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41,842
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40237
|
Discharge summary
|
report
|
Admission Date: [**2107-12-9**] Discharge Date: [**2107-12-15**]
Date of Birth: [**2061-12-8**] Sex: M
Service: MEDICINE
Allergies:
neurontin
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Seroquel overdose.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 46 year-old male PMH bipolar, depression, substance
abuse, suicidal ideation who presents with seroquel overdose.
.
Per report patient presented to an OSH. There he reported
ingestion of 23 tablets of Seroquel 400 mg around 6 PM following
an arguement. Denied any other ingestions. He reportedly became
increasingly lethargic, and was intubated for airway protection
and given charcoal. He was transferred here due to lack of
psychiatry at the OSH. He drinks alcohol daily - last drink
yesterday. On lithium for presumed bipolar disorder but denies
taking more than prescribed dose.
.
In the ED, presenting VS: T 96.9, HR 92, BP 153/72, RR 11, 100%
on vent. CT head ordered due to lack of history. CXR confirmed
location of ET tube and NG was replaced. Toxicology was
consulted - amp of bicarb given for prolonged QT and then
patient placed on bicarb drip. No family presented with patient.
Vital signs on transfer 86 102/69 15 96% RA.
.
ROS: Unable to provide as intubated.
Past Medical History:
Bipolar
Depression with h/o previous suicidal ideation and attempts
Substance abuse
Social History:
Per OSH records: Drinks everday - last drink yesterday.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 8214**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45079**] ([**12-9**]): "His stepmother [**First Name8 (NamePattern2) 8214**] [**Last Name (NamePattern1) **] and
Lauritz [**Doctor Last Name 45079**] live in [**Location (un) 5131**] [**Telephone/Fax (1) 88328**], but are
vacationing in [**State 108**] for the winter phone number [**Telephone/Fax (1) 88329**]
after [**12-22**]. He also has a sister, [**Name (NI) 13762**] [**Name (NI) 81431**] in
[**Name (NI) 88330**], NY. He has a 12 year old daughter in [**Name (NI) 108**]. His
mother [**Name (NI) **] has passed away. He drug and drinking problem
started in HS and was triggered after his [**Name (NI) **] divorced at
age 13. His previous suicide attempt was laying on train track.
It involved the cops as he threatened he was armed with
attempted rescue. Last year had been at east [**Doctor Last Name **] medical
center for suicide attempt, sent to therapy was promised place
to live and a job afterward. He is not in touch with his
family, last contact with step mother and father was 1 year ago
when hospitalized after suicide attempt. This was the first
time in 11 years that he was in contact. His [**Name2 (NI) **] would be
happy to hear from him."
Family History:
Unknown.
Physical Exam:
On Admission:
Vitals: BP: 113/71 HR: 95 RR: 17 O2Sat: 100% vented.
GEN: Intubated and sedated. Wearing hard collar.
HEENT: PERRL, charcoal outlining mouth
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB anteriorly, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
OSH: Rate 96. Normal axis. QRS 102, OTc 417.
2:01 HR 90. Normal axis. QRS 112. OTc 418.
2:25 following bicarb challenge. HR 108. Normal axis. QRS 102.
QTc 398.
6:17: QRS 112, QTc 432.
.
Admission Labs: [**2107-12-9**] 02:00AM
WBC-5.3 RBC-3.69* HGB-11.4* HCT-34.5* MCV-94 PLT COUNT-288
PT-12.9 PTT-24.9 INR(PT)-1.1
LITHIUM-0.6
ALT(SGPT)-34 AST(SGOT)-38 ALK PHOS-66 TOT BILI-0.2
GLUCOSE-123* LACTATE-1.3 NA+-140 K+-3.3* CL--103 TCO2-27 UREA
N-11 CREAT-1.3*
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG
mthdone-NEG
.
Imaging:
CT Head: No acute intracranial process.
CXR: Bibasilar atelactasis. ET 5 cm above carina
Discharge Labs:
[**2107-12-13**] 06:15AM
WBC-7.9# RBC-4.23* Hgb-13.3* Hct-40.3 MCV-95 Plt Ct-269
[**2107-12-14**] 06:50AM
Glucose-88 UreaN-14 Creat-1.0 Na-138 K-4.6 Cl-102 HCO3-25
AnGap-16
Brief Hospital Course:
46 year-old male with history of bipolar, depression, ETOH
abuse, suicidal ideation who presents with seroquel overdose.
# Overdose. Per patient report at outside hospital ingested 23,
400mg tablets of seroquel: total of 9.2gms. He denied
additional ingestions. The main clinical findings in quetiapine
overdose are hypotension, tachycardia, and somnolence, all of
which were seen. Patient was intubated for airway protection at
OSH. Admission labs were notable for LFTs wnl, tox screen + for
benzos (which he received at OSH), otherwise negative including
tylenol level. Lithium level within normal limits. Patient's
admission EKG demonstrated qrs 112, QTc 418 - toxicology
recommended trial bicarb amp with which qrs improved to 102
consequently recommended bicarb drip which was stopped on [**12-9**]
after EKG with evidence of nl QTc. Patient was monitored on
telemetry. FS monitored QID as hyperglycemia known side effect
but he did not need insulin from a sliding scale. Psych was
consulted after extubation, suicide precautions and 1:1 sitter
in place. Patient section 12'ed. He experienced a hypermanic
delirium for the next 48 hours of admission, requiring 4 point
restraints. This was treated with frequent Haldol dosing per
psychiatry recommendations, however. His delirium gradually
resolved on its own. He required no Haldol for the last 48 hours
of his stay.
# Respiratory distress. Likely secondary to Seroquel sedation.
CXR with bibasilar atelactasis but no acute process. Remained
intubated during overdose phase and sedated with propofol.
Patient extubated without difficulty on [**12-9**], and was
subsequently on room air.
# ETOH abuse: He was monitored for signs of withdrawal with a
CIWA scale and placed on daily MVI, thiamine, folate. He was
agititated on [**12-10**] and received a total of 60mg of Valium. On [**12-11**]
agitation thought secondary to anxiety and not outright
withdrawal as patient without signs of autonomic dysregulation.
Valium discontinued and agitation treated with prn haldol.
# Renal insufficiency: Unclear of baseline. Trial of continous
fluids. Creatinine trended daily. Renally dosed meds, avoid
nephrotoxic medications. Creatinine stable at 1.0 at time of
transfer.
# Depression/Bipolar: Held all medications on admission. Psych
consulted once extubated. Recs to continue to hold all bipolar
and antidepressant medications. Use haldol intermittently to
treat agitation. Patient sectioned. Awaiting psychiatric
placement.
# Elevated TSH. On day of transfer TSH found to be 6.6. Free T4
4.1. These should be repeated in the outpatient setting after
his acute illness has resolved.
# Penile lesions: Suspicious for HPV. Patient reports they have
been present for several months and have not increased in size
or number; no associated pain, pruritus, or discharge. Further
evaluation deferred to the outpatient setting.
Medications on Admission:
Per OSH list:
Seroquel
Lithium
Discharge Medications:
1. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. haloperidol 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
3. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for agitation, insomnia.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Depression
Alcohol abuse
Seroquel overdose
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 following a Seroquel overdose
and were intubated for airway protection. You had mild renal
failure on presentation, which resolved. You were seen in
consultation by psychiatry and it was determined that you would
require inpatient psychiatric care for your depression and
alcohol abuse.
Followup Instructions:
Please follow-up with your primary care physician within two
weeks of discharge.
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27,298
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32199
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Discharge summary
|
report
|
Admission Date: [**2107-12-3**] Discharge Date: [**2107-12-3**]
Date of Birth: [**2057-3-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
abdominal pain, nausea vomiting
Major Surgical or Invasive Procedure:
Nasogastric leavage
History of Present Illness:
50 yo F transferred from [**Hospital1 **] w/ pmh of psychosis,
anxiety, HTN, seizure disorder presents w/ 1-2 weeks of abd pain
and small blood in her BMs, N/V x1 day (2-3x). She was able to
tolerate her lunch (which included red hawaiian punch Also this
afternoon she became dizzy and lightheaded when standing.
In the ED initial vitals: 96.7, 139/97, 108. She was
intermittantly tachycardic to the 110-130s (on atenolol). An NGT
was placed with return of red-tinged fluid which cleared but
contained red/coffee ground flecks of blood. Per ED report,
rectal exam revealed a small amount of BRBPR. Her abdominal exam
was benign. No episodes of vomiting in the ED. The pt. was seen
by GI who repeated the NG lavage again showed clear fluid with
some amt. of red flecks and the rectal exam which was c/w prior
rectal exam. The Pt. was given 3L of IVF with improvement in her
tachycardia to 105 bpm. She received solumedrol 125mg IV due to
lethargy on presentation and her recent course of prednisone
(for asthma exacerbation). The NGT was removed for discomfort,
okay per GI.
.
Note: pt. is a very poor historian, does not give clear answers
to questions regarding her medical hx. She had a head CT 2 days
PTA at [**Hospital3 2783**]. Pt. cannot articulate regarding the
circumstances. According to nursing records faxed from
[**Hospital3 2783**] pt. presented on [**2107-12-1**]. Apparently there
was a question of domestic dispute. At [**Hospital1 2436**], she was
hysterical (believes that her husband cheated on her). Pt. was
seen by psychiatry. She had a head CT (w/o con) which was
normal. She was then sent to [**Hospital1 **] ([**Location (un) 246**]) for eval
(section 12). Per her boyfriend, pt. started to have mental
status changes when she started
.
ROS: pt. denies HA, no CP, no SOB, no weight loss. she does take
81mg ASA daily. reports intermittent constipation. Also, reports
decreased sleep for 3 days.
.
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Location (un) 246**] [**Telephone/Fax (1) 75293**]
Past Medical History:
Psychosis
Anxiety
hypertension
GERD
asthma
seizure history - clarified with PCP that she does not have a
history of seizure and is under no medical treatment for this
Social History:
Limited history available. Currently at [**Hospital1 **] psych
facility with psychosis.
Family History:
Not available at this time.
Physical Exam:
On Admission:
Exam: P 119 BP 105/76 Sat 100%RA
Gen: pleasant, comfortable, in NAD
HEENT: dry MMM
Lungs: CTA
CVS: regular, tachycardic
Abd: slight tenderness to deep palpation in the LUQ/ND, BS
normoactive, soft, no rebound
Ext: no edema
On transfer:
V/S HR 88 BP 119/79 Pox97% on RA Afebrile
Pertinent Results:
[**2107-12-2**] 10:29PM WBC-15.7* RBC-5.21 HGB-16.2* HCT-47.0 MCV-90
MCH-31.1 MCHC-34.4 RDW-13.3 NEUTS-75.1* LYMPHS-18.8 MONOS-5.7
EOS-0.3 BASOS-0.1 PLT COUNT-352
[**2107-12-2**] ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2107-12-2**] HCG-<5
[**2107-12-2**] CALCIUM-10.5* PHOSPHATE-4.2 MAGNESIUM-2.5
[**2107-12-2**] CK-MB-NotDone cTropnT-<0.01
[**2107-12-2**] ALT(SGPT)-24 AST(SGOT)-27 CK(CPK)-31 ALK PHOS-83
AMYLASE-66 TOT BILI-0.9
[**2107-12-2**] GLUCOSE-105 UREA N-10 CREAT-0.8 SODIUM-141
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-28 ANION GAP-17
[**2107-12-2**] PT-11.6 PTT-24.4 INR(PT)-1.0
[**2107-12-3**] 07:35AM WBC-16.9* RBC-4.69 HGB-14.3 HCT-43.7 MCV-93
MCH-30.6 MCHC-32.8 RDW-12.4 CALCIUM-8.7 PHOSPHATE-3.0
MAGNESIUM-2.2 GLUCOSE-161* UREA N-7 CREAT-0.6 SODIUM-140
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-21* ANION GAP-15
NEUTS-95.0* LYMPHS-4.0* MONOS-1.0* EOS-0 BASOS-0
CHEST (PORTABLE AP) [**2107-12-2**] 11:21 PM
CHEST (PORTABLE AP)
Reason: r/o free air
[**Hospital 93**] MEDICAL CONDITION:
50 yo F GERD p/w epigastric pain, +BRB rectal and NGL, belly
diffusely tender
REASON FOR THIS EXAMINATION:
r/o free air
STUDY: Portable AP view of the chest.
INDICATION: 50-year-old female with epigastric pain. Assess for
free air.
COMPARISONS: None.
FINDINGS: There is no subdiaphragmatic free air. The heart and
mediastinum are unremarkable in appearance. The lungs are clear.
There is no pleural effusion. A nasogastric tube is identified
with side port well below the gastroesophageal junction. The
aorta is mildly ectatic.
IMPRESSION: No acute cardiopulmonary process. No
subdiaphragmatic free air.
Brief Hospital Course:
50 yo F w pmh of psychosis, anxiety, htn presents w/ abd pain,
N/V. +NG lavage and small amount of BRBPR on rectal exam. BP
stable, tachycardia responsive to IVF. N/V resolved. Per GI- not
actively bleeding remaining hemodynamically stable overnight,
not requiring any blood transfusions.
.
#UGI: pt. presents w/ UGI of unclear origin. +NG lavage and
BRBPR. tachycardia responsive to fluids. Seen by GI in the ED
who felt that pt. was not actively bleeding. NGT removed for
discomfort. No more vomiting since presentation. Diff. includes
PUD, varices, gastritis, [**Doctor First Name 329**] [**Doctor Last Name **], malignancy, Dieulafoy's
lesion, AV malformation, hemmorhoids. Pt. has been on recent
steroids which could cause PUD. Given history of red drink prior
to presentation, there is potential for contamination of NG
leavage. Hematocrit trend overnight was stable on q4 hour
checks. Patient recieved one dose of IV PPI, then switched to
po PPI daily for 2-4 weeks when tolerating po. Abdominal exam
remained benign. GI team cleared patient for outpatient
followup prn and po PPI daily for 2-4 weeks on day of transfer.
# tachycardia: likely [**2-4**] to dehydration, as improved with
fluids, with hct 47.0 suggesting hemoconcentration. Tachycardia
could also be [**2-4**] to anxiety. patient was monitored on
telemetry with episodes of sinus tachycardia that resolved with
po fluids and resuming po atenolol.
# psychosis: pt. hx. unclear, appears to have had a psychotic
break recently at [**Hospital3 2783**] and was section 12'd to
[**Hospital1 **]. Believed to be related to steriods. Patient
received last dose of IV steriods in ED on presentation to
[**Hospital1 18**]. Psych meds at home dose were continued: risperdol,
ativan, prozac, klonopin, remeron, thorazine, tigan. We
obtained psychiatric hx from PCP which includes depression
disoder and anxiety. Psychiatry consulted with section 12 and
recommendation to return patient to [**Hospital1 **] with medical
clearance. BEST team contact[**Name (NI) **] for transfer clearance.
# seizure hx: Per PCP, [**Name10 (NameIs) **] has no history of seizure
disorder. pt. had a transient episode of eye lid fluttering,
associated with tachycardia, 20 sec of unresponsiveness,
spontaneous resolution with ? period of confusion per nurses
report. When the patient was questioned, she states this is her
usual "seizure pattern". She does not report being medicated for
this condition. Patient was not incontinent of stool or bladder.
Episode is not consistent with seizure activity and likely
related to underlying psychiatric disorders.
# leukocytosis- Afebrile throughout entire stay. Unclear source.
Negative CXR. Likely [**2-4**] steriod dose.
# Hypertension: Resumed home atenolol.
# FEN: Resumed regular diet, repleted lytes prn
.
# PPX: po PPI, zofran prn, pneumoboots, SSI.
.
# Code status: presumed full
.
# Dispo: Return to Bournwood pending BEST team clearance.
Patient medically cleared for discharge from medical hospital.
If patient did not have comorbid psychiatry concerns at this
time, she would be discharged to home.
Medications on Admission:
Atenolol 25mg qam
Risperdol 1mg po bid
Prednisone 10mg po qd
Atenolol 25 qAM
Prozac 10mg qAM
Klonopin 0.5mg po TID
Albuterol inhaler 2 puff prn
Remeron 30mg qHS
Thorazine 50mg po q6hrs prn
Ativan 1mg q6hrs prn
Tigan 200mg q8hrs PRN
ASA 81mg qdaily
tylenol 650mg prn
MOM 30mg po qhs prn
trazadone 50mg po qhs prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: [**1-4**] PO BID (2 times a
day).
4. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
7. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Abdominal Pain
Depression
Anxiety
Tachycardia
Discharge Condition:
Medically stable, with risk for potential harm to self.
Discharge Instructions:
You have been evaluated for nausea and vomiting and concern for
bleeding from your gastrointestinal tract. All evaluation was
negative by the Gastroenterologists who recommended that you try
2-4 weeks of a medication call protonix to treat these symptoms.
Please follow up with your primary care physician if your
abdominal problems persist for further referral to a
gastroenterologist.
You were also evaluated by the psychiatry team who found you
unable to make decisions for your self and recommended transfer
back to a psychiatric hospital for treatment of your depression
and anxiety.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**2-6**] weeks
to discuss further need for protonix.
|
[
"493.90",
"401.9",
"300.4",
"298.9",
"276.51",
"530.81",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9301, 9316
|
4839, 7952
|
346, 367
|
9406, 9464
|
3148, 4169
|
10104, 10243
|
2791, 2820
|
8315, 9278
|
4206, 4284
|
9337, 9385
|
7978, 8292
|
9488, 10081
|
2835, 2835
|
275, 308
|
4313, 4816
|
396, 2479
|
2849, 3129
|
2501, 2670
|
2686, 2775
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,095
| 101,754
|
9385
|
Discharge summary
|
report
|
Admission Date: [**2117-4-5**] Discharge Date: [**2117-4-8**]
Date of Birth: [**2043-7-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
left-sided chest pain and new left-sided pleural effusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 y/o woman with PMH notable for malignant melanoma admitted
with left-sided chest pain and new left-sided pleural effusion
on [**2117-4-6**] s/p thoracentesis w/ 1000cc drainage of hemorrhagic
fluid c/w metastatic effusion. Overnight she developed recurrent
left chest/shoulder pain while ambulating to the bathroom and an
increase in her oxygen requirement. On the am of transfer to the
[**Hospital Unit Name 153**] she developed acute tachycardia to 170s while ambulating to
the bathroom and progressive hypoxia with sat in mid 90s on 5L
facemask. Repeat CXR obtained at that time demonstrated
increasing left pleural effusion. EKG showed SVT at a rate of
130. ABG was 7.29/64/77 on 5L facemask, RR of 22. She was
transferred to the [**Hospital Unit Name 153**] for closer monitoring and consideration
of non-invasive ventilation.
.
On arrival to the [**Hospital Unit Name 153**], she received 1L NS bolus. She noted her
SOB was improved but continued with left shoulder/chest pain.
.
Past Medical History:
HTN
malignant melanoma (see below)
.
Oncologic history (per OMR):
Ms. [**Known lastname 32058**] [**Last Name (Titles) 1834**] shave biopsy of a left eyebrow skin
lesion revealing a 1.3 mm thick, [**Doctor Last Name 10834**] level IV, non-ulcerated
melanoma with 15 mitoses per high-powered field in 12/[**2112**]. In
[**12/2113**], she [**Year (4 digits) 1834**] wide local excision and left parotid
sentinel lymph node biopsy. There was no sentinel lymph node
biopsy involvement with melanoma. Wide local excision revealed
residual melanoma extending to 4.5 mm thick, [**Doctor Last Name 10834**] level IV
with evidence of microsatellitosis. She did not receive adjuvant
therapy. She [**Doctor Last Name 1834**] punch biopsy of a right forearm lesion in
[**2115-5-24**] revealing microinvasive melanoma, [**Doctor Last Name 10834**] level II,
0.22 mm, extending to the peripheral specimen margins. She
[**Doctor Last Name 1834**] wide local excision in [**2115-6-23**] revealing focal
residual melanoma in situ, completely excised. On her three-year
followup scans in [**3-1**], her torso CT revealed multiple lung
nodules with a large left hemidiaphragm lesion measuring 7.9 x
6.3 x 3.7 cm. Biopsy was positive for melanoma. Considered for
IL2 therapy but not a candidate [**1-25**] PFTs. Plan for chemotherapy.
Social History:
Lives with husband. Daughter is [**Name8 (MD) **] RN at [**Hospital1 **], very
involved in care. Quit smoking. No alcohol.
Family History:
NC
Physical Exam:
GENERAL - ill-appearing female in NAD, in mild respiratory
distress, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - decreased BS bilat, L>R, fair air movement, resp
minimally labored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no calf tenderness
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-27**] throughout, sensation grossly intact throughout, cerebellar
exam and gait deferred
Pertinent Results:
[**2117-4-5**] 07:18PM LACTATE-1.6
[**2117-4-5**] 12:10PM GLUCOSE-145* UREA N-17 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14
[**2117-4-5**] 12:10PM estGFR-Using this
[**2117-4-5**] 12:10PM WBC-12.2* RBC-4.15* HGB-12.2 HCT-35.1* MCV-85
MCH-29.5 MCHC-34.8 RDW-14.5
[**2117-4-5**] 12:10PM NEUTS-88.4* LYMPHS-6.8* MONOS-3.9 EOS-0.6
BASOS-0.3
[**2117-4-5**] 12:10PM PLT COUNT-308
[**4-5**] CTA
IMPRESSION:
1. No pulmonary embolism.
2. Marked interval increase in size of metastatic lesions at the
left lung
base, now associated with a large, and likely malignant, left
pleural
effusion. The right paraesophageal mass has also increased in
size with other small bilateral pulmonary nodules again noted.
[**4-7**] CXR
: Large left and small right pleural effusion, unchanged.
Streaky right
perihilar opacities, could be atelectasis. Dense LLL opacity
likely a
combination of known mass atelectasis and effusion. Widened
right lower
paramediastinal region part of it is likely due to known
paraesophageal mass.
Brief Hospital Course:
73 yo F with metastatic melanoma with acute presentation of
malignant pleural effusion s/p thoracentesis with short-interval
reacummulation concerning for hemothorax from melanoma.
#. Respiratory Distress, hypercapnic/mild hypoxia - [**1-25**]
effusion, space occupying lesion, underlying COPD, respiratory
depression from narcotics. Possible PE but unable to
anticoagulate [**1-25**] hemorrhagic effusion. In setting of hemothorax
from melanoma there are few options for treatment. Any further
drainage would like result in another quick reexpansion. Given
there is no treatment to stop the bleeding, placing a permanent
drain or pleurex cath is not indicated. Patient's family chose
to transition Ms. [**Known lastname 32058**] to comfort measures with morphine.
Patient died on the AM of [**4-8**] from respiratory failure.
.
#. Metastatic Melanoma - Mets to pleural space, likely
hemorrhagic, prognosis poor. As a result, family chose to
transition patient to comfort measures.
Medications on Admission:
At home:
- atenolol 50 mg daily
- caltrate 600 mg daily
- multivitamin daily
- asa 81 mg daily
- hctz/lisinopril 12.5/10 mg daily
- compazine/zofran prn
.
On transfer:
Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Aspirin 81 mg PO DAILY
Docusate Sodium 100 mg PO BID
HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN
Heparin 5000 UNIT SC TID
Ipratropium Bromide Neb 1 NEB IH Q6H
Multivitamins 1 TAB PO DAILY
Ondansetron 4-8 mg IV Q8H:PRN nausea
Prochlorperazine 10 mg IV Q6H:PRN
Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient passed away [**4-8**]
Discharge Condition:
Patient passed away [**4-8**]
Discharge Instructions:
Patient passed away [**4-8**]
Followup Instructions:
Patient passed away [**4-8**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2117-4-8**]
|
[
"V10.82",
"786.3",
"401.9",
"197.2",
"511.89",
"496",
"198.89",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
6226, 6235
|
4627, 5613
|
378, 384
|
6308, 6339
|
3555, 4604
|
6417, 6612
|
2899, 2903
|
6256, 6287
|
5639, 6203
|
6363, 6394
|
2918, 3536
|
281, 340
|
412, 1403
|
1425, 2743
|
2759, 2883
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,403
| 190,662
|
55130
|
Discharge summary
|
report
|
Admission Date: [**2158-9-19**] Discharge Date: [**2158-9-21**]
Date of Birth: [**2115-2-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
ethylene glycol ingestion
Major Surgical or Invasive Procedure:
Hemodialysis x 3, temporary HD catheter placement and removal
History of Present Illness:
Mr. [**Known lastname **] is a 43yo male presenting status post 0.5-1 pint
of antifreeze ingestion around 3pm. Over the last two weeks the
patient has felt like people were following and targeting him.
He has had decreased sleep (1-2 hrs/night), decreased appetite,
diarrhea, heart palpitations, and [**10-23**] lb weight loss over the
last 1-2 weeks. A month and a half ago he tried chantix for two
weeks to help him quit smoking, but he found that he was angrier
on the drug and had 'less of a filter' in what he said so he
stopped taking it.
This AM he was on his way to work when he thought that people
were following him- seeing the same cars etc. He drove to a
radio tower and climbed it hoping to jump off, but he climbed
back down, drove to a gas station and bought gatorade and
antifreeze (green, unknown brand). At his birth mother's
cemetery he drank ~10 oz of antifreeze in his car until his wife
tracked him down and took him to the ED.
In the [**Hospital3 **] ED and had a bicarbonate of 18,
creatinine of 1.1, osmolar gap of 67, pH 7.34 and was given 1.1g
of fomepizole at 8pm. The patient reports that he drank the
antifreeze in the setting of feeling paranoid while at his
mother's grave. In the ED, he denied vision changes,
intercurrent alcohol or drug ingestion, or cramping. He did
endorse headache. He was placed on section 12 for suicide
attempt.
In the [**Hospital1 18**] ED, initial VS were: 23:04 2 98.8 93 123/75 18 98%
RA and remained unchanged. He was given Thiamine 100mg,
Fomepizole 750 mg in NS, folic acid 50 mg ind 5% dextrose, a
nicotine patch and pyridoxine. He endorses cutting himself on
his wrist and inner thighs.
On arrival to the MICU, he is alert and oriented. He does not
endorse current suicidal ideation or current thoughts of
paranoia. He is tearful talking about the day's events. EKG on
the floor showed sinus tachycardia without any ischemic changes
or prolonged QTc.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure or weakness. Denies nausea,
vomiting, constipation, or abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
None
Psych PMH: No history of suicide attempts. Some suicidal
ideation in the past. No psychiatric hospitalizations. No
episodes of paranoia in past. Has never seen a psychiatrist.
Social History:
Works as a janitor in [**Location (un) 40609**], MA. Married with four kids.
- Tobacco: Usually smokes 1ppd. Currently is smoking [**1-9**] ppd.
Wants to quit.
- Alcohol: Currently drinks 3 beers/week. Cut down one year ago
when he wife was in the hospital. Was driking as much as 12
beers/night in past.
- Illicits: marajuana- uses all the time per family.
Family History:
DM2
No family history of depression or suicide attempts.
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly. Mildly tender to palpation in lower abdomen.
GU: no foley
Ext: Superficial cut marks on wrist bilaterally. warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: grossly intact
.
DISCHARGE EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, dressing from site of IJ
placement c/d/i
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, non-tender, bowel sounds present,
no organomegaly.
GU: no foley
Ext: Superficial cut marks on wrist bilaterally. warm, well
perfused, 2+ pulses, no clubbing, no cyanosis or edema
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS:
[**2158-9-18**] 11:30PM TYPE-ART RATES-/20 O2-20 PO2-86 PCO2-28*
PH-7.39 TOTAL CO2-18* BASE XS--6 INTUBATED-NOT INTUBA
VENT-SPONTANEOU
[**2158-9-18**] 11:40PM PT-11.8 PTT-29.4 INR(PT)-1.1
[**2158-9-18**] 11:40PM WBC-13.5* RBC-5.17 HGB-15.9 HCT-47.5 MCV-92
MCH-30.7 MCHC-33.5 RDW-13.5
[**2158-9-18**] 11:40PM ASA-NEG ETHANOL-ETHANOL NO ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-9-18**] 11:40PM OSMOLAL-358*
[**2158-9-18**] 11:40PM GLUCOSE-107* UREA N-10 CREAT-1.1 SODIUM-138
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-18* ANION GAP-18
[**2158-9-18**] 11:40PM BLOOD ETHYLENE GLYCOL - 315
.
RELEVANT LABS:
[**2158-9-19**] 12:44AM LACTATE-5.3*
[**2158-9-19**] 02:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-9-19**] 02:40AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2158-9-19**] 03:08AM OSMOLAL-351*
[**2158-9-19**] 03:08AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2158-9-19**] 03:08AM GLUCOSE-109* UREA N-11 CREAT-1.2 SODIUM-141
POTASSIUM-5.2* CHLORIDE-112* TOTAL CO2-16* ANION GAP-18
[**2158-9-19**] 03:19AM LACTATE-4.0*
[**2158-9-19**] 03:37AM LACTATE-4.1*
[**2158-9-19**] 06:32AM CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-2.0
[**2158-9-19**] 06:32AM GLUCOSE-109* UREA N-11 CREAT-1.2 SODIUM-144
POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-17* ANION GAP-19
[**2158-9-19**] 12:05PM OSMOLAL-331*
[**2158-9-19**] 12:05PM WBC-11.9* RBC-4.77 HGB-14.9 HCT-43.7 MCV-92
MCH-31.3 MCHC-34.1 RDW-13.8
[**2158-9-19**] 12:05PM ALT(SGPT)-19 AST(SGOT)-29 LD(LDH)-206 ALK
PHOS-49 TOT BILI-0.3
[**2158-9-19**] 12:05PM GLUCOSE-116* UREA N-10 CREAT-1.1 SODIUM-144
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-21* ANION GAP-19
[**2158-9-19**] 12:24PM LACTATE-1.7
[**2158-9-19**] 07:00PM ETHANOL-ETHANOL NO
[**2158-9-19**] 07:00PM OSMOLAL-296
[**2158-9-19**] 07:00PM GLUCOSE-138* UREA N-3* CREAT-0.6 SODIUM-141
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-32 ANION GAP-10
[**2158-9-19**] 09:48PM OSMOLAL-295
[**2158-9-19**] 09:48PM CALCIUM-8.8 PHOSPHATE-1.8* MAGNESIUM-1.8
[**2158-9-19**] 09:48PM GLUCOSE-126* UREA N-7 CREAT-0.8 SODIUM-138
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-28 ANION GAP-10
[**2158-9-19**] 10:02PM LACTATE-0.8
[**2158-9-19**] 10:02PM TYPE-[**Last Name (un) **] PO2-77* PCO2-40 PH-7.46* TOTAL
CO2-29 BASE XS-4
[**2158-9-21**] 07:45AM BLOOD Glucose-103* UreaN-13 Creat-1.0 Na-142
K-4.0 Cl-106 HCO3-28 AnGap-12
[**2158-9-21**] 07:45AM BLOOD Osmolal-293
.
MICRO:
[**2158-9-19**] 3:31 am MRSA SCREEN (Final [**2158-9-21**]): No MRSA
isolated.
EKG [**2158-9-19**]: Sinus rhythm. No previous tracing available for
comparison. Normal ECG.
CXR [**2158-9-19**]:
AP single view of the chest has been obtained with patient in
upright position. EKG electrodes and cables as well as multiple
onvoluted cables are overlying the chest and right axillary
area. Chest findings are grossly normal on this single chest
view. No pneumothorax is identified. A right internal jugular
approach central venous line terminates in the right mediastinal
structures at the level of the carina. This is compatible with
the position in the mid portion of the SVC. Our records do not
include any previous chest examination available for comparison.
Referring physician was paged as requested.
Brief Hospital Course:
43M who presented with antifreeze ingestion after more than a
week of paranoia with metabolic acidosis and serum osm gap.
# POLYETHYLENE GLYCOL INGESTION: presented with anion Gap
Acidosis/Osm gap secondary to ethylene glycol ingestion. At an
outside ED he had an Osm gap of 67, pH 7.34 and received 1.1g
fomepizole. On admission he had a mild acidosis (ABG pH 7.39 CO2
28 O2 86) with AG 14 and low bicarb (18) suggesting that it is a
metabolic acidosis with some respiratory alkalosis (expected
pCO2 with bicarb of 18 is 33-37). Per toxicology, acidosis was
mild because ADH was blocked fairly early in course by
fomepizole administration, which he was given at OSH and again
at [**Hospital1 18**] ER. He completed a course of cofactors (folic acid,
thiamine and pyridoxine) to optimize non toxic metabolites. Tox
screen for ethanol, acetaminophen, ASA, benzos, barbits, and
TCAs negative. Since pH >7.3, bicarbonate therapy was not
necessary. On admission ethylene glycol level was ~300 mg/dL on
admission so a right IJ line was places and he received
hemodialysis. The Osm gap closed to 5 after dialysis but the
ethylene glycol level remained elevated at 50 (>20 toxic) so he
received fomepizole after hemodialysis. His osm gap increased to
10 that evening and decreased to ~3 on [**9-19**]. Ethylene glycol
level was 32 at this point and he got another session of
hemodialysis on [**9-20**]. He received his final dose of fomepizole
on evening of [**9-20**]. His ethylene glycol on [**9-21**] was 1.4mg/dl,
at which point he was medically cleared for discharge.
# Elevated lactate: On admission the lactate was 5.3. This
likely was a false elevation of lactate since the assay can be
falsely positive in the presence of glycoate, one of the
metabolites of ethylene glycol. Lactate decreased to 1.2 after
dialysis and remained low at 0.8 the next morning.
# Leukocytosis: On admission he had a WBC 13.4 with normal diff
and no bands. He was afebrile and did not have any history to
suggest an infection. Without intervention the WBC decreased to
normal at discharge. The elevation was likely due to a stress
response in the setting of a stressful few weeks and attempted
suicide.
# Suicide attempt: Patient presented to OSH and reported
antifreeze ingestion. He reported a history of behavioral
changes and paranoia over last two weeks. A month and a half
before admission he had tried Chantix for two weeks in an
attempt to quite smoking but he found that it made him angry and
made his behavior less inhibited when he was talking. Psychiatry
was consulted and he was placed on section 12. On admission he
stated that he no longer had any suicidal ideation. He does not
have a known psychiatric history. Psychiatry was consulted and
thought that this represented a major depressive episode
possibly with pschotic features since he reports paranoia about
people following and targeting him. Some interaction between
marijuana cessation and chantix with stress is suspected to have
driven his transient psychosis. He was discharged to a
psychiatric facility for ongoing care.
PENDING TESTS AT DISCHARGE: none
# Transitional Issues:
-psychiatric evaluation
-eventual smoking cessation
-PCP followup following discharge
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Location (un) 10059**]
Discharge Diagnosis:
Polyethylene glycol ingestion
Suicide attempt
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital after ingesting antifreeze,
which is a potentially deadly condition. You were agressively
treated in the intensive care unit with an antidote called
fomepizole and hemodialysis, which were both extremely effective
at purifying your blood. You are medically quite healthy now.
Because of your suicide attempt, you are being discharged to
receive psychiatric care at an inpatient facility.
We have made no changes to your medicines.
We wish you the very best of luck, Mr. [**Known lastname **]!
Followup Instructions:
please followup with Dr. [**Last Name (STitle) 21721**] when you are discharged from
your facility.
|
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"982.8",
"305.1",
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"296.24",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
] |
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330, 394
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11360, 11360
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11375, 11487
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2721, 2904
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2920, 3280
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,384
| 190,248
|
9791
|
Discharge summary
|
report
|
Admission Date: [**2136-9-6**] Discharge Date: [**2136-9-11**]
Date of Birth: [**2099-9-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Tetracyclines / Succinylcholine / Clozaril /
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Transhepatic catheter self-d/c at [**Hospital3 7**]
Major Surgical or Invasive Procedure:
[**2136-9-7**]: Attempted replacement of Transhepatic catheter
[**2136-9-8**]: Succesful placement of Transhepatic catheter
History of Present Illness:
36 year old woman with ESRD [**3-9**] IgA nephropathy with a
transhepatic HD catheter presents 2 days after discharge after
having her transhepatic catheter was pulled out by the patient
while at her rehabilitation facility. She has had multiple
failed accesses in the past, last time with tunneled femoral
line sepsis (MRSA) with removal of line and I+D right groin. She
has
bilateral iliac vein thromboses. She was recently discharged on
warfarin, Flagyl and Meropenem. She had been dialyzing through
the transhepatic catheter.
She was recently discharged from [**Hospital1 18**] after undergoing
construction of a graft from the brachial vein to the right
atrium. This was complicated by thrombosis x 2. She also
received a tracheostomy in the previous admission.
While at [**Hospital3 **], her transhepatic catheter was
reported to have been removed by the patient
Past Medical History:
PAST MEDICAL HISTORY:
1. ESRD due to IgA nephropathy
2. Schizoaffective disorder
3. Depression
4. Anemia
5. GERD
6. Cardiomyopathy
7. Hypothyroidism
8. GI bleed
9. Coagulase negative staph infection
10. RLE DVT
11. Seizures x 2 [**8-11**]
PAST SURGICAL HISTORY:
s/p L upper & lower AV fistula - failed
s/p R AV fisula basilic v transposition - failed
s/p R forearm AV graft - failed
s/p PD catheter '[**27**] - failed
central venous stenosis - R brachiocephalic v.
occlusion of inominate v.
s/p R arm brachial->axilla AV graft ([**2133-10-9**])
s/p thrombectomy & angioplasty of outflow stenosis ([**2133-10-11**])
s/p thrombectomy ([**2133-10-23**])
s/p thrombectomy and revision of R arm AV graft ([**2133-11-12**])
s/p thrombectomy of R arm AV graft ([**2133-11-16**], [**2133-12-15**])
s/p excision of infected R arm AV graft ([**2133-12-25**])
[**2136-8-2**] right brachial artery to right atrium graft
[**2136-8-3**] rue graft thrombectomy
7/-/07 Trache
[**2136-8-13**] RUE exploration -seroma
[**2136-8-31**] UTI, pseudomonas
[**2136-9-8**] replacement of transhepatic hemodialysis catheter
Social History:
Lives at [**Location (un) **] Health and Rehab center, unemployed, no
tobacco, alcohol, or recreational drug use. Estranged from
mother [**Name (NI) **] ([**Telephone/Fax (1) 32972**])
Family History:
Non-contributory.
Physical Exam:
VS: 99.5, 103, 131/92, 20, 98% 2L, wt 74.5 kg
Gen: pale female, lying in bed, NAD, answers yes/no questions.
HEENT: Tracheostomy out after strap malfunction during initial
staff assessment. Wound C/D/I.
Lungs: Clear to auscultation
Heart: RRR, no M/R/G noted
Abdomen: soft, round, non-tender, non-distended, small defect in
the abdominal wall at the previous catheter site; dressing C/D/I
Extr: Left lower extremity swollen and tender, improved from
discharge.
Skin: dry, warm
Pertinent Results:
On Admission: [**2136-9-6**]
WBC-7.5 RBC-2.87* Hgb-9.2* Hct-27.4* MCV-96 MCH-32.1* MCHC-33.6
RDW-16.1* Plt Ct-247
PT-25.6* PTT-27.5 INR(PT)-2.6*
Glucose-99 UreaN-48* Creat-5.1* Na-136 K-4.5 Cl-97 HCO3-30
AnGap-14
Calcium-9.1 Phos-5.8* Mg-2.5
Brief Hospital Course:
Patient was admitted from [**Hospital **] Rehab following loss of
transhepatic catheter for hemodialyis. This was reported as a
self d/c, however this was apparently unwitnessed; Catheter was
found in the patient's bed.
An attempt was made to replace catheter on [**9-7**] which was
unsuccessful. On [**9-8**] another attempt was made under anesthesia.
Successful placement of a transhepatic hemodialysis catheter was
accomplished through the left hepatic vein into the SVC through
a previously established tract. Post procedure, she was sent to
the SICU for monitoring. She was dialyzed without event. She was
then transferred back to the med-[**Doctor First Name **] floor.
On the night of admission, her trache fell out while she was
turned. A #6, cuffless, non-fenestrated trache was replaced by
ENT on [**9-7**]. She did well post placement of trache with sats in
high 90's on 40% trache collar. The Passy Muir valve remained
off due to edema. Other recs included the following:
Trach suctioning prn
Trach should not be changed at least until Monday or Tuesday
([**9-17**])
Maximal PPI [**Hospital1 **]
Diet as tolerated. Speech and swallow if concern for aspiration
Aspiration precautions, Reflux precautions
She was also seen by psychiatry for noted sleepiness. Notation
was made of 2nd seizure while at [**Hospital **] Rehab on [**2136-8-6**].
Thorazine at HS was stopped and prolixin was increased to 5mg at
lunch (in addition to am and pm dose). Monitoring for worsening
of any psychotic symptoms was recommended given that she would
be off thorazine and is off fluphenazine decanoate injection
given being on anticoagulant. Follow up with her outpatient
psychiatrist (Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 32975**]was recommended.
Neurology was called for h/o 2nd seizure while at rehab. An EEG
was recommended as well as avoidance of fluoroquinolones which
can lower seizure threshold and finding alternative to Flagyl
which can also lower seizure threshold. An EEG was not done on
this admission. Flagyl was stopped. Of note, she has been on
flagyl for an extended course to cover for C.diff resolution 2
weeks post meropenum. Meropenum stopped on [**9-10**].
Patient was to undergo another attempt at thrombectomy of the
right venous/atrial graft. However this was deferred per Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Coumadin was on hold from [**9-7**] to [**9-10**] for this reason.
Coumadin was resumed on [**9-10**] at 2mg qd. Goal INR is 2.0. She
should have an INR on [**9-12**].
A peripheral saline lock was placed in her right foot on [**9-8**].
Last HD was [**9-10**]. While in HD she received 2 units of PRBC for
hct 24.4. Hct was 29 on [**9-11**].
Medications on Admission:
Colace 100 mg Capsule PO BID, Folic Acid 1 mg PO Daily,
Levothyroxine 150 mcg PO Daily, Ropinirole 1.5 mg PO QPM,
Fluphenazine 5 mg PO Daily, Fluphenazine 10 mg PO HS, and at
lunch, Mirtazapine 37.5 mg PO HS, Clonazepam 0.75 mg PO BID,
Metronidazole 500 mg PO TID, Insulin Regular sliding scale four
times a day, Famotidine 20 mg PO Q24H, Chlorpromazine 25 mg PO
HS, Hexavitamin 1 Cap PO Daily, Senna 8.6 mg Tablet 1 PO BID,
Percocet 5-325 mg 1-2 Tablets PO Q4H as needed, Camphor-Menthol
0.5-0.5 % Lotion 1 Appl Topical 4 times a day as needed for
pruritus, Metoprolol 25 mg PO TID hold for sbp <110 or HR <60,
Miconazole 2 % Powder 1 Appl Topical TID to peri area/groin,
Coumadin 3 mg Tablet PO daily, meropenum 500 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Ropinirole 1 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
5. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
6. Fluphenazine HCl 1 mg Tablet Sig: Five (5) Tablet PO LUNCH
(Lunch).
7. Mirtazapine 15 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime).
8. Clonazepam 0.5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for sbp <100 and HR <55.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
14. Fluphenazine HCl 1 mg Tablet Sig: Five (5) Tablet PO
BREAKFAST (Breakfast).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed: Sarna for pruritus.
17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
check inr [**9-12**].
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
ESRD with placement of new transhepatic catheter
Thrombus of venous/atrial graft
Replacement of trach
Discharge Condition:
Fair
Discharge Instructions:
Please call if the patient experiences fever > 101.4, chills,
nausea, vomiting, diarrhea, bleeding, pain.
Please see new schedule for psych meds
Continue Hemodialysis schedule q M-W-F using new transhepatic
dialysis catheter
No Passy-Muir valve until notified by ENT that this is safe to
use due to swelling at the site of the Trach
Followup Instructions:
Follow-up with outpatient psychiatrist Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 32975**]
Appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2136-9-18**] for Trach change
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2136-9-17**]
8:50
Completed by:[**2136-9-11**]
|
[
"583.9",
"425.4",
"V55.0",
"585.6",
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"345.90",
"530.81",
"311",
"996.73",
"V56.1",
"295.70",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"99.07",
"99.04",
"97.23",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8697, 8776
|
3636, 6363
|
453, 578
|
8921, 8927
|
3370, 3370
|
9309, 9707
|
2836, 2856
|
7142, 8674
|
8797, 8900
|
6389, 7119
|
8951, 9286
|
1780, 2617
|
2871, 3351
|
361, 415
|
606, 1479
|
3384, 3613
|
1523, 1757
|
2633, 2820
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,377
| 153,032
|
38677
|
Discharge summary
|
report
|
Admission Date: [**2120-4-17**] Discharge Date: [**2120-4-29**]
Date of Birth: [**2038-3-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fall
tSAH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is an 82 year old male with PMHx of MI with cardiac
pacemaker, CABG and cardiac stents (on coumadin), and old prior
CVA presents s/p fall this morning while standing. Has baseline
difficult ambulating d/t prior stroke and l-sided weakness, but
thinks his weakness has worsened over the past several days. He
was using the bathroom and fall backwards, due to this weakness,
and hit his head on bathroom floor. No LOC. Crawled back to bed,
went to sleep for 2 hours, and awoke with a headache. Called
ambulance. Upon arrival to [**Hospital3 1280**], had an INR of 4.0 - was
give 10mg of Vit K only. CT scan positive for tSAH. Transferred
to [**Hospital1 18**] for further care.
Patient currently complains of a HA and abdmominal pain. Also,
he
does feel increased weakness on the L upper and lower extremity.
He denies diplopia, nausea/vomiting, or sensory deficits.
Past Medical History:
PMHx:
1.MI - s/p CABG. on Coumadin
2.HTN
3.Hypertension
4.Cardiac Pacemakes
5.R CVA with residual L-sided weakness
Social History:
Non-contributory
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
O: T: 97.8 BP: 163/94 HR:72 R:18 O2Sats: 94% 4L
Gen: WD/WN, comfortable, NAD.
HEENT: Large hematoma to R occipital scalp with 2cm laceration.
not actively bleeding Pupils: 2 bilat and minimally reactive
EOMs intact. L nasolabial fold flattening, possible from prior
CVA
Abd: Soft, tender to palpation.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-27**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-29**] throughout the R side. Left
side
5- in upper extremities, [**5-29**] LLE. Left pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
On discharge: As above.
Pertinent Results:
ADMISSION LABS:
[**2120-4-17**] 09:45AM PT-28.2* PTT-30.4 INR(PT)-2.8*
[**2120-4-17**] 09:45AM WBC-7.3 RBC-4.10* HGB-11.7* HCT-35.3* MCV-86
MCH-28.4 MCHC-33.0 RDW-13.6
[**2120-4-17**] 09:45AM GLUCOSE-89 UREA N-36* CREAT-2.0* SODIUM-137
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-31 ANION GAP-13
DISCHARGE LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2120-4-27**] 06:40AM 5.6 3.65* 10.7* 32.8* 90 29.4 32.8 14.3
256
BASIC COAGULATION (PT [**Name (NI) 263**]
[**2120-4-29**] 08:55AM 20.1* 1.9*
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
CT Head from [**Hospital3 1280**] [**4-17**]:
1.1cm area of subarachnoid centered within left sylvian fissure.
No mass effect, no midline shift.
Ct head [**4-17**]:
1. Left frontotemporal subarachnoid hemorrhage. No mass effect
or midline
shift.
2. Remote ischemia or infarct in the right putamen with ex vacuo
dilatation of the right lateral ventricle. Small vessel ischemic
disease and predominantly frontal atrophy as described.
CT Torso [**4-17**]:
1. Moderate to severe left hydroureteronephrosis without
definite obstructing stone or mass given of lack of IV contrast.
Enlarged prostate with apparent bladder wall thickening, which
could in part be relate to underdistension around the Foley,
though chronic outlet obstruction cannot excluded, which could
conceivably cause left hydroureternephrosis. Recommend urologic
consultation/evaluation.
2. Left base pulmonary consolidation, infectious process not
excluded.
3. Gallbladder sludge versus small stones. No cholecystitis.
4. Ventral hernia containing nonobstructed bowel.
5. Left inguinal hernia with soft tissue density within,
possibly herniated omentum versus Prolene plug from prior
repair. Please correlate with surgical history
6. Ill-defined sclerotic lesions are identified in the right
ilium adjacent to the right SI joint as well as in the right
acetabular roof. These are not definitely benign, and bony
infarction or blastic lesions cannot be excluded. Please
correlate clinically with history of primary malignancy, such as
prostate, and consider nonemergent bone scan.
7. Mild L1 compression deformity and sclerosis of superior
posterior endplate of L2, of indeterminate age.
8. Marked left atrial enlargement status post mitral valve
replacement.
Ct C-spine [**2120-4-17**]:
prelim: No fracture or malalignment
Ct Head [**2120-4-17**]:
1. No significant change in blood products in/adjacent to left
sylvian
fissure, most likely representing fall, subarachnoid hemorrhage
and possible adjacent hemorrhagic contusions.
2. Geographic area of decreased decreased attenuation in the
right frontal and parietal bones at the vertex, unchanged from
prior, of uncertain nature. Comaprison with any remote iamges
can be helpful.
CT Head [**4-20**]:
IMPRESSION:
1. Interval decrease in density of the known left Sylvian
subarachnoid
hemorrhage, compatible with expected evolution of subarachnoid
hemorrhage.
2. Appearance of new tiny right frontal subdural hematoma, could
represent
interval increase of density of hyper-acute subdural hematoma
from contrecoup injury. Cannot rule out new subdural hematoma.
No significant mass effect. Recommend short-interval follow-up
and monitoring.
Brief Hospital Course:
The patient was admitted to the NSurg stepdown unit for Q2 neuro
checks and for reversal of his INR. His neurological exam
remained unchanged throughout the day. Following 2 U FFP and
10mg Vit K x2, his INR reversed to 1.1 on [**4-18**]. His Cpsine
imaging was negative for fracture and his collar was removed.
Corrected dilantin level was 16.5. Floor orders were written.
From a neurosurgical standpoint, he did well; specifically, a
repeat Head CT demonstrated complete resolution of the SAH on
[**4-20**], with an evolving R frontal SDH. He was seen by geriatrics
on [**4-19**] for increased agitation and confusion. They made some
simple recommendations regarding his medications, but attributed
his delerium to the SAH. It was recommended by [**Female First Name (un) 1634**] and PT that
the patient be sent to a rehab/nursing home facility. He
refused discharge to anywhere but home; therefore social work
consult was obtained to facilitate the discharge process. A
psychiatry consult was also obtained to ascertain his competance
to make decisions regarding his care. They concluded that there
was no need for a capacity assessment given the patient's
eventual agreement to go to a [**Hospital1 1501**].
He was restarted on his Coumadin on [**4-24**]. At the time of
discharge, his INR was nearly therapeutic at 1.9. This is on 4
MG Daily.
he was screened by a [**Hospital1 1501**], and was discharged to [**Hospital1 **] on
[**2120-4-29**].
Medications on Admission:
1. Coumadin
2. Lasix
3. Digoxin
4. Lovastatin
5. Lisinopril
6. Atenolol
7. Metolazone
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) as needed for until patient OOB.
9. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 85916**] Hospital
Discharge Diagnosis:
tSAH
Delerium
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You were on Coumadin (Warfarin) prior to your injury, you were
restarted on this medication on [**2120-4-24**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
You should have your INR checked weekly. Your INR should remain
therapeutic between 2.0-3.0.
Completed by:[**2120-4-29**]
|
[
"728.89",
"V45.01",
"852.01",
"348.30",
"V58.61",
"V45.81",
"309.4",
"550.90",
"438.89",
"E885.9",
"412",
"V43.3",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8863, 8919
|
6268, 7725
|
329, 336
|
8977, 9001
|
2943, 2943
|
10112, 10567
|
1429, 1447
|
7862, 8840
|
8940, 8956
|
7751, 7839
|
9025, 10089
|
3254, 6245
|
1477, 1836
|
2913, 2924
|
280, 291
|
364, 1241
|
2129, 2899
|
2959, 3238
|
1851, 2113
|
1263, 1379
|
1395, 1413
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,221
| 162,318
|
19965
|
Discharge summary
|
report
|
Admission Date: [**2137-12-20**] Discharge Date: [**2137-12-24**]
Date of Birth: [**2062-11-27**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 75-year-old man
with a history of hypertension, former smoker, RCA stent at
[**Hospital3 2358**], peripheral vascular disease status post
axillo-bifemoral bypass, chronic renal insufficiency, who is
admitted to an outside hospital after an episode of jaw pain,
chest pain, and shortness of breath. Patient's cardiac
enzymes were found to be elevated with a troponin-I of 3.22.
While receiving aspirin and Heparin, he developed melena with
a fall in hematocrit from 44.8 to 36.4 requiring 2 units of
packed red blood cells.
EKG showed no ST segment elevations. The patient also had an
episode of hypotension with a blood pressure of 66/40,
nausea, no vomiting, and bradycardia. His EKG at that time
showed a junctional rhythm at 50 beats per minute. The
patient responded to normal saline bolus.
PAST MEDICAL HISTORY: As stated above.
ALLERGIES: Iodine dye.
CURRENT MEDICATIONS:
1. Allopurinol.
2. Furosemide 40 q.d.
3. Lopressor 50 b.i.d.
4. Calcitriol.
5. Hydralazine 25 b.i.d.
6. Phenergan prn.
PHYSICAL EXAMINATION: Vitals: Patient was afebrile, blood
pressure 132/58, heart rate 68, sating 98% on 2 liters.
General: Elderly man laying comfortably in bed in no
apparent distress. HEENT: Moist mucous membranes, clear
oropharynx. Cardiovascular: Regular, rate, and rhythm, no
murmurs, rubs, or gallops. Abdomen: Soft, nontender,
nondistended. Extremities: No clubbing, cyanosis, or edema.
LABORATORY VALUES: Significant for a hematocrit of 33.9 and
a creatinine of 2.8.
HOSPITAL COURSE: Patient was transferred to the [**Hospital1 346**] and admitted to the Coronary Care
Unit. There a GI consult was obtained for his history of
melena and drop in hematocrit. The GI consult felt that no
urgent need for endoscopy was needed. Patient had a normal
gastric lavage. No evidence of bleeding was found. However,
bile was not returned on the gastric lavage. Patient was
started on a beta blocker and aspirin for his history of
coronary artery disease and his elevated troponin. He was
typed and screened. Adequate peripheral intravenous access
was obtained. Patient was at this time asymptomatic without
chest pain or EKG changes. His cardiac enzymes were down
trending. He was in normal sinus rhythm.
In addition, he was started on IV Protonix and made NPO. The
patient received blood transfusion of 2 units of packed red
blood cells with the goal of keeping his hematocrit above 35.
His renal function was closely monitored. The following day
he underwent cardiac catheterization. He was found to have a
100% discrete stenosis of his proximal RCA. His left main
was noted to have a 30% discrete stenosis. His LAD was
diffusely diseased. His mid CX had a discrete 100% stenosis.
His OM-1 and OM-2 were also with significant stenosis.
The patient was pretreated with Solu-Medrol and Benadryl and
acetylcysteine for his history of contrast allergy and for
his known renal insufficiency. Coronary angiography revealed
a right dominant system with significant two vessel coronary
artery disease. No intervention was conduction.
The patient was returned to the CCU and then after a period
of observation was transferred to the floor. He was seen
again by the Gastrointestinal service, who felt that urgent
endoscopy was again not required. The patient required no
further blood transfusion and his hematocrit remained stable.
He was discharged home with appropriate followup.
DISCHARGE MEDICATIONS:
1. Aspirin 325 q.d.
2. Metoprolol 50 mg b.i.d.
3. Pantoprazole 40 mg q.d.
FOLLOW-UP INSTRUCTIONS: He was scheduled for followup to see
the Gastrointestinal service in [**5-19**] weeks. He was asked to
make a follow-up appointment with his primary care doctor,
Dr. [**Last Name (STitle) **]. He was also asked to make a follow-up appointment
to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for Cardiology followup.
DISCHARGE DIAGNOSES:
1. Gastrointestinal hemorrhage.
2. Subendocardial myocardial infarction.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 9719**]
MEDQUIST36
D: [**2137-12-30**] 08:52
T: [**2137-12-31**] 09:02
JOB#: [**Job Number 53830**]
|
[
"578.9",
"V45.82",
"593.9",
"414.01",
"443.9",
"274.9",
"401.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"37.22",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
4184, 4478
|
4088, 4162
|
3619, 3694
|
1692, 3596
|
1208, 1674
|
1065, 1185
|
164, 978
|
3719, 4067
|
1001, 1044
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,547
| 121,038
|
34180
|
Discharge summary
|
report
|
Admission Date: [**2165-5-14**] Discharge Date: [**2165-5-20**]
Date of Birth: [**2100-11-16**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Glucotrol
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Planned admission for TIPS evaluation
.
Major Surgical or Invasive Procedure:
Transjugular intrahepatic portovenous shunt
.
History of Present Illness:
Ms. [**Name14 (STitle) 20788**] is a 64-year-old lady with cirrhosis most likely
secondary to nonalcoholic steatohepatitis. The patient presented
in [**2158**] with upper GI bleeding. Evaluation at that time revealed
bleeding esophageal varices that required banding and evidence
of cirrhosis. Thereafter, the patient continued to be in a
well-compensated state until [**2164-10-4**] when she started
developing ascites. Subsequently she was admitted to [**Hospital 1263**]
Hospital in [**2164-12-4**] and required paracentesis. Despite
the diuretic therapy the patient continued to accumulate fluid
and developed azotemia and dizziness from the Lasix and
Aldactone. She had a paracentesis in [**Month (only) 547**] with 13L removed.
Diuretics were discontinued on [**4-23**] due to intolerance. 2 weeks
ago she had 8L liters of fluid removed and last Thursday had 11L
removed. She was seen in liver clinic on [**5-9**] and now presents
for TIPS eval.
.
ROS: Does note some worsening of her SOB over the past 2 days.
Occurs mainly with exertion, occasionally at rest. Also c/o
dizziness when getting up from lying or sitting position over
the past 3-4 days. +early satiety. + weight loss (240lbs
[**10-11**]--> 184lbs today), which she attributes to decreased
appetite. Denies f/c/n/v/abdominal pain.
.
Past Medical History:
-Cirrhosis- dx [**2158**], likely [**1-5**] NASH, c/b bleeding varices, no
h/o encephalopathy. No biopsy. Outpatient hepatologist is Dr.
[**First Name (STitle) 5656**] at [**Doctor Last Name 1263**].
-DM
-HTN
-Obesity
-Hypothyroidism
-s/p cholecystectomy
.
Social History:
No smoking, no alcohol, no drugs, she reports no history of ETOH
abuse in the past. She is not married and has no children. She
gets support from her friends.
.
Family History:
No liver disease, no liver cancer, diabetes mellitus (mother and
2 siblings), cancer (sister with breast cancer).
.
Physical Exam:
Vitals: T 96.3, BP 82/60, HR 57, RR 18, SaO2 100% RA
Gen: well-appearing middle-aged woman, NAD
HEENT: MMM, OP clear
Heart: RRR, no m/r/g
Lungs: CTAB, no w/r/r
Abd: decreased BS, soft, NTND, mild amount of ascites with
+fluid wave
Ext: trace b/l LE edema
Neuro: A+Ox3, appropriate
.
Pertinent Results:
[**2165-5-15**] WBC-6.4 Hgb-11.2 Hct-32.1 MCV-84 Plt Ct-275
[**2165-5-15**] PT-13.7 PTT-35.3 INR(PT)-1.2
[**2165-5-15**] Glucose-108 UreaN-74 Creat-1.9 Na-130* K-4.2 Cl-99
HCO3-23
[**2165-5-20**] Glucose-110 UreaN-38 Creat-1.1 Na-135 K-4.0 Cl-104
HCO3-20
[**2165-5-15**] ALT-26 AST-38 LD(LDH)-155 AlkPhos-125 TotBili-0.9
[**2165-5-18**] ALT-15 AST-26 LD(LDH)-153 AlkPhos-95 TotBili-1.2
[**2165-5-15**] Albumin-2.9 Calcium-8.7 Phos-5.1 Mg-2.6
[**2165-5-17**] 05:28AM BLOOD Cortsol-8.4
.
[**2165-5-16**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.039*
Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR RBC-[**5-14**]* WBC-[**2-6**]
Bacteri-RARE Yeast-NONE Epi-0
[**2165-5-16**] URINE Osmolal-568 UreaN-1078 Creat-105 Na-LESS THAN 10
.
[**2165-5-16**] URINE CULTURE (Final [**2165-5-17**]): NO GROWTH.
.
STUDIES:
ABDOMINAL ULTRASOUND WITH DOPPLER ([**2165-5-14**]):
1. Findings consistent with cirrhosis and portal hypertension.
2. Large amount of ascites.
3. No evidence of portal vein thrombosis.
.
TTE ([**2165-5-15**]): Normal regional and global biventricular systolic
function. No pathologic valvular abnormality seen. Normal
pulmonary artery systolic pressure.
.
ABDOMINAL ULTRASOUND WITH DOPPLER ([**2165-5-16**]):
Patent TIPS shunt with appropriate flow. Flow within the main
portal vein is noted to be at a slow velocity of only 15.3
cm/sec. Because of this, a short-term six-week followup
ultrasound is recommended. Large amount of ascites.
.
Brief Hospital Course:
64 year-old woman with cirrhosis, most likely [**1-5**] NASH,
complicated by recurrent ascites requiring frequent paracenteses
and failure of diuretic therapy. Admitted for TIPS eval,
transferred for overnight observation in MICU due to difficulty
weaning neosynephrine gtt, now off pressors and BPs stable.
.
#. Cirrhosis: Likely NASH, no Bx. History of recurrent ascites
now requiring TIPs. No history of encephalopathy. Had TIPS
placed, complicated by post-procedure hypotension (as below).
TIPS was patent on ultrasound. Started low-dose diuretics prior
to discharge, which she tolerated well. Will follow up with
Liver as outpatient. Will have follow-up ultrasound in 6 weeks
to assess TIPS.
.
#. Hypotension: In the PACU after TIPS procedure, pt was noted
to have hypotension to 67/30. She was asymptomatic during this
episode, with no dizziness/lightheadedness and normal mentation.
Her baseline BP at outpatient clinic appointments has been
90s/50s. Required neosynephrine for BP support. Due to inability
to wean neo in the PACU, she was admitted to the MICU for
observation. In the MICU, she was weaned off pressors gently and
her BP returned to baseline 85-100/30-50s. Octreotide and
midodrine were started for hypotension and renal failure (see
below). She returned to the floor the following day. BP remained
stable with SBP in the 90s, asymptomatic. She was discharged on
midodrine.
.
#. Acute renal failure: Cr was 1.9 on admission. Obtained PCP
[**Name Initial (PRE) 14453**]. Cr was 0.8 on [**2164-12-10**]--> 2.0 on [**2165-5-9**]. Ddx includes
hepatorenal, pre-renal from diuretics, ATN in setting of
hypotension or post-renal etiolgies. She was started on
octreotide/midodrine in the MICU for question of hepatorenal
syndrome. Cr improved to 1.1 by the day of discharge. She was
continued on midodrine at discharge.
.
#. DM: Continued home lantus regimen with humalog insulin
sliding scale.
.
#. Hypothyroidism: Continued levothyroxine 200 mcg PO daily.
.
#. Code: FULL
Medications on Admission:
Lantus 40 units SC daily
Aspart 5 units TID before meals
Lactulose 15mL PO daily prn
Levothyroxine 200 mcg PO daily
Nadolol 20mg PO daily
Furosemide 40mg PO daily (stopped on [**4-23**])
Spironolactone 100mg PO daily (stopped on [**4-23**])
.
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Insulin Glargine 100 unit/mL Cartridge Sig: 40-50 units
Subcutaneous once a day.
6. Novolog 100 unit/mL Cartridge Sig: Five (5) units
Subcutaneous three times a day: before meals.
.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary: TIPS placement
.
Secondary: Cirrhosis, hypothyroidism
.
Discharge Condition:
Hemodynamically stable. Renal function improved.
.
Discharge Instructions:
You were admitted to the hospital for TIPS placement. After the
procedure your blood pressure was very low and you were observed
in the intensive care unit. You also had worsening of your
kidney function, but this improved with medications.
.
You were started on three new medications:
- Lasix and spironolactone are diuretics which you have been on
before.
- Midodrine is a medication to keep your blood pressure up.
.
If you develop fevers>101, severe abdominal pain, nausea, or
vomiting, or other symptoms that are concerning to you you
should go to the nearest emergency room.
.
Followup Instructions:
You should follow-up with your GI doctor Dr. [**Last Name (STitle) 7493**]. An
appointment has been scheduled for you on [**6-17**] at 3:30pm.
Telephone number [**Telephone/Fax (1) 54080**].
.
You will need to follow-up with one of the doctors in the liver
center. The office will contact you to schedule this. Telephone
number [**Telephone/Fax (1) 2422**].
.
You will require a repear Ultrasound of your liver in 6 weeks to
make sure your TIPs is operating properly. An appointment has
been scheduled for you on Monday [**7-1**] at 10am, [**Hospital Ward Name **]
clinical center, [**Location (un) 470**]. Do not eat anything 6 hours prior to
the procedure. Telephone number [**Telephone/Fax (1) 327**].
.
|
[
"789.59",
"278.00",
"V58.67",
"244.9",
"584.9",
"250.00",
"571.5",
"458.29",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
7041, 7092
|
4169, 6162
|
333, 381
|
7200, 7252
|
2627, 4146
|
7884, 8593
|
2190, 2308
|
6456, 7018
|
7113, 7179
|
6188, 6433
|
7276, 7861
|
2323, 2608
|
254, 295
|
409, 1714
|
1736, 1995
|
2011, 2174
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,778
| 186,565
|
12446
|
Discharge summary
|
report
|
Admission Date: [**2148-3-18**] Discharge Date: [**2174-8-18**]
Date of Birth: [**2128-3-11**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
male who was transferred from an outside hospital with a
large subarachnoid hemorrhage as well as chronic liver
failure. The night before admission, the patient had fallen
out of bed twice, striking himself against a filing cabinet.
The patient acted appropriately at the time but later the
next morning was noticed to have a change of mental status
with increased confusion, was noticed to have several bruises
on his chest and then later that day was found in the house
with marked confusion and broken furniture in the room
suggesting that he had become extremely disoriented and
agitated.
At the outside hospital, the patient had a CT scan which
noted frontal subarachnoid hemorrhage. The patient was
intubated and transferred to [**Hospital6 2018**].
PAST MEDICAL HISTORY:
1. Alcoholic liver failure, end stage
2. Duodenal ulcers
3. Alcohol abuse
HOME MEDICATIONS:
1. Protonix
2. Actigall
3. Aldactone
4. Trental
5. Propanolol
PHYSICAL EXAM ON ADMISSION:
VITAL SIGNS: The patient's heart rate was 53, blood pressure
161/93, respiratory rate 12, O2 saturation 100% on
ventilator.
GENERAL: The patient was intubated, sedated, but moving all
four extremities.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils were equal, round
and reactive to light. The patient was icteric. The patient
had right orbital ecchymosis and swelling. Nares were clear
with a nasogastric tube in place.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. There was a large
ecchymosis of her anterior chest.
ABDOMEN: Soft with ecchymosis and a small laceration.
BACK: There was no ecchymosis, no stepoff.
EXTREMITIES: Upper extremities - there was bilateral forearm
and hand swelling an ecchymosis in the left forearm and elbow
abrasion. Legs - distal pulses were strong bilaterally.
There were bilateral knee bruises and abrasions on the right
knee.
LABS: White blood count was 8.3. Hematocrit was 27.6.
Platelets were 98. Sodium 134, potassium 4.5, chloride 96,
bicarbonate 28, BUN 19 creatinine 0.5, glucose 177 and INR of
2.5, ammonia level of 46.
IMAGING: Head CT showed a large anterior subarachnoid
hemorrhage with interventricular bleeding bilaterally. No
mass effect or shift. CT of the abdomen and pelvis showed
ascites, splenomegaly, liver cirrhosis, bilateral pleural
effusions.
HOSPITAL COURSE: The patient was admitted to trauma service
with consultation from neurosurgery and the liver service.
The patient remained intubated and was subsequently
transferred to the Medical Intensive Care Unit. Two
significant events during his hospital course were ongoing
decrease in hematocrit and posterior cranial lesion which was
noted on MRI of the cervical spine which was noted to
possibly be a metastatic lesion with an unknown primary
lesion. This mass in the cerebellum and posterior
compartment was compressing the fourth ventricle causing a
mass effect in the brain stem with ............. The patient
was transfused with large amounts of fresh frozen plasma for
his coagulopathy secondary to liver cirrhosis. INR was
consistently above 1.9. The family was informed of the poor
neurological prognosis and the patient had been listed for do
not resuscitate. After several discussions with medical
staff, the patient's mother and sister expressed the
patient's previously stated desire for no CPR, no
defibrillation and no further blood products. They
understood the poor prognosis of the patient. The patient's
mental status continued to deteriorate, possibly secondary to
continued intracranial bleeding, but also possibly due to
hepatic encephalopathy. After further discussion with the
patient's family, they expressed a desire to withdraw all
supportive care, including ventilator, all medications,
except those required for comfort, intravenous fluids, feeds
and oxygen. This was done and the patient was pronounced
dead on [**2174-3-28**] at 5:45 p.m.
DISCHARGE CONDITION: Deceased
DISCHARGE DIAGNOSES:
1. Alcoholic liver cirrhosis
2. Subarachnoid hemorrhage
3. Coagulopathy
4. Cerebellar mass
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Doctor Last Name 38667**]
MEDQUIST36
D: [**2174-8-18**] 12:26
T: [**2174-8-25**] 09:36
JOB#: [**Job Number 38668**]
|
[
"401.9",
"852.05",
"E884.4",
"571.2",
"518.81",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4139, 4149
|
4170, 4538
|
2544, 4117
|
1083, 1165
|
176, 965
|
1179, 2526
|
987, 1065
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,984
| 155,804
|
20586
|
Discharge summary
|
report
|
Admission Date: [**2188-4-17**] Discharge Date: [**2188-5-9**]
Date of Birth: [**2141-3-21**] Sex: M
Service: MEDICINE
Allergies:
Imipenem
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 47 year-old male w/ PMHx significant for HIV/AIDS off
anti-retroviral therapy, hx of pancreatitis, hx of depression
who was in his usual state of health until one day prior to
admission when he awoke this AM from sleep with acute onset
abdominal pain. He describes the pain as [**8-16**] sharp, located on
his LUQ, non-radiating, and constant. He went to the bathroom
and had a small loose bowel movement. He took some tylenol with
very little relief. He also states that his urine output
decreased over the course of the day. He states that the pain
was different then the prior pain that he felt with his
pancreatitis. He also states that he felt sweaty with chills,
nausa, and non-bilious vomiting. He denies shortness of breath,
chest pain, bloody stool.
In the ED the patient had a CT of the abdomen that showed
pancreatitis. The patient was seen by surgery and deemed not a
candidate for surgery. He was given IVF, dilaudid, and a dose
of imipenem.
Past Medical History:
HIV/AIDS w/ hx of PCP, [**Name10 (NameIs) 11395**], and opthalmic zoster
Depression
Self inflicted stab wound
Two prior hospitalizations for pancreatitis
Social History:
The patient is divorced but living with his children and a
fiance. He still smokes [**2-8**] pack of cigarettes a day. He no
longer is consuming alcohol at this time, but on occasion he
does
have a glass of wine. Last drink approximately 2 weeks agod. He
does have 4 cups of coffee per day. He is currently disabled and
not able to work.
Family History:
Both mother and father died from complications of cancer. His
mother had breast cancer. It is not certain whether she also had
lung cancer or whether it was metastatic from breast. His father
died from lung cancer, had a history of peptic ulcer disease and
hiatal hernia. The patient has a younger female sibling who is
alive and well.
Physical Exam:
Vitals - 95.7 88 132/80 22 100% RA
Gen: lying in bed, groaning, appears in great pain
HEENT: asymmetric left pupil, right reactive, dry mmm, no JVD
CV: RRR, nl S1, S2, no murmur/rubs/gallops
RESP: rhonchi in lower lobes b/l
Abd: rigid, tender to palpation on LUQ and LLQ, + BS
Ext: no c/c/e
Neuro: A&O x3
Skin: no rash
Pertinent Results:
LACTATE-3.1*
AMYLASE-508*
LIPASE-1401*
RUQ US - No evidence of gallstones or cholecystitis. Edematous
pancreas. Please correspond with CT scan of same day.
.
CXR - 1) No free air under the diaphragm. No evidence of acute
cardiopulmonary process. 2) Curvilinear calcific density at the
right hilar region that may represent mural calcification of the
ascending aorta. This raises the question of syphylitic or
collagen vascular disease of the aorta.
.
MRCP - slight irregularity in dilated side [**Last Name (un) **] of pancreatic
duct.
.
EGD - erythema erosion of antrum c/w gastritis
.
[**4-17**]:
CT abd
1. Pancreatitis in patient with evidence of prior pancreatitis.
Hypodensity in the tail and head represent edema. A small fluid
collection is seen between the stomach and the pancreas. Fluid
in the anterior perirenal space and gallbladder fossa.
2. Hemangioma in liver.
3. Several too - small - to characterize kidney cysts.
4. Atelectasis of the left lung base.
.
[**4-19**]:
CT ABd/Pel
1) Interval worsening of disease with new intra-abdominal
ascites, small bilateral pleural effusions, and increased size
of focal peripancreatic fluid collections within the lesser sac.
There is again seen hypoenhancement within the distal body/tail
of the pancreas consistent with focal pancreatic necrosis.
.
[**4-21**]:
1) IR Paracentesis:
PROCEDURE/FINDINGS: After discussion of risks and benefits with
the patient by the clinical team, written informed consent was
obtained. A limited ultrasound was performed demonstrating a
pocket of fluid in the left lower quadrant and a spot was marked
overlying the skin suitable for paracentesis. The area was
prepped and draped in the standard sterile fashion. Local
anesthesia was achieved with subcutaneous injection of
approximately 3 cc of 1% lidocaine with bicarbonate. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11097**]
catheter was then inserted into the peritoneum with successful
withdrawal of approximately 700 cc of clear yellow/brown ascites
fluid. The patient tolerated the procedure well with no
immediate postprocedural complications. Samples were sent to the
laboratory for analysis and cytology.
.
[**4-23**]:
CT Abd: IMPRESSION:
Necrosis of the pancreatic tail, with surrounding small fluid
collection, but overall less inflammatory changes since
[**2188-4-19**]. No vascular complications identified.
.
[**4-26**]:
CT HEAD:
There is evidence of fluid collections in the right frontal and
left parietal/occipital scalp. There is no intracranial
hemorrhage, shift of normally midline structures, hydrocephalus,
or mass effect. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. There is no major vascular territorial infarct. The
sulci are normal. There are no osseous lesions. There is near
complete opacification of the frontal sinus, sphenoid sinus,
maxillary sinuses, and ethmoid air cells.
.
[**4-29**]:
CT ABD/PELVIS:
1. Necrosis of the pancreatic tail, with slightly reduced
surrounding inflammatory changes, but no definite organized
fluid collection.
2. Persistent moderate-sized bilateral pleural effusions with
adjacent atelectasis, and a right perihilar density as well. A
chest x-ray could be helpful for further evaluation of the
entire thorax.
[**4-30**]:
CTA Chest: IMPRESSION: No evidence of acute pulmonary embolus.
Brief Hospital Course:
Pt is a 47 yo male w/ PMHx sig for HIV/AIDS off anti-retroviral
therapy, pancreatitis, depression who was in his USOH last PM
when he awoke this AM from sleep with acute onset abdominal
pain. He describes the pain as [**8-16**] sharp, located on his LUQ,
non-radiating, and constant. He went to the bathroom and had a
small loose bowel movement. He took some tylenol with very
little relief. He also states that his urine output decreased
over the course of the day. He states that the pain was
different then the prior pain that he felt with his
pancreatitis. He also states that he felt sweaty with chilla,
nausa, and non-bilious vomiting. He denies shortness of breath,
chest pain, bloody stool.
In the ED the patient had a CT of the abdomen that showed
pancreatitis. The patient was seen by surgery and deemed not a
candidate for surgery. He was given IVF, dilaudid, and a dose of
imipenem.
He was then admitted to the medicine service and was managed
conservatively but he began to have increased pain, tachypnea,
and hypoxia on the floor. In addition, his CT scan on [**4-19**]
showed necroting pancreatits. Therefore he was transferred to
the ICU and intubated for tachypnea and respiratory failure due
to increasing metabolic acidosis.
.
[**Hospital **] hospital COurse:
The patient was admitted to the MICU for increasing pain from
pancreatitis and CT scan which showed increased nectoric areas
as compared to the one 1 week prior. Once admitted to the MICU,
he quickly decompensated. His mental status declined and he
became rigid and hyperthermic. Though this appeared to be
neuroleptic malignant syndrome, he had not recieved any
medications that could be implicated. He was intubated for
decreased mental status and respirtory alkalosis [**1-9**] to rigid
rib cage and decreased inspiratory effort. His rigidiy resolved
once he was intubated and he had no further problems with
increased tone.
His prognosis was guarded for many days in the ICU as his
pancreatitis continued to worsen clinically. Surgery was
following and extensive discussion was made about whether to
preform an FNA of the nectoric tail of his pancreas. It was
decided that a FNA would not change mamagement in that he would
not be taken to the OR if it was infected since his status was
too tenuous. He was treated with broad spectum antibiotics (no
antifungals per ID), aggressive fluid repletion, and aggressive
electrolyre repletions. For antibiotics, he was initially
started on Imipenem but was changed to Zosyn due to leukopenia.
He continued to have leukopenia so it was switched to
levofloxacin. He continued to retain fluid in pleural
effusions, ascites, and RP edema. He had bladder pressures
measured daily and never was above 25. He underwent a
thorcentesis which showed an exudative sympathetic effusion high
in amylase. He underwent a paracentesis which by WBC was
positive for SBP though the culture did not grow out.
Repeat abdominal CT has shown improving pancreatitis. He was
eventually transferred to the medicine floor. He was having
slowed and altered mental status while he was in the ICU
requiring multiple antipsychotics. On the floor, he seemed very
slow and lethargic, but improved as we discontinued multiple
psych medications he was getting (standing haldol 2.5 mg [**Hospital1 **],
olanzapine prn, ativan). For nutrition, he was at bowel rest
and was TPN, but he was able to slowly advance diet as his
mental status improved. Prior to discharge, he was alert and
oriented x 3, able to ambulate without minimal assistance, and
was able to tolerate low fat diet. When he was getting TPN, he
required insulin sliding scale, but his FS has been normal after
TPN was discontinued.
The etiology of his pancreatitis still remaines unclear. In the
past, it has been attributed to the HAART therapy, but this time
pancreatitis developed while off the medications. He will be
followed by Dr. [**Last Name (STitle) 3315**] from GI, and Dr. [**First Name (STitle) **] from I.D.
withing 1 week from the discharge.
Medications on Admission:
bactrim
acyclovir
azithromycin
Discharge Medications:
1. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2498**] VNA
Discharge Diagnosis:
Primary:
1)Acute necrotizing pancreatitis
2)Altered mental status
3)Chronic sinusitis
Secondary:
1)HIV
2)Depression
Discharge Condition:
Stable, ambulating, eating low fat diet.
Discharge Instructions:
Patient needs to take all of the medications as directed. He
needs to seek medical attention if he develops fever, chills,
nausea, vomiting, abdominal pain, diarrhea, constipation, or any
other concerning symptoms. He needs to refrain from high fat
diet to prevent the recurrence of pancreatitis. He needs to
follow up with the [**Hospital **] clinic for his HIV management.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] on [**2188-5-14**] at 12:00
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-5-14**] 12:00
Please follow up with Dr. [**Last Name (STitle) 3315**] on [**2188-5-13**] 9:40. TEL:
[**Telephone/Fax (1) 4538**]
Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 4538**] Date/Time:[**2188-5-13**] 9:40
Completed by:[**2188-5-11**]
|
[
"276.2",
"042",
"577.0",
"789.5",
"567.2",
"473.9",
"284.8",
"518.81",
"296.7",
"276.5",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"54.91",
"96.72",
"96.04",
"99.04",
"34.91",
"96.6",
"99.05",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10136, 10195
|
5900, 7164
|
283, 289
|
10356, 10398
|
2541, 4934
|
10824, 11454
|
1842, 2183
|
10010, 10113
|
10216, 10335
|
9955, 9987
|
7181, 9929
|
10422, 10801
|
2198, 2522
|
229, 245
|
317, 1292
|
4943, 5877
|
1314, 1469
|
1485, 1826
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,828
| 164,816
|
1810+55319
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-7-12**] Discharge Date: [**2129-7-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 10137**] is an 83 year old male with Alzheimer's Dementia,
DMII, HTN who presented from [**Hospital3 400**] with sudden onset
of shaking, nausea and vomiting. According to his son, he was
feeling well until the morning of admission when he returned
from a walk and was noted to be pale, diaphoretic and shaky. He
was thought to be hypoglycemic (received metformin 850mg in am)
and was given some OJ which he soon vomited non-bloody stomach
contents. Vitals at the time were stable (T97.5, HR60, BP120/56,
RR14). FS 228. He was thought to be "not himself", more confused
than at baseline and less interactive than usual. Patient and
family denied cough, SOB, diarrhea, chest pain, palpitations,
headache, nightsweats, recent weightloss, recent travel, sick
contacts. [**Name (NI) **] was transferred to the ED for further work up. In
ED patient was pan cultured with +UA and was diagnosed with
urosepsis. He was given vanc and ceftaz and admitted to the
[**Hospital Unit Name 153**] for further care.
Past Medical History:
DM II
HTN
Pancrease deficiency
Prior history of alcohol abuse (detox in [**2111**])
Alzheimers dz
? TIA in [**12-29**] with anomia and dysarthria t
Social History:
Social History: Lives at [**Location 10138**], specialized [**Hospital **] for Alzheimer's Dementia. Able to walk unassisted. Wife
(health proxy) is currently traveling (visiting family in
Europe).
past president of [**University/College 5130**] [**Location (un) **]
no etoh
approx 80 pack year hx of tobacco use, stopped 10 years ago
Family History:
No strokes/CAD
Physical Exam:
On admission:
Vitals: T 98 HR 110 BP 134/54 R 19 Sa02 97% on 4L NC
Gen: Elderly male in NAD. Awake, alert, talkative, following
commands though occasionally has to have questions repeated.
HEENT:MM moist. Sclera clear and anicteric. OP clear. Poor
dentition, no pain on palpation of the teeth.
Skin: no rashes, excoriations or breaks in skin.
Neck: No [**Doctor First Name **]. no JVD
CV: tachy, regular, heart sounds distant. Nl S1 and S2, no
murmurs/gallops/rubs.
Lung: CTA bilaterally, except for few crackles in LLL, no
wheezes, or rhonchi
Ext:No cyanosis/edema, feet cold but quick capillary refill. 1+
radial and DP pulses b/l.
Neuro: Awake, alert, talkative. Oriented x 0. Occasionally slurs
speech. CN II-XII intact. Reflexes 2+ b/l. Babinsky equivocal.
Pertinent Results:
RUE U/S [**2129-7-30**]: No definite evidence of right upper extremity
deep venous thrombosis. No fluid collection. If clinical
suspicion for DVT persist, the examination could be repeated.
LUE U/S [**2129-7-29**]: Persistent occlusive thrombus within the left
cephalic vein without evidence of extension into the deep veins.
Renal U/S [**2129-7-24**]: The exam is slightly limited due to
difficulties with patient positioning and inability to
breath-hold. The left kidney measures approximately 9.5 cm.
There is no hydronephrosis seen. The hypodense area of the left
upper pole seen on CT is not well delineated by ultrasound,
though a hypoechoic area with a slightly bulging contour is seen
in the upper pole, which likely corresponds to the CT findings.
No large fluid collection is seen.
CT abd [**2129-7-23**]: 1. 3.6 x 3.3 cm low-attenuation lesion with an
enlarged left kidney which cannot be further characterized.
Given presence of perinephric stranding, nephronia should be
considered. Differentials include underlying lesion or cyst. An
ultrasound can be performed for further evaluation.
2. Punctate nonobstructing left renal calculi. Possible left
distal ureteral calculi.
3. 1.5 x 1.2 cm soft tissue attenuation lesion arising off the
body of the pancreas. MRI can be performed for further
evaluation.
4. Bilateral small pleural effusions with associated
atelectasis.
5. Coronary artery calcifications.
ECHO [**2129-7-13**]: The left atrium is normal in size. The estimated
right atrial pressure is [**3-31**] mmHg. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with mild hypokinesis of
the inferior and inferolateral walls. Right ventricular chamber
size and free wall motion are normal.The aortic root is
moderately dilated at the sinus level. The ascending aorta is
mildly dilated. There are three aortic valve leaflets. An
aortic valve vegetation/mass cannot be excluded. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. A mass or vegetation on the mitral valve cannot be
excluded. No mitral regurgitation is seen. There is a small
pericardial effusion, with echo dense material, consistent with
blood, inflammation or other cellular elements. If clinically
suggested, the absence of a vegetation by 2D echocardiography
does not exclude endocarditis, a transesophageal
echocardiographic examination is recommended. Compared with the
prior study (images reviewed) of [**2129-1-6**], the focal
hypokinesis seems to be more prominent and the left ventricular
function is slightly worse.
Brief Hospital Course:
1. urosepsis/pyelonephritis -- Mr. [**Known lastname 10137**] was initially admitted
to the [**Hospital Unit Name 153**] and treated broad spectrum IV antibiotics, then
changed to IV ciprofloxacin after blood cultures and urine
culture showed pan sensitive Klebsiella. He improved and was
transferred to the [**Location **] service. He was changed to
oral antibiotics after several stable days, and unfortuanately
significantly declined, with presistant fevers. An extensive
workup for additional source of infection found little, except
that he had profuse diarrhea. He improved after being
transitioned back to intravenous antibiotics. He was also found
to have c diff colitis and was started on vancomycin orally.
Infectious disease was consulted and followed throughout his
course. Further limited imaging was performed, as his renal
function excluded the use of IV contrast, but his left kidney
showed signs of infection without obvious abscess formation.
There was no apparent fluid collection to drain per radiology
and urology. His infection was felt to be related to severe
pyelonephritis, likely from the original Klebsiella organism, as
no other cultures were positive. Antibiotic coverage was
narrowed again, but remained IV. Plan is for 3 weeks total of
ceftriaxone. Day one was [**2129-7-23**], he will complete ceftriaxone
on [**2129-8-12**].
2.stress related cardiac ischemia -- Troponins were elevated on
admission, nadir of 0.64, probably related to the stress of
septic shock. No invasive therapy was performed, and this
desire was discussed and verified by the family, and he was
treated medically with aspirin and a beta blocker. Echo showed
mild hypokinesis which is slightly worse than prior echo.
3. acute renal failure -- multifactorial, related to sepsis,
pyelonephritis and possibly ATN. Improved slowly prior to
discharge, but not entirely back to baseline. In the last day of
hospitalization pt had a creatinine of 1.7. The worst
creatinine while in hospital was 2.3. His baseline in 1.3.
4. C. difficile colitis -- patient is receiving vancomycin
orally at advice of infectious disease team. This should be
continued until one week after ceftriaxone is finished, that is
to be continued until [**2129-8-19**].
5. Malnutrition -- Patient initially with poor caloric intake.
He responded well to encouragement, and will benefit from close
nursing attention at meal times to encourage increased intake.
Would benefit from Ensure or other supplement.
6. Diabetes -- Isolated FSBG on day of discharge 300. Responded
to regular insulin. Previously well controlled on 5 units of
lantus qd.
Medications on Admission:
Aricept 10mg po qhs
Avandia 4mg po BID
Glimepiride 2mg po daily
metformin850 po BID
metoprolol po 12.5 BID
namenda 10mg po BID
pangestyme MT16 3 tabs TID
Discharge Medications:
1. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours) for 12 days: last
dose [**2129-8-12**].
2. Outpatient Lab Work
q3day CBC, complete metabolic panel while on antibiotics
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for alzheimer's.
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for dementia.
5. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID (3 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 19 days: last dose [**2129-8-19**].
10. Insulin Glargine 100 unit/mL Solution Sig: Five (5)
Subcutaneous at bedtime.
11. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
13. Regular insulin sliding scale per [**Hospital3 **]
Center protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
urosepsis/pyelonephritis
acute renal failure
NSTEMI
Discharge Condition:
afebrile, stable vitals signs, PICC line right upper extremity
Discharge Instructions:
You were hospitalized with a severe kidney infection. This is
slowly improving and you are now well enough to transfer to
[**Hospital 100**] Rehab. Please call your physician or return to the
hospital with any concerns or questions, particularly fever
greater than 101, redness or oozing around the PICC site,
decreased urination, inability to eat or drink, decline in
mental status, shortness of breath, abdominal or chest pain.
Followup Instructions:
1. ultrasound left kidney after discontinuation of antibiotics
2. ultrasound doppler left upper exptremity to assure no
extention of the cephalic vein thrombus after [**2129-8-12**]
3. [**Hospital 100**] Rehab physician to follow
4. Follow up with Dr. [**Last Name (STitle) 2903**], your primary physician, [**Name10 (NameIs) 10139**] you
have discharged from [**Hospital 100**] Rehab. Call [**Telephone/Fax (1) 2205**] for an
appointment.
5. Remove PICC line after finsihing antibiotics in two weeks.
Completed by:[**2129-7-31**] Name: [**Known lastname 1406**],[**Known firstname **] G Unit No: [**Numeric Identifier 1407**]
Admission Date: [**2129-7-12**] Discharge Date: [**2129-7-31**]
Date of Birth: [**2046-3-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1408**]
Addendum:
Pt has an occlusive left cephalic vein thrombus. This does not
extend into deep veins. Repeat u/s to ensure no progression in
[**12-25**] weeks. In regards to the right arm, swelling was noted on
[**2129-7-30**] in the right upper arm. This resolved spontaneously. A
RUE U/S showed no thrombus.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1410**] MD [**MD Number(2) 1411**]
Completed by:[**2129-7-31**]
|
[
"038.40",
"410.71",
"590.80",
"577.8",
"294.11",
"276.7",
"V12.59",
"995.92",
"008.45",
"250.00",
"263.9",
"276.2",
"403.90",
"285.9",
"451.84",
"584.9",
"585.9",
"331.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11425, 11668
|
5343, 7981
|
278, 285
|
9636, 9701
|
2692, 5320
|
10181, 11402
|
1878, 1894
|
8186, 9432
|
9561, 9615
|
8007, 8163
|
9725, 10158
|
1909, 1909
|
222, 240
|
313, 1339
|
1923, 2673
|
1361, 1510
|
1542, 1862
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,183
| 193,517
|
47352
|
Discharge summary
|
report
|
Admission Date: [**2137-2-21**] Discharge Date: [**2137-3-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
anterior wall STEMI
Major Surgical or Invasive Procedure:
Coronary Catheterization X2
Intubation/Extubation
History of Present Illness:
83yo with a history DM, HTN, and MI with RCA stenting in [**2127**]
arrived to ED by ambulance after 1 hr of substernal chest pain
that came on while shoveling snow at approximately 11am this
morning. Upon arrival to the ED he was found to have ST
elevations in V1-V5 with ST depressions in II, III, AvF and Q
waves in v1-V5 and new RBB. He was urgently taken to cardiac
cath where he was found to have complete acute occlusion of the
proximal LAD with an completely occluded RCA and 90% occluded
circumflex. After angioplasty flow was recovered in the LAD and
a stent was placed. During the procedure the patient had
multiple episodes of ventricular tachycardia and underwent
electrocardioversion several times and started on amiodarone. He
vomitted and was intubated. He became hypotensive and was
started on dopamine 15mcg/kg. Post procedure PCWP was 40 mm/Hg
with V waves to 80. Bedside echo showed an VEF of 20-25% with
3+ MR. [**Name13 (STitle) 6**] aortic balloon pump was not placed because he has a
tortuous aorta.
During the procedure he received over 600cc of contrast and was
given 40mg of lasix.
ROS: Per wife, cardiac review of systems is notable for two
weeks of fatigue, dyspnea on exertion, and presyncope. No chest
pain before today's acute event. Also no paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, or palpitations.
Past Medical History:
# Myocardial Infarction with two stents placed in the RCA in
[**2127**].
# Diabetes: HA1c 6.4% on [**11-30**]. High grade proteinuria X 1yr.
# Hypertension
# Hypercholesteremia
# Asthma
Social History:
Social history is significant for: smokes [**1-27**] cigarettes a day.
Lives with his wife.
Family History:
No family history of early coronary disease or stroke and no
family history of sudden cardiac death.
Physical Exam:
VS: T 99.0 , BP 130/67 , HR 79 , RR 21 , O2 % 100 on 100% FIO2
MechVent.
Gen: WDWN middle aged male sedated on mechanical ventilation.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with prominent JVP
CV: RR, distant heart sounds normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. No
crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. Rt Groin access site clean and intact.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; 2+ DP
Pertinent Results:
HEMODYNAMICS:
Cardiac Output 4.7
Cardiac index 2.27
SVR 1209
LABORATORY DATA on admission:
[**2137-2-21**] 08:40PM GLUCOSE-132* UREA N-43* CREAT-2.2* SODIUM-137
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-20* ANION GAP-17
[**2137-2-21**] 08:40PM CK(CPK)-6935*
[**2137-2-21**] 08:40PM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-2.0
[**2137-2-21**] 08:40PM WBC-21.9* RBC-4.62 HGB-12.4* HCT-37.1*
MCV-80* MCH-26.8* MCHC-33.4 RDW-14.8
[**2137-2-21**] 08:40PM NEUTS-92.8* BANDS-0 LYMPHS-3.9* MONOS-2.9
EOS-0.3 BASOS-0.1
[**2137-2-21**] 05:07PM LACTATE-1.2
Laboratory Data on discharge:
WBC 13.2, Hct 30.5, Plt 451
BUN/Cr 77/2.5 (stable from day prior)
Na 139, K 5.0, Cl 105, HCO3 22, Glucose 126
[**8-22**] elevations in V1-V5; ST depressions in
II, III, and aVF ; Q waves in V1-V5; and RBBB not seen on
previous ECG.
.
#ECHO on [**2-21**]: LVEF = 20% ; 3+ MR ;
Left ventricular wall thicknesses and cavity size are normal.
There is severe regional left ventricular systolic dysfunction
with akinesis of the anterior wall, septum, distal LV segments
and apex. There is hypokinesis of the remaining segments (LVEF =
20%). No masses or thrombi are seen in the left ventricle. There
is no ventricular septal defect. Right ventricular chamber size
is normal. with focal hypokinesis of the apical free wall.
Moderate to severe (3+) mitral regurgitation is seen (no
papillary muscle rupture or frank prolapse seen). There is no
pericardial effusion.
.
#Cardiac Catheterization on [**2137-2-21**]
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
3 vessel CAD. The LMCA had no obstruction. The LAD was flush
occluded
proximallly. The LCX had an 80% mid lesion adn an 80% OM1. The
RCA was
occluded in the mid vessel and filled distally via collaterals.
2. Resting hemodynamics revealed severely elevated left and
right sided
filling pressures, cardiogenic shock with a PCWP of 40 with V
waves to
55.
3. Left ventriculography was deferred.
4. Successful PTCA and stenting of the proximal LAD with a
overlapping
2.5 x 18 and 2.5 x 12 mm minivision stents which were post
dilated with
a 3.0 x 15 mm Quantum balloon. Final angiography revealed no
residual
stenosis, no dissection and TIMI III flow.
5. Acute anterior STEMI, cardiogenic shock and VT requiring
defibrillation/pacing for heart block.
#Cardiac Catheterization on [**3-1**]
COMMENTS:
1. Coronary angiography of this right dominant system revealed
stent
thrombosis within the previously placed proximal LAD distal BMS.
The
LMCA had no significant disease. The LAD stents were patent with
a
distal filling defect and probable stent underexpansion with
stent
thrombosis. The LCX was unchanged from prior. The RCA was not
engaged.
2. Resting hemodynamics revealed normal systemic arterial
pressures with
an SBP of 120 mm Hg.
3. Left ventriculography was not performed.
4. Successful balloon angioplasty of the LAD stents with a 2.75
balloon
with no residual stenosis, defect or dissection.
# [**2-28**] BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: [**Doctor Last Name **]-scale
and Doppler
examination of the bilateral common femoral, superficial
femoral, and
popliteal veins was performed. There is a deep venous
thrombosis in the right
superficial femoral vein extending all the way down to the
popliteal vein with
intraluminal clot expanding the vein and absence of flow
consistent with
complete occlusion. The right common femoral vein is patent.
There is no
evidence of deep venous thrombosis involving the left leg.
IMPRESSION: DVT on the right extending from the superficial
femoral vein to the popliteal vein.
# [**3-4**] V/Q scan: Low probability
# [**3-4**] CXR:IMPRESSION: Mild CHF with small pleural effusion.
Brief Hospital Course:
83 yo male with a history of coronary artery disease status post
STEMI and RCA stent in [**2127**], anterior STEMI [**2137-2-21**] with 2
overlapping BMS to proximal LAD, anterior STEMI [**2137-3-1**] with
stent thrombosis, DMII, HTN, and CRI.
# CAD/Ischemia: Status post STEMI and RCA stent in [**2127**],
anterior STEMI [**2137-2-21**] with 2 overlapping BMS to proximal LAD,
anterior STEMI [**2137-3-1**] with stent thrombosis. Patient presented
with anterior STEMI with ST elevations V1-V4 and ST depressions
in II III and aVf. By cardiac angiography he was found to have
completely occluded proximal LAD, 80% occlusion of the Lcx and
complete proximal occlusion of the RCA with distal flow from
collaterals. The LAD lesion was opened by angioplasty and a bare
metal stent was placed. During the procedure the patient became
hypotensive with episodes of V Tach and V fib requiring multiple
cardioversions. After emesis he was intubated for airway
protection. He was then transfered to the CCU and started on
[**Month/Day/Year **], plavix, and heparin. On [**2137-3-1**] pt developed chest pain
while at rest and was found to have anterior ST elevations in
V1-V3. He was treated with nitroglycerin, O2, and morphine which
resulted in alleviation of his symptoms. At cardiac
catheterization he was found to have an LAD stent thrombosis
that was opened with balloon angioplasty resulting in improved
flow through the LAD stent. He remains on Toprol XL 25mg daily,
[**Last Name (LF) 17339**], [**First Name3 (LF) **], and Plavix daily.
.
# Pump: At presentation the patient developed cardiogenic shock
and was found to have a PCWP of 40 with VEF 20% by echo with 3+
MR, and septal and anterolateral ventricular akenesis. An IABP
was not used becasue the patient has a tortutous aorta. He was
initially started on dopamine. In the first 24 hours post cath
he developed several episodes of sinus bradycardia and
hypotension when attempting to wean down the dopamine that
required atropine boluses on one occasion. He was transitioned
to levophed on [**2-23**]. Metoprolol was started on [**2-24**]. After
maintaining pressure well he taken off levophed on [**2-26**]. On [**3-1**]
he developed dyspnea and appeared fluid overloaded on clinical
exam and has begun on Lasix for diuresis. On the day of
discharge the lasix dose was increased to 80mg daily. This can
be titrated based on fluid status and blood pressure parameters.
ACE-I/ARBs was held due to concerns for renal function; if
renal function recovers to baseline, we would strongly
recommended ACE inhibitor therapy for decreased EF. Will need to
have creatinine and potassium checked in 2 days at rehab
facility. Needs strict intake/output measurement along with
daily weights.
.
# Rhythm: During cardiac catherization patient had ventricular
tachycardia and ventricular fibrillation that required multiple
cardioversions to regain perfusing rhythm. At that time he was
then started on amiodarone drip. He was transfered to the CCU
in NSR and the amiodarone was discontinued. On [**2-23**] and then
again on [**2-24**] he developed atrial fibrillation with rapid
ventricular repsonse in the context of attempted ventilator
weens. Both episodes were treated with amiodarone and
metoprolol and he returned to NSR. Since [**2-24**] he has been in NSR
on daily metropolol and amiodarone. He is also on coumadin.
Coumadin dose was held on [**3-25**] for supratherapeutic INR.
Plan is to restart coumadin on [**3-6**], INR on [**3-5**] at the time of
discharge was 3.1, was receiving a dose of 5mg, patient was
being loaded on amiodarone. The dose of amiodarone will be
decreased and it is reasonable to initiate warfarin at 5mg and
check frequent INR level to ensure he is not supratherapeutic
and adjust as necessary.
.
# Respiratory: During cardiac arrest the patient vomitted and
was intubated for airway protection. He was removed from
mechanical ventilation on [**2-25**]. Since, he has used up to 3L O2
by nasal canula after patient reported subjective dyspnea though
he has maintained 02 saturations above 95%. After ecoli was
found in a sputum culture he completed a course of
ciprofloxacin. He has had episodes of dyspnea with elvated JVP
and lower extremity edema, and signs of CHF on CXR; Diuresis
with lasix was begun on [**3-1**]. The dose was uptitrated from 40mg
PO lasix to 80mg PO lasix based on increased pulmonary edema on
CXR. VQ scan was low probability for pulmonary embolism on
[**3-4**].
# CKD: Cr 1.4-1.8 at baseline. During initial cardiac
catheterization he received 600cc dye load and had episodes of
hypotension. He arrived to the CCU with a Non AG acidosis of
unclear etiology that resolved over the next several days. His
Cr peaked on [**2-23**] at 4.4 and then declined steadily declined to
2.4 on [**3-4**] despite receiving another 60cc dye load on [**3-1**]. He
never required HD, although renal consult team followed closely.
He will need renal follow up as an outpatient.
# DVT: Despite therapeutic heparin levels, patient developed a
right sided femoral to popliteal DVT discovered on ultrasound on
[**2-28**]. As mentioned above VQ scan was negative. He was maintained
on heparin and then transitioned to coumadin. Because of DVT
despite heparin for ACS on presentation and antiplatelet therapy
peri-MI as well as in-stent thrombosis on adequate antiplatelet
therapy, concern for hypercoagulable state is high and pt should
have full hypercoagulable work up once other issues are stable.
.
# R arm cellulitis: In addition he developed an infiltrated
right forearm venous access site that became ecchymotic and
tender and was presumptive treated with cefelaxin for concern of
a possible cellulitis.
.
# BPH: Restarted on Flomax on day of discharge.
Medications on Admission:
1. Diltiazem ER 240 mg
2. Flomax 0.4 mg
3. Quinine 324 mg
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day) as needed.
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 2 days.
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED) as needed for chest
pain.
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 6 days.
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start after [**Hospital1 **] dosing finishes.
14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime:
Start on [**3-5**].
17. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
18. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
Coronary Artery Disease, s/p ST elevation myocardial infarction
Diabetes Mellitus type 2
Hypertension
Hypercholesteremia
Benign Prostatic Hypertrophy
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] with an ST elevation myocardial
infarction. This is a blockage in a vessel supplying blood to
the heart. This vessel was opened with a stent. You suffered
from a clot in the stent following the placement. You also had
a decrease in the pumping function of your heart and medications
have been added to compensate for this.
Please take your medications as prescribed. The following
changes has been made to your medications:
- Please start taking aspirin 325mg daily for secondary
cardiovascular prevention (to prevent another heart attack)
- Please start taking atorvastatin 80mg daily for your heart and
for your cholesterol
- Please start taking Toprol XL 25mg daily for your heart and
blood pressure (prevents remodelling of the heart)
- Please start taking clopidogrel (Plavix) 75 mg daily to keep
stents open. DO NOT STOP PLAVIX UNTIL INSTRUCTED BY A
CARDIOLOGIST, EVEN IF ANOTHER DOCTOR RECOMMENDS STOPPING IT. YOU
MUST TAKE THIS MEDICINE EVERY DAY TO PREVENT HEART ATTACKS FROM
YOUR STENTS.
- Please start taking Lasix 80mg daily to help keep your fluid
status appropriate.
Your Flomax was restarted the day of your discharge from the
hospital. You will need to have your blood pressure monitored
with the addition of this medication.
If you develop chest pain, jaw pain, or chest pressure with pain
radiating into arm, or if you for any reason become concerned
about your medical condition please call 911 or present to
nearest ED.
- We also gave you Nitroglycerin tablets to take if you
experience chest pain, please call 911 or your doctor if chest
pain recurs even if it dissapears with nitroglycerine.
**DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO
DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO**
Followup Instructions:
Please call Dr.[**Name (NI) 8156**] office to schedule a follow up in the
next 2-4 weeks.
You have a follow up appointment with Dr. [**Last Name (STitle) **] (cardiology) on
Tues. [**3-12**] at 11am in the [**Hospital Ward Name 23**] Building. Floor 7. ([**Telephone/Fax (1) 3942**]
Please call the [**Hospital 10701**] Clinic at ([**Telephone/Fax (1) 773**] to schedule
a follow up appointment in the next 2-4 weeks.
Please schedule a follow up appointment with you podiatrist as
needed.
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32,042
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34110
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Discharge summary
|
report
|
Admission Date: [**2127-7-9**] Discharge Date: [**2127-7-17**]
Date of Birth: [**2058-6-10**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Levofloxacin / Nifedipine / Tetracycline
/ Lisinopril / Cefaclor
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 69 yo WF with h/o idiopathic pulmonary fibrosis
and severe pulmonary HTN who presented with hypoxia, SOB and c/o
cough. She had previously been followed by Dr. [**Last Name (STitle) 55911**] at
[**Hospital6 16029**] in [**Location (un) 5583**]. SOB has been progressive
over a period of years since being diagnosed with IPF and PH in
[**2124**]. Since then, her O2 requirement has steadily gone up from
2L NC to 12 L NC. Over the past few weeks, she has been unable
to walk more than a few steps before being winded and is now
unable to sit up in bed without dyspnea. She also c/o worsening
cough with green-yellowish sputum as well as nasal discharge and
chest congestion for the past 10 days. Denies fevers, chills,
sick contacts and no recent travel. As per patient, she had CT
chest performed in [**2-21**] that showed a stable appearance of her
lungs. Recent TTE reportedly measured pulmonary artery systolic
pressures of 81 mmHg, PCWP 42 mm Hg. Pulmonologist then
prescribed Tracleer and Rivatio (Sildenafil) which she has not
taken due to her fear of medication side effects. She also
wishes to have another opinion by a pulmonologist here at [**Hospital1 18**].
She explains that she has been rejected as a possible recipient
at 2 lung transplant centers, once because of her age and the
last because of her weight. She is still being evaluated at the
[**State 78655**] for a possible bilateral lung transplant.
In the ED, patient was afebrile, RR 20, O2 sat 92% on 8L NC.
However, she markedly desaturated to 70% with coughing and
removal of O2 with eating. She was placed on 80% FM with
improvement in saturations to 95%. Given O2 requirement and
extreme of hypoxic values she was admitted to MICU for further
care. ROS was otherwise notable for urinary frequency and panic
attacks.
Past Medical History:
Pulmonary Fibrosis (per OSH CT report, has biopsy proven UIP/IPF
however patient denies ever having any invasive biopsy
performed)
Pulmonary HTN
HTN
Hypothyroidism
Diverticulosis
Eczema
Psoriasis
Anxiety
h/o Afib with RVR, self terminated to NSR in [**2126**]
Social History:
The patient lives in [**Location 22201**] [**State 350**]. Prior 30 pack year
history of tobacco, quit in [**2108**]. No EtOH, denies illicit drug
use. Lives alone at home with good social supports from church.
Retired book-keeper/administrative assistant.
Family History:
No family h/o pulmonary disease.
Physical Exam:
VS: 97.7 146/60 68 28 93% high flow 95% FM
GEN: anxious appearing female awake, alert
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
moist and without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. II/VI SEM along LSB.
CHEST: Resp slightly labored with some accessory muscle use. dry
crackles b/l
ABD: Soft, NT, ND, no HSM
EXT: No c/c/e
SKIN: No rash
Pertinent Results:
Labs on Admisssion:
Na 136, K 4.4, Cl 99, Bicarb 29, BUN/Cr 16/0.8, glucose 118, WBC
10.6 (70% N, 19% L, 6% E), Hct 36.9, Platelets 218.
Lactate 1.2
PT 13.8, PTT 23.1, INR 1.2
WBC-10.6 RBC-4.26 HGB-12.2 HCT-36.9 MCV-86 MCH-28.7 MCHC-33.2
RDW-13.1
[**2127-7-10**] UA: negative
EKG - NSR @ 70 bpm, nl axis, nl intervals, no ST elevations or
depressions, TWI III, aVF, no priors for comparison.
.
CT chest [**2-21**] (from [**Hospital6 16029**]) - essentially
stable appearance of the lungs with fibrotic change,
honeycombing, and intralobular septal thickening compatible with
known diagnosis. Interval improvement in patchy airspace disease
in the superior segments of bilateral lower lobes as compared
with prior CT.
CT chest [**2127-7-10**]: Extensive reticular opacities and honeycombing
with multifocal ground glass opacities bilaterally. Overall, CT
shows worsening of fibrosis as compared to [**2-21**] CT
[**2127-7-10**] CXR (AP) : In comparison with the study of [**7-10**],
allowing for differences in technique, there is no interval
change. Again, there is extensive reticular opacification
persisting throughout both lungs, consistent with the clinical
history of pulmonary fibrosis.
[**2127-7-10**]: TTE results : left and right atrium moderately dilated.
RA pressure 10-20mmHg. Mild symmetric LVH. LVEF 60-70%. There is
mild aortic valve stenosis and 1+ AR. Severe 3+ TR seen. Severe
pulmonary artery systolic hypertension (60-95%). Dilated PA. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. No
pericardial effusion.
Brief Hospital Course:
The patient is a 69 yo WF with h/o idiopathic pulmonary
fibrosis, severe pulmonary HTN who presented with hypoxia, SOB,
cough who continued to improve clinically with oxygen
saturations consistently >90% on support, was also given
sildenafil with some clinical improvement initially, discharged
with pulmonary follow up.
.
# SOB/hypoxia - patient had poor pulmonary reserve at baseline
given setting of her idiopathic pulmonary fibrosis/usual
interstitial pneumonitis and severe pulmonary hypertension. She
has history of noncompliance and has collected a plethora of
input from multiple major medical facilities regarding her
prognosis and diagnosis. She had not followed up with treatment
recommendations from pulmonologist at [**Hospital1 11485**] and was not
taking bronchodilators, inhalers, or steroids at this time. She
states she has had prior course of azithromycin for bronchitis
and pneumonia with improvement in her symptoms. Despite
saturations in 70s on arrival to ED patient very stable on Fio2
40% facemask with sats > 93%. As per pulmonary consult, patient
was started on sildenafil, steriods, high flow facemask with
home oxygen. The patient was discharged with pulmonary follow
up.
.
# Cough - Chest congestion, cough improving. Patient completed
a course of azithromycin.
.
# Anxiety - Reasonable considering severity of disease and
oxygen requirement. If exacerbates, will seek further
intervenion. Patient was started on benzodiazepines as needed.
.
# HTN - Sildenafil started for pulmonary HTN in MICU. As also
lowers BP, beta-blocker dose reduced. Patient not happy with
this, as she feels increased heart rate is contributing to her
increased oxygen demand. Sildenafil continued at decreased dose
until discharge.
.
# Hypothyroidism - Continued synthroid.
Medications on Admission:
Synthroid 100 mcg daily
Betamethasone Biproprionate 0.05% cream prn
Atenolol 37.5 [**Hospital1 **] (prescribed as 75 mg daily, pt's friend
reports she often takes [**1-17**] to [**1-21**] of her pills throughout the
day)
Discharge Medications:
1. Oxygen Therapy
Please use 10L of nasal cannula at rest and upon periods of
exertion or transition please use the provided non-rebreather
facemask.
2. Betamethasone Dipropionate 0.05 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H PRN ().
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal
QID (4 times a day) as needed.
6. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
8. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ASDIR8 (ASDIR).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 11485**] VNA
Discharge Diagnosis:
1. Idiopathic Pulmonary Fibrosis
2. Pulmonary Hypertension
Discharge Condition:
Pt. stable, with oxygen saturations between 97-99 on 5L NC and
Facemask when non-ambulatory.
Discharge Instructions:
You are being discharged with 10 L of nasal cannula with a
non-rebreather face mask for periods of exertion or transition.
Please take Viagra as prescribed.
Followup Instructions:
1. Dr. [**Last Name (STitle) 55911**], [**2127-8-18**] 11:45 AM
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2127-10-27**]
|
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22,449
| 167,990
|
8704
|
Discharge summary
|
report
|
Admission Date: [**2181-8-21**] Discharge Date: [**2181-8-23**]
Date of Birth: [**2104-12-15**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
transfer for cath
Major Surgical or Invasive Procedure:
Central Venous Line
Swan Ganz catheter
Arterial line
History of Present Illness:
76F w hx of CAD s/p CABG [**2174**] (LIMA->LAD), s/p multiple PCIs,
bioprosthetic AVR w/ aortic root repair, s/p BiV PPM, COPD, DM2,
presented to [**Hospital3 10377**] on [**2181-8-18**] with compaints of
increasing dyspnea on exertion and progressive weakness x3-4
weeks. Also had intermittent non-productive cough, denied
fevers or increased peripheral edema. In the ED at OSH, she
complained of chest pressure and was noted to have tachycardia.
Chest pressure located on left upper chest in area of pacemaker,
no radiation. Was watching television at onset, no known
exacerbating or alleviating factors, not associated with
inspiration, did not get worse with walking, +/- was worse with
moving arms. She was given nitro, asprin, oxygen and morphine.
She continued to have progressive dyspnea and persistent chest
discomfort with a warm/flushed feeling. Due to concern for
heart failure, she was given IV lasix 100mg and responded well.
There was also concern for rapid afib HR 140s and she was given
diltiazem 15mg IV with improvement of heart rate to 100bpm.
However, her pacemaker was interrogated at Caritas on [**2181-8-20**] by
Dr. [**Last Name (STitle) **], and only showed underlying sinus rhythm.
.
She was transferred to the ICU during which time she had SBP
70s, asymptomatic, improved slowly to SBP 100s after stopping
beta blocker and ?lisinopril. Maintained oxygen with nasal
canula 2-4L, had some tachypneic episodes that responded to
CPAP.
.
Cardiac biomarkers positive at outside hospital, initially with
trop 0.14 and CK-MB of 3.7, placed on heparin drip; trop peaked
at 8.11 on [**2181-8-19**]. TTE showed EF 20-25% with severe global
hypokinesis.
.
At baseline, dyspnea at rest on exertion. At baseline was able
to climb 3 stairs and walk around house with cane, able to go
out to the restaurant once/week. Starting 3-4 weeks ago, was
unable to walk up the 3 stairs and could no longer go out,
having trouble walking around her house as well. + orthopnea.
No PND. No increased peripheral swelling. No
fevers/chills/rigors. Intermittent non-productive cough. New
urinary urgency and incontinence, but no dysuria. Some nausea
after eating "feels heavy", no vomitting, no change in stool
pattern, no bloody stools. No leg pain. No history of stroke,
? TIAs. Currently no CP or palpitations. Continues to feel SOB
but able to talk in full sentences on 3L.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
.
2. CARDIAC HISTORY:
-CABG: [**2174**] (LIMA->LAD)
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2180-8-14**] BMS LCX, [**1-/2181**]
patent LCX, LAD occuled, first DM jailed by LCX stent, patent
LIMA, RCA occluded
-PACING/ICD: [**1-/2181**]
.
3. OTHER PAST MEDICAL HISTORY:
Ischemic Cardiomyopathy, EF 20-25% by OSH echo
s/p AVR (bioprosthetic) w Aortic Root Repair
Pseudo-Aortic Stenosis first noted in [**1-/2181**]
History of TIA
COPD
anemia - history of gastrointestinal ectasias
depression and anxiety
arthritis in hands
Past surgical history
Cholecystectomy
b/l carotid endarterectomy
Social History:
lives with husband, stopped smoking 1 year ago, no ETOH, no
IVDU, see HPI for baseline status details. Has 4 children, 3 of
which live in the area, one lives in [**State 108**].
Family History:
Mother with heart disease, father died of throat cancer, one
brother had a stroke, other brother healthy and well.
Physical Exam:
Upon admission:
VS: T=96.6 BP=117/55 HR 131 RR=20 O2 sat 97% on 3L NC
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
Slurred speech. Skin is pale.
HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink.
NECK: Supple with JVP at jaw. No carotid bruits.
CARDIAC: tachy, normal S1, S2. [**2-17**] early peaking systolic murmur
no radiation to carotids best heart at LUSB and LLSB, also can
hear it at RUSB. No gallop or rub. No thrills, lifts. Pacer
site c/d/i.
LUNGS: kyphosis. Anterior wheezing, posterior wheezing cleared
with coughing, crackles 2/3 up on right side (patient was lying
dependently on right), no rhonchi. Poor aeration mostly in area
of crackles.
ABDOMEN: Soft, NTND. No tenderness.
EXTREMITIES: No c/c/e. Cannot palplate LE pulses, but feet warm.
Femoral cath site c/d/i no bruit, no hematoma, no bleeding.
SKIN: various ecchymosis on UE b/l
PULSES:
Right: Carotid 2+ radial 2+
Left: Carotid 2+ radial 2+
Pertinent Results:
Outside hospital results upon admission:
.
EKG at OSH: rapid afib with intermittent PVCs and intermittent
Vpaced complexes
.
CXR at OSH: cardiomegaly and CHF
.
OSH labs
INR 1.2
Glucose 190
BNP 912
Trop 0.14 (initial)
.
2D-ECHOCARDIOGRAM at OSH ([**2181-8-15**]): EF 20-25% w severe global
hypokinesis. AV peak gradient was 34mmHg, aortic valve mean
gradient 18mmHg w trace aortic regurg and a bioprosthetic valve
.
OSH LENI: no DVT b/l
.
Labs upon admission
.
[**2181-8-21**] 05:38PM BLOOD WBC-7.9 RBC-3.33* Hgb-10.2* Hct-32.2*
MCV-97# MCH-30.7# MCHC-31.8 RDW-15.3 Plt Ct-248
[**2181-8-21**] 05:38PM BLOOD Neuts-95.6* Lymphs-2.8* Monos-0.8*
Eos-0.5 Baso-0.3
[**2181-8-21**] 05:38PM BLOOD PT-13.7* PTT-22.9 INR(PT)-1.2*
[**2181-8-21**] 05:38PM BLOOD Glucose-149* UreaN-42* Creat-0.9 Na-141
K-4.1 Cl-99 HCO3-25 AnGap-21*
[**2181-8-21**] 05:38PM BLOOD ALT-41* AST-43* LD(LDH)-349* CK(CPK)-55
AlkPhos-159* TotBili-0.6
[**2181-8-21**] 05:38PM BLOOD CK-MB-6 cTropnT-0.26*
[**2181-8-22**] 04:53AM BLOOD CK-MB-38* MB Indx-14.8* cTropnT-0.65*
[**2181-8-22**] 04:14PM BLOOD CK-MB-85* MB Indx-14.6* cTropnT-1.42*
[**2181-8-21**] 05:38PM BLOOD Calcium-9.5 Phos-4.1 Mg-2.2
[**2181-8-21**] 03:12PM BLOOD Type-ART pO2-70* pCO2-37 pH-7.45
calTCO2-27 Base XS-1 Intubat-NOT INTUBA
[**2181-8-21**] 03:12PM BLOOD Glucose-154* Lactate-2.0 K-4.0
[**2181-8-21**] 03:12PM BLOOD Hgb-10.0* calcHCT-30 O2 Sat-93
.
Last labs available
.
[**2181-8-22**] 04:48PM BLOOD WBC-12.4*# RBC-2.99* Hgb-9.1* Hct-28.4*
MCV-95 MCH-30.3 MCHC-31.9 RDW-15.2 Plt Ct-263
[**2181-8-22**] 04:53AM BLOOD PT-14.9* PTT-25.3 INR(PT)-1.3*
[**2181-8-22**] 04:14PM BLOOD Glucose-164* UreaN-60* Creat-1.7* Na-137
K-4.3 Cl-99 HCO3-21* AnGap-21*
[**2181-8-22**] 04:53AM BLOOD ALT-34 AST-65* LD(LDH)-343* CK(CPK)-257*
AlkPhos-127* TotBili-0.6
[**2181-8-22**] 04:14PM BLOOD CK(CPK)-584*
[**2181-8-22**] 04:14PM BLOOD Calcium-9.0 Phos-4.8* Mg-2.1
[**2181-8-22**] 04:17PM BLOOD O2 Sat-96
[**2181-8-22**] 06:12PM BLOOD O2 Sat-37
[**2181-8-22**] 07:41PM BLOOD O2 Sat-35
.
ECHO [**2181-8-22**] at [**Hospital1 18**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated with severe global hypokinesis. The basal inferolateral
wall contracts best (LVEF = 20-25 %). [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. Right ventricular chamber size is
normal with borderline normal free wall function. A well-seated
bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. There is critical aortic valve stenosis (valve area
<0.8cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate to severe (3+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Critical aortic valve prosthesis stenosis. Left
ventricular cavity enlargement with severe globa hypokinesis.
Moderate to severe mitral regurgitation. Pulmonary artery
systolic hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2181-1-25**], the aortic valve gradient andf
pulmonary artery systolic hypertension have progressed. Left
ventricular cavity size is slightly larger.
.
Cardiac catheterization: [**2181-8-21**] at [**Hospital1 18**]
.
COMMENTS:
1. Coronary angiography of this right dominant system
demonastrated no
new obstructrive coronary artery disease. The LMCA has stents
present
without any obstructive disease. The LAD has a total occlusion
to the
middle portion of the vessel which is then patent with
competitive flow
filling the vessel. The LCX has stents present that are patent.
There
is mild disease throughout the vessel, but no obstructive
disease. The
RCA is known to be occluded and wasn't engaged. The right side
had
collateral flow provided from the left system.
2. Graft angiography demonstrated a widely patent LIMA to mid
LAD.
3. Resting hemodynamics revealed elevated right sided filling
pressures
with an RVEDP of 25 mmHg. Pulmonary capillary wedge pressure
was
severely elevated with a mean pressure of 37mm Hg. There was
severe
pulmonary hypertension present at 76/37 mmHg with a low cardiac
index of
2 l/min/m2.
FINAL DIAGNOSIS:
1. Markedly elevated pulmonary capillary wedge pressure,
markedly
elevated right heart pressures, low cardiac output.
2. No epicardial disease to treat.
.
EKG [**Hospital1 18**]: rate 100, sinus tach with ventricular pacing and
frequent PVCs.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 30476**] was a 76 year old female with CAD, s/p CABG in
[**2174**], h/o bioprosthetic AV replacement, HTN, HLD, chronic
systolic CHF, prediabetes, who initially presented to an oustide
hopsital on [**2181-8-18**] with worsening dypsnea for 3-4 weeks and new
onset chest pressure. She was found to have acute on chronic
systolic heart failure, sinus tachycardia, hypotension and new
NSTEMI. She was transferred to [**Hospital1 18**] on [**2181-8-21**] for a cardiac
catheterization that showed no interval change in her coronary
anatomy (no new ischemic lesions), but very elevated left and
right sided filling pressures, pulmonary hypertension and
decreased cardiac output (pulmonary capillary wedge pressure 45,
RA pressure 22, PA pressure 75/7, CI 1.8). An echocardiogram
was completed which showed worsened critical aortic valve
prosthesis stenosis (she has a history of known pseudoaortic
stenosis diagnosed with dobutamine stress at [**Hospital1 18**] [**1-/2181**]),
progressive left ventricular cavity enlargement with severe
global hypokinesis, moderate to severe mitral regurgitation and
worsened pulmonary artery systolic hypertension.
.
Due to elevated filling pressures on cardiac catheterization,
SOB and elevated JVP, it was presumed the patient was in florid
heart failure with volume overload. She was given 80mg IV Lasix
in the cath lab and diuresed approximately 720cc. She was then
started on a lasix gtt in the CCU, after which she dropped urine
output to <30cc/hr. Due to concern for cardiac output and flow
to her kidneys, she was started on milrinone for ionotropic
support. Upon uptitrating the milrinone to achieve better urine
output, her systolic blood pressures dropped to the 80-90s, she
developed chest pain and nausea and her cardiac enzymes spiked.
She was started on dopamine for pressure support. However, her
chest pain continued and she was tachycardic with rates
120-140bpm. She was given morphine for pain which caused her
pressures to drop further. Out of concern for preload
dependence at that time, the lasix drip was discontinued, the
milrinone and dopamine were stopped, and she was given a fluid
500cc bolus after which time her MAPs returned >60. However,
over the next few hours her pressures declined again, she was
started on norepinephrine. A Swan Ganz catheter was placed
which showed declining cardiac output and elevated PCWP 38. She
continued in tachycardia and her pacer was interrogated by the
EP team who determined she was in sinus tachycardia and the
pacer was functioning correctly. Various different combinations
of ionotropic support were then tried including phenylephrine,
norepinephrine and milrinone. She was given boluses with lasix
with minimal urine output.
.
CVVH was considered to help remove volume, however her pressures
were too unstable to attempt dialysis. An intra-aortic balloon
pump was also considered, however, her ultimate prognosis was so
poor that weaning of the balloon pump would be next to
impossible.
.
A family meeting was then held with Dr. [**Last Name (STitle) 911**] in consultation
with Dr. [**First Name (STitle) 437**] and the CCU team regarding the patient's very
poor prognosis and diagnosis of end-stage congestive heart
failure and lack of current options for intervention. In
considering the patient's wishes, she was made comfort measures
only. She continued on her current regimen of pressure support
and was given morphine due to progressive shortness of breath
and work of breathing. Her blood pressure slowly declined and
she passed away at 1:48 am [**2181-8-23**] with her family at the
bedside.
Medications on Admission:
HOME MEDS:
[**Year (4 digits) **] 81mg daily
Mirtazipine 15mg qHS
Atorvastatin 80mg daily
Ferrous gluconate 325mg daily
Lisinopril 5mg daily
Ranitidine 150mg daily
Furosemide 120mg daily
Metoprolol 25mg [**Hospital1 **]
Plavix 75mg daily
.
MEDS on TRANSFER:
.
Zocor 80mg daily
nitroglycerin 1inch topically q6hr
morphine 2mg q2hr PRN
mirtazipine 15mg qHS
milk of mag 10mL qHS
metoprolol 25mg [**Hospital1 **]
lisinopril 5mg dialy
famotidine 20mg daily
weight based heparin gtt protocol
insulin aspart sliding scale qACHS
docusate 100mg [**Hospital1 **] PRN
plavix 75mg daily
[**Hospital1 **] 325mg daily
acetaminophen 650mg q4hr PRN
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2181-8-23**]
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20,181
| 120,654
|
12032+12033+12034+56319+56320+56321+56322
|
Discharge summary
|
report+report+report+addendum+addendum+addendum+addendum
|
Admission Date: [**2173-10-13**] Discharge Date: [**2173-10-25**]
Date of Birth: [**2152-3-29**] Sex: M
Service:
The patient is a 21-year-old with history of Wolfran Syndrome
otherwise known as Didmoad which is diabetes insipidus,
diabetes mellitus optic atrophy and deafness who presently
was hospitalized for a prolonged period of time with
complicated pneumonia, Methicillin resistant Staphylococcus
aureus and pseudomonas for which he was treated long-term
with high dose Vancomycin, was intubated per respiratory
failure and eventually needed to be trached. He was sent to
[**Hospital1 1319**] following his discharge from the hospital in
[**Month (only) 359**]. At [**Hospital1 1319**] he was able to be weaned from
ventilatory support and was kept on trach collar. Although
he showed some improvement as far as his mental status and
ability to care for himself at [**Hospital1 1319**] he developed further
agitation over the two weeks he was at [**Hospital1 1319**] and although
he was able to be weaned off the vent for 48 hours prior to
his most recent admission the agitation required him to be
seen in the emergency department the [**Hospital3 **] on [**2173-10-13**].
It was notable that when he did present to the Emergency Room
he had a temperature to 102 degrees and also had demonstrated
some increasing in his secretions from the trach tube. Per
the parents, the patient's baseline mental status was such
that he was able to speak normally and care for himself and
most of the activities of daily living and had been eating on
his own before the prolonged hospital course and the two
weeks at [**Hospital1 1319**] before his mental status greatly
deteriorated. They noted there might be potential volitional
component to this since he had been severely depressed
reportedly because of the [**Hospital1 **] Syndrome and the complete
loss of vision which had been getting worse over the two
weeks prior to his admission. He also has diabetes
insipidus, he had diabetes mellitus, optic atrophy with
almost complete blindness and high pitched hearing loss.
PAST MEDICAL HISTORY:
1. [**Hospital1 **] Syndrome.
2. Hashimoto's thyroiditis and hypothyroidism.
3. Depression with history of suicidal ideation.
4. Anxiety.
5. Questionable seizure disorder thought to be due to
hypoglycemia.
6. Trach collar secondary to failure to wean from mechanical
ventilator.
7. Methicillin resistant Staphylococcus aureus and
pseudomonas pneumonia.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. DDAVP 0.5 twice a day.
2. Heparin subcutaneously three times a day.
3. Colace 100 mg twice a day.
4. Klonopin 1 mg twice a day.
5. Synthroid 250 mg q day.
6. Prozac 40 mg q day.
7. Dilantin 200 mg three times a day.
8. Questionable central hypoventilation.
9. Percutaneous endoscopic gastrostomy tube.
PHYSICAL EXAMINATION: On initial evaluation vital signs were
temperature of 100.3 with a T-max of 102.4. Pulse 138, blood
pressure 193/106 sating 100% On examination he was
agitated, sitting up back and forth in bed, trying to roll
off the bed, not responding to any commands or communicating.
His sclera were anicteric. Pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
intact. There were no focal neurologic deficits although he
did have some straightening and shaking of his left
extremity. Neck was supple. Chest was clear to auscultation
anteriorly and laterally with decreased breath sounds at the
left base. He was mostly uncooperative with a posterior
field examination. Heart was regular although tachycardiac,
normal S1 and S2. No murmurs, rubs or gallops were
appreciated. His abdomen was nontender, nondistended, no
tenderness to palpation. Bowel sounds were active. He had a
percutaneous endoscopic gastrostomy tube site that was
without erythema or drainage. Extremities were warm without
edema. His pulses were 2+, he was moving all extremities and
he was diaphoretic.
INITIAL LABORATORY: White count significant for 23.4,
hemoglobin and hematocrit of 13/40.7, platelets 605, no bands
on the differential. His coags were 13.9 for prothrombin
time, 1.3 for INR, 26.1 for PTT. Chem 7: Sodium 148,
potassium 4.4,chloride 100, bicarbonate 30, BUN 23,
creatinine 1.0, glucose 81. Lactate of 2.6, ALT 33, AST 22,
alk phos 270. Total bili 0.2. Albumin 4.7, amylase 30,
lipase 11. Troponin less than .01. Calcium 11.2, magnesium
2.2, phosphorus 4.3.
On lumbar puncture his cerebrospinal fluid showed 1 white
blood cell, 0 red blood cell, negative gram stain for
organisms. His urinalysis showed a small LE, negative
nitrate, 20 to 50 red blood cells, greater than 50 white
blood cells, moderate bacteria.
His chest x-ray showed a left lower lobe consolidation. His
electrocardiogram was sinus tachycardia at 133 with normal
intervals and no ST changes.
HOSPITAL COURSE: As far as his altered mental status goes,
there were a couple of potential sources for the altered
mental status, none of which was ever clearly able to be
attributed in the end. The first thing was his source of
infection which appeared to be coming from respiratory source
above all given that his sputum cultures ended up growing out
Methicillin resistant Staphylococcus aureus. It was unclear
whether this was due to colonization or active infection
although he did show signs eventually of bilateral lobar
collapse and left lower lobe consolidation particularly on
the CAT scan that he had during his hospital stay although
this CAT scan was remarkably unchanged from the previous
study on from [**8-27**]. He did not grew further pseudomonas
from this culture as he had in the previous hospital stay and
no other cultures were positive for infection. For this
infection the patient was treated with Vancomycin at a higher
dose of 1 gram q 8 hours and seemed to respond well as far as
his fever curved symptoms although his white blood count
never did trend down and ended up slightly trending up on his
transfer to the floor.
The patient at times was also on Zosyn which he was on for
approximately three days and then discontinued for two days
and then restarted. It was started for broad coverage and
then discontinued when the cultures had only grown out
Methicillin resistant Staphylococcus aureus. It was
restarted when the patient spiked again and his white count
went up and his altered mental status did not seem to be
improving. This was also restarted given slight increase in
left lower lobe consolidation on the chest x-ray and the
history of pseudomonal pneumonia. The Zosyn was discontinued
approximately day 10.
Also in the issue of his altered mental status was the issue
of his altering sodium levels due to the diabetes insipidus
for which he entered at a sodium of 148 and trended down into
the 120's and upon transfer to the floor was stabilized
between 132 and 138 on a dose of DDAVP of .5 mcg twice a day.
It was also managed via fluid restriction while the patient
had altered mental status and by allowing the patient to
drink per his thirst when his altered mental status improved.
At the time of his transfer to the floor sodium had been
stabilized again in the mid 130's. The third issue for his
altered mental status was issue of his thyroid for which he
had hypothyroidism and his TSH was elevated approximately 20
on admission. Per the endocrinology consult that was
obtained they had suggested increasing the dose to 300 q day
which was done just to check the trending levels a repeat TSH
and free T4 were checked both which were within normal
limits. It was noted that it was not an accurate
determination of exactly what was happening given that the
thyroid function tests take time to normalize and thus it was
suggested to repeat the thyroid function test after four
weeks and continue with the same Synthroid dose.
The patient was on Dilantin when he came in. There was a
question of whether there was any toxicity. The levels were
within normal limits however, the Dilantin was discontinued
because it was not felt the patient had a significant seizure
disorder as he had only had one seizure in the past and it
was felt to be due to hypoglycemia in the past so that after
an EEG was done and Neurology was consulted Dilantin was
discontinued.
The other aspect of his altered mental status which was never
really able to be determined was that there was felt to be a
volitional component given that the patient had been
complaining of severe depression and per his parents was just
not wanting to talk to people because of the loss of his
eyesight. The patient did start talking normally on the day
of his transfer to the floor. It is unclear what kind of
volitional component there was to this.
For this altered mental status, just of note, there were
several consults obtained including Infectious disease,
Endocrinology and Neurology as described above.
The next issue is that the patient on [**2173-10-22**] developed
about a 6 to 7 minute run of supraventricular tachycardia
which was then felt to be Arteriovenous nodal reiterate
tachycardia. This episode reverted spontaneously although he
did have a repeat episode the next evening which reverted
after 6 mg of Adenosine times two, maintained after on 5 mg
intravenous Lopressor and 25 of Pilopressor and then
maintained on a dose of 25 mg three times a day of Lopressor.
At the time of his transfer to the floor the patient did not
have further episodes of supraventricular tachycardia and
Cardiology was aware. Further history of the
supraventricular tachycardia will be updated on the discharge
addendum from the Medicine floor team.
As far as the infectious issues go as described above the
patient did only grow out Methicillin resistant
Staphylococcus aureus from a sputum culture, no other
cultures grew out anything to suggest any other sources of
infection. Also as noted above the patient did have a CT of
his chest to see if there was any role for further
bronchoscopy or what the status of his pneumonia was. it was
clear that the pneumonia had not really changed much since
[**2173-8-25**]. Throughout the course of his hospital stay
he did develop some new infiltrates on the left side lending
some suggestion to aspiration verses developing new pneumonia
for which he was treated with Vancomycin and Zosyn. Seemed to
be doing well clinically per his transfer to the floor. The
patient also benefited from the use of something called the
Cougholator which was used by respiratory to increase his
secretions and clear out the focal point for the pneumonia.
The day prior to transfer to the floor the patient also
complained of abdominal pain so he was evaluate with right
upper quadrant ultrasound for cholecystitis which was
negative.
The next issue was his diabetes insipidus which as explained
above. Endocrinology was consulted on, recommended keeping
the DDAVP at 0.5 mcg twice a day. Continue to follow the
sodium levels twice a day which maintained stable round 132
to 138 throughout his stay on the medical Intensive Care
Unit. We made an attempt to transfer the DDAVP over to
subcutaneously dose but it was not available in the pharmacy
in that dose and should be transferred to his oral dose
eventually by the medical floor team.
We attempted to free water restrict the patient when his
sodium levels were low and there was an effort made initially
to free water bolus the output although the sodium level
stayed remarkably stable even without free water bolusing so
fluid restriction was maintained until the sodium levels were
stabilized between 135 and 138.
For his diabetes mellitus Endocrinology was consulted.
Initially he was on an insulin drip which was then changed to
Lantis approximately 23 units twice a day and Regular insulin
sliding scale. The patient had poor control on Lantis and
insulin sliding scale particularly there was occasional
continuation and then discontinuation of his tube feeds. By
the end of his stay in the Medical Intensive Care Unit he had
been on 30 q AM and 23 q h.s. of Lantis and Humalog insulin
sliding scale for control. This issue will be followed up by
the medical floor team as well.
For his hypothyroidism again Endocrinology was consulted. He
was continued on Synthroid 300 mg q day, TSH and Free T4 were
rechecked and within normal limits. As noted above this
level should be checked within approximately six weeks to see
if it is trending in the right direction.
For his respiratory failure the patient was stable on trach
collar and was abbeded by the use of the Anexoflator which
helped put out his secretions. The patient was vented for
one day on assist control when he went for an magnetic
resonance scan to evaluate the situation of his [**Year (4 digits) **]
syndrome and the potential of osmotic demyelination due to
his hyponatremia but was then taken off the next day and put
back on the trach collar and tolerated this well.
For his psychiatric concerns of depression and suicidal
ideation. Psychiatry was consulted. They were unable to
fully evaluate this situation due to his altered mental
status and medical floor team will follow this up further
once he has been on the floor and Psychiatry has had a chance
to appropriately evaluate him. He was managed with Haldol on
a three times a day basis p.r.n. to manage his agitation.
For his [**Year (4 digits) **] syndrome there was no change in the magnetic
resonance scan to suggest any progression of the [**Year (4 digits) **]
syndrome. There was also no change on the magnetic resonance
scan to suggest osmotic demyelination due to hyponatremia or
correction of hyponatremia. At the beginning of his hospital
stay it was unclear whether the [**Name (NI) **] was contributing to
his altered mental status but due to the remarkable change in
his mental status and improvement towards the end of his
Intensive Care Unit stay it was felt that there was not much
further decline due to the [**Name (NI) **] syndrome except for
potentially his eyesight.
Eye sight which Ophthalmology was consulted for to see
whether there was any other organic basis for the eyesight.
There was felt to be no change organically or anatomically
and that is still the only likely explanation was the optic
atrophy due to the [**Name (NI) **]'s syndrome.
Seizure disorder. The patient had seizures questionably
prior to his admission in [**Month (only) **]. It was felt that these
seizures were due to hypoglycemia and the Dilantin was
discontinued during the hospital stay.
Overall, the patient's clinical condition improved by the end
of his hospital stay, he was stable for discharge from the
Intensive Care Unit on [**2173-10-22**]. Just as a synopsis the
consultations obtained in the Intensive Care Unit included:
1. Endocrinology.
2. Ophthalmology.
3. Neurology.
4. Infectious Disease.
5. Neurophthalmology by Dr. [**First Name (STitle) 2523**].
6. Cardiology/Electrophysiology.
The remainder of the hospital course including his final
discharge medications, follow-up and diagnosis will be added
by the Medical Floor Team.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2173-10-25**] 20:08
T: [**2173-10-25**] 19:44
JOB#: [**Job Number 37775**]
Admission Date: [**2173-10-13**] Discharge Date: [**2173-11-1**]
Date of Birth: [**2152-3-29**] Sex: M
Service:
ADDENDUM: This is a Discharge Summary Addendum which will
cover the hospital course from [**2173-10-24**] when the
patient was transferred to the Medicine Service until
discharge on [**2173-11-1**].
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM
(CONTINUED):
1. CARDIOVASCULAR ISSUES (Arrhythmias): The patient was
noted to have one episode of supraventricular tachycardia to
the 200s in the Medical Intensive Care Unit. He then had
recurrent episode on transfer to the medical floor.
On the next day, the patient had four episodes of
supraventricular tachycardia which appeared to be consistent
with atrioventricular nodal reentrant tachycardia.
Therefore, the Electrophysiology Service was consulted to see
the patient, and they recommended an electrophysiologic study
and possible ablation.
The patient did go to the Electrophysiology Laboratory for an
electrophysiology study with successful induction of his
supraventricular tachycardia which was confirmed to be
atrioventricular nodal reentrant tachycardia and received
successful ablation. The patient did not have any further
arrhythmias throughout his hospital stay.
2. PNEUMONIA ISSUES: The patient's white blood cell count
initial decreased on transferred to the floor; however, his
Zosyn was discontinued, and his white blood cell count
increased to 20. Therefore, the Zosyn was restarted
empirically although there had not been any blood cultures or
sputum cultures to indicate gram-negative or anaerobic
infection. However, due to the patient's deterioration it
was assumed that he had a polymicrobial process going on with
methicillin-resistant Staphylococcus aureus pneumonia and
either anaerobic or gram-negative pneumonia in addition.
Therefore, the plan was to continue the Zosyn to complete a
14-day course. In addition, the patient completed 14 days of
vancomycin while on the medical floor. However, due to the
severity of his pneumonia, and due to the long-time course
and slow recovery, it was decided to continue the vancomycin
until either a follow-up sputum culture was negative for
methicillin-resistant Staphylococcus aureus or the patient
completed an additional 10 days of vancomycin.
The patient was continued on aggressive pulmonary toilet and
chest physical therapy and continued to have oxygen
saturations of 96% on a 40-liter tracheal mask, and the
patient continued to have a cough productive of thick yellow
sputum requiring frequent aggressive respiratory toilet with
suctioning.
3. DIABETES INSIPIDUS ISSUES: The patient was switched from
intravenous desmopressin acetate to subcutaneous desmopressin
acetate and then to intranasal desmopressin acetate at a dose
of 1 gram twice per day. This dose seemed to be appropriate
for the patient as his sodium were maintained between 133 and
140. The patient did have large amounts of urine output with
an average 1.5 liters to 3 liters per day; however, this was
thought to be due to glucosuria and forced diuresis due to
the patient's difficult to control blood sugars.
4. DIABETES MELLITUS ISSUES: The patient's blood sugars
proved very difficult to control on the medical floor. The
patient was allowed access to food and did request food
constantly throughout the day.
In conjunction with an Endocrinology consultation, the
patient's Glargine and Humalog sliding-scale were increased
incrementally throughout his hospital stay in an effort to
control his blood sugars.
5. HYPOTHYROIDISM ISSUES: The patient was continued on
levothyroxine at his current dose.
