plt Ct-70*
[**2117-6-3**] 06:53AM BLOOD WBC-8.7 RBC-3.97* Hgb-12.2* Hct-33.6*
MCV-85 MCH-30.8 MCHC-36.4* RDW-15.6* Plt Ct-128*
[**2117-6-8**] 06:00AM BLOOD WBC-11.5* RBC-3.48* Hgb-10.7* Hct-30.5*
MCV-88 MCH-30.8 MCHC-35.2* RDW-17.5* Plt Ct-75*
[**2117-5-21**] 02:05PM BLOOD PT-21.6* PTT-41.3* INR(PT)-2.1*
[**2117-5-21**] 02:05PM BLOOD Plt Ct-109*
[**2117-5-26**] 05:15AM BLOOD PT-25.0* PTT-51.0* INR(PT)-2.5*
[**2117-5-26**] 05:15AM BLOOD Plt Ct-66*
[**2117-5-29**] 05:45AM BLOOD PT-22.9* PTT-49.7* INR(PT)-2.3*
[**2117-5-29**] 05:45AM BLOOD Plt Ct-74*
[**2117-6-2**] 11:02PM BLOOD PT-21.3* PTT-150* INR(PT)-2.1*
[**2117-6-2**] 11:02PM BLOOD Plt Ct-109*
[**2117-6-8**] 06:00AM BLOOD PT-12.9 PTT-27.5 INR(PT)-1.1
[**2117-6-8**] 06:00AM BLOOD Plt Ct-75*
[**2117-5-21**] 02:05PM BLOOD Glucose-106* UreaN-38* Creat-1.2 Na-125*
K-5.1 Cl-93* HCO3-21* AnGap-16
[**2117-5-27**] 05:10AM BLOOD Glucose-88 UreaN-15 Creat-0.9 Na-127*
K-4.0 Cl-92* HCO3-25 AnGap-14
[**2117-6-3**] 06:53AM BLOOD Glucose-247* UreaN-21* Creat-1.2 Na-132*
K-4.1 Cl-97 HCO3-24 AnGap-15
[**2117-6-8**] 06:00AM BLOOD Glucose-116* UreaN-105* Creat-2.8*
Na-122* K-5.0 Cl-90* HCO3-20* AnGap-17
[**2117-6-3**] 06:53AM BLOOD CK-MB-14* MB Indx-4.5 cTropnT-0.29*
[**2117-6-3**] 11:33AM BLOOD CK-MB-12* MB Indx-3.2 cTropnT-0.31*
[**2117-5-21**] 02:05PM BLOOD TotProt-6.1* Albumin-2.4* Globuln-3.7
Calcium-8.5 Phos-4.1 Mg-1.9
[**2117-5-27**] 05:10AM BLOOD Calcium-8.7 Phos-1.9* Mg-2.1
[**2117-6-3**] 06:53AM BLOOD Calcium-11.4* Phos-6.7* Mg-2.3
[**2117-6-8**] 06:00AM BLOOD Albumin-2.4* Calcium-7.7* Phos-6.5*
Mg-3.0*
[**2117-5-27**] 05:10AM BLOOD Free T4-1.2
[**2117-5-22**] 07:00AM BLOOD AFP-18.9*
[**2117-5-27**] 05:10AM BLOOD PSA-0.1
[**2117-6-5**] 07:40AM BLOOD FK506-3.4*
[**2117-6-8**] 06:00AM BLOOD FK506-8.8
[**2117-6-5**] 08:05AM BLOOD freeCa-1.16
[**2117-5-21**] 05:30PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.015
[**2117-5-21**] 05:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-1 pH-6.5 Leuks-NEG
[**2117-5-22**] 09:32AM URINE Hours-RANDOM UreaN-820 Creat-150 Na-14
[**2117-6-3**] 06:52AM URINE Osmolal-424
[**2117-6-3**] 06:52AM URINE Hours-RANDOM Creat-76 Na-59 K-36
[**2117-6-3**] 06:52AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2117-6-3**] 06:52AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2117-6-3**] 06:52AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.024
[**2117-5-21**] 05:14PM ASCITES WBC-263* RBC-85* Polys-16* Lymphs-10*
Monos-0 Mesothe-1* Macroph-73*
[**2117-5-28**] 01:50PM ASCITES WBC-75* RBC-150* Polys-7* Lymphs-14*
Monos-64* Mesothe-4* Other-11*
/12 U/S -
1. Hepatic cirrhosis. The hepatic parenchyma is difficult to
assess with ultrasound due to the heterogeneity and the
abnormality identified on recent MRI is not visualized.
2. Patent hepatic veins, hepatic arteries, and portal veins.
3. Moderate ascites.
.
[**5-22**] CT chest -
No good evidence for intrathoracic malignancy. Probable
bronchiolitis and minimal reactive lymph node enlargement.
.
[**5-24**] MRI abdomen -
1. Significant interval enlargement of the previously identified
hepatic mass, which demonstrates minimal enhancement. Given the
presence of a new nodule within the right hepatic lobe and the
patient's underlying cirrhosis, these findings raise concern for
hepatocellular carcinoma, though the enhancement pattern is
unusual. Alternatively, given the presence of vessels coursing
through this mass, a soft lesion such as lymphoma is within the
differential diagnosis. We would recommend a repeat
ultrasound-guided biopsy of this lesion.
2. Findings compatible with cirrhosis and portal hypertension.
3. Ascites.
4. New intrahepatic biliary ductal dilatation.
.
[**5-31**] CT abd/pelvis
1. Large heterogeneously hypodense mass in the right lobe of the
liver as described above, associated with bilateral intrahepatic
ductal dilatation, several smaller areas of hypodensity
especially in the right lobe measuring 1.8 cm. Liver with
increased ascites and splenomegaly. The constellation of the
finding is most worrisome for hepatocellular carcinoma with
multiple foci in the liver. Correlation with biopsy result is
recommended.
2. 4-mm noncalcified nodule at the right lung base, which needs
to be followed in three months in this patient with liver tumor.
3. Cholelithiasis.
Echo
Conclusions:
The left atrium is normal in size. No mass/thrombus is seen in
the left atrium or left atrial appendage. Left ventricular wall
thickness and cavity size are normal.Left ventricular function
is hyperdynamic EF 60-70% .No regional wall motion abnormality
is obseved Right atrium is mildly dilated.Right ventricular
chamber size and free wall motion is normal. Pulmonary artery
catheter is seen in the right ventricle and right ventricular
outflow tract.There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade. Interatrial septum is lipomatous a small PFO
cannot be ruled out .The mitral valveleaflets are normal, no
mitral regurgitation is seen at a SBP of100mm Hg. Due to poor
echo windows unable to comment on tricuspid and aortic
regurgitation
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL
1) No fluid collections around the liver.
2) No evidence of biliary dilatation.
3) Patent portal vein with normal direction of flow. Patent
hepatic veins.
4) The hepatic arteries appear to be patent. However, there is
no diastolic blood flow and perhaps some reversibility of the
diastolic blood flow. Short- term follow up with ultrasound is
recommended.
Brief Hospital Course:
# ESLD - Patient was admitted for worsening liver failure and
workup for liver transplant. He was started on SBP prophylaxis
with daily ciprofloxacin given no evidence of recurrent SBP by
paracentesis and no growth from cultures. No evidence for
portal vein thrombosis on U/S. Patient was started on
rifaximin, actigall, and lactulose. His bilirubin continued to
climb. Repeat imaging showed dramatic enlargement of his liver
mass, preliminary results of liver biopsy were consistent with
hepatocellular carcinoma. Despite liver mass size of 8.8x8.1
cm, it was felt that the rapid growth in size may have been due
to hemorrhage or overestimation on size of mass due to
surrounding vessels. The decision was made to keep the patient
on the transplant list and would receive a transplant if he had
no evidence of metastatic lesions during exploration in the OR.
On [**2117-6-2**] the patient was brought to the OR for liver
transplant. Please see the operative note for further details.
Induction immunosuppression was started intra-op with a tapering
steroid protocol. He remained intubated overnight per protocol
and was brought to the SICU. Diuesis was begun, and he was
extubated late on POD1 without any complications. He remained in
the ICU until POD 2 when he was transfered to the floor. The
patient's course followed the newly developed liver transplant
pathway.
His LFT's improved daily with ast decreasing to 28, alt 55, alk
phos 115, and t.bili 1.8. Albumin was 2.5. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes
center consult was obtained for blood glucose control post-op.
He was treated with a sliding scale insulin regimen. The patient
continued to be diuresed and worked with physical therapy.
Calorie counts were initiated on POD 5. The Chest tube was d/c'd
on POD 8.
.
# ARF/hyponatremia- His acute renal failure responded well to
gentle hydration and he required midodrine/octreotide/albumin
for a short period of time early in his admission. He was
persistently hyponatremic and did not tolerate the addition of
lasix or aldactone. His sodium slowly corrected with fluid
restriction from 750-1000cc.
In the post-op period hyponatremia again was an issue. A renal
consult was obtained. Urine electrolytes revealed a relatively
hypotonic urine, indicating that his kidneys were responding
appropriately. Diuresis was continued. Creatinine improved to
2.8 on pod 13. Fluconazole was renally dosed as well as bactrim
(single strength 3x/wk).
The medial JP was removed on pod 5 with the lateral JP
continued to have outputs of 800 to 650cc/day. He was sent home
with the lateral JP and VNA services were arranged. The
recipient liver pathology report was still pending at time of
discharge. He will follow up in the outpatient clinic for
monitoring of overall function and monitoring of right lung base
non-calcified nodule.
Medications on Admission:
Aldactone 100 mg [**Hospital1 **]
Prilosec 20 mg QD
MVI
Lactulose once daily --> 4 BMs per day
Lasix 40 mg twice a day - recently started
Atenolol 25 mg QD
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks: through POD20, then 17.5 per taper.
Disp:*7 Tablet(s)* Refills:*0*
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily) for 5 weeks.
Disp:*28 Patch 24HR(s)* Refills:*0*
7. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Kayexalate Powder Sig: Thirty (30) grams PO prn.
Disp:*1 * Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Transdermal
once a day for 2 weeks: then d/c.
Disp:*14 * Refills:*0*
12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
13. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection every six (6) hours.
Disp:*1 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] home health
Discharge Diagnosis:
Cirrhosis
HCV
Hyponatremia
Acute renal failure
Discharge Condition:
good
Discharge Instructions:
If you develop fevers, chills, increasing abdominal
pain/distention, persistent nausea/vomiting, bloody or black
stools or other concerning symptoms call your primary care
doctor or return to the emergency room.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2117-6-23**] 11:20
2. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2117-7-29**] 10:00
3. Follow-up with with Dr [**Last Name (STitle) **] or Dr [**First Name (STitle) **] in [**1-11**] weeks. Call
to schedule that appointment. [**Telephone/Fax (1) 673**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2117-6-17**]
|
[
"112.0",
"997.5",
"572.2",
"567.23",
"572.3",
"155.0",
"401.9",
"286.9",
"571.5",
"584.9",
"998.89",
"250.00",
"070.54",
"789.5",
"276.1",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"50.59",
"99.06",
"00.93",
"99.05",
"54.91",
"99.04",
"89.60",
"50.11",
"99.07",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12959, 13017
|
8361, 11246
|
335, 703
|
13108, 13115
|
2369, 8338
|
13375, 13969
|
1794, 1798
|
11452, 12936
|
13038, 13087
|
11272, 11429
|
13139, 13352
|
1813, 2350
|
275, 297
|
731, 1605
|
1627, 1693
|
1709, 1778
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,062
| 131,024
|
24443
|
Discharge summary
|
report
|
Admission Date: [**2102-8-2**] Discharge Date: [**2102-9-1**]
Date of Birth: [**2047-4-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Heparin Agents
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Bleeding right abdominal wound
Major Surgical or Invasive Procedure:
Vac on left abdominal wound to be replaced by plastics, wet to
dry dressings on right abdominal wound
History of Present Illness:
55 yo F, with PMH IDDM x 27 yrs, presents with a spontaneously
bleeding R abdominal wound. Today at 1 pm, pt was lying in bed
and noticed wet bedsheets, and realized that the bedsheets was
drenched in bright red blood. The bleeding stopped for a few
hours, and then re-started again at 4 pm. Total blood loss was
estimated as 1000 ml as per patient. Pt is morbidly obese.
.
Patient has several areas of skin breakdown on abdomen and
sacrum, but most severe are 2 abdominal wounds, one on R lateral
abdomen, one on L lateral abdomen. In mid-[**2102-4-4**], patient
originally presented with an abdominal wall soft tissue
infectionover her bilateral lower quadrants, L>R. Two weeks
after noticing the lesions, she presented to her PCP after they
grew in size. The lesions started draining yellowing malodorous
fluid. She was admitted to [**Hospital1 **] on [**2102-5-30**].
.
The L wound more than the R wound was debrided on [**2102-5-31**] at
[**Hospital 1110**] [**Hospital **] Hospital. The tissue sample at time of
debridement was consistent with "atherosclerosis obliterans with
necrotizing gangrene" as per pathology report. The wound was
healing well initially, but then patient developed more
extensive tunneling necrosis. The wound was cultured and grew
out MSSA and Citrobacter. She was started on IV unasyn, on
which she remained from [**5-31**] to [**2102-6-7**], and was discharged home
on no antibiotics.
.
Both wounds were debrided at [**Hospital1 18**] on [**2102-6-26**], as an outpatient.
She re-presented on [**2102-7-4**] with recrudescence and extension of
her wound from the abdomen down to her LE bilaterally. She was
started on IV unasyn. She had also been treated for chronic
renal insufficiency, anemia (received rbcs and epo). Upon
discharge, patient complained only of minor throbbing pain
associated with the abdominal lesions, slight nausea, and poor
appetite.
.
Both wounds were debrided last Friday at [**Hospital1 18**]. Pt is staying
at [**Hospital 1110**] Rehab Hospital since the end of [**2102-6-4**]. She was
brought to the [**Hospital1 18**] ER after receiving one unit of pRBC. Pt
vomited today, no blood, no mucus.
.
Pt had no fever, chills, cough, runny nose, sore throat,
headache, dizziness, chest pain, SOB. Pt has had no diarrhea or
constipation, no dysuria or urinary urgency. She has no
arthralgias or myalgias. Pt has had normal appetite, and is
independently ambulatory if she may be helped to her feet.
Past Medical History:
-insulin dependent diabetes mellitus
-chronic renal insufficiency
-HTN
-GERD
-COPD
-s/p Caesarian section x 2
-s/p appendectomy
Social History:
The pt. lives with her husband in [**Name (NI) 1110**]. No history of
tobacco, alcohol or illicit drug use.
Family History:
Remarkable for three first degree relatives with AAA.
Physical Exam:
PE:
Vitals: Afebrile / 72 / 18 / 145/25
Gen: In mild distress, in bed, cannot move well
HEENT: PERRL, no JVD, no LAD, dry oral mucosa
Lungs: CTA B
Heart: RRR, no m/r/g
Abd: R abdominal wound is quite large and deep, is mildly
malodorous, packed by Plastics. L abdominal wound has a vac
attached to it, with the end of it free
Extr: No c/c, 3+ pitting edema
Neuro: [**6-8**] motor, sensation equal and intact throughout, pulses
cannot be palpated due to overlying adipose tissue
Pertinent Results:
[**2102-8-1**] 09:30PM PT-15.4* PTT-29.4 INR(PT)-1.6
[**2102-8-1**] 09:30PM PLT COUNT-468*
[**2102-8-1**] 09:30PM NEUTS-89.1* BANDS-0 LYMPHS-4.9* MONOS-4.2
EOS-1.5 BASOS-0.3
[**2102-8-1**] 09:30PM WBC-14.2* RBC-3.33* HGB-9.3* HCT-29.8* MCV-90
MCH-27.9 MCHC-31.1 RDW-15.7*
[**2102-8-1**] 09:30PM CALCIUM-7.7* PHOSPHATE-6.9*# MAGNESIUM-1.6
[**2102-8-1**] 09:30PM GLUCOSE-73 UREA N-97* CREAT-5.6*# SODIUM-130*
POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-12* ANION GAP-25*
[**2102-8-1**] 10:08PM LACTATE-1.4
[**2102-8-1**] 11:55PM URINE RBC-0-2 WBC-[**12-24**]* BACTERIA-MOD
YEAST-MANY EPI-[**4-8**] TRANS EPI-[**4-8**]
[**2102-8-2**] 03:10PM ALT(SGPT)-9 AST(SGOT)-12 LD(LDH)-252* ALK
PHOS-296* AMYLASE-266* TOT BILI-0.5
[**2102-8-2**] 05:17PM PTH-485*
Brief Hospital Course:
1. ABDOMINAL WOUNDS:
The patient's abdominal wounds were each approximately 10x14x10
cm, on lateral sides of the abdomen. The right wound had
initially presented with profuse bleeding, which was stopped
with suture of the vessel by plastics. 1 unit RBC was
transfused before admission. The wounds were diagnosed as
likely calciphylaxis, due to disposition and risk factors of
patient. The wound biopsy report did note, however, that there
was focal calcification around vessels rather than medial
calcification characteristic of calciphylaxis. Plastic surgery
recommended no further debridement for the wounds, since
previous debridements had simply left larger wounds which had
not healed.
.
The pt's abdominal wounds were chronically colonized with
bacteria. Two wound cultures revealed presence of Enterococcus,
Stenotrophomonas, and Pseudomonas in both wounds. The wounds
improved initially in draining much less purulent material, and
wet to dry dressings TID to QID were far less green and yellow.
Dressing changes revealed clear serosanguinous drainage with
streaks of pale green. Throughout the pt's course on the floor,
the pt was on Augmentin, Unasyn, Cipro, Vanco, Tobra, Zosyn,
Gent. Infectious disease consult reported that wounds were
likely colonized, and thus all abx were stopped.
.
Significantly, from [**Date range (1) 61844**]/05, pt's wounds started evolving
and becoming worse. The wounds had always been black and
necrotic, but erythema started extending onto the skin around
the wounds, and large blistering of the skin started occurring
around the edges of the wounds. The pt had not needed pain
medications for wound changes until these last 7-10 days, when
wound changes became very painful.
.
There were multiple areas of skin breakdown on the pt's body,
including a total of 18 areas of skin breakdown. Other
significant areas of skin breakdown included the medial areas of
the proximal LEs, where there was extensive large blistering and
denudation of the epithelial layer, sacral and spinous ulcers,
and a large R heel ulcer.
.
2. ACUTE ON CHRONIC RENAL FAILURE:
Pt had a chronic severe anion gap metabolic acidosis, presumed
to be from uremia and lactic acidosis, as well as a
hypochloremic metabolic alkalosis, presumed to be from chronic
episodic vomiting QOD from uremia. The pt's metabolic acidosis
was extremely difficult to control. Etiologies of chronic renal
insufficiency were diabetes mellitus type 2 and HTN.
.
Significantly, from [**Date range (1) 61844**]/05, the pt's Cr rose from 3.5 to
6.7, and pt rapidly went into acute anuric renal failure.
Etiology of acute on chronic renal failure was not identified.
Pt was not prerenal, but urine eosinophils were present. Renal
US was not done due to habitus of pt and likely difficulty in
interpreting results. Renal biopsy was also not performed, due
to pt's gradually increasing INR and risk of gross hemorrhage,
and also because pt would not be a viable candidate for steroid
treatment, and thus the endpoint of treatment for pt would
likely include dialysis.
.
3. LEUKOCYTOCLASTIC VASCULITIS:
On admission, pt had a chronic, moderate morbilliform pustular,
non-pruritic rash on her shoulders, proximal UEs, and upper
back.
.
On [**2102-8-9**], pt started developing a palpable, erythematous,
pruritic maculopapular rash predominantly on her shoulders and
arms, but also on her back, trunk, and upper abdomen, that
evolved into urticarial lesions over one day, and then evolved
into a confluent, erythematous, diffuse, non-palpable, pruritic
maculopapular rash with desquamation around her wrists, which
then evolved into [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] reticular rash characteristic of livedo
reticularis. Skin biopsy revealed the presence of
leukocytoclastic vasculitis, presumed to be drug-related from a
penicillin derivative, due to urticarial lesions and increase in
serum eosinophils to 5-11%. ESR was elevated to 87, and CRP was
over 200.
.
The skin rash on her arms resolved over several days from the
shoulders down to the wrists and hands.
.
4. MENTAL STATUS CHANGE:
The pt had no mental status changes until [**2102-8-13**], when pt was
noted to be more irritable and restless. Mental status changes
and delirium developed quickly from [**8-13**] until [**Hospital **] transfer to
MICU. Early in mental status change, pt was only irritable, but
A&Ox3. After 2-3 days, pt had changes of disorientation, not
knowing her own name, trying to climb out of bed on her own,
slurring speech, visual changes which would occur only at night.
Approximately 4-5 days from start of mental status changes,
changes occurred at all times of the day. Etiology of mental
status change was likely due to infection, although other
possibilities are renal failure and CNS vasculitis. CT Head
showed no acute intracranial bleed, which had been a concern due
to chronically increased INR of 1.5, due to poor nutrition and
low Vit K.
.
5. DIABETES MELLITUS, TYPE 2:
Pt had had a diagnosis of diabetes mellitus type 1 upon
admission, but was re-diagnosed with diabetes mellitus type 2
during this admission. Pt's serum glucose was tightly
controlled from 70-150 at all times. Pt was maintained on
Lantus 80 QHS, but starting from [**8-13**] on, the amount of Lantus
was gradually decreased, until the pt was not maintained on any
insulin in the last few days before transfer to MICU.
.
6. SEPSIS:
The patient was transferred to the MICU [**2102-8-28**] with sepsis
secondary to worsening abdominal wounds and pseudomonal
bacteremia. She required blood pressure support with levophed
and vasopressin. She was treated with broad spectrum
antibiotics including vancomycin, Zosyn, and metronidazole. She
was intubated. Infectious diseases, dermatology, and plastic
surgery services were consulted. Despite all efforts, he
pseudomonal necrotizing skin wounds continue to progress. She
required increasing pressor support. Several family meetings
were held to provide the family and healthcare proxy with
updated medical information. Recognizing lack of improvement
and progression of underlying ulcerative disease and sepsis, a
unanimous family decision was made on [**2102-9-1**] to withdraw care.
She expired within hours. An autopsy was performed.
Medications on Admission:
Lasix 160 mg PO QD -- held
Glargine insulin 80 units QHS
Humalog insulin sliding scale
Procrit 10,000 units sc 2x/week -- held
Renagel 1600 mg PO TID
Unasyn 1.5 g IV Q8H
Percocet 5/325 mg 1-2 tabs PO q4-6 h prn pain
Atenolol 25 mg PO BID
Compazine 10 mg PO Q8H prn nausea
Acetaminophen 650 mg PO Q4H prn pain
Discharge Medications:
expired
Discharge Disposition:
Extended Care
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"286.7",
"278.01",
"995.92",
"446.29",
"285.1",
"518.81",
"707.8",
"287.5",
"729.39",
"348.39",
"V58.67",
"588.81",
"584.9",
"403.91",
"496",
"785.4",
"250.40",
"785.52",
"038.43",
"998.32",
"682.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"39.32",
"96.72",
"99.15",
"00.14",
"00.17",
"39.95",
"96.04",
"38.95",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11270, 11285
|
4579, 10879
|
314, 417
|
11337, 11347
|
3793, 4556
|
11404, 11541
|
3216, 3271
|
11238, 11247
|
11306, 11316
|
10905, 11215
|
11371, 11381
|
3286, 3774
|
244, 276
|
445, 2921
|
2943, 3073
|
3089, 3200
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,255
| 100,087
|
40317
|
Discharge summary
|
report
|
Admission Date: [**2126-11-1**] Discharge Date: [**2126-11-6**]
Date of Birth: [**2069-11-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
s/p PEA arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 year old male with history of atrial fibrillation, DM2, prior
MI presents s/p PEA arrest at an OSH after VATS.
.
Patient is intubated and unresponsive on arrival, history is
obtained from outside records.
.
In early [**Month (only) 359**], he had a sore throat and felt poorly. He went
to his PCP and was treated with 10 days of ammoxicillin. he then
was treated with penicillin for a dental extraction. Shortly
after this, he became progressively short of breath. He saw his
PCP who referred him to Cardiology (Dr. [**Last Name (STitle) 77919**]. At that
time a CXR was performed that showed opacification of the right
lower [**12-9**] to [**12-8**] hemithorax, interpreted as infiltrate + pleural
effusion. He also had a stress echocardiogram and a cardiac
catheterization was planned. A chest X-ray was repeated on
[**2126-10-28**], which was unchanged. His cath was deferred and he was
scheduled to undergo VATS with possible pleural decortication.
.
He was admitted to [**Hospital3 26615**] on [**2126-10-30**] for VATS and
bronchoscopy. 2600 cc of straw colored pleural fluid was
removed, and pleural biopsy was taken. At the end of the
procedure, prior to extubation, patient had a drop in blood
pressure and suffered a PEA arrest. Patient received
defibrillation, epinephrine, and chest compresions for 17
minutes. He returned to [**Location 213**] sinus rhythm, and was transferred
to the ICU. He was put on a lasix drip. There an echo
demonstrated no pericardial effusion, and and CT PA demonstrated
no PE. His labs were significant for a WBC of 12. Cardiac
enzymes were flat. He was treated with levaquin and unasyn for
presumed PNA. He was weaned off of sedation and only responded
to noxious stimuli. He was evaluated by neurology who
recommended MRI and EEG. He is transferred to [**Hospital1 18**] for further
cardiology and neurology evaluation. On transfer, he was on a
heparin drip, midazolam/fentanyl for sedation and mechanical
ventilation (AC).
Past Medical History:
- Atrial Fibrillation
- Diabetes Type II
- H/O MI
Social History:
-Tobacco history: Quit smoking three years ago, 1 ppd x 20 years
previously
-ETOH: 12 pack on weekends
-Illicit drugs:
Family History:
NC
Physical Exam:
VS: T= 99.7 BP= 126/81 HR= 78 RR= 16 O2 sat= 100/ AC FiO2 100,
Tv 550, RR 16, PEEP 5
GENERAL: Intubated, sedated, not responsive to commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 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.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
NEURO: Unresponsive to commands. Pupils reactive to light,
corneal relfex intact. Babinski up going. no spontaneous
movement observed.
.
At time of death: extubated
Pertinent Results:
[**2126-11-1**] 06:22PM BLOOD WBC-9.1 RBC-4.64 Hgb-14.7 Hct-41.6 MCV-90
MCH-31.8 MCHC-35.4* RDW-13.5 Plt Ct-222
[**2126-11-1**] 06:22PM BLOOD Neuts-74.9* Lymphs-17.0* Monos-5.7
Eos-0.7 Baso-1.8
[**2126-11-1**] 06:22PM BLOOD PT-15.6* PTT-32.2 INR(PT)-1.4*
[**2126-11-2**] 04:11AM BLOOD ESR-30*
[**2126-11-1**] 06:22PM BLOOD Glucose-143* UreaN-16 Creat-1.0 Na-136
K-3.7 Cl-98 HCO3-29 AnGap-13
[**2126-11-1**] 06:22PM BLOOD ALT-24 AST-51* CK(CPK)-100 AlkPhos-75
TotBili-2.1*
[**2126-11-2**] 04:11AM BLOOD ALT-22 AST-50* AlkPhos-69 TotBili-2.0*
[**2126-11-3**] 04:26AM BLOOD ALT-22 AST-54* AlkPhos-69 TotBili-2.4*
[**2126-11-1**] 06:22PM BLOOD CK-MB-1 cTropnT-<0.01
[**2126-11-1**] 06:22PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
[**2126-11-2**] 04:11AM BLOOD CRP-41.7*
[**2126-11-2**] 04:11AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2126-11-1**] 06:27PM BLOOD Type-ART pO2-386* pCO2-39 pH-7.48*
calTCO2-30 Base XS-6
[**2126-11-3**] 05:12AM BLOOD Type-ART pO2-143* pCO2-39 pH-7.47*
calTCO2-29 Base XS-5
[**2126-11-1**] 06:27PM BLOOD Lactate-1.6
.
EEG: This is an abnormal routine EEG due to the presence of a
low-voltage background that was invariant and nonreactive to
external
stimulation. This finding suggests a diffuse and severe
encephalopathy,
such as that caused by hypoxic-ischemic injury, toxic-metabolic
changes,
or medication effect, among other things. There were no focal
abnormalities or epileptiform features noted.
.
PCXR: The ET tube tip is 5.2 cm above the carina. The NG tube
tip passes below the diaphragm with its tip being in the
stomach.
Diffuse pericardial calcification is noted, circumferential.
Mediastinum is minimally widened but it might be related to
portable technique of the study. There is minimal vascular
congestion but no overt edema. Left retrocardiac opacity might
represent area of atelectasis, aspiration or infectious process
and should be closely monitored.
.
TTE: The left atrium is elongated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. There is mild to moderate regional left ventricular
systolic dysfunction with basal to mid inferior, inferolateral,
and anterolateral hypokinesis. Due to suboptimal technical
quality, additional focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
mildly depressed (LVEF= 40%). Unable to assess left ventricular
diastolic function. Right ventricular chamber size and free wall
motion are normal. There is abnormal septal motion/position. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
.
MR HEAD W/ and W/O CON:
1. Extensive confluent areas of decreased diffusion in the
bilateral parietal and occipital [**Month/Day/Year 3630**] and parts of the frontal
lobes likely related to cortical infarction with some degree of
cortical swelling. Spreading of the temporal lobes, the basal
ganglia and the right cerebellar hemisphere and probably the
left cerebellar hemisphere. Correlate clinically and consider
followup/correlation with brain scan.
2. Area of increased signal intensity on the T2 and FLAIR
sequences in the
right frontal [**Last Name (LF) 3630**], [**First Name3 (LF) **] relate to changes in the parenchyma
surrounding small developmental venous anomaly. However, given
the lack of prior studies and the extent of FLAIR hyperintense
area, which measures 2.1 x 2.6 cm, consider followup to assess
stability/progression to exclude any associated low-grade
neoplasm.
3. Mucosal thickening in the mastoid air cells on both sides,
right more than left.
.
Brief Hospital Course:
#. s/p PEA arrest. Post-op/peri anesthesia hypotension most
likely precipitant of PEA. Possible contribution from hypoxia
given lung collapse seen on CT. CT PA negative for PE, echo
negative for tamponade. Labs essentially normal, cardiac enzymes
negative. Neurology consulted and EEG and MRI head done, all
consistent with very poor neurologic prognosis. Neurology team
explained prognosis to patient's family and they agreed that it
would not be within his wishes to exist without meaningful
interaction. NEOB was initially contact[**Name (NI) **] but pt. was no longer
a possible donor once extubated.
.
# Respiratory Failure/Pleural Effusion: Patient was never
extubated post-thoracentesis. Continued levaquin and unasyn
given concern for aspiration/oral flora given unilateral PNA,
recent tooth extraction and alcohol history. Pleural fluid
analysis not an empyema, but suggestive of exudate. Fluid
cytology negative. Patient was overbreathing vent with excellent
RSBI prior to extubation. He was made DNR/DNI prior to
extubation. He was successfully extubated on [**11-4**] and morphine
drip was given with scopolamine patch for comfort measures. He
expired on the morning of [**11-6**]. Autopsy was requested by the
family.
Medications on Admission:
HOME MEDICATIONS:
Metformin 1000mg PO bid
ASA 325mg PO daily
Glyburide 5mg PO bid
Imdur 30mg PO daily
.
MEDICATIONS ON TRANSFER:
Combivent
Heparin gtt 900 U/hr
Unasyn 3gm IV q6
Levaquin 750 mg q24
Lasix 40mg IV q daily
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p PEA arrest
Death
Discharge Condition:
Expired
|
[
"412",
"428.0",
"401.9",
"511.9",
"427.5",
"423.2",
"250.00",
"518.0",
"348.1",
"E879.4",
"348.30",
"518.81",
"486",
"V15.82",
"427.31",
"997.1",
"428.20",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8964, 8973
|
7462, 8694
|
330, 336
|
9037, 9047
|
3582, 7439
|
2562, 2566
|
8994, 9016
|
8720, 8720
|
2581, 3563
|
8738, 8824
|
276, 292
|
364, 2335
|
8849, 8941
|
2357, 2409
|
2425, 2546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,582
| 159,171
|
6330
|
Discharge summary
|
report
|
Admission Date: [**2157-7-12**] Discharge Date: [**2157-7-25**]
Service: CARDIOTHOR
CHIEF COMPLAINT: Shortness of breath and back pain.
HISTORY OF THE PRESENT ILLNESS: The patient is an
83-year-old woman with a history of atrial fibrillation,
hypertension, hypothyroidism, who presented with shortness of
breath and back pain. The patient was well until four days
ago, when she noted rapid heart rate. This was accompanied
by whole-body muscle aches. The patient went to her primary
care physician and after being given medicine she was sent
home. Later that evening, she had acute onset of sharp pain
in the scapula and back. The pain was constant, lasting over
the last four days, worse with inspection. The patient also
felt unsteady, but denied chest pain, nausea, vomiting,
diaphoresis, abdominal pain, constipation, or diarrhea. The
patient was also noted to be increasing shortness of breath
with exertion over the past several days. The patient cannot
say how long she usually walks, but she feels that it is a
lot less today. The patient denies shortness of breath at
rest, orthopnea, and nocturnal dyspnea.
Last night, the patient felt symptoms worsen since the
previous two nights. She could not sleep. She was scheduled
for an echocardiogram this AM, but deferred to the emergency
department, where she was given 6 mg morphine to treat the
pain.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Atrial fibrillation.
3. Mitral valve prolapse.
4. Hypothyroidism.
5. Osteoporosis.
6. Colonic cancer, status post partial colectomy in [**2126**].
7. B12 deficiency.
8. Hypercholesterolemia.
9. Depression.
10. Degenerative joint disease.
11. Congestive heart failure.
12. Status post appendectomy.
13. Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy and status post cataract removal.
ALLERGIES: The patient is allergic to PENICILLIN, WHICH
CAUSES A RASH.
MEDICATIONS PRIOR TO ADMISSION:
1. Warfarin 1 mg q.h.s.
2. Amiodarone 400 mg q.d.
3. Toprol 200 mg q.d.
4. Synthroid 88 mcg q.d.
5. Vitamin E 400 mg q.d.
6. Diltiazem XL 240 mg q.d.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is widowed. The patient lives
with son. [**Name (NI) 1139**]: Greater than 40 pack years, however,
quit years ago. Alcohol: Occasional use. No other drug
use.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: VITAL SIGNS: Temperature 95.2, heart rate 93,
blood pressure 117/68, respiratory rate 22, oxygen saturation
95% on two liters. GENERAL: This is an elderly woman, lying
in bed in no acute distress. HEENT: No JVD, no
lymphadenopathy. Cor: Regular rate and rhythm, no murmurs,
rubs, or gallops. LUNGS: Lungs were clear to auscultation
bilaterally. ABDOMEN: Soft, nontender, nondistended with
positive bowel sounds. EXTREMITIES: No edema, 2+ dorsalis
pedis pulses bilaterally.
LABORATORY DATA: Laboratory data revealed the following:
White count 10, hematocrit 29.3, platelet count 263,000,
sodium 143, potassium 4.6, chloride 108, CO2 22, BUN 59,
creatinine 1.5, glucose 139, AST 39, ALT 41, alkaline
phosphatase 83, amylase 102, lipase 20, INR 3.3, PTT 33.2,
urinalysis trace ketones and 3+ protein. Urine toxicity
screen was positive for opiates.
EKG: Sinus rhythm, PR of 0.214 and QRS of 100.
Echocardiogram done on [**4-6**], showed an EF of 55% with
normal wall motion. Echocardiogram done on the day of
admission showed 4+ mitral regurgitation, 2+ tricuspid
regurgitation, with normal LV.
HOSPITAL COURSE: The patient was admitted to the Medical
Service for rule out myocardial infarction. Cardiothoracic
Surgery was consulted regarding possible mitral valve
replacement. At that point, they requested that the patient
be catheterized. She remained in the hospital due to an
elevated INR, waiting for the INR to become less than 17 so
that she could be catheterized. On [**7-15**], she was
brought to the catheterization laboratory. (please see
catheterization report for full details). Summary of the
catheterization showed mildly elevated wedge pressure with
normal EF and 4+ MR. [**Name13 (STitle) **] coronary arteries were widely
patent. She was also noted to have trace aortic
insufficiency. Following this study, cardiothoracic surgery
was again consulted and the patient was scheduled for mitral
valve replacement. On [**7-19**], the patient was brought
to the operating room. (please see operating report for full
details). In summary, the patient had mitral valve
replacement with a #29 St. [**Male First Name (un) 923**] mechanical valve. The
patient tolerated the operation well. Following surgery, the
patient was transferred from the operating room to the
Cardiothoracic Intensive Care Unit. The patient did well in
the immediate postoperative period. Following arrival in the
Intensive Care Unit, anesthesia was reversed and she was
weaned from the ventilator and ultimately successfully
extubated. On postoperative day #1, she was weaned from all
cardio-active drugs. The chest tubes were removed. On
postoperative day #2, she was transferred to the floor for
continuing postoperative care and cardiothoracic
rehabilitation. Once on the floor, the patient's activity
level was increased with the assistance of the nursing staff
and the Department of Physical Therapy. She was begun on
Coumadin.
On postoperative day #4, it was felt that the patient was
stable and ready to be transferred to the Rehabilitation
Floor for continuing recovery from her surgery. At the time
of transfer, the patient's physical examination was as
follows; VITAL SIGNS: Temperature 98.1, heart rate 92,
blood pressure 127/75, respiratory rate 18, oxygen saturation
92% on room air. Weight, preoperatively was 41.5 kg and on
discharge the weight was 46.2 kg.
LABORATORY DATA: Laboratory data revealed the following:
White count 11, hematocrit 29, platelet count 197,000, PT
12.8, INR 1.1, sodium 133, potassium 4.3, chloride 98, CO2
25, BUN 18, creatinine 0.8, glucose 91.
PHYSICAL EXAMINATION: Examination revealed the patient to be
alert and oriented times three, moves all extremities,
follows commands, conversant. RESPIRATORY: Breath sounds
clear to auscultation bilaterally. CARDIOVASCULAR:
atrial fib, S1, S2, with click. Sternum is
stable. Incision with Steri Strips, open to air, clean, and
dry. ABDOMEN: Soft, nontender, normoactive bowel sounds.
EXTREMITIES: Warm, dry, and well perfused, no clubbing,
cyanosis or edema.
DISCHARGE MEDICATIONS:
1. Metoprolol 100 mg b.i.d.
2. Ranitidine 150 mg b.i.d.
3. Colace 100 mg b.i.d.
4. Furosemide 20 mg b.i.d. times two weeks.
5. Potassium chloride 20 mEq b.i.d. times two weeks.
6. Synthroid 88 mcg q.d.
7. Warfarin 2 mg q.h.s. goal INR is 2.5 to 3. Of note:
Warfarin dose at home prior to surgery was 1 mg and she was
admitted to the hospital with INR of 3.3.
8. Tylenol 650 mg q.6h.p.r.n.
9. Ibuprofen 400 mg to 600 mg q.4h.p.r.n.
10. Amiodarone 200 mg q.d.
CONDITION ON DISCHARGE: Stable.
The patient is to be discharged to rehabilitation. She is to
have follow up with Dr. [**Last Name (STitle) **] in four weeks and follow up
with her primary care physician also in four weeks.
DISCHARGE DIAGNOSES:
1. Status post mitral valve replacement with a #29 St. [**Male First Name (un) 923**]
mechanical valve.
2. Hypothyroidism.
3. Hypertension.
4. Atrial fibrillation.
5. Colonic cancer status post partial colectomy.
6. Osteoporosis.
7. Hypercholesterolemia.
8. Vitamin B deficiency.
9. Degenerative joint disease.
10. Depression.
11. Status post appendectomy.
12. Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy.
13. Status post cataract removal.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2157-7-22**] 16:52
T: [**2157-7-22**] 17:03
JOB#: [**Job Number 24501**]
|
[
"401.9",
"272.0",
"V10.05",
"424.0",
"427.31",
"244.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"37.23",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
2127, 2145
|
7240, 7984
|
6523, 6992
|
3544, 6031
|
1953, 2110
|
6054, 6500
|
114, 1386
|
1408, 1921
|
2162, 2340
|
7017, 7219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,369
| 194,696
|
40914
|
Discharge summary
|
report
|
Admission Date: [**2200-5-21**] Discharge Date: [**2200-5-27**]
Date of Birth: [**2128-6-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
intermittant chest pain
Major Surgical or Invasive Procedure:
[**2200-5-22**]: s/p Coronary artery bypass grafting x3 (left internal
mammary artery to left anterior descending artery; and
saphenous vein grafts to the obtuse marginal artery and the
posterior descending artery).
History of Present Illness:
71 year old female with history of CAD and previous PCI in [**2196**],
was in good health until 2 weeks ago when she developed chest
pain across her chest when ingesting food. Pain was relieved
with TUMS and belching. No history of GERD.
[**Year (4 digits) **] with chest pain on [**2200-5-20**] and was scheduled to see her
PCP for clearance for left retina surgery. EKG revealed changes.
She was then sent to her cardiologist Dr. [**Last Name (STitle) 8579**] for evaluation
of unstable angina.
She was admiited to [**Hospital **] Hospital and underwent cardaic cath
on [**2200-5-21**] which showed 3 vessel disease. She was transffered to
[**Hospital1 18**] for evaulaton of surgical revascularization.
Past Medical History:
PMH:
Coronary Artery Disease- Percutaneous Intervention(RCA) [**2196**],
hyperlipidemia,
diabetes,
Peripheral artery disease,
osteoarthritis
Chronic Renal Insufficiency(1.3)
Left retinal hemorrhage ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11401**]-[**Hospital1 3278**]/opthamologist)
PSH:
Bladder suspension
Bilat knee replacement
Bilat carpal tunnel
Bilat cataract [**Doctor First Name **]
Thrombebectomy left popliteal
Social History:
Race: caucasian
Last Dental Exam: edentulous
Lives with:divorced
Occupation: retired
Tobacco: non-smoker
ETOH: occaisional
Family History:
Mother , brother , sister w/ diabetes, father peripheral
vascular disease
Physical Exam:
T 97.3 Pulse: 66 Resp: 20 O2 sat: 96%-RA
B/P Right: 140/57 Left:
Height: 5'2" Weight: 230lbs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] non JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur-none
Abdomen:Obese: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None
Neuro: Grossly intact, nonfocal exam
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit Right: no Left: no
Pertinent Results:
Admission Labs:
[**2200-5-21**] 08:20PM PT-12.5 PTT-22.9 INR(PT)-1.0
[**2200-5-21**] 08:20PM PLT COUNT-194
[**2200-5-21**] 08:20PM WBC-6.9 RBC-4.10* HGB-11.5* HCT-35.1* MCV-86
MCH-28.1 MCHC-32.8 RDW-14.2
[**2200-5-21**] 08:20PM %HbA1c-8.2* eAG-189*
[**2200-5-21**] 08:20PM ALBUMIN-3.8 MAGNESIUM-2.0
[**2200-5-21**] 08:20PM CK-MB-4 cTropnT-0.08*
[**2200-5-21**] 08:20PM LIPASE-22
[**2200-5-21**] 08:20PM ALT(SGPT)-19 AST(SGOT)-24 CK(CPK)-120 ALK
PHOS-72 AMYLASE-46 TOT BILI-0.2
[**2200-5-21**] 08:20PM GLUCOSE-264* UREA N-41* CREAT-1.4* SODIUM-134
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-24 ANION GAP-13
Discharge labs:
[**2200-5-27**] 05:20AM BLOOD WBC-11.8* RBC-3.12* Hgb-8.9* Hct-26.8*
MCV-86 MCH-28.6 MCHC-33.3 RDW-14.7 Plt Ct-180
[**2200-5-27**] 05:20AM BLOOD Plt Ct-180
[**2200-5-23**] 01:27PM BLOOD PT-14.0* PTT-27.9 INR(PT)-1.2*
[**2200-5-27**] 05:20AM BLOOD UreaN-32* Creat-1.2* Na-139 K-5.3* Cl-99
[**2200-5-26**] 06:35AM BLOOD Glucose-118* UreaN-38* Creat-1.4* Na-138
K-4.9 Cl-101 HCO3-30 AnGap-12
[**2200-5-27**] 05:20AM BLOOD Mg-2.3
Radiology Report CHEST (PA & LAT) Study Date of [**2200-5-26**] 5:16 PM
Final Report: Post-operative enlargement of the upper
mediastinum improved between [**5-23**] and [**5-25**] and has not
changed subsequently. Mild-to-moderate cardiomegaly is
comparable to the pre-operative appearance. Pleural effusion on
the left is minimal, absent on the right. No pneumothorax. Mild
atelectasis left upper lobe unchanged. No pulmonary edema.
DR. [**First Name (STitle) 13879**] [**Name (STitle) 13880**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Date/Time: [**2200-5-23**] at 09:10 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. 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. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] 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.
Conclusions
Prebypass
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 simple
atheroma in the descending thoracic aorta. 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. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**5-23**]/2011at 900am
Post bypass
Patient is a paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Aorta is intact
post decannulation. Trace mitral regurgitation present .
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2200-5-23**] 14:36
Brief Hospital Course:
Ms [**Known lastname 89329**] [**Last Name (Titles) 5058**] with chest pain on [**2200-5-20**] and saw her PCP an
EKG revealed changes. She was then sent to her cardiologist Dr.
[**Last Name (STitle) 8579**] for evaluation of unstable angina.
She was admiited to [**Hospital **] Hospital and had a cardaic
catheterization on [**2200-5-21**] which showed 3 vessel disease. She
was transffered to [**Hospital1 18**] for evaulaton of surgical
revascularization. She had the usual cardiac surgery preop
evaluation and was found to have a urinary tract infection that
was appropriately treated. She was brought to the operating room
for coronary bypass grafting on [**2200-5-22**]. Please see operative
report for details, in summary she had: Coronary artery bypass
grafting x3 with left internal mammary artery to left anterior
descending artery; and
saphenous vein grafts to the obtuse marginal artery and the
posterior descending artery. Endoscopic harvesting of the long
saphenous vein. Her bypass time was 87 minutes with a
crossclamp time of 76 minutes. She tolerated the operation well
and post operatively was transferred to the cardiac surgery ICU.
She was hemodynamically stable in the immediate post-op period,
she woke neurologicvally intact and was extubated on the day of
surgery. She continued to do well post-operatively and was
transferred to teh cardiac surgery stepdown floor on POD2. All
tubes lines and drains were removed per cardiac surgery
protocol. The remainder of her hospital course was uneventful.
On POD4 she was transferred to rehabilitation at [**Hospital 19771**]
Nursing Care in [**Location (un) 2624**]. She is to followup with Dr [**Last Name (STitle) 7772**]
in 3 weeks.
Medications on Admission:
Medications at home:
lantus 62 units at bedtime, Novolog 15 units TID,
atenolol 50mg [**Hospital1 **],
Diovan 320 qhs,
lasix 20mg daily,
simvastatin 80mg daily,
ASA 81mg daily,
Prednisone 1% left eye 1 drop QID,
Nitro SL prn.
Plavix - last dose: one dose 75mg [**2200-5-20**]
On transfer
Heparin 600u/hr
Omeprazole 40 daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
5. tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
6. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. insulin glargine 100 unit/mL Cartridge Sig: 62 units
Subcutaneous at bedtime.
10. insulin lispro 100 unit/mL Cartridge Sig: see Sliding Scale
Subcutaneous ACHS: per SS protocol.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Hellenic - [**Location (un) 2624**]
Discharge Diagnosis:
coronary artery disease
s/p Coronary artery bypass grafting x3 (left internal mammary
artery to left anterior descending artery; and saphenous vein
grafts to the obtuse marginal artery and the posterior
descending artery).
Secondary:
CAD w/ PCI(RCA) [**2196**],
hyperlipidemia,
diabetes,
Peripheral artery disease,
osteoarthritis
Chronic Renal Insufficiency(1.3)
Left retinal hemorrhage ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11401**]-[**Hospital1 3278**]/opthamologist)
Past Surgical History:
Bladder suspension
Bilat knee replacement
Bilat carpal tunnel
Bilat cataract [**Doctor First Name **]
Thrombebectomy left popliteal
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: Trace (B) LE
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call 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) 170**] on [**6-19**] at 1:15pm
Cardiologist:Dr. [**Last Name (STitle) 8579**] on [**6-26**] at 10:30am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 8535**],[**First Name8 (NamePattern2) 768**] [**Doctor Last Name 162**] [**Telephone/Fax (1) 8539**] in [**12-29**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2200-5-27**]
|
[
"250.50",
"585.9",
"362.02",
"276.7",
"443.9",
"411.1",
"272.4",
"414.01",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
9755, 9817
|
6724, 8430
|
335, 554
|
10511, 10744
|
2665, 2665
|
11631, 12245
|
1914, 1990
|
8805, 9732
|
9838, 10334
|
8456, 8456
|
10768, 11608
|
3299, 6701
|
8477, 8782
|
10357, 10490
|
2005, 2646
|
271, 297
|
582, 1290
|
2681, 3283
|
1312, 1757
|
1773, 1898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,855
| 157,239
|
49241
|
Discharge summary
|
report
|
Admission Date: [**2193-12-2**] Discharge Date: [**2193-12-4**]
Date of Birth: [**2135-6-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Rigid Bronchoscopy with tumor ablation and bleeding coagulation.
History of Present Illness:
The patient is a 58 female with a h/o met breast CA to lung
(RUL), retroperitoneum, and right ureter s/p stent with
recurrent episodes of hemoptysis x 1 week who presented to
[**Hospital3 7571**]Hospital. She was transferred from [**Hospital **]for further assessment of her hemoptysis.
Past Medical History:
R breast CA dx [**2175**] s/p mesectomy
L breast CA dx [**2190**] s/p lumpectomy + chemo
Ovarian CA dx [**2191**] s/p TAH+BSO + chemo
Osteoporosis
Asthma
Social History:
Lives with her husband and has a son and daughter. She denied
smoking and drinks EtOH socially.
Family History:
Mother with ovarian cancer.
Physical Exam:
DISCHARGE PE:
Vitals: 98.0 107 90/47 33 98% 6 liters nasal cannula
Gen: NAD
CVS: RRR
Resp: CTA bilaterally
Abd: soft, ND, NT, NABS
Ext: no cyanosis, cords, or edema.
Pertinent Results:
[**2193-12-4**] 05:00AM BLOOD WBC-8.5 RBC-3.66* Hgb-10.7* Hct-32.3*
MCV-88 MCH-29.2 MCHC-33.1 RDW-17.8* Plt Ct-261
[**2193-12-4**] 05:00AM BLOOD PT-12.3 PTT-24.7 INR(PT)-1.1
[**2193-12-4**] 05:00AM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-138
K-3.6 Cl-99 HCO3-32 AnGap-11
[**2193-12-4**] 05:00AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.8.
.
CHEST (PORTABLE AP) [**2193-12-3**] 5:05 PM
REASON FOR THIS EXAMINATION:
r/o ptx and pneumomediatinum
INDICATION: Status post rigid bronchoscopy for tumor destruction
- tumor ablation. Evaluate for pneumothorax or
pneumomediastinum.
FINDINGS: AP single view with patient in upright sitting
position has been obtained. There are extensive central
pulmonary infiltrates on the right side, a lesser degree also in
the central portion of the left lung. In addition, multiple
round densities are disseminated in both lungs and suggest the
possibility of secondary metastatic deposits. There is no
evidence of pneumothorax or pneumomediastinum on this single AP
view chest examination. A chest CT was performed earlier during
the same day, but previous chest examinations are not available
so that direct comparison can be performed.
.
CT CHEST W/CONTRAST [**2193-12-3**] 12:36 AM
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with questionable RUL mass with h/o hemoptysis
REASON FOR THIS EXAMINATION:
eval RUL mass
INDICATION: Hemoptysis. Questionable right upper lobe mass.
History of breast cancer.
No prior chest radiographs or chest CT scans are available for
comparison. Comparison is made to CT abdomen of [**2191-3-2**].
Multidetector CT of the chest was performed following
intravenous administration of 65 cc of Optiray. Images were
presented for display in the axial plane at 5 mm and 1.25 mm
collimation.
Numerous bilateral pulmonary nodules are present involving all
lobes of both lungs. These range in size from less than 1 cm to
several cm in diameter. On thin section images, the vast
majority of the nodules have spiculated and lobulated margins.
Though most of the lesions measure less than 3 cm in diameter, a
dominant mass in the lateral segment right middle lobe measures
3.1 cm x 2.4 cm (image 139, series 102). In addition to the
multiple nodules and mass, there are multilobar areas of
ground-glass attenuation within the lungs as well as
geographically marginated areas of consolidation in the
perihilar and paramediastinal portions of the lungs, worse on
the right than the left. Inferiorly, below the level of the
right hilum, the geographically marginated opacities traverse
the fissure in an non-anatomic distribution that is suggestive
of radiation therapy pneumonitis. However, at a higher level,
the opacities are sharply demarcated by the fissure. Additional
findings include smooth septal thickening with diffuse
distribution but most pronounced in the lower lobes and lung
apices, right greater than left. Thickening is present along the
walls of the central airways, particularly the bronchus
intermedius and right upper lobe bronchi posteriorly.
Bilateral hilar lymphadenopathy is present. Additionally, there
are several prominent right paratracheal lymph nodes measuring
less than 1 cm in greatest short axis dimension, which do not
meet strict criteria for enlargement. The heart size is normal.
A small pericardial effusion is present. Small right pleural
effusion is present as well.
In the imaged portion of the upper abdomen, extrarenal pelves
are present bilaterally in the kidneys. Adrenal glands are
stable in appearance compared to the prior CT abdomen study with
no evidence of suspicious lesions to suggest adrenal metastases.
Heterogeneous appearance of the spleen is likely due to phase of
contrast. Please note that the examination was not specifically
tailored for evaluating the abdominal organs.
There has been prior right mastectomy.
Skeletal structures demonstrate several healed right rib
fractures with marked callus formation. Healing or healed lower
left rib fractures are also noted.
IMPRESSION:
1. Multiple bilateral pulmonary nodules with spiculated and
lobulated margins. Dominant 3.1 cm mass in right middle lobe
with similar morphology to other lesions. In a patient with
history of breast cancer, this may be due to widespread
metastatic disease. Primary lung cancer with metastatic lesions
and diffuse fungal infection are considered less likely.
2. Extensive areas of consolidation with geographic margins in
the perihilar and paramediastinal portions of both lungs. Some
of these traverse the fissure and could potentially reflect
radiation pneumonitis, but coexisting infection, hemorrhage, or
cryptogenic organizing pneumonia is also possible. Correlation
with the portal would be helpful.
3. Multifocal ground-glass opacities and septal thickening.
Differential diagnosis includes interstitial pulmonary edema,
drug toxicity, pulmonary hemorrhage, and lymphangitic
carcinomatosis.
4. Small pericardial effusion.
5. Bilateral hilar lymphadenopathy and borderline right
paratracheal lymph nodes.
6. If available, direct comparison to prior CT scans would be
helpful to determine change from prior exams.
Brief Hospital Course:
The patient is a 58 female with a h/o met breast CA to lung
(RUL), retroperitoneum, and right ureter s/p stent with
recurrent episodes of hemoptysis x 1 week who presented to
[**Hospital3 7571**]Hospital. She was transferred to Dr.[**Name (NI) 1816**]
[**Name (STitle) 1092**] Surgery Service at the [**Hospital1 1170**] from [**Hospital3 7571**]for further assessment of her
hemoptysis on [**2193-12-2**]. She underwent a rigid bronchoscopy on
HD 2 ([**2193-12-3**]) which demonstrated friable mucosa and RUL and
RLL bleeding which was coagulated. For details of the
operation, please refer to the operative report. Her
postoperative course has been uncomplicated.
.
On POD 1, she was afebrile and stable. She has had no episodes
of hemoptysis since admission to the [**Hospital1 827**]. She continued to tolerate a regular diet and
has intermittently had coughing episodes for which she has been
given codeine for. She was deemed stable for discharge home and
has elected to go home first before deciding on hospice care.
She has been instructed to follow-up with her primary care
physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to setup hospice care. An appointment
scheduled for [**2193-12-5**] at 2:30PM has been made for her with her
primary care physician. [**Name10 (NameIs) **] will also be discharged home on her
oxygen as she has been on previously.
Medications on Admission:
Fosamax
Ativan
Lipitor
Zantac
Neurontin
[**Doctor First Name **]
Advair
Tussinex
Discharge Medications:
1. Codeine Phosphate 30 mg Tablet, Soluble Sig: One (1) Tablet,
Soluble PO every six (6) hours as needed for cough.
Disp:*30 Tablet, Soluble(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic breast Cancer
Ovarian Cancer
Osteoporosis
Asthma
Discharge Condition:
Stable
Discharge Instructions:
Call your primary care physician's ffice if you experience chest
pain, shortness of breath, fever, chills, redness or drainage
form your surgical incisions.
Please resume your previous medications as precribed and the
codeine medication as newly prescribed.
Followup Instructions:
Scheduled Appointments :
Provider [**Name9 (PRE) **],[**First Name3 (LF) **] [**Name Initial (PRE) **]. GYN ONC PPS (SB) Date/Time:[**2194-5-1**] 11:00
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on [**2193-12-5**] at
2:30PM. Please coordinate with you PCP for hospice care as
discussed.
Appointments to be made:
Please follow-up with your pulmonologists.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
|
[
"197.6",
"733.00",
"V10.43",
"786.3",
"197.0",
"493.90",
"198.1",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.01"
] |
icd9pcs
|
[
[
[]
]
] |
8120, 8126
|
6376, 7807
|
301, 368
|
8230, 8239
|
1229, 1605
|
8546, 9086
|
994, 1023
|
7938, 8097
|
2474, 2540
|
8147, 8209
|
7833, 7915
|
8263, 8523
|
1038, 1038
|
1052, 1210
|
251, 263
|
2569, 6353
|
396, 686
|
708, 864
|
880, 978
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,320
| 104,916
|
14219+56514
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-5-28**] Discharge Date: [**2133-6-15**]
Date of Birth: [**2057-7-5**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman with a past medical history significant for coronary
artery disease, status post coronary artery bypass graft in
[**2115**], hypertension and elevated cholesterol who presented on
[**2133-5-28**] with burning epigastric pain. This was originally
thought to be cardiac ischemia and the patient was taken to
cardiac catheterization and found to have patent vein grafts.
Laboratory studies then revealed that the patient had
pancreatitis with an amylase of approximately 3300. The
patient was intubated somewhat prophylactically in the
catheter lab and then admitted to the Medical Intensive Care
Unit. The Medical Intensive Care Unit course was complicated
by hypotension. The patient was on dopamine transiently,
which was thought to secondary to a gastrointestinal
infection. She was anemic to 24 and received multiple units
of packed red blood cells. She also began to spike some
temperatures on [**2133-6-1**], despite being on antibiotics and
continued to have fevers up until her transfer to the floor.
The patient was covered with ceftriaxone and clindamycin
initially for a multilobar vent associated pneumonia. Sputum
grew out Serratia which was sensitive to ceftriaxone. The
patient was ultimately transitioned from clindamycin to
Flagyl in part because there was concern that the patient
might have Clostridium difficile colitis. Flagyl was
ultimately discontinued after the patient had three negative
Clostridium difficile cultures. The patient also had some
transient oliguria, presumably from fluid sequestration while
in the Intensive Care Unit. Over the course of her Medical
Intensive Care Unit stay, she became approximately 10 liters
positive. Her liver function tests, amylase and lipase
decreased to normal and the patient improved clinically an
was extubated on [**2133-6-9**] and transferred that day to the
general wards. The patient currently denies any shortness of
breath, chest pain or abdominal pain.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft performed at [**Hospital1 2025**] 15 years ago with a diagonal to
LAD graft and saphenous vein graft to PDA graft.
2. Hypertension
3. Elevated cholesterol
4. Question history of chronic obstructive pulmonary disease
HOME MEDICATIONS (to be confirmed by her primary care
physician):
1. Aspirin
2. Atenolol
3. Lipitor
4. Hydrochlorothiazide
5. Vasotec
TRANSFER TO FLOOR MEDICATIONS FROM MEDICAL INTENSIVE CARE
UNIT:
[**Unit Number **]. Regular insulin sliding scale
2. Protonix 40 mg intravenous q 24 hours
3. Ceftriaxone 1 gm intravenous q 24 hours
4. Miconazole cream
5. Flagyl 500 mg intravenous q 8 hours
6. Lopressor 10 mg intravenous q6h
7. Nitroglycerin drip for which the patient was currently
being weaned off.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM AT TRANSFER TO THE GENERAL FLOOR:
VITAL SIGNS: Temperature 98.8??????, pulse 90, blood pressure
169/84, respiratory rate 20s, pulse oximetry 98% to 99% on a
shelf mask.
GENERAL APPEARANCE: The patient was awake, alert and mildly
uncomfortable, appearing in no acute distress.
HEAD, EARS, EYES, NOSE AND THROAT: Dry oral mucosa, no oral
lesions.
NECK: Jugular venous pressure was prominent.
CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2, no
murmurs.
LUNGS: Bilateral rales and crackles. There were no wheezes.
Breath sounds were decreased at the bases bilaterally.
ABDOMEN: Soft, nontender, nondistended with active bowel
sounds.
EXTREMITIES: The patient complained of left wrist pain which
later resolved after re-siting of the patient's peripheral
intravenous.
NEUROLOGIC: The patient moved all four extremities and
followed commands.
IMAGING AND LABORATORY STUDIES ON [**2133-6-10**]: White blood count
20.1, hematocrit 32.6, platelets 636. INR 1.2, sodium 145,
potassium 3.3, chloride 106, bicarbonate 26, BUN 32,
creatinine 0.6, glucose 136. The patient had a prior
echocardiogram which showed a normal ejection fraction of 61%
with posterobasal wall motion abnormalities, normal filling
pressures on cardiac catheterization of [**2133-5-28**]. In addition
to sputum culture on [**2133-6-6**] revealing Serratia sensitive to
ceftriaxone, urine cultures on [**2133-6-8**] revealed greater than
100,000 organisms per ml of yeast. In response to this
culture result, the patient's Foley catheter was discontinued
and replaced.
HOSPITAL COURSE BY SYSTEM:
1. INFECTIOUS DISEASE: The patient ultimately presented to
the Intensive Care Unit intubated with evidence of a vent
associated pneumonia. Sputum cultures were positive for
Serratia, sensitive to ceftriaxone for which the patient
received a 14 day course of antibiotics. The patient was
temporarily on anaerobic coverage for question of aspiration
pneumonia, as well as for question of Clostridium difficile
colitis. The patient gradually defervesced on antibiotics
and her respiratory status improved substantially to the
point where she was saturating 95% on room air by the time of
discharge. The patient continued to have bilateral crackles
which were thought to be consistent with some underlying
interstitial lung disease which will be confirmed with her
primary care physician prior to discharge. Regarding the
question of Clostridium difficile, the patient had three
negative cultures and was taken off Flagyl following her
transfer to the floor. The patient's only other infectious
issue was a question of a sinusitis, given recurrent fevers
on antibiotics and the patient's history of having a
nasogastric tube in place while she was in the Intensive Care
Unit. CT of the sinuses did reveal some paranasal sinus
thickening and partial opacification of the mastoid air
cells. Given that the patient was essentially afebrile
following her transfer to the floor, she was taken off of
Flagyl and this etiology was not further pursued. We did
hesitate to place an additional nasogastric tube for feeding
purposes given this result.
2. GASTROINTESTINAL: Patient with presumed gallstone
pancreatitis resolved by the time of her transfer to the
floor. Her amylase and liver function tests had essentially
returned to baseline. The patient received TPN for nutrition
while in the Intensive Care Unit. Please see the nutrition
section for further details. The patient denied any
abdominal pain through the remainder of her hospital stay and
tolerated her advanced diet.
3. CARDIOVASCULAR: The patient with a history of
hypertension by report. As she was unable to take po's, she
relied on intravenous Lopressor and hydralazine for blood
pressure control. After she was started back on po's, she
was put on po Lopressor, po hydralazine and po Vasotec. The
doses of these will be confirmed with her primary care
physician and noted in page 1.
The patient also with a history of coronary artery disease.
She underwent a cardiac catheterization when she was admitted
thinking that her symptoms were related to cardiac ischemia.
This study revealed patent grafts. She has an intact
ejection fraction with some posterobasal wall motion
abnormality as noted on recent cardiac echocardiogram.
During her course on the floor, the patient was gently
diuresed to keep her 500 cc to 1 liter negative per day,
given the fact that she was 10 liters positive and seemed to
mobilizing a lot of fluid following her extubation in the
Medical Intensive Care Unit. The patient was noted to have
some short runs of supraventricular tachycardia for which she
was asymptomatic while in the Intensive Care Unit. She was
kept in telemetry during her floor course for further
monitoring.
4. ENDOCRINE: Patient with slightly elevated blood sugars
while on TPN. Her sugars were followed as we returned her to
her regular diet. She had no known history of diabetes.
5. NUTRITION: The patient relied on TPN while in the
Medical Intensive Care Unit. She failed a swallowing study
upon her return to the floor and was continued on TPN for
several days. A repeat swallowing study on [**2133-6-15**] revealed
good tolerance of po's. She was subsequently taken off of
TPN and her diet gradually advanced.
6. HEMATOLOGICAL: The patient was anemic requiring
transfusion in the setting of her Intensive Care Unit
presentation.
7. ORTHOPEDICS: The patient initially complained of some
left wrist pain while in the Intensive Care Unit. She had
negative wrist x-rays. After resetting of her intravenous,
she exhibited full range of motion without pain of that
extremity.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSIS:
1. Coronary artery disease with a history of coronary artery
bypass grafts x2
2. Hypertension
3. Pancreatitis
4. Serratia pneumonia
5. Interstitial lung disease
DISCHARGE MEDICATIONS: Please see page 1 for full details.
1. Enteric coated aspirin 325 mg po qd
2. Protonix 40 mg po qd
3. Hydralazine 25 mg po tid
4. Lopressor 25 mg po bid
5. Lipitor 10 mg po qd
6. Vasotec dose to be confirmed by her primary care
physician
7. Albuterol metered dose inhaler 2 puffs q 4 to 6 hours
prn.
DISCHARGE INSTRUCTIONS: At rehabilitation, the patient
should receive physical therapy and occupational therapy.
She should have pulmonary toilet as necessary. She should
have outpatient follow up schedule with her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42281**], whose phone number is
([**Telephone/Fax (1) 42282**].
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2133-6-16**] 07:25
T: [**2133-6-16**] 07:34
JOB#: [**Job Number 42283**]
Name: [**Known lastname 7621**], [**Known firstname 3351**] Unit No: [**Numeric Identifier 7622**]
Admission Date: [**2133-5-28**] Discharge Date: [**2133-6-15**]
Date of Birth: [**2057-7-5**] Sex: F
Service:
ADDENDUM:
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg p.o.q.d.
2. Protonix 40 mg p.o.q.d.
4. Atenolol 25 mg p.o.q.d.
5. Lipitor 20 mg p.o.q.d.
6. Vasotec 20 mg p.o.q.d.
7. Albuterol inhaler two puffs q.4h. to 6h.p.r.n.
8. Ceftriaxone one gram IV q.24h., last dose to be given on
[**2133-6-17**].
9. Multivitamin, one tablet p.o.q.d.
11. Artificial tears p.r.n.
DR.[**Last Name (STitle) 1661**],[**First Name3 (LF) 1662**] 12-869
Dictated By:[**Last Name (NamePattern4) 555**]
MEDQUIST36
D: [**2133-6-16**] 11:23
T: [**2133-6-16**] 11:38
JOB#: [**Job Number 7623**]
|
[
"507.0",
"285.9",
"788.5",
"276.6",
"414.01",
"574.20",
"515",
"577.0",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"96.04",
"99.15",
"88.57",
"96.72",
"96.6",
"38.93",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8699, 8707
|
10168, 10761
|
8728, 8895
|
9252, 10145
|
4598, 8677
|
159, 2136
|
2158, 4570
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,416
| 162,181
|
33871
|
Discharge summary
|
report
|
Admission Date: [**2109-11-29**] Discharge Date: [**2109-12-3**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Fever + not acting like himself
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old male with COPD, CAD and admission for aspiration
pneunonia in [**1-/2108**] who was doing well at his senior nursing
home facility until about lunch today. He was noted to have
fever, rigors and "not acting like himself" which is why EMS was
called to transfer him to the unit. Of note, his daughter last
saw him two days ago when he was fully functional with good
appetite and no fever, chills or cough. She reports he had
problems with aspiration pneumonia at his old nursing home which
is why he was transferred to his current nursing home where he
had not had any aspiration pneumonia for a year.
.
Patient through his daughter reports doing well today with good
breakfast and lunch. He does not report much after that.
.
In the ED, initial VS were: 100.0 rectal 114 180/92 30 98% NRB.
CXR showed infiltrate at right base. He was given
vancomycin/cefepime/levaquin for healthcare associated
pneumonia. He was given 1LNS. Labs significant for normal WBC,
HCT, platelets, electrolytes but creatinine of 1.6 and lactate
of 2.9. He was transferred to MICU due to elevated lactate in
setting of pneumonia.
.
On arrival to the MICU, he reports having right lower and upper
teeth pain. He reports having tooth extraction on his right
upper tooth two weeks ago and had his sutures removed yesterday.
Past Medical History:
COPD
CAD (severe LAD disease, unknown if intervention, on plavix)
Chronic diastolic heart failure
DM (followed by [**Last Name (un) **]), type II
HTN
Arthritis
s/p compression fx L1
Spinal stenosis L4-5
presumed Gout
left rib fracture [**9-15**]
Stage II chronic renal failure
Social History:
Lives at [**Location 78275**] living ([**Telephone/Fax (1) 78276**]). Uses cane at baseline.
No EtOH, smoking, drugs per patient
Family History:
No sudden death or early CAD
Physical Exam:
ADMISSION EXAM:
Gen: NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD:
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Inspiratory crackles at bilateral bases. Coarse
upper airway sounds throughout.
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present, guaiac negative
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, asterixis absent, speech fluent,
DTR's 2+ patellar, achilles, biceps, triceps, brachioradialis
bilaterally, babinski down-going bilaterally
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
GU: + foley
.
Discharge PE:
Vitals: Tm=97.3=Tc, BP=110s-150s/60s-90s, HR=60s-100s, RR=20,
POx=92% RA, blood sugars=170s-300s
General: Elderly Italian male sitting up in a chair in NAD
HEENT: Anicteric sclera, EOMI, dry MM
Neck: Supple, JVD difficult to assess given body habitus
Cardiovascular: RRR; normal s1, s2; no murmurs, rubs or gallops
Respiratory: Inspiratory crackles at bilateral bases. Coarse
upper airway sounds throughout.
Abd: Soft, non tender, non distended, bowel sounds present
Extremities: No cyanosis, clubbing, edema
Neurological: Alert, orientation difficult to assess given
language barrier, slightly tremulous but asterixis absent
Pertinent Results:
[**2109-11-29**] 02:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2109-11-29**] 02:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2109-11-29**] 02:50PM URINE RBC-<1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2109-11-29**] 02:36PM GLUCOSE-162* LACTATE-2.9* K+-5.2*
[**2109-11-29**] 02:30PM cTropnT-<0.01
[**2109-11-29**] 02:30PM CALCIUM-9.1 PHOSPHATE-2.0* MAGNESIUM-1.3*
[**2109-11-29**] 02:30PM WBC-6.5 RBC-5.10# HGB-15.7# HCT-45.6# MCV-89
MCH-30.7 MCHC-34.4 RDW-13.6
[**2109-11-29**] 02:30PM NEUTS-84.6* LYMPHS-11.8* MONOS-2.1 EOS-1.2
BASOS-0.3
[**2109-11-29**] 02:30PM PLT COUNT-150
[**2109-11-29**] 02:30PM PT-11.2 PTT-27.0 INR(PT)-1.0
[**11-29**] CXR- FINDINGS: AP portable view of the chest demonstrates
bibasilar opacities, new since prior exam, right > left. Left
costophrenic angle is obscured, suggestive of trace pleural
effusion. Hilar and mediastinal silhouettes are unchanged. The
aortic arch calcifications are again noted. Mild cardiomegaly
persists. There is no pneumothorax. Partially imaged upper
abdomen is unremarkable.
IMPRESSION: Bilateral lower love opacities concerning for
pneumonia. Trace
left pleural effusion.
Brief Hospital Course:
This is a [**Age over 90 **] year old male with PMH of COPD, h/o aspiration
pneumonia, CAD, diastolic heart failure, HTN, CKI with baseline
creatinine around 2, and DM2 who was admitted on [**11-29**] to the
ICU from his nursing facility for concern of aspiration
pneumonia low grade fevers, altered mental status, and lactate
of 2.9.
.
#. Aspiration Pneumonia: The patient's low grade fevers,
hypoxia, and altered mental status are likely secondary to an
aspiration pneumonia as he has had a history of aspiration in
the past and it appears the his PNA is developing in the RML on
CXR which is suggestive of aspiration. Per report, he was also
on a regular diet with thin liquids per his preference when it
had been recommended in the past that he be on a soft diet with
nectar thickened liquids. He was initially started on
Vancomycin/Zosyn in the ICU on [**11-30**] which was transitioned to
oral Augmentin 875mg [**Hospital1 **] on [**12-2**] to complete a 7 day antibiotic
course scheduled to end [**12-7**]. If he develops any diarrhea or
abdominal pain prior to [**12-7**], the antibioitcs should be stopped
altogether and his stool should be checked for C. diff. Speech
and swallow re-evaluated him prior to discharge and once again
recommended a soft diet and nectar thickened liquids with 1:1
supervision. His home Advair was continued and he will be given
an albuterol inhaler to use PRN.
.
#. CAD: Per prior history, the patient has suspected LAD
involvement but it is unclear whether there was an intervention.
He was continued on his home regimen of aspirin, Plavix,
simvastatin, isosrbide, and metoprolol.
.
#. CKI: Creatinine at discharge was 1.4 which is below his
recent baseline of 2.
.
#. Type 2 DM. Patient was initially hypoglycemic to the 50s
requiring amps of D50 and D10 drip in setting of being NPO and
receiving glipizide prior to admission. He was given one dose
of octreotide to reverse the glipizide effect. Therefore, his
home metformin and glipizide were held throughout the admission.
His sugars ranged from 170s-300s after his initial hypoglycemia
and were covered with an insulin sliding scale. An A1C was sent
but pending at time of discharge. Given his elevated
creatinine, his metformin will be discontinued altogether. His
home glipizide will be restarted but the dose will be decreased
to 2.5mg of extended release daily from his previous dose of
10mg given his unreliable PO intake. His sugars should be
monitored on this regimen and the dose should be escalated as
tolerated.
.
#. Gluacoma: Continue home eye drop regimen of
dorzolamide/timolol and latanoprost.
.
#. Communication: Patient and daughter (HCP): [**Telephone/Fax (1) 78280**];
[**Telephone/Fax (1) 74640**]
.
#. Code Status: Confirmed DNR/DNI with daughter who is HCP
Medications on Admission:
-Penicillin VK 500 mg po q6 ([**11-13**] - [**11-20**])
-Simvastatin 20 mg po qdaily
-Aspirin 81 mg po qdaily
-Clopidogrel 75 mg po qdaily
-Glipizide 10 mg po qdaily
-Dorzolamide/timolol 2%-0.5% drops 1 drop to each eye [**Hospital1 **]
-Fluticasone-salmeterol 250/50 inh [**Hospital1 **]
-Brimonidine 0.15 % Drops [**Hospital1 **]
-Metformin 1000 mg po BID
-Metoprolol tartrate 50 mg po BID
-Isosorbide dinitrate 10 mg po TID
-Latanoprost 0.005 % Drops qhs
-Tamsulosin 0.4 mg po qhs
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): into both eyes.
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
6. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): inito both eyes.
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
13. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once 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.
15. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day: ending [**12-7**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Aspiration Pneumonia
.
Secondary diagnoses:
-COPD
-CAD
-Diastolic heart failure
-DM2
-CKI
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
further evaluation of fevers, confusion, and cough. You were
found to have a likely aspiration pneumonia. You were treated
with antibiotics and improved. You were also seen by our speech
and swallow specialists who assessed your swallowing and
recommended that supervised feeding of a soft diet with nectar
thickened liquids would be the best way to prevent future
aspiration events.
.
The following changes have been made to your home medication
regimen:
- Please START Augmentin 875mg twice daily ending [**12-7**]
- Please START Albuterol inhaler as needed
- Please DECREASE your home glipizide dose to 2.5mg daily
- Please STOP your home metformin
Followup Instructions:
Please follow-up with all of your outpatient appointments listed
below:
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2110-2-26**] at 2:15 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: MONDAY [**2110-7-28**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,732
| 129,574
|
36520
|
Discharge summary
|
report
|
Admission Date: [**2157-7-27**] Discharge Date: [**2157-8-9**]
Date of Birth: [**2096-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 61 year old gentleman with a history of
active/untreated CLL/AML and disseminated fusarium on therapy
with ambisome and voriconazole admitted to the [**Hospital Unit Name 153**] on [**7-27**] with
fever and abdominal pain.
.
On presentation to the ED, initials vitals were 103.5 113 136/72
18 100% 4L Nasal Cannula. A CT scan of the abdomen was negative
and he was started on vancomycin and cefepime. In the [**Hospital Unit Name 153**] he
was switched to Daptomycin from Vanco due to his history of VRE
and also started on empiric C. Diff treatment with PO Vanco and
IV Flagyl as well as continued on his Fusarium treatment.
.
TTE showed a small effusion. CT Chest showed a bilateral,
moderate on the right and small to moderate on the left pleural
effusions, associated with bibasal consolidations. Repeat TTE on
[**7-29**] showed a stable effusion. Voriconazole and metronidazole
were discontinued. On [**7-30**] Daptomycin was also discontinued. He
was started on decitabine on [**7-30**].
.
Currently, he is resting comfortably. Denies chest pain or
shortness of breath. Denies abdominal pain, N/V/D.
Past Medical History:
Past Oncologist History:
Biphenotypic Leukemia - Initially prsented with "autoimmune
pancytopenia" treated with steroids and IVIG. In [**3-/2157**] his
cytopenias worsened and he was noted to have about 90% blasts
and he was transferred to [**Hospital1 18**]. Preliminary bone marrow biopsy
was suspicious for a biphenotypic leukemia and therapy was
initiated with hyperCVAD. His day 14 marrow showed persistent
disease and his regimen was changed to 7+3. Day 14 and two
subsequent marrows all continued to show persistent involvement
with leukemia. Further chemotherapy was held as he was found to
have disseminated fusarium infection in the setting of prolonged
neutropenia. He was ultimately discharged on G-CSF and daily
Ambisome.
Other PMH:
Disseminated Fusarium - [**5-14**] - treated with Ambisome and
Voriconazole
h/o hepatitis B - on lamivudine
s/p appendectomy
s/p umbilical hernia repair
Social History:
Currently on disability. Wife is a retired physician. [**Name10 (NameIs) **]
from [**Country 5976**]. Nonsmoker.
Family History:
One brother died of ALL.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: T 97.5, BP: 118/66, HR: 78, RR: 20, O2: 99% RA.
GEN: NAD
[**Country 4459**]: OP clear, no lesions
CV: RRR, no M/R/G
RESP: few crackles L base
ABD: soft, NT/ND, NABS
EXT: 2+ LE edema
Skin: no new rashes, lesions
Neuro: A&Ox3, moving all extremities
PHYSICAL EXAM ON DISCHARGE:
GEN: comfortable, NAD
[**Country 4459**]: normocephalic, PERRL, [**Country 3899**], OP clear, no lesions,
mucositis or thrush
CV: RRR, no M/R/G, pulsus 8
RESP: decreased breath sounds b/l bases, crackles L base
ABD: +BS, soft, NT/ND
EXT: warm, well perfused, trace edema
Skin: no rashes, lesions
Neuro: A&Ox3, moving all extremities
Pertinent Results:
LABS ON ADMISSION:
[**2157-7-26**] 10:10AM BLOOD WBC-0.9* RBC-2.89* Hgb-9.2* Hct-25.1*
MCV-87 MCH-31.9 MCHC-36.8* RDW-18.1* Plt Ct-24*
[**2157-7-26**] 10:10AM BLOOD Neuts-43* Bands-12* Lymphs-33 Monos-2
Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 Blasts-6*
[**2157-7-26**] 10:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ellipto-OCCASIONAL
[**2157-7-26**] 10:10AM BLOOD UreaN-18 Creat-1.0 Na-143 K-3.7 Cl-111*
HCO3-24 AnGap-12
[**2157-7-26**] 10:10AM BLOOD ALT-44* AST-26 LD(LDH)-156 AlkPhos-394*
TotBili-0.6
[**2157-7-26**] 10:10AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.6
[**2157-7-27**] 03:18PM BLOOD Lactate-0.9
LABS ON DISCHARGE:
[**2157-8-9**] 12:00AM BLOOD WBC-0.4* RBC-2.89* Hgb-9.0* Hct-24.0*
MCV-83 MCH-31.1 MCHC-37.5* RDW-15.3 Plt Ct-11*
[**2157-8-9**] 12:00AM BLOOD Neuts-37* Bands-0 Lymphs-45* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-17*
[**2157-8-9**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2157-8-9**] 12:00AM BLOOD Gran Ct-152*
[**2157-8-9**] 12:00AM BLOOD Glucose-111* UreaN-39* Creat-1.0 Na-142
K-3.0* Cl-110* HCO3-27 AnGap-8
[**2157-8-9**] 12:00AM BLOOD ALT-36 AST-24 LD(LDH)-142 AlkPhos-191*
TotBili-0.6
[**2157-8-9**] 12:00AM BLOOD Calcium-8.4 Phos-5.2* Mg-1.8
IMAGING:
PA AND LATERAL CHEST, [**2157-7-27**] AT 18:01 HOURS.
FINDINGS: Lung volumes are profoundly diminished. There is
accentuation of
vascular markings and new bilateral pleural effusions and fluid
tracking
within the fissures. The cardiomediastinal silhouette is
exaggerated by the low lung volumes. There is no pneumothorax.
The osseous structures are
unremarkable.
IMPRESSION: Low lung volumes with apparent superimposed
interstitial edema. Repeat radiography after appropriate
diuresis is recommended to assess for underlying infection.
CT ABD PELVIS [**2157-7-27**]
1. Increased bilateral pleural effusions, new moderate
pericardial effusion,
and new small volume ascites, all suggestive of fluid overload.
2. No evidence of colitis, intra-abdominal abscess, or other
acute process toaccount for patient's pain and fever.
3. Stable splenomegaly and left renal cyst.
TTE [**2157-7-28**]
The left atrium is mildly dilated. The left atrium is elongated.
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
hypokinesis of the septum and mid-distal inferior/infero-lateral
walls. The remaining segments contract normally (LVEF = 40-45
%). The right ventricular cavity is mildly dilated with focal
hypokinesis of the apical free wall. There is abnormal septal
motion/position. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild to
moderate ([**11-21**]+) mitral regurgitation is seen. There is at least
moderate pulmonary artery systolic hypertension. There is a
small to moderate sized pericardial effusion. The effusion
appears circumferential but predominantly located along the
infero-lateral wall of the LV. There is right ventricular
diastolic collapse, consistent with impaired fillling/tamponade
physiology.
IMPRESSION: Mild focal left ventricular dysfunction with mildly
depressed LVEF. Small-moderate circumferential pericardial
effusion with evidence of tamponade physiology. No evidence of
vegetations or abscesses.
ABDOMINAL US [**2157-7-28**]
IMPRESSION:
1. Bilateral pleural effusions.
2. Splenomegaly.
3. No ascites.
4. No intrahepatic or extrahepatic biliary ductal dilatation.
5. No cholelithiasis.
CHEST CT [**2157-7-28**]
IMPRESSION:
1. Moderate pericardial effusion. No definitive evidence of
tamponade
physiology, but correlation with echocardiography is required.
The amount of
effusion appears to be slightly increased even compared to prior
CT abdomen
from less than 24 hours ago.
2. Bilateral, moderate on the right and small to moderate on the
left pleural effusions, associated with bibasal consolidations
that potentially might represent atelectasis, although infection
cannot be entirely excluded. No focal consolidations within the
upper lobes of the lungs noted.
3. Severe splenomegaly.
4. Unchanged left renal cyst.
TTE [**2157-7-29**]
The estimated right atrial pressure is 5-10 mmHg. Overall left
ventricular systolic function is low normal (LVEF 50-55%). RV
with borderline normal free wall function. There is a small
pericardial effusion. No right ventricular diastolic collapse is
seen. There is brief right atrial diastolic invagination
consistent with elevated intrapericardial pressure without overt
tamponade.
Compared with the prior study (images reviewed) of [**2157-7-28**], no
major change (no RV diastolic collapse was seen on review of the
prior study).
IMPRESSION: Small, circumfirential pericardial effusion without
overt echocardiographic tamponade.
CXR [**2157-7-29**]
FINDINGS: In comparison with the study of [**7-27**], there is probably
slightly
less engorgement of the pulmonary vascularity. Substantial
enlargement of the cardiac silhouette persists with moderate
residual pulmonary congestion.
Costophrenic angles are more sharply seen, indicating some
decrease in the
degree of pleural effusion. Opacification at the right base
medially most
likely represents crowding of residually dilated pulmonary
vessels.
TTE [**2157-7-30**]
The left ventricular cavity size is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
right ventricular cavity is mildly dilated with normal free wall
contractility. Mild (1+) mitral regurgitation is seen. There is
a small pericardial effusion. There are no echocardiographic
signs of tamponade.
IMPRESSION: Small pericardial effusion without signs of
tamponade.
TTE [**2157-8-1**]
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with mild hypokinesis of the basal septum and inferior wall. The
mid inferior wall is also mildly hypokinetic. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2157-7-30**], LV
systolic dysfunction appears regional on the current study. The
size of the pericardial effusion and other findings are similar
CT THORAX [**2157-8-2**]
IMPRESSION:
1. Stable moderate pericardial effusion and stable bilateral
pleural
effusions with associated basilar atelectasis.
2. No acute intra-abdominal process.
3. Stable left renal cysts.
4. Stable splenomegaly.
Brief Hospital Course:
Primary Reason for Hospitalization:
61M with active biphenotypic leukemia, neutropenia and
disseminated fusarium infection admitted on [**7-27**] with fever and
right-sided abdominal pain.
Active diagnoses:
#. Biphenotypic Leukemia. The patient's [**7-21**] bone marrow showed
50% blasts. While in house, he was treated with a 10 day course
of decitabine, which he tolerated without complications. His
LFTs have remained normal throughout treatment.
#. Neutropenic Fever. Patient had neutropenic fever, in which
all blood and urine cultures showed no growth and CT thorax
showed no evidence of pneumonia or fungal infiltrate. The
patient had no diarrhea. He was treated with cefepime and
daptomycin (for hx of VRE) as well as ambisome for fursarium.
Daptomycin was discontinued when the patient was afebrile and
transferred out of the ICU. When patient remained afebrile for
several days, he was switched to levofloxacin. At time of
discharge, he remained neutropenic and is expected to remain
neutropenic for several days from decitabine treatment. He was
discharged on levofloxacin and ambisome.
#. Disseminated Fusarium. Patient was double covered with
ambisome and voriconazole in ICU, but voriconazole was
discontinued while on decitabine because it suppresses cell
lines. He was continued on Ambisome 800 mg IV Q24H throughout
hospital course and prescribed to restart voriconazle when
patient 72hrs post-chemotherapy.
#Abdominal pain. Pain in RLQ and RUQ was noted on admission to
ICU and persisted on the floor. LFTs remained normal throughout
admission with the exception of persistently elevated alk phos;
CT abd on admission showed no evidence of liver or biliary
abnormality and normal colon. RUQ US similarly did not show
evidence of abnormality. Patient stated pain in right abdomen
increased with breathing and with movement, suggesting some type
of diaphragmatic involvement. CT torso obtained after transfer
to the floor did not suggest any intra-abdominal pathology;
liver in particular looks normal. Variation of abdominal pain
with respiration suggested possible pleuritic component.
Pulmonary consult was obtained and did not believe there was a
thoracic cause to patient's abd pain and did not believe a
bronchoscopy would be useful as there was no clinical or
radiological evidence of pneumonia. Per radiology, however,
phase of contrast could miss subtle liver lesions, thus it is
still possible patient had mild tumor involvement of liver or
liver capsule not picked up by imaging. Abdominal pain resolved
by its own on Day 5 if decitabine and remained stable until
discharge.
#. Pericardial Effusion. A pericardial effusion was noted on TTE
obtained shortly after admission. Cadiology consult was
obtained and daily TTEs were performed to monitor for tamponade
physiology. DDx included hypervolemia, malignant effusion, or
pericarditis. Effusion was not amenable to pericardiocentesis
as patient had low platelet count. Cardiology believed unless
patient developed hemodynamic instability, no need to obtain
pericardiocentesis. Serial TTEs showed no evidence of tamponade
for several days, thus cardiology recommended no further need to
repeat daily TTEs. Upon transfer to the floor, the patient had
blood pressures within the normal range and pulsus <10. He did
not complain of chest pain, SOB, or show any hemodynamic
instability for his hospital stay.
# Hypervolemia. The patient was fluid overloaded secondary to
CHF (EF 45%), 1L NS boluses around ambisome infusions and later
on, volume associated with chemotherapy. Originally upon
transfer to the floor, diuresis was held secondary to fear of
lowering preload in the setting of pericardial effusion, but
once this was deemed stable stable, patient was diuresed on 3
consecutive days with 20 IV lasix, and then remained euvolemic
throughout the remainder of hospitalization.
Chronic Diagnoses:
#Hepatitis B. Surface antibody + and core antibody + in [**Month (only) 116**]. He
was continued on lamivudine throughout hospitalization.
Transitional Issues:
The patient is set up to come to [**Hospital1 18**] oncology outpatient on a
daily basis to get his ambisome infusions, labwork, and prn
platelet and RBC transfusions. He will follow-up with his
primary oncologist. Transportation to/from the hospital has
been set up with The Ride.
Medications on Admission:
Acyclovir 400 mg PO/NG Q8H
Ambisome 800 mg IV Q24H
CefePIME 2 g IV Q8H
Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
LaMIVudine 100 mg PO DAILY
Discharge Medications:
1. voriconazole 200 mg Tablet Sig: 1.5 Tablets PO once a day:
Please start taking this pill Thursday, [**8-11**].
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. olanzapine 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Ambisome 800 mg IV Q24H
Please space by 2 hours from platelet transfusions.
8. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Biphenotypic leukemia
Pericardial effusion
Disseminated fusarium infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1005**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with fever and right-sided
abdominal pain. You were initially in the intensive care unit,
where your fever resolved, and a fluid collection around your
heart was monitored. Because the fluid collection around your
heart appeared stable, you were transferred to the
hematology/oncology floor, where you were given a 10 day course
Decitabine chemotherapy for your chemotherapy. CT scan and
expert consultation did not reveal a source of your abdominal
pain, which resolved on its own. You were discharged at the end
of your chemotherapy to follow-up as an outpatient.
Please note that the following changes have been made to your
medications:
- Please begin taking voriconazole again on Thursday, [**8-11**]. This medication was held while you were on chemotherapy;
please do not take it before this date.
- Please begin taking levofloxacin 500mg daily until you are
told to stop.
- You were not given neupogen on discharge today because that
should start 24 hrs after your last chemotherapy, so you should
receive it tomorrow when you visit for your nursing appointment.
Followup Instructions:
Please follow-up with the following appointments:
** The BMT social worker will be contacting you and your wife
regarding your transportation to/from [**Hospital1 18**] from your house via
The Ride.
Department: BMT/ONCOLOGY UNIT
When: WEDNESDAY [**2157-8-10**] at 1:30 PM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2157-8-11**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2157-8-11**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2157-8-12**]
|
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icd9cm
|
[
[
[]
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|
2402, 2517
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,420
| 166,510
|
34619+57933
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-7-20**] Discharge Date: [**2146-7-29**]
Date of Birth: [**2068-1-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Emergent Coronary artery bypass graft x4 (LIMA>LAD, SVG>DIAG,
SVG>OM, SVG>RCA) [**7-20**]
History of Present Illness:
78 year old male with new onset substernal chest pain and
presented to outside emergency department, underwent cardiac
catherization with intra aortic balloon pump insertion. Ruled
in for anterior wall myocardial infarction based on ST elevation
and troponin I 1.48 CK MB 18.
Past Medical History:
Asthma
Hepatitis C
Diabetes mellitus
Hypertension
Social History:
Lives with daughter
tobacco quit 20 years ago
Family History:
Brother +CAD
Physical Exam:
General NAD
Skin rash chest
HEENT Benign
Neck supple full ROM no bruit
Chest CTA bilat
Heart RRR no M/R/G
Abd soft, ND, NT, +BS
Ext warm well perfused, pulses palpable
Neuro nonfocal, alert, oriented to time, place, person
Pertinent Results:
[**2146-7-27**] 05:36AM BLOOD WBC-10.9
[**2146-7-26**] 05:20AM BLOOD WBC-13.1* RBC-3.92* Hgb-12.6* Hct-37.4*
MCV-95 MCH-32.0 MCHC-33.6 RDW-16.1* Plt Ct-223
[**2146-7-20**] 09:48PM BLOOD WBC-8.0 RBC-3.93* Hgb-13.4* Hct-36.9*
MCV-94 MCH-34.1* MCHC-36.3* RDW-13.2 Plt Ct-179
[**2146-7-27**] 05:36AM BLOOD PT-19.5* INR(PT)-1.8*
[**2146-7-26**] 05:20AM BLOOD Plt Ct-223
[**2146-7-20**] 09:48PM BLOOD Plt Ct-179
[**2146-7-20**] 09:48PM BLOOD PT-16.2* PTT-76.8* INR(PT)-1.4*
[**2146-7-27**] 05:36AM BLOOD K-3.4
[**2146-7-26**] 05:20AM BLOOD Glucose-127* UreaN-20 Creat-0.8 Na-140
K-3.3 Cl-102 HCO3-24 AnGap-17
[**2146-7-20**] 09:48PM BLOOD Glucose-267* UreaN-12 Creat-0.8 Na-137
K-3.9 Cl-104 HCO3-25 AnGap-12
[**2146-7-24**] 12:45AM BLOOD ALT-31 AST-95* AlkPhos-49 TotBili-1.0
[**2146-7-20**] 09:48PM BLOOD ALT-90* AST-225* LD(LDH)-517* AlkPhos-54
TotBili-0.4
[**2146-7-20**] 09:48PM BLOOD CK-MB-151* cTropnT-2.50*
[**2146-7-27**] 05:36AM BLOOD Mg-2.1
[**2146-7-20**] 09:48PM BLOOD %HbA1c-7.9*
Radiology Report CHEST (PA & LAT) Study Date of [**2146-7-26**] 3:40 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2146-7-26**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 79429**]
Reason: f/u atx, effusionq
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
f/u atx, effusionq
Final Report
REASON FOR EXAMINATION: Followup of a patient after CABG.
PA and lateral upright chest radiograph was compared to prior
study obtained
[**2146-7-22**].
Patient is after median sternotomy and CABG. The
cardiomediastinal silhouette
is stable. There is overall improvement in bibasilar opacities
consistent
with atelectasis. Small bilateral pleural effusions
demonstrated, left more
than right, decreased since the prior study. There is no
evidence of
pneumothorax or mediastinal air.
IMPRESSION: Overall improvement in bibasilar aeration with still
present left
basilar atelectasis. Small bilateral pleural effusions, left
more than right.
No pneumothorax. No failure.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: WED [**2146-7-27**] 10:01 AM
Cardiology Report ECG Study Date of [**2146-7-26**] 12:39:38 PM
Sinus rhythm and frequent atrial ectopy. Low limb lead voltage.
Prior
anteroseptal myocardial infarction. There is T wave inversion in
leads V1-V3
consistent with further evolution of acute anterior wall
myocardial infarction
recorded on [**2146-7-21**]. Followup and clinical correlation are
suggested.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
86 200 78 368/413 0 65 99
[**Known lastname **], [**Known firstname 1569**] [**Hospital1 18**] [**Numeric Identifier 79430**] (Complete)
Done [**2146-7-20**] at 11:15:11 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2068-1-14**]
Age (years): 78 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG WITH IABP
ICD-9 Codes: 402.90, 786.05, 786.51, 799.02, 440.0, 410.91,
424.0
Test Information
Date/Time: [**2146-7-20**] at 23:15 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW-1: Machine: AW3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**12-8**]+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-CPB:
LV systolic fxn is reduced to an EF of 40 - 45%. The septum,
antero-septal and infero-septal walls are hypokinetic.
No spontaneous echo contrast is seen in the left atrial
appendage.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
An IABP is seen well-positioned in the proximal descending
aorta.
The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-8**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
Patient is AV-Paced, on a NTG infusion.
RV systolic fxn is good.
LV systolic fxn is improved to an EF of 45 - 50%. The septum
shows improved motion compared to pre-bypass.
MR remains 1 - 2+.
No AI. Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2146-7-21**] 02:25
Brief Hospital Course:
Transferred in from outside hospital with intra aortic balloon
pump and went emergently to the operating room for coronary
artery bypass graft. See operative report for further details.
He was transferred to the intensive care unit for furthe
hemodynamic monitoring. He was weaned from sedation, awoke, and
was extubated in the first twenty four hours. He remained with
the intra aortic balloon pump until POD 1 due to hemodynamic
instability when it was weaned. He was started on ACE inhibitor
and IABP was weaned and removed. Cardiology was consulted for
heart block postoperatively which was second degree mobitz type
1, beta blockers were started and titrated up. He continued to
do well and remained on the intensive care unit as oral
medications were titrated and he was weaned from vasodilators.
He had atrial fibrillation on post op day 3 and was treated with
increased beta blockers and amiodarone. He returned to sinus
rhythm but continued to have episodes of atrial fibrillation
with rate controlled, and he was started on coumadin for
anticoagulation. He continued to do well and was discharged to
rehab on post op 6.
Medications on Admission:
ASA 81 mg daily
Lisinopril/HCTZ 20/25 daily
Atenolol 50 daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 1 months: 30 day course started [**7-24**], then
discontinue .
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
10. Warfarin 1 mg Tablet Sig: INR 2-2.5 Tablets PO once a day:
please dose based on INR results - goal INR 2-2.5 for atrial
fibrillation
received 3mg [**7-26**] and [**7-27**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Acute myocardial infarction with post infarction angina
Type 1 second degree heart block
Post operative atrial fibrillation
Diabetes mellitus
Hypertension
Asthma
Hepatitis C
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:
Please call to schedule all appointments
Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) in 4 weeks
Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) 5456**] ([**Telephone/Fax (1) 79431**]in [**1-9**] weeks
Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] in [**1-9**] weeks
Completed by:[**2146-7-27**] Name: [**Known lastname 12764**],[**Known firstname **] Unit No: [**Numeric Identifier 12765**]
Admission Date: [**2146-7-20**] Discharge Date: [**2146-7-29**]
Date of Birth: [**2068-1-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Following discharge, Mr. [**Known lastname **] was readmitted back to the [**Hospital1 8**]
with reported agitation/altered mental status/aggressive
behavior on admission to the rehabilitation facility. His
medications were resumed and Haldol was initiated. Over several
days, his mental status improved. At discharge, he should remain
on Haldol with attempt to wean in the near future.
In regards to his postoperative atrial fibrillation, no further
episodes of atrial fibrillation were noted on readmission. He
should remain on Amiodarone for one month only per Ep
recommendations. Amiodarone should be discontinued given his
history of Type I second degree AV block. He will remain on
Warfarin with a goal INR between 2.0 - 2.5. His discharge
Warfarin dose will be 1mg as 3mg caused him to have a
supratherapeutic prothrombin time. He should remain on Warfarin
until followup with his local cardiologist.
Given his low-normal ejection fraction, he is to remain on beta
blockade, ACEI along with Lasix. Medications should be titrated
accordingly.
Pertinent Results:
[**2146-7-29**] 05:20AM BLOOD WBC-11.8* RBC-3.74* Hgb-12.0* Hct-36.1*
MCV-96 MCH-32.1* MCHC-33.2 RDW-16.2* Plt Ct-293
[**2146-7-26**] 05:20AM BLOOD WBC-13.1* RBC-3.92* Hgb-12.6* Hct-37.4*
MCV-95 MCH-32.0 MCHC-33.6 RDW-16.1* Plt Ct-223
[**2146-7-25**] 02:27AM BLOOD WBC-14.4* RBC-3.50* Hgb-11.1* Hct-32.4*
MCV-92 MCH-31.6 MCHC-34.2 RDW-15.9* Plt Ct-193
[**2146-7-24**] 12:45AM BLOOD WBC-19.7* RBC-3.29* Hgb-10.6* Hct-29.9*
MCV-91 MCH-32.2* MCHC-35.5* RDW-15.9* Plt Ct-152
[**2146-7-29**] 05:20AM BLOOD PT-33.2* INR(PT)-3.5*
[**2146-7-28**] 01:00PM BLOOD PT-41.8* INR(PT)-4.6*
[**2146-7-28**] 09:30AM BLOOD PT-39.0* INR(PT)-4.2*
[**2146-7-27**] 05:36AM BLOOD PT-19.5* INR(PT)-1.8*
[**2146-7-25**] 02:27AM BLOOD PT-18.1* INR(PT)-1.7*
[**2146-7-29**] 05:20AM BLOOD Glucose-73 UreaN-12 Creat-0.9 Na-138
K-4.0 Cl-101 HCO3-25 AnGap-16
[**2146-7-28**] 09:30AM BLOOD K-4.4
[**2146-7-26**] 05:20AM BLOOD Glucose-127* UreaN-20 Creat-0.8 Na-140
K-3.3 Cl-102 HCO3-24 AnGap-17
[**2146-7-25**] 02:27AM BLOOD Glucose-118* UreaN-25* Creat-0.8 Na-140
K-3.6 Cl-103 HCO3-27 AnGap-14
[**2146-7-24**] 12:45AM BLOOD Glucose-90 UreaN-26* Creat-0.8 Na-141
K-3.4 Cl-107 HCO3-24 AnGap-13
[**2146-7-23**] 02:04AM BLOOD Glucose-153* UreaN-20 Creat-0.7 Na-142
K-4.1 Cl-109* HCO3-20* AnGap-17
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 271**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2146-7-29**]
|
[
"410.01",
"493.90",
"401.9",
"426.13",
"414.01",
"427.31",
"518.0",
"070.70",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"97.44",
"39.61",
"99.04",
"38.93",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
13642, 13865
|
7359, 8498
|
331, 423
|
10004, 10011
|
12356, 13619
|
10522, 12337
|
881, 895
|
8610, 9616
|
2500, 2530
|
9774, 9983
|
8524, 8587
|
10035, 10499
|
6170, 7336
|
910, 1134
|
281, 293
|
2562, 6121
|
451, 729
|
751, 802
|
818, 865
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,186
| 126,936
|
52253+59414
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-1-22**] Discharge Date:
Date of Birth: [**2081-3-21**] Sex: M
Service: [**Location (un) **] MICU
NOTE: This dictation will encompass the patient's time from
the time of admission to [**2120-2-2**] when he was in the
Intensive Care Unit. For further discharge summary, look to
a different statement.
HISTORY OF THE PRESENT ILLNESS: This is a 38-year-old
previously healthy male who was transferred from an outside
hospital to the [**Hospital3 **] Emergency Department for septic
shock. He was intubated on arrival. From reports from the
outside hospital, the patient had walked into the Emergency
Department earlier that day complaining of right hand pain
where he had sustained an open wound which he reported from
falling down the stairs previously that week. Within the
hour, he rapidly decompensated at the outside hospital
dropping his blood pressure and becoming hypoxic. At that
point, he was intubated and pressors were started. He was
started on Neo-Synephrine given a dose of Unasyn and
ceftriaxone and transferred to [**Hospital1 18**]. He was also given
Vasopressin in route with an increase in systolic blood
pressures to 120/130.
As stated, when the patient arrived at the [**Hospital1 18**] Emergency
Room, he was intubated. He was immediately enrolled into the
sepsis protocol. He had systolic blood pressures to the 120s
to 130s on double pressors of Neo and Vasopressin. His
initial ABG was 7.11, 63, and 63 on 100% FI02. In the
Emergency Room, his central line access was changed so he
received a left groin triple lumen as well as a ART line.
Initial lactate was 5.3. He continued to receive fluid
boluses and was aggressively managed on the ventilator, as
described below.
He was transferred to the Medical Intensive Care Unit floor
for further management of his critical and serious condition.
PAST MEDICAL HISTORY:
1. This patient has a history of drug abuse including
cocaine and heroin.
2. History of left spontaneous pneumothorax as a child. Per
the patient's family, he had a tube placed and the area
stapled.
3. Seasonal allergies.
4. Bipolar disorder.
ADMISSION MEDICATIONS: Celexa.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He works as a custodian. He has a history
of illicit drug use, as mentioned above. Smoking background
is unknown.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
of 101.6 rectally, heart rate 117, blood pressure 90/59 on
two pressors, 02 saturation 86% on assist control, tidal
volume 600, 28 respirations, 100% FI02 and a PEEP of 20.
General: This is an intubated and sedated male who on
presentation had mottled arms and legs with cyanotic lips.
His pupils were equal and reactive going from 2 mm to 1 mm.
His neck is full. It was difficult to assess his JVP. His
heart rate was tachycardiac with no murmurs. Lungs: On his
lung examination, he was clear to auscultation anteriorly at
the apices with decreased breath sounds at the bases.
Abdomen: His abdomen was distended, yet soft and nontender.
There were thready peripheral pulses of the bilateral lower
extremities with mottled appearance. Neurologic: He was
moving all extremities when the sedation medicines were
weaned off. Extremities: His right hand was visibly swollen
with purulent drainage from an open wound on the dorsum of
his index finger. His index finger was ecchymotic in
appearance. There was blistering and bullae on the dorsum of
his hand as well as some erythema and redness extending down
to his wrist on presentation.
LABORATORY/RADIOLOGIC DATA: On presentation to the [**Hospital3 **] Hospital, he had a CBC which showed a white blood cell
count of 14.9 which was down from 18.3 at the outside
hospital. The differential included 37 neutrophils, 48
bands, 4 lymphocytes, and 7 monocytes. His hematocrit was
33.3, platelets of 220,000. He had an INR of 2.9. His
Chem-7 showed a sodium of 136, potassium 6.9 which was
accurate on repeat, chloride of 103, bicarbonate of 21, BUN
44, creatinine 3.9, and a glucose of 101. His calcium was
6.2, magnesium of 1.5, and phosphorus 5.6. His CK was 924
with an MB of 26, troponin T was 0.05. His ALT was 1,529.
His AST was 2,040. His alkaline phosphatase was 62, lipase
23, amylase 43, total bilirubin 0.4, albumin 2.9, total
protein 5.1. His lactate was 5.3.
Urine tox was positive for cocaine and opiates. A serum tox
was negative.
A chest x-ray showed left lung with a diffuse opacity and a
right basilar opacity.
A right hand x-ray from the outside hospital showed soft
tissue swelling but no gas.
His initial ABGs showed a pH of 7.20 with a C02 of 40 and an
02 of 74. This was on a ventilator setting of assist control
with a tidal volume of 600, respiratory rate of 30, and an
FI02 of 100%. The PEEP was not recorded.
An EKG showed sinus tachycardia at [**Street Address(2) 108066**] changes.
There were low limb lead voltages throughout.
HOSPITAL COURSE: 1. RESPIRATORY FAILURE: This patient
presented in hypoxic respiratory failure. The leading
diagnosis was ARDS versus pneumonia. It was felt that he
could potentially have ARDS resulting from his septic shock.
However, on gathering further history from his family, it was
noted that there was vomitus found in the car that he drove
himself to the ED. His x-ray also showed asymmetric
opacities leading to a conclusion that this was an aspiration
pneumonia versus ARDS.
At the time of presentation, this was not known and in fact
there was great difficulty adequately oxygenating this
patient. Multiple ventilator settings were tried in his
initial eight hours of admission and multiple modes of
ventilation were tried, initially pressure support and then
assist control as well as ARPV. Repeated ABGs showed that
optimal oxygenation was not obtained and the decision was
made to pronate this patient. The patient was subsequently
pronated for approximately 12 hours, during which his
oxygenation improved and he was maintained on assist control.
There was some concern given the high levels of PEEP that
were required to maintain his pressures and an esophageal
balloon was placed. Via these methods, an appropriate
ventilator setting was obtained within the first 24-48 hours
of the patient's admission and he was maintained on this up
until the time of this dictation. At the time of this
dictation, it was felt that he can be extubated successfully.
In reality, he is clinically ready for extubation sooner than
today, however, multiple trips to the OR postponed any
aggressive measures on the ventilator as each OR trip would
require an intubation we decided to maintain status quo until
his debridements were finished.
At the time of this dictation, the patient is able to
ventilate and oxygenate adequately on a pressure support of
12 and 5. It is anticipated that he will be extubated
successfully tomorrow.
This patient has an aspiration pneumonia. X-rays show
opacities in the left midlung zone and the right base. It is
presumed that this pneumonia is from aspiration that occurred
on his way to the ER on the date of his admission as vomitus
was found in his car.
During the course of his hospital stay up until the point of
this dictation, he has been on a variety of antibiotics,
adjusting for sensitivities obtained from both his wound
cultures as well as his sputum cultures. He received
ceftriaxone and Unasyn at the outside hospital. Initially,
he was kept on a course of Unasyn, vancomycin, and
clindamycin while he was at the [**Hospital1 **]. With
time, Unasyn was discontinued and Levaquin was added.
At the time of this dictation, he is being maintained on an
antibiotic regimen of Levaquin and vancomycin as he has had
recent Pseudomonas heavy growth in his sputum, sensitivities
pending. Gentamicin was added just today for double coverage
of Pseudomonas.
2. SEPTIC SHOCK: This patient came in initially on two
pressors with a systolic blood pressure of 120s that then
subsequently dropped into the 90s. During the first 24
hours, his blood pressures were maintained on a Levophed drip
with aggressive fluid boluses. The goal was to maintain mean
arterial pressure greater than 60. Within 24 hours of his
admission, the Levophed was able to be weaned down and
discontinued. Since then, the patient has maintained his
pressures without medication, ranging from the 140s to
150s/80s-90s. All blood cultures up to this date including
the ones from the outside hospital have been negative.
However, of note, with the exception of the outside hospital
blood cultures, all blood cultures were drawn after the
patient had received heavy doses of antibiotics.
3. RIGHT HAND INFECTION: Necrotizing fasciitis from group A
Streptococcus and toxic shock syndrome. As stated, the
patient's initial complaint on presentation was the wound to
his right hand. It is believed that this wound was sustained
from IV drug use that subsequently became infected. Cultures
from the outside hospital that were in concurrence with
cultures from this hospital grew out group A Streptococcus.
There was also methicillin-resistant Staphylococcus aureus.
Management for this was per the Plastics Team and Infectious
Disease. To date, Mr. [**Known lastname 4643**] has been to the OR three times
for management of his right hand infection.
On hospital day number four, he had his first OR trip where
he underwent a volar fasciotomy which showed pressures
greater than 40 as well as frank pus in the tendon sheath.
He had a carpal release of that wrist as well as the
amputation of the index finger which was necrotic.
A return to the OR two days ago was for debridement and
placement of an allograft to the area of fasciotomy. Six
days later, he returned for a wound check, debridement, and
placement of a VAC dressing. At the time of this dictation,
there are no further plans for Mr. [**Known lastname 4643**] to go to the OR.
It is anticipated that he will continue with VAC dressing
changes and management per Plastics.
Of note, during the initial four days that Mr. [**Known lastname 4643**] was
here in the hospital prior to his first operation, the
infection of his hand worsened. The swelling started to
extend up to his elbow, up to his axilla, and onto his
anterior chest. His forearm was very tense in appearance
with redness, swelling, and blistering that again went all
the way up to his forearm. He continued to have a radial
pulse throughout all of this but given the worsening
appearance and the rapid time sequence, the decision was made
to go to the OR, as mentioned.
Antibiotic treatment was initially broad range and per ID
consult, clindamycin and penicillin G were initially started
as the best medicines for treatment of group A Streptococcus.
But as will be mentioned below, it is believed that the
patient had a drug reaction so these medicines were
discontinued. At the time of this dictation, he remains on a
course of levofloxacin, vancomycin and gentamicin.
This patient received a five day course of IV Ig per
Infectious Disease consult recommendation.
4. ACUTE RENAL FAILURE AND HYPERKALEMIA: This patient
presented with an elevated creatinine and markedly elevated
potassium. He had no EKG changes on presentation. While in
the Emergency Department, he received 2 amps of calcium
gluconate, Kayexalate, 10 units of insulin with D50 infusion.
He also received aggressive IV fluids. Laboratories were
checked frequently. His K rapidly corrected and slowly over
time his creatinine has decreased. On the day of this
dictation, his creatinine was 1.2.
5. DISSEMINATED INTRAVASCULAR COAGULATION AND SHOCK LIVER:
This patient presented with elevated LFTs and a markedly
elevated INR. He initially received FFP and vitamin K.
Hepatology serologies were checked which were all negative.
LFTs were followed throughout his course and have trended
down and at the time of dictation they are within normal
limits. His INR is 1.3 at the time of dictation. During his
course thus far, he was transferred FFP only in anticipation
of any procedural events in order to keep his INR below 1.5.
6. DRUG RASH: On hospital day number ten, the patient
developed a diffuse maculopapular erythematous rash that
started on the torso and subsequently extended up to his neck
and face and all extremities. He also had a fever spike as
well as a slight increase in his creatinine to 1.5. It is
thought that this reaction is a drug reaction. Urine
eosinophils were checked which were negative. A review of
his medications was done in conjunction with the infectious
disease service and the dermatology service and it was
decided that penicillin and clindamycin were the most likely
culprits given the amount of medications that he had been on
in the previous ten days. However, it is difficult to say
with certainty what exactly is the causative [**Doctor Last Name 360**].
Mr. [**Known lastname 4643**] is in need of continued antibiotics so a course of
Levaquin and vancomycin were decided on. Gentamicin was
added as discussed above for double Pseudomonas coverage.
7. CONTINUED FEVER SPIKES: At the time of this dictation,
Mr. [**Known lastname 4643**] continues to have regular fever spikes. There has
not been a period of 24 hours where he has been afebrile
since this admission here. Initially, this was thought to be
related to his right hand infection causing widespread shock
and septicemia. However, clinically this has improved and is
not thought to be the cause of his fever spikes. It is
concerning that perhaps his continued fever spikes may be a
combination of his drug reaction in conjunction with lack of
appropriate Pseudomonas coverage. Double coverage was
started on the day of this dictation and it is hoped that his
temperatures will be afebrile.
8. FLUIDS, ELECTROLYTES, AND NUTRITION: This patient
receives regular tube feeds which he is tolerating well. At
the time of this dictation, he is autodiuresing very well
without any exogenous agents with a urine output of [**11-24**]
liters negative per day. Our transfusion threshold is to
maintain a crit greater than 21 as the echocardiogram early
in his course showed no cardiac disease. His electrolytes
have been repleted as needed. As stated, he has received
blood products including FFP and packed red blood units
during his course here.
9. ACCESS: Currently, Mr. [**Known lastname 4643**] has a left IJ and a left
radial line.
10. COMMUNICATION: Mr. [**Known lastname **] wife, [**Name (NI) **] [**Name (NI) 4643**], has been
in the hospital frequently and has been updated on an almost
daily basis. He also has multiple family members who come in
to visit him.
11. CODE: This patient is a full code.
At the time of this dictation, he remains in the Medical
Intensive Care Unit in serious condition. The remainder of
his course will be dictated at a further date.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 37631**]
MEDQUIST36
D: [**2120-2-2**] 11:29
T: [**2120-2-4**] 07:27
JOB#: [**Job Number 108067**]
Name: [**Known lastname **], [**Known firstname 133**] Unit No: [**Numeric Identifier 17666**]
Admission Date: Discharge Date: [**2120-2-14**]
Date of Birth: Sex:
Service:
This will cover hospital course from [**2120-2-12**] until date of
discharge [**2120-2-14**].
Please see previous discharge summaries covering hospital
stay from admission through [**2-2**] and for [**2-3**] through
[**2120-2-7**].
Fasciitis, bacteremia: The patient with right arm
necrotizing fasciitis. Cultures grew out group A
Streptococcus for which he has been on IV antibiotics as per
previous dictations. He also had multiple visits to the OR
for debridement and was followed by the Plastic Surgery
service. Patient was continued on IV antibiotics
specifically vancomycin and aztreonam. His fasciitis
continued to improve on this regimen. A PICC line was placed
to facilitate delivery of IV antibiotics.
Patient continued to be followed by the Plastic Surgery
service. Plans were for a skin graft placement for his right
hand, however, this was initially delayed given concerns for
wound dehiscence. Patient received moist dressings with
Xeroform to be changed three times a day. He is then to
followup in the Plastic Surgery Clinic as an outpatient,
where should his wound continue to improve, he will then
undergo a skin graft. The patient completed a course of
aztreonam for a total of 10 days of aztreonam following his
last positive blood culture. He also was maintained on
vancomycin. He was discharged on vancomycin 1 gram IV b.i.d.
to be continued for a total of five weeks following
discharge.
Anemia: The patient with microcytic anemia in the setting of
sepsis, prolonged ICU course, and prolonged hospitalization.
He had no evidence of bleeding or hemolysis. His hematocrit
did remain stable.
FEN: The patient was on a regular house diet, which he
tolerated well. He was evaluated by Nutrition given concerns
for his weight loss and malnutrition following his prolonged
hospital stay. He was also started on Boost supplementation.
DISCHARGE DIAGNOSES: Necrotizing fasciitis.
Septic shock syndrome complicated by respiratory failure
requiring intubation.
Renal failure.
Shock liver.
Group A Streptococcus bacteremia.
Acute respiratory distress syndrome.
Renal failure.
Status post right index finger amputation and wound
debridement.
Anemia.
MAJOR PROCEDURES: Surgical debridement x3 in right hand.
Right index finger amputation.
PICC placement left arm.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE FOLLOWUP: Follow up with Dr. [**Last Name (STitle) **] on [**2-20**]
at 2 p.m. in the Plastic Surgery Clinic.
Follow up with Dr. [**Name (NI) 9304**] on [**3-12**] at 10 a.m. in the
Infectious Disease Clinic.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gram IV b.i.d. x5 weeks.
2.
Ambien 5 mg q.h.s. prn.
3. Percocet 5-10 mg every 4-6 hours prn pain.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Dictated By:[**Last Name (NamePattern1) 17667**]
MEDQUIST36
D: [**2120-5-3**] 09:54:41
T: [**2120-5-3**] 10:21:14
Job#: [**Job Number **]
|
[
"518.5",
"507.0",
"785.52",
"584.9",
"286.6",
"570",
"038.0",
"728.86",
"785.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"86.22",
"82.01",
"99.07",
"99.04",
"04.43",
"84.01",
"83.14",
"83.45",
"38.93",
"96.72",
"82.11"
] |
icd9pcs
|
[
[
[]
]
] |
17731, 17769
|
17294, 17709
|
18014, 18371
|
4977, 17272
|
2167, 2230
|
17790, 17991
|
2400, 4959
|
1895, 2144
|
2247, 2385
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,200
| 131,944
|
59173
|
Discharge summary
|
addendum
|
Name: [**Known lastname **], [**Known firstname 16739**] Unit No: [**Numeric Identifier 16740**]
Admission Date: [**2124-3-22**] Discharge Date: [**2124-3-29**]
Date of Birth: [**2064-7-14**] Sex: M
Service:
ADDENDUM: This addendum will cover the hospital course from
[**2124-3-27**] until discharge on [**2124-3-29**]. The
original date of admission was [**2124-3-22**].
The patient is a 59-year-old male with metastatic esophageal
carcinoma here with a left lower lobe aspiration pneumonia.
HOSPITAL COURSE: From [**2124-3-27**] until discharge:
The patient continued on levofloxacin and clindamycin for an
aspiration pneumonia. He remained afebrile throughout the
remainder of his course. His pain regimen was altered to
reflect the discharge medications (see below). His pain was
well controlled on this regimen.
Regarding his initial hypotension (adrenal insufficiency),
the patient resumed his usual prednisone 10 mg b.i.d. and
fluticasone 0.1 mg b.i.d. with stable blood pressures by the
time of discharge.
From an oncologic perspective, the Radiation/Oncology staff
saw the patient and there was no indication for further
radiation. There was no indication for radiosurgical
intervention. The patient will not continue 5-FU therapy nor
other forms of chemotherapy.
In terms of nutrition, the patient tolerated tube feeds. The
patient's family refuses hospice. The patient was discharged
to home with services.
DISCHARGE MEDICATIONS:
1. Florinef 0.1 mg p.o. b.i.d.
2. Prednisone 10 mg p.o. b.i.d.
3. Fentanyl patch 75 micrograms transdermal q. 72 hours.
4. Oxycontin 20 mg p.o. b.i.d.
5. Dilaudid 2-4 mg p.o. q. 1-2 hours p.r.n. pain.
6. Protonix 40 mg p.o. q.d.
7. Tylenol 650 mg p.o. q. four hours p.r.n.
8. Dulcolax 10 mg p.o. q.d. p.r.n. constipation.
9. Ativan 1 mg p.o. q. four hours p.r.n.
10. Gabapentin 600 mg p.o. t.i.d.
11. Senna one tablet p.o. b.i.d.
12. Calcitonin 200 units intranasally q.d.
13. Levofloxacin 500 mg p.o. q.d. times seven days.
14. Clindamycin 150 mg p.o. q.i.d. times seven days.
15. Tube feeds: ProMod with fiber 140 cc an hour times 12
hours times one month with sterile H20 10 cc washes to J tube
flush q. four hours and 30 cc flushes before and after tube
feed cycle.
DISCHARGE DIAGNOSIS:
1. Metastatic esophageal carcinoma.
2. Left lower lobe aspiration pneumonia.
3. Hypotension.
4. Hypothyroidism.
5. Status post adrenalectomy.
6. Gastroesophageal reflux disease.
DISCHARGE PLAN: The patient will be discharged to home with
services including physical therapy and VNA. He should
receive IV fluids in the form of normal saline 1 liter q.d.
times three weeks. He will require Foley catheter care,
decubitus ulcer care. Tube feed care (doses and tube feed
type given above).
CODE STATUS: The patient is DNR/DNI, confirmed on [**2124-3-29**]
by Dr. [**First Name4 (NamePattern1) 1650**] [**Last Name (NamePattern1) 1651**].
The patient's hematologist/oncologist is Dr. [**First Name4 (NamePattern1) 1650**] [**Last Name (NamePattern1) 1651**].
DISCHARGE CONDITION: Stable.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6954**]
Dictated By:[**Name8 (MD) 16741**]
MEDQUIST36
D: [**2124-3-29**] 06:33
T: [**2124-3-29**] 18:44
JOB#: [**Job Number 16742**]
|
[
"198.3",
"V10.03",
"507.0",
"276.5",
"196.2",
"197.7",
"255.4",
"458.9",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
3092, 3330
|
1499, 2280
|
2301, 2486
|
557, 1476
|
2503, 3070
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,337
| 104,154
|
36676
|
Discharge summary
|
report
|
Admission Date: [**2108-7-1**] Discharge Date: [**2108-7-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4071**]
Chief Complaint:
pulseless left hand
Major Surgical or Invasive Procedure:
[**2108-7-1**] Left axillary to brachial artery bypass with reversed
right greater saphenous vein.
[**2108-7-1**] Open reduction left proximal humerus fracture with
manipulation.
[**2108-7-16**] Pacemaker placement
History of Present Illness:
87F s/p unwitnessed fall in driveway this morning. Her
neighbors found her and called EMS who arrived at 9:40am. On
the scene she was complaining of left arm pain and per EMS
report she had a palpable pulse with good capillary refill. She
was taken to [**Hospital1 18**] [**Location (un) 620**] where she was found to have a left
humeral neck fracture. She was transferred to [**Hospital1 18**] for further
management.
Upon arrival she was noted to have a cool left hand with no
radial pulse, no motor function, and decreased sensation in the
radial distribution. In the ED at [**Hospital1 18**], orthopedics attempted
to reduce left arm and left hand became a bit warmer yet pulses
were still intermittent.
Past Medical History:
PMH: Alzheimers dementia, falls, anxiety, hyperlipidemia, ?htn,
depression, DJD, thrombocytopenia, Anemia, ?afib
Past Surgical History: s/p TAH/BSO
Social History:
Son is HCP [**Name (NI) 21976**] [**Telephone/Fax (1) 82944**], who lives in [**State 531**].