6. OPTIC ATROPHY ISSUES: The patient was seen by Dr. [**First Name (STitle) 2523**]
who noted that the patient appeared to have no remaining
vision and requested that the patient follow up with him in
the clinic.
7. DEPRESSION ISSUES: The patient was followed by the
Psychiatry Service throughout his stay on the medical floor,
and he did appear to be extremely anxious but less depressed.
The patient was managed with Klonopin at a standing dose and
Ativan as needed which seemed to help; although, it was
inadequate in controlling his anxiety which was at times
severe.
DISCHARGE DISPOSITION: The patient was to be discharged to
[**Hospital6 85**].
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to [**Hospital6 19682**].
MEDICATIONS ON DISCHARGE:
1. Folic acid 1 mg by mouth once per day.
2. Thiamine 100 mg by mouth once per day.
3. .................... 50 mcg by mouth every day.
4. Vancomycin 1 gram intravenous q.12h. (times seven days).
5. Desmopressin nasal 10 mcg twice per day.
6. Metoprolol 50 mg by mouth twice per day.
7. Zosyn 4.5 grams intravenously q.6h. (times seven days).
8. Clonazepam 1 mg by mouth at hour of sleep.
9. Clonazepam 0.5 mg by mouth in the morning.
10. Haloperidol 1 mg to 2 mg intravenously at hour of sleep.
11. Miconazole 2% one application three times per day as
needed.
12. Senna one tablet by mouth twice per day as needed.
13. Lactulose 30 mL by mouth three times per day.
14. Docusate 100 mg by mouth twice per day.
15. Levothyroxine 300 mcg by mouth every day.
16. Haloperidol 0.5 mg to 2 mg intravenously three times per
day as needed.
17. Albuterol nebulizer one nebulizer q.6h. as needed.
18. Acetaminophen as needed.
19. Fluoxetine 40 mg by mouth once per day.
20. Heparin 5000 units subcutaneously q.8h.
21. Insulin glargine 35 units subcutaneously before
breakfast and 35 units subcutaneously before bed with a
Humalog sliding-scale.
DISCHARGE DIAGNOSES:
1. Methicillin-resistant Staphylococcus aureus pneumonia.
2. Tachycardic arrhythmia; status post ablation procedure.
3. Hyperglycemia.
4. Hyponatremia.
5. Hypernatremia.
6. Diabetes insipidus.
7. Diabetes mellitus.
8. Optic atrophy.
9. Blindness.
10. Anxiety.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his primary
care physician in one to two weeks.
2. The patient was instructed to follow up with Dr. [**First Name (STitle) 2523**]
as an outpatient after discharge from [**Hospital3 6373**] Center.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 5615**]
MEDQUIST36
D: [**2173-10-29**] 19:58
T: [**2173-10-30**] 04:46
JOB#: [**Job Number 37776**]
Admission Date: [**2173-10-13**] Discharge Date: [**2173-11-4**]
Date of Birth: [**2152-3-29**] Sex: M
Service: Medicine
ADDENDUM: This Discharge Summary Addendum will cover the
hospital course from [**2173-11-1**] to [**2173-11-4**]
when the patient was transferred to the Medical Intensive
Care Unit.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM
(CONTINUED):
1. CARDIOVASCULAR ISSUES: The patient did not have any
further arrhythmias once his atrioventricular node had been
ablated.
2. PNEUMONIA ISSUES: The patient's vancomycin was
discontinued as he had completed greater than a 30-day
course. Repeat sputum cultures did grow
methicillin-resistant Staphylococcus aureus; however, at this
time it was thought that this was most certainly a colonizer
as the patient had previously had adequate vancomycin
treatment. The patient's white blood cell count remained
stable off the vancomycin. The patient was continued on the
Zosyn in order to complete a total of a 14-day course from
the most recent start date which was [**10-25**]. In
addition, the patient's sputum culture did grow
Stenotrophomonas maltophilia which was thought to be a
colonizer. Therefore, the patient was not started on any
Bactrim therapy.
The patient was continued on aggressive pulmonary toilet and
continued to do well from an infectious standpoint.
3. HYPOXIA ISSUES: The patient was noted to have several
episodes of hypoxia during the night; the first of which
occurred on [**10-25**] at midnight. At that time, the
patient desaturated to 70%. His face mask was found to have
fallen off of his tracheotomy. Therefore, it was thought
that his acute oxygen desaturation with resultant somnolence
was due to the lack of oxygen, and the event was not further
investigated. The blood gas at that time showed a pH of
7.31, a PCO2 of 53, and a PAO2 of 300, and 53 once the
patient was placed back on his oxygen.
As there was an inciting event; namely removal of the oxygen
mask, it was not further investigated. However, the patient
had a repeat episode of unresponsiveness in the middle of the
night which occurred several days later (on [**10-31**]). At
that time, the patient's oxygen saturations were normal.
However, while the patient was being evaluated he became
acutely cyanotic without any stridor or wheezing, but he was
noted to be apneic, and his oxygen saturation dropped to 30%
to 70%. The cyanotic episode lasted less than 10 seconds and
then resolved. The patient woke up and began responding to
simple commands and moving his extremities; although,
initially he had been fully unresponsive. The patient
suffered a third episode of unresponsiveness at night the
following night (on [**10-30**]); however, at this time, his
oxygen saturation was completely normal throughout with no
cyanosis noted.
Due to these episodes, the patient was evaluated by Neurology
who felt that electroencephalogram telemetry would be useful.
In addition, they recommended a formal sleep study which
could not be performed as the patient was an inpatient at the
time. The electroencephalogram study showed a slight
abnormality with a regular poorly developed 7-hertz to
8-hertz beta and alpha activity interrupted by occasional
bursts of generalized frontal occipital predominant 2-hertz
delta activity. It was interpreted that the patient did not
have any seizure activity, but he did have the propensity for
further seizures due to several spikes that were noted that
were not seizure activity. Neurology felt that seizures were
not the etiology for the patient's apneic or unresponsive
episodes and invoked central sleep apnea.
Therefore, the patient underwent an abbreviated sleep study
on the floor which incurred overnight oxymetry as well as
overnight seizure dilator activity as measured by a finger
monitor. This sleep study showed 14.7 respiratory
disturbances events per hour and 8.7 oxygen desaturation
events per hour; which suggested central sleep apnea. These
events occurred mostly between the hours of midnight and in
the morning and were likely associated with REM sleep. Due
to the patient's likely sleep apnea, he was transferred to
the Medical Intensive Care Unit in order to receive [**Hospital1 **]-level
positive airway pressure titration so that he could remain on
[**Hospital1 **]-level positive airway pressure overnight with a backup
rate to compensate for his central sleep apnea. Of note,
central sleep apnea is a cause of death in most [**Doctor Last Name **]-man
syndrome patients and is a known complication. In addition,
the patient has clear brain stem atrophy on magnetic
resonance imaging which correlates with these symptoms.
In addition, the patient had several other unresponsive
events during the day; during which time he was noted to have
normal muscle tone, withdrawal to touch, held his eyes shut
so that they could not be opened, and was intermittently
verbal. It was thought that these occasions were most likely
consistent with voluntary pseudocatatonia and related to the
patient's depression which he freely admitted was a result of
his extended hospital stay and poor functional capacity. The
patient was completely normal on neurologic examination after
these episodes.
4. DIABETES INSIPIDUS ISSUES: The patient was transitioned
to Glargine once per day with a new Humalog sliding-scale,
and this seemed to control his blood sugars very well.
In terms of other systems, the patient was stable with no
changes from the prior Discharge Summary except for
increasing depression. The patient was transferred to the
Medical Intensive Care Unit in fair condition for further
[**Hospital1 **]-level positive airway pressure titration.
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-944
Dictated By:[**Last Name (NamePattern1) 5615**]
MEDQUIST36
D: [**2173-11-4**] 09:50
T: [**2173-11-4**] 10:13
JOB#: [**Job Number 37777**]
Name: [**Known lastname 6805**], [**Known firstname **] Unit No: [**Numeric Identifier 6806**]
Admission Date: [**2173-10-13**] Discharge Date: [**2173-11-4**]
Date of Birth: [**2152-3-29**] Sex: M
Service:
Patient was transferred to the ICU unit for a CPAP
titration/trial in preparation for discharge to rehab center.
This trial was decided on after patient had episodes of
desaturation during his sleep study.
Since transfer to the ICU, the patient did well while awake,
however, the patient was unable to tolerate CPAP for pressure
support, and experienced numerous episodes of apnea once
asleep. This required the triggering of the vent for these
apneic episodes. The settings at which patient experienced
episodes of desaturation into the high 80s was FIO2 at 0.4,
PEEP of 4, and pressure support of 8. ABG was obtained which
showed 7.39/53/72/33/5. With these results, the triggers of
the vent setting was adjusted and after various attempts, a
final decision was made to put the patient on MMV mode. The
settings remained at PEEP of 4, pressure support of 10, tidal
volume of approximately 400 as well as 0.4 FIO2.
Since patient was not able to tolerate only CPAP to ensure
adequate oxygenation and ventilation, it was decided that
patient will need further ventilator support at nighttime.
Suggested settings for the support is assist control mode at
PEEP of 4, pressure support of 10, tidal volume of 500,
respiratory rate of 12. If available, another option was to
start patient on BiPAP with backup rate. Otherwise, patient
remains stable on the floor, was afebrile, and blood pressure
was within normal limits. Respiratory rate also within
normal limits as well as no further episodes of tachycardia.
Patient also notably saturated well with pulse oximetry
ranging in the mid to high 90s throughout the episode with
the exception of the apneic episodes. Patient will be
discharged to rehab center for further weaning off the vent
as well as ventilatory support.
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**Last Name (NamePattern1) 6818**]
MEDQUIST36
D: [**2173-11-4**] 12:26
T: [**2173-11-4**] 12:47
JOB#: [**Job Number 6819**]
Name: [**Known lastname 6805**], [**Known firstname **] Unit No: [**Numeric Identifier 6806**]
Admission Date: [**2173-10-13**] Discharge Date: [**2173-11-7**]
Date of Birth: [**2152-3-29**] Sex: M
Service:
ADDENDUM:
ADMITTING DIAGNOSIS: Pneumonia.
This is an addendum to the previous Discharge Summary
dictated on [**2173-11-4**], at which time the patient was
transferred to the Intensive Care Unit for overnight CPAP
titration study before discharge to [**Hospital3 **]
Facility following episodes of desaturation while asleep.
The patient's course in the Intensive Care Unit was largely
unremarkable. The delay in discharge was in large part due
to the Intensive Care Unit Team's decision to hold this
medically complex patient until after the weekend for
transfer to rehabilitation.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE / SYSTEM:
1. RESPIRATORY: Since transferred to the Intensive Care
Unit, the patient did well while awake; however, the patient
did experience numerous episodes of apnea once asleep
requiring adjustment of the vent. The patient was
periodically put on MMV mode until exclusion of prolonged
apnea or seizure activity could be excluded.
In light of the patient's underlying Wolfram's the objective
was to obtain levels of CPAP which could safely support the
patient at night without vent dependence. The course was
remarkable for an air leak from the tracheostomy site which
was corrected by extending the tracheostomy tube on [**11-6**].
No complications from the procedure were noted.
For the rest of the course, the patient expressed distinct
preference to remain off the vent as long as possible.
2. CARDIOVASCULAR: The patient remained in tachycardia
throughout his Intensive Care Unit stay. Metoprolol was
continued.
3. INFECTIOUS DISEASE: The patient's Vancomycin and Zosyn
was discontinued. The patient remained afebrile. White
count trended downward and had no clinical sign of infection.
The positive sputum culture likely represented colonization.
The patient was continued on aggressive pulmonary toilet and
continued to do well from an infection standpoint.
4. NEUROLOGICAL: The patient was again monitored by
overnight event EEG monitoring. Review of the data revealed
no seizure activity but probable underlying procedures. In
conjunction with this, the patient's Dilantin was continued
and noted to be therapeutic. No clinical seizure activity
was noted during the Intensive Care Unit stay.
5. ENDOCRINE: Diabetes mellitus - the patient was briefly
put on an insulin drip while seizure and apnea episodes were
being investigated. He transitioned well to the regimen of
45 units of Glargine q. h.s. and customized sliding scale [**First Name8 (NamePattern2) **]
[**Last Name (un) 616**] recommendations.
Diabetes insipidus: The patient's electrolytes fell within
normal limits without intervention once the patient was
allowed free access to p.o. fluids.
Hypothyroidism: The patient remained on levothyroxine
regimen.
6. PSYCHIATRIC: The patient was followed by a psychiatric
consultation throughout his Intensive Care Unit stay. The
patient's mood was notably improved when off the vent and
closer to his discharge date. Prozac, Klonopin and Haldol
was continued with the latter two titrated down.
DICTATION ENDS
[**Name6 (MD) 3354**] [**Last Name (NamePattern4) 5357**], M.D. [**MD Number(1) 6820**]
Dictated By:[**Last Name (NamePattern1) 6818**]
MEDQUIST36
D: [**2173-11-7**] 18:53
T: [**2173-11-7**] 21:00
JOB#: [**Job Number 6821**]
Name: [**Known lastname 6805**], [**Known firstname **] Unit No: [**Numeric Identifier 6806**]
Admission Date: [**2173-10-13**] Discharge Date: [**2173-11-7**]
Date of Birth: [**2152-3-29**] Sex: M
Service:
ADDENDUM: This is an addendum to Discharge Summary.
DISCHARGE MEDICATIONS:
1. Heparin subcutaneously 5000 units q. eight.
2. Prozac 20 mg, two capsules p.o. q. day.
3. Albuterol nebulizer q. six p.r.n.
4. Levothyroxine 300 micrograms p.o. q.day.
5. Colace 100 mg p.o. twice a day.
6. Lactulose 10 grams in 15 millimeter syrup, 30 ml p.o. q.
day.
7. Senna 8.6 mg p.o. twice a day.
8. Miconazole nitrate powder, one application three times a
day as needed.
9. Clonazepam 0.5 mg p.o. q. a.m.; 0.5 mg p.o. q. h.s.
10. Metoprolol 50 mg p.o. twice a day.
11. Desmopressin intranasally twice a day.
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**Last Name (NamePattern1) 6818**]
MEDQUIST36
D: [**2173-11-7**] 19:01
T: [**2173-11-7**] 21:39
JOB#: [**Job Number 6822**]
Name: [**Known lastname 6805**], [**Known firstname **] Unit No: [**Numeric Identifier 6806**]
Admission Date: [**2173-10-13**] Discharge Date: [**2173-11-7**]
Date of Birth: [**2152-3-29**] Sex: M
Service:
ADDENDUM TO DISCHARGE MEDICATIONS:
The patient was discharged in addition to medicines
previously listed with:
1. Phenytoin 100 mg, three capsules p.o. q. a.m.
2. Haloperidol 5 mg q. h.s.
3. Insulin sliding scale.
4. Glargine 45 units q. h.s.
5. Thiamine.
6. Cyanocobalamin.
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**First Name3 (LF) 6823**]
MEDQUIST36
D: [**2173-11-7**] 19:08
T: [**2173-11-7**] 21:44
JOB#: [**Job Number 6824**]
|
[
"276.9",
"482.41",
"427.1",
"275.42",
"253.5",
"780.57",
"377.16",
"518.83",
"250.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"37.34",
"38.93",
"97.23",
"89.18",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
19626, 19693
|
21024, 21303
|
35149, 35665
|
19838, 21002
|
4892, 19602
|
21336, 30391
|
2869, 4874
|
19708, 19811
|
30413, 34039
|
2119, 2846
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,806
| 161,535
|
12336+56354
|
Discharge summary
|
report+addendum
|
Admission Date: [**2163-9-1**] Discharge Date: [**2163-9-9**]
Date of Birth: [**2120-1-10**] Sex: M
Service:
CHIEF COMPLAINT: The patient is a 43 year-old male found
unresponsive at home with suicidal ideation note.
HISTORY OF PRESENT ILLNESS: This is a 43 year-old male with
a history of major depressive disorder with psychotic
features who was found unresponsive by police the morning of
admission in his house with a suicidal note. The patient has
progressive major depressive disorder episodes since the loss
of his long term partner two weeks prior to admission. Per
psychologist the patient had missed two appointments with him
that week, which prompted his psychiatrist to break
confidentiality and called the police to investigate the
home. Police noted that the patient was found obtunded and
was immediately referred to [**Hospital1 188**] Emergency Department. The patient was unresponsive
upon arrival and was febrile with a temperature of 100.8.
His heart rate was 137 with a blood pressure of 99/68 and
oxygen saturations 88% and 100% nonrebreather mask. His
respiratory rate was 38. He was immediately intubated for
airway protection and hypoxia. Thick secretions were noted
on suction. A Foley was placed to closely monitor his urine
output. He was given 2 amps of bicarb for a questionable
tricyclic antidepressant overdose. His urine tox was
positive for benzos and amphetamines, otherwise negative. He
was also given Levaquin as his chest x-ray was suspicious for
left aspiration pneumonia. Per the patient's friend who last
spoke with him on Tuesday evening the patient had been very
depressed about the death of his significant other and spoke
about suicide by overdosing on his medication. Per his
power of attorney [**First Name8 (NamePattern2) 698**] [**Last Name (NamePattern1) **] the patient had planned
for suicide via overdose on medications as well.
PAST MEDICAL HISTORY:
1. Major depressive disorder status post electrolysis
therapy five times. The patient also had auditory
hallucinations.
2. Gastroesophageal reflux disease.
3. Asthma not requiring inhalers.
4. HIV negative in [**2163-1-22**].
ALLERGIES: Penicillin leading to anaphylaxis.
MEDICATIONS:
1. Effexor XR 150 mg two tablets q.h.s.
2. Clonazepam .5 mg po b.i.d.
3. Risperdal.
4. Nortriptyline.
FAMILY HISTORY: Both mother and brother of the patient
committed suicide.
SOCIAL HISTORY: The patient denies alcohol, tobacco or
intravenous drug use.
PHYSICAL EXAMINATION: On presentation to the Emergency
Department the patient had a temperature of 100.8, heart rate
137, blood pressure 99/68, respiratory rate 36, 100% on a
nonrebreather mask. His pupils were approximately 2 mm
dilated and were sluggishly reactive bilaterally. His head
was normocephalic, atraumatic. His neck did not have any
signs of lymphadenopathy and there was no thyromegaly. His
lungs had decreased breath sounds anterolaterally and also
had coarse breath sounds, but did not have any wheezes. His
heart was tachycardic and regular rhythm with a normal S1 and
S2. His abdomen was soft and nondistended with bowel sounds.
There was no hepatosplenomegaly appreciated. His
extremities did not have any clubbing, cyanosis or edema.
Neurologically he had no clonus. He was intubated and
sedated with brisk deep tendon reflexes symmetrically. His
skin was moist without any track marks and he had warm
extremities.
LABORATORIES ON ADMISSION: CBC was white blood cell count
9.7, hematocrit 49.8, platelets 193. His electrolytes were
sodium 139, potassium 5.1, chloride 101, bicarb 23, BUN 48,
creatinine 1.1, glucose 130. His urine was positive for
benzos and amphetamines. Urinalysis showed moderate blood, 0
to 2 red blood cells, trace protein, 15 ketones. His serum
tox screen was negative for tricyclics, alcohol, benzos, and
amphetamines. His electrocardiogram showed sinus tachycardia
with a rate of 110 with normal axis. Intervals were within
normal limits. There was good R wave progression. There
were no ST changes. Chest x-ray showed an endotracheal tube
in place and an nasogastric tube in place. There was los of
left diaphragm due to an opacity. It was unclear whether
there was a pneumonia in the left lower lobe versus an
effusion.
HOSPITAL COURSE: 1. Pulmonary: Due to a questionable
aspiration pneumonia versus pneumonitis and due to sedation
from overdosing the patient was intubated and admitted to the
MICU. The patient was intubated for several days. He was
extubated on [**2163-9-4**]. After extubation the patient required
several liters of oxygen and he was also placed on
nebulizers. Upon transfer to the floor after extubation the
patient's oxygen saturations were somewhat stable ranging
from 93 to 95% on 2 liters. However, on [**2163-9-7**] the patient
complained of sharp pleuritic pain located on the left side
of his chest. He was also spiking temperatures to
approximately 101 degrees Fahrenheit. Electrocardiogram did
not show any acute changes and a chest x-ray was done, which
showed an increased left lower lobe opacity. The patient was
started on Vancomycin to cover for staph aureus pneumonia.
CT angio was done, which showed a pulmonary emboli in the
right lung, left effusion and a left lower lobe worsening
infiltrate. An ultrasound was done in the pulmonary
specialty unit, which revealed a small effusion, which was
unable to be tapped. Gentamycin was added to the patient's
regimen so that he was covered with Vancomycin, Gentamycin
and Flagyl. Due to the pulmonary emboli seen on CT angio the
patient was started on heparin. Coumadin was added to his
regimen the day after heparin was started. The patient's
oxygen saturations during the initial part of his hospital
stay after starting on the heparin were stable on
approximately 94% on 2 liters. After starting the heparin
the patient continued to complain of pain localized over his
chest for which he was given several pain medications
including morphine. He stated that the pain improved within
the next few days after starting the heparin.
2. Musculoskeletal: The patient was diagnosed with
rhabdomyolysis while he was in the MICU due to CK levels that
were highly elevated. The patient was aggressively fluid
resuscitated and his CKs trended down each day. On [**2163-9-9**]
his CK had decreased to approximately 300. He was continued
on his intravenous fluids.
3. Psychiatric/neurological: The patient required a
Klonopin and Ativan drip in the MICU due to his
benzodiazepine withdraw. After the patient was transferred to
the floor initially he was placed on Ativan according to the
CIWA scale. Per psychiatry consult he was then restarted on
his Klonopin and the Ativan was discontinued. The patient's
mental status improved gradually during his hospital stay.
Upon transfer to the floor from the Intensive Care Unit he
was alert and oriented times three and he had fluent speech.
Pain was managed using Oxycodone and morphine. Eventual plan
was for the patient to be transferred to an inpatient
psychiatry unit upon medical clearance.
4. Infectious disease: The patient initially was placed on
Levaquin and Flagyl in the Intensive Care Unit due to a
questionable aspiration pneumonia. However, due to continued
spiking temperatures to 101 Vancomycin and Gentamycin were
added to his regimen. He was continued on the Flagyl, but
the Levaquin was discontinue. His blood cultures and urine
cultures through the initial part of his stay failed to grow
any organisms. His sputum culture was also negative. He was
continued on his antibiotics throughout his hospital stay.
5. Skin: The patient had a stage two sacral decubitus
ulcer, which required DuoDerm placement per plastic surgery
consult. He also had a pressure sole on his heel that was
closely observed.
6. Fluid, electrolytes and nutrition: While the patient was
in the Intensive Care Unit he was given nasogastric tube
feeds. Upon transfer to the floor the patient was
transitioned to a normal diet. His electrolytes were
monitored closely during his hospital stay. He was
transitioned to a regular diet as per speech and swallow
consult evaluation.
7. Gastrointestinal: The patient had increased liver
function tests, which appeared to be a transaminitis, but not
a cholestatic picture. His right upper quadrant ultrasound,
which was done was unrevealing. His hepatitis panel was
negative as well. His liver function tests were closely
monitored during his hospital stay, which trended downward
each day.
An addendum to this discharge summary will be added at a
later date.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10621**], M.D. [**MD Number(1) 10622**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2163-9-9**] 10:03
T: [**2163-9-12**] 07:52
JOB#: [**Job Number 38461**]
Name: [**Known lastname 6956**], [**Known firstname 77**] Unit No: [**Numeric Identifier 6957**]
Admission Date: Discharge Date: [**2163-10-5**]
Date of Birth: [**2120-1-10**] Sex: M
Service:
ADDENDUM: This is an addendum to dictation number [**Serial Number 6958**].
This is a discharge addendum from the date [**2163-9-9**] to the
date of discharge, [**2163-10-5**].
HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient was
noted to have spiking fevers, evaluated by CTA on [**2163-9-8**]
showing a left-sided consolidation and effusion. Ultrasound
at that time did not show an effusion large enough to tap.
The patient was started on Cipro, Flagyl, and vancomycin.
Chest x-ray on [**2163-9-12**] showed a layering effusion. This was
tapped on [**2163-9-13**] with 800 cc removed, demonstrating a
sterile exudate. The pleural effusion reaccumulated in two
days and a second thoracentesis was performed on [**2163-9-15**]
with another 800 cc removal and study showing another sterile
exudate.
The patient continued to have low-grade temperatures and
developed night sweats. A CT on [**2163-9-23**] showed partially
loculated moderate left pleural effusion. CT Surgery was
consulted and considered a VATS procedure but deferred
secondary to a clot burden. A chest tube was placed at the
bedside.
Alteplase times three days was used to destroy loculations.
Culture of the pleural fluid only showed rare
coagulation-negative Staphylococcus which was likely a
contaminant. All antibiotics were discontinued on [**2163-9-26**]
as no pathogen was identified. The chest tube was removed on
[**2163-9-28**] secondary to a clot in the tube. Low-grade fevers
persisted and were likely secondary to multiple PEs and clots
in the lower extremities. The chest x-ray showed decreasing
effusion and loculations. Temperatures had resolved at the
time of discharge.
2. PE: The patient had increased left-sided chest pain and
shortness of breath with fever and increased 02 requirements.
The [**2163-9-8**] CTA was done that showed multiple right-sided
PEs including right distal main as well as a left-sided
consolidation and effusion. The patient was started on
heparin GTT. Follow-up CT demonstrated good resolution of
the multiple PEs on this therapy. On [**2163-9-23**], LENIs were
done as a prep for VATS procedure which demonstrated large
clot burden in the right femoral popliteal venous system.
The patient was transitioned to Warfarin once the chest tube
was removed.
3. HYPOTENSION: The patient demonstrated hypotension
throughout this portion of the hospital course. He was
orthostatic. Risperdal was discontinued as a potential
cause. Psychiatry advised possible medication interactions.
A 100 mcG [**Last Name (un) **] stim test showed an appropriate increase in
Cortisol. The patient's ACTH level which was 14 was normal
and the adrenals appeared normal on CT.
4. DEPRESSION/SUICIDAL IDEATION: The patient was evaluated
on a day to day basis and had a sitter as needed. A friend
of the patient brought in a suicide letter found in the
patient's home from the time of the initial attempt. All
caregivers agree that the patient needs inpatient psychiatric
care. The patient's therapist visited occasionally.
5. SACRAL DECUBITUS ULCER: Assessed by Wound Care Nursing.
Treated with Duoderm dressings. Culture was negative. The
patient had a nutrition consult and increased supplement
shakes to improve healing.
6. PHYSICAL THERAPY: The patient improved strength and
mobility throughout this portion of his admission and was
able to work with physical therapy.
DISCHARGE DIAGNOSIS:
1. Pneumonia.
2. Pleural effusion with loculation status post chest tube.
3. Rhabdomyolysis.
4. Transaminitis.
5. Benzodiazepine withdrawal.
6. Sacral decubitus ulcer.
7. Pulmonary emboli.
8. Deep venous thrombosis.
9. Depression.
10. Status post suicide attempt by overdose.
FOLLOW-UP: The patient is to follow-up with his inpatient
psychiatric care status post suicide attempt, monitoring or
INR q. week for Warfarin adjustments. The patient is to
follow-up with Dr. [**Last Name (STitle) 6959**] within the next two weeks for
adjustment of pain medications, changing Duoderm q. 72 hours.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 q.d.
2. Albuterol p.r.n.
3. Clonazepam one b.i.d.
4. Senna.
5. Miconazole powder.
6. Olanzapine 2.5 mg p.o. t.i.d. p.r.n. anxiety.
7. Docusate.
8. Morphine sustained release 15 q. 12 hours.
9. Warfarin 5 q.h.s. per INR level.
10. Venlafaxine XR.
11. Tylenol.
12. Albuterol inhaler p.r.n.
CONDITION ON DISCHARGE: The patient was walking well with
walker, taking good p.o. with supplement shakes, afebrile,
pain well controlled.
[**First Name11 (Name Pattern1) 499**] [**Last Name (NamePattern4) 6960**], M.D. [**MD Number(1) 6961**]
Dictated By:[**Last Name (NamePattern1) 4245**]
MEDQUIST36
D: [**2163-10-5**] 04:10
T: [**2163-10-5**] 18:36
JOB#: [**Job Number 6962**]
|
[
"518.81",
"296.34",
"780.01",
"969.4",
"276.5",
"507.0",
"728.88",
"E950.3",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"94.65",
"34.04",
"88.43",
"94.25",
"38.91",
"96.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
2352, 2411
|
13192, 13509
|
12565, 13169
|
9334, 12396
|
12415, 12544
|
2513, 3449
|
142, 233
|
262, 1913
|
3464, 4281
|
1935, 2335
|
2428, 2490
|
13534, 13931
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,520
| 115,134
|
33689
|
Discharge summary
|
report
|
Admission Date: [**2148-3-11**] Discharge Date: [**2148-3-21**]
Date of Birth: [**2105-5-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Barrett's Esophagus
Major Surgical or Invasive Procedure:
[**2148-3-11**] Transhiatal esophagectomy, feeding jejunostomy.
History of Present Illness:
The patient is a 42-year-old gentleman who had a longstanding
history of gastroesophageal reflux disease, almost since birth.
Despite being on many
medications, the patient has had persistent symptoms. Repeat EGD
has shown the patient of the long segment Barrett's disease,
approximately 7 cm in length. Biopsy of one of these areas of
Barrett's revealed high-grade dysplasia. As such, it was decided
to proceed with esophagectomy.
Past Medical History:
GERD (since birth, protonix since [**8-20**]), Hiatal Hernia
OSA w/ home CPAP, RA, IBS,
s/p R tib ORIF '[**19**], s/p R testicular rupture, s/p Right Inguinal
Hernia Repair, s/p L knee synovectomy for RA
Social History:
25 pk-yr active smoker, no ETOH
Family History:
Non-Contributory
Physical Exam:
General: 42 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopathy
Card: RRR, normal S1,S2, mucus membranes moist
Resp: decreased breath sounds throughout
GI: obese, abdomen soft non-tender/non-distended. J-tube in
place
Extr; warm tr edema
Incision: Neck; open clean pink granuated tissue with mild
dishcarge, Mid-Abdomn clean/dry/intact w/staples
Neuro: non-focal
Brief Hospital Course:
Mr. [**Known lastname 4541**] was admitted on [**2148-3-11**] and underwent successful
Transhiatal esophagectomy, and feeding jejunostomy tube
placement. He was awakened, extubated, and brought to the SICU
in stable condition. The NG-tube and left chest tube were placed
to suction. The J-tube was to gravity, neck drain to bulb
suction and foley to gravity. He had an epidural and PCA for
pain managed by the pain service. He was monitored overnight
remained hemodynamically stable and was transferred to the
floor. On POD #2 he was started on beta-blockers, gently
diuresed, and trophic feeds were started. He was seen by
nutrition who recommended Replete with fiber goal of 70cc/hr.
POD #3 the chest-tube was removed. POD #4 the neck drainage was
noted to have a leak at the anastomosis site, the wound was
opened and treated with wet-dry dressing. The drain was removed.
The epidural and PCA were removed and he was converted to PO
oxycodone elixir via J-tube with good control. His foley was
removed and he voided without difficulty. On POD #5 his bowel
function returned and his tube feeds was advanced to goal which
he tolerated. He was followed by physical therapy. On POD #8 he
underwent left thoracentesis for 500cc fluids. A follow-up
chest x-ray was stable no pneumothorax. He continued to make
steady progress and was discharged to home with VNA on POD 10.
He will follow-up with Dr. [**Last Name (STitle) **] and undergo a Barium Swallow
in weeks.
Medications on Admission:
Protonix 40 daily, Leucin 40 tid, Imodium prn
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed: give via J-tube.
Disp:*480 ML(s)* Refills:*0*
2. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ML PO BID (2
times a day): give via J-tube.
3. Lopressor 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day:
Crush and give via J-tube and flush with 50cc of water after.
Disp:*60 Tablet(s)* Refills:*2*
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: give via J-tube.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Barrett's esophagus w/ HG dysplasia, s/p transhiatal
esophagectomy
Hiatal Hernia, OSA w/ home CPAP, RA, Irritable bowel syndrome
s/p R tib ORIF '[**19**], s/p R testicular rupture, s/p Right Hiatal
Hernia repair, s/p L knee synovectomy for RA
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Last Name (STitle) 28484**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills,
-Increased shortness of breath, chest pain
-Difficulty swallowing or pain with swallowing
-Vomiting, diarrhea or abdominal pain
-Incision develops discharge or increased redness
You may shower, no bathing or swimming for 6 weeks
No driving while taking narcotics. Continue stool softners with
narcotics.
If your feeding tube sutures become loose or break, please tape
tube securely and call the office [**Telephone/Fax (1) 170**]. If your feeding
tube falls out, save the tube, call the office immediately
[**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner
because the tract will close within a few hours.
Do not put any medication down the tube unless they are in
liquid form.
Flush your feeding tube with 50cc every 8 hours if not in use
and before and after every feeding and medications
Neck Dressing change wet-moist twice daily
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on [**2148-4-4**] at 11:30am on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Report to the [**Location (un) **] Radiology Department for a UPPER GI
RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2148-4-4**] 10:30am
Tube feeds off at Midnight [**2148-4-4**] for Barium Swallow
Completed by:[**2148-3-21**]
|
[
"327.23",
"530.81",
"511.9",
"560.1",
"530.85",
"997.4",
"E878.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.6",
"44.29",
"42.41",
"43.5"
] |
icd9pcs
|
[
[
[]
]
] |
3872, 3927
|
1600, 3072
|
295, 361
|
4214, 4221
|
5245, 5664
|
1115, 1133
|
3170, 3849
|
3948, 4193
|
3098, 3147
|
4245, 5222
|
1148, 1577
|
235, 257
|
389, 823
|
845, 1050
|
1066, 1099
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,229
| 114,860
|
16152
|
Discharge summary
|
report
|
Admission Date: [**2184-4-7**] Discharge Date: [**2184-4-21**]
Date of Birth: [**2112-6-18**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD
PICC line placement
History of Present Illness:
71 year old female with history of AF on coumadin, CHF with EF
35%, t2DM on insulin, CAD/PVD s/p multiple stenting and
interventions presents with 4 days of dark stools. She has been
stooling about 3x/day for these past 4 days, accompanied by a
decrease in appetite and headaches. 1 day prior to admission,
she began to feel increasingly dizzy and weak, with the onset of
chills but no documented fevers. She was unable to walk today
on her own and was instructed to be taken to the Emergency Room.
She denies any recent weight loss, hematemesis, hematochezia,
bruising/mucosal bleeding, chest pain, or palpitations. No
recent NSAID use. She does endorse shortness of breath with
minimal activity, no different than her baseline. She also
states that while someone comes to her house every week to check
her INR, no one had come this week and she missed her check
(confusion with not hearing the doorbell when VNA arrived). She
was supposed to have it checked this Friday.
In the ED, initial vitals were 98.0, 88/60, 57, 20 and 97% on
RA. Labs notable for BUN 132, Cr 2.1, WBC 20.1 (N 86, 0 bands),
Hb 5.9 / Hct 19.0 (re-check 17), INR 4.1. U/A large blood, mod
bact, trace leuks. Patient was given 1 unit FFP, 2 units pRBCs,
vit K 10mg IM, and acetaminophen x1 for headache. She was seen
by GI who recommended reversing the INR, PPI drip, and NG lavage
(which patient refused), and blood cx's. She was sent to the
ICU with an 18g in R foot and 22g in R hand. No other available
peripheral access. Vitals on transfer: 97.1, 105/64, 72, 16 and
100% on 2L.
In the ICU, she is hemodynamically stable and is pleasant and
conversive, visiting with family. She still has a headache, but
has not had a melenotic stool yet.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations. Denies nausea, vomiting, diarrhea.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
1. Diabetes
2. Hypertension
3. Coronary artery disease
- MI [**2168**]
- PCI [**2173-6-29**]
- Cath [**7-21**]
4. Atrial fibrillation
5. CHF, EF 35% ([**Hospital1 112**] TTE on [**11/2182**]), LVH, mod TR/pulm HTN
6. PVD s/p multiple lower ext bypasses
7. CKD (baseline Cr 1.2)
8. Colonic adenoma (on [**2180-4-13**])
9. Anxiety
10. Gout
Social History:
Lives with daughter, spends most of the day alone, but has a
"lifeline" for emergencies. Able to get up and down her stairs
with some difficulty.
Occupation: homekeeper
Tobacco: quit in [**2178**], 10pack years,
EtOH: denies
Family History:
Lung cancer - son
CAD/PVD - mother, maternal grandmother
Physical Exam:
Vitals: T: 98.5, BP: 111/42, P: 57, R: 20, O2: 100% on 2L
General: Alert, oriented, no acute distress, pleasant
HEENT: NC/AT, PERRL, EOMI, sclera anicteric, conjunctivae pale,
dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregularly irregular, normal S1 + S2, II/VI holosystolic
murmur best heard over LLSB; no rubs or gallops
Abdomen: obese, soft, mildly tender in RUQ (no [**Doctor Last Name 515**]),
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly appreciated
GU: foley in place
Ext: trace edema B/L, right leg slightly cooler than the left,
1+ pulses; no clubbing, cyanosis; scarring from previous bypass
surgeries over left lower leg
Pertinent Results:
EGD ([**2184-4-8**]): Erythema and erosion in the stomach body
compatible with gastritis. Diverticulum in the unlcear -
somewhere between the second and fourth part of the duodenum.
Just proximal to the diverticulum a large necrotic area was seen
on the side wall of the duodenum. The full extent could not be
visualized. There was fresh and old blood pooling throughout the
duodenum with no obvious source. With extensive washing this was
confined to the regiion between the second and fourth portions
of the duodenum. There were several large clots in this area
preventing full visualzation of the underlying mucosa. Otherwise
normal EGD to third part of the duodenum.
.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2184-4-10**] Final Report
INDICATION: Recent GDA embolization. Assess for duodenal wall
ischemia.
TECHNIQUE: Axial imaging post-oral contrast medium was performed
from the
lung bases to pubic symphysis. Intravenous contrast was not
administered due to renal impairment.
FINDINGS: The majority of the oral contrast had passed through
the duodenum at the time of imaging. A 2.3 x 3.1 cm duodenal
diverticulum is present at the junction of D3 and D4 (series 2,
image 35). Oral contrast is retained within the diverticulum
with evidence of layering. No proximal obstruction is
identified. No intramural air is present and there is no
significant stranding around the duodenum. Embolization clips
are present in the gastroduodenal artery. .
Non-contrast imaging of the liver, spleen, pancreas are normal.
The
gallbladder appears distended and hyperdense. The increased
density is likely related to vicarious excretion of the contrast
from the embolization procedure. The renal cortex also appears
dense again likely related to delayed excretion of the contrast
from the embolization procedure. A 17-mm nodule is present in
the left adrenal gland with mean Hounsfield units of -100.
Features consistent with a myelolipoma. The right adrenal gland
is normal. Extensive colonic diverticulosis is present.
PELVIS: No small or large bowel obstruction. Diverticulosis as
noted above.
Review of the lung bases demonstrates right-sided linear
atelectasis with
pleural thickening. Minor pleural thickening is also present in
the left
base. Cardiomegaly is noted.
Bone review is unremarkable.
IMPRESSION: There is a duodenal diverticulum at the junction of
D3 and D4. The duodenal wall appears normal.
.
[**2184-4-21**] ABDOMEN (SUPINE & ERECT) Preliminary Report !! PFI !!
No evidence of obstruction or perforated viscus.
.
URINE CULTURE (Final [**2184-4-16**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 8 S <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
.
.
[**2184-4-7**] 11:14AM BLOOD WBC-20.1*# RBC-2.28*# Hgb-5.9*#
Hct-19.0*# MCV-83 MCH-25.9* MCHC-31.2 RDW-18.6* Plt Ct-307
[**2184-4-20**] 03:04AM BLOOD WBC-8.2 RBC-3.34* Hgb-9.8* Hct-28.4*
MCV-85 MCH-29.4 MCHC-34.5 RDW-16.8* Plt Ct-474*
[**2184-4-7**] 11:14AM BLOOD Glucose-156* UreaN-132* Creat-2.1* Na-137
K-4.8 Cl-103 HCO3-20* AnGap-19
[**2184-4-21**] 04:17AM BLOOD Glucose-162* UreaN-42* Creat-1.1 Na-138
K-4.5 Cl-106 HCO3-27 AnGap-10
[**2184-4-21**] 04:17AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.8
[**2184-4-21**] 04:17AM BLOOD Triglyc-186*
.
INR (On Warfarin 5 mg po q day since [**4-14**]); dose increased at
discharge.
[**4-17**] 1.3
[**4-19**] 1.5
3.9 1.3
Brief Hospital Course:
1. Gastrointestinal bleed. Presented with upper GI bleed
requiring massive transfusion (9 units within first 24 hours).
EGD showed large necrotic duodenal lesion of unclear nature.
After patient declined surgerical intervention, interventional
radiology performed angiography with prophylactic embolization
of the gastroduodenal artery.
Given desire to promote as much healing as possible, patient was
kept NPO and TPN was initiated. After bowel rest for ~week, oral
feeding was restarted and attempted to wean TPN off, however pt
continued to have poor po intake and some nausea with po intake.
GI is to see the patient in follow-up on [**2184-4-22**] with possible
repeat EGD for biopsy to be scheduled. Per discussion with
Gastroenterology consult, planning for EGD/biopsy approx [**7-20**]
weeks to allow stabilization of embolized territory.
Regarding anti-coagulation, given history of CAD with prior MI
and stenting, aspirin was felt ideal with low-dose (81 mg) used.
Similarly, given stroke risk in atrial fibrillation, warfarin
was restarted. She was started on Warfarin 5 mg po q day, but
her INR did not increase, so her dose was increased at discharge
to 7 mg po q day.
2. Congestive heart failure. No evidence of fluid overload on
admission, but did devlop some SOB and crackles after massive
transfusion in the ICU. At the time of discharge, remained off
furosemide with excellent saturations.
Her other chronic CHF medication, metoprolol, was also held
during much of the hospitalization. Initially this was in
setting of her GI bleed. Over the last days of admission, her HR
would range in the 40s-50s (asymptomatic) so it remained on
hold.
3. Acute on chronic renal failure. Elevated to 2.1 in the
setting of hypovolemia; improved with blood. Pt later developed
worsened Bun/Cr in the setting of treatment of UTI with Bactrim;
her Cr gradually improved after discontinuation.
4. Diabetes mellitus. Patient presented on high-dose of lantus
insulin. While NPO she did not require lantus and while on TPN
she recieved 15 units with each infusion.
5. Coronary artery disease. Aspirin as above. Metoprolol was
discontinued due to GI bleed and persistent bradycardia.
6. Right buttock pain. Chronic in nature. Used dilaudid/lyrica;
lidocaine patch was not helpful.
7. Urinary tract infection. Noted to have dysuria and positive
UA with bactrim sensitive e.coli. Pt received Bactrim for 3 days
with resolution of symptoms.
Communication: [**Name (NI) 46144**] [**Known lastname 174**] - son and HCP ([**Telephone/Fax (1) 46145**])
Code: Full (discussed with patient)
Medications on Admission:
Medications (confirmed with HCP and prior records):
*Calcium 600mg daily
*ASA 325mg daily
*Colace 100mg daily
*Coumadin 8mg daily
*Simvastatin 40mg daily
*Metoprolol 25mg [**Hospital1 **]
*Lasix 40mg QAM
*Lasix 40mg QAM (M,W,F)
*Lasix 20mg QPM (T,Th,[**Last Name (LF) **],[**First Name3 (LF) **])
*Omeprazole 20mg [**Hospital1 **]
*Allopurinol 100mg daily
*Lyrica 300mg daily
*Trazodone 50mg-100mg QHS
*Lantus 52 units qhs
*Novolog sliding scale
Discharge Medications:
1. calcium carbonate 600 mg (1,500 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. pregabalin 75 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
9. trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
10. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: Please see attached sliding scale.
11. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
13. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-15**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
1. Acute blood loss anemia
2. Duenodenal necrosis
3. GI bleeding
4. CAD, native vessel
5. Diabetes, type II, controlled with complications
6. CKD, stage II
7. Malnutrition, moderate
8. Atrial fibrillation
9. Urinary tract infection
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted with bleeding from your gastrointestinal tract
(possibly from a large necrotic lesion in the duodenum). After
many blood transfusions your blood counts have stabilized. Given
that you need to be on aspirin and coumadin long-term, it will
be important that you remain attentive to the possibility of
future bleeding.
Followup Instructions:
Rehabilitation will schedule a follow-up appointment with your
PCP.
Name: [**Last Name (LF) 26390**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: Gastroenterology
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Thursday, [**4-22**] at 2:40PM
|
[
"584.9",
"557.0",
"403.90",
"285.1",
"428.0",
"428.23",
"599.0",
"427.31",
"250.00",
"414.01",
"V58.61",
"V45.82",
"263.0",
"276.1",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"99.15",
"38.93",
"45.13",
"44.44"
] |
icd9pcs
|
[
[
[]
]
] |
12444, 12492
|
8165, 10754
|
275, 301
|
12768, 12858
|
3929, 8142
|
13277, 13701
|
3065, 3123
|
11250, 12421
|
12513, 12747
|
10780, 11227
|
12919, 13254
|
3138, 3910
|
2081, 2436
|
229, 237
|
329, 2062
|
12873, 12895
|
2458, 2806
|
2822, 3049
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,366
| 131,929
|
13031
|
Discharge summary
|
report
|
Admission Date: [**2106-12-6**] Discharge Date: [**2107-1-13**]
Date of Birth: [**2029-8-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2106-12-10**] Cardiac Catheterization
[**2106-12-13**] Aortic Valve Replacement(23mm Pericardial Tissue Valve)
[**2106-12-31**] Tracheostomy and PEG Placement
History of Present Illness:
This is a 77 year old female with known aortic stenosis and
congestive heart failure, who was transferred from [**Hospital1 5979**] with symptoms of shortness of breath. BNP at that time
was 500. ECHO in [**2106-10-24**] showed [**Location (un) 109**] of 0.8 square
centimeters, peak gradient of 49mmHg, and mean gradient of
30mmHg, with an LVEF of 60% and trace mitral regurgitation. She
reported chronic shortness of breath, and admitted to
progressive DOE, [**2-26**] pillow orthopnea and frequent lower
extremity edema. She denied history of syncope, palpitations,
and pre-syncope. She has a vague history of chest pain five
years ago with normal cardiac catheterization at that time.
Past Medical History:
Congestive Heart Failure, Aortic Stenosis, Hypertension, Type II
Diabetes Mellitus, Hypercholesterolemia, Chronic Renal
Insufficiency(baseline creatinine 1.8), Obstructive Sleep Apnea
- utilizes BiPAP, Osteoarthritis, Anemia, Left Eye Blindness,
History of Skin Cancer
Social History:
Quit tobacco 30 years ago. Denies ETOH.
Family History:
Denies family history of premature coronary artery disease.
Physical Exam:
Vitals on Admission T 98.4, HR 64, BP 135/51, RR 21, SAT 95% on
2L
General: Elderly female in no acute distress
HEENT: Edentulous, left eye cloudy, moist mucous membranes
Neck: Neck vein markedly elevated, transmitted murmurs noted
Heart: Regular rate and rhythm, [**5-29**] loud systolic murmur noted
throughout precordium radiates to neck, normal s1s2, s3 noted
Lungs: Crackles noted 3/4 up from bases bilaterally
Abdomen: obese, nontender, nondistended, normoactive bowel
sounds
Extremities: cool, 2+ edema bilaterally, ecchymotic areas noted
Neuro: Alert and oriented, CN 2-12 grossly intact, no focal
deficits
Pertinent Results:
[**2106-12-6**] 04:45PM BLOOD WBC-4.5 RBC-3.04* Hgb-9.4* Hct-28.7*
MCV-95 MCH-30.9 MCHC-32.7 RDW-16.9* Plt Ct-264
[**2106-12-6**] 04:45PM BLOOD PT-22.1* PTT-33.5 INR(PT)-2.2*
[**2106-12-6**] 04:45PM BLOOD Glucose-413* UreaN-59* Creat-2.6* Na-129*
K-4.9 Cl-96 HCO3-23 AnGap-15
[**2106-12-6**] 04:45PM BLOOD ALT-17 AST-18 AlkPhos-65 Amylase-52
TotBili-0.4
[**2106-12-6**] 04:45PM BLOOD %HbA1c-7.5* [Hgb]-DONE [A1c]-DONE
[**2106-12-6**] Chest X-ray: The heart is enlarged. Calcification of
the mitral annulus is present. There is evidence of failure with
bilateral effusions in upper zone redistribution.
[**2017-1-9**] ECHO:
Conclusions:
1. The left atrium is mildly dilated. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic
(EF>75%). There is a mild resting left ventricular outflow tract
obstruction.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.A bioprosthetic aortic valve prosthesis is present. The aortic
prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular
gradients. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is
seen.
6.Moderate [2+] tricuspid regurgitation is seen.
7.There is moderate pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
Brief Hospital Course:
Mrs. [**Known lastname 39896**] was admitted to cardiac surgical service and
underwent further evaluation and treatment. Given acute on
chronic renal insufficiency(creatinine 2.6 on admission), the
renal service was consulted. Her acute renal failure was
attributed to pre-renal azotemia for which diuretics were
titrated accordingly. The [**Last Name (un) **] service was also consulted to
assist in the management of her diabetes mellitus. Preoperative
diagonstics included carotid ultrasound and cardiac
catheterization. Given her renal insufficiency, she was
pre-treated with hydration and Mucomyst. Carotid ultrasound
found 60-69% stenosis of the left internal carotid artery.
Cardiac catheterization showed a left dominant system and normal
coronary arteries. Prior to surgical intervention, her renal
function improved with creatinine reaching 1.8. She otherwise
remained stable on medical therapy and was eventually cleared
for surgery. On [**12-13**], Dr. [**Last Name (STitle) 1290**] performed an aortic
valve replacement. For further surgical details, please see
seperate dictated operative note. Following the operation, she
was brought to the CSRU for invasive monitoring.
.
Pt was followed post-op by Renal and [**Last Name (un) **]. Pt was awake on
POD 2 and vent was weaned. Pt was extubated but quickly went
into respiratory failure and was reintubated. POD 4 pt on
natricor and UOP dwindled. Pt noted to be in ARF and CHF. POD 5
pt into Afib, converted to NSR with amiodarone. On lasix and
insulin drips, continued oliguria w/ increasing creatinine.
Hemodialysis started on POD 7 ([**12-20**]). POD 8 pt extubated, and
quickly reintubated for resp. failure. Pt in Afib and rate
controlled. PT on tube feeds. POD 9 family meeting held. POD
10 pt started on CVVHDF. POD 11 pt on pressor. POD 13 pt
extubated and CCVVH stopped. Derm consulted for a worsening rash
and hemorrhagic bullae, biopsies taken. Pathology returned
suggesting linear IgA disease possibly due to vancomycin used
peri-operatively. Vanco stopped. POD 15 CVVH restarted.
Ciprofloxacin started for UTI x5 days, foley removed. Pt failed
bedside swallow eval. POD 18 pt again in respiratory failure on
BiPAP, required reintubation and Thoracic surgery was consulted
for Trach/PEG. Pt taken for operation, tolerated well, but
became hypothermic and required continued pressor support. Tube
feeds were held until POD 22/4. POD 23/5 pt found to be HIT
positive. CVVH stopped and Cipro started for GNR in sputum.
POD 24/6 pt spike temp, diflucan started. Argatroban started.
POD 26/8 Daptomycin started for continued fevers and GPC on a
catheter tip. Hematology consulted to manage Argatroban and ID
consulted for positive cultures. POD 28/10 all central
catheters removed. POD 30/12 pt made CMO. At 0010 on [**1-13**]
(POD 31/13) pt died.
Medications on Admission:
Toprol XL 200 qd, Imdur 60 qd, Lasix 40 IV qd, Prozac 20 qd,
Warfarin 2.5 qd, Zocor 40 qd, Epogen, Norvasc 10 qd, Plaquenil
200 qd, Glipizide 10 [**Hospital1 **], Aspirin
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Severe AS s/p aortic valve replacement
CHF
ARF/CRI (baseline Cr 1.8)
DM2
Skin CA
arthritis
OS blindness
HIT
respiratory failure s/p tracheostomy
post op anemia
sepsis
Linear IgA dermatosis
Obstructive Sleep Apnea
hyperlipidemia
hypertension
left carotid stenosis
AFib
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"403.91",
"518.5",
"584.5",
"790.7",
"996.62",
"250.00",
"398.91",
"427.31",
"709.8",
"396.3",
"369.60",
"585.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.07",
"99.05",
"99.04",
"86.11",
"43.11",
"37.22",
"39.61",
"88.56",
"00.13",
"31.1",
"96.6",
"39.95",
"93.90",
"88.72",
"33.22",
"38.95",
"96.72",
"35.21",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6826, 6841
|
3729, 6576
|
301, 464
|
7152, 7162
|
2259, 3706
|
7219, 7230
|
1547, 1608
|
6797, 6803
|
6862, 7131
|
6602, 6774
|
7186, 7196
|
1623, 2240
|
242, 263
|
492, 1182
|
1204, 1474
|
1490, 1531
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,677
| 111,600
|
45899+58867
|
Discharge summary
|
report+addendum
|
Admission Date: [**2172-11-14**] Discharge Date: [**2172-11-23**]
Date of Birth: [**2088-7-18**] Sex: M
Service: MEDICINE
Allergies:
Amitiza / Oxybutynin / Bactrim
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
Chest pain, diarrhea, "feeling lousy"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 year old male with CAD s/p CABG and bovine AVR, T2DM,
hypotonic bladder with chronic foley and chronic cystitis who
presents with chest pain, diarrhea, and feeling lousy.
.
His last admission for chest pain was [**7-25**] and it was felt to
be due to GERD or gas/constipation and was recommended an
exercise stress test as an outpatient. He was last admitted to
the hospital [**8-25**] with weakness and falls of unclear etiology.
He has had 8 ED visits since that admission, typically for
dysuria and abdominal pain. He was seen in the ED yesterday for
UTI, worsening of a fungal groin infection and balanitis and
discharged to rehab. There are plans for suprapubic catheter
placement with urology next week due to his frequent UTIs and
fungal infections. He has been treated with Macrobid and
fluconazole intermittently since [**9-25**] and has a h/o ESBL E
Coli.
.
Today he reports that he started to "feel lousy" at rehab. He
developed diarrhea (2 episodes) that was nonbloody. Also had 2
episodes of vomiting, also nonbloody. After that, he developed
substernal chest pressure that moves across his chest. Denies
SOB, but endorses diaphoresis associated with the diarrhea and
vomiting. Also continues to complain of lower abdominal pain,
which is suprapubic and unchanged in character from his prior
presentations. Denies fevers, but states he has had chills. He
denies change in weight, PND, orthopnea.
.
Per rehab notes, he also complained of SOB and O2 sat decreased
to 88% on room air and improved with O2. Now denies SOB.
.
In the ED, initial VS were 98.0 60 111/64 16 99% 2L. Labs were
notable for troponin of 0.05 (baseline) and ECG showed NSR with
resolved RBBB. He was also given 1L IV fluids. Was guaiac
negative. UA was positive and he was given Macrobid. Given ASA
81mg x 4. Most recent vitals 95.6 64 106/62 18 93-97%2L
.
Review of systems:
(+) Per HPI. Also c/o chronic cough at night.
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied shortness of breath. Denied palpitations. Denied
arthralgias or myalgias.
Past Medical History:
1. Hypotonic hyposensitive bladder with incomplete emptying, s/p
indwelling foley since [**1-24**] c/b frequent Multidrug resistent
UTIs, incl MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in [**2158**]
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting [**2164**] of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in [**4-22**] with Dr. [**Last Name (STitle) 2230**].
4. Bovine AVR in [**4-22**]
5. Type 2 Diabetes Mellitus
6. Hypertension
7. Hx of Chronic constipation
8. Hyperlipidemia
9. Depression /Anxiety
10. Asbestosis
11. Spinal stenosis
12. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
13. Osteoarthritis
14. Carotid stenosis - chronic occlusion of [**Doctor First Name 3098**], [**Country **] with 40%
stenosis
Social History:
lives with daughter, her long term boyfriend, grandson. Wife
died several years ago. Retired from [**Country **] and from construction.
Distant tobacco use, denies EtOH or IVDU. Does to adult daycare
few days a week.
Family History:
Daughter died at 48 of breast cancer. Father died from MI in his
70s.
Physical Exam:
Vitals: 95.9 104/66 58 22 94%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to lower jawline, no LAD
Lungs: Rhonchi at right base with thin rales bilaterally at the
bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to palpation over suprapubic area,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pitting edema bilaterally up to
calfs with mild erythema that appears chronic
GU: Erythematous patches in bilateral folds of groin and
erythema and mild swelling of the head of the penis, foley in
place
.
Pertinent Results:
Admission Labs:
[**2172-11-13**] 09:57AM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-FEW
EPI-0
[**2172-11-13**] 09:57AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2172-11-13**] 09:57AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2172-11-13**] 09:57AM PLT COUNT-166
[**2172-11-13**] 09:57AM NEUTS-70.3* LYMPHS-21.3 MONOS-4.6 EOS-2.9
BASOS-1.0
[**2172-11-13**] 09:57AM WBC-5.2 RBC-5.19 HGB-15.0 HCT-44.7 MCV-86
MCH-28.8 MCHC-33.5 RDW-17.4*
[**2172-11-13**] 09:57AM GLUCOSE-124* UREA N-17 CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
.
Imaging:
CT abd/pelvis [**11-13**]: Stable appearence of enhancing right renal
mass concerning for renal cell Ca. Stable small left hydrocele.
Bilateral fat containing inguinal hernias. No acute pathology.
.
CXR (my read)): mild to moderate pulmonary edema, left elevated
hemidiaphragm, obscured right heart border
Inpatient Labs:
[**2172-11-20**] 08:00AM BLOOD WBC-5.7 RBC-5.10 Hgb-14.7 Hct-44.2 MCV-87
MCH-28.8 MCHC-33.2 RDW-17.5* Plt Ct-198
[**2172-11-20**] 08:00AM BLOOD Neuts-67.8 Lymphs-21.0 Monos-6.2 Eos-4.4*
Baso-0.7
[**2172-11-20**] 08:00AM BLOOD Plt Ct-198
[**2172-11-20**] 08:00AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.7
[**2172-11-19**] 08:00AM BLOOD PT-14.5* PTT-29.7 INR(PT)-1.3*
[**2172-11-20**] 08:00AM BLOOD Glucose-103* UreaN-15 Creat-0.9 Na-140
K-3.8 Cl-100 HCO3-32 AnGap-12
[**2172-11-15**] 04:58PM BLOOD ALT-20 AST-29 CK(CPK)-56 AlkPhos-74
TotBili-0.6
[**2172-11-15**] 04:58PM BLOOD CK-MB-4 cTropnT-0.04*
[**2172-11-15**] 12:37PM BLOOD Type-ART pO2-78* pCO2-49* pH-7.37
calTCO2-29 Base XS-1
[**2172-11-15**] 12:37PM BLOOD Lactate-1.3
Brief Hospital Course:
84 year old male with CAD s/p CABG and bovine AVR, T2DM,
hypotonic bladder with chronic foley and chronic cystitis who
presents with chest pain, diarrhea, and overall malaise.
.
# Complicated UTI: History of Vanc Sensitive Enterococci & ESBL
E.Coli.
The patient arrived with the following prior labwork: urine cx
from [**10-30**] was known to have ESBL E coli and VSE, urine cx from
[**11-13**] that ultimately grew ESBL E coli and yeast. Admitted to
the floor normotensive. Treated with [**Last Name (un) 2830**] given mico history,
and broadened to Vanc in the acute setting of hypotension. Vanc
was subsequently discontinued once the patient stabilized and
urine culture was negative. Completed inpatient [**Last Name (un) 2830**] course for
6 days.
.
# Labile blood pressure: Several hours after being admitted to
the floor, triggered for BP in the low 80s, subjective malaise /
lethargy, and decreased attention. ABG was reassuring. Was
transiently responsive to fluid boluses but because of
refractory hypotension and concern for urosepsis, transferred to
the MICU for observation; flagyl was empirically started because
of concern for C.Dif. While in the MICU remained hemodynamically
stable with SBP in the low 100s and satting 93% on 2L, never
requiring pressors; returned to the floor in < 24h. As discussed
above, vanc was discontinued; flagyl was also stopped once
clinically stable.
.
#. Diarrhea, lower abdominal pain, bladder spasm:
His pain was localized to his upper midline groin, and was
ultimately attributed to bladder spasm. Given patient's history
of antibiotic use, C.dif was considered when hypotensive;
started on empiric flagyl therapy in the acute setting of labile
pressures as discussed above. The patient did not produce any
stools for culture/guaiac after transfer from MICU even with
bowel regimen. C.Dif was never confirmed; Flagyl was
discontinued.
.
# Recurrent UTI s/p suprapubic catheter: Underwent placement of
a suprapubic catheter [**2172-11-20**] with urology for recurrent UTIs
and bladder spasm. Will follow-up with Dr. [**Last Name (STitle) **] 8 weeks after
discharge per urology.
.
# Hypoxia / Possible infiltrate on CXR:
Possible infiltrate on CXR: Patchy R Base infiltrate on CXR on
admission was concerning for PNA and in the setting of labile
pressures, was empirically covered with meropenem. Resolution of
hypotension and symptomatic improvement with improvement of UTI
was reassuring for the patient not having a pulmonary process.
Saturations were in the low 90s on RA on discharge.
.
#. Atypical, non-specific chest pain:
Presentation per the patient's usual non-specific CP. CK & Trop
flat x 3. Echo EF > 50%. No ECG changes. Pain was reproducible
with palpation pointing to it likely being MSK in etiology.
.
# Post-procedure hypoxia and CAD: Became hypoxic after placement
of the suprapubic catheter, thought to be due to volume overload
from IVF administered during the procedure. CXR was suggested of
pulmonary edema. Hypoxia improved with diuresis. The day of
discharge a nuclear stress test was performed that showed a
partially reversible inferior wall defect with associated
hypokinesis and reversible low inferolateral ischemia associated
with hypokinesis; EF was 43% from 63% in [**2164**] and EDV was
elevated at 104cc. Results were discussed with Dr. [**Last Name (STitle) **] who
deferred invasive intervention this admission; the patient was
sent home on medical management, including statin, ASA,
atenolol, ACEi. He has a long history of medication non
compliance and would not be a candidate for more aggressive
interventions at this time.
.
#. tinea cruris:
The patient was given topical Miconazole Powder 2% as needed.
The groin infection was likely fungal in etiology.
.
# Conjunctivitis:
The patient was observed to have injected conjunctiva on [**11-19**]
with thick white discharge bilaterally. Although he was
asymptomatic, he was given Bacitracin/Polymyxin B Sulfate
Ophthalmic Ointment for a 7 day course to cover for bacterial
conjunctivitis.
.
#. Hypertension:
The patient was restarted on his lisinopril following transfer
from the MICU back to the medicine floor and discharged on his
previously prescribed regimen.
.
# Diabetes mellitus:
The patient was kept on humalog insulin sliding scale with good
glycemic control. He was discharged on no oral hypoglycemics or
insulin per Dr. [**Last Name (STitle) **].
.
# CAD:
Med management of CAD with home dose atenolol and ASA 81mg po
daily.
Medications on Admission:
-Atenolol 25mg po daily
-Atorvastatin 80mg po daily
-Citalopram 40mg po daily
-Econazole 1% Cream to groin twice daily
-Lisinopril 20mg po daily
-Trazodone 50-75mg po daily
-ASA 81mg po daily
-Bisacodyl 10mg po daily prn
-Docusate 100mg po bid
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. econazole 1 % Cream Sig: One (1) application Topical twice a
day: to groin [**Hospital1 **].
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
solution Injection TID (3 times a day): If not ambulating daily.
10. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours) for 6 days.
11. trazodone 50 mg Tablet Sig: 1-1.5 Tablets PO once a day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary Diagnoses:
Antibiotic resistant urinary tract infection associated with
urinary catheter
Bladder spasm
Secondary Diagnoses:
Diabetes Mellitus type 2
Coronary Artery Disease
High blood pressure
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:
It has been a privilege to take care of you in the hospital.
You were hospitalized because of a recurrent urinary tract
infection, which you were susceptible to developing because you
had an indwelling foley catheter in your penis. Your infection
was treated with IV antibiotics and your condition improved.
You had lower abdominal pain this admission as well, which we
believe was caused partially by your urinary tract infection.
This pain improved with IV antibiotics but did not resolve
completely because of your chronic bladder spasm. You underwent
a procedure this hospitalization to place a urinary catheter
into your bladder through your lower abdomen. This catheter
should improve your abdominal pain and also make you less
susceptible to infection.
During this hospitalization you had low blood pressures, which
may have been caused by your infection, although this is not
certain because no cultures have grown any bacteria. You were
briefly transferred to the ICU for close observation and fluids
until your blood pressure returned to [**Location 213**].
You had chest discomfort prior to this admission and difficulty
breathing as well. We performed numerous tests which showed that
you were not having a heart attack.
No changes were made to your medications other than as detailed
below. Please take your medications as previously prescribed.
# START Polymixin eye ointment for conjunctivitis - for 6 days
Please attend your follow-up appointments as detailed below.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2173-1-13**] at 2:00 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname 15601**],[**Known firstname 2481**] Unit No: [**Numeric Identifier 15602**]
Admission Date: [**2172-11-14**] Discharge Date: [**2172-11-23**]
Date of Birth: [**2088-7-18**] Sex: M
Service: MEDICINE
Allergies:
Amitiza / Oxybutynin / Bactrim
Attending:[**First Name3 (LF) 14946**]
Addendum:
Let the record reflect the following changes to this discharge
summary:
# Acute decompensation of Systolic CHF: The patient's pulmonary
edema was like the result of the patient having an acute
decompensation of systolic CHF as detailed in the above bullet
entitled # Post-procedure hypoxia and CAD.
# Hypotension: The patient's hypotension was due to hypovolemia
NOT due to sepsis. Although he was managed accordingly due to
initial concern for sepsis in the setting of known UTI, sepsis
was ultimately ruled out when the patient responded to a modest
IVF bolus.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14947**] MD [**MD Number(2) 14948**]
Completed by:[**2173-1-18**]
|
[
"250.00",
"112.3",
"041.4",
"300.4",
"501",
"428.21",
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"599.0",
"564.09",
"428.0",
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"401.9",
"V45.81",
"272.4",
"433.10",
"799.02",
"596.8",
"996.64",
"414.01",
"E879.6",
"372.00",
"600.00",
"596.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.17"
] |
icd9pcs
|
[
[
[]
]
] |
15106, 15359
|
6074, 10553
|
331, 337
|
12139, 12139
|
4337, 4337
|
13835, 15083
|
3535, 3606
|
10848, 11776
|
11914, 12026
|
10579, 10825
|
12322, 13812
|
3621, 4318
|
12047, 12118
|
2227, 2477
|
254, 293
|
365, 2208
|
4354, 6051
|
12154, 12298
|
2499, 3283
|
3299, 3519
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
470
| 188,804
|
19452
|
Discharge summary
|
report
|
Admission Date: [**2132-4-1**] Discharge Date: [**2132-4-6**]
Date of Birth: [**2061-2-20**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
male, who had an episode of chest pain on [**2132-1-11**].
He was admitted to an outside hospital and ruled out for
myocardial infarction. He stated that he had increased
dyspnea on exertion starting in [**2131-12-31**].
He saw his primary care physician who referred him to a
cardiolgoist. His exercise tolerance test showed ischemia.
An echocardiogram was done at Dr.[**Name (NI) 52851**] office.
Cardiac catheterization was performed on the 13th which
showed a calcified left main, calcified left anterior
descending with a 70% lesion at the diagonal I, circumflex
lesion of 80%, right coronary artery totally occluded at
100%, with an ejection fraction of 65-70%. Please refer to
the official cardiac catheterization report.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia.
3. Peripheral vascular disease with known carotid disease.
4. Bilateral CEA, left and right, in [**2131**]. 5.
Gastroesophageal reflux disease. 6. Squamous cell carcinoma
in [**2125**] status post radiation therapy and chemotherapy.
MEDICATIONS ON ADMISSION: Nifedipine 60 mg p.o. q.d.,
Metoprolol 50 mg p.o. b.i.d., Norvasc 2.5 mg p.o. q.d.,
Isosorbide 60 mg p.o. q.d., Gemfibrozil 600 mg p.o. b.i.d.,
Lovastatin 40 mg p.o. b.i.d., Folic Acid p.o. q.d., Pepcid
a.c. 10 mg p.o. q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES, BUT HE STATED THAT
NITROGLYCERIN SOMETIMES DROPS HIS HEART RATE.
SOCIAL HISTORY: He discontinued smoking 22 years prior. He
drinks alcohol only on social occasions.
PHYSICAL EXAMINATION: Vital signs: Height 5 ft 7 in, weight
175 lb. Heart rate 76, respirations 20, blood pressure
160/80. Neck: No jugular venous distention or bruits.
Chest: Clear. There was an old healed PermCath site on his
chest wall. Heart: Regular, rate and rhythm. Abdomen:
Positive bowel sounds. No hepatosplenomegaly. Extremities:
No clubbing, cyanosis, or edema. Peripheral pulses were
present throughout. No varicosities. Neurological:
Nonfocal.
The patient was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] for
coronary artery bypass grafting.
IMAGING: Preoperative chest x-ray showed minimal atelectasis
or scar in the right middle lobe with no other
cardiopulmonary abnormality.
LABORATORY DATA: Preoperative lab values revealed a white
count of 8.9, hematocrit 44.1, platelet count 194,000; PT
13.4, PTT 27.8, INR 1.2; negative urinalysis; sodium 140,
potassium 4.2, chloride 102, bicarb 27, BUN 16, creatinine
1.0, blood sugar 90, anion gap 15; ALT 15, AST 15, alkaline
phosphatase 115, total bilirubin 0.6, total protein 8.2,
albumin 4.6, globulin 3.6.
HO[**Last Name (STitle) **] COURSE: On [**4-1**], the day of admission, the
patient underwent coronary artery bypass grafting times three
by Dr. [**Last Name (Prefixes) **] with a LIMA to the left anterior
descending, vein graft to the obtuse marginal and a vein
graft to the posterior descending artery. The patient was
transferred to the Cardiothoracic Intensive Care Unit in
stable condition.
On postoperative day #1, the patient had been extubated at 11
p.m. the night prior. He was on a Nitroglycerin drip at 0.3
mcg/kg/min. He started his Aspirin. His incision drip,
which was at 2 U/hr was weaned to off. He was receiving
Morphine and Percocet for pain. He continued his
perioperative Kefzol.
His pulse was 83 in sinus rhythm with a blood pressure of
120/46. His arterial blood gases was 7.36, 40, 119, 24, -2.
He had an oxygen saturation of 100% on 4 L nasal cannula. He
was alert and oriented.
Postoperative labs revealed a white count of 17.1, hematocrit
27.7, platelet count 172,000; sodium 142, potassium 4.1,
chloride 114, bicarb 23, BUN 16, creatinine 0.9, blood sugar
104. He was awake and in no apparent distress. Heart was
regular, rate and rhythm. His sternal incision was clean,
dry, and intact. Chest tubes were in place. His lungs were
clear bilaterally. His left leg dressing was clean, dry, and
intact.
He was transferred out to the floor on the morning of
postoperative day #1. He was seen by Case Management. He
received pain medication for discomfort.
On postoperative day #2, he began Lasix diuresis and began
beta-blockade with Metoprolol 12.5 mg p.o. b.i.d. He was
also started on Aspirin. He finished his perioperative
Kefzol. He started his Percocet and Ranitidine. His blood
pressure was 160/66. He was in sinus rhythm, tachycardiac at
114, with an oxygen saturation of 96% on 2 L nasal cannula.
His chest tubes remained in place for some drainage. They
were switched to water seal. He continued to have a little
bit of hematuria. The issue was raised of whether to obtain
a GU consult.
He began to work with Physical Therapy on his ambulation and
continued to do well on the floor managing his pain with p.o.
medications and some Dilaudid, in addition to Percocet.
He went into atrial fibrillation once which resolved within
15 min with intravenous Lopressor, and p.o. Lopressor was
given in addition to his morning dose.
On postoperative day #3, his chest tubes were pulled, and he
had a pneumothorax on chest x-ray. He was breathing
comfortably. He had no other events over night. He was
started on Amiodarone and was on 400 t.i.d. for his atrial
fibrillation. He was back in normal sinus rhythm in the
morning with a heart rate of 79 and a pressure of 110/58 and
was hemodynamically stable. He continued on his Aspirin,
Lasix, and Metoprolol which was increased to 50 mg p.o.
b.i.d., as well as pain control medication.
He had an oxygen saturation of 97% on room air with a
respiratory rate of 20. Hematocrit was 26.3, white count
14.3, potassium 4.9, BUN 24, creatinine 1.2.
His lungs were clear bilaterally. His wounds were clean,
dry, and intact. His abdominal exam was benign. His heart
was regular, rate and rhythm. He was not in any distress.
A chest x-ray was ordered. Metoprolol was increased to 75
p.o. b.i.d., and a rehabilitation screen was begun.
He was seen by GU on Urology consult on [**4-4**] who
recommended sending urine for cytology to rule out any
malignancy and recommended follow-up CT of the abdomen and
pelvis to rule out malignancy and checking PSA level. The
patient was assigned to Dr. [**Last Name (STitle) 770**] for follow-up
postoperatively as an outpatient.
The patient was also seen and continued to work with Physical
Therapy on postoperative day #4. The patient continued with
his beta-blockade and Amiodarone with normal sinus rhythm at
70 with a blood pressure of 128/51. His chest x-ray did show
a bilateral pneumothorax with right greater than left. He
had an oxygen saturation of 94% on room air with a stable
white count of 11.3 and hematocrit of 23.7, BUN of 30, and
creatinine of 1.2.
His exam was benign. His chest was stable. His heart was
regular, rate and rhythm. His lungs were clear. Incisions
were clean, dry, and intact. He was transfused 1 U packed
red blood cells for a hematocrit of 22. Rehabilitation
screen continued.
On postoperative day #5, chest x-ray showed that the
pneumothorax was stable. He was hemodynamically stable in
sinus rhythm at 70 with a blood pressure of 121/44, with an
oxygen saturation of 95% on room air with adequate urine
output. His CBC from the day prior showed a white count of
10.4, hematocrit 23.0, and a platelet count of 131,000.
He was at level 4. His telemetry was discontinued, and the
patient was discharged to home in stable condition with VNA
services on [**2132-4-6**].
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting times three.
2. Hypertension.
3. Hyperlipidemia.
4. Peripheral vascular disease.
5. Status post bilateral carotid endarterectomies in [**2131**].
6. Gastroesophageal reflux disease.
7. Squamous cell carcinoma in [**2125**] status post radiation
therapy and chemotherapy.
FO[**Last Name (STitle) **]P: The patient was instructed to make a follow-up
appointment with Dr. [**Last Name (Prefixes) **] and see him in the office
four weeks postdischarge and follow-up with his cardiologist
and internist, Dr. [**First Name (STitle) 3613**] .................., and also to
follow-up with Dr. [**Last Name (STitle) 770**] of Urology.
DISCHARGE MEDICATIONS: Aspirin enteric coated 325 mg p.o.
q.d., Colace 100 mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d. for
5 days, Potassium Chloride 20 mEq p.o. b.i.d. for 5 days,
Dilaudid 2 mg p.o. p.r.n. q.3-4 hours as needed for pain,
Amiodarone 400 mg p.o. t.i.d. for 1 week, followed by
Amiodarone 400 mg p.o. b.i.d. for 1 week, followed by
Amiodarone 200 mg p.o. b.i.d. x 1 week, and then per the
instructions of the cardiologist for further Amiodarone
therapy, Metoprolol 75 mg p.o. b.i.d.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2132-6-10**] 13:33
T: [**2132-6-10**] 13:34
JOB#: [**Job Number 52852**]
|
[
"414.01",
"413.9",
"401.9",
"V10.83",
"440.21",
"599.7",
"E878.2",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8440, 9174
|
7709, 8416
|
1274, 1602
|
1728, 7688
|
182, 946
|
969, 1247
|
1619, 1705
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,444
| 115,027
|
28568
|
Discharge summary
|
report
|
Admission Date: [**2175-10-12**] Discharge Date: [**2175-11-17**]
Date of Birth: [**2151-6-30**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
Motor vehicle collision.
Major Surgical or Invasive Procedure:
[**10-12**]: Patient admitted. Went to OR for ex fix. of right leg. R
needle decompression and CT placed for decr BP in OR, no rush of
air. In OR w/ ortho/vascular for ex-fix, angiography. [**10-13**]:
[**10-15**]: new subclavian line. increasing temp. Knee aspirated. New
R. sub clav. Vanc/Zosin started (cefazolin/levo d/c)
[**10-16**]: IVC filter placement. Reconstruction of RLE by Ortho. In
ICU.
[**10-18**]: Pt. operated on for hand and femur. Extubated. In ICU
[**2175-10-20**] WV placed to R. LE
[**10-24**]: Pt taken to OR for latissimus free flap to R. LE
History of Present Illness:
24 y/o male s/p MVC [**2175-10-12**] - unrestrained, multiple rollover
ejecteed 40 feet. Patient transported by lifeflight
intubated.(GCS 13 in the field). Gross right leg deformity with
a pulseless right.
Past Medical History:
NIDDM
Social History:
Musician, +tob, +MJ
Family History:
non-contributory
Physical Exam:
VS: 112, 123/73
GEN: intubated, sedated
Neuro: E4VtM6
HEENT:pupils 3+ bilaterally
CV: tachy, no murmurs
Pulm: BS bilaterally
Abd/GI:
GU/flank: R flank abrasions
Ext: gross R leg deformity, bone visible, + R popliteal pulse,
no DP pulse on R. laceration on anterior aspect R thigh; R
should abrasions
Skin: ashen, multiple abrasions
Pertinent Results:
[**2175-10-12**] 11:35PM TYPE-ART PO2-124* PCO2-48* PH-7.32* TOTAL
CO2-26 BASE XS--1
[**2175-10-12**] 11:35PM LACTATE-5.1*
[**2175-10-12**] 11:27PM GLUCOSE-133* UREA N-13 CREAT-0.9 SODIUM-142
POTASSIUM-4.9 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14
[**2175-10-12**] 11:27PM CK(CPK)-9819*
[**2175-10-12**] 11:27PM CK-MB-111* MB INDX-1.1 cTropnT-<0.01
[**2175-10-12**] 11:27PM CALCIUM-7.3* PHOSPHATE-5.2* MAGNESIUM-2.0
[**2175-10-12**] 11:27PM WBC-10.1# RBC-3.12* HGB-10.1* HCT-27.4*
MCV-88 MCH-32.3* MCHC-36.8* RDW-14.8
[**2175-10-12**] 11:27PM PLT COUNT-116*
[**2175-10-12**] 11:27PM PT-13.5* PTT-31.9 INR(PT)-1.2*
[**2175-10-12**] 09:21PM TYPE-ART PO2-91 PCO2-42 PH-7.33* TOTAL CO2-23
BASE XS--3
[**2175-10-12**] 07:54PM TYPE-ART PO2-130* PCO2-46* PH-7.32* TOTAL
CO2-25 BASE XS--2
[**2175-10-12**] 07:54PM LACTATE-4.5*
[**2175-10-12**] 07:54PM freeCa-1.20
[**2175-10-12**] 07:44PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]->=1.035
[**2175-10-12**] 07:44PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2175-10-12**] 07:44PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2175-10-12**] 07:44PM URINE GRANULAR-0-2
[**2175-10-12**] 07:36PM GLUCOSE-114* UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-5.3* CHLORIDE-111* TOTAL CO2-23 ANION GAP-12
[**2175-10-12**] 07:36PM CALCIUM-8.1* PHOSPHATE-5.6* MAGNESIUM-2.1
[**2175-10-12**] 07:36PM HCT-30.7*
[**2175-10-12**] 07:36PM PT-12.5 PTT-29.9 INR(PT)-1.1
[**2175-10-12**] 05:46PM TYPE-ART PEEP-16 PO2-108* PCO2-44 PH-7.32*
TOTAL CO2-24 BASE XS--3 INTUBATED-INTUBATED
[**2175-10-12**] 05:46PM LACTATE-4.6*
[**2175-10-12**] 03:52PM PO2-83* PCO2-30* PH-7.36 TOTAL CO2-18* BASE
XS--6
[**2175-10-12**] 03:52PM LACTATE-3.5*
[**2175-10-12**] 03:52PM freeCa-0.96*
[**2175-10-12**] 03:45PM GLUCOSE-102 UREA N-13 CREAT-0.9 SODIUM-142
POTASSIUM-5.2* CHLORIDE-112* TOTAL CO2-23 ANION GAP-12
[**2175-10-12**] 01:01PM OTHER BODY FLUID AMYLASE-0
[**2175-10-12**] 01:01PM OTHER BODY FLUID WBC-0 RBC-3556* POLYS-67*
LYMPHS-5* MONOS-23* MACROPHAG-5*
[**2175-10-12**] 12:19PM TYPE-ART PO2-156* PCO2-40 PH-7.34* TOTAL
CO2-23 BASE XS--3
[**2175-10-12**] 12:19PM LACTATE-4.7*
[**2175-10-12**] 12:11PM GLUCOSE-118* UREA N-13 CREAT-1.0 SODIUM-146*
POTASSIUM-5.3* CHLORIDE-114* TOTAL CO2-22 ANION GAP-15
[**2175-10-12**] 12:11PM CALCIUM-7.8* PHOSPHATE-4.6* MAGNESIUM-1.6
[**2175-10-12**] 12:11PM WBC-4.3 RBC-3.60*# HGB-11.6*# HCT-31.6*#
MCV-88 MCH-32.3* MCHC-36.8* RDW-14.6
[**2175-10-12**] 12:11PM PLT COUNT-130*
[**2175-10-12**] 12:11PM PT-14.0* PTT-35.6* INR(PT)-1.2*
[**2175-10-12**] 09:56AM TYPE-ART PO2-115* PCO2-49* PH-7.24* TOTAL
CO2-22 BASE XS--6
[**2175-10-12**] 09:56AM LACTATE-4.1*
[**2175-10-12**] 09:56AM freeCa-1.07*
[**2175-10-12**] 09:39AM GLUCOSE-134* UREA N-12 CREAT-0.9 SODIUM-144
POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-24 ANION GAP-12
[**2175-10-12**] 09:39AM ALT(SGPT)-45* AST(SGOT)-98* LD(LDH)-357*
CK(CPK)-2794* ALK PHOS-34* AMYLASE-33 TOT BILI-0.5
[**2175-10-12**] 09:39AM LIPASE-24
[**2175-10-12**] 09:39AM CK-MB-38* MB INDX-1.4 cTropnT-0.13*
[**2175-10-12**] 09:39AM ALBUMIN-2.2* CALCIUM-8.1* PHOSPHATE-4.6*
MAGNESIUM-1.4*
[**2175-10-12**] 09:39AM WBC-3.6*# RBC-2.80*# HGB-8.9*# HCT-24.9*#
MCV-89 MCH-31.6 MCHC-35.6* RDW-14.9
[**2175-10-12**] 09:39AM PLT COUNT-142*#
[**2175-10-12**] 09:39AM PT-15.3* PTT-42.4* INR(PT)-1.4*
[**2175-10-12**] 08:26AM TYPE-ART PO2-87 PCO2-46* PH-7.29* TOTAL
CO2-23 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED
[**2175-10-12**] 08:07AM HGB-7.8* calcHCT-23
[**2175-10-12**] 08:07AM freeCa-1.08*
[**2175-10-12**] 07:34AM WBC-9.6# RBC-1.96* HGB-6.3*# HCT-17.6*#
MCV-90# MCH-31.9 MCHC-35.6* RDW-15.4
[**2175-10-12**] 07:34AM PLT SMR-VERY LOW PLT COUNT-70*#
[**2175-10-12**] 07:34AM PT-21.5* PTT-71.3* INR(PT)-2.1*
[**2175-10-12**] 07:34AM FIBRINOGE-81*
[**2175-10-12**] 06:22AM TYPE-ART PO2-297* PCO2-40 PH-7.30* TOTAL
CO2-20* BASE XS--5
[**2175-10-12**] 06:22AM GLUCOSE-89 LACTATE-5.2* NA+-138 K+-3.8
CL--118*
[**2175-10-12**] 06:22AM HGB-8.6* calcHCT-26
[**2175-10-12**] 06:22AM freeCa-1.07*
[**2175-10-12**] 05:16AM TYPE-ART PO2-241* PCO2-43 PH-7.19* TOTAL
CO2-17* BASE XS--11
[**2175-10-12**] 05:16AM GLUCOSE-116* LACTATE-5.3* NA+-138 K+-3.9
CL--119*
[**2175-10-12**] 05:16AM HGB-9.9* calcHCT-30
[**2175-10-12**] 05:16AM freeCa-1.20
[**2175-10-12**] 04:38AM TYPE-ART PO2-279* PCO2-46* PH-7.21* TOTAL
CO2-19* BASE XS--9 INTUBATED-INTUBATED
[**2175-10-12**] 04:38AM GLUCOSE-122* LACTATE-5.5* NA+-138 K+-3.9
CL--119*
[**2175-10-12**] 04:38AM HGB-8.7* calcHCT-26
[**2175-10-12**] 04:38AM freeCa-1.07*
[**2175-10-12**] 03:55AM TYPE-ART PO2-193* PCO2-51* PH-7.16* TOTAL
CO2-19* BASE XS--10
[**2175-10-12**] 03:23AM HGB-8.9* calcHCT-27
[**2175-10-12**] 03:00AM PT-18.2* PTT-38.3* INR(PT)-1.7*
[**2175-10-12**] 01:57AM GLUCOSE-211* LACTATE-6.2* NA+-140 K+-3.6
CL--109 TCO2-20*
[**2175-10-12**] 01:45AM UREA N-16 CREAT-1.1
[**2175-10-12**] 01:45AM AMYLASE-35
[**2175-10-12**] 01:45AM ASA-NEG ETHANOL-161* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2175-10-12**] 01:45AM URINE HOURS-RANDOM
[**2175-10-12**] 01:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2175-10-12**] 01:45AM WBC-30.7* RBC-2.58* HGB-8.9* HCT-25.2* MCV-98
MCH-34.4* MCHC-35.2* RDW-13.7
[**2175-10-12**] 01:45AM PLT COUNT-246
[**2175-10-12**] 01:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2175-10-12**] 01:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2175-10-12**] 01:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2175-10-12**] 01:45AM URINE AMORPH-FEW
[**10-12**] CT Chest/Abd/Pelvis:
1) Probable injury to the distal right common femoral vein with
extensive
hematoma tracking along its course proximally into the right
paracolic gutter and distally into the right femoral region.
The adjacent right common and external iliac arteries appear
intact. No evidence of active arterial extravasation on this
study.
2) Constellation of findings including hyperenhancing small
bowel mucosa and flattened IVC consistent with "shock bowel".
3) No definite solid organ injury.
4) Fractures involving the right femoral diaphysis, sacrum,
right inferior
pubic ramus, and multiple transverse processes of the lower
lumbosacral spine and diastasis of SI joints as described above.
Thoracolumbar vertebral bodies are normally aligned and intact.
5) Lung consolidations consistent with massive aspiration with
possible
coexisting contusion. Tiny right apical pneumothorax.
6) Large thigh intramuscular hematoma.
[**10-12**] CT Cspine: neg fx/disloc.
[**10-12**] CT Head s contrast: No acute intracranial hemorrhage or
evidence of other traumatic injury.
9/24 L. Knee: suprapatellar effusion (prelim).
[**10-15**] CXR: Right internal jugular approach central line as above.
No
radiographic evidence for immediate complication. Small left
pleural
effusion. Re-expanded left lower lobe.
[**10-12**] CT head: No acute ic. hem or evidence of other injury.
[**10-12**] CT Cspine: No acute cervical spine fracture or
malalignment.
[**10-12**] CT pelvis/spine: Minimally displaced fracture off
the anterior-inferior endplate of the T2 vertebral body with a
small adjacent mediastinal hematoma
[**10-12**] CT torso: R apical bleb, tiny PTX; aorta ok; B/L
aspiration/contusion; liver/spleen/panc/kidneys ok; R common
iliac vein ? injury w/ surrounding hematoma, no extrav, stable
on repeat CT; sacral fx, pubic rami fx
RLE: open femur fx, open tib-fib
[**10-12**]: Abdominal and pelvic arteriogram performed today w/ no
active extravasation of contrast. Mild arterial spasm in right
common femoral artery. mild dissection, intimal flap, in the
left ext iliac.
[**10-26**]: L foot -no fracture.
[**11-5**]: Sacrum comminuted fracture of the R sacrum &
anterolisthesis of S2 on S3.Bilateral transverse process
fractures at L4
[**11-6**]: R tib/fib- Diaphysial fracture of fibula unchanged
Brief Hospital Course:
[**10-12**]: Patient admitted. Went to OR for ex fix. of right leg. R
needle decompression and CT placed for decr BP in OR, no rush of
air. In OR w/ ortho/vascular for ex-fix, angiography. Not
operating on ? iliac vein injury at this time.
[**10-15**]: new subclavian line. increasing temp. Knee aspirated. New
R. sub clav. Vanc/Zosin started (cefazolin/levo d/c)
[**10-16**]: IVC filter placement. Reconstruction of RLE by Ortho. In
ICU.
[**10-17**]: Recovering from surgery yesterday. Doing well. OR tomorrow
for femur/pelvis/L. hand.
[**10-18**]: Pt. operated on for hand and femur. Extubated. In ICU
[**2175-10-20**] WV placed to R. LE
[**10-23**]: Patient transferred to CC6.
[**10-24**]: Pt taken to OR for latissimus free flap to R. LE
[**11-4**]: Began dangle protocol without difficulty.
[**11-11**]: JP drain d/c'd RLE
[**11-12**]: found to have approx 5x5 cm seroma at site of back
incision. Overlying skin no erythematous, not warm, not tender,
so opted to allow seroma to reabsorb on its own rather than
draining it actively.
[**11-16**] : Cleared by PT for d/c home with services.
Medications on Admission:
klonopin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
2. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
once a day.
Disp:*qs qs* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for muscle spasm.
Disp:*30 Tablet(s)* Refills:*0*
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-23**] Sprays Nasal
TID (3 times a day) as needed.
Disp:*qs qs* Refills:*0*
6. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours) as needed
for pain.
Disp:*90 Tablet Sustained Release 12HR(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Nasal daily ().
9. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
11. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Motor vehicle collision
Discharge Condition:
Stable
Discharge Instructions:
Please make sure you keep all your follow-up appointments.
Please make sure you continue taking all the medications that
you were taking prior to you hospitalization.
Please seek medical attention if you experience any fevers,
chills, vomiting, nausea or night-sweats.
Followup Instructions:
Please follow up with plastic surgery. Please call [**Telephone/Fax (1) 274**]
to schedule your appointment in 2 weeks from hospital discharge.
Please follow up with orthopedic surgery. Please call
[**Telephone/Fax (1) 1228**] to schedule your appointment in 2 weeks from
hospital discharge.
Please call the ortho spine [**Telephone/Fax (1) 69179**] to schedule an
[**Hospital 6669**] clinic appointment in 4 weeks from hospital
discharge.
Completed by:[**2175-11-18**]
|
[
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"293.0",
"817.0",
"820.32",
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"805.6",
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"860.0",
"507.0",
"518.5",
"805.2",
"805.4",
"305.00",
"904.2",
"850.2",
"250.00",
"788.69",
"285.1",
"861.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.25",
"38.7",
"03.53",
"79.65",
"88.42",
"99.05",
"79.26",
"79.13",
"34.04",
"83.82",
"78.15",
"86.69",
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"88.48",
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"96.72",
"79.35",
"86.22",
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"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12249, 12300
|
9742, 10843
|
341, 912
|
12368, 12377
|
1617, 8736
|
12695, 13171
|
1231, 1249
|
10902, 12226
|
12321, 12347
|
10869, 10879
|
12401, 12672
|
1264, 1598
|
277, 303
|
940, 1148
|
8745, 9719
|
1170, 1178
|
1194, 1215
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,913
| 110,314
|
4856
|
Discharge summary
|
report
|
Admission Date: [**2148-6-10**] Discharge Date: [**2148-6-21**]
Date of Birth: [**2092-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Celebrex / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2148-6-13**] Three Vessel Coronary Artery Bypass Grafting utilizing
left internal mammary artery to left anterior descending artery,
vein grafts to ramus intermedius, and posterior descending
artery.
History of Present Illness:
Mrs. [**Known lastname 7710**] is a 55 year old female with multiple cardiac risk
factors who presented to [**Hospital3 20284**] Center with worsening
chest pain. She ruled out for myocardial infarction. Cardiac
catheterization revealed critical three vessel coronary artery
disease. Surgical revascularization was recommended and she was
subsequently transferred to the [**Hospital1 18**] for surgical intervention.
Of note, prior to catheterization, patient did receive Plavix.
Past Medical History:
Coronary Artery Disease
Diabetes Mellitus Type I
Hypertension
Hypercholesterolemia
Hypothyroidism
Right Bundle Branch Block
Low Back Pain - prior Back Surgery
Partial Thyroidectomy
Hysterectomy
Carpal Tunnel Surgery
Pneumonia - early [**2147**]
Social History:
No tobacco for over 20 years. Admits to only social ETOH. She is
married and lives with her husband.
Family History:
She denies history of premature coronary artery disease.
Physical Exam:
Vitals: T 97.9, BP 122/80, HR 70, RR 18, SAT 92% on room air
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, full ROM, no carotid bruits
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally, right groin angioseal
Neuro: nonfocal
Pertinent Results:
[**2148-6-21**] 09:05AM BLOOD WBC-9.9 RBC-3.55* Hgb-11.7* Hct-34.0*
MCV-96 MCH-32.9* MCHC-34.4 RDW-14.6 Plt Ct-611*
[**2148-6-18**] 02:33AM BLOOD PT-10.6 PTT-21.2* INR(PT)-0.9
[**2148-6-21**] 09:05AM BLOOD Glucose-305* UreaN-12 Creat-0.8 Na-136
K-4.9 Cl-97 HCO3-31 AnGap-13
[**2148-6-19**] 06:20AM BLOOD ALT-240* AST-208* LD(LDH)-299*
AlkPhos-461* Amylase-24 TotBili-0.5
RADIOLOGY Final Report
CHEST (PA & LAT) [**2148-6-19**] 6:10 PM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman with s/p CABG
REASON FOR THIS EXAMINATION:
evaluate effusion
REASON FOR EXAMINATION: Followup of a patient after CABG.
PA and lateral upright chest radiographs were compared to [**6-15**], [**2147**].
The heart size is normal. The mediastinal contours are stable.
The post-surgery sternal wires and skin sutures are unchanged.
There is slight increase in bilateral basal linear atelectasis
accompanied by small bilateral pleural effusion which _____
increase in size. The rest of the lung is unremarkable, and
there is no evidence of congestive heart failure.
There is no pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Cardiology Report ECHO Study Date of [**2148-6-13**]
PATIENT/TEST INFORMATION:
Indication: Chest pain. Coronary artery disease. Left
ventricular function. Right ventricular function.
Status: Inpatient
Date/Time: [**2148-6-13**] at 09:31
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW209-9:2
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 1.8 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF
(>55%).
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic
(normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure.
Conclusions:
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
POSTBYPASS
Preserved biventricular systolic function. Study otherwise
unchanged from
prebypass.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD on [**2148-6-13**] 11:14.
Brief Hospital Course:
Mrs. [**Known lastname 7710**] was admitted and underwent routine preoperative
evaluation. Given her recent Plavix, surgery was delayed for
several days. On [**6-13**], Dr. [**Last Name (STitle) **] performed coronary artery
bypass grafting surgery. For surgical details, please see
seperate dictated operative note. Following the operation, she
was brought to the CSRU for invasive monitoring. Within 24
hours, she awoke neurologically intact and was extubated without
incident. She maintained stable hemodynamics and weaned from
inotropic support without difficulty. Her CSRU course was
uneventful and she transferred to the SDU on postoperative day
one. Despite resumption of preoperative Insulin dose, she
remained hyperglycemic. She was started on Insulin drip and
returned to the CSRU for closer observation. The [**Last Name (un) **] service
was consulted to assist in the management of her diabetes.
Lantus was initiated along with Humalog sliding scale. Over
several days, blood sugars were better controlled and she
returned to the SDU for further care and recovery. The remainder
of her hospital stay was uncomplicated. She remained in a normal
sinus rhythm and continued to make clinical improvements with
diuresis. Medical therapy was optimized and she was eventually
cleared for discharge to home on postoperative day #8 in stable
condition.
Medications on Admission:
Moexipril 15 qd, Zetia 10 qd, Fexofenadine 60 qd, Amlodipine 5
qd, Lipitor 20 qd, Folate, Toprol XL 25 qd, Levoxyl, Flexeril,
Humalog SS, Humulin NPH 8 units [**Hospital1 **], B12, Plavix - last dose
[**6-10**]
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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Lantus 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous QAM.
Disp:*1 month supply* Refills:*2*
8. Humalog 100 unit/mL Cartridge Sig: 0-5 units Subcutaneous
four times a day: Take as directed according to sliding scale.
Disp:*1 month supply* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
11. sliding scale
Humalog
51-100 101-150 151-200 201-[**Telephone/Fax (3) 20285**]
Breakfast 3 5 7 9 11
Lunch 3 5 7 9 11
Dinner 3 5 7 9 11
Bedtime 0 0 0 2 3
12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Postoperative Hyperglycemia
Diabetes Mellitus Type I
Hypertension
Hypercholesterolemia
Hypothyroidism
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**]
Blood glucose monitoring please call [**Last Name (un) 387**] for blood glucose >
200 x2 or < 60 [**Last Name (un) **] ([**Telephone/Fax (1) 3537**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**2-29**] weeks - call for appt, [**Telephone/Fax (1) 170**].
Dr. [**Last Name (STitle) **] 1-2 weeks - call for appt, [**Telephone/Fax (1) 2384**].
Dr. [**First Name (STitle) **] in [**12-30**] weeks - call for appt, [**Telephone/Fax (1) 4775**].
Dr. [**Last Name (STitle) **] in [**12-30**] weeks - call for appt.
Appointments already scheduled:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2149-1-28**] 1:40
Dr [**Last Name (STitle) 11679**] ([**Last Name (un) 387**]) Thrus [**6-27**] at 10am
[**Hospital Ward Name 121**] 2 wound check with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 20286**] [**6-27**] at 9am [**Telephone/Fax (1) 3633**]
Completed by:[**2148-6-21**]
|
[
"414.01",
"410.71",
"272.0",
"362.01",
"244.0",
"998.59",
"682.6",
"401.9",
"250.51",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9685, 9734
|
5986, 7343
|
324, 529
|
9915, 9922
|
1949, 2433
|
10582, 11382
|
1442, 1500
|
7604, 9662
|
2470, 2502
|
9755, 9894
|
7369, 7581
|
9946, 10559
|
3378, 5963
|
1515, 1930
|
274, 286
|
2531, 3352
|
557, 1038
|
1060, 1308
|
1324, 1426
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,838
| 164,557
|
32121
|
Discharge summary
|
report
|
Admission Date: [**2193-11-17**] Discharge Date: [**2194-1-23**]
Date of Birth: [**2144-5-19**] Sex: F
Service: SURGERY
Allergies:
Chlorhexidine Gluconate / Honey Bee Venom / Yellow Jacket Venom
/ Yellow Hornet Venom / Wasp Venom
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
pancreatitis with pseudocysts
Major Surgical or Invasive Procedure:
PICC
Pleural Tap
Left Chest pigtail drain
IVC Filter
.
1. Exploratory laparotomy.
2. External closed drainage of multiple peripancreatic
fluid collections in the subdiaphragmatic, perihepatic
and retroperitoneal locations.
3. Placement of multiple drains in the perihepatic,
subphrenic and paracolic gutter locations.
4. Gastrostomy tube placement.
5. Feeding jejunostomy tube placement.
.
VAC dressing change
.
Placement of intra-abdominal peripancreatic drain and VAC
dressing change
.
ERCP
A 9 cm by 7 Fr Zimmon single pigtail pancreatic stent was placed
successfully acorss the narrowing into the cystic cavity.
History of Present Illness:
This is a 59 year old female with no significant PMH who
presented to PCP with [**Name Initial (PRE) **] few days of RUQ pain, nausea and
vomiting after meals. She was admitted from the office and
underwent a laparoscopic cholecystectomy on [**2193-10-22**] for
acute cholecystitis. Intraoperative cholangiogram was not done.
The pt was discharged home on POD2 with an uncomplicated
hospital stay. On POD8, the pt returned to the office with
repeat episodes of acute RUQ pain, elevated LFTs, amylase and
lipase; an abdominal ultrasound demonstrated a normal caliber
CBD. On [**2193-10-30**] an ERCP with sphincterotomy, stent placement,
stone extraction was done. Again the pt was discharged home.
On [**2193-11-7**], however, she returned with acute onset epigastric
pain, radiating to the back. The pt was again admitted and CT
demonstrated a new pancreatic pseudocyst. She was started on
antibiotics. A PICC was placed, and she was started on TPN.
This hospitalization was complicated by a pulmonary embolus on
[**11-13**], at which time a heparin drip was started. Repeat CT
demonstrated multiple pancreatic pseudocysts. Diagnostic tap on
[**11-13**] demonstrated budding yeast and the patient was started on
antifungals per ID. The pt was transfered to [**Hospital1 18**] for further
management. At the time of transfer the pt was on TPN, heparin
drip, and vancomycin, meropenem, ciprofloxacin, fluconazole.
Past Medical History:
PE ([**2193-11-13**])
PSH: s/p ERCP ([**2193-10-30**]), s/p lap chole ([**2193-10-22**]), s/p L breast
lumpectomy ([**2188**]), s/p B tubal ligation ([**2185**]), c-section x2
([**2167**], [**2169**])
Social History:
no Etoh
Lives in [**State 1727**] with husband and son
[**Name (NI) 4906**] a [**Name2 (NI) **]
Physical Exam:
T 98.5 P 101 BP 154/62 RR 24 89% on RA WT: 97.7kg
NCAT, EOM full, PERRL, anicteric
Neck supple
Chest decreased BS on left, otherwise clear
Heart reg rate, tachycardic, no MRG
Abd soft and round, diffusely tender to palpation, radiating to
back, no rebound, minimal guarding, hypoactive bowel sounds
LE 2+DP pulses, min edema at ankles
OSH CT: multiple pancreatic pseudocysts: tail of pancreas
inferior to L pericolic gutter, mid-body, near L lobe of liver
Pertinent Results:
[**2193-11-17**] 05:35PM BLOOD WBC-14.5* RBC-3.17* Hgb-9.3* Hct-27.9*
MCV-88 MCH-29.5 MCHC-33.4 RDW-13.2 Plt Ct-312
[**2193-11-23**] 11:50PM BLOOD WBC-23.2* RBC-3.55* Hgb-10.4* Hct-31.2*
MCV-88 MCH-29.4 MCHC-33.4 RDW-14.0 Plt Ct-558*
[**2193-11-25**] 12:48AM BLOOD WBC-26.6*# RBC-4.03* Hgb-12.0 Hct-35.7*
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.2 Plt Ct-856*
[**2193-11-27**] 01:38AM BLOOD WBC-27.4* RBC-3.27* Hgb-9.5* Hct-29.9*
MCV-91 MCH-28.9 MCHC-31.7 RDW-14.4 Plt Ct-470*
[**2193-11-27**] 01:38AM BLOOD Glucose-115* UreaN-23* Creat-0.5 Na-144
K-4.7 Cl-113* HCO3-24 AnGap-12
[**2193-11-17**] 05:35PM BLOOD ALT-42* AST-37 LD(LDH)-295* AlkPhos-189*
Amylase-192* TotBili-0.8
[**2193-11-23**] 06:30AM BLOOD ALT-71* AST-73* AlkPhos-256* Amylase-232*
TotBili-0.6
[**2193-11-26**] 12:10AM BLOOD ALT-71* AST-59* AlkPhos-141* Amylase-249*
TotBili-0.5
[**2193-11-27**] 01:38AM BLOOD ALT-95* AST-80* AlkPhos-215* Amylase-190*
TotBili-0.6
[**2193-11-17**] 05:35PM BLOOD Lipase-112*
[**2193-11-22**] 03:26AM BLOOD Lipase-92*
[**2193-11-27**] 01:38AM BLOOD Lipase-82*
[**2193-11-24**] 10:58AM BLOOD Albumin-2.4* Calcium-7.9* Phos-4.2 Mg-2.5
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2193-11-18**] 10:41 AM
IMPRESSION:
1. Pulmonary emboli as noted above within segment arteries of
the right lower lobe. Pleural effusions and pulmonary
parenchymal atelectasis and airspace disease as noted.
2. Multiple large pancreatic pseudocysts including left hepatic
subcapsular psuedocysts. The pancreatic parenchyma in the body
is replaced by the pseudocyst but the tail, head, and uninate
process enhance.
3. Thrombosis of the splenic vein with collaterals. No splenic
artery aneurysm.
.
CTA CHEST W&W/O C&RECONS, NON-; CT ABD W&W/O C
IMPRESSION:
1. Interval progression of pancreatic pseudocysts and associated
ascites.
2. Overall, no progression of pulmonary arterial clot burden,
with a new right upper lobe segmental artery thrombus, but
resolution of the previously described right lower lobe
thrombus.
3. Interval stable large left pleural effusion, with interval
resolution of the right pleural effusion.
4. Interval improvement in right upper lobe peripheral airspace
disease.
5. Redemonstration of splenic vein thrombosis.
.
CHEST (PORTABLE AP) [**2193-11-27**] 6:00 AM
IMPRESSION: Unchanged appearance of a left-sided pleural
effusion. Right lower lobe opacity, likely consistent with
atelectasis is again identified.
.
[**2193-12-23**] 05:18AM BLOOD WBC-8.9 RBC-3.10* Hgb-8.8* Hct-27.1*
MCV-87 MCH-28.5 MCHC-32.7 RDW-16.2* Plt Ct-699*
[**2193-12-30**] 04:35AM BLOOD WBC-13.6* RBC-3.06* Hgb-8.5* Hct-26.0*
MCV-85 MCH-27.8 MCHC-32.7 RDW-16.6* Plt Ct-696*
[**2193-12-30**] 04:35AM BLOOD PT-23.7* PTT-34.1 INR(PT)-2.4*
[**2193-12-30**] 04:35AM BLOOD Lipase-110*
[**2193-12-30**] 04:35AM BLOOD Albumin-2.7* Calcium-8.6 Phos-4.3 Mg-2.2
Iron-PND
.
CT DRAIN PANCREATIC CYST [**2193-12-5**] 9:34 AM
IMPRESSION:
1. Interval placement of a pigtail catheter into a pancreatic
pseudocyst, with aspiration of 250 cc of fluid.
2. Interval decrease in size of a left paracolic fluid
collection, and a subcapsular fluid collection.
3. Stable large left pleural effusion, with interval development
of a small right pleural effusion.
.
CT ABSCESS CATH CHANGE [**2193-12-16**] 10:38 AM
IMPRESSION:
1. Slight interval increase in size of the peripancreatic fluid
collection.
2. Slight interval increase in size of the fluid collection seen
between the stomach and the descending colon.
3. Interval decrease in size of the lentiform fluid collection
along the posterior left abdominal wall.
4. Bilateral pleural effusions.
CT-GUIDED CATHETER EXCHANGE/DRAINAGE:
IMPRESSION:
Satisfactory CT-guided exchange of the pre-existing catheter to
a 16 French drainage catheter.
.
CT GUIDANCE DRAINAGE [**2193-12-19**] 2:58 PM
IMPRESSION:
1. Patient status post placement of an 8 French catheter into a
left subphrenic pseudocyst, without immediate complication.
2. Slight interval decrease in the size of a peripancreatic
pseudocyst, with a pigtail catheter in appropriate position.
3. No significant interval change in the size of bilateral
pleural effusions (left greater than right), a left paracolic
fluid collection and moderate abdominal ascites.
.
CT ABDOMEN W/CONTRAST [**2193-12-26**] 11:59 PM
IMPRESSION:
1. Decrease in size of pancreatic fluid collection with pigtail
catheter in place. Decrease in size of adjacent small fluid
collection anterior to the left kidney. Mild fat stranding
surrounding these collections.
2. Moderate free fluid in the abdomen and pelvis with small
amount of free air unchanged since prior study. No new fluid
collection.
3. Moderate left pleural effusion with atelectasis.
4. Fatty liver.
.
CT PELVIS W/CONTRAST [**2194-1-14**] 9:58 AM
FINDINGS:
ABDOMEN: There is a new small-to-moderate size left pleural
effusion with associated atelectasis. Two small sub 5 mm
pulmonary nodules noted in the right lung base (2, 7 and 2, 10)
which are likely a residual fluid from prior effusion. Heart
size is within normal limits.
There has been interval removal of a percutaneous drain which
entered via a right paraumbilical approach extending to lie just
superior to the pancreatic tail. There is a residual fluid
collection which extends from the pancreatic tail anteriorly to
the healing midline incision, with an overall volume of fluid
which is unchanged from prior study but which is redistributed
from the subcutaneous collection posteriorly towards pancreatic
tail, along the course of the previously located catheter. There
is further continuation of the fluid collection along the left
anterior perirenal fascia to terminate in a small collection in
the left paracolic gutter, which is decreased in size when
compared to prior examination. No new collections are seen. The
pancreas enhances homogeneously. There is no pancreatic ductal
dilatation. The splenic vein remains patent, although markedly
attenuated. Liver and spleen are unchanged, with likely fatty
replacement of the liver and stable haziness within the
mesentery from prior pancreatitis.
There is a G-tube and a more distally located J-tube unchanged
in position. IVC filter is again noted in the IVC. Surgical
clips in the gallbladder fossa from prior cholecystectomy.
Kidneys enhance and excrete contrast symmetrically without
hydronephrosis.
PELVIS: There are segmental areas of colonic wall thickening
predominantly involving the transverse/sigmoid colon as well as
sparing of the right colon, which may be due to peritoneal
fluid, however infectious entities are a consideration. Clinical
correlation is advised.
Review of bone windows demonstrates no suspicious lytic or
blastic lesion. _____ injury anterior to right ASIS is again
noted.
IMPRESSION:
1. Interval removal of peripancreatic catheter with residual
fluid tracking along the catheter track from the pancreatic tail
to the anterior midline abdominal wall incision site, without
significant increase in volume of overall fluid from the prior
study. Communicating fluid collection in the left paracolic
gutter also has decreased slightly in volume.
2. New left pleural effusion.
3. Colonic wall thickening, which may be due to underdistension,
however colitis is a consideration and clinical assessment would
be advised.
.
ERCP
1. Previous sphincterotomy was noted in the major papilla.
2. Cannulation of the pancreatic duct was performed with a 5-4-3
tapered catheter using a free-hand technique.
3. Pancreaticogram showed a narrowing of the pancreatic duct in
the area of the head with a leak into a cystic cavity.
4. A 9 cm by 7 Fr Zimmon single pigtail pancreatic stent was
placed successfully acorss the narrowing into the cystic cavity.
[**2194-1-22**] Amylase 51, Lipase 68
[**2194-1-23**] INR 1.9
[**2193-12-2**] 02:35AM
PREALBUMIN
Test Result Reference
Range/Units
PREALBUMIN 7 L 17-34 MG/DL
[**2194-1-6**] 04:04AM
PREALBUMIN
Test Result Reference
Range/Units
PREALBUMIN 10 L 17-34 MG/DL
Brief Hospital Course:
This is a 59 year old female s/p ERCP-induced pancreatitis
complicated by multiple
pseudocysts and pulmonary embolism transferred to [**Hospital1 18**] for
further management
Pancreatic Pseudocyst: WE hoped to stabilize her and delay
operating for a couple weeks in order to allow the pseudocyst to
mature and form a wall.
On [**2193-11-28**] she went to the OR for an Ex lap, peri-pancreatic
fluid drainage(5 L), G-J tube placement. She was left with 4
drains in place on the right side.
.
ID: Cultures from the OSH only showed +[**Female First Name (un) **] Albicans from the
pancreatic pseudocyst. She was transferred with vancomycin,
meropenem, ciprofloxacin, fluconazole. We stopped all
antibiotics, one at a time over 3 days , except Fluconazole.
.
PE: She was transferred her with a PE. She was continued on a
Heparin gtt. Vascular was consulted and on [**11-25**], she had a IVC
filter placed.
.
Pain: She complained of severe abdominal pain. She was continued
on Demerol. CPS was consulted and a Fentanyl patch was also
ordered.
.
Pleural effusion: She was having dyspnea and sating in the low
90's% on O2 by nasal cannula, her RR was 30. IP was consulted
and she had a therapeutic and diagnostic left-sided
ultrasound-guidance thoracentesis for 900cc of serous pleural
fluid.
On [**11-26**] L-sided Thoracentesis w/ pigtail catheter placement.
.
Fluid Volume Overload: She was edematous and reportedly had an
approximate weight gain of ~30 lbs in the last 2 weeks. She was
ordered for Lasix and responded well. The Lasix was stopped on
[**11-25**] as her BUN/Cr were rising and she continued to be
tachycardic. Her BUN/Cr stabilized after holding the Lasix. She
was then started on a Lasix drip for continued diuresis.
.
FEN: She was NPO and continued on TPN. After the feeding tube
was placed, tube feedings were advanced and she was tolerating
goal tube feeding.
.
Tachycardia: On [**11-24**] she was triggered for tachycardia to 140,
increased pain, RR >30. She was transferred to the ICU for
further monitoring. She received IV Lopressor for HR control.
She continued to be tachycardic in the ICU. A Diltiazem drip was
started on HD 12 ([**2193-11-27**]).
During the episode of Psychosis, as mentioned below, she became
hypotensive and was stated on Neo and Esmolol for tachycardia.
The Esmolol was weaned off and IV Lopressor ordered instead.
Due to continued tachycardia, she was placed back on Esmolol and
a Diltiazem gtt.
The Esmolol was turned off and PO Lopressor was started on
[**2193-12-2**].
.
Confusion/Psychosis: on the early morning of [**11-25**], she became
confused and pulled out her NGT and was pulling at her IV's, she
was saying she needed to leave the hospital because we were
trying to harm her. She received Haldol without effect. She
became hypotensive and was stated on Neo and esmolol for
tachycardia. She was treated with Versed and finally calmed.
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On [**12-2**], she was transferred out to the floor. She continued to
recover with 4 abdominal drains and a left chest tube. Her
antibiotics continued.
On [**12-5**], due to a rising WBC and abdominal pain, a CT was done
and showed an addition pancreatic pseudocyst. She had an
interval placement of a pigtail catheter into a pancreatic
pseudocyst, with aspiration of 250 cc of fluid. This collection
had a Amylase of [**Numeric Identifier 75167**]. Interval decrease in size of a left
paracolic fluid collection, and a subcapsular fluid collection.
Again, her WBC counts jumped to 23K on [**12-9**]. A repeat CT on
[**12-9**] showed interval significant decrease in size of multiple
pancreatic pseudocyst and associated ascites. _____ left flank
fluid collection. No new drainable fluid collection.
A repeat CT was done on [**12-16**], due to a persistent leukocytosis
of 18.7K. This showed a slight interval increase in size of the
peripancreatic fluid collection. Slight interval increase in
size of the fluid collection seen between the stomach and the
descending colon. Interval decrease in size of the lentiform
fluid collection along the posterior left abdominal wall.
Bilateral pleural effusions. She had satisfactory CT-guided
exchange of the pre-existing catheter to a 16 French drainage
catheter.
We were able to sequentially remove her JP drains one at a time
on 3 consecutive days. She had JP #1 drain remaining, as this
had an Amylase of 784.
On [**2193-12-19**], she received 4 units of FFP prior to going to
radiology to drain an additional collection. A left
subdiaphragmatic fluid collection measures 4.7 x 8.0 cm,
compared to 4.8 x 8.6 cm on the previous study.
The peripancreatic collection of fluid and air measures
approximately 7.7 x 3.9 cm, compared to 9.6 x 3.7 cm on the
prior study. The up sized pigtail catheter is in appropriate
position. The left paracolic fluid collection measures
approximately 2.8 x 3.2 cm, compared to 2.6 x 3.2 cm on the
prior study. Scattered air locules in an intraperitoneal
location in the anterior abdomen appear increased when compared
to the prior study. The majority of the air is adjacent to the
pigtail catheter. A gastrostomy tube remains. There has been
interval removal of one surgical drain. The remaining drain
terminates in the left paracolic region.
She had:
1. Patient status post placement of an 8 French catheter into a
left subphrenic pseudocyst, without immediate complication.
2. Slight interval decrease in the size of a peripancreatic
pseudocyst, with a pigtail catheter in appropriate position.
3. No significant interval change in the size of bilateral
pleural effusions (left greater than right), a left paracolic
fluid collection and moderate abdominal ascites.
The Amylase from this collection was 3928.
On [**2193-12-23**] her abdominal wound was opened ~cm due to a
pancreatic fistula. The wound was cleaned and a VAC dressing
applied.
On [**2193-12-24**], we were able to pull out the remaining #1 JP drain.
The VAC was changed on [**12-27**] and again on [**12-29**].
Her antibiotics were stopped on [**2193-12-26**]. Due to a rising WBC the
antibiotics were restarted. She continued on Flagyl, Cipro and
Fluconazole. On [**12-30**], the Flagyl was stopped.
On exam, she was found to have a large amount of fluid from the
upper aspect of the wound. There was a large loculated
collection which appeared to be intraperitoneal as at this site
there was a defect in the fascia. On [**2194-1-2**], she had
exploration of abdominal wound with drainage of loculated
intra-abdominal abscess and vacuum-
assisted closure dressing placement.
She continued with VAC dressing changes and required a take back
to the OR on [**1-8**] for Incision and drainage of abdominal wall
abscess and VAC dressing placement under anesthesia.
She went to the OR on [**2194-1-15**] for a VAC change and had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**]
drain placed into the pancreatic fluid collection.
She then went for ERCP on [**2194-1-21**]:
1. Previous sphincterotomy was noted in the major papilla.
2. Cannulation of the pancreatic duct was performed with a 5-4-3
tapered catheter using a free-hand technique.
3. Pancreaticogram showed a narrowing of the pancreatic duct in
the area of the head with a leak into a cystic cavity.
4. A 9 cm by 7 Fr Zimmon single pigtail pancreatic stent was
placed successfully across the narrowing into the cystic cavity.
Continue with VAC dressing change and [**Doctor Last Name 406**] drain care.
.
C.Diff: She complained of frequent, loose stool and had a rising
WBC on [**2111-1-10**]. We tested her stool and she was found to be
C.diff positive. She was started on PO Vancomycin and PO Flagyl.
She immediately felt better and had much less stool output.
Continue with PO Flagyl for 2 weeks.
.
Pleural Effusion: The pigtail Chest tube was removed on [**12-4**]. A
CT on [**12-5**] showed stable large left pleural effusion, with
interval development of a small right pleural effusion. A CT on
[**12-9**] showed interval increase in right pleural effusion, slight
decrease in size of left pleural effusion. Adjacent
atelectasis/airspace consolidation at the bases bilaterally.
FEN: She continued on tube feedings and was tolerating these. On
[**12-10**], we were able to decrease the tube feeding as she was able
to tolerate a PO diet. On [**12-11**], the tube feedings were stopped.
We encouraged PO intake. She was anxious about not eating enough
and if needed. She had nausea and emesis on [**12-14**] and [**12-15**] and
was on a clear diet. We then restarted her tube feedings. She
continues with intermittent nausea and tolerates occasional food
between bouts of nausea.
PE: She continued on a Heparin drip and she was therapeutic.
Coumadin was started on [**12-8**] and we monitored her INR. She
received 5mg of coumadin for the past 6 days. Her INR at time of
discharge was 1.9.
.
Anxiety: She became increasingly very anxious during her
hospitalization and was requiring Ativan and pain medication for
any type of bed-side procedure.
Pt. describes a feeling of overall un safety, hyper-vigilance
around the next
"bad" thing.
She benefits from strict limit setting, encouragement and
reassurance. Continue to promote independence.
Medications on Admission:
None
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
2. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): hold for SBP<100 or HR <60.
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks: C.diff.
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 1XHS (once (at
bedtime)) for 1 doses: Please monitor INR and dose accordingly.
10. Meperidine (PF) 50 mg/mL Syringe Sig: 12.5-25 mg Injection
Q3H (every 3 hours) as needed.
11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed.
12. Meperidine (PF) 50 mg/mL Syringe Sig: 0.5-1 ml Injection
Dressing Change: Please give prior to dressing change.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Pancreatitis
Pancreatic Pseudocyst
Pleural Effusion
Respiratory Distress
Fluid Volume Overload
Tachycardia
Pulmonary Embolism
Pancreatic Fistula
Anxiety
C.Diff
Discharge Condition:
Good
Tolerating limited regular diet and tubefeedings
Drain in place
VAC in place
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.
* 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.
* 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.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please take any new meds as ordered.
* Continue to amubulate several times per day.
* Continue with drain care and VAC wound changes.
* Continue to eat several, small meals through-out the day and
drink plenty of fluids.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1924**] on [**2194-2-4**] at
12:45pm. Call [**Telephone/Fax (1) 7508**] with questions or concerns.
Completed by:[**2194-1-23**]
|
[
"577.8",
"567.22",
"574.50",
"415.19",
"577.0",
"577.2",
"511.9",
"998.59",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.19",
"46.39",
"43.19",
"99.15",
"52.93",
"38.7",
"52.09",
"96.6",
"34.09",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
21883, 21962
|
11418, 20687
|
390, 1020
|
22166, 22250
|
3306, 11395
|
23147, 23326
|
20742, 21860
|
21983, 22145
|
20713, 20719
|
22274, 23124
|
2826, 3287
|
320, 352
|
1048, 2473
|
2495, 2698
|
2714, 2811
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,589
| 140,435
|
42283
|
Discharge summary
|
report
|
Admission Date: [**2114-8-28**] Discharge Date: [**2114-9-4**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Fall from standing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo male with frequent falls, TIA, hx of DVTs ([**2073**] x2), s/p
fall with SDH and dens fracture admitted to neurosurgery, now
being transferred to medicine after dx pt presents with
delerium, UTI and DVT.
.
The patient had an unwitnessed fall from standing on [**2114-8-28**]
and was found to have a subdural hematoma and dens fracture at
OSH. He was then transferred to [**Hospital1 18**] for further management.
The patient was unable to give a history but the family states
that he has right arm weakness since a TIA 2-3 years ago.
However, over the past few months he has been complaining of LUE
weakness. He has also been acting more confused/forgetful over
the last few months, especially in the mornings. They state he
has has several unwitness falls since his TIA which were not
assessed medically. They recall he said he felt dizzy before
the falls, there was often LOC, and that they occured when going
from sitting to standing.
.
At [**Hospital1 18**], he was admitted to neurosurgery who decided to use a
conservative approach to treat the C2 fracture. They also felt
hte subdural was chronic and did not require treatment. He was
monitored with frequent neurological examinations. On
evaluation, it was noted he has a positive UA and the patient
was started on ciprofloxacin on [**2114-8-29**]. The patient also
complained of left leg pain and and US was performed which
showed a DVT - partial nonocclusive thrombus seen within the
proximal portion of the left femoral vein. He was started on
lovenox on [**2114-8-30**] (NSG not concerned about the SDH). He also
became confusion/delirium and which was felt to likely be
multifactorial in etiology related to his
medications/pain/hospitalization/SDH. Given the multiple
medical issues, NSG requested a transfer to medicine. Family is
aware and realistic about his over prognosis. Patient expressed
suicidal ideation while on neurosurgery, but the family states
the patient has been stating "I want to die" for several years.
He was evaluated by psychiatry who determined he is low risk and
felt he did not need a 1:1 sitter. Geriatrics was consulted on
delirium and goals of care discussion. They spoke by telephone
to the patient's daughter, [**Name (NI) 5877**] [**Last Name (NamePattern1) 4249**] who is his HCP.
.
On the floor the patient was transferred in a canopy bed. He is
unsure of where he is and why he is int he hospital. He was
A+Ox1. His family states he typically is A+Ox3 except in the
mornings when he is often confused. The patient stated he only
had pain in his neck and at the back of his head and it was "not
so bad" but "annoying". He was unable to characterize it
further. He denies any chest pain, shortness of breath,
abdominal pain, changes in his bowel or bladder habits, pain in
his legs or arm.
Past Medical History:
-?HTN: Per daughter.[**Name (NI) **] had been on atenolol but this
medication was stopped 9 months ago, and his PCP stated he did
not need this medication
.
-?arrythmia history: Pt has hx of an arrythmia on the [**2073**], for
which the atenolol may have been started per his daugther.
Unknown if the arryhtmia was atrial fibrillation.
.
-TIA 2-3 years ago, however has residual right arm weakness
.
-DVT-Patient has 2 episodes of DVT in the [**2073**]. His daughter
states she did not believe he was hospitalized/had any surgeries
prior to those events. Also unclear if he has a history of
atrial fibrillation. His daughter states he had been on coumadin
after these events but is unclear on when this was stopped.
.
-Dementia: Per the family, the patient has been acting
confused/forgetful over the last several months. He voluntarily
gave up driving several years ago. He lives in an adjacent
apartment next to his son and his son and daughter check on him
daily. His son prepares all his meals. His daughter notes he
often is unable to care for himself and his apartment. Of note,
his daugther states in [**2114-4-6**] the patient was hospitalized
for taking too much of ex-lax and was found on the floor with
diarrhea. He was discharged to home from that with PT/OT. At
that time his family had wanted to place him in a nursing home,
but the patient preferred to live at home, though he has
sometimes voiced the desire to live in a nursing home for fear
of being a burden.
.
-Vericose vein surgery-per daughter unsure of year.
Social History:
Occasional alcohol, never a problem, nothing in several years.
Pt has smoked a pipe daily x60 years. No recreational drugs. Pt
lives in apartment attached to his son's home in [**Location (un) 5028**].
Wife died 8 years ago. He has 4 son and 1 daughter, One son and
his daughter, [**Name (NI) 717**] live close and are involved daily. He
served in the Army in Europe for 5 years during WWII. Worked as
a chef. He enjoys painting, carving wood. He has been depressed
about not being able to carve wood over the last several years
due to his hand weakness/lack of fine motor skill. Uses a cane
to ambulate.
.
Family History:
NC
Physical Exam:
Exam on Admission
O: BP: 128/87 HR: 57 R: 20
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 5mm on right, non-reactive, 2-1mm on left EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, uncooperative with exam,
inappropriate behavior.
Orientation: Oriented to person only.
Motor: patient did not cooperate with exam enough to test
strength, but moves all extremeties. some weakness in the b/l UE
was apparent but family states this is his baseline
Reflexes: B T Br Pa Ac
Right 1 1 1 1
Left 2 1 1 1
Toes downgoing bilaterally
EXAM ON DISCHARGE:
VS: 99.61 152/60 82 20 97RA
GENERAL: Well-appearing in NAD, comfortable.
HEENT: NC/AT, PERRL in left eye, Right eye is not reactive to
light, but this at baseline for patient, EOMI, sclerae
anicteric, MMM-patient has upper and lower dentures, OP clear.
Healing abrasion to forehead, healing well.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: quiet heart sounds, RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
GU: No CVA tenderness bialterally. No lesions on genitalia
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
LYMPH: No cervical LAD.
NEURO: Awake, oriented to person, CNs II-XII grossly intact,
with the exception of R pupil not reactive, which is baseline
for patient. muscle strength 5/5 throughout, with the exception
of his right hand grip which is [**4-10**] in strength. sensation
grossly intact throughout, DTRs 2+ and symmetric
Pertinent Results:
LENIs - [**8-29**] Non-occlusive left femomal DVT
[**2114-8-28**] 06:55PM URINE HOURS-RANDOM
[**2114-8-28**] 06:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2114-8-28**] 06:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2114-8-28**] 06:55PM URINE BLOOD-TR NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2114-8-28**] 06:55PM URINE RBC-2 WBC-80* BACTERIA-MOD YEAST-NONE
EPI-0 TRANS EPI-<1
[**2114-8-28**] 04:50PM LACTATE-1.0
[**2114-8-28**] 04:46PM GLUCOSE-110* UREA N-21* CREAT-1.4* SODIUM-138
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2114-8-28**] 04:46PM estGFR-Using this
[**2114-8-28**] 04:46PM cTropnT-<0.01
[**2114-8-28**] 04:46PM WBC-5.9 RBC-4.51* HGB-14.5 HCT-42.0 MCV-93
MCH-32.2* MCHC-34.5 RDW-13.8
[**2114-8-28**] 04:46PM NEUTS-64.5 LYMPHS-27.7 MONOS-5.5 EOS-1.4
BASOS-0.9
[**2114-8-28**] 04:46PM PLT COUNT-148*
[**2114-8-28**] 04:46PM PT-12.6 PTT-24.7 INR(PT)-1.1
[**2114-9-4**] 06:15AM BLOOD WBC-2.6* RBC-4.47* Hgb-14.2 Hct-40.7
MCV-91 MCH-31.7 MCHC-34.8 RDW-13.5 Plt Ct-107*
[**2114-9-3**] 06:00AM BLOOD WBC-2.7* RBC-4.20* Hgb-14.0 Hct-38.8*
MCV-92 MCH-33.3* MCHC-36.0* RDW-13.6 Plt Ct-91*
[**2114-9-2**] 05:45AM BLOOD WBC-4.1 RBC-4.38* Hgb-14.1 Hct-40.3
MCV-92 MCH-32.2* MCHC-35.0 RDW-13.6 Plt Ct-110*
[**2114-9-4**] 06:15AM BLOOD Neuts-72.2* Lymphs-16.8* Monos-7.5
Eos-2.7 Baso-0.8
[**2114-9-2**] 05:45AM BLOOD Neuts-82.8* Lymphs-11.1* Monos-4.2
Eos-1.8 Baso-0.1
[**2114-9-4**] 06:15AM BLOOD Plt Ct-107*
[**2114-9-3**] 06:00AM BLOOD Plt Smr-LOW Plt Ct-91*
[**2114-9-4**] 06:15AM BLOOD Glucose-98 UreaN-16 Creat-1.2 Na-136
K-3.7 Cl-103 HCO3-23 AnGap-14
[**2114-9-3**] 06:00AM BLOOD Glucose-121* UreaN-20 Creat-1.4* Na-132*
K-3.5 Cl-101 HCO3-22 AnGap-13
[**2114-9-2**] 05:45AM BLOOD Glucose-134* UreaN-23* Creat-1.5* Na-134
K-3.7 Cl-101 HCO3-22 AnGap-15
[**2114-9-3**] 06:00AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.0
[**2114-8-31**] 06:00AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.5 Mg-1.9
[**2114-8-31**] 06:00AM BLOOD VitB12-140* Folate-8.2
[**2114-9-4**] 12:27PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2114-9-4**] 10:03AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2114-9-4**] 12:27PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2114-9-4**] 10:03AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2114-9-4**] 12:27PM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2114-9-4**] 10:03AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2114-9-4**] 12:27PM URINE CastHy-2*
[**2114-9-4**] 12:27PM URINE Mucous-RARE
[**2114-9-4**] 10:03AM URINE Mucous-RARE
[**2114-8-28**] 06:55PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
EKG: Study Date of [**2114-8-28**] 4:53:56 PM
Rate PR QRS QT/QTc P QRS T
60 0 106 448/448 0 -8 38
Baseline artifact. Regular supraventricular rhythm, sinus versus
ectopic atrial rhythm. Low limb lead voltage. Q waves in leads
V1-V2. Consider septal myocardial infarction. Minor ST-T wave
abnormalities. No previous tracing available for comparison.
Clinical correlation is suggested.
.
EKG: Study Date of [**2114-8-29**] 5:36:46 AM
Intervals Axes
Rate PR QRS QT/QTc P QRS T
49 0 100 492/472 0 -18 11
Supraventricular bradycardia. Since the previous tracing the
rate is slower. QTc interval is longer. Otherwise, findings are
unchanged.
.
CHEST (PORTABLE AP) Study Date of [**2114-8-28**] 5:06 PM
FINDINGS: Two AP images of the chest were obtained portably with
patient supine. Comparison with a CT C-spine from same date from
an outside hospital. The lungs appear essentially clear
bilaterally without focal consolidation, effusion, or signs of
CHF. A skinfold projecting over the lateral margin of the left
lung simulates a pneumothorax though no definite sign of
pneumothorax is seen and there is no pneumothorax seen in the
imaged lung apices on the CT
C-spine from earlier today. Cardiomediastinal silhouette appears
unremarkable, though aorta is somewhat unfolded. The imaged
osseous
structures appear intact.
IMPRESSION: No acute intrathoracic process.
.
OSH Films: per neursurgery consult note.
CT C-SPINE: old dens fracture with cortication below new tip of
dens fracture with hematoma
CT HEAD: b/l chronic SDH
.
US of LE:
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2114-8-29**]
12:53 PM
.
IMPRESSION: Partial nonocclusive thrombus seen within the
proximal portion of the left femoral vein. No additional deep
vein thrombosis identified in either leg. Note is made that the
left calf veins could not be identified as the patient would not
cooperate.
.
CT head [**2114-8-31**]:
IMPRESSION:
1. Stable appearance of the right and left subdural hematomas
compared to
study on [**2114-8-28**] given the difference in head position
and angle. No
new hemorrhage.
2. Mild chronic small vessel ischemic changes.
[**2114-8-31**]
Radiology Report VIDEO OROPHARYNGEAL SWALLOW
FINDINGS: Multiple consistencies of oral barium were
administered. Note is
made of deep penetration with thick and thin liquids. There is
no evidence of
aspiration. There is a small amount of residue seen with thick
liquids.
Swallow of a barium tablet shows holdup of the tablet in the
distal esophagus
just above the gastroesophageal junction.
[**2114-8-28**] 9:30 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2114-8-31**]**
MRSA SCREEN (Final [**2114-8-31**]): No MRSA isolated.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 91634**] M 97 [**2017-1-29**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2114-9-2**] 7:31
PM
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Borderline size of the cardiac silhouette without
evidence of
pulmonary edema. No pleural effusions. No evidence of pneumonia.
Brief Hospital Course:
Mr. [**Known lastname 39162**] was admitted to the Neurosurgery service and observed
in the intensive care unit over night with frequent neuro
checks. An MRI of the cervical spine was ordered to rule out
ligamentus injury. However, patient was unable to tolerate. On
HD#2, pt was trasferred to floor in stable condition. Pt was
complaining of right calf pain and was found to have a left
femoral DVT on ultrasound. As a result patient was started on
enoxaprin [**Hospital1 **]. He also was discovered to have a urinary tract
infection and was started on a five day course of ciprofloxacin.
Medicine was consulted and they accepted transfer for further
management from a medical standpoint. On transfer to the
medicine floor the patient complained only of a minimal amount
of pain at neck and back of head. He denied any leg pain, chest
pain/SOB. The rest of review of systems was negative.
ASSESSMENT & PLAN:
The patient is a [**Age over 90 **] yo man with hx of mechanical fall on
[**2114-8-28**] dx'd with subdural hematoma and dens fracture at OSH,
admitted to neurosurgery and found to have DVT and delerium
.
#Delirium: Patient has baseline dementia,delirium is likely
related to post-head injury/SDH or medications a well as UTI
with some baseline dementia. Psychiatry consult recommend
Quetiapine Fumarate PO/NG [**Hospital1 **] PRN agitation. Patient is
currently in a canopy bed to prevent evacuating bed. Geriatrics
has also been consulted and recommended checking B12, Folate,
TSH. The patient;s B12 was found to be low and he was
subsequently started on supplementation.
.
#DVT: Patient complained of left leg pain and accordingly an US
was performed. The US found a partial nonocclusive thrombus seen
within the proximal portion of the left femoral vein. Pt has a
history of DVTs in the remote past, had been anticoagulated, but
unclear when this was stopped. NSG was not concerned about
anticoagulation bleeding risk to SDH and he was started on
lovenox. However, the risks and benefits of anticoagulation were
discussed. Patient has a history of falls with severe injury
including cervical spine fracture and subdural hematomas. He is
at high risk for falling and bleeding. Patient Primary Care
Physician's office was [**Name (NI) 653**], the covering physician felt
that as she did not know the patient well, it was difficult for
her to weigh in on decision, however if the risks of bleeding
were felt to be greater than risk of PE, a decision should be
made accordingly. The patient's lovenox was stopped. Patient was
placed on Aspirin 325mg. Patient was placed on prophylactic
heparin for rest of hospital stay.
.
#Dens Fracture: Patient was found to have old and new dens
fracture on OSH CT. NSG has seen and evaluated this patient.
Patient currently in c-collar. NSG felt the patient was not a
surgical candidate. They recommend follow up in ortho spine
center in 1 month for repeat CT with the collar on at all times
until follow up.
.
#Subdural: Patient found to have SDH at OSH. Neurosurgery felt
SDH was chronic. They also felt it was safe to anticoagulate the
patient for his DVT even with the SDH. They recommend 4-6 weeks
F/U with NSG and repeat CT head at that time A repeat head CT on
[**2114-8-31**] showed stable SDH. Family and health care proxy felt
given patient does not want to be further hospitalized, they do
not wish to have this follow up appoitnment with neurosurgery
with CT scan. They request for it to be cancelled.
.
#Frequent falls: Given that these have typically occured in
context of patient going from sitting to standing, and patient
has stated he feels dizzy beforehand, likely orthostatic. Family
is concerned patient is now unable to care for self. Will order
PT consult and SW consult. It was determined that patient would
benefit from Extended Care Facility after hospitalization.
.
# Catheter-associated bacteriuria. Patient was found to have 80
WBC with a positive nitrate on UA with foley catheter in place.
He was started on ciprofloxacin on [**2114-8-29**]. Patient's urine
culture showed STAPHYLOCOCCUS, COAGULASE NEGATIVE and the
patient was switched to bactrim. The foley catheter was
removed, and bactrim was then stopped. A repeat urinalysis did
not show any evidence of infection. 2 days prior to discharge,
the patient had a fever of 102. CXR showed no signs of
pneumonia A UA showed no infection, while a Urine Culture showed
no infection. Blood cultures were pending at time of discharge,
and he had no recurrence of fever.
.
#Depression: While on NSG service, patient voiced depressed
thoughts and suicidality, psychiatry was consulted and felt
patient did not need a 1:1 sitter and that patient was low risk.
Patient continued to voice depressed thoughts and suicidality,
psychiatry following. Geriatrics did recommend mirtazapine for
appetite and depression, pt was started on this on [**2114-9-3**].
Patient did not voice suicidality while on the medical service.
.
#HTN: The patient has a history HTN per his daughter but has not
been on medications for 9 months. His blood pressures were
monitored and were stable.
.
#?Arrythmia: Patient has a questionable history of an arrythmia,
possibly atrial fibrillation, though he has not exhibitted an
irregularly regular rhythm here. His EKGs here have shown a
regular rhythm with no irregularly irregular rhythms.
.
# Diet: Patient had a swallowing evaluation on [**2114-8-29**] for
evaluation of choking [**Doctor Last Name 13205**] in setting of head injury, and
c-spine fracture. Initial recommendations were soft foods,
however patient had follow up video swallow examination and was
progressed to regular diet.
# CODE: Do not resuscitate (DNR/DNI) Do not rehospitalize per
HCP
# Health Care Proxy: [**Name (NI) 717**] [**Name (NI) 4249**], HCP-[**Telephone/Fax (1) 91635**]. Case
discussed at length with health care proxy, who felt that the
patient's wishes were to focus on comfort and that no life
prolonging treatment measures were to be taken. She understands
that he is not being anticoagulated for his DVT given his risk
of falling and she was in agreement with this.
Transitional issues:
Continue B12 supplementation
Continue Mirtazipine 7.5mg qhs last day [**9-5**] then to 15mg qhs
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. senna 8.6 mg Capsule Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
3. quetiapine 25 mg Tablet Sig: 0.25 Tablet PO BID PRN () as
needed for agitation.
4. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) injection Injection DAILY (Daily) for 7 days: daily for 7
days (started on [**2114-8-31**], last day is [**2114-9-7**]) then every week
for 1 month, then every month.
8. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime):
take 0.5 tab for 3 days (3rd day is [**9-5**]) Then take 1 tab every
night. .
Discharge Disposition:
Extended Care
Facility:
Port Healthcare Center - [**Location (un) 5028**]
Discharge Diagnosis:
Dens fracture
catheter-associated UTI
Delirium
Left DVT
Oliguria
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Patient must be in C-collar at all times.
Discharge Instructions:
Dear Mr. [**Known lastname 39162**],
It was a pleasure seeing you during your hospitalization at [**Hospital1 1535**]. You were admitted because you
fell. It was discovered that you had a fracture in your neck at
C2 (dens fracture). You also were found to have an old dens
fracture which looked to be headling. You also had some bleeding
in your brain (subdural hematoma) which appeared to be chronic,
and not acute. Our neurosurgeons evaluated you and felt you did
not need immediate surgery. However, you were found have an
infection in your urine as well as a blood clot in your leg. You
were also acting confused which can be caused by infections,
your head injury and pain medication.
For your blood clot you were initially put on a blood thinner,
however, after careful consideration of the dangers of blood
clots and of the increased risk of bleeding, we decided to stop
the blood thinner. This decision was made because you had many
recent falls which have resulted in serious injuries and we feel
the risk of you falling and bleeding is very high.
For your urinary infection, the catheter was removed, and there
was no evidence of infection on repeat urine tests.
We also found that your vitamin B12 levels are low and are
giving you supplementation.
Please keep your C-Collar on until your follow-up on [**9-24**] with the spine center (orthopedics).
Changes in Medication
Cyanocobalamin (Vitamin B12) Daily injections for 1 week (last
day [**2114-9-7**]) then once a week for a month, then every month.
Aspirin
Remeron (Mirtazepine)
Medication that are taken only as needed
Acetaminophen
OxycoDONE
Quetiapine
Senna
Docusate Sodium
Instructions from Neurosurgery:
?????? Do not smoke.