Lives with husband in [**Name (NI) 620**], has one son.
-Tobacco history: smoked as teen x 4 years [**12-16**] PPD
-ETOH: wine on holidays
-Illicit drugs: none
Family History:
Noncontributory
Physical Exam:
On admission [**2108-7-1**]
PE: 72, 184/71, 22, 99% on NRB
HEENT: PERLA, EOMI, bilateral ecchymoses, forhead laceration
Chest: RRR, lungs clear
Abdomen: soft, nontender, nondistended, well healed
infraumbilical midline incision
Ext: bilateral LE edema
Right arm: 2+ radial pulse, motor and sensation intact
Left arm: dopplerable pulse, hand cool, insensate in radial
distribution, no motor function
Pulses: palpable femoral and DP bilaterally, palpable right
radial, dopplerable left radial
Pertinent Results:
LABORATORIES:
[**2108-7-15**] 06:45AM BLOOD WBC-9.2 RBC-3.24* Hgb-9.9* Hct-31.9*
MCV-99* MCH-30.6 MCHC-31.0 RDW-21.8* Plt Ct-245
[**2108-7-5**] 04:25AM BLOOD WBC-11.3* RBC-3.13* Hgb-9.5* Hct-28.3*
MCV-90 MCH-30.5 MCHC-33.7 RDW-20.6* Plt Ct-244
[**2108-7-1**] 04:00PM BLOOD WBC-24.5* RBC-3.67* Hgb-12.5 Hct-36.0
MCV-98 MCH-34.1* MCHC-34.8 RDW-21.1* Plt Ct-263
[**2108-7-5**] 04:25AM BLOOD Plt Ct-244
[**2108-7-1**] 04:00PM BLOOD Plt Ct-263
[**2108-7-15**] 06:45AM BLOOD Glucose-84 UreaN-18 Creat-0.7 Na-138
K-4.3 Cl-102 HCO3-27 AnGap-13
[**2108-7-5**] 04:25AM BLOOD Glucose-114* UreaN-17 Creat-0.6 Na-139
K-3.8 Cl-106 HCO3-25 AnGap-12
[**2108-7-1**] 02:38PM BLOOD Glucose-160* UreaN-18 Creat-0.6 Na-140
K-3.5 Cl-107 HCO3-21* AnGap-16
[**2108-7-11**] 06:55AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1
[**2108-7-5**] 04:25AM BLOOD Calcium-8.1* Phos-1.4* Mg-2.3
[**2108-7-1**] 09:45PM BLOOD Calcium-7.9* Phos-3.5 Mg-1.9
[**2108-7-12**] 07:00AM BLOOD CK(CPK)-23*
[**2108-7-12**] 07:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2108-7-2**] 12:49AM BLOOD CK(CPK)-231*
[**2108-7-1**] 02:38PM BLOOD CK(CPK)-116
=========================
[**2108-7-3**] Shoulder X-Ray:
FINDINGS: Again seen are comminuted fractures of the left
humeral head and neck with medial displacement of the humeral
diaphysis. Alignment is not significantly changed since the
previous radiograph. The acromioclavicular joint is intact.
There has been placement of staples overlying the anterolateral
left chest.
IMPRESSION:
Comminuted fractures of the proximal left humerus, not
significantly changed.
.
[**2108-7-1**] Shoulder X-ray:
LEFT HUMERUS, PORTABLE FRONTAL VIEW: The severely comminuted
fracture of the humeral head and neck, with marked medial
displacement of the humeral shaft is unchanged.
IMPRESSION: Comminuted fracture of the left humeral head and
neck. Please
refer to subsequent CT for additional details.
.
[**2108-7-1**] CTA OF THE LEFT SHOULDER AND PROXIMAL HUMERUS:
Comparison is made with a left humeral radiograph from earlier
the same day.
FINDINGS: There is a comminuted fracture of the left humeral
head and neck with dislocation of the left humeral head
fragments from the glenoid fossa. The distal shaft of the
humerus is medially and posteriorly displaced. There is
extensive surrounding hematoma. The left AC joint appears well
aligned. No additional fractures are seen.
In the included portion of the left lung, hypoventilatory
changes are noted without frank consolidation or effusion. The
heart is enlarged, though incompletely imaged. There is no
pneumothorax or rib fracture. The scapula appears intact.
CTA: The subclavian artery and proximal segment of the left
axillary artery appear widely patent and normal in course and
caliber. There is a truncated appearance of the distal aspect of
the left axillary artery at the level just distal to the origin
of the posterior circumflex humeral artery. Distal to this
point, the left brachial artery is thrombosed. There is a small
collateral vessel along the medial left humerus, which is
contrast-filled and this likely represents the ulnar collateral
artery. There is no extravascular pooling of contrast to
indicate active extravasation.
IMPRESSION:
1. Thrombosis of the left brachial artery at the level just
distal to the origin of the posterior circumflex humeral artery.
2. Comminuted fracture of the left humeral head with associated
dislocation.
.
[**2108-7-5**] CHEST (PORTABLE AP)
The right subclavian line tip is at the right atrium and should
be pulled back for about 2 cm to secure its position at the
cavoatrial junction or low SVC. Cardiomediastinal silhouette is
unchanged. There are no areas of consolidation worrisome for
interval development of pneumonia. Minimal opacity at the left
lung base is unchanged and most likely representing area of
atelectasis. There is no appreciable pleural effusion or
peumothorax.
The patient is after recent surgery of the left arm, most likely
related to left humerus fracture. Enchondroma of the right
humeral head is noted.
IMPRESSION: The right subclavian line tip is in the proximal
right atrium and should be pulled back for about 2 cm. Known
left humerus fracture.
Enchondroma of the right humerus.
.
[**2108-7-17**] CXR:
As compared to the previous radiograph, the image quality is
improved. There is no evidence of right-sided pneumothorax after
pacemaker implantation. No evidence of overhydration, no pleural
effusions. Unremarkable course of the pacemaker leads. Normal
size of the cardiac silhouette. Known bilateral shoulder
pathologies.
========================
TTE [**2108-7-6**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal(LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Normal global and regional biventricular systolic function. Mild
pulmonary hypertension.
Brief Hospital Course:
87yo woman was admitted after fall with humerus fracture.
.
# L Humeral Fracture: Patient was Transfered from [**Hospital1 18**] [**Location (un) 620**]
after unwitnessed fall. She underwent Left axillary to brachial
artery bypass with reversed right greater saphenous vein by
vascular surgery and open reduction left proximal humerus
fracture with manipulation by orthopedics. The patient has
almost no motor function of the left hand and arm below the
biceps and very limited sensation post-fall and
post-operatively, though the hand is now well perfused with a
good pulse. Patient's pain was very well controlled with
standing tylenol 1000mg TID. Mrs. [**Known lastname 82945**] needs to keep her
followup appointments with the Orthopedic and Vascular surgeons.
She will also be followed by occupational therapy at acute
rehab.
.
# Tachy-Brady Syndrome: Patient was found to be in afib on
arrival to ED and preop. Because of persistent afib, patient was
transferred to cardiology service on [**7-5**] for better management
of her arrythmia. Metoprolol and ASA were started. Electrolytes
repleted and pain controlled prior to transfer. Upon transfer,
she was given separate trials of PO diltiazem and metoprolol for
rate control, which were both unsuccessful. Her rate initially
had to be controlled on a diltiazem drip; when the diltiazem
drip was used in combination with oral nodal agents, there were
apparent attempts to self-cardiovert with conversion pauses of 2
to 3 seconds and brief episodes of sinus bradycardia in the 30s.
After consultation with the Electrophysiology service,
amiodarone was started; once loaded, the amiodarone appeared to
significantly help control rhythm. During the first couple of
days, she had conversion pauses lasting up to 4.7 seconds;
however, the patient was soon mostly controlled in sinus
bradycardia with rate in the 50s with frequent PACs and PVCs.
She did have multiple brief episodes of atrial fibrillation into
the 120s-140s, but these were easily controlled with 5mg IV
metoprolol; the IV metoprolol would slow her rate down enough to
allow it to convert itself back to sinus bradycardia. Due to
the lability of the patient's rate and rhythm, a pacemaker was
placed on [**7-16**]. The pacemaker was not placed until the urinary
tract infection had completely cleared. Since the pacemaker was
placed, patient continued to go into afib episodically, so PO
metoprolol dose was gradually increased. On discharge to acute
rehab, patient's PO metoprolol was at 50mg TID with good blood
pressure. In the discharge instruction, the rehab was informed
that the dose can be increased to 75mg TID if blood pressure
tolerates the higher dose.
.
# Urinary Tract Infection: Mrs. [**Known lastname 82945**] was found to have a
positive urine analysis and treated accordingly with
cephalosporins. Sulfa drugs were avoided due to a reported
allergy; fluoroquinolones were avoided because the patient had a
prolonged QT initially. She was treated for 14 days for a
complicated UTI; the pacemaker was placed after finishing a full
10 days of antibiotics. The urinary tract infection was likely
largely contributing to the altered mental status of the patient
on admission and post-operatively.
.
# Bright Red Blood Per Rectum: The patient had 1 episode of [**12-16**]
teaspoons of bright red blood per rectum, likely from
hemorrhoids. Her hematocrit remained stable throughout the rest
of her hospitalization, though she was typed and screened as a
precaution. The patient appears to have a problem with
constipation, so she was given an escalated bowel regimen. Her
colonoscopy history was unclear, and she may need a colonoscopy
as an outpatient to rule out other sources of GI bleed.
.
# Hyperlipidemia: Home statin was continued.
.
# Dementia: Patient had significant sundowning and
delirium/agitation. She was confused about where she was most of
the time, and required frequent reorientation. She was out in
[**Female First Name (un) **] chair at the Nursing Station frequently when she was more
agitated which seemed to help.
.
# Anemia: Hct was stable at 28-30, baseline not known.
.
# Anxiety/Depression: Patient was put on sertraline which
appeared to help.
.
# FEN: Patient was put on cardiac diet, she tolerated POs well.
.
Patient was on subcutaneous heparin for DVT ppx. She received
bowel regimen. She was continued on ranitidine given that it is
home med, though no clear h/o GERD. Her code was full (confirmed
with son). Her contact is son [**Name (NI) 21976**] (HCP):
[**Telephone/Fax (5) 82946**] (aware of transfer to medicine);
husband [**Name (NI) **]: [**Telephone/Fax (1) 82947**].
Medications on Admission:
Ranitidine 150mg daily
Lorazepam 0.5mg daily
Lipitor 5mg daily
B12 1000mcg daily
MVI daily
Calcium and Vitamin D
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 0.5 ml
Injection TID (3 times a day).
4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for SBP<90 or HR<50.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold if loose stools.
12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
13. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for constipation.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
16. B-12 DOTS 500 mcg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
- s/p fall
- left humeral neck fracture c/b traumatic injury to left
axillary artery
- s/p Left axillary to brachial artery bypass with reversed
right greater saphenous vein and open reduction left proximal
humerus fracture with manipulation
- Atrial Fibrillation s/p Pacemaker placement
- Urinary Tract Infection
- Delirium
Secondary diagnoses:
- Hyperlidipemia
- Dementia--has poor short term memory but is verbal and
interactive
- Anemia (baseline not known)
- Possible Myelodysplastic syndrome
- Anxiety/Depression
- Osteoarthritis
Discharge Condition:
Stable, afebrile, A-V paced. Patient occasionally goes into afib
with HR in the 150s. Patient is asymptomatic when this happens.
If this does occur, please consider giving patient 25mg PO
metoprolol.
Discharge Instructions:
It was a pleasure to be involved in your care, Mrs.
[**Known lastname 82945**]. You were admitted to [**Hospital1 1170**] after having fallen. You had orthopedic and vascular
surgery to fix your Left arm. You have been having some trouble
moving your left arm since the fall, but an occupational
therapist will help you rehabilitate your arm in the extended
care facility.
While you were in the hospital recovering from surgery, you were
found to have an irregular heart rhythm called Atrial
Fibrillation. This rhythm was going very fast, and we had some
difficulty controlling it; with medicines, it would go too slow,
so you underwent a procedure to get a pacemaker.
You were also found to have a Urinary Tract Infecton, for which
you were treated with antibiotics.
The following changes were made to your medications:
Lorazepam was discontinued
We added the following medications:
Aspirin 325 mg PO DAILY
Metoprolol Tartrate 50 mg PO TID
Amiodarone 200mg PO DAILY
Tylenol 1000mg TID
Sertraline 25 mg PO DAILY
Heparin 5000 units SubQ TID
TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Ibuprofen 400 mg PO Q8H:PRN pain
Please follow the following instructions from the Vascular
Surgeons:
Division of Vascular and Endovascular Surgery
Upper Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the arm you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-17**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative arm:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches) no direct spray on
incision, let the soapy water run over incision, rinse and pat
dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks (from
[**7-6**]) for staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your arm or the
ability to feel your arm
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Please be sure to keep all of your followup appointments.
Please seek medical attention if you begin to have dizziness,
chest pain, shortness of breath, palpitations, fevers, or if
experience anything other symptoms that concern you.
Followup Instructions:
Please keep the following appointments that have been scheduled
for you:
Orthopedic Surgery: You have a visit scheduled with Dr.
[**Last Name (STitle) **] on Thursday, [**2108-7-26**] at 9:00pm on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building at [**Hospital1 18**] in [**Location (un) 86**]. Office number:
[**Telephone/Fax (1) 1228**]. Please arrive at 8:40am to get x-ray done. If Dr.
[**Last Name (STitle) **] needs to change the date of your appointment, he will
call you directly.
You have a visit scheduled with Dr.[**Name (NI) 7446**] office on
Date/Time: [**2108-7-26**] 11:45. [**Telephone/Fax (1) 2625**]. [**Hospital Ward Name **] Office Building,
[**Doctor First Name **] 5B [**Location (un) 86**], [**Numeric Identifier 718**]
You have a visit scheduled in the Device clinic for your
pacemaker check on [**2108-8-6**] at 3pm. [**Location (un) 8661**] building, [**Location (un) 436**],
at [**Hospital1 18**].
Cardiologist:
You have a visit scheduled with Dr. [**Last Name (STitle) 29111**] [**Name (STitle) 11302**]. ([**Telephone/Fax (1) 69986**]
Wed, [**2108-8-1**]. 11:00am
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]
|
[
"903.01",
"293.0",
"599.0",
"458.29",
"788.5",
"331.0",
"427.32",
"564.00",
"285.9",
"873.42",
"414.8",
"920",
"955.9",
"455.8",
"E888.9",
"812.01",
"427.81",
"427.31",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"37.72",
"79.21",
"37.83",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13775, 13854
|
7561, 12207
|
282, 501
|
14454, 14656
|
2252, 7538
|
18857, 20071
|
1708, 1725
|
12371, 13752
|
13875, 14220
|
12233, 12348
|
14680, 18189
|
18215, 18834
|
1405, 1418
|
1740, 2233
|
14241, 14433
|
222, 244
|
529, 1245
|
1267, 1382
|
1434, 1692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,402
| 191,981
|
53015
|
Discharge summary
|
report
|
Admission Date: [**2140-1-13**] Discharge Date: [**2140-1-19**]
Date of Birth: [**2075-3-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2140-1-15**] Coronary artery bypass grafting times six with the left
internal mammary artery to the left anterior descending artery
and sequential saphenous vein graft to the posterior descending
artery and posterior left ventricular branch artery and
sequential reverse saphenous vein graft to the ramus intermedius
artery and the obtuse marginal artery and reverse saphenous vein
graft to the second diagonal artery
History of Present Illness:
This 64 year old male presented to the [**Hospital3 10310**] Hospital
ER on [**1-11**] with chest pain. He had ST elevations on EKG and was
immediately transferred to [**Hospital **] Hospital for cardiac cath.
There he had a PTCA of the RCA and he was found to have
significant disease of the LAD, LCX, ramus, and diagonal
vessels. He ruled in for an MI with a peak troponin of 1.25 and
has been pain free since the cath. He was transferred to [**Hospital1 18**]
for CABG.
Past Medical History:
Coronary Artery Disease s/p Coronary artery bypass graft x 6
Past medical history:
s/p PTCA of RCA [**2140-1-12**], s/p Inferior Myocardial Infarction in
[**2128**] w/ PTCA and stenting of RCA, s/p non Q wave Myocardial
Infarction in [**2130**] w/ stent to the LCX
Hypertension
Hyperlipidemia
Diabetes Mellitus
s/p DVT of LLE
s/p MVA at age 21 with coma x 3 weeks.
Past Surgical History:
s/p T+A
s/p L ankle fx
Social History:
Race: caucasian
Last Dental Exam: recent, was to have filling today
Lives with: wife
Occupation: interior designer and Reiki master
Tobacco: none
ETOH: 1 glass wine per night
Family History:
unremarkable
Physical Exam:
Pulse:84 Resp: 18 O2 sat: 96% RA
B/P Right: 134/86 Left:
Height: 77" Weight: 90.7 kg
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft[x] non-distended[x] non-tender[x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema-None
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ lg ecchymosis from cath, soft Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2140-1-14**] Carotid U/S: There is less than 40% stenosis within the
right internal carotid artery. There is no evidence of
significant stenosis within the left internal carotid artery.
[**2140-1-14**] Echo: PRE-BYPASS: The left atrium is normal in size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
The ascending and transverse thoracic aorta are normal in
diameter and free of atherosclerotic plaque. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion. POST-BYPASS: The patient is in SR on no
inotropes. Preserved biventricular systolic fxn. Trivial MR, no
AI. Aorta intact.
Admission labs:
[**2140-1-13**] 11:50PM BLOOD WBC-5.8 RBC-4.82 Hgb-14.8 Hct-41.6 MCV-86
MCH-30.7 MCHC-35.5* RDW-13.6 Plt Ct-149*
[**2140-1-13**] 11:50PM BLOOD PT-12.9 PTT-23.0 INR(PT)-1.1
[**2140-1-14**] 05:41PM BLOOD PT-14.1* PTT-34.7 INR(PT)-1.2*
[**2140-1-13**] 11:50PM BLOOD Glucose-306* UreaN-14 Creat-0.9 Na-138
K-3.6 Cl-99 HCO3-30 AnGap-13
[**2140-1-13**] 11:50PM BLOOD ALT-75* AST-53* LD(LDH)-297* AlkPhos-64
TotBili-0.7
[**2140-1-16**] 01:34AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
[**2140-1-13**] 11:50PM BLOOD %HbA1c-10.8* eAG-263*
Discharge labs:
[**2140-1-19**] 04:35AM BLOOD WBC-6.2 RBC-3.25* Hgb-9.8* Hct-28.4*
MCV-87 MCH-30.1 MCHC-34.5 RDW-14.6 Plt Ct-224
[**2140-1-19**] 04:35AM BLOOD Plt Ct-224
[**2140-1-19**] 04:35AM BLOOD Glucose-143* UreaN-24* Creat-0.9 Na-136
K-3.9 Cl-100 HCO3-26 AnGap-14
[**2140-1-19**] 04:35AM BLOOD Calcium-8.7 Phos-5.1*# Mg-2.1
Radiology Report CHEST (PA & LAT) Study Date of [**2140-1-17**] 4:10 PM
Final Report
The previously seen tiny left apical pneumothorax has resolved.
No
pneumothoraces are seen on either side. The right IJ catheter
has been
removed. Cardiac silhouette is enlarged but unchanged. Median
sternotomy
wires are intact. There are no signs of fluid overload. There is
improved
aeration at the left base.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 109280**] presented to outside
hospital with chest pain and ruled in for myocardial infarction.
Underwent cardiac catheterization there which showed severe
three vessel coronary artery disease and transferred to [**Hospital 61**] for surgical management. Upon admission he underwent
surgical work-up and medical management with planned surgery on
[**1-13**]. On [**1-13**] he was brought to the operating room where he
underwent a coronary artery bypass graft x6. Please see
operative report for surgical details. In summmary he had:
Coronary artery bypass grafting times six with the left internal
mammary artery to the left anterior
descending artery and sequential saphenous vein graft to the
posterior descending artery and posterior left ventricular
branch artery and sequential reverse saphenous vein graft to the
ramus intermedius artery and the obtuse marginal artery and
reverse saphenous vein graft to the second diagonal artery. His
bypass time was 103 minutes with a crossclamp of 88 minutes.
He tolerated the surgery well and following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact. Beta blockers and diuretics were started
and he was diuresed towards his pre-op weight. Chest tubes and
epicardial pacing wires were removed per cardiac surgery
protocol. On post-op day 2 he was transferred to the step-down
floor for further care. He continued to make good progress while
working with physical therapy for strength and mobility. Only
concern post-op was his diabetes management. He initially
required Insulin gtt before being started on his pre-op oral
medications. In addition to doubling his pre-op oral agents, he
required Lantus. [**Last Name (un) **] was consulted on post-op day 4 for help
with diabetes management. Glipizide was discontinued, his
increased Metformin was continued and Lantus was continued. He
had diabetic teaching for glucometer checks and Lantus
injections. He is to follow up with his usual endocrinologist
as an outpatient. On POD 5 he was ambulating in the halls
without difficulty, his incisions were healing well and he was
tolerating a full oral diet. On post-op day 5 he was discharged
home with VNA services with appropriate follow-up appointments.
Medications on Admission:
ASA 325 mg PO daily
Carvedilol 25 mg PO BID
Ramipril 5 mg PO BID
Glipizide 5 mg PO BID
Colace 100 mg PO BID
Crestor 25 mg PO daily
Glucophage 500 mg PO BID
[**Doctor First Name **] 60 mg PO BID
Norvasc 5 mg PO daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day: take
with 5 mg tablet for a total of 25 mg.
Disp:*30 Tablet(s)* Refills:*2*
7. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): total 25mg/day.
Disp:*30 Tablet(s)* Refills:*2*
8. ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
11. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty
(40) units Subcutaneous once a day.
Disp:*1 month supply* Refills:*2*
12. [**Doctor Last Name 109281**] Sig: One (1) box four times a day: pleaese dispense
one month supply.
Disp:*1 month supply* Refills:*2*
13. glucose test strips Sig: One (1) strip four times a day:
please give 1 month supply.
Disp:*1 month supply* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary artery bypass graft x 6
Past medical history:
s/p PTCA of RCA [**2140-1-12**], s/p Inferior Myocardial Infarction in
[**2128**] w/ PTCA and stenting of RCA, s/p non Q wave Myocardial
Infarction in [**2130**] w/ stent to the LCX
Hypertension
Hyperlipidemia
Diabetes Mellitus
s/p DVT of LLE
s/p MVA at age 21 with coma x 3 weeks.
Past Surgical History:
s/p T+A
s/p L ankle fx
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating independently with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg- Left- healing well, no erythema or drainage.
Edema- 1+ pedal edema bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2140-2-10**] at 1:15pm # [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 8573**] on [**2140-2-12**] at 1:30pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 78054**] [**Name (STitle) 78055**] in [**4-19**] weeks
Endocrinologist: Dr [**First Name4 (NamePattern1) 2092**] [**Last Name (NamePattern1) 109282**]- within 10 days
**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:[**2140-1-19**]
|
[
"272.4",
"458.29",
"410.91",
"250.00",
"401.9",
"414.01",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9269, 9318
|
5009, 7369
|
321, 743
|
9772, 10021
|
2555, 3716
|
10861, 11533
|
1887, 1901
|
7635, 9246
|
9339, 9400
|
7395, 7612
|
10045, 10838
|
4271, 4986
|
9727, 9751
|
1916, 2536
|
271, 283
|
771, 1245
|
3732, 4255
|
9422, 9704
|
1695, 1871
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,979
| 102,299
|
53025
|
Discharge summary
|
report
|
Admission Date: [**2163-4-21**] Discharge Date: [**2163-5-5**]
Date of Birth: [**2100-9-29**] Sex: F
Service: SURGERY
Allergies:
Hydralazine Hcl / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
several month history of intermittent changes in mental status
(odd affect, word finding problems, delayed verbal responses
progressing to unresponsiveness and - perhaps - right sided
weakness).
carotid stenosis
Major Surgical or Invasive Procedure:
[**2163-5-3**] Left internal carotid artery stent
History of Present Illness:
62 y/o female known to Dr. [**Last Name (STitle) **] for PVD now admitted
with multi-lobar pneumonia, NSTEMI and AMS. During workup for
episodic AMS issues during hospitalization, she received duplex
of carotid arteries showing 80-99% stenosis of the left internal
carotid artery, then confirmed by CTA. On retrospect, the
patient does not recall ever having any motor or sensory
deficits that would indicate a prior CVA or TIA. She does
relate a very short burst of garbled words that occurred approx
2-3mos ago. No other episodes of aphasia or dysphagia.
Past Medical History:
1) IDDM - Has had diabetes for 20 years. Checks fingersticks QAM
and sometimes QPM. Fingersticks generally in 100s. No problems
with hypoglycemia.
2) HTN - Baseline SBP generally 150-160 before dialysis, 130
after dialysis.
3) Anemia [**2-22**] chronic kidney disease
4) ESRD, on hemodialysis
5) Arthritis in her knees
6) Hyperlipidemia
7) COPD
8) Left Posterior tibial angioplasty [**2151**]
9) C-section [**2142**]
10) Cholecystectomy [**2132**]
Social History:
Immigrant from Barbados. Former hospital employee. 1 child, 18
years old. Husband also involved in care. Denies tob / etoh /
drug abuse
Family History:
mom / dad/ sister w/ DM type 2, sister had ESRD, sister with
CAD. Father w/ lung ca, though non-smoker
Physical Exam:
PHYSICAL EXAM:
98.8 74 121/43 18 94% ra FS 110-182
A&O, NAD
No focal neurologic deficits, CNII-XII intact, motor [**5-25**] b/l
LE/UE, sensory intact globally.
No dysarthria, no aphasia
No carotid bruits appreciated
RRR
Lungs clear bilaterally
Abd soft, obese, ND/NT, no AAA appreciated
No LE edema
Pulses Fem DP PT
Rt P Dop Dop
Lt P P Dop
Groin- C/D/I. No hematoma or bleeding
Pertinent Results:
[**2163-5-5**] 08:40AM BLOOD WBC-10.5 RBC-4.66# Hgb-13.3# Hct-38.1
MCV-82 MCH-28.6 MCHC-35.0 RDW-17.1* Plt Ct-247
[**2163-5-5**] 08:40AM BLOOD Plt Ct-247
[**2163-5-5**] 08:40AM BLOOD Glucose-141* UreaN-14 Creat-4.2*# Na-139
K-5.0 Cl-97 HCO3-30 AnGap-17
[**2163-4-28**] 08:50AM BLOOD ALT-28 AST-28 LD(LDH)-342* AlkPhos-68
TotBili-0.4
[**2163-5-5**] 08:40AM BLOOD Calcium-9.4 Phos-3.1# Mg-1.8
Brief Hospital Course:
[**Date range (1) 109294**]/10 On Medical Service
Altered Mental Status: Patient was working with nursing and
after standing from the comode and standing from the bedside
chair she was noted to have a "glazed" look on her face, become
slow to respond, and improve with lying flat, though not to her
full baseline. An EKG was checked, electrolytes were checked,
cardiac enzymes were checked, a CXR was checked and a blood gas
was drawn. EKG was unchanged from prior, electrolytes were
notable for a bicarb of 35, CE were not elevated, and CXR was
unchanged. ABG was 7.47 PCO2 51 and pO2 78. The patient had
positive orthostatics. Our conclusion was that the patient was
dry between being run negative in dialysis and having had
diarrhea all day yesterday. However as this continued to recurr
we became suspicious for other pathologies. Doppler of the
carotids was undertaken revealing an 80-99% stenosis of the left
carotid leading ot vascular consult and below hospital course.
.
PNEUMONIA: The shortness of breath, cough, elevated white count
with left shift and RUL infiltrate on chest film are consistent
with pneumonia. Given her history of dialysis, she meets the
definition for a healthcare acquired infection. Agree with
antibiotic choices in MICU as patient is clinically improving.
ID ok'd vancomycin today
- attempt sputum culture
- f/u blood cultures
- continue vancomycin, ceftriaxone, azithromycin plan 7-10d
course
- supportive treatment of cough
- Duonebs
.
NSTEMI: Patient ruled in with Cardiac enzymes, cards was
consulted in the unit and was briefly placed on heparin. Noting
that she is pain free this likely demand ischemia. Her MB
fraction remains low and stable, and its hard to interpret her
CK and Troponins in the setting of her renal faillure. Cards
was following and was consulted last night and stated that there
would be no benefit to cathing uless the patient is either a)
having a STEMI or b) having chest pain as cathing for angina or
demand ischemia has only a symptomatic benefit without a
survival benefit. We will cycle her enzymes again for full rule
out, though this mornings event was highly unlikely to be
cardiac.
- monitor on telemetry
- continue aspirin
- continue statin
- continue beta blocker
- finish rule out
.
ESRD: Patient with ESRD on hemodialysis on
Monday/Wednesday/Friday schedule currently being evaluated for
renal transplant. Patient with electrolytes at baseline.
.
PVD: aspirin and plavix were continued
.
DM:
- We continued home insulin regimen with ISS
.
HYPERTENSION:
- We continued labetalol, amlodipine, lisinopril
.
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: Subcutaneous heparin
# Access: peripherals
# Communication: [**Name (NI) 109295**] (husband) [**Telephone/Fax (1) 109296**]
# Code: Full (discussed with patient)
# Disposition: Floor for now
[**2163-5-3**] Underwent uneventful left carotid stent and transfered
from medical service to vascular surgery/[**Doctor Last Name **] service.
POC- VSS, on nitro for BP control (SBP kept 110-140). Neuro
intact. RT groin with small amount of bloody drainage. No
hematoma. Bedrest, NPO overnight.
[**2163-5-4**]- VSS. No events. Renal following for HD. Nephrocaps
requested by renal and ordered. Jolsin following for BS
management, no new orders. WIll continue current insulin regime.
Nitro weaned to off. Neuro follwoing. Neuro exam stable post
carotid stent, signed off. Transfused 2u PRBCs with HD.
[**2163-5-5**] VSS. No events. RT groin is stale. Discharged home.
Follow up visit and duplex with Dr. [**Last Name (STitle) **] scheduled in 4 weeks.
Medications on Admission:
Active Medication list as of [**2163-4-21**]:
Medications - Prescription
AMLODIPINE [NORVASC] - 10 mg Tablet - one Tablet(s) by mouth
once
a day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day
CALCITRIOL - (Prescribed by Other Provider) - 0.25 mcg Capsule
-
1 (One) Capsule(s) by mouth three days a week, on Monday,
Wednesday and Friday. Pt. states she is not taking, ran out.
CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg
Capsule - 1 Capsule(s) by mouth three times a day
CLOPIDOGREL - 75 mg Tablet - 1 Tablet(s) by mouth once a day
FLUOCINONIDE - 0.05 % Cream - applly to affected areas twice a
day
INSULIN LISPRO PROTAM & LISPRO [HUMALOG MIX 75-25] - 100 unit/mL
(75-25) Suspension - inject subcutaneously 30u in am/45u in pm
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 1-2 puffs(s) po every six (6) hours sob
LABETALOL - 200 mg Tablet - 1 Tablet(s)(s) by mouth twice a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth twice daily
hold
a.m. dose on dialysis days
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth twice daily as
needed for pain
Medications - OTC
ASPIRIN - 81MG Tablet - ONE BY MOUTH EVERY DAY
B COMPLEX-VITAMIN C-FOLIC ACID - 400 mcg Tablet - 1 Tablet(s) by
mouth daily
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - use
as directed to test blood sugar up to qid
DOCUSATE SODIUM - (OTC) - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day as needed for constipation
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE] - 28 gauge X
[**1-22**]" Syringe - use as directed for insulin twice a day .5 cc
LANCETS - Misc - AS DIRECTED FOR CHECKING BLOOD SUGAR
POLYVINYL ALCOHOL [ARTIFICIAL TEARS] - (OTC) - Dosage uncertain
SENNA - (OTC) - 8.6 mg Tablet - 1 Tablet(s) by mouth twice
daily
as needed for constipation
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): refill per PCP.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not discontinue with discussing with Dr.
[**Last Name (STitle) **] or Dr. [**Last Name (STitle) **].
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-22**]
Inhalation every six (6) hours as needed for cough.
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
[**Month/Day (2) **]:*qs ML(s)* Refills:*0*
10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
[**Month/Day (2) **]:*30 Capsule(s)* Refills:*0*
13. Insulin
Breakfast Dinner
Humalog 75/25- Take 20 Units at Brekfast and DInner
Breakfast Lunch Dinner Bedtime
Humalog Sliding Scale
Glucose Insulin Dose
0-70 mg/dL eat/drink, [**Name8 (MD) 138**] MD
[**MD Number(1) 109297**] mg/dL 0 Units
151-200 mg/dL 3 Units
201-250 mg/dL 5 Units
251-300 mg/dL 7 Units
301-350 mg/dL 9 Units
351-400 mg/dL 11 Units
> 400 mg/dL Notify M.D.
14. Humalog Insulin 75/25 Sig: 20 units twice a day:
breakfast and dinner.
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily): refills per renal.
[**MD Number(1) **]:*30 Cap(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Vascular:
62F w/ 80-99% stenosis of the left internal carotid artery, ?
asymptomatic found during w/u of altered mental status; MRI
evidence of infarct, now s/p L carotid stent
Admitted with Primary diagnosis:
-Hospital acquired pneumonia
-NSTEMI
-Altered mental status
-Orthostatic in setting of diarrhea
Secondary:
-End-stage renal disease
-Diabetes mellitis, type 2
-Hypertension
-Hypercholesterolemia
Discharge Condition:
Alert and oriented x3
Discharge Instructions:
The following changes were made to your medications:
-Started Loperamide 2mg up to 4x a day as needed for diarrhea
-Started Guaifenesin 5-10ml every 6 hrs as needed for cough
-Aspirin increased to 325mg daily
-Atorvastin increased to 80mg daily
.
Continued the following medications:
Calcium acetate
Labetalol
Plavix
home regimen of insulin
lisinopril
combivent nebs
senna
colace
artificial tears
amlodipine
vitamin B and vitamin C complex
tramadol
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Division of Vascular and Endovascular Surgery
Carotid Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Take Plavix (Clopidogrel) 75mg 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
?????? You should not have an MRI scan within the first 4 weeks after
carotid stenting
?????? Call and schedule an appointment to be seen in [**3-24**] weeks for
post procedure check and ultrasound
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
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**6-1**] at 9am. You will have a carotid ultrasound and
then see Dr. [**Last Name (STitle) **]. [**Telephone/Fax (1) 2395**]
IT IS EXTREMELY IMPORTANT THAT YOU CALL YOUR PRIMARY CARE DOCTOR
ON MONDAY TO SET UP AN APPOINTMENT FOR SOMETIME IN THE NEXT WEEK
[**Telephone/Fax (1) 250**]
.
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2163-5-10**] at 11:15 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: TRANSPLANT CENTER
When: FRIDAY [**2163-5-20**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: TRANSPLANT CENTER
When: FRIDAY [**2163-5-20**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Neurology: Dr. [**Last Name (STitle) **] on [**6-7**] at 1pm
Completed by:[**2163-5-12**]
|
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"410.71",
"440.20",
"486",
"V58.67",
"403.91",
"433.11"
] |
icd9cm
|
[
[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,872
| 134,153
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6957+6958+6959+55797
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2106-7-29**] Discharge Date:
Service:
HISTORY OF PRESENT ILLNESS: This is an 83 year old female
with a history of hypertension, supraventricular tachycardia
and chronic obstructive pulmonary disease who presented with
two days of increased shortness of breath, wheezing and
nonproductive cough. On [**2106-7-19**] the patient was seen by
her pulmonologist where she was found to be at baseline with
room air saturation of 93%. On [**7-30**], she was seen by her
cardiologist and her Sotalol was increased to 80 mg t.i.d.
Since then the patient reported increased shortness of
breath, nonproductive cough and denied chest pain, fever or
chills. On the day of admission, the patient was seen in
Pulmonary Clinic where she appeared cyanotic with an oxygen
saturation of 72 to 74% on room air and was dyspneic. Her
temperature at that time was 98.8 and arterial blood gas at
that time showed a pH of 7.33 with a pCO2 of 56 and a pO2 of
37. The patient was referred to the Medical Floor for
admission. Repeat arterial blood gases at that time showed
pH of 7.23, pCO2 of 76 and pO2 of 40. The patient appeared
increasingly lethargic and was transferred to the Medicine
Intensive Care Unit.
Her review of systems at that time revealed that she had no
previous admission, no history of steroid use, though she had
been prescribed Prednisone in the beginning of [**Month (only) 205**] she did
not take the medicine. The patient had baseline use of
oxygen at home only at night and during the daytime when she
naps.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease/asthma
2. Hypertension
3. History of supraventricular tachycardia
MEDICATIONS ON ADMISSION:
1. Fosamax
2. Serevent 2 puffs b.i.d.
3. Atrovent 4 puffs q.i.d.
4. Beclovent 4 puffs q.i.d.
5. Albuterol nebulizer prn
6. Sotalol 80 mg t.i.d.
7. Coumadin 2 mg q.h.s.
8. Vitamin B12
9. Calcium
10. Oxygen 2 liters prn
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Tobacco, one pack per day times 67 years.
Still smokes approximately ?????? pack per day. Alcohol, one
drink per day. Lives with husband in retirement community.
PHYSICAL EXAMINATION: On examination the patient was found
to be a pleasant elderly woman who appeared comfortable. Her
vital signs revealed a temperature of 98.7, heartrate 77,
blood pressure 103/60, respiratory rate 24 and oxygen
saturation 93% on room air. Her head, eyes, ears, nose and
throat revealed pupils which were equal, round, and reactive
to light and mucous membranes which were moist. Her neck was
supple with no jugulovenous distension. Her heart revealed a
regular rate and rhythm with distant heartsounds. Her lungs
revealed wheezes on expiration diffusely bilaterally with
rhonchi and dullness at the right base. Her abdomen was
soft, nontender, nondistended with good bowel sounds. Her
extremities showed 1+ pedal edema with no clubbing or
cyanosis. Her neurological examination revealed that she was
alert, oriented and appropriate with no focal deficits.
LABORATORY DATA: Admission laboratory data revealed white
blood count of 13.6, hematocrit 46.9, platelets 279. Chem-7
revealed sodium 140, potassium 5.5, chloride 99, bicarbonate
26, BUN 13, and creatinine 0.6, glucose 119, calcium 8.0,
magnesium 2.1, phosphate 3.6, lactate 0.7 and arterial blood
gas at 6 PM revealed a pH of 7.22, pCO2 76, pO2 of 40, repeat
blood gas at 8 PM revealed pH of 7.28, pCO2 of 70 and pO2 of
44. Chest x-ray revealed hyperinflated lungs with a right
lower lobe infiltrate. An electrocardiogram revealed rate of
129 beats/minute and atrial fibrillation with normal axis
with slight ST depression in leads V3 through V5.
HOSPITAL COURSE:
1. Chronic obstructive pulmonary disease flare and pneumonia
- The patient was treated with Atrovent and Albuterol
nebulizers and inhalers. Levofloxacin 500 mg q. day was
given for right lower lobe pneumonia. The patient was
started on intravenous Solbuterol which was later changed to
oral Prednisone on the first hospital day. The patient was
continued on Beclovent.
[**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15074**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2106-8-3**] 17:32
T: [**2106-8-3**] 19:52
JOB#: [**Job Number 3164**]
Admission Date: [**2106-7-29**] Discharge Date:
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is an 83 year old female
with a history of hypertension, supraventricular tachycardia
and chronic obstructive pulmonary disease who presented to
Dr.[**Name (NI) 4025**] office with cyanosis and dyspnea. She had
been seen in clinic on [**2106-7-19**] when she was at baseline
with a room air oxygen saturation of 93%. On [**7-30**], she
was seen by her cardiologist where her Sotalol was increased
to 80 mg t.i.d. Since that time the patient reported
increased shortness of breath, nonproductive cough but denied
chest pain, fever or chills. The patient was seen [**7-29**],
in clinic. She appeared cyanotic with oxygen saturation of
72 to 74% on room air and she was dyspneic. Her temperature
at that time was 98.8. She appeared mildly lethargic and
arterial blood gas was done which revealed a pH of 7.23, a
pCO2 of 56 and a pO2 of 37. Her oxygen saturation increased
to 93% on 3 liters of oxygen. The patient was referred to
the Medical Floor for admission. Repeat arterial blood gases
at that time showed pH of 7.23, pCO2 of 76 and pO2 of 40.
The patient appeared increasingly lethargic and was
transferred to the Medicine Intensive Care Unit.
Of note, questioning revealed that she had no previous
history of intubation, and had been prescribed steroids on a
previous admission at [**Hospital1 **] Gluver, however, she did not
take this medication. The patient uses oxygen at home only 2
liters at night and during naps.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease/asthma
2. Hypertension
3. History of supraventricular tachycardia
MEDICATIONS ON ADMISSION:
1. Fosamax
2. Serevent 2 puffs b.i.d.
3. Atrovent 4 puffs q.i.d.
4. Beclovent 4 puffs q.i.d.
5. Albuterol prn
6. Sotalol 80 mg t.i.d.
7. Coumadin 2 mg q.h.s.
8. Vitamin B12
9. Oxygen 2 liters prn
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Tobacco use-one pack per day times 67 years,
currently 2 cigarettes to ?????? pack per day. Alcohol use-one
drink per day. Lives with husband in [**Hospital3 **].
PHYSICAL EXAMINATION: Examination revealed a pleasant
elderly woman who appeared comfortable on 3 liters of oxygen
by nasal cannula. Her vital signs revealed a temperature of
98.7, heartrate 77, blood pressure 103/60, and respiratory
rate 24 with an oxygen saturation 93% on 3 liters nasal
cannula. Her head, eyes, ears, nose and throat revealed
pupils which were equal, round, and reactive to light and
mucous membranes which were moist. Her neck was supple with
no jugulovenous distension. Her heart had a regular rate and
rhythm with distant heartsounds. Her lungs had diffuse
expiratory wheezes bilaterally with rhonchi and dullness at
the right base. Her abdomen was soft, nontender,
nondistended with good bowel sounds. Her extremities showed
1+ pedal edema with no clubbing or cyanosis. Her
neurological examination revealed that she was alert,
oriented, appropriate and showed no focal deficits.
LABORATORY DATA: White blood cell count was 13.6, hematocrit
46.9, platelets 279. Electrolytes revealed sodium 140,
potassium 5.5, chloride 99, bicarbonate 26, BUN 13, and
creatinine 0.6, glucose 119, lactate 0.7. Arterial blood
gases, initial blood gas revealed pH of 7.33, pCO2 56, pO2 of
37, repeat blood gas revealed pH of 7.22, pCO2 of 76 and pO2
of 40. Chest x-ray revealed hyperinflated lungs, and a right
lower lobe infiltrate. An electrocardiogram revealed atrial
fibrillation with a rate of 129 with a normal axis and slight
ST depressions in V3 through V5.
HOSPITAL COURSE:
1. Chronic obstructive pulmonary disease and pneumonia - In
the Medicine Intensive Care Unit the patient was treated with
Atrovent and Albuterol nebulizers and inhalers. She was
started on Levofloxacin 500 mg q. day for her right lower
lobe pneumonia. She was given Salmeterol which was later
switched to Prednisone and thereafter tapered. She was
continued on Flovent inhalers as well as an Atrovent inhaler.
After transfer to the floor the patient's oxygen demand
decreased to 2 to 2.5 liters nasal cannula. She received
chest physical therapy and was using incentive spirometry.
2. Supraventricular tachycardia - On hospital day #2 the
patient went into atrial fibrillation with a rate of 110 to
160. She was given intravenous Lopressor times one and
intravenous Diltiazem times two as well as p.o. Diltiazem and
eventually converted to a sinus rate. She was continued on
her Sotalol and remained in sinus rhythm. Her INR was found
to be supertherapeutic while she was initially started on
Flagyl for her pneumonia, which was thought to increase the
Coumadin levels in her blood. Coumadin was held at this
point until the INR dropped to a therapeutic level at which
point it was restarted at 2 mg q.h.s. The Flagyl was
discontinued.
DISCHARGE STATUS: The patient felt by physical therapy to
require rehabilitation services. Please see physical therapy
for evaluation details.
Further details will be added in an addendum to this
discharge summary.
[**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15074**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2106-8-3**] 17:54
T: [**2106-8-3**] 20:08
JOB#: [**Job Number 26134**]
Admission Date: [**2106-7-29**] Discharge Date:
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: This is an eighty-three-year-old
woman with a history of hypertension, supraventricular
tachycardia and chronic obstructive pulmonary disease who was
admitted from her pulmonologist's office because she appeared
cyanotic and had an oxygen saturation of 72% to 74% on room
air and was dyspneic. The patient had been seen by her
pulmonologist previously on [**2106-7-19**], when she was at
baseline with her room air saturation of 93% on room air. On
the third of [**2106-7-18**], she was seen by her cardiologist who
increased her Sotalol dose to 80 mg three times a day. Since
then, the patient reported increased shortness of breath and
a non-productive cough. The patient denied chest pain, fever
or chills. On the day of [**2106-7-29**], the patient's
temperature was 98.8 F and her peak flow was 75 with a
baseline greater then 175. The patient appeared mildly
lethargic. Arterial blood gas revealed a pH of 7.23, PCO2 of
50 and a PO2 of 37. The patient was placed on three liters of
oxygen with an increase in her oxygen saturation to 93%. The
patient was referred to the medical floor for admission. A
repeat arterial blood gas revealed a pH of 7.23, PCO2 of 76
and PO2 of 40. The patient appeared increasingly lethargic
and was transferred to the Medical Intensive Care Unit for
further care. The patient had not previously been intubated
and did not have a history of steroid use. The patient's home
oxygen use was limited to night time and napping use only.
PAST MEDICAL HISTORY: 1) Chronic obstructive pulmonary
disease. Pulmonary function tests on [**2106-7-28**], revealed
an FVC which was 51% of predicted FEV1, 38% of predicted and
a FEV1/FVC ratio 74% of predicted. 2) Hypertension. 3)
History of supraventricular tachycardia.
MEDICATIONS ON ADMISSION: 1) Fosamax. 2) Serevent 2 puffs
twice a day. 3) Atrovent 4 puffs four times a day. 4)
Beclovent 4 puffs four times a day. 5) Albuterol 2 puffs as
needed. 6) Sotalol 80 mg three times a day. 7) Coumadin. 8)
Vitamin B12.
ALLERGIES: None.
SOCIAL HISTORY: Positive tobacco history, one pack per day
times sixty-seven years, still smoking up to one-half pack
per day prior to admission. Also, positive alcohol history
with one drink per day. The patient lives with her husband in
an independent living facility.
PHYSICAL EXAMINATION: In general, this is a pleasant elderly
woman who appears comfortable. The patient's vital signs
revealed a temperature of 98.7 F, pulse 77, blood pressure
103/60, respirations 24, oxygen saturation 93% on three
liters oxygen by nasal cannula. The patient's head, eyes,
ears, nose and throat examination revealed pupils which were
equal, round and reactive to light and mucous membranes were
moist. The patient's neck was supple with no jugular venous
distension. The patient's heart had a regular rate and rhythm
with distant heart sounds. The patient's lungs were wheezy,
diffusely bilaterally on expiration. The patient had rhonchi
and dullness at the right base. The patient's abdomen was
soft, nontender and nondistended with good bowel sounds. The
patient's extremities revealed 1+ pedal edema, no clubbing or
cyanosis. The patient's neurological examination was
appropriate. The patient was alert and oriented and had no
focal deficits.
LABORATORY DATA: Significant laboratory values, white blood
cell count 13.6, hematocrit 46.9, platelet count 279,000.
Sodium 140, potassium 5.5, chloride 99, bicarbonate 26,
blood, urea and nitrogen 13 and creatinine 0.6, glucose 119.
Calcium 8.0, magnesium 2.1, phosphorous 3.6, free calcium
1.18.
Prothrombin time 27.3, international normalized ratio 4.9.
The patient's lactate level was 0.7.
The patient's arterial blood gas had a pH of 7.22, PCO2 of 76
and PO2 of 40.
Chest x-ray, hyperinflated lungs, right lower lobe
infiltrate.
HOSPITAL COURSE: This is an eighty-three-year-old woman with
hypertension, supraventricular tachycardia and chronic
obstructive pulmonary disease who was admitted with right
lower lobe infiltrate, consistent with pneumonia and a
chronic obstructive pulmonary disease exacerbation. The
[**Hospital 228**] hospital course by systems is as follows.
1) Pulmonary: the patient was admitted with chronic
obstructive pulmonary disease flare in the setting of a right
lower lobe pneumonia and a recent increase in her Sotalol
dose to 80 mg three times a day. The patient was treated with
Levofloxacin and Flagyl for a total of nineteen days during
her admission. In the Intensive Care Unit, she was initially
treated with Solu-Medrol which was then switched to
Prednisone, as well as nebulized Albuterol and Atrovent. The
patient was transferred to the floor on [**2106-8-2**].
However, the patient's pulmonary status failed to improve.
The Sotalol was discontinued on the premise that her
continued cyanosis was due to continued bronchospasm,
secondary to the beta effect of the Sotalol, and she was
started on Disopyramide for her supraventricular tachycardia.
The patient was also started on Diamox on the floor, which
resulted in a severe acidemia which resulted in respiratory
failure. On [**2106-8-10**], the patient was found to be
obtunded with an arterial blood gas with a pH of 7.01, PCO2
of 152 and a PO2 of 67. A respiratory code was called and she
was intubated and returned to the Medical Intensive Care
Unit. In the Medical Intensive Care Unit for the second time,
she briefly required pressors, however, was able to be
extubated on [**2106-8-13**]. However, she failed extubation
and early on [**2106-8-14**], required re-intubation. During
her Medical Intensive Care Unit course, she was again treated
with Solu-Medrol and later switched to Prednisone. On [**2106-8-19**], she was able to tolerate extubation. The patient's
continued respiratory distress in the Medical Intensive Care
Unit was felt to be secondary to a combination of her chronic
obstructive pulmonary disease flare and congestive heart
failure in the setting of supraventricular tachycardia.
Post-extubation, she continued to require three to five
liters of nasal cannula to achieve an oxygen saturation of
86% to 92%.
2) Cardiovascular: the patient has a history of
supraventricular tachycardia and had recently increased her
Sotalol dose prior to admission. On admission, her heart rate
remained stable on Sotalol, however, the Sotalol was
discontinued after her first transfer to the medical floor,
as it was felt that the Sotalol was contributing to her
respiratory failure. Shortly, the patient was switched to
Disopyramide, however, she reverted to atrial
fibrillation/atrial flutter. Diltiazem was added with good
control. During her second unit stay, she was restarted on
Sotalol, however, she re-entered atrial fibrillation/atrial
flutter and was subsequently changed to Amiodarone and
Diltiazem in various combinations and various routes of
administration. The patient failed to convert back to normal
sinus rhythm and continued to have variable rate control.
After transfer to the floor on [**2106-8-23**], she continued
to be in atrial flutter with a rate which ranged from the
70's to 150's. DC cardioversion was planned for [**2106-8-27**].
3) Heme: the patient was anticoagulated on admission for her
history of atrial fibrillation. On [**2106-8-14**], she was
found to have a sudden hematocrit drop from 34 to 25, with
guaiac positive stools. The patient received five units of
packed red blood cells in the Intensive Care Unit and
subsequently her hematocrit has been stable with guaiac
negative stools.
This summarizes the [**Hospital 228**] hospital course from [**2106-7-29**], to [**2106-8-26**]. The remainder of her admission will
be summarized in an addendum to this discharge summary.
[**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15074**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2106-8-26**] 17:29
T: [**2106-9-2**] 08:27
JOB#: [**Job Number 26135**]
Name: [**Known lastname 4496**], [**Known firstname 4497**] Unit No: [**Numeric Identifier 4498**]
Admission Date: [**2106-8-26**] Discharge Date: [**2106-8-30**]
Date of Birth: [**2023-1-30**] Sex: F
Service: Medicine
This is an addendum to the discharge summary dated [**2106-8-26**]. This summary covers the [**Hospital 1325**] hospital course from
[**2106-8-26**] to discharge on [**2106-8-30**].
1. Cardiovascular: The patient remained in atrial flutter
with variable block. She was started on amiodarone and
diltiazem. On [**8-27**], the patient underwent DC
cardioversion and her amiodarone was subsequently changed to
a once daily dose. Following cardioversion, she remained in
normal sinus rhythm, however, her blood pressure fell and
therefore her diltiazem dosing was decreased. She remained
on Coumadin.
2. Pulmonary: The patient was continued on her medications
for congestive obstructive pulmonary disease. These included
multiple-dose inhalers and steroid taper. Her oxygenation
improved following her cardioversion.
3. Fluids, electrolytes, and nutrition: The patient was
diuresed gently for her fluid overload and pleural effusions
secondary to her diastolic dysfunction. Her effusions were
clinically improved at the time of discharge.
4. GI: The patient was constipated and required aggressive
bowel regimen to improve this.
CONDITION ON DISCHARGE: The patient was discharged to
rehabilitation hospital secondary to her deconditioning. She
was in fair condition at discharge. She will be followed up
with Dr. [**Last Name (STitle) 1614**] and Dr. [**Last Name (STitle) **] of Cardiology.
DISCHARGE DIAGNOSES:
1. Congestive obstructive pulmonary disease.
2. Atrial flutter.
3. Hypoxic and hypercarbic respiratory failure.
4. Pleural effusion.
5. Status post direct-current cardioversion.
DISCHARGE MEDICATIONS:
1. Tums one po tid.
2. Serevent multiple-dosed inhaler two puffs inhaled [**Hospital1 **].
3. Amiodarone 800 mg po q day changed to 600 mg po q day on
[**8-31**].
4. Coumadin 3 mg po q hs.
5. Beclovent MDI two puffs qid.
6. Atrovent MDI two puffs qid.
7. Lactulose 30 cc po bid prn.
8. Nicotine patch 7 mg topical q day.
9. Albuterol MDI two puffs q4-6 hours prn.
10. Lasix 20 mg po q6 hours.
11. Colace 100 mg po bid.
12. Vitamin D 400 mg po q day.
13. Folate 1 mg po q day.
14. Protonix 40 mg po q day.
15. Prednisone taper to end [**2106-9-2**].
16. Diltiazem CD 120 mg po q day.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3570**]
Dictated By:[**Last Name (NamePattern1) 4499**]
MEDQUIST36
D: [**2107-10-13**] 22:19
T: [**2107-10-17**] 08:02
JOB#: [**Job Number **]
|
[
"427.31",
"486",
"491.21",
"427.89",
"585",
"285.9",
"427.32",
"518.81",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
19620, 19799
|
19822, 20710
|
11708, 11946
|
13743, 19332
|
12240, 13726
|
9938, 11406
|
11428, 11682
|
11962, 12218
|
19357, 19599
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,132
| 106,777
|
13362
|
Discharge summary
|
report
|
Admission Date: [**2156-4-13**] Discharge Date: [**2156-4-14**]
Date of Birth: [**2083-10-18**] Sex: M
Service: MEDICINE
Allergies:
Ceftriaxone
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
[**First Name3 (LF) **] meningitis, ceftriaxone desensitization
Major Surgical or Invasive Procedure:
PICC line
History of Present Illness:
72-year-old male with history of [**First Name3 (LF) **] disease ([**2149**] and [**2154**])
and glaucoma who developed Bell's palsy after a trip to [**Hospital3 **] two weeks ago presents to the [**Hospital3 12145**] for ceftriaxone
desensitization for presumed [**Hospital3 **] meningitis.
.
His symptoms started on [**2156-3-29**] when he developed a left sided
headache. He also had low-grade fever of 100.5 around this time.
He saw Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] on [**2156-4-1**] who ordered an MRI head, which
came back negative. His symptoms continued to worsen and he
developed left sided numbness and difficulty closing his left
eye. He was concerned for closed angle glaucoma, which he has a
history of and presented to [**Hospital 13128**], where he was ruled
out for this and told to see an opthalmologist for the
difficulty closing his left eye. He continued to worsen and was
seen in the ED on [**4-4**] and blood taken in the ED returned
positive for [**Month/Year (2) **]. He was seen by neurology who thought that he
should be discharged with prednisone and seen by neuro urgent
care. They decided not to take the prednisone because his wife
read on the internet that you are not supposed to take steroids
during an infection. He was referred to a neurologist who saw
him yesterday on [**2156-4-12**] and did an LP which showed 53 WBC in
4th bottle, 94% lymphs (2RBC, protein 50, glucose 59) and was
sent for VZV, HSV and Borriella PCR which are pending. Given his
clinical course and lab results he was presumed to have [**Date Range **]
meningitis requiring Ceftriaxone. However, he has a hisory of
rash immediately following Ceftriaxone in the past so he is
being directly admitted to the ICU for Ceftriaxone
desensitization.
.
On arrival, the patient complains of mild left sided headache
with retroorbital pain, which is the same as his prior pain for
the past 2 weeks. He denies any other symptoms including chest
pain, shortness of breath, cough, chills, sweats, nausea,
vomitting, diarrhea, abdominal pain, calf pain, focal weakness,
numbness or tingling, seizures, or any other neurologic
symptoms. Positive neck soreness but no stiffness.
Past Medical History:
#. Hyperlipidemia, diet controlled.
#. Ventricular ectopy on stress test.
#. History of glaucoma, controlled.
#. Lipoma removed left hip
#. [**Date Range **] disease twice ([**2145**], [**2149**] both treated with
Doxycycline. In [**2154**] he had a tick bite and was treated with 1
dose of doxycycline)
Social History:
Retired editor of a sailing magazine. Never smoker and drinks
[**12-21**] glasses of wine weekly. No drugs. Lives with his wife in
[**Location (un) 2030**] and exercises 3-4 times per week.
Family History:
Father: CVA age 38 lived till 93, mother CVA age
76 lived to 84. Brother: melanoma and CAD
Physical Exam:
GEN: pleasant, comfortable, NAD, obvious left sided facial droop
HEENT: PERRLA, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact except for complete left sided
facial droop with inability to close left eye lid, left sided
facial numbness in all 3 dermatomes, an inability to smile with
left side of face. 5/5 strength throughout upper and lower
extremities. No sensory deficits to light touch appreciated. No
pass-pointing on finger to nose. 2+DTR's-patellar and biceps. No
nuchal rigidity.
Pertinent Results:
Labs on admission:
[**2156-4-13**] 03:58PM BLOOD WBC-4.7 RBC-4.40* Hgb-14.5 Hct-41.2
MCV-94 MCH-33.0* MCHC-35.2* RDW-12.6 Plt Ct-233
[**2156-4-13**] 03:58PM BLOOD Neuts-67.9 Lymphs-25.9 Monos-4.1 Eos-1.6
Baso-0.5
[**2156-4-13**] 03:58PM BLOOD Plt Ct-233
[**2156-4-13**] 03:58PM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-140
K-4.3 Cl-104 HCO3-28 AnGap-12
[**2156-4-13**] 03:58PM BLOOD Calcium-8.9 Phos-3.1 Mg-2.2
[**2156-4-12**] 03:40PM CEREBROSPINAL FLUID ([**Month/Day/Year **]) PROTEIN-50*
GLUCOSE-59
[**2156-4-12**] 03:40PM CEREBROSPINAL FLUID ([**Month/Day/Year **]) WBC-53 RBC-2*
POLYS-0 LYMPHS-94 MONOS-6
[**2156-4-12**] 03:40PM CEREBROSPINAL FLUID ([**Month/Day/Year **]) WBC-44 RBC-7*
POLYS-0 LYMPHS-94 MONOS-6
.
Labs on discharge:
[**2156-4-14**] 03:26AM BLOOD WBC-4.5 RBC-4.17* Hgb-13.5* Hct-38.6*
MCV-93 MCH-32.4* MCHC-35.0 RDW-12.7 Plt Ct-217
[**2156-4-14**] 03:26AM BLOOD Glucose-118* UreaN-12 Creat-0.9 Na-139
K-3.9 Cl-107 HCO3-26 AnGap-10
.
Pending labs:
- To follow up [**Month/Day/Year **] [**Month/Day/Year **] IGM/IGG results call [**Company 5620**]
at [**Telephone/Fax (1) 40616**]
- To follow up blood [**Telephone/Fax (1) **] IGM/IGG results call [**Hospital **] Medical Labs
at [**Telephone/Fax (1) 40617**], be sure to have [**Hospital1 18**] account # if necessary
([**Numeric Identifier 40618**])
Brief Hospital Course:
72-year-old male with history of [**Numeric Identifier **] disease ([**2149**] and [**2154**])
and glaucoma who developed Bell's palsy after a trip to [**Location (un) 7453**] two weeks ago presents to the [**Location (un) 12145**] for ceftriaxone
desensitization for presumed [**Location (un) **] meningitis.
.
#. Subacute meningitis: Presumed [**Location (un) **] meningitis given recent
exposure, positive [**Location (un) **], Bell's Palsy and [**Location (un) **] done as an
outpatient with normal glucose, lymphocytic predominence, and
negative gram stain. Patient's PCP arranged for him to be
admitted to the hospital for Ceftriaxone desensitizaton given
his history of immediate allergy to Ceftriaxone. HSV
encephalitis is unlikely given the lack of confusion or altered
mental status and lack of associated changes on recent MRI brain
imaging. HSV titer is pending. Plan was discussed with
infectious disease, neurology (Dr. [**Last Name (STitle) **], PCP, [**Name10 (NameIs) 12145**], and
allergy attendings on call.
-Patient tolerated ceftriaxone desensitization on [**4-13**]
-he received his first dose of ceftriaxone 2 grams on [**4-14**]
-per discussion with neurology (Dr. [**Last Name (STitle) **], will proceed
with 2 gram IV ceftriaxone for 28 days
-PICC line was placed on [**4-14**] for 28 days of Abx
-HSV, VZV, [**Month/Year (2) **] culture, [**Month/Year (2) **] IgM and IgG serologies, and
B.Burgdorferi PCR in [**Month/Year (2) **] are pending and will be followed by
PCP, [**Name10 (NameIs) **] [**Last Name (STitle) 1007**]
.
#. Ceftriaxone Allergy:
-Ceftriaxone Desensitization per protocol completed without
adverse reaction
.
#. Hyperlipidemia
-diet controlled
-fish oil as an outpatient
.
F/U on discharge:
- routine PICC line care
- ceftriaxone 2 gram IV x 28 days with PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]
- HSV, VZV, [**Last Name (NamePattern1) **] culture, [**Last Name (NamePattern1) **] IgM and IgG serologies, and
B.Burgdorferi PCR in [**Last Name (NamePattern1) **] are pending and will be followed by PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] [**Name11 (NameIs) **] IGM/IGG results [call [**Company 5620**] at
[**Telephone/Fax (1) 40616**]]
- [**Telephone/Fax (1) **] IGM/IGG results [call [**Hospital **] Medical Labs at [**Telephone/Fax (1) 40617**],
be sure to have [**Hospital1 18**] account # if necessary ([**Numeric Identifier 40618**])]
Medications on Admission:
1) Aspirin 81 mg
2) Fish Oil
Discharge Medications:
1. ceftriaxone 2 gram Recon Soln Sig: Two (2) grams Intravenous
once a day for 28 days.
2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
3. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
Capsule(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. [**Numeric Identifier **] meningitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you have [**Numeric Identifier **] meningitis and
you needed Ceftriaxone desensitization. You tolerated this
well. It is very important that you continue to take your
Ceftriaxone on time every day or else you are at risk of an
allergic reaction. It is also important to know that once your
course of antbiotics is finished you will still be allergic to
Ceftriazone. If you need this medication again you will have to
come to the hospital again.
.
We made the following changes to your medications:
Ceftriaxone 2g IV q24 hours for 28 days
Please continue to take all your medications as tolerated.
Followup Instructions:
You will follow-up with neurology, Dr. [**First Name8 (NamePattern2) 5464**] [**Last Name (NamePattern1) **], on
[**5-21**] at 11:30 AM. If there are any concerns, please call her
at [**Telephone/Fax (1) 31415**].
.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], your PCP, [**Name10 (NameIs) **] arrange for you to come in to his
office for daily IV antibiotics and weekly blood tests during
the four weeks of ceftriaxone.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
|
[
"320.7",
"088.81",
"V14.3",
"365.9",
"272.4",
"351.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8305, 8311
|
5439, 7165
|
337, 348
|
8404, 8404
|
4092, 4097
|
9213, 9759
|
3146, 3239
|
7954, 8282
|
8332, 8383
|
7901, 7931
|
8555, 9061
|
3254, 4073
|
7179, 7875
|
9090, 9190
|
234, 299
|
4832, 5416
|
376, 2591
|
4111, 4813
|
8419, 8531
|
2613, 2923
|
2939, 3130
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,802
| 192,204
|
29708
|
Discharge summary
|
report
|
Admission Date: [**2147-11-28**] Discharge Date: [**2147-12-12**]
Service: SURGERY
Allergies:
Percocet / Morphine / Codeine / Oxycodone
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p MVC with injuries
Major Surgical or Invasive Procedure:
[**2147-11-30**]: ORIF left acetabulum, right knee aspiration and closed
treatment of right patella fracture with manipulation under
anesthesia
History of Present Illness:
Mr. [**Known lastname **] is an 86 yo male with hx of sick sinus syndrome s/p
pacer, HTN, and high cholesterol who was transferred to [**Hospital1 **] with
an acetabular fx. Per report, the patient was in a MVA where he
was in the passenger seat and they rear-ended another vehicle at
approx 30mph. EMS arrived on scene and the patient was
complaining of hip pain radiating to his low back.
The patient was taken to [**Hospital 5279**] [**Hospital 1108**] transferred to WX VA
who then transferred him to [**Hospital1 **] for management of left acetabular
fracture and right patellar fracture. He denied any chest pains,
shortness of breath, PND, orthopnea, palpitations, dizziness.
.
In the ER pt was seen by trauma and ortho services. C-spine was
cleared. Pt was transferred to the ortho service and medically
cleared for surgery. Had ORIF of L acetabular fracture on [**11-30**].
During he had narrow complex tachycardia (afib vs AVNRT) with
HRs up to the 180s. He had a CTA to evaluate for PE which was
negative. However, CT showed 2 focal areas of irregularity in
the aorta thought to be ulceration vs. dissection.
He was transferred to the SICU on [**12-2**] due to rapid HR and
possible dissection. Vascular and cardiac surgery were consulted
and recommended repeat CTA. He had repeat CTA in the AM of [**12-2**]
which showed no dissection. HRs went up to the 190s and pt had
narrow complex tachycardia. He was given esmolol and SBPS
dropped, so he was transiently started on peripheral levophed
for 2 hours. He was seen by EP who thought he had an AVNRT as
well as atrial fibrillation. He was started on a dilt gtt in the
MICU, with continued rapid HRs to the 140s and SBPs 80s-90s. He
ultimately was hemodynamically stable and titrated off the
diltiazem drip and responded to PO diltiazem 75 mg QID
(increased from 50 on [**12-4**]) and lopressor 25 mg PO TID. His HR
remained in the low 100s to high 90s with SBP in the 120-130s.
He was then transferred to the cardiology service for HR
control.
.
Currently patient is without complaints. Denies dizziness, chest
pain, SOB, abd pain, N/V.
Past Medical History:
Sick sinus syndrome s/p pacer [**3-24**]
HTN
High cholesterol
CHF, ECHO [**10-24**] EF 35-40%
ILD [**12-22**] amiodarone toxicity
Hypothyroidism due to amino toxicity
Gout
BCC on forehead(scheduled for removal)
Hx of melanoma
Barrett's esophagus
Fe deficiency anemia
Hx of hyperparathyroidism s/p resection
Social History:
Lives with brother
Family History:
n/a
Physical Exam:
Upon admission
Alert, confused
Cardiac: L side pacer
Chest: Clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: RLE Able to straight leg raise, Right knee without
pain, + pulses, +sensation. Left LE + sensation, + pules, pain
with ROM
Pertinent Results:
[**2147-11-28**] 09:30PM GLUCOSE-165* UREA N-31* CREAT-1.4* SODIUM-143
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-30 ANION GAP-13
[**2147-11-28**] 09:30PM estGFR-Using this
[**2147-11-28**] 09:30PM WBC-12.4* RBC-4.17* HGB-13.1* HCT-39.3*
MCV-94 MCH-31.5 MCHC-33.4 RDW-14.7
[**2147-11-28**] 09:30PM NEUTS-91.3* BANDS-0 LYMPHS-4.9* MONOS-3.5
EOS-0.1 BASOS-0.2
[**2147-11-28**] 09:30PM PLT COUNT-208
[**2147-11-28**] 09:30PM PT-24.0* PTT-29.4 INR(PT)-2.4*
RENAL U.S. [**2147-12-6**] 1:34 PM
IMPRESSION: Limited study. Cystic lesion seen on pelvic CT
corresponds to a 4.3 cm exophytic simple renal cyst from the
left lower pole. No hydronephrosis.
CHEST (PORTABLE AP) [**2147-12-3**] 1:13 AM
FINDINGS: There continues to be moderate cardiomegaly. Leads
from a dual-lead pacemaker is seen projecting over the heart in
similar location to prior. The left lateral chest is off the
film. There is a new area of opacity in the right lower lobe
that could represent an early infiltrate or some volume loss.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2147-12-2**] 1:52 AM
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Two focal aortic contour irregularities as described above.
Please see corresponding dedicated CTA of the aorta from [**2147-12-2**]
(Clip [**Clip Number (Radiology) 71165**]). 3. Bilateral severe centrilobular emphysema.
4. Multinodular thyroid, with adjacent clips suggesting prior
surgery. Correlation with patient's history is recommended.
5. Small hiatal hernia.
CTA ABD W&W/O C & RECONS [**2147-12-2**] 5:15 AM
Contour irregularities in the thoracic aorta and right common
iliac artery likely represent chronic changes associated with
atherosclerosis. No evidence of acute dissection or contrast
extravasation.
CT C-SPINE W/O CONTRAST [**2147-11-28**] 10:34 PM
IMPRESSION: No evidence of acute fracture. Multilevel
degenerative changes as detailed above.
CT PELVIS ORTHO W/O C [**2147-11-28**] 10:35 PM
IMPRESSION:
1. Comminuted left acetabular fracture involving the posterior
column and acetabular roof.
2. Two lytic lesions, involving the right iliac bone and the
left pubic symphysis. The larger lesion in the right iliac bone
demonstrates cortical destruction and a small associated soft
tissue mass. Given the multiplicity of lesions, metastatic
disease is the most likely differential consideration.
3. Low density structure in the left abdomen that is
incompletely evaluated, possibly representing an exophytic cyst
arising from the lower pole of the left kidney. This could be
further evaluated with renal ultrasound or CT.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2147-12-7**] 11:18 AM
1. Small right common iliac artery aneurysm with thrombus
component.
2. Descending thoracic aorta penetrating ulcer with small
associated hematoma unchanged.
3. At the aortic arch at the apex medially, there is a small
focal outpouching from which originates a small paraspinal
artery. These findings are unchanged as well. No aortic
dissection or aortic aneurysm identified.
4. Small bilateral effusions, right greater than left.
5. Indeterminate left upper pole renal lesion for which a
dedicated non- contrast CT of the abdomen could be performed,
alternatively, a dedicated MR could be performed.
6. Abnormal enlarged right hilar lymph node.
7. Multinodular goiter for which a throid ultrasound could be
performed for further assessment.
Brief Hospital Course:
Mr. [**Known lastname **] presented to [**Hospital1 18**] via transfer from [**Hospital 5279**] hospital
after being a restrained passenger in a MVC. He was evaluated
by trauma and orthopaedic surgery. He was found to have a Left
acetabular fracture and a right patella fracture. He was
admitted to orthopaedics and consulted on by medicine to clear
for surgery. Due to his elivated INR he was given Vitamin K.
On [**2147-11-30**] he was prepped and consented for surgery. He
tolerated the procedure well, was extubated, and taken to the
recovery room. In the recovery room he remained hemodynamically
stable with his pain controlled. He was then transferred to the
floor for further recovery. On the floor he remained stable
with his pain controlled. He was seen by physical and
occupational therapy to improve his strenght and mobility. On
[**2147-12-1**] he began to experience several episodes of SVT
associated with hypotension. The patient was r/o for PE with
CTA and transfered to the unit where he continued to have runs
of SVT. EP saw the patient and made recommendations for beta
blocker increase as well as hydration - plus possible cardiac
ablation. On [**2147-12-2**] the patient was transferred to the
medicine service.
.
Atrial fibrillation: Patient has a known history of atrial
fibrillation.
- His RVR was thought to be precipitated by dehydration and
catecholamines in setting of fracture and pain. Ruled out for PE
by CTA.
-Digoxin loading initiated in the MICU but subsequently
discontinued.
-EP evaluated the patient in-house and felt there was no acute
indication for cardioversion. After speaking with his PCP, [**Name10 (NameIs) **]
has been cardioverted in the past.
- TFTs were not consistent with hyperthyroidism.
-He was also started on a diltiazem gtt which was titrated down
and started on diltiazem 75 mg po QID on [**2147-12-3**]. This is
titrated up to 90 QID and switched to 360 XR on [**2147-12-7**].
However, as he started to AV pace with a pulse in the 60s, this
was decreased to 240 XR where he intermittently has 1st degree
AV block and AV pacing with rare 4 beat NSVT.
-He was also started on metoprolol 25 mg po TID but his heart
rate did not improve with this. Therefore, he was started on
sotalol 80 mg PO BID on [**2147-12-5**] and subsequently converted from
atrial fibrillation to 1st degree AV block. He is intermittently
AV paced vs. V paced on telemetry throughout the rest of his
stay.
-DC'd lovenox on [**12-5**] and started heparin. His heparin was
discontinued when his INR was therapeutic on coumadin 5 mg. This
was OK'd by orthopedic surgery. His coumadin was decreased to 2
mg on the day of discharge for an INR goal of [**12-23**].
.
*Hypotension: This likely occurred prior to MICU stay secondary
to dilt gtt in combination with RVR. It has subsequently
resolved and his SBP has been in the 110-130s. Indeed, his ACE
has been titrated up.
.
*Hip fracture: S/p ORIF for left acetabular fracture on [**2147-11-30**]
[**12-22**] to MVA.
- Also has right patellar fracture in brace.
- LLE non-weight bearing.
- The patient did not complain of pain and did well with PT.
- He will need his staples removed from the left hip 2 weeks
from [**2147-11-30**]. If this is not done in rehab, he will need to see
Dr. [**Last Name (STitle) 1005**] for this. Otherwise, he may follow up with Dr.
[**Last Name (STitle) 1005**] in 4 weeks.
.
* CHF (EF 35-40%): The patient remained euvolemic as an
inpatient. He may benefit from an outpatient echo for routine
care.
-Captopril 6.25 mg TID started on [**2147-12-6**] as BP in 118-120
range. The patient had been on Lisinopril 80 mg PO at home.
Lisinopril 2.5 mg PO QD was started on [**2147-12-8**]. This was
increased to 5 mg prior to DC.
.
# Aortic ectasia
- This was originally seen on a CT of the chest s/p MVA.
Vascular recommended repeat CTA prior to DC. The repeat CTA
showed a stable appearing outpouching of the aortic arch,
descending aortic ulceration with thrombus and small hematoma as
well as small right common iliac aneurysm. No AAA or dissection.
The patient will follow up with vascular surgery as an
outpatient as outlined in the DC planning.
.
* Fe deficiency anemia: The patient's Hct trended down to 27
from 39 at admission; this occurred in the peri-operative
period.
- He was started on iron supplements.
- His Hct remained stable throughout his stay.
.
* High cholesterol: Cont statin
.
*Interstitial Lung Disease secondary to amiodarone toxicity:
Chest CT shows severe emphysema (the patient has a significant
history of tobacco as well). Sats remained stable.
-His albuterol was held in the setting of tachycardia. This may
be restarted as an outpatient if needed.
-atrovent nebs if necessary. He was not hypoxic prior to
discharge and had no acute pulmonary issues.
.
# Lytic lesions in bone
- This was an incidental finding on a CT of the pelvis. Concern
for metastatic disease. UPEP, SPEP not suggestive of MM. The
patient has a history of Barrett's esophagus, BCC. He denies a
history of melanoma. His PCP was [**Name (NI) 653**] and made aware and
informed us that the patient had never received a colonoscopy.
- HE MUST see an oncologist as soon as possible for further
evaluation.
- The patient was made aware of the impending diagnosis of
cancer as was his son [**Name (NI) **].
-Cystic lesion noted on kidney incidentally, likely benign.
- Renal ultrasound showed 4.6 cm exophytic simple cystic lesion
in left kidney.
.
* Hypothryoidism due to amio toxicity: The patient was found to
have a mildly low TSH and multinodular thyroid goiter. He was
continued on his outpatient Synthroid dose. He should have
outpatient follow up for this.
* Basal cell carcinoma- Needs OP follow up with plastics and
dermatology for removal.
Medications on Admission:
Tylenol prn
Allopurinol 100mg daily
Calcium 1300mg daily
ASA 81mg daily
Colace/senna
Felodipine 10mg daily
Iron 325mg [**Hospital1 **]
Lisinopril 80mg daily
Lovastatin 20mg daily
Toprol XL 50mg daily
Omeprazole 20mg daily
Coumadin-goal INR [**12-23**]
Albuterol 2puffs QID
Lasix 20mg [**Hospital1 **]
Synthroid 25mcg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO AC MEALS
PRN ().
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB.
11. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for pruritus.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p motorvehicle crash
Left acetabular fracture
Right patellar fracture
Left renal cyst
Lytic lesions in right iliac and pubic symphysis
Atrial fibrillation
Sick sinus syndrome
Aortic ectasis, ulceration
Multinodular thyroid goiter
Discharge Condition:
Stable
Discharge Instructions:
Continue to be non-weight bearing on your left leg
You may be weight bearing as tolerated on your right leg with
your [**Doctor Last Name 6587**] brace locked in extension.
You must have your staples removed from your left hip 2 weeks
from [**2147-11-30**]. If this is not performed at rehab, you must see
Dr. [**Last Name (STitle) 1005**] in 2 weeks. If the staples are removed at rehab,
you may follow up with Dr. [**Last Name (STitle) 1005**] in 4 weeks.
You must see an oncologist as soon as possible. You may have
cancer with involvement of bone.
Your sutures/staples can come out 14 days after surgery
You may apply a dry sterile dressing over your incision as
needed for comfort or drainage
Your goal INR is [**12-23**]
If you notice any 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 Dr. [**Last Name (STitle) 1005**] in [**12-24**] weeks please call
[**Telephone/Fax (1) 1228**] to schedule that appointment.
You were evaluated by our electrophysiology team for your atrial
fibrillation. If you wish to continue your cardiac care at
[**Hospital1 18**], please call ([**Telephone/Fax (1) 9530**] to schedule an appointment
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 3 months. Otherwise, please follow up
with your cardiologist within the next 3 months.
Vascular: You will need an appointment with Dr [**Last Name (STitle) **] in three
months. You will also need a study called an CTA. His office
will call you at home. If they do not, he can be reached at
[**Telephone/Fax (1) 3121**].
You may have to be ddmitted prior for hydration to protect your
kidneys.
You will need to follow up with Dr. [**First Name (STitle) 4587**] in 1 week. You will
need to see an oncologist as soon as possible for concern of
cancer.
|
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"441.2",
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icd9cm
|
[
[
[]
]
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[
"81.91",
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icd9pcs
|
[
[
[]
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6642, 12412
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272, 419
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14773, 14782
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3235, 6619
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,852
| 130,065
|
42039
|
Discharge summary
|
report
|
Admission Date: [**2123-9-9**] Discharge Date: [**2123-9-15**]
Date of Birth: [**2046-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Niacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fatigue/Dyspnea/Dizziness
Major Surgical or Invasive Procedure:
[**2123-9-9**] - 1. Aortic valve replacement with a 23-mm [**Doctor Last Name **]
Magna Ease aortic valve bioprosthesis.
2. Coronary artery bypass grafting x2 with left internal mammary
artery to the left anterior descending coronary artery; reverse
saphenous vein single graft from the aorta to the distal right
coronary artery.
History of Present Illness:
76 year old female with known aortic stenosis who presented with
acute onset of chest discomfort and shortness of breath in
[**2123-6-28**]. She was admitted to the [**Hospital1 18**] and found to now have
severe aortic stenosis with mild left ventricular hypertrophy.
She also developed atrial fibrillation during the her hospital
stay which resolved with a dose of diltiazem. During the
admission, black tarry stools were noted suggesting a
gastrointestinal bleed. Dr. [**Last Name (STitle) 1940**] was consulted and an EGD
showed only mild gastritis with a duodenal ulcer. She was
evaluated by Dr. [**Last Name (STitle) 914**] who felt and aortic valve replacement
was warranted however wanted her GI issues resolved prior to
proceeding. She returned to the EDon [**2123-8-17**] with shortness of
breath.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- HYPERTENSION
- HYPERCHOLESTEROLEMIA
- DIABETES MELLITUS
- MEMORY DISORDER
- OSTEOPENIA
- Aortic valve stenosis severe
Social History:
married, lives with her husband. She has 4 adult children. Her
daughter [**Name (NI) **] lives nearby. Denies ever drinking ETOH, smoking
or using illicit drugs.
Family History:
Her father died of an MI in his 50s. She has a paternal uncle
who died suddenly in his 20s. She has a brother who recently had
a stroke.
Physical Exam:
Pulse:61 Resp:20 O2 sat:98/RA
B/P 112/58
Height:64" Weight:62.5 kgs
General: NAD, WGWN, appears 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 [x] Irregular [] Murmur [] grade 2/6 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit: radiation of cardiac murmur vs. bruits
Pertinent Results:
ECHO [**2123-9-9**]:
PRE-BYPASS:
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No spontaneous echo contrast is seen in the
body of the right atrium. No atrial septal defect is seen by 2D
or color Doppler. There is moderate symmetric left ventricular
hypertrophy.
The left ventricular cavity size is top normal/borderline
dilated. Overall left ventricular systolic function is normal
(LVEF>55%). with normal free wall contractility.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is
seen.
The mitral valve leaflets are moderately thickened. Mild to
moderate ([**11-29**]+) mitral regurgitation is seen. There is no
pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results before
surgical incision.
POST_Bypass:
The patient is AV paced on a low dose phenylephrine infusion.
There is a well seated bioprosthetic valve in the aortic
position. The mean gradient across the prosthetic valve is
5mmHg. The remaining valves are unchanged. Biventricular
function is maintained. The aorta remains intact. Overall LVEF
55%.
[**2123-9-15**] 04:26AM BLOOD WBC-5.3 RBC-3.13* Hgb-9.8* Hct-29.6*
MCV-95 MCH-31.2 MCHC-32.9 RDW-13.4 Plt Ct-267
[**2123-9-10**] 12:17PM BLOOD PT-13.9* PTT-27.6 INR(PT)-1.2*
[**2123-9-15**] 04:26AM BLOOD Glucose-92 UreaN-27* Creat-1.0 Na-142
K-4.1 Cl-102 HCO3-34* AnGap-10
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on 10/ 13/11 for surgical
management of her aortic valve and coronary artery disease. She
was taken to the operating room where she underwent coronary
artery bypass grafting to two vessels and an aortic vlave
replacement using a 23-mm [**Doctor Last Name **] Magna Ease aortic valve
bioprosthesis. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. She was transfused for postoperative anemia. Over
the next several hours, she awoke neurologically intact and was
extubated. On postoperative day one her beta blockade, aspirin,
and a statin were resumed. She was started on amiodarone for
transient atrial fibrillation. She was then transferred to the
step down unit for further recovery. Her epicardial wires were
removed. After chest tube removal she had bilateral
pneumonthoraces which remained stable on multiple chest
radiographs over several days. For anemia she was started on
folic acid and iron. By post-operative day six she was ready
for discharge to [**Hospital 4470**] Rehab. All follow-up appointments
were advised.
Medications on Admission:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. donepezil 10 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO
once a day.
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet, PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14
days.
Disp:*14 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] HealthCare Center at [**Location (un) 38**]
Discharge Diagnosis:
Diabetes
Dyslipidemia
Hypertension
Memory disorder
Osteopenia
Aortic valve stenosis
Coronary artery disease
Gastritis/Duodenal Ulcer [**6-/2123**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] on [**10-26**] at 1:00 pm
Cardiologist: Dr [**First Name (STitle) **] on [**9-29**] at 2:40 pm in [**Location (un) 38**] office
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 1356**] in [**3-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2123-9-15**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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8269, 8359
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4592, 5754
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297, 629
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8550, 8761
|
2827, 4569
|
9735, 10291
|
1995, 2133
|
6537, 8246
|
8380, 8529
|
5780, 6514
|
8785, 9712
|
2148, 2808
|
1574, 1647
|
232, 259
|
657, 1466
|
1678, 1799
|
1488, 1554
|
1815, 1979
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,591
| 139,265
|
37477
|
Discharge summary
|
report
|
Admission Date: [**2169-1-26**] Discharge Date: [**2169-2-9**]
Date of Birth: [**2150-8-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
intubated at scene
Major Surgical or Invasive Procedure:
[**2169-1-31**]
Tracheostomy
Percutaneous gastrostomy tube
[**2169-2-3**]
Left AC PICC line
History of Present Illness:
17 year old man, unrestrained driver MVC at high speed, car
vs tree this AM. GCS 3T, intubated at scene. +EtOH, cannabis.
Taken to outside hosptial, found to have pulmonary contusions,
possible IPH, no other obvious injuries. Transfer by [**Location (un) **]
for continued care. Recieved veccuronium at approximately 0400,
100mcg fentanyl and 1mg versed at 0610.
Past Medical History:
none
Social History:
Lives with his mother, parents divorced
ETOH +< Tobacco + No IVDA
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
O: BP: 114/60 HR: 62 R: 18 O2Sats: 100%
Gen: Intubated, not on sedation, no spontaneous movement
HEENT: Pupils: Equal, round, minimally reactive to light
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS 3T, no corneals, no gag. Minimal movement of
head with strong sternal rub.
Cranial Nerves:
I: Not tested
II: Pupils equally round minimally reactive to light, 1mm
bilaterally.
III, IV, VI: unable to test
V, VII: unable to test
VIII: unable to test
IX, X: unable to test
[**Doctor First Name 81**]: unable to test
XII: unable to test
Motor: No abnormal movements, tremors. unable to test strength.
Sensation: unable to test
Toes mute bilaterally
Coordination: unable to test
Pertinent Results:
[**2169-1-26**] 06:39AM WBC-16.6* RBC-4.56* HGB-15.1 HCT-41.8 MCV-92
MCH-33.1* MCHC-36.2* RDW-13.0
[**2169-1-26**] 06:39AM PLT COUNT-243
[**2169-1-26**] 06:39AM PT-12.8 PTT-25.8 INR(PT)-1.1
[**2169-1-26**] 06:39AM ASA-NEG ETHANOL-190* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2169-1-26**] 06:44AM GLUCOSE-109* LACTATE-2.9* NA+-139 K+-4.0
CL--109 TCO2-20*
[**2169-1-26**] 06:39AM UREA N-6 CREAT-0.9
[**2169-1-26**] CT C Spine : 1. No fracture or malalignment.
2. Tiny radiopaque density in the region of the hypopharynx and
oropharynx . Clinical correlation is suggested.
[**2169-1-26**] Head CT : 1. Hyperdensity in the right perimesencephalic
cistern, concerning for small focus of subarachnoid hemorrhage.
2. Possible tiny focus of layering hemorrhage within the
occipital [**Doctor Last Name 534**] of
the left lateral ventricle.
[**2169-1-26**] CT Torso :
1. Multifocal consolidation in the lungs, predominantly in the
upper lobes, which most likely reflect pulmonary contusions.
There are associated pneumatoceles, largest in the left upper
lobe.
2. Multiple radiopaque densities within the skin of the upper
and mid back, likely reflect foreign bodies.
[**2169-1-27**] MRI Head :
1. Multiple punctate blooming foci of susceptibility artifact,
some of which demonstrate corresponding restricted diffusion,in
the frontal lobes and splenium of the corpus callosum,
bilaterally. These findings are consistent with extensive
diffuse axonal injury, likely explaining the clinical
presentation.
2. Subarachnoid hemorrhage predominately within the bilateral
occipital lobar and at the left vertex sulci, with a small
amount of hemorrhage layering in the left lateral ventricle, and
no evidence of hydrocephalus.
3. Small fluid levels within the paranasal sinuses. Given that
the initial head CT dated [**2169-1-26**] demonstrated clear
sinuses, these findings are most likely related to intubation
and supine positioning.
[**2169-1-27**] MRI C Spine : 1. No evidence of traumatic injury to the
cervical spine or spinal cord.
2. Fluid noted in the oropharynx, attributable to recent
intubation and
retained secretions.
[**2169-2-8**] CXR :
Comparison is made with prior study [**2-3**].
Tracheostomy tube is in standard position. There has been
markedly improved lung opacities, some opacities persist in the
left lower lobe in the retrocardiac area and superior to the
right hilum medial in the right upper lobe. There is no
pneumothorax or pleural effusion. Cardiac size is top normal.
There are low lung volumes. Pneumoperitoneum has decreased.
Brief Hospital Course:
Mr. [**Known lastname 19219**] was evaluated in the Emergency Room by the Trauma
team and then admitted to the Trauma ICU for further management
and care. He had a small subdural hematoma by Head CT and on
exam had no eye opening, small non reactive pupils and a strong
cough. He moved his right side to pain. All other extremities
responded with abnormal extension. He had no spontaneous
movements. He was maintained on full mechanical ventilation and
underwent frequent neuro checks. He was placed on a 7 day
course of prophylactic Keppra.
An MRI of his head revealed diffuse axonal injury and an MRI of
his neck showed no ligamentous injury therefore his C collar was
removed on [**2169-1-27**]. He required increased doses of Propofol and
Fentanyl as he was extremely agitated when his sedation was
weaned and actually required reintubation twice as he self
extubated himself with his right hand. He eventually underwent
tracheostomy to protect his airway and PEG tube placement for
nutrition.
Daily temperature spikes prompted multiple cultures and
sinusitis was demonstrated on CT. He was subsequently treated
with Flagyl and Cephapine for a 7 day course.
From a pulmonary standpoint he was eventually weaned off the
respirator and maintained on a trach collar with vigorous
pulmonary toilet.
He was evaluated by the ENT service as a foreign body was noted
in the hypopharynx on CT of the C spine. Direct laryngoscopy was
done at the bedside but no foreign body was noted nor were there
any signs of mucosal infection. He will follow up with ENT as
an out patient.
[**Doctor First Name **] was transferred to the Trauma floor on [**2169-2-3**] for further
rehabilitation.
He remained restless and agitated and continued to have strong,
spontaneous movements of his right side but less so on the left.
He does not respond to commands. His agitation and restlessness
was controlled with Haldol around the clock and on occasion he
would need an IV dose. His pain was controlled with Methadone
20 mg [**Hospital1 **]. It should be weaned down to 10 mg [**Hospital1 **] as long as he
is able to tolerate his PT regime at rehab.
Multiple urine cultures were done as he had an elevated WBC to
19K without bandemia. All of his cultures were negative and his
WBC was 15K. On [**2169-2-8**] he had a high temperature of 100.7
along with an elevated WBC of 18.9 without bands. For that
reason he had blood, urine and sputum cultures obtained. His
urinalysis was negative and a chest xray showed no pneumonia.
He did have a PICC line in which was then removed and the tip
was cultured. Currently all cultures are prelinarily negative
and he has not had any other fevers. He remains off antibiotics.
He was seen daily by the Physical Therapy service and
Occupational Therapy. The Social Workers were very involved
with his family during his admission
to try to keep them updated on his condition and help them deal
with this devastating injury. After a prolonged hospital stay he
was discharged to rehab for vigorous treatment in the hopes of
his regaining some of his baseline function.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for eye care.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for bowel regimen.
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
12. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for eye care.
13. Haloperidol Lactate 5 mg/mL Solution Sig: 2-3 mg Injection
Q4H (every 4 hours) as needed for increased agitation.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain or fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary diagnosis
S/P MVC car v. tree
1. Subarachnoid hemorrhage
2. Multifocal pulmonary contusions
3. [**Doctor First Name **]
4. Foreign body in hypopharynx
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Bedbound
Discharge Instructions:
* Work hard with Physical Therapy, Occupational Therapy and
Speech Therapy.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1837**] at [**Telephone/Fax (1) 41**]
regarding a possible foreign body in your throat identified on
CT scan.
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1669**] for a follow up appointment in 8
weeks with a repeat MRI. The secretary will arrange that for
you.
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1864**] for a follow up appointment in
[**2-15**] weeks.
Completed by:[**2169-2-9**]
|
[
"305.00",
"780.60",
"851.25",
"786.03",
"338.0",
"E935.2",
"860.0",
"482.49",
"E816.0",
"E915",
"310.1",
"288.60",
"861.21",
"287.5",
"933.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"38.91",
"31.1",
"96.72",
"43.11",
"31.42",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8838, 8885
|
4384, 7488
|
331, 424
|
9088, 9088
|
1773, 4361
|
9814, 10287
|
944, 962
|
7543, 8815
|
8906, 9067
|
7514, 7520
|
9218, 9791
|
992, 1254
|
273, 293
|
452, 817
|
1365, 1754
|
9102, 9194
|
839, 845
|
861, 928
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,043
| 129,934
|
6101
|
Discharge summary
|
report
|
Admission Date: [**2191-3-15**] Discharge Date: [**2191-3-18**]
Date of Birth: [**2132-6-22**] Sex: F
Service: MEDICINE
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Vocal cord injection
Intubation
Bronchoscopy
Arterial Line
Central veinous line
History of Present Illness:
58 year old woman with stage IV SCLC with large right hilar
mass, pleural effusion (had recent talc pleurodesis), right
cervical [**Doctor First Name **] who had received 8 cycles of carboplatin, now on
irinotecan.
Patient was transferred from ENT service for increased dyspnea,
decreased urine output to Oncology service.
She was admitted to the ENT service for right vocal cord
injection performed on [**2191-3-15**]; she was noted to have
progressive odynophagia and dysphonia, believed to be from right
cervical mass pressing on vocal cord. Her symptoms were so
severe that she had poor oral intake and was coming in for IV
fluids. She was intubated [**2191-3-15**] and had injection of the
right vocal cord; at that time she was noted to have candidal
laryngitis and esophageal laryngitis. After the procedure
yesterday, she had improvement in her voice and decreased
odynophagia.
However, today, she feels worse again. In particular, she has
dyspnea on exertion, and her odynophagia has returned. She
denies chest pain. + cough (chronic). No headache, visual
changes, arthralgias, skin changes. Admits to "fear of dying".
At 11:30 PM on [**2191-2-14**], patient was triggered RR > 30, SaO2 <
90 % in spite of oxygen, and marked nursing concern. VS at time
were HR 115, BP 100/65, RR 33, T 96.9, pOx 78 % on 70 % FiO2 FM.
She was tachypneic and had time with air movement. She had a
coughing spell about 15 minutes before the episode started. She
was given albuterol nebs x 4 with resultant pOx 85 % on RA. It
was favored that this may be aspiration pneumonitis or mucous
plugging. Patient had continuing respiratory distress despite
multiple nebs. RR was 33 with pOx 92 % on 100 FiO2. It also felt
she was somnolent at times.
ABG showed: pH 7.38 pCO2 34 pO2 77 HCO3 21 AADO2 607 Lactate 2.4
CXR showed ? pulmonary edema, ? aspiration in left lower
Past Medical History:
- Small cell lung cancer s/p chemo and XRT
- Chronic kidney disease (baseline creatinine 2.0) presumed due
to diabetes and/or hypertension
- Hypertension
- Hyperlipidemia
- PCOS
- Neuropathy in the toes secondary to diabetes
- GERD
- Diabetes type II
.
PAST ONCOLOGIC HISTORY:
- Presented [**2-/2189**] with cough, thought to be due to Lisinopril
- [**7-/2189**]: developed lymphadenopathy in the right supraclavicular
area which was non-mobile. Also had dysphagia. Admitted for
work-up.
- [**2189-8-12**]: CT Chest showed large right hilar/mediastinal mass
with encasement of R mainstem bronchus
- [**2189-8-13**]: bronchoscopy and EUS done with biopsy confirmed small
cell lung cancer; brain MRI negative
- [**-8/3148**]: [**Doctor Last Name **] (6 AUC) and etoposide 60mg/m2 started as an
inpatient with concurrent XRT; completed 20 session from
[**Date range (3) 23906**]
- chemotherapy course complicated by febrile neutropenia after
cycles 1 and 2. Cycles 3 and 4 were given with 25% dose
reduction ([**Doctor Last Name **] 4 AUC, Etoposide 60mg/m2) and Neulasta was
given. Received a total of 4 cycles with response on imaging.
- [**2190-5-19**]: Disease recurrence intrathoracic and right
supraclavicular lymph nodes
- [**2190-6-1**] Restarted [**Doctor Last Name **]/Etoposide at doses of [**Doctor Last Name **] 5 AUC,
Etoposide 60mg/m2 and Neulasta, received 6 cycles with disease
response on CT
- [**2190-10-12**]: Cycle 7 [**Doctor Last Name **]/Etoposide
- [**2190-11-9**]: Cycle 8 [**Doctor Last Name **]/Etoposide
- [**2190-11-26**]: CT Chest with stable lymphadenopathy; moderate
pleural effusion
Social History:
Lives with husband and pet cats in [**Name (NI) **]. No children. Quit
smoking about two years ago. Drinks occasional alcohol. Does not
work at this time due to illness.
Family History:
No lung cancers in family. Mother died of ovarian cancer.
Physical Exam:
Deceased
Pertinent Results:
[**2191-3-18**] 05:35AM BLOOD WBC-4.1# RBC-4.32# Hgb-13.0# Hct-37.6#
MCV-87 MCH-30.2 MCHC-34.7 RDW-15.4 Plt Ct-34*
[**2191-3-18**] 05:35AM BLOOD PT-16.0* PTT-52.2* INR(PT)-1.5*
[**2191-3-18**] 05:35AM BLOOD Glucose-163* UreaN-26* Creat-1.7* Na-137
K-4.9 Cl-110* HCO3-16* AnGap-16
[**2191-3-18**] 05:35AM BLOOD ALT-7 AST-20 CK(CPK)-99 AlkPhos-98
TotBili-1.7*
[**2191-3-18**] 05:35AM BLOOD CK-MB-8 cTropnT-1.03*
[**2191-3-18**] 09:41AM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-51* pH-7.21*
calTCO2-21 Base XS--8
ECHO [**2191-3-18**]
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is probably mildly to moderately depressed
(LVEF= 40-45 %). The right ventricular cavity appears dilated
with moderate global free wall hypokinesis. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2191-3-17**], LV
systolic function appears more vigourous (in the setting of
increased tachycardia and more pressor support). The RV appears
more dilated and RV systolic function appears depressed.
CXR [**2191-3-17**]
As compared to the previous radiograph, the patient has received
a
new left internal jugular vein catheter. The tip of the catheter
projects
over the mid-to-low SVC, the course of the catheter is
unremarkable. There is no evidence of complications, notably no
pneumothorax.
The patient also has received an endotracheal tube. The tip of
the tube
projects 3.8 cm above the carina, the tube could be advanced by
approximately 1 cm. Normal course of the new nasogastric tube,
the tip of the tube is not included on the image.
Unchanged appearance of the lung parenchyma.
Brief Hospital Course:
58-year-old woman with metastatic SCLC admitted to ENT service
for injection of right vocal cord, was symptomatically improved
after procedure. She had worsening tachypnea and was initially
transferred to the hospitalist service prior to transfer to the
MICU for hypotension and respiratory distress. She died on
[**2191-2-15**] at 11:13am, with causes including pneumonia, STEMI and
SCLC.
# Hypoxemic respiratory failure
Thought to be related to poor lung reserve from SCLC and
surgery, as well as a new LLL pneumonia that was presumed to be
aspiration related. She was intubated for respiratory support
and started on vancomycin, cefepime, zosyn, micafungin, and
voriconazole. She required increasing ventilation requirements
throughout the hospital stay.
#STEMI:
On the day prior to her death she was noted to have ECG changes
consistent with an ST elevation MI. Her troponins were also
elevated. Most likely etiology was a right ventricle infarction.
She required increasing pressors but her bicarb and urine
continued to decline. On [**2-15**], after a discussion with the
family, it was decided that further escalation of care and/or
CPR would be futile. She passed at 11:13am.
# Shock
Likely cardiogenic, hypovolemic and septic. Treated likely
pneumonia with vancomycin, cefepime, micafungin, voriconazole
and zosyn. Echo was obtained to assess heart function, which
showed global hypokinesis with LVEF of 25%. A subsequent echo
confirmed severe RV hypokinesis.
# SCLC:
Widespread disease; patient now with poor functional status,
unable to meet her nutritional needs. Pancytopenic due to
chemo. Ongoing discussion with family and caregivers regarding
poor prognosis.
Medications on Admission:
- Lantus 4-6 units qAM and 6 units qHS
- Humalog 4 units qAM and 4-6 units at suppertime
- Ativan 0.5 mg PO qD
- omeprazole 40 mg PO qD
- setraline 100 mg PO BID
- benzonatate 100 mg PO TID
- guaifenesin 400 mg PO q 6 hr prn cough
- prochlorperazine 10 mg PO q 6 hr prn
- ondansetron 8 mg PO BID prn
- Imodium 2 mg PO prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
ST Elevation Myocardial Infarction
Small cell lung cancer
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
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"995.92",
"272.4",
"403.90",
"250.60",
"518.81",
"410.91",
"162.2",
"530.81",
"507.0",
"263.9",
"357.2",
"585.9",
"V15.82",
"464.00",
"785.52",
"196.0",
"250.40",
"112.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.0",
"96.04",
"31.42",
"38.97",
"96.71",
"42.24",
"99.29",
"38.91",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8158, 8167
|
6075, 7757
|
289, 370
|
8278, 8288
|
4210, 6052
|
8340, 8346
|
4106, 4166
|
8130, 8135
|
8188, 8257
|
7783, 8107
|
8312, 8317
|
4181, 4191
|
229, 251
|
398, 2261
|
2283, 3902
|
3918, 4090
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,348
| 161,526
|
46256
|
Discharge summary
|
report
|
Admission Date: [**2181-7-2**] Discharge Date: [**2181-7-8**]
Date of Birth: [**2119-10-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Augmentin / Sulfa (Sulfonamide Antibiotics) / Flagyl /
Penicillins / Ultram / Percocet
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea with minimal exertion. Fatigue.
Major Surgical or Invasive Procedure:
[**2181-7-2**] Redo-sternotomy, Mitral valve replacement ([**First Name8 (NamePattern2) 17009**] [**Male First Name (un) 923**]
tissue) , Tricuspid valve repair (#28 ring)
History of Present Illness:
61 year old female with history of rheumatic heart disease who
underwent a mitral valve repair in [**2170**] by Dr. [**Last Name (STitle) 1290**]. More
recently she has noted worsening heart failure symptoms which
include dyspnea with minimal exertion. She has been followed for
what is believed to be significant mitral stenosis, secondary
pulmonary hypertension and right ventricular dysfunction with
interventricular dependence in the setting of severe tricuspid
regurgitation related to the mitral stenosis. As her symptoms
have worsened, a repeat echo was obtained which showed trivial
mitral stensosis with severe 4+ tricuspid regurgitation. Given
the severity of her disease and the progression of her symptoms
despite an escalating medical therapy, she has been referred for
surgical evaluation.
Past Medical History:
1. Rheumatic valve disease, status post mitral valve repair for
severe MR, with residual mild mitral stenosis.
2. Secondary pulmonary hypertension and severe tricuspid
regurgitation due to mitral stenosis.
3. Hypertension.
4. Obstructive sleep apnea.
5. Depression.
6. Cutaneous lupus.
7. Diverticulosis gastritis.
8. Gout.
9. Chronic low back pain.
10. Osteoarthritis, left hip with arthroplasty, bilateral hip
replacements, bilateral rotator cuff disease.
11. Left knee bursitis and cellulitis.
12. Pancreatitis
13. Lupus
14. H/O labial herpes/PID
15. Headaches
16. Chronic lower back pain
Past Surgical History:
1. [**11/2171**] - Mitral valve repair (26 mm [**Doctor Last Name 405**] annuloplasty
ring).
2. [**6-/2162**] - Diagnostic laparoscopy with the [**Last Name (un) 24631**] method.
3. [**7-/2162**] - Laparotomy with lysis of adhesions and total
abdominal hysterectomy.
4. [**1-/2163**] - Exploratory laparotomy, extensive dissection of
multiple abdominal and pelvic adhesions, bilateral
salpingo-oophorectomy and appendectomy.
5. [**10/2165**] - Cystometrogram, uroflow, voiding cystourethrogram.
6. [**8-/2166**] - Left total hip arthroplasty
7. [**11/2166**] - Laparoscopic cholecystectomy.
8. [**8-/2171**] - Arthroscopy, right knee. Subtotal medial
meniscectomy. Chondroplasty of medial femoral condyle. Lysis of
medial plica.
9. [**4-/2175**] - 1. Right great toe Akin osteotomy. 2. Second
proximal interphalangeal joint arthroplasty.
10. [**1-/2176**] - Arthroscopy left knee, subtotal medial and lateral
meniscectomies.
11. [**7-/2179**] - Primary right total hip arthroplasty
Social History:
Race: African american
Last Dental Exam: 3 yrs ago
Lives with: Grand-daughter
Contact: Phone #
Occupation: -
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use: Denies
ETOH: < 1 drink/week [X] [**1-16**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
Mother with MI at age 52. Father died of a stroke.
Physical Exam:
Pulse: 55 Resp: 18 O2 sat: 100%
B/P Right: 104/68 Left: 131/107
Height: 69" Weight: 230
General: Well-developed female in no acute distress
Skin: Dry [X] intact [X] bug bites right foot and upper right
back
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade [**2-13**]
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] obese
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: - Left: -
Pertinent Results:
Echo [**2181-7-2**]: PRE BYPASS The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is dilated with
borderline normal free wall function. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal
diastolic septal motion/position consistent with right
ventricular volume overload. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve is s/p
repair. The annular ring is well seated. The gradient across the
mitral valve is increased (mean = 9 mmHg). There is severe
valvular mitral stenosis (area <1.0cm2) using the PISA method.
Physiologic mitral regurgitation is seen (within normal limits).
Severe [4+] tricuspid regurgitation is seen. Systolic reversal
of blood flow in the inferior vena cava is seen. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
POST BYPASS The patient was initially AV paced but then
transitioned to sinus rhythm. She was receiving epinephrine,
norepinephrine, and milrinone by infusion. There is some septal
dyssynchrony but overall left ventricular systolic function is
normal. The right ventricular free wall appears dyskinetic. In
total, right ventricular systolic function is severely
depressed. There is a bioprosthesis located in the mitral
position. It appears well seated and the leaflets appear to have
normal mobility. There is trace valvular mitral regurgitation.
The maximum gradient through the valve was 16 mmHg with a mean
of 4 mmHg at a cardiac output of around 4 liters/minute. The
tricuspid valve is s/p placement of a valvuloplasty ring. It
appears well seated. There is at least mild tricuspid
regurgitation seen, though it may be as much as mild to
moderate. The thoracic aorta is intact after decannulation. No
other significant changes from the pre-bypass study.
[**2181-7-6**] 09:35AM BLOOD WBC-8.2 RBC-3.03* Hgb-9.4* Hct-28.4*
MCV-94 MCH-30.8 MCHC-33.0 RDW-16.5* Plt Ct-78*#
[**2181-7-5**] 01:51AM BLOOD WBC-7.6 RBC-2.88* Hgb-9.3* Hct-26.4*
MCV-92 MCH-32.5* MCHC-35.3* RDW-16.5* Plt Ct-48*
[**2181-7-4**] 01:36PM BLOOD WBC-9.8 RBC-2.71* Hgb-8.3* Hct-25.0*
MCV-92 MCH-30.7 MCHC-33.3 RDW-16.5* Plt Ct-51*
[**2181-7-4**] 04:06AM BLOOD WBC-9.0 RBC-2.93* Hgb-9.0* Hct-26.7*
MCV-91 MCH-30.8 MCHC-33.8 RDW-16.4* Plt Ct-65*
[**2181-7-6**] 09:35AM BLOOD Glucose-145* UreaN-20 Creat-1.2* Na-139
K-4.4 Cl-105 HCO3-27 AnGap-11
[**2181-7-5**] 09:20PM BLOOD Na-136 K-4.1 Cl-102
[**2181-7-5**] 01:51AM BLOOD Glucose-95 UreaN-19 Creat-1.3* Na-139
K-4.2 Cl-103 HCO3-28 AnGap-12
[**2181-7-4**] 04:06AM BLOOD Glucose-99 UreaN-18 Creat-1.2* Na-139
K-4.0 Cl-107 HCO3-26 AnGap-10
Brief Hospital Course:
Mrs. [**Known lastname 23081**] was a same day admit and on [**7-2**] was brought
directly to the operating room where she underwent a
redo-sternotomy, mitral valve replacement and tricuspid valve
repair. Please see operative note for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. She was received from the OR on
Epinephrine/Levophed/Milrinone. She was weaned off epineprhine
and levophed by POD#1. She was kept on Milrinone until POD#2 and
this subsequently weaned with good cardiac index/SVO2. She was
started on a lasix drip on POD#1 for a negative fluid balance
and extubated without incidence after diuresing. She was
transitioned from a lasix drip to TID Lasix on POD3 and beta
blockers were started at a low dose and titrated up as BP
tolerated. Chest tubes were removed without incidence and she
was transferred to F6. Pacing wires were left in with
thrombocytopenia and platelets slowly recovered with HIT coming
back negative. Pacing wires were removed POD#5 per cardiac
surgery protocol. She continued to progress well and worked with
physical therapy for strength and endurance. By POD #6 she was
tolerating a full oral diet, her incisions were healing well
with a scant amount of serosanguinous drainge noted from distal
aspect of sternal incision. incision was painted with cloraprep
and covered with a DSD. she was evaluated by physical therapy
and able to ambulate with assistance. On POD#6 she was claered
for discharge to [**Hospital3 2558**] Rehab in stable condition. She
will return for a wound check and to have the staples in her
right groin removed- instructions and appointmenst have been
advised.
Medications on Admission:
ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - one Tablet(s) by
mouth every six hours prn pain
ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth daily
CLINDAMYCIN HCL - 300 mg Capsule - 2 Capsule(s) by mouth 30-60
minutes before dental procedure
CLOBETASOL - 0.05 % Solution - apply to scalp qhs as needed for
scaling max of 2 weeks per month
COLCHICINE [COLCRYS] - 0.6 mg Tablet - 1 Tablet(s) by mouth
daily as needed for as needed for gout attack
DICYCLOMINE [BENTYL] - 10 mg Capsule - 1 Capsule(s) by mouth
twice a day
KETOCONAZOLE - 2 % Shampoo - wash scalp 2-3 times per week
LISINOPRIL - 30 mg Tablet - one Tablet(s) by mouth daily
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider) - 40 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
TORSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - Apply to affected area
[**Hospital1 **] for max of 2 weeks
WARM MIST HUMIDIFICATION UNIT - For dry mucous membranes/nose
bleeds.
Medications - OTC
ARTIFICIAL TEAR (HYPROMELLOSE) - (Prescribed by Other Provider)
- Dosage uncertain
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth qday
Discharge Medications:
1. Allopurinol 300 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Bisacodyl 10 mg PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider*please
check w/House officer prior to 1st dose
6. Milk of Magnesia 30 ml PO HS:PRN constipation
7. Omeprazole 40 mg PO DAILY
8. Acetaminophen w/Codeine [**12-11**] TAB PO Q4H:PRN pain
RX *acetaminophen-codeine 300 mg-15 mg [**12-11**] tablet(s) by mouth
every four (4) hours Disp #*65 Tablet Refills:*0
9. Furosemide 40 mg PO BID
to help your body get rid of excess fluid gained during surgery
[**78**]. Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Mitral stenosis and tricuspid regurgitation s/p Mitral valve
replacement and tricuspid valve repair
Past medical history:
1. Rheumatic valve disease, status post mitral valve repair for
severe MR, with residual mild mitral stenosis.
2. Secondary pulmonary hypertension and severe tricuspid
regurgitation due to mitral stenosis.
3. Hypertension.
4. Obstructive sleep apnea.
5. Depression.
6. Cutaneous lupus.
7. Diverticulosis gastritis.
8. Gout.
9. Chronic low back pain.
10. Osteoarthritis, left hip with arthroplasty, bilateral hip
replacements, bilateral rotator cuff disease.
11. Left knee bursitis and cellulitis.
12. Pancreatitis
13. Lupus
14. H/O labial herpes/PID
15. Headaches
16. Chronic lower back pain
Past Surgical History:
1. [**11/2171**] - Mitral valve repair (26 mm [**Doctor Last Name 405**] annuloplasty
ring).
2. [**6-/2162**] - Diagnostic laparoscopy with the [**Last Name (un) 24631**] method.
3. [**7-/2162**] - Laparotomy with lysis of adhesions and total
abdominal hysterectomy.
4. [**1-/2163**] - Exploratory laparotomy, extensive dissection of
multiple abdominal and pelvic adhesions, bilateral
salpingo-oophorectomy and appendectomy.
5. [**10/2165**] - Cystometrogram, uroflow, voiding cystourethrogram.
6. [**8-/2166**] - Left total hip arthroplasty
7. [**11/2166**] - Laparoscopic cholecystectomy.
8. [**8-/2171**] - Arthroscopy, right knee. Subtotal medial
meniscectomy. Chondroplasty of medial femoral condyle. Lysis of
medial plica.
9. [**4-/2175**] - 1. Right great toe Akin osteotomy. 2. Second
proximal interphalangeal joint arthroplasty.
10. [**1-/2176**] - Arthroscopy left knee, subtotal medial and lateral
meniscectomies.
11. [**7-/2179**] - Primary right total hip arthroplasty
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tyleonol #3
Incisions:
Sternal - healing well, no erythema Scant serosang drainage from
distal [**12-12**]- painted w/ chloraprep and covered w/ DSD- NO TAPE
Groin: staples in right groin
Leg: Trace 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***Pad w/ gauze as needed
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check [**2181-7-12**] at 10:45 AM in [**Hospital **] medical office building,
[**Doctor First Name **] [**Hospital Unit Name **]***staples in right groin****
Surgeon: Dr. [**Last Name (STitle) **] on [**2181-8-15**] at 1:45 PM in [**Hospital **] medical
office building, [**Doctor First Name **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2181-7-18**] at 11:40 AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**3-15**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2181-7-9**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,398
| 191,165
|
12838
|
Discharge summary
|
report
|
Admission Date: [**2112-7-12**] Discharge Date: [**2112-7-21**]
Date of Birth: [**2036-11-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2112-7-13**] s/p internal debrillator placement - [**Company 1543**]
[**Name6 (MD) 39503**] XT CRT-D
[**2112-7-15**] 1s/p Left mini thoracotomy and placement of epicardial
lead
x2. Multilevel intercostal nerve block with 0.25% Marcaine
History of Present Illness:
75 year old gentleman with cardiomyopathy, LVEF 25%, prior CABG
and atrial fibrillation who was admitted to [**Hospital3 417**]
hospital with severe and acute shortness of breath. Prior to
arrival he had been having increasingly short of breath over a
month period but it acutely worsened [**7-8**]. On presentation to
outside hospital, he was hypoxic with SaO2 at 70-88%% on 6 L.
He was treated with lasix IV, NTP, enalaprilat, and biPAP with
improvement in dyspnea. After he improved clinically he
continued with slowed heart rates as low as the 30-40 range
while sleeping, with pauses 3-5 seconds in atrial fibrillation.
He reports that he had two unsuccessful cardioversion attempts
within the past month due to atrial fibrillation. Due to the
ongoing rhythm disturbances, he was transfered for further
cardiac evaluation.
Past Medical History:
Diabetes Mellitus
Dyslipidemia
Hypertension
Coronary artery bypass graft surgery [**2108**]
Myocardial infarction [**2094**]
Ischemic cardiomyopathy
Atrial fibrillation
Chronic Systolic heart failure, EF 25% on [**2-26**]
Hypothyroidism
Carotid endarterectomy
Social History:
-Tobacco history: quit ~ 10 years ago, prior 30+ pack year hx
-ETOH: denies
-Illicit drugs: denies
Lives with his wife, retired police officer.
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.6, BP 146/75, HR 60, RR 16, O2 sat 94% RA
GENERAL: NAD. Oriented x3. Difficulty in memory recall
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 15 cm.
CARDIAC: normal S1, S2. No m/r/g. + S3
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Mild lower extremity edema bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2112-7-21**] 08:20AM BLOOD WBC-7.9 RBC-3.97* Hgb-12.4* Hct-36.7*
MCV-92 MCH-31.3 MCHC-33.8 RDW-14.1 Plt Ct-290
[**2112-7-12**] 03:10PM BLOOD WBC-10.7 RBC-4.44* Hgb-14.1 Hct-41.9
MCV-94 MCH-31.8 MCHC-33.7 RDW-14.9 Plt Ct-261
[**2112-7-21**] 08:20AM BLOOD Plt Ct-290
[**2112-7-21**] 08:20AM BLOOD PT-16.9* PTT-26.9 INR(PT)-1.5*
[**2112-7-12**] 03:10PM BLOOD Plt Ct-261
[**2112-7-12**] 03:10PM BLOOD PT-17.7* INR(PT)-1.6*
[**2112-7-21**] 08:20AM BLOOD Glucose-200* UreaN-78* Creat-1.8* Na-136
K-5.0 Cl-94* HCO3-32 AnGap-15
[**2112-7-20**] 06:46AM BLOOD Glucose-49* UreaN-79* Creat-2.2* Na-140
K-4.5 Cl-96 HCO3-34* AnGap-15
[**2112-7-16**] 04:51PM BLOOD Glucose-172* UreaN-64* Creat-3.2* Na-137
K-5.1 Cl-94* HCO3-32 AnGap-16
[**2112-7-12**] 03:10PM BLOOD Glucose-196* UreaN-38* Creat-1.4* Na-141
K-4.7 Cl-95* HCO3-40* AnGap-11
[**2112-7-17**] 03:34AM BLOOD ALT-8 AST-40 LD(LDH)-361* AlkPhos-107
Amylase-150* TotBili-1.0
[**2112-7-14**] 06:50AM BLOOD ALT-14 AST-22 AlkPhos-116 TotBili-1.1
[**2112-7-21**] 08:20AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.4
[**2112-7-12**] 03:10PM BLOOD Calcium-9.6 Phos-3.9 Mg-2.3
[**2112-7-14**] 06:50AM BLOOD %HbA1c-6.2* eAG-131*
[**2112-7-14**] 06:50AM BLOOD TSH-0.66
Cardiology Report ECG Study Date of [**2112-7-12**] 1:50:18 PM
Baseline artifact. Probable atrial fibrillation with controlled
ventricular response. Left anterior fascicular block.
Intraventricular conduction delay. Q waves in leads V1-V2 with
late R wave progression may be related to axis or myocardial
infarction. No previous tracing available for comparison.
Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 0 136 452/464 0 -62 117
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Left Ventricle - Stroke Volume: 59 ml/beat
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg
Aortic Valve - LVOT VTI: 13
Aortic Valve - LVOT diam: 2.4 cm
Aortic Valve - Valve Area: *2.6 cm2 >= 3.0 cm2
Findings
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Severely depressed LVEF.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mild (1+) MR.
Conclusions
Overall left ventricular systolic function is severely depressed
(LVEF= XX %). with moderate global free wall hypokinesis. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. Mild (1+) mitral regurgitation is seen.
Brief Hospital Course:
Transferred in from outside hospital with bradycardia and was
evaluated by electrophysiology and decision was made to place
ICD/pacer due to heart failure. On [**7-13**] he was taken to the
cardiac lab for placement and generator was placed however they
were unable to advance leads. See procedure note for further
details. He was then referred to cardiac surgery for epicardial
lead placement. He underwent preoperative workup and continued
to be treated with lasix for volume overloaded and beta blockers
continued to be held due to slow ventricular rhythm. On [**7-15**] he
was brought to the operating room for epicardial lead placement
via throacotomy. See operative report for further details. He
was transferred to the intensive care unit for post operative
management. That evening he was weaned from sedation, awoke
neurologically intact and was extubated without complications.
On post operative day one he had decreased urine output with
increased creatinine and was started on dopamine with improved
output however creatinine continued to climb with peak 3.2,
acute kidney injury, but then progressively decreased. He was
started on coumadin for anticoagulation for atrial fibrillation.
He remained in the intensive care unit on dopamine. On post
operative day 5 he was weaned off the dopamine, creatinine
continued to improve and he was transferred to the floor.
Physical therapy worked with him on strength and mobility. He
continued to progress and was ready for discharge home with
services on [**7-21**] with creatinine back down to 1.8 and plan for
INR check [**7-22**] with further dosing by primary care. Additionally
due to blood pressure he was unable to be started on carvedilol
and valsartan. His diuretic was stopped due to fluid balance
negative and no evidence of overload. Discussed with Dr
[**Last Name (STitle) **] and plan to re evaluate as outpatient.
Medications on Admission:
Simvastatin 40 mg daily
Carvedilol 3.125 mg daily
Coumadin 5 mg daily
Lasix 20 mg daily
Sulindac 200 mg po bid
Omeprazoel 20 mg daily
Levothyroxine 175 mcg daily
Valsartan 320 mg daily
ASA 81 mg daily
Albuterol MDI prn
NPH 30 QAM 16 QPM
Regular insulin 12 QAM, 6 QPM
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. BB, [**Last Name (un) **], and Diuretic
Unable to start betablocker, [**Last Name (un) **], and lasix due to blood
pressure and volume status - to be reevaluated by cardiology as
outpatient
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous once a day: before breakfast .
9. NPH insulin human recomb 100 unit/mL Suspension Sig: Sixteen
(16) units Subcutaneous qevening.
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
11. insulin regular human 100 unit/mL Solution Sig: Twelve (12)
units Injection qam.
12. insulin regular human 100 unit/mL Solution Sig: Six (6)
units Injection qpm .
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Acute on chronic systolic heart failure
Acute kidney injury
Atrial Fibrillation
Bradycardia
Diabetes Mellitus
Dyslipidemia
Hypertension
Ischemic cardiomyopathy
Hypothyroidism
Carotid stenosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram as needed
Incisions:
Left thoracotomy - healing well, no erythema or drainage
Left Subclavian - 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 4 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**] on [**2112-8-2**] 1:45 [**Telephone/Fax (1) 170**]
Cardiologist: Dr [**Last Name (STitle) **] on [**2112-7-25**] at 10:45 am
Wound check at [**Hospital **] medical center cardiac surgery -
[**Telephone/Fax (1) 170**]
on [**2112-7-27**] at 10 am
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2112-7-27**] 9:00
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 25693**] in [**4-19**] weeks [**Telephone/Fax (1) 25694**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2-2.5
First draw [**7-22**] friday
Results to Dr [**Last Name (STitle) 25693**] phone [**Telephone/Fax (1) 25694**] fax [**Telephone/Fax (1) 39504**]
Please check INR monday, wednesday, and friday for 2 weeks and
then as directed by Dr [**Last Name (STitle) 25693**]
Completed by:[**2112-7-21**]
|
[
"427.89",
"272.4",
"584.9",
"427.31",
"414.8",
"250.00",
"585.9",
"428.0",
"403.90",
"244.9",
"V45.81",
"412",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.74",
"00.51"
] |
icd9pcs
|
[
[
[]
]
] |
9374, 9429
|
5592, 7491
|
330, 571
|
9665, 9907
|
2566, 5569
|
10746, 11844
|
1893, 1910
|
7808, 9351
|
9450, 9644
|
7517, 7785
|
9931, 10723
|
1950, 2547
|
271, 292
|
599, 1431
|
1453, 1714
|
1730, 1877
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,636
| 170,601
|
45842
|
Discharge summary
|
report
|
Admission Date: [**2105-7-1**] Discharge Date: [**2105-7-5**]
Service: SURGERY
Allergies:
Morphine Sulfate / Aspirin / Metoprolol / Levaquin
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Cecal Mass
Major Surgical or Invasive Procedure:
Laparoscopic converted to open right colectomy
History of Present Illness:
[**Age over 90 **] year old man previously admitted with RLQ pain that started
acutely while straining. No radiation of pain. Pain got better
with ice packs. Had a restless night and this morning noticed
that the pain was worse on movement. Patient has a previously
known cecal mass identified on colonoscopy, and was discharged
home from his previous hospitalization with plan to return for
scheduled right colectomy
Past Medical History:
coronary artery disease status post CABG in [**2080**], subsequent
protected left main stenting in [**2100**], chronic atrial
fibrillation, tachy-brady syndrome, status post pacemaker
implantation in [**9-/2099**], Chronic renal insufficiency due to
renal
sclerosis, Iron def anemia
Social History:
Retired Internist. Lives in a retirement home. Independent
No ETOH/Tob
Family History:
AFib, No colon cancer
GF: DM, stroke. Aunts, Uncles with DM. M died at 92. F: died at
72 of a tachycardia
Physical Exam:
97.9 97.9 70 120/52 16 97RA
NAD A&Ox3
CTAB
RRR
Abd soft, NTND
Wound cdi
Pertinent Results:
[**2105-7-1**] 09:46PM WBC-8.7# RBC-3.76* HGB-12.6* HCT-37.4*
MCV-100* MCH-33.5* MCHC-33.6 RDW-16.6*
Brief Hospital Course:
Pt was taken to the operating room for a laparoscopic right
colectomy. The procedure was converted to open because of
difficult adhesions after a previous laparotomy. The remainder
of the procedure was performed without complication and the
patient recovered from anesthesia without difficulty in the
PACU. He was taken to the ICU overnight for observation and
transferred to the floor the following morning. His ICU stay was
significant only for low urine output which improved once the
patient was restarted on his bumex. The patient was seen by the
pain service, and his pain controlled with a PCA which was
converted to PO medications once he would tolerate these.