>> You must wear your cervical collar on at all times
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? If you are required to wear one, wear your cervical collar or
back brace as instructed.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Department: SPINE CENTER
When: MONDAY [**2114-9-24**] at 8:40 AM
With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3736**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2114-9-4**]
|
[
"V62.84",
"599.0",
"294.8",
"E885.9",
"V49.86",
"584.9",
"996.64",
"805.02",
"453.41",
"311",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20211, 20287
|
13005, 19128
|
239, 246
|
20396, 20396
|
6973, 11369
|
23620, 23971
|
5293, 5297
|
19303, 20188
|
20308, 20375
|
19274, 19280
|
20623, 23597
|
5312, 5577
|
19149, 19248
|
180, 201
|
274, 3092
|
5987, 6954
|
11378, 12982
|
20411, 20599
|
3115, 4649
|
4665, 5277
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,522
| 119,359
|
47570
|
Discharge summary
|
report
|
Admission Date: [**2139-6-9**] Discharge Date: [**2139-6-23**]
Date of Birth: [**2060-2-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2139-6-9**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
OM, SVG to RCA), Mitral Valve Replacement (27mm pericardial
tissue valve), [**Month/Day/Year **] Valve Replacement (23mm pericaridial
tissue valve), Ascending Aorta Replacement (28m gelweave graft)
[**2139-6-10**] Mediastinal exploration with evacuation of clot
History of Present Illness:
79 y/o female who developed a respiratory infection in [**Month (only) 958**]
which was treated with antibiotics. She then underwent a CT scan
which showed an enlarged ascending aorta. Echo revealed a
dilated ascending aorta, [**Month (only) 8813**] insufficiency, and mitral
regurgitaion. Cath also revealed these results along with three
vessel coronary artery disease. She was referred for surgical
intervention.
Past Medical History:
Hyperlipidemia, Hypertension, Gastroesophageal Refulx Disease,
Renal Insufficiency, Hypothyroidism, Degenerative Joint Disease,
Anxiety/Depression, Detached Left Retina, h/o Colon perforation
with colonoscopy, s/p R ear stapedectomy
Social History:
Artist. Denies tobacco. Rare wine.
Family History:
Mother with RHD.
Physical Exam:
VS: 74 SR 132/40 61" 143#
General: 79 y/o wdwn female in NAD
Skin: W/D -lesions
HEENT: NCAT, PERRL, Anicteric sclera, OP benign
Neck: Supple, FROM, -JVD, ?bruit vs. transmitted murmur
Chest: CTAB -w/r/r
Heart: RRR, 3/6 systolic murmur
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, BLE varicosities R>L. Lipoma
RLE
Neuro: A&O x 3, MAE, non-focal, Strength 5/5
Pertinent Results:
Echo [**6-9**]: PREBYPASS: The left atrium is moderately dilated.
Overall left ventricular systolic function is normal (LVEF>55%).
The ascending aorta is markedly dilated at 5.3 cm. The
sinotubular junction is 3.5cm. The descending thoracic aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta. Moderate to severe (3+) [**Month/Year (2) 8813**] regurgitation is
seen. There is partial posterior mitral leaflet flail. With a
torn mitral chordae are present. Moderate (2+) mitral
regurgitation is seen. The mitral regurgitation jet is eccentric
and directed toward the anterior mitral valve leaflet.
POSTBYPASS: There is a well seated well functioning biprosthesis
in the [**Month/Year (2) 8813**] position. There is trace valvular AI. There is a
well seated well functioning bioprosthesis in the mitral
position. There is trace valvular MR. [**First Name (Titles) 6**] [**Last Name (Titles) 8813**] tube graft is
visualized in the proximal ascending aorta.
Echo [**6-10**]: ICU/ preop: Overall left ventricular systolic
function is normal (LVEF>55%). The left heart appears
underfilled. There is a collection of fluid measuring 1.6-1.7 cm
in greatest diameter both anterior to and posterior to the
heart. There is some stranding in these collections, suggesting
early organization. There are large bilateral pleural effusions,
right greater than left. Post evacation: The pericardial fluid
collections are now absent. Pleural effusions are now small to
trivial in size. Biventricular function is preserved with LVEF
>55%.
Head CT [**6-11**]: 1. No evidence of intracranial hemorrhage. 2. No
large acute major vascular territorial infarct. If there is
further clinical concern, an MRI would be more sensitive in
evaluating for ischemic injury. 3. Status post intubation.
Vascular calcifications are noted within the vertebral arteries
and carotid siphons bilaterally.
CXR [**6-22**]: 1. Stable moderate-sized left pleural effusion and
left lower lobe atelectasis. 2. Decreased size of small right
pleural effusion with minimal residual right lower lobe
atelectasis.
[**2139-6-9**] 04:53PM BLOOD WBC-11.7* RBC-2.81*# Hgb-6.9*# Hct-20.1*#
MCV-72* MCH-24.4* MCHC-34.1 RDW-18.2* Plt Ct-140*
[**2139-6-10**] 05:23PM BLOOD WBC-8.6 RBC-3.67* Hgb-10.8* Hct-30.3*
MCV-83 MCH-29.4 MCHC-35.6* RDW-16.5* Plt Ct-154#
[**2139-6-14**] 03:02AM BLOOD WBC-12.3* RBC-3.60* Hgb-10.6* Hct-30.0*
MCV-83 MCH-29.4 MCHC-35.4* RDW-17.1* Plt Ct-131*
[**2139-6-23**] 05:40AM BLOOD WBC-12.4* Hct-37.3
[**2139-6-9**] 04:53PM BLOOD PT-19.7* PTT-48.2* INR(PT)-1.9*
[**2139-6-23**] 05:40AM BLOOD PT-21.9* PTT-38.0* INR(PT)-2.1*
[**2139-6-9**] 06:56PM BLOOD UreaN-32* Creat-1.1 Cl-109* HCO3-23
[**2139-6-23**] 05:40AM BLOOD Glucose-79 UreaN-30* Creat-1.4* Na-132*
K-4.3 Cl-92* HCO3-30 AnGap-14
[**2139-6-22**] 05:45AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2
[**2139-6-20**] 10:00AM URINE RBC-11* WBC-3 Bacteri-MOD Yeast-NONE
Epi-<1
Brief Hospital Course:
Ms. [**Known lastname **] [**Known lastname 33455**] was a same day admit and underwent all pre-op
work-up as an outpatient. On [**2139-6-9**] she was brought to the
operating room where she underwent an Coronary Artery Bypass
Graft x 3, Mitral Valve Replacement, [**Date Range **] Valve Replacement,
and Ascending Aorta Replacement. Please see operative report for
surgical details. She was transferred to the CSRU for invasive
monitoring in stable condition. Post-operatively she required
volume resuscitation and received FFP, pRBC's, and Protamine. On
post-op day one she was on multiple pressors/inotropes and
underwent a bronchoscopy to evaluate LLL opacity. Also on this
day she underwent an echo for hemodynamic instability which
ultimately required a re-operation for mediastinal exploration
and clot evacuation. On post-op day two she had an episode of
atrial fibrillation and she was given Lopressor and started on
Amiodarone. Her neurological status was also examined (with
weaning sedation) and she had poor movement in her left upper
extremity. She underwent a head CT which was negative for a CVA.
On post-op day three she underwent a bronchoscopy for a
therapeutic aspiration of secretions. She continued to be in
atrial fibrillation and electrical cardioversion was attempted
with conversion to slow sinus. Cardiology (EP) was consulted for
further management of arrhythmias. By post-op day four she
converted back to afib and heparin gtt was started. She was
ultimately started on Coumadin and heparin was stopped once her
INR was therapeutic. For the rest of her hospital course she
converted in and out of afib. She continued to remain intubated
and again underwent therapeutic aspiration via bronchoscopy.
There continued to be a persistent left basilar atelectasis with
left pleural effusion. Her chest tubes were removed and she was
finally weaned off sedation on post-op day six, appeared
neurologically intact and was extubated. On post-op day seven
she underwent a speech and swallow study and her diet was
advanced as tolerated. She had aggressive pulmonary toilet with
IS, INH/MDI's and diuretics for her pleural effusions. On
post-op day eleven she had a +UA and was started on antibiotics.
She remained in the CSRU until post-op day twelve d/t the
extended intubation, post-op afib, poss. CVA and her
desaturating following extubation. As mentioned she was
transferred to the telemetry cardiac floor on post-op day
twelve. She continued to have pleural effusions and atelectasis
despite aggressive pulmonary toilet. Physical therapy followed
patient during entire post-op course. She appeared to be stable
and physical therapy recommended rehab placement d/t decreased
endurance and mobility. On post-op day fourteen she was
discharged to rehab facility in stable condition and will f/u
with appropriate appointments.
Medications on Admission:
Diovan 160/25mg qd, Synthroid 88mcg qd, Triamteren/HCTZ
37.5/25mg qd, Toprol XL 25mg qd, Cymbalta 60mg qd, Prevacid,
Immodium, Benefiber
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
10. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):
3 mg for 2 days, then check INR and dose coumadin.
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg daily x 6 days then 200 mg daily.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 6978**] House of [**Location (un) 5871**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Mitral Regurgitation s/p Mitral Valve Replacement
[**Location (un) **] Insuffiency s/p [**Location (un) **] Valve Replacement
Ascending [**Location (un) **] Aneurysm s/p Ascending Aorta Replacement
Post-operative Atrial Fibrillation
PMH: Hyperlipidemia, Hypertension, Gastroesophageal Refulx
Disease, Renal Insufficiency, Hypothyroidism, Degenerative Joint
Disease, Anxiety/Depression, Detached Left Retina, h/o Colon
perforation with colonoscopy, s/p R ear stapedectomy
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving.
Followup Instructions:
Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**0-0-**] Follow-up appointment
should be in 2 weeks
Dr. [**First Name (STitle) 1075**] 2 weeks
Completed by:[**2139-6-23**]
|
[
"441.2",
"518.0",
"401.9",
"244.9",
"585.9",
"427.31",
"396.3",
"414.01",
"998.11",
"286.9",
"518.5",
"599.0",
"519.1",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"96.05",
"34.03",
"88.72",
"96.6",
"39.61",
"35.23",
"36.15",
"96.72",
"35.21",
"36.12",
"99.62",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9249, 9335
|
4760, 7609
|
293, 625
|
9911, 9917
|
1815, 4737
|
10173, 10499
|
1394, 1412
|
7796, 9226
|
9356, 9890
|
7635, 7773
|
9941, 10150
|
1427, 1796
|
234, 255
|
653, 1070
|
1092, 1326
|
1342, 1378
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,043
| 141,224
|
1686
|
Discharge summary
|
report
|
Admission Date: [**2151-10-19**] Discharge Date: [**2151-10-31**]
Date of Birth: [**2091-4-15**] Sex: M
Service: GREEN SURGERY
HISTORY OF PRESENT ILLNESS: Patient is a 60-year-old male
seen in the Advanced Heart Failure Clinic with problems of
ischemic cardiomyopathy with chronic systolic heart failure,
left ventricular ejection fraction 30%, status post
non-Q-wave myocardial infarction, status post CABG in [**2135**],
status post PTCA in [**11-10**]. An exercise MIBI in [**4-12**] showed
a moderate reversible inferior wall defect with moderate
septal fixed defect, without change from prior study. His
history also includes type 2 diabetes with recent worsening
of chronic renal failure with persistent hyperkalemia. His
ACE inhibitor was stopped secondary to worsening creatinine
and hyperkalemia.
Patient presented at the clinic with worsening shortness of
breath and orthopnea. He reports weakness and fatigue. He
denied chest pain, palpitations, lightheadedness, or
dizziness.
PAST MEDICAL HISTORY:
1. Congestive heart failure with an ejection fraction of 30%.
2. Insulin dependent diabetes.
3. Chronic renal failure.
MEDICATIONS:
1. Lasix 80 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d.
4. Toprol XL 100 mg p.o. q.d.
5. Lipitor 30 mg p.o. q.d.
6. Imdur 30 mg p.o. q.d.
7. Actos 15 mg q.d.
PHYSICAL EXAM: A thin man. HEENT: Weight of 128 pounds.
Blood pressure of 98/60. Heart rate 70 and regular. JVD at
the angle of the ear. Neck veins engorged. Chest: Rales at
bilateral bases. Cardiovascular: Left ventricular lift,
+S3, 2/6 systolic ejection murmur. Abdomen was distended,
firm with hepatomegaly. Extremities: [**3-15**]+ pitting edema.
LABORATORIES: From [**2151-10-18**] included a BUN of 102 and
creatinine of 2.2, which is stable. Potassium of 4.8,
chloride of 92, bicarb of 29.3.
EKG showed normal sinus rhythm, borderline QRS prolongation,
ST-T wave abnormalities, which are unchanged from the
previous studies.
The patient was admitted to Cardiac Medicine for treatment of
congestive heart failure and diuresis. The patient was on a
Natrecor drip, and [**Last Name (un) **] was consulted regarding
discontinuing the Actos.
A ventral hernia was noted upon admission. Found to be
reducible. Patient was also noted to have ascites. On
[**10-21**], a BV ICD implant was implanted by EPS. Please see
procedure note. Patient tolerated procedure well and was
transferred back to the floor. Patient was continued on a
Natrecor drip, and was diuresing well.
Patient's creatinine was decreasing to 1.7 on [**10-21**] and
[**Last Name (un) **] recommended q.i.d. fingersticks. On [**10-21**], the
patient's hematocrit dropped to 24 and the patient was
transfused 2 units of PRBC to keep hematocrit above 30 with
IV Lasix in between.
Renal team was consulted regarding the patient's chronic
renal failure, and they recommended to restarting an ACE
inhibitor and to follow up as an outpatient. Natrecor was
continued, diuresis was being continued, and the patient was
being monitored via telemetry, and strict I's and O's in
addition to laboratory values.
On [**2151-10-24**], Prandin was started secondary to elevated
fingersticks as [**First Name8 (NamePattern2) **] [**Last Name (un) **]. Glucose levels were being
monitored.
On [**2151-10-25**], the patient's ventral hernia was noted to be
nonreducible, and Surgery was consulted. KUB was obtained
and the patient was placed NPO. The patient reported
abdominal pain on examination. Positive nausea and vomiting.
Patient was afebrile with stable vital signs.
A CT with p.o. and IV contrast was obtained, which showed
incarcerated small bowel with a ventral hernia and
intraabdominal ascites.
The patient was brought to the OR on [**2151-10-26**] for repair of
incarcerated ventral hernia. Patient tolerated the procedure
well. Please see op note. The patient underwent an
unremarkable PACU course, and was transferred to the floor in
stable condition. Patient was kept NPO with IV fluids, pain
medication, and Ancef antibiotic prophylaxis. Prandin was
being held given NPO status and diuresis was halted as per
Heart Failure team.
Patient was afebrile with stable vital signs and a white
count of 6.6 on [**2151-10-28**] with stable electrolytes and BUN of
42 and creatinine of 1.3. Patient was transferred to the
SICU on [**2151-10-28**] for labile blood pressures and increase in
heart rate.
Patient was given Morphine for pain control. Metoprolol and
enalapril for cardiac medications, and blood sugars were
being controlled by regular insulin-sliding scale. In the
SICU, the patient was afebrile with a blood pressure of
109/65, heart rate of 78, V-paced, sating well on room air,
good urine output and laboratory studies. CK of 220, MB of
5. Patient's vital signs were stable with heart rates in
70s-90s, and blood pressures systolic 100-120. The patient
was started on p.o. medications and diet, tolerated well.
On [**2151-10-30**], patient was transferred back to the floor in
stable condition. Plavix was restarted on [**10-31**] patient
tolerated a regular diet, gotten out of bed without problem.
Patient's pain control was adequate and the patient had no
complaints.
Cardiology was consulted for rise in troponin on [**10-26**] 0.05,
[**10-27**] 0.08, [**10-28**] 0.20, and [**10-29**] 0.16, [**10-30**] 0.25, and [**10-31**]
0.34 with CK MBs within normal limits. Cardiology's
impression is this is a nonspecific troponin elevation in the
setting of elevated creatinine. The EP service was consulted
secondary to episodes of tachycardia with the heart rates in
the 120. They recommended adjustments of the settings.
On [**2151-11-1**], the patient was afebrile with stable vital
signs, tolerating the diet, no nausea or vomiting, plus bowel
movement (incontinence). Patient was discharged to home with
services on [**2151-11-1**]. The patient was instructed to weight
than 3 pounds. Patient was instructed to adhere to a 2-gram
sodium diet with fluid restriction. Patient was instructed
to call physician if he experiencing fevers, bleeding,
drainage from wound site.
FINAL DIAGNOSES:
1. Incarcerated ventral hernia.
2. Congestive heart failure with ejection fraction of 30%.
3. Diabetes mellitus.
4. Chronic renal failure.
FOLLOW-UP INSTRUCTIONS: The patient is recommended to call
the office of Dr. [**Last Name (STitle) **] for an appointment in two weeks.
Patient was instructed to see his internist, Dr. [**Last Name (STitle) 1968**], in
two weeks. Patient is instructed to followup with the [**Hospital **]
Clinic regarding diabetic regimen. Patient was instructed to
call Cardiology for follow-up appointment as an outpatient.
Patient is status post incarcerated ventral hernia repair on
[**2151-10-26**], BV ICD placement on [**2151-10-21**].
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Lasix 80 mg p.o. b.i.d.
3. Plavix 75 mg p.o. q.d.
4. Lipitor 30 mg p.o. q.d.
5. Tylenol #3 1-2 tablets p.o. q.4-6h. prn pain.
6. Toprol XL 50 mg two tablets p.o. q.d. for a total of 100
mg per day.
7. Lisinopril 2.5 mg p.o. q.d.
8. Prandin 0.5 mg p.o. t.i.d. with meals.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Last Name (NamePattern1) 3365**]
MEDQUIST36
D: [**2151-11-1**] 14:44
T: [**2151-11-5**] 07:11
JOB#: [**Job Number 9716**]
|
[
"428.0",
"552.29",
"285.9",
"789.5",
"V45.81",
"412",
"414.8",
"414.01",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.69",
"00.51",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
6869, 6878
|
6901, 7483
|
1368, 6158
|
6175, 6315
|
173, 1013
|
6340, 6847
|
1035, 1352
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,875
| 153,818
|
28003
|
Discharge summary
|
report
|
Admission Date: [**2190-10-13**] Discharge Date: [**2190-10-15**]
Date of Birth: [**2165-3-8**] Sex: M
Service: MEDICINE
Allergies:
Prozac / Haldol
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
EtOH withdrawal with a possible episode of emesis and a possible
seizure.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 68181**] is a 25 year-old man with a history of alcoholism and
seizure disorder who presents with alcohol withdrawal. His last
drink was 3pm on day prior to admission, [**10-12**]. Patient has a
history of seizures and believes he may have had one yesterday
but cannot recall. He awoke outside his apartment covered in
dirt which usually happens after he has a seizure.
.
He was last admitted for alcohol withdrawal in early [**2190-9-15**]
and had a positive urine tox for benzos at that time. He was
discharged with a plan to follow-up with the [**Hospital 778**] clinic and
declined substance abuse treatment. Patient briefly restarted
his antiepileptic medications but stopped them about 10 days
ago. He has been drinking between [**1-16**] to 1.5 gallons of liquor
(vodka or whiskey) daily. Last night, he presented to the ED
for evaluation, as he felt chest pain, general malaise, was
tremulous, and had some abdominal pain.
.
In the ED, initial vs were: 99.2 128 139/79 20 100%. He was
given valium 10 mg IV x 3, 2 liters NS, a banana bag,
multivitamin, and zofran x 2. His serum EtOH was 330 with
osmolality of 380 (gap 86 which correlates with his EtOH level)
with otherwise negative serum and urine tox screen. Patient had
a negative CXR, CT head and C-spine. While in the ER, he had an
episode of coffee ground emesis that cleared with NG lavage. He
was given IV PPI and admitted to the [**Hospital Unit Name 153**] for further
monitoring. Vitals on transfer were 98.7, 112, 147/90, 20, 96%
RA.
.
On the floor, he is anxious and tremulous but feels better after
NG lavage. He did not have any emesis prior to coffee grounds
in the ED but has had frequent painful burping over the past few
days. No current nausea but he does complain of headache behind
his eyes and across his temples, left sided chest pain with deep
inspiration and light sensitivitity. He has had loose, greenish
stools over the past few days that he associates with his
alcohol intake. Patient endorses visual hallucinations of
cockroaches on the floor.
Past Medical History:
- Alcoholism
- Hx. seizures (GTC) related to hx. of head injury (hit by bat
per pt.); was on tegretol until 1 year ago and neurontin since
then for ppx
- Previous 1 year admission in [**2184-5-15**] to psychiatry at [**Hospital1 **]
state hospital w/ dx of Schizoaffective disorder, GAD, social
anxiety and PTSD. Tried on numerous antipsychotic meds and SSRIs
according to patient. Pt now on clonazepam for anxiety, but
admits poor compliance. Previous suicide attempt by jumping,
broke his ankles according to pt.
- ?Hepatitis C
Social History:
He drinks approximately a quart of vodka daily and two 40 oz
beers daily and smokes a quarter pack a day. He reports using
cocaine on a single ocassion (last use [**7-24**]) though some OMR
notes report regular cocaine use. No IVDU. The pt related that
he was living in [**Hospital1 778**] with a much older boyfriend who has
dementia and has recently developed fecal incontinence. The pt
maintains he was the main caregiver and the two of them were
living off the boyfriend's pension. Recently, the boyfriend has
been sent to a nursing home by his brother and the pt no longer
has access to the apt where they were staying. Many of his
belongings remain in the apt.
The pt is considering moving in with his parents who live in New
[**Location (un) **].
Family History:
The patient reports that his mother was depressed and had an
anxiety disorder. He also reports that his mother's side of the
family has struggled with EtOH abuse.
Physical Exam:
Vitals: T: 100.5 BP: 158/81 P: 112 R: 16 O2: 96%
General: Alert, oriented, tremulous, somewhat flattened affect.
Neuro: PERLA, normal EOM, normal sensation in V, good strength
in facial muscles, hearing well bilaterally, normal movements of
the tongue with rising palate, good strength of [**Doctor First Name 81**]. Strength 4/5
and equal bilaterally in UE and LE. Poor finger to nose test,
trembling when holding hands out, photophobia.
HEENT: EOMI, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: tachy, normal S1/S2, no murmurs
Abdomen: soft, mildly tender over RUQ and mid lower quadrant,
non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Multiple scars - appear to be from cutting on the arms,
one is recent and still healing. Also multiple scars over the
pt's torso.
Pertinent Results:
[**2190-10-14**] 12:00PM BLOOD WBC-3.6* RBC-4.54* Hgb-13.8* Hct-42.3
MCV-93 MCH-30.4 MCHC-32.7 RDW-15.2 Plt Ct-84*
[**2190-10-15**] 04:26AM BLOOD WBC-2.8* RBC-4.35* Hgb-13.3* Hct-40.7
MCV-94 MCH-30.6 MCHC-32.7 RDW-15.3 Plt Ct-75*
[**2190-10-15**] 04:26AM BLOOD Plt Ct-75*
[**2190-10-15**] 04:26AM BLOOD Glucose-114* UreaN-15 Creat-0.7 Na-137
K-4.2 Cl-102 HCO3-24 AnGap-15
[**2190-10-15**] 04:26AM BLOOD Calcium-8.7 Phos-2.0* Mg-2.0
[**2190-10-13**] 01:10AM BLOOD ASA-NEG Ethanol-330* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Mr. [**Known lastname 68181**] is a 25 year-old man with a history of alcoholism and
seizure disorder who presents with alcohol withdrawal and coffee
ground emesis.
.
# Alcoholism/withdrawal: History of alcoholism with multiple
admissions for withdrawal. Has attempted detox in past but
unsuccessful. Also has history of seizures in setting of
withdrawal. Treated with diazepam 10mg IV q1hr CIWA x12hrs and
then switched to PO diazepam. Currently requiring diazepam
~q4hrs as per CIWA. started on thiamine, folate, MVI. Social
work and Psych consulted.
.
# Coffee ground emesis: Reported in the ED and cleared with NG
lavage. He has a positive Hep C antibody but no titer in our
system and no known history of varices. Current coffee grounds
could be related to small [**Doctor First Name **]-[**Doctor Last Name **] tear in the setting of
retching or gastritis. Treated with PPI IV BID and PRN Zofran.
Now switched to PO PPI. Hct stable with No further melena or
emesis. Appears pt not actively bleeding. [**Month (only) 116**] need EGD as
outpatient. Would recommend HCV viral load and genotyping as
well as HIV test as an outpatient
.
# Psychiatric history: Psychiatry consulted for any suggestions
about treatment of possible psych conditions while in-patient
and requested that pt not be given clonazepam. Will need
psychiatric f/u as outpatient
# Seizure disorder: Was on gabapentin in past but has not been
taking medications for weeks. We were unable to obtain
outpatient neurology records. We restarted gabapentin. No
documented seizures during ICU stay
.
# Transaminitis: His transaminitis may be related to alcohol
intoxication but he does have a history of positive Hep C
antibody without viral load. LFTs stable during hospital
course. Recommend f/u of Hep C and consider HIV testing
.
# Left chest pain: Unlikely to represent ACS, patient states it
is associated with withdrawal. No EKG changes. CP resolved as
withdrawal improved. [**Month (only) 116**] be related to anxiety
Medications on Admission:
Acetaminophen 650 mg PO/NG Q6H:PRN pain
Clonazepam 2 mg PO/NG QAM
Clonazepam 1 mg PO/NG QPM
Gabapentin 600 mg PO/NG Q8H
Multivitamins 1 TAB PO/NG DAILY
Nicotine Polacrilex 2 mg PO Q1H:PRN smoking cessation
Thiamine 100 mg PO/NG DAILY
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for pain.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Diazepam 10 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for CIWA > 10: Take 1 pill 6 times a day on
[**10-15**] times a day on [**10-16**] and 2 times a day on [**10-15**] and then
stop.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Withdrawl
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with symptoms of withdrawing from
alcohol. We admitted you to the ICU and monitored you for
seizures but did not see any. We treated your alcohol withdrawl
with diazepam and consulted psych and social work. We strongly
believe that you need to go to a program to help your problems
with alcoholism. You have been provided information about
alcohol withdrawl programs for you to attend on Monday. You
also have information about shelters in the area.
.
We also strongly suggest that you need to have your hepatitis C
followed up, the combination of hepatitis and alcohol can have a
serious effect on your liver and you should be monitored
closely.
.
We also noted that your blood counts were low, and this is
probably from your alcohol use, but we suggest that you get an
HIV test with your primary care doctor or at a local department
of health or community health center.
.
We have made the following changes to your medications:
ADDED Diazepam taper over the next 3 days:
-6 times a day then 4 times a day then 2 times a day then stop.
ADDED Pantoprazole for stomach protection
ADDED Folic Acid
Decreased Tylenol to 350 up to four times a day
Stopped Clonazepam (replaced by diazepam)
.
You should continue to take all your medications as directed and
follow up with your primary care doctor.
Followup Instructions:
Call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment in the
next week
.
Attend the suggested outpatient alcohol treatment program
starting Monday [**10-18**].
|
[
"295.70",
"V60.0",
"786.50",
"303.01",
"291.81",
"345.90",
"578.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
8569, 8575
|
5429, 7440
|
350, 356
|
8637, 8637
|
4872, 5406
|
10136, 10343
|
3801, 3965
|
7725, 8546
|
8596, 8616
|
7466, 7702
|
8788, 9719
|
3980, 4853
|
9748, 10113
|
237, 312
|
384, 2456
|
8652, 8764
|
2478, 3010
|
3026, 3785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,196
| 169,815
|
5946
|
Discharge summary
|
report
|
Admission Date: [**2107-11-10**] Discharge Date: [**2107-11-20**]
Date of Birth: [**2042-3-8**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Food Extracts
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
T11 metastatic cancer
Major Surgical or Invasive Procedure:
T11 posterior corpectomy and T9-L1 fusion
History of Present Illness:
As you know, Mr. [**Known firstname **] [**Known lastname 4249**] is a
delightful 65-year-old male with a medical history of bladder
carcinoma and prior cirrhosis who describes now a three-month
history of left-sided buttock and left anterior thigh pain. He
thinks that this may have started initially after a sprain or
strain sustained in a quahog incident when his foot was trapped
in the mud.
Since that time, his pain at rest has been approximately [**4-2**]
and
with activity is also a [**4-2**]. Certain positions, however, do
exacerbate his pain including standing upright as well as laying
flat in bed. It is typically more comfortable with a flexed
position.
With walking, his pain does not get worse, but he does have the
onset of bilateral leg tiredness, however. He does not find
this
considerably bothersome, however.
Past Medical History:
His past medical history is significant for gastroesophageal
reflux disease as well as hepatitis and cirrhosis. He has a
history of bladder carcinoma that required surgical treatment
with cystectomy, prostate, appendectomy, lymph node dissection
as
well as a bladder reconstruction.
Social History:
Social history, family history and review of systems are listed
in intake sheet as part of the medical record
Physical Exam:
On physical exam, the patient is alert and oriented in no
apparent distress. He is 5 feet 6 inches tall, weighs 250
pounds, his blood pressure is 144/68 and his pulse is 59 beats
per minute at rest.
Palpation of the bony elements of the thoracic, lumbar and
sacral
spine is nontender. He is able to walk a fluid and symmetric
narrow-based gait. He can walk upon his toes and heels
demonstrating good strength.
Flexion and extension of the knees and internal and external
rotation of the hips is full and symmetric although there is
some
hamstring tightness. There is no pain with these motions.
Palpation of the calves is soft, nontender. The DP and PT
pulses
are full and symmetric.
Motor muscle testing reveals 5/5 strength in bilateral lower
extremities. Reflex provocation is full and symmetric in the
patellar and Achilles regions.
Pertinent Results:
The study
does demonstrate the previously imaged lesion within the T11
vertebral body. This is associated with moderate central canal
narrowing and bilateral mild neural foraminal stenosis. The
lesion is T1 hypointense, but heterogeneously T2 hyperintense
which does enhance with administration of gadolinium contrast
within the body of T11. Focus of lesion is leftward to the
midline and does extend to the posterior elements, specifically
into the left pedicle. Posterior wall is bowed causing
mild-to-moderate central canal stenosis. There does not appear
to be any thecal sac or spinal cord signal abnormalities or
morphologic abnormalities in the neurological structures. There
are no other lesions identified on the study. There are
multilevel degenerative changes throughout the thoracic spine,
which are generally mild.
Brief Hospital Course:
Mr [**Known lastname 4249**] went to the operating room on [**2107-11-10**], where he
underwent a T11 corpectomy and T9-L1 posterior fusion. He
tolerated the procedure well and there were no complications.
He lost 4500mL of blood during the procedure and required
transfusion with 2 units of blood. Post-operatively, he was
neurologically intact. He developed a post-operative DVT on
POD3 and required treatment with IV Heparin for anticoagulation.
He ultimately went to the endoscopy suite for an EGD for
evaulation of his alcoholic liver cirrhosis and possible
esophageal varices. All varices discovered were banded and he
was treated with coumadin for his DVT. He was started on a
bridge of Lovenox. He was dischaged in stable condition.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Propranolol 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Omeprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 1 weeks.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed for constipation.
12. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day for 1
months: Take as directed by coumadin clinic for INR of [**12-26**].
Disp:*30 Tablet(s)* Refills:*0*
13. Vicodin 1-2 tablets q 4hours prn for breakthrough pain.
Disp:*100 Tablet(s)* Refills:*0*
14. Oxycontin 10 mg PO BID for pain. Disp #30 tablets for 2 week
duration
15. Outpatient Lab Work
Please draw INR, platelets, and BUN/Creatinine on [**2107-11-21**] and fax results to: Dr[**Name (NI) 14065**] office:[**Telephone/Fax (1) 6309**] and
call [**Telephone/Fax (1) 250**]
16. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day for
as directed months: Please take as directed by Dr[**Name (NI) 14065**]
office/coumadin clinic.
Disp:*30 Tablet(s)* Refills:*0* target INR [**12-26**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Metastatic bladder cancer, T11 metastasis
Discharge Condition:
Stable
Discharge Instructions:
Keep your incision clean and dry. Okay to shower on POD5. Do
not immerse your incision in water until follow-up. If you have
any redness or drainage from the incision, or develop a fever of
101.5 or greater, please contact Dr.[**Name (NI) 19421**] office or go to
your nearest emergency room.
Your coumadin dosage will be followed by your PCP, [**Name10 (NameIs) **] [**First Name (STitle) **],
and by the coumadin clinic ([**Telephone/Fax (1) **]). Please call to schedule
an appointment. Please take daily coumadin and lovenox until
directed to stop taking the Lovenox by the coumadin clinic or by
Dr [**First Name (STitle) **].
Please follow-up with Dr [**Last Name (STitle) **] in 3 weeks for another EGD.
Please call his office to arrange an appointment.
Physical Therapy:
Gait training
Treatments Frequency:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
-
Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. . Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Followup Instructions:
As above, follow-up with coumadin clinic, your PCP, [**Name10 (NameIs) **] Dr
[**Last Name (STitle) **].
Follow-up with Dr [**Last Name (STitle) 1007**] in 2 weeks.
Completed by:[**2107-12-8**]
|
[
"571.2",
"198.5",
"285.22",
"511.9",
"V10.51",
"572.3",
"453.41",
"V43.5",
"456.20",
"789.59",
"401.9",
"V45.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"80.99",
"84.51",
"00.94",
"81.08",
"42.33",
"81.06",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
5764, 5819
|
3390, 4139
|
301, 345
|
5905, 5914
|
2530, 3367
|
8513, 8709
|
4162, 5741
|
5840, 5884
|
5938, 6703
|
1662, 2511
|
6721, 6735
|
6757, 6963
|
8047, 8490
|
240, 263
|
6975, 8035
|
373, 1212
|
1234, 1520
|
1536, 1647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,000
| 146,461
|
19575+57066
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-1-30**] Discharge Date: [**2173-2-8**]
Date of Birth: [**2133-7-8**] Sex: F
Service: NEURO MED
HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old
female with no significant past medical history who presented
with headache, vomiting and loss of consciousness. On the
day of admission the patient complained of the sudden onset
of headache followed by vomiting and then followed shortly
thereafter by loss of consciousness. She was taken to an
outside hospital where a head CT showed intercerebral
hemorrhage. The patient was transferred to [**Hospital1 346**].
PAST MEDICAL HISTORY:
Obesity.
MEDICATIONS:
None.
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY: The patient is married with several
children.
FAMILY HISTORY: There is no known family history of stroke.
PHYSICAL EXAMINATION ON ADMISSION:
VITAL SIGNS: Blood pressure 140/90. Pulse 70. Respiratory
rate 18.
GENERAL: The patient was intubated.
NECK: Supple.
LUNGS: There were decreased lung sounds on the right.
HEART: Showed regular rate and rhythm.
MENTAL STATUS: The patient was intubated but not sedated and
still had no response to verbal or tactile stimulation.
CRANIAL NERVE: There is no blink to threat. Her right pupil
is 4 mm and minimally reactive. Her left pupil is 4 mm
minimally reactive. Corneal reflexes are active. Motor
testing there is decreased tone throughout. There was no
spontaneous movements. On noxious stimulation she had
extensor posturing. Reflexes were decreased throughout.
Toes are upgoing bilaterally.
LABORATORY DATA:
Head CT on arrival showed a right posterior fossa bleed with
the epicenter at the cerebellar pontine angle involving the
pons, the medulla and right cerebellum. There was mass
effect on the fourth ventricle with no evidence of
hydrocephalus. There is no shift of midline structures.
The patient was admitted to the Neurologic Intensive Care
Unit.
HOSPITAL COURSE:
1. Neurology: The stroke service met with the
family to discuss that there was a very poor
neurologic prognosis. The patient's family wanted all
measures to be taken. The patient was evaluated by
Neurosurgery and felt there was no surgical intervention
indication. She was started on Mannitol to decrease any
intracranial pressure as well as she was hyperventilated to a
goal of PCO2 of approximately 25. The Mannitol and
hyperventilation were continued for several days without any
significant change in her exam. Serial head CT's were
obtained. The most recent head CT was on [**2-1**] which
showed extensive cerebellar and brain stem hemorrhage with
surrounding edema. There was effacement of the basal
cisterns. There was no hydrocephalus. The patient's
neurologic exam has remained essentially the same.
2. Cardiovascular: The patient was initially on a Nipride
drip and at times also on a Labetalol drip. Initially, her
blood pressure goal was less than 130 and this was gradually
liberated to goal of less than 140. She was converted to
oral hypertensives in the form of Lopressor and Hydralazine.
3. Respiratory: The patient was intubated by EMS. She
remains intubated on the ventilator. She was initially on
assist control and has recently transitioned to CPAP with
pressures aport. Plan is for a tracheostomy to be placed.
4. Fluid, electrolytes and nutrition: The patient was
initially on intravenous fluids. An nasogastric tube was
placed and she was started on nasogastric tube feeds. The
plan is for percutaneous endoscopic gastrostomy placement.
5. The patient was on gut protection with Pepcid.
6. Hematologic: The patient's hematocrit was consistently
low, most likely a combination of the intracerebral
hemorrhage, iron deficiency and her menses. The patient
given transfusions as needed to maintain a goal hematocrit of
approximately 30.
7. Infectious Disease: The patient was intermittently
febrile and cultured as clinically indicated. Sputum
cultures grew staph aureus and the patient was started on
Vancomycin. She is continuing on a course of Vancomycin with
a plan for 10 day course. Urine cultures also grew
klebsiella pneumoniae which were pan sensitive. She is
currently on Levofloxacin with a plan of a seven day course.
8. Code Status: The patient remains a full code. The
family desires percutaneous endoscopic gastrostomy and
tracheostomy placement which will be performed this week.
DIAGNOSES:
1. Pontine cerebellar hemorrhage.
2. Hypertension.
3. Anemia.
4. Pneumonia.
5. Urinary tract infection.
DR [**Last Name (STitle) **] [**Name (STitle) **] 13.279
Dictated By:[**First Name3 (LF) 53088**]
MEDQUIST36
D: [**2173-2-8**] 18:03
T: [**2173-2-10**] 14:07
JOB#: [**Job Number 53089**]
Name: [**Known lastname 9864**], [**Known firstname 9865**] Unit No: [**Numeric Identifier 9866**]
Admission Date: [**2173-1-30**] Discharge Date: [**2173-2-25**]
Date of Birth: [**2133-7-8**] Sex: F
Service: NEUROLOGY
This is an addendum to the previous discharge summary.
HOSPITAL COURSE:
1. Neurologic: The patient's neurologic exam did progress
slightly to the point that she did have bilaterally
spontaneous blinking eyes with some mild oculocephalic
reflexes consisting of inferior deviation, mainly of both
eyes, more prominent in the right eye than the left. There
was minimal abduction of the eyes bilaterally to
oculocephalic maneuvers. She did have gag and cough. She
was, also, seen to be spontaneously twitching her mouth.
However, despite the progression in the cranial nerve exam,
her mental status essentially remained the same, not
responding to any stimulus, including verbal or sternal rub.
2. Cardiovascular: The patient is maintained on metoprolol
for hypertension, and we allowed the goal of the systolic
blood pressure to be less than 160.
3. Respiratory: The patient initially was on the ventilator
until [**2173-2-25**], after which she was placed on the trach mask.
At this time, she is tolerating this well and will probably
be observed to insure that the trach is tolerated. She did
grow out sparse gram negative rods and gram staph aureus coag
positive in the sputum, and she was resumed on a new course
of oxacillin starting [**2173-2-24**] for a total of at least seven
days. Her blood gas on the trach mask was satisfactory.
4. Fluids, electrolytes, and nutrition: The patient is
still on tube feeds and had received percutaneous endoscopic
gastrostomy on [**2-10**]. In addition, it should be mentioned
that the patient, also, received a tracheostomy on that day,
[**2-10**].
5. Hematologic: The patient's hematocrit remained stable
and she did not receive any other transfusions since the time
of the last dictation.
6. Infectious disease: As prior.
7. Code status: The patient is still a full code.
DISCHARGE DIAGNOSES:
1. Pontine hemorrhage.
2. Obesity.
3. Hypertension.
DISCHARGE MEDICATIONS:
1. Oxacillin, 2 grams IV q 6 hours for an additional five
days.
2. Heparin, 5,000 units SQ q 12 hours.
3. Regular insulin sliding scale.
4. Miconazole powder 2%, one application TP q.i.d. p.r.n.
5. Sodium chloride nasal spray, one to two sprays NU t.i.d.
p.r.n. congestion.
6. Metoprolol, 75 mg PO t.i.d.
7. Tylenol, 325-650 mg PO q 4-6 hours p.r.n.
At the time, the plan for this patient is observation for 24
hours on the trach and she will be discharged on [**2173-2-26**] to a
chronic vent facility where the expectation is that she will
continue to wean off the artificial ventilation.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 74**]
MEDQUIST36
D: [**2173-2-25**] 08:34
T: [**2173-2-25**] 08:37
JOB#: [**Telephone/Fax (3) 9867**]
|
[
"473.8",
"288.0",
"482.41",
"431",
"599.0",
"507.0",
"518.81",
"285.9",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.6",
"38.93",
"93.90",
"43.11",
"99.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
781, 847
|
6866, 6922
|
6945, 7776
|
5075, 6845
|
164, 611
|
861, 1078
|
1094, 1940
|
633, 700
|
717, 764
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,523
| 133,248
|
21523
|
Discharge summary
|
report
|
Admission Date: [**2169-9-29**] Discharge Date: [**2169-10-3**]
Date of Birth: [**2138-7-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Right IJ and Swan-Ganz catheter placed
History of Present Illness:
Pt is a 31 yo with pmh significant for pulmonary hypertension,
active Heroin use, HIV, Hepatitis C, seizures related to heroin
use, recent MRSA soft tissue infection, who presented to the
[**Hospital Unit Name 153**] from direct transfer from OSH ED where had nl wbc count but
40% bands, hypotension to systolic of 50's requiring Levophed,
elevated AST, ALT, T.Bili, RUQ ultrasound showing edematous
thickened GB but no stones or CBD dilation. Pt was presumed to
have acute cholangitis, and sent to [**Hospital1 18**] for emergent ERCP.
During a recent hospitalization from which she was discharged
one week prior, she was found to have elevated AST and ALT
(isolated) which was thought due to either shock liver or toxin
(drugs or medications). RUQ pain radiates from just right of
the xiphoid process along the costal margin to the back. No
alleviating or exacerbating symptoms. No cp, sob, cough, ha,
fever, diarrhea, constipation.
Past Medical History:
Heroin abuse
Hepatitis C
Seizures associated with heroin use
HIV - on HARRT
pulmonary htn
Social History:
Lives with parents in [**Location (un) 5503**]. Has three children.
Previously worked at child care facility.
Family History:
non-contributory
Physical Exam:
T 99.0 HR 88 BP 98/62 RR 15 O2 sat 94%
Gen: lethargic, mild distress, skin without jaundice
HEENT: PERRLA, EOMI, sclera anicteric
Neck: no JVD, supple
Card: RRR, nl S1, loud S2, mild right sided heave, 4/6 SEM
loudest at LSB, no r/g
Lung: Soft rales at lung bases b/l
Abd: soft, mildly tender along right costal margin, no
rebound/gaurding; no [**Doctor Last Name 515**] sign; no ascites
Ext: wwp, no cce
Neuro: AAOx3, strength 5/5 throughout, 2+ reflexes throughout
Pertinent Results:
[**2169-9-29**] 08:46AM WBC-27.8* RBC-5.09 HGB-11.7* HCT-38.7 MCV-76*
MCH-23.1* MCHC-30.4* RDW-19.8*
[**2169-9-29**] 08:46AM NEUTS-67 BANDS-12* LYMPHS-4* MONOS-5 EOS-2
BASOS-0 ATYPS-0 METAS-8* MYELOS-2*
[**2169-9-29**] 08:46AM ALT(SGPT)-1551* AST(SGOT)-1578* LD(LDH)-557*
ALK PHOS-114 AMYLASE-89 TOT BILI-4.2*
[**2169-9-29**] 08:46AM GLUCOSE-85 UREA N-38* CREAT-1.6* SODIUM-133
POTASSIUM-5.6* CHLORIDE-106 TOTAL CO2-15* ANION GAP-18
CT abd/chest/pelvis:
IMPRESSION:
1. Slightly limited examination for pulmonary embolus due to
suboptimal bolus timing, with no pulmonary embolus identified.
2. Extensive bilateral pulmonary parenchymal consolidation and
bilateral pleural effusions, consistent with diffuse infectious
process.
3. Small pericardial effusion. Contrast refluxes into the
hepatic veins and IVC, consistent with right heart failure.
4. Anasarca and ascites.
5. No definite infectious source visualized in the abdomen.
U/S Abdomen:
IMPRESSION: 1) No evidence of acute cholecystitis. Gallbladder
wall thickening and echogenicity, consistent with AIDS
cholangiopathy. No intra or extrahepatic biliary ductal
dilatation. If there is persistent clinical concern, a HIDA scan
could be performed for further evaluation.
2) Enlarged and echogenic kidneys, consistent with HIV
nephropathy.
3) Small amount of ascites, not sufficient to mark for tap.
4) Small right pleural effusion.
5) Limited Doppler examination of the liver is grossly
unremarkable.
Blood Culture at OSH: 4/4 bottles with pneumoncoccus
Brief Hospital Course:
Pt was admitted and placed on vasopressors. She was found to be
septic with high wbc count, bandemia, hypotension, tachycardia,
hyperthermia, and blood cultures from OSH found to be positive
for pneumococcus. Pt was treated with broad antibiotic coverage
upon arrival. Repeat abdominal ultrasound with doppler at [**Hospital1 18**]
again showed no sign of bile duct obstruction and no portal
hypertension. Further review of the abdomen showed elevated
LFTs which trended down, thought secondary to shock liver vs.
effects of toxins. In work-up of abdominal pain there was no
abscess, no significant ascites. CT scan of chest showed no PE,
was positive for pneumonia. As patient continued to be
hypotensive on vasopressors, a swan-ganz catheter was placed and
she was found to have severe pulmonary hypertension with
systolic pulmonary artery pressure in 150's. A nitrous oxide
inhalation trial was without response. The patient had increased
work of breathing and eventually required intubation for
respiratory exhaustion. After several days of worsening heart
failure and elevated pulmonary hypertension the patient had a
cardiopulmonary arrest with PEA and despite efforts to
resuscitate, died.
Medications on Admission:
At Home:
Epivir
Naprosyn
Videx
Stavudine
*
From OSH ED:
Ceftriaxone
Tequin
Dilaudid
Morphine
Cefepime
Protonix
Vit K
Discharge Medications:
N/A
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Hypertension
HIV
Hepatitis C
Heroin Use
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2169-10-16**]
|
[
"305.51",
"428.0",
"286.7",
"570",
"481",
"038.2",
"518.5",
"785.51",
"V08",
"780.39",
"995.92",
"070.70",
"416.8",
"427.5",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"00.12",
"99.07",
"38.91",
"96.71",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
5051, 5057
|
3653, 4856
|
325, 365
|
5151, 5156
|
2110, 3630
|
5208, 5243
|
1590, 1608
|
5023, 5028
|
5078, 5130
|
4882, 5000
|
5180, 5185
|
1623, 2091
|
274, 287
|
393, 1333
|
1355, 1446
|
1462, 1574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,610
| 188,265
|
2691
|
Discharge summary
|
report
|
Admission Date: [**2172-5-26**] Discharge Date: [**2172-6-23**]
Date of Birth: [**2115-2-7**] Sex: F
Service: MEDICINE
Allergies:
Provera
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
Shortness of breath, orthopnea
Major Surgical or Invasive Procedure:
Pericardial window
Inferior vena cava filter
History of Present Illness:
Patient complaining of SOB and dry cough x 5 days especially
with any type of exertion. Patient is currently getting
chemotherapy for peritoneal cancer. No fevers or chills. No
URI Sx. Unchanged Nausea and vomiting. Positive constipation,
no diarrhea. Patient unable to lay flat. Patient reports that
this feels similar to a few years ago when she had pleural
effusions requiring a tap.
.
In the ED, initial VS were: 99 112/93 30 100. 97% 4L NC. Her
exam was notable for decreased breath sounds on the right. A
chest X-ray confirmed the presence of a large pleural effusion
and there was a question of an infiltrate and so the patient was
given vanc/cefepime to cover HAP. She was noted to be
tachycardic and so was given 1.5L NS without improvment in her
tachycardia. She was also given morphine 2mg and zofran 4mg for
pain. There was also confern for a pericardial effusion based
on her CXR. A bedside ultrasound revealed what appeared to be a
moderate pericardial effusion without evidence of RV collapse.
Patient was transferred to the MICU for further care which
included a pericardial drainage.
.
Upon transfer to the OMED floor, she is breathing more
comfortably with the pericardial drain removed. She is still
tachypneic, still tachycardic.
Past Medical History:
.
Past Oncologic History: *per most recent clinic note, with
updates*
Ms. [**Known lastname **] presented with dyspnea and a pleural effusion in
12/[**2166**]. Pleural fluid cytology was consistent with poorly
differentiated adenocarcinoma. CT showed a moderate amount of
intra-abdominal ascites and enhancing nodularity within the
peritoneal/omental fat consistent with carcinomatosis/omental
caking. CA-125 was elevated at 909. On [**2167-12-23**] she underwent a
thoracoscopy with pleurodesis, biopsy of the left parietal
pleura and right percutaneous drainage of pleural effusion.
There was bulky metastatic disease within the pleural space. She
started carboplatin and paclitaxel on [**2167-12-31**]. After 3 cycles,
she underwent surgical debulking and TAH/BSO by Dr. [**Last Name (STitle) 2028**] on
[**2168-3-31**]. She was optimally debulked and had minimal residual
disease. She received 3 additional cycles of carboplatin/taxol
post-operatively, last treatment on [**2168-6-15**]. Her CA 125 started
trending up in [**4-3**]. CT torso in [**6-3**] was notable for a right
sided pleural effusion which was malignant based on cytology
from thoracentesis on [**2169-7-28**]. She started carboplatin/taxol
again on [**2169-8-17**]. She had recurrent pleural effusion and
underwent thoracentesis on [**2169-9-14**] and again in [**12-6**]. She
underwent talc pleurodesis on [**2170-1-10**]. CT on [**2170-2-14**] showed new
mediastinal and retroperitoneal lymphadenopathy as well as
markedly increased soft tissue thickening along the right
pleura, extending into the anterior mediastinum. She started
Doxil on [**2170-2-21**]. She stopped after 7 cycles because her CA 125
rose and her CT was unchanged. She was given a chemotherapy
break. However, she developed rapidly enlarging lymphadenopathy
in her neck in 11/[**2169**]. She started Navelbine 30mg/m2 on
[**2170-11-1**]. She received D1 and D8 doses, but was neutropenic on
D15.
.
Navelbine was dose reduced to 25mg/m2 during her second cycle,
but she again became neutropenic and the D15 dose was held. Her
regimen was changed to Navelbine 30mg/m2 on D1 and D15 of a 28
day cycle and each dose is being followed with neulasta. Her
CA-125 decreased from 340 to 167 after 3 cycles, but then rose
to 273 in early 3/[**2170**]. Vaginal biopsy on [**2171-2-21**] performed due
to vaginal bleeding was notable for metastatic poorly
differentiated carcinoma. Patient started gemcitabine C1 D1 on
[**2171-10-3**]. She completed 4 cycles of gemcitabine until having
her dose held on [**2172-1-23**] due to concern of either progression
of disease or gemcitabine pulmonary toxicity causing. On
[**2172-2-11**], patient began external beam radiotherapy to a dose of
3000 cGy in 10 fractions.
.
OTHER PAST MEDICAL AND SURGICAL HISTORY:
-HTN
-h/o postmenopausal bleeding w/uterine fibroids
-TAH-BSO with optimal debulking in [**2168-3-28**]
-pleurodesis x2
-right knee surgery
-hysteroscopic myomectomy in [**2163**]
-ventral hernia repair
-status post exploratory laparotomy in [**2169-11-28**]
-placement of a port in [**2170-6-29**]
-poorly differentiated adenocarcinoma - peritoneal
adenocarcinoma.
.
Social History:
Denies past or present use of tobacco. She denies use of
alcohol. She lives at home with her husband and works 2 jobs,
both in the medical field. Has children, including a daughter
by the name of [**Name (NI) 13409**], as well as a sister in [**Name (NI) 622**].
Family History:
Sister with breast cancer.
Physical Exam:
VS: T 98.2, 110/80, HR 80, R22, 96% RA NC 2L
GEN: AOx3, NAD (slightly lethargic -> blood glucose 58, given
juice and improved)
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal.
Chest: Decreased breath sounds bilaterally, no crackles or
wheezes
Abd: soft, NT, +BS. no rebound/guarding. epigastric/RUQ
nontender mass.
Extremities: wwp, no edema. DPs, PTs 2+, no evidence of hematoma
Skin: no rashes or bruising.
Pertinent Results:
Admission Labs
[**2172-5-26**] 04:55PM PT-14.1* PTT-24.9 INR(PT)-1.2*
[**2172-5-26**] 04:55PM PLT COUNT-714*
[**2172-5-26**] 04:55PM NEUTS-78.8* LYMPHS-11.3* MONOS-8.1 EOS-1.5
BASOS-0.4
[**2172-5-26**] 04:55PM WBC-9.0 RBC-3.90* HGB-9.3* HCT-29.6* MCV-76*
MCH-23.7* MCHC-31.3 RDW-20.6*
[**2172-5-26**] 04:55PM cTropnT-<0.01
[**2172-5-26**] 04:55PM estGFR-Using this
[**2172-5-26**] 04:55PM GLUCOSE-118* UREA N-20 CREAT-1.0 SODIUM-134
POTASSIUM-6.6* CHLORIDE-97 TOTAL CO2-27 ANION GAP-17
[**2172-5-26**] 05:41PM LACTATE-2.4*
[**2172-5-26**] 05:41PM COMMENTS-GREEN TOP
[**2172-5-26**] 05:49PM SODIUM-138 POTASSIUM-4.2 CHLORIDE-96
[**2172-5-26**] 07:50PM URINE HYALINE-[**10-17**]*
[**2172-5-26**] 07:50PM URINE RBC-0-2 WBC-[**1-31**] BACTERIA-MOD YEAST-NONE
EPI-[**10-17**]
[**2172-5-26**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-NEG
[**2172-5-26**] 07:50PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.031
[**2172-5-26**] 08:47PM HGB-9.0* calcHCT-27
[**2172-5-26**] 07:50PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.031
[**2172-5-26**] 08:47PM HGB-9.0* calcHCT-27
[**2172-5-26**] 08:47PM GLUCOSE-113* LACTATE-1.7 NA+-137 K+-3.7
CL--102
[**2172-5-26**] 08:47PM TYPE-ART TEMP-36.3 PO2-148* PCO2-35 PH-7.49*
TOTAL CO2-27 BASE XS-4 INTUBATED-NOT INTUBA COMMENTS-O2 DELIVER
.
Discharge Labs
.
[**2172-6-6**] 06:30AM BLOOD WBC-8.6 RBC-3.78* Hgb-9.6* Hct-31.7*
MCV-84 MCH-25.4* MCHC-30.3* RDW-19.6* Plt Ct-352
[**2172-6-6**] 01:59AM BLOOD WBC-8.2 RBC-3.69* Hgb-9.3* Hct-30.3*
MCV-82 MCH-25.2* MCHC-30.6* RDW-19.5* Plt Ct-307
[**2172-6-5**] 05:57PM BLOOD WBC-7.3 RBC-3.81* Hgb-9.8* Hct-31.3*
MCV-82 MCH-25.6* MCHC-31.2 RDW-19.6* Plt Ct-364
[**2172-6-5**] 05:55AM BLOOD WBC-8.5 RBC-3.62* Hgb-9.3* Hct-29.9*
MCV-83 MCH-25.8* MCHC-31.2 RDW-19.5* Plt Ct-335
[**2172-6-6**] 06:30AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL
[**2172-6-5**] 05:57PM BLOOD Hypochr-1+ Anisocy-3+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-2+ Polychr-1+ Target-OCCASIONAL
Burr-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2172-6-5**] 05:55AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
[**2172-6-6**] 06:30AM BLOOD Plt Smr-NORMAL Plt Ct-352
[**2172-6-6**] 06:15AM BLOOD PTT-101.0*
[**2172-6-6**] 01:59AM BLOOD Plt Ct-307
[**2172-6-5**] 10:59PM BLOOD PTT-117.9*
[**2172-6-5**] 05:57PM BLOOD Plt Ct-364
[**2172-6-6**] 06:30AM BLOOD Glucose-80 UreaN-14 Creat-0.6 Na-136
K-4.4 Cl-102 HCO3-26 AnGap-12
[**2172-6-5**] 05:55AM BLOOD Glucose-79 UreaN-15 Creat-0.6 Na-137
K-4.5 Cl-103 HCO3-28 AnGap-11
[**2172-6-4**] 06:01AM BLOOD Glucose-91 UreaN-17 Creat-0.7 Na-136
K-4.6 Cl-103 HCO3-26 AnGap-12
[**2172-6-3**] 03:28AM BLOOD Glucose-91 UreaN-15 Creat-0.3* Na-144
K-5.0 Cl-111* HCO3-24 AnGap-14
[**2172-6-2**] 05:35AM BLOOD ALT-8 AST-18 LD(LDH)-232 AlkPhos-81
TotBili-0.5
[**2172-5-31**] 08:31PM BLOOD CK(CPK)-22*
[**2172-5-30**] 06:08AM BLOOD ALT-8 AST-16 LD(LDH)-192 AlkPhos-76
TotBili-0.2
[**2172-6-1**] 05:35AM BLOOD CK-MB-1 cTropnT-0.02*
[**2172-5-31**] 08:31PM BLOOD CK-MB-1 cTropnT-0.02*
[**2172-5-26**] 04:55PM BLOOD cTropnT-<0.01
[**2172-6-6**] 06:30AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.8
[**2172-6-5**] 05:55AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8
[**2172-6-4**] 06:01AM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.7#
Mg-1.9
[**2172-6-3**] 03:28AM BLOOD Calcium-8.2* Phos-1.9*# Mg-2.2
[**2172-5-31**] 06:35AM BLOOD calTIBC-194* Ferritn-202* TRF-149*
[**2172-5-29**] 12:18PM BLOOD CA125-669*
[**2172-6-6**] 06:30AM BLOOD Vanco-22.2*
[**2172-5-28**] 06:28AM BLOOD Vanco-26.4*
[**2172-6-3**] 03:28AM BLOOD EDTA Ho-HOLD
[**2172-5-30**] 06:08AM BLOOD GreenHd-HOLD
[**2172-5-30**] 06:07AM BLOOD Type-MIX pO2-38* pCO2-50* pH-7.37
calTCO2-30 Base XS-1 Intubat-NOT INTUBA
[**2172-5-27**] 12:53PM BLOOD Type-ART pO2-105 pCO2-38 pH-7.45
calTCO2-27 Base XS-2 Intubat-NOT INTUBA
[**2172-5-26**] 08:47PM BLOOD Type-ART Temp-36.3 pO2-148* pCO2-35
pH-7.49* calTCO2-27 Base XS-4 Intubat-NOT INTUBA Comment-O2
DELIVER
[**2172-5-30**] 06:07AM BLOOD Lactate-1.6
[**2172-5-27**] 12:53PM BLOOD Glucose-117* Lactate-1.9 K-4.8
[**2172-5-26**] 08:47PM BLOOD Glucose-113* Lactate-1.7 Na-137 K-3.7
Cl-102
[**2172-5-27**] 12:53PM BLOOD O2 Sat-97
[**2172-5-26**] 08:47PM BLOOD Hgb-9.0* calcHCT-27
.
Microbiology:
.
STaph coagulase negative grew in urine culture [**6-3**] and a blood
culture [**5-17**].
.
Reports:
.
OTHER BODY FLUID
OTHER BODY FLUID ANALYSIS WBC Hct,Fl Polys Lymphs Monos Mesothe
Other
[**2172-5-27**] 12:50 3500* 12.0*1 16* 1* 10* 63* 10*2
PERICARDIAL FLUID
SPUN HEMATOCRIT PERFORMED
CLUSTERS OF LARGE ATYPICAL CELLS, SOME IN CLUSTERS
HIGHLY SUSPICIOUS FOR MALIGNANCY
REFER TO CYTOLOGY FOR CONFIRMATION
REVIEWED BY [**Last Name (NamePattern4) 13410**], MD [**2172-5-29**]
OTHER BODY FLUID CHEMISTRY TotProt Glucose LD(LDH) Amylase
Albumin
[**2172-5-27**] 12:50 5.3 57 1261 34 2.3
PERICARDIAL FLUID
.
CT OF THE ABDOMEN AND PELVIS
HISTORY: 57-year-old female with history of primary peritoneal
carcinoma with
metastasis to the pleura s/p pleurodesis, pericardium, and
retroperitoneum.
Admitted with shortness of breath and positive pulmonary emboli.
Progression
of carcinoma?
COMPARISONS: CTA of the chest dated [**2172-6-2**]. CT torso dated
[**2172-3-27**].
TECHNIQUE: CT of the abdomen and pelvis performed from the lung
bases to the
pelvis after administration of oral and intravenous contrast.
Patient
received 100 cc of Optiray intravenously without complication.
Additionally,
sagittal and coronal reformats were obtained for review.
FINDINGS:
LUNG BASES: Stable appearance of the partially included right
hemithorax with
air bronchograms and consolidative right lower lung. Pleural
thickening and
soft tissue enhancement of the pleural space is unchanged.
Hyperdense pleura
appears stable and likely the sequelae of pleurodesis. Partially
loculated
left effusion with pleural enhancement and focal nodularity is
unchanged in
the interim. Loculated pericardial collections are stable. The
largest
loculation appears to significantly indent the right atrium.
Coronary
calcifications. Pulmonary arteries are partially included, and
redemonstrate
nonocclusive left lower lobe clot. Enhancing nodes in the
anterolateral chest
wall.
CT OF THE ABDOMEN FOLLOWING CONTRAST:
Liver enhances normally without focal masses. Gallbladder is
unremarkable.
Spleen is within normal limits. Slightly atrophic pancreas with
mild
prominence of the proximal pancreatic duct, not significantly
changed. Adrenal
glands are unremarkable bilaterally. Kidneys enhance normally
without
hydronephrosis or focal lesion. Abdominal aorta is normal in
caliber and no
opacification. Numerous soft tissue masses in the
retroperitoneum likely
representing lymphadenopathy versus primary carcinoma deposits
are unchanged.
Stomach slightly distended containing oral contrast material and
ingested
debris. Interval progression of fluid filled small bowel
distention
predominantly in the mid abdomen and pelvis. Small bowel loops
measure up to
3cm. Apparent fecalization of the segmental small bowel loop in
the midline of
the pelvis. The terminal ileum appears relatively decompressed.
This suggests
a transition point possibly in the ileum. The colon is
nondilated containing
abundant stool. Stable scattered soft tissue lesions throughout
the small
bowel mesentery predominantly in the lower abdomen and pelvis,
likely
representing carcinoma deposits, unchanged. Worsening diffuse
anasarca and
intraabdominal and pelvic ascites. No evidence of perforation,
pneumatosis or
abnormal fluid collections.
Abdominal aorta is normal in caliber and opacification. Proximal
branch
vessels are patent.
CT PELVIS:
Under-filled urinary bladder is unremarkable. Uterus and adnexa
stable.
Distended rectal vault containing air and stool.
BONE WINDOWS: Stable minimal degenerative changes with anterior
osteophyte
formation of the mid thoracic spine. No destructive osseous
lesions.
IMPRESSION:
1. Progressive dilatation of multiple fluid-filled small bowel
loops
predominantly in the mid and lower abdomen and pelvis. Relative
decompression
of the terminal ileum. This raises question of a transition
point in the
ileum and partial small bowel obstruction. No pneumatosis,
extraluminal air,
or abnormal fluid collections. Worsening intraabdominal and
pelvis ascites.
2. Stable known right pleural/pericardial metastasis and left
pleural/pericardial loculated effusions.
3. Stable soft tissue deposits within the small bowel mesentery
and
retroperitoneum.
4. Worsening anasarca.
The study and the report were reviewed by the staff radiologist.
.
CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 13411**]
Reason: please eval for PE
Field of view: 36 Contrast: OPTIRAY Amt: 75
[**Hospital 93**] MEDICAL CONDITION:
57 year old woman with peritoneal ca who presents with
pericardial effusion s/p
drainage. Repear ECHo shows RV dilation concerning for
possible PE that is new
since her last ECHO on [**5-28**] and prior CTA [**5-27**]. Pt with SOB,
hypoxia and
tachycardia
REASON FOR THIS EXAMINATION:
please eval for PE
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: ENYa TUE [**2172-6-2**] 6:02 PM
1. Multifocal small LUL and LLL segmental pulmonary emboli. No
ascciated
parenchymal abnormality in the left lung to suggest pulmonary
infarct.
2. An isoldate tiny pulmonary embolus in the RLL lobar branch
(image 3:49),
non-occlusive.
3. Mostly consolidated right lung, with air-bronchogram and
moderate volume
loss, grossly unchanged prior to [**5-27**], compatible with prior
tumor
infiltration and pleurodesis.
4. Unchanged small left-sided pleural effusion.
5. Small-to-moderate pericardial effusion, slightly increased
from prior.
6. No definite CT evidence of RV straining.
Final Report
CT PULMONARY ANGIOGRAM
INDICATION: Peritoneal carcinoma, post drainage of pericardial
effusion with
concern for pulmonary embolus on echocardiography. Shortness of
breath,
hypoxia, tachycardia.
TECHNIQUE: CTA chest performed prior to and after IV contrast.
COMPARISON STUDY: [**2172-5-27**].
CTA CHEST:
FINDINGS: Evaluation of pulmonary arteries show tiny
subsegmental pulmonary
emboli identified in the left upper and left lower lobe, new
since prior
imaging.
There is evidence for prevascular and axillary adenopathy, the
maximum in the
prevascular space measuring 1.6 x 0.8 cm. Left axillary lymph
node measures
up to 1.6 x 2.1 cm. These are stable when compared with prior
CT. There is a
pericardial effusion, unchanged in appearance since prior
radiograph and
slightly enlarged compared to CT [**2172-5-27**].
Extensive consolidated lung found in the posterior segment of
the right upper
lobe. The entire right lower lobe again consolidated, unchanged
since prior
examination. There is evidence of previous right-sided
thoracotomy with
volume loss and pleurodesis at the right lung base. Stable since
[**2170-1-27**].
There are small bilateral pleural effusions, greater on the left
side, again
stable when compared with prior examination. No osseous
abnormalities.
IMPRESSION:
1. Tiny subsegmental left upper and left lower lobe pulmonary
emboli.
2. Extensive consolidation within the right hemithorax stable
when compared
with prior imaging.
3. Persistent mediastinal and axillary adenopathy.
4. Slight increase in pericardial fluid.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) 13412**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2172-6-4**] 5:15 AM
.
ECHO [**6-2**]
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. There is abnormal septal motion/position. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is a very small
apical pericardial effusion without evidence of hemodynamic
compromise.
Compared with the prior study (images reviewed) of [**2172-5-28**], the
right ventricle is now larger and more hypokinetic. Is there a
history to suggest a primary pulmonary process (e.g., pulmonary
embolism, bronchospasm, pneumonia, etc.)
.
Pericardial fluid, cell block:
Scantly cellular preparation with rare atypical cells,
(seen only on levels S7-S10.) (See note.)
Note: Most of the atypical cells show nuclear
staining with WT-1 and cytoplasmic staining with cytokeratin
AE1-3/CAM5.2. The cells are nonreactive for calretinin. The
stains [**Last Name (un) **]-31 and B72.3 are non-contributory due to insufficient
cellular material. This immunoprofile is non-specific. See
also corresponding cytology report C10-[**Numeric Identifier 12993**].
.
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 13413**]
Reason: r/o pna v. effusion
[**Hospital 93**] MEDICAL CONDITION:
57F h/o peritoneal CA p/w gradually worsening SOB and dry
cough x5d
REASON FOR THIS EXAMINATION:
r/o pna v. effusion
Final Report
INDICATION: 57-year-old female with history of peritoneal
cancer, now
presents with gradually worsening shortness of breath and dry
cough for five
days.
COMPARISON: Chest radiograph [**2172-2-19**] and CT torso [**3-27**], [**2171**].
AP UPRIGHT CHEST RADIOGRAPH: There is increased opacification of
the right
hemithorax compared to the prior study with faint air
bronchograms in the mid
and lower right lung. There is an interval increase in the
layering moderate
right pleural effusion. Changes reflect progression of the
patient's known
metastatic pulmonary and pleural disease. A superimposed
infection cannot be
excluded. The left lung is unremarkable. There has been interval
increase in
small-to-moderate left pleural effusion. No pneumothorax is
detected. The
enlargement of the heart is stable. The hilar contours are
unremarkable.
IMPRESSION:
1. Interval increase in the pleural effusions bilaterally.
2. Increasing pulmonary opacities in the right mid and lower
lung, suggest
progression of the patient's known pleural and parenchymal
metastatic disease.
A superimposed infection cannot be excluded.
The study and the report were reviewed by the staff radiologist.
IVC Placement [**2172-6-8**]:
HISTORY: Peritoneal cancer with pulmonary embolus and slow GI
bleed for IVC
filter placement.
PHYSICIANS: Procedure was performed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**], Dr.
[**First Name (STitle) 13414**]
[**Name (STitle) 13415**], and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9441**]. Dr. [**Last Name (STitle) 9441**], the attending
radiologist, was
present and supervised throughout the entire procedure.
COMPARISON: Comparison is made with a CT abdomen and pelvis of
[**2172-6-4**].
ANESTHESIA: 1% buffered lidocaine for local anesthesia.
PROCEDURE AND FINDINGS: The risks, benefits, and alternatives to
the
procedure were explained to the patient and written informed
consent was
obtained. The patient was brought to the angiography suite and
placed supine
on the table. Her right groin was prepped and draped in the
usual sterile
fashion. A preprocedure timeout and huddle were performed per
standard [**Hospital1 18**]
protocol.
Under [**Name (NI) 13416**], the right common femoral vein was punctured
with a 19-gauge
needle, through which [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was advanced into the
inferior vena cava.
Needle was exchanged for an Omni Flush catheter, which was
advanced to the
confluence of the iliac veins. Venogram was performed and
demonstrated a
single IVC with no filling defects in the infrarenal portion.
The origin of
the renal veins was noted to be at the level of the upper
endplate of L2.
Based on these diagnostic findings, a decision was made to place
an infrarenal
OptEase IVC filter.
The [**Last Name (un) 7648**] wire was placed through the catheter and the
catheter removed.
Over the wire, an OptEase vena cava filter sheath was placed.
The wire and
inner dilator were removed and the filter was placed through the
sheath and
successfully deployed in the infrarenal position. A fluoroscopic
spot image
was obtained and saved digitally.
The sheath was removed and hemostasis achieved with digital
compression for 10
minutes. Sterile dressings were applied.
The patient tolerated the procedure well with no immediate
complications.
IMPRESSION:
1. IVC gram with no IVC duplication and no filling defects
noted.
2. Successful infrarenal placement of an OptEase IVC filter via
the right
common femoral venous access approach. This filter is
retrievable for a
period of two weeks if clinically indicated or may stay as a
permanent
filter.
The study and the report were reviewed by the staff radiologist.
CXR [**2172-6-10**]
IMPRESSIONS: Pleural effusions remain small. Consolidation of
right lung
persists. No pericardial air.
.
KUB [**2172-6-12**]
IMPRESSION: No evidence of obstruction or ileus.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
57 year old F with poorly differentiated primary peritoneal
adenocarcimona who is s/p multiple treatment modalities and who
presented on [**2172-5-26**] with SOB and cough for 5 days that
subsequently improved with pericardiocentesis. Her hospital
course, which now spans nearly one month, has had multiple
complications, including bilateral PEs, now s/p IVC stent, Afib
with RVR, gastrointestinal bleed, slowly resolving partial bowel
obstruction, acute kidney injury, and complicated UTI.
.
# Pericardial effusion: Large effusion seen on echo which was
drained - 650cc bloody fluid; shortness of breath vastly
improved following the dranaige in the ICU, and she was
transferred to the OMED floor on [**5-29**] as a result. Gram stain/cx
of the fluid showed POLYMORPHONUCLEAR LEUKOCYTES and the fluid
culture was negative for acid fast bacteria. The fluid had many
white blood cells and atypical cells indicating mailignant
origin. CT scan of chest [**5-27**]: the small size of the right
atrium, if not due to hypovolemia, may indicate constrictive
physiology. Repeat Echo on [**6-2**] showed no significant
reaccumulation of pericardial fluid, however showed right heart
strain.
# Bilateral PEs: Because of the evidence of right heart strain
on Echo, CTA was done to r/o PE's. On CTA ([**6-2**]) the patient was
found to have bilateral segmental PE's, as a result heparin drip
was started after testing stool guiac which was negative. IVC
stent was subsequently placed without any complications. Heparin
was stopped in the setting of guaiac positive stool. ASA 81mg
was started for anticoagulation prophylaxis.
.
# Pleural effusions: Bilateral chronic effusions. Has had 2
pleurodeses in the past. The follwing CT findings were seen on
CT chest [**5-27**]: 1. Progressive consolidation of the right lung,
sparing only the apex and obscuring previous tumor infiltration
is probably due to restrictive effects of circumferential right
pleural thickening, partially calcified following pleurodesis.
2. Despite a small residual pericardial effusion, and the
indwelling pericardial drain, the small size of the right
atrium, if not due to hypovolemia, may indicate constrictive
physiology. Clinical correlation is needed. Since the patient
was symptomatically improved with good oxygen saturations
following the pericardiocentesis, it was deduced that the
pleural effusions were not a significant contributor to her
presenting complaints. The pleural effusions remained stable
throughout the remainder of her hospitalization.
.
# GI bleed: Downtrending Hct in the setting of blood clots
following an enema were concerning for GI bleed. Lovenox, which
was started in the setting of PE, was changed to Heparin. GI was
consulted, who recommended that heparin be discontinued and that
no further anticoagulation be given. Aspirin was started for
anticoagulation in the setting of Afib as recommended by
Cardiology.
.
# AFib with RVR: The patient triggered on [**6-2**] for heart rate in
the 160-170 and found to have atrial fibrillation. She was
effectively rate controlled with IV lopressor pushes. She
subsequently had several more episodes of Afib with RVR that
were precipitated by sitting up and moving to the cammode; she
responded to lopressor pushes. She was started on PO metoprolol
tartrate, which was titrated to 50mg [**Hospital1 **] based on the
recommendations of a cardiology consult. Cardiology diagnosed
her arrhythmia as asymptomatic episodic paroxysmal atrial
fibrillation, requiring no intervention with antiarrhythmic
medications because she spontaneously converts on her own and
only gentle rate control. Due to repeated episodes of
asymptomatic tachycardia due to afib, she was taken off of
telemetry monitoring per cardiology.
.
# Partial bowel obstruction: Over the course of the
hospitalization, she developed a partial bowel obstruction -
presenting with a tense, tender abdomen, abdominal pain, and
nausea. GI was consulted who diagnosed the partial obstruction
and bleeding as being due to invasion of the colonic wall by her
cancer. She was made NPO and her diet was gently advanced to
clears. A KUB was obtained, which ruled out perforation and
showed significant constipation. Supportive laxatives were given
orally and rectally daily, but to no significant avail. To date
she has had fewer than 5 bowel movements, which have been watery
and loose. She continues to tolerate a conservative full clear
liquid diet without any abdominal pain or nausea.
.
# Anemia: Was transfused 2 units [**6-1**] in effort to increase
hemoglobin in the setting of sinus tachycardia and blood clots
per rectum.
.
# Bacteremia: The patient had gram positive cocci growing in
clusters, coagulase negative which grew in her blood from
culture sample taken from her port on [**6-2**]. Most probably a
contaminant since the patient had no leukocytosis, fevers, or
other clinical signs of an infection. No signs of infection at
her port either. The patient had also grown staph. bacteria
coagulase negative from urine culture taken [**6-3**]. This bacteremia
could be caused by infected port even though the port site does
not have any erythema or fluctuation. It also could still be
contamination because of no clinical signs of fever or
leukocytosis. Started and currently continuing Vancomycin as a
precaution ([**6-4**]). We took another blood sample from her port on
[**6-4**], to reassess. Subsequent cultures were negative and
antibiotics were discontinued.
.
# [**Last Name (un) **]: Developed elevated creatinine suggestive of pre-renal
[**Last Name (un) **], which resolved to her baseline with supportive IVF.
.
# Complicated UTI: Developed a UTI in the setting of a recent
indwelling urinary catheter. She was treated with Cipro and sent
home with 1 day of antibiotics for a total course of 10 days.
.
# Peritoneal carcinoma: Failed multiple treatments including two
cycles of alimta. Was decided during this admission that further
treatment would be with palliative intent.
.
Medications on Admission:
Codeine-Guaifenesin 100 mg-10 mg/5 mL
Compazine 10 mg 6 hours as needed for nausea
Dexamethasone 4 mg one Tablet(s) by mouth twice a day The day
before, the day of and the day after chemotherapy [**2172-5-7**]
Dicyclomine 10 mg 2 Capsule(s) by mouth four times a day
(Prescribed by Other Provider; [**2172-3-30**] discharge meds - not
started med yet) Folic Acid 1 mg
Hydromorphone 4 mg [**11-30**] Tablet(s) by mouth 2very 4-6 hours as
needed for pain
Hydromorphone 4 mg Tablet [**11-30**] Tablet(s) by mouth q3h (every
three hours) as needed for pain (Prescribed by Other Provider;
[**2172-3-30**] discharge meds)
Lorazepam 0.5 mg Tablet [**11-30**] Tablet(s) by mouth Q8 hours as
needed for nausea, insomnia
Reglan 5 mg Tablet QIDACHS
Ondansetron HCl 8 mg 1 Tablet(s) by mouth Q8 hours as needed for
nausea
Bisacodyl 5 mg Tablet, 2 Tablet(s) by mouth DAILY (Daily) as
needed for constipation
Docusate Sodium
Senna 8.6 mg Tabletonce a day
Discharge Medications:
1. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Disp:*28 Tablet(s)* Refills:*4*
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for nausea: Hold for oversedation .
Disp:*42 Tablet(s)* Refills:*4*
4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
5. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous PRN (as needed) as needed for DE-ACCESSING port.
6. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*28 * Refills:*4*
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Disp:*120 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily): for constipation; may refuse; hold for diarrhea.
Disp:*30 Suppository(s)* Refills:*2*
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation: may refuse; hold for
diarrhea.
Disp:*30 units* Refills:*2*
14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO BID (2 times a day): for constipation; patient may refuse;
hold for diarrhea.
Disp:*30 units* Refills:*2*
15. Morphine 10 mg/5 mL Solution Sig: 10-20 mg PO Q2H (every 2
hours) as needed for pain.
Disp:*30 units* Refills:*2*
16. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea:
dissolve sublingually.
Disp:*48 Tablet, Rapid Dissolve(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Lower [**Doctor Last Name 4048**]
Discharge Diagnosis:
Primary Peritoneal Carcinoma
Secondary: Pericardial Effusion
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It has been my privilege to take care of you in the hospital.
.
You were brought to the hospital because of worsening shortness
of breath. Several imaging studies showed fluid around your
heart. This fluid was successfully drained without complication
and your diffuculty breathing improved. Radiographic imaging
also showed fluid accumulating in your chest cavity, known as
pleural effusions. These fluid collections remained stable and
were not thought to be contributing significantly to your
shortness of breath because your symptoms improved after
draining fluid from around your heart.
.
Further radiographic imaging of your chest showed clots in both
lungs. To prevent further clots, you were started on an
anticoagulation medication, but at a low dose because blood
clots observed in your rectum raised concern for
gastrointestinal bleeding. Due to the risk of bleeding presented
by increasing the anticoagulation medication in the setting of a
suspected gastrointestinal bleed, the decision was made to place
a filter in your inferior vena cava instead - the inferior vena
cava is a major vein feeding blood into the heart. This was done
to prevent further clots from being pumped into your lungs. This
procedure was successfully completed and the decision was made
to stop the anticoagulation medication and to start a
conservative, safe dose of aspirin in its place.
.
During your hospitalization, you developed several bouts of
rapid heart rate found to be caused by an irregular heart rhythm
known as atrial fibrillation. The episodes were controlled with
a medication that slows the heart rate to safe levels known as
metoprolol. Cardiology specialists saw you in the hospital and
diagnosed your heart rhythm as intermittent paroxysmal atrial
fibrillation, which is a rhythm that often causes patients who
have it no symptoms and which corrects itself. Given this
diagnosis and that you experienced no symptoms from the rhythm,
we stopped 24h monitoring of your heart based on the
recommendations of our cardiac colleagues. We will be
discharging you on metoprolol.
.
Due, in part, to your progressive peritoneal cancer, you
developed a partial bowel obstruction during this
hospitalization. Radiographic imaging showed no evidence of a
complete bowel obstruction or evidence of a hole in your bowel,
but did show that you were quite backed up with stool.
Aggressive bowel regimens were given to you by mouth and per
rectum with mixed success. You continued to pass gas per rectum
over the course of the hospitalization, but you only had
intermittent watery bowel movements. In addition, you had
several episodes of abdominal pain without associated nausea,
which were partially relieved with IV and oral morphine. After
these episodes, we made your diet order nothing per mouth (NPO)
and slowly advanced your nutrition as tolerated. We were very
conservative in advancing your diet because you have not had a
sizable bowel movement for some time now; you will be discharged
on an agressive bowel regimen by mouth and per rectum and on a
full liquid diet.
.
During this hospitalization, your kidneys showed temporary signs
of dehydration, but this resolved with intravenous fluid.
.
You were also found to have a suspected urinary tract infection,
which was treated with oral antibiotics. You will be discharged
on this antibiotic to complete a total 10 day course.
.
Other than what is detailed below, no changes were made to your
outpatient medication regimen.
# NEW: Ciprofloxacin 500mg 2x daily x 2 days (last day [**2172-6-24**])
# NEW: Metoprolol 50mg 2x daily
# NEW: Aspirin 81mg daily
# NEW: Bisacodyl 10 mg per rectum daily as needed for
constipation
# NEW: Lactulose 30 mL by mouth every 8h as needed for
constipation
# NEW: Polyethylene Glycol 17g by mouth 2x daily
# NEW: Fentanyl 50 mcg/hr transdermal patch replaced every 72h
# NEW: Morphine Sulfate (Oral Soln.) 10-20 mg by mouth every 2h
as needed for pain
# NEW: Ipratropium Bromide 1 NEB inhaled every 6h
.
# INCREASED TO: Metoclopramide 10 mg every 6h as needed for
nausea
# DECREASED TO: Ondansetron HCl 4 mg 1 Tablet(s) by mouth every
8h as needed for nausea
.
# STOPPED: HYDROmorphone (Dilaudid) 4 mg [**11-30**] Tablet(s) by mouth
2very 4-6 hours as needed for pain
# STOPPED: Dexamethasone 4 mg one Tablet(s) by mouth twice a
day; the day before, the day of and the day after chemotherapy
# STOPPED: Dicyclomine 10 mg 2 Capsule(s) by mouth four times a
day
# STOPPED: Docusate Sodium as needed for constipation
# STOPPED: Senna as needed for constipation
# STOPPED: Bisacodyl 5 mg Tablet, 2 Tablet(s) by mouth daily as
needed for constipation
# STOPPED: Folic acid 1mg daily
.
The following medications were not changed:
# UNCHANGED: Codeine-Guaifenesin 100 mg-10 mg/5 mL
# UNCHANGED: Lorazepam 0.5-1 mg every 8h as needed for anxiety
# UNCHANGED: Prochlorperazine Maleate 10 mg Tablet 1 Tablet PO
every six (6) hours as needed for nausea.
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD
Office Phone: ([**Telephone/Fax (1) 5562**]
Office Location: [**Hospital Ward Name 23**] 9
Division: Hematology/Oncology
|
[
"158.8",
"197.0",
"560.9",
"996.64",
"198.89",
"238.71",
"584.9",
"599.0",
"518.81",
"578.9",
"285.9",
"197.2",
"427.31",
"E879.6",
"415.11",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.21",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
32146, 32223
|
22981, 28977
|
298, 344
|
32328, 32328
|
5611, 14478
|
37422, 37586
|
5112, 5140
|
29970, 32123
|
18810, 18878
|
32244, 32307
|
29003, 29947
|
32467, 37399
|
5155, 5592
|
228, 260
|
18910, 22958
|
372, 1635
|
32343, 32443
|
1657, 4814
|
4830, 5096
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,950
| 173,995
|
13385
|
Discharge summary
|
report
|
Admission Date: [**2155-4-19**] Discharge Date: [**2155-4-26**]
Date of Birth: [**2108-2-1**] Sex: M
Service: CCU
CHIEF COMPLAINT: Chief complaint of status post ventricular
fibrillation arrest.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
male with a history of coronary artery disease, status post
acute myocardial infarction 20 years ago, status post
4-vessel coronary artery bypass graft in [**2136**], status post
myocardial infarction in [**2151**] (with an right coronary artery
to saphenous vein graft stent), status post myocardial
infarction in [**2152**] (with an saphenous vein graft to left
anterior descending artery percutaneous transluminal coronary
angioplasty; at that time had an ejection fraction of 40%),
history of diabetes, and hypertension who was admitted to
[**Hospital1 69**] after surviving a
ventricular fibrillation arrest on a flight from [**Location (un) 86**] to
Venezuelae. The plane landed in [**Male First Name (un) 1056**].
Per nephew, the patient had four to five weeks of progressive
chest pressure with exertion with increased use of
nitroglycerin. He refused to seek medical advice at that
time. Per wife, the patient has had angina for several years
but was told in [**State 2690**] there was no more they could do. On
flight from [**Location (un) 86**] to Venezuelae, the patient had a
ventricular fibrillation arrest on Thursday evening,
automatic external defibrillator was used and with two to
three shocks was delivered from ventricular fibrillation. No
available strips at this time. The plane was diverted to
[**Male First Name (un) 1056**] where his nephew met him. The patient was
intubated on the airstrip, but answering questions
appropriately at that time.
He was transferred to a second hospital in [**Male First Name (un) 1056**] and
started on amiodarone drip, heparin drip, and nitroglycerin
drip. There, revealed an ejection fraction of 30%. It was
reported that a maximum troponin of greater than 500 with a
maximum creatine kinase of greater than 16,000. The patient
was subsequently transferred to [**Hospital1 188**] from [**Male First Name (un) 1056**].
At [**Hospital1 **], the patient was lightly sedated, on
a propofol drip. He recognized his wife and nephew and
answered all questions appropriately. He denied any chest
pain.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post myocardial
infarction 20 years ago; status post 4-vessel coronary artery
bypass graft in [**2146**] (saphenous vein graft to first obtuse
marginal, saphenous vein graft to circumflex, saphenous vein
graft to left anterior descending artery, saphenous vein
graft to right coronary artery); status post myocardial
infarction in [**2151**] and [**2152**].
2. Diabetes.
3. Hypertension.
MEDICATIONS ON ADMISSION: Medications on arrival included
atenolol 50 mg p.o. q.d., Vascor 200 mg p.o. q.d.,
Imdur 20 mg p.o. q.d., sublingual nitroglycerin p.r.n.,
aspirin 81 mg p.o. q.d., Zantac 150 mg p.o. b.i.d.,
niacin 500 mg p.o. q.d., Zocor 40 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in [**Location 40655**]. He is an
emergency medical technician physician. [**Name10 (NameIs) 40656**] use; quit
20 years ago. He is married with two children.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
intubated, on assist control of 12, tidal volume of 900, FIO2
of 40%, positive end-expiratory pressure of 5, temperature
of 102.4, pulse of 69, blood pressure of 99/55, respiratory
rate of 12, satting 95% to 99% on room air. In general, a
middle-aged male, intubated, lightly sedated. Head, eyes,
ears, nose, and throat revealed pupils were equally round and
reactive to light. The oropharynx was clear. Endotracheal
tube in place. Mucous membranes were moist. Jugular venous
distention not visualized. Chest was clear anteriorly. No
wheezes or rales. Cardiovascular examination revealed a
regular rate. No murmur. First heart sound and second heart
sound were normal. There was a third heart sound audible.
Abdomen revealed bowel sounds were positive, soft and
nontender. No rebound or guarding. Extremities revealed
there was trace edema, cool extremities, good distal pulses
bilaterally. No femoral bruits. There was a large left
groin hematoma. On neurologic examination, the patient was
lightly sedated. He opened his eyes to command, comprehended
simple commands. Skin revealed there was no rash.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
revealed a white blood cell count of 13.7 (78% polys and
16% lymphocytes), hematocrit of 41.2, platelets of 170. PT
of 13.6, INR of 1.3, PTT of 37.2. Sodium of 145, potassium
of 3.5, chloride of 107, bicarbonate of 25, blood urea
nitrogen of 18, creatinine of 1.2, glucose of 117. ALT
of 179, AST of 339, alkaline phosphatase of 58, total
bilirubin of 0.8. Creatine kinases on admission were 8585;
MB of 14; with an index of 0.2, and a troponin of greater
than of 50.
RADIOLOGY/IMAGING: Chest x-ray revealed a right subclavian
line in the right anterior inferior vena cava, endotracheal
tube about 6 cm above the carina. There was evidence of
cardiomegaly with pulmonary congestion.
Electrocardiogram on arrival revealed sinus rhythm at 72,
with normal axis, Q waves in V1 to V3, flat T waves
throughout, biphasic D in first diagonal, tall P in lead II.
HOSPITAL COURSE:
1. CARDIOVASCULAR: The patient was admitted with
ventricular fibrillation arrest, likely in the setting of an
acute coronary syndrome given the fact that his troponins and
creatine kinases were elevated. However, the patient
presented chest pain free. His aspirin, Lopressor, Lipitor,
heparin drip, nitroglycerin drip were continued. The
patient's creatine kinases were cycled; however, they
continued to remain elevated with a negative index. The
patient's statin was held secondary to elevated creatine
kinases. The patient was extubated on the following morning
and was stable. The patient was sent for cardiac
catheterization.
Cardiac catheterization revealed an occlusion of the left
anterior descending artery at the site of the saphenous vein
graft to left anterior descending artery graft. The patient
also had two grafts that were occluded. The native left
anterior descending artery was stented successfully, and the
patient was returned to the Coronary Care Unit.
The patient was continued on Plavix status post
catheterization and Integrilin. The patient also had an
echocardiogram which showed an ejection fraction of 15% to
20% with inferobasal aneurysm. The patient was started on
anticoagulation for a low ejection fraction and a question of
an aneurysm; initial on heparin and then converted to
Coumadin.
Given the patient's ventricular fibrillation arrest, the
patient was taken for an Electrophysiology study which
revealed fossae of ventricular tachycardia, and the patient
was taken the following day for implantable
cardioverter-defibrillator placement. Status post
defibrillator placement, the patient's chest x-ray was okay.
Interrogation revealed that the defibrillator was working,
and the patient was discharged with implantable
cardioverter-defibrillator in place, off amiodarone.
2. PULMONARY: The patient was admitted intubated on
arrival. However, the following morning the patient was
successfully extubated and had stable room air saturations.
On hospital day two, after extubation, the patient developed
flash pulmonary edema and was treated with intravenous Lasix,
morphine, and nitrates. The patient continued to be diuresed
aggressively (1 liter to 2 liters per day). The patient
eventually regained stable saturations and was discharged on
a low dose of Lasix 20 mg p.o. q.d.
3. INFECTIOUS DISEASE: The patient was admitted with a
question of pneumonia given a temperature of 102.4 and
question of a retrocardiac density on chest x-ray. The
patient also with a question of dirty urine, consistent with
a urinary tract infection. The patient was placed on
Levaquin and will be treated with a 14-day course. The
patient remained afebrile during the rest of his
hospitalization.
4. ENDOCRINE: The patient with a history of diabetes and
was treated initially with an insulin drip and was switched
over to a regular insulin sliding-scale.
5. RHEUMATOLOGY: The patient was admitted with increased
creatine kinases, although negative index, question of a
myopathy versus myositis. The patient was on niacin and a
statin as an outpatient which were discontinued upon arrival,
and the patient creatine kinases continued to trend down with
a maximum of 9000, trending down to 1700 upon discharge.
DISCHARGE DIAGNOSES:
1. Acute myocardial infarction; status post ventricular
fibrillation arrest; status post implantable
cardioverter-defibrillator placement.
2. Congestive heart failure with inferobasal aneurysm; on
anticoagulation.
3. Pneumonia.
4. Elevated creatine kinases secondary to statin/niacin.
5. Diabetes.
6. Hypertension.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Atenolol 25 mg p.o. q.d.
2. Zestril 10 mg p.o. q.d.
3. Coumadin 5 mg p.o. q.h.s. (to be adjusted at the
[**Hospital 197**] Clinic).
4. Lasix 20 mg p.o. q.d.
5. Aspirin 325 mg p.o. q.d.
6. Plavix 75 mg p.o. q.d.
7. Folate 1 mg p.o. q.d.
8. Colace 100 mg p.o. b.i.d.
9. Sublingual nitroglycerin p.r.n.
10. Zyrtec 10 mg p.o. q.d.
DISCHARGE FOLLOWUP: The patient was to follow up with the
Electrophysiology Clinic on Tuesday. The patient was also to
follow up at the [**Hospital 197**] Clinic for an INR check. The
patient was also to follow up with Dr. [**Last Name (STitle) **] for follow up of
his low ejection fraction and coronary artery disease.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2155-4-30**] 18:40
T: [**2155-5-1**] 14:38
JOB#: [**Job Number 40657**]
|
[
"412",
"427.41",
"401.9",
"414.02",
"428.0",
"250.00",
"427.5",
"V45.81",
"410.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"88.56",
"36.01",
"99.20",
"96.04",
"37.23",
"96.71",
"37.26",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
8690, 9012
|
9039, 9422
|
2817, 3094
|
5408, 8669
|
149, 214
|
9443, 10004
|
243, 2341
|
2363, 2790
|
3111, 5390
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,769
| 121,431
|
2046
|
Discharge summary
|
report
|
Admission Date: [**2175-11-18**] Discharge Date: [**2175-11-21**]
Date of Birth: [**2107-11-25**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 5188**]
Chief Complaint:
perisplenic hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 67 female directly admitted from [**Hospital **] [**Hospital 1459**]
Hospital to te [**Hospital1 18**] SICU. Patient was admitted to the [**Hospital **]
[**Hospital 1459**] hospital on [**2175-11-9**] with a cecal vulvulous, small
bowel obstruction, and cecal perforation. She underwent a right
colectomy on [**2175-11-9**] and was recovering enough to be transfered
out of the ICU on [**11-10**]. On [**11-17**] she developed LUW pain, was
found to be hypotensive and had a HCT of 24 (down from 31). CT
scan showed a perisplenic hematoma. She was transfused to units
PRBC's and returned to the SICU. Per the patient's family's
wishes, she was transfered to [**Hospital1 18**]. No CP/SOB/N/V. Mild
abdominal pain on presentation to [**Hospital1 18**]. Previously was
tolerating a regular diet post-op with return of bowel function.
Past Medical History:
1. COPD last PFT's [**4-3**]
2. stage III Non-small cell ling ca s/p L upper lobectomy when
stage I with concurrant chemo, then lefo pneumonectomy [**6-3**],
completed further course of chemo. CT [**9-4**] shows no evidence of
new dz
3. HTN
4. Echo [**2175-11-10**]: LVEF 65%, mild LVF, mild MR, LAE, mild TR
Social History:
fomer smoker, 2 glasses of wine per day
Physical Exam:
P 105 BP 153/3 RR 16 96% RA
NAD, AOx3
tachy
CTA on R, no BS on left
Abd mildly distended by soft. tender in LUQ with gaurding. no
rebound. Incision with 2 areas of open wound packed with
iodoform gauze, staples in place with no wound cellulitis
ext warm with no edema
Pertinent Results:
[**2175-11-18**] 09:19PM BLOOD WBC-11.7*# RBC-3.28* Hgb-10.4* Hct-28.9*
MCV-88# MCH-31.8 MCHC-36.2* RDW-15.1 Plt Ct-469*
[**2175-11-18**] 10:06PM BLOOD Glucose-118* UreaN-4* Creat-0.4 Na-134
K-3.8 Cl-99 HCO3-25 AnGap-14
[**2175-11-18**] 10:06PM BLOOD Calcium-7.8* Phos-2.5*# Mg-1.4*
[**2175-11-20**] 05:35AM BLOOD WBC-11.7* RBC-3.16* Hgb-10.1* Hct-29.3*
MCV-93 MCH-32.1* MCHC-34.6 RDW-14.7 Plt Ct-608*
Brief Hospital Course:
Upon transfer the patient was admited to the general surgery
service and placed in the SICU. The patient was kept NPO, HCT
was checked q4 hrs, and IV antibiotics were continued from the
OSH (ceftriaxone and flagyl). On [**2175-11-18**] the hematocrits had
been stable and the patient was doing well clinically. She was
transfered to the floor and started on clear liquids to advance
as tolerated. HCT's were checked q12 hours; again they were
stable. LUQ abdominal pain persisted but lessened with time. On
[**2175-11-20**] several additional staples were removed from the
abdominal wound allowing it to drain; it was packed with
det-tot-dry dressings [**Hospital1 **]. On [**2175-11-21**] the patient was
tolerating a regular diet, had bowel function and a stable
hematocrit; she was subsequently discharged home with VNA for
dressing changes.
Medications on Admission:
lisinopril 10mg [**Hospital1 **]
clonidine 0.1mg TID
metoprolol 25mg [**Hospital1 **]
fosamax
albuterol and atrovent
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
peripslenic hematoma, wound infection
Discharge Condition:
good
Discharge Instructions:
Restart you home medications as usual. Regular diet. You may
resume activity as tolerated.
You may shower, then pat-dry incision. Do not rub incision. No
tub baths or swimming for 3-4 weeks. Keep the wound packed as
instructed.
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Inability to pass gas or stool
* Other symptoms concerning to you
Followup Instructions:
1. Call Dr.[**Name (NI) 6045**] office for a follow-up appointment
[**Telephone/Fax (1) 5189**]
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
|
[
"998.59",
"V10.11",
"496",
"401.9",
"998.12",
"E878.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4039, 4097
|
2342, 3194
|
339, 346
|
4179, 4186
|
1916, 2319
|
4612, 4818
|
3361, 4016
|
4118, 4158
|
3220, 3338
|
4210, 4589
|
1628, 1897
|
279, 301
|
374, 1224
|
1246, 1556
|
1572, 1613
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,801
| 167,451
|
7958
|
Discharge summary
|
report
|
Admission Date: [**2116-11-16**] Discharge Date: [**2116-11-20**]
Date of Birth: [**2035-12-10**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Iodine; Iodine Containing / Influenza Virus
Vaccine
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Found down, hypotensive in the ED
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 yo man with history of neuroendocrine tumor s/p colostomy and
chemotherapy, paroximal atrial fibrillation on coumadin who
presents being found down by wife. [**Name (NI) **] had been feeling weak for
4 days. Then today, he was taking his sock off when he slipped
off the bed and fell to floor. His wife reports that he did not
hit his head. He was unable to crawl to phone to call 911. His
wife arrived after approximately 3 hours and called EMS. BP
initially 140/90.
.
In the ED: VS 102.4, 150/88, HR 94, RR16, 98% RA, EKG no change
per ED (not avail). Labs: lactate 1.0, Creatinine, Hct at
baseline. WBC 9.7, up from baseline 4.0. U/A neg and CXR w ? RLL
infiltrate per ED res. Trop 0.04 (baseline). Cultures and flu
test drawn. He received cipro, flagyl, 1gm tylenol. Then SBP
dropped to 80s. Given 3L IVF and added ceftriaxone 2gm IV once.
SBP up to 100 (baseline 150).
.
Currently, reports persistent bilateral proximal upper extremity
weakness x 1-2 weeks. He did have a fall 2 weeks prior and
caught himself with his arms. Did not note increased pain
immediately, but in the days following. Has been using arms
less, which could explain some deconditioning, but he thinks
there may be an additional cause. He reports good compliance
with medications. No head pain, no meningismus, no photophobia.
POS rhinorrhea but no cough, URI-like sx. No chest pain, sob,
palpitations, abd pain, fevers. No increased diarrhea or
constipation. POS chills x1-2 weeks. POS upper ex prox weakness
x1-2 weeks. No dysuria.
Past Medical History:
1. Prostate cancer status post definitive radiation treatment
from [**1-/2113**] to 05/[**2112**]. This treatment was delivered under the
care of Dr. [**Last Name (STitle) 656**] here at [**Hospital1 18**] and Dr. [**Last Name (STitle) 9125**] of urology.
2. Cardiomyopathy, echo [**12-3**]: EF 60%.
3. Atrial fibrillation, s/p pacemaker, on coumadin
4. Hiatal hernia.
5. Diverticular disease status post a diverticular stricture
status post low anterior resection by Dr. [**Last Name (STitle) **] here at [**Hospital1 18**]
6. Neuroendocrine rectal cancer dx [**2115-6-29**]. per heme/onc
notes: "s/p two cycles of cisplatin and etoposide following his
surgery prior to which he had also received the same regimen
with a good response. Recently, he was found on a followup CT
scan to have what appeared to be a recurrence of his disease.
However, the nature of this recurrence was not clear, and he
recently underwent a biopsy of a pelvic mass which does not show
any evidence of malignancy. In addition, his PSA has been rising
as well which in [**1-/2116**] was 3.5 and then in [**4-/2116**] was 5.3 and
most recently on [**2116-5-29**] was 6.1."
Social History:
Married, 5 children, lives in [**Location **]. Retired police
commander. Quit tobacco 30yrs ago. No current EtOH.
Family History:
Family history is unremarkable for colorectal cancer. His
father had esophageal cancer but was a heavy smoker. His
paternal aunt had stomach cancer.
Physical Exam:
VS: 98.5 144/84 HR 90 97% RA, RR 17
GEN: NAD, comfortable, interactive,
NEURO
- alert to person, place, time, situation
- CN ii-xii intact
- motor: [**5-2**] bilat upper distal. [**3-2**] upper right prox, [**4-2**] upper
left prox. [**5-2**] bilat lower distal/prox strength
- [**Last Name (un) 36**] intact light touch
- reflexes: toes down, 1+ ankle, knees, brachiorad bilat
HEENT: MM dry, PERRLA, anicteric, JVP flat
CARDS: irreg, no murmurs, no heave
LUNGS: no wheeze, no crackles, clear, nl effort
ABD: incision midline, colostomy left lower ex with yellow/brown
stool. BS+ NT ND, no hepatomeg, no rebound
EXT: no edema, DP 2+ bilat, no palpable cord or assymetry
GROIN: erythematous rash w satellites
SKIN: no hematomas. 18 [**Doctor Last Name **] 20g IVs
OB: trace positive
Pertinent Results:
[**2116-11-16**] 03:00PM WBC-9.7# RBC-4.38* HGB-13.3* HCT-37.7* MCV-86
MCH-30.5 MCHC-35.4* RDW-14.0
[**2116-11-16**] 03:00PM NEUTS-90.3* LYMPHS-5.4* MONOS-3.8 EOS-0.3
BASOS-0.1
[**2116-11-16**] 03:00PM PT-24.1* PTT-36.8* INR(PT)-2.4*
[**2116-11-16**] 03:00PM ALT(SGPT)-16 AST(SGOT)-37 LD(LDH)-289* ALK
PHOS-97 AMYLASE-24 TOT BILI-0.7
[**2116-11-16**] 03:00PM GLUCOSE-120* UREA N-29* CREAT-1.5*
SODIUM-130* POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-22 ANION GAP-16
[**2116-11-16**] 09:29PM TSH-0.24*
[**2116-11-16**] 05:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
[**2116-11-19**] 9:34 AM CT CHEST W/CONTRAST; CT ABD W&W/O C
CHEST: Note is made of goiter with calcification and multiple
small nodules, unchanged since prior study. There is significant
mediastinal and hilar lymphadenopathy. The lymph node in
pretracheal measures 12 mm in short axis, and the right hilar
node measures 22 mm in short axis, and subcarinal node measures
42 x 26 mm. These lymph nodes are overall slightly increased in
size since prior study. The heart is moderately enlarged, and
there is dense calcification of the coronary arteries. There is
small bilateral pleural effusion, new since prior study.
Calcified pleural plaque is again noted, suggestive of prior
asbestos exposure. There is a large hiatal hernia. In the lung
window, note is made of new patchy consolidation in the right
lower lobe, associated with interlobular septal thickening and
faint ground-glass opacities, suspicious for pneumonia or
aspiration/aspiration pneumonia or hemorrhage if the patient has
hemoptysis. There are several patchy nodules without
calcification measuring up to 8 mm in the right upper lobe,
overall unchanged since prior study. No endobronchial lesion is
noted.
ABDOMEN: There are multiple hypoattenuating foci in the liver as
noted on the prior study, likely representing cysts. There are
several other ill-defined hypoattenuating foci, one in segment
IV and the other in segment VI, for which metastasis cannot be
totally excluded. However the evaluation for these liver lesions
is limited on this single-phase study. There is no intrahepatic
ductal dilatation. Portal vein is patent. Spleen is normal.
Again note is made of enlarged left adrenal gland likely
representing adenoma. Right adrenal gland is within normal
limits. Pancreas is atrophic, with prominent main pancreatic
duct measuring up to 3 mm, unchanged since prior study. CBD
measures 9 mm. Gallbladder is contracted without evidence of
calcification. There is no ascites or fluid collection. There is
no significant lymphadenopathy in the abdomen. There are
multiple hypoattenuating foci in the kidneys, likely
representing cysts, without hydronephrosis or suspiciously
enhancing mass. The visualized portions of large and small
intestines are within normal limits with ileostomy. There is a
2.0 cm enhancing nodule in the right subcutaneous tissues in the
back at the level of L2, representing increased metastasis.
PELVIS: Again note is made of large heterogeneous masses lateral
to the right psoas muscle measuring 88 x 69 mm, and other
mesenteric metastasis on the left measuring 39 x 37 mm (series
3: image 89), increased in size since prior study. There is no
free fluid or significant lymphadenopathy. There are tiny
bladder diverticula with air in the diverticula and in the
urinary bladder.
Degenerative changes of thoracolumbar spine are again noted.
There is severe scoliosis. Again note is made of thickened
trabecula and cortex in the right ilium and sacrum, as seen
since [**2112**], consistent with Paget disease. In the region of
Paget disease, it is difficult to exclude new metastasis,
however, otherwise, no suspicious lytic or blastic lesion is
noted.
IMPRESSION:
1. Slight increase in size of mediastinal and hilar
lymphadenopathy as well as increase in size of intraperitoneal
metastatic masses. 2.0-cm subcutaneous nodule in the posterior
right back at the level of L2 increased in size since prior
study, also representing metastasis.
2. Multiple hypoattenuating foci in the liver, likely
representing cysts. Two other ill-defined foci, which are
equivocal, however, metastasis cannot be totally excluded for
these findings. Please consider dedicated liver imaging if
indicated.
3. Unchanged left adrenal adenoma.
4. New bilateral pleural effusion with underlying calcified
plaques, and new patchy consolidation in the right lower lobe
with surrounding faint ground- glass opacity, suspicious for
pneumonia or aspiration versus aspiration pneumonia, or
hemorrhage if the patient has hemoptysis. Please correlate
clinically.
5. Overall unchanged noncalcified small nodule in bilateral
lungs, measuring up to 8 mm.
6. Degenerative changes and Paget disease in the pelvis. With
the underlying Paget disease, it is difficult to exclude new
metastasis in this location, however, no obvious suspicious new
lytic or blastic lesion is noted.
Brief Hospital Course:
A/P: 80yo man with hx of neuroendocrine colon ca s/p resection
and chemo now with recurrence, prostate cancer, atrial
fibrillation on coumadin here with 1-2 weeks of proximal UE
weakness, decreased PO x 4 days, and hypotensive episode in the
ED. He was febrile but improved with 3L IVF.
.
# Hypotension: Transient (<1h) in the ED but after having a
fever to 102.4. Infectious etiologies possible and initially no
localizing symptoms. Assessed for adrenal insufficiency (but
denies history of steroid use), cardiogenic (but no CP, SOB and
EKG reportedly unchanged), allergic (no new medications),
hypovolemia [**1-31**] poor intake, blood loss (hct at baseline).
Resolved with IVF, ROMI completed with 3 negative CEs. Stable
since initial hypotensive episode. CT evaluation revealed
probable pneumonia, and was treated with antibiotics.
.
# Mechanical Fall: Patient AAOx3 and good historian. Wife
confirms story. Given history of colon ca, found down, and INR
2.4, head CT performed and revealed no evidence of hemorrhage.
Rule-out completed for acute MI. States he has unsteady gait,
with both cane and walker at home, which he doesn't use. States
he will use cane in the future. PT consulted - recommended d/c
home with continued therapy
.
# Fever: Negative ROS for localizing symptoms. Received cipro,
flagyl, ceftriaxone in ED. [**11-17**]: Spiked temp with some rigors.
Empirically started levo/flagyl. DFA flu negative. Blood cx with
1/4 bottles GPC indicating likely contaminant but given
hypotension and fever, started Vancomycin despite minimal
bottles being positive. C.dif checked and negative.
Levo/flagyl discontinued. Speciation of blood cultures
consistent with contaminant. CT findings suggestive of PNA
though continued to have minimal symptoms. Discharged on
levoquin for a 10 day course.
.
# Atrial fibrillation - s/p pacer on coumadin. Coumadin
continued and INR monitored throughout his stay.
.
# HTN: Continued on beta blocker. Lisinopril held due to
hypotension and poor renal function. Well controlled during
stay with only beta blocker. Discharged with instruction to
follow-up with PCP to discuss continued management.
.
# Acute Renal Failure: Baseline creatinine 1.3, elevated on
admit. Thought to be c/w with prerenal. Urine lytes sent for
confirmation. Rehydrated with IVF and creatinine monitored.
Resolved to baseline and discharged with confirmed complete
resolution.
.
# Proximal muscle weakness: For 1-2 weeks s/p mechanical fall
and catching himself with his arms extended. DDx includes
deconditioning [**1-31**] pain, polymyalgia rheumatica, vasculititis,
hypothyroidism, fibromyalgia, malignancy, and rhabdomyolysis.
Elevated ESR & CRP. TSH slight below normal, free T4 normal.
By discharge had symmetric strength on exam, nonpainful. [**Doctor First Name **]
negative. Suspect likely due to deconditioning. CK monitored
and downward trending on discharge. Sent with home PT and
follow-up with primary care physician.
.
# Neuroendocrine tumor: Dr. [**Last Name (STitle) **] [**Name (NI) 653**] and saw patient while
in the hospital. CT torso completed to assess for further
metastases, and new lesions were seen. These findings were
discussed with Mr. [**Known lastname 28553**]. Catecholamines were checked, and
pending on discharge. On discharge he had follow-up
appointments for lesion biopsy and to discuss these results with
Dr. [**Last Name (STitle) **].
.
# Groin rash: Noted on admit, stated to have been there for [**12-31**]
weeks. Appears fungal. Treated with miconazole cream PRN with
improvement. Was discharged with this medication and
instruction to follow-up with his primary care should it not
resolve.
.
# Anemia: HCT stable. Will work-up various etiologies including
decreased production; lysis or loss. Stable throughout stay.
Stools were guaiac negative, no evidence of lysis on labs. To
follow-up with primary care physician.
.
# History of prostate cancer: Flomax held on admission given
hypotension, but restarted when became normotensive. Unclear
whether lesions on CT represent recurrence of prostate cancer or
neuroendocrine tumor. To follow-up with Dr. [**Last Name (STitle) **], after tissue
biopsy within the next month.
Medications on Admission:
colace [**Hospital1 **] prn
coumadin 2mg daily but 1mg tues/fri
enalapril 10mg [**Hospital1 **]
flomax 0.8mg qhs
toprol XL 25mg [**Hospital1 **]
Vitamin C
Iron
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
2. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO twice a
day.- INSTRUCTED TO HOLD until discussion with PCP
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
7. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
8. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 8 days.
Disp:*12 Tablet(s)* Refills:*0*
9. Miconazole Nitrate 2 % Cream Sig: One (1) application Topical
twice a day as needed for rash for 7 days.
Disp:*1 Tube* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA caregroup
Discharge Diagnosis:
Primary: Mechanical fall, pneumonia
Secondary: Prostate cancer, cardiomyopathy, atrial fibrillation,
diverticular disease, neuroendocrine rectal cancer s/p LAR
Discharge Condition:
Hemodynamically stable, afebrile and ready for continued
outpatient PT
Discharge Instructions:
You were admitted after being found down, after falling. You
were found to have an episode of low blood pressure which
resolved with fluid administration. You were also found to have
pneumonia. You are being discharged on antibiotics for this.
You were also evaluated by CT imaging for extension of your
cancer, you should follow up with Dr. [**Last Name (STitle) **] for further
evaluation of this ongoing issue.
.
Please continue to take all medications as prescribed. In
addition to your regular medications you have been given an
antibiotic, levoquin, for an additional 8 days.
.
Please keep all your outpatient appointments.
.
Please return to the ED or contact your regular physician if
your notice worsening cough, bloody sputum, fevers/chill,
vomiting, loose stools or for any other symptom which is
concerning to you.
Followup Instructions:
Dr.[**Name (NI) 11574**] office will contact you to schedule a follow-up
appointment in the next 1-2 weeks. His office number is
[**Telephone/Fax (1) 250**] if you would like to contact them yourself.
.
For your upcoming biopsy you need to check in at:
Provider: [**Name10 (NameIs) 454**],TWO [**Name10 (NameIs) 454**]
Date/Time:[**2116-12-1**] at 9:00AM
.
Provider: [**Name10 (NameIs) **] SCAN scheduled for biopsy
Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2116-12-1**] at 10:30AM
.
To discuss the results of your biopsy:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2116-12-11**] at 9:30AM
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
|
[
"486",
"276.1",
"584.9",
"427.31",
"V44.3",
"728.87",
"425.4",
"110.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14535, 14579
|
9216, 13442
|
365, 372
|
14783, 14856
|
4212, 9193
|
15735, 16521
|
3243, 3395
|
13653, 14512
|
14600, 14762
|
13468, 13630
|
14880, 15712
|
3410, 4193
|
291, 327
|
400, 1920
|
1942, 3094
|
3110, 3227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,453
| 154,583
|
54325
|
Discharge summary
|
report
|
Admission Date: [**2191-1-7**] Discharge Date: [**2191-1-20**]
Date of Birth: [**2113-4-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Increase in chest discomfort with activity
Major Surgical or Invasive Procedure:
Aortic valve replacement.
Coronary artery bypass grafting.
Ascending aortic arch replacement.
History of Present Illness:
Ms. [**Known lastname 745**] is a 77 yo woman with known aortic stensis followed
by serial echocardiograms. She reports recent increase in chest
discomfort with ambulation for which she was referred for
acrdiac cath revealing 85-90% LM stenosis and a 90% ostial D1
stenosis.
Last echocardiogram in [**9-30**] showed aortic valve area of 0.6,
with a peak gradient of 100, mild tricuspid regurgitation, mild
mitral regurgitation, and ejection fraction of 60%.
On the day of her cardiac cath she was transferred from [**Hospital **] to [**Hospital1 18**] for further eval and management.
Past Medical History:
Hypertension.
Hyperlipidemia.
Gastroesophageal reflux disease.
Transient Ischemic Attack in [**2173**] and [**2184**].
Subacute right occipital infarct [**9-30**] (no deficit).
S/P sex change operation in [**2167**].
Former tobacco -- quit in [**2181**].
Physical Exam:
Neuro: Grossly intact.
Pulmonary: Lungs clear to ascultation bilaterally.
Cardiac: S1S2. III/IV systolic ejection murmur.
Abdomen: Soft, non-tender, non-distended.
Extremities: Warm. Multiple superficial varicosities. Trace
pedal edema.
Pertinent Results:
[**2191-1-7**] 09:18PM BLOOD WBC-8.4 RBC-3.71* Hgb-11.2* Hct-33.2*
MCV-89 MCH-30.2 MCHC-33.8 RDW-13.7 Plt Ct-216
[**2191-1-7**] 09:18PM BLOOD Plt Ct-216
[**2191-1-7**] 09:18PM BLOOD PT-12.7 PTT-31.4 INR(PT)-1.0
[**2191-1-7**] 09:18PM BLOOD Glucose-112* UreaN-21* Creat-1.1 Na-140
K-4.1 Cl-104 HCO3-31* AnGap-9
[**2191-1-7**] 09:18PM BLOOD ALT-15 AST-25 LD(LDH)-185 AlkPhos-56
TotBili-0.2
[**2191-1-7**] 09:18PM BLOOD Albumin-4.1
[**2191-1-7**] 09:18PM BLOOD %HbA1c-5.8
Brief Hospital Course:
Ms. [**Known lastname 745**] was transferred to the [**Hospital1 18**] from MWMC on [**2191-1-7**] s/p
cardiac cath showing 2 vessel disease.
She proceeded to the operating room on [**2191-1-8**] with Dr.
[**Last Name (STitle) **] for an aortic valve replacement, ascending aortic arch
replacement, and coronary artery bypass grafting x 2. Please
see OR note for full details.
Patient was successfully weened and extubated on her operative
evening.
On post-operative day (POD) 1, all of her IV drip medications
were discontinued and she was started on PO lopressor for heart
rate and blood pressure control.
On POD 2, Ms. [**Known lastname 745**] was transfused with one unit of red cells
for a Hct of 24.6.
On POD 3, her chest tubes and cardiac pacing wires were
discontinued and she was transfused with an additional unit of
red cells for Hct of 26.8. On this same day she was transferred
from the intensive care unit to the inpatient floor for ongoing
recovery and rehabilitation. Ms. [**Known lastname 745**] was found to be
confused secondary to narcotic use with discontinuation of these
medications. A one-to-one sitter was initiated to maximize
patient safety.
On POD 4 she cleared some but remained slightly confused and she
was started on haldol with some mental clearing. Her lopressor
dosing was adjusted for elevated heart rate and blood pressure.
On POD 5 Ms. [**Known lastname 745**] experienced some atrial fibrillation treated
with IV lopressor and increase in PO lopressor dose to 100 mg
twice daily.
On POD 6 Ms. [**Known lastname 745**] experienced continued bursts of atrial
fibrillation and her lopressor was further increased to 100 mg
tid with addition of PO amiodarone.
On POD 7 she was started on a heparin drip and PO coumadin for
anticoagulation with ongoing atrial fibrillation.
POD [**7-5**] were uneventful with conversion of heart rhythm to NSR
(POD 8). Also ongoing haldol for mild confusion.
On POD 10, Ms. [**Known lastname 27546**] INR elevated to 4.8; her heparin was
discontinued and her coumadin was held for two days.
On POD 11, Ms. [**Known lastname 27546**] BUN and creatinine were elevated at 40
and 2.0. Her lasix and ibuprofen were discontinued with drop to
36 and 1.6 on POD 12. On POD her INR also dropped to 2.9.
Mrs. [**Known lastname 745**] was followed by physical therapy throughout her
hospital stay and it was felt that she would benefit from
rehabilitaion to help regain her strength prior to discharge
home.
Medications on Admission:
Zocor 40 daily
Aspirin 325 daily
Norvasc 2.5 daily
Zestril 40 daily
Atenolol 100 daily
Multiviatmin
Viatmin C
Protinix 40 daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Warfarin Sodium 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): target INR 2-2.5.
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): 400mg [**Hospital1 **] x 1 week then 400mg QD x 1 wk then 200
mg QD.
9. Warfarin Sodium 1 mg Tablet Sig: Two (2) Tablet PO ONCE
(once) for 1 doses.
10. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location (un) 47**]
Discharge Diagnosis:
Status-post Ascending Aortic Arch replacement with a #28
Gelweave/AVR #27 pericardial.
Status-post Coronary Artery Bypass Graft x 2 with LIMA->LAD and
SVG->OM.
Post-op AFIB.
Hypertension.
Hyperlipidemia.
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr [**Last Name (Prefixes) **] in 4 weeks
Dr [**Last Name (STitle) 20222**] in [**1-28**] weeks after d/c from rehab
Dr [**Last Name (STitle) 111273**] in [**1-28**] weeks after d/c from rehab
Completed by:[**2191-1-20**]
|
[
"414.01",
"424.1",
"427.31",
"530.81",
"441.2",
"401.9",
"V15.82",
"272.0",
"293.0",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.45",
"36.12",
"89.60",
"36.15",
"99.04",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
5701, 5769
|
2073, 4547
|
316, 411
|
6016, 6022
|
1580, 2050
|
4726, 5678
|
5790, 5995
|
4573, 4703
|
6046, 6200
|
6251, 6475
|
1319, 1561
|
234, 278
|
439, 1026
|
1048, 1304
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,002
| 186,693
|
37810
|
Discharge summary
|
report
|
Admission Date: [**2106-12-16**] Discharge Date: [**2106-12-29**]
Date of Birth: [**2033-11-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
bilateral leg pain
Major Surgical or Invasive Procedure:
1. aortobifemoral bypass with graft
2. left common femoral to above-knee popliteal artery bypass
History of Present Illness:
73yo male with non insulin dependent diabetes, hypertension,
hyperlipidemia, COPD, and GERD with complaints of right buttock
pain and lower extremity claudication. He presented to Dr [**Name (NI) 4436**] office several years ago with complaints of bilateral
claudication. At that time he was started on Pletal, however he
did not see any benefit in the relief of his symptoms and he
subsequently self discontinued it. He presented this past
[**Month (only) 216**] with complaints mostly relating to some right buttock
discomfort that he describes as a "stabbing sensation" that
occurs with ambulation and resolves with rest. He states the
symptoms can occur at as little as 200 feet. He also notes some
numbness in his right leg that he describes as though his "leg
has fallen asleep". This occurs independently of the right
buttock pain. He also states he experiences a cramping and
tightness in his calves with ambulation. He is very active in
caring for his 3 grandchildren and this has become very
limiting.
Past Medical History:
1. non insulin dependent diabetes
2. hypertension
3. hyperlipidemia
4. COPD
5. GERD
Social History:
lives in [**Location 20935**] MA with his wife at in-law apartment of their
daughter's family home, actively involved in caring for his
daughter's 3 children. He performs many of the household chores,
laundry, and shopping, does not use any assistive devices. He
does not drink alcohol and quit smoking last month.
Family History:
father with MI and subsequent death at 75
brother with first MI at 43, CABG, and multiple PCI's.
Physical Exam:
upon admission:
97.9 82 143/65 18 98RA
General: AOx3, NAD
Chest: CTAB
CV: RRR
Pertinent Results:
[**2106-12-16**] 10:46PM TYPE-ART PO2-98 PCO2-46* PH-7.31* TOTAL
CO2-24 BASE XS--3
[**2106-12-16**] 10:46PM LACTATE-2.0
[**2106-12-16**] 10:46PM freeCa-1.33*
Brief Hospital Course:
Mr [**Name13 (STitle) 84624**] is a 73yo male admitted to [**Hospital1 18**] on [**2106-12-16**],
for bilateral lower extremity ischemia with disabling
claudication. He was taken to the operating room for an
aortobifemoral bypass with a 16 x 8 Dacron graft and a left
common femoral to above-knee popliteal artery bypass with 8-mm
polytetrafluoroethylene. He tolerated the procedure and
anesthesia well. Patient was fluid rescuscitated, transfused w/
three units of PRBCs intra-op and postoperatively. Patient was
unable to extubate on the day of surgery, vital signs were
labile therefore patient was transferred to the CVICU. On POD1:
Patient remained in the CVICU w/ Swan Ganz and intubated.
Patient was extubated later then eventually transferred down to
[**Hospital Ward Name 121**] 5 VICU. Post-operatively, he developed worsening renal
function, low urine output requiring fluid boluses. Patient had
problems with pain and pain service was consulted with a
recommendation of a dilaudid PCA. Remained on pressors for BP
control. Patient started becoming agitated and required
sedation. Renal service consulted for worsening renal status.
On POD2-3: He continued to have poor urine output with renal
function not imrpoving, renal service following, escalating
doses of lasix was given with no major diuresis response, given
other diuretics, that also did not result in increased urine
output as well. POD4: Continued to be in ATN, renal service
continued to follow, ultimately recommended for hemodialysis.
Swan [**Doctor Last Name **] was discontinued, Cordis was changed over to a
hemodialysis line for this purpose. Additionally, a PICC line
was placed for intravenous access and TPN. The The patient
continued to be intermittently confused, self-removed the PICC
line that night. POD5: A new PICC was replaced, nutrition
consulted and TPN started. Patient received hemodialysis
treatment. Physical therapy was consulted, patient taken out of
bed w/ assistance- very deconditioned, physical therapy will
follow. POD6: Patient continued to sundown and get more
delirious at night, pulled PICC line out again, required mitts
and side rails up for restraints. Ileus resolved, moved bowels
and tolerating PO's. Majority of medications switched to PO and
had another round of hemodialysis. POD7: Hemodialysis deferred
per renal. No repeat attempt for PICC placement. POD8-13:
Patient was placed on M/W/F hemodialysis schedule and cleared by
renal for discharge with hemodialysis. Previously noted
sundowning improved. Patient reported intermittent diarrhea, C.
diff negative, noted to have previous history of diarrhea
requiring lomotil. On POD12, a tunneled hemodialysis catheter
was placed and abdominal and left lower extremity staples
removed with steristrips placed. Patient was discharged to
rehabilitation facility presently requiring M/W/F hemodialysis
in stable condition.
Medications on Admission:
Glyburide 5mg tablet daily
Lisinopril 20mg tablet daily
Metformin 500mg 2 tablets [**Hospital1 **]
Simvastatin 80mg tablet daily
Lomotil OTC 2.5 mg tablet daily
Aspirin 325 tablet pre procedure on [**12-2**]
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED).
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) as needed for diarhea.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezes.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
bilateral lower extremity ischemia with disabling claudication
acute renal failure - requiring M/W/F hemodialysis
delirium- possibly related to renal failure and prolonged
hospitalization
ileus- kept NPO, started TPN on POD#4, resolved and TPN d/c'd,
diet and PO meds resumed
History of:
NIDDM
HTN
Hyperlipidemia
COPD
GERD
Osteoporosis
Rosacea
Allergies Rhinitis
PSH: Basal Cell CA resection, Tonsillectomy, Appendectomy, Left
Inguinal Hernia Repair, Mastoidectomy
Discharge Condition:
stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower 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
?????? Unless you were told not to bear any weight on operative foot:
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 leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-16**]
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 foot:
?????? 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 or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? 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 leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
please call Dr[**Name (NI) 1392**] office for follow-up appointment
telephone: [**Telephone/Fax (1) 1393**]
please call nephrology for a follow-up appointment in [**4-14**] weeks
telephone: [**Telephone/Fax (1) 721**] (Dr [**First Name (STitle) 30217**] [**Name (STitle) 28760**])
Completed by:[**2106-12-29**]
|
[
"440.21",
"440.0",
"250.00",
"401.9",
"560.1",
"733.00",
"530.81",
"272.4",
"275.3",
"584.5",
"276.7",
"444.0",
"V15.82",
"293.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"39.95",
"39.25",
"38.95",
"39.29",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6386, 6456
|
2342, 5241
|
336, 435
|
6967, 6976
|
2153, 2319
|
9820, 10134
|
1936, 2035
|
5499, 6363
|
6477, 6946
|
5267, 5476
|
7000, 9387
|
9413, 9797
|
2050, 2052
|
278, 298
|
463, 1480
|
2066, 2134
|
1502, 1587
|
1603, 1920
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,497
| 164,566
|
32312
|
Discharge summary
|
report
|
Admission Date: [**2136-3-18**] Discharge Date: [**2136-3-19**]
Date of Birth: [**2078-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
CVL insertion x2
Intubation
Pressors
Arterial line placement
History of Present Illness:
Patient is a 57 y/o male with prostate CA, metastatic melanoma
s/p chemo [**2136-3-14**] (dacarbazine), HTN and anxiety who presented
from home complaining of increased SOB over the past 2 days.
Patient unable to give history currently so history obtained
from chart. Per notes patient was unable to ambulate due to his
breathing and also reported decreased PO since his chemo. Also
has had decreased UOP and no BM. Per ED nursing notes the
patient was also complaining of RUQ pain. He called his outpt.
oncologist with these complaints and was referred to the ED.
.
In the ED the patient was noted to be cool and cyanotic but was
able to answer questions. Initial VS showed T 97.8 rectally, HR
69, BP 105/54, RR 28 and O2 sat was unobtainable. EKG showed
afib, FSBG 76, received [**12-28**] amp D50. IJ CVL attempted on both
sides unsuccessfully (unable to pass wire). ABG 7.17/17/104/7
with lactate 11.2. Started on levophed for BP 85/49. Received
vanco 1gm and cefipime 2gm. Patient was intubated and given a
total of 6L IVF. Foley placed with 20cc UOP. CT torso showed no
PE, extensive mets to liver (known), b/l atelectasis and
persistent pancreatic ductal dilatation and calcification. INR
noted to be 14.1 and pt. was given vit K 5mg and 2 units FFP. A
right fem line was placed and the patient was admitted to MICU 7
for further treatment. Multiple attempts were made to reach the
patient's brother without response.
.
On arrival to the ICU the patient was unresponsive, cool and
cyanotic. A RIJ CVL was placed and repeat ABG 6.82/47/114.
Past Medical History:
metastatic melanoma with PET uptake in liver and bones
anxiety/panic attacks
hypertension
atrial fibrillation
prostate cancer diagnosed [**12-2**]
splenectomy - ?alcohol related (per patient)
Social History:
No smoking. Drinking history: 1 case of beers a day for 35
years, has quit entirely 3 years ago. He drank to calm his
anxiety, but since starting oxazepam has not needed alcohol.
Denies illicit drug use. Lives alone in the [**Hospital1 778**] area. For a
living he cooks at a North Station facility that trains handicap
individuals. Has not worked since the melanoma diagnosis.
Family History:
Fa w/brain ca died in his 50s. Mother died of MI at 75. Sister
overdosed on heroin at 38. Brother healthy, 53yo.
Physical Exam:
VS: BP 108/42 HR 68 RR 12 O2 sat unatainable
Gen: intubated, sedated
Skin: mottled
HEENT: ETT, OG tube, pupils pinpoint, sluggish
NECK: Supple, no JVD
CV: irreg irreg, NL rate. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
Lungs: CTA anteriorly
Abdomen: soft, large well-healed scar across left side of
abdomen, ND, +BS
Ext: 2+ pedal edema, cool, cyanotic, pulses dopplerable
Neuro: sedated, absent corneal reflex
Pertinent Results:
[**2136-3-18**] 01:13PM BLOOD WBC-20.6* RBC-4.66 Hgb-14.4 Hct-44.4
MCV-95 MCH-30.9 MCHC-32.4 RDW-15.0 Plt Ct-261
[**2136-3-18**] 07:34PM BLOOD WBC-16.9* RBC-3.61* Hgb-11.2*# Hct-35.9*
MCV-99* MCH-30.9 MCHC-31.1 RDW-14.7 Plt Ct-225
[**2136-3-18**] 11:50PM BLOOD WBC-16.3* RBC-3.38* Hgb-10.5* Hct-34.0*
MCV-101* MCH-30.9 MCHC-30.8* RDW-14.7 Plt Ct-214
[**2136-3-18**] 01:13PM BLOOD PT-104.8* PTT-150* INR(PT)-14.1*
[**2136-3-18**] 07:34PM BLOOD PT-48.9* PTT-150* INR(PT)-5.5*
[**2136-3-18**] 11:50PM BLOOD PT-36.3* PTT-150* INR(PT)-3.9*
[**2136-3-18**] 01:13PM BLOOD Glucose-66* UreaN-77* Creat-6.2*# Na-123*
K-5.7* Cl-83* HCO3-6* AnGap-40*
[**2136-3-18**] 07:34PM BLOOD Glucose-150* UreaN-68* Creat-5.5* Na-122*
K-5.7* Cl-95* HCO3-8* AnGap-25*
[**2136-3-18**] 11:50PM BLOOD Glucose-102 UreaN-68* Creat-5.6* Na-126*
K-6.3* Cl-91* HCO3-LESS THAN
[**2136-3-18**] 01:13PM BLOOD ALT-108* AST-623* AlkPhos-319*
TotBili-3.2*
[**2136-3-18**] 01:13PM BLOOD CK-MB-40* cTropnT-<0.01
[**2136-3-18**] 11:50PM BLOOD CK-MB-61* MB Indx-2.3 cTropnT-<0.01
[**2136-3-18**] 01:13PM BLOOD Albumin-2.8* Calcium-8.0* Phos-10.7*#
Mg-2.1
[**2136-3-18**] 07:34PM BLOOD Calcium-6.3* Phos-10.8* Mg-2.1
[**2136-3-18**] 11:50PM BLOOD Calcium-6.8* Phos-12.1* Mg-2.3
[**2136-3-18**] 07:34PM BLOOD Digoxin-2.5*
[**2136-3-18**] 01:13PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-15.9
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2136-3-18**] 02:31PM BLOOD pO2-104 pCO2-17* pH-7.17* calTCO2-7* Base
XS--20
[**2136-3-18**] 07:42PM BLOOD Type-[**Last Name (un) **] Rates-/12 Tidal V-550 PEEP-5
FiO2-100 pO2-70* pCO2-56* pH-6.79* calTCO2-10* Base XS--29
AADO2-605 REQ O2-96 Intubat-INTUBATED Vent-CONTROLLED
[**2136-3-18**] 08:00PM BLOOD Type-ART pO2-114* pCO2-47* pH-6.82*
calTCO2-9* Base XS--28
[**2136-3-18**] 09:36PM BLOOD Type-ART pO2-108* pCO2-36 pH-6.92*
calTCO2-8* Base XS--26
[**2136-3-18**] 11:06PM BLOOD Type-ART Rates-30/ pO2-93 pCO2-28*
pH-6.88* calTCO2-6* Base XS--29 -ASSIST/CON Intubat-INTUBATED
[**2136-3-18**] 11:51PM BLOOD Type-ART pH-6.85*
[**2136-3-19**] 01:28AM BLOOD Type-ART pO2-89 pCO2-24* pH-6.90*
calTCO2-5* Base XS--29
[**2136-3-18**] 02:07PM BLOOD Lactate-11.2* K-4.8
[**2136-3-18**] 02:31PM BLOOD Glucose-113* Lactate-10.9* K-4.4
[**2136-3-18**] 05:29PM BLOOD Glucose-106* Lactate-10.3* K-5.1
[**2136-3-18**] 07:42PM BLOOD Lactate-11.0*
[**2136-3-18**] 09:36PM BLOOD Lactate-11.9*
.
Studies:.
CXR [**3-18**]: A single portable upright radiograph is available for
review obtained at 2:10 p.m. There is cardiomegaly, without
interstitial opacities to suggest acute pulmonary edema. New
bibasilar opacities are most consistent with
effusions/atelectasis; however, underlying consolidation cannot
be completely excluded. There is no evidence of
pneumoperitoneum.
.
CTA chest/abd:
1. No evidence of pulmonary embolism.
2. Extensive metastatic disease to the liver.
3. Soft tissue and induration in the left axilla with enlarged
lymph nodes, consistent with known metastatic disease.
4. Persistent pancreatic ductal dilatation and calcification.
5. No definite osseous lesions to correspond to multiple foci of
metastatic disease on recent FDG-PET of the torso.
.
EKG: afib, rate 67, poor r-wave progression, no significant ST
changes
Brief Hospital Course:
A/P: 57 y/o M with PMH metastatic melanoma, prostate CA, HTN and
anxiety who presents with profound acidosis, respiratory
failure, acute renal failure, hepatic failure and septic shock,
intubated and on pressors.
.
# Shock: presumed sepsis given elevated WBC, hypothermia,
elevated lactate. Had retrocardiac opacity on CXR concerning for
PNA, also dirty UA concerning for GU source. Not neutropenic but
had recent chemo on [**3-14**] so likely immunosuppressed, also s/p
splenectomy. DDx also included cardiogenic shock, however EKG
unchanged and first set of enzymes neg. No e/o PE on CTA. With
h/o [**Month (only) **]. PO and diuretics, hypovolemia also contributing.
Lactate elevated, however in setting of liver mets and liver
failure. Patient was given aggressive IVF resuscitation to
maintain CVP>13. Received 6L in ED and additional 2L on arrival
to ICU. A second CVL (RIJ) was placed and CVP measured 16-18
indicating adequate fluid resuscitation. He was continued on
levophed which was titrated up to maximum dose. The patient
only made 5cc of urine in the ICU and renal was consulted given
worsening acidosis and anuria. Given his hemodynamic
instability and coagulopathy they felt that inserting an HD
catheter for dialysis was too unsafe and risky in this patient.
He was given 2 amps bicarb q 90 min. in lieu of his severe
acidosis. Cultures were sent including blood, urine and sputum
to look for source of infection. Patient had been c/o RUQ pain,
however CT abdomen did not show any acute infectious process or
ischemic bowel. He was continued on broad-spectrum antibiotics
including vancomycin and cefipime. He was placed under a
bear-hugger for hypothermia.
.
Patient was severely acidotic with a pH on presentation of 7.17.
This was felt to be a combination of lactic acidosis from liver
failure and possible sepsis. Also acute renal failure
contributing as well. Given his large tumor burden in the liver
it was felt that he may have had necrosis of his tumor as well.
There was no evidence of ischemic bowel. Surgery evaluated him
in the ED and felt there were no acute surgical issues. In
order to manage his severe acidosis his rate on the ventilator
was serially inceased up to a rate of 35 in order to decrease
his CO2. Unfortunately his acidosis was so overwhelming that
his pH was unable to be corrected above 6.9 and RR could not be
increased further due to airway pressures and breath stacking.
The patient was also in ARF with Cr elevated to 6.2 on admission
from baseline of 1.6 prior to chemo. Felt to be ATN in setting
of shock. Also on diuretics and ACE at home which in setting of
hypovolemia likely also contributed. He remained anuric depite
volume resuscitation. The patient was also significantly
coagulopathic on arrival with INR 14.2. This was felt to be [**1-28**]
hepatic failure and impaired synthesis in the setting of large
tumor burden. plts were normal and fibrinogen was elevated so
not DIC, however pt. at high risk of this given malignancy,
infection. Received 2 units of FFP and vit. K in the ED with
correction of his INR to 3.9. The patient also had liver
failure that was felt to be due to his extensive metastatic
disease in liver and also a component of shock liver given
hypotension.
.
Prior to intubation in the ED the patient expressed that he
wanted everything done. Resuscitation was continued in the ICU
as above, however the patient became progressively more acidotic
and hemodynamically unstable. His brother was [**Name (NI) 653**] as the
next of [**Doctor First Name **] and indicated that there was no other family member
or HCP. The patient's blood pressure continued to decline and
vasopressin was started without effect. Given the gravity of
his condition and severe uncorectable acidosis as well as
aggressive metastatic melanoma the ICU team made the patient CPR
not indicated. The patient's brother was in aggreement with
this decision. At 0235 the patient expired due to cardiac
arrest. The patient's brother was notified and declined a
post-mortem exam. The ME was also notified and also declined a
post.
Medications on Admission:
1. Digoxin 125 mcg daily.
2. Diltiazem 180 mg daily.
3. Hydrochlorothiazide 25 mg daily.
4. Vicodin p.r.n. pain.
5. Lisinopril 5 mg daily.
6. Metoprolol 100 mg b.i.d.
7. Serax 30 mg q.4h.
8. Compazine p.r.n. nausea, vomiting.
9. Trazodone 200 mg q.h.s.
10. Aspirin 325 mg daily.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Multiorgan system failure, septic shock, metastatic melanoma
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"276.2",
"V10.46",
"995.92",
"518.81",
"785.52",
"198.5",
"427.31",
"197.7",
"401.9",
"584.9",
"038.9",
"196.3",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
10854, 10863
|
6389, 10496
|
318, 380
|
10967, 10976
|
3159, 6366
|
11028, 11034
|
2584, 2698
|
10826, 10831
|
10884, 10946
|
10522, 10803
|
11000, 11005
|
2713, 3140
|
275, 280
|
408, 1957
|
1979, 2172
|
2188, 2568
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,099
| 145,797
|
55160
|
Discharge summary
|
report
|
Admission Date: [**2130-6-10**] Discharge Date: [**2130-6-17**]
Date of Birth: [**2058-9-24**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
cerebral angiogram with intervention
History of Present Illness:
Mr. [**Known lastname **] is a 72 year-old right-handed man with PMH
significant for CABG who presents with acute onset left sided
weakness. His wife was present with him and noted that around 1
PM, he suddenly started sweating, slumping over and slurring his
words. He was immediately brought to the [**Hospital1 18**] ED within 25
minutes of symptom onset. Prior to the onset of these symptoms,
he was in good health. He has no prior history of strokes. His
vascular risk factors include CAD s/p CABG, brief history of HTN
for which he was on a medication (believed to be B-blocker,
though not currently on any meds) and about 50 pack year smoking
history.
Past Medical History:
-CAD s/p 3 vessel CABG in [**2125**]
-HTN (treated for 1 year in the past, but apparently improved
and
not currently on any meds)
-duodenal ulcer s/p cauterization about 2 years ago (this
occurred in the setting of being on ASA, which has seen been
d/c)
Social History:
He lives in [**Country 11150**] and is currently in [**Location (un) 86**] visiting
family; he arrived [**6-1**]. He is retired. He smokes 8 cigarettes
per day, prior to CABG smoked [**9-25**] cigarettes per day, he has
smoked for about 50 years.
Family History:
There is significant vascular history (CAD and
strokes) in his father and brothers.
Physical Exam:
At admission:
Vitals: P: 77 R: 26 BP: 151/91 SaO2: 98% on 2L O2
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Neurologic:
NIH Stroke Scale score was: 18
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 1 (right gaze preference)
3. Visual fields: 2
4. Facial palsy: 2
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 2
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 2
Mental Status: Awake, alert, oriented to person, city, month and
year (said date was [**6-9**]). He has a dense left sided neglect
(says his hand is examiner's). Speech is dysarthric but fluent.
He has anomia for low frequency objects but able to name high
frequency objects. He is able to repeat. Comprehension is
intact.
Cranial Nerves: PERRL 3 to 2mm. Left hemianopia vs. left
hemineglect. Right gaze preference at rest. He is able to track
finger across midline with full EOMs. Left facial droop.
Motor: Normal bulk. left UE flaccid tone and diminished tone in
LLE. LUE plegic. LLE initially plegic but subsequently able to
hold LLE against gravity briefly. Right sided strength is all at
least antigravity.
Sensory: No grimmace to noxious stimuli on left and says he does
not feel pinprick on left. he has extensor posturing with
noxious
stimulation of left upper extremity and during time in ED, did
have withdrawal of left lower extremity to noxious.
DTRs: Patellar reflex slightly brisker on right compared to
left,
though brisk b/l. there was a flexor plantar response b/l.
Coordination: no dysmetria on right finger-nose. Plegic on left
so not assessed.
Gait: deferred
Physical Exam on Discharge:
Pertinent Results:
[**2130-6-10**] 01:45PM BLOOD WBC-7.7 RBC-5.29 Hgb-15.7 Hct-45.7 MCV-87
MCH-29.8 MCHC-34.4 RDW-13.8 Plt Ct-345
[**2130-6-10**] 01:45PM BLOOD PT-9.9 PTT-21.5* INR(PT)-0.9
[**2130-6-10**] 01:40PM BLOOD Creat-0.8
[**2130-6-11**] 03:16AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-137
K-4.0 Cl-107 HCO3-19* AnGap-15
[**2130-6-11**] 03:16AM BLOOD ALT-19 AST-21 AlkPhos-62 TotBili-1.1
[**2130-6-10**] 08:20PM BLOOD cTropnT-<0.01
[**2130-6-11**] 03:16AM BLOOD cTropnT-<0.01
[**2130-6-11**] 03:16AM BLOOD Albumin-3.4* Calcium-8.0* Phos-3.0 Mg-1.8
Cholest-164
[**2130-6-11**] 03:16AM BLOOD %HbA1c-5.7 eAG-117
[**2130-6-11**] 03:16AM BLOOD Triglyc-80 HDL-51 CHOL/HD-3.2 LDLcalc-97
[**2130-6-10**] 01:50PM BLOOD Glucose-98 Na-138 K-4.2 Cl-102 calHCO3-24
[**2130-6-10**] 08:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005
[**2130-6-10**] 08:20PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
[**2130-6-10**] 08:20PM URINE RBC-30* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2130-6-10**] 08:20PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
MR head without contrast:
IMPRESSION: Bilateral areas of restricted diffusion, more
significant on the right, involving the frontal, occipital, and
caudate nucleus on the right and also the left frontal lobe,
left centrum semiovale, likely consistent with an acute/subacute
thromboembolic ischemic event, previously demonstrated by head
CT.
NCHCT:
IMPRESSION: Right frontal and parieto-occipital hypodensities
compatible with acute on subacute evolving watershed infarcts.
No signs of hemorrhage. Correlation with MRI is recommended.
Cerebral angiogram:
FINDINGS: Left common carotid artery arteriogram shows filling
of the left internal carotid artery along the cervical, petrous,
cavernous, and
supraclinoid portion. The anterior and middle cerebral arteries
are seen
well. The anterior cerebral artery is seen to be dominant on
the left side. There is no stenosis at the carotid bifurcation
in the neck though there is significant calcification.
Right common carotid artery arteriogram again shows high-grade
stenosis of the right common carotid bifurcation at the origin
of the external carotid. The stenosis at this segment is about
80%. There is also distal disease involving the first 20 mm of
the internal carotid artery. The left middle cerebral artery
fills well with no branch occlusion.
Right common carotid artery arteriogram status post stenting and
angioplasty shows widely patent right common and internal
carotid artery. There is no residual stenosis. Right common
femoral artery arteriogram shows widely patent right common
femoral artery.
IMPRESSION: [**Known firstname 112523**] [**Known lastname **] underwent carotid stenting and
angioplasty after he presented with a high-grade stenosis and a
right hemispheric syndrome. There were no complications.
CTA head and neck:
IMPRESSION:
1. Evidence of extensive acute ischemia throughout the right
middle cerebral arterial territory, with focal abnormalities of
rCBV/CBF, within, as well as in the contralateral hemisphere,
suspicious for "core" infarcts.
2. Extensive steno-occlusive disease involving the right
internal carotid
artery from its origin and throughout its cervical portion.
There is only
minimal evidence of recanalization, with flow to the carotid
terminus and
ipsilateral MCA via cross-filling from a patent circle of
[**Location (un) 431**], as detailed above.
3. Markedly anomalous posterior circulation, as detailed above,
including a very large-caliber and tortuous left persistent
trigeminal artery (a patent fetal carotico-basilar anastomosis),
as well as a robust fetal-type right PCA. This likely accounts
for the markedly small caliber of the distal V4 segments of both
vertebral arteries, which demonstrate effective
PICA-termination, as well as the very diminutive basilar artery.
4. No evidence of significant steno-occlusive disease or
aneurysm larger than 2 mm involving the intracranial
circulation.
5. Severe bullous pan-acinar emphysema involving the included
lung apices.
CXR:
IMPRESSION:
An endotracheal tube is seen with its tip approximately 5 to 5.5
cm above the carina. A nasogastric tube is seen coursing below
the diaphragm with its tip within the stomach. The patient is
status post median sternotomy. Heart is upper limits of normal
in size. The mediastinal contours are within normal limits.
Calcification of the aorta is consistent with sclerosis. There
is some perihilar fullness and vascular redistribution
suggestive of pulmonary venous hypertension, no overt pulmonary
edema. No focal airspace consolidation is seen to suggest
pneumonia. No pleural effusions or pneumothoraces
Transthoracic Echo:
Mild pulmonary artery systolic hypertension. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function. No definite structural cardiac
source of embolism identified.
Transesophageal Echo:
No PFO, ASD or intracardiac thrombus. Complex artheroma in the
descending aorta. Normal biventricular size and global systolic
function.
Labs on Discharge:
none
Brief Hospital Course:
Mr. [**Known lastname **] is a 72 year-old right-handed man with PMH significant
for CAD s/p CABG (in [**2125**]) who presents with left sided
weakness.
NEURO: He was a CODE STROKE, with deficits notable for right
gaze preference, left neglect, left facial droop and initially
left sided plegia and sensory loss; initial NIHSS 18. On
imaging, he was found to have an acute R MCA stroke and found to
have right ICA occlusion with distal recanalization, but then
also with apparent R superior divivision MCA occlusion. He
received IV tpA- bolus at 1350 (symptom onset at 1300). There
were no clear initial improvement in deficits aside from some
improvement in movement of left lower extremity and pupils more
in midline at rest. Given lack of significant improvement and
clot noted on CTA, he was sent for interventional angiogram. A
stent was placed in the right proximal ICA for high-grade
stenosis with good perfusion afterwards. MRI post intervention
showed infarcts involving the frontal, occipital, and caudate
nucleus on the right and the left frontal lobe and left centrum
semiovale. The patient was seen by physical and occupational
therapy and his strength gradually improved in his left leg,
though not left arm, over the ensuing days. The right MCA and
PCA infarcts are most probably due to emboli/hypoperfusion from
the right ICA occlusion (the right PCA infarct can be explained
by emboli through the right fetal PCA to the occipital lobe).
The small left frontal and left centrum semiovale infarcts are
possibly due to emboli that were generated by the catheter
during the conventional angiogram procedure. Despite extensive
evaluation, no cardioembolic source was found. The patient was
recommended to undergo Holter monitoring as an outpatient to
evaluate again for possible atrial fibrillation.
CARDIAC: The patient was monitored on telemetry with no signs of
atrial fibrillation. TTE revealed no intracardiac thrombus and
no PFO. TEE showed complex atheroma in the descending aorta.
Clopidogrel 75mg po daily started for secondary stroke
prevention and to prevent stent rethrombosis. Simvastatin 20mg
po daily was started for goal LDL < 100.
DIET: after being seen by speech and swallow the patient had
pureed solids and thin liquids.
Patient was Full Code
1. Dysphagia screening before any PO intake? y
2. DVT Prophylaxis administered? Y
3. Antithrombotic therapy administered by end of hospital day 2?
Y
4. LDL documented? Y LDL 97
5. Intensive statin therapy administered? No, LDL <100
6. Smoking cessation counseling given? Y
7. Stroke education given? Y
8. Assessment for rehabilitation? Y
9. Discharged on statin therapy? Y
10. Discharged on antithrombotic therapy? Y Plavix
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? N/A
PENDING RESULTS
Platelet Aggregation Assay
Medications on Admission:
none
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
Please start morning of [**6-11**]
RX *clopidogrel 75 mg 1 Tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 Tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 Tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right ischemic stroke with Right ICA occlusion
Discharge Condition:
General: Awake, cooperative, NAD. oriented x3
Right gaze preference and (largely resolved) partial left-sided
visual neglect and mild sensory neglect. Motor: 4+ left hip
flexor, 5 left Ham. Flaccid Left arm. Toes upgoing on the left.
joint position sense impaired on left toe and left arm up to
elbow.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital with a stroke due to a clot in
a blood vessel in your brain. We treated you with a medication
that breaks up the clot and also went into the blood vessel in
your brain and placed a stent to keep the artery open. You had
an ultrasound of your heart which did not show a clot, which was
reassuring.
You should have a holter monitor arranged by your primary doctor
to evaluate you further for any abnormal heart rhythms.
We have started you on medications for cholesterol and blood
pressure, it is very important that you continue these.
We have made the following changes to your medications:
START
Clopidogrel 75mg daily (a blood thinner)
Lisinopril 10mg daily (for blood pressure)
Simvastatin 20mg daily (for cholesterol control)
On discharge, please follow up with your primary care doctor and
ask him to refer you to a neurologist. Also, you would benefit
from physical therapy. Please discuss this with your doctor [**First Name (Titles) **] [**Country 112524**].
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
You should see your primary doctor when you return home
and ask him to arrange for you to see a Neurologist near you.
|
[
"V45.81",
"433.11",
"342.92",
"305.1",
"401.9",
"781.94",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"99.10",
"96.71",
"00.63",
"96.04",
"88.41",
"00.40",
"99.20",
"88.72",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
12131, 12137
|
8843, 11682
|
333, 371
|
12228, 12532
|
3645, 8794
|
13685, 13806
|
1619, 1705
|
11737, 12108
|
12158, 12207
|
11708, 11714
|
12556, 13188
|
1720, 2409
|
3626, 3626
|
13217, 13662
|
274, 295
|
8813, 8820
|
399, 1060
|
2749, 3596
|
2424, 2733
|
1082, 1338
|
1354, 1603
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,775
| 101,668
|
40190
|
Discharge summary
|
report
|
Admission Date: [**2177-1-30**] Discharge Date: [**2177-2-7**]
Date of Birth: [**2158-2-7**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Left neck mass
Major Surgical or Invasive Procedure:
[**2177-1-30**]: Incision and drainage of left deep neck abscess with
sacrifice of internal jugular vein.
History of Present Illness:
The patient is an 18 M who presents with worsening L neck
fullness, pain and dysphagia two weeks after L wisdom teeth
extraction. The patient reports that he noticed neck fullness 8
days ago and presented to his dentist; at that time, swelling
was felt to be postoperative in nature. Because of persistent
symptoms, he saw his PCP four days ago who started him on
amoxicillin and Tylenol/codeine; he had some difficulty with
nausea with these medications. Tm 101 over the past several
days. He noticed difficulty with normal eating starting five
days ago, with sensation that liquid gets stuck in his throat
and
regurgitates upward to nose for the past 2 days. He noticed
change in his voice since yesterday. No odynophagia. He is able
to tolerate his oral secretions. No difficulty breathing, no
stridor. No trismus, no otalgia. No chest pain. No sick
contacts.
Past Medical History:
None
Social History:
Works as a fire fighter. Denies tobacco, EtOH.
Family History:
No history of immunodeficiency or bleeding disorder.
Physical Exam:
On admission [**2177-1-30**]:
VS: 99.0 103 153/95 16 99% RA
Gen: NAD, pleasant, voice slightly muffled, no stridor, no
increased work of breathing
Ear: AD: auricle, canal and TM normal [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: Septum midline, no purulent drainage, turbinates normal.
OC/OP: Moist mucus membranes. Good dentition. L molar area
without fluctuance. Masseter space without fullness or
fluctuance. No trismus, symmetrical palatal elevation, no
erythema. FOM, BOT and oral cavity mucosa, and palatal area
soft
and nontender without abnormal lesions.
Neck: Fullness in the left lateral neck with tenderness to
palpation extending from anterior to SCM to posteriorly.
Displacement of laryngeal apparatus anteriorly and to the right.
CNII-XII intact
FOE: Verbal consent obtained. Nasal cavity sprayed with Afrin.
Scope passed through nasal cavity. No purulent drainage,
eustachian tubes patent, nasopharynx normal. L lateral and L
posterior pharyngeal walls with significant bulge into the
airway, touching epiglottis, obscuring visualization of the L
piriform. Glottic apparatus deviated anteriorly and toward the
right. Minimal supraglottic edema. No significant pooling of
secretions. TVF fully mobile and symmetric. Airway compromised
given displacement from pharyngeal abscess.
Pertinent Results:
On admission:
[**2177-1-30**] 02:40PM WBC-18.3* RBC-4.40* HGB-13.4* HCT-39.4*
MCV-90 MCH-30.5 MCHC-34.0 RDW-12.5
[**2177-1-30**] 02:40PM NEUTS-79.6* LYMPHS-12.4* MONOS-6.6 EOS-0.5
BASOS-0.9
CT Neck on admission:
1. Large left retropharyngeal and parapharyngeal
abscess,extending to the
carotid space measuring 7.0 x 4.2 x 3.2 cm. Stranding in the
base
of the neck, but no definite extension into the mediastinum.
2. Significant mass effect on the oropharyngeal airway,
3. Compression of the left internal jugular vein, without
complete occlusion.
4. No osteomyelitis.
Brief Hospital Course:
The patient is a 18 year old male who presented to the [**Hospital1 18**] ED
with enlarging left neck mass with CT demonstrating a large
parapharyngeal and retropharyngeal abscess surrounding the great
vessels. He was taken urgently to the OR for drainage. He
underwent fiberoptic intubation and incision and drainage of the
abscess. Intra-op findings notable for a well loculated abscess
in the parapharyngeal and retropharyngeal space as well as
lateral to the SCM. The left internal jugular vein was ligated
as it was involved in the abscess pocket. A large amount of
purulent material was drained and three penroses placed in the
potential spaces. The patient tolerated the procedure without
immediate complications. For details, please see separately
dictated operative note by Dr. [**Last Name (STitle) 1837**]. Postoperatively,
the patient was kept intubated and taken to the ICU for closer
observation.
The remainder of his hospital course is reviewed here by
systems:
Wound: The patient had a horizontal incision left neck incision
with three penroses in place. The wound continued to be open and
drain during this period. On POD #4, the patient underwent
repeat CT imaging of the neck in the setting of a slight rise in
his WBC to 12 and chest pain, which was negative for any
residual abscess or for evidence of mediastinitis. His symptoms
thereafter resolved. The penroses were slowly inched out daily
and removed on POD #7. Following removal of the penroses, the
wound cavity was irrigated and then packed with 1-inch iodaform
strip gauze (10 cm) with plan for continued dressing changes
daily as an outpatient with assistance of VNA, as the cavity
slowly seals in.
Neuro: The patient's cranial nerves were fully intact following
the procedure. His voice was strong and a post-op FOE
demonstrated bilateral, symmetric vocal cord mobility. He was
noted to have a left-sided Horner's syndrome, without
significant functional compromise. The patient's pain was
initially controlled with IV antibiotics. He was kept sedated
while on the ventilator. Post-extubation, the patient was
transitioned to PO pain medications with good effect. By time of
discharge, the patient was requiring minimal narcotic pain
medications. He was given 0.5mg ativan as needed for anxiety
with good effect.
Resp: The patient remained intubated in the ICU until POD#2. He
was extubated on this date without difficulty and subsequently
transferred to the floor. He was weaned off of oxygen by POD #4.
CT on [**2-3**], showed scattered opacities which were consistent
with aspiration or pneumonia. He received aggressive chest PT,
ambulation and incentive spirometry throughout his hospital
course and was satting >95% by time of discharge.
CV: The patient remained hemodynamically stable throughout his
hospitalization. He complained of transient left chest pain on
[**2-3**] with EKG showing ? of T-wave inversions in lateral leads.
His cardiac enzymes were cycled and negative x 3. His symptoms
resolved. CT performed on this date showed no evidence of
mediastinitis.
ID: The infectious disease department was consulted and they
recommended Unasyn, Clindamycin and vancomycin as emperic
coverage initially, which was subsequently simplified to
Unasyn/Vancomycin. The patient had repeat imaging on [**2177-2-3**]
which demonstrated a well drained abscess pocket without
evidence of mediastinal involvement or residual abscess. The
patient remained afebrile and his WBC trended down for the
remainder of the hospitalization. Per ID, the patient is being
dicharged on Ertapenem and Vancomycin to complete a 14 day IV
course, and thereafter transition to moxifloxacin for additional
14 days or as instructed further by ID.
GI: The patient was NPO until extubation. Thereafter, his diet
was advanced to regular, which he tolerated without coughing or
difficulty.
GU: The patient had a foley in place which was discontinued
following extubation. He voided without issue.
Endo: No issues.
Heme: The patient remained hemodynamically stable throughout
his hospitalizaiton. He received SQH throughout his hospital
course and was ambulating the halls frequently.
The remainder of the hospital course was uneventful; the patient
remained afebrile and hemodynamically stable. His pain was well
controlled on oral pain medications. By the day of discharge, on
[**2177-2-7**], he was tolerating a regular diet, able to void without
difficulty and ambulate without assistance. He and his family
expressed the readiness and desire to go home and was discharged
to home with VNA services for dressing changes and IV
antibiotics, on POD # 8, [**2177-2-7**], with instructions to follow
up with Dr. [**Last Name (STitle) 1837**] and Dr. [**Last Name (STitle) 6137**] (Infectious disease)
as an outpatient. Additional discharge instructions as listed
below.
Medications on Admission:
Amoxicillin
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
3. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
Q24H (every 24 hours) as needed for infection, deep neck for 6
days: to start [**2177-2-8**] at home. First dose given in hospital on
[**2177-2-7**]. To complete on [**2177-2-13**].
Disp:*6 gram* Refills:*0*
4. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**5-14**]
hours for 35 doses: take with stool softener to avoid
constipation, do not drink or drive while taking narcotic pain
medication. try to wean off pain medication by follow-up.
Disp:*35 Tablet(s)* Refills:*0*
5. vancomycin in 0.9% sodium Cl 1.5 gram/250 mL Solution Sig:
One (1) vial Intravenous every twelve (12) hours for 7 days: to
continue at home [**2177-2-7**] and to end on [**2177-2-13**].
Disp:*14 vials* Refills:*0*
6. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO every
twenty-four(24) hours for 14 days: To start [**2177-2-14**] and resume
for 14 days until further instructed by infectious disease.
Disp:*14 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
CBC, Bun, Crea, LFTs, CRP, ESR, Vanco trough
FREQUENCY: on [**2177-2-12**].
Please fax results to: [**Hospital1 18**] Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
8. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for anxiety for 30 doses: try to wean off in two
weeks. follow-up with PCP regarding refills.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Home Care
Discharge Diagnosis:
Left deep space neck infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- continue antibiotics as perscribed, You should take Ertapenem
and Vancomycin IV until/through [**2177-2-13**]. Then on [**2177-2-14**], start
moxifloxacin PO for 14 days or unless otherwise instructed by
ID.
- have your labs checked on [**2177-2-12**] and results sent to ID
department for follow-up. These are routine labs for monitoring:
CBC, Bun, Crea, LFTs, CRP, ESR, Vanco trough
- All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
- All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**], or to on call
infectious disease MD in when clinic is closed
- Your neck wound should be packed with 10 cm of 1-inch iodaform
packing gently. Gradually, the amount of packing should be
decreased to allow the cavity to heal in from the inside out.
This should be changed daily. Apply a dry gauze dressing on the
outside and you can change the outer dressing as needed.
- Seek immediate medical attention for fever >101.5, chills,
increased redness, swelling or discharge from incision, chest
pain, shortness of breath, or anything else that is troubling
you. OK to shower. No strenuous exercise or heavy lifting until
follow up appointment, at least. Do not drive or drink alcohol
while taking narcotic pain medications. Narcotic pain
medications may cause constipation, if this occurs take an over
the counter stool softener. Resume all home medications.
Followup Instructions:
- Follow up with infectious disease, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**] on
[**2177-2-17**] at 11:30am. The [**Hospital **] clinic lis located in the LM [**Hospital Ward Name **]
BLDG ([**Doctor First Name **]), BASEMENT, ID WEST (SB). Call ([**Telephone/Fax (1) 88244**] if you have any questions regarding your appointment.
- Call Dr.[**Name (NI) 20390**] office at ([**Telephone/Fax (1) 21740**] to make
follow up appointment to be seen within 1-2 weeks. His office is
located on [**Doctor First Name **], [**Location (un) **] ENT SUITE 6E.
- Follow-up with your PCP [**Last Name (NamePattern4) **] [**2-10**] weeks regarding this
hospitalization
Completed by:[**2177-2-9**]
|
[
"E849.8",
"478.24",
"786.09",
"459.2",
"493.90",
"478.22",
"998.59",
"041.19",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"29.11",
"28.0",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9935, 9996
|
3436, 8290
|
323, 431
|
10071, 10071
|
2838, 2838
|
11725, 12446
|
1435, 1489
|
8352, 9912
|
10017, 10050
|
8316, 8329
|
10222, 11702
|
1504, 2819
|
269, 285
|
459, 1327
|
3056, 3413
|
10086, 10198
|
1349, 1355
|
1371, 1419
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,292
| 163,110
|
37376
|
Discharge summary
|
report
|
Admission Date: [**2170-11-12**] Discharge Date: [**2170-11-23**]
Date of Birth: [**2086-4-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Influenza Virus Vaccine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Dysnpea, dysphagia
Major Surgical or Invasive Procedure:
[**2170-11-14**]: Left thoracotomy. Repair of proximal left main stem
bronchus laceration,intercostal muscle flap buttress, drainage
of
hemothorax.
[**2170-11-14**]: Rigid bronchoscopy and flexible bronchoscopy.
[**2170-11-12**] Placement of an 18-French chest tube into the left
hemithorax.
History of Present Illness:
84F s/p TEVAR for ruptured thoracic aortic aneurysm [**2170-10-30**].
She was discharged on [**2170-11-5**] in good condition. She presents
[**11-12**] with a four day history of weakness, low grade fevers.
She has developed worsening cough over the last 3 days
associated with shortness of breath and dysphagia/odynophagia.
The cough is mostly nonproductive (white phlegm). She also has
abdominal pain
and nausea and diarrhea. She denies, melena, BRBPR, hematemesis,
or hemoptysis. She was started on antibiotics for pneumonia.
Imaging at [**Hospital3 52206**] showed that she had a left side pleural
effusion and atelectasis concerning for re-rupture with mass
effect on trachea and esophagus. She was transfered to [**Hospital 61**] for further management.
CTA chest was performed [**2170-11-12**] demonstrating evidence of
endoleak and increased left pleural effusion. An interventional
pulmonary consult was obtained, they placed a chest tube and
drained 250cc of dark blood.
Past Medical History:
Hypertension
Hypercholesterol
Sciatica
Cold feet
PSH: Hysterectomy
Social History:
lives with husband. active and independent in ADLs. no tobacco
(husband was a smoker in the house). no etoh
Family History:
No CAD
Physical Exam:
On admission:
Temp 99.2 HR: 74 BP: 124/58 RR: 21 O2 Sat: 94% 2L
Gen: alert and oriented x 3, NAD
Card: RRR no murmer, rubs, gallops, clicks
Pulm: CTA on R, decreased breath sounds on L. Dull to percussion
on L.
Abd: Soft, nontender, nondistended
Ext: Palp DP, PT, radial
Pertinent Results:
[**2170-11-12**] 06:03PM PLEURAL WBC-750* Polys-17* Bands-1* Lymphs-72*
Monos-5* Eos-5* Metas-0
[**2170-11-12**] 06:03PM PLEURAL Hct,Fl-5.5*
Pleural Fluid negative
[**2170-11-14**] 08:04PM BLOOD WBC-10.4 RBC-3.40* Hgb-10.4* Hct-30.4*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.8 Plt Ct-487*
[**2170-11-14**] 08:04PM BLOOD Plt Ct-487*
[**2170-11-14**] 08:04PM BLOOD Glucose-128* UreaN-17 Creat-0.7 Na-139
K-3.9 Cl-109* HCO3-22 AnGap-12
[**2170-11-14**] 08:04PM BLOOD Calcium-8.8 Phos-4.8*# Mg-1.9
[**2170-11-14**] 08:19PM BLOOD Type-ART pO2-83* pCO2-44 pH-7.32*
calTCO2-24 Base XS--3
[**2170-11-14**] 08:19PM BLOOD freeCa-1.26
[**2170-11-14**] 04:05PM BLOOD Glucose-117* Lactate-1.4 Na-136 K-3.6
Cl-107
[**2170-11-18**] 01:43AM BLOOD WBC-12.3* RBC-3.79* Hgb-11.3* Hct-33.4*
MCV-88 MCH-29.9 MCHC-34.0 RDW-13.9 Plt Ct-633*
[**2170-11-18**] 01:43AM BLOOD Plt Ct-633*
[**2170-11-17**] 01:31AM BLOOD Glucose-108* UreaN-17 Creat-0.6 Na-138
K-3.8 Cl-105 HCO3-23 AnGap-14
[**2170-11-18**] 01:43AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.0
CXR [**10/2570**]
Left fourth posterior rib fracture is difficult to visualize on
the upright
prior study probably post surgical. Extensive subcutaneous
emphysema,
otherwise unchanged.
[**2170-11-22**] 09:27PM BLOOD WBC-13.2* RBC-3.73* Hgb-11.2* Hct-33.9*
MCV-91 MCH-30.0 MCHC-33.1 RDW-14.7 Plt Ct-386
[**2170-11-22**] 09:27PM BLOOD Plt Ct-386
[**2170-11-22**] 09:27PM BLOOD Glucose-111* UreaN-30* Creat-0.9 Na-143
K-4.2 Cl-105 HCO3-31 AnGap-11
[**2170-11-22**] 09:27PM BLOOD Calcium-8.3* Phos-3.1 Mg-2.1
Brief Hospital Course:
The patient was admitted to the vascular service on [**2170-11-12**].
Interventional pulmonary was consulted for thoracentesis. They
placed an 18Fr chest tube to drain the left collection which was
of dark bloody consistency.
She was taken to the operating room on [**2170-11-14**] for planned
left VATS, washout and chest tube placement. However, after the
patient was intubated in the OR, the
anesthesiologist was checking tube position with the
bronchoscope, it was noted that there was a laceration of the
proximal left main stem bronchus. A rigid bronchoscopy was then
performed demonstrating a 1.5 cm full thickness tear. The
patient then proceeded to have a left thoracotomy and primary
repair. See operative note for full details. The patient
remained intubated following the procedure and was transferred
to the TSICU. She was treated prophylactically with vanco/levo,
was intubated, NG tube in place, 2 chest tubes and one [**Doctor Last Name **]
drain in place, foley in place.
She was extubated on [**11-15**] without any issues, her chest tubes
were placed to water [**Last Name (LF) **], [**First Name3 (LF) **] epidural was placed for pain
control.
[**11-16**] - NG tube was removed, speech and swallow assessed the
patient and she started thin liquids and ground solids.
[**11-18**] - due to poor intake, a dobhoff tube was placed and tube
feeds were started
[**11-19**] - the patient was transferred to the floor for continued
monitoring, she removed her dobhoff overnight, PO intake was
encouraged, chest tubes removed
[**11-20**] - antibiotics discontinued, chest drain removed
[**11-21**] - physical therapy continued working with the patient and
recommended rehab
[**11-22**]- Physical therapy continued working with the patient.
Patient over night got moderate respiratory depression, with ABG
showed hypoxemia. 1 time dose naloxone was administrated with
good response. We change pain management to Tylenol and
Ibuprofen, no narcotics.
[**2170-11-23**]- Patient was stable , doing fine, VS stable , afebrile.
Patient was discharge to rehab.
Medications on Admission:
lovastatin 10, motrin 400 tid, premarin, enalapril 10, HCTZ 25
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-29**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
4. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a
day: hold SBP < 100.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) SC
Injection TID (3 times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for mucoltytic.
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day) as needed for hold hr<55, SBP<100.
13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Catholic [**Hospital1 107**] Home
Discharge Diagnosis:
Left hemothorax
s/p TEVAR for ruptured thoracic aortic aneurysm [**2170-10-30**]
Hypertension
Hypercholesterol
Sciatica
Cold feet
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills.
-Increased shortness of breath, cough or sputum production
-Chest pain
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**12-6**] 3:30 pm on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
CXR on the [**Location (un) 861**] Radiology Department 45 minutes before your
appointment
Completed by:[**2170-11-23**]
|
[
"E878.2",
"511.89",
"998.11",
"272.0",
"724.3",
"401.9",
"998.2",
"E870.8",
"519.19",
"787.20",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"88.73",
"38.93",
"34.04",
"33.41",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7182, 7242
|
3724, 5799
|
310, 603
|
7416, 7425
|
2178, 3701
|
7649, 7942
|
1852, 1861
|
5912, 7159
|
7263, 7395
|
5825, 5889
|
7449, 7626
|
1876, 1876
|
252, 272
|
631, 1617
|
1890, 2159
|
1639, 1708
|
1724, 1836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,346
| 106,893
|
3555
|
Discharge summary
|
report
|
Admission Date: [**2136-2-8**] Discharge Date: [**2136-2-24**]
Date of Birth: [**2077-2-19**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 59-year-old female
with a past medical history significant for type 2 diabetes
mellitus with diabetic neuropathy, hypertension,
hypercholesterolemia, low TSH, obesity, claudication, and a
bulging lumbar disk causing leg numbness.
PAST SURGICAL HISTORY:
1. Hysterectomy.
2. Tonsillectomy.
SOCIAL HISTORY: Patient is a smoker, smoking one pack per
week, drinking socially.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg q day.
2. Toprol XL 100 mg [**Hospital1 **].
3. Imdur 60 mg q day.
4. Pletal 100 mg [**Hospital1 **].
5. Univasc 15 mg q day.
6. Prozac 40 mg q day.
7. Insulin NPH 40 [**Hospital1 **].
8. Insulin regular sliding scale.
9. Neurontin 600 mg q hs.
10. Zanaflex two [**Hospital1 **].
11. Lipitor 10 mg q day.
This is a 59-year-old female with known coronary artery
disease who is referred to [**Hospital1 188**] for an outpatient cardiac catheterization due to
increased exertional anginal symptoms. Over the past year,
the patient had been complaining of progressive angina
described as tightness of the left side of her chest with
left arm and shoulder discomfort, which was sometimes
accompanied by diaphoresis, nausea, and shortness of breath.
She also has a history of bilateral claudication of her legs
after walking about a half a block with her left greater than
right, being followed by Dr. [**Last Name (STitle) **].
Cardiac catheterization was performed which revealed left
main with 40% stenosis, right coronary artery with 80%
stenosis, posterior descending artery 80% stenosis, left
anterior descending artery 70% stenosis, circumflex with 80%
stenosis with an ejection fraction of 70% with no valvular
disease. The patient was subsequently referred for coronary
artery bypass grafting.
Patient underwent coronary artery bypass grafting x3 [**2136-2-20**] with a left internal mammary artery to the left
anterior descending artery, saphenous vein graft to the
posterior descending artery, and saphenous vein graft to the
obtuse marginal. Total cardiopulmonary bypass time was 123
minutes, total cross-clamp time was 49 minutes. The patient
was transferred in stable condition in normal sinus rhythm at
81 beats per minute on propofol at 10, insulin drip at 2, and
Neo-Synephrine at 0.7 mcg/kg/min.
Postoperative day one, 24 hour events included the patient
being extubated without event and a right chest tube being
placed at the bedside for a right pleural effusion. Patient
still on a Neo-Synephrine drip at 0.25, sinus tachycardic at
100 beats per minute, blood pressure stable, CVP 12. White
count of 16.3, hematocrit of 28.5, and a platelet count of
200. BUN of 15, creatinine of 0.5 and a glucose of 109.
Patient was transferred to the floor that same day
postoperative day one.
Postoperative day two, no significant events over the last 24
hours. The patient's right pleural chest tube was placed on
suction and then was later discontinued, with the mediastinal
chest tube still placed on suction, on physical examination,
the patient's lungs had coarse breath sounds bilaterally.
The patient was encouraged to use her incentive spirometer.
Her Foley was discontinued. Patient remained with a low
grade temperature of 99.8. Vital signs otherwise stable with
continued complaints of pain which was treated with Vicodin
and ibuprofen with good effect.
Postoperative day three, no 24 hour events of note with
patient's pain improving after administration of Neurontin.
Still had a low grade temperature at 99.7. Vital signs
stable otherwise, sating at 92% on room air. Physical
examination: Patient with 2+ edema of the lower extremities.
Plan for the patient is to possibly discontinue the patient's
chest tube, to get the patient out of bed with Physical
Therapy.
Postoperative day four, patient was discharged. Physical
examination was unremarkable, aside from the patient's 1+
pedal edema. Twenty-four hour events included transfusion of
1 unit of packed red blood cells for a hematocrit of 23
yesterday, [**2-23**]. The patient was discharged home in
good condition.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg [**Hospital1 **].
2. Lasix 20 mg [**Hospital1 **] for seven days.
3. Potassium chloride 20 mEq [**Hospital1 **] for seven days.
4. Colace 100 mg [**Hospital1 **].
5. Aspirin 325 mg q day.
6. Fluoxetine 40 mg po q day.
7. Lipitor 10 mg q day.
8. Vicodin 5/500 1-2 tablets po q4h prn pain.
9. Neurontin 600 mg [**Hospital1 **].
DISCHARGE INSTRUCTIONS: Followup with her cardiologist in
[**1-19**] weeks, and follow up with Dr. [**Last Name (STitle) 70**] in [**4-22**] weeks.
DISCHARGE DIAGNOSIS: Coronary artery disease status post
coronary artery bypass grafting x3.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 2011**]
MEDQUIST36
D: [**2136-4-3**] 14:39
T: [**2136-4-4**] 06:41
JOB#: [**Job Number 16250**]
|
[
"070.54",
"357.2",
"997.3",
"511.9",
"250.60",
"414.01",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
4240, 4586
|
4758, 5124
|
590, 4217
|
4611, 4736
|
443, 479
|
179, 420
|
496, 564
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,341
| 152,612
|
50703
|
Discharge summary
|
report
|
Admission Date: [**2158-11-20**] Discharge Date: [**2158-12-20**]
Date of Birth: [**2108-8-19**] Sex: F
Service: SURGERY
Allergies:
Percocet / Sulfonamides / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
RLE pain and swelling
Major Surgical or Invasive Procedure:
Right lower extremity open venous thrombectomy, fasciotomy
Right lower extremity lateral and medial debridement w/ medial
VAC closure
Right lower extremity lateral debridement at bedside
History of Present Illness:
50 year old female presents to the ED with severe RLE and R.
back pain. She was in her usual state of health until about 2-3
weeks ago when she was admitted to [**Hospital **] Hospital with
shortness of breath and diagnosed with a RLE DVT and PE. She was
started on heparin ggt, however she developed a rectus sheath
hematoma, so this was stopped and an IVC filter was placed. She
was discharged home around [**11-7**] and had been well until
3 days ago when she developed acute onset of R. lower back pain
and right groin pain. This progressed over the past 3 days until
she came to the ED.
Past Medical History:
- HTN
- hyperlipidemia
- asthma
- L. back melanoma
PSH: IVC filter around [**2158-11-7**], L. back melanoma excision with
axillary lymph node dissection, laparotomy x 2 for ovarian cysts
as a teenager, C-section, appendectomy, lap cholecystectomy
Social History:
Lives with husband and kids
Family History:
N/C
Physical Exam:
VS: TM 100.3 TL97.1 80 137/72 16 96% RA
Gen; AAOx3, NAD
HENT: supple no bruits
card: RRR, nl S1S2
Lungs: CTA b/l, no distress
Abd: obese, NT, ND
Extremities: both well perfused and warm.
Right: has bilateral faciotomies (lateral and medial), the
medial is beefy and granulating, the lateral s/p debridement at
the bedside [**12-20**], is mildly cellulitic around, no exudate,
medial thigh staples are intact, incision is healed and well
anastomosed. The right groin has an area of wound dehescense
with clean and beefy base.
Pertinent Results:
[**2158-12-20**] 06:02AM BLOOD WBC-7.1 RBC-3.33* Hgb-9.8* Hct-29.4*
MCV-88 MCH-29.4 MCHC-33.3 RDW-17.8* Plt Ct-341
[**2158-12-19**] 05:27AM BLOOD WBC-6.9 RBC-3.38* Hgb-10.0* Hct-29.9*
MCV-88 MCH-29.6 MCHC-33.5 RDW-17.7* Plt Ct-351
[**2158-12-20**] 06:02AM BLOOD PT-16.0* INR(PT)-1.4*
[**2158-12-19**] 05:27AM BLOOD PT-16.5* INR(PT)-1.5*
[**2158-12-20**] 06:02AM BLOOD Glucose-109* UreaN-14 Creat-0.7 Na-141
K-4.0 Cl-102 HCO3-29 AnGap-14
[**2158-12-15**] 05:48AM BLOOD Glucose-98 UreaN-17 Creat-0.6 Na-138
K-4.2 Cl-101 HCO3-29 AnGap-12
Cardiology reports:
ECG Study Date of [**2158-11-20**] 2:10:10 PM
Sinus rhythm. Low precordial lead QRS voltage is non-specific
and tracing is probably within normal limits. No previous
tracing available for comparison.
ECG Study Date of [**2158-11-22**] 2:21:10 AM
Sinus rhythm with borderline sinus tachycardia. QRS
configuration in
leads III and aVF raises the consideration of prior inferior
myocardial
infarction although is non-diagnostic. Otherwise, tracing may be
within normal limits but unstable baseline and baseline
artifacts in lead V3 makes assessment difficult. Clinical
correlation is suggested. Since the previous tracing of [**2158-11-20**]
axis is more leftward with a change in QRS configuration in lead
aVF and late precordial QRS transition is present. Otherwise,
there may be no significant change.
Portable TTE (Complete) Done [**2158-11-22**] at 9:31:26 AM
FINAL: The left atrium is dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). There is a mild
resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis (velocities increased due to mild left
ventricular outflow gradient). No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
ECG Study Date of [**2158-12-11**] 3:01:38 PM
Sinus tachycardia. Consider left atrial abnormality. Consider
prior inferior myocardial infarction, although it is
non-diagnostic. Delayed R wave progression with late precordial
QRS transition. Findings are non-specific. Since the previous
tracing of [**2158-11-22**] no significant change.
Radiology reports:
[**2158-11-20**] 2:23 PM
CHEST (PORTABLE AP) IMPRESSION: Left basilar atelectasis,
otherwise normal. Limited study.
[**2158-11-20**] 2:36 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST; CT CHEST W/O
CONTRAST
IMPRESSION:
1. Right rectus abdominus muscle hematoma.
2. No retroperitoneal hematoma.
3. 18 x 23 mm hyperdense retroperitoneal lesion within the
aortocaval region, likely a lymph node, new from prior. A pelvic
MR can be obtained for further characterization.
[**2158-11-20**] 7:48 PM BILAT LOWER EXT VEINS
IMPRESSION: Extensive venous thrombosis extending through all
the deep veins of the right lower extremity and no evidence of
left lower extremity deep venous thrombosis.
[**2158-11-20**] 7:49 PM RENAL U.S.
IMPRESSION: Normal study
[**2158-11-21**] 11:14 AM CT PELVIS W/O CONTRAST
IMPRESSION:
1. Ovoid area of high density within the aortocaval space at the
level of the IVC filter with adjacent fatty stranding which is
unchanged in size compared to the prior study. This finding is
concerning for a small, atable appearing retroperitoneal
hematoma.
2. Stable right rectus abdominis muscle hematoma.
[**2158-11-23**] 7:42 AM
BILAT LOWER EXT VEINS PORT
IMPRESSION: Limited exam, however a small amount of flow is now
visualized in the right common and superficial femoral veins,
which remain partially
occluded. Reconstituted flow within the right popliteal vein is
observed.
[**2158-11-27**] 8:26 AM PORTABLE ABDOMEN
IMPRESSION: Small bowel dilatation most consistent with ileus.
[**2158-11-29**] 3:06 PM LIVER OR GALLBLADDER US (SINGLE ORGAN)
IMPRESSION: Normal-appearing liver without focal lesion or
biliary ductal
dilatation.
[**2158-12-10**] 7:10 PM UNILAT LOWER EXT VEINS LEFT
IMPRESSION: Limited exam; however, no evidence of DVT. Calf
veins could not be visualized.
[**2158-12-11**] 9:46 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
IMPRESSION:
1. Minimal contraction in the right rectus sheath hematoma.
2. New asymmetric expansion of the left iliopsoas muscles, with
adjacent left retroperitoneal stranding and small focal fluid
collection posterior to the inferior pole of the left kidney.
Findings are compatible with new left retroperitoneal hematoma.
3. Post-surgical changes in the right groin, without associated
right groin or thigh hematoma. Inflammatory stranding is noted
throughout the soft tissues of the right thigh.
4. Aortocaval density is again demonstrated. As previously
described, it is decreased in size and attenuation, most likely
representing a small resolving hematoma.
Study Date of [**2158-12-13**] 11:22 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
IMPRESSION:
1. Interval enlargement of left retroperitoneal hematoma, as
described above.
2. New small left pleural effusion with associated atelectasis.
Otherwise unchanged CT examination of the abdomen and pelvis
compared to
[**2158-12-11**].
Brief Hospital Course:
[**2158-11-20**] Patient admitted via ED for increasing right lower
extremity pain and swelling. S/p IVC filter placement from an
OSH complicated by right rectus muscle hematoma, s/p several
units blood transfusion. In ED found to have creatinine in 8.4,
hydrated overnight, creatinine came down to 6.8. Renal consulted
and following. RLE US showed clot in deep veins of RLE from calf
to common femoral, cannot visualize iliacs. CT of pelvis and
abd. was done-Right rectus abdominus muscle hematoma. Renal
US-showed Both kidneys show patent main renal arteries and veins
with appropriate arterial and venous waveforms. RLE was ace
wrapped and elevated. Started heparin drip conservatively. Kept
NPO. RLE noted to have significantly diminished sensation from
toes -knee with no foot motor fucntion and drop foot.
[**2158-11-21**] Patient was scheduled for angiojet thrombectomy. Kept
NPO, pre-oped and consented. Patient had abd/pelvic CT-that
showed stable rectus muscle hematoma. Became unstable, BP down
to the 70's, given fluid, blood products, transferred to the
CVICU. Arterial line and central access lines were placed for
blood pressure monitoring. Continued to be oliguric, and
creatinine remain elevated. CPKs were sent that came back
elevated. Reanl consult placed, recommended Bicarb infusion
which was started. In the CVICU patient recieved more blood
tranfusions, started on Neo drip for BP support. Angio
thrombectomy cancelled. Renal service following. Heparin drip
continued. Patient had problems w/ hyperkalemia-treated w/
Insulin/Bicarb/D50/CaGluconate IV.
[**2158-11-22**] Remained in CVICU, continued to require fluid
resucitation w/ Bicard drip and Neo drip to maintain BP.
Compartment pressures were done by ortho service-found to be
elevated, w/ CPK elevated as well. Pre-oped and consented for
open venous thrombectomy and faciotomy. Taken to OR and
underwent RLE open venous thrombectomy and fasciotomy. Patient
tolerated procedure, was transferred back to the CVICU for
recovery. Portable TTE was done-w/ LVEF >55%.
[**2158-11-23**] ICUD2/POD1: Remained Oliguric, BP remain labile
requiring pressors and fluid boluses. Continued to require blood
transfusions for low HCT. Remained intubated and sedated. Renal
following, started on Lasix drip. Started on heparin drip.
Patient had copious liquid stools-rectal tube was placed, stools
came back negative for c-diff. Noted to have increased swelling
of LE's bilateral US were done-ruled out for DVT.
12/11-13/09 ICU3-5 POD2-4: remained in the ICU, intubated and
sedatedsedated. On Lasix drip to keep UOP >100cc/h, heparin and
Bicarb drips. R lateral faciotomy w/ muscle noted to be necrotic
at superficial level. Creatinine continued to rise and started
to improve [**11-26**]. Renal following. Failed extubation [**11-25**].
Started on Cefazolin [**11-24**], added Cipro [**11-25**]. Transfused PRBCs
for low HCT.
[**11-27**] ICU6/POD5: Remained in ICU. On lasix drip and Diamox.
Started tube feeds. Remained intubated on CPAP/PS ventillation.
Remains lightly sedated on Fentanyl and Versed drips, and
continued on Heparin drip. Continued antibiotics. Renal
continued to follow.CK's and creatinine improving.Bicarb drip
discontinued. Patient's abdomen became distended and w/
vomiting, abd. x-ray showed ileus-tube feeds stopped.
[**2158-11-28**] ICU7/POD6: Patient remained in ICU, now weaned and
extubated. ARF/Rhabdo improving with hydration.Lasix drip off.
Renal signed off. PCA fentany for pain, tolerated well. Patient
found to be confused but not agitated.
[**2158-11-29**] ICU8/POD7: Remained in ICU. Maintained off ventillator.
Continued Heparin drip, started Coumadin. Now auto diuresing.
CK's and creatine continued to trend down. Physical therapy
consulted, patient taken out of bed to chair w/ a lift,
tolerated. Continue to have diarrhea w/ rectal tube. patient
reamied confused. Started PO liquids. Abdomen remain distended-
Gallbladder US-showed normal biliary ductal dilatation.
[**2158-11-30**] ICU9/POD8: Continued heparin drip, dosed with Coumadin.
Transferred to VICU [**Hospital Ward Name **] 5. Continued to be confused. Continued
to have diarrhea, priorly negative for C-diff. Tolerating PO's
but w/ poor intake.
[**2075-11-30**] POD9-16: Remained in VICU, continued to be dosed w/
Coumadin, Heparin drip came off, INR came up to 5.9 Coumadin
held for a couple days. Patient now AAOx3. Wound vac taken down
and replaced every third day. The R lateral wound was debrided
and w/ wet-dry dressing. Thigh incision dehised, dressing w/
DSD. Pain management changed to PO Dilaudid. Physical therapy
working w/ patient to get OOB. Creatinine normalized, CKs down
to the 4k, stopped cycling. HCt had been stable in the high 20's
all week.
[**Date range (1) 105490**]/10 POD17-24: Remained in the VICU. Left LLE noted to
be more swollen, unilateral US done negative for DVT. This week
patient's HCT went down to 22 from 27. Abd./pelcis CT showed
-stable R rectus sheath hematoma and w/ Minimal contraction in
the right rectus sheath hematoma. New asymmetric expansion of
the left iliopsoas muscles, with adjacent left retroperitoneal
stranding and small focal fluid collection posterior to the
inferior pole of the left kidney. Findings are compatible with
new left retroperitoneal hematoma. Patient recived numerous
blood transfusions. Heme oncology consulted-recommended to d/c
Aspirin and lower INR goal to 1.5-2.2. Aspirin was d/c'd.
Coumadin was held and res-started to target goal INR per Heme
recommendations. Kept on bedrest.
[**Date range (1) 105491**] POD 25-27: Remained in the VICU. HCT had been stable
at 29-30, transfused another unit of blood to keep HCT above 29.
Patient is stable hymodynamically. Re-started out of bed
activity. Wound vac therpay continued on R medial wound and R
groin wound. The R lateral wound was again debrided at the
bedside w/ routine wet-dry dressing found to be cellulitic all
around started Nafcillin IV. Physical therapy recommended rehab.
Rehab screening initiated.
[**2158-12-20**] POD28: Patient's HCT had been stable for almost 1 week
now, w/ almost stable Coumadin dose between 5-7.5 daily, keeping
an INR between 1.5-2.2. Patient was discharged to Rehab in
stable condition. The right LE remain to have no motor function,
sensation is almost normal w/ new cellulitis around the lateral
faciotomy, now being treated w/antibiotics. Patient's PO intake
remain poor but improving. Her creatinine is now normal. Patient
will FU w/ Dr. [**Last Name (STitle) 1391**] in 2 weeks to re-evaluate wounds and
assess for possible skin grafting. Instructions provided to
patient.
Medications on Admission:
Triamterene-HCTZ 37.5/25 mg qd
Lisinopril 20 mg qd
Spiriva 18
Coreg 25 mg qd
Omeprazole 20 mg qd
Effexor XL 150 mg [**Hospital1 **]
Carbamazepine 100 mg po BID
Neurontin 600 mg [**Hospital1 **]
Simvastatin 20 mg qd
Singulair 10 mg qd
ProAir HFA 90 mcg inhaler
Discharge Medications:
1. Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO four
times a day for 2 weeks.
2. Outpatient Lab Work
INR three times a week (goal INR 1.5-2.2) patient has history of
bleeding
3. Carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
4. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheezing.
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever or pain.
12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
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. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
18. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM: titrate to INR goal of 1.5-2.2.
19. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 5 days: d/c [**2158-12-25**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
- Right lower extremity venous thrombosis now s/p Common Iliac
thrombus s/p thrombecomy/embolectomy
- Rectus muscle hematoma
- Anemia-secondary to bleeding
- Acute renal failure- on arrival creatinine peaked at 8.9,
recovered w/ fluid resusciation, alcalinization w/ Bicarb drip,
creatinine now normal
Rhabdomyolysis- RLE ischemia 2nd to compartment syndrome,
required faciotomy-now resolved
- R Foot drop- prior to hospitalization, persistent, will need
agressive physical therapy and splinting
History of:
HTN
hyperlipidemia
asthma
L back melanoma
PSH: IVC filter ([**10-23**]), L back melanoma excision with ax LN
dxn, laparotomy x 2 for ovarian cysts, C-section, app, lap chole
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Labs: INR three times a week (if daily cannot be done) INR upon
discharge is 1.4 (goal INR is between 1.5-2.2)
Discharge Instructions:
- You were admitted for right lower extremity pain, found to
have
right rectus sheath hematoma and venous thrombosis extending
through all the deep veins of the right lower extremity,
-You became critically ill from the released chemicals from your
right lower extremity muscles, you required ICU care before and
after your surgery,
-You had to be taken to the OR for removal of thrombus and
faciotomy to relieve pressure in your right calf,
-As part of your therapy we started you on Coumadin that you
will need to be on for an extended period of time. You will need
INR levels checked frequently until your dose and INR levels are
stable.
-You were discharged on antibiotics that you will take for 2
weeks,
-You will have a wound vac placed in your wounds at the rehab
facility(right medial and groin wounds) to be changed every
third day until you get seen in Dr. [**Last Name (STitle) 1391**] for FU.
-You also developed right "drop foot", you will need a spilt to
for this, this was custom nade for you and will be delivered to
your rehab.
-You will FU w/ Dr. [**Last Name (STitle) 1391**] in 2 weeks to re-evaluate your
wounds for the need for skin grafting.
Followup Instructions:
Dr. [**Last Name (STitle) 1391**] in 2 weeks. Call to make an appointment
Phone:[**Telephone/Fax (1) 1393**]
Completed by:[**2158-12-20**]
|
[
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] |
icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
]
] |
16292, 16358
|
7497, 14119
|
336, 525
|
17085, 17085
|
2044, 7474
|
18563, 18704
|
1479, 1484
|
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|
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|
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|
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|
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|
17099, 17343
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,686
| 132,328
|
28012
|
Discharge summary
|
report
|
Admission Date: [**2151-12-11**] Discharge Date: [**2151-12-12**]
Date of Birth: [**2082-3-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation [**2151-12-11**]
History of Present Illness:
69 yo male history of CVA with residual right sided paralysis,
history MSSA bacteremia, afib and hx of LGIB s/p colectomy
presents with fever and diminished responsiveness at [**Hospital **] and L-sided twitching in the ED. [**Hospital3 **] reports
that he was in his USOH until he was found unresponsive with
increased chest congestion, and febrile to 103.2, HR 110-120, BP
160/88, RR 24-28, o2 sat 61% on RA. His oxygen improved with a
face mask to 91-96%. He was sent to [**Hospital1 18**] for further evaluation
by ambulance. The ED was told by EMS that he was full code. In
ED, found to be have ULE and LLE twitching, with his head turned
toward the left. PIV placed and he was given 2 mg IV ativan at
which point his jerky movements slowed but he remained
unresponsive. He was intubated without issue then paralyzed with
20 of etomidate and 120 of succynlcholine. He was given another
4 mg of ativan after intubation and later was more responsive.
Neuro saw him and thought possible that this was seizure
activity vs rigoring. He was loaded with 1 gram of dilantin, and
neuro is following. Of note, it appears that he was previously
on valproic acid 750mg qAM and 500mg qPM, but this was recently
discontinued per [**Hospital3 537**] records.
.
He was in afib with rapid ventricular rates of 150-180 and had
lateral ST depressions on EKG. BP was stable. He received 1L of
NS and his afib spontaneously broke to sinus rhythm in 90s.
.
He was febrile to 101.8 in the ED. Urine was purulent and
urinalysis revealed a UTI. Blood cultures were drawn. He was
also hypoxic to 51% on RA. A CXR was done and found to be within
normal limits. He received ceftriaxone, vancomycin, and
ampicillin for menigitis coverage. CT head was unremarkable for
acute lesion. LP was performed and CSF was without [**Known lastname **] cells.
Prior to transfer from the ED, he received 2L of NS. He is
currently sedated with propofol. OGT with 100cc coffee grounds,
no lavage performed. Rectal revealed brown guaiac positive
stool. Labs pertinent for a hematocrit drop to 23. Received
Protonix 40mg IV bolus. Daughter arrived and confirmed DNR/DNI
status. Vital signs prior to transfer to the [**Hospital Unit Name 153**] were HR 76, BP
110/62, RR 14,o2 sat 100% on assist control TV 500 x RR 14, PEEP
5 FiO2 50%.
Past Medical History:
CVA [**2144**] c/b residual facial droop, dysarthria, dysphagia, right
sided paralysis, nonverbal at baseline
Vascular dementia
Depression
Insomnia
Urinary incontinence
Diverticulosis s/p recent colectomy on [**5-24**] for a lower GI bleed
Repair of several abd wall ventral hernias on [**5-25**]
HTN
Hyponatremia
hx MSSA bacteremia
gastritis with anemia
Vitamin D deficiency
s/p appendectomy
Social History:
Currently residing in [**Hospital3 537**] nursing home, formerly was
employed as a cook at [**Hospital1 112**]. Previously married twice, with 10
children. History of 20 pack years of tobacco, quit x 25 years.
Former occasional EtoH.
Family History:
Mother with hypertension.
Physical Exam:
VS: Temp: 96.1 BP: 137/73 HR: 72 RR: 14 O2sat 100%
GEN: intubated and sedated, NAD
HEENT: anicteric, MMM, op without lesions
neck: supple, R-EJ in place
RESP: CTA anteriorly with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: +bs, soft, nt, nondistended, PEG tube in place, midline
scar c/d/i
EXT: no c/c/e, wwp, DP 2+ bilaterally
SKIN: no rashes/no jaundice/no splinters
NEURO: sedated, not arousable
Pertinent Results:
Admission labs:
[**2151-12-11**] 08:45AM BLOOD WBC-7.2# RBC-2.43* Hgb-8.0* Hct-23.5*
MCV-97 MCH-33.0* MCHC-34.2 RDW-15.7* Plt Ct-338
[**2151-12-11**] 08:45AM BLOOD Neuts-87.2* Lymphs-7.9* Monos-4.5 Eos-0.3
Baso-0.1
[**2151-12-11**] 08:45AM BLOOD PT-14.5* PTT-27.1 INR(PT)-1.3*
[**2151-12-11**] 08:45AM BLOOD Glucose-136* UreaN-29* Creat-1.5* Na-131*
K-4.6 Cl-97 HCO3-23 AnGap-16
[**2151-12-11**] 08:45AM BLOOD Calcium-8.5 Phos-4.6*# Mg-1.5*
[**2151-12-11**] 02:52PM BLOOD Type-ART Temp-35.6 Tidal V-500 PEEP-5
FiO2-50 pO2-213* pCO2-31* pH-7.43 calTCO2-21 Base XS--2
-ASSIST/CON Intubat-INTUBATED
[**2151-12-11**] 02:52PM BLOOD Lactate-1.2
[**2151-12-11**] 08:54AM BLOOD Lactate-2.2*
.
.
CSF
.
[**2151-12-11**] 10:22AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1* Polys-44
Lymphs-50 Monos-6
[**2151-12-11**] 10:22AM CEREBROSPINAL FLUID (CSF) TotProt-32
Glucose-101
.
.
Urine:
[**2151-12-11**] 09:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2151-12-11**] 09:00AM URINE Blood-MOD Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2151-12-11**] 09:00AM URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE
Epi-0-2
.
.
Microbiology:
.
[**2151-12-11**] 9:00 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2151-12-13**]**
URINE CULTURE (Final [**2151-12-13**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2151-12-11**] 10:22 am CSF;SPINAL FLUID TUBE 2.
GRAM STAIN (Final [**2151-12-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
.
BC [**12-11**] no growth to date at time of writing
.
[**2151-12-11**] 1:04 pm SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2151-12-11**]**
GRAM STAIN (Final [**2151-12-11**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
.
.
Radiology:
.
CT HEAD W/O CONTRAST Study Date of [**2151-12-11**] 8:32 AM
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or
recent infarction. Old lacunes within the bilateral basal
ganglia are
unchanged. There is prominence of the ventricles and sulci,
stable since he prior examination, reflective of diffuse
cortical atrophy. Hypoattenuation of the periventricular [**Known lastname **]
matter, reflective of chronic microvascular ischemic disease, is
stable. No acute fracture is detected. The middle ear cavities,
mastoid air cells, and included views of the paranasal sinuses
are clear.
IMPRESSION: No acute intracranial process. MRI is a more
sensitive test or acute ischemia if there is a clinical concern
for stroke.
.
CHEST (PORTABLE AP) Study Date of [**2151-12-11**] 8:45 AM
An ET tube is appropriately positioned with its tip 4 cm above
the carina.
The lungs are low in volume and show a left lower lobe opacity.
The cardiac silhouette is mildly enlarged. The mediastinal
silhouette and hilar contours are normal. There is a small left
pleural effusion. No pneumothoraces are present. An NG tube
terminates in the stomach appropriately. A GJ tube is partially
imaged.
IMPRESSION:
Left lower lobe opacity may represent atelectasis or pneumonia,
with small
left pleural effusion. ET tube is appropriate in position.
Brief Hospital Course:
69 yo male history of CVA with residual right side paralysis,
afib, gastritis, and hx of LGIB s/p colectomy presented with
fever and altered mental status and found to have an E coli UTI
which was pan-sensitive and treated with ciprofloxacin.
Presentation was consistent with infection causing multiple
consequences including possible aspiration event,
rigors/possible seizure activity, AMS, and hypotension
triggering AF with RVR. AF resolved following treatment of
infection and was rate-controlled with metoprolol. He was in
sinus rhythm at discharge. He was intubated in the ED and was
quickly able to be extubated and maintained good oxygen
saturation son room air. For AMS he was investigated with an LP
which was unremarkable and a CT-head which showed no new stroke.
He had vomiting and diarrhea on discharge and this was treated
symptomatically.
.
# Code status: confirmed DNR/DNI/DNH. HCP requested [**Name2 (NI) **]
care only with the addition of antibiotics and antiepileptics as
necessary to maintain [**Name2 (NI) **].
.
# Altered mental status: Given positive UA, this was felt most
likely infectious in origin UTI vs gastroenteritis causing
delirium on a backgraound of underlying vascular dementia. CXR
also showed left basal atelectasis vs pneumonia with small left
pleural effusion. He also had Na 131 and given HCP request no
further labs were drawn. He had a CT-head which was
unremarkable. He had an LP in the ED which was unremarkable with
WBC 0 RBC 1 and Pr 32 Glc 101. Preliminary CSF culture revealed
no growth and given the cell count there is a very low
likelihood of CNS infection. If final CSF culture is revealing
we will contact his residence and appropriate treatment will be
instituted. UTI was initially treated with ceftriaxone and
latterly with po ciprofloxacin on [**12-12**]. Cultures cam back as
pan-sensitive E coli. He had diarrhea and vomiting whcih may be
due to a viral infection. He was discharged back to [**Hospital **] with hospice care on [**12-12**].
.
# Respiratory failure: Pt was noted to be hypoxic at rehab to
61% on RA. CXR showed left base atelectasis vs pneumonia. He
was intubated in the ED and latterly was extubated maintaining
good O2 saturations. Initially this was considered to have been
a further stroke although CT-head revealed no new infarct. He
was stable off ventilation on discharge.
.
# Diarrhea and vomiting: He develped diarrhea and vomiting on
discharge. This may represent a viral infection. He has PIVs in
situe and can be given IV fluids is unable to take PEG. He
should be treated symptomatically per hospice care and was
prescribed ondansetron.
.
# UTI: UA showed mod LeukE, many bacteria and WBC >50. He
received IV ceftriaxone in the ED. Urine cultures grew E coli
whcih was pan-sensitive and he was treated with ciprofloxacin.
.
# AF with RVR: CHADS2 = 3 likely secondary to shift in volume
status and latterly was rate controlled in sinus rhythm.
Metoprolol aws effective for rate control. We continued
simvastatin for CVA risk reduction.
.
# Hyponatremia: sodium was 131 and deemed unlikely to be causing
AMS at this level. This was felt possibly secondary to
hypovolemia or SIADH from pain or infected state. Given HCP
preferences, he had no further blood tests taken.
.
# Possible seizures: In the ED, he was found to be have ULE and
LLE twitching, with his head turned toward the left. PIV placed
and he was given 2 mg IV ativan at which point his jerky
movements slowed but he remained unresponsive. He was intubated
without issue on [**12-11**] then paralyzed with 20 of etomidate and 120
of succynlcholine. He was given another 4 mg of ativan after
intubation and later was more responsive.
He was reviewed by Neurology who felt that this may have
reprsenetd a seizure vs rigoring. He was loaded with IV
phenytoin in [**Month/Day (4) 4171**] ED for possible seizure activity vs rigors.
Additionally, he has a positive UA in keeping with a UTI. Na 132
and other electrolytes were within normal limits. He had no
further seizure actiovity and was restarted on home schedule of
valproic acid.
.
# Anemia: Hb was roughly at his baseline og Hb [**7-18**]. He has a
history of both upper and lower GIB, now s/p colectomy. He
required no transfusions and we continued iron supplementation.
.
# CKD: Creatinine appeared to be at baseline 1.5. We continued
vitamin D. He was treated for a UTI with po ciprofloxacin for a
7 day course - pansensitive E coli grown on culture.
.
# Hypertension: This was stable. We continued lisinopril and
metoprolol.
.
# GERD/gastritis: We continued omeprazole and sucralfate.
.
# Pain control: Patient appeared comfortable. We continued
tylenol and morphine.
.
# Insomnia: We continued trazodone.
Medications on Admission:
-ferrous sulfate 220/5ml solution
-gevratonic liquid 15ml per peg daily
-vitamin d3 1,000 units daily
-omeprazole 40mg daily
-simvastatin 20mg daily
-calcium carbonate 500mg [**Hospital1 **]
-tylenol extra strength 2 tabs [**Hospital1 **]
-metoprolol tartrate 100mg [**Hospital1 **]
-sucralfate 1gm table qid
-trazodone 75mg at bedtime
-lisinopril 10mg daily
-tylenol prn
-maalox 30ml prn
-lorazepam 0.5mg q4h prn agitation
-MOM prn
-morphine sulf conc 5mg q2h prn pain
-trazodone 50mg q6h prn agitation
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Hospital1 **]: One
(1) Tablet, Chewable PO BID (2 times a day).
5. metoprolol tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID
(2 times a day).
6. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times
a day).
7. trazodone 50 mg Tablet [**Hospital1 **]: 1.5 Tablets PO HS (at bedtime).
8. lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. morphine concentrate 20 mg/mL Solution [**Hospital1 **]: Five (5) MG PO
Q2H (every 2 hours) as needed for pain.
10. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]:
15-30 MLs PO QID (4 times a day) as needed for gerd.
11. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Hospital1 **]: One (1)
PO DAILY (Daily).
12. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
13. acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
14. magnesium hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
15. valproic acid (as sodium salt) 250 mg/5 mL Syrup [**Hospital1 **]: Seven
[**Age over 90 1230**]y (750) mg PO QAM (once a day (in the morning)).
16. valproic acid (as sodium salt) 250 mg/5 mL Syrup [**Age over 90 **]: Five
Hundred (500) mg PO QPM (once a day (in the evening)).
17. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
18. ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
19. ondansetron HCl 4 mg/5 mL Solution [**Last Name (STitle) **]: Four (4) mg PO
Q8H:PRN as needed for vomiting.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnoses:
Urinary tract infection
Diarrhea and vomiting - possible gastroenteritis
Possible seizures vs rigors
Self-limiting atrial fibrillation with fast ventricular rate
Hyponatremia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and minimally arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure taking care of you during your stay at [**First Name9 (NamePattern2) 4171**]
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented following
decreased responsiveness and fevers. You were treated with
antibiotics in the EDand given the possibility of seizure
activity you were given IV anti-seizure medications. Of note you
had valproic acid recently stopped at [**Hospital3 537**]. Due to
these possible seizures, you had a breathing tube inserted
(intubated) and once these twicthing movements had stopped we
were easily able to remove this tube and you had good oxygen
levels on room air. You were found to have a urinary tract
infection and you were treated with an IV antibiotic and
latterly an oral antibiotic called ciprofloxacin. You should
continue this for 7 days. We are awaiting for the final
resultsof the culture results of your urine and if we find that
ciprofloxacin is not adequate we will inform [**Hospital3 537**].
Given decreased consciousness and possible seizures, you had a
spinal tap (lumbar puncture) which was normal and a CT scan of
the head which showed no new stroke. You had diarrhea nd
vomiting and thsi was treated symptomatically with ondansetron.
.
Changes to medications:
We started valproic acid
We started ondansetron
Followup Instructions:
You should be reviewed by your PCP at [**Hospital3 537**].
Department: RADIOLOGY CARE UNIT
When: WEDNESDAY [**2152-2-23**] at 8:30 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2152-2-23**] at 10:00 AM [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"276.1",
"311",
"530.81",
"799.4",
"401.9",
"518.81",
"437.0",
"041.4",
"438.53",
"290.40",
"599.0",
"344.1",
"427.31",
"558.9",
"285.9",
"780.39",
"268.9",
"349.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
15282, 15353
|
7936, 8982
|
328, 357
|
15591, 15591
|
3851, 3851
|
17118, 17661
|
3367, 3394
|
13208, 15259
|
15374, 15570
|
12680, 13185
|
15737, 17095
|
3409, 3832
|
267, 290
|
385, 2683
|
3867, 6113
|
15606, 15713
|
2705, 3100
|
3116, 3351
|
6145, 7913
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,188
| 133,608
|
1748
|
Discharge summary
|
report
|
Admission Date: [**2180-4-20**] Discharge Date: [**2180-4-25**]
Date of Birth: [**2100-12-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Transfer from OSH with chest pain for consideration of cardiac
catheterization.
Major Surgical or Invasive Procedure:
Drug eluting stent to RCA
cardiac catheterization
History of Present Illness:
79 yoF PMH CAD s/p CABG [**12/2172**]
(SVG->LAD, SVG->OM, SVG->RCA), HTN, DM II, COPD, presented to an
OSH ED after falling off of her chair at home. Her husband
called EMS and she complained of having chest pain for the prior
four days, described as substernal chest pressure, rated [**9-8**].
She denied SOB, LH, or palpitation. She did endorse some nausea
and lower extremity edema recently.
.
At the OSH she wsa noted to have ST elevations in I and L and
new Q waves in the same. He Trop I was 10.6 (unknown lab
standard) with normal CK-MB fraction. Four hours later repeat
Trop was 14. She was given SL NTG for relief of her CP with
intermittant success.
.
She was given ASA 325, plavix 400 mg times one, Integrellin 1
mg/kg, Heparin gtt, lipitor 80, lopressor 75 tid. She was
transferred to [**Hospital1 **] for cardiac catheterization.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for 4/10 chest pain on
arrival which resolved spontaneously; she denies dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations,
syncope or presyncope. She has some lt. ankle edema.
Past Medical History:
1. Coronary artery disease status post CABG [**12/2172**] (SVG->LAD,
SVG->OM, SVG->RCA)
2. Hypertension X 40-50 years.
3. Noninsulin dependent diabetes mellitus X 14 years.
4. Hyperlipidemia.
5. Congestive heart failure with an ejection fraction of 35%.
6. Carotid stenosis status post carotid endarterectomy in [**2166**]
and [**2171**].
7. Bilateral claudication.
8. Spinal stenosis status post lumbar laminectomy L4-L5 in
[**2168**].
9. COPD with FEV1/FVC of 65 or 91%.
10. Obesity.
11. Post-operative deep venous thrombosis status post CABG
with coumadin subsequently discontinued for gastrointestinal
bleed.
.
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, +
Hypertension, +Smoking history
.
Cardiac History: CABG, in [**12/2172**] anatomy as follows: SVG->LAD,
SVG->OM, SVG->RCA
.
No percutaneous coronary intervention.
.
No Pacemaker/ICD.
.
Social History:
Social history is significant for the absence of current tobacco
use but history of 75 pack years. There is a history of alcohol
abuse but patient quit 13 years ago.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - 97.7 70 119/51 22 100% on 2 L NC
Gen: Obese middle aged female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 6 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
[**Last Name (un) **], normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: Lt. pedal and ankle edema 1+. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 1+ DP, PT dopplerable only
Left: Carotid 2+ Femoral 1+ DP, PT dopplerable only
Pertinent Results:
[**2180-4-20**] 11:50PM BLOOD WBC-13.7* RBC-3.80*# Hgb-12.2# Hct-36.6#
MCV-96 MCH-32.0 MCHC-33.3 RDW-13.3 Plt Ct-180#
[**2180-4-20**] 11:50PM BLOOD PT-12.9 PTT-43.5* INR(PT)-1.1
[**2180-4-20**] 11:50PM BLOOD Glucose-222* UreaN-44* Creat-1.1 Na-137
K-3.9 Cl-101 HCO3-23 AnGap-17
[**2180-4-21**] 04:29AM BLOOD ALT-26 AST-37 CK(CPK)-106 AlkPhos-58
TotBili-0.6
[**2180-4-20**] 11:50PM BLOOD CK(CPK)-137
[**2180-4-20**] 11:50PM BLOOD CK-MB-8 cTropnT-2.64*
[**2180-4-21**] 04:29AM BLOOD CK-MB-7 cTropnT-2.35*
[**2180-4-20**] 11:50PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.3
.
ECG Study Date of [**2180-4-20**] 11:24:08 PM
Sinus rhythm. Left atrial abnormality. Frequent atrial ectopy.
Prior anterior wall myocardial infarction. Compared to the
previous tracing of [**2173-1-21**] there is new T wave inversion in
leads V4-V6 and associated ST segment depression which may
represent an active lateral ischemic process. Frequent atrial
ectopy has appeared, while the intrinsic rate has slowed. Rule
out infarction. Followup and clinical correlation are suggested.
.
Cardiac catheterization report:
1. Selective coronary angiography in this right dominant system
demonstrated three vessel coronary artery disease. The LMCA had
a 50%
stenosis at its origin. The LAD had diffuse disease to 100% in
the mid
vessel. The LCx had diffuse disease to 80% in the mid vessel.
The LCx
obtuse marginal branch had a 95% stenosis. The RCA had difuse
disease
distally to 80% and give rise to R->L collaterals that supplied
the OM.
2. Vein graft angiography revealed a totally occluded SVG-OM and
SVG-RCA. The SVG-LAD was patent with luminal irregularities to
40%.
3. Central aortic pressure was normal at 116/51
(systolic/diastolic in
mmHg).
4. [**Name (NI) 9927**] PTCA and stenting of the Right coronary artery with
a 3.00
Cypher DES. The final angiogram demonstrated no residual
stenosis with
no angiographic evidence of dissection, embolization or
perforation with
TIMI III flow in the distal vessel. (See PTCA comments)
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. PTCA to the RCA.
.
.
CXR [**2180-4-21**]
Moderate cardiomegaly more pronounced, particularly due to left
atrial enlargement. Pulmonary vasculature engorgement is present
but there is no edema or pleural effusion. No pneumothorax.
.
ECHO [**2180-4-21**]
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is severely depressed (ejection
fraction 20-30 percent) secondary to severe hypokinesis of the
anterior free wall, lateral wall, and posterior wall, with
extensive apical akinesis; the basal and midventricular segments
of the inferior free wall contract best. There is no ventricular
septal defect. Right ventricular chamber size is normal. Right
ventricular systolic function appears depressed. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
a trivial/physiologic pericardial effusion.
Brief Hospital Course:
79 year-old female with known CAD s/p CABG who presented to OSH
after fall at home complaining of 4 days of CP found to have
STEMI by new ST elevations transitioning to Q waves in I and AVL
prior to transfer and positive Troponin I suggestive of subacute
ST elevation MI. Hospital course is as follows:
.
#. Coronary artery disease: Patient status post CABG in [**2172**] and
now DES to RCA on this admission for subacute STEMI. The patient
was initially maintained on heparin, integrilin, and
nitroglycerin drips for control of chest pain in addition to
aspirin, plavix, beta-blocker, ACE-inhibitor, and high-dose
statin. No further evidence of active ischemia. The patient's
outpatient regimen is unknown, but prior to discharge, she was
instructed multiple times to be sure to take her Plavix given
her stent placement. She stated that she understood the risks of
not taking and will be compliant.
- at rehab, she will benefit from reiteration to take her
medications
.
#. Pump: Echocardiogram on this admission revealed depressed EF
20-30%. Patient appeared euvolemic/dry during admission. The
patient was given gentle IVF. The patient was started on
beta-blocker and ACE-inhibitor. The patient's cardiologist could
consider repeat echocardiogram in two months for ICD evaluation,
although the patient has a history of dementia.
.
#. Rhythm: Frequent ectopy (PACs, PVCs) and NSVT, longest run 8
beats. The patient's potassium was maintained greater than 4 and
magnesium greater than 2.
.
#. Acute on chronic renal failure: The patient's creatinine on
admission was 1.1 for GFR 48. This is likely secondary to the
patient's longstanding hypertension and diabetes. The patient's
creatinine bumped to 1.4 during admission which was likely
pre-renal versus contrast-induced. Creatinine remained stable
and slowly trended downward at time of discharge to 1.3. Her
ACE-I was initially stopped in setting of very mild renal
insufficiency and was restarted prior to discharge.
- At rehab, she should have one more creatinine check to ensure
normalization.
.
# Depressed mood: Throughout hosp course, pt had labile emotions
and occasionally expressed loss of hope and "I want to die, I
don't want any pain." She was concerned that her family did not
want her anymore and was "abandoning her". After speaking to her
son, she has had several long hosp courses recently and since
her lung cancer, she had had depressed mood. She denied any
active suicidal ideation. She was seen by social work, and would
likely benefit from outpatient psych evaluation.
.
# GI bleed: The patient had brown but guaiac positive stools
during admission. The patient has a known history of
diverticulosis. Hematocrit remained stable at this time. The
patient's aspirin was decreased to 81 mg. The patient should
have an outpatient work-up by gastroenterology.
.
# Diabetes mellitus type 2: Oral regimen held. The patient was
maintained on humalog sliding scale and continued this at d/c.
.
# E. coli UTI: Pt developed a pan sensitive E. coli UTI on [**4-21**]
and was started on Ceftriaxone. She was discharged with plans to
complete a 7 day course.
.
#. FEN: Cardiac/diabetic, replete lytes prn
.
#. Access: PIV
.
#. PPx: Heparin SC, bowel regimen
.
#. Code: Full
.
#. Dispo: Rehab facility
Medications on Admission:
Pt did not know her home medications
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 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 for SOB, wheeze.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheeze.
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary:
ST segment myocardial infarction
s/p stent placement in right coronary artery
Hypertension
acute renal insufficiency
Secondary:
Diabetes
Discharge Condition:
stable, chest pain free
Discharge Instructions:
You had a myocardial infarction or heart attack and had a stent
placed in your right coronary artery.
Please call 911 or go to the emergency room if you have any
chest pain, chest pressure, shortness of breath, fever, chills,
nausea, vomiting or any other concerning symptoms.
It will be very important for you to take your heart medication
especially after you have had a stent placed in your coronary
arteries. You must take your plavix and aspirin. Do not skip a
dose.
Followup Instructions:
Please make an appointment to follow-up with your primary care
physician as well as your cardiologist as soon as you are
discharged from rehab.
Your primary care doctor should follow-up on your guaiac
positive stools.
|
[
"278.00",
"428.0",
"272.4",
"250.40",
"V58.67",
"562.12",
"V10.11",
"V11.3",
"414.01",
"599.0",
"041.4",
"428.20",
"V15.82",
"403.90",
"300.4",
"424.0",
"496",
"414.02",
"410.81",
"585.9",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"00.40",
"36.07",
"88.57",
"99.20",
"00.45",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
11959, 12036
|
7295, 10561
|
396, 448
|
12226, 12252
|
4020, 6023
|
12774, 12996
|
3017, 3100
|
10648, 11936
|
12057, 12205
|
10587, 10625
|
6040, 7272
|
12276, 12751
|
3115, 4001
|
277, 358
|
476, 1921
|
1943, 2818
|
2834, 3001
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,275
| 169,824
|
23554
|
Discharge summary
|
report
|
Admission Date: [**2164-1-20**] Discharge Date: [**2164-1-23**]
Date of Birth: [**2090-1-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
transfer from OSH for management of ESRD
Major Surgical or Invasive Procedure:
angiogram and embolization
intubation
central line placement
History of Present Illness:
Pt is a 73 yo male with h/o HTN, ESRD with PD catheter placed 3
wks ago, AS but non surgical candidate, who taken by ambulance
to OSH last evening c/o porgressive SOB over 12 hrs. Was put on
O2 and BIPAP and given 160mg IV lasix during ED visit. Initially
no UOP but "filled his Foley bag" when placed. Weaned off BIPAP
and sating well with NC. Per pts daughter, he has had recurrent
episodes of SOB, which have been attributed to AS and worsening
renal function. Pt had PD catheter placed 3 weeks ago. s/p PD
dialysis last th/friday but found that PD cath leaking when pt
sitting up. Pt developed diarrhea on wed ([**1-18**]) and had his
"belly drained" at clinic.
Past Medical History:
1. ESRD, PD catheter placed 3 wks ago
2. HTN
3. Severe aortic stenosis - non operable as had chest opened for
surgery but deemed to calcified to operate
4. s/p CVA with residual weakness on L
Social History:
Pt is married and lives with wife; h/o smoking; no etOH
Family History:
noncontributory
Physical Exam:
T: 97.4 P: 62 BP: 100/54 RR: 16 O2: 94% 2L
wt: 70.4
GEN: Pt somnolent, but arousable, answering questions
appropriately, min inc WOB, NAD
HEENT: EOMI, sclerae mildly injected bilat, OP-pink/clear, neck:
supple, FROM
CARDIAC: reg rate/rhythm, harsh SEM heard best at RUSB but
throughout precordium
LUNGS: cta at apices; bibasilar crackles and [**Month (only) **] BS at R base
Abd: soft, nt/nd, peritoneal site - c/d/i with tube clamped. no
exudate at site. +BS
EXT: warm/dry; no c/c/e, spont movt of all ext
NEURO: A&OX3, somnolent but arousable; CN 2-12 grossly intact -
no focal deficits; noted min L sided weakness ( 4+ to 5-/5 on
left upper/lower ext vs [**3-22**] on R)
Pertinent Results:
[**2164-1-20**] 07:29PM GLUCOSE-68* UREA N-153* CREAT-9.4*
SODIUM-132* POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-14* ANION
GAP-25*
[**2164-1-20**] 07:29PM CALCIUM-5.6* PHOSPHATE-11.0* MAGNESIUM-2.0
[**2164-1-20**] 07:29PM WBC-5.4 RBC-3.60* HGB-9.9* HCT-30.6* MCV-85
MCH-27.5 MCHC-32.3 RDW-18.0*
[**2164-1-20**] 07:29PM PT-14.2* PTT-34.2 INR(PT)-1.3
[**2164-1-20**] 07:29PM PLT COUNT-139*
*
ECHO: The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate global
left ventricular hypokinesis. No masses or thrombi are seen in
the left ventricle. Right ventricular chamber size is normal
with mild global free wall hypokinesis. The aortic valve
leaflets are moderately thickened. There is severe aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
appears structurally [**Doctor First Name **]. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
*
CT Abdomen:
1) No evidence of retroperitoneal or intraabdominal hemorrhage.
2) Bilateral pleural effusions, right greater than left, with
changes of both atelectasis and consolidation in peribronchial
pattern, which may suggest aspiration.
3) Small right kidney, consistent with chronic renal disease.
4) Diverticulosis.
5) Wall thickening of virtually the entire colon may be related
to infectious causes such as C. difficile colitis.
6) Calcification of the coronary and abdominal/pelvic arteries.
*
Angio:
1. Abdominal aortogram revealed a diffusely diseased and
tortuous abdominal aorta, along with significant angiographic
stenosis of the left common iliac artery and the left internal
iliac artery. The renal arteries were not visualized, nor was
the inferior mesenteric artery.
2. Selective superior mesenteric arteriography reveals
retrograde opacification of the gastroduodenal and hepatic
arteries, suggesting severe obstruction of the proximal celiac
trunk. Delayed imaging reveals patency of the superior
mesenteric and portal veins. In addition, a focus of
intermittent extravasation was identified from a branch of the
marginal artery at the hepatic flexure.
3. Injection of Methylene Blue at the site of extravasation
followed by prophylactic embolization using GelFoam slurry with
good angiographic results.
Brief Hospital Course:
74 yo male presented to OSH with SOB - attributed to CHF
exacerbation, ESRD s/p placement of PD - now w/ leak, HTN,
admitted for further management of ESRD and initiation of HD--
course complicated by GI bleed on night of admission requiring
unit transfer. On night of transfer taken for tagged red blood
cell scan with evidence of bleeding at hepatic flexure. Then
taken to angiography that night with surgery following along.
Angio embolized the right colic artery and patient brought back
to the unit and supported with blood products and slowly the GI
bleeding resolved with stable hematocrits and decreased melena
and clots from rectum. During the proceudre was noted to be in
increased respiratory distress and intubated on arrival back to
intensive care unit. He required pressors to help maintain his
blood pressure even with supportive blood products and fluid
boluses. He was started on CVVH for acidosis and renal failure.
Then started showing signs of bilateral infiltrates and
remained difficult to oxygenate, requiring elevated PEEPs to
help support his oxygenation. As persistently hypotensive even
with stable anemia and bleeding had stopped concern for sepsis
with low grade temperatures and started on Vancomycin and zosyn.
Also was showing signs of coagulopathy and pancytopenia
concerning for sepsis. After discussion with wife and based on
patient's wished prior to intubation, he would not have wanted
to continue this level of care with concern of quality of life
after this event. After waiting and seeing little improvemtn in
his prognosis, Ms [**Known lastname 60303**] wished to withdraw care and patient
was weaned off sedation, started on morphine drip and extubated.
All other meds were discontinued and patient expired at 3/7 at
7:25pm.
Medications on Admission:
unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
acute respiratory distress
metabolic acidosis
septic shock
acute on chronic renal failure
blood loss anemia
pancytopenia
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2164-1-23**]
|
[
"424.1",
"428.0",
"729.89",
"E879.1",
"440.1",
"785.52",
"038.9",
"276.2",
"285.1",
"995.92",
"447.1",
"578.1",
"996.56",
"403.91",
"584.9",
"438.89",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"38.93",
"39.95",
"99.29",
"88.47",
"38.95",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6367, 6376
|
4501, 6280
|
354, 416
|
6540, 6549
|
2143, 4478
|
6602, 6637
|
1416, 1433
|
6338, 6344
|
6397, 6519
|
6306, 6315
|
6573, 6579
|
1448, 2124
|
274, 316
|
444, 1112
|
1134, 1327
|
1343, 1400
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,513
| 124,736
|
163
|
Discharge summary
|
report
|
Admission Date: [**2140-11-16**] Discharge Date: [**2140-11-24**]
Date of Birth: [**2080-4-23**] Sex: M
CHIEF COMPLAINT: Cough/shortness of breath.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1726**] is a 60-year-old male
with a past medical history significant for hypertension,
times two, who developed a dry cough in late [**Month (only) **] while
fly fishing in [**State 1727**]. The cough persisted and he was given
erythromycin times ten days times two courses by his primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1728**]. The erythromycin did not improve
the patient's symptoms.
The patient describes the cough as dry, not worse at night,
breath. He denied fevers and chills. He states that he
lost about six pounds over the past two months intentionally.
Over the past one to two weeks, however, he has noted
increasing dyspnea with stairs, as well as fatigue. On the
day prior to admission, he started a Z pack.
At his primary care physician's office today, he had a chest
x-ray which disclosed an enlarged heart and interstitial
infiltrates. An esophagogastroduodenoscopy was done, as well
as an echocardiogram which disclosed evidence of a
pericardial effusion with tamponade.
There was diastolic collapse of the right atrium and right
ventricle. The patient was sent to the Emergency Department
at [**Hospital6 256**] for evaluation of the
pericardial effusion and drainage. His pulses paradoxes was
18. The echocardiogram performed in the Emergency Department
was consistent with cardiac tamponade. The patient remained
hemodynamically stable.
PAST MEDICAL HISTORY:
1. Melanoma. Patient is status post removal of melanoma in
[**2118**] and in [**2138**].
2. Empyema of the left lung in [**2122**].
3. Labile hypertension.
4. Overweight.
5. Hypercholesterolemia.
6. Myxomatous mitral valve prolapse with mild mitral
regurgitation.
7. Non-sustained ventricular tachycardia.
8. Chronic asymptomatic VEA.
9. Peripheral vision loss.
10. History of smoking, quit in [**2122**].
MEDICATIONS:
1. Tenormin 150 mg q.d.
2. Lipitor 80 hs.
3. Enteric coated aspirin 325 mg po q.d.
4. Accupril 20 mg po q.d.
5. Multivitamin.
6. Folate 2 tablets b.i.d.
7. Vitamin E.
8. Vitamin B6.
9. Vitamin B12.
10. Ativan prn sleep.
ALLERGIES: Penicillin. Patient has a rash.
SOCIAL HISTORY: Patient does office work. He has been a
widow for the past nine years. He coaches a girls basketball
team. He has two children, ages 30 and 25. He lives with
his 30-year-old daughter. [**Name (NI) **] has a 2-year-old grandchild.
He smoked cigars until [**2122**]. He has not had alcohol for the
past nine years.
FAMILY HISTORY: No heart disease and no diabetes mellitus.
REVIEW OF SYSTEMS: No fevers, chills or night sweats.
Patient reports a six pound intentional weight loss over the
past two months. No history of positive PPD or Tuberculosis
exposure. No upper respiratory infection symptoms with
cough. No nausea, vomiting, diarrhea or abdominal pain, but
occasionally "spits up" after his cough. Reports dyspnea
with stairs and chest tightness occasionally on stairs. No
rash, no joint symptoms, no melanoma, no bright red blood per
rectum, no dysuria, no edema, no paroxysmal nocturnal
dyspnea, no orthopnea, no palpitations, no dizziness.
PHYSICAL EXAMINATION: Temperature 97 degrees. Pulse 86.
Blood pressure 124/63. Respiratory rate 23. Oxygen
saturation 95% on three liters nasal cannula. General:
Elderly white male in no apparent distress. Head, eyes,
ears, nose and throat: Anicteric, oropharynx clear, pupils
equal, round and reactive to light, extraocular movements
intact. Neck: Supple, no carotid bruit, no jugular venous
distention. Cardiovascular: Regular rate and rhythm, soft
S1, S2, no murmurs, rubs or gallops, pericardial drain in
place. Chest clear to auscultation anteriorly, left lateral
chest scar. Abdomen soft, nontender, nondistended with
positive bowel sounds. Extremities: No cyanosis, clubbing
or edema, 2+ dorsalis pedis pulses bilaterally.
Neurological: Cranial nerves II through XII are intact.
Alert and oriented times three. Exam otherwise nonfocal.
Note: This physical examination was done after the patient
underwent his cardiac catheterization.
LABORATORY DATA ON ADMISSION: White blood cell count 7.3,
hematocrit of 41, platelet count of 294,000. PT 13, PTT
23.6, INR 1.1. Echocardiogram: Normal sinus rhythm, 71
beats per minute, electrical alternans, low voltage
precordial leads, prolonged PR. After the procedure,
esophagogastroduodenoscopy showed a sinus rhythm at 82 beats
per minute, normal axis, prolonged PR, T wave inversions I
and aVL, biphasic T in V2, Qs in V1 to V2, increased voltage.
HOSPITAL COURSE: The patient was admitted initially to the
Coronary Care Unit. He underwent a cardiac catheterization
on [**11-16**] for pericardiocentesis. Hemodynamics showed
elevated and equal RA and pericardial pressures, 11-12 mm
mercury, slightly lower than pulmonary capillary wedge
pressure. There was preserved cardiac index. There is
preserved blood pressure with 15-20 mm mercury pulses
paradoxes. During the pericardiocentesis, 1116 ml of
serosanguinous fluid was easily removed. Fluid was sent to
the laboratory for analysis.
Following the pericardiocentesis, the patient was admitted to
the Coronary Care Unit for further management. On [**11-17**], the pericardial drain was removed. Repeat echocardiogram
did not disclose recurrence of the pericardial effusion.
Patient underwent CT of the chest which disclosed diffuse
interstitial infiltrates consistent with lymphangitic spread.
There was also a positive mediastinal lymphadenopathy and
lytic sclerotic bone lesions.
On [**11-19**], the patient was transferred to the [**Location (un) **]
Service. On the night of the 16th, he was tachycardic to the
160s. Echocardiogram disclosed atrial flutter. His blood
pressure was stable. He was started on sotalol 120 mg b.i.d.
The following day this was decreased to 80 mg b.i.d. While
on sotalol, his QTC interval was monitored and his potassium
was kept between 4.5 and 5.2. Repeat echocardiogram did not
disclose re-accumulation of the pericardial effusion.
While on the [**Location (un) **] Service. A Pulmonary Consult was
obtained for further evaluation of the diffuse infiltrates
seen on the CT. Pulmonary Service recommended awaiting the
final pathology from the pericardial fluid. They were
willing to perform transbronchial biopsy if necessary.
Patient was also seen by his Oncologist, Dr. [**Last Name (STitle) 1729**]. Patient
underwent an MRI of his brain on [**11-23**]. MRI disclosed
foci on the surface of the brain that appeared consistent
with leptomeningeal spread of cancer. An abdominal CT was
done on [**11-23**]. CT of the abdomen disclosed one
lymphangitic spread of metastatic disease throughout the
lungs was stable since the study one week before. There was
an increase in the pericardial fluid since the study one week
prior. There was interval development of multiple sclerotic
and lytic lesions within the osseous structures since [**2139**].
There were stable hepatic lesions that likely represent
simple cysts. There was a stable splenic lesion that likely
represents a hemangioma. Although, colon appeared grossly
normal, radiologist's caution that the study was not
diagnostic for colon cancer.
Finally, pathology results from pericardial fluid were
obtained. Pathologists performed multiple stains to identify
the type of cancer, the types of cells in the pericardial
fluid. Pathologist's concluded that the malignant cells were
from adenocarcinoma. The tumor cells are positive for CK7
and TTF1 markers. TTF1 marker is specific for lung and
thyroid. The cells were focally positive for CK20.
Pathologist's concluded that this immunoprofile is consistent
with an adenocarcinoma arising in the lung.
The patient was discharged on [**11-24**]. He will have
outpatient work-up of his malignancy.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Patient discharged home on Monday,
[**2140-11-28**].
DISCHARGE FOLLOW-UP: He will follow-up with his Oncologist,
Dr. [**Last Name (STitle) 1729**], at 2 p.m. He will be seen by Dr. [**Last Name (STitle) 724**] in the
Brain [**Hospital 341**] Clinic at 4 p.m. on [**2140-11-28**]. He will
follow-up with his Cardiologist, Dr. [**Last Name (STitle) **], on Wednesday,
[**2140-11-30**]. He was encouraged to call his primary
care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment. Patient was
given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Heart's monitor so that his QTC interval
could be monitored for an additional week while on sotalol.
DISCHARGE DIAGNOSES:
1. Pericardial effusion with cardiac tamponade.
2. Non-sustained ventricular tachycardia.
3. Hypertension.
4. Atrial Fibrillation.
DISCHARGE MEDICATIONS:
1. Sotalol 80 mg po b.i.d.
2. Lipitor 80 hs.
3. Enteric coated aspirin 325 mg po q.d.
4. Accupril 20 mg po q.d.
5. Multivitamin.
6. Folate 2 mg po b.i.d.
7. Vitamin E.
8. Vitamin B6.
9. Vitamin B12.
10. Ativan prn sleep.
11. Potassium chloride 30 mEq po q.d.
12. Celebrex 100 mg po b.i.d. as needed.
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern1) 1731**], M.D. [**MD Number(1) 1732**]
Dictated By:[**First Name3 (LF) 1733**]
MEDQUIST36
D: [**2140-11-25**]
T: [**2140-11-27**] 19:57
JOB#: [**Job Number 1734**]
|
[
"162.8",
"427.32",
"401.9",
"424.0",
"272.0",
"997.1",
"427.1",
"198.89",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
8057, 8797
|
2712, 2756
|
8818, 8953
|
8976, 9560
|
4778, 8035
|
3362, 4314
|
2776, 3339
|
138, 166
|
195, 1630
|
4329, 4760
|
1652, 2358
|
2375, 2695
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,940
| 154,446
|
23143
|
Discharge summary
|
report
|
Admission Date: [**2142-2-13**] Discharge Date: [**2142-4-21**]
Date of Birth: [**2110-6-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vancomycin / Oxycodone / Daptomycin
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Neutropenia and Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] is a delighful 31 year-old female day +229 status post a
matched related allogeneic transplant for [**Location (un) 5622**]
chromosome negative ALL now in remission. Her course was
complicated by Grade II skin GVHD, and recently new pancytopenia
with BM biopsies X 3 negative for leukemia. It remains unclear
whether she has graft failure versus graft rejection. She has
been neutropenic since [**12/2141**], and was on Neupogen which was
discontinued yesterday by Dr. [**Last Name (STitle) 410**]. Acyclovir, Protonix,
Cellcept, fluconazole, and Norvasc held.
She now presents with new fever starting last night, with Tmax
100.5 at home. On ROS, she reports mild rhinorrhea, no sore
throat or new cough. No headache or visual changes. No urinary
complaints. Some diarrhea yesterday, self-limited, without
abdominal pain. Her skin GVHD has improved a lot over the past
few weeks. She has no known sick contacts. [**Name (NI) **] chills.
In ED, Tmax 101.4, BP 104/68, HR low 100s, RR 18, Sat 98% on RA.
CXR negative, U/A unremarkable. She was given NS 3L, Cefepime 2
gm IV X1, and Tylenol 1 gm.
Past Medical History:
1. [**Location (un) 5622**] chromosome negative pre-B ALL diagnosed [**12/2140**],
status post matched allogeneic transplant (brother)
2. Grade II GVHD with psoriatic skin lesions, on phototherapy
Social History:
She currently lives alone. She has one brother, who was her
donor. Non-smoker, no etOH.
Family History:
Significant for an uncle with prostate cancer and another uncle
who had neck cancer. Her grandmother had [**Name (NI) 4278**] lymphoma.
Physical Exam:
VITALS: Tm 101/4 in ED, BP 104/68, HR 98, RR 18, Sat 98% on RA.
GEN: Delightful Caucasian woman, in NAD.
Integument: No petechiae or ecchymoses. Psoriatic-like lesions.
HEENT: Clear OP. No mucositis. No thrush.
LN: No cervical [**Doctor First Name **].
RESP: CTAB, without adventitious sounds.
CVS: RRR. Normal S1, S2. No S3, S4. No murmur or rub.
GI: BS NA. Abdomen soft, non-tender.
EXT: Without edema.
Pertinent Results:
[**2142-2-13**] CT Neck: Possible tiny retropharyngeal fluid collection.
Findings discussed with surgical house staff caring for the
patient at 9:30 a.m. on [**2142-2-14**], as well as relayed
to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], house officer caring for the patient last
night ([**2-13**]) at 8PM, by Dr. [**Last Name (STitle) **].
[**2142-2-13**] CT Sinus: Prominence of the nasopharyngeal tissues has
evolved, compared with [**2141-7-28**] CT scan of the head. A neck
CT scan could be obtained for further evaluation.
[**2-13**] CXR: No acute cardiopulmonary process.
[**2142-2-17**] Skin Left Dorsal Hand: Spongiotic dermatitis with
vesiculation and lymphocyte exocytosis (see note).
[**2142-2-18**] CT Torso: No occult infectious source visualized. Small
nodule in the right lobe of the thyroid gland.
[**2142-2-23**] CT Sinus: Slightly more extensive mucosal thickening in
the paranasal sinuses, but no air-fluid levels or other change.
[**2142-2-23**] CT Neck: Persistent thickening of the prevertebral and
parapharyngeal soft tissues, for which correlation with clinical
exam is suggested, as further details are difficult to discern
by CT. No discrete fluid collection, however.
[**2142-3-6**] CT Chest: Multiple new tiny pulmonary nodules. Given
recent onset infectious etiology is favored
[**2142-3-8**] ECHO: Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal
[**2142-3-19**] CT Chest: Several tiny pulmonary nodules, which were
seen in the previous study, become slightly larger and more
numerous. With given history of neutropenia and fever, the
differential diagnosis may include fungal infection such as
aspergillosis and nocardia. The other possibilities such as CMV
and PCP cannot be excluded as well.
[**2142-3-26**] CT Chest: No new or progression of a handful of
subcentimeter pulmonary nodules. Continued involution of
thyromegaly. Increased small pericardial effusion, no pleural
effusion.
[**2142-4-3**] CT Chest: Stable appearance of small pulmonary nodules.
No new nodules identified. Unresolved small pericardial
effusion.
[**2142-4-5**] CT Sinus: Increased paranasal sinus inflammatory changes
since [**2142-3-6**].
[**2142-4-6**] Skin Biopsy (left wrist): Lichenoid interface dermatitis
with associated spongiotic epidermal hyperplasia, parakeratosis,
dyskeratotic keratinocytes and occasional neutrophils (see
note).
[**2142-4-9**] CT Chest/Abdomen: Faint tiny bilateral lower lobe
pulmonary nodules, which are different in location than on
previous examination. Nodules seen on prior CT are no longer
present. These findings are more consistent with an inflammatory
or infectious process. Multiple prominent mediastinal lymph
nodes, which overall do not meet CT criteria for pathologic
enlargement. Small pericardial effusion. No acute
intra-abdominal abnormalities identified.
[**2142-4-14**] CXR: No pneumothorax. No acute pulmonary disease
Brief Hospital Course:
31 year-old female admitted day + 231 status post matched
allogeneic transplant for [**Location (un) 5622**] chromosome negative ALL
in remission, with febrile neutropenia, no clear source.
ONCOLOGY:
ALL/Pancytopenia: Patient had allo transplant ~240 days prior to
admission but was found to have low counts and found to have
graft loss. Sent peripheral blood for FISH/XY/chimerism x 3
which showed, 58% XY, 42% XX the first time and 54%XY and 46%XX
the second time. Initially thought this was likely graft
rejection, but no underlying cause to explain why this would
have occurred 240 days out from transplant (all viral data
negative: parvo, adeno, HHV-6, HHV-8, CMV viral load all
negative). Patient given high dose steroids x 3 days in hopes
of immunosuppressing to prevent rejection of donor cells. This
did not work. Patient had stem cell transplant from brother
(donor) [**3-16**] and had pre-treatment with ATG, fludarabine and
cytoxan. She received stem cells on [**2142-3-16**]. Her methotrexate
was stopped because of elevated LFTs. Her counts started to come
back around day 10 and patient did well with no pulmonary
symptoms. Her hct was maintained above 25 and platelets above
10. On day +25 ([**2142-4-6**]) chimerism was again sent because counts
continued to be low and she was found to have only [**8-23**] XY
cells. She was discharged on cyclosporin 225 PO BID. This will
need to tapered down in the hopes of getting graft v leukemia
effect. A bone marrow should be performed within the next [**2-5**]
weeks.
INFECTIOUS DISEASE:
The patient was admitted for febrile neutropenia, and had no
clear localizing signs or symptoms. CXR without acute
cardiopulmonary process. U/A not suggestive of UTI. Multiple
blood cultures and urine cultures obtained and showed no growth.
Repeat CMV viral loads were negative. Parvovirus, adenovirus,
HHV-6 and HHV-8 all negative. Receives pentamidine treatment
monthly and received last dose while inpatient on [**2142-4-3**]. LFTs
WNL. Patient was put on empiric antibiotics with cefepime and
daptomycin (vancomycin allergy and Red Man's), as well as
restarted on prophylactic fluconazole and acyclovir. When she
continued to spike, caspofungin was added. Viral washings x 2
were sent for rapid respiratory antigens and were negative x 2.
Throat cultures x 2 sent and were negative. CT sinus was done
on [**2-13**] was negative except for soft tissue density in
nasopharyngeal region. Neck CT performed to further delineate
and very small retropharyngeal fluid collection was seen. ENT
was consulted, reviewed films with neuroradiology, and felt
fluid collection too small to aspirate or to be cause of fevers.
Repeat CT sinus/neck unchanged. ID was consulted and followed
patient closely. Workup negative for blasto, histo, cocciodio,
crypto, GGT (nml), amylase (nml), lipase (nml). CT of torso
negative for acute infection. IVIG 55,000 mg over 2 days was
administered to help fight off infectious process. Fever curve
trended down and patient was afebrile for several days. Flagyl
was added for a couple of days d/t concern for C.diff, but
C.diff negative x 2 and this was stopped.
Fever curve trended down and was afebrile for several days, then
became persistently febrile and was found to have
stomatoccocus/micrococcus in one bottle of bcx on [**3-5**]. Pan scan
also showed ? of small infectious nodules in lung. Was treated
with multiple abx and antifungals for bacteremia with ID input.
Her central line was removed and a new line was placed. She
again was afebrile for a few days, but spiked again so Aztreonam
and Linezolid were added. Patient developed a rash during her
stay. Was unclear which drug was causing the rash, but
azithromycin, cefepime and dapto were dc'd b/c of concern for
rash and it eventually improved. Patient continued to spike
during her stay. All bcx after [**3-5**] have shown no growth. Repeat
chest CTs showed decreasing size of lung nodules. Repeat
b-glucan, galactomannan, urine histo, coccidomycosis,
blastomycosis, cryptococcus, adenovirus, HSV-6 were negative.
CMV VLs were checked weekly and were negative. While patient
continued to spike temperatures she remained clinically stable
so antibiotics were pulled back.
The patient was getting ready for discharge and had been
afebrile for days, when she again began spiking fevers with a
diffuse full body rash. We were initially worried about a line
infection and she was started on daptomycin. Her central line
was pulled. Blood/urine/nasal cultures were all sent and have
remained negative. A CT sinus showed diffuse sinutsitis. ENT
saw the patient and did not feel this was the source of her
infection. Daptomycin was stopped because of concern for drug
fever. She continued to spike fevers to 104. She was on
caspo/vori/linezolid/levo/ acyclovir/aztreonam. Her fevers
started to improve around the time of adding double coverage for
fungal infections and adding the linezolid. There was
discussion of this being serum sickness (2 weeks after receiving
ATG) because complement levels were progressivly going down.
Other thoughts were that this was all acute GVHD. At the same
time as being on her antibiotics, the patient was also started
on solumedrol 60mg [**Hospital1 **] and tapered down over 10 days to
prednisone 20 [**Hospital1 **] on discharge. Cultures are all negative to
date.
CARDIOLOGY:
The patient had episode of AVNRT with HR to 240s. Ice water and
vagal manuevers were initially tried but did not help.
Cardiology was called and the rhythm broke with adenosine. She
was observed in the medical ICU for one night. Patient revealed
she has a congenital h/o this problem. She was continued on
amlodipine adn then metoprolol for control of her rate and BPs.
Nifedepine was later added. She had no further episodes during
hery stay. She
GASTROENTEROLOGY:
Elevated bilirubin: Bilirubin was found to be rising several
days after her SCT. The patient was noted to have scleral
icterus at that time. Because of concern for VOD, liver
ultrasound was done. Liver u/s showed patent hepatic vein
(ruling out [**Last Name (un) **]-occlusive dz that can happen in transplant
patients). Some biliary sludge was noted on ultrasound.
Ambisome could have caused some LFT abnormalities, but LFTs
trended down while the patient remained on amiodarone. She had
fluctuations in bilirubin levels and LFTs during her stay .
Could have been secondary to biliary sludge or possibly GVHD.
LFTs were followed.
Persistent diarrhea: Patient had diarrhea throughout her
admission. She was ruled out for c. diff x3 no two different
occasions. She was given immodium with some relief of symptoms.
She also had persistent nausea. This was then thought to be
d/t GVHD of the gut. Her symptoms improved on solumedrol and she
was therefore, started on Entocort. She was also started on TPN
for persistent nausea and poor PO intake. She was quickly
tapered off the TPN as she began to tolerate PO intake.
SCALP:
Patient also have GVHD lesions on scalp vs. fungal infection.
The areas were excoriated at times and treated with ketoconazole
shampoo, selsun blue, carmol 10 and dermasmoothe when the
patient was willing to apply these medications. The lesions
appeared to improve over the course of the admisssion.
Medications on Admission:
Folic acid 5 mg PO QD
MVI 1 tab PO QD
Prednisone 3 mg PO QD
Cyclosporine 100 mg PO BID
Magnesium replacement
Neupogen discontinued yesterday
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
Disp:*150 Tablet(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*90 Capsule(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
DAILY (Daily).
6. Ketoconazole 2 % Shampoo Sig: One (1) Appl Topical DAILY
(Daily).
Disp:*1 bottle* Refills:*2*
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
8. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*60 Tablet(s)* Refills:*2*
9. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Two (2)
ML Intravenous DAILY (Daily) as needed.
10. Cyclosporine 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*100 Capsule(s)* Refills:*3*
11. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO twice a
day.
Disp:*180 Capsule(s)* Refills:*3*
12. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
13. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
14. Metoprolol Succinate 100 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*
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
16. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
17. Entocort EC 3 mg Capsule, Sust. Release 24HR Sig: Three (3)
Capsule, Sust. Release 24HR PO once a day.
Disp:*42 Capsule, Sust. Release 24HR(s)* Refills:*2*
18. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
19. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
ALL s/p allogenic stem cell transplant
Viral upper respiratory infection
Drug rash
Discharge Condition:
Good.
Discharge Instructions:
1) Please take all of your medications as prescribed
2) Please call your PCP or return to the ED if you have fevers,
chills, night sweats, shortness of breath, chest pain, abdominal
pain, nausea, diarrhea, or any other symptoms that are of
concern to you.
Followup Instructions:
** Psychiatry Appointment --> Provider: [**Name10 (NameIs) **],[**Doctor Last Name **],TZIPORAH
PSYCHIATRY HMFP Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2142-4-30**] 9:00
**You will need to come to 7F for followup appointments at 9AM
sunday ([**4-22**]) and 9AM monday ([**4-23**]). On Monday we will arrange
for clinic follow up with Dr.[**Last Name (STitle) 18619**]/Dr [**Last Name (STitle) **] later in the
week.
|
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icd9pcs
|
[
[
[]
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] |
15048, 15067
|
5441, 12742
|
333, 339
|
15194, 15202
|
2409, 5418
|
15506, 15935
|
1830, 1968
|
12934, 15025
|
15088, 15173
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12768, 12911
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15226, 15483
|
1983, 2390
|
271, 295
|
367, 1488
|
1510, 1708
|
1724, 1814
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,551
| 133,123
|
47186
|
Discharge summary
|
report
|
Admission Date: [**2197-7-19**] Discharge Date: [**2197-8-17**]
Date of Birth: [**2135-7-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
status epilepticus
Major Surgical or Invasive Procedure:
Serial sterotactic biopsy of Right Frontal Brain Mass [**2197-8-7**]
History of Present Illness:
62 yo male w/ PMHx sig for DM II, HTN, and severe
hyperlipidemia who was found down at home. Pt was apparently
last seen well by his friends on Saturday. When he did not show
up
for a golfing outing with friends, they went to his house
and found him seizing behind the house on a bed of trash. His
house was apparently condemned by the [**Location (un) **] Police due to
multiple dead animals on the property including rats and racoons
EMS was called and administered 5 mg of Valium and 10mg of
Morphine in the field. He was intubated given abnormal
respirations. FS was 190.
In the ED, the patient was found to have a temperature of 104,
HR
131s, SBP 76/59. The patient was given a total of 11 liters IVF
in the ED and his pressure rose to 103/60 on arrival to the
MICU.
He was placed on broad spectrum abx and given 10 mg IV valium,
10
mg IV Ativan and 1 gram of dilantin load in the ED for continued
L eye deviation with rhythmic jerking of the L arm and leg. The
patient continued to have seizures in the MICU, he was given an
extra 600 mg of Phenytoin and subsequently started on a Propofol
gtt.
Past Medical History:
Dyslipidemia with Triglycerides in [**2190**]
DM type II
Macular degeneration
HTN
Kidney stone
Gastritis
Cervical spondylosis
Colonic polyp
Social History:
Insurance [**Doctor Last Name 360**]. Lives in [**Location (un) 55**]. Lives
alone. No tobacco, no drinking. Single. No children.
Family History:
Brother - lives in [**State 2748**], sister - [**State **].
Mother - dementia, [**Name (NI) 108**].
Father - 95, lives in [**State 108**].
Physical Exam:
Vitals: T 104/97.0; BP 102/59; P 67; RR 14; O2 sat 100%
General: intubated, intermittently seizing with left sided limb
shaking
HEENT: necrotic L side of tongue
Pulmonary: CTA b/l
Cardiac: tachycardic, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neuro:MS-intubated
Cranial Nerves: Pupils 2 mm, reactive, + corneal reflex, + VOR,
mouth obscured by ETT support so difficult to assess symmetry
Motor/[**Last Name (un) **]: No spontaneous movements except seizure activity
with
L sided limb shaking. No withdrawal on L side to nail bed
pressure. Mild reflexive withdrawal to nailbed pressure on R
side
Reflexes: 1 + symmetric. Toes mute.
Pertinent Results:
[**2197-8-16**] 10:35AM BLOOD WBC-6.6 RBC-4.05* Hgb-12.9* Hct-37.4*
MCV-93 MCH-32.0 MCHC-34.6 RDW-19.5* Plt Ct-301
[**2197-8-16**] 10:35AM BLOOD Glucose-70 UreaN-15 Creat-0.6 Na-139
K-4.3 Cl-100 HCO3-30 AnGap-13
[**2197-8-13**] 03:38PM BLOOD ALT-52* AST-28 LD(LDH)-187 AlkPhos-304*
TotBili-0.3
[**2197-8-8**] 02:57AM BLOOD Lipase-35
[**2197-8-11**] 03:26AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2197-8-11**] 03:26AM BLOOD VitB12-1338*
[**2197-8-9**] 03:00AM BLOOD TSH-3.6
[**2197-7-20**] 08:36AM BLOOD Free T4-1.1
[**2197-8-11**] 04:45AM BLOOD Cortsol-28.0*
Routine EEG: [**2197-8-15**] Abnormal EEG due to the reduced voltage
overall, the
posterior background slowing, and the single isolated left
mid-temporal
spike discharge.
MR [**Name13 (STitle) 430**]: Upon detailed analysis of the FLAIR images, comparison
with the
prior study shows slightly less extensive appearance of a
semicircular area of heterogeneously diminished FLAIR signal in
its central portion seen
along theanteromedial border of the principal tumor mass. I am
not certain if this change relates to the biopsy procedure.
Lastly, there is a moderate-sized air-fluid level within the
left sphenoid air cell with moderate mucosal thickening. This
finding could relate to prior intubation or potentially be
inflammatory in origin, as fluid levels were seen on the prior
study within both sphenoid air cells on [**2197-7-22**]. There is
also prominent high T2 signal within the mastoid sinuses, which
again could relate to prior intubation or be inflammatory in
origin.
Stereotactic Biopsy and pathology results:
With the available material, the tumor is best classified as a
DIFFUSE ASTROCYTOMA (or a diffusely infiltrating astrocytoma).
No mitotic figures are identified in the above blocks. No
necrosis or vascular proliferation is present. By WHO criteria,
the later attributes indicate the tumor is a grade 2 out of 4
astrocytoma. The available tissue lacks satisfactory pathology
that would explain the enhancement in the neuroimaging, which
suggests the enhancing areas were not sampled.
***NOTE: These immunostaining results confirm the sampled tumor
is a glioma with a low proliferative potential. The staining
features in #11 are more suggestive of a grade 2 astrocytoma
while those in #4 are more suggestive of a grade 2
oligodendroglioma. Further subclassification cannot be
confidently determined with the available material. The tumor
should be considered a grade 2 out of 4 infiltrating glioma with
low proliferative potential
Brief Hospital Course:
On arrival to the [**Name (NI) **], pt was found to be septic with a
temperature of 104,
blood pressure of 76/59, and was given a total of 11L IV fluids
and
broad-spectrum antibiotics. He was also loaded with Dilantin,
given IV Ativan and Valium for continued seizures. He had left
arm and left leg as well as left deviation throughout
examination. He was transferred to the MICU where he was loaded
with phenobarbital and given propofol for continued evidence of
seizures. He was monitored by bedside EEG and finally
around 5:00 p.m. on [**7-20**] he stopped having electrographic
seizures. Pt had initially required pressors for BP support in
the ICU and remained intubated for respiratory failure and
pulmonary edema. The pressors were weaned over the first few
days in the ICU. He was monitored by EEG on [**7-22**] with showed
no evidence of any more epileptiform activity. LP was done on
[**7-20**] that
showed three white blood cells, nine red blood cells, 74
protein,
130 glucose. HSV-I and II were negative in the CSF. MRI was
done on [**7-22**] and showed a right frontal lobe lesion with
small
areas of enhancement in the anterior and posterior area
suggestive of neoplasm. CSF cultures came back negative. The
patient was then seen by neurosurgery, planned to biopsy these
on
[**7-25**]. This was delayed as the patient had desaturated and
was found to have a PE. Weight based heparin was started for
treatment of PE and
therefore, surgery was delayed. Pt then had recurrence of fever
while intubated and was treated with a full course of
antibiotics for presumed ventilator associated pneumonia. The
patient had an IVC filter placed as he could not be on IV
heparin for the biopsy. Finally, the biopsy was performed on
[**2197-8-7**]. Pathology showed a diffusely infiltrating
Astrocytoma grade 2. After diuresis and resolution of pulmonary
edema/pneumonia, the patient was extubated on [**8-9**]. The
patient has been maintained on Dilantin and phenobarbital for
seizure suppresion. EEG on [**8-10**] showed no signs of
continued seizure. Pt was transferred out of the ICU to regular
floor where he has done well since [**8-12**]. He has been
weaned from facetent and has been sating 99% on room air without
any continued evidence of pulm edema. He has been stable from a
cardiovascular standpoint, with good control of BP with
Valsartan 80mg daily. Pt passed his swallow study on [**8-14**], NG
tube was removed and he has been eating well since with no need
for supplemental nutrition. Pt has recovered a significant
amount of neuro function, now using both his distal extremities
and more proximal extremities, however, there is still a deficit
more noticable on Left than Right. Pt was restarted on Lovenox
sc BID for ongoing treatment of PE and was restarted on most of
his pre-admission medications. His Metformin was not restarted
due to normal fasting blood sugars and minimal need for sliding
scale insulin. This may need to be revisited as pt returns to
his pre-admission weight. Niacin was restarted at 500mg PO qhs
and this should be increased by 500mg each sunday until he
reachs a goal dose of 2000mg qhs as tolerated, per his PCP. [**Name10 (NameIs) **]
neurology recommendations, pt should have drug levels monitored
daily with a goal Dilantin level of [**11-18**] and a goal
Phenobarbital level of 20-30.
Medications on Admission:
ALLOPURINOL TAB 100MG 2 qd
LEVOXYL 0.175MCG 1 QD
[**Doctor First Name **] CAP 60MG one po bid
LIPITOR TAB 80MG 1 QD
FLONASE SPR 0.05% 2 SPRAYS EACH NOSTRIL QAM
DIOVAN CAP 160MG 1 QD
EPA-CON CAP 500MG 2 QD
SELENIUM TAB 200MCG 1 QD
VITAMIN E CAP 200IU 1 QD
NIACIN TAB 500MG TR NO FLUSH NIACIN 4 HS
METFORMIN HCL 500 MG TAB 1 [**Hospital1 **]
PHENTERMINE CAP 15MG 1 QD
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Insulin Regular Human Injection
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Nystatin 100,000 unit/mL Suspension Sig: One (1) ML PO QID (4
times a day) as needed for oral exudate.
7. Phenobarbital 100 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
8. Phenytoin Sodium Extended 30 mg Capsule Sig: Three (3)
Capsule PO TID (3 times a day).
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
10. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QHS (once a day (at bedtime)).
14. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
16. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed: for severe pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
Brain Tumor
Secondary:
Dyslipidemia TG [**2190**]
Type II DM
Macular degeneration
HTN
Kidney stone
Gastritis
Cervical spondylosis
Colonic polyp
Gout
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after having a seizure that went on for some
time and was difficult to stop. You were in the intensive care
unit and had some complications of having a breathing tube but
these have all resolved. It was discovered that you have a mass
in your brain that is being followed by neuro surgeons. You
will need to come back and see them in a few weeks after you
have spent some time working with physical therapy. If you
experience any chest pain, severe headache, shortness of breath,
recurrent seizures or any other general worsening of condition
you should return to the ED immediately.
Followup Instructions:
You have a follow up appt at the Epilepsy Center on Monday, [**8-28**] at 8:30am with Dr. [**First Name (STitle) 437**] & Dr. [**First Name (STitle) 1557**]. The epilepsy center
is in the [**Hospital Ward Name 23**] Building [**Location (un) **] ([**Hospital Ward Name **] [**Hospital1 18**])
You have an MRI scheduled at 11am on [**9-18**] on the [**Hospital Ward Name 12837**] of [**Hospital1 18**]. You should arrive 30min beforehand. You will
then be transported via ambulance to the [**Hospital Ward Name **] for a
follow-up appt on with Dr. [**Last Name (STitle) 4253**] ([**9-18**] at 2pm).
This appointment will be on the [**Location (un) **] [**Hospital Ward Name 23**] Blding [**Hospital Ward Name 5074**] [**Hospital1 18**].
|
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"995.92",
"486",
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icd9cm
|
[
[
[]
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] |
[
"96.72",
"38.7",
"96.6",
"03.31",
"38.93",
"01.13",
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] |
icd9pcs
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[
[
[]
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] |
10454, 10551
|
5278, 8643
|
332, 403
|
10754, 10763
|
2735, 5255
|
11417, 12161
|
1867, 2008
|
9060, 10431
|
10572, 10733
|
8669, 9037
|
10787, 11394
|
2023, 2342
|
274, 294
|
431, 1539
|
2358, 2716
|
1561, 1703
|
1719, 1851
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,507
| 165,992
|
12579
|
Discharge summary
|
report
|
Admission Date: [**2187-6-29**] Discharge Date: [**2187-7-9**]
Date of Birth: [**2118-10-20**] Sex: F
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Sternal wound infection with drainage of
pus
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 68-year-old
female who had coronary artery bypass surgery in [**2187-5-16**] by Dr. [**Last Name (STitle) **]. Postoperatively, she had multiple
problems with her sternal wound, and was most recently
admitted in [**2187-4-16**]. She now returns from an outside
hospital after a positive culture for methicillin resistant
staphylococcus aureus from the wound. She reports being
otherwise stable, and is getting ready for discharge home
from the rehabilitation where she has been postoperatively.
She denies any fevers or chills. She does state that she has
a small hole at the inferior aspect of her sternum that oozes
copious amounts of pus.
PAST MEDICAL HISTORY:
1. Status post coronary artery bypass graft in [**2187-3-16**]
2. Asthma and chronic obstructive pulmonary disease, steroid
dependent
3. Gastroesophageal reflux disease
4. Transient ischemic attack and cerebrovascular accident
5. Insulin-dependent diabetes mellitus
6. Hypertension
7. Status post total knee replacement
8. Seizure disorder
9. Renal mass, not otherwise specified
10. Anxiety disorder
11. Right subclavian steal syndrome
ALLERGIES: Aspirin and ACE inhibitors give her anaphylaxis.
She is also allergic to beta blockers, which give her
bronchospasm.
MEDICATIONS ON ADMISSION:
1. Prevacid 30 mg by mouth once daily
2. Amiodarone 200 mg by mouth once daily
3. Lasix 20 mg by mouth once daily
4. Imdur 90 mg by mouth once daily
5. Multivitamin
6. Albuterol and Atrovent nebulizers as needed
7. Lovenox 40 mg subcutaneously once daily
8. Dilantin 300 mg by mouth twice a day
9. Humalog 75/25, 20 units every morning
10. Sliding scale insulin
11. Tylenol 650 mg by mouth every four to six hours as needed
12. Vicodin 5/500
13. Ambien 5 mg by mouth daily at bedtime
14. Aldactone 75 mg by mouth once daily
15. Plavix 75 mg by mouth once daily
16. Prednisone 5 mg by mouth once daily
17. Colace 100 mg by mouth twice a day
18. Accolate 20 mg by mouth once daily
19. Combivent metered dose inhaler
PHYSICAL EXAMINATION: She is a well-appearing, pleasant
female, in no acute distress. Her temperature is 97.5, pulse
87, blood pressure 120/60, respiratory rate 16, oxygen
saturation 97% on room air. Neurologically, she is grossly
intact. Cardiovascular: She has a regular rate and rhythm
without murmur. Breath sounds are coarse, with scattered
rhonchi but no wheezes. Her abdomen is obese, soft,
nontender, nondistended, with bowel sounds present. Her
sternal incision has skin that is well healed with the
exception of a .5 cm open area along the inferior portion,
draining large amounts of yellow pus. There is no erythema,
and the sternum is stable to palpation. Her left lower
extremity vein harvest site distal to the knee also has a
small open area with minimal drainage and a small amount of
erythema.
LABORATORY DATA: White blood cell count 13.5, hematocrit
34.8, platelets 424. Sodium 142, potassium 4.1, chloride
106, bicarbonate 26, BUN 11, creatinine 0.8, glucose 101.
Her coagulation studies are normal.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Surgery service with a diagnosis of sternal wound infection.
A culture was immediately taken of the wound. A PICC line
was placed, and she was started on intravenous vancomycin
and, in addition, she was started on oral Levaquin. A
urinalysis was sent that revealed that she had a urinary
tract infection. In addition, the wound culture was positive
for 4+ PMNs in addition rule out 4+ gram-positive cocci and
4+ gram-negative rods. This culture ultimately grew
methicillin resistant staphylococcus aureus, group B strep,
another unidentified gram-positive rod that we are presuming
was diphtheroids or Carinii bacterium. In addition, from her
anaerobic culture, she grew Prevotella that was beta
lactamase positive and Peptostreptococcus.
A CT scan was obtained that demonstrated inflammatory changes
within the anterior mediastinum and a 7 x 13 mm fluid
collection. In addition, there were some small lymph nodes
within the mediastinum. In addition, they found a tiny
calcified nodule in the right middle lobe that was felt to
likely represent a granuloma, and another tiny noncalcified
nodule in the lingula that was also likely benign in origin.
Finally, her adrenal mass was imaged and demonstrated no
change in size. The Radiology staff believes that this is
likely an adenoma.
A Plastic Surgery consult was obtained regarding this
patient's sternal wound infection. They ultimately
recommended a two-stage operation in which the patient was
debrided and later received a closure flap. Therefore, on
[**2187-7-2**], the patient was taken to the operating room,
where she had a sternal debridement. The procedure itself
was unremarkable. Postoperatively, she was taken to the
Cardiac Surgery Intensive Care Unit. During this time, her
white blood cell count climbed to as high as 19.9. She did
have wet-to-dry dressings to her sternum and, within about
two days, it was felt that her wound looked improved enough
for the second stage of her operation. On [**2187-7-4**], she
was taken to the operating room by Dr. [**Last Name (STitle) 13797**] and his team.
There she received bilateral pectoralis major muscle
advancement flap closure of her wound. The patient's
procedure itself was unremarkable. Postoperatively, she was
kept in the Post-Anesthesia Care Unit for some time for
observation, but ultimately arrived on the floor.
She did have some postoperative issues with pain management,
and it was difficult to find an appropriate regimen for her.
Initially she was kept on Vicodin with morphine for
breakthrough pain. This did not adequately control her. We
tried her on a patient-controlled analgesia, which she was
not able to use effectively. Finally, she was started on
oral percocet, and that appeared to manage her pain
adequately well.
The patient's hematocrit did drop as low as 20,000. She
received a total of four units of packed red blood cells.
Throughout the ensuing days of her hospitalization, she
demonstrated continued improvement. Her wound remained
clean, dry and intact, without erythema. On the day prior to
her transfer back to rehabilitation, the Plastic Surgery team
asked us to start applying bacitracin to the wound twice a
day. She did have two [**Doctor Last Name 406**] drains that were left in place
with bulb suction. In addition, she has wound anchors going
through some of her breast tissue that need to remain in
place until her postoperative visit. Finally, she is to wear
a surgical bra at all times, and is to only have it open and
removed for wound inspection and dressing changes.
While the patient was here, we had a consult from the [**Last Name (un) **]
diabetes team. They recommended changing her insulin from
75/25 once daily to a twice a day regimen. She appeared to
be stable on 9 units of NPH in the morning and 5 units of NPH
in the evening with a sliding scale to cover.
A Medicine consult was obtained to help manage the patient's
multiple medical problems. They ultimately recommended that
she be continued on her antibiotics and that her Aldactone be
restarted, which was held postoperatively. In addition, they
recommended that a Dilantin level be checked. It was found
to be therapeutic at 12.3. All of her other medical problems
during this hospitalization appeared to be stable.
As the patient progressed to postoperative day number three
and four from her advancement flap, her white blood cell
count improved. On the day prior to discharge, her white
count was down to 14,000.
On [**2187-7-9**], the patient was transferred back to
rehabilitation for further care and management. She needs to
return in eight days to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13797**]
in his [**Hospital 3816**] clinic.
The patient is transferred on the following medications:
1. Vancomycin 1 gram intravenously every 12 hours for six
weeks
2. Levaquin 500 mg by mouth once daily for six weeks
3. Protonix 40 mg by mouth once daily
4. Amiodarone 200 mg by mouth once daily
5. Lasix 20 mg by mouth twice a day
6. Imdur 90 mg by mouth once daily
7. Ambien 5 mg by mouth daily at bedtime
8. Potassium chloride 20 mEq by mouth twice a day
9. Multivitamin once daily
10. Lovenox 40 mg subcutaneously twice a day
11. Plavix 75 mg once daily
12. Prednisone 5 mg once daily
13. Ativan 0.5 mg twice a day
14. Colace 100 mg twice a day
15. Dilantin 300 mg twice a day
16. Accolate 20 mg by mouth once daily
17. Spironolactone 25 mg once daily
18. Bacitracin ointment to wound twice a day
19. Combivent metered dose inhaler one to two puffs four
times a day
20. Percocet 5/325 one to two by mouth every four to six
hours as needed
21. Morphine sulfate intravenously/subcutaneously, 1 to 5 mg
every six hours for breakthrough pain
22. NPH 9 units in the morning, 6 units in the evening at
bedtime
23. Sliding scale regular insulin
24. Albuterol and Atrovent nebulizers as needed
Note to rehabilitation staff: The patient has subclavian
steal syndrome and has a significantly lower blood pressure
in the right arm. We ask that all blood pressures be
measured in the left forearm below her PICC line.
DISCHARGE DIAGNOSIS:
1. Sternal wound infection, now status post surgical
debridement and bilateral pectoralis major muscle advancement
flap closure
2. Methicillin resistant staphylococcus aureus infection
3. Insulin-dependent diabetes mellitus, partially controlled
4. Hypertension
5. Right subclavian steal
6. Status post coronary artery bypass graft
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2187-7-8**] 20:20
T: [**2187-7-9**] 00:26
JOB#: [**Job Number 38925**]
|
[
"V45.81",
"599.0",
"435.2",
"530.81",
"401.9",
"780.39",
"250.01",
"998.59",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"83.82",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
9515, 10131
|
1544, 2268
|
3321, 9494
|
2292, 3302
|
166, 212
|
241, 919
|
941, 1518
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,195
| 141,251
|
31292
|
Discharge summary
|
report
|
Admission Date: [**2160-2-14**] Discharge Date: [**2160-2-19**]
Date of Birth: [**2129-7-21**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Menorrhagia
Major Surgical or Invasive Procedure:
Peritoneal dialysis
History of Present Illness:
Ms. [**Known lastname 1005**] is a 30F with a PMH s/f type 1 DM with severe
[**Known lastname 31217**] resistance, and ESRD on PD who presents with
menorrhagia. The patient describes having heavy vaginal
bleeding since [**2-8**], going through 4 pads per hour. While
undergoing PD dialysis today, she was noted to have a HCT of 17.
She received 1 unit of PRBC, with no improvement ( 21 --> 21). A
vaginal ultrasound was obtained, and showed normal vaginal
anatomy. She remained hemodynamically stable, with SBPs between
140-170. The patinet was additonally given one dose of IV lasix
40mg.
The primary team consulted medicine for assistance in manegment
of the patinet's anion-gap acidosis and [**Last Name (un) **] for T1DM. The
patient had erradic blood sugars. She became hypoglycemic, with
blood sugar of 62, but rose to 376 following 1 amp of D50. With
concern that she may need an [**Last Name (un) 31217**] gtt she was transfered to
the MICU for further manemgent. Of note, the patient was
admitted to the MICU in [**1-15**] for DKA.
ROS: 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:
* ESRD on PD, followed by Dr. [**Last Name (STitle) 4090**], currently undergoing
[**Last Name (STitle) **] workup. Uses following regimen at home:
- CCPD with 2L volume, 2.5% dextrose and 2h dwell, 5
dwells/night, no daytime dwell.
* DM1 complicated by neuropathy, nephropathy, retinopathy
* HTN
* hyperlipidemia
* depression/anxiety
* OSA on bipap at night
Social History:
Initially from [**Male First Name (un) 1056**], moved to US 12 years ago. She lives
with boyfriend and her daughter. She does not work outside the
house, she is on disability. She quit smoking over a year ago
but has restarted and is smoking [**2-9**] ppd. She and denies alcohol
or drug use.
Family History:
Her parents are both alive and have diabetes and hypertension.
She has one sister who is obese and has hypertension.
Physical Exam:
Physical exam at time of transfer from MICU:
PHYSICAL EXAM:
Vitals - T:97.8 BP:131/79 HR:96 RR:19 02 sat:98% RA
GENERAL: Sleeping, arousable, pleasant. NAD
HEENT: enucleated L eye, mild bilateral palpebral edema. MMM. No
OP lesions,
NECK: Thick, supple
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN:Hernia at PD site. Tense, distended with dwell.
[**Last Name (un) **]-tender. No rebound/guarding.
EXTREMITIES: No edema or calf pain.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Pelvic ultrasound:
1. Normal uterus, endometrium and ovaries.
2. Echogenic material in the vaginal canal likely represents
blood products, but vascularity was not assessed. Recommend
correlation with direct visualization and follow up to
resolution.
3. Free fluid in the abdomen, likely related to end-stage renal
disease.
.
MR [**First Name (Titles) 73809**] [**Last Name (Titles) **]-contrast
Preliminary Report !! PFI !!
Clearly limited examination demonstrates no expansion of the
sella or obvious sellar mass. There is mild leftward deviation
of the infundibulum, finding which can be seen in the setting of
a pituitary lesion, though may simply reflect anatomic
variation. Further [**Last Name (Titles) 2742**] with gadolinium a the patient
tolerate would be useful in followup
.
Peritoneal fluid culture:
GRAM STAIN (Final [**2160-2-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2160-2-18**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
Brief Hospital Course:
Ms. [**Known lastname 1005**] is a 30F with Type 1 diabetes mellitus,
complicated by severe [**Known lastname 31217**] resistance, and ESRD on PD, who
presented on [**2160-2-14**] with severe mennorrhagia.
.
1. Menorrhagia: The patient was managed with intravenous
estrogen, which successfully decreased her menorrhagia. A
transvaginal ultrasound confirmed the absence of structural
uterine abnormalities to cause her bleeding. She received a
total of four units of pRBCs, and her HCT improved to 29 (from
17). Her prolactin was noted to be mildly elevated to 46, which
was felt to be secondary to ESRD. Because hyperprolactinemia
can cause a hypoestrogenic state, it was felt that this was the
cause of her menorrhagia. In consultation with gynecology, the
patient was initiated on cabergoline at 0.25mg twice weekly, and
a pituitary MRI was obtained. Unfortunately, because of her
ESRD and risk for nephrogenic systemic fibrosis, the MRI was
performed without contrast, and thus the read was not
definitive. The preliminary read showed no obvious pituitary
lesion, however, a slight leftward infundibular shift was noted,
which could be an anatomic variant vs. a pituitary lesion. In
light of her clinical exam, which did show concerns for
acromegaly, we opted to obtain a consultation with endocrinology
as an outpatient. We deferred measuring IGF levels given their
inconsistency in ESRD. This was discussed with the on-call
endocrinology fellow, who agreed with the aforementioned plan.
2. Diabetes- The patient's DM was very difficult to control
during her hospital course. She developed an anion-gap acidosis
and was briefly transferred to the MICU for concern that she had
developed DKA, however, her ketones were negative. She also had
several episodes of hypoglycemia requiring glucagon, D50, etc.
It was likely that shifting her PD schedule from night-time to
daytime made her blood sugars much worse, as her highs
correlated with instillation of the 2.5% dextrose. We attempted
to change her diasylate, but unfortunately a lower concentration
was not available. We did change her schedule back to
night-time, and her labile blood sugars improved somewhat.
Her chronic issues including ESRD, HTN, and OSA were managed as
per her home regimen.
Medications on Admission:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Nortriptyline 10 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
4. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day:
11. [**Year (4 digits) **] Regular Hum U-500 Conc 500 unit/mL Solution Sig: As
directed as directed Injection As directed: Take 8 units at
breakfast; take 22 units at lunch; take 28 units at bedtime.
12. Novolog 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous At dinner: Give yourself 12 units of Humalog. Also
use your Humalog [**Year (4 digits) 31217**] sliding scale at dinner.
13. Epoetin Alfa 10,000 unit/mL Solution Sig: 7500 (7500) units
Injection once a week: Pt received 10,000 units on [**2160-1-14**] and
5,000 units on [**2160-1-18**].
14. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
15. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qHS () as
needed for restless legs.
18. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day) as needed for nasal congestion.
19. Medroxyprogesterone(Contracep) 150 mg/mL Suspension Sig: One
[**Age over 90 1230**]y (150) mg Intramuscular every 12-14 weeks: Last
dose given [**2160-1-1**] in clinic.
20. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
21. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
22. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO PRN as
needed for pain: Do not drive, lift heavy objects or drink while
taking this medication.
23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Nortriptyline 10 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
3. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
13. [**Month/Day/Year **] Regular Hum U-500 Conc 500 unit/mL Solution Sig: Per
your sliding scale units Injection ASDIR (AS DIRECTED).
14. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
15. Cabergoline 0.5 mg Tablet Sig: 0.5 Tablet PO twice weekly on
Monday and Thursday.
Disp:*8 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
Menorrhagia, likely secondary to hyperprolactinemia of ESRD
Discharge Condition:
Stable vital signs and HCT
Alert and oriented x3
Independent of ADLs, ambulatory
Discharge Instructions:
You were admitted with severe vaginal bleeding. This resolved
with intravenous estrogen. We found that a hormone called
"prolactin" was mildly elevated, which is most likely due to
your renal failure, however, this can cause vaginal bleeding.
We started a new medication called "cabergoline" to help control
this. We have also set up a consultation with endocrinology to
help us manage this better.
.
Please take all of your medications as directed, we have made
the following changes:
1. We started a new medication called cabergoline, please take
this twice per week on Mondays and Thursdays
2. We decreased your calcitriol from 0.5 to 0.25mcg daily
3. We would like you to discontinue your depot provera
injections, and discuss alternative contraceptive options with
your OB-GYN
**Otherwise, take all of your usual medications
.
Please follow up with OB-GYN, your PCP, [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as
outlined below. Your OB-GYN will discuss insertion of an IUD
with you to further control your bleeding.
.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2160-2-20**] 1:45
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2160-2-27**]
2:45
Provider: [**First Name8 (NamePattern2) 971**] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2160-3-3**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2160-2-27**]
4:20
|
[
"250.43",
"250.83",
"300.4",
"285.1",
"362.01",
"253.0",
"250.63",
"276.1",
"276.2",
"357.2",
"585.6",
"626.2",
"250.53",
"333.94",
"272.4",
"327.23",
"253.1",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
10406, 10467
|
4423, 6693
|
280, 301
|
10571, 10654
|
3237, 4349
|
11776, 12349
|
2335, 2453
|
9076, 10383
|
10488, 10550
|
6719, 9053
|
10678, 11753
|
2529, 3218
|
229, 242
|
329, 1626
|
4385, 4400
|
1648, 2008
|
2024, 2319
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,243
| 146,845
|
50697
|
Discharge summary
|
report
|
Admission Date: [**2159-10-22**] Discharge Date: [**2159-11-9**]
Date of Birth: [**2097-7-9**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
S/P Fall, pericardial effusion
Major Surgical or Invasive Procedure:
Pericardiocentesis
bilateral thoracentesis
endotracheal intubation
bone marrow biopsy
PICC line placement
History of Present Illness:
62F h/o CML on maintenance hydroxyurea in remission for 15 years
with recent relapse, followed at [**Hospital1 **], who is s/p fall last
night, found to have SAH/SDH and possible brain mets at OSH, as
well as pericardial effusion. The patient reports progressively
worsening difficulty breathing for the past couple weeks. Today
she reported SOB then falling and hitting her head. She does not
remember the time before after very well but does state that she
lost consciousness. She does not recall bladder or bowel
incontinence or tongue/lip biting. The fall was not observed
though her mother heard her fall. Her mother is not here now.
The patient went to [**Hospital3 **] and had CT showing e/o SAH with
possible brain mets and edema, as well as pericardial effusion,
and was transferred to [**Hospital1 18**].
.
In the ED, initial vitals were 98.3 77 142/89 20 98% 8L. The
patient was given decadron 10 mg IV, and a bedside ECHO was done
showing large pericardial effusion with RV wall bowing and the
patient was taken to the cath lab for pericardial drain
placement. V/S prior to transfer to cath lab: 142/82 84 27 95%
on 5L NC. In the cath lab, 750cc removed, clear and straw
colored fluid. Post Echo with small posterior collection, much
improved from prior. Large left pleural effusion still present.
Pericaridal pressures were 18, now 3.
.
Currently, she is reporting some pain at the drain site as well
as irritation in her neck from the C-Spine collar but no pain in
the neck itself. She also denies HA. She still c/o SOB but
denies cough, hemoptysis, fevers, chills, urinary or bowel
symptoms.
.
Of note she has recently started desatinib for CML recurrence.
She has required multiple PRBC and plt transfusions recently
including 1 uPlt in the ED.
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:
CML
?psoriasis
?Stomach problem
Social History:
- Tobacco history: Never
- ETOH: None
- Illicit drugs: None
Lives with 85 year old mother
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: Alive at 85
- Father: Father MI 60s
Physical Exam:
ADMISSION EXAM:
VS: HR 86 BP 115/79 RR 25 sat 93% on 6L
GENERAL: S/P fall with echymoses over forehead, eye, head.
C-collar in place. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: In C collar
CARDIAC: RR, normal S1, S2. No m/g, Audible rub. 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, mild epigastric tenderness. 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: + DP 2+ PT 2+
Left: DP 2+ PT 2+
.
DISCHARGE EXAM:
###########################
Pertinent Results:
ADMISSION LABS:
[**2159-10-22**] 02:06PM BLOOD WBC-4.1 RBC-3.61* Hgb-10.4* Hct-31.1*
MCV-86 MCH-28.8 MCHC-33.5 RDW-16.1* Plt Ct-79*
[**2159-10-22**] 02:06PM BLOOD Neuts-76.2* Lymphs-21.1 Monos-2.4 Eos-0.3
Baso-0.1
[**2159-10-22**] 02:06PM BLOOD PT-13.2 PTT-24.3 INR(PT)-1.1
[**2159-10-26**] 04:42AM BLOOD Gran Ct-1620*
[**2159-10-22**] 02:06PM BLOOD Glucose-124* UreaN-30* Creat-1.1 Na-146*
K-3.3 Cl-111* HCO3-23 AnGap-15
[**2159-10-23**] 05:01AM BLOOD LD(LDH)-328*
[**2159-11-2**] 09:42AM BLOOD ALT-67* AST-49* AlkPhos-57 TotBili-0.6
[**2159-10-22**] 07:48PM BLOOD Calcium-7.8* Phos-3.5 Mg-1.9
[**2159-10-23**] 05:01AM BLOOD TotProt-4.4* Albumin-2.7* Globuln-1.7*
Mg-2.2
[**2159-10-27**] 05:05PM BLOOD Hapto-244*
[**2159-10-25**] 09:25PM BLOOD Triglyc-108
[**2159-10-26**] 04:42AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2159-10-23**] 07:08AM BLOOD Type-ART pO2-54* pCO2-31* pH-7.48*
calTCO2-24 Base XS-0
[**2159-10-22**] 02:09PM BLOOD Lactate-1.4
[**2159-10-23**] 03:12PM BLOOD Lactate-1.5 K-4.0 calHCO3-24
[**2159-10-23**] 10:15PM BLOOD Glucose-133* Lactate-1.3
[**2159-10-23**] 07:08AM BLOOD freeCa-1.16
Pertinant Labs:
[**2159-10-25**] 05:10AM BLOOD WBC-4.3 RBC-3.52* Hgb-10.1* Hct-30.3*
MCV-86 MCH-28.6 MCHC-33.2 RDW-16.5* Plt Ct-26*#
[**2159-10-25**] 12:04PM BLOOD WBC-1.1*# RBC-3.01* Hgb-8.6* Hct-25.5*
MCV-85 MCH-28.5 MCHC-33.6 RDW-16.4* Plt Ct-69*#
[**2159-11-3**] 05:16AM BLOOD WBC-1.7* RBC-3.34* Hgb-9.6* Hct-27.6*
MCV-83 MCH-28.7 MCHC-34.7 RDW-14.9 Plt Ct-39*
[**2159-11-9**] 06:10AM BLOOD WBC-2.7* RBC-2.61* Hgb-7.3* Hct-21.8*
MCV-83 MCH-28.1 MCHC-33.7 RDW-17.4* Plt Ct-70*
[**2159-11-6**] 09:16AM BLOOD PT-13.6* PTT-23.7 INR(PT)-1.2*
[**2159-10-28**] 07:48AM BLOOD Gran Ct-510*
[**2159-11-7**] 06:12AM BLOOD Gran Ct-1510*
Studies:
[**Known lastname **],[**Known firstname **] [**Medical Record Number 105475**] F 62 [**2097-7-9**]
Cytology Report PERICARDIAL FLUID Procedure Date of [**2159-10-22**]
REPORT APPROVED DATE: [**2159-10-31**]
SPECIMEN RECEIVED: [**2159-10-23**] [**-1/3776**] PERICARDIAL FLUID
SPECIMEN DESCRIPTION: Received 450ml amber color clotted fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: None provided.