Additionally, he was seen by the cardiology service, but had no
acute cardiac issues at this time. He was maintained on sips/IVF
until he had return of bowel function at which time his diet was
advanced to regular. On POD 4, the patient was discharged to
rehab to continue his physical therapy. At the time of discharge
he was tolerating a general diet, his pain was well controlled
and his abdominal exam was benign.
Medications on Admission:
Plavix 75 mg daily, aspirin 81 mg daily, Zocor 20mg daily,
Protonix 40 mg daily, Bumex 1 mg daily, calcitriol 0.25
mg daily, carvedilol 12.5 mg [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*qs Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
Disp:*qs Capsule(s)* Refills:*2*
6. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
lassell
Discharge Diagnosis:
Cecal Mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-If you have staples, they will be removed during at your follow
up appointment.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your 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 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* 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 ([**11-6**] lbs) until your follow up appointment.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1120**] in [**1-24**] weeks. Call ([**Telephone/Fax (1) 6316**] to make an appointment.
Please also keep the following scheduled appointments:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2105-11-26**]
3:00
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2105-11-26**] 3:40
|
[
"796.3",
"153.4",
"V64.41",
"587",
"V45.01",
"428.0",
"V45.81",
"568.0",
"428.22",
"427.31",
"V45.82",
"585.9",
"414.01",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.77",
"45.73",
"54.51"
] |
icd9pcs
|
[
[
[]
]
] |
4014, 4048
|
1514, 2602
|
266, 314
|
4102, 4102
|
1387, 1491
|
6127, 6561
|
1173, 1280
|
2813, 3991
|
4069, 4081
|
2628, 2790
|
4252, 4341
|
4357, 6104
|
1295, 1368
|
216, 228
|
342, 762
|
4117, 4228
|
784, 1068
|
1084, 1157
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,751
| 114,622
|
44644
|
Discharge summary
|
report
|
Admission Date: [**2127-7-11**] Discharge Date: [**2127-7-18**]
Date of Birth: [**2049-5-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Influenza Virus Vaccines / Iodine; Iodine
Containing
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78 y/o F with new diagnosis of metastatic ovarian cancer who was
brought in for confusion. Today she presented to [**Hospital1 **] [**Location (un) **] for
a blood draw and was confused. She eloped before a section 12
could be completed. After going home, she was unable to get
upstairs and her cab called 911; she was initially brought to
[**Last Name (un) 4199**]. Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**] had a Section 12 enforced and she
was transferred here for further care. Per notes, she had been
acting strangely at home since her recent discharge on [**6-26**]. She
denies any changes in her mental status, but does note that she
is alone and has no one to help her. She denies SI/HI, visual or
auditory hallucinations.
.
In the ED, initial vs were: T 98.0, P 68, BP 96/58, R 14, O2 sat
98% on RA. Pt then became hypotensive to 60s/30s, although was
mentating throughout with no complaints except "fatigue." She
received 3L NS and was started on peripheral dopamine. She was
covered with broad spectrum abx and received cipro in the ED,
with an order to get vanco and flagyl after transfer to the
MICU. She was seen by psych in the ED who did not find her
competent to leave AMA. A bedside echo showed no pericardial
effusion.
.
On the floor, she is comfortable and complaining of only being
very tired. She denies recent fevers, chills. No dizziness or
falls. She does say she has been getting weaker and that she has
new swelling in her bilateral extremities. Her legs are tender.
She does not have chest pain or shortness of breath. She does
not want to have any interventions tonight because she is
"tired," but would be ok with interventions later. She is
planned for chemo in the next few weeks per her. She has not
been needing her antinausea meds yet as she hasn't started
chemo; taking her other meds as prescribed.
.
Review of sytems:
(+) Per HPI - weight gain, swelling, abdominal girth
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
Metastatic Ovarian Cancer
Malignant Pleural Effusion s/p Pleurex Cath
Hypertension
COPD
Chronic renal insufficiency (baseline 1.8)
Hyperlipidemia
S/p tonsillectomy and appendectomy
Social History:
Patient lives at home with her cat; apparently has been not
taking care of herself and just sitting on the porch without
eating or drinking. She is originally from [**Country 6607**] and her family
still all lives there; has many friends who live in the area.
Has history of tobacco use.
Family History:
father died @ 74 - MI, smoked
mother died - CAD, type 2 DM
youngest of 10 children, 1 sister still living, age 84
strong family hx of CAD in siblings
nephew - DM
no children
Physical Exam:
Vitals: T: 96.7, BP: 106/46, P: 71, R: 16, O2: 95% on 2L
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,
rhonchi; R pleurex catheter in place, no erythema, mild drainag
in tube
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: firm, distended, nontender to palpation, BS are
hypoactive but present, no obvious fluid wave
GU: foley
Ext: cool, 3+ edema to thigh, tender to palpation bilaterally,
dopplerable pulses
Pertinent Results:
[**2127-7-11**] 08:58PM LACTATE-2.3*
[**2127-7-11**] 08:53PM LD(LDH)-1463* ALK PHOS-119* TOT BILI-0.2
[**2127-7-11**] 08:53PM LIPASE-12
[**2127-7-11**] 08:53PM ALBUMIN-2.9*
[**2127-7-11**] 08:53PM CORTISOL-44.8*
[**2127-7-11**] 08:53PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-7-11**] 08:53PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2127-7-11**] 08:53PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2127-7-11**] 08:53PM URINE RBC-0-2 WBC-[**5-14**]* BACTERIA-MOD
YEAST-NONE EPI-0-2 RENAL EPI-0-2
[**2127-7-11**] 08:53PM URINE GRANULAR-[**5-14**]* HYALINE-[**5-14**]*
[**2127-7-11**] 08:53PM URINE MUCOUS-OCC
[**2127-7-11**] 06:04PM GLUCOSE-66* UREA N-72* CREAT-3.4* SODIUM-139
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-19* ANION GAP-23*
[**2127-7-11**] 06:04PM CALCIUM-8.9 PHOSPHATE-4.1 MAGNESIUM-2.1
[**2127-7-11**] 06:04PM WBC-10.9 RBC-3.90* HGB-10.8* HCT-35.3* MCV-91
MCH-27.7 MCHC-30.6* RDW-15.2
[**2127-7-11**] 06:04PM NEUTS-91.9* BANDS-0 LYMPHS-5.1* MONOS-2.7
EOS-0.1 BASOS-0.1
[**2127-7-11**] 06:04PM PLT COUNT-401
[**2127-7-11**] 10:30AM GLUCOSE-78
[**2127-7-11**] 10:30AM UREA N-70* CREAT-3.3* SODIUM-140
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-23 ANION GAP-18
[**2127-7-11**] 10:30AM ALT(SGPT)-35 AST(SGOT)-92*
[**2127-7-11**] 10:30AM %HbA1c-5.9
[**2127-7-11**] 10:30AM WBC-12.2* RBC-3.82* HGB-10.7* HCT-33.8*
MCV-88 MCH-28.0 MCHC-31.7 RDW-15.8*
[**2127-7-11**] 10:30AM NEUTS-90.2* BANDS-0 LYMPHS-5.8* MONOS-3.8
EOS-0.1 BASOS-0
[**2127-7-11**] 10:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2127-7-11**] 10:30AM PLT SMR-NORMAL PLT COUNT-402
[**2127-7-10**] 10:00AM GLUCOSE-25* UREA N-63* CREAT-3.3*#
SODIUM-132* POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-7* ANION
GAP-33*
.
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). 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. There
is an anterior space which most likely represents a fat pad.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen but is probably normal. No pathologic
valvular abnormality seen. Moderate pulmonary artery systolic
hypertension.
.
IMPRESSION:
Stable right chest tube with no pneumothorax and clear lungs.
.
IMPRESSION:
1. Sludge in the gallbladder, but otherwise no son[**Name (NI) 493**]
evidence of acute cholecystitis.
2. Small amount of ascites in the abdomen.
The study and the report were reviewed by the staff radiologist.
.
IMPRESSION:
No evidence of hydronephrosis bilaterally.
Moderate amount of free fluid in the abdomen.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
78 y/o F with hx of HTN, COPD, and new diagnosis of metastatic
ovarian cancer who presents with delerium, ARF and hypotension.
.
# Hypotension: The patient presented with hypotension, thought
to be either secondary to sepsis versus poor PO intake in the
weeks prior to admission. The patient was initally placed on
Levophed and broad spectrum antibiotics, and she remained stable
with these interventions. However, throughout this admission,
she became progressively more hypotensive despite Levophed,
fluid boluses, and broad spectrum antibiotics. Given the
patient's prior wishes of minimally invasive procedures, and her
poor prognosis, further pressors were not added, and the patient
expired on [**2127-7-18**].
.
# ARF: The patient has a history of CKD stage IV with baseline
creatinine around 1.8. Her creatinine increased to 3.4 on this
admission, and she became oliguric. Renal was consulted, and
the patient was found to have muddy brown casts in her U/A,
consistent with ATN. She was placed back on Levophed in an
attempt to increase UOP; however, this had minimal effect. The
patient expired on [**7-18**], before her renal function had
recovered.
.
# Delerium: The patient presented with AMS in the setting of
hypotension. Psychiatry was consulted, and her mental status
gradually improved over this admission. However, the patient
did not appear to regain capacity to discuss her medical
condition with the primary team or oncology.
.
# Ovarian Cancer: She was recently diagnosed with metastatic
ovarian cancer. She was seen by heme/onc on this admission, who
deferred chemotherapy in the setting of infection and altered
mental status.
Medications on Admission:
Amlodipine 5 mg daily
Atenolol 50 mg daily
Lipitor 10 mg daily
HCTZ 25 mg daily
Lorazepam 0.5 mg q6hr PRN for nausea
Zofran 8 mg PO tid PRN for nausea
Prochlorperazine 10 mg q6hr PRN for nausea
Ascorbic Acid 500 mg daily
Cyanocobalamin 500 mg daily
Albuterol MDI PRN for wheezing
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2127-7-18**]
|
[
"251.2",
"183.0",
"276.2",
"455.6",
"453.41",
"272.4",
"789.59",
"584.5",
"784.7",
"038.9",
"458.9",
"403.90",
"511.81",
"585.4",
"293.0",
"576.8",
"E934.2",
"496",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9419, 9428
|
7384, 9047
|
339, 345
|
9479, 9488
|
3973, 7361
|
9544, 9582
|
3176, 3351
|
9378, 9396
|
9449, 9458
|
9073, 9355
|
9512, 9521
|
3366, 3954
|
287, 301
|
2257, 2650
|
373, 2239
|
2672, 2855
|
2871, 3160
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,135
| 149,108
|
49824+49825
|
Discharge summary
|
report+report
|
Admission Date: [**2161-4-25**] Discharge Date: [**2161-5-15**]
Service:
CHIEF COMPLAINT: Left parotitis.
HISTORY OF PRESENT ILLNESS: [**Age over 90 **]-year-old male with history of
coronary artery disease, congestive heart failure, acute
renal failure on hemodialysis, MRSA, recently discharged
after CLO urosepsis and [**Female First Name (un) **] fungemia in [**2161-3-23**], now
admitted with left parotitis, increased white blood cell
count and microangiopathic blood smear.
According to referral in ER notes (patient only speaks
Russian), patient with a left temporal firm swelling which is
warm and tender. Patient was afebrile at nursing home with
stable blood pressure and oxygen sats.
REVIEW OF SYSTEMS: Headache but no mental status change per
granddaughter, no rashes. Patient denies pain, shortness of
breath, chest pain, decreased po intake recently.
PAST MEDICAL HISTORY: Klebsiella urosepsis, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]
fungemia, congestive heart failure, acute renal failure now
on hemodialysis, non-insulin dependent diabetes mellitus,
MRSA, history of right great toe osteo status post amputation
in [**2161-1-23**], coronary artery disease, status post MI
times two in [**2128**] and [**2138**], increased alkaline phosphatase,
atrial fibrillation, status post pacer in [**2155**] for
bradycardia, peptic ulcer disease, benign prostatic
hypertrophy, history of acoustic neuroma status post benign
brain tumor resection in [**2136**] with residual right facial
droop.
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin, Protonix, Heparin subcu, Regular
insulin sliding scale, Vitamin C, Combivent, Multivitamins,
Senna, Colace, Lacrilube, TUMS, Zyprexa, Dulcolax, nebs,
Tylenol, Captopril.
SOCIAL HISTORY: Lives at [**Hospital1 **] Home Rehab, ambulates with
walker, history of tobacco and cigar use in the past, quit
recently.
PHYSICAL EXAMINATION: Temperature 99.1, 85, 110/41, 16 and
91% on room air. In general, thin, Russian speaking male in
no acute distress. HEENT: Right facial droop, left parotid
region erythematous, swollen and firm with no fluctuants.
Oropharynx clear, no lymphadenopathy. Chest clear to
auscultation bilaterally. Cardiovascular, regular rate and
rhythm, no murmurs, rubs or gallops. Abdomen soft,
nontender, non distended, positive bowel sounds.
Extremities, no clubbing, cyanosis or edema. Right great toe
amputation with sutures intact. Two scabs, clean, dry and
intact. Faint peripheral pulses. Neuro, speaking, moving
all extremities. Skin, scattered areas of erythema on the
legs and erythematous patches on the soles of the feet and
toes, non blanching.
LABORATORY DATA: On admission, white blood cell count 25.2,
hematocrit 32.9, platelet count 352,000, 79% neutrophils, 7
bands, 8 lymphs, 3 monos, 1 meta and 2 myelo. Chemistry,
sodium 138, potassium 4.9, chloride 106, CO2 23, BUN 10,
creatinine 1.7 and glucose 154. CT of the neck showed
enlarged left parotid gland associated prominently with
lymphadenopathy, airway intact.
IMPRESSION: [**Age over 90 **]-year-old male with CAD, CHF, status post
Klebsiella and [**Female First Name (un) **] sepsis in [**2161-3-23**], now admitted
with left parotitis.
HOSPITAL COURSE:
1. Hypotension: The patient was initially treated with
Vancomycin for his parotitis. A urinalysis returned on the
7th indicative of infection. The patient was treated with
Ceftaz and Levofloxacin for UTI. Later blood and urine
cultures were found to grow out gram negative rods resistant
to Ceftaz and Levofloxacin. The patient was then started on
Imipenem on the 8th which was then changed to Meropenem on
the 9th. Subsequently on the 9th the patient was found to be
hypotensive with blood pressures 60/palp. The patient's
mental status was difficult to evaluate secondary to being
Russian speaking and hard of hearing. The [**Hospital Ward Name 332**] ICU team
was called to evaluate at this time. That evening patient
responded well to IV fluids and maintained adequate blood
pressures at that time. The following evening the MICU team
was again called to evaluate for hypotension. Fluid
resuscitation was again attempted. After third liter of
normal saline patient's blood pressure was still only in the
70's, pulse 60, respiratory rate 16 and 96% on three liters
nasal cannula. It was decided to take patient to MICU this
evening secondary to new onset of bilateral pulmonary
crackles on exam which previously had been clear to
auscultation bilaterally.
In the MICU the patient was continued on IV fluids. The
patient was believed to be in septic shock and therefore was
maintained on a complete course of Vancomycin times 14 days
and Meropenem times 14 days. The patient was started on
Dopamine for pressor support on [**5-1**]. Throughout the rest of
the hospital stay the patient was on varying doses of
Dopamine which for a short period of time during MICU stay
was weaned to off. Within 24 hours the patient required
pressor support once again. The source for the hypotension
was never identified initially. Initially it was believed to
be secondary to septic shock. After patient completed his
two week course of both Vancomycin and Meropenem, the source
became unclear. [**Name2 (NI) **] other sources of infection were ever
identified. Subsequent urine cultures, blood cultures, and
sputum cultures were negative. Right upper quadrant
ultrasound and LFTs were within normal limits except for an
isolated, elevated alkaline phosphatase. CT was unable to be
completed to look for abscess formation secondary to
patient's instability.
2. Renal: At time of admission the patient was requiring
hemodialysis. On [**2161-5-2**] it was decided that patient was not
hemodialysis dependent. Therefore, patient's Perma-cath line
was discontinued as a potential source of infection. The
patient's creatinine remained stable status post
discontinuation of hemodialysis. Issues that patient did
develop were oliguria and ultimately anuria prior to
expiration. The patient became very fluid overloaded and
unresponsive to high dose diuresis including Lasix 160 mg IV
bid and q d Zaroxolyn. The renal team continued to follow
patient but did not feel that patient was any longer a
candidate for hemodialysis given severely decompensated
state.
3. Pulmonary: Patient with CHF evident on chest x-ray. He
received nebulizer treatments while in the ICU and received
high flow oxygen. The patient's respiratory status decreased
throughout hospital stay with slowly rising PCO2 and
bilateral pleural effusion. A thoracentesis was done to tap
patient's left sided pleural effusion which revealed a
transudate consistent with congestive heart failure. The
effusions then reaccumulated and exacerbated as patient's
fluid overload worsened.
4. Cardiovascular: Patient with hypotension, unexplained by
other causes. Therefore, a transthoracic echo was repeated
which revealed an EF of 60-70%, possibly diastolic
dysfunction, RV dilation and systolic dysfunction.
5. Fluids, Electrolytes & Nutrition: As above, patient with
significant hypervolemia. The patient was started on tube
feedings.
6. Communication: There were extensive conversations with
patient's son and granddaughter who just completed medical
school. Conversations consisted of end of life care,
changing patient to DNR status and ultimately to DNR/DNI.
Discussions were lengthy and patient's family was informed of
patient's poor prognosis as his condition further declined.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-924
Dictated By:[**Name8 (MD) 15885**]
MEDQUIST36
D: [**2161-5-15**] 15:29
T: [**2161-5-18**] 19:10
JOB#: [**Job Number 26052**]
Admission Date: [**2161-4-25**] Discharge Date: [**2161-5-15**]
Service:
HOSPITAL COURSE: Endocrine: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stimulation test was
done, which was within normal limits. Therefore it was
unable to explain the patient's hypotension.
Vascular: Patient with asymmetric right greater then left
and to rule out deep venous thrombosis and were found to be
negative.
In the final days, the patient's white blood cell count
continued to rise. No culture data returned with the source
of infection. The patient's Dopamine requirement also
increased. He also was displaying increased ventricular
tachycardia. His breathing became increasingly more labored
with paradoxical breathing. His extremities began to have
decreasing temperature with cool throughout. His feet
especially his right foot became increasingly dusky especially
over the amputation site of the right great toe. It was
decided by the team and the son that no more pressors would
be added when the patient had maximized his Dopamine. He
slowly became oliguric and then anuric unresponsive to high
does diuresis. Ultimately after the patient was made DNR/DNI
and the patient's final blood gas on the day of expiration
showed a pH of 7.09, PCO2 of 107 and a PO2 of 94. Two hours
earlier patient with a chest x-ray showing a right sided
white out and a right sided tracheal shift. Later that
morning repeat chest x-ray showed reexpansion of the right
lung and most likely this was secondary to mucous plugging.
The patient's son decided to add a morphine drip and at 1:57
p.m. on [**2161-5-15**] the patient expired. The son, daughter
and granddaughter are all aware. The patient was without
breath sounds, heart beat, bowel sounds for greater then two
minutes. He had a negative corneal reflex and was
unresponsive to pain. His electronic pacemaker continued to
fire, but there was no longer any cardiac capture.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Name8 (MD) 15885**]
MEDQUIST36
D: [**2161-5-15**] 15:58
T: [**2161-5-19**] 06:46
JOB#: [**Job Number **]
|
[
"599.0",
"585",
"428.0",
"427.31",
"263.9",
"527.2",
"458.9",
"785.59",
"038.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
7876, 9988
|
1945, 3257
|
731, 884
|
100, 117
|
146, 711
|
907, 1782
|
1799, 1922
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,051
| 142,918
|
48811
|
Discharge summary
|
report
|
Admission Date: [**2118-3-6**] Discharge Date: [**2118-3-15**]
Date of Birth: [**2061-8-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
This is a 56 year old female an extensive medical history
including renal transplant who presented on [**3-6**] with slurred
speech and somnolence for three days. The patient's husband
reports she had an orthopedic procedure [**2118-2-4**] without
complications and was in significant pain but was alert and
oriented. On Wednesday, the patient was also noted to have
"black diarrhea", with 4-5 BM's QD of watery stools with
complaints of tactile fevers. On Thursday, she was noted to have
slurred speech, confusion, and somnolence. On Friday, she began
taking vicodin for her spine surgery which mildly improved her
pain but worsened her slurred speech and somnolence. The
patient's husband also noticed that she seemed to be "breathing
fast", as if she had "just been running." On Saturday morning,
pt woke up and "was breathing really quickly" and remained
somnolent and confused. That morning, she began to complain of
chest pain and the husband noted her heart felt as though it was
racing. She was brought to the ED for further evaluation.
.
In the ED, code stroke was called. She was answering questions
appropriately and, per her husband, was only slightly off from
her baseline mental status. CT head was negative (preliminary
read) and Neurology did not feel this was an acute stroke, but
rather a toxic/metabolic event. Labs showed Cr of 2.9 (from
baseline 1.2-1.4), BUN 70 (baseline 20's), K 3.1 (baseline 4.1).
EKG demonstrated new lateral ST depressions and initial trop was
0.08. She received potassium and levofloxacin for UTI and was
admitted to the medicine floor. On transfer, vital signs were T-
97.6, HR- 89, BP- 158/89, RR- 23, SaO2- 100% on RA.
.
On arrival to the floor, vital signs were T- 97.5, BP- 160/100,
HR- 96, RR- 28, SaO2- 100% on RA. Patient was confused and
disoriented, and was noted to be significantly tachypneic. HCO3
was 5, pCO2 9. ABG showed 7.22 pCO2 10 pO2 126 HCO3 4,
Lactate:0.8. She was transferred to the MICU with concern for
severe sepsis, where she was started on a bicarb gtt and was
treated for urosepsis with IV cefepime. Echo showed RV strain
concerning for PE, but as this was not consistent with clinical
picture it was not further worked up or treated. Given h/o
recent lumbar surgery and pt c/o lumbar pain, she was also
evaluated by ortho who found that her incision did not appear
infected and no concern for osteomyelitis. Patient's symptoms
improved and she is currently back to her baseline mental
status. Her antibiotic has been narrowed to ceftriaxone. She is
now being transferred back to the medical floor.
.
On transfer to the floor, vitals are 98.1 155/95 72 22 100% RA.
Patient complains of back pain (chronic, but worsened by
physical therapy this morning as well as transfer to bed). Also
complains of nausea. She is AAOx3.
Past Medical History:
1) ESRD since [**2102**] - HD x 7 years s/p cadaveric renal transplant
[**2110-8-11**] at [**Hospital1 2177**]
2) Stroke [**2106**] - Sxs were L-sided hemiparesis, some residual -
uses a cane at times
3) h/o obesity
4) h/o HTN d. [**2097**]
5) R shoulder rotator cuff tear - repair [**1-12**] (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **])now w/ recurrent tear awaiting completion of fistula
removal prior to return to OR
6) Epilepsy - since stroke in [**2106**]; last sz > 1 [**Last Name (un) **]
7) Depression/Anxiety
8) s/p multiple UTIs since transplant
9) s/p varicose vein stripping on Left
10) post-partum cardiomyopathy
11) small hiatal hernia
12) grade II hemorrhoids
13) h/o colitis [**2107**]
14) s/p CCY [**2082**]
15) L leg abscess 995 s/p I&D
16) LMP - 8 years ago (when started dialysis)
17) LGIB s/p colonoscopy on [**2107-4-19**]
18) bursitis in the knees and ankles
19) migraines
20) toxemia of pregnancy [**2095**]
21) gastroesophageal reflux disease
Social History:
Pt uses a walker at baseline, has a personal care aid to help
her dress and sometime assist with her eating. [**Year (4 digits) 4273**] tobacco,
EtOH or illicits. Daughter endorses h/o oxycodone abuse.
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.5, BP- 160/100, HR- 96, RR- 28, SaO2- 100% on RA.
GENERAL - Distressed, repeating the same phrase over and over,
staring into space, not interactive
HEENT - sclerae anicteric, dry mucus membranes, OP clear
NECK - Supple, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - Tachypneic, clear to ausculatation laterally, good air
movement, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 1+ edema bilaterally, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, non-interactive, no meaningful statements,
repeating spelling of her first name and "he has to go to work",
AAO x 1 (to first name only), answers occasionally with "yes",
"no". CNs II-XII grossly intact, unresponsive with strength
exam. gait deferred.
.
DISCHARGE PHYSICAL EXAM:
VITALS: T 98.1 BP 140/80 P 68 RR 20 SaO2 90% RA
General: elderly F in NAD, AAOx3
HEENT: PERRL, EOMI, no icterus, MMM
Neck: supple, no JVD
Cardiac: RRR S1 S2 no rubs, murmurs, gallops
Respiratory: CTAB, no crackles/wheezes/rhonchi
Abdominal: Soft, diffusely mildly TTP (improved), Bowel sounds
present, no peritoneal signs
Back: well-healed perispinal surgical scars (well healed),
nontender
Extremities: [**1-10**]+ nonpitting peripheral edema, pulses 2+ DP/PT
Skin: Warm
Neurologic: AAOx3. Moves all 4 extremities.
Pertinent Results:
ADMISSION LABS:
-Glucose-125* UreaN-70* Creat-2.9* Na-143 K-3.1* Cl-110* HCO3-<5
-Calcium-9.7 Phos-5.5* Mg-2.2
-WBC-8.4 RBC-3.67* Hgb-10.8* Hct-33.5* MCV-91 MCH-29.3 MCHC-32.1
RDW-17.1* Plt Ct-332
-Neuts-88.5* Lymphs-7.1* Monos-2.5 Eos-1.2 Baso-0.7
-PT-12.1 PTT-39.8* INR(PT)-1.1
-ALT-51* AST-138* LD(LDH)-903* CK(CPK)-1799* AlkPhos-224*
TotBili-0.2
-POsm: 333*
-Ammonia-43
-TSH-0.11* (hemolyzed)
-Tacro level-3.4*
-Drug screen: ASA-NEG Acetmnp-12 Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
-Lactate-1.0
.
DISCHARGE LABS:
-WBC-7.5 RBC-2.72* Hgb-8.0* Hct-24.1* MCV-89 MCH-29.5 MCHC-33.4
RDW-17.1* Plt Ct-280
-PT-12.0 PTT-28.1 INR(PT)-1.1
-Glucose-92 UreaN-18 Creat-1.5* Na-141 K-4.5 Cl-112* HCO3-20*
AnGap-14
-Calcium-9.3 Phos-2.2* Mg-2.5
.
LIVER FUNCTION TESTS:
-[**2118-3-6**]: ALT-51* AST-138* LD(LDH)-903* CK(CPK)-1799*
AlkPhos-224* TotBili-0.2
[**2118-3-8**] 12:07AM BLOOD ALT-29 AST-32 AlkPhos-173* TotBili-0.3
-[**2118-3-9**]: Lipase-661* Amylase-462* ALT-22 AST-18 LD(LDH)-282*
AlkPhos-177* Amylase-462* TotBili-0.3
-[**2118-3-13**]: Lipase-163* Amylase-252*
.
MICROBIOLOGY:
BCx ([**3-6**],final): NEGATIVE
UCx ([**3-6**]): E. coli >100,000 organisms/mL. 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
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
C. diff toxins A/B ([**2-/2035**]): NEGATIVE
C. diff toxins A/B ([**2118-3-14**]): NEGATIVE
.
CARDIAC ENZYMES:
[**2118-3-5**] 11:31PM BLOOD cTropnT-0.08*
[**2118-3-6**] 07:45AM BLOOD CK-MB-17* MB Indx-0.9 cTropnT-0.06*
[**2118-3-6**] 02:00PM BLOOD CK-MB-5 cTropnT-0.05*
.
CT HEAD WITHOUT CONTRAST ([**2118-3-6**]): No acute intracranial
hemorrhage, large vascular territory infarct, shift of midline
structures or mass effect is present. The ventricles and sulci
are normal in size and configuration. The visible paranasal
sinuses and mastoid air cells are well aerated. IMPRESSION: No
acute intracranial process.
.
RENAL ULTRASOUND ([**2118-3-6**]): No hydronephrosis, perinephric fluid
collections and normal renal morphology. Resistive indices range
from 0.68-0.74 with normal waveforms. No evidence of rejection.
.
CHEST X-RAY ([**2118-3-6**]): Rotated positioning. The lungs are well
expanded, without chf, focal infiltrate, effusion, or ptx.
Possible cardiomegally. Lumbar spinal hardware is partially
imaged. IMPRESSION: No acute intrathoracic process.
.
EEG ([**Date range (1) 102560**]): Evidence for some mild diffuse background
abnormalities with the generally slightly slow background rhythm
and
little to no anterior-posterior gradiation. But superimposed
upon the
background slowing is further slowing that is seen as a
generalized
disturbance and as a disturbance in the left central region
suggesting
possibility of structural pathology in the left central area. No
clear
seizure or interictal epileptic activity was identified.
.
TRANSTHORACIC ECHO ([**2118-3-7**]): The left atrium is normal in size.
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is mildly dilated with focal basal free wall hypokinesis
([**Last Name (un) 13367**] sign). The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Right ventricular cavity enlargement with basal free
wall hypokinesis. Moderate pulmonary artery hypertension.
Tricuspid regurgitation. Mild mitral regurgitation. This
constellation of findings is suggestive of an acute pulmonary
process, e.g. pulmonary embolism.
.
RUQ ULTRASOUND ([**2118-3-9**]):
1. CBD was not visualized throughout its entire course.
2. No evidence for intrahepatic biliary duct dilatation or
choledocholithiasis. Distal common bile duct is partly obscured
by overlying bowel gas. If clinical suspicion for bile duct
stones is high and further evaluation is needed, MRCP is
recommended.
.
CT ABDOMEN WITH CONTRAST ([**2118-3-9**]):
1. Mild edema of the pancreas and peripancreatic stranding,
compatible with acute pancreatitis. 1-cm hypodensity in the tail
could represent evolving pseudocyst versus preexisting cystic
lesion. If no interval CT scans are planned, this finding should
be evaluated by MRCP in 6 months.
2. Mild edema and hypoenhancement of the transplant kidney,
reflecting recent renal failure.
Brief Hospital Course:
56 yo woman with complicated medical history who is s/p renal
transplant ([**2110**]) admitted with somnolence and slurred speech,
found to have a urinary tract infection and severe sepsis
complicated by acute renal failure anion gap metabolic acidosis,
and acute pancreatitis.
.
#Encephalopathy/Urinary tract infection/Severe sepsis/Acute
renal failure/Anion Gap Metabolic acidosis:
On admission, pt was not answering questions with meaningful
answers and is repeating the same [**2-11**] phrases unintelligably.
Code stroke was called in ED, where neurology found stroke
unlikely and that this was toxic metabolic process. Head CT
showed no acute process and EEG revealed diffuse slowing c/w
encephalopathy. Given history of transplant on
immunosuppression, infection was a concern. CXR within normal
limits but UA positive for white cells and urine culture later
grew out >100,000 E. coli. Patient was initially admitted to the
floor but soon transferred to the MICU for worsening renal
failure (Cr up to 2.9) and anion gap metabolic acidosis with
HCO3 of 16. She was treated with Cefepime for her complicated
urinary tract infection and patient was transiently placed on
bicarbonate drip with improvement in infection, encephalopathy,
and stabilzation of metabolites. Renal function improved as well
with IV hydration and treatment of infection. Concurrently, her
home narcotics and benzodiazepines were also held and decreased
with improvement in mental status. Ultimately, Cefepime was
narrowed to Ceftriaxone based on culture sensitivities and
patient completed a 2 week total antibiotic course. Blood
cultures were negative.
.
#ACUTE PANCREATITIS: On transfer back to the floor on [**2-/2035**],
patient had nausea and vomiting and c/o severe back pain
(chronic, but worse than usual) and lipase 282, amylase 462.
Abdominal CT was c/w acute pancreatitis and patient was managed
supportively with IVF and IV pain medication. RUQ US showed no
e/o gallstones (though suboptimal quality [**2-10**] overlying bowel
gas). The cause of the pancreatitis is unclear as patient denied
alcohol abuse and triglycerides were normal. A 1cm hypodense
lesion was seen in the tail of the pancreas but this was felt to
be less likely to be the cause. There is a possibility this was
due to azathioprine as patient had not filled azathioprine
recently and re-initiation in the hospital in the setting
reduced GFR may have caused toxic levels of azathioprine and
resultant pancreatitis. Azathioprine was subsequently DC'd.
Other etiologies such as Lasix was considered. Patient improved
with supportive care and was able to tolerate a regular diet
prior to discharge. She will follow up with GI for further
evaluation/workup of the cause of her pancreatitis including
MRCP for pancreatic hypodensity and further evaluation of the
biliary tree.
#HEMATEMESIS/esophagitis/gastritis:
Pt had several episodes of hematemesis (moderate volume) and
guaiac positive stool on transfer to floor on [**2-/2035**]. She was
started on pantoprazole IV BID, home ASA was held, and she
required one pRBC transfusion overnight on [**2-/2035**] after which HCT
remained stable. EGD revealed only mild gastritis and
esophagitis. She was started on sucralfate and pantoprazole;
symptoms resolved.
.
#ACUTE ON CHRONIC Renal failure s/p renal transplant: pt s/p
renal transplant with Cr of 1.4 on [**2-20**]; Cr elevated to 2.9 on
admission. Per husband, she has been taking her Prograf as
prescribed, but Tacro level was 3.4 (subtherapeutic) on
admission. Renal U/S revealed no hydronephrosis or focal e/o
transplant rejection or renal damage. Transplant medicine was
consulted. [**Last Name (un) **] resolved with holding home Lasix and treatment of
underlying issues. As noted above, azathioprine was DC'd during
hospitalization due to concern it may have caused pancreatitis.
Tacro levels were monitored, and Tacro titrated to 3mg [**Hospital1 **]. Home
prednisone 5mg daily was continued. Pt will f/u with transplant
medicine as outpatient.
.
#DIARRHEA: Patient c/o loose stools throughout hospitalization.
Initially guaiac positive on [**3-8**]. C diff negative x2 ([**3-8**] and
[**3-14**]). This appears to be a chronic issue for her, likely
exacerbated by acute infection and pancreatitis. Controlled with
loperamide once ruled out for C diff.
.
#HYPERTENSION: Pt hypertensive to 160s-180s on transfer back to
floor; likely [**2-10**] pain and nausea. Per medical records, has h/o
HTN but not on any antihypertensives as outpatient. Blood
pressure gradually improved to baseline as pain and nausea
resolved.
.
#.BACK PAIN: chronic pain [**2-10**] several lumbar surgeries, likely
with superimposed referred visceral pain from pancreatitis.
Ortho consult in MICU found osteomyelitis unlikely; surgical
incisions look good. Pain was helped by supportive care for
pancreatitis as well as addition of lidocaine patch.
.
#.DEPRESSION/ANXIETY: continued home abilify and paxil. Held
home klonopin until altered mental status resolved, then
restarted at lower dose (0.5mg PO BID).
#CODE: FULL
#Dispostion: Patient was discharged home with outpatient PCP and
GI follow up.
Medications on Admission:
Per OMR and pt's husband:
- abilify 10mg QD
- ASA 81mg QD
- klonipin 2mg QAM, 3mg QHS
- compazine 5mg [**Hospital1 **] PRN
- ensure 1 can TID
- folic acid 1mg QD
- keppra 500mg [**Hospital1 **]
- prograf 5mg [**Hospital1 **]
- prednisone 5mg QD
- paxil 60mg QD
- tylenol extra strength 1,000mg TID PRN
- vitamin D 50,000 units Q12weeks
- azathioprine 100mg [**Hospital1 **]
- furosemide 80mg [**Hospital1 **] PRN edema
- hydrocodone-acetaminophen 5/500 1 tab Q4-6H PRN
- hydroxyzine 25mg TID PRN
- omeprazole 40mg QD
Per records from CVS, [**Company 4916**] and Target:
-hydromorphine 2-4mg PO q4 hrs PRN pain
-klonopin 2mg qAM, 3mg qPM
-topomax 150mg PO BID
-compazine 5mg PO daily PRN nausea
-hydroxyzine 25mg PO 1-2mg [**Hospital1 **] prn itch
-prograf 3mg [**Hospital1 **]
-vit D 50,000 q other week
-folic acid 1mg daily
-abilify 10mg daily
-furosemide 30mg PO 1-2 times daily PRN leg swelling
-vicodin 7.5/500 one tab q4-6 hrs PRN pain ([**1-27**])
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Paxil 30 mg Tablet Sig: Two (2) Tablet PO once a day.
3. Abilify 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Leave
on for 12 hours, take off for 12 hours.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. ondansetron 4 mg Film Sig: One (1) PO every eight (8) hours
as needed for nausea.
Disp:*120 0* Refills:*0*
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*180 Capsule(s)* Refills:*2*
11. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 4 days: first
day = [**2118-3-6**]
last day = [**2118-3-19**].
Disp:*4 bags* Refills:*0*
12. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
13. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for diarrhea for 4 days.
Disp:*30 Capsule(s)* Refills:*0*
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO q 2
weeks.
16. NaCl 0.9% line flushes
Please flush PICC line with 3mL normal saline every 8 hours and
PRN.
17. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
18. Transfer tub seat
Please dispense one transfer tub seat.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
1. Early necrotizing pancreatitis
2. UTI/possible urosepsis
3. Hematemesis (unclear etiology)
4. Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital with confusion. You were found
to have a serious urinary tract infection and went to the
intensive care unit. Your symptoms improved, but then you
developed nausea and back pain, and were found to have
pancreatitis. This may have been caused by the azathioprine
which you take for your kidney transplant. Your symptoms were
treated with pain control and IV fluids, and gradually improved.
You also had some episodes of bloody vomit, for which you had an
upper endoscopy which only showed some esophagitis (acid
reflux).
.
Please attend the follow up appointments listed below with your
primary care doctor, gastroenterology, transplant nephrology
(kidney doctors), neurology and the spine center to follow up on
this hospitalization.
.
We made the following changes to your medications:
1. STARTED Ceftriaxone 1gram IV every 24 hours for 2 weeks
(first day = [**2118-3-6**], last day = [**2118-3-19**])
2. STARTED sulcralfate (Carafate) 1gram by mouth 4 times daily -
this is for your acid reflux.
3. STARTED lidocaine patch 1 application daily to lower back as
needed
4. STARTED loperamide (Immodium) 2mg by mouth 4 times daily as
needed for diarrhea
5. DECREASED Tacrolimus (Prograf) to 3mg by mouth three times
daily
6. STOPPED Azathioprine 100mg twice daily - VERY IMPORTANT to
stop this, because might have caused your pancreatitis!
7. STOPPED Lasix 30mg once-twice daily
8. STOPPED aspirin
9. STOPPED Hydrocodone-Acetaminophen (Vicodin)
10. DECREASED Dilaudid to 2mg by mouth every 6 hours as needed
for pain
11. DECREASED Klonopin to 0.5mg by mouth twice daily as needed
for anxiety
12. CHANGED from omeprazole 40mg daily to pantoprazole 40mg
daily for heartburn
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2118-3-16**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2118-3-21**] at 11:00 AM
With: DR. [**First Name (STitle) 3523**] [**Name (STitle) 3524**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PAIN MANAGEMENT CENTER
When: MONDAY [**2118-3-21**] at 2:40 PM
With: [**First Name4 (NamePattern1) 3049**] [**Last Name (NamePattern1) 8155**], NP [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: SPINE CENTER
When: MONDAY [**2118-4-4**] at 11:20 AM
With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 8603**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 572**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**]-DIVISION OF GASTROENTEROLOGY/ GI/WEST
Address: [**Doctor First Name **], STE 8E, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 463**]
It is recommended that you follow up with a GI doctor within [**1-10**]
weeks. Dr. [**First Name (STitle) 572**] is working on an appointment for you, and his
team will contact you with details.
Department: TRANSPLANT CENTER
When: MONDAY [**2118-4-18**] at 1:40 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
|
[
"345.10",
"780.09",
"535.50",
"401.9",
"349.82",
"724.5",
"787.91",
"V42.0",
"276.2",
"530.19",
"530.81",
"311",
"300.00",
"577.0",
"041.49",
"599.0",
"578.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
18965, 19042
|
10816, 15961
|
308, 337
|
19201, 19201
|
5818, 5818
|
21144, 23228
|
4417, 4421
|
16967, 18942
|
19063, 19180
|
15987, 16944
|
19384, 20208
|
6333, 7550
|
4461, 5257
|
20237, 21121
|
7567, 10793
|
247, 270
|
365, 3161
|
5834, 6317
|
19216, 19360
|
3183, 4181
|
4197, 4401
|
5282, 5799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,185
| 168,758
|
18900+56998
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-11-7**] Discharge Date: [**2159-11-13**]
Date of Birth: [**2081-5-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 38821**] is a 78-year-old
male who recently underwent coronary artery bypass graft
times four on [**2159-10-17**] at [**Hospital1 190**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. The procedure was
complicated by postoperative bleeding and left hemothorax
necessitating repeat operation on [**2159-10-18**] which
revealed oozing at the left internal mammary artery branch.
The patient then had an uneventful postoperative course
except for some postoperative atrial fibrillation. He was
rate controlled, and anticoagulated, and discharged to
rehabilitation on [**2159-10-29**].
He was admitted to [**Hospital3 7571**]Hospital on [**2159-11-5**] with increased shortness of [**Year (4 digits) 1440**]. Bilateral
thoracenteses were performed with approximately one liter per
side obtained. He was placed on ceftriaxone for presumed
pneumonia. Echocardiogram on [**11-6**], showed vigorous
left ventricular function, positive pericardial effusion,
with tamponade physiology. He was transferred to [**Hospital1 346**] for definitive treatment.
PAST MEDICAL HISTORY: (The patient's past medical history is
significant for)
1. Coronary artery bypass graft times four (on [**2159-10-17**] with re-exploration for bleeding).
2. Insulin-dependent diabetes mellitus.
3. Hypertension.
4. Hypothyroidism.
5. Hypercholesterolemia.
MEDICATIONS ON TRANSFER: (To [**Hospital1 188**])
1. Ceftriaxone 1 g intravenously once per day
2. Avandia 4 mg by mouth once per day.
3. Humalog sliding-scale.
4. Aspirin 81 mg by mouth once per day.
5. Amiodarone 200 mg by mouth once per day.
6. Solu-Medrol 60 mg intravenously q.12h.
7. Synthroid 75 mcg by mouth once per day.
8. Coumadin (was held).
9. Natrecor 0.1 mcg/kg per minute.
10. Albuterol and Atrovent.
MEDICATIONS ON ADMISSION: (Medications at home included)
1. Lipitor 40 mg by mouth once per day.
2. Cozaar 50 mg by mouth once per day.
3. Atenolol 100 mg by mouth once per day.
ALLERGIES: No known drug allergies.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
at [**Hospital3 7571**]Hospital on [**11-7**] (on the day of
admission) revealed his white blood cell count was 21.8, his
hematocrit was 25.9, and his platelets were 689. Chemistries
revealed his sodium was 134, potassium was 4.3, chloride was
101, bicarbonate was 22, blood urea nitrogen was 72,
creatinine was 12.3, and his blood glucose was 209. His INR
was 3.3. The patient had an INR of 4.4 on [**11-6**];
thus, his Coumadin was held.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed his temperature was 98.4 degrees
Fahrenheit, his heart rate was 93, his respiratory rate was
24, his blood pressure was 121/43, and his oxygen saturation
was 92% on 6 liters nasal cannula. Neurologically, the
patient was alert and oriented. No apparent deficits.
Pulmonary examination revealed the patient had coarse [**Month (only) 1440**]
sounds throughout with decreased bilateral [**Month (only) 1440**] sounds at
the bases. Cardiovascular examination revealed a regular
rate and rhythm. No murmurs, rubs, or gallops. The abdomen
was soft, nontender, and nondistended. Normal active bowel
sounds. The extremities were warm and without edema. The
sternal incision was healing well, with a positive click,
with cough, without drainage, a stable sternal wound.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient had left
thoracostomy tube placed, #28 French tube, to 27 cm, and 200
cc of fluid were initially drawn; 1800 with positional
changes. A chest x-ray showed proper placement of left chest
tube.
Cardiology was called on the day of admission for assessment
of questionable tamponade physiology, and global left
ventricular function was found to be normal without wall
motion abnormalities. The patient had difficult windows;
however, the study demonstrated small-to-moderate anterior
and apical adhesions without right atrial collapse or right
ventricular diastolic collapse.
The patient continued to remain the Cardiac Surgery Recovery
Unit and was found not to have tamponade physiology. The
patient was started on vancomycin and levofloxacin.
On [**2159-11-9**], the patient continued to do well and
was transferred to the floor. The patient had begun 3 mg of
Coumadin daily at night at that point. Lopressor was
increased on hospital day five, postoperative day 25, and the
chest tube was removed. While on the floor, the patient did
extremely well. The patient was ambulating well with
Physical Therapy and was getting 2 mg of Coumadin q.h.s.
On the day of discharge, the patient had an INR of 2 and was
discharged without event. On the day prior to discharge, the
patient had a white blood cell count of 11.4, hematocrit was
30.4, and his platelets were 504. Coagulations revealed
prothrombin time was 17.3, partial thromboplastin time was
28.9, and his INR was 2. Chemistries revealed sodium was
131, potassium was 5.3, chloride was 101, bicarbonate was 21,
blood urea nitrogen was 46, creatinine was 1.4. The
patient's calcium was 7.6, magnesium was 2.2, and phosphate
was 3.1.
MEDICATIONS ON DISCHARGE: (The patient was discharged on
medications of)
1. Amiodarone 200 mg by mouth once per day.
2. Levoxyl 75 mcg by mouth once per day.
3. Albuterol nebulizer solution.
4. Atrovent nebulizer solution.
5. Aspirin 81 mg by mouth once per day.
6. Colace 100 mg by mouth twice per day.
7. Protonix 40 mg by mouth once per day.
8. Levofloxacin 250 mg by mouth once per day.
9. Lopressor 50 mg by mouth twice per day.
10. Iron complex.
11. Warfarin 2 mg by mouth once per day.
12. Avandia 8 mg by mouth once per day.
13. NPH insulin 15 units subcutaneously q.a.m. and 15 units
subcutaneously q.p.m.
DISCHARGE DISPOSITION: The patient was to be discharged to
rehabilitation.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE DIAGNOSES: Sternal wound instability/moderate
infection; status post coronary artery bypass graft.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 6297**]
MEDQUIST36
D: [**2159-11-13**] 17:09
T: [**2159-11-13**] 17:51
JOB#: [**Job Number 51703**]
Name: [**Known lastname 9612**], [**Known firstname **] Unit No: [**Numeric Identifier 9613**]
Admission Date: [**2159-11-7**] Discharge Date: [**2159-11-14**]
Date of Birth: [**2081-5-30**] Sex: M
Service:
The patient had an elevated creatinine to 1.4 and a K of 5.3
on [**11-13**]. He was hydrated with 1 liter of fluid and the
following day his creatinine came down to 1.2. His
potassium, however, was still elevated at 5.6. Rehab was
notified, and he will have his creatinine and potassium
checked on [**11-15**], and followed closely until it normalizes.
He will also be treated with Levaquin for seven days at rehab
and on [**11-14**], he was discharged to rehab in stable condition.
He will be followed by Dr. [**Last Name (STitle) 1653**], Dr. [**Last Name (STitle) 9614**], and Dr.
[**Last Name (STitle) 690**].
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Last Name (NamePattern1) 8913**]
MEDQUIST36
D: [**2159-11-14**] 11:39
T: [**2159-11-14**] 12:17
JOB#: [**Job Number 9615**]
|
[
"401.9",
"998.89",
"511.9",
"997.3",
"250.01",
"244.9",
"998.59",
"414.01",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
5998, 6061
|
6131, 7641
|
5361, 5973
|
2036, 3595
|
3624, 5334
|
6076, 6110
|
157, 1286
|
1597, 2009
|
1309, 1571
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,375
| 189,218
|
44973
|
Discharge summary
|
report
|
Admission Date: [**2110-11-27**] Discharge Date: [**2110-11-30**]
Date of Birth: [**2044-3-23**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Subdural hemorrhage
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr [**Known lastname **] is a 66-year-old right-handed man presenting after a
large subdural hematoma was found at an outside hospital on a
background of supratherapeutic INR, atrial fibrillation,
diabetes, hypercholesterolemia and cerebrovascular disease.
He was discharged home from rehabilitation only four weeks prior
after a large thigh hematoma in the context of supratherapeutic
INR. He was managing independently again and returned to work
recently. He was seen at work yesterday [**2110-11-26**] and seemed
well.
He did not come to work on [**2110-11-27**] and his collaegues became
concerned. He was eventually found at home. He was naked and
beside his bed, tangled in a disabled rail. He had minor
bruising
to his head and was either unresponsive or moaning (unclear). [**Name2 (NI) **]
was taken to an OSH where his INR was greater than six, with
head
CT revealing a large acute on acute right SDH with subfalcine
herniation. His right pupil was blown and he was unresponsive.
he
was intubated with etomidate and sedation and transferred to
[**Hospital1 18**] for neurosurgical evaluation. Neurosrugery, in discussion
with his sister (who was in contact with his neice and other
sister) felt that it was appropriate not to intervene.
Past Medical History:
- Left carotid EA
- CABG, 4 vessel
- DM II, complicated with two toe amputations on right
- Peripheral and cerebrovascular disease
- Overweight
- Hypertension
- Hypercholesterolemia
Social History:
Lives with four cats and has a cat sitter. Working. Wife died
with subdural hematoma in [**Month (only) 547**].
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 140s systolic. Afebrile. 50s - bradycardic, sinus.
General Appearance: Head to left, intubated, bloody discharge
from mouth.
HEENT: NC, bloody mouth, MMM.
Neck: Supple. No bruits.
Lungs: CTA bilaterally anteriorly.
Cardiac: [**Last Name (LF) 8450**], [**First Name3 (LF) **].
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses reduced.
Two missing toes right foot, amputated.
Neurologic:
Mental status:
Intubated. Sedated. Unresponsive. Movements to pain as below.
Cranial Nerves:
I: Not tested.
II: Right pupil 5 mm and left pupil 2 mm, surgical, both
unreactive.
III, IV, VI: Doll's eyes present, minimal, lateral movements.
V, VII: Face symmetric.
VIII: Not tested.
IX, X: No gag.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bulk.
XII: Intubated.
Increased extensor tone in right arm. Otherwise normal.
Power
Strong movements away from pain with right arm. Some spontaneous
movements, proximal at shoulders.
Reflexes: B T Br Pa Ac
Right 1 0 1 1 0
Left 1 0 1 1 0
Toes downgoing bilaterally
Responses to pain as above.
----
DISCHARGE EXAM: Deceased
Pertinent Results:
ADMISSION LABS:
[**2110-11-27**] 06:00PM BLOOD WBC-16.6* RBC-2.56* Hgb-7.4* Hct-23.9*
MCV-93 MCH-29.0 MCHC-31.0 RDW-16.3* Plt Ct-335
[**2110-11-27**] 06:00PM BLOOD Neuts-92.1* Lymphs-2.8* Monos-4.9 Eos-0.2
Baso-0.1
[**2110-11-27**] 06:00PM BLOOD PT-34.1* PTT-34.1 INR(PT)-3.4*
[**2110-11-27**] 06:00PM BLOOD Glucose-190* UreaN-52* Creat-1.9* Na-143
K-5.3* Cl-113* HCO3-17* AnGap-18
[**2110-11-27**] 06:00PM BLOOD CK(CPK)-2592*
[**2110-11-28**] 01:37AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.9 Mg-1.9
[**2110-11-27**] 06:11PM BLOOD Type-ART Rates-/14 Tidal V-500 PEEP-5
FiO2-100 pO2-35* pCO2-38 pH-7.30* calTCO2-19* Base XS--7
AADO2-637 REQ O2-100 -ASSIST/CON Intubat-INTUBATED
[**2110-11-27**] 06:13PM BLOOD Lactate-1.6
IMAGING:
CT ABD/PELVIS [**2110-11-27**]: IMPRESSION:
1. Multifocal consolidations are compatible with pneumonia,
which may be due to aspiration. Small bilateral simple
effusions.
2. Simple perihepatic fluid and fluid within the pelvis. No
hematomas.
3. Possible nondisplaced left-sided rib fractures at the seventh
and eighth
ribs. Correlate with clinical exam.
4. Coronary artery disease status post CABG.
CT HEAD [**2110-11-27**]: IMPRESSION:
1. Overall stable appearance to large right-sided subdural
hematoma causing
1.9 cm leftward shift of midline with compression of the right
lateral
ventricle entrapping and enlarging the left lateral ventricle.
2. Blood layers within the left lateral ventricle.
3. Parafalcine and bilateral tentorial subdural hematomas.
4. Right uncal herniation.
Brief Hospital Course:
Mr [**Known lastname **] is a 66-year-old right-handed man who presented after
a large subdural hematoma was found at an outside hospital on a
background of supratherapeutic INR, atrial fibrillation,
diabetes, hypercholesterolemia and cerebrovascular disease.
.
# NEURO: pt's family was very adamant about no invasive measures
being taken, including blood products being given. Patient's
exam continued to worsen throughout his course. Pt's family
wanted to wait until his sister arrived from [**Name (NI) 4565**], and
then patient was made CMO. He was extubated and passed on
[**2110-11-30**]. The family declined autopsy.
# HEMATOLOGY: his INR was 6.0 at the OSH, and despite being
given vitamin K on DOA, it was 5.6 the next day. We decided,
after discussion with the family to continue to give 10mg IV of
vitamin K daily, but not to give blood products like FFP as they
felt that would be "too invasive".
# CODE: DNR/DNI, confirmed with sister. [**Name (NI) **] invasive methods to
be done including blood products.
Medications on Admission:
coumadin, but otherwise unknown
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis: Subdural Hemorrhage
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"585.9",
"584.9",
"278.02",
"V66.7",
"427.31",
"344.09",
"403.90",
"V49.86",
"432.1",
"E934.2",
"357.2",
"V49.72",
"331.4",
"780.01",
"790.92",
"440.20",
"348.4",
"V45.81",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5856, 5865
|
4717, 5746
|
326, 338
|
5947, 5957
|
3177, 3177
|
6009, 6107
|
1968, 1977
|
5828, 5833
|
5886, 5886
|
5772, 5805
|
5981, 5986
|
2017, 2445
|
3147, 3158
|
267, 288
|
366, 1616
|
2539, 3131
|
3194, 4694
|
5905, 5926
|
2460, 2523
|
1638, 1822
|
1838, 1952
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,216
| 195,381
|
5628+5629
|
Discharge summary
|
report+report
|
Admission Date: [**2182-11-1**] Discharge Date: [**2182-11-3**]
Date of Birth: [**2123-7-24**] Sex: F
Service: SURGERY
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Tertiary hyperparathyrodism
Major Surgical or Invasive Procedure:
[**2182-11-1**]: Subtotaled parathyroidectomy.
History of Present Illness:
Ms [**Known lastname 13551**] is a 59 year-old female with history of ESRD on HD, HIV
on HARRT, Hep C cirrhosis, and tertiary hyperparathyroidism who
was admitted for subtotal parathyroidectomy.
Past Medical History:
- ESRD due to HIV nephropathy on HD TuThSa
- HIV, diagnosed [**2165**]; last CD4 246, VL: [**2165**]
- Hepatitis C with cirrhosis and portal hypertension
- Zoster [**2177**]
- Bronchitis
- GIB - chronic, thought to be due to AVM
- Thrombocytopenia
- Tertiary hyperparathyroidism
Social History:
Patient is on disability. Lives with adult son; has 5 adult
children. Tob: >25 pack-year tobacco history, currently smokes
few cigarrettes/day. EtOH: Denies EtOH use. None for several
years since diagnosis of cirrhosis. Drugs: History of crack
cocaine use and IVDU (last use 10 yrs
ago); stopped since starting dialysis ~[**2171**]. Family aware of
HIV diagnosis.
Family History:
Mother with DM and HTN; died from brain aneurysm.
GM with DM, HTN; died from diabetic coma.
Older sister died of liver cancer.
[**Name (NI) **] sister w/ breast cancer; in remission
No history of colon cancer. No history of bleeding disorders or
GIB.
Physical Exam:
Physical Exam on Discharge:
Vitals: 98.5, 111, 160/70, 20, 99RA
Gen: AOx3
HEENT: Surgical horizontal neck incision c/d/i with steri strips
in place and without signs of infection or hematoma
CV: RRR, no m/r/g
Resp: CTA bilaterally
Abd: Soft, NT/ND
Ext: No c/c/e
Pertinent Results:
[**2182-11-2**] 06:05AM BLOOD Glucose-201* UreaN-31* Creat-7.7* Na-134
K-4.8 Cl-94* HCO3-19* AnGap-26*
[**2182-11-3**] 05:35AM BLOOD Glucose-34* UreaN-19 Creat-5.5*# Na-138
K-4.5 Cl-86* HCO3-22 AnGap-35*
[**2182-11-1**] 10:30AM BLOOD Calcium-11.1* Phos-5.6* Mg-1.8
[**2182-11-2**] 02:00PM BLOOD Calcium-9.1
[**2182-11-3**] 05:35AM BLOOD Calcium-9.5 Phos-6.4*# Mg-2.0
[**2182-11-1**] 10:30AM BLOOD PTH-463*
[**2182-11-2**] 06:05AM BLOOD PTH-7*
[**2182-11-1**] 10:30AM BLOOD WBC-3.3* RBC-4.47 Hgb-13.1 Hct-41.8
MCV-93 MCH-29.2 MCHC-31.3 RDW-17.9* Plt Ct-67*
[**2182-11-2**] 06:05AM BLOOD WBC-3.9* RBC-4.53 Hgb-13.8 Hct-42.3
MCV-93 MCH-30.4 MCHC-32.5 RDW-18.0* Plt Ct-61*
[**2182-11-1**] 10:30AM BLOOD PT-20.0* PTT-32.0 INR(PT)-1.8*
Brief Hospital Course:
The patient was admitted to the East 1 Surgical Service for
evaluation and treatment for tertiary hyperparathyroidism . On
[**2182-11-1**] the patient underwent subtotal parathyroidectomy (the
right inferior was left as a partial remnant) which went well
without complication (reader referred to the Operative Notes
for details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating clears, on maintenance
IV fluids, and PO pain medication for pain control. The patient
was hemodynamically normal.
.
Neuro: The patient received PO pain medications with good effect
and adequate pain control.
.
HEENT: Neck monitored for signs of hematoma of which there were
none. Pt demonstrated excellent phonation, no stridor and denied
dyspnea.
.
Endocrine: Denied perioral numbness/tingling,
parathesias/tingling in hands and fingers. POD 1 calcium
demonstrated normocalcemia. The patient was evaluated by the
renal team, who recommended 1 g of TUMS TID on discharge, and
follow up labs to be drawn with the patient's next HD treatment.
There was no need for additional calcitriol or calcium
supplementation.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Etravirine 100'', lamivudine 50', sevelamer 1600''', and
tenofovir 300 once a week, metoprolol 25', nephrocaps qd
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. lamivudine 10 mg/mL Solution Sig: Five (5) mL PO DAILY
(Daily).
3. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
6. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO QFRI (every Friday).
7. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
9. calcium carbonate 1,177 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day for 4 weeks.
Disp:*84 Tablet, Chewable(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
-Tertiary hyperparathyroidism
-HIV
-Hepatitis C with cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a parathyroidectomy for
tertiary hyperparathyroidism. The procedure went well, and you
were kept in the hospital overnight for observation. Following
the procedure, you were taken to dialysis to keep your normal
schedule.
On discharge, you can resume your normal diet and activity
without restriction. You may shower, but do not scrub or soak
your incision. You should plan to follow up with Dr. [**Last Name (STitle) **]
in [**2-10**] weeks, and should call his office to schedule an
appointment.
Please also bring a copy of your discharge paperwork to your
next [**Date Range 13241**] appointment as well as to your next
appointment with your primary care doctor. [**First Name (Titles) 2172**] [**Last Name (Titles) 13241**]
providers should continue to follow you calcium after this
procedure.
Please call or return to the hospital if you experience any
nausea/vomiting, fevers/chills, numbness or tingling in your
face or arms, or worsening swelling/redness around your incision
site.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**2-10**] weeks. You can call
([**Telephone/Fax (1) 9011**] to make an appointment.
Please plan to continue your [**Telephone/Fax (1) 13241**] on your normal
schedule and plan to make an appointment to see your primary
care provider in the next few weeks.
Completed by:[**2182-11-3**] Admission Date: [**2182-11-4**] Discharge Date: [**2182-11-23**]
Date of Birth: [**2123-7-24**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
transjugular liver biopsy [**2182-11-8**]
History of Present Illness:
59 ESRD on HD, HIV, HCV not being treated. s/p parathyroidectomy
[**11-1**], d/c'ed today [**11-3**]. Pt reports that today she went home
and felt weak, had abdominal pain, and was nauseated, vomited
non-bilious non-bloody material then came to the ER. The pt
reports that she hasn't eaten anything all day, has no appetite,
and hasn't had a BM since before the surgery. The pt reports
that she may have felt this way while in the hospital this
recent admission. On arrival to the ED her FSBG was 30, and in
the ED they administered D50 ampule and raised the FSBS to 72,
which was then followed and trended to be 130, 155, to 108. In
the ER the pt also received approximately 300ml of D5 1/2 NS,
and was put on a drip of 50cc/hr. Pt reports that her last
dialysis administration was the day before yesterday.
.
On arrival to the MICU, the pt is lethargic and generally slow
to respond to questions. The pt continued to endose abdominal
pain, but said that she wasn't particularly nauseated. The pt
repeatedly would say that she's "not long for this world".
.
In discussion with the surgeons who performed the procedure,
they could not identify any connection between the surgery and
liver failure. The noted that the surgery was uncomplicated.
Past Medical History:
- ESRD due to HIV nephropathy on HD TuThSa
- HIV, diagnosed [**2165**]; last CD4 246, VL: [**2165**]
- Hepatitis C with cirrhosis and portal hypertension
- Zoster [**2177**]
- Bronchitis
- GIB - chronic, thought to be due to AVM
- Thrombocytopenia
- Tertiary hyperparathyroidism s/p parathyroidectomy
Social History:
Patient is on disability. Lives with adult son; has 5 adult
children.
Tob: >25 pack-year tobacco history, currently smokes few
cigarrettes/day.
EtOH: Denies EtOH use. None for several years since diagnosis of
cirrhosis.
Drugs: History of crack cocaine use and IVDU (last use 10 yrs
ago); stopped since starting dialysis ~[**2171**]. Family aware of
HIV diagnosis.
Family History:
Mother with DM and HTN; died from brain aneurysm.
GM with DM, HTN; died from diabetic coma.
Older sister died of liver cancer.
[**Name (NI) **] sister w/ breast cancer; in remission
No history of colon cancer. No history of bleeding disorders or
GIB.
Physical Exam:
ADMISSION EXAM:
VS: 83, 98/62, 98%RA on 2L NC, r22
General: Middle-aged female laying in bed in NAD. Alert and
appropriate.
HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear.
Surgical horizontal neck incision c/d/i with steri strips in
place and without signs of infection or hematoma.
Neck: supple, JVP not elevated, no LAD
Lungs: Breathing comfortably, crackles bilaterally at the bases.
CV: RRR, + 3/6 systolic murmur present.
Abdomen: +BS, soft, no guarding, no rebound, but TTP in the RUQ,
noted hepatomegaly.
Ext: warm, well perfused, trace edema bilaterally
Access: RUE AVF with aneurysms, + bruit, + thrill
DISCHARGE EXAM
VSS, afebrile
General: AOX3
HEENT: Sclera anicteric, mucous membranes moist, oropharynx
clear. Surgical horizontal neck incision c/d/i with steri
strips in place and without signs of infection or hematoma.
Neck: supple, JVP not elevated, no LAD
Lungs: Breathing comfortably, crackles bilaterally at the bases.
CV: RRR, 4/6 systolic murmur palpable best at the LLSB,with
radiation to axilla
Abdomen: +BS, soft, nontender, nondistended, no guarding, no
rebound,
Ext: warm, well perfused, right UE edema
Access: RUE AVF with aneurysms, + bruit, + thrill,
Pertinent Results:
ADMISSION LABS
[**2182-11-3**] 11:05PM BLOOD WBC-10.8# RBC-5.12 Hgb-15.2 Hct-49.4*
MCV-97 MCH-29.7 MCHC-30.7* RDW-21.5* Plt Ct-62*
[**2182-11-3**] 11:05PM BLOOD Neuts-92.0* Lymphs-4.9* Monos-2.5 Eos-0.3
Baso-0.3
[**2182-11-4**] 03:50AM BLOOD PT-30.9* PTT-36.0* INR(PT)-3.0*
[**2182-11-3**] 05:35AM BLOOD Glucose-34* UreaN-19 Creat-5.5*# Na-138
K-4.5 Cl-86* HCO3-22 AnGap-35*
[**2182-11-3**] 11:05PM BLOOD ALT-544* AST-854* AlkPhos-58 Amylase-180*
TotBili-3.7* DirBili-2.5* IndBili-1.2
[**2182-11-3**] 05:35AM BLOOD Calcium-9.5 Phos-6.4*# Mg-2.0
[**2182-11-3**] 11:12PM BLOOD Lactate-11.6*
[**2182-11-3**] 11:12PM BLOOD freeCa-0.82*
PERTINENT LABS
[**2182-11-3**] 11:05PM BLOOD ALT-544* AST-854* AlkPhos-58 Amylase-180*
TotBili-3.7* DirBili-2.5* IndBili-1.2
[**2182-11-4**] 06:00AM BLOOD ALT-541* AST-799* LD(LDH)-748* CK(CPK)-59
AlkPhos-51 Amylase-168* TotBili-3.6* DirBili-2.7* IndBili-0.9
[**2182-11-5**] 05:10AM BLOOD ALT-544* AST-723* AlkPhos-61 Amylase-192*
TotBili-4.9*
[**2182-11-6**] 02:48AM BLOOD ALT-504* AST-514* AlkPhos-68 Amylase-278*
TotBili-8.0* DirBili-5.9* IndBili-2.1
[**2182-11-7**] 04:39AM BLOOD ALT-379* AST-298* AlkPhos-78 Amylase-161*
TotBili-10.3* DirBili-7.5* IndBili-2.8
[**2182-11-8**] 04:19AM BLOOD ALT-247* AST-134* AlkPhos-70
TotBili-12.5* DirBili-9.1* IndBili-3.4
[**2182-11-9**] 03:57AM BLOOD ALT-181* AST-89* LD(LDH)-293* AlkPhos-74
TotBili-15.3*
[**2182-11-10**] 03:40AM BLOOD ALT-136* AST-92* LD(LDH)-414* AlkPhos-80
TotBili-15.3*
[**2182-11-11**] 03:15AM BLOOD ALT-128* AST-111* AlkPhos-91
TotBili-18.4*
[**2182-11-12**] 02:00AM BLOOD ALT-96* AST-94* LD(LDH)-328* AlkPhos-72
Amylase-321* TotBili-17.8*
[**2182-11-13**] 03:50AM BLOOD ALT-78* AST-67* AlkPhos-70 Amylase-150*
TotBili-19.0* DirBili-14.2* IndBili-4.8
[**2182-11-7**] 04:39AM BLOOD calTIBC-229* Ferritn-862* TRF-176*
[**2182-11-5**] 10:10AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HAV-NEGATIVE
[**2182-11-5**] 10:10AM BLOOD Smooth-POSITIVE *
[**2182-11-5**] 10:10AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2182-11-5**] 10:10AM BLOOD IgG-2794*
[**2182-11-3**] 11:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS
[**2182-11-23**] 07:30AM BLOOD WBC-5.0 RBC-3.32* Hgb-10.6* Hct-34.7*
MCV-105* MCH-31.9 MCHC-30.5* RDW-24.4* Plt Ct-63*
[**2182-11-23**] 07:30AM BLOOD PT-16.0* PTT-28.0 INR(PT)-1.4*
[**2182-11-23**] 07:30AM BLOOD Glucose-112* UreaN-30* Creat-5.5*# Na-134
K-4.2 Cl-96 HCO3-26 AnGap-16
[**2182-11-23**] 07:30AM BLOOD ALT-42* AST-55* AlkPhos-56 TotBili-12.5*
[**2182-11-23**] 07:30AM BLOOD Calcium-9.5 Phos-4.5 Mg-2.4
MICROBIOLOGY
HIV Viral Load: 252 copies/ml
HCV viral load: 1,280,000 IU/mL.
CMV: IgG pos, IgM neg
VZV: IgG pos, IgM pos 1.22 (nl range 0-0.9)
EBV: Ig
HSV1: IgG pos
HSV2: IgG pos
Blood Culture: no growth
PERTINENT STUDIES
[**11-8**] Transjugular liver bx:
Liver, transjugular needle core biopsies:
Fragmented core biopsies of liver demonstrating:
1. Established cirrhosis (confirmed with Trichrome stain),
Stage 4 fibrosis, with delicate sinusoidal fibrosis.
2. Moderate predominantly microvesicular steatosis without
associated ballooning degeneration or intracytoplasmic hyalin.
3. Moderate canalicular cholestasis with occasional associated
lobular neutrophils.
4. Scattered focal areas of hepatocyte dropout/necrosis and
parenchymal collapse (confirmed with reticulin stain).
5. Iron stain shows marked Kupffer cell and mild hepatocellular
iron deposition.
[**11-8**] ABD US
1. Patent portal vein with antegrade flow.
2. Small amount of ascites, unchanged.
3. Small amount of gallbladder sludge, but no cholelithiasis or
acute
cholecystitis.
[**11-6**] MRCP
IMPRESSION:
1. Hepatic and splenic iron deposition without pancreatic
involvement,
consistent with hemosiderosis.
2. Cirrhosis of the liver, without evidence of focal lesions or
biliary
dilation.
3. Small ascites and bilateral pleural effusions with basal
atelectasis.
Brief Hospital Course:
59F with HIV, ESRD, Hep C cirrhosis, pHTN, Calciphylaxis-related
valvular disease s/p subtotal parathyroidectomy on [**11-1**] presents
hours after discharge from surgical service who was admitted
with acute hepatitis secondary to sevoflurane used in
anesthesia.
#.Acute liver failure: Pt developed acute liver failure with
transaminitis, hyperbilirubinemia, elevated INR, decreasing
albumin and altered mental status. Pt was ruled out for
obstructive or infectious etiology. Liver biopsy showed
microvesicular steatosis and focal necrosis consistent with drug
induced hepatitis. Leading diagnosis is desflourane induced
hepatitis. Pt was initially treated with Vancomycin,
Cefetazidime and Flagyl for concerns of cholangitis.
Antibiotics were withdrawn upon clinical improvement and finding
on liver biopsy. Her HAART therapy was stopped due to her acute
liver failure and will need to be restarted as an outpatient
(which per ID should be [**12-4**] and not sooner). Her LFTs trended
down, however her Bilirbuin remained elevated at the time of
discharge and the patient was still jaundiced. SHe was being
treated with urosdiol while inpatient however due to attempt to
decrease the amount of medications the patient takes for
medication compliance this was discontinued, as was her
lactulose and rifaximin. On discharge, pt is alert and oriented
X3, with no asterixis. She is not on the liver transplant list
because she took herself off.
#. Hypotension - Patient required IV pressors while in the
MICU, This was felt to be multifactorial due to her MR, MS, and
AS as well as her fistula. Her baseline systolic blood pressures
are generally in the 90s, and once out of the ICU her blood
pressures ranged from high 70s-90s. Because of her low blood
pressures her metoprolol succinate 25mg po once a day was
changed to metoprolol tartate 12.5mg po BID. The hope was that
by slowly her heartrate down would increase her preload and help
with her systolic blood pressure.
# Pancreatitis- the patient also developed pancreatitis in the
setting of her acute liver failure as her lipase was elevated.
This trended down and she was able to tolerate a regular diet
#.Thrombocytopenia: Seems to be baseline low, likely secondary
to liver dysfunction. She did not require any interventions for
her low platlets.
#. ESRD: The patient was continued on her normal HD schedule,
until she developed hypotension. She was on CVVHD from
[**Date range (1) 22564**] for hypotension, and then resumed her
normal HD schedule starting on [**11-13**]. She had a temporary IJ
dialysis line placed, however this was removed as her Rsided
fistula was working. It was felt that her right arm swelling was
due to a blockage in the fistula. She was scheduled for a
fistulagram, multiple times however due to noncompliance with
being NPO this did not happen as an inpatient. The fistula
continued to function well prior to discharge. She will need to
have the fistulagram done as an outpatient. The IR department
will contact the rehab facility on [**2182-11-25**] in order to
coordinate a date and time.
#.HIV: The pt's HIV medications were initially held in the
setting of her acute liver failure. ID was consulted who
recommended that she not restart them until 30 days after her
inpatient, which was on [**2182-11-3**]. She will need to discuss
restarting these medications with her outpatient providers. She
was given one dose of pantamidine inh prior to discharge. Her
HIV viral load was no longer undetectable on this admission
#.HCV: Pt is currently not on any antivirals for her HCV. Her
HCV viral load is not undetectable. The patient will need to
flow up with ID and hepatology what should be done about HCV
management.
#.s/p parathyroidectomy: The patient's ionized calcium and
phosphorus were monitored daily and was given calcium prn. The
patient's free-calcium was discharged in the normal range.
#Depression- after the patient was transferred to the medical
floor, she expressed many concerns about her goals of care,
which were waxing and [**Doctor Last Name 688**]. Multiple family meetings took
place to discuss what medications she was interested in
continuing and any barriers to taking her medications. As she
mentioned wanting to give up, and not wanting to eat and having
problems sleeping, psychiatry was consulted and they recommended
Mirtazipine 7.5mg po qhs to help with her appetitie and sleep.
At the time of discharge she was eating well and her sleeping
had improved.
Transitional Issues:
Pending labs: Blood cultures [**2182-11-19**]
Medications started:
1. Mirtazpine 7.5mg by mouth at bedtime (for mood/sleep)
Medications changed:
1. Metoprolol- changed from long acting version of 25mg once a
day to short acting (tartate) 12.5 mg by mouth twice a day
Medicaiton stopped:
Lamivudine 10 mg/mL 5ml daily
Sevelamer carbonate 1600 mg TIDQAC
Omeprazole 20 mg daily
Oxycodone 5-10 mg Q4H:PRN pain
Tenofovir disoproxil fumarate 300 mg QFIR
Etravirine 200 mg [**Hospital1 **]
Follow-up:
1. Continue dialysis
2. Outpatient fistulogram pending scheduling, IR will call rehab
to schedule date and time of procedure
3. Discuss when to restart HAART with outpatient [**Provider Number 22565**]. Will need follow-up with surgery about parathyroidectomy post
op treatment
Medications on Admission:
B complex-vitamin C-folic acid 1 mg daily
Lamivudine 10 mg/mL 5ml daily
Sevelamer carbonate 1600 mg TIDQAC
Omeprazole 20 mg daily
Oxycodone 5-10 mg Q4H:PRN pain
Tenofovir disoproxil fumarate 300 mg QFIR
Etravirine 200 mg [**Hospital1 **]
Metoprolol succinate 25 mg daily
Calcium carbonate 1,177 mg TID x 4 weeks
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for pain.
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Primary: Acute liver failure, Drug induced hepatitis,
Secondary: HIV, HCV cirrhosis, End stage renal disease,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 13551**],
You were admitted to our hospital because you had worsening
liver function and were feeling very sick after you had been
discharged from your parathyroidectomy. You were found to have
acute liver failure. You underwent a liver biopsy to determine
the cause of the liver biopsy as all of your blood tests were
negative for cuases. THe changes that were seen in the biopsy
were consistent with a medication caused liver toxicity, of the
medications that you had received during your previous hospital
stay it is most likely from the anesthesia that you had, and
this is a very very rare possible side effect. You were
originally monitored and taken care of in the ICU. Your liver
function was improving and you were transferred to the regular
medical [**Hospital1 **] for continued monitoring Your HIV medications were
held because they can affect the liver. You will need to discuss
restarting these after [**12-4**] (1 month after the liver
injury) with your outpatient provider.
[**Name10 (NameIs) **] mood was very low while you were here and you were seen by
psychiatry who felt that you would benefit from an
antidepressant called Mirtazipine which were you started on and
seemed to help with your sleeping and your appetite.
You continued to undergo dialysis while you were inpatient. Your
right arm was swollen and it was felt that this was most likely
due to a small blockage in your fistula, however your fistula
was still working prior to your discharge. We tried to have
this fixed while you were inpatient with a fistulagram, however
this was not done and will need to be done as an outpatient.
The Interventional Radiology department will contact your rehab
facility on [**Name (NI) 766**] [**2182-11-25**] to coordinate the date and time of
your fistulogram. You CANNOT eat or drink anything the morning
of the date of your fistulogram.
Transitional Issues:
Pending labs: Blood cultures [**2182-11-19**]
Medications started:
1. Mirtazpine 7.5mg by mouth at bedtime (for mood/sleep)
2. Tramadol for pain
Medications changed:
1. Metoprolol- changed from long acting version of 25mg once a
day to short acting (tartate) 12.5 mg by mouth twice a day
Medicaiton stopped:
Lamivudine 10 mg/mL 5ml daily
Sevelamer carbonate 1600 mg TIDQAC
Omeprazole 20 mg daily
Oxycodone 5-10 mg Q4H:PRN pain
Tenofovir disoproxil fumarate 300 mg QFIR
Etravirine 200 mg [**Hospital1 **]
Follow-up:
1. Continue dialysis
2. Fistulagram still needed
3. Discuss when to restart HAART with outpatient [**Provider Number 22565**]. Will need follow-up with surgery about parathyroidectomy post
op treatment
Followup Instructions:
Name: [**Name6 (MD) 3577**] [**Last Name (NamePattern4) 11407**], MD
Specialty: Internal Medicine
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
We are working on a follow up appointment for you to see Dr.
[**Last Name (STitle) **] within 2 weeks of your discharge from the hospital. You
will be called at home with the appt. If you have not heard
within 2 business days, please call the number above.
Department: ADVANCED VASC. CARE CNT
When: WEDNESDAY [**2182-12-4**] at 9:30 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
You will be contact[**Name (NI) **] by the interventional radiology department
on [**Name (NI) 766**] [**2182-11-25**] to coordinate the date and time of your
fistulogram
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
[
"585.6",
"427.32",
"276.2",
"E879.1",
"416.8",
"780.09",
"276.51",
"251.2",
"583.9",
"996.73",
"571.5",
"458.21",
"V45.11",
"E878.2",
"577.0",
"042",
"311",
"E938.2",
"789.00",
"572.3",
"287.5",
"570",
"070.54",
"424.1",
"573.3",
"252.08"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"50.13",
"39.95",
"38.93",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
20613, 20656
|
14614, 19116
|
7135, 7178
|
20810, 20810
|
10677, 14591
|
23650, 24767
|
9185, 9438
|
20275, 20590
|
20677, 20789
|
19938, 20252
|
20993, 22886
|
9453, 10658
|
1567, 1802
|
22907, 23627
|
7062, 7097
|
7206, 8461
|
20825, 20969
|
8483, 8785
|
8801, 9169
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,976
| 106,735
|
46829
|
Discharge summary
|
report
|
Admission Date: [**2167-11-23**] Discharge Date: [**2167-12-9**]
Date of Birth: [**2105-6-4**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Haldol / Darvon / Keppra
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
TIPS
Endotracheal Intubation and Mechanical Ventilation
History of Present Illness:
Ms. [**Known lastname **] is a 62 year-old woman with a history of HCV
cirrhosis, polysubstance abuse, and history of hemorrhoidal
bleeding presented [**2167-11-24**] with 1-2 wks BRBPR and discovery of
Hct 18 at PCP's office. Her creatinine was 1.1. In the ED, she
was found to have a hct of 10% and acute renal failure with
creatinine of 1.6. She had a femoral cordis placed. She was
given IVF and had emergency released blood transfused. Her BP
was as low as 80/40, but stabilized with IVF to 100/60. She
refused NG lavage.
Past Medical History:
1) iron deficiency anemia
2) GI bleed - presumed secondary to hemorrhoids
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duoenal polyps and duodenitis
6) MGUS
7) ?etoh/ HCV cirrhosis followed by Dr. [**Last Name (STitle) 497**] (vl 9k in [**5-15**])
8) psychotic disorder
9) remote polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) compex partial seizures
Social History:
She lives alone, 10 blocks from her daughter. She smokes several
cigaretts per day, and occasionally uses EtOH, marijuana, and
cocaine. She is originally from [**State 3908**], and changed her name
when she became a practicing Muslim, which she says she
currently still practices. She worked as an administrative
assistant when she was younger, but is now on SSDI (for
schizophrenia and seizure disorder, per pt, both now quiescent).
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy
Physical Exam:
Physical Exam on Discharge
Gen: Awake and alert. Oriented to month, year, person.
Tangential speech. Easily re-directed.
HEENT: Mucous membranes moist. EOMI. Pupils equal and reactive.
Marked scleral icterus.
Neck: Bandage in place.
Heart: Regular Rate and Rhythm. Normal S1, S2. No murmurs.
Chest: Diffuse crackles bilaterally
abd: Soft. Nt/ND.
Extremities: 1+ peripheral edema
Neuro: CN II-XII intact. Moving all extremities. Tangential
speech but easily directed.
Pertinent Results:
Echo [**2167-11-28**]-The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60-70%) There is no ventricular septal defect. The
right ventricular cavity is dilated. Right ventricular systolic
function appears depressed. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Impression: moderate pulmonary hypertension; dilated
hypocontractile right ventricle
.
Chest X-ray [**2167-12-8**]:Severe infiltrative pulmonary abnormality
has worsened radiographically but this may be a function of
extubation and the end of positive pressure ventilatory support
which has produced slightly lower lung volumes. Small bilateral
pleural effusions may be present. Heart size is normal.
Mediastinal vascular engorgement is moderate and unchanged. No
pneumothorax. Tip of the right supraclavicular central venous
line projects over the upper SVC.
Brief Hospital Course:
# Gastrointestinal bleed: Pt admitted with significant lower GI
bleed at hemorrhoids likely thought secondary hepatitis C
associated cirrhosis. She underwent EGD with two cords of Grade
I varices identified, no stigmata of bleeding. Colonoscopy led
to rectal prolapse and bleeding thought likely from rectal
varices. A TIPS by interventional radiology was performed with
the intention of relieving portal hypertension and rectal
variceal bleeding. Rectal bleed recurred on [**11-27**], with rectal
foley placed by surgery later expelled with Valsalva.
Hepatology placed a rectal [**Last Name (un) **] to tension, which
controlled bleeding. Ultrasound revealed patents TIPS and it
was thought that bleeding may be secondary to hemorrhoids versus
varices. Patient was transfused intermittely to maintain stable
hematocrit. [**Last Name (un) **] subsequently discontinued with no
significant bleeding since. Hematocrit is stable at discharge at
30.8.
.
# Respiratory distress: On [**11-27**] in the setting of acute
re-bleed, Ms. [**Known lastname **] was intubated secondary to wheezing, severe
shortness of breath, and increasing rales. Vancomycin,
cefepime, flagyl started [**11-27**] to cover for nosocomial PNA.
Metronidazole later discontinued. Endotracheal suction removed
particulate matter consistent with aspiration. She also
demonstrated fluid overload and pulmonary edema. She has
received intermittent furosemide to relieve pulmonary vascular
congestion. To maximize respiratory capacity, she was started on
standing ipratropium MDI 6 puff IH Q4H, albuterol 6 puff IH Q4H,
fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]. On [**12-3**], pt noted
to have respiratory distress likely [**2-13**] flash pulmonary edema
after administration of D5W 250ml over 2 hours for
hypernatremia; stat CXR demonstrated increased opacities. She
was extubated on [**12-7**] and was saturating well on nasal cannula.
Vancomycin and cefepime were discontinued on [**2167-12-8**] after a
12 day course.
.
# Hypernatremia: On [**2167-12-3**], Ms. [**Known lastname **] was noted to have
increasing sodium (147), and therefore free water boluses were
begun and IV D5W administered. Because of pulmonary vascular
congestion, IV fluids were discontinued were and free water
boluses titrated to maintain stable sodium. Once patient was
extubated, IV fluid boluses were discontinued in favor of oral
free water repletion. Sodium is 148 on the day of discharge.
.
# Acute renal failure: Creatinine was noted to be gradually
increasing, with consideration of acute interstitial
nephritis/acute tubular necrosis in setting of hypotension or,
given positive rare eosinophils in urine, of new drug.
Creatinine gradually improved as overall condition improved.
Creatinine is 1.7 on the day of discharge. Electrolytes and
renal function should be monitored daily for the next several
days given new oral diuretic regimen.
.
# Tachycardia: Pt demonstrated episodic tachycardia to 160s-170s
during suctioning, but persistent tachycardia as well into 100s
even without stimulation. In addition, pt developed concomitant
hypertension into the 190s-220s. Pt received Haldol for
agitation, hydralazine 10 mg IV x2, Dilt 10 mg IV x1. She was
started on metoprolol which was discontinued in favor of the
non-selective blockade with labetalol 100mg PO BID given
patient's recent cocaine use.
.
# Coagulopathy: Ms. [**Known lastname **] has had persistently abnormal
coagulation factors. This was thought likely secondary to poor
synthetic function in the setting of hepatic failure. Vitamin K
was initially given to correct any component of nutritional
deficiency with little effect. She was transfused with FFP in
times of acute bleeding with a goal of INR < 2.5. At the time
of discharge, Ms. [**Known lastname **] INR was stable at 2.4.
.
# HCV cirrhosis: Pt not on medical therapy for HCV cirrhosis.
Paracentesis results during hospitalization demonstrated no
evidence of spontaenous bacterial peritonitis. Pt is s/p TIPs
and there is concern that TIPS may have worsened encephalopathy
noted during admission. Lactulose continued for encephalopathy
prevention. Total bilirubin reached a peak of 11 on [**2167-12-1**]
and has been trending downward to 8.2 at time of discharge. She
should continue lactulose and rifaximin. and follow-up with Dr.
[**Last Name (STitle) 497**] of hepatology [**2167-11-18**].
.
# Altered Mental Status- Following extubation, Ms. [**Known lastname **] has
had intermittent delirium which is likely a combination of
hepatic encephalopathy and delirium associated with prolonged
hospital stay. If needed, recommend low dose Haldol for
behavioral control with attention to QT interval on
electrocardiogram. QT interval 438 on day of discharge.
.
# Substance abuse: Pt continued using cocaine, marijuana, and
EtOH. SW consult pending. HIV was tested given risk factors
and was negative.
.
# Full code
.
# Communication: Daughter [**Name (NI) 4850**] [**Telephone/Fax (1) 99373**] (HCP), Son [**Name (NI) **]
[**Name (NI) 5857**]) [**Telephone/Fax (1) 99374**]
Medications on Admission:
None
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution [**Telephone/Fax (1) **]: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for Agitation.
4. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Last Name (STitle) **]: One
(1) Inhalation 2 puffs [**Hospital1 **] () as needed for SOB.
5. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day) as needed for itching.
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Inhalation Q6H (every 6 hours).
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: [**1-13**]
Inhalation Q2H (every 2 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: [**1-13**] Inhalation Q6H
(every 6 hours).
9. Lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO QID (4
times a day).
10. Rifaximin 200 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times
a day).
11. Labetalol 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times
a day).
12. Haloperidol Lactate 5 mg/mL Solution [**Month/Day (2) **]: One (1) Injection
(0.5mg) TID (3 times a day) as needed for agitation.
13. Lasix 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
Tablet(s)
14. Spironolactone 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a
day. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Lower Gastrointestinal Bleed
Cirrhosis
Hepatic Encephalopathy
Respiratory Distress/ Aspiration Pneumonia
Acute Renal Failure
Hypernatremia
Coagulopathy secondary to liver failure
Hepatitis C
Hepatic Cirrhosis
Discharge Condition:
Good
Discharge Instructions:
Per hepatology recommendations, Ms. [**Known lastname **] should begin Lasix
40mg PO daily and spironolactone 50mg PO daily, and electrolytes
and creatinine should be checked daily for the next several
days. These medications may be titrated up as tolerated by
electrolytes, renal function and blood pressure. She should
follow-up with Dr. [**Last Name (STitle) 497**] in hepatology clinic on Friday,
[**12-18**] as described below.
She should continue on lactulose and rifaximin for hepatic
encephalopathy. Haldol at low dose as needed for agitation.
Please take all medications as prescribed. Return to the
hospital for:
.
* Bleeding
* Frank blood in stools
* Tarry black stools
* Bloody emesis
* Fevers, chills
* Abdominal pain
* Nausea, vomiting
* Worsening cough
* Decline in mental status
Followup Instructions:
[**2167-12-18**], morning- Appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]
of hepatology [**Location (un) 858**] of the [**Hospital Unit Name **] at [**Last Name (NamePattern1) **].
Call ([**Telephone/Fax (1) 1582**] with questions.
Primary Care Dr. [**Last Name (STitle) **] on [**2167-12-31**] at 1:45 pm at [**Hospital **]
Community Health Center. Phone ([**Telephone/Fax (1) 10975**]
|
[
"070.54",
"428.0",
"571.2",
"496",
"507.0",
"518.81",
"572.3",
"455.2",
"276.0",
"428.32",
"345.90",
"286.9",
"455.5",
"572.2",
"584.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"45.23",
"45.13",
"96.6",
"99.15",
"54.91",
"39.1",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10629, 10684
|
3853, 8944
|
330, 404
|
10937, 10944
|
2456, 3830
|
11798, 12233
|
1818, 1952
|
8999, 10606
|
10705, 10916
|
8970, 8976
|
10970, 11775
|
1967, 2437
|
263, 292
|
432, 961
|
983, 1351
|
1367, 1802
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,512
| 146,610
|
49009
|
Discharge summary
|
report
|
Admission Date: [**2142-4-23**] Discharge Date: [**2142-4-28**]
Date of Birth: [**2089-3-1**] Sex: M
Service: MEDICINE
Allergies:
Zestril / Nitroglycerin
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Fluoro-guided left subclavian tunneled dialysis catheter
placement
History of Present Illness:
53y/o M sent from NEBH after Dx cath revealed RCA 99% lesion,
sent for pre-hydration and PCI cath w/[**First Name3 (LF) **] in AM. Pt with h/o
CAD, IMI-[**2142-4-22**] was here in CCU w/CHF exacerbation, refused
cath unless done by [**Month/Day/Year **]. Pt states that he was completly
asymptomatic after treatment in the CCU and decided to leave
AMA. At that time w/CHF, CRI worsened Cr 4.0-> high 7, had
hickman placed, got HD x1. PCP sent him to NEBH for cath w/[**Month/Day/Year **]
Friday which revealed 99% RCA lesion.
Past Medical History:
CAD MI as above, positive dobutamine echo [**1-27**] for basal/inf
ischemia. EF 50%. CRI 4.0 until [**4-26**], ESRD but creat improving
and UO increased now. CHF exacerbation. HTN. RAS s/p stenting.
PVD s/p aortobifem, SFA dz. OA. cervical disc disease. LBP after
MVA. frequent amnesia due to head trauma. Anemia, CRI and blood
loss 30s baseline. gout. foot gangrene.
Social History:
lives in [**Hospital3 **], 20pk-yr hx quit 1 mo ago, disabled,
separated, lives with son, h/o heavy etoh none current. PCP
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**] [**Numeric Identifier 102881**]
Family History:
dad died of CAD/MI @55yrs
Physical Exam:
vitals: T 98.4 BP 116/52 HR 60 RR 18 POx 97%RA
Gen: A+Ox3, NAD, well appearing
HEENT: oral mmm/clear, PERRLA
CV: RRR no murmurs/rubs/gallops, no JVD/carotid bruits
Pulm: CTABL
Ab: S/NT/ND/NM, +BS
Ext: no LE edema, 1+DPP BL
Pertinent Results:
[**2142-4-28**] 05:01AM BLOOD WBC-6.9 RBC-3.79* Hgb-10.5* Hct-32.4*
MCV-86 MCH-27.8 MCHC-32.4 RDW-15.8* Plt Ct-174
[**2142-4-28**] 07:00AM BLOOD PT-12.4 PTT-61.5* INR(PT)-1.0
[**2142-4-28**] 05:01AM BLOOD Glucose-162* UreaN-79* Creat-6.7* Na-136
K-3.5 Cl-100 HCO3-20* AnGap-20
[**2142-4-27**] 11:18PM BLOOD CK(CPK)-65
[**2142-4-27**] 11:18PM BLOOD CK-MB-NotDone cTropnT-1.52*
[**2142-4-23**] 02:47PM BLOOD CK(CPK)-222*
[**2142-4-23**] 02:47PM BLOOD CK-MB-24* MB Indx-10.8*
[**2142-4-28**] 05:01AM BLOOD Calcium-9.3 Phos-5.8* Mg-2.2
[**2142-4-23**] 02:47PM BLOOD Calcium-9.9 Phos-7.8*# Mg-1.9 Iron-25*
Cholest-233*
[**2142-4-23**] 02:47PM BLOOD Triglyc-98 HDL-47 CHOL/HD-5.0
LDLcalc-166*
[**2142-4-24**] 05:30AM BLOOD PTH-528*
Brief Hospital Course:
1. CAD: documented RCA disease, presented the night prior to
repeat cardiac cath for IV hydration, mucomyst. Patient
underwent cardiac cath with stent to RCA wihtout complication
and did well post cath. He was discharged with BB, asprin,
plavix, statin. The ACEi was held in the setting of renal
failure.
.
2. CHF: well compenstated post cath, fluid restricted
.
3. CRI: Cr at discharge last week was 6.7, baseline Cr approx
4.0 per OMR, good UO in house. Pt was pretreated with mucomyst,
bicarb prior to cath. Meds were renally dosed. Pt discharged
with phophate binders, bicitra, procrit.
.
4. HTN: continued on outpt regiment with good BP control
.
7. FEN: maintained on 2gNa cardiac/renal diet, fluid restricted
to 2L/day
.
10. Code: full
.
11. Access: decided to leave in hickman in anticipation of
possible initiation of HD as outpt.
.
12: Dispo: to home with f/u Dr. [**Last Name (STitle) **] (cardiology), Dr [**First Name (STitle) **]
(renal) and PCP for cardiac rehab
Medications on Admission:
asa 325, plavix 75 (was loaded w/300), lipitor 80, lopressor XL
100mg [**Hospital1 **], procrit 4K M/Th, protonix 40, phoslo 667w/meals,
renagel 800w/meals, hydralazine 25 qid, imdur 30, bicitra just
started, mucomyst given [**5-6**].
.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes as needed for chest pain: up to three
times- if chest pain not relieved call 911.
Disp:*90 tablets* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
End Stage Renal disease, now requiring dialysis
Non-ST elevation myocardial infarction
Discharge Condition:
Against medical advice - unrevascularized coronary artery
disease, end-stage renal disease
Discharge Instructions:
You have decided to leave the coronary care unit against medical
advice. Please return to the emergency room if you have
increasing chest pain or shortness of breath.
If you have chest pain, use nitroglycerin under the tongue every
5 minutes up to three times. If chest pain persists, call 911
immediately.
See your primary care physician first thing next week for
followup of your creatinine, potassium, phosphate, blood
pressure.
Followup Instructions:
End-stage Renal disease - return for dialysis
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-5-8**] 1:00
Completed by:[**2142-9-24**]
|
[
"272.0",
"403.91",
"428.30",
"443.9",
"428.0",
"410.71",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.71",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
5192, 5198
|
2608, 3590
|
294, 363
|
5329, 5422
|
1858, 2585
|
5906, 6184
|
1568, 1595
|
3878, 5169
|
5219, 5308
|
3616, 3855
|
5446, 5883
|
1610, 1839
|
244, 256
|
391, 918
|
940, 1309
|
1325, 1552
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,348
| 124,709
|
377+55210
|
Discharge summary
|
report+addendum
|
Admission Date: [**2119-5-18**] Discharge Date: [**2119-5-27**]
Date of Birth: [**2050-10-17**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Heparin Agents / Vancomycin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Tx for hypotension/ sepsis
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
History of Present Illness:
Pt is a 68 yo male with DM, HTN, deep brain stimulator, who is
being transferred from the floor from hypotension. Pt says that
he has been having fevers off and on for 5 weeks. Max temp
reached 104. No weight loss, night sweats with this but pt does
endorses rigors/chills. He states that some nights he would have
fever and sometimes his temperature would be 98.5 (fevers
generally occured at night). Pt did not go to his [**First Name3 (LF) 3390**] until this
past Tuesday. Blood cultures were drawn and grew out GPC in
clusters and pt was told to come to the ED. In the ED, lactate
was 4.7 (attributed to rigors as lactate was lower previously)
but patient did not meet strict criteria for sepsis then and was
admitted to the floor and started on vancomycin.
Past Medical History:
1. DM 2 x 11 years
2. Essential tremor followed by Dr [**Last Name (STitle) **], w/ DBS placed in [**2117**]
3. HTN
4. melanoma of ear 15 years ago
5. h/o falls, admitted in [**2115**]
6. hypertTG leading to pancreatitis in [**2107**]
7. ETOH hepatitis
8. s/p CCY in [**2106**]
9. h/o peripheral neruopathy
10. hx of CHF
11. depression/anxiety
Social History:
former physics instructor at [**University/College **]. Nonmarried no children. Lives
with sister in [**Name (NI) 745**]. No smoking. former heavy EtOH, none now.
Family History:
Mother died of pancreatitis. Sister died of pancreatic cancer;
father died of bone cancer and another sister died of ovarian
cancer.
Physical Exam:
Temp 101.7
BP 114/74
Pulse 106
Resp 20
O2 sat 96% RA
Gen - Alert, no acute distress, arousable from sleep
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes dry
Neck - no JVD, no cervical lymphadenopathy
Lymph: no axiallr LAD
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, 2/6 SEM at LUSB
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds, RUQ surgical scar
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**2-20**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - red papularmacular rash over chest wall and arms, AK's on
neck, no osler nodes or [**Last Name (un) **] lesions, no skin breaks
Pertinent Results:
[**2119-5-18**] 02:35PM BLOOD WBC-6.7 RBC-4.62 Hgb-15.8 Hct-43.8 MCV-95
MCH-34.1* MCHC-36.0* RDW-14.2 Plt Ct-131*
[**2119-5-19**] 08:00AM BLOOD WBC-19.8*# RBC-4.29* Hgb-14.7 Hct-41.5
MCV-97 MCH-34.3* MCHC-35.4* RDW-14.2 Plt Ct-145*
[**2119-5-19**] 07:43PM BLOOD WBC-19.4* RBC-4.23* Hgb-14.3 Hct-40.2
MCV-95 MCH-33.8* MCHC-35.5* RDW-14.2 Plt Ct-136*
[**2119-5-27**] 05:30AM BLOOD WBC-5.6 RBC-3.48* Hgb-11.8* Hct-33.8*
MCV-97 MCH-34.0* MCHC-35.0 RDW-14.0 Plt Ct-117*
.
[**2119-5-18**] 02:35PM BLOOD PT-13.6* PTT-24.1 INR(PT)-1.2*
[**2119-5-24**] 05:54AM BLOOD PT-14.5* PTT-37.1* INR(PT)-1.3*
.
[**2119-5-20**] 04:24AM BLOOD Fibrino-250 D-Dimer-642*
[**2119-5-18**] 02:35PM BLOOD ESR-0
[**2119-5-25**] 05:56AM BLOOD ESR-28*
.
[**2119-5-18**] 02:35PM BLOOD Glucose-148* UreaN-18 Creat-1.0 Na-143
K-3.5 Cl-107 HCO3-27 AnGap-13
[**2119-5-27**] 05:30AM BLOOD Glucose-104 UreaN-12 Creat-1.1 Na-142
K-3.5 Cl-108 HCO3-26 AnGap-12
[**2119-5-18**] 02:35PM BLOOD ALT-54* AST-50* LD(LDH)-204 AlkPhos-65
[**2119-5-21**] 03:14AM BLOOD ALT-54* AST-37 LD(LDH)-212 AlkPhos-42
Amylase-20 TotBili-0.8
[**2119-5-26**] 07:07AM BLOOD ALT-41* AST-56* AlkPhos-48 Amylase-17
TotBili-0.9
[**2119-5-20**] 04:24AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.9
[**2119-5-27**] 05:30AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.2
[**2119-5-19**] 08:00AM BLOOD TSH-2.0
[**2119-5-18**] 02:35PM BLOOD RheuFac-6 CRP-0.8
[**2119-5-25**] 05:56AM BLOOD CRP-61.8*
[**2119-5-18**] 02:43PM BLOOD Lactate-1.3
[**2119-5-18**] 09:42PM BLOOD Lactate-4.7*
[**2119-5-19**] 11:51AM BLOOD Lactate-2.8*
[**2119-5-19**] 09:39PM BLOOD Lactate-1.6
.
[**2119-5-25**] 08:04AM BLOOD HIV Ab-NEGATIVE
[**2119-5-19**] 07:43PM BLOOD Parst S-NEG
[**2119-5-23**] 05:00AM BLOOD Parst S-NEGATIVE
.
[**2119-5-26**] URINE URINE CULTURE-FINAL INPATIENT
[**2119-5-25**] BLOOD CULTURE ISOLATE FOR MIC-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE} INPATIENT - this culture are bacteria sent
from the [**Location (un) **] blood culture of [**2119-5-16**].
[**2119-5-25**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2119-5-25**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-FINAL INPATIENT
[**2119-5-24**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2119-5-24**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL INPATIENT
[**2119-5-23**] URINE URINE CULTURE-FINAL INPATIENT
[**2119-5-23**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2119-5-21**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2119-5-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2119-5-20**] URINE URINE CULTURE-FINAL INPATIENT
[**2119-5-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2119-5-19**] ABSCESS GRAM STAIN-FINAL; FLUID CULTURE-FINAL {STAPH
AUREUS COAG +, STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY INPATIENT
[**2119-5-19**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2119-5-19**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2119-5-19**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2119-5-18**] BLOOD CULTURE ANAEROBIC BOTTLE-FINAL; BRUCELLA BLOOD
CULTURE-PRELIMINARY INPATIENT
[**2119-5-18**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2119-5-18**] BLOOD CULTURE ANAEROBIC BOTTLE-FINAL; BRUCELLA BLOOD
CULTURE-PRELIMINARY EMERGENCY [**Hospital1 **]
[**2119-5-18**] BLOOD CULTURE ANAEROBIC BOTTLE-FINAL; BRUCELLA BLOOD
CULTURE-PENDING EMERGENCY [**Hospital1 **]
.
[**2119-5-18**] CXR - IMPRESSION: No acute cardiopulmonary process.
.
[**2119-5-19**] chest ultrasound - ordered to examine deep brain
stimulator for infection. IMPRESSION: No soft tissue fluid
collection.
.
[**2119-5-21**] CXR - IMPRESSION: No acute pulmonary process.
.
[**2119-5-22**] - CT-torso with contrast.
IMPRESSION:
1. Enlarged caudate and left lobes of liver with secondary signs
of portal hypertension, including perigastric and periesophageal
varices suggesting cirrhosis. Splenomegaly has also progressed
since [**2115**]. Small amount of perihepatic ascites.
2. Diverticulosis without evidence of diverticulitis.
3. Mediastinal lymph nodes measuring up to 13mm in short-axis
diameter, not significantly changed.
.
[**2119-5-22**] - Transesophageal Echocardiogram.
IMPRESSION: Mildly thickened mitral and aortic valves with no
vegetations or abscess seen. Mild mitral regurgitation.
.
[**2119-5-25**] - Tagged white blood cell nuclear scan.
IMPRESSION: No source of fever or bacteremia is identified.
Brief Hospital Course:
This is a 68 year old male with DM, HTN, a deep brain
stimulator, who presented with 5 weeks of fever, and 2 of 4
positive blood cultures at [**Location (un) 620**] for Staph. lugdunensis on
[**2119-5-16**].
1. Fever - The patient was febrile on admission and on [**2119-5-19**]
began to have difficulty with hypotension. Despite nearly 1.5
liters in bolus normal saline his systolic blood pressure was
persistently in the low 70s in the setting of recieving his
anti-hypertensive medication (lasix, verapamil, lisinopril). He
was asymptomatic and his heart rate remaind within normal
limits. He was transferred to the intensive care unit where he
recieved another 3.5 liters of normal saline and was on a
peripheral dopamine drip for 24 hours. A central venous
catheter was not placed. The patient was transferred back to
the floor on [**10-21**]. His pressure remained stable for the rest
of his stay, but he was presistently febrile. A vigorous
attempt was made to identify the source of the fever. Blood
cultures, urinalysis, urine cultures, two parasite smears, Chest
x-rays, CT-torso, trans thoracic and esophageal echocardiograms,
chest ultrasound of his deep brain stimulator, panorex and
tagged white blood cell scan were all negative. Blood tests for
HIV, brucella and lyme were negative. Blood tests for ehlichia,
bartonella and babesia were pending at the time of discharge.
The patient was covered on a variety of antibiotics during his
stay including vancomycin, doxycycline, ceftriaxone, and
nafcillin. Concern arose that the patient's fever was intially
caused by an infectious [**Doctor Last Name 360**] (possibly staph. lugdenensis),
which had been treated, but then continued due to drug fever.
At the time that this hypothesis arose the patient was on
doxycycline and vancomycin. The vancomycin was exchanged for
nafcillin and the patient defervesced. A PICC line was placed
and the patient was sent home on a course of PO and IV
antibiotics (see discharge plan).
.
2. Acute renal failure - This was attributed to the patient's
episode of hypotension that was likley related to his Staph.
lugdenensis bacteremia. The renal failure resolved with volume
resucitation and treatment of the bacteremia. Mucomyst was
given for nephroprotection before and after the CT-torso.
.
3. Diabetes - We held the patient's sulfonylurea and biguanide
in setting of IV contrast. We covered the patient with lantus
and a tight humalog insulin sliding scale.
.
4. Hypertriglyceridemia - we held the patient's tricor, as he
had reported that he recently started this medication and though
this is not classically associated with fever, we held the
medication based on the following monograph:
Diabetes Metab. [**2113**] [**Month (only) **];27(1):66-8.
Rare side-effects of fenofibrate.
Rabasa-Lhoret R, Rasamisoa M, Avignon A, [**Last Name (un) 3391**] L.
See copy of abstract in the chart.
.
5. Other Medical Issues - managaed with outpatient regimen.
Medications on Admission:
lantus 80 u qhs
amaryl 4 mg
tricor 48 mg daily
lisinopril 40 mg daily
ASA
lasix 40 mg daily
b12 q mth
novolog scale
paxil 20 mg daily
glyburide 5 mg [**Hospital1 **]
verapamil 180 mg daily
KCL
Discharge Medications:
1. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) g
Intravenous Q6H (every 6 hours) for 5 days.
Disp:*40 g* Refills:*0*
2. Insulin Glargine 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous at bedtime.
3. Amaryl 4 mg Tablet Sig: One (1) Tablet PO once a day.
4. PICC Care by VNA
PICC line care per NEHT protocol. Please don't use heparin.
5. Discussion
Please discuss your discontinuing tricor with your primary care
physician. [**Name10 (NameIs) 357**] inform him that we discontinued this
medication because of your fever.
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Cyanocobalamin Oral
10. Novolog 100 unit/mL Solution Sig: per sliding scale. units
Subcutaneous once a day.
11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 3 days.
Disp:*6 Capsule(s)* Refills:*0*
12. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Verapamil 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
15. Potassium Chloride 8 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day: Please take
potassium as you were prior to admission.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therpies
Discharge Diagnosis:
Fever
Sepsis secondary to Staph Lugdunensis
Drug induced fever - Vancomycin
? Heparin induced thrombocytopenia
Discharge Condition:
Vital signs stable. Fever resolved for greater than 24 hours.
Ambulating. Tollerating POs. Toileting independently. Still
requiring IV antibiotics.
Discharge Instructions:
Please take your medications as prescribed.
Please follow up with your primary care doctor within 1 to 2
weeks of discharge.
For now, you should avoid heparin products until you talk to
your [**Location (un) 3390**]. [**Name10 (NameIs) **] will be doing further studies in collaboration with
our blood bank to verify this dx.
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Last Name (STitle) 1941**] AND [**Name5 (PTitle) 3392**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2119-10-2**] 11:00
Provider: [**Name Initial (NameIs) 3390**]: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3393**] Date/Time:
[**2119-6-1**] 1:00pm
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3394**] [**2119-6-6**] 8:30 am Phone [**Telephone/Fax (1) 3395**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2119-5-29**] Name: [**Known lastname 388**],[**Known firstname 389**] Unit No: [**Numeric Identifier 390**]
Admission Date: [**2119-5-18**] Discharge Date: [**2119-5-27**]
Date of Birth: [**2050-10-17**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Heparin Agents / Vancomycin
Attending:[**First Name3 (LF) 391**]
Addendum:
The patient was noted to have thrombocytopenia. Test for
heparin induced antibodies were sent. This came back positive.
Heme/onc was informally consulted and felt that the probability
of a true positive result was unlikely given the less than 50%
drop in the PLT and partial recovery prior to discharge, no
thrombosis, and infection as possible etiology for the patient's
platelet drop. Nevertheless, a plan was put into place to
consult with the pathology lab regarding this test and to follow
up with the PCP if they felt that this was a true positive.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Home Therpies
[**Name6 (MD) 116**] [**Name8 (MD) 117**] MD [**MD Number(1) 392**]
Completed by:[**2119-5-29**]
|
[
"E930.8",
"305.03",
"V15.88",
"584.9",
"995.92",
"428.0",
"300.4",
"401.9",
"333.1",
"356.9",
"V58.67",
"038.19",
"458.9",
"250.00",
"E934.2",
"287.4",
"V10.82",
"780.6",
"272.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
14198, 14389
|
7305, 10277
|
325, 358
|
12121, 12275
|
2683, 7282
|
12649, 14175
|
1714, 1848
|
10521, 11875
|
11987, 12100
|
10303, 10498
|
12299, 12626
|
1863, 2664
|
259, 287
|
386, 1149
|
1171, 1517
|
1533, 1698
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,651
| 193,407
|
20187
|
Discharge summary
|
report
|
Admission Date: [**2191-11-23**] Discharge Date: [**2191-12-9**]
Date of Birth: [**2135-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
A 56-year-old gentleman with a history of
IgG multiple myeloma who is approximately three months following
an autologous stem cell transplant admitted with progressive
fatigue, shortness of breath and inability to ambulate.
Major Surgical or Invasive Procedure:
[**11-24**]-Thoracentesis
History of Present Illness:
56 yo male with PMH of multiple myeloma who was recently
admitted with a pericardial effusion and tamponade (pulsus
reportedly 24 mmHg) s/p pericardiocentesis and balloon
pericardiotomy presents with increased shortness of breath. Of
note during the last admission, he was also found to have a
large left pleural effusion on CT chest, but refused
thoracentesis at that time. Since being discharged the patient
has noted increased dyspnea, even with minimal activity such as
getting dressed. He denies chest pain, pleuritic symptoms,
orthopnea, PND, LE edema. He does report some cough productive
of yellow sputum. He denies fevers, chill, sweats. Of note he
also reports increasing lower extremity weakness to the point
that he was unable to get to his outpatient oncology appointment
for his dose of [**Month/Day (4) **]. He denies bowel/bladder incontinence,
urinary retention, numbness, tingling, or burning. He also
reports that his back pain is unchanged and remains a [**6-25**]
decreased to [**1-18**] /10 with oxycontin and oxycodone.
Past Medical History:
1.Plasma cell myeloma
Mr. [**Known lastname 54249**] is a 56-year-old gentleman who presented in
[**2190-9-15**] with complaints of muscle pain
between his shoulders and difficulty sleeping. He was seen by
his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in late [**Month (only) 1096**] of
[**2189**]. An x-ray performed at [**Hospital 1562**] Hospital showed a large
plasmacytoma in the posterior chest wall. He was then
transferred to [**Hospital1 69**] for further
evaluation. CT guided biopsy of the right posterior chest wall
mass was consistent with a plasmacytoma. Immunoperoxidase
studies showed tumor CD-134 positive and containing monoclonal
kappa and cytoplasmic immunoglobulin. MIB staining showed a
fraction of approximately 20%. Bone marrow biopsy revealed 80%
involvement with plasma cell myeloma. Plasma cells represented
41% of the marrow cellularity. Skeletal survey on [**2190-12-2**]
showed no additional lytic lesions. CT of the torso demonstrated
a large mass in the right posterior mediastinum and hemithorax
destroying the transverse process of the vertebral body of T3
and T4 and ribs at that level. IgG at that time was 8703, an
SPEP showed an abnormal band representing 58%, and beta 2
microglobulin was 3.4.
Mr. [**Known lastname 54249**] was initially treated with steroids and radiation
therapy, which started on [**2190-12-3**]. He was then seen as an
outpatient following his radiation treatments. He demonstrated a
fall in his immunoglobulin with IgG of 5041, representing 47% of
the total protein. He began Doxil, vincristine, and Decadron on
[**2191-1-24**], which he tolerated well. Following his first cycle of
DVD, however, Mr. [**Known lastname 54249**] presented with difficulty with balance
and coordination. His speech was garbled and he had poor
attention span. He was admitted for further workup to rule out
any neurologic developments. He was diagnosed with a
polyneuralgia and was started on folic acid and vitamin B12
subcutaneous monthly. Workup included an MRI, which showed only
prominent ventricular sulci and an LP showing no changes
consistent with infection. He was negative for HSV and it was
therefore felt that this was somewhat of his baseline neurologic
status in the setting of medication. He was being maintained on
fentanyl 75 mcg patch with oxycodone as needed for pain.
He then proceeded with cycle 2 of DVD chemotherapy. Mr. [**Known lastname 54249**]
had initial responses to the DVD chemotherapy, but then began
showing a plateauing of his IgG level. He was also noted to have
an increasing neck mass. A CT scan obtained at that time showed
that he had some enlargement of the neck mass. He had a single
chest lesion that was somewhat smaller and another one at the
rib that was somewhat larger. As such, his regimen was then
changed to pulse Cytoxan along with pulse Decadron therapy 40 mg
times four days on and four days off. He was then treated with
radiation therapy to his neck following an MRI, which ruled him
out for any spinal cord compression.
Mr. [**Known lastname 54249**] then was switched to [**Known lastname 4387**] chemotherapy, and
received three cycles. He showed a dramatic response to the
[**Known lastname 4387**], most notably a drop in his IgG level to within normal
range at 789 and his SPEP now representing 4% of the total
protein.
He then [**Known lastname 1834**] stem cell mobilization with Cytoxan and
[**Known lastname 1834**] autologous stem cell transplant with high-dose
melphalan on [**2191-7-28**]. He overall tolerated his high-dose
therapy well but had somewhat a slow recovery of his counts with
now normal levels. He otherwise had no other complications
posttransplant, until the end of [**10-20**] when he was
admitted with acute pericardial tamponade and recurrent
mediastinal mass.
Mr [**Known lastname 54249**] [**Last Name (Titles) 1834**] pericardocentesis with stabiliation of his
symptoms. His pericardial fluid was negative for malignantcells.
During this hospitalization, a CT scan on [**11-11**] revealed a a
large prevertebral soft tissue mass with anterior displacement
of the esophagus and trachea, 4 x 2.5 cm in greatest dimensions.
Images of the upper thorax demonstrated massive mediastinal
adenopathy. A lucency in the C6 vertebral body, suggestive of a
myeloma metastasis as well as an expansile lytic lesion of the
right fourth rib, with extension into the right side of the T4
vertebral body.
Although his presentation was certainly concerning for recurrent
MM, Mr. [**Name13 (STitle) 54250**] refused further evaluation including
bronchoscopy and biospsy, but simply wanted to be treated with
more [**Name13 (STitle) 4387**]. Mr [**Known lastname 54249**] [**Last Name (Titles) 54251**], was ambulating with a cane
and was discharged home with plans to followup as for outpatient
[**Last Name (Titles) 4387**]. Unfortunately, Mr. [**Known lastname 54249**] failed to show up for his
[**Known lastname 4387**] appointments c/o progressive weakness.
2. Recurrent zoster.
3. History of tobacco abuse.
4. History of viral encephalitis in 12/[**2177**].
5. Depression.
6. SIADH with hyponatremia.
7. Hypertension.
8. Anemia.
9. Odynophagia.
10.Steroid induced diabetes.
11.History of pneumonia in 02/[**2190**].
12.History of general herpes.
13.Mild restrictive lung disease.
PFTs: [**2191-6-14**]
Act Pre %Pred
FVC 4.19 5.16 75
FEV1 3.02 3.93 77
FEV1/FVC 72 70 103
Social History:
Lives on Cape w/ wife who is [**Name Initial (MD) **] former RN. 3 children from
previous marriage. Tobacco >1PPD X >20 yrs, quit [**2187**]. Former
ETOH abuse, now occ. ETOH. NO IVDU
Family History:
DM, HTN (brother at 58yo), Father deceased [**1-17**] CHF.
Physical Exam:
Temp 96.5
BP 116/68
Pulse 87
Resp 20
O2 sat 90-93%
Gen - Alert, no acute distress, no shortness of breath when
supine
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist, no oropharyngeal lesion/thrush
Neck - no JVD, no cervical lymphadenopathy, FROM, difficult to
appreciate JVD [**1-17**] neck
Chest - decreased breath sounds throughout lung fields L>R,
dullness to percussion left-[**1-18**] way up
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops, pulsus ~18
mmHg
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds, no hepatosplenomegaly
Rectal - normal rectal tone, no saddle anesthesia
Back - No costovertebral angle tenderness, no spinal/paraspinal
tenderness
(+) stage II decub on right buttock-superficial
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**1-27**] intact,
sensation grossly intact Motor [**4-20**] UE b/l, [**3-21**] hip flexion b/l,
df/pf [**4-20**] bilaterally, patellar reflexes 3+
Skin - No rash
Pertinent Results:
[**2191-11-23**] 05:30PM WBC-4.9 RBC-3.22* HGB-10.7* HCT-32.2*
MCV-100* MCH-33.3* MCHC-33.3 RDW-14.3
[**2191-11-23**] 05:30PM NEUTS-73.0* LYMPHS-19.2 MONOS-7.0 EOS-0.5
BASOS-0.2
[**2191-11-23**] 05:30PM HYPOCHROM-1+ MACROCYT-1+
[**2191-11-23**] 05:30PM PLT COUNT-194
[**2191-11-23**] 05:30PM PT-14.1* PTT-24.8 INR(PT)-1.3
[**2191-11-23**] 05:30PM WBC-4.9 RBC-3.22* HGB-10.7* HCT-32.2*
MCV-100* MCH-33.3* MCHC-33.3 RDW-14.3
[**2191-11-23**]: CT chest - IMPRESSION:
1) Stable appearance to mediastinal and hilar conglomerative
nodal masses.
2) Slight interval decrease in size to small pericardial
effusion.
3) Interval increase in size of tiny right pleural effusion, now
small. Also,
mild increase in size of large left pleural effusion.
[**2191-11-25**]: Non contrast head CT
IMPRESSION: No intracranial hemorrhage or mass effect. No change
from the
prior study of [**2191-2-9**].
[**2191-11-26**]: MRI spine:
IMPRESSION: Diffuse bony and epidural tumor is evident on total
spine MRI.
There is cord compression, particularly at the C6 to T4 levels
and from T6-7
to T9-10.
Brief Hospital Course:
The patient is a 56 year old male with PMH significant for
relapsed multiple myeloma s/p auto BMT in [**7-/2191**] who presents
with shortness of breath and lower extremity weakness.
#Shortness of breath - There were 3 concerning
etiologies-tamponade, increasing pleural effusion, increasing
mediastinal mass.
--On admission, the patient had a pulsus of 15-18 mmHG. This
was concerning in the setting of his recent cardiac tamponade, a
TTE was done which was notable for improvement in the recent
pericardial effusion and no evidence of tamponade.
--On admission, a CT of the chest was done which was notable for
a stable mediastinal mass, but an increasing left pleural
effusion which was already cited as large on the last admission.
The procedure team was consulted and a thoracentesis of the left
pleural effusion was performed. The procedure was complicated by
a small pneumothorax which resolved with 100% FIO2 by face mask.
The patient became less short of breath after the therapeutic
thoracentesis was performed. He was then able to maintain an
oxygen saturation of 94-97% on 2 Liters (baseline on previous
admission). The preliminary [**Location (un) 1131**] per pathology of the
pleural fluid was positive for plasma cells. No further
management of the effusion or therapy for the shortness of
breath was performed.
#LE Weakness - In the ED, the patient was seen by neurology who
also noted asterixis in addition to proximal lower extremity
weakness. An MRI was suggested, but the patient refused to have
one done on the first hospital day. TSH, B12 and LFTs were sent
to evaluate for metabolic causes of asterixis, all of which were
within normal limits. On HD 2, the patient had increasing lower
extremity weakness and actually fell to the ground because his
legs "buckled" underneath him. He agreed to an MRI if he could
be sedated. Since weakness in his legs was worsening and
conscious sedation by anesthesia could not be arranged for the
same day, the patient was given 2.5 mg Xanax and sent down to
MRI. The patient refused the MRI when he got there because of
pain and anxiety despite the xanax. He was started on decadron
(40 mg) for possible spinal cord compression due to the
mediastinal mass/cervical mass. Later that evening the patient
became acutely agitated/violent and then within minutes became
unresponsive for a period of 20 minutes. During this time he was
hemodynamically stable but exhibited no response to painful
stimuli and no gag reflex. After the episode he was confused,
lethargic and disoriented. He was seen by neuro who felt the
presentation could be c/w a seizure and sent to the [**Hospital Unit Name 153**] for
observation. A head CT was done which was negative for an acute
bleed, mass or mass effect. The following morning the patient
was placed under conscious sedation for an MRI of his head and
spine. While the head MRI was negative for masses/lesions, the
MRI of the spine was notable for diffuse bony and epidural tumor
and cord compression, particularly at the C6 to T4 levels and
from T6-7 to T9-10. The patient's dose of steroids was changed
to 6 mg IV q 6 hours and he [**Hospital Unit Name 1834**] emergent XRT of the spine.
The patient had XRT x 2, but became more confused prior to the
third session and began to refuse all therapies, including xrt
and a central line placement. He was given a second dose of
[**Hospital Unit Name **]. His neurologic status declined, and he continued to
refuse further therapy. A family meeting was held with his wife
and 2 sisters in law. It was decided to make the patient DNR/DNI
with comfort measures and to have the patient placed in
inpatient hospice. His steroids were tapered off.
#Pain control - On the first few days of admission, the
patient's pain was fairly well controlled with oxycontin 60 mg
[**Hospital1 **], with occassional oxycodone for breakthrough. The patient
then started to have increasing pain, not controlled with PO
medication alone. He was started on a 75 mcg fentanyl patch with
a fentanyl pca for breakthrough. As the patient's confusion
progressed, he did not push the PCA button for medication and he
refused peripheral access, so his regimen was changed to an
increased dose of fentanyl by transdermal patch with roxinol for
breakthrough pain. He
#Hematuria - While the patient was in the ICU, he had a foley
catheter placed. on HD 6, there was no urine in the foley bag,
so the foley was flushed and a clot was noted. The following
morning, more clots were noted and continuous bladder irrigation
was started. Red urine was in the bag after irrigation so a
sample was sent for cytology. The cytology was pending at
discharge.