REPORT TO: DR. [**First Name4 (NamePattern1) **] [**First Name8 (NamePattern2) 975**] [**Doctor Last Name **]
DIAGNOSIS: Pericardial fluid:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells and histiocytes (see note).
Note: See also the corresponding cell block specimen
(S11-[**Pager number 105476**]L).
DIAGNOSED BY:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35028**], CT(ASCP)
[**Name6 (MD) **] [**Last Name (NamePattern4) 76121**], M.D.
[**10-22**] ECG: Sinus rhythm. Possible left atrial abnormality.
Diffusely low QRS voltage.
Complete right bundle-branch block. Cannot exclude prio inferior
myocardial
infarction. Clinical correlation is suggested. No previous
tracing available
for comparison.
[**10-22**] Cardiac Cath: COMMENTS:
1. Pericardiocentesis was performed with needle entry from the
subxiphoid position. The opneing pericardial pressure was 18
mmHg.
2. Subsequent removal of ~700 mL of straw coloured pericardial
fluid
(all sent for studies) and confirmation by echocardiography of
only a
small posterior rim of pericardial fluid with the catheter
positioned in
pericardial space. The pericardial pressure decreased to 3 mmHg
after
removal of the effusion.
FINAL DIAGNOSIS:
1. Pericardial tamponade with improvement in hemodynamics after
removal
of 700 mL of straw coloured fluid.
[**10-24**] TTE: There is severe regional left ventricular systolic
dysfunction with near-akinesis of the distal one third to one
half of the left ventricle. Right ventricular chamber size and
free wall motion are normal. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. LVEF 25-30%
[**10-27**] CTA chest, abdomen, and pelvis: IMPRESSION:
1. No pulmonary embolism.
2. Near-complete resolution of previously large right pleural
effusion.
However, new multifocal consolidations in the right lower lobe
concerning for pneumonia. Stable moderate left pleural effusion
with left lower lobe
collapse.
3. Status post cholecystectomy with minimal intrahepatic biliary
ductal
dilation which can be seen in post-cholecystectomy patients.
4. Tortous enlarge splenic vein, but without evidence for portal
hypertension. No splenic enlargement.
5. No definite evidence for malignancy in the chest, abdomen or
pelvis.
However, the opacities in the right lung should be followed to
resolution.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 105475**] F 62 [**2097-7-9**]
Cytology Report PLEURAL FLUID Procedure Date of [**2159-10-29**]
REPORT APPROVED DATE: [**2159-10-31**]
SPECIMEN RECEIVED: [**2159-10-30**] [**-1/3874**] PLEURAL FLUID
SPECIMEN DESCRIPTION: Received 40ml cloudy yellow fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: R/O malignancy in the patient with CML.
PREVIOUS SPECIMENS:
[**2159-10-26**] [**-1/3844**] PLEURAL FLUID
[**2159-10-23**] [**-1/3776**] PERICARDIAL FLUID
REPORT TO: DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DIAGNOSIS: Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, macrophages and mature
lymphocytes.
DIAGNOSED BY:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35028**], CT(ASCP)
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D.
([**-1/3874**])
[**10-31**] MRI Head: IMPRESSION: Bilateral predominantly
parieto-occipital signal changes and
enhancement with slow diffusion, imaging differentials include
evolving
infarcts, PRES. Given presence of abnormal FLAIR signal along
the sulci,
meningo-encephalitis is also a consideration. Please correlate
with CSF
studies.
[**10-31**] pre-MRI orbits: ORBITAL RADIOGRAPHS, TWO VIEWS: There is
no evidence of retained metallic foreign body in either orbit.
The included portions of the paranasal sinuses and mastoid air
cells are grossly clear.
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 105477**],[**Known firstname **] [**2097-7-9**] 62 Female [**-1/4903**] [**Numeric Identifier 105478**]
Report to: DR. [**Last Name (STitle) **]. POTOSEK/DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7211**], [**First Name3 (LF) **],E/dif
SPECIMEN SUBMITTED: BONE MARROW (1 JAR)
Procedure date Tissue received Report Date Diagnosed
by
[**2159-11-1**] [**2159-11-2**] [**2159-11-6**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dsj??????
Previous biopsies: [**-1/4799**] Cell block Pleural fluid,
C11-[**/0-0-**] pericardial fluid for cell block
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
HYPOCELLULAR MARROW WITH SPARSE ERYTHROPOIESIS (SEE NOTE)
Note: The marrow aspirate is paucicellular and the core biopsy
is predominantly subcortical hypocellular marrow spaces. Deeper
levels revealed more evaluable marrow spaces, with sparse
erythroid colonies, and absent megakaryocytes. While a sampling
issue cannot be ruled out, the constellation of findings is
suggestive of bone marrow suppression, concomitant to therapy or
infectious etiologies.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate. Red blood cells are hypochromic with
anisopoikilocytosis including dacrocytes, elliptocytes and rare
schistocytes seen. The white blood cell count appears
decreased. Platelet count appears decreased. The white cells
consist predominantly of dysplastic neutrophils including
hypogranular and pseudo-Pelger forms, occasional hyperlobated
forms are also seen. Differential shows 63% neutrophils, 16%
bands, 1% monocytes, 21% lymphocytes.
Aspirate Smear:
The aspirate material is suboptimal for evaluation due to
paucity of spicules. Erythroid precursors are proportionately
decreased in number and exhibit normoblastic maturation.
Myeloid precursors appear proportionately increased and show
left shifted dyspoietic maturation. Megakaryocytes are present
in decreased number, some hypolobated and monolobated forms and
micromegakaryocytes in tight clusters are also seen.
A 400 cell differential shows <1% blasts, 9% promyelocytes, 1%
myelocytes, 2% metamyelocytes, 44% bands/neutrophils, 2% plasma
cells, 25% lymphocytes, 17% erythroid.
Clot Section and Biopsy Slides:
The core biopsy material is inadequate for evaluation It
consists of a 0.6 cm core biopsy of periosteum, trabecular
marrow with a cellularity of <5%.
The bone marrow consists almost exclusively of adipose tissue
and stroma cells. Rare clusters of erythroid cells are seen.
Megakaryocytes are rare to absent.
Clinical: 62 y/o female with history of CML, most recently on
dasatimib now with persistent pancytopenia.
Gross:
The specimen is received in a B+ container, labeled with the
patient's name, "[**Known lastname **], [**Known firstname **]", the medical record number and
"M11-699." It consists of a bone core biopsy measuring 0.7 cm in
length x 0.2 cm in diameter entirely submitted in cassette A
following decalcification.
[**11-9**] TTE: The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF 75%). The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with severe global free wall
hypokinesis. The mitral valve leaflets are mildly thickened.
There is mild posterior leaflet mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a small to moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2157-10-24**], the left ventricle is now frankly
hyperdynamic (including the apex), but the right ventricle now
appears severely hypokinetic. A small/moderate pericardial
effusion is now present.
Microbiololgy:
[**2159-10-22**] 3:40 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final [**2159-10-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2159-10-25**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2159-10-28**]): NO GROWTH.
ACID FAST SMEAR (Final [**2159-10-23**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final [**2159-11-5**]): NO FUNGUS ISOLATED.
[**2159-10-25**] 4:45 pm PLEURAL FLUID
GRAM STAIN (Final [**2159-10-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2159-10-28**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2159-10-31**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2159-10-26**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2159-10-25**] 2:13 pm URINE Source: Catheter.
**FINAL REPORT [**2159-10-27**]**
URINE CULTURE (Final [**2159-10-27**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM POSITIVE BACTERIA. ~1000/ML. SUGGESTING
STAPHYLOCOCCI.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2159-10-25**] 5:30 pm BLOOD CULTURE Source: Line-ij.
**FINAL REPORT [**2159-10-29**]**
Blood Culture, Routine (Final [**2159-10-29**]):
STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
Penicillin = 1.5 MCG/ML, Sensitivity testing performed
by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE----------- 0.5 S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- <=0.5 S
MEROPENEM------------- 1 R
PENICILLIN G---------- S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2159-10-26**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by DR [**Last Name (STitle) **].ROSE [**2159-10-26**] 1205PM.
Anaerobic Bottle Gram Stain (Final [**2159-10-26**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2159-10-25**] 7:01 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2159-10-25**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2159-10-30**]):
MODERATE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
STAPH AUREUS COAG +. HEAVY GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STREPTOCOCCUS PNEUMONIAE
| |
CEFTRIAXONE----------- 0.5 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S <=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S <=0.5 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- =>0.5 R 1 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ <=1 S
LEGIONELLA CULTURE (Final [**2159-11-1**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Final [**2159-11-7**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2159-10-26**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2159-10-27**] 4:58 pm Blood (CMV AB) Source: Line-aline.
**FINAL REPORT [**2159-10-30**]**
CMV IgG ANTIBODY (Final [**2159-10-30**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
106 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2159-10-30**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
If current infection is suspected, submit follow-up serum
in [**1-18**]
weeks.
Greatly elevated serum protein with IgG levels >[**2147**] mg/dl
may cause
interference with CMV IgM results.
[**2159-10-27**] 5:03 am Blood (Toxo) ADD ON TESTS.
**FINAL REPORT [**2159-10-30**]**
TOXOPLASMA IgG ANTIBODY (Final [**2159-10-30**]):
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
1.0 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
TOXOPLASMA IgM ANTIBODY (Final [**2159-10-30**]):
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
The FDA is advising that the result from any one
toxoplasma IgM
commercial test kit should not be used as the sole
determinant of
recent toxoplasma infection when screening a pregnant
patient.
[**2159-10-30**] 4:16 am Immunology (CMV) Source: Line-aline.
**FINAL REPORT [**2159-11-1**]**
CMV Viral Load (Final [**2159-11-1**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
[**2159-10-29**] 12:31 pm PLEURAL FLUID
**FINAL REPORT [**2159-11-4**]**
GRAM STAIN (Final [**2159-10-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2159-11-1**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2159-11-4**]): NO GROWTH.
[**2159-11-1**] 2:39 pm CSF;SPINAL FLUID Source: LP TUBE 3.
GRAM STAIN (Final [**2159-11-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2159-11-4**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
[**2159-11-1**] 2:39 pm CSF;SPINAL FLUID Source: LP TUBE 3.
**FINAL REPORT [**2159-11-1**]**
CRYPTOCOCCAL ANTIGEN (Final [**2159-11-1**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
Results should be evaluated in light of culture results
and clinical
presentation.
[**2159-11-2**] 7:07 pm STOOL CONSISTENCY: NOT APPLICABLE
**FINAL REPORT [**2159-11-3**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2159-11-3**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2159-11-3**]
AT 0625.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2159-11-2**] 4:00 pm BLOOD CULTURE
**FINAL REPORT [**2159-11-8**]**
Blood Culture, Routine (Final [**2159-11-8**]): NO GROWTH.
Lab Results on Discharge:
[**2159-11-9**] 06:10AM BLOOD WBC-2.7* RBC-2.61* Hgb-7.3* Hct-21.8*
MCV-83 MCH-28.1 MCHC-33.7 RDW-17.4* Plt Ct-70*
[**2159-11-9**] 06:10AM BLOOD Neuts-45* Bands-1 Lymphs-36 Monos-15*
Eos-0 Baso-1 Atyps-0 Metas-1* Myelos-1* NRBC-3*
[**2159-11-9**] 06:10AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Tear Dr[**Last Name (STitle) **]1+ Bite-OCCASIONAL
[**2159-11-6**] 09:16AM BLOOD PT-13.6* PTT-23.7 INR(PT)-1.2*
[**2159-11-7**] 06:12AM BLOOD Gran Ct-1510*
[**2159-11-8**] 06:49AM BLOOD Glucose-94 UreaN-28* Creat-0.7 Na-141
K-3.8 Cl-110* HCO3-25 AnGap-10
[**2159-11-8**] 06:49AM BLOOD Calcium-8.1* Phos-4.2 Mg-1.7
[**2159-10-29**] 04:23AM BLOOD Lactate-2.0
[**2159-10-29**] 07:44PM BLOOD O2 Sat-95
[**2159-10-28**] 04:54AM BLOOD freeCa-1.16
Brief Hospital Course:
Primary Reason for Hospitalization: Patient is a 62yo female
with past medical history of CML in remission on hydroxyurea for
15 years with recent relapse and initiation of dasatinib who
presented to the hospital following a fall at home. At outside
hospital she was found to have brain lesions concerning for
bleed or possible brain metastases as well as pericardial
effusion. She was transferred to [**Hospital1 18**] for pericardiocentesis.
During her stay she required ICU level care for acute systolic
heart failure, bilateral pleural effusions and septicemia, and
required a period of intubation for respiratory failure.
Re-imaging of brain lesions via MRI reveals findings consistent
with PRES vs. evolving infarcts. The pericardial effusion did
not recur, and patient was discharged to rehab for
re-conditioning.
.
ACUTE CARE
1. Pericardial Effusion: Following a fall at home, patient was
found to have pericardial effusion at OSH. She was transferred
to [**Hospital1 18**] and underwent pericardiocentesis. Bedside ECHO in the
ED showed evidence of RV wall bowing and pericardiocentesis was
done, draining 700 cc of straw colored fluid. Cytology was
negative. Her drain output was monitored, and once output
started decreasing, pericardial drain was pulled. A TTE was
checked after pulling the drain to ensure that the pericardial
fluid did not reaccumulate and the patient was monitored on
telemetry throughout. Although she has a history of CML, the
patient's pericardial fluid cytology was negative; possible that
a recently started chemo drug, dasatinib, was the underlying
cause of the pericardial effusion. Follow-up TTE revealed LVEF
75% demonstating frank hyperkinesis and severe right ventricle
free wall hypokinesis.
.
2. Stress induced cardiomyopathy with Acute Systolic Heart
Failure: Unclear what patient's heart failure history is, but
Lasix 20mg PO is home medication. Apical akinesis was seen on
Echo with depressed EF of 25-30% and takasubos distribution. The
patient also developed resiratory distress early on in the
admission, with hypoxic failure and was intubated. This was
thought to be due, in part, to volume overload as per CXR. Once
intubated, the patient became hypotensive, likely from
fent/versed and an IJ and a-line were placed. The patient was
started on dopamine post intubation, but because of tachycardia,
she was switched to neo, from which she was weaned. Once her
pressures were stablized, diuresis was continued; creat was
closely trended, as patient was found to have creat bump. A
Swan was floated for closer monitoring and the patient was found
to have normal pressures. Patient was extubated and transferred
to the floor. She had normal hemodynamics following and repeat
echo showed hyperdynamic LVEF of 75% and severe right
ventricular wall hypokinesis on discharge. The acute heart
failure was likely due to sepsis and resolved with completion of
IV antibiotics. She was dishcarged with cardiology follow-up
referral.
.
3. Respiratory status/bilateral pleural effusions: The patient
developed hypoxic respiratory failure secondary to pulmonary
edema from acute heart failure and was intubated for about a
week. While intubated, the patient was diuresed aggressively.
She was also found to have b/l pleural effusions on CXR. This
was thought to be contributing to her respiratory difficulties.
The patient had a R thoracentesis done, taking out ~ 700 cc of
straw colored fluid. The patient also had a L thoracentesis done
by IP, taking out a total of 1500 cc (Pleurex was left in for
about two days before it was removed). The patient was
eventually weaned from vent and is now satting well on RA, and
breathing comfortably.
.
4. Strep pneumo bacteremia/infection: The patient spiked a
temperature after the R thoracentesis, was found to have Strep
pneumo growing out of her blood and sputum. Was also found to
have Staph aurues, Strep pneumo, and H. flu growing out of
sputum. The patient was initially started on vanc/cefepime and
was later switched to Zosyn and Levofloxacin to better cover the
Strep pneumo. However, the patient later spiked and she was
reswitched to cefepime. When afebrile for several days, patient
was placed ceftiraxone and patient remained afebrile through
completion of an 14-day course of cefepime then ceftriaxone.
.
5. Bone Marrow suppression: The patient has been
thrombocytopenic since admission, and because of her recent head
bleed/fall, her platelet goal was kept >50 during ICU stay and
she required mulitple platelet transfusions. Throughout the
hospital course, the patient's hematocrit, platelets, and white
count all trended down. The patient was briefly started on
Neupogen, which was eventually discontinued as there was minimal
improvement in her white count. The granulocyte count reached a
nadir at 510 then began to recover. Bone marrow biopsy showed
bone marrow suppression from drug effect of tyrosine kinase
inhibitor vs. infection with no evidence of active CML. Hem/Onc
followed the patient and recommended avoiding tyrosine kinase
inhibitors for now and possible re-initation as an outpatient.
On discharge, patient's granulocyte count was close to 1500 and
monocytes were at 15% of the differential, signaling bone marrow
recovery.
.
6. SAH/Brain lesions with edema: The read on patient's OSH CT
head showed that there were possible metastatic brain lesions,
as well as SAH s/p fall. CML is unlikely to met to the brain,
however, another primary cancer should be considered, including
breast or colon cancer. Neuro and neurosurgery were contact[**Name (NI) **] in
the [**Name (NI) **]. Neurosurgery did not think that intervention was
needed. Neurology started the patient on Keppra and Decadron.
EEG was negative, with no electrographic evidence of seizure
seen. Brain MRI showed findings consistant either with evolving
infarct or PRES involving the parieto-occipital region. Patient
has vision deficits related to the lesion in this area.
Ophthalmology saw the patient and agrees that she has likely
cortical blindness.
.
7. C diff colitis: Upon transfer to the floor, patient developed
profuse watery diarrhea. C. diff toxin was sent, and came back
positive. She was started on oral vancomycin therapy to be
continued 2 weeks after finishing all other antibiotics.
Diarrhea resolved and she was dishcharged to complete oral
vancomycin as an outpatient.
.
8. CML: As per the patient's primary oncologist, the patient's
CML had been well controlled on maintenance hydroxyurea in
remission for 15 years. Patient was recently started on
dasatinib as an outpatient. While hospitalized, the patient's
cell lines all started trending down and she required multiple
platelet and blood transfusions. Marrow suppression is likely
from drug effect from dasatinib vs. infection as read in a bone
marrow biopsy in-house. This biopsy showed no increased blasts
or other marrow invasion. Patient was dishcarged on no oncologic
medication and instructed to follow-up with her primary
oncologist.
.
9. Acute on chronic kidney disease: The patient's creatinine was
initially elevated (up to 1.9). Eventually improved with
diuresis and has since resolved; creatinine down to 0.7 on
discharge.
.
CHRONIC CARE
.
1. Depression/Anxiety: Patient's Doxepin and venlafaxine were
held as an inpatient because of bone marrow suppression and
complicated picture. They will be restarted as an outpatient
after discussion with outpatient oncologist.
.
TRANSITIONAL ISSUES:
1. Medication Changes:
- STOP taking dasatinib
- START vancomycin 125mg by mouth every 6 hours for 13 days.
- STOP taking venlafaxine and doxepin for now. You will need to
discuss potential side-effects of these medications with your
oncologist before restarting.
- STOP taking Lasix for now until directed to re-start by your
outpatient primary care doctor or cardiologist.
- START Dexamethasone 0.5mg daily for 3 days to complete steroid
taper
- START Lansoprazole 30mg by mouth for 3 days while on steroid
taper
2. Code Status: Full
3. Follow-up:Please follow-up with the following appointments:
Department: Hematology/ Oncology
Name: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Please call the office number to make a hospital follow up
appointment for 9-15 days after your hospital discharge.
Location: [**Doctor Last Name **] [**Doctor Last Name **] BLDG, [**Apartment Address(1) **]
Address: 131 ORNAC, [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 61873**]
OUTPATIENT ONCOLOGIST: Dr. [**Last Name (STitle) **] cell:[**Telephone/Fax (1) 105479**]
Department: Ophthalmology
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
When: Please call the office number to schedule a hospital
follow up appointment for 30 days after your hospital discharge.
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 5, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 253**]
Department: NEUROLOGY
When: WEDNESDAY [**2159-11-21**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
4. Contacts:
Daughter [**Name (NI) **]: [**Telephone/Fax (1) 105480**]
[**Name2 (NI) **]er [**Name (NI) 2331**]: [**Telephone/Fax (1) 105481**]
[**Name2 (NI) **]er [**Name (NI) 547**]: [**Telephone/Fax (1) 105482**]
Medications on Admission:
Dasatinib 100mg once daily (last dose two weeks prior to
admission)
Doxepin 10mg once daily
Venlafaxine 75mg once daily
Bmega for dry eye
Multivitamin
Caclium tablet
clobestol ointment
Furosemide 20mg once daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Artificial Tears Drops Sig: 1-2 drops Ophthalmic as
needed as needed for dry eyes.
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 13 days.
6. dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
7. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) **]
Discharge Diagnosis:
Primary: Pericardial effusion from adverse drug reaction
Secondary: Strep pneumo septicemia, C. diff colitis, PRES
syndrome, bilateral pleural effusions, CML, pancytopenia
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 following a fall at home and
you were found to have fluid building up around your heart. The
fluid was drained and the drain was removed. You also developed
fluid around the lungs which was also drained. Your blood cell
counts dropped as well. There are lesions that we imaged in the
brain that are contributing to your memory problems and your
vision loss. We believe there may be some degree of
reversibility of these lesions. These effects are likely related
to side effects from dasatiib. Other problems that were treated
were sepsis, and C. diff colitis. You will need to continue
treatment for the colitis as an outpatient.
Please make the following changes to your medications:
1. STOP taking dasatinib
2. START vancomycin 125mg by mouth every 6 hours for 13 days.
3. STOP taking venlafaxine and doxepin for now. You will need to
discuss potential side-effects of these medications with your
oncologist before restarting.
4. STOP taking Lasix for now until directed to re-start by your
outpatient primary care doctor or cardiologist.
Please take all other medications as prescribed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with the following appointments:
Department: Hematology/ Oncology
Name: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Please call the office number to make a hospital follow up
appointment for 9-15 days after your hospital discharge.
Location: [**Doctor Last Name **] [**Doctor Last Name **] BLDG, [**Apartment Address(1) **]
Address: 131 ORNAC, [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 61873**]
Department: Ophthalmology
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
When: Please call the office number to schedule a hospital
follow up appointment for 30 days after your hospital discharge.
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 5, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 253**]
Department: NEUROLOGY
When: WEDNESDAY [**2159-11-21**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,139
| 160,907
|
10417
|
Discharge summary
|
report
|
Admission Date: [**2132-8-27**] Discharge Date: [**2132-9-12**]
Date of Birth: [**2061-9-24**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Oxacillin / Heparin Agents
Attending:[**First Name3 (LF) 826**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
Placement of tunneled dialysis line
Endoscopy
History of Present Illness:
70 yo M with history of ESRD on HD, multiple MRSA line
infections, atrial fibrillation, and CAD who is admitted to the
MICU for dialysis line repair.
.
He was recently admitted to [**Hospital1 18**] MICU for pneumonia from
[**Date range (3) 34484**]. Vent settings at [**Hospital3 672**] SIMV
4/500/40% FIO2, Peep 5 PS 15. He has a 3 Lumin Quentin catheter
in rt subclavian, according to oral report this was a temporary
catheter and he was scheduled to have a replacement performed
here.
.
He has not been febrile at [**Hospital3 672**], he has had clear
blood cultures there. He has not had any evidence of infection
per their report.
Past Medical History:
1. As above
2. ESRD (unclear etiology) on HD M/W/F s/p R cadaveric tx '[**19**] at
[**Hospital1 2177**], failed '[**29**], removed [**6-26**]
3. Staph aureus (sensitive to Ox, resistant to PCN) sepsis,
recent line infections; [**2131-5-24**] micro data
4. HTN
5. AFib
6. DDD Pacemaker
7. CAD - mild 40% prox LAD on cath '[**27**]
8. LUE DVT
9. Left TKR '[**23**]
10. Hypothyroidism
11. Hx of TB as child, PPD neg
12. PEG tube placed [**6-18**].
Social History:
Retired dentist, was living in [**Location (un) **] with wife, kids, and
[**Name2 (NI) 7337**], denies etoh/tob.
Family History:
Both parents died in 90's, healthy.
Physical Exam:
VS: Temp 101, Pulse 70, BP 114/48, RR 20, 99% on SIMV + PS tv
500 rr 10, FIO2 0.40 PEEP 5, PS 15
GEN; alert, responsive with eyes, male, trached, non-verbal
Neck: tracheostomy in place
Chest: right sided sub-clavian quentin catheter in place, site
C/D/I
CV: RRR, S1S2 normal, no m/r/g
Lung: anterior: coarse rhonchi bilaterally
Abd: soft, nt, nd, +BS, G-tube in place, surgical scars
Extrema: - edema, DP 2+ b/l
Pertinent Results:
[**2132-8-27**] 04:39PM WBC-18.1*# RBC-3.89* HGB-11.4* HCT-35.1*
MCV-90 MCH-29.4 MCHC-32.6 RDW-17.6*
[**2132-8-27**] 04:39PM PLT COUNT-252#
[**2132-8-27**] 04:39PM GLUCOSE-149* UREA N-39* CREAT-2.7* SODIUM-139
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-31 ANION GAP-14
[**2132-8-27**] 04:39PM CALCIUM-9.3 PHOSPHATE-2.0* MAGNESIUM-2.0
[**2132-8-27**] 05:47PM PT-23.2* PTT-42.3* INR(PT)-3.9
[**2132-8-27**] CXR: 1. Tracheostomy tube balloon overinflation.
Clinical evaluation is recommended.
2. Marked interval improvement in pneumonia compared to [**2132-7-24**],
with small
residual opacities in the right mid lung zone and left lower
lobe.
3. Small left pleural effusion, markedly improved compared to
[**2132-7-24**].
[**2132-9-2**] CT Spine: There are multiple large, presumably
calcified subcarinal lymph nodes. Has the patient had prior
granulomatous disease? Also, there is some soft tissue density
along the posterior aspect of both hemithoraces. Is there
evidence on prior imaging studies for pleural effusions?
[**2132-9-9**] CT CAP: 1. No intra-abdominal, retroperitoneal or
pelvic hematoma.
2. Minor consolidation in the dependent portion of the lower
lobes unchanged compared to recent CT.
3. Moderate left colonic diverticulosis without sign of acute
complication.
4. End-stage native kidneys. Other findings previously described
on CT of [**2132-9-2**] are unchanged.
Brief Hospital Course:
70 yo M with history of ESRD on HD, multiple MRSA line
infections, atrial fibrillation, and CAD who is admitted to the
MICU for dialysis line placement, but was found to be febrile
and hypotensive on admission, now with resolved fever and WBC
count, grew MRSA in blood, now culture negative and clinically
improved.
1. Fever/sepsis - Mr. [**Known lastname 4154**] has a history of MRSA line
infections and currently had MRSA bacteremia/sepsis on
admission. This was felt to be likely related to line infection,
and Quentin was d/c'd after IR placed new groin line and INR was
reduced with FFP. However the line tip culture was negative
(after treating through the line for 5 days). L knee film showed
small effusion, and MR. [**Known lastname 4154**] refused a tap by the ortho team. L
ankle film showed mild soft tissue swelling, no bony injury, no
evidence osteomyelitis. Sputum cultures were negative, and he is
anuric. CT abd/pelvis/spine shows no source of sepsis. It was
thought that he may have an endocarditis that was the source of
his recurrent infections. A TTE was negative. A TEE was felt to
be too risky given esophageal narrowing on EGD. Therefore he
will be treated for suspected endocarditis given inability to
perform TEE. He needs to receive six weeks vancomycin from
[**2132-8-30**] for empiric treatment of endocarditis. Vancomycin will
be dosed by level with his HD. Surveillance blood cultures have
been negative since [**36**]/08/5, and he should receive repeat
surveillance cultures once vancomycin course completed.
.
2. Hypoxic respiratory failure: Mr. [**Known lastname 4154**] has been vent
dependent since [**Month (only) 205**]. He was admitted on assist control
ventilation,a nd has been weaned down to pressure support
ventilation as low as [**6-27**], with short trach mask trials PRN.
Speech and swallow was consulted for a passy muir valve so that
the patient can talk. He had poor NIFs initally (-16), and these
have improved to ??? on discharge. He should continue to wean
further at rehab as tolerated with hope of breathing
independantly again.
.
3. Access for Hemodialysis - Mr. [**Known lastname 4154**] was transfered to have
his access revised however he was febrile and bacteremic, and a
new temporary line was intially placed after he was afebrile for
>24 hours. After surveillance blood cultures were negative, a
new tunneled groin line was placed for HD on his L side.
.
4. Anemia: Mr. [**Known lastname 4154**] is chronically anemic due to his ESRD. He
is on aranesp and iron as an outpatient. He was on Epo, and Fe
supplements while hospitalized. He was transfused 1 unit pRBCs
on [**2132-9-9**] after his line placement, and his hemtocrit was
otherwise stable.
.
5. ESRD: Mr. [**Known lastname 4154**] has anuric renal failure. He was hemodialysed
three times a week while hospitalized.
.
5. Atrial fibrillation: Mr. [**Known lastname 4154**] has a history of atrial
fibrillation and HIT. He is intermittently V-paced. His pacer
appeared to be pacing on his T waves on admission. Cardiology
was consulted and said it was safely pacing. They interrogated
his pacer and it was functioning properly. he was continued on
amiodarone. He was on an argatroban gtt until after his line was
placed, at which time coumadin was rtestarted for long term
outpatient anticoagulation. On discharge he is therapeutic on
coumadin and off argatroban.
.
6. FEN: Mr. [**Known lastname 4154**] was on tubefeeds at goal per nutrition recs.
These were held for his line placement only. His tube feeds can
be increased as needed to maintain his weight.
.
7. Access: Mr. [**Known lastname 34485**] old left SC line was initially used until
he was afebrile and a R side temporary groin line was placed.
This line was then used for meds and lab draws until DC. His new
tunneled line was used by renal for HD and vancomycin only.
8. PPX: Mr. [**Known lastname 4154**] was on pneumoboots, PPI, and argatroban drip -
bridged to coumadin
.
9. Full Code: DNR/DNI was discussed, but Mr. [**Known lastname 4154**] has not
wanted to change his code status, and did not want to discuss
with his family.
.
10. Communication was with Mr. [**Known lastname 4154**] and his wife, who is also
his health care proxy.
.
11. Dispo: Mr. [**Known lastname 4154**] came to [**Hospital1 18**] from [**Hospital3 672**] and will
go once coumadin therapeutic and argatroban off. PT/OT were
consulted and worked with Mr [**Known lastname 4154**] in bed. Now that he has a
tunneled line and his temporary groin line is out, he can be out
of bed, and work more extensively with PT to rebuild his
strength.
Medications on Admission:
Coumadin 3 mg PO q M/W/F/S
Coumadin 2 mg [**Doctor First Name **]/Tu/Th
Eucerin oint
Novolin SS
Cordarone 200mg daily
Senokot liquid
Vitamin B12 1000mg daily
Protonix 40mg daily
Feosol 325mg daily
Colace
Aranesp 60 mcg syringe
Benadryl prn
Ativan prn
Tylenol prn
Renagel 800 mg TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
MRSA bacteremia with septic shock
Secondary:
end-stage renal disease on hemodialysis
hypertension
atrial fibrillation
history of multiple deep vein thromboses
hypothyroid
L total knee replacement
PEG tube in place
Discharge Condition:
Stable, afebrile, with clear surveillance blood cultures.
Discharge Instructions:
Please notify care facility care-givers if fevers, chills,
nausea, vomiting, or any other health concern.
Followup Instructions:
Please follow up for hemodialysis three times a week as directed
by the renal team. Pls wean vent as tolerated. Pls check R
groin site on [**9-12**] and [**9-13**] since fem line was pulled from
there on [**9-12**]
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62,995
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40612
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Discharge summary
|
report
|
Admission Date: [**2192-3-24**] Discharge Date: [**2192-3-29**]
Date of Birth: [**2109-3-7**] Sex: F
Service: MEDICINE
Allergies:
ibuprofen / Penicillin G
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
83 year-old Spanish-speaking female with a history of
hypercarbic respiratory failure, HTN, chronic diastolic heart
failure, diabetes mellitus type II, and history of CVA who
presents with AMS and SOB.
She lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] and she was noted to be "restless,
sweating, twitching, and difficulty breathing." Per report she
had been having increasing fatigue, AMS, and shortness of breath
since the afternoon. She had finger-stick blood glucose in the
50's at some point today and was given juice. EMS was called
this evening. EMS found her to have O2 sat 83% on 3L, 88% on
NRB with blood glucose 106 after juice. She was then
transferred to the ED.
In the ED, initial VS were HR 83, BP 130/67, RR 12, O2 sat 88%
on NRB. On exam she would occasionally follow commands but was
very somnolent. She was intubated and started on a propofol
gtt. NGT was placed. CXR showed bilateral patchy opacities.
ETT pulled back slightly since that film. She was given
vancomycin and levaquin. ABG after intubation was
7.40/66/456/42/13. Other labs were notable for K 6.4, Cl 89,
Bicarb 34, BUN 62, Creat 1.4, WBC 10.9. She was given
kayexelate and repeat K was 5.8. Lactate was 1.6. CT head was
done which showed no acute intracranial process. She was
admitted to the ICU.
This is the third time she has been intubated.
Review of systems: Unable to be obtained in the ICU.
On the floor, patient is now feeling back to her baseline. She
denies fevers, chills, chest pain. Still has shortness of
breath, wheezing, but this is her baseline. Denies abdominal
pain. Per HPI otherwise all other review of systems is
negative.
Past Medical History:
Hypercarbic respiratory failure
Hypertension
Hyperlipidemia
Chronic diastolic heart failure
Diabetes mellitus, type II
History of CVA with residual dysarthria
Depression
Spinal stenosis (lumbar)
Peripheral vascular disease
COPD
Social History:
Lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Daughter is her healthcare proxy and
lives in [**Name (NI) 86**]. Pt formerly smoked and has approximately a 120
pack-year history. She stopped drinking alcohol several years
ago, previously drank 6 beers per week. Denies illicit drug
use. Originally from [**Male First Name (un) 1056**], moved to USA [**2148**]. She has 7
children.
Family History:
Sister died of diabetes.
Physical Exam:
ICU EXAMINATION [**2192-3-24**]:
Vitals: 97.6 78 166/49 14 100% AC
General: Intubated, sedation, appears comfortable
HEENT: PERRL but slightly constricted, sclera anicteric, MM
slightly dry, ETT in place, OG tube present
Neck: Supple, JVP unable to assess
Lungs: Ventilated breath sounds clear bilaterally, no wheezes,
rales, rhonchi anteriorly but unable to listen posteriorly
CV: Regular rate and rhythm with distant heart sounds but no
audible murmurs
Abdomen: Soft, non-tender, protuberant but non-distended, bowel
sounds present, no rebound tenderness or guarding obvious, no
organomegaly
GU: Foley in place
Ext: warm, well perfused, faint pulses, chronic skin changes but
no edema
FLOOR EXAM [**2192-3-26**]:
VS: T 98.9, BP 124/79, HR 74, RR 20, O2sat 96% on 3L
GEN: NAD, obese, not in respiratory distress
HEENT: PERRL, EOMI, MMM
NECK: Supple
CHEST: + Wheezes and some rhonchi diffusely
CV: RRR, normal s1 and s2
ABD: Soft, nontender, bowel sounds normal
EXT: No lower extremity edema
NEURO: Alert, oriented x3, CN 2-12 intact, sensory intact
throughout, [**4-5**] BUE/BLE strength, fluent speech
PSYCH: Calm, appropriate
Pertinent Results:
ECG [**2192-3-24**]: Baseline artifact. Sinus rhythm. Left atrial
abnormality. Right bundle-branch block. Inferior wall myocardial
infarction. Low precordial voltage. Since the previous tracing
there is probably no significant change.
.
IMAGING:
[**3-25**] CXR: Comparison with the previous study done [**2192-3-24**].
Prominent
interstitial markings persist. Streaky bilateral densities
consistent with
subsegmental atelectasis are unchanged, as is blunting of the
left
costophrenic sulcus. Mediastinal structures are unchanged. An
endotracheal
tube, nasogastric tube and PICC line remain in place.
IMPRESSION: No significant interval change.
.
CXR [**3-26**] CXR-FINDINGS: Lung volumes are decreased, and as
expected, this has worsened since [**2192-3-25**] when the patient was
intubated. Bilateral lower lobe atelectasis is worse in the
right side. Hazy opacities in both lungs,
particularly in the right side are consistent with edema.
Mildcardiomegaly
is unchanged since [**2192-3-24**].
Mid thoracic spine degenerative disc disease is moderately
severe.
IMPRESSION:
1. Decreased lung volumes and atelectasis.
2. Probable pulmonary edema.
.
[**3-24**] CT HEAD:
1. No acute intracranial process. Chronic atrophy and remote
right PCA
infarct.
2. Moderate paranasal sinus and mastoid opacification
post-intubation.
Please correlate clinically for mastoiditis.
.
[**2192-3-29**] 05:09AM BLOOD WBC-9.7 RBC-4.08* Hgb-10.7* Hct-34.6*
MCV-85 MCH-26.3* MCHC-31.1 RDW-13.4 Plt Ct-216
[**2192-3-28**] 04:39AM BLOOD WBC-11.0 RBC-3.90* Hgb-10.9* Hct-33.0*
MCV-85 MCH-27.9 MCHC-32.8 RDW-13.0 Plt Ct-242
[**2192-3-26**] 04:25AM BLOOD WBC-9.7 RBC-4.15* Hgb-11.4* Hct-35.7*
MCV-86 MCH-27.6 MCHC-32.0 RDW-13.2 Plt Ct-252
[**2192-3-25**] 04:40AM BLOOD WBC-7.3 RBC-4.49 Hgb-12.3 Hct-38.9 MCV-87
MCH-27.5 MCHC-31.7 RDW-13.1 Plt Ct-305#
[**2192-3-24**] 08:22AM BLOOD WBC-10.4 RBC-4.20 Hgb-11.2* Hct-35.6*
MCV-85 MCH-26.8* MCHC-31.6 RDW-13.5 Plt Ct-182
[**2192-3-24**] 03:00AM BLOOD WBC-10.9 RBC-4.31 Hgb-11.7* Hct-37.5
MCV-87 MCH-27.3 MCHC-31.3 RDW-13.4 Plt Ct-279
[**2192-3-24**] 08:22AM BLOOD Neuts-65.1 Lymphs-24.9 Monos-5.9 Eos-2.8
Baso-1.2
[**2192-3-24**] 03:00AM BLOOD Neuts-83.3* Lymphs-8.6* Monos-4.5 Eos-3.2
Baso-0.4
[**2192-3-29**] 05:09AM BLOOD Plt Ct-216
[**2192-3-28**] 04:39AM BLOOD Plt Ct-242
[**2192-3-26**] 04:25AM BLOOD Plt Ct-252
[**2192-3-25**] 04:40AM BLOOD Plt Ct-305#
[**2192-3-24**] 03:03PM BLOOD PT-12.0 PTT-22.7 INR(PT)-1.0
[**2192-3-24**] 08:22AM BLOOD Plt Ct-182
[**2192-3-24**] 03:00AM BLOOD Plt Ct-279
[**2192-3-29**] 05:09AM BLOOD Glucose-76 UreaN-64* Creat-1.1 Na-135
K-4.5 Cl-93* HCO3-38* AnGap-9
[**2192-3-28**] 04:39AM BLOOD Glucose-175* UreaN-68* Creat-1.3* Na-135
K-4.2 Cl-91* HCO3-38* AnGap-10
[**2192-3-27**] 05:32AM BLOOD Glucose-290* UreaN-71* Creat-1.6* Na-134
K-4.7 Cl-90* HCO3-37* AnGap-12
[**2192-3-26**] 04:25AM BLOOD Glucose-184* UreaN-64* Creat-1.8* Na-138
K-4.2 Cl-93* HCO3-38* AnGap-11
[**2192-3-25**] 04:02PM BLOOD Glucose-333* UreaN-61* Creat-1.6* Na-134
K-4.2 Cl-89* HCO3-35* AnGap-14
[**2192-3-25**] 04:40AM BLOOD Glucose-348* UreaN-59* Creat-1.6* Na-134
K-4.5 Cl-88* HCO3-35* AnGap-16
[**2192-3-24**] 03:02PM BLOOD Glucose-147* UreaN-54* Creat-1.1 Na-134
K-4.0 Cl-85* HCO3-37* AnGap-16
[**2192-3-24**] 08:22AM BLOOD Glucose-215* UreaN-57* Creat-1.3* Na-136
K-4.3 Cl-89* HCO3-36* AnGap-15
[**2192-3-24**] 03:00AM BLOOD Glucose-127* UreaN-62* Creat-1.4* Na-134
K-6.4* Cl-89* HCO3-34* AnGap-17
[**2192-3-24**] 03:02PM BLOOD CK(CPK)-55
[**2192-3-24**] 08:22AM BLOOD ALT-25 AST-23 CK(CPK)-65 AlkPhos-76
TotBili-0.3
[**2192-3-24**] 03:00AM BLOOD CK(CPK)-76
[**2192-3-24**] 03:02PM BLOOD CK-MB-3 cTropnT-0.03*
[**2192-3-24**] 08:22AM BLOOD CK-MB-3 cTropnT-0.03* proBNP-1046*
[**2192-3-24**] 03:00AM BLOOD cTropnT-0.02*
[**2192-3-29**] 05:09AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.8*
[**2192-3-24**] 04:04AM BLOOD O2 Sat-98
.
Microbiology:[**2192-3-24**] SPUTUM GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL INPATIENT
[**2192-3-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2192-3-24**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2192-3-24**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2192-3-24**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2192-3-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
83 year-old Spanish-speaking woman with history of hypertension,
diabetes, COPD, chronic diastolic heart failure presented with
hypoxia and hypercarbic respiratory failure that required
intubation and ICU admission.
[**Hospital Unit Name 153**] Course:
# Respiratory failure: The presentation was initially thought to
be [**1-4**] volume overload vs pulmonary edema. She was diuresed
(1500cc in ICU). Flash pulmonary edema from hypertension was
considered given poorly controlled BP. Clonidine was increased
to TID for better BP control. She had no fevers or leukocytosis
to suggest PNA and urine legionella is negative. Ruled out for
MI. She was extubated and remained stable on home diuretic
regimen and home 4L NC (has h/o COPD). Productive cough noticed
the day after extubation with diffuse wheezing, raising
suspicion for COPD exacerbation. She was started on prednisone
and Zpak on day of transfer to the floor. Her creatinine
increased with diuresis to 1.8 (1.4 admission, baseline
uncertain). She was continued on amlodipine and metoprolol. On
the regular medical floor, pt remained on her home 02 regimen,
in fact had a lower requirement of 3L NC. She was continued on
azithromycin and prednisone, 5 day course total for both (2 days
left on day of discharge). Pt should continue duonebs after
discharge. Pt should continue on torsemide per prior home
regimen. Goals of care were continually discussed after
discharge from the ICU as it was patient's 3rd intubation for a
similar issue. Pt appeared very conflicted and could not make a
decision regarding further intubated and did not care to discuss
this issue any further. Pt could not answer whether she would
want reintubation or ICU care in the future. This was discussed
with patient's HCP, her daughter and HCP raised concerns that pt
is constantly changing her mind not only about goals of care but
about her ultimate disposition home vs. [**Hospital1 1501**]. Pt stated that she
wanted to return to [**Hospital1 1501**]. Original, plan had been to take patient
home with 24hr care, [**Name (NI) **], PT and if another event were to
reoccur to discuss GOC further. However, at time of discharge
there was no 24hr care solidified in place and safe discharge
plan was made for patient to return to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Can
consider starting advair in outpt setting after prednisone
dosing is complete.
.
#DM2-continued lantus and HISS. Continued asa
.
#asthma/COPD-see above. Duonebs, inhalers,
prednisone/azithromycin. Consider starting advair and
pulmonology consult. On 4L at baseline.
.
#acute renal failure-unclear chronicity, unclear baseline. Pt
can discuss need for ACEI in outpt setting. Range 1.1-1.6 during
admission. FEUREA consistent with prerenal state. Urine culture
neg. CXR with pulm edema. Cr 1.1 on day of discharge. Pt can
continue torsemide per dosing prior to admission.
.
#metabolic alkalosis-likely conpensatory due to chronic resp
acidosis also ?contraction alkalosis due to diuresis. Stable
during admission.
.
#HTN, benign-conitnue clonidine (uptitrated this admission to
TID), amlodipine, metoprolol
.
#mild normocytic anemia-no signs of active bleeding.
Trend/monitor. can be f/u as outpt. HCT on discharge 34.6. Can
discuss need for colonoscopy with PCP.
.
#depression-continued citalopram
.
FEN: heart healthy, DM diet.
.
DVT PPx: heparin SC TID
.
# Code status: DNR, currently okay to intubate, continued to
discuss with patient and her daughter who is her healthcare
proxy during admission, however, pt very conflicted and declined
to discuss this topic any further.
# Disposition: to [**Hospital1 1501**]. Pt can discuss dispo home with 24hr care,
[**Hospital1 **], PT if resources were to become available.
Medications on Admission:
Azithromycin 500mg x1, then 250mg po daily "for URI" started on
[**2192-3-22**]
Duonebs started [**2192-3-22**]
Albuterol nebs q4h prn SOB/wheeze
Lantus 16 units subcutaneous QHS
Novolog 2 units with breakfast, 7 units with lunch, 10 units
with dinner
Bisacodyl 10mg pr daily prn constipation
MOM 30ml po daily prn constipation
Robitussin 10ml po q4h prn cough
Senna 1 tab po bid prn constipation
Fleets enema prn
Clonidine 0.1mgpo [**Hospital1 **]
Natural balance tears 2 drops each eye daily
Torsemide 60mg po daily
Famotidine 20mg po daily
Acetaminophen 1000mg po tid
Combivent 18-103mcg 2 puffs QID
Amlodipine 10mg po daily
Citalopram 40mg po daily
Metoprolol succinate 100mg po daily
MVI 1 tab po daily
DIET: House ground, meals w/ supervision
Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
2. Combivent 18-103 mcg/Actuation Aerosol Sig: [**12-4**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
3. Lantus 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous at bedtime.
4. novolog
2 units with breakfast, 7 units with lunch, 10units with dinner
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-4**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) 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. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-4**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
14. multivitamin Tablet Sig: One (1) Tablet PO qday ().
15. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days.
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
three times a day.
18. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
-acute respiratory failure-from acute diastolic heart failure
and COPD exacerbation.
-hypercarbia
-HTN
-Hyperlipidemia
-Diabetes
-h.o CVA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with shortness of breath. You
initially were intubated and in the ICU because of respiratory
difficulities which were due to heart failure and COPD
exacerbation. You were able to be extubated and transferred to
the regular medical floor where you remained stable on your home
oxygen requirement. Please continue to discuss your goals in
terms of further care and whether you would want to be
reintubated with your family.
.
Medication changes:
1.Please start prednisone for 2 more days
2.Please start azithromycin for 2 more days.
3.start famotidine for stomach protection while on steroids
4.your clonidine was increased to three times a day
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6382**] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 10238**] to schedule a follow up as needed if you are
discharged from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **].
|
[
"584.9",
"443.9",
"276.3",
"250.00",
"493.22",
"401.9",
"518.81",
"428.33",
"438.13",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14409, 14531
|
8235, 12005
|
287, 299
|
14713, 14713
|
3911, 5069
|
15687, 15989
|
2718, 2744
|
12805, 14386
|
14552, 14692
|
12031, 12782
|
14891, 15349
|
2759, 3892
|
1729, 2016
|
15369, 15664
|
244, 249
|
327, 1710
|
5078, 8212
|
14728, 14867
|
2038, 2267
|
2283, 2702
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,421
| 118,817
|
2532
|
Discharge summary
|
report
|
Admission Date: [**2115-4-16**] Discharge Date: [**2115-4-24**]
Date of Birth: [**2062-10-17**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamides) / Seroquel / Heparin Agents
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 449**] is a 52 year-old male with CAD, history of HBV & HCV,
former IVDU presents with chest pain and cough with hemoptysis
since the night prior to admission. He took aspirin and
sublingual nitroglycerin without improvement of his chest pain.
He developed chest pain in the clinical center lobby and so a
code blue was called. He had a pulse and was interactive, so was
taken to the ED.
In the ED, initially patient was tachycardic to 137, BP 142/87,
RR 26, 97% on 4LNC, T 105 Rectal. He got an EKG which showed an
unchaged LBBB and had negative cardiac enzymes. He got a CTA
which showed no PE, but was notable for bibasilar pneumonia. He
was given Vancomycin, Levofloxacin, and Piperacillin-Tazobactam.
He was given Aspirin, Tylenol, and Morphine as well and admitted
to the floor.
Upon arrival to the floor, patient reports 5 days of subjectives
fevers, chills, cough with hemoptysis. CP worsens with deep
cough. He denies melena, BRBPR, hematemasis, diarrhea,
constipation, nausea, vomiting. He reports occasional RUQ pain.
He denies change in color of stool or urine. He denies passing
out recently.
Past Medical History:
- Diabetes mellitus, type 2, diet controlled
- CAD s/p STEMI [**4-/2112**] from LAD occlusion s/p bypass LIMA to LAD
- Hypertension
- Hyperlipidemia
- CVA [**8-/2112**], thalamo-capsular infarct
- Hepatitis B
- Hepatitis C genotype 1, (viral load [**2112**])
- Thrombocytopenia
- GERD
- PTSD
- BPH
- Depression
- Former IVDA, on methadone
- Obstructive sleep apnea
- [**2083**]: L knee gun shot wound; [**2104**]: L knee total arthroplasty;
- [**2105**]: L knee fusion
Social History:
He smokes [**1-26**] PPD. He denies any current or past EtOH. Lives
alone, is on methadone.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother died of lung cancer when he was 3 years
old. Father was murdered.
Physical Exam:
Vitals: T 99.3, HR 101, BP 110/68, RR 24, 95% on 6LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear w/o blood
Neck: supple, JVP not elevated, no LAD
Lungs: rhonchi at bases bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP in RUQ, distended with soft ascites,
bowel sounds present, no rebound tenderness or guarding,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left leg without knee. no palmar erythema, no spiders, no
caput, no asterixis.
Pertinent Results:
[**2115-4-16**]
WBC-14.8*# RBC-3.91*# Hgb-12.5*# Hct-35.0*# MCV-90 Plt Ct-86*
Neuts-88.7* Bands-0 Lymphs-7.9* Monos-2.6 Eos-0.6 Baso-0.2
ALT-24 AST-42* LD(LDH)-359* AlkPhos-79 TotBili-1.2
Lipase-12
[**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-POS
[**2115-4-16**] 06:35PM BLOOD CK-MB-2 cTropnT-<0.01
[**2115-4-17**] 03:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2115-4-17**]
Albumin-3.1* Calcium-7.8* Phos-3.7 Mg-1.6
CXR [**2115-4-16**]: Right middle lobe pneumonia. Ill-defined opacity
in the left lower lobe may reflect additional site of infection,
or aspiration.
CT Chest Abdomen Pelvis [**2115-4-16**]:
1. Multifocal consolidation and pulmonary opacities within the
right middle lobe and both lower lobes, most compatible with
multifocal pneumonia. Lower lobe nodular opacities may represent
a component of aspiration. Interval enlargement of mediastinal
and hilar lymph nodes, likely reactive.
2. Cirrhosis, splenomegaly and perisplenic varices compatible
with portal
hypertension.
ECG [**2115-4-17**]: Sinus rhythm. Leftward axis. Intraventricular
conduction delay. Late R wave progression. ST-T wave
abnormalities. R wave progression may be related to anteroseptal
myocardial infarction or axis and intraventricular conduction
delay. Since the previous tracing of [**2114-9-25**] the rate is slower.
Brief Hospital Course:
Mr. [**Known lastname 449**] is a 52 year old male with CAD, h/o CVA, Hep B & C,
former IVDA presents with pneumonia secondary to aspiration from
paralyzed vocal cords.
#. Pneumonia: Patient presented with fever, leukocytosis, chest
pain, and hemoptysis with labs notable for leukocytosis. CTA
notable for bibasilar infiltrates, likely secondary to
aspiration or CAP. He was initially started on Vancomycin,
Levofloxacin, and Zosyn by the ED, but on arrival to the ED was
narrowed to Levofloxacin. He reported that his sister was
recently diagnosed with TB. He was placed on respiratory
isolation and was ruled out for TB. He had 3 negative smears
for AFB and respiratory isolation was discontinued.
Speech/swallow evaluated the patient and felt that he had
significant aspiration and requested an ENT consult (see below).
He likely had a severe aspiration pneumonia and was
transitioned to Ceftriaxone and Metronidazole. He received a
weeks course of antibiotics and will finish off a 7-day course
of Metronidazole. Pt is on Morphine for chest pain relating to
PNA and cough.
#. Aspiration: Speech and Swallow evaluated the patient and felt
his aspiration was secondary to vocal cord dysfunction (probably
a complication from prior surgery). Speech and Swallow
recommend that all liquids be nectar-thickened. ENT consulted
for medialization of paralyzed vocal cords. The plan will be
for a Video Stroboscopy study to be performed on [**2115-4-29**] and
followed up in [**Hospital **] clinic on [**2115-4-30**]. Other recommendations to
reduce aspiration include raising the head of the bed to at
least 30 degrees and treating GERD with PPI.
#. CAD, s/p MI, s/p CABG: Serial troponins and EKG were
unchanged. Aspirin, Atorvastatin, Toprol, and Lisinopril.
#. Hep B & C Cirrhosis. Evidence of cirrhosis and portal
hypertension on CT scan. This was noted on CT abd/pelvis in
9/[**2114**]. Defer to PCP to refer for hepatology follow up.
#. H/o IVDU: Maintained on methadone 170mg daily.
#. HTN: Toprol XL and lisinopril were continued.
#. Anxiety: Klonipin was continued. Medical management by Dr.
[**Last Name (STitle) 12884**] [**Name (STitle) 12885**], his primary psychiatrist.
#. Depression: Doxepin was continued. Medical management by Dr.
[**Last Name (STitle) 12884**] [**Name (STitle) 12885**], his primary psychiatrist.
#. Diabetes mellitus, type 2, diet controlled
#. DVT prophylaxis: Ambulation
Medications on Admission:
Clonazepam 1 mg TID (Rx [**Last Name (un) 12885**] [**Telephone/Fax (1) 12886**])
Clonidine 0.3 [**Hospital1 **]
Doxepin 300 mg daily
Methadone 170mg 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 4 days: Next dose tonight [**2115-4-24**], then
continue for 3 more days.
Disp:*10 Tablet(s)* Refills:*0*
4. Morphine 15 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours)
as needed for pain: Use minimum needed to control pain. Do not
operate heavy machinery or drive while taking this medication as
it is a sedating med.
Disp:*50 Tablet(s)* Refills:*0*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhalers* Refills:*0*
10. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
Disp:*1 bottle* Refills:*0*
11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for anxiety.
12. Doxepin 150 mg Capsule Sig: Two (2) Capsule PO at bedtime.
13. Methadone 10 mg Tablet Sig: One [**Age over 90 12887**]y (170) mg PO
DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Aspiration pneumonia
- Vocal cord dysfunction
- Chest pain from pneumonia
SECONDARY DIAGNOSES:
- Diabetes mellitus, type 2, diet controlled
- CAD s/p STEMI [**4-/2112**] from LAD occlusion s/p bypass LIMA to LAD
- Hypertension
- Hyperlipidemia
- CVA [**8-/2112**], thalamo-capsular infarct
- Hepatitis B
- Hepatitis C genotype 1, (viral load [**2112**])
- Thrombocytopenia
- GERD
- PTSD
- BPH
- Depression
- Former IVDA, on methadone
- Obstructive sleep apnea
- [**2083**]: L knee gun shot wound; [**2104**]: L knee total arthroplasty;
- [**2105**]: L knee fusion
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted for evaluation of chest pain. You were found
to have a severe pneumonia which is likely caused by chronic
aspiration from vocal cord paralysis. You were treated with
antibiotics and will finish a course of antibiotics.
Your swallow function was evaluated by Speech and Swallow
therapists and you were found to be at risk for aspiration
because of vocal cord dysfunction. You were recommended to
nectar-thicken all liquids to drink to reduce the risk of
aspiration. You should also raise the head of your bed to 30
degrees and have your reflux disease treated with an acid
reducer. A follow up study for your vocal cord dysfunction has
been scheduled for next week with subsequent follow up in
[**Hospital **] Clinic.
See the the medication list for your the complete list of
medications you should be taking.
The following medications should be prescribed by your
psychiatrist:
- Clonazepam
- Doxepin
The following medication should be dispensed by a methadone
clinic:
- Methadone
Followup Instructions:
APPOINTMENT #1:
Department: VOICE SPEECH & SWALLOWING
When: MONDAY [**2115-4-29**] at 12:30 PM
With: [**Doctor Last Name **] WORTH, MS SLP [**Telephone/Fax (1) 3731**]
Building: Span Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
APPOINTMENT #2:
Department: OTOLARYNGOLOGY (ENT)
When: WEDNESDAY [**2115-5-1**] at 11:15 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Must have the study on Monday prior to visit with Dr [**Last Name (STitle) **]
on Wednesday.
APPOINTMENT #3:
Department: PSYCHIATRY
When: [**2115-5-2**] at 1:00 PM
With: Dr. [**Last Name (STitle) 12884**] [**Name (STitle) 12885**]
Phone: [**Telephone/Fax (1) 12888**]
Location:
Personnel Building, G3
[**Hospital **] [**Hospital 4189**] Health Center
[**Last Name (NamePattern1) 12889**], [**Numeric Identifier 7023**]
APPOINTMENT #4:
Department: [**Hospital3 249**]
When: FRIDAY [**2115-5-3**] at 11:30 AM
With: [**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
Please call your insurance company and switch your care to [**Hospital 61**]. Thanks.
APPOINTMENT #5:
Department: [**Hospital3 249**]
When: MONDAY [**2115-5-27**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Dr. [**Last Name (STitle) **] is your new physician in [**Name9 (PRE) 191**] and Dr [**Last Name (STitle) **] works
closely with Dr [**First Name (STitle) 9466**] [**Name (STitle) **], [**First Name3 (LF) **] both will be involved in your
care. For insurance purposes please indicate Dr [**First Name (STitle) **]. as your
Primary Care Physician.
|
[
"401.9",
"250.00",
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"327.23",
"287.5",
"412",
"530.81",
"478.30",
"571.5",
"572.3",
"070.54",
"507.0",
"300.4",
"414.00",
"786.3",
"272.4"
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icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8716, 8791
|
4251, 6683
|
331, 337
|
9421, 9421
|
2884, 4228
|
10599, 12752
|
2114, 2269
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6889, 8693
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8812, 8908
|
6709, 6866
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9568, 10576
|
2284, 2865
|
8929, 9400
|
281, 293
|
365, 1496
|
9436, 9544
|
1518, 1989
|
2005, 2098
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,316
| 127,975
|
36317
|
Discharge summary
|
report
|
Admission Date: [**2176-6-1**] Discharge Date: [**2176-6-3**]
Date of Birth: [**2122-11-7**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
severe headache
Major Surgical or Invasive Procedure:
[**6-1**] cerebral angiogram
History of Present Illness:
Ms. [**Name13 (STitle) **] is a R handed F who presented to OSH with sudden
onset frontal WHOL that woke her up out of her sleep at 5am
yesterday. She did have nausea and a persistent HA all day but
denies any weakness, numbness or other neurologic symptoms. The
headache was not throbbing or positional and different from
other
headaches in the past. Given the persistent HA, she presented to
OSH for evaluation. Morphine provided minimal relief. She was
initially evaluated with a CTH, which was negative. LP was then
performed with 2400 RBC in tube 1 and 1625 RBC in tube 4. Given
her headache and bloody CSF, there was concern for SAH and she
was transfered to [**Hospital1 18**] for further management.
Past Medical History:
ADHD
OSA
Carpal Tunnel Syndrome
Depression
CCY 20y ago
Csection x 2
Social History:
Divorced. Fundraiser for private HS. Social ETOH,
denies IVDU or tobacco.
Family History:
Mother: depression, hypothyroidism
Father: heart disease, ETOH
Ssiter: Hypothyroid
Brother: HTN, obesity, ETOH
Son: ADD
Physical Exam:
At admission:
GCS E:4 V:5 Motor:6
O: T 99.5 HR 105 BP 123/86 RR 16 Sat 96%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 B EOMs intact
Neck: Supple. No nunchal rigidity
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-20**] throughout. No pronator drift
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right + + + + +
Left + + + + +
Toes downgoing bilaterally
Coordination: normal rapid alternating
movements
At discharge:
stable neurologically
Pertinent Results:
[**2176-6-1**] 02:55AM BLOOD WBC-5.7 RBC-4.42 Hgb-13.2 Hct-39.2 MCV-89
MCH-29.8 MCHC-33.6 RDW-12.5 Plt Ct-204
[**2176-6-1**] 02:55AM BLOOD Neuts-82.0* Lymphs-15.5* Monos-1.6*
Eos-0.3 Baso-0.6
[**2176-6-1**] 02:55AM BLOOD PT-11.5 PTT-28.1 INR(PT)-1.1
[**2176-6-1**] 02:55AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-138
K-3.8 Cl-103 HCO3-26 AnGap-13
[**2176-6-1**] 12:54PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2176-6-1**] 12:54PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2176-6-1**] 12:54PM URINE RBC-3* WBC-21* Bacteri-NONE Yeast-NONE
Epi-2 TransE-<1
[**2176-6-1**] 12:54PM URINE Mucous-RARE
Blood cultues x 2 NGTD
Cerebral Angiogram [**2176-6-1**]:
1. 1-1.5 mm tiny protuberance vs infundibulum vs aneurysm is
noted at the
junction of the distal right posterior communicating artery and
right posterior cerebral artery, best seen on the lateral view
of the right internal carotid artery. There are tiny branches
coming off the protuberance.
2. Fetal right posterior cerebral artery noted.
3. Absent/hypoplastic left A1 segment noted.
4. The left vertebral artery arises directly from the aortic
arch, a normal anatomical variant.
Brief Hospital Course:
53F with worse headache of life started the morning of [**5-31**]
presented to OSH with negative head CT but bloody CSF on LP,
concerning for SAH. She was loaded with fosphenytoin in the ED
for seizure prophylaxis and continued on maintenance dosing.
She was admitted under Neurosurgery to the Neuro ICU for close
monitoring with plans for cerebral angiogram the next morning.
Cerebral angiography performed on [**6-1**] demonstrated a small
protuberance versus infundibulum versus aneurysm at the junction
of the distal right posterior communicating artery and posterior
cerebral artery and an absent/hypoplastic left A1 segment.
CT Angiogram demonstrated no obvious aneurysm or vascular
anomaly. Neurology was consulted about headaches and it was
determined that her headaches were tension related. Patient was
started on Fioricet and Flexeril with good response. Now
patient is afebrile and vital signs are stable. She will be
discharge and instructed to follow-up with Neurology for her
tension headaches and will see Dr. [**First Name (STitle) **] in Clinic in 4 weeks
with an MRI/A Brain to follow the infundibulum.
Medications on Admission:
Lisinopril 2.5mg po daily
Discharge Medications:
1. Lisinopril 2.5 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Acetaminophen-Caff-Butalbital [**12-18**] TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg four times
a day Disp #*90 Tablet Refills:*0
4. Cyclobenzaprine 5 mg PO BID:PRN headache
hold for excess sedation or RR < 12
RX *cyclobenzaprine 5 mg twice a day Disp #*60 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *Bactrim DS 800 mg-160 mg twice a day Disp #*6 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Tension headaches
Distal Right PCA infundibulum
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
Followup Instructions:
- Please follow up with your PCP upon discharge from hospital.
- Follow up in 4 weeks with Dr. [**First Name (STitle) **] in clinic with MRI/A
Brain. Call [**Telephone/Fax (1) 1669**] to schedule both the appointment and
the MRI.
- Follow up with Neurology Dr. [**Last Name (STitle) **] to follow your
headaches in [**12-18**] months. Call [**Telephone/Fax (1) 541**] to schedule an
appointment.
- Follow up with pain clinic for trigger point injections for
your tension headaches. Call [**Telephone/Fax (1) 1652**] to schedule an
appointment.
Completed by:[**2176-8-27**]
|
[
"314.01",
"311",
"401.9",
"307.81",
"225.2",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5718, 5724
|
3981, 5108
|
322, 353
|
5840, 5840
|
2731, 3958
|
6228, 6807
|
1291, 1413
|
5184, 5695
|
5745, 5819
|
5134, 5161
|
5991, 6205
|
1428, 1722
|
2689, 2712
|
267, 284
|
381, 1091
|
1959, 2674
|
5855, 5967
|
1113, 1183
|
1199, 1275
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,110
| 180,697
|
52643
|
Discharge summary
|
report
|
Admission Date: [**2181-5-29**] Discharge Date: [**2181-6-7**]
Date of Birth: [**2103-9-13**] Sex: F
Service: SURGERY
Allergies:
Midazolam
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Abdominal Pain - hepatoma, cholelithiasis
Major Surgical or Invasive Procedure:
[**2181-5-29**] - Exploratory laparotomy, cholecystectomy, segment V
resection, intraoperative ultrasound.
[**2181-6-1**] R thoracentesis
History of Present Illness:
Ms. [**Known firstname 4489**] [**Known lastname **] presents from an outside facility with
abdominal pain. She underwent workup that demonstrated a
cholelithiasis and a hepatoma. She has
had known liver disease for some time. She also underwent a
chest CT scan that demonstrated diffuse pulmonary nodules not
felt to be consistent with hepatoma and she is currently being
followed by thoracic surgery.
Past Medical History:
autoimmune hepatitis.
PSH: total abdominal hysterectomy in [**2135**]
appendectomy in [**2124**]
Social History:
Lives alone, will be staying with sister [**Name (NI) **] post surgery
Current tobacco usage
Family History:
N/C
Physical Exam:
Post Op:
VS: 97.5, 66, 125/44, 22, 94%RA
Gen: Sleeping but easily aroused
Card: RRR
Lungs: clear
Abd: Sanguinous stain on RUQ dressing. JP with serosanguinous
fluid
GU: Foley with dark straw colored urine 15-25cc/hr
Extr: No C/C/E, DP's 2+
IV with D5 1/2NS and 20K at 100cc/hr
Pertinent Results:
POD 1 [**2181-5-30**]
WBC-21.2*# RBC-4.79# Hgb-10.0*# Hct-32.6* MCV-68* MCH-20.9*
MCHC-30.7* RDW-14.4 Plt Ct-167
PT-14.4* PTT-33.2 INR(PT)-1.3*
Glucose-112* UreaN-8 Creat-0.6 Na-142 K-3.7 Cl-107 HCO3-25
AnGap-14
ALT-169* AST-217* AlkPhos-61 TotBili-1.6* Lipase-18
Calcium-8.2* Phos-2.0* Mg-1.9
On Discharge [**2181-6-7**]
WBC-10.9 RBC-4.92 Hgb-10.2* Hct-32.6* MCV-66* MCH-20.7*
MCHC-31.2 RDW-17.1* Plt Ct-300
Glucose-114* UreaN-13 Creat-0.8 Na-139 K-3.3 Cl-102 HCO3-24
AnGap-16
ALT-60* AST-39 AlkPhos-109 TotBili-1.3
Brief Hospital Course:
77 y/o female wdmitted from OSH with Dx of Hepatocellular CA,
segment V. On [**2181-5-29**]: Exploratory laparotomy, cholecystectomy,
segment V resection, intraoperative ultrasound with Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. The surgery was unremarkable, extubated in the OR, gall
bladder sent for permanent section.
On POD 1 her O2 Sat was reported as 85%. She had been somnolent
and pain meds were scaled back. She appeared confused and at
that time she was transferred to the SICU. CTA of the chest
ruled out PE. She underwent aggressive chest PT.
On POD 3 ([**6-1**])an Ultrasound-guided diagnostic and therapeutic
right-sided thoracentesis was done for a right pleural effusion.
Specimen was sent with following results: NEGATIVE FOR MALIGNANT
CELLS, fluid contains Mesothelial cells, histiocytes and blood.
She was transferred out of the SICU on POD 5.
She was reported to be having visual hallucinations, a U/S was
sent which indicated a UTI and she was started on Cipro. This
grew out Citrobacter which was sensitive to Cipro, she will
complete the course at home. C diff was negative. She was sent
on a course of Flagyl, although diarrhea was improved.
She was seen by PT several days in a row. She would become tired
and hypotensive. HCTZ was discontinued for now. Every day she
became stronger, and the decision was made to send her to stay
with her sister with [**Name (NI) 269**] and PT. As well she was supplied with a
walker.
By day of discharge she was tolerating diet, walking with
assistive device, JP drain was pulled.
Medications on Admission:
Atenolol 50', HCTZ 25', ASA 81', KCL 20', MVI
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days: for UTI.
Disp:*6 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
3. Hydrochlorothiazide
hold for now. check with PCP or resume if edema
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day:
without iron.
Discharge Disposition:
Home With Service
Facility:
Caregroup [**Name (NI) 269**]
Discharge Diagnosis:
Hepatoma s/p segment V liver resection
Respiratory failure
UTI
Diarrhea
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you experience fever
>101, chills, nausea, vomiting, increasing redness along
incision or drainage, chest pain, shortness of breath or any
other concerns.
Take pain medications only as needed. Do not drive while taking
pain medications. Resume home medications\except hold
hydrochlorothiazide for now
Get out of bed slowly, sit at side of bed and dangle legs. Upon
rising, stay at chair or bed until you are sure you are not
dizzy or really tired. Only walk short distances with the walker
and your sister should be with you when you are moving about the
house.
Check your blood pressure daily or if you are feeling
tired/weak. Report low blood pressure (top [**Location (un) 1131**] less than
100) to Dr [**Last Name (STitle) 9411**] office.
Drink plenty of fluids, keep urine light yellow.
Finish antibiotics for urinary tract infection
Continue to use the incentive spirometer. You should stop
smoking, talk to your PCP for additional help if necessary.
It is okay to shower. Do not tub bathe for 3 weeks. Do not
lift greater than 10 lbs for the next 6 weeks.
Follow up as directed
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD, Phone [**Telephone/Fax (1) 673**] [**6-15**], 3PM
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2181-9-13**] 9:00
Completed by:[**2181-6-7**]
|
[
"571.49",
"155.0",
"571.5",
"599.0",
"518.5",
"E935.2",
"511.9",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"50.22",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
4364, 4424
|
1987, 3558
|
309, 449
|
4540, 4547
|
1446, 1964
|
5755, 6040
|
1129, 1134
|
3654, 4341
|
4445, 4519
|
3584, 3631
|
4571, 5732
|
1149, 1427
|
228, 271
|
477, 882
|
904, 1003
|
1019, 1113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,648
| 102,957
|
41238
|
Discharge summary
|
report
|
Admission Date: [**2108-5-10**] Discharge Date: [**2108-5-28**]
Date of Birth: [**2056-3-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Fatigue and hyponatremia
Major Surgical or Invasive Procedure:
Diagnostic and therapeutic paracentesis ([**2108-5-11**])
PICC ([**2108-5-17**])
EGD with feeding tube placement ([**2108-5-18**])
History of Present Illness:
Mr. [**Known firstname **] [**Last Name (NamePattern1) 7183**] is a 52 year-old gentleman with MVP and MR,
EtOH cirrhosis MELD of 18, CPS of 12 (C) not on the transplant
list (not sober for >3 months), HFE mutation (heterocygus) who
comes with fatigue and hyponatreima. He was in his prior state
of health until [**Month (only) 404**] of this year when he started noticing
URI symptoms. He went fo see a new primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 17528**] (Atrius) after nos seeing a doctor since [**2093**]. He
was diagnosed with influenzae, but was also found to have
abnormal LFTs (AST 124, ALT 99, AP 115, TB 2.5, creat 0.63). He
had edema and ascities. It was thought that he had alcohol
hepatitis given that he had history of drinking >10 beers daily
for ~30 years. He was started on furosemide 20 mg daily and
spironolactone 50 md daily. He lost 12 pounds and his abdomen
and legs significantly improved.
.
He had extensive work up including: Abdominal US in early [**Month (only) **]
of this year demonstrated nodular liver, splenomegaly, ascities
and forward flow in portal vein. He was refered to a Dr. [**First Name11 (Name Pattern1) **]
[**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10113**] (GI) who thought he had Grade I encephalopathy given
his daytime sleepiness and difficulty falling asleep at night.
He reveiewed the labs and recommended starting lactulose. His
labs were significant for: WBC 9.6 with slight increase in PMNs,
but no blasts. PLTs 80, HCT 38, Creatinine of 0.6 on [**2108-4-16**].
AST 102, ALT 81, AP 124, TB 5.2, Direct bili of 1.8, albumin of
2.6, on [**2108-5-8**]. , AFP of 3.64, [**Doctor First Name **] positive (unkown titer),
[**Last Name (un) 15412**] weakly positive, AMA negative, iron 45, TIBC 186, ferritin
860, PT 1.9, ceruloplasmin 49, A1-antitrypsin 283, HAVAb
negative, HBVSAb positive, HCVab negative. Guaiac negative.
.
During the last days his fatigue has been worse. He is requiring
to take naps during the day. He also developped a [**Hospital1 **]-temporal
headache without any other neurologic symptoms and went to see
his PCP. [**Name10 (NameIs) **] had been feeling very dry and was very thirsty. He
had increased his fluid intake having close to 4 L of free water
per day. He had lab work that showed a sodium of 124 5 days ago.
He was immediately called and told to stop his diuretics and
have high-salt diet. His apetite was very poor and therefore he
did not eat much. His renal function was stable and his LFTs
were pretty much unchanged from 1 week prior. His symptoms did
not improve and therefore he was sent here for further work up.
.
Of note, he reports feeling cold, but not chills, rigors. He has
no cough, dysuria, but has been very constipated and has not
moved his bowels in [**4-14**] days, despite the lactulose. He has also
noted a lot of difficulty concentrating at work, needing >15 min
for some calculations that take him [**2-12**] at baseline. He reports
day-night cycle pattern inversion.
.
In our ED his initial VS were: 99.4 116 139/76 20 99%. He was
found to be cachectic, no asterexis. There was no neuro exam
done (other than asterexis), no documentation of his
concentration or formal delirium assesment. His labs were
significant for: WBC 7.7, HCT 31.8, PLT 75, ALT 92, AST 121, AP
108, TB 4.2, Alb 2.6, Lip 146, negative serum tox, PT: 18.9 PTT:
47.2 INR: 1.7, Lactate 1.5, Na 118, K 4.2, Cl 90, CO2 20, BUN
14, Cr 0.9, glu 111. He had no imaging done such as chest x-ray,
no UA or UC and no diagnostic tap. VS prior to transfere: 99,9
86 108/58 16 99%ra. He is admitted for hyponatremia. The liver
fellow was paged and recommended fluid restriction and 500cc of
5% albumin.
Past Medical History:
PAST MEDICAL HISTORY:
* Cirrhosis: with ascities, thought [**3-14**] EtOH, no prior episodes
of encephalopahty, never hospitalized. HFE positive
(heterozygous) with ferritin of ~800, Hep serologies negative,
normal cerulopasmin, A-antitrypsin, etc. AMA weakly positive.
Never scoped, no prior episodes of SBP.
* Mitral valve regurgitation
* MVP
* Venous insufficiency with varicose veins
* HFE mutation (H3D1 copy mutated; C282Y, S65C normal)
* Splenomegaly (portal HTN)
* Thrombocytopenia (most likely [**3-14**] cirrhosis)
* Abnormal LFTs ([**3-14**] cirrhosis)
Social History:
He works for the [**Location (un) 86**] police officer performing accident
investigation. He is married with 3 children. He quit smoking in
[**2091**]. He quit drinking in [**Month (only) 404**] and has history of heavy
drinking, having 10 beers/day for many years and even more at
parties. He denies any illicit drug use.
Family History:
Son had Hodgkin's lymphoma. Father had MI in his 70s. No family
history of premature CAD, stroke, SCD.
Physical Exam:
GENERAL - well-appearing man in NAD, comfortable, appropriate,
jaundiced (skin, mouth, conjuntiva)
HEENT - NC/AT, PERRLA, EOMI, sclerae mildly icteric, MMM, OP
clear, mildly enlarge parotid glands
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
CHEST - no gynecomastia
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses, mild splenomegaly, no
rebound/guarding, spiders present, patient has positive fluid
wave, but not tense abdomen
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no asterexis
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3 (including hosp, floor, exact date,
season), CNs II-XII grossly intact, muscle strength 5/5
throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait; good
concentration, could do months backwards, could not do serial
sevens.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2108-5-10**] 07:05PM BLOOD WBC-7.7 RBC-3.03* Hgb-11.9* Hct-31.8*
MCV-105* MCH-39.1* MCHC-37.2* RDW-16.5* Plt Ct-75*
[**2108-5-28**] 06:00AM BLOOD WBC-4.3 RBC-2.62* Hgb-9.9* Hct-27.8*
MCV-106* MCH-37.8* MCHC-35.6* RDW-20.4* Plt Ct-70*
[**2108-5-10**] 07:05PM BLOOD Neuts-84.2* Lymphs-7.7* Monos-7.3 Eos-0.4
Baso-0.4
[**2108-5-19**] 06:44AM BLOOD Neuts-71.9* Lymphs-18.8 Monos-6.1 Eos-2.7
Baso-0.4
[**2108-5-10**] 09:56PM BLOOD PT-18.9* PTT-47.2* INR(PT)-1.7*
[**2108-5-28**] 06:00AM BLOOD PT-18.0* PTT-49.7* INR(PT)-1.6*
[**2108-5-19**] 06:44AM BLOOD ESR-30*
[**2108-5-24**] 05:46AM BLOOD ESR-43*
[**2108-5-10**] 07:05PM BLOOD Glucose-111* UreaN-14 Creat-0.9 Na-118*
K-4.2 Cl-90* HCO3-20* AnGap-12
[**2108-5-28**] 06:00AM BLOOD Glucose-104* UreaN-22* Creat-0.8 Na-132*
K-3.9 Cl-102 HCO3-22 AnGap-12
[**2108-5-10**] 07:05PM BLOOD ALT-92* AST-121* AlkPhos-108 TotBili-4.2*
[**2108-5-28**] 06:00AM BLOOD ALT-41* AST-60* LD(LDH)-347* AlkPhos-81
TotBili-1.6*
[**2108-5-14**] 05:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2108-5-14**] 05:15PM BLOOD CK-MB-17* MB Indx-12.0* cTropnT-0.12*
[**2108-5-14**] 11:15PM BLOOD CK-MB-18* cTropnT-0.27*
[**2108-5-15**] 04:13AM BLOOD CK-MB-14* MB Indx-11.0* cTropnT-0.29*
[**2108-5-11**] 04:40AM BLOOD VitB12-1743* Folate-10.1
[**2108-5-19**] 06:44AM BLOOD %HbA1c-5.3 eAG-105
[**2108-5-11**] 04:40AM BLOOD Osmolal-262*
[**2108-5-11**] 04:40AM BLOOD TSH-1.3
[**2108-5-10**] 07:14PM BLOOD Lactate-1.5
Brief Hospital Course:
Mr. [**Known lastname 7173**] was a 52 year-old male with MVP and MR, EtOH
cirrhosis (admit MELD of 18) not on the transplant list (not
sober for >3 months) who presents with fatigue and hyponatremia
found to have spontaneous bacterial peritonitis and native valve
endocarditis with high-grade S. viridans bacteremia. Hospital
course complicated by embolic phenomena from endocarditis with
asymptomatic inferior STEMI from vegetation in RCA terrority,
kidney/splenic infarcts in addition to non-convulsive seizures
from encephalopathy, melena from portal gastropathy.
#. Cirrhosis with Grade I encephalopathy and spontaneous
bacterial peritonitis:
Patient has alcoholic cirrhosis with MELD of 18 and Child-[**Doctor Last Name 14477**]
score of 12 (Class C). He had not seen a doctor since [**2093**] and
reported to a PCP in [**Name9 (PRE) 404**] for influenza and found to have
incidentally elevated liver function tests. He has been sober
since [**Month (only) 404**] and seems to have good social support although it
is uncertain if he had drank in the past few months given his
AST/ALT ratio. Outpatient GI work-up has included heterozygous
for HFE (H3D1) with ferritin of 830. He has a borderline [**Doctor First Name **] and
negative antibodies otherwise. AFP is normal. US not suggestive
of PVT. On admission, his transaminases appeared at baseline;
however, he total biliruin and INR were elevated. He also
displayed grade I encephalopathy with inversion of day-night
cycle and difficulty concentrating as well as fatigue. He was
placed on lactulose and rifaximin with clearing of
encephalopathy. Etiology of decompensated liver disease is
infection as below. EGD was performed for feeding tube placement
showing 3 cords of grade II varices. Diagnostic and therapuetic
paracentesis was performed revealing neutrocytic ascites from
portal hypertension (WBC 825, PMNs 313, SAAG > 1.1, low protein)
with a 5-day course of SBP received in addition to albumin on
day # 1 and # 3. He will need to start SBP prophylaxis
(ciprofloxacin 250 mg PO qD) after finishing his below
antibiotic course. He was discharged on spironolactone 50 mg PO
qD, nadolol, lactulose, and rifaximin.
.
# Native valve endocarditis with high-grade S. viridans
bacteremia:
Patient met Duke criteria based on ECHO, sustained bacteremia,
predisposition with MVP, fever, and embolic phenomena with
STEMI, conjunctival hemorrhages, and splenic and renal infarcts.
He was initially started on ceftriaxone for SBP, flagyl, and
vancomycin given high-grade gram positive bacteremia. He
completed a 5-day course of ceftriaxone for SBP. He antibiotics
were narrowed to ceftriaxone ([**2108-5-11**] - [**2108-5-23**]) with
vancomycin and cefepime briefly re-started ([**2108-5-23**] - [**2108-5-25**])
in setting of fever from embolic phenomena. Etiology of
recurrent fever likely embolism and infarction. No evidence of
nosocomial or other concurrent infections such as PICC line
infection. Initial ECHO on [**2108-5-14**] suggestive of likely mitral
valve vegetation/endocarditis. Repeat ECHO in setting of fever
on [**2108-5-24**] showed similar findings and was read perhaps
myxomatous mitral valve leafts with bileafet prolapse, which has
become partially flail. TEE was not pursued given risk with
varices. Initial ESR/CRP was 30 and 10.4 on [**2108-5-19**] with repeat
on [**5-24**] 43 and 12.7, respectively. Patient had multiple embolic
phenomena including inferior STEMI and renal/spleen infarcts
from emboli. Cardiac surgery evaluated, but given advanced liver
disease, the risk of operation were too high to be considered a
surgical candidate for AVR.
The plan will be to continue ceftriaxone for 4 week course with
ID follow-up before end date intended to be [**2108-6-9**] for 4 week
total course. ESR/CRP in addition to safety labs will be drawn
and if continued to be elevated, the course will need to be
extended to 6 weeks or longer. He will also follow-up with
atrius cardiology in [**5-16**] weeks with repeat ECHO. Of note, serial
ECG were obtained with non-specific changes and PR interval
remained within normal limits with very mild intraventricular
conduction delay.
Of note, if he is re-admitted with fevers, his PICC line should
be discontinued. He should be re-started on cefepime and
vancomycin with imaging to look for abscess given embolic
phenomena. Medications such as meropenem and flagyl should be
avoided given prior seizures. If he would continue to spike,
cefepime should be broadened to zosyn or tigecycline.
# Melena secondary to portal gastropathy:
Patient has had dark stool likely from portal gastropathy in
setting of feeding tube placement resulting in transient
transfusion-depedent anemia. Stools returned to [**Location 213**] color
after initiation of 5-day course of octreotide ([**5-21**] - [**5-25**])
with Hct stable at discharge.
He was continued on vitamin K 5 mg PO daily for coagulopathy and
pantoprazole 40 mg PO q 12.
# Inferior STEMI:
Patient had ECG on [**2108-5-14**] suggesting inferior STEMI likely
from embolic phenomenon with repeat ECG showing resolved
changes. Patient was asymptomatic during event, which likely was
very transient with no subsequent wall motion abnormalities
noted on repeat ECHO. Troponin peaked at 0.29 and CK-MB at 18,
which trended down. Atrius cardiology was consulted, and the
patient was deemed to not be a candidate for anti-coagulation
secondary to coagulopathy of liver disease and thrombocytopenia.
He was initially placed on metoprolol and transitioned to a
non-selective beta blocker (nadolol) after varices were noted on
EGD. His Hgb was kept above 10. As above, serial ECG remained
similar to prior.
He will follow-up with cardiology as above.
# Non-convulsive seizure
Code stroke called on [**2108-5-15**] after patient averbal, clenching
teeth, and had left facial twitching and altered mental status.
CT head with no acute intracranial pathology. Neurology
impression was non-convulsive seizure in setting of
encephalopathy. There was no evidence to suggest alcohol
withdrawal. He was placed on a brief course of keppra with
lactulose dosing enforced. He subsequently had no seizures after
keppra was tapered off.
# Nutrition
Physical exam notable for sarcopenia and wasting. A feeding tube
was placed and the patient was trasiently receiving feeding
formula in addition to oral feeds. On the day of discharge, he
was eating well and no longer required tube feeds. He was
strongly advised to continue to consume a 2800 calorie diet.
.
# Transitions of care
- Safety and inflammatory marker labs will be faxed to Dr. [**First Name (STitle) 1075**]
([**Hospital1 18**] Infectious Diseases) at [**Telephone/Fax (1) 2258**]. If inflammatory
markers continue to elevate, antibiotic course should be
extended to 6 weeks
- continue ceftriaxone until [**2108-6-9**] with ID follow-up before
course ends
- Follow-up with cardiology with repeat ECHO
- Patient needs prophylaxis with ampicillin 2 grams by mouth
30-60 minutes before dental procedures. Before any
interventions, the need for antibiotic prophylaxis must be
reviewed.
- Patient needs nutrition follow-up
- Patient may benefit from Alcoholic Anonymous referral to
maintain abstinence
-outpatient vaccination for Hepatitis A and B
- consideration for transplant evaluation if maintains alcohol
abstinence
Medications on Admission:
Lasix 20 mg Daily (stopped 5 days ago)
Spironolactone 50 mg Daily (stopped 5 days ago)
Lactulose titrate to [**3-15**] bowel movements per day
Discharge Medications:
1. Outpatient Lab Work
[**2108-5-31**]: Chem 10, Liver function tests (AST, ALT, Tbili, LDH,
ALP), CBC with differential, ESR/CRP
[**2108-6-5**]: Chem 10, Liver function tests (AST, ALT, Tbili, LDH,
ALP), CBC with differential, ESR/CRP
Fax results to Dr. [**First Name (STitle) 1075**] ([**Hospital1 18**] Infectious Disease) [**Telephone/Fax (1) 1419**]
2. ampicillin 500 mg Capsule Sig: Four (4) Capsule PO before
dental procedures: Take 30-60 min before procedure for any
dental procedure in future.
Disp:*4 Capsule(s)* Refills:*2*
3. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: Start this antibiotic on the morning following completion
of your ceftriaxone course.
Disp:*30 Tablet(s)* Refills:*2*
4. Carnation Instant Breakfast
Four times daily
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
Disp:*3600 ML(s)* Refills:*2*
6. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. ceftriaxone 2 gram Recon Soln Sig: One (1) Intravenous once
a day for 11 days: Date of completion [**2108-6-8**] unless otherwise
directed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] [**Telephone/Fax (1) 11486**] (has appointment
[**2108-6-8**]).
Disp:*11 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Health Services
Discharge Diagnosis:
Primary diagnosis: spontaneous bacterial peritonitis, native
valve endocarditis with embolic phenomena, Streptococcus
viridans bacteremia, ST-elevation myocardial infarction,
non-convulsive seizure, melena secondary to portal gastropathy,
alcoholic cirrhosis, esophageal varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for fatigue and low sodium in your blood. You
were found to have an infection in your belly (spontaneous
bacterial peritonitis) in addition to an infection of your heart
valve called endocarditis. You will be treated with an
antibiotic to clear your infection. It is important to follow-up
with Dr. [**First Name (STitle) 1075**] before your antibiotic course ends to determine if
you need a longer course of antibiotics.
You also had a small heart attack from your heart infection and
will need to follow-up with a cardiologist as below. You were
also noted to have dark stools, which is from bleeding in your
stomach. If you notice additional episodes of dark stools,
fevers, or other symptoms concerning to you, please call your
primary care doctor immediately or report to the nearest
emergency room.
You must STOP drinking alcohol completely. Drinking any more
alcohol will result in further damage to your liver and increase
your chance of death and other medical problems. [**Name (NI) **] line is
that you ABSOLUTELY CANNOT DRINK ALCOHOL ANYMORE.
Nutrition is very important to survival. Liver disease and
infection make your body need much more calories than the normal
person. It is important maintain a calorie count at home - your
goal is around 2800 calories per day, which can be achieved by
eating regular food along with supplements such as at least four
Carnation Instant Breakfast supplements a day. If you are not
able to maintain your nutrition, please call the liver center
for further evaluation.
The following changes have been made to your home medications:
1. START TAKING ceftriaxone 2 g IV daily
2. START TAKING lactulose 30 mg by mouth four times daily for a
clear mind. You may adjust the dose so that you are having [**4-13**]
bowel movements daily. You need to take AT LEAST one to two
doses of lactulose a day. Although having diarrhea is
unpleasant, the lactulose will prevent confusion from toxins in
your body that your liver is not clearing.
3. START TAKING nadolol 20 mg by mouth daily. This medication is
to minimize the risk of bleeding from enlarged veins in your
esophagus.
4. START TAKING pantoprazole 40 mg by mouth twice daily. This
medication is to prevent further bleeding from inflammation in
your stomach caused by your liver disease.
5. START TAKING rifaximin 550 mg by mouth twice daily. This
medication is also to prevent confusion.
6. START TAKING folic acid 1 mg by mouth daily. This is a
nutritional supplement.
7. START TAKING thiamine 100 mg by mouth daily. This is a
nutritional supplement.
8. WHEN CEFTRIAXONE COURSE IS COMPLETE, START TAKING
ciprfloxacin 250 mg by mouth daily. This medication will prevent
another infection in your belly.
9. TAKE AS NEEDED ampicillin 30-60 minutes before any dental
procedure. *** Please talk to your primary care doctor before
any dental or other surgical procedures. You will need to take
ampicillin 2 grams by mouth 30-60 minute before any dental
procedure. You will likely need antibiotics before any other
procedures as well. If you do not take antibiotics as prescribed
for your heart valve condition, your valve may become infected
again resulting in severe morbidity and death.***
10. STOP TAKING furosemide unless/until directed to resume by
your physician.
Please take your medications as prescribed. Please follow up
with your physicians as recommended below.
Followup Instructions:
1. PRIMARY CARE
Name: [**Last Name (LF) 17528**],[**First Name3 (LF) 17529**]
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**]
Phone: [**Telephone/Fax (1) 17530**]
Fax: [**Telephone/Fax (1) 6808**]
- Please call to schedule an appointment with your primary care
doctor to discuss this admission. You should review your
medications with your doctor and plan for any necessary
referrals to cardiology, infectious disease, and hepatology
(liver clinic) as below.
2. INFECTIOUS DISEASE
Department: INFECTIOUS DISEASE
When: FRIDAY [**2108-6-8**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
3. CARDIOLOGY
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **]
Phone: [**Telephone/Fax (1) 2258**]
- Please set up an appointment for 4-6 weeks. You will require a
follow up echocardiogram at this visit.
4. LIVER
Description: Liver Center
Department: Medicine
Location: W/LMOB-8E
Organization: [**Hospital1 18**]
Phone: ([**Telephone/Fax (1) 1582**]
- Please call to schedule follow up with a hepatologist for [**3-15**]
weeks or as available. You may ask to see Dr. [**Last Name (STitle) 497**] who saw you
in the hospital; if he has no availability Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) 679**]
or Dr. [**Last Name (STitle) **] would also be appropriate.
|
[
"567.23",
"572.3",
"444.89",
"287.49",
"276.2",
"572.2",
"789.59",
"410.41",
"421.0",
"578.1",
"571.2",
"537.89",
"593.81",
"303.93",
"041.09",
"286.9",
"276.1",
"780.39",
"427.1",
"790.7",
"456.21",
"112.0",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"54.91",
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17294, 17369
|
7882, 15217
|
328, 461
|
17692, 17692
|
6433, 7859
|
21255, 22828
|
5160, 5264
|
15411, 17271
|
17390, 17390
|
15243, 15388
|
17843, 19429
|
5279, 6414
|
19447, 21232
|
264, 290
|
489, 4215
|
17409, 17671
|
17707, 17819
|
4259, 4803
|
4819, 5144
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,874
| 197,840
|
44926
|
Discharge summary
|
report
|
Admission Date: [**2152-3-16**] Discharge Date: [**2152-4-22**]
Date of Birth: [**2085-5-14**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 69838**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 yo F transferred from [**Location (un) 620**] for likely COPD exacerbation.
Reports 4 days of increased dyspnea, mild cough productive of a
small amount of yellow sputum (new for her), no fevers. She was
down to 10 mg of prednisone on a steroid taper and her PCP had
increased the dosage to 15 mg a couple of days ago [**3-4**] her
increased SOB. Denies CP, palp, N/V. No sick contacts. + chills.
No myalgias or HA. + back pain that started yesterday and is
constant. She has baseline low-back pain for which she takes
dilaudid and oxycodone. Currently cannot walk 3 feet without
getting SOB. + PND and gets paroxysmal SOB even when sitting. On
2L O2 at home and had been using nebs more frequently than
prescribed over the past day. Has been in and out of the
hospital frequently over the past year (including a stay at
[**Hospital3 **]) and usually receives her care at [**Hospital1 2025**]. She was
last hospitalized at [**Hospital1 2025**] through [**2-28**]. She was supposed to
be set up with BIPAP at home but this was never completed.
.
At [**Location (un) 620**], 90% on 2L - given solumedrol 125 mg IV, azithro 500
mg IV, nebs, CE neg and sent here as no beds. En route by report
high 90s on 2L.
.
In [**Hospital1 18**] ED, Vitals 99.2, 86, 130/67, 16, 98% on 2L. Became
sleepy in the ED with hypercarbia, likely [**3-4**] to breath so BIPAP was started and is now much more awake
and less tachypneic.
Past Medical History:
Severe Emphysema/COPD: On 2L home O2 but has trouble completing
her ADLs [**3-4**] dyspnea. [**11-4**] Nasal Bipap on 2L PFTs from [**Hospital1 2025**] show
FEV1 14% of predicted
h/o severe asthma as a child
h/o asian flu as a child and was very ill at the time
HTN
GERD
T6 Fx - on dilaudid and oxycodone chronically
s/p INH treatment for + PPD
Vocal cord node removal
s/p tonsillectomy and adenoidectomy
Osteopenia
Social History:
+ smoking (54 pack years, quit at 61), no alcohol, no drug use.
Lives alone, although in the recent past her son (who has
[**Name (NI) 96091**] syndrome) lived with her to help her [**3-4**] frequent
hospitalizations. She walks with a rollator. She uses Meals on
Wheels. + trouble with ADLs.
Family History:
NC
Physical Exam:
VS: Temp: 97.2 BP: 129/82 HR: 101 RR: 21 O2sat 93% on 2L NC
GEN: apppears dyspneic, more comfortable when lying on her R
side, desats when lying on her back
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, JVD to 12
cm at 60 degrees, no carotid bruits
RESP: diffuse expiratory wheeze anteriorly, decreased breath
sounds posteriorly
CV: tachy, reg, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, 2+ radial pulses, trace dp pulses
SKIN: dry, no rashes/no jaundice
.
Pertinent Results:
[**2152-3-16**] CXR:
1. Unusual appearance of right hilum as described, concerning
for potential [**Location (un) 21851**]. Contrast-enhanced chest CT is
suggested to better assess this region.
2. Emphysema, most severe at the lung bases, raising concern for
possible alpha-1-antitrypsin deficiency.
[**2152-3-16**] CTA Chest:
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Small pericardial effusion.
3. Severe panlobular emphysema, markedly involving the lower
lobes. This raises the possibility of alpha-1 antitrypsin
deficiency in the appropriate clinical setting.
4. Atelectasis of the medial portion of the right middle lobe.
No definite obstructing mass is visualized by CT.
5. Bilateral lung nodules, for which six-month CT followup is
recommended.
6. Mild coronary artery calcifications.
[**2152-3-16**] TTE: The left atrium is normal in size. The estimated
right atrial pressure is 0-10mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF 80%). There is a moderate resting left
ventricular outflow tract obstruction. There is no ventricular
septal defect. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is systolic anterior motion of the mitral
valve leaflets. The pulmonary artery systolic pressure could not
be determined. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
IMPRESSION: small, hypertrophic, hyperdynamic left ventricle
with moderate resting outflow tact gradient
Labs:
[**2152-3-15**] 09:30PM BLOOD WBC-12.8* RBC-3.92* Hgb-11.6* Hct-37.5
MCV-96 MCH-29.7 MCHC-31.0 RDW-13.8 Plt Ct-378
[**2152-3-15**] 09:30PM BLOOD Neuts-96* Bands-2 Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2152-3-16**] 04:36AM BLOOD PT-11.9 PTT-24.3 INR(PT)-1.0
[**2152-3-16**] 04:36AM BLOOD Glucose-135* UreaN-22* Creat-0.9 Na-141
K-5.2* Cl-102 HCO3-33* AnGap-11
[**2152-3-15**] 09:30PM BLOOD CK(CPK)-88
[**2152-3-15**] 09:30PM BLOOD cTropnT-<0.01
[**2152-3-15**] 09:30PM BLOOD Calcium-9.7 Phos-4.4 Mg-2.0
[**2152-3-15**] 11:51PM BLOOD Type-ART Rates-/26 FiO2-50 pO2-103
pCO2-85* pH-7.27* calTCO2-41* Base XS-8 Intubat-NOT INTUBA
[**2152-3-16**] 05:41PM BLOOD Glucose-180* Lactate-2.1* Na-138 K-4.7
Cl-95*
[**2152-3-16**] 05:41PM BLOOD freeCa-1.23
Brief Hospital Course:
66 year old female with severe COPD admitted to [**Hospital1 18**] on [**2152-3-16**]
for COPD exacerbation. She was initially admitted to the MICU
and treated with BiPAP, steroids, nebs and azithromycin. CTA
negative for PE and TTE demonstrated hyperdynamic EF and
moderate LVOT obstruction. She did well and was called out to
the floor where she continued a prednisone taper and standing
nebs. Her course was complicated by significant anxiety which
limited her compliance with BiPAP and other therapies.
.
On [**2152-3-20**] the patient had a trigger for hypoxia (86% on 2L) and
ABG demonstrated 7.29/79/81. She had refused BiPAP for the
previous 2 nights and had a temp to 102. She was transferred
back to MICU and treated with antibiotics X 2 days. She was
monitored in the MICU and used BiPAP nightly and continued on
prednisone taper (thought to be contributing to her anxiety) and
nebs. The patient was taken off antibiotics (cefepime,cipro,
vanc) after a few days. She was transferred back to the floor
and triggered for hypotension (64/25) on [**3-27**] which was
responsive to fluid. She came off prednisone on [**2152-3-28**]. The
patient had been doing well from a COPD stand point over the
past several days, though continued to be noncompliant with
BiPAP at night. The team was treated her anxiety with standing
klonopin with good effect, seroquel, buspar and escalating doses
of dilaudid and oxycodone for her back pain. The day of
transfer the patient had a temp to 102.2 and complained of
nausea. She had been constipated for several days but refused
bowel regimen.
.
She was transferred back to the MICU on [**2152-4-2**] after being found
to be somnolent on the floor. ABG 7.26/112/72/53. She was
started on BiPAP on the floor with some improvement in her
mental status and was transferred to the ICU for further
monitoring. The patient also had a brief period of hypotension,
BP 78/D but improved with a small bolus to 110/70 prior to
transfer to the ICU. It was throught that her hypercarbia was a
combination of an underlying infection and increasing sedating
medications. She was started on a 5 day course of levofloxacin,
as source of fever was not found (neg CXR, blood cultures, urine
culture). She had an abdominal CT to evaluate for
intra-abdominal process, and this was negative for abscess, but
did demonstrate an abnormality in the bladder. (see below). She
was managed with standing nebs and advair was restarted. It was
not felt that she was having a new flare of her COPD, as she had
baseline shortness of breath, no new cough and no new wheezing.
She received two doses of IV Solumedrol around the time of
transfer, but this was discontinued. She also intermittently
was placed on her home nasal bipap which she was able to
tolerate.
.
She was called back to the floor where she remained stable from
a respiratory standpoint for the rest of her hospital stay with
02 sats 90-92% on 1-2L NC.
.
#. COPD exacerbation: Completed steroids and antibiotics, is
back to baseline.
- Keep sats between 88-92% as she is a chronic retainer, and
loses her respiratory drive when she is higher
- Continue nebs
- aggressively control anxiety
-On 2L 02 and bipap at home, appears to be at her baseline
interms of 02 requirement. Not tolerating Bipap
-Completed levaquin on [**4-9**]
.
# Anxiety: Seen by psych during hospitalization for assitance
with controlling crippling anxiety affecting respiratory status.
Has been well controlled since last MICU callout.
-Continue standing buspar, QHS seroquel, with PRN seroquel [**Hospital1 **].
-off steroids
-pt expressed more comfort with her home meds, have changed
lorazepam back to clonazepam and have added back on remeron per
her PCP.
.
# Hypertension:
-Continue losartan and amlodipine with parameters.
.
# Chronic back pain: percocet prn for now, all opiates held for
patient's most recent transfer back to the MICU for hypercarbic
respiratory failure. Added percocet prn, pain well controlled
currently.
-Added ATC tylenol.
-NSAID for symbiosis
.
# Osteopenia: Calcium, Vit D
.
#Eyes watering. No objective signs to support this complaint.
Unclear precipitant. Pt on multiple anti-cholinergics which
might cause dry eyes, perhaps decreased need for atrovent has
resulted in subjective increased eye moisture. Also possible
allergies although denies eye itching. Ophthalmology was
consulted. No glaucoma, will need outpatient ophtho appointment.
Artificial ointment and tears prn. Per pt her symptoms have
improved.
.
# Dispo: Pt seen initially by palliative care in ICU, quite
upset by this stating that she doesn't want to hear negative
things, only hopeful things. Will request SW consult for
support. Defer end of life discussions for now. Pt rescreened
by PT who continue to recommend rehab, per discussion with case
management [**Hospital1 **] has been requesting need for bed close to
nursing station. Pt has been hospitalized in bed far from
nursing station in hospital, has been quite calm with anxiety
controlled since coming out of unit a week ago, does not warrant
closer observation.
.
# Code Status: Full but would not want trach and would not want
to be kept on ventilator if she could not be weaned off
(confirmed w/ pt [**3-20**])
.
# Communication HCP [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 96092**]
.
On day of discharge pt was afebrile with stable vital signs. PT
had evaluated the patient and recommended further rehab, she
will be discharged to a rehab facility with outpatient follow
up.
Medications on Admission:
albuterol nebs
Atrovent nebs
Protonix
Buspar 15 mg tid
Norvasc 5 mg daily
Cozaar 50 mg [**Hospital1 **]
Klonopin 0.5 mg tid
ASA 325
Prednisone 15 mg daily
Calcium TID
Vitamin D TID
MVI
Oxycodone 5 mg [**Hospital1 **] prn
Dilaudid 4 mg po qid prn
Bactrim for PCP prophylaxis
[**Name9 (PRE) **] 1 inh daily
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] health center
Discharge Diagnosis:
Primary diagnosis
COPD exacerbation
Secondary diagnosis:
Hypertension
Anxiety
Gastroesophageal reflux
Osteopenia
T6 compression fracture with chronic pain
Discharge Condition:
Fair, 02 requirement at baseline.
Discharge Instructions:
You were admitted with an exacerbation of your COPD. You were
treated with steroids and antibiotics as well as inhalers and
supplemental oxygen.
Important follow up with your primary care physician: [**Name10 (NameIs) 2172**] CT
scan showed a right middle lobe atelectasis that may represent a
mass in the lung, although this was not seen on the CT scan.
Your doctor should follow this with more definitive studies to
evaluate this finding.
Please attend all scheduled follow up appointments. Please take
all medications as prescribed.
Call your doctor or return to the emergency department if you
develop intractable shortness of breath or for any other
concerning symptoms
Followup Instructions:
You have an appointment scheduled with your primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] on [**2152-5-4**] at 12:40pm, please contact
her office if you need to reschedule: [**Telephone/Fax (1) 96093**].
You have an appointment with your pulmonologist Dr. [**First Name4 (NamePattern1) 429**]
[**Last Name (NamePattern1) **] for follow up on [**2152-5-1**] at 10:30am. Please contact
his office if you need to reschedule: ([**Telephone/Fax (1) 96094**]
Please contact the [**Name2 (NI) 464**] department for follow up in
clinic after hospital discharge, ([**Telephone/Fax (1) 5120**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 69841**]
Completed by:[**2152-4-22**]
|
[
"401.9",
"518.84",
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"300.00",
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"530.81",
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"733.90",
"790.29",
"458.9",
"V15.81",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11531, 11592
|
5644, 11175
|
280, 286
|
11791, 11827
|
3105, 5621
|
12553, 13373
|
2498, 2502
|
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|
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11851, 12530
|
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|
237, 242
|
315, 1732
|
11670, 11770
|
1754, 2173
|
2189, 2482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,620
| 126,802
|
25519
|
Discharge summary
|
report
|
Admission Date: [**2158-6-21**] Discharge Date: [**2158-6-24**]
Date of Birth: [**2110-6-3**] Sex: M
Service: MEDICINE
Allergies:
Nickel
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Abdominal Pain
Reason for MICU Admission: Hyperkalemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 63744**] is a 48 year old man with a history of end stage
renal disease (on HD), hypertension, hypercholesterolemia and
substance abuse who presents from home with adominal pain.
He was in his usual state of health until 2 weeks ago when he
developed nausea, vomiting, and diffuse crampy abdominal pain.
He had difficulty taking POs without vomiting, grew
progressively fatigued, and did not go to his scheduled
dialysis. After a few days, he developed diarrhea and difficulty
breathing. As his symptoms worsened, he decided to come to the
emergency room on [**2158-6-21**].
.
He received dialysis at Frecenius dialysis [**Location (un) 6409**]
(Tuesday, Thursday, Saturday). Last dialysis was 2 weeks ago. He
states he felt unwell first and then was unable to go to
dialysis due to his illness.
.
In the ED, initial vitals were: T 97.3, BP 149/103, P 80, R 19,
O2 sat 100% on RA. Labs revealed K 6.9, Cr 22.2. Patient was
given kayexylate 30 mg, calcium gluconate 10 mg, 1 amp sodium
bicarbonate, 10 units IV insulin and 1 amp D50 IV x 2. He had a
CT abdomen without contrast that was negative for acute process.
CXR did not show significant volume overload.
.
He was admitted initially to the ICU for monitoring overnight.
His potassium improved with medical management prior to HD. He
underwent dialysis the following morning (hospital day 1) and
was tranferred to the floor at night in stable condition. On
hospital day 2, he underwent dialysis again.
.
His abdominal pain, n/v have resolved and he is tolerating POs.
His diarrhea has resolved and he had a well-formed bowel
movement yesterday.
.
Past Medical History:
- ESRD: secondary to hypertension on HD x 10 years with LUE
fistula. Frecenius dialysis [**Location (un) 6409**] (Tuesday, Thursday,
Saturday). Peripheral neuropathy (pain in hands, feet, shooting
down lateral L leg) started 1 year ago.
- hypertension
- hypercholesterolemia
- Gastroesophageal reflux disease: asymptomatic on PPIs
- migraine headaches: 3-4 per year
- polysubstance abuse including cocaine, ethanol, marijuana
- history of depression: says he no longer feels depressed; not
on antidepressants; previously prescribed prozac
Social History:
Currently living alone in an apartment [**Location (un) 6409**]. Divorsed
4-5 years ago. His sister and aunt live nearby. He smokes 1 pack
per week. He hasn't had alcohol or cocaine in 1 year. Pt reports
previous alcohol, cocaine use has caused him to miss dialysis.
Family History:
Mother has end stage renal disease, diabetes and RA. Cousins
also have renal disease. Grandparents have hypertension.
Physical Exam:
Vitals: T: 97.2 BP: 154/98 P: 22 R:18 O2: 99% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, unable to appreciate JVP, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly, mild tenderness in
bilateral lower quadrants
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis.
Trace edema in the feet bilaterally.
Neurologic: Faint asterixis
Pertinent Results:
[**2158-6-21**] 02:00PM BLOOD WBC-5.7 RBC-3.83* Hgb-11.6* Hct-35.6*
MCV-93 MCH-30.2 MCHC-32.4 RDW-15.8* Plt Ct-180
[**2158-6-21**] 02:00PM BLOOD Neuts-46.8* Lymphs-40.6 Monos-7.9
Eos-4.3* Baso-0.4
[**2158-6-21**] 02:00PM BLOOD PT-12.0 PTT-26.0 INR(PT)-1.0
[**2158-6-21**] 02:00PM BLOOD Glucose-61* UreaN-111* Creat-22.2*#
Na-139 K-6.9* Cl-90* HCO3-25 AnGap-31*
[**2158-6-21**] 11:25PM BLOOD Calcium-9.2 Phos-6.8* Mg-2.3
[**2158-6-21**] 02:00PM BLOOD ALT-15 AST-12 Amylase-417* TotBili-0.2
[**2158-6-21**] 02:00PM BLOOD Lipase-397*
[**2158-6-21**] 06:17PM BLOOD CK(CPK)-69 CK-MB-NotDone
cTropnT(2pm)-0.05*
[**2158-6-21**] 11:25PM BLOOD CK(CPK)-66 CK-MB-NotDone cTropnT-0.04*
[**2158-6-22**] 04:25AM BLOOD CK(CPK)-68 CK-MB-NotDone cTropnT-0.05*
[**2158-6-21**] 06:17PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2158-6-24**] 07:20AM BLOOD WBC-5.9 RBC-3.61* Hgb-11.3* Hct-34.9*
MCV-96 MCH-31.2 MCHC-32.3 RDW-15.5 Plt Ct-200
[**2158-6-24**] 02:20PM BLOOD Glucose-122* UreaN-22* Creat-7.8*# Na-140
K-4.8 Cl-100 HCO3-28 AnGap-17
.
[**2158-6-21**] CXR: Low lung volumes. No acute cardiopulmonary
process.
.
[**2158-6-21**] CT abd/pelvis w/o contrast:
1. No acute findings in abdomen and pelvis.
2. Hypodense lesion in the abdominal to liver, incompletely
evaluated due to
lack of IV contrast.
3. Hypodense renal lesions, not fully characterized.
4. Bony changes compatible with renal osteodystrophy.
Brief Hospital Course:
48 year old male with a history of end stage renal disease,
hypertension, hypercholesterolemia and substance abuse who
presents from home with fatigue, nausea, dyspnea and abdominal
pain after missing dialysis for two weeks.
1) Uremia/End Stage Renal Disease
It was suspected that the patient's symptoms were in large part
secondary to missing dialysis for two weeks. He may have
initially had a viral gastroenteritis (see below) that
preciptated these events; the patient says he intially felt ill
and as a result was unable to go to dialysis. Of primary concern
in the emergency room was his hyperkalemia with peaked T waves
on EKG. His potassium was initially 6.9. He was not
encephalopathic. He was treated with kayexylate and transferred
to the ICU for hemodialysis. He was transferred to the floor and
continued hemodialysis, for a total of 3 sessions over 3 days.
His potassium decreased to 4.8. His symptoms described below
resolved with dialysis. He was also treated with sevelamer and
calcium acetate. At discharge, he planned to attend his
regularly scheduled dialysis.
2) Chest Pain
The patient intially reported vague diffuse chest pain with mild
dyspnea. He was ruled out for MI by cardiac enzymes and there
were no ischemic changes on EKG. There were no signs of
pericarditis on EKG. His chest pain resolved with hemodyalsis.
3) Abdominal Pain/Pancreatitis:
The patient reported abdominal pain and diarrhea with chills and
cough x 2 weeks. The patient had mild diffuse bilateral
mid-epigastric to lower abdominal pain without rebounding or
guarding. Patient was afebrile and without leukocytosis. Workup
in the emergency room was negative with the exception of mildly
elevated pancreatic enzymes. He may have had viral
gastroenteritis exacerbated by and leading to missing dialysis.
CT abdomen/pelvis showed no acute findings. His abdominal pain
resolved with hemodialysis.
4) Diarrhea
Patient reports having diarrhea for the past 2 weeks and
vomiting (last emesis 3 days prior to admission). No recent
hospitalization or antibiotics per his report. It was suspected
that his bowel symptoms were related to uremia. Diarrhea
resolved with dialysis. Patient remained afebrile and without
leukocytosis.
5) Hypertension
The patient's blood pressures were mildly elevated during
admission. He was continued on atenolol and norvasc. Lisinopril
was held for hyperkalemia and as held on discharge at least
until follow-up with his nephrologist.
Code: Full (discussed with patient)
Communication: Patient, mother [**Name (NI) 63746**] [**Name (NI) 63747**] [**Telephone/Fax (1) 63748**]
Medications on Admission:
Pantoprazole 40 mg daily
Aspirin 81 mg daily
Lisinopril 20 mg daily
Calcium Acetate 667 mg TID with meals
Atenolol 100 mg daily
Norvasc 10 mg daily
Neurontin 300 mg PRN
Trazodone 50 mg QHS
Colace
Nephrocaps 1 tab QD
Discharge Medications:
1. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: End Stage Renal Disease
Secondary: Hypertension
Discharge Condition:
Ambulatory.
Hemodynamically stable.
Maintaining normal oxygen saturation on room air.
Discharge Instructions:
You were admitted to the hospital with abdominal pain, nausea,
and vomitting. Your potassium levels in your blood were found to
be high. This happened because it had been 2 weeks since your
last dialysis. In the hospital, you were treated with dialysis
and your potassium levels decreased.
Your medication regimen has changed. Please take sevelamer (also
called Renagel) 800 mg three times a day. This will help control
your phosphate levels, which have been high. Also, please do not
take your lisinopril until you see your nephrologist (please
schedule an appointment with him as explained below).
Please follow-up with your providers as listed below.
Please call your primary care office or visit the emergency room
if your abdominal pain, nausea, and vomiting returns or for any
other symptoms which are concerning to you.
Followup Instructions:
Please call your nephrologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 32691**])
and make an appointment with him as soon as possible (preferably
within the next two weeks) to discuss the best medication
regimen for you and whether you should restart your lisinopril.
Completed by:[**2158-6-30**]
|
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icd9cm
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[
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,591
| 133,087
|
46790
|
Discharge summary
|
report
|
Admission Date: [**2168-7-31**] Discharge Date: [**2168-8-7**]
Date of Birth: [**2117-11-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Outpatient therapist: [**First Name5 (NamePattern1) 38329**] [**Last Name (NamePattern1) 99302**] at [**Hospital1 3494**] Mental
Health ([**Telephone/Fax (1) 3784**]
Group home staff: [**Last Name (LF) **], [**First Name3 (LF) 54260**]- program director [**Telephone/Fax (1) 99299**]
Case worker: Elvita ([**Telephone/Fax (1) 99303**])
.
cc:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo man with extensive history of polysubstance abuse
(including cocaine, EToH with DT's), on methadone,
schizophrenia, multiple prior psychiatric admissions brought by
EMS from group home with likely polysubstance overdose.
Apparently patient was brought by EMS to the hospital after
staff at group home where he lives found him in his room with 2
different tablets (white and green) around that could not be
identified.
Patient came home last night around 11:30PM intoxicated, but
denied alcohol consumption. He then disappeared again around 1AM
until about 3:20 AM when he was found intoxicated and with a
forehead laceration. On his table 9 white and 2 green pills were
found. Per staff report, patient fell backward but it is unclear
whether he lost consciousness. EMS was called that brought him
to the ED.
.
In the ED, VS were HR 52, BP 143/93, RR 20 and O2 sat 100% on
RA. ECG showed sinus bradycardia. Serum tox screen was negative,
CBC and Chem 7 unremarkable. INR was 1.3 and fibrinogen 141. He
was given a total of 3 litres normal saline. Patient was
combative per ED notes. He was intubated for airway protection
and an OGtube was placed. He was transferred to MICU for further
management. Per ED resident pills were sent to pharmacy for
identification. See below for imaging studies.
.
ROS: unable to obtain due to sedation
Past Medical History:
PSYCHIATRIC HISTORY (per OMR):
Reports a number of hospitalizations >10 times of which he has
now lost count. Most recently down at [**Location (un) 22870**] for "hearing
voices". Denies any hx of SA. Will not confirm or deny whether
or not he has ever tried to commit homicide.
Has an outpatient psychiatrist of whom he doesn't remember his
name, out of [**Hospital1 3494**] Mental Health. He has been seeing him
for about 2-3 months now, and he has monthly appointments with
him.
.
PAST MEDICAL HISTORY (per OMR):
1. H/o Pancreatitis.
2. Hepatitis B and C. Unclear status
3. HIV positive; not on antiretrovirals, with no information
about his status. (could not be confirmed by group home
staff)
4. Schizo-affective disorder.
5. Major depressive disorder.
6. Alcohol abuse and fetal alcohol syndrome.
Social History:
Pt currently lives in a group home, [**Hospital1 99298**] in [**Hospital1 8**] with 6
other people, where he has been living for approximately 7
years.
He receives SSI for his schizophrenia.
History of multiple detoxes >10 , he has lost count, most recent
detox at [**Hospital 8**] Hospital then was transferred to [**Location (un) 22870**]
in
[**2167-7-31**] when he was detoxing from benzodiazepines.
Per OMR has hx of heroin abuse.
Family History:
FAMILY HISTORY (per OMR):
Reports his brother might have depression. Denies any
additional
history.
Physical Exam:
VS T 95.5, HR 46, BP 120/70, RR 16, O2 Sat 100% AC 650x16, FiO2
0.5, PEEP 5
Gen: sedated, intubated
HEENT: anicteric, MMM, pupils equal, but slow reaction to light
Chest: CTA b/l, no r/r/w
CV: brady, RR, no r/m/g
Abd: S/NT/ND, hypoactive BS
Ext: no edema, warm
Skin: multiple abrasions (head, knee)
Neuro: sedated
Pertinent Results:
[**2168-7-31**] 09:44AM GLUCOSE-130* UREA N-10 CREAT-0.7 SODIUM-142
POTASSIUM-3.3 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12
[**2168-7-31**] 09:44AM CALCIUM-8.4 PHOSPHATE-2.5* MAGNESIUM-1.9
[**2168-7-31**] 09:44AM WBC-4.9 RBC-3.72* HGB-13.0* HCT-35.9* MCV-96
MCH-34.9* MCHC-36.2* RDW-13.6
[**2168-7-31**] 09:44AM NEUTS-69.8 LYMPHS-21.9 MONOS-5.6 EOS-2.4
BASOS-0.3
[**2168-7-31**] 09:44AM PT-14.5* PTT-31.9 INR(PT)-1.3*
[**2168-7-31**] 04:50AM GLUCOSE-140* LACTATE-2.3* NA+-140 K+-3.7
CL--98* TCO2-31*
[**2168-7-31**] 04:42AM UREA N-12 CREAT-1.0
[**2168-7-31**] 04:42AM estGFR-Using this
[**2168-7-31**] 04:42AM AMYLASE-55
[**2168-7-31**] 04:42AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-7-31**] 04:42AM WBC-5.2 RBC-3.78* HGB-13.2* HCT-37.0* MCV-98
MCH-35.0* MCHC-35.7* RDW-13.7
[**2168-7-31**] 04:42AM PT-14.4* PTT-29.5 INR(PT)-1.3*
[**2168-7-31**] 04:42AM PLT COUNT-109*
[**2168-7-31**] 04:42AM FIBRINOGE-141*
.
CT head: No acute intracranial hemorrhage or mass effect.
Mucosal thickening in paranasal sinuses. There is a 2mm
calcification seen along the posterior aspect of the choroid in
the right globe superior to the plane of the optic papilla-
please correlate this observation via ophthalmology
consultation. Its etiology is uncertain, but may merely be
dystrophic in origin.
.
CT C-spine:
Both the prior [**2168-7-6**] and present examinations disclose
a mild compression deformity of the superior endplate of C1,
which has not changed since the prior study, and therefore is
not an acute injury. Also, there is a minute osteophyte arising
from the superior endplate of C5 anteriorly, seen on both
studies as well.
.
CXR: Tubes and lines as described above. No acute
cardiopulmonary process.
.
FRONTAL VIEW OF THE PELVIS: There is no evidence of gross
fracture or subluxation seen on this frontal radiograph. SI
joints are symmetric. Hip joints are unremarkable. There is mild
degenerative change in the lower lumbar spine.
.
THREE VIEWS OF BILATERAL KNEE: There is no evidence of acute
fracture or subluxation. Joint spaces are preserved. There is no
focal osseous lesion in the visualized portion of the skeletal
structure. There is no abnormal soft tissue calcification.
.
Right wrist: No acute fracture. Possible dorsal subluxation of
the ulna, correlate clinically.
Brief Hospital Course:
A&P: 50 M with schizophrenia, polysubstance abuse, multiple past
psychiatric admissions, now presents from group home with
probable overdose; required intubation in ED and MICU admission.
.
#) Overdose: unclear which substances, pills found next to
patient were reportedly sent to pharmacy for identification;
however, unable to track them down after the fact. Still
unknown what he ingested. Serum Tox was negative. Utox positive
for benzos and methadone. Bradycardia at admission, otherwise
VS were stable. He remained stable medically over course of
[**9-2**], and no further intervention was felt necessary. He was
transferred to the medical floor while awaiting inpatient psych
placement. Pt was discharged to psychiatry for further
management.
.
#) Intubation: patient intubated in ED for combativeness and
airway protection. He was reportedly alert and oriented before
intubation. No h/o underlying lung disease (although on nebs).
Chest exam clear in MICU. pt was extubated [**8-1**] without
difficulty. He remained off oxygen without desaturation or
dyspnea.
.
# UTI - pt was febrile to 101.9 [**8-2**], found to have +UTI (UCx
with pansensitive Klebsiella). Started on CTX to avoid QT
prolonging agents, then switched to bactrim [**8-4**]. Pt afebrile
since [**8-3**]. He needs a 7 day course (this should end [**2168-8-8**]).
.
# Agitation: pt followed by psych, and was initially quite
combative requring increasing doses of haldol (25mg over 12hrs)
with ativan during multiple code grey's after extubation. 1:1
sitter was continued for agitation and suicide precautions.
Psych regimen modified per psych recs, and pt substantially more
calm after d/c'ing soft restraints with standing regimen of
haldol q3-4h, later was switched to prn. Agitation may have
also been [**1-1**] UTI and component of ICU psychosis, however this
continued on the medical floor following treatment of UTI. One
Code Purple was called on the medical floor. Daily ECGs revealed
stable QTc. CT head x 2 were negative for acute pathology.
.
#) C1 compression fracture: seen on C-spine CT, no apparent
neuro deficits per ED exam or following extubation. Per rads
attending review, fracture present on [**2168-7-6**] C-spine CT-spine,
collar was d/c'd after neurosurgery consult.
.
#) Wrist injury: No fracture. R hand in splint, pt seen by
ortho who recommend splint.
.
#) Bradycardia: no h/o CAD, patient with mild sinus brady 50s,
stable BP. Felt likely [**1-1**] recently started nadolol.
Bradycardia resolved once nadolol was discontinued; with restart
of low dose, HR remained in 60's.
.
#) Liver cirrhosis: apparently relatively new diagnosis, cared
for at [**Hospital1 2177**] (Dr [**Last Name (STitle) **] [**Numeric Identifier 99304**], Dr[**Name (NI) 7517**] [**Numeric Identifier 99305**]), pt was
continued on home regimen of lactulose, aldactone, rifaximin,
however nadolol was initially held as above.
.
#) HIV: per some OMR notes. Not on HAART, ? med-compliance. no
active issues currently.
.
#) EtOH abuse: h/o withdrawals with likely DT years ago, pt
treated with ativan per CIWA. Pt also continued on home regimen
of clonidine 0.1mg qid for alcohol, narcotic withdrawal. Given
folate, thiamine daily.
Medications on Admission:
. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
6. Methadone 10 mg Tablet Sig: 3.3 Tablets PO DAILY (Daily).
7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily).
Disp:*1000 ML(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 unit* Refills:*2*
14. Pantoprazole 40 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*
15. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 unit* Refills:*2*
17. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath, wheezing.
Disp:*1 inhaler* Refills:*0*
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain, fever.
Disp:*120 Tablet(s)* Refills:*0*
nadolol 20 mg daily
Campral 666mg daily
Discharge Medications:
1. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
2. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Methadone 10 mg/mL Concentrate Sig: Thirty Three (33) mg PO
DAILY (Daily).
7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every
8 hours) as needed.
10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Further psych medication regimen to be determined during
inpatient psychiatric admission to follow.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
polysubstance overdose
Urinary tract infection
hepatitis C cirrhosis
subacute C1 compression fracture
Schizoaffective disorder
Discharge Condition:
Medically stable
Discharge Instructions:
You were admitted for an overdose. We were unable to determine
what pills you took or why exactly you took them. You had a
breathing tube inserted and were monitored in the intensive care
unit. You were given medications as needed for agitation and
possible withdrawal.
.
Please return to the emergency room if you experience feelings
of being out of control or wanting to hurt yourself or others,
if you have seizures or confusion, or if you experience any
other symptoms that you or others are concerned about.
.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed.
Followup Instructions:
Please followup with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in
[**12-1**] weeks. Please call [**Telephone/Fax (1) 92717**] to schedule an appointment.
.
You should also followup with your outpatient therapist and
psychiatry team as recommended by our psychiatrists here at
[**Hospital1 18**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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|
2917, 3355
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,627
| 119,612
|
32184
|
Discharge summary
|
report
|
Admission Date: [**2198-11-12**] Discharge Date: [**2198-11-13**]
Date of Birth: [**2140-6-2**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Iodine / Shellfish / Demerol / Darvon / Sulfa
(Sulfonamides)
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
This is a 58 y.o. female with a history of type II DM,
hypertension, and schizophrenia who presented to [**Hospital3 **]
on [**11-8**] with chest pain. She reports that on the day of
admission, while babys[**Name (NI) 12854**] her grandchildren, she began to
have sudden onset of substernal chest pain radiating to the neck
and to the left arm. She reports that this pain was [**11-7**] in
severity and she describes it as a "squeezing" pain. She also
reports that her pain was accompanied by left arm numbness. She
also notes lightheadedness, diaphoresis, and nausea. She also
became acutely short of breath and called EMS. She was brought
to the ED where she had VS as follows: BP 123/70, HR 90, T 98.4,
O2 Sat 99% RA. She continued to have pain despite sl NTG x 3
with only mild improvement. Her pain improved from [**11-7**] to [**7-8**]
in severity after NTG x 3 and she was started on nitro gtt and
her pain resolved approximately 4 hours following its onset.
.
Her cardiac markers were negative x 3 and she had no EKG
changes. She had 3 more transient episodes of chest pain during
her hospitalization at the OSH. These episodes lasted for
approximately 5 minutes each and resolved with SL NTG. Her last
episode was on the evening of [**11-10**]. Of note, she had a positive
stress test with a reversible anterior apical defect on [**11-9**].
She was transferred here for aspirin desensitization follwed by
cardiac cath.
.
She reports that she has been having similar chest pain on
exertion for approximately 3 weeks. She reports that she has had
chest pain on climbing approximately 2 flights of stairs. She
has complete resolution of pain with rest. Her chest pain has
been progressively more severe in intensity and more frequent
leading up to her chest pain that brought her to the ED. She
also reports that approximately 10 years ago, she had chest pain
on exertion which self-resolved without intervention. She was
told that these episodes were episodes of "angina." She
reportedly had a negative stress test at that time.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for chest pain. No history
of paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Schizophrenia
Type II DM
Hypertension
Asthma
Rhinitis
Hiatal hernia
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. She is a retired
teacher's aide.
Family History:
Her father had an MI in his 40s and died in his 60s from an MI.
Mother with stroke in her 60s. Cousin who died of an MI at age
44.
Physical Exam:
VS: T 99.8, BP 113/56, HR 65, RR 22 , O2 97% on RA
Gen: WDWN middle aged female in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no JVD
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. No m/r/g.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2198-11-12**] ADMISSION LABS:
WBC-11.4* RBC-3.87* Hgb-10.6* Hct-31.6* MCV-82 MCH-27.5
MCHC-33.5 RDW-15.1 Plt Ct-376
.
COAGS:
PT-12.1 PTT-23.6 INR(PT)-1.0
.
CHEMISTRY:
Glucose-185* UreaN-23* Creat-1.0 Na-137 K-4.5 Cl-102 HCO3-26
AnGap-14
.
CE's:
CK(CPK)-25* CK-MB-NotDone cTropnT-<0.01
.
IRON STUDIES:
calTIBC-381 Ferritn-66 TRF-293
.
DIABETES MONITORING:
%HbA1c-6.4*
.
CHOLESTEROL PANEL:
Triglyc-87 HDL-49 CHOL/HD-2.2 LDLcalc-41
.
[**11-13**] CARDIAC CATHETERIZATION:
LEFT VENTRICULOGRAPHY:
Volumetric data:
LV end diastolic volume index (nl 50-90 ml/m2). 45
LV end systolic volume index (nl 15-30 ml/m2). 18
LV stroke volume index (nl 35-75 ml/m2). 27
LV ejection fraction (nl 50%-80%). 60
Qualitative wall motion:
[**Doctor Last Name **]:
1. Antero basal - normal
2. Antero lateral - normal
3. Apical - normal
4. Inferior - normal
5. Postero basal - normal
Other findings:
Mitral valve was normal.
.
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated an LMCA, LAD, LCX and RCA all free of
angiographically-apparent CAD.
2. Left ventriculography showed normal LV EF of 60%; there were
no focal
wall motion abnormalities noted. No mitral regurgitation.
3. Limited resting hemodynamics showed elevated LV filling
pressure of
25 mmHg. There was no gradient across the aortic valve.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Mild diastolic ventricular dysfunction.
Brief Hospital Course:
58 year old female with HTN, DM who presents with exertional
chest pain, found to have abnormal stress test and transferred
for ASA desensitization prior to cardiac catheterization.
Hospital course by problem:
.
1. ASA desensitization: She meets criteria for ASA-exacerbated
respiratory disease (AERD) which includes asthma, ASA
sensitivity, and rhinitis/nasal polyps. She underwent ASA
desensitization per protocol with Benadryl prior to
desensitization and epinephrine by bedside. There were no
reactions and she tolerated the desensitization without problem.
.
2. Chest pain: Her history was suggestive of unstable angina.
Per OSH records she had a positive stress-MIBI with a reversible
anterior apical defect. Her TIMI score of 2 on admission at OSH
prompted conservative management at OSH with plavix, BB, and
statin. She was transferred for ASA desensitization, after which
cardiac cath was performed. She was premedicated appropriately
for her contast allergy. The catheterization was entirely
normal, with clean coronary arteries and a preserved ejection
fraction of 60%. For primary coronary artery disease prevention,
she was discharged on a statin, BB, and [**Last Name (un) **], with the addition
of a daily plavix instead of Aspirin, as this has been shown to
have therapeutic equivalence in MI prophylaxis.
.
3. DM: Held glucophage in setting of cardiac cath. Her
Hemoglobin A1c was 6.4%, reflecting good glycemic control. She
was covered with an insulin sliding scale while hospitalized,
with FSG QID. Instructed to resume taking metformin on [**2198-11-16**].
.
4. Schizophrenia: Stable, continued home regimen of abilify and
sertraline
.
5. HTN: Well controlled here. Continued [**Last Name (un) **] and BB.
.
6. Anemia: Hct 31.6 (34.8 at OSH). Iron studies revealed a
low-normal iron level
- Guaiac stool
.
7. Leukocytosis: No evidence of acute infection with no
localizing symptoms, and resolved on hospital day #1. Likely
stress response, as she was afebrile throughout.
.
8. F/E/N: Ate a diabetic, cardiac diet.
.
9. Code: Full
Medications on Admission:
MEDICATIONS on admission at OSH:
Glucophage 500 [**Hospital1 **]
Cogentin 0.5 [**Hospital1 **]
Diovan 40 daily
Zoloft 100 daily
Omeprazole 20 daily
Abilify 5 daily
Vytorin 1 daily
Oxazepam 15 qhs
Alprazolam 0.5 TID
Albuterol nebs
Flovent
Discharge Medications:
1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Glucophage 500 mg Tablet Sig: One (1) Tablet PO twice a day:
First dose 10/19.
3. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Vytorin [**10/2171**] 10-80 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
11. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for anxiety.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
chest pain
Discharge Condition:
stable, pain-free
Discharge Instructions:
You were admitted to the hospital with chest pain. You had a
cardiac catheterization which showed no coronary artery disease
and entirely preserved cardiac function. You did NOT have any
stents placed.
.
You were found to be slightly anemic (low red blood cell counts)
while you were here. This is most likely due to iron deficiency.
We have begun you on a daily iron pill, but you must also
follow-up with your PCP to arrange an outpatient colonoscopy, to
make sure you are not bleeding from a lesion in your gut or
colon.
.
Please continue to take all your previous medicines as
prescribed, with the following exceptions:
- only resume taking your metformin on Friday, [**11-16**]. Do
not take it prior to Friday
- we started you on a heart-protective medicine that also lowers
blood pressure called metoprolol.
- we would like to add a daily aspirin to you medications, but
since you have an aspirin allergy, we cannot. A drug that has
been shown to be as effective as aspirin in preventing heart
attacks, especially in diabetics, is Plavix. For this reason we
are adding a daily Plavix to your medication list.
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**] in the next 1-2 weeks.
If you experience any further chest or jaw/arm pain, shortness
of breath, or other symptoms that are cncerning to you, please
call your physician or go to the nearest ER.
Followup Instructions:
Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
[**Telephone/Fax (1) 22166**]. Please make an appointment to see her in the next
2 weeks.
.
Please follow-up wth your cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) 1955**] J.
[**Telephone/Fax (1) **]. Please make an appointment to see him in the next
2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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"401.9",
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icd9cm
|
[
[
[]
]
] |
[
"88.53",
"99.12",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
9513, 9519
|
5778, 5960
|
343, 369
|
9573, 9593
|
4209, 4226
|
11045, 11561
|
3215, 3347
|
8119, 9490
|
9540, 9552
|
7856, 8096
|
5677, 5755
|
9617, 11022
|
3362, 4190
|
293, 305
|
5988, 7830
|
397, 2949
|
4242, 5660
|
2971, 3041
|
3057, 3199
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,824
| 194,032
|
41017
|
Discharge summary
|
report
|
Admission Date: [**2143-6-17**] Discharge Date: [**2143-6-28**]
Date of Birth: [**2071-7-17**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation L2-S1
History of Present Illness:
Ms. [**Known lastname 89460**] has a long history of back and leg pain. She has
attempted conservative therapy but has failed. She now presents
for suirgical intervention.
Past Medical History:
PMH: HTN, GERD, monoclonal gammopathy, depression,
hypothyroidism
PSH: Tonsillectomy, tubal ligation, L2-S1 posterior
fusion/decompression
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2143-6-21**] 04:34AM BLOOD WBC-13.7* RBC-3.71* Hgb-11.0* Hct-31.1*
MCV-84 MCH-29.8 MCHC-35.5* RDW-15.4 Plt Ct-117*
[**2143-6-20**] 08:03PM BLOOD WBC-14.0* RBC-3.77* Hgb-11.3* Hct-31.7*
MCV-84 MCH-30.0 MCHC-35.7* RDW-15.7* Plt Ct-125*
[**2143-6-20**] 04:03AM BLOOD WBC-11.4* RBC-3.61* Hgb-11.1* Hct-29.5*
MCV-82 MCH-30.7 MCHC-37.7* RDW-15.8* Plt Ct-128*
[**2143-6-19**] 03:12PM BLOOD WBC-9.7 RBC-3.14* Hgb-9.5* Hct-26.0*
MCV-83 MCH-30.1 MCHC-36.4* RDW-15.3 Plt Ct-142*
[**2143-6-21**] 04:34AM BLOOD Glucose-125* UreaN-14 Creat-0.6 Na-137
K-3.6 Cl-103 HCO3-27 AnGap-11
[**2143-6-20**] 08:03PM BLOOD Glucose-106* UreaN-14 Creat-0.6 Na-138
K-3.5 Cl-106 HCO3-27 AnGap-9
[**2143-6-20**] 04:03AM BLOOD Glucose-126* UreaN-23* Creat-0.7 Na-138
K-3.7 Cl-103 HCO3-31 AnGap-8
[**2143-6-21**] 04:34AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.8
[**2143-6-20**] 04:03AM BLOOD Calcium-8.4 Phos-2.0*# Mg-1.6
[**2143-6-19**] 03:12PM BLOOD Calcium-9.4 Phos-3.6 Mg-1.6
[**2143-6-28**] 06:40AM BLOOD WBC-15.5* RBC-3.93* Hgb-11.4* Hct-36.1
MCV-92 MCH-29.0 MCHC-31.5 RDW-15.3 Plt Ct-491*
[**2143-6-27**] 03:24AM BLOOD WBC-14.9* RBC-3.87* Hgb-11.4* Hct-34.9*
MCV-90 MCH-29.6 MCHC-32.8 RDW-15.3 Plt Ct-432
[**2143-6-26**] 04:00AM BLOOD WBC-14.1* RBC-3.75* Hgb-11.2* Hct-33.5*
MCV-89 MCH-29.9 MCHC-33.5 RDW-15.0 Plt Ct-354
[**2143-6-25**] 03:13AM BLOOD WBC-14.0* RBC-3.68* Hgb-11.0* Hct-32.3*
MCV-88 MCH-29.9 MCHC-34.1 RDW-14.6 Plt Ct-275
[**2143-6-27**] 03:24AM BLOOD Glucose-117* UreaN-25* Creat-0.7 Na-138
K-3.7 Cl-98 HCO3-33* AnGap-11
[**2143-6-26**] 04:00AM BLOOD Glucose-114* UreaN-28* Creat-0.5 Na-139
K-3.8 Cl-98 HCO3-33* AnGap-12
[**2143-6-25**] 03:13AM BLOOD Glucose-103* UreaN-23* Creat-0.6 Na-139
K-3.7 Cl-97 HCO3-33* AnGap-13
[**2143-6-27**] 03:24AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.4
[**2143-6-26**] 04:00AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.3
Brief Hospital Course:
Ms. [**Known lastname 89460**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2143-6-17**] and taken to the Operating Room for L2-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled L2-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was low and she was
transfused PRBC effectively.
She remained in the PACU intubated for diuresis purposes. She
was subsequently extubated and transfered to the SICU. She
developed pulmonay edema which caused low oxygen saturation.
This resolved over 4 days and she was transfered to the floor
for further management.
She was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was removed on POD#2
from the second procedure. She was fitted with a lumbar
warm-n-form brace for comfort. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. levothyroxine 100 mcg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. levothyroxine 100 mcg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 89461**] Rehab
Discharge Diagnosis:
Lumbar disc degeneration and spondylosis
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Out of bed to chair with LSO brace
Treatments Frequency:
Please continue to change the dressing daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2143-6-28**]
|
[
"244.9",
"738.4",
"401.9",
"518.82",
"300.00",
"518.7",
"285.1",
"721.3",
"530.81",
"273.1",
"564.00",
"278.00",
"E934.7",
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] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"84.51",
"81.63",
"84.52",
"81.07",
"03.90",
"81.06"
] |
icd9pcs
|
[
[
[]
]
] |
6483, 6536
|
3163, 4867
|
306, 368
|
6653, 6660
|
1314, 3140
|
8796, 8876
|
774, 779
|
5539, 6460
|
6557, 6632
|
4893, 5516
|
6684, 6783
|
794, 1295
|
8645, 8704
|
8726, 8773
|
6819, 7012
|
257, 268
|
7048, 7515
|
7527, 8627
|
396, 571
|
593, 734
|
750, 758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,484
| 196,045
|
2704
|
Discharge summary
|
report
|
Admission Date: [**2129-7-4**] Discharge Date: [**2129-7-8**]
Date of Birth: [**2061-2-6**] Sex: M
Service: MEDICINE
Allergies:
Trilisate
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Central line placement and removal.
PICC placement in Right arm.
History of Present Illness:
Mr [**Known lastname 13448**] is a 68 yoM w/ a h/o paraplegia C4-C5 [**2-21**] to a fall
remotely, he has DMII, ETOH related cirrhosis, h/o SBOs,
suprapubic catheter and has baeen sent in by his nursing home
for lethargy / MS changes and tachycardia.
Per [**Hospital1 1501**] he became more lethargic x 3 days or so, a few hours of
MS changes (usually AOx3 and interactive). Abd distension
increased from baseline- given suppository and rectal
stimulaiton and had a BM. Suprapubic catheter was changed the
day prior to admission (routine q 1 month change) but also
leaking around the tube. His HR increased 120 x 1 day and
patient stated he felt poorly. T max 99.0 in [**Hospital1 1501**].
The patient currently feels unwell, unable to identify any
painful areas, cough, fever / chills or any other specific
symptoms.
In the emergency department, initial vitals: T 99.5 HR 116 BP
100/58 RR 18 O2 99
In the ER Tm 102.2 rectally, he rec'd vanc / zosyn in the ER.
UA +, UCx and blood cultures sent. Stool sent for culture and C
diff. 2L IVF given in ER. Prior to transfer to the ICU HR 120,
BP 117/47. Access is 2 PIV x 18g.
Past Medical History:
Quadraplegia, C4/C5 work related injury 17years ago
Constipation, chronic
h/o Heart failure, echo [**2124**] with EF 75%, likely diastolic, not
symptomatic
copd
DM2-diet controlled
etoh abuse, none for 19years
cirrhosis w/occassional ascites, splenomegaly and
thrombocytopenia
suprapubic cath-h/o MRSA uti and pseudomonas UTI
h/o SBO [**7-26**], conservatively managed per surgery
(NGT/NPO/enemas)
h/o peritonitis 10years ago s/p laparotomy/washout, complicated
extended course (liver/renal/pulm failure)
Social History:
[**Doctor First Name 391**] Bay NH resident x7years, dependent with all ADLs. h/o
etoh abuse in past quit 19years ago, no drugs and tobacco. DNR/I
Family History:
Noncontributory
Physical Exam:
GEN: NAD, AOx2.5 (aware of person and place, year is [**2129**] unsure
of month / date)
HEENT: MM dry, JVP flat
CHEST: CTAB anteriorly and laterally
CV: Tachycardic, regular, no m/r/g
ABD: soft, moderately distended, + BS, nontender, no HSM, no
ascites
EXT: WWP, 1+ edema, 2+ DP and PT pulses
NEURO: Upper ext contractures, LE extended, reports minimal but
intact sensation of extremities, EOMI, PERRL, AOx2.
Pertinent Results:
Admission:
[**2129-7-4**] 12:08AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2129-7-4**] 12:08AM URINE RBC-[**3-24**]* WBC->50 BACTERIA-MOD YEAST-NONE
EPI-<1 RENAL EPI-0-2
[**2129-7-4**] 12:08AM PT-16.1* PTT-29.0 INR(PT)-1.4*
[**2129-7-4**] 12:08AM WBC-6.8 RBC-3.84* HGB-12.1* HCT-36.7* MCV-96
MCH-31.7 MCHC-33.0 RDW-16.6*
[**2129-7-4**] 12:08AM NEUTS-80.5* LYMPHS-15.1* MONOS-3.8 EOS-0.4
BASOS-0.1
[**2129-7-4**] 12:08AM LACTATE-2.5*
[**2129-7-4**] 12:08AM AMMONIA-53*
[**2129-7-4**] 12:08AM ALT(SGPT)-14 AST(SGOT)-20 ALK PHOS-47 TOT
BILI-1.0
[**2129-7-4**] 12:08AM GLUCOSE-303* UREA N-17 CREAT-0.8 SODIUM-127*
POTASSIUM-3.6 CHLORIDE-94* TOTAL CO2-23 ANION GAP-14
Studies:
1. CT abd/pel: New since the prior study of [**2128-11-21**] is
enlargement of the left kidney with heterogeneous enhancement
and perinephric as well as periureteral stranding. Given the
patient's history, these findings are likely from
pyelonephritis. Suprapubic catheter is in place. No evidence of
bowel obstruction. While collapsed, there is mild stranding
surrounding the right colon, possibly representing nonspecific
focal colitis. Chronic osteomyelitis of right ischial tuberosity
unchanged with adjacent sinus tract. Irregular partially
calcified plaque along the infrarenal abdominal aorta, again
with luminal narrowing down to 8 mm. Findings suggesting
underlying cirrhosis. Splenomegaly unchanged. Suggestion of
paraesophageal varices.
2. CXR: Atelectasis remains in the left lung base. No definite
focal
consolidation is seen concerning for pneumonia.
MICRO:
UCx [**7-4**]: Mixed flora
BCx: [**7-4**]: Coag negative staph (2/4 bottles), Pansensitive
Citrobacter (2/4 bottles)
Stool cx and c diff [**7-4**]: Neg
Brief Hospital Course:
68 yoM w/ C4-C5 quadraplegia presents w/ mental status changes
and tachycardia found to have sepsis and pyleonephritis.
# Sepsis: Pt initially admitted to ICU for aggressive IVF,
antibiotics and pressors (required for 24hs). He quickly
responsed to IVF and was able to be weaned of pressors and be
transferred to the medical floor. The source of sepsis was
thought to be urinary, given suprapubic catheter, multiple
bacteria growing in urine, and evidence of left pyelonephritis
on CT scan. Pt also has chronic ischial ulcer with chronic
osteomyelitis per CT scan which may act as source, but was
evaluated by plastic surgery and not thought to be infection. Pt
grew citrobacter and coag negative staph in multiple bottles of
initial cultures and had multiple surveillance cultures
negative. He was initailly treated with Vanc, Zosyn and Gent,
then switched to Vanc and [**Last Name (un) **] and on discharge to vancomycin
and ciprofloxacin based on sensitivities. These end on [**2129-7-18**].
Pt's suprapubic catheter was changed again in the ICU. For
access pt initially had central line placed and was replaced
with PICC line and several peripheral IVs. Please check Blood
cultures on [**2129-7-24**] after completion of antibiotics to ensure
clearance of bacteria. PICC line should be removed when
antibiotic course is completed.
# Electrolyte abnormalities: Pt had repeatedly low electrolytes,
including K, Mg, phos, and these were aggressively repleted.
Cause was unclear but appears chronic. Please check chem 10 on
[**2129-7-11**].
# Altered mental status: Resolved, likely due to infection
rather than encephalopathy.
# Pancytopenia: After initial leukocytosis, pt was pancytopenic
with WBC 2s, HCt high 20s, platelets ~50. This was likely due to
sepsis induced marrow suppression and chronic effects of
cirrhosis. Meds were unlikely to be contributing. All cell lines
were increasing at time of discharge.
# Cirrhosis: Etoh induced, longstanding with thrombocytopenia,
INR 1.4, anemia.
# DM2: Pt usually diet controlled, but blood sugars elevated
while in house likely due to infection. He was managed with
QACHS FS and humalog insulin sliding scale.
# Ischial wound: Pt with chronic wound, followed by plastic
surgery as inpt and outpt. Usually with VAC at facility, but
just wet to dry dressings [**Hospital1 **] while inpt per plastics/wound care
recs. Pt to resume VAC when discharged.
# Quadraplegia: Pt was continued on his home regimen of
baclofen, supplements, vitamins, bowel regimen. Keflex for UTI
prophylaxis was held while on other antibiotics.
Medications on Admission:
Keflex 500 mg 1 cap(s) QID
Tums 500 mg 1 tab(s) TID
Compazine 10 mg 1 tab(s) Q 8hrs,prn
Robitussin 100 mg/5 mL 5 mL Q4H
MiraLax - 17 g qd x3 then resume qod
Dulcolax 10 mg 1 SUPP(s) once a day
senna 8.6 mg 2s ta QOD
baclofen 10 mg
1 tab q6am,4 tabs q12p,2tabs q6pm and 3 tabs q 12a
Valium 5 mg 1 tab(s) QHS
Prilosec OTC 20 mg 1 tab(s) once a day
Multiple Vitamins with Minerals 1 tab(s) QD
Vitamin C 500 mg 1 tab(s) [**Hospital1 **]
Zinc Sulfate 220mg as directed QD
vitamin A 10,000 units 1 QD
Ultram 50 mg 1 tab(s) [**Hospital1 **],prn
Hydrocort cream 2.5% 1 app TID
Ear Wax 6.5% 5 gtt 2X/week
Tylenol 500 mg 2 tab(s) Q6H
neutra-phos 1.25 gm pkt 1 [**Hospital1 **]
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
3. Robitussin Chest Congestion 100 mg/5 mL Liquid Sig: Five (5)
ml PO every four (4) hours as needed for cough.
4. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO
every other day.
5. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
once a day.
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO QOD ().
7. Baclofen 10 mg Tablet Sig: see below Tablet PO DAILY (Daily):
10mg q6am
40mg qnoon
20mg q6pm
30mg qmidnight.
8. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Multivitamins with Minerals Tablet Sig: One (1) Tablet
PO once a day.
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
15. Hydrocortisone 2.5 % Cream Sig: One (1) application Topical
three times a day as needed for rash.
16. Ear Wax Removal Drops 6.5 % Drops Sig: Five (5) drops Otic
twice a week.
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain,fever.
18. Phos-NaK 280-160-250 mg Powder in Packet Sig: One (1) packet
PO twice a day.
19. Outpatient Lab Work
Blood cultures on [**2129-7-24**]
20. Outpatient Lab Work
Please check electrolytes (Chem 10) on [**2129-7-11**]
21. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days: last day [**7-18**].
22. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
every twelve (12) hours for 11 days: last day is [**2129-7-18**].
23. Line care
PICC line care per protocol.
24. saline
Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
Primary:
Sepsis from UTI
Left pyelonephritis
Colitis
Secondary:
Quadraplegia, C4/C5 work related injury 17years ago
Constipation, chronic
Diastolic heart failure, [**2124**] EF 75%
COPD
DM2-diet controlled
Cirrhosis (alcoholic)
Discharge Condition:
Stable, Afebrile x 3days, BP stable on beta blocker
Discharge Instructions:
You were admitted for fast heart rate and found to have multiple
bacteria in your blood. We believe that this came from the
urine, as a CT scan of your abdomen showed inflammation of your
left kidney. You were treated in the ICU with antibiotics, IV
fluids and "pressors" (medications used to increase your blood
pressure). You quickly improved on these treatments and were
able to transfer to the medical floor.
You also had some abnormalities in your labs. Your cell counts
were all low (white count, hematocrit and platelets). This is
likely due to your infection and temporary suppression of your
bone marrow, as well as your liver cirrhosis. On discharge these
numbers were improving.
Your electrolytes were also very low. This can happen when
someone does not eat temporarily and resumes eating. These were
all repleted on discharge were in the normal range.
We made the following changes to your medications:
1) START antibiotics: Oral Cipro, IV vanco for 2 week course,
last day [**7-18**]
2) STOP Keflex while you are on the above antibiotics. Once you
have completed the Vancomycin and Cipro, you can resume Keflex.
Please check chem 10 (sodium, potassium, bicab, chloride, BUN,
creatinine, glucose, magnesium, calcium and phosphorus) on
[**2129-7-11**] and replete electrolytes as needed.
Please check a set of blood cultures on [**2129-7-24**] to ensure they
are clear after antibiotic course.
Otherwise please continue your medications as previously
prescribed.
PICC line can be removed after vancomycin course completed.
Please resume VAC dressing as previously had in place for sacral
wound per recommendations from plastic surgery. WHile waiting
for vac, please use wet to dry dressings as on the Page 1
supplement sheet.
Please call your doctor or return to the hospital if you develop
fevers >102, shortness of breath, lightheadedness or weakness,
chest pain, palpitations, or any other concerning symptoms.
It was a pleasure taking care of you, we wish you the best!
Followup Instructions:
Please follow up with you physician at your rehab facility as
regularly scheduled.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2129-7-18**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,623
| 140,861
|
36266
|
Discharge summary
|
report
|
Admission Date: [**2137-4-28**] Discharge Date: [**2137-5-7**]
Service: MEDICINE
Allergies:
Depakote / Dilantin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hip fracture, post-operative delirium, hypertension.
Major Surgical or Invasive Procedure:
Hemiarthroplasty, [**2137-4-30**]
History of Present Illness:
Ms. [**Known lastname 51305**] is a [**Age over 90 **] year old woman with a history of dementia, a
prior stroke, and a seizure disorder who was initially admitted
to the orthopaedics service at [**Hospital1 18**] on [**2137-4-28**] following an
unwitnessed fall at her nursing home. She was reportedly found
on the floor of her bathroom complaining of low back pain and
was brought to [**Hospital6 **] in [**Location (un) 1110**] for
evaluation. There, she was found to have a subcapital left
femoral neck fracture as well as a subdural hematoma along the
falx and left tentorium; this was stable on a repeat head CT
later the same day. Her labs were notable for a creatinine of
1.59 (unknown baseline), WBC 8.8, troponin-T 0.02, and were
otherwise normal. She was transferred to the [**Hospital1 18**] orthopaedic
service on [**2137-4-28**] further orthopaedic care and preoperative
medical and neurosurgical evaluation.
Past Medical History:
- dementia; per daughter [**Name (NI) **], the patient is conversant at
baseline and can usually recognize her location and some
familiar people, but is generally not oriented to time/recent
daily events
- abdominal aortic aneurysm
- left frontotemporal stroke more than ten years ago
- reported cardiomyopathy (unknown if systolic and/or diastolic)
- hyperlipidemia
- macular degeneration; surgical right pupil
Social History:
Lives at Golden [**Hospital **] nursing home. Former smoker. No alcohol
use. Daughter [**Name (NI) **] is HCP. [**Name (NI) **] daughter, patient is minimally
ambulatory at baseline without assistance.
Family History:
Cardiovascular disease on paternal side of family.
Physical Exam:
General: Elderly woman, somewhat communicative, intermittently
lying still and thrashing her arms
Neck: flat JVP; supple
HEENT: moist mucous membranes; no scleral icterus or
conjunctival erythema
Chest: clear to auscultation throughout with no wheezes, rales,
or ronchi
CV: regular rate/rhythm, normal s1s2, no murmurs
Abdomen: soft, nontender, mildly distended, normal bowel sounds,
no HSM or palpable masses
Extr: mildly cool, thin, 1+ PT pulses; (+) hallux valgus
deformity of left foot; left hip incision with small dressing
that has minimal serosanguinous drainage
Neuro: intermittently awake and thrashing and somnolent; follows
some simple verbal commands (opening eyes and taking deep
breaths); left pupil 5 mm and reactive to 3 mm; right pupil 6 mm
and minimally reactive (baseline s/p surgery, per daughter);
equivocal plantar reflexes bilaterally; 5/5 strength in
bilateral deltoids, biceps, triceps, grip strength when patient
fighting exam; 2+ biceps reflexes bilaterally
Pertinent Results:
Labs on admission:
[**2137-4-28**] 09:28PM BLOOD WBC-13.3* RBC-3.92* Hgb-11.0* Hct-33.6*
MCV-86 MCH-28.1 MCHC-32.8 RDW-15.3 Plt Ct-203
[**2137-4-28**] 09:28PM BLOOD Neuts-85.1* Lymphs-8.8* Monos-5.2 Eos-0.7
Baso-0.1
[**2137-4-28**] 09:28PM BLOOD PT-12.7 PTT-25.8 INR(PT)-1.1
[**2137-4-28**] 09:28PM BLOOD Glucose-117* UreaN-19 Creat-1.4* Na-145
K-4.4 Cl-114* HCO3-21* AnGap-14
[**2137-4-28**] 09:28PM BLOOD CK(CPK)-66
[**2137-4-28**] 09:28PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2137-4-28**] 09:28PM BLOOD Calcium-9.0 Phos-2.8 Mg-2.2
CT HEAD: (repeat CT's showed no change)
1. Small parafalcine subdural hematoma, stable from outside
hospital CT of
nine hours earlier. No mass effect.
2. Atrophy, small vessel ischemic disease and prior left
frontotemporal
infarct.
3. Sinus atelectasis of the right maxillary sinus with complete
opacification.
HIP PLAIN FILM ON ADMISSION:
Technically limited study shows apparent overriding of the
femoral
neck and shaft with respect to the femoral head, which appears
to be well
seated within the acetabulum. There is generalized
demineralization and
severe degenerative changes involving the lumbar spine.
Discharge Labs:
[**2137-5-6**] 07:00AM BLOOD WBC-12.0* RBC-2.99* Hgb-8.6* Hct-26.6*
MCV-89 MCH-28.7 MCHC-32.3 RDW-16.6* Plt Ct-134*
[**2137-5-6**] 07:00AM BLOOD Glucose-86 UreaN-24* Creat-1.1 Na-148*
K-3.3 Cl-117* HCO3-22 AnGap-12
Brief Hospital Course:
This is a [**Age over 90 **] year old woman with a history of dementia, a prior
stroke, and a seizure disorder who was initially admitted to the
orthopaedics service at [**Hospital1 18**] on [**2137-4-28**] following an
unwitnessed fall at her nursing home, found to have femoral neck
fracture.
The patient was transferred to the [**Hospital1 18**] orthopaedic service on
[**2137-4-28**] further orthopaedic care and preoperative medical and
neurosurgical evaluation. She underwent left hip
hemiarthroplasty on [**2137-4-30**] with [**2128**] mg of IV perioperative
cefazolin. She did not experience any acute surgical
complications; she received 800 cc of intraoperative crystalloid
fluid and 150 cc of estimated blood loss. Post-operatively in
the PACU, she was noted to be quite agitated and delirious and
was given serial boluses of IV haloperidol (total 1.5 mg). She
was also noted to be hypertensive with SBPs as high as the 190s,
though these readings were taken on her right radial arterial
line in the setting of her thrashing around; she was given
standing IV metoprolol and a dose of IV labetalol for BP
control. She was also noted to be oliguric with less than 10 cc
of urine output for several hours; this increased modestly with
a 1000 cc bolus of LR. She was seen again by the medical consult
team regarding transfer to medicine, though she was not felt to
be safe for the floor. The PACU was unable to arrange for the
patient to have a sitter on the floor and, particularly in the
setting of her oliguria and hypertension, was transferred to the
MICU for further management. She remained stable overnight and
was called out to the floor on [**2137-5-1**]. The patient will not
be discharged on anti-coagulation due to her subdural hematoma.
#. Delirium: Since admission here, her course has been notable
for significant delirium. Pre-operatively, she received numerous
boluses of 0.25 mg IV lorazepam for agitation as well as
haloperidol 0.5 mg IV once last night. For pain, she received a
total of 22 mg of IV morphine over the 36 hours prior to
surgery, as well as 0.125 mg of IV hydromorphone. She does have
dementia at baseline with apparent disorientation, though she
usually does recognize familiar faces and post-op did appear to
be worse than baseline. After transfer to floor, all narcotics
were discontinued. Mental status improved and close to baseline
per family. Pain control with tylenol has been successful.
#. Subdural Hematoma: The patient was reportedly found on the
floor of her bathroom complaining of low back pain and was
brought to [**Hospital6 **] in [**Location (un) 1110**] for evaluation.
There, she was found to have a subcapital left femoral neck
fracture as well as a subdural hematoma along the falx and left
tentorium; this was stable on a repeat head CT later the same
day. She was seen by neurosurgery who felt that her small
subdural hematoma was stable on serial head CT scans and did not
feel this was a contraindication to surgery. She should not be
restarted on Aggrenox at this time. If the family so desires,
she will need follow up in 4 weeks per neurosurgery at which
time a repeat CT will be obtained and the decision of whether or
not to restart Aggrenox will be made at that time.
# Acute Renal Failure: Cr 1.4 on admission with unknown
baseline. Trended down with IVF to 1.0.
# Anemia: Admission hct 33, trended down to 24, received 1u
pRBC with appropriate bump. Unknown baseline. Hct on discharge
was stable at 26.
# Hypoxia: Occurred in setting of over sedation as above.
Resolved after discontinuation of narcotics and benzodiazepines.
Was 96% on room air upon discharge.
# NSTEMI: Had in setting of surgery, MB slightly elevated,
trending down. NeuroSurgery advised no systemic Anticoagulation
at this time given head bleed.
# Hypertension: Has at baseline, was treated with iv metoprolol
while not taking po's. Improved after pain and delirium
decreased. She will be discharged on Metoprolol PO.
# Seizure disorder: Medications held while delirious as not
felt safe to take po's. Resume lamotrigine and gabapentin once
able to take PO meds.
# Goals of Care: Family meetings held and palliative care team
consulted to discuss goals of care and the patient will be
discharged to hospice.
Medications on Admission:
(per records)
- lamotrigine 50 mg PO bid
- gabapentin 100 mg PO tid
- Aggrenox 1 tablet PO bid
- atenolol 12.5 mg daily
- isosorbide dinitrate 2.5 mg PO tid
- vitamin C 500 mg [**Hospital1 **]
- folic acid 1 mg daily
- lorazepam 0.5 mg prn agitation
- hydromorphone 0.5 mg SC prn
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours).
Disp:*60 Suppository(s)* Refills:*2*
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on 12 hours off, apply nearL hip surgical incision.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
3. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation: hold for loose stool.
Disp:*30 Suppository* Refills:*2*
4. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
every four (4) hours as needed for Sever pain or breathlessness:
Tonly be used for severe pain, patient has altered mental status
with narcotics.
Disp:*1 30mL bottle* Refills:*2*
5. Lorazepam 2 mg/mL Concentrate Sig: One (1) mg PO every six
(6) hours as needed for Anxiety or agitation.
Disp:*1 30mL Bottle* Refills:*2*
6. Atropine 1 % Drops Sig: Two (2) Drops sublingual Ophthalmic
every four (4) hours as needed for secretions.
Disp:*1 5mL Bottle* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Max 4g total dose daily, please note
PR order.
Disp:*240 Tablet(s)* Refills:*5*
8. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO twice a day:
Can hold if patient not taking POs.
Disp:*120 Tablet(s)* Refills:*2*
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times
a day: Can hold if patient not taking POs.
Disp:*90 Capsule(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
twice a day: Hold for SBP <100, HR<60.
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**]
Discharge Diagnosis:
Delirium
Dementia
Hip Fracture
Hypertension
Subdural Hematoma
Discharge Condition:
Stable
Discharge Instructions:
You have been admitted after a fall resulting in a hip fracture
(break). Our orthpedic surgerons repaired your hip, but some of
the medication used to control your pain also caused you to
become more confused. After the medicine wore off, your
confusion decreased. We have discussed your care with your
family and we will discharge you to a hospice facility to focus
on your comfort.
Followup Instructions:
The patient can follow with Neurosurgery & Orthopedics within
2-4 weeks per the families wishes.
Dr. [**Last Name (STitle) **] (neurosurgery) can be reached at ([**Telephone/Fax (1) 88**]
Dr. [**Last Name (STitle) **] (Orthopedics) can be reached at ([**Telephone/Fax (1) 2007**]
|
[
"820.09",
"272.4",
"799.02",
"852.21",
"345.90",
"E885.9",
"584.9",
"293.0",
"438.89",
"401.9",
"285.9",
"290.0",
"362.50",
"441.4",
"V58.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
10654, 10754
|
4410, 8692
|
278, 313
|
10859, 10867
|
3008, 3013
|
11302, 11584
|
1935, 1987
|
9022, 10631
|
10775, 10838
|
8718, 8999
|
10891, 11279
|
4170, 4387
|
2002, 2989
|
186, 240
|
341, 1265
|
3552, 3870
|
3884, 4154
|
1287, 1700
|
1716, 1919
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,074
| 173,852
|
8969
|
Discharge summary
|
report
|
Admission Date: [**2163-6-7**] Discharge Date: [**2163-6-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Dehydration.
Major Surgical or Invasive Procedure:
PICC line placement x 2
EGD
History of Present Illness:
Briefly, pt is a [**Age over 90 **] y/o F w/hv PVD, ruptured AAA s/p repair
[**10-9**], who presented from [**Hospital 100**] Rehab on [**2163-6-7**] for decreased po
intake. Pt was recently hospitalized from [**Date range (1) 31136**] for
pneumonia and was treated with a course of levofloxacin. Per
report from [**Hospital 100**] Rehab, she then developed oral thrush and
refused to eat or drink, although she denied pain with eating
and drinking. The pt's son visited her at the nursing home and
felt she did not appear as alert as her baseline. Due to concern
for dehydration, she was admitted to the [**Hospital Ward Name **].
Past Medical History:
1. Ruptured abdominal aortic aneurysm repaired in [**Month (only) **]
of [**2158**].
2. Depression.
3. Peripheral vascular disease.
4. Degenerative joint disease.
5. Hypertension.
6. Status post total abdominal hysterectomy.
7. CAD s/p mi managed medically.
Social History:
The patient does not drink. Does not smoke.
Is a retired attorney and retired teacher. Is a widow and
has one son.
Currently living at an [**Hospital3 **] facility.
She ambulates with assistance.
Family History:
non-contributory
Physical Exam:
T=98, 140/60 HR 68, RR=18, O2=95% RA
sleeping, in NAD
neck supple, no JVD, no nodes
dry MM, opaque yellow discharge in post pharnx
RRR nml S1S2, no mrg
Abd soft, NT, ND, naBS
Ext no cce, ecchymoses on b/l LE
Pertinent Results:
[**2163-6-7**] 02:02AM WBC-15.1*# RBC-4.50 HGB-14.3 HCT-42.9# MCV-95
MCH-31.8 MCHC-33.3 RDW-15.0
[**2163-6-7**] 02:02AM NEUTS-80* BANDS-2 LYMPHS-10* MONOS-6 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0 NUC RBCS-1*
[**2163-6-7**] 02:02AM PLT SMR-NORMAL PLT COUNT-195
[**2163-6-7**] 02:02AM PT-13.4* PTT-26.6 INR(PT)-1.2*
[**2163-6-7**] 01:32AM GLUCOSE-112* UREA N-70* CREAT-1.3*
SODIUM-148* POTASSIUM-4.1 CHLORIDE-115* TOTAL CO2-21* ANION
GAP-16
[**2163-6-7**] 10:00AM GLUCOSE-116* UREA N-61* CREAT-1.1 SODIUM-150*
POTASSIUM-3.8 CHLORIDE-114* TOTAL CO2-22 ANION GAP-18
[**2163-6-7**] 05:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2163-6-7**] 05:30AM URINE RBC->50 WBC-[**4-11**] BACTERIA-FEW YEAST-NONE
EPI-0-2
.
.
CXR [**6-16**]):
Bilateral effusions as above with diminished lung volumes. The
bibasilar opacities are likely atelectasis, although early
developing pneumonia cannot be entirely excluded particularly in
light of leukocytosis. No failure.
.
.
TTE:
There is mild (non-obstructive) focal hypertrophy of the basal
septum. The
left ventricular cavity size is normal. Overall left ventricular
systolic
function is mildly depressed with mid-septal and mid to distal
inferior
hypokinesis. Tissue Doppler imaging suggests an increased left
ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The
tricuspid valve leaflets are mildly thickened. The end-diastolic
pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
# [**Female First Name (un) 564**] esophagitis: Admitted with poor po in setting of
thrush. EGD confirmed [**Female First Name (un) **] esophagitis. On IV fluconazole
with clotrimazole troches and nystatin for mouth care. She
should complete a 21d course of fluconazole (day 10 at
discharge).
.
# MRSA septicemia due to UTI with PICC seeding: Hypotensive
during hospital admission, requiring ICU admission for frequent
fluid boluses to maintain bp. Blood cultures subsequently grew
MRSA. Subsequent urine cultures grew MRSA. Patient was treated
with vancomycin x 7 days (d1=[**2163-6-11**]). PICC line (placed for
TPN) discontinued. TTE negative for vegetation. Surveillance
cultures since [**2163-6-10**] (date of PICC removal) no growth to date
so new PICC line placed for TPN.
.
# Acute change in mental status: Onset while on IV fluconazole
and vancomycin. Lactate/ABG/lytes/LFTs/head CT. No focal
deficit appreciated but exam limited. Head MRI showed no acute
process. Likely delirium, severe constipation, and hypothermia
contributing. After bowel regimen, manual disimpaction, warming
blanket, mental status back near baseline, per son. She
continued to have intermittent mild delerium however.
.
# Severe malnutrition: Initially started on TPN but PICC had to
be discontinued due to MRSA line infection. Subsequently,
platelets dropped, concerning for HIT. HIT ab negative and plt
rebounded spontaneously. DEspite risk of PICC and TPN
(infection, fungemia) given that a feeding tube (nasal) would be
uncomfortable for pt, it was decided after d/w family, to
replace PICC and restart TPN.
.
# Thrombocytopenia: HIT antibody negative. Fibrinogen/FDP do
not suggest DIC. Plt rebounded to normal level.
.
# CAD: On ASA. Holding BB.
.
# Afib: On ASA. Rate controlled off BB.
.
# Anemia: Suspect AOCD. HCt was variable over the admission but
not requiring transfusion. No signs of blood loss or hemolysys.
Hct was stable 2d prior to discharge at 27 but overall downward
trend. Would rpt in [**3-12**] days.
.
# DNR/DNI. Goals of care d/w son [**Name (NI) 382**] and he is leaning
towards to do not hospitalized status if she were to
decompensate again.
.
# FEN: Restarted TPN. Trials of POs were intermittently
successful with periods of aspiration at times. However, given
pt expressing desire to eat, soft diet was attempted. Due to
difficulty taking meds, her PO med regimen was pared down and
even with this she was only taking intermittent PO meds.
Medications on Admission:
Aspirin 325 mg Tablet (had been discontinued on floor [**3-11**] LE
ecchymoses)
Venlafaxine 37.5 mg
Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Neutra-Phos [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) pckt PO once a
day for 3 days.
Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
Lovenox
Levothyroxine 25 mcg po qd
Prilosec
Lisinopril
HCTZ
toprol 20 qd
valium 0.5 mg po qhs
Discharge Medications:
1. Aspirin 300 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day).
4. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
5. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback Sig:
One Hundred (100) mg Intravenous once a day for 10 days:
complete 21d course.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
PRIMARY:
Candidal esophagitis
MRSA bacteremia
MRSA UTI
Severe Malnutrition
Delerium
Discharge Condition:
Fair--afebrile, vital signs stable.
Discharge Instructions:
1. Take medications as prescribed.
2. You will be seen by the doctors at rehab. You can address
any concerns with them.
Followup Instructions:
You will be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab
|
[
"558.9",
"V15.81",
"496",
"995.91",
"443.9",
"707.10",
"401.9",
"038.11",
"715.90",
"261",
"412",
"599.0",
"311",
"276.0",
"458.9",
"787.2",
"427.31",
"414.01",
"112.84",
"V09.0",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
7435, 7500
|
3524, 4335
|
274, 303
|
7628, 7666
|
1739, 3501
|
7838, 7939
|
1477, 1495
|
6656, 7412
|
7521, 7607
|
6044, 6633
|
7690, 7815
|
1510, 1720
|
222, 236
|
332, 965
|
4351, 6018
|
987, 1247
|
1263, 1461
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,538
| 145,833
|
43650
|
Discharge summary
|
report
|
Admission Date: [**2161-9-23**] Discharge Date: [**2161-9-25**]
Date of Birth: [**2082-12-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Evaluation for failure to wean from vent.
Possible pneumonia
Major Surgical or Invasive Procedure:
Flexible bronchoscopy
History of Present Illness:
78 M with complicated past medical history presented from
[**Hospital3 105**] for rigid bronchoscopy and possible tracheal
stenting. Patient spirometry consistent with COPD and asthma. In
[**2161-1-21**] he underwent a tracheostomy for prolonged
intubation and has failed weaning since. Recent symptoms include
shortness of breath while on tracheostomy [**Last Name (un) **] and increasing
secretions. Prior to admission to [**Hospital1 18**], sputum cultures were
consistent with stenotrophomonas and pseudomonas bacteria as
well as enterobacter. Recent urine culture from [**2161-9-14**] was
consistent with MRSA and proteus.
-
Past Medical History:
COPD, HTN, diverticulosis, c.diff colitis in past, prostate CA
s/p resection, peripheral vascular disease, CHF with diastolic
dysfunction, non ST elevation MI in [**2158**], chronic pain (L2
compression fracture, 9th rib fracture), hyperlipidemia, chronic
anemia.
Social History:
Married. 50 pack-year history, quit 20 years ago. Married.
Denies alcohol use.
Physical Exam:
No acute distress.
Sclerae anicteric. PERRL.
Neck supple, no lymphadenopathy. Tracheostomy in place. Clean,
dry.
Regular rate and rhythm. S1 S2 normal. No rubs, gallops
Mild end-expiratory wheezes.
Abdomen with PEG tube in place. Clean and dry. Bowel sounds
diminished but present.
Extremities cool but well perfused. Limited movement of
extremities. No edema.
Pertinent Results:
[**2161-9-25**] 03:47AM BLOOD WBC-17.5*# RBC-3.41* Hgb-10.7* Hct-33.6*
MCV-99* MCH-31.5 MCHC-31.9 RDW-16.9* Plt Ct-738*
[**2161-9-24**] 12:10AM BLOOD WBC-10.5 RBC-2.98* Hgb-9.7* Hct-28.5*
MCV-96 MCH-32.4* MCHC-33.9 RDW-17.2* Plt Ct-746*
[**2161-9-25**] 03:47AM BLOOD Plt Ct-738*
[**2161-9-24**] 12:10AM BLOOD Plt Ct-746*
[**2161-9-24**] 12:10AM BLOOD PT-12.0 PTT-NOTIFIED D INR(PT)-1.0
[**2161-9-25**] 03:47AM BLOOD Glucose-112* UreaN-49* Creat-1.3* Na-140
K-4.4 Cl-98 HCO3-30 AnGap-16
[**2161-9-24**] 12:10AM BLOOD Glucose-90 UreaN-49* Creat-0.9 Na-143
K-4.7 Cl-99 HCO3-34* AnGap-15
[**2161-9-24**] 12:10AM BLOOD ALT-33 AST-23 AlkPhos-227* Amylase-40
TotBili-0.5
[**2161-9-25**] 03:47AM BLOOD Calcium-9.1 Phos-5.1* Mg-2.4
[**2161-9-24**] 12:10AM BLOOD Albumin-3.4 Calcium-9.9 Phos-4.9* Mg-2.7*
[**2161-9-24**] 12:10AM BLOOD Vanco-<2.0*
[**2161-9-24**] 12:10AM BLOOD GreenHd-HOLD
[**2161-9-23**] 10:59PM BLOOD Type-ART pO2-106* pCO2-49* pH-7.48*
calTCO2-38* Base XS-11
[**2161-9-24**] 12:10AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2161-9-24**] 10:57PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-0.2 pH-5.0 Leuks-SM
[**2161-9-24**] 12:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2161-9-24**] 10:57PM URINE RBC-0-2 WBC-[**5-2**]* Bacteri-MOD Yeast-NONE
Epi-0
[**2161-9-24**] 12:10AM URINE RBC-0 WBC-[**10-12**]* Bacteri-NONE Yeast-NONE
Epi-1
[**2161-9-24**] 10:57 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2161-9-25**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS. [**2161-9-23**] 11:38 pm
SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2161-9-24**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Pending):
Cardiology Report ECHO Study Date of [**2161-9-24**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function.
Weight (lb): 145
BP (mm Hg): 115/40
HR (bpm): 59
Status: Inpatient
Date/Time: [**2161-9-24**] at 14:43
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W052-0:37
Test Location: West SICU/CTIC/VICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.7 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.43 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 70% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 0.89
Mitral Valve - E Wave Deceleration Time: 252 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded. Overall normal LVEF (>55%). TVI E/e' >15, suggesting
PCWP>18mmHg.
Transmitral Doppler and TVI c/w Grade I (mild) LV diastolic
dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root.
AORTIC VALVE: Aortic valve not well seen. No AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Mild thickening of mitral valve chordae.
Calcified tips
of papillary muscles. No MS. Mild (1+) MR. Prolonged (>250ms)
transmitral
E-wave decel time. LV inflow pattern c/w impaired relaxation.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - poor parasternal views. Suboptimal image quality
- poor apical
views.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded.
Overall left ventricular systolic function is normal (LVEF 70%).
Tissue
velocity imaging E/e' is elevated (>15) suggesting increased
left ventricular
filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue
velocity
imaging are consistent with Grade I (mild) LV diastolic
dysfunction. Right
ventricular chamber size and free wall motion are normal. The
aortic valve is
not well seen. There is no aortic valve stenosis. The mitral
valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired
relaxation. There is no pericardial effusion.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2161-9-24**] 15:21.
[**Location (un) **] PHYSICIAN:
RADIOLOGY Final Report
PORTABLE ABDOMEN [**2161-9-25**] 8:08 AM
PORTABLE ABDOMEN
Reason: nausea / vomiting r/o obstruction
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with resp failure s/p aspiration
REASON FOR THIS EXAMINATION:
nausea / vomiting r/o obstruction
INDICATION: 78-year-old man with respiratory failure status post
aspiration. Nausea and vomiting. Rule out obstruction.
COMPARISON: None.
TECHNIQUE: A single supine portable radiograph of the abdomen
and pelvis was obtained. A paucity of bowel gas is identified
with no obviously dilated bowel identified. Stool is identified
within the colon. G tube is identified and appears unremarkable.
No obvious evidence of free intraperitoneal air, however, full
evaluation for free air is limited by supine technique.
Evaluation of osseous structures reveals an ill-defined bony
formation abuting the right acetabulum. Involvement of the right
femur cannot be excluded. Recommend plain radiograph of hips for
further evaluation if a work up has not been performed in the
past.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Patient was admitted to the CSRU at [**Hospital1 18**] in the evening of
[**2161-9-23**] for further evaluation. Vancomycin and Zosyn was started
for suspected pneumonia. Urine, sputum and blood cultures were
sent with sputum Gram stain showing 4+ (>10 per 1000X FIELD):
GRAM POSITIVE COCCI N PAIRS AND CLUSTERS, and 2+ (1-5 per
1000X FIELD): GRAM NEGATIVE ROD(S). Cultures are pending.
Urine showed STAPH AUREUS COAG +. 10,000-100,000
ORGANISMS/ML. with sensitivites pending.
Echocardiogram was obtained and showed LVEF = 70%. Patient
underwent a flexible bronchoscopy on [**9-24**] that showed severe
epiglottic and supra-epiglottic edema. Because of this, it was
deemed unsafe to proceed with a rigid bronchoscopy. GRAM . On
[**9-24**] patient also experienced nausea and a probable aspiratory
event. He remained hemodynamically stable and respiratory status
was not compromised. On the evening of [**9-24**] he spiked a fever to
103 degrees F. This was thought to be secondary to the
aspiration event. Repeat Gram stain cultures showed 1+ (<1 per
1000X FIELD): GRAM NEGATIVE ROD(S), 1+ (<1 per 1000X
FIELD): GRAM POSITIVE COCCI IN PAIRS. Because of this,
antibiotics were changed to Linezolid and Cefepime. Famotidine
frequency was increased to [**Hospital1 **] and patient was started on
Reglan. He is being discharged to rehabilitation facility on an
8 day course of antibiotics and will follow up with Dr. [**First Name (STitle) **]
[**Name (STitle) **] for possible rigid bronchoscopy in 4 weeks.
Discharge Medications:
1. Bisacodyl 10 mg Suppository [**Name (STitle) **]: [**11-24**] Suppositorys Rectal HS
(at bedtime) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
3. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: [**11-24**] PO Q4-6H (every
4 to 6 hours) as needed for fever.
4. Simethicone 80 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
5. Buspirone 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a
day).
6. Isosorbide Dinitrate 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
(3 times a day).
7. Cefepime 2 g Recon Soln [**Month/Day (2) **]: One (1) Recon Soln Injection
Q24H (every 24 hours) for 8 days.
Disp:*8 Recon Soln(s)* Refills:*0*
8. Metoclopramide 5 mg/mL Solution [**Month/Day (2) **]: One (1) Injection Q6H
(every 6 hours).
9. Linezolid 600 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H (every 12
hours) for 8 days.
10. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Metoprolol Tartrate 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
13. Senna 8.6 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO BID (2 times a day)
as needed.
14. Therapeutic Multivitamin Liquid [**Month/Day (2) **]: One (1) Cap PO
DAILY (Daily).
15. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Month/Day (2) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Two
(2) Puff Inhalation Q4H (every 4 hours).
18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
19. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) Injection [**Hospital1 **] PRN ()
as needed for anxiety.
20. Morphine 2 mg/mL Syringe [**Hospital1 **]: One (1) Injection Q4H (every
4 hours) as needed for pain.
21. Tube feeds
1. Tubefeeding: Start Now; Nutren Pulmonary Full strength;
Starting rate: 20 ml/hr; Advance rate by 20 ml q4h Goal rate: 65
ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 30 ml water q8h
22. Outpatient Lab Work
Please check liver function tests, chem 7 and CBC once per week
of more freaquently if deemed necessary.
Repleate electrolytes as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Upper airway swelling, aspiration pneumonia, COPD, failure to
wean from vent.
Discharge Condition:
Stable to rehabilitation facility.
Discharge Instructions:
come to ER if having worsening pains, fevers, chills, nausea,
vomiting, shortness of breath, chest pain, redness or drainage
about the wounds, or if there are any questions or concerns.
Patient to take antibiotics and other medications as directed.
Patient to take all medications as directed.
Please keep all follow up appointments.
Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] office at [**Telephone/Fax (1) 3020**] with
questions or concerns.
Followup Instructions:
Please follow up with your primary care physician.
[**Name10 (NameIs) 357**] call Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Telephone/Fax (1) 3020**] to schedule your
follow up appointment. Your appointment should be in 4 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2161-9-25**]
|
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"519.19",
"493.20",
"401.9",
"507.0",
"272.4",
"518.83",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"33.23",
"96.71"
] |
icd9pcs
|
[
[
[]
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|
8467, 9993
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382, 406
|
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12724, 12804
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12886, 13353
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4138, 7292
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1464, 1826
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282, 344
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7570, 8444
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434, 1066
|
7326, 7455
|
1088, 1353
|
1369, 1449
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,121
| 123,819
|
35815
|
Discharge summary
|
report
|
Admission Date: [**2176-12-20**] Discharge Date: [**2176-12-25**]
Date of Birth: [**2120-3-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
dyspnea, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 56 yo M with a history of PE's (has had two in
distant past, w/u supposedly negative). He presented yesterday
with dyspnea to [**Hospital1 **] ED, where he was found to have
a large saddle embolus on CTA. He was started on a heparin drip
and transferred to [**Hospital1 18**]. In the ED here, VS were 95% on 4L, RR
20-22, T 97.7, HR 105, BP 129/86. Troponin was 0.02.
Of note, he has been progressively SOB for the last month.
Three-plus weeks ago he presented to his PCP, [**Name10 (NameIs) 1023**] felt obtained
a CXR (which was negative) and prescribed Xanax for anxiety.
Over the holidays he developed URI sx with rhinorrhea and
eventually a productive cough. He was also scheduled for a
stress test by his PCP, [**Name10 (NameIs) 6643**] he never went to because of his
cold sx. Last week, he returned to his PCP office when he was
given an inhaler and a nasal steroid. the night PTA, he felt
severely SOB walking up a flight of steps when he went to bed,
and the morning of admission, he called the paramedics after
feeling severely SOB walking to work.
He has not had long flights recently (last was to Bermuda in
[**8-19**]) or leg swelling, denied trauma to legs. Smoked some
cigars last summer, but never a cigarette smoker. Colonoscopy
was 3 years ago (two adenomatous polyps removed). No known
prostate history. No family history of clotting disorder.
ROS:
Negative for CP, back/abd pain, nausea, diaphoresis, F/C. Has
had 10 lb weight loss in last month but also admitted to
decreased PO intake with cold.
Past Medical History:
Asthma in childhood
Two prior PE's
-- Post-op ankle surgery PE ~25 years ago
-- idiocratic PE ~10 years ago
-- supposeldy has no fam hx of clot and had neg heme-onc w/u for
PE
-- non-smoker
Social History:
-- life-time non-smoker though started smoking some cigars last
summer (last was in [**Month (only) 216**])
-- denied IVDU, EtOH
-- lives with a friend
-- not married, has girlfriend
Family History:
no known clotting disorders, father has bladder + prostate CA
and had DVT
Physical Exam:
Afebrile. Satting well on room air and > 90% on ambulatory
sats, uses CPAP overnight
General: well nurished, overweight; appears SOB resting in bed
but able to speak in full sentences
Lungs: CTA b/l, no crackles, no wheezes
Cardio: RRR, no m.r.g.
Abd: + BS, soft, tender to deep palpation
Extremities: calves non-tender, warm or ertythematous, no cords
Neuro: AA, Ox3; CN II - XII in tact; moving all extremities,
gait deferred
Pertinent Results:
CBC:
[**2176-12-20**] 02:20PM BLOOD WBC-11.5* RBC-4.91 Hgb-15.5 Hct-41.0
MCV-84 MCH-31.6 MCHC-37.9* RDW-13.5 Plt Ct-182
[**2176-12-24**] 06:05AM BLOOD WBC-6.4 RBC-4.59* Hgb-14.4 Hct-38.4*
MCV-84 MCH-31.4 MCHC-37.6* RDW-13.4 Plt Ct-247
Coags:
[**2176-12-20**] 03:31PM BLOOD PT-15.8* PTT-124.5* INR(PT)-1.4*
[**2176-12-24**] 11:25AM BLOOD PT-30.8* PTT-40.8* INR(PT)-3.2*
[**2176-12-25**] 05:10AM BLOOD PT-30.8* PTT-42.5* INR(PT)-3.2*
Chemistry:
[**2176-12-20**] 02:20PM BLOOD Glucose-107* UreaN-12 Creat-1.0 Na-140
K-4.2 Cl-107 HCO3-18* AnGap-19
[**2176-12-24**] 06:05AM BLOOD Glucose-87 UreaN-12 Creat-1.2 Na-140
K-4.4 Cl-108 HCO3-25 AnGap-11
[**2176-12-20**] 06:24PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2
[**2176-12-24**] 06:05AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.4
Cardiac Enzymes:
[**2176-12-20**] 02:20PM BLOOD cTropnT-0.02*
[**2176-12-21**] 04:28AM BLOOD CK-MB-6 cTropnT-<0.01 proBNP-3323*
[**2176-12-20**] 02:20PM BLOOD CK(CPK)-142
[**2176-12-21**] 04:28AM BLOOD CK(CPK)-129
RADIOLOGY:
[**2176-12-19**] CTA from OSH: large saddle embolus with extension into
the left PA segments
[**2176-12-19**] CXR: clear, NAD; + vascular markings
ECHO:
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The
estimated cardiac index is borderline low (2.0-2.5L/min/m2).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). The right ventricular cavity is
markedly dilated with focal basal free wall hypokinesis
([**Last Name (un) **] sign). 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. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
severe pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Underfilled left ventricle with normal systolic and
diastolic function (apparent hypertrophy likely a result of
underfilling). Markely dilated right ventricle with basal
hypokinesis. Severe pulmonary artery systolic hypertension.
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and color
Doppler
son[**Name (NI) 493**] images were obtained that demonstrate the bilateral
common
femoral, superficial femoral, greater saphenous veins are
compressible with wall-to-wall flow and normal response to
respiration and augmentation. There is a occlusive thrombus in
the right popliteal that extends into the right posterior tibial
and peroneal veins. On the left the popliteal vein is
compressible with wall-to-wall flow and normal response to
respiration and augmentation and calf veins are visualized.
IMPRESSION: Occlusive thrombus of the right popliteal, posterior
tibial and peroneal veins.
Brief Hospital Course:
(#) Saddle PE: Patient was started on heparin drip and
Coumadin. He was transitioned from the heparin drip to Lovenox
and continued on his Coumadin. A echo showed evidence of right
heart strain but he remained hemodynamically stable. LENIs
showed that he had a DV. An IVC filter was discussed but as he
had not failed Coumadin therapy the decision was made to
anticoagulate him for life. He will have his INR followed at
his PCPs office.
.
Per the patient he has had a hypercoagulable work up done in the
past which was negative. He was not set up with a hematologist
as he will need lifelong anticoagulation at this point. The
decision to do any further workup for a hypercoagulable state
was deferred to his PCP and the patient.
.
(#) COUGH: Was not thought to be infectious. He remained
afebrile and without an elevated white count. The cough was
thought be related either to a UTI or lung irritation from the
PE. He was treated symptomatically with Tessalon pearls and
codeine.
.
(#) Code: Full
Medications on Admission:
Albuterol-- recently added for URI
Xanax
Nasal steroid spray
Discharge Medications:
1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
2. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for 1 months.
Disp:*QS ML(s)* Refills:*1*
4. Codeine Sulfate 30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for 1 months.
Disp:*QS Tablet(s)* Refills:*1*
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
Have your INR checked on Friday [**2176-12-27**]. Have results sent to
Dr. [**Last Name (STitle) 13959**] if not drawn at his office (p[**Telephone/Fax (1) **],
f[**Telephone/Fax (1) **])
Discharge Disposition:
Home
Discharge Diagnosis:
Deep Vein Thrombosis
Pulmonary Embolism
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because of shortness of breath
and found to have a clot in your lungs (Pulmonary Embolism).
You were then found to more clot in your leg. You were started
on a blood thinner to prevent more clot from forming. You will
most likely need to take coumadin for the rest of your life.
Medication changes:
1) Coumadin 3mg have your INR checked on Friday [**2176-12-27**]. Your
dose may be adjust by Dr. [**Last Name (STitle) 13959**] based on those results.
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:
Dr. [**Last Name (STitle) 13959**] in [**12-13**] weeks [**Telephone/Fax (1) 41186**]
Please visit Dr.[**Name (NI) 29792**] office on [**2176-12-26**] to have your INR
checked. They will instruct you on further blood draws.
|
[
"V58.61",
"786.2",
"453.41",
"327.23",
"415.19",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7936, 7942
|
5993, 7005
|
329, 336
|
8026, 8035
|
2899, 3661
|
8815, 9043
|
2360, 2435
|
7116, 7913
|
7963, 8005
|
7031, 7093
|
8059, 8375
|
2450, 2880
|
3678, 5970
|
8395, 8792
|
277, 291
|
364, 1929
|
1951, 2143
|
2159, 2344
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,601
| 155,131
|
237
|
Discharge summary
|
report
|
Admission Date: [**2131-12-23**] Discharge Date: [**2131-12-29**]
Service: MEDICINE
Allergies:
Bactrim / Amiodarone / Quinine / Codeine / Zithromax /
Lisinopril / Citalopram / Ciprofloxacin / Hydralazine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation
PICC line placement
Hemodialysis
Transfusion of one unit packed red blood cells
History of Present Illness:
A [**Age over 90 **] year-old female with past medical history of chronic
obstructive pulmonary disease, Wegener's granulomatosis, recent
admission [**Date range (1) 2374**] for acute on chronic renal failure
with decision to initiate hemodialysis at that time and hospital
stay complicated by left lower lobe Moraxella pneumonia
presenting with altered mental status. Per her daughter, the
patient was home this past week and accidentally took trazodone
50 mg two days prior to admission, which had been discontinued
due to confusion. Her confusion/visual hallucinations improved
the day prior to admission. She complained of increased
productive cough and oxygen requirement (previously intermittent
2L NC, now continuous) over the past two days, responding to an
increase in nebulizer treatments. The patient was noted to be
lethargic this afternoon, responsive to sternal rub. When
aroused, she was oriented x 3 and moving all extremities well,
however. The patient was noted to be "cold." She has not
complained of recent fevers, chills, chest pain, abdominal pain,
nausea, vomiting, diarrhea, erythema around line.
.
In the ED, initial VS T 96, HR 63, BP 77/55, RR 18 SaO2 98%
(oxygen not documented). Per report, patient had poor
respiratory effort, became apneic, and was subsequently
intubated. Chest x-ray showed bilateral effusions and left
lower lobe pneumonia. Head CT negative for acute process. A
right femoral line was placed for access. She was given
etomidate and roccuronium for intubation, vancomycin 1 gm IV x
1, zosyn 4.5 gm IV x 1, 1L NS. The patient was started on
levophed for hypotension peri-intubation, off within half an
hour.
.
On arrival to the MICU, she is responsive to tactile stimuli.
Past Medical History:
- Chronic obstructive pulmonary disease: No pulmonary function
testing in our system; currently managed with Duonebs
- Wegener's granulomatosis: Complicated by renal failure
requiring HD
- End-stage renal disease on hemodialysis: Started on
hemodialysis last admission, was previously on two years prior
- Atrial fibrillation: Rate-controlled; on coumadin
- Transient ischemic attack: Occurred during prior
hospitalization when her anticoagulation was held
- Hard of hearing: Bilateral hearing aids
Social History:
The patient lives with her daughter. She is able to perform
most of her ADLs on her own. 60 py smoking history but quit 20
yrs ago. She has a caretaker/friend who comes to the house to
help once a week.
Family History:
Non-contributory
Physical Exam:
General Appearance: Well nourished
Head, Ears, Nose, Throat: Normocephalic, PERRL
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Breath Sounds: Rhonchorous: L > R)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, failed AV fistula in
left upper extremity
Skin: Warm
Neurologic: Responds to: Verbal stimuli, Movement: Non
-purposeful, Sedated, Tone: Normal
Pertinent Results:
Labs on Admission:
[**2131-12-23**] 04:50PM WBC-9.6# RBC-3.22* HGB-8.6* HCT-27.8* MCV-86
MCH-26.6* MCHC-30.8* RDW-15.6*
[**2131-12-23**] 04:50PM NEUTS-73* BANDS-2 LYMPHS-18 MONOS-2 EOS-1
BASOS-0 ATYPS-0 METAS-4* MYELOS-0
[**2131-12-23**] 04:50PM PLT SMR-NORMAL PLT COUNT-330#
[**2131-12-23**] 04:50PM PT-21.4* PTT-57.4* INR(PT)-2.0*
[**2131-12-23**] 04:50PM GLUCOSE-135* UREA N-45* CREAT-6.3*
SODIUM-131* POTASSIUM-5.6* CHLORIDE-94* TOTAL CO2-28 ANION
GAP-15
[**2131-12-23**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2131-12-23**] 09:22PM CK(CPK)-22*
[**2131-12-23**] 09:22PM CK-MB-NotDone cTropnT-0.03*
Labs on Discharge:
[**2131-12-29**] 06:07AM BLOOD WBC-6.4 RBC-3.18* Hgb-8.8* Hct-26.9*
MCV-85 MCH-27.6 MCHC-32.7 RDW-18.2* Plt Ct-250
[**2131-12-29**] 06:07AM BLOOD Glucose-139* UreaN-11 Creat-3.5* Na-142
K-3.6 Cl-104 HCO3-30 AnGap-12
MICRO:
[**2131-12-24**] Sputum Culture: MORAXELLA CATARRHALIS. MODERATE
GROWTH.
Studies:
[**2131-12-28**] CT CHEST:
1. Simple bilateral pleural effusions are moderate on the left
and small on the right. No definite underlying consolidation is
seen.
2. Recommend three-month followup for right apex lesion with
internal
calcification, which may represent scarring, although underlying
neoplastic process cannot be excluded.
3. Moderate-to-severe coronary artery atherosclerosis is most
prominent in
the left anterior descending artery.
4. Small pericardial effusion causes no mass effect.
5. Splenic hypodensity is not well characterized and ultrasound
may be
obtained for evaluation if clinically indicated.
6. Moderate emphysema.
[**2131-12-23**] CXR: Bibasal effusions with a pneumonic consolidation
in the left lower lobe. Please ensure followup to clearance.
[**2131-12-23**] CT HEAD:
1. No evidence of acute intracranial hemorrhage.
2. Left frontal encephalomalacia with probable slight further
involution.
3. Left maxillary sinus disease.
Brief Hospital Course:
Mrs. [**Known lastname 46**] is a [**Age over 90 **] yo F with past medical history of COPD,
Wegener's granulomatosis with resulting chronic kidney disease,
recent admission [**Date range (3) 2374**] for acute on chronic renal
failure, started on hemodialysis w/hospital stay c/b left lower
lobe Moraxella pneumonia admitted with recurrant moraxella
pneumonia and sepsis.
1)Moraxella pneumonia: Most likely explanation for respiratory
failure/hypotension in ED requiring intubation. She was
successfully extubated on [**12-25**] and maintaining O2 sats on O2
via NC without e/o respiratory distress. Her sputum culture
from [**2131-12-24**] is again growing Moraxella, no other new
organisms. CXR continues to show same LLL infiltrate concerning
for partially treated pneumonia. Concerning for endobronchial
lesion with postobstructive pneumonia however chest CT did not
show any underlying structural cause for recurrance of
pneumonia. She did have bilateral pleural effusions which
appeared simple and did not appear to be parapneumonic. She was
initially treated with vancomycin and zosyn however this was
changed to ceftriaxone once culture data returned with
moraxella. She improved daily from a repiratory standpoint and
was on minimal to no oxygen on discharge. She was changed to
cefpodoxime on discharge to be given only on hemodialysis days,
after dialysis as this antibiotic is renally cleared.
2)Altered mental status: Likely delirium in the setting of
infection, sedating meds, ICU stay especially in setting of
advanced age. In addition, daughter reports that she took
trazodone two days prior to admission, which has caused
confusion in the past. She had a CT head on admission without
acute process. Her mental status cleared during her hospital
stay and treatment of pneumonia.
3)Coagulopathy: Her INR was 2 on admission, however climbed to
peak of 5.3 likley due to poor nutrition and antibiotics. Her
coumadin was stopped [**12-25**] and held throughout the remainder of
her admission. She was restarted on 1mg coumdain on discharge
with INR checks with dialysis. Her INR was 2.9 on the day of
discharge.
4)Chronic renal failure: Secondary to ANCA vasculitis. Decision
made to initiate HD last admission. She was dialysed for volume
overload in the hospital and was dishcarged with plan for
dialysis at FMC - West Suburban Dialysis Center. She was
continued on epogen with dialysis, nephrocaps, calcitriol,
calcium.
5)Anemia: Baseline mid-20s as of most recent [**12-10**] admission;
prior to that was in the low 30s. No signs or symptoms of active
bleeding, guaiac negative. She was transfused one unit PRBC
with dialysis on [**12-26**] with stable hematocrit around 26
throughout the remainder of her hospitalization. She should be
continued on epogen with dialysis.
6)Diarrhea - patient has developed diarrhea in setting of
multiple admissions and antibiotics. She had one stool that was
negative for C. diff and was started on loperamide to decrease
stool output given skin breakdown. She was also advised to eat
yogurt three times daily. Diarrhea is most likely antibiotic
associated due to alteration of normal bowel flora, however she
will require two additional stool samples to rule out C.diff.
She will require monitoring of in's and out's and encouragement
for oral intake to prevent dehydration.
7)Skin Breakdown: During her admission she began developing skin
breakdown on her gluteal cleft likely due to a combination of
immobility due to acute illness and diarrhea as discussed above.
She will require close monitoring of her skin and frequent
personal care to keep her buttocks clean and protected.
8)Paroxysmal Atrial fibrillation: Her metoprolol was initially
held in the ICU given sinus bradycardia and sepsis. It was
resumed at home dose on [**12-26**] however given borderline blood
pressures, it was decreased to 75mg [**Hospital1 **] on [**12-27**].
9) Spiculated lesion on CT chest: as discussed in radiology
report, will need repeat CT in 3 months to reassess this lesion
for stability.
10)Hypothyroidism: Continue levothyroxine
11)Code: Full
12) Comm: [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Name (NI) 46**] [**Telephone/Fax (1) 2373**], daughter/HCP
Medications on Admission:
Medications:
1. Coumadin 1 mg PO DAILY
2. Nephrocaps 1 mg PO DAILY
3. Metoprolol Tartrate 100 mg PO BID
4. Levothyroxine 125 mcg PO DAILY
5. Fluticasone 50 mcg Spray [**1-3**] Sprays Nasal [**Hospital1 **]:PRN nasal
symptoms
6. Albuterol Sulfate Nebulization Q4H:PRN
7. Ipratropium Bromide Inhalation Q6H
8. Pantoprazole 40 mg PO BID
9. Fexofenadine 30 mg PO BID:PRN allergies
10. Calcitriol 0.25 mcg PO DAILY
11. Guaifenesin 100 mg/5 mL Syrup 5-10 MLs PO Q6H:PRN cough
12. Miconazole Nitrate 2 % Powder Appl Topical TID
13. Fluocinolone 0.01 % Cream Topical [**Hospital1 **]:PRN eczema
14. Cefpodoxime 200 mg 3x/week for 12 days
Discharge Medications:
1. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:
please have your INR checked at dialysis and dose adjusted .
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray
Nasal twice a day as needed for rhinorrhea.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Epoetin Alfa 10,000 unit/mL Solution Sig: according to
protocol Injection ASDIR (AS DIRECTED): at dialysis.
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 5 days.
14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO QHD (each
hemodialysis): please give only on HD days, please give after HD
complete
Day 1 =[**2131-12-24**]
Last Day=[**2131-1-6**].
16. Outpatient Lab Work
Please send stool two stool samples for C.difficile
17. Outpatient Lab Work
Please check INR with hemodialysis and adjust coumadin
accordingly.
Discharge Disposition:
Extended Care
Facility:
st. [**Doctor Last Name 2375**] manor
Discharge Diagnosis:
Chronic Kidney disease on hemodialysis
Wegener's granulomatosis
Paroxysmal atrial fibrillation
COPD
Non-infectious diarrhea
Secondary Diagnoses:
Anemia
Discharge Condition:
fair
O2 saturation 95% on 0.5L NC
Discharge Instructions:
You were admitted to the hospital with confusion, low blood
pressure and low oxygen most likely due to a serious pneumonia.
You were intubated and sent to the ICU for care. You improved
and were able to be extubated the following day. You were
treated with antibiotics for pneumonia and your breathing
improved. You had blood cultures, urine cultures and stool
cultures which did not show any evidence of infection.
You had dialysis with fluid removal as you were given a large
amount of IV fluids on admission for your infection which caused
swelling in your arms and fluid around your lungs.
You developed diarrhea during your admission which is most
likely due to antibiotics. You were started on loperamide to
attempt to decrease the diarrhea and to prevent further skin
breakdown.
Medications:
1)You will be discharged on cefpodoxime to complete a 2 week
course of antibiotics. This should be taken only on dialysis
days, after your dialysis.
2)You can take loperamide as needed to decrease your diarrhea.
3)Your coumadin was held during your admission but can be
restarted on discharge as your INR was down to 2.9.
4)Your metoprolol was decreased to 75mg twice daily as your
blood pressure was borderline low.
No other changes were made to your medications.
Please follow up as below.
Please call your doctor or return to the hospital if you have
any concerning symptoms including fevers, confusion, chest pain,
trouble breathing, low blood pressure or other worrisome
symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB)
Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2132-1-23**] 11:15
.
Dialysis:
FMC - West Suburban Dialysis Center
[**Last Name (NamePattern1) 2376**].
[**Location (un) 47**] [**Telephone/Fax (1) 2377**]
Due to the upcoming holiday the pt. will be on special holiday
schedule, which will be [**Telephone/Fax (1) 766**], Wednesday and Saturday at
11:00am. Her confirmed dialysis schedule will be every Tues.,
Thurs. and Saturday at 11:00am.
.
Please call the radiology departement at [**Telephone/Fax (1) 250**] #1 to
schedule an appointment for an ultrasound of your left arm.
Please call Dr. [**Last Name (STitle) 1683**] or Dr. [**First Name (STitle) 805**] after you have this study
so they know to look for the results.
Please call Dr. [**Last Name (STitle) 1683**] at [**Telephone/Fax (1) 1144**] and schedule an
appointment to follow up within one to two weeks of discharge.
Please discuss with Dr. [**Last Name (STitle) 1683**] schedule a CT scan of your chest
in 3 months to further evaluate a nodule seen on chest CT during
your admission.
Please call Dr. [**First Name (STitle) 805**] at [**Telephone/Fax (1) 2378**] and schedule an
appointment to follow up.
|
[
"707.03",
"447.6",
"995.92",
"496",
"285.21",
"286.9",
"787.91",
"584.9",
"V12.54",
"244.9",
"585.6",
"482.83",
"518.81",
"E932.0",
"733.00",
"427.31",
"403.91",
"V58.61",
"446.4",
"707.21",
"E930.8",
"443.9",
"249.00",
"V58.67",
"038.9",
"V45.11",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"39.95",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12267, 12331
|
5600, 7026
|
339, 432
|
12528, 12564
|
3594, 3599
|
14107, 15414
|
2956, 2974
|
10528, 12244
|
12352, 12477
|
9873, 10505
|
12588, 14084
|
2989, 3575
|
12498, 12507
|
278, 301
|
4306, 5410
|
460, 2194
|
5419, 5577
|
3613, 4287
|
7041, 9847
|
2216, 2716
|
2732, 2940
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,296
| 121,970
|
12200
|
Discharge summary
|
report
|
Admission Date: [**2147-2-9**] Discharge Date: [**2147-2-19**]
Date of Birth: [**2075-3-29**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 71 year old
male with a history of hypertension, hypercholesterolemia,
past tobacco use, past myocardial infarction in [**2133**] and left
circumflex percutaneous transluminal coronary angioplasty in
[**2133**]. The patient is very active, swimming 5 times a week.
He was in his usual state of health until 1-1/2 weeks ago
when he developed dyspnea on exertion noted during swimming
and then increasing to walking short distances. Denies
shortness of breath at rest. Presented to [**Hospital3 417**]
Emergency Department yesterday with worsening dyspnea on
exertion, ruled out for myocardial infarction, found to be in
atrial fibrillation which was new for the patient. Apgars
showed severe mitral regurge. Of note, echocardiogram from
[**2137**] showed 3+ mitral regurge. The patient was started on
heparin and given one dose of Coumadin last night. The
patient was transferred to [**Hospital1 188**] for cardiac catheterization to rule out ischemia and
further evaluation for surgical intervention.
MEDICAL HISTORY: Includes;
1. Coronary artery disease status post non Q wave myocardial
infarction in [**2133**] and status post left circ percutaneous
transluminal coronary angioplasty in [**2133**].
2. Newly diagnosed atrial fibrillation.
3. Hypertension.
4. Elevated cholesterol.
5. History of childhood rheumatoid.
6. Peptic ulcer disease.
7. Pneumothorax in [**2137**].
PAST SURGICAL HISTORY: Includes;
1. Right inguinal hernia repair.
2. Appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: Include
1. Atenolol 100 mg p.o. q.d.
2. Accupril 10 mg p.o. q.d.
3. Folic acid 1 mg p.o. q.d.
4. Tagamet 800 mg p.o. q.d.
At the outside hospital he was on Lipitor 20 mg p.o. q.d.,
aspirin 81 mg p.o. q.d., Pepcid 40 mg p.o. q.d., heparin 1100
units/hr and Coumadin 5 mg p.o. q.d. times one dose.
LABS ON ADMISSION: White count 6.3, hematocrit of 39,
platelets 278, Chem-7 of 138, 4.3, 103, 28, 16, 1.4 and 107.
PHYSICAL EXAMINATION: On physical examination, he is a white
male in no acute distress. No shortness of breath with
conversation, alert and oriented times three. Vital signs:
Heart rate of 70's, blood pressure 122/72, his saturating 86%
on room air and respiratory rate of 16. Neck: No bruits.
Lungs are clear. Heart: S1, S2 loud, [**4-24**] holosystolic
murmur at the apex, [**5-25**] in the left lying position. Abdomen
is soft, nontender, nondistended. Femoral; right groin 1+,
no bruits, left 1+ no bruits, palpable DP/PT pulses
bilaterally.
The patient was admitted to the Medical Service on [**2147-2-9**]
and an echocardiogram was repeated as well as a cardiac
catheterization. The cardiac catheterization demonstrated
subacute severe 4+ mitral regurge with depressed CIMBP. The
patient was referred to the Cardiothoracic Surgery Service
for repair of his mitral valve. On [**2147-2-13**], the patient
underwent a mitral valve repair with a 29 mm [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**]
valve. The patient did well postoperatively and was
transferred to the unit. He was weaned off of his Neo drip
on postoperative day number one and his chest tube was
removed on postoperative day number one. On postoperative
day number two, the patient developed left sided facial droop
and left arm weakness. Neurology was consulted regarding
this issue. Upon their evaluation, they seemed to have a
right MCA territory with neglect and distal hand weakness.
The patient had carotid ultrasound studies which was negative
and head CT which was negative. Physical Therapy evaluated
the patient and felt that he would be appropriate for short
term rehabilitation. On postoperative day number three it
was felt that his arm weakness was improving as well as his
facial droop. The patient was started on heparin with the
start of his stroke symptoms. The patient was also started
on Coumadin. Goal INR is 3 to 3.5 because of the patient's
[**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] valve. Occupational Therapy also saw the patient
on [**2147-2-17**] and thought that he would be appropriate for
short term rehabilitation. On postoperative day number six,
[**2147-2-19**], the patient was ready for rehabilitation and was
transferred to the rehabilitation facility. The patient was
transferred in stable condition.
The patient's medications on discharge were
1. Coumadin 7.5 mg p.o. q. h.s. for a goal INR of 3 to 3.5.
2. Heparin drip 1000 units/hr until therapeutic on the
Coumadin and then off.
3. Lipitor 20 mg p.o. q. h.s.
4. Calcium carbonate 500 mg p.o. t.i.d.
5. Lopressor 25 mg p.o. b.i.d.
6. Captopril 12.5 mg p.o. t.i.d.
7. Percocet 325 one to two tabs one p.o. q.4-6h. p.r.n.
8. Lasix 20 mg p.o. b.i.d. times seven days.
9. KCL 20 mg p.o. b.i.d. times seven days.
10. Colace 100 mg p.o. b.i.d.
11. Aspirin 325 mg p.o. q.d.
12. Oxazepam 15-30 mg p.o. q. h.s. p.r.n. sleep.
The patient was to follow-up in four weeks with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2147-2-19**] 08:22
T: [**2147-2-19**] 08:24
JOB#: [**Job Number 38169**]
|
[
"272.0",
"V45.82",
"401.9",
"412",
"997.02",
"424.0",
"E878.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"35.24",
"37.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
1593, 2015
|
2150, 5449
|
159, 1569
|
2030, 2127
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,259
| 189,465
|
7070
|
Discharge summary
|
report
|
Admission Date: [**2137-8-19**] Discharge Date: [**2137-9-8**]
Date of Birth: [**2107-7-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Abdominal pain, Shortness of breath and cough
Major Surgical or Invasive Procedure:
Liver mass biopsy
[**2137-8-30**] ex lap, Debridement of liver tumor.
2. Resection and primary repair of diaphragm.
3. Intraoperative ultrasound.
History of Present Illness:
30M with h/o chronic hep B (HbeAg+, HbeAg-, VL undetectable
[**7-/2137**]) on epivir and adefovir, with newly diagnosed large liver
mass by MRI (followed by [**Doctor Last Name **]) who presented to ED with acute
worsening of RUQ pain and shoulder pain at 12am. Pt states that
he has had similar episodes of abdominal pain over the past [**3-10**]
months which he has treated with tylenol. He also reports
intermittant cough dyspnea on exertion over the same time
period. Pt was given the news of cancer by Dr. [**Last Name (STitle) **] 2 days
prior to presentation.
ED vitals were afebrile, 69, 102/47, 99%RA. In ED, received
morphine and dilaudid for pain. No change in liver mass by
ultrasound.CTA done which showed multiple PEs. Patient
Type/Crossed and 2IVs placed. Spoke with Liver fellow and Dr.
[**Last Name (STitle) **] and plan to hold on anticoagulation for PE as risk of
bleeding/rupture of liver mass was higher than risk of PE.
Patent continued to be hemodynamically stable with O2 sat of 99%
on RA, and was sent to floor for further eval.
On arrival, patient was in [**7-16**] abdominal pain, but otherwise
denies SOB.
Past Medical History:
PAST MEDICAL HISTORY:
Chronic hepatitis B with cirrhosis: Epivir since [**2133-8-6**], and
was started on adefovir 10 mg daily in [**2135-7-7**], most recent VL
undetectable
Social History:
Born in [**Country 3992**]. Moved to [**Location (un) 6847**] in teens. The patient lives
in [**Location (un) 686**] with elderly cousin. [**Name (NI) **] occasionally smokes
tobacco and is currently working as a waiter. ETOH social beer
drinker
was in [**Country 3992**] in [**2133**]
Family History:
The patient does not know his family history outside of
hepatitis B in the patient's mother.
Physical Exam:
VS - Temp 98.3 F, BP 112/58 , HR 76 , R 18 , O2-sat % 99 2L
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
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 non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-10**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
On Admission: [**2137-8-19**]
WBC-6.9 RBC-4.56* HGB-14.1 HCT-42.1 MCV-92 MCH-30.9 MCHC-33.4
RDW-12.8
ALT(SGPT)-38 AST(SGOT)-48* ALK PHOS-227* TOT BILI-0.4
GLUCOSE-111* UREA N-15 CREAT-0.9 SODIUM-141 POTASSIUM-4.0
CHLORIDE-103 TOTAL CO2-27 ANION GAP-15
On Discharge: [**2137-9-8**]
RBC-3.75* Hgb-11.1* Hct-32.8* MCV-88 MCH-29.6 MCHC-33.8 RDW-15.0
Plt Ct-343
PT-21.4* PTT-35.0 INR(PT)-2.0*
Glucose-93 UreaN-8 Creat-0.7 Na-138 K-4.0 Cl-98 HCO3-26 AnGap-18
ALT-41* AST-35 AlkPhos-173* TotBili-0.4
Calcium-9.2 Phos-3.8 Mg-2.2
Other [**Month/Day/Year **] Tests of Note:
[**2137-8-19**] AFP- 8.9*
[**2137-8-19**] CA [**48**]-9 < 3
[**2137-8-27**] Aspergillus Ag, S 0.021 Range: < 0.5 Index
[**2137-8-27**] B-GLUCAN-Test <31 pg/ml Negative = Less than 60 pg/ml
Brief Hospital Course:
30M with h/o chronic hep B with cirrhosis and with newly
diagnosed large liver mass by MRI presenting with acute RUQ pain
and also found to have subsegmental pulmonary embolisms. He
underwent liver biopsy on the morning of admission. There were
no complications of the biopsy. Pathology reports were
indicative of hepatocellular carcinoma, moderately
differentiated. The patient continued to have RUQ pain for
several days post biopsy which was well controlled. Heparin IV
was initially held prior to liver biopsy then started and
titrated for ptt goal of 60-80. This was transitioned to lovenox
Last HBV VL was undetectable. LFTs were midly elevated but he
exhibitd no synthetic dysfunction. He was continued on his home
medications of lamivudine and adefovir.
.
[**Name (NI) 25933**] Pt was afebrile on admission, however on [**8-21**], he spiked
a fever to 102. CXRay was without evidence of infiltrate,
consolidation or effusion. He was started on levaquin, but
continued to spike fevers nightly. Daily blood and urine
cultures remained negative. Disscussion with the patient
revealed a 2 month hx of fever which he had been treating at
home with steam therapy. On [**8-26**], the patient again spiked a
fever to 103.4. The patient reported having a big cough which
caused him to expell a small amount of red sputum. A CT torso
was obtained which showed changes suggestive of infarct or
sequela of a septic embolus. The patient finished an 8 day
course of antibiotic. He was afebrile in the 24 hours prior to
surgery.
Cough- The patient complained of cough which had been bothering
him for several months. Further description of symptoms
revealed some obvious allergic components. The patient was
started on [**Doctor First Name 130**] and albuterol with improvement of throat
irritation. He continued to have intermittant cough and on the
evening of [**8-26**], the patient reported coughing up a small about
of red blood. A CT chest was obtained which was notable for
peribronchovascular opacities. Pulmonology was consulted who
felt that these changes were consistant with resolving
bronchopneumonia or reaction to aspirated blood.
Given his diagnosis, cancer staging was peformed and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] (Hepatobiliary surgeon) was consulted and the patient was
evaluated for resection. He remained in hospital until [**8-30**] when
he was taken to the OR and underwent debridement of liver tumor
with resection and primary repair of diaphragm. Operative
findings were notable for a large tumor mass involving the dome
of the right liver, including segments VII, VIII and extending
to the junction with the middle hepatic vein. Intraoperative
ultrasound demonstrated thrombus in the middle hepatic vein. The
left lateral segment was clear of tumor. The mass was necrotic
and adherent to the diaphragm. He received intrathecal morphine
for postop analgesia with intermittent iv morphine for
breakthrough.
PACU was uneventful. He was extubated without event and
transferred to the SICU given anesthesia. Pain was well
controlled. He returned to the Med-[**Doctor First Name **] unit on pod 2 where he
continue to receive a dilaudid pca.
On pod 1, hct decreased to 24 from 32. Two units of PRBC were
transfused. He continued to spike on pod 2 to 101.6. Blood and
urine cultures have been negative to date. he was encouraged to
use incentive [**Location (un) **].
Diet was advanced slowly and tolerated. He was assisted to
ambulate. The foley was removed on pod 3 without incident. The
JP continued to drain serosanuinous fluid. Drainage decreaesd to
10cc/day. PCA was converted to po oxycodone. This was switched
after a few days as he continue to complain of poor pain control
with pain on the right side.
Pathology demonstrated hepatocellular carcinoma moderately
differentiated, with extensive necrosis. Residual, subcapsular
liver with dense fibrosis and bile ductular proliferation.
He remianed on the heparin drip and was started on Coumadin. He
was treated with 1 unit FFP for supertherapeutic INR on day 3 of
Coumadin. He stabilized and was d/c'd home on 2mg Coumadin, INR
to be followed by Hepatology.
On discharge the patient is ambulating, tolerating diet. Pain
managed with PO pain meds. He will be followed as outpatient
with social work services in addition to medical clinic visits.
Medications on Admission:
Hepsera 10mg daily
Lamivudine 100mg daily
Discharge Medications:
1. Adefovir 10 mg Tablet Sig: One (1) Tablet PO daily ().
2. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Outpatient [**Name (NI) **] Work
PT/INR q Monday and Thursday
Please fax results to [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 805**] NP ([**Hospital1 18**] Hepatology)
[**Telephone/Fax (1) 4400**]
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hepatocellular carcinoma, unresectable
Pulmonary emboli
RLL lung nodule
Discharge Condition:
Hemodynamically stable and with pain controlled.
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you develop fever
>101, chills, nausea/vomiting, increased abdominal pain,
shortness of breath or pain, lightheadedness/dizziness, blood in
your stool/urine, or easy bruising/nose/gums bleeding
Continue coumadin as ordered
Labs twice weekly for INR, [**Telephone/Fax (1) **] slip given, fax results to
[**Telephone/Fax (1) 4400**] ([**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 805**] NP, Hepatology)
Followup Instructions:
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]: on [**2137-9-12**] at 3pm. You will be seen by Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with an interpreter
[**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2138-1-28**] 10:15
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2137-9-12**] 1:00
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2137-9-23**] 10:00
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2138-1-28**] 10:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2137-9-11**]
|
[
"784.7",
"155.0",
"486",
"V58.61",
"415.19",
"518.0",
"070.32",
"571.5",
"305.1",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.81",
"50.22",
"34.82",
"99.04",
"99.07",
"50.11",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
9205, 9262
|
3846, 8227
|
358, 506
|
9378, 9429
|
3055, 3055
|
9972, 10927
|
2190, 2285
|
8319, 9182
|
9283, 9357
|
8253, 8296
|
9453, 9949
|
2300, 3036
|
3321, 3823
|
273, 320
|
534, 1672
|
3069, 3307
|
1716, 1869
|
1885, 2174
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,036
| 142,787
|
14538
|
Discharge summary
|
report
|
Admission Date: [**2115-10-7**] Discharge Date: [**2115-10-17**]
Date of Birth: [**2073-12-15**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Compazine / Penicillins / Codeine
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
L subclavian line placement.
History of Present Illness:
Briefly, this is a 40 yo M with a hx of ulcerative colitis with
ileoanal pouch then diverting ileostomy with multiple hospital
admissions for abdominal pain, diarrhea, and BRBPR which have
been dx'ed as UC flares, chronic pouchitis, small bowel
obstructions, C. difficile colitis.
The pt now presents with his usual sx of abd pain, BRBPR and
n/v.
He was recently treated at admitted to [**Hospital3 **] for 8
days for similar symptoms including nausea, large stool output,
and BRBPR, he was treated with supportive care and pain control,
and then discharged home. The pt returned to [**Hospital1 18**] on the
following day for recurrent symptoms.
In the past, the pt has recieved large doses of IV dilaudid, up
to 6mg IV q4, as per records in POE to treat his abd pain, the
pt remains very insistent that 6 mg of IV dilaudid is the only
treatment that really works to treat his pain.
.
In ED, central line placed. Given dilaudid 4mg, flagyl 500mg,
and promethazine. Continued to complain of pain.
Pt was transferred to [**Hospital Unit Name 153**] with tachycardia to 170's,
hypertension, and hypoxia. ABG revealed 7.38/54/57/lactate 3.8
on 10L Face Mask. He was given Narcan for somulence without a
change in his vitals. He was A&Ox3; answering questions
appropriately. He denies CP, change in baseline abdominal pain,
N/V, cough, weakness, or numbness. He notes chills and mild
dyspnea. He had received a dose of IV dilaudid for pain in
addition to his standing regimen of Oxycontin 80 tid and SC
dilaudid 6 mg q 3 prn.
Past Medical History:
1. Proctocolectomy with ileal pouch - anal anastamosis: 10/03
[**2114-1-16**]: LOA for small bowel obstruction. At this time the
ileostomy was closed, with end to end anastomosis of small
intestine to resume flow through intestines through to the ileal
pouch and rectum.
[**2114-8-20**]: Ileostomy replaced because of recurrent symtoms which
"quite frankly were never clearly delineated" per Op note.
Symtoms were thought to be possibly relating to flow through
ileoanal pouch.
3. Inflammatory bowel disease - dx 22 years ago
4. Grand mal seizure disorder s/p motorcycle accident in [**2095**]
5. Chronic back pain with c-spine fx s/p MVA
4. Iron Deficiency Anemia
5. Narcotic Dependence
6. Recurrent C. difficile enteritis
7. Anxiety
8. GERD
9. Postoperative multifocal aspiration pneumonia with
parapneumonic effusion
10. Lysis of adhesions and ileostomy take-down: [**1-4**]
Social History:
Married x 25 years. Lives with his wife and children on the
water in [**Name (NI) 392**]. Used to work in law enforcement. + marijuana
about 3 times per week, no IVDU. No tob or EtOH in last 20 yrs
Family History:
His mother had "Crohn's disease" and died at the age of 63 from
colon cancer. His father is still alive, at age 79, without any
known health problems. His 5 brothers and one sister are all
alive and healthy.
Physical Exam:
Physical Exam:
T 97.7 BP 144/80 HR 94 RR 20 Sat 98% RA
Gen: appears uncomfortable, NAD
HENNT: MMM, anicteric, MMM
Neck: No LAD, JVD
CV: RRR, no m/r/g
Lungs: CTAB
Abd: Soft, tender to palpation diffusely, no rebound/guarding.
BS+. ileostomy site without surrounding erythema, c/d/i.
ileostomy bag with tan-colored stool.
Ext: No edema, strong DP/PT pulses bilaterally
Pertinent Results:
CXR [**2115-10-14**]:
IMPRESSION: Improving multilobar pneumonia and resolution of
right pleural effusion.
.
upper ext US [**2115-10-12**]:
IMPRESSION: No evidence of DVT.
.
Chest CT [**2115-10-10**]:
IMPRESSION:
1. Limited study for evaluation of pulmonary embolism due to
suboptimal opacification of the pulmonary arteries. However, no
central pulmonary embolus identified.
2. Coronary artery calcification.
3. Progression of multifocal consolidation in bilateral lungs,
associated with lymphadenopathy, probably representing worsening
multifocal pneumonia.
.
CT abd [**2115-10-7**]:
IMPRESSION:
1No evidence for bowel obstruction, bowel wall ischemia or
surrounding inflammatory fat stranding to explain the patient's
symptoms. No interval change in the appearance of the bowel and
anastamosis since the prior exam.
.
[**2115-10-7**] 11:09AM GLUCOSE-54* UREA N-12 CREAT-0.6 SODIUM-144
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-28 ANION GAP-15
[**2115-10-7**] 11:09AM ALT(SGPT)-115* AST(SGOT)-43* ALK PHOS-84 TOT
BILI-0.2
[**2115-10-7**] 11:09AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE IgM HAV-NEGATIVE
[**2115-10-7**] 11:09AM HCV Ab-NEGATIVE
[**2115-10-7**] 11:09AM WBC-15.7* RBC-3.78* HGB-11.0* HCT-33.8*
MCV-89 MCH-29.1 MCHC-32.5 RDW-14.0
[**2115-10-7**] 11:09AM PLT COUNT-249
[**2115-10-7**] 02:30AM GLUCOSE-105 UREA N-16 CREAT-0.7 SODIUM-138
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-14
[**2115-10-7**] 02:30AM ALT(SGPT)-144* AST(SGOT)-68* LD(LDH)-203 ALK
PHOS-121* AMYLASE-40 TOT BILI-0.2
[**2115-10-7**] 02:30AM LIPASE-15
[**2115-10-7**] 02:30AM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-3.5
MAGNESIUM-1.9
[**2115-10-7**] 02:29AM LACTATE-2.4* K+-4.1
[**2115-10-7**] 12:05AM WBC-15.1*# RBC-3.84* HGB-11.9* HCT-34.3*
MCV-90 MCH-31.1 MCHC-34.7 RDW-14.0
[**2115-10-7**] 12:05AM NEUTS-84* BANDS-0 LYMPHS-6* MONOS-4 EOS-0
BASOS-0 ATYPS-6* METAS-0 MYELOS-0
[**2115-10-7**] 12:05AM PLT COUNT-262
[**2115-10-7**] 12:05AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2115-10-7**] 12:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
A/P:
41 yo M UC s/p colectomy, ileoanal pouch, ileostomy, multiple
procedures, multiple admissions, narcotic seeking behavior, with
recurrent UC flares, p/w N/V and diarrhea, BRBPR, elevated
transaminases.
.
1. Abd pain:
The pt initially presented with symptoms of abdominal pain which
the pt described as very severe as well as an elevated WBC and
mildly elevated LFTs. The inital CT scan of the abdomen was
negative. The initial impression was that the pt had UC flare vs
gastroenteritis. Stool cx and C. diff were found to be negative.
There was a high suspicion that there was a component of
narcotic seeking as well as described below. The pt's symptoms
of pain improved over the subsequent days, with increasing
levels of narcotic pain regimen, avoiding IV dilaudid, using PO
oxycontin and SC dilaudid for breakthrough pain relief. The pt
stated that mesalamine or rectal anusol or mesalamine was not
helpful for the pain relief. The pt has a long history of
chronic flares of abdominal pain which have involved recurrent
colonoscopies/EGD(6 over the past 1-2 years) as well as multiple
surgical operations which have included total colectomy,
ileostomy diversion, reveral of ileostomy, replacement of the
previously reversed ileostomy. These procedures and studies have
been unable to obtain a definitive diagnosis or treatment for
this unfortunate patient's refractory pain and inflammatory
symptoms. The GI consultants agreed that a Crohn's was a likely
diagnosis given the symptoms although none of the pathology
specimens or scoping procedures definitively demonstated the dx.
The initial total colectomy specimen in [**2112**] showed no active
colitis. Given this history, a plan for conservative treatment
was favored, with the idea to reserve the pt from further risks
of procedures or surgeries only if there would be a clear
benefit to the patient. The GI as well as surgery consultants
were called to evaluate whether there may be such options to
provide the patient a benefit for his symptoms. The GI
consultants initially considered a diagnostic scope procedure,
although later decided against the procedure after the pt
required ICU transfer for sepsis. The surgery consultants on Dr. [**Name (NI) 42920**] team evaluated the pt and recommended that surgery
to staple off the efferent limb of the ostomy to cut off the
flow of stool to the ileal pouch. The goal was to decrease the
symtoms of inflammation and also of dribbling of stool.
.
2 Sepsis/pneumonia:
On HD#3, the pt developed respiratory distress and oxygen
desaturation. His situtaion deteriorated despite increasing
oxygen, and he was transferred to [**Hospital Unit Name 153**] with tachycardia to
170's, hypertension, and hypoxia. ABG revealed 7.38/54/57/
lactate 3.8 on 10L Face Mask. He had received a dose of IV
dilaudid for pain in addition to his standing regimen of
Oxycontin 80 tid and SC dilaudid 6 mg q 3 prn. There was a
concern that he may have aspirated. The Chest CT showed
multi-focal consolidation c/w pneumonia. The pt developed WBC to
20 as well as fever to 104. The pt was given levo/flagyl, with
coverage later expanded to add vanc and aztrenam given the
allergy to penicillin. The pt gradually improved clinically over
the subsequent days. F/u CXR pa/lat showed resolving of the
infiltrates. The vital signs as well as the WBC count
stabilized. The pt was able to be discharged to home in stable
condition on [**10-17**] with a prescription to continue abx treatment
for the PNA with metronidazole and cefpodoxime to continue for 8
days to complete a 14 day course of abx.
.
3. Narcotic dependence:
The has been difficulty with coordination of the pt's narcotic
prescribing in the past. The pt has a history of missing most of
his outpatient appointments. He presents as an inpatient and has
received the narcotics. Mr [**Known lastname **] has mutliple admissions over
the past year at [**Hospital1 18**] as well as [**Hospital3 **]. He refuses to
see the pain clinic at [**Hospital1 18**] since he states that he had a
negative experience with the physicians. The pt agreed to an
appointment at the [**Hospital1 392**] pain clinic. This clinic was called to
establish an appoinment for the pt. The receptionist stated that
the pt has missed several scheduled appointment's there in the
past and has not attended any of his appointments. The staff
there is familiar with Mr. [**Known lastname **] however from being consulted
to see him as an inpatient at [**Hospital1 392**]. An attempt was made to
help acheive better coordination in the pt's narcotic medicines.
The primary care physician was [**Name (NI) 653**]. The pt was explained
that he would have to go through his pcp to have narcotic pain
medicines in the future.
.
4. Anemia:
The pt has a chronic anemia. Laboratory work-up was consistent
with multi-factorial cause, low iron and chronic disease. Given
the h/o chronic GI irritation and BRBPR, the pt was directed to
take supplemental iron.
.
5. h/o seizure: anti-epileptics were continued.
6. chronic back pain: Cont oxycontin.
7. FEN: NPO, IVFs. follow lytes.
8. PPX. PPI
Medications on Admission:
Pantoprazole40 mg PO Q24H
Levetiracetam 1000 mg PO BID
Oxcarbazepine 300 mg PO BID
Mesalamine 400mg DR [**Last Name (STitle) **] [**Name (STitle) **]
Alprazolam 2 mg PO [**Name (STitle) **]
Oxycodone 80 mg Sustained Release PO Q8H
Clonazepam 2 mg PO BID
Phenergan PRN
Canasa 500 mg Suppository twice a day
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. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO [**Name (STitle) **] (4 times a day).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO [**Name (STitle) **] (4 times a day) as needed.
8. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
9. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 8 days.
Disp:*qs Tablet(s)* Refills:*0*
11. Clonazepam 2 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Alprazolam 2 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for anxiety.
Disp:*40 Tablet(s)* Refills:*0*
13. Oxycodone 80 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release 12HR(s)* Refills:*0*
14. Oxycodone-Acetaminophen 10-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
abdominal pain
ulcerative colitis flare
narcotic dependence
anxiety
Discharge Condition:
stable.
Discharge Instructions:
You must follow up as described below.
If you have worsening shortness of breath, chest pain, fevers,
or chills, please return to the [**Hospital1 18**] ED or call Dr. [**Last Name (STitle) **].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] for GI surgery by
[**Telephone/Fax (1) 9**]. They would like to schedule you for surgery as
soon as possible.
You must attend your appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], your PCP on
[**10-31**] at 3:00 p.m. in the [**Hospital Ward Name 23**] building. If you do not
attend this appointment you must call and cancel and reschedule
at [**Telephone/Fax (1) 250**]. You will not be able to get refills on your
prescriptions unless you see Dr. [**Last Name (STitle) **].
|
[
"V44.2",
"780.39",
"280.9",
"556.9",
"724.2",
"304.01",
"038.9",
"995.92",
"507.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12899, 12905
|
5834, 10928
|
323, 353
|
13026, 13035
|
3662, 5811
|
13278, 13837
|
3046, 3258
|
11284, 12876
|
12926, 13005
|
10954, 11261
|
13059, 13255
|
3288, 3643
|
268, 285
|
381, 1913
|
1935, 2814
|
2830, 3030
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,027
| 155,000
|
6631
|
Discharge summary
|
report
|
Admission Date: [**2124-4-24**] Discharge Date: [**2124-4-26**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Right humeral fracture
Major Surgical or Invasive Procedure:
Right ORIF [**2124-4-24**]
History of Present Illness:
[**Age over 90 **] year old female with a history of CAD, CHF EF 45%, and
gastric ca who is s/p fall 2 weeks ago that is post-op from ORIF
of R shoulder for a displaced 2 part proximal humerus fracture.
Pt fell 2 weeks ago sustaining both a right intertrochanteric
hip fracture which was fixed at [**Hospital 1474**] Hospital and a Right
shoulder fracture. She was discharged to rehab and was noted
while in rehab to have further displacement of her proximal
humerus fracture. Dr. [**First Name (STitle) **] saw her [**2124-4-19**] for evaluation
deonstrating new displacement, she was scheduled for ORIF of the
humerus on [**2124-4-24**]. Pt transferred to the [**Hospital Unit Name 153**] secondary to
hypertension to 210/... early in the operation treated with 80mg
of propofol, 20mg labetolol, and titration of the sevoflurane.
BPs improved to 120/..... In the [**Hospital Ward Name 332**] ICU, the patient was
intubated and ventilated on SIMV and remained hemodynamically
stable with SBP ranged between 90s to 160s on propofol.
Extubated without difficulty at 9am. Post extubation her SBPs
ranged in the 150 to 170s. Currently she denies headache,
shortness of breath, pain with breathing, chest pains, vomiting,
abdominal pains. She does note mild nausea at this time.
Past Medical History:
1. CAD-3 vessel disease- status post CABG in [**2116**], SVG to LAD,
SVG to OM, SVG to RCA. Catheterization in [**2118**] revealed patent
SVG to LAD
but occluded SVG to RCA and SVG to OM. EF was 45% at that
time. The ejection fraction in [**Month (only) 404**] of this year was 50%.
[**2-/2123**]- Stenting of Left Main into Lcx.
2. Pacemaker.
3. Congestive heart failure- EF 45% ([**2-18**]).
4. Osteoarthritis.
5. Upper GI bleed secondary to esophageal erosions in [**2115**].
6. Left eye cataract.
7. Status post lumbar disk surgery.
8. Status post hysterectomy.
9. Status post appendectomy.
10. Diverticulosis.
11. Status post gastric surgery for cancer in [**2119**].
12. COPD- ? on chronic prednisone.
Social History:
The patient has smoked a pack per day for
her entire life and still continues to smoke. She does not
drink alcohol or use other drugs. She is currently living
Physical Exam:
Afebrile, 63 120/38 100% Intubated SIMV
NAD, on the ventillator, appears comfortable, cachectic
Right arm is in sling
MMM, OP- ETT in place, no appreciable JVP
RR
Coarse BS anteriorly
soft, NT/ND +BS
No LE edema, Right arm with echymosis in sling, Right
radial/ulnar 1+
Pertinent Results:
SHOULDER (AP, NEUTRAL & AXILLARY) SOFT TISSUE RIGHT PORT
[**2124-4-25**] 9:44 AM
IMPRESSION: Status post ORIF right humeral neck fracture.
Alignment impossible to assess given the one view.
PORTABLE ABDOMEN [**2124-4-25**] 2:10 PM
IMPRESSION: No evidence of free air on this supine radiograph.
If clinically indicated, further evaluation can be obtained with
a decubitus film.
[**2124-4-25**] 12:04AM BLOOD WBC-18.3*# RBC-3.28*# Hgb-9.2*# Hct-29.4*
MCV-90 MCH-28.0 MCHC-31.3 RDW-19.4* Plt Ct-265
[**2124-4-25**] 12:04AM BLOOD PT-13.7* PTT-23.2 INR(PT)-1.2
[**2124-4-25**] 12:04AM BLOOD Glucose-116* UreaN-25* Creat-0.8 Na-136
K-4.8 Cl-107 HCO3-20* AnGap-14
[**2124-4-26**] 05:30AM BLOOD ALT-<4 AST-19 LD(LDH)-180 AlkPhos-133*
Amylase-559* TotBili-0.4
[**2124-4-25**] 04:20AM BLOOD Calcium-7.9* Phos-5.4* Mg-1.7
[**2124-4-24**] 04:41PM BLOOD Type-ART pO2-180* pCO2-38 pH-7.38
calHCO3-23 Base XS--1
[**2124-4-24**] 04:41PM BLOOD Glucose-138* Lactate-1.1 Na-137 K-4.4
Cl-108
[**2124-4-24**] 04:41PM BLOOD Hgb-10.8* calcHCT-32
[**2124-4-24**] 06:59PM BLOOD Hgb-9.9* calcHCT-30
[**2124-4-24**] 06:59PM BLOOD freeCa-1.17
HUMERUS (AP & LAT) RIGHT [**2124-4-26**] 8:26 AM
Single bedside frontal radiograph of the right humerus and
shoulder show large plate and across the proximal humerus with
multiple associated screws and overlying skin staples. No
discrete fracture lines are identified but assessment is
suboptimal on this portable exam. One of the screws projects [**12-19**]
mm beyond the subchondral bone of the humeral head. Generalized
demineralization. Pacing device overlies a partially visualized
right upper thorax. Soft tissue gas is present in the operative
site. No dislocation. No position change from similarly
positioned single radiograph done one day ago (10 in [**4-20**]).
Brief Hospital Course:
A/P: [**Age over 90 **] YO female with MMP admitted s/p ORIF of Right shoulder
intubated from the OR. She was admitted to the ortho service and
remained intubated post-op so she was transferred to the MICU.
She was extubated uneventfully on [**4-25**]. Post operatively, she
was noted to have a purplish right arm, with minimal radial
pulse but palpable antevubital pulse, which ortho did not feel
was unusual. Her medications were continued post-operatively
including aspirin and plavix. She was kept on lovenox post
operatively. Her hematocrit slowly decreased to 25 post
operatively and she was transfused 1 unit pRBC on [**4-26**]. She was
given ultram for pain, and developed decreased urine output post
operatively and received numberous fluid boluses with urine
output around 15 cc per hour, which was deemed to be acceptable
for her very low body mass. She developed some nausea and
vomiting after extubation, but a KUB showed no free air or
evidence of obstruction. She was transferred to the medical
floor on [**4-26**].
That evening, she was alert and tolerating minimal PO intake
with some persistent nausea. She did not receive any further
fluid boluses. She lost IV access and the IV team reevaluated
her at around 8 pm, and was unable after multiple attempts to
secure access. She was not receiving IV medications so a PICC
line was ordered for the morning for access. Around 9:35 pm, a
coworker went into her room and found her to be unresponsive. As
she was DNR/DNI, a code was not called but the medical team
immediately evaluated her and found her apneic, pulseless, and
without reflexes. She was pronounced dead at 9:40 pm. The
immediate cause of death was likley due to cardiac arrest, as
she was not short of breath or in any distress prior to being
found.
Medications on Admission:
1. Atenolol 50 mg q.d.
2. Lipitor 10 mg q.h.s.
3. Colace 100 mg b.i.d.
4. Atrovent MDI two puffs inhaler q.i.d.
5. Prednisone 5 mg q.d.
6. Folic acid 1 mg q.d.
7. Guaifenesin p.r.n. cough and secretions.
8. Imdur 30 mg QD
9. MVI
10. Nicotine Patch
11. Norvasc 5 mg QD
12. Protonix 40 mg QD
13. CaCO3
14. Vicodin PRN for pain
15. Coumadin 3 mg QD
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac arrest
Discharge Condition:
dead
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"428.0",
"812.01",
"V45.81",
"414.01",
"496",
"584.9",
"V10.04",
"276.2",
"V58.65",
"V45.01",
"V54.13",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.31",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6798, 6807
|
4618, 6401
|
250, 278
|
6865, 7002
|
2798, 4595
|
6828, 6844
|
6427, 6775
|
2507, 2779
|
188, 212
|
306, 1582
|
1604, 2314
|
2331, 2492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,709
| 146,756
|
24148
|
Discharge summary
|
report
|
Admission Date: [**2200-3-11**] Discharge Date: [**2200-3-21**]
Date of Birth: [**2122-7-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77M with metastatic melanoma BRAF V600R mutated on vemurafenib
presenting with fatigue s/p fall at home with head strike. He
reports 1 week of worsening fatigue and lethargy witnessed fall
this AM. Pt called oncology fellow who recommended ED
evaluation. He also reports increasing confusion over the past
day with escalating arm pain. Note, he had cellulitis in the L
axilla over a met in the past. Denies chest pain or SOB.
.
ED Course (labs, imaging, interventions, consults): initial
vitals 98.6 98 157/72 16 98%/RA. C-spine cleared from fall. CT
head negative for acute process including mass effect or midline
shift. Chest xray was concerning for acute LLL pna and he
received azithromycin, ceftriaxone for CAP. He also received a
dose of vancomycin for presumed persistent cellulitis of L
axilla. He recieved 2L NS. Labs notable for WBC 79.8 (N 88), Hct
33.2, Plt 244, coag wnl, AP 720 (LFTs otherwise wnl), calcium
12.5, alb 3.7, PO4 2.3, Na 135, creat 1.3 (baseline range
1.0-1.6), anion gap 13, lactate 4.9 and recheck 3.5 after IVF.
UA notable for trace blood and protein 100. PIV for access. EKG
with non-shorted QT and no ST changes.
.
On arrival to the ICU, pt is comfortable and c/o mild pain in
his L axilla. The appearance of the axilla is unchanged per son.
Denies fever, chills. Denies nausea, vomiting, constipation,
increased anxiety/depression, polyuria, msk pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations. 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:
PAST ONCOLOGIC HISTORY:
Melanoma stage IB with recurrent disease
- [**3-/2196**] Diagnosed with melanoma on the left forearm
- [**4-/2196**] Underwent wide local resection and SLND without
evidence if metastatic disease, final path stage IB, Clarkes
level IV, 1.1 mm thick
- [**1-/2200**] Presented with weight loss, L supraclavicular and
axilary LAD
- [**2200-1-15**] FNA of the left axilla confirmed metastatic melanoma
- [**2200-1-16**] MRI head negative for metastatic disease
.
.
PAST MEDICAL HISTORY:
Hypertension
Depression
BPH s/p prostatectomy
Paroxysmal SVT secondary to PEs [**1-/2200**]
Cellulitis overlying left axillary melanoma [**1-/2200**]
Hypercalcemia possibly secondary to paraneoplastic syndrome.
Improved with zolendronic acid and fluids [**1-/2200**]
.
.
Social History:
From southern [**Country 2559**]. He is retired painter. He lives with his
wife and son in [**Name (NI) 1411**]. He does not use tobacco or illicit
drugs. He drinks a beer occasionally.
Family History:
Father died of leukemia. Two sisters with breast cancer. No
history of melanoma, colon, or prostate cancer.
Physical Exam:
PHYSICAL EXAM:
Vitals - T 98 bp 154/90 HR 96 RR 16 SaO2 97 RA
GENERAL: pleasant, NAD
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, patent
nares, MMM, poor dentition, no JVD
Neck: Left supraclavicular fullness with hard mass
CARDIAC: RRR, S1/S2, I/VI systolic murmur
LUNGS: CTAB, no rhonchi or wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Ext: Left axilla with large firm mass with overlying blanching
erythema, nontender ("much better" by son's report); left
forearm with soft, mobile, well circumscribed mass; no cyanosis,
clubbing or edema
NEURO: AOx3, logical, no focal deficitis
SKIN: warm, dry
PSYCH: appropriate
DISCHARGE EXAM:
Vitals -
GENERAL: alert and interactive, pleasant, NAD
HEENT: AT/NC, PERRL, anicteric sclera, pink conjunctiva, NC in
place, MMM with food particles, poor dentition, no JVD
Neck: Left supraclavicular fullness with hard mass
CARDIAC: RRR, S1/S2, I/VI systolic murmur
LUNGS: CTAB
ABDOMEN: +BS, mildly distended, tympanitic, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
UG: foley in place draining somewhat concentrated urine
Ext: Left axilla with large firm mass with overlying blanching
erythema, nontender; left forearm with soft, mobile, well
circumscribed mass; no cyanosis, clubbing or edema
NEURO: AOx1 (knows he's in [**Location (un) 86**], but cannot pick out a place
when asked "school, stadium or hospital," no focal deficitis
SKIN: warm, dry. Numerous hyperpigmented, hypertrophic lesions
on back
Pertinent Results:
Pertinent Labs:
[**2200-3-11**] 07:50AM BLOOD WBC-79.8*# RBC-3.50* Hgb-10.2* Hct-33.2*
MCV-95 MCH-29.3 MCHC-30.8* RDW-16.9* Plt Ct-244
[**2200-3-12**] 03:26AM BLOOD WBC-90.4* RBC-2.96* Hgb-9.1* Hct-28.1*
MCV-95 MCH-30.9 MCHC-32.4 RDW-16.8* Plt Ct-231
[**2200-3-11**] 07:50AM BLOOD Neuts-88* Bands-0 Lymphs-8* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-1*
[**2200-3-12**] 03:26AM BLOOD Neuts-89* Bands-3 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2200-3-11**] 07:50AM BLOOD PT-11.7 PTT-28.2 INR(PT)-1.1
[**2200-3-11**] 07:50AM BLOOD Glucose-121* UreaN-16 Creat-1.3* Na-135
K-4.3 Cl-95* HCO3-27 AnGap-17
[**2200-3-12**] 03:26AM BLOOD Glucose-102* UreaN-13 Creat-1.2 Na-135
K-4.2 Cl-103 HCO3-21* AnGap-15
[**2200-3-11**] 07:50AM BLOOD ALT-16 AST-27 LD(LDH)-404* AlkPhos-720*
TotBili-0.6
[**2200-3-12**] 03:26AM BLOOD ALT-12 AST-21 LD(LDH)-328* AlkPhos-596*
TotBili-0.7
[**2200-3-11**] 07:50AM BLOOD Albumin-3.7 Calcium-12.5* Phos-2.3*
Mg-2.3
[**2200-3-11**] 01:25PM BLOOD Calcium-11.2* Phos-2.3* Mg-2.1
[**2200-3-12**] 03:26AM BLOOD Calcium-10.1 Phos-2.6* Mg-1.9
[**2200-3-11**] 08:10AM BLOOD Lactate-4.9*
[**2200-3-11**] 11:20AM BLOOD Lactate-3.5*
[**2200-3-11**] 03:27PM BLOOD Lactate-3.6*
[**2200-3-11**] 09:15AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2200-3-11**] 09:15AM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-NEG
[**2200-3-11**] 09:15AM URINE RBC-3* WBC-7* Bacteri-FEW Yeast-NONE
Epi-1
[**2200-3-11**] 09:15AM URINE CastGr-4* CastHy-14*
[**2200-3-11**] 01:42PM URINE Hours-RANDOM UreaN-394 Creat-82 Na-32
K-46 Cl-40
[**2200-3-11**] 01:42PM URINE Osmolal-344
Imaging:
CT C-SPINE W/O CONTRAST Study Date of [**2200-3-11**] 7:38 AM
IMPRESSION:
1. No acute fracture or malalignment.
2. Moderate mainly left-sided degenerative changes as described
above.
CT HEAD W/O CONTRAST Study Date of [**2200-3-11**] 7:38 AM
IMPRESSION:
1. No acute intracranial process. No fracture. Please note
noncontrast CT is not particulary sensitive for detection of
subtle metastasis.
2. Stbale scattered white matter hypodensities, most commonly
seen in chronic small vessel ischemic disease.
4. Left frontal sinus lesion is unchanged.
CHEST (PA & LAT) Study Date of [**2200-3-11**] 8:15 AM
IMPRESSION: No definite acute cardiopulmonary process based on
this limited exam due to poor inspiratory effort.
CHEST (PORTABLE AP) Study Date of [**2200-3-12**] 5:13 AM
FINDINGS: No focal consolidation or pneumothorax is detected.
There is mild blunting of the left costophrenic angle, which may
represent minimal effusion or atelectasis. Borderline
cardiomegaly and mediastinal contours are stable.
IMPRESSION: No radiographic evidence for acute process.
[**2200-3-14**] 07:15AM BLOOD WBC-100.3* RBC-2.95* Hgb-8.7* Hct-28.3*
MCV-96 MCH-29.5 MCHC-30.7* RDW-17.3* Plt Ct-231
[**2200-3-15**] 09:05AM BLOOD WBC-91.8* RBC-2.7* Hgb-8.5* Hct-29*
MCV-96 MCH-31.7 MCHC-33.2 RDW-17.3* Plt Ct-202
[**2200-3-16**] 07:45AM BLOOD WBC-94.2* RBC-2.69* Hgb-8.1* Hct-26.0*
MCV-97 MCH-30.2 MCHC-31.2 RDW-17.6* Plt Ct-212
[**2200-3-17**] 07:20AM BLOOD WBC-85.9* RBC-2.65* Hgb-8.2* Hct-25.2*
MCV-95 MCH-31.1 MCHC-32.6 RDW-17.8* Plt Ct-204
[**2200-3-17**] 10:51PM BLOOD WBC-78.3* RBC-2.54* Hgb-7.7* Hct-24.1*
MCV-95 MCH-30.5 MCHC-32.1 RDW-18.0* Plt Ct-192
[**2200-3-19**] 10:45AM BLOOD WBC-70.9* RBC-2.39* Hgb-7.4* Hct-23.1*
MCV-97 MCH-30.9 MCHC-31.9 RDW-19.9* Plt Ct-177
[**2200-3-11**] 07:50AM BLOOD Glucose-121* UreaN-16 Creat-1.3* Na-135
K-4.3 Cl-95* HCO3-27 AnGap-17
[**2200-3-11**] 01:25PM BLOOD Glucose-76 UreaN-13 Creat-1.2 Na-137
K-4.6 Cl-100 HCO3-22 AnGap-20
[**2200-3-12**] 03:26AM BLOOD Glucose-102* UreaN-13 Creat-1.2 Na-135
K-4.2 Cl-103 HCO3-21* AnGap-15
[**2200-3-12**] 02:59PM BLOOD Glucose-113* UreaN-13 Creat-1.3* Na-134
K-4.4 Cl-101 HCO3-22 AnGap-15
[**2200-3-13**] 06:45AM BLOOD Glucose-86 UreaN-14 Creat-1.3* Na-139
K-4.0 Cl-105 HCO3-21* AnGap-17
[**2200-3-14**] 07:15AM BLOOD Glucose-122* UreaN-16 Creat-1.3* Na-141
K-4.0 Cl-110* HCO3-19* AnGap-16
[**2200-3-15**] 09:05AM BLOOD Glucose-72 UreaN-15 Creat-1.3* Na-146*
K-3.6 Cl-111* HCO3-20* AnGap-19
[**2200-3-16**] 07:45AM BLOOD Glucose-112* UreaN-18 Creat-1.3* Na-149*
K-4.1 Cl-115* HCO3-22 AnGap-16
[**2200-3-17**] 07:20AM BLOOD Glucose-108* UreaN-21* Creat-1.2 Na-146*
K-3.8 Cl-116* HCO3-20* AnGap-14
[**2200-3-17**] 04:20PM BLOOD Glucose-109* UreaN-24* Creat-1.4* Na-146*
K-5.2* Cl-115* HCO3-15* AnGap-21*
[**2200-3-17**] 10:51PM BLOOD Glucose-122* UreaN-25* Creat-1.5* Na-149*
K-4.2 Cl-116* HCO3-22 AnGap-15
[**2200-3-18**] 07:00AM BLOOD Glucose-99 UreaN-24* Creat-1.4* Na-149*
K-4.2 Cl-117* HCO3-20* AnGap-16
[**2200-3-19**] 10:45AM BLOOD Glucose-152* UreaN-25* Creat-1.4* Na-143
K-3.4 Cl-110* HCO3-20* AnGap-16
[**2200-3-11**] 07:50AM BLOOD ALT-16 AST-27 LD(LDH)-404* AlkPhos-720*
TotBili-0.6
[**2200-3-12**] 03:26AM BLOOD ALT-12 AST-21 LD(LDH)-328* AlkPhos-596*
TotBili-0.7
[**2200-3-13**] 06:45AM BLOOD ALT-13 AST-23 LD(LDH)-438* AlkPhos-640*
TotBili-0.5
[**2200-3-17**] 10:51PM BLOOD ALT-8 AST-21 LD(LDH)-423* AlkPhos-522*
TotBili-0.4
[**2200-3-18**] 07:00AM BLOOD ALT-9 AST-22 LD(LDH)-508* AlkPhos-556*
TotBili-0.5
[**2200-3-11**] 01:25PM BLOOD GGT-360*
Brief Hospital Course:
Mr. [**Known lastname 34989**] is a 77M with hx metastatic melanoma c/b prior
episodes encephalopathy and hypercalcemia who presents to the ER
with lethargy, fall, and hypercalcemia concerning for underlying
infection.
.
# Goals of care: patient was admitted with toxic metabolic
encephalopathy secondary to hypercalcemia of malignancy with
possible contribution from infection. He was given adequate
trial of reversal of his calcium as well as treatment for
infection without resolution of his delerium. Throughout he
remained AOx1-2. Due to his persistent delerium, and in light
of his metastatic melanoma, he was made comfort measures only
with home hospice.
.
# Hypercalcemia: Likely [**1-16**] underlying malignancy and
contributing to his lethargy. An EKG was obtained and wnl. He
was started on NS at 200cc/hr and given pamidronate infusion.
His calcium decreased to within normal limits but his
encephalopathy did not clear.
.
# Encephalopathy: Pt was noted to be lethargic on admission.
Most likely etiology for his lethargy was hypercalcemia as his
lethargy improved as his calcium normalized. Other etiologies
included possible UTI which was treated with ciprofloxacin.
Treatment of his UTI and calcium did not result in complete
improvement in delerium; other etiologies were ruled out.He did
improve somewhat with less lethargy/improved alertness but some
confusion/disorientation persisted. In discussion with family
and his primary oncologist, the patient was made comfort
measures only with home hospice.
.
# Leukemoid reaction: WBC as recent at 3/6 was downtrending on
vemurafenib but on admission it was acutely elevated to 79.8 on
admission and then increased to 90 the following day prior to
discharge from the unit. We initially started IV antibiotics out
of concern for a possible cellulitis over the tumor in his left
axilla. The antibiotics were then discontinued the following
day. His Leukemoid reaction was most likely related to his
metastatic melanoma.
.
# Metastatic melanoma: Hx of dx since [**2195**] with evidence of mets
diagnosed recently [**1-/2200**] after complaints of anorexia, weight
loss and axillary pain since winter [**2198**]. Recently started
therapy with vemurafenib. Due to his persistent toxic metabolic
encephalopathy in setting of poor prognosis due to metastatic
melanoma, the patient was made comfort measures only with home
hospice.
.
# Acute kidney injury: On admission the pt's Cr was slightly
elevated above baseline. His Cr improved with IVF and resolution
of hypercalcemia. His medications were renally adjusted.
Medications on Admission:
Cipro 500mg PO BID ([**1-31**] - [**2-14**])
Clindamycin 300mg PO q8 ([**1-31**] - [**2-9**])
amlodipine 10 mg daily
atenolol 100 mg daily
mirtazapine 30 mg qHS
venlafaxine 100 mg TID
calcium carbonate 1g PO 1 tab in AM and 2 in afternoon
colace 100 mg [**Hospital1 **]
senna 1 tab [**Hospital1 **] prn constipation
Vemurafenib 240 mg Tablet 4 Tablet(s) by mouth twice a day
([**2200-1-27**])
Discharge Medications:
1. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. venlafaxine 100 mg Tablet Sig: One (1) Tablet PO three times
a day.
5. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. oxyfast Sig: 1-20 mg q1hr as needed for pain: concentrated
solution 20mg/mL.
Disp:*30 mL* Refills:*0*
11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO at bedtime as needed for confusion.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Toxic metabolic encephalopathy
Hypercalcemia
Acute kidney injury
Urinary tract infection
Metastatic melanoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted for confusion and delerium. This was due to
the progression of your cancer, which caused you to have a high
calcium level in your blood leading to confusion. We attempted
to correct this, but we were unable to successfully do so.
You are being discharged on the following medication list with
this documention. Please stop all other medications other than
these.
Followup Instructions:
None
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
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"196.1",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14195, 14273
|
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|
311, 317
|
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|
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14441, 14652
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2691, 2964
|
2980, 3168
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,811
| 180,947
|
44087+58681
|
Discharge summary
|
report+addendum
|
Admission Date: [**2189-1-9**] Discharge Date: [**2189-1-28**]
Date of Birth: [**2111-6-6**] Sex: M
Service: C-Medicine
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 94633**] is a 77 year old male
who has had multiple medical problems, including severe
valvular ischemic heart failure, class III to IV, coronary
artery disease, status post coronary artery bypass grafting,
chronic obstructive pulmonary disease, gastroesophageal
reflux disease, recurrent pneumoniae and a gastrointestinal
bleed. The patient was admitted for worsening shortness of
breath times one week. He initially had shortness of breath
walking in his home, progressing to being short of breath at
rest. He reports difficulty lying flat. His Lasix dose was
recently decreased.
The patient was admitted on [**2189-1-9**], initially to
the [**Hospital Ward Name 516**] and initially treated for a pneumonia with
Levaquin and Flagyl. He was switched to cefodizime on
[**2189-1-12**]. He has intravenous Lasix titrated to 80 mg
twice a day. He has also been on an ACE inhibitor and
nitroglycerin patch on [**2189-1-10**]. During the
hospitalization, he had an episode of chest pain radiating to
the left arm which was relieved by sublingual nitroglycerin
and morphine sulfate. He ruled out for a myocardial
infarction. He has been diuresed but has had decreased blood
pressure and increased creatinine with continued rales and
shortness of breath. His Lasix on [**2189-1-10**] was held
and was restarted on [**2189-1-11**]. His telemetry
suggests recurrent atrial fibrillation.
The patient was transferred to the cardiology medicine team
on [**2189-1-12**] for Natrecor therapy. The congestive
heart failure service was consulted regarding the patient's
care.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus.
2. Chronic renal failure with a baseline creatinine between
2.2 and 2.5.
3. Ischemic and valvular heart disease.
4. Congestive heart failure, left ventricular ejection
fraction estimated at 30% to 35%.
5. Severe mitral regurgitation.
6. Sick sinus syndrome, status post DDD pacemaker in [**2179**].
7. Recurrent pneumoniae.
8. Coronary artery disease, status post coronary artery
bypass grafting in [**2184**] with a saphenous vein graft to
posterior descending coronary artery and saphenous vein graft
to obtuse marginal one and left internal mammary artery to
left anterior descending artery; cardiac catheterization in
[**2188-2-29**] had native three vessel disease with saphenous
vein grafts occluded, left internal mammary artery to left
anterior descending artery patent.
9. Gastroesophageal reflux disease.
10. Hypothyroidism.
11. Hypercholesterolemia.
12. History of gastrointestinal bleed secondary to peptic
ulcer disease.
13. Urinary tract infection with Methicillin resistant
Staphylococcus aureus.
14. History of osteoporosis.
15. Gout.
MEDICATIONS ON ADMISSION: Lasix 80 mg p.o.b.i.d., amiodarone
200 mg p.o.b.i.d., metoprolol 37.5 mg p.o.b.i.d., Protonix 40
mg p.o.q.d., spironolactone 12.5 mg p.o.q.d., Levoxyl 25 mcg
p.o.q.d., Colace 100 mg p.o.b.i.d., Lipitor 10 mg p.o.q.d.,
Humalog insulin 24 units q.a.m. with 36 units Humulin q.a.m.
and 60 units Humulin q.h.s.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is a
retired electrical engineer. He quit smoking in [**2184**].
PHYSICAL EXAMINATION: Physical examination on transfer to
the c-medicine team, the patient had a blood pressure of
108/50, heart rate 90s, temperature 97 and oxygen saturation
96% on three liters nasal cannula. General: Uncomfortable,
lying flat in bed. Head, eyes, ears, nose and throat: Neck
supple, moist mucous membranes, extraocular movements intact,
pupils equal, round, and reactive to light and accommodation,
jugular venous distention approximately 11 cm up.
Cardiovascular: Regular rate and rhythm, III/VI holosystolic
murmur. Lungs: Crackles bilaterally one-third up. Abdomen:
Soft, positive bowel sounds, no rebound tenderness, obese.
Extremities: 1+ lower extremity edema to the upper shin.
Neurologic examination: Alert and oriented times three,
speaks Russian.
LABORATORY DATA: Admission white blood cell count 9.1 with
72% neutrophils, 20% lymphocytes, 6% monocytes and 2%
eosinophils, hematocrit 33.3, platelet count 301,000, sodium
139, potassium 4.2, chloride 100, bicarbonate 24, BUN 50,
creatinine 2.5, glucose 215. [**2189-1-8**], 11:00 p.m., CK
107; [**2189-1-9**], 2:20 p.m. 29, [**2189-1-10**], 11:00
a.m. 79, [**2189-1-10**] 9:00 p.m. 73, [**2189-1-11**],
7:00 a.m. 93. [**2189-1-8**] at 11:00 p.m., troponin was
less than 0.3; [**2189-1-9**] one troponin less than 0.3,
[**2189-1-10**] two troponins less than 0.3 and [**2189-1-11**], one troponin less than 0.3
Admission chest x-ray shows resolution of right upper lobe
infiltrate consistent with [**2188-12-11**], right lower
extremity opacity with increased confluence, small bilateral
pleural effusions, left base atelectasis, indistinct
pulmonary vasculature consistent with mild congestive heart
failure; summary, pneumonia with superimposed congestive
heart failure. Electrocardiogram on admission was paced with
a left bundle branch pattern; compared with old
electrocardiogram, it was completely paced, however, by
transfer to c-medicine, he was in atrial fibrillation.
HOSPITAL COURSE: The patient is a 77 year old male with a
history of diabetes mellitus, recurrent pneumoniae,
significant coronary artery disease, significant congestive
heart failure secondary to ischemic and valvular disease,
atrial fibrillation, and sick sinus syndrome status post
permanent pacemaker, who presents with worsening shortness of
breath and symptoms consistent with worsened congestive heart
failure. He was treated initially for pneumonia and
transferred to c-medicine for management of congestive heart
failure.
1. Congestive heart failure: The patient was loaded on
nesiritide at 2 mcg/kg and later started on 0.1 mcg/kg/minute
drip. He also initially received intravenous bumetanide 2 mg
twice a day. Nesiritide was increased to 0.15 mcg/kg/minute
due to lack of initial response. The patient was placed on
spironolactone 12.5 mg daily, continued on an ACE inhibitor
for afterload reduction for his mitral regurgitation at 20 mg
daily. The patient was on a two liter fluid restriction, 2
gram sodium diet. He refused a Foley catheter.
On [**2189-1-15**], the patient was transferred to the
Coronary Care Unit for tailored therapy secondary to poor
diuresis on the floor despite Natrecor therapy. The
patient's weight had actually increased to being 102.6
kilograms on the day of transfer. He still had jugular
venous distention to the angle of the mandible and still had
crackles on lung exam and complained of paroxysmal nocturnal
dyspnea four to five times on the night of [**2189-1-14**].
However, on [**2189-1-15**], he actually was negative 1.7
liters to the nesiritide and Bumex combination, the first day
that he had been negative during his stay.
On [**2189-1-15**], the patient had a right internal jugular
cordis placed. A Swan-Ganz catheter was floated without
difficulty. His numbers were a pulmonary artery pressure of
47/19, pulmonary capillary wedge pressure 16, mixed venous
62, CTP 9, cardiac output 5.8, SVR 1,000. He was initially
started on dobutamine 2.5 mcg/kg/minute and continued on
nesiritide drip 0.1 mcg/kg/minute.
On the evening of [**2189-1-16**], the patient complained of
chest pain. He ruled out for a myocardial infarction. His
dobutamine and Natrecor drips were stopped. He had a
nitroglycerin drip started and received morphine sulfate,
which resolved his chest pain. On [**2189-1-16**], the
patient also had a transesophageal echocardiogram
cardioversion and was shocked into normal sinus rhythm.
On [**2189-1-17**], the patient was transfused two units of
packed red blood cells. His Bumex was changed to PRN on
[**2189-1-17**] and the Swan-Ganz was discontinued and his
cordis was changed to a triple-lumen over a wire. He was
transferred to c-medicine on [**2189-1-18**]. When the
patient was discharged from the Unit, his nitroglycerin drip
was changed to oral nitrates and he received intravenous
Bumex as needed for diuresis. His weight decreased to 98.7
kilograms on [**2189-1-21**]. The patient's oxygen
requirements improved to be 93% in room air. The patient had
decreased complaints of paroxysmal nocturnal dyspnea. Then,
on [**2189-1-22**], his weight had increased to 100.1
kilograms and he had a slight increase in chest fullness and
some shortness of breath. The patient was diuresed an
additional 2 mg of intravenous Bumex. With that, he was 98.3
kilograms on [**2189-1-25**]. Imdur was on a stable regimen
of 60 mg daily. On [**2189-1-25**], the patient was
comfortable in room air, reporting that he was not short of
breath.
2. Valvular disease: The patient had an echocardiogram on
[**2188-12-15**] prior to this admission, with left atrium
moderately dilated, no thrombus, left ventricular function
mildly depressed, +1 tricuspid regurgitation, +1 aortic
regurgitation, +4 mitral regurgitation and a simple atheroma
in the descending artery. The patient was evaluated by the
surgical service for a mitral valve repair, especially in the
context of his severe congestive heart failure. It was felt
that a large component of his congestive heart failure was
secondary to the mitral valve disease and, if it could be
corrected, the patient would benefit greatly . In workup for
the mitral valve replacement, the patient had an ultrasound
of the carotids on [**2189-1-20**]; impression was minimal
left internal carotid artery plaque, no associated stenosis,
study otherwise normal.
The patient had a transthoracic echocardiogram on [**2189-1-22**]; left atrium was moderately dilated, right atrium mildly
dilated, there was a catheter or pacing wire seen in the
right atrium and/or right ventricle, left ventricular wall
thickness was normal, left ventricular cavity was mildly
dilated, overall left ventricular systolic function was
mildly depressed, no resting left ventricular outflow
obstruction, right ventricular free wall hypertrophied, right
ventricle mildly dilated, focal hypokinesis of the apical
free wall of the right ventricle, focal calcifications of the
ascending aorta, 1 to 2+ aortic regurgitation, left
ventricular ejection fraction 30%, tricuspid gradient 50 mm
of mercury, severe +4 mitral regurgitation, mild mitral
annular calcification, mild thickening of mitral valve
chordae, tips of papillary muscles were calcified, 3+
tricuspid regurgitation, moderate pulmonary systolic
hypertension, no definitive vegetations seen but this is best
concluded by a transesophageal echocardiogram.
The initial plan was to have tailored therapy for congestive
heart failure in the Unit and preoperatively evaluate the
patient for possible mitral valve surgery but, due to
complications during the patient's course that will be
discussed in the infectious disease section, the surgery was
deferred.
3. Rhythm: The patient initially presented with a paced
rhythm, referred into atrial fibrillation. He was initially
on amiodarone 200 mg twice a day. For his atrial
fibrillation, the patient was DC cardioverted with a
transesophageal echocardiogram in the Coronary Care Unit.
The transesophageal echocardiogram on [**2189-1-16**] read
left atrium mildly dilated, no contrast or thrombus seen in
the body of left atrium, left atrial appendage or body of the
right atrium, right atrial appendage; right atrium mildly
dilated, intra-atrial septum normal, no atrial septal defect
seen by 2D or color Doppler; left ventricular wall thickness
and cavity normal; there was a simple atheroma in the aortic
arch; descending aorta normal diameter, simple atheroma in
descending thoracic aorta, 4+ mitral regurgitation, mitral
regurgitation jet was eccentric; mitral valve shows
characteristic rheumatic deformity with fused commissures and
tethering of leaflet motion; no change in this study from
[**2188-12-15**]. After being discharged from the Unit, the
patient was on amiodarone 200 mg daily times ten days and he
was placed on a heparin drip.
4. Coronary artery disease: The patient has severe native
three vessel disease. He is status post coronary artery
bypass grafting. His last cardiac catheterization was [**2188-3-14**] which showed the saphenous vein graft to posterior
descending coronary artery, saphenous vein graft to obtuse
marginal one and left internal mammary artery to left
anterior descending artery patent; coronary artery bypass
grafting was done in [**2184**].
The patient had three episodes of chest pain, one on the [**Hospital Ward Name 8559**], one while in the Unit and a final one on the floor.
During all three, he ruled out for a myocardial infarction.
The last episodes was on [**2189-1-21**]. Likely some
episode of congestive heart failure and anxiety contributed
to the chest pain. The last episode on [**2189-1-21**], the
patient had CKs of 32 and 44, troponin 0.4 and less than 0.3.
The pain was relieved with 2 mg of morphine and 1 mg of
Ativan, and the patient was resting comfortably in bed.
4. Coronary artery disease treatment: The patient was
treated with aspirin 162 mg daily, lisinopril as stated
above, Lipitor 10 mg daily, and Toprol XL 12.5 mg daily.
5. Renal: The patient, on [**2189-1-25**], had a
creatinine of 2. His baseline is roughly 2.2 to 2.5. He has
a history of prerenal azotemia secondary to vigorous
diuresis. That was not the case during this hospital
admission.
6. Endocrine: The patient was continued on his outpatient
regimen of NPH and Humalog, with good control. He was also
continued on levothyroxine.
7. Infectious disease: As stated earlier, the patient was
transferred to the Coronary Care Unit back to the c-medicine
team with a right internal jugular line in place. This was
at the site where he had had his cordis, triple-lumen.
Overnight, from [**1-18**], the patient
complained of right neck pain at the right internal jugular
site; he said it was terribly painful. Two peripheral lines
were placed and the right internal jugular line was pulled.
The patient had two sets of positive blood cultures on
[**2189-1-20**] for Staphylococcus aureus, Methicillin
resistant Staphylococcus aureus and an negative urine
culture. In the past, he has had a history of MRSA urinary
tract infection. The patient was then treated with
vancomycin. The blood cultures were drawn on [**2189-1-20**]. The patient spiked to 101.4, prompting a blood
culture. The first bottle became positive on [**2189-1-21**] and the patient was dosed with vancomycin promptly. At
the time, he had a stable chest x-ray.
The infectious disease team was consulted. Clostridium
difficile was checked on [**2189-1-21**] that was negative.
One set of blood cultures drawn on [**2189-1-22**] was
negative. Three sets were drawn on [**2189-1-23**], all
were negative. An additional set was drawn on [**2189-1-26**], which was negative. The patient had a transesophageal
echocardiogram repeated on [**2189-1-27**]; no mass or
thrombus seen in left atrium or left atrial appendage, no
mass or thrombus seen in right atrium or right atrial
appendage, no atrial septal defect, no mass or vegetation
seen on aortic valve; mitral valve thickened but no mass or
vegetation seen in mitral valve and there was no change in
terms of the severity of the regurgitation.
8. Prophylaxis: The patient had been on Protonix and
heparin.
This covers the hospital course through [**2189-1-22**].
Dr. [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **] will follow-up and do the course from
[**1-25**], including discharge diagnoses
and discharge medications as well as follow-up plans.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2189-6-23**] 02:42
T: [**2189-6-30**] 15:02
JOB#: [**Job Number 94644**]
Name: [**Known lastname 14962**], [**Known firstname 133**] Unit No: [**Numeric Identifier 14963**]
Admission Date: [**2189-1-9**] Discharge Date: [**2189-1-28**]
Date of Birth: [**2111-6-6**] Sex: M
Service:
ADDENDUM:
CONTINUATION OF HOSPITAL COURSE:
Transient bacteremia: The patient underwent a
transesophageal echocardiogram which showed no vegetation on
cardiac valves. He was continued on Vancomycin dose to
maintain a level above 15. Infectious Disease continued to
follow, and agreed that this was most likely a transient
bacteremia and not endocarditis, and recommended to discharge
the patient with a total course of Vancomycin for two weeks
from the day of removal of the infected line. The patient
was discharged on Vancomycin 1 mg IV qod. Vancomycin level
will be checked by visiting nurse who will report to Dr.
[**Last Name (STitle) 83**], Infectious Disease fellow for directions on when
to dispense it.
Congestive heart failure: The patient continued to diurese
nicely. His weight on discharge was 95.6. Lungs were clear
to auscultation bilaterally, although he continues to
complain of subjective feeling of needing oxygen
supplementation.
Chronic renal failure: His creatinine remains stable around
2.3-2.4 which is his baseline and a BUN around 36-40.
DISPOSITION: The patient was evaluated by Physical Therapy,
who found him fit for discharge home.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Ischemic valvular cardiomyopathy.
3. Mitral regurgitation 4+.
4. Chronic renal insufficiency.
5. Atrial fibrillation.
6. Transient bacteremia.
DISCHARGE MEDICATIONS:
1. Vancomycin 1,000 mg IV q48h. Levels will be checked and
reported to Dr. [**Last Name (STitle) 83**].
2. Bumex 2 mg po q day.
3. Iron sulfate 325 mg po q day.
4. Spironolactone 12.5 mg po q day.
5. Docusate sodium 100 mg po bid.
6. Enteric coated aspirin 81 mg po q day.
7. Isosorbide mononitrate extended release 30 mg po q day.
8. Levothyroxine sodium 25 mcg po q day.
9. Atorvastatin 10 mg po q day.
10. Metoprolol 12.5 mg po q day.
11. Lisinopril 5 mg po q day.
12. Sublingual nitroglycerin 0.3 mg prn one tablet every five
minutes if needed for chest pain up to three total doses.
13. Insulin NPH 60 units at bedtime, insulin NPH 36 units at
breakfast, insulin Humalog 24 units at breakfast.
DISCHARGE STATUS: Home.
DISCHARGE CONDITION: Fair.
FOLLOWUP: The patient will follow up with Dr. [**First Name (STitle) **] in two
weeks and will follow up with [**First Name8 (NamePattern2) 1518**] [**Last Name (NamePattern1) 14964**] in the
Congestive Heart Failure Service in one week. VNA will visit
the patient on [**2189-1-29**] and will check electrolytes which
are to be reported to [**First Name8 (NamePattern2) 1518**] [**Last Name (NamePattern1) 14964**], N.P, and a Vancomycin
level which is to be reported to Dr. [**Last Name (STitle) 83**].
[**First Name8 (NamePattern2) 577**] [**Last Name (NamePattern1) 578**], M.D. [**MD Number(2) 579**]
Dictated By:[**Last Name (NamePattern1) 6048**]
MEDQUIST36
D: [**2189-1-28**] 17:01
T: [**2189-1-29**] 05:28
JOB#: [**Job Number **]
|
[
"414.8",
"424.0",
"507.0",
"250.00",
"428.0",
"427.31",
"790.7",
"585",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.62",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
18486, 19272
|
17538, 17714
|
17737, 18464
|
2915, 3223
|
16385, 17517
|
3381, 4072
|
166, 1765
|
4097, 5332
|
1787, 2888
|
3240, 3358
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,136
| 170,330
|
50498
|
Discharge summary
|
report
|
Admission Date: [**2137-11-24**] Discharge Date: [**2137-12-19**]
Date of Birth: [**2094-6-10**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 43 year old
woman who was admitted on [**2137-11-24**], from an outside
hospital with a subarachnoid hemorrhage. The patient was at
home in bed with her husband and suddenly became
unresponsive. Her husband called 911. Upon arrival, the
patient was disoriented. The pupils were pin point. She
received some Narcan with improvement in mental status and
then began to vomit, complaining of headache and nausea. On
physical examination, the pupils are equal, round and
reactive to light and accommodation in the Emergency
Department. Her neck was supple, nontender, no
lymphadenopathy. Respiratory - Her lungs were clear to
auscultation bilaterally. Cardiac - Regular rate and rhythm,
no murmur, rub or gallop. The abdomen was soft, nontender,
positive bowel sounds. Neurologically, alert. Motor
strength was [**5-8**] in all muscle groups. Cranial nerves II
through XII are intact. Her extremity strength was symmetric
and full strength. The patient became increasingly more
alert while in the Emergency Department. There, head CT
showed a diffuse subarachnoid hemorrhage and the patient was
transferred to [**Hospital1 69**] for
further management. Upon arrival from [**Hospital3 1280**], she
continued to have nausea and vomiting.
HOSPITAL COURSE: Upon arrival to [**Hospital1 190**], she was lethargic, awakened when stimulated
and fell back to sleep snoring. She was on Nipride to keep
her blood pressure less than 130. She had a ventricular
drain placed at the bedside in the Emergency Department. She
did start to follow commands after her drain was placed. She
was taken to angiography on [**2137-11-24**], and possibly coiling of
an aneurysm. The angiogram showed an anterior communicating
artery aneurysm which was wide-necked and not suitable for
endovascular therapy. She was then taken directly to the
operating room for clipping of the aneurysm, which was done
without complications. Postoperatively, she was monitored in the
Intensive Care Unit. She had difficulty with high ICP
postoperatively with ICP elevated above 25 cm H2O and was taken
back emergently for decompressive craniectomy and duroplasty.
Again, there were no complications and postprocedure the patient
was brought back to the Intensive Care Unit for close neurologic
observation. Postoperatively, the patient remained intubated and
sedated. She would occasionally open her eyes and follow
commands times four.
On [**2137-11-27**], she was taken back to angiography which showed
that the aneurysm was secured and also showed vasospasm. Her
head CT on [**2137-11-25**], showed no change. The patient was
extubated on [**2137-11-26**]. She was awake, alert and following
commands by [**2137-11-29**]. She continued to have her vent drained
and leveled at ten above the tragus. Blood pressure was capped
in the 170 to 180 range because of evidence of vasospasm by
angiography. She did have difficulty with temperature spikes. As
of [**2137-12-1**], all her cultures were pending or negative. On
[**2137-12-1**], the patient remained awake, alert and oriented times
three with slight headache. The pupils are equal, round and
reactive to light and accommodation. Face symmetric with no
drift. Her strength was [**5-8**] in all muscle groups. She continued
to have daily temperature spikes without any clear source.
Therefore, infectious disease was consulted. She continued
on Ancef for prophylaxis for the vent drain. Her goal blood
pressure was 160 to 170. Her CVP eight to ten. She was on
triple H therapy. At the time of the initial infectious
disease consultation, there was no need for antibiotics. At
that time, the patient had a central line changed. Her liver
function tests were checked with still no clear source of
infection. The patient also was very verbally abusive to the
staff during this entire admission in the Intensive Care
Unit. On [**2137-12-4**], a psychiatry consultation was called.
The patient became combative and was threatening to leave
against medical advice. Psychiatry recommended medicating
her with Haldol as necessary. On [**2137-12-5**], the patient had
LENIs which were negative for deep venous thrombosis. She
also had a CTA which still showed evidence of vasospasm. The
patient's temperature resolved and infectious disease signed
off with no clear source of infection. Temperature did
improve without antibiotic treatment. The patient remained
in the Intensive Care Unit with a vent drain in place. The
patient had head CT on [**2137-12-8**], that showed no change from
prior CTA.
She continued to remain neurologically stable.
On [**2137-12-13**], the patient was taken back to the operating
room for replacement of her bone flap which was stored in the OR
bone bank freezer. She tolerated the procedure well.
There were no intraoperative complications. Postoperatively,
she was awake, alert and oriented following commands. The
patient continued to have periods of being uncooperative and
threatening to leave against medical advice. Psychiatry
continued to follow her and she continued to receive Haldol
as necessary. She was transferred to the Step-Down Unit on
[**2137-12-15**], with her vent drain still in place. She remained
neurologically stable The drain was removed on [**2137-12-18**].
The patient was transferred to the regular floor. She
remained neurologically stable. She did complain of
bilateral calf pain on [**2137-12-19**], and had bilateral lower
extremity Dopplers that were negative for deep venous
thrombosis. The patient was therefore discharged on
[**2137-12-19**], in stable condition with follow-up with Dr. [**Last Name (STitle) 1132**]
in two weeks with a repeat head CT. Her vital signs were
stable at the time of discharge.
MEDICATIONS ON DISCHARGE:
1. Hydromorphone 2 mg one tablet p.o. q2hours p.r.n.
2. Colace 100 mg p.o. twice a day.
3. Ferrous Sulfate 325 mg p.o. daily.
4. Fioricet one to two tablets p.o. q4hours p.r.n. for
headaches.
CONDITION ON DISCHARGE: The patient's condition was stable
at the time of discharge.
FOLLOW UP: She will follow-up with Dr. [**Last Name (STitle) 1132**] in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2137-12-20**] 10:48:22
T: [**2137-12-21**] 13:58:52
Job#: [**Job Number 105189**]
|
[
"E936.1",
"285.9",
"401.9",
"348.5",
"435.9",
"276.8",
"430",
"693.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.51",
"88.41",
"01.39",
"02.04",
"02.39",
"02.12",
"99.04",
"38.93",
"02.03"
] |
icd9pcs
|
[
[
[]
]
] |
5946, 6143
|
1451, 5920
|
6242, 6571
|
167, 1433
|
6168, 6230
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,072
| 121,196
|
18374
|
Discharge summary
|
report
|
Admission Date: [**2140-9-15**] Discharge Date: [**2140-9-27**]
Date of Birth: [**2095-7-18**] Sex: M
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45 yo male with recurrent Ph+ ALL s/p allo transplant on [**2140-3-2**]
admitted [**2140-9-15**] to MICU for hypotension and febrile. Responded
to pressors and antibiotics, but subsequently developed mental
status changes. Found to have two subdural effusions
superiorly, that could represent leukemic involvement +/-
infection +/- bleed. Pt also uremic. Pt's overall prognosis
was poor. Pt transferred to BMT floor on [**2140-9-23**].
Past Medical History:
Ph+ ALL with CNS involvement diagnosed in [**6-9**], status post
multiple chemo therapeutic regimens, s/p allo BMT. Hx of ARDS
with two weeks intubation. GVHD. CMV enteritis. Hypertension.
Hyperlipidemia. GERD
Social History:
No tobacco or alcohol use, patient is married with three grown
children, lives in Mass, former air force officer. Lives with
wife who is very supportive.
Family History:
No history of leukemia in family.
Physical Exam:
VS:
Gen: pt supine in MICU bed, non-responsive, eyes open but does
not seem to recognize surroundings, non-coversant, not tracking
eye movements
HEENT: scabbed lesions on lips, dry blood on nose, dry MM
Chest: CTAB anteriorly
Cor: RR, nl s1 s2
Abd: NABS, pt appears to guard on palpation of epigastrium,
hepatomegaly ~5cm below right costal margin, no splenomegaly
appreciated
Ext: 3+/3+ pitting edema
Pertinent Results:
[**2140-9-15**] 10:24PM GLUCOSE-105 UREA N-35* CREAT-1.3* SODIUM-143
POTASSIUM-4.0 CHLORIDE-112* TOTAL CO2-20* ANION GAP-15
[**2140-9-15**] 10:24PM CALCIUM-6.9* PHOSPHATE-5.2*# MAGNESIUM-1.7
[**2140-9-15**] 10:24PM WBC-3.0* RBC-2.38*# HGB-7.3*# HCT-20.6*#
MCV-87 MCH-30.7 MCHC-35.5* RDW-16.4*
[**2140-9-15**] 10:24PM PT-13.2 PTT-32.9 INR(PT)-1.1
[**2140-9-15**] 10:24PM PLT COUNT-30*#
[**2140-9-15**] 11:14PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
CXR: [**9-15**]
No evidence of CHF. A hazy opacity is noted in the left middle
lung zone, which likely represents an infiltrate/pneumonia given
the acuity of
its appearance.
CT head: [**9-21**]
IMPRESSION: New bilateral low-attenuation fluid collections
likely consistent
with chronic subdural hematomas, which were not present on the
previous CT
examination of [**2140-3-9**]. No evidence of more acute
intracranial bleed.
Symmetric mass effect with no evidence of midline shift. The
results of this
CT scan were verbalized by telephone to Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 334**] on
[**2140-9-21**], at approximately 5:30 PM.