#Multiple Myeloma - course as above. The patient received 2
doses of [**Hospital1 4387**] during this admission. A third dose was not
administered as the patient was put on best supportive measures
only. A follow up CT scan of his chest suggested an increase in
the mediastianl mass despite the two doses of [**Last Name (LF) **], [**First Name3 (LF) **] the
patient was maintained on best supportive measures. He was
originally put on fentanyl patch with morphine for breakthrough
pain, but his pain increased and he was eventually started on a
morphine drip. The patient passed away on [**2191-12-9**].
Medications on Admission:
Discharge Medications:
1. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
3. OxyContin 20 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO twice a day.
Disp:*120 Tablet Sustained Release 12HR(s)* Refills:*0*
4. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: Two (2) Capsule PO twice a day.
Disp:*120 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
7. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for nausea.
Disp:*40 Tablet(s)* Refills:*0*
8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Clotrimazole 10 mg Troche Sig: One (1) Mucous membrane five
times a day.
Disp:*500 mg* Refills:*2*
Discharge Medications:
Deceased
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Multiple Myeloma with spinal cord compression
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"V42.82",
"512.1",
"336.9",
"E878.8",
"599.7",
"203.00",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
16049, 16064
|
9674, 14944
|
542, 570
|
16154, 16164
|
8559, 9651
|
16221, 16232
|
7426, 7486
|
16015, 16026
|
16085, 16133
|
14970, 14970
|
16188, 16198
|
7501, 8540
|
277, 504
|
598, 1642
|
1664, 7206
|
7222, 7410
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,058
| 134,558
|
50767
|
Discharge summary
|
report
|
Admission Date: [**2143-10-24**] Discharge Date: [**2143-10-28**]
Date of Birth: [**2081-7-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 922**]
Chief Complaint:
recurrent angina/ NSTEMI
Major Surgical or Invasive Procedure:
[**2143-10-24**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary to left anterior descending, saphenous vein
grafts to ramus and PDA)
History of Present Illness:
62 year old male who lost a filling
while eating and cracked his tooth. He developed pain in
his neck with radiation to his shoulder following his cracked
tooth incident. He describes the pain as throbbing. This pain
continued for a few days however he states he has a high
tolerance for pain and he ignored it. On [**2143-9-19**] he
continued with pain the back of his neck. After dinner he was
resting in bed and developed diaphoresis and anxiety. The
diaphoresis was similar to his MI and he became concerned enough
that he took 2 (most likely outdated) nitroglycerin's without
any
relief. EMS was summoned and he received a nitro spray with
relief. He was admitted to [**Hospital1 **] [**Location (un) 620**]. He was found to have no
EKG changes however he did have a Troponin of 0.21 at peak. He
received 48 hours of Heparin and was discharged home. Following
discharge he underwent an exercise thallium where he developed
ST
depression and imaging revealed antero-apical and inferoseptal
ischemia. LVEF of 44% with inferior and septal hypokinesis. His
Aspirin was increased to 325mg daily. He was referred for
cardiac
catheterization. He was found to have left main disease upon
catheterization and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Coronary Artery Disease, s/p Coronary Artery Bypass x 3 on
[**2143-10-24**]
PMH:
MI [**2120**] treated with thrombolytics (back pain and diaphoresis)
NSTEMI [**2130**]; cath with distal RCA occlusion and mild to
moderate LAD disease with LVEF 50% (inferior and posterior
hypokinesis). Treated medically
[**2134**] abnormal stress; cath with 90% proximal LAD treated with
2 Express stents [**Hospital1 112**]
Hypertension
Hyperlipidemia
Diabetes
GERD
Anxiety
Glaucoma
right Achilles tear no surgical repair
Past Surgical History:
s/p tooth extraction 5 days ago (off Plavix for 4 days prior
and started up right away following the extraction)
Social History:
Lives with:Wife
Contact:[**Name (NI) 2048**] [**Name (NI) 24421**] (wife) (cell)[**Telephone/Fax (1) 105604**]
Occupation:retired architect but works part-time managing 8
apartments
Cigarettes: Smoked no [] yes [x] Hx:1-1.5 ppd x20 + years and
quit at the age of 40
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**1-21**] drinks/week [x] >8 drinks/week []
Illicit drug use:denies
Family History:
Father with massive MI at the age of 78, prior CAD with CABG in
his 60's.
Physical Exam:
Pulse:60 Resp:18 O2 sat:97/RA
B/P Right:137/62 Left:149/68
Height:5'6.5" Weight:185 lbs
General:
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: Left:
Pertinent Results:
Conclusions
PRE-BYPASS: Mild spontaneous echo contrast is seen in the body
of the left atrium. Mild spontaneous echo contrast is present in
the left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No thrombus is seen in the left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is top normal/borderline
dilated. The apex, apical and mid portions of the inferior,
inferolateral and inferoseptal walls are hypokinetic. Overall
left ventricular systolic function is mildly depressed (LVEF= 40
%). Right ventricular chamber size and free wall motion are
normal. There are complex (>4mm) atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. 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. Mild to moderate
([**12-16**]+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results at
time of surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Biventricular function is unchanged. Mitral
regurgitation is trace. The aorta is intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician
[**2143-10-28**] 06:05AM BLOOD WBC-7.2 RBC-3.74* Hgb-11.3* Hct-32.8*
MCV-88 MCH-30.1 MCHC-34.4 RDW-13.3 Plt Ct-228
[**2143-10-27**] 06:20AM BLOOD WBC-8.9 RBC-3.69* Hgb-11.0* Hct-31.9*
MCV-87 MCH-29.9 MCHC-34.5 RDW-13.0 Plt Ct-205
[**2143-10-28**] 06:05AM BLOOD UreaN-25* Creat-1.3* Na-139 K-4.7 Cl-100
[**2143-10-27**] 06:20AM BLOOD UreaN-18 Creat-1.2 Na-139 K-4.4 Cl-101
[**2143-10-26**] 06:50AM BLOOD Glucose-135* UreaN-16 Creat-1.3* Na-140
K-4.6 Cl-104 HCO3-27 AnGap-14
Brief Hospital Course:
[**Known lastname **],[**Known firstname 177**] was a same day admit and on [**10-24**] was brought
directly to the operating room where he underwent:
1. Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary
artery; reversed saphenous vein single graft from the
aorta to the ramus intermedius coronary artery; reversed
saphenous vein single graft from the aorta to the
posterior descending coronary artery.
2. Endoscopic left greater saphenous vein harvesting.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. Glyburide was resumed for Diabetes
management.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility.
By the time of discharge on POD 4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with VNA in good
condition with appropriate follow up instructions.
Medications on Admission:
ATENOLOL 50 mg by mouth once a day
CLOPIDOGREL [PLAVIX] 75 mg Tablet by mouth once a day ( last
dose 10/26)
FENOFIBRATE MICRONIZED 200 mg by mouth once a day
GLYBURIDE 2.5 mg 0.5 tablets by mouth [**Hospital1 **]
LISINOPRIL 10 mg by mouth once a day
METFORMIN 1,000 mg by mouth twice a day
NITROGLYCERIN 0.4 mg Tablet, Sublingual - [**12-17**] Tablet(s)sub
lingually as needed for chest pain
RANITIDINE HCL 150 mg by mouth twice a day
ROSUVASTATIN [CRESTOR] 20 mg by mouth once a day
ASPIRIN 325 mg by mouth once a day
Keflex (pt does not know dose) q6 hours, has 3 days left - was
on
it since tooth extraction
--------------- --------------- --------------- ---------------
Plavix - last dose:75mg [**2143-10-9**]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
8. glyburide 1.25 mg Tablet Sig: One (1) Tablet PO twice a day.
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
11. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule
PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Coronary artery disease - s/p CABG
Prior Myocardial Infarction
Hypertension
Hyperlipidemia
Diabetes Mellitus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Dr.[**Name (NI) 9379**] office will call you with the following
appointments
Wound Check in 1 week
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] [**Telephone/Fax (1) 170**] in 4 weeks
.
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8506**] in [**3-19**] weeks
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
**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:[**2143-10-28**]
|
[
"530.81",
"V15.82",
"300.00",
"365.9",
"414.01",
"250.00",
"412",
"272.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9158, 9216
|
5699, 7204
|
335, 490
|
9369, 9591
|
3650, 5676
|
10431, 11111
|
2877, 2953
|
7972, 9135
|
9237, 9348
|
7230, 7949
|
9615, 10408
|
2342, 2457
|
2968, 3631
|
271, 297
|
518, 1791
|
1813, 2319
|
2473, 2861
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,411
| 148,581
|
36677
|
Discharge summary
|
report
|
Admission Date: [**2197-7-31**] Discharge Date: [**2197-8-1**]
Date of Birth: [**2136-8-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of Breath, Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known firstname 3065**] [**Known lastname 82948**] is a very nice 60 year-old gentleman with
prior history of schizofrenia, CAD, systolic CHF, DM, COPD,
alcohol abuse, hepatic encephalopathy who was sent from NH
Bejamin HC center with SOB and AMS. Of note, Pt reportedly was
admitted to [**Hospital3 417**] hospital in [**Hospital1 1474**] 1 week ago
because he was experiencing increased anxiety/panic attacks. The
pt sisters feel that this was precipitated by the anniversary of
his father's death 1 year ago which he took very hard. When he
experienced the increased anxiety his medications were adjusted,
but he became drowsy, drooling, incontinent so he was
hospitalized and the medications were titrated back down. He was
D/C'd [**7-24**] back to his NH continent and with increased energy.
However, he started to decline a few days later with difficulty
speaking/confusion/decreased short term memory, he had
complained of SOB and gotten albuterol INH at nrsing home. Per
nursing home nurse, felt increased abdominal distention
recently.Pt was noted to be oriented x1 and confused and was
sent to the ER.
.
In the ED vitals were: 98.3 97/63 69 20 97% RA. His sodium was
122 after fluids with a potassium of 5.7. EKG with LBBB and ST
depressions 2,3,AVG, and cardiac enzymes were negative. Lactate
was 2.3, WBC 12.9, INR 1.7, UA negative, CXR negative, CT of the
abdomen showed ascities with enlarged prtostate, distended
bladder and dislocated right prostethic hip. Pt received lithium
and lactulose, 1 L NS bolus, clozapine 200 mg, pentoxyfylline SR
400 mg in ER and was admitted to medicine serivce. Blood
cultures were sent.
.
On the floor his vitals were: 97.1 90/60 76 24 96% om RA.
Shortly after arriving pt triggeter for hypoxia up to SpO2 60%
on RA. he was suctioned and put on NRB. He was transfered to the
MICU.
.
In the MICU patient's VS were: HR 76, BP 118/84 mmHg, RR 12 x',.
SpO2 100%, Temp 96.2 F. Patient appeared with cold and clammy
extremities. He was not following commands. He was given IVF
boluses with isotonic bicarbonate (2 L), intubated without
immediate return of SaO2 and emergent bedside fiberoptic
pronchoscopy. He had RIJ placed with a CVP of ~25 mmHG with x
and y descents but no large v wave. Pt was started on levophed.
Then, emergent cardiac echocardiogram showed normal LV thickness
with severely dilated LV and global hypokinesis and EF of ~15%.
RV was moderately dilated with severe global free wall
hypokinesis and signs of volume overload. There was [**Month/Year (2) 1192**] to
severe MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] TR. There wasn't any pericardial
effusion. Patient underwent a PE-CT that rueld out PE and
showed. At this point, patient was transfered to CCU team for
amazing cardiovascular care.
.
Of note, Liver service was consulted in regards to LFTs with AST
of 451, ALT 1134 and a ratio of 2.5 with AP 63, TB 4.0. Trauma
consulted re: dislocated hip, but patient refuset going to x-ray
or sedation to have it re-positioned.
.
<br>
On review of systems (per records), 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. S/he denies exertional buttock or calf pain.
All of the other review of systems were negative.
<br>
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:
<br><b>PAST CARDIOVASCULAR HISTORY: </b>
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: Unknown.
-PACING/ICD: None.
Coronary Artery Disease
Systolic Heart Failure (Chronic)
<br><b>PAST MEDICAL HISTORY: (from medical records)</b>
Chronic paranoid schizophrenia
DEmentia second stage
Anxiety
Systolic Chronic Heart Failure
Coronary Artery Disease
Hepatic Encephalopathy
Diabetes Mellitus Type 2
L1 compression vertebral fracture
h/o hyponatremia
GERD
h/o COPD
h/o alcohol abuse
h/o right hip fracture s/p repair
h/o liver failure, wnl LFTS as of [**2197-7-12**]
Social History:
SOCIAL HISTORY:
Pt lives in a nusring home, whre he moved [**4-16**] yuears ago. He
does not work given psych disease. Denies any illegal drug use.
Prior history of smoking (unclear when he stoopped), prior
history of alcohol. Never married, 5 brothers, 3 sisters.
Family History:
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION:
VITAL SIGNS - Temp 100 F, BP 91/54 mmHg, HR 70 BPM, RR 16 X',
O2-sat 100% RA
GENERAL - well-appearing man, intubated, sedated.
HEENT - NC/AT, PERRLA, very miotic, EOMI, sclerae anicteric,
MMM, OP clear, Conjunctiva were pink, no pallor or cyanosis of
the oral mucosa. No xanthalesma.
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2 with decreased A2. SEM in RUSB [**2-17**] and
[**3-17**] in tricuspid area without any radiation. No thrills, lifts.
No S3 or S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Abd aorta not enlarged by palpation. No
abdominial bruits. Presence of ascities with shifting dullness.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), No c/c/e. No femoral bruits. No edema.
SKIN - no rashes or lesions. No stasis dermatitis, ulcers,
scars, or xanthomas. Scar in right leg.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - Sedated.
Pertinent Results:
[**2197-7-31**] 01:00AM BLOOD WBC-12.9* RBC-4.01* Hgb-11.5* Hct-35.8*
MCV-89 MCH-28.7 MCHC-32.2 RDW-14.7 Plt Ct-184
[**8-1**]: BLOOD WBC-14.0* RBC-3.87* Hgb-11.0* Hct-34.4* MCV-89
MCH-28.5 MCHC-32.1 RDW-14.8 Plt Ct-209
[**7-31**]: BLOOD PT-18.5* PTT-29.6 INR(PT)-1.7*
[**8-1**]: BLOOD PT-18.0* PTT-29.2 INR(PT)-1.6*
[**7-31**]: BLOOD Glucose-211* UreaN-32* Creat-1.2 Na-122* K-5.7*
Cl-93* HCO3-19* AnGap-16
[**8-1**]: BLOOD Glucose-272* UreaN-23* Creat-1.0 Na-134 K-4.2 Cl-97
HCO3-29 AnGap-12
[**7-31**]: BLOOD ALT-1134* AST-451* CK(CPK)-56 AlkPhos-63
[**8-1**]: BLOOD ALT-1187* AST-383* LD(LDH)-334* AlkPhos-66
Amylase-30 TotBili-0.7
[**2197-7-31**] 01:00AM BLOOD cTropnT-<0.01
[**2197-7-31**] 06:15AM BLOOD CK-MB-4 cTropnT-0.01
[**7-31**]: BLOOD TSH-0.96
[**2197-7-31**] 01:00AM BLOOD Digoxin-1.1
[**2197-7-31**] 01:00AM BLOOD Lithium-1.2
[**7-31**]: BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**8-1**]: BLOOD HCV Ab-PND
[**7-31**]: BLOOD Type-ART pO2-34* pCO2-45 pH-7.30* calTCO2-23 Base
XS--4
[**8-1**]: BLOOD Type-ART Temp-37.8 Rates-/16 pO2-284* pCO2-52*
pH-7.37 calTCO2-31* Base XS-3 Intubat-INTUBATED
Cultures: Pending
Studies:
ECHO ([**2197-7-31**]): The left atrium is elongated. The right atrium
is moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is severely dilated. There
is severe global left ventricular hypokinesis (LVEF = 15-20 %).
Overall left ventricular systolic function is severely
depressed. The right ventricular cavity is moderately dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets do not fully coapt.
An eccentric, posteriorly directed jet of [**Month/Day/Year 1192**] to severe
(3+) mitral regurgitation is seen. [**Month/Day/Year **] [2+] tricuspid
regurgitation is seen. There is [**Month/Day/Year 1192**] pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Severely dilated left ventricle with severe global
hypokinesis. Moderately dilated right ventricle with severe
hypokinesis. At least [**Month/Day/Year 1192**] pulmonary hypertension. [**Month/Day/Year **]
to severe mitral regurgitation. [**Month/Day/Year **] tricuspid
regurgitation.
CTHead ([**2197-7-31**]): No acute intracranial hemorrhage or mass
effect.
CTAbd/Pelvis ([**2197-7-31**]): 1. Ascites extending down to the pelvis.
The liver appears within normal limits on this single phase
study. 2. The patient is status post total right hip
replacement. The femoral head is dislocated from the acetabulum.
3. Enlarged prostate with distended bladder.
ECG ([**2197-7-31**]): Sinus rhythm. Right axis deviation. Left atrial
abnormality. Intraventricular conduction defect. Possible
lateral myocardial infarction of indeterminate age. Inferior
ST-T wave changes which are non-specific. No previous tracing
available for comparison.
CXR ([**2197-7-31**]): Tip of the new ET tube is at the thoracic inlet,
between 5 and 6 cm from the carina, in standard placement. Aside
from minimal peribronchial opacification in left lower lobe,
lungs are clear. Heart size is severely enlarged. No pleural
effusion or pneumothorax.
Brief Hospital Course:
Mr. [**Known firstname 3065**] [**Known lastname 82948**] is a very nice 60 year-old gentleman with
prior history of schizophrenia, CAD, systolic CHF, DM, COPD,
alcohol abuse, hepatic encephalopathy who was sent from NH
Bejamin HC center with SOB and AMS and then hypotensive
requiring pressors.
#. Hypotension - On admission patient was borderline hypotensive
in the ED. EKG showed LBBB and ST depressions 2,3. Cardiac
enzymes were negative. Labs in ED were significant for Lactate
was 2.3, WBC 12.9. Other work up included a CXR negative, CT of
the abdomen showed ascities with enlarged prtostate, distended
bladder and dislocated right prostethic hip. Pt received lithium
and lactulose, 1 L NS bolus, clozapine 200 mg, pentoxyfylline SR
400 mg in ER. Blood cultures were sent.On the floor patient
remained borderline hypotensive with pressure of 90/60. In the
MICU, Patient appeared with cold and clammy extremities. He had
RIJ placed with a CVP of ~25 mmHG with x and y descents but no
large v wave. Pt was started on levophed and given isotonic
bicarbonate (2L). Then, emergent cardiac echocardiogram showed
normal LV thickness with severely dilated LV and global
hypokinesis and EF of ~15%. RV was moderately dilated with
severe global free wall hypokinesis and signs of volume
overload. There was [**Known lastname 1192**] to severe MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] TR. There
wasn't any pericardial effusion. Based on ECHO results patient
thought to be in cardiogenic shock. Transfered to CCU care. CCU
started dopamine to improve inotropism. Pressures were stable.
After family meeting and discussion it was discovered that
patient was DNR/DNI. Prognosis was discussed in detail with
family by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**]. Family descided to providing comfort
measures only would be most in line with the patient's wishes.
.
#. CAD: Patient had history of coronary artery disease. This
issue was not addressed during admission.
.
#. Acute on Chronic systolic heart failure - Patient with acute
on chronic systolic heart failure. Acute preciptant unknown at
this time but thought to be secondary to metabolic disturbance.
ECHO was performed and noted above. Levophed was first provided
and then weaned when Dopamine was started for increased
inotropic support.
.
#. Respiratory failure - When patient was transferred to the
floor his oxygen sat was 96% on RA. Shortly after arriving pt
triggeer for hypoxia up to SpO2 60% on RA. He was suctioned and
put on NRB. On admission to MICU intubated without immediate
return of SaO2 and emergent bedside fiberoptic pronchoscopy.
Patient saturation returned to 100% on room air after intubation
with an arterial blood gas 7.37/52/284. Pt with acute on chronic
respiratory acidosis with metabolic acidosis and hypoxia. Most
likely secondarely to COPD, possible exacerbation, but not
wheezing and poor cardiac forward flow causing increase lactic
acid and poor kidney perfusion.
.
#. Transaminitis -On admission patient had transaminitis. The
etiology of this elevation was unknown but may be secondary to
CHF. Viral serologies were drawn, however this is unlikely.
Liver enzymes were trended during the admission.
.
#. Hyperkalemia - Unclear, but could be medication related given
normal renal function and patient on spironolactone and oral
potassium. Pt may have component of acute renal failure with
poor perfusion that we have not yet seen, but this may not
explain the level. Cortical stimulation test performed, with
appropriate response, making adrenal insufficiency unlikely.
.
#. Schizophrenia - Outpatient medications continued.
.
#. Hyponatremia - Pt most likely hypervolemic given high CVP
(increased given TR!) and echocardiogram. However, lungs are
clear, there is not HSM, no peripheral edema. At this point
diuresis with lasix may improve his hyponatremia and as we
correct CHF his sodium should improve.
.
#. AMS - Pt with abnormal LFTs, psych disorders and shock. Will
treat shock as above, resume psych medications and continue
lactulose. Correcting electrolyte imbalances as well and looking
for infection.
.
CODE/ FAMILY MEETING: Team met with HCP [**Name (NI) **] and sisters [**Name (NI) **]
and one other sister discussed patient's code status. Family had
conveyed to floor that patient DNR/DNI, but this was not
conveyed to MICU staff. Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], discussed current
understanding: patient critically ill, likely large cardiac
component, unclear short term prognosis. On [**8-1**] it was decided
that providing comfort measures only would be most in line with
the patient's desires.
Medications on Admission:
Spirinolactone 15 mg QD
Potassium chloride 40 mEq
Lasix 20 mg QD
Digoxin 0.125 mg QD
Prilosec 20 mg [**Hospital1 **]
Lactulose 30 ml [**Hospital1 **]
Coreg 6.25 [**Hospital1 **]
Sennecot 2 tab [**Hospital1 **]
Lithium 300 mg Q am
Lithium 400 mg TID
Clozapin 200 mg Q Am
Clozapin 300 mg QPM
Pentoxifylline 400 mg TID
Tylenol 325 mg 2 Tabs PO Q4 hrs PRN pain
Simethicone liquid 30 mg PO PRN
Albuterol HFA 90 mcg 2 pugg Q4 hrs PRN SOB
Ativan 0.25 mg 2 tab PO q6hrs PRN anxiety or aggitation
Glucerna shake
Pentoxiphylin 400 mg PO TID
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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55,601
| 139,938
|
36646
|
Discharge summary
|
report
|
Admission Date: [**2119-3-22**] Discharge Date: [**2119-4-3**]
Date of Birth: [**2059-7-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Monosodium Glutamate
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Worsening mitral valve function, admit for evaluation for repair
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2119-3-22**]
Mitral valve repair, oversewing of left atrial appendage [**2119-3-28**]
History of Present Illness:
59 year old gentleman has a history
of cardiomyopathy, previous cardiac arrest and s/p ICD implant
in
[**2117**]. He has a history of ventricular tachycardia and has had 2
prior ablation procedures in the summer of [**2118**] after recurrent
ventricular tachycardia and multiple AICD shocks. He was also
started on Amiodarone in [**Month (only) 216**] following his ablations after
Sotalol was unsuccessful. He also has a history of atrial
fibrillation for 15 years and more recently atrial flutter. On
[**2118-11-30**], he underwent an unsuccessful atrial flutter ablation
and
had an electrical cardioversion of atrial fibrillation to sinus
rhythm, however he reverted back to atrial fibrillation again
1-2
days after his cardioversion. He was seen by Dr. [**Last Name (STitle) **] on
[**2118-12-12**] at which time his EKG revealed left atrial tachycardia
with 3:1 conduction. In early [**2119-2-27**], the patient was
hospitalized at [**Hospital 3236**] [**Hospital 107**] Hospital with what he describes
as HF. He underwent echocardiogram [**3-20**] which revealed increased
LA size and worsening mitral regurgitation. He now presents for
cardiac catheterization and surgical evaluation
Past Medical History:
Mitral regurgitation
Cardiac arrest [**1-3**]
Hypertrophic cardiomyopathy
acute on chronic diastolic heart failure
Hyperlipidemia
dyslipidemia
h/o atrial fibrillation
Renal failure [**9-4**]
Embolic stroke [**2103**] with no residual
Fractured rib left side [**9-4**]
Gout
Depression
Tonsillectomy
Appendectomy
Obstructive sleep apnea ??????cannot tolerate CPAP
Anxiety
Pneumonia [**2118-12-27**] and in [**2117**]
Social History:
Lives alone. Instructor in Risk Reduction for the State, teaches
classes for people convicted of DWI- currently on medical leave.
Walks dog 30 minutes daily regularly, kayaking, mountain
climbing
-Tobacco history: Quit 26 years ago, 30pkyr
-ETOH: None since [**2099**]
-Illicit drugs: None
Family History:
Mother, Brother and [**Name (NI) 53767**]: "had what I have (cardiomyopathy)."
Otherwise non-contributory.
Physical Exam:
Pulse: 75 Resp: 16 O2 sat: 100% RA
B/P Right: 111/70 Left: 124/82
Height: 188 cm Weight: 81.6 kg
General: no acute distress, thin
Skin: Dry [x] intact [x] right lower abd surgical scar
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [**4-1**]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], Edema none Varicosities: None [x]
Neuro: Alert and oriented x3 nonfocal
Pulses:
Femoral Right: +2 Left: +2
DP Right: doppler Left: doppler
PT [**Name (NI) 167**]: doppler Left: doppler
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2119-4-2**] 08:35AM BLOOD WBC-9.8 RBC-4.15* Hgb-10.9* Hct-34.4*
MCV-83 MCH-26.2* MCHC-31.7 RDW-15.4 Plt Ct-306#
[**2119-3-31**] 05:05AM BLOOD WBC-12.1* RBC-3.97* Hgb-10.3* Hct-32.8*
MCV-83 MCH-26.0* MCHC-31.5 RDW-15.4 Plt Ct-181
[**2119-4-2**] 08:35AM BLOOD Glucose-131* UreaN-28* Creat-1.0 Na-137
K-3.5 Cl-100 HCO3-28 AnGap-13
[**2119-4-2**] 08:35AM BLOOD Mg-2.0
ADMISSION LABS
.
[**2119-3-22**] 12:30PM BLOOD WBC-7.4 RBC-5.46 Hgb-14.3 Hct-44.3
MCV-81* MCH-26.2* MCHC-32.3 RDW-15.2 Plt Ct-436
[**2119-3-22**] 12:30PM BLOOD PT-21.8* PTT-26.2 INR(PT)-2.0*
[**2119-3-22**] 12:30PM BLOOD Glucose-88 UreaN-25* Creat-1.4* Na-143
K-4.5 Cl-106 HCO3-28 AnGap-14
[**2119-3-22**] 12:30PM BLOOD ALT-54* AST-48* LD(LDH)-229 AlkPhos-267*
Amylase-54 TotBili-0.8
[**2119-3-22**] 12:30PM BLOOD Lipase-37
[**2119-3-25**] 07:05AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.0
[**2119-3-22**] 04:50PM BLOOD Albumin-3.6
[**2119-3-22**] 12:30PM BLOOD Albumin-4.1
[**2119-3-22**] 12:30PM BLOOD %HbA1c-6.0* eAG-126*
[**2119-3-22**] CARDIAC CATH
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated no significant coronary artery disease.
The LMCA had a 40% lesion. The LAD, LCx, and RCA were without
any
angiographically apparent coronary artery disease.
2. Limited resting hemodynamic measurement revealed elevated
left and
right sided filling pressures. The mean RA was moderately
elevated at
14 mmHg. RVEDP was moderately elevated at 15 mmHg. PCW mean
was
severely elevated at 25 mmHg. There was moderate pulmonary
artery
hypertension with PA of 49/30 mmHg. The cardiac index was
calculated
using the FICK equation and showed a severely reduced cardiac
index of
1.5 l/min/m2.
.
FINAL DIAGNOSIS:
1. No angiographically significant coronary artery disease.
2. Moderate right ventricular diastolic dysfunction.
3. Severe left ventricular diastolic dysfunction.
4. Moderate pulmonary artery hypertension.
5. Reduced cardiac index.
.
[**2119-3-22**] EKG
Atrial flutter, average ventricular rate 82. Marked leftward
axis at
minus 58 degrees. Intraventricular conduction delay with a QRS
duration
of 168 milliseconds. There are marked ST-T wave changes in the
lateral
precordial leads and poor R wave progression in leads V1-V4.
Compared to the
previous tracing of [**2119-3-20**] the rate is faster and there are no
longer
ventricular premature beats. The previously described lateral ST
segment
depressions persist unchanged.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 0 168 430/468 0 -58 115
.
[**2119-3-22**] CXR
FINDINGS: There is massive cardiomegaly. An AICD is identified
in
appropriate position. There is no focal consolidation, effusion,
or
pneumothorax.
IMPRESSION: Massive cardiomegaly. Otherwise, no acute
cardiopulmonary
process.
.
[**2119-3-23**] ECHO
IMPRESSION: Posterior mitral leaflet prolapse associated with
eccentric [**3-30**]+ mitral regurgitation and a markedly dilated left
atrium. Spontaneous echo contrast in the descending thoracic
aorta suggestive of reduced forward stroke volume.
.
[**2119-3-23**] CAROTIDS
IMPRESSION: No significant carotid artery stenosis (less than
40% on the
right, and no stenosis on the left).
Intra-op Echo [**2119-3-28**]
PRE-CPB:1. The left atrium is markedly dilated. Mild spontaneous
echo contrast is present in the left atrial appendage. No
thrombus is seen in the left atrial appendage.
2. The right atrium is moderately dilated. No atrial septal
defect is seen by 2D or color Doppler. The coronary sinus is
dilated (diameter >15mm). Agitated saline was injected into the
right arm and returned to the SVC.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. LV systolic function
appears depressed. [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] No masses or thrombi are seen in the left
ventricle.
4. The right ventricular cavity is mildly dilated with mild
global free wall hypokinesis.
5. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen.
7. The mitral valve leaflets are moderately thickened. An
eccentric, posteriorly directed jet of Moderate (2+) mitral
regurgitation is seen. There was posterior leaflet prolapse(P2)
and restriction. The anterior leaflet also had some prolapse of
A3. The mitral annulus is dilated to 4.3 cm.
8. Moderate [2+] tricuspid regurgitation is seen. The tricuspid
annulus is dilated to 4.9 cm.
9. There is a small pericardial effusion.
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 4043**] notified in person of the results.
POST-CPB: On infusion of epinephrine, phenylephrine. AV pacing.
Well-seated annuloplasty ring in the mitral position. Trivial
MR, trace stenosis with a peak gradient of 4 mmHg and mean of 2
mmHg. MVA is now 2.4 cm2. LVEF is now 45% on inotropic support
with persistent anterioseptal hypokinesis, although this could
represent temporary pacing artifact. RV function appears normal.
TR is improved to mild. Aortic contour is normal post
decannulation.
Brief Hospital Course:
59yoM with h/o HOCM, previous cardiac arrest with ICD placement
at [**Hospital 52455**] Hospital [**12/2117**], prior 2 ablation procedures in
summer [**2118**], chronic AFib/Flutter on Coumadin, CVA [**24**] yrs ago,
recently admitted for CHF exacerbation at [**Location (un) 15961**] [**1-/2119**],
who was admitted for Atach ablation and device upgrade to
pacer/ICD, then found on echo to have worsening MR [**First Name (Titles) **] [**Last Name (Titles) 40004**]
LA, and is admitted for workup for mitral valve repair
1. Mitral valve repair: Workup for MVR included cath [**2119-3-22**]
showing clean coronaries but mod RV diastolic dysfxn, severe LV
diastolic dysfxn, mod PA HTN, reduced CI. Echo [**2119-3-23**] showed
EF 55%, posterior mitral leaflet prolapse with eccentric [**3-30**]+ MR
and markedly dilated LA. Carotids with <40% on R and nothing on
L. Dental clearance was obtained. UA was negative. CXR with
cardiomegaly, but no other acute process. LFT's were elevated,
of unclear etiology, but downtrending.
Pt was admitted and Coumadin was held for surgery. When INR was
less than 1.5, a Heparin gtt was started.
2. Rhythm: Pt in AFib in the 70's, occasional NSVT 3-5 beats but
asymptomatic, and ICD did not fire through admission (v-sensing,
not dependent). Pt was continued on home Amiodarone 200mg daily,
Metoprolol 12.5 mg [**Hospital1 **], Dilt ER 240 mg daily. Coumadin was held
as above and Heparin gtt was started when INR drifted to
subtherapeutic levels.
3. Chronic renal failure: His Cr was 1.4 on admission which
appears to be his baseline at least since [**Month (only) 216**]. Cr on
discharge was 1.0.
4. H/o CHF: Known diastolic failure, MR, with EF 55%. Did not
appear volume overloaded and was continued on home Lasix 20mg PO
bid, Lisinopril 5mg daily.
The patient was admitted to the cardiac surgery service and
brought to the operating room on [**2119-3-28**] where the patient
underwent mitral valve repair and oversewing of the left atrial
appendage. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Vancomycin was
used for surgical antibiotic prophylaxis, given his inpatient
stay of longer than 24 hours. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. The
patient was confused in the immediate post-op period. Narcotics
were eliminated and he cleared mentally. He was A&Ox3 by the
time of discharge.
The patient's AICD was interrogated and pacing wires were
discontinued on POD 1. Coumadin was resumed for atrial
fibrillation. Chest tubes were discontinued without
complication. 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. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. He did develop a hoarse
voice. Cool nebs were administered and voice was improving by
the time of discharge. By the time of discharge on POD 6 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to rehab in good condition with appropriate follow up
instructions.
Medications on Admission:
ALPRAZOLAM - (Prescribed by Other Provider) - 1 mg Tablet -
1/2-1 Tablet(s) by mouth three times a day as needed
AMIODARONE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 200 mg Tablet - 1 Tablet(s) by mouth once a day
DILTIAZEM HCL [CARDIZEM CD] - (Prescribed by Other Provider) -
240 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once
a day
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth twice a day
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth daily
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 0.5 (One half) Tablet(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet -
one Tablet(s) by mouth daily
TEMAZEPAM - (Prescribed by Other Provider) - 15 mg Capsule - 1
Capsule(s) by mouth as needed for for sleep
VENLAFAXINE - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth twice a day
WARFARIN - (Prescribed by Other Provider) - 3 mg Tablet - 1
Tablet(s) by mouth once a day until INR >2
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Venlafaxine 50 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Temazepam 15 mg Capsule Sig: [**1-28**] Capsules PO HS (at bedtime)
as needed for insomnia.
7. Magnesium Oxide 400 mg Tablet Sig: 0.5 Tablet PO twice a day.
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for sleep .
16. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for anxiety .
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose
to change daily for goal INR [**3-1**] for atrial fibrillation.
19. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab
Discharge Diagnosis:
Mitral regurgitation
PMH:
Cardiac arrest [**1-3**]
Hypertrophic cardiomyopathy
acute on chronic diastolic heart failure
Hyperlipidemia
dyslipidemia
h/o atrial fibrillation
Renal failure [**9-4**]
Embolic stroke [**2103**] with no residual
Fractured rib left side [**9-4**]
Gout
Depression
Tonsillectomy
Appendectomy
Obstructive sleep apnea ??????cannot tolerate CPAP
Anxiety
Pneumonia [**2118-12-27**] and in [**2117**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Sternal pain managed with ultram prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] [**2119-5-4**] 1pm [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 82865**] in [**1-28**] weeks
Cardiologist Dr. [**Last Name (STitle) 82912**],[**First Name3 (LF) **] L [**Telephone/Fax (1) 82865**] in [**1-28**] weeks
Dr. [**Last Name (STitle) 82864**] to resume management of coumadin dosing on discharge
from rehab (confirmed with [**Doctor First Name 233**])
Completed by:[**2119-4-3**]
|
[
"272.4",
"327.23",
"428.32",
"428.0",
"424.0",
"311",
"416.8",
"V12.54",
"V45.02",
"274.9",
"425.1",
"397.0",
"427.31",
"427.1",
"427.32",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.36",
"35.33",
"39.61",
"88.52",
"88.72",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
14822, 14874
|
8662, 11956
|
350, 464
|
15339, 15436
|
3346, 5037
|
15976, 16514
|
2452, 2560
|
13081, 14799
|
14895, 15318
|
11982, 13058
|
5054, 8639
|
15460, 15953
|
2575, 3327
|
246, 312
|
492, 1687
|
1709, 2127
|
2143, 2436
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,321
| 110,189
|
10431
|
Discharge summary
|
report
|
Admission Date: [**2158-11-13**] Discharge Date: [**2158-11-18**]
Date of Birth: [**2121-7-21**] Sex: F
Service: PSURG
Allergies:
Cephalexin Hcl
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
Breast CA
Major Surgical or Invasive Procedure:
bilateral mastectomy with bilateral [**Last Name (un) 5884**] flap reconstruction
History of Present Illness:
37 year old female with hx of L breast CA by core biopsy [**9-23**],
s/p XRT in 97 for previous CA now presents for mastectomy with
[**Last Name (un) 5884**] reconstruction with prophylactic right mastectomy with [**Last Name (un) 5884**]
reconstruction.
Past Medical History:
Hx of L breast CA [**2151**] s/p XRT
Social History:
No tobacco, EtOH, Rx
Family History:
Father d. 52 lung ca
Maternal Aunt breast CA at 35
Physical Exam:
NAD
perrl, eomi
CTA b/l
1.3 cm mass lower inner quad, L breast
RRR
Soft, NT, ND
No c/c/e
Brief Hospital Course:
Pt admitted on [**11-13**] when she underwent a bilateral mastectomy
with bilateral [**Last Name (un) 5884**] reconstruction. Pt the pt tolerated the
procedure well, was transferred to the SICU and extubated the
same day. Pt remained in SICU until [**11-5**] due to tachycardia to
the 140s. Pt Hct was stable, she was ruled out for PE, and was
not hypoxic. It was noted that the pt has a baseline resting
heart rate of 100-110, and she was transferred to the floor in
good condition on [**11-16**]. Pt has continued to improve since that
time and is currently ambulating and tolerating POs. She was
discharged on [**11-18**] in good condition to follow up with Drs.
[**Last Name (STitle) 11635**] and [**Location (un) **]
Medications on Admission:
None
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-25**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO four
times a day for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
status post bilateral mastectomy with bilateral [**Last Name (un) 5884**] flap
reconstruction
Discharge Condition:
Good.
Discharge Instructions:
Please take all medications as directed. You may shower with
your drains in place if you cover the drain sites with adhesive
plastic dressings to seal them off.
Followup Instructions:
Please arrange followup with both Dr. [**Last Name (STitle) 11635**] from breast
surgery ([**Telephone/Fax (1) 17487**] and Dr. [**First Name (STitle) **] from plastic surgery within
one week ([**Telephone/Fax (1) 34503**].
|
[
"V10.3",
"530.81",
"427.89",
"V16.3",
"174.3",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.7",
"99.00",
"85.48"
] |
icd9pcs
|
[
[
[]
]
] |
2201, 2207
|
946, 1675
|
284, 368
|
2345, 2352
|
2562, 2789
|
766, 818
|
1730, 2178
|
2228, 2324
|
1701, 1707
|
2376, 2539
|
833, 923
|
235, 246
|
396, 652
|
674, 712
|
728, 750
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,799
| 107,417
|
52808
|
Discharge summary
|
report
|
Admission Date: [**2184-7-12**] Discharge Date: [**2184-7-15**]
Date of Birth: [**2113-4-2**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Lisinopril / Morphine
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p fall with right ankle injury
Major Surgical or Invasive Procedure:
[**2184-7-12**]: I+D right ankle fracture
[**2184-7-12**]: ORIF right ankle fracture
History of Present Illness:
72 year old female, s/p fall with twisting injury to right ankle
Past Medical History:
CAD s/p MI x 3
CABG in 96
Cardiac Arrest During cath in [**8-20**]
AAA repair
Hypertension
Hypertension
Hyperlipidemia
Ruptured Appendix s/p partial colectomy
GI Bleed (large Vol on anticoagulation) colonoscopy found to
have Diverticulosis and Melanosis of entire colon
Social History:
Lives w Daughter
no tobacco
no etoh
Family History:
MI/death father at 61
Physical Exam:
Upon discharge:
AVSS
NAD
A+O
CTA b/l
RRR
S/NT/ND/+BS
RLE: bivalve in place c/d/i
incision c/d/i
wiggles toes
SILT
brisk cap refill
Pertinent Results:
[**2184-7-12**] 07:09PM GLUCOSE-128* UREA N-13 CREAT-0.7 SODIUM-141
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15
[**2184-7-12**] 07:09PM CK(CPK)-131
[**2184-7-12**] 07:09PM CK-MB-5 cTropnT-<0.01
[**2184-7-12**] 07:09PM WBC-11.4* RBC-3.98* HGB-11.8* HCT-34.9*
MCV-88 MCH-29.7 MCHC-34.0 RDW-15.8*
[**2184-7-12**] 07:09PM PLT COUNT-243
[**2184-7-12**] 05:57PM TYPE-ART PO2-160* PCO2-38 PH-7.37 TOTAL
CO2-23 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED
[**2184-7-12**] 05:57PM GLUCOSE-136* LACTATE-1.6 NA+-139 K+-4.1
CL--107
[**2184-7-12**] 05:57PM HGB-11.7* calcHCT-35
[**2184-7-12**] 05:57PM freeCa-1.16
[**2184-7-12**] 02:00PM GLUCOSE-156* UREA N-16 CREAT-0.8 SODIUM-141
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-20* ANION GAP-17
[**2184-7-12**] 02:00PM WBC-11.2*# RBC-4.16* HGB-12.3 HCT-36.2 MCV-87
MCH-29.6 MCHC-33.9 RDW-15.8*
[**2184-7-12**] 02:00PM NEUTS-87.6* LYMPHS-9.0* MONOS-3.0 EOS-0.2
BASOS-0.2
[**2184-7-12**] 02:00PM PLT COUNT-280
ANKLE (AP, MORTISE & LAT) RIGHT [**2184-7-12**] 1:23 PM
ANKLE (AP, MORTISE & LAT) RIGH
Reason: eval fx, disloctn
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with R tib fib fx
REASON FOR THIS EXAMINATION:
eval fx, disloctn
HISTORY: Right tibiofibular fracture.
RIGHT ANKLE, FOUR VIEWS: There is a fracture/dislocation of the
tibiotalar joint, including that of the medial and lateral
malleolus. The posterior malleolus appears to be intact as does
the talus. There is gas within the medial soft tissues. There is
lateral soft tissue irregularity, which appears to be open
communication to the skin surface. There are multiple fracture
fragments seen within the distal fibula.
Brief Hospital Course:
The patient was brought to the operating room on [**2184-7-12**] for I+D
and ORIF of her right ankle. See operative note for details.
She tolerated the procedure well. She was extubated and brought
to the recovery room in stable condition. Once stbale in the
PACU she was transferred to the floor. On the floor she did
well. She was evaluated by physical therapy and progressed
well. She was placed in a bivalve cast on POD#2. Her labs and
vitals remained stable. Her pain was well-controlled. Her
hospital course was otherwise without incident. She is being
discharged today in stable condition.
Medications on Admission:
Fosamax
Lasix
Aricep
Protonix
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 weeks.
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-19**]
Drops Ophthalmic PRN (as needed).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q6H
(every 6 hours) as needed.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
16. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Right open ankle fracture
Discharge Condition:
Stable
Stable
Discharge Instructions:
Please do not bear weight on your right foot. Use
crutches/walker for ambulation.
Please keep incision clean and dry. Dry sterile dressing daily
as needed under bivalve cast. If you notice any increased
redness, swelling, drainage, temperature >101.4, or shortness of
Take all medications as prescribed. You may continue any normal
home medications.
Please follow up as below. Call with any questions.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Non weight bearing
Treatments Frequency:
Keep wound clean and dry. Apply a dry sterile dressing as
needed. Bicalve cast at all times.
Call your doctor if you have any increased swelling, pain,
redness or temp >101.4.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the BIMCD orthopedic
clinic in 2 weeks. Call [**Telephone/Fax (1) **] to make an appointment.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] OB/GYN Date/Time:[**2184-8-5**] 2:00
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2184-8-27**] 11:20
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2184-8-27**] 11:40
Completed by:[**2184-7-15**]
|
[
"E888.9",
"824.5",
"V45.81",
"414.00",
"401.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"79.66"
] |
icd9pcs
|
[
[
[]
]
] |
4934, 5004
|
2763, 3371
|
318, 405
|
5074, 5091
|
1072, 2165
|
5841, 6425
|
863, 886
|
3451, 4911
|
2202, 2238
|
5025, 5053
|
3397, 3428
|
5115, 5524
|
901, 901
|
5542, 5619
|
5641, 5818
|
246, 280
|
2267, 2740
|
917, 1053
|
433, 499
|
521, 793
|
809, 847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,431
| 199,159
|
51317
|
Discharge summary
|
report
|
Admission Date: [**2140-2-23**] Discharge Date: [**2140-2-29**]
Date of Birth: [**2083-6-22**] Sex: M
Service: [**Hospital1 **] A
CHIEF COMPLAINT: Multiple falls and chest pain.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old male with
multiple medical problems including diabetes mellitus, end
stage renal disease, who was recently discharged from
rehabilitation with an episode of hypoglycemia. Since
discharge, he has had multiple falls, which he describes as
being unstable. He bumps into something, he becomes shaky
and falls. He does not describe any postural association
with his falls nor does he become dizzy. He says it is
partly due to his external fixation on lower right extremity
for tibiofibular fracture with nonunion. Since Saturday, he
has noticed that he has not felt well and describes the
feeling as similar to episodes of hypoglycemia, no dizziness,
nausea or vomiting, however, when his blood sugar is
measured, it has been greater than 300s, only once in the
90s. He admits to using a sliding scale and his nightly dose
has been normal for him at around 10-15 units.
Reportedly, he went to rehabilitation again yesterday and
came back okay. But once again, fell in the kitchen, sat
down, sat up, and fell back again. Rehabilitation nurse
called to check up on him and recommended going into the
hospital. Patient called for transport. He admits to having
intermittent chest pain, not associated with falls. Chest
pain is nonexertional and does not produce shortness of
breath, but feels like pressure which begins in the center of
his chest and moves to the left scapula region. No radiation
to the jaw. Patient reports that he can reproduce his pain
with arm movement, however, nurse at outside hospital
suggested trying a nitroglycerin tablet which patient did,
only with help after two hours.
In the Emergency Room, patient's course was remarkable for
receiving Kayexalate for hyperkalemia. Potassium was reduced
from 7.4 to 6.4. Also insulin D50, calcium gluconate were
added.
PAST MEDICAL HISTORY:
1. Past medical history:
2. Diabetes mellitus.
3. End stage renal disease with status post failed
transplant on hemodialysis.
4. Right tibiofibular nonunion with external fixation
complicated with osteomyelitis and multiple infections.
5. Hypertension.
6. Diabetic ketoacidosis.
7. Peripheral vascular disease.
8. Neuropathy.
9. Deep vein thrombosis.
10. Pulmonary embolism.
11. Gastroesophageal reflux disease.
12. Pancreatic insufficiency anemia.
13. Left foot amputation at the toes.
14. Asthma.
MEDICATIONS:
1. Celexa 40 q.d.
2. Aspirin 81 mg po q.d.
3. Lipitor 10 mg po q.d.
4. Lopressor 50 mg po q.d.
5. Norvasc 10 mg po q.d.
6. Protonix 40 mg po q.d.
7. Nephrocaps.
8. Calcium acetate.
9. Phos-Lo.
10. Pancrease.
11. Neurontin 100 mg po q.i.d.
12. Trazodone 25 mg po q.h.s.
13. OxyContin 20/10 mg.
14. Wellbutrin 100 mg po t.i.d.
15. Tylenol.
16. Insulin subcutaneously q.d.
17. Regular insulin sliding scale.
ALLERGIES: Codeine, Prograf, Phenergan and Haldol.
SOCIAL HISTORY: He lives with his wife at home.
PHYSICAL EXAMINATION: Vital signs: Afebrile. Blood
pressure 180/.100. Heart rate 61. Respiratory rate 16.
Oxygen saturation 99% on room air. General exam: In no
acute distress, appears comfortable. Cardiovascular exam:
Regular rate and rhythm, 1/6 systolic murmur at the right
upper sternal border, no rubs or gallops. Pulmonary exam:
CTA bilaterally. No wheezes, crackles or ralese.
Gastrointestinal exam: Good bowel sounds, nontender,
nondistended, no hepatosplenomegaly. Extremities: Bilateral
venous stasis changes, left toe amputation, right lower
extremity external fixation, 1+ pitting edema bilaterally and
dorsalis pedis not appreciated bilaterally. Neurological
exam: Cranial nerves II through XII are intact. No
asterixes.
LABORATORIES: White blood cell count 9.2 with a normal
differential. Hematocrit of 38, platelet count 288,000.
Sodium 139, potassium initially 7.3, decreased to 6.4 in the
Emergency Room. Chloride of 103, bicarbonate 26, BUN 37,
creatinine of 8.3 and a glucose of 69. His coagulation
studies showed a PT of 13, PTT 29.3, INR 1.1. CKs were
initially measured at 46 with an MB fraction of 3 and
troponin of 0.02. A incidental right lower lobe pneumonia
was found on CT with small effusion and electrocardiogram
showed sinus rhythm at 64 with biphasic T waves in V2 through
V5 with deeper inversions on V4 and V5.
ANALYSIS OF PLAN AND SUMMARY: This is a 56-year-old male
with multiple medical problems including diabetes mellitus,
end stage renal disease with multiple falls and chest pain.
Chest pain was evaluated by serial enzymes. Initial set was
negative, as well as subsequent two sets. Currently on
aspirin, Lopressor and Lipitor. He states his last stress
was in [**2138-2-21**]. We performed another stress test in
light of this on presentation and given risk factors involved
in his history.
Hyperkalemia and end stage renal disease: Currently on
Dialysis on Tuesday, Thursday, Saturday's. We checked
potassium after hemodialysis which had stabilized. We
discontinued Kayexalate and continued on telemetry to monitor
for signs of any electrocardiogram changes. He was being
treated with levofloxacin. Will treat up to seven days.
Currently he is on the seventh day.
Diabetes mellitus: Given his tenuous blood sugars, we
continued him initially on his home dose, which he continued
to be hyperglycemia with an put him on diabetic diet, as well
as continued him on his insulin sliding scale.
Hypertension: Hypertension was treated with his normal
regimen.
HOSPITAL COURSE: [**Hospital **] hospital course was unremarkable.
He initially ruled out by enzymes times three. Given the
patient's history of diabetes and questionable history, T
MIBI was performed which resulted in his baseline
electrocardiogram changes with no signs of myocardial
ischemia. He continued to receive hemodialysis throughout
the hospital stay. On Friday, patient was increasingly
confused and agitated and after rounds became more
dysarthric. A CT was performed to evaluate for signs of CVA
during which the patient became unresponsive. We immediately
wheeled him back to nursing. Blood sugar fingerstick was
performed which was 29. The patient received multiple amps
of D50 which only temporarily corrected his sugars. He was
sent to the Intensive Care Unit for closer monitoring.
During his Intensive Care Unit stay, his blood sugars
continued to dip into the 40s and 50s and any exogenous
insulin that was administered many resulted in hypoglycemic
episodes. After a while, patient stabilized and was able to
maintain blood sugars in the normal range.
In regards to the patient's multiple falls, he has mechanical
reasons for falling including his external fixation,
diabetes, peripheral neuropathy, as well as his left toe
amputation. Patient should be evaluated at rehabilitation
until he is more stable on his feet.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
1. Rule out myocardial infarction.
2. Hypoglycemia.
DISCHARGE MEDICATIONS: Same as above with the exception of
insulin, which is now 2 units of glargine q.h.s., as well as
a regular insulin sliding scale.
[**Doctor Last Name **],[**Last Name (un) 106448**] E. M.D. [**MD Number(1) 4518**]
Dictated By:[**First Name3 (LF) 106449**]
MEDQUIST36
D: [**2140-2-29**] 02:28
T: [**2140-2-29**] 14:15
JOB#: [**Job Number 106450**]
|
[
"250.80",
"781.2",
"250.60",
"786.59",
"403.91",
"486",
"E878.0",
"276.7",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.27",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7022, 7070
|
7091, 7146
|
7170, 7555
|
5664, 7000
|
3134, 5646
|
169, 201
|
230, 2049
|
2097, 3061
|
3078, 3111
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,320
| 188,164
|
53913
|
Discharge summary
|
report
|
Admission Date: [**2130-7-3**] Discharge Date: [**2130-7-10**]
Date of Birth: [**2092-12-15**] Sex: F
Service: MEDICINE
Allergies:
Robitussin A-C / Ceclor / Erythromycin Base / cefuroxime /
Sudafed
Attending:[**First Name3 (LF) 38616**]
Chief Complaint:
Neutropenic fever to 106.3 with hypotension to the 70s.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname 110592**] [**Known lastname 77713**] is a 37F with Ph+ ALL admitted on D11 of
Hyper-CVAD part B. She developed some minor back pain last
night and husband felt her to be febrile today, so she came to
the [**Hospital 3242**] clinic today where she had Tmax 106.3 and HR to 140's.
She received cefepime and vancomycin in clinic, plus tylenol and
demerol, and transferred to the ED. She was neutropenic.
In the ED she received flagyl, plus a total of 6L NS and 1U
pRBC. She was started on levophed after hypotension to the 70s.
VS in ED:
T 105.6 HR 146 BP 109/51 RR 24 SaO2 97%, on 0.21 of levo.
She states that she feels well except for feeling hot. She has
a cough that is at her baseline, no sputum, no chest pain, no
n/v/d or abd pain. Received intrathecal injection on [**6-27**] and
has some pain at site, also radiating down her L leg. She has no
other neurlogic complaints. Labs were remarkable for ALT 161,
ALT 44, Alk Phos 132, LDH 204, TBili 5.7, DBili 1.5. Notably,
she started mepron last Thursday.
VS in MICU:
T 99.7 HR 117 BP 107/59 RR 23 SaO2 99% on RA
Past Medical History:
1. [**Location (un) 5622**] chromosome positive, pre-B cell ALL
Dianosed in [**2130-3-19**] treated with hyperCVAD and
dasatibine(cycle 1- [**2130-4-19**], cycle 2 - [**2130-5-12**], cycle 3 D1 on
[**2130-6-2**]). She received IT cytarabine on [**6-9**] in IR.
2. History of nephrolithiasis
3. s/p cholecystectomy
4. s/p Cesarean section
Social History:
She lives with her husband and 3 children (ages 17, 14, 11). She
does not work outside the home but used to babysit children.
Drinks 1 glass of wine daily. no illicit drugs. no tobacco.
Family History:
paternal GM- lung CA
Paternal Aunt- uterine CA
Paternal aunt- breast CA
No FH of hematalogic malignancy
5 siblings, all healthy
Physical Exam:
On Admission to MICU:
General: AOx3, NAD.
HEENT: Sclera icteric. MMM, EOMI, PERRL.
Neck: JVP 9cm, no LAD
CV: RRR, faint S1 + S2, I/VI systolic murmur loudest at base.
No rubs/gallops
Lungs: CTAB
Abdomen: Soft, mildly distended, +BS, no tenderness to
palpation, no rebound or guarding.
Back: Two faint 1-cm ecchymoses: one over L-spine (LP site)
non-tender; one over iliac crest (BM biopsy site) minimally
tender to deep palpation
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. PICC in RUE with mild erythema but without fluctuance or
tenderness.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, 1+
reflexes bilaterally, gait deferred.
.
On admission to BMT:
T 98.8 BP 112/80 P 90 RR 18 98% on RA
GEN: AAOx3, NAD
HEENT: PERRLA, + scleral icterus, EOMI, MMM, + oral thrush
NECK: supple, no LAD, no JVD
CV: RRR. NS1&S2. 2/6 SEM heard best at LUSB
LUNGS: reg resp rate, breathing unlabored, no accessory muscle
use, lungs clear to auscultation bilaterally
ABD: soft, obese, NT/ND, +BS
ext: 2+ pulses, non-pitting edema in legs, arms/hands
bilaterally, RUE PICC without erythema/tenderness
Skin: no rashes
neuro: CN 2-12 intact, strength 5/5 in UE and LE bilat.
.
Discharge exam:
GEN: AAOx3, NAD
HEENT: PERRLA, scleral icterus resolved, EOMI, MMM, no oral
thrush
NECK: supple, No JVD
CV: RRR. NS1&S2. 2/6 SEM heard best over LUSB
LUNGS: CTAB. Good air flow
ABD: soft, obese, NT/ND, +BS
ext: No c/c/e. RUE PICC free from erythema/induration/tenderness
Skin: no rashes
neuro: CN 2-12 intact, strength 5/5 in UE and LE bilat.
Pertinent Results:
Admission Labs:
[**2130-7-3**] 09:55AM BLOOD WBC-0.1*# RBC-2.44* Hgb-7.5* Hct-20.6*
MCV-84 MCH-30.7 MCHC-36.4* RDW-15.3 Plt Ct-14*#
[**2130-7-3**] 09:55AM BLOOD Neuts-0* Bands-0 Lymphs-90* Monos-0 Eos-0
Baso-0 Atyps-10* Metas-0 Myelos-0
[**2130-7-3**] 09:55AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2130-7-3**] 06:16PM BLOOD PT-13.6* PTT-27.3 INR(PT)-1.3*
[**2130-7-4**] 02:46AM BLOOD Fibrino-440*
[**2130-7-4**] 02:46AM BLOOD FDP-0-10
[**2130-7-4**] 02:46AM BLOOD Gran Ct-0*
[**2130-7-3**] 09:55AM BLOOD Ret Aut-0.3*
[**2130-7-3**] 09:55AM BLOOD UreaN-15 Creat-0.6 Na-134 K-3.7 Cl-100
HCO3-23 AnGap-15
[**2130-7-3**] 09:55AM BLOOD ALT-161* AST-44* LD(LDH)-204 AlkPhos-132*
TotBili-5.7* DirBili-1.5* IndBili-4.2
[**2130-7-3**] 09:55AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.7
[**2130-7-3**] 09:55AM BLOOD Hapto-74
[**2130-7-3**] 12:45PM BLOOD Lactate-3.2*
.
Discharge Labs:
[**2130-7-10**] 12:00AM BLOOD WBC-6.8 RBC-2.71* Hgb-8.3* Hct-22.9*
MCV-85 MCH-30.6 MCHC-36.2* RDW-14.7 Plt Ct-93*
[**2130-7-10**] 12:00AM BLOOD Neuts-73* Bands-6* Lymphs-6* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-3* NRBC-1*
[**2130-7-10**] 12:00AM BLOOD PT-11.6 PTT-28.5 INR(PT)-1.1
[**2130-7-10**] 12:00AM BLOOD Glucose-101* UreaN-6 Creat-0.4 Na-138
K-3.9 Cl-103 HCO3-28 AnGap-11
[**2130-7-10**] 12:00AM BLOOD ALT-51* AST-33 AlkPhos-131* TotBili-0.9
[**2130-7-10**] 12:00AM BLOOD Calcium-9.0 Phos-5.7* Mg-1.9
.
Pertinent Labs:
[**2130-7-4**] 02:46AM BLOOD ALT-122* AST-43* LD(LDH)-200 AlkPhos-103
TotBili-6.5* DirBili-2.4* IndBili-4.1
[**2130-7-5**] 05:00AM BLOOD ALT-85* AST-25 LD(LDH)-208 AlkPhos-100
TotBili-5.5*
[**2130-7-6**] 12:00AM BLOOD ALT-65* AST-19 LD(LDH)-190 AlkPhos-96
TotBili-3.7* DirBili-1.9* IndBili-1.8
[**2130-7-7**] 12:00AM BLOOD ALT-50* AST-17 LD(LDH)-199 AlkPhos-98
TotBili-2.1* DirBili-0.9* IndBili-1.2
[**2130-7-8**] 12:00AM BLOOD ALT-43* AST-19 LD(LDH)-212 AlkPhos-96
TotBili-1.0
[**2130-7-3**] 12:45PM BLOOD Lactate-3.2*
[**2130-7-3**] 06:33PM BLOOD Lactate-1.3
[**2130-7-6**] 12:00AM BLOOD calTIBC-205* Ferritn-2077* TRF-158*
[**2130-7-6**] 10:36AM BLOOD calTIBC-212* Ferritn-2115* TRF-163*
[**2130-7-9**] 12:00AM BLOOD Gran Ct-7075
.
Culture Data:
[**2130-7-3**] Blood culture- Positive for K. Oxytoca and E. Cloacae in
[**3-22**] bottles
[**2130-7-3**] Urine culture-No growth
[**2130-7-4**] Blood culture- No growth in [**3-22**]
[**2130-7-4**] C. diff PCR- Negative
[**2130-7-5**] Blood culture- No growth in [**3-22**]
[**2130-7-6**] Urine culture- No growth
.
Pending Labs:
[**2130-7-6**] Blood culture x2
.
Imaging:
[**2130-7-3**] Liver/Gallbladder U/S-Status post cholecystectomy. No
evidence for intrahepatic biliary ductal dilatation or liver
abscess.
.
[**2130-7-4**]: MRCP-Redemonstration of focal wall thickening and
enhancement of the right anterior intrahepatic biliary duct
suggestive of focal cholangitis. Slight interval decrease in the
amount of peribiliary enhancement. No new regions of abnormal
biliary thickening or enhancement.
No evidence of hepatic or intra-abdominal abscess identified.
.
[**2130-7-5**]: RUE U/S-No right upper extremity deep venous
thrombosis. The study and the report were reviewed by the staff
radiologist.
.
[**2130-7-6**]: TTE-No echocardiographic evidence of endocarditis.
Normal regional and global biventricular systolic function. The
valves are well seen without significant regurgitation making
endocarditis unlikely.
Brief Hospital Course:
37F with ALL admitted with neutropenic fever and found to have
GNR sepsis, initially requiring pressor support and MICU stay.
Patient subsequently improved and was transferred to the floor
where she was ultimately discharged on an extended course of IV
antibiotics for her infection.
.
ACTIVE ISSUES:
#Neutropenic fever: Admitted to ICU from clinic in setting of
fever, hypotension and altered mental status. Temp to 106, SBP
in 70's, and ANC 0. Blood cx x2 drawn and positive for GNR.
Started on empiric vanc and cefepime, resuscitated w/6L NS, 1
unit PRBC, and started on levophed gtt. MRCP performed and
demonstrated no hepatic/biliary source of infection. Weaned off
of pressors in ICU, and transferred to floor. Pt was switched
to meropenem and vanc was discontinued after GNR's speciated to
pan-sensitive K. Oxytoca and E. Cloacae. It was felt that the
source of infection was bacterial translocation from the GI
tract. Afebrile for several days prior to discharge while on IV
meropenem. ANC was >[**2117**] for 3 days prior to discharge.
Infectious disease recommended treatment for at least 10 more
days with IV ertapenem, as the possibility of PICC colonization
had not been completely ruled out. Pt was discharged on this
medication with instructions to stop on [**2130-7-21**].
.
#GNR Sepsis: See above. Came into ICU with temp to 106 and SBP
~70. s/p 6L NS and levophed gtt. [**3-22**] blood cx drawn on admission
(+) for Enterobacter cloacii and Klebsiella oxytoca. Likely
source is transient gut migration, MRCP ruled out hepatic
abscess. Changed cefepime to meropenem as literature indicates
that E. cloacii has tendency to become resistant to cefepime and
better controlled with ESBLactamase. Subsequent cultures all
negative. D/c'ed on IV ertapenem x 10 days.
.
#Elevated LFTs: Thought to be cholangiopathy of sepis, as all
LFT's normalized with improvement in clinical status. Although
MRCP was read as suggestive focal cholangitis, this was not
thought to be cause of abnormality. Patient was evaluated by the
liver consult team. Iron studies significant for ferritin
>[**2117**], but this cannot be evaluated properly in the setting of
chronic blood transfusions.
.
#Thrush: Several plaques of thrush noted on posterior
oropharynx. Inadequately treated with nystatin mouthwash. Given
micafungin x2 days and thrush cleared by time of discharge.
.
#Diarrhea: C. diff negative and resolved after ICU stay. Thought
to be [**1-19**] sepsis and subsequent cytokine release.
.
#Thrombocytopenia/Anemia: Thought to be [**1-19**] underlying AML.
Received 3u plt and 4u blood transfusions.
.
#Acute Leukemia: Continued dastatinib through [**7-8**] as planned.
Continued neupogen, ursodiol, and acyclovir. Scheduled to return
for next round of Hyper-CVAD on [**2130-7-13**]. Plan for eventual MUD
alloSCT.
.
CHRONIC ISSUES:
#Back pain: Exam was unremarkable and pain does not seem to be
out of proportion for recent LP/BM bx. No focal deficts on exam.
Pain resolved on floor
.
#Cough: Previoulsy worked up with CT scan. CXR on admission
unremarkable. Low suspicion for PNA. Resolved at time of
discharge
.
TRANSITIONAL ISSUES:
#Leuprolide: Has fragmented history of leuprolide injections,
and was spotting during admission and at discharge. Will need
additional injections when not on menses.
.
#Blood cultures: Blood cultures drawn on [**2130-7-6**] are pending and
will need to be followed up
Medications on Admission:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID
3. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
4. oxycodone 5 mg Tablet Sig: One Tablet PO Q4H PRN
5. ursodiol 300 mg Capsule Sig: One Capsule PO BID
6. docusate sodium 100 mg Capsule Sig: One Capsule PO BID PRN
7. polyethylene glycol 3350 17 gram Powder in Packet PO QD PRN
8. Claritin 10 mg Tablet Sig: One (1) Tablet PO BID PRN
9. dasatinib 100 mg Tablet Sig: One (1) Tablet PO once a day for
14 days: start date: [**6-24**]; end date [**7-8**].
10. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO Q4H PRN nausea
11. Neupogen 480 mcg/1.6 mL Solution Sig: One (1) injection QD
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Clonazepam 0.5 mg PO Q 8H anxiety
Hold for oversedation or RR<10
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. Ursodiol 300 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
hold for constipation
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Nystatin Oral Suspension 5 mL PO QID thrush
8. Fexofenadine 60 mg PO BID
9. ertapenem *NF* 1 gram Intravenous daily infection Duration:
10 Days Reason for Ordering: Going home. Needs first dose in
hospital
RX *Invanz 1 gram 1 gram intravenous daily Disp #*10 Gram
Refills:*0
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis:
Gram negative rod sepsis
Secondary Diagnosis:
[**Location (un) 5622**] chromosome positive acute lympohoblastic anemia
Neutropenic fever
Elevated liver function tests
Thrush
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted to
the hospital because you had a fever to 106 in the clinic and
your blood pressure was low. You were transferred to the ICU and
given 6 liters of fluid through your veins and one unit of red
cells. You were growing two bacteria in your blood, and needed
antibiotics through your veins. Your liver enzymes were also
elevated and an image of your liver was taken to look for
infection, but none was found.
Once your blood pressure had normalized you were transferred to
the BMT service. We continued you on intravenous antibiotics in
addition to your dasatanib for your AML. Your fever came down
and you were fever free for several days prior to leaving the
hospital. Your liver tests improved and all blood cultures taken
after your initial culture did not grow anything. You were
discharged on a home intravenous medication, and instructed to
take this for 10 days total, and to stop on [**2130-7-20**]. This will
help prevent your infection from reoccuring.
You had a fungal infection on the back of your throat during
your stay. This is adequately treated with oral nystatin, and
will need to be continued at home. Dr. [**Last Name (STitle) **] will instruct you
on how long to use this.
It is very important that you continue your intravenous
antibiotics and follow up with Dr. [**Last Name (STitle) **] after you leave. Your
appointment is scheuled for Thursday, [**7-13**]. He will tell
you how long he wants you to continue your medication. Do not
take neupogen after you leave because your white blood count has
come back up.
Please follow-up with Dr. [**Last Name (STitle) **] to discuss your lupron therapy.
Medications to START:
Ertapenem 1g IV every day x10 days (STOP on [**2130-7-20**])
Medications to CONTINUE:
Acyclovir 400mg every 8 hours
Clonazepam 0.5mg every 8 hours as needed for anxiiety
Colace 100mg twice a day as needed for constipation
Nystatin 5ml 4x a day
Polyethylene Glycol 17g daily as needed for constipation
Ursodiol 300mg 2x day
Fexofenadine 60mg 2x day
Medications to STOP:
Neupogen (until next round of chemotherapy)
Followup Instructions:
Department: HEMATOLOGY/BMT
When: THURSDAY [**2130-7-13**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2130-7-13**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BMT CHAIRS & ROOMS
When: THURSDAY [**2130-7-13**] at 12:30 PM
[**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**]
|
[
"787.91",
"995.91",
"780.61",
"285.3",
"038.49",
"790.4",
"V13.01",
"288.00",
"E933.1",
"112.0",
"794.8",
"V70.7",
"276.8",
"204.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12070, 12122
|
7301, 7587
|
384, 390
|
12360, 12360
|
3834, 3834
|
14670, 15518
|
2097, 2226
|
11463, 12047
|
12143, 12143
|
10736, 11440
|
12511, 14647
|
4767, 5285
|
2241, 3454
|
3470, 3815
|
10441, 10710
|
289, 346
|
7602, 10122
|
418, 1515
|
12209, 12339
|
3850, 4751
|
12162, 12188
|
12375, 12487
|
5301, 7278
|
10138, 10420
|
1537, 1877
|
1893, 2081
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,941
| 139,110
|
31847
|
Discharge summary
|
report
|
Admission Date: [**2131-8-2**] Discharge Date: [**2131-8-21**]
Date of Birth: [**2067-11-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Reason for admission: Seizures
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 916**] is a 63yo male with PMH significant for seizures,
atrial fibrillation, and s/p CABG who is being transferred from
OSH for management of seizures. Per patient's wife, on Tuesday
the patient complained of seeing spots in his eyes. On Wednesday
night/early morning the patient complained of seeing spots
again. At approximately 4am Mr. [**Known lastname 916**] attempted to go the
bathroom but fell on the floor at which time his wife woke up
and found her husband seizing. She called 911 and the patient
was brought to [**Hospital 1562**] Hospital. Initial vitals in ED were T
100.4 BP 182/66 AR 128 RR 14 O2 sat 96% RA. In the ED he had
another generalized tonic clonic seizure. He was given Keppra
via the NGT. He was intubated for airway protection. Per OSH
records, the intubation was difficult and required help of
anesthesiologist. CT scan of head and C spine were unrevealing.
.
He was then transferred to the ICU for closer management. In the
ICU the patient spiked a temperature to 102 and he was given
Rocephin and Clindamycin for suspected aspiration pneumonia. On
[**8-2**] at 3am patient went into 15-30 minutes of status
epilepticus. He was loaded with Dilantin 500mg IV x1. and placed
on benzos. Ventilation settings at this time were: SIMV TV 600
RR 10 FiO2 60% PS 15 PEEP 5. He was then transferred to [**Hospital1 18**]
for further management.
.
Per patient's wife, he was diagnosed with seizures 1 year ago
when he had a seizure at home and presented to [**Hospital1 2025**]. Found to
have CVA which was thought to be cause of seizure. He was
started on Keppra. He has not had a seizure since then but has
complained of seeing spots occasionally. She is followed closely
by her neurologist and saw him 1 month ago.
.
No recent fevers, chills, chest pain, SOB, dizziness, or
dysuria. Per wife, the patient has good and bad days but had
been feeling well prior to this admission.
Past Medical History:
1)CAD s/p CABG 9 years ago
2)Seizure disorder-last seizure 1 year ago
3)Atrial fibrillation on anticoagulation
4)Ulcerative colitis
Social History:
Patient lives with wife in [**Hospital3 **]. Currently retired. No
history of tobacco, alcohol, or IVDA.
Family History:
Nothing relevant, per wife
Physical Exam:
vitals T 102.4 BP 159/114 AR 103 RR 14
vent settings: AC FI02 1.0 TV 600 RR 14 PEEP 5
Gen: Patient sedated, responsive to sternal rub
HEENT: ETT in place
Heart: Irregularly, irregular. +systolic murmur
Lungs: Course breath sounds anteriorly
Abdomen: Obese, soft, NT/ND, decreased BSs
Extremities: No edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
[**2131-8-2**] 05:30PM PT-24.6* PTT-43.6* INR(PT)-2.5*
[**2131-8-2**] 05:30PM PLT COUNT-259
[**2131-8-2**] 05:30PM WBC-5.7 RBC-3.38* HGB-12.9* HCT-37.5*
MCV-111* MCH-38.3* MCHC-34.6 RDW-16.1*
[**2131-8-2**] 05:30PM TSH-0.39
[**2131-8-2**] 05:30PM ALBUMIN-3.1* CALCIUM-8.1* PHOSPHATE-3.1
MAGNESIUM-2.4
[**2131-8-2**] 05:30PM CK-MB-6 cTropnT-0.10*
[**2131-8-2**] 05:30PM LIPASE-12
[**2131-8-2**] 05:30PM ALT(SGPT)-25 AST(SGOT)-27 LD(LDH)-312*
CK(CPK)-187* ALK PHOS-47 AMYLASE-174* TOT BILI-1.5
[**2131-8-2**] 05:30PM GLUCOSE-124* UREA N-14 CREAT-1.2 SODIUM-143
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-21* ANION GAP-15
[**2131-8-2**] 06:11PM URINE URIC ACID-FEW
[**2131-8-2**] 06:11PM URINE RBC-[**5-13**]* WBC-[**2-5**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2131-8-2**] 06:11PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2131-8-2**] 06:11PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2131-8-2**] 09:51PM PHENYTOIN-4.5*
[**2131-8-2**] 09:51PM DIGOXIN-0.9
[**2131-8-2**] 10:51PM TYPE-ART TEMP-38.2 RATES-14/0 TIDAL VOL-600
PEEP-5 O2-60 PO2-133* PCO2-43 PH-7.36 TOTAL CO2-25 BASE XS--1
-ASSIST/CON INTUBATED-INTUBATED
[**2131-8-3**] 03:22AM BLOOD WBC-5.0 RBC-3.24* Hgb-12.3* Hct-34.8*
MCV-107* MCH-38.0* MCHC-35.4* RDW-17.3* Plt Ct-223
[**2131-8-4**] 03:14AM BLOOD WBC-4.5 RBC-2.98* Hgb-11.3* Hct-32.0*
MCV-107* MCH-38.1* MCHC-35.4* RDW-16.8* Plt Ct-209
[**2131-8-3**] 03:22AM BLOOD Glucose-115* UreaN-12 Creat-1.2 Na-143
K-4.0 Cl-113* HCO3-21* AnGap-13
[**2131-8-3**] 03:44PM BLOOD Glucose-119* UreaN-10 Creat-1.0 Na-143
K-3.7 Cl-111* HCO3-21* AnGap-15
[**2131-8-4**] 03:14AM BLOOD Glucose-119* UreaN-8 Creat-0.9 Na-143
K-3.6 Cl-110* HCO3-21* AnGap-16
[**2131-8-5**] 03:01AM BLOOD Glucose-92 UreaN-5* Creat-0.8 Na-146*
K-3.2* Cl-111* HCO3-25 AnGap-13
[**2131-8-5**] 03:01AM BLOOD Lipase-75*
[**2131-8-3**] 03:22AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with SOB, hypoxia
REASON FOR THIS EXAMINATION:
r/o DVT
Shortness of breath and hypoxia. Question DVT.
Grayscale and Doppler son[**Name (NI) 1417**] were performed of the IJ,
subclavian and axillary veins on the left and of the IJ on the
right. There was diminished compressibility in the left cephalic
vein compatible with acute thrombosis. There was normal
compressibility, flow, and augmentation in the other vessels.
IMPRESSION: Superficial venous thrombus noted in the cephalic
vein. No DVT.
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with SOB, hypoxia
REASON FOR THIS EXAMINATION:
r/o DVTs
INDICATION: Rule out DVT.
[**Doctor Last Name **] scale and Doppler son[**Name (NI) 1417**] of bilateral common femoral,
superficial femoral, popliteal, posterior tibial and peroneal
veins was performed. There is normal compressibility, color
flow, and augmentation.
IMPRESSION: No evidence of right or left leg DVT.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2131-8-17**] 8:37 AM
Brief Hospital Course:
HD#1 ([**2131-8-2**]): Patient arrived in the [**Hospital1 18**] MICU-6 the
afternoon of [**2131-8-2**] intubated, sedated and in stable condition
with NGT in place. On arrival active patient medications
included Keppra 1000 mg [**Hospital1 **] and sedation with Fentanyl 50 mcg/hr
and Midazolam 4 mg/hr. All other home medications were intially
held. Given suspicion for meningitis in the setting of seizure
+ fevers patient was given one dose of Ceftriaxone 2 gm IV with
infectious disease consent required for further treatment.
Also, a history suspicious for Patient was sent for urgent MRA
of head & neck and MR of head which showed: 1)No enhancing
lesions. Chronic infarct in left parieto-occipital lesion, and
2)50% narrowing of right proximal ICA. Left ICA origin
atheroma." Patient was initially seen on unit by Neurology who
recommended continuation of Keppra, EEG to evaluate for seizure
activity, ECHO for new murmur + fever, LP when INR < 1.5, and an
increase in versed drip with consideration of dilantin load if
patient seized again. Suctioning from ETT showed brownish-grey
aspirate and UA that day showed no organisms. Patient remained
febrile throughout first day in MICU.
.
HD#2 ([**2131-8-3**]): Patient received Tylenol for fever overnight
and had ECHO and EEG in the morning. ECHO showed no signs of
valvular vegetations and EEG showed no signs of an epileptiform
focus. In the setting of seizure + fevers meningitis remained
at the top of our differential diagnosis and an LP was arranged.
Prior to admission patient had taken coumadin for his atrial
fibrillation and on transfer to MICU initial INR was 2.5,
patient was initially given 3 units of FFP with following
INR=1.7. Transfusion of two more units of FFP resulted in no
change in INR so plan for LP was aborted. During the day
patient became very anxious, became tachycardic to the 140s,
began demonstrating tremor in his lower extremities bilaterally
and started pulling against his restraints. His fentanyl was
incresaed to 75 mg/hr and versed was increased to 5.0 mcg/hr.
He was also bolused with Dilantin 1000 mg IV once since patient
was also displaying tremor in LE bilaterally while sedated.
Patient remained tachycardic to the 120s-130s depsite the
increase in sedation and diltiazem 60 mg PO QID was started with
diltiazem 5 mg IV for immediate control. To empirically cover
aspiration pneumonia Vancomycin & Flagyl were started and ID
approval for Ceftriaxone therapy (to cover pneumococcus) was
obtained. Ampicillin was also started to cover Listeria
monocytogenes and acyclovir was started due to concern for HSV
encephalitis after blood drawn for HSV PCR. Temperature spiked
to 101 at 18:00 with repeat panculture including mini-BAL which
showed 1+ PMNs and oropharyngeal flora. ETT was advanced 1 cm
after CXR showed approx 5 cm above the carina. Patient remained
NPO.
.
HD#3 ([**2131-8-4**]): Patient remained febrile and began having
episodes of loose stools. Patient with long history of
ulcerative colitis, but stool sample sent for C.diff toxin which
was negative. Restarted on 6-mercaptopurine for UC. LP was
re-attempted prior to which patient received an additional 5
units of FFP with following INR=1.3. Following LP tube feedings
were intiated and changed later in the day to include fiber with
a goal of 90 cc/hr. Urine output was noted to be poor, patient
putting out approximately 15 cc/hr. Two fluid boluses of 500 cc
were given with no effect.
.
HD#4 ([**2131-8-5**]): Patient remained febrile, with attempts to wean
sedation aborted due to increased patient anxiety/agitation. In
light of negative blood/CSF/urine cultures acyclovir, ampicillin
and ceftriaxone were discontinued. Mr. [**Known lastname 916**] continued to take
Vancomycin for [**8-4**] sputum culture that grew 2+ G(+) cocci in
pairs and clusters and Flagyl for empiric tx of C.diff diarrhea
despite negative stool toxin screens. CT of chest with contrast
showed: 1)bilateral pleural effusions with associated
atelectasis & consolidation, left>right, 2)2 small pulmonary
nodules in RUL ~4 cm in diameter, 3)airspace disease in the LUL,
and 4)coronary artery and mitral annulus calcifications.
.
HD#5 ([**2131-8-6**]): Patient continued to be febrile, reaching
temperature of 102 degrees overnight. Also continued to have
loose stools with output of 2L, flagyl discontinued due to
multiple negative C.diff toxin screens. However, stool was
re-sent for C.diff A&B toxins and banana flakes were added to
tube feeds to bulk-up stools. Plan for GI consult the following
day. Urine output continued to be poor, patient was given
one-time dose of lasix IV 40 mg with transient increase in UOP.
Patient was placed on trial of pressure support starting @ 13:00
and continuing on throughout the night without adverse events.
Sedation was gradually weaned with fentanyl decreased from 75
mcg/hr to 60 mcg/hr and versed at 4.0 mg/hr. Patient continued
to have episodes of anxiety throughout the day for which he was
given Lorazepam 1 mg IV for breakthrough relief. PICC line was
place in right arm in the a.m. Zosyn 4.5 mg IV Q8H was started
to empirically cover G(-) organisms causing pneumonia
.
HD#6 ([**2131-8-7**]): No high fever spikes, but patient ran low-grade
fever of 100.5. Per CXR, PNA not progressing/worsening.
Azithromycin 500 mg PO BID added to cover atypical causes of PNA
(mycoplasma/chlamydia/etc). GI consulted for increased, watery
stool output (patient has h/o UC treated with 6-MP, requested
consult to determine any additional management
options/symptomatic relief). No recommendations per GI, cannot
determine at this time if current stooling is any change from
baseline. Per neurology, Keppra dose was increased to 1250 mg
PO BID (from 1000 mg). Patient on coumadin as outpatient for
A.fib, held on admission to perform LP. Heparin ggt restarted
for DVT prophylaxis. Given another single dose of lasix 40 mg
IV to removed third-spaced fluid, net -850 cc at end of day with
LOS fluid net +8.6L. Diltiazem ggt titrated up to 10 U/hr to
maintain HR<100 bpm. Overnight, patient became agitated on
CPAP+PS, AC restarted briefly for a few hours and placed back on
pressure support.
.
HD#7 ([**2131-8-8**]): Patient placed back on Pressure Support with PS
15/PEEP 8 (increased from [**11-7**]). Arterial line placed in right
arm without complications. ABG showed 7.44/33/102/23. Dosed
again with Lasix 40 mg IV to removed fluid that had third spaced
into tissues/pleural space. Continued Vanc/Zosyn/Azithro.
Again spiked temperature to 101.5 degrees at mid-day and was
pancultured. Patient also became tachycardic with HR increase
to 130s-140s, diltiazem drip increased to 10 mg/hr. Began
having apneic episodes on pressure support and was placed back
on AC at 20:00. Sedation weaned to Versed 3.0 mg/hr and
fentanyl 25 mcg/hr. Lost last PIV access, patient only with
arterial line and right PICC line. K 3.2, corrected. Tube
feeds held due to continued high gastric residuals. During late
afternoon/evening patient was dosed once again with lasix 20 mg
IV with repeat Cr 1.8.
.
HD#8 ([**2131-8-9**]): Cr this a.m. 2.0. Urine sent for urine lytes
(Na, BUN, creatinine), urine eosinophils, microscopic analysis.
Likely due to hypovolemia secondary to diuresis. Lasix held
today, monitoring Cr for improvement of [**Last Name (un) **]. Throacic
ultrasound performed to look for possible empyema/loculated
plueral effusions and did not reveal any significant fluid
collection that would benefit from throacentesis. Patient
remained on AC vent overnight, RISBI in the a.m. 103, mid-day
ABG on AC 7/46/36/106. Decided to give patient spontaneous
breathing trial. Patient maintained own ventilation for 30 min
at which time respirations were ~40/min, SaO2 92% and patient
having difficulty breathing. Trial was stopped and patient put
back on pressure support with PS 5/PEEP 0. ID consulted for
further work-up of FUO. Recommended checking Borellia and
Ehrlichia serologies and inspecting peripheral smear of blood
for parasites (babesiosis) if spiked temp again. Also
recommended changing azithromycin to doxycycline if spiked temp
again. Later in evening patient spiked temp to 102.5 and ID
recs were instituted.
.
HD#9 ([**2131-8-10**]): Renal consulted for decline in renal fxn and
proposed ATN vs. prerenal azotemia vs. AIN, though most likely
non-oliguric ATN. Recommended increase in free water intake as
patient was also hypernatremic and renally dosing medications.
Renal US showed no evidency of hydronephrosis. Had CT of
head/sinuses which showed no acute sinusitis with mild mucosal
thickening and non-contrast CT of chest & abdomen which showed:
1. Bilateral pleural effusions with associated atelectasis and
consolidation, greater on the left than the right. This is
stable from prior exam. 2. Stable pulmonary nodules in the
upper lobe. 3. Stable extensive coronary artery and aortic
calcifications. 4. No discrete focus of infection is identified
although this study is limited by lack of contrast. 5. Anasarca
of the body wall in abdomen and pelvis.
.
HD#10 ([**2131-8-11**]): Stopped diltiazem gtt & started esmolol gtt to
control HR & BP. Sedation weaned and discontinued and patient
extubated, after which patient was tachypneic but ABGs looked
good. ID recommended further checking CMV serologies, patient
spiked temp to 101 and blood was cultured again for anaerobic
bacteria and fungus.
.
HD#11 ([**2131-8-12**]): Patient continued tx with IV vancomycin (dosed
by levels) and renally-dosed zosyn. Received 1 gm vanc when
afternoon levels 13.5. Attempted to wean esmolol gtt, could not
maintain adequate control of HR & BP. Stopped drip and gave
metoprolol 25 mg PO TID, soon increased to 75 mg PO TID with
additional dosing of diltiazem 10 mg IV once to control rate.
Patient then started on diltiazem 30 mg PO QID in addition to
metoprolol 75 mg PO TID to control rate, though patient
continued to be tachycardic and HTNive throughout day.
Metroprolol increased to 100 mg PO TID and diltiazem increased
to 60 mg PO QID. Overnight patient remained confused, likely
residual effect of multiple heavy sedatives, and attempted to
climb out of bed and required one-time doses of ativan &
zyprexa. Patient will require one-on-one sitter upon tx to
floor. Patient had TEE which showed no vegetations and severely
deformed aortic valve. D/C'd doxycycline per ID recs and had
repeat CXR due to increased airway secretions and concern over
?aspiration while taking a.m. medications. Order placed for
speech & swallow eval, post-poned until tomorrow due to patient
having brief episode of tachypnea and sats down to 92% requiring
non-rebreating mask. Per renal, adjusted dose of Keppra
according to GFR, approved by neuro and will be seen by their
service tomorrow. Na noted to be 149 and given 1L D5W over 24
hours.
.
HD#12 ([**2131-8-13**]): Patient not seen by NEURO. Patient continued
to be hypernatremic and was given 1L D5W @ 200 cc/hr and another
at 125 cc/hr. Metoprolol was increased to 100 mg PO TID and
diltiazem was increased to 60 mg PO QID to control heart rate.
Per nursing that morning, patient had questionable episode of
aspiration while taking morning medications. Repeat CXR showed
marginal worsening infiltrates in the RML. Later that night
patient dropped sats to 85% and given CPAP for 30 minutes with
improvement. He had several hours of respiratory stability but
eventually re-developed tachypnea (50) and hypoxemia (7.48/36/61
on NRB) followed by an episode of hypotension and was
re-intubated. The rest of hospital summary will be in
problem-based format:
.
1)Hypoxic Respiratory Failure: patient intubated @ OSH in
setting of status epilepticus in order to protect airway.
Initially struggling against ventilator requiring increases in
sedation, suctioning of ETT showing brownish-[**Doctor Last Name 352**] sputum. Now
weaning sedation with vent on CPAP+PS as patient tolerates,
decreased sputum production. Arterial line placed [**2131-8-8**], d/ced
by pt on [**8-11**]. Pt extubated [**8-11**], required supplemental O2 via NC
and HiFlow NRB over following days & developed tachypnea and
hypoxia early morning of [**8-15**] requiring re-intubation. [**8-15**] LENI
and L UENI show no DVT, CT chest same day showing new bilat LL
consolidation concerning for aspiration, bridging
small-to-moderate pleural effusions and new hydrostatic
pulmonary edema. BNP 30,173 on [**8-15**]. Serial cardiac enzymes r/o
MI.
-rested overnight on PSV, good SBT this a.m. and extubated
without complications. NGT placed prior to extubation for tube
feedings due to recent h/o aspiration.
-continue suppl. 02, wean as tolerated to maintain Sa02 >90%.
Chest PT. Patient OOB with assist to chair.
-thoracic US [**8-16**] showed ~1.6 ml of pleural fluid, IP unable to
tap effusions.
-aspriation PNA most likely culprit, cont IV vanc/zosyn renal
dosing. Concern for developing lung abscess. Currently on day
13/14 of zosyn regimen, will extend until chest can be re-imaged
and abscess confirmed/ruled-out.
-continue lasix gtt with goal of net negative 1L fluid balance
today. If patient auto-diureses may stop gtt and begin scheduled
regimen.
-daily CXR
-PT to evaluate for rehab.
.
2)Fevers: Patient presents with fevers since he was admitted to
OSH. Likely cause of new onset seizures. Possible sources of
infection include LLL infiltrate. No report of productive cough,
dysuria, other symptoms at home. Still unclear source. TEE done,
blood and urine negative to date, cdiff negative, csf negative.
Lack of leukocytosis may be due to UC tx with 6-MP. [**8-4**], [**8-5**],
[**8-6**] C.diff screens negative.
[**8-4**] blood culture showing not growth. [**8-11**] Non-contrast CT of
head/chest/abdomen for eval of possible sinusitis and
surveillance of occult focus of infection =>no infectious
source. Pt continues to spike temps nightly. [**2131-8-13**] TEE shows
not evidence of endocarditis and a severely deformed aortic
valve. -Lyme, -HSV, C.diff toxin B negative. Relatively afebrile
[**8-12**] through [**8-14**] but spiked temp to 102 degrees AM of [**8-15**],
resolved to low-grade temp ~100.5 by [**8-20**]. Negative
Ehrlichia/Coxiella/Legionella BAL culture.
- Tylenol PRN for fever
- Continue broad coverage of PNA. Zosyn renally dosed to 2.25 gm
IV Q6 hours, back on scheduled vanc 750 mg IV daily, follow vanc
levels
- check routine vanc levels.
- f/u [**8-15**] and [**8-17**] blood cultures as well as [**8-11**] fungal/AFB
cultures. C.diff rechecked and negative [**8-17**].
- f/u additional ID recs, appreciate input,
.
3)Acute Kidney Injury: Cr stable now. Likely due to
hypovolemia/prerenal azotemia secondary to lasix diuresis. Urine
lytes show no eosinophiluria, FENa and FEuria indicate intrinsic
renal etiology of [**Last Name (un) **].
- Cr stable, monitor daily
- Renal consult, appreciate recs
- Dose medications for patient's creatinine
- continue lasix gtt, stop if Cr >2.5. [**Month (only) 116**] start schuled IV
lasix this PM.
.
4)Hypernatremia: Increased to 149 [**2131-8-14**] & decreased to 139
with D5W supplementation. Morning of [**8-15**] found to be 155 but
patient sedated after reintubation and difficult to assess for
mental status changes. Patient with good UOP.
-Na now WNL
-NGT placed prior to extubation and tube feedings stopped. [**Month (only) 116**]
gently re-start tube feedings this PM. D/C free water boluses.
-continue Lasix gtt and monitor UOP.
-daily chem7.
.
5)Atrial fibrillation: Patient remains in atrial fibrillation;
confirmed by EKG on admission to OSH and [**Hospital1 18**]. Previously on
coumadin for A.fib.
- on heparin drip at 1400 U/hr. Holding coumadin 5 mg PO daily.
- [**2131-8-9**] shows severe AS with valve diameter of 0.8 cm2. Patient
will need aggressive rate control to decrease stress to heart.
- continue metoprolol 100 mg TID, PO diltiazem increased at 90
mg PO QID.
.
6)Seizure disorder (requiring intubation): Patient was diagnosed
with seizure disorder 1 year ago in setting of CVA. Now presents
with recurrent seizures despite being on Keppra. Differential
for seizures include infection, stroke, metabolic
encephalopathy, drugs, head trauma, tumors, etc. Most likely
infection since patient has been febrile. Concerned about
meningitis as a possible etiology though ruled out by negative
LP. [**2131-8-3**] MRA head/neck and MR of head show no new enhancing
lesions. Same day ECHO for new murmur showed no vegetations and
EEG showed no epileptiform focus.
- Infectious etiology continues to be at top of differential,
but pneumonia only foci identified thus far.
- Keppra renally-dosed to 750 mg PO BID, approved by neuro.
- IV ativan if patient becomes symptomatic for seizures
.
7)Ulcerative colitis: Patient on Mercaptopurine as outpatient.
Per wife, patient has history of cramping and loose stools on a
regular basis.
- continue mercaptopurine 75 mg PO daily. 400 cc stool OP
yesterday.
- Per GI consult, no evidence current stool OP is change from
baseline.
- Banana flakes added to tube feeds if having loose stools.
.
8)CAD s/p CABG: No complaint of recent SOB or chest pain during
this admission.
- Continuing home statin, on oral beta blocker and CCB for rate
& pressure control.
.
9)FEN:
- speech & swallow evaluation shows okay to take pre-thickened
nectar feeds, however will initially feed via NGT s/p
extubation.
- repeat speech & swallow study in the AM
- restart Nutren full-strength tube feedings tonight at 10 cc/hr
with goal of 45 cc/hr, advance as tolerated and checking
residuals Q6 hours
.
10)Access: Right PICC line placed [**2131-8-6**]. Arterial line placed
[**2131-8-15**] in RUE and PIVx1 (20g).
.
11)Prophylaxis: IV heparin, PPI.
.
12)Code: Full (verified with wife
.
13)Dispo: c/o to floor bed.
.
Final instructions to accepting team:
1) Monitor Na
2) Follow mental status for return to baseline. Will likely
need 1:1 sitter due to increased PM agitation, pulling NGT,
well-controlled with IV ativan.
3) Continue IV zosyn (day 14) due to concern for ? lung
abscess. Per ID okay to D/C vanc (18 day course total)
4) Follow-up 9/12 & [**8-17**] blood cultures, [**8-11**] fungal/AFB culture
5) Wean 02, continue chest PT and
6) Speech & swallow to perform video swallow eval once mental
status improves
7) Screen for rehab
8) f/u PT/OT consult on day of transfer, OOB with assistance.
Medications on Admission:
Digoxin
Diltiazem 240mg PO daily
Lasisx 40mg PO daily
Isordil
Coumadin
Omeprazole
Purinethol 75mg PO daily
Keppra 750mg PO daily
Discharge Medications:
Keppra 750 mg PO BID
Diltiazem 90 mg PO QID
Metoprolol 100 mg PO TID
ASA 81 mg PO daily
Lasix 40 mg IV BID
Zosyn 2.25 gm IV Q6 hours (day 14/16)
Protonix 40 mg IV daily
Mercaptopurine 75 mg PO daily
Ativan 1 mg IV PRN agitation
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Recurrent seizures/status epilepticus of unknown etiology
requiring intubation complicated by aspiration pneumonia and
recurrent fevers.
Discharge Condition:
Stable, mental status not returned to baseline.
Discharge Instructions:
Please keep all scheduled medical appointments. Call a
physician or go to the emergency room if experiencing the
following symptoms: chest pain, shortness of breath, change in
mental status/increased confusion, fever greater than 102
degrees, recurrent seizures or loss of consciousness, onset of
weakness or loss of sensation or any other concerning symptoms.
Followup Instructions:
Please call your Neurologist and primary care provider within
two weeks of leaving rehabilitation to set up an appointment.
Please also have your primary care provider refer you to a
cardiologist or see your pre-existing cardiologist to evaluate a
valvular abnormality that was noted during your hospital stay.
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26,579
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21349
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Discharge summary
|
report
|
Admission Date: [**2185-5-19**] Discharge Date: [**2185-6-7**]
Date of Birth: [**2107-5-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Diarrhea, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77F recent admission for peripheral angioplasty and wound
infection, GI bleed on vascular service, here w/
nausea/vomiting/diarrhea, hypotension, colitis. Admitted
[**Date range (1) 56420**] with GI bleed, peripheral arterial disease and
underwent angioplasty to R mid SFA, BK [**Doctor Last Name **] and anterior tibial
artery for unhealing wound.
<BR>
Two days prior to admission, had episode of feeling unwell and
nausea/vomiting. Had been taking toprol XL up until this point,
at which time she stopped taking the PM dose of this medication.
Then one day prior to admission had three large black diarrheal
bowel movements. Was brought to see PCP today for evaluation
where she was found to be hypotensive to 80s, sent to ED for
further evaluation.
Past Medical History:
Gallstone pancreatitis s/p CCY
h/o Acute cholangitis
Rheumatoid arthritis w/ contractures
s/p Appendectomy
s/p c-section
Hypertension
Peripheral vascular disease, w/ unhealing ulcers
- [**4-6**] s/p angioplasty to R SFA, BK [**Doctor Last Name **], [**Doctor First Name **]
Social History:
negative for tobacco and alcohol
attends adult day care program
Family History:
non-contributory
Physical Exam:
VS 95.7 120 94/54 20 97% RA
GENERAL: Cute elderly female, slightly confused, unable to
answer questions appropriately
HEENT: EOMI, anicteric
NECK: JVP flat, slt stiff
CARDIOVASCULAR: S1, S2, tachy
LUNGS: CTAB
ABDOMEN: R side is not tender, but slt firm, L side is soft, non
distended, nontender.
EXTREMITIES: Warm
NEURO: A/O to self and place only.
Pertinent Results:
Admission labs:
[**2185-5-19**] 10:25PM WBC-16.6* RBC-3.17* HGB-7.6* HCT-24.3*
MCV-77* MCH-24.0* MCHC-31.2 RDW-18.0*
[**2185-5-19**] 10:25PM GLUCOSE-73 UREA N-52* CREAT-1.5* SODIUM-142
POTASSIUM-4.0 CHLORIDE-113* TOTAL CO2-17* ANION GAP-16
[**2185-5-19**] 10:25PM CALCIUM-6.2* PHOSPHATE-4.2 MAGNESIUM-2.7*
[**2185-5-19**] 10:36PM LACTATE-1.1
[**2185-5-19**] 10:25PM PT-13.8* PTT-32.8 INR(PT)-1.2*
[**2185-5-19**] 06:54PM LACTATE-0.9
IMAGING:
.
CT ABD/PEL:pancolitis most likely reflecting infectious
etiology; consider C. difficile infection. Inflammatory causes
also possible. Due to its global nature, ischemic colitis is
considered less likely.
.
CXR:No acute cardiopulmonary process identified.
.
[**2185-6-1**] CTA: IMPRESSION:
1. No pulmonary embolism.
2. Large bilateral pleural effusions, left greater than right.
Complete collapse of the left lower lobe. Secretions and mucous
are seen within the bronchus of the left lower lobe.
3. Significant anasarca.
4. Pneumobilia developed since [**2185-5-19**], has been interval
instrumentation?
Brief Hospital Course:
77 yo woman with abd pain and hypotension, initial concern for
ischemic colitis given h/o pvd and CAD.
.
1 C. Diff Colitis: The patient had a CT ABD/Pel in the ER that
showed pan colitis, more consistent with infectious etiology.
She was seen by the surgical team who determined there was no
indication for operative intervention. Meanwhile, the C.
dificile toxin test of her stool returned positive. She was
started on PO flagyl. Blood pressure was low, and she received
fluid and levophed. THe levophed was quickly weaned in the
MICU, and her blood pressure remained stable.
She was started on a regular diet and tolerated it well, without
abdominal pain. SHe continued to put out large amounts of
stool, and received IVF to replete these losses. She was
treated with IV vanco, PO vanco, IV levaquin, IV flagyl
initially in the MICU and this was tapered to just PO vanco/IV
flagyl. She should complete upon discharge a 14d course of
flagyl and a 6 week taper of vanco.
.
2. Tachycardia - She had intermittent runs of supraventricular
tachycardia in the MICU; this was responsive to carotid massage
and IV lopressor. Her metoprolol dose was uptitrated to control
this arrhythmia. She maintained her pressures during periods of
this tachycardia. On the general floor patient had Po metoprolol
uptitrated. She still had occassional episodes of SVT to the
130s, but continued to maintain her pressures and was always
assymptomatic. Patient does not require telemetry. We
recommend vital signs three times a day with prn doses of PO
metoprolol for tachycardia. She runs a fine line in terms of
fluid status and aggressive diuresis should be avoided.
.
3. UOP/Diuresis. She had periods of diminished urine output in
the MICU but her Cr and BUN did not significantly worsen. This
was thought due to fluctuations in her daily PO intake. Her UOP
was improved on the floor and patient had good diuresis with
minimal assistance. She had autodiuresis as her albumin
improved assisted by 20mg doses of lasix for tachycardia.
.
# Tachypnea: Patient had persistent tachypnea, thought to be
multifactorial with pleural effusions and pulmonary edema
(secondary to hypoalbuminemia), some amount of reactive disease.
She had a CTA which did not show pulmonary embolis nor
infection. Her tachypnea is generally not uncomfortable,
responsive to very gentle diuresis and nebs.
.
# Nutrition: Patient had poor nutrition secondary to prolonged
hospital course and GI illness. Patient was seen by nutrition.
Encourage/Assist with PO intake and give supplements at minimum
of 3 times daily.
.
# Hypothyroidism: Patient had TSH of 8 in [**12/2184**] and started on
levothyroixine at that time. During this hospitalization she
did not recieve it, but it was restarted on discharge at time of
medication reconciliation.
.
# Pneumobilia: Assymptomatic. Should be followed up as
outpatient.
.
4. Code - DNR/DNI discussed with patient and patient's daughter.
.
5. Social issues - Pt. at one point expressed concern re: being
left alone at home intermittently. SW aware involved and
investigated. Patient then denied this complaint. SW found
Daughter is very involved. SW strongly suggested that the
patient be provided with more services through [**Location (un) 86**] Senior
Home Care at d/c from rehab.
.
* Comm:
[**Telephone/Fax (1) 56421**] [**First Name4 (NamePattern1) **] [**Known lastname 7474**] (Cell)
[**Telephone/Fax (1) 56422**] (home)
Medications on Admission:
Calcium Vit D
Fosamax
HCTZ 12.5
Levothyroxine 25
Lipitor 20
Toprol 50 [**Hospital1 **] - hasn't been taking PM dose since VNA noticed
that BP was low.
Mobic 15, voltaren
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP < 100, HR < 60.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for for rash.
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 14 days: .
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO see taper
schedule for 6 weeks: Week 1 ?????? 125 mg four times daily
Week 2 ?????? 125 mg twice daily
Week 3 ?????? 125 mg once daily
Week 4 ?????? 125 mg every other day
Weeks 5 and 6 ?????? 125 mg every three days .
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
12. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
C. Diff colitis
pleural effusions
pulmonary edema
anasarca
poor nutritional status
Discharge Condition:
Fair
Discharge Instructions:
You were admitted with c. diff colitis, it has resolved
clinically. You will need to continue with a long taper of
antibiotics.
.
You also have poor nutrition which is causing swelling in your
arms and legs and fluid in your lungs. Continue eating as well
as you can.
.
You were changed from your toprolol XL to metoprolol. We have
stopped your HCTZ while you were here; it may be restarted by
your PCP.
.
Please go to your follow up apointments.
Followup Instructions:
Please follow up with your PCP:
[**Name Initial (NameIs) 2169**]: [**First Name4 (NamePattern1) 674**] [**Last Name (NamePattern1) 56423**] ([**Doctor Last Name 815**]), MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2185-6-14**] 3:00
.
Please have TSH rechecked at that time.
|
[
"440.23",
"578.1",
"514",
"511.8",
"458.9",
"782.3",
"008.45",
"427.0",
"707.19",
"244.9",
"714.0",
"733.00",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8020, 8099
|
3012, 6459
|
336, 342
|
8226, 8233
|
1927, 1927
|
8730, 9013
|
1524, 1542
|
6680, 7997
|
8120, 8205
|
6485, 6657
|
8257, 8707
|
1557, 1908
|
275, 298
|
370, 1128
|
1944, 2989
|
1150, 1426
|
1442, 1508
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,766
| 156,947
|
4098
|
Discharge summary
|
report
|
Admission Date: [**2179-11-20**] Discharge Date: [**2179-12-2**]
Date of Birth: [**2098-1-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Right foot pain
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
81 year old woman recently hospitalized for tri-malleolar rt
ankle fracture s/p closed reduction presents to the ED after
becoming agitated and removing her soft cast at her
rehabilitation hospital. She sustained her fracture after
falling on [**10-26**]. She underwent closed reduction and was
discharged from [**Hospital1 18**] on [**11-4**] to extended care facility. Shortly
after discharged, she was admitted to [**Hospital1 2025**] for AMS and thought to
have PNA. There, she was noted to have abnormal LFT's and
possible Afib per telephone note in OMR. She recently finished a
course of IV abx prescribed at [**Hospital1 2025**]. Back at her ECF, she started
having increasing pain of the right foot over the last several
days. Today the pain became 'excruciating' and patient became
agitated before taking off her cast. She was taken to the [**Hospital1 18**]
ED for further evaluation.
.
In the ED inital vitals were, T:97 P:76 BP:89/46 RR:18 O2:97%
RA. While getting plain films, she triggered for SBP of 70's
after feeling 'poorly'. UA was grossly purulent and CXR
suspicious for PNA. Patient received 1 dose of vancomycin,
cefepime, and levofloxacin. Foley catheter was exchanged, and
noted to have visible pus. BP was not responsive to 3.5 L IVF's
and patient was started on levophed prior to transfer to [**Hospital Unit Name 153**].
On arrival to [**Hospital Unit Name 153**], BP was 134/60 and patient was weaned off
levophed. She denies recent fevers or chills. She has had a
chronic foley for several weeks, but denies discomfort. She
denies cough, but her sister notes that she has had one for
several weeks. She denies current pain in foot. No shortness of
breath, chest pain or dizziness.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache. Denies chest pain, chest pressure, or
palpitations. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits.
Past Medical History:
1. Non-Hodgkin's lymphoma, followed by Dr. [**Last Name (STitle) 3274**].
2. Breast cancer, diagnosed [**2160**].
3. Endometrial cancer.
4. Lymphedema since [**2173**].
5. Osteoarthritis.
6. Hypertension.
7. Paroxysmal supraventricular tachycardia and atrial ectopy.
8. ?Afib per recent [**Hospital1 2025**] hospitalization
Social History:
The patient was a bank officer for 52 years until her
retirement. She is single, no children. She is living in the
same home with her sister that she has lived in since [**2162**] .
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Mother died of cirrhosis of the liver secondary to hepatitis age
89. Father died of stomach cancer at age 64. Brother died of
CHF.
Physical Exam:
Admission Physical Exam:
Vitals: T: 96 (ax) BP: 134/60 P:64 R:16 O2:100% RA
General: Alert, oriented to person only, tangential thought
process with poor account of recent events, no acute distress
HEENT: Sclera anicteric, PERLL, 0.5cm white papule on lower rt
eyelid, Dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Nonlabored on RA, scattered expiratory wheeze with
crackles over LLL
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. No CVA
tenderness.
GU: foley in place
Ext: Extensive lower extremity lymphedema, distal pulses intact
to doppler, 3x3cm black eschar over rt without surrounding
erythema or drainage.
Neuro: CNII-XII intact, strength 4/5 bilaterally in UE, [**4-17**] hip
flexors bilaterally. Wiggling toes on command. No gross sensory
loss.
Pertinent Results:
[**2179-11-20**] 11:20AM BLOOD WBC-5.6 RBC-2.58* Hgb-8.6* Hct-27.2*
MCV-105*# MCH-33.4* MCHC-31.8 RDW-17.5* Plt Ct-52*#
[**2179-11-20**] 11:20AM BLOOD Neuts-57.4 Bands-0 Lymphs-25.6 Monos-6.9
Eos-9.6* Baso-0.5
[**2179-11-21**] 11:55AM BLOOD PT-19.1* PTT-41.8* INR(PT)-1.7*
[**2179-11-20**] 11:20AM BLOOD Ret Aut-3.4*
[**2179-11-23**] 10:31AM BLOOD Fibrino-108*#
[**2179-11-23**] 10:31AM BLOOD FDP-10-40*
[**2179-11-20**] 11:20AM BLOOD Glucose-107* UreaN-48* Creat-1.6* Na-142
K-4.7 Cl-113* HCO3-23 AnGap-11
[**2179-11-20**] 11:20AM BLOOD ALT-40 AST-58* LD(LDH)-326* AlkPhos-98
TotBili-2.5* DirBili-1.2* IndBili-1.3
[**2179-11-22**] 02:24AM BLOOD proBNP-6603*
[**2179-11-21**] 01:28AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.5*
[**2179-11-20**] 11:20AM BLOOD Hapto-<5*
[**2179-11-27**] 04:00AM BLOOD Ammonia-49
[**2179-11-25**] 03:33AM BLOOD TSH-0.52
[**2179-11-22**] 02:24AM BLOOD Cortsol-5.0
[**2179-11-20**] 02:02PM BLOOD Lactate-2.3*
.
UA
[**2179-11-20**] 12:12PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2179-11-20**] 12:12PM URINE Blood-LG Nitrite-POS Protein-100
Glucose-100 Ketone-TR Bilirub-SM Urobiln-1 pH-5.0 Leuks-MOD
[**2179-11-20**] 12:12PM URINE RBC-145* WBC->182* Bacteri-FEW Yeast-MANY
Epi-0
[**2179-11-20**] 12:12PM URINE CastHy-328*
[**2179-11-20**] 12:12PM URINE Mucous-OCC
URINE Site: NOT SPECIFIED TAKEN FROM 60740A.
**FINAL REPORT [**2179-11-21**]**
URINE CULTURE (Final [**2179-11-21**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
IMAGING
CTA
1. No PE. New pulmonary hypertension, possibly due to chronic
venous occlusion.
2. Pulmonary atelectasis, with possible superimposed aspiration
or infection.
3. Volume overload, with bilateral pleural effusions and
ascites.
4. Subacute left 4th-9th rib fractures.
5. Right thyroid goiter is similar to [**2174**], but merits
outpatient followup
ultrasound.
6. Right peripheral catheter in midline position.
7. Endotracheal tube 2 cm from carina, please retract 2-3 cm.
CT Head
IMPRESSION: Chronic involutional changes. No intracranial
hemorrhage or
other concerning findings. Please note that MR with contrast
enhancement
would be more sensitive for detection of intracranial
metastases.
EEG
MPRESSION: Abnormal portable EEG due to the slow and
disorganized background rhythm and due to the bursts of
generalized slowing. These findings indicate a widespread
encephalopathy affecting both cortical and subcortical
structures. Medications, metabolic disturbances, and infection
are among the most common causes. There were no areas of
prominent focal slowing, but encephalopathies may obscure focal
findings. There were no epileptiform features. A markedly
abnormal cardiac rhythm was noted.
Renal U/s
1. No hydronephrosis or suspicious renal mass.
2. Stable nonobstructing stone in the left kidney.
3. High resistance state in the right kidney on Doppler
evaluation. No renal artery stenosis.
Brief Hospital Course:
MICU COURSE:
Patient was admitted to the [**Hospital Unit Name 153**] due to concern for sepsis
secondary to a UTI. She was started on pressors and
aggressively fluid resuscitated. Patient was noted to be in
atrial fibrillation with intermittent RVR. She was also
profoundly delerious, which was thought to be multifactoral in
etiology. When her pressor requirement did not improve with
antibiotic therapy and her urine culture was unremarkable, the
patient was electively intubated for a CTA and CT head, both of
which were unremarkable. She remained intubated for a few days,
and then was successfully extubated. However, her mental status
continued to deteriorate and she had only limited responses to
voice and painful stimuli. Her urine output continued to
decline and her imaging should signs of fluid overload. She was
diuresed with good response with her urine, however her mental
status did not improve.
Following a discussion with her sister, the focus of her care
was transitioned to comfort measures only on [**2179-11-28**].
FLOOR COURSE: The patient was transferred to the floor on
[**2179-12-1**] and expired on [**12-2**] at 6:37PM. The patient's PCP was
notified by the covering physician and post [**Name9 (PRE) 18001**] arrangements
were made by her proxy.
Medications on Admission:
- atelonol 50mg daily
- lasix 40 mg po daily
- lisinopril 5mg daily
- KCl 30 meq po daily
- Triamcinolone acetonide 0.1% apply [**Hospital1 **]
- Vitamin D3 1000 U daily
- Vitamin B12 1000mcg daily
- Risperdal 0.25 prn
- Lactulose 30 cc daily
- Duonebs q6
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"V13.02",
"348.31",
"V49.86",
"707.20",
"995.92",
"276.69",
"V43.64",
"584.5",
"459.81",
"286.7",
"428.0",
"287.5",
"416.8",
"571.8",
"V10.44",
"585.9",
"518.81",
"403.90",
"427.31",
"824.6",
"482.42",
"518.0",
"038.12",
"V87.41",
"996.64",
"E879.6",
"202.80",
"590.10",
"V10.3",
"E885.9",
"707.07",
"V49.87",
"253.6",
"457.1",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8773, 8782
|
7178, 8466
|
322, 347
|
8828, 8837
|
4055, 7155
|
8888, 8893
|
2970, 3103
|
8803, 8807
|
8492, 8750
|
8861, 8865
|
3143, 4036
|
2106, 2350
|
266, 284
|
375, 2087
|
2372, 2698
|
2714, 2954
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,133
| 110,826
|
37297
|
Discharge summary
|
report
|
Admission Date: [**2103-5-8**] Discharge Date: [**2103-5-12**]
Date of Birth: [**2073-11-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Bicuspid aortic valve
Major Surgical or Invasive Procedure:
[**2103-5-8**] Bentall(29 StJude mech valved conduit)
History of Present Illness:
29 year old gentleman with a heart murmur since childhood
however he had never been told the significance of his murmur.
Oddly, this mumur dissapeared for a period of time and he was
told he "grew out of it". He was seen by his primary care
physician who noted [**Name Initial (PRE) **] combined systolic and diastolic murmur and
sent him for an echocardiogram. This revealed a bicuspid aortic
valve, severe aortic insufficiency with a dilated aortic root
and ascending aorta. He is extremely active and notes no
symptoms at rest. He has noted some very mild lightheadedness
towards the end of a very tough workout which he himself
ascribes to dehydration. Given the findings on his
echocardiogram, he has been referred for surgical evaluation.
Pain free today, but new symptoms noted
as above.
Past Medical History:
Bicuspid aortic valve with aortic insufficiency
Dialted aortic root and ascending aorta
seborrheic dermatitis
s/p Arthroscopic left knee surgery [**2089**], Metal plate R fibula
[**2091**] (football)
Social History:
Last Dental Exam: [**2102**]
Lives with: Alone
Occupation: Project manager for a medical company
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use: -
ETOH: < 1 drink/week [] [**3-20**] drinks/week [X] >8 drinks/week []
Illicit drug use: -
Family History:
No Premature coronary artery disease, GF with CABG in his 60's
Physical Exam:
Discharge exam:
VS: T: 100.1 HR: 93 SR BP: 106/62 Sats: 96% RA
General: 29 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Card: RRR normal S1,S2 good click
Resp: decreased breath sounds greater left lower lobe than right
GI: benign
Extr: warm no edema
Wound: sternal clean dry intact no erythema
Neuro: awake, alert oriented
Pertinent Results:
[**2103-5-12**] WBC-8.0 RBC-3.11* Hgb-10.0* Hct-28.9* MCV-93 MCH-32.0
MCHC-34.4 RDW-12.7 Plt Ct-231
[**2103-5-8**] WBC-6.5# RBC-3.75* Hgb-11.6* Hct-34.9* MCV-93# MCH-30.8
MCHC-33.1# RDW-12.2 Plt Ct-131*
[**2103-5-12**] Glucose-110* UreaN-9 Creat-0.8 Na-140 K-4.1 Cl-101
HCO3-30
[**2103-5-12**] PT-37.0* PTT-39.5* INR(PT)-3.6*
[**2103-5-11**] PT-34.0* INR(PT)-3.3*
[**2103-5-10**] PT-17.3* PTT-32.5 INR(PT)-1.6*
[**2103-5-8**] PT-17.5* PTT-37.3* INR(PT)-1.6*
[**2103-5-8**] PT-18.7* PTT-38.8* INR(PT)-1.8*
CXR: [**2103-5-12**]: Continued opacification at the bases is
consistent with pleural effusions and compressive atelectasis.
No evidence of vascular congestion.
Echocardiogram [**2103-5-8**]: PRE-BYPASS: No spontaneous echo
contrast is seen in the body of the left atrium or left atrial
appendage. A patent foramen ovale is present. An occassional
left-to-right shunt across the interatrial septum is seen at
rest. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic valve is bicuspid. There is no
aortic valve stenosis. Moderate to severe (3+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results at time of surgery.
POST-BYPASS: The patient is atrially paced. There is normal
biventricualr systolic function. The patient is s/p a Bental
procedure. There is a bileaflet prosthesis in the aortic
position. It is well seated and displays normal leaflet
function. The normal washing jets of aortic regurgitation are
visualized. The ascending aortic graft is not well seen. The
neo-sinus area is visualized. The descending thoracic aorta and
distal portions of the aortic arch appear intact after
decannulation. The rest of valvualr function is unchanged from
the pre-bypass study.
Brief Hospital Course:
The patient was brought to the operating room on [**2103-5-8**] where
the patient underwent Aortic Valve replacement with a Bentall(29
[**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical valved conduit). 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. Anticoagulation therapy was started. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD4 the patient was ambulating freely, the wound was healing
and pain was controlled with oral analgesics. The patient was
discharged home with Caregroup VNA in good condition with
appropriate follow up instructions.
Medications on Admission:
Fluocinonide 0.5% solution and cream, ketoconazole 2% cream
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. 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:*2*
4. warfarin 1 mg Tablet Sig: One (1) Tablet PO Take as Directed:
INR Goal 2.0-3.0.
Disp:*100 Tablet(s)* Refills:*2*
5. 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*
6. sennosides 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*10 Capsule(s)* Refills:*2*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 1 weeks.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Bicuspid aortic valve with aortic insufficiency
Dialted aortic root and ascending aorta
Seborrheic dermatitis
s/p Arthroscopic left knee surgery [**2089**], Metal plate R fibula
[**2091**] (football)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
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
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2103-5-17**] 10:15 in
the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2103-6-20**] 1:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
[**Hospital Unit Name **]
Cardiologist:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2103-5-30**] 9:40 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2010**] for further
Coumadin management
**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 AVR mechanical
Goal INR 2.0-3.0
First draw Sunday [**2103-5-13**]
Please call [**Telephone/Fax (1) 83933**] and ask for the Mid-level for further
Coumadin instructions.
The office will call on Monday with further warfarin follow-up
instructions.
Completed by:[**2103-5-12**]
|
[
"746.4",
"441.2",
"780.60",
"V70.7",
"690.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.45",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
6657, 6715
|
4345, 5555
|
332, 388
|
6959, 7176
|
2195, 4322
|
8017, 9370
|
1734, 1799
|
5665, 6634
|
6736, 6938
|
5581, 5642
|
7200, 7994
|
1814, 1814
|
1830, 2176
|
271, 294
|
416, 1212
|
1234, 1435
|
1451, 1718
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,644
| 191,064
|
48232
|
Discharge summary
|
report
|
Admission Date: [**2155-1-28**] Discharge Date: [**2155-2-8**]
Date of Birth: [**2081-9-9**] Sex: F
Service: NEUROLOGY
CHIEF COMPLAINT: The patient was admitted to undergo coiling
of her left anterior communicating artery aneurysm.
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
woman with a history of CAD, PVD, right internal carotid
artery stenosis status post stenting, lung nodule and left
ACOM aneurysm, who was admitted for coiling. The left ACOM
aneurysm is 4 x 5 mm in diameter and asymptomatic. However,
patient requires an open resection of her lung nodule as
previous attempts at more noninvasive diagnostic procedures
have not yielded a definitive diagnosis. Her cardiothoracic
surgeons require that the left ACOM aneurysm be coiled prior
to taking her to surgery. She underwent cerebral angiogram
and an attempted coiling procedure of [**2155-1-28**].
However, the coiling was not successful as the base of the
aneurysm was large and did not allow for sufficient
aneurysmal luminal closure. Post procedure patient had high
blood pressure and required unit level care with IV agents to
maintain her pressure below a systolic of 200.
PAST MEDICAL HISTORY: CAD. Right ICA disease status post
stenting. Lung mass. Hypothyroidism. History of breast
cancer.
MEDICATIONS: Levoxyl 150 mcg p.o. q.day, Celexa 10 mg p.o.
q.day, folic acid 1 mg p.o. q.day, tamoxifen 10 mg p.o.
b.i.d., mesalamine DR 800 p.o. t.i.d., Neurontin 300 p.o.
t.i.d., Celebrex 100 p.o. b.i.d., sublingual nitroglycerin
0.3 mg p.r.n. chest pain, isosorbide dinitrate 10 p.o.
t.i.d., aspirin 325 mg p.o. q.day, Lopressor 50 mg p.o.
b.i.d., losartan potassium 50 mg p.o. q.d., Fosamax 70 mg
p.o. q.week, Percocet p.r.n.
ALLERGIES: Penicillin and codeine.
SOCIAL HISTORY: The patient lives with her daughter. She
does not smoke.
FAMILY HISTORY: Diabetes, hypertension, heart disease.
PHYSICAL EXAMINATION: Temperature 97.2, blood pressure
200/85, heart rate 80, oxygen saturation 98% in room air. In
general, obese woman in no acute distress. Cardiovascular
regular rhythm, normal rate. Pulmonary clear to auscultation
bilaterally. Abdomen positive bowel sounds, soft,
nondistended, nontender. Neurologic awake, alert and
interactive. Language and comprehension were intact.
Cranial nerves pupils equal and reactive to light.
Extraocular motions were full. Visual fields were full.
Facial movement and palatal elevation were normal. Tongue
protruded midline. Facial sensation was intact to touch,
temperature and pin prick. Motor normal bulk, tone and power
throughout except for the iliopsoas which could not be tested
adequately as there were two sheaths in place post procedure.
There were positive pulses in the femoral arteries as well as
more distally bilaterally. Sensation was intact to touch,
temperature and pin prick. Reflexes were symmetric and toes
were downgoing.
HOSPITAL COURSE: The patient was admitted to the intensive
care unit where IV agents were used to lower her blood
pressure to more normal range. Her oral agents were
restarted. However, the next morning patient was found to be
weak on the left side, particularly in her face, arm and leg.
She transiently improved. However, subsequently redeveloped
the same symptoms and, therefore, she underwent a stat head
CT which revealed a right ACA distribution ischemic infarct
which was small and in the right frontal lobe perisagittally.
Over the next several hospitalization days patient improved
strength-wise. Her facial, leg and arm weakness improved
back to normal strength, however, she had a difficult time
initiating movement on that side. This may be secondary to
the small stroke in the premotor cortex.
She improved steadily throughout her course and was weaned
off IV antihypertensive agents and transferred to the floor.
Her course there was complicated by chest pain and cardiac
enzymes consistent with a non-ST segment elevation MI with
troponins which steadily climbed to greater than 50 troponin
I. CKs remained unchanged at less than 100 without an
elevated MB fraction. EKG showed some nonspecific T wave
changes, but there was no ST segment elevation. Cardiology
was consulted at that time and they recommended conservative
management with heparin IV. However, her IV access became
problem[**Name (NI) 115**] and, therefore, surgery was consulted to place a
central venous line. This procedure was complicated by post
procedure ecchymosis and hematoma in the left chest and neck
owing to failed attempt at left IJ and subclavian venous
cannulations. Her hematocrit dropped from 35 to 28. She
received 2 units of blood and her hematocrit went up
appropriately and was most recently 33.
Except for an episode of substernal chest pain in the setting
of a low hematocrit, patient has been chest pain free. She
underwent cardiac echo which did not show any evidence of
abnormal wall motion. Her ejection fraction was within the
normal range. Cardiology, therefore, recommended
discontinuation of heparin and continued conservative
management. They expect the troponin elevation to last
several weeks.
The patient had an episode of left ptosis which was evaluated
with MR imaging of the head and neck. This did not reveal
any acute infarction. However, there was diffusion and T2
abnormalities in the ACA distribution as described by the CT
scan previously. There was also a smaller area of
abnormality both on T2 and diffusion in the right ACA
territory which was further rostral in the brain. There was
also evidence of previous small vessel disease.
The patient continued to do well clinically and, therefore,
she would be appropriate for physical therapy and
rehabilitation. At the time of this dictation she is chest
pain free and doing well. She should follow up with
cardiology, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**], in two to three weeks' time.
CONDITION ON DISCHARGE: Clinically stable.
DISCHARGE STATUS: Discharged to [**Hospital 246**] rehabilitation
facility.
DISCHARGE DIAGNOSES:
1. Left ACOM aneurysm.
2. Right ACA ischemic infarction.
3. Non-ST segment elevation myocardial infarction with
troponin greater than 50.
4. Post central line ecchymosis and hematoma.
SECONDARY DIAGNOSES:
1. Lung nodule.
2. CAD.
3. Hypothyroidism.
4. Breast cancer.
5. Hypertension.
DISCHARGE MEDICATIONS:
1. Levoxyl 150 mcg p.o. q.day.
2. Celexa 10 mg p.o. q.day.
3. Folic acid 1 mg p.o. q.day.
4. Tamoxifen 10 mg p.o. b.i.d.
5. Mesalamine DR 800 mg p.o. t.i.d.
6. Neurontin 300 mg p.o. t.i.d.
7. Celebrex 100 mg p.o. b.i.d.
8. Sublingual nitroglycerin 0.4 mg p.r.n. chest pain.
9. Percocet one tablet p.o. q.four to six hours p.r.n.
10. Colace 100 mg p.o. b.i.d.
11. Isosorbide dinitrate 10 mg p.o. t.i.d.
12. Lopressor 50 mg p.o. b.i.d.
13. Losartan 50 mg p.o. q.day.
14. Fosamax 70 mg p.o. q.week.
15. Aspirin 325 mg p.o. q.day.
16. Plavix 75 mg p.o. q.day.
17. Cream for psoriasis to include hydrocortisone cream
b.i.d., triamcinolone cream b.i.d.
NOTE: The patient was restarted on her Plavix regimen which
had been stopped prior to her angiogram.
FOLLOWUP: The patient is to follow up with Dr. [**Last Name (STitle) **].
She will also follow up with cardiology, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**],
at [**Telephone/Fax (1) 902**], in two to three weeks' time. The exact date
will be placed on the page one.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**MD Number(1) 2107**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2155-2-7**] 02:17
T: [**2155-2-7**] 15:16
JOB#: [**Job Number 101644**]
|
[
"518.89",
"V10.3",
"244.9",
"443.9",
"507.0",
"410.71",
"437.3",
"997.02",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
1874, 1914
|
6089, 6278
|
6406, 7726
|
2940, 5945
|
6299, 6383
|
1937, 2922
|
158, 255
|
284, 1186
|
1209, 1781
|
1798, 1857
|
5970, 6068
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,866
| 112,538
|
54663+59620
|
Discharge summary
|
report+addendum
|
Admission Date: [**2104-7-1**] Discharge Date: [**2104-7-15**]
Date of Birth: [**2045-5-4**] Sex: F
Service: SURGERY
Allergies:
Codeine / Penicillins
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59F who is s/p motor vehicle crash. She was in the front seat
when the car ran into a crowd of people and then into a pole.
There was reportedly no LOC. Her c-spine was cleared at the
OSH. Her EtOH level was 122. She had bilateral rib fractures and
a 24Fr R chest tube was placed into the subcutaneous tissue of
the R chest wall at the OSH. She was transferred from an OSH via
med flight.
Past Medical History:
PMH: COPD, bipolar depression, NIIDM, EtOH abuse, ?old R humeral
fx?
PSH: bilateral knee replacement, CCY, VHR
Social History:
H/o EtOH abuse, has had multiple trauma in the past
Family History:
NC
Physical Exam:
Discharge day exam:
99.1 97.7 105 95/61 18 93% trach mask
Gen: NAD, alert, appropriately responsive to yes/no questions
CV: RRR
Pulm: coarse breath sounds, breathing comfortably on trach mask,
most of subcutaneous emphysema resolved, chest tube sites appear
clean
Abd: soft, nontender, nondistended
Ext: WWP
Pertinent Results:
[**2104-7-1**] 05:50PM BLOOD WBC-11.7* RBC-2.96* Hgb-9.8* Hct-30.1*
MCV-102* MCH-33.0* MCHC-32.4 RDW-14.7 Plt Ct-147*
[**2104-7-1**] 07:46PM BLOOD WBC-11.7* RBC-3.41* Hgb-11.1* Hct-34.3*
MCV-101* MCH-32.7* MCHC-32.5 RDW-15.4 Plt Ct-155
[**2104-7-15**] 03:20AM BLOOD WBC-12.7* RBC-3.30* Hgb-10.3* Hct-31.8*
MCV-96 MCH-31.2 MCHC-32.4 RDW-14.8 Plt Ct-336
[**2104-7-1**] 07:46PM BLOOD Glucose-150* UreaN-16 Creat-1.1 Na-139
K-5.1 Cl-111* HCO3-17* AnGap-16
[**2104-7-15**] 03:20AM BLOOD Glucose-151* UreaN-20 Creat-0.9 Na-138
K-4.9 Cl-93* HCO3-37* AnGap-13
[**2104-7-1**] 05:50PM BLOOD ASA-NEG Ethanol-48* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2104-7-1**] CT Abd/Pelv:
IMPRESSION:
1. Extensive subcutaneous emphysema. 2. Right chest tube
within the subcutaneous air and not within the pleural space. 3.
Small right pleural pneumothorax. 4. Trace bilateral
hemothoraces. 5. Trace pneumomediastinum. 6. Trace complex
perihepatic fluid without evidence of injury to the solid
organs. 7. Right third through tenth and left fourth through
eighth rib fractures. Sternal fracture. 8. Small subcutaneous
hematoma overlying the right upper abdomen. 9. Loss of height
of the L4 vertebral body, likely chronic. 10. Complex splenic
cyst. 11. Apparent soft tissue lesion with dense calcifications
in the region of the right anterior mediastinum, not clearly
evaluated on this exam. After the acute findings have resolved,
recommend followup with dedicated chest CT for further
evaluation. 12. Findings suggestive of chronic pancreatitis
with possible obstructing calculus in the distal pancreatic duct
within the pancreatic head. An MRCP can be obtained for further
evaluation.
CT Head:
IMPRESSION:
No acute intracranial abnormality.
[**2104-7-4**] Echo: Left ventricular wall thickness, cavity size, and
overall systolic function are normal (LVEF 65%). Right
ventricular chamber size and free wall motion are normal.
However, in very suboptimal imaging, the basal segment of the
posterior wall may be hypokineticThere is no aortic valve
stenosis. 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. There is an anterior space which most
likely represents a prominent fat pad. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
59F s/p MVC partially restrained passenger, front seat, car vs
crowd and then a pole, -[**Hospital 63213**] transferred from OSH via med
flight, neck cleared at OSH. Pt was hypotensive in the CT scan,
triggered was called, pt received 1 U PRBC. CT was found to be
placed in chest wall subcutaneous tissue. She was stable until
arrival in the TICU when she began to have respiratory distress
and was intubated, sedated and is paralyzed. CT scan shows to
have numerous rib fractures, sternal fx, Sub-Q emphysema,
pneumomediastinum, and R PTX. R anterior chest pigtail was
placed initially but it was not resolved her PTX. Bilateral CT
were then placed in the TSICU. On [**7-5**]+ gram negative
diplococci was detected on SCx.Cultures grew w/ Moraxella.
Vanco/Cipro/Cefepime started. Bedside trach was placed on [**7-7**].
On [**7-9**], pt was doing well, +OOB to chair, b/l CT to waterseal.
On [**7-10**]: Left sided chest tube D/c'd. Mental status starts to
improve. [**7-11**]: dobhoff placed. R Chest tube dc'd. On [**7-13**], Pt
was weaned to trach mask and she passed bedside swallow
evaluation. Pt was advanced to regular diet with supplements.
The rest of her hospital course per systems are detailed below:
Neurologic:
Oxycodone/IV dilaudid, zyprexa/seroquel/paxil. TLSO brace when
OOB for T12 Fx
h/o EtOH
on thiamine, folate supplementation
Cardiovascular: Stable, Echo: normal EF, very small effusion, no
tamponade. Cont to monitor for S&S of blunt cardiac injuries
Pulmonary:
On Trach mask, cont to wean as tolerates
Cont pulmonary toilet, breathing treatment (Ipratropium,
Albuterol)
Gastrointestinal:
Regular diet
Hematology:
Stable, cont to monitor
Endocrine:
- DM
Cont GlipiZIDE, Metformin
- Hypothyroidism
continue synthroid
Infectious Disease:
Cont abx for VAP
Prophylaxis: SQ heparin
Medications on Admission:
detrol LA 4 XR', vesicare 10', lorazepam 0.5'', MVI', glipizide
5'', pantoprazole 40', levothyroxine 75', doxepin 100', zyprexa
10', paroxetine 40', folate 1', metformin 500'', spiriva 18',
klor-con 20', albuterol 90 q4h, hydroxyzine 50''' prn,
ranitidine 150'', albuterol nebs prn
Discharge Medications:
1. Bisacodyl 10 mg PR HS:PRN constipation
2. CeftriaXONE 1 gm IV Q24H Duration: 6 Days
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H
5. Doxepin HCl 100 mg PO HS home med
6. GlipiZIDE 5 mg PO BID home med
7. Heparin 5000 UNIT SC TID
8. HydrOXYzine 50 mg PO Q8H:PRN home med- anxiety
9. Levothyroxine Sodium 100 mcg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID home med
11. Paroxetine 40 mg PO DAILY
12. Senna 1 TAB PO BID
13. FoLIC Acid 1 mg PO DAILY
14. Ipratropium Bromide Neb 1 NEB IH Q4H
15. Multivitamins 1 TAB PO DAILY
16. OLANZapine 15 mg PO DAILY
17. Quetiapine Fumarate 25 mg PO BID
18. Furosemide 20 mg PO DAILY:PRN for volume overload
19. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
bilateral rib fractures, sternal fracture, small
pneumomediastinum, small right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the ACS service after your trauma. Please
follow these directions:
You should resume walking and exercising as you can tolerate.
You have rib fractures and a sternal fracture. If you have pain,
you can take tylenol or motrin. You can also take narcotic
medication if your pain is severe. You can resume a regular
diet.
Followup Instructions:
Please call [**Hospital 2536**] clinic to schedule a follow-up appointment [**12-31**]
weeks after your discharge. The clinic # is [**Telephone/Fax (1) 600**]
Name: [**Known lastname 18353**],[**Known firstname 11090**] Unit No: [**Numeric Identifier 18354**]
Admission Date: [**2104-7-1**] Discharge Date: [**2104-7-15**]
Date of Birth: [**2045-5-4**] Sex: F
Service: SURGERY
Allergies:
Codeine / Penicillins
Attending:[**Doctor Last Name 18355**]
Addendum:
Pt already finishes her course of antibiotics. She will not need
antibiotics for her pneumonia at the new facility.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 95**]
([**Hospital3 96**] Center)
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD [**MD Number(2) 18356**]
Completed by:[**2104-7-15**]
|
[
"401.9",
"296.80",
"807.2",
"244.9",
"276.69",
"276.9",
"250.00",
"V43.65",
"733.00",
"305.00",
"860.4",
"496",
"291.81",
"997.31",
"807.08",
"458.9",
"958.7",
"E823.1",
"805.2",
"285.1",
"518.52",
"041.85",
"E879.8",
"733.13",
"891.0",
"307.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.24",
"31.1",
"38.97",
"34.04",
"97.89",
"38.91",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8075, 8343
|
3682, 5494
|
288, 295
|
6871, 6871
|
1282, 2971
|
7419, 8052
|
934, 938
|
5826, 6575
|
6755, 6850
|
5520, 5803
|
7054, 7396
|
953, 1263
|
241, 250
|
323, 714
|
2980, 3659
|
6886, 7030
|
736, 849
|
865, 918
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,248
| 186,327
|
52256
|
Discharge summary
|
report
|
Admission Date: [**2166-2-17**] Discharge Date: [**2166-2-21**]
Date of Birth: [**2115-12-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] [**Known lastname 349**] is a 50 yo male with history of lymphoma as a
child, now in remission for many years, HLD, and current smoker
(30 PY) who presents with shortness of breath. He does not have
any known history of COPD or asthma. He reports that he has had
intermittent cough and viral symptoms for the past 1-2 months,
but he has not been SOB until about 3 days ago. He has had
severe cough and some wheezing for the past 3 days as well.
Cough is productive of clear sputum. He reports low grade
fevers for 1 day, low 100s in ED. He denies chills, chest pain
or pressure. He was admitted to OSH earlier today, he was given
steroids and antibiotics, but eloped as he was unstatisfied with
their care. He was still SOB so came here for further
evaluation. He denies any recent sick contacts.
.
In the ED, initial VS were: T 98.2, HR 117, BP 135/73, RR 18,
SpO2 90% on RA. Patient was found to be tachypneic and wheezy
on exam. His peak flow was noted to be 200. He was given
Duonebs x3, Solumedrol, Ceftriaxone, and Azithromycin. No
elevated WBC, but lactate increased at 4.4. EKG showed sinus
tachycardia at 112, no ischemia. CTA chest was negative for PE.
His VS prior to transfer were: T 98.5, HR 110, BP 139/79, SpO2
96% on NRB.
Review of systems:
(+) Per HPI and for rhinorrhea and sneezing
(-) Denies weight gain, orthopnea, PND or LE edema.
Denieschills, night sweats. Denies headache, sinus tenderness 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:
# Lymphocytic non-Hodgkin's lymphoma, in remission, diagnosed at
age 16, presented with a right tongue lesion as well as a neck
mass, underwent surgeries to excise these and also Adriamycin,
vincristine, 6-MP, prednisone and methotrexate at [**Hospital1 108069**]. He also underwent XRT at [**Hospital1 756**]. He had
some peripheral neuropathy from the vincristine, which has since
resolved. Has poor denition due to radiation.
# Hyperlipidemia
# Scoliosis. Wears a right shoe-lift.
# Bilateral inguinal hernia repair as a child
# Tonsillectomy and adenoidectomy x2 as a child.
# Tobacco abuse
Social History:
He lives in [**Hospital1 392**] with his wife, no kids. He works as an
attorney. Has 2 birds at home.
- Tobacco: Current 1PPD for past 30 years.
- Alcohol: Rarely
- Illicits: Denies
Family History:
The patient is adopted and does know know his biological family
medical history.
Physical Exam:
Physical Exam On Admission:
General: Alert, oriented, SOB with speaking in full sentences
and with mild
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP at 8cm, no LAD
Lungs: faint wheezes heard more in the upper lung fields, poor
airflow. no rales/ronchi
CV: rapid rate/rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O x3, CN grossly intact, MAE.
.
Pertinent Results:
Labs On Admission:
[**2166-2-16**] 11:30PM BLOOD WBC-7.0 RBC-4.74 Hgb-14.6 Hct-41.4 MCV-87
MCH-30.8 MCHC-35.3* RDW-13.9 Plt Ct-223
[**2166-2-16**] 11:30PM BLOOD Neuts-91.1* Lymphs-6.1* Monos-2.4 Eos-0.4
Baso-0.1
[**2166-2-16**] 11:30PM BLOOD PT-12.4 PTT-23.4 INR(PT)-1.0
[**2166-2-16**] 11:30PM BLOOD UreaN-14 Creat-0.9
[**2166-2-16**] 11:30PM BLOOD freeCa-1.13
Other Relevant Labs:
[**2166-2-17**] 07:01AM BLOOD proBNP-1302*
[**2166-2-17**] 07:01AM BLOOD Calcium-8.1* Phos-2.0* Mg-1.6
[**2166-2-17**] 07:01AM BLOOD TSH-0.79
[**2166-2-17**] 04:13PM BLOOD IgG-671* IgA-47* IgM-11*
ABG:
[**2166-2-17**] 07:28AM BLOOD Type-ART pO2-80* pCO2-34* pH-7.39
calTCO2-21 Base XS--3 Intubat-NOT INTUBA
.
Lactate Trend:
[**2166-2-16**] 11:30PM BLOOD Lactate-4.4*
[**2166-2-17**] 12:24AM BLOOD Lactate-3.5*
[**2166-2-17**] 01:58AM BLOOD Lactate-3.5*
[**2166-2-17**] 07:28AM BLOOD Lactate-3.2*
[**2166-2-18**] 06:16AM BLOOD Lactate-1.6
Urinalyis:
[**2166-2-17**] 01:17PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.018
[**2166-2-17**] 01:17PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Toxicology:
[**2166-2-17**] 07:01AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2166-2-17**] 01:17PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Microbiology:
[**2166-2-17**] 7:08 am Influenza A/B by DFA (Source: Nasopharyngeal
swab)
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2166-2-17**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2166-2-17**]):
Negative for Influenza B.
Respiratory Viral Culture (Pending):
Imaging / Studies:
# CHEST (PA & LAT) ([**2166-2-16**] at 11:29 PM):
FINDINGS: AP and lateral chest with no prior for comparison
demonstrates low lung volumes, though the lungs are clear. There
is no pleural effusion or pneumothorax. The heart is at the
upper limits of normal for size, the mediastinal contours are
unremarkable. The pulmonary vasculature appears normal.
IMPRESSION: No acute thoracic pathology.
CTA CHEST W&W/O C&RECONS, NON-CORONARY ([**2166-2-17**] at 2:30 AM):
FINDINGS: Vascular opacification is somewhat suboptimal, but no
pulmonary embolism is present to the level of the segemental
vessels. The main pulmonary artery is slightly enlarged
measuring 3.2 cm. The thoracic aorta appears within normal
limits. No pericardial, or pleural effusions are present.
Minimal bibasilar dependent atelectasis is present. Otherwise,
the lungs are clear and the airways are patent. No significant
hilar, mediastinal, or axillary lymphadenopathy is present. In
the right lobe of the thyroid is a 14-mm nodule, a small nodule
is present in the left lobe. Although not evaluated for
subdiaphragmatic evaluation, the liver appears diffusely fatty
infiltrated without focal lesions. Remainder of the abdomen
appears normal.
BONE WINDOWS: Spinal degenerative changes are present but no
suspicious bone lesions are present.
IMPRESSION:
1. No pulmonary embolism. Main pulmonary artery is somewhat
enlarged, could indicate pulmonary hypertension.
2. Thyroid nodules, for which ultrasound should be performed to
better evaluate.
3. Fatty liver without focal lesions; however, this evaluation
for lesions is limited on this study.
Portable TTE ([**2166-2-18**] at 8:37:01 AM):
The left atrium is mildly dilated. No definite atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
CHEST (PORTABLE AP) ([**2166-2-18**] at 4:48 AM):
FINDINGS: In comparison with study of [**2-16**], there is no interval
change or evidence of acute cardiopulmonary disease. Relatively
low lung volumes but no pneumonia, vascular congestion, or
pleural effusion.
Brief Hospital Course:
50 yo male with a history of childhood lymphoma in remission
after chemotherapy and radiation, HLD, and significant smoking
history (30 PY) who presents with shortness of breath.
Dyspnea/Hypoxia: very likely related to a severe viral pneumonia
or an atypical pneumonia. CTA of the chest without PE or any
infiltrate. Viral culture and flu swab negative although the
patient was treated with a full course of tamiflu. In addition
he was treated with a 7 day total course of levofloxacin. For
the first few days he was on steroids given significant
wheezing, the steroids were stopped without any recurrance of
wheezing. Dry mild cough persisted at the time of discharge,
but he felt generally well and was without fevers. His Ig panel
was low in IgG, IgA, and IgM. He will f/u with a pulmonologist.
He was sating well on room air upon discharge.
Medications on Admission:
Not taking any medication currently.
Prescribed:
Aspirin 81 mg PO daily
Fenofibrate micronized 200 mg PO daily
Discharge Medications:
1. nicotine 21-14-7 mg/24 hr Patch Daily, Sequential Sig: One
(1) patch Transdermal once a day: use 21mg/24hr patch daily for
4 weeks then 14mg/24hr patch daily for 2-4 weeks then 7mg/24hr
patch daily for 2-4 weeks .
2. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO
once a day.
4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days: take 1 tablet on [**2-22**] and 1 tablet on [**2-23**].
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Viral Pneumonia
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 severe pneumonia, you
were treated for the flu and for a bacterial pneumonia with
antibiotics. You should take levofloxacin (antibiotic) for 2
additional days (1 pill on [**2-22**] and 1 on [**2-23**])
Please take your medications as prescribed and make your follow
up appointments.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2166-2-28**] at 9:10 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Name: [**Last Name (LF) 3517**], [**Name8 (MD) 915**] MD.
Location: [**Hospital1 2025**] PULMONARY AND CRITICAL CARE
Address:[**Street Address(2) 12266**], [**Location (un) **],[**Numeric Identifier 18228**]
Phone: [**Telephone/Fax (1) 86145**]
*Please call the number above to register with [**Hospital1 2025**] and set up an
appointment with Dr. [**Last Name (STitle) 3517**].
Department: [**Hospital3 249**]
When: WEDNESDAY [**2166-3-26**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"272.0",
"305.1",
"480.9",
"785.0",
"799.02",
"V10.71",
"737.30",
"482.9",
"241.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9434, 9440
|
7864, 8719
|
324, 331
|
9519, 9519
|
3624, 3629
|
10018, 11326
|
2929, 3011
|
8882, 9411
|
9461, 9461
|
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|
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|
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|
1655, 2088
|
265, 286
|
359, 1636
|
9480, 9498
|
3643, 7841
|
9534, 9646
|
2110, 2711
|
2727, 2913
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,084
| 129,690
|
10262
|
Discharge summary
|
report
|
Admission Date: [**2163-12-24**] Discharge Date: [**2163-12-30**]
Date of Birth: [**2096-4-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / Aspirin
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Chest pain, delerium.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 67 year old male with hypertension (HTN), diabetes
mellitus (DM), and hyperlipidemia who initially presented on
[**2163-12-24**] complaining of chest pain. In the ED, the patient was
given ASA 325 mg x 1 and nitro SL x 3 with pain down from [**7-30**]
to [**3-30**], and after morphine x 1, elimination of all pain. His CK
was elevated to 1800, but troponin was negative, with MB 17, MB
index 7.9. EKG was unchanged from prior. He was admitted to the
[**Wardname 13764**] for a rule-out MI.
Past Medical History:
-Hypertension
-Diabetes Type 2
-Hyperlipidemia
-Spinal stenosis
-Impotence
-History of prostate cancer
Social History:
The patient is married. He is employed as a carpenter for [**Street Address(1) 34162**] Service. He has 5 children, whose ages range from
the 40s down to the 30s. He is a former smoker who stopped about
18 years ago. He did report abuse of alcohol though his wife
states he does drink rum of unclear quantities.
Family History:
Remarkable for diabetes and hypertension. Father died from CVA.
Mother died from cancer.
Physical Exam:
Vitals: T 98.1, BP 140/98, HR 109, RR 24, O2sat 98% on room air.
Tm 98.1, 136-158/70-98, 84-109, 20-24, 98-100% on RA.
General: NAD, A&Ox3
HEENT: Normocephalic. Laceration under right eye healing well,
sclera anicteric, miist mucous membranes.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: borderline tahcycardia, normal S1/S2, no m/r/g
Abdomen: obese, soft, non-tender, non-distended, hypoactive
bowel sounds
Ext: trace pitting edema bilaterally, BUE with edema, left hand
swollen from IV infiltration, r-hand with laceration which is
closed and healing well.
Pertinent Results:
Labs on admission:
[**2163-12-24**] 04:40PM BLOOD WBC-6.4 RBC-4.62 Hgb-12.8* Hct-37.8*
MCV-82 MCH-27.7 MCHC-33.8 RDW-14.9 Plt Ct-210
[**2163-12-24**] 04:40PM BLOOD Neuts-70.4* Lymphs-23.7 Monos-5.0 Eos-0.3
Baso-0.6
[**2163-12-24**] 04:40PM BLOOD PT-12.6 PTT-22.3 INR(PT)-1.1
[**2163-12-24**] 04:40PM BLOOD Glucose-200* UreaN-20 Creat-1.0 Na-135
K-4.0 Cl-97 HCO3-23 AnGap-19
[**2163-12-24**] 04:40PM BLOOD CK(CPK)-1865*
[**2163-12-25**] 07:05AM BLOOD Albumin-4.4
[**2163-12-26**] 02:25AM BLOOD VitB12-428 Folate-12.2
[**2163-12-25**] 07:05AM BLOOD TSH-2.1
[**2163-12-26**] 02:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Labs on discharge:
[**2163-12-30**] 05:20AM BLOOD WBC-6.7 RBC-3.85* Hgb-10.7* Hct-31.5*
MCV-82 MCH-27.9 MCHC-34.0 RDW-14.1 Plt Ct-189
[**2163-12-30**] 05:20AM BLOOD PT-11.7 PTT-26.8 INR(PT)-1.0
[**2163-12-30**] 05:20AM BLOOD Glucose-122* UreaN-15 Creat-1.0 Na-140
K-3.9 Cl-107 HCO3-24 AnGap-13
[**2163-12-30**] 05:20AM BLOOD ALT-26 AST-36 LD(LDH)-297* CK(CPK)-1036*
AlkPhos-66 TotBili-0.4
[**2163-12-30**] 05:20AM BLOOD Albumin-4.1 Mg-2.0
Cardiac enzymes:
[**2163-12-24**] 04:40PM BLOOD CK-MB-17* MB Indx-0.9 cTropnT-0.01
[**2163-12-25**] 01:09AM BLOOD CK-MB-13* MB Indx-0.8 cTropnT-<0.01
[**2163-12-25**] 07:05AM BLOOD CK-MB-12* MB Indx-0.8 cTropnT-<0.01
[**2163-12-26**] 02:25AM BLOOD CK-MB-17* MB Indx-0.6 cTropnT-0.01
Chest x-ray [**2163-12-24**]: No acute cardiopulmonary process.
CT head [**2163-12-26**]: No acute intracranial pathology including no
hemorrhage.
X-ray right hand [**2163-12-26**]:
1. No acute fracture detected.
2. Probable film artifact -- please see comment above.
Otherwise, no foreign body detected. In particular, no foreign
body detected along dorsum of hand. Soft tissue swelling.
3. Positive ulnar variance with evidence of ulna-lunate
impaction.
Brief Hospital Course:
This is a 67 year old male with HTN, DM2, and hyperlipidemia,
who presented with chest pain and ruled out for MI, but was
found in an acutely delirious state presumably due to unforeseen
EtOH withdrawal.
.
On the evening of [**2163-12-25**], the patient had been ruled out by
enzymes and was awaiting a stress test on [**2163-12-26**]. In the middle
of the night he was found wandering the hallways acutely
delirious. He had walked over to an adjacent building, took a
fire extinguisher, and broke windows with his hands, trying to
get out. The patient was given 4-pt restraints overnight, and
required Haldol 5mg x 1, Diazepam 10mg PO x 1, and Ativan scale
for CIWA>10 (had received total 10mg as of 8:30am on [**12-26**]).
Although he had denied any ingestions or EtOH abuse on
admission, further history revealed a regular drinking habit,
with at least 2 drinks/day on most days. Per his wife, his last
drink was either [**12-23**] or [**12-24**]. He was transferred to the MICU for
agitation, EtOH withdrawal, and concern for delirium tremens.
.
Upon arrival to the MICU, he was sedated and awoke briefly to
sternal rub. He required ativan on an hourly basis, as well as
PRN Haldol. He was actively delirious. He required IV metoprolol
for tachycardia and hypertension. Eventually, able to wean
benzodiazepine requirement down with aid of psychiatry team.
Ativan was decreased to a small standing dose with no PRN.
Restraints were discontinued and oral antihypertensives were
started as he was able to tolerate.
.
CK's were trended, which predictably went up after his agitation
and restraints. Aggressive IVF was initiated. CKs peaked at
3700, with no change in renal function. He had no fever and
never received antibiotics. There was no evidence of infection
on urinalysis or blood culture to suggest this as a cause of
delirium. Head CT was negative. Folate, B12, RPR, and TFTs were
negative.
.
The patient was transferred to the floor and weaned from
benzodiazepines without further incident. His Verapamil
continued to be held and he was started on Metoprolol. The
patient was unable to complete a cardiac stress test during the
admission and was advised to complete this during his outpatient
follow up.
Medications on Admission:
Enablex (darifenacin) 7.5 mg daily
Enalapril 20 mg [**Hospital1 **]
Hytrin (terazosin) 5 mg QHS
Lantus 32 units QHS
Humalog Sliding scale
Pantoprazole 40 mg daily
Flomax (tamsulosin) 0.4 mg daily
Verapamil 240 mg daily
Vytorin 10/20 mg daily
ASA 81 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily). Disp:*1 month supply* Refills:*0*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). 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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day). Disp:*60 Tablet(s)* Refills:*2*
10. Enablex 7.5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO qam.
11. Lantus 32U qHS
12. Humalog Sliding scale as before
Discharge Disposition:
Home
Discharge Diagnosis:
-Chest pain
-Alcohol withdrawal
Discharge Condition:
Stable, afebrile, chest pain free.
Discharge Instructions:
You were admitted for chest pain and alcohol withdrawal. You did
not have a heart attack. While you were you went through a
period of delirium caused by alcohol withdrawal for which you
were treated with benzodiazepines. It is important for you to
avoid alcohol.
Your medications were changed. Please discontinue taking
Verapamil. Please take Metoprolol 25mg twice a day. You should
resume taking your other medications as before.
Please adhere to your follow-up appointments. They are important
for managing your long-term health.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] on [**1-3**] at 9:40am.
His office can be reached at [**Telephone/Fax (1) 250**].
Please discuss your blood pressure medications at this visit.
Please also discuss a stress test for your heart during this
visit.
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2164-1-3**] 9:40.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2164-1-13**]
|
[
"882.1",
"728.88",
"303.01",
"272.0",
"250.00",
"401.9",
"E928.8",
"312.9",
"788.1",
"882.0",
"V15.81",
"785.0",
"786.59",
"E849.7",
"291.0",
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icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7556, 7562
|
3909, 6125
|
316, 323
|
7637, 7673
|
2047, 2052
|
8497, 9157
|
1326, 1416
|
6433, 7533
|
7583, 7616
|
6151, 6410
|
7697, 8474
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1431, 2028
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3159, 3886
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255, 278
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2721, 3142
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351, 853
|
2066, 2702
|
875, 980
|
996, 1310
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,793
| 171,750
|
22786
|
Discharge summary
|
report
|
Admission Date: [**2158-2-27**] Discharge Date: [**2158-2-28**]
Date of Birth: [**2091-1-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Elective admission for coronary and carotid
angiography/angioplasty.
Major Surgical or Invasive Procedure:
Angiography
Carotid [**First Name3 (LF) **] placement
History of Present Illness:
Ms. [**Known lastname **] is a 67 year-old female with a PMHx significant for
CAD, HTN, and hypercholesterolemia, now referred for carotid and
coronary angiography and angioplasty.
Per report, she was recently admitted to [**Hospital 1474**] Hospital in
[**2157-12-14**] following 3 pre-syncopal episodes. At that time,
carotid angiography revealed 80-99% stenosis in the [**Country **]. No
intervention was performed. She was referred to a [**Country 1106**]
surgeon, and deemed a poor surgical candidate. Per records, she
had another dizzy spell in [**2158-1-14**] while on a cruise. This,
however, was in the setting of poor PO intake and generally
feeling unwell. She was subsequently referred to Dr. [**Last Name (STitle) **] in
consultation, and referred today for elective carotid and
coronary angiography with endovascular intervention.
She denies ever experiencing any episodes of amaurosis,
diplopia, visual loss,
focal weakness, focal numbness, incoordination, gait difficulty,
or headache. No chest pain, no orthopnea or PND.
She is being admitted to the CCU for close observation following
[**Country **] [**Country **] placement.
Past Medical History:
Coronary artery disease, no prior MI.
Hyperlipidemia
Hypertension
Hypothyroidism
Deafness
Carpal tunnel syndrome
Past surgical history:
Status post hysterectomy
Social History:
She is deaf and lives with her son. She communicates with ASL.
She does drink a few glasses of wine per week. She is an active
smoker and smokes [**1-15**] pack per day x 49 years. She is employed
as a housekeeper. Is active in all of her ADLs.
Family History:
Colon cancer in her mother. Brother with myocardial infarction
at age 58. Father with myocardial infarction.
Physical Exam:
Physical examination on admission to CCU.
VITALS: BP 120/63, HR 77 regular, RR 22, Sat 97% on room air.
GEN: Deaf, communicates with ASL. Well-appearing. In no
distress.
HEENT: PEERL. MMM. Anicteric.
NECK: Supple neck. No carotid bruits. JVP difficult to assess.
RESP: Chest clear to auscultation anteriorly.
CVS: RRR. Normal S1, S2. No S3, S4. 2/6 SEM at heart base
radiating to both carotids. Distinct S2.
GI: BS normoactive. Abdomen soft. Mild diffuse tenderness,
non-focal.
EXT: No pedal edema. 2+ DPs, 1+ PT. Right groin (cath site): no
bruit or hematoma.
NEURO: Alert and oriented. No facial asymmetry. Strong grip.
Moves all 4 extremities.
Pertinent Results:
[**2158-2-27**] CATHETERIZATION:
PTCA COMMENTS: Initial angiography demonstrated a tight 90%
lesion of the [**Country **] sparing the bulb in a tortuous segment.
Heparin was initiated. A 6F Shuttle sheath was taken into the
RCCA over a Supracore placed in the RECA. The lesion was crossed
with a Accunet Filterwire that was deployed distally. The
lesion was then pre-dilated with a 2.5 x 20 mm Maverick at 8
ATM. A 6.0 x 30 mm Acculink was then deployed at the origin of
the [**Country **] but the [**Country **] missed covering the distal lesion.
Attempts to deliver a 6.0 x 20 mm Acculink failed secondary to
incomplete expansion of the first [**Last Name (LF) **], [**First Name3 (LF) **] we post-dilated with
a 4.5 x 20 mm Maverick at 12 ATM. We were then able to deliver
the 6.0 x 20 mm [**First Name3 (LF) **] distally and deploy it in overlapping
fashion. Attempts to recapture the filter failed secondary to
inability to deliver beyond the proximal [**First Name3 (LF) **]. We post-dilated
the proximal [**First Name3 (LF) **] again with the 4.5 x 20 mm Maverick at 12
ATM. The filter was then recaptured with some difficulty. Final
angiography demonstrated no residual stenoses, no dissections,
and normal flow. The patient became hypotensive with catheter
and balloon manipulation around the carotid bulb, but this was
responsive to IV Phenylephrine.
COMMENTS:
1. Access was retrograde via the right CFA to the selective
carotid,
subclavian, vertebral and coronary arteries.
2. Coronary angiography in this left-dominant circulation
demonstrated
no flow-limiting coronary artery disease. The LMCA was normal.
The LAD, LCX and RCA had mild irregularity without significant
disease.
3. Thoracic aorta: Type I arch without lesions.
4. Subclavian arteries: Bilaterally normal without lesions.
5. Carotid/vertebral arteries: The RCCA was normal. There were
no
critical lesions in the [**Country **]. The [**Country **] filled the ipsilateral
ACA and
MCA with contralateral filling of the ACA. The right vertebral
was normal. There were no lesions in the posterior cerebral or
cerebellar
arteries. The left vertebral was normal. The LCCA was normal.
The [**Doctor First Name 3098**] had a mid-segemnt 80-90% lesion with modest
calcification. The [**Doctor First Name 3098**] filled the MCA predominantly with the
ACA filled from the contralateral ACOM.
6. Successful stenting of the [**Country **] was performed with
overlapping 6.0 x
30 mm and 6.0 x 20 mm Acculink stents.
7. Angioseal of the groin was performed.
****************
DATA FROM OUTSIDE HOSPITAL:
[**2158-1-12**] Carotid Duplex: 80-99% stenosis at the origin of the
right internal carotid artery. The left side has a 16-49%
stenosis at its origin.
[**2158-1-12**] ECHO (OSH report): Normal LV size and function with EF
60-65%. Mild AS, peak/mean 26/15 mm Hg, peak aortic velocity 2.5
m/s. Mitral valve thickening, mitral annular calcification,
trace MR. RV size and function normal. No pericardial effusion.
Brief Hospital Course:
67 year-old female with CAD, HTN, hypercholesterolemia and
active smoker, admitted for elective coronary and carotid
angiography and endovascular intervention, now status post [**Country **]
[**Country **] placement.
1) Carotid stenosis s/p [**Country **] [**Country **] placement: Post-procedure,
she was continued on ASA, Plavix, as well as Lipitor. She was
noted to be relatively hypotensive in the CCU post-procedure
with SBP 80-90. She was bolused 1.5 liters of NS, then started
on Neosynephrine to maintain SBP>120 overnight. Neosynephrine
was slowly weaned in the morning, with concomitant
administration of IVF. Her hypotension was felt most likely
secondary to excess vagal stimulation post carotid [**Country **]
placement. She was asymptomatic, both at rest and on ambulation.
Imdur and Metoprolol were held both in hospital and at
discharge, and should be reintroduced as an out-patient.
Emphasis should also be placed on smoking cessation. Follow-up
appointments were arranged with Dr. [**Last Name (STitle) 7047**], Dr. [**First Name (STitle) **] and Dr.
[**First Name (STitle) **]. A follow-up carotid ultrasound was also scheduled in a
month (patient enrolled in CAPTURE trial).
2) CAD: Cardiac catheterization revealed no flow limiting CAD on
angiography. She was continued on ASA, Plavix, and Lipitor. As
mentionned above, Metoprolol and Imdur were held in hospital
given her relative hypotension, and should be reintroduced as an
out-patient. Please emphasize smoking cessation.
3) COPD: No acute issues in hospital. She was continued on
Combivent prn.
Medications on Admission:
Ecotrin 81mg PO daily
Imdur 30mg PO daily
Lipitor 40mg PO daily
Levoxyl 50mcg PO daily
Plavix 75mg PO daily
Metoprolol 25mg PO bid
Combivent inhaler 2puffs daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 9 months.
Disp:*30 Tablet(s)* Refills:*9*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Carotid stenosis status post carotid [**First Name (STitle) **] placement
Coronary artery disease
Hyperlipidemia
Hypertension
Secondary diagnoses:
Hypothyroidism
Deafness
Discharge Condition:
Patient discharged home in stable condition.
Discharge Instructions:
You have an appointment with Dr. [**Last Name (STitle) 7047**] on Friday [**3-3**]
at 11:30. It is important that you go to this appointment. He
will check your blood pressure and adjust your medications.
You also have a scheduled appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
(Neurology) on [**4-5**] at 13:30. Please see below for details.
We have also scheduled a repeat carotid ultrasound on [**4-21**] at
0800, followed by an appointment with Dr. [**First Name (STitle) **] at 0900. Please
see below for details.
Please call Dr. [**First Name (STitle) **] or return to the hospital if you
experience lightheadedness, dizziness, visual changes, or
numbness/tingling in your extremities.
Please take all medications as prescribed. Most importantly, you
need to take Plavix and Aspirin daily. Please note that we have
stopped Metoprolol and Imdur. Dr. [**Last Name (STitle) 7047**] will reintroduce these
medications at your follow-up appointment on Friday.
Followup Instructions:
1) You have an appointment with Dr. [**Last Name (STitle) 7047**] on Friday [**3-3**] at 11:30. It is important that you go to this appointment. He
will check your blood pressure and restart some of your
medications.
2) You have a scheduled appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
(Neurology) on [**4-5**] at 13:30 as indicated below.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2158-4-5**] 1:30
3) Finally, we have scheduled a repeat carotid ultrasound on
[**4-21**] at 0800, followed by an appointment with Dr. [**First Name (STitle) **] at
0900. Please see below for details.
- Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2158-4-21**] 8:00
- Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2158-4-21**] 9:00
Completed by:[**2158-3-1**]
|
[
"305.1",
"458.29",
"244.9",
"389.9",
"433.10",
"272.0",
"401.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"99.19",
"88.53",
"88.56",
"37.22",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
8264, 8270
|
5895, 7474
|
384, 439
|
8486, 8532
|
2871, 5872
|
9586, 10680
|
2078, 2189
|
7686, 8241
|
8291, 8418
|
7500, 7663
|
8556, 9563
|
1774, 1800
|
2204, 2852
|
8439, 8465
|
276, 346
|
467, 1615
|
1637, 1751
|
1816, 2062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,813
| 169,535
|
2384
|
Discharge summary
|
report
|
Admission Date: [**2109-6-23**] Discharge Date: [**2109-7-29**]
Date of Birth: [**2060-3-14**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Ceftriaxone / Zosyn
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
SOB, fever
Major Surgical or Invasive Procedure:
Tracheostomy Placement
PEG placement
PICC line placement
History of Present Illness:
49M h/o schizophrenia, poor historian, p/w SOB, non-productive
cough, fevers and CP. States he has had a progressively
worsening non-productive cough over the last month. Denies any
subjective fevers or rigoring chills, but admits night sweats x
1 month. Denies weight loss or known TB exposures. No recent
travel or sick contacts. Over the last 5-7 days, his symptoms
have worsened. He began experiencing chest pain, though only
when coughing. Was found to be hypertensive to 160s/100s,
tachycardic to 130s by EMS, satting 90% on 2L NC (RA sat not
recorded). Given ASA 325mg by ems and nitro sl.
.
In the ED, he was febrile to 102.3F and tachycardic to 130s w/
inferior STD and RAD on ECG. Heartrate improved to 100s with a
total of 4L NS. CE's negative x2 although CK elevated at 2609
with negative MB fraction. CXR w/ LUL consolidation. CTA chest
negative for PE, and reconfirmed lobar LUL consolidation with
prominent air bronchograms. Bedside echo negative for effusion.
WBC 20.9 w/ left shift of 10% bands; lactate 2.3. Blood cultures
sent and given levofloxacin, combivent nebs. Other labs notable
for Na 127 and Cre 1.9 that improved to 132 and 1.3,
respectively, after IV hydration. As patient remained
tachycardic and hypoxic, satting 93% on 4L NC, admitted to the
MICU for management.
Past Medical History:
Schizophrenia - h/o hospitalization at [**Hospital 1263**] Hospital and
[**Hospital1 1680**] JP
HTN
Social History:
rare EtOH, +smoker, currently trying to quit, last cigarette [**3-12**]
days ago, no h/o cocaine. Lives at home with mother, on
disability. Has been court ordered to take Haldol IM 100 mg q30
days until [**1-16**] because of assault charges.
Family History:
T2DM
Physical Exam:
T HR BP RR SaO2 Weight
General: Anxious appearing Hispanic male, diaphoretic, having to
stop in midsentence to breathe. Warm to the touch.
HEENT: PERRL, EOMI, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: Tachycardic, regular rhythm, s1s2 normal, no m/r/g, no
JVD
Pulmonary: Mild rhonchi and inspiratory wheezing LUL, slight
decrease to percussion and egophony.
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, no edema, no calf tenderness
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities
Pertinent Results:
CBC: Max WBC 19.3, 11.8 on d/c.
.
Chem-7: Max K: 5.3 on [**7-20**]
Max P04: 7.5
Max Na: 150 on 7.13
Baseline Cre: 1.1,
max of 7.6 on [**7-8**], d/c-ed at Cre of 4.4 on [**7-29**].
.
LFTs: Max Tbili: 11.3, down to 2.5 on d/c.
Hct: 34 on admit, min 20.9 on [**2109-7-10**], stable at ~24 x5 days on
d/c.
.
Lactate: max 4.0 at admit, 0.8 on [**2109-7-24**]
Micro:
2 blood cx's + for coag neg staph. ([**6-28**], [**7-12**]).
remainder of 33 blood cx's neg.
.
BALs ([**7-3**], [**7-17**]): neg on GS, cx's for
Legionella/PCP/fungal/viral all neg.
.
Catheter tip (R IJ) [**7-18**]: + for MRSE. All other cath tip cx's
neg (central lines/a-lines/HD femoral catheter)
.
all sputum cx's neg for bacteria/mycobacteria/fungal/viral
.
stool cx's neg for C.diff x5, neg for SSYCE organisms, and OVA +
Parasites.
.
Pathology:
R upper arm bx: ([**7-9**]) focal spongiosis w/ perivascular
dermatitis (rare PMNs, dyskeratotic cells, and eosinophils) c/w
drug eruption, vasculititis not suspected. all
bacterial/fungal/viral cx's negative.
.
IMAGING:
CARDIOLOGY*****************
TTE: ([**6-25**]) The left atrium is normal in size. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with mild
global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve is not well seen. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. The mitral valve
leaflets are structurally normal. No masses or vegetations are
seen on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
No masses or vegetations are seen on the tricuspid valve, but
cannot be fully excluded due to suboptimal image quality. The
pulmonary artery systolic pressure could not be determined.
.
IMPRESSION: Suboptimal image quality. Normal left ventricular
global function. Right ventricle is dilated, hypertrophied, and
mildly hypokinetic. No vegetations identified. If clinically
suggested, the absence of a vegetation by 2D echocardiography
does not exclude endocarditis.
.........................
TTE: [**2109-7-2**]
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is dilated with mild
global free wall hypokinesis. The aortic valve is not well seen.
No masses or vegetations are seen on the aortic valve, but
cannot be fully excluded due to suboptimal image quality. The
mitral valve leaflets are structurally normal. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Physiologic mitral
regurgitation is seen (within normal limits). No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. There is an anterior
space which most likely represents a fat pad.
.
IMPRESSION: Suboptimal study. No obvious vegetations identified,
but valvular structures not well visualized. If clinically
indicated, a TEE may better assess for valvular endocarditis.
Normal eft ventricular systolic function. Dilated right
ventricle with global hypokinesis. Marked resting tachycardia.
.
Compared with the prior study (images reviewed) of [**2109-6-25**],
the findings are similar.
...............................
TTE ([**2109-7-19**]) The left atrium is mildly dilated. 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 60-70%) The right ventricular cavity
is dilated with normal free wall contractility. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. 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 pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a fat pad.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis
VASCULAR
LENIs: IMPRESSION: No evidence of DVT on [**7-3**] or [**7-19**] studies.
RADIOLOGY
.....................................
[**2109-7-18**] RUQ U/S: 1. Large amount of sludge within the
gallbladder. No intrahepatic or extrahepatic biliary dilatation.
2. Small right pleural effusion.
.
[**2109-7-10**] RUQ U/S: IMPRESSION: Sludge within the gallbladder,
without son[**Name (NI) 493**] evidence for acute cholecystitis.
.
[**2109-7-4**] RUQ U/S: IMPRESSION:
1. Sludge within the gallbladder. No son[**Name (NI) 493**] findings
specific for acute cholecystitis.
2. Trace ascites. Right-sided pleural effusion.
.
[**2109-6-28**] Abdominal U/S:
IMPRESSION:
1. No signs of cholecystitis and no biliary dilatation.
2. Bilateral pleural effusions.
3. Trace of ascites.
.....................................
[**2109-7-17**] Head CT: FINDINGS: There is no acute intracranial
hemorrhage or major vascular territorial infarct, hydrocephalus
or edema. The ventricles and sulci are normal in appearance.
There are no fractures. There is diffuse opacification of the
paranasal sinuses and mastoid air cells.
IMPRESSION: No intracranial process. Diffuse mucosal thickening
in the
paranasal sinuses and mastoid air cells.
.
[**2109-7-17**] CT Chest/Abdomen/Pelvis: IMPRESSION:
1. Interval worsening of bilateral effusions bilaterally,
consolidation and collapse. No evidence of loculated effusion.
Intravenous contrast
would be necessary to definitely rule out empyema.
2. Right upper lobe nodule, which is likely also infectious.
Suggest follow- up on subsequent imaging.
3. No acute intra-abdominal process, GB normal.
.
[**2109-6-22**] CTA Chest: 1. Extensive pneumonic consolidation
involving the lingular and apical posterior segments of the left
upper lobe, perhaps necrotizing. 2. No evidence of PE or aortic
dissection.
..........................
[**2109-7-6**] Renal U/S: IMPRESSION: Normal renal ultrasound. No
evidence of hydronephrosis. Non specific enlarged size of
bilateral kidneys, [**Month/Day/Year **] correlation is recommended.
.............................
CXR ([**6-22**]) admission:
PORTABLE UPRIGHT CHEST: Dense airspace opacity involving the mid
left lung
with numerous air bronchograms is unchanged. The remainder of
the lungs are
clear, without evidence of effusion or pneumothorax. The
cardiomediastinal
silhouette is normal.
IMPRESSION: Unchanged pneumonic consolidation in the left mid
lung.
.
Brief CXR summaries: consolidation increased to complete
opacificatin of the entire L lung, c/w multilobar PNA. L pleural
effusions developed, along w/ increased consolidation of R
mid/lower lung zones. Some c/f superimposed CHF. Pneumonia on
CXR noted to be stabilized around [**2109-7-19**]. Likely progression to
fibrosis, resolving inflammation, hepatization,
stabilization/decrease noted in pleural effusions, improved
aeration of lung bases.
.
CXR (on discharge)[**7-28**]:
HISTORY: Progressive resolution of pneumonia.
FINDINGS: In comparison with the study of [**7-26**], there may be
further slight decrease in opacification in the left lung
consistent with pneumonia. The right lung remains clear.
Tracheostomy tube is in place.
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM
.
49 yoM with a hx of schizophrenia diagnosed with ARDS 2' to
Legionella PNA -- the patient was intubated for hypoxic
respiratory distress from [**2109-6-23**] to [**2109-7-19**], treated with a 21
day course of Levofloxacin, and received a tracheostomy on
[**2109-7-19**]. His hospital course was complicated by persistent
fevers attributed to a a pneumonia and later drug
hypersensitivity reaction (Zosyn vs. Vancomycin vs.
Ceftriaxone), a line infection, and acute renal failure
requiring CVVH.
.
1. Respiratory failure/ARDS from Legionella PNA: Patient had
hypoxic respiratory decompensation requiring ventilatory
support. He was diagnosed w/ Legionella PNA (positive Legionella
urine antigen on [**2109-6-24**]) and completed a 21-day course of
Levofloxacin on [**7-18**]. He was intubated on [**6-23**] and remained
intubated until [**7-19**]. He had extensive dead space, calculated
to be 67% on [**7-16**]. He had 2 BALs on [**7-3**] and [**7-17**] which showed no
growth on all cultures. His ventilatory settings were requiring
high PIPs and PEEP, with stable plateau pressures. ETT was
found to be clogged with hardened secretions, and was unable to
be exchanged by anesthesia. Interventional Pulmonary was called,
and successfully cryoprecipitated and removed the hardened
secretions.After the ETT cleaning, and finishing his antibiotics
course, he tolerated a ventilatory wean, with a decrease in his
PEEP down from 20s to 8 on [**7-18**], despite demonstrated an
interval worsening of pleural effusions on Chest CT. His CXRs
showed stabilized PNA of the L lung after he was extubated on
[**2109-7-19**], and remained stable/improved for the remainder of his
hospital course. A tracheostomy was placed on [**7-19**], and he was
placed on pressure support with eventual transfer to trach mask
with cool nebs and oxygen. A PM valve was fitted by Speech and
Swallow on [**7-25**] so the patient could speak and use along with
his trach mask. His sedation was weaned from fentanyl drip to
fentanyl patch and versed drip to valium PO, and agitation was
controlled by PO and IM Haldol (see Schizophrenia below).
.
2. Mental status: Patient intubated/sedated from [**6-23**] until
[**7-19**]. He received trach on [**7-19**]. By [**7-24**], patient became much
more awake and able to follow commands as well as interact with
the medical team. Mental status continued to improve and
patient received PM valve for intermittent use on [**7-25**]. On
discharge, he was interacting appropriately with staff.
.
3. Fevers, Sepsis- The patient had persistently elevated fevers
throughout his hospital course. The differential diagnosis was
broad, including:
-- CAP/HAP (+ Cx from [**7-12**] showed coagulase negative staph, and
patient was placed on vancomycin/zosyn for coverage of hospital
acquired PNA. His sputum and blood cultures remained negative,
and these antibiotics were stopped with the advent of the drug
rash, and he was transitioned over to Levoquin after his urine
legionella antigen returned positive.
.
-- Drug fevers: The patient was seen by dermatology on [**2109-7-9**]
for a worsening rash on his upper extremities and chest while he
was on Vancomycin/Zosyn. Dermatology diagnosed him with a drug
rash, (skin biopsy on [**2109-7-9**] showed focal spongiosis and
perivascular dermatitis w/ rare PMNs and eosinophilia c/w drug
eruption w/o vasculitis) with likely offenders being ceftriaxone
vs. B-lactams. He was treated with clobetasol, and his rash
resolved.
.
Pt subsequently had positive blood cx's and a R IJ catheter tip
cx positive for coag neg staph on [**2109-7-12**] and [**2109-7-18**],
respectively. He was restarted on Vancomycin on [**2109-7-12**] for a
line infection, and received a 10 day course. During this time,
he continued to spike fevers as high as 102 F, rigors (treated
w/ demerol), and rashes on his upper extremities, chest, and
flexor aspects of knees BL worsened. He was extensively cultured
throughout this period, with no growth. His differential showed
an elevated eosinophilia of 12.4%, leading the team to suspect a
drug fever to either Vancomycin or Zosyn. His antibiotics were
discontinued (Zosyn on [**7-21**], Vancomycin on [**7-22**] after a 10 day
course for his line infection), clobetosol ointment was
re-started. He defervesced to temps in the 100s, his
eosinophilia resolved, and his rashes improved.
Other sources of fever were investigated, but were ruled out,
including possible acute cholecystitis (LFT abnormalities and
elevated bilirubins noted, distended abdomen, icteric sclera,
but RUQ U/S negative on [**7-19**] and Abdominal CT on [**7-17**] was
negative), C. diff infection (negative x3), endocarditis (TTE on
[**7-19**] negative for vegetations), and UTI (urine cx's all
negative).
.
It was also thought possible that fevers during his early
intubation period had been masked previously w/ hypothermic
fluid from CVVH.
.
4.ARF- Cre peaked at 7.6 on [**7-8**]. Thought to be likely ATN in
the setting of hypotension and of exposure to possible
nephrotoxic drugs such as vancomycin. Line was placed for CVVH
on [**7-8**], which was continued until [**7-16**] when U/O began to
increase. U/O noted to be very dependent on BPs. SBPs were
maintained in the 120s-160s, and the amount of fluid pulled off
by dialysis was titrated to blood pressure. Patient was treated
with Lasix as needed to improve UOP and in response to fluid
overload/pleural effusions noted on CXR. Creatinine slowly
trended downwards over latter hospital course, and was 4.4 on
discharge. Electrolyte abnormalities were treated as needed
(kayexalate for elevated Potassium, and renagel for elevated
phosphate.) His foley was removed on [**7-27**], and his urine output
remained well above 100 ccs/hr.
.
5. Anemia: In the setting of hypotension patient had coffee
ground emesis, requiring transfusion of two units of pRBCs. HTC
responded and then stabilized. Fecal occults negative throughout
and no more NG tube coffe ground emesis afterwards. Anemia was
thought to be secondary to initial renal failure and sepsis. Pt
was on epo, which was discontinued prior to d/c. Hct stable at
~24 on discharge.
.
6. Hyperbilirubinemia: Patient had evidence of cholestatic liver
picture (persistenly elevated LFTs, bili elevated, sclera
icteric, distended abd), likely associated w/ TPN. Abd CT on [**7-17**]
showed no acute gallbladder processes. RUQ ultrasound on [**7-19**]
showed sludge but no ductal dilatation, wall thickening, or
stones. Tube feeds through PEG were initiated. Starting on
[**7-27**], LFTs and Bili trended downward; ursodiol 300 PO BID
was started per hepatology and was continued on discharge.
.
7. Drug hypersenitivity rash: See Fever/Sepsis above as well.
Patient developed large dark brown to reddish purple, flat rash,
covering the back and armpit area from neck to buttocks, first
noted on [**7-2**]. derm bx showed focal spongiosis w/ perivascular
dermatitis w/ rare PMNs and eosinophils and rash was thought to
be [**2-9**] beta lactam or ceftriaxone. Topical steroids (clobetasol
ointment w/ saran wrap for improved occlusion) were started and
the rash improved. He later began to spike fevers as per above,
and peripheral eosinophilia was noted (12.4%) and it was thought
these fevers were likely representative of drug fever. He then
re-developed a desquamating rash with Vancomycin/Zosyn and was
restarted on clobetasol; the rash improved and peripheral
eosinophilia decreased slightly.
.
8. Schizophrenia: Patient had long history of paranoid
schizophrenia complicated by medication non-compliance resulting
in many psychiatric hospitalizations. Patient's medications
were held while he was intubated; after extubation psych was
consulted re: patient's psychiatric medications. Psychiatry was
instrumental in obtaining his past psychiatry records from
[**Doctor Last Name 1263**] and [**Hospital1 1680**] JP and [**Hospital1 **], which indicated that patient is
court ordered until [**1-16**] to take IM Haldol 100 mg q30 days, and
has been on Zyprexa (5-20 mg Qdaily) in the past.
.
He was kept sedated w/ propofol/versed/fentanyl during his
intubation. As he was transitioned to trach mask, psychiatry was
consulted, and he was started on haldol 1-2mg PO TID per their
recs, as well as haldol 5 mg IV/IM PRN agitation. EKG was
monitored for prolonged QTc while on haldol, and remained < 440.
He also had a standing order from state court mandating a 100mg
monthly haldol injection, which was given on [**7-26**]. His standing
haldol was then weaned and stopped completely on [**2109-7-29**]. His
sedation was also weaned from a fentanyl drip to a fentanyl
patch, and his versed drip was changed to valium 5 mg PO TID,
which was weaned and stopped on [**2109-7-29**]. He remained
appropriate interactive with staff, w/o psychosis,
hallucinations, or thought disorders after being extubated.
.
9. HTN: Patient was persistently hypertensive during his stay,
with high SBPs to the 180s. He had no history of any
antihypertensive medication use. Target SPB 120-160 and patient
was treated with standing labetalol and given hydralazine PRN
for BP control. His PO labetolol was titrated to 200 mg PO TID,
and IV anti-hypertensives were discontinued.
.
10. Hypernatremia: Patient developed hypernatremia because of
significant free water deficit [**2-9**] fever, dialysis, tube feeds.
He was given free water boluses and IV D5W to correct the
hypernatremia. His Na resolved to low 140s prior to discharge.
.
11. FEN- Patient was initially placed on TPN but this was D/C
after increasing LFTs. Patient received PEG on [**7-19**] and then
received tube feeds. Once he was off sedation and passed speech
and swallow eval, his diet was advanced to regular. His
electroLytes were checked daily.
.
# PPx: continued on PPI (d/c-ed on [**7-28**]), heparin sc,
pneumoboots, bowel regimen.
.
# Access: PICC line.
.
# Code status: Full Code on discharge. (was DNR on [**7-10**], reversed
on [**7-24**] based on improved MS [**First Name (Titles) **] [**Last Name (Titles) **] picture)
.
Dispo: Rehabilitation.
Medications on Admission:
Haldol Decanoate IM q1mo, dose unknown
Discharge Medications:
1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): via PO or Gtube.
2. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): hold for SBP<100, HR<60 .
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 6-15 Puffs
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
7. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
injection Injection three times a day.
8. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for agitation.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 686**]
Discharge Diagnosis:
ARDS 2' to Legionella PNA
Acute Renal Failure
Line Infection
Anemia
Drug Rash
Drug associated Fevers
Schizophrenia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the [**Hospital1 18**] with a diagnosis of legionella
pneumonia and acute respiratory distress syndrome (ARDS) that
required you to be intubated and mechanically ventilated from
[**2109-6-23**] to [**2109-7-19**]. You were treated with three weeks of an
antibiotic called Levofloxacin for your pneumonia. You also
developed renal failure (failure of the kidneys) requiring
dialysis (running your blood through a filter to remove the
build-up of toxic particles and electrolytes.)
You were eventually taken off the ventilator, and a tracheostomy
was placed in your neck to help you breathe, with a valve to
help you talk. You also developed a line infection, which was
treated with a 10 day course of antibiotics. You also had
persistent fevers and a skin which we discovered were due to a
drug sensitivity/allergy to Vancomycin and/or Zosyn. You also
have a PICC line (a peripherally inserted central line) from
which blood can be drawn and medication can be administerred.
You also were restarted on your psychiatric medications, as you
have been given your Haldol 100 mg IM, with your next dose due
on [**2109-8-26**]. You are also being discharged on Actigall for
treatment of your elevated bilirubin levels, and Labetolol 200
mg PO three times a day for your blood pressure. You are being
discharged to a rehabilitation center where your tracheostomy
can be properly cared for, you can obtain physical therapy to
become stronger, and your labs can be check daily to monitor
your kidney failure.
Please return to the nearest emergency department or contact
your primary care physician if you experience any of the
following symptoms:
Temperature greater than 102 F, increased shortness of breath,
worsened cough, increased chest pain with coughing, loss of
consciousness, shaking chills, light
headedness/dizziness/hypotension. Also return if your urine
output starts to decrease to less than 15 ccs/hr, indicating
worsening renal failure. Please also return if your mood changes
significantly, if you are having difficulty with your thoughts,
start hearting voices, or you start feeling thoughts of wanting
to commit suicide or to hurt other people, or if those around
you feel your previous symptoms of psychosis are returning and
you may be a harm to yourself or others. Please also return if
you experience any other symptoms not listed here that are
concerning to you or to your rehabilitation center.
Followup Instructions:
--Please follow up with the psychiatrists who follow you (Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12355**]: [**Telephone/Fax (1) 12356**], [**Location (un) 12091**] Community Health
Center).
--Please follow up with your primary care physician at [**Name9 (PRE) 12091**]
Community Health Center (unknown).
--You may contact Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] at [**Telephone/Fax (1) 817**] for
outpatient renal follow-up.
Completed by:[**2109-8-13**]
|
[
"996.59",
"578.0",
"584.5",
"482.84",
"693.0",
"276.2",
"785.52",
"285.9",
"995.92",
"276.6",
"E879.8",
"560.1",
"E915",
"999.31",
"934.0",
"E930.8",
"518.84",
"305.1",
"038.8",
"401.9",
"295.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"33.24",
"38.91",
"39.95",
"96.56",
"31.1",
"38.93",
"96.6",
"96.04",
"96.72",
"33.23",
"86.11",
"38.95",
"99.15",
"00.12"
] |
icd9pcs
|
[
[
[]
]
] |
21838, 21910
|
10703, 12855
|
304, 363
|
22069, 22075
|
2748, 8343
|
24555, 25060
|
2087, 2093
|
20908, 21815
|
21931, 22048
|
20845, 20885
|
22100, 24532
|
2108, 2729
|
254, 266
|
391, 1689
|
8352, 10680
|
12870, 20819
|
1711, 1812
|
1828, 2071
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,428
| 167,305
|
16892
|
Discharge summary
|
report
|
Admission Date: [**2116-11-4**] Discharge Date: [**2116-11-6**]
Date of Birth: [**2095-5-6**] Sex: F
Service: MEDICINE
Allergies:
Sulfamethizole / Zosyn / Penicillins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
hemodialysis with 4 L fluid removed.
History of Present Illness:
21 year old woman with a history of ESRD, SLE, lupus nephritis,
BOOP, h/o pericarditis, who was admitted for exertional
dyspnea/orthopnea. SHe is now transferred for acute desat on the
floor.
.
Her symptoms began yesterday after HD. SHe complains of DOE and
orthopnea. She had to sleep sitting up in a chair last night.
Dry weight after HD yesterday was 54kg. She was seen in clinic
yesterday for scheduled appointment and was sent from clinic.
Her weight was 56 kg. Of note, she was recently admitted in
[**10-5**] for SOB thought to be from volume overload and resolved
with dialysis.
.
In the ED, initial VS T97 P88 BP164/124 R18 95% on RA she was
given her home doses of celexa and metoprolol as well as a dose
of ambien. On the floor, patient trigerred for desat to 88% on
RA and increased to 100% on NRB. Other VS were R50 T99.4 P102
BP172/102. EKG was unchanged. Hydralazine 10mg and ethacrynic
acid 50mg given. CXR was though to be consistent with fluid
overload.
.
Seen in MICU, feeling better, RR down to 20s, saturating well on
5L NC. Admits to mild pleuritic chest pain, has had similar
pain with episodes of fluid overload.
Past Medical History:
-Hypertension
-ESRD, presumed [**1-2**] lupus nephritis -> HD T,TH,Sat
-BOOP of unclear etiology diagnosed during [**2116-5-13**] admission
-h/o pericarditis c/b pericardial effusion w/o tamponade
-h/o Right lower extremity myositis NOS
-HSV Type 1 infection
Social History:
She is no longer working or going to school, but plans to go
back to school in [**Month (only) 404**]. She used to work as a waiter with
[**Last Name (un) 47587**] Puck catering. She was a former student at [**First Name4 (NamePattern1) 392**]
[**Last Name (NamePattern1) 1688**]. She reports no tobacco or alcohol use and reports no
other drug use.
Family History:
Sister with lupus. Mother with asthma, cousin with [**Name2 (NI) 14165**] cell
trait; no other issues. No history of bleeding diatheses.
Physical Exam:
VS: Temp 97.5, HR 108, BP 149/96, RR 31, O2 sat 97% on 5L NC
Gen: young woman, shallow breats, mild accessory muscle use,
able to speak in full sentences:
HEENT: anicteric, OP clear, MMM, tunneled R subclavian line in
place
Neck: no JVD, no LAD
Resp: crackles at bases, moves good air, no wheezes
Abd: soft, ND, NT, + BS
Extr: no edema, good distal pulses
Neuro: AAOx3, non-focal
.
Pertinent Results:
[**2116-11-4**] 11:15PM CK(CPK)-17*
[**2116-11-4**] 11:15PM cTropnT-0.02*
[**2116-11-4**] 11:15PM CK-MB-NotDone
[**2116-11-4**] 05:00PM GLUCOSE-80 UREA N-27* CREAT-8.0*# SODIUM-139
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-27 ANION GAP-18
[**2116-11-4**] 05:00PM estGFR-Using this
[**2116-11-4**] 05:00PM WBC-3.3* RBC-5.26 HGB-13.9 HCT-43.6 MCV-83
MCH-26.4* MCHC-31.8 RDW-18.9*
EKG: sinus tachycardia, nl axis, nl intervals, old T wave
inversions anterolaterally, good voltage, no QRS alterations
Echo [**11-5**]- The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is moderate global left ventricular hypokinesis (EF
30-35%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
left ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The estimated
pulmonary artery systolic pressure is normal. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is a small (0.7
cm behind LA, 1.0 cm lateral to RV) pericardial effusion.
Brief Hospital Course:
MICU course: 21 yof with ESRD, SLE admitted with SOB on the
floor to the MICU. Patient's hypoxia most likely [**1-2**] pulmonary
edema, given similar prior hx, some weight gain, and appearance
on CXR. No evidence of pneumonia. Echo showed slightly lower
EF compared to previous and small pericardial effusion. Patient
was dialysed for ~4L negative in the ICU and her symptoms
improved. PE was lower on the differential for her hypoxia, and
CTA was deferred given her marked improvement after dialysis.
Patient was also hypertensive on admission to the ICU and also
during hemodialysis. She was given one dose of nifedipine 10mg
along with resuming her medications. Her lisinopril was
increased to 40 mg daily from 20mg. Norvasc was continued at
outpatient dose. Echocargiogram was obtained which showed small
pericardial effusion as well as a depressed EF. Cardiology was
consulted and recommended a cardiac MRI to evaluate the observed
pattern of diastolic dysfunction to see if there may be
myocardial enhacement or edema related to SLE. In addition,
toprol was increased and changed to toprol XL at 200mg daily.
She was discharged home with plans to have regularly scheduled
dialysis tomorrow, have outpatient MRI and f/u with Dr. [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 437**] from cardiology. Prescription for toprol xl was provided.
Medications on Admission:
MEDICATION AT HOME
1. Amlodipine 10 mg
2. B Complex-Vitamin C-Folic Acid 1 mg (nephrocaps)
3. Sevelamer 800 mg Tablet PO TID
4. Lisinopril 20 mg PO DAILY
5. Aspirin 81 mg Tablet
6. Citalopram 20 mg
7. Metoprolol Tartrate 50 mg PO BID
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Toprol XL 200 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure
End stage renal disease
Discharge Condition:
stable
Discharge Instructions:
Please take your medications as prescribed. Your metoprolol was
increased. You should have your regularly scheduled dialysis
tomorrow. Cardiac MRI was ordered and you will be called to
schedule a time for this.
Please follow-up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 9304**] below. You
should seek medical attention if you develop any further chest
pain, shortness of breath, fever, chills, or any other
concerning symptoms. Check your weight daily and notify your
doctor if it increases by more than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2116-11-9**] 3:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 6405**] [**Name (STitle) 6406**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2116-11-11**] 8:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2116-12-30**] 2:30
You should received a phone call to schedule the cardiac MRI.
You should follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] from Cardiology after
your MRI has been done. Please call ([**Telephone/Fax (1) 13786**] to schedule
this appointment within 4 weeks.
Completed by:[**2116-11-6**]
|
[
"582.81",
"585.6",
"428.0",
"428.31",
"710.0",
"516.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6407, 6413
|
4125, 5503
|
299, 337
|
6506, 6515
|
2727, 4102
|
7105, 7873
|
2172, 2310
|
5787, 6384
|
6434, 6485
|
5529, 5764
|
6539, 7082
|
2325, 2708
|
256, 261
|
365, 1507
|
1529, 1789
|
1805, 2156
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,196
| 112,776
|
6780
|
Discharge summary
|
report
|
Admission Date: [**2117-9-15**] Discharge Date: [**2117-9-30**]
Date of Birth: [**2042-8-13**] Sex: F
Service: SURGERY
Allergies:
Cephalosporins / Theophylline / Prevacid
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Abdominal pain with BRBPR
Major Surgical or Invasive Procedure:
Total abdominal colectomy and ileostomy ([**2117-9-15**])
Tracheostomy ([**2117-9-22**])
History of Present Illness:
Pt is a 75F with oxygen depended COPD and T2DM on insulin,
who was treated at OSH with levaquin from [**Date range (1) 25729**] for [**Date range (1) 25730**]
pneumonia. She was discharged home and was doing well until
yesterday afternoon when she began experiencing sudden left
sided
abdominal pain with nausea/vomiting and bloody diarrhea.
She was evaluated at OSH ED, where on presentation she was
afebrile, with SBPs 170s and HR 71. WBC was elevated at 24.4,
with 78% PMNs, 8% Bands. LFTs were normal, lactate 2.8. KUB
showed no evidence of free air, CT ab/pelvis showed fluid loops
in the small bowel and colon with wall thickening transverse and
descending colon, and atherosclerotic calcifications throughout
the abdominal aorta with apparent decreased flow throughout the
celiac axis. The surgery and ID services were consulted, and
were
concerned for ischemic vs. infectious colitis (given her recent
levaquin use for pna). Prior to transfer to [**Hospital1 18**], she received
100 mg stress dose steroids, IV levaquin and flagyl x 1 this
morning, and zosyn IV x1 this afternoon.
Past Medical History:
-Oxygen and steroid dependent COPD (3L)
-T2DM on insulin
-Htn
-LGIB in past of unclear etiology
-[**Name (NI) 25730**] pna [**7-/2117**], tx'ed with levaquin [**Date range (1) 25729**]
-GERD
Past Surgical History:
-s/p CCY
-s/p hysterectomy
Social History:
-Lives with husband, former [**Name2 (NI) 1818**] but none since [**2097**]; no EtOH
Family History:
Noncontributory
Physical Exam:
On admission:
Vitals: T 99.1, HR 107, BP 103/48, RR 30, 94% 3L
GEN: Generally uncomfortable, though AOx3
HEENT: No scleral icterus, mucus membranes dry
CV: No M/G/R
PULM: inspiratory crackles left lower lung fields
ABD: Moderately distended, diffuse tenderness, +guarding,
evidence of peritoneal irritation
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2117-9-30**] 02:09AM BLOOD WBC-14.1* RBC-3.26* Hgb-10.6* Hct-30.5*
MCV-94 MCH-32.6* MCHC-34.7 RDW-14.2 Plt Ct-434
[**2117-9-30**] 02:09AM BLOOD Glucose-199* UreaN-19 Creat-0.6 Na-137
K-3.8 Cl-96 HCO3-32 AnGap-13
[**2117-9-30**] 02:09AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
[**2117-9-28**] 06:49PM BLOOD Lactate-1.3
.
CHEST (PORTABLE AP) Study Date of [**2117-9-22**] 3:10 AM
FINDINGS: Single AP view of the chest shows an ET tube to be 4.8
cm above the carina. An OG tube courses over the esophagus and
off the screen past the GE junction. A right IJ catheter tip
terminates in the low SVC. Unchanged small bilateral pleural
effusions and left basilar atelectasis. Increasing opacity at
the right lung base likely represents gravitational edema
recurrence of aspiration in the right clinical setting should be
considered. Cardiac silhouette remains large. No pneumothorax.
Aortic calcifications noted.
CHEST (PORTABLE AP) Study Date of [**2117-9-29**] 4:32 AM
FINDINGS: In comparison with the study of [**9-28**], the monitoring
and support
devices remain in good position. Continued opacification at the
left base is consistent with atelectasis and effusion. Little
overall change in the degree of pulmonary vascular congestion.
The patient has taken a somewhat better inspiration.
.
Portable TTE (Complete) Done [**2117-9-16**] at 12:40:22 PM
Small, hyperdynamic left ventricle with mid-cavitary pressure
gradient. Dilated right ventricle. No clinically significant
valvular regurgitation or stenosis. Mild pulmonary artery
systolic hypertension. Very small pericardial effusion.
Compared with the prior study (images reviewed) of [**2114-1-5**],
the left ventricle is now small and hyperdynamic with a
mid-cavity pressure gradient identified. Right ventricular
dilitation is now seen. Mild pulmonary artery systolic
hypertension is present on the current study and was not
previously assessed.
.
Pathology Examination ([**2117-9-15**])
I. Right and transverse colon, open colectomy, A-M:
1. Patchy mucosal and focal transmural necrosis.
2. Ileal and colonic resection margins free of necrosis.
3. Status post appendectomy.
4. See note.
II. Splenic flexure, ascending and descending colon, open
colectomy, N-Y and AB:
1. Patchy mucosal and focal submucosal necrosis with focal
transmural acute inflammation.
2. Mucosal necrosis present at one resection margin.
3. The other resection margin free of necrosis.
III. Terminal ileum, open colectomy, Z-AA: Patchy mucosal
necrosis at stapled end; see note.
.
Microbiology:
[**2117-9-18**] 7:45 am SPUTUM Site: ENDOTRACHEAL
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- 32 I
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
[**2117-9-20**] 4:26 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
RESPIRATORY CULTURE (Final [**2117-9-22**]):
Commensal Respiratory Flora Absent.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
329-4820F
ON [**2117-9-18**].
Brief Hospital Course:
Mrs [**Known lastname 25731**] was transferred to [**Hospital1 18**] on [**2117-9-15**] with severe
abdominal pain and bright red blood per rectum concerning for
ischemic vs infectious colitis and was taken emergently to the
operating room for an exploratory laparotomy, total abdominal
colectomy and end-ileostomy. The patient was trensferred to the
surgical ICU post-op for close monitoring, where she remained
throughout her hospital stay.
Neuro: the patient was sedated on propofol and intermittent
fentanyl and midazolam while intubated. After tracheostomy was
placed, the patient's sedation was weaned to intermittent
fentanyl and ativan only.
CVS: the patient required pressors post-op and was successfully
weaned off within 24 hrs from her operation, and given albumin
and pRBCs for fluid status and blood pressure support.
Resp: the patient remained intubated until POD2, when she was
extubated but subsequently became tachypneic with desaturation,
and required re-intubation. A second attempt at extubation was
made on POD5, but she again experienced desaturations with RLL
mucous plugging suggestive of possible aspiration event. She
was again re-intubated at this time. Sputum cultures grew ESBL
E.Coli organisms, and she was started on meropenem for a 14 day
course. A decision was made to proceed with tracheostomy, and
she received a bedside trach on [**2117-9-22**]. She tolerated this
well, and was weaned to pressure support and eventually to
intermittent trach collar, with rest periods on the ventilator.
GI/FEN: the patient was NPO on IVF with an NGT in place post-op.
She was started on tube feeds on POD4 with a concentrated
formula, which was eventually switched to Replete (currently at
goal rate of 55 cc/hr).
GU: urine output was closely monitored post-op. Her creatinine
initially increased to 1.3 from a baseline of 1 and went back to
baseline on POD1. Her Cr remained stable throughout her stay,
and her BUN rose in the postoperative period but then returned
to baseline. She was started on Lasix 20 [**Hospital1 **] on POD2 due to
fluid third-spacing, and was eventually transitioned to her home
dose of 80mg daily via her NGT. This dose was decreased to
lasix 40 daily on [**2117-9-29**] and she was started on diamox due to a
rising CO2 level.
Heme: the patient received 1U of PRBC on POD0. Her Hct was
closely monitored, and was stable. She did receive albumin on
POD 2,3,and 5, but did not require any additional RBCs.
Endo: the patient was on an insulin drip for 24 hrs post-op for
tight glycemic control. The [**Last Name (un) **] service was consulted and
followed this patient throughout her stay. She was transitioned
off the insulin drip and eventually to a combination of [**Hospital1 **] NPH
insulin plus a regular insulin sliding scale.
ID: Zosyn and Flagyl was started on POD0, and she was switched
to meropenem on POD5 after sputum cultures grew ESBL E.Coli with
sensitivity to meropenem. She had a persistently elevated WBC
count beginning on POD6 which slowly trended down through the
remainder of her hospital course. A CT abdomen/pelvis on [**2117-9-25**]
failed to reveal any abdominal fluid collections to explain her
leukocytosis. C.difficile was negative x2, and her central line
was replaced with no growth from the catheter tip. Her CVL was
eventually D/C'ed after a PICC line was placed on [**2117-9-29**].
Vancomycin was added on [**2117-9-28**] after an area of erythema was
noticed at the inferior portion of her abdominal incision.
There did not appear to be a drainable collection, and the
erythema is stable on the vanco, of which she is to complete a
10-day course.
Proph: the patient received famotidine and SQH throughout her
stay. She also had venodyne boots in place while in bed.
Medications on Admission:
Singulair 10', Advair 500/50'', Insulin SS, Insulin Humulin
28Units QAM, 10 units QPM, Pravastatin 10' Ativan 0.5mg'',
Diltiazem 240'', ventolin inhaler, Lisinopril 40', Fosamax 35,
Prednisone 5', Vitamin D, Trazodone 100', Wellbutrin 100'',
Lasix 80', Toprol 25'
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
2. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. prednisone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for anxiety.
8. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours).
11. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 4 days: continue through
[**2117-10-4**] to complete 14 day course.
12. acetazolamide sodium 500 mg Recon Soln Sig: Two Hundred
Fifty (250) mg Injection once a day.
13. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 8 days: continue through
[**2117-10-8**] to complete 10 day course.
14. Insulin sliding scale
Fingerstick Q6HInsulin SC Fixed Dose Orders
Breakfast Bedtime
NPH 14 Units NPH 24 Units
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-100 mg/dL 0 Units
101-150 mg/dL 10 Units
151-200 mg/dL 12 Units
201-250 mg/dL 14 Units
251-300 mg/dL 16 Units
301-350 mg/dL 18 Units
351-400 mg/dL 20 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
ischemic colon s/p total abdominal colectomy and ileostomy
respiratory failure
cellulitis
diabetes mellitus
pneumonia
hypernatremia
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:
It was a pleasure to take care of you at [**Hospital1 18**].
Please continue to take all medications you are receiving in the
hospital. Continue to sit in a chair as tolerated and continue
to work on taking slow, deep breaths and use your incentive
spirometer.
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*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 your follow-up appointment.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 1 week. Call ([**Telephone/Fax (1) 8818**] to schedule an appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2117-10-25**]
10:40
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2117-12-3**] 9:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2117-12-3**] 10:00
|
[
"293.0",
"276.0",
"789.59",
"491.21",
"557.1",
"V46.2",
"V58.65",
"250.02",
"428.30",
"507.0",
"518.5",
"V58.67",
"557.0",
"998.59",
"482.82",
"530.81",
"416.8",
"682.2",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.21",
"96.72",
"33.23",
"96.6",
"31.1",
"45.82"
] |
icd9pcs
|
[
[
[]
]
] |
11697, 11769
|
5858, 9636
|
326, 417
|
11945, 11945
|
2326, 5835
|
12708, 13285
|
1922, 1939
|
9951, 11674
|
11790, 11924
|
9662, 9928
|
12125, 12685
|
1774, 1803
|
1954, 1954
|
261, 288
|
445, 1537
|
1968, 2307
|
11960, 12101
|
1559, 1751
|
1819, 1906
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,229
| 197,736
|
36508+58091
|
Discharge summary
|
report+addendum
|
Admission Date: [**2179-3-10**] Discharge Date: [**2179-3-30**]
Date of Birth: [**2103-2-9**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Statins: Hmg-Coa Reductase
Inhibitors / Naprosyn
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Transfer to [**Hospital1 18**] for further care of post-ERCP pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per MICU Admit Note:
The patient is a 76 yo female with a history of hyperlipidemia
and hypothyroidism presenting from [**Hospital3 417**] Hospital with
acute pancreatitis. She was being worked up for chronic nausea,
vomitting, and epigastric pain, for which she had a RUQ U/S on
[**1-18**] which showed sludge in the gallbladder and a prominent
pancreatic duct with a possible stricture in the head of the
pancreas, and dilation of the common bile duct. This was
confirmed by MRCP. She thus underwent an ERCP on [**2179-3-8**] for
further evaluation. The ERCP showed a dilated common bile duct,
ductal ectasia and evidence of mild chronic pancreatitis. No
sphincterotomy was done, only brushings.
Unfortunately post procedure the patient developed acute
abdominal pain, nausea, and vomiting. Labs revealed an acute
pancreatitis with [**Doctor First Name **]/lip of 2100/1500, respectively. A CT scan
revealed non-enhancement of the body and tail of the pancreas,
consistent with necrosis. She was treated with antibiotics,
aggressive IVF, and a dilaudid PCA, but developed an O2
requirement, mild ARF, and a significant leukocytosis, though
she remained afebrile and hemodynamically stable. She was then
transferred to [**Hospital1 18**] for further treatment and surgical
evaluation.
Past Medical History:
PMH: hypothyroidism, hypercholesterolemia, s/p appy
Social History:
Married, with children. Lives with her husband, very active,
energetic. + long term hx of tobacco (but quit 3 years ago),
rare EtOH, no illicits.
Family History:
N/C
Physical Exam:
Upon discharge
Alert, Oriented, but quiet, NAD
98.7 94 140/80 97% RA
EOMi, anicteric, no JVD
CVL L chest
RRR no m/r/g
CTAB
soft NT/ND + BS
no c/c/e
Neuro grossly intact
Pertinent Results:
Imaging:
[**3-9**] CT abd (on PACS from OSH); nonenhancing body/tail of
pancreas, significant inflammation of pancreas, no intrahepatic
biliary ductal dilatation, small spleen, ?dilation pnacr duct,
?nonobstructive spenic vein thrombosis and moderate ascites.
[**3-9**] MRI abd OSH:
[**3-14**] CT Abd/Pelvis: B/L pleural effusions, Necrotizing
pancreatitis involving greater than 50% of the pancreas. Only
the pancreatic head and a small amount of the pancreatic tail
enhance normally, associated extensive peripancreatic fluid,
without defined collection or gas. Ascites in the abdomen and
pelvis, patent, but attenuated splenic vein. Increased size of
collateral vessels indicates compromised splenic vein flow.,
Bowel wall thickening of the sigmoid colon.
[**3-24**] RUE U/S no DVT
[**3-25**] CT abd/pelvis:
Persistent findings of severe necrotizing pancreatitis, with
normal enhancement seen involving only a portion of the
pancreatic head and tail, and interval development of peripheral
enhancement of a large pancreatic bed fluid collection, which
may represent abscess. As before, the splenic vein is attenuated
but patent. Persistent moderate left pleural effusion.
Decreased small right pleural effusion. Hepatic and renal
hypodensities, too small to characterize.
Brief Hospital Course:
OPERATIONS DURING ADMISSION
None
CONSULTATIONS DURING ADMISSION
General Surgery
MICU
PRINCIPAL DIAGNOSES
Severe, Necrotizing Post-ERCP Pancreatitis
ARDS
Acute Renal Failure
Pancreatic pseudocyst formation (likely)
Delerium in the setting of severe illness
BRIEF HOSPITAL COURSE
***Please note that the patient was under the care of the MICU
team (Dr. [**Last Name (STitle) **] with consultation from general surgery from
[**2179-3-10**] - [**3-22**]. I am summarizing the entirety of her hospital
course but she was directly under my care only from [**3-22**] -
[**3-30**]***
[**3-10**] The hepato-biliary team was consulted by MICU team for help
with management of severe necrotizing pancreatitis; the patient
had been admitted from an OSH tfollowing ERCP with development
of severe abdominal pain and shock. CT and MRI at the OSH
revealed a nonenhancing body/tail of pancreas consistent with >
50% necrosis, significant inflammation of pancreas, no
intrahepatbiliary ductal dilatation, and a small spleen.
She underwent extensive fluid resucsitation with normal saline,
and subsequently the patient developed hyperchloremic
hypernatremic metabolic acidosis that resolved as below. The
patient was also started on broad-spectrum antibiotics
(vancomycin/meropenem), an NGT was placed, as well as CVL and A
line.
[**3-11**] The patient was given d5W in setting of the above; we
suggested to the team that we use LR/colloid in lieu of D5W.
She was also intubated in the setting of respiratory distress in
the setting of fluid resuscitation and her underlying severe
necrotizing pancreatitis.
[**3-12**]- [**3-15**] The patient was given PO contrast for CT scan but may
have aspirated after PO contrast, though no changes in her vent
settings were noticed. Diuresis was initiated as her blood
pressure stabilized and her fluid requirements decreased. Her
antibiotics were discontinued given the lack of evidence for
infected necrotizing pancreatitis. Indeed, she did remain with
a fever and leukocytosis to a height of 39, but this was
attributed to pancreatic necrosis as her hemodynamics remained
stable.
[**3-14**] She eventually did get the CT scan, which revealed B/L
pleural effusions, necrotizing pancreatitis involving greater
than 50% of the pancreas. Only the pancreatic head and a small
amount of the pancreatic tail enhance normally, associated
extensive peripancreatic fluid, without defined collection or
gas. Ascites in the abdomen and pelvis, patent, but attenuated
splenic vein. Increased size of collateral vessels indicates
compromised splenic vein flow., Bowel wall thickening of the
sigmoid colon - all expected findings.
[**3-16**] The patient was weaned off sedation but, remained with a
very poor mental status - initially quite unresponsive even off
sedation as time passed - but she eventually improved to become
oriented, interative, though remained with a much flatter affect
compared to her prior mental status.
[**3-17**] IR c/s for dophoff placement, diuresing still
[**3-18**] dophoff placed, put back on fentanyl gtt for agitation,
diuresed
[**Date range (1) 20011**] The patient was extubated, transferred to floor, her
NGT was discontinued, she was started on sips. She had a PICC
line placed and was started on TPN. She was seen by PT, and got
OOB. She was started back on her PO meds (had been on IV
synthroid)
[**3-23**] PT consult continued, advanced to clears - the patient was
tolerating well. She was started on nebulizers for persistent
wheezing and underwent a CXR that revealed a small effusion on
the right.
[**3-24**] Her diet was advanced to low fat. She underwent a
surveillance CT scan of her abd/pelvis that revealed persistent
findings of severe necrotizing pancreatitis, with normal
enhancement seen involving only a portion of the pancreatic head
and tail, and interval development of peripheral enhancement of
a large pancreatic bed fluid collection. As before, the splenic
vein is attenuated but patent. Persistent moderate left pleural
effusion. Decreased small right pleural effusion. Hepatic and
renal hypodensities, too small to characterize.
[**3-24**] She also underwent a RUE U/S for the ? of DVT that was
negative.
[**Date range (1) 82670**] The patient was started on calorie counts, which
unfortunately revealed that the patient was meeting only 30% of
goal. This is expected in the setting of her mental status, her
poor volition, and her severe necrotizing pancreatitis. Per
nursing the patient refuses food, even when being spoon fed, and
has no volition to eat of her own. The patient was also noted
to develop diarrhea, which was negative for C. dif and
attributed to pancreatic malapbsorption.
[**3-29**] She was started on creon for the diarrhea. Her fentanyl
patch was discontinued. Her nebulizers were changed to PRN.
She continued to work with physical therapy.
At the time of dictation the patient is deemed stable for
discharge to rehab per patient and staff. She does remain with
a significant leukocytosis, however, this is consistent with
prior levels, and I do not suspect this to be consistent with
Medications on Admission:
[**Last Name (un) 1724**]: ativan 0.5', Ca, cymbalta 30', FeSO4, prilosec 20', zocor
80', singulair 10', [**Last Name (LF) 82671**], [**First Name3 (LF) **] 81', avapro 150', florinef 0.05',
toprol 50'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 160 mg/5 mL Solution Sig: [**12-11**] PO Q6H (every 6
hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for loose stool.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
12. Outpatient Lab Work
Please check electrolytes qweekly as the patient is on TPN.
Please check thyroid levels as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Severe, necrotizing post-ERCP pancreatitis
ARDS
Acute Renal Failure
Pancreatic pseudocyst formation (likely)
Delerium in the setting of severe illness
PMH: hypothyroidism, hypercholesterolemia, s/p appendectomy
Discharge Condition:
Stable
Discharge Instructions:
* Please resume all regular home medications and take any new
medicines as prescribed
* Please help patient to eat and encourage PO intake.
* Please administer TPN as prescribed in the attached.
* Please check weekly electrolytes while on TPN
* Consider checking thyroid levels given pt's history and now
acute illness as she may have increased thyroid needs
Please call your doctor or return to the emergency room if you
have any of the following:
* Increased redness, swelling, and/or pain at your wound, or
foul-smelling drainage from your wound
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
1. CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2179-4-23**] 10:15
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2179-4-23**] 11:30
3. Please follow up with your primary care doctor, especially to
have your thyroid levels checked given that you have just
recovered from an acute illness.
Completed by:[**2179-3-30**] Name: [**Known lastname 13215**],[**Known firstname **] E Unit No: [**Numeric Identifier 13216**]
Admission Date: [**2179-3-10**] Discharge Date: [**2179-3-30**]
Date of Birth: [**2103-2-9**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Statins: Hmg-Coa Reductase
Inhibitors / Naprosyn
Attending:[**First Name3 (LF) 2083**]
Addendum:
Addendum to Brief Hospital Course:
On [**3-30**] the patient has been deemed stable for discharge per
patient and staff: she is afebrile, hemodynamically stable,
tolerating her TPN and diet though with little appetite, her
diarrhea had decreased with the creon, and she is ambulating.
She does remain with a significant leukocytosis, however, this
is unchanged from previous levels and most likely is secondary
to her necrotic pancreas and not an infection.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2179-3-30**]
|
[
"577.2",
"577.8",
"511.9",
"518.5",
"244.9",
"272.0",
"276.0",
"276.2",
"584.9",
"577.0",
"401.9",
"272.4",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"99.15",
"38.93",
"99.04",
"96.08",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
13030, 13257
|
12581, 13007
|
414, 420
|
10506, 10515
|
2212, 3490
|
11714, 12558
|
1999, 2004
|
8869, 10155
|
10271, 10485
|
8643, 8846
|
10539, 11691
|
2019, 2193
|
301, 376
|
448, 1743
|
1765, 1818
|
1834, 1983
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,475
| 101,662
|
48795
|
Discharge summary
|
report
|
Admission Date: [**2104-6-3**] Discharge Date: [**2104-6-19**]
Date of Birth: [**2043-10-7**] Sex: M
Service: SURGERY
Allergies:
Enalapril
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**6-10**]: ex lap, colon & SBR, abd left open
[**6-11**]: ex lap, hematoma evacuation,
[**6-12**]: ex lap, end jejunostomy
History of Present Illness:
60M with PMHx of COPD, HTN, ESRD s/o CRT, DM2 presented
overnight to ED with acute onset SOB. States he noted
progressively worsening dyspnea over past two days. Reports
subjective fevers 99-100 at home with chills. No recent increase
in sputum production.
Past Medical History:
-Coag negative staph right hip joint infection, s/p removal,
spacer placement 9/08and prolonged abx course.
-Chronic pain on narcotics
-COPD, not on home 02, last spirometry from [**2092**] with mild to
moderate obstructive defect.
-HTN
-End stage renal disease secondary to malignant hypertension
-s/p CRT [**2097**]
-baseline creat [**3-4**]
-Diverticulitis s/p right colectomy.
-Prostate cancer status post radiation therapy in [**3-5**]
-Diabetes, not on medication
-Perirectal abscess [**1-31**]
-bilateral avascular necrosis
-s/p fall with femoral neck fracture
Social History:
Lives alone at home, now retired, formerly worked as a security
guard. Tobacco x 30-40 yrs, [**2-1**] pk/day, [**Doctor First Name 1638**] EtOH or illicit
drugs, per OMR has h/o alcoholism and marijuana use.
Family History:
malignant hyperthermia - mother, siblings
Physical Exam:
On admission
Vitals: T:96.8 BP: 190/90 P:61 R:13 SaO2: 96%3L NC
General: Awake, alert, appears comfortable.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM slightly dry.
Muddy sclera.
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Limited air movement, quiet deep pitched wheezes
anteriorly and posteriorly, with prolonged expiratory phase. No
crackles, no rhonchi.
Cardiac: Unable to appreciate through breath sounds.
Abdomen: Minimally distended, hypoactive bowel sounds present.
Diffusely minimally tender to palpation. No rebound or guarding.
No tympany
Extremities: No edema. Has non-functional right UE fistula.
Skin: Multiple keloids
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout.
Pertinent Results:
[**2104-6-19**] 04:05AM BLOOD WBC-2.3*# RBC-2.34* Hgb-7.1* Hct-22.6*
MCV-97 MCH-30.2 MCHC-31.2 RDW-16.5* Plt Ct-35*
[**2104-6-19**] 04:05AM BLOOD PT-24.1* PTT-96.9* INR(PT)-2.3*
[**2104-6-19**] 04:05AM BLOOD Glucose-138* UreaN-54* Creat-2.0* Na-134
K-5.5* Cl-102 HCO3-18* AnGap-20
[**2104-6-19**] 04:05AM BLOOD ALT-91* AST-123* AlkPhos-67 TotBili-8.3*
DirBili-6.6* IndBili-1.7
[**2104-6-19**] 06:13AM BLOOD Type-ART Temp-35.6 pO2-62* pCO2-78*
pH-6.97* calTCO2-19* Base XS--16
[**2104-6-19**] 04:19AM BLOOD Type-ART pO2-148* pCO2-76* pH-7.00*
calTCO2-20* Base XS--14
[**2104-6-19**] 06:13AM BLOOD Glucose-88 Lactate-8.6*
Brief Hospital Course:
In ED, initial VS 96.8 193/113 78 24 100% NRB. He desatted to
91% on RA. He had a CXR which did not show any infiltrate or
effusion. His labs were notable for acute renal failure and
hypernatremia, BNP lower than last value from [**6-4**]. His
shortness of breath worsened acutely and he was tried on BiPap
which he did not tolerate. He was admitted to the [**Hospital Unit Name 153**] for
further monitoring in setting of elevated BP and transient need
for BiPap. He detereorated further and was intubated. Abdominal
exam became more distended and a tranplant Surgery consult was
requested . Initially, he was persistently hypertensive and was
treated with nitro and nicardipine drips. On HD #2, renal U/S
showed no abnormalities. On HD #3, he was intubated for
progressive pulmonary decompensation. On HD #4, renal biopsy
concerning for rejection with superimposed ATN. Progressive
acidosis at this time. On HD #7, acute hypotensive episode, SBP
70, minimally responsive to fluid resuscitation and
vasopressors, guiac positive stool, KUB showing bowel
dilatation. CT abdomen showed bowel pneumatosis. On HD #8,
approximately 6 hours after initial surgical consultation, the
patient was taken to the OR. At this point, he was on three
vasopressors, LFT markedly elevated, coagulopathic, and anemic.
Also of note, he demonstrated a methemoglobinemia as high as 13%
(nl 0-2%) on the day of his decompensation. There was frankly
necrotic and perforated bowel, encompassing the majority of his
small bowel and transverse/proximal left colon, as well patchy
necrosis of his liver. These portions of dead bowel were
resected and the patient was left in discontinuity, abdomen
open, and returned to the [**Hospital Unit Name 153**] and then later transferred to the
SICU. Massive resuscitation continued, with copious blood
product transfusions, CVVH initiated. On POD #1, he was taken
back to the OR and there was a large amount of hematoma
evacuated without obvious source of bleeding, omentectomy was
performed, bowel looked viable, abdomen left open. On POD #2,
he went into rapid afib with associated hypotension, treated
with electrical cardioversion and rate control. Later that day,
he was taken back to the OR and an end jejunostomy was performed
after failed attempts at re-establishing continuity secondary to
tissue friability. On POD #[**4-4**], vasopressors on and off,
continued CVVH, developed neutropenia (WBC 0.3) treated with
Neupogen, gradual increase in ventilator requirements (increased
FiO2 and PEEP). On POD #7, he was taken back to the OR for
abdominal wash-out, vicryl mesh closure of abdomen, and VAC
dressing placement. Bowel looked viable at this time. On POD
#8, the patient went back into rapid afib with hypotension,
treated with electrical cardioversion, but progressed to
refractory shock requiring three vasopressors. On POD #9,
precipitous decompensation ensued, family was consulted, CMO
status and expiration shortly thereafter.
Medications on Admission:
HOME MEDICATIONS (per OMR as pt did not know on admit, now
intubated:)
Albuterol inhaler 1-2 puffs Q4 hours
Atorvastatin 20mg daily
duloxetine 30mg daily
ezetimibe 10mg daily
Fosomax 70mg daily
Furosemide 40mg daily
Gabapentin 900mg TID
Hydromorphone 4mg up to 5x per day prn
Methadone 7.5mg PO TID
Metaclopromide 10mg TID (per transplant)
Metoprolol 50mg [**Hospital1 **]
Mycophenolate mofetil 500mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Oxycodone SR 30mg [**Hospital1 **]
Prednisone 5mg daily
Salmeterol 50mcg 2 puffs [**Hospital1 **]
Tacrolimus 4mg [**Hospital1 **]
Valsartan 160mg [**Hospital1 **]
Varenicline 0.5mg [**Hospital1 **]
Ferrous sulfate 325mg daily
Discharge Medications:
Calcium Gluconate/ 500 mL D5W
Albuterol Inhaler
Artificial Tears
Calcium Chloride
Chlorhexidine Gluconate 0.12% Oral Rinse
Citrate Dextrose 3% (ACD-A) CRRT
Ciprofloxacin
Famotidine
Fentanyl Citrate
Filgrastim
Fluticasone Propionate 110mcg
Hydrocortisone Na Succ.
Insulin
Ipratropium Bromide MDI
Magnesium Sulfate
MetRONIDAZOLE (FLagyl)
Meropenem
Midazolam gtt
Phenylephrine
Potassium Chloride
Prismasate (B22 K4)*
Tacrolimus
Vancomycin
Vasopressin
Discharge Disposition:
Expired
Discharge Diagnosis:
COPD, Sepsis, Mesenteric ischemia, Afib, Death
Discharge Condition:
Deceased
Completed by:[**2104-6-20**]
|
[
"584.5",
"518.81",
"V43.64",
"785.52",
"401.1",
"998.12",
"733.42",
"V15.3",
"276.7",
"V10.46",
"997.1",
"276.4",
"287.4",
"493.22",
"250.00",
"V42.0",
"427.31",
"V15.81",
"995.92",
"733.00",
"038.9",
"557.0",
"569.89",
"288.00",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.15",
"96.72",
"53.61",
"54.62",
"46.23",
"55.23",
"96.6",
"38.93",
"45.62",
"45.73",
"45.79",
"54.4",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
7250, 7259
|
3063, 6049
|
275, 400
|
7349, 7388
|
2418, 3039
|
1521, 1564
|
6777, 7227
|
7280, 7328
|
6075, 6754
|
1579, 2399
|
228, 237
|
428, 687
|
709, 1279
|
1295, 1505
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,724
| 194,833
|
39439
|
Discharge summary
|
report
|
Admission Date: [**2156-10-12**] Discharge Date: [**2156-10-20**]
Date of Birth: [**2099-7-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Emergency coronary artery bypass grafts x
3(LIMA-DG,SVG-LAD,SVG-RCA)
left heart catheterization. coronary angiogram, attempted LAD
stent
History of Present Illness:
This 57 year old female presented to [**Hospital3 **] several
days ago with several days of chest painand ruled in for
inferior STEMI. She was transferred for PCI. She underwent
successful PCI of RCA on Tues. She returned to cath lab for
staged intervention of the LAD today- it was found to be
100%occluded, and she is taken emergently to the OR for CABG.
Social History:
Race: Caucasian
Last Dental Exam:
Lives with:
Occupation:
Tobacco: smoking until admission this week
ETOH:
Family History:
Family History:
mother MI at 64yo
Physical Exam:
Pulse: 68 Resp: 19 O2 sat: 94%
B/P Right: 137/117 Left:
Height: Weight: 92kg
General: anxious on cath table
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema- none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: A-line Left: 2+
Carotid Bruit Right: Left:
Pertinent Results:
[**2156-10-19**] 09:06AM BLOOD WBC-8.5 RBC-2.61* Hgb-7.9* Hct-23.6*
MCV-91 MCH-30.2 MCHC-33.4 RDW-14.5 Plt Ct-405#
[**2156-10-15**] 12:44PM BLOOD PT-13.6* PTT-29.7 INR(PT)-1.2*
[**2156-10-17**] 08:45AM BLOOD Glucose-117* UreaN-16 Creat-0.6 Na-138
K-4.6 Cl-102 HCO3-29 AnGap-12
[**2156-10-12**] 09:50PM BLOOD cTropnT-0.98*
[**2156-10-13**] 09:20AM BLOOD CK-MB-8 cTropnT-0.96*
[**2156-10-14**] 06:35AM BLOOD cTropnT-0.63*
[**Known lastname **],[**Known firstname **] [**Medical Record Number 87143**] F 57 [**2099-7-18**]
Echo:
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. A patent foramen ovale is present.
There is an inferobasal left ventricular aneurysm with
dyskinesis. The remaining segments contract normally (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.
Moderate to severe (3+) mitral regurgitation is seen with
retraction of posterior leaflets. Sometimes MR changed to 2+
during the procedures when PA numbers were normal, indicating
active ischemic MR.
There is a very small pericardial effusion.
Dr.[**Last Name (STitle) 911**] and [**Doctor Last Name **] were notified in person of the
results on Ms. [**Known lastname **] before surgical incision.
POST-BYPASS:
Normal RV systolic fucntion.
LVEF 55%.
3+ MR [**First Name (Titles) 151**] [**Last Name (Titles) 34486**] jet toward posterior leaflet similar to
prebypass.
Mild TR.
Intact thoracic aorta.
[**2156-10-20**] 03:47AM BLOOD WBC-9.7 RBC-3.72*# Hgb-10.8*# Hct-32.6*#
MCV-88 MCH-29.2 MCHC-33.3 RDW-15.7* Plt Ct-412
[**2156-10-12**] 09:50PM BLOOD WBC-8.7 RBC-3.91* Hgb-11.8* Hct-34.8*
MCV-89 MCH-30.1 MCHC-33.9 RDW-13.5 Plt Ct-230
[**2156-10-20**] 03:47AM BLOOD Na-139 K-4.2 Cl-102
[**2156-10-12**] 09:50PM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-143
K-3.4 Cl-108 HCO3-23 AnGap-15
Brief Hospital Course:
Following admission she remained pain free. On [**10-14**] she was
taken to the lab fro angioplasty/stenting of the LAD. This was
complicated by dissection and closure of the LAD. She then went
emergently to the Operating Room where revascularization was
performed. She weaned from bypass on Neo-Synephrine and
Propofol in stable condition. She weaned from the ventilator
and pressors easily, was weaned and extubated. CTS and wires
were later removed per protocols.
Diuresis towards her preoperative weight was begun and beta
blockade instituted. She was seen by Physical Therapy for
mobility and strength. She progressed somewhat slowly initially,
but made satisfactory progress. she was transfused 2 units of
blood for a hematocrit of 23 with an improvement of her well
being. She was ready for discharge home on [**10-20**].
Arrangements were made fro follow up, VNA care and medications.
Wounds were healing well.
Medications on Admission:
Plavix 75 daily
aspirin
nicotine patch
metoprolol
lisinopril
lipitor
Discharge Medications:
1. clopidogrel 75 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(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. 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*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for PAIN/TEMP.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
hypertension
Coronary artery disease
s/p emergency coronary artery bypass
s/p myocardial infarction [**2156-10-12**]
s/p RCA stent
hypercholesterolemia
Discharge Condition:
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema none
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema none
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema none
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema 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**]
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. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**11-8**] @ 1PM
Cardiologist: Dr. [**Last Name (STitle) **] on [**2156-11-16**] @ 9AM
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2156-10-20**]
|
[
"272.4",
"E878.2",
"410.41",
"305.1",
"414.12",
"998.2",
"285.1",
"E934.8",
"414.2",
"458.29",
"401.9",
"424.0",
"414.01",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"38.93",
"36.12",
"00.40",
"88.56",
"00.46",
"39.61",
"36.15",
"00.66",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
5862, 5930
|
3860, 4790
|
333, 472
|
6871, 7092
|
1716, 3837
|
8019, 8515
|
1019, 1039
|
4910, 5839
|
5951, 6105
|
4816, 4887
|
7116, 7996
|
1054, 1697
|
283, 295
|
500, 862
|
878, 987
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,679
| 184,642
|
44542
|
Discharge summary
|
report
|
Admission Date: [**2169-1-11**] Discharge Date: [**2169-1-17**]
Date of Birth: [**2087-2-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cipro Cystitis / Hayfever / Perfume Ht52
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain on exertion
Major Surgical or Invasive Procedure:
1. Emergency coronary artery bypass graft x5 -- left
internal mammary artery to left anterior descending
artery, saphenous vein sequential graft to ramus and
distal circumflex, and saphenous vein grafts to diagonal
and posterior descending arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
81 year old male with 2 months of dyspnea on exertion and
exertional chest pain. A few months ago he noticed weakness if
walking greater then 100 feet, and 3 weeks ago developed
exertional epigastric pain. Over the last few weeks
symptoms have increased and presented to PCP office and had EKG
changes and admitted to [**Hospital1 18**] and had elevated troponins. Found
to have left main disease upon cardiac catheterization and IABP
placed and sent to OR for CABG.
Cardiac Catheterization: Date:[**2169-1-12**] Place:[**Hospital1 18**]
report pending
LM 80%
Cardiac Echocardiogram:[**7-/2165**]
moderate LVH, EF 55-60%, 1+AR, mild pulmonary HTN
Other diagnostics:
Chest xray [**2169-1-11**] [**Hospital1 18**]
IMPRESSION:
1. Prominent right hilum. While this may be due to engorgement
of
the central pulmonary vasculature, its asymmetry when compared
to
the left hilum raises concern for a right hilar mass or
adenopathy and further evaluation with a contrast enhanced chest
CT is recommended.
2. Mild pulmonary edema.
Past Medical History:
Hypertension
Hyperlipidemia
GERD
panic attacks
BPH
Hermerroidal GIB causing anemia
Past Surgical History:
s/p TURP
s/p thyrogylossal cyst removed removal in [**2159**] with diffcult
intubation
Social History:
Race:caucasian
Last Dental Exam: not known
Lives with:wife
Contact:[**Name (NI) 81252**] [**Name (NI) 3100**] (wife) Phone #[**Telephone/Fax (1) 95414**]
Occupation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-21**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Brother died of MI at age 54, another brother died of
pericarditis at age 65. Mother had MI in her 80s but survived.
Father had multiple strokes. Son recently had CVA post lap
chole, survived and doing well.
Physical Exam:
Pulse:61 Resp:18 O2 sat:100/RA
B/P Right:118/56 Left:125/76
Height:5'6.5" Weight:192 lbs
General: awake alert oriented
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]; healed scar below chin
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
+ bowel sounds
Extremities: Warm [x], well-perfused [x] no Edema; no
Varicosities
Neuro: Grossly intact []
Pulses:
Femoral Right: IABP in place Left: 2
DP Right: 1+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 2+
Radial Right: 2+ Left: 2+
Discharge Exam:
VS: T: 97.5 HR: 88 SR BP: 137/74 Sats: 97% RA WT: 89 Kg
General: 81 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds at bases otherwise clear
GI: benign
Extr: warm 1+ edema Bilateral
Incision: sternal clean, dry intact, no erythema, Left lower
extremity vasoview site clean dry intact
Neuro: awake, alert oriented, moves all extremities
Pertinent Results:
[**2169-1-17**] Hct-27.6*
[**2169-1-16**] WBC-13.8* RBC-3.64* Hgb-8.9* Hct-28.3* MCV-78*
MCH-24.5* MCHC-31.5 RDW-16.1* Plt Ct-323
[**2169-1-15**] WBC-14.7* RBC-3.42* Hgb-8.5* Hct-26.6* MCV-78*
MCH-24.8* MCHC-31.9 RDW-15.9* Plt Ct-246
[**2169-1-14**] WBC-12.8* RBC-3.50* Hgb-8.7* Hct-27.1* MCV-77*
MCH-24.7* MCHC-31.9 RDW-15.7* Plt Ct-201
[**2169-1-16**] UreaN-22* Creat-1.0 Na-137 K-4.4 Cl-98 HCO3-27
[**2169-1-15**] Glucose-94 UreaN-17 Creat-0.9 Na-138 K-4.1 Cl-101
HCO3-28
[**2169-1-14**] Glucose-140* UreaN-12 Creat-0.9 Na-138 K-3.9 Cl-104
HCO3-26
[**2169-1-13**] Na-140 K-4.2 Cl-109*
[**2169-1-12**] TTE
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.6 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 75 ml/beat
Left Ventricle - Cardiac Output: 3.59 L/min
Left Ventricle - Cardiac Index: *1.80 >= 2.0 L/min/M2
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.8 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 10 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 6 mm Hg
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 2.3 cm
Aortic Valve - Valve Area: *1.7 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild (non-obstructive) focal
hypertrophy of the basal septum. Mildly dilated LV cavity. Low
normal LVEF.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. No atheroma in
ascending aorta. Simple atheroma in aortic arch. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
AS (area 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
to moderate ([**1-16**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Mild PR.
PERICARDIUM: No pericardial effusion.
CXR: [**2169-1-15**]
IMPRESSION: PA and lateral chest compared to [**1-15**]:
Small bilateral pleural effusions and moderate bibasilar
atelectasis have not changed appreciably since [**1-15**].
There is no pneumothorax or pulmonary edema. Cardiomediastinal
silhouette has a normal postoperative appearance.
Brief Hospital Course:
The patient was admitted to the hospital with chest pain
accompanied by ST segment depression and elevated troponin and
left main disease required IABP placement. He was brought to the
operating room on [**1-13**] where the patient underwent coronary
artery bypass grafting x 5. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. He
arrived from the OR intubated, sedated, on Neo. POD 1 found the
patient extubated, alert and oriented and breathing comfortably,
IABP removed. The patient was neurologically intact and
hemodynamically stable weaned of pressors 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 on POD#2. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD5 the patient was ambulating with assistance, the wound
was healing and pain was controlled with oral analgesics. The
patient was discharged to [**Hospital **] Hospital of the Northshore,
[**Hospital1 3597**], MA [**Telephone/Fax (1) **] in good condition with appropriate follow
up instructions.
Medications on Admission:
- allopurinol 300mg daily
- atenolol 50mg daily
- atorvastatin 10mg daily
- colace
- Tums
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary Diagnosis:
Coronary artery disease
Secondary diagnosis:
Hypertension
Hyperlipidemia
GERD
panic attacks
BPH
Hermerroidal GIB causing anemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait with assistance
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. 1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2169-2-21**] 1:00
in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Primary Care/Cardiologist Dr. [**Last Name (STitle) 172**] in [**4-20**] weeks [**Telephone/Fax (1) 133**]
Date/Time:[**2169-2-7**] 1:45
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2169-1-17**]
|
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icd9cm
|
[
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[]
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[
"37.61",
"37.22",
"39.61",
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,330
| 157,471
|
26831
|
Discharge summary
|
report
|
Admission Date: [**2181-7-30**] Discharge Date: [**2181-8-8**]
Date of Birth: [**2113-3-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
60 yo male with history of CABG in [**2176**], DM, and HTN, presented
to an OSH last night with RUQ pain. Over the past few days
prior to admission, the patient was having intermittent RUQ pain
associated with fevers, chills, and nausea. The pain has been
progressively worsening in the RUQ and epigastric area, with a
sense of abdominal fullness and excessive burping. He also
notes cough and feels as if he is unable to take a deep breath
as a result of the pain. He denies CP, SOB, vomiting,
hemoptysis, and melena, but notes three episodes of diarrhea
last night. At the OSH, he was found to be hypotensive upon
arrival. He was given IVF with peripheral dopamine for support.
Labs were notable for a lipase of 5000, WBC of 20K with 10%
bands, creatinine of 2.9 up from 1.6, bili of 4.2, and
transaminases in 80-150s. CXR was within normal limits. RUQ
U/S with pancreas obscured by gas and multiple mobile stones and
debris but no acute signs seen. CT abdomen revealed a mild
prominent pancreatic head with very mild surrounding stranding,
hepatomegaly, cholelithiasis, duodenal diverticulum, and chronic
diverticulosis. UA on [**7-29**] reveals SG of 1.027 with 10 WBC's,
and positive leuk esterase. He was given IVF and sent to [**Hospital1 18**]
for further management.
.
On the floor, the patient was in a significant amount of
abdominal discomfort with excessive burping. He reports that he
has never had this pain before, has never had a gallstone
before, and does not drink EtOH.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
vomiting, 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:
CAD s/p CABG x3
HTN
Gout
Anemia
Stage 3 CKD
Obesity
Hyperlipidemia
s/p appy
Social History:
Originally from [**Country 11150**]. He lives with his wife, daughter, son,
son's wife, daughter's children. He was previously a grade
school teacher. Recent travel to [**Country 11150**], returned on [**7-12**].
- Tobacco: None. Prior 15ppd history, quit [**2162**].
- Alcohol: None.
- Illicits: None.
Family History:
parents died of "natural causes"; Noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: 99.2 69 106/50 15 93% on RA
General: Alert, oriented, no acute distress,
HEENT: Sclera anicteric, MMdry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Faint bibasilar crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2181-7-30**] 02:10AM PT-19.4* PTT-25.8 INR(PT)-1.8*
[**2181-7-30**] 02:10AM PLT COUNT-123*
[**2181-7-30**] 02:10AM NEUTS-91.1* LYMPHS-4.8* MONOS-3.3 EOS-0.5
BASOS-0.2
[**2181-7-30**] 02:10AM WBC-11.8* RBC-2.58* HGB-8.1* HCT-26.0*
MCV-101*# MCH-31.2 MCHC-31.0 RDW-12.8
[**2181-7-30**] 02:10AM TRIGLYCER-175*
[**2181-7-30**] 02:10AM ALBUMIN-2.9* CALCIUM-6.4* PHOSPHATE-3.0
MAGNESIUM-1.2*
[**2181-7-30**] 02:10AM LIPASE-1604*
[**2181-7-30**] 02:10AM ALT(SGPT)-56* AST(SGOT)-90* ALK PHOS-22* TOT
BILI-2.7*
[**2181-7-30**] 02:10AM GLUCOSE-79 UREA N-25* CREAT-2.3* SODIUM-143
POTASSIUM-4.1 CHLORIDE-115* TOTAL CO2-17* ANION GAP-15
[**2181-7-30**] 02:40AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-SM
[**2181-7-30**] 02:40AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
[**2181-8-8**] 05:00AM BLOOD WBC-10.9 RBC-3.33* Hgb-10.3* Hct-31.2*
MCV-94 MCH-31.0 MCHC-33.0 RDW-12.8 Plt Ct-381
[**2181-8-8**] 05:00AM BLOOD Plt Ct-381
[**2181-8-8**] 05:00AM BLOOD Glucose-114* UreaN-11 Creat-1.3* Na-138
K-4.0 Cl-101 HCO3-22 AnGap-19
[**2181-8-6**] 07:10AM BLOOD ALT-29 AST-43* LD(LDH)-217 AlkPhos-66
TotBili-0.8
[**2181-8-6**] 07:10AM BLOOD Lipase-944*
[**2181-7-30**] 02:41PM BLOOD calTIBC-355 VitB12-620 Folate-12.6
Ferritn-350 TRF-273
[**2181-8-2**] 03:50PM BLOOD Triglyc-240* HDL-13 CHOL/HD-10.5
LDLcalc-75
[**2181-8-7**] 06:21AM BLOOD TSH-5.2*
Brief Hospital Course:
A/P
# Gallstone pancreatitis:
-lipase of 1600 on admission
-No history of EtOH abuse. TG were 175.
-ERCP was done which showed multiple filling defects c/w sludge
/ stone fragments in the CBD. Otherwise normal cholangiogram. A
sphincterotomy was also performed and multiple stone fragments
and sludge were extracted using a balloon.
Prior to ERCP the patient received 1 unit of blood and 2 units
of FFP.
# Hypotension: presented with Hypotension with leukocytosis and
bandemia only responsive to pressors at OSH. Suspected that this
was likely a result of pancreatitis, and less likely a second
infection.
-did not require pressors at the [**Hospital1 18**]
#A. Fib/aflutter
-on [**8-1**] developed AF with RVR and angina
-described angina, though likely rate-related, was easy to
terminate with NTG, O2, ASA,
-the RVR required three IV Metoprolol 5mg doses Pkus oral
metoptolol followed by Dilt 20mg IV followed by standing oral
metoprolol. Converted to sinus rhythm and has been in SR or
sinus brady in the 50s ever since. Also his atenolol was held
on presentation. He also had recurrent afib rvr on [**8-7**] that
was controlled with IV diltiazem and he has been in sinus since
dose adjustments. He will be sent home on diltiazem 180mg xl qd
for rate control
-Ruled out for MI. Suspecion that his AF was due to volume
overload in the ICU.
-CHADS = 2. Initially started on ASA 325mg given recent
procedure and since his CBC remained stable we started coumadin
5mg on [**8-7**] without a LMWH bridge. He was guaic negative on
exam. He is instructed to have his INR checked within 5 days
and have results managed by his PCP, [**Name10 (NameIs) 1023**] he will see on [**8-13**]. He
will also see his cardiologist on [**8-17**]. He Was not
anticoagulated due to his recent GI procedure with bleed, but
was started on ASA 162mg and given stable hematocrit this was
advanced to 325mg.
--TSH checked for afib w/u and returned at 5.2 (elevated),
possible sick euthyroid. Recommend outpatient repeat TSH value.
#Acute systolic and diastolic heart failure: with h/o CAD s/p
3vCABG
-Echo ([**2181-8-1**]) = LVEF of 50%, increased left ventricular
filling pressure (PCWP>18mmHg), Grade II (moderate) left
ventricular diastolic dysfunction, focal hypokinesis of the
distal septum c/w CAD (new since [**2176**]) - has known CAD
-diuresis was started with furosemide and the evidence of volume
overload (likely due to aggressive fluid resuscitation in the
ICU), including B/L LE and scrotal edema, improved. Of note, he
did not respond to 20 mg or oral lasix, but did respond to 40mg.
Cardiology was consulted and did not feel he required cath or
stress test at this time. Serial troponins negative. No BB on
board as he is on CCB for rate control. Ace-I dose reduced as
BPs in the low 100-110s.
# Acute kidney injury:
-Creatinine initially elevated from baseline of 1.6 to 2.9.
-was aggressively hydrated and his serum creatinine fell to 1.1
#Right ankle and foot pain:
-acute, severe - clinically consistent with his history of gout
-responded to oral colchicine, which is stopped prior to
discharge
-NSAIDS were avoided due to his renal failure and heart failure
-steroids avoided in the setting of DM
.
# DM II - questionable history as A1c is 5.6 on check. Not
discharged on any diabetic drugs at discharge.
# HTN: Lisinopril and now diltiazem, atenolol stopped.
Medications on Admission:
ASA 81mg daily
Atenolol 25mg daily
doxazosin 2mg daily
lisinopril 5mg daily
simva 80 daily
omeprazole 20mg daily
lasix 20mg daily prn swelling
cyclopenzaprine 10mg prn pain
fluticasone nasal spray
meloxicam 7.5mg prn
allopurinol 100mg daily
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
x3doses.
6. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
Disp:*16 Tablet(s)* Refills:*0*
9. Diltia XT 180 mg Capsule,Ext Release Degradable Sig: One (1)
Capsule,Ext Release Degradable PO once a day.
Disp:*30 Capsule,Ext Release Degradable(s)* Refills:*0*
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal once a day.
12. Outpatient Lab Work
INR: please fax results to:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: GREATER [**Hospital1 **] FAMILY HEALTH CENTER
Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 66039**]
Fax: [**Telephone/Fax (1) 66040**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **] [**Hospital1 **]
Discharge Diagnosis:
Gallstone pancreatitis
Sepsis
Atrial fibrillation
Acute systolic and diastolic heart failure
Acute gout - right ankle
Acute kidney injury-resolved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with gallstone pancreatitis. The stones were
removed with an endoscope via a procedure called ERCP with
sphincterotomy.
You also developed atrial fibrillation this admission. You were
started on coumadin for stroke prevention. This drug increases
your risk of bleeding and you will need to have blood work to
check your INR (how thin your blood is). Please have this
checked in the next 7 days and have the results forwarded to
your PCP. [**Name10 (NameIs) **] you develop bleeding please call your doctor.
You developed fluid retention and heart failure following
aggressive IV fluid resuscitation in the intensive care unit.
This has been improving with diuretics.
You also developed right ankle arthritis which improved with
colchicine and is most likely acute gout. You should follow up
with your primary care doctor or a rheumatologist for this
problem once you are discharged from the hospital.
Followup Instructions:
Department: Primary Care
Name: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 66037**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
When: Monday [**2181-8-13**] at 9:30.
Location: GREATER [**Hospital1 **] FAMILY HEALTH CENTER
Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 66039**]
Department: Cardiology
Name: Dr. [**First Name8 (NamePattern2) 29069**] [**Name (STitle) 29070**]
When: Thursday [**2181-8-23**] at 9 AM
Location: [**Location (un) **] CARDIOLOGY
Address: [**Apartment Address(1) 66041**], [**Hospital1 **],[**Numeric Identifier 10774**]
Phone: [**Telephone/Fax (1) 37284**]
|
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] |
icd9cm
|
[
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[]
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[
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] |
icd9pcs
|
[
[
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,584
| 178,976
|
13691+13692
|
Discharge summary
|
report+report
|
Admission Date: [**2139-5-9**] Discharge Date: [**2139-5-21**]
Date of Birth: [**2069-11-28**] Sex: M
Service: CCU
CHIEF COMPLAINT: Respiratory failure.
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is a
69-year-old previously healthy male who was transferred from
an outside hospital for admission into the Medical Intensive
Care Unit with the following primary problems; respiratory
alkalosis, anion gap, metabolic acidosis, respiratory failure
requiring intubation secondary to ventilatory fatigue, acute
liver failure, and acute renal failure of unclear etiology.
The history was obtained from two daughters; the patient was
comatose at the time of presentation.
One month ago, the patient was well walking roughly five
miles per day. At that time he started complaining of
exertional dyspnea and insomnia. His daughters described
frequent weakness secondary to dyspnea and palpitations. He
was seen at "urgent care" and diagnosed with anxiety. He was
started on amitriptyline, lorazepam, and Tylenol PM. He also
complained of coughing at that time and had a chest x-ray
that was notable for a large heart and fluid. He was
subsequently treated for pneumonia with a 10-day course of
antibiotics and Combivent for one week.