NOTE ADDED AT ATTENDING REVIEW: In the setting of infection,
these collections
may represent subdural effusions, which may be associated with
meningitis.
This possibility was discussed with Dr. [**Last Name (STitle) 334**] at 11:10 am on
[**2140-9-22**].
Brief Hospital Course:
45 yo male with ALL s/p allo transplant on [**2140-3-2**] admitted
[**2140-9-15**] to MICU for sepsis, transferred to BMT floor [**2140-9-23**] with
mental status changes, uremia, and two subdural effusions which
may represent meningitis. Patient overall prognosis was grim.
Dr. [**First Name (STitle) **] spoke with Mrs. [**Known lastname **], patients wife. Considering
grave prognosis and pts and family wishing a DNR- DNI order was
written. Confort measures only. IV morphine prn was started.
Initially antibiotics and blood pressure medications were
continued, but were d/c'd d/t increased fluid overload. Mr.
[**Known lastname **] expired on [**2140-9-27**] at 9:04am.
Discharge Medications:
Morphine Drip
Discharge Disposition:
Home
Discharge Diagnosis:
ALL
Discharge Condition:
Expired
|
[
"996.85",
"996.62",
"276.2",
"428.0",
"038.11",
"486",
"584.9",
"995.92",
"284.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"99.05",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
3846, 3852
|
3106, 3785
|
318, 324
|
3899, 3909
|
1690, 2335
|
1216, 1252
|
3808, 3823
|
3873, 3878
|
1267, 1671
|
272, 280
|
352, 796
|
2344, 3083
|
818, 1029
|
1045, 1200
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,082
| 124,569
|
41859
|
Discharge summary
|
report
|
Admission Date: [**2168-10-25**] Discharge Date: [**2168-11-7**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
mechanical fall
Major Surgical or Invasive Procedure:
[**2168-10-28**] - Intramedullary nailing with cephalomedullary device,
TFN 11 x 420 x 130 with a 100-mm spiral blade.
[**2168-10-27**] - Re-Exploration for bleeding
[**2168-10-27**] - Coronary artery bypass grafting times three (Left
internal mammary to left anterior descending, saphenous vein
graft to ramus, saphenous vein graft to posterior descending
artery)
[**2168-10-26**] - Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 9671**] is a 89 year old man with known atrial
fibrillation on coumadin who presented to the [**Hospital1 18**] emergency
department after a fall the night of admission. Mr. [**Known lastname 9671**]
was found to have a left femur fracture with associated hematoma
and was admitted to the orthopedic service. During his
admission, Mr. [**Known lastname 90902**] metoprolol was held (both afternoon
and evening doses). Mr. [**Known lastname 9671**] was transferred to the
orthopedic floor and was noted to be in atrial fibrillation at a
rate of 140 beats per minute, with a systolic blood pressure of
90mmHg. A medicine consult was called and an ECG showed TWI and
ST depressions with a rapid rate. His rate decreased to below
100 after administration of metoprolol. Mr. [**Known lastname 9671**] was
transferred to the cardiology service for further management of
his arrhythmia prior to orthopedic surgery for his hip fracture.
His cardiac enzymes were noted to be elevated and a cardiac
catheterization was performed that showed multi-vessel disease.
He was referred to cardiac surgery.
Past Medical History:
Coumadin 2 mg daily
Metoprolol Tartrate 100 mg TID
Omeprazole 20 mg daily
Social History:
Mr. [**Known lastname 9671**] is a retired architect and lives at home with
wife. [**Name (NI) **] has two children, one who lives in [**Hospital1 789**], and one
who lives in [**Location **]).
He drinks three glasses of wine per day versus one glass of
scotch.
He has a remote history of smoking during WWII, when he reports
smoking less than six cigarettes per day for few years.
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM
VS: T 96.8 HR 85 (irregular) BP 114/76 RR 10 O2 sat 100% RA
GENERAL: "hungry and in pain," lying comfortably in bed, in NAD
HEENT: CNII-XII intact with MMM
NECK: Supple with JVP of ~6 cm to angle of the jaw.
CARDIAC: PMI not displaced, irregular rhthym with irregular rate
in the 70s-80s, normal S1/S2, no S3 or S4 auscultated.
LUNGS: CTAB anteriorly.
ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No femoral bruits, right leg full ROM without pain,
left leg immobilized, externally rotated and shortened, strength
and sensation intact distally.
SKIN: actinic keratoses noted on chest
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
ECHOCARDIOGRAPHY
LEFT ATRIUM: Probble thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Low normal LVEF.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
(1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
Conclusions
Pre-CPB:
A probable thrombus is seen in the left atrial appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with borderline normal free wall function. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are moderately thickened. No aortic
regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
There is no pericardial effusion.
.
[**2168-10-26**] Cardiac catheterization
1. Coronary angiography in this right dominant system
demonstrated left main and three-vessel disease. The LMCA had
an 80%
ostial lesion. The proximal LAD had a 70% lesion. The mid-LAD
had a
50% lesion. The LCx had an ostial 95% lesion. The mid-RCA had
a 95%
lesion. 2. Limited resting hemodynamics revealed a normal
systemic
arterial pressure with a central aortic pressure of 101/60 mmHg.
.
[**2168-10-27**] Carotid Ultrasound
Minimal heterogeneous plaque in the distal common and proximal
internal carotid arteries on both sides. No evidence of a
hemodynamically significant stenosis on either side. The flow in
the vertebrals is prograde.
.
[**2168-10-25**] CT Scan
1. Moderate-to-large right simple pleural effusion and small
left pleural
effusion. No evidence of hemothorax.
2. Comminuted left femur fracture extending from the lesser
trochanter into the proximal left metadiaphysis as seen on the
previous radiograph.
3. Small amount of simple free fluid in the pelvis.
4. Arterially enhancing liver lesions are non-specific and might
represent
flash-filiing hemangiomas, adenomas, or areas of FNH. Further
nonurgent
evaluation with MRI is recommended.
[**2168-11-6**] 05:05AM BLOOD WBC-7.3 RBC-2.87* Hgb-9.1* Hct-27.4*
MCV-95 MCH-31.6 MCHC-33.2 RDW-15.8* Plt Ct-266
[**2168-10-25**] 08:01PM BLOOD WBC-6.8 RBC-3.52* Hgb-12.1* Hct-33.5*
MCV-95 MCH-34.3* MCHC-36.1* RDW-13.8 Plt Ct-208
[**2168-10-27**] 06:09AM BLOOD Neuts-74.3* Lymphs-19.0 Monos-5.3 Eos-1.2
Baso-0.2
[**2168-11-7**] 05:00AM BLOOD PT-17.4* INR(PT)-1.6*
[**2168-11-6**] 05:05AM BLOOD Plt Ct-266
[**2168-10-25**] 09:07PM BLOOD PT-23.0* PTT-32.4 INR(PT)-2.2*
[**2168-10-25**] 08:01PM BLOOD Plt Ct-208
[**2168-10-29**] 02:47AM BLOOD Fibrino-462*#
[**2168-10-27**] 03:25PM BLOOD Fibrino-168
[**2168-11-7**] 05:00AM BLOOD Glucose-132* UreaN-53* Creat-1.0 Na-135
K-4.0 Cl-95* HCO3-34* AnGap-10
[**2168-10-25**] 08:01PM BLOOD Glucose-155* UreaN-18 Creat-0.8 Na-137
K-4.8 Cl-101 HCO3-28 AnGap-13
[**2168-11-7**] 05:00AM BLOOD ALT-26 AST-36 LD(LDH)-365* AlkPhos-125
Amylase-122* TotBili-2.9*
[**2168-11-6**] 05:05AM BLOOD ALT-23 AST-41* LD(LDH)-376* AlkPhos-119
Amylase-132* TotBili-2.9*
[**2168-11-7**] 05:00AM BLOOD Lipase-126*
[**2168-11-6**] 05:05AM BLOOD Lipase-132*
[**2168-10-26**] 05:05AM BLOOD ALT-21 AST-45* CK(CPK)-242 AlkPhos-66
TotBili-1.3
[**2168-10-27**] 06:09AM BLOOD CK-MB-13* MB Indx-6.0 cTropnT-0.52*
[**2168-10-26**] 12:45PM BLOOD CK-MB-46* MB Indx-10.4* cTropnT-1.04*
[**2168-10-26**] 05:05AM BLOOD CK-MB-28* MB Indx-11.6* cTropnT-0.36*
[**2168-11-7**] 05:00AM BLOOD Albumin-2.9* Calcium-8.4 Phos-4.3 Mg-2.1
[**2168-10-26**] 09:05AM BLOOD VitB12-532 Folate-17.3
[**2168-10-26**] 03:30PM BLOOD %HbA1c-5.9 eAG-123
Brief Hospital Course:
Mr. [**Known lastname 9671**] was admitted with a left femur fracture with
associated hematoma to the orthopedic service on [**2168-10-25**].
After his admission, Mr. [**Known lastname 90902**] metoprolol was held (both
afternoon and evening doses). Mr. [**Known lastname 9671**] was transferred to
the orthopedic floor and was noted to be in atrial fibrillation
at a rate of 140 beats per minute, with a systolic blood
pressure of 90mmHg. A medicine consult was called and an ECG
showed TWI and ST depressions with a rapid rate. His rate
decreased to below 100 after administration of metoprolol. Mr.
[**Known lastname 9671**] was transferred to the cardiology service for further
management of his arrhythmia prior to orthopedic surgery for his
hip fracture. His cardiac enzymes were noted to be elevated and
a cardiac catheterization was performed that showed multi-vessel
disease. He was referred to cardiac surgery. Mr. [**Known lastname 9671**] was
worked-up in the usual preoperative manner.
On [**2168-10-27**] he underwent coronary artery bypass grafting times
three (Left internal mammary to left anterior descending,
saphenous vein graft to ramus, saphenous vein graft to posterior
descending artery) and ligation of his left atrial appendage
performed by Dr. [**Last Name (STitle) **]. Please see the operative note
for details. He tolerated the procedure well and was
transferred in critical but stable condition to the surgical
intensive care unit. He was noted to have an increased chest
tube output and was returned to the operating room for a
re-exploration for bleeding. Hemoststasis was acheived and he
was transferred back to the intensive care unit for monitoring.
He was kept intubated over night and on post-operative day one
underwent a left hip repair. Please see the operative note for
details. The electrophysiology [**Last Name (un) 12003**] was consulted in regards
to his atrial fibrillation. Anticoagulation and rate control
with beta blockade was recommended. On [**2168-10-29**], he was extubated
without complications but had confusion that medications were
adjusted. He was gently diuresed towards his preoperative
weight. On [**2168-10-30**], Mr. [**Known lastname 9671**] was transferred to the step
down unit for further recovery. he worked with physical therapy
to increase his strength and mobility. His confusion cleared and
he was alert and oriented for several days prior to discharge
and was restarted on oxycodone IR in small dose for pain
management of left leg to facilitate physical therapy. Coumadin
was resumed for anticoagulation as per preoperatively for his
atrial fibrillation. Additionally diltiazem was added for rate
control and was titrated slowly without any complications, and
his rate remains in 70-90 in atrial fibrillation. A small area
of erythema/reddened tissue was noted on his coccyx. Ulcer
preventative care was initiated. Lisinopril was started for
treatment of his blood pressure and as he had a preoperative
myocardial infarction, however it was stopped when he was
started on diltiazem for rate control. He remains off any ace
inhibitor due to blood pressure as he is requiring the current
doses of diltiazem and lopressor for heart rate management.
Also his diuresis was increased and zaroxlyn added due to
ongoing pleural effusions that are slowly decreasing, and will
plan to continue lasix at rehab.
He had multipods boots placed and AFO splint as per orthopedics
prior to discharge. Plan to continue with weight bearing as
tolerated on the left leg and continues with sternal precautions
for upper extremities. He was ready for discharge to rehab on
telemetry for rhythm monitoring due to rapid atrial fibrillation
and previous bradycardia preoperatively.
Medications on Admission:
Coumadin 2 mg daily
Metoprolol Tartrate 100 mg TID
Omeprazole 20 mg daily
Discharge Medications:
1. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week:
start [**11-21**] .
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
9. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day)
as needed for 1 hour prior to PT : only 2.5 mg .
Disp:*30 Tablet(s)* Refills:*0*
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for severe pain.
11. Lopressor 100 mg Tablet Sig: One (1) Tablet PO three times a
day.
12. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
13. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
14. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
17. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
please check INR [**11-8**] for further dosing by rehab physician [**Name Initial (PRE) **]
[**Name10 (NameIs) **] INR 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
coronary artery disease s/p CABG
femur fracture s/p repair
rapid atrial fibrillation
Non ST elevation myocardial infarction
Diabetes mellitus type 2
Anemia
Secondary diagnosis
Gastroesophageal reflux disease
Discharge Condition:
Alert and oriented x3 nonfocal
Standing with assist device with max assist, has not ambulated
Incisional pain managed with ultram prn and then oxycodone IR
2.5 mg just prior to PT for left leg discomfort
Incisions:
left leg ortho sites - staple removal on [**11-10**] - mild erythema
at staples no drainage well approximated
Sternal - healing well, no erythema or drainage
Leg Right EVH - healing well, no erythema or drainage.
Edema 1+ lower extremity left > right
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
4) 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
5) No lifting more than 10 pounds for 10 weeks
6) 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**
Orthopedics
In order to decrease your risk of fracture you have been started
on calcium and vitamin d. In addition, we have also recommended
that you start taking Fosamax (alendronate sodium) 70 mg once a
week to further decrease your risk of having a fracture. You
should take the first dose of this medication starting two weeks
after you are discharged from the hospital. It is very important
that Fosamax (alendronate sodium) is taken with a full glass of
water first thing in the morning, on an empty stomach, with no
lying down or eating for at least 30 minutes following
administration. Following discharge, please be sure to talk with
your primary care doctor and inform them that you have been
started on this medication
Any concern in relation to left femur repair please contact
orthopedics [**Telephone/Fax (1) 1228**]
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2168-12-5**] at 1:00 pm
Cardiologist: Dr [**Last Name (STitle) 8051**] on [**11-21**] at 11:45am
Orthopedics [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90903**] NP [**Telephone/Fax (1) 1228**] on [**12-22**] at 9:00 am
**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
[**Telephone/Fax (1) 18303**] INR 2.0-2.5
First draw [**11-8**]
to be dosed by rehab physician, [**Name10 (NameIs) **] set up with primary care
physician when being discharged from rehab
Please check INR monday, wednesday and friday for the first two
weeks and then decrease as directed by physician
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2168-11-7**]
|
[
"414.01",
"788.29",
"E849.0",
"E849.7",
"V58.61",
"416.8",
"E885.9",
"348.30",
"427.81",
"E878.2",
"821.01",
"998.11",
"285.9",
"250.00",
"427.31",
"530.81",
"410.71",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15",
"88.56",
"34.03",
"79.15",
"37.36",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
12529, 12612
|
6923, 10674
|
273, 682
|
12865, 13333
|
3132, 6900
|
15023, 16034
|
2342, 2360
|
10798, 12506
|
12633, 12844
|
10700, 10775
|
13357, 15000
|
2375, 3113
|
218, 235
|
710, 1827
|
1849, 1925
|
1941, 2326
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,957
| 118,811
|
11646
|
Discharge summary
|
report
|
Admission Date: [**2183-1-9**] Discharge Date: [**2183-1-22**]
Date of Birth: [**2120-4-1**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old
right handed woman with a history of uterine and ovarian
cancer status post a resection with chemo and radiation who
presents with a two to three week history of behavior changes
and mental status changes which have become progressively
over the last week becoming agitated, disoriented, not
eating. She has never had mental status changes in the past.
She had a upper respiratory infection a few days prior to
admission. No falls in the past history. She was seen by her
primary care physician [**Last Name (NamePattern4) **] [**2182-11-9**].
She appears confused. Cardiovascular - regular rate and
rhythm. Lungs are clear to auscultation. Abdomen is soft,
nontender, nondistended. Extremities - no edema.
Neurologically - awake, alert, oriented to name. She knows
the month, day and the year, [**First Name4 (NamePattern1) 19450**] [**Last Name (NamePattern1) **]. Sparse speech,
no dysarthria, repetition intact. Names knuckles,
stethoscope. She cannot name fingernails. She cannot say the
months of the year. She cannot do serial 7's. Pupils are
equal, round and reactive to light. Extraocular muscles are
full, no nystagmus. Unable to fully evaluate visual fields
secondary to patient unable to follow commands. Slight
flattening of the right nasal labial folds. Motor exam -
full strength in the upper and lower extremities. Question
of slight weakness of the right IP, right deltoid, biceps
versus poor effort. Sensation intact to light touch
throughout. Does not answer to pinprick. Finger to nose
intact on the left, refuses to do on the right. Gait is
steady.
LABORATORY DATA: Head CT scan shows a large heterogeneous
mass on the left frontal lobe extending across the
right.
Sodium 143, potassium 4.2, chloride 103, CO2 29, BUN 26,
creatinine 0.7, glucose 165, white count 8.8, crit 40.7,
platelet count 329,000. Her INR is 1.1, PT 12.6, PTT 25.6.
Chest x-ray shows alveolar opacity in the left lung base.
HOSPITAL COURSE: The patient was admitted to the
Neurosurgery service and on [**2182-11-13**] she underwent a
craniotomy for excision of tumor. There were in
intraoperative complications. Postoperative her vital signs
were stable. She was afebrile. She did have mild right upper
extremity weakness. She was mute. Her neurologic status
improved to the point where she is now oriented times two to
three. She moves everything strongly with no drift. Her
dressing is clean, dry and intact. A speech and swallow
study found to be able to tolerate a regular
diet.
She is seen by Physical Therapy and Occupation Therapy and
found to require rehab prior to discharge to home. She will
follow up in the Brain [**Hospital 341**] Clinic with Dr. [**First Name (STitle) **] on Monday,
[**2183-1-27**].
The patient's condition was stable at the time of discharge.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2183-1-22**] 11:30
T: [**2183-1-22**] 11:57
JOB#: [**Job Number 36923**]
|
[
"348.3",
"250.00",
"V10.42",
"787.2",
"V10.43",
"191.8",
"401.9",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"38.93",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
2144, 3267
|
157, 2126
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,326
| 126,406
|
5289
|
Discharge summary
|
report
|
Admission Date: [**2114-11-3**] Discharge Date: [**2114-11-16**]
Date of Birth: [**2058-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Hives at dialysis, EKG changes
Major Surgical or Invasive Procedure:
Exploration of AVF
TEE
Hemodialysis
History of Present Illness:
56 year old male with non-ischemic cardiomyopathy, seizure
disorder since starting dialysis eight years ago, with frequent
seizures during dialysis, managed with anti-epileptic
medications daily, and ESRD secondary to longstanding
hypertension, on dialysis, who was admitted early this morning
for hives at dialysis and EKG changes. He was admitted from
dialysis where he had developed the sudden-onset of itching and
hives diffusely. In the ED the total body rash was confirmed. He
denies any new medications or recent medication changes.
Hemodialysis was reportedly done as per routine, without any new
changes in the dialysate. At the time he denied any shortness of
breath, difficulty swallowing or speaking, and he had no
wheezes. His only complaint was general fatigue. He denies any
fevers or chills, and had been in his usual state of health
prior to this.
.
In the ED, he was febrile to 101, HR 135, BP 100/66, RR 20, 97%
on RA. His EKG demonstrated TWI and cardiac enzymes were added
on which have been flat. He was given levaquin and vancomycin
for the fever, as well as pepcid and solumedrol for presumed
allergic reaction, and admitted to the floor.
.
He went for routine hemodialysis this afternoon, with starting
vitals T 102.2, BP 105/68, HR 112. About 1 hour into HD he had a
generalized tonic clonic seizure lasting about 2 minutes. He
received 200 cc of NS. Vital signs after the seizure were BP
183/105, HR 113. He received vancomycin 1000 mg x 1. He
completed HD, during which he had 1 liter of ultrafiltrate
removed. While awaiting transport after HD he had another
generalized tonic clonic seizure, this time terminated by 2 mg
of ativan. His vitals were again stable, with O2 sat 92% on
rebreather mask at 10 L flow. An ABG at the time was
7.43/38/124. It was decided to transfer him to the MICU for
closer respiratory monitoring overnight.
.
In MICU blood cultures sent grew out gram + cocci in [**5-29**]
bottles, concerning for line infection. Patient initially on
vancomycin, converted to linezolid given concern for VRE, then
to nafcillin today with patient afebrile. Concern for infection
at AVF site. Ultrasound performed with evidence of fluid
collection along course of AV graft.TEE attempted but had to be
aborted due to gagging. Potassium noted to be 5.6, kayexalate
given prior to transfer. Dialysis line pulled given likely
infective source. Pt transferred to medicine for continued
treatment of bacteremia, seizures.
.
Past Medical History:
1. Seizure disorder, onset of seizures in mid [**2097**] after
starting dialysis. He seems to have seizures quite frequently at
dialysis, per neurology this seems to be attributed to both
non-compliance with the medications, as well as taking his
medications later on those days.
2. End stage renal disease on hemodialysis due to hypertensive
nephropathy
3. Non-ischemic cardiomyopathy, EF 20%
4. AV fistula, status post thrombectomy [**7-/2114**]
5. Hungry bone syndrome status post parathyroidectomy
.
Social History:
Pt reports he lives alone in an apartment in the [**Location (un) **].
Notes say he is living with a friend in [**Name (NI) 3494**] currently. He
denies any alcohol. No tobacco use. Occasion alcohol use as per
patient. No IV drug use that he admits. Reports director of
music at local church and states sole source of income.
Concerned illness will lead to loss of livelihood.
Family History:
Mother died at age of 41 of renal failure. Father is 85 and has
diabetes. He does have a son who is healthy.
Physical Exam:
FROM MICU
Vitals 98.5, 125/77, 106, 18, 92% on RA.
GENERAL: Slim african americal male resting comfortably in bed,
sleepy but arousable and answering questions appropriately.
Thinks it is early Sunday morning.
HEENT: Mildly dry mucous membranes.
NECK: JVP not visible.
COR: RR, tachycardic, no murmurs, rubs, or gallops.
CHEST: Clear bilaterally. Right dialysis line removed with
overlying bandage.
ABDOMEN: Normoactive bowel sounds, soft, non-tender.
EXTR: Right arm with palpable pulse over fistula, however no
thrill. No edema. DP pulses palpable
Pertinent Results:
[**2114-11-2**] 07:00AM POTASSIUM-5.1
[**2114-11-2**] 05:20PM NEUTS-84.0* LYMPHS-11.6* MONOS-3.3 EOS-1.0
BASOS-0.1
[**2114-11-2**] 05:20PM CK-MB-3 cTropnT-0.09*
[**2114-11-2**] 05:20PM CK(CPK)-243*
[**2114-11-2**] 05:20PM GLUCOSE-100 UREA N-45* CREAT-10.4*#
SODIUM-139 POTASSIUM-6.2* CHLORIDE-89* TOTAL CO2-27 ANION
GAP-29*
[**2114-11-2**] 11:55PM LACTATE-1.6
[**2114-11-3**] 04:30AM CALCIUM-8.3* PHOSPHATE-6.1* MAGNESIUM-2.1
[**2114-11-3**] 04:30AM CK-MB-2
[**2114-11-3**] 04:30AM cTropnT-0.09*
[**2114-11-3**] 04:30AM GLUCOSE-84 UREA N-59* CREAT-12.2*# SODIUM-136
POTASSIUM-5.6* CHLORIDE-95* TOTAL CO2-18* ANION GAP-29*
[**2114-11-3**] 10:25AM WBC-14.0*# RBC-5.54 HGB-14.8 HCT-44.7 MCV-81*
MCH-26.7* MCHC-33.1 RDW-16.8*
[**2114-11-3**] 10:25AM CALCIUM-8.4 PHOSPHATE-6.6* MAGNESIUM-1.9
IRON-21*
[**2114-11-3**] 10:25AM GLUCOSE-93 UREA N-65* CREAT-12.9* SODIUM-136
POTASSIUM-6.1* CHLORIDE-95* TOTAL CO2-17* ANION GAP-30*
[**2114-11-3**] 04:14PM LACTATE-2.2*
.
CHEST (PA & LAT) [**2114-11-2**] 10:22 PM
No evidence of pneumonia.
.
ECHO Study Date of [**2114-11-4**] TTE
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed with global hypokinesis and akinesis of the inferior
wall. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve appearsmildly thickened with mild
mitral regurgitaiton .
IMPRESION: No valvular vegetations seen but unable to exclude.
If clinically indicated, a TEE is recommended.
Compared with the prior study (images reviewed) of [**2112-8-16**],
the findings are similar.
.
US EXTREMITY NONVASCULAR RIGHT [**2114-11-5**] 10:01 AM
Fluid collections with small pockets of air along the course of
the right AV graft concerning for infection with a gas forming
organism.
.
[**2114-11-10**] AV graft exploration- There was no purulent material.
The
graft was well incorporated, no evidence of a perigraft sepsis.
.
ECHO Study Date of [**2114-11-14**] TEE
EF 25-30% 1. The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler.2. Left ventricular wall
thicknesses are normal. The left ventricular cavity is dilated.
Overall left ventricular systolic function is severely
depressed.3. Right ventricular chamber size is normal.4.There
are simple atheroma in the aortic arch and the descending
thoracic aorta. 5.The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic, mitral, tricuspid or
pulmonic valves. No aortic valve abscess is seen. Trace aortic
regurgitation is seen.6.The mitral valve appears structurally
normal with trivial mitral regurgitation.7.There is no
pericardial effusion.
Impression: No echocardiographic evidence of endocarditis seen.
Brief Hospital Course:
56 year old male with non-ischemic cardiomyopathy (EF 20%),
seizure disorder with frequent seizures during HD, and ESRD on
HD presenting with seizures in the setting of dialysis,
bacteremia with staph aureus, ESRD, concerning for endocarditis.
.
#) Bacteremia: Patient had [**5-29**] blood culture bottles with gram
positive cocci. Patient started on vancomycin. In [**2105**] high
grade VRE bacteremia occurred with vancomycin treatment, however
given his history of VRE and continued fevers despite
vancomycin, MICU team changed from vancomycin on admission to
linezolid. With MSSA found, patient changed to Nafcillin 2 grams
q 6 then to q 4 as speciation returned and patient has been
afebrile. The hemodialysis line deemed as likely source which
was pulled with tip growing gram + cocci. Had temporary HD line
placed [**11-6**]. Source of infection and seeding of infection to AV
graft also considered especially in light of new fluid
collection likely demonstrating infection seen on U/S.
Exploration with no evidence of infection on [**11-9**]. Endocarditis
with seeding of the valves also considered given temp spikes,
bacteremia and 1st degree AV block on his EKG, with
interventricular conduction delay, however on prior EKGs his PR
interval was already borderline (190 ms), with interventricular
conduction delay. [**11-4**] TTE with no evidence of endocarditis but
given up to 50% of catheter related endocarditis can be missed
on TTE, TEE was attempted [**11-5**]. Unable to complete given
patient gagging. Given likely source catheter which was removed,
TEE held until requested by ID for treatment course [**11-14**],
severely depressed EF as baseline but no vegetation or other
findings concerning for endocarditis. With tunneled catheter
removed held off on dialysis for three days and then resumed
with temporary cath with triple port with ABX infusion through
port. As blood CX negative, permanent tunneled catheter and PICC
line placed [**11-12**] for hemodialysis and ABX treatments. Nafcillin
continued until one day prior to discharge when given Ancef post
dialysis to be started for total of 4 week course of ABX since
last negative blood culture which was on [**11-6**]. Pt discharged
afebrile blood culture negative with new tunneled catheter, PICC
line removed to receive Ancef 1 gram q dialysis for a total of
two weeks more.
.
#) [**Name (NI) 5964**] Pt had HD [**11-2**], [**11-3**]. HD catheter pulled on [**11-3**] as
likely source of bacteremia with patient febrile. Temporary HD
catheter placed [**11-6**], and patient received HD [**11-6**], [**11-7**],
[**11-8**], [**11-10**], [**11-11**], [**11-13**], [**11-14**]. Tunneled catheter was placed
[**11-12**]. Patient discharged on sevelamer, calcium acetate,
Nephrocaps to return for previous hemodialysis schedule with
Ancef post dialysis for two weeks.
.
#) Seizures: Managed with levetiracetam and oxcarbazepine in the
past due to frequent seizures during hemodialysis. He is
followed by Dr. [**Last Name (STitle) 2442**] of neurology. Considered medication non
compliance, metabolic and infective triggers, decreased levels
of anti seizure medication given dialysis and lowered seizure
threshold given temperature spikes as possible factors leading
to seizures during dialysis. Neurology team consulted which
recommended continued Trileptal and Keppra with close
monitoring. Keppra 1000mg and oxcarbemazepine 300 mg qam on days
not receiving dialysis, and qpost-HD on dialysis days. Keppra
250 mg on dialysis days started per renal recs. Ativan 1 mg TID
standing if continued seizures and 2 mg IV if seizure noted.
Standing Ativan slowly tapered as patient did not have recurrent
seizures post first episode. Tylenol for fevers to decrease risk
of seizures. No seizure activity after first dialysis on
admission.
.
#) Hyperkalemia- K 5.6 on admission. Likely due to ESRD,
inability to dialyze and remove potassium. 15 mg Kayexalate
given on admission. Monitored on tele. Continued with dialysis
with stabilization within a day.
.
#) Urticarial reaction: Occurred during dialysis. Likely
secondary to an allergic reaction, although he did not receive
any new medications. Anti-convulsants of which oxcarbazepine
would be more likely to cause idiosyncratic allergic reactions
than levetiracetam. Benadryl prn, and Pepcid. Pruritis stopped
day two of dialysis.
.
#) Non-ischemic cardiomyopathy: EF 20%. Cath on [**6-27**] which
showed no ischemic disease. Deepening TWI on EKG in ED. Cardiac
enzymes flat. Likely secondary to severe untreated hypertension.
Continued digoxin 125 mcg qod. TTE and TEE with similar findings
as prior.
.
#) Elevated HCT: Given history of pruritis, had considered
polycythemia [**Doctor First Name **], though likely was a result of
hemoconcentration. Crit stabilized to near 40.
.
#)FEN- Cardiac, renal diet.
Medications on Admission:
Levitiracetam 1000 mg daily
Oxcarbazepine 600 mg daily
Allopurinol 100 mg daily
Digoxin 125 mcg QOD
Folic Acid 1 mg daily
Calcium acetate 667 (5 tabs with meals TID)
Nephrocaps daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
10. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*0*
11. Ancef 1 g Piggyback Sig: One (1) gram Intravenous q
dialysis for 14 days: will be given at dialysis .
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
MSSA bacteremia
Secondary:
ESRD
Seizure disorder
Non-Ischemic cardiomyopathy, EF 20%
AV fistula
Discharge Condition:
afebrile, stable
Discharge Instructions:
-Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
-You were admitted with a MSSA bacteremia likely from an
infected dialysis catheter. You were treated with antibiotics,
nafcillin and will be discharged on Ancef to be given during
dialysis for two weeks.
-Please take medications as prescribed to you in addition to the
antibiotic Ancef to be given during dialysis.
-Please maintain all follow- up appointments.
-Dialysis will continue on monday.
-Please return to the hospital if you are experiencing chest
pain, shortness of breath, fever, increased weight, cough,
seizures, pain or redness, or pus from tunneled catheter site.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 1860**], but will follow up during dialysis.
[**Telephone/Fax (1) 60**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2114-11-26**] 3:20
Provider: [**Name10 (NameIs) 14876**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2114-12-4**] 4:00
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2115-1-2**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2115-2-5**] 10:20
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43,937
| 151,838
|
1261
|
Discharge summary
|
report
|
Admission Date: [**2199-8-23**] Discharge Date: [**2199-9-1**]
Date of Birth: [**2113-3-30**] Sex: M
Service: MEDICINE
Allergies:
Depakote / Zarontin / Phenobarbital / Aspirin
Attending:[**Last Name (un) 7835**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 86 year old male with a history of CAD,
congestive heart failure, and dementia who presents from
[**Hospital3 **] with shortness of breath, hypoxia, and a chest
x-ray showing pneumonia. He was reportedly feeling more short of
breath all day, with general malaise. He was given oxygen and
nebulizer treatments without improvement and CXR at [**Hospital 7137**] showed bilateral infiltrates concerning for pneumonia. He
was given a dose of Levofloxacin and Flagyl. He was brought to
[**Hospital1 18**] by EMS. While en route, he was given a bolus of normal
saline and Duonebs by EMS.
.
In the ED, initial vital signs were T 97.0, BP 85/44, HR 107, RR
28, and SpO2 91% on NRB. He triggered for hypotension and was
given additional IV fluids. Labs showed WBC 6.5 but with 37%
bands and 3% metas. He had creatinine 2.1 with unknown
baseline, bicarb 17 with anion gap 17, and lactate 5.5. His
Troponin was 0.05 and his BNP was [**Numeric Identifier 7836**]. CXR in the ED again
showed bibasilar infiltrates concerning for pneumonia. He was
given Vancomycin 1000 mg IV and Levofloxacin 750 mg IV. He was
admitted to the ICU for further management. Prior to transfer,
his vitals were BP 119/53 (105/43 sleeping), HR 103, RR 15, and
SpO2 97% on NRB.
.
Once in the ICU, he reported some continued shortness of breath
and cough. On questioning, he noted that he often coughs after
eating. He has been feeling unwell and more fatigued over the
last few days. He notes having some intermittent chest pain at
baseline, but no pain currently. He was quickly weaned down to
nasal cannula.
Past Medical History:
# Coronary artery disease
-- stenting of D1 in [**7-/2191**]
# Ischemic cardiomyopathy
# Cerebrovascular accident ([**2187**])
# Hypertension
Social History:
# Tobacco: Past smoking history, none currently
# Alcohol: None
# Illicits: None
Family History:
Noncontributory
Physical Exam:
ICU admission exam:
General: Alert, no acute distress
HEENT: Sclera anicteric, PERRL, very dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles, wheezes and coare breath sounds
throughout
CV: Distant heart sounds, RRR, no murmurs appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: No clubbing, cyanosis, or edema. Distal pulses 2+
Pertinent Results:
ECHOCARDIOGRAM [**2199-8-23**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. LV systolic function appears
depressed (ejection fraction ? 30 percent) with regional
variation. Left ventricular mechanical function appears markedly
dyssynchronous. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve is not well seen. The study is
inadequate to exclude significant aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
CXR [**2199-8-23**]: AP UPRIGHT VIEW OF THE CHEST: There is increased
left retrocardiac opacity worrisome for infection . Bibasilar
atelectasis is present. Lung volumes are low. Heart size is top
normal. There is no large effusion or pneumothorax. The aorta is
tortuous.
Brief Hospital Course:
86 yo M with CAD, systolic HF (EF 30%), h/o CVA ([**2187**]), HTN,
recurrent [**Year (4 digits) **], admitted from [**Hospital3 2558**] to ICU on
[**2199-8-23**] with hypoxia, hypotension, apparent bilateral pneumonia
(likely [**Date Range **]), and acute renal failure. Per [**Hospital1 1501**] report,
was feeling increasing dyspnea, malaise on [**8-23**]. CXR performed at
[**Hospital3 **] was concerning for bilateral PNA. He was given
levofloxacin and metronidazole and transferred to [**Hospital1 18**].
In the ED, he was hypotensive (85/44), hypoxic (91% NRB). He
received Vancomycin and was admitted to the [**Hospital Unit Name 153**]. In the ICU,
his blood pressure remained stable in the low 100s systolic and
O2 sats in low 90s on 3L NC. He was continued on vancomycin and
levofloxacin and cefepime was added on the afternoon of [**8-23**] to
cover for hospital acquired pathogens. A bedside swallowing
study by his nurse [**First Name (Titles) 7837**] [**Last Name (Titles) **] of apple sauce as well as
his own secretions. He was made NPO. ICU course also significant
for elevated troponin suggesting demand cardiac ischemia.
.
# Sepsis due to [**Last Name (Titles) **] PNA: PNA was felt unlikely to be due
to MRSA so vancomycin was stopped upon transfer out of the ICU.
Levofloxacin and metronidazole were continued via parenteral
route as he was not taking oral medications consistently.
Formal swallowing eval by Speech Therapy on [**2199-8-26**] showed gross
[**Date Range **] of all consistencies. He appeared to have another
[**Date Range **] event on [**2199-8-26**], with increase in supplemental oxygen
requirement and CXR showing worsening bibasilar opacities. He
remained NPO and completed a course of Levofloxacin and Flagyl
IV on [**2199-8-31**]. His clinical status improved to the point he was
not requiring supplemental oxygen by [**2199-8-30**] and appeared
comfortable at rest.
.
#Recurrent [**Month/Day/Year **]: Initial swallow evaluation done on
[**2199-8-26**] showed gross [**Date Range **] of all consistencies. He was
placed NPO and a family meeting (discussed below) was held on
[**2199-8-28**]. Due to prolonged NPO status the patient was started on
TPN for nutrional support for 4 days prior to re-evaluating
swallow. His repeat swallow evaluation on [**2199-8-30**] showed
persistent risk of [**Date Range **], which was discussed with his
guardian by phone communication. However, pt is at risk of
[**Date Range **] even while being NPO due to continued [**Date Range **] from
oral secretions and this is known to be a chronic condition,
unlikely to improve. Knowing these risks, after discussion with
guardian, patient was started on pureed solids and continued on
strict [**Date Range **] precautions as deliniated by Speech Therapy
with the goal of transferring back to NH. He tolerated pureed
solids for 2 days without respiratory decompensation and will be
discharged with the following recommendations:
a) PO diet: pureed solids, nectar thick liquids
b) PO meds crushed in puree
c) Strict [**Date Range **] precautions
d) Continue Q4 oral care including oral care just prior to
any PO intake.
.
# Hypotension: Improved with aggressive fluid resuscitation.
Home BP meds (metoprolol, furosemide) were held in the ICU. On
[**8-24**] his SBP was in the 130s, so metoprolol was restarted, nitrol
patch was added instead of the prior Imdur(erratic PO intake)and
metoprolol dose was changed to 12.5 mg [**Hospital1 **]. His BP remained
controlled during his stay on this dosing.
.
# Acute on chronic renal failure: His initial creatinine was
elevated to 2.1 (baseline ~1.2), improved with IVF
resuscitation. Creatinine at discharge was 0.8.
.
# Known CAD with elevated troponin - likely demand cardiac
ischemia. Continued plavix. Allergic to aspirin. Statin was held
due to his dysphagia/[**Hospital1 **], this was be restarted at NH if
felt indicated by PCP. [**Name10 (NameIs) **] beta blocker and long-acting nitrate.
.
# Systolic Congestive Heart Failure, chronic: TTE in the ICU
showed an EF 30%. Held furosemide in house, as he was
essentially NPO and getting IV fluids before initiation of TPN.
Daily weights were monitored and should continue to be monitored
in NH as lasix has not been restarted due to decreased po
intake. Pt remained euvolemic off Lasix during admission.
.
# While NPO, colchicine, Cyanocobalamin, vitamin D were all
held. These have not been restarted to simplify regimen and will
be at the discretion of PCP whether to restart.
.
# Goals of care: family meeting was held on [**2199-8-28**]. In
attendance were Mr. [**Known lastname 7838**] wife and son, his legal guardian
([**Name (NI) **] [**Name (NI) 1005**]), attending physician at the time (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]), and representatives from Social Work ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7839**]),
Speech Therapy ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]), and Nutrition ([**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 7840**]).
Discussed Mr. [**Known lastname 7838**] current status, and in particular his
high risk for [**Known lastname **].
Agreements between Mr. [**Known lastname 7838**] wife and son and other providers
at the meeting (to be acted upon by his legal guardian)
included:
-No PEG tube
-Start TPN
-NPO
-Repeat evaluation by Speech Therapy on Friday [**8-30**]
-Further recommendations and discussion about oral feeding to
occur after evaluation on Friday [**8-30**]
-Criteria for discharge to [**Hospital3 2558**] or another skilled
nursing facility would include: requirement for little to no
supplemental oxygen, plan for nutrition, and plan for action if
he develops respiratory distress or failure
-Would be OK for re-hospitalization
-Code status now DNR-DNI
-After repeat evaluation ([**2199-8-30**]) with no major improvement in
swallowing, it was felt pt will not improve and will have
chronic [**Month/Day/Year **]. Since no expected improvement, TPN was
weaned and pt was restarted on pureed solids after discussing
with guardian following above recommendations for [**Month/Day/Year **]
precautions.
Medications on Admission:
Diet: puree with nectar thick liquids, Ensure TID
Cortisporin otic drops 2 gtt to L ear on 1st and 15th of each
month
mirtazapine 30mg QHS
colchicine 0.6mg daily
doxazosin 8mg daily (AM)
furosemide 40mg daily
Imdur 60mg daily
Lipitor 20mg daily
Plavix 75mg daily
vit B12 500mcg daily
Lactulose 15ml daily (AM)
Senna 2tabs [**Hospital1 **]
vit D3 400unit daily
metoprolol tartrate 25mg [**Hospital1 **]
docusate 100mg [**Hospital1 **]
gabapentin 200mg QHS
lorazepam 1mg QHS
APAP 1000mg [**Hospital1 **] (not to exceed 4g/day)
MOM 30ml PRN constipation
Duonebs Q6H
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as
needed for SOB.
4. ipratropium bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for SOB.
5. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
9. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
10. Cortisporin 3.5-10,000-1 mg-unit/mL-% Drops, Suspension Sig:
Two (2) drops Otic on 1st and 15th of each month.
11. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
[**Location (un) **] pneumonia
NSTEMI
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted with [**Location (un) **] pneumonia, dehydration, and
kidney failure. You received antibiotics and IV fluids and
improved. You also had evidence of damage to your heart muscle
and a cardiac ultrasound showed that your heart does not empty
normally. You had a swallowing evaluation which showed
[**Location (un) **] risk so you should continue on [**Location (un) **] precautions
(elevated head of bed to 30 degrees, frequent oral care and
suctioning of secretions). You have been given a diet of pureed
foods and thicked nectar liquids as these would be best
tolerated in your condition. If you experience shortness of
breath, increased coughing with fever or decreased oxygen
saturation you should be re-evaluated.
Followup Instructions:
You will be followed by your physician at the nursing home, Dr.
[**First Name8 (NamePattern2) 7841**] [**Name (STitle) 7842**]. She will determine what folow-up tests and
physician evaluations are necessary.
|
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"428.22",
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"294.8",
"411.89",
"276.2",
"276.51",
"403.90",
"995.92",
"585.3",
"507.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11959, 12029
|
3832, 10047
|
311, 317
|
12111, 12111
|
2738, 3809
|
13049, 13260
|
2234, 2252
|
10662, 11936
|
12050, 12090
|
10073, 10639
|
12289, 13026
|
2267, 2719
|
264, 273
|
345, 1953
|
12126, 12265
|
1975, 2119
|
2135, 2218
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,872
| 137,056
|
54332
|
Discharge summary
|
report
|
Admission Date: [**2160-10-5**] Discharge Date: [**2160-10-21**]
Date of Birth: [**2074-5-25**] Sex: F
Service: MEDICINE
Allergies:
Tramadol / Nsaids / Oxycodone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
Placement of tunneled dialysis catheter
History of Present Illness:
The patient is an 86-year-old woman with a complicated medical
history who was recently discharged from the [**Hospital1 1516**] service at
[**Hospital1 18**] ([**Date range (1) 29441**]) after a CHF exacerbation who is presenting with
nausea and found to have worsening kidney function. The patient
has been experiencing nausea for several days now.
.
At last adm on [**9-20**], torsemide 100mg increased to 200mg [**Hospital1 **]
lasix with 5mg metolazone. Cr baseline around 3.8 prior to last
adm, but during last adm was low 4s. now up to 5.2. BUN has been
steadly trending up, and was 181 on adm (88 last adm to [**Hospital1 1516**]).
.
On [**2160-10-2**], she saw her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**],
who felt that the nausea may be secondary to her diuretics. The
patient's metolazone was stopped and furosemide decreased/held
unless patient's weight was to exceed 187 pounds. (Dry weight
estimated at 185 pounds.) Since that visit, the patient has had
increasing nausea and loss of appetite. She has been able to
keep her medications down. The patient denies any blood in her
emesis, she has not vomitted much, it is primarily feeling too
nauseous to eat. The patient further denies any sick contacts,
new foods, or recent travel. She has not had any abdominal pain,
though she has been constipated, with her last movement 5 days
ago. The patient has been having flatus. The patient denies any
recent worsening of her breathing, cough, or worsening of lower
leg edema. She is able to lay flat with [**Last Name **] problem. She has no
cough. She states she has not been urinating as much as
previously.
.
In the Emergency Department, the patient's initial vitals were
97.2 62 124/47 24 97%. She underwent a chest X-ray, which showed
improvement in pulmonary congestion in comparison to previous
radiograph. A KUB showed no evidence of obstruction or
intraperitoneal free air. The patient received lactulose and
40mEq of potassium in the ED. Her vitals on transfer were
97.4po, 123/45, 64, 16, 99% 2L.
.
On the medicine floor, the patient continued to be nauseated and
had an episode of greenish emesis. The emesis had no evidence of
blood. The patient was otherwise comfortable on 2L nasal
cannula.
.
Currently, pt states she is feeling "better" but still nauseous,
with no new complaints. She states she has talked about the need
for HD at some point in the future. She denies changes in her
sleep-wake cycle recently. She denies chest pain or pressure and
denies tremor. She does note that she has some epigastric pain.
.
ROS: Endorses occasional chills, nausea, vomiting, constipation.
Denies fever, night sweats, rhinorrhea, congestion, sore throat,
cough, shortness of breath, chest pain, abdominal pain,
diarrhea, dysuria, hematuria.
.
Past Medical History:
1. CARDIAC RISK FACTORS:
-Diabetes, insulin-dependent, complicated by nephropathy
-Dyslipidemia
-Hypertension
2. CARDIAC HISTORY:
-CAD s/p CABG [**2143**]
-most recent persantine MIBI in [**2157-7-26**] c/w old LAD
infarct and areas of ischemia in PDA and OM distributions
-systolic CHF with mild symm LVH, most recent EF 30-35% [**Month (only) 205**]
[**2160**]
-CABG: [**2143**], LIMA->provimal LAD, SVG->distal LAD, SVG->OM2 and
OM3
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2153**], DES to proximal LAD
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Chronic kidney disease: Cr baseline 3.1-3.7, Stage IV-V. EPO
qmonthly, secondary to diabetes; with secondary
hyperparathyroidism
- asthma: uses albuterol once per day and Flovent once per day
- sciatica
- arthritis s/p knee replacement
- gout
- GERD
- osteoporosis
- anemia
- colonic adenomas with last colonoscopy [**6-/2159**] (hyperplastic
only, next colonoscopy [**6-/2164**])
- low back pain
Social History:
Lives with her husband and daughter in [**Name (NI) **], where she grew
up. Used to work in a bank. Likes to sew, but the patterns are
too expensive now.
-Tobacco history: prior - stopped 30-40 years ago and smoked 1
pack/week before that
-ETOH: none
-Illicit drugs: none
Family History:
Colon cancer
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Adm PE:
VS: Weight 84.5 kgs. T 97.1 BP 142/50 HR 69 RR 18 98% RA FSBS
130.
GENERAL: Elderly woman, comfortable, appropriate.
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, oropharynx clear,
dentures.
NECK: Supple, no JVD
HEART: S1, S2, 3/6 systolic mumur along sternal border. Scar
along sternum.
LUNGS: CTA bilaterally, no crackles. Respirations unlabored. No
accessory muscle use.
ABDOMEN: Soft, non-tender, bowel sounds positive.
EXTREMITIES: WWP, scant pedal edema, 2+ radial/pedal pulses,
surgical scars on both knees.
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, CNs III-XII grossly intact, muscle strength
grossly intact, patellar refelexes 2+.
.
Discharge PE:
VITALS: 96.9 124/49-133/55 55 12 96% RA
GENERAL: Appears in no acute distress. Alert and interactive,
pleasant woman.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. R tunneled dialysis line
in place
CVS: PMI located off of the 5th intercostal space, off the
mid-clavicular line. Regular rate and rhythm, without murmurs,
rubs or gallops. paradoxically split S2.
RESP: Respirations unlabored, no accessory muscle use. Decreased
breath sounds bilaterally without adventitious sounds. No
wheezing, or rhonchi, but minimal bibasilar crackles. Stable
inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; bilaterally trace or 1+ pitting
edema, 2+ peripheral pulses
DERM: No stasis dermatitis, ulcers, scars. Left groin with
substantial ecchymosis and palpable hematoma; no purulence or
drainage, no active bleeding; Right groin with hematoma,
resolving
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.
Pertinent Results:
Adm labs:
[**2160-10-5**] 03:57PM BLOOD WBC-9.5 RBC-3.23* Hgb-10.0* Hct-27.9*
MCV-86 MCH-31.1 MCHC-36.1* RDW-14.6 Plt Ct-167
[**2160-10-5**] 03:57PM BLOOD Neuts-79.8* Lymphs-15.7* Monos-3.8
Eos-0.3 Baso-0.4
[**2160-10-5**] 03:57PM BLOOD Glucose-222* UreaN-181* Creat-5.2*
Na-130* K-2.9* Cl-81* HCO3-32 AnGap-20
[**2160-10-6**] 06:40AM BLOOD ALT-17 AST-21 CK(CPK)-43 AlkPhos-49
TotBili-0.3
[**2160-10-6**] 06:40AM BLOOD CK-MB-2 cTropnT-0.10*
[**2160-10-6**] 04:05PM BLOOD CK-MB-2 cTropnT-0.10*
[**2160-10-7**] 07:45AM BLOOD CK-MB-2 cTropnT-0.09*
[**2160-10-6**] 06:40AM BLOOD Calcium-9.3 Phos-5.5*# Mg-2.9*
[**2160-10-5**] 03:58PM BLOOD Lactate-1.6
[**2160-10-6**] 08:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2160-10-6**] 08:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2160-10-6**] 08:30PM URINE RBC-1 WBC-2 Bacteri-MANY Yeast-NONE Epi-6
[**2160-10-6**] 08:30PM URINE Hours-RANDOM UreaN-553 Creat-91 Na-14
K-48 Cl-25
[**2160-10-6**] 08:30PM URINE Osmolal-353
[**2160-10-6**] 08:30PM URINE Mucous-RARE
.
2D-ECHO ([**2160-8-7**]): The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with moderate global
hypokinesis and akinesis of the distal anterior septum and apex.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP > 18 mmHg). Mild to moderate ([**1-27**]+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion. LVEF
30-35%
.
CARDIAC CATH ([**2160-10-10**]): Attempted but aborted given no groin
access sites.
.
MICROBIOLOGY DATA:
[**2160-10-5**] Blood culture - no growth
[**2160-10-6**] Urine culture - Gram positive bacteria (> 100K) - Alpha
hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp
[**2160-10-8**] Blood cultures (x 2) - no growth
[**2160-10-9**] Urine culture - Gram positive bacteria (> 100K) - Alpha
hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp
[**2160-10-9**] Blood culture - no growth
[**2160-10-10**] Blood culture - no growth
.
IMAGING:
.
[**2160-10-10**] THROMBIN INJ PSEUDOANERY - 2.5-cm pseudoaneurysm within
a 6-cm hematoma with 90% thrombosis after injection of 1000
units of topical thrombin. Recommend observation at this point
rather than reinjection. Patient may resume heparin
.
[**2160-10-11**] FEMORAL VASCULAR US LEFT - No overall increase in size
in a 5.4 x 2.8 x 2.7 cm hematoma in the left groin, but interval
resumption of flow within a 2.5-cm portion of the hematoma
consistent with continued pseudoaneurysm. The pseudoaneurysm
neck appears slightly increased in size
.
[**2160-10-12**] FEMORAL VASCULAR US LEFT - No significant interval
change in the partially thrombosed left common femoral
pseudoaneurysm since the earlier study of [**2160-10-11**].
.
[**2160-10-15**] FEMORAL VASCULAR US LEFT - No significant interval
change in the left common femoral pseudoaneurysm; PSA measuring
2.8 x 2.0-cm with overlying 6-cm hematoma
.
[**2160-10-20**]
[**Hospital 93**] MEDICAL CONDITION:
86F with a PMH significant for CAD (s/p CABG [**2143**], PCI with
stenting of the LAD in [**6-/2153**]), ischemic cardiomyopathy (EF
30-35%), DM, HTN, HLD, CKD stage IV-V (baseline creatinine
3.5-4) who presented to [**Hospital1 18**] with complaints of nausea and
emesis found to have acute CHF exacberation with resulting acute
respiratory failure requiring MICU admission for worsening
acute respiratory failure, complicated by NSTEMI with medical
management, initiation of hemodiayslis complicated by left
femoral pseudoaneurysm vs. fistula who is hemodynamically stable
REASON FOR THIS EXAMINATION:
patient has temporary right IJ for HD - please replace with
tunneled HD line
Brief Hospital Course:
IMPRESSION: 86F with a PMH significant for CAD (s/p CABG [**2143**],
PCI with stenting of the LAD in [**6-/2153**]), ischemic cardiomyopathy
(EF 30-35%), DM, HTN, HLD, CKD stage IV-V (baseline creatinine
3.5-4) who presented to [**Hospital1 18**] with complaints of nausea and
emesis found to have acute CHF exacberation with resulting acute
respiratory failure requiring MICU admission for worsening acute
respiratory failure, complicated by NSTEMI with medical
management, initiation of hemodiayslis complicated by left
femoral pseudoaneurysm vs. fistula who is hemodynamically
stable.
.
# CORONARIES - The patient had a prior CABG in [**2143**] with (LIMA
-> proximal LAD, SVG -> distal LAD, SVG -> OM2 and OM3) and is
status-post PCI in [**6-/2153**] (DES to proximal LAD) with a
persantine MIBI in [**7-/2157**] which showed his old LAD infarct and
areas of ischemia in the distribution of the PDA and OM. This
admission, the patient was admitted to the MICU on [**10-9**] with
concerns of acute respiratory failure precipitated by acute CHF
exacerbation and volume overload. In that setting, the patient
developed evidence of NSTEMI with Troponins peaking at 3.62
(CK-MB 70) in light of her renal dysfunction with some
intermittent chest pain. Given these findings, she was medically
optimized at that time with Aspirin 325 mg PO, we continued her
statin, dosed her beta-[**Month/Year (2) 7005**] and started a heparin gtt (this
was intermittently on/off given concerns for a femoral left
pseudoaneurysm, as noted below). The patient underwent cardiac
catheterization via radial artery access on [**10-10**], where she had
a distal RCA lesion, which by itself was not felt to be a
culprit lesion and the patient also had stenosis about the area
where one of her LIMA to LAD bypasses was. The cath was only
diagnostic in that no interventions on the coronaries were
performed at that time, and at the same time it was discovered
that the patient had irregularities of the bilateral femoral
arteries on informal angiography. We continued medical
optimization as listed above, added Plavix 75 mg PO daily given
the delay in catheterization and titrated her beta-[**Month/Year (2) 7005**]. We
trended her EKG findings, monitored her for chest pain, and
trended her Troponins and CK-MB for resolution of her NSTEMI
concerns.
.
# PUMP (ACUTE CHF EXACERBATION)- The patient had her last
2D-Echo in [**7-/2160**] which showed symmetric LVH, moderate regional
LV systolic dysfunction with moderate global hypokinesis and
akinesis of the distal anterior septum and apex and an LVEF of
30-35%. There was also evidence of mild to moderate ([**1-27**]+)
mitral regurgitation. There was moderate pulmonary artery
systolic hypertension. As noted above, the patient initially
presented to the ED with nausea for several days and evidence of
acute renal insufficiency. On [**2160-10-2**], she saw her PCP who felt
that the nausea was secondary to diuretics and her Metolazone
and Lasix were decreased (or held?). Since then, her nausea
persisted and her appetite became suppressed - but she was able
to keep her medications down. In the ED ([**2160-10-5**]) her VS 97.2
124/47 24 97% 2L NC. A CXR showed pulmonary congestion. She was
admitted to the Medicine service on [**2160-10-5**]. Of note, the
patient was recently discharged from [**Hospital1 18**] after an admission
for acute CHF exacerbation ([**Date range (1) 29441**]). At that time, Torsemide
100 mg was changed to Lasix 200 mg PO BID with 5 mg of
Metolazone to augment his loop diuretic. Her creatinine baseline
is around 3.8-4.0. On the Medicine service, the patient's nausea
improved intially and then worsened, responding to intermittent
Zofran IV. She was seen by Nephrology who opted for conservative
management initially. Her diuretics were held and her BUN
trended from 181 -> 167, with a creatinine of 5.2 -> 5.0.
Because there was not significant improvement and her symptoms
were worsening, the plan was for HD line placement in IR on the
day of transfer to the ICU. At some point in the night prior to
transfer the patient woke up dyspneic and was placed on 4L NC.
At 7:30 AM she became more acutely dyspneic and was satting 89%
4L NC and which improved to 96% on a NRB. She was tachypneic at
a rate in the 40s. She was given Lasix 100 mg IV and put out 700
cc in the first hour, but remained dyspneic. There was concern
for aspiration vs. MI vs. fluid overload. A CXR showed diffuse
pulmonary edema, and it was difficult to assess whether an
underlying apiration or consolidation was present. Nephrology
then recommended placement of an emergent dialysis line so the
patient was transferred to the MICU on [**2160-10-9**]. At time of
transfer, her dyspnea had improved, but she remained on a
non-rebreather. In the MICU, on [**10-9**], the patient was preparing
for HD line placement per Nephrology recommendations, Metolazone
and Lasix were continued. HD initiated on [**10-11**] (-500 cc) and she
tolerated this well and her oxygen requirement resolved. She was
weaned to 2L NC before transferring to the floor on [**2160-10-14**]. We
continued medical optimization of her CHF regimen (held off on
ACEI/[**Last Name (un) **] given her renal issues) including Metoprolol, Imdur, a
CCB and monitored her with daily weights, monitored her I/Os and
aimed for a goal of even to negative 1L daily. We performed
aggressive electrolyte optimization and monitored her via
telemetry.
.
# RHYTHM - The patient presented in sinus rhythm appearing on
telemetry and EKGs with no history of dysrrhythmias. We
performed aggressive electrolyte optimization and monitored her
via telemetry.
.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY (HEMODIALYSIS) - On
[**2160-10-2**], she saw her PCP who felt that the nausea was secondary
to diuretics and her Metolazone and Lasix were decreased (or
held?). Since then, her nausea persisted and her appetite became
suppressed - but she was able to keep her medications down. Of
note, the patient was recently discharged from [**Hospital1 18**] after an
admission for acute CHF exacerbation ([**Date range (1) 29441**]). At that time,
Torsemide 100 mg was changed to Lasix 200 mg PO BID with 5 mg of
Metolazone to augment his loop diuretic. Her creatinine baseline
is around 3.8-4.0. On the Medicine service, the patient's nausea
improved intially and then worsened, responding to intermittent
Zofran IV. She was seen by Nephrology who opted for conservative
management initially. Her diuretics were held and her BUN
trended from 181 -> 167, with a creatinine of 5.2 -> 5.0.
Because there was not significant improvement and her symptoms
were worsening, the plan was for HD line placement in IR on the
day of transfer to the ICU. At some point in the night prior to
transfer the patient woke up dyspneic and was placed on 4L NC.
Nephrology then recommended placement of an emergent dialysis
line so the patient was transferred to the MICU on [**2160-10-9**]. At
time of transfer, her dyspnea had improved, but she remained on
a non-rebreather. In the MICU, on [**10-9**], the patient was
preparing for HD line placement per Nephrology recommendations,
Metolazone and Lasix were continued. HD initiated on [**10-11**] (-500
cc) and she tolerated this well and her oxygen requirement
resolved. She was weaned to 2L NC before transferring to the
floor on [**2160-10-14**] (a temporary right IJ was placed for this
purpose). We monitored her phosphorus, provided Nephrocaps and
continued her on dialysis. She was making minimal urine at the
time of floor transfer. We avoided nephrotoxins and renally
dosed all medications. A permanent HD-line was tunneled on
[**2160-10-20**] without issue and she will continue on outpatient
hemodialysis. (Tuberculin testing negative [**10-12**], in OMR). The
dialysis social worker will contact the rehab facility to
arrange outpatient dialysis.
.
# LEFT FEMORAL PSEUDOANEURYSM VS. FISTULA - After bilateral
attempts at cannulation of the femoral artery for HD-access, the
patient subsequently developed a large partially thrombosed left
femoral pseudoaneurysm (6-cm) which may have progressed to an
AV-distula based on imaging. She underwent thrombin injection
without avail and a repeat at thrombin injection which was again
unsuccessful. Vascular surgery was consulted and following with
plan for surgical repair pending stabilization of her cardiac
issues. Serial ultrasound imaging was performed which showed the
left PSA was stable. Her bilateral serial pulse exams were
stable and we monitored her groins. Vascular surgery operatively
repaired this PSA via an open, primary approach on [**2160-10-17**]
without issue, she tolerated this well. She will follow up with
vascular surgery as an outpatient.
.
# DYSPNEA, PULMONARY EDEMA - As noted above, the patient
initially presented with acute respiratory failure in the
setting of an acute CHF exacerbation with a new oxygen
requirement which was weaned from NRB -> 4L to 2L via NC with
initiation of hemodialysis and diuresis. A CXR showed bilateral
effusions and she had no evidence of infiltrate on imaging (with
no cough or URI symptoms). We continued aggressive volume
control with hemodialysis, provided oxygen supplementation with
plan to wean, and maintained her on albuterol and ipratroprium
nebs as needed with pulse oximetry monitoring and incentive
spirometry.
.
# NORMOCYTIC ANEMIA - The patient presented with baseline
chronic renal insufficiency-induced normocytic anemia with HCT
in the 30-32% range with Epopoeitin injections monthly. Upon
MICU transfer she required 5 units of packed red cells during
for a HCT of 24-25% which responded appropriately. The patient's
hematocrit was trended closely and our transfusion goal was to a
HCT > 26% given her significant CAD.
.
# INSULIN-DEPENDENT DIABETES MELLITUS - The patient was admitted
on Humulin 70/30, 20 units before breakfast and 26 units before
dinner, as a home regimen. The patient was given half her
standing NPH at the time of transfer (blood glucose in the
250-300 mg/dL range) until she resumed her diet. The patient was
continued on an insulin sliding scale as well with Q6 hour blood
glucose monitoring.
.
# HYPERTENSION - The patient was continued on her home blood
pressure regimen; with a goal BP < 130/80 mmHg. Her cardiac
medications were optimized this admission.
.
# HYPERLIPIDEMIA - Her home Simvastatin 40 mg PO daily was
changed to atorvastatin.
.
# GOUT - The patient recently completed a course of Prednisone
on her last admission for gout flare and thus we continued her
home Allopurinol medication (renally dosed).
.
# REACTIVE AIRWAY DISEASE - We continued her home Albuterol and
Flovent medications; albuterol and ipatropium nebs were dosed as
needed.
.
TRANSITION OF CARE ISSUES:
1. Patient was discharged to a rehab facility
2. The dialysis caseworker will follow-up with the rehab
facility regarding outpatient dialysis.
3. The patient will f/u with Dr. [**Last Name (STitle) 1391**] from vascular surgery
4. The patient remained full code throughout this
hospitalization
Medications on Admission:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
cough/wheezing.
2. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q12H (every 12 hours) as needed for pain.
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Can take up to three tablets, each separated by five minutes.
If chest pain persists, please call your doctor or go to the
hospital immediately.
8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO
three times a day: with meals.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK
(MO,WE,FR).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Tablet Sig: One (1) Tablet PO once a day.
15. hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
16. Lasix 40 mg Tablet Sig: Five (5) Tablet PO twice a day ([**Month (only) **]
at outpt visit).
17. metolazone 5 mg Tablet Sig: One (1) Tablet PO twice a day:
Please take 1 hour prior to taking Lasix (Furosemide), (being
held)
18. darbepoetin alfa in polysorbat 100 mcg/0.5 mL Syringe Sig:
One (1) Injection once a month.
19. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
20. fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
21. Humulin 70/30 Pen 100 unit/mL (70-30) Insulin Pen Sig: As
Directed units Subcutaneous twice a day: Please resume your
previous regimen of 20 units before breakfast and 26 units
before supper.
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-27**] nebs Inhalation every 4-6 hours as needed
for cough/wheeze.
6. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
7. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR
(Monday -Wednesday-Friday).
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP)
Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by
Heparin as above daily and PRN.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. ipratropium bromide 0.02 % Solution Sig: One (1) neb
neb Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
16. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
19. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO QID (4
times a day).
20. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
21. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
22. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
23. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
24. multivitamin Tablet Sig: One (1) Tablet PO once a day.
25. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
26. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: see below Subcutaneous twice a day: 20 units before
breakfast, 26 units before dinner.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital -[**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
1. Non-ST segment elevation myocardial infarction (NSTEMI)
2. Acute respiratory distress
3. Acute congestive heart failure exacerbation
4. Left femoral artery pseudoaneurysm, overlying hematoma
5. Initiation of hemodialysis
6. Acute on chronic renal insufficiency
.
Secondary Diagnoses:
1. Hypertension
2. Hyperlipidemia
3. Coronary artery 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:
Patient Discharge Instructions:
You were admitted to the [**Hospital1 1516**] Cardiology-Internal Medicine
service at [**Hospital1 69**] on [**Hospital Ward Name 121**] 3
regarding management of your heart issues. You were initially
admitted to the Medicine floor but developed concerns for volume
overload in the setting of renal failure with the need for
respiratory support. For this, you were transferred to the
medical ICU and hemodialysis was initiated. You improved
following dialysis, with improvement in your volume status. Your
heart had some demand ischemia changes from the extra volume,
but this resolved with dialysis. In an attempt to get access for
dialysis, one of your attempts resulted in a left femoral artery
pseudoaneurysm (or dilation) which had to be surgically repaired
by Vascular surgery (without complication). After this, you had
a permanent dialysis line placed. At discharge, you were
improved and will continue outpatient hemodialysis and were
discharged to a rehabilitation facility.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* Worsening swelling in your legs or a weight gain of 3 lbs or
more, fatigue or excessive weakness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
* Upon admission, we ADDED the following medications:
You should START: Lisinopril 5 mg, once daily
You should START: Plavix 75 mg, once daily
You should CHANGE: Simvastatin to Atorvastatin 80 mg, once daily
You should INCREASE: Aspirin to 325 mg, once daily
You should CHANGE: Metoprolol Succinate to Metoprolol Tartrate
37.5 mg, four times daily
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Sevelamer 800 mg three times a day
DISCONTINUE: Lasix 40 mg, 5 tabs twice a day
DISCONTINUE: Metolazone 5 mg, twice a day
DISCONTINUE: Prednisone 30 mg daily
DISCONTINUE: Hydralazine 100 mg, twice a day
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Name: [**Last Name (LF) 1391**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Address: [**Doctor First Name **] STE 5C, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1393**]
Appointment: Wednesday [**2160-11-5**] 12:15pm
Department: CARDIAC SERVICES
When: FRIDAY [**2160-12-5**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*You have been placed on a cancellation list for this
appointment. The office will contact you if a sooner appointment
becomes available. Dr. [**Last Name (STitle) **] is out of the office for 2
weeks in [**Month (only) 359**].
|
[
"250.40",
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"585.5",
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"414.04",
"276.50",
"414.8",
"588.81",
"403.91",
"410.71",
"E879.8",
"V16.0",
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"716.96",
"274.9",
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"276.3",
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"416.8",
"276.1",
"447.0",
"584.9",
"276.8",
"442.3",
"428.23",
"518.81",
"564.00",
"997.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.52",
"37.22",
"88.56",
"38.95",
"88.77",
"88.53",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
26415, 26485
|
10481, 21526
|
306, 347
|
26896, 26896
|
6539, 9727
|
29938, 30795
|
4527, 4655
|
23909, 26392
|
9767, 10350
|
26506, 26791
|
21552, 23886
|
27111, 29915
|
4670, 5327
|
26812, 26875
|
3389, 3788
|
5341, 6520
|
260, 268
|
10379, 10458
|
375, 3221
|
26911, 27055
|
3819, 4219
|
3243, 3365
|
4235, 4511
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,229
| 165,227
|
39060
|
Discharge summary
|
report
|
Admission Date: [**2109-6-20**] Discharge Date: [**2109-6-28**]
Date of Birth: [**2055-12-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
ICU monitoring
Major Surgical or Invasive Procedure:
Hernia repair
History of Present Illness:
Ms. [**Known lastname **] is a 53 y/o obese F w/ DM2, HTN, and 2 vessel CAD. She
presented to the surgical service w/ abdominal pain from
recurrent ventral hernia. She underwent open incisional
herniorrhapy w/ surgi-mesh and had no intra-operative
complications. She had general anesthesia and was extubated
prior to arrival to ICU. Reason for ICU admission was for
cardiovascular monitoring given pt's extensive cardiac history
including VF arrest during an admission for hernia repair in the
past. Pt states her ventral hernia dates back to [**2104**] when she
had it repaired on [**2104-12-27**] with lap assisted reduction/LOA and
open repair with mesh. By [**9-2**], her hernia recurred and was
evaluated for repair; however, this was postponed by NSTEMI/VF
arrest on [**2108-9-24**] which required emergent catheterization and
placement of DES to LAD and POBA to LCx. Further repair and
eval for
panniculectomy were put on hold given comborbidities and
reduction in symptoms. In the ICU, she is hemodynamically
stable, complaining of abdominal discomfort and nausea.
Past Medical History:
CAD s/p VF arrest on floor [**2108-9-24**] resulting in cardioversion
and cath showing 2vd, DES--> LAD and POBA--> LCx
Obesity
Depression
DM2
HTN
Social History:
Open Chole [**2087**], Lap assisted open ventral hernia repair
[**2104-12-29**] (per OSH records, no mesh used though patient states
mesh was used), Tubal ligation.
Family History:
Non-contributory.
Physical Exam:
Vitals: afebrile, HR 67 BP 146/87 SaO2 99%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, NGT in place
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft obese, TTP, midline incision wound dressing c/d/i
w/ B/L JP drains in place draining blood
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2109-6-20**] 07:45PM GLUCOSE-151* UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2109-6-20**] 07:45PM estGFR-Using this
[**2109-6-20**] 07:45PM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-1.7
[**2109-6-20**] 07:45PM WBC-15.9*# RBC-4.05* HGB-12.4 HCT-34.9*
MCV-86 MCH-30.7 MCHC-35.6* RDW-13.3
[**2109-6-20**] 07:45PM PLT COUNT-271
[**2109-6-20**] 07:45PM PT-11.9 PTT-23.0 INR(PT)-1.0
Brief Hospital Course:
53 yo obese F w/ DM2, HTN, known CAD w/ 2vd s/p DES->LAD and
POBA-> LCx following VF arrest, here in ICU for hemodynamic
monitoring s/p ventral hernia repair.
S/p hernia repair- pt w/ recurrent ventral hernia. She presented
with multiple small and large bowel obstructions. Taken to the
OR [**6-20**] for incisional hernia repair with mesh. No initial
complications. Developed Afib with RVR on POD 2. Transferred to
the cardiology service for further management. Her course was
also complicated by development of a hematoma in patient's
abdomen. Her hematocrit decreased from 32.6 -> 24.5. She was
monitored closely and received two units of prbc's. Upon
discharge her hematocrit was 26.8. She will have a repeat Hct 3
days post discharge and follow up closely with PCP and surgery.
Atrial Fibrillation with RVR: Appears to be first episode in
setting of post-operative hernia repair. Transferred to
cardiology where diltiazem drip was initiated as well as
aggressive uptitration of po metoprolol which helped to decrease
patient's rate. She was also started on a heparin gtt as well as
coumadin. Patient did not convert to sinus rhythm on own, so
was DC cardioverted within 48 hours of onset. After one shock,
patient converted to sinus rhythm and maintained this rhythm
throughout the remainder of hospitalization. She was started on
disopyramide given her extreme presentation and difficult to
control rate. It was felt this medication would only be
necessary for one month s/p DC cardioversion, however she will
follow up closely with her home cardiologist for further
management and monitoring. Metoprolol was increased to 200 mg
daily. Patient's heart rate and blood pressure tolerated this
increase without incident. Given her hematoma complication, it
was felt the risk of continuing anti-coagulation (for afib) was
greater than the benefit. Heparin and coumadin were stopped. She
will continue on aspirin and clopidogrel which will offer some
protection from developing a stroke s/p cardioversion.
CAD- Patient developed mild chest discomfort in setting of afib
with RVR. Mild troponin leak with peak of 0.09. This was not
felt to be ACS, but demand ischemia in setting of rapid
ventricular response. Patient is status post DES 9/[**2108**]. Given
patient's financial constraints, she was not able to continue
plavix for 12 months and stopped after 6 months. Given patient's
DES, it was felt the patient should be re-started on this
medication until 9/[**2109**]. To help with cost, Crestor was changed
to simvastatin 80 mg daily.
Pump: Pt had normal echo [**2109-5-22**] w/ LVEF >55%. Ramipril
initially held in setting of surgery, but restarted without
incident. Sprinolactone was not restarted as patient did not
appear fluid overloaded and her blood pressure was stable prior
to discharge. Metoprolol was up-titrated without incident.
DM2- Per report, however pt not on oral hypoglycemics or insulin
at home. A1c was 5%. Unclear of patient truly has this
diagnosis. She was placed on insulin sliding scale and required
minimal amounts of insulin.
HTN- Blood pressure was initially elevated in setting of pain to
the 160s and holding of home blood pressure medications.
Ramipril was re-started. Metoprolol was up-titrated, and pain
was controlled. Patient's blood pressure was within normal
limits on this regimen, and amlodipine and spironolactone were
not re-started.
Further management of her blood pressure regimen will be
deferred to her pcp and cardiologist.
Dyslipidemia: Crestor was changed to simvastatin due to
financial constraints. Patient tolerated this medication well.
Medications on Admission:
1. Amlodipine 10mg daily
2. ASA 325mg daily
3. Rosuvastatin 20mg daily
4. Metoprolol tartrate 50mg [**Hospital1 **]
5. Ramipril 10mg daily
6. Plavix 75mg daily
7. Aldactone 25mg daily
8. SL NTG
Discharge Medications:
1. Disopyramide 150 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO every twelve (12) hours.
Disp:*60 Capsule, Sustained Release(s)* Refills:*0*
2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*4*
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. 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:*6*
6. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Ramipril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please draw CBC, potassium and magnesium. Send results to
patient's primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 66161**]. Phone:
[**Telephone/Fax (1) 86598**] Fax: [**Telephone/Fax (1) 86599**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ventral Hernia Repair secondary to encarcerated hernia
complicated by hematoma
Atrial Fibrillation with Rapid Ventricular Response
Secondary:
Hypertension
Diabetes Type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for a ventral hernia repair. This was
complicated by some bleeding in your abdomen. You received two
units of blood. Your bleeding stopped and your blood counts
stabilized.
After your surgery, you developed a fast heart rhythm called
atrial fibrillation. We gave you medications to slow this down
and you did not convert out of this rhythm on your own. So, you
were cardioverted electrically and after one shock back to a
normal sinus rhythm. You were started on a medication to help
keep you in this normal rhythm called Disopyramide. You should
take this medication for approximately one month and will need
to follow up with your cardiologist for further management. Your
appointment is scheduled below.
You should take all of your medications as prescribed with the
following important changes:
1. START Disopyramide CR 150 mg every 12 hours
2. START Metoprolol Succinate 200 mg daily
3. CHANGE Rosuvastatin to Simvastatin as this is a cheaper
medication
4. CONTINUE Plavix 75 mg, you should take this medication for
one year past your stent placement. Further management will be
directed by your home cardiologist
5. Stop Spironolactone 25 mg daily
6. Stop Amlodipine 10 mg daily as your blood pressure was fine
without this medication.
***[**Last Name (LF) 766**], [**7-1**], you should have a CBC and results should be
sent to your pcp. [**Name10 (NameIs) 2172**] received 2 units of blood in the hospital
and before you were discharged, your hematocrit was 26.8.
***You should see your primary doctor within one week to have
your blood pressure checked as well as your potassium and
magnesium. You should call your doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] if you do not
hear from them sooner.
When you see your cardiologist, he will need to manage your
anti-arrythmic medication.
It is important that you keep all of your doctor's appointments.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**]
Date/Time:[**2109-7-9**] 12:15 (Plastic Surgery)
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 2723**]
Date/Time:[**2109-7-26**] 1:45 (General Surgery)
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 86600**], MD Phone: ([**Telephone/Fax (1) 86601**] Date/Time:
Tuesday, [**7-23**] at 1:00 pm (Cardiology)
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 251**] L. [**Telephone/Fax (1) 86598**]. I left a message for his
office to call you for an appointment in 1 week. If you do not
hear from his office on [**Telephone/Fax (1) 766**], you are to call and set up an
appointment to be seen in one week. You should ensure you have a
blood pressure check as we have adjusted your medications in the
hospital.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
|
[
"412",
"998.12",
"414.01",
"427.31",
"552.21",
"E878.8",
"278.00",
"V45.82",
"272.4",
"530.81",
"401.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.61",
"38.93",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
7860, 7866
|
2842, 6448
|
329, 344
|
8090, 8090
|
2388, 2819
|
10195, 11246
|
1814, 1833
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6692, 7837
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7887, 8069
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6474, 6669
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8273, 10172
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1848, 2369
|
275, 291
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372, 1447
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8105, 8249
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1469, 1616
|
1632, 1798
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,630
| 182,793
|
36582+58100+58101
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2105-6-7**] Discharge Date: [**2105-6-22**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymptomatic, serial CT scan reveal increasing aneurysm
Major Surgical or Invasive Procedure:
[**2105-6-9**] - Endovascular stent graft repair of descending thoracic
aneurysm
[**2105-6-11**] - Endovascular stent graft extension and evacuation of
left groin hematoma
History of Present Illness:
80 year old male with a history of descending thoracic aneurysm
s/p open stent graft in [**2095**]. Recent surveilance reveals an
increase in the size of aneurysm and he was referred for
endovascular stent placement.
Past Medical History:
descending thoracic aortic aneurysm
aortic stenosis s/p aortic valve replacement [**2095**] (mechanical)
benign prostatic hyperplasia
hypothyroidism
?lymphoma [**2103**]- s/p surgery, chemo, XRT
lymph node excision (?cervical)
aortic valve replacement [**2095**] (mechanical)
descending thoracic aortic aneurysm stent [**2095**] (open)
appendectomy remotely
Social History:
Occupation: retired contractor/carpenter
Lives alone
Tobacco: quit 40 yrs. ago
ETOH: denies
Family History:
father deceased at 65 of heart condition
Physical Exam:
Pulse: 61 Resp: 18 O2 sat: 99%RA
B/P Right: 121/78 Left:
Height: Weight: 73.2
General:
Skin: Dry [x] intact [x] no rash
well healed sternotomy/upper abdominal midline incision
HEENT: PERRL [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
audible mechanical click, no murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] 2+edema bilateral ankles
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: Left: not palpable [**12-22**] edema
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**2105-6-17**] 12:35PM BLOOD WBC-3.4* RBC-3.20* Hgb-9.1* Hct-28.3*
MCV-89 MCH-28.5 MCHC-32.2 RDW-15.0 Plt Ct-249
[**2105-6-17**] 05:10AM BLOOD WBC-3.4* RBC-2.90* Hgb-8.4* Hct-25.9*
MCV-89 MCH-28.9 MCHC-32.3 RDW-14.4 Plt Ct-197
[**2105-6-7**] 02:50PM BLOOD WBC-5.0 RBC-4.40* Hgb-12.9* Hct-38.3*
MCV-87 MCH-29.3 MCHC-33.8 RDW-15.6* Plt Ct-156
[**2105-6-17**] 12:35PM BLOOD Plt Ct-249
[**2105-6-17**] 12:35PM BLOOD PT-31.4* INR(PT)-3.1*
[**2105-6-7**] 02:50PM BLOOD Plt Ct-156
[**2105-6-17**] 05:10AM BLOOD Glucose-119* UreaN-32* Creat-1.4* Na-139
K-4.4 Cl-102 HCO3-28 AnGap-13
[**2105-6-7**] 02:50PM BLOOD Glucose-110* UreaN-37* Creat-1.5* Na-140
K-4.3 Cl-104 HCO3-26 AnGap-14
[**2105-6-12**] 03:09AM BLOOD ALT-5 AST-22 AlkPhos-55 Amylase-12
TotBili-2.0*
[**2105-6-7**] 02:50PM BLOOD ALT-9 AST-16 LD(LDH)-230 AlkPhos-105
TotBili-0.9
[**2105-6-12**] 03:09AM BLOOD Lipase-18
[**2105-6-14**] 03:30PM BLOOD UricAcd-6.4
[**2105-6-7**] 02:50PM BLOOD %HbA1c-5.6
[**2105-6-15**] 03:50PM BLOOD TSH-5.9*
[**2105-6-15**] 03:50PM BLOOD T3-61* Free T4-1.1
[**2105-6-15**] 03:50PM BLOOD T3-61* Free T4-1.1
CTA OF THE CHEST AND ABDOMEN
INDICATION: 85-year-old man with endovascular stent placement
for thoracic
aneurysm. An endoleak was seen at the previous examination on
[**7-14**]
with additional stent placed. Followup study.
COMPARISON: Comparison was performed to the previous study on
[**2105-6-11**].
TECHNIQUE: CT study of the chest, abdomen and pelvis was
obtained after
administration of intravenous contrast material. The images were
reformatted
in the axial, coronal and sagittal planes.
FINDINGS: Following interval changes are seen as compared to the
previous
examination: there is no endoleak seen on the current
examination. It is
reported that additional stent was placed for endoleak seen in
the previous
exam. There is a hematoma surrounding the thoracic stent in the
aorta.
Pleural fluid is of similar small amount in the left pleural
cavity. Localized
flap is seen in the abdominal aorta and it was not seen in the
previous exam.
The localized flap is seen in the series 2, image 164 at the
level of L4
vertebra at the right lateral part of the aorta. Further noted
that left
inguinal hematoma, which was seen in the previous examination,
currently is of
the smaller size and of lower density with number of air bubbles
in it, most
probably due to the recent intervention. The celiac artery
origin is just on
the distal edge of the stent that is patent. Further noted is
vicarious
excretion of the contrast material in the gallbladder.
IMPRESSION: No endoleak. Localized flap in the abdominal aorta
at the level
of L4 at the right lateral wall.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82791**] (Complete)
Done [**2105-6-9**] at 10:38:26 AM 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: [**2020-1-26**]
Age (years): 85 M Hgt (in): 71
BP (mm Hg): 126/59 Wgt (lb): 161
HR (bpm): 54 BSA (m2): 1.92 m2
Indication: Intra-op TEE for Thoracic endostent
ICD-9 Codes: 440.0, 441.2, V43.3
Test Information
Date/Time: [**2105-6-9**] at 10:38 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW05-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Markedly
dilated descending aorta Thickened aortic wall c/w intramural
hematoma.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR
leaflets move normally. Trace AR.
MITRAL VALVE: Mild (1+) MR.
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
1. 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.
The descending thoracic aorta is markedly dilated. The aortic
wall is thickened consistent with an intramural hematoma. A
bileaflet aortic valve prosthesis is present. The aortic valve
prosthesis leaflets appear to move normally. Trace aortic
regurgitation is seen ( washing jets). Mean gradient is 13-15 mm
of Hg.. Mild (1+) mitral regurgitation is seen.
Post deployment stents are seen in the DTA
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2105-6-9**] 11:29
Brief Hospital Course:
Was admitted for surgical management of his descending thoracic
aortic aneurysm. He was worked-up in the usual preoperative
manner which included a carotid ultrasound and CT scan. Please
see reports listed separately. Heparin was started given his
mechanical aortic valve. On [**2105-6-9**], Mr. [**Known lastname 33148**] was taken to
the operating room where he underwent endovascular stenting of
his descending thoracic aortic aneurysm. 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. Heparin was resumed as a bridge to coumadin
for his mechanical aortic valve. A follow-up CT scan revealed an
endovascular leak and hematoma noted in left groin on [**6-11**]. He
returned to the operating room on [**2105-6-11**] where he underwent
evacuation of his groin hematoma and endovascular stent
extension for leak. See operative report for further details.
He was returned to the intensive care unit for monitoring. He
was weaned from sedation and extubated without complications.
Heparin and coumadin were resumed for his mechanical aortic
valve. A heparin induced thrombocytopenia assasy was sent for
thrombocytopenia which was negative. He was transferred to the
step down unit on [**2105-6-12**] for further recovery. He developed
swelling and pain in his right knee and the orthopedic surgery
was consulted. Due to the concern for gout after fracture was
ruled out, rheumatology was consulted and he was started on
colchicine and indomethacin. He improved and plan to discharge
home on colchine every other day and follow up with primary care
physician. [**Name10 (NameIs) **] therapy worked with him on strength and
mobility, which he progressed slowly due to knee pain but
tolerating ambulation and stairs [**2105-6-17**]. Plan for discharge
home with walker for assistance. Plan for follow up with Dr
[**Last Name (STitle) **] for coumadin dosing and staple removal.
Medications on Admission:
coumadin 6' (last dose 7/15)
finasteride
lasix 20'
flomax 0.4'
synthroid
naproxen prn
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*15 Tablet(s)* Refills:*0*
5. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day: dose
to be adjusted based on INR by Dr [**Last Name (STitle) **]
goal INR 2.5-3.0.
6. Outpatient Lab Work
Please have PT/INR drawn on friday [**6-19**] for coumadin dosing with
results to Dr [**Last Name (STitle) **] Office # [**Telephone/Fax (1) 82792**] fax # [**Telephone/Fax (1) 82793**]
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Descending thoracic aortic aneurysm s/p endovascular stent
placement
Left groin hematoma s/p evacuation
Gout vs Pseudogout right knee
Aortic stenosis s/p AVR [**2095**] (Mechanical)
Benign prostatic hypertrophy
Hypothyroid
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any fever greater then 100.5.
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.
Left groin has staples that need to remain for two weeks
Please call with question or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 82792**]
CT scan Torso in 6 months and then yearly results to Dr [**Last Name (STitle) **]
and Dr [**Last Name (STitle) 914**]
Please have PT/INR drawn on friday [**6-19**] for coumadin dosing with
results to Dr [**Last Name (STitle) **] Office # [**Telephone/Fax (1) 82792**] fax # [**Telephone/Fax (1) 82793**]
Follow up with Dr [**Last Name (STitle) **] staple removal left groin appointment
wednesday [**7-1**] at 2:30pm at PCP [**Name Initial (PRE) 3726**]
Completed by:[**2105-6-17**] Name: [**Known lastname 13238**],[**Known firstname 2381**] H Unit No: [**Numeric Identifier 13239**]
Admission Date: [**2105-6-7**] Discharge Date: [**2105-6-22**]
Date of Birth: [**2020-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Discharged [**6-18**]
Chief Complaint:
Chronic descending thoracic aortic aneurysm
Major Surgical or Invasive Procedure:
[**2105-6-9**] - Endovascular stent graft repair of descending thoracic
aneurysm
[**2105-6-11**] - Endovascular stent graft extension and evacuation of
left groin hematoma
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2105-6-18**] Name: [**Known lastname 13238**],[**Known firstname 2381**] H Unit No: [**Numeric Identifier 13239**]
Admission Date: [**2105-6-7**] Discharge Date: [**2105-6-22**]
Date of Birth: [**2020-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Mr. [**Known lastname **] was placed on Bactrim for a urinary tract
infection. He was discharged to home on [**2105-6-22**].
Chief Complaint:
asymptomatic, serial CT scan reveal increasing aneurysm
Major Surgical or Invasive Procedure:
[**2105-6-9**] - Endovascular stent graft repair of descending thoracic
aneurysm
[**2105-6-11**] - Endovascular stent graft extension and evacuation of
left groin hematoma
History of Present Illness:
80 year old male with a history of descending thoracic aneurysm
s/p open stent graft in [**2095**]. Recent surveilance reveals an
increase in the size of aneurysm and he was referred for
endovascular stent placement.
Past Medical History:
descending thoracic aortic aneurysm
aortic stenosis s/p aortic valve replacement [**2095**] (mechanical)
benign prostatic hyperplasia
hypothyroidism
?lymphoma [**2103**]- s/p surgery, chemo, XRT
lymph node excision (?cervical)
aortic valve replacement [**2095**] (mechanical)
descending thoracic aortic aneurysm stent [**2095**] (open)
appendectomy remotely
Social History:
Occupation: retired contractor/carpenter
Lives alone
Tobacco: quit 40 yrs. ago
ETOH: denies
Family History:
father deceased at 65 of heart condition
Physical Exam:
Pulse: 61 Resp: 18 O2 sat: 99%RA
B/P Right: 121/78 Left:
Height: Weight: 73.2
General:
Skin: Dry [x] intact [x] no rash
well healed sternotomy/upper abdominal midline incision
HEENT: PERRL [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
audible mechanical click, no murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] 2+edema bilateral ankles
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left:1+
PT [**Name (NI) **]: Left: not palpable [**12-22**] edema
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**2105-6-17**] 12:35PM BLOOD WBC-3.4* RBC-3.20* Hgb-9.1* Hct-28.3*
MCV-89 MCH-28.5 MCHC-32.2 RDW-15.0 Plt Ct-249
[**2105-6-19**] 05:35AM BLOOD WBC-2.7* RBC-2.91* Hgb-8.4* Hct-25.5*
MCV-88 MCH-28.8 MCHC-32.9 RDW-15.0 Plt Ct-322
[**2105-6-20**] 07:10AM BLOOD WBC-4.3# RBC-3.23* Hgb-9.1* Hct-29.4*
MCV-91 MCH-28.1 MCHC-30.9* RDW-14.4 Plt Ct-363
[**2105-6-18**] 09:20AM BLOOD PT-36.0* INR(PT)-3.7*
[**2105-6-19**] 05:35AM BLOOD PT-36.0* PTT-46.5* INR(PT)-3.7*
[**2105-6-20**] 07:10AM BLOOD PT-34.8* PTT-52.4* INR(PT)-3.6*
[**2105-6-21**] 07:30AM BLOOD PT-26.1* INR(PT)-2.5*
[**2105-6-17**] 05:10AM BLOOD Glucose-119* UreaN-32* Creat-1.4* Na-139
K-4.4 Cl-102 HCO3-28 AnGap-13
[**2105-6-19**] 05:35AM BLOOD Glucose-99 UreaN-21* Creat-1.3* Na-141
K-4.5 Cl-109* HCO3-25 AnGap-12
[**2105-6-20**] 07:10AM BLOOD Glucose-131* UreaN-19 Creat-1.1 Na-139
K-4.9 Cl-105 HCO3-26 AnGap-13
[**2105-6-18**] 10:47 pm URINE Source: CVS.
**FINAL REPORT [**2105-6-21**]**
URINE CULTURE (Final [**2105-6-21**]):
SERRATIA MARCESCENS. 10,000-100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days therefore be warranted if third generation
cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
Final Report
HISTORY: 85-year-old male with new onset right knee pain and
swelling.
RIGHT KNEE, THREE VIEWS: There are no prior radiographs for
comparison.
There is diffuse osteophytic spurring and joint space narrowing
in all three
compartments of the knee. There is a small joint effusion. There
are no
fractures or dislocations. There is mild soft tissue swelling. .
IMPRESSION: Tricompartmental osteoarthritis, small joint
effusion.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
The patient developed confusion and discharge was delayed.
Urine culture was sent, which would return positive for Serratia
Marcescens. He was treated accordingly. Additionally,
geriatrics consult was obtained. We appreciate their
recommendations. The confusion did clear and the patient
returned to his baseline mental status prior to discharge.
Colchicine and indocin were discontinued when the patient
developed leukopenia, diarrhea and anemia. Symptoms improved on
discontinuation of these meds. The patient was cleared for
discharge home on [**2105-6-22**]. Explicit instructions regarding
follow up and necessary appointments were given.
Medications on Admission:
coumadin 6' (last dose 7/15)
finasteride
lasix 20'
flomax 0.4'
synthroid
naproxen prn
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day: dose
to be adjusted based on INR by Dr [**Last Name (STitle) **]
goal INR 2.5-3.0.
5. Outpatient Lab Work
Please have PT/INR drawn on tues. [**2105-6-23**] for coumadin dosing
with results to Dr [**Last Name (STitle) **] Office # [**Telephone/Fax (1) 13240**] fax #
[**Telephone/Fax (1) 13241**]
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) as needed for uti for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Descending thoracic aortic aneurysm s/p endovascular stent
placement
Left groin hematoma s/p evacuation
Gout vs Pseudogout right knee
Aortic stenosis s/p AVR [**2095**] (Mechanical)
Benign prostatic hypertrophy
Hypothyroidism
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any fever greater then 100.5.
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.
Left groin has staples that need to remain for two weeks
Please call with question or concerns [**Telephone/Fax (1) 1477**]
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 13240**]
CT scan Torso in 6 months and then yearly results to Dr [**Last Name (STitle) **]
and Dr [**Last Name (STitle) **]
Please have PT/INR drawn on Tues. [**2105-6-23**] for coumadin dosing
with results to Dr [**Last Name (STitle) **], Office # [**Telephone/Fax (1) 13240**] fax #
[**Telephone/Fax (1) 13241**]
Follow up with Dr [**Last Name (STitle) **] staple removal left groin appointment
wednesday [**7-1**] at 2:30pm at PCP [**Name Initial (PRE) 4682**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2105-6-22**]
|
[
"599.0",
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"V43.3",
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"287.5",
"274.0",
"V58.61",
"E878.1",
"715.33",
"600.00",
"996.1",
"244.9",
"441.2",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
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] |
icd9pcs
|
[
[
[]
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|
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|
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|
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|
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13371, 13429
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13669, 13889
|
13911, 14271
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14287, 14381
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,305
| 137,157
|
26135
|
Discharge summary
|
report
|
Admission Date: [**2107-2-19**] Discharge Date: [**2107-2-22**]
Date of Birth: [**2087-5-31**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
overdose
Major Surgical or Invasive Procedure:
Intubation [**2-19**], extubation [**2-20**]
History of Present Illness:
This is a 19 y/o female with a h/o of depression who presented
with a benadryl overdose on [**2107-2-19**]. Per patient, she had felt
more depressed recently secondary to financial issues. Due to
not enough money, she had not taken her prozac for almost 2
weeks as she was unable to fill script and pay for the
medication. She OD'd on 105 tablets of benadryl, to ensure the
dose would be lethal. Denies OD of prozac and OCP, as she has
not been able to fill the scripts. After taking the pills, she
told her roommates, who called EMS. Patient was unresponsive by
the time EMS arrived and she was intubated for airway
protection. Initially, in the ED she was tachycardiac to 148,
had an AG of 19 and lactate of 10. She received 50 g of charcoal
and 4 L of NS in the ED and then sent to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**],
she was managed supportively and extubated without complications
yesterday. Now transferred to the medical service as stable for
further management.
Currently, her only c/o is a slightly productive cough with
whitish to yellow phlegm. No f/c/s, although the patient felt
hot and flushed earlier. No CP, SOB, n/v, abdominal pain,
diarrhea, dysuria, swelling in extremities. Last BM was
yesterday night.
She reports that she doesn't know if she stills feels depressed,
but denies any current SI or HI. No history of prior suicide
attempts.
Past Medical History:
Depression, diagnosed prior to 9th grade, on Prozac since that
time. No previous suicide attempts.
Social History:
SH - Lives in [**Location **] with her roommates and is currently a
student at BU. Originally from [**Doctor First Name 5256**], where her PCP is
and who prescribes Prozac. Smokes socially (<1 cigarette/day),
drinks socially, no illicit drug use.
Family History:
FH - Mother has depression, HTN. No h/o suicides within family.
No CAD, strokes, cancers, DM.
Physical Exam:
VS in ED: HR: 123, BP: 160/102, RR: 21, SaO2: 100% on vent
setting: AC: 450x14, PEEP: 5, FiO2: 50%.
VS in [**Hospital Unit Name 153**]: HR: 92, BP: 116/52, RR: 14, SaO2: 100% on AC:
450/14, PEEP: 5, FiO2: 40%
Genl: young female, intubated and sedated on propofol. Moving UE
spontaneously. does not withdraw from stimuli
HEENT: pupils 3-4mm, minimally reactive, tongue protruding, mmm
CV: RRR, S1, S2, no m/r/g
Chest: CTA bilaterally
Abd: distended, soft, NT, ND, BS+ bilaterally
Ext: wwp, no c/c/e
Neuro: no babinski
PE on call-out from [**Hospital Unit Name 153**]:
VS: T BP 110/60, HR 110, RR 16, sats 94%/RA
GENERAL: AO x 3, NAD. Sitting in bed comfortably.
HEENT: NC/AT, PERRL, EOMI. Anicteric sclerae. MMM and OP clear.
NECK: supple
CHEST: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
ABD: soft, NT/ND, NABS
EXT: no c/c/e, pulses 2+ b/l
NEURO: AO x 3, CN II-XII intact, MS [**5-27**] throughout
Pertinent Results:
STUDIES:
CXR [**2107-2-19**]: The endotracheal tube tip is approximately 4 cm
above the carina. The nasogastric tube extends below the left
hemidiaphragm into the expected location of the stomach,
terminating below the inferior margin of the image. The heart,
mediastinum and pulmonary vessels appear normal. The lungs are
clear. There is no pleural effusion. The visualized osseous
structures appear unremarkable.
IMPRESSION: Satisfactory position of the endotracheal and
orogastric tubes.
Brief Hospital Course:
ASSESSMENT/PLAN - 19 y/o female with h/o depression, s/p drug
overdose as suicide attempt, s/p intubation for airway
protection. No extubated and medically stable.
.
1. Benadryl overdose - s/p ingestion of 105 tablets of 25 mg
each, s/p activated charcoal administration, s/p
intuabtion/extubation. HD stable, closed AG
- need to monitor for anticholinergic toxicity - symptoms
include tachycardia, HTN, flusing, fever, agitation, dry
membranes - no current symptoms
- supportive care as necessary
.
2. Depression/SI -
- 1:1 sitter
- psych following, apprec recs
- restarted Prozac for depression - patient did not overdose on
Prozac as she had not filled her script for Prozac in two weeks
- to be admitted to in-patient psych
.
3. Cough, low-grade temp - resolved at this time
- CXR w/o signs of obvious PNA
- stable WBC, afebrile this AM
- likely [**2-24**] URI vs. pneumonitits
- Abx not indicated at this time -> if patient develops a
productive cough and/or fever, would repeat CXR (PA & lateral)
and depending on findings, may need antibiotics
.
4. UTI - urine cx from [**2107-2-20**] positive for Gm negative rods,
patient with symptoms of dysuria
- will treat with Ciprofloxacin 250 mg [**Hospital1 **] x 3 days
- please follow sensitivites of urine culture in case
antibiotics need to be tapered
.
5. Anemia
- Hct stable during admission, stools guiac negative
- iron studies significant for low iron, high TIBC, normal
ferritn -> indicative for iron deficiency anemia, will start
iron supplements
- patient should have outpatient work-up of iron deficiency
anemia
.
6. F/E/N - regular diet, replete lytes prn
.
7. PPx - eating, OOB
.
8. Code - full
.
9. Dispo - to inpatient psych when bed available as medically
stable
.
10. Communication - [**Name (NI) **] [**Known lastname **] (Mother): [**Telephone/Fax (1) 64831**]
Medications on Admission:
1. Kariva - desogesterol/ethinyl estradiol
2. Prozac 30mg once daily
3. Benadryl prn
Discharge Medications:
1. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
twice a day.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days: Start [**2107-2-22**].
Discharge Disposition:
Extended Care
Facility:
Deaconess4
Discharge Diagnosis:
Primary - suicide attempt, drug overdose, depression
Secondary - iron deficiency anemia
Discharge Condition:
Medically stable
Discharge Instructions:
- you will be admitted to the Inpatient Psychiatric unit for
further care
- please comply with all therapy and management while in the
Psych unit
- please follow up with Dr. [**Last Name (STitle) 2185**] at [**Hospital6 733**] on
[**2107-3-24**] for general medical follow-up as you should have a
primary care physician while in [**Name9 (PRE) 86**]
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2107-3-24**]
1:30
Completed by:[**2107-2-22**]
|
[
"E950.4",
"E849.0",
"311",
"785.0",
"401.9",
"V40.3",
"V62.89",
"280.9",
"963.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
6152, 6189
|
3747, 5580
|
323, 370
|
6322, 6341
|
3231, 3724
|
6739, 6915
|
2195, 2290
|
5717, 6129
|
6210, 6301
|
5606, 5692
|
6365, 6716
|
2305, 3212
|
275, 285
|
398, 1793
|
1815, 1915
|
1931, 2179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,675
| 112,633
|
22838
|
Discharge summary
|
report
|
Admission Date: [**2114-12-26**] [**Month/Day/Year **] Date: [**2115-1-7**]
Date of Birth: [**2058-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Azithromycin / Lipitor
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 56 year old female with past medical history
significant for ESRD s/p live donor kidney [**First Name3 (LF) **] in [**2108**]
currently immunosuppressed with tacrolimus/ prednisone/cellcept
who was recently admitted from [**2114-11-8**] to [**2114-11-28**] and [**2114-12-5**]
to [**2114-12-20**] to [**Hospital1 69**] for hypoxic
respiratory failure requiring intubation and acute tubular
necrosis requiring CVVH during both admissions. No cause of her
hypoxic respiratory distress were found at either admission but
thought to be precipated by a pneumonia which was treated with
broad spectrum antibiotics.
.
She is reported to be doing well since [**Hospital1 **]. She woke up
this morning went to the bathroom and on her way back to the
bedroom experienced sudden onset [**7-10**] tight left sided chest
pressure that radiated to her back. She was noted to have SBP
in 230s, hypoxic in 80% on room air at outside hospital. She
received IV lasix and was started on nitro gtt for chest pain
and transferred to [**Hospital1 18**] for further evaluation and management.
.
In the ED, she was noted to have SBP in 150s and satting well on
3LNC. Chest x-ray was consistent with pulmonary edema. V/Q
scan showed low probability of pulmonary embolism. She was
transferred to MICU on nitro gtt for furthere evaluation and
management.
.
In the unit, she reports having [**4-9**] pleuritic chest pain but
improved shortness of breath. She does not report fever, cough,
abdominal pain, nausea, vomiting or headache. She does report
she had soup from a can yesterday.
Past Medical History:
1. Fulminant liver failure [**1-5**] likely caused by Azithromycin
2. End-stage renal disease s/p living related donor in [**2108**]
3. Hypertension
4. Depression
5. Dyslipidemia
6. Nephrolithiasis
7. Melasma
8. Hepatitis B - carrier
Social History:
Married with 5 children. Lives at home with husband, daughter
and grandchildren. She moved from [**Country 5737**] in [**2098**] and last
visited in [**Month (only) **]. She denies any cigarette use, and quit
alcohol, though she used to abuse alcohol. No IVDU. While in
[**Country **], she lived on a farm for 3 years-- exposure to many
domestic farm animals. She does not recall any skin rashes or
febrile illnesses during that period. She does not know if she
received the BCG vaccine as a child.
Family History:
No history of liver or renal disease. Five brothers and father
were killed in [**Country **]. Mother had stroke. Sister alive and
well.
Physical Exam:
ADMISSION:
Gen: Awake. Alert and oriented to person, place and time.
Vitals: 98.3 154/73 72 18 95%2LNC
HEENT: Normocephalic. Nontraumatic. Anicteric. PERRLA. Supple
neck wtihout lymphadenopathy.
Chest: Crackles upto mid lung bases
Heart: Regular rate and rhythm. No murmurs or gallops
appreciated
Abdomen: Soft and nondistended. Grimaces to palpation but no
guarding appreciated. No rebound tenderness.
External: No edema. No rash. Appropriate temperature of the
extremities. 2+ radial and dorsalis pedis pulses
.
[**Country 894**]:
VS: 98.1 185/93 74 16 100%RA 119
Pertinent Results:
IMAGING:
CXR ([**2114-12-28**]): Stable cardiomegaly and pulmonary vascular
congestion as well as persistent mild volume loss in the right
upper lobe. Possible very small pleural effusions.
.
CXR ([**2114-12-26**]):
1. Moderate vascular congestion and interstitial edema have
developed, right greater than left, most consistent with
asymmetric edema, although superimposed infection can not be
excluded.
2. Moderate cardiomegaly.
.
CTA chest ([**2114-12-26**]):
1. Moderate vascular congestion and interstitial edema have
developed, right greater than left, most consistent with
asymmetric edema, although superimposed infection can not be
excluded.
2. Moderate cardiomegaly.
.
V/Q scan ([**2114-12-26**]): Matched, non-segmental decrease in
perfusion and ventilation in the posteromedial right lung. Low
likelihood ratio of recent pulmonary embolism.
.
Renal US ([**2114-12-27**]): Stable mild-to-moderate hydronephrosis of
the [**Month/Day/Year **] kidney with patent vasculature.
.
EKG ([**2114-12-26**]): Sinus rhythm. Borderline prolonged QTc interval.
Diffuse non-specific inferolateral ST segment changes. Compared
to the previous tracing of [**2114-12-9**] the ST segment changes are
less evident on the current tracing.
Rate PR QRS QT/QTc P QRS T
73 144 80 452/474 33 11 24
.
LABS ON ADMISSION:
[**2114-12-26**] 02:30PM BLOOD WBC-8.7# RBC-3.09* Hgb-9.2* Hct-27.3*
MCV-89 MCH-29.9 MCHC-33.7 RDW-16.8* Plt Ct-123*#
[**2114-12-26**] 02:30PM BLOOD Neuts-94.1* Lymphs-3.8* Monos-0.9*
Eos-0.5 Baso-0.7
[**2114-12-27**] 02:24AM BLOOD PT-12.9 PTT-24.4 INR(PT)-1.1
[**2114-12-26**] 02:30PM BLOOD Glucose-160* UreaN-28* Creat-1.6* Na-134
K-5.0 Cl-109* HCO3-15* AnGap-15
[**2114-12-26**] 02:30PM BLOOD ALT-9 AST-15 LD(LDH)-433* AlkPhos-53
TotBili-0.9
[**2114-12-26**] 02:30PM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier 59032**]*
[**2114-12-27**] 02:24AM BLOOD CK-MB-3 cTropnT-<0.01
[**2114-12-27**] 02:24AM BLOOD Albumin-3.4* Calcium-8.4 Phos-5.3* Mg-1.8
[**2114-12-27**] 08:05AM BLOOD tacroFK-8.0
.
LABS ON [**Month/Day/Year 894**]:
.
MICRO:
[**2114-12-29**] URINE CULTURE-PENDING
[**2114-12-28**] URINE CULTURE-PENDING
[**2114-12-26**] MRSA SCREEN-PENDING
.
URINE:
[**2114-12-28**] 07:14PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.006
[**2114-12-28**] 07:14PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2114-12-28**] 07:14PM URINE RBC-1 WBC-43* Bacteri-MOD Yeast-NONE
Epi-0
[**2114-12-28**] 07:14PM URINE WBC Clm-FEW
[**2114-12-29**] 10:19AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2114-12-29**] 10:19AM URINE Blood-NEG Nitrite-NEG Protein-150
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2114-12-29**] 10:19AM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-NONE
Epi-0-2
Brief Hospital Course:
56F w/PMH significant for ESRD s/p live donor kidney [**Month/Day/Year **]
admitted to ICU with chest pain and SOB in setting of
hypertensive emergency, transferred to floor in stable medical
condition without supplemental O2 or chest pain after diuresis.
Remained hypertensive but asymptomatic.
.
# Hypertensive urgency: Patient had one episode of hypertensive
emergency approximately 1 week prior to [**Month/Day/Year **] with headache,
visual changes, chest pressure and nausea. For the remainder of
her admission, patient had ongoing elevated blood pressures but
was asymptomatic. Overall, blood pressures trended down. Denied
any headache, vision changes or nausea on [**Month/Day/Year **]. Her
antihypertensive regimen was changed significantly throughout
admission in an attempt to achieve optimal blood pressure
control. Serum metanephrines, renin & aldosterone were pending
at the time of [**Month/Day/Year **].
.
# Acute on chronic kidney injury: Patient is s/p kidney
[**Month/Day/Year **] in [**2108**]. She was continued on tacrolimus and
prednisone. Creatinine was 2.3 at the time of transfer to the
floor, 1.6 at time of admission; s/p contrast load for CTA on
[**12-26**]. Baseline creatinine ~1.2 previously; as high as 3.5 during
recent admissions. Creatinine trended down after patient was
transferred to floor. Renal ultrasound showed patent vasculature
and stable mild-to-moderate hydronephrosis.
.
# Urinary tract infection: Urine cultures from [**2114-12-28**] and
[**2114-12-29**] grew E. coli & cipro-resistant Psuedomonas. Patient
denied any urinary symptoms, but was treated in the context of
immunosuppression. She will complete a 14 day course of
meropenem (day 1 = [**12-31**]; last dose on [**1-13**]).
# Anemia: Secondary to chronic inflammation and renal disease.
Hematocrit stable and at baseline.
# Hyperglycemia: Patient stated that she was not on insulin at
home. It appears that lantus and HISS were started in the
context of increasing her prednisone dose during her previous
admission. Glucose was well controlled overall and she was
placed on a humalog sliding scale during admission.
# Depression: Continued citalopram 20 mg po daily.
# Prophylaxis: Patient received heparin products during this
admission.
Medications on Admission:
1. Citalopram 20 mg po qdaily
2. Aspirin 325 mg po qdaily
3. Tacrolimus 2 mg po BID
4. Sevelamer HCl 800 mg po BID
5. Prednisone 5 mg po qdaily
6. acetaminophen 325 mg po q6 prn pain
7. docusate sodium 100 mg po BID
8. pantoprazole 40 mg po q12
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol [**12-2**] puff q4-6
hrs prn shortness of breath
10. fluticasone-salmeterol 250-50 mcg/dose inhalation twice a
day
11. diazepam 5 mg Tablet po q8 prn anxiety
12. Lantus 5 units SC qhs
13. Humalog sliding scale
14. epoetin alfa 4,000 unit/mL Solution every MWF
15. Labetalol 400 mg po BID
[**Month/Day (2) **] Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. tacrolimus 1 mg Capsule, twice daily Sig: One (1) Capsule,
twice daily PO every twelve (12) hours.
Disp:*60 Capsule, twice daily(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache, pain.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-2**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Inhalation twice a day.
8. diazepam 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety.
9. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Recon
Soln Intravenous Q12H (every 12 hours) for 6 days: last dose
[**1-13**].
Disp:*qs mg Recon Soln(s)* Refills:*0*
10. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
12. epoetin alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
Disp:*qs * Refills:*2*
13. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
16. amlodipine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
17. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
[**Month/Year (2) **] Disposition:
Home With Service
Facility:
Home Solutions
[**Month/Year (2) **] Diagnosis:
Primary:
Hypertensive emergency
Pulmonary edema
Asymptomatic bacteriuria
.
Secondary:
End-stage renal disease status post [**Month/Year (2) **]
[**Month/Year (2) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Month/Year (2) **] Instructions:
# You were admitted to the hospital for high blood pressure and
difficulty breathing. Your blood pressure and breathing improved
with some changes to your medications. You were also found to
have a urinary tract infection that is being treated with
antibiotics.
.
We made the following changes to your medications:
-STOP sevelamer
-STOP labetalol
-STOP lantus
-STOP humalog
.
-START meropenem (last dose on [**1-13**])
-START Lasix (furosemide) 80mg every morning
-START Imdur (isosorbide mononitrate) 30 mg daily
-START amlodipine 5 mg every night
-START carvedilol 25 mg twice a day
-START lisinopril 20 mg twice a day
.
-CHANGED dose of prednisone to 2 mg daily
-CHANGED dose of tacrolimus to 1 mg twice a day
-CHANGED dose of epoetin to 10,000 units once weekly
.
# Please continue all of your other medications as prescribed.
.
# It is important that you keep your follow up appointments.
.
# Dr. [**Last Name (STitle) **] requested that you get your labs checked next
week (per your usual routine).
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2115-1-14**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PFT
When: MONDAY [**2115-1-14**] at 1:30 PM
.
Name: [**Year (4 digits) **],[**Year (4 digits) **]
Location: [**Hospital **] COMMUNITY HEALTH CENTER
Address: [**Location (un) 59033**], [**Hospital1 **],[**Numeric Identifier 59034**]
Phone: [**Telephone/Fax (1) 59035**]
When: Wednesday, [**1-16**], 1PM
.
Department: [**Month (only) **] CENTER
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
We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
for you on Friday [**1-25**]. You will be called at home with
the appointment. If you have not heard or have questions, please
call the above number.
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
Completed by:[**2115-1-13**]
|
[
"996.81",
"287.5",
"041.4",
"591",
"285.21",
"041.7",
"311",
"250.00",
"584.9",
"585.9",
"E878.0",
"599.0",
"518.4",
"276.2",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6303, 8558
|
330, 336
|
3475, 4772
|
12566, 13734
|
2737, 2874
|
8584, 11374
|
2889, 3456
|
11852, 12543
|
270, 292
|
364, 1947
|
4786, 6280
|
11389, 11823
|
1969, 2204
|
2220, 2721
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,935
| 191,305
|
51255
|
Discharge summary
|
report
|
Admission Date: [**2146-9-14**] Discharge Date: [**2146-10-7**]
Date of Birth: [**2083-10-7**] Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Tracheal Intubation
Video swallow
[**Last Name (un) 1372**]-Intestinal tube placement
History of Present Illness:
62M hx of EtOH abuse with recent admission [**8-19**] - [**9-7**] after GI
bleed from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear with complicated hospital course
MICU course with intubation for air-way protection complicated
by PNA and PTx after TLC was placed in the R IJ, [**Last Name (un) **] to Cr 2.3
(from 1.0) as well as new diagnosis of hypothyroidism with TSH
in the 40's. Pt was dc'd to [**Hospital1 **] for rehab, per their
notes patiet did well for the first several days and
participated in PT, OT, soon after his admission he had fall
without any head injury or LOC. He completed therapy with
amoxicilline + clarithromycine for H.pylori and remained on
omeprazole. His stool continued to be guiac positive. On [**9-12**] he
became confused and delirious, fevers but WBC of 13.7. UA showed
some bacteria w/o significant leukocyturia, culture was sent and
is pending. He was given lorazepam d/t concern for alcohol
and/or BZ withdrawal with little effect. He was also noted to
have continous diarrhea with neg c.dif. On day of his admission
his family decided to take him back to [**Hospital1 18**] for evaluation. In
the [**Name (NI) **] Pt endorsed some cough, +N and V, denied abd pain.
Endorsed dull chest pain at center of chest at baseline but not
increased from baseline. No C, no SOB, no diarrhea, no dysuria,
no changes in bowel or bladder habits.
.
In the ED admission vitals were 95.4 70 98/60 18 100% RA,
- labs were notable for leukocytosis to 12 with 80% Neu,
macrocytic anemia with Hct 25 which is unchanged from discarge,
coags mildly elevated to INR 1.4 and PTT 36 which is at
baseline, cr:BUN 1.3/8 from 0.8:11 at discharge, ALKP 238 from
100 at discharge. T,bili 0.8 with direct at 0.5, normal
transaminases, Lipase = 6, trop neg X2, Albumin 2.7, bicarb 21
with AG (corrcted for albumin) = 11. Lactate = 1.2, Amonia = 24.
UA showed small leukocytes.
- cxr: resolving pna with residual bil LL opacities.
ekg: SR at 67. leftward axis, low voltage, new twi, v2-v5
- ct head: no acute bleed
- GI consult: stable hemodynamically-does not need ng lavage.
recommended protonix drip.
Pt was was given protonix drip + bolus, levofloxacin 750mg to
cover for pna and IV NS X2.
.
On the floor, remains mildly confused, poor historian, denies
any focal symptoms.
Past Medical History:
# ETOH abuse
- denies history of blackout, withdrawal seizure, DTs
- history of DUI, attended mandatory AA
- currently reports drinking gin 3-4 days per week with a few
shots per day
# M-W tear with UGIB [**8-/2146**]
# hypothyroidism
# h/o acute pancreatitis requiring hospitalization [**9-/2145**]
# fatty liver
# peripheral neuropathy
# macrocytic anemia
# gout
# HTN
# impaired vision secondary to a battery acid splash in his eyes
# Cyst removal from the back about 40 years ago.
Social History:
Prior notes from [**2145**] indicate heavy drinking, up to half a
gallon of gin every couple of days. Prior to [**8-/2146**] admission
the patient lived with a friend. His son and daughter also live
in [**Location (un) 686**]. Tobacco use consists of about 14-15 cigarettes
per day.
Family History:
Family History (from chart):
The patient has a sister aged 63 who has diabetes. The patient's
father died at 94. The patient's mother died at 84. She had
diabetes and hypertension. The patient's maternal grandmother
died at age [**Age over 90 **].
Physical Exam:
ADMISSION EXAM:
Vitals: T:unmeasurable BP: 106/67 P: 70 R:18 O2: 96% RA, FS =
204
General: Alert, oriented to self, knows year but not month or
day, known hospital but says B&W. Speech is confused able to
answer basic questions and cooperate with exam but unable to
give history or explain what brought him to the hospital. no
acute distress.
SKIN: epidermal sloughing on 4 extremities but not on trunk or
face, no rash or ditinct lesions, raw and abrased skin in
perineal area with suspected severe tinea cruris no evidence of
[**Female First Name (un) **] or bacterial infection.
HEENT: left traumatic pupil enlarged and unreactive, right pupil
round and reactive, arcus senilis, EOMI, Sclera anicteric, MMM,
oropharynx clear, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi at bases
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. Guiac
negative stool yesterday.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact, pupils above, strength UE/LE
flexion/extension intact bilaterally, sensation intact
throughout. No asterixus, no pronator drift.
.
DISCHARGE EXAM:
VS: 94.6-97 Tc 97, 108/74, 85, 16, 98% RA
General: Pt is resting comfortably, sitting up in bed in no
acute distess
Heart: RRR, nl S1 and S2, no MRG
Lungs: Poor respiratory effort, clear anteriorally
Abd: +BS. Soft, nontender, nondistended. No masses.
Ext: wwp. radial, DP pulses 2+
Skin: 8cm diameter round erythematous scaly rash on L flank,
continued improved erythema
Neurologic: Awake and alert. Oriented to self and place but not
date (stated it is [**2144**]), moving all extremities well, [**5-10**]
strength throughout, sensation intact.
Pertinent Results:
ADMISSION LABS:
[**2146-9-14**] 05:21PM BLOOD WBC-12.1*# RBC-2.40* Hgb-8.2* Hct-25.2*
MCV-105* MCH-34.2* MCHC-32.5 RDW-19.2* Plt Ct-167#
[**2146-9-14**] 05:21PM BLOOD Neuts-79.5* Lymphs-14.4* Monos-2.4
Eos-2.7 Baso-1.1
[**2146-9-14**] 05:21PM BLOOD PT-15.7* PTT-36.6* INR(PT)-1.4*
[**2146-9-14**] 05:21PM BLOOD Glucose-113* UreaN-8 Creat-1.3* Na-141
K-4.2 Cl-109* HCO3-21* AnGap-15
[**2146-9-14**] 05:21PM BLOOD ALT-26 AST-38 AlkPhos-238* TotBili-0.8
DirBili-0.5* IndBili-0.3
[**2146-9-14**] 05:21PM BLOOD Lipase-6 GGT-321*
[**2146-9-14**] 05:21PM BLOOD cTropnT-0.01
[**2146-9-14**] 05:21PM BLOOD Albumin-2.7* Calcium-8.8 Phos-5.1* Mg-1.6
[**2146-9-14**] 08:40PM BLOOD Ammonia-24
[**2146-9-14**] 05:21PM BLOOD TSH-12*
[**2146-9-16**] 09:06PM BLOOD T4-3.5* T3-49* calcTBG-0.85 TUptake-1.18
T4Index-4.1* Free T4-0.87*
[**2146-9-14**] 08:53PM BLOOD Lactate-1.9
[**2146-9-17**] 2:00 pm BLOOD CULTURE Source: Line-central.
**FINAL REPORT [**2146-9-23**]**
Blood Culture, Routine (Final [**2146-9-23**]): NO GROWTH.
[**2146-9-19**] 10:29 am URINE Source: Catheter.
.
**FINAL REPORT [**2146-9-20**]**
Legionella Urinary Antigen (Final [**2146-9-20**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
.
Sputum GRAM STAIN (Final [**2146-9-23**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
DISCHARGE LABS:
[**2146-10-5**] 06:17AM BLOOD WBC-5.2 RBC-2.62* Hgb-8.8* Hct-26.4*
MCV-101* MCH-33.5* MCHC-33.4 RDW-19.7* Plt Ct-355
[**2146-10-6**] 04:50AM BLOOD WBC-5.2 RBC-2.70* Hgb-9.2* Hct-26.6*
MCV-99* MCH-34.2* MCHC-34.6 RDW-19.9* Plt Ct-315
[**2146-10-7**] 04:50AM BLOOD WBC-6.7 RBC-2.69* Hgb-8.7* Hct-26.8*
MCV-100* MCH-32.5* MCHC-32.6 RDW-19.2* Plt Ct-300
[**2146-10-7**] 04:50AM BLOOD Glucose-89 UreaN-7 Creat-1.0 Na-142 K-4.0
Cl-110* HCO3-22 AnGap-14
[**2146-10-7**] 04:50AM BLOOD Calcium-8.9 Phos-5.6* Mg-2.0
[**2146-10-3**] 07:50AM BLOOD T4-9.2 T3-84 calcTBG-0.86 TUptake-1.16
T4Index-10.7 Free T4-1.7
Blood cultures [**2146-10-3**] pending
Urine culture [**2146-10-3**] No growth
.
IMAGING:
.
CT HEAD W/O CONTR ([**2146-9-14**]): FINDINGS: There is no acute
intracranial hemorrhage, edema, mass effect, or vascular
territorial infarct. The ventricles and sulci are prominent,
consistent with age-related involutional changes.
Periventricular and subcortical white matter hypodensities
reflect small vessel ischemic disease. Calcifications are noted
in the bilateral cavernous carotid arteries and right vertebral
artery. There is mild S-shaped deviation of the nasal septum.
The paranasal sinuses are well aerated. There are apparent
chronic posttraumatic defects in the bilateral lamina papyracea,
with herniation of periorbital fat into the bilateral ethmoid
cavities. The roofs of the ethmoid sinuses is intact. Incidental
note is made of cavernous sinus gas, likely from prior
intravenous line placement. Globes, optic nerves, and
extraocular muscles are symmetric.
IMPRESSION: No acute intracranial process. Chronic involutional
changes and sequelae of prior trauma.
.
CXR ([**2146-9-14**]): FINDINGS: AP upright and lateral views of the
chest were obtained. There is improvement in aeration of the
lower lungs compared with [**2146-8-31**] compatible with resolving
pneumonia. There may still be residual subtle opacity within the
lower lobes bilaterally suggestive of residual infection. There
are no large pleural effusions or pneumothorax.
Cardiomediastinal silhouette appears normal. Bony structures are
intact.
IMPRESSION: Improved aeration in the lower lungs though with
mild residual
opacity suggestive of residual infection.
.
ABDOMEN U.S. ([**2146-9-15**]): IMPRESSION:
1. Unchanged echogenic liver, findings consistent with hepatic
steatosis.
Other forms of liver disease and more advanced liver disease
including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this examination. No focal hepatic mass.
2. Sludge- and stone-filled gallbladder without secondary signs
of acute
cholecystitis.
3. No intra- or extra-hepatic biliary ductal dilatation.
.
CTA ABD & PELVIS W/ & W/O CONTR ([**2146-9-17**]): IMPRESSION:
1. Progressive multifocal pneumonia and lower lobe collapse.
2. Pancolitis, likely infectious given the diffuse distribution,
and more
than usually expected simply from third-spacing. Mesenteric
circulation
appears patent. However, possibility of superimposed ischemia
from low-flow state cannot be excluded.
3. Volume overload, with changes of third-spacing such as body
wall edema,
ascites, and pleural effusions.
4. Cholelithiasis and partially distended gallbladder, likely
due to
patient's fasting status. However, if there is concern for acute
cholecystitis, ultrasound or HIDA scan can be considered.
.
Chest Xray ([**2146-10-3**])
Appearance of the right lower lung, combination of pleural
effusion and
consolidation, has not changed appreciably over a week, but left
lower lobe
consolidation and left pleural effusion are clearing. Heart size
is normal,
and there is no pneumothorax.
.
Video Swallow ([**2146-10-5**])
.
1. Penetration and trace aspiration of thin liquids.
2. Penetration of nectar thick contrast.
3. Delayed oropharyngeal phase with constant spilling.
4. Moderate amount of residue in the vallecula.
.
Chest Xray ([**2146-10-7**])
IMPRESSION: No new aspiration pneumonia. Improvement in right
small pleural
effusion and atelectasis.
Brief Hospital Course:
HOSPITAL COURSE
Patient is a 62 y/o man PMHx EtOH abuse, recent GI bleed
admission complicated by respiratory failure, recently
discharged, then re-admitted with altered mental status, found
to be aspirating with subsequent HCAP and ARDS requiring
intubation, vasopressors, treated with 14d course of abx,
exubtated, transferred to floor.
.
ACTIVE ISSUES:
.
# Altered Mental Status: Pt was delirious upon transfer out of
MICU, likely related to long stay in MICU. On transfer, his
mental status waxed and waned with periods of increased lucency
when he is interactive and periods of hypoactive delirium. On
the floor, he continued to improve over the remainder of his
admission. He was started on PRN zyprexa for agitation which he
tolerated well. At the time of discharge he was oriented to self
and place with, interactive and responsive. He did continue to
have periods of mild confusion but was overall much improved and
per the family near baseline.
.
# Recurrent Aspirations, HCAP, Sepsis and ARDS: Patient
presented with altered mental status increasing oxygen
requirements / leukocytosis, worsening clinical status resulted
in transfer to the ICU afterwhich patient was soon intubated for
hypoxic respiratory distress; subsquent imaging demonstrated
diffuse pulmonary infiltrates consistent with ARDS; patient was
ventilated on ARDSnet protocol and treated with broad spectrum
abx (vancomycin, meropenem, ciprofloxacin). The patient did have
a leukocytosis which responded to therapy. Blood cultures and
legionella antigen were negative and sputum cultures grew yeast.
Hypotension necessitated the use of vasopressors and aggressive
fluid boluses (~26L). Once hemodynamically stabilized patient
was aggressively diuresed back to baseline weight. Given
recurrent aspirations, concern that extubation of patient might
result in repeat aspiration; after discussion w family, decided
to give patient trial of extubation with plan for tracheostomy
and PEG if patient demonstrated repeat aspiration episodes.
Post extubation the patients respiratory status remained stable
with oxygen saturations of 95-100% on room air. The patient
underwent video swallow evaluation that demonstrated aspiration
and he was kept NPO. IR was consulted to place an
nasointentestinal tube as attempts at NG placement were
unsuccessful. Tube feeds were initiated however a few hours
later the patient pulled out the tube stating it was
uncomfortable. Repeat swallow evaluation a few days later
demonstrated the patient was safe to have nectar thick liquids
and pureed solids which he tolerated well. Repeat chest xray
showed not recurrent aspiration pneumonia.
.
#Hypothemia- Patient was hypothermic on admission in the setting
of hypotension with temperature of 91-92 F. While on the floor
he remained intermittently hypothemic with temperatures of 93-94
F. His blood pressure remained stable and he was asymptomatic
during these events. He responded well to warming with a bare
hugger.
.
# Rash: Pt was found to have a 8cm diameter round erythematous
rash on L flank with satellite vesicles up to high L back,
spanning across >6 dermatomal layers on [**10-1**]. The rash was most
consistent with [**Female First Name (un) 564**] intertrigo and was treated with topical
clotrimazole cream x4 day. The rash improved markedly throughout
his hospitalization.
.
# Volume Imbalance: Pt was given >20 fluids in the MICU and
subsequently aggressively diuresed. The patient was 3.3L
negative on transfer out of the MICU, and euvolemia was
maintained on the floor. While NPO he was continued on IV
maintenance fluids. These were stopped when PO intake improved
.
# Diarrhea: Patient w high stool output, Cdiff tox negative x
multiple tests, Cdiff PCR negative, thought to be [**3-9**]
non-infectious abx effect; resolved without intervention.
.
# Hypothyroidism: Patient w recent diagnosis hypothyroidism on
prior admission he was continued on levothyroxine. Endocrine
was consulted and recommended outpatient follow-up to determine
if he will need long term thyroid replacement therapy.
.
# GI bleed: Patient w h/o prior GI bleeds (most recent [**7-/2146**]
[**3-9**] [**Doctor First Name **]-[**Doctor Last Name **] tear), w guiaic positive stool during this
admission; required 3 units pRBCs during this hospitalization
([**Date range (1) 106354**]) for Hct trending down to low 20s. Patient was
maintained on IV PPI w/o any subsequent signs of hemodynamic
instability. He was transitioned to oral PPI which he will need
to be on for a total of [**7-13**] weeks. His hct was stable at the
time of discharge. On last admission the patients EGD showed a
gastric ulcer with adherent clot that was endoclipped, several
small duodenal ulcers, and some gastritis. It was was
recommended he continue high dose PPI. He was also treated for
H. pylori after serologies were equivocal. The patient will
need a repeat EGD which has been scheduled [**2146-10-17**] at 08:00.
.
INACTIVE
# EtOH Abuse - Continued thiamine and folic acid.
.
# GERD - PO omeprazole was changed to IV Protonix while NPO then
to dissolvable lansoprazole since omeprazole cannot be crushed.
.
# Psych - Held ambien and ativan in setting of acute illness.
.
TRANSITIONAL ISSUES
- Patient will be discharged to a rehab facility
- Patient will f/u with Dr. [**Last Name (STitle) **] of endocrinology on
[**2146-11-9**].
- Patient will f/u with GI for repeat EGD on [**2146-10-17**]
- Patient remained full code throughout this hospitalization
Medications on Admission:
Thiamine 100mg PO QD
Folic Acid 1mg QD
Omeprazole 20mg [**Hospital1 **]
Levothyroxine 50mcg QAM
Nicotine Patch 14mg TD QD
Ambien 10mg QHS PRN sleep
Ativan 1mg Q6H prn agitation
senna 2 tabs qhs prn constipation
Docusate 100mg [**Hospital1 **] PRN
Lotirim cream for groin rash
Duonebs q4hr prn SOB/wheezing
Discharge Medications:
1. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation every 4-6 hours as needed
for shortness of breath or wheezing.
2. clotrimazole 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
3. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 50 mcg Capsule [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily): Please crush in applesauce and do not give with meals
or at the same time as iron .
6. ferrous sulfate 300 mg (60 mg iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
7. olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for Agitation.
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnosis: UTI, delirium, hypothyroidism
Secondary Diagnosis: Aspiration pneumonia, delirium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your admission at
the [**Hospital1 69**]. You were admitted for
difficulties thinking and diarrhea, but your hospital course was
complicated when food went down the wrong tube and you developed
a lung infection. After nearly 2 weeks in the intensive care
unit, your condition improved. You still had some difficulty
with swallowing but were as you got stronger you were able to
swallow thick liquids and mashed up food without choking.
The last time you were in the hospital you had some bleeding
from your stomach. You were seen by the GI doctors and they
would like to see you as an outpatient to make sure your stomach
is healing.
We made a few changes to your medications. We changed your
omeprazole to lanzoprazole 30 mg daily for acid reflux. We
started you on a medicine called zyprexa to help calm you. We
started you on iron to help your blood counts. We stopped your
Ambien and ativan because these medicines can make you confused.
You should continue taking all of your other medications. Please
fee free to call if you have any questions or concerns.
Followup Instructions:
GI:
[**2146-10-17**] 08:00a [**First Name8 (NamePattern2) **] [**Location (un) **] - [**Hospital Ward Name **] 4
[**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
ENDOSCOPY SUITES
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2146-11-9**] at 5:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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27,760
| 126,013
|
30743
|
Discharge summary
|
report
|
Admission Date: [**2143-11-22**] Discharge Date: [**2143-12-6**]
Date of Birth: [**2084-5-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Septic shock
Major Surgical or Invasive Procedure:
mechanical ventilation
History of Present Illness:
Mr. [**Known lastname **] is a 59 year old man with history of likely pancreatic
malignancy who was transferred from [**Hospital **] Hospital with
abdominal pain and rising bilirubin for ERCP evaluation. At
[**Hospital1 **], he had worsening abdominal pain, and he was noted to
have a rising bilirubin. ERCP/stenting cannot be performed at
[**Last Name (LF) **], [**First Name3 (LF) **] he was transferred here for urgent evaluation and
stenting.
In the ED, he was given vancomycin and piperacillin-tazobactam.
He was seen by surgery, who reiterated that he is not a surgical
candidate. On arrival he was confused, and his mental status
deteriorated, and he was intubated. He received a total of 7L
normal saline. Dopamine was started for BP 58/38 (which
decreased to 46/25), and norepinephrine was added after a right
IJ triple lumen was placed. A foley was placed and he was sent
to the ICU. He received a total of 7L normal saline in the ED.
In the ICU, he was seen by the ERCP team, who emergently
performed an ERCP, discovering a blocked CBD stent with frank
pus and placed a new stent within the blocked stent.
Past Medical History:
Pancreatic mass s/p stent placement ([**4-/2143**])
Type 2 Diabetes, on insulin
CVA
Chronic renal insufficiency - baseline 1.5
s/p pacemaker placement for bradycardia
Hypertension
CAD s/p MI
Gout
COPD/OSA
Chronic LBP
Arthritis
History of venous stasis ulcers, recent cellulitis
Social History:
Unemployed, previously worked as a mechanic. Lives at [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) **] house. H/o tobacco x 4-5 years, alcohol and
polysubstance abuse, but currently sober. Per previous notes,
wheelchair bound and very little ambulation.
Family History:
Unable to obtain
Physical Exam:
VITALS: T99.9F, BP 167/90, HR 130, RR 21, Sat 100%
VENT: A/C, FiO2 100%, TV 550, Rate 14, PEEP 5
GEN: Sedated, intubated, jaundiced
HEENT: Scleral icterus, PERRL
NECK: Unable to appreciate JVP
RESP: CTA bilaterally anteriorly
CV: Tachycardic, no murmurs
ABD: Obese, distended, decreased bowel sounds; opens eyes and
becomes agitated with palpation and shaking the bed
EXT: Trace edema bilaterally, lower extremities with 2+ DP
pulses, dry skin
SKIN: Jaundiced
RECTAL: Guaiac + in ED
Pertinent Results:
[**2143-11-22**] 03:50PM WBC-12.7*# RBC-4.12* HGB-12.2* HCT-37.7*
MCV-92 MCH-29.7 MCHC-32.4 RDW-16.2*
[**2143-11-22**] 03:50PM NEUTS-69 BANDS-15* LYMPHS-6* MONOS-4 EOS-1
BASOS-0 ATYPS-0 METAS-5* MYELOS-0
[**2143-11-22**] 03:50PM GLUCOSE-108* UREA N-31* CREAT-2.2*#
SODIUM-125* POTASSIUM-4.3 CHLORIDE-85* TOTAL CO2-17* ANION
GAP-27*
[**2143-11-22**] 03:50PM ALT(SGPT)-58* AST(SGOT)-117* LD(LDH)-256*
CK(CPK)-410* ALK PHOS-689* AMYLASE-10 TOT BILI-13.1*
[**2143-11-22**] 03:50PM cTropnT-0.02*
[**2143-12-5**] 02:50AM BLOOD WBC-9.5 RBC-2.59* Hgb-8.0* Hct-24.8*
MCV-96 MCH-30.9 MCHC-32.3 RDW-19.3* Plt Ct-281
[**2143-12-6**] 02:12PM BLOOD PT-18.5* PTT-46.2* INR(PT)-1.7*
[**2143-12-5**] 02:50AM BLOOD Glucose-149* UreaN-32* Creat-2.6* Na-140
K-3.8 Cl-101 HCO3-26 AnGap-17
[**2143-12-6**] 02:31AM BLOOD ALT-26 AST-59* LD(LDH)-197 CK(CPK)-22*
AlkPhos-371* Amylase-14 TotBili-6.8*
[**2143-12-6**] 02:31AM BLOOD Lipase-36
[**2143-12-6**] 02:31AM BLOOD Albumin-2.3* Calcium-9.1 Phos-3.9 Mg-2.3
[**2143-11-24**] 04:58PM BLOOD Cortsol-35.5*
[**2143-11-24**] 06:19PM BLOOD Cortsol-35.8*
[**2143-11-24**] 06:32PM BLOOD Cortsol-36.3*
[**2143-11-28**] 03:05PM BLOOD Vanco-17.4
[**2143-12-6**] 10:27AM BLOOD Type-ART Temp-37.4 Rates-15/ Tidal V-500
PEEP-5 FiO2-50 pO2-81* pCO2-37 pH-7.26* calTCO2-17* Base XS--9
-ASSIST/CON Intubat-INTUBATED
[**2143-12-6**] 05:19AM BLOOD Lactate-2.7*
.
ABG on admission: 7.13/46/113/16
.
MICROBIOLOGY:
Blood cultures grew Klebsiella and then later Enterococcus
faecium
.
IMAGING/REPORTS:
.
[**2143-10-8**] CBD brushings/cytology: no evidence of malignant cells.
.
Echo [**2143-10-10**]: Preserved global left ventricular systolic
function. Right ventricle appears dilated with probable RV
systolic dysfunction. Mildly dilated thoracic aorta. Limited
study.
EKG: Sinus tachycardia at 107bpm. Q in III. Normal axis, normal
intervals. Wavy baseline. TWF in V1-V3.
.
CT Abd/Pelvis [**2143-10-8**]: 1. 3.5 x 3.5 cm mass in the head of the
pancreas concerning for malignancy. There is approximately 50%
involvement of the SMV circumference. 2. Fatty liver without
evidence of focal lesion.
.
CXR [**2143-11-22**]: 1. Tip of the endotracheal tube is 2 cm from the
carina and may be withdrawn approximately 2 cm for standard
positioning. 2. Apparent widening of the cardiomediastinum
likely secondary to rotation, and can be reassessed once repeat
radiographs are obtained following ET tube repositioning. 3. No
acute process identified.
.
CXR [**2143-11-22**] (line placement): 1. Right IJ in cavoatrial
junction.
2. Otherwise, no change since one hour ago.
Liver US [**11-24**]:
The liver displays no focal masses and unremarkable parenchyma.
Again identified is mild prominence to the extra- hepatic
biliary system measuring approximately 6 mm and large amount of
sludge within the gallbladder. Portal vein is patent with normal
hepatopetal flow. Of note, the recently placed CBD stents were
unable to be visualized by ultrasound.
Non-contrast CT Head [**12-3**]:
Limited study. No acute intracranial hemorrhage or mass effect.
Old lacunar infarct. Please note that MRI is more sensitive for
acute stroke and metastasis.
Renal US [**12-3**]:
Normal renal ultrasound without evidence of hydronephrosis.
Liver US [**12-5**]:
1. Dilated extrahepatic common bile duct, with stent and sludge
seen within. No evidence of intrahepatic biliary ductal
dilatation.
2. Sludge again seen within the gallbladder, without evidence of
acute cholecystitis.
CXR [**12-6**]:
Improved bibasilar atelectasis and bilateral pleural effusions,
now very small.
Brief Hospital Course:
Mr. [**Known lastname **] is a 59yM with pancreatic mass (likely malignant) s/p
CBD stenting in [**2143-4-9**] who presents with abdominal pain,
jaundice, and hypotension, found to have blocked CBD stent with
frank pus. He developed respiratory failure and was treated in
the ICU for septic shock. On [**12-6**], after discussing the matter
with his family, he was made comfort measures only and he passed
away that evening.
# Hypotension/Septic Shock:
Most likely secondary to biliary source. ERCP performed and
re-stented in ICU on arrival, with frank pus behind occluded
stent. Re-ERCP on [**11-24**] after deterioration and re-intubation.
This ERCP showing occluded stent and frank pus. Another stent
placed in parallel. Blood grew klebsiella pneumoniae (2 species,
pan-sensitive), VRE (sensitive only to linezolid). Patient was
put on linezolid and zosyn according to ID recommendations. His
blood pressure was supported with levophed and IV fluids.
Nevertheless, he continued to develop episodes of hypotension
with recurrent fevers on [**12-5**] and [**12-6**]. While awaiting
another repeat ERCP, he continued to deteriorate. After meeting
with the patient's family, the team agreed to withdraw pressors
and provide comfort measures only. He passed away in the
evening of [**12-6**].
#) Respiratory failure:
Intubated in ED secondary to altered mental status, extubated
[**11-23**] and re-intubated [**11-24**] with low bp and rigors. He had
underlying CHF and COPD, and he continued to be difficult to
wean from the vent.
#) Acute on chronic renal failure:
Likely secondary to hypotension (SBP in 50s prior to intubation.
His ACE inhibitor was held and his medications were renally
dosed. He was supported with IV fluids and pressors.
Nevertheless, his Cr continued to increase to 2.9 on the day of
his death.
#) Pancreatic mass:
Patient was deemed a poor surgical candidate. He had no tissue
diagnosis, but given that his CA [**54**]-9 was elevated, there was
high suspicion that the mass represented a malignant process.
#) Mental status.
Unclear if he may have underlying encephalopathy vs delerium
related to critical illness. Poor synthetic function indicates
likely underlying liver abnormality. With upgoing Babinski (?
new [**12-2**]) and slight tremor in upper extremities b/l with
repositioning. No clonus on exam. Head CT negative for acute
process. He was given lactulose empirically.
#) Coagulopathy:
Nutritional vs. liver disease. He received FFP prior to
procedures, and his coagulopathy somewhat increased during his
course.
#) Type 2 Diabetes:
He was alternately treated with insulin gtt and with fixed and
sliding scale insulin for sugar control.
#) CAD:
He was given ASA, and beta blocker was started once his
hypotension resolved. ACE inhibitor was held because of his
renal failure.
Medications on Admission:
- Omeprazole 20mg PO daily
- ASA 81mg PO daily
- Furosemide 40mg daily
- Metoprolol 12.5mg PO BID
- Captopril 25mg PO TID
- Fluoxetine 40mg PO daily
- Colchicine 0.6mg daily
- Lantus 50mg SQ Qam
- Regular Insulin Sliding Scale
- Dilaudid 2-4mg IV Q3H PRN severe pain
- Dilaudid 4mg PO Q3H PRN pain
- Heparin SubQ DVT prophylaxis
- Colace 100mg PO BID
Discharge Medications:
none/deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Possible pancreatic malignancy.