Three weeks prior to presentation, he returned to urgent care
with a chief complaint of "thrush," but he was told he did
not have pneumonia (per radiologist read of a chest x-ray),
but he did have cardiomegaly; and, again "fluid in his
lungs." At that time, Lasix was started. He saw Pulmonary
on [**4-28**] where he had abnormal pulmonary function tests
and an arterial blood gas as follows: 7.44/32/76 on room
air. The patient was felt to have idiopathy pulmonary
fibrosis. His daughters noted some slurred speech and
tremors subsequent to that, and he was seen by his primary
care physician four days prior to the current admission for
an evaluation for profound exertional dyspnea. He was unable
to go from chair to bed. His Lasix dose was increased, and
over the past two to three days he has had continued
worsening exertional dyspnea, increasing confusion, and
disorientation. He coughed up some sputum. He was nauseated
and had dry heaves for three, and he developed watery
diarrhea and was started on p.r.n. Imodium. His daughters
felt he was yellow three days ago and somewhat
ashen-appearing today.
The review of systems was also notable for an 18-pounds
weight loss over the last four weeks. There is no history of
intravenous drug use, recent travel, and the patient denies
any sexual activity.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Esophageal stricture, status post multiple dilatations.
MEDICATIONS ON ADMISSION:
1. Prilosec 20 mg p.o. q.d.
2. Paxil 20 mg p.o. q.d.
3. Combivent 2 puffs q.i.d.
4. Imodium AD p.r.n.
5. Amitriptyline 100 mg p.o. q.d.
6. Lorazepam 0.5 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone. He has 10
children. He is a widower since [**2134**]. One of his daughters
died approximately one year after cocaine ingestion. She was
the patient's primary care giver. The patient had a son who
died in [**2125**] from human immunodeficiency virus/acquired
immunodeficiency syndrome. The patient smokes one pack per
day for the last 40 years. He is a former heavy alcohol
drinker 30 years ago. He has been sober for the last 20
years. For the past 10 years he has had one drink per day.
FAMILY HISTORY: The patient's family denies a family history
of diabetes, hypertension, coronary artery disease, and
cancer. Both of the patient's parents died in their 80s.
HOSPITAL COURSE: (From [**Hospital6 41256**]) The patient
presented intermittently apneic and tachypneic. An arterial
blood gas there was as follows: 7.52/16/212 on 55% face
mask. Subsequently, he went to 7.38/19/105. The patient was
intubated for worsening ventilatory fatigue. His
laboratories demonstrated acute renal failure with a
creatinine of 2.2 (when it had been normal two weeks prior),
and hepatitis transaminases in the 400s (climbing to greater
than 1000 prior to transfer). A lactate level was 3.5, and
TCA level was 550. An electrocardiogram demonstrated a wide
QRS. On arrival here, he was hemodynamically stable,
over-breathing the ventilatory, and unresponsive.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
blood pressure of 87/63, pulse of 77, oxygen saturation of
98%. Ventilator settings the patient was on were assist
control, 14 X 700, with a positive end-expiratory pressure
of 10, an FIO2 of 60, and arterial blood gas was 7.39/26/191.
In general, intubated and comatose. Head, eyes, ears, nose,
and throat revealed left pupil was 4 mm (down to 3 mm with
light), the right was 3.5 mm (down to 3 mm). There was no
blinking to threat, and there were absent corneal reflexes.
The oropharynx was dry. Scleral icterus was noted. Chest
had coarse breath sounds bilaterally. The cardiovascular
examination was notable for distant heart sounds. The
abdomen was soft, distended. There was flank dullness to
percussion. The liver edge was 2 cm below the costal margin.
The extremities showed 2+ pitting lower extremity edema and
palmar erythema. The neurologic examination was as follows:
the patient was comatose. The pupils were minimally
reactive. There was no corneal reflex. There was withdraw
to pain on the right but not on the left. The patellar
reflexes were absent bilaterally. Babinski was upgoing
bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
evaluated a white blood cell count of 11.6, hematocrit of 42,
platelets of 185. The urinalysis showed large blood,
negative nitrites, 30 protein, greater than 50 red blood
cells, 6 to 10 white blood cells, many bacteria, and 6 to 10
hyaline casts. The PTT was 34.4. The PT was 19.1. INR
was 2.5. SMA-7 revealed a sodium of 133, potassium of 5.4,
chloride of 99, bicarbonate of 18, blood urea nitrogen of 89,
creatinine of 2.9, and glucose of 141. The creatine kinase
was 375 (it had been 158 and then 221). Alkaline phosphatase
was 122, magnesium of 3.1, total bilirubin of 2.8, albumin
of 3.8, calcium of 8.7, phosphorous of 9. Troponin was less
than 0.4. The serum toxicology screen was negative except
for TCA, and the urine toxicology screen was negative. The
TCA level at [**Hospital6 41256**] was 550. The ALT
was 1784, and the AST was 3065.
RADIOLOGY/IMAGING: A CT of the head was suggestive of
pontine stroke.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for management of multiple medical
problems including comatose state of unclear etiology,
worsening exertional dyspnea requiring intubation, evolving
acute liver failure, and new acute renal failure of unclear
etiology.
In the Intensive Care Unit, the patient underwent a magnetic
resonance imaging after the head CT suggested a pontine
stroke. The magnetic resonance imaging was unremarkable.
The patient was started on an acetylcysteine for possible
Tylenol toxicity; although, a level was low/undetectable. He
was extubated without difficulty on hospital day two. He was
afebrile and hemodynamically stable throughout the rest of
his acute course.
His acute renal failure improved with gentle diuresis, and
his liver function tests began trending down of their own
[**Location (un) **]. It was felt that the elevated transaminases may have
been secondary to shocked liver versus TCA toxicity versus
Tylenol toxicity. The patient's mental status was also noted
to improve to the point where he was interactive.
The patient was transferred to the floor on [**2139-5-11**],
and the Congestive Heart Failure Service was consulted. It
was felt that the patient's course of worsening dyspnea,
cardiomegaly, and fluid overload on chest x-ray were all
consistent with the development of new congestive heart
failure. The patient was on captopril which was titrated up
and switched to Zestril. Aldactone was added, and diuresis
was attempted first with oral Lasix and then with increasing
amounts of intravenous Lasix.
From a pulmonary standpoint, the patient grew out Escherichia
coli from his sputum and was started on Levaquin after his
white blood cell count became to trend up and the patient
started developing low-grade temperatures.
In terms of gastrointestinal, the patient's transaminases
continued to trend down for a peak AST of 3000 and a peak ALT
of 1700, but the alkaline phosphatase and total bilirubin
remained elevated. A right upper quadrant ultrasound was
subsequently obtained that was consistent with congestive
hepatopathy.
From a renal standpoint, the patient's creatinine trended
down to 1.4 to 1.5 with volume repletion.
From a hematologic standpoint, the patient's platelets were
noted to be decreasing on a daily basis, and heparin
antibodies were eventually sent which came back positive for
antiplatelet Factor IV antibody. The patient was on
subcutaneous heparin at the time, which was discontinued.
On the day of transfer to the Coronary Care Unit, the patient
underwent a cardiac catheterization, and the right heart
catheterization revealed the following pressures, right
atrial mean of 15, right ventricular 60/18, pulmonary artery
of 60/30, wedge 30, cardiac output of 3, with an index of 1.5
measured by sic, superior vena cava oxygen saturation of 48%,
and a pulmonary artery saturation of 52%. These numbers
improved with milrinone with his pulmonary artery diastolic
pressure dropping from 30 to 18, and the wedge dropping from
30 to 15, cardiac output improving from 3 to 5.8, with an
index improving from 1.5 to 2.9.
Coronary angiography revealed 40% to 50% left main stenosis,
a mild proximal circumflex lesion, and minimal luminal
irregularities in the left anterior descending artery.
The patient was brought to the Coronary Care Unit on
[**2139-5-15**] for the management of Swan-[**Location (un) **]/milrinone
therapy to aid in diuresis. While in the Coronary Care Unit,
the patient responded well to diuresis with milrinone. He
was also maintained on Lasix, Zestril, and Aldactone to
manage his heart failure.
On [**2139-5-18**], the patient's milrinone was discontinued,
but he became tachycardic and dyspneic and developed elevated
right-sided pressures. The central venous pressure went up
from 12 to 23, and the mean pulmonary artery pressure rose
from 30 to 65. At that time, the patient also spiked a
temperature to 103.4.
It was felt that the patient failed to come off the milrinone
in the setting of a new infection. Blood cultures obtained
at the time of the temperature spike revealed 4/4 bottles
positive for methicillin-resistant Staphylococcus aureus.
The patient was empirically started on vancomycin, and then
gentamicin was added 24 hours later. Over the next 48 hours,
the patient's milrinone was slowly weaned off without
difficulty. On the day prior to discharge from the Coronary
Care Unit, the patient was noted to put out 3600 cc of urine
with 500 cc of intake reported on 0.188 mcg/kg per minute of
milrinone and a standing Lasix of 80 mg intravenously b.i.d.
On [**2139-5-18**], the patient's PA catheter was removed and
the line tip was cultured. It grew out greater than 15
CFU/mL of Staphylococcus aureus which has yet to be further
speciated. Given the clinical setting, it was felt that the
patient's bacteremia was secondary to line-related infection,
tunnel site more so than endoluminal.
At the time of discharge from the Coronary Care Unit, the
patient was also noted to have two other mild laboratory
abnormalities: (1) The patient's platelet count drifted down
over a course of 48 hours from 104 to 83 in the setting of
having all heparin held. A further workup is currently
pending including DIC panel and repeat liver biochemistries.
(2) The patient also had mild hyponatremia to 127 with a
serum osmolality of 272, and a urine osmolality of 325. The
hyponatremia was felt the be multifactorial including the
patient's congestive heart failure, use of milrinone and
Lasix, and possible excessive unsupervised free water intake.
ACTIVE DISCHARGE PROBLEMS: At the time of discharge from the
Coronary Care Unit, the patient's active problems remained as
follows:
1. Congestive heart failure with a low ejection fraction (an
ejection fraction of 10% by a prior echocardiogram)
complicated by congestive hepatopathy.
2. Thrombocytopenia.
3. Mild hyponatremia.
4. Line-related methicillin-resistant high-grade
Staphylococcus aureus bacteremia.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2139-5-21**] 12:28
T: [**2139-5-21**] 18:35
JOB#: [**Job Number 41257**]
Admission Date: [**2139-5-9**] Discharge Date: [**2139-5-25**]
Date of Birth: [**2069-11-28**] Sex: M
Service:
This Discharge Summary addendum covers the [**Hospital 228**] hospital
course from [**2139-5-21**] to [**2139-5-25**] at which time he patient was
discharged from the floor to acute rehabilitation.
On the floor the patient had continued modifications of his
congestive heart failure regimen with his Lasix dose
eventually decreased to 80 mg p.o. q.d. He was also started
on standing potassium and magnesium in the setting of ongoing
diuresis.
The patient's hyponatremia responded well to fluid
restriction to one liter per day.
The patient's platelets stabilized around 110, again off
heparin.
From the infectious disease standpoint the patient's
surveillance blood cultures from [**5-20**] and [**5-21**] remained
negative and the patient has received five days of Gentamicin
overlapped with a two week course of Vancomycin. The course
of Vancomycin will finish on [**2139-6-2**].
The patient had a PICC line placed on [**2139-5-22**] without
complications.
While on the floor it was observed that the patient had three
episodes of seven to eight beats of NSVT (nonsustained
ventricular tachycardia) with no symptoms. Given the fact
that he has very mild coronary artery disease and is symptom
free, despite his low ejection fraction, EP consultants felt
that there is no indication for electrical mapping of the
ventricles and possible placement of an AICD at this point.
They recommended EP follow up after the patient's left main
is revascularized. In the interim they were comfortable with
the current medication regimen.
On [**2139-5-25**] the patient was felt to be stable for discharge to
acute rehabilitation.
DISCHARGE DIAGNOSE:
1. Congestive heart failure secondary to cardiomyopathy
of unclear etiology, viral versus idiopathic of 10
to 15 percent at time of discharge with left
ventricular dilatation.
2. MRSA bacteremia with negative surveillance culture
on Vancomycin and Gentamicin.
3. Mild hyponatremia resolving with fluid restriction
with serum and urine osmolality suggestive of
antidiuretic hormone action.
4. Heparin induced thrombocytopenia type 2. No
thrombotic complications observed clinically.
DISCHARGE FOLLOW UP: Patient should continue to have one
liter per day fluid restriction and will follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the heart failure clinic for further management.
An EP referral may be in order as an outpatient.
DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., Captopril
25 mg p.o. q.d., iron sulfate 325 mg p.o. t.i.d., Lasix 80 mg
p.o. q.d., Aldactone 25 mg p.o. q.d., Protonix 40 mg p.o.
q.d., K-Dur 20 mEq p.o. q.d., magnesium oxide 400 mg p.o.
q.d., Vancomycin 1 gram q 12, last day [**2139-6-2**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2139-5-24**] 11:13
T: [**2139-5-24**] 12:55
JOB#: [**Job Number 41258**]
|
[
"996.62",
"790.7",
"780.01",
"276.2",
"428.0",
"276.3",
"518.81",
"570",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"88.53",
"96.04",
"88.55",
"37.21",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3522, 3682
|
15508, 16006
|
2753, 2965
|
6573, 15208
|
15220, 15484
|
150, 172
|
201, 2607
|
2629, 2727
|
2982, 3505
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,065
| 183,314
|
51273
|
Discharge summary
|
report
|
Admission Date: [**2189-9-8**] Discharge Date: [**2189-9-20**]
Date of Birth: [**2111-7-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Colchicine / Aspirin / Macrobid / Percocet / Minocycline /
Levofloxacin
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
T3, N 0 adenocarcinoma of the distal esophagus.
Major Surgical or Invasive Procedure:
trans hiatal distal esophagogastrectomy, total gastrectomy, roux
en Y
History of Present Illness:
Ms. [**Known lastname 1191**] is a 78-year-old woman with history
of rheumatoid arthritis and biopsy-proven adenocarcinoma of
the distal esophagus. There was some discordant staging
information with a PET scan and CT scan suggesting disease
confined to the esophagus. An EUS suggested transmural
involvement. She is otherwise a reasonable candidate for
resection. We felt it important to define her specific
surgical stage before deciding regarding chemotherapy and
radiation. Therefore, a resection was recommended and we
initially planned a transhiatal esophagectomy. This also
would require feeding jejunostomy. Her methotrexate given for
rheumatoid arthritis was held for 10 days preoperatively and
she had a standard mechanical bowel prep. She agreed to proceed.
Past Medical History:
Avascular necrosis R hip, THR [**2183**]
Glaucoma
Osteoporosis
Gout
Hypertension
TIA [**2152**]
Hypercholesterolemai
Fe Def Anemia
s/p TAH
GERD
Carpal Tunnel Syndrome
PMR/RA variant
Thyroid Nodule s/p thyroidectomy
BCC
Macular Degeneration
Cataracts
CRI
h/o septic arthritis and MRSA bacteremia
h/o SBO, internal herniation and strangulation of mid jejunum
[**6-9**]
reactive airways disease
s/p appendectomy
s/p TKR
Polio as a child
Social History:
No tobbacco, occ EtOH. Retired school teacher.
Family History:
Father had prostate ca. Brother has CAD. Sister had breast
cancer.
Physical Exam:
GENERAL: Shows a pleasant and fit woman weighing 169 pounds.
Blood pressure is 142/58, pulse 68 and regular and room air
saturation is 99%.
HEENT: She has no scleral icterus or adenopathy in the neck or
either supraclavicular fossa. She has a well-healed skin
incision over the nose at the site of removal of carcinoma.
LUNGS: Clear to auscultation and percussion.
HEART: Regular rhythm and rate without a murmur or gallop.
ABDOMEN: Soft and nontender with a well-healed midline incision
and no hernia and a well-healed McBurney incision in the right
lower quadrant without hernia.
EXTREMITIES: She has mild nonpitting edema on the left.
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2189-9-16**] 05:42AM 9.0 2.54* 7.5* 22.2* 87 29.5 33.8 16.6*
444*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2189-9-16**] 05:42AM 444*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2189-9-16**] 05:42AM 104 16 0.7 137 4.2 105 24 12
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2189-9-16**] 05:42AM 7.7* 2.9 2.1
Gastrograffin and barium swallow [**2189-9-15**]:
There is free passage of contrast through the esophagus and the
esophagojejunal anastomotic site with no evidence of leak or
holdup. Contrast flows freely into the more distal small bowel.
A final overhead image performed at the end of the procedure
demonstrates a small amount of contrast in the distal esophagus,
and contrast seen in distal bowel.
IMPRESSION:
No evidence of anastomotic leak or holdup of contrast, with free
flow of contrast into the small bowel. Findings were discussed
Brief Hospital Course:
pt was admitted and taken to the OR for esophagectomy for T3 ,
N0 adeno ca of the esophagus. During the surgery cancer was
found at the GE junction and therefore a distal esophagectomy
with total gastrectomy, Roux-en-Y esophagojejunostomy and
feeding jejunostomy. Post op pt remained intubated post
operatively and was admitted to the CSRU. Of note, pt had a
left arm swelling d/t IV infiltrate. Vasc [**Doctor First Name **] was consulted d/t
swelling and recommended conservative management of LUE
elevation and ace wrapping since CSM intact. Swelling resolved
with in approx 36 hrs w/o sequelae.
Extubated on POD#O w/o complcation. PCA for pain control.
Anastomotic JP w/ minimal sersang drainage. NGT to LCS and
J-tube to gravity. NPO. Low U/O -responded to volume
resusitation.
POD#2 trophic j-tube feedings begun.
POD#3 Iv lopressor started and titrated for HR and BP control-
previously on toprol XL and norvasc PTA. Transferred from ICU
for ongoing post op care including PT/OT. Awaiting return of
bowel function.
POD#4 Return of bowel function. NGT d/c'd Jtube feed increasing
to goal. Progessing w/ post op recovery.
POD#5 large amount loose stool w/ full sterngth tube feed at
goal- decreaased to 3/4 strength w/ improvement in diarrhea.
POD#7 gastrograffin and barium swallow done -neg for anastomtic
leak and showed thru passage of barium. Started on sips and
[**Last Name (un) 1815**].
POD#8 progressed to clears and po meds if small in size. Cont's
on goal TF.
POD#9 dumping syndrome - po diet changed to post gastrectomy and
advanced to soft solids. C-line d/c'd. and abd staples d/c'd.
POD#10 Her J-tube became clogged and had to be miled at the area
of the suture. It then flushed nicely with NS.
POD#11 Diarrhea decreased
POD#12 J tube clogged again. Flushed with papain and it worked.
Medications on Admission:
Norvasc 5', Toprol XL 50', cardura 2', methotrexate 5 Q week,
Protonix 40', doxazosin, simvastatin, Tylenol, Timolol, Alphagan
eyedrops, folic acid, MVI.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
4. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) ml PO
Q4-6H (every 4 to 6 hours) as needed for pain.
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
10. Hexavitamin Tablet Sig: Five (5) ML PO DAILY (Daily).
11. J-tube
NO crushed meds via J-tube- may give elixir only
12. Simvastatin 10 mg Tablet Sig: 0.5 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 for pain.
14. B -12
monthly B-12 injections
15. Methotrexate 2.5 mg Tablet Sig: Two (2) Tablet PO once a
week: BEGIN Methotrexate on monday [**2189-9-28**].
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) 1459**]
Discharge Diagnosis:
T3, N 0 adenocarcinoma
distal esophagogastrectomy, total gastrectomy, roux en Y
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] with any questions
regarding surgey, GI function, swallowing difficulties, changes
in incisional appearance, fever, chills.
Followup Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] for a follow up
appointment upon d/c from rehab/ nursing home.
Completed by:[**2189-9-20**]
|
[
"733.00",
"197.8",
"196.2",
"151.0",
"585.9",
"714.0",
"272.0",
"401.9",
"530.81",
"999.2",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.99",
"96.6",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
6857, 6931
|
3550, 5361
|
385, 457
|
7055, 7062
|
2537, 3527
|
7305, 7470
|
1794, 1862
|
5567, 6834
|
6952, 7034
|
5387, 5544
|
7086, 7282
|
1878, 2518
|
298, 347
|
485, 1256
|
1278, 1713
|
1729, 1778
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,945
| 145,535
|
41047
|
Discharge summary
|
report
|
Admission Date: [**2188-12-16**] Discharge Date: [**2188-12-29**]
Date of Birth: [**2125-5-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2188-12-16**] Cardiac cath
[**2188-12-24**] Coronary artery bypass graft x 5 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
diagonal, saphenous vein graft to obtuse marginal 1, saphenous
vein graft to obtuse marginal 2, saphenous vein graft to
posterior descending artery)
History of Present Illness:
63 year old male with no known prior cardiac history, presented
to his PCP, [**Name10 (NameIs) **] [**Last Name (STitle) 24862**], on [**12-15**] to report progression of symptoms
of dyspnea and a lesser sensation of chest discomfort. This was
noticed last fall. He initially attributed discomfort to GI
upset, but increasingly aware of fatigue and Dyspnea on exertion
with minor activities such as walking to his mailbox since
[**Month (only) **]. While at Dr [**Last Name (STitle) 24862**] office he experienced chest
heaviness, associated with diaphoresis and presyncopal symptoms.
He was transported to GSMS for evaluation. The office EKG was
noted for new T wave inversions V3-V6. He reports being pain
free since admission. MI r/o'd by EKG and TnI negative x2. He
has been referred to cardiac surgery for possible
revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Peripheral artery disease: carotid: R ICA 70% stenosis
s/p left pontine CVA '[**85**] (R hemiparesis)
Chronic constipation
Depression
Social History:
Race:Caucasian
Last Dental Exam:few months ago
Lives with: with roommate, sister is close by for support
Occupation:retired
Tobacco:denies
ETOH:pt states "moderate"
Family History:
Father died of MI age 62
Physical Exam:
Pulse:72 Resp:18 O2 sat:99/RA
B/P Left: 118/66
Height: 5'9" Weight:228 lbs
General: NAD, slightly unkempt
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema- none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: cath site, 2+ Left: 2+
Carotid Bruit Right: Left:
no carotid bruits
Pertinent Results:
[**2188-12-16**] Cardiac cath: 1. The patient had a vasovagal reaction
with hypotension and bradycardia during attempts to advance the
5 French JL4 catheter into the proximal brachiocephalic artery
through a tortuous loop. Dopamine 10 mcg/kg/min was required to
get the systolic blood pressure back to 120 mm Hg, but this was
accompanied by tachycardia and chest pain. The dopamine was
weaned off, with stable SBP but continued chest pain and
tachycardia. Metoprolol 2.5 mg IV was given with improvement of
heart rate int the 90s and gradual improvement of his chest pain
(after a brief period of IV TNG infusion). 2. Coronary
angiography in this codominant system revealed native three
vessel coronary artery disease. The LMCA had a distal 25%
stenosis. The LAD was heavily calcified throughout with an
ostial 60% stenosis, a calcified mid vessel complex bifurcation
lesion involving D1 with 90% in left anterior descending and 80%
in first diagonal branch. There was moderate to severe diffuse
disease in branching first diagonal with occlusion of a medial
distal pole. There were septal and apical collaterals to an AM
and the RPDA. The left circumflex had focal heavy calcification
with a tortuous moderate high OM1 and a mid AV groove circumflex
stenosis of 60% after OM2. The distal AV groove circumflex had a
subtotal vs. total occlusion after the tortuous LPL2. The OM2
was totally occluded and filled late by left-to-left
collaterals. The RCA had proximal severe disease with proximal
to mid vessel occlusion, seen both while on dopamine and
subsequently (arguing against vasopressor
induced spasm). 3. Post-angiography hemodynamics revealed normal
left sided filling pressures with LVEDP of 10 mmHg. Central
aortic pressures were normal 111/56 with a mean of 58 mmHg.
[**2188-12-17**] Carotid U/S: Right ICA stenosis 40-59%.
Left ICA stenosis <40%.
[**2188-12-24**] Echo: Prebypass: No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. Regional left ventricular [**Known lastname **] motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free [**Known lastname **] motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of
the results on [**2188-12-24**] at 900 am. Post bypass: Patient is A
paced and receiving an infusion of phenylephrine. Biventricular
systolic function is unchanged. Mild mitral regurgitation
persists. Aorta is intact post decannulation.
[**2188-12-29**] 06:00AM BLOOD WBC-9.4 RBC-4.29* Hgb-10.3* Hct-33.2*
MCV-77* MCH-24.0* MCHC-31.1 RDW-18.8* Plt Ct-333
[**2188-12-16**] 02:15PM BLOOD WBC-7.1 RBC-4.25* Hgb-9.1* Hct-30.3*
MCV-71* MCH-21.5* MCHC-30.2* RDW-15.8* Plt Ct-218
[**2188-12-16**] 02:15PM BLOOD PT-14.6* INR(PT)-1.3*
[**2188-12-29**] 06:00AM BLOOD UreaN-11 Creat-0.9 Na-136 K-4.2 Cl-103
[**2188-12-16**] 02:15PM BLOOD Glucose-149* UreaN-12 Creat-1.3* Na-136
K-3.6 Cl-105 HCO3-22 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname **] presented to [**Hospital1 18**] on [**2188-12-16**] with acute coronary
syndrome. He underwent a cardiac cath and was found to have
multivessel disease. A pre-op work up was completed and after a
plavix washout he was cleared for cardiac surgery. He was taken
to the operating room for surgical revascularization on [**2188-12-24**]
and underwent a coronary artery bypass x5. Please see operative
note for details.
Post operatively he was intubated and sedated and admitted to
the CVICU for hemodynamic monitoring and management. He awoke
neurologically intact and was extubated. He was transferred to
the stepdown unit for ongoing post operative management.
Betablockers/Statin/aspirin and diuresis were started and he was
diuresed toward his pre-operative weight. Chest tubes and
temporary pacing wires were removed per protocol. The remainder
of this postoperative course was essentially uneventful. He was
evaluated by physcial therapy for strength and conditioning and
cleared for discharge to his girlfriend's home with home PT on
POD#5. All follow up appointments were advised.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1
(One) Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 (One) Tablet(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
(One) Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
(One) Tablet(s) by mouth once a day
Discharge Medications:
1. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO Q12H (every 12 hours)
for 10 days.
Disp:*20 Tablet, ER Particles/Crystals(s)* Refills:*0*
2. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 5
Past medical history:
Hypertension
Hyperlipidemia
Peripheral artery disease: carotid: R ICA 70% stenosis
s/p left pontine CVA '[**85**] (R hemiparesis)
Chronic constipation
Depression
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/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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:
[**Last Name (un) **]??????s office closed, msg left
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**1-15**] at 1:30PM
Cardiologist: Needs referral
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 24862**] in [**2-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2188-12-29**]
|
[
"311",
"531.90",
"438.20",
"401.9",
"564.09",
"530.85",
"280.9",
"455.0",
"511.9",
"E879.0",
"272.4",
"433.10",
"458.29",
"414.01",
"411.1",
"211.3",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.22",
"45.23",
"88.56",
"36.15",
"45.13",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
9007, 9070
|
5938, 7050
|
322, 635
|
9358, 9585
|
2607, 5915
|
10508, 11014
|
1886, 1912
|
7638, 8984
|
9091, 9152
|
7076, 7615
|
9609, 10485
|
1927, 2588
|
272, 284
|
663, 1503
|
9174, 9337
|
1704, 1870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,375
| 185,687
|
6248
|
Discharge summary
|
report
|
Admission Date: [**2150-2-3**] Discharge Date: [**2150-2-11**]
Date of Birth: [**2082-8-27**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Aspirin
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p MVC with multiple injuries
Major Surgical or Invasive Procedure:
[**2150-2-4**]: ORIF R femur fracture with proximal femoral plate, ORIF
R tibial plateau fracture with tibial [**Last Name (un) 101**] plate
History of Present Illness:
67 yo F s/p MVC, struck on right side by a vehicle traveling at
20-25 mph. Per EMS, pt made contact with vehicle's windshield,
flipped over car and
experienced brief LOC. RLE pain/deformity upon arrival to ED
Past Medical History:
knee arthroscopy
urge incontinence
HTN, OSA
PSH: Splenectomy, Gastric stapling, knee scope, cystoscopy
Social History:
Lives alone. Has 3 grown children
Family History:
n/a
Physical Exam:
AVSS, afebrile, HD stable
NAD, AxOx3
forehead lac
Lungs CTAB, no chest wall crepitus
RRR no MRG
R hip deformity, ecchymosis R knee, 2+DP pulse
Pertinent Results:
[**2150-2-3**] 09:23PM HCT-24.1*#
[**2150-2-3**] 08:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2150-2-3**] 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2150-2-3**] 08:40PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2150-2-3**] 08:40PM URINE HYALINE-0-2
[**2150-2-3**] 08:40PM URINE MUCOUS-FEW
[**2150-2-3**] 07:33PM GLUCOSE-157* LACTATE-2.4* NA+-139 K+-4.7
CL--100 TCO2-27
[**2150-2-3**] 07:32PM UREA N-29* CREAT-1.3*
[**2150-2-3**] 07:32PM CK(CPK)-352*
[**2150-2-3**] 07:32PM LIPASE-45
[**2150-2-3**] 07:32PM CK-MB-6 cTropnT-<0.01
[**2150-2-3**] 07:32PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-2-3**] 07:32PM WBC-13.1* RBC-3.69* HGB-11.1* HCT-33.5*
MCV-91 MCH-30.1 MCHC-33.1 RDW-14.1
[**2150-2-3**] 07:32PM PT-12.4 PTT-26.2 INR(PT)-1.0
[**2150-2-3**] 07:32PM PLT COUNT-296
[**2150-2-3**] 07:32PM FIBRINOGE-281
CT C-SPINE W/O CONTRAST Study Date of [**2150-2-3**] 6:41 PM
No fracture or traumatic malalignment
TIB/FIB (AP & LAT) RIGHT Study Date of [**2150-2-3**] 7:54 PM
Comminuted proximal tibia and fibular fractures with
intra-articular extension of the tibial fracture. Large
suprapatellar joint effusion.
TRAUMA #3 (PORT CHEST ONLY) Study Date of [**2150-2-3**] 6:45 PM
No acute traumatic injury identified within the chest.
FEMUR (AP & LAT) RIGHT Study Date of [**2150-2-3**] 7:53 PM \
Comminuted fractures involving the right proximal femur, right
proximal tibia and right proximal fibula. Fractures involving
the right
sacral ala as well as the right superior and inferior pubic rami
are
redemonstrated, but better assessed on the recent CT. Large
right-sided
pelvic hematoma, displacing the bladder to the left. Large
suprapatellar
joint effusion.
Brief Hospital Course:
The patient was initially admitted to the trauma service on
[**2150-2-3**]. She was given aggressive volume resuscitation with NS
for hypotension. CT scan showed active extravasation of blood
in the pelvis and she was sent to IR for emergent embolization
of a bleeding small branch artery off the right external iliac
artery. She also received two units of blood in IR.
Her head laceration was repaired with sutures. On [**2150-2-4**], the
patient went to the operating room with Dr. [**Last Name (STitle) **]. See op
note for further detail. The patient had ORIF of her proximal
femur and proximal tibia. Postoperatively, she did well. She
was kept intubated overnight in the TSICU and then transferred
to the floor onto the orthopaedic service on [**2150-2-9**] once her
Hct was stable after receiving 2 units of blood on [**12-10**].
She tolerated a regular diet. Her foley was d/c'd without
problem. She worked with physical therapy to improve strength
and mobility while remaining TDWB on her RLE. She remained
hemodynamically stable and afebrile on the floor. Her wounds
continued to look healthy without any erythema or drainage.
Medications on Admission:
Vesicare, Fe
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for cosntipation.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for cosntipation.
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily) for 4 weeks.
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for Pain: hold for oversedation,
rr<12, confusion.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
R intertroch fracture w/subtroch extension.
R superior/inferior pubic rami frx w/ R posterior sacral buckle
frx
R tiial plateau frx V-->VI
L ribs fractures #[**3-22**]
Injury to inferior epigastric vessel requiring embolization
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:
-Keep incision dry. Do not soak in tub or pool.
-Continue to be touch down weight bearing on your right leg.
-Resume your regular diet.
-Take all medications as directed.
-Continue taking the Lovenox to prevent blood clots.
-Avoid Nicotine products to promote healing. Nicotine directly
inhibits bone healing.
-Avoid Non-steroidal anti-inflammatory medications such as
Ibuprofen.
-Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
-Percocet contains Acetaminophen. Taking more Acetaminophen
than recommended may cause serious liver problems. [**Name (NI) **] not take
Acetaminophen containing products with this prescription.
If you have any questions or concerns please call your doctor at
[**Telephone/Fax (1) 1228**]
If you experience any of the below listed danger signs then go
to your local emergency room or call your doctor at
[**Telephone/Fax (1) 1228**].
Physical Therapy:
Out of bed w/ assist
Pneumatic boots
Right lower extremity: Touchdown weight bearing
Hinged knee brace unlocked for range of motion, right knee.
pneumoboots to left leg
Treatment Frequency:
Staples on R hip and knee need to be removed on [**2-19**]
Dry gauze dressings to R hip and knee prn
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery, in 2 weeks for
evlauation of your rib fractures. Call [**Telephone/Fax (1) 2359**] for an
appointment and inform the office that you will need an 'upright
end expiratory chest xray' for this appointment.
Follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedic clinic in 2
weeks. Call [**Telephone/Fax (1) 1228**] to schedule this appointment
|
[
"401.9",
"808.2",
"805.6",
"807.04",
"823.02",
"920",
"E814.7",
"E849.5",
"820.21",
"902.53",
"285.1",
"V45.86",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"79.35",
"88.49",
"38.93",
"79.36"
] |
icd9pcs
|
[
[
[]
]
] |
4795, 4865
|
2933, 4082
|
302, 444
|
5137, 5137
|
1062, 2910
|
6750, 7202
|
878, 883
|
4145, 4772
|
4886, 5116
|
4108, 4122
|
5314, 6405
|
898, 1043
|
6424, 6600
|
232, 264
|
472, 684
|
5151, 5290
|
6622, 6727
|
706, 811
|
827, 862
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,208
| 158,522
|
761
|
Discharge summary
|
report
|
Admission Date: [**2186-1-13**] Discharge Date: [**2186-1-20**]
Date of Birth: [**2126-12-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Acute Renal Failure
Major Surgical or Invasive Procedure:
HD line placement
History of Present Illness:
59 y/o M w/ h/o hepatitis C, HTN, CKD with baseline Cr of 2.0.
Patient had been having 2 weeks of fatigue, fever, chills,
dysuria with watery stools and decreased PO intake. Had been
essentially bed bound. By Sunday was able to get out of bed and
on Tuesday visited his PCP who found to have Cr of 20 and BUN of
120. Was brought in for repeat labs which confirmed initial
findings and then referred to ED for evaluation.
.
In the ED, initial vs were: T98.8 P83 BP 161/102 R 18 O2 sat 93%
RA. SBP of 220/125 at maximum during ED stay. Exam notable for
diminished breath sounds. LUQ TTP on exam. Asterixis and coarse
tremor on exam. CXR - LLL infiltrate with mild to moderate
congestion. Treated with lasix as per Renal with 250cc urine
output. Azithromycin/CTX for pneumonia. Renal planned to
continue diuresis and consider HD. Vitals on transfer HR 84, BP
180/100, RR 21, O295% 2L.
.
On arrival patient was c/o mild LUQ pain that had been present
for some time.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-Hep A/B
-Hep C
-HTN
-CKD w/ baseline Cr 2.0
-Asthma
-s/p CVA
-OSA
-h/o Etoh abuse off for 6-7 years.
Social History:
h/o etoh abuse, has been clean for 6-7 years.
Family History:
non-contributory
Physical Exam:
Vitals: T:98.1 BP:138/88 P:94 R:18 O2:94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: tunneled Right dialysis line, mildly tender
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2186-1-12**] 11:30AM UREA N-119* CREAT-20.2* SODIUM-149*
POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-22 ANION GAP-29*
[**2186-1-13**] 12:15PM NEUTS-55.2 LYMPHS-36.1 MONOS-3.9 EOS-4.2*
BASOS-0.6
[**2186-1-13**] 12:15PM WBC-8.6 RBC-4.08* HGB-9.9* HCT-30.7*# MCV-75*
MCH-24.2* MCHC-32.2 RDW-14.5
[**2186-1-13**] 12:15PM RHEU FACT-9
[**2186-1-13**] 12:15PM PTH-844*
[**2186-1-13**] 12:15PM CK-MB-10 MB INDX-0.8
[**2186-1-13**] 12:15PM cTropnT-0.10*
[**2186-1-13**] 12:15PM ALT(SGPT)-28 AST(SGOT)-32 CK(CPK)-1245* ALK
PHOS-126* TOT BILI-0.1
[**2186-1-13**] 12:39PM LACTATE-1.4
[**2186-1-13**] 12:50PM URINE RBC-21-50* WBC-[**1-26**] BACTERIA-FEW
YEAST-NONE EPI-0
[**2186-1-13**] 12:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2186-1-13**] 12:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2186-1-13**] 01:40PM URINE OSMOLAL-348
[**2186-1-13**] 08:00PM CK(CPK)-1057* AMYLASE-160*
[**2186-1-20**] 06:35AM BLOOD WBC-9.7 RBC-3.64* Hgb-8.9* Hct-28.3*
MCV-78* MCH-24.6* MCHC-31.6 RDW-14.8 Plt Ct-329
[**2186-1-20**] 06:35AM BLOOD PT-14.0* PTT-29.3 INR(PT)-1.2*
[**2186-1-20**] 06:35AM BLOOD Glucose-93 UreaN-58* Creat-13.9*# Na-135
K-4.8 Cl-97 HCO3-25 AnGap-18
[**2186-1-13**] 12:15PM BLOOD ALT-28 AST-32 CK(CPK)-1245* AlkPhos-126*
TotBili-0.1
[**2186-1-13**] 08:00PM BLOOD CK(CPK)-1057* Amylase-160*
[**2186-1-14**] 04:16AM BLOOD CK(CPK)-972*
[**2186-1-15**] 06:25AM BLOOD CK(CPK)-601*
[**2186-1-16**] 06:15AM BLOOD CK(CPK)-458*
[**2186-1-13**] 08:00PM BLOOD Lipase-55
[**2186-1-13**] 12:15PM BLOOD CK-MB-10 MB Indx-0.8
[**2186-1-13**] 12:15PM BLOOD cTropnT-0.10*
[**2186-1-13**] 08:00PM BLOOD CK-MB-9 cTropnT-0.10*
[**2186-1-15**] 06:25AM BLOOD CK-MB-5 cTropnT-0.10*
[**2186-1-20**] 06:35AM BLOOD Calcium-8.2* Phos-6.9* Mg-1.9
[**2186-1-17**] 12:25PM BLOOD Cryoglb-NEGATIVE
[**2186-1-14**] 06:30PM BLOOD calTIBC-187* Ferritn-586* TRF-144*
[**2186-1-13**] 12:15PM BLOOD PTH-844*
[**2186-1-17**] 05:40AM BLOOD HBcAb-POSITIVE IgM HBc-NEGATIVE
[**2186-1-14**] 06:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
[**2186-1-13**] 04:33PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2186-1-13**] 12:15PM BLOOD RheuFac-9
[**2186-1-13**] 05:08PM BLOOD C4-46*
[**2186-1-13**] 12:15PM BLOOD C3-153
[**2186-1-19**] 07:10AM BLOOD HIV Ab-NEGATIVE
[**2186-1-13**] 08:00PM BLOOD ASA-7 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2186-1-13**] 12:39PM BLOOD Lactate-1.4
[**2186-1-13**] 12:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2186-1-13**] 12:50PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2186-1-13**] 01:40PM URINE Hours-RANDOM Creat-100 Na-56
[**2186-1-13**] 01:40PM URINE Osmolal-348
[**2186-1-14**] 04:16AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
ASO Screen (Final [**2186-1-16**]):
< 200 IU/ml PERFORMED BY LATEX AGGLUTINATION.
Reference Range: < 200 IU/ml (Adults and children > 6
years old).
**FINAL REPORT [**2186-1-16**]**
HCV VIRAL LOAD (Final [**2186-1-16**]):
1,190,000 IU/mL.
**FINAL REPORT [**2186-1-17**]**
HBV Viral Load (Final [**2186-1-17**]):
HBV DNA not detected.
Blood Cx: [**1-13**], [**1-13**], [**1-16**], [**1-17**]: no growth
Urine: [**1-13**], [**1-13**], [**1-15**]: no growth
Images:
CXR:
CONCLUSION: Overall, findings are suggestive of mild CHF with
superimposed infection at the left lung base. Please ensure
followup to clearance.
.
EKG: NSR at 77 bpm, nml axis, nml intervals, new anterior
q-waves suggesting prior MI, isolate ST elevation in V2, TWF
laterally.
[**1-14**] renal u/s:
IMPRESSION:
1. No evidence of hydronephrosis.
2. Doppler evaluation limited due to patient body habitus. Left
renal
artery not evaluated. The abnormal appearance of the right renal
waveform
could be due to suboptimal study quality, presence of stenosis
not excluded.
Brief Hospital Course:
This is a 59 y/o M w/ Hep C, HTN, CKD, a/w HTN emergency and
Acute on Chronic Renal Failure.
.
# Uremia/Acute Renal Failure:
The patient had been having fatigue, fever, chills, dysuria with
watery stools and decreased PO intake 2 weeks PTA. He was bed
bound by his symptoms and began to improve 5 days prior and went
to his PCP on Tuesday. His symptoms had improved, but labwork
showed Cr of 20 and BUN of 120. He was brought in for repeat
labs which confirmed initial findings and then referred to ED
for evaluation.
.
In the ED, initial vs were: T98.8 P83 BP 161/102 R 18 O2 sat 93%
RA. SBP of 220/125 at maximum during ED stay. A CXR showed LLL
infiltrate with mild to moderate congestion. The patient was
started on Azithromycin/CTX for pneumonia. The patient was
started on a nitro gtt for BP control with SBP 160-180's. The
patient was evaluated by Renal and underwent dialysis, RIJ was
placed. The patient's urine sediment was bland. The patient
remained stable and underwent his second session of dialysis
prior to transfer to the floor. His renal U/S showed a right
kidney of 11.1 cm and the left kidney of 10 cm. The patient
underwent CT-guided biopsy on [**1-17**]. The final pathology is still
pending, but preliminary review showed extensive scar and immune
complex deposition. The patients labwork was negative for RF,
[**Doctor First Name **], ANCA, cryo, C3/C4, ASO. The patient's Hep C VL was 1.19
million. The patient was continued on dialysis and had had a
tunneled line placed on [**1-19**]. He also underwent vein mapping.
The patient was setup for outpatient dialysis for MWF. His PPD
was negative and HepB serologies conisistent with previous
infection.
# Hypertensive Emergency: The patient's SBP was initially in the
200's. He was started on a nitro gtt in the ED with SBP
160-180's and was continued in the MICU. The patient was also
restarted on his home amlodipine. The patient's blood pressure
regimen was amlodipine 10mg daily, labetolol 200mg TID and
clonidine 0.1mg TID. Additionally, he had 1" of nitro paste.
His blood pressures decreased with the regimen and after
dialysis. His clonidine and nitro paste were eventually
discontinued. His labetolol was also changed to [**Hospital1 **] dosing
after his blood pressure ranged 100-120's. On [**1-19**] the patient
was found to be orthostatic with a 20 point drop in his SBP with
standing. This was most likely secondary to aggressive volume
removal at HD. On [**1-20**] he was given 500cc IVF with improvement
in his orthostasis. The patient was sent home on amlodipine 10mg
daily and labetolol 200mg TID.
.
# Pulmonary/Asthma/OSA: The patient inially had a 2L O2
requirement and was weaned to room air after fluid removal at
HD. The patient was continued on nebulizers prn and BiPAP
overnight.
.
# Hepatitis C: The patient has a history of Hep C and was a
non-responder to therapy. His VL was 1.19million.
# Q-Waves on EKG: His ECG finding were consistent with prior MI.
He had 3 negative CE and no complaints of chest pain.
# Elevated CK's: This was likely [**12-26**] to recent viral syndrome.
His CK were not elevated enough to be the primary etiology for
renal failure. His CK trended down thoughout his admission.
Medications on Admission:
trazodone 100mg qhs
sertraline 100mg q24
seroquel 200mg qhs
lisinopril 20mg q24
gabapentin 300mg
fluticasone
buproprion 150mg q24
amlodipine 5mg q24
albuterol PRN
Discharge Medications:
1. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
2. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. Quetiapine 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO QHS (once a day (at bedtime)).
4. Gabapentin 100 mg Tablet Sig: Two (2) Capsule PO QHD (each
hemodialysis).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Bupropion 150 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours.
Disp:*1 inhaler* Refills:*2*
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
13. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
w/meals.
Disp:*90 Tablet(s)* Refills:*2*
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary:
Acute on Chronic Renal Failure
Hypertension
Secondary:
Hep C
HTN
Asthma
OSA
Discharge Condition:
stable, ambulating with cane, normotensive, tolerating regular
diet
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of hypertension
and worsening kidney failure. You were started on dialysis and
will follow-up with with your kidney doctor. You also had a new
dilayis line placed and will start dialysis on Monday. You were
seen by SW and setup with transporation to your dialysis center:
[**Location (un) **] Northeast [**Hospital1 3597**] Dialysis
[**Street Address(2) 5531**].
[**Hospital1 3597**] [**Telephone/Fax (1) 5532**]
Your dialysis sessions are Monday, Wednesday, Friday at 2:30pm
Please follow the medications prescribed below.
1) Please stop taking your lisinopril
2) Please take 10mg amlopdipine and 200mg labetolol
3) You will be taking Calcium Acetate and Sevelamer with meals
4) Please take your nephrocaps vitamin
5) You were given a rx for percocet for pain for your tunneled
line
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) **] [**1-24**] 3:45pm
PCP: [**Name10 (NameIs) 5533**],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 3581**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2186-2-6**] 2:40
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2186-2-28**]
1:45
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2186-3-9**] 11:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2186-1-23**]
|
[
"588.81",
"285.21",
"493.90",
"458.21",
"276.0",
"585.3",
"327.23",
"070.54",
"280.9",
"311",
"403.90",
"079.99",
"584.9",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.23",
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11485, 11560
|
6538, 9760
|
335, 354
|
11690, 11760
|
2511, 6515
|
12927, 13703
|
1949, 1967
|
9974, 11462
|
11581, 11669
|
9786, 9951
|
11784, 12904
|
1982, 2492
|
276, 297
|
1364, 1744
|
382, 1346
|
1766, 1870
|
1886, 1933
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,349
| 195,128
|
45647
|
Discharge summary
|
report
|
Admission Date: [**2110-6-10**] Discharge Date: [**2110-6-17**]
Date of Birth: [**2046-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Haloperidol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
aortic valve replacement (25mm [**Company 1543**] Mosaic Ultra-porcine)
[**2110-6-10**]
History of Present Illness:
63 yo M with h/o aortic stenosis with c/o dyspnea on exertion
referred for left and right heart cath.
Past Medical History:
HTN
^lipids
NSTEMI [**3-20**]
Schizophrenia with depression
Diabetes on insulin
Hepatitis, remote history
S/P aspiration pneumonia, [**2110-4-11**] treated with antibiotics
Left ventricular diastolic dysfunction
Aortic stenosis
GERD
Anxiety
Bilateral hearing loss
Eczema
H/O skin cancer
+ BPH
per pt, bullet still at base of spine- not removed during
surgery
Social History:
B&[**Initials (NamePattern4) **] [**Location (un) 669**], middle of 6 kids, dad was an abusive
alcoholic. Pt. attended prep school. After graduation worked for
Turnpike for several years. He's been on disability for >20yrs.
Pt said he has been living in a group home in [**Location (un) **] for the
past five years.
Family History:
UNKNOWN
Physical Exam:
Physical Exam
Pulse:62 Resp:18 O2 sat:
B/P Right:119/76 Left:124/76
Height:5'[**10**]" Weight:185 LBS
General:Alert & oriented x 3
Skin: Dry [X] intact [X]
HEENT: PERRLA [x] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur Holo-Sys [**3-17**],w/radiation to
carotids
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X], No masses
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:+2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:+2 Left:+2
Carotid Bruit Right:+ Left:+
Pertinent Results:
[**2110-6-16**] 06:00AM BLOOD WBC-14.4* RBC-3.23* Hgb-9.2* Hct-27.5*
MCV-85 MCH-28.5 MCHC-33.5 RDW-14.3 Plt Ct-242
[**2110-6-15**] 06:00AM BLOOD WBC-12.6* RBC-3.33* Hgb-9.3* Hct-28.1*
MCV-85 MCH-28.1 MCHC-33.2 RDW-14.2 Plt Ct-204#
[**2110-6-14**] 07:40AM BLOOD WBC-16.3*
[**2110-6-15**] 06:00AM BLOOD Glucose-209* UreaN-20 Creat-0.9 Na-140
K-4.2 Cl-106 HCO3-26 AnGap-12
PRE-BYPASS:
1. A left-to-right shunt across the interatrial septum is seen
at rest. A secundum type atrial septal defect is present.
2. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). No aortic
regurgitation is seen.
5. Trivial mitral regurgitation is seen.
6. There is a trivial/physiologic pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced.
1. Biventricular function is intact
2. A bioprosthesis is well seated in the Aortic position.
Leaflets move well. Trace central AI is noted. Mean gradient is
< 10 mm of Hg.
3. Aortic contours appear intact post decannulation
[**2110-6-17**] 06:15AM BLOOD WBC-12.4* RBC-3.45* Hgb-9.4* Hct-29.6*
MCV-86 MCH-27.4 MCHC-31.9 RDW-13.8 Plt Ct-283
[**2110-6-16**] 09:16PM BLOOD Glucose-212* UreaN-20 Creat-1.1 Na-138
K-4.2 Cl-99 HCO3-31 AnGap-12
Brief Hospital Course:
On [**2110-6-10**] Mr. [**Known lastname 496**] [**Last Name (Titles) 1834**] an aortic valve replacement
with a 25mm [**Company **] mosaic ultra porcine valve. Please see
the operative note for details. He tolerated this procedure
well and was transferred in critical but stable condition to the
surgical intensive care unit. He was extubated and weaned from
his pressors. His psych meds were restarted. Chest tubes were
removed. On post-operative day two he was transferred to the
step down floor. Epicardial wires were removed. He was placed
on Vancomycin/Zosyn for a presumed pneumonia, but as he remained
afebrile, his leukocytosis resolved, and his chest radiograph
improved these antibiotics were discontinued at discharge. By
post-operative day seven he was ready for discharge to home with
services.
Medications on Admission:
Amlodipine 10 mg daily
nr Clonazepam [Klonopin] 0.5 mg [**Hospital1 **]
Clozapine [Clozaril] 100 mg Tablet 3 Tablet(s) by mouth daily
Hydrocortisone 2.5 % Cream
apply to rectal area as needed (Prescribed by Other Provider)
Insulin Lispro Protam & Lispro [Humalog Mix 75-25] 100 unit/mL
(75-25) Suspension 24 units in the am, 14 units in the pm Twice
daily
Metoprolol Tartrate 25 mg [**Hospital1 **]
Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
one packet(s) by mouth Twice daily as needed for prn
Simvastatin 40 mg daily
Aspirin 325 mg daily
Omeprazole Magnesium [Prilosec OTC] 20 mg Tablet, Delayed
Release
(E.C.) daily
Discharge Medications:
1. Clozapine 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. 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*
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. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin
Pen Sig: Twelve (12) units Subcutaneous once a day: 75/25
insulin 12 units daily in the morning until otherwise directed
by your endocrinologist.
Disp:*qs units* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days: assess for need for further diuresis at end of course.
Disp:*20 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
11. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) PO once a day.
Discharge Disposition:
Home With Service
Facility:
City psych VNA
Discharge Diagnosis:
aortic stenosis
s/p aortic valve replacement this admission
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, and while taking
narcotics
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) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] (PCP) [**Telephone/Fax (1) 97328**] in 1 week
Dr. [**Last Name (STitle) **] (cardiologist)in [**1-14**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2110-6-17**]
|
[
"424.1",
"511.9",
"429.9",
"V10.83",
"295.90",
"692.9",
"412",
"300.4",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
6799, 6844
|
3693, 4513
|
285, 375
|
6948, 6955
|
1993, 3670
|
7495, 7918
|
1243, 1252
|
5207, 6776
|
6865, 6927
|
4539, 5184
|
6979, 7472
|
1267, 1974
|
238, 247
|
403, 507
|
529, 890
|
906, 1227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,693
| 138,199
|
16040
|
Discharge summary
|
report
|
Admission Date: [**2173-3-24**] Discharge Date: [**2173-3-27**]
Date of Birth: [**2131-6-22**] Sex: F
HISTORY OF PRESENT ILLNESS: Ms [**Known lastname 12746**] is a 41 year old
woman who first presented to the [**Hospital **] Clinic with a known
high risk for developing breast cancer due to having a BRCA-2
mutation. Prior to her presentation she felt a lump within
undergone a fine needle aspiration at the time which was
nondiagnostic. She had also undergone a diagnostic left
mammogram and ultrasound which were suspicious for cancer.
The patient then underwent excision of the mass at the [**Hospital 36653**]
Clinic in [**2173-2-10**] which revealed infiltrating ductal
carcinoma.
anemia. 3. Iron deficiency. 4. Chronic fatigue syndrome.
5. Fibromyalgia. 6. Obsessive compulsive disorder. 7.
Mitral valve prolapse with murmur. 8. Endometriosis. 9.
Cervical arthritis. 10. Asthma. 11. History of
sarcoidosis. 12. Neurogenic bladder. 13. Probable
atypical migraine. 14. Probable Raynaud's phenomenon. 15.
Possible Sjogren's disease.
FAMILY HISTORY: Significant for her sister developing breast
cancer at age 41 and testing positive for mutation of the BRCA
gene. She also has a mother who had breast cancer at the age of
62 and both maternal aunts and maternal grandmother with breast
cancer their the early 60s. No history of ovarian cancers in
the family.
ALLERGIES: Codeine as well as narcotics, Prozac, Neurontin,
Penicillin, Bactrim, Iodine, Betadine, Versed, Stadol, Biaxin
and adhesive tape.
MEDICATIONS ON ADMISSION: 1. Lexapro 10 mg p.o. q. day; 2.
Clonazepam 1.5 mg t.i.d.; 3. Synthroid 1 mg q. day; 4.
Verapamil 120 mg q. AM; 5. Hydrochlorothiazide 37.5 mg q.
day; 6. Chlorcon q. AM; 7. B12 vitamin; 8. Iron; 9.
Elavil 40 mg p.o. q.h.s.; 9. Flovent inhaler; 10. Atrovent
inhaler; 11. Albuterol inhaler
PAST SURGICAL HISTORY: 1. Laparoscopy followed by two
further surgeries for endometriosis; 2. Total thyroidectomy;
3. Partial parathyroidectomy; 4. Sinus surgery; 5.
[**Last Name (un) 14896**] procedure; 6. Stimulator placement for neurogenic
bladder.
SOCIAL HISTORY: The patient does not smoke and does not
drink. She has one daughter.
PHYSICAL EXAMINATION: Well-appearing female in no acute
distress. Blood pressure 106/76, pulse 80, respiratory rate
12. Head, eyes, ears, nose and throat examination, within
normal limits. Lung examination, clear to auscultation
bilaterally. Cardiac examination, regular rate and rhythm
without murmurs, gallops or rubs. Breast examination shows
prior [**Last Name (un) 14896**] procedure scar in the upper inner quadrant
of the left breast as well as transverse healing scar along
the lower inner quadrant of the left breast. There were no
suspicious skin changes in four positions. To palpation she
has normal postoperative changes with no dominant masses.
She has a normal feeling axillary node within the left with
no suspicious axillary, supraclavicular or infraclavicular
lymphadenopathy.
LABORATORY DATA: Radiologic data - A left mammogram from the
outside hospital was reviewed which showed dense parenchymal
tissue as well as the denser nodule within the lower inner
quadrant of her left breast. Ultrasound showed a very
irregular hypoechoic mass which was suspicious for carcinoma.
HOSPITAL COURSE: The patient was explained the different
possibilities given her diagnosis of infiltrating ductal
carcinoma as well as her testing positive for the BRCA gene.
The decision was made to proceed with bilateral mastectomy.
Informed consent was signed and the patient understood the
risks and benefits of the procedure. On [**2173-3-24**],
the patient was taken to the Operating Room and underwent
bilateral mastectomies and left axillary dissection. There were
no complications. [**Location (un) 1661**]-[**Location (un) 1662**] drains were placed, two on each
side. The patient was successfully extubated and transferred to
the Post Anesthesia Care Unit in stable condition. In the Post
Anesthesia Care Unit she was noted to be very sedated.
Consequently, due to the late hour, the patient was transferred
to the Intensive Care Unit over night. She continued to do well.
She received adequate intravenous fluids. She remained NPO over
night. Her sedation gradually resolved and she was more
alert and oriented on postoperative day #1. Her pain was
treated with extra strength Tylenol and intravenous Toradol as
she wished to avoid all narcotics. The patient was advanced to
clears and then regular diet as tolerated. She was noted to be
hypotensive on post op day #2 slowing ambulation and received
extra intravenous fluids. Her usual Verapamil as well as the
Hydrochlorothiazide were held and her blood pressure stabilized.
She continued to ambulate first with some difficulty but she then
continued to do well without assistance. Physical therapy was
consulted as well and she ambulated without difficulty. The
patient was continued on the rest of her outpatient medications
as mentioned above. The [**Location (un) 1661**]-[**Location (un) 1662**] drains continued to put
out serosanguinous fluid which somewhat decreased in amount.
Her incision continued to look clean, dry and intact
bilaterally. There was no significant erythema. There was
minimal swelling. There were no signs of infection. The
patient was tolerating regular diet. The patient received
drain teaching. She was discharged to home in stable
condition on [**2173-3-27**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DESTINATION: Home with [**Hospital6 407**]
Services.
DISCHARGE DIAGNOSIS:
1. Left breast cancer, status post bilateral mastectomies.
2. Thyroid cancer.
3. Pernicious anemia.
4. Iron deficiency anemia.
5. Chronic fatigue syndrome.
6. Fibromyalgia.
7. Obsessive compulsive disorder.
8. Endometriosis.
9. Asthma.
10. Cervical arthritis.
11. History of sarcoidosis.
12. Neurogenic bladder.
DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr.
[**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] next week as arranged. The patient is to empty
her [**Location (un) 1661**]-[**Location (un) 1662**] drains with the help of the visiting nurse
[**First Name (Titles) 3**] [**Last Name (Titles) 8757**] and they are to be removed in the next visit
with Dr. [**Last Name (STitle) **].
DISCHARGE MEDICATIONS:
1. Extra strength Tylenol and Ibuprofen as needed
2. Lexapro
3. Clonazepam
4. Synthroid
5. Verapamil
6. Hydrochlorothiazide
7. Chlorcon
8. Vitamin B12
9. Elavil
10. Iron supplements
11. Flovent
12. Atrovent
13. Albuterol
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 45904**], M.D. [**MD Number(1) 45905**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2173-3-28**] 18:00
T: [**2173-3-28**] 18:06
JOB#: [**Job Number 45906**]
|
[
"V16.3",
"280.9",
"710.2",
"493.90",
"300.3",
"424.0",
"174.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.44"
] |
icd9pcs
|
[
[
[]
]
] |
1101, 1555
|
6387, 6898
|
5626, 5948
|
1582, 1879
|
3348, 5508
|
5973, 6364
|
1903, 2138
|
2249, 3330
|
151, 1084
|
2155, 2226
|
5533, 5605
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,660
| 198,105
|
29625
|
Discharge summary
|
report
|
Admission Date: [**2144-6-5**] Discharge Date: [**2144-6-8**]
Date of Birth: [**2104-8-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Central Venous Line Placement
History of Present Illness:
39 yo M with h/o cranial mass admitted to [**Hospital Unit Name 153**] for decreased
responsiveness. Patient initially presented [**6-5**] after being
found by roommate with decreased mental status in the setting of
overtreatment with LBP with fentanyl patches. In the ED he was
hypotensive to 79/52 which improved with 5L NS IVF and narcan
but also was febrile to 101.2 so initially was treated with 2 gm
CTX, 1 gm vanc and acyclovir. LP was normal but ABG was
7.26/77/71 so he was started on a naloxone drip in the ED which
was discontinued in the [**Hospital Unit Name 153**] for concern for narcotic
withdrawal. Of note tox screen in ED was positive for cocaine as
well. On arrival to the [**Hospital Unit Name 153**] the patient was afebrile,
normotensive, and 98% on room air. However he was exhibiting
signs of narcotic withdrawal including abdominal pain and
yawning. He also reported back pain. Still somewhat confused but
appropriate, responsive to voice, and following commands. Denied
fevers, chills, chest pain, shortness of breath, HA.
.
He does not recall how he came to the hospital, but his last
memory is using cocaine with a friend after being sober for 5
years and next thing woke up in the ED. He states that he may
have used 2x100mc fentanyl patches instead of his normal 50mcg
and 100mcg as prescribed. He denies current chest pain, chest
tightness, shortness of breath, focal weakness or loss of
sensation. Currently he reports poorly controlled back pain in
the cervical region [**11-11**], nonradiating deep inside his neck. He
also feels nauseaous with no vomiting, has chronic diarrhea, and
[**11-11**] abdominal pain as well.
Past Medical History:
- Glioblastoma (not yet confirmed with hospital records): Gamma
Knife therapy. Diagnosed 2 years ago, but not followed.
-Chronic pancreatitis: reports he has had three attempted stent
placements which had failed and has had pancreatitis throughout
his life.
-Left thumb amputation: 2-1/2 years ago after an IV infiltrated
in his hand for 18 hours.
-post appendectomy
-post cholecystectomy
-GI bleed due to an ulcer in [**2134**] (while on NSAIDs).
-muliple obdominal tumors requiring resection of partial bowel,
liver, and pancreas due to pseudocyst and tumor syndrome. He is
followed by a Dr. [**Last Name (STitle) **] in [**State 33977**].
-Asthma
-Recurrent PNA
Social History:
The patient says that he has been sober for 5 years. He states
that he smokes 8 cigarettes a day, and he used to smoke 3-1/2
packs a day for 14 years. He states he has used marijuana.
Denies IVDU.
Family History:
Sister and father committed suicide. Mother died from MI and
stroke. Paternal grandfather with history of "brain and stomach
cancer." No diabetes in the family.
Physical Exam:
T 98.3 HR 83 BP 90/74 RR 18 O2 At 95% [**Female First Name (un) **]
Gen: sleeping comfortably but easily aroused
HEENT-PERRL, MMM, edentulous, hairless scar on left occiput,
neck supple
Hrt-RRR, nS1S2 no MRG
Lungs- Clear to auscultation bilaterally.
Abd: soft, mild diffuse tenderness with negative stethascope
press sign, NABS, midline scar, no HSM but difficult to assess
as pt was distended
Ext: no peripheral edema, Amputated left thumb.
Pertinent Results:
[**2144-6-5**] CT HEAD: Pineal region mass measuring 18 x 11 mm with no
focal mass effect. However, the study was limited since no IV
contrast was used. Please note that MRI is the best modality for
assessing intracarnial masses. No hemorrhage, mass effect or
hydrocephalus.
.
[**2144-6-5**] CXR: Bibasilar opacities left greater than right, likely
represent aspiration.
.
[**2144-6-5**] ECG: Sinus rhythm, rate 99. Small Q waves are seen in the
inferior leads. The electrocardiogram is otherwise, normal. No
previous tracing available for comparison.
.
[**2144-6-6**] CXR: Previous left lobe atelectasis has cleared.
Pulmonary vascular congestion suggests volume overload or
borderline cardiac decompensation although heart is normal size.
This may also explain hilar enlargement. Very small right
pleural effusion is new or newly apparent. There are no findings
to suggest pneumonia.
.
[**2144-6-5**] 8:20 pm URINE Site: CATHETER
URINE CULTURE (Final [**2144-6-7**]): NO GROWTH.
.
[**2144-6-6**] 5:27 pm CATHETER TIP-IV Source: Femoral line.
WOUND CULTURE (Final [**2144-6-8**]): No significant growth.
.
[**2144-6-5**] 09:30PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-2* Polys-9
Lymphs-42 Monos-49
[**2144-6-5**] 09:30PM CEREBROSPINAL FLUID (CSF) TotProt-26 Glucose-71
.
[**2144-6-5**] 08:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2144-6-5**] 08:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2144-6-5**] 08:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
.
[**2144-6-5**] 04:00PM BLOOD WBC-18.2* RBC-4.02* Hgb-13.4* Hct-39.6*
MCV-98 MCH-33.3* MCHC-33.8 RDW-14.1 Plt Ct-356
[**2144-6-5**] 04:00PM BLOOD Neuts-89.0* Bands-0 Lymphs-5.5* Monos-5.1
Eos-0.2 Baso-0.1
[**2144-6-5**] 04:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2144-6-5**] 04:00PM BLOOD PT-11.2 PTT-71.2* INR(PT)-0.9
[**2144-6-5**] 04:00PM BLOOD Plt Smr-NORMAL Plt Ct-356
[**2144-6-5**] 04:00PM BLOOD Glucose-79 UreaN-18 Creat-1.2 Na-135
K-7.0* Cl-97 HCO3-30 AnGap-15
[**2144-6-5**] 04:00PM BLOOD Calcium-9.2 Phos-5.3* Mg-2.3
[**2144-6-5**] 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-6-5**] 04:26PM BLOOD Type-[**Last Name (un) **] pO2-71* pCO2-77* pH-7.26*
calTCO2-36* Base XS-3 Intubat-NOT INTUBA Comment-NON-REBREA
[**2144-6-5**] 08:46PM BLOOD Lactate-1.2
[**2144-6-5**] 05:00PM BLOOD K-5.3
[**2144-6-5**] 04:26PM BLOOD Glucose-77 Na-136 K-7.1* Cl-94*
.
[**2144-6-6**] 04:51AM BLOOD WBC-11.2* RBC-3.52* Hgb-11.4* Hct-34.3*
MCV-98 MCH-32.3* MCHC-33.1 RDW-13.7 Plt Ct-364
[**2144-6-6**] 12:43AM BLOOD WBC-13.3* RBC-3.49* Hgb-11.3* Hct-34.2*
MCV-98 MCH-32.4* MCHC-33.0 RDW-13.5 Plt Ct-352
[**2144-6-6**] 04:51AM BLOOD Neuts-77.6* Lymphs-16.7* Monos-5.1
Eos-0.4 Baso-0.2
[**2144-6-6**] 04:51AM BLOOD Macrocy-1+
[**2144-6-6**] 04:51AM BLOOD Plt Ct-364
[**2144-6-6**] 12:43AM BLOOD Plt Ct-352
[**2144-6-6**] 12:43AM BLOOD PT-12.0 PTT-27.0 INR(PT)-1.0
[**2144-6-6**] 04:51AM BLOOD Glucose-86 UreaN-10 Creat-0.7 Na-142
K-3.8 Cl-109* HCO3-26 AnGap-11
[**2144-6-6**] 12:43AM BLOOD Glucose-83 UreaN-11 Creat-0.7 Na-142
K-4.1 Cl-108 HCO3-26 AnGap-12
[**2144-6-6**] 04:51AM BLOOD CK(CPK)-378*
[**2144-6-6**] 12:43AM BLOOD ALT-33 AST-41* LD(LDH)-210 AlkPhos-142*
Amylase-107* TotBili-0.2
[**2144-6-6**] 12:43AM BLOOD Lipase-7
[**2144-6-6**] 04:51AM BLOOD CK-MB-11* MB Indx-2.9 cTropnT-<0.01
[**2144-6-6**] 12:43AM BLOOD CK-MB-13* cTropnT-<0.01
[**2144-6-6**] 04:51AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.1
[**2144-6-6**] 12:43AM BLOOD Albumin-3.2* Calcium-8.0* Phos-2.2*#
Mg-2.0
[**2144-6-6**] 02:01AM BLOOD Type-ART pO2-75* pCO2-42 pH-7.42
calTCO2-28 Base XS-2
[**2144-6-6**] 02:01AM BLOOD Lactate-0.6
.
Brief Hospital Course:
# Mental status change: Pt back to normal mental status and
likely due to cocaine and fentanyl overuse. Fever resolved and
may have been related to cocaine use.
There was an initial question of whether this was a suicide
attempt and patient was placed on 1:1 sitter. He was
subsequently reevaluated after leaving ICU and adamantly denied
any SI or suicide attempts. Psychiatry cleared him at this time.
An attempt was made to verify this with his roommate but he
could not be reached.
.
# Fever:-No infiltrate on CXR and no clear source of infection
at this time. Only localizing symptom is pain in cervical spine.
However he reports back pain for the last 6-7 years. Had no
focal neurologic signs. It was recommended to him that he follow
up with his PCP here or in [**State 33977**] to have an MRI of his spine
to evaluate this chronic back pain.
.
#Anemia-Pt anemic with elevated MCV concerning for EtOH although
he denies.
B12, folate, Fe studies wnl.
.
# Polysubstance abuse: When patient was initially interviewed on
the floor he denied ever having any medication/narcotic
prescriptions filled in Massachussetts since moving here in
[**Month (only) 404**]. However after calling several pharmacies it became
clear he has had multiple narcotic prescriptions filled by
several different providers at several different pharmacies. The
patient was told that because of the concern that he has been
abusing these medications and not using them safely that no new
narcotic prescriptions could be given to him at discharge. He
will need to follow up with a PCP and establish regular care and
follow up. It is my recommendation that this patient not be
prescribed any narcotic medications unless he establishes
regular medical care and we obtain his medical records from
[**State 33977**].
.
# Aspiration: Suspected aspiration on admission given fever and
elevated WBC in setting of narcotics overdose. To complete
course of augmentin.
# Brain Tumor: appears to be meningioma. No need to get MRI as
inpt but would benefit from follow-up as oupt. Mass is
extraaxial making it not a GBM although unclear why he would get
gamma knife for a meningioma. Needs to follow up with PCP.
.
Medications on Admission:
Fentanyl 100 mcg patch q.72h, now says it's 150mcg
Lortab 10/500 1 tab q.4-6h.
Neurontin 800 mg two tabs t.i.d.
Topamax 100 b.i.d.
Phenergan 25 one tab q.6h. p.r.n.
Proventil inhaler two puffs p.r.n.
Prozac 40 b.i.d.
Valium 10 mg b.i.d.
Soma 350 b.i.d.
Discharge Medications:
1. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Narcotics Overdose
Respiratory Failure
Cocaine Abuse/Dependence
Chronic Back Pain
Intracranial Mass
Discharge Condition:
stable
Discharge Instructions:
Please do not take unprescribed narcotic medication or illicit
drugs. Take only the medications listed below. You will need to
follow up with your PCP in the next week to arrange a follow up
thoracic spine MRI to evaluate your chronic back pain. You will
also need to arrange oncology follow up with your PCP.
Followup Instructions:
1. Please either follow up with Dr. [**Last Name (STitle) 71015**] in [**Hospital 191**] clinic at
[**Telephone/Fax (1) 250**] in the next week or with your PCP in [**Name9 (PRE) 33977**] if
you decide to return to [**State 33977**]. You will need to see your PCP
in the next week and to arrange a follow up thoracic MRI with
your PCP and also follow up of your intracranial mass. If you do
chose to follow up here in [**Company 191**], you will need to bring all of
your medical records with you from [**State 33977**].
|
[
"E950.2",
"348.9",
"724.5",
"967.9",
"338.29",
"518.81",
"304.20",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10236, 10242
|
7443, 9625
|
335, 367
|
10386, 10395
|
3614, 3629
|
10753, 11277
|
2974, 3136
|
9929, 10213
|
10263, 10365
|
9651, 9906
|
10419, 10730
|
3151, 3595
|
274, 297
|
395, 2053
|
3638, 7420
|
2075, 2743
|
2759, 2958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,855
| 131,030
|
48234
|
Discharge summary
|
report
|
Admission Date: [**2153-1-4**] Discharge Date: [**2153-1-7**]
Date of Birth: [**2104-8-24**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 48 year old male with
a history of esophageal cancer diagnosed in [**9-22**], after
presenting with hematemesis, received preoperative
chemotherapy and radiation therapy, resected in [**12-23**], and
received chemotherapy until [**4-23**]. No known metastasis from
the esophageal cancer. Two weeks ago, he had intense
vomiting for three days and none since prior to admission in
the Emergency Department. He also had a dull generalized
headache for two weeks, the worst headache of his life,
worsened by Valsalva maneuvers, also off balance when walking
for two weeks without falls, slurred speech for two days. He
denies any visual changes, vertigo, weakness, numbness,
tingling or fever. CAT scan showed a right cerebellar mass.
PAST MEDICAL HISTORY:
1. Esophageal cancer as mentioned above.
2. Hypertension.
MEDICATIONS ON ADMISSION:
1. Toprol 50 mg p.o. twice a day.
2. Prevacid one tablet p.o. once daily.
ALLERGIES: Prilosec, Lipitor.
SOCIAL HISTORY: Married and works as a superintendent. No
tobacco, one to two drinks on the weekend. He denies drug
use.
FAMILY HISTORY: No cancer.
PHYSICAL EXAMINATION: Temperature is 97.7, blood pressure
154/104, pulse 90, respiratory rate 16, oxygen saturation
96%. In general, the patient is a well nourished man in no
acute distress. Neck is supple with no carotid bruits. The
lungs are clear to auscultation bilaterally. Heart shows
regular rate and rhythm. The abdomen shows well healed
epigastric scar. The abdomen is soft, nondistended.
Neurologically, the patient is awake, alert, cooperative with
examination normal. The patient is oriented to person, place
and month. Attention - can spell the word world backwards
and forwards. Language was fluent. No dysarthria. No
paraphrasic errors. Naming is intact. No right to left
confusion. Motor strength was [**4-25**] in both his upper and
lower extremities. Facial sensation was normal. Slight left
lower facial asymmetry. Gait - The patient fell towards the
right when standing.
LABORATORY DATA: Complete blood count, Chem7, coagulation
studies within normal limits. Chest, abdomen and pelvis
negative for masses. Brain magnetic resonance scan showed
heterogeneous right cerebellar mass, 5.0 centimeters in the
largest transverse plane. Increased T1 signal with
hemorrhage within the mass. Irregular diffuse enhancement.
Compression of the inferior pons and distortion of the
medulla. Marked narrowing of the fourth ventricle resulting
with mild to moderate hydrocephalus.
HOSPITAL COURSE: The patient was admitted to the Neurology
Intensive Care Unit and given Decadron 10 mg intravenously
and then 8.0 mg q4hours. Systolic blood pressure was kept
less than 130. The patient was placed on a Nipride drip and
A line was placed. He was made NPO and oncology was
notified. On [**2153-1-4**], the patient was brought to the
operating room where he had a suboccipital craniotomy and
tumor resection. Postoperatively, the patient was awake and
alert. His cerebellar symptoms seemed to have improved. His
vital signs revealed temperature 99.1, heart rate 90, blood
pressure 130/75. He had no drift, no dysmetria on the left,
improved dysmetria on the right. We kept the systolic blood
pressure less than 150. He had a magnetic resonance scan
which showed normal postoperative changes in the right
cerebellar region with significant direction and edema, mass
effect and midline shift. Diffusion weighted images did
demonstrate no MR evidence of acute infarct. He was seen
postoperatively by oncology who felt that the patient looked
much better postoperatively and that he should start
stereotactic radiation treatment to the tumor bed and that
will be set up as an outpatient. The patient was transferred
on [**2153-1-5**], to the neurosurgical floor where he remained
awake, alert, oriented, face symmetric, no pronator drift.
He was evaluated by physical therapy who felt he had no
postoperative physical therapy needs. The patient was
discharged on [**2153-1-7**], neurologically stable.
DISCHARGE INSTRUCTIONS:
1. The patient is to keep his wound clean and dry until
staples are removed.
2. He should watch for any redness or drainage at the site.
3. If he develops a fever greater than 101, he should call
Dr.[**Name (NI) 14510**] office.
4. No heavy lifting.
5. Activity as tolerated.
6. No driving while on narcotics.
7. Make follow-up appointment to be seen in the Brain [**Hospital 341**]
Clinic and the telephone number was given to him.
8. He should have his staples removed on or about [**2153-1-15**].
MEDICATIONS ON DISCHARGE:
1. Colace one p.o. twice a day.
2. Famotidine 20 mg one p.o. twice a day.
3. Percocet 5/325 one to two tablets p.o. q4-6hours.
4. Metoprolol 50 mg sustained release one p.o. q24hours.
5. Decadron taper.
DISCHARGE DIAGNOSES:
1. Cerebellar mass.
2. Esophageal cancer.
3. Hypertension.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2153-1-7**] 10:08
T: [**2153-1-7**] 10:24
JOB#: [**Job Number 101648**]
|
[
"198.3",
"530.81",
"V10.03",
"331.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
1261, 1273
|
4999, 5341
|
4769, 4978
|
1010, 1119
|
2701, 4210
|
4234, 4743
|
1296, 2683
|
154, 901
|
923, 984
|
1136, 1244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,196
| 142,781
|
23633
|
Discharge summary
|
report
|
Admission Date: [**2109-3-27**] Discharge Date: [**2109-4-1**]
Date of Birth: [**2070-8-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
s/p Multiple stab wound assault
Major Surgical or Invasive Procedure:
[**2109-3-27**] Exploratory lap with left lateral liver segmentectomy,
diaphragm repair, left breast repair/evacuation of hematoma.
Suture repair of multiple left hand/arm, breast lacerations.
[**2109-4-1**] Removal of JP drain
History of Present Illness:
38 yo married Armenian female s/p being stabbed multiple times
by her husband who also suffered stab wounds reportedly self
inflicted. Patient sustained stab wounds to her arms,
breast/chest and abdomen. She was A&Ox3 upon arrival,
extremely anxious, but able to provide some information. She
reports that she has 2 children ages 13 and 14 yo who witnessed
the assault. It is unclear who called 911. She was immediatley
taken to the operating room for an exploratory laparotomy.
Past Medical History:
Cholecystectomy [**2106**]
Social History:
Married with 3 children, reportedly 3rd child lives out of state
Family History:
Noncontributory
Pertinent Results:
Upon admission:
[**2109-3-27**] 10:18PM GLUCOSE-166* UREA N-14 CREAT-0.6 SODIUM-140
POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-18* ANION GAP-15
[**2109-3-27**] 10:18PM CALCIUM-9.6 PHOSPHATE-2.9 MAGNESIUM-1.1*
[**2109-3-27**] 10:18PM WBC-9.1 RBC-3.62*# HGB-10.9*# HCT-31.1*#
MCV-86 MCH-30.1 MCHC-35.0 RDW-14.0
[**2109-3-27**] 10:18PM PLT SMR-LOW PLT COUNT-85*
[**2109-3-27**] 06:26PM WBC-10.7 RBC-2.54* HGB-7.5* HCT-21.7* MCV-86
MCH-29.7 MCHC-34.6 RDW-14.0
CT CHEST W/CONTRAST [**2109-3-27**] 6:12 PM
IMPRESSION:
1. Laceration of the left hepatic lobe with active extravasation
of blood resulting in large volume of hemoperitoneum.
2. Stab wound to the left chest with hematoma in the medial left
breast with evidence of active bleeding. Anterior mediastinal
hematoma noted which appears contiguous with the stab wound in
the left breast.
3. Probable laceration along the anterior aspect of the
diaphragm at the level of the mediastinal hematoma.
3. Small hematoma in the lateral aspect of the left buttock at
the site of a stab wound with a small amount of subcutaneous
air. No evidence of active extravasation.
4. Hypoperfusion complex including flattening of the diaphragm
and enhancing and thickened small bowel.
HAND, AP & LAT. VIEWS BILAT [**2109-3-28**] 10:47 AM
RIGHT ELBOW, FOREARM, AND HAND: There is a comminuted and
impacted fracture involving the distal metadiaphysis of the
third metacarpal. There is dorsal displacement of the distal
fracture fragment. The joint spaces are maintained without
periarticular erosion. Mineralization is normal. No radiopaque
foreign body is identified. The intercarpal spaces are normal.
There is no elbow joint effusion. Radiopaque IVs and tubing
project over the right wrist and antecubital fossa.
LEFT ELBOW, FOREARM, AND HAND: There are two punctate densities
projecting over the soft tissues along the proximal and radial
aspects of the left fifth finger. The finding is not well
assessed secondary to overlying dressing material. It is unclear
if these densities reside within the soft tissues or within the
overlying dressing material. Similarly, assessment for
subcutaneous emphysema is limited by overlying dressing
material. No discrete fracture is identified. No elbow joint
effusion is detected. Dressing material projects over the
posterior aspect of the left elbow.
CHEST (PA & LAT) [**2109-3-30**] 11:38 AM
CHEST, TWO VIEWS.
Bilateral pleural effusions, with underlying collapse and/or
consolidation. No CHF. Compared with [**2109-3-29**], the CHF findings
have improved in the size of the effusions which is decreased.
At the periphery of these films, surgical staples and drains are
seen in the abdomen. No pneumothorax is detected.
Brief Hospital Course:
She was admitted to the Trauma Service and taken immediately to
the operating room for exploratory laparotomy and repair of her
injuries. There were no intraoperative complications.
Postoperatively she was taken to the Trauma ICU where she was
monitored closely. She was extubated on [**3-28**] and would be later
transferred to the regular nursing unit.
Plastic Surgery was consulted for the right hand injury; she is
scheduled for an elective repair of this on [**4-4**].
Several days later her diet was advanced and she is tolerating
this; her pain is being managed with prn Oxycodone. She is
ambulatory and independent with care; limited only by her right
hand injury which is non weight bearing. A gutter splint was
made and she has been instructed on how to wear this device.
Social work was closely involved throughout her hospital stay
and she was referred to the Center for Violence Prevention and
Recovery for counseling services available both inpatient and
outpatient. A safe post hopsital plan was formulated and she was
discharged to a relatives' home.
Medications on Admission:
Advil prn
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Multiple stab wound assault
Liver injury
Diaphragmatic injury
Left breast hematoma
Multiple lacerations to left digits and arm
Right comminuted and imapcted distal metadiaphysis of 3rd
metacarpal
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency room if you deelop any fevers, chills,
headache, dizziness, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, increased redness/drainage
from your wounds or surgical incisions and/or any other symptoms
that are concerning to you.
DO NOT bear any weight on your right hand. Wear the splint as
instructed.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Surgery to have your staples removed
on [**Last Name (LF) 2974**], [**4-5**] at 11:15 a.m. Location [**Hospital **] Medical
Office Bldg [**Last Name (NamePattern1) **], [**Location (un) 86**], MA [**Telephone/Fax (1) 2359**].
You will also need to follow up with Plastic Surgery regarding
your upcoming surgery scheduled for this week. Call [**Telephone/Fax (1) 5343**]
for an appointment.
Completed by:[**2109-4-3**]
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20,759
| 125,245
|
47542
|
Discharge summary
|
report
|
Admission Date: [**2197-5-9**] Discharge Date: [**2197-6-2**]
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Presents for surgery
Major Surgical or Invasive Procedure:
[**5-9**] total colectomy with end ileostomy
History of Present Illness:
83F CAD w/ DES to RCA+RPL in [**2194**], EF 45%, a-fib not
anticoagulation for GIB, now with post-op MI and afib s/p
colectomy on [**5-10**]. She was admitted on [**5-9**] for total colectomy
with end ileostomy which she underwent on [**5-10**]. The immediate
post op course was complicated by SVT, hypotension, and low
urine output and she was found to have an NSTEMI with CK peak
708 on [**5-12**]. Echo on [**5-15**] showed EF 45% with new WMA compared
with previous echo: anterior, apical, septal HK. She was
monitored in the SICU until [**5-21**] for rapid afib that was
difficult to control as well as CHF. Today she states that she
is doing well with no episodes of SOB or CP. She was transferred
to [**Hospital Ward Name 121**] 6 because her telemetry showed HR 110s, although she is
quite well appearing satting 98% on RA, awaiting rehab
placement.
Past Medical History:
-Atrial fibrillation. She is on Plavix, but held in ten days
prior to colonoscopy on [**2197-3-16**]. Will not restart until [**3-26**], [**2197**], as increased risk of bleeding following procedures.
-Hypertension.
-Anemia.
-History of gastrointestinal bleeding.
-History of ovarian cancer.
-Glaucoma.
-Macular degeneration.
-Depression.
-Gastroesophageal reflux disease.
-Lumbar scoliosis and spinal stenosis.
-Ovarian cancer.
-Ulcerative colitis
- Mass in distal colon, planned for total colectomy after
Passover
- type 2 DM
Social History:
She is a widow, does not smoke cigarettes or drink alcohol.
Recently moved to senior center in [**Location (un) **]. Two daughters and
three grandchildren. One daughter lives in area
Family History:
Positive for CAD, diabetes, negative for inflammatory bowel
disease, or colon cancer.
Physical Exam:
Vitals: T 100.7 HR 82 BP 114/58 RR 94% RA
Gen: elderly female in NAD, quite animated and talking on the
phone Oriented x3. Mood, affect appropriate.
CV: irregularly irregular, SEM at LUSB.
Chest: mostly clear, basilar crackles.
Abd: mild TTP throughout, midline incision, well healing, though
inferior aspect of scar is open with packing, with minimal
serous drainage, no surrounding erythema, there is an ostomy bag
in place.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission labs:
[**2197-5-9**] 02:00PM GLUCOSE-112* UREA N-18 CREAT-0.8 SODIUM-143
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
[**2197-5-9**] 02:00PM estGFR-Using this
[**2197-5-9**] 02:00PM CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-2.3
[**2197-5-9**] 02:00PM WBC-6.0 RBC-3.88* HGB-11.8* HCT-34.7* MCV-90
MCH-30.4 MCHC-34.0 RDW-15.9*
[**2197-5-9**] 02:00PM PLT COUNT-220
[**2197-5-9**] 02:00PM PT-12.2 INR(PT)-1.0
[**2197-5-23**] 01:10AM BLOOD CK(CPK)-27
[**2197-5-11**] 06:44AM BLOOD CK(CPK)-213*
[**2197-5-11**] 03:15PM BLOOD CK(CPK)-424*
[**2197-5-14**] 04:15PM BLOOD CK(CPK)-227*
[**2197-5-14**] 10:48PM BLOOD CK(CPK)-210*
[**2197-5-12**] 09:50AM BLOOD CK-MB-4 cTropnT-0.08*
[**2197-5-14**] 04:15PM BLOOD CK-MB-8 cTropnT-0.34*
[**2197-5-14**] 10:48PM BLOOD CK-MB-6 cTropnT-0.36* proBNP-[**Numeric Identifier 100507**]*
[**2197-5-15**] 04:23AM BLOOD CK-MB-5 cTropnT-0.28* proBNP-[**Numeric Identifier 100508**]*
[**2197-5-15**] 12:21PM BLOOD CK-MB-4 cTropnT-0.22*
[**2197-5-18**] 11:24AM BLOOD CK-MB-NotDone cTropnT-0.13*
2D-ECHOCARDIOGRAM performed on [**2197-5-15**] demonstrated:
EF 45% anterior, apical, septal HK
RV FW HK TR gradient 26-38
[**1-17**]+TR, trivial MR
Compared with the prior study (images reviewed) of [**2194-12-1**],
the regional left ventricular systolic dysfunction is new.
Persantine Mibi performed on [**2197-3-31**] demonstrated:
IMPRESSION: Normal myocardial perfusion scan.
CONCLUSION: Mild chest pain with dypiridamole infusion and no
ischemic EKG changes. Nuclear findings under separate report.
.
CARDIAC CATH performed on [**2194-12-1**] demonstrated:
right dominant circulation
LMCA: 20% distal lesion.
LAD: "twin LAD system" with major diagonal branch (larger than
LAD).
eccentric 60-70% stenosis at the origin of D1.
LCX: nl
RCA: had 60% ostial, 60% focal mid (cypher placed), 90% focal in
mod sized RPL branch beyond PDA (cypher placed).
--Successful PTCA of the PLB with a 2.5 mm balloon, PTCA of the
mid RCA with a 2.5 mm balloon and PTCA and stenting of the
ostial RCA with a 3.0 mm Cypher drug-eluting stent. Final
angiography showed a 30% residual stenosis of the PLB, a 50%
residual stenosis of the mid RCA and no residual stenosis of the
RCA origin, a type A dissection of the PLB with normal flow in
the vessel (see PTCA comments).
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Normal left ventricular diastolic function.
3. Successful PTCA of the PLB and mid RCA.
4. Successful PTCA and stenting of the ostial RCA.
.
CXR [**2197-5-19**]:
Previous mediastinal vascular congestion has improved. Lungs
are clear. Hilar enlargement suggests longstanding elevated
pulmonary artery pressure, although heart size is top normal.
Pleural effusion, if any, is small and probably bilateral.
Severe gaseous distention of the stomach persists.
Findings were discussed by telephone with the medical student
answering for resident, [**Doctor Last Name **], at the time of dictation.
[**2197-6-2**]:
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
single-lumen PICC line placement via the right brachial venous
approach. Final internal length is 33 cm with the tip positioned
in the distal SVC. The line is ready to use.
Discharge labs:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2197-6-1**] 07:00AM 8.3 3.07* 8.9* 26.8* 87 29.0 33.2 16.0*
408
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2197-5-26**] 06:55AM 76* 11* 8* 4 0 1 0 0 0
ADDED DIFF [**2197-5-26**] 10:16AM
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2197-6-2**] 04:49AM 21.7* 38.5* 2.1*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2197-6-2**] 04:49AM 45*1 19 0.7 139 4.3 105 28 10
TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2197-6-2**] 04:49AM 8.3* 2.8 2.2
ANTIBIOTICS Vanco
[**2197-6-1**] 09:05AM 14.51
Source: Line-R CVL; Vancomycin @ Trough
[**2197-5-29**] 1:14 pm SWAB Source: abd wound.
**FINAL REPORT [**2197-6-2**]**
GRAM STAIN (Final [**2197-5-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final [**2197-6-2**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
GRAM NEGATIVE ROD(S). HEAVY GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
ANAEROBIC CULTURE (Final [**2197-6-2**]): NO ANAEROBES ISOLATED.
[**2197-5-28**] 1:36 pm MRSA SCREEN Source: Rectal swab.
**FINAL REPORT [**2197-5-31**]**
MRSA SCREEN (Final [**2197-5-31**]): No MRSA isolated.
[**2197-5-15**] 12:20 pm SWAB Source: Rectal swab.
**FINAL REPORT [**2197-5-17**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2197-5-17**]):
No VRE isolated.
Cardiology Report ECG Study Date of [**2197-5-26**] 8:59:50 AM
Atrial fibrillation with a rapid ventricular response. Right
bundle-branch
block with left anterior fascicular block. Diffuse low voltage.
Compared to the
previous tracing of [**2197-5-23**] no diagnostic interval change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
126 0 122 330/[**Telephone/Fax (2) 100509**]
Chest X-Ray [**6-2**] after removal of CVL shows PICC line in good
position.
Brief Hospital Course:
Pt is a 83F CAD w/ DES to RCA+RPL in [**2194**], EF 45%, a-fib not
anticoagulation for GIB, now with post-op MI and afib s/p
colectomy on [**5-10**]
CAD:
The immediate post op course was complicated by SVT,
hypotension, and low urine output and she was found to have an
NSTEMI with CK peak 708 on [**5-12**]. Echo on [**5-15**] showed EF 45% with
new WMA compared with previous echo: anterior, apical, septal
HK. She was monitored in the SICU until [**5-21**] for rapid afib that
was difficult to control as well as CHF. She was transferred to
the [**Hospital Ward Name 121**] 6 cardiology step down unit because her telemetry
showed HR 110s, although she was quite well appearing satting
98% on RA. She was continued on Plavix, Statin, and metoprolol.
She is not on aspirin because of GI intolerance.
Rhythm:
She has a history of A-fib with a bifascicular block. Her heart
rate is difficult to rate control. Oral dilt and metoprolol were
used in combination and she seemed to respond better to the
dilt. When these medicines were held for low pressure, the HR
rose to 130s, the the rate was 100s generally when on the
medications. Cardiology consultants were called by the surgery
team when the post-op MI was diagnosed. The consultants
recommended restarting anticoagulation. She was not
anticoagulated as outpatient for a history of GI bleed. Heparin
gtt was started as well as Coumadin, however the patient was
noted to have several teaspoons of BRBPR as a small puddle on
the floor in the bathroom noted by the nurse. This was assessed
as likely [**2-17**] post-operative bleeding from the colectomy and the
heparin gtt was stopped. The hct was trended and remained
stable, she was transfused PRBC's for a hematocrit of 22.9 with
appropriate response to 26, has remained hemodynamically stable.
She was rate controlled with oral Diltiazem and Digoxin. She was
to resume low dose Coumadin anticoagulation with a target INR of
2.0 at rehab. until full dose anticoagulation could be resumed
as an outpatient. Plavix was also resumed post-operatively.
CHF, EF 45%
Currently euvolemic. Did have acute CHF with pulmonary edema in
setting of post-op MI and rapid AF. However, by the time the
patient arrived on [**Hospital Ward Name 121**] 6 on [**5-23**], she was euvolemic. She was
continued on oral Metoprolol and Isosorbide.
S/P Colectomy on [**5-10**]:
She underwent the operation without immediate complications,
though soon afterwards was noted to develop hypotension in the
setting of post-op MI as described above.
DM2:
Sugars were monitored targeting tight glycemic control, episodes
of hyperglycemia with euglycemia achieved with the addition of
NPH and tight Regular Insulin sliding scale. Glyburide was
restarted, she was kept in an insulin sliding scale along with
NPH at rehab.
UC:
Low dose Prednisone continued post-operatively, continued to
have small amount of daily rectal leakage, topical steroid foam
to be provided to rectal area three times a week at rehab.
FEN/Hypophosphatemia:
Electrolytes were monitored and repleted as necessary.
Tolerating a regular cardiac, diabetic diet without difficulty.
Ostomy functioning well but with high outputs, improved with
tincture of opium.
ID: POD 19, incision opened with copious purulent drainage and
necrotic areas present, bedside debridement performed with
improvement, Zosyn and Vancomycin started; final cultures
pending at time of discharge to be followed and antibiotic
coverage tailored accordingly. PICC line placed for optimal
intravenous access. Wound VAC placed with white and black foam
and 125 mmHg continuous suction, to be changed every 2-3 days.
Afebrile without leukocytosis.
Pain: Minimal incisional pain, well controlled with Tylenol and
low dose Oxycodone as needed.
GU: Foley replaced secondary to intermittent leakage, urine
culture without bacteria, to be removed at rehab when patient
ambulating and able to toilet independently.
Pt. discharged to acute level rehab in good condition on [**6-2**],
she was to follow-up with Dr. [**Last Name (STitle) 1120**] in 1 week, her cardiologist
and PCP upon discharge from rehab facility.
Medications on Admission:
Outpatient:
Plavix 75 mg PO once a day
Metoprolol 12.5 HS
Isosorbide Mononitrate 30 mg PO DAILY (Daily)
Atorvastatin 20 mg PO DAILY
Lisinopril 20 mg PO DAILY
Amlodipine 5 mg PO DAILY (Daily).
Lopid 600 mg PO twice a day
Glyburide 1.25 mg PO once a day.
Prednisone 5 mg PO DAILY
Sulfasalazine 1000 mg PO BID
Gabapentin 300 mg PO BID
Ferrous Sulfate, Dried 160 (50) mg PO once a day.
Paroxetine HCl 20 mg PO DAILY
Prilosec 40 mg PO once a day.
CALCIUM 600 + D 600-125 mg-unit PO once a day.
Lomotil 2.5-0.025 mg PO once a day as needed for diarrhea.
Ocuvite (2) Tablet PO twice a day.
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for wheeze.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
12. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection twice a day: D/C when patient ambulating.
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP < 110
Hold for HR < 55.
16. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
17. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q6H
(every 6 hours) for 2 weeks.
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) for 2 weeks.
19. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain: Be sure pt. takes with food.
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: To each PICC lumen
and prn.
21. PICC Sig: PICC care once a day: PICC line care as per
protocol.
22. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 10 days: Last dose 5/27.
23. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 10 days: Last dose pm
[**6-11**].
24. Vancomycin trough Sig: One (1) every 3 doses: While on
Vancomycin
Next one [**6-5**]
Adjust Vancomycin dose according to levels.
25. CBC, chemistry 10 panel Sig: One (1) twice a week for 2
weeks: Monitor CBC and chemistry panel:
Na+,K+,CL,CO2,BUN,Creat.,Glucose,Mg+,Ca+,Phosph.
Replete lytes prn.
26. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous With breakfast and at bedtime.
27. Regular Insulin Sliding Scale Sig: Follow sliding scale
before breakfast, lunch, dinner: Regular Insulin
0-60 mg/dL
4 oz juice and crackers
61-120 mg/dL
2 units
121-140 mg/dL
4 units
141-160 mg/dL
6 units
161-180 mg/dL
8 units
181-200 mg/dL
10 units
201-220 mg/dL
10 units
221-240 mg/dL
12 units
241-260 mg/dL
14 units
261-280 mg/dL
16 units
> 281 mg/dL
Notify MD.
28. Regular Insulin Sliding Scale Sig: Bedtime Regular Insulin
Sliding Scale at bedtime: 0-60 mg/dL
4 oz. juice
61-200 mg/dL
0 units
201-240 mg/dL
2 units
241-280 mg/dL
4 units
> 281 mg/dL
Notify MD.
29. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea for 10 days: While on antibiotics.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Ulcerative Colitis s/p colectomy
Wound infection
non-ST elevation MI
Atrial fibrillation, poorly controlled
Congestive Heart failure exacerbation
Diabetes, poorly controlled, insulin dependent
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
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 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Please note that your medication regimen has been altered.
1. You should stop taking norvasc
2. The lisinopril dose has been decreased to 5mg daily
3. The metoprolol dose has been increased to 37.5 mg [**Hospital1 **]
4. Two new medications have been started to control your heart
rate, diltiazem and digoxin.
5. since you had a colectomy, you should discontinue the
sulfasalazine and we are decreasing the prednisone dose. You
should follow-up with your primary care physician to continue to
taper the prenisone dose to lower doses until it can be
completely stopped.
6. You have not been receiving Paxil in the hospital. You should
avoid this medicine until you call your primary care doctor. We
recommend that you instead take Celexa because it has less
interaction with all of the new medications that you are taking
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1120**] in 1 weeks, call [**Telephone/Fax (1) 160**]
for an appointment
You should call Dr.[**Name (NI) 9388**] office to arrange for a follow-up
appointment to be seen within 3 weeks after you are discharged
from the rehab. ([**Telephone/Fax (1) 10085**]
You have an appointment with your PCP for [**Name9 (PRE) 702**]. Provider
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (PRE) **].O. Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2197-6-7**] 2:30
Completed by:[**2197-6-2**]
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|
2587, 2587
|
18591, 19165
|
1940, 2027
|
13142, 16470
|
16580, 16775
|
12535, 13119
|
4904, 5794
|
16828, 18568
|
5810, 8357
|
2042, 2568
|
173, 195
|
308, 1167
|
2603, 4887
|
1189, 1721
|
1737, 1924
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,520
| 112,767
|
53702+59541
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-3-31**] Discharge Date: [**2200-4-17**]
Date of Birth: [**2129-1-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
doxycycline
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2200-4-11**]
Aortic valve replacement with a 19-mm [**Doctor Last Name **]
Magna Ease pericardial tissue valve
History of Present Illness:
THis 71F w/HTN, COPD, AS and chronic diastolic heart failure was
admitted to [**Hospital3 **] w/CHF exacerbation and RLE
cellulitis on [**2200-3-28**] and was transferred to [**Hospital1 18**] cardiology
after referral from Dr. [**Last Name (STitle) **] for further AS evaluation and
management.
At [**Hospital3 **] she was diagnosed w/CHF exacerbation -
presenting complaints included 10-lb weight gain, leg swelling,
and dyspnea on exertion.
Currently the patient feels better. Her dyspnea has improved and
she has no presenting complaints. She has lost 17 Ibs since
friday and diuresis. Her dry weight is between 205 -210 Ibs. She
did stop smoking this past [**Month (only) **] and has had a dry cough
since then. This cough has been slowly improving. She denies any
fevers/chills, chest pain, current dyspnea, leg pain, abdominal
pain, diarrhea, syncope.
Past Medical History:
Hypertension
Aortic Stenosis
OTHER PAST MEDICAL HISTORY:
OSTEOPOROSIS
OSTEOARTHRITIS
MILD PARKINSON'S DISEASE
CHRONIC VENOUS STASIS
OBESITY
COPD
ANXIETY
DEPRESSION
STRESS URINARY INCONTINENCE
Social History:
Lives with: widowed. Has supportive daughter [**Name (NI) **]
Occupation: retired
Cigarettes: Smoked no [] yes [x] last cigarette [**2199-11-12**] Hx:50
pk
year
Other Tobacco use:none
ETOH: < 1 drink/week [x] [**2-18**] drinks/week [] >8 drinks/week []
Illicit drug use; none
Family History:
non-contributory
Physical Exam:
ON ADMISSION:
VS: 98.5, 155/74, 82, 20 95% 2L
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate, speaking in full sentences.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP up to the mandible
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**5-18**] pan systolic murmurin the second
intercostal space radiating to the carotids. Second systolic
murmur in the 4th intercostal space [**4-18**] radiating to the left
axilla. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, insp crackles
bibasilar, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+Pitting edema to the knees b/l. No erythema or
rubor b/l. No femoral bruits.
SKIN: Chronic stasis dermatitis changes b/l lower extremities,
no ulcers, scars, or xanthomas.
PULSES: 1 + DP pulses B/l
Foley in place with yellow urine
Pertinent Results:
Cardiac cath [**2200-4-4**]
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Markedly elevated left-sided filling pressures
3. Mildly elevated right-sided filling pressures.
4. Moderate pulmonary arterial hypertension
5. Borderline cardiac index.
.
XR ankle
Three views of the right ankle were reviewed.
There is no evidence of fracture, dislocation, lytic or
sclerotic lesions
demonstrated. Minimal soft tissue swelling around lateral
malleolus is noted with otherwise no appreciable abnormality
seen. If clinically warranted, correlation with cross-sectional
imaging might be considered.
.
CAROTID U/S SHOWED
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA <40% stenosis.
Left ICA <40% stenosis
.
[**2200-4-11**] Intra-op TEE
Conclusions
PRE-CPB: 1. The left atrium is moderately dilated. No thrombus
is seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler.
2. There is severe symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Right ventricular
chamber size and free wall motion are normal.
3. There are simple atheroma in the ascending aorta. There are
complex (>4mm) atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta.
4. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic
regurgitation is seen. The annulus measures 19 mm.
5. The mitral valve appears structurally normal with trivial
mitral regurgitation.
6. Moderate [2+] tricuspid regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of nitroprusside. AV pacing transiently.
Well-seated bioprosthetic valve in the aortic position with no
AI seen. Gradient measures peak of 26 at a cardiac output of 5.1
L/min. MR [**Name13 (STitle) **] trace, TR is 2+. The aortic contour is normal
post decannulation.
.
[**Known lastname **],[**Known firstname 3679**] [**Medical Record Number 110263**] F 71 [**2129-1-2**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2200-4-14**] 1:38
PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2200-4-14**] 1:38 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 110264**]
Reason: eval for effusion
Final Report
INDICATION: Recent aortic valve replacement. Evaluation for
effusion.
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: [**4-11**] through [**2200-4-13**].
FINDINGS: Low lung volumes are noted along with obscuration of
the left
costophrenic angle, likely representing a pleural effusion.
There is mild
pulmonary vascular congestion. The right IJ catheter terminates
in the right
atrium. There is no focal consolidation or pneumothorax. Median
sternotomy
wires and aortic valve replacement are noted. There is no change
in the
cardiomediastinal silhouette.
IMPRESSION: Left pleural effusion and mild pulmonary vascular
congestion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 251**] [**Name (STitle) 20492**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
[**2200-4-16**] 06:35AM BLOOD WBC-7.3 RBC-2.55* Hgb-7.0* Hct-22.8*
MCV-89 MCH-27.6 MCHC-30.9* RDW-14.4 Plt Ct-188
[**2200-4-12**] 01:03AM BLOOD PT-12.9* PTT-25.6 INR(PT)-1.2*
[**2200-4-16**] 06:35AM BLOOD Glucose-132* UreaN-36* Creat-0.9 Na-138
K-4.7 Cl-100 HCO3-27 AnGap-16
Brief Hospital Course:
This 71F w/HTN, COPD, AS and chronic diastolic heart failure
admitted to [**Hospital3 **] w/CHF exacerbation and RLE
cellulitis on [**2200-3-28**], transferred to [**Hospital1 18**] for AS eval/mgmt.
She continued to be gently diuresed and had a cardiac cath which
revealed no coronary artery disease. Her cellulitis in the RLE
was treated initially with Keflex with an inadequate response.
She was changed to Vancomycin and the cellulitis improved.
Cardiac surgery was consulted and on [**2200-4-11**] she underwent
aortic valve replacement.
She 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. Blood pressure was
initially labile, requiring high volume resuscitation. The
patient was neurologically intact and hemodynamically stable,
weaned from inotropic and vasopressor support. Parkinson's meds
were resumed. Beta blocker was initiated and the patient was
gently diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
Neurology was consulted for the patient's history of Parkinson's
with generalized weakness/lethargy post-op. She was started on
Sinemet and became more alert and less rigid. Speech and Swallow
evaluated the patient for aspiration risk and diet modifications
were made. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD #6 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged on POD#6 to [**Hospital1 **] [**Location (un) 86**] in good
condition with appropriate follow up instructions.
Medications on Admission:
Home Medications
Lasix 40mg daily
Amodipine
Setraline 100mg daily
Potassium supplements
.
Transfer MEDICATIONS:
ZOLOFT 100 qd
ASA 81 MG QD
AZILECT 1 MG QAM
MIRAPEX 1.5 MG QAM
DILTIAZEM CR 180 QD (NEW MED)
LASIX 40 IV QD
CALCIUM +D 1 TAB QD
NORVASC (DISCONTINUED AT OSH)
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
7. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. AZILECT 1 mg Tablet Sig: One (1) Tablet PO Q AM ().
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
12. Mirapex 1.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. carbidopa-levodopa 10-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
17. furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day).
18. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Hypertension
Aortic Stenosis
OTHER PAST MEDICAL HISTORY:
OSTEOPOROSIS
OSTEOARTHRITIS
MILD PARKINSON'S DISEASE
CHRONIC VENOUS STASIS
OBESITY
COPD
ANXIETY
DEPRESSION
STRESS URINARY INCONTINENCE
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2200-5-14**] 8:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2200-5-15**]
1:15
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) **] [**First Name3 (LF) 251**] [**Telephone/Fax (1) 39393**] in [**4-17**] weeks
Completed by:[**2200-4-17**] Name: [**Known lastname 3838**],[**Known firstname **] Unit No: [**Numeric Identifier 18062**]
Admission Date: [**2200-3-31**] Discharge Date: [**2200-4-17**]
Date of Birth: [**2129-1-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
doxycycline
Attending:[**First Name3 (LF) 135**]
Addendum:
The pt. is being discharged on lasix 40 mg IV BID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2200-4-17**]
|
[
"682.6",
"733.00",
"285.9",
"278.00",
"311",
"715.90",
"428.33",
"625.6",
"459.81",
"496",
"V26.51",
"428.0",
"287.5",
"V15.82",
"424.1",
"332.0",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"39.61",
"35.21",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
12913, 13140
|
6605, 8482
|
297, 413
|
10710, 10866
|
2998, 3026
|
11737, 12890
|
1830, 1848
|
8802, 10381
|
10495, 10530
|
8508, 8598
|
3043, 6582
|
10890, 11714
|
1863, 1863
|
238, 259
|
8620, 8779
|
441, 1303
|
1877, 2979
|
10552, 10689
|
1535, 1814
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,211
| 154,589
|
9699
|
Discharge summary
|
report
|
Admission Date: [**2120-5-31**] Discharge Date: [**2120-6-8**]
Date of Birth: [**2061-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2120-5-31**] Cardiac Catheterization
[**2120-6-4**] Aortic Valve Replacement(29 millimeter pericardial
valve) with closure of Aorto-RVOT fistula
History of Present Illness:
Mr. [**Known lastname **] is a 58 year old male with a current history of AV
endocarditis with resultant aortic insufficiency and congestive
heart failure. On [**5-7**], he was hospitalized with complaints
of [**2-9**] month history of fatigue, weight loss, and low grade
fever. He was found to have HACEK endocarditis and was treated
with Ceftriaxone. A TEE at that time revealed severe AI and a
small vegetation on the right coronary cusp of the aortic valve.
He was readmitted on [**5-20**] for worsening SOB. He was found to
have pulmonary edema and required further diuresis. His
shortness of breath has been slowly improving since he started
taking Lasix daily. He denies any chest pain, palpitations, LE
edema, claudication or lightheadedness. Prior to cardiac
surgical intervention, he will be admitted for preop cardiac
catheterization to rule out coronary artery disease.
Past Medical History:
Aortic valve endocarditis(HACEK)
Aortic insufficiency
Congestive Heart Failure
Back Injury
Social History:
Lives at home with his wife. [**Name (NI) 1403**] as a supervisor at a sheet
metal company. No alcohol/tobacco/drugs. Daughter and wife are
both nurses.
Family History:
Father died at age 83. Mother still alive at age [**Age over 90 **]. Both were
diagnosed with "heart problems" in their 60's.
Physical Exam:
Vitals: T 96.0, BP 130-140/58-62, HR 88, RR 14, SAT 100% on room
air
General: well developed male in no acute distress, non toxic
appearance
HEENT: oropharynx benign, PERRL
Neck: supple, mild JVD,
Heart: regular rate, normal s1s2, 2/6 systolic and [**4-11**] diastolic
murmurs noted
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities. Left upper extremity PICC
in place.
Pulses: 2+ distally
Neuro: alert and oriented, nonfocal, gait steady
Pertinent Results:
[**2120-5-31**] 07:45AM BLOOD WBC-6.2 RBC-4.44* Hgb-13.4* Hct-38.3*
MCV-86 MCH-30.2 MCHC-35.0 RDW-14.7 Plt Ct-204
[**2120-5-31**] 07:45AM BLOOD PT-13.9* INR(PT)-1.2*
[**2120-5-31**] 07:45AM BLOOD UreaN-29* Creat-1.1 K-4.2
[**2120-5-31**] 07:45AM BLOOD ALT-42* AST-40 AlkPhos-86 TotBili-0.6
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent cardiac catheterization
which was notable for a right dominant system and normal
coronary arteries. Further workup included dental consultation
which cleared him for surgery after clinical and radiographic
evaluation found no evidence of infection. He otherwise remained
stable on medical therapy. Prior to the OR, the PICC line was
successfully removed.
On [**6-4**], Dr. [**Last Name (STitle) 1290**] performed an aortic valve replacement
with closure of an aorto-right ventricular outflow tract
fistula. For surgical details, please see seperate dictated
operative note. Following the operation, he was brought to the
CSRU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated. The central line and
chest tubes were removed without complication. He maintained
stable hemodynamics and transferred to the SDU on postoperative
day one. A PICC line was placed on [**2120-6-7**] for continuation of
IV antibiotic upon discharge, in coordination with the
infectious disease consultant. He participated with physical
therapy successfully and was discharged home on POD 4.
Medications on Admission:
Lasix 80 qam, 40 qpm
Lisinopril 40 qd
Ceftriaxone 2g qd
Aspirin 325 qd
Ambien 5 qhs
Ativan prn
Heparin flush for PICC line
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) g Intravenous Q24H (every 24 hours) for 2 weeks.
Disp:*28 g* Refills:*0*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. PICC line care per protocol
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapy
Discharge Diagnosis:
Aortic valve endocarditis (HACEK), Aortic insufficiency,
Congestive Heart Failure - s/p Aortic Valve Replacment
(pericardial valve)
Elevated left hemidiaphragm
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Take medications as directed. Continue antibiotic for 2 further
weeks. Take percocet for pain; do not drive or drink alcohol
while taking percocet.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**4-10**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] in [**2-9**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**2-9**] weeks.
[**Hospital **] clinic, Drs. [**First Name (STitle) 2505**] and [**Name5 (PTitle) **] [**2120-6-11**].
Chem7, LFTs, CBC 1 weeks from D/c from hospital - Will check at
[**Hospital **] clinic appointment
|
[
"421.0",
"424.1",
"423.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"88.56",
"37.49",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
5113, 5180
|
2639, 3801
|
298, 447
|
5384, 5390
|
2325, 2616
|
5859, 6342
|
1660, 1787
|
3974, 5090
|
5201, 5363
|
3827, 3951
|
5414, 5836
|
1802, 2306
|
239, 260
|
475, 1358
|
1380, 1473
|
1489, 1644
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,582
| 117,745
|
38388
|
Discharge summary
|
report
|
Admission Date: [**2192-7-29**] Discharge Date: [**2192-9-1**]
Date of Birth: [**2133-5-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
OSH transfer for evaluation and treatment of TTP
Major Surgical or Invasive Procedure:
Intubation and extubation
Bone Marrow Biopsy
HD line placed and removed
Liver biopsy [**8-8**]
History of Present Illness:
Patient is a 59 yo male who recently was hospitalized at [**Hospital1 18**]
after diagnosis of TTP. At that time no underlying cause could
be identified, he was treated with plasmapharesis and steroids,
and ultimately improved however remained HD dependant. On the
day of presentation patient fellt ill, and "passed out". He was
transferred to [**Hospital 945**] [**Hospital **] hospital.
.
In the OSH patient was found to be profoundly anemic and
hypocoaguable. he was given 4 units of FFP and transferred to
[**Hospital1 18**]
.
In the [**Hospital1 18**] ED, initial vs were: T 97.7 P 102 BP 134/92 R 22 O2
sat 95%4L. ED discussed the case with BMT fellow, 125 solumedrol
was given, 2 units of prbc were recomended by Heme fellow, non
cont abd contrast for abd pain obtainedm, 2mg iv morphine, and
10 mg of vit K given.
.
.
Patient reports that he felt overall well up until the day of
his presentation. He endorses no UOP over the past 8 hours. He
denies any fever/chills, or diarrhea, but endorses nausea and
abdominal pain.
Past Medical History:
- Asthma
- Hypercholesterolemia
- TTP unclear etiology
- Renal failure, was on HD Tue/Th/Sat
- Hemophagocytic lymphohistiocytosis
Social History:
Married and lives with his wife. [**Name (NI) **] retired from working as a
case manager. He denies chemical exposure.
- Tobacco: 25 pack year history, quit in [**2158**]
- Alcohol: rare
Family History:
Throat cancer in mom and uncle.
Physical Exam:
Vitals: T: 98.6 BP: 135/86 P: 103 R: 30 O2:92%
General: Alert, oriented, tired appearing
HEENT: Sclera icteric, MMM, oropharynx with no ulcers or lesions
Neck: supple, JVP moderately elevated, no LAD
Lungs: Slight bibasilar crackles
CV: Sinus rhythm, nl S1S2, no S3S4, no murmurs, rubs, gallops
Abdomen: soft, non tender, non-distended, bowel sounds present,
no rebound tenderness or guarding,
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, with
minimal dependent edema 1+ and pitting around the ankles
Neuro: CN II-XII intact, Upper extremitites shoulder shrug,
deltoid extension, bicep and tricep flexion and extension [**6-20**]
b/l, lower extremities hip flexion, Knee flexion/extension,
ankle flexion/dorsiflexion [**5-21**] b/l
Psych: mood and attitude appropriate
Pertinent Results:
DATA FROM LAST ADMISSION:
=========================
Blood cultures - [**7-8**], [**7-10**], [**7-13**] - no growth
CMV Ab - [**7-8**] - IgM negative, IgG positive
Catheter Tip - [**7-13**] - no growth
CMV Viral Load - negative
.
Leptospirosis - negative
Lyme serologies - negative
Sputum (OSH) - Pseudomanoas cultures, pan-sensitive to
Levofloxacin, Meropenem, Ceftriaxone, Ceftazidime, R to
Aztreonam
Stool cultures - negative for Salmonella, Shigella, Yersinia,
E. coli O157:H7 - negatve
B Glucan - negative
Galactomannan - negative
HIV - negative
.
Urine Gonorrhea/Chlamydia PCR - negative
Urine culture [**7-9**] - Enterococcus species (but contaminated
sample), [**7-17**] - Coag Negative Staph
Repeat urine cultures from [**7-12**], [**7-16**] negative
.
Hepatitis Titers:
Hep B sAb - negative
Hep B sAB - positive
Hep C Ab - negative
Hep A IgG - positive, IgM - negative
.
Parvovirus IgG positive, IgM negative
.
[**2192-7-12**] 02:07PM BLOOD Parst S-NEGATIVE
.
[**2192-7-11**] 07:31PM BLOOD HERPES SIMPLEX (HSV) 2, IGG- negative
[**2192-7-11**] 07:31PM BLOOD HERPES SIMPLEX (HSV) 1, IGG- postive
.
PPD normal from [**7-19**], read on [**7-21**]
.
Rheumatologic Work-up:
Anti-GBM Ab: negative
[**Doctor First Name **], ANCA - negative
Ceruloplasm - negative
.
[**2192-7-8**] 11:24AM BLOOD Lupus-NEG
[**2192-7-9**] 03:36AM BLOOD ACA IgG-4.1 ACA IgM-9.6
[**2192-7-8**] 11:23AM BLOOD ANCA-NEGATIVE B
[**2192-7-11**] 07:31PM BLOOD Smooth-NEGATIVE
[**2192-7-8**] 02:38PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2192-7-11**] 07:31PM BLOOD IgG-780 IgM-75
[**2192-7-10**] 04:39AM BLOOD C3-93 C4-13
.
Miscellaneous:
ADAMTS13 Activity and Inhibitor: 38%
[**2192-7-8**] 01:19AM BLOOD Fibrino-246
.
Serum Tox Screen:
[**2192-7-8**] 12:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2192-7-12**] 01:01AM BLOOD COPPER (SERUM)- normal
Hereditary Hemochromatosis: Negative
.
ADMISSION LABS:
================
[**2192-7-29**] 10:05PM BLOOD WBC-8.8 RBC-1.95*# Hgb-6.2*# Hct-17.8*#
MCV-91 MCH-36.8*# MCHC-34.7 RDW-16.1* Plt Ct-53*#
[**2192-7-29**] 10:05PM BLOOD Neuts-77* Bands-3 Lymphs-17* Monos-1*
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1*
[**2192-7-29**] 10:05PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Schisto-1+
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) **]1+
[**2192-7-29**] 10:05PM BLOOD PT-23.6* PTT-55.1* INR(PT)-2.2*
[**2192-7-29**] 10:05PM BLOOD Fibrino-81*#
[**2192-7-30**] 04:06AM BLOOD Fibrino-118*
[**2192-7-30**] 04:06AM BLOOD FDP-[**Telephone/Fax (1) 14007**]*
[**2192-7-30**] 04:06AM BLOOD QG6PD-11.5
[**2192-8-2**] 04:55PM BLOOD Gran Ct-1044*
[**2192-8-2**] 10:40PM BLOOD Gran Ct-1512*
[**2192-8-3**] 03:00AM BLOOD Gran Ct-328*
[**2192-7-30**] 04:06AM BLOOD Ret Aut-3.2
[**2192-7-29**] 10:05PM BLOOD Glucose-94 UreaN-59* Creat-3.4*# Na-132*
K-4.7 Cl-94* HCO3-18* AnGap-25*
[**2192-7-29**] 10:05PM BLOOD ALT-262* AST-614* LD(LDH)-3850*
AlkPhos-288* TotBili-17.6* DirBili-8.3* IndBili-9.3
[**2192-7-31**] 02:56AM BLOOD ALT-1393* AST-2319* LD(LDH)-5860*
AlkPhos-271* TotBili-30.7*
[**2192-7-31**] 08:03PM BLOOD ALT-1652* AST-2896* AlkPhos-411*
TotBili-27.1*
[**2192-7-29**] 10:05PM BLOOD Lipase-211*
[**2192-7-30**] 04:06AM BLOOD Lipase-585*
[**2192-7-31**] 02:56AM BLOOD Lipase-2627*
[**2192-7-31**] 01:37PM BLOOD Lipase-1399*
[**2192-8-1**] 01:57AM BLOOD Lipase-669*
[**2192-7-30**] 04:06AM BLOOD Calcium-8.2* Phos-4.0# Mg-1.5*
[**2192-7-30**] 04:06AM BLOOD Hapto-73 Ferritn-[**Numeric Identifier 85484**]*
[**2192-8-6**] 04:42AM BLOOD Ferritn-[**Numeric Identifier 85485**]*
[**2192-7-30**] 04:06AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HAV-NEGATIVE
[**2192-7-31**] 09:03AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2192-7-31**] 01:37PM BLOOD ANCA-NEGATIVE B
[**2192-7-31**] 01:37PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2192-7-30**] 02:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-7-30**] 04:06AM BLOOD HCV Ab-NEGATIVE
[**2192-7-30**] 04:24AM BLOOD Lactate-7.2*
[**2192-7-30**] 09:15PM BLOOD freeCa-0.83*
MICROBIOLOGY:
==============
# ASPERGILLUS GALACTOMANNAN ANTIGEN: NEGATIVE
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 0.1 <0.5
(Sera with an Index <0.5 are considered to be negative)
# B-GLUCAN- NO RESULT
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
No Result * Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive > OR
equal to
80 pg/mL
# RUBEOLA ANTIBODY, IGM: NEGATIVE
Test Result Reference
Range/Units
MEASLES ANTIBODY, (IGM) <1:10 <1:10 titer
# ADENOVIRUS PCR: NEGATIVE (No DNA Detected)
# HERPES 6 DNA PCR, QUANTITATIVE: <500
#HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Simplex Virus (HSV) [**2-18**] IgM Ab, IFA (Serum)
HSV 1 IgM, IFA <1:20
<1:20
HSV 2 IgM, IFA <1:20
<1:20
Interpretive Criteria
<1:20 Antibody Not Detected
> or = 1:20 Antibody Detected
#HERPES SIMPLEX (HSV) 1, IGG
Test Result Reference
Range/Units
HSV 1 IGG TYPE SPECIFIC AB >5.00 H index
HSV 2 IGG TYPE SPECIFIC AB <0.90 index
# [**2192-7-30**] 4:03 am MRSA SCREEN Nasal swab.
MRSA SCREEN (Final [**2192-8-1**]): No MRSA isolated.
# [**2192-7-30**] 4:06 am BLOOD CULTURE
Blood Culture, Routine (Final [**2192-8-5**]): NO GROWTH.
.
.
# [**2192-7-30**] 8:48 pm Blood (CMV AB) Source: Line-aline.
CMV IgG ANTIBODY (Final [**2192-7-31**]): POSITIVE FOR CMV IgG ANTIBODY
BY EIA.
227 AU/ML.
.
.
# [**2192-7-30**] 8:48 pm Blood (EBV) Source: Line-aline.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2192-8-1**]):
Test canceled and patient credited due to a prior EBV
panel sent on
[**2192-7-8**] indicating evidence of past infection (EBV
VCA-IgG positive,
EBNA IgG positive and EBV VCA-IgM negative). A repeat
panel is
unlikely to detect EBV reactivation. Serum will be held
for 3months.
.
# [**2192-7-30**] 8:48 pm Immunology (CMV) Source: Line-aline.
CMV Viral Load (Final [**2192-8-1**]): 650 copies/ml.
.
.
# [**2192-7-30**] 11:11 pm
BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
# [**2192-7-30**] 10:15 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2192-8-2**]**
GRAM STAIN (Final [**2192-7-31**]):
[**12-10**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2192-8-2**]):
RARE GROWTH Commensal Respiratory Flora.
.
# [**2192-7-31**] 2:56 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-aline.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
# [**2192-7-31**] 9:43 am
SEROLOGY/BLOOD CHEM # 09480W [**7-31**].
**FINAL REPORT [**2192-8-3**]**
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2192-8-3**]):
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
ICTERIC SPECIMEN.
[**Month (only) **] EFFECT PATIENT RESULTS.
INTERPRET RESULTS WITH CAUTION.
# [**2192-7-31**] 10:08 am Rapid Respiratory Viral Screen & Culture
Site: NASOPHARYNGEAL SWAB
**FINAL REPORT [**2192-8-2**]**
Respiratory Viral Antigen Screen (Final [**2192-7-31**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
Respiratory Viral Culture (Final [**2192-8-2**]):
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.
#[**2192-7-31**] 3:29 pm IMMUNOLOGY Source: Line-a-line.