Sepsis
Biliary duct obstruction
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
Completed by:[**2143-12-16**]
|
[
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"403.90",
"412",
"496",
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"724.2",
"576.1",
"593.9",
"038.0",
"157.0",
"414.01",
"518.81",
"585.9",
"338.29",
"785.52",
"250.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"96.04",
"96.71",
"00.14",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9520, 9529
|
6244, 9081
|
329, 353
|
9636, 9647
|
2648, 4033
|
9705, 9746
|
2111, 2129
|
9482, 9497
|
9550, 9615
|
9107, 9459
|
9671, 9682
|
2144, 2629
|
277, 291
|
381, 1501
|
4047, 6221
|
1523, 1802
|
1818, 2095
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,914
| 101,361
|
8885
|
Discharge summary
|
report
|
Admission Date: [**2145-12-1**] Discharge Date: [**2145-12-18**]
Date of Birth: [**2090-11-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Bronchoscopy
lumbar Puncture
History of Present Illness:
Mr. [**Known lastname 3060**] is a 55 year old male with hypertension, type II
diabetes, alcohol abuse, ESLD s/p orthotopic liver transplant in
[**6-/2137**], and severe motor vehicle accident with cervical spinal
fracture and subsequent tracheostomy and PEG tube placement in
[**8-/2145**] who was admitted to [**Hospital3 417**] Hospital from [**Hospital1 15454**] Rehabilitation Facility on [**2145-11-21**] for evaluation
of fevers. History is taking exclusively per notes. Per notes,
he spiked a fever to 104.5 degrees on the day of presentation
and was initially tachycardic and hypotensive and was initially
started on doripenem. Upon arrival to the emergency room at OSH,
he was no longer hypotensive but was persistently tachycardic.
In the emergency room his initial vitals were T: 103.8, HR 127
RR: 20 BP: 113/69 O2: 100% on ventilator. Initial WBC count was
7.3, Hct 25, creatinine 1.85, AST of 61. UA with 10-20 RBCs, [**3-10**]
WBCs. He received IVF and was admitted to the medical ICU. While
in the ICU it appears that he had a broad infectious workup.
Initial blood and urine cultures were negative. He was c. diff
negative. Sinus cultures from [**2145-11-21**] and endotracheal washings
from [**11-24**] grew acinetobacter sensitive to tobramycin, amkacin
and bactrim and he was started on amikacin from [**2145-11-21**] and
received this until [**2145-11-30**]. G-tube cultures [**2145-11-25**] with
enterobacter, enterococcus and mixed gram negative rods. He had
a non-contrast head CT which showed sinus disease but was
otherwise negative. CT of the abdomen without contrast did not
show evidence of abscess. CT chest showed a possible hazy right
sided infiltrate. Gallium scan showed uptake in areas of known
fractures and in the tracheostomy and PEG tube sites. He
continued to spike fevers as high as 106 degrees despite broad
spectrum antibiotics. He was also persistently tachycardic as
high as the 170s which they were treating with metoprolol. He
received amikacin as above, with a short period of levofloxacin
and micafungin early in his hospitalization. All antibiotics it
appears were discontinued on [**11-30**] after no fever source was
identified but he continued to spike fevers and was started on
vancomycin and cefepime on [**12-1**]. Final blood cultures from
[**11-30**] are now 4/4 bottles with gram negative rods, not yet
speciated.
Was transfered to [**Hospital1 18**] for further w/u and management
.
Unable to obtain review of systems secondary to mental status
Past Medical History:
Alcoholic Cirrhosis s/p orthotopic liver transplant [**2137-6-11**] (last
seen in transplant center in 5/[**2143**]). Per notes he had a liver
biopsy in [**9-14**] which showed early chronic rejection
Alcohol Abuse with relapse in [**2141**]. History of DTs in the past
Type II Diabetes
Pancytopenia following liver transplant thought to be secondary
to immunosuppressive medications
Hyperlipidemia
Hypertension
Motor Vehicle Accident with multiple injuries [**8-13**] (C6-C7 facet
fractures s/p corpectomy, C7-T1 anterior cervical fusion and
C5-T2 posterior cervical depression fusion, left mandibular
fracture, left wrist fracture s/p ORIF, multiple rib fractures,
right clavicular fracture, mediastinal hematoma, small
pericardial effusion, asysolic arrest for 5 minutes)
Social History:
Currently living at [**Hospital1 **] LTAC. Remote smoking
history. Past alcohol abuse, currently not drinking. No IVDU.
Wife died after fall in the setting of longstanding alcohol
abuse, daughter died in the car accident this summer, son has
substance abuse issues but is health care proxy.
Family History:
Noncontributory.
Physical Exam:
Vitals: Tm 100.4 97 120/90-->90/60s 120 100% on 35%FM
Pain: unknown-nonverbal, no grimacing
Access: RUE PICC [**12-3**]
Gen: chronically ill, diaphoretic
HEENT: trach site clean
CV: tachy, regular, no m
Resp: scattered rhonchi, mostly clear, poor effort
Abd; soft, no grimacing, PEG tube, +BS, foley yellow urine
Ext; no edema
Neuro: baseline nonverbal, blinks to command, contractures UE/LE
Skin: b/l lateral feet with deep erythematous area with
darkened center(blood blister vs deep tissue injury), no skin
breakdown
Pertinent Results:
Other labs/interpretation:
no leukocytosis
Hgb stable [**8-14**]
Chem panel remarkable for rising BUN 38 today, creat 1.0
Tobra 14.6 [**12-15**]
.
UA [**12-11**] negative
Sputum cx [**12-6**] mod acenitobacter, sparse pseudomonas, proteus,
klebsiella
BAL [**12-11**]: mod acenitobacter, sparse pseudomonas.
LP negative cx
.
Imaging/results:
EEG [**12-16**] prelim: diffuse encephelopathy, no seizures
.
.
cxr [**12-14**]
In comparison with the study of [**12-12**], there has been decrease in
lung volumes. Some prominence of ill-defined pulmonary vessels
persists,suggesting continued pulmonary vascular congestion.
Poor definition of the left hemidiaphragm could reflect
atelectasis and small pleural effusion. No evidence of acute
focal pneumonia.
.
[**12-7**] CT chest
IMPRESSION:
1. Right upper lobe collapse due to obstruction of the right
upper lobe bronchus with secretions; nonobstructive left lower
lobe collapse.
2. Bilateral nonhemorrhagic pleural effusions, more marked on
the right with dependent right lung base atelectasis.
3. Small pericardial effusion.
4. Aortic annulus, aortic valve, and coronary artery
calcifications.
5. Multiple old fractures and fixation hardware in the
ervicothoracic spine from previous trauma.
.
.
CHEST (PORTABLE AP) Study Date of [**2145-12-1**] 7:19 PM
IMPRESSION: Perihilar opacities, raising question of early CHF.
Multiple rib fractures and right clavicle fracture. No
pneumothorax detected. Patchy opacity at the left base, question
atelectasis versus early infiltrate.
.
FOOT 2 VIEWS RIGHT PORT Study Date of [**2145-12-1**] 11:28 PM
IMPRESSION:
Somewhat limited exam, but no findings to confirm the presence
of
osteomyelitis
.
CT ABDOMEN W/O CONTRAST Study Date of [**2145-12-2**] 2:44 AM
IMPRESSION:
1. No acute pathology is identified in the abdomen and pelvis to
explain the patient's symptoms. No abscess cavity is identified.
2. Mild bibasilar atelectasis.
3. Unchanged calcified hepatic lesion in the interlobar fissure.
.
TTE (Complete) Done [**2145-12-3**] at 11:27:07 AM FINAL
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened. No masses or vegetations are seen
on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. There is no aortic valve stenosis. 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 estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No vegetations found.
Normal overall left ventricular systolic function. If clinically
suggested, the absence of a vegetation by 2D echocardiography
does not exclude endocarditis.
Compared with the report of the prior study (images unavailable
for review) of [**2137-5-21**], there is no significant change
Brief Hospital Course:
55 year old male with DM, ETOH abuse/cirrhosis s/p OLT [**6-/2137**] c/b
chronic rejection, ETOH related MVA [**8-13**], complicated course,
now anoxic brain injury s/p trach/PEG admitted from extended
care facility->OSH [**11-21**]-->[**Hospital1 18**] [**Hospital Unit Name 153**] [**11-30**] for persistant
fevers, presumed pulm source, stable on Abx, now on Gen Med [**12-14**]
awaiting placement. Complicated patient, please see progress
note below that details his plan per problem:
.
.
Sepsis/fevers: Blood cx/Urine Cx here all negative. Imaging so
far has been unrevealing and has included abdominal CT without
contrast, head CT (sinus disease) and chest CT. TTE negative for
gross endocarditis. LP was performed after several Abx, but Cx
negative after. Gallium scan also not revealing. ID following,
Presumed source likely pulmonary, OSH enterobacter bacteremia
(?source), here sputum/BAL with acenitobacter/pseudomonas/
klebsiella/ proteus -->trancheobronchitis vs HCAP. No open skin
lesions. no diarrhea. UA negative. Afebrile for >48hours, only
low grade temps likely [**2-6**] atelectasis from thick mucous.
-cont IV Tobramycin 100mg IV q12 (adjust dose c level) and
Meropenem until [**12-22**] (10day course), finally defervesced with
addition of Tobra. note, will send to LTAC on ertapenum (cost
issue), got one dose here and tolerated.
- blood cx here negative to date
-aggressive Chest PT, frequent suctioning, mucomyst nebs for
thick secretions
-ID signed off, reconsult if fevers.
.
.
Altered Mental Status/Encephelopathy: we do not have a clear
baseline for this patient with anoxic brain injury. Exams here
have been inconsistent by neuro and ID. Per neuro, severe
baseline anoxic injury with toxic/metabolic encephalopathy. ID
reports a few instances where pt was more interactive. multiple
RF for seizures (tacrolimus, carbepenem abx, baseline anoxic
injury) but none clinically obvious and EEG on [**12-16**] c/w
encephlopathy (prelim), no seizures.
-encephalopathy is likely from diffuse axonal damage (anoxic
injury) but worse with acute infection, multiple meds, etc.
-would be great to have pt seen by his prior caregivers
(neurologists, nurses, doctors) to know what his baseline was
previously
-plan will be for neuro f/u in 2-3weeks after discharge (at
LTAC), can reeval at that time.
.
.
Tachycardia: sinus tachy. some degree volume depletion
(insensible losses with sweats) since BP also low when tachy
worse. Also worse when low grade fevers. Was on albuterol,
stopped today. note, echo [**11-13**] normal EF/function
-small IVFs prn tachy >115 and SBP<100. Cant give continuous
IVF [**2-6**] pulm edema on CXR.
-no albuterol. tylenol for fevers.
.
.
Wound: b/l feet with deep erythema, pressure ulcer/Deep tissue
injury. per staff, has been STABLE since admission to [**Hospital Unit Name 153**].
-appreciate wound care reccommendations, boots
.
.
Acute on Chronic Respiratory Failure: Patient required vent
support for few days in setting of likely
pneumonia/tracheobronchitis and possible volume overload. Now
improved, on trach mask 35%.
- wean O2 as tolerated, agressive pulm toilet, frequent
suctioning, cont mucomyst nebs
- treat infection as above
-CXR suggesing pulm edema but intravascularly depleted
(hypotension/tachy/elevated BUN) so cannot do now
.
.
Acute Renal Failure - Resolved, likely secondary to sepsis on
initial presentation
- monitor, BUN has been going up, gets IVFs boluses prn, 1L
today. Monitor closely for volume depletion.
.
.
ESLD s/p orthotopic transplant: Patient seen by Hepatology this
admission. Recommendation was goal levels in high 3s.
Recommendation to check once weekly
- tacro level 1.7 [**12-15**] (low). increased tacro to home dose of
2mg [**Hospital1 **].
- LFTs normal
.
.
Diabetes II, controlled without complication:
- continue lantus 28 U with sliding scale
.
.
Anoxic brain injury: as above, unsure about baseline MS (see
above), noncommunicative currently. decorticate posturing. s/p
trach/PEG. Contractures. Pressure ulcers. EEG c/w enceph
-cont baclofen 10mg tid (increased dose [**2-6**] frequent spasm)
fentanyl patch 50mcg q72, roxicodone 5mg q4prn (likely
confounding proper neuro MS [**Last Name (Titles) **])
-tube feeds as tolerated, bowel regimen
-turn q2, wound care, physical therapy for ROM
.
.
Hypertension: Blood pressures currently in high 90s not on any
anti-hypertensive
- hold outpatient Lopressor
- receiving feeds/fluids, bolus PRN
.
.
FEN/proph: 1L IVF today, small boluses prn, monitor lytes, Tube
feeds with free water flushes, TEDs/SCDs, heparin tid, PPI,
bowel regimen, wound care
.
.
Dispo: transfering to LTAC
Code: Full per current proxy/guardian
.
Communication:
Son/guardian, [**Name (NI) **] [**Telephone/Fax (1) 30916**], has not been reachable
Sister: [**Name (NI) **] [**Name (NI) 7716**] [**Telephone/Fax (3) 30917**], working on
guardianship
[**Name (NI) 30918**]: [**Name (NI) **] [**Name (NI) 30919**] ([**Telephone/Fax (1) 30920**] cell ([**Telephone/Fax (1) 30921**]
Medications on Admission:
Lactulose 20 grams daily per G tube
Heparin SC
Nexium 40 mg daily
Haldol 10 mg Q4H:PRN
Lopressor 25 mg PO Q8H
Baclofen 5 mg PO TID
Tylenol 650 mg PO Q4H:PRN
Roxicodone 5 mg PO Q4H:PRN
Miconazole powder
Morphine 2 mg IV Q1H:PRN
Regular insulin sliding scale
Atrovent inhaler 6 puffs Q6H
Prograf 2 mg PO BID
Levemir 28 units QHS
Free water flushes 250 mL Q6H
Vancomycin 1 gram IV Q18 hours
Ceftazidime 2 grams IV Q12H
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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection twice a day.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
8. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours).
10. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
13. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Levemir 100 unit/mL Solution Sig: 28 Units Subcutaneous at
bedtime.
15. Insulin Regular Human 100 unit/mL Cartridge Sig: per sliding
scale Injection three times a day.
16. Tobramycin Sulfate 60 mg/6 mL Solution Sig: 100mg
Intravenous every twelve (12) hours for 5 days: until [**12-22**].
17. Ertapenem 1 gram Recon Soln Sig: 1gram Intravenous every
twenty-four(24) hours for 5 days: until [**12-22**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Fevers
tracheobronchitis vs HCAP/VAP
Acute renal failure
Discharge Condition:
STABLE
Discharge Instructions:
Admitted with fevers, likely tracheobronchitis vs PNA, on
antibiotics (tobramycin/ertapenum) until [**12-22**]
Followup Instructions:
please f/u PCP Dr, [**Name9 (PRE) **] in 2weeks. Please f/u neurology in
2weeks
|
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icd9cm
|
[
[
[]
]
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[
"99.21",
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icd9pcs
|
[
[
[]
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14891, 14963
|
7853, 12858
|
324, 354
|
15064, 15073
|
4592, 7830
|
15233, 15316
|
4015, 4033
|
13325, 14868
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14984, 15043
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12884, 13302
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15097, 15210
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4048, 4573
|
278, 286
|
382, 2889
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2911, 3688
|
3704, 3999
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,188
| 147,137
|
4052+55535
|
Discharge summary
|
report+addendum
|
Admission Date: [**2152-1-13**] Discharge Date: [**2152-1-21**]
Date of Birth: [**2083-10-19**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Fever and Cough
Major Surgical or Invasive Procedure:
Intubation [**2152-1-13**]
Axillary a-line
RIJ CVL
Bronchoscopy
History of Present Illness:
This is a 68 year-old female with a history of DM2, HTN, CAD s/p
angioplasty, multiple vascular bypass procedures who presents
with weakness, cough, nausea and vomiting x 3-4 days. The
patient lives in a senior residence with her own provide
apartment. Her great-granddaughter has had a viral URI per the
family. The family reports that she has been hving fevers to
102, decreased energy and nausea and vomiting. Her po intake
has been severely decreased due to her vomiting. Additionally,
the patient's breathing has also progressively worsened. The
family reports that she was difficulty speaking to them. She
was pale and just "didn't look well" so they brought her to the
ED. No recent travel or hospitalizations.
.
In the ED, 95.8 HR:63 BP:89/50 now 100/60 Resp:20 O(2)Sat:100.
The patient was hypotensive and received a total of 6L in the ED
with improvedment with SBP in the 90-100's. She was given CTX,
Levoflox and Tamiflu. Additionally, she was given abuterol neb.
Her CXR showed left mid and right lower lung fields in chest
x-ray. She developed worsening work of breathing, with belly
breathing and severe SOB. She was intubated in the ED and then
sent to the MICU
Past Medical History:
coronary artery disease with an angioplasty
type 2 diabetes on oral agents,
hypertension
hypercholesterolemia.
Past Surgical History:
Multiple bypass vascular procedures:
s/p left retroperitoneal to left femoral with left vein graft on
[**2147-2-24**].
s/p thrombectomy of right axillo-femoral-femoral graft on [**11-18**]
s/p Aorto-bifem [**3-/2141**] excision of infected aorto-[**Hospital1 **]-femoral graft
in [**9-18**]
s/p right axillofemoral to left profunda bypass 10/[**2145**].
Social History:
She lives in a senior living complex alone. Smokes 1.5ppd x 45
years, no EtoH
Family History:
NC
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: intubated and sedated
HEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry,
COR: RRR, no M/G/R, normal S1 S2,
PULM: Lungs coarse rhonchi and occasional wheezes
ABD: Soft, NT, ND, +BS,
EXT: No C/C/E,
Pertinent Results:
[**2152-1-13**] 12:15PM BLOOD WBC-11.9* RBC-4.51# Hgb-13.7# Hct-40.3#
MCV-89 MCH-30.4 MCHC-34.0 RDW-12.2 Plt Ct-227
[**2152-1-14**] 06:23AM BLOOD WBC-7.5 RBC-3.63* Hgb-10.5* Hct-33.4*
MCV-92 MCH-28.9 MCHC-31.4 RDW-11.9 Plt Ct-180
[**2152-1-20**] 06:25AM BLOOD WBC-12.8* RBC-3.84* Hgb-11.3* Hct-34.2*
MCV-89 MCH-29.5 MCHC-33.1 RDW-12.3 Plt Ct-272
[**2152-1-21**] 05:58AM BLOOD WBC-10.4 RBC-3.94* Hgb-11.3* Hct-35.4*
MCV-90 MCH-28.7 MCHC-32.0 RDW-12.1 Plt Ct-253
[**2152-1-13**] 12:15PM BLOOD Neuts-78.4* Lymphs-14.5* Monos-6.2
Eos-0.6 Baso-0.2
[**2152-1-17**] 04:01AM BLOOD PT-12.2 PTT-24.2 INR(PT)-1.0
[**2152-1-13**] 12:15PM BLOOD Glucose-240* UreaN-31* Creat-1.1 Na-138
K-4.0 Cl-101 HCO3-24 AnGap-17
[**2152-1-14**] 06:23AM BLOOD Glucose-250* UreaN-25* Creat-1.0 Na-139
K-4.0 Cl-111* HCO3-19* AnGap-13
[**2152-1-20**] 06:25AM BLOOD Glucose-140* UreaN-28* Creat-1.0 Na-143
K-3.3 Cl-99 HCO3-35* AnGap-12
[**2152-1-21**] 05:58AM BLOOD Glucose-118* UreaN-40* Creat-1.1 Na-142
K-3.4 Cl-99 HCO3-34* AnGap-12
[**2152-1-13**] 12:15PM BLOOD ALT-13 AST-19 LD(LDH)-243 CK(CPK)-49
AlkPhos-61 TotBili-0.3
[**2152-1-13**] 12:15PM BLOOD CK-MB-NotDone
[**2152-1-13**] 12:15PM BLOOD cTropnT-<0.01
[**2152-1-14**] 06:23AM BLOOD CK-MB-4 cTropnT-<0.01
[**2152-1-13**] 11:25PM BLOOD Calcium-6.9* Phos-3.3 Mg-1.4*
[**2152-1-14**] 06:23AM BLOOD Calcium-7.5* Phos-2.3* Mg-2.0
[**2152-1-20**] 06:25AM BLOOD Calcium-9.5 Phos-3.5 Mg-1.6
[**2152-1-21**] 05:58AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.6
[**2152-1-13**] 12:15PM BLOOD Lactate-2.5*
[**2152-1-13**] 02:17PM BLOOD Lactate-1.7
[**2152-1-13**] 11:37PM BLOOD Lactate-0.6
[**2152-1-13**] 03:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024
[**2152-1-13**] 03:50PM URINE Blood-NEG Nitrite-NEG Protein-500
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2152-1-13**] 03:50PM URINE RBC-0-2 WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2152-1-13**] 03:50PM URINE CastHy-[**5-25**]*
[**2152-1-17**] 03:20PM OTHER BODY FLUID Polys-96* Lymphs-2* Monos-1*
Mesothe-1*
[**2152-1-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2152-1-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2152-1-17**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL
[**2152-1-17**] BRONCHIAL WASHINGS GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; POTASSIUM HYDROXIDE PREPARATION-FINAL; FUNGAL
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY
[**2152-1-17**] BRONCHIAL WASHINGS GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL
[**2152-1-14**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL
[**2152-1-14**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL; Respiratory
Viral Culture-FINAL
[**2152-1-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
[**2152-1-13**] MRSA SCREEN MRSA SCREEN-FINAL
[**2152-1-13**] URINE Legionella Urinary Antigen -FINAL
[**2152-1-13**] BLOOD CULTURE Blood Culture, Routine FINAL
[**2152-1-13**] BLOOD CULTURE Blood Culture, Routine FINAL
Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-1-13**]
12:06 PM
UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette is normal
in size. The
mediastinal and hilar contours are within normal limits. The
right internal
jugular central venous catheter has been removed. There are
subtle focal
airspace opacities projecting over the left mid lung field as
well as the
right lower lung field, which could represent sites of
infection. There is no
pleural effusion or pneumothorax seen. The pulmonary vascularity
is within
normal limits. No acute skeletal abnormalities are present.
IMPRESSION: Ill-defined focal opacities within the left mid and
right lower
lung fields, which could infection.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Portable TTE (Complete) Done [**2152-1-14**] at 10:11:51 AM FINAL
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.1 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 116 ml/beat
Left Ventricle - Cardiac Output: 7.09 L/min
Left Ventricle - Cardiac Index: 3.71 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 14 < 15
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 37
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 1.5 m/sec
Mitral Valve - E/A ratio: 0.80
Findings
This study was compared to the report of the prior study (images
not available) of [**2146-10-30**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Moderate regional LV systolic dysfunction. Estimated cardiac
index is normal (>=2.5L/min/m2). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR. [Due to acoustic shadowing, the severity of MR may be
significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
focal basal inferior hypokinesis, where the myocardium is also
slightly thinned. The remaining segments contract normally (LVEF
= 50-55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. 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 mildly
thickened. Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Mild focal left ventricular systolic dysfunction,
c/w prior inferior infarction.
Compared with the report of the prior study (images unavailable
for review) of [**2146-10-30**], basal inferior hypokinesis is seen.
The other findings appear similar.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2152-1-15**]
9:03 PM
There is no evidence of hemorrhage, edema, masses, mass effect,
or acute
infarction. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
The
ventricles and sulci are normal in caliber and configuration.
Note is made of
atherosclerotic calcification in the bilateral internal carotid
arteries and
vertebral arteries. No acute fracture. The mastoid air cells are
completely
opacified bilaterally, there is opacification of the right
middle ear, and
mild partial opacification of the left maxillary sinus and
ethmoid air cells.
The left middle ear is not well evaluated on this study.
IMPRESSION: No acute intracranial process. Bilateral mastoid air
cell
opacification and right middle ear opacification. These changes
may reflect
chronic inflammation, but the possibility of more acute
infection cannot be
excluded.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Date
[**2152-1-16**]
CT OF THE CHEST WITH IV CONTRAST: Coronary artery calcifications
are noted.
The heart and pericardium are otherwise unremarkable, without
pericardial
effusion. Atherosclerotic calcifications of the thoracic aorta
are also
noted. There is no evidence for pulmonary embolism.
There is centrilobular emphysema. There is left hilar fullness
with vague
suggestion of hilar adenopathy or mass. There is associated
airspace
consolidation of the left upper lobe posteriorly, which may
reflect
post-obstructive pneumonia. Scattered nodules along a
peribronchovascular
distribution within the right lower and right upper lobes may be
infectious or
inflammatory. Small bilateral pleural effusions with associated
atelectasis of
the adjacent lung are noted.
Additionally, there are scattered nodules, with an irregular
nodular opacity
in the right upper lobe (3:30). A 5-mm nodule is present within
the right
middle lobe (3:67), and a 4-mm ground-glass nodule in the left
upper lobe
(2:30). These findings are of indeterminate chronicity. An NG
tube is in
stomach. An endotracheal tube tip terminates approximately 4.5
cm from the
carina.
Limited views of the upper abdomen reveal a trace amount of
perihepatic free
fluid.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions
identified.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Left hilar fullness with vague suggestion of hilar adenopathy
or mass.
Associated left upper lobe consolidation may reflect
post-obstructive
pneumonia.
3. Small bilateral pleural effusions, with associated
atelectasis of the
adjacent lung.
4. Scattered peribronchiolar nodular opacities in the right
upper and right
lower lobes, may be infectious or inflammatory.
5. Bilateral pulmonary nodules as detailed, comparison to prior
studies
suggested.
Brief Hospital Course:
Assesment: This is a 68 year-old female with a history of DM2,
HTN, CAD s/p angioplasty, multiple vascular bypass procedures
who presents with pneumonia, hypotension and respiratory
distress, worsening overnight.
#. Respiratory Failure / ARDS: The patient had fever, cough, SOB
x 3 days prior to admission. She also reported poor po intake
and N/V. The family brought the patient to the ED and initial
vital signs were 95.8 HR:63 BP:89/50. The patient was
hypotensive and received a total of 6L in the ED with
improvement with SBP in the 90-100's. She was given CTX,
Levoflox and Tamiflu. Additionally, she was given abuterol neb.
Her CXR showed left mid and right lower lung fields in chest
x-ray. She developed worsening work of breathing, with belly
breathing and severe SOB. She was intubated in the ED and then
sent to the MICU. The patient was started on solumedrol 125mg
and q1 albuterol nebs. The patient was initially on levophed
for hypotension, but was able to be weaned off within 24hrs.
She also required ~11L of IVF. CXR showed b/l opacities and
underwent CT-scan of her chest that showed possible left upper
lobe mass. She underwent bronchoscopy on [**2152-1-17**] and findings
were concerning for malignancy. The patient respiratory status
improved with diuresis, abx and COPD treatment. The patient's
viral culture, legionella antigen were negative and given
improvement in CXR and CT-scan findings her treatment was
narrowed to levofloxacin for a planned 14 day course. The
patient was successfully extubated on [**1-18**] and weaned to nasal
canula. She was subsequently transfered to the medicine floor in
stable condition. She was continued on levofloxacin and
sucessfully weaned off O2 with sats in the mid 90s% range. She
was discharged with instructions as prescriptions to finish a 14
day course of levofloxacin and a fast steroid taper.
.
#. HTN: Patient with initial hypotension as above requiring IVF
and levophed. It was subsequently weaned off and the patient
became hypertensive. She was started on IV hydral and restarted
on her oral regimen of amlodipine 10mg, clonidine 0.2 [**Hospital1 **], HCTZ
12.5 and lisinopril 20mg daily. She also required a nitro gtt
that was weaned off on [**1-19**]. She had good control of her HTN
after being transfered to the medical floor.
.
#. Pulmonary Nodules: CTA showed multiple small pulmonary
nodules. She underwent bronchoscopy on [**2152-1-17**] and findings were
concerning for malignancy. Repeat bronchoscopy, to better
evaluate for malignancy, was planned as an inpatient initially
but given that she was taking aspirin this had to be delayed.
She was discharged with an appoinment for a bronchoscopy as an
outpatient.
Medications on Admission:
Glyburide 20mg daily
Metformin 2000mg daily
Amlopdipine 10mg daily
Lisinopril/HCTZ 20/12.5 daily
Vytorin 10/80mg daily
Coreg CR 40mg daily
clonidine 0.2mg [**Hospital1 **]
Tricor 145mg daily
ASA 325mg daily
Discharge Medications:
1. Lisinopril-Hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
6 days: please take for 6 more days (until [**2152-1-27**]).
Disp:*6 Tablet(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO daily () for 1
days: take on [**1-22**] only.
Disp:*2 Tablet(s)* Refills:*0*
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 3
days: take on [**1-24**], and [**1-25**].
Disp:*3 Tablet(s)* Refills:*0*
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 3
days: take on [**2-14**], and [**1-28**].
Disp:*3 Tablet(s)* Refills:*0*
9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
10. Vytorin [**9-/2122**] 10-80 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Coreg CR 40 mg Cap, Multiphasic Release 24 hr Sig: One (1)
Cap, Multiphasic Release 24 hr PO once a day.
12. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
14. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
15. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
Disp:*360 Tablet(s)* Refills:*0*
16. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
inh Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Disp:*1 month supply* Refills:*0*
18. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) inhalation Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 month supply* Refills:*0*
19. Home oxygen
Continuous via nasal Cannula 2L/min. Pulse Dose for Portability.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Community acquired pneumonia
2. Lung mass
3. Acute Chronic Obstructive Pulmonary Disease Exacerbation
4. Hypertension
5. Diabetes Mellitus
SECONDARY DIAGNOSIS:
1. Coronary artery disease
2. Hypercholesterolemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
2L oxygen requirement with walking
Discharge Instructions:
You were admitted to the hospital and spent time in the ICU with
a severe pneumonia. You will need to take an antibiotic called
levaquin until [**2152-1-27**] for this pneumonia. You will also need to
take steroids as listed. Incidentally, we found that you also
had a mass in your lungs. We will need to take a better look
with a bronchoscopy (a small camera into the lungs), which you
will have done as an outpatient. That will give us a better idea
of what this mass in the lungs might be.
You also had high blood pressure while you were here, so please
follow the medication changes below.
As we discussed STOP SMOKING. It is the best thing you can do
for your health right now! You can do it! You are being given a
nicotine patch to help you with this.
The following changes have been made to your medicines:
1. Start taking hydralazine three times a day
2. Increase your clonidine from twice a day to three times a day
3. Start taking prednisone as prescribed
4. Start taking levaquin until [**2152-1-27**] (this is an antibiotic
for pneumonia)
5. Start taking ipratropium and albuterol inhalers as needed.
Followup Instructions:
You will have an outpatient bronchoscopy on Wednesday, [**2152-1-26**]
with Dr. [**Last Name (STitle) **]. You have an appointment at 9am in the Chest
Disease Center on [**Hospital Ward Name 121**] 1 at [**Hospital1 18**]. Dr. [**Last Name (STitle) **] will then see you
for an appointment at 10am that same day.
**We checked with the lung doctors and they [**Name5 (PTitle) **] its okay to
continue your aspirin before the bronchoscopy**
Please see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on [**2152-2-16**] at 2:15pm. Your PCP's
office was closed when we tried to schedule this appointment,
but they will contact you on [**Name (NI) 766**] if there is an earlier
appointment available. You should also call on [**Name (NI) 766**] if they do
not contact you. The phone number is [**0-0-**].
You will need a Chest Xray in 4 weeks, to be followed up by your
lung doctors.
You had multiple small lung nodules on CT-scan. A follow-up
Chest CT in 3 months is recommended.
Name: [**Known lastname 2836**],[**Known firstname 1940**] Unit No: [**Numeric Identifier 2837**]
Admission Date: [**2152-1-13**] Discharge Date: [**2152-1-21**]
Date of Birth: [**2083-10-19**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2838**]
Addendum:
#. Respiratory Failure / ARDS Correction: Patient was discharged
on 2L/m NC not off O2.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) 499**] [**Last Name (NamePattern4) 2839**] MD [**MD Number(1) 2840**]
Completed by:[**2152-1-28**]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,635
| 145,553
|
22813
|
Discharge summary
|
report
|
Admission Date: [**2171-1-9**] Discharge Date: [**2171-1-11**]
Date of Birth: [**2114-3-31**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 y/o female with interstitial lung disease presents with
mildly productive cough, low grade fever, and chills over [**3-16**]
days. Associated worsening of DOE and chest tightness with
severe limitation of activity. Cough is several times per day,
productive of yellow sputum. She denies headache, myalgias, or
high fevers. She had her flu shot this year. She denies sick
contacts.
.
Review of systems positive for orthopnea and DOE. Also stress
incontinance. Denies history of MI or CHF. No diarreha or
constipation, no dysuria or frequent urination, no arthralgias.
.
Age appropriate cancer screening with mamogram, colonoscopy, pap
up to date.
Past Medical History:
1. Interstitial Lung Disease (Sarcoidosis vs. Hypersensitivity
Pneumonitis)- Granulomas on Liver Biopsy and by Lung Biopsy in
[**3-/2169**] as well as interstital lung disease evident on Chest
imaging. RAST and IgE testing in in [**4-/2169**] and [**8-/2169**] were
negative for hypersensitivity Pneumonitis. [**Year (4 digits) 1570**]'s [**2170-11-27**] FEV1
1.62 L (62% pred)
FEV 1/FVC ratio 82 (109% pred)DSB 4.76 ( 24% pred)
2. Moderate pulmonary hypertension: Diagnosed by Echo with PA
systolic estimated at 44 mm Hg
3. HTN- for many years, treated with antihypertensives
4. [**Doctor Last Name 933**] disease S/P thyroidectomy, on Thyroxine
5. Ulcerative [**Name (NI) 1866**] unclear how diagnosed
Social History:
Worked in chemical lab for many years. No other exposures.
Married. Remote history of smoking- very mild. Daily alcohol
use- several glasses of wine per day. No drug use.
Family History:
Negative for sarcoidosis, asthma, cancer.
[**Name (NI) 58979**] mother and brother at early ages- both smokers.
Mother died age 61, brother dx in his 40's.
Physical Exam:
Vitals: T 96 BP133/77 HR 106 RR 27 Sat 96% on 6L trach cannula
Cushingoid, pletheric appearance, duskiness of lips and upper
body with desaturations
Noraml inspiratory and expiratory ratio, enhanced breath sounds,
no rales, rhonchi or wheezes
Irregularly irregular, tachycardiac pulse, no murmurs
Obese abdomen with good bowel sounds and no tenderness
Clubbing of digits, no cyanosis at rest, good peripheral pulses
Pertinent Results:
[**2171-1-9**] 04:00PM PT-60.8* PTT-41.7* INR(PT)-7.5*
[**2171-1-9**] 04:00PM PLT COUNT-264#
[**2171-1-9**] 04:00PM MACROCYT-3+
[**2171-1-9**] 04:00PM NEUTS-91.9* LYMPHS-3.9* MONOS-3.1 EOS-1.0
BASOS-0
[**2171-1-9**] 04:00PM WBC-11.2*# RBC-3.78* HGB-13.7 HCT-39.7
MCV-105*# MCH-36.4* MCHC-34.6 RDW-15.2
[**2171-1-9**] 04:00PM CALCIUM-9.6 PHOSPHATE-4.0 MAGNESIUM-2.2
[**2171-1-9**] 04:00PM CK-MB-NotDone cTropnT-<0.01
[**2171-1-9**] 04:00PM CK(CPK)-49
[**2171-1-9**] 04:00PM estGFR-Using this
[**2171-1-9**] 04:00PM GLUCOSE-122* UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
[**2171-1-9**] 04:25PM LACTATE-2.6*
.
[**1-9**] CXR PA & LAT: IMPRESSION: Diffuse interstitial changes
with fibrosis, similar in appearance to previous examinations,
and consistent with history of sarcoidosis. No acute change
identified.
.
[**1-10**] Echo: Conclusions:
The cardiac rhythm is atrial fibrillation with a mean
ventricular rate of
110-120 beats per minute. The left atrium is moderately dilated.
The right atrium is moderately dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. No masses or thrombi are seen in the
left ventricle. Overall left ventricular ejection fraction is
low normal (LVEF 50%), probably secondary to atrial
fibrillation. 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 leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**2-12**]+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Ms. [**Known lastname **] is a 56 y/o female with interstitial lung disease
presents with dyspnea and productive cough, likely bronchitis vs
PNA. Her brief hospital course, by problem:
.
# Bronchitis vs. PNA: CXR showed possible infiltrate. She was
treated with Ceftriaxone and azithromycin for two days, then
sent home on Levaquin 500mg QD.
.
# Dyspnea: On home O2 at 2-4 L by tracheal cannula. She
tolerated 6L on transtracheal catheter throughout her admission.
.
# Elevated WBC count: Considered to be steroids vs. stress
reaction vs. infection. Elevated neutrophils on diff without
left shift. A possible pneumonia was treated, cultures were
negative to date, and her WBC decreased by the time of
discharge.
.
# AFib: On EKG and exam. Her beta blocker dosage was changed
from atenolol [**Hospital1 **] to metoprolol 150mg [**Hospital1 **]. Her coumadin was
held; at the time of discharge, it had decreased to 3.5, and she
was instructed to start again the day after discharge and have
it followed up three days after discharge.
.
# HTN: Blood pressure under good control. Atenolol was changed
to metoprolol and increased. She received one day's worth of
diltiazem 30mg QID, but it was discontinued at discharge with
close outpatient follow up.
# Macrocytosis: On B12 and folate. Positive alcohol history.
.
# S/P Thyroidectomy. Levothyroxine was continued.
.
# F/E/N: Heart healthy diet, protonix continued,
supratherapeutic INR, insulin sliding scale while on prednisone
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
2. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Methotrexate 2.5 mg Tablet Sig: Six (6) Tablet PO 1X/WEEK
(SA).
10. Lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every
4 to 6 hours) as needed for anxiety.
11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Actiq Buccal
13. Albuterol Sulfate Inhalation
14. Robitussin-DM Oral
15. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
twice a day.
Disp:*180 Tablet(s)* Refills:*2*
16. Coumadin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: Take
2.5-5.0mg every other day for blood clots.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper respiratory infection
Discharge Condition:
Stable
Discharge Instructions:
Please take all of your medications as prescribed. If you
experience sudden worsening shortness of breath, chest pain,
fever, or other concerning symptoms, please seek medical
attention immediately.
You should restart your Coumadin tomorrow. Please take 2.5mg on
Saturday and 2.5mg on Sunday, and have your blood checked on
Monday.
We changed one of your blood pressure medications from atenolol
to metoprolol. You should follow up with your primary care
doctor for a blood pressure follow up.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2171-2-12**] 8:30
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2171-2-12**] 8:30
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2171-2-12**] 9:00
You should also call the lung transplant program at [**Hospital1 2025**].
|
[
"515",
"427.31",
"401.9",
"424.0",
"416.8",
"556.9",
"486",
"397.0",
"135"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7335, 7341
|
4538, 6019
|
280, 287
|
7413, 7422
|
2506, 4515
|
7966, 8431
|
1896, 2053
|
6042, 7312
|
7362, 7392
|
7446, 7943
|
2068, 2487
|
233, 242
|
315, 965
|
987, 1692
|
1708, 1880
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,503
| 144,657
|
22272
|
Discharge summary
|
report
|
Admission Date: [**2154-6-19**] Discharge Date: [**2154-6-27**]
Date of Birth: [**2094-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Lisinopril
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
dyspnea s/p bronchial stent placement and removal secondary to
bleeding, inability to clear secretions and multiple respiratory
infections.
Major Surgical or Invasive Procedure:
[**6-20**] Flexible bronchoscopy, right thoracotomy, thoracic
tracheoplasty with mesh, right main stem bronchus/bronchus
intermedius bronchoplasty with mesh, left main stem bronchus
bronchoplasty with mesh.
[**2154-6-23**] Flexible bronchoscopy.
History of Present Illness:
Mr. [**Known lastname **] is a 60-year-old gentleman with a history of recurrent
pneumonias and shortness of breath who was found to have severed
tracheobronchomalacia with a particularly collapsed segment in
the right main stem bronchus and bronchus intermedius. In
[**11/2153**], he underwent tracheobronchial Y stenting and bronchus
intermedius silicone stenting to the open the collapsed
segments. He experienced some relief of his dyspnea with this
stenting, but these stents were removed in [**1-/2154**] secondary to
granulation tissue and bleeding. Because of his continued
constellation of symptoms including SOB, recurrent PNA, and
inability to clear his secretions and the profound anatomic
abnormalities in his central airways, surgical correction was
recommended.
Past Medical History:
COPD
CHF (EF 20-25%)
CABG [**2139**], MI [**2139**]
Removal of vocal chord polyp
Social History:
He is married and lives with wife, quit smoking in [**2139**]. He has
1 beer a week. He has 1 cup of coffee a day. He works as an
engineer.
Family History:
Mother died of brain cancer at the age of 73. He does not know
his father's history. Siblings are in good health.
Pertinent Results:
[**2154-6-19**] 10:21PM TYPE-ART PO2-108* PCO2-53* PH-7.26* TOTAL
CO2-25 BASE XS--3
[**2154-6-19**] 10:21PM LACTATE-2.9*
[**2154-6-19**] 10:21PM O2 SAT-97
[**2154-6-19**] 10:21PM freeCa-1.04*
[**2154-6-19**] 10:01PM GLUCOSE-142* UREA N-33* CREAT-1.3* SODIUM-141
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-23 ANION GAP-14
[**2154-6-19**] 10:01PM CK(CPK)-4948*
[**2154-6-19**] 10:01PM CK-MB-36* MB INDX-0.7 cTropnT-<0.01
[**2154-6-19**] 10:01PM CALCIUM-8.3* PHOSPHATE-5.3* MAGNESIUM-2.0
[**2154-6-19**] 10:01PM WBC-14.3*# RBC-3.76* HGB-11.3* HCT-33.2*
MCV-88 MCH-29.9 MCHC-33.8 RDW-13.4
[**2154-6-19**] 10:01PM PLT COUNT-250
Brief Hospital Course:
59M w/TBM s/p
[**6-19**] Flexible bronchoscopy, right thoracotomy, thoracic
tracheoplasty with mesh, right main stem bronchus/bronchus
intermedius bronchoplasty with mesh, left
main stem bronchus bronchoplasty with mesh
The pt was extubated in the OR and transferred to the ICU in
stable condition. Posteratively, the pt experienced hypotension
and was placed on pressors to keep MAP>60. Pain control was
acheived with an epidural.
[**6-19**] CK 4000 - Started LR 150 ml/hr
[**6-20**] CK continued to elevate (from [**Numeric Identifier 2249**] to [**Numeric Identifier 7923**]). Started
bicarbonated drip.
His CK began to trend down on [**6-21**] [**Numeric Identifier 58050**]--> 11,137-->
9522-->8234 ([**6-22**]) and his blood pressure began to stabalize
such that his phenyleprhine drip was weaned. Also at this time
there was interval increase in the right pleural effusion. On
[**6-23**], the patient had a bronchoscopy that showed a large amount
of edema and swelling, increased secretions, with near complete
blockage of the Right upper lobe. A BAL was also performed and
sent for culture but came back with 2+ PMN's only. At that time
IP felt that it was likely secondary to post-surgical edema and
was not related to infection given his negative BAL, lack of
fever, and normal white blood count. He was given albuterol
nebulizers and agressive pulmonary toilet and continued to
improve such that he was able to be transferred to the floor.
On the floor, the patient continued to improve and on [**6-24**]
his chest tube was removed and he tolerated it well. His f/u CXR
did not show a new pneumothorax.
On the day of discharge the patient had well controlled pain,
was ambulating, tolerating oral intake, voiding without
difficulty.
Medications on Admission:
aldactone 40 mg q day
atacaide
vytorin 40-20 qday
Lasix 60 mg [**Hospital1 **]
Toprol 60 mg q day
Imdur dosage unknown
Advair diskus 500-50
Aspirin 81 mg qday
guaifenisen 1200mg sustained release [**Hospital1 **] prn
Tiotropium bromide 18mcg 1 cap qday
KCl 20mEq 1 qday
Ranitidine 150mg [**Hospital1 **]
Discharge Medications:
1. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
2. Lasix 40 mg Tablet Sig: 1.5 Tablets PO twice a day.
3. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
7. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.
8. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
11. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*5*
Discharge Disposition:
Home
Discharge Diagnosis:
COPD severe Bronchomalacia
CHF diastolic (EF 20-25%),
CABG [**2139**]
Removal of vocal chord polyp
Discharge Condition:
hemodynamically stable, ambulating, tolerating oral intake,
voiding without difficulty
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Difficulty or painful swallowing
-Incision develops drainage
You may shower: No swimming or tub bathing for 6 weeks
No driving while taking narcotics: take stool softners with
narcotics
Daily weights: keep log call your PCP if have 3 pound weight
gain
Fluid restriction: 1500 cc per day
Diet: low sodium
Followup Instructions:
Follow-up appointment on [**7-9**] at 8:30am for Bronchoscopy
then 11:00am with Dr. [**Last Name (STitle) **] in the [**Hospital Ward Name 121**] Building,
[**Hospital1 **] One Chest Disease Center.
NOTHING TO EAT OR DRINK After MIDNIGHT on [**7-8**] in
preparation for your Bronchoscopy.
Completed by:[**2154-7-3**]
|
[
"500",
"414.00",
"511.9",
"458.29",
"428.30",
"519.19",
"428.0",
"E879.8",
"491.21",
"E849.7",
"V45.81",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.05",
"31.79"
] |
icd9pcs
|
[
[
[]
]
] |
5967, 5973
|
2570, 4325
|
434, 683
|
6116, 6205
|
1908, 2547
|
6732, 7053
|
1772, 1889
|
4681, 5944
|
5994, 6095
|
4351, 4658
|
6229, 6709
|
255, 396
|
711, 1491
|
1513, 1595
|
1611, 1756
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,423
| 127,838
|
34026
|
Discharge summary
|
report
|
Admission Date: [**2183-8-7**] Discharge Date: [**2183-9-19**]
Date of Birth: [**2118-8-18**] Sex: M
Service: UROLOGY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
Bladder and Prostate Cancer
Major Surgical or Invasive Procedure:
Cystoprostatectomy and Neobladder creation
History of Present Illness:
64 yoM seen in Multidisciplinary Prostate Cancer Clinic with
newly diagnosed [**Doctor Last Name **] 7 (3+4) prostate cancer found on w/u of
PSA 7.68 and nodule on R. Prostate MRI revealed suspicious
bladder lesion, worrisome for invasion. Cystoscopic bx of
bladder lesion revealed 5cm mass with path revealing high grade
TCC.
PMH: The patient has ahistory of factor V deficiency, which
leads to hypercoagulability. Htn, hyperlipidemia.
Meds: simvastatin, Lisin/HCTZ
All: amox
Brief Hospital Course:
Mr [**Known lastname **] was admitted to Urology after undergoing
cystoprostatectomy and neobladder creation. No concerning
intraoperative events occurred; please see dictated operative
note for details. He initially progressed along as expected
tolerating a house diet by POD4, but then developed an ileus. A
CT scan POD 7 revealed a fascial dehiscence and he was taken for
emergent repair. Intra-operatively a small bowel anastomotic
leak was discovered. General Surgery was called and assisted in
the anastomotic revision. Please see dictated operative notes
separately. He was taken to the ICU post-op for aggressive IVF
hydration due to Creatinine elevation. This elevation resolved
with hydration and returned to baseline. He was transferred to
the floor. Throughout his hospitalization he received SQ heparin
and pneumoboot prophylaxis. However, he developed a PE
diagnosedby VQ scan. A hematology consult was called, IV
heparinization was performed and a L common femoral DVT was
discaovered. Since the time of revision he was unable to advance
his diet due to profound ileus and abdominal distension. He
received TPN beginning POD3 from his revision until the day
before discharge. A GI consult was called and found no
definitive cause or therapy for his ileus. He developed gout in
his Left Ankle and Right Knee. A rheumatology consult was
obtained and a steriod taper performed. Gout resolved.
Eventually bowel functin returned. He transitioned to PO
coumadinization and became therapeutic. However, as diet
advanced his INR fell again to 1.6. His coumadin dose was
adjusted. Prior to discharge, a cystogram showed an intact
neobladder. The Foley was removed. He time-voided without
significant residuals. He was discharged to home to follow up
with Dr. [**First Name (STitle) **] and hematology. His primary care doctor, Dr.
[**Last Name (STitle) **], agreed to manage his post-op INR monitoring/coumadin
management.
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain fever.
4. Preparation H Rectal
5. Lisinopril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
6. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily):
Over the Counter.
Disp:*30 Packet(s)* Refills:*2*
7. Warfarin 4 mg Tablet Sig: Two (2) Tablet PO at dinner: Follow
up INR with Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*2*
8. Dulcolax 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation, bloating, or cramps: Over the
Counter.
Disp:*100 supp* Refills:*0*
9. Urocit-K 10 10 mEq Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day: Take with breakfast and
dinner until seen by Dr. [**First Name (STitle) **].
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Prostate and Bladder cancer
Discharge Condition:
Stable
Discharge Instructions:
-Perform scheduled voiding- void every 3 hours during the day
and every 5 hours at night during sleep. We want your bladder to
hold no more than 400 mL of urine.
-Follow up for an INR check related to Coumadin monitoring
Monday [**9-22**] with Dr. [**Last Name (STitle) **]. Call her office early monday
morning [**Telephone/Fax (1) 7401**] to be seen.
-You may shower, but do not tub bathe, swim, or soak.
-No strenuous excercise or heavy lifting until you follow up
with Dr. [**First Name (STitle) **]. If it hurts, stop doing it.
[**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
-OK to drive.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] in clinic in [**11-27**] weeks. Call
[**Telephone/Fax (1) 6317**] for an appointment.
Completed by:[**2183-9-20**]
|
[
"401.9",
"E878.6",
"415.11",
"285.1",
"188.4",
"274.9",
"453.41",
"289.81",
"997.4",
"560.9",
"185",
"997.2",
"584.9",
"272.4",
"998.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.71",
"54.12",
"38.93",
"40.3",
"45.62",
"56.51",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
3863, 3869
|
877, 2810
|
298, 343
|
3941, 3950
|
4712, 4875
|
2833, 3840
|
3890, 3920
|
3974, 4689
|
231, 260
|
371, 854
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,592
| 120,901
|
41213
|
Discharge summary
|
report
|
Admission Date: [**2171-5-14**] Discharge Date: [**2171-5-21**]
Date of Birth: [**2090-11-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Claritin / [**Doctor First Name **] / Sulfa (Sulfonamide Antibiotics) /
Furosemide / Lipitor / Zocor / Lescol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2171-5-14**] Cardiac Catheterization
[**2171-5-16**] Redo mitral valve replacement ([**First Name8 (NamePattern2) 17009**] [**Male First Name (un) 923**]
Bioprosthetic) via right thoracotomy and atrial septal defect
closure
History of Present Illness:
80 year old female with a history of prosthetic mitral valve 8
years ago, who now has worsening prosthetic valve stenosis that
is causing progressive shortness of breath and lower extremity
edema which has been treated medically. In [**2171-2-5**], she was
deemed inoperable. Stated by Dr. [**Last Name (STitle) 914**] at that
time, if after balloon valvuloplasty her PA pressures return to
normal and her RV recovers, she may be a candidate for surgery.
She underwent valvuloplasty on [**2171-2-19**]. She returns today for
repeat cath and echo to further evaluate efficacy of
valvuloplasty based on response of PA pressures. Last dose of
coumadin was [**2171-5-9**] and she will be admitted post cath for
heparin and pre-op workup.
Past Medical History:
Mitral Regurgitation
Prosthetic Valve Mitral Stenosis
Dyslipidemia
Hypertension
Anxiety
COPD
Severe Pulm Hypertension
s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3843**] [**Doctor Last Name **] Bovine Pericardial MVR w/ preservation of
anterior/posterior chordal structure/ CABG LIMA to LAD, SVG to
OMI, SVG to OM2 and SVG to PDA ([**Hospital3 **] [**2163**])
s/p left atrial cyroablation, Left atrial appendage resection
s/p appendectomy
s/p removal of breast, sinus and abdominal tumor (benign)
Social History:
Lives with: husband
Occupation: retired
Tobacco: Quit somking 35 years ago,history of [**12-9**] ppd for 20
years
ETOH:denies
Family History:
Mom with cerebral hemorrhage at 48 yo. Dad had CVA at 72
Physical Exam:
Pulse: 60SR Resp: 20 O2 sat: 94%RA
B/P 150/73
Height: Weight: 60.7 kgs
General: NAD, supine post cath
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Midline incision is well healed.
Lungs clear bilaterally [x] but diminished at bases
Heart: RRR [x] Irregular [x] Murmur early [**1-13**] diastolic murmur
with radiation to the right carotid area
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + [x]
Extremities: Warm [x], well-perfused [x]
2+ pitting Edema bilaterally; no Varicosities or venous
insufficiency changes. Vein harvested from the right leg
endoscopically.
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 0 Left: 0
PT [**Name (NI) 167**]: 0 Left: 0
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits appreciated
Pertinent Results:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aorta - Annulus: 1.7 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.3 cm <= 3.0 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - Peak Velocity: 2.0 m/sec
Mitral Valve - Pressure Half Time: 304 ms
Mitral Valve - MVA (P [**12-9**] T): 0.7 cm2
Findings
LEFT ATRIUM: Moderate LA enlargement. Probable thrombus in the
LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Small LV cavity. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Dilated RV cavity. RV function depressed.
Abnormal septal motion/position consistent with RV
pressure/volume overload.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta. No thoracic
aortic dissection.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AS. No
AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).
Thickened MVR leaflets.. Increased MVR gradient. Severe valvular
MS (MVA <1.0cm2). Mild to moderate ([**12-9**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**12-9**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Mild PR.
Conclusions
PRE-CPB:
The left atrium is moderately dilated. The LAA has been ligated.
A probable thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler.
The left ventricular cavity is unusually small. Overall left
ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular volume overload.
There are simple atheroma in the descending thoracic aorta. No
thoracic aortic dissection is seen.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen.
A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral valve leaflets are thickened. The gradients
are higher than expected for this type of prosthesis. There is
severe valvular mitral stenosis (area <1.0cm2). Mild to moderate
([**12-9**]+) mitral regurgitation is seen.
POST-CPB:
There is a new bioprosthetic valve in the mitral position. The
valve is well-seated with normal leaflet motion. There is no MR.
A trivial paravalvular jet is seen at the 7-o-clock position.
The peak gradient across the mitral valve posthesis is 17mmHg,
the mean gradient is 8mmHg with CO of 4.7. The MVA by PHT is
1.7cm2.
The RV systolic function remains depressed, however appears
slightly improved from pre-op. (The pt is on milrinone and
norepi infusions as well as inhaled NO.) The LV systolic
function remains normal, estimated EF is 60%.
The aortic valve remains normal in structure and function. The
TR has decreased to trace.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2171-5-21**] 06:03 11.0 4.34 11.2* 35.8* 83 25.8* 31.3 16.5*
121*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2171-5-21**] 06:03 121*
[**2171-5-21**] 06:03 22.2* 29.8 2.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2171-5-21**] 06:03 811 25* 0.8 138 4.9 102 31 10
[**Known lastname **],[**Known firstname **] [**Medical Record Number 89781**] F 80 [**2090-11-13**]
Radiology Report CHEST (PA & LAT) Study Date of [**2171-5-21**] 8:24 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2171-5-21**] 8:24 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 89782**]
Reason: eval for effusion
Final Report
INDICATION: Evaluate for effusion after MVR.
COMPARISON: Multiple radiographs dating back to [**2171-5-14**], most
recently
[**2171-5-18**].
FINDINGS: The patient is status post mitral valve replacement
with intact
median sternotomy wires. The right internal jugular introducer
has been
removed. Small bilateral pleural effusions, left greater than
right, and
associated atelectasis are stable. The right mid lung pleural
density is
unchanged from [**2171-5-17**] but is new from [**2171-5-14**] and is likely a
loculated
pleural effusion. There is no pneumothorax. Aortic valve
calcifications are
re-demonstrated. Cardiac and mediastinal silhouettes and hilar
contours are
stable. Right axillary clips are again noted.
IMPRESSION:
1. Bilateral pleural effusions and atelectasis, left greater
than right, are
stable.
2. Small right loculated pleural effusion.
Brief Hospital Course:
Mrs. [**Known lastname 33590**] presented for cardiac catheterization on [**5-14**] and was
admitted post procedure for preoperative workup. On [**5-16**] she was
brought to the operating room and underwent redo mitral valve
replacement and atrial septal defect via right thoracotomy.
Please see operative report for further details. She received
cefazolin and vancomycin for perioperative antibiotics and was
transferred to the intensive care unit for post operative
management. She was paced coming out of the operating room with
an underlying rhythm of atrial fibrillation. Post-op she had
some hypotension that required Levophed and Milrinone. Due to
hemodynamics she remained intubated until post-op day two. On
this day she was weaned from sedation, awoke neurologically
intact and extubated. In addition to continuing pre-op
medications, she was started on beta-blockers and diuretics and
diuresed towards her pre-op medications. On post-op day three
she was difficult to arouse and a stat head CT and neuro consult
were performed. CT was negative and neurology thought her mental
status was from sedative medications. Chest tubes and epicardial
pacing wires were removed per protocol. Coumadin was restarted
and titrated for a goal INR of [**1-9**].5. The following day she was
transferred to the step-down unit for further recovery where she
worked with physical therapy for strength and mobility. On
post-op day five she appeared to be doing well and was
discharged to rehab with the appropriate medications and
follow-up appointments.
Medications on Admission:
ALBUTEROL SULFATE 90 mcg HFA 2 puffs inhaled PRN up to three
times a day
ATENOLOL 12.5 mg twice a day
ETHACRYNIC ACID 25 mg tablet - [**12-9**] Tablet(s) by mouth once a day
FLUTICASONE-SALMETEROL 250 mcg-50 mcg/Dose Disk 2 puffs daily
FOLIC ACID 1 mg DAILY
IPRATROPIUM-ALBUTEROL 18 mcg-103 mcg (90 mcg)/Actuation Aerosol
- 2 (Two)
puffs inhaled four times a day
LEVALBUTEROL HCL 0.63 mg/3 mL q6hrs prn () as needed for
wheezing/SOB
PREDNISONE 5 mg every other day
VALSARTAN 80 mg twice a day
WARFARIN 2.5 mg daily (Sunday, Tu/Thurs/Saturday, none on other
days. Last dose [**2171-5-9**] pre mitral valve surgery)
ASCORBIC ACID 500 mg once a day
ASPIRIN 81 mg once a day
B COMPLEX VITAMINS 1 Capsule(s) by mouth once a day
B COMPLEX VITAMINS 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE 200 mg calcium (500 mg) Tablet, Chewable - 1
Tablet(s) by mouth twice a day
CHOLECALCIFEROL 1,000 unit once a day
CYANOCOBALAMIN 1,000 mcg once a day
CYANOCOBALAMIN 50 mcg DAILY
DOCUSATE SODIUM 100 mg twice a day
FLAXSEED OIL 1,000 mg twice a day
MULTIVITAMIN twice a day
VITAMIN E 400 unit once a day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ethacrynic acid 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea.
8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for dyspnea.
9. prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
12. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
18. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
19. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
20. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
21. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Titrate for Goal INR 2-2.5.
(Pre-op doses were 0.5mg Sat, Sun, Tues, [**Last Name (un) **]. None on other
days).
22. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg [**Hospital1 **] x 5 days, then 200mg daily until stopped by
cardiologist.
23. bumetanide 2 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
Prosthetic Mitral Valve Stenosis s/p Mitral Valve Replacement
Atrial septal defect s/p ASD closure
Past medical history:
Dyslipidemia
Hypertension
Anxiety
Chronic obstructive pulmonary disease
Severe Pulmonary Hypertension
Past Surgical History:
-s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3843**] [**Doctor Last Name **] Bovine Pericardial MVR w/ preservation
of
anterior/posterior chordal structure/ CABG LIMA to LAD, SVG to
OMI, SVG to OM2 and SVG to PDA ([**Hospital3 **] [**2163**])
-s/p left atrial cyroablation, Left atrial appendage resection
-s/p appendectomy
-s/p removal of breast, sinus and abdominal tumor (benign)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Right thoracotomy - healing well, no erythema or drainage
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check on [**5-28**] at 10:45am in [**Last Name (un) 2577**] [**Hospital Unit Name **]
Surgeon: Dr.[**Last Name (STitle) 914**] on [**6-11**] at 1:15pm
Cardiologist: Dr [**Last Name (STitle) 74605**] on [**6-26**] at 11:15am in
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**3-12**] weeks [**Telephone/Fax (1) 41901**]
**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 - Wed [**5-22**]
Completed by:[**2171-5-21**]
|
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"416.8",
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"401.9",
"440.20",
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icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.21",
"88.55",
"35.71",
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icd9pcs
|
[
[
[]
]
] |
13009, 13097
|
8083, 9630
|
396, 624
|
13786, 13950
|
3100, 8060
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14873, 15597
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2087, 2145
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10776, 12986
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13118, 13217
|
9656, 10753
|
13974, 14850
|
13364, 13765
|
2160, 3081
|
337, 358
|
652, 1389
|
13239, 13341
|
1944, 2071
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,541
| 160,642
|
32013
|
Discharge summary
|
report
|
Admission Date: [**2114-9-12**] Discharge Date: [**2114-9-18**]
Date of Birth: [**2045-10-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2114-9-14**] Mitral Valve Replacement(31mm [**Company 1543**] Mosaic Porcine
Valve) and Five Vessel Coronary Artery Bypass Grafting(LIMA to
LAD, SVG to DIAG, SVG to OM1, SVG to PDA-OM3)
History of Present Illness:
Mr. [**Known lastname **] is a 68 year old male who recently underwent
PCI/stenting of his right coronary artery with a drug eluding
stent. Surveillance stress test on the day of admission,
reproduced his symptoms of chest pain and shortness of breath.
Echocardiogram demonstrated lateral wall hypokinesis and new,
severe mitral regurgitation. He was subsequently transferred to
the [**Hospital1 18**] for cardiac surgical evaluation and treatment.
Past Medical History:
Coronary Artery Disease - s/p PCI with DES to RCA in [**Month (only) **]
[**2113**], Hypertension, Hypercholesterolemia
Social History:
Denies tobacco. Admits to 3 beers per day. He is a former cement
hauler. He is married with one child.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: 98.1, 114-143/72-89, 75, 20, 95%RA
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, [**1-23**] holosystolic murmur noted at
the left lower sternal border, no rub
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2114-9-12**] 11:50PM BLOOD WBC-7.9 RBC-3.72* Hgb-11.8* Hct-34.6*
MCV-93 MCH-31.8 MCHC-34.2 RDW-13.4 Plt Ct-291
[**2114-9-12**] 11:50PM BLOOD PT-13.2* PTT-28.5 INR(PT)-1.2*
[**2114-9-12**] 11:50PM BLOOD Glucose-104 UreaN-28* Creat-1.3* Na-145
K-4.4 Cl-104 HCO3-28 AnGap-17
[**2114-9-13**] 12:45PM BLOOD %HbA1c-5.7
[**2114-9-12**] 11:50PM BLOOD Triglyc-61 HDL-48 CHOL/HD-2.5 LDLcalc-58
[**2114-9-13**] Echocardiogram: The left atrium is mildly dilated.
There is moderate 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 root is
moderately dilated at the sinus level. 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 to moderate ([**12-19**]+) mitral regurgitation
is seen. There is no pericardial effusion.
[**2114-9-18**] 06:30AM BLOOD Hct-29.4*
[**2114-9-16**] 04:05AM BLOOD WBC-10.1 RBC-3.29* Hgb-10.3* Hct-30.1*
MCV-91 MCH-31.2 MCHC-34.2 RDW-15.0 Plt Ct-166
[**2114-9-16**] 04:05AM BLOOD PT-13.9* PTT-32.2 INR(PT)-1.2*
[**2114-9-18**] 06:30AM BLOOD K-4.2
[**2114-9-16**] 04:05AM BLOOD UreaN-26* Creat-1.0 Na-137 Cl-108 HCO3-22
[**2114-9-15**] 02:00AM BLOOD Glucose-92 UreaN-19 Creat-1.0 Na-138
K-4.5 Cl-111* HCO3-20* AnGap-12
CHEST (PA & LAT) [**2114-9-17**] 10:07 AM
PA AND LATERAL CHEST X-RAY: A tiny left apicla pnuemothorax is
unchanged. The patient is status post coronary artery bypass
graft. Small foci of gas in the anterior mediastinum is likley
related to recent surgery. There is a small, stable left pleural
effusion, with left lower lobe atelectasis. The right lung is
clear.
IMPRESSION:
1. No significant interval change in tiny left apical
pneumothorax, small left pleural effusion and left lung base
atelectasis.
2. Small foci of gas in anterior mediastinum are likley normal
given the recent surgery. These should be followed to resolution
on Chest X-ray.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to cardiac surgery and underwent routine
preoperative evaluation. Echocardiogram was obtained(see result
section) and oral surgery was consulted which performed tooth
extraction on [**9-13**] for tooth abscess. The remainder of
his preoperative course was uneventful and he was cleared for
surgery. On [**9-14**], Dr. [**Last Name (STitle) 914**] performed a mitral valve
replacement and coronary artery bypass grafting. For surgical
details, please see seperate dictated operative note. Following
the operation, he was brought to the CVICU for invasive
monitoring. He initially experienced a postop coagulopathy which
improved after multiple blood products. On postoperative day
one, he awoke neurologically intact and was extubated without
incident. Aspirin and Plavix were resumed for his recent drug
eluding stent. He maintained stable hemodynamics and weaned from
inotropic support without difficulty. Antibiotics were continued
to tooth abscess. His CVICU course was otherwise unremarkable
and he transferred to the SDU on postoperative day two. He
remained in a normal sinus rhythm. Beta blockade was advanced as
tolerated. Over several days, medical therapy was optimized and
he continued to make clinical improvements with diuresis. He was
eventually cleared for discharge to home on postoperative day 4.
Medications on Admission:
Lipitor 40 qd, Lisinopril 20 qd, Zetia 10 qd, Aspirin 325 qd,
Plavix 75 qd
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:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 3 days.
Disp:*24 Capsule(s)* Refills:*0*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 10
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
Disp:*40 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:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
Mitral Regurgitation, Coronary Artery Disease - s/p MVR/CABG
Tooth Abscess - s/p Extraction
Postop Bleeding/Coagulopathy
Hypertension
Hypercholesterolemia
Discharge Condition:
Stable
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in [**3-22**] weeks, call for appt
Dr. [**Last Name (STitle) 10851**] in [**1-20**] weeks, call for appt
Dr. [**Last Name (STitle) 39975**] in [**1-20**] weeks, call for appt
Completed by:[**2114-9-18**]
|
[
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"272.0",
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"427.1",
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"424.0",
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icd9cm
|
[
[
[]
]
] |
[
"39.61",
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"36.14",
"36.15",
"99.05",
"99.04",
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] |
icd9pcs
|
[
[
[]
]
] |
6763, 6807
|
3856, 5210
|
286, 477
|
7006, 7015
|
1751, 3833
|
7351, 7590
|
1234, 1277
|
5335, 6740
|
6828, 6985
|
5236, 5312
|
7039, 7328
|
1292, 1732
|
236, 248
|
505, 955
|
977, 1098
|
1114, 1218
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,199
| 135,740
|
11890
|
Discharge summary
|
report
|
Admission Date: [**2139-10-29**] Discharge Date: [**2139-11-2**]
Date of Birth: [**2077-2-3**] Sex: M
Service: SURGERY
Allergies:
clindamycin
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
[**2139-10-30**]: small bowel enteroscopy
[**2139-10-31**]: colonoscopy
History of Present Illness:
62M with a history of HCV cirrhosis s/p orthotopic liver
[**Year (4 digits) **] [**2139-10-15**] complicated by a bile duct leak necessitating
Roux-en-Y hepaticojejunostomy [**2139-10-16**], and hepatic arterial
thromectomy [**2139-10-18**] returns with GI bleeding and anemia. Mr
[**Known lastname **] was discharged home [**2139-10-25**] on aspirin and Plavix. He
reports persistent maroon-colored stools that have progressively
become darker since discharge, approximately [**4-10**] stools per day.
He notes increasing fatigue, weakness, and anorexia in the
recent days, with subsequent lightheadness, dry heaving, and
dyspnea yesterday, for which he presented to the [**Hospital 37477**]
Hospital ED in [**State 1727**]. He was found to have a Hct of 15.1 (INR,
fibrinogen normal) and was transfused 1u PRBC with an increase
to 18.8. He proceeded to receive an additional 2u PRBC prior to
arrival via ambulance to [**Hospital1 18**]. He was reported to remain
hemodynamically stable throughout his ED course and transport.
Upon interviewing Mr [**Known lastname **], he denies abdominal pain, bright
red blood per rectum, hematemesis, fevers/chills. He notes
quite minimal PO intake since his discharge but has been taking
his medications as scheduled with the assistance of his wife.
Past Medical History:
HCV cirrhosis and HCC, s/p OLT [**2139-10-15**], c/b bile leak requiring
Roux-en-Y hepaticojejunostomy [**2139-10-16**], c/b hepatic arterial
thrombosis requiring exlap, hepatic arterial thrombectomy
[**2139-10-18**]; HTN; Dysphoria; GERD; erectile dysfunction; L thumb
verrucae; chronic knee pain
Past Surgical History:
s/p RFA ablation for HCC [**6-/2139**]; s/p OLT [**2139-10-15**]; s/p Roux-en-Y
hepaticojejunostomy, liver bx for bile leak [**2139-10-16**]; s/p exlap,
hepatic arterial thrombectomy [**2139-10-18**]
Social History:
Lives at home with wife; has two adult children. Has occasional
cigar. Reports distant history of alcohol use, now only
occasionally. Denies illicits.
Family History:
Non-contributory
Physical Exam:
On admission:
Temp: 98.1, HR: 93, BP: 126/72, RR: 18, O2 Sat: 97% RA
GEN: NAD. Somewhat lethargic. Oriented x3.
HEENT: Sclerae anicteric. Mucous membranes moist, pale.
PULM: CTA bilaterally
ABD: Soft, nontender, nondistended. No R/G. Chevron incision w/
staples c/d/i. Prior drain sites w/ suture intact, c/d/i No
erythema, induration.
EXT: Warm. No edema.
DRE: Small external hemorrhoids. Enlarged prostate. No
additional palpable masses. Normal tone. Gross maroon stool.
Pertinent Results:
[**2139-10-30**] 12:21AM BLOOD WBC-7.7 RBC-2.47* Hgb-8.1* Hct-22.1*
MCV-89 MCH-32.9* MCHC-36.8* RDW-19.7* Plt Ct-200
[**2139-10-30**] 06:00AM BLOOD Hgb-9.9* Hct-27.1*
[**2139-10-30**] 11:57AM BLOOD Hct-29.5*
[**2139-10-30**] 05:30PM BLOOD Hct-31.8*
[**2139-10-30**] 10:50PM BLOOD Hct-33.2*
[**2139-10-31**] 03:19AM BLOOD WBC-8.3 RBC-4.01*# Hgb-13.0*# Hct-37.3*
MCV-93 MCH-32.4* MCHC-34.8 RDW-19.6* Plt Ct-158
[**2139-10-31**] 02:23PM BLOOD Hgb-12.8* Hct-35.3*
[**2139-11-1**] 12:30AM BLOOD Hct-34.5*
[**2139-11-1**] 05:35AM BLOOD WBC-5.2 RBC-3.46* Hgb-11.5* Hct-31.1*
MCV-90 MCH-33.3* MCHC-37.0* RDW-18.8* Plt Ct-143*
[**2139-10-30**] 12:21AM BLOOD PT-13.9* PTT-27.9 INR(PT)-1.2*
[**2139-10-30**] 12:21AM BLOOD Fibrino-292#
[**2139-10-30**] 12:21AM BLOOD Glucose-110* UreaN-44* Creat-1.6* Na-134
K-4.6 Cl-104 HCO3-22 AnGap-13
[**2139-11-1**] 05:35AM BLOOD Glucose-123* UreaN-14 Creat-0.8 Na-134
K-4.2 Cl-103 HCO3-22 AnGap-13
[**2139-10-30**] 12:21AM BLOOD ALT-75* AST-40 AlkPhos-123 TotBili-1.1
[**2139-10-30**] 09:32AM BLOOD LD(LDH)-152
[**2139-10-31**] 03:19AM BLOOD ALT-65* AST-36 AlkPhos-135* TotBili-1.0
[**2139-11-1**] 05:35AM BLOOD ALT-43* AST-28 AlkPhos-102 TotBili-0.8
Small bowel enteroscopy [**2139-10-30**] showed:
Varices at the lower third of the esophagus. The scope was
advanced down to the jejunal anastomosis. There was bile at the
anastomosis with no evidence of bleeding. Small nonbleeding
ulcers were seen at the anastomosis. Otherwise normal small
bowel enteroscopy to jejunal anastomosis
CT abdomen/pelvis [**2139-10-30**] showed:
1. No evidence of retroperitoneal hemorrhage. Hemorrhage noted
within the descending colon. The site of origin of the
hemmorhage is not identified.
2. Status post liver [**Year (4 digits) **]. Allowing for the lack of IV
contrast, the transplanted liver is normal in appearance.
3. Persistent splenomegaly.
4. Small amount of intra-abdominal ascites with perihepatic,
perisplenic and pelvic free fluid.
5. Small bilateral pleural effusions with overlying atelectasis.
Colonoscopy [**2139-10-31**] showed:
Normal mucosa in the whole colon. No evidence of diverticulum,
angiodysplasia, polyps, masses or active bleeding. Grade 1
internal hemorrhoids. One (1) cord of rectal varices was
identified. No active bleeding or recent stigmata. Otherwise
normal colonoscopy to cecum.
Brief Hospital Course:
On the night of [**2139-10-29**], the patient was admitted to the SICU
on [**Year (4 digits) **] surgery for GI bleed. He was rendered NPO and
aspirin and plavix were held. After receiving 3 units PRBC en
route to [**Hospital1 18**], he was transfused another 4 units PRBC on the
morning of [**2139-10-30**], after which his hematocrit remained
stable. Small bowel enteroscopy and colonoscopy were
unrevealing, as was CT abdomen/pelvis. On [**2139-10-31**], he showed
no further evidence of acute hemorrhage and was transferred to
the floor and his diet was advance to regular food. On
[**2139-11-1**], aspirin and plavix were restarted.
On [**11-2**] the hct remained stable at 33%. The patient offered no
complaints and will be discharged to home. Omeprazole has been
incresed to [**Hospital1 **].
Prograf dosing was adjusted per daily levels, all other
immunosuppression was continued per protocol.
Medications on Admission:
omeprazole 20, bupropion HCl 100, docusate sodium 100'',
mycophenolate mofetil 1000'', sulfamethoxazole-trimethoprim
400-80', lamivudine 100', fluconazole 400, valganciclovir 900,
hydromorphone 2-4mg q3 PRN, ASA 81, clopidogrel 75, prednisone
15, sodium polystyrene sulfonate PRN hyperkalemia, Calcium 600 +
D(3)600 mg(1,500mg)-400'', NPH 6u qXX, Humalong SSI, Tacrolimus
3'', tadalafil 20 PRN
Discharge Medications:
1. insulin lispro 100 unit/mL Solution Sig: see printed scale
Subcutaneous ASDIR (AS DIRECTED).
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
Disp:*5 pens* Refills:*1*
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
5. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): follow printed taper schedule.
7. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
8. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
13. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal QID (4 times a day) as needed for hemorrhoidal
irritation.
14. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular prn: bee sting: give in thigh.
go to local hospital if bitten and epinephrine used.
Disp:*1 pen* Refills:*1*
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **] of Southern [**State 1727**]
Discharge Diagnosis:
s/p liver [**State **]
GI bleed
anemia
Hyperglycemia due to steroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
VNA of Southern [**State 1727**] arranged
Please call the [**State 1326**] Office [**Telephone/Fax (1) 673**] if you have any
of the following:
fever (temperature of 101 or greater), shaking chills, nausea,
vomiting, jaundice, inability to take any of your medications,
increased abdominal pain, incision redness/bleeding, black or
blood stool, shortness of breath/dizziness
Followup Instructions:
Labs in [**State 1727**] on Wednesday [**11-4**] and Thursday [**11-5**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2139-11-9**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2139-11-19**] 1:20
Provider: [**Name10 (NameIs) 278**] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2139-11-23**] 8:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2139-11-2**]
|
[
"719.46",
"338.29",
"V12.09",
"455.0",
"401.9",
"V42.7",
"285.9",
"790.29",
"578.9",
"584.9",
"534.90",
"530.81",
"E932.0",
"607.84",
"456.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
8161, 8237
|
5295, 6204
|
279, 352
|
8350, 8350
|
2935, 5272
|
8900, 9560
|
2404, 2422
|
6649, 8138
|
8258, 8329
|
6230, 6626
|
8501, 8877
|
2019, 2220
|
2437, 2437
|
231, 241
|
380, 1675
|
2451, 2916
|
8365, 8477
|
1697, 1996
|
2236, 2388
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,545
| 111,627
|
3050
|
Discharge summary
|
report
|
Admission Date: [**2200-5-2**] Discharge Date: [**2200-5-3**]
Date of Birth: [**2130-6-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
penicillin desensitization
Major Surgical or Invasive Procedure:
penicillin desensitization
History of Present Illness:
69 year old male with a past medical history
of prostate cancer, peripheral neuropathy, osteoarthritis,
secondary polycythemia from sleep apnea and syphilis. Per his
records he was first diagnosed with syphilis back in [**2187**] when
at
that time his RPR was noted to be ">1:4" with a positive
treponemal test. At that time he received 2 IM injections of
PCN, but reportedly developed a rash after the second injection
so he never completed the therapy. The next RPR assessment we
have after that was in [**2195**] at which time his titer was 1:8.
After that it has been persistently in the 1:4 range since early
[**2197**]. In [**2198-11-9**] he was treated with Doxycycline for
28 days as second line treatment for late latent syphilis. He
also had a lumbar puncture during that time period in [**Month (only) 404**]
[**2198**] (he was also getting a workup with neuro for his peripheral
neuropathy). He had no significant pleocytosis in his CSF and
his VDRL was negative.
His RPR was rechecked on [**2200-3-24**] and it is still reactive at
1:4.
He was admitted to the MICU for penicillin desensitization as
his RPR was still reactive when last checked. His review of
systems was negative for chest pain, shortness of breath,
abdominal pain, changes in bowel habits, fevers, chills, rashes.
He reported arm and leg "numbness and tingling" that has been
persistent for one year. He denies back pain, saddle
anesthesia, bowel incontinence.
Past Medical History:
+PPD from bcg vaccine
polycythemia [**Doctor First Name **]
prostate ca
DM diet controlled
OA
depression
neuropathy
OSA (does not tolerate bipap)
syphillis
Social History:
rare etoh, no tob
denies IVDU, sexually active
originally from [**Country **], married but separated from his wife
Family History:
NC
Physical Exam:
VS: T 98.0, HR 55, BP 128/69, 97%ra, 19
Gen-NAD, lying in bed comfortably
CV-RRR, S1, S2 no m/r/g
Pulm-CTAB
Abdomen-soft, NT, +BS
Extremities-no edema
Pertinent Results:
[**2200-5-2**] 09:23PM BLOOD WBC-7.2 RBC-5.54 Hgb-14.2 Hct-45.3 MCV-82
MCH-25.6* MCHC-31.3 RDW-15.4 Plt Ct-277
[**2200-5-2**] 09:23PM BLOOD PT-18.1* INR(PT)-1.7*
[**2200-5-2**] 09:23PM BLOOD Plt Ct-277
[**2200-5-2**] 09:23PM BLOOD Glucose-124* UreaN-17 Creat-1.1 Na-142
K-3.8 Cl-107 HCO3-26 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 14517**] is a 69 yo male with late latent syphilis with a
penicillin allergy, admitted to the MICU for penicillin
desensitization
.
1) Syphilis: Patient with a persistently reactive RPR, now
admitted for penicillin desensitization per protocol. He
received escalating doses of penicillin q 30 minutes x 7 doses.
His last dose of protocol will be followed by Penicillin 2.4
million units IM q week x 3 weeks. Patient to maintain blood
levels of PCN between IM doses with oral PCN 500 mg [**Hospital1 **] at
discharge, he will f/u in [**Hospital **] clinic on [**5-9**] for next IM dose
Epinephrine, diphenyhydramine, ibuprofen PRN adverse reaction,
which did not occur. The patient tolerated the desensitization
well and was discharged the following morning.
.
2) Atrial flutter: Was in NSR on telemetry for the duration of
his hospitaliation.
He is anticoagulated on coumadin, and was in his target INR [**1-12**].
He was rate controlled on his home dose of metoprolol.
.
3) PPx: None, as he is anticoagulated on coumadin.
.
4) FEN: He was NPO until after first dose of penicillin, then
cardiac diet.
.
5) Code statu: full code.
Medications on Admission:
Metoprolol 50 mg [**Hospital1 **]
Percocet 5/325 [**Hospital1 **]
Warfarin 5 mg daily
Discharge Medications:
1. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Penicillin V Potassium 500 mg Tablet Sig: One (1) Tablet PO
twice a day for 2 weeks.
[**Hospital1 **]:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
penicillin desensitization for treatment of latent syphillis
atrial fibrillation
prostate cancer
secondary polycythemia
Discharge Condition:
stable, afebrile, good po intake
Discharge Instructions:
You were admitted to the MICU for penicillin desensitization.
The complete series of penicillin doses were administered
without event. You received an intramuscular dose of penicillin
at the end of the series. You will need to take penicillin
500mg by mouth twice daily for two weeks. Please continue to
take your medications as prescribed.
Call your doctor or go to the ER if you have any shortness of
breath, dizzyness, rashes, swelling, wheezing, chest pain, or
any other concerning symptoms.
It is important that you follow up as outlined below.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14518**] office will contact you regarding an
appointment you will have on Friday [**5-9**]
You should follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13959**]
[**Telephone/Fax (1) 250**] within two weeks
Completed by:[**2200-5-11**]
|
[
"V10.46",
"427.32",
"096",
"250.00",
"238.4",
"V07.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
4247, 4253
|
2648, 3806
|
296, 324
|
4417, 4452
|
2324, 2625
|
5053, 5426
|
2134, 2138
|
3942, 4224
|
4274, 4396
|
3832, 3919
|
4476, 5030
|
2153, 2305
|
230, 258
|
352, 1806
|
1828, 1985
|
2001, 2118
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,958
| 114,893
|
27404
|
Discharge summary
|
report
|
Admission Date: [**2139-10-6**] Discharge Date: [**2139-10-12**]
Date of Birth: [**2099-6-16**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8480**]
Chief Complaint:
right neck swelling
Major Surgical or Invasive Procedure:
[**2139-10-6**]: Incision and drainage of right neck abscess
History of Present Illness:
40 y/o M with h/o IVDA (last used 4 months ago) who presented to
OSH with R neck swelling and odynophagia. Sore throat began on
Saturday, neck swelling began on Sunday. He went to [**Hospital 4199**] hosp
on Monday who told him he had a blocked salivar gland, and
started augmentin. His swelling worsened today and he went back
to [**Hospital 4199**] hospital where they obtained a neck CT which was read
as a having a cystic neck mass with some compression of airway.
He was given decadron 10 x1, and unasyn and transferred to
[**Hospital1 18**]. He states he has some difficulty breathing through his
mouth, but breathing easily through his nose. He is tolerating
po's. He has some deepening of his voice. Denies fevers,
chills, dysphagia, fevers, chills, diplopia, blurry vision, cp,
sob, n, v, abd pain, otalgia, ear complaints, headache,
numbness, weakness. Per report negative HIV 6 months ago. Of
note the patient self-aspirated 1cc of pus from right neck mass.
Last po intake 1pm. No previous neck infections.
Past Medical History:
PMH: IVDA 4 months ago last use, Hep C, Chronic LBP, rcotic
dependence
PSURG Hx: bilateral hip surgeries, adenoidectomy, tonsillectomy
as a child
Social History:
On disability, 2ppd x 27 years, non drinker, former cocaine
and heroin user.
Family History:
non-contributory
Physical Exam:
98.0 80 115/80 16 99 RA
NAD
RRR
CTA B
moderate right neck swelling, much improved from before.
CN [**Last Name (LF) **], [**First Name3 (LF) 81**], and XII intact
Pertinent Results:
[**2139-10-5**] 10:03PM PT-13.5* PTT-27.6 INR(PT)-1.2*
[**2139-10-5**] 10:03PM WBC-10.4 RBC-4.23* HGB-11.8* HCT-35.7* MCV-84
MCH-27.8 MCHC-33.0 RDW-14.1
[**2139-10-5**] 10:03PM PLT COUNT-176
[**2139-10-5**] 10:03PM GLUCOSE-120* UREA N-8 CREAT-0.8 SODIUM-137
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-12
[**2139-10-5**] 10:06PM LACTATE-0.7
[**2139-10-6**] 05:07AM PT-14.2* PTT-27.3 INR(PT)-1.2*
[**2139-10-6**] 05:07AM WBC-8.1 RBC-3.94* HGB-11.3* HCT-32.9* MCV-84
MCH-28.8 MCHC-34.4 RDW-14.7
[**2139-10-6**] 05:07AM PLT COUNT-184
[**2139-10-6**] 05:07AM GLUCOSE-164* UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
[**2139-10-6**] 05:07AM CALCIUM-9.0 PHOSPHATE-2.3* MAGNESIUM-2.3
CT OSH, Second Opinion Read from [**2139-10-5**]: 1. Large rim-enhancing
fluid collection below the right angle of mandible, centered in
the right parapharyngeal space and extending to the submucosa as
described above, displacing adjacent structures. Diagnostic
possibilities include an abscess and a superinfected branchial
cleft cyst. 2. Extension of hypodense material from the
collection to the retropharyngeal and prevertebral spaces at
C3-C6, concerning for phlegmon or early abscess formation. C5-6
endplate irregularities are most likely degenerative, but
infection cannot be excluded. Cervical spine MRI is suggested
for further evaluation.
MRI Spine [**2139-10-8**]: Extensive soft tissue edema and residual right
parapharyngeal fluid collection as described above. Extremely
limited study due to motion and lack of IV contrast. Please
refer to concurrent CT neck for details.
CT Neck [**2139-10-8**]: 1. Interval drainage of a large rim-enhancing
right neck fluid collection with multiple small residual
collections in the operative bed, colectively measuring upto 3.6
cm.
Brief Hospital Course:
Mr. [**Known lastname 67102**] was transferred from an OSH for a large right neck
abscess and odynophagia. The patient was taken to the OR for
operative drainage. Please see dedicated operative report for
full details. The patient was kept intubated and taken to the
ICU for overnight observation. On POD 1, the patient was
extubated and his diet was advanced. He stayed one more day in
the ICU while awaiting a bed and was then transferred to the
floor. He had been started on vanc/unasyn in the ED here at
[**Hospital1 18**] and cultures were obtained, which grew out beta lactamase
negative Haemophilus influenzae. Due to continuing concern about
his neck, an MRI was attempted on [**2139-10-8**], but the patient could
not tolerate the procedure. A follow up CT was then obtained and
further drainage was deemed unnecessary based on those results.
An ID consult was obtained and the antibiotics were changed to
cefepime and flagyl. They also suggested an HIV test, which was
negative. The patient responded well on this regimen. During his
hospital stay, he had good pain control on oral meds, had normal
hemodynamics and oxygen saturations, was ambulatory, and
tolerated an oral diet. On Monday, [**2139-10-12**], the patient expressed
a desire to go home. ID recommendations included a week of IV
antibiotics. Thus, the patient decided to sign himself out of
the hospital against medical advice. He will be completing a
course of oral antibiotics, will have VNA services for dressing
changes, and will follow up with Dr. [**First Name (STitle) **] soon. The patient was
counseled as to the risks of his going home, and he decided to
leave against medical advice to go home.
Medications on Admission:
Methadone 100mg QD, oxycodone 15mg q6 prn pain
Discharge Medications:
1. Methadone 40 mg Tablet, Soluble Sig: 2.5 Tablet, Solubles PO
DAILY (Daily) as needed for home maintenence dose.
2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
3. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q6H (every 6
hours) as needed for pain.
Disp:*300 mL* Refills:*0*
4. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 21 days.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
right neck abscess
Discharge Condition:
Stable
Discharge Instructions:
VNA will come to change your packing and dressing once a day.
Call your doctor's office or go to the ED if you start to have
fevers/chills, increasing difficulty breathing, new redness or
swelling at the surgical site, or if you have any other
concerns.
Followup Instructions:
Call Dr.[**Name (NI) 18353**] office at [**Telephone/Fax (1) 2349**] to schedule a follow-up
appointment to be seen in [**8-14**] days.
|
[
"305.1",
"682.1",
"478.24",
"478.22",
"304.01",
"724.2",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"28.0"
] |
icd9pcs
|
[
[
[]
]
] |
6089, 6147
|
3816, 5497
|
342, 405
|
6209, 6218
|
1962, 3793
|
6520, 6659
|
1742, 1760
|
5595, 6066
|
6168, 6188
|
5523, 5572
|
6242, 6497
|
1775, 1943
|
283, 304
|
433, 1461
|
1483, 1632
|
1648, 1726
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,521
| 118,704
|
37770
|
Discharge summary
|
report
|
Admission Date: [**2136-9-24**] Discharge Date: [**2136-11-15**]
Date of Birth: [**2062-5-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
Video swallow study
EGD
Insertion of Pigtail catheter in R pleural space
History of Present Illness:
74 year-old man with glottic squamous cell carcinomal s/p chemo
and XRT as well as T3N0Mx poorly differentiated carcinoma of the
lung in remission presenting after a recent hospitalization for
dysphagia with continued dysphagia and poor PO intake leading to
weakness. He was discharged approximately a week before this
presentation and at that time was admitted for dysphagia. He
had dilation of a relativley quite minor esophageal stricture
during that hospitalization and afterwards improved and was
discharged. He reports that his swallowing is slightly better
but he is not able to take much food at all. He reports his
appetite is very poor. In the context of this poor intake he
reports he has gotten very week and though he reports a month or
so ago he could walk several blocks over the last weeks he does
not think he could do this. Aside from his weakness and poor
intake he reports chronic back pain on his left side, where he
had a previous surgery. He has subjective fevers and chills and
reports chronic cough but this is nonproductive. He does have
chronic production of sputum in his mouth that he does not feel
he can handle and swallow and spits in a basin throughout our
interview. He denies odynophagia. He also endorses chronic
anorexia and more recently having had some subjective fevers or
chills though he reports dysuria or localizing singns except for
his chronic, nonproductive cough and approximately two episodes
of loose stool a day, which he reports are immediately after he
eats. He has mild headache. He denies abdominal pain, dysuria,
or flank pain. He very rarely has nausea and will vomit with
dyspnea after vomiting. He denies dyspnea at any other time.
Because of inability to manage these symptoms at home he
presented to the ED.
In the ED all vital signs were stable. T 98, P 108, BP 92/65,
RR 18, O2 Sat 100% RA. He had labs and cultures, which revealed
a leukocytosis but UA and chest radiograph were both without
signs of acute infection and he was afebrile. He was admitted
for further management.
Currently, he discusses his litany of complaints and is very
irritated by how poorly he is feeling. He is particularly
concerned about how little he is eating and mentioned to a nurse
he would die without IVF. He does ask for supplements, however,
and is very concerned with his PO intake.
REVIEW OF SYSTEMS:
Positive per HPI.
Notably negative for abdominal pain, shortness of breath (except
immediately following emesis), and vomiting with liquids.
Otherwise review of systems performed and unremarkable.
Past Medical History:
- Diabetes mellitus, type II
- Hypertension
- T3 N0 M0 glottic squamous cell carcinoma s/p chemoradiation
therapy
- Tracheostomy on [**2134-11-3**]
- PEG tube placed on [**2134-11-17**].
- Poorly differentiated large cell carcinoma T3N0MX in the left
upper lobe s/p left thoracotomy, partial decortication of lung,
left upper lobectomy, mediastinal lymphadenectomy, en bloc
resection of pericardium on [**2136-6-12**].
- Hospitalization for dysphagia a week previous with very minor
stricture that was dilated
Social History:
He quit smoking three years ago after 150-pack-year history.
Previously a teacher in [**Country 5881**]. History of heavy alcohol use
but quit in his 50s. He used to be a teacher in [**Country 5881**]. Former
ETOH use, quit 20 years ago. Lives with his wife and son.
Family History:
His mother died at age 85 of unclear causes. Father died in
Siberia after being taken from family, unclear medical history.
Sisters and sons without notable problems at this time.
Physical Exam:
ADMISSION EXAM:
VS: T 99.1, P 94, BP 116/60, RR 18, O2 99% on RA
Appearance: Thin elderly man appearing uncomfortable and
frequently spitting in a basin but non-toxic
Eyes: EOMI, Conjunctiva Clear
ENT: Dry appearing, Edentulous,no ulcers or erythema, no JVD,
chronic fibrotic changes of anterior throat (presumably from
radiation)
CV: Regular, normal S1 and S2, no systolic or diastolic murmurs,
no lower extremity edema appreciated
Respiratory: Breathing appears comfortable, diminished breath
sounds over the left upper chest, , diminished breath sounds at
the bases bilaterally with a few crackles at the left base on
auscultation, lidocaine patches on left back
GI: Soft, Nontender, nondistended, bowel sounds positive, No
hepatomegaly or splenomegaly
MSK: Tone WNL, Bulk WNL, Upper Extremity Strength 5/5 and
symmetrical, Lower Extremity Strength 4+/5 and symmetrical, No
cyanosis, No clubbing, No joint swelling
Neuro: CNII-XII intact, Normal attention, Fluent heavily
accented speech
Integument: Warm, dry, no rash
Psychiatric: Appears anxious but generally pleasant
Hematologic / Lymphatic: No Cervical [**Doctor First Name **], Thyroid WNL
Discharge Exam (prior to death)
VS: 98.1 90s/40s 90s AF 98% on FiO2 35% Trach collar
General: non-alert, cachectic man sitting in bed, in distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, trach site without
oozing
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi. Transmitted upper airway sounds from trach.
CV: Irreg irreg. Rate approx 80s. Normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: PEG dressing and wound C/D/I. Abdomen soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley drainaing dark yellow urine
Ext: Diffuse anasarca with 2-3+ pitting edema. Warm, well
perfused, 2+ pulses, no clubbing, cyanosis. RUE PICC without
erythema or purulence
Pertinent Results:
===================
LABORATORY RESULTS
===================
WBC-14.1* RBC-3.50* Hgb-9.8* Hct-29.2* MCV-84 RDW-13.7 Plt
Ct-514*
---Neuts-88* lymphs-4* Monos-8
Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL
Microcy-NORMAL Polychr-OCCASIONAL
Glucose-196* UreaN-23* Creat-0.8 Na-134 K-4.1 Cl-96 HCO3-25
==============
OTHER STUDIES
==============
Chest radiograph PA and lateral [**2136-9-24**] (my read): General
greater density over the left lung field, likely due to volume
loss (chronic). No infiltrate or pulmonary edema appreciated.
No effusions. There is a circular lucency of the left clavicle
that appears new from previous chest radiographs though
radiograph from [**Month (only) 216**] shows a circular lucency likely linked to
the lung. No acute intrapulmonary process, ? lytic lesion in
left clavicle.
Bed Side Swallow Study
SUMMARY / IMPRESSION:
Mr. [**Known lastname 84573**] is well known to me from previous swallowing
evaluations. He had been tolerating thin liquids and ground
solids before his recent left thoracotomy, Left upper lobectomy
and pericardial resection for biopsy proven non-small cell lung
cancer. We repeated his video swallow after that procedure
before d/c but swallow function was c/w previous exams and he
remained safe for thin liquids and soft foods with extra sauce
and gravy. He was given a 10 days course of antibiotics for H
pylori but was only able to take 3 1/2 days of the medication
and
did not finish the prescription.
It is unlikely his oral and pharyngeal have changed since [**Month (only) 205**]
when we did his last video swallow and he has been recently
dilated which rules out the possibility he restrictured. My
guess
is that the biggest change is likely continued H pylori, as he
vomited up most of the medication and stoped taking it after 3
days. Suggest considering restarting meds for H pylori (not sure
if it needs to be rediagnosed before starting meds) to try to
improve comfort.
He remains safe to drink his liquid supplements, and takes 5
cans
of Nutren 2.0, 500 calories each which he should be ordered for
here. He can also take water safely, which can keep him
hydrated.
We will plan to f/u with him after treatment for H pylori to see
if he feels his oral and pharyngeal swallow has improved
further.
This swallowing pattern correlates to a Functional Oral Intake
Scale (FOIS) rating of 5.
.
TTE ([**2136-10-12**]):
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2136-6-15**], no
change.
.
Gastric biopsy ([**2136-10-3**]):
Gastric antrum and body, mucosal biopsies:
Antral and corpus mucosa with focal intestinal metaplasia, focal
regeneration of gastric pits and minimal inflammation; see note.
Note: The findings are non-specific, but are most suggestive of
a chemical-type gastropathy. At the request of the clinician, a
Helicobacter immunostain is performed and is negative for H.
pylori, with satisfactory controls.
.
EGD ([**2136-10-3**])
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered MAC
anesthesia. Supplemental oxygen was used. The patient was placed
in the left lateral decubitus position and an endoscope was
introduced through the mouth and advanced under direct
visualization until the third part of the duodenum was reached.
Careful visualization of the upper GI tract was performed. The
procedure was not difficult. The patient tolerated the procedure
well. There were no complications.
Findings: Esophagus:
Mucosa: stricture seen near upper esophogeal sphincter as
previously described. The scope was able to traverse the lesion.
Stomach:
Lumen: A medium size hiatal hernia was seen.
Mucosa: Erythema of the mucosa was noted in the stomach. This
was worse in the antrum. Consistent with pan gastritis.
Duodenum: Normal duodenum.
Impression: Abnormal mucosa in the esophagus
Erythema in the stomach
Medium hiatal hernia
Otherwise normal EGD to third part of the duodenum
.
Gastric emptying study ([**10-5**]): IMPRESSION: Normal gastric
emptying study.
.
[**2136-10-30**] Radiology CHEST (PORTABLE AP)
1. Moderate bilateral pleural effusions, likely stable.
2. Bibasilar opacities, probable compressive atelectasis.
Pneumonia and
aspiration are within the differential, though less likely.
4. Widened mediastinum corresponding with fluid and adenopathy
seen on recent
chest CT.
5. Known pulmonary nodules not well characterized.
[**2136-10-29**] Radiology MR [**Name13 (STitle) 6452**]/T-SPINE W & W/O CONT
1. Severe compression deformity of T6 vertebral body with mild
retropulsion,
but no cord compression. This finding is compatible with either
a pathologic fracture secondary to a metastasis, or an
osteoporotic fracture. No additional metastases are seen in the
thoracic or lumbar spine.
2. Chronic moderate compression deformity of the L2 vertebral
body with mild retropulsion, but no nerve root compression
[**2136-10-29**] Radiology N-G TUBE PLACEMENT/PERC G/G-J TUBE PLMT
Prelim report not available
[**2136-10-27**] Radiology [**Last Name (un) **]-INTESTINAL TUBE PL
Unsuccessful attempted passage of a nasogastric tube despite
fluoroscopy. Findings discussed with Dr. [**Last Name (STitle) **] by Dr. [**Last Name (STitle) **] at
1510 hours on [**10-27**]. Please note this precludes gastrostomy
by the IR team. Surgical consult suggested.
[**2136-10-26**] Radiology CT NECK W/CONTRAST
1. Status post tracheostomy. No evidence of recurrent laryngeal
tumor. 2. 2. Upper mediastinal lymphadenopathy and right pleural
effusion, better evaluated on the dedicated chest CT examination
performed on the same day.
3. Persistent left hydrothorax.
ATTENDING NOTE: 1. A right sided level 2 lymphnode (2:19) has
increased in
size since [**2136-7-1**] and measures 13-mm and has hetrogenous
density suggestive of metastasis. 2. Right pleural effusion is
new since [**2136-7-1**], correlate with Chest CT. 3. There is
increased glottic and supra-glottic edema likely related to
treatment changes
[**2136-10-26**] Radiology CT CHEST W/CONTRAST
1. Incompletely-imaged multiple liver masses, new since the
[**2136-8-16**] CT examination, compatible with malignancy.
Further evaluation with abdominal and pelvic CT is recommended.
2. See neck CT report assessment for any recurrent right
laryngeal tumor.
3. Interval complete collapse of the T6 vertebral body since the
[**2136-8-16**] examination may be pathologic given the findings of new
hepatic
malignancy.
4. Enlarging right upper lobe pulmonary nodule, new left lower
lobe nodule, and equivocal left pleural-based nodule.
5. Status post tracheostomy, with patent airways to the
subsegmental levels.
6. Moderate-sized bilateral pleural effusions, greater on the
right, with
adjacent compressive atelectasis.
7. Persistent left hydrothorax, with resolution of a previously
seen small
loculated pneumothorax.
8. New small amount of intra-abdominal ascites.
9. New prominent upper mediastinal lymph nodes, suspicious for
malignancy.
[**2136-10-26**] Radiology CHEST (PORTABLE AP)
1. Developing retrocardiac opacity compatible with aspiration,
pneumonia, or atelectasis.
2. Small left pleural effusion
[**2136-10-25**] Radiology VIDEO OROPHARYNGEAL SWA
Aspiration of thin liquids and nectar-thick liquids. Pharyngeal
residue with pudding. Please refer to note from speech and
swallow division in the OMR for further details.
[**2136-10-24**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) 2437**],[**First Name3 (LF) **]
Approved
1. Diffuse increase in left lung opacity, compatible with
worsening pleural effusion.
2. Right lower lung atelectasis.
[**2136-10-23**] Radiology RIB UNILAT, W/ AP CHEST [**Last Name (LF) **],[**First Name3 (LF) **]
Approved
No definite rib fx or rib lesion. Gallstones noted. Changes in
left lung, as described
Microbiology
[**2136-10-28**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2136-10-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {PSEUDOMONAS AERUGINOSA, STAPH AUREUS COAG
+} INPATIENT
[**2136-10-28**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2136-10-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-24**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2136-10-21**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL {CLOSTRIDIUM DIFFICILE} INPATIENT
[**2136-10-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2136-10-18**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-17**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-17**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2136-10-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-13**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-2**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-2**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-2**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-9-29**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-9-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2136-9-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-9-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
=
================================================================
[**2136-11-7**] 10:20 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2136-11-7**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2136-11-10**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
PSEUDOMONAS AERUGINOSA.
MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
GRAM NEGATIVE ROD #3. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 4 S
LEVOFLOXACIN---------- 2 S
MEROPENEM------------- 2 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
LEGIONELLA CULTURE (Final [**2136-11-14**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2136-11-8**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
===========================================================
[**2136-9-24**] 11:00AM BLOOD WBC-14.1* RBC-3.50* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.1 MCHC-33.7 RDW-13.7 Plt Ct-514*
[**2136-9-27**] 06:55AM BLOOD WBC-13.1* RBC-2.94* Hgb-8.1* Hct-24.6*
MCV-84 MCH-27.6 MCHC-33.0 RDW-14.3 Plt Ct-452*
[**2136-10-2**] 07:20AM BLOOD WBC-15.0* RBC-2.97* Hgb-8.0* Hct-24.7*
MCV-83 MCH-26.9* MCHC-32.2 RDW-14.0 Plt Ct-481*
[**2136-10-5**] 01:59PM BLOOD WBC-15.1* RBC-2.75* Hgb-7.5* Hct-23.0*
MCV-84 MCH-27.4 MCHC-32.8 RDW-14.1 Plt Ct-452*
[**2136-10-18**] 03:23AM BLOOD WBC-18.5* RBC-2.57* Hgb-6.8* Hct-22.5*
MCV-87 MCH-26.3* MCHC-30.1* RDW-15.2 Plt Ct-565*
[**2136-10-27**] 04:33AM BLOOD WBC-22.4* RBC-2.75* Hgb-7.2* Hct-23.8*
MCV-87 MCH-26.1* MCHC-30.1* RDW-15.4 Plt Ct-230
[**2136-10-28**] 03:32AM BLOOD WBC-22.5* RBC-2.77* Hgb-7.3* Hct-24.0*
MCV-87 MCH-26.2* MCHC-30.3* RDW-16.6* Plt Ct-144*
[**2136-11-6**] 03:53AM BLOOD WBC-12.3* RBC-2.33* Hgb-6.4* Hct-20.1*
MCV-86 MCH-27.4 MCHC-31.8 RDW-16.5* Plt Ct-106*
[**2136-11-7**] 06:00AM BLOOD WBC-11.9* RBC-2.70* Hgb-7.1* Hct-23.2*
MCV-86 MCH-26.4* MCHC-30.7* RDW-17.1* Plt Ct-107*
[**2136-11-15**] 05:23AM BLOOD WBC-10.8 RBC-2.69* Hgb-7.5* Hct-23.6*
MCV-88 MCH-27.8 MCHC-31.7 RDW-16.9* Plt Ct-49*
[**2136-11-11**] 06:00AM BLOOD Glucose-135* UreaN-21* Creat-0.6 Na-139
K-3.5 Cl-100 HCO3-33* AnGap-10
[**2136-11-12**] 06:00AM BLOOD Glucose-125* UreaN-21* Creat-0.6 Na-141
K-3.6 Cl-101 HCO3-31 AnGap-13
[**2136-11-12**] 02:35PM BLOOD Glucose-112* UreaN-21* Creat-0.6 Na-141
K-4.3 Cl-103 HCO3-32 AnGap-10
[**2136-11-13**] 05:50AM BLOOD Glucose-139* UreaN-27* Creat-0.9 Na-141
K-4.0 Cl-102 HCO3-30 AnGap-13
[**2136-11-14**] 05:28AM BLOOD Glucose-154* UreaN-39* Creat-1.1 Na-143
K-3.4 Cl-104 HCO3-30 AnGap-12
[**2136-11-15**] 05:23AM BLOOD Glucose-220* UreaN-52* Creat-1.6* Na-141
K-4.7 Cl-104 HCO3-28 AnGap-14
[**2136-11-15**] 05:23AM BLOOD Albumin-1.5* Calcium-7.0* Phos-4.8*
Mg-2.6
[**2136-11-13**] 05:50AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.3
[**2136-11-12**] 02:35PM BLOOD TotProt-3.5* Albumin-1.5* Globuln-2.0
Calcium-7.1* Phos-2.6* Mg-2.1
[**2136-11-12**] 06:00AM BLOOD Calcium-7.5* Phos-2.7 Mg-2.2
[**2136-11-11**] 06:00AM BLOOD Albumin-1.6* Calcium-7.2* Phos-3.1 Mg-2.1
[**2136-11-10**] 03:08PM BLOOD Calcium-7.6* Phos-3.4 Mg-2.1
======================================
[**Known lastname **],[**Known firstname 84574**] [**Medical Record Number 84575**] M 74 [**2062-5-27**]
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2136-11-12**] 6:22 PM
[**Last Name (LF) **],[**First Name3 (LF) **] OMED 11R [**2136-11-12**] 6:22 PM
CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 84576**]
Reason: ?r/o PE
Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
74 year old man with metastatic lung cancer, glottic cancer,
presumed
aspiration pneumonia, and acutely worsening SOB.
REASON FOR THIS EXAMINATION:
?r/o PE
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: YGd MON [**2136-11-12**] 10:31 PM
Subtle filling defect involving RML subsegmental branch
(4:158-161, 402b:25,
and 3:4) could represent trace pulmonary embolism. Small right
ptx and right
posterior pleurx catheter in place. Fluid distends esophagus and
aerosolized
material in lower lobe airways and extensive aspiration
pneumonitis.
Bilateral pulmonary nodules some pleural based. Right apical
paraseptal
emphysema. Trace pleural effusions. Left 7th rib sclerosis,
probably post
traumatic. Stable severe T6 wedge compression.
d/w Dr. [**Last Name (STitle) **] at 7:30 pm and 10:00 pm on [**2136-11-12**] via
phone by [**Doctor Last Name **] x
[**Numeric Identifier 27921**]
Final Report
CTA CHEST WITH AND WITHOUT CONTRAST
DATE: [**2136-11-12**].
COMPARISON: [**2136-10-26**] CT chest; MR thoracic spine [**10-29**], [**2136**]; CT
abdomen and pelvis [**2136-10-31**].
CLINICAL INDICATION: 74 year old man with metastatic lung
cancer, glottic
cancer, presumed aspiration pneumonia, and acutely worsening
SOB. Rule out PE.
TECHNIQUE: Axial images of the chest were obtained without the
use of
intravenous contrast. Subsequently, axial images were obtained
after the
uneventful administration of 100 mL Optiray intravenous
contrast. Coronal and
sagittal reformatted images were constructed.
CHEST FINDINGS:
There is no central or segmental pulmonary embolus. Evaluation
of distal
subsegmental branches is slightly limited secondary to
incomplete
opacification with contrast. The previously described subtle
filling defect
involving the right middle lobe subsegmental branch is favored
to be
artifactual. No additional filling defects are identified.
The heart is normal in size. There is a small pericardial
effusion. Loculated
fluid in the left anterior hemithorax with peripheral
enhancement is
unchanged. There are small, left greater than right, bilateral
pleural
effusions with adjacent compressive atelectasis at the bases.
There is no
axillary lymphadenopathy. Mediastinal lymphadenopathy,
predominantly
involving the prevascular space/anterior mediastinum, is
unchanged in size.
A small right pneumothorax is new from the prior examination. A
right
posteriorly placed chest tube is in place. There is underlying
centrilobular
and periseptal emphysema. There are new and worsening areas of
scattered
ground-glass opacities with septal thickening, predominantly
involving the
right lung. On the left, there is bronchial wall thickening
involving the
lower lobe bronchi, minimally progressed from the prior
examination. Patchy
parenchymal opacity in the medial base is noted.
There is a new subpleural nodular opacity measuring 6 mm in the
left upper
lobe (3:12). A pleural-based nodule at the left base measuring
10 x 12 mm is
essentially unchanged. Also stable is the right upper lobe
pulmonary nodule
(9mm, 2:10).
The esophagus is newly distended and fluid filled.
Atherosclerotic changes are present within the normal caliber
aorta. There is
focal narrowing of mild degree in the left main pulmonary
artery, unchanged
from prior examinations (3:16).
The patient has a tracheostomy tube which is unchanged in
appearance.
An enlarging liver lesion in the left hepatic lobe measures 6.1
x 8.2 cm. This
is incompletely imaged. There is abdominal ascites.
MUSCULOSKELETAL FINDINGS: There is asymmetric left greater than
right
subcutaneous fat stranding in the chest wall. Compression
deformity of T6
vertebral body is redemonstrated and stable. Post-surgical
changes are
present in the left posterior ribs. Incompletely healed fracture
with callus
formation is present in the left fifth lateral rib.
IMPRESSION:
1. New small right pneumothorax. Right chest tube is posteriorly
positioned.
Please ensure chest tube is to suction.
2. No definite evidence of pulmonary embolus.
3. Stable pleural/parenchymal nodules, left hydrothorax and
small left
pleural effusion.
4. New areas of scattered ground-glass opacities with septal
thickening,
predominantly on the right, related to inflammatory or
infectious etiology.
5. Bronchial wall thickening at the left base with patchy
consolidation,
minimally progressed, possibly secondary to aspiration.
6. Fluid-filled and dilated esophagus, new from the prior
examination which
may relate to esophagitis or possibly early stricture formation.
Please
correlate for symptoms of esophagitis.
7. Enlarging incompletely imaged liver metastasis.
8. Stable T6 wedge compression deformity.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: TUE [**2136-11-13**] 5:09 PM
Imaging Lab
Brief Hospital Course:
74 year-old man with laryngeal cancer and NSCLC s/p chemo and
XRT, history of chronic dysphagia (to solids), and H.pylori
infection presents with progressive nausea and resulting
decreased PO intake.
.
#ICU course #1: He was first admitted to the ICU shortly after
admission when he looked very sleepy, with tachypnia and labored
breathing. In the ICU, he was started on heliox, racemic
epinephrine and IV dedacrdone. He was kept strict NPO and some
of his meds were switched to IV form. He was evaluated by ENT
who placed tracheostomy on the day of the admission with no
complications. CXR post trach showed no complications with
larger lung volumes.
.
# ICU course #2: Patient was readmitted to the ICU on [**10-23**] for
AFib with RVR. He was initially placed on a diltiazem drip and
amiodarone infusion was also started to obtain rhythm control.
Heart rate was better controlled with amiodarone, but attempts
to transition to po amiadorone were hindered by persistent
dysphagia. Patient failed video swallow study and patient had G
tube placed by IR on [**10-29**]. He was then transitioned to po dilt.
During this stay, he complained of persistent dyspnea and CXR
showed a new worsening pleural effusion on the right. CT of the
chest on [**10-26**] showed multiple liver mets, T6 collapse,
enlarging rt upper pulm nodule, new LLL nodule, equivocal lft
pleural based nodule, prominent mediastinal nodes, and moderate
sized bilateral pleural effusions, greater on the right.
Heme/onc was consulted who did not feel chemotherapy or further
imaging was indicated. Diagnostic thoracentesis of rt pleural
effusion was considered, but patient could not be properly
positioned. Additionally, radiation oncology was consulted for
palliative XRT, but again, patient positioning limited treatment
options. MRI of the spine was ordered, and spine consult planned
at this time. He was called out to the floor [**10-30**].
.
# Metastatic disease: Patient with glottic SCC (T3N0)s/p
chemoradiation in [**2134**] and stage IIB NSCLC s/p left upper
lobectomy in [**2136-5-13**]. Following surgery in [**Month (only) 116**], patient was
told he was 'cancer free'. Patient developed persistent dyspnea
during hospital stay, and CXR noted bilateral pleural effusions.
CT of the chest on [**10-26**] showed multiple liver mets, T6
collapse, enlarging rt upper pulm nodule, new LLL nodule,
equivocal lft pleural based nodule, prominent mediastinal nodes,
and moderate sized bilateral pleural effusions, greater on the
right. Heme/onc was consulted who did not feel chemotherapy or
further imaging was indicated. Diagnostic thoracentesis of rt
pleural effusion was considered, but patient could not be
properly positioned. Additionally, radiation oncology was
consulted for palliative XRT, but again, patient positioning
limited treatment options. MRI of the spine was ordered, and
spine consult planned at this time.
# Nausea, heartburn: Initially an attempt at H.pylori
eradication was done to eliminate that as a potential cause of
his nausea. However, he was unable to tolerate sequential
therapy and was taken off of it. He was therefore started on PPI
[**Hospital1 **] and given antiemetics, particularly zofran. He then had an
EGD and gastric emptying study. His gastric emptying study was
normal. EGD showed stricture in his upper esophageal sphincter,
abnormal mucosa in the esophagus, erythema in the stomach,
medium hiatal hernia. His UES was dilated. He also had
heartburn, which was treated as above and with zofran, which
would aid in gastric motility given his lack of a LES. His
nausea and heartburn gradually improved. However, due to
persistent dysphagia, he was made NPO and G tube was placed on
[**10-29**].
.
# CDiff: During his hospital course, he began having low grade
fevers and diarrhea. CXR, blood cultures, urine culture were
unrevealing. CDiff antigen was positive on [**10-21**] and patient was
started on IV flagyl. Due to his high risk, vancomycin enemas
were added on [**10-26**] as he could not tolerate po vancomycin. PO
vancomycin was added to regimen following successful placement
of G tube on [**10-29**].
.
# Dysphagia: He has history of glottic cancer s/p chemo XRT, s/p
trach with course complicated by chronic dysphagia with dilation
esophageal stricture [**2136-9-16**]. Pt had an EGD approximately one
week prior to admission that did not show a significant
narrowing and patient had dilation with improvement and even
acknowledges this improvement in the dysphagia component of his
symptoms. To ensure that esophageal stricture was not still
contributing to his symptoms, he had a video swallow study which
was none revealing of contributory pathology. He was
supplemented with nutren given his risk for malnutrition.
However, as his hospital course prolonged, his dysphagia
progressed and he failed a second video swallow study on [**10-25**].
He was made NPO with TPN until a G-tube was placed by IR on
[**10-29**].
.
#Chronic pain, like post-thoracotomy pain: He was seen by the
chronic pain service as well as the pain and palliative care
service. He was treated with a lidocaine patch, prn dilaudid,
basal fentanyl patch, and gabapentin. Plain films of right ribs
were negative for fracture. CT scan of thorax to eval
progression of pleural effusion noted compression fracture of
T6. He was previously being considered by pain clinic for nerve
block for post-thoracotomy pain; he may follow with them. He
will also follow with palliative care upon outpt referral by
oncology. Given newly found metastatic disease, may also
consider bone scan to r/o mets as outpt.
# Atrial fibrillation: He was noted to have asymptomatic atrial
fibrillation with RVR on [**10-11**]. TSH was checked and normal; TTE
showed elongated LA but was unchanged from prior TTE. On [**10-23**],
he again developed RVR and attempts to control with IV nodal
agents resulted in decreased blood pressure. He was transferred
to the ICU where diltiazem gtt was started to control rate.
During this time, amiadarone infusion was started and rhythm
control was adequately obtained. He was transitioned to po
amiadarone following placement of G tube.
#Normocytic Anemia: Pt with poor po may also be component of
iron deficiency although normocytic. He may also have some mild
gastric blood loss due to his severe gastritis. Studies included
levated ferritin, ESR, CRP markedly elevated, pointing to anemia
of chronic disease. His Hct responded appropriately to 1 unit
PRBC [**10-8**]. He again received 1 unit PRBC on [**10-21**] and [**10-29**].
.
# Thrombocytopenia: Plt count began trending down from 403 on
[**10-21**] to 120 on [**10-30**]. Etiology was thought to be due to platelet
clumping seen on smear, although CDiff infection and amiadarone
therapy could not be ruled out.
.
# Cough, dry mouth, upper airway secretions: Various other
complaints were addressed, including cepacol prn cough; mouth
swabs for dry mouth (may consider artificial saliva); albuterol
nebulizers for thick secretions from upper airway chronic
disease. He should follow up with PPC as an outpt (to be
referred by outpt oncology).
.
Status: full code
OMED COURSE ([**10-31**] - [**2136-11-15**]):
# fevers/PNA: Pt febrile on [**11-11**] with CXR concerning for
pneumonia, witnessed aspiration of bilious content. IV vanc and
zosyn restarted on [**2136-11-7**]. Zosyn coverage obtained because of
risk for aspiration pneumonia and better coverage of anaerobes.
Furthermore, prior pseudomonas cultures were intermediate to
cefepime and sensitive to zosyn. Sputum Cx positive gram
negative rods (pseudomonas-[**Last Name (un) 36**] to zosyn and
stenotrophomonas-[**Last Name (un) 36**] to levo/bactrim). IV zosyn and bactrim
discontinued on [**2136-11-15**] due to renal toxicity and worsening
thrombocytopenia, levofloxacin started for
pseudomonas/stenotrophomonas coverage. Mr. [**Known lastname 84573**] was
eventually made CMO by his family on [**2136-11-15**] and passed that
evening. The family declined an autopsy.
.
# Dyspnea: A pigtail pleural drain was placed by IR on [**11-12**] for
palliation of shortness of breath. 1200 cc of pleural fluid was
drained. The tube was capped from [**11-14**] - 3 for hypotension.
.
# AF with RVR: rate was well controlled eventually on amiodarone
200mg daily.
.
# Anasarca: Likely secondary to hypoalbuminuria. Attempts were
made to diurese daily ~500 cc. However hypotension from [**11-7**] to
[**11-15**] made diuresis impossible during these dates. Albumin
administration from [**Date range (1) **] did little to improve anasarca and
pulmonary edema. Mr. [**Known lastname 84573**] was eventually made CMO by his
family on [**2136-11-15**] and passed that evening.
.
# [**Last Name (un) **]: Mr. [**Known lastname 84573**] developed renal failure on [**11-12**] with
progressive worsening over the next 4 days. Given his
hypotension, he was not a candidate for hemodialysis. The family
ultimately decided against initiating CVVH in the ICU, he was
made CMO on [**2136-11-15**] and passed that evening.
.
#. Metastatic disease (Glottic SCC and NSCLC; s/p trach): Pt has
two underlying malignancies and evidence of likely metastatic
disease with liver lesions and spine lesions. ortho spine rec'd
TLSO brace when OOB. No liver biopsy was obtained per family
discussion. Pain control with intermittent IV morphine was
continued. Mr. [**Known lastname 84573**] was eventually made CMO by his family
on [**2136-11-15**] and passed that evening.
.
# C diff: Mr. [**Known lastname 84573**] was maintained on PO vanc/IV flagyl
with persistent diarrhea.
.
# Anemia: Given guiac positive bilious secretions and stool,
coupled with slow drop in hct, likely slow bleeding from glottic
carcinoma. Mr. [**Known lastname 84573**] was transfused intermittently for hct
< 25.
.
# Thrombocytopenia: Drop to 90s by date of demise from 600 on
admission. Likely [**2-15**] tumor invasion, but initially could not
rule out HIT given heparin use. 4T's score was 3 and workup with
HIT antibody was currently not indicated. On [**11-12**], Mr.
[**Known lastname 84573**] complained of acute worsening shortness of breath. A
CTA was obtained and a HIT antibody was sent. The CTA was
negative for pulmonary embolism, and the HIT antibody was
negative. Thrombocytopenia likely [**2-15**] tumor invasion of marrow
vs. drug effect. On date of demise, given thrombocytopenia,
zosyn was discontinued.
.
# Gastritis: Continue PPI and sucrafate, triggered [**2136-11-9**] for
emesis of bilious secretions with aspiration. Guiac positivity
is expected given gastritis/SCC. Standing antiemetics were
started and tube feeds were slowed.
.
# Penile lesion: On [**11-12**], a stage 3 penile ulcer was noted.
Urology and wound consults were obtained. Likely secondary to
anasarca and paraphimosis. [**Hospital1 **] wet-to-dry dressings were
started.
Medications on Admission:
-Metformin 1000 mg PO twice a day.
-Omeprazole 20 mg PO DAILY
-Dilaudid 2-4 mg PO every four hours as needed for pain.
-Colace 100 mg PO twice a day as needed for constipation.
-Senna 8.6 mg : 1-2 Tablets PO twice a day as needed for
constipation.
Discharge Medications:
NONE, patient died
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Non-Small Cell Lung Cancer
Glottic Squamous Cell Carcinoma
Sepsis secondary to HCAP
C diff infection
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
|
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76,782
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50449
|
Discharge summary
|
report
|
Admission Date: [**2104-6-9**] Discharge Date: [**2104-6-26**]
Date of Birth: [**2035-1-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Sulfonamides
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
mechanical fall, SOB
Major Surgical or Invasive Procedure:
Liver biopsy
History of Present Illness:
69 yo F with DM, hypercholesterolemia, Asthma, and
schizoaffective disorder h/o lbp, found on bedroom floor after
mechanical fall, there for 6-9 hrs. Patient was a night float
admission. She reportedly slipped out of bed while trying to get
up to go to bathroom. She denied feeling dizzy, head trauma or
LOC. She reports that she felt weak/wobbly/unsteady but that she
didn't have any numbness or strange sensation in her legs.
Because she was on the floor for so long she did urinate, but
volitionally. She denies any urinary/bowel incontinence. She
reports that she also fell yesterday. She confirms that she has
had several other falls in the last several months, she
estimates [**6-28**] since the new year. She reports that she has felt
"crappy" lately, but when pressed she denies f/c/n/v/d/abd
pain/cough. She has had back pain, sometimes lower, sometimes up
in her ribs but none now. She has been seen in ED ([**5-7**] with
negative x-rays) and epi clinic and rx'd ibuprofen for this
pain. She endorses 24 hours of chest pain-sharp like someone
kicking her in the chest, but not pleuritic, constant but waxing
and [**Doctor Last Name 688**] in intensity and she had this pain 20+ years ago. She
reports a worsening of her SOB x ~3 weeks.
.
In the ED she complained of CP for 24 h and shortness of breath.
Dyspnea improved with salumedrol, also giving combivent nebs.
Her CXR showed no significant change per radiology; she was
guaiac negative; and EKG showed sinus tachycardia, no ischemic
changes.
.
In the AM, the patient was evaluated by the medical team taking
over her care and she was noted to be sating in the 90s on 3L.
She was visible tachypneic to the 30-40's. Studies returned and
CTA to r/out PE showed a large right sided breast mass with mets
to bone/ribs a/w fractures. RUQ U/S was also performed which
showed a liver mass as well. Subequently, the patient triggered
for O2 sat 90% on 6L-->NRB 97%. Code discussion was initiated by
the resident and Attending regarding her new diagnosis of likely
cancer and the patient said she does not want to be intubated.
Patient was made DNR/DNI. Palliative care also became involved.
Given that the patient is not CMO and it is unclear what is
causing her respiratory distress she is being transferred to the
ICU for monitoring and further workup.
.
Currently she is sating okay on NRB and has been managed on the
floor. Of note she did eat and became more tachypneic from that.
She was treated empirically with 20 mg IV Lasix. No evidence of
PE or PTX. ?splinting for pain or fracture. She was given
morphine and ativan for anxiety and SOB. Patient also ordered
for echo. ?Amenable to non invasive ventilation.
Past Medical History:
1. Diabetes. followed at [**Last Name (un) **] Diabetes Center. Her last
hemoglobin A1c was 7.7 in [**5-/2103**] at [**Last Name (un) **].
2. Hypercholesterolemia/?hypertension
3. Schizoaffective disorder. The patient is followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] and is on Clozaril with q 1 month CBCs
4. COPD/Asthma. The patient is maintained on Advair and
albuterol for this. She does state that she uses her albuterol
approximately
one time per day. Her last pulmonary function tests were in
[**2096**].
5. h/o Falls
6. Back pain
Social History:
The patient lives alone in [**Location (un) **]. She denies tobacco,
alcohol, or drug use. Last mammogram in [**2090**], has refused repeat
mammography and other health maintenance screening tests.
Family History:
The patient's grandmother had coronary artery
disease. Her parent's died of cervical cancer and stroke.
Physical Exam:
Vitals 99.7, 126/70 93 26 93% 2L-5L, 88% RA
General marked central obesity in mild respiratory distress
HEENT: EOMI, OP clear without teeth
Neck no LAD, no thyromegaly
Heart RRR no m/r/g, no current TTP of sternum or right ribs
Lungs: upper airway sounds but not crackels, poor air movement
Abd: obese, NT, hypoactive bowel sounds
Ext no edema, +tinea
Neuro: 5/5 strength throughout, sensation intact to light touch
Psych: + concrete thinking
Skin: bruise on left knee
Pertinent Results:
[**2104-6-9**] 04:59PM BLOOD WBC-15.9* RBC-4.03* Hgb-9.5*# Hct-31.4*
MCV-78* MCH-23.5*# MCHC-30.1* RDW-16.6* Plt Ct-627*
[**2104-6-10**] 06:50AM BLOOD WBC-15.0* RBC-3.62* Hgb-8.5* Hct-27.6*
MCV-76* MCH-23.6* MCHC-31.0 RDW-17.3* Plt Ct-588*
[**2104-6-11**] 05:09AM BLOOD WBC-21.6* RBC-3.53* Hgb-8.1* Hct-27.5*
MCV-78* MCH-23.0* MCHC-29.5* RDW-16.9* Plt Ct-593*
[**2104-6-12**] 02:17PM BLOOD Hct-28.6*
[**2104-6-13**] 04:31AM BLOOD WBC-16.6* RBC-3.54* Hgb-8.6* Hct-27.4*
MCV-77* MCH-24.3* MCHC-31.4 RDW-17.8* Plt Ct-476*
[**2104-6-15**] 04:39AM BLOOD WBC-16.4* RBC-3.37* Hgb-8.0* Hct-26.0*
MCV-77* MCH-23.8* MCHC-30.8* RDW-18.1* Plt Ct-400
[**2104-6-9**] 04:59PM BLOOD Neuts-87.9* Lymphs-7.9* Monos-3.6 Eos-0.5
Baso-0.2
[**2104-6-10**] 06:50AM BLOOD Neuts-93.7* Bands-0 Lymphs-4.3*
Monos-1.9* Eos-0 Baso-0.1
[**2104-6-11**] 05:09AM BLOOD Neuts-92.0* Bands-0 Lymphs-4.2* Monos-3.7
Eos-0 Baso-0.1
[**2104-6-9**] 05:20PM BLOOD PT-14.0* PTT-24.1 INR(PT)-1.2*
[**2104-6-10**] 06:50AM BLOOD PT-13.9* PTT-25.3 INR(PT)-1.2*
[**2104-6-11**] 05:09AM BLOOD PT-14.1* PTT-25.9 INR(PT)-1.2*
[**2104-6-12**] 04:59AM BLOOD PT-14.1* PTT-24.3 INR(PT)-1.2*
[**2104-6-9**] 04:59PM BLOOD Glucose-135* UreaN-27* Creat-1.1 Na-146*
K-4.6 Cl-107 HCO3-27 AnGap-17
[**2104-6-10**] 06:50AM BLOOD Glucose-193* UreaN-38* Creat-1.1 Na-141
K-4.3 Cl-105 HCO3-24 AnGap-16
[**2104-6-11**] 05:09AM BLOOD Glucose-164* UreaN-57* Creat-1.5* Na-140
K-4.4 Cl-105 HCO3-27 AnGap-12
[**2104-6-13**] 04:31AM BLOOD Glucose-220* UreaN-47* Creat-1.2* Na-145
K-4.4 Cl-110* HCO3-28 AnGap-11
[**2104-6-15**] 04:39AM BLOOD Glucose-122* UreaN-31* Creat-0.8 Na-145
K-4.5 Cl-108 HCO3-30 AnGap-12
[**2104-6-9**] 04:59PM BLOOD ALT-63* AST-96* LD(LDH)-449* CK(CPK)-656*
AlkPhos-254* TotBili-0.5
[**2104-6-10**] 06:50AM BLOOD CK(CPK)-632*
[**2104-6-11**] 05:09AM BLOOD ALT-52* AST-56* LD(LDH)-311* CK(CPK)-364*
AlkPhos-238* TotBili-0.3
[**2104-6-12**] 04:59AM BLOOD ALT-53* AST-72* LD(LDH)-487* CK(CPK)-206*
AlkPhos-311* TotBili-0.3
[**2104-6-13**] 04:31AM BLOOD ALT-58* AST-64* LD(LDH)-451* AlkPhos-324*
TotBili-0.4
[**2104-6-9**] 04:59PM BLOOD cTropnT-0.02*
[**2104-6-10**] 01:30AM BLOOD CK-MB-6 cTropnT-<0.01 proBNP-576*
[**2104-6-10**] 06:50AM BLOOD CK-MB-5 cTropnT-<0.01
[**2104-6-9**] 04:59PM BLOOD Albumin-3.8 Calcium-11.5* Phos-3.6 Mg-2.3
Iron-24*
[**2104-6-10**] 06:50AM BLOOD TotProt-6.2* Calcium-10.6* Phos-3.4
Mg-2.1
[**2104-6-11**] 05:09AM BLOOD Albumin-3.4 Calcium-10.5* Phos-4.1 Mg-2.3
[**2104-6-12**] 04:59AM BLOOD Albumin-3.2* Calcium-9.9 Phos-3.5 Mg-2.4
[**2104-6-14**] 04:00AM BLOOD Calcium-10.1 Phos-2.3* Mg-2.3
[**2104-6-15**] 04:39AM BLOOD Calcium-10.0 Phos-1.9* Mg-2.1
[**2104-6-11**] 05:29PM BLOOD CEA-71* CA27.29-265*
[**2104-6-10**] 06:50AM BLOOD PEP-TWO ABNORM IgG-935 IgA-171 IgM-50
IFE-BICLONAL I
[**2104-6-10**] 06:50AM BLOOD %HbA1c-6.0*
[**2104-6-9**] 04:59PM BLOOD calTIBC-307 VitB12-1824* Folate-12.9
Ferritn-400* TRF-236
[**2104-6-10**] 02:59AM BLOOD Type-ART O2 Flow-3 pO2-65* pCO2-41
pH-7.46* calTCO2-30 Base XS-4 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2104-6-10**] 07:06AM BLOOD Type-[**Last Name (un) **] pH-7.45
[**2104-6-10**] 01:40PM BLOOD Type-[**Last Name (un) **] pO2-105 pCO2-46* pH-7.37
calTCO2-28 Base XS-0 Comment-GREEN TOP
[**2104-6-11**] 06:05AM BLOOD Type-MIX pO2-54* pCO2-55* pH-7.33*
calTCO2-30 Base XS-0
[**2104-6-11**] 07:25AM BLOOD Type-ART pO2-81* pCO2-49* pH-7.38
calTCO2-30 Base XS-2 Intubat-NOT INTUBA
[**2104-6-13**] 12:46AM BLOOD Type-ART pO2-75* pCO2-51* pH-7.39
calTCO2-32* Base XS-4
[**2104-6-14**] 04:48AM BLOOD Type-[**Last Name (un) **] Temp-37.9 Rates-/16 pO2-39*
pCO2-67* pH-7.32* calTCO2-36* Base XS-5 Intubat-NOT INTUBA
Comment-AXILLARY=9
[**2104-6-14**] 11:40AM BLOOD Type-ART Temp-36.4 pO2-61* pCO2-49*
pH-7.44 calTCO2-34* Base XS-7 Intubat-NOT INTUBA
[**2104-6-15**] 11:59AM BLOOD Type-[**Last Name (un) **] Temp-37.7 Rates-/30 FiO2-40 O2
Flow-5 pO2-65* pCO2-54* pH-7.43 calTCO2-37* Base XS-9
Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2104-6-10**] 01:40PM BLOOD Lactate-1.4
[**2104-6-13**] 12:46AM BLOOD Lactate-1.4
[**2104-6-10**] 02:59AM BLOOD Hgb-9.1* calcHCT-27
[**2104-6-14**] 11:40AM BLOOD O2 Sat-90
[**2104-6-10**] 02:59AM BLOOD freeCa-1.36*
[**2104-6-10**] 07:06AM BLOOD freeCa-1.30
[**2104-6-13**] 12:46AM BLOOD freeCa-1.41*
CXR: REASON FOR EXAM: Newly diagnosed cancer. Followup lung
abnormalities.
Comparison is made to prior study performed a day earlier.
.
Cardiac size is top normal. The aorta is tortuous. Bibasilar
atelectasis and discoid atelectasis in the right upper lobe and
left lower lobe are unchanged. There are no enlarging pleural
effusions or pneumothorax.
CT Chest: IMPRESSION:
1. Suboptimal study for evaluation of tracheobronchial malacia
due to poor airway expansion in inspiratory phase.
Tracheobronchomalacia can not be excluded in this setting.
2. Right hilar and axillary adenopathy with right breast mass
with lytic osseous lesions, may indicate osseous metastases from
possibly a breast malignancy. A bone scan for further evaluation
of extent of osseous metastases is recommended.
3. Multiple low-attenuation hepatic lesions, incompletely
evaluated in the non-contrast setting and may represent
metastatic lesions.
4. There is no definite evidence of lymphangitic tumor spread;
however, the evaluation of the pulmonary parenchyma and
interstitium is limited due to hypoventilatory changes.
TTE [**2104-6-11**]: The left atrium is dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 70-80%). There is no ventricular septal defect.
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. The pulmonary artery systolic pressure could not
be determined. There is a small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
Compared with the findings of the prior report (images
unavailable for review) of [**2096-10-9**], a small
pericardial effusion is now evident.
IMPRESSION: small, consolidating pericardial effusion; no
tamponade
--------
Repeat Echo [**2104-6-17**] : No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. The left ventricular cavity is small. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a small pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
IMPRESSION: small pericardial effusion, unchanged; small,
hyperdynamic left ventricle; no shunt seen
CT Head [**6-10**]: FINDINGS: There is no evidence of intracranial
mass, infarct, hemorrhage, mass effect or edema. The ventricles,
cisterns, and sulci are normal. There is preservation of
[**Doctor Last Name 352**]-white differentiation. The visualized paranasal sinuses are
clear. There are no fractures.
IMPRESSION: No evidence of mass, intracranial hemorrhage or
infarct.
--------------
Abd X-ray:Limited demonstrating small or large bowel distention
which could be secondary to ileus or partial small-bowel
obstruction; if further evaluation needed, consider CT.
-------------
Liver U/S: The entire study was significantly limited by patient
body habitus. The liver is heterogeneous, with a dominant mass
in the right hepatic lobe, measuring approximately 6 cm. There
are additional hypoechoic masses in the hepatic hilum which
measure up to 5.1 cm, which may represent massively enlarged
lymph nodes or additional liver lesions. There is no
intrahepatic biliary ductal dilatation. The main portal vein is
patent, with hepatopetal flow. The remainder of the hepatic
vessels cannot be interrogated.
-----------
Liver biopsy:Liver, targeted needle core biopsies:
A) Right lobe #1:
Metastatic carcinoma; see note.
B) Right lobe #2:
Metastatic carcinoma; see note.
Note: Immunostains of the tumor cells are positive for
cytokeratin 7, and mammoglobin, and negative for cytokeratin 20,
supporting the diagnosis of metastases from a breast primary.
Additionally, the tumor cells are positive for ER, negative for
PR and demonstrates 3+ staining by Her2 (as reviewed by Dr. [**Last Name (STitle) **].
[**Doctor Last Name **]; see separate addendum for full report). In these
limited samples, the tumor has mixed ductal and lobular
features. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] was notified of the preliminary
diagnosis on [**2104-6-13**].
---------
LENI: no DVT
-----------
Brief Hospital Course:
Patient was admitted to the ICU for management of altered mental
status and hypoxemia.
.
# Breast CA: The patient was admitted with a fall and hypoxia.
She had a CT chest. There was no PE. However, a right breast
mass and right rib lytic lesions were noted, concerning for
breast cancer with bony metastasis. A Head CT showed no mets.
Ultrasound of liver showed masses. These masses were biopsied
and were consistent with breast cancer. She was started on and
completed a cycle of cyclophosphamide and adriamycin. She was
also placed on neupogen. She then bumped her WBC to 44 but the
quickly came down when her WBC fell. She will need 3 more days
of neupogen. She will need a daily CBC with differential faxed
to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 34802**]. She was started on fentanyl
for chest and right upper chest pain [**2-23**] metastasis) She was
also started on Ibuprofen. She is written for PRN oxycodone but
has only needed it occaisonally.
.
#Respiratory Distress: Initial work-up was notable for
tracheo-bronchial malacia (TBM) but little other acute lung
pathology. Patient was treated for COPD flare with IV steroids,
nebulizers. CT of the chest demonstrated no e/o lymphangitic
spread of tumor, significant effusions, or PE. She had an echo
showing a normal EF bu small effusion w/o tamponade physiology.
She had a repeat echo a week later showing an unchanged small
effusion w/o tampondade. Her CXR showed a question of mild
pulmonary edema; however, it was difficult to evaluate given her
body habitus. Patient was diuresed. The patient's respiratory
distress improved. However, she continued to require oxygen. It
was thought that hypoventilation was a significant of her
underlying lung disease. She has severe sleep apnea and
desaturates to 84%, retains CO2 and becomes nearly unarousable
if she does not use CPAP. She requires O2 via NC during the day,
tirated Sa02 90-93%. It is imperative that she use CPAP at night
and any time she naps.
.
# Altered Mental Status: The patient was somnolent in the ICU.
She received a head CT which was normal. She was pan-cultured
with no evidence of infection - neg UA, neg blood cultures. An
ABG showed CO2 retention. She was started on CPAP. It was found
that everytime she did not use CPAP, that she became drowsy and
even frankly unarousable. She returns to normal when placed on
CPAP. If she starts CPAP at 8 or 9pm at night and keeps it on
all night and if she is awake, sitting in a chair upright during
the day, her mental status is greatly improved. It was
determined that her narcotics were not related to her mental
status as she barely required any PNR medication and as she was
doing well on fentanyl.
.
# Schizoaffective: She was maintained on Clozapine.
.
# Diabetes: The patient was kept on a sliding scale while in
house. She should return to her normal insulin regimen as an
outpatient - NPH, metformin and rosaglitazone. She is followed
at the [**Hospital 387**] clinic for diabetes.
Medications on Admission:
- Actos 45 mg daily
- ADVAIR DISKUS 250 mcg-50 mcg/Dose [**Hospital1 **]
- ALBUTEROL 90MCG--2 puffs every 4-6 hours as needed
- ASPIRIN 81 mg
- CLOZARIL 25 mg--9 tablet(s) by mouth once a day
- Insulin NPH 74u in am, 34u in pm
- LIPITOR 80 mg daily
- LISINOPRIL 10 mg daily
- METFORMIN HCL 1,000 mg [**Hospital1 **]
- VITAMIN D 800 U daily
Discharge Medications:
1. Clozapine 25 mg Tablet Sig: Five (5) Tablet PO qam.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation: titrate to one BM
daily.
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection
Q24H (every 24 hours) for 5 days.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
14. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
15. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day: take at noon and at night.
16. Clozapine 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2)
puffs Inhalation twice a day.
18. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day.
19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) puff Inhalation once a day.
20. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
21. Humalog
give as per attached sliding scale
22. Oxygen
Oxygen via nasal cannula
Titrate to 90-93%
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] senior life
Discharge Diagnosis:
Breast Cancer
Severe Sleep Apnea
Discharge Condition:
improved, but still requiring O2 in the day and CPAP at night
Discharge Instructions:
You were admitted with a fall. You were found to have metastatic
breast cancer and were started on chemotherapy. You were also
found to have low oxygen levels and high carbon dioxide because
of sleep apnea. You were started on CPAP, but you will also need
oxygen during the day. It is very important that wear your CPAP
or you become very sleepy and difficult to wake up.
.
If you have fevers, chills, difficulty breathing or severe pain,
you should return to the emergency room.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 14703**] [**7-8**],[**2104**] at 12:00pm at [**Hospital1 18**].
.
She will need a daily CBC with differential faxed to Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 34802**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"272.4",
"V07.39",
"493.22",
"799.02",
"599.0",
"E888.9",
"295.70",
"584.9",
"733.19",
"198.5",
"276.0",
"174.8",
"250.00",
"338.3",
"197.7",
"519.19",
"913.0",
"285.9",
"V15.88",
"780.57",
"401.9",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.28",
"50.11",
"93.90",
"99.04",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
18523, 18578
|
13262, 15260
|
324, 338
|
18655, 18719
|
4488, 13239
|
19247, 19694
|
3875, 3981
|
16641, 18500
|
18599, 18634
|
16276, 16618
|
18743, 19224
|
3996, 4469
|
264, 286
|
366, 3043
|
15275, 16250
|
3065, 3644
|
3660, 3859
|
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