HBV Viral Load (Final [**2192-8-2**]): HBV DNA not detected.
.
# [**2192-8-1**] 9:24 am URINE Source: Catheter.
URINE CULTURE (Final [**2192-8-2**]): NO GROWTH.
.
# [**2192-8-1**] 12:37 pm Immunology (CMV) Source: Line-a-line.
CMV Viral Load (Final [**2192-8-3**]): CMV DNA not detected.
.
# [**2192-8-4**] 10:49 am BLOOD CULTURE Source: Line-hd line SET
#2.
Blood Culture, Routine (Pending):
# [**2192-8-5**] 14:30
EBV PCR, QUANTITATIVE, WHOLE BLOOD Results Pending
# [**2192-8-6**] 11:32 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2192-8-6**]):
[**12-10**] 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 [**2192-8-6**]):
TEST CANCELLED, PATIENT CREDITED.
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.
# CMV Viral Load (Final [**2192-8-29**]):
1,260 copies/ml.
# [**2192-8-29**] 09:45AM BLOOD WBC-6.2 RBC-2.86* Hgb-9.0* Hct-26.5*
MCV-92 MCH-31.4 MCHC-34.0 RDW-23.5* Plt Ct-63*
# [**2192-8-29**] 03:20PM BLOOD Na-129* K-4.7 Cl-95*
#[**2192-7-31**] 08:03PM BLOOD ALT-1652* AST-2896* AlkPhos-411*
TotBili-27.1*
[**2192-8-29**] 09:45AM BLOOD ALT-202* AST-50* AlkPhos-466*
TotBili-4.8*
# [**2192-8-6**] 04:42AM BLOOD Ferritn-[**Numeric Identifier 85485**]*
[**2192-7-30**] 04:06AM BLOOD Hapto-73 Ferritn-[**Numeric Identifier 85484**]*
# [**2192-8-29**] 09:45AM BLOOD Cyclspr-33*
IMAGES/STUDIES:
===============
[**2192-7-29**] 10:07:34 PM
Normal sinus rhythm. Possible left ventricular hypertrophy.
Non-specific
ST-T wave abnormalities. Compared to the previous tracing of
[**2192-7-9**]
QRS voltage in the left lateral leads has increased raising the
possibility of
left ventricular hypertrophy. Suggest clinical correlation and
repeat tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
96 136 82 350/413 66 62 91
.
#[**2192-8-1**] 2:32:34 PM
Atrial fibrillation with rapid ventricular response. Left
ventricular
hypertrophy. Diffuse non-specific ST-T wave changes. Compared to
the previous tracing of [**2192-7-29**] atrial fibrillation with a rapid
ventricular response and diffuse ST-T wave flattening have
appeared.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 0 88 [**Telephone/Fax (2) 85486**]0
.
#Atrial fibrillation with rapid ventricular response. Diffuse
non-specific
ST-T wave flattening. Compared to the previous tracing of
[**2192-8-1**] no diagnostic interim change.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
115 0 86 342/438 0 67 80
# CHEST (PA & LAT) Study Date of [**2192-7-29**] 10:37 PMA double-lumen
catheter is seen with tip in the lower SVC.
Heart size is enlarged with the vascular pedicle more prominent
than on [**2192-7-15**]. There is an ill-defined opacificity overlying the
right mid lung.
There is no pleural effusion or pneumothorax.
IMPRESSION:
1. New cardiomegaly and enlarged vascular pedicle, suggestive of
fluid
overload.
2. Ill-defined opacity in the right mid lung could be pneumonia
or pulmonary hemorrhage in the appropriate clinical context.
.
#PATHOLOGY:
DIFFICULT CROSSMATCH AND/OR EVALUATION OF IRREGULAR
ANTIBODIES Study Date of [**2192-7-30**]
(ICD9 CODE: 999.7)
INDICATION FOR CONSULT: DIFFICULT CROSSMATCH AND/OR EVALUATION
OF IRREGULAR ANTIBODIES
INDICATIONS FOR CONSULT:
Difficult crossmatch and/or evaluation of irregular antibody (s)
CLINICAL/LAB DATA: Mr. [**Known lastname 74316**] is a 59 year old male who was
admitted
with renal and hepatic dysfunction, as well as a picture
concerning for
sepsis/DIC. A blood sample was sent for type and screen.
Laboratory Data:
Patient ABO/Rh: Group O, Rh positive
Antibody screen: Positive
DAT: 3+ IgG, 1+ C3
Eluate: panagglutination of all cells
Antibody identity: Panagglutinating antibody ([**Hospital1 18**]); anti-Jkb
identified by the American Red Cross reference laboratory after
performing heterologous adsorption [required due to recent
transfusion]
Antigen phenotype: performed [**2192-7-8**]- E, K, Jkb, Fya,
Fyb-antigen
negative
Transfusion history:
7 non-reactive red cell transfusions during previous admission
[**Date range (2) 85487**] (5 of 7 units retrospectively determined to be
positive
for Jkb)
Previous non-reactive plasma transfusions: 123 (in setting of
plasmapheresis)
Previous non-reactive platelet transfusions: 2
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname 74316**] has a
new
diagnosis of Anti-Jkb antibody, in addition to his known warm
autoantibody. Jkb-antigen is a member of the Kidd blood group
system.
Jkb-antibody is clinically significant and capable of causing
hemolytic
transfusion reactions. During his last admission [**Date range (2) 85487**],
Mr.
[**Known lastname 74316**] received 5 units of Jkb positive blood. These units
will
likely be cleared more quickly than Jkb negative units. The ICU
team
was made aware that delayed hemolysis could be taking place,
although it
will be difficult to assess in the face of his other lab
abnormalities.
In the future, Mr. [**Known lastname 74316**] should receive Jkb-antigen negative
products
for all red cell transfusions. Approximately 26% of all ABO
compatible
blood will be Jkb-antigen negative. A wallet card and a letter
stating
the above will be sent to the patient.
.
# ECHO [**2192-7-30**]:
The left atrium is mildly 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 global left ventricular hypokinesis (LVEF
= 40-45 %). There is no ventricular septal defect. with
depressed free wall contractility. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2192-7-9**],
biventricular systolic function now appears mildly depressed.
.
#CT OF THE ABDOMEN/PELVIS W/O INTRAVENOUS CONTRAST:
In the visualized thorax, there is septal thickening in the left
lower lobe that is consistent with pulmonary edema. Proximally
there are small nodular densities. There is mild basilar
atelectasis, worse on the left. There is no pleural effusion or
pneumothorax. The visualized heart is normal in size with a
trace pericardial effusion. Relative attenuation of the
ventricles relative to muscle suggests anemia.
Evaluation of the solid organs in the abdomen is limited without
intravenous contrast. Calcific foci are seen within the liver
and spleen suggesting prior granulomatous insult. A sliver of
fluid is seen between the hepatic parenchyma and the gallbladder
(series 2, image 25). There is no pericholecystic fat stranding.
The pancreas and adrenals appear normal.
There is a 1.7-cm diameter hypodensity within the lower pole of
the left
kidney and a second 1.2-cm hypodensity in the interpolar region,
incompetely characterized. Abdominal loops of small bowel appear
normal without distension or pericolonic fat stranding. There is
moderate fecal loading of the large bowel. The appendix is not
clearly visualized, but there are no secondary signs to suggest
appendicitis. There is no abdominal free air, free fluid, or
pathologic lymphadenopathy.
Pelvic loops of bowel appear normal. The bladder and distal
ureters appear
normal. The prostate measures to 5 cm.
MUSCULOSKELETAL: There is no suspicious osteolytic or
osteoblastic lesion.
Multilevel degenerative changes are seen with prominent
Schmorl's nodes at
L3-L4.
IMPRESSION:
1. Sliver of pericholecystic fluid adjacent to the hepatic wall
may reflect
liver pathology rather than acute cholecystitis given no
definitive
gallbladder wall edema or adjacent fat stranding. Nonetheless
recommend US
for further characterization.
2. Left renal cysts are incompletely characterized. These can be
evaluated
concurrently with gallbladder
3. Left lower lobe septal thickening and proximal nodularity are
consistent
with focal edema and an inflammatory/infectious process.
3. Moderate fecal loading.
4. Enlarged prostate.
5. Anemia
.
# [**2192-7-30**] 2:17 PM
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL)
Comparison is made to prior CT examination
dated [**2192-7-30**]. The echotexture of the liver is unremarkable
except for a
1.1-cm slightly hyperechoic lesion in segment VIII of the liver.
A similarly hyperechoic region is seen more medially in segment
VIII. This measures 1.3 cm. These areas do not demonstrate color
flow consistent with hemangiomas. There is gallbladder wall
edema; however, the gallbladder is not distended. There are no
stones in the gallbladder. No pericholecystic fluid is noted.
The gallbladder wall edema causes wall thickening up to 6.5 mm.
On color flow and Doppler images, there is normal flow in the
main portal vein. Adequate flow is also identified in the left
portal vein. There is normal flow visualized in the hepatic
veins, although it was difficult to obtain waveforms as the
patient was unable to hold his breath for a sufficiently long
period of time.
IMPRESSION:
1. Portal vein and its branches as well as hepatic veins are
patent.
2. Gallbladder wall edema, the presence of a non-distended
gallbladder most
consistent with hypoalbuminemia or liver disease.
3. Too small hyperechoic lesions in the liver are most
consistent with
hemangiomas.
.
# [**2192-8-4**] 4:08 AM CHEST (PORTABLE AP)
Cardiomediastinal contours are unchanged. Lungs are grossly
clear
except for a patchy area of opacity in the left retrocardiac
region, which has slightly improved when compared to an earlier
radiograph of 15th at 5:43 a.m. This is most likely atelectasis
and less likely an infectious pneumonia.
.
# [**2192-8-6**] 11:15 AM CHEST (PORTABLE AP):
New poorly well-defined round opacities and right mid and left
lower lung, concerning for infection such as septic emboli or
fungal
organisms. Consider chest CT for confirmation and further
characterization.
.
# [**2192-8-6**] CT CHEST W/O CONTRAST:
There has been partial resolution of the diffuse ground-glass
opacities since the previous CT with residual well-demarcated
ground-glass opacities which are predominantly in the right
upper lobe (2.27) and the right lung base, to a lesser extent.
The appearances of these abnormalities are similar to the
previous CT with no newly affected areas. Pleural surfaces are
smooth with no pleural effusion. Linear atelectasis is new and
mild in the lower lobes bilaterally with thickening of the left
major fissure due to mild atelectasis.
Several lung cysts which were accentuated by the ground-glass
opacities in the prior study are now separate to the lung
abnormality; these may represent sequelae of previous
hemorrhage, i.e. prior hematoceles. Paraseptal emphysema is
mild.
The pulmonary artery is enlarged at 37 mm, slightly larger than
on the
previous study suggesting pulmonary arterial hypertension. The
caliber of the aorta and heart size is normal,no pericardial
effusion. Relative hypodensity in the cardiac [**Doctor Last Name 1754**] in
comparison to the myocardium suggests anemia.
Although this examination was not designed for subdiaphragmatic
evaluation.
review of the upper abdominal organs is unremarkable. Punctate
calcification in the liver and spleen in addition to several
calcified mediastinal lymph nodes suggest prior granulomatous
exposure.
No destructive or sclerotic bone lesions are concerning for
malignancy.
IMPRESSION:
1)Partial resolution of the diffuse ground-glass opacities which
are
predominantly in the right upper lobe and right lower lobe to a
lesser extent. These abnormalities appear to have cleared over
several intervening chest radiographs and suggest recurrent
pulmonary hemorrhage, particularly given the coexistent
thrombocytopenia, other causes such as infection (PCP) are less
likely.
2)Liver, splenic and mediastinal lymph node calcifications
suggest prior
granulomatous exposure.
.
# [**2192-8-6**] CT HEAD W/O CONTRAST:
There is no intracranial hemorrhage, edema, mass effect, or
other
CT sign of acute major vascular territorial infarction. The
ventricles and
sulci are normal in size and configuration.
There are fluid levels within the left maxillary, right frontal
and bilateral sphenoid sinuses, as well as complete
opacification of left frontal sinus. Aeration of the ethmoid air
cells has improved since the prior study. Wall thickening in the
sphenoid and possibly also frontal sinuses suggests chronic
sinusitis. High-density material within the paranasal sinuses
suggests inspissated secretions, hemorrhagic secretions, or
fungal colonization. It is not clear whether there are
postsurgical changes in the incompletely evaluated nasal cavity.
IMPRESSION:
1. No intracranial hemorrhage or evidence of other acute
intracranial
abnormalities.
2. Chronic sinusitis. Fluid in the paranasal sinuses may
indicate the
presence of an acute component. High density contents within the
sinuses may reflect inspissated secretions, hemorrhagic
secretions, or fungal
colonization.
Labs results on 2 days prior to discharge:
[**2192-9-1**]
10:22a
Na 132 K4.9 Cl100 Cl 100 Bun 35 K 4.9 HCO3 100 creat 1
Ca: 7.9 Mg: 1.8 P: 3.0
CWBC 7.8 HCT 27.6 plts 60
[**2192-8-31**] Cyclspr: 70
ALT: 245 AP: 466 Tbili: 5.3 Alb: 2.7
AST: 50
Brief Hospital Course:
# HLH:
Clinical scenario consistent with HLH. Pt was admitted with
severe anemia and thrombocytopenia. He has had 4 days of ATG,
which was stopped early due to neutropenia - he later received
the 5th dose when neutropenia resolved. Pt was also placed on
high dose IV steriods, initially solumedrol 120mg [**Hospital1 **] that were
ultimately tapered to prednisone 40mg [**Hospital1 **] by beginning of [**Month (only) 205**].
Only possible cause of HLH that could be identified was ? of CMV
infection with two different viral load tests showing positive
viral load. Pt ended up getting two bone marrow biopsies ([**7-9**]
and [**8-14**]) which both showed evidence of some hemophagycytosis.
The liver biopsy on [**8-8**] showed no evidence of malignancy,
necrosis, or infections. The pathology present was predominantly
cholestatic and most consistent with drug induced changes. Pt
was held off other chemotherapeutic regimens for the first 6
weeks of the hospitalization because of his combined renal
failure and liver cholestasis. Once pt recovered renal function
and was declared by nephrology to no longer required
hemodialysis, he was started on low dose cyclosporine 50 mg [**Hospital1 **]
on the evening of [**8-23**]. Initial trough value was very low (<30)
two days later. His cyclosporine was gradually increased in
dose with the most recent dose being 175mg po BID. Cyclosporine
goal trough is 150-200 and should next be checked on [**2192-9-2**] and
should be checked every 48 hrs. Lab results should be faxed
every 48 hrs as soon as test results come back to Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 638**] and to Dr. [**Last Name (STitle) 85488**] [**Telephone/Fax (1) 85489**]. Along with these
you can fax CBC and chem 10 pls obtain as detailed on order
sheet. Pt started on standing magnesium given cyclosporine
results in magnesium wasting. Pt is also on predisone 40mg [**Hospital1 **].
Throughout admission pt continued to show evidence of red cell
and plt destruction on laboratory data (hgb/plts would drift
down, haptoglobin low, retics high). Initially numerous PRBC and
platelet transfusions were needed to stabilize pt while in the
ICU. Once he recovered enough to be on the floor, pt was
intermittently given PRBCs when his Hct was low enough that
there was concern for it causing symptoms. He only received plts
on the floor one time per IR before they pulled out the HD
catheter. He was followed closely by hematology while in the
hospital who recommend the following treatment for his HLH:
Unfortunately with HLH the patient's prognosis over the next
year is very poor.
# Sepsis/DIC: Mr. [**Known lastname 74316**] presented with hypotension, elevated
WBC, elevated lactate, decreased haptoglobin, elevated PT/PTT,
and elevated fibrinogen. No clear infectious source, possible
liver or lung. Upon presentation pt was treated empirically with
meropenem, levofloxacin from HAP with GN coverage since pt had
been hospitalized and was on immunosuppression. He ultimately
completed a 14 day course of meropenem. Culture data was
ultimately all negative with the only positive micro test being
a low CMV VL. ID started pt on Gancyclovir for ppx, and initial
Acyclovir was stopped. Pt then suffered from neutropenia thought
possible related to Gancyclovir vs ATG. Repeat CMV VLs were
negative and Gancyclovir was stopped. Histo was negative so also
okay to stop Ambisome. Pt had been on bactrim as an outpatient
for PCP prophylaxis while on steroids, but this was changed to
atovaquone due patients liver injury and concerns for bactrim
involvement. Later in hospital course, pt was restarted on
acyclovir for prophylaxis while on the steroids. Repeat CMV VL
from [**2192-8-22**] was positive for 1,630 copies and he was restarted
on Valganciclovir 900 mg PO BID with a plan for 3 weeks of
treatment total after discharge. His CBC will need to be
monitored daily to look for neutropenia, but has remained stable
after 4 days of treatment.
# Respiratory failure: Electively intubated on [**7-30**] and
extubated on [**8-3**]. Post extubation maintained oxygen sats on
nasal cannula and then on room air. Throughout admission pt
continued to have cough, occasionally productive, and somewhat
congested chest, but no evidence of infection was found and pt
was not treated with Abx for PNA after initial presentation. Pt
has hx of asthma and was previously on Advair. So neb tx and
advair were given throughout hospitalization. Pt had CT of chest
for f/u of new poorly well-defined round opacities and right mid
and left lower lung, concerning for infection such as septic
emboli or fungal. CT scans shows areas of opacity overall
improving when compared to prior image in [**Month (only) 116**]. As per above, ID
added Atovaquone for PCP [**Name9 (PRE) **] given that Bactrim can cause BM
suppression and liver damage.
# ATRIAL FIBRILLATION (AFIB): Pt developed A-fib on [**8-1**] which
then resolved on [**8-4**]. This was likely related infection and
respiratory distress. He was started on metoprolol 25mg [**Hospital1 **], he
converted to sinus. Currently NSR. Metoprolol 25mg PO BID was
continued throughout admission although pt did not have any more
incidences of documented afib while on hospital.
# Elevated LFTs: Uncertain about etiology initially, but after
liver bx results were final the leading likelyhood is
cholestatic drug induced liver injury [**3-20**] to bactrim. Overall
improvement in LFT??????s, but t.bili was significantly elevated (38
at one point). Tbili slowly came down over course of the next
month although ALT and Alk phos remained stably somewhat
elevated. The LFT improvement that was noted initially dis seem
to correlate with ATG treatment.
# Anemia: Hemolyzing. Schistocytes previously seen on smear.
Hemophagocytosis seen in BM. Pt was intermittently transfused as
noted above when Hct would get around 21 or when there was
concern that pt was getting symptomatic from his anemia. Epogen
was given with HD while pt was on dialysis. Once dialysis was
discontinued, it was given MWF (4k units). As pt clinically
stabilized, he was kept in the hospital by the concern that he
continued to show evidence of red cell destruction.
# Thrombocytopenia: Pt required plt transfusions in the ICU as
initially his plts were low and somewhat labile. He was also
transfused for liver biopsy. Once the patient was stable enough
for the floor his plts ranged from 20k-80k. On the floor he was
transfused plts once when IR took out the HD cath, but otherwise
his transfusion parameter was set at spontaneous bleeding. The
exact etiology of the low plts was never completely clear but it
is likely multifactorial and related to HLH, medications, and
overall health.
# Neutropenia: Pt became neutropnic after 4 doses of ATG and 2
doses of Gancyclovir which may have caused BM suppression.
Counts quickly resolving after stopping offending meds. Once
count improved pt was given last dose of ATG. Gancyclovir was
kept off until [**8-24**] when a repeat CMV viral load was again
suddenly positive. Low dose gancyclovir was restarted and WBC
counts should be monitored daily. Pt was then swtiched to
Galvancyclovir as per ID and his WBC have been monitored and
have been stable. Will monitor his WBC while in [**Hospital 3782**] rehab to
watch for recurrence of the neutropenia
# Coagulopathy: Related to liver disease, infection, HLH. Pt did
not need FFP. Pt was given vit K x 3 days early in admission.
INR was stable around 1 for most of admission.
# Renal failure: Received CVVHx 3 days. This was stopped on
[**8-2**]. He then had microfiltration on the same day to help with
diureses for extubation. He was started on HD [**8-4**]. Stayed on
HD until [**8-18**] with slow improvement of kidney function. After HD
was stopped, Cr was observed for a few days and when it
continued to show improvement down below 2, and pt continued to
make very good urine output, his HD line was pulled by IR on
[**8-23**]. Renal followed throughout course of disease and helped
manage electrolytes and guide HD therapy.
#Hyponatremia: Mr. [**Known lastname 74316**] developed hyponatremia on [**2192-8-28**]
when he was autodiuresis after his kidney recovered from his
ARF. His hyponatremia and autodiuresis is likely also related to
poor glc control. He made up to 6.5L of urine 3 days prior to
discharge. PLEASE FLUID RESTRICT TO 2.5L daily as his sodium
improved with free water fluid restriction.
# Hypertension: Pt had elevated BP that was worse with ATG
infusion. He initially required Nitro drip for better BP
control. This was discontinued quickly once control was achieved
and he was restarted on his home dose of amlodipine 7.5mg which
was then increased dose to 10mg Qday. HD also helped with BP
control. Some additional control was provided by the metoprolol
on which the patient was kept to control Afib.
#Hyperglycemia: Pt not a diabetic, but glucose was elevated in
the setting of high dose steroids and tube feeds. Managed with
NPH of varying AM and PM doses with humalog ISS. Once tube feeds
were stopped and oral intake restarted he again had to adjust
NPH and ISS to keep sugars in an acceptable range. He is being
discharged on NPH and an ISS.
# Delerium: After patient was transferred to the floor from the
ICU he developed delirium over the first weekend which
manifested as inappropriate and sometimes violent actions with
pt attempting to hit staff and spitting on staff. Pt had to be
restrained with leather restraints for parts of two days because
he was able to break out of the soft restraints despite his
deconditioning. The first night this occurred pt had to be given
haloperidol and ativan. Psych was then involved in care and
recommended giving quitiapene QHs with extra prn doses as
needed. Pt was on this regimen, with slow tapering of the QHs
dose for the next two weeks, although delirium never again was
an issue. Pt was intermittently mildly depressed about his body
weakness and how long he had been in the hospital.
.
# Lung nodule: New poorly well-defined round opacities and right
mid and left lower lung, concerning for infection such as septic
emboli or fungal organisms. Chest CT showed areas of opacity
overall improving when compared to prior image in [**Month (only) 116**] (when he
was previously admitted for what was thought to be TTP). This
was thought to be related to prior pulmonary hemorrhage that is
now resolving. Nodule will need follow-up as an outpatient after
discharge.
# HA: Early in admission, pt c/o bilateral frontal HA with no
focal neurological deficits found on exam, however this was a
new finding and given low platelet count this was concerning for
head bleed. Head CT showed no IC bleeding or other acute
process. HA resolved over next few days and was not an issue for
the rest of admission.
# Chest pain: pt had two episodes of epigastric pain which
raised concerns for chest pain. At each time EKGs were
unremarkable and cardiac enzymes did not show evidence of acute
MI (although troponin was stably elevated in context of renal
failure). Pt described pain as not unlike the GERD pain he
occasionally had in the past, and both times pain seemed to
resolve with a GI cocktail.
# Insomnia: He had difficulty with sleeping during his hospital
course and was started on trazodone qhs with good effect.
Medications on Admission:
1. Pantoprazole 40 mg PO once a day.
2. Zyprexa 5 mg PO at bedtime: while on steroids.
3. Fexofenadine 60 mg PO BID
4. Sulfamethoxazole-Trimethoprim 800-160 mg One Tablet PO MWF
5. Montelukast 10 mg PO DAILY
6. Prednisone 50 mg PO DAILY
7. Fluticasone-Salmeterol 500-50 [**Hospital1 **]
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS
10. Amlodipine 7.5 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Polyethylene Glycol as needed for constipation.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: hold for sedation or RR<12.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for wheeze.
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP<110.
6. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) servings
(total 1500mg) PO DAILY (Daily).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for moderate pain.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for GERD symptoms.
10. Labs and heme follow up
Most recent dose being 175mg po BID. Cyclosporine goal trough is
150-200 and should next be checked on [**2192-9-2**] and should be
checked every 48 hrs. Check 1/2 hr prior to AM dose but give am
dose after. Lab results including CBC and chem 10 should be
faxed every 48 hrs as soon as test results come back to Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) 638**] and to Dr. [**Last Name (STitle) 85488**] [**Telephone/Fax (1) 85489**].
11. Follow up
Needs transportation arranged for appointment at [**Hospital3 328**]
with Dr. [**Last Name (STitle) 85490**] on [**2192-9-3**] at 1:15pm
Needs transportation arranged for appointment with Dr.
[**Last Name (STitle) **]/[**Last Name (STitle) 85488**] at [**Hospital3 **] on [**9-6**] at 2:30pm
Needs transportation arranged for Infectious Disease appointment
at [**Hospital3 **] on [**2192-9-13**]
12. CMV viral load
Plase check CMV viral viral load each Thursday, pls check CBC
three x a week and chem 7 every other day for the next week and
then once weekly.
Pls fax CMV viral load and three x a week CBC and once a week to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] infectious disease at [**Hospital1 **] or her RNS
at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
13. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule
PO Q12H (every 12 hours).
14. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold loose stool.
16. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) dose
Injection QMOWEFR (Monday -Wednesday-Friday).
17. Maalox
15ml po TID prn for gerd sx
18. Ondansetron 8 mg IV Q8H:PRN Nausea
19. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
20. Insulin
pls continue attached insulin SS, AM NPH increased from 26-28 to
start on [**2192-9-2**]
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
22. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for Delerium and Agitation: has not been
needing recently.
23. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for pruritis.
24. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
25. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): last dose expected to be [**2192-9-15**] unless told
otherwise by infectious disease doctor.
26. Magnesium 300 mg Capsule Sig: One (1) Capsule PO twice a
day: pls increase dosing if magnesium is low.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary Diagnosis:
-Hemophagocytic lymphohistiocytosis
-Acute on chronic renal failure
-Liver failure due to drug rxn
-Cytomegalovirus
Secondary Diagnosis:
- Asthma
- Allergies
- Hypercholesterolemia
Discharge Condition:
Alert and oriented x3
Unable to ambulate independently
Full code
Discharge Instructions:
Mr. [**Known lastname 74316**] as you know you had a difficult hospital course but
we are very pleased that you are well enough now to go to rehab.
You originally came in with low blood pressure, bleeding, renal
failure, liver failure, and hemolysis (destruction of your red
blood cells and platelets. You required intubation in the
intensive care unit and transfusions of blood and platelets.
Your liver biopsy ultimately showed your liver problems were due
to a drug reaction, likely bactrim so you were changed from
bactrim to atovaquone. Your liver has been slowly recovering.
Your kidney function has improved and you no longer require
hemodialysis. You are urinating a lot as a result of your
improved renal function which caused your sodium levels to
decrease. This improved with getting IV fluids.
You had 2 bone marrow biopsies that ultimately diagnosed
hemophagocytic lymphohistiocytosis which as you know is a very
serious disease. You were originally treated with ATG and
steroids but later switched to cyclosporine. Our hematologists
will give your rehab advice on how to continue treatment with
cyclosporine. You are also going to [**Hospital3 328**] on Monday for a
second opinion which we encourage you to do. You have this
appointment on [**2192-9-3**].
You currently have an infection called CMV which is being
treated with valgancyclovir which you will continue atleast
until [**2192-9-15**].
PLEASE TAKE ONLY THOSE MEDICATIONS FOUND ON THE ATTACHED LIST
Followup Instructions:
Please let Mrs. [**Known lastname 74316**] and the inpatient team know that I have
arranged for Mr. [**Known lastname 74316**] to be seen at [**Company 2860**] by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85491**]
(expert in HLH wrote the uptodate card) on [**2192-9-3**] at 1:15, [**Location (un) **] of [**Hospital3 328**] Phone: [**Telephone/Fax (1) 85492**]
.
*We are working on an appointment for you to be seen in our
Dermatology department. The office will contact you with an
appointment. Please call ([**Telephone/Fax (1) 8132**] if you do not hear from
them.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2192-9-6**] at 2:30 PM
With: [**First Name8 (NamePattern2) 25**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2192-9-6**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2192-9-13**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
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Discharge summary
|
report
|
Admission Date: [**2110-3-16**] Discharge Date: [**2110-3-20**]
Date of Birth: [**2045-2-2**] Sex: F
Service: MEDICINE
Allergies:
benzoyl peroxide / Cipro / Codeine / doxycycline / fexofenadine
/ Penicillins / Prazosin / spironolactone / Sulfa(Sulfonamide
Antibiotics) / Vitamin A / sunflower seeds
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath, chest pressure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65 year-old woman with HTN, seizure disorder, MS c/b wheelchair
bound and suprapubic catheter presents with shortness of breath
and dull non-radiating chest pressure since 6:30pm. Patient live
in [**Hospital1 1501**]. EMS gave neb with some imrpvement in SOB. Patient denies
sick contacts, [**Name (NI) 94472**] pain, diarrhea, nausea/vomiting.
Initial VS in the ED were [**Age over 90 **]F 120 119/74 18 92% RA. Labs were
significant for WBC 20.9 89.7%N, HCT 40.6, PLTS 389, Na 131, K
3.7, HCO3 33, Gluc 152, D-dimer 833 and TropT <0.01. UA s/f 26
RBC, 4 WBC, Nitr pos and moderate bacteria. CTA Chest identified
no PE and RLL opacity c/f PNA. The patient received 650mg PO
tylenol, 1g IV Vanc, 1g IV ceftriaxone and 500mg PO azithromycin
in the ED. Vitals on transfer were 101.7 115 18 146/72 95%3L
On arrival to the medical floor, the patient is ansering
queation with full sentenses and appears comfortable.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
multiple sclerosis dx'ed [**2079**], patient is wheelchair bound
Left laterocollis 20 degrees, thought [**12-26**] to dystonic spasms
External and internal hemorrhoids s/p banding
Social History:
Denies tobacco, alcohol or illict drug abuse
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
VS [**Age over 90 **]F 111 122/76 16 98% 2L
GENERAL - Alert, appropriate and comfortable woman in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP non-elevated, limited ROM of
neck at baseline per patient [**12-26**] to MS
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - poor air movement balaterally, distant breath sounds
ABDOMEN - soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 1+ BL LE edema, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, 0/5 strenght in BL LE, 0/5 RUE, 1+/5 LUE
(hand only), limited ROM of neck as above, CNII-XII appear
intact
Discharge Physical Exam:
Tmax: 37 ??????C (98.6 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 93 (87 - 123) bpm
BP: 94/54(69) {87/51(65) - 151/84(108)} mmHg
RR: 16 (16 - 27) insp/min
SpO2: 94%
GENERAL - Alert, appropriate woman in NAD, uncomfortable
HEENT - PERRLA, sclerae anicteric, MMM, OP clear. Diaphoretic.
NECK - Supple, no thyromegaly, JVP non-elevated, limited ROM of
neck at baseline per patient [**12-26**] to MS . SC CVL in place,
dressing CDI
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - poor air movement balaterally, distant breath sounds ,
significant rales to mid-lung L>R
ABDOMEN - soft/NT/ND, no masses or HSM . Suprapubic catheter in
place, draining clear yellow urine
EXTREMITIES - WWP, 2+ BL LE edema, 2+ peripheral pulses. Large
eccymosis interior left forearm.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, 0/5 strength in BL LE, 0/5 RUE, 1+/5 LUE
(hand only), limited ROM of neck as above, CNII-XII appear
intact
Pertinent Results:
Admission labs:
WBC-20.9* RBC-4.54 HGB-12.9 HCT-40.6 MCV-89 MCH-28.4 MCHC-31.8
RDW-14.2
NEUTS-89.7* LYMPHS-5.6* MONOS-3.4 EOS-1.1 BASOS-0.3
PLT COUNT-389
GLUCOSE-152* UREA N-12 CREAT-0.7 SODIUM-131* POTASSIUM-3.7
CHLORIDE-86* TOTAL CO2-33* ANION GAP-16
ALT(SGPT)-14 AST(SGOT)-19 CK(CPK)-28* ALK PHOS-72 TOT BILI-0.4
LIPASE-23
cTropnT-<0.01 CK-MB-1
ALBUMIN-4.0
Urinalysis-
BLOOD-SM NITRITE-POS PROTEIN-300 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-8.5* LEUK-LG
RBC-26* WBC-4 BACTERIA-MOD YEAST-NONE EPI-0 RENAL EPI-<1
Discharge -
[**2110-3-20**] 04:39AM BLOOD WBC-11.3* RBC-3.56* Hgb-10.0* Hct-32.4*
MCV-91 MCH-28.0 MCHC-30.8* RDW-14.8 Plt Ct-292
[**2110-3-19**] 03:36AM BLOOD PT-14.8* PTT-27.8 INR(PT)-1.4*
[**2110-3-20**] 04:39AM BLOOD Glucose-90 UreaN-11 Creat-0.5 Na-138
K-4.6 Cl-103 HCO3-30 AnGap-10
[**2110-3-20**] 04:39AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.8
.
Other Pertinent Labs
[**2110-3-19**] 03:36AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.0
[**2110-3-19**] 03:36AM BLOOD PTH-90*
[**2110-3-19**] 03:36AM BLOOD 25VitD-PND
.
Microbiology:
[**3-15**] URINE CULTURE (Final [**2110-3-20**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. 2ND TYPE.
Piperacillin/tazobactam sensitivity testing available
on request.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
_________________________________________________________
PROTEUS MIRABILIS
| PROTEUS MIRABILIS
| | ENTEROCOCCUS
SP.
| | |
AMPICILLIN------------ <=2 S <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 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
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
VANCOMYCIN------------ 1 S
.
Blood culture [**3-15**], [**3-16**], [**3-18**] NGTD (pending)
Urine culture [**3-17**] final negative
Imaging:
.
CXR [**3-15**]- Low lung volumes, making evaluation of the lateral
view
suboptimal. Given this, there is right>left bibasilar linear
atelectasis/scarring without definite focal consolidation.
CTA [**3-15**]-
1. No PE or acute aortic syndrome.
2. Streaky density in the right lower lobe may represent
atelectasis,
aspiration, or early infection.
3. Hepatic cysts.
CXR [**3-16**]:
Bibasilar opacities -- ? atelectasis and/or scarring -- are
unchanged. Due to respiratory motion, there is limited
assessment for focal infiltrate on the lateral view.
Renal U/S [**3-17**]:
Normal renal ultrasound. No evidence of perinephric fluid
collection.
[**3-19**] CXR (PICC placement)
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
4 French
single-lumen PICC line placement via the right brachial venous
approach.
Final internal length is 46.5 cm, with the tip positioned in
SVC. The line is ready to use.
[**3-20**] RUE US - no hematoma
Brief Hospital Course:
65 yo F with h/o MS presenting with shortness of breath and
chest pain, found to have sepsis with unclear infectious source,
PNA vs UTI.
# SEPSIS
Patient met SIRS criteria for septic shock on admission with
fever, white count, and tachycardia. Likely source was urinary
+/- PNA (see below). Patient denied abdominal pain, and had no
diarrhea; however, with recent antibiotics, also at risk for
c.difficile. Patient broadly covered with vancomycin, cefepime
and flagyl; flagyl stopped 4d prior to discharge with plan to
continue vanc/cefepime via PICC line for 7-day course to end
[**3-22**].
.
# HYPOTENSION
On the evening of admission patient was noted to be hypotensive
to systolic 60s. This was in the context of receiving a total of
2L ivf since admission and home lasix, hctz, furosemide as well
as her home sedating medications: seroquel, trazodone, doxepin,
tizanidine, klonopin, fexophenadine. Patient was noted to be A+O
x 1 during this episode. Due to her hypotension she was
transferred to the MICU where she was aggressively fluid
resuscitated with 6L NS. Required pressure support w/ levophed
overnight. Mental status improved with improving blood pressure.
Her home blood pressure medications were held as were her
sedating medications; these were gradually restarted
w/stabilization of BPs and treatment of underlying infections.
.
# URINARY TRACT INFECTION
Her urinalysis on arrival showed evidence of infection with
+leuk/nitrites, and mod bacteria but only 4 WBC. Urine culture
grew pan-sensitive Proteus and enterococcus, which would be
covered by the vanc/cefepime regimen started on admission.
Repeat urine culture clean.
.
# PNEUMONIA
Admission CXR and CT scan showed RLL opacity, and she was
hypoxic to 91% on RA. We note that diagnosis of PNA uncertain,
as she could also have low lung volumes because of atelectasis
and decreased lung volumes secondary to her multiple sclerosis.
Also had a CTA to evaluate for PE as alternate explanation for
hypoxia - this was negative for PE despite elevated d-dimer.
Received vanc/cefepime as discussed above.Patient was maintained
on supplemental O2 (3L) through NC in ICU and placed on PRN
nebs. CXR on day of admission showed some vascular congestion
(likely from all the IVF she had gotten for sepsis), so she was
diuresed w/ lasix 40mg IV x1, with good response, before being
sent back to [**Hospital1 1501**] on increased dose of lasix 40mg PO daily x 1
week (will need lytes checked) with plan to decrease back to 20
QD after 1 week.
.
# Multiple sclerosis
Chronc progresive, with limited mobility. Has chronic suprapubic
catheter for neurogenic bladder. She was continued on tizanadine
standing and as needed per home regimen for bladder spasms. Also
continued on bowel regimen per home regimen, naprosyn and
tylenol for pain.
.
# Hypertension
Continued home metoprolol and HCTZ
.
# Depression
Continued home medications unchanged.
.
# Allergic rhinitis
Continued home medications.
.
=
=
=
=
=
=
=
=
=
================================================================
# Transitional issues-
- monitor respiratory status, nebulizer requirement (expect this
to wean)
- needs follow-up chem7 check on Monday [**3-24**] while on increased
dose lasix
- ensure patient returns to 20 PO lasix QD after 1 week;
reassess volume status by lung exam and adjust lasix dosing
thereafter PRN
- PICC line to be pulled by [**Hospital1 1501**] after abx complete (3 more days,
end date [**3-22**])
- f/u pending blood cultures
- vitamin D level pending
- PTH level high; consider further outpatient follow-up
Medications on Admission:
# Anucort-HC 25 mg PR [**Hospital1 **] prn constipation
# tizanidine 2 mg po daily @ 13:00
# tizanidine 8 mg po qHS
# tizanidine 2 mg q4h prn bladder spasm
# bisacodyl 10 mg PR daily prn constipation
# clonazepam 3 mg QHS
# calcium carbonate-vitamin D3 600 mg (1,500)-400 1 tab po daily
# fexofenadine 60 mg po BID
# hydrochlorothiazide 37.5mg daily
# hyoscyamine sulfate 0.125 mg TID prn salivation
# lactrase 250 mg po daily prn
# metoprolol succinate ER 25 mg daily
# Mytab Gas 240 mg TID
# omeprazole 20 mg [**Hospital1 **]
# Preparation H PR [**Hospital1 **] prn anal pain
# calcium carbonate 1500mg po daily prn indigestion
# vitamin B Complex 1 tab po daily
# vitamin C 1000 mg po daily
# vitamin D3 400 units po daily
# vitamin E 400 unit po qHS
# acetaminophen 650mg po q4-6h prn pain or fever
# doxepin 10 mg po qHS
# seroquel 100 mg po qHS
# seroquel 12.5 mg po BID prn agitation/paranoia
# chlorpheniramine 4mg po BID prn itch
# acidophillus 1 tab po daily
# sertraline 200 mg po qAM
# trazodone 200 mg po qHS
# trazodone 100 mg po q6h prn depression
# clobetasol 0.05 % cream apply to skin [**Hospital1 **] prn itch
# hydrocortisone 0.2% cream to nape of neck prn itch
# aspirin 325 mg po daily
# refresh tears to right eye TID
# cranberry-probiotic-vitamin c 450mh-30mg-50mill 1 tab po daily
# naprosyn 500 mg po BID
# lasix 20 mg po daily
# trimethoprim 100 mg po BID x 3 days (starting [**3-14**])
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Fever or pain.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-25**] Inhalation Q6H (every 6 hours) as needed
for SOB.
3. tizanidine 2 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
4. tizanidine 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for bladder spasms.
5. tizanidine 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
at 13:00.
6. clonazepam 1 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
7. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. hydrochlorothiazide 12.5 mg Capsule Sig: Three (3) Capsule PO
DAILY (Daily).
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual TID (3 times a day) as needed for
salivation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. sertraline 100 mg Tablet Sig: Two (2) Tablet PO qAM.
16. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
17. trazodone 100 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for depression.
18. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for agitation/paranoia.
19. naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
20. furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 weeks.
21. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO once a day.
22. Vitamin B Complex Tablet Sig: One (1) Tablet PO once a
day.
23. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
24. Vitamin D3 400 unit Tablet Sig: One (1) Tablet PO once a
day.
25. vitamin E 400 unit Tablet Sig: One (1) Tablet PO at bedtime.
26. Acidophilus Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
27. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
28. simethicone 80 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO three times a day as needed for gas or bloating.
29. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 3 days.
30. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 3 days.
31. chlorpheniramine maleate 4 mg Tablet Sig: One (1) Tablet PO
twice a day as needed for itching.
32. Anucort-HC 25 mg Suppository Sig: One (1) PR Rectal twice a
day as needed for constipation.
33. Lactrase 250 mg Capsule Sig: One (1) Capsule PO once a day:
lactose intolerance.
34. Preparation H Ointment Sig: One (1) anal pain Rectal
twice a day.
35. clobetasol 0.05 % Cream Sig: One (1) Topical twice a day as
needed for itching.
36. Refresh Tears 0.5 % Drops Sig: One (1) drop Ophthalmic three
times a day: R eye.
37. Cranberry-Probiotics-Vitamin C [**Medical Record Number 18595**] mg-mg-million
Tablet Sig: One (1) Tablet PO once a day.
38. hydrocortisone 0.5 % Cream Sig: One (1) appl Topical four
times a day as needed for itching: to nape of neck
may use 0.2% cream.
39. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO once a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 388**] center for living
Discharge Diagnosis:
Primary diagnosis:
# Sepsis secondary to pneumonia and urinary tract infection
Secondary diagnosis:
# Multiple sclerosis w/ suprapubic catheter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms [**Known lastname 94473**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for pneumonia and a urinary tract infection, and also had low
blood pressures. For this, you were given fluids and
antibiotics, and you improved. You will need IV antibiotics for
a few more days, so you are getting a PICC line in order to get
these.
The following changes were made to your medication regimen:
** START vancomycin [antibiotic] for 3 additional days, end [**3-22**]
** START cefepime [antibiotic] for 3 additional days, end [**3-22**]
** START ALBUTEROL NEB TREATMENTS, [**11-25**] EVERY 4-6 HOURS AS-NEEDED
** INCREASE lasix to 40 mg daily for 1 week, then go abck to
taking 20 mg daily.
** STOP BACTRIM
Followup Instructions:
Further follow up per Skilled Nursing Facility MD
You will need to have labs checked in 4 days, to check your
sodium and creatinine levels while on an increased dose of
lasix.
See page 1 instructions for antibiotic course and PICC removal
instructions.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"473.9",
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"995.92",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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"38.91"
] |
icd9pcs
|
[
[
[]
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15792, 15905
|
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471, 477
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2024, 2702
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16027, 16073
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15945, 16006
|
16109, 16205
|
1707, 1888
|
1904, 1950
|
2727, 3714
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,059
| 181,623
|
48135
|
Discharge summary
|
report
|
Admission Date: [**2122-1-19**] Discharge Date: [**2122-1-27**]
Date of Birth: [**2065-11-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Celery / Bee Sting Kit
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 56F with a hx of pulmonary HTN, OSA, obesity
hypoventilation sydrome on BIPAP and home O2 who presents with a
transient episode of palpitations this afternoon. The patient
reports that she had been in her USOH. She was watching
television for 2 hours when she stood up and started
experiencing palpitations and shortness of breath. Her family
called EMS.
.
On arrival to [**Hospital1 18**] the patient's vitals were as follows T 98.8,
BP 120/70, HR 80, R 24, O2 sat 90% RA. The patient received
combivent nebs, prednisone 40mg, levaquin 500mg IV and lasix
80IV (750cc output). A CXR was done which showed cardiomegaly
and pulmonary HTN w/o pulmonary vascular congestion or
consolidation. The patient reports that since being here she
has not had recurrence of the palpitations. Her breathing feels
fine.
Past Medical History:
1)morbid obesity s/p hernia repair [**6-1**],
2)OSA on nocturnal BIPAP and 3-5L home O2, obesity
hypoventilation syndrome, COPD, pul HTN (PAP 54)
3)SLE
4)R CHF
5)chronic anemia (bl 32), iron def anemia
6)asthma
7)restrictive lung dz
8)HTN
9)OA
10) Hay fever
Social History:
The patient lives with her family. She denies any ciggs or etoh
use.
Family History:
mother also uses BiPAP, and had breast ca
Physical Exam:
T97.3 HR83 BP126/70 RR24 O2sat91% 4l
GEN: obese AAF in NAD, speaking in full sentences
HEENT: MMM, OP clear
HEART: nl rate, S1S2, no gmr
LUNGS: faint expiratory wheezes and crackles at the bases
ABD: scars from multiple abdominal surgeries
EXT: 1+ peripheral edema, pigmentation c/w chronic venous stasis
changes, 2+DP b/l
Pertinent Results:
Hematology:
[**2122-1-19**] 04:40PM BLOOD WBC-8.1 RBC-4.91 Hgb-11.9* Hct-40.1
MCV-82 MCH-24.2* MCHC-29.6* RDW-18.1* Plt Ct-137*
[**2122-1-27**] 05:25AM BLOOD WBC-7.5 RBC-5.29 Hgb-12.7 Hct-43.3 MCV-82
MCH-24.1* MCHC-29.4* RDW-19.1* Plt Ct-272
[**2122-1-19**] 04:40PM BLOOD Neuts-81.6* Lymphs-12.1* Monos-3.1
Eos-2.3 Baso-0.9
[**2122-1-19**] 04:40PM BLOOD D-Dimer-752*
[**2122-1-19**] 04:58PM BLOOD pO2-39* pCO2-74* pH-7.40 calTCO2-48* Base
XS-16 Intubat-NOT INTUBA Comment-TYPE NOT K
.
Chemistry:
[**2122-1-19**] 04:40PM BLOOD Glucose-130* UreaN-21* Creat-1.0 Na-146*
K-3.7 Cl-96 HCO3-47* AnGap-7*
[**2122-1-27**] 05:25AM BLOOD Glucose-123* UreaN-14 Creat-0.9 Na-141
K-4.2 Cl-92* HCO3-44* AnGap-9
[**2122-1-23**] 05:45AM BLOOD ALT-11 AST-16 LD(LDH)-234 AlkPhos-74
Amylase-72 TotBili-0.4
[**2122-1-19**] 04:40PM BLOOD CK(CPK)-27
[**2122-1-23**] 05:45AM BLOOD Lipase-22
[**2122-1-19**] 04:40PM BLOOD CK-MB-NotDone proBNP-7510*
[**2122-1-19**] 04:40PM BLOOD cTropnT-<0.01
[**2122-1-19**] 04:40PM BLOOD cTropnT-<0.01
[**2122-1-20**] 09:47AM BLOOD cTropnT-0.02*
[**2122-1-23**] 05:45AM BLOOD Albumin-3.1* Calcium-8.1* Phos-4.1 Mg-2.1
[**2122-1-23**] 05:45AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**Last Name (un) **]
.
CXR [**2122-1-19**]: Cardiomegaly and pulmonary arterial hypertension
without
pulmonary vascular congestion or focal consolidation.
.
CTA CHEST 1/22/7:
1. Evaluation for pulmonary embolism severely limited due to
patient motion. No evidence of saddle embolus or first-order
branch PEs.
2. Cardiomegaly.
3. Mosaic-like ground-glass opacities which could be indicative
of reactive airway disease.
.
TTE [**2122-1-20**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is dilated. Due to suboptimal image quality,
right ventricular function cannot be reliably assessed. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2119-11-28**], minimal aortic stenosis is now
present. Estimated pulmonary artery systolic pressures are
similar. The severity of tricuspid regurgitation has increased.
Brief Hospital Course:
Ms. [**Known lastname **] is a 56F with MMP including hypoventilation syndrome,
OSA and pulmonary HTN who presents with an episode of
palpitations and found to be in decompensated heart failure.
.
1. Palpitations/ ?presyncope: Etiology of palpitations seems
unclear. [**Name2 (NI) **] reports that she has been maintaining adequate
PO intake, thus no reason to suspect that she was
intravascularly depleted. Patient's body habitus does not
support hyperthyroidism. ECHO shows worsened TR but otherwise
little change from prior TTE on [**11-1**]. Heart function is
hyperdynamic with EF 60-65% on this admission, but does not
explain her presenting complaint of palpitations. No clear
etiology for palpitations. Patient without any events on
telemetry throughout hospital stay and without recurrence of
palpitations. Follow-up with cardiology as outpatient scheduled.
.
2. Pulm HTN: Continue patient on Viagra and BiPAP. New settings
recommended by Sleep service were made to patient's home machine
and she tolerated using it well in the hospital. Patient was
seen by the Pulonary service who recommend that she continue on
lasix for aggressive diuresis. Do not feel that she would
tolerate addition of other medications well and that much of her
difficulties are related to fluid overload. Pulmonary
recommended diuresing 1-2 liters of fluid off per day and
closely following her weights. While an inpatient, she received
80 mg PO Lasix [**Hospital1 **] with vigorous response. Her electrolytes were
closely monitored in the setting of aggressive diuresis but did
not require repletion. She was discharged to home on 80mg lasix
qd for continued diuresis (see CHF below). Discharged with home
O2 (3L resting, 4L with ambulation). Pulmonary followup.
.
3. Asthma/ COPD: Patient's bicarb reflects chronic hypercarbia.
Steroids were discontinued in the MICU secondary to low
suspicion of flare and minimal wheezes on initial exam. Her home
nebs were continued as needed and the patients respiratory
status remained stable. She did not require antiobiotics or oral
steroids during her stay.
.
4. r/o PE: D-dimer was 700, CTA showed no saddle embolus or PE
in the large vessels. Pulmonary embolism successfully ruled out.
.
5. CHF: Preserved EF, likely diastolic dysfunction. BNP elevated
on admission. Patient presents with bilateral LE edema which has
been worsening over past few weeks and reported 20+ pound weight
gain (reports dry weight 163). Long h/o med non-compliance.
Repeat TTE unchanged from prior. Dietary teaching for low sodium
diet. Diuresed per above. Will need continued diuresis as
outpatient and cardiology followup.
.
6. HTN: Well-controlled. Continued home BB, ACEi.
.
7. Ischemia: No active issues. No known CAD but multiple risk
factors. Cont ASA, BB, ACEi. Consider starting statin as
outpatient.
.
8. Hematuria: Mild, likely irritation from foley. U/A not
suspicious for UTI and culture negative. Foley removed and
hematuria resolved.
Medications on Admission:
1. Sildenafil 25 mg Tablet tid
2. Lisinopril 5 mg qd
3. Fluticasone 110 mcg/Actuation Aerosol 2Puff [**Hospital1 **]
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Q6H
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Two Puffs QID
6. Metoprolol Tartrate 25 [**Hospital1 **]
7. Docusate Sodium 100 mg [**Hospital1 **]
8. Furosemide 80 [**Hospital1 **], per pt.
9. Senna 8.6 mg [**Hospital1 **]
10. oxygen 2-4L NC continuous as needed
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: [**12-30**] Inhalation Q6H
(every 6 hours).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
Disp:*1 months supply* Refills:*0*
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Oxygen-Air Delivery Systems Device Sig: Three (3) liters
per min Miscellaneous continuous at rest: increase to 4 liters
per minute with exercise.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Heart palpitations, NOS
Obstructive sleep apnea
Diastolic heart failure
Pulmonary hypertension
COPD
Asthma
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital for new onset palpitations of
unclear cause. You had an Echocardiogram and EKGs which showed
no signficant change from prior studies you have had done. You
were also volume overloaded and diuresed with lasix. You will
need to continue to take lasix at home.
Some adjustments were made to your home BiPap machine while you
were in the hospital. You should continue to use your BiPAP at
night as usual but keep the new settings.
Continue all medications as prescribed, including your Lasix.
You will need to use supplemental oxygen continuously: 3L/min at
rest and 4L/min with activity. When active, stop and rest at
least every 30 feet.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases > 3
lbs. Adhere to 2 gm sodium diet. Fluid restriction 1500ml.
Contact a physician for fever > 101.5, nausea, vomiting, chest
pain, repeat palpitations, increased difficulty breathing, loss
of conciousness, weakness, abdominal pain, or any other
concerns.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
.
Provider: [**First Name8 (NamePattern2) 1409**] [**First Name8 (NamePattern2) 11593**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-2-2**] 2:30. Dr. [**Last Name (STitle) **] is a partner of Dr. [**Last Name (STitle) 3029**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2122-2-6**]
10:30
.
Provider: [**First Name8 (NamePattern2) 1409**] [**First Name8 (NamePattern2) 11593**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-2-9**] 2:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2122-3-11**] 8:00
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3172**]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2122-4-1**] 10:30
|
[
"493.20",
"428.30",
"416.0",
"428.0",
"710.0",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9524, 9581
|
4830, 7790
|
326, 332
|
9732, 9739
|
1992, 4807
|
10792, 11872
|
1588, 1632
|
8279, 9501
|
9602, 9711
|
7816, 8256
|
9763, 10769
|
1647, 1973
|
273, 288
|
360, 1204
|
1226, 1485
|
1501, 1572
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,220
| 107,938
|
47451
|
Discharge summary
|
report
|
Admission Date: [**2175-7-3**] Discharge Date: [**2175-7-4**]
Date of Birth: [**2112-4-1**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
s/p fall, acidosis.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 63 year old woman with PMHx of Hep C & ETOH
Cirrhosis, Gastritis/Duodenitis, HTN & CKD who presents with
fall 2 days ago after tripping on a rug at home. She was able
to ambulate after the fall but as the hip pain persisted she
came to the ED for evaluation.
.
In the ED, initial vs were: T 94.4 P 105 BP 88/53 RR 18 O2 sat
100%ra. Right hip films were negative for fracture. Laboratory
results were most notable for signficant anion-gap acidosis, and
pancytopenia (worsened from baseline low Hct and Plt). She was
given 2L of NS, as well as vanc/zosyn/Mag sulfate/KCl.
.
She denied cough, pain other than hip pain. She had no abd
pain. no headache. no dysuria. no rash. no diarrhea. no neck
stiffness. She denies metformin use. She denies anti-freeze
ingestion. In speaking with her fiance (who lives with her) she
was feeling well yesterday and had visited by daughter. Eating
normally yesterday with family. Temp check at home 98.3F at
home. Feet were swelling.
.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Diabetes Mellitus, type 2 - on insulin
Chronic Kidney Disease, baseline Cr 1.6-2.0
Hepatitis C-Rx with rebetron-discontinued after poor response
h/o acute hepatitis from tylenol overdose
Hypertension
h/o Chronic Pancreatitis
s/p TAH/BSO [**2155-1-26**]
Substance Abuse (Cocaine, EtOH)
h/o SBO with small bowel resection [**7-1**] and again [**11-1**]
Carpal Tunnel Syndrome
Depression
NSTEMI [**10-3**] in the context of cocaine use
Anemia with baseline Hct 26-30
Social History:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 73770**] (fiance) lives with her. she states she last had
a mixed drink with gin 2 days ago. she denies illicit drug use.
[**First Name9 (NamePattern2) **] [**First Name8 (NamePattern2) 1439**] [**Known lastname 46**] is her HCP.
Family History:
Hypertension. No history of premature CAD. Father with lung
cancer who died in his early 60s, mother with sarcoid who died
in her early 50s. No family hx of breast CA.
Physical Exam:
Vitals: T: 92.4 (oral) BP: 120/53 P: 92 R: 17 O2: 96%2L
General: Arousable to voice and follows commands, oriented
(hosp, year, day), no acute distress, tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear. right surgical
pupil.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachy. regular rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: cool, 2+ pulses, no clubbing, cyanosis or edema
Neuro:
-MS: awake, response to voice answering questions in short but
appropriate answers. no dysarthria. no R/L confusion or neglect
-CN: right surgical pupil. EOMI to full gaze. face symmetric.
tongue/palate midline.
-Motor: moving all 4 extremities symmetrically.
-[**Last Name (un) **]: light touch intact to face/hands/feet.
-Gait: deferred
Pertinent Results:
LABS:
[**2175-7-3**] 06:30AM BLOOD WBC-0.9*# RBC-3.11* Hgb-9.8* Hct-31.3*
MCV-101*# MCH-31.6 MCHC-31.3 RDW-16.2* Plt Ct-65*#
[**2175-7-3**] 07:20AM BLOOD WBC-2.7*# RBC-2.65* Hgb-8.5* Hct-27.3*
MCV-103* MCH-32.0 MCHC-31.1 RDW-17.2* Plt Ct-50*
[**2175-7-3**] 02:29PM BLOOD WBC-1.1*# RBC-2.03* Hgb-6.4* Hct-21.5*
MCV-106* MCH-31.7 MCHC-29.9* RDW-17.8* Plt Ct-18*#
[**2175-7-4**] 12:21AM BLOOD WBC-2.9*# RBC-2.12* Hgb-6.7* Hct-21.6*
MCV-102* MCH-31.5 MCHC-30.9* RDW-16.8* Plt Ct-12*
[**2175-7-4**] 03:37AM BLOOD WBC-2.6* RBC-1.96* Hgb-5.9* Hct-18.7*
MCV-96 MCH-30.1 MCHC-31.5 RDW-17.8* Plt Ct-11*
[**2175-7-3**] 06:30AM BLOOD Neuts-52 Bands-8* Lymphs-22 Monos-0 Eos-0
Baso-0 Atyps-0 Metas-4* Myelos-14*
[**2175-7-3**] 07:20AM BLOOD Neuts-61 Bands-3 Lymphs-20 Monos-2 Eos-1
Baso-0 Atyps-0 Metas-6* Myelos-7*
[**2175-7-3**] 06:30AM BLOOD Plt Ct-65*#
[**2175-7-3**] 07:20AM BLOOD PT-22.9* PTT-52.0* INR(PT)-2.2*
[**2175-7-3**] 02:29PM BLOOD PT-59.6* PTT-150* INR(PT)-7.1*
[**2175-7-4**] 03:37AM BLOOD PT-150* PTT-150* INR(PT)->21.8*
[**2175-7-3**] 06:30AM BLOOD Glucose-264* UreaN-27* Creat-2.8* Na-132*
K-3.4 Cl-94* HCO3-6* AnGap-35*
[**2175-7-3**] 07:20AM BLOOD Glucose-241* UreaN-26* Creat-2.6* Na-137
K-3.3 Cl-96 HCO3-6* AnGap-38*
[**2175-7-4**] 12:21AM BLOOD Glucose-201* UreaN-18 Creat-2.1* Na-139
K-6.5* Cl-94* HCO3-7* AnGap-45*
[**2175-7-4**] 03:37AM BLOOD Glucose-489* UreaN-15 Creat-1.8* Na-132*
K-7.4* Cl-85* HCO3-7* AnGap-47*
[**2175-7-3**] 07:20AM BLOOD ALT-54* AST-117* CK(CPK)-2426*
AlkPhos-125* TotBili-1.6*
[**2175-7-3**] 02:29PM BLOOD LD(LDH)-553* CK(CPK)-[**Numeric Identifier 100369**]*
[**2175-7-4**] 12:21AM BLOOD CK(CPK)-[**Numeric Identifier 3026**]*
[**2175-7-4**] 03:37AM BLOOD ALT-59* AST-353* LD(LDH)-875*
CK(CPK)-7550* AlkPhos-72 TotBili-0.8
[**2175-7-3**] 07:20AM BLOOD cTropnT-0.10*
[**2175-7-3**] 02:29PM BLOOD CK-MB-80* MB Indx-0.7 cTropnT-0.08*
[**2175-7-3**] 07:20AM BLOOD Albumin-2.4* Calcium-6.8* Phos-5.1*#
Mg-0.9*
[**2175-7-4**] 03:37AM BLOOD Calcium-8.3* Phos-8.2*# Mg-1.8
[**2175-7-3**] 07:20AM BLOOD Acetone-NEGATIVE Osmolal-306
[**2175-7-3**] 07:20AM BLOOD ASA-NEG Ethanol-19* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-7-3**] 11:01AM BLOOD Type-ART pO2-96 pCO2-30* pH-6.96*
calTCO2-7* Base XS--25 Intubat-NOT INTUBA
[**2175-7-3**] 12:46PM BLOOD Type-ART pO2-105 pCO2-35 pH-6.91*
calTCO2-8* Base XS--26
[**2175-7-3**] 05:18PM BLOOD Type-CENTRAL VE pO2-98 pCO2-25* pH-6.96*
calTCO2-6* Base XS--26
[**2175-7-4**] 12:25AM BLOOD Type-[**Last Name (un) **] Temp-34.4 pO2-38* pCO2-29*
pH-6.97* calTCO2-7* Base XS--26
[**2175-7-4**] 04:25AM BLOOD Type-[**Last Name (un) **] Temp-34.2 pO2-36* pCO2-21*
pH-7.08* calTCO2-7* Base XS--23
[**2175-7-3**] 11:01AM BLOOD Lactate-17.8*
[**2175-7-3**] 03:11PM BLOOD Lactate-19.8* K-4.6
[**2175-7-4**] 04:25AM BLOOD Lactate-20.8*
[**2175-7-3**] 03:11PM BLOOD freeCa-0.88*
[**2175-7-4**] 04:25AM BLOOD freeCa-0.97*
[**2175-7-3**] 05:17PM BLOOD CYANIDE-PND
.
.
MICRO:
BLOOD CX:
[**2175-7-3**] 9:50 am BLOOD CULTURE VENIPUNTURE.
Blood Culture, Routine (Preliminary):
THIS IS A CORRECTED REPORT [**2175-7-4**].
GRAM NEGATIVE ROD(S).
PREVIOUSLY REPORTED ALSO POSITIVE FOR GRAM POSITIVE
COCCI [**2175-7-3**].
Anaerobic Bottle Gram Stain (Final [**2175-7-3**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name 50967**] [**Doctor Last Name **] ON [**2175-7-3**] @ 7:45 P.M..
Aerobic Bottle Gram Stain (Final [**2175-7-3**]):
THIS IS A CORRECTED REPORT [**2175-7-4**].
GRAM NEGATIVE ROD(S).
PREVIOUSLY REPORTED AS [**2175-7-3**].
GRAM POSITIVE COCCI IN CLUSTERS.
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name 50967**] [**Doctor Last Name **] [**2175-7-4**] 3:15PM.
.
.
STUDIES:
[**2175-7-3**] CT ABD/PELVIS:
IMPRESSION:
1. Limited assessment without IV or oral contrast. There is a
suggestion of wall thickening involving the hepatic flexure of
the colon ( c/w colitis), as well as in recto-sigmoid. No free
air or pneumatosis.
2. Diffusely fatty liver.
3. Pancreatic parenchymal calcifications, likely sequela from
chronic
pancreatitis.
4. Bilateral lower lobe consolidation in the visualized lungs,
with tiny
adjacent pleural effusions.
.
[**2175-7-3**] CXR:
IMPRESSION: No acute intrathoracic process.
.
[**2175-7-3**] ECG:
Sinus tachycardia with ventricular premature depolarizations and
diffuse
non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2175-6-21**] the heart rate is increased, now
with ventricular ectopic activity
.
Brief Hospital Course:
63 year old woman with medical history notable for HepC/EtOH
cirrhosis, DM2, hypertension and CKD presenting after a fall c/b
hip pain found to have significant anion-gap metabolic acidosis.
.
# Anion-gap metabolic acidosis with notable lactic acidosis: The
etiology of her acidosis remained unclear, though was ultimately
felt more likely due to an overwhelming septic picture,
supported by rapid growth of gram negative and gram positive
bacteremia. Initial delta-delta suggested co-incident non-anion
gap acidosis as well, and initial pCO2 of 30 suggested
inadequate respiratory compensation.
.
As above, the source of her profound lactic acidosis remained
unclear given lack of clear causitive medication; additionally
she initially appeared to have adequate organ perfusion (global
and mesentery) given benign abdominal exam, lack of abdominal
complaints, and relative normotension. Metabolic derangements
could have been related to severe thiamine deficiency, though
uncommon, this was treated. Ethylene glycol ingestion was also
entertained, but felt less likely given negative serum osm gap
unless it is now very late in the course.
.
Toxicology consult was obtained, without clear etiology, though
cyanide poisoning was entertained, and the antidone was
administered given lack of alternate explanations and the
patients rapid clinical decline. She was also empirically
treated with broad spectrum antibiotics (vancomycin, cefepime,
flagyl) without clear source. Surgical consult and CT abdomen
were obtained to further evaluate for an abdominal source, and
preliminary [**Location (un) 1131**] revealed no clear abcess or evidence of
mesenteric ischemia.
.
Over the course of her first 12 hours in hospital, her acidemia
progressed, her arterial PCO2 rose (to 47) and her mental status
declined prompting intubation. She also developed worsening
hypotension, prompting placement of a central venous catheter,
and iniation of levophed and vasopressin. Multiple attempts to
place an arterial line were unsucessful (residents x2, critical
care attending, surgical resident). OGT revealed coffee
grounds, though her HCT (baseline 30) declined slightly (27),
her labs ultimately revealed a DIC picture over the course of 12
hours, (INR >21, platlets 11), GIB was felt unlikely to
contribute to such a profound acidemia, despite her known liver
history. Cardiac enzymes were flat (CK MB 80s, MBI 0.7, though
peak trop 0.10).
.
Given lack of alternate explanations for her acidemia and
clinical decline, the renal service was consulted regarding
initiation of CVVH for removal of possible toxic ingestions and
to optimize management of the acidemia. She was treated
empirially with continuous bicarbonate infusion and CVVH was
initiated via a left femoral temporary HD catheter.
.
Despite the above interventions, her clinical status continued
to decline. Her CK rose to >10,000 (no evidence of rhabdo on
UA), her acidemia progressed, with venous PH=6.81/24/80 at 8PM,
her potassium rose to 7 despite CVVH. Given her grave
condition, a family meeting was held, led by her daughter
[**Name (NI) 1439**]. Decision was made to make the patient DNR/DNI, but to
continue with current measures. Her acidemia improved slightly
however lactate continued to rise. Microbiology data revealed
rapid growth of gram negative rods (2/2 bottles), and gram
positive cocci (1/2 bottles), supporting an overwhelming septic
picture of unclear etiology, but possibly enteric translocation
from GIB.
.
Despite the above efforts, the patient expired at 3AM the
following morning. An autopsy was offered to the family, and
accepted.
.
.
# Pancytopenia: most likely [**2-27**] septic picture as above.
Rapidly rising INR 2->7->21, also likely reflected DIC, though
fibrinogen 60. She was treated empirically with antibiotics as
above.
.
# Fall c/b hip pain: initial hip films were unremarkable for
fracture.
.
# Hep C cirrhosis: LFTs within her baseline range. her altered
mental status was felt more likely related to acidosis as
opposed to hepatic encephalopathy
.
# CKD - initially near her baseline Cr of 2.6. she rapidly
became anuric, likely [**2-27**] hypotension, and was started on CVVH
as above, primarily given concern for toxic ingestion.
.
# Diabetes mellitus type 2 uncontrolled: no clear evidence of
DKA. she was followed with q4 HISS.
.
# FEN: she remained NPO.
# Prophylaxis: pneumoboots
# Access: PIV, and R IJ TLC.
# Code: DNR/DNI after discussion with daughter [**Name (NI) **].
# Communication: Patient, daughter is HCP [**Location (un) 1439**] h
[**Telephone/Fax (1) 100367**], c [**Telephone/Fax (1) 100370**])
.
Medications on Admission:
Medications: (per d/c summary on [**2175-6-23**])
Cholecalciferol 800 unit daily
Calcium Carbonate 500 mg TID
Pantoprazole 40 mg Q12H
Humalog 6 units Subcutaneous qac.
Verapamil 180 mg daily
Albuterol Sulfate 1-2 Puffs Q6H prn
Amylase-Lipase-Protease 20,000-4,500- 25,000 unit TID W/MEALS
Sertraline 100 mg daily
Discharge Medications:
pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired.
Discharge Condition:
pt expired.
Discharge Instructions:
pt expired.
Followup Instructions:
pt expired.
|
[
"995.92",
"286.6",
"518.81",
"578.9",
"276.2",
"250.02",
"571.2",
"284.1",
"412",
"403.90",
"276.8",
"038.9",
"070.54",
"585.9",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
13269, 13278
|
8233, 12870
|
288, 294
|
13333, 13346
|
3649, 6664
|
13406, 13420
|
2519, 2688
|
13233, 13246
|
13299, 13312
|
12896, 13210
|
13370, 13383
|
2703, 3630
|
6708, 8210
|
1332, 1704
|
229, 250
|
322, 1313
|
1726, 2191
|
2207, 2503
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,544
| 183,049
|
5414
|
Discharge summary
|
report
|
Admission Date: [**2141-12-12**] Discharge Date: [**2141-12-21**]
Date of Birth: [**2078-9-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
One day hematuria
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
This is a 63 year old male with a history of Down's syndrome,
seizure disorder, hypothyroidism who presents to the ED with
gross hematuria for one day. Pt was in his USOH when his group
home staff found him to have bright red blood in his urine. Pt
has had nocturnal enuresis over the last 3-4 months and was seen
by Dr. [**Last Name (STitle) 770**] on [**2141-10-18**] for enuresis and was found at that
time to have a large residual for which behavioral modifications
were implemented. He also has a hx of holding his urine for
several years. It is unknown if this enuresis is due to
neurogenic bladder or if pt does not choose to release his
urine. He denies pain upon urination, but his sister reports
that he has intermittently reported sharp abdominal pain of
unknown origin 4x in the past 12 hours. He has no prior hx of
hematuria. No recent weight loss, fever, chills, diarrhea,
vomiting, nausea, abdominal pain. No changes in his urinary
frequency, hesitancy, dribbling, or dysuria. His sister does
report that the patient appears to have increased lethargy and
sleepiness today. Denies trauma, recent change in medication,
travel, or sick contacts.
Past Medical History:
1. Down's syndrome. Baseline oriented x 2 (person and place), is
wheelchair bound (s/p hip surgery), and is able to talk in
simple sentences.
2. Seizure disorder dx when pt was a teenager: Followed by Dr.
[**Last Name (STitle) 2442**]. Last seizure was in 06/[**2140**]. Seizure free > 1 year,
seizures are usually with partial right face twitching followed
by generalized tonic clonic convulsions. On chornic treatment
with keppra and dilantin.
3. Hypothyrodism
4. Bilateral Hip Surgery in [**2113**]. Pt had a L hip infection in
[**2116**] that was treated w/ L hip removal
5. MRSA infection of buttock in [**10/2141**] improved with Bactrim
6. Bilateral knee arthritis
7. Bell's Palsy [**10/2140**], improved without treatment in 3 days
Social History:
Lives in a group home at [**First Name4 (NamePattern1) 7306**] [**Last Name (NamePattern1) **] at [**Last Name (un) 21966**]in
[**Location (un) 686**]. Pt enjoys attending workshops from 6AM until 5PM
Monday through Friday at [**State 350**] Association for the
Blind. Pt has no hx of alcohol, smoking, or illicit drug use.
He denies depression, enjoys talking to people, and cannot
tolerate loud noises.
Family History:
Mother: died of pancreatic CA
Father: died of unknown kidney disease, hx of chronic kidney
stones
Sister (65yrs): Down's Syndrome and [**Name (NI) 2481**] Disease
Sister (68 yrs): multi-nodular goiter, thyrodectomy without dx
CA
Brother (72yrs): thyroid CA at age 22, currently healthy
Brother (59 yrs): Healthy
Sisters (75 and 66yrs): Healthy
Physical Exam:
General: Pleasantly smiling male resting comfortably, younger
appearing than stated age
Vital Signs: Tmax 101.7 Tc:101.7 86/58 HR 82 RR 18 95% RA
HEENT: NC/AT, large tongue with multiple elevated papillae, EOMI
Neck: Supple, no LAD, no JVP
Respiratory: CTA b/l
Cardiovascular: RRR, normal s1 s2, [**12-27**] holosystolic murmur at
base
Abdomen: BSx4, soft, non-tender, non-distended, no masses or
hepatomegaly
Extremities: No edema, left hip shortened and externally
rotated, 2+ DP/PT pulses, +Simian crease bilaterally
Neurological: CNII-XII grossly in tact, alert, oriented x 2
(person, place), grossly non-focal
Pertinent Results:
[**2141-12-14**] 04:10PM BLOOD Hct-33.5*
[**2141-12-14**] 07:05AM BLOOD WBC-11.8* RBC-3.72* Hgb-12.8* Hct-35.5*
MCV-95 MCH-34.3* MCHC-36.0* RDW-13.3 Plt Ct-100*
[**2141-12-13**] 07:20AM BLOOD WBC-15.3* RBC-4.33* Hgb-14.3 Hct-41.1
MCV-95 MCH-33.0* MCHC-34.7 RDW-13.5 Plt Ct-127*
[**2141-12-12**] 11:25AM BLOOD WBC-13.7*# RBC-4.71 Hgb-15.7 Hct-45.2
MCV-96 MCH-33.4* MCHC-34.8 RDW-13.5 Plt Ct-143*
[**2141-12-12**] 11:25AM BLOOD Neuts-91.8* Bands-0 Lymphs-5.1* Monos-2.9
Eos-0 Baso-0.1
[**2141-12-12**] 11:25AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2141-12-14**] 07:05AM BLOOD Plt Ct-100*
[**2141-12-13**] 07:20AM BLOOD Plt Ct-127*
[**2141-12-12**] 11:25AM BLOOD Plt Ct-143*
[**2141-12-12**] 11:25AM BLOOD PT-14.2* PTT-29.5 INR(PT)-1.2*
[**2141-12-14**] 07:05AM BLOOD Glucose-129* UreaN-25* Creat-1.9* Na-139
K-4.0 Cl-104 HCO3-25 AnGap-14
[**2141-12-13**] 07:20AM BLOOD Glucose-114* UreaN-28* Creat-2.0* Na-137
K-4.3 Cl-101 HCO3-25 AnGap-15
[**2141-12-12**] 11:25AM BLOOD Glucose-168* UreaN-23* Creat-1.8* Na-139
K-4.5 Cl-102 HCO3-28 AnGap-14
[**2141-12-12**] 11:25AM BLOOD estGFR-Using this
[**2141-12-13**] 07:20AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.8
[**2141-12-13**] 07:20AM BLOOD Phenyto-16.2
[**2141-12-12**] 11:25AM BLOOD RedHold-HOLD
[**2141-12-12**] 11:25AM BLOOD GreenHd-HOLD
[**2141-12-19**] 05:50AM BLOOD Phenyto-5.2*
[**2141-12-18**] 05:50AM BLOOD TSH-0.27
[**2141-12-18**] 05:50AM BLOOD Free T4-0.81*
.
Renal US [**12-12**]: IMPRESSION: Extensive clot filling the bladder
consistent with clot given history. There is bilateral
hydronephrosis, right worse than left. There has been interval
significant decrease in the size and cortical thickness of the
right kidney.
.
Renal US [**12-14**]: IMPRESSION:
1. Interval resolution of right hydronephrosis with persistent
mild left hydronephrosis.
2. Clotted blood within the urinary bladder, perhaps slightly
less than on prior.
.
CXR [**12-14**]: Widespread mild-to-moderately severe interstitial
pulmonary abnormality in the perihilar and right lower lung
could be due to pulmonary edema since the azygos vein is
distended indicating elevated central venous pressure.
Nevertheless heart is normal size. Pleural effusion, if any, is
minimal. More discrete areas of opacification at both lung bases
could represent pneumonia or atelectasis or, in the right
clinical setting, pulmonary infarction. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and I
discussed these findings at the time of dictation.
.
CXR [**12-16**]: IMPRESSION:
1. Stable evidence of pulmonary edema, with bilateral effusions.
.
CXR [**12-19**]: IMPRESSION: Tip of new right-sided PICC line likely
terminating in the mid right atrium. Discussed with IV therapy.
.
ECHO [**12-15**]: IMPRESSION: Suboptimal image quality. Hyperdynamic
left ventricular systolic function with valvular [**Male First Name (un) **] and resting
LVOT gradient. Mild mitral regurgitation. No definite vegetation
seen (does not exclude).
Brief Hospital Course:
HEMATURIA: Mr. [**Known lastname 8389**] was admitted for hematuria and found to
have fevers, leukocytosis, and pyuria. Renal ultrasound showed
clot filling the bladder consistent with bilateral
hydronephrosis R>L and decrease in the size and cortical
thickness of the right kidney. He was placed on empiric
Ceftiaxone for the infection and monitored by urine lytes and
urine analysis. Urology was consulted and recommended the
patient be placed on continuous bladder irrigation (CBI) with
three way [**Known lastname **] but the hematuria did not resolve on the third
hospital day. Patient's in's and outs were monitored along with
renal function tests. He had a urine culture return positive
for MRSA. He was started on vancomycin, and this is to be
continued until [**2141-12-28**]. He will need a vancomycin trough
measured on [**2141-12-23**], and the level should be between 15 and 20.
The MD's at his rehab will need to adjust his dose to maintain
this level.
His urine cleared, and prior to discharge he had his [**Known lastname **]
catheter removed, and he voided clear urine. He had no fever
issues in the subsequent days of the admission.
ARF: He was in acute renal failure on admission, with a
creatinine of 1.8 to 2.0. He was hydrated, and his cystitis was
treated. With treatment, his creatinine returned to his (?new)
baseline of 1.3 to 1.4. He had good urine output. He had a
elevated [**Last Name (LF) 21967**], [**First Name3 (LF) **] it was felt that the UTI / hydronephrosis was
responsible.
His hematuria resolved as mentioned above. URology was
following, and he has an appointment with Dr. [**Last Name (STitle) 770**] in [**Month (only) 958**]
[**2141**] for follow up.
HYPOTENSION He developed hypotension on the medical floor.
Given concern for sepsis, he was transferred to the MICU and
given aggressive fluids. Of note, upon transfer and placement
of an arterial line, his BP was read as normal (consistently
30mm Hg higher than the non-invasive measurements). He was
returned to the medical floor after that.
DVT: He developed some brief hypoxia, corrected with oxygen, and
this was felt to be fluid overload from all of the fluids. But,
he had a d.dimer checked for evidence of a DVT, and it was
positive. Given his elevated creatinine, a CTA was deferred,
and LENI was done. He was found to have a LE DVT, and was
started on heparin. Discussion with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], as
well as his neurologist, Dr. [**Last Name (STitle) 2442**], ensued, and it was
decided to start him on warfarin for a 6 month course. He was
transitioned to lovenox prior to dishcarge, and plan to bridge
to warfarin INR [**12-24**]. Of note, warfarin and phenytoin can
interact and lower BOTH levels, so they need to monitored
closely, especially with any dose adjustments.
SEIZURE D/O: He has a seizure disorder, and there was a question
of a possible seizure in the setting of a vagal episode while
getting his PICC line. It was brief. His phenytoin level was
low at 5.8 - and his dose was changed to 100mg qam and 200mg
qpm. It needs to be rechecked after 4 days ([**2141-12-23**]), and if
still low, the new dose should be 200mg [**Hospital1 **]. The level should
be checked every 4 days until a good level is acheived.
ANEMIA (ACUTE BLOOD LOSS and RENAL): He was noted to be anemic,
which was felt to likely be due to his acute illness and
possible renal issues. He was stable without any transfusions.
HYPOTHYROID: He has hypothyroidism, and had a TSH checked twice.
At first it was low, and then it was low-normal. The second
time it was checked his free T4 was also checked, and it was
low. This was likley sick euthyroid, and he should have this
level rechecked in 4 weeks as an outpatient.
HYPERGLYCEMIA: He was also hyperglycemic, which appears to be a
new diagnosis. Starting an oral [**Doctor Last Name 360**] was deffered as an
inpatient givne his otehr illnesses. He will continue on an
insulin sliding scale and will need to decide about oral agents
as an outpatient.
He was DNR/DNI on admission, but this was changed to FULL CODE
during his ICU stay.
He has been eating a diabetic diet, and tolerating this without
problems.
His sister / guardian, was very involved in his plan of care and
agreeable to his discharge plan.
Medications on Admission:
DILANTIN 100 [**Hospital1 **], alternated with 100 qam, 200 qpm
FLONASE 1 spray daily
FOSAMAX 70 mg weekly
KEPPRA 1000 [**Hospital1 **] (used for 8 yrs)
LEVOXYL 125MCG daily
LOTRIMIN 1 % daily
MULTIVITAMIN daily
SIMVASTATIN 10 mg qhs
DEBROX EAR DROPS
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO QAM (once a day (in the morning)).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection
Subcutaneous ASDIR (AS DIRECTED).
11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO QPM (once a day (in the evening)).
12. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)): Take 5mg for the next two days. Check INR
after that and adjust dose for INR [**12-24**]. Then after 3 days of
this INR the lovenox can be stopped.
13. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours): 60 mg.
14. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
once a day for 8 days.
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8221**] - [**Location (un) 583**]
Discharge Diagnosis:
PRIMARY:
Hematuria
MRSA cystitis
Deep venous thrombosis
Seizure disorder
Acute renal failure
Hyperglycemia
Hypothyroidism
Anemia, stable
Discharge Condition:
Stable, tolerating PO diet, afebrile, clear urine
Discharge Instructions:
You were admitted with bloody urine, and found to have a bladder
infection. Urology was consulted, and recommended keeping the
[**Known lastname **] catheter in place, and you should follow up with them in
one week.
You also were found to have a blood clot in your legs. You were
treated with a blood thinner, heparin, and started on one by
mouth, called coumadin. You will need to be given lovenox
injections twice daily until your INR is between 2 and 3 for
three days.
You will need to have your INR measured daily until then. When
the lovenox is completed, you will have your INR adjusted by the
[**Company 191**] anticoagulation nurses through Dr.[**Name (NI) 20819**] office once
you leave rehab. You will be notified of an appointment. But,
you can have your INR levels drawn and faxed to Dr.[**Name (NI) 20819**]
office attention [**Company 191**] anticoagulation nurses after discharge from
rehab.
Your bladder infection was caused by a resistant organism, MRSA,
and you will need to continue IV vancomycin for 7 more days.
You have a PICC line for that. You will need to have your
vancomycin level checked on [**2141-12-23**], as a trough level (just
BEFORE your morning dose). This level should be between 15 and
20 mg /dl. This should be followed by the MD's at the rehab.
The dose should be adjusted to maintain this level.
You possibly had a seizure while here. Your dilantin level was
low, and your dose was adjusted. You need to have your
phenytoin level checked on [**2141-12-23**]. If the level is low, then
you should be on 200mg [**Hospital1 **]. If it is 9 or greater, then keep it
at 100mg qam and 200mg qpm.
If you have any worsening pain, difficulty breathing, or
profound bleeding, please seek immediate medical attention.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2142-1-22**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-3-30**] 11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"V16.0",
"591",
"790.29",
"788.30",
"285.9",
"244.9",
"345.90",
"758.0",
"584.9",
"V09.0",
"V16.8",
"595.9",
"038.9",
"041.11",
"458.9",
"715.36",
"995.91",
"453.42",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
12962, 13035
|
6796, 11136
|
335, 357
|
13216, 13268
|
3756, 6773
|
15081, 15516
|
2761, 3106
|
11437, 12939
|
13056, 13195
|
11162, 11414
|
13292, 15058
|
3121, 3737
|
278, 297
|
385, 1555
|
1577, 2321
|
2337, 2745
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,846
| 180,399
|
6073
|
Discharge summary
|
report
|
Admission Date: [**2136-2-6**] Discharge Date: [**2136-2-27**]
Date of Birth: [**2074-2-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Hypotension 2/2 blood loss from large leg wound
Major Surgical or Invasive Procedure:
dialysis and CVVH
tunneled catheter placement
temporary HD line removal
History of Present Illness:
62F h/o ESRD, on dialysis, presented from [**Hospital3 2558**] [**Hospital1 1501**]
hypotensive to 56/41 and bleeding from a R lateral thigh wound.
Pt reports a [**Month (only) **] operation during which IVC filter was
removed. [**First Name8 (NamePattern2) **] [**Hospital1 1474**] reports, pt had infected IVC filter
removed but no mention of a lateral thigh surgery. On the
discharge summary, it does state to continue "duoderm to her
sacral and right thigh decubiti." She had been initiated on
coumadin therapy for DVT (unclear when this was diagnosed). The
d/c summary did comment that she was having guaiac + stools
prior to starting coumadin. She was being seen by visiting
nurses for the dressing changes to the decubiti. Pt reports
that the wound had been bleeding over the past 5 days but
started bleeding a lot today. Patient's initial hct here is 20
and INR 7.7.
In the ED, T 96.2, BP 56/41, HR 71, RR 28, SaO2 93% on RA.
Pressure dressing applied. Vascular surgery and transplant
surgery saw her in the ED. Pt received 4units PRBC and 1unit
FFP, as well as vitK 10mg SC x1. Pt also received vanco x 1,
ceftazidime x1 and levofloxacin x1. Pt also received calcium
gluconate 1g IV x1.
MICU course was notable for intermittent asymptomatic
hypotension. She has received 7 pRBC and 1 unit of FFP for the
hospital course to date. The last of which was on [**2136-2-8**]. As
her admission weight was markedly elevated above her estimated
dry weight, she aggresively ultra-filtrated with CVVH for 3
days. A set of blood cultures from arrival to the ED were [**2-18**]
positive (result available day 2 days after admission) for
viridans strept and she has remained on vanc/aztreonam. Renal
team recommeded obtaining doing venogram to r/o central stenosis
as the patient had a recent history of low flows via her HD
catheters. Wound care team made recommendations regarding her
numerous pressure ulcers. Midodrine was added to help with her
baseline arterial dilation from her ESRD. Her LOS fluid balance
in the MICU was -15.8L.
Upon arrival to the medical floor, she is breathing comfortably
and has only some mild itching around the tape over the leg
wound.
ROS: no chest pain, no SOB, no abd pain, no diarrhea. still
constipated.
Past Medical History:
# ESRD on HD T, Th, Sat
# DM
# CHF
# Hypercholesterolemia
# BLE DVTs, on warfarin
# OSA
# OA
# Multiple line infections
--[**2135-12-17**]: Providencia, finished 4wk course of aztreonam
--[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin
and gentamicin
# h/o C. Diff
# GERD
# Depression
# Morbid obesity
Past surgical history:
# L forearm radial-basilic AV graft ([**12-21**])
# Multiple lines in L upper arm with AV graft
# 1/07 L femoral PermaCath placed
# L upper arm thrombectomy, revision, then removal of LUE AV
graft ([**3-23**])
# [**12-23**] PermaCath and IVC filter removed
Social History:
Has lived at [**Hospital3 2558**], [**Location (un) **] MA, since
[**2135-12-17**]
Family History:
NC
Physical Exam:
VS: Temp: 97.1, BP: 83/32, HR: 70, RR: 15-17, O2sat 100 on 2L NC
GEN: pleasant, morbidly obese, comfortable, NAD, conversing,
alert and oriented.
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no teeth
NECK: very obese neck and exam difficult but no obvious
supraclavicular or cervical lymphadenopathy, jvd
RESP: CTA b/l with good air movement throughout
CV: distant RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no hepatosplenomegaly, large hard
subcutaneous mass on RLQ
EXT: no c/c/e, warm, good pulses. ?Fungal infection at bilateral
soles
SKIN: patient with right ?surgical wound, pressure ulcer on
folds of abdomen.
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout upper
body, 4/5 strength in LE. No sensory deficits to light touch
appreciated.
RECTAL: stool guiaic positive here
Pertinent Results:
[**2136-2-6**] 09:35PM
BLOOD WBC-9.4 RBC-1.87*# Hgb-5.9*# Hct-19.9*# MCV-106* MCH-31.7
MCHC-29.8* RDW-18.5* Plt Ct-477*
[**2136-2-6**] 09:35PM BLOOD Neuts-75* Bands-1 Lymphs-16* Monos-3
Eos-3 Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-1*
[**2136-2-6**] 09:35PM BLOOD Hypochr-OCCASIONAL Anisocy-2+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-1+ Spheroc-OCCASIONAL
Ovalocy-OCCASIONAL Burr-1+ Acantho-1+
[**2136-2-6**] 09:35PM BLOOD Ret Man-2.3*
[**2136-2-6**] 09:35PM BLOOD PT-64.0* PTT-47.5* INR(PT)-7.7*
[**2136-2-6**] 09:35PM BLOOD Glucose-122* UreaN-19 Creat-3.8*# Na-137
K-4.0 Cl-107 HCO3-16* AnGap-18
[**2136-2-6**] 09:35PM BLOOD ALT-19 AST-32 LD(LDH)-223 CK(CPK)-29
AlkPhos-173* TotBili-0.2
[**2136-2-6**] 09:35PM BLOOD Albumin-1.6* Calcium-6.4* Phos-5.4*
Mg-2.4 Iron-58
[**2136-2-6**] 09:35PM BLOOD calTIBC-72* VitB12-519 Folate-9.6
Ferritn-995* TRF-55*
[**2136-2-6**] 09:45PM BLOOD Lactate-4.5*
[**2136-2-7**] 02:43AM BLOOD Lactate-1.8
[**2136-2-11**] 10:38PM BLOOD WBC-12.2* RBC-3.21* Hgb-10.1* Hct-31.9*
MCV-100* MCH-31.6 MCHC-31.7 RDW-20.2* Plt Ct-582*
[**2136-2-11**] 10:38PM BLOOD Glucose-116* UreaN-18 Creat-2.5* Na-135
K-4.9 Cl-102 HCO3-23 AnGap-15
[**2136-2-11**] 03:48AM BLOOD ALT-19 AST-20 LD(LDH)-210 AlkPhos-240*
TotBili-0.3
.
EKG: Rate of 70, NSR, Nl axis, Nl intervals, no significant ST
changes. unchanged from prior.
.
Imaging:
.
[**2136-2-6**] CXR: Costophrenic angle excluded from the radiograph.
Mild left basilar opacity, likely atelectasis. No evidence for
CHF or airspace consolidation.
.
[**2136-2-7**] bilateral lower extremity veins: No evidence of deep
vein thrombosis in either leg.
[**2136-2-14**] venogram / svc gram: Wideliy patent central veins
including the subclavain veins and brachiocephalic veins
bilaterally. Small collateral veins were noted at the level of
the proximal right subclavain vein.
[**2-14**] tunneled line placement: Successful exchange of indwelling
temporary hemodialysis catheter with a 15.5 French tunneled
hemodialysis catheter with 23 cm tip-to-cuff length and tip
positioned at the right atrium. The catheter is ready for use.
Patent central veins with small collateral veins at the level of
the proximal right subclavain vein.
[**2136-2-15**]: No valvular vegetations seen. Moderate pulmonary
hypertension is suggested. Compared to the prior study dated
[**2135-5-9**], no change.
[**2136-2-16**]: No mass/thrombus is seen in the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the aortic arch and
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are structurally normal. No
mass or vegetation is seen on the mitral valve. Mild to moderate
([**1-18**]+) mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal biventricular systolic function. Mild to moderate mitral
regurgitation.
[**2136-2-16**] CT ABD/PELVIS W/ CONTRAST:
ABDOMEN: The lung bases are clear, with minimal dependent
atelectasis noted. Mitral annular calcifications are present.
The liver, spleen, pancreas, and adrenal glands are within
normal limits. Medullary pyramid density likely represents a
small amount of excreted contrast as this has not been present
on prior studies. The gallbladder appears somewhat distended.
However, no stones are seen and there is no evidence of biliary
ductal dilatation. The size is similar to the CT of [**2135-5-6**].
There is no free fluid, bowel dilatation, or pathologic lymph
node enlargement within the abdomen or pelvis. Vascular
calcifications are moderate.
PELVIS: An enlarged uterus with multiple fibroids persists.
The rectum and sigmoid appear normal. The bladder is collapsed.
There is diffuse muscle atrophy.
OSSEOUS STRUCTURES: There are no suspicious lytic or blastic
lesions. Facet joint degenerative changes are moderate.
IMPRESSIONS:
1. No CT evidence of acute process within the abdomen or
pelvis. Although the gallbladder is slightly distended, it is
similar in size when compared to the study of [**2135-5-6**].
DISCHARGE LABS:
INR 2.0
CHEM 10: NA 130 K 4.2 CL 93 BICARB 25 BUN 32 CR 5.1 glucose
92 CA 9.9 PHOS 5.3 MG 2.2
CBC: HCT 32.1 WBC 9.5 PLT 529
CULTURE DATA:
BLOOD CULTURE [**2-6**]:
Blood Culture, Routine (Preliminary):
VIRIDANS STREPTOCOCCI. OF THREE COLONIAL MORPHOLOGIES.
ISOLATED FROM ONE SET ONLY.
Sensitivity testing per DR.[**First Name (STitle) 815**],[**First Name3 (LF) **] PAGER [**Numeric Identifier 23828**]
[**2136-2-15**].
BEING ISOLATED FOR SENSITIVITIES.
Anaerobic Bottle Gram Stain (Final [**2136-2-7**]):
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name 10280**] @ 3:15PM [**2136-2-7**].
GRAM POSITIVE COCCI IN CHAINS.
BLOOD CULTURES: NEGATIVE ON [**1-4**], PENDING UPON DISCHARGE
ON [**1-31**], [**2-13**] (NO GROWTH TO DATE)
RECTAL SWAB + FOR VRE INFERRING COLONIZATION
Brief Hospital Course:
Hypotension: patient initially presented as hypotensive and was
transferred to the ICU. She was very anemic due to her blood
loss to a hct of 19.9 on [**2-6**] (in [**2135-7-17**] her hct was
41.4). She was transfused 7 units and volume resuscitated. It
was thought her hypotension was due directly to blood loss from
right leg wounds associated with a [**Doctor Last Name **] lift injury, upon
presentation her INR was 7.7 (on coumadin for DVT). She was
hemodynamically stable although very volume overloaded and
transferred to the floor.
ESRD: as above, transferred to floor very volume overloaded and
she was ultrafiltrated aggressively and dialyzed intermittently.
She should resume a Saturday, Tuesday, Thursday schedule for
dialysis. Her dialysis line was removed as it was pulled out
about 10cm and a new tunneled L IJ was placed. This was done
under interventional radiology and at this time she underwent a
venogram and svc gram to evaluate for clot or stenosis and she
had no venous clots or SVC stenosis. On [**2-7**] she had lower
extremity dopplers without any DVT seen.
SHE WILL HAVE DIALYSIS TUES / THURS / SATURDAY AT THE [**Last Name (un) **] IN
[**Location (un) **].
DVT: she was on coumadin for DVT in the past, her INR was
supratherapeutic on admission, she was on 6mg po daily. This
was held in the setting of her bleed. As above no DVT on
current venogram / ultrasounds, but given high risk (recent DVT,
immobilization and ESRD on dialysis) the patient should be
anticoagulated, she was started on coumadin on [**2136-2-15**] with 5mg
daily, her INR should be checked q2-3 days in her skilled
nursing facility / rehab and her coumadin should be titrated to
a goal INR of [**2-19**].
BACTEREMIA: the patient was found to have three different
morphologies of strep viridans on a blood culture drawn for
hypotension (even though she had a obvious other cause of blood
loss). Repeats were negative, no new murmur or endocarditis.
No localizing source of infection, no underlying valvular
disease. TTE and TEE echos were performed which effectively
ruled out endocarditis and a CT of her abdomen and pelvis with
contrast ruled out any infection / abscess in these regions.
She should continue a 2 week course of vancomycin dosed with
hemodialysis as day # 1 being [**2136-2-8**]. She should continue
until [**2136-2-22**] for "simple" bacteremia. Per micro lab this is
likely a contaminant but given the patients high risk for
microbial infection given diabetes, vascular access and skin
breakdown issues our infectious disease specialists felt it
prudent to treat for a 2 week course with vancomycin.
Sensitivies on the strep viridans were pending upon discharge,
although it would be very rare for this organism to be
vancomycin resistant.
VOMITING: patient is without dentures and occasionally vomits
after eating, she does feel like food is "getting stuck" but
does feel much better with a mechanical soft diet. She should
be set up for dentures while at her nursing home through a
dentist. Until that time she should remain on a mechanical soft
diet. If her dysphagia / vomiting persists after she has teeth
and is on a normal diet she should likely have a barium swallow
and motility study to evaluate this process and possibly and
upper endoscopy.
Right Leg wounds: patient was seen by wound care nurses as an
inpatient and wound care recommendations were made. Please
continue local wound care, no active infection. Please continue
medications on medication list for wound care.
DM - NPH 20units QAM + plus insulin sliding scale (beginning
with 2 units of humalog for a blood glucose of 150-200). Blood
glucose was very well controlled on this regimen.
Sleep apnea: patient is intolerant of CPAP mask and frequently
desats overnight if not wearing supplement O2. She did well on
2 liters nasal cannula overnight.
Communication: HCP is oldest daughter [**Name (NI) **] [**Name (NI) 23081**], currently in
[**State 2690**] without phone number. Other daughters [**Name (NI) 23829**],
[**Telephone/Fax (1) 23830**], and [**Doctor First Name **], [**Telephone/Fax (1) 23831**].
Medications on Admission:
Medications confirmed with [**Hospital3 2558**]:
Warfarin 6mg QHS
Metoprolol 25mg [**Hospital1 **]
MVI
Tylenol
Paroxetine (Paxil) 10mg daily
Oxazepam (Serax) 10mg QHS PRN insomnia
Lactulose PRN constipation
NPH 20units QAM, RISS
Senna 8.6mg QHS
Colace 100mg PO BID
Calcium carbonate 500mg QID PRN indigestion
============================================
Additional medications from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23832**] [**2136-2-6**] OMR note:
Dulcolax 10mg daily
Renagel 1600mg TID
Furosemide 40mg [**Hospital1 **]
Nephrocaps
Ferrous sulfate 325mg daily
Metoprolol 25mg qTuTHSa with dialysis
Discharge Medications:
1. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed Subcutaneous once a day: 20 units of NPH qam.
5. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection four times a day: per sliding scale.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical DAILY (Daily).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
12. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
13. Diphenhydramine HCl 25 mg Capsule Sig: [**1-18**] Capsules PO Q6H
(every 6 hours) as needed for itching.
14. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical DAILY (Daily).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): continue until INR is therapeutic
(INR [**2-19**]).
16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16) for 3 days: PLEASE MONITOR INR EVERY 2 OR 3 DAYS
AND ADJUST COUMADIN DOSE ACCORDINGLY.
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: as
directed Intravenous HD PROTOCOL (HD Protochol): 1 gram per HD
protocol, total 2 week course, last day is [**2136-2-22**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
HEMORRHAGIC SHOCK
ESRD
STREP VIRIDANS BACTEREMIA
Discharge Condition:
stable
Discharge Instructions:
You were admitted because your blood pressure was low because
you were bleeding from your leg wounds. This was complicated by
the fact that your blood was too thin while you were on
coumadin.
Your INR (coumadin level) needs to be monitored very closely
after you leave and should be in the range of [**2-19**]. You should
continue your dialysis as an outpatient and your local wound
care. Our nurses will send the wound care recommendations to
your nursing home or rehab for the nurses there to help with
your daily wound care.
Please call your doctor or return to the emergency room if you
have chest pain, worsening pain in your leg, bleeding, or any
other symptoms that worry you.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks
of your discharge from the hospital.
YOU WILL HAVE DIALYSIS AT 11A.M. ON SATURDAY [**2-18**] AT THE [**Last Name (un) **]
KIDNEY CENTER AND THE FOLLOWING TUES / THURS / SATURDAY AT THE
[**Last Name (un) **] IN [**Location (un) **]. YOU WILL CONTINUE TO RECEIVE VANCOMYCIN
DOSED AT YOUR DIALYSIS SESSIONS UNTIL [**2-22**] FOR A TOTAL 2
WEEK COURSE FOR 'SIMPLE BACTEREMIA.'
Please follow up with the first available appointment for
plastic surgery at the [**Hospital1 18**]. Call the following number to set
up this appointment, the nursing home can help you with this.
([**Telephone/Fax (1) 2868**]
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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"707.03",
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"V58.61",
"790.7",
"V12.51",
"250.00",
"272.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.28",
"38.95",
"88.67",
"88.72",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
16070, 16140
|
9533, 13663
|
317, 391
|
16252, 16261
|
4261, 8631
|
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|
3411, 3415
|
14340, 16047
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16161, 16161
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|
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8647, 8828
|
3037, 3295
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3430, 4242
|
8872, 9510
|
230, 279
|
419, 2670
|
16180, 16231
|
2692, 3014
|
3311, 3395
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 108,977
|
42967
|
Discharge summary
|
report
|
Admission Date: [**2185-1-2**] Discharge Date: [**2185-1-14**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
hypotension, bacteremia
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
Mr. [**Known firstname 6164**] is a 36 yo male with h/o DM, HTN, gastroparesis who
has been hospitalized numerous times over the past 2 years for
N/V/D and hypertensive emergencies. He now presents with
typical symptoms of N/V/D and fever. He states he was feeling
well up until midnight of last night. At that time he developed
fever, nausea, vomting, and diarrhea. States yesterday he was
dialyzed without problems. Tolerated PO's yesterday and then
developed these symptoms last night. Pt also noted sore throat,
occasional cough. He denies any SOB, DOE, PND, orthopnea.
Currently he denies any abdominal pain, nausea has improved.
In the ED he was noted to be febrile to 103, tachycardic,
hypertensive, and had a lactate of 4.8. Therefore code sepsis
was initiated. He had a central line placed. Given 8 liters of
IV fluids. However his BP was 230, so he was also given
nifedipine and dilaudid, which got his BP down to 180 then into
the 110-120 range. He was also empirically given levofloxacin,
flagyl, and vancomycin in the ED. Also recieved numerous doses
of dilaudid and anzemet.
Past Medical History:
1. DMI for over 10 years
2. Severe autonomic dysfunction with recurrent hospitalizations
for hypertensive emergencies, gastroparesis, and orthostatic
hypotension
3. ESRD on HD started [**2-18**]
4. History of esophageal erosion, MW tear
5. CAD withh 50% first diagonal stenosis, nl stress in [**11-15**]-CAD
6. Recent admit in late [**Month (only) **] for aspiration vs
community-acquired pneumonia
7. History of port-a-cath related coag neg staph infection, s/p
prolonged course IV vancomycin and replacement of port-a-cath in
[**12-17**]
Social History:
Living situation labile now as he and his girlfriend broke up.
He has five children, ranging in age from 11 to 15. Has limited
finances currently as child support is being taken from his SSDI
checks, so he is having difficulty getting his medications.
Social work is working with him to get him established in
pharmacy program. No tob, EtOH or illicits.
Family History:
His father recently died of ESRD and diabetes. His mother is in
her 50s and has hypertension. He has two sisters, one with
diabetes, and six brothers, one with diabetes.
Physical Exam:
T 103(in ED) BP 230/110->111/60 HR 104 RR 23 O2sats 96% RA CVP
12
Gen: Lethargic, young male, falling asleep throughout interview
HEENT: Dry MM, PERRL, EOMI, anicteric, clear OP no exudate
Neck: no JVD
Lungs: CTAB
Heart: Tahcy, no m/r/g
Abd: Soft, NT, ND + BS
Ext: Trace edema
Neuro: A&O times 3, grossly intact
Pertinent Results:
Labs/Imaging
CXR- Right subclavian port-a-cath, left subclavian central line,
no cardiopulmonary process
CT abd scattered/patchy opacities, increased septal lines, sm
b/l pleural effusions, liver/GB/spleen/kidneys/adrenals all
normal, diffuse stranding indicative of anasarca, sm ascites
[**2185-1-2**] 06:20AM BLOOD WBC-6.7 RBC-4.72 Hgb-12.2* Hct-37.6*
MCV-80* MCH-25.9* MCHC-32.5 RDW-19.7* Plt Ct-129*
[**2185-1-14**] 04:15AM BLOOD WBC-5.4 RBC-3.89* Hgb-9.6* Hct-30.8*
MCV-79* MCH-24.8* MCHC-31.3 RDW-19.7* Plt Ct-221
[**2185-1-2**] 06:20AM BLOOD Neuts-92.0* Bands-0 Lymphs-5.8*
Monos-0.7* Eos-1.2 Baso-0.3
[**2185-1-2**] 11:35AM BLOOD Neuts-68 Bands-31* Lymphs-1* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-4*
[**2185-1-3**] 04:30AM BLOOD Neuts-60 Bands-33* Lymphs-1* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2185-1-4**] 04:36AM BLOOD Neuts-78* Bands-10* Lymphs-3* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-2*
[**2185-1-5**] 04:06AM BLOOD Neuts-76* Bands-13* Lymphs-4* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2185-1-6**] 04:19AM BLOOD Neuts-94.0* Bands-0 Lymphs-4.7*
Monos-0.9* Eos-0.1 Baso-0.3
[**2185-1-7**] 06:00AM BLOOD Neuts-92* Bands-0 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* Plasma-2*
[**2185-1-8**] 05:25AM BLOOD Neuts-82* Bands-0 Lymphs-7* Monos-8 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1* Plasma-2*
[**2185-1-10**] 03:38AM BLOOD Neuts-76.9* Lymphs-14.5* Monos-8.5
Eos-0.1 Baso-0.1
[**2185-1-2**] 06:20AM BLOOD Plt Smr-LOW Plt Ct-129*
[**2185-1-3**] 04:30AM BLOOD PT-16.7* PTT-57.0* INR(PT)-1.9
[**2185-1-3**] 08:15AM BLOOD Plt Smr-LOW Plt Ct-92*
[**2185-1-3**] 01:50PM BLOOD Plt Ct-83*
[**2185-1-9**] 05:39AM BLOOD Plt Ct-126*
[**2185-1-10**] 03:38AM BLOOD Plt Ct-202#
[**2185-1-11**] 06:50AM BLOOD PT-13.2 PTT-32.5 INR(PT)-1.2
[**2185-1-14**] 04:15AM BLOOD Plt Ct-221
[**2185-1-3**] 08:15AM BLOOD Fibrino-262 D-Dimer->[**Numeric Identifier 961**]*
[**2185-1-3**] 08:15AM BLOOD FDP-320-640*
[**2185-1-3**] 01:50PM BLOOD Fibrino-320
[**2185-1-3**] 01:50PM BLOOD FDP-160-320*
[**2185-1-4**] 04:36AM BLOOD Fibrino-400
[**2185-1-5**] 04:06AM BLOOD Fibrino-514*
[**2185-1-2**] 06:20AM BLOOD Glucose-226* UreaN-19 Creat-5.8* Na-142
K-3.3 Cl-97 HCO3-26 AnGap-22*
[**2185-1-14**] 04:15AM BLOOD Glucose-134* UreaN-28* Creat-5.5*# Na-136
K-3.6 Cl-98 HCO3-28 AnGap-14
[**2185-1-2**] 06:20AM BLOOD ALT-5 AST-14 LD(LDH)-230 CK(CPK)-87
AlkPhos-104 Amylase-85 TotBili-0.4
[**2185-1-3**] 08:15AM BLOOD LD(LDH)-218 TotBili-0.5
[**2185-1-3**] 10:55AM BLOOD ALT-11 AST-30 AlkPhos-89 Amylase-43
TotBili-0.4
[**2185-1-6**] 04:19AM BLOOD ALT-33 AST-20 AlkPhos-191* TotBili-0.7
[**2185-1-7**] 06:00AM BLOOD ALT-16 AST-15 CK(CPK)-21* AlkPhos-145*
TotBili-0.4
[**2185-1-7**] 03:50PM BLOOD CK(CPK)-22*
[**2185-1-2**] 06:20AM BLOOD Lipase-126*
[**2185-1-3**] 10:55AM BLOOD Lipase-13
[**2185-1-6**] 04:19AM BLOOD GGT-56
[**2185-1-2**] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.25*
[**2185-1-7**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2185-1-7**] 03:50PM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2185-1-8**] 05:25AM BLOOD CK-MB-2 cTropnT-0.21*
[**2185-1-2**] 06:20AM BLOOD Cortsol-41.0*
[**2185-1-3**] 09:40AM BLOOD Cortsol-29.0*
[**2185-1-3**] 12:05PM BLOOD Cortsol-46.3*
[**2185-1-3**] 12:50PM BLOOD Cortsol-51.0*
[**2185-1-2**] 06:20AM BLOOD CRP-2.6
[**2185-1-3**] 04:30AM BLOOD Vanco-29.4*
[**2185-1-3**] 10:55AM BLOOD Vanco-26.2*
[**2185-1-3**] 10:45PM BLOOD Vanco-22.6*
[**2185-1-4**] 04:36AM BLOOD Vanco-24.0*
[**2185-1-9**] 05:39AM BLOOD Vanco-24.2*
[**2185-1-10**] 03:38AM BLOOD Vanco-21.1*
[**2185-1-11**] 08:00AM BLOOD Vanco-17.4*
[**2185-1-2**] 06:28AM BLOOD Lactate-4.8*
[**2185-1-2**] 07:38AM BLOOD Lactate-3.9*
[**2185-1-2**] 08:31AM BLOOD Lactate-7.0*
[**2185-1-2**] 05:52PM BLOOD Lactate-4.0*
[**2185-1-5**] 12:31PM BLOOD Lactate-1.1
[**2185-1-10**] 01:11PM BLOOD Lactate-1.9
Brief Hospital Course:
1. Fever: Pt with an elevated temp, tahcycardia, relative
hypotension and elevated lactate therefore put into code sepsis
protocol. Also came back with significant bandemia. Possible
sources for sepsis include line infection, cdiff, influenza.
CXR showed no evidence of pneumonia or opacities. CT abd/pelvis
showed no obvious infectious source. Blood cultures drawn on
admission grew out 4/4 bottles of pan-sensitive Klebsiella. He
was given aggressive IVF (13 L). He was initially started on
Meropenem/Vancomycin; this was changed to ceftriaxone once
sensitivities were performed, and vancomycin was discontinued.
He continued to defervesce, and WBC improved. He was initially
placed on vasopressors (Levophed, vasopressin), but these were
weaned off when possible. He failed a cortisol stimulation test
and was placed on hydrocortisone/fludricortisone. Source of
infection was thought to be his port-a-cath, and this was
removed. Surveillance blood cultures remained negative. Sputum
was negative for Influenza, and stool was negative for C.
difficile. Lactate levels were followed and improved with
treatment. After transfer to the floor, he devoloped hypoxia,
hypotension, perhaps [**3-17**] worsening pna. Antibiotics were
changed to Vanco/ceftazidime/flagyl to more broadly cover. The
flagyl was discontinued and the patient was going to be treated
with a 14 day course of vanco and ceftaz. Unfortanately, the
patient eloped from the hospital on day 12 of his antibiotic
course.
2. Hypercarbic respiratory failure: Pt was initially intubated
due to fatigue. He also had signs of pulmonary edema on CXR
(likely [**3-17**] IVF received as part of sepsis protocol/treatment).
Fluid status was managed with hemodialysis. After pressors were
weaned, he was transitioned to pressure support and ultimately
extubated on [**1-5**]. He was initially placed on NC O2, and this
was weaned as possible. After transfer to the floor, he
developed hypoxia with an increasing O2 requirement, CXR showing
worsening failure and ?PNA. He was transferred back to ICU; CTA
was negative for PE, TTE was unchanged. Hypoxia improved with
dialysis and was most likely secondary to volume overload with
superimposed worsening pna (VAP, nosocomial, ?aspiration from
extubation). HD was continued, and abx coverage was expanded to
vanco/ceftazidime/flagyl. He had also been hypotensive in the
setting of this hypoxia, started on levophed (which was
ultimately weaned); this was perhaps [**3-17**] pna/bacteremia,
restarting of antihypertensives. The patient improved and was
oxygenating well on RA on the medical floor.
3. N/V/D: Antiemetics were continued as necessary; he had tube
feeds/NGT while intubated. PO (diabetic, renal) diet was
commenced after extubation.
4. Anion gap: Pt has had this on past admissions. Likely
secondary to lactate and uremia. Gap corrected after fluids.
5. ESRD: Sevalemer was initially held secondary to low
phosphate but restarted with PO diet. Renal was consulted, and
hemodialysis was continued in-house. He was given
Epogen/ferrlecit as per renal. US of fistula was performed;
fistula was thought to be patent, with a likely benign fluid
collection. Sevalemer and ampogel were restarted prior to the
patient leaving the hospital.
6. DM: While in the unit, he was maintained on a humalog scale
and was transitioned to his outpatient regimen ([**Hospital1 **] lantus).
His sugars were running high in the 200-300's and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consult was called, but unfortunatly, the patient left prior to
being seen.
7. HTN: Patient with hypertensive urgency on admission. BP
went from the 230's to 120's after getting nifedipine and
dilaudid. Blood pressure was low upon initiation of MUST
protocol, and he was placed on pressors as above.
Antihypertensives were restarted as hemodynamic status improved.
8. Thrombocytopenia: Patient developed low platelets following
initial aggressive fluid resuscitation. This was initially
thought to be secondary to dilution. This persisted, however,
and other etiologies were considered. HIT was sent, and heparin
products were held (pt had been on SQ heparin). Medications
were reviewed (he had received Vancomycin and meropenem, both of
which could cause this). Cause was likely multifactorial,
secondary to sepsis, s/p pressors, medications effect.
9. Gastroparesis: Reglan was continued when pt was taking PO's.
10. Positive PPD: He has history of positive PPD. No lesions
on CXR, however since he is on transplant list being treated
with isoniazide and pyridoxine. These were held on admission to
prevent hepatotoxicity but were restarted later during the
admission.
11. Disposition: He was transitioned from the MICU to the floor
and continued to improve. Unfortunatly, the patient eloped the
hospital prior to being officially discharged. Security was
called but could not locate the patient. I am attempting to
contact the patient with a follow up appointment to have a new
port placed by general surgery.
Medications on Admission:
Clonidine 0.3 mg/24 hr qweek (sun), Aspirin 325 mg qday, Insulin
Glargine 6 units [**Hospital1 **], Nifedipine 60 mg qday, Pantoprazole 40 mg
qday, Isoniazid 300 mg qday, Pyridoxine 50 mg qday, Sevelamer
800 mg tid, Metoprolol 50 mg [**Hospital1 **], Reglan 10 mg qid, Clonidine
0.4 mg tid, Insulin Lispro per scale
Discharge Medications:
Patient eloped
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Sepsis
Discharge Condition:
patient eloped
Discharge Instructions:
Patient eloped
Followup Instructions:
Patient eloped; I will attempt to contact the patient to set up
an appointment with his PCP and with general surgery (for a
PORT)
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"337.1",
"486",
"287.4",
"403.01",
"414.01",
"038.49",
"995.92",
"996.62",
"585.6",
"250.61",
"536.3",
"276.2",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"39.95",
"96.71",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
12313, 12332
|
6838, 11907
|
339, 364
|
12383, 12399
|
2976, 6815
|
12462, 12686
|
2456, 2628
|
12274, 12290
|
12353, 12362
|
11933, 12251
|
12423, 12439
|
2643, 2957
|
275, 301
|
392, 1499
|
1521, 2066
|
2082, 2440
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,239
| 182,787
|
44392
|
Discharge summary
|
report
|
Admission Date: [**2145-9-21**] Discharge Date: [**2145-9-24**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
lightheadedness, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness: [**Age over 90 **] year old woman with a history of
CAD, hypertension, and schizoaffective disorder who presents
with lightheadedness, and altered mental status noted at her
living facility. On EMS arrival, the patient was noted to be
tachycardic in 170s with SBPs in 90-100s. She complained of
dyspnea and productive cough. No chest pain. No abdominal pain,
nausea, or vomiting. No frequency, urgency, dysuria. The patient
underwent EKG concerning initally for SVT and was given 2 doses
of adenosine without improvement. She was transported to the
[**Hospital1 18**] ED.
In the ED, initial vital signs 98.1 164 89/45 16 100%. EKG
showed Afib with RVR at 160s LAD Qtc 445. No STEMI. CXR showed
with Right lower lobe infiltrate. The patient received a dose of
vancomycin and cefepime for pneumonia. For her tachycardia, she
was bolused with IV fluids for likely profound dehydration. She
received 5 mg IV diltiazem, and was started on a drip at 2.5
mg/hr. She was also started on neosynephrine for hypotension.
During her ED stay, she began to complain of worsening dyspnea.
VS at time of transfer BP 114/50, O2 93% on 4L, RR 30.
.
On arrival to the MICU, the patient complained of mild chest
pressure. Telemetry with several short runs of V. tach,
bigeminy. Otherwise the patient denied pain.
.
Review of systems:
(+) endorses cough, chest pressure, palpitations
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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:
Schizoaffective disorder
CAD
Osteoporosis
B12 deficiency
HTN
Left proximal humeral fracture [**2144-2-27**] sp sling and PT
Social History:
lives at [**Hospital3 **] facility. Has 2 children who are her
proxys. 3 grandchildren. non smoker, no ETOH. used to work in a
clerical job.
Family History:
Brother had HTN and DM, MI in his 80s. Sister w/ HTN. No known
GI malignancies.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98 BP: 129/63 P: 76 R: 24 O2: 95% 40%face mask
General: Alert, oriented, no acute distress; interacting
appropriately
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregular S1, S2 with variable rate (intermittently
bradycardic) with intermittent loss of S1
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE EXAM
Vitals: T: 98.6 BP:140/90 P:83 R:16 O2:95 RA
General: Alert, oriented X3, no acute distress, thin
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP low.
CV: irregularly irregular. Variable intensity of S1, normal S2.
No murmurs, rubs, clicks, or [**Last Name (un) 549**]
LUNGS: decreased BS at bases, with rhonchi particularly at the R
base
ABD: NABS. Soft, NT, ND.
EXT: WWP, NO CCE.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Non-focal
Pertinent Results:
Labs on Admission:
[**2145-9-21**] 12:35PM TYPE-[**Last Name (un) **]
[**2145-9-21**] 12:35PM LACTATE-1.7
[**2145-9-21**] 12:27PM WBC-5.7 RBC-4.00* HGB-9.8* HCT-31.0* MCV-78*
MCH-24.6* MCHC-31.8 RDW-16.2*
[**2145-9-21**] 12:27PM PLT COUNT-215
[**2145-9-21**] 06:38AM GLUCOSE-117* UREA N-17 CREAT-0.6 SODIUM-137
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-23 ANION GAP-11
[**2145-9-21**] 06:38AM CK(CPK)-37
[**2145-9-21**] 06:38AM CK-MB-2 cTropnT-<0.01
[**2145-9-21**] 06:38AM CALCIUM-7.6* PHOSPHATE-2.3* IRON-23*
[**2145-9-21**] 06:38AM calTIBC-312 FERRITIN-14 TRF-240
[**2145-9-21**] 06:38AM TSH-2.4
[**2145-9-21**] 06:38AM WBC-8.7 RBC-3.51* HGB-8.6* HCT-27.4* MCV-78*
MCH-24.5* MCHC-31.4 RDW-16.2*
[**2145-9-21**] 06:38AM PLT COUNT-208
[**2145-9-21**] 03:27AM LACTATE-2.8*
[**2145-9-21**] 03:00AM GLUCOSE-146* UREA N-22* CREAT-0.7 SODIUM-136
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
[**2145-9-21**] 03:00AM estGFR-Using this
[**2145-9-21**] 03:00AM cTropnT-<0.01
[**2145-9-21**] 03:00AM proBNP-886*
[**2145-9-21**] 03:00AM CALCIUM-9.3 PHOSPHATE-2.5* MAGNESIUM-2.1
[**2145-9-21**] 03:00AM WBC-7.4 RBC-4.48 HGB-11.0* HCT-34.8* MCV-78*
MCH-24.5*# MCHC-31.7 RDW-16.2*
[**2145-9-21**] 03:00AM NEUTS-76* BANDS-0 LYMPHS-12* MONOS-11 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2145-9-21**] 03:00AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-OCCASIONAL BITE-OCCASIONAL
[**2145-9-21**] 03:00AM PLT COUNT-240
[**2145-9-21**] 03:00AM PT-10.4 PTT-27.2 INR(PT)-1.0
CTA Chest [**9-21**]
IMPRESSION:
1. No pulmonary embolism
2. Chronic right middle lobe collapse
3. Large hiatal hernia, responsible for left basal atelectasis.
Echo [**9-21**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal. with borderline normal free
wall function. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] 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. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
ECG [**9-21**]
Narrow complex irregular supraventricular tachycardia. P waves
are difficult
to discern. Occasional ventricular premature contractions.
Possible prior
anteroseptal myocardial infarction. Compared to the previous
tracing
of [**2144-6-3**] supraventricular tachycardia is new.
Brief Hospital Course:
[**Age over 90 **] year old woman with a history of CAD, hypertension, and
schizoaffective disorder admitted with atrial tachycardia and
concern for pneumonia.
.
1. Arrhythmia: Thought to be SVT, treated unsuccessfully with
adenosine; then thought to be Atrial fibrillation. The patient
was admitted to the MICU on a diltiazem drip in sinus rhythm
with prolonged PR interval and frequent PVCs. Cardiology was
consulted. On further review of EKG from ED, patient likely had
an episode of atrial tachycardia. To evaluate for source of
atrial tach, the patient underwent chest CTA that showed left
lower lobe consolidation and no evidence of pulmonary embolism.
She was started briefly on vancomycin and cefepime. However,
she never developed clinical evidence of pneumonia and
antibiotics were stopped. Electrolytes and TSH returned normal.
ECHO showed moderate pulmonary hypertension, severe TR, 1+
aortic stenosis, 1+ MR. The patient's home atenolol was
discontinued and she was started on metoprolol tartrate 25mg [**Hospital1 **]
for rate control. The patient had a second episode of narrow
complex tachycardia on [**9-22**] up to the 200s which resolved after
IV metoprolol and diltiazem. It was not captured on EKG
therefore it was not possible to tell the underlying rhythm.
There was no clear trigger. She was subsequently transferred to
the floor [**9-23**] and on [**9-24**] had a third episode of 45 seconds of
asymptomatic SVT that spontaneously resolved. On tele, looked to
be A tach with unknown trigger. Patient's metoprolol was
uptitrated and she was discharged on metoprolol succinate 75 mg
[**Hospital1 **].
.
2. Left lower lobe consolidation: Patient with productive cough
and radiographic evidence of a possible left lower lobe
pneumonia while living in an [**Hospital3 **] facility. She was
started on vancomycin and cefepime to cover for HCAP. However,
with no fevers in 24 hours, antibiotics were discontinued. Left
lower lobe consolidation likely represents aspiration
pneumonitis vs. atelectasis. On discharge, patient had a
nonfocal lung exam, was afebrile, with no white count, and a
sparse cough. She was sent home off Abx.
.
3. Coronary Artery disease: Chronic. Unclear history at this
time. The patient was continued on home aspirin and
simvastatin. Home atenolol was transitioned to PO metoprolol
succinate at discharge as above.
.
4. Schizoaffective disorder/Delusional disorder: Chronic. Alert,
oriented, and with appropriate affect at most times but had
intermittent episodes of delerium while in the ICU requiring PRN
Haldol and Zyprexa. Overnight on the general floors, she had no
events and remained alert, oriented, and cooperative.
.
5. Osteoporosis: Chronic. The patient was continued on vit D
and calcium. Alendronate was held.
.
6. Iron deficiency anemia: Diagnosed on admission. The patient
was started on PO ferrous sulfate. Recommend outpatient workup
of iron deficiency anemia.
.
TRANSITIONAL ISSUES:
# Code: DNR/DNI: confirmed with patient, daugther (HCP:
[**Telephone/Fax (1) 95173**]), and [**Hospital3 **] facility paperwork.
# Continue to follow-up with outpatient Cardiologist. The family
could not remember Cardiologist's name or contact information.
Originally was thought to be Dr [**Last Name (STitle) **], but this was not the
case. The daughter has been instructed to call this Cardiologist
and schedule an appointment within 2 weeks.
# Recommend outpatient workup of iron deficiency anemia.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient medication records.
1. Atenolol 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Vitamin D 800 UNIT PO DAILY
7. Simvastatin 20 mg PO HS
8. Alendronate Sodium 70 mg PO QWED
9. Risperidone 0.5 mg PO Q 6PM
10. Senna 1 TAB PO HS:PRN constipation
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Risperidone 0.5 mg PO Q 6PM
6. Senna 1 TAB PO HS:PRN constipation
7. Simvastatin 20 mg PO HS
8. Vitamin D 800 UNIT PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Alendronate Sodium 70 mg PO QWED
11. Lisinopril 5 mg PO DAILY
12. Metoprolol Succinate XL 75 mg PO BID
You will take 3- 25mg tablets twice daily.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Supraventricular tachycardia
Secondary diagnoses:
delirium
possible CAP
schizoaffective disorder
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 came to the hospital with palpitations and a fast heart
rhythm. This resolved with medications that slow your heart
rate. To monitor your blood presssures, you were first kept in
the Intensive Care Unit. You did very well while you were there
and were then transfered to a regular Medicine service. We added
a medication to your daily regimen to help control your heart
rate.
While in the hospital, you were found to be iron deficient. You
have been started on oral iron.
You have been taken off atenolol and started on a new medication
called metoprolol.
Please see your follow-up appointments listed below. It was a
pleasure taking care of you Ms [**Known lastname **].
Followup Instructions:
Name: [**Last Name (LF) 22673**],[**First Name3 (LF) **] V.
Location: BIDHC [**Location (un) **] SUBACUTE CARE EXTENDED COMMUNITY
PRACTICE
Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 14405**]
*Your primary care provider will visit you at home within 72
hours of being discharged. Any questions or concerns please call
the office.
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 6937**]
*Please call your cardiologist to book a follow up appointment
for your hospitalization. You need to be seen within 2 weeks of
discharge.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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"793.19",
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"414.01",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
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|
6604, 9544
|
279, 285
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|
3685, 3690
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3704, 6581
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|
2194, 2336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,643
| 181,462
|
4823
|
Discharge summary
|
report
|
Admission Date: [**2103-8-18**] Discharge Date: [**2103-8-23**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
CC: shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 yo male with Hx of CAD s/p NSTEMI, severe COPD with multiple
intubations on chronic steroids who was recently discharged on
[**2103-8-13**] after a flare now being admitted for hypercarbic
respiratory failure and hypotension. Pt was recently
hospitalized for similar presentation on [**2103-8-4**] for which he
was intubated for 3 days and treated with an 8 day course of
Ceftazadime for pseudomonas that grew from his sputum and
Vancomycin for suspected sepsis for 3 days. He also breifly
required Norepinephrine for hypotension although all blood
cultures and Urine cultures remained negative. He now presents
from with home after waking up acutely short of breath. He
reports feeling well after discharge but was having difficulty
last night sleeping and decided to take Ambien 5mg which has
worked well for him in the past. He awoke 4 hours later with
shortness of breath. He attempted using his albuterol nebulizer
with minimal response and decided to call EMS. He denied any
cough, sputum production, fever, chills or increasing SOB
leading up to this episode. He denied any chest pain, chest
tightness or palpitations.
.
In the ED he was started on bipap with ABG of 7.35/58/265
although no initial ABG obtained. He was initially hypertensive
and tachycardix with BP of 200/100 and HR 140 but became
hypotensive after starting BIPAP mask. He was started on
Ceftazadime and vancomycin due to hx of Pseudomonas in sputum
and MRSA PNA in the past. He was also given IV solumedrol for
COPD exacerbation. His SBP was mildly improved after 1L IVF so
sepsis protocol was not initiated.
.
On transfer from [**Name (NI) 153**] pt reports that he is breathing much, much
better than on admission, feels that the majority of his
symptoms were exacerbated by the heat and humidity. Feels that
he will be ready to go home soon, after another day or so.
Wants to get out of bed and walk more. Pt has been off
antibiotics, and has been transitioned to PO steroids. O2
requirement is 4L currently, which is his home level. Pt is
very pleased with how things are going. No F/C, no N/V, no
CP/SOB, no dysuria, no BRBPR/melena.
Past Medical History:
1. COPD on 4 L O2 at home and s/p multiple admissions and
intubations for flares-FEV1 .47(19%) FEV1/FVC 36% on 4L home 02
2. Hypertension
3. Hyperlipidemia
4. CAD s/p NSTEMI ([**2101**]) [**4-10**] with cath normal
5. Chronic low back pain L1-2 laminectomy from accident at work
6. Steroid induced hyperglycemia
7. Left shoulder pain for several months
8. Cataract
9. GERD
Social History:
Married with six children. Lives at home in [**Location (un) 16174**] with
wife. Retired [**Company 19015**] mechanic. Exposed to a lot of spray
paint.
Former smoker. Quit 25 years ago. 20 pack year history.
Occassional EtOH Quit marijuana 3 years ago. Denies IV drug
use.
Activity limited due to prior spine and current shoulder
problems.
Family History:
Mother with asthma and [**Name (NI) 2481**]
Father with [**Name2 (NI) 499**] cancer
Physical Exam:
PE: T 97.6 105/68 95 32 96% 4L NC
General: Awake, alert, sitting up in bed with O2NC.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Pt able to converse in full sentences, decreased air
movement, no crackles or wheezes
Cardiac: RR, nl. S1S2, no M/R/G noted, hrt sounds best
auscultated at the xiphoid process
Abdomen: soft, NT, mild RUQ tenderness, normoactive bowel
sounds, no masses or organomegaly noted.
Extremities: No LE edema, 2mm mobile subcutaneous nodules over
shins bilat, no LE edema, 2+ rad and dp pulses
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:-mental status: Alert, oriented x 3. Able to relate
history without difficulty.-cranial nerves: II-XII intact,
moving all extrem well
Pertinent Results:
EKG: sinus tachycardia at 120 nl axis, TW flat in v1-2, TWI in
AVL and AVF unchanged from previous, RBBB and RAA
CXR-COPD. No CHF or pneumonia. Slight blunting of
both costophrenic angles, not significantly changed
compared to the most recent prior study.
[**2103-8-18**] 04:15AM PT-12.5 PTT-23.0 INR(PT)-1.0
[**2103-8-18**] 04:15AM NEUTS-69.1 LYMPHS-25.2 MONOS-4.0 EOS-1.5
BASOS-0.2
[**2103-8-18**] 04:15AM WBC-19.9* RBC-4.56* HGB-12.3* HCT-38.0*
MCV-83 MCH-27.0 MCHC-32.4 RDW-15.3
[**2103-8-18**] 04:15AM GLUCOSE-137* UREA N-22* CREAT-0.9 SODIUM-137
POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17
[**2103-8-18**] 06:11AM LACTATE-1.7
[**2103-8-18**] 06:47AM PO2-265* PCO2-58* PH-7.34* TOTAL CO2-33* BASE
XS-4
[**2103-8-18**] 10:00AM CK-MB-6 cTropnT-0.02*
[**2103-8-18**] 10:00AM CK(CPK)-41
[**2103-8-18**] 07:06AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is mildly dilated with good systolic
function. The aortic valve leaflets appear structurally normal
with good leaflet excursion. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
Brief Hospital Course:
1. Acute respiratory failure: The patient was admitted to the
[**Hospital Unit Name 153**] with hypercarbic respiratory distress, although the ABG
obtained in the ED suggested that the patient had good response
to noninvasive ventilation. There was no sign of pneumonia on
CXR, and no evidence of increased sputum production to suggest
bronchitis or bronchiectasis. Pt was placed on Prednisone 60mg
with plans for a slow taper. It was felt the the acute nature
of this episode's onset was concerning for CHF in the setting of
ischemia. Even though he has no CAD on cath in [**4-10**], he does
have a hx of NSTEMI representing possible troponin leak from
diastolic dysfunction and subendocardial ischemia. The initial
ECG on admission suggested rt heart strain but this is not
unexpected in the setting of the patient's known pulmonary
disease. Cardiac enzymes were obtained x3 and were negative.
The patient was observed overnight in the [**Hospital Unit Name 153**] where good O2
sats were observed on 4L by NC, along with neb treatments and
prednisone. A TTE was obtained that showed no evidence of new
CHF. The patient was transferred to the general medical floor,
where he remained stable and by self-report was near or at his
baseline. The patient did note exercise intolerance [**2-7**] air
hunger, but stated that this was not proportionally different
from his USOH PTA. The patient received a total of 3 days of
Prednisone 60mg, and was then decreased to 40mg on the day of
discharge. The patient was given instructions for a very slow
taper that would bring him to no less than 20mg per day of
prednisone by the time Dr. [**Last Name (STitle) 575**] saw the patient later in
the month. PCP prophylaxis was considered by the attending
given the length of the prednisone taper, but was decided
against. Dr. [**Last Name (STitle) 575**] recommended BiPAP overnight, and this
was started and titrated by respiratory care to settings of
[**12-11**]. The patient tolerated this overnight without significant
problems. The patient had been given a BiPAP machine roughly 6
months ago from his home health agency, but he had not been
using it due to what he calls 'incorrect settings'. Eventually
they took it back from him. In order for him to re-qualify for
reimbursement for BiPAP, Medicare requires documentation of an
ABG with a PCO2 greater than 55 (which this patient has many of)
and also documentation of the patient desaturating to < 88% on
2L or less of O2 by nasal cannula for 5 or more minutes. The
home health company stated that this must be in the form of a
computer printout or graph. No oximeter in the inpatient side
of [**Hospital1 18**] is capable of producing this printout. Hence, the
patient will be discharged without BiPAP and Dr. [**Last Name (STitle) 575**] and
the patient will work toward getting a study that will qualify
him for home BiPAP as an outpatient.
*
2. Hypotension: The patient had episode of hypotension in the ED
in the context of non-invasive ventilation. The hypotension in
addition to the patient's elevated WBC count on admission raised
concern for sepsis, but the patient's low lactate as well as the
rapid BP response to cessation of CPAP and starting of IV fluids
allayed this concern. The patient was initially started on
Ceftazidime and Vancomycin amid this picture, but these
medications were quickly discontinued as the initial clinical
picture quickly improved. His outpatient Lisinopril dose was
initially held in the [**Hospital Unit Name 153**], but was restarted on the medical
floor prior to discharge, with no further episodes of
hypotension.
*
4. Thyroid function: a TSH was checked in the [**Hospital Unit Name 153**], which was
very low. A follow-up free T4 was also checked, and was found
to be in the normal range. It is difficult to interpret these
findings given the patient's acute COPD exacerbation and the
stresses of an ICU stay. Hence, the patient should have his TSH
re-checked as an outpatient for further management.
Medications on Admission:
1.Aspirin 325 mg qd
2.Atorvastatin Calcium 10 mg qd
3.Calcium Carbonate 500 mg qd
4.Cholecalciferol (Vitamin D3) 400 unit qd
5.Senna 8.8 mg/5 mL [**Hospital1 **]
6.Sertraline 50 mg qd
7.Albuterol Sulfate 0.083 % Neb q4hours
8.Ipratropium Bromide Nebq4hours
9.Multivitamin qd
10.Lisinopril 5 mg qd
11.Prednisone 30mg qd on taper(down from 40mg on [**7-25**])
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QD ().
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q4H (every 4 hours).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb treatment
Inhalation Q4H (every 4 hours).
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
Two (2) Spray Nasal [**Hospital1 **] (2 times a day).
11. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic TID (3 times a day).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS PRN as
needed for anxiety.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
13. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a
day for As directed days: Please take 40mg for 7 days, then 30mg
for 7 days, then 20mg for 14 days.
[**Hospital1 **]:*63 Tablet(s)* Refills:*0*
14. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation QID PRN as needed for shortness of breath or
wheezing.
[**Hospital1 **]:*1 inhaler* Refills:*6*
15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Dx:
COPD exacerbation
Hypertension
CAD
.
Secondary Dx:
Hyperlipidemia
Hyperglycemia
Glaucoma
GERD
Discharge Condition:
Stable, tolerating PO, ambulating without assistance.
Discharge Instructions:
If you experience fevers, chills, nausea, vomiting, chest pain,
shortness of breath greater than usual, increased mucus
production, or any other concerning symptoms, contact your
physician or return to the emergency room. Do not take your
Lisinopril until you meet with your primary doctor, Dr.
[**Last Name (STitle) 8499**]. Your Lisinopril was discontinued this admission
because you had low blood pressures.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 8499**] tomorrow in clinic as
directed below. If you cannot come to this appointment, please
call to re-schedule.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Where: [**Hospital1 7975**] INTERNAL
MEDICINE Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2103-8-23**] 2:15
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2103-8-31**]
9:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2103-8-31**] 10:00
Provider: [**Name10 (NameIs) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] SURGICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 10941**] Date/Time:[**2103-9-4**] 9:50
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2103-8-28**]
|
[
"251.8",
"518.84",
"458.9",
"733.00",
"365.9",
"530.81",
"789.06",
"491.21",
"272.4",
"414.01",
"412",
"E932.0",
"401.9",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11834, 11892
|
5782, 9802
|
296, 303
|
12042, 12098
|
4252, 5759
|
12559, 13690
|
3233, 3318
|
10211, 11811
|
11913, 12021
|
9828, 10188
|
12122, 12536
|
4193, 4233
|
3333, 4097
|
233, 258
|
331, 2456
|
4112, 4176
|
2478, 2855
|
2871, 3217
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,696
| 192,374
|
1500+55294
|
Discharge summary
|
report+addendum
|
Admission Date: [**2119-1-12**] Discharge Date: [**2119-1-20**]
Date of Birth: [**2047-9-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Percocet
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2119-1-13**] cardiac catheterization
[**2119-1-16**] s/p Coronary artery bypass graft surgery (Left internal
mammary artery > left anterior descending, saphenous vein graft
to RAMUS, saphenous vein graft to PDA.
History of Present Illness:
71 year old male with complaints of intermittent episodes of
left-sided chest pressure with radiation down his left arm [**12-24**]
weeks, [**2119-2-23**], lasting 1-1.5 min, resolving on it's own but
improved with deep breaths and unchanged with exercise. He
stated that his chest pain was dull/sore in nature, not
radiating to his back, and was without pleurisy. He also stated
that he felt lightheaded without vertigo. He has had SOB going
up stairs.
Past Medical History:
hypertension
diabetes mellitus type 2
hypercholesterolemia
chronic renal insufficiency
left groin hernia repair [**2108**]
right shoulder- plated
right hand- trigger finger release
Social History:
Lives with: alone
Occupation: retired oil burner worker
Tobacco: 20pack years, quit 10 yrs ago
ETOH: none for many years
Family History:
Mother with CAD in late 60s and CABG.
Physical Exam:
Pulse: 58 Resp: 19 O2 sat: 98%RA
B/P Right: 148/64 Left:
Height: Weight: 106.1
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: cath Left: 2+
DP Right:2+ Left: 2+
PT [**Name (NI) 167**]:2+ Left: 2+
Radial Right:2+ Left: 2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**2119-1-16**] at 11:15:19 AM
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal [**Year (4 digits) 8813**] diameter at the sinus level. Focal
calcifications in [**Year (4 digits) 8813**] root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal [**Year (4 digits) 8813**] arch
diameter. Focal calcifications in [**Year (4 digits) 8813**] arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
[**Year (4 digits) **] VALVE: Mildly thickened [**Year (4 digits) 8813**] valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild (1+) 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.
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the [**Year (4 digits) 8813**] arch. There are
simple atheroma in the descending thoracic aorta. The [**Year (4 digits) 8813**]
valve leaflets (3) are mildly thickened but [**Year (4 digits) 8813**] stenosis is
not present. No [**Year (4 digits) 8813**] 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.
Dr. [**Last Name (STitle) **] was notified in person of the results on Mr.[**Known lastname 8814**]
before surgical incision.
Post_Bypass:
Preserved biventricular systolic function. LVEF 50%.
Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **], tricuspid valves.
Intact thoracic aorta.
Brief Hospital Course:
Underwent cardiac evaluation for chest pain, which cardiac
catheterization revealed coronary artery disease. He underwent
preoperative work up including labs which creatinine increased
to 1.9 post cardiac catheterization. On [**2119-1-16**] he was brought
to the operating room and underwent coronary artery bypass graft
surgery. See operative report for further details. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. He was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support at this time. He
was found suitable for transfer to telemetry. Chest tubes and
pacing wires were discontinued without complication. Physical
therapy was consulted for assistance with post-operative
strength and mobility. The patient progressed as planned
through the cardiac surgery pathway without compication. He was
discharged home in good condition on POD 4 after being cleared
for discharge by DR. [**Last Name (STitle) **].
Medications on Admission:
ASA 81mg daily
Metoprolol tartrate 50mg [**Hospital1 **]
Lisinopril 40mg daily
Norvasc 10mg daily
Glyburide 5mg [**Hospital1 **]
Metformin 500mg [**Hospital1 **]
Simvastatin 40mg daily
Synthroid 112 mcg daily
Doxazosin 4mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
11. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p cabg
Hypertension
diabetes mellitus type 2
hypercholesterolemia
chronic renal insufficiency
left groin hernia repair [**2108**]
right shoulder- plated
right hand- trigger finger release
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with ultram and tylenol prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2119-2-22**]
1:00
Primary Care Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] in [**12-24**] weeks
Cardiologist Dr [**Last Name (STitle) **] [**Name (STitle) **] in [**12-24**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2119-1-20**] Name: [**Known lastname 1218**],[**Known firstname 33**] Unit No: [**Numeric Identifier 1219**]
Admission Date: [**2119-1-12**] Discharge Date: [**2119-1-20**]
Date of Birth: [**2047-9-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Percocet
Attending:[**First Name3 (LF) 135**]
Addendum:
Correction to discharge medication list
Mr. [**Name14 (STitle) 1220**] was also on Simvastatin 40mg upon discharge.
He will also follow up with Dr.[**First Name8 (NamePattern2) 1221**] [**Name (STitle) 1222**] as cardiologist.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2119-1-20**]
|
[
"285.9",
"600.00",
"429.9",
"414.01",
"278.00",
"250.00",
"411.1",
"272.0",
"403.90",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.15",
"88.53",
"88.56",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8851, 9066
|
4481, 5470
|
295, 512
|
7075, 7181
|
2062, 4458
|
7721, 8828
|
1356, 1395
|
5749, 6736
|
6838, 7054
|
5496, 5726
|
7205, 7698
|
1410, 2043
|
245, 257
|
540, 997
|
1019, 1202
|
1218, 1340
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,906
| 104,005
|
22721
|
Discharge summary
|
report
|
Admission Date: [**2194-11-17**] Discharge Date: [**2194-11-20**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a [**Age over 90 **]-year-old gentleman who is s/p a right
colectomy for cecal adenocarcinoma on [**2194-10-28**] with Dr.
[**Last Name (STitle) **]. He was discharged to rehab on [**2194-11-5**]. Per
daughter he was having low blood pressures and constipation at
rehab. He returns now with difficulty breathing and coughing.
In the ED he is requiring 15L NRB.
Past Medical History:
# Right colecomy [**2194-11-5**]
# Hemophilia C: diagnosed in [**2194-4-24**]
# hypertension
# valvular CHF: TEE [**2194-6-24**]: Severe, possibly flail TR,
moderate AS, severe MR, EF 65-75%, PAP of 35
# question of prior rheumatic fever
# glaucoma
# BPH, s/p TURP.
# bacteremia of unknown source c/b C.diff colitis ([**2194-5-24**],
[**Hospital1 112**])
# hernia repair x 3
# Hip and Shoulder Surgery 3yrs ago
Social History:
- Tobacco: past history of 3ppd (stopped 50-60yrs ago)
- Alcohol: rare and small amounts per family (pt says not at
all)
- Ambulates with walker. Supportive and involved children.
Family History:
non-contributory
Physical Exam:
Vitals - not collected, pt 98 at 0400
Gen - A&O x 3, NAD
Pulm - crackles bilat
CV - atrial fibrillation with rate 120-150
Abd - soft, NTND, incision healing well, clean, dry, intact
extrem - bilat lower extremity edema
Pertinent Results:
none
Brief Hospital Course:
The patient was admitted to the general surgery service on
[**2194-11-17**] for treatment of a pneumonia. He was intubated on HD1
and started on broad spectrum antibiotics, which he tolerated
well.
Neuro: The patient received tylenol PO with good effect and
adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. During HD 1 he was placed
brifly on an esmolol drip and after a brief episode of
bradycardia he converted to sinus rhythm. On HD 3 he declined
further care and was made CMO, his atrial fibrillation returned
and at the time of discharge his heart rate was 120-150.
Pulmonary: The patient was intubated on HD 1 but the
ventillatoor was weaned and he remained on 4LNC throughout the
remainder of his hospital stay.
GI/GU: Fluids were kept to a minimum throughout this hospital
stay because of his history of CHF. On HD 3 he was given a 10mg
dose of lasix, which caused the patient to diurese nicely. he
took minimal PO through this hospital stay. Foley was kept in
place and the patient will be discharged to home with it for
comfort.
ID: The patient was started on IV vanc, cipro, cefapime, and
flagyl upon admission. this was continued through HD 3, when the
patient refused any further care. After HD 3 th epatient's
temperature was watched closely and treated with tylenol PRN to
provide comfort.
Prophylaxis: The patient received subcutaneous heparin until HD
3.
At the time of discharge on HD 4, the patient was afebrile abd
his pain was well controlled.
Given his decision to become CMO and to expire at his home among
his family, a palliative care consult was obtained to maximize
patient comfort while inhouse and hospice was set up for the
patient.
He will be discharged to [**Last Name (un) **] on oxygen and suction, as well as
pain medication to be administered by hospice via their
protocol.
Medications on Admission:
finasteride 5mg q/day, gabapentin 300mg q/day, tramadol 50mg
QHS, MVI, Fe, timolol gtt 0.5%, xalatan gtt 0.005%
Discharge Medications:
1. Home Oxygen
Please provide home oxygen, titrate for comfort per company
protocol.
2. Suction
Please provide suction device for patient per company protocol.
3. hyoscyamine sulfate 0.125 mg/mL Drops Sig: [**1-25**] PO every four
(4) hours as needed for shortness of breath or wheezing.
Disp:*30 ml* Refills:*0*
4. morphine concentrate 20 mg/mL Solution Sig: One (1) ml PO q1H
as needed for pain.
Disp:*30 ml* Refills:*0*
5. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) ml PO
every four (4) hours as needed: Please administer for agitation.
Disp:*30 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Pneumonia
Sepsis
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You have been admitted to the hospital for treatment of a
pneumonia. You have decided to decline further medical treatment
and receive hospice care. Please follow the instructions of the
Hospice Liason taht will be providing further comfort care.
Followup Instructions:
Please feel free to follow up with Dr [**Last Name (STitle) **] if you decide
you want further medical care. His office number is [**Telephone/Fax (1) 58832**].
Completed by:[**2194-11-20**]
|
[
"401.9",
"593.9",
"428.0",
"V66.7",
"518.81",
"V64.2",
"780.96",
"038.9",
"286.0",
"427.31",
"995.92",
"V10.05",
"574.20",
"365.9",
"507.0",
"414.01",
"V49.86",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"33.29",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4304, 4362
|
1648, 3541
|
283, 290
|
4474, 4474
|
1619, 1625
|
4880, 5073
|
1347, 1365
|
3704, 4281
|
4383, 4453
|
3567, 3681
|
4609, 4857
|
1380, 1600
|
224, 245
|
318, 698
|
4489, 4585
|
720, 1133
|
1149, 1331
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,955
| 183,561
|
42966
|
Discharge summary
|
report
|
Admission Date: [**2192-3-1**] Discharge Date: [**2192-3-7**]
Date of Birth: [**2151-8-28**] Sex: M
Service: MEDICINE
Allergies:
Zantac / Tagamet / Megace / Zyban / Iodine; Iodine Containing /
Zoloft / Ceftriaxone / Cefepime / Abacavir
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
This is a 40 year-old man with AIDS diagnosed in [**2171**] last CD4
count of 27 and viral load of [**Numeric Identifier **] re-started on HAART salvage
this month who activated EMS today for shortness of breath. He
is admitted to [**Hospital Unit Name 153**] after being intubated for airway protection
due to altered mental status and on pressors for hypotension.
History is obtained from family and partner, [**Name (NI) **] notes and [**Name (NI) **]
notes/doctors.
As per his family and partner, he was feeling well until this
afternoon. He was at work and apparently felt he had an
"anxiety attack". He felt short of breath and palpitations and
was brought to the ED by EMS.
Family also notes that last friday he started a new HIV
medication and subsequently developed chills, diarrhea, fever to
103 and some new red "bumps" appeared on his legs. The following
day felt better.
As per Dr.[**Initials (NamePattern4) 42346**] [**Last Name (NamePattern4) **] notes confirm initiation of abacivir,
truvada and kaletra. A [**2-17**] telephone contact notes initiation
of all meds at that time without significant complication. The
patient's family thinks he may have been staggering initiation
of meds. As per ED physician and [**Name9 (PRE) 9168**] notes, patient reported
that he started a new medication today before his shortness of
breath started.
History obtained in ED from patient documents that patient
became short of breath after using crystal meth today.
Of note, recent hospitalization in [**2191-12-11**] with fevers,
MRSA finger infection, pancytopenia, transaminitis. Treated for
MRSA infection and had seeming resolution of other issues. At
that time had AFB sent--was positive but no TB as per state
lab--thought was it could be MAC but state lab results still
outstanding.
In the ED, T 99.2 at 12 noon-->102.4 at 4:30PM Hr 128 BP 138/76
at 12 noon-->72sbp by about 4:30PM RR 25 Sats 98%. He received 5
liters of fluid, significant amount of ativan, was noted to have
altered mental status with bizarre behavior, intubated for
airway protection, given cefipime and vancomycin, started on
pressors.
Past Medical History:
1. HIV disease- HIV/AIDS since [**2172**] off HAART since
[**4-/2190**],(Absolute CD4 count 27, CD4 1%, HIV viral load was 41,800
copies per mL)
Prior HIV regimens
-monotherapy with AZT [**2173**]-[**2178**], and complicated by nausea
-monotherapy with DDI, complicated by neuropathy in [**2181**]
Combivir/Indinavir on 5/96-8/96, nausea to AZT
-D4T, 3TC, Crixivan from 11/96-4/04.
2. History of "hepatitis" unclear as to what type.
3. History of nephrolithiasis.
4. History of prostatitis.
5. Arthroscopic knee surgery.
6. History of depression, briefly on SSRI.
7. Eczema.
8. Tension headaches.
9. Positive hep B core antibody and surface antibody.
10. [**2191-12-11**] admission for MRSA finger infection,
transaminitis, pancytopenia/leukopenia, fevers
Social History:
Per [**Last Name (LF) **], [**First Name3 (LF) **] h/o smoking, social ETOH only, no illicit drug
use; lives in JP with long-time partner, also HIV+; they are
sexually active and use condoms 100% of the time per pt; he was
born and raised in [**University/College **] and came to the US in [**2172**], first
living in [**State 108**] for 4 months and then moving to [**Location (un) 538**],
where he has lived ever since; works as a florist doing visual
displays; he has 1 adult cat at home; travels frequently to
[**Country 5976**], [**Country 12649**], [**Country 74323**], S.America, but denies ever traveling to
[**Country 480**]/[**Female First Name (un) 8489**]. Toxo IgG negative in [**2188**].
Family History:
FH - He reports his mother is alive and well but has diabetes.
Father is alive and obese, also with diabetes and coronary
artery disease.
Physical Exam:
VS: Temp:98.5 BP: 112/65 HR:99 RR:20 100% O2sat
VENT 650 x 20 fio2100 peep 5
ABG:7.30/35/377
general: intubated, sedated
HEENT: pupils equal 4mm, round, sluggish but reactive, no
scleral icterus, MMM, op without lesions, no supraclavicular or
cervical lymphadenopathy, no thyromegaly or thyroid nodules
lungs: Coarse anteriorly
heart: tachy, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: 1+edema
skin/nails: rash over lower extremities
neuro: intubated, sedated, responds to pain
Pertinent Results:
[**2192-3-1**] CT Head - No evidence of hemorrhage or mass defect.
Sinus findings as described above. Apparent fullness of the
nasopharynx. Correlation with clinical exam is recommended.
[**2192-3-1**] CXR - No acute cardiopulmonary process
[**2192-3-5**] RUQ U/S - Two small hemangiomas in the liver, otherwise
normal right upper quadrant ultrasound.
[**2192-3-6**] CT Chest - Multifocal patchy consolidation in both lower
lobes and peripheral ground- glass opacities in the upper lobes
with bronchocentric nodules in the right lower lobe and
enlarging noncalcified pulmonary nodule in the right middle
lobe. Bilateral small pleural effusions. The findings are
consistent with an infectious process but are not specific for a
particular organism. Differential diagnosis includes fungal
infection such as cryptococcus or bacterial or mycobacterial
infection.
[**2192-3-6**] MR [**Name13 (STitle) 430**] - Unremarkable examination of the brain. Diffuse
paranasal sinus disease as indicated on the CT examination.
Bilateral changes of mild mastoiditis of uncertain chronicity.
Brief Hospital Course:
Mr. [**Known lastname **] [**Known lastname 92744**] is a 40 year-old man with history of AIDS
recently started on salvage HAART as an outpatient who initially
presented with shortness of breath in the setting of crystal
methamphetamine use. He was noted to have bizarre behavior in
the ER and was intubated for airway protection. He was not
hypoxic and had a clear CXR. Notably, in the ER he was also
found to have neutropenia and was given one dose of cefepime.
The patient has a cephalosporin allergy (reaction being
hypotension) and in this setting he became hypotensive, briefly
requiring pressors. He was also noted to be febrile, however
this was in the setting of having already received the cefepime.
He was intubated only briefly, and did well post-extubation in
the ICU.
Reportedly his fevers did not start until after receiving the
cefepime in the ED suggesting a medication reaction. However he
was febrile up to 104 overnight [**2111-3-3**]. He is certainly
susceptible to multiple infections given his HIV status and at
least transient neutropenia. All cultures, with the exception of
a positive serum cryptococcal antigen, were negative. With
CD4=29 the differential was broad. He was followed by
infectious disease during his stay. Head MRI was unremarkable
and chest CT was unrevealing. cultures remained negative. The
patient was initially treated with broad spectrum antibiotics,
including antibacterials, acyclovir and fluconazole. Acyclovir
was discontinued after HSV PR from CSF was negative. AFB x 3
was sent from induced sputum. The patient has a positive AFB
culture at the state lab for 2 months that returned
MYCOBACTERIUM FORTUITUM.
The patient was discharged on levo/flagyl to complete a 10 day
course (today is day #5) and was continued on fluconazole
indefinately until seen by Dr. [**Last Name (STitle) **]. At the time of discharge
all HIV meds were being held. He will be restarted on a new
regimen by Dr. [**Last Name (STitle) **]. There was a question as to whether some
of his symptoms were abacavir hypersensitivity.
Medications on Admission:
abicavir, kaletra, bactrim, truvada, azithromycin--although
unclear which of these he was taking recently
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*15 Tablet(s)* Refills:*2*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Cryptococcal Infection
Crystal Meth OD
Abacavir Hypersensitivity
Cefepime Allergy
Discharge Condition:
Stable
Discharge Instructions:
--Please take all medications as prescribed. You will be taking
levofloxacin and Flagyl for the next 5 days (to complete a 10
day course). You need to continue the fluconazole until Dr.
[**Last Name (STitle) **] tells you to stop. Please notify your doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**]
[**Name5 (PTitle) **] numbness or weakness.
-- Do NOT take your HIV medicines
--Please return to the ER for any shortness of breath,
difficulty breathing, fevers, or chills.
Followup Instructions:
** You have an appointment with Dr. [**Last Name (STitle) **] on [**3-21**] at 11AM.
She is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. Please
call [**Telephone/Fax (1) 250**] if you need to reschedule.
***You have an appointment with Dr. [**Last Name (STitle) **]/Dr. [**Last Name (STitle) **]
(Pulmonary) at 3:15 on [**4-2**]. They are located on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. Check in at the Medical
Specilities Desk.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"117.5",
"305.50",
"486",
"042",
"965.02",
"276.2",
"288.0",
"E850.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
8649, 8707
|
5924, 7999
|
372, 384
|
8833, 8842
|
4820, 5899
|
9382, 10008
|
4068, 4207
|
8155, 8626
|
8728, 8812
|
8025, 8132
|
8866, 9359
|
4222, 4801
|
325, 334
|
412, 2543
|
2565, 3331
|
3347, 4052
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,526
| 116,325
|
35473+58007
|
Discharge summary
|
report+addendum
|
Admission Date: [**2201-4-2**] Discharge Date: [**2201-4-8**]
Date of Birth: [**2152-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Myocardial infarction/Unstable angina
Major Surgical or Invasive Procedure:
[**2201-4-2**] - CABGx4 (Left internal mammary artery->Left anterior
descending artery, saphenous vein graft(SVG)->obtuse marginal
artery, Saphenous vein 'Y' graft to distal circumflex artery and
posterior descending artery.)
History of Present Illness:
This 48-year-old patient with exertional chest pain was
investigated and an angiogram showed very tight lesion in the
circumflex and severe triple-
vessel disease with 100% blockage of the right coronary artery
and critical stenosis of the left anterior descending artery. He
had persistent chest pain and hence was transferred urgently for
emergency coronary artery bypass
grafting. Intraoperative transesophageal echocardiogram showed
the ejection fraction to be about 45%.
Past Medical History:
Hyperlipidemia
Myocardial infarction
Social History:
Works in a restaurant in food prep. Current heavy smoker. Mild
alcohol use.
Family History:
Brother with CABG at 53. Father with MI at age 75
Physical Exam:
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis. HEENT: PERRL,
Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM.
LUNGS: distant breath sounds anteriorly
HEART: RRR, No M/R/G
ABD: Soft, ND/NT/NABS
EXT:warm, well perfused, no bruits, no varicosities
NEURO: No focal deficits.
Pertinent Results:
[**2201-4-2**] ECHO
PRE-CPB:1. The left atrium and right atrium are normal in cavity
size. No atrial septal defect is seen by 2D or color Doppler.
2. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-50 %).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. No aortic regurgitation is seen.
6. The mitral valve leaflets are structurally normal. Mild to
moderate ([**2-6**]+) mitral regurgitation is seen.
7. There is no pericardial effusion.
There was an episode of inferior wall akinesis with 3+ MR,
occasional PVC's and elevation of the PA pressures. After
treatment with phenylephrine and nitroglycerine there was
resolution of the RWMA and improvement of the MR.
POST-CPB: On infusion of phenylephrine. A-pacing. Preserved
biventricular systolic function post-cpb. MR is now 1+. The
aortic contour is normal post decannulation.
[**2201-4-2**] 11:14AM %HbA1c-5.8
[**2201-4-8**] 05:10AM BLOOD WBC-6.8 RBC-3.04* Hgb-8.6* Hct-24.9*
MCV-82 MCH-28.4 MCHC-34.7 RDW-13.7 Plt Ct-269
[**2201-4-8**] 05:10AM BLOOD Glucose-92 UreaN-15 Creat-0.7 Na-139
K-4.0 Cl-103 HCO3-26 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 80822**] was admitted to the [**Hospital1 18**] on [**2201-4-2**] via transfer
from [**Hospital6 **] for urgent coronary artery bypass
grafting. He was taken from the intensive care unit to the
operating room where he underwent four vessel coronary artery
bypass grafting. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. He later awoke neurologically intact and was
extubated. Beta blockade, aspirin and a stain were started. On
postoperative day one, he was transferred to the step down unit
for further recovery. Mr. [**Known lastname 80822**] was gently diuresed towards
his preoperative weight, the physical therapy service was
consulted for assistance with his postoperatve strength and
mobility. His chest tubes and wires were removed. On the
evening of post operative day two he was found to have increased
work of breathing with desaturation so he was returned to the
indensive care unit. Multiple sputum and blood cultures were
sent to the laboratory in response to a very wet chest
radiograph with questionable infiltrates. He was placed on
Vancomycin and zosyn originally for the same findings, and then
switched to levofloxacin as cultures began to return negative.
He was treated aggressively with bronchodilators and his
respiratory status improved markedly. By post-operative day five
he was no longer symptomatic and his chest radiograph had
cleared. The patient continued to progress and was discharged
home with VNA services on POD6 in good condition.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Clopidogrel 75 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 5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
Myocardial infarction
Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 1295**] in 2 weeks.
Please follow-up with Dr. [**Last Name (STitle) 80823**] (PCP) in [**3-10**] weeks.
[**Telephone/Fax (1) 45333**]
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
please call for appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2201-4-8**] Name: [**Known lastname 12975**],[**Known firstname 3749**] S Unit No: [**Numeric Identifier 12976**]
Admission Date: [**2201-4-2**] Discharge Date: [**2201-4-8**]
Date of Birth: [**2152-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Discharge instructions/follow-up appointments were adjusted from
original discharge summary. See below.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 437**] VNA
Followup Instructions:
Dr. [**Last Name (STitle) **] (for Dr. [**First Name (STitle) **] in [**3-10**] weeks at [**Hospital1 **] for wound
check and post-op follow-up : [**Telephone/Fax (1) 5412**]
Dr. [**Last Name (STitle) 7592**] in 3 weeks
Dr. [**Last Name (STitle) 12977**] (PCP) in [**3-10**] weeks. [**Telephone/Fax (1) 12978**]
please call for appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2201-4-8**]
|
[
"412",
"305.1",
"272.4",
"414.01",
"486",
"E878.2",
"410.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7811, 7869
|
2929, 4488
|
357, 584
|
5997, 6004
|
1635, 2906
|
7892, 8356
|
1259, 1310
|
4543, 5776
|
5879, 5976
|
4514, 4520
|
6028, 6780
|
1325, 1616
|
280, 319
|
612, 1090
|
1112, 1150
|
1166, 1243
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,305
| 106,092
|
14242
|
Discharge summary
|
report
|
Admission Date: [**2180-1-4**] Discharge Date: [**2180-1-6**]
Date of Birth: [**2123-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
CC:[**CC Contact Info 42331**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 56 year-old male with a history of ETOH cirrhosis with
esophageal varices s/p TIPS as well as active EtOH use who
presents with hematemesis x2 yesterday per VNA report. He was
brought in by his cousin for concern for GIB, and currently
denies that he had any hematemesis but instead endorses
hematochezia. He Denies abdominal pain, diarrhea, melena or
hematochezia. Denies CP/palps/SOB/lightheadedness. Per report
has been eating/drinking OK w/o aspiration/N/V.
.
In the ED, they did not gastric lavage due to varices and risk
of bleed. He was hemodynamically stable w/ HR 74 BP 117/74 O2sat
98%RA.
GI was consulted and pt was started on an octreotide gtt;
received cipro IV and IV PPI.
.
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 edema, cough, urinary frequency,
urgency, dysuria, lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash or skin changes.
.
Past Medical History:
- Alcoholic cirrhosis - hx of esophageal variceal bleed and
hepatic encephalopathy. He has had 2 TIPS procedures with stent
placement in [**2166**] and again in [**2176**]. Underwent TIPS revision in
[**8-17**] and [**9-17**].
- EGD [**2179-9-14**]: Grade [**2-11**] esophageal varices, Esophagitis, Portal
hypertensive gastropathy
- Chronic pancreatitis complicated by a parapancreatic cyst
that was infected with enteroccocus and coagulase negative
staph. On vancomycin from [**Date range (2) 42329**], then linezolid
[**Date range (1) 42330**].
- Type 2 DM on insulin
- Anemia of chronic disease
- Thrombocytopenia
- Depression
- Umbilical Hernia
- History of delerium tremens
.
Social History:
Pt lives alone with sisters in area and friends in the building.
Unemployed. Last used ETOH "in [**2177**]" - per other reports, still
actively drinking and removed from [**Year (4 digits) **] list. No h/o IVDU
or other drug use. Says he smokes "5 packs a day".
Family History:
father - cirrhosis
Physical Exam:
On Presentation to ICU:
Vitals: T: 98.4 BP: HR: 83 RR: 19 O2Sat: 100% RA
GEN: jaundiced, disheveled, no acute distress
HEENT: EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea,
dryMM, 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: distended, no peripheral dullness to percussion, Soft, NT,
+BS, + HSM, no masses
Rectal: guiac (-)
EXT: No C/C/E, no palpable cords
NEURO: + asterixis, alert, oriented to place, unable to
reidentify people, not oriented to time. CN II ?????? XII grossly
intact. Moves all 4 extremities. Strength 5/5 in upper and lower
extremities. Patellar DTR +1. Plantar reflex downgoing.
+dysdiadokokinesia.
SKIN: +jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
[**2180-1-4**] 07:00PM WBC-6.8 RBC-3.58*# HGB-13.2*# HCT-35.1*
MCV-98# MCH-36.9* MCHC-37.6* RDW-14.4
[**2180-1-4**] 07:00PM NEUTS-72.7* LYMPHS-12.0* MONOS-6.9 EOS-7.1*
BASOS-1.2
[**2180-1-4**] 07:00PM PLT COUNT-49*
.
[**2180-1-4**] 07:00PM PT-16.7* PTT-32.9 INR(PT)-1.5*
.
[**2180-1-4**] 07:00PM GLUCOSE-293* UREA N-20 CREAT-1.0 SODIUM-128*
POTASSIUM-2.4* CHLORIDE-90* TOTAL CO2-24 ANION GAP-16
[**2180-1-4**] 07:00PM ALT(SGPT)-43* AST(SGOT)-94* ALK PHOS-379* TOT
BILI-12.7*
[**2180-1-4**] 07:00PM LIPASE-138*
.
[**2180-1-4**] 06:50PM AMMONIA-252*
.
[**2180-1-4**] 11:03PM BLOOD Hct-34.2* Plt Ct-51*
[**2180-1-5**] 04:12AM BLOOD Hct-30.3* Plt Ct-47*
[**2180-1-5**] 11:39AM BLOOD Hct-30.7*
.
CXR: IMPRESSION: Interval improvement in right basilar opacity
with persistent small right pleural effusion. Findings are
suggestive of resolving pneumonia. No new areas of abnormality
otherwise identified.
.
Liver U/S with Doppler:
1. Unchanged occluded anterior TIPS and unchanged patent
posterior TIPS with normal flow in the proximal, mid and distal
portions of the stent.
2. Cholelithiasis with no evidence of cholecystitis.
3. Cirrhotic liver.
Brief Hospital Course:
56 yo male with EtOH cirrhosis and esophageal varices s/p 2 TIPS
with multiple revisions, as well as active EtOH use who presents
with hematemesis x2, without further episodes and a stable Hct.
# Hematemesis: Patient had two episodes of hematemesis by report
has a history of grade I-III varices. He initially received an
octreotide drip, IV PPI, and IV cipro, however this was stopped
on the day after admission as his Hct was stable and he did not
appear to have an active GI bleed. He had no further episodes
of hematemesis while hospitalized and has been guaiac negative
here. As his story changes depending who speaks with him, it is
unclear if he actually had hematemesis, however he is not
currently bleeding and his Hct has been stable. He was
continued on a PPI daily and nadolol 20 mg daily for variceal
ppx. His diet was advanced and he was tolerating a regular diet
without problem the night prior to discharge.
# EtOH cirrhosis: The patient has alcoholic cirrhosis and is not
on the [**Month/Day/Year **] list due to recent alcohol use (the patient
denies using alcohol in the past 3 years, however he recently
received a letter in [**Month (only) **] from the [**Month (only) **] board stating he
was being inactivated from the list due to recent alcohol use).
He was continued on rifaximin and lactulose (titrating for [**4-13**]
bowel movements) for ppx of encephalopathy. He was continued on
nadolol and a PPI as above. At discharge he was restarted on
his aldactone.
# Type 2 DM: The patient's lantus was initally held as he was
NPO, however it was added back as he began to eat. His finger
sticks were checked qid and he was covered with sliding scale
insulin. He was discharged on his home dose of 38 units of
lantus qpm.
# EtOH abuse: The patient denies recent alcohol use, but has a
history of DT's. Teh patient was monitored closely for
withdrawal and placed on a CIWA scale. He required no diazepam
during this admission. He was continued on folic acid,
thiamine, and a MVI. He was counceled to avoid alcohol use due
to his liver disease.
# History of depression: The patient was continued on his home
dose of amitriptyline.
# Thrombocytopenia: The patient has chronic thrombocytopenia,
likely secondary to liver disease. His platlets remained stable
during this admission.
Medications on Admission:
Per [**11-27**] d/c Summary. Unclear of pt compliance.
1. Multivitamin one QD
2. Nadolol 20 mg Daily
3. Rifaximin 200 mg Tablet three tabs [**Hospital1 **]
4. Lactulose Thirty (30) ML PO QID
5. Omeprazole 40 mg [**Hospital1 **]
6. Spironolactone 150mg Daily
7. Amitriptyline 10 mg QHS
8. Thiamine HCl 100 mg Daily
9. Folic Acid 1 mg Daily
10. Insulin Glargine 100 unit/mL Solution Sig: 38U Subcutaneous
at bedtime.
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO twice a day.
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO four
times a day: Titrate to [**4-13**] bowel movements per day.
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Glargine 100 unit/mL Solution Sig: Thirty Eight (38)
units Subcutaneous at bedtime.
10. Aldactone 100 mg Tablet Sig: 1.5 Tablets PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary-
Hematemeis
Secondary-
Alcoholic cirrhosis
Diabetes
Depression
Discharge Condition:
Stable, no signs of bleeding and tolerating a regular diet.
Discharge Instructions:
You were admitted to the hospital due to two episodes of
hematemesis (vomiting of blood). You were monitored in the ICU
overnight and you had no signs of active bleeding and your blood
counts were stable. Your diet was slowly advanced and you had
no difficulty tolerating a regular diet. Your blood counts
remained stable throughout your hospitalization.
No changes were made to your medications. Continue to take your
outpatient medications as prescribed.
Call your primary doctor or go to the emergency room if you
experience fevers, chills, dizzines, shortness of breath,
vomiting of blood, blood in your stool, or black stool.
Followup Instructions:
Please keep your previously scheduled appointments:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2180-1-7**] 9:15
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-2-9**] 8:40
Completed by:[**2180-1-6**]
|
[
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"571.2",
"456.21",
"250.00",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8111, 8117
|
4513, 6836
|
344, 350
|
8233, 8295
|
3331, 4490
|
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|
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|
8138, 8212
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6862, 7282
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8319, 8958
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2476, 3312
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274, 306
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378, 1439
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1461, 2145
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2161, 2425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,728
| 102,013
|
48196
|
Discharge summary
|
report
|
Admission Date: [**2173-12-23**] Discharge Date: [**2173-12-31**]
Date of Birth: [**2108-4-13**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman with
hypertension, hypercholesterolemia, obesity, question CAD,
diabetes mellitus, OSA with increased dyspnea and hypoxia x2
weeks, especially increasing over the past two days prior to
admission, has required constant CPAP for the past two-and-a-
half weeks. Of note, the patient's Lasix dose was decreased
from 100 mg b.i.d. to 60 mg b.i.d. three weeks ago for
unknown reasons.
REVIEW OF SYSTEMS: The patient has orthopnea, PND, and lower
extremity edema. No chest pain or diaphoresis. No cough or
fever. On arrival to the ER on [**2173-12-22**], the patient's blood
pressure was 128/78, heart rate was 85, and oxygen saturation
83 percent on room air and 97 percent on 1.5 liters nasal
cannula. The patient was diuresed with a total of 300 mg
intravenous Lasix with no change in oxygenation. She was
also started on intravenous nitro drip. Urine output has
been about 1200 cubic centimeters over the past six hours.
Chest x-ray this a.m. is consistent with CHF. EKG consistent
with atrial fibrillation, which was new. The patient was
started on intravenous heparin drip. CT was done, which was
negative for PE, though it was one minute secondary to the
patient's obesity. Lower extremity duplexes were negative
for DVT. The patient was switched to BiPAP after an ABG
showed a PCO2 of 77 and a PAO2 of 71 on 4 liters nasal
cannula. A repeat echo was performed and revealed an EF of
55 percent, concentric LVH, new 1 to 2 plus MR, moderate
pulmonary artery hypertension.
PAST MEDICAL HISTORY: Hypertension.
High cholesterol.
Obesity.
Coronary artery disease.
Prior knee surgery.
Osteoarthritis.
Gout.
Diabetes mellitus diagnosed in [**2169**], A1c 7.4.
Obstructive sleep apnea on 2 liters CPAP for pulmonary
hypertension, noncompliant previously (no sleep study).
Hypothyroid.
Diastolic heart function.
Chronic hypoxemia.
Restrictive lung disease, ground glass, on CT.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Insulin 70/30, 42 units in the morning and 16 units in the
night.
2. Aspirin 325 mg p.o. q.d.
3. Norvasc 10 mg p.o. q.d.
4. Lisinopril 40 mg p.o. q.d.
5. Atenolol 100 mg p.o. q.d.
6. Atorvastatin 20 mg p.o. q.d.
7. Colace.
8. Indocin p.r.n.
9. Lasix 60 mg b.i.d. as of [**2173-11-8**].
10. Protonix.
11. Insulin sliding scale.
12. Hydrochlorothiazide 50 mg q.d.
13. Levoxyl.
14. Nitro drip on admission.
SOCIAL HISTORY: No tobacco, no alcohol.
FAMILY HISTORY: Positive for CAD.
PHYSICAL EXAMINATION: Vital signs: Temperature 96.2 degrees
F., pulse 95, blood pressure 112/59, respiratory rate 21,
pulse oximetry 95 percent on BiPAP. Examination: In
general, the patient is obese, comfortable appearing, in no
acute distress. HEENT: Obese. Neck veins difficult to
appreciate. Cardiovascular: Irregularly irregular, no
appreciated murmur, and no S3 or S4. Lungs: Clear
posteriorly without wheezes or crackles. Abdomen: Soft,
distended, nontender, bowel sounds positive. Extremities: 2
plus edema one-half way to the knees bilaterally. Rectal:
Guaiac positive per ED.
LABORATORY DATA: Laboratories are significant for an ABG on
[**2173-12-23**] at 10:00 a.m., which showed a pH of 7.35, a PCO2 of
61, and a PAO2 of 41 on room air. On [**2173-12-23**] at 3:45 p.m.,
pH of 7.34, PCO2 of 71, and PAO2 of 77 on 4 liters of nasal
cannula. An EKG showed atrial fibrillation at 90 with a
normal axis, normal QRS, QT, poor R-wave progression. An
echo showed elongated LA, elongated RA, moderate symmetric
LVH, and EF of 55 percent. Laboratories showed a white count
of 10.6, hematocrit of 37.7, platelets of 236,000, and
creatinine of 1.1. CK x3 were 5 and troponin x2 less than
0.01. Chest x-ray showed cardiomegaly and interstitial
edema. Chest CTA showed no PE and proximal pulmonary artery
bronchus and ground-glass opacity with question of some CHF.
HOSPITAL COURSE: Hypoxia. The patient was admitted to the
CCU for continued hypoxia requiring BiPAP in the ER. The
hypoxia was thought to be secondary to the patient's
obstructive sleep apnea and pulmonary hypertension in
addition to her diastolic heart failure, which was worsened
by the patient's new atrial fibrillation. Pulmonary
consultation was obtained. They recommended controlling the
patient's heart rate, diuresing the patient, continuing her
BiPAPs, following with a sleep study in the future, and
avoiding hypoxemia. The patient was diuresed while overnight
and was discharged to the floor. She continued with CPAPs at
night and was continued to be diuresed with Lasix with some
improvement, though continued dyspnea on exertion. On
discharge, she was able to ambulate with a cane, but was
requiring oxygen still. It was thought that the patient
would do better once she could be cardioverted, but this
would have to be done later. The patient was also continued
on ACE inhibitor for after-load reduction for her CHF, as
well as fluid restriction.
New atrial fibrillation. The patient was rate controlled
with Lopressor. She was started on a heparin drip in the ER
and also was initiated on Coumadin. The patient was planned
for outpatient cardioversion after therapeutic INRs.
Appointments were scheduled for cardioversion after
discharge.
Hematuria. The patient had episodes of hematuria after her
Foley was discontinued while on heparin. Her heparin drip
was turned down somewhat. The scale was tightened, and this
resolved. The UA and urine culture were negative. The
patient needs this hematuria to be worked up as an
outpatient.
Hypothyroidism. The patient is still hypothyroid by TSH;
however, she is already on Levoxyl. We thought that in this
initial setting, especially with atrial fibrillation, her
Levoxyl should not be increased. TFTs will be followed after
discharge and stabilization.
Diabetes mellitus. The patient was continued on a rising
insulin sliding scale and her 70/30 while in-house.
CONDITION ON DISCHARGE: Fair.
DISCHARGE FOLLOWUP: Pulmonary examination on [**2174-1-26**] and
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at that time and PFTs as
well that day. Also with Dr. [**Last Name (STitle) **] on [**2174-1-13**] at [**Company 191**],
as well as appointment for atrial fibrillation cardioversion
to be set up by Cardiology.
DISCHARGE DIAGNOSES: Hypoxia and hypoxemia.
Type 2 diabetes.
Obstructive sleep apnea.
Atrial fibrillation.
Congestive heart failure with left heart failure.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg one p.o. q.d.
2. Lisinopril 40 mg p.o. q.d.
3. Levoxyl 25 mcg p.o. once daily.
4. Atorvastatin 10 mg once at night.
5. Metoprolol 100 mg once three times a day.
6. Coumadin 7.5 mg once at night.
7. Lasix 80 mg once a day.
8. Weekly INR checks.
9. 20 units of insulin 70/30 in the a.m. and 8 units of 70/30
in the p.m.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 27875**]
Dictated By:[**Last Name (NamePattern1) 2864**]
MEDQUIST36
D: [**2174-10-31**] 15:00:14
T: [**2174-11-1**] 08:49:00
Job#: [**Job Number 101587**]
|
[
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"250.00",
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"599.7",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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2642, 2661
|
6520, 6661
|
6684, 7266
|
4070, 6101
|
2684, 4052
|
597, 1683
|
6154, 6498
|
167, 577
|
1706, 2583
|
2600, 2625
|
6126, 6133
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,080
| 132,450
|
23379
|
Discharge summary
|
report
|
Admission Date: [**2177-10-4**] Discharge Date: [**2177-10-10**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
right lower abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 83 year old female with recently complicated medical
history, including lengthy admission in [**1-4**] for anemia,
proliferative pauci-immune glomerulonephritis requiring
temporary dialysis, and RLE DVT, last admitted [**Date range (1) 59994**]/05 for
GNR bacteremia, pseudomonal PNA (gent resistant, 2 strains,
treated with meropenem), and CHF, also somewhat vent dependent
with trach collar since SICU admission [**Date range (1) 59995**] with unclear
etiology, now presenting from [**Hospital **] rehab with RLQ abdominal
pain x 3 days. Ms. [**Known lastname 59996**] was discharged to rehab on [**8-12**]
after her most recent admission as above. She had been doing
well at rehab until 3 days ago when she began complaining of RLQ
abdominal pain, and was noted to be agitated, pulling out her
PICC line 1 day prior to admission. Her last BM was the day
prior to admission and was non-bloody. She has been afebrile,
but has been taking tylenol. Denies shortness of breath,
dysuria.
.
In the ED her vitals were 97.3, HR 75, 126/50, RR 22, O2 sat
100%. Given her history of pelvic abscesses, a CT abdomen was
performed in the ED which demonstrated a large R rectus sheath
hematoma. She was seen by surgery in the ED who did not feel
operative management was necessary. Transferred to the [**Hospital Unit Name 153**] for
trach management, monitoring of hct.
Past Medical History:
1. Respiratory failure: had large pleural effusions and
bilateral pneumothoraces, s/p chest tube placement, s/p talc
pleurodesis. s/p trach, has been off vent x3 weeks, placed back
on it 2 days ago
2. Sjogren's
3. Glomerulonephritis, proliferative. Rx with prednisone and
cytoxan, required HD [**2-5**].
4. R popliteal DVT [**1-4**], rx with heparin gtt and coumadin for
approx one month (stopped [**2-5**] when admitted with GI bleed)
5. CHF, EF 55%
6. Thrombocytopenia felt [**3-5**] cytoxan (nadir at 40, had been in
200s prior to d/c in [**Month (only) 547**])
7. GI bleed adm early [**2-5**]: gastritis, esophagitis on EGD,
proctitis with erythema and small ulcers, diverticulosis on
colonoscopy. Readmitted with GI bleed later that month,
underwent left colectomy, appy, colorectal anastomosis, and
gastrostomy.
8. Pelvic abscess, adm [**3-8**], s/p drainage by surgery.
9. Elevated LFTs during hospitalization, unclr etiology s/p
extensive w/u
10. Hx CDiff colitis, treated with flagyl, oral vanc, linezolid
11. Serratia UTI (ESBL), rx with cefepime
12. Adrenal insufficiency
13. Raynaud's
14. Cryoglobulinemia
15. Peripheral neuropathy
16. Paget's disease, found incidentally on CT scan [**1-4**]
17. Secondary hyperparathyroidism
Social History:
Lived at home with her 83 y/o sister prior to hospitalization in
[**Name (NI) 404**], has been at [**Hospital1 **] since. Worked as an
administrative assistant, retired [**2162**]. Never married, has no
children. No hx tobacco. Used to drink [**3-6**] alcoholic
drinks/week.
Family History:
Positive for gastric cancer in father, otherwise negative. No
autoimmune disease.
Physical [**Month/Day (3) **]:
PE: 96.5, 75, 175/63, RR 20, 100% on AC/PS FiO2 30%, Vt 400, RR
8 (breathing 20), PEEP 5, PSV 10.
Gen: Slim caucasian female resting comfortably in bed,
communicative.
HEENT: Conjunctival injection on the R, no discharge. PEARL.
Anicteric sclerae.
Cor: RR, normal rate, no m/r/g.
Lungs: CTA anteriorly.
Abd: NABS, marked tenderness to palpation in RLQ over area of
mass with mild ecchymosis. Otherwise, no rebound, no guarding,
no rigidity, soft in other 3 quadrants. Mutliple ecchymoses at
sites of SQ heparin injections.
Extr: 1+ edema of RLE to ankle. Both feet in multipodous
boots. Ecchymoses over dorsum of hands b/l.
Rectal: Guaiac negative per ED.
Pertinent Results:
[**2177-10-4**] 07:45PM WBC-16.1* RBC-3.00* HGB-8.9* HCT-27.5* MCV-92
MCH-29.6 MCHC-32.2 RDW-18.4*
[**2177-10-4**] 07:45PM PLT COUNT-281
[**2177-10-4**] 08:16AM PT-11.9 INR(PT)-0.9
[**2177-10-4**] 08:15AM LACTATE-1.8
[**2177-10-4**] 08:10AM GLUCOSE-97 UREA N-122* CREAT-1.7* SODIUM-138
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
[**2177-10-4**] 08:10AM ALT(SGPT)-19 AST(SGOT)-24 ALK PHOS-102
AMYLASE-69 TOT BILI-0.2
[**2177-10-4**] 08:10AM LIPASE-28
[**2177-10-4**] 08:10AM CALCIUM-10.2 PHOSPHATE-2.0*# MAGNESIUM-1.8
[**2177-10-4**] 08:10AM WBC-13.9* RBC-3.08* HGB-9.0* HCT-28.2* MCV-92
MCH-29.2 MCHC-31.9 RDW-18.5*
[**2177-10-4**] 08:10AM NEUTS-86.8* LYMPHS-4.3* MONOS-6.0 EOS-2.6
BASOS-0.4
[**2177-10-4**] 08:10AM ANISOCYT-2+ MACROCYT-1+ MICROCYT-1+
[**2177-10-4**] 08:10AM PLT COUNT-293
CT abd [**2177-10-4**]:
IMPRESSION:
1. Right-sided anterior abdominal wall rectus sheath hematoma.
2. Scattered air-space opacities at the left lung base. Clinical
correlation is recommended.
_________________________
CXR [**2177-10-4**]:
IMPRESSION: Interval resolution of pleural effusions and
pulmonary parenchymal opacities. No pneumonia.
__________________________
CXR [**2177-10-10**]:
A tracheostomy tube and left PICC line remain in place. Cardiac
silhouette is upper limits of normal in size. A bilateral
central alveolar pattern shows some interval improvement. There
is mild volume loss in the right upper lobe, which is also
improved. Bilateral pleural effusions, right greater than left
show slight improvement on the right, and no significant change
in the left. There may be a subpulmonic component of the right
effusion.
IMPRESSION: Improving perihilar pulmonary edema and right upper
lobe volume loss.
___________________________
Echo [**2177-10-8**]
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Normal regional LV systolic function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. Moderate (2+) MR. LV inflow pattern c/w impaired
relaxation.
TRICUSPID VALVE: Mild to moderate [[**2-2**]+] TR. Moderate PA
systolic
hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
3. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
5. There is moderate pulmonary artery systolic hypertension.
6. Compared with the findings of the prior report (tape
unavailable for
review) of [**2177-3-25**], the severity of mitral regurgitation has
increased.
Brief Hospital Course:
83 year old female with multiple medical problems, and multiple
recent admissions, last discharged to rehab on [**8-12**], presenting
with RLQ pain, found to have large rectus sheath hematoma, acute
on chronic renal failure.
.
1) Rectus sheath hematoma: Likely secondary to SQ heparin
injections plus possibly uremic platelets. INR < 1.0, hct
relatively stable, currenlty stable at 25 for 3 days. Surgery
was consulted at the ED and recommended no surgical intervention
at the present time. Patient is status post transfusion of 4
units of PRBCs to keep Hct above 25. Suggest checking labs qd
or qod, and transfuse PRBCs if Hct drops below 20. Pain was
well controlled with PRN percocet and morphine. platelets WNL.
Patient had very poor IV access so IR was consulted and placed a
PICC line in the L arm.
.
2) Acute on chronic renal failure: As above, etiology of chronic
renal failure unclear. Appears to have returned to creatinine of
0.9 in [**5-6**], last found to be 1.1 in [**8-5**], now up to 1.7. BUN
also elevated, suggesting pre-renal, however BUN possibly also
elevated from hematoma resorption. Most likely pre-renal in the
setting of blood loss, and FENa of 0.8. Renal was consulted on
the patient and recommended hydration in addition to placing the
patient on qod EPO injections in the setting of chrnoic renal
disease. Patient's steroids (for h/o glomerulonephritis) were
continued during her stay in the ICU. Patient with hx of pauci
immune glomerulonephritis treated with steroids/cytoxan.
Baseline Cr. 0.9. Last value here was 1.6. In addition BUN>>Cr,
likely secondary to degradation of hematoma.
.
3) Ventilator dependence: It is unclear what caused the patient
to be intubated to begin with - occurred during a long SICU
course in the setting of bilateral pleural effusions and
pneumothoraces, s/p talc pleurodesis and tracheostomy formation.
Has been on pressure support 10 for the most part, PEEP of 5
tolerating intermittent trach mask with FiO2 28%. She even
tolerated a spontaneous breathing trial on trach mask for > 6
hours. However, patient had several episodes of desaturation
down into the 80s during her ICU stay, thought to be due to 1.
Fluid overload in the setting or worseing MR (as revealed by the
echo performed during this hospital stay); 2. Pneumonia due to
Gr- rods found in her sputum (speciating and sensitivities
pending). As a result, her ventilator setting had to be turned
up: pressure support, PEEP, and FIO2 were increased, though
intermitently. The patient was already treated with Imipenem
(for resistant kliebsiella UTI, see below), so no futher gram
negative coverage was needed. In addition, she was aggessively
diuresed with Lasix gtt, and aggressively afterload reduced with
isordil, hydralazine, and verapamil. Her labetalol and
amlodipine were thought to be suboptimal in managing her heart
failure with fluid overload and were discontinued. On the day
of discharge, the patient was back on her vent settings of
Pressure support 5/PEEP 5, 30% FIO2 and diuresing >200cc/hr on
4mg/hr lasix gtt. She should be weaned off lasix drip and
transitioned to standing lasix pending the resolution of
pulmonary edema on her CXR. Her afterload reduction should be
adjusted based on her blood pressures.
.
UTI: resistant kleibsiella was cultured from her urine.
Sensitivies were as follows:
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
.
She was started on Imipenem based on her h/o of allergies to
b-lactams. Imipenem was thought to have least incidence of
x-reactivity, and the patient tolerated the treatment well. She
has received 4 days of treatment, and should be continued on the
same regimen for 10 more days (20 total doses). Repeat cultures
of her urine and of her sputum should be obtained.
.
.
4) Leukocytosis: Chronic since [**4-5**], possibly secondary to
steroids. In addition, see infections as above. On the day of
discharge, the WBC count was 15.5, similar to admission Hct.
Appears to be at recent baseline, patient afebrile, without
complaints other than abdominal pain attributed to hematoma.
Mild neutrophilia, chronic, c/w steroid effect.
.
5) Anemia: Chronic, baseline appears to be around 29. Iron
studies c/w anemia of inflammation in the recent past, repeated
in house as well. Has required numerous transfusions in the
past, as well as epo. Also with h/o GI bleed, guaiac negative
here. Re-started on EPO while in house.
.
6) History of adrenal insufficiency: Continued on outpatient
dose of prednisone.
.
7) Atrial fibrillation: History of AF, patient has been in sinus
while stayin in the ICU. Patient coumadin was held in the
setting of recent bleed, but was restarted at a lower dose due
to h/o popliteal DVT in [**2177-2-1**]. She should be kept on
coumadin qhs and titrated to INR of [**3-6**]..
.
8) Hypertension: patient's medication were changed to verapamil,
isordil and hydralazine. Regimen should be optimized at your
discretion. Blood pressures stayed between 100-140/50-70 during
her stay.
.
9) FEN: we continued her J-tube feeds. Recs as per discharge
worksheet.
.
10) PPx: we held the SubQ heparin due to recent bleed, but
maintained the patient on pneumoboots, giving her intermittent
breaks for comfort.
11) Access: R PIV.
.
12) Code: DNR. confirmed with patient and her sister, who makes
the majority of medical decisions for her. Phone No.
[**Telephone/Fax (1) 59997**].
.
13) Communication: [**First Name8 (NamePattern2) 2429**] [**Name (NI) 47550**], sister, [**Telephone/Fax (1) 59997**]
.
14) Dispo: Will return to rehab when hematoma stabilized. ICU
while in house for resp care. likely to go to rehab on Tuesday,
[**10-7**].
Medications on Admission:
1. Prednisone 20 mg PO DAILY
2. Lansoprazole Suspension 60 mg PO BID
3. Ursodiol 300 mg PO BID
4. Ascorbic Acid 90 mg/mL Drops 5 PO DAILY
5. Lorazepam 0.25 mg PO Q4-6H PRN
6. Polyvinyl Alcohol 1.4 % x 1-2 Drops Ophthalmic PRN
7. Heparin Sodium 5,000 unit TID
8. Nystatin 2.5 ML PO TID
9. Acetaminophen 320 mL PO Q4-6H PRN
10. Regular insulin sliding scale
11. Labetalol 400 mg PO TID
12. Amlodipine 10 mg PO DAILY
13. Morphine 2 mg Q4H as needed for dressing change.
14. Gabapentin 200 mg PO QHS
15. Tramadol 25 mg Q4 PRN
16. Quinine 325 PO QHS
17. Albuterol NEBS Q4 hours, Q2 hours PRN
18. Epo
19. Senna 10 ml PO QHS
20. Mirtazapine 7.5 mg PO QHS
21. Simethicone 80 mg PO QID
22. Ferrous Sulfate 300 mg PO TID
23. Folic acid 1 mg PO QDay
24. Zinc 220 mg PO Qday
25. Bisacodyl 10 mg PO qday
26. MVI
27. Lactulose 20 grams PO daily
Discharge Medications:
1. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*qs Capsule(s)* Refills:*2*
3. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4-6H (every 4 to 6
hours) as needed.
Disp:*qs Tablet(s)* Refills:*0*
4. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*qs Capsule(s)* Refills:*2*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*qs qs* Refills:*0*
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
Disp:*qs qs* Refills:*2*
7. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*qs Tablet(s)* Refills:*2*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*qs Tablet(s)* Refills:*0*
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*qs qs* Refills:*2*
11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
12. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs ML(s)* Refills:*0*
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*qs qs* Refills:*0*
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*0*
15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
16. Morphine Sulfate 1-2 mg IV Q4H:PRN
ONLY FOR USE IF PERCOCET NOT EFFECTIVE
17. Imipenem-Cilastatin 500 mg IV Q12H
18. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
19. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*qs Capsule, Delayed Release(E.C.)(s)* Refills:*2*
20. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
21. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
Disp:*qs Tablet, Chewable(s)* Refills:*0*
22. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
23. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
24. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMO, WE, FRI ().
Disp:*qs Tablet(s)* Refills:*2*
25. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs qs* Refills:*2*
26. Isosorbide Dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
27. Furosemide 10 mg/mL Solution Sig: 4mg/hr gtt Injection
INFUSION (continuous infusion).
Disp:*qs qs* Refills:*2*
28. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
titrate up to INR of [**3-6**].
Disp:*qs Tablet(s)* Refills:*2*
29. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*2 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Rectus Sheath Hematoma
Kliebsiella Urinary Tract Infection
Respiratory Failure due to Pulmonary Edema and Fluid Overload
Acute on Chronic Renal Failure
Anemia of Chronic Inflammation
Discharge Condition:
stable, on pressure support ventilation, good O2 sats, good
urine output
Discharge Instructions:
-please take all medications as directed
-please monitor urine output and change foley catheter as needed
-continue Imipenem 500 IV q12 for two weeks for resistant
kliebsiella UTI
-continue pressure support ventilation, 5 Pressure Support, 5
PEEP, FIO2 30%. Wean as tolerated
-continue afterload reduction with isordil, hydralazine and
verapamil
Followup Instructions:
Provider [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 59986**] Call to schedule
appointment
Completed by:[**2177-10-10**]
|
[
"396.3",
"582.0",
"V44.0",
"285.29",
"E934.2",
"599.0",
"710.2",
"728.89",
"398.91",
"255.4",
"285.1",
"518.83",
"V58.65",
"584.9",
"427.31",
"V44.4",
"588.81",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.04",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17365, 17444
|
7130, 13256
|
246, 252
|
17671, 17746
|
4036, 7107
|
18141, 18306
|
3233, 4017
|
14139, 17342
|
17465, 17650
|
13282, 14116
|
17770, 18118
|
180, 208
|
280, 1655
|
1677, 2920
|
2936, 3217
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
456
| 113,035
|
53266
|
Discharge summary
|
report
|
Admission Date: [**2197-11-16**] Discharge Date: [**2197-11-22**]
Date of Birth: [**2150-7-30**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 47 year old
male without any significant cardiovascular history who,
while exercising this morning on the exercise bike at the
gym, slumped over and, according to eyewitnesses, was caught
and lowered by his neighbor. [**Name (NI) **] was given chest compression
when found to be pulseless by a witness and was defibrillated
times two by a portable defibrillator sensing probably
ventricular fibrillation. Estimated time to defibrillation
was five to 10 minutes. He was intubated and transported to
[**Hospital3 20284**] Center. In the E.D. he was found to be
agitated, dyspneic and unresponsive to commands. He was
given Lopressor and nitroglycerin. His agitation and
difficulty ventilating were improved with vecuronium and
Ativan. He apparently had an exercise tolerance test earlier
this year, exercising to stage 4 without any symptoms. It
was unclear at the time of admission why this test was
obtained. His cardiovascular risk factors included use of
tobacco, hypertension and hypercholesterolemia.
PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia.
OUTPATIENT MEDICATIONS: BuSpar.
ALLERGIES: Unknown.
FAMILY HISTORY: Unknown.
PHYSICAL EXAMINATION: On admission the patient was sedated
and intubated. Vital signs were blood pressure of 102/57,
pulse 90, afebrile, O2 sat 98% to 100% on assist control
ventilation with FiO2 of 60%.
LABORATORY DATA: On admission sodium was 139, potassium 4.4,
chloride 101, bicarb 21, BUN 16, creatinine 1.5, glucose 196.
White blood cell count was 15, hematocrit 48.6, platelets
380.
HOSPITAL COURSE: The patient was emergently taken to the
cath lab where coronary angiography was done which showed a
right dominant system with two vessel coronary artery
disease. The left main coronary artery was angiographically
normal. The proximal LAD had discrete 99% stenosis with some
haziness at the distal pole of the lesion suggesting
thrombus. The remainder of the LAD had mild luminal
irregularities as well as focal 50% stenosis in the mid-LAD.
The first diagonal branch had 50% proximal stenosis. The
left circumflex artery had mild luminal irregularities and
produced a first obtuse marginal that was of moderate caliber
and had 90% proximal stenosis. The RCA had mild luminal
irregularities and 30% to 40% mid-RCA stenosis. The LAD was
stented without dissection and without residual stenosis and
TIMI 3 flow.
Over the course of his stay in the hospital the patient
remained hemodynamically stable and was successfully
extubated. He was continued on aspirin and Plavix.
Lopressor and captopril were added to his regimen as
tolerated by his blood pressure. Repeat echocardiogram
showed left ventricular cavity size to be normal. Overall
left ventricular systolic function was mildly depressed with
mild septal hypokinesis. No LV thrombus was seen. Aortic
valve leaflets were mildly thickened and mitral valve
leaflets were also mildly thickened with 1+ mitral
regurgitation. In comparison with the previous study there
was marked improvement in LV function.
In light of questionable thrombus on the first
echocardiogram, the patient was started on Coumadin with
cross coverage with heparin. On day of discharge the
patient's INR was therapeutic at 2.3 and heparin was
discontinued. During the course of his stay the patient was
also started on Lipitor 10 mg q.day. During his stay in the
hospital the patient reported some short term memory loss and
was scheduled to follow up with Dr. [**First Name8 (NamePattern2) 17804**] [**Last Name (NamePattern1) **] in
behavioral neurology clinic.
The patient was discharged home with VNA to help with
medication education and monitoring of INR levels for
anticoagulation.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.day.
2. Lopressor 25 mg p.o. b.i.d.
3. BuSpar 5 mg p.o. t.i.d.
4. Lipitor 10 mg p.o. q.day.
5. Benadryl 25 mg p.o. q.six hours p.r.n.
6. Plavix 75 mg p.o. q.day for one month.
7. Sublingual nitroglycerin 0.4 mg p.r.n. for chest pain.
8. Zestril 2.5 mg p.o. q.day.
9. Coumadin 3 mg p.o. q.h.s.
DISCHARGE DIAGNOSIS: Acute MI with v-fib arrest status post
cath and stent to LAD.
DISCHARGE STATUS: Discharged home.
CONDITION ON DISCHARGE: Stable.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2197-11-28**] 18:15
T: [**2197-11-30**] 08:38
JOB#: [**Job Number 109626**]
|
[
"414.01",
"427.5",
"305.1",
"272.4",
"401.9",
"780.9",
"427.89",
"410.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"88.56",
"36.01",
"37.23",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1329, 1339
|
3906, 4234
|
4256, 4356
|
1752, 3883
|
1281, 1312
|
1362, 1734
|
163, 1195
|
1218, 1256
|
4381, 4656
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,968
| 176,478
|
6739
|
Discharge summary
|
report
|
Admission Date: [**2122-7-25**] Discharge Date: [**2122-7-31**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 80 year-old
male with a history of coronary artery disease, status post
prior left anterior descending artery stent, congestive heart
failure with a known ejection fraction of 60 to 65% by
echocardiogram one year ago, diabetes, chronic renal
insufficiency, hypertension, who was admitted with a several
week history of substernal intermittent chest pain both at
rest and with exertion for which he is taking multiple
sublingual nitroglycerin per day. The pain typically resolves
with one to two sublinguals. This morning the patient
experienced his usual substernal chest pain which was
unresolved after two sublingual nitroglycerin. The patient
had no associated shortness of breath, diaphoresis or
lightheadedness.
REVIEW OF SYSTEMS: Notable for a chronic dry, nonproductive
cough. The patient denies having recorded fevers at home. No
abdominal pain, nausea, vomiting. The patient has had some
chronic diarrhea. No bright red blood per rectum, no melena.
The patient's current chest pain is equal to his anginal
equivalent. The patient after taking the three sublingual
nitroglycerin at home without relief the patient called EMS.
En route he got an aspirin and three additionally sublingual
nitroglycerin.
In the Emergency Department his blood pressure was 200/100
with a heart rate of 100, respiratory rate of 20, temperature
101.0 F. His O2 saturation was initially unrecordable.
Initial ABG revealed a PaO2 42 which improved with diuresis
and Morphine to PaO2 of 79. Both on 100% nonrebreather.
EKG initially showed sinus tachycardia at 111 beats per
minute with a right bundle branch block which was new. Repeat
EKG showed 1 to [**Street Address(2) 1766**] depressions in leads V4 through V6 as
well as aVL.
In the Emergency Department the patient was given 40 mg of IV
Lasix, 5 mg of IV Lopressor and started on a Heparin drip.
Chest x-ray was suggestive of CHF with question of a right
base infiltrate. The patient had one episode of bilious
emesis times one after getting Nitroglycerin. He was
subsequently started on Nitroglycerin drip and his blood
pressure was noted to drop to the 80s systolic, even at two
units per hour. The Nitro drip was shut off. The patient got
an additional dose of Morphine and Zofran. He was also given
500 mg of IV Levaquin and 800 mg of IV Flagyl after blood and
urine cultures were sent. The patient's labs were notable for
elevated white blood cell count, bicarbonate of 15 with an
anion gap of 18 and a lactate of 3.6.
On arrival to the floor the patient was complaining of
persistent [**3-29**] substernal chest pain and was made pain free
with upward titration of the Nitroglycerin drip and
additional 2 mg of IV Morphine.
Review of systems reveals that the patient has baseline
dyspnea on exertion and baseline rest angina as documented.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes with hemoglobin A1C of 9.6. The patient is
poorly compliant with finger sticks per his wife. Hemoglobin
A1C was recorded on [**2122-3-20**].
3. Elevated cholesterol.
4. Peripheral vascular disease status post AAA repair,
status post femoral popliteal bypass surgery, status post
bilateral toe amputations.
5. Chronic renal insufficiency with prior baseline
creatinine of 2 to 3 several months ago.
6. Coronary artery disease status post recent stent to the
left anterior descending coronary artery.
7. Congestive heart failure thought to be diastolic
dysfunction with prior ejection fraction of 60 to 65 % by
echo in [**2121-3-20**].
ADMISSION MEDICATIONS:
1. Digoxin 0.125 mg po q day.
2. Lasix 40 mg po q day.
3. Lopressor 50 mg po bid.
4. Lipitor 10 mg po q day.
5. Isordil 20 mg po bid.
6. Prn Nitroglycerin.
7. Regular insulin approximately 7 units q A.M. and NPH
insulin 55 units q A.M.
ALLERGIES: The patient with no known drug allergies.
SOCIAL HISTORY: The patient admits to half a pack per day of
smoking times 60 years although he is not currently using. No
current alcohol or drug use.
FAMILY HISTORY: Notable for coronary artery disease in his
mother and father.
PHYSICAL EXAMINATION: Vital signs on arrival to the floor
temperature 99.4 F, pulse 84, blood pressure 150/112,
saturation 93 to 97% on two liters nasal cannula.
Physical exam showed an elderly patient awake, alert and
oriented, in no obvious distress. HEENT - slightly dry oral
mucosa. Neck - notable for jugular venous distention to just
below the angle of the jaw. Cardiovascular - regular rate and
rhythm, distal heart sounds, no appreciable murmurs. Lungs -
decreased breath sounds at the bases bilaterally with trace
bibasilar crackles. Abdomen is soft, nontender. Abdomen is
soft, nontender with partially reproducible midline hernia
which is also nontender. There are active bowel sounds
throughout. Extremities - no significant lower extremity
edema. The patient was chronic venous stasis / post surgical
skin changes with dopplerable lower extremity pulses. The
rectal examination was guaiac negative per the ED exam.
INITIAL LABORATORY DATA: White blood count 19.5, hematocrit
28.5, platelet count 288,000. INR 1.3, sodium 137, potassium
5.4, chloride 104, bicarbonate 15, BUN 66, creatinine 4.5,
glucose 294. Urinalysis was negative. Digoxin level was 0.3,
lactate was 3.6. LFTs were within normal limits. Magnesium
1.7, calcium 8.6, phosphate 6.2, albumin 3.6. CK peaked at
187 with Troponin of 48.7.
HOSPITAL COURSE:
1. Cardiovascular - The patient with a known history of
coronary artery disease with known two vessel disease and
recently stented left anterior descending coronary artery
presenting with unstable angina with refractory chest pain.
EKG initially showed new right bundle branch block
alternating with left bundle branch block. The patient had
evidence of lateral ST depressions with normal QRS
morphology. The patient was ultimately made pain free with IV
Nitroglycerin. He was started on Heparin which he received
for approximately 48 hours. His CK is peaked at 187 with a
maximum Troponin of 48.7. He was not started on 2B3 inhibitor
given severe renal failure.
Initial chest x-ray revealed congestive heart failure. The
patient was initially severely hypoxic but responded to
diuresis and Morphine with resolution of his chest pain
symptoms the patient remained essentially pain free without
complaints of chest pain or dyspnea throughout the remainder
of his hospital stay. He received some additional gentle
diuresis while in the Intensive Care Unit to which he
responded readily. He required no further diuresis and had
clear lung exam throughout the remainder of his hospital
stay. His O2 saturations gradually improved with treatment of
his congestive heart failure and IV antibiotics for potential
pneumonia. The patient was also continued on his Lipitor for
his history of hypercholesterolemia.
On [**2122-7-28**] the patient had an echocardiogram which revealed
ejection fraction of 20% down from prior echo showing normal
systolic function. He also had multiple new wall motion
abnormalities most notable for inferior and lateral akinesis,
as well as RV systolic dysfunction and new 3+ mitral
regurgitation. The patient also with severe anterior
hypokinesis. TTE showed no evidence of valvular vegetations.
However given history of positive blood cultures, fever, new
conduction abnormalities and new mitral regurgitation, the
patient underwent a transesophageal echo to further rule out
endocarditis. Again there was no evidence of valvular
vegetations or abscess.
Given renal failure the patient was not continued on his Ace
inhibitors. He was started on Isordil and Hydralazine for
after load reduction and these were gradually titrated up
throughout the remained of his hospital stay. Prior to
discharge we discussed repeat cardiac catheterization after
the resolution of the patient's infection for diagnosis and
possible therapeutic intervention. Given the possibility that
the patient might end up on dialysis following cardiac
catheterization, the patient was opposed to undergoing
cardiac catheterization at this time. He will be set up with
Cardiology follow up and will be treated conservatively with
medical management at the current time.
2. Infectious Disease - The patient presented with a low
grade fever and evidence of a right sided pneumonia on chest
x-ray. He was initially started on Levaquin and Flagyl. Blood
cultures were ultimately positive in two out of four bottles
for Group B strep without a clear source. Repeat chest x-ray
was also suggestive but not definitive for a right sided
pneumonia. The patient had no symptoms suggestive of a
pneumonia aside from a chronic cough and some hypoxia which
could be attributed to congestive heart failure. The patient
was ultimately started on IV Ceftriaxone and then switched to
IV Penicillin following sensitivities on the Group B strep.
Possible sources included endocarditis, pneumonia, or skin or
bone sources.
The patient underwent a left foot plain film to rule out
osteomyelitis since he has a chronic left lateral foot
ulceration. This film was negative for either soft tissue or
bony involvement. Repeat serial blood cultures were negative.
On the day of discharge the patient was noted to have a small
increase in his potassium to 5.5. Given the fact that the
penicillin antibiotics were mixed and potassium the patient
was switched to IV Ceftriaxone to complete a 14 day course of
antibiotics.
3. Renal - The patient presenting with acute and chronic
renal insufficiency with prior baseline creatinine of 2 to 3
and now with a creatinine of 4 to 5. This was thought to be
either secondary to acute hypotensive episode in the setting
of his cardiac ischemia versus chronic renal insufficiency
which may actually have triggered his congestive heart
failure secondary to volume overload. The patient was
initially gently diuresed. His Ace inhibitors was held. Renal
consult was obtained for a question of a need for future
dialysis in case we went to cardiac catheterization. The
renal team recommended starting po bicarbonate for his
chronic acidosis as well as Epogen for anemia of chronic
disease. They recommended a renal ultrasound which showed
some evidence of left renal artery stenosis by doppler. They
also recommended pursuing a renal MRI / MRA in case the
patient might benefit from a intervention to stent one of his
renal arteries in hopes of improving renal profusion and
preventing need for future dialysis.
We were going to proceed with this plan although the patient
was opposed to having an MRI done given prior history of
claustrophobia and need to discontinue an MRI. Given that the
patient has also been opposed to cardiac catheterization
given risk of renal failure and dialysis will plan to consult
with the patient's primary care physician. [**Name10 (NameIs) **] issue of an
MRI with renal artery intervention may be further addressed
in the future.
4. Hematology - The patient with enema, iron studies
consistent with anemia of chronic disease. The patient was
started on Epogen and iron during this hospitalization.
5. Endocrine - The patient with diabetes. He was continued
on NPH and an insulin sliding scale.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Congestive heart failure with decreased ejection
fraction.
3. Group B strep bacteremia.
4. Acute and chronic renal failure.
5. Anemia of chronic disease.
6. Diabetes.
DISCHARGE MEDICATIONS:
1. NPH insulin 27 units q A.M., 10 units q P.M.
2. Regular sliding scale insulin.
3. Hydralazine 50 mg po tid.
4. Iron Sulfate 325 mg po tid.
5. Tums 500 mg po tid with meals.
6. Lipitor 10 mg po q day.
7. Lopressor 50 mg po bid.
8. Enteric coated aspirin 325 mg po q day.
9. Sublingual Nitroglycerin 0.3 mg sublingual prn chest
pain.
10. Lasix 20 mg po qod.
11. Isordil 30 mg po tid.
12. Ceftriaxone 1 gram IV q 24 hours times nine days to
complete a 14 day course.
13. Sodium bicarbonate 1300 mg po bid.
DISCHARGE INSTRUCTIONS:
1. The patient should have daily weights checked. His "dry
weight" at discharge was 156 lbs.
2. The patient's Lasix does should be adjusted if he is
noted to have fluctuations with his daily weights.
3. For at least the next two to three days the patient
should have daily chem 7 to follow his potassium and
creatinine. The patient was noted to have elevated potassium
at the time of discharge thought secondary to renal failure
plus potassium which the patient was getting in his
antibiotic solution. Antibiotic was changed at the time of
discharge. The patient should be given additional doses of
Kayexalate if his potassium remains in the mid 5.
DISCHARGE FOLLOW UP: The patient should follow up with
Nephrology, Cardiology and his primary care physician as
noted on page one.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2122-7-31**] 11:04
T: [**2122-7-31**] 11:24
JOB#: [**Job Number 25642**]
|
[
"272.0",
"413.9",
"584.9",
"V45.82",
"403.91",
"250.00",
"790.7",
"285.29",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
11280, 11289
|
4113, 4176
|
11538, 12054
|
11310, 11515
|
5513, 11258
|
12078, 12741
|
3644, 3943
|
12752, 13141
|
4199, 5496
|
868, 2928
|
112, 848
|
2950, 3621
|
3960, 4097
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,102
| 100,995
|
5861
|
Discharge summary
|
report
|
Admission Date: [**2135-3-4**] Discharge Date: [**2135-3-15**]
Date of Birth: [**2060-11-2**] Sex: M
Service: MEDICINE
Allergies:
Ampicillin / Dilantin / Haldol / Ceftazidime
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 23203**] is a 74 yo male with recent history of CVA ([**12/2134**]) on
coumadin who presented with rhinorrhea (3 days), productive
cough (2 days) and mental status change (over the 16 hours PTA).
The night PTA, he had restless sleep, woke at 3:30am and
showered to get ready for the day. His wife got up at 6:30 and
prepared breakfast. Prior to breakfast he was sitting [**Location (un) 1131**]
the newspaper and his wife noted that he was "shaking" badly.
He commented that he was "cold". She took his temp, which was
97F. They sat down to eat breakfast and he began to act odd.
He sat very far away from the table. With prompting, he scooted
to the table. He then was unable to properly use his fork to
eat his eggs. His wife then called her PCP who recommended that
they go to the ED. She called 911.
Per the ED report (but no documentation in the chart), the pt
was hypoglycemic in field to 27 and received dextrose.
In the ED, he had a head CT that was negative for bleed or
infarct. Glucose was 108. He had a temperature of 104.
Initially his VS were BP 133/78, H 84 and evolved to 90-100s
systolic and HR of 100-120s. He was given dilt 5mg x 2 for RVR.
CXR was initially read as right middle lobe infiltrate and he
was given ceftriaxone 1 g and azithromycin 500mg. There was
some discussion about meningitis, but he was not given
meningitis doses of medications. His neurologist felt that this
was less likely meningitis and recommended against LP in the
setting of therapeutic INR.
When he arrived to the MICU, his SBPs were in the 70s. An
arterial line was placed. He was bolused 4 more liters with
improvement to 90-100s.
ROS: +cough, +rhinorrhea, -diarrhea, -chest pain, -urinary
problems
Past Medical History:
Traumatic Subdural/Subarachnoid hemorrhage- ([**2124**]) relating to
fall in setting of ? alcohol use. No apparent residual symptoms.
Hypertension
Hypercholesterolemia
Bipolar disorder- well controlled on depakote
Depression- on effexor
? BPH- tried flomax and developed orthostatic
syncope/hypotension.
? Delirium with prior hospital admission for SDH/SAH.
? Atrial fibrillation
Social History:
lives at home with his wife, retired schoolteacher and coach
for baseball, football and other sports, 3 grown children live
in
the [**Location (un) 86**] area, ? history of alcoholism, currently rarely
drinks, had 2 drinks last night for new year's celebration, no
h/o illicit drug use.
Family History:
Mother- had DM, had strokes in her 50's
[**Name (NI) 12238**] CAD
[**Name (NI) 8765**] died from DM complications
Physical Exam:
MICU Admission Exam:
T: 103.0 rectal BP: 84/52 NIBP, 97/52 Art line P: 106 afib RR:
17 O2 sats: 96% 4LNC
Gen: lethargic
HEENT: icteric injected, PEERL 3-2mm, OP with dry mucous
membranes
Neck: JVP flat
CV: tachy, slightly irregular, distant
Resp: clear anteriorly
Abd: +BS, slightly distended, non-tender
Ext: bruise on right arm, No edema/warm 2+ pulses
Neuro: lethargic, oriented x 3, short-term memory difficulty,
5/5 strength,
Pertinent Results:
ADMISSION LABS:
[**2135-3-4**] 10:50AM BLOOD WBC-11.1* RBC-5.33 Hgb-16.0 Hct-46.6
MCV-88 MCH-30.1 MCHC-34.4 RDW-13.4 Plt Ct-217
[**2135-3-4**] 10:50AM BLOOD Neuts-77* Bands-15* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2135-3-4**] 10:50AM BLOOD PT-25.4* PTT-30.0 INR(PT)-2.5*
[**2135-3-4**] 10:50AM BLOOD Glucose-113* UreaN-17 Creat-0.8 Na-137
K-4.2 Cl-99 HCO3-27 AnGap-15
[**2135-3-4**] 10:50AM BLOOD ALT-38 AST-24 AlkPhos-60 TotBili-0.8
[**2135-3-5**] 04:03AM BLOOD Albumin-3.2* Calcium-7.3* Phos-2.3*
Mg-1.5*
[**2135-3-4**] 03:07PM BLOOD Type-ART pO2-213* pCO2-29* pH-7.50*
calTCO2-23 Base XS-0
[**2135-3-4**] 11:06AM BLOOD Lactate-2.6*
[**2135-3-4**] 10:50AM BLOOD Valproa-41*
[**2135-3-4**] 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2135-3-10**] 07:10AM BLOOD VitB12-1148*
[**2135-3-9**] 07:10AM BLOOD calTIBC-229* Ferritn-762* TRF-176*
[**2135-3-10**] 07:10AM BLOOD TSH-1.3
[**2135-3-10**] 07:10AM BLOOD Free T4-1.1
IMAGING:
[**2135-3-4**] CT HEAD W/O CONTRAST:
1. No acute intracranial hemorrhage or major vascular
territorial infarct. If
there is continued concern for ischemia, MRI with DWI is more
sensitive.
2. Extensive bifrontal encephalomalacia.
[**2135-3-4**] CXR:
Likely right middle lobe pheumonia; follow up in 6 weeks
recommended
MICROBIOLOGY:
[**2135-3-5**] INFLUENZA DFA: Positive for Influenza A viral antigen.
[**2135-3-11**] RIGHT CHIN DFA of VESICULAR RASH: Positive for Herpes
Simplex Virus Type 1 by direct antigen staining
[**3-4**], [**2135-3-5**] Blood cultures: no growth
[**2135-3-5**] Urine cultures: no growth
[**2135-3-5**] Sputum: OP flora
[**2135-3-7**] ECHOCARDIOGRAM:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Suboptimal image quality. Normal
biventricular cavity sizes with preserved global biventricular
systolic function. Mild mitral regurgitation. Trace aortic
regurgitation. Dilated ascending aorta.
Brief Hospital Course:
RESPIRATORY SYMPTOMS:
Mr. [**Known lastname 23203**] is a 74 yo male who presented with a three-day history
of progressive respiratory symptoms (rhinorrhea, productive
cough, fevers) and mental status change. He was found to have a
RML pneumonia radiographically and was positive for influenza A.
On presentation, he initially required aggressive fluid
resuscitation, but thereafter remained hemodynamically stable.
He required admission to the MICU for hypotension and concern
for sepsis. He was started empirically on vancomycin and
ceftrazidime, as well as tamiflu for influenza. Sputum cultures
were negative. He competed a five day course of levofloxacin
and tamiflu.
CHANGE IN MENTAL STATUS:
The patient's course was complicated by delirium, in particular
sun-downing in the evenings. This was felt to be due to his
underlying flu, pneumonia and the ICU environment. He became
significantly agitated at night, requiring chemical and
mechanical restraints. He also required a 1:1 sitter for
safety. The decision was made to start the patient on a low
dose of seroquel early in the evening, although this was
discontinued by the time of discharge. His mental status
dramatically improved with treatment of his underlying lung
processes, and he was doing crossword puzzles and had no
evidence of delirium upon discharge.
ATRIAL FIBRILLATION WITH RVR:
While in the ICU, the patient was noted to have AFib with RVR
with heart rates as high as 150 during periods of intense
agitation. He was started on a diltiazem drip. He later became
hypotensive and was temporarily on digoxin until blood pressure
stabilized, at which point he was restarted on home lopressor.
An ECHO was also obtained which showed normal cardiac function.
He was maintained on coumadin for anticoagulation, though his
INR was labile while on antibiotics.
HSV-1 OUTBREAK:
The patient was noted to have multiple vesicular lesions on the
upper and lower lips in the mid-line, as well as a small area of
vesicles on the right chin and right neck. DFA was positive
for HSV-1. He was started on a short course of acyclovir PO.
**** PENDING ISSUES FOR FOLLOW-UP:
(1) He needs an INR check with necessary Coumadin dosage
adjustment on Friday, [**3-18**]. This is to be done by the PCP
[**Name Initial (PRE) 3726**].
Medications on Admission:
Venlafaxine SR 225 mg QHS
Divalproex 500 mg Tablet Sustained Release QHS
Warfarin 3 mg QHS
Metoprolol Tartrate 50 mg [**Hospital1 **]
Discharge Medications:
1. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO at bedtime.
2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours.
4. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
Influenza
Secondary Diagnoses:
Hypertension
Hypercholesterolemia
BPH
Discharge Condition:
Stable-- feeling well; breathing comfortably and satting in the
upper 90's on room air at rest and on ambulation. Uses a cane
for ambulation, as before.
Discharge Instructions:
You were admitted to the hospital with influenza. Please call
your doctor if you develop new symptoms such as shortness of
breath or fever. Please return to the emergency department if
you cannot reach your doctor.
Followup Instructions:
Please see your primary care doctor, Dr. [**First Name8 (NamePattern2) 951**] [**Last Name (NamePattern1) **], on
Friday, [**3-18**], at 9 am. His office number is [**Telephone/Fax (1) 6163**].
You also need to have your coumadin levels checked at this
appointment.
|
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"401.9",
"285.9",
"V70.7",
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"995.92",
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"251.2",
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icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
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] |
9067, 9125
|
6114, 6806
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313, 320
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9258, 9414
|
3399, 3399
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9197, 9237
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264, 275
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348, 2090
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3415, 6091
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6821, 8419
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2112, 2493
|
2509, 2798
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,726
| 121,696
|
44702
|
Discharge summary
|
report
|
Admission Date: [**2160-8-15**] Discharge Date: [**2160-8-22**]
Date of Birth: [**2114-1-7**] Sex: F
Service: MED
Allergies:
Penicillins / Codeine / Kefzol / Strawberry / Vancomycin
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
pus from right groin hemodialysis catheter, missed hemodialysis
Major Surgical or Invasive Procedure:
Right hemodialysis catheter removal on [**2160-8-17**]
History of Present Illness:
The patient is 46 y.o. female with end-stage renal disease on
hemodialysis, HCV, history of stroke, and polysubstance abuse
with multiple episodes of hypertensive urgencies who was
referred to the ED for hemodialysis and questionable line
infection. The patient missed her Thursday dialysis. She
reported pain in her right thigh in the area of her dialysis
catheter. She denied any fevers/chills/nausea/vomiting. She does
however report diarrhea and shortness of breath which improved
after dialysis.
In the ED, it was noted that the patient's systolic blood
pressure was 250/152 with a heart rate of 87. She was started on
a labetolol drip and transferred to the unit. She received
gentamicin, levoquin and vancomycin with her hemodialysis.
Past Medical History:
End-stage renal disease on hemodialysis
Hypertension
Hepatitis C
Polysubstance abuse
Stroke with residual R sided weakness
Asthma
Bilateral internal jugular deep vein thromboses
Depression with a history of suicidal ideation
History of small bowel obstruction s/p resection
Septic arthritis
Social History:
Unemployed, lives with children, denies etoh, smokes 1
pack/3days. + cocaine use 2 weeks ago prior to admission.
Physical Exam:
VS
General -
Pertinent Results:
[**2160-8-15**] 12:46PM GLUCOSE-81 UREA N-65* CREAT-8.6*# SODIUM-143
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-19* ANION GAP-20
[**2160-8-15**] 12:46PM CK(CPK)-75
[**2160-8-15**] 12:46PM CK-MB-NotDone cTropnT-0.10*
[**2160-8-15**] 12:46PM ACETONE-TRACE
[**2160-8-15**] 12:46PM WBC-6.5 RBC-4.27 HGB-11.8* HCT-37.7 MCV-88
MCH-27.7 MCHC-31.4 RDW-17.5*
[**2160-8-15**] 12:46PM NEUTS-61.5 LYMPHS-15.4* MONOS-3.1 EOS-19.4*
BASOS-0.6
[**2160-8-15**] 12:46PM HYPOCHROM-1+ ANISOCYT-1+ MICROCYT-1+
[**2160-8-15**] 12:46PM PLT COUNT-202
Brief Hospital Course:
1) HTN: Longstanding hx of refractory htn.
The patient was placed on Labetolol 800 mg TID with goal SBP
160-170
and she remained on maximum doses of clonidine, enalapril and
norvasc. In fact, she was placed on Elanapril 40 mg PO BID. She
at times required Hydralazine 10 mg but would refuse IV so was
placed on PO prn for systolic BPs over 200. Her BP dropped from
250 in the ED prior to MICU admission to 140/80 in the days
prior to discharge. She initially complained of a headache which
resolved with lowering of BP to the 140-150s systolic. The
patient was placed on telemetry for monitoring while HTN urgency
resolved. An EKG was remarkable for [**Street Address(2) 1766**] elevations (not new)
believed to be J-point elevation. She ruled out for an acute
myocardial infarction on admission.
2) Line infection: The patient presented with right groin
pustules believed to be secondary to a line infection in her
right groin. As a result, the patient was covered empirically
with Vanco which she received with dialysis and was dosed by
level. [**Street Address(2) 1326**] surgery removed the line on Sunday, [**2160-8-17**].
She then went to IR for a right venogram on Monday [**2160-8-18**] at
which time a left groin cath was placed. After the placement of
the left groin cath, she was noted to have developed pustules on
the left near the cath site. Wound cultures from the right had
no growth and her blood cultures were negative. The patient
remained afebrile. She was placed on the OR schedule for AV
fistula on [**2160-8-20**] secondary to concern that the patient had
poor compliance and would not return for a graft placement if
told to remain on a 2 week course of antibiotics. She is now
status post RUE graft on [**2160-8-20**] which remains patent. The
question remained however, if the pustules represented a true
line infection vs. superficial skin disease or allergic/contact
dermatitis. As a result, dermatology was consulted on [**2160-8-21**].
They performed a punch biopsy on the lesion and drew cultures
for HSV, VZV, bacterial and fungal smears including acid-fast.
The result came back as positive for herpes simplex type I that
was cultured from the groin around the cath site.
3) ESRD: s/p HD [**8-15**]. BC x2 through line.
- [**Month/Year (2) 1326**] evaluated the patient on [**2160-8-17**] and requested a
right venogram of her right upper extremity to assess access for
possible right cephalo-radial AV fistula. A right upper
extremity AV graft was placed on [**2160-8-20**]. Her renagel was also
increased to 2400 TID. She was noted at one point to have a K of
7.1 in a non-hemolyzed sample while she was in dialysis. She was
dialyzed to remove the K and a repeat K showed a level less than
5.0. The graft remained patent upon discharge but the patient
will not be able to use that site for another two weeks.
4) Anemia: Hct stable. She was continued on epogen through
dialysis.
5) Diarrhea: Initial stool cultures and c. diff. were negative.
Apparently, the patient has a history of intermittent diarrhea.
Ova and parasites were also evaluated for in the stool given her
history of eosinophilia. She was given Imodium for symptomatic
relief. She also has a history of small bowel resection that
could contribute to the chronic loose stool/diarrhea.
6) Eospinophilia: The eosinophilia appears to be chronic since
[**2-6**]. Bumex was discontinued in the MICU with no decrease in her
eosinophils. The possibilities may include Churg-[**Doctor Last Name 3532**] given
her history of asthma, medication-induced, or parasitic to name
a few. Allergy was consulted to comment on [**2160-8-21**]. Their
recommendations were that the eosinophilia could be contributed
to the vancomycin she is receiving, however, as it is causing
her no symptoms and if there was strong suspicion for a line
infection, that eosinophilia alone would not be a reason to
discontinue the medication.
Discharge Medications:
1. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: Three (3) Patch
Weekly Transdermal QMON (every Monday).
Disp:*30 Patch Weekly(s)* Refills:*2*
2. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
3. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)).
4. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Labetalol HCl 200 mg Tablet Sig: Four (4) Tablet PO TID (3
times a day).
Disp:*360 Tablet(s)* Refills:*2*
6. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*2*
7. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 * Refills:*2*
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO QID (4 times a day).
Disp:*240 Tablet, Chewable(s)* Refills:*2*
9. Amlodipine Besylate 10 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
12. Percocet 2.5-325 mg Tablet Sig: 1-2 Tablets PO every [**4-8**]
hours for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency, right groin catheter infection
Discharge Condition:
Stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight gain > 3 lbs.
Adhere to 2 gm sodium diet
Please return to the ER or call your primary physician if you
experience any fevers/chills, discharge from the groin catheter
site, chest pain, shortness of breath, lightheadedness,
dizziness or severe headaches.
Please resume your hemodialysis schedule as you did prior to
your admission.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] 1 week.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 819**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Where: LM [**Hospital Unit Name **] [**Hospital **] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2160-9-2**]
11:30
Please follow up with Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**], your
allergist/immunologist, to follow up on your increased
eosinophil count by calling [**Telephone/Fax (1) 9051**] in [**1-4**] weeks.
|
[
"070.54",
"728.87",
"054.10",
"311",
"304.21",
"403.01",
"250.00",
"996.62",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.93",
"86.09"
] |
icd9pcs
|
[
[
[]
]
] |
7560, 7566
|
2260, 6171
|
375, 432
|
7663, 7672
|
1699, 2237
|
8117, 8708
|
6194, 7537
|
7587, 7642
|
7696, 8094
|
1665, 1680
|
272, 337
|
460, 1205
|
1227, 1519
|
1535, 1650
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,795
| 182,522
|
52678
|
Discharge summary
|
report
|
Admission Date: [**2105-10-26**] Discharge Date: [**2105-11-3**]
Date of Birth: [**2028-2-20**] Sex: M
Service:
CHIEF COMPLAINT: Left scrotal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 77 year old
male with a past medical history of prostate cancer, status
post prostatectomy in [**2097**]. Status post penile implant in
[**2092**] by Dr. [**Last Name (STitle) 9125**]. He presented today to the Emergency
Department complaining of testicular pain, left more than
right, since Saturday. The patient denies any fevers, chills,
night sweats or vomiting. The patient also denies dysuria or
hematuria. His prosthesis stopped working two years ago per
patient's wife. The patient has had low grade temperature
and chills for one week prior to admission.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, prostate
cancer.
PAST SURGICAL HISTORY: Status post fusion of C4 through C6
in [**2102**]. Status post laminectomy, C3 to C7 in [**2102**]. Status
post appendectomy. Status post retropubic radical
prostatectomy in [**2097-1-2**] and status post penile
implant in [**2092**].
MEDICATIONS:
Neurontin 600 mg q. a.m., 300 mg at noon and 900 mg q h.s.
Celebrex 100 mg twice a day.
Verapamil XL 240 mg q. day.
Prilosec 20 mg q. day.
Ziac 5/6.25 mg q. day.
Lipitor 10 mg q. day.
Benecol 20 mg q. day.
Aspirin 325 mg q. day.
Darvocet prn for pain.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No smoking currently; 65 packs per year
history.
PHYSICAL EXAMINATION: Vital signs 97.7 temperature; heart
rate of 81; blood pressure 129/58; respiratory rate of 16;
saturations 98% on room air. Pharynx is clear. Neck is
supple. No lymphadenopathy. Lungs are clear to auscultation.
Heart sounds: S1 and S2 regular rate and rhythm. Abdomen is
soft, full, nontender. Genitourinary examination: Left
scrotum is tense and erythematous with exquisite tenderness
to palpation, diffusely swollen, with minimal swelling and
tenderness in the left inguinal region. Normal penis.
Palpable left scrotal sac.
LABORATORY DATA: White blood cell count of 38; hematocrit of
33.1; platelets of 488. Electrolytes are within normal
limits with the exception of creatinine of 2.7. Lactate 4.5.
PT 14.1; PTT 87.9; INR of 1.3. Scrotal ultrasound shows 4 by
3 by 3 hypoechoic area above the left testis, consistent with
a left scrotal pyocele.
HOSPITAL COURSE: The patient was admitted to the hospital
the same day, [**2105-10-26**] for further work-up of the
left scrotal pyocele. Questionable infected scrotal
component of prosthesis. An abdominal pelvic CT was ordered
to rule out incarcerated hernia and aggressive hydration was
instituted to correct acute renal failure (creatinine of 1.3
is baseline and today is 2.7).
CT of the pelvis was consistent with infected penile
prosthesis. Infection was contagious with focal area of
sigmoid diverticulitis. Also, an abscess anterior to the
left psoas muscle was seen just proximal to the sigmoid
colon. The patient was taken to the operating room at 10
o'clock at night where he underwent removal of his penile
prosthesis and wash-out of his left scrotum. Penrose drain
was placed for continuous drainage of the pyocele.
The infected fluid in the scrotal sac was sent for pathology
and cultures (aerobic and anaerobic). The patient was taken
to the Post Anesthesia Care Unit and from there to the
Surgical Intensive Care Unit for further stabilization of his
condition. The patient was started on Ampicillin,
Dicloxacillin and Flagyl as wide empiric antibiotic treatment
until the results from the fluid culture returned. Blood
cultures drawn the same day were negative. Urine culture was
positive for gram positive bacteria. Culture returned on the
26th and was positive for Alpha strip, Proteus, Pseudomonas
and Bacteroides fragilis. As a result, the patient's
antibiotic regimen was supplemented with Ceftazidime to cover
Pseudomonas.
On postoperative day number two, the patient started having
symptoms of agitation and confusion and threatened to sign
out against medical advice. Psychiatry was consulted to
evaluate the patient. Narcotics were held (being suspicious
of causing this postoperative agitation and confusion) and
the patient was under restraints, on continuous Haldol 5 mg
three times a day with security sitter overnight. Management
was consulted for his scrotal swelling. Subsequently, the
infectious disease was consulted to evaluate the patient and
recommend appropriate antibiotic treatment and duration,
based on cultures. According to infectious disease
recommendations, the patient's antibiotic regimen was changed
on [**11-1**] to Zosyn 4.5 grams q. eight hours and the rest
of the antibiotics were discontinued. The patient was able
to tolerate clears and immediately a regular diet on [**10-29**]. He was ambulatory. Intravenous Haldol was slowly
weaned off by [**11-1**]. On [**11-3**], the PICC line
was placed. In addition, the patient was discharged home on
intravenous Zosyn to complete two week course per infectious
disease recommendations. In addition to the above consults,
general surgery was also consulted to evaluate the patient
regarding the patient's diverticulitis. Per surgery
recommendations, the patient should complete a course of two
weeks of intravenous antibiotic treatment (congruent with
infectious disease recommendations) and the patient was to
return see Dr. [**Last Name (STitle) 1888**] as an outpatient, to be re-evaluated
and undergo elective sigmoidectomy after resolution of the
inflammatory process that brought the patient into the
operating room.
Finally, physical therapy was consulted for home safety
evaluation since the patient came to the hospital ambulatory
with cane but now the patient was only able to ambulate with
a walker. Additional studies throughout the patient's stay
included CT of the abdomen and pelvis on [**2105-10-31**],
just five days after prior CT of the abdomen and pelvis, to
re-evaluate the diagnosed abscess anterior to the left psoas
muscle. No abscess was seen in the second CT and the patient
was shown to be safe to be discharged home and follow-up as
an outpatient with Dr. [**Last Name (STitle) 1888**] of general surgery.
The patient was discharged on [**2105-11-3**] with services.
He was instructed to take his medications as scheduled. He
was to take intravenous Zosyn .5 grams q. 8 hours via PICC
line. He was to attend his appointments. Visiting nurse was
arranged to see the patient every day, administer the
antibiotic, intravenous Zosyn, check his blood pressure and
vital signs, check laboratory studies once a week and report
to the infectious disease fellow. Dressing changes, wet to
dry on his scrotal area twice a day.
Appointments were scheduled with urology, general surgery,
infectious disease.
DISCHARGE DIAGNOSES:
Status post removal of penile prosthesis and wash-out of
scrotal sac.
MEDICATIONS:
Metoprolol 25 mg p.o. twice a day.
Gabapentin 600 mg p.o. q. a.m., 300 mg p.o. lunch, 900 mg
p.o. q. p.m.
Verapamil SR 240 mg q. day.
Protonic 40 mg q. day.
Atorvastatin 10 mg p.o. q. day.
Aspirin 325 mg p.o. q. day.
Tylenol 325 mg p.o. q. four to six hours.
Hydrochlorothiazide 10 mg p.o. q. day.
Ziac 5/6.25 mg p.o. q. day.
Zosyn 4.5 grams q. 8 hours for 12 days post discharge.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2105-11-4**] 06:31
T: [**2105-11-4**] 19:10
JOB#: [**Job Number 108691**]
|
[
"996.65",
"584.9",
"293.0",
"041.7",
"562.11",
"276.5",
"562.10",
"608.4",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"64.96",
"61.3",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6852, 7607
|
2393, 6831
|
880, 1422
|
1512, 2375
|
150, 170
|
199, 785
|
808, 856
|
1439, 1489
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,593
| 128,407
|
36801
|
Discharge summary
|
report
|
Admission Date: [**2136-9-3**] Discharge Date: [**2136-9-13**]
Date of Birth: [**2099-8-28**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
ATV rollover
Major Surgical or Invasive Procedure:
1. Irrigation and debridement of open clavicle fracture.
2. Open reduction, internal fixation of left clavicle
fracture.
3. Examination under anesthesia with stress manipulation of
pelvis to assess stability of the pelvic ring fracture.
History of Present Illness:
Mr. [**Known lastname **] is a 37 year old man who was on an ATV when he had a
rollover with the ATV landing on him, he also had no helmet on.
He was taken from the scene by [**Location (un) **] to the [**Hospital1 18**] for
further evaluation and care.
Past Medical History:
Denies
Social History:
+ETOH
Family History:
n/a
Physical Exam:
Gen: AFVSS
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: open punctate lesion over middle of clavicle
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-20**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Brief Hospital Course:
Mr. [**Known lastname **] presented to the [**Hospital1 18**] on [**2136-9-3**] via [**Hospital **]
transfer from the scene of his ATV rollover. He was evaluated
by the trauma, orthopaedic, and neurosurgical services. He was
admitted, consented, and prepped for surgery. On [**2136-9-4**] he was
taken to the operating room and underwent an ORIF of his left
clavicle fracture and evaluation of his pelvic fractures under
anesthesia. On [**2136-9-7**] he was transfused with 2 units of packed
red blood cells due to acute blood loss anemia. Also on [**2136-9-7**]
he used his left arm to push himself up in bed and had
displacement of his left clavicle plate. Dr. [**Last Name (STitle) 1005**] examined
x-rays after the event and determined there was no need for open
reduction and that the clavicle would heal on its own.
He was seen throughout his hospital stay by physical and
occupational therapy. The rest of his hospital stay was
uneventful with his lab data and vital signs within normal
limits and his pain controlled. He is being discharged today in
stable condition.
Medications on Admission:
Denies
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. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day for 4 weeks.
Disp:*28 * Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*125 Tablet(s)* Refills:*0*
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Left open clavicle fracture
Bilateral pubic rami fractures
Right sacral fracture
Right nondisplaced acetabular fracture
Right thalamus punctate focus
Left temproal lobe hemorrhage
Acute blood loss anemia
Discharge Condition:
Stable/Good
Discharge Instructions:
Continue to be non-weight bearing on your left arm at all times
and wear your sling at all times.
Continue to be partial weight bearing on your right leg and
weight bearing as tolerated on your left leg
If you experience any shortness of breath, new redness,
increased swelling, pain, or drainage, or have a temperature
>101, please call your doctor or go to the emergency room for
evaluation.
Please resume all of the medications you took prior to your
hospital admission. Take all medication as prescribed by your
doctor.
You have been prescribed a narcotic pain medication. Please
take only as directed and do not drive or operate any machinery
while taking this medication. There is a 72 hour (Monday
through Friday, 9am to 4pm) response time for prescription refil
requests. There will be no prescription refils on Saturdays,
Sundays, or holidays. Please plan accordingly.
Physical Therapy:
Activity: As tolerated
Right lower extremity: Partial weight bearing
Left lower extremity: Full weight bearing
Right upper extremity: Full weight bearing
Left upper extremity: Non weight bearing
Sling: At all times on LUE
Treatments Frequency:
Staples/Sutures out 14 days after surgery
Dry dressing daily or as needed for drainage or comfort
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 548**] in 4 weeks. Call [**Telephone/Fax (1) 2992**] for this
appointment, please tell them that you will also need head CT
prior to this appointment.
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.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
|
[
"E821.0",
"868.04",
"853.06",
"V15.81",
"810.12",
"E878.1",
"996.49",
"285.1",
"808.2",
"805.6",
"808.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.69",
"79.39"
] |
icd9pcs
|
[
[
[]
]
] |
3114, 3120
|
1487, 2572
|
332, 579
|
3368, 3382
|
4689, 5199
|
931, 936
|
2629, 3091
|
3141, 3347
|
2598, 2606
|
3406, 4292
|
951, 1464
|
4310, 4544
|
4566, 4666
|
280, 294
|
607, 862
|
884, 892
|
908, 915
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,807
| 177,797
|
29902
|
Discharge summary
|
report
|
Admission Date: [**2195-12-2**] Discharge Date: [**2195-12-5**]
Date of Birth: [**2121-4-27**] Sex: F
Service: MEDICINE
Allergies:
Clonidine
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
mental status changes, PE/DVT, RP bleed
Major Surgical or Invasive Procedure:
placement of left subclavian
History of Present Illness:
75yoW with h/o COPD, Alzheimer's dementia, diagnosed with DVT/PE
at Caritas [**Hospital6 5016**] and transferred to [**Hospital1 18**] ED with
RP bleed and hypotension.
.
The patient was initially transferred from her nursing home to
[**Hospital6 5016**] on [**2195-11-30**] with low grade fever, failure to
thrive, and altered mental status after staff found her
unresponsive for 40sec at breakfast. She had been discharged
from that hospitalization the week prior after admission for
urosepsis with hypotension, UTI, and dehydration. On admission
she was diagnosed with RLE DVT by U/S and bilateral PE by CT
angiogram. Heparin gtt was started, and she was sent for IVC
filter placement. Post-procedure she became hypotensive. She
was intubated and transfused 5units PRBC and 4units FFP after
Hct noted to be 20. Heparin gtt was discontinued. Abdominal CT
revealed a large left retroperitoneal hematoma. Prior to
transfer blood was also noted in the G-tube. She was
transferred to [**Hospital1 18**] on peripheral dopamine for continued BP
support.
Past Medical History:
1. Chronic obstructive pulmonary disease
2. Right tonsillar laryngeal carcinoma, status post XRT and
status
post resection in [**2186**].
3. Depression.
4. Arthritis
5. S/p cholecystectomy
6. Hypothyroidism
7. Hyperglycemia
8. Right upper lobe lung mass with negative biopsy in
[**2188-10-15**]
9. Alzheimer's dementia
10. osteoporosis
11. Peripheral vascular disease
12. Hypertension
13. prior stroke
Social History:
lives in nursing home. has 3 sons
[**Name (NI) **]: h/o 70pack yrs, quit [**2186**]
EtOH: none
Family History:
not elicited
Physical Exam:
T 100.4 HR 84 BP 139/89 RR 21
AC FiO2 50% PEEP 5.0 Tv 500 RR 20
GEN: somnolent, withdraws to pain
HEENT: PERRL, anicteric, MMM, ETT
Neck: supple, no LAD, JVP nondistended
CV: distant heart sounds, regular, no mrg
Resp: coarse B anteriorly R>L, no crackles
Abd: +BS, ttp, no guarding, ND, no masses
Ext: left groin echymoses, BLE edema R>L
Neuro: withdraws to pain, at baseline oriented x1
Pertinent Results:
[**2195-12-3**] 12:34AM BLOOD WBC-14.1* RBC-3.28* Hgb-10.3* Hct-28.2*
MCV-86 MCH-31.4 MCHC-36.5* RDW-16.1* Plt Ct-120*
[**2195-12-4**] 03:18AM BLOOD WBC-11.9* RBC-3.51*# Hgb-10.7* Hct-28.3*
MCV-81* MCH-30.4 MCHC-37.7* RDW-20.3* Plt Ct-76*
[**2195-12-3**] 12:34AM BLOOD Neuts-80* Bands-14* Lymphs-2* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-4*
[**2195-12-3**] 12:34AM BLOOD PT-20.9* PTT-34.0 INR(PT)-2.0*
[**2195-12-3**] 12:34AM BLOOD Plt Smr-LOW Plt Ct-120*
[**2195-12-4**] 11:18AM BLOOD Fibrino-420* D-Dimer-9033*
[**2195-12-4**] 11:18AM BLOOD FDP-80-160*
[**2195-12-3**] 12:34AM BLOOD Glucose-126* UreaN-36* Creat-1.9* Na-144
K-3.8 Cl-109* HCO3-20* AnGap-19
[**2195-12-3**] 12:34AM BLOOD ALT-2737* AST-6183* LD(LDH)-[**Numeric Identifier 7156**]*
CK(CPK)-548* AlkPhos-108 TotBili-0.6
[**2195-12-3**] 04:39AM BLOOD ALT-2511* AST-5932* AlkPhos-97
Amylase-587* TotBili-0.7
[**2195-12-4**] 03:18AM BLOOD ALT-1812* AST-3156* LD(LDH)-5992*
CK(CPK)-501* AlkPhos-119* TotBili-1.5
[**2195-12-3**] 12:34AM BLOOD CK-MB-21* MB Indx-3.8 cTropnT-0.34*
[**2195-12-3**] 12:34AM BLOOD Albumin-2.4* Calcium-6.7* Phos-6.5*
Mg-2.2
[**2195-12-3**] 04:00AM BLOOD Ammonia-39
[**2195-12-3**] 12:34AM BLOOD TSH-3.0
[**2195-12-3**] 12:34AM BLOOD Free T4-1.5
[**2195-12-3**] 12:42AM BLOOD Type-ART pO2-158* pCO2-24* pH-7.51*
calTCO2-20* Base XS--1
[**2195-12-4**] 03:32AM BLOOD Type-ART Temp-36.1 pO2-116* pCO2-29*
pH-7.42 calTCO2-19* Base XS--3 Intubat-INTUBATED
[**2195-12-3**] 10:51AM BLOOD Lactate-2.9*
[**2195-12-4**] 11:45AM BLOOD Lactate-2.0
[**2195-12-3**] 12:42AM BLOOD freeCa-0.93*
[**2195-12-4**] 11:45AM BLOOD freeCa-1.03*
.
Echo The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is no ventricular septal defect. The right
ventricular cavity is dilated. Right ventricular systolic
function is normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
CXR: Portable AP chest radiograph was reviewed. The ET tube
tip is 3.2 cm above the carina. The NG tube passes below the
diaphragm and terminates most likely in the stomach. The left
subclavian line tip terminates at the level of mid low SVC.
Minimal left apical pneumothorax cannot be excluded. There is
no apical hematoma. A small left pleural effusion as well as
right tiny effusion is identified. There is no congestive heart
failure or focal lung consolidation. The hila are bilaterally
enlarged, which may be related due to pulmonary emboli mentioned
in the patient's history.
Brief Hospital Course:
74yo woman with h/o COPD, Alzheimer's dementia, transferred from
OSH with RLE DVT, bilateral PE, RP bleed, and NSTEMI. During
her hospitalization the following issues were addressed. On
[**2195-12-4**], she was extubated and did not tolerate it with
persistant secretions and desaturation. Extensive discussion
was held with her son and health care proxy, [**Name (NI) **] [**Name (NI) 37080**],
and the decision was made to focus on comfort measures. She
expired [**2195-12-5**].
.
# RP bleed: This occurred following IVC filter placement while
on heparin. Serial hematocrits were followed. She did not
require further PRBC transfusion. Vitamin was given for INR
2.0.
# Hypotension: She was initially hypotensive requiring
dopamine for BP support. CVL was placed and CVP found to be
[**5-22**]. She was hypovolemic from bleeding and dehydration. She
was administered NS iv fluids. BP normalized and the dopamine
was stopped. She subsequently became hypertensive with BP
200s/100s, which was treated with propofol gtt sedation, iv
labetolol and hydralazine boluses.
.
# DVT/PE: filter in place for DVT. She was not anticoagulated
for the PE given her retroperitoneal bleed. Echo was performed.
.
# ARF: her renal function declined with rising BUN/Cr despite
fluid rehydration, and she became oliguric-anuric. This was
thought to be due to ATN although no casts were seen in urine
specimen.
.
# Resp failure: She presented with a respiratory alkalosis
which persisted with compensatory and concommittent metabolic
acidosis. She was weaned to pressure support ventilation and
extubated on the day prior to death.
.
# NSTEMI: She sufferred a leak of cardiac enzymes without ECG
changes during the episodes of hypovolemia/hypotension and
anemia. She received statin.
.
# Shock liver: she developed shock liver in setting of
hypotension and hypovolemia
.
# Dispo: She continued to decline with development of oliguric
renal failure, shock liver. Sedation was lifted but mental
status did not return. In discussion with her son and health
care proxy, decision was made to focus of comfort. She expired
[**2195-12-5**]. Communication is with her son [**Name (NI) **] [**Name (NI) 37080**]
[**Telephone/Fax (1) 71462**](h), [**Telephone/Fax (1) 71463**](c)
Medications on Admission:
Meds on Admission to OSH:
Depakote sprinkles 125mg 3caps [**Hospital1 **]
Folate 1mg daily
Plavix 75mg daily
Lasix 20mg daily
Cetrocal +D 1tab [**Hospital1 **]
Aclonel 35mg QThurs
Lipitor 10mg daily
Atenolol 50mg daily
ASA 325mg daily
KCl 30mEq daily
.
Meds on Transfer:
Folate 1mg daily
Depakote 125mg 3tabs [**Hospital1 **]
Zocor 20mg daily
Nexium 40mg iv daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"410.71",
"733.00",
"584.9",
"294.10",
"496",
"276.51",
"244.9",
"415.19",
"331.0",
"311",
"401.9",
"570",
"276.3",
"453.42",
"518.81",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8089, 8098
|
5358, 7643
|
309, 339
|
8149, 8158
|
2454, 5335
|
8214, 8224
|
2001, 2015
|
8057, 8066
|
8119, 8128
|
7669, 7922
|
8182, 8191
|
2030, 2435
|
230, 271
|
367, 1428
|
1450, 1871
|
1887, 1985
|
7940, 8034
|
